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 A practical manual of mental medicine. 
 
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 FROM THE 
 
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 THE GIFT OF 
 
 aHeniTQ W. Sags 
 
 1891 
 
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 FUND 
 
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A PRACTICAL MANtlAL 
 
 OF 
 
 MENTAL MEDICINE 
 
 BY 
 
 Dr. E. R£GIS 
 
 Formerly Chief of Clinlque of Mental Diseases, Faculty of Medicine, Paris 
 Formerly Assistant Physician of the Sainte-Anne Asylum 
 Physician of the Maison de Sant6 de Castel d'Andorte 
 Laureate of the Medico-Psychological Society and of the Faculty of Med- 
 icine of Paris 
 Professor of Mental Diseases, Faculty of Medicine, Bordeaux 
 
 WITH A PREFACE 
 
 BY 
 
 M. BEISTJAMIK BALL 
 
 Clinical Professor of Mental Diseases, Faculty of Medicine, Paris 
 
 A Work Crowned hy the Faculty of Medicine of Paris 
 Chateauvillard Prize 1886 
 
 SECOND EDITION 
 
 Thoroughly Revised and Largely Re-Written 
 
 AUTHORIZED TRANSLATION 
 
 BY 
 
 H. M. BANNISTER, A. M., M. D. 
 
 Late Senior Assistant Physician, Illinois Eastern Hospital for the Insane 
 
 Member of the American Medico-Psychological Association 
 
 Member of the American Neurological Association 
 
 Member of the American Academy of Medicine, etc. 
 
 WITH INTRODUCTION BY THE AUTHOR 
 
 PHILADELPHIA 
 
 P. BLAKISTON, SON & CO. 
 1012 WALNUT STREET 
 
TO MY FATHER 
 
 Dr. LOUIS R^GIS 
 
PREFACE 
 
 To THE FiKST Edition. 
 
 The study of mental- disease has within a few 
 years attained an unlooked-for development. Its 
 corps of instruction has been enlarged by the addition 
 of many chairs, and its literature enriched by numer- 
 ous works, some of which, like the recent volume of 
 Maudsley, view the subject from a philosophical 
 and physiological point of view, while others, like 
 the classic treatises, handle the subject on its sys- 
 tematic side, and still others, intended to fatniliarize 
 students and practitioners with the elements of men- 
 tal medicine, take the more modest form of manuals. 
 
 This work of M. Regis occupies a middle place 
 among these various types. On the one hand it rep- 
 resents the manual, by its condensation of material, 
 its brevity and clearness, and by its order and con- 
 ciseness, which wUl be especially appreciated by those 
 who desire to acquire a moderate acquaintance with 
 the subject without devoting to it long and labor- 
 ious studies. On the other hand, it is almost a 
 didactic work in the very elaborate manner in which 
 
Vi PEBFACB TO FIEST EDITION. 
 
 the subjects of certain chapters are treated, and m 
 the frequent personal and original views which it 
 contains. I will mention in this last connection the 
 attempts at classification which, following so many 
 authors, he has sketched, and the chapters on hallu- 
 cinations, partial insanity, sympathetic insanities, 
 and especially that on general paralysis. 
 
 The spirit which has controlled the production 
 of this work is before all clinical and practical. 
 Without disdaining high philosophical conceptions, 
 the author applies them in general to bring to the 
 front only such subjects as will offer a direct inter- 
 est in point of view of the diagnosis, treatment and 
 government of the patients. His book is, therefore, 
 especially designed for students who wish to rapidly 
 acquire the necessary knowledge to properly com- 
 plete their studies, and for practitioners who desire 
 the information indispensable to those who, having 
 to do with the insane, are not always able to com- 
 mand the assistance of the skill of a specialist, which 
 is so readily obtained in the great scientific centres. 
 
 In a general way, the ideas expressed in the work 
 of M. Rfegis, are in accord with the instruction I 
 have given for many years in the asylum of St. Anne, 
 and in which, in his capacity as chef de clinique, he 
 has himself borne an important part. The origin- 
 
tEEFACB TO FIEST EDITION. VIl 
 
 ality of an independent mind, however, cannot but 
 reveal itself in a work like the present one ; and it 
 is not a servile copy of my lectures that is here 
 offered to the public; in many respects he differs 
 decidedly from the views I have taught. I am aU 
 the more free, on this account, to praise the excellent 
 spirit in which this volume is conceived, to notice its 
 incontestable merits, and to wish for it a happy for- 
 tune in medical literature. 
 
 Peofessoe B. Bau.. 
 
INTEODUCTION. 
 
 This work, crowned by the Faculty of Medicine 
 of Paris, and having attained in a few years its 
 second edition, has had a success as unexpected as 
 it has been undeserved. Surely the least I could do 
 towards a recognition of that generous reception was 
 to subject my manual to serious correction and adapt 
 it, to the best of my ability, to the progress of 
 science. I have therefore revised the entire book 
 thoroughly, suppressing superfluities, modifying 
 certain passages, adding new articles and chapters, 
 and aiming always to be as practical as possible. 
 Have I succeeded in this task? It is not for me to 
 say. In any event I hope that I shall be credited, 
 as in the case of the first edition, with good 
 intentions. 
 
 E. Regis. 
 NOVEMBEB 14, 1891. 
 
TRAJSrSIiATOE'S NOTE. 
 
 It is a rather remarkable, and perhaps not alto- 
 gether a creditable fact that, up to the present, we have 
 had no English translation of any modern standard 
 French work on mental diseases and their treatment. 
 No apology therefore seems necessary for having 
 endeavored to present to American readers the work 
 of Dr. Regis which is, as it is considered in France, 
 a model of its kind. 
 
 No alterations have been made, the aim having been 
 to give as far as possible a literal translation of the 
 original. Two chapters, however, that appeared in 
 the French edition, — those in regard to the commit- 
 ment of the insane and their relations to the civil 
 code, — ^have been omitted, with the permission of 
 the author. They referred exclusively to French 
 law and usage, and hence their practical value could 
 not be conveyed into an American translation. 
 
 H. M. B. 
 
 Chicago, 103 State St., 
 July, 1894. 
 
AUTHOR'S PREFACE TO TRANSI^ATION. 
 
 On dit communement que la Science n' a pas de frontifircs. 
 Get aphorisme, vrai peut-fitre pour quelques unes des con- 
 naissances humaines, ne I'etait certainement pas il y a quel- 
 qucs annecs encore, povii la, psychiatrie. Jusqu'fl, ces der- 
 niers temps, en effet, chaque pays a, pour ainsi dire, cul- 
 tive isolement les maladies mentales, ayant S, cet egard ses 
 traditions, ses vues particulifires, ses methodes cliniques et 
 thSrapeutiques et juSqu' S, sa terminologie. II en resultait 
 un manque de cohesion dans les efforts et un retard dans le 
 progrSs. 
 
 Aujourd'hui, nous comprenons mieux la nScessite de ne 
 pas rester livres 3, nos propres forces et de nous tenir au 
 courant des travaux internationaux, soit par des analyses, 
 soit par des traductions reciproques. Ce mouvement de 
 collaboration univcrseUe a dejS, produit de tons resultats et 
 il en produira de meilleurs encore dans 1' avenir. 
 
 La traduction, sur la deuxifime edition fran9aise, de mon 
 Manuel pratique de medecine meniale, doit 6tre considerle 
 sans doute comme une des manifestations de ce tesoin gen- 
 eral de se connaltre et de s'entendre entre ouvriers separls 
 d'une cauvre commune. Je n' y vois pas d'autre raison en 
 tout cas, n'ayant pas la presomption de croire 3, mon livrc 
 assez de valeur pour s' imposer par ses quaUtes personnelles, 
 a I'attention de 1' etranger. 
 
 En France il a eu quelque succ6s, par ce qu'il essayait do 
 presenter sous une forme t la fois methodique, claire et con- 
 
xiv AITTHOE's PEEFACE to TEANSXATION. 
 
 cise, nos connaissances les plus importantes en psychiatrie, 
 midicale et in§dico-l§gale. Aura-t-il la mfime fortune aux 
 Etats-Unis ? Je n'ose me laisser aUer 3, cette illusion et 
 je m'estimerai heureux s' il y obtient seulement un accueil 
 quelque peu sympathique. 
 
 Quel que soit le degrg de favour qu'il puisse rencontrer, 
 je dois declarer trfis sincSrement qu' il la devra tout entiSre 
 S. ses InterprStes americains : au savant Dr. Bannister, qui a 
 realise une irrgprochable traduction, tant par la forme que 
 par le fond; au Dr. Alder Blumer, l'6minent publiciste, 
 qui a con9u I'lieureuse idee de faire imprimer le livre El 
 I'asile d' Utica, par ses malades, et de lui donner cette appar- 
 ence elegante et coquette sous laquelle il se pr&ente ici. 
 C'est la premiSre fois assur6ment, qu'un ouvrage traitant 
 d' ali§nation mentale, se trouve 3, la fois ferit par un alien- 
 iste, traduit par un alieniste et, sous la direction d' un 
 ali&iste, imprimS et relie par des alignes. Puisse-t-il, pour 
 6tre complet S, ce point de vue, 8tre lu et gotitS par les 
 alienistes des Etats-Unis I C'est 13, mon voeu de la fln. 
 
 Je m' en remets pour eel a 3, mes excellents confreres, les 
 
 Drs. Bannister et Alder Blumer, 3 qui je serre les mains par 
 
 del3 les mers, en les remerciant bien cordialement de leur 
 
 precieux concours. 
 
 E. EfiGIS. 
 BoEDBAUX, 17 fevrier, 1894. 
 
 [It is a common remark tbat science recognizes no fi-on- 
 tiers. This aphorism, true perhaps for some branches of 
 human knowledge, certainly has not been true within a 
 comparatively recent period for psychiatry. Up to within 
 
AUTHOB S PEEPACE TO TKANSLATION. XV 
 
 a few years, indeed, each country has, so to speak, 
 studied mental disorders by itself alone, having in this re- 
 gard its own special traditions, its own particular views, 
 clinical and therapeutic methods, and even its own termin- 
 ology. The result has heen a lack of unity of efEort and a 
 hindrance to progress. 
 
 To-day we better appreciate the necessity of not confining 
 ourselves to our own investigations and of keeping ourselves 
 in touch with foreign workers, either by means of abstracts 
 and reviews or by reciprocal translations. This tendency 
 to universal collaboration has already given us good results 
 and will produce still better ones in the future. 
 
 This translation of the second French edition of my 
 Practical Manual of Mental Medicine should without doubt 
 be considered as one of the manifestations of this general 
 desire of workers in a common field to know and understand 
 each other. I can see no other reason in any case, not 
 having the presumption to believe my book of such value 
 as to impose itself by its own merits upon the attention of 
 foreign readers. 
 
 In France it has met with some success as an attempt to 
 present in a form at once methodic, clear and concise the 
 more important facts of our knowledge of medical and 
 medico-legal psychiatry. Will it have the same good for- 
 tune in the United States ? I do not permit myself to in- 
 dulge in this illusion and will consider myself fortunate if 
 it obtains only a moderately sympathetic reception. 
 
 Whatever favor it may meet, I ought to say will be due 
 to its American sponsors : to Dr. Bannister, who has made 
 an irreproachable translation, both as to letter and substance ; 
 
XVI AurnoE 8 peeface to teanslation. 
 
 and to its eminent publisher. Dr. Alder Blumcr, who con- 
 ceived the happy idea of having it printed at the Utica 
 asylum by his patients and who has devised for it the neat 
 and elegant appearance it here presents. It is assuredly the 
 first instance of a work treating of mental alienation, writ- 
 ten by an alienist, translated by an alienist, and, under the 
 direction of an alienist, printed and bound by the insane. 
 May it not, to carry the point to completion, be read and 
 approved by the alienists of the United States. This is my 
 prayer for its future. 
 
 I leave it for this to my excellent confrires, Drs. Bannister 
 and Alder Blumer, to whom I stretch my hand across the 
 seas, cordially thanking them for their valuable assistance. 
 
 E. r6GIS.] 
 BoKDEATix, February 17, 1894. 
 
A PRACTICAL MANUAL 
 
 OF MEKTAL MEDICIKE. 
 
 PART FIRST 
 MENTAL PATHOLOGY. 
 
 HISTORICAL. 
 
 Ill order to begin the study of mental alienation 
 with profit, it seems necessary to summarize briefly 
 the history of its progress down the centuries. 
 
 This history of insanity, viewed as a whole, in- 
 cludes four distinct epochs. 
 
 The first or primitive epoch is that period of 
 ignorance and superstition prior to any medical 
 ideas, in which insanity was considered as coming 
 from the gods, and its treatment confided to the 
 priests. It extended from the beginning of the 
 world down to Hippocrates, who marks the advent 
 of a new era, and with whom begins mental medi- 
 cine properly so-called. 
 
 The second epoch is the classic medical epoch, 
 which starts from Hippocrates and ends with the 
 Roman decadence, after having successively passed 
 through three brilliant periods: the Hippocratic 
 period, the Alexandrine period and the Grseco- 
 Roman period. 
 
X HISTOEIOAL. 
 
 The third epoch or epoch of transition, the be- 
 ginning of which is marked by the return to the 
 primitive superstitions adapted to the requirements 
 of a new religion, and which did not begin to be 
 dispelled until towards the last days of its history, 
 also includes two periods : the middle ages and the 
 Renaissance. It extends from the commencement of 
 the Christian era to the end of the eighteenth cen- 
 tury, that is to say, from Coelius Aurelianus and 
 Galen down to Pinel. 
 
 The fourth or modern epoch is that scientific 
 period par excellence, which commences with Pinel, 
 that is, from the great and memorable reform of 
 1793, was continued with Esquirol and his students, 
 and may be considered at the present time to be 
 attaining gradually its apogee. 
 
 Such are the principal stages in the history of in- 
 sanity. It is noAv necessary to pass in review and 
 notice briefly the principal facts relative to each. 
 
 FIRST EPOCH. 
 
 (Primitive epoch). 
 
 If there is one well established historical fact, it 
 is that of the predominance of the divine idea in the 
 beginnings of society. All peoples in their infancy 
 have submitted to the exclusive yoke of a religious 
 belief to the extent that it seems as if superstition 
 was necessarily one of the first phases of their evolu- 
 tion. In the first periods of existence everything is 
 
PRIMITIVE EPOCH. 3 
 
 referred to celestial intervention, and insanity itself 
 was considered by them as the possession of the in- 
 dividual by a benevolent or avenging divinity. 
 
 It was thus with the Jews, as is evidenced by the 
 episodes of the maniacal behavior of king Saul and 
 the attack of lycanthropy of Nebuchadnezzar. 
 
 We find analogous beliefs and practices among the 
 Egyptians.* There is in the Biblioth^que of Paris, 
 an-Egyptian stile dating from the third century B.C., 
 the inscription on which gives the account of an 
 Asiatic princess possessed by a spirit, who was cured 
 by the intercession of the god Khons. We know 
 also that there existed in Egypt temples dedicated 
 to Saturn where they purified the insane with the 
 purpose of restoring them. 
 
 In ancient Greece the condition was the same, and 
 the names 6aifiovuiXrinToi, 6s6X7]TTTot, ivepyoviievoi, 
 demoniacs, possessed of the gods, energunienes, 
 which were given to those deprived of reason, show 
 plainly enough to what origin was attributed their 
 insanity. 
 
 Everyone is acquainted with the history of the 
 
 *The restricted size of this book forbids us from citing 
 on each page all the authors, French and foreign, to whom 
 we are indebted for ideas or expressions, and we can only 
 refer, for the bibliography of each chapter, to special treat- 
 ises and articles in the Dictionnaires. We cannot refrain, 
 however, from saying how much we have been aided in the 
 preparation of this history, by the publication of the works 
 of Trelat, Lasfigue and Morel, Marce, Ball, and especinlly the 
 excellent work of Semelaigne. 
 
4 HISTORICAL. 
 
 unhaiDpy Meleager, with that of the parricide Orestes, 
 and those not less celebrated of the daughters of 
 Pretus, king of Argos, who, afflicted by Juno with 
 a sort of lepra, believed themselves transformed into 
 cows and lowed in imitation of those animals. 
 Tradition relates that they were cured by the shep- 
 herd Melampus with the aid of hellebore, purifica- 
 tions and religious ceremonies. 
 
 The insane were not always considered, neverthe- 
 less, as the prey of the infernal divinities. Among 
 them were found gome, who, by reason of their 
 delusive exaltations, passed, on the other hand, as 
 friends of the gods, as inspired, and who prophesied 
 the future. Among these last the Delphian pyth- 
 oness is one of the most celebrated. With such 
 beliefs as to the nature of insanitj', the treatment 
 of the insane ought clearly to consist in religious 
 ceremonies and to be confided to the priests. This 
 is what occurred. In Greece the Asclepiades, a sort 
 of medical priests, who managed the temples of 
 ^sculapius, were specially charged with their cure. 
 Hippocrates, who later scored these charlatan priests 
 and denounced their curative practices in which 
 speculation evidently played the principal part, has 
 left us a detailed account of their treatment of the 
 insane. 
 
 The ceremony had for a prelude an adjuration to 
 the malignant deity; they besought it to depart 
 from the body of the possessed. After this, the 
 patient was submitted to purifications, expiations, 
 
PBIMITIVB EPOCH. 5 
 
 exorcisms, ablutions with tlie lustral water or the 
 blood of a sacrificial victim. 
 
 Occasionally there were added to these religious 
 ceremonies some wise hygienic practices : spectacles, 
 recreations, music, promenades, sojourns at thermal 
 baths and exercise in the gymnasium. It thus hap- 
 pened that some of the patients were cured, and tliis 
 was then attributed at once to the appeasement of 
 the offended deity, and necessarily involved the 
 giving of valuable offerings, to the enrichment of 
 the priests. 
 
 Such, in the early ages, were the prevalent ideas 
 in regard to insanity and the means employed for its 
 cure. We shall have to pass rapidly over this 
 rather confused period of the history of mental 
 disease, and merely mentioning the Pythagorean 
 philosophers who, in the fourth and fifth centuries 
 before Christ, received from the priests the notions 
 they possessed to only confuse them sometimes with 
 philosophj', sometimes with physics and metaphys- 
 ics, we come to Hippocrates, with whom really 
 commences the medical science of antiquity. 
 
 SECOND EPOCH. 
 (Medical epoch of antiquity). 
 
 1. HippocBATic Period. 
 
 Hippocrates, the creator of mental medicine, be- 
 longed to a family of priests, the Asclepiades, who 
 
6 HISTORICAL. 
 
 claimed descent from iEsculapius and possessed, as 
 we have seen, the monopoly of the treatment of the 
 insane in ancient Greece. 
 
 He was born, as is well known, in the island of 
 Cos, 460 B. C. Although he wrote no special treat- 
 ise on mental alienation, it is easy to perceive from 
 an attentive perusal of his writings, that he had a 
 tolerably accurate knowledge of this class of dis- 
 orders. Even before him some distinctions had been 
 made, as he appears to have borrowed from tradition 
 the terms he employed of phrenitis, /nanni, melan- 
 cholia and sdcrcil ditease. 
 
 Hippocrates describes phrenitifi according to its 
 etymology, together with pleuritis and pneumonia, 
 and locates its seat in the phrenic center. It con- 
 sists, according to him, in a continuous delirium 
 in an acute fever. Its cause is the heating of the 
 whole body by the blood, itself over-heated by mix- 
 ture with the bile which displaced it and changed it 
 to serum, affected its movement and its habitual con- 
 stitution. As to the symptoms, they are fully indi- 
 cated in the following formula, as succinct as accurate, 
 which is taken from the treatise on epidemic affec- 
 tions : ' 'Acute delirium with high fever, carphologia, 
 small and wiry pulse." The disease, the duration of 
 which varied between the extreme limits of three 
 and one hundred and twenty days, ended in death 
 more often than in recovery. 
 
 Although it is difficult to say exactly what Hippo- 
 crates and other ancient writers understood b}' 
 
HIPPOCBATIC PEKIOD. 7 
 
 phrenitis, it is allowable to conjecture that they in- 
 cluded under this term the majority of the acute 
 idiopathic or symptomatic insanities, and, in particu- 
 lar, acute febrile delirium. 
 
 If the indications relative to phrenitis lack clearness 
 in the Hippocratic writings, this is still more the 
 case in regard to mania. Scientifically the ancient 
 authors, including Hippocrates, considered mania as 
 a violent delirium, either acute or chronic. In the 
 Hippocratic collection we find it generally confounded 
 with phrenitis and melancholia. 
 
 Melancholia also lacked any very precise significa- 
 tion. Its two principal characters, according to 
 Hippocrates, seem to have been fear and sadness. 
 The syndrome varied also according to whether the 
 altei-ation in the brain was due to the phlegm or the 
 bile. If the first, there was no excitement, if the 
 second, this general condition was in different degrees 
 the principal character of the malady. 
 
 Besides phrenitis, mania and melancholia, Hippo- 
 crates appears to have recognized the insanity of 
 pregnancy and alcoholic insanity. In any case he 
 seems to have observed examples of these. 
 
 In the domain of nervous diseases he possessed 
 some vague notions about hysteria, but it is epilepsy 
 that he was best acquainted with, and which he 
 described with the greatest care. He even remarked 
 the fact that epilepsy might be complicated by 
 insanity. 
 
 Hippocrates had not merely the merit of first rec- 
 
8 HISTOEICAL. 
 
 ognizing the pathological nature of insanity. With 
 the most praiseworthy persistence he combated 
 the medico-religious practices of the Asclepiades in 
 order to substitute for them a more rational and 
 medical treatment. From that time the ablutions, 
 exorcisms and incantations were succeeded by phle- 
 botomy, purgation, emetics, baths, vegetable diet, 
 hygienic exercises, music, traveling, in a word by 
 all the medical appliances available at that epoch. 
 It was he who regulated the use of hellebore 
 (Veratrum album) employed empirically from a 
 very high antiquity as a specific for insanity, and he 
 had his patients go and collect it themselves at 
 Anticyra, a little village in Thessaly, where was 
 found the variety in most repute. Hippocrates ap- 
 pears to have likewise employed mandragora, as a 
 special drug, in cases of suicidal melancholia. 
 
 As to how they managed the insane, whether or 
 not there existed especial establishments for their 
 care, and whether restraint or coercion was em- 
 ployed in severeVand difficult cases, we are unfortu- 
 nately left only to conjecture. It seems probable 
 that quiet and inoffensive patients were left at 
 liberty or, at least, in their homes under the surveil- 
 lance of their servants or relatives, and that certain 
 cases were cared for in asylums {Idrpia), as appears to 
 be the case from a passage in Plutarch relative to 
 Antiphon, a physician at Coi-inth. Moreover, a 
 history of a lunatic related by Herodotus leads us 
 to suppose that very rigorous methods of restraint 
 
ALBXAirDBIAX PERIOD. 9 
 
 were employed by the ancients in the treatment of 
 dangerous cases. He says, in fact, that Cleomenes, 
 king of Lacedsemon, having fallen into a frenzy, 
 with violent agitation, his family had him secured 
 by wooden fetters. 
 
 Hippocrates by himself alone, as regards the his- 
 tory of insanity, comprises or covers the whole 
 Hippocratic period. His successors, who were only 
 his imitators, added nothing to his medical ideas on 
 insanity, and, at the time of the dismemberment of 
 the empire of Alexander, scientific tradition found 
 itself transported into Egypt, where it assumed a 
 certain brilliancy under the reign of the Ptolemies. 
 
 3. Alexandriak Pbkiod. 
 
 The Alexandrian period, represented especially by 
 Herophilus and Erasistratus, who lived about three 
 hundred years prior to the Christian era, is, in reality, 
 only an intermediate period between Hippocrates or 
 the Greek school and Asclepiades and Celsus or the 
 Gr£eco-Roman school. 
 
 Lacking documents in regard to this period, its 
 history is very obscure, and we are compelled to seek 
 what we can learn from Galen, the works of Erasis- 
 tratus and Herophilus not having come down to us. 
 But from what we learn of the scientific knowledge 
 of these celebrated men and the progress they had 
 attained, especially in anatomy and nerve physiology, 
 we can believe that they possessed rather accurate 
 and extensive knowledge of insanity, and that they 
 
10 HISTOEICAL. 
 
 had taken up and developed in this regard the ideas 
 of the father of medicine. 
 
 About a century later, under Ptolemy Evergetus 
 II, the scientific movement passed from Alexandria 
 to Rome, thanks to the discords occurring in the 
 family of the Lagides and the dispersion of learned 
 men that followed it. But it was more especially 
 after the victory of Lucullus and of Pompey in 
 Asia, that this movement became prominent in the 
 Roman Empire. 
 
 3. Gk^co-Roman Period. 
 
 This period of the'history of insanity is merely 
 represented by the names of Asclepiades, Celsus, 
 Aretaeus, Soranus, Coelius Aurelianus and Galen. 
 It ended with Alexander of Tralles, Paul of Egina, 
 and the Arabs who form a transition between the 
 ancient world and the middle ages. 
 
 Asclepiades of Bythinia (80 B. C), at first a 
 rhetorician, then a physician, an eminent partisan 
 of the philosophical theory of atoms, established 
 formally the line of demarcation of insanity ad- 
 mitted implicitly by Hippocrates, and dating from 
 him authors divided it into aoiUe alienation with 
 fever and phreuitis, and chronic alienation without 
 fever, or mania and melancholia. Asclepiades also 
 studied the apperceptions (visa), and distinguished 
 them very clearly into hallucinations and illusions. 
 
 Finally, the fact of the transformation of one 
 form of insanity into another struck his attention, 
 
GB^CO-EOMAN PEEIOD. 11 
 
 and it is probably under the influence of this observa- 
 tion that he came to attempt substitutive medication, 
 amd especially to advise intoxication in the general 
 treatment of mental alienation. 
 
 Cblsus (A. D. o), devoted to insanity only a few 
 pages. In place of the general term alienatio 
 mentis employed by Asclepiades, he used the term 
 insania, which he applied to the three species com- 
 prised in his classification, namely: frenzy (acute 
 insanity), melancholia which he attributed to black 
 bile, and lastly, a third form which he divided into 
 two sub-species; 1, hallucinatory imanity , gay or 
 sad without delirium (imaginibus non mente fallun- 
 tur) ; 3, general and partial delirium (animi desi- 
 piunt) . , 
 
 Celsus went more at length into the subject of 
 therapeutics and formulated some very wise and 
 judicious rules as to hygienic and moral treatment. 
 Unfortunately there is a shadow in the picture, 
 since he advises the use of hunger, chains and 
 chastisements to subjugate the victim of insanity 
 when his acts or his words evidence his want of 
 reason. " Ubi perperam dixit aut fecit, fame, vin- 
 culis, plagis coercendus ist." 
 
 Abetabus of Cappadocia, (A. D. 80), belonged 
 to the sect of the pneumatists. His greatest title to 
 renown is that he has left behind him very remarka- 
 bly accurate and truthful descriptions of the various 
 forms of mental alienation, and especially mania 
 
12 HISTORICAL. 
 
 and melancholia. He considered melancholia as a 
 mental depression with concentration of thought on 
 one fixed idea, without fever : " Melancholia in una 
 re aliqua est lapsus, constants in reliquis judicio. 
 Animi angor in una cogitatione di fixus atque inhoer- 
 ens, absque febre et furore a phantasmate melan- 
 colict) ortus." It was, therefore, according to him, a 
 circumscribed insanity with limited delusion, in which 
 respect it was different from mania, which he con- 
 sidered to be a generalized disorder of the intelli- 
 gence. 
 
 Aretaeus described melancholia at length and very 
 clearly, and noted especially the bodily symptoms, 
 such as constipation, scantiness of urine, eructations, 
 fetor of the breath, smallness of the pulse, etc. 
 
 As regards mania, he considered it, as has already 
 been said, as a general continuous insanity, without 
 fever, and he distinguished it from the toxic delirium 
 produced by wine, mandragora and hyoscyamus by 
 the fact that these latter have a sudden onset 
 and equally sudden disappearance, while mania is 
 stable and permanent. In his description of mania 
 he notes the mental exaltation which in some patients 
 quickens the faculties of memory and imagination so 
 that they converse on astronomy and philosophy and 
 compose poetry apparently beyond their normal 
 ability. 
 
 Aretaeus shows in a number of places in his 
 writings that melancholia is a commencement or a 
 species of demi-mania, and that on the other hand 
 
GE-«ICO-BOMAN PBEIOD. 13 
 
 when it tends to subside, it sometimes changes into 
 mania rather by its progress than by the intensity of 
 the disease. He also remarked the fact that an 
 attack of mania may be followed by a period of 
 depression. 
 
 That part of the work of Aretaeus devoted to the 
 treatment, and especially that of the treatment of 
 maniacal delirium, has not come down to us. We 
 may presume, nevertheless, from what indications 
 we have, that since the time of Celsus a reaction 
 had taken place in favor of the insane since Aretaeus 
 nowhere mentions restraints or ligatures in his 
 descriptions of even furious cases of frenzy. 
 
 SoEANUs of Ephesus (A. D. 95), whose works have 
 been lost, is only known to us through Ccelius 
 Aurelianus who appears in his writings as his trans- 
 lator and commentator. 
 
 It is impossible to say what, in the admirable 
 work of Ccelius Aurelianus, properly belong,? to 
 the author and what must be credited to the com- 
 mentator. It is probable, nevertheless, that Ccelius 
 Aurelianus has, on a great number of points, 
 expressed his own personal opinions. 
 
 Ccelius Aueelianus lived about a century after 
 Soi-anus, of whom he was, as seen, the translator and 
 commentator. 
 
 In a point of view of mental pathology, strictly 
 speaking, Ccelius Aurelianus has added but little to 
 the magnificent descriptions left by AretCBUs; his 
 
14 HI8T0EICAL. 
 
 work is limited to perfecting in a number of points, 
 the ideas of his predecessor. Thus he remarks the 
 distinction between frenzy or febrile delirium and 
 mental alienation properly so-called, and he insists 
 on the organic disorders that accompany melancholia, 
 in regard to which he says : "In melancholicis 
 stomachus, in furiosis vero caput afficitur." 
 
 It is especially, however, the chapter relative to 
 the treatment of insanity that forms the most valu- 
 able part of the work of Ccelius Aurelianus. It 
 gives an admirable exposition of the rules of the 
 physical and moral treatment of the insane, an elo- 
 quent plea for gentle measures and consequently for 
 the suppression of coercive methods, in a word, a 
 full statement of that method which has been 
 revived in our day under the title of Non-restraint . 
 CobHus Aurelianus expresses himself forcibly in 
 regard to those physicians who have recourse to 
 severe methods of treatment. One passage in par- 
 ticular deserves to be quoted : " They seem rather 
 to lose their own reason " says he of these physicians, 
 " than to be disposed to cure their patients, when they 
 liken them to wild beasts who must be tamed by the 
 deprivation of food and the torments of thirst. 
 Misled, doubtless, by the same error, they advise the 
 inhuman use of chains, not considering how their 
 members may be lacerated or broken and how much 
 better it is to control by the hands of men than by 
 the often useless weight of iron. They go so far as 
 to counsel bodily violence and blows, as if to compel 
 
GR^CO-EOMAN PERIOD. 15 
 
 the return of reason by such provocations, a deplor- 
 able method of treatment that can only aggravate the 
 patients' condition, injure them physically, and offer 
 to them the miserable remembrance of their suffer- 
 ings whenever tliey recover the use of their reason." 
 In another passage Ca-lius Aurelianus says further, 
 after advising that the difficult and disturbed cases 
 be cared for by skilled attendants : "If the sight of 
 other persons irritates them, and only in very rare 
 cases, restraint by tying may be employed, but with 
 the greatest precautions without any unnecessary 
 force, and after carefully protecting all the joints 
 and with special care to use only restraining appara- 
 tus of a soft and delicate texture, since means of 
 repression employed without judgment increase 
 and may even give rise to furor instead of repressing 
 it." One could hardly plead better in the cause of 
 humanity or lay down wiser rules on the subject of 
 the means of restraint for the insane. 
 
 Galen (A. D. 150) the celebrated physician of 
 Pergamus, who wrote five hundred memoirs and 
 whose ideas had an immense influence on his own 
 times and retained the same during the following 
 fourteen centuries, gave a little attention to the 
 subject of mental alienation. The leading point in 
 his writings in this regard, is the division he made 
 between idiopathic insanity and sympathetic in- 
 sanity, or insanity by consensus, and the importatice 
 he accords to the latter in his descriptions. 
 
16 HI8T0BICAI-. 
 
 After Galen everything fell into obscurity and 
 confusion. Alexander of Tralles (A. D. 560) and 
 Paul of Egina (A. D. 630) brought out nothing new 
 in regard to insanity, and as to the Arab physicians 
 Avecenna, Rhazes (10th century) they confined them- 
 selves to developing the ideas of Galen as to insanity 
 by consensus, the seat of which they placed in 
 different viscera, and especially in the liver and 
 spleen. 
 
 THIRD EPOCH. 
 
 (Epoch of transition). 
 
 1. The Middle Ages. 
 
 During the whole duration of the middle ages the 
 study of insanity lost itself in the general chaos and 
 no traces of it were to be found. The belief in 
 demons dominated all imaginations ; superstition 
 spread itself in all parts ; it was the reign of sorceiy, 
 of the witches' Sabbath, of demonopathy, of lycan- 
 thropy and of demoniac possession. 
 
 Thus occurred in all parts, those terrible epidem- 
 ics of hysterical religious insanity, the detailed his- 
 tory of which Calmeil has preserved, all of which, 
 after a series of exorcisms, and of more or less sol- 
 emn mystical ceremonies, ended in the condemnation 
 of the unfortunate insane and their punishment by 
 torture or execution. Thousands of unhappy beings, 
 victims of popular prejudice, atoned with their lives 
 for their loss of reason and became the prey of the 
 
THE RENAISSANCE. 17 
 
 flames. Not a single voice was raised in their be- 
 half, the parliaments themselves were the most blood- 
 thirsty in this barbarous slaughter, and we have to 
 come down to the fifteenth century to take up, in 
 the point of view of the history of mental medicine, 
 the chain so long interrupted. Religious delusions 
 were then still firmly rooted, for the first physicians, 
 among them Ambrose Par6 himself, despite the timid 
 protests of Nider, gave supernatural interpretations 
 of insanity and attributed it to demoniacal inter- 
 vention. 
 
 2. The Renaissance. 
 
 At the close of the sixteenth century, under the 
 influence of the impulse given by Alciat, Wier, Le- 
 loyer, Montaigne, physicians returned little by little 
 to healthier traditions, and Baillon, Nicolas Lepois, 
 Felix Plater, Sennert, Sylvius de le Boe, and Bonet 
 endeavored, not always with success, to loosen the 
 yoke of prejudice that had so tenaciously subjected 
 the foregoing centuries. ' 
 
 Paul Zacchias (1584-1659), proto-physician to 
 the Pope and the states of the church, in his admira- 
 ble work entitled Questions MMico- Leg ales, devoted 
 a very important chapter to various states of mental 
 alienation. We find developed in it, besides exact 
 and concise clinical descriptions, all the medico-legal 
 considerations suggested by insanity, notably those 
 touching on civil capacity, validity of acts, lucid in- 
 tervals, and the moral and legal responsibility of the 
 insane. 
 
 Ment. Med.— 8, 
 
18 HISTORICAL. 
 
 Sydenham (1624-1689), treated of insanity in 
 only an incidental manner, but he noted one interest- 
 ing point, that of mania developed in consequence 
 of intermittent fevers. 
 
 Willis (1622-1675), whose works are more im- 
 portant and mark a progress beyond those of his 
 predecessors, gives good descriptions of mania and 
 melancholia, which he divides into partial and 
 general ; of stupidity, in which he includes, as has 
 been done since, imbecility and idiocy; of dementia,_ 
 and even of stupor. 
 
 His descriptions are unfortunately involved with 
 long discussions on the animal spirits. He ob- 
 served the succession of mania and melancholia, 
 and in this are found the first traces of that 
 which has been described later as circular insanity. 
 Willis also admits, though with certain reservations, 
 the intervention of demons. The rules of treatment 
 he gives are full of good sense; unfortunately, 
 however, he did not hesitate to advise, as frequently 
 needful, rigorous methods: '■'■Prima indicatio 
 curatoria disciplinam, minas, vvii.cula, ceque ac 
 rnedicinam requirit. Furiosi nonnunquam citias 
 per supplicia et cruciatus, qtiam phar/nacia aiit 
 niedicametttis cura/Uur. " 
 
 Bonet(1700), in his Sepulcretnut insists, like Galen 
 and the Arabs, on the importance of visceral lesions 
 in insanity, and reports at length the lesions met 
 with in autopsies in different organs. 
 
THE EENAlSSANCE. 19 
 
 At this same period there were made some fortu- 
 nate experiments in medication, and the cure of a 
 ease of relapse of mania by transfusion of blood 
 was reported, also some other cases cured by 
 trephining. 
 
 In the eighteenth century the study of mental 
 pathology entered definitely upon a new course. 
 There still occurred some epidemics of religious and 
 hysterical insanity, perhaps among the persecuted 
 Calvinists, perhaps at the tomb of the deacon at 
 Paris, but their morbid nature was recognized 
 and they were met with treatment, medical' in its 
 character. 
 
 ViEUSSEXs (1641-1730), aside from some neuro- 
 ses the seat of which he fixed definitely in the brain, 
 onlj' attempted to adapt his knowledge of mental 
 diseases to the humoral theories he supported. 
 
 BoERHAAVE (1668-1738), and his commentator 
 VanSwieten (1700-1773) also subordinated their ideas 
 of insanity to their mechanical theories and attrib- 
 uted everything to the malignity of the blood and 
 the black bile. They give nevertheless here and 
 there good descriptions of mania and melancholia, 
 and they point out, particularly in the following, the 
 principal physical characters of melancholia with 
 profound depression, or, in other words, of stupor: 
 '' Pulstis lentior; frigus rnajus; respiratio lenta; 
 drniJatio per sanguined vasa bona; 2^^i' lateralki 
 minus bona; hinc hwnorum secretiorum, et ex- 
 
20 HlSTOftlCAt, 
 
 cretiori/hi ndnor, tardior, cratior exitvfi ; nitiior 
 ijoiisii,nqjtio, parriiir appetitus.'''' 
 
 Soon however, under the impulsion of Bonet, 
 Vieussens,and particuFarly of Morgagni (] 683-1771), 
 pathological anatomy made rapid progress and there 
 was more and more tendency to abandon the hu- 
 moral and pseudo-chemical theories and to devote 
 more attention to the examination of the solid 
 structures of the body. 
 
 Sauvagbs (1706-1767), a nosologist joar ed'cellence 
 made an infinite division of the vaiious forms of 
 nervous, disorder. His eighth class made up of tlie 
 vesanias, or disorders that affect the mind, is itself 
 sub-divided into four orders: 1. Ilallur /nations 
 vertigo, dimness of vision, diplopia, tinnitus, hypo- 
 chomlria, somnambulism. 3. Mbrositien, depraved 
 desires or affections (pica, bulimia, polydipsia, 
 antipathies, nostalgia, panic terrors, satyriasis, 
 uterine furor, tarentism, hydrophobia). 3. TJ<dir- 
 him (ecstacy, dementia, melancholia, mania, demono- 
 mania). 4. Ahnonnal aberrations (loss of memory, 
 insomnia). Each of these is again split up into more 
 or less numerous subdivisions. 
 
 Here and there we find in Sauvages some good 
 descriptions, notably that of anxious melancholia 
 (melancholia attonita). But his merit is in having 
 brought together under the name vesanias and in a 
 complete classification, nearly all that was known in 
 his day of mental diseases. 
 
 LoREY (1725-1772) published some good descrip- 
 
THE RENAISSANCE. 21 
 
 tions which were confused, however, by his return to 
 a doctrine half solidist, half humoral. 
 
 CuLLEN (1713-1792), who forms the transition 
 between the Renaissance and the modern epoch, 
 rejected the humoral theory entirely and insisted 
 upon the necessity of anatomo-pathological re- 
 searches. He classed mental disorders among the 
 neuroses, which form the fourth class in his work. 
 He described syst&matized insanity^ remarking at the 
 same time the rarity of finding insanity limited to a 
 single subject, and admitted in his final arrangement 
 only two primary forms of insanity from which he 
 derived all others : mania and melancholia. In the 
 part devoted to treatment he recommends employ- 
 ment, baths, and bodily exercises, and authorizes 
 forcible methods of repression only reservedly. 
 
 With Cullen we are already far removed from the 
 ignorance and obscurity of the mid,dle ages and 
 mental science had already realized an immense 
 advance. The condition of the insane was, however, 
 still deplorable ; they were scattered through the jails, 
 in a few asylums, or in miserable cells. Very few 
 were in hospitals, and the so-called hospitals that 
 contained these were in reality only prisons. Their 
 study was therefore as difficult and incomplete as 
 their lot was deplorable. 
 
 At Paris, after an act of Parliament dated Sep- 
 tember 16, 1660, the insane passed first through the 
 Hotel Dieu, where two wards were reserved for 
 them. The ward St. Louis, devoted to men, con 
 
22 HISTORICAL. 
 
 tained ten beds for four each and two small beds. 
 St. Martin ward for females contained six large beds 
 and six small ones. Some places in these wards 
 were reserved for cases of hydrophobia, then the 
 treatment employed consisted invariably in douches, 
 cold baths and repeated bleedings, with the in- 
 ternal use of hellebore, purgatives and antispas- 
 modics. 
 
 If after several weeks the patients remained un- 
 cured, and we can see readily how such a course 
 could do little to restore the reason, they were con- 
 sidered incurable and distributed either to the Petits 
 Maisons, which afterward became the hospital of the 
 Manages, the Salpetri^re, or the Bic^tre. 
 
 There ill-nourished, covered with rags, loaded 
 with chains and collars of iron, confined in infected 
 cells intended for criminals, bedded on rotten straw, 
 breathing a mephitic atmosphere, they dragged out 
 a miserable existence, exposed to the view of the 
 public who, being admitted on holidays on the pay- 
 ment of a fee, repaired to view the sight and to 
 tease them like wild animals through the bars of 
 their cages. 
 
 It was at this time that Pinel appeared and 
 brought about the memorable reform of 1793, 
 which changed completely the lot of the insane and 
 inaugurated a new era in the history of mental 
 medicine. 
 
MODBBN EPOCH. 23 
 
 FOURTH EPOCH. 
 
 {Modem epoch). 
 
 Philip Pinbl, born in 1755 at St. Paul, near 
 Lavaur (Tarn), and graduated at Toulouse, became 
 physician to the insane at the Bic^tre in 1793. 
 
 We have seen in what condition he found the 
 insane. Thanks to his earnest protests, which he 
 made to be heard-, he succeeded in removing their 
 chains, and provoked also a general movement in 
 favor of these unfortunates. For bad treatment, 
 brutal violence, blows and chains, he substituted 
 wisely combined methods of repression, he praised 
 the effects of firmness combined with mildness and 
 patience, and finally laid down the first bases of 
 moral treatment. He demonstrated the necessity of 
 creating special establishments for the insane, 
 pointed out the principles that ought to govern their 
 construction, their organization and their manage- 
 ment, the need of the separation of the patients 
 in distinct quarters according to the nature of" their 
 mental disease ; in a word drew up the first rules for 
 the hospitalization of the insane and made to be un- 
 derstood the rdle of the physician in the observation, 
 and medical and material direction of his patients. 
 He was aided in the practical details of his reform 
 by the overseer of the Salpdtri^re, Pussin, his modest 
 collaborator, whose part was not a less active one 
 and whom Pinel himself has associated, in a certain 
 measure, with the honor of his glorious innovation. 
 
24 HISTORICAL. 
 
 Such is, in substance, the story of the reform insti- 
 tuted by Pinel. One man by his generous initiative 
 and his persistent will, realized that which many 
 centuries had vainly sought : the rehabilitation of 
 the lunatic and his elevation to the dignity of a 
 sufferer from disease. It is needful, however, to be 
 just, to recognize that this undertaking came in its 
 own time and that it was, so to speak, one of 
 the manifestations of that immense philanthropic 
 tendency that en wrapt all the great spirits of that 
 epoch. 
 
 Moreover, the undertaking of Pinel was not an 
 isolated one. At the same moment similar efforts 
 were being made at other points. Already in Savoy 
 Daquin had preached the same humanitarian doctrine 
 in a more modest sphere, while Chiaruggi in Italy 
 published in 1794 his treatise on Insanity, General 
 and Special, in which he stated the results of the 
 ameliorations obtained by him in the asylum of San 
 Bonafacio in Florence. 
 
 In' England, a simple citizen of the city of York, 
 William Tuke, succeeded by his own endeavors in 
 doing still better. Witnessing the grave abuses that 
 prevailed in the asylums, he influenced his co-relig- 
 ionists of the sect of Quakers, or the Society of 
 Friends, to found an institution from which should 
 be banished all severe physical measures and bad 
 treatment. The first stone of the York Retreat 
 was thus laid in 1792, and from its opening in 
 1796 it became the starting point of the sue- 
 
MODBEN EPOCH. 25 
 
 cessive improvements in the care of the insane in 
 England.* 
 
 Pinel was not merely a reformer, he was also a man 
 of science. Bringing together all the clinical and ther- 
 apeutical observations he had made in regard to the 
 insane, he published in the year IX, his TraiU de. 
 la Munie, in which, after recalling the admirable 
 works of ancient writers, he stated his own medico- 
 philosophical views on mental alienation. This little 
 work, of which Cuvier said in the Institute, ' ' That 
 it was not only a medical work but also a masterlj' 
 work on philosophy and even morals," had a great 
 success, and has since remained justly celebrated. 
 
 Pinel admits and describes four species of insanity, 
 mania, melancholia, dementia and idiocy, in which 
 he confuses, like Willis, idiocy and cretinism, and 
 also dementia with melancholic stupor. 
 
 At this time there arose in Germany the school 
 known as the German psychological school which 
 started from the spiritualistic theory of Stahl, accord- 
 ing to which diseases are only the perversion of the 
 
 *This quasi-simultaneousness of reforms in different 
 countries has, as might have been expected, brought up 
 more or less irritating disputes as to priority as to the claims 
 of Daquin, Chiaruggi, Tuke, and Pinel. Such controversies 
 tend to diminish their glory, and it seems better to include 
 them all alike in our admiration. In the words of Hack Tuke, 
 the worthy grandson of the English philanthropist : ' ' There 
 are enough evils in the world for the few reformers who 
 appear from time to time and there is no need of creating 
 between them a state of hostile rivalry," 
 
36 msTOKicAi. 
 
 moral tendencies of the soul produced by sin. Sin, 
 therefore, became the principal cause of insanity. 
 
 Langermann and his pupil Ideler were the found- 
 ers of this psychological school which counted among 
 its adherents some illustrious names, and one of its 
 most celebrated representatives was Heinroth (1773- 
 1843), one of the better disciples of Pinel, who 
 held that insanity had its source in the absence of 
 morality, that its essential character was the loss of 
 liberty, and its best preservative, attachment to the 
 truths of the Christian religion. 
 
 The opinions of the German psychologists, by their 
 exaggeration, did not fail to provoke a lively oppo- 
 sition. In Germany, there arose a new school, the 
 soiitatio school, which had for its chiefs, Nasse, 
 Friedreich, Vering, Amelung, Jacobi, Griesinger, 
 and in Holland, Schroeder van der Kolk. They all 
 protested against the outre spiritualistic doctrines of 
 the psychologists, and labored to prove that insanity 
 was connected with physical lesions, either cerebral or 
 visceral. Like Galen and the Arabs, they accorded 
 the place of honor in psychiatry to the sympathetic 
 insanities. 
 
 In France, Esquirol, born in Toulouse in 1772, 
 succeeded Pinel, and his work was as important in 
 its influence on mental medicine, properly speaking, 
 as that of Pinel, on the moral condition and the 
 treatment of the insane. 
 
 As a philanthropist and reformer, he continued 
 the work of Pinel, contributed to the construction 
 
MODEBW EPOCH. 27 
 
 and organization of numerous asylums, of wliich he 
 liimself drew up the plans, he improved more and 
 more the condition of the insane ; and finally prepared 
 the way, by his travels and writings, for the move- 
 ment that ended in the famous law of 1838, that 
 has been of so great service, and for which Falrct, 
 Sr. and Feri'us worked actively. 
 
 As a savant, Esquirol left the domain of pure 
 speculation to devote himself to observation and 
 clinical work; he drew up admirable tables of the 
 principal forms of insanity, to which he added 
 monomania, and finally suspected the existence of 
 general paralysis. 
 
 As a teacher he formed and directed a magnificent 
 constellation of students, so numerous and brilliant 
 that discoveries accumulated, and mental medi- 
 cine has nevei' made so great a progress within so 
 short a time. 
 
 At Charenton, Bayle, Delaye, Georget, Foville, 
 Sr. and the venerable Calmeil discovered and 
 described the symptoms and lesions of general 
 paralysis. 
 
 At the SalpStri^re Tr61at described reasoning 
 mania; F61ix Voisin made a profound study of 
 idiocy ; Falret, Sr. , combated the doctrine of mono- 
 mania, sent out new general ideas on mental diseases, 
 and, Jeacher in his turn, left behind him pupils like 
 Morel (the illustrious author of the memoirs on degen- 
 erations, hereditary insanity,- the etiological classifi- 
 <j3,tion, and the introducer into France of the system 
 
28 HISTORICAL. 
 
 of nou.-restraint recommended in England by Gardi- 
 ner Hill and Conolly), Charles Lasegue, (the 
 describer of persecutory insanity), and finally his 
 own son, the eminent clinicist, Jules Falret. There 
 is also Leuret, the promoter, perhaps too much the 
 subject of attack, of moral treatment, and M. 
 Baillarger, whose clinical discoveries so important 
 and well known are too numerous to be enumerated 
 here. 
 
 Still to be mentioned are the names of Marc and 
 Fodere, the revivers of the legal medicine of 
 insanity; Ferrus, Parchappe, Marce, and others in 
 France and elsewhere too numerous to mention. It 
 will suffice to cite only Conolly, Guislain and Rush, 
 whose influence in the progress and treatment of in- 
 sanity in England, Belgium and America is more or 
 less comparable to that of Pinel in France. 
 
 It is necessary to stop here since we encroach on 
 the present times and some of the names we might 
 cite, although already belonging to history, belong 
 to those who are still our masters. The future will 
 have to judge as to the progress made in the study 
 of mental alienation since Pinel and Esquirol. 
 
FIRST SECTION. 
 
 GENERAL PATHOLOGY. 
 
 Cbapter IF. 
 
 § I. DEFINITION. 
 
 Distinction between Insanity and Mental 
 Alienation. — In common medical language the 
 term mental alienation has become synonymous 
 with insanity, and these two designations are usu- 
 ally employed interchangeably. Scientifically, never- 
 theless, they have different significations, and it 
 seems the more necessary to define them accurately 
 as this difference is a fundamental one in the 
 classification here adopted. 
 
 Mental alienation is a generic term that includes 
 in a general way all the alterations of the intelli- 
 gence from the normal, whether constitutional or 
 functional, congenital or acquired, transitory or 
 persistent. Insanity has a less extended significa- 
 tion, it is only one of the conditions of mental 
 alienation, and signifies the loss of reason strictly 
 speaking, occurring as a disease in an individual 
 hitherto sane. An example will serve to illustrate 
 the distinction. An imbecile is mentally alienated, 
 inasmuch as he presents an evident defect of intel- 
 
30 OENEEAL fATHOLOGY. 
 
 lect, an arrested development, but, however imbecile 
 he may be, he may not be insane, and may use nor-^ 
 mally the restricted intelligence he possesses ; he is 
 not a lunatic. But when this imbecile, under the 
 influence of any cause whatever, is attacked with 
 mania or melancholia, we have a new element in his 
 case, his insanity, which is superimposed upon the 
 primitive basis of alienation ; the mentally alienated 
 individual has become a lunatic. 
 
 We may add, to accentuate the distinction, that 
 beyond the symptoms it has in common with men- 
 tal alienation, insanity is nearly always unconscious 
 of itself to such a degree that it may be called a 
 misfortune that ignores itself, and that it has for a 
 jirincipal symptom, if not an absolute criterion, the 
 loss of free will, that is, of the faculty by which the 
 sane man decides and acts with knowledge of the 
 cause, with full freedom and reflection. For this 
 reason, so far as an insane person is not really dom- 
 inated by his morbid influences, and remains to a 
 certain degree master of himself, co'inpon syi, he can 
 be considered as not being a lunatic in the full sense 
 of the word, there still remains a last step for him to 
 take, that of the pathological subordination of his 
 ego. 
 
 We may call mental alienation therefore, the total 
 of th.e pathological conditions essentially character- 
 ized by disorders of the intelligeiicc. 
 
 As to insanity, it has been thus defined by Esquirol : 
 "A cerebral affection, ordinarily chronic, without 
 
DEFINITION. 31 
 
 fever, characterized by disorders of tlie sensibility, 
 of the intelligence, and of the will." 
 
 This definition, considered as the best of all those 
 so far offered, and they are numerous, is nevertheless 
 ^■ery imperfect, inasmuch as it may be applied in- 
 diiferently lo all chronic cerebral affections in which 
 there is any psychic disorder, and in that it does not 
 especially include the distinction we have noted 
 Jbetween mental alienation and insanity. 
 
 In order to be more precise and yet without pre- 
 tending to give an accurate definition of insanity, 
 which is in the present state of our knowledge almost 
 an impossibility, we may say that insanity is a 
 special disease, is a form of alienation characterized 
 by the accidental, unconscious, and more or less per- 
 manent disturbance of the reaso7i. 
 
 Synonymy. Tebminology. — Mental alienation 
 has as synonyms, mental diseases ov phrenopathias ; 
 insanity, psychosis or psychopathy; mental medi- 
 cine, psychiatry ov freniatry. 
 
 As to the words dementia, monomania, hallucina- 
 tion, delusion, which are often improperly used by 
 the public as synonyms of insanity, they have each 
 a particular and very different signification. Thus 
 dementia is a form of alienation, and it can scarcely 
 be made the equivalent of insanity anywhere except 
 in judicial language where this usage has prevailed. 
 The same is the case with monomania or systematized 
 insanity, which is only a special form of insanity, 
 and should not therefore be confounded with it. 
 
33 GENEEAl PATHOLOGY. 
 
 Finally, as to delusion and hallucination, they are 
 merely the names of two primary or symptomatic 
 elements of insanity. 
 
 There remains a term, habitually misapplied, 
 whose signification as established in scientific lan- 
 guage it is important to state correctly : it is the 
 term vesania. We give the name vesania to the 
 pure insanities in order to distinguish them from 
 those connected with other morbid conditions, into . 
 which they enter only as symptoms or complications. 
 For example, the insanity of persecution is a type of 
 vesania, as it is idiopathic and forms by itself alone 
 the existing morbid condition; paralytic insanity, 
 or the insanity that so frequently accompanies 
 general paralysis, on the other hand, is not a vesania 
 since it is connected with a cerebral disease, an 
 organic affection of the nervous centres. It is need- 
 less to add that the insane termed vesanics are in 
 consequence those affected with pure insanity or 
 vesania. 
 
 § 11. ETIOLOGY. 
 
 One of the most important parts of the study of • 
 mental alienation is that of its etiology, and this is 
 what many authors, notably Morel, have made the 
 basis of their classification. 
 
 The same as with most diseases, there are, for 
 mental alienation, predisposing and occasional 
 causes. The more important of these have been 
 
ETIOLOGY. 
 
 33 
 
 brought together by Marce in the following syn- 
 optical table : 
 
 Predisposing 
 causes. 
 
 Occasional 
 causes. 
 
 General. 
 
 Individual. 
 
 Moral. 
 
 Physical. 
 
 Civilization. 
 
 Religious ideas. 
 
 Political events. 
 
 Heredity. 
 
 Age. 
 
 Sex. 
 
 Climate. 
 
 Civil condition. 
 
 Profession. 
 
 i;ducation. 
 
 Emotions, passions, chagrin. 
 
 Imitation. 
 
 Cellular imprisonment. 
 
 Acting directly on the 
 
 bram. 
 Acting at a distance 
 and sympathetically. 
 An3emia,cachexia, sem- 
 inal losses, onanism. 
 Biathesis, dartres, rheu- 
 matism, typhoid and 
 intermittent fevers. 
 Menstruation, pregnan- 
 cy, confinement, lac- 
 tation. 
 {Intoxications : lead, 
 mercury, opium, bel- 
 ladonna, poisonous 
 solanaciae haschioh. 
 
 Local 
 causes. 
 
 General 
 causes. 
 
 Physiolog- 
 ical 
 causes. 
 
 Specific 
 causes. 
 
 A word on each of these causes in particular. 
 
 Pbbdisposing Causes. 
 
 Civilization. Race. — It is generally recognized 
 that civilization, by the needs it creates, the habits 
 of luxury and pleasure it excites, and finally by the 
 struggle for existence that it necessitates, favors the 
 development of mental alienation. Nevertheless, 
 it is impossible to say with certainty whether the 
 number of the insane actually increases progressively, 
 and, if so, in what proportion. The census figures 
 have shown how it has been in France ; in 1835 there 
 
 Mbht. Mbd.— 8. 
 
34 GEWEEAL PATHOLOGT. 
 
 were 16,538 insane or 4.96 to each 10,000 inhab- 
 itants; in 1841, 18,367 or 5.37 to each 10,000; 
 1861, 46,367 or 12.95; in 1866, 90,709 or 33.82; 
 in 1876, 83,012 or 22.50 to the 10,000. Judging 
 only from these results it would appear that the 
 number of the insane among us has quintupled dur- 
 ing the past thirty-five years, but tfiere is in this 
 evidently an exaggeration due to the greater accuracy 
 of the recent censuses. If we take the insane, not 
 as enumerated in the census, but the number admit- 
 ted to the hospitals, we find that the increase of ad- 
 missions which was annually 12.5 per cent, forty 
 years ago, is to-day only 1.70 per cent. The num- 
 ber of admissions has therefore a tendency to be- 
 come stationary. This proves, as Lunier states, 
 that the increase in the number of the insane, 
 admitting that it exists, is, in any event, less con- 
 siderable than is generally believed. 
 
 Another interesting series of statistics is that of 
 the insane of the Department of the Seine from 1801 
 to 1883. It is seen from these figures, that there 
 were on January 1, 1801 , 945 insane maintained at 
 public expense, while on the 3l8t of December, 
 1888, the number was 8,907, or more than six times 
 greater, while in the same space of time the general 
 population of Paris has hardly more than tripled 
 itself, having been 600,000 at the beginning of the 
 century and 2,237,928 by the census of 1881. 
 
 The statistios^of other countries seem likewise to 
 afford contradictoi-y results. 
 
ETIOLOGY. 35 
 
 There is, nevertheless, an interesting fact to be 
 noted relative to the progress of insanity in the 
 black race. Solbrig had already observed that in 
 America the free negroes of the Northern States had 
 proportionally, as it appeared, five times as much 
 insanity among them as existed among their colored 
 brethren of the South. According to the more re- 
 cent researches of Buchanan, the development of 
 insanity has increased rapidly in the colored race 
 since emancipation. 
 
 In 1850 there were enumerated 618 insane amongst 
 the black population of the United States, in 1860 
 their number was 766, or one for every 5,799. In 
 1870 there were 3,695 colored lunatics; in 1880 the 
 proportion was 1 to 1,096, so that, admitting a 
 regular increase, this proportion, says the author, 
 will rise to 1 to 500 in 1890, thus equaling the fre- 
 quency of mental alienation among the Americans 
 of the white race. 
 
 If it is impossible, according to these data, to 
 establish in any positive manner the influence of 
 civilization upon the frequency of insanity, its 
 influence on the type of alienation, on the other 
 hand, is much more certain. We may say, in- 
 deed, that the pure insanities, or vesanias, 
 have existed from all time and probably with- 
 out increasing to any considerable extent. 
 Among them the generalized insanities, mania and 
 melancholia, have continued absolutely identical 
 with their type in ancient times, as anyone may con- 
 
36 GENEEAi PATHOXOGT. 
 
 vince himself by comparing the description given by 
 the writers of antiquity with the diseases as we see 
 them at present. As to the systematized insanities, 
 while remaining fundamentally the same, they vary in 
 expression according to the period and the surround- 
 ings. The mental infirmities due to a vice of 
 organization (idiocy, cretinism) seem to diminish 
 with civilization, mainly on account of the ameliora- 
 tion in the material life that results from it. 
 Alcoholism, alcoholic insanity, and in a general way 
 all the toxic cerebropathies increase very notably, 
 especially in certain countries and in the great 
 centres. Finally, general paralysis, absolutely un- 
 known prior to the present century, whether it 
 existed then or not, is becoming more and moi'e 
 frequent, especially in the female sex. 
 
 It would be interesting, aside from the effects of 
 civilization in general, to indicate the comparative 
 liability of the various races to mental alienation and 
 to each of its forms. Unfortunately we lack reliable 
 statistics on this point. It appears, however, from 
 certain memoirs, particularly an interesting publica- 
 tion in 1888, by Drs. Bannister and Ludwig Hektoen 
 of Illinois, in regard to a considerable number of 
 patients treated in their asylums, that the Jewish 
 race stands at the head, especially as regards general 
 paralysis, mania and melancholia. The African, 
 Anglo-Saxon and Anglo-American, Latin, Teutonic, 
 Celtic, and Scandinavian races follow after with 
 figures more or less variable. But, I repeat, these 
 
ETIOLOGY. 31t 
 
 results, being purely local, cannot be taken as repre- 
 senting tlie real state of affairs in its totality. 
 
 Religious Ideas. — The influence of religious 
 ideas in the production of insanity varies according 
 to the epoch, the country and the surroundings. 
 Very active in Prance at the times of the religious 
 wars of the reformation, and of ardent polemics, it 
 has become much less at the present day, though 
 still somewhat apparent. On the other hand, it still 
 plays a large part in countries where the religious 
 sentiments occupy one of the chief places in the 
 public mind. Nothing is more communicable than 
 ideas of religion and mysticism ; for this reason the 
 insanity they engender takes most frequently an 
 epidemic type. 
 
 Religious ideas give rise to insanity principally in 
 those who offer the easiest prey, that is, in a general 
 way, the weak-minded, children, females, nervous 
 persons, and especially members of religious orders, 
 male and female, and more particularly those of a 
 mystic and contemplative character. 
 
 They have also a very manifest effect at certain 
 stages of life, especially the great epochs of sexual 
 life: puberty and the menopause. It is known, 
 moreover, that direct relations exist between mystic 
 and erotic ideas, and that very often these two kinds 
 of conceptions are found associated together in 
 insanity. 
 
 Political Events. Wars. — The importance of 
 political commotions, revolutions and wars as a cause 
 
38 GENERAL PATHOLOGT. 
 
 of mental alienation has always been overestimated. 
 The truth is that these great events have for a 
 special effect that they call out and bring before the 
 ])nblic a certain number of lunatics who in peaceful 
 times would have passed unnoticed, and also that 
 they communicate a special coloring to the delusive 
 ideas of the time. Great scientific or social move- 
 iTients that occur in society act in the same way. 
 Great discoveries, or inventions, and powerful asso- 
 ciations hardly indeed affect the insane except to 
 color their delusions and im])ress upon them a special 
 physiognomy. 
 
 Heredity. — Heredity, which is, without contra- 
 diction, the most powerful and important of all the 
 causes of insanity, merits a few words. 
 
 Definituyn. — By heredity is understood in mental 
 pathology c«(, ori<i'ni<tl predisx>osition to mental alien - 
 (it'ion tr>irif:niitff<7 to children from their 23rirents. 
 
 Natwc. Frequency. — The source of this predis- 
 position may be not merely mental alienation in the 
 ancestors, but other related diseases, eccentricity, 
 neuroses, alcoholism, certain diatheses, consan- 
 guinity, &c. Because of not accepting hereditj^ in its 
 widest and truest signification and restricting it 
 more or less to cases of direct transmission of in- 
 sanity itself, there was some disagreement as to the 
 exact frequency of this cause of alienation. In re- 
 alitj^ we may admit with Marce, that we find some 
 antecedent in nine-tenths of all the cases. 
 
ETIOLOGY. 39 
 
 Characters. Forms. Varieties. — Heredity is most 
 frequently from the parents, that is, it is immediate. 
 It may be on the side of both father and mother, and 
 in that case, it is called double, or from converffent 
 factors. Generally, it is from one parent, either 
 father or mother, and then it is simple heredity, 
 either paternal or maternal. According to Esquirol 
 the latter is the more serious of the two. It is also 
 three times more common than paternal heredity, 
 according to M. Baillarger. 
 
 The heredity may be traced from the grand- 
 parents, having passed by the immediate ancestors. 
 It is then mediate heredity. It may also have existed 
 for many prior generations and in that case it is 
 called cumulative. 
 
 Heredity is either direct or collateral according as 
 it is observed in parents or grandparents or in 
 collateral branches of the family. 
 
 Hereditary insanity may appear in children at the 
 same time that it appeared in the parent, and it is 
 then called homochronous. It may also appear in 
 children a longer or shorter time before it is seen in 
 the parent. It may then be called anticipatory as 
 regards the parental disease, which has so far 
 remained latent. 
 
 The hereditary taint may reveal itself in the 
 children by a mental disorder identical with that of 
 the parent. This occurs in cases of suicidal impulse 
 and sometimes also in certain forms of alienation, 
 such, for example, as circular insanity. It is then 
 
40 GENEEAL PATHOLOGT. 
 
 similar or homologous. It is dissimilar or trans- 
 formed, on tlie other hand, when it is modified in 
 passing from one generation to another. This is 
 generally the case and it may become more and 
 more intensified and end in the degeneration of the 
 race, i, e. , be progressive; or it may, on the contrary, 
 become attenuated by a series of fortunate crossings, 
 and finally disappear entirely, — it is then regressive. 
 
 The hereditary taint does not afPect all the mem- 
 bers of the same family indiscriminately,- a certain 
 number may escape its influence. It is even the rule, 
 according to Morel, to see in insane families dis- 
 similar types. This dissimilarity may sometimes 
 reach a point that we find in these families, together 
 with insane and degenerated individuals, men of 
 talent and even of genius. (Relation of genius with 
 insanity.) In some instances, two or more brothers 
 or sisters, together or separated, are afPected sim- 
 ultaneously and in an identical manner. (Folie d deux, 
 Folie gemellaire) . 
 
 As a rule, the children most liable to the heredi- 
 taiy taint are those whose birth was nearest in time 
 to the attack of insanity of the parents. This is 
 notably the case with children born of a mother in 
 an attack of puerperal mania, or begotten by a 
 father in a state of intoxication. 
 
 Heredity, in mental alienation, seems to aifect 
 several types, the principal ones of which are: 
 (1) vesanio heredity, or the heredity of pure insan- 
 ity or vesania ; (2) cerebral or congestive heredity. 
 
SlTIOLOG-?. 41 
 
 i. e. , the heredity of cerebral affections and general 
 paralysis; (3) neurotic heredity, or that of the 
 neuroses. 
 
 Age. — The frequency of mental alienation is most 
 marked in the middle period of life; before and 
 after that it gradually diminishes according as we 
 approach the two extremes of infancy and old age. 
 The principal important periods of life, such as 
 puberty and the climacteric, are the signal for a recru- 
 descence of the frequency of insanity. 
 
 Sex. — In general statistics of mental alienation the 
 male sex figures more largely than the female : the 
 proportion is 114 to 129 males to each 100 females. 
 If the cases of idiocy and cretinism, most frequent 
 among males, are excluded, a certain equilibrium is 
 re-established, and if we go further and take out all 
 the cases of general paralysis and alcoholism, we find 
 that pure insanity is more frequent in the female than 
 in the male. It is necessary to add that certain 
 mental disorders, like those connected with preg- 
 nancy, are peculiar to the female, and that some 
 others, common to both sexes, have special char- 
 acters in women. 
 
 Climate. Sbasons. Lunar Phases. — It is 
 scarcely possible to state the comparative influence 
 of different climates on the production of insanity, be- 
 cause of the multiplicity, and especially the diversity, 
 of the superadded causes. The one fact that appears 
 to be settled is the greater frequency of alienation 
 
43 GENEEAL PATHOLOGY. 
 
 at certain seasons, especially in the semester of March 
 to September. Examining, from this point of view, 
 the statistics of 32,000 patients passed through the 
 Inflrmerie du Depot at Paris, Planes found that the 
 iiuinber of insane constantly increased from January 
 to June. After June a decrease was observed with 
 almost or quite the same regularity, and was followed 
 by a considerable increase in October. Legoyt and 
 Ogle obtained similar results. The latter, among 
 42,030 suicides in England and "Wales, found the 
 minimum in December and the maximum in June. 
 The order of importance of the trimesters is, accord- 
 ing to Planes : the second, the third, the first, the 
 fourth. The maximum does not correspond, as is 
 generally believed, with the heats of summer, but 
 with the effervescence of spring. 
 
 The ancients and, in more recent times, Esquirol, 
 attached a certain importance to the influence of the 
 seasons, not only on the development but also on the 
 course of insanity: this or that attack should pass off 
 at such a time ; if is was passed without recovery the 
 prognosis became more serious. As to the influence 
 of the lunar phases, formerly regarded as so import- 
 ant that in some countries it gave a name to the in- 
 sane individual (lunatic), it is hardly admitted at the 
 present time. It appears, nevertheless, that it may 
 have some effect on the return of the attack in inter- 
 mittent insanity, and especially in circular insanity. 
 
 Civil Condition. — All statistics are in accord in 
 recognizing that insanity is more common amongst 
 
ETIOLOGY. 43 
 
 celibates than amongst married individuals. The 
 fact is usually explained by saying that the condition 
 of celibacy favors irregularities of living and deprives 
 the individual of moral support. It would perhaps 
 be more correct to say that the same cause that pro- 
 duced insanity was also responsible for the celibacy. 
 It appears, in fact, that those predisposed to insanity 
 are, by reason of their special temperament, often led 
 to put off marriage and lead a solitary and egoistic 
 existence. It is also to be remarked here that by a 
 sort of attraction, frequently unconscious, the predis- 
 posed to insanity have a tendency to seek out alliances 
 amongst themselves. Finally it is proper to say that 
 the condition of widowhood has a positive influence 
 on tlie development of insanity. 
 
 Professions. — In all countries, but in England 
 especially, soldiers and sailors occupy the first place, as 
 regards numbers, in the statistics of mental alienation. 
 General paralysis is especially frequent amongst 
 thena. Certain forms of epidemic insanity, such as 
 nostalgia, suicidal impulse, are not infrequently met 
 with in the ranks of the army. 
 
 In the liberal professions, lawyers, ecclesiastics, 
 physicians, writers, and artists appear to pay the 
 largesttribute to insanity. According to a rather wide- 
 spread notion, alienists and all others who live with 
 the insane will have a tendency to lose their reason, 
 from the effect of contiguity. This is, it is needless 
 to say, a popular error, since contact with the in- 
 
44 GENERAL PATHOLOGY. 
 
 sane can have no effect except upon those already 
 predisposed. 
 
 In the manual professions those most exposed to 
 become insane are such as work in toxic or dangerous 
 substances, and in particular alcohol, and those who 
 are exposed to intense heat, such as firemen, engineers, 
 cooks, employes in manufactories, etc. 
 
 Education. — A vicious education, too rigid or 
 too lax, as well as too rapid and precocious, may 
 give rise in the child to tendencies to insanity, or, 
 what is more common, develop tendencies already 
 existing. The education therefore of those predis- 
 posed to insajiity and the children of the insane 
 require special care and regulation. 
 
 Occasional Causes. 
 
 1. Moral Causes. 
 
 Passions. Emotions. Imitation. — The action 
 of occasional .causes, moral and physical, on tlie 
 development of insanity is undeniable, but it ought 
 not to be overestimated, and it is well to know that 
 without an already existing predisposition, without 
 the conjunction of the seed and the soil, in the words 
 tif M. Ball, this action would be inefficacious. 
 
 Among the occasional causes, the moral causes 
 take the first place, and among these the passions 
 and the emotions, which really include all. The 
 depressive emotions have a much more powerful 
 
BT^IOIiOGT. 45 
 
 action than their opposites. Those that have the 
 most effect are the violent emotions, terror, the moral 
 shock due to criminal assault, the impression made by 
 the lirst conjugal relations (post-connubial insanity), 
 the loss of a beloved wife, disappointment in love, 
 the mental preoccupations due to povei-ty, strange 
 "mystic emotions, but, before all, domestic troubles 
 and business reverses. However sudden and un- 
 expected the action of these causes may be, it is 
 very rarely that the insanity manifests itself im- 
 mediately, as is wrongly supposed by the public, at 
 least in its full intensity. 
 
 As to imitation, it may have a certain action on 
 weak mental organizations always ready for any 
 occasional cause. This action may affect at the same 
 time a large number, as in the famous epidemics of 
 insanity in the middle ages, and, as happens at 
 present, from the influence of the recitals of certain 
 crimes and suicides in the press ; at other times it 
 acts within narrow limits, the intimate relations of 
 the family and the home {folie d deux, suicide d 
 deux). 
 
 Solitary Confinbmbnt. — As has been said by 
 Lelut, the greater frequence of insanity in a crim- 
 inal and convict population is a fact as well known 
 to science as to the law. But if it be correct to say 
 that imprisonment, and solitary confinement more 
 particularly, have a certain influence on the mental 
 condition of the prisoners, it is necessary to recog- 
 
46 GENEEAIi PATHOLOGT. 
 
 nize also the fact that the true cause of prison 
 insanity is not in the prison but in the prisoners, who 
 are often lunatics or on the point of becoming such 
 at the time of their condemnation, and who, more- 
 over, are frequently recruited among the semi- 
 imbecile, the perverse and ill-balanced. M. Semal, 
 of Mons, who has made a minute inquiry in regard 
 to 905,000 accused and convicted persons in Belgium, 
 (Congress of Paris, 1889), has likewise shown that 
 individual predispositions, heredity in particular, con- 
 stitute the principal factors of insanity among 
 prisoners. As to the occasional causes, they rank 
 in the following order: 1, Insufficient food; 2, 
 solitary confinement ; 3, onanism; 4, loss of freedom, 
 sedentary life; 5, various moral influences. The 
 atmosphere of the prison has, he claims, an evident 
 action on the evolution, and more particularly on 
 the form of the mental disorder. The frequency of 
 hallucinations of hearing, notably in those confined 
 by themselves, is an undeniable proof of this. 
 
 3. Phtsical Causes. 
 
 a. — Local Causes. 
 
 1. Direct. — Injuries of the head may be the 
 starting point of insanity, and even, it is said, of 
 general paralysis. The same is true of diseases of the 
 bones of the cranium, cerebral tumors, erysipelas of the 
 scalp, and especially inflammation of the middle or 
 inner ear. Insolation also calls for special mention, 
 
ETIOLOGY. 47 
 
 among these causes, as in some countries it is a 
 frequent source of insanity. 
 
 2. Sympathetic. — Some local physical causes, 
 produce insanity by an action at a distance and by 
 aoiitrecoKp instead of directly, whence the terms 
 sympathetic insanity or insanity by oo?ise)i»us given 
 to the disorder they thus produce. The principal 
 ones of these causes are, the physiological and 
 pathological processes of the genital apparatus 
 (puberty, menstruation, menopause, pregnancy, 
 affections of the genitals), disease of the abdominal 
 viscera, the presence of worms in the intestines, etc. 
 The mechanism of the production of the insanity in 
 these cases seems often to be an auto-intoxication, 
 through excessive production or retention of poisons 
 of the system. 
 
 b. — Oeneral Causes. 
 
 Anjemia. Cachexia. Diatheses. Fbteks. — 
 Chlorosis and anaemia, by debilitating the organism 
 and the brain, favor the development of insanity. 
 Excessive seminal losses and onanism seem to act m 
 the same way. As to the diatheses, such as the 
 aithritic, dartrous, syphilitic, etc., they also have an 
 action in the development of insanhy, either as they 
 directly give rise to lesions in the brain, or as the 
 insanity supervenes during one of their acute phases, 
 or after the disappearance of one of their manifesta- 
 tions, cutaneous or otherwise, as if by a sort of 
 metastasis, or as the toxic effect of a nutrition 
 retai'dant. 
 
48 GENEEAi PATHOLOGY. 
 
 Among the fevers, typhoid and intermittent fevers 
 are more or less important producers of insanity. 
 This latter has also been observed to follow cholera 
 and la grippe. It is less rare to see it occur, either 
 during the course or the decline of certain acute 
 affections such as pneumonia, variola, erysipelas, etc. 
 
 c. — Physiological Oautes. 
 
 Puberty, menstruation, the climacteric, pregnancy, 
 confinement, lactation, etc., are very often accom- 
 panied with intellectual disturbances which, in some 
 cases, may end in insanity. This is usually ranked 
 among the sympathetic insanities. 
 
 d. — Specific Causes. 
 
 A certain number of toxic substances that have a 
 •decided action on the nervous system may give rise 
 to insanity. The more active of these substances, at 
 least in Europe, are alcohol, the ravages of which are 
 fearful in France, in the large cities of the north, 
 lead, opium, tobacco, haschisch, and lastly morphine 
 and cocaine which for some years have been the 
 fashionable poisons, especially amongst nervous 
 women, ataxics, and ill balanced individuals. 
 
 § III. PROGRESS. 
 
 Distinction of Insanity into Acute and 
 Chbonic. — Mental alienation, though a disorder of 
 slow evolution and usually chronic, may present it- 
 
PEOGKESS. 49 
 
 self under an acute or under a chronic form, properly- 
 so-called. 
 
 The mental alienations that we shall study later on 
 under the name of constitutional alienations, are 
 durable and permanent conditions. As to the insani- 
 ties or functional alienations, only one class, that of 
 the generalized insanities, can take on an acute form; 
 the second class, that of the systematized insanities, is 
 essentially chronic from the first. The distinction 
 of the insanities into acute and chronic is the more 
 important since the former only are curable ; whence 
 it follows, a priori^ that only the generalized in- 
 sanities are susceptible of bemg cured. 
 
 Beginning of Insanity. — Chronic insanity always 
 begins in a slow and progressive manner. As to 
 acute insanity, while it may in certain exceptional 
 cases break out suddenly, it much more commonly 
 appears by a series of gradual transitions. What- 
 ever may be its progress and final form, insanity is 
 generally preceded by a period of malaise or depress- 
 ion, more or less marked, which sometimes consti- 
 tutes a veritable stage of melancholia. 
 
 Passage to the Cheonic Condition. — The 
 acute insanities may pass, after a time, into the 
 chronic condition; dating from that instant they 
 cease to be curable. The precise moment when an 
 attack of mania or melancholia becomes chronic is 
 very hard to deteraiine, nevertheless, as a practical 
 matter, it is of the first importance. The absence 
 
 Mbnt. Mbd.— 4. 
 
60 gbnbeAl pathology. 
 
 of remissions of the disease, the persistence and 
 uniformity of the delusive ideas, the change from 
 acute excitement and melancholia into a sub-acute 
 condition, certain earthy or bronze colorations of the 
 skin, but more than all other signs, the return of 
 strength and increase of flesh, which contrasts with 
 the lack of improvement of the mental functions, 
 and seems to indicate that the body, ceasing to be 
 one with the mind, has now begun a life apart and 
 independent, such are the indicatipns that permit us 
 generally to decide almost to a certainty. 
 
 Different Types of Evolution of Insanity. — 
 Insanity may be continuous, as seen mostly in the 
 acute and curable attacks, or remittent or intermittent, 
 which is the usual type in the chronic, hereditary 
 and curable forms. The remittent type is the most 
 frequent one. 
 
 Remission. — A remission is an attenuation of the 
 symptoms of the disease. It may occur either in 
 the course of an attack, which takes on a special 
 character from this fact, or at the end of an attack, 
 as a signal of approaching recovery, or yet between 
 two attacks which it connects by a sort of pathologi- 
 cal transition. Remissions may be more or less pro- 
 nounced, but to whatever degree they attain, thej' 
 are only attenuation and not absolute cessation of 
 the symptoms, which continue to exist to the same 
 extent. It is this feature that differentiates remis- 
 sions from lucid intervals or recovery. 
 
bUteATION. 51 
 
 iNTEEiiissiONS. — An intermission is a complete 
 return to the normal condition occurring between 
 two attacks of insanity. Such insanities character- 
 ized by intermissions with regular returns of the 
 disorder are called intermittent. Of this kind are 
 intermittent mania, certain varieties of double form 
 insanity, etc. 
 
 Lucid Intervals. — A lucid interval is a tem- 
 jjorary and complete suspension of the symptoms of 
 insanity. It differs from a remission in tliat it is 
 not a simple attenuation but a complete disappear- 
 ance of the symptoms and from an intermission in 
 that it jnerely interrupts, like a momentary gleam, 
 the course of an attack. 
 
 All these peculiarities of tlie course of mental 
 disorders, and \\'hich have been well elucidated by 
 M. Doutrebente in a special memoir, have a consider- 
 able importance in a medico-legal point of view. 
 
 t; IV. DURATION. 
 
 Duration of Subacute Insanity, Transitory 
 Insanity. — Insanitj^ is a disease the evolution of 
 which is rarely rapid. It is only in a few particular 
 forms like acute delirium and transitory insanity that 
 its duration is limited to but a few days. Generally 
 it takes a more or less considerable period of time, 
 even in acute cases. 
 
 Duration op Acute Insanity. — It is very rarely 
 that a recent acute case of mania lasts less than one 
 
53 geneeaL pathology. 
 
 month ; and the same is the case with acute melan- 
 cholia. Ordinarily, the recoveiy takes place, if it 
 occurs at all, between the second and the eleventli 
 month. 
 
 DuKATioN OF Chronic Insanity. — The chronic 
 and incurable fornis of insanity are usually of very 
 long duration. Certain manias, and, more especially, 
 systematized insanities are, so to speak, interminable. 
 It is not uncommon to find, in asylums, old cases of 
 \'esania, constantly deluded, living thirty or forty 
 years, and even more. 
 
 S V. TEKMINATIONS.— COMPLICATIONS. 
 
 The three possible terminations of mental alienation 
 are reeo^'ery, incurability, and death. 
 
 Recoveky. — Recovery, which only occurs in 
 acute cases, may take place in several different ways : 
 (1) suddenly or instantaneously, which is not the 
 rule, and is most frequent in intermittent insanities 
 and hereditary forms; (2) by a series of gradual os- 
 cillations terminating in the return of reason ; (3) by 
 a gradual disappearance or diminution of the symp- 
 toms. These last two modes are rather frequent, and 
 generally satisfactory. 
 
 Incurability. — Incurability may exist from the 
 first, as in constitutional alienations, chronic general- 
 ized insanity, and systematized insanity, or secondary 
 
TEEMINATIOifS. . COMPLICATIONS. 53 
 
 or consecutive to the passage of acute insanity into 
 the chronic state, as has been already indicated. 
 
 Death. — Death is sometimes tlie consequence of 
 the mental disease itself, but tliis rarely occurs except 
 in some superacute insanities like acute delirium, and 
 in some other disorders, like general jjaralysis. More 
 frequently it is the result of a complication or in- 
 cidental disease. 
 
 Complications. Incidental Disorders. Crises. 
 — Generally speaking, the mortality of the insane is 
 higher than that of the population as a whole. An 
 equilibrium is, however, more nearly re-established if 
 we deduct from the number of the insane, the general 
 paralytics, inevitably doomed to die within a short 
 period. One very curious fact is the immunity, 
 sometimes very marked, that is enjoyed by the 
 chronic insane to atmospheric influences and acci- 
 dental endemic or epidemic diseases, and this in spite 
 of their frequent unconscious imprudences. Another 
 peculiarity, equally striking, is the good effect that 
 intercurrent disorders sometimes exert on the progress 
 of the insanity, acting in this as a sort of derivation. 
 This action, to which attention was called by 
 Esquirol, goes by the name of crisis, and he goes so 
 far as to say that there can be no effective cure of 
 insanity but in this way. Finally, it is well recog- 
 nized that, very often, intercurrent affections, and 
 organic diseases generally, take on in the insane 
 an oscillatory course, or even a latent form, so that 
 
54 GENERAL PATHOLOGY. 
 
 they may pass unperoeived and only be recognized 
 at the autopsy. The incidental disorders most com- 
 mon in the insane, apart from cerebral disorders, are 
 those of the respiratory apparatus, typhoid fever, 
 diarrhoea, disorders of menstruation, heart disease, 
 uterine disorders, etc. 
 
 § VI. PROGNOSIS. 
 
 The prognosis of insanity is one of the most im- 
 portant subjects of mental pathology. It is deduced 
 from the chai'acters of the disease and from certain 
 particulars in regard to the patient himself. 
 
 Prognosis prom the Character of the 
 Disease. — Out of all forms of mental alienation or 
 insanity only the generalized types, i. e. , mania and 
 melancholia, are curable. The systematized insanities 
 are essentially chronic, and recover only very excep- 
 tionally. A favorable prognosis is therefore limited 
 to the generalized insanities, which frequently recover. 
 Indeed, while we can count only about one cure to 
 every eight or nine cases of insanity taken at random, 
 this proportion changes to about one in three or even 
 more if we exclude the incurable forms. 
 
 In a general way, the more acute the generalized 
 insanity, the more favorable its prospects. Hence it 
 follows that, of all forms, acute mania and melan- 
 cholia are the most curable. It is claimed that in 
 acute mania there are at least seven recoveries out of 
 every ten cases, Of course it is understood, that the 
 
PROGNOSIS. 55 
 
 hyperacute insanities must be excluded in this state- 
 ment on account of febrile complications. 
 
 The less generalized and intense the mania or melan- 
 cholia, the less is their chance of recovery. The 
 more sudden the onset of the disorder and the quicker 
 it reaches its greatest height, the better are the 
 chances of recovery. And vice versa, the longer the 
 period of incubation and the more lingering the pro- 
 gress, the more serious are the prospects. 
 
 Further, if the condition of excitement or de- 
 pression remains stationary for a long period, the 
 chances of cure will not be as good, as when glimmer- 
 ings of reason and moments of calm occasionally 
 occur. Also the appearance of improved nutrition, 
 as already said, not coincident with a parallel im- 
 provement mentally, is a sign of bad augury. 
 Finally the existence of hallucinations, particularly 
 those of hearing, the creation of new words, the 
 adoption by the patient of a pathological language, 
 of a costume, of a special attitude, his tendency to 
 collect things, to fill his pockets, to deck himself 
 fantastically, are all indices of threatening incura- 
 bility. It is not necessary to mention at length the 
 disorders of menstruation, the menopause, and inter- 
 current diseases, whose action, although variable, 
 may influence, in some instances, the course of the 
 insanity. 
 
 The longer the disease continues it is evident it is 
 the less curable. The chances are best within the first 
 siif months, during the second half year they are 
 
56 GENEEAL PATHOLOGT. 
 
 twice as had ; in the second year the chances of cure 
 diminish to about one-sixth of the figure for the first 
 half year. After the fourth year they may be con- 
 sidered as almost nil, and the cases reported of more 
 or less delayed recoveries are altogether exceptional 
 and do not affect the nile. 
 
 The cause of the disease has also an influence on 
 the prognosis. In general a single and accidental 
 cause leaves good chances for recovery ; multiple and 
 permanent causes have an action directly opposite. 
 
 Peognosis Deduced peom the Patient Him- 
 self. — The age of a patient is not a matter of no 
 importance ; the younger he is, as a rule, the better 
 his chances. Sex has likevidse some influence : women, 
 indeed, recover more often than men, a fact due 
 largely to the rarity in them of general paralysis. 
 To make up for this, they are more often subject to 
 relapses. The cause, however, inherent to the 
 patient, which has the greatest influence on the 
 prognosis, is, without question, the absence or exist- 
 ence of predisposition or heredity. Not that the 
 subjects of heredity and the predisposed recover less 
 readily, but because that in them the cure is seldom 
 complete and permanent. 
 
 Relapses. — According to most authorities re- 
 lapses wUl occur in the proportion of 12 or 14 to the 
 100, and are especially frequent within the first year. 
 Apart from hereditaiy predisposition, relapses have 
 their origin in the return of the same causes that pro- 
 
PATHOLOGICAL ANATOJIT. 57 
 
 duced the original disease, morbidly intense emo- 
 tions, suffering, and, in needy patients, the diffienlly 
 of obtaining work after leaving the asylum. Usually 
 it is the same form of insanity as before and some- 
 times with the same characters. 
 
 §VII. PATHOLOGICAL ANATOMY. 
 
 Has insanity corresponding material lesions, or not? 
 In order to answer this, it is necessary to first settle 
 the limits of the question, and to exclude all the 
 pathological conditions, such as alcoholism, general 
 paralysis, neuroses, etc., into which insanity only 
 enters as a complication. 
 
 1. Pathological Anatomy of Mental Alien- 
 ation IN Gbnbeal. — There remains mental alien- 
 ation, properly speaking, comprising the consti- 
 tutional and the functional alienation. 
 
 The constitutional alienations, congenital or ac- 
 quired, i. e. idiocy, cretinism, imbecility, and demen- 
 tia, are usually accompanied by manifest material alter- 
 ations, affecting the whole person, but more especially 
 the cranium and the nervous centres. To cite only 
 the principal ones, we find, absence or weakness of 
 an organ or a sense, vicious conformation of the 
 cranium, facial asymmetry, flattening of the ears, 
 arched structure of the palatine vault, prognathism, 
 anomalies of the genital organs, impuberty and ab- 
 sence of hair, smallness of the brain, especially the 
 absence or diminution of certain regions or convolu- 
 
58 GENERAL PATHOLOGY. 
 
 tions, softening in places, etc., etc. Here material 
 lesions exist, frequently very gross ones. 
 
 Pathological Anatomy of Insanity. — The 
 question is harder to answer in regard to tbe func- 
 tional alienations or true insanities, and there are 
 very diverse opinions on this point. 
 
 a. — Acute Insanities. — It appears certain that in 
 the great majority of cases, the acute insanities leave 
 no traces. All the more may we suppose that ma- 
 niacal conditions, or those of excitement, correspond 
 to a hypersemia, and melancholic or depressed states 
 to an ischfemia of certain regions of the brain. 
 Yet these purely functional disorders usually 
 disappear at the autopsy, so that they cannot always 
 be verified. It is necessary also to remember that 
 in very many cases, cerebral hypersemia and isch- 
 semia, or congestion and anaamia, are insufficient to 
 produce insanity. We have therefore to admit that 
 lesions are lacking, and the case reported by Esquirol 
 is well known in which a patient in full tide of acute 
 mania was killed by another patient by blows with 
 a sabot, and the autopsy revealed no alteration. 
 
 Together with hypertemias and sanguine stases, 
 serous effusions are sometimes met with in acute in- 
 sanity. It has even been proposed to make cei-ebral 
 oedema the characteristic of one particular form of 
 mental disease, melancholia with stupor. We find 
 also occasionally minute haemorrhages, some men- 
 ingeal, some cortical. 
 
PATHOLOGICAL ANATOMY. 59 
 
 b. — Chronic Insanities. — If the results of autop- 
 sies of acute insanity are generally negative, the 
 case is different, at least usually, with chronic 
 insanity. 
 
 Frequently this disease leaves its imprint on the 
 exterior form of the brain. There is atrophy of some 
 regions, flattening of the convolutions, especially 
 anteriorly, lacunse, loss of substance and filling of 
 the space with a turbid liquid. We have noticed 
 also irregularity of the first and second frontal con- 
 volutions, hypertrophy of the paracentral lobe, 
 widening of the fissures, etc. The weight of the 
 brain is nearly always diminished, and, contrary to 
 the visual rule, the right hemisphere very often 
 weighs more than the left. 
 
 Among circulatory disturbances we may meet 
 with arterial atheroma, varicose condition and fatty 
 degeneration of the capillaries, vascular alterations of 
 the pia mater with injection of its network, minute 
 apoplexies, varicose condition of the vessels, milky 
 patches and thickening of the membranes, adhesions 
 of the meninges to each other and to the cortex, 
 hsematomas of the dura, etc. , etc. 
 
 Among cerebral lesions, properly so-called, we 
 find especially degenerations of the cells and nerve 
 fibres, sclerosis of the neuroglia and more or less 
 proliferation of the same, vascular alterations of the 
 opto-striate bodies, the pons, and the medulla, 
 softening or sclerosis of certain nerve nuclei, etc., 
 etc. 
 
60 GENERAL PATHOLOGY. 
 
 Chemically it is believed that the water in 
 the brain is increased in the insane, and that 
 fatty substances, on the other hand, are in less 
 proportion. As regards phosphorus, the results are 
 negative. 
 
Cbapter fllf. 
 
 SYMPTOMATIC ELEMENTS OP MENTAL 
 ALIENATION. 
 
 Before undertaking the description of the various 
 tonus of mental alienation, it is necessary to first 
 study its morbid elements. In order to do this satis- 
 factorilj', it must be borne in piind that insanity is not 
 merely an intellectual disorder, but a disease affecting 
 the whole being, and that consequently its constit- 
 uent elements may exist together or separately both 
 in the psychic and the somatic spheres. 
 
 Division of the Symptomatic Elements. — 
 Bearing in mind the above, the fundamental division of 
 the symptomatic elements of alienation seems to me 
 to be based on the fact that some affect only the 
 functions of the psycho-physique, while others in- 
 volve its constitution. Hence, two very distinct 
 groups of elements: (1) the functional or dynamic; 
 (3) the organic or constitutional elements. 
 
 §1. FUNCTIONAL ELEMENTS. 
 
 These elements resolve themselves into general 
 disturbances or those of the general activity, and 
 partial disturbances referable to the psychic and the 
 physical activities. 
 
63 ELEMENTS OP MENTAL ALIENATlOif. 
 
 1. DlBOBDERS OF GkNEKAI, ACTIVITY. 
 
 The general activity is the total of the systemic 
 reactions under the influence of psychic impressions. 
 It may be abnormal in two ways, either by excess or 
 by default. In the first case there is excitement, in 
 the second depression. 
 
 Excitement. — Excitement consists in the exalta- 
 tion of the general activity, or functional reaction. 
 When very intense and generalized, it reveals itself 
 in a disordered activity of the intelligence, sensa- 
 tions, and acts that is absolutely uncontrollable. If 
 less intense, it is limited to a simple exaggeration of 
 the normal activity, and then affects more particu- 
 lai'ly the psychic or the motor sphere. It is the 
 principal element of maniacal conditions, the \'arie- 
 ties of which derive their characters from its degree 
 of intensity and generalization. 
 
 Depbbs.sion. — Depression is the opposite condi- 
 tion to excitement. It consists in a defect of expan- 
 sion of the general activity, which ranges from sim- 
 ple concentration of the reaction of the organism to 
 its complete suppression. It then translates itself 
 externally by an absolute immobility or stupor. In 
 a minor degree it may affect more particularly cither 
 the psychic or the somatic sphere. Like excite- 
 ment it is characteristic of a special type of gen- 
 eralized insanity, the conditions of lypemania or 
 melancholia, 
 
fftJNCTlONAl EtBMEN'rS. 63 
 
 2. DiSOEDERS IN THE PsYCHIC SPHERE. 
 
 llie powerful elements of insanity in tlie psychic 
 sphere are: (1) of the intellect ; (3) of the emotions; 
 (3) of the motor impulses. 
 
 Disorders of the IntellectoaIj Type. 
 
 Of these we have to describe: «, delusive concep- 
 tions ; b, hallucinations ; c, illusions. 
 
 n. — Delvsive Coiiceptions. 
 
 A delusive conception, or what amounts to the 
 same thing, delirium, for delirium is nothing- else in 
 the individual than the sum total of his delirious 
 conceptions, is very difficult to define. If, in cer- 
 tain cases, the delusive ideas are absurd or impossi- 
 ble, in other very numerous ones they have noth- 
 ing in themselves absurd or incompatible with the 
 natural order of things ; they are only contrary to 
 fact, and irrational in the mouth of the person utter- 
 ing tliem. A man believes he has been changed into 
 butter, it is a delusive conception and also an 
 absurdity; another believes himself dishonored, 
 ruined, condemned ; this is an idea that involves no 
 impossibility, and is only delusive in respect to him 
 who believes it of himself. Leuret says truly: "I 
 have sought both in Charenton, in the BicStre, and 
 in the SalpStri^re, for the notions that appeared the 
 most insane ; then, when I have compared a number 
 of these with what actually occurs, I have been 
 
64 ELEMENTS OF MENTAL ALIENATION. 
 
 altogether surprised and almost ashamed at not per- 
 ceiving the difference." 
 
 Delusive conceptions are not only difficult to define 
 because they are far from being alvi^ays absurd in 
 themselves, but also bec.iuse it is not always easy 
 to distinguish them from error. The difference 
 docs not consist, as has been claimed, in that the delu- 
 sive idea is not changed in spite of the accumulation 
 of the most absolute proofs of its falsity. There are 
 errors, indeed, that are held more tenaciously, per- 
 haps, than delusions. The truth is, that there is 
 not, properly speaking, any essential difference 
 between the two, and that the delusion is separated 
 from mere error only by its causes and consequences, 
 which give it a pathological character never possessed 
 by the other. 
 
 Delusive conceptions, and consequently the various 
 delusions, are as numerous as there are modes of 
 manifestation of human thought. Nevei-theless the 
 principal categories of delusions met with in insanity 
 are the following (Ball and Ritti) : 
 . (1.) Delusions of satisfaction, of grandeur, of 
 riches. 
 
 (2.) Delusions of humility, despair, ruin, culpa- 
 bility. 
 
 (3.) Delusions of persecution. 
 
 (4.) Hypochondriacal delusions. 
 
 (5.) Religious delusions. 
 
 (6.) Erotic delusions. 
 
 (7.) Delusions of bodily transfonnatlon. 
 
PTTN'CTION'AL BLEMENTS. 65 
 
 The delusive idea, being only a symptomatic 
 element of insanity cannot constitute it alone, and 
 enters, only as a part, in its constitution. There 
 are forms of insanity without delusions, such, for 
 example, as those that have been called reasoning 
 mania and unpulsive insanity. 
 
 b. — HallueinatioiM. 
 
 Definition. — "A man," says Esquirol, "who has 
 a profound conviction of actually perceiving a sensa- 
 tion, when there is no external object to excite that 
 sensation and it is not brought through any of his 
 organs of sense, is in a state of hallucination." M. 
 Ball abridges this definition by saying : " A hallucin- 
 ation is a sensation without an object." Thus an 
 individual who hears voices when no sound strikes 
 his ear has a halluoiaation. We may say also that 
 an hallucination is an idea projected externally, an 
 exteriorized perception. 
 
 Division. — Hallucinations are designated accord- 
 ing to the nature of the sensation perceived ; there 
 are therefore as many varieties of hallucinations as 
 there are senses. In case of those senses that have 
 a double and symmetrical organ, like hearing, sight, 
 tact, the hallucinations may afFeot only the organ of 
 one side ; it is then unilateral. When, being double, 
 the hallucination takes a different character in each 
 of the two sides, it may then, it seems to us, be 
 properly called duplicated, 
 
 Meht. Mbd.— 6. 
 
66 BLEMENTS OF MENTAX ALIENATION. 
 
 There are hallucinations involving no particular 
 sense organs, such cases, for example, as those in 
 which the patients say that they converse soul to 
 soul, without language of any sort. Such hallucina- 
 tions in which the sensorial element is lacking have 
 been designated by M. Baillarger, "psychic hallu- 
 cinations," and byM. S6glas, " psycho-motor hallu- 
 cinations. 
 
 Nature. — The nature of hallucinations is not yet 
 very well known. There are three theories : (1) 
 the psychic theory, which makes them purely 
 intellectual, the revival of an idea ; (2) the physical 
 theory that makes them a purely physical and organic 
 phenomenon ; and (3) the mixed, or psycho-sensorial 
 theory, which admits in their production at once a 
 sensory and a psychic element. It is the last of these 
 that counts the most supporters. 
 
 The intervention of a physical element in the 
 genesis of hallucinations is made beyond a doubt by 
 the finding of various lesions in the sensory organs 
 involved, in their nei-ves, in the thalami and the 
 corpora striata, in sensory centres in the cortex ; by 
 the alteration, in unilateral hallucinations, of the 
 peripheral or central portion of the sense organ of 
 the affected side; and finally by experiments with 
 provoked hallucinations in hysterical oases. 
 
 There is a constantly increasing tendency, at pres- 
 ent, to locate the seat of hallucinations in the per- 
 ceptive centres of the cerebral cortex. This is the 
 view held by Tamburini, by Per6 and Binet, by 
 
I'UNCTIONAl ELEMENTS. 67 
 
 Ballet, and by Seglas, who, in a recent memoir, 
 divides hallucinations into psycho-sensorial and psy- 
 cho-motor (verbal, visual and auditory), according 
 as the sensory or the motor centres of the cortex are 
 involved. A Russian physician, Dr. Kandinsky, who 
 suffered from an attack of lypemania, analyzed in 
 himself the mechanism of hallucinations, and also 
 attributes them, conformably to Meynert's theory, 
 to a subjective or automatic stimulation of the cor- 
 tex of the anterior lobes of the brain. 
 
 Hallucinations without Insanity. — Like de- 
 lusions, hallucinations are only symptomatic elements 
 of insanity, and do not, by themselves alone, consti- 
 tute it. Moreover, hallucinations may, in some cases, 
 exist without insanity, and sane persons are subject, 
 especially at the moments of passage between sleep- 
 ing and waking, to hallucinations which they appre- 
 ciate very sanely (hypnagogic hallucinations). 
 Nevertheless these phenomena have been incorrectly 
 called physiological hallucinations. A hallucination 
 is always a morbid phenomenon ; it is only its inter- 
 pretation that can be either physiological or patho- 
 logical. 
 
 Hallucinations occur in many forms of insanity, 
 and it is not possible to separate a special type under 
 the name of hallucinatory insanity. They are especi- 
 ally frequent in melancholia, persecutory insanity, 
 toxic insanities, etc. 
 
 Hallucinations of Heaeing. — Auditoiy hallu- 
 cinations are most frequently met with in insanity. 
 
68 BLEMBNTB OF MENTAI. ALIBNATIOW. 
 
 They are a grave symptom, and may serve as a 
 criterion to distinguish, in a general way, the dan- 
 gerous lunatics. Every subject of auditory hallu- 
 cinations is, it may be said, an essentially dangerous 
 patient. They are frequently met with in melan- 
 cholia, but are most frequent in insanity with delu- 
 sions of persecution, in which form they are the 
 characteristic symptom. 
 
 An auditory hallucination consists essentially in the 
 perception of fictitious sounds. These may be con- 
 fused and inarticulate ; but they rarely continue thus ; 
 after lasting a short time the hallucination organizes 
 itself, becomes articulate, and, to use the common 
 expression of the patients, it becomes a voice. 
 
 These voices may be unknown to the patients as 
 to sound and intonation, but are frequently recog- 
 nized by them as belonging to their parents, friends, 
 or such and such a person as they designate. They 
 may also belong to imaginary persons, to the defunct, 
 to God, the devil, the Virgin, the saints, etc. 
 Animals and inanimate objects even are charged 
 with conversing by patients. 
 
 The voices may say pleasant things to the patients, 
 but more often the hallucinations have a distressing 
 character, and consist in insults, reproaches, men- 
 aces, accusations, etc. Many patients, those with 
 delusions of persecution more especially, complain 
 that they have their thoughts repeated aloud, and 
 mostly those they most desire to hide, and also 
 that the most secret acts of their life are told. 
 
FUNCTIONAL ELEMENTS. 69 
 
 This phenomenon bears the name of echo of 
 thought. 
 
 The direction of the voices is very variable. They 
 may come from above or below, from one side or the 
 other, from before or behind, and even from the 
 patient's body itself. In the last case they have 
 sometimes the effect finally to give rise in the patient's 
 mind to the idea that he is double, and thus originate 
 that cui-ious condition known as duplication of the 
 ])ersonality. The distance from whence they come 
 is also variable, and the hallucinated individuals ai-e 
 quite certain as to their distance, they estimate it 
 sometimes as a metre or two, sometimes hundreds of 
 kOometres. 
 
 The voices are so natural and the conviction 
 of their existence is so irresistible, that very intelli- 
 gent patients, physicians and alienists themselves, 
 will not suffer a doubt, and have recourse, in explain- 
 ing their existence, to all kinds of absurd and incredi- 
 ble interpretations ; for example, to the intervention 
 of various forces, electricity, acoustic tubes, the 
 telephone, phonograph, etc., etc. 
 
 The language of the voices is usually the ordinary 
 one, and the words those of the current vocabulary. 
 Nevertheless they may be in a foreign or unknown 
 tongue. The well-known case reported by Esquirol 
 is in point, of an insane polyglot who heard them 
 speak ra.any languages, but become confused when 
 they used, one with which he was little acquainted. 
 Ball has reported an analogous case. Finally the 
 
70 ELEMENTS OF MENTAL ALIENATION. 
 
 voices may manufacture words, pronounce neolog- 
 isms, which then pass into the speech of the patient, 
 constituting gradually a new vocabulary. This is 
 then a sign of ehronicity. Hallucinations of hear- 
 ing are often connected with other hallucinations. 
 
 The actively hallucinated patients, those who are 
 always conversing with their voices, often have a 
 peculiar physiognomy that is recognizable after some 
 experience. The characteristic is the brightness of 
 the eyes, wide open, fixed and brilliant, which can be 
 best compared to the appearance of a man absorbed 
 in thought who sees without taking notice. More- 
 over in following these patients one remarks that 
 they are talking with imaginary personages. Thus 
 they laugh at what they hear or reply to the voices, 
 either aloud in more or less broken exclamations, or 
 silently by simply moving their lips. Finally they 
 ai-e liable to do sudden, violent or dangerous actions 
 caused by their hallucinations. 
 
 In closing the subject of auditory hallucinations, 
 it is well to add that deafness is no obstacle to their 
 production. On the contrary nearly all the insane 
 who are deaf or hard of hearing, have auditory 
 hallucinations. It may be the same with the other 
 senses. 
 
 Hallucinations of Sight. — Visual hallucinations, 
 less common than those of hearing, present analogous 
 characters and hardly differ in that they constitute 
 a less serious symptom, and that they are character- 
 istic of certain special forms of insanity, such as the 
 
FUNCTIONAL ELEMENTS. 71 
 
 toxic and neuropathic forms. Hallucinations of 
 sight may consist in visions of persons and objects of 
 the most varied character, landscapes, animals, 
 phantoms, monsters, etc. They take on, in certain 
 cases, a terrifying character. 
 
 Hallucinations of Smell and Taste. — The 
 hallucinations of smell and taste are the most in- 
 frequent of all. They are met with especially in 
 certain forms of melancholia, in hypochondria, some- 
 times also in the insanity of persecution ; they fre- 
 quently co-exist with a saburral condition of the 
 digestive tracts, and ordinarily carry with them 
 refusal of food. The patients may experience strange 
 odors and tastes, such especially as those of arsenic, 
 copper, sulphur, ammonia, rotten eggs, etc. Some- 
 times they fancy that they themselves give out 
 frightful odors and condemn themselves under the 
 influence of this idea to live alone apart from 
 society. 
 
 Hallucinations of General Sensibility. Gen- 
 ital Hallucinations. — Hallucinations of general 
 sensibility are rather frequent in insanity, especially 
 with delusions of persecution. They consist in the 
 sensation of shocks, electric commotions, of being- 
 lifted in the air, which the patients interpret accord- 
 ing to their delusions. We may denominate certain 
 hallucinations genital which cause all kinds of 
 voluptuous or painful sensations in the genital 
 organs. 
 
73 ELEMENTS OF MENTAL ALIENATION. 
 
 c. — Illusions. 
 
 Definition. — Illusion is a morbid phenomenon 
 rather common in insanity. It is not, like hallucina- 
 tions, a perception without an object, but is an 
 erroneous perception; it is, if a closer definition is 
 required, the false interpretation of a perceived 
 sensation. As has been stated, a person who hears a 
 voice when none strikes his ear has an hallucination. 
 If he hears the sound of a bell, for example, but 
 fancies that it is an insult that is addressed to him, 
 he has an illusion. Las^gue has very aptly pointed 
 out this distinction between an illusion and a halluci- 
 nation, in the following : An illusion is to a 
 hallucination what innuendo is to calumny. The 
 illusion is based on a truth which is embellished, the 
 hallucination is a pure invention, there is no truth 
 in it. 
 
 Chaeaotees. Division. — An illusion, still more 
 than a hallucination, is a psychic phenomenon, since 
 in it the sensory perceptions are altogether normal 
 and it is only the intelligence that is in fault. As 
 has been well said by M. Descourtis, in a memoir 
 yet unpublished (Civrieux Prize, 1889, Hallucina- 
 tions of Searing), illusions are not errors of the 
 senses ; they simply constitute a form of delusion . 
 
 As regards prognosis, illusion is not so grave a 
 symptom as hallucination. It is very common in the 
 curable forms of insanity, especially in acute mania 
 and intoxications. 
 
FUNCTIONAL ELEMENTS. 73 
 
 Illusions, like hallucinations, are classed according 
 to the special senses whicli are the point of departure 
 of the phenomenon. Unlike hallucinations, illusions 
 of sight are altogether the most frequent. They 
 may be also unilateral. 
 
 IxTEEXAL Illusions. — There is a special class of 
 illusions which cannot be properly referred to any of 
 the special sensex, and which are known by the name 
 of internal or coensesthetic illusions. Thej' consist 
 in false interpretations of actual organic sensations. 
 Thus, very frequently, affections of the intestines, 
 the stomach, or the uterus, induce in patients, by the 
 reactions they cause, ideas that they have animals 
 in their bellies, that they have been violated, etc., 
 etc. These internal illusions are especially frequent 
 in the so-called sympathetic insanities. 
 
 Mental Illusions. — Another class of non-sensory 
 illusions, very frequent in acute mania, is made up 
 of illusions of persons, objects, surroundings, some- 
 times awakened by some vague resemblance, but 
 more often by a simple association of ideas. These 
 are purely mental illusions. 
 
 Scientifically, illusions are not clearly separated 
 from hallucinations, and it is sometimes difficult Co 
 class the morbid phenomenon under one or the other 
 of these. Clinically, however, the distinction is a 
 necessary one and should be preserved. 
 
 There are other intellectual phenomena, such, for 
 example, as the disorders of memory, of attention, of 
 
74 BLBMBNTS OF MBNTAl AlIBNATION. 
 
 the will, etc. , that are very common in insanity, but 
 these are not primary elements, they are complex 
 phenomena, more often consecutive, and their 
 description belongs more properly in works on 
 psychology. They have been learnedly discussed 
 by Theodore Ribot in his remarkable monographs. 
 
 DiSOEDBKS OP THE EMOTIONS. 
 
 Disorders in the sphere of the emotions are, so to 
 speak, constant in mental disease and constitute a 
 true moral insanity, corresponding ynih the in- 
 tellectual disorder. 
 
 The insanity of the feelings and affections is not 
 of itself more necessarily absurd than is that of ideas ; 
 its pathological character is derived entirely from the 
 fact that it is not in accordance with the actual 
 situation of the individual. There are as many in- 
 sane types of feeling as there are modes of activity 
 in the emotional nature of man. The principal aberra- 
 tions met with, of this kind, in insanity are, apart 
 from disorders of affections, strictly speaking, which 
 are almost constantly encountered : 
 
 1. Egoism, which is often the fundamental 
 character of the insanity. 
 
 2. Pride, which is observed especially in ambi- 
 tious insanity. 
 
 3. Malice, knavery, deceitfulness andi falsity , in 
 reasoning mania. 
 
 4. Mebelliousness, hatred and revenge, in delu- 
 sions of persecution. 
 
FUNCTIONAL ELEMENTS. 75 
 
 5. Generosity, philanthropy a-ndi prodigality, in 
 general paralysis with expansive delusions. 
 
 6. Discouragement, weakness, in intellectual 
 and moral hypochondria. 
 
 7. Humility, contrition, apprehensiveness, terror, 
 in melancholia and its various forms. 
 
 8. Aivxiety, also in melancholia and in emotional 
 neurasthenias. 
 
 The disordered feelings, which in their total form 
 moral insanity, give to patients in each form of 
 mental disease, a special character, that is too often 
 overlooked in giving attention to the intellectual 
 disturbances. There are certain forms, reasoning- 
 mania for example, in which the moral insanity 
 alone exists, without any marked involvement of the 
 intellect. 
 
 Motor Disokdebs. 
 
 In the psycho-motor sphere we have to do with 
 disorders of the instincts and those of acts. 
 
 a. — Initinttme Insanity. 
 
 The different instincts often undergo changes in 
 insanity, analogous to those of the intellect and the 
 emotions. 
 
 These changes are extremely various. The most 
 common are those involving the sexual instinct, and 
 show themselves by all kinds of sexual depravity, 
 such as sodomy, saphism, bestiality, voluntary 
 mutilations, reversed sexual instinct (contrdre 
 sexual Empfindung^ ; violations of cadavers, etc. 
 
76 ELEMENTS OF MENTAL ALIENATION. 
 
 The instinct of self-preservation is likewise fre- 
 quently impaired in insanity, and there are, it is well 
 known, some patients who, without having a jiositive 
 tendency to suicide, would not make a movement to 
 protect themselves from imminent death. Sxich cases 
 were recently obsei-ved in the burning of the asylum 
 at Montreal in Canada (May 5, 1890). 
 
 b. — Insanity of Acts. 
 
 In the same way that disordered intellection and 
 emotions constitute intellectual and emotional 
 insanities, propei'ly speaking, so disordered action in 
 mental alienation constitutes the insanity of acts 
 {delire des acted). 
 
 Among insane actions there are some that are 
 absurd in themselves, others are wot per se illogical, 
 and are only so in that they do not fit the actual con- 
 dition of the actor. All possible acts may therefore 
 become morbid in special cases, so that insane acts 
 are innumerable. 
 
 Those most frequently seen in insanity are : 
 
 1. Acts of impoliteness or impropriety, obscene 
 exhibitions, tendencies to eat filth and excrements 
 (skatophagia), which are met with especially in 
 demented conditions. 
 
 3. Acts of violence, destiuctiveness, of sudden 
 and blind fury, most special to maniacal conditions 
 and epilepsy. 
 
 3. Refusal of food, suicide, almost peculiar to 
 melancholia. 
 
FTJNCTIONAL BLEMBNTS. 77 
 
 4. Homicide, especially frequent with delusions 
 of persecution, epilepsy, etc. 
 
 5. Theft, incendiarism, in states of dementia, 
 imbecile furor, epilepsy, etc. 
 
 As regards consequences, morbid acts resolve 
 themselves into dangerous and non-dangerous. 
 
 As regards their nature they are distinguishable 
 into reflex acts and irresistible or impulsive actions. 
 
 Impulsions. — A morbid impulse is an irresistible 
 tendency to perform an action. 
 
 In the normal condition every sensation tends to 
 translate itself with an action, but this tendency is 
 restrained by the ego, which intervenes, perceives 
 the sensation, analyzes it, and finally decides for or 
 against the accomplishment of the act. The 
 equilibrium between the tendency to the act and the 
 restraining power of the ego (determinism), consti- 
 tutes the normal condition in this point of view. 
 The impulse results from a rupture of this equilibrium. 
 
 The equilibrium being lost, either by weakness of 
 of the ego, or by an increase of the tendency to re- 
 flex action, or by both together, it follows that 
 the impulse may be the consequence of one or 
 other of these conditions, hence it occurs in those 
 forms of alienation in which it is observed. Practi- 
 cally, it is especially in the emotional neurasthenia, 
 the degenerative conditions, imbecility, dementia, 
 (enfeeblement of the ego'), acute mania, hallucinatory 
 insanities (exaggerated reflex tendency), and, finally, 
 in epilepsy,^ (mixed state), that we meet with impul- 
 
78 ELEMENTS OF MENTAL ALIENATION. 
 
 sions. Impulsions divide into besetting impulses (ob- 
 sessions) and reflex impulses (impulsions, properly 
 socalled), according as they act with or without resist- 
 ance on the part of the individual. They may also 
 be divided into mtellectual, emotional, or motor im- 
 pulsions, according to the sphere afi'ected. 
 
 Motor impulsions, which are those generally re- 
 ferred to in the clinique when we speak of impulsions, 
 are, further, designated by the morbid acts to which 
 they give rise. Thus we speak of impulsion to theft 
 (kleptomania), to incendiarism (pyromania) , to drink 
 (dipsomania), to murder, suicide, etc., etc. At one 
 time there was a tendency to consider each foim of 
 impulsion as an insanity, a special monomania; now- 
 a-days that is completely abandoned, and it is gener- 
 ally admitted that morbid impulse is only a symp- 
 tomatic element of insanity, that may occur under 
 different characters, in widely differing conditions. 
 
 3. — Phtbical Disoedbrs.* 
 
 The symptomatic elements of insanity in the 
 physical sphere may involve the nervous functions 
 and those of vegetative life. 
 
 DiSORDEBS OP THE NbRVOUS FUNCTIONS. 
 
 The principal disorders of the nervous functions 
 are those that affect sleep, sensibility and motility. 
 
 *In the preparation of this part of the chapter, much 
 abridged In the first edition, I have utilized with especial 
 profit the excellent jJ/anMa J tfe Semeiologie Psyehiatrique of 
 Prof. Morselli of Turin, 1885. 
 
FUNCTIONAL BLBMENT8. 79 
 
 a. — Sle&p. 
 
 Sleep is one of the functions most constantly 
 affected in insanity. In acute attacks, insomnia is 
 one of the first symptoms to appear ; it reveals itself 
 particularly in agitation, dreams and nightmares. 
 On the other hand, the return of sleep, at the end of 
 an attack of mania or melancholia, is an excellent 
 augury, and can pass for one of the most certain 
 indices of approaching recovery, except always in 
 those cases where this return, in connection with the 
 re-establishment of the processes of assimilation, 
 does not coincide with a parallel improvement of the 
 mental condition. Insomnia is infrequent in chronic 
 insanity, excepting in patients with hallucinations or 
 ooensesthetic illusions. 
 
 The power of endurance of insomnia of the insane 
 sometimes attains a surprising degree. We see them 
 pass whole weeks without sleep whatever means are 
 employed to produce it. This absolute and complete 
 loss of sleep, which may depend upon a loss of the 
 sense of fatigue, is generally a bad prognostic, since 
 it is due to a profound alteration of the nervous 
 centres. 
 
 The question arises whether the insane have 
 dreams connected with their disorder. This, in 
 itself probable, has been put beyond doubt by 
 many observers. 
 
 Dreams have, moreover, very direct relations 
 with insanity. Besides the hypnagogic hallucina- 
 tions, already mentioned, occurring in the semi-wak- 
 
80 ELEME]<rTS OF MENTAL ALIENATION. 
 
 ing condftion, it is well known that both dreams 
 and insanity take their source in the involuntary or 
 automatic exercise of the cerebral functions. It has 
 been demonstrated further that the delusions of in- 
 sanity may follow the images of the dreams in such 
 a way as to be at once their psychological and 
 and chronologic continuations (Lasfegue, Ghaslin). 
 Finally there are obseiwations that tend to show 
 that dreams may sometimes be a precursory sign and 
 reveal more or less in advance a coming disease, 
 such as a neurosis or mental alienation. 
 
 b.- 
 
 The disorders of sensibility, by their importance 
 and frequency, play a very important part in mental 
 disease. We may divide them, for convenience of 
 study, into disorders of special sensation (external 
 sensations) , and those of organic sensibility (internal 
 sensations) . 
 
 Special Sensation (external sensation). — The 
 cutaneous sensibility may exhibit notable alteration 
 in the insane. There is notwithstanding an important 
 distinction to be made here. It is not usually the 
 tactile sensibility, strictly speaking, that is modified, 
 that which gives us notions of form, direction, con- 
 sistence, position, and resistance of objects, that is 
 commonly intact. What is impaired is the sensibility 
 to physical agents, heat, pain, electricity, etc. These 
 various sensibilities, which probably have their own 
 special conductors, and whose alteration seems to be 
 
FtlNCTIONAL ELEMENTS. 81 
 
 located in the cerebral cortex, may be simultaneously 
 or singly affected. 
 
 Cutaneous hypersesthesia is rarer in insanitj"^ tban 
 anesthesia. It may be encountered, nevertheless, in 
 mania, and in toxic insanities, where it is often 
 limited to certain parts of the body, but before all in 
 the systematized insanities, where it often becomes 
 the point of departure of tegumentary hallucinations 
 that are designated under the name of disorders of 
 general sensibility. 
 
 Anaesthesia, much more common, may be general 
 or local, slight or pronounced. In the latter case 
 there is almost complete insensibility of the whole 
 external surface, as in certain forms of stupor. It 
 may involve the tactile sensibility, but it is difficult 
 to estimate it accurately in the insane, on account of 
 the retardation of sensation which seems to be rather 
 frequent in them. Ziehen has observed, in general 
 paralytics, a lesion of memory of sensations, on 
 account of which they cannot, after a few seconds, 
 localize correctly any more the prick of a pin. This 
 symptom, which, according to that authority, often 
 is present from the beginning of the disorder, may 
 be, in some cases, useful for diagnostic purposes. 
 The more ordinary anaesthesia in the insane is that to 
 temperature and pain (analgesia) . Nothing is more 
 surprising than the ease, one might say the indiffer- 
 ence, with which the majority of the insane endure 
 excessive cold, heat, burns, wounds, operations of all 
 kinds; it seems as if they felt nothing. This 
 
 Mbmt. Mbd.— 6. 
 
82 ELEStBN'TS OT" MfiNT^AL AttENAtlON. 
 
 explains, at least in part, their desire to unclothe 
 themselves, the resistance they oppose to diseases a 
 frigore, and the stoicism they occasionally exhibit 
 in the most frightful sufferings. In some the 
 susceptibility to cold, which disappeared at the onset 
 of the insanity, reappears at the moment of recovery. 
 We encounter angesthesia more especially in torpid 
 melancholia, depressive general paralysis, the toxic 
 insanities, the degenerations and conditions of mental 
 weakness. 
 
 There are but few accurate data in regard to the 
 electrical sensibility of the insane. It is known, 
 however, that it may be increased or diminished, 
 and that its alterations go most ii'e({\i.e!\t\j pari pasm 
 with the tactile sensibility. In some oases, never- 
 theless, we find electrical hyperalgesia or, more often, 
 analgesia without any corresponding modification of 
 the local cutaneous sensibility. M. Seglas has re- 
 cently observed, as a special symptom of lypemania, 
 an increase of electrical resistance, that sometimes 
 attains a high figure (70,000 ohms). This resist- 
 ance is more marked in the stuporous than in the 
 anxious form. 
 
 The magnetic sensibility (action of magnets) has 
 been found exaggerated, as is well known, in hys- 
 teria, and, in a general way, in the neuropathies. 
 In the insane, it seems proven that it is generally 
 augmented, especially in melancholia. The same is 
 the case with the metallic sensibility (metalloscopy). 
 
 The meteoric sensibility (action of cosmic and 
 
t'UNC'TlONAL ELEMENTS. 83 
 
 telluric variations) , which is very marked in the neu- 
 ropathies, is still more so amongst the insane, mainly 
 as regards the return of periodic attacks, and in 
 epilepsy. 
 
 The special senses, independently of hallucinations 
 and illusions already described, may undergo more 
 or less pronounced changes in insanity. 
 
 The gustatorj^ sense may be increased (hyper- 
 geusia) , diminished (hypogeusia) , or abolished (ageu- 
 sia), principally in neuropathic and toxic insanity, 
 melancholia with sitiophobia, and the organic and 
 tabetic dementias. It may also be perverted (par- 
 ageusia) . This is what occurs in some melancholiacs 
 and many hallucinated cases, who profess, for 
 example, a great horror of meat and thus become 
 vegetarians. 
 
 The olfactory sense is likewise found exalted 
 (hyperosmia) , diminished (hyposmia), or abolished 
 (anosmia), in certain conditions of insanity, especially 
 in hysteria, localized cerebral disease, paralytic de- 
 mentia, systematized insanity, and, lastly, mania. 
 
 Not uncommonly the defect is localized in one 
 nostril (hemianosmia), for example, in the beginning 
 stage of general paralysis (Voisin). Finally, we en- 
 c(junter in nearly every form of insanity, perversions 
 of the sense of smell (paraosmia) which often form 
 the substratum of hallucinations and illusions of 
 this sense. 
 
 As regards the sense of hearing, we find in many 
 insane, either its exaltation (hyperacusia) , dimi,- 
 
84 ELEMENTS OF MENTAL ALIENATION. 
 
 nution (hypoacusia) or its perversion (paracusia). 
 Hysteria, ecstasy, the hypnotic condition, febrile 
 delirium, and acute mania, are most frequently ac- 
 companied by acoustic hypersesthesia ; the depressive 
 and stuporous melancholias and localized encephalitis 
 rather give rise to its hyposesthesia. Paracusia is 
 characteristic of hallucinatory and congestive 
 insanity, hypochondria, and neurasthenia. 
 
 The anomalies of visual sensibility are, of all, the 
 most variable and most frequent in the insane. We 
 obsei-ve optic hyperesthesia (photopsia, chromop- 
 sia) in diffuse encephalitis and states of excitement; 
 optic hyposesthesia (amblyopia, hemiopia, diplopia) 
 in the complicated or secondary forms of insanity, 
 general paralysis, tabetic dementia, intoxications, 
 hysteria, epilepsy, and neurasthenia; optic anaes- 
 thesia (blindness, amaurosis) in mania and general 
 paralysis; optic parajsthesia (color blindness. Dal- 
 tonism, nyctalopia, hemeralopia) in sensorial delirium, 
 alcoholic insanity, systematized insanity, epilepsy) 
 and hysteria. 
 
 The muscular sense and the reflexes are not, 
 ])roperly speaking, a part of the special sensibility, 
 but their alterations in mental disease may, never- 
 theless, be mentioned here. 
 
 In the insane the muscular sense is usually exalted 
 in excited states of mania, and it is doubtless owing 
 to this, in great part, that certain patients are able 
 to undergo continuous and intense exertions without 
 feeling the least fatigue. On the other hand, the 
 
FUNCTIONAL BLEMBNTS. 85 
 
 muscular sense is always more or less diminished 
 in states of depression or melancholia, and this 
 explains the lack of action, the prolonged atti- 
 tudes, and the cataleptiform immobility of some 
 among them who seem to have changed to veritable 
 statues. 
 
 With this hypersesthesia and anaesthesia of the 
 muscular sense we have also paresthesia or perver- 
 sion, which indicates a more or less profound disorder 
 of the sentiment of personality. The patients 
 believe their limbs or bodies are extraordinarily 
 enlarged or diminished, are made of glass, wood, 
 or metal, and therefore do not dare to move (acute 
 hallucinatoiy conditions, katatonia, hebephrenic 
 stupor) . 
 
 The sense of equilibrium, which may be compared 
 to the muscular sense, although its origin is more 
 complex, presents two kinds of alterations in 
 insanity. Sometimes these alterations are transitory 
 and accidental epiphenomena of the organic nervous 
 changes (insanity from cerebral traumatism, peri- 
 encephalitis, tabes dorsalis, cerebral tumors and syph- 
 ilis, chronic intoxication, and epilepsy) ; sometimes 
 they form true symptoms of an exclusively psychic 
 character, and reveal themselves either by the loss 
 or anaesthesia of the sense of equilibrium (melan- 
 cholia, stupor, hebephrenia, organic dementia, 
 acute sensorial derangement), or by perversion or 
 parsesthesia of the sense of orientation in space 
 (hallucinatory insanity, melancholia with religious 
 
86 ELEMENTS OF MENTAL ALIENATION. 
 
 or demoniacal delusions, secondary systematized 
 insanity, general paralysis). 
 
 The reflexes have hardly been seriously studied 
 up to the present time, excepting in general 
 paralysis, and the results are so far contradictory. 
 According to Bianchi, there is in the beginning an 
 exaggeration, and, later, progressive diminution. 
 According to Mickle, exaggeration is the rule in 
 syphilitic general paralysis, as is diminution in the 
 alcoholic form. According to Betteneouri-Rod- 
 riguez, the commencement of general paralysis is 
 characterized by a diminution or abolition of the 
 cutaneous reflexes and an exaggeration of the 
 tendon reflexes, which combination foi-ms a useful 
 element in the diagnosis. Besides we frequently 
 observe in general paralysis, as in tabes, the 
 Argyll-Robertson symptom (sensibility of the pupil 
 to accommodation and not to light) and Pitres' symp- 
 toms (diminution or absence of the testicular reflex) . 
 
 Among the insane (properly so-called) it seems, 
 according to the essays that have been attempted 
 in this direction, that, in chronic insanity, all the 
 reflexes, cutaneous, sensorial, and tendinous, remain 
 usually normal, while they are diminished in 
 depressive conditions and increased in states of 
 excitement. We find also in certain cases, notably 
 in melancholia cum stupore, the existence of 
 paradoxal reflexes. 
 
 Okganio Sensibility (internal sensations). — Or- 
 ganic sensibility includes all the sensations that, 
 
FUNCTIONAL ELEMENTS. 87 
 
 conveyed by the centripetal nerves of each organ, 
 transmit to the brain the impressions produced by 
 their functional activity, their needs, and their condi- 
 tion of health or disease. It is this, as Morselli states, 
 that gives us, in great part, the collective or synthetic 
 feeling of organic individuality (coensesthesis) . In 
 the normal condition the organic sensibility is re- 
 duced to rudimentary sensations that arise in the 
 depth of unconsciousness. But these sensations 
 may be exalted, disappear, or be perverted, and it 
 is principally among the insane that we encounter 
 these alterations. 
 
 Sometimes the patients think their organs cease 
 their functions ; it seems to them that something is 
 lacking in their vital equilibrium, that they are unlike 
 the rest of the world, and this is plainly the origin in 
 them of the delusive conceptions that are so common in 
 general paralysis, cerebral syphilis, tabetic insanity) 
 neurasthenia, and melancholia, which cause them to 
 say that they have no stomach, heart, mouth or arms, 
 that their food does not go down, that they are choked, 
 that they feel ill, that they are dead. I have many 
 times found an absolute anaesthesia of the digestive 
 tract in these cases, and (Esophageal catheterism could 
 be performed without producing the least reaction of 
 any kind. 
 
 At other times, on the contrary, the sensations of 
 the organic activity are increased. The patients feel 
 then more lively and active ; they experience a feel- 
 ing of extraordinary well-being, the more intense 
 
88 ELEMENTS OF MENTAL ALIENATION. 
 
 sometimes since it follows a condition of discomfort 
 and depression. This is what occurs in the period 
 of excitement in circular insanity, and especially in 
 the period of functional exaltation of general paral- 
 ysis, when the patients declare that " they never were 
 better," just at the moment when the disorganiza- 
 tion has taken possession of their whole system. We 
 must recognize doubtless in this state of organic 
 sensibility, if not the absolute cause, at least, 
 the point of departure of those delusions of power, 
 of vigor and force, seen in most cases of insanity of 
 the exalted type, especially in the expansive form of 
 general paralysis. 
 
 As to the sensations of organic wants, they may 
 be increased, as in mania, or abolished, as in melan- 
 cholia. This is particularly the case with the feel- 
 ings of hunger and thirst, hence the anorexias and 
 bulimias, the polydipsias and adipsias so common 
 in the insane. 
 
 The perversions of the organic sensibility are yet 
 more frequent and varied in the patients. They may 
 develop in all parts of the body and from all the vis- 
 cera, but their seat of predilection is the abdomen. 
 Thus we hear of strange feelings (organs that shift 
 about, animals in the stomach or belly, nocturnal out- 
 rages, sudden pregnancies, demon in the heart, etc., 
 etc. ) which give rise to the most extravagant delusions. 
 These perversions are connected usually with func- 
 tional or organic affections of the viscera, to which 
 we shall return later on, 
 
PtrNCTIONAL ELBMENTS. 89 
 
 c. — Disorder's of Motility. 
 
 All possible lesions of motility are observed in 
 conditions of mental alienation. We will examine 
 successively the anatomical condition of the muscles, 
 the passive and active attitudes of the body, the con- 
 tractility to mechanical stimulation, the electro-mus- 
 cular contractility, the dynamometric and dynamo- 
 gi-aphio mensuration, and finally the functional 
 lesions, properly so-called. 
 
 The muscles are most frequently flaccid and re- 
 laxed, sometimes even atrophied, either from the 
 effect of inertia (melancholia, stupor, dementia), or 
 from disorder of the general nutrition (marasmus of 
 paralysis, stupor and dementia), or, finally, from di- 
 rect lesion of the nervous trophic centres (paralytic 
 dementia) . 
 
 The spontaneous attitudes in certain forms of 
 psychoses are truly characteristic. Sometimes there 
 is complete abandon with resolution of the whole 
 muscular system, as if a patient had collapsed 
 (general paralysis) ; sometimes there is a crouching 
 together, as if he desired to occupy the least possible 
 space (melancholiacs, hallucinated cases, dements) ; 
 sometimes again, there is an absolute immobility, a 
 complete default of reaction to stimulation and an 
 inert indifference to surroundings (stupor). 
 
 Among the motor alterations, allied to voluntary 
 attitudes we should notice the loss of equilibrium in 
 the erect posture, the eyes being closed (Romberg's 
 symptom), which is usual in tabetic dementia, and 
 
90 ELEMENTS OF MENTAL ALIENATION. 
 
 is met with also in paralytic dementia. We can 
 also observe, in certain delusional neurasthenias, 
 astasia-abasia, noted by Charcot and his pupils 
 among neuropathic cases. 
 
 The muscular contractility induced by mechan- 
 ical or thermal agents is either increased (stuporous 
 and cataleptiform melancholia, hypochondria, neur- 
 asthenia, mania), or diminished (simple melancholia, 
 general paralysis, and dementia). Most commonly 
 it remains normal. 
 
 The electro-muscular excitability is found habit- 
 ually increased in mania, melancholia with coensesthe- 
 tic hallucinations, and simple lypemania. In the con- 
 vulsive forms of insanity and also in general paralysis, 
 we sometimes encounter the so-called reaction of 
 convulsibility (Benedikt). On the contrary, the 
 electro-muscular excitability is decreased, and at last 
 abolished, in profound dementia and general paralysis 
 accompanied with spinal symptoms. The reaction 
 of exhaustion (Benedikt) is met with in many 
 paralytics. 
 
 Besides these quantitative alterations of the electric 
 excitability, there are also qualitative changes, but 
 these are very variable and not yet well known. 
 Melancholia with stupor may thus be accompanied 
 with a partial degenerative reaction, consisting in 
 the anode closing reaction occurring before that the 
 cathode closing. Also in general paralysis the 
 galvanic excitability is ordinarily more diminished 
 than is the faradic. Finally in melaiicholiacs we 
 
FUNCTIOlSrAL ELEMENTS. 91 
 
 Bometimes find a difference of excitability in the two 
 sides of tlie body, and when convulsive phenomena 
 occur, a tremulous contraction of the muscle during 
 the passage of the galvanic current (interpolar 
 hyperexcitability) . 
 
 The force of contraction of the different muscular 
 groups is not easily tested with the dynamometer in 
 ■ the insane and this method hardly serves to more 
 than indicate the amount of volitional energy they 
 possess (passive melancholia, stupor, apathetic 
 dementia). The dynamograph is more useful; it 
 shows that the curve varies in different mental 
 affections according to the state of the motor centres 
 and of the muscles (hemiplegic dementia, progressive 
 general paralysis, alcoholic pseudo-general paralysis, 
 neurasthenia, etc.). 
 
 Among the lesions of motility, properly so-called, 
 observed in the insane we may mention : paralysis 
 and paresis, general or partial (diffuse cerebro-spinal 
 affections, general paralysis, hemiplegic dementia, 
 epileptic insanity, acute febrile delirium, idiocy) ; 
 spasms and cramps (hypochondria, acute mania, 
 excited periods of circular insanity, spasmodic 
 melancholia, hysteria, epilepsy), among which special 
 mention should be made of the pharyngeal spasm of 
 hydrophobic insanity and the grinding of the teeth 
 in general paralytics; contractures, localized or in- 
 volving all the members (idiocy, hysteria, paralytic 
 and hemiplegic dementia) ; tremors and tremulous- 
 ness, dependent either op a central lesion (paraljrtip 
 
92 ELEMENTS OF MENTAL ALIENATION. 
 
 dementia, alcoliolism, epilepsy), or upon a psychic 
 condition (anxious melancholia, neurasthenia); 
 ataxia or motor incoordination, which is observed in 
 all forms of paralysis, alcoholic intoxication, etc., 
 sometimes diffuse, sometimes localized ; convulsions, 
 general or partial, with more or less complete loss of 
 consciousness (general paralysis, cerebral syphilis, 
 alcoholic and saturnine intoxication, grave form of 
 senile dementia), with which we should rank that 
 extraordinary excitability of the nervous system not 
 quite reaching convulsions, which goes under the 
 name of convulsibility (acute mania, anxious melan- 
 cholia, neurasthenic insanity) ; tetany of the muscles 
 presenting a great analogy to convulsibility (stupor- 
 ous melancholia) ; catalepsy and pseudo-catalepsy 
 (hysterical insanity, melancholic ecstasy, stupidity, 
 acute hallucinatory conditions), which are usually 
 accompanied by a profound cutaneous and muscular 
 anaesthesia; parakinesis, or abnormal distribution 
 and transmission of motor impulsion, consisting in 
 paradoxical contractures and rigidity to movement 
 of the muscles (stupidity, katatonic melancholia, 
 insanity of doubt or contact) ; psychic or imaginary 
 paralysis, consisting in phenomena of motor inhibi- 
 tion (hysterical and hypochondriacal insanities, 
 abulic neurasthenias) ; alteration of the tone and 
 timbre of the voice, of the movements of writing, 
 etc. , which are seen in certain insanities with intense 
 agitation (acute mania, anxious melancholia, general 
 paralysis). According to Morselli, change of voice 
 
FUNCTIONAL ELEMENTS. 93 
 
 is sometimes a prodromic symptom of chronic 
 periencephalitis. The same may be the case with 
 change of handwriting. 
 
 DiSOKDBHS OF THE VEGETATIVE FUNCTIONS, 
 
 Following Morselli, we shall study successively 
 under this head: the circulation, the respiration, 
 nutrition and assimilation, the secretions, the tem- 
 perature, and the trophic and vaso-motor functions. 
 
 a. — Circulation. 
 
 Affections of the heart are, in a general way, more 
 frequent in the insane than in those of sound mind. 
 According to Dr. Duncan Greenlees, the proportion 
 of deaths from cardiac disease are 9.36 per cent, in 
 the former, and 8.73 per cent, in the latter. Most 
 frequently, the heart disorder antedated the insan- 
 ity, and has played an important part in its produc- 
 tion ; in certain cases, nevertheless, it seems to be 
 the consequence of excessive agitation, (mania, lype- 
 mania, epilepsy.) 
 
 Many of the insane present all the signs of a pre- 
 cocious atheromatous degeneration; in others we 
 find atrophy, fatty degeneration of the heart or its 
 spontaneous rupture. The disorder most commonly 
 met with is, according to most authors, mitral in- 
 sufficiency with hypertrophy of the left ventricle. 
 Among functional disorders we find ansBmic bruits 
 de souffle, frequency, feebleness, and intermittence 
 of the cardiac pulse. 
 
94 ELBMfiNTS O*" MENTAL ALIENATION. 
 
 En resumd, in a great number of the insane, 30 
 per cent, according to some authorities, 75 per cent, 
 according to others, the useful action of the labor 
 of the heart is diminished so that the amount of 
 blood circulating in the organs is diminished, and 
 its distribution altered. 
 
 The pulse does not offer in insanity any character- 
 istic alteration of quantity and quality. In a 
 general way, however, it is frequent and high 
 in states of excitement, and slow and feeble in 
 depressive conditions. But this is not an absolute 
 rule since in many melancholiacs, and even in stupor, 
 it may attain to 100 or 120 per minute. In the 
 chronic forms the pulse is habitually normal, except 
 in hallucinated cases and during periods of agitation. 
 Rapid variations, dicrotism, and polycrotism are 
 very frequent in the insane. 
 
 Wolf, who has made numerous sphygmographic 
 researches on the pulse in different psychoses, lays 
 stress on the fact that we meet more often than 
 otherwise with the loss of the parallelism, which 
 exists in the noiTnal condition, between the curve of 
 temperature and that of the oscillations of the pulse. 
 MOrselli claims, however, that the later investiga- 
 tions of Claus do not confirm Wolf's results. Sphyg- 
 mography will be of especial value, according to 
 Shaffer, in distinguishing the different periods of 
 circular insanity. 
 
 Greenlees {Jour. Ment. Sci., 1887), draws from 
 his sphygmographic observations the following 
 
ftTNCTlOtifAl ELEMENtS. 95 
 
 conclusions: In acute mania we find the nervous 
 centres congested, the arterial walls relaxed, whence 
 a diminution of arterial tension and dicrotic trace of 
 the pulse. In the chronic form the trace approaches 
 the normal. 
 
 In acute melancholia, feeble cai'diac systole, 
 incomplete filling of the arteries. In the chronic 
 form the pulse recovers its force. 
 
 In general paralysis, pulse variable according to 
 the period. In the first stage, systole energetic, 
 arterial tension feeble. In the second, less energetic 
 systole, arterial tension restored. In the third, sys- 
 tole feeble, but the complete tracing resembles that 
 of the first stage. 
 
 In dements the tracing shows a torpid circulation 
 due to a weakness of the vaso-motor system. 
 
 In imbeciles there is always increase of the 
 arterial tension and of the systole. 
 
 b. — Bespiration. 
 
 The examination of the respiration is much less 
 significant in the insane than that of the circulation. 
 
 o 
 
 We encounter, nevertheless, chronic diseases of 
 the chest, pulmonary phthisis, bronchial catarrh, 
 emphysema. 
 
 In the maniacs the respiration exhibits nothing- 
 special as a rule, as regards its frequency. In the 
 melancholiacs the respiratory movements are some- 
 times shallow and veiy frequent, sometimes slow 
 and deep ; we may also meet here the inverse type 
 
96 ELEMENTS OF MElTTAL ALIENATION. 
 
 of respiration, i. e., the expiration longer than the 
 inspiration. Maroe has ohserved in these patients 
 an abnormal proportion between the number of 
 inspiration and cardiac beats. This ratio, one to 
 four normally, becomes less in melancholia when 
 it may be only one to five or six pulsations. 
 
 In certain emotional conditions the thoracic move- 
 ments may be made by jerks and recoveries and 
 sometimes even with tremors and starts. In ad- 
 vanced general paralysis, especially during apoplecti- 
 form attacks, we see intermittent, remittent, and 
 arhythmic respiration, as in the Cheyne-Stokes 
 phenomenon. 
 
 c. — Niitrition and Assimilation. 
 
 The first thing to do, in judging of the state of 
 nutrition of an individual, is to examine the ratio of 
 weight to stature. 
 
 In the prodromic period of many insanities, before 
 the mental disorders reveals itself even, the weight 
 of the body is notably reduced. In agitated states 
 and mania, there is a general lack of nutrition; 
 in the apathetic forms, on the contrary, the patients 
 may become obese. In the intermittent and circu- 
 lar insanities regular changes of body weight are 
 often observed in each period of the attacks. In 
 the marasmus of melancholia, mania, and general 
 paralysis, emaciation is progressive and may reach 
 an excessive degree. Finally at the decline of the 
 acute attacks, the nutrition is re-established, and 
 
FUNCTIONAL ELEMENTS. 97 
 
 tMs is a favorable symptom on condition it coin- 
 cides with a parallel amelioration of the mental 
 condition. 
 
 The disorders of the digestive tract are very com- 
 mon in mental alienation . We encounter particularly : 
 cancer, ulcers, gastric dilatation, dyspepsia, gas- 
 tritis, chronic peritonitis, duodenal catarrh, cancer 
 of the rectum, displacement of the transverse colon, 
 dysentery, enteritis; congestion and abscess of the 
 liver, nephritis, interstitial and parenchymatous ; ves- 
 ical catarrh, cystitis, hypertrophy of the prostate, 
 etc., etc. 
 
 The functional troubles are not less numerous and 
 important. They are saburral conditions, fetor of 
 the breath, regurgitation with pyrosis, vomiting, 
 gastrorrhagias and enterorrhagias, intestinal colic, 
 meteorism; tympanitis, constipation particularly, 
 diarrhcEa, and incontinence of urine and faeces. 
 These symptoms may be observed in all forms of 
 insanity, acute or chronic, simple or associated, but 
 they are more special to melancholic conditions, 
 where they are rarely lacking. It is to them that 
 is due, in great part, the sitiophobia, or refusal of 
 food, which is not to be confounded with lack of 
 desire, though this accompanies it in many cases. 
 
 d. — Secretions. 
 
 The salivary secretion is most often altered by 
 
 excess in mental diseases (ptyalism, sialorrhcea) . 
 
 The insane who present the symptom may be 
 
 Mbnt. Med.— 7. 
 
98 ELEMENTS 0¥ MENTAL ALIENATION. 
 
 divided, according to Reinhardt, into three groups : 
 (1) The imbeciles, idiots, dements, and paralytics 
 in whom the saliva is fluid and aqueous, (vaso-motor 
 paralysis) ; (3) the cases of systematized insanity 
 with delusions of poisoning and sitiophohia, in 
 whom the saliva, at first very abundant and watery, 
 becomes later thick and turbid from fragments of 
 glandular epithelium (conscious reflection and mor- 
 bid action of psychic centres) ; (3) cases of mania 
 and circular insanity, and sexually excited insane, 
 in whom the saliva is glassy, tenacious, whitish and 
 viscous (local mechanical excitation or irritation of 
 the great sympathetic). 
 
 In certain cases, as in acute delirium and delirium 
 tremens, the discharge of saliva may become, so to 
 speak, incessant. 
 
 The gastric secretion is almost always disordered 
 in the dyspepsia and sitiophobia of the melancholiacs 
 and delusional insane, in the polyphagia of mania 
 and dementia, in the stomachal vertigoes of hypo- 
 chondria and epilepsy, in the anorexia of alcoholism, 
 in the gastric dilatation of neurasthenia, etc. , etc. 
 
 In late years, chemical analysis of the gastric juice, 
 obtained by the stomach tube during digestion, has 
 led to the division of the dyspepsias into several cate- 
 gories: from excess of peptone; from dilution of 
 the gastric juice; from hyperchlorhydi'ia ; from 
 anachlorhydria ; from fermentation (Alb. Robin). 
 The same scientific methods have enabled Carl v. 
 Noorden (1887) and Pachoud (1888) to demon- 
 
rUNCTIONAL ELEMENTS. 99 
 
 strate that in melancholiacs there is generally accel- 
 eration of digestion and hyperacidity of the gastric 
 juice, due almost exclusively to the presence of free 
 hydrochloric acid. 
 
 There have not yet been as thorough investiga- 
 tions of the biliary secretion in the insane. We 
 know, nevertheless, that there is an excess of bile in 
 many cases (melancholia, chronic insanity, toxic 
 insanity), and that it gives rise either to sub-acute 
 attacks of jaundice, or to the more or less unre- 
 vealed formation of gall stones which we find in 
 great numbers at the autopsy. The intestinal 
 atony of certain lypemaniacs and delusional insane 
 may also be connected with insufficient biliary 
 secretion. 
 
 The perspiration is frequently altered in emotional 
 conditions, as is well known, and in diseases of 
 the spinal cord. This occurs also in the insane. 
 Many have a dryness of the skin, hair bristly and 
 dry owing to a lack of secretion (anidrosis) ; such 
 are found among the melancholiacs, the stuporous 
 oases, and general paralytics. Others, on the con- 
 trary, perspire abundantly (hyperidrosis) , so that 
 their skin becomes sometimes cold and (Edematous 
 (mania, emotional neurasthenia) . The beginning of 
 certain mental diseases is marked, in some cases, by 
 the absence of perspiration, or, on the other hand, by 
 the appearance of local or general sweating (general 
 paralysis, hypochondriacal insanity). I have ob- 
 served in some diathetic psychoses, especially in 
 
100 ELEMENTS OF MENTAL ALIENATION. 
 
 arthritism, a very marked alternation between the 
 mental condition and the secretion of sweat. 
 
 The nauseous odor of many of the insane, which 
 has been compared to that of mice, depends, accord- 
 ing to Morselli, upon the untidiness and the fetid 
 breath of the patients, rather than upon any chemi- 
 cal modification of the cutaneous exhalations. There 
 is, nevertheless, an increased acidity ordinarily accom- 
 panying the phases of agitation of cyclical insanity. 
 Some idiots give out an odor like musk (Frigerio). 
 
 The sebaceous secretion has been scarcely studied 
 in the insane. We know it, moreover, only very im- 
 perfectly in the normal conditions. M. Arnozan, 
 according to some experiments made in conjunction 
 with myself, has noted some peculiarities in the 
 insane, without, however, attaining any precise data, 
 as yet. After much research we have discovered, 
 nevertheless, the existence of sebaceous matter, in 
 general paralytics, in regions where it is not found 
 habitually, for example, in the axilla. 
 
 The study of the blood finds its place either 
 amongst the functions of nutrition or the trophic 
 functions. We range it here because it is insepara- 
 ble from that of the urine. 
 
 It has been observed that in most of the insane, 
 either in the beginning or in the course of their dis- 
 order, the number of blood- globules is notably 
 diminished (melancholia, stupor, dementia), and 
 that this hypoglobuly is especially marked in the 
 females. It has also been observed, perhaps even 
 
FUNCTIONAL ELEMENTS. 
 
 101 
 
 more frequently, that there is a dimiiuition of the 
 hemoglobin of the blood (depressive and stuporous 
 forms). In the maniacs, the composition of the 
 blood approaches the normal. In no case are the 
 proportions of the red and white globules altered. 
 
 In a recent memoir [Jonr. Ment. Sci., Oct., 1890), 
 Dr. Johnson Smyth reports the results of numerous 
 experiments made by him on the blood of the insane. 
 We give their summary in the following table : 
 
 State of Health 
 
 Melancholia 
 
 Epilepsy 
 
 General Paralysis . . . 
 Secondary Dementia 
 
 Hemoglobin, Red Globules Specific 
 ^ per cubic mm. gravity. 
 
 93. per ct. 
 
 69.7 " 
 
 63.8 " 
 68.7 •■ 
 53.7 " 
 
 5,106,000 
 4,684,000 
 4,520,800 
 4,700,350 
 4,070,000 
 
 1.056 
 1.057 
 1.059 
 1.060 
 1.061 
 
 Whence it follows, very clearly, that in the insane, 
 there is, in a general way, a decrease of hsBmoglobin 
 and the red globules of the blood, while, on the 
 other hand, the specific weight of the fluid is aug- 
 mented. It also appears that the morbid species 
 in which these peculiarities are most marked are in 
 decreasing order: secondary dementia, epilepsy, 
 melancholia, and general paralysis. As to the ratio 
 of white to red corpuscles, the author affirms that 
 he has found no constant variation from the normal. 
 
 The most important of the secretions in the insane, 
 as it is in the physiological condition, is that of the 
 urine. It may be altered in insanity both as to 
 quantity and quality. 
 
102 
 
 ELEMENTS OF MENTAL ALIENATION. 
 
 In a qualitative point of view, the alterations con- 
 sist in modifications of the physiological principles 
 and introduction of pathological ones. 
 
 Urea, phosphates, and chlorides are found some^ 
 times in excess (paralytics and maniacs), sometimes 
 below the normal figure (melancholia, dementia). 
 
 As regards the elimination of phosphoric acid, it 
 appears from the studies of Mendel and Mairet that 
 in mania, lypemania, and excited periods of insanity, 
 there is an increase of the phosphates, especially 
 the earthy ones, in the urine, while in idiocy and 
 dementia, in which the general nutrition is retarded, 
 there is a decrease of these salts. 
 
 Dr. Johnson Smyth, in the memoir already cited, 
 sums up as follows, the composition of the urine in 
 the different forms of insanity : 
 
 a h u 
 
 O 0<p 
 d oj p) 
 
 mi" 
 
 EH 
 
 -< (3 
 
 a S) 
 
 fl2 
 
 State of Health 
 
 Melancliolia 
 
 Epilepsy 
 
 Secondary Dementia. 
 General Paralysis . . . 
 
 1356.3 
 1295.8 
 1536.8 
 1408.0 
 1578.0 
 
 37.8 
 
 38.87 
 
 36.8 
 
 34.8 
 
 47.0 
 
 33.3 
 
 35.94 
 
 35.17 
 
 30. 
 
 36.0 
 
 0.9 
 
 1.8 
 
 3.1 
 
 3. 
 
 3.1 
 
 1.3 
 
 3.9 
 3.3 
 
 9. 
 
 1.3 
 
 1.65 
 
 3.19 
 
 0.69 
 
 1.6 
 
 From this table it appears : (1) That the quantity 
 of urine excreted is above the normal in general par- 
 alysis and epilepsy, inferior in melancholia and sec- 
 ondary dementia; (3) that the total of solids is 
 
FUNCTIONAX ELEMENTS. 103 
 
 greatly increased in general paralysis ; (3) that the 
 amount of urea is slightly in excess in the psychoses, 
 except in dementia ; (4) that the amount of uric acid 
 is notably above the physiological average, first, 
 in general paralysis, then in epilepsy and dementia ; 
 (5) that creatinine also is more abundant in general 
 paralysis and dementia ; (6) finally, that there seems 
 to be a slight excess of phosphoric acid in epilepsy, 
 but that this constituent differs very little from the 
 pormal in the other disorders. 
 
 Among the pathological elements of the urine, 
 sugar and albumen are the ones chiefly to be sought 
 for. Sugar may be found in varying proportion in 
 diabetic insanity, acute delirium, delirium tremens, 
 chronic alcoholism, epilepsy, general paralysis, at 
 the beginning or after the congestive attacks. 
 
 Albumen, according to Kappen (1888), is espe- 
 cially frequent in insanity connected with chronic 
 nephritis, or arterio-sclerosis, in acute delirium, 
 general paralysis and epilepsy. It appears either in 
 its usual form, or under the form of propeptone 
 (hemialbumenose or paralbumen) . In some cases of 
 so-called Brightic insanity (Dieulafoy, Raymond,) 
 the mental condition follows exactly the fluctuations 
 of the uraemia. 
 
 Dr. Marro, {Neurol. Centralbl., 1888), claims to 
 have constantly found peptonuria in twenty-one par- 
 alytic dements. The amount of peptone was some- 
 times minimal and required as much as 800 to 1,000 
 cubic centimetres of urine to give Hofmeister's re- 
 
104 ELEMENTS OE MENTAL ALIENATION. 
 
 action. It was greatest in cases that followed an 
 acute course or were complicated. This author goes 
 so far as to affirm that the absence, of peptone ex- 
 cludes the diagnosis of general paralysis. 
 
 The same author, {Arch, de Freniatria, 1889,) has 
 found acetone in marked quantity in the urine of 
 patients dying from acute delirium with terrifying 
 hallucinations. He believes that the presence of 
 this substance has to do with the exisfience of this 
 kind of hallucinations. 
 
 We sometimes find also in the urine of the insane, 
 cylinders, generally with albumen (acute conditions) 
 mucus, pus, epithelial cells, leucocytes, and even 
 blood (paralytic dementias). Finally, mention should 
 be made, as of possible occurrence, of azoturia, urae- 
 mia, with its convulsive and delusive forms, ischuria, 
 strangury from spasm of the neck of the bladder, or 
 paralysis, retention and incontinence, conscious or 
 unconscious (F6re). 
 
 e. — Temperature. 
 
 Insanity is almost always an apyretic disorder, 
 which, in many cases, does not affect the equilib- 
 rium of the sources of animal heat and is not accom- 
 panied, sav^ in special phases and in certain particular 
 forms, with any reaction of the organism. For this 
 reason, thermometric investigation has in it but a 
 limited application. 
 
 The general temperature may be increased in 
 acute cases of insanity, but only in the congestive 
 
FUNCTIONAL ELEMENTS. 105 
 
 types (mania, epilepsy, general parslysis) . The tem- 
 perature is lowered, on the other hand, in the 
 depressed or apathetic forms, in marasmus, and 
 melancholia. We may meet with extraordinary ele- 
 vations of' temperature in certain stages of general 
 paralysis. We also may encounter an irregular dis- 
 tribution of bodily heat in the peripheral parts 
 (local asphyxias) , but these are more of the order of 
 vaso-motor troubles. 
 
 The cranio-cerebral temperature has been found 
 increased in the exalted forms, and lowered in the 
 depressive forms. There have even been noted 
 notable differences between the two halves of the 
 head and the different lobes of the brain. But it is 
 not necessary to unreservedly accept these results. 
 
 /. — TropMe and Vaso-motor jninctions. 
 
 The disorders of these functions are very import- 
 ant in psychiatry. We will notice among the 
 trophic disorders: 
 
 (1) Alterations of the skin, either in the distri- 
 bution of pigment, or abnormal pigmentations, or in 
 the nutrition of the different tegumentary layers. 
 Sometimes we encounter true dermatoses, such as 
 eczema, zona, herpes, ichthyosis, phthiriasis, endemic 
 myxoedema, at other times the skin exhibits the 
 symptoms of a general intoxication of the organism, 
 as in alcoholism and pellagra. 
 
 (2) Difficult cicatrization of wounds, eschars of 
 wounds and bedsores, mal perforant, spontaneous 
 
106 KLEMElTTS OP MENTAL ALIBUATION. 
 
 shedding of nails and teeth, othsematoma, lesions 
 due, for the most jjart, to peripheral neuritis. 
 
 (3) Fragility of the bones, trophic arthropathies, 
 especially in the chondro-stemal articulations. 
 
 (4) Muscular atrophies and degenerations, which 
 attain a very high degree of development in the 
 paralytic forms of insanity, marasmus of dementia, 
 and melancholic cachexia. 
 
 (5) Neuro-trophic keratitis, diminution of lachry- 
 mal secretion, and finally fatty degeneration of 
 various organs. 
 
 Among vaso-motor disorders, we find in the insane 
 vaso-motor paralysis of the limbs or of certain regions 
 of the skin, causing cyanosis and cedema (stuj)orous 
 and apathetic forms of melancholia, circular insanity 
 (Ritti), dementia) ; so-called local asphyxias from 
 spasmodic contraction of the capillaries; iiTegular- 
 ities in the blood-supply of parts; subjective sen- 
 sations of heat, cold, formication, shivering, angio- 
 paralytic and angio-kinetic phenomena, localized, 
 and, so to say, alternating (cyclic and periodic forms 
 and raptus melancholicus) . We may find also, 
 under the influence of light mechanical or electrical 
 irritations, partial persistent fl^ushings, and some- 
 times also the symptom known by the name of the 
 vaso-motor alphabet (dermography) . 
 
 Finally, we may mention praecordial pain, so im- 
 portant in certain forms (melancholia, ej^ilepsy, hypo- 
 chondria, hysteria, alcoholism, neurasthenia), which 
 is a sort of painful sense of constriction and gives 
 
{JUNCTIONAL ELEMENTS. W^ 
 
 rise to delusive conceptions of the most widely dif- 
 fering kinds. It is rarely lacking in the initial 
 melancholic stage of insanity. 
 
 g. — Appendix. 
 
 Action of Disokdbes ov the Vegetative 
 Functions on Insanity: Sympathy. — Thboeies 
 OP Bouchard. 
 
 It is evident, from the rather imperfect enumer- 
 ation that has been made, that insanity is frequently 
 connected with physical disorders and that none of the 
 bodily organs escape these alterations. This is why, 
 from all time, there has existed a tendency to consider 
 certain mental diseases as the immediate or remote 
 effect of a pathological change of the viscera, or the 
 humors of the body. Hence the names, melancholia, 
 hypochondria, phrenitis, derived from the supposed 
 origins of the various known forms of insanity. 
 Melancholia, indeed, has always been especially 
 attributed to a functional or organic alteration of 
 the abdominal organs, and Coelius Aurelianus wrote, 
 in Roman times, "In melaucholicis stomachus, in 
 furiosis vero caput afficitur." 
 
 The theories advanced to explain this influence of 
 the disordered viscera on the brain, are those that 
 have accorded with the successive epochs and con- 
 ditions. One of them, the most ancient, perhaps, 
 since it dates from Hippocrates and Galen, is the 
 theory of sympathy, which, in modified form, has 
 survived to the present time. 
 
108 ELEMENTS OF MENTAL ALIENATION. 
 
 It is to be Stated, however, that the present time 
 is a critical phase of this question and that the 
 ancient idea of this morbid sympathy is giving way 
 to a new conception, more in accord with modern 
 scientific notions, that of auto-intoxication. 
 
 The admirable memoirs of Bouchard, on the dis- 
 orders produced in the organism by the exaggera- 
 ted formation or retention of normal poisons in the 
 system, and in particular those which appear in the 
 digestive canal and the urine, are well known. 
 Admitting now the existence of the gastro-intestinal 
 symptoms that accompany most acute forms of 
 insanity, especially melancholia, and also admitting 
 the good effects obtained by washing out the 
 stomach, not merely on the melancholiac sitiophobia, 
 but also on the lypemania itself, it is perfectly 
 logical to assume that in many of these cases the 
 insanity is the result of an auto-intoxication. 
 
 Some papers have already been published support- 
 ing this pathogenic view. I will cite especially, the 
 communication of M. Bettencourt-Rodriguez, to 
 the International Congress of Mental Medicine 
 (1889), on "The influence of the phenomena of 
 auto-intoxication and of dilatation of the stomach 
 in the depressive and melancholic forms ; " the thesis 
 of Chardon, inspired by Prof. Lcmoine, on "The 
 influence of infectious diseases on the development 
 of mental disorders" (Lille, 1889-90), and that of 
 Feyal on "Constipation in the insane" (Lyons, 
 1890). I will mention finally the opening lecture 
 
FUNCTIONAX ELEMENTS. 109 
 
 of my free course at Bordeaux (1889-90) : " Insanity 
 and the auto- intoxications ; " and especially the ex- 
 cellent thesis of one of my pupils, Dr. Chevalier- 
 Lavaure who, analyzing the toxic power of the 
 urine of the acutely insane, according to Bouchard's 
 method, has been able to demonstrate that, in these 
 conditions and especially in mania, the urine loses a 
 large proportion of its toxicity, undoubtedly from 
 the morbid retention of norm.al poisons. While an 
 average of 25 cubic centimetres of normal daily 
 urine and 35 cubic centimetres of healthy night 
 urine are required per kilogram- to kill an animal, 
 60 cubic centimetres of maniacal day urine and 69 
 of night urine, are required to produce the same 
 effect. In one case all the urine passed in a day 
 was insuiEcient to destroy a rabbit experimented 
 upon (JDes auto-intoxications, clans les maladies 
 mentales. Bordeaux, July, 1890). These results 
 are comparable to those obtained by M. Fere, on 
 the urine of epileptics, recognized as more toxic 
 before than after a convulsive attack. 
 
 Attention has hardly been given to other than the 
 auto-intoxications alone, in the insane, and especially 
 those that have, for their point of departure, the 
 digestive tract and its annexes. The theories of 
 Bouchard, however, in regard to general disorders 
 from retardation of nutrition seem to me equally 
 applicable to the pathogeny of certain so-called 
 diathetic forms of insanity, particularly those some- 
 times engendered by arthritism. This is the opinion 
 
110 ELEMENTS OF MENTAL ALIENATION. 
 
 of Prof. Pierret (International Congress, 1889) and 
 of M. Charpentier, who, besides general paralysis 
 from congestion, admits the existence of another 
 group of general paralyses from intoxication, in 
 which he ranks those due to gout, diabetes, arthrit- 
 ism, and overalimentation {Ann. Med. Psychol., 
 Oct., 1890). For my part I have observed one very 
 clear case of hereditary arthritic insanity with uric 
 retention, anidi'osis, and manifold trophic disorders, 
 in which the insanity, incontestably due to the 
 effects of retarded nutrition, constantly followed the 
 oscillations of the diathetic intoxication. 
 
 It will be seen what a horizon is opened for the 
 future in psychiatry by the theories and methods of 
 the present day. "We may, it is true, expect that 
 the permissible limits of deduction wiU be soon 
 passed, as is always the case, and that some 
 adventurous spirits will go, doubtless, to the extent 
 of making all insanity the result of the poisoning of 
 the organism, of an intoxication. Some positive 
 data however will be gained, and the discoveries of 
 chemical biology, moi-e fruitful in this direction than 
 histology, will necessarily lead to some progress in 
 the treatment of nervous diseases. We have already 
 seen that experimental analysis of the gastric juice 
 has enabled Van Noorden and Pachoud to determine 
 the existence of gastric hyperchlorohydria, in 
 melancholia and consequently to recommend the 
 use of alkalies. A still more minute analysis of 
 this liquid, according to recent methods (Gaston 
 
CONSTITUTIONAL OR ORGANIC ELEMENTS. Ill 
 
 Lyon : U' Analyse du sue gastrique, sa technique, 
 ses applications cliniques et therapeutiqites; These 
 de Paris, 1890), gives us without question the data 
 for a rational treatment of melancholiac dyspepsias, 
 or we may say the dyspeptic lypemanias, and, 
 especially, for transforming the present lavage of the 
 stomach into a rational therapeutic method, scien- 
 tifically based upon the condition of the gastric 
 juice and the organs of digestion. The same results 
 will follow thorough study of the blood, and of the 
 urine, and, in various degrees, that of other excre- 
 tions, such as the perspiration, the saliva, and the 
 sebaceous secretion, X (1) 
 
 §11. CONSTITUTIONAL OR ORGANIC ELEMENTS. 
 
 These elements are divided into the lesions of 
 organization or of evolution, and lesions of disor- 
 ganization or of involution, according as they attack 
 the individual during the time of his development 
 or after it has been completed. 
 
 Lesions of Organization. 
 
 The lesions of organization characterize more, 
 especially a group of mental diseases which we shall 
 consider later under the name of degeneracies of' 
 evolution of vices of psychic organization. But we 
 may encounter them, more or less isolated, in a 
 large number of the insane. They consist in; 
 
112 ELEMENTS OF MENTAL ALIENATION. 
 
 deviations, excesses, or arrests of development, 
 which involve not only the cerebral functions, but 
 also all the apparatuses or organs of the economy. 
 We will pass them rapidly in review under the 
 denominations of psychical stigmata and physical 
 stigmata. 
 
 a. — Psychic. Stigmata. 
 
 The law that controls the teratological alterations 
 of the intelligence is, in opposition to the normal, 
 the discordance or defect of equilibrium. It follows 
 that the essential characteristic of the psychic 
 anomalies, is, before everything else, a lack of pro- 
 portion between certain undeveloped faculties and 
 others noiinal or in excess. 
 
 In the intellectual spheres, properly speaking, it 
 is the higher faculties, the judgment, the mental 
 consecutiveness, the attention, and the will, that are 
 defective, while the other mental powers, on the 
 other hand, such as memory, imagination, inven- 
 tion, the power of expression, or the various artistic 
 aptitudes, may be very well developed. 
 
 In the moral or emotional sphere, the arrest of 
 development affects particularly as a rule, the loftier 
 sentiments and the higher affections, while, on the 
 contrary, there is often a veritable hypertrophy of 
 the passions and the lower feelings and instincts. 
 The ensemble of this condition, as it appears in some 
 degenerated cases, is commonly known under the 
 name of absence of the moral sense. 
 
CONSTITUTIONAL OE OEGANIC ELEMENTS. 113 
 
 b. — Physical Stigmata. 
 
 The stature is often abnormal in insanity, especi- 
 ally in the degeneracies and the monstrosities. We - 
 may meet with dwarflshness or with excessive 
 stature, eifeminacy, and various deformities of the 
 spine and thorax. 
 
 In the limbs we may find paralyses, contractures, 
 tics, hypertrophies, and partial or general atrophies. 
 The extremities are sometimes characteristic; there 
 may be syndactylism, polydactylism, club feet, flat- 
 footedness, and what has been called the idiot hand 
 (long and slender with defective development of the 
 thumb). 
 
 The cranium exhibits numerous deformities. Its 
 volume is generally above the normal. From a com- 
 parison of 475 skulls of the insane and 312 others, 
 Seppilli obtained the following averages: insane 
 males, 1,544 c. c, other males, 1,474 c. c. ; insane 
 females, 1,341 c. c. , other females, 1,316 c. c. The 
 fonn is very variable. Together with orthocephaly 
 we encounter microcephaly, megalocephaly, brachy- 
 cephaly, (eurycephaly and acrooephaly) , dolicho- 
 cephaly (scaphocephaly and plagiocephaly), and 
 general or partial asymmetry. Next follow hyper- 
 trophy and atrophy of the walls, persistence of 
 fontanelles and sutures or their premature ossifica- 
 tion, exostoses, flattened spots, wormian bones, etc. , 
 etc. 
 
 The face also shows asymmetry, deformities of the 
 palatine vault, which may be narrow, deep and 
 
 Ment. Med.— 8. 
 
114 ELEMENTS OF MENTAL ALIENATION. 
 
 ogival, deviation of the nasal septum, promin- 
 ence of the zygomas, protuberance of the frontal 
 sinuses, fullness and separation of the orbital cavi- 
 ties, prognathism, simple or double, prominence and 
 heaviness of the jaw, etc., etc. 
 
 Dr. Cuylitz claims that degeneracy is controlled 
 by one law, i. e., the vitiation of the proportions 
 between diameters. This being so, anthropological 
 science, as applied to the study of mental aliena- 
 tion, is especially a science of indices. According 
 to him it matters little whether the brain has more 
 expansion in one way or the other, or equally in all 
 directions, i. e., whether the individual be dolicho- 
 cephalic, brachycephalic, or orthocephalic. The 
 essential thing is that the organ is not hindered in its 
 development by any isolated resistance, since, in 
 that case, it undergoes a settling which shows itself 
 externally by a deformity of the palatine vault. 
 
 "For a long lime" says M. Cuylitz (unpublished 
 communication) ' ' it has been recognized that an 
 ogival, narrow, and deep palatine vault is an iadex 
 sign of mental inferiority. The phenomenon can 
 be explained as follows : The brain tends to develop 
 transversely, but, it meets in some cases a 
 resistance in the parietal region which crowds it 
 back. This pressure is transmitted by the 
 zygomatic temporal and molar processes, pushes 
 together the alveolar bodies of the superior maxil- 
 laries, like a workman's tongs, the separation of the 
 main branches of which, that is of the parietals, 
 
CONSTITUTIONAL OB ORGANIC BLBMBNTS. 115 
 
 brings the ends together, the hinge being repre- 
 sented by the body of the sphenoid and the occipital. 
 The bringing together of the alveolar bodies or the 
 ogival palate, is therefore only the expression of a 
 cerebral collapse, an abnormal effort which in the 
 psychic life reveals itself by degeneracy. There is 
 normally a proportion of one to three and a half 
 between the distance from each other of the alveo- 
 lar margins at the horizon of the last iij)per molars 
 and the parietal or maximum transverse diameter of 
 the skull. In the hereditary degenerate, and there- 
 fore mentally imperfect, the intermolar distance and 
 the interparietal diameter, are as 1 -A^ or 5, and 
 in the idiot as even 1:6 or 6.8. This proportion or 
 index is therefore, as regards the anthropology of 
 the insane, of an extreme importance, which has 
 not up to the present been recognized." 
 
 The alterations of the encephalon are very 
 common in the insane. The meninges are frequently 
 thickened, adherent to the cranial walls or to the 
 cortex, contain osseous corpuscles, and scattered 
 here and there deposits or cysts of serous matter. 
 
 In the brain we find general or partial hypertro- 
 phy or atrophy, absence of some convolutions or 
 presence of supplementary ones, widening of 
 grooves and fissures, and anomalies of different 
 regions, particularly the psychomotor, the fissure of 
 Sylvius, the calcarine fissure, the external perpendic- 
 ular, the Rolandic and the frontal furrows. 
 
 As regards its weight, we find in the simple acute 
 
116 ELEMENTS OF MENTAL ALIENATION. 
 
 insanity a brain larger than the normal, and in the 
 chronic forms an atrophy, more or less pronounced, 
 as is also the case in idocy and imbecility. Nothing, 
 moreover, is more variable than the brain weight in 
 the insane, not only in general, but also in the 
 different forms. It may range in the pure insanities 
 from 1,200 to 1,580 grams; in dementia, from 986 
 to 1,580 grams; in imbecility from_l,040 to 1,575 
 grams; and in idiocy from 566 to 1,710. 
 
 Many authors have remarked that, contrary to the 
 normal rule, the right hemisphere often outweighs 
 the left in the insane. 
 
 The cerebellum, pons, and cranial nerves present 
 morphological changes much less frequently. 
 
 The lesions of the structure of the mass of the 
 brain vary according to the disorder. We wiU only 
 cite here, among the more frequent, hydrocephaly, 
 porencephaly, induration or softening, sclerosis and 
 degenerations of all kinds, affecting the vessels, the 
 neuroglia, and the nervous elements. 
 
 On the part of the eyes and vision we note, blind- 
 ness, myopia, hypermetropia, astigmatism, con- 
 centric contraction of the visual field, daltonism, 
 hemeralopia, pigmentary retinitis, albinism, epi- 
 canthus, microphthalmia, exophthalmus, coloboma 
 of the choroid and iris, chromatic asymmetry of the 
 iris {stigmata irien of F^re), strabismus, nystagmus, 
 ptosis, alterations of the papilla, deformities and 
 inequality of the pupil, etc. , etc. 
 
 The anomalies of the ears and hearing are quite 
 
CONSTITUTIONAL OK ORGANIC ELEMENTS. 117 
 
 frequent and important, and they are justly consid- 
 ered as true stigmata of degeneracy. They have 
 been specially stxidied of late years by Giacchi, Fere, 
 Lannois, and Frigerio. Besides complete or unilat- 
 eral deafness, which is sometimes hereditary, and 
 otitis of every kind, we find in the insane, ears badly 
 implanted, asymmetrical, enormous or rudimentary, 
 flat, fleshy, pointed, (satyr ears of Schwalbe) , widened 
 {en anse) or flat against the skull. We find also par- 
 tial deformities, absence of the tragus or antitragus, 
 arrest of development or absence of the helix and 
 antihelix, prolongation of the root of the helix, 
 which, joining the antihelix, divides the concha into 
 two parts, (F6r6) the smoothing and rolling out of 
 the pavilion, the adherence or absence of the lobule, 
 (Morel's ear) the persistence of the tubercle of Dar- 
 win, the anomalies of the scaphoid fossette, which 
 may be lacking, be single, double or triple, and con- 
 tinue itself in the lobule even independently of the 
 inversion of the antitragus, etc. , etc. According to 
 Fere, the morphological alteratiops occur more com- 
 monly on the left side. 
 
 Frigerio, who has employed a special instrument 
 in the anthropological study of the external ear 
 (Arch. d'Anthrop. Griminelle, 1888,) notices further 
 the following peculiarities : (1) The auricular tem- 
 poral angle (dcartement de V oreille), which is under 
 90 degrees in sane individuals, and only reaches this 
 figure in 20 out of 100, tends to increase in the insane 
 individuals, where we find 39 per 100 with it 90 de- 
 
118 ELEMENTS OF MENTAL ALIENATION. 
 
 grees, and in criminals in whom it is found in 55 out 
 of a hundred, and in apes where the angle is generally- 
 over 100 degrees. (2) The average index of the 
 concha for the two ears is greater in the insane than 
 in the normal individual, while that of the pavilion 
 is inferior. Nevertheless, in the insane, the concha 
 is more developed than the pavilion, especially in 
 the transverse sense. 
 
 In the mouth and teeth we find : congenital divi- 
 sion of the palate, of the uvula, hare lip, megalo- 
 glossus, persistence of first dentition, absence or 
 duplication of certain teeth, their smallness (micro- 
 dentism) or their exaggeration {geantism), tubercles, 
 notches, caries, anomalies of direction, especially of 
 canines and incisors, the presence of grooves, de- 
 formities of the dental arch, etc. , etc. (Bourneville 
 and Sollier). 
 
 In the genital organs, likewise well studied by 
 Bourneville and Sollier, (1888), we find in males: 
 hernia, rudimentary condition or exaggerated size of 
 the penis, club shaped penis, phymosis, epispadias, 
 hypospadias with three varieties, balanic, pelvic and 
 scrotal, anorchidia, monorchidia, cryptorchidia, atro- 
 phy and asymmetry of the testicles, varicocele, scar- 
 city or absence of spermatozoa, impuberty, gyneco- 
 mastia (Emile Laurent) . In the female, narrowness, 
 imperf oration or transverse or longitudinal partition 
 of the vagina, absence of the ovaries and tubes, es- 
 pecially of one side, uterus bicornis, polymastia, 
 amenorrhcea, etc, 
 
CONSTITUTIOJTAL OE ORGANIC ELEMENTS. 119 
 
 As regards the skin, we will confine ourselves to 
 mentioning albinism, vitiligo, pigmentary naevi, 
 erectile noevi, icthyosis, myxcedema, scarcity or 
 abundance of hair, beard or mustache in women, 
 tufts of hair, and double vortex, trace of anomalous 
 development of the cephalic extremity of the verte- 
 bral canal (Fer6). 
 
 Finally, we note, as to the larynx and voice, the 
 hypertrophy or absence of the thyroid body, mutism, 
 persistence of the infantile voice, and of various vices 
 of pronunciation, stammering, repetition or convul- 
 sive suspension of certain syllables, stuttering,thick- 
 ness of speech, zezaiement (giving g or j the sound 
 of z). 
 
 Lesions of Disorganization. 
 
 Lesions of disorganization are especially charac- 
 teristic of a group of mental disorders that we shall 
 study later or under the name of degeneracies of in- 
 volution or psychic disorganizations. They consist 
 essentially in acquired infirmities, i. e. , in the decay 
 of the psycho-physical being, and, like the lesions 
 of organization, they may affect not only the cere- 
 bral functions but all the apparatus and organs of 
 the economy. 
 
 It seems needless to enter into detail and enumerate 
 here these lesions, as they are all noticed under spe- 
 cial pathology. It may be said merely, that those 
 most frequently met with in the psychic sphere are : 
 weakness of memory for recent events, ideas, and 
 
130 ELEMENTS OF MENTAL ALIENATION. 
 
 words (intellectual and verbal amnesia), loss of vol- 
 untary attention {polyideisme) , obnubilation of af- 
 fections, feelings, habits of education, etc., etc., with 
 more or less marked persistence of automatic intel- 
 ligence and instincts. 
 
 In the physical organization the decay may involve 
 all parts. It affects especially the nervous centres, 
 the muscular functions, the organs of sense, the gen- 
 ital instinct, and the excretions. 
 
Cbapter ITiriF. 
 
 CLASSIFICATION. 
 
 The importance of classification in any science 
 whatever is self-evident. In mental pathology it is 
 an absolutely essential guide. 
 
 It has therefore been attempted by a great num- 
 ber of authors, from ancient times to the present, 
 and apropos to this it has been maliciously remarked 
 by Buchez, ' ' When they think they have finished 
 their studies, the rhetoricians construct a tragedy 
 and the alienists a classification." 
 
 All classifications proposed up to the present may 
 be classed under four chief heads : (1) psychological 
 classification, based on the nature of the intellect- 
 ual disorders (Ex. Hammond's, of New York) ; 
 (3) symptomatic, based upon the outward manifes- 
 tations of the disease (Ex. Esquirol, Marc6) : (3) path- 
 ogenic or etiological, based on the causes and origin 
 of development of the insanity (Ex. Morel) ; (4) an- 
 atomical, based on the character of the lesions (Ex. 
 Voisin, Luys). 
 
 The majority of classifications are mixed rather 
 than truly systematic, that is to say, they are con- 
 structed at once on several of the lines above 
 enumerated. 
 
 I will confine myself here to reproducing simply 
 
132 CLASSIFICATION. 
 
 and without comment, the classifications of MM." 
 Baillarger, Ball, and Magnan for France: that of 
 Hack-Tuke and Bucknill in England, and that of 
 Krafft-Ebing in Germany, and finally the nomen- 
 clature adopted by the International Congress of 
 Mental Medicine (1889) from the report of M. Morel 
 of Gand, and which is merely designed to furnish 
 alienists of all countries with a series of denomina- 
 tions or rubrics under which they can hereafter ar- 
 range their clinical cases so as to make them readily 
 comparable. 
 
 Classification op M. Baillaboeb. 
 
 The Insanitibs. The Demehtias. 
 
 FuTuAmnal Permrsians. PanctloncU Abolitions. 
 
 I.— 
 
 Pure Imcmities. 
 Such as, when not oui-ed, 
 terminate most frequently 
 in simple dementia. 
 
 Partial insanity. 
 Mania. 
 Melancholia. 
 Double form. 
 
 II. Paralytic Insanities. f 
 
 Such as, when not cured, J Ambitious mania. 
 
 terminate most frequently | Hypochondriacal melancholia. 
 
 in paralytic dementia. [ 
 
 i Simple intermittent insanity. 
 
 III. Intermittent Insanity ■< Insanity with alternating 
 
 ( forms. 
 
 IV. Cirimlar Insanities | ^"anitr"' '^""''^^ '"^ "" 
 
 I Alcoholic insanity. 
 
 V. Insanities of Toxic Origin. . . . •< Pellagrous insanity. 
 
 ( Insanity of malarial origin. 
 
 VI. Insanities associated with vari- I Epileptic insanitj. 
 
 ous neuroses ( Hysterical insanity. 
 
 11.— Demeniias. 
 1. General Paralysis (demence parcUytique). 
 II. Senile Dementia. 
 
 III. Dementia, symptomatic of various circumscribed cerebral 
 
 disorders. 
 
 IV. Dementia following vesanias. 
 
 III. — Arrests of Development. 
 Idiocy, Imbecility, Mental Debility, Cretinism. 
 
CLASSIFICATION. 
 
 133 
 
 Classification of Professor Ball. 
 
 Insanities. ■ 
 
 Vesanic or essential (without lesion). Types : 
 cular insanity, systematized insanity. 
 ( Hysterical. 
 
 Neuropathic -< Epileptic. 
 
 ( Choreic, etc. 
 f Gouty. 
 Hheumatio. 
 
 Diatlietic i Tuberculous. 
 
 Cancerous. 
 [ Ansemio, etc. 
 'Genital. 
 
 Cir- 
 
 4. Sympatlitlic : 
 
 Cardiac. 
 I Gastro-intestinal. 
 .Pulmonary, etc. 
 I Alcoholic. 
 
 Toxic J. Saturnine. 
 
 ( Morphine, etc. 
 
 6. Organic or cerebro- 
 
 7. CongeiiitaZ or nwrpJio- 
 
 iZiZj •""'^"'"- \ Imbecility. 
 '^^^"^ I Cretinism. 
 
 (■ General paralysis. 
 
 I Aphasia. 
 
 ] Acute delirium. 
 
 [Hemipleglo dementia, etc. 
 
 ( Idiocy. 
 
 Classification of M. Magnan. 
 
 I.— Mixed states, both pathological and mental. 
 
 General paralysis. 
 
 Senile dementia (cerebral atheroma). 
 
 Circumscribed cerebral lesions, aphasia for j Hen^rtuiEe 
 
 e^^^Vle i Tumors, etc' 
 
 Hysteria. 
 Epilepsy. 
 
 f Absinthe. 
 
 Alcoholism and intoxication . 
 
 Mania 
 
 Melancholia 
 
 Morphine and opium. 
 
 Verdigris. 
 
 Ergot. 
 
 Lead, etc. 
 
 H.— Insanities properly so-called. Psychoses. 
 
 \ Simple elements. 
 
 Clirpnio Insanity. 
 
 r Incubation. 
 1 persecution. 
 * 1 Ambition, 
 [pementia, 
 
124 CLASSIFICATION. 
 
 {Simple. 
 Circular. 
 Double form. 
 Alternate. 
 Insanity of degenerates, with episodic syndromes, and the ddires 
 
 d^embUe (pnmary). 
 Idiots, imbeciles, weaklings, iU-balanced individuals. 
 
 CLASSIFICATrON OF HaCK TuKE. 
 
 l.—Protopathic Insanity. 
 Idiocy. 
 
 Hemiplegic dementia. 
 General paralysis. 
 Epileptic insanity. 
 Senile and idio-f unctional insanities. 
 
 II. — DeuteropatMc Insanity. 
 
 Insanity of puberty. 
 Uterine insanity. 
 Climacteric insanity. 
 Puerperal insanity. 
 Eheumatismal insanity. 
 Syphilitic insanity. 
 
 111.— Toxic Inanity. 
 Alcoholism. 
 Pellasrous insanity, etc. 
 
 Classification of Krafft-Ebing. 
 
 A. — Psychic Affections of tlie Normally Developed Brain. 
 I . — PsijcJio-neuroBeB. 
 
 Mplancholin i Simple melancholia. 
 Melancholia -j Melancholia with stupor, 
 
 Mnnfo j Maniacal exaltation. 
 
 ^'^°''' 1 Acute mania. 
 
 Stupor or curable dementia. 
 "Wahnsiun" vesania, properly so-called, 
 apart from mania and melancholia. 
 
 2. Secondary insanity (Verriicktheit). 
 
 3. Dementia (terminal) (with agitation or with aphasia). 
 
 1. Primary curable con- 
 ditions 
 
CLASSIFICATION. 125 
 
 II.— Psychic Degeneracies. 
 1. Eeasoning Insanity. 
 8. Moral insanity. 
 3. Primitive insanity iprim^re J With delusions of persecution. 
 
 Verrucktheit) ( With erotic or religious delusions. 
 
 4. 
 
 f Epileptic insanity. 
 5. Insanity due to constitutional J Hysterical insanity. 
 
 neuroses | Hypochondriacal insanity. 
 
 [Periodical insanity. 
 
 in. — Cerebral Bisoj'ders with predomiTiant ni&ntal troubles. 
 
 1. Paralytic dementia. 
 
 2. Cerebral syphilis. 
 
 3. Chronic alcohohsm. 
 
 4. Senile dementia. 
 
 5. Acute delirivim. 
 
 B. — Arrests of Development. 
 
 Idiocy. 
 Cretinism. 
 
 InTEKNATIONAI, NOMENCIiATURB. 
 
 Adopter! by the Congress of Paris (1889). 
 
 1. Mania (acute deUrium). 
 
 2. Melancholia. 
 
 3. Periodical insanity (circular insanity, etc.) 
 
 4. Progressive systematized insanity. 
 
 5. Vesanlc dementia. 
 
 6. Organic dementia. 
 
 7. Paralytic insanity. 
 
 8. Neurotic insanity (hypochondria, hysteria, epilepsy, etc.) 
 
 9. Toxic insanity. 
 
 10. Moral and impulsive insanity. 
 
 11. Idiocy. 
 
 I come now to my own classification, which is the 
 same, except for successive variations produced by 
 the progress of the times, as the methodic arrange- 
 ment I have many times reported, and especially in 
 the earlier edition of this work. 
 
1^6 CLASSII'ICATION. 
 
 In constructing it I aimed at two principal 
 ends: (1) to group the morbid forms according to 
 their most important nosological characters, in such 
 a way as to obtain rational and methodical divisions ; 
 (3) to retain only the absolutely primary forms, and 
 to rank apart those secondary states that encumber 
 most classifications, so as to have the classification 
 at once simple and complete. 
 
 First, I will state how I proceed to obtain the 
 first. of these results. 
 
 The intelligence, considered as a biological entity, 
 presents itself to us under two aspects: (1) its con- 
 stitution^ that is to say, its composition, its intimate 
 structure ; (2) its functions, that is, its life properly 
 speaking, its mode of action. In other words, we 
 may consider in it, as with all the great vital appara- 
 tuses, the organ and the function. But the diseases 
 of the intelligence differ essentially according as the 
 lesion involves one or the other of these elements, and 
 it is in this, in my judgment, that is to be found 
 the fundamental division of conditions of mental 
 disease. 
 
 We will divide, therefore, these states into two 
 great classes : (1) functional or dynamic alienations 
 (vesanias, insanities, psychoses) ; and (2) constitu- 
 tional or organic alienations (degeneracies, devia- 
 tions, mental infirmities). The first represent, so 
 
CLASSIFICATION. 13? 
 
 to speak, the diseases of quality, the second those 
 of quantity of the intelligence. 
 
 This first landmark fixed, we pursue our study 
 with this dichotomous division of these two classes 
 of mental alienation. 
 
 Insanity, as follows from what has been said, is a 
 state of mental alienation characterized especially 
 by a functional alteration of the intelligence. But 
 this disease is not a single one : it forms a class 
 including many distinct groups which it is import- 
 ant to specify. 
 
 From all time it has been customary to divide 
 insanities into general and partial according to the 
 greater or less extension of the delirium. Thus 
 we have general mental aberrations (mania, melan- 
 cholia) and partial ones (monomanias). This is, 
 moreover, the basis of the well known classification 
 of Esquirol. The idea was certainly good, but its 
 application is bad, since mental aberration is not 
 insanity, it is only one of its elements, , and the 
 terms general deliriums, partial deliriums, do not 
 coiTespond to the terms general and partial insanity. 
 Moreover, these are genuine insanities without 
 mental aberration, and it is not uncommon to see 
 generalized insanities with only a partial delirium 
 and, inversely, partial insanities presenting very 
 extensive delusions (megalomania). 
 
 It is not, therefore, the degree of extension of the 
 mental aberration that should serve as a basis for the 
 division of insanities into general and partial ; this 
 
138 CLASSIFICATION. 
 
 basis is better sought in the principal characters of 
 the insanity itself. 
 
 What are these characters ? 
 
 In a biological point of view, the insane fall into 
 two very distinct classes. In the one, the whole 
 being takes part in the disorder by reason of the 
 permanent reaction of the mental trouble on the 
 whole organism : there is, we say, a lesion of general 
 activity. In the others, the disorder remains limited 
 to the psychic sphere, without seriously modifying 
 ordinary vital phenomena, which continue in a 
 regular and, as it were, an independent manner : 
 the general activity is unaffected. 
 
 It is from this point of view that we can, in my 
 opinion, consider insanity as general or partial .: we 
 would not call it complete and incomplete — insanity 
 is always complete and irreducible so far as it is a 
 disease — but rather generalized from involvement of 
 the whole being, or, on the contrary, specialized to 
 the intellectual sphere, its proper domain. 
 
 I retain therefore as primary divisions of conditions 
 of mental disease : (1) generalized insanities; (3) 
 partial insanities. 
 
 Generalized Insanity. — It follows- from what 
 has been said that the generalized insanities are 
 those in which the general activity, which we have 
 considered as the total of the reactions of the organ- 
 ism under the influence of psychic impressions, is 
 found to be altered. But this alteration may take 
 place, as we have stated, in two ways : by excess or 
 
CLASSIFICATION. 129 
 
 by default. In- the first case there is excitation; in 
 the second, depression. 
 
 This excitation and this depression, which consti- 
 tute the two modes of alteration of the general 
 activity, characterize also very correctly the two 
 kinds of generalized insanity, which are : (1) mania 
 (generalized insanity with excitement) ; (3) melan- 
 cholia or lypemania (generalized insanity with de- 
 pression). Most authorities admit a third species, 
 which may be considered as the union of the two 
 preceding ones : (3) insanity of double form or 
 alternating insanity (generalized insanity with 
 successive excitement and depression).* 
 
 In closing the subject of generalized insanities I 
 will state that the two species mania and melancholia 
 subdivide into a number of parallel or corresponding 
 varieties. We have according to the intensity of 
 the disease; (1) maniacal excitation or subacute 
 mania, which has its pendant in melancholic depres- 
 
 * Other authorities consider insanity of double form, and, 
 in a genera] way, all the periodical insanities, not as morbid 
 entities, but simply as manifestations of the mental con- 
 dition in desenerative cases. This opinion does not seem 
 to have yet sufficient basis in the present state of our knowl- 
 edge, to authorize its acceptance in my classification. 
 Whenever it prevails, tbat is to say, when it is proven that 
 the element of degeneracy predominates in the so-called 
 double form insanity and in the other periodical insanities, 
 it will be easy to take them from the group of generalized 
 insanities and to put them in the degenerative phrenopathies 
 (Table V of classification). 
 
 MENT. llBD. — 9. 
 
130 CLASSmCATION. 
 
 sion or subacute melancholia ; (2) acute mania or 
 typical mania, corresponding to acute, or typical 
 melancholia ; (3) acute delirium, or superaoute mania, 
 which is the extreme form, often febrile and mortal, 
 of mania, like melancholia with stupor or superacute 
 melancholia, the highest development, hardly less 
 grave, of melancholia. In the point of view of 
 progress, we have also as special types, (4) chronic 
 mania and melancholia ; and (5) remittent and inter- 
 mittent mania and melancholia. 
 
 As to insanity of double form, the attacks of 
 which consist essentially in a period of excitement 
 or mania and one of depression or melancholia, it 
 includes only two species : (1) the continued insan- 
 ity of double form, or circular insanity, in which 
 the attacks follow each other without interrup- 
 tion; and (2) insanity of double form with sep- 
 arate or intermittent attacks, in which the attacks 
 are separated by a longer or shorter lucid intei-val. 
 
 We come now to the division of the partial 
 insanities. 
 
 Partial Insanities. — The theory of partial men- 
 tal aberration or monomanias has had for a long 
 time a bad influence on the progress of mental med- 
 icine. Starting from the principle that all insanities, 
 all the aberrations, all abnormal tendencies, how- 
 ever isolated, represent distinct entities, we have 
 come to admit as many partial insanities or mono- 
 manias as there are morbid manifestations in the 
 spheres of ideation, feeling, or acts. Hence the 
 
CLASSIFICATION. 131 
 
 division of monomanias into intellectual, moral or 
 reasoning, and impulsive or instructive. Hence also 
 a regular invasion of so-called special insanities into 
 the nosological lists. Ambitious delusions become 
 megalomania ; i-eligious delusions, theomania ; erotic 
 insanity, erotomania ; impulse to theft, kleptomania ; 
 impulse to drink, dipsomania, etc., etc. The field 
 of monomanias is unlimited and the discoveries pain- 
 fully acquired in the past, are threatened with being 
 swept away by this torrent of new diseases. Falret, 
 Sr., was the first to lift his voice against this evil 
 tendency which was likewise combated by his suc- 
 cessors, and to-day, thanks especially to the labors 
 of Magnan, Morel, and many other French and 
 foreign alienists, the great majority of the mono- 
 manias, and, in particular, the reasoning and impul- 
 sive monomanias, have been relegated to their 
 proper place and are considered as only more or less 
 striking episodes of the condition of degeneracy. 
 There only remain, under the name, itself inexact, of 
 partial insanities, a few of the old intellectual mono- 
 manias: hypochondriacal insanity, persecutory 
 insanity, ambitious, religious, erotic, insanities, etc. 
 Further, some of these insanities have been subjected 
 to a synthesis that combines them, in an evolution- 
 ary point of view, under the same pathological 
 formula. 
 
 According to many authorities, the partial insan- 
 ities recognized at the present time may be com- 
 prehended in a single general type which, in its 
 
132 CLASSIFICATION. 
 
 normal form, presents a typical evolution in three 
 periods : (1) a period of subjective analysis, (hypo- 
 chondriacal insanity); (3) a period of delusional 
 interpretation (persecutory, religious, erotic, jealous, 
 insanities) ; (3) a period of transformation of the 
 personality (ambitious delusions). We will call it, 
 on these grounds, systematized progressive insanity* 
 (Chronic delirium. Primary systematized insanity. 
 Paranoia primaria. Primare Verrticktheit. ) 
 
 Such is the division of the functional alienations 
 or insanities that appears to me most rational and 
 most in accordance with clinical teachings. We 
 must now take up the constitutional alienations, 
 i. e., the degeneracies, deviations, and mental 
 infirmities. 
 
 CONSTITUTIONAl, ALIENATIONS OB DEGBNBKACIBS. 
 
 The second class of states of mental alienations 
 comprises, as has been said, the constitutional insan- 
 ities or degeneracies. They represent the alter- 
 ations of the intelligence, in an organic and, so to 
 say, quantitative point of view. 
 
 The intellect, however, from this point of view, 
 can be injured in only two ways: either it was 
 affected in the time of its evolution, experiencing 
 
 * To those who do not admit this theoretic conception, 
 partial insanity is not a disease of periods or stages, but 
 one of varieties. The simple substitution of t,he word 
 "variety" for the word "stage" in our synoptical table 
 will therefore answer all their requirements. 
 
CLASSIFICATION. 133 
 
 then a deviationjor arrest of development ; or, having 
 attained its complete development, it has undergone 
 a regressive evolution or process of decay. There 
 are, therefore, two groups of constitutional alien- 
 ations: (1) degeneracies of evolution or vices of 
 psychic organization ; (3) degeneracies of involution, 
 or psychic disorganizations. We will study these 
 groups in detail. 
 
 Degeneracies of Evolution (Vices of Organ- 
 ization). — Vices of psychic organization are com- 
 posed of anomalies and malformations of the 
 intelligence, altogether comparable to bodily anom- 
 alies and malformations, with which they frequently 
 coexist, being, like them, the habitual product of 
 hereditary degeneracy. 
 
 These anomalies and malformations are, it is true, 
 infinitely variable, and thus elude any rigorous sub- 
 division; but, viewed in their total, they exhibit, 
 none the less, a progressive scale of mental de- 
 ficiencies, susceptible of being classed according to 
 an ascending scale of gravity. 
 
 At the first step of the ladder, imperfectlj^ separa- 
 ted from the normal by undecisive limits, like every- 
 thing appertaining to this neutral or borderland 
 zone, we find the defects of cerebral equilibrium 
 which have for their basis a lack of unity in the psy- 
 chic organization, and for a predominant character, 
 a morbid instability. These are indeed not yet act- 
 ual diseases ; but they are already deviations of struct- 
 ure, anomalies of origin, that, as such, deserve to be 
 
134 CLASSIFICATION. 
 
 ranked at the threshold of the constitutional alien- 
 ations, under the general title of disharmonies. 
 
 At the highest degree we encounter the mental 
 infirmities, properly so called, which reveal them- 
 selves by arrests of development and profound lacu- 
 naj of the intelligence, most commonly associated 
 with analogous" physical lesions forming thus the 
 most serious morphological alterations compatible 
 with life. We designate these under the name of 
 monstrosities. 
 
 Between these two conditions, marking the extreme 
 limits of cerebral anomalies, exist a crowd of inter- 
 mediate states in which the vice of organization is 
 usually connected with neuro- and psychopathic dis- 
 orders of the most varied kinds. Hence the morbid 
 syndromes of dubious identity, classed by some in 
 the neuroses and monomanias, and considered by 
 others under the names of the mental states of the he- 
 reditaires, episodic syndromes or psychic stigmata of 
 heredity, insanity of the hereditaires, or degenerates, 
 primary and degenerative paranoia, etc. , as veritable 
 degeneracies in which the ground defect is the chief 
 element, the neuropathic or phrenopathic element 
 being an accessory and purely episodic element. This 
 view, which conforms best with the general results of 
 clinical observation, seems the best to adopt in the 
 present state of our knowledge, recognizing, neverthe- 
 less, that in certain cases the same neuropathic and 
 phrenopathic disorders may occur without any hered- 
 ity or degeneracy, properly speaking. We admit, 
 
CLASSIFICATION. 136 
 
 therefore, with certain reservations, in the constitu- 
 tional alienations, two intermediate genera, the neu- 
 rasthenias and the phrenasthenias, according to the 
 nature of the syndrome present. 
 
 We have therefore the four following genera, in 
 the order of theu- gravity: (1) the disharmonies, 
 
 (3) the neurasthenias, (3) the phrenasthenias; and 
 
 (4) the monstrosities. 
 
 These four genera include in their turn many 
 species and clinical varieties. 
 
 In the first, we can admit as common types of 
 disharmonies with their diverse individual physiog- 
 nomies : lack of balance, originality or singularity , 
 and eccentricity. 
 
 In the second the varieties are much more numer- 
 ous, at least in appearance. It is easy to see, indeed, 
 from the table of M. Magnan, how the cerebral neu- 
 rasthenias have so recently become so important. 
 There are still many other forms possible to be met 
 with, since it is sufficient to create a new species, to 
 simply take the predominant tendency or idea in a 
 neurasthenic, to give it a name and attach to it the 
 termination "phobia" or " mania," according to the 
 case. This is, in fact, what has been done as regards 
 the most of those already made. Instead of follow- 
 ing this cult of the infinitely little, that can have no 
 other result than to mislead and uselessly complicate 
 the study of psychic degeneracies already sufficiently 
 difficult, I think it better, for my part, to attempt 
 to point out, in an accessible order, the specific types 
 
136 CLASSIFICATION. 
 
 around which all possible varieties and sub-varieties 
 can gradually be arranged. 
 
 But in studying closely what we have called the 
 neurasthenias of degeneracy, it is seen that they are 
 clinically species of hysterif orm conditions, with par- 
 oxysmal crises sometimes preceded by auras, which 
 are based on a lesion of the will or, to speak physio- 
 logically, a tendency, more or less pronounced, to re- 
 flex acts by excitation or inhibition. We should 
 search then for the principle of their division, and, 
 proceeding thus, we have only to extend to the total 
 of these conditions, that which Magnan, Morselli, 
 and Ribot have attempted to do for some of them. 
 In doing this, we find that the lesion of the will in 
 the neurasthenias may present itself under three as- 
 pects, constituting, so to speak, three successive de- 
 grees. In one the morbid suggestions remain local- 
 ized, in the perceptive sphere. An idea or group of 
 ideas, generally under the form of interrogations, or 
 metaphysical apprehensions, imposes itself upon an 
 individual who is forced to painfully chase them 
 away or resolve them. It is a species of ' ' psycho- 
 logical rumination " as remarks Le Grand du SauUe, 
 apropos to the ^'■folie du doute" a mental anxiety 
 from which the will tries in vain to free itself, but 
 which is rarely accompanied with any irresistible 
 tendency. 
 
 These are the psychic or ideative neurasthenias 
 (paranoia, rudimentaria ideativa of Morselli), 
 which include aU the episodic syndromes, known or 
 
CLASSIFICATION. 137 
 
 unknown, essentially characterized by fixed ideas. 
 In a second type, the conflict between the suggest- 
 tion and the will does not remain a purely ideative 
 phenomenon ; there is a tendency to action, to the 
 impulsive repetition of a word, a gesture, a ridicu- 
 lous or unreasonable act, and it is the strife with 
 this besetting tendency that causes again an anxious 
 revolt of the will. These are the psycho-motor 
 neurasthenias (conscious impulsions : paranoia rudi- 
 mentaria impulsiva of Morselli) including all the 
 morbid syndromes, known or unknown, essentially 
 characterized by an impulsive besetment anxiously 
 combated by the will. Finally, in a degree more 
 marked, the will is so enfeebled that its potential en- 
 ergy no longer exists and the distress of the individual 
 is not because he is fatally urged to the act but, on the 
 other hand, from an agonizing feeling of his inabil- 
 ity to accomplish it. These cases are the aboulic 
 neurasthenias (aboulias) the psychological condition 
 of which has been .very well elucidated by Theodore 
 Ribot in his remarkable work on "The Diseases of 
 the Will," but the clinical description of which is 
 still to be given. They comprise all the episodic 
 syndromes, known or unknown, essentially charac- 
 terized by the abolition of power with persistence of 
 desire, a genuine phenomenon of arrest and in- 
 hibition. 
 
 Psychic, psycho-motor, and aboulic neurasthenias, 
 i. e. , fixed ideas, impulsions, and aboulias, are, there- 
 fore, in my opinion, the subdivisions to be recog- 
 
138 CLASSIFICATIOK. 
 
 nized in the neurasthenia of degeneracy, the different 
 varieties of which may moreover, coexist or replace 
 each other in the same individual. In regard to the 
 phrenasthenias I have also thought best to make a 
 sort of synthesis, and, instead of enumerating suc- 
 cessively all the varieties, that is to say, the numer- 
 ous manifestations of degenerative insanity, I have 
 aimed to unite them all under three principal heads 
 as they present themselves: (1) under the delirious 
 or hallucinatory type ; (3) the lucid or reasoning ; 
 and (3) the impulsive or instinctive form. 
 
 As to the group of monstrosities, its varieties: 
 imbecility, idiocy, and cretinism, are adm.itted by 
 all, and I am compelled, like Morselli, to exclude the 
 form "mental weakness," an indefinite type which 
 at its extremes is confused with imbecility, and in 
 its lighter forms with the phrenasthenias. 
 
 Summing up, the degeneracies of evolution or vices 
 of psychic organization divide up, according to my 
 views, into four principal genera, which are, going 
 from the simple to the complex: (1) the disharmonies; 
 (2) the neurasthenias; (3) the phrenasthenias; (4) 
 the monstrosities. Each of these genera includes in 
 its turn, as species : (1) the disharmonies : defect of 
 balance, originality, eccentricity; (2) the neuras- 
 thenias: fixed ideas, impulsions, aboulias; (3) the 
 phrenasthenias: the delusional, reasoning, and in- 
 stinctive, phrenasthenias ; (4) the monstrosities : im- 
 becility, idiocy, and cretinism, to which may be 
 added myxcedema. 
 
CLASSIPIOATIOlSr. 
 
 139 
 
 -PlTNCTIONAL ALIENATIONS (INSANITIES, VeSANIAS, 
 
 Psychoses.) 
 
 Generalized 
 symptomatic 
 sanities 
 
 (1) Mania. 
 
 (2) MdancIutUa or 
 
 Partial or essen- 
 tial INSANITIES. 
 
 (3) Insanity of 
 dwMe form. 
 
 pro- 
 
 Subaoute mania (maniacal 
 
 excitation). 
 Acute mania (typical 
 
 mania). 
 Hyperacute mania (acute 
 
 delirium). 
 Chronic mania. 
 Remittent or intermittent 
 
 mania. 
 Subacute melancholia 
 
 (melancholic depression.) 
 Acute melancholia (typical 
 
 melancholia). 
 Hyperacute melancholia 
 
 (melancholia with 
 
 stupor). 
 Chronic melancholia. 
 Remittent or intermittent 
 
 melancholia. 
 Continuous insanity of 
 
 double form. 
 Intermittent insanity of 
 
 double form. 
 First stage (hypochondria- 
 cal insanity^ 
 Second stage (persecutory, 
 
 religious, political, 
 
 erotic, etc. insanity.) 
 Third Stage (ambitious 
 
 insanity). 
 
 II. — Constitutional Alienations (Degeneracies, De- 
 viations, Mental Infirmitibs). 
 
 Degeneracies of 
 
 EVOLXTTION (viCCS 
 
 of organization.) 
 
 r I^isMr^ies ] "l^«f„,^4, e%t^^^: 
 
 Neurastkenla. ] ^l^^ui^^' im^uMon., 
 
 r Delusional (multiple delu- 
 sions of degenerates). 
 PhrmaMenias \ Keasoning (reasoning in- 
 
 fnrenmmemas -j ganity, moral insanity). 
 
 Instinctive (instinctive in- 
 t sanity). 
 ,( Imbecility. 
 
 •< Idiocy. 
 
 ( Cretinism, myxoedema. 
 
 Dbqeneracies of I 
 Involution (Dis--^ Dementias.. 
 organization.) ( 
 
 Simple dementia. 
 
140 CLASSIFICATION. 
 
 We pass now to the degeneracies of involution or 
 psychic disorganization. 
 
 Dbgenbracibs of Involution ob Psychic Disor- 
 ganization. — While the vices of organization form a 
 vast total of morbid states, the grouping of which, as 
 we have seen, offers numerous difficulties, the psychic 
 disorganizations present themselves under a simpler 
 form, and without any complexity. Being essen- 
 tially based on cerebral enfeeblement, that is to say, 
 on the decadence of the individual, they sum up in 
 a single genus, the dementias. It is true, all the 
 cases of dementia are not absolutely alike, but they 
 have all a common fundamental characteristic, the 
 progressive dissociation of the faculties, in an almost 
 unvarying order. For this reason we may have in 
 an etiological, not clinical, sense many kinds of de- 
 mentias; there is in reality only one type, that of 
 simple dementia. 
 
 We have now reached the end of our classifica- 
 tion, in which we have attempted, as we proposed 
 to ourselves, "to group the morbid forms according 
 to their more important nosological characters, in 
 such a~way as to obtain rational and methodical di- 
 visions." The exposition may have seemed some- 
 what arid and diffuse, — that is difficult to prevent in 
 such a matter, — but the total of the preceding state- 
 ments will not fail, we think, to make it clear with 
 the aid of the table opposite, which gives in a syn- 
 thetic list the natural grouping of classes, groups, 
 genera, species, and varieties, that we have adopted. 
 
CLASSIFICATION. 141 
 
 III. 
 
 Our classification stated, that is, the first part of 
 the problem solved, we begin upon the second, which 
 we have, it will be remembered, formulated as fol- 
 lows : To retain in this classification only absolutely 
 primary conditions and to rank apart the secondary 
 states which uselessly encumber most classifications. 
 
 Nothing is easier than to realize this desideratum 
 clinically. 
 
 If we go actually to the bottom of things we per- 
 ceive that the innumerable insanities existing, apart 
 from the primary types defined and named above, 
 can all be reasonably considered as morbid associa- 
 tions, composed of two elements: (1) a vesanic 
 element represented by any variety whatever of 
 primary alienation (usually mania or melancholia), 
 always identical fundamentally with itself; (2) a 
 physiological or pathological element that serves, so 
 to speak, as a substratum and varies according to 
 the case. 
 
 Thus puerperal insanity is nothing but the asso- 
 ciation of a mania or melancholia with the puerperal 
 condition ; uterine insanity the association of this 
 mania or melancholia with a disease of the uterus ; 
 paralytic insanity its association with general paral- 
 ysis, etc., etc. That which differs in these morbid 
 associations is therefore not the insanity, which is 
 always the same thing, but only the existing process, 
 and its proof is that with information and testimony 
 
142 CLAssmcATioiir. 
 
 it is impossible to distinguish the different cona^posite 
 insanities from one another. 
 
 To close, the case, the symptomatic insanities are 
 not special forms and if they present any more or 
 less striking peculiarities by reason of the condition 
 with which they are connected, they do not essentially 
 differ from simple insanity, of which they may rightly 
 be considered as combinations. 
 
 This view, exact and practical, has the further 
 merit of simplifying the general conception of 
 mental disorders, since it shows that alienation 
 is at bottom reducible to a few primary types and 
 that all the other insanities are nothing but an 
 association of these types, invariably playing 
 the rdle of a radical, with some organic process or 
 other. 
 
 In this way we believe we have solved the second 
 term of the problem, in striking out from our class- 
 ification "all the secondary conditions which encum- 
 ber the majority of classifications." 
 
 If now we take a general view of the route by 
 which we have come, we perceive that the data which 
 have been given may be summed up in the following 
 f ormulse : 
 
 I. The conditions of mental alienation are sus- 
 ceptible of being divided into two great classes: 
 (1) functional alienations or insanities ; (3) constitu- 
 tional alienations or degeneracies. 
 
 The insanities subdivide into two groups : (1) 
 generalized insanities; (3) partial insanities. The 
 
CLASSIFICATION. 143 
 
 generalized insanities comprise in their turn three 
 genera: (1) mania, (species: subacute, acute, hyper- 
 acute, chronic, remittent, and intermittent mania) ; 
 (3) melancholia, (species : subacute, acute, hyper- 
 acute, chronic, remittent, and intermittent melan- 
 cholia.) (3) Insanity of double form (species: 
 continuous and intermittent double form insanities.) 
 The partial insanities have only one genus ; system- 
 atized progressive insanity, composed of three stages 
 or species : (1) hypochondriacal insanity ; (3) persecu- 
 tory, religious, political, erotic, jealous, etc., 
 insanities; (3) ambitious insanity. 
 
 The degeneracies subdivide also into two groups : 
 (1) degeneracies of evolution or vices of psychic 
 organization ; (2) degeneracies of involution or psy- 
 chic disorganizations. The vices of organization 
 include four genera: (1) disharmonies (species: de- 
 fect of balance, originality, eccentricity) ; (3) neu- 
 rasthenias (species : fixed ideas, impulsions, aboulias) ; 
 (3) phrenasthenias (species : delusional, reasoning, 
 instinctive, phrenasthenias) ; (4) monstrosities (spe- 
 cies : imbecility, idiocy, cretinism) . The psychic 
 disorganizations include but one genus : the demen- 
 tias, which are also summed up in one species, simple 
 dementia. 
 
 II. There are no primary states of mental alien- 
 ation other than the preceding. All other insanities 
 do not exist as distinct entities. They are nothing 
 but associations of a generalized simple insanity, 
 
144 CLASBIFICATIOlir. 
 
 mania or melancholia, with some physiological or 
 pathological process in the organism. 
 
 Such, in brief, is the classification that is to serve 
 us as a guide. It is, in effect, in the order indi- 
 cated in the table which exhibits it, that we now 
 pass to study, under the head of special pathology, 
 the various primary forms of mental alienation. 
 
SPECIAL PATHOLOGY. 
 
 FIRST SECTION 
 PRIMARY STATES OF MENTAL ALIENATION. 
 
 FIEST CLASS 
 
 FUNCTIONAL ALIENATIONS 
 (iNSAiriTrBB, Vesaihas, Psychoses). 
 
 FIRST GROUP 
 
 GENERALIZED OR SYMPTOMATIC INSANITIES. 
 
 The generalized insanities, also called erroneously- 
 general insanities, are, as has been stated, those in 
 which there is a permanent reaction of the mental 
 disorder on the whole organism, that is to say, a lesion 
 of the general activity. Apart from this fundamental 
 character, they possess other fundamental characters 
 which are summed up in this : (1) heredity is less 
 frequent and serious ; ('2) occasional causes play in 
 them a more important part ; (3) they often appear 
 as acute disorders ; (4) they are essentially curable ; 
 (5) they frequently are associated with various other 
 physiological or morbid conditions to form the com- 
 pound or symptomatic insanities. 
 
 The generalized insanities include two genera: 
 (1) mania ; (3) melancholia or lypemania. 
 
 Hbnt. Hied. — 10. 
 
Cbapter 1FD. 
 
 MANIA. 
 
 I— Acute Makia (Typical Mania). II— Sub-acute Mania 
 (Maniacal Excitation). Ill — Hyper- acute Mania 
 (Acute Delirium). IV— Chronic Mania. V— Remit- 
 tent AND Intermittent Mania. 
 
 §1. ACUTE MANIA (TYPICAL MANIA). 
 
 Definitiok. — Acute mania is the typical or simple 
 form of mania. It is defined by Esquirol as " A 
 cerebral affection, cbronic, ordinarily afebrile, char- 
 acterized by disturbance and exaltation of the sen- 
 sibility, the intelligence, and the will." M. Ball 
 defines it, in his turn, as: "An insanity character- 
 ized by a generalized delirium, with marked hyper- 
 excitation of the intelligence and a tumultuous desire 
 for movement." 
 
 Etiology. — Mania has not, properly speaking, any 
 special etiology, and may recognize, singly or to- 
 gether, the majority of the causes enumerated in 
 the etiology of insanity generally. It should be 
 remarked, however, that it attacks, by preference, 
 subjects of expansive and excitable temperament, 
 young persons, the female sex, and that it is most 
 liable to occur in the spring and during the summer. 
 
ACUTE MANIA (tTPICAL MANIa). 147 
 
 Symptomatology. — There may be recognized in 
 acute mania a period of invasion, a period of culmin- 
 nation, and a period of termination or subsidence. 
 
 1 — Period of Invasion. — The onset of acute 
 mania is generally characterized by a phase of de- 
 pression, fatigue, vague discomforts, moroseness, 
 together with certain nervous and organic disturb- 
 ances, such as cephalalgia, insomnia, loss of appetite, 
 constipation, etc. This premonitory stage continues 
 for a variable period, from a few hours to several 
 days; when the general malaise passes away, and at 
 the same time the psychic disorder begins to appear, 
 so that at the moment the insanity really commences, 
 the patients often experience a really surprising sen- 
 sation of well-being. Little by little the excitement 
 makes its appearance, an imperious desire for action 
 is felt, all the faculties and functions become grad- 
 ually exalted. From this arises an extreme mobility 
 in thought and actions, continual changes of place, 
 multiplied projects and conceptions, irritability of 
 character, causeless outbreaks of passion, and, fre- 
 quently, a more or less pronounced tendency to alco- 
 holic and venereal excesses, which one must be on his 
 guard against mistaking for the causes of the disease, 
 of which they are really only among the earlier 
 symptoms. 
 
 In certain cases, following, for example, a sudden 
 suppression of the menses, or in periodical insanity, 
 there is a very short stage of invasion, and the attack 
 appears, as it were, in its full intensity from the first ; 
 
148 MAinA. 
 
 generally, however, there is a gradual onset; finally 
 in some instances there occurs a very characteristic 
 series of oscillations between the excitement and the 
 normal condition before the psychosis takes on its 
 continuous character. 
 
 In one of these ways, sooner or later, the case 
 progresses to its culmination. 
 
 2 — Period of Culmination. — An attack of acute 
 mania does not conform to any one invariable de- 
 scription, the symptoms, although essentially the 
 same, vary more or less according to the case. It 
 seems to me best, therefore, to study the principal 
 characters successively in the intellectual, moral or 
 emotional, and physical spheres respectively. 
 
 a. Intellectual Sphere. — The characteristic trait 
 of the state of the intelligence in acute mania, is the 
 disorderly excitation of the faculties, which, freed 
 from the domination of the will, act at hazard and 
 without restraint. There follows: (1) a defect of 
 consecutivness of the ideas, which arising en masse 
 and unceasingly, accumulate, crowd, confuse and 
 override each other without any apparent connection ; 
 (2) very marked incoherence of speech, revealing 
 the disorder and the confusion of the ideas, and 
 showing itself by a constant flow of words and un- 
 connected phrases, and especially by obscene ex- 
 pressions which are frequent even from the mouths 
 of young girls of irreproachable antecedents. On 
 account of this excessive mobility of ideas, there are 
 
ACUTE MANIA (tTPICAL MANIA). 149 
 
 not, properly speaking, any delusions in mania, and 
 if ambitious or persecutory notions manifest them- 
 selves, they rarely do so in any systematic or consec- 
 utive fashion ; (3) another very important symptom 
 consists in the existence of very numerous and 
 varied illusions. Hallucinations are, on the con- 
 trary, very rare, if indeed they really occur. The 
 illusions in mania are either sensorial or mental. 
 The sensorial illusions, connected with the hyper- 
 iESthesia of the organs of sense and the precipitateness 
 with which the patients respond to their sensations 
 without analyzing them, involve especially the sense 
 of sight and consist in misj udgments of form, volume, 
 positions, of objects, persons, etc. The very charac- 
 teristic mental illusions are equally common. Also 
 the result of the automatic activity of the mind, they 
 are due to the rapidity of impressions and especially 
 to the hyperactivity of the association of ideas ; which 
 gives rise in these patients to extraordinary conjunc- 
 tions of ideas. A word uttered before them calls up a 
 complete scene with which the word is connected ; the 
 termination of another word causes them at once to 
 pronounce another word with a similar ending ; and 
 they thus construct whole sentences by assonances or 
 rhymes. Similarly the names or faces of strangers 
 about them recall to them individuals they have pre- 
 viously known and awaken in them a whole world of 
 memories of the past which they adapt to their present 
 life. This is the explanation of their designation of 
 these individuals by special names and treating them 
 
150 MANIA. 
 
 as if old aquaintances. The least object, the shape of 
 a room or window, the reading of a word or even of a 
 single letter, becomes with them the point of depart- 
 ure for the most fantastic dreams ; and they believe 
 themselves successively, and in the space of a few 
 minutes : popes, kings, physicians, farmers, orators, 
 women; in a palace, a prison, a hospital, a theatre, etc., 
 etc. They assist in their imagination s in the strangest 
 scenes. Their delirium is a dream in action. Maniacs 
 that have recovered, and who, curiously enough, can 
 recall day by day and minute by minute what they 
 have said and done in the course of their attack, ex- 
 plain very well how the least word or object became 
 with them the starting point of the most extra- 
 ordinary ideas. We may say that the maniac, in 
 his acute stage, lives in a condition of perpetual 
 illusion. 
 
 Their writings are altogether similar to their 
 speech, that is to say, incoherent, unconsecutive, 
 full of designs and arabesques, of citations and un- 
 usual words, and written in every direction. 
 
 b. Moral or Emotional Sphere. — In the moral 
 sphere the tableau is the same and is likewise 
 summed up in a disordered activity of the feelings, 
 instincts, and acts. Hence a mobility, an incoher- 
 ence, an incessant changing of the feelings, 
 affections, and emotions. The patients weep and 
 laugh; they are pleasant and amiable; a moment 
 later they burst into passion and sometimes into 
 fuiy (maniacal furor). At bottom the maniacs are 
 
ACUTE MANIA (TYPICAL MANIa). 151 
 
 not altogether bad, for they are incapable of plan- 
 ning evil on account of the variability and lack of 
 continuousness of their impressions. They have, 
 properly speaking, no character. As to the in- 
 stincts, they are also morbidly exalted, especially the 
 sexual instinct, and it happens too frequently that 
 we see these patients give themselves furiously to 
 the habit of masturbation, or when they are at large, 
 indulge to complete exhaustion in sexual excess. 
 
 With this disordered excitement of the mental 
 and moral faculties there is a corresponding excite- 
 ment in action, which betrays itself by a constant 
 desire to move, run, leap, dance, to indulge in 
 bizarre gesticulations, to vociferate and cry inces- 
 santly. From this tumult of ideas and feelings, 
 the maniacs, obedient blindly to their sensations, 
 are subject to continual and instantaneous impul- 
 sions. They are in this way unconsciously danger- 
 ous, without intention, but they are more inclined 
 to break, tear, or overturn whatever comes in their 
 way, from a sort of automatic impulsion, than they 
 are to conceive and execute the acts of homicide or 
 suicide, which necessitate a reflection of which they 
 are incapable. 
 
 c. Physical Sphere [Morbid Meaction). — Here 
 also we encounter a disordered excitation that re- 
 veals itself in the most of the bodily manifestations. 
 
 The general attitude of maniacs is characteristic. 
 They are in perpetual motion and excitement and no 
 part of their body is quiet. They display an in- 
 
152 MANIA. 
 
 cessant and absolute license of acts, gestures, sing- 
 ing, laughing, crying, contortions ; the voice has a 
 peculiar raucous quality ; the countenance is animated, 
 flushed; the eyes sparkling; the dress disordered 
 and torn; the females especially are disheveled, 
 semi-nude, they assume indecent attitudes and in 
 some cases resemble actual furies. 
 
 Sleep is nearly or quite absent, and the nights are 
 often more disturbed than the day. The insomnia 
 is rebellious to all calmatives and sometimes lasts 
 several months. General sensibility is usually much 
 deadened, and the patients, in spite of the disorder 
 of their attire, seem insensible to the most decided 
 changes of temperature. The organs of special 
 sense, on the other hand, are almost always the seat 
 of a more or less marked hyperaesthesia. Muscular 
 force seems to be increased, in any event we see the 
 patients, even frail young females, display a vigor 
 of which we could hardly believe them capable; 
 moreover, in spite of the persistent excitement and 
 frightful expenditure of force, the patients never 
 seem exhausted. 
 
 As regards the organic functions, they almost in- 
 variably are affected by this excitement. The pulse 
 becomes more frequent; the temperature often is 
 elevated ; the respiratory rhythm is quickened ; the 
 secretions augmented, especially the saliva, which is 
 gotten rid of by a sometimes incessant expectoration, 
 and the perspiration which is said to sometimes 
 give off the odor of mice. The appetite is exagger- 
 
ACTJTB MANIA (tTPICAL MANIA). 153 
 
 ated, and some cases develop a revolting degree 
 of voracity and gluttony; constipation may be 
 obstinate." The bodily weight is much reduced, the 
 patient becomes more and more emaciated, and it 
 is only at convalescence, or, on the other hand, at 
 the passage to the chronic state, that the embonpoint 
 begins to reappear. In females the menses are 
 usually suppressed ; when they persist their return is 
 nearly always the occasion of an exacerbation of the 
 excitement. 
 
 3 — Period of Termination. — An attack of acute 
 mania may end: (1) in recovery; (2) in death; (3) 
 by the passage into the chronic state. 
 
 Rbcovbet. — Recovery takes place in acute mania 
 in several different ways. 
 
 The excitement may disappear all at once, between 
 two days, and tlie patient who fell asleep in a state 
 of acute mania, may awake in the morning, per- 
 fectly calm, and in the full possession of his reason ; 
 often indeed, he is never more lucid than at the first 
 moment. This mode of recovery should not be 
 considered as of good omen, and it appears to be 
 more special to mania of the intermittent or remit- 
 tent types. It is best, therefore, to mistrust it, 
 and when it occurs to be on one's guard against 
 relapses. 
 
 A second mode of recovery is that by progressive 
 oscillations. When the attack is about to end there 
 is a glimmer of calm, which repeats itself at shorter 
 
154 MANIA. 
 
 and shorter intervals, increasing each time in degree 
 and duration, and alternating with the return of ex- 
 citement which becomes each time less ititense and 
 prolonged till it finally entirely disappears. 
 
 A final mode of recovery is that by progressive 
 and uninterrupted decrease of the symptoms. It 
 begins with diminution of the excitement, return of 
 sleep, and body weight, and gradually progresses 
 till health is fully re-established. It is evident that 
 this improvement in the symptoms is without value 
 unless it involves both the mental and the bodily 
 condition, since, as has been stated, the return of 
 embonpoint coincident with persistence of the men- 
 tal disorder is, on the contrary, a sign of bad augury. 
 Aside from this eventuality, recovery by progressive 
 amelioration is, like the preceding mode, a gener- 
 ally favorable one. 
 
 Death. — Acute mania rarely terminates in death. 
 When this occurs, it is almost invariably due to a 
 super-added acute delirium or some organic affection, 
 especially a pulmonary disease. 
 
 Passage to the Cheonic Condition. — Next to 
 recovery, termination by passage into the chronic 
 state is the most frequent one in acute mania. 
 
 The critical moment when the acute disorder 
 ceases to be curable, to become definitely chronic, 
 is one of the most diflSicult matters to determine in 
 mental medicine. When it occurs, we see the ex- 
 citement after being slightly diminished, persist in- 
 
ACUTE MANIA (tTPIOAX MANIa). 155 
 
 definitely in this new degree, always accompanied 
 by incoherence and confusion of ideas while, on the 
 other hand, the strength returns and bodily nutrition 
 is re-established. Nothing is more variable than 
 the epoch of this change to the chronic state. In 
 some cases it takes place almost at once, at the end 
 of the second or third month from the beginning of ' 
 the attack ; in others it has not yet occurred after 
 three or four years. 
 
 Peogebss. — DuEATiosr. — Simple acute mania has 
 generally a regular evolution, comprising periods 
 of increase, culmination, and decline; but it may 
 present an irregular course, with times of arrest, 
 lucid intervals, and remissions. Its duration is also 
 variable, and while we may assign it an average of 
 between two and eight months, it may prolong it- 
 self much more, and last several years. 
 
 Pathological Anatomy. — Autopsies in acute 
 mania are generally negative ; the lesions encountered 
 may be usually stated as being comprised in a gen- 
 alized hypersemia of the nervous centres. 
 
 Prognosis. — The prognosis of acute mania is 
 most frequently favorable, as, according to most 
 authorities, it ends in recovery about twice out of 
 three times when it is uncomplicated. 
 
 The chances of a cure are particularly good in the 
 first six months; they are only half as good, the 
 second semester; and become almost nil after the 
 third year. The instances of recovery after many 
 
156 MANIA. 
 
 years that have been reported are exceptional and do 
 not invalidate the rule. 
 
 The season has its influence on the mode of 
 termination. In general there are few cures of 
 mania in winter; they increase in number in the 
 springtime, and it is in summer and autumn that the 
 greatest number of recoveries are observed. Also, 
 the younger the patient the better the chances of 
 recovery. A first attack is more curable than a 
 second or a third. The curability varies also accord- 
 ing to the causes and the course of the disorder. 
 
 Diagnosis. — Acute mania is, as a rule, very easy 
 of recognition. Nevertheless it may be confounded, 
 during the first few days, with a febrile delirium, 
 marking the beginning of an acute affection. The 
 thermic evolution, however, is quite different in the 
 two cases. 
 
 The most important point in the diagnosis is to 
 determine whether the attack of acute mania is un- 
 complicated, or whether it is symptomatic of any 
 other morbid condition, general paralysis, alcoholism, 
 epilepsy, the puerperal state, etc. , etc. This point, 
 sometimes very diiBcult to decide, can only be resolved 
 by a thorough acquaintance with the symptoms of 
 the principal disease and the peculiarities it impresses 
 upon the mania itself. We will, therefore, find the 
 elements of this diagnosis in the continuation of our 
 studies. 
 
 It is finally necessary to ask, in the presence of 
 an attack of acute mania, whether it is not the first link 
 
SUB- ACUTE MAKIA (MANIACAL EXCITATION). 16 7 
 
 of a pathological chain, that is to say, the commence- 
 ment of an intermittent or double form insanity. 
 The succession of attacks can alone dispel all doubts. 
 It is well to suspect this, as a rule, when there is 
 pronounced hereditary taint, when cases of intermit- 
 tent or circular insanity have existed in the ances- 
 tors, or, finally, whenever the attack begins and 
 ends suddenly, and when the mind is never brighter 
 than during the first days of recovery. 
 
 Treatment. — Isolation as soon as possible. Dur- 
 ing the attack, sedative measures of all kinds, 
 especially warm baths prolonged for several hours. 
 For the agitation and insomnia, bromides, 
 chloral, paraldehyde, methylal, sulfonal, hyoscy- 
 amine, hyoscine, etc. Derivatives by the intestinal 
 canal. When the passage to the chronic condition 
 is threatened, strong revulsive measures may be tried 
 and artificial suppuration established. Symptom- 
 atic treatment. In certain cases, the use of the cami- 
 sole and of artificial feeding may be required. 
 
 §11. SUB-ACUTE MANIA (MANIACAL 
 EXCITATION). 
 
 Sub-acute mania, or maniacal excitation is only 
 the first degree of mania. It forms a variety by it- 
 self in the nosological scale, with its own special 
 symptoms. 
 
 Etiology. ■ — Maniacal excitation recognizes the 
 same causes as acute mania and insanity m general ; 
 
158 MANIA. 
 
 it arises more often from heredity than does simple 
 mania, and it may be said that the majority of 
 maniacally excited individuals are cases of hereditary 
 predisposition. 
 
 Desckiption. — Maniacal excitation reveals itself 
 in an infinite number of degrees, from simple hyper- 
 activity of the physiological operation of the 
 intellect, to quite disorderly delirious excitement. 
 
 In its slightest degree it amounts to merely an 
 exaggeration of the psychic activity, and may thus 
 form a part of the constitutional make-up of some 
 individuals who are all their lives mild cases of ma- 
 niacal excitation. 
 
 In a more advanced degree, it is clearly patholog- 
 ical and is accompanied by well marked symptoms. 
 
 In- the intellectual sphere all the faculties are in a 
 state of extreme exaltation. The over-stimulated 
 imagination leads the patients to devise a thousand 
 projects, no sooner conceived than abandoned; busi- 
 ness plans, political and social schemes, inventions, 
 scientific, artistic, and literary ideas arise in multi- 
 tudes, but differ very decidedly from the delirious 
 ideas of acute mania, since, although for the most 
 part unrealizable, they are not in themselves absurd 
 and move constantly within the range of possibility. 
 Often, indeed, on account of the exaltation of the fac- 
 ulties, they have a stamp of originality, of novelty, or 
 of distinction and superiority that makes them really 
 noteworthy. Patients in this condition have pro- 
 duced useful inventions, solved important problems, 
 
STJB- ACUTE MANIA (mANIACAL BXCITATIOn). 159 
 
 brought out valuable works, in a word, have shown 
 themselves more intelligent and productive than 
 they had ever been before. 
 
 The memory is also in a condition of functional 
 hyper-excitation, (hypermneaia) ; sometimes to such 
 an extent that all recollections, even those that 
 seemed most forgotten, reproduce themselves en 
 masse, so that the patients recite long passages from 
 the classics, make citations in all languages most cor- 
 rectly and appropriately, give names, dates, and 
 figures with surprising accuracy ; in short, display 
 in detail without any omissions, all their acquire- 
 ments, small and great, that they have made since 
 their infancy. 
 
 The faculty of language is in keeping with the 
 other faculties, that is to say, the animation of the 
 excited maniacs is inexhaustible. Loquacious to the 
 extreme, they express themselves with extraordinary 
 facility, often even with ohoiceness and elegance; 
 their discourse is full of bright remarks, jests, caustic 
 pleasantries and anecdotes full of interest. The 
 same is true of their writings and all other intel- 
 lectual products which all bear the marks of this 
 brilliant exaltation of their faculties. 
 
 The character of the ideas themselves is extremely 
 variable and mobile. The predominating concep- 
 tions are those of pride, ambition, fortune, vague 
 persecution, etc. ; but they keep as a rule within 
 the limits of coherency, and there are, properly 
 speaking, no delusions. 
 
160 MANIA. 
 
 In some cases, nevertheless, the excitation of the 
 faculties is more marked, and there is a true delirium, 
 always semi-coherent, that commonly assumes the 
 ambitious type and reveals itself by ideas of inven- 
 tion, statesmanship, erotism, etc., etc. From these 
 there have, in former times, been made a number of 
 varities of intellectual mania, called, according to 
 the type of ruling ideas, ambitious mania, mania of 
 inventors, erotic mania, etc. When the maniacal ex- 
 citation is thus accompanied by delusions, there are 
 often added, as in acute mania, sensorial and mental 
 illusions, but not of as unreasonable a nature. Hallu- 
 cinations never occur, or at least if they are present, 
 they are due to some superadded morbid condition. 
 
 In the moral or emotional sphere the hyper-excita- 
 tion is shown generally by a more or less marked ex- 
 aggeration of the evil tendencies and the vicious in- 
 stincts. The maniacally excited individuals are, for 
 the most part, vicious, proud, litigious, prodigal, ob- 
 scene, malignant, passionate, even violent. They 
 enjoy ridiculing everything, in plotting mischief, and 
 are aided wonderfully in their perverse tendencies by 
 their lucidity and shrewdness. At the same time 
 they have frequently a very marked propensity to 
 manoeuvring, to scandal, to drink, to lewdness, es- 
 pecially when the attack takes on an acute form. 
 It is almost only in general paralysis that maniacal 
 excitation ever reveals itself by a moral erethism 
 in the contrary sense, that is by a generous disposi- 
 tion and excessive philanthropy. 
 
SUB- ACUTE MANIA (mANIACAL EXCITATIOn). 161 
 
 Maniacal excitement is nearly always accompan- 
 ied by bodily activity, but moderated, coherent, and 
 always very different from the incoercible agitation 
 of acute mania. There are also occasional symptoms 
 of transient congestion, such as pupillary inequality, 
 tremor, slight hesitancy in speech, which complicate 
 the diagnosis, all the more inasmuch as maniacal ex- 
 citation is often symptomatic of incipient general 
 paralysis. 
 
 Course. — Duration. — Termination. — The at- 
 tack of maniacal excitation follows nearly the same 
 course and has about the same duration as that of 
 acute mania. Its most frequent termination is re- 
 covery ; it rarely passes into the chronic condition ; 
 occasionally it is replaced by an attack of acute 
 mania. 
 
 Prognosis. — If we consider only the attack it- 
 self, the prognosis is very good. It must be borne 
 in mind, nevertheless, that maniacal excitation is 
 often only the first stage of a double form insanity 
 or an intermittent mania, when it is not symptomatic 
 of commencing general paralysis or of hysteria, 
 which sensibly modifies the prognosis. 
 
 Pathologicax Anatomy. — There is nothing to 
 state in this regard unless it be that there is a more 
 circumscribed hypersemia than in acute mania. 
 Autopsies, also, are very unusual in this disorder. 
 
 Diagnosis. — Maniacal excitation, with its pathog- 
 nomonic symptoms of intellectual hyper-activity is 
 
 Ment. Med.— 11. 
 
162 MANIA., 
 
 recognizable at once. It is hardly possible to con- 
 found it with acute mania, from which it is dis- 
 tinguished by the absence of disordered agitation, 
 nor with ambitious delusion (partial insanity)which, 
 aside from its other characters, is almost never pri- 
 mary. It is much harder to distinguish the morbid 
 species with which it may be connected, especially 
 when it is a double form insanity or beginning gen- 
 eral paralysis. It should be remembered that in 
 these cases of double form insanity the physical 
 symptoms are often lacking, the conceptions are 
 never absurd or demented, and finally that the 
 patients are thoroughly vicious and dangerous. 
 
 Tkeatment. — When maniacal excitation attains 
 a certain height it is almost always necessary to se- 
 questrate the patients, on account of danger to their 
 families and to society. Otherwise the same treat- 
 ment as for acute mania is applicable. 
 
 §111. HYPER- ACUTE MANIA (ACUTE DELIRIUM). 
 
 Acute delirium lacks a definite position in the 
 list of mental diseases. According to some authori- 
 ties, it is a morbid entity, according to others, a mei"e 
 symptom or complication. In reality it maybe con- 
 sidered as the highest degree of mania, of which, it 
 forms, by its peculiar characters, a special variety. 
 
 Etiology. — Acute delirium is usually the se- 
 quence of grave moral or physical disturbances. It 
 
HTPEK-ACUTE MANIA (acUTE DBLIEIUm). 163 
 
 is especially symptomatic, that is to say, connected 
 with different morbid conditions, such as general 
 paralysis, alcoholism, puerperal states, etc. 
 
 Description. — The commencement of the disor- 
 der is nearly always marked by a period of premon- 
 itory depression, that in some cases may suggest an 
 incipient melancholia. There has even been de- 
 scribed a melancholic form of acute delirium, but 
 this seems more properly to belong to the type of 
 melancholia with stupor. Generally, after a longer 
 or shorter depressive phase, the agitation makes its 
 appearance and, in a few days, sometimes only a 
 few hours, it reaches its maximum of intensity. 
 The tongue becomes dry, the fever quickens, the 
 pulse is over 120, the temperature rises rapidly to 
 40° or 41" (=104° to 105.8° F.), the head is hot, 
 the eyes wild, the skin covered with a viscous per- 
 spiration. The patients appear terrified; they are 
 the prey of an intense agitation ; they give utter- 
 ance to incessant cries, they expectorate constantly 
 their saliva in whitish sputa, have a horror of food, 
 and sometimes even exhibit symptoms of hydropho- 
 bia. The reflexes are exaggerated and the least ex- 
 citation produces convulsive attacks. 
 
 At this moment, a cure is still possible by gradual 
 defervescence, followed usually by a long convales- 
 cence; but the usual termination of the disease is 
 death between the fifth and tenth day. When this 
 is to occur the fever increases ; a sort of coma suc- 
 ceeds the agitation ; the pulse becomes more rapid 
 
164 MANIA. 
 
 and weaker; the tongue and lips are covered with 
 dark colored crusts, the breath is fetid, the respira- 
 tion puffing ; the urine and fasces are passed involun- 
 tarily, insomnia is persistent; subsultus of the ten- 
 dons and general or partial convulsions appear; 
 typhoid symptoms make their appearance ; diarrhcea 
 occurs, the pulse becomes imperceptible, coma is 
 deeper and deeper ; finally failure approaches and the 
 patient dies, either suddenly in syncope or slowly 
 from nervous exhaustion. 
 
 Pathological Anatomy. — In most cases of sim- 
 ple or vesanic acute delirium we find no apparent 
 lesions at the autopsy (acute delirium without 
 lesions) ; it is only when the disorder is symptom- 
 atic of some other afl^ection (general paralysis, 
 alcoholism), that we encounter marked alterations, 
 especially of the congestive type. They consist of 
 venous stasis and swelling of the brain with promin- 
 ence of the convolutions, whitish streaks on the 
 vessels of the pia, engorgement of the lymphatics, 
 sanguineous extravasations scattered in the cerebral 
 parenchyma, injection of the meninges with adher- 
 ences to the cortex, pink tint of gray matter, oedema 
 of the convolutions, increase of cephalo-rhachidian 
 fluid, etc., and, in the viscera, various traces of con- 
 gestion. 
 
 Briand counts acute delirium among the infectious 
 disorders. He found bacteria in the urine and in 
 the blood. It is, in fact, probable that acute delir- 
 
CHEONIC MANIA. 165 
 
 ium is the result of an auto-intoxication ; in any 
 case it deserves investigation in this direction. 
 
 Diagnosis. — Acute delirium may be confounded 
 with typhoid fever or pneumonia, and oases occur 
 virhen only the autopsy can decide. Nevertheless, 
 the evolution of the disorder, careful examinations 
 of all the organs, and especially the temperature 
 curve will usually furnish the requisite elements for 
 the diagnosis. 
 
 Tkeatmbnt.^ — Treatment is essentially symptom- 
 atic. It consists in fortifying and nourishing the 
 system, keeping the patients in quiet and darkened 
 rooms, in order to restrain their agitation, and the 
 use of the usual sedatives and hypnotics. In the be- 
 ginning, attempts may be made to prevent or atten- 
 uate auto-intoxication by antisepsis of the intestinal 
 and the digestive tract. 
 
 §IV. CHRONIC MANIA. 
 
 Chronic mania' is rarely a primary disorder. It 
 commonly follows acute mania, of which it is, as we 
 have seen, one of the modes of termination. It is 
 not therefore, properly speaking, a special variety 
 of insanity. 
 
 It is characterized essentially by the indefinite 
 persistence in an attenuated form of the symptoms 
 of mania. There is no longer the violent and in- 
 coercible agitation, but there is a more moderate 
 excitement, varied, at differing intervals, by exacer- 
 
166 MANIA. 
 
 bation resembling the preceding acute form. The 
 special distinguishing mark of chronic mania, 
 however, is that the delusive ideas, so mobile and 
 transitory in acute mania, here gradually assume a 
 fixedness and consistency, so that they resemble, in 
 some cases, a true systematized insanity. This type, 
 which has hardly been studied in France, and which 
 has elsewhere received the designation of secondary 
 systematized insanity or secondary paranoia, takes 
 on usually the ambitious form. It is not always 
 easy to distinguish it from primary or essential 
 systematized insanity, and only an acquaintance with 
 the antecedents can clear up the diagnosis in some 
 cases. 
 
 Chronic mania is incurable. When death does 
 not occur from a visceral or cerebral complication, it 
 terminates in dementia, which then bears the name 
 of maniacal dementia, from its origin and the per- 
 sistence amid the mental ruin, of some symptoms 
 recalling the condition of the preceding mania. 
 Life may thus be prolonged for many years. 
 
 §V. REMITTENT AND INTERMITTENT MANIA. 
 
 Remittent mania is a variety of continued mania, 
 characterized by the more or less regular return of 
 acute crises or paroxysms, separated by periods of 
 attenuations or remissions. 
 
 Strictly speaking, chronic mania might take its 
 place with remittent mania as it is likewise foymed, 
 
REMITTENT AND INTERMITTENT MANIA. 167 
 
 in most cases, of alternating remissions and exacerba- 
 tions. In it, however, these alternatives are neither 
 constant nor regular, nor identical, as in true remit- 
 tent mania where the regular alternation, often even 
 periodical, between the remission and the exacerba- 
 tion, forms the fundamental element of the disease. 
 
 Usually the order is as follows : An attack of 
 acute mania occurs, passes its culmination and de- 
 clines. A decided improvement is believed to be des- 
 tined to end in recovery, but after a while a new 
 acute attack appears followed by another improve- 
 ment, and so on for years. The morbid succession 
 is thereafter regular. 
 
 Intermittent mania differs from remittent mania 
 in that the attacks are not separated by simple 
 periods of amelioration or remissions, but by inter- 
 vals of complete return to the normal condition or 
 intermissions. Remittent mania is therefore a con- 
 tinuous insanity with exacerbations, while intermit- 
 tent mania is an insanity of attacks alternating with 
 the normal mental condition. This distinction is 
 especially important in a medico-legal point of 
 view. 
 
 True intermittent mania is that in which the 
 attacks and intermissions succeed each other always 
 in a regular and identical manner. The return of 
 the different phases often then coincides with the 
 return of certain seasons. It is rarely, however, 
 that the insanity realizes so perfect an isochronism, 
 and its periodicity is therefore more often only rela- 
 
168 MANIA. 
 
 tive. The attack is sometimes longer or shorter, 
 lighter or more severe ; sometimes it is the intermis- 
 sion that is longest ; it lasts sometimes several years . 
 
 Intermittent and remittent mania in nowise form 
 varieties in a symptomatic point of view, and the 
 attacks composing them, taken in themselves, are 
 only the ordinary ones of acute mania and maniacal 
 excitation. 
 
 What distinguishes them and gives them a par- 
 ticular physiognomy is: (1) that the attacks are 
 reproduced in a more or less regular fashion ; 
 
 (2) that they are usually identical with each other ; 
 
 (3) that they begin and end, as a rule, suddenly ; 
 
 (4) that they are always separated by remissions or 
 intermissions ; (5) that the duration of their alterna- 
 tion is indefinite and ceases only when chronicity 
 or dementia ensues. 
 
 It is necessary to add, for the sake of complete- 
 ness, that remittent and intermittent mania, like in- 
 sanity of double form, are rather special to the 
 hereditarily disposed and degenerates. For this 
 reason, several French and foreign authors (Morselli, 
 Magnan) rank these forms, under the generic name 
 of cyclical insanity, in the mental state of the degen- 
 erates. 
 
 The return of the attacks may also be influenced 
 by different occasional circumstances, the seasons, 
 the return of the menses, etc. , and, according to Dou- 
 trebente, the intermittent insanities are at bottom 
 related to the great neurosis epilepsy. According 
 
EBMITTBNT AND INTBBMITTBNT MANIA. 169 
 
 to Other memoirs, quite recently published, the in- 
 termittent maniacs more especially belong to the 
 class of diathetic cases whose attacks of insanity cor- 
 respond each time to acute attacks of auto-intoxica- 
 tion (Mabille and Lallemand, 1890). 
 
 Tebatmbnt. — Anti-periodics, quinine in particu- 
 lar, in large doses have been recommended to combat 
 the intermittence, but the results have hardly been 
 favorable. The attacks need, in reality, the same 
 treatment as the ordinary ones of acute mania. 
 A certain number of patients have, recourse to the 
 asylum of their own accord as soon as- they feel the 
 coming on of the attack. 
 
Cbapter li>. 
 
 MELANCHOLIA OR LYPEMANIA. 
 
 I. — Acute Melancholia (Typical Melancholia). II. — 
 Sub-acute Melancholia (Melancholic Depbbssion). 
 III. — Htpeh- ACUTE Melancholia (Melancholia with 
 Stupor). IV. — Chronic Melancholia. V. — Remittent 
 AND Intermittent Melancholia. 
 
 §1. ACUTE MELANCHOLIA (TYPICAL 
 MELANCHOLIA). 
 
 Definition. — Melancholia, says Marc6, is a 
 mental disorder characterized by delirium of _a 
 sorrowful nature and a depression carried sometimes 
 to the extent of stupor. 
 
 It will be more exact to say that melancholia is a 
 generalized insanity with delirious concentration of 
 the mind on sad ideas, and with a painful reaction 
 on the organism. 
 
 Etiology. — In contrast to mania, which attacks, 
 by preference, subjects of expansive, exuberant, and 
 naturally excitable disposition, melancholia occurs 
 mostly in timid, reserved, timorous and scrupulous 
 individuals. For this reason it is much more fre- 
 quent amongst women th^n men. The proportion 
 is about 2,038 females to 1,099 males, while in mania 
 the ratio is 2,988 females to 2,679 males (Planat), 
 
ACUTB MELANCHOLIA. 171 
 
 The most frequent causes of melancholia, apart from 
 heredity, are violent emotions, prolonged grief, 
 bodily fatigue, the puerperal condition, and visceral 
 affections, that is to say, debilitating and depressing 
 causes. More frequently than is commonly believed, 
 it is the immediate result of an auto-intoxication, 
 especially a gastro-intestinal one. 
 
 Symptomatology. — Acute melancholia presents 
 a period of invasion, one of culmination, and one of 
 termination or decline. 
 
 1 — Period of Invasion. — The onset of melancho- 
 lia is still slower than that of mania. It may com- 
 mence with gastro-intestinal disorders, such as the 
 saburral state, constipation, anorexia, etc., or even 
 be consecutive to a more or less ancient dyspepsia. 
 There are ' at the same time', general malaise, weak- 
 ness, depression, insomnia, disgust at everything, 
 anxiety. In the very begimiing we sometimes see an 
 obstinate tendency to worry in regard to the health, 
 money matters, business, family affairs, and past con- 
 duct, etc. But, aside from the fixedness of these 
 ideas and the disquiet they cause, the mind seems 
 unimpaired, and it is often only after the patient has 
 made an attempt at suicide that those around him 
 begin to believe in his insanity. 
 
 This premonitory stage lasts for a longer or shorter 
 period, but the symptoms become gradually worse 
 and the stage of full development of the disorder is 
 re^.ch^d, 
 
173 MELA]S'CHOHA OE LYPBMANIA. 
 
 2 — Period of Full Development or Culmination. — 
 We shall here describe, as was done in regard to 
 mania, the psychic and the physical disorders of 
 this stage. 
 
 a. Disorders of the Psychic Functions. — In the in- 
 tellectual sphere, strictly speaking, the principal symp- 
 toms consist in a painful concentration of the mind, 
 a characteristic delusive tendency, and hallucination. 
 
 The painful mental concentration reveals itself by 
 a limitation and fixedness of the ideas, in contrast with 
 their mobility and diffuseness as we observe them in 
 mania. Here the whole being is painfully filled with 
 one set of ideas and is absorbed in their inces- 
 sant meditation. ' ' Animi angor in una cogitatione 
 defvxMs atque inhaerens'''' as Aretaeus has well ex- 
 pressed it. 'With this, there is more or less complete 
 lucidity in regard to everything unconnected with 
 the delusions, so that the mind seems affected only 
 on this one point. For this reason melancholia was 
 classed before Baillarger, among the partial insanities 
 or monomanias {lypem.ania or monomania triste of 
 Esquirol) . 
 
 The delusions of acute melancholia are character- 
 istic. They may be extremely variable in expression, 
 but the basis is always the same : They are composed 
 of painful conceptions, such as ideas of ruin, impo- 
 tence, hypochondria, damnation, vague persecutions, 
 poison, disgrace, but especially of culpability and im- 
 aginary crimes. The patients believe themselves lost, 
 covered with disgrace, they go back over the thou- 
 
ACUTE MBLAkOHOLIA. 173 
 
 sand details of their lives and find unpardonable sins 
 for which they are condemned to terrible punishments 
 or to death ; they reproach themselves for all they 
 have done and said ; they accxise themselves of lack- 
 ing affection for their parents, and of having caused 
 their .ruin or death ; they have offended God, made 
 wrong confessions, committed sacrilege, lost the 
 world and merit hell-fire ; they think they are objects 
 of every one's condemnation. Pusillanimous and 
 timid in the highest degree, they are afraid to go alone, 
 they fear everything without knowing why, they be- 
 believe themselves in prison, surrounded with jailors, 
 executioners, etc. Unlike the victims of persecutory 
 delusions, who refer their torments to the external 
 world and accuse others for everything they suffer, the 
 melancholiacs refer all the evil that occurs around 
 them to themselves and accuse themselves of being its 
 cause. The distinction is characteristic, and, more 
 than any other symptom, aids the diagnosis, which 
 presents, at times, some difliculties. 
 
 Corresponding with these delusions, there is a spe- 
 cial symptom in the speech. The patients talk but 
 little, in a dull tone, slow and lugubrious, and, except 
 in the groanings and complaints they utter, they have 
 to, as it were, force out the words they use. Some- 
 times there is even complete mutism. They also write 
 very little or none at all. 
 
 Hallucinations are nearly constant in acute mel- 
 ancholia. They may be multiple and involve sev- 
 eral senses, nevertheless, those of hearing are the 
 
174 MELANCHOLIA OK LYPEMANIA. 
 
 most ^regpent. Thejjatients^hear night and day, 
 but especially at night, voice s^ accusing and re- 
 proaching them and threatening them with various 
 punishments; they see phantoms, death's-heads, 
 angels, the fires of hell, dramatic or terrifying 
 scenes, such as battles, massacres, etc., etc. They 
 claim to smell bad odors ; their food has the taste of 
 human flesh; they feel disagreeable sensations, are 
 rotten, etc., etc. Som.etimes also they experience 
 internal illusions, genital or intestinal, of the most 
 varied nature. 
 
 In the moral or emotional sphere the disorder may 
 assume either of two different forms. Either the 
 patients are apathetic and indifferent, not only to 
 what concerns themselves, but also to whatever af- 
 fects their family and whoever is most dear to them, 
 going so far sometimes as to have a positive aversion 
 to them, or, on the other hand, their affective senti- 
 ments are in a condition of exaltation, and they are 
 in a state of morbid preoccupation about their rela- 
 tives and friends. At the same time, they are gen- 
 erally anxious, self -tormented, lacking in will, and 
 live in a state of perpetual apprehension. 
 
 The instincts are, for the most part, blunted and 
 without reaction. 
 
 As regards morbid actions, they are character- 
 istic. In fact, there are two tendencies almost inev- 
 itably connected with acute melancholia ; they are : 
 (1) refusal of food (2) the suicidal tendency. 
 
 Refusal of food, in some degree, is almost the 
 
ACtTTB MELANCHOLIA. 175 
 
 rule. It arises from the delusive ideas of the pa- 
 tients who think they are dishonored, ruined, and 
 unable to pay for their food, whence they 
 declare that they feel no hunger, are unfit to 
 eat or wish to do penance. This refusal of food is 
 also induced by the gastro-intestinal disorders nearly 
 always existing. Sitiophobia in melancholiacs pre- 
 sents special characters which it is necessary to rec- 
 ognize. The patients, being incapable of any 
 energetic exercise of the will, do not generally offer 
 an obstinate or invincible opposition, like those 
 suffering with delusions of persecution for example. 
 Theirs is an inert, passive refusal, without firmness, 
 so that sometimes it is possible to make them take 
 food from a nipple like infants ; it is often necessary, 
 nevertheless, to use continuously the methods of 
 artificial alimentation. 
 
 As to the tendency to suicide, it exists almost invari- 
 ably^o some extent in acute melancholia^ and exhibits 
 itself with the same characters of inertia and inde- 
 cision^s the refusal of food. The melancholiac has 
 a strong enough desire to die, as, with all the morbid 
 ideas that haunt his brain, life is a burden; but he 
 is most frequently incapable of making a serious 
 effort to destroy himself or to employ the least 
 energy in carrying out the project. It seems to 
 him that death ought of itself to come to him. There- 
 fore, in many instances, his attempts are imperfect 
 and ridiculous. Some patients limit themselves to 
 thrusting pins through the skin, or swallowing some 
 
176 MELANCHOLIA OR LTPEMANIA. 
 
 inoffensive substance, others tie a cord or handker- 
 chief around the neck and leave it there without hav- 
 ing the energy to draw it tight. The majority con- 
 sider a long time over their project, they take up 
 again and again the weapon or the poison they have 
 chosen ; in short, they manifest an absolute want of 
 initiative or decision. Such are the usual characters 
 of the suicidal tendency in the melancholiacs, but it 
 must not be forgotten that no absolute rule can be 
 laid down, and that these patients may, under the 
 influence of a sudden impulse or an unforeseen ac- 
 cession of energy, make way with themselves sud- 
 denly and without hesitation {raptus melancholicus.) 
 
 b. Disorders of the Bodily Functions. — The in- 
 sane, like normal individuals, do not all react in the 
 same fashion under the influence of painful emotions. 
 Some keep all their troubles to themselves and let 
 nothing escape them, so that their physical activity 
 is in an inverse ratio to their psychic exaltation. In 
 others, on the contrary, the suffering manifests itself 
 by disturbed or anxious activity and this bodily reac- 
 tion is in direct proportion to the delirious exaltation. 
 There are, therefore, two types of melancholiacs as 
 regards attitude and external manifestations : the de- 
 pressed and the exalted types. 
 
 The depressed cases have a corresponding appear- 
 ance, the head hanging, the arms pendent, movements 
 slow, gestures infrequent, the physiognomy is altered, 
 the features drawn, the face thin and pale, the expres- 
 sion sad, the aspect gloomy and dull, the fore- 
 
ACUTE MELANCHOLIA. I"?? 
 
 head wrinkled, the mouth contracted ; they are im- 
 movable, inert and passive,4t is neoessaiy to dress 
 tTiehi, make them rise, walk, or eat, without com- 
 pulsion they^ will do nothing. It is only on rare 
 occasions that they are seized, all at once, with a kind 
 of impulsive attack during which they give them- 
 selves up to automatic acts of violence (raptus). 
 
 The exalted cases, on the other hand, have a dis- 
 turbed countenance, the eyes bright, the manner anxi- 
 ous or terrified. Their feelings manifest themselves 
 in tears, cries, groanings, disconnected complainings, 
 jerky gestures, and the constant identical repetition 
 of certain mechanical acts. They undress themselves, 
 tear their apparel, twist their fingers and lips, and tear 
 the skin of their hands and face without feeling it or, 
 as it were, without paying to it any attention. 
 
 In all, the sleep is disturbed and unsatisfactory, 
 troubled by dreams, nightmares and hallucinations. 
 
 The sensibility is very obtuse, occasionally, so to 
 speak, abolished. The special sensory functions are 
 likewise weakened and retarded. 
 
 The respiration is slow, incomplete, and its ratio to 
 the cardiac rhythm reduced. Hsematosis is, there- 
 fore, interfered with, which fact explains the frequent 
 occurrence of passive congestions of the lungs in 
 melancholiacs. 
 
 The heart beats with less energy and its move- 
 ments are slower. The pulse is variable, sometimes 
 it reaches 100 or 130, sometimes it falls to 35 and 
 40 per minute. Bodily temperature is lowered, es- 
 
 Ubnt. TiSD.—li. 
 
178 MELANCHOLIA OE LTPEMANLA. 
 
 pecially at the periphery where it may fall three 
 or four degrees (Centigrade). The extremities 
 (hands, nose, ears) are chilled and cyanosed. 
 
 Gastro-intestinal complications are almost invari- 
 ably encountered. They consist in a saburral con- 
 dition of the digestive passages, dyspepsia with 
 hyperacidity, flatulence and constipation. These 
 disorders are in part responsible for the refusal of food 
 and are among the causes of the emaciation it pro- 
 duces. The breath of melancholiacs is strong and 
 offensive, especially in patients that do not eat. The 
 secretions are also diminished, and the same usually 
 occurs in the genital activity. 
 
 3. Period of Termination or Decline. — Acute 
 melancholia may terminate, like mania, (1) in 
 recovery; (3) by death; (3) by passing into the 
 chronic state. 
 
 Rbcovebt. — This is the most frequent termina- 
 tion. It occurs customarily by a progressive re- 
 awakening of activity, return of sleep, and gradual 
 disappearance of the delusive conceptions. Very 
 frequently there is left a residue of general depres- 
 sion and obtusion of the faculties that continues 
 for a longer or shorter time after recovery. 
 
 Death. — Termination in death is not rare, 
 especially in debilitated cases. It occurs either 
 from a gradual enfeeblement, the result of inanition, 
 from bodily decay, or from some visceral compli- 
 
ACUTE MELANCHOLIA. 179 
 
 eation, diarrhoea, pulmonary congestion, etc. 
 Finally, death may be from suicide. 
 
 Passage to the Chronic State. — Passage to the 
 chronic condition is less frequent than in mania. 
 When it occurs, the depression decreases, but per- 
 sists in a subacute form, the delusions and hallu- 
 cinations become fixed and permanent, while the 
 general bodily health is in whole or in part re- 
 established. 
 
 Poems of Acute Melancholia. — Many authors 
 admit the existence of various forms of acute melan- 
 cholia, and distinguish: religious, demoniac, hypo- 
 chondriacal and suicidal melancholias ; also depres- 
 sive, anxious, groaning, panophobic varieties, etc. 
 etc. Fundamentally there is only one disease, acute 
 melancholia, varying in its aspect only as it is looked 
 at from the point of view of predominating tenden- 
 cies and ideas or from that of its general attitude 
 and mode of external reaction. 
 
 CouESE AND Duration.— Acute melancholia has 
 habitually, like mania, a reg ular cou rse, susceptible 
 of division into distinct periods. It is, notwithstand- 
 ing, particularly subject, during its course, to fre- 
 quent, more or less marked, oscillations. Its duration 
 is generally longer than that of mania, as reco very 
 rarely takes place before three or four months. It 
 occurs, on the average, between the sixth and the 
 twelfth month. 
 
180 MELANCHOLIA OB LTPEMANIA. 
 
 Pathological Anatomy. — The lesions of acute 
 melancholia are hardly known. They consist, it is 
 said, in an ischsemia of various regions of the brain. 
 The visceral alterations, particularly those of the ab- 
 domen, are perhaps more constant and pronounced. 
 This is the reason why so much influence has always 
 been attributed to them in the production of melan- 
 cholia, whatever might be the mechanism (sym- 
 pathy, auto-intoxication.) 
 
 Prognosis. — The prognosis of acute, uncompli- 
 cated melancholia is almost as good as that of acute 
 mania. When melancholia is symptomatic, the prog- 
 nosis varies according to the affection with which it 
 is allied. In opposition to mania, melancholia is 
 aggravated in autumn and winter, and recovers 
 easily in the spring. It is especially serious on 
 account of the morbid acts it indiices, refusal of food 
 and tendency to suicide. 
 
 Diagnosis. — Acute melancholia may l)e mistaken 
 for typhoid fever, especially in the beginning when 
 it is accompanied with accelerated pulse and a 
 saburral condition of the digestive canal. The char- 
 acter of the delirium and the course of the temper- 
 ature suffice usually to clear up all doubts. 
 
 Melancholia with predominating ideas of perse- 
 cution may be taken for progressive systematized 
 insanity. The general depression, the absence of the 
 fixedness of the delusions and hallucinations, the 
 suicidal tendency, and, finally the humility, and con- 
 
ACUTE MELANCHOLIA. 181 
 
 tritioii of the patient, form the principal differential 
 signs. 
 
 The important point for diagnosis is whether the 
 melancholia is simple, or allied with some morbid 
 state, such as alcoholism, general paralysis or some 
 visceral disorder. We should never, therefore, neg- 
 lect to search in melancholiacs for somatic disorders, 
 and especially to examine the different viscera and 
 organs of the economy. 
 
 Treatment. — At the commencement, moral treat- 
 ment by traveling and recreations, aided by general 
 therapeutic agents like hydrotherapy and electricity, 
 may be tried. These, howe^'er, generally fail. The 
 best results, in mitigating or keeping down the attack, 
 are obtained by instituting a medical treatment in- 
 tended to combat the phenomena of auto-intoxica- 
 tion (repeated purgation, gastro-intestinal antisepsis, 
 etc.) 
 
 When the disease is fully established, asylum treat- 
 ment is nearly always necessary, for the triple pur- 
 pose of isolation, treatment, and oversight of the 
 patient, whom it is always necessary to guard agamst 
 possible attempts at suicide. There may be em- 
 ployed, according to the case, hydrotherapy, wet pack, 
 Russian or Turkish baths, mustard baths, dry fric- 
 tion, or electricity (galvanism and faradism). Suit- 
 able food, and, if needed, forced alimentation, should 
 be administered. Nervous sedatives and hypnotics 
 (bromides, chloral, injections of cocaine (Mor- 
 selli and Buccola), tincture of nux vomica and laud- 
 
182 MELANCHOLIA OB LTPBMANIA. 
 
 anum in progressive doses), combined with confine- 
 ment to bed, daily purgatives and douches (Bell and 
 Lemoine). Tonics (quinine, iron, caffeine, kola, 
 peptones). Repeated purgations. Methodic lavage 
 of the stomach (alkaline, acid or antiseptic, according 
 to the case). Complications are to be treated as 
 they occur. 
 
 SII. SUB- ACUTE MELANCHOLIA. 
 (Melancholic Dbpbbssion). 
 
 This variety of melancholia also bears the name 
 of melancholia with consciousness. 
 
 Etiology. — Heredity very common. Arthritism 
 (Rouillard). Predominance- of female sex. Influ- 
 ence of menstruation and especially of the meno- 
 pause. 
 
 Desckiption. — The beginning of the attacks is 
 usually more sudden than in acute melancholia. 
 They may occur either in the non-delusional or the 
 delusional form. In the first the whole is comprised 
 in or limited to a general condition of depression, in- 
 action, and impotence. The patients avoid all labor, 
 all occupation and all society; they isolate them- 
 selves in their rooms, wi(ere they stay sometimes for 
 weeks and whole months, not wishing to see any 
 one, passing their time seated or in bed, incapable 
 of wishing or deciding or of making an effort. This 
 is simple melancholic depression, which is also caUed, 
 
SUB-ACUTE MBLANCHOLIA. 183 
 
 according to the case, moral hypocliondria, misan- 
 thropic melancholia, pei"plexed melancholia, aboulic 
 melancholia. With it, there are usually combined 
 constipation, retardation of the general nutrition, 
 insomnia, and sometimes a conscious and reasoning 
 tendency to suicide (suicidal melancholia). 
 
 The delusional form of sub-acute melancholia 
 may appear under various forms, according to the 
 nature of the morbid ideas. The prrucipal ones 
 are: hypochondriacal melancholia (nosomania of 
 the older writers) characterized by unreasonable ap- 
 prehensions relative to the health and to the func- 
 tioning of the different organs. It is often con- 
 nected with visceral disorders, of which it is then 
 the indirect consequence. Melancholia with ideas 
 of persecution, characterized, as its name indicates, 
 by varying ideas of persecution, unsystematized 
 without hallucinations, and which must not be 
 confounded with essential imsanity of persecution, 
 which wUl be described later on. Religious melan- 
 cholia, especially common at puberty and at the 
 menopause in persons of piety, which is essentially 
 characterized by scruples of conscience, ideas of re- 
 ligious culpability, fear of damnation, etc. 
 
 Under whatever form sub-acute melancholia may 
 present itself its essential characteristic is the lucidity 
 of the patient, often accompanied by a genuine con- 
 sciousness of his condition, whence the name of 
 melancholia with consciousness that has been given 
 it. The patients are capable of appreciating their 
 
184 MELANCHOLIA OE LTPEMAITIA. 
 
 disorder in its true light and, sometimes even, of re- 
 sisting their pathological homicidal or suicidal tend- 
 encies. 
 
 Cause. Dubation. TBBMiNATioisr. — Sub-acute 
 melancholia generally manifests itself in the form of 
 more or less lengthened attacks, beginning and end- 
 ing suddenly, and ordinarily occurring several times 
 in the same patient. The usual termination is 
 therefore in recovery, but in one that is liable to 
 relapses. In some cases death may take place, 
 almost always by suicide. 
 
 Prognosis. — The prognosis is more grave than 
 that of acute melancholia. 
 
 Pathological Anatomy. — The lesions are varia- 
 ble and little known ; the same fundamentally as 
 those of acute melancholia. 
 
 Diagnosis. — Sub-acute melancholia, especially in 
 its delusional form, may be confounded with certain 
 forms of partial insanity, notably with hypochondri- 
 acal and religious insanity and insanity of persecu- 
 tion. The essential elements of the diagnosis are : 
 the painful nature of the delusions, the fundamental 
 general depression and the tendency to suicide which 
 are wanting in partial insanity. We will point out 
 later on the distinction between aboulic melancholia 
 and aboulic neurasthenia. 
 
 Tbbatmbnt. — The treatment is the same as for 
 acute melancholia. Moral treatment is especially to 
 
HTPBR-ACUTB MBLAlfCHOLIA. 185 
 
 be emphasized. The medication should be suited 
 to the case when the disorder is symptomatic of a 
 visceral affection. 
 
 ijIII. HYPER-ACUTE MELANCHOLIA. 
 (]VIblanoholia with Stupoh.) 
 
 Stupor has been placed under the head of melan- 
 cholia only since M. Baillarger demonstrated that it 
 was its highest expression ; previously it was regarded 
 as a variety of dementia (acute dementia of Esquirol). 
 In reality it may be considered as a hyper-acute mel- 
 ancholia, that is to say, as being to melancholia what 
 acute delirium is to mania. 
 
 Etiology. — Stupor generally follows an acute 
 melancholia or complicates it. It is especially fre- 
 quent in the different stages of sexual life ; puberty, 
 menstruation, puerperal condition, menopause. 
 
 Descbiptiox. — In a psychic point of view we dis- 
 tinguish eases where the jjatient is plunged into a 
 veritable stupor (simple stupor, without delusions, 
 or passive) , and those where the stupor is only appar- 
 ent and masks very active mental workings. In 
 this last condition, elucidated by Baillarger, the 
 patients are the prey of the most terrible delusions, 
 of terrifying hallucinations, they assist in their inter- 
 nal consciousness in the most frightful dramas which 
 have nearly always for their themes, massacres, burn- 
 ings, and scenes in the infernal regions. 
 
186 MELANCHOLIA OE LTPEMANLA. 
 
 In a physical point of view the depression is pushed 
 to the extent of completely abolishing the general 
 activity of the organism. Every effort is concen- 
 trated in the mental domain, but there is no exter- 
 nal manifestation, and nothing of that -which is 
 passing in the thought is revealed outside. The 
 patients are absolutely inert and immobile ; they do 
 not talk, walk, eat or make any gesture or move- 
 ment; their limbs are eemi-contracted, and retain 
 the position in which they are put, like those of the 
 oataleptics ; their countenances are impassive and 
 present the mask of a profound hebetude ; their lips 
 are half opened and dripping saliva; their whole 
 bodies, and especially their extremities, are cold and 
 bluish ; anaesthesia and analgesia are complete ; the 
 bodily temperature is lowered several degrees; the 
 pulse is very slow, the sitiophobia is invincible, and 
 their untidiness is absolute. These patients remain 
 in this condition for whole months, sometimes in 
 bed, sometimes erect, or sitting in some corner of the 
 ward doubled upon themselves with the immobility 
 of a statue. Occasionally, under the influence of a 
 sudden impulse, they drop all at once their torpor, 
 have a sudden spell of agitation, or commit some act 
 of violence, then everything is again quiet and they 
 fall anew into their inertia. 
 
 The majority of foreign authors recognize and 
 describe under the name of attonitdt and of kata- 
 tonia (Kahlbaum), conditions which are fundament- 
 ally, as S6glas and Chaslin have recently demon- 
 
SUB- ACUTE MELANCHOLIA. 187 
 
 Stated, nothing else than melancholia with stupor 
 under its different aspects, and in which predominate 
 either the phenomena of hebetude, or spasmodic and 
 cataleptiform symptoms. 
 
 Course. Duration. Termination. — Melan- 
 cholia with stupor has a slow chronic course, of 
 variable duration. It is susceptible of cure and in 
 this case the patients can generally recall all the 
 phases of their delirium ; but more frequently when 
 the affection is prolonged, they fall into cachexia 
 and marasmus and end by being swept away by the 
 progress of the physical decay or by some complica- 
 tion, such as passive congestion or gangrene of the 
 lungs. 
 
 Pathological Anatomy. — -In a physiological 
 point of view, stupor is, according to M. Ball, a 
 phenomenon of arrest. As to the anatomical alter- 
 ations to which it is connected, mention should be 
 made of oedema of the brain, that has been claimed 
 to be its characteristic lesion, but which is far from 
 being constant, and of an atrophy of the convolutions 
 that has been observed in certain cases. 
 
 Treatment. — ^Is the same as that for acute mel- 
 ancholia. Tonics and general excitants, hydrother- 
 apy and electricity are to be insisted upon. Forced 
 alimentation. 
 
188 MELANCHOLIA OR LTPEMANIA. 
 
 §IV. CHRONIC MELANCHOLIA. 
 
 Chronic melancholia is, ;is we have seen, one of the 
 modes of termination of acute melancholia. It may 
 succeed either the depressive or the anxious forms. 
 
 In the first case, it consists in the persistence in an 
 attenuated form of the psychic and bodily symptoms 
 of acute melancholia. Nevertheless, the delusive 
 ideas become gradually modified at the same time' as 
 they take on a special fixedness. They are ideas of 
 persecution or religious delusions, nearly always ac- 
 companied with multiple hallucinations, and they 
 form a sort of systematized insanity, differing only 
 from true progressive systematized delusions 
 by its mode of beginning and evolution, the exist- 
 ence of a certain degree of general depression and 
 the return at irregular intervals of melancholic par- 
 oxysms accompanied with suicidal tendency that 
 recall the former acute attack. This is what is 
 called, very accurately, by some foreign writers, sec- 
 ondary systematized insanity of the melancholic type 
 {^paranoia secondaria ni.elanrholica). 
 
 \"ery nearly the same course is followed in chronic 
 melancholia consecutive to the anxious form. Here, 
 however, the delusions take on a special character, to 
 which attention has been very properly called by 
 Cotard. They consist in absurd hypochondriacal 
 conceptions, resembling closely the hypochondriacal 
 delusions of depressive general paralysis. The 
 patients believe themselves dead, decomposed, 
 
BEMITTBNT AND INTBEMITTENT MELANCHOLIA. 189 
 
 choked up, annihilated. Others say that they 
 have neither age, sex, nor name, that they do not 
 exist and that nothing exists (insanity of negation or 
 enormity, of Cotard). These delusions finally lead 
 to a veritable transformation or duplication of the 
 personality (Cotard, S6glas). 
 
 In any case of chronic melancholia we may see 
 occur, either temporarily or permanently, ideas of 
 grandeur, the existence of which cannot fail to com- 
 plicate an already difficult diagnosis. Nevertheless, 
 the ideas of grandeur may manifest themselves in an 
 altogether characteristic melancholic form. The 
 patient will say, for example, not that he possesses 
 or that he has stolen, but that he owes millions and 
 thousands of millions. These various symptoms of 
 chronic melancholia and, in a general way, of the 
 different types of secondary systematized insanity 
 have not yet been sufficiently studied. 
 
 Chronic melancholia is incurable. It may continue 
 indefinitely and finally change to a special form of 
 dementia (melancholic dementia) or it may terminate, 
 at any moment during its course, by death(suicide, 
 chronic visceral disease, acute incidental disorders). 
 
 §V. REMITTENT AND INTERMITTENT MELAN- 
 CHOLIA. 
 
 All the considerations already brought forward in 
 regard to remittent and intermittent mania will, 
 without exception, apply to remittent and intermit- 
 
190 MBLANCHOLIA OB LTPKMAinA. 
 
 tent melancholia. It is therefore unnecessary to 
 reproduce them. 
 
 We will confine ourselves to the statement that 
 cyclical insanity is less frequent under the melan- 
 cholic form, and that when it does exist it mani- 
 fests itself by preference in the acute or sub-acute 
 form. 
 
Cbapter m. 
 
 INSANITY OF DOUBLE FORM. 
 
 (Oireulwr Insanity, Delirium of Alternating Forms, Insanity 
 of Double Phase.) 
 
 Definition. — Insanity of double form is a gener- 
 alized insanity, characterized by the regular success- 
 ion of melancholico-maniacal attacks, that is to say, 
 of attacks made up of a period of melancholia and one 
 of mania, or vice versa. 
 
 Etiologt — The chief cause of insanity of double 
 form is heredity, which assumes here most often the 
 similar tj^e. Next follow the other physical and 
 moral causes of insanity. The disorder is more com- 
 mon in females than in males. It usually commences 
 between the ages of 30 and 30, either following some 
 accidental cause or without any apparent reason. 
 
 Dbsceiption — Insanity of double form, vaguely 
 suspected by older writers, was actually discovered 
 by M. Baillarger and by Falret, Sr. M. Ritti gave in 
 1883 a complete and very excellent description of it. 
 
 In order to make ourselves well acquainted with 
 this form, we must study successively: (l)The com- 
 position of the attacks ; (2)the manner in \7hich they 
 are connected one with another. 
 
193 INSANITY OF DOUBLE FORM. 
 
 (1). The attack of insanity of double form is com- 
 posed of two distinct periods, one of mania the 
 other of melancholia. But this mania and thi s melan- 
 cholia are not conditions special to circular insanity ; 
 they are nothing but simple mania and melancholia, 
 such as we have studied in the foregoing chapters. 
 There is, therefore, no need of describing here a spe- 
 cial symptomatology of this form ; it is enough to state 
 that the attack which composes it is made up of a 
 period of mania and a period of melancholia, to be 
 acquainted in advance with all the symptoms. 
 
 All the varieties of mania and melancholia that 
 have been passed in review may be combined to make 
 up the attack of insanity of double form. Thus the 
 attack may be formed of a period of acute mania 
 and one of melancholia with stupor, of a period of 
 maniacal excitation and one of melancholic depres- 
 sion, etc. , etc. We repeat, all combinations are pos- 
 sible, and it should be recognized that there is no 
 necessary relation between the degree of intensity of 
 one or the other period. Thus a period of slight 
 maniacal agitation may be associated with one of 
 acute melancholia or of stupor to form the attack, 
 and, reciprocally, a period of simple melancholic 
 depression may be combined with one of acute 
 mania. The most usual constitution of the at- 
 tack, however, is the union of a period of more or 
 less acute maniacal excitation with one of melan- 
 cholic depression. ^ 
 
 An important point to know, is that when one at- 
 
DESCEipnox. 193 
 
 tack has occurred, it is usual for the succeeding ones 
 to resemble it in all particulars, to present the same 
 symptomatic physiognomy ; so that when we know 
 one attack we know all. 
 
 The transition from one period to another is not 
 always in the same fashion. Sometimes the change 
 is brusque, instantaneous; it may then occur even 
 during sleep, so that the patient going to sleep a 
 maniac, awakens in the morning a melancholiac. 
 This is often the case in double form insanity of very 
 short periods. It is more common, however, to see 
 the passage from one state into the other made by 
 insensible gradations, in such a way that there is a 
 moment when the individual seems to be neither 
 maniacal nor melancholic, but in a condition of per- 
 fect equilibrium. This moment of equilibrium has 
 been, from the first, variously interpreted. Falret 
 considered it a true intermission of short duration, 
 so that, in his opinion, the attack was made up of 
 three periods: one of mania, a second of intermis- 
 sion, and the third of melancholia. Baillarger 
 showed, on his part, that the moment of equilibrium 
 is not an intermission, but a simple instant, difficult 
 to grasp, traversed without stopping by the patient 
 in passing from the period of mania to that of mel- 
 ancholia, and that, consequently, these two con- 
 ditions follow each other without interruption 
 Uke the different stages of intermittent fever. 
 This is, indeed, what usually occurs; but the 
 intermission claimed by Falret may be observed 
 
 UBMI. USD.— 13. 
 
194 INSANITY OF DOUBLE FORM. 
 
 in certain exceptional oases. Ritti holds that 
 these are not cases of insanity of double form, 
 but alternating attacks of periodic mania and mel- 
 ancholia (periodical insanity of alternating forms). 
 A last mode of transition by successive alternations 
 consists in rapid alternations of excitement and de- 
 pression serving as an intermediary between the end 
 of one period and the commeucement of the other. 
 
 Whatever may be the way in which the periods 
 succeed each other, the characteristic mark of insan- 
 ity of double form is the striking contrast the 
 patients present when observed in one period or the 
 other. In their condition of maniacal excitation 
 they are youthful appearing, full in tlesli, lively, 
 vigorous, alert, the face is animated, the complexion 
 bright, they are loquacious, talkative, turbulent and 
 constantly in action. They are prodigal, spend- 
 thrifts, vain, false, litigious, passionate, violent, in- 
 clined strongly to evil, and very often excessive in 
 alcohol and sexual indulgence. If they have delu- 
 sions, they are those of pride, haughtiness, ambition 
 and grandeur. In their stage of melancholic de- 
 pression they are so different from the above that 
 one would hardly take them for the same individuals. 
 During this period they are old looking, emaciated, 
 broken down, wrinkled, without force or energy; 
 their countenance is downcast, dull, their complexion 
 pale ; they do not speak or move but pass their time 
 lying down or altogether inactive. They are avari- 
 cious, economical to excess, they do not eat or drink 
 
DESCfilPTION. 195 
 
 or have any sexual desire, they show themselves 
 humble, submissive, without volition, obedient and 
 passive. If they have delusive ideas, they are those 
 of ruin and culpability that haunt them, and these 
 very often induce refusal of food and suicide. Even 
 the organic functions do not fail to suffer in these 
 two different conditions, and the pulse which is active 
 to its full physiological limits in the period of mania, 
 falls to 40 or 50 pulsations during that of melan- 
 cholia. 
 
 The same is true in regard to the temperature, the 
 peripheral circulation, the appetite, the secretions 
 and excretions, which exhibit very remarkable differ- 
 ences in the two periods : it has been found also that 
 the bodily weight increases during the period of 
 mania to fall again in that of depression. 
 
 This, so striking a contrast presented by the 
 patients, is in reality one of the most curious and in- 
 teresting of the peculiarities of mental medicine. 
 
 (3). The constitution of the attack being known 
 it remains to examine how the different attacks suc- 
 ceed each other in series. The altogether excep- 
 tional cases where the malady includes only one 
 attack may be therefore left without consideration. 
 
 Two oases may present themselves. Either the 
 attacks may follow one another uninterruptedly 
 and without being separated by any intermission, 
 thus constituting continuous insanity of double form, 
 or they may be separated fi-om each other by a 
 longer or shorter intermission, by a more or lees pro- 
 
i96 INSAJSriTT OF DOUBLE FOfilt. 
 
 longed return to the normal condition, thus consti- 
 tuting intermittent insanity of double form or that 
 made up of separate attacks. Many authors also 
 designate the first of these circular insanity or 
 the insanity of double form, properly speaking. 
 
 There are, therefore, only these two varieties of 
 double form insanity, if we agree with M. Ritti 
 that the periodical insanity of alternating forms is 
 not to be included under this head, which is a point 
 open to question. 
 
 Course. Duration. Termination. — The course 
 of insanity of double form is essentially chronic and 
 intermittent, or rather periodical. 
 
 As regards its duration, we must consider sepa- 
 rately the duration of the attack and of each of the 
 periods that compose it, and the duration of the 
 malady itself. 
 
 The attack may last months or years, or, on the 
 other hand, it may be limited to a few days. The 
 first is, however, the most frequent; the attack has 
 usually a duration of ■ six months, one year, or 
 eighteen months, and is composed of a period of ex- 
 citement of one to three months or more, and a 
 period of melancholia generally somewhat longer. 
 Although the attacks have nearly always the same 
 duration, this equality is only approximate ; one at- 
 tack niay be longer, another shorter, and the same, 
 moreover, is the case with the periods that compose 
 them'. Nevertheless, we may say that, as a rule, 
 
COTJESE. DUEATION. TERMINATION. 197 
 
 they have the same general character and the same 
 duration. 
 
 In the second case the attacks last a day, two 
 days, three days, and so on, up to one month. Gen- 
 erally, in this case, the periods have nearly the same 
 duration and the attacks are more regular. 
 
 The duration of the intermission is very variable. 
 It is in double form insanity, with very brief attacks, 
 that it is most often lacking. On the other hand, 
 it is almost always present when the attacks are 
 of long duration. It may have a duration of a 
 few days, of many months, and even of several 
 years. 
 
 As regards the duration of the disorder itself, it 
 is very long. It may be said, even, that it is indef- 
 inite, interminable, since with the alternations once 
 established, the patients revolve in the same circle 
 for many years, and generally as long as they 
 survive. 
 
 Insanity of double form may end in recovery, 
 a termination very infrequent, and so to speak, 
 exceptional. It usually terminates in dementia, but 
 only after a long time, as the patients yield very 
 slowly to the failure of the intellect. It may change 
 into some other form of insanity, simple mania or 
 melancholia, for example, but this is very rarely 
 the case. Finally, it may terminate by death, which 
 occurs, so to speak, by accident, or from an inter- 
 current disease, i. e. , from suicide, cerebral congest- 
 ion, epileptiform attacks, pneumonia, etc., etc, 
 
198 INSANITT OF DOITBLE FORM. 
 
 Pathological Anatomy. — Except in cases 
 where the patient dies of apoplexy and there is found 
 at the autopsy an evident organic alteration, insanity 
 of double form has no peciiliar lesion. On the con- 
 trary, this succession of two opposed conditions, 
 mania and melancholia, which replace each other 
 and are generally followed by a return to the normal 
 condition, is proof enough that there exist only 
 functional disorders, susceptible not only of disap- 
 pearing, but also of being replaced by directly 
 opposed conditions. It is probable that the stage 
 of excitement corresponds to a cerebral hyper- 
 aemia, and that of depression to an ischsemia, 
 as in simple mania and melancholia. 
 
 Prognosis. — The prognosis of insanity of double 
 form is very grave, as the disorder is, like most of 
 the intermittent or periodical insanities, almost 
 never curable. Falret, Sr. , has already called atten- 
 tion to the noteworthy peculiarity that double form 
 insanity, which is made up of the two most curable 
 forms of mental disease, mania and melancholia, is 
 itself one of the most incurable. 
 
 Diagnosis. — Taken as a whole, insanity of double 
 form, with its regular succession of opposite condi- 
 tions, cannot be confounded with any other. Never- 
 theless, when the stage of Tnelancholic depression is 
 but slightly marked, it may happen that it passes 
 unrecognized, and the malady is taken for a chronic 
 mania of the remittent or intermittent type, all the 
 
PEOGlfOSIS. DIAGNOSIS. 199 
 
 more probably, since in these tbe attack of mania is 
 also sometimes succeeded by a slight depi'essive re- 
 action. 
 
 It very often happens that an isolated period of 
 double form insanity is mistaken for a simple attack 
 of mania or melancholia, and that on its termination 
 the patient is considered cured. This mistake has 
 been often made, and, notably, by M. Baillarger 
 himself. It is in consequence of the fact that the 
 mania and melancholia of insanity of double form 
 are in no respects different from simple mania and 
 melancholia, and that, taken by themselves alone, it 
 is impossible to distinguish them. All that can be 
 said, is that, as a rule, whenever we^have to do with 
 an attack of maniacal excitation we ought to be on 
 our guard, and make sure whether it is not due to a 
 commencing general paralysis, or to hysteria, or to 
 insanity of double form. 
 
 It may be mentioned that insanity of double form 
 may be confounded in its maniacal stage, with the 
 prodromic period of the expansive form of general 
 paralysis. This error is the more possible as the 
 excitement may cause the appearance in insanity of 
 double form, of certain congestive phenomena such 
 as pupillary inequality, tremor, hesitation of speech, 
 which complicate the diagnosis. The distinction is 
 established by the fact that in general paralysis, 
 even in its beginning, the ideas have a stamp of de- 
 mentia that is lacking in double form insanity, and, 
 further, by the fact that in the excited stages of eir- 
 
200 nsrsAOTTY or dottble foem. 
 
 cular insanity, the patients are tliorouglily vicious and 
 malevolent, while the expansive general paralytics 
 are, at least in appearance, generous and benevolent. 
 Insanity of double form once recognized, it still 
 remains to be determined whether it is simple, which 
 is usually the case, or whether it is connected with 
 some other morbid condition. If the latter, it is 
 almost always with general paralysis (circular gen- 
 eral paralysis or paresis of double form), epilepsy, 
 or hysteria. 
 
 Treatment. — Sulphate of quinine in large doses, 
 30 or 40 centigrams to 2 grams per diem, has been 
 recommended for this disease, principally on account 
 of its periodic character. Bromide of potash and 
 hypodermic injections of opium and morphine have 
 likewise been employed. The treatment of the at- 
 tacks and that of each period call for the ordinary 
 means used in attacks of mania and melancholia. 
 Dr. Hurd has recommended hyoscyamine in the ex- 
 cited periods, and codeine and citrate of cafEeine in 
 those of depression. Sequestration of the patient is 
 especially demanded during the period of excite- 
 ment, the patients being then habitually dangerous. 
 It is less necessary during the periods of melancholia, 
 especially when the depression is not very great. 
 
APPENDIX. 
 
 The G-eaphic Representation op Gbnebalized 
 Insanities. 
 
 In order to furnish a clearer idea of the many 
 special points relative to the constitution and the 
 course of the generalized insanities, it seems to me 
 to be of utility to represent them here in a graphic 
 form, by the aid of a diagram specially devised for 
 the purpose. 
 
 This form, which I presented to the Soci6t6 M6d- 
 ico-psychologique in 1883, and which I have con- 
 stantly used since then, in my free instruction in the 
 medical school at Bordeaux, is composed essentially 
 of a dotted horizontal line representing the normal 
 condition. Above this diverge, according to their 
 intensity, the lines representing the various types 
 of excitement or mania ; below, in an inverse order, 
 those- of the different types of depression or lype- 
 mania. The schematic diagram thus formed is cut 
 by vertical lines indicating, as in the temperature 
 diagrams, the division into days. 
 
 With this very simple diagram we can reproduce 
 exactly, and in their minutest traits, the types of 
 generalized insanity we have passed in review. 
 
 For instance, we have in figure 1 an attack of 
 acute mania. We see represented there; 
 
303 GENERALIZED INSANITIES. 
 
 (1). The initial period (AB) characterized first 
 by depression, then by progressive excitement which 
 may reach its apogee either suddenly or very grad- 
 ually, or, as here indicated, by a series of gradual 
 oscillations. 
 
 (2). The period of full development {periocle 
 fV etat) (BC), or that of the attack, properly 
 speaking, characterized by the acute evolution of 
 the excitement with more or less marked variations. 
 
 (3) . The period of termination (C D) , which in the 
 ease of recovery, here selected, is characterized by a 
 return, either sudden,, by oscillations, or by insen- 
 sible transitions, to the normal condition. 
 
 It will be readily seen that an attack of sub-acute 
 or hyperacute mania, as well as any variety of mel- 
 ancholia, with their special variations of beginning, 
 intensity, evolution, and termination, can also be thus 
 represented. 
 
 Figure 3 represents remittent mania. This vari- 
 ety of insanity is constituted, as we are aware, by 
 the more or less regular return of acute crises or 
 paroxysms of mania, separated by periods of 
 attenuation or remission.' Here is seen, in the 
 clearest manner, this succession of phenomena. 
 ABCD gives us the curve of the acute attack 
 with its three periods of onset, culmination, and 
 decline; DA shows the remission, its intensity, 
 and duration ; then a new exacerbation ABCD is 
 produced, followed by a new remission, and so on 
 indefinitely. 
 
GBNBEAXIZED INSANITIES. 203 
 
 Instead of remittent mania we may take for our 
 tracing remittent lypemania, which will not require 
 further explanation. 
 
 Figure 3 represents intermittent mania. This 
 variety of insanity is formed, as we are aware, by a 
 succession of maniacal attacks separated from each 
 other, not by phases of attenuation like remittent 
 mania, but by complete returns to the normal con- 
 dition, or intermissions. A B C D figures the attack, 
 with its initial period, its sudden termination, and 
 its period of culmination ; D A is the return to the 
 normal condition, a true recovery, as is seen, differ- 
 ing only from an absolute recovery in that it is 
 intermediate between two attacks. Following it, in 
 fact, we see a new attack ABCD produced, alto- 
 gether identical with the former one, then a new 
 intermission, and so on. 
 
 Figures 4, 5 and 6, are devoted to the representa- 
 tion of insanity of double form. In figure 4, we have 
 continuous double form or circular insanity in which 
 the attacks of insanity are connected end to end and 
 follow each other without interruption. ABCD A 
 represents the complete attack of double form in- 
 sanity, in which we see the sudden beginning of the 
 phase of excitement (A B) ; its period of full develop- 
 ment (B C) ; the instantaneous passage' of the phase 
 of excitement into that of depression (C T)) ; the 
 period of full development of the phase of depres- 
 sion (D A) ; the sudden passage from ihe phase of 
 depression to that of excitement (AB). Then a 
 
204 GENEEAXIZED rNSAlTITlES. 
 
 new attack like in all points to the former one, 
 etc., etc. 
 
 In figure 5, we see figured the curve of intermittent 
 double form insanity or that with separated attacks, in 
 which the attacks, instead of succeeding each other 
 uninterruptedly are separated by longer or shorter re- 
 turns to the normal condition. A B C D E F here re- 
 presents the complete attack : the onset of the stage of 
 excitement by gradual oscillations (A B) ; the period 
 of full development (B C) ; the passage by gradual 
 oscillations to the phase of depression (C D) ; the cul- 
 mination of this phase (D E) ; and the rapid return 
 to the normal (E F). This normal interval is figured 
 in FA. Then follows a new attack A B C D E F 
 with the same features as the first and followed, like 
 it, by another return to the normal condition F A, 
 etc., etc. 
 
 In figure 6, we have what M. Ritti calls peripdi- 
 cal insanity of alternating forms, and which he con- 
 siders as the combination in the same individual of 
 an intermittent mania and an intermittent melancho- 
 lia, while, according to other authorities, it is a third 
 variety of insanity of double form in which an inter- 
 mission or return to the normal occurs, not only after 
 each complete attack, as in the proceeding form, but 
 also after each phase of the attack. Whichever 
 theoretical conception is adopted, this variety of 
 mental disease is none the less exactly represented 
 here. A B C D is the maniacal phase ; D E the con- 
 secutive normal condition ; E F G H the melancholic 
 
GENEBALIZED INSANITIES. 205 
 
 phase ; H A the second return to the normal. Then 
 the same cycle is repeated anew under the same 
 conditions. 
 
 It will be noticed how all the technical considera- 
 tions relative to the different forms of generalized 
 insanity are simplified and cleared up, thanks to 
 these diagrams. By their means it is likewise easy 
 to apprehend and appreciate with a rapid glance the 
 differences, so important in a medico-legal point of 
 view, that exist between the various states of lucid- 
 ity or lucid intervals ; the lucid moment, which is a 
 transitory return to the normal condition during an 
 attack : the remission, which is a simple attenuation 
 of the symptoms of the attack; the intermission or 
 intermittence, which is a true recovery between two 
 attacks. 
 
 The utility of the diagrams is not shown merely 
 in a theoretic point of view and in figuring schemat- 
 ically the diverse forms of generalized insanity. 
 They may also be clinically useful as a record on 
 which to inscribe from day to day the state of 
 patients, permitting us thus to obtain faithful 
 tracings of the attacks that are eminently suggestive. 
 I have adapted it to this use by a very easily made 
 addition of horizontal lines for the record of the 
 curves of the pulse, the temperature, and the respi- 
 ration, together with that of the attack itself. 
 

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Cbapter ID1F1F. 
 
 PARTIAL OR ESSENTIAL INSANITIES. 
 § I. GENERAL REMARKS. 
 
 We are already acquainted with the principal 
 differential characters of the generalized and the 
 partial insanities. We are aware that the first are 
 accompanied with a morbid reaction of the general 
 activity, excitement or depression; that they are 
 often curable ; and that they form, by their associa- 
 tion with other physiological or pathological condi- 
 tions, the symptomatic insanities. We also know 
 that the partial insanities are not accompanied 
 by any permanent morbid reaction, that they are 
 seldom curable, finally that they are idiopathic or 
 essential, that is to say, independent and autonomous. 
 
 When viewed in respect to the form of their de- 
 lusions, the partial insanities are relatively numerous : 
 they comprise in fact, hypochondriacal insanity, in- 
 sanity of persecution, religious, political, jealous, 
 erotic, ambitious, etc., insanities. But as we have 
 seen in the chapter on classification, all these names 
 do not, properly speaking, represent distinct entities ; 
 they are varieties or rather phases of one and the 
 same disease. 
 
 The patient passes first through a state of painful 
 
GBNEEAL EEMAEKS. 2l3 
 
 disquietude, during which, he has strange feelings 
 and believes his relations with the external world 
 have been modified, he falls back on himself and 
 busies himself in painful self analysis. With a 
 mental acuteness, the more pronounced since all his 
 faculties are concentrated on one object, he scrutin- 
 izes closely all he says and does and all that goes on 
 around him, and he finds in everything, by a course 
 of reasoning more or less logical, some hidden mean- 
 ing, sonae reference to his person or his situation. 
 This is the hypochondiiacal stage of Morel, the period 
 of inquietude of Magnan, which I myself have 
 called the period of analytic concentration or of 
 subjective analysis, on account of the tendency to 
 inductive analysis predominating for the time in the 
 patient. Hallucinations may also occur, but it is in 
 the succeeding period that we meet with them almost 
 invariably. 
 
 In this second period, the patient imagines a ra- 
 tional explanation of his sufferings, of his inquie- 
 tude and of the attentions of which he believes 
 himself to be the object; he finds, as it has been 
 happily expressed, the formula of his delusion. If, 
 as he thinks, disturbing incidents multiply about 
 him; if he hears voices insulting him and answering 
 his most secret thoughts ; if he smells noisome odors ; 
 if he experiences in his body veritable electric shocks ; 
 it is because he is the object of the malevolence and 
 animosity of mankind, and of certain persons in 
 particular. Powerful enemies, bent on his rain, 
 
•Hi PARTIAL OK ISSS&NTIAL INSANITItJg. 
 
 have organized a conspiracy against him, and have 
 employed for his injury various mysterious agencies, 
 such as magnetism, electricity, the telephone, etc. 
 This is the insanity of persecution discovered hy 
 Lasfegue, who has given of it a masterly description. 
 Once implanted in the mind of the patient, the delu- 
 sions gradually assume shape and become elaborated, 
 and come by insensible degrees to form an unvarying 
 theme, a romance of which the patient is at once the 
 author and the hero. This second phase well merits, 
 as we see, the name of period of delusive explication. 
 
 After a longer or shorter period, sometimes not 
 for many years, an important change occurs in the 
 condition of the patient, who, from being a subject 
 of persecution, becomes ambitious or, as it is called, 
 a megalomaniac. There is here not merely a change 
 of delusions, a new explanation substituted for the 
 former one; the whole personality of the patient is 
 transformed: he is a prince, king, prophet, or even 
 Deity himself. Thus appear ambitious ideas, join- 
 ing themselves to those of persecution not by simple 
 association, but in a most intimate combination, in 
 such a way as to form a perfectly homogeneous 
 whole in which the two delusional elements enter in 
 varying degree according to the case. From this on 
 the patient remains permanently incrusted in this 
 condition which persists, it may be said, till his 
 death. It is the third and last stage, or stage of 
 transformation of the personality. 
 
 As regards the fourth period, admitted by M. 
 
GEITBEAL EBMAEKS, 315 
 
 Magnan under the name of the period of dementia, 
 it is not, in reality, a phase of the disease, but only 
 one of its modes of termination, as it is of other 
 forms of mental alienation. Many of the partially 
 insane never reach dementia, properly so called, and 
 even when their intellect does gradually become en- 
 feebled, their delusions still survive in their essential 
 characters. 
 
 This conception of the typical partial insanity is 
 very correct and corresponds, save in exceptional 
 cases of which we shall speak later on, to the actual 
 facts. But there is more : the other partial insani- 
 ties, whose existence has -been mentioned, may also 
 fall into this synthetic class. Thus religious in- 
 sanity is not, when closely regarded, a species liy 
 itseK, but simply a variety of delusive explanation 
 made during insanity of persecution. The same is 
 true of erotic, political, jealous insanity, etc. 
 
 The patients in whom we obsei-ve these symptoms 
 begin with a period of inquietude or of subjective 
 analysis altogether analogous to that preceding de- 
 lusions of persecution. It is only when they en- 
 deavor to explain to themselves their discomforts 
 that they are separated; some find it in celestial or 
 diabolic intervention (religious delusions), others in 
 the love of some ideal or earthly beauty (erotic in- 
 sanity), and still others in the intrigues of dynastic 
 parties (political insanity), or of enemies of their 
 conjugal happiness (delusions of jealousy) . All these 
 delusional conditions, and other analogous ones, 
 
216 PARTIAL OB fiSSENTIAt INSANlTtfiS. 
 
 when they exist, are therefore only simple varieties 
 of the delusive explanation of partial insanity, differ- 
 ent statements of one formula, and therefore pertain 
 to the same disease. As evidence of this, they are 
 very often associated with delusions of persecution, 
 and it is not rare to see patients in these patholog- 
 ical conditions, with religious, erotic, political, and 
 even jealous delusions, all revolving around persecu- 
 tory delusions as a common centre. A still further 
 proof is ■ that all these delusions, have the same 
 point of departure, a phase of hypochondria or of 
 subjective analysis, and also, in the same way, the 
 transformation of the personality or megalomania. 
 
 The partial insanities, actually known, form there- 
 fore one and the same vesania, which, in its normal 
 form presents a typical evolution in three periods: 
 (1) a period of inquietude or of subjective analysis 
 (hypochondriacal insanity) ; (2) a period of delu- 
 sional explanation (persecutory, religious, erotic, po- 
 litical, jealous delusions, etc). ; (3) a period of trans- 
 formation of the personality (grand delirium). We 
 denominate it for this reason, progressive systema- 
 tized insanity. Progressive systematic psychosis 
 (Gamier). Chronic progressive systematic psychosis 
 (Ballet). Chronic delirium (Magnan). Paranoia 
 primaria (Italian). Priinare Verrucktheit (German). 
 
 A long discussion took place within a few years 
 in the Medico-psychological society of Paris on the 
 subject of partial insanities. Some, with Magnan, 
 recognized two forms of systematized insanity or, as 
 
GENBRAIi EEMABKS. 217 
 
 they improperly name it, chronic delirium: (1) sys- 
 tematized progressive insanity evolving always in 
 distinct periods; (2) systematized insanity of de- 
 generacy, irregular and atypical. Others, with M. 
 Ball, deny the distinct existence of a systematized 
 insanity of degeneracy, and hold that systematized 
 insanity, progressive itself, has always the path- 
 ognomonic evolution attributed to it. An agree- 
 ment between the two sides was not reached. 
 
 At base these two views have each their share of 
 truth, and it may be admitted that there is a typical 
 systematized insanity characterized by an habitual 
 evolution in three periods, with abnormal forms, the 
 principal one of which is that met with in cases of 
 degeneracy. 
 
 Moreover, this view of the subject is not new nor 
 special to France, as it has been given long since in 
 the majority of foreign works. The Italians, 
 especially, who include all the systematized insanities 
 under the generic name of paranoia, divide them 
 into two very distinct species : (1) degenerative para- 
 noia, original or late, according to the epoch of its 
 appearance ; (3) psycho -neurotic paranoia, piimary or 
 secondary, according as it shows itself at once or 
 succeeds a generalized insanity. This semeiological 
 grouping of systematized insanities corresponds, it 
 will be seen, to the division proposed in France : it 
 is even more complete. The Italians have gone so 
 far as to formulate an original theory to explain 
 how systematized insanity may be primary in some 
 
 Mkkt. Med.— 14, 
 
318 PAETIAL OE ESSENTIAL INSANITIES. 
 
 subjects and secondary in others. They pretend, in 
 fact, that systematized insanity is always consecu- 
 tive to a generalized insanity, of which it forms a 
 more advanced stage ; when it appears primarily in 
 an individual it succeeds a generalized insanity in 
 his ancestors ; when it is secondary the succession is 
 confined to the one individual. 
 
 We have to take up here only primary systema- 
 tized insanity (paranoia primaria), as we have 
 already spoken of secondary systematized insanity 
 (paranoia secondaria) in the chapters on mania and 
 melancholia. As to the systematized insanity of 
 degeneracy (paranoia degenerativa) , it will find its 
 natural place in the descriptions of the mental con- 
 ditions of degeneracy. 
 
 §11. PEOGRESSIVE SYSTEMATIZED INSANITY, 
 
 Definition. — Progressive systematized insanity 
 may be defined as: a chronic, essential insanity, 
 without disorder of the general activity, character- 
 ized by hallucinations, especially of hearing, by de- 
 lusions tending to become systematized, and ending 
 in a transformation of the personality. 
 
 Etiology. — Systematized insanity, we have said, 
 constitutes the essential insanity, the true insanity. 
 Its etiology is also rather limited. In it, accessory 
 causes hardly come in play, it is an integrant part 
 of the. individual. The patients receive its germ at 
 birth and it develops at its appointed hour under the 
 
PKOGESSSIVK systematized IKSAisriTY. 319 
 
 influence of the sliglitest cause, for example, poverty, 
 difficulties of social life, disappointments, mortifica- 
 tions, conjugal unhappiness, the menopause, etc., 
 etc. That is to say, that the principal cause of 
 partial insanity is heredity. It is well known that 
 it is more frequent in females, celibates, and espe- 
 cially in those horn out of wedlock. It affects, by 
 preference, those of a gloomy, suspicious, irritable 
 character, and inclined to pride and misanthropy. 
 
 1. — Pbeiod of Subjectivb Anaiybis. 
 Hypochondriacal Insanity. 
 
 The disorder begins, most frequently, with un- 
 comfortable sensations, functional or organic dis- 
 turbances, which commence by startling the patient, 
 attracting his attention and leading him to analyze 
 them. These are uncomfortable sensations, for 
 example, headaches, palpitations, buzzing in the 
 ears, and dazzling the eyes. Still more often they 
 are vague uneasinesses located usually in the genital 
 organs or the digestive tract. Sometimes also there 
 are abnormal sensations of cranial constriction, of 
 emptiness of the skull, with diificulty of working, 
 thinking, etc. The patient is unduly disturbed by 
 these symptoms, he studies himself, thinks over all 
 his feelings and finds them increasing. What ap- 
 pears to him most strange is that, besides the bodily 
 symptoms he experiences, he thinks his intelligence 
 is being overturned ; his mind acts without his voli- 
 
^30 PAJEtTIAL OE ESSENTIAL INSAN-I*lflS. 
 
 tion, he cannot control it, and this automatic part of 
 his being may sometimes become so powerful that 
 his thoughts exteriorize themselves and become more 
 or less oonsciouslj^ acted out. There are here, as 
 M. Seglas has demonstrated, actual psycho-motor 
 hallucinations, which are, in spite of the received 
 opinion, among the first symptoms observed in these 
 patients. 
 
 Thus far the future paranoiac resembles more or 
 less strongly a simple hypochondriac, for which, 
 moreover, he may be mistaken; but soon, by a 
 natural mental tendency in which he is unlike all other 
 lunatics, he begins to search for a cause of his 
 troubles, not in himself, but externally. This is, it 
 may be said, the first step of his psychic evolution, 
 which may in some cases be manifested at once 
 without any preceding hypochondria. 
 
 From this time on the patient extends his investi- 
 gation to his surroundings, and refers to himself 
 every thing that he hears or sees around him {auto- 
 philia of Ball). It seems to him that persons and 
 things are altered, that people look at him, - make 
 signs and whisper when he passes; everything said 
 has a double meaning, he cannot find things in their 
 places ; he is unable to work ; his business goes wrong ; 
 nothing succeeds with him. 
 
 Always keeping to himself the result of his 
 thoughts, he becomes more and more gloomy and 
 sometimes feels even driven to suicide ; but these are 
 only temporary discouragements to which the para- 
 
PROGRESSIVE SYSTEMATIZED INSANITY. 221 
 
 noiac rarely succumbs; he usually resists them, 
 accepts the battle against fate, seeks to find out 
 more, and becomes more and more wrapped up in 
 his morbid investigations. 
 
 Reviewing his whole former life, he finds trivial 
 incidents that seem to him significant, and, which, 
 taken together, convince him that he has long been 
 the object of a hidden animosity. 
 
 By this time, however, sensory disorders have 
 made their appearance, if indeed they have not all 
 along existed. Sometimes they are false auditory 
 sensations, plaintive cries, sound of bells, detonations, 
 confused voices, repetition of his thoughts; some- 
 times they are false olfactory or gustatory sensations ; 
 and again, various disorders of the tactile or genital 
 senses. 
 
 With these new elements in operation, the delus- 
 ions make rapid progress, and the second period of 
 the disorder soon appears. 
 
 2. — Period op Dblxjsional Explanation. 
 {Insanity of Persecution. Lasigue's Disease.) 
 
 This type of insanity, first studied in 1852 by 
 Lasfegue, whose description is still authoritative, 
 consists essentially in the development and progressive 
 systematization of the tendency of the patient to refer 
 everything to the hostility and malevolence of others. 
 Although its symptoms are far from being absolutely 
 identical in all cases, the following is the usual 
 course of the disorder. 
 
223 PAETIAl OE BSSBNTIAL INSANITIES. 
 
 At first the delusions are confused. The patients 
 believe that there is ill will toward them, that is all. 
 They do not know by whom nor why nor how_. 
 They, is their habitual expression. "They wish me 
 ill, they insult me, they trouble me, electrify, poison, 
 violate, throw bad smells on me," tliey say. Then, 
 some quickly, others more slowly, select in their past 
 life, their customary occupations or their mode of 
 living, some special fact that draws their attention 
 to such and such a group of persons, or even to a 
 single individual. Some, according as they have 
 previously had their attention drawn to the idea of 
 the police, free masonry, the Jesuits, etc. , attribute 
 what they call their troubles to the police, free 
 masons, and Jesuits. Others, who have already en- 
 emies or simply those whom they distrust, make 
 them the responsible authors of all the evil that 
 happens to them. A conspiracy has been made 
 against them, they say, into which have entered 
 neighbors, servants, relatives, friends, frequently 
 also unknown individuals ; sometimes a whole town 
 is moved against them, and the patients believe 
 everything they see or hear is directed against them ; 
 they interpret everything according to their morbid 
 ideas. In this is the first step toward the organiza- 
 tion of the delusions. As regards the explanation 
 of the proceedings of their so-called enemies, it is at 
 base almost invariably the same. In the presence 
 of phenomena for which they can not give a natural 
 interpretation, the patients seek to account for them 
 
PEOGEESSIVB SYSTEMATIZED INSAOTTT. 233 
 
 by the most extraordinary ways. Holes are made 
 in tlie wall to speak to them, to address insults to 
 them, to blow irritating powders and evil odors 
 through, to electrify them ; electric batteries are put 
 up in their vicinity, or even in their chambers, also 
 acoustic tubes and telephones, with the aid of which 
 their enemies insult them and produce in them all 
 kinds of disagreeable sensations. 
 
 During this time the hallucinations multiply; if 
 heretofore they were psychic or psycho-motor, they 
 now become fully psycho-sensorial. The voices are 
 clear, plainly insulting; they are heard not only at 
 night and at intervals, as in the beginning, but also 
 during the day and almost uninterruptedly, some- 
 times in only one ear (unilateral hallucinations) , gen- 
 erally in both ; they use coarse language, injurious epi- 
 thets, slang, and whole sentences in which accusations, 
 insults and threats predominate. Very often at this 
 time, sometimes even from the beginning, as we 
 have seen, there occurs a curious hallucinatory phe- 
 nomenon, the echo of the thoughts. The patient 
 hears his thought distinctly uttered as soon as it 
 arises, not in a loud tone, but in a sort of more or 
 less variable internal voice : and he then believes that 
 others also hear them which is to him an inexpress- 
 ible torture, since the thoughts he most desires to 
 keep secret are those most distinctly heard. He 
 perceives that others hear his thoughts since they 
 respond before he has uttered them, and because he 
 hears mentioned facts of his past life which were 
 
224 PAETIAL OR ESSENTIAL nSTSANITIES. 
 
 only known to himself, etc., etc. This phenome- 
 non, so marvelous to him, he explains by the inter- 
 vention of electricity, the telephone, or phonograph ; 
 sometimes he comes to imagine that this voice that 
 he hears in him belongs to another individual, and 
 this I believe to be the usual starting point of that 
 curious pathological condition known as duplication 
 of the persopality. 
 
 In reality the echo of the thought is only a path- 
 ological manifestation of that which psychologists 
 have called animated internal speech (Egger, 
 Strieker), Ballet, motor representation of articula- 
 tion, and finally that called by S6glas verbal psycho- 
 motor hallucination. The patients unconsciously 
 form in speech their thoughts, and some (R%is, 
 S6glas), are conscious of rudimentary movements of 
 the tongue and lips that accompany the production 
 of the mental phenomenon. 
 
 In some cases, but usually at a much later period, 
 the patients hear voices in each of the two ears (double 
 hallucinations. Magnan). On one side he hears 
 disagreeable things, insults and threats ; on the other, 
 agreeable words, encouragement and advice. These 
 two kinds of hallucinations constitute for the patients, 
 says Seglas, the attack and the defense. 
 
 As Las6gue has justly remarked, hallucinations 
 of sight are very rare in the insanity of persecution. 
 The patient hears his enemies, recognizes more or 
 less fully their voices, but generally does not see 
 them. His false visual sensations, when he has them, 
 
PEOGEESSIVE SYSTESLATIZED INSAOTTT. 235 
 
 consist mainly in hostile apparitions, in grimacing 
 figures, in writings full of threats, in changes of ap- 
 appearance of persons and things, which he accuses 
 his enemies of making him see by their machinations. 
 It is exceptional that visual hallucinations occur in 
 any connected fashion, at least when not complicated 
 with other pathological conditions, such ap alcoholism 
 or hysteria. 
 
 On the other hand, the sense of smell, that of taste, 
 and especially the sense of tact, and what we call the 
 general sensibility, internal or external, play a great 
 part in the delusions. The patients smell odors of 
 manure, of sulphur; they have the taste of arsenic, 
 copper, or phosphorus in their mouths, whence they 
 conclude that attempts are made to poison their food, 
 and this drives them sometimes to sitiophobia or, at 
 least, to only eat certain substances and from certain 
 dishes. Lastly they experience all kinds of extra- 
 ordinary sensations. They feel spasms produced 
 throughout their bodies, cramps, blows, torsions, 
 burns ; they have had their stomachs torn out, their 
 abdomens opened ; gas is blown into their bowels ; 
 foreign bodies are introduced into their sexual organs ; 
 they are outraged, sodomized, masturbated, their 
 semen is drawn off, etc., (genital persecutory cases). 
 All these sensations are infinitely variable, and the 
 expressions by which the patients describe them are 
 as typical as they are impossible to reproduce. 
 
 At this time the patient begins to act as a per- 
 secutory case. Nearly always his first act is a com- 
 
326 PARTIAL OE ESSENTIAL INSANITIES. 
 
 plaint. He addresses himself orally, but by 
 preference in writing, to the public authorities to 
 have the persecution of which he is the object dis- 
 continued, and especially to the police, the public 
 prosecutor, sometimes even to the minister of justice 
 or to the President. It is such individuals as this 
 that weary all the magistrates, greater and lesser, 
 with their demands, and assail them with the most 
 voluminous briefs. At the same time they fre- 
 quently change their residence to escape from their 
 tormentors and to remove themselves from their 
 operations (alienes migrateurs. Foville). But they 
 change places or hide themselves in vain, the per- 
 secutions follow them everywhere. 
 
 After having made vain efforts to obtain justice, 
 and after having, so to speak, exhausted all juris- 
 dictions, the patients attempt to secure justice for 
 themselves. Now they enter upon a new phase, 
 that of active conflict, which Lasegue has defined 
 perfectly by saying that from being subjects of 
 persecution, they become persecutors themselves. 
 
 The greatest peril any one can incur is to be taken 
 by a persecutory lunatic for the head of the conspir- 
 acy that surrounds him, for the person against whom 
 he must avenge himself; a peril that is the greater, 
 since the victim is ignorant of it, and the patient in 
 full possession of his mental resources, puts in the 
 service of his enmity an astuteness and a cruelty truly 
 Machiavellian. This situation is not without anal- 
 ogy with the legendary Corsican vendetta, but it is 
 
PROGRESSIVE SYSTEMATIZED INSAJSnTT. 227 
 
 Still worse. At the moment when he least expects 
 it, when everything is peaceable and tranquil, an 
 individual finds himself attacked suddenly by a person 
 he does not know, often one he has never seen and 
 to whom he has done nothing whatever. Sometimes 
 even, the patient, without having his persecutor def- 
 initely fixed in his mind, attacks whoevi.'r he first 
 meets, under the influence of a hallucination of hear- 
 ing or a morbid impulse. It cannot be too often 
 repeated; that, equally with the epileptics, 
 and jjossibly even more than these, the persecutory 
 insane are, of all lunatics, the most dangerous. The 
 greater part of the crimes committed outside of the 
 asylums by the insane, and nearly all those committed 
 within them, are to be credited to this class. More- 
 over, it is not only homicides that they commit; 
 they may attem.pt arson, poisoning, and occasionally, 
 contrary to general opinion, and in exceptional cases, 
 suicide. Whatever their acts may be, they very 
 frequently assume the impulsive character. 
 
 During all this time the patient is more and more 
 wrapped up in his delusions, which, having taken 
 definite shape, become systematized, and, as we may 
 say, crystallized, and, except in some very slight vari- 
 ations, remain thereafter imchangeable. If he has 
 not yet created any neologisms to express his con- 
 ceptions, he does so now, and inserts in his remark a 
 a greater or lesser quantity of odd and unknown 
 terms by means of which he expresses his delusions, 
 or designates his persecutors. This pathological Ian- 
 
238 PARTIAL OB BSSBNTIAL INSANITIES. 
 
 guage is the best evidence of the chronicity of the 
 delusions, and, if there had been any hopes of recov- 
 ery, they have to be dismissed when it appears. 
 
 The character of the persecutory paranoiacs is 
 generally bad. They are suspicious, quick to take 
 offense, cold and harsh in their manner, short and 
 surly in their speech ; they answer questions addressed 
 to them impolitely, and often limit themselves to a 
 few very characteristic phrases, such as: "I have 
 nothing to say to you; you know it better than I," 
 which seem to carry the idea that the questioner has 
 had occult communications with them, and that their 
 thoughts have been heard. 
 
 Further, the majority of these patients are reticent 
 to the highest degree, and if some of them choose to 
 make public their grievances by speech or writing, 
 the greater number keep them to themselves and give 
 no outward demonstration of their hallucinations and 
 their delusions. An extensive experience and a cer- 
 tain amount of tact are necessary, therefore, to 
 enable one to overcome their obstinate mistrustful- 
 ness, and penetrate the mystery of their conceptions. 
 They exhibit to a large extent the general appear- 
 ance and special physiognomy that has been described 
 as connected with hallucinations of hearing in the 
 second chapter of this work. Very often, they may 
 be seen in silent converse, or even replying to them- 
 selves, smiling or frowning at their own remarks, 
 answering them, or giving way under their influence 
 to sudden acts of eccentricity or violence, It is 
 
PEOGEllSSIVB SYSTEMATIZED INSAlinTY. 2^9 
 
 more particularly on account of the persistence of 
 these hallucinations, and the passive obedience in 
 which they live to them, that the persecutory insane 
 are subject to sudden impulses and consequently are 
 essentially dangerous patients. 
 
 After a longer or shorter period, of some weeks 
 or months, and still oftener of several years, the 
 paranoiac tends gradually to attain that condition 
 which is the culmination of his disease, that is the 
 transformation of his personality. 
 
 This is brought about in two different ways: it 
 either occurs suddenly under the influence of a hal- 
 lucination or suggestion that reveals to the patient 
 all at once, his royal origin or his character as an 
 exalted personage ; or it occurs slowly, through the 
 logical evolution of his delusions that ends in con- 
 vincing him that, since every one is against him, 
 he must necessarily be a person of some consequence. 
 In either case the result is the same, a new person- 
 ality comes on the stage whose presence is announced 
 by ambitious or exalted notions that begin to appear 
 amid the delusions of persecution that had hereto- 
 fore alone existed. At this moment the patient 
 enters upon the third stage of his disorder. 
 
 Mystical Dblibium (Religious Insanity). 
 
 Another delusional type, that may characterize, 
 as has been stated, the second period of the disorder, 
 of partial insanity, is that of delusions of a mystical 
 
330 PARTIAL OE ESSENTIAL INSANITIES. 
 
 or religious nature. Fundamentally this condition 
 is the same as that described, and the same events 
 unfold themselves ; the delusive explanation only is 
 changed. Instead of charging his extraordinary 
 sensations to human intervention, the patient attrib- 
 utes them to divine agency. That is all the differ- 
 ence. However it may be, whether predisposed by 
 their birth, their natural disposition, their education, 
 their ignorance, or their profession, to be influenced 
 by religious or superstitious ideas, some patients, 
 who have experienced, during the earlier stage of 
 their disorder, the same symptoms as those who 
 afterwards suffer from persecutory delusions, are 
 gradually led to attribute these phenomena either to 
 sorcery or to a divine or diabolic influence. The 
 voices they hear seem to them to be those of God or 
 of devils ; their bizarre sensations are proofs to them 
 that they are punished from heaven or are persecu- 
 ted by sorcerers. Almost invariably, and this is a 
 special symptom of mystic delusions, the patients 
 present internal illusions of a sexual nature, which 
 they interpret in various ways, but always accord- 
 ing to their delusions. The men think they are sub- 
 jected to carnal temptations, sent from Deity to test 
 their virtue; the women imagine that they have 
 secret relations either with God or the devil, and say 
 that they are pregnant by one o!r the other. Hence 
 come the delusions of a mystic nature relating to cel- 
 estial or infernal powers, which, in the epochs when 
 religious insanity raged as an epidemic, have given rise 
 
PROGRESSIVE SYSTEMATIZED INSANITY. 2^1 
 
 to all the subdivisions and designations of theomania, 
 demotiomania, demonolatry, incuM, sucoubi, etc. 
 
 Whatever shape they may take, mystical delusions 
 progress in the same fashion as those of persecution. 
 They are based on morbid sensations, especially hal- 
 lucinations of hearing and disturbances of general 
 sensibility, internal or external. Like persecutory de- 
 lusional insanity, this type evolves slowly and tends 
 gradually to systematize and crystallize itself, to reveal 
 itself by more and more coordinated conceptions and 
 a pathological language full of neologisms and odd ex- 
 pressions. Frequently, indeed, the delusions show a 
 mixture of mystical and persecutory ideas, so that 
 the patient belongs at once to both categories. Thus 
 we have some cases of partial insanity who believe 
 they have divine revelations and have commerce with 
 Deity or with the Virgin Mary, and who, feeling 
 themselves charged with upholding the true faith, 
 consider as their enemies and agents of the devil 
 bent on their ruin, all sorcerers, free masons, Jesuits, 
 priests, the members of their own family, or this 
 or that other person whom they consider as their 
 persecutors. 
 
 Mystic delusions are more often accompanied with 
 visual hallucinations than are those of persecution, 
 and in this they seem to have rather close relations 
 with hysteria. 
 
 Aside from these special features the conditions are 
 the same, and while not as positively dangerous as 
 the persecutory insane, the m.ystics very often com- 
 
^32 PAlfttAl oft BSSfiTiTtlAL INSAlOTIES. 
 
 mit barbarous or criminal acts, based on their delu- 
 sions or hallucinations. Sometimes they go from 
 town to town, catechising, preaching, threatening 
 the divine anger and the vengeance of heaven, 
 and even attempting violence against the enemies 
 and detractors of religion; sometimes they extM 
 self mortification and the most shocking mutilations, 
 which they practice upon themselves and urge then- 
 followers to perform, thus founding more or less 
 extended religious sects (skoptzi, etc.); sometimes, 
 obedient to the voices they hear, they attack this or 
 that person who seems to them to take the part of a 
 demon ; and finally, they often attempt to repeat 
 the sacrifice of Abraham, and immolate upon the 
 altar their own children. 
 
 In these cases, as in the persecutory ones, 
 the transformation of the personality is grad- 
 ually accomplished, and in the same manner. It 
 occurs either suddenly as a consequence of the 
 hallucinations, or slowly as, in the progress of 
 the delusions, they come to believe themselves import- 
 ant personages in the religious world, charged with 
 a divine mission, destined to reform the world, to 
 represent the Deity ; sometimes they imagine them- 
 selves to be Christ, Antichrist, the Virgin Mary, or 
 even God himself. They then, like the persecutory 
 paranoiacs, enter into the third period of their disorder. 
 
 Ekotic, Political Jealous Insaottibs. 
 
 It seems useless to here enter into a detailed 
 description of the erotic, political or jealous delir- 
 
PBOGRESSIVE SYSTEMATIZED INSANITY. 233 
 
 iums. In fact, it is rare for them to appear singly 
 and as distinct forms of systematized insanity. 
 Generally they are only psychological modalities of 
 the insanity of persecution. The patients, for exam- 
 ple, in whom sexual hallucinations predominate, are 
 naturally led by that fact to build up delusions of 
 persecution of a specially sexual or erotic nature, in 
 which they charge one or many of their enemies with 
 attacks on theu- chastity, with rape, and with all sorts 
 of outrages, on which they dilate with the greatest 
 satisfaction. Others see political enemies every- 
 where, they take him for a conspirator, they watch, 
 spy on him, lay informations against him, try to have 
 him arrested and imprisoned. Another thinks that 
 every one is trying to seduce his wife ; he cannot see 
 any one near her without thinking his motive is to 
 betray or deceive her : he follows her, sees evil in her 
 least actions, quarrels with her, threatens her, and 
 often goes so far as to attack her in a more or less 
 violent manner. 
 
 Fundamentally all these are only varieties of per- 
 secutory insanity, which are usually combined, either 
 singly or together, with it, more or less intimately, 
 except only in degenerative cases in whom they may 
 constitute a species apart. 
 
 I have had under observation for five years, a 
 patient who is very typical, inasmuch as her system- 
 atized insanity is composed at the same time of delu- 
 sive ideas and hallucinations of persecution, erotism, 
 politics and religion. From the fusion of all these 
 
 HSHT. ]|£bd. — 15. 
 
234 PAETIAX OE ESSENTIA!. INSAiaTIES. 
 
 elements there results in her case a protean persecu- 
 tory delirium, but one not differing in its characters 
 and evolution from the classic type. I have been 
 very curious to know how it would terminate in 
 exalted delusions, if it reached that stage, and have 
 always thought that it would take a political color- 
 ing, from the greater predominance of conceptions 
 of that nature over the others. This is what is being 
 at present effected, as the patient who has for years 
 been "insulted by the Republic," has during a 
 few months begun to affiliate herself to the royal 
 family under the characteristic designation of 
 "Marie Antoinette." 
 
 .3. — Pbbiodof TBAJsrsroEMATioN op the Personality. 
 Ambitious Insanity. 
 
 As persecuted, erotic, mystic, political, or jealous, 
 the partially insane reach, by apparently different 
 routes, the third period of their pathological condi- 
 tion, which consists, as we have stated, in the trans- 
 formation of their personality, revealing itself by 
 characteristic ambitions or exalted delusions. This, 
 at first only a few ideas of pride, lost amid the 
 notions of persecution, rapidly develops and be- 
 comes more concentrated, and mingling with the 
 pre-existiag delusions, the patient at a certain stage 
 presents the phenomenon of the manifest co-existence 
 of persecutory and exalted delusions, revolving in 
 this vicious pathological circle, that he is of conse- 
 
PEOGBBSSIVB SYSTEMATIZED INSANITY. 235 
 
 quence because he has enemies and that he has ene- 
 mies because of his greatness. Soon, however, the 
 exalted notions begin to predominate and to gradu- 
 ally crowd out those of persecution, which undergo 
 a regressive course and become more or less con- 
 fused ; so that the period soon arrives when the per- 
 secuted individual becomes a megalomaniac, a happy 
 expression, that describes this new condition very 
 aptly, provided, however, that no signification is 
 attached to the terms maniac or monomania, since 
 this condition has nothing in common with mania. 
 
 During all this period the hallucinations persist, 
 and it is only after a long time, and when dementia 
 begins to appear, that they become gradually weak- 
 ened or diminished. 
 
 The patients continue, for the most part, to be 
 egoistic, haughty, and vicious. They have, how- 
 ever, at this time, a characteristic peculiarity, viz. , 
 that they 'make themselves up, after their own 
 fashion, in the costume of the personage they believe 
 themselves to be. These are the patients we see 
 in asylums rigged out in plumes, bits of cloth of 
 striking colors, crosses, medals, chaplets, and tinsel 
 of every description; they frequently do up their 
 hair and beard in a special and characteristic man- 
 ner. Nothing is more common than to see those 
 whose head and countenance recall, for example, 
 the conventional representation of the head and face 
 of Christ. All these patients are haughty, dignified 
 and majestic in their attitude, and they do not lay 
 
236 PAETIAl OE BSSBNTIAX INSAITITIBS. 
 
 aside for an instant their serious or solemn air. 
 We might say that they are tragedians in some 
 royal r6le who continue to play their part in public 
 and in their appropriate costumes. 
 
 This period of ambitious insanity lasts indefinitely, 
 up to the time when dementia appears and enfeebles 
 the mind, and gradually plunges aU the vain concep- 
 tions of the patient into a chaotic nothingness. 
 
 Course. Duration, lamination. — The course 
 of systematized insanity is essentially a chronic one, 
 with or without remissions, and it covers the whole 
 period of the patient's life from the moment of its 
 development. 
 
 Foreign authors have, nevertheless, described an 
 acute form (paranoia acuta) to which they seem to 
 attribute a considerable importance and frequency. 
 With us this form has never been described. If it 
 really exists as a distinct variety, we can say that it 
 is rather rare. 
 
 The duration of each period is exceedingly variable, 
 according to the case. In some the hypochondriacal 
 stage is very long ; in others the megalomania occurs 
 almost at the beginning of the stage of delusive 
 explanation, so as to seem sometimes primary. It 
 may happen also that the first stage, short and not 
 pronounced, passes unperceived, or that the patient 
 makes the second, so to speak, indefinite, continuing 
 to have his mystical or persecutory delusions till he 
 finally dies without having undergone the terminal 
 
PEOGEBSSIVE SYSTEMATIZED INSANITT. 337 
 
 transformation of his personality. At bottom these 
 are all only apparent individual variations of the 
 normal evolution, in which we can always discover 
 more or less distinctly the typical progress of the 
 malady. 
 
 The usual termination of systematized insanity is 
 in dementia, except in the acute form which is more 
 curable. The dementia is, however, very late in 
 appearing, and the patients may continue in their 
 delusions 15, 20, or 25 years without presenting 
 any marked enfeeblement of their intelligence. 
 Moreover, even after dementia has supervened, they 
 still preserve evident traces of their delusions and 
 vestiges of their hallucinations, which give a pecu- 
 liar character to their dementia (ambitious dementia) . 
 
 Death usually occurs from some complication, or 
 some intercurrent disorder, and rather frequently 
 from cerebral Ijsemorrhage. 
 
 Prognosis. — It is not needful to state how serious 
 is the prognosis of chronic or typical systematized 
 insanity. When once fairly established it is almost 
 always incurable. It is only during the early stages 
 when the delusions have not yet become stereotyped, 
 that we see recovery or at least a temporary ame- 
 lioration. 
 
 Pathological Anatomy. — Pathological anatomy 
 is ordinarily silent. Nevertheless we find after death 
 more or less marked cerebral atrophy. This, how- 
 
238 PAETIAX OE BSSBimAr INSANITIES. 
 
 ever, is only a terminal lesion explainable by the fact 
 of long duration of the disease, and is, moreover, not 
 peculiar to it^ since it is met with in the majority of 
 cases of insanity of long duration. 
 
 Diagnosis. — The diagnosis of systematized insan- 
 ity, rather easy to be made when the disorder has 
 attained its culmination, may present difficulty in 
 certain cases. It may happen, for example, that, on 
 account of the reticence of the patients and their 
 skill in concealing their delusions, as well as the lack 
 in them of any general pathological reaction, they 
 are mistaken for persons of sound mind. This error 
 is rather frequently committed by the pubUc, who 
 have a very different idea of what is insanity. To 
 avoid it, it is necessary to proceed in the examin- 
 ation of these patients with all possible tact and 
 carefulness. 
 
 In the beginning of partial insanity, when it still 
 is comprised only of hallucinations and vague hypo- 
 chondriacal and persecutory delusions, it may be 
 mistaken for an attack of delusional melancholia. 
 We have already laid stress on differences between 
 partial and generalized insanity,' especially melan- 
 cholia with delusions of persecution, and need not 
 review them here. It should be remembered, how- 
 ever, that melancholiacs are contrite and paranoiacs 
 rebellious. The ambitious delirium of the later 
 stage of partial insanity must also not be confounded 
 with that which may appear in maniacal excitation. 
 
PEOGRESSIVE SYSTEMATIZED INSANITY. 239 
 
 Besides the facts that the former is accompanied 
 with none of the general symptoms that character- 
 ize mania, that it is systematized and coordinated, we 
 also know, as has been especially shown by AchUle 
 Foville, that it is not primary and that it is habitu- 
 ally accompanied by hallucinations, which are never 
 present in the ambitious delirium of maniacal excite- 
 ment. There are stOl better grounds for distra- 
 guishing the megalomania of systematized insanity 
 from that of general paralysis. Besides the history 
 of the case, the characters of the evolution of the 
 delusions, so different in the two cases, and the pres- 
 ence or absence of the physical signs of paralytic 
 dementia, ought to be sufficient to relieve all doubts. 
 There are cases of incipient systematized insanity 
 where the patients, under the influence of their 
 troubles, take to drink, so that a sort of more or 
 less acute alcoholic delirium may mask, or at least 
 modify, the delusive conceptions that form the basis 
 of the affection. Such patients are commonly 
 taken for simple alcoholic cases, and surprise is felt 
 when, as the toxic delirium disappears, there is 
 unmasked an insanity of persecution which there- 
 after progresses through its successive stages. One 
 ought always, therefore, to be reserved in the prognosis 
 and suspicious of cases of alcoholic insanity with 
 delusions of persecution and especially with predom- 
 inating hallucinations of hearing, 
 
 Treabment. — The treatment of partial insanity 
 can hardly be more than palliative. It is limited to 
 
240 PARTIAL OE ESSENTIA! INSAKITIBS. 
 
 isolation, which is needful in almost all cases on 
 account of the essentially dangerous character of 
 the malady. Moral treatment is ineffective, or 
 nearly so, in this disease. One is limited to the 
 treatment of complications and to watchiug with 
 especial care to prevent the patients, as far as pos- 
 sible, from committing the dangerous acts to which 
 they are so often inclined. 
 
SECOND CLASS 
 
 CONSTITUTIONAL ALIENATIONS. 
 
 (Degbnekacibs, Deviations, Mental Infirmities). 
 
 Cbapter mn. 
 
 FIRST GROUP 
 
 DEGENERACIES OF EVOLUTION. 
 
 (Vices op Oeganization). 
 
 I — Psychic Discordances {Desharmonies). (Defect of 
 Equilibrium:, Originality, Eccentricity). II— 
 Neurasthenias. (Fixed Ideas, Impulsions, Abou- 
 LiAs). Ill — Phrbnasthenias. (Delusional, Reason- 
 ing, Instinctive). IV — Monstrosities. (Imbecility, 
 Idiocy, Cretinism). 
 
 The degeneracies of evolution, or vices of psychic 
 organization, differ from the insanities in that they 
 involve the intellect in its constitution itself and not 
 merely in its mode of activity. They represent 
 anomalies of the organ, the insanities being the dis- 
 orders of its function. 
 
 From this fundamental point start all the other 
 differential characters which may be summed up as 
 follows : 
 
242 DBGElirEEAClBS OP EVOLUTION. 
 
 The degeneracies of evolution are not mere acci- 
 dents of psycMc life, but are genuine original de- 
 fects, usually involving the whole race (hereditary 
 insanity in that of degeneracy: Morel, Legrand du 
 SauUe, Magnan). They show themselves also in the 
 physical organization, as well as in the mental, by 
 . embryogenic deviations or malformations, that go 
 under the name of stigmata or degeneracies, (Morel, 
 Magnan). These malformations or stigmata are 
 essentially indelible, and may be accompanied by va- 
 rious, more or less lasting, neuropathic or phreno- 
 pathic disturbances (episodic syndromes : Magnan) . 
 
 The degeneracies of evolution include four genera 
 or progressive degrees: (1) Psychic discordances, 
 disharmonies (defects of equilibrium, originality, ec- 
 centricity) ; (2) Neurasthenias (fixed ideas, impul- 
 sions, aboulias) ; (3) phrenasthenias (delusional, 
 reasoning, instinctive) ; (4) monstrosities (imbecUity, 
 idiocy, cretinism). We wUl examine successively 
 each of these divisions. 
 
 §1. PSYCHIC DISCORDANCES.— DISHARMONIES. 
 
 (DeI-BCTS op EQUILrBRITJM, ObIGINALITT, EoCBlifTBICITT). 
 
 The disharmonies form, so to speak, the transition 
 between the normal and the pathological conditions. 
 They are the border ground on which we find indi- 
 viduals, intelligent and sometimes even brilliantly 
 endowed, but mentally incomplete and already the 
 bearers of a blemish that reveals itself by a defect 
 
PSYCHIC DISCOEDAKCBS. 343 
 
 of harmony and poise between the various faculties 
 and inclinations. "We can distinguish as types of 
 these: the ill-balanced, the original, and the eccen- 
 tric. 
 
 The III Balanced. (D^sequilibres) . — These are 
 abnormal individuals characterized by an unequal 
 assemblage of deficiencies and excess in their psychic 
 elements. 
 
 From their infancy they are marked for their 
 precocity, their aptitude to perceive and comprehend, 
 and at the same time for their capriciousness, their 
 wayward disposition, their cruel instincts, and their 
 attacks of violent and almost convulsive passion. At 
 the period of puberty they suffer from nervous 
 troubles such as chronic or hysteriform disturbances, 
 migraines, neuralgias, convulsive tics, simultaneously 
 with transitory speUs of excitement or depression, 
 with exaggeration of certain psychic or emotional 
 tendencies (mysticism, onanism, vague sexual as- 
 pirations, desire to travel, or for conspicuous actions). 
 
 After maturity they are complex beings, hetero- 
 geneous, made up of disproportioned elements, contra- 
 dictory qualities and defects, and as over endowed 
 in some directions as they are deficient in others. 
 Intellectually, they often possess in a very high 
 degree, the faculties of imagination, of invention, . 
 and of expression, that is to say, the gifts of speech, 
 the arts, and poetry; on the moral side, they possess 
 a singular emotivity, or rather, sensibility. What 
 they lack, more or less completely, is good judgment. 
 
244 DEGENEEACtES OF EVOLUTION. 
 
 the moral sense, and especially continuity or logical 
 consecutiveness, a unity of diroction in intellectual 
 production and the actions of life. It follows, that 
 in spite of their often superior qualities, these persons 
 are incapable of conducting themselves in a rational 
 manner, of following regularly the exercise of a 
 profession that seems well beneath their capacity, of 
 looking after their interests or those of their 
 families, of carrying on business prosperously, or of 
 directing the education of their children: their exis- 
 tence therefore, constantly recommencing, is one 
 long contradiction between the apparent wealth of 
 means and poverty of results. They are the Utopians, 
 the theorists, the dreamers, who are enamored with 
 the best things but accomplish nothing. 
 
 The public which sees only the brilliant exterior 
 often looks upon these individuals as artists and 
 superior beings. The medal is reversed, however, 
 to those who are compelled to associate with them 
 and share their existence; they see their defects, 
 their incapacities and evil tendencies, of which they 
 are not merely the witnesses, but also the victims. 
 
 Aside from their lack of mental poise these iudi- 
 \'iduals also display an excessive emotional sensibility 
 and an enfeeblement of psychic energy that reveals 
 itself by a noticeable predominance of spontaneity 
 over reflection and volition. Hence their inability, 
 their instability, and their irresolution ; hence also 
 their alternations of apathy and activity, of excite- 
 ment and torpor, their violent attacks of passion 
 
PSTCHIC DISCOBDANCES. 245 
 
 and their cries of despair for the most trivial 
 and slightest reasons. 
 
 In certain cases, finally, we can already distinguish 
 in them the existence of some of the physical signs 
 that characterize the conditions of degeneracy. 
 
 Oeiginalitt — EccENTEiciTT. — The psychic dis- 
 harmonies exhibit themselves in a more marked 
 degree, besides the lack of balance above described, 
 in certain morbid peculiarities that pass under the 
 names of singularities or eccentricities. These are 
 isolated anomalies, manias as they are properly 
 called, that are shown in the external habits, in a 
 style of dress, of wearing the hair, of walking, of 
 writing, or of speaking perhaps in an odd gesticula- 
 tion, a phrase, or tic, or a grimace. Frequently, also, 
 originality reveals itself lq an imperious overmaster- 
 ing tendency which impels the individual in a definite 
 intellectual or emotional direction to the exclusion 
 of any practical or useful occupation : leads him, 
 for example, to surround himself with birds, flowers, 
 or cats, to make collections of insignificant objects, 
 to become absorbed in ridiculous investigations, 
 calculations, or researches. He may have singular 
 emotional tendencies, irresistible attractions for, or 
 fear of, such and such an animal or object. Excessive 
 prodigality, sordid avarice, religious or political ex- 
 altation, erotic excesses, causeless falsehood, a spirit of 
 iatrigue or duplicity, the passion for gambling or 
 drinking, hypochondria and misanthropy, are also 
 
246 DEGENEEACIES OF EVOLUTION. 
 
 often observable in these individuals, who are com- 
 motily known to the public under the names of ec- 
 centric persons, maniacs, and cranks. 
 
 It is hardly necessary to state that all these cases, 
 being at most only somewhat abnormal, live at 
 liberty in society, and that they are never met with 
 in asylums, at least, except as they may happen to 
 be accidentally taken with an attack of insanity. 
 
 §11. NEURASTHENIAS. 
 (Fixed Ideas, iMPTXLSioisrs, Abouliab.) 
 
 The term neurasthenia, invented by Beard in 1868, 
 and accepted to-day by most writers, is a generic 
 term applied to all the morbid conditions essentially 
 characterized by exhaustion of the nervous system 
 (nervous exhaustion). It is what has been called 
 according to the periods and the eases : nervosism, 
 irritable weakness, spasmodic conditions, nervous as- 
 thenia, proteiform neurosis, nervous marasmus, hys- 
 tericism, spinal irritation, hypochondria, cerebro- 
 cardiac neuropathy, cerebro-gastric disease, etc. , etc. 
 It is, therefore, not a disease but a group of diseases, 
 a sort of diathesis with a most varied symptomatic 
 expression. 
 
 According to the predominating phenomena, 
 many forms are to be distinguished, the principal 
 ones of which are: the cerebral form (cerebras- 
 thenia) ; the spinal form (myelasthenia) ; the cardiac 
 
NEURASTHENIAS. 247 
 
 form (cerebro-cardiac neuropathy) ; the gastro-intes- 
 tinal form (cerebro-gastrio and intestinal neuras- 
 thenia) ; and lastly the genital type (sexual neuras- 
 thenia) . 
 
 The essential cause of neurasthenia is heredity. 
 This, which takes its source in the dififerent diathe- 
 ses, notably in the neuroses, the psychoses, alcohol- 
 ism, arthritism, syphilis and tabes, induces from the 
 beginning in the subjects, a special condition of 
 degeneracy of the nervous system, upon which, 
 under favoring conditions, the malady develops. 
 Occasionally, it is true, hereditary taint may be 
 lacking, and the neurasthenia seems to be due to a 
 purely accidental cause, like a moral shock or the 
 traumatism of a railway spine, for example; but 
 even in these cases it is unusual if there did not 
 exist a more or less latent original predisposition. 
 
 As occasional causes we have all the circum- 
 stances, physiological or pathological, moral or 
 physical, capable of either suddenly or slowly pro- 
 ducing nervous exhaustion: puberty, troublesome 
 pregnahcies, local disorders of the uterus and intes- 
 tines, typhoid fever, hasmorrhage, venereal disorders, 
 onanism, continence, and sexual excess, mental 
 strain, great fatigue, and excessive mortifications. 
 
 While neurasthenia is protean in its manifest- 
 ations, there are still certain symptoms rarely in 
 default, which, for this reason, have been called by 
 Charcot neurasthenic stigmata. These are : a spe- 
 cial form of headache {casque newrasth4mque\ an^ 
 
248 DEGENERACIES OF EVOLUTION. 
 
 a sensation of emptiness in the head; insomnia and 
 disturbed sleep ; psychic adynamia ; motor enf eeble- 
 ment; spinal hypersesthesia and rhachialgia with 
 points of election (plaque cervicale, plague sacree, 
 and coccygodinia) ; gastro-intestinal atony ; genital 
 and vaso-motor disorders. 
 
 Cebebhal Nbueasthenia (Obsessions.) 
 
 Cerebral neurasthenia the only form with which 
 we have to occupy ourselves here, is that form in 
 which psychic troubles predominate. Based essen- 
 tially upon an impotence of the will, with preserva- 
 tion of the intelligence, properly so called, it shows 
 itself in fixed ideas, obsessions (or besetments), 
 active or negative impulses, all with full conscious- 
 ness and reasoning powers, but irresistible and 
 anxious. It comprehends consequently a host of 
 conditions scattered here and there in the nosology 
 under the names of lucid insanity, insanity with con- 
 sciousness, reasoning and impulsive monomania, 
 psychic syndromes of the degenerates, rudimentary 
 paranoia, etc., etc. 
 
 These different designations indicate serious 
 divergences of doctrine, and psychic neurasthenia 
 is far from being universally accepted to-day under 
 the label and aspect we have described. According 
 to some, it is still a form of insanity, differing from 
 the other forms only by its characters of conscious- 
 ness and lucidity (Ball) ; according to others, it is a 
 mental sjmptom of neurasthenia (Beard) ; some con- 
 
NEURASTHENIAS. 249 
 
 sider it an elementaiy psychic disorder analogous to 
 hallucinations, and liable to be observed in all neuro- 
 ses and insanities (Pitres) ; and finally, according to 
 some, it is a sign of degeneracy, not appertaining 
 to neurasthenia except as a complication (Charcot, 
 Magnan). 
 
 In our view, emotional obsession is especially a 
 symptom of neurasthenia, having, it is true, close 
 relations with degeneracy, but only indirectly and' 
 through the neurasthenia, wheri that is of a degen- 
 erative character, as is usually the case. 
 
 It is, in fact, certain that in the vast majority of 
 cases the psychic neurasthenics are also degenerates. 
 Their degeneracy, which is, as we have stated, 
 almost always the result of heredity, reveals itself 
 not only by a defect of equilibrium, but often also 
 by more serious symptoms, true stigmata. Men- 
 tally, they are generally persons of intelligence, 
 bright and quick witted, but timid, lacking in 
 energy, weak willed, and endowed with a very pro- 
 nounced emotional sensibility. In early life, but 
 especially from the age of puberty, they begin to 
 show oddities, tics, and fixed ideas ; they are readily 
 worried and worked up about nothing. Physically, 
 they show certain vices of conformation, either in the 
 genitals, or in the head, the ears, the eyes, the pala- 
 tine vault. Lastly, they are all subject to various 
 nervous disorders : neuralgias, migraine, palpitations, 
 ana3mia, dyspepsia, exophthalmic goitre, cramps, 
 convulsions, etc. 
 
 ](EitI, MSO.— IS, 
 
250 DEGEXEEACIES OF ET0LUTI03T. 
 
 Sucli is the soil in which is planted the emotional 
 neurosis under the influence of a favorable occasional 
 cause. The rule, nevertheless, is not absolute, and 
 it would be an exaggeration to say that all these 
 patients, and all the neurasthenics are degenerates. 
 In certain cases there exists at least no apparent trace 
 of degenerative heredity, and the neurasthenia seems 
 in them to be a true accidental disease. For this 
 reason, we believe that there exist two veiy distinct 
 types of psychic neurasthenia : the chronic, constitu- 
 tional neurasthenia, or that of degeneracy, which is 
 most frequent, and the acute, functional, and non- 
 degenerative neurasthenia ; both susceptible of being 
 accompanied with obsessions, but with these of very 
 different degrees of gi-avity in the two cases. 
 
 However these psychic neurasthenias are consid- 
 ered and named (insanity with consciousness, emo- 
 tional insanity, fixed ideas, Zwangsvorstellungen, 
 paranoia ntdimentaire, anxious obsessions, morbid 
 fears, episodic syndromes, etc.), the authorities are 
 none the less in accord, in a clinical point of view, 
 as to the general characters that they present. 
 
 These general characters have been fully indicated 
 by M. J. Falret in his report on Obsessions to the 
 International Congress of Mental Medicine of 1889. 
 
 The following are the conclusions of that report, 
 as voted on and adopted by the Congress : 
 
 "The different varieties of the intellectual, emot- 
 ional, and instinctivie obsessions have common 
 characters, which may be stated as follows : 
 
NEUEASTHENIAS. 251 
 
 (1). They are all accompanied with consciousness 
 of the condition of the disease. 
 
 (2). They are usually hereditary. 
 
 (3). They are essentially remittent, periodical, 
 and intermittent. 
 
 (4) . They do not remain isolated mentally in the 
 form of monomania, but propagate themselves 
 throughout a very extensive range of the intellectual 
 and emotional nature, and are always accompanied 
 by distress and anxiety, internal conflict, hesitancy 
 in thought and action, and also with physical symp- 
 toms of an emotional kind, more or less pronounced. 
 
 (5). They never are accompanied with hallu- 
 cinations. 
 
 (6). They preserve the same psychic character 
 throughout the whole life of the affected individuals, 
 in spite of the frequent and often prolonged alterna- 
 tions of paroxysm and remission, and they do not 
 change into other foiins of mental disease. 
 
 (7). They never terminate in dementia. 
 
 (8). In some rare instances they may be compli- 
 cated with delusions of persecution, or with those 
 of anxious melancholia at an advanced stage of 
 the disease, while preserving fully their primitive 
 characters." 
 
 Heredity, as a rule, complete consciousness, con- 
 comitant anxiety, absence of hallucinations, remit- 
 tent or paroxystic character, indefinite duration, 
 such therefore, together with a dwelling on their 
 condition which often goes so far as to lead them to 
 
252 DEGBWEEACIES OF EVOLUTION. 
 
 desire death, are the pathognomonic characters of 
 obsessions in a mental point of view. 
 
 There should be added here, also, the physical 
 neurasthenic symptoms, episodic and permanent, of 
 which mention has already been made, and the prin- 
 cipal ones of which are: headache, palmar and 
 plantar hyperidrosis (cutaneous dropsy), flushes of 
 heat in the face, feelings of profound exhaustion, 
 palpitations, precordial anxiety, insomnia, various 
 pains and neuralgias, sensations of twitching of the 
 limbs, excess of oxalates and urates in the urine, 
 heaviness in the kidneys and limbs, dilatation of the 
 pupils and look of hesitation, localized muscular 
 spasms, etc. 
 
 If there is general concord as to the principal 
 symptoms of psychic neurasthenia, there is less ar- 
 gument as to their division. 
 
 Beard limited himself to enumerating certain of 
 them under the generic name of morbid fears, ac- 
 cording to their objective cha.racters. 
 
 Morselli, who places them in his classification of 
 mental diseases, under the designation of rudiment- 
 ary paranoia, divides them into two species: (1) 
 simple fixed ideas, or those with principle of action 
 (paranoia rudimentaria ideativa), in which the ob- 
 session remains purely psychic without tendency to 
 the impulsive act ; and (2) impulsive ideas (paranoia 
 rudimentaria impulsiva), in which the obsession is 
 accompanied with an irresistible tendency. 
 
 Tamburini, who describes the same under the 
 
NEUE ASTHENIAS. 253 
 
 name of fixed ideas, recognizes three species : simple 
 fixed ideas, emotional ideas, and impulsive ideas, ac- 
 cording as the obsession causes a forced attention, a 
 distressed condition, or an action. 
 
 Luys, who bases his study on cerebral physiology, 
 divides obsessions into psychic, psycho-emotive, and 
 psycho-motor, according as tliey involve singly the 
 centi-es of ideation, those of emotion, or the motor 
 centres. 
 
 Falret, on clinical grounds, also divides them, as 
 we have seen, into -intellectual, emotional and 
 instinctive. 
 
 Lastly, Magnan, who, apropos to genital obsessions, 
 has formulated an anatomico-physiological concep- 
 tion of these syndromes, also divides these subjects 
 of obsessions into cerebral, cerebro-spinal, and spinal 
 cases, according as the obsession causes a purely 
 psychic, superior cortical, or medullary reflex, that 
 is to say, a fixed idea, a conscious irresistible im- 
 pulse, a purely automatic act. 
 
 As will be readily seen, these divisions differ from 
 each other very little in reality, and they all end in 
 the fundamental distinction between purely psychic 
 obsessions and obsessions with impulsion. 
 
 This way of viewing the subject, although gener- 
 ally adopted, meets only very imperfectly the clinical 
 facts. It is impossible, indeed, to establish sympto- 
 matically so well defined a distinction between a 
 fixed idea and an impulsion. The fixed idea, in- 
 deed, is only the commencement of the impulsion, if 
 
354 DEGENEEACIES OF EVOLUTION. 
 
 it is not actually identical with it, a true intellectual 
 impulsion, as it has been admitted to he by certain 
 authors (Ball). As regards the impulsion itself, 
 conscious and rational as it is in neurasthenia, it is a 
 very complex syndrome, in which the unresistible 
 act is only the last term of a morbid process, of 
 which the fixed idea is the starting point and the 
 anxious emotion the intermediate stage. Thus in- 
 sanity of doubt, the type of fixed ideas, consists not 
 only in involuntary mental questionings, but also in 
 emotional crises, often acconrpanied by automatic 
 acts. So also agoraphobia or fear of spaces, consid- 
 ered as an emotional obsession, is almost always 
 accompanied by a fixed idea of motor impotence 
 and a morbid act. So also onomatomania, coprol- 
 alia, rupophobia, homicidal impulse, ranked among 
 the impulsive obsessions, include at once the fixed 
 ideas of a word, of grossness, of contamination, of 
 homicide, the anxious feeling of resistance, and 
 finally the tendency to the act. 
 
 Further, the division of obsessions into intellect- 
 ual, emotional and impulsive, has the defect of not 
 taking into account a whole class of obsessions, and 
 a very important one: those that are characterized 
 not by the impossibility of getting rid of an idea or 
 act, but, on the contrary, that of fixing an idea or 
 accomplishing an act. It is true that obsessions of 
 this kind pass under the name of aboulias, in some 
 of the nomenclatures (Magnan, Saury, Legrain) : but 
 they figure there only accessorily, since they consti- 
 
NEITRASTUENIAS. 255 
 
 tnte a special form opposed to impulsions of which 
 they are, so to speak, the counterpart. 
 
 The best way to comprehend obsessions is to go 
 back to their source and take pathogeny as a 
 basis. But when we analyze the intimate me- 
 chanism of the phenomenon, it is seen that what 
 is affected in it is the will, taken as a cerebral func- 
 tion. This truth has been recognized by all psychol- 
 ogists and clinicists, from Billod, who first called 
 attention to it in desci'ibing some eases of this kind 
 under the significant title of lesions of the will, down 
 to Morel, Theo. Ribot, and Tamburini, who have 
 made it very evident. 
 
 What then is the will and how does it normally 
 act? Fi-om various excitations, of the sensibility, 
 stimuli pass to the nervous centres, where they finally 
 produce, after a series of more or less complicated 
 operations, two kinds of reactions : the reaction of 
 arrest or inhibition which suppresses certain others; 
 and the reaction of reinforcement or impulsion, which 
 transmits the others to the motor organs to be 
 transformed into acts. 
 
 The will, according to this synthetic formula, 
 is therefore a cerebral function composed of three 
 elements: a centripetal element, the excitation, and 
 a double reactional element, the function of arrest 
 and the motor functions. The normal condition 
 exists in the equilibrium between these three forces, 
 and there is plainly a lesion of the will whenever 
 this equilibrium is destroyed. 
 
256 DEGENEEACIES OF ETOLUTIOK. 
 
 Many examples present themselves. In the one 
 the lesion involves the excitant element, the reac- 
 tional forces remain the same, and then either the 
 excitation may be too strong and there follows an 
 irresistible act (impulsion), or it may be too weak or 
 be wanting, and activity is suspended (aboulia). In 
 another case the excitation being normal, the lesion 
 may affect the reactional element, and if the arrest 
 is the function involved an irresistible act (impul- 
 sion) is produced, ov if it is the motor function, then 
 action is impossible (aboulia). 
 
 Lesions of the will are therefore of two kinds : (1) 
 those due to disorder of the centripetal excitation 
 (impulsion and aboulia, from excess or deficiency of 
 excitation) ; (2) lesions due to disorder of central reac- 
 tion (impulsion or aboulia from deficient force of 
 arrest or motor force). 
 
 This classification of the diseases of the will, psy- 
 chological and theoretical as it may seem, is none 
 the less a clinical one, and suffices to explain the 
 differences observed in the difl^erent forms of 
 impulsion and aboulia. It will be seen by it how 
 the lesions of the will from disorder of the centripetal 
 excitant element are met with in the forms of insan- 
 ity characterized by exaggeration or diminution of 
 the sensibility (hallucinatory insanity, melancholia), 
 while those due to disturbance of the central reac- 
 tions, are met with in cases due to nervous exhaus- 
 tion (neurasthenia). Further, we see how the 
 impulsions of systematized insanity, induced by an 
 
liTEUEASTHBNIAS. 25'(' 
 
 intense sensorial excitation, such as a hallucination, 
 takes on its special character of spontaneity and sud- 
 denness, thus differing from the impulsion of neuras- 
 thenia due to lack of central inhibition with its more 
 or less prolonged resistance and its accompanying 
 distress. In the same way we see the difference 
 between the inert, passive, and indolent aboulia of 
 the melanoholiac who is not called to act from lack 
 of peripheral excitation {non vouloir), and the emo- 
 tional, painful, and even agonizing aboulia of the 
 neurasthenic who, called to action by normal 
 incitations, exhausts himself in superfluous effortsj 
 having lost his active power (jion pouvoir). 
 
 We can therefore say that neurasthenic obses- 
 sions are lesions of the will from disorder of central 
 reaction, and different from similar lesions met with 
 in insanity, and that it is possible to divide them into 
 impulsions and aboulias, according as the power of 
 arrest oi- that of action is more specially involved- 
 
 Thus every neurasthenic obsession characterized by 
 an idea, an emotion, or an irresistible act, from insuffi- 
 cient inhibition, is an impulsion : oh the other hand, 
 every neurasthenic obsession characterized by an 
 idea, emotion, or impossible act, from insufficiency 
 of motor action, is an aboulia, whatever may be 
 the final result of the mental conflict that takes 
 place. 
 
 It is possible now for us to draw up a very nearly 
 accurate list of the principal varieties of psychic neu- 
 rasthenia that are known at the present time. 
 
25S DEGENEEACIES OE EVOLUTIOIT. 
 
 1. — Impulsive Neukasthenias ok Obsessions. 
 
 The impulsive neurasthenias or obsessions, are, as 
 has been stated, those in which the inhibitory power 
 of the will is disordered. 
 
 In order to comprehend their mechanism, it must 
 be remembered that in the condition of normal cere- 
 bral automatism a crowd of ideas arise in the mind 
 which are fixed or rejected at its will by the volun- 
 tary attention by means of its double power of 
 action and arrest. This is the polyideisme physi- 
 ologique of Ribot. In the impulsive neurasthenic 
 the conditions of cerebration are changed: the 
 lessened will power tries vainly to chase away an 
 idea induced by the automatism, and from this 
 conflict between the voluntary energy and the pre- 
 ponderant spontaneity arises a crisis of anguish and 
 anxiety which ends finally in an irresistible act or 
 exhaustion. 
 
 Impulsive neurasthenia is therefore nothing else 
 than a sort of pathological monoidelsme consisting 
 in the invasion of the mind by an automatic idea 
 under the influence of a diminution of the volition 
 of arrest. Its fundamental characters are : (1) the 
 fixed idea, which is the very essence of the impulsive 
 obsession; (2) in the anxious or emotional crisis 
 engendered by the efforts of resistance of the will ; 
 (3) in the final result, varying according to the 
 case, and which may be as much inhibitory as 
 dynamogenic, that is to say, it may end in a psycho- 
 motor paralysis as well as in an irresistible act. 
 
NEtTEASTHENIAS. 259 
 
 It follows from tbis, as we have already seen, that 
 all impulsive obsessions are primarily intellectual 
 and that their starting point is always a fixed 
 idea, the phenomena of feeling and action being 
 only a continuance and result. It follows also that 
 any idea capable of arising spontaneously within us, 
 whether it refers to abstractions, words, figures, 
 persons, or things, or any object whatever, may 
 become fixed in the mind of a neurasthenic and 
 consequently be the origin of an obsession. 
 
 This last statement is confirmed by the facts that 
 show that the various species of obsessions extend 
 and multiply the more the better they are known. 
 In reality their number is unlimited, and we may 
 say that there exist as many varieties of obsessions 
 as there are thoughts occurring in the human mind. 
 
 Is it logical under these circumstances to give a 
 name and special description to each of these varie- 
 ties, the number of which extends and will extend 
 without cessation with the progress of observation? 
 Personally I do not so think, and it is already long 
 since I began to notice this regrettable ' tendency of 
 modern clinicists to individualize the infinitely little. 
 
 Every one agrees, in the main, in recognizing 
 that neurasthenic obsessions are not only identical, 
 in their essence and their characters, whatever form 
 the fixed idea may take, but that they also rarely 
 exist singly in the patients in whom we almost 
 always find them combined with other similar obses- 
 sions. What utility is there then, of creating for 
 
260 DEGENEEACIES OE EVOLUTION. 
 
 each of them not only a special designation, which 
 should strictly be understood as merely for conven- 
 ience in describing them, but also a separate symp- 
 tomatology, which is perfectly useless and makes 
 it appear that we wish to erect them, if not 
 into diseases, at least into distinct varieties of a 
 disease ? 
 
 Nevertheless, this is what has been done hereto- 
 fore, at the risk of uselessly complicating the study 
 of these syndromes, already so difficult. Let us take, 
 for example, the fear of objects or of contacts, which 
 is one of the most frequent of the impulsive obses- 
 sions. It ought to be sufficient in describing this 
 obsession to mention the principal elements or subjects 
 of the morbid fear. Instead of this the tendency is 
 to separate each fear of objects and we have already, 
 of these : the fear of dirt or defilement, (rupophobia 
 or misophobia) ; the fear of virus and poisons (iopho- 
 bia) ; fear of points (aichmophobia) ; fear of needles 
 (belonephobia) ; fear of glass or pieces of glass (crys- 
 tallophobia) ; fear of objects of metal, door knobs, 
 pieces of money (metallophobia) ; fear of hair and 
 down of fruits (trichophobia). Moreover, the obses- 
 sion that shows itself by fear of places and of the 
 elements includes: fear of wide spaces (agorapho- 
 bia) ; fear of narrow spaces (claustrophobia) ; fear of 
 high places (acrophobia) ; fear of precipices (cremno- 
 phobia) ; fear of thunder and lightning (astraphobia) ; 
 fear of water and of rivers (potamophobia) ; fear of 
 fire (pyrophobia), etc. etc. 
 
NEURASTHENIAS. 261 
 
 It is evident that under these conditions, there is 
 no limit to the morbid subdivisions. 
 
 For my own part, considering that all impulsive 
 obsessions of whatever nature, have exactly the same 
 characters, and that the description of each of them 
 singly can only produce confusion, I am forced to bring 
 together the similar forms and group them in a few 
 principal categories. I have thus admitted for con- 
 venience of study: (1) obsessions characterized by 
 indecisions, of which doubting insanity is the type ; 
 (2) obsessions characterized by fears, namely : fear 
 of objects (ex : rupophobia) ; fear of places or of the 
 elements (ex : agoraphobia) ; fear of living beings 
 (ex : zoophobia) ; (3) obsessions characterized by 
 propensities or irresistible tendencies (ex: onoma- 
 tomania, kleptomania, dipsomania, homicidal or 
 suicidal impulse.) 
 
 It wiU be sufficient to describe here the principal 
 types of each class, to give as complete as possible 
 an idea of all the varieties, at present known, of 
 impulsive obsessions. StUl I will only lay stress on 
 the mental symptoms they may present, the general 
 phenomena, that is to say, the stigmata of degen- 
 eracy and the bodily symptoms of neurasthenic 
 attacks are almost always found in the majority of 
 the cases. 
 
 Obsessions or Indecision : Maladie du doute. — 
 The insanity of doubt is the type of the obsessions 
 characterized by indecision. Described in 1866 by 
 
263 DEGENERACIES OF EVOLUTION. 
 
 Jules Falret and after him by Legrand du SauUe, 
 Eitti, and various foreign writers, it is generally 
 known in Germany under the name of Grlibelsucht, 
 and in France under the incorrect name of '■'■ folie 
 du doute avec delire du toucher." It consists in 
 iixed ideas that besiege the patient under the form 
 of interrogations, hesitations, and indecisions of all 
 sorts, and of which he anxiously seeks the solution. 
 
 M. Ball has divided the doubters into five classes, 
 according to the nature of the predominating ideas : 
 the metaphysicians, the realists, the scrupulous, the 
 timorous, and the counters. These divisions, prop- 
 erly understood, will serve to facilitate the descrip- 
 tion of the condition. 
 
 The metaphysicians are those who are especially 
 haunted by abstract questions. Their psychological 
 rumination, as Legrand du SauUe calls it, is in ref- 
 erence to Deity, the Virgin Mary, heaven, hell, the 
 soul, the future life, the world, and all the most ob- 
 scure problems of nature. They are constantly 
 inquiring as to the why and wherefore of persons 
 and things, without being able to drive from their 
 minds the interrogations thus irresistibly imposed 
 upon them and which plunge them into inexpressible 
 tortures. M. J. Falret has very ingeniously and 
 accurately called this condition ' ' the torment of the 
 question." 
 
 The realists are those whose ideas, with the same 
 character of irresistibility and tenacity, take on a 
 more or less trivial nature. They revolve in their 
 
NEUEASTHEXIAS. 263 
 
 thouglits, for example, over the conformation of 
 the genital organs, copulation, the difference of the 
 sexes, the color of the eyes, the presence of the 
 beard, the lowest and coarsest details of objects. 
 
 The scrupulous are those whose doubts are in re- 
 gard to matters of religion. In their spells of 
 anxiety these patients torment themselves to the ut- 
 most with the ideas that, for example, they have 
 laughed at mass, have omitted some sin in confess- 
 ing, have offended God in some thought or act. 
 I have known a neurasthenic degenerate, who, pos- 
 sessed with an apprehension of this kind, would only 
 leave the church walking backward, so as not to 
 turn his back to the altar, and who before making 
 use of the cabinets read over and over the pieces of 
 paper he used without being able to assure himself 
 that he did not involuntarily profane any sacred 
 word. 
 
 The timorous are those who are fearful of com- 
 mitting some indelicate action, and more particu- 
 larly a theft. The type of these cases is the young 
 woman cited by Esquirol who was always afraid of 
 carrying off some object of value, and, under the 
 influence of this obsession, passed all her time in 
 brushing herself, taking off her shoes, examining her 
 hair, her hands, the floors and seats she occupied, for 
 fear lest something of value should stick to her per- 
 son or clothing. • 
 
 The counters, lastly, are those whose doubts are 
 manifested under the form of irresistible enumera- 
 
264 DEGENBEACIBS OP EVOLUTION. 
 
 tions. This one is compelled to count gas burners, 
 or the trees along his route, and if he believes he 
 has made any mistake, he turns back once, twice, or 
 ten times over his steps to make the same calcula- 
 tions over again. Another (obsei-vation of Trelat) 
 passes his time in counting how many times the 
 same letters are repeated in the Scriptures: how 
 many pages in this edition begin or finish with a P, 
 or a B. , etc. Another, finally, who came to consult 
 Legrand du Saulle, cried out in departing: "You 
 have forty-four books on your table, and you wear a 
 waistcoat with seven buttons. Excuse me, it is invol- 
 untary, but I have to count." 
 
 Not all the forms of morbid doubt are included in 
 this enumeration since they are infinitely variable. 
 The superstitious and the fatalists who anxiously 
 order their lives according to this or that insignifi- 
 cant event might, for example, be added to the list. 
 Persons, things, names, words, figures have for them 
 a fortunate or unfortunate signification according to 
 their nature or their appearance, and they thus pass 
 suddenly from terror to joy, and the reverse, accord- 
 ing to the presage encountered. Others are im- 
 pelled to perform some ridiculous act, or to repeat 
 many times the same performance to exorcise the 
 spell, and neglecting which they suffer increasing dis- 
 tress until they finally yield to their obsession. 
 Some recommence indefinitely the same work with- 
 out being able to satisfy themselves that it is well 
 done, To dress themselves becomes to them one of 
 
NBTTEASTHENIAS. 265 
 
 the most difficult of operations, and they pass whole 
 hours in putting on their footwear, buttoning up 
 their clothing and dressing their hair, always the 
 prey of an uncertainty as torturing as it is futile. 
 Many of them cannot put a letter in the post-office 
 without hesitating a dozen times and, in spite of all 
 this, after it is deposited, asking if they haven't for- 
 gotten the address or dropped it outside the box; 
 they are afraid they have left a door unclosed, a 
 light burning, a faucet running, and whatever they 
 do and however much they resist their fixed idea, 
 they are distressed untU they become assured once 
 or many times in succession that their apprehensions 
 are useless. 
 
 The obsession of doubt, like most of the analo- 
 gous conditions, progresses by crises, by spasms, 
 more or less acute and nearly connected. Like 
 them it is tenacious, chronic, and, in general, incur- 
 able. The patients demand an outside affirmation 
 to calm their ever reviving indecision; but shortly 
 this moral support becomes insufficient and they fall 
 into a sort of mechanical automatism; passing their 
 lives in incessantly repeating humiliating or ridicu- 
 lous actions, muttering over the same phrases or 
 interjections, sometimes even swearing at their con- 
 dition of which they unhappily retain full conscious- 
 ness. 
 
 Stress has been laid in this description only on the 
 mental phenomena of obsession. But it is under- 
 stood, once for aU, as has been said, that the indica- 
 
266 DEGENBBACIES OF ETOLUTIOIT. 
 
 tions of degeneracy are to be met with in most 
 cases, and that almost always the emotional attacks 
 are also habitually accompanied by bodily symptoms 
 (palpitations, praecordial pain, alternating flushes 
 and pallor, local sweats, especially of the face and 
 hands, chills, tremor, swoons, etc., etc.) 
 
 Obsessions of Fbak (Phobias) : (1) Fear of ob- 
 jects. — This obsession, mentioned by Morel in 1866, 
 in his Delire Smotif, was described the same year 
 by J. Falret under the name of "partial alienation 
 with predominance of fear of contact of external 
 objects. " In this description, which remains classic, 
 and to which very little has since been added, Falret 
 included at once both the malady of doubt and that 
 of contact. The writers succeeding him did the 
 same, and Legrand du Saulle evidently considered 
 the fear of contact as not only one of the manifest- 
 ations but as one of the periods of the former, 
 naming it therefore "insanity of doubt with delu- 
 sions as to contact." The majority of alienists at 
 the present time make the doubt and the fear of 
 contact two distinct obsessions. It is certainly true 
 that these two syndromes are not inseparably allied, 
 and that one is not a phase of evolution of the 
 other; but it is not less true that the fear of con- 
 tact, like, moreover, the majority of impulsive 
 obsessions, is at bottom only a sort of morbid 
 doubt. 
 
NEFftASTHfiNlAS. ^67 
 
 The fear of objects* has for its basis a fixed idea, 
 and consequently an anxious dread. Its expression 
 is extremely varied and may involve all kinds of ob- 
 jects. I have criticised carefully all the observa- 
 tions of fear of contacts so far published, and find 
 that it is manifested most frequently by fear of 
 hydrophobic virus or that of cancer, or glanders, of 
 contact with phosphorus, or vi'ith poisons ; the fear 
 of defilement (rupophobia or misophobia) ; by the 
 fear of pins, of pointed objects, of bone (aichmo- 
 phobia, belonephobia) ; by the fear of bits of glass, 
 of jet (crystallophobia) ; by the fear of metallic ob- 
 jects, of door knobs, and of pieces of money (raet- 
 allophobia) ; by the fear of hairs and especially the 
 down of fruits (trichophobia) ; and lastly, the rarer 
 fears of grease, of quicklime, of mastic, etc., etc. 
 
 The other forms of fear of objects, less frequent, 
 and especially less studied, have for their motive : 
 the sight of blood {hematophohia of Fere), of knives, 
 of swords, of matches, of the sounds of bells, thunder, 
 and firearms, of the odor of flowers and perfumes, 
 the taste of certain articles of food or drink. 
 
 Whatever form the morbid fear may take, and it 
 
 *The fear of contacts, which has alone been in view in 
 the. descriptions, is itself only a form of a more general fear : 
 the fear of objects, the starting point of which is not only 
 contact, but also the sight, sound, odor and even the taste 
 of certain objects. It is necessary, therefore, in my opinion, 
 to unite the study of these different forms and to designate 
 them collectively under the generic name of fear of objects, 
 
268 BSGBNEEACIfiS Of BVOtUTlOlf. 
 
 is often multiple, it manifests itself by agonizing 
 spells accompanied by usual neurastlienic symptoms. 
 What proves that this fear is really of psychic ori- 
 gin is that it arises from only a thought or a memory 
 of the object. 
 
 The feeling that results from this almost invaria- 
 bly impels the patients to wash their hands to such 
 an extent that reiterated and continual washing of 
 the hands may be taken as one of the most constant 
 signs of this variety of obsession. It is a curious 
 fact also that it is not from any horror of slovenli- 
 ness or because they see dirt on their hands that the 
 misophobes are given to these ablutions, since they 
 endure such things very well and may go many days 
 or even weeks without changing or bathing ; on the 
 other hand, as soon as they touch the w^ater the 
 obsession appears, distressing and irresistible, and 
 the more they wash the more they are impelled 
 to continue it by an impulsive and, so to speak, 
 automatic need. 
 
 It will hardly be believed how far the tyranny 
 of a fixed idea will extend if one has not closely 
 observed these unfortunates. For nearly a year I 
 have observed one such daily and almost every hour 
 of the day, and I avow that I know nothing more 
 extraordinary or m^ore saddening than this mixture 
 of perfect rationality and extravagance, of conscious- 
 ness and impulse. I wUl mention but one detail out 
 of a thousand. When my patient goes to the cabi- 
 net to urinate, he remains there for hours, at least if 
 
NEUEASTHENIAS. 269 
 
 we do not come to take him away, since this simple 
 act becomes for him, like all others, one of frightful 
 diflBculty. In order to avoid having to renew the act 
 often he tries to empty his bladder completely, and as 
 the last drops are drained, he makes violent efforts at 
 expulsion and shakes the organ to complete it, with 
 the result only to throw him more into anxiety, 
 fatigue and perspiration. Next, when he adjusts his 
 clothing, is the most prolonged and difficult part of 
 the operation, since, haunted with the idea that he 
 may imprison something unclean in his shirt, espe- 
 cially a fly or a spider, he folds and unfolds it many 
 times, till flushed, panting, and possessed, he finally 
 succeeds in securing the organ hermetically against 
 his body in many skilful wraps, always the same. If 
 any one comes, at any time whatever, the obsession 
 ceases and the patient urinates and adjusts himself 
 most naturally and rapidly, for we are aware that the 
 subjects of these besetments obtain in the presence 
 of strangers, or at least in that of certain individuals, 
 a moral support, that is, the backing of a wUl that 
 they lack when they are alone. 
 
 Like the malady of doubt of which it is, as we 
 have seen, only one of the modalities in most cases, 
 and with which even it is often confounded, the fear 
 of objects is extremely persistent ; and in spite of the 
 longer or shorter lulls that may occur, it tends to 
 become chronic and to gradually overcome the 
 individual, who is reduced to the state of an autom- 
 aton, leaving always perfect mental lucidity and 
 coosciousuess, 
 
270 DEGENEEACIES OF EVOLUTION. 
 
 (3). Fear of places^ elements, and diseases. — 
 The type of this form of fear is agoraphobia, long 
 known from the memoirs of Cordes, Westphal, 
 Legrand du Saulle, Ritti, etc. It consists in an obses- 
 sion which has for its object the fear of wide spaces. 
 In a desert place, a very wide street, on a bridge, 
 in a church or a theatre, the patient is suddenly 
 taken with the idea that he cannot get over the 
 space before him, that he will die or suffer ill. A 
 distressing attack follows accompanied by palpita- 
 tions, prsecordial anguish, feelings of oppression, shiv- 
 ering, flushes and pallor ; the strength gives way, the 
 legs bend, cold sweat occurs, and the subject falls 
 from weakness. But if he has any one's arm, if he 
 walks alongside a wall, if he walks in the shelter of 
 a carriage, if he carries a sword or cane, this aid, 
 small as it may be, suffices to vanquish or relieve 
 the obsession and he overcomes the obstacle with the 
 greatest facility. 
 
 Cremnophobia, or fear of precipices, and acro- 
 phobia, or fear of summits, described recently by 
 Verga, who gives himself as one of its victims, are 
 obsessions alogether analogous to agoraphobia, with 
 this difi'erence that the patients feel their distress, not 
 in large spaces, but when they are before a gulf, or 
 on a height. An American alienist, who confesses 
 himself an acrophobe like Verga, noticed among his 
 sensations at the moment of the attack, a quick and 
 painful contraction of the scrotum. 
 
 Potamophobia is an agonizing fear of the §ame 
 
NEUEASTHENIAS. 271 
 
 nature that has for its object rivers, lakes, etc. It 
 is especially felt on large sheets of water. 
 
 GlauBtrophohia, pointed out by Mesehede, and 
 best known from the memoir of M. Ball (1879), 
 the opposite obsession to agoraphobia, i. e. , the fear 
 of confined spaces. The patients cannot remain in 
 narrow quarters and at the mere idea that they are 
 or may be in a close place they fall into a paroxysm 
 of distress that causes them to rush out, no matter 
 what obstacles they may encounter. They feel on 
 these occasions, says M. Ball, a sensation of con- 
 strictive anxiety, analogous to that one would exper- 
 ience in creeping along a long and narrow branch. 
 
 Astra-phobia, described and named by Beard, is 
 a similar dread, which has for its object thunder 
 storms and lightning. It presents in itself nothing 
 worth being described. Its principal symptoms, apart 
 from the obsession, are, according to Beard, pain 
 in the head, nausea, vomiting, and, in some cases, 
 convulsions. 
 
 We can compare these fears which have intangi- 
 ble things for their objects with the fear of diseases, 
 known as nosophobia, or pathophobia. The patients 
 who suffer from this are not to be confounded with 
 ordinary hypochondriacs and certainly not with 
 insane hypochondriacs ; since in them the hypochon- 
 dria presents itseK with clearly cut neurasthenic 
 characters, that is to say, under the form of con- 
 scious, distressing, and paroxysmal obsessions. The 
 patient, while alone by himself or on the street, is 
 
272 DEGENEEACIES OF EVOLUTIOlir. 
 
 all at once seized with a fixed idea as violent as it is 
 sudden: he believes that his heart is about to be 
 arrested, that his brain is empty, that his limbs are 
 paralyzed, that he will fall and is going to die. 
 Panting, anxious and perspiring, he either drops on 
 the spot, or runs to a physician begging him to save 
 him, or more often, he hastens to swallow some 
 drug or cordial that he always carries with him 
 in view of this event. The attack once over, he is 
 again calm, matters are as before, and he can attend 
 to his business till the return, within a longer or 
 shorter time, of the next similar paroxysm. This, 
 it wiU be seen, is a special condition, clearly differ- 
 ent in its characters from vesanic hypochondria which 
 is essentially continuous and uniform ia its manifest- 
 ations. The nosophobic obsession may exist relative 
 to any disorder or organ. Sometimes it may even 
 be fixed on a simple morbid peculiarity, like some 
 peculiarity of the nose or tongue (Pitres) : limited, 
 tenacious hypochondriacal ideas are, nevertheless, 
 more characteristic of non-neurasthenic degenerate 
 cases. 
 
 (3). Fear of Living JBeings. — The type of this 
 form of morbid obsession is anthropophobia, named 
 and described by Beard, who considered it one of 
 the more frequent forms. It consists in an aversion 
 to society, a fear of seeing a crowd or of mixing with 
 one, or of seeing people about one. In veiy many 
 cases, says the American author, this obsession 
 becomes so pronounced that it impels the sufferers 
 
NEUEASTHEinAS. 273 
 
 to abandon their occupations and their business 
 because they cannot look their fellow men in the 
 face or negotiate with them ; they are afraid of the 
 human species. Beard considered as an important 
 and constant symptom of these neurasthenics the fact 
 that it is impossible for them to look any one steadily 
 in the face, and affirms that they can be recognized 
 at first sight merely by the manner in which they 
 keep their eyes looking downward and away. In 
 some cases the dread is limited to only one sex, 
 especially the female (gynephobia) or to certain classes 
 of persons, such, for example, as drunken men. 
 
 In other subjects the obsession takes the opposite 
 form : this is monophobia, or fear of solitude. The 
 monophobes cannot travel or walk out alone, or leave 
 their homes without being accompanied. Beard 
 cites the case of a patient of Dr. C. L. Mitchell 
 who, under the influence of a fixed idea of this kind, 
 was brought to paying a man twenty thousand dol- 
 lars to be his constant companion. 
 
 The abnormal emotivity towards living beings 
 may finally be dii'ected toward the lower animals. 
 The aversion to certain animals, dogs, cats, 
 frogs, serpents, mice, spiders, etc., and the exag- 
 gerated liking for others are, it is well known, 
 very common in many persons, especially women, 
 and in non-neurasthenic cases; and it may here 
 be remarked that all morbid obsessions are 
 nothing more than the reproduction, carried to a 
 pathological extent, of ideas, sentiments or tenden- 
 
374 DBGENBEACIBS OP EVOLUTION. 
 
 cies that are all met with, in a move or less rudimen- 
 tary condition, in normal individuals. In the 
 neurasthenics the obsession reveals itself here either 
 by a dread of certain animals (zoophobia), or by 
 the impossibility of seeing them suffer in any way 
 (zoophilia, antivivisectionists of Magnan) ; in these 
 two cases it gives rise to anxious attacks analogous to 
 those already described. The contact, the sight, or 
 even the recollection of certain animals is sufficient 
 to provoke these attacks. 
 
 Obsession-Pbopensions. — Obsession-propensions 
 or obsessions, properly so called, are those in which 
 the fixed idea has for its effect not a fear, but an 
 irresistible tendency. Of this class, are : onomato- 
 mania, kleptomania, pyromania, dipsomania, and 
 homicidal and suicidal impulses. 
 
 Onomatomania. — This is the obsession of a name 
 or word, described in 1885 by Charcot and Magnan. 
 
 It follows from their observations that this obses- 
 sion may manifest itself: (1) by the distressing seek- 
 ing for a word or name ; (2) by the attribution of a 
 harmful or preservative influence to certain names or 
 words ; (3) by the impulse to repeat some name or 
 word that obtrudes itself ; (4) by the obligation to 
 eject, as it were after efforts of expectoration, a name 
 or word that has become a veritable foreign body to 
 be thrown off. 
 
 These two last forms only are irresistible tenden- 
 cies ; the others appertain more to psychic indecision 
 
NBUEASTHENIAS. 275 
 
 or malady of doubt, in reference to which I have 
 already mentioned them. 
 
 Arithmomania, described by the same authors, is 
 only onomatomania with special reference to numbers 
 and figures. It is well known that the number 13 
 plays a capital role in this obsession. 
 
 Blasphematory mania, noticed long since by 
 Verga is also a form of onomatomania in which the 
 verba] impulsion shows itself in oaths and blasphemies. 
 
 The irresistible tendency to repeat coarse or 
 obscene words is likewise the characteristic of a 
 more complex, but certainly a similar condition 
 recently brought into notice by Charcot and his 
 pupils, under the title of maladie des tics convulsifs, 
 or Gilles de la Tourette's disease. A detailed account 
 of this has been given by Dr. Catrou in a recent 
 thesis (Paris, 1890). 
 
 This disease comprises two kinds of symptoms: 
 (1) tics, sudden and violent movements of certain 
 parts of the body, especially the arms, having the 
 characters of symmetry and coordination and of 
 reproducing, as if from electric shocks, certain nat- 
 urally associated movements, always identical in the 
 same individuals, (sudden blowing of the nose, 
 quick and repeated closing of the eyelids, sudden 
 and automatic scratching, sniffling, expectoration, 
 blows on the chest as if in an act of contritlou, etc., 
 etc.); (2) coprolalia, a term invented by Gilles de 
 la Tourette to designate the, as it were, explosive, 
 find forced ejaculation of oaths and vile language ac- 
 
376 DEGENEEACIES OF EVOLtTTION. 
 
 companying eacli attack of the tics. There is 
 sometimes added an irresistible tendency to imitate 
 words and gestures (echolalia, eckokinesis, echoma- 
 tism). The chief and pathognomonic symptom, ac- 
 cording to Catrou, is the coprolalia. 
 
 The malady of tics is chronic, remittent, parox- 
 ysmal, and usually incurable. It is frequently 
 connected with some of the already described 
 obsessions. 
 
 "We have here undoubtedly a degenerative condi- 
 tion of the neurasthenic type, as the tics are nothing 
 but the stigmata of an hereditary neuropathy, 
 analogous to the others. As M. Charcot well says 
 (Tuesday lectures): "The tic is a disorder that is 
 only in appearance material ; it is, on the one side, a 
 psychic disease, for there are mental as well as bodily 
 tics." 
 
 Kleptomania. — This is the conscious and irresis- 
 tible impulse to theft. Tendency to steal may be 
 encountered, as a symptom, in some mental affec- 
 tions, notably in general paralysis, imbecility, 
 dementia ; but here it exhibits the special characters 
 of a neurasthenic impulsion. That is, it presents 
 itself under the form of an obsession, accompanied 
 with resistance and distress, and which causes the 
 ordinary phenomena of paroxysmal attacks. The 
 articles stolen are often insignificant; occasionally 
 only one object, always the same, is stolen, and the 
 patient accumulates most incredible collections of 
 these, 
 
JtETTEASTHENIAS. 37'?' 
 
 Pyromania. — Pyromania is an impulsion to set 
 things on fire. Like all the other morbid impulses, 
 it is not special to neurasthenics, and it is also met 
 with notably in epileptics, imbeciles, and dements. 
 With them it is a thoughtless, unconscious, morbid 
 act, without conflict and concomitant anxiety, and con- 
 sequently shows none of the pathognomonic charac- 
 ters of an obsession. It is most common in the 
 female sex, and the attacks occur especially in con- 
 nection with the yarious periods of sexual life, 
 particularly at puberty and during the menstrual 
 period. 
 
 Dipsomania. — Dipsomania is the irresistible 
 tendency to drink. This tendency is frequent in 
 the commencement of psychoses accompanied by 
 excitement, especially in mania and general paralysis, 
 where it is one of the manifestations of the morbid 
 craving for activity that leads the patient into all 
 sorts of excesses. In subjects of degeneracy, and 
 especially in the neurasthenics, it constitutes a true 
 dipsomania. 
 
 Magnan, who has given an excellent description, 
 lays stress on the intermittent and paroxysmal char- 
 acter of the attacks. At the beginning the patient 
 suffers from bodily discomfort, anorexia and gastro- 
 intestinal disorders, simultaneously with sadness and 
 depression. Then the desire for drink is awakened, 
 an irresistible craving that must be satisfied at any 
 price. Now nothing can check the patients, in spite 
 of their lucidity and efEorts at resistance, they are 
 
278 DEGENfiSACIfiS 61- EVOtUTtdN. 
 
 forced to yield to the impulse. Many of them fly 
 from their homes at this period, to plunge outside, 
 into the most deplorable excesses and debauchery, 
 going even so far as to sell their clothing or prosti- 
 tute themselves to procure the money for drink, and 
 when they return after some days they fall into a 
 state of sadness, remorse, and shame, which marks 
 the end of the attack. 
 
 Very different from the alcoholic case, who intox- 
 icates himself more or less regularly with the liquor 
 of his choice, the dipsomaniac is habitually very 
 sober in his intervals of calm. During his attack, 
 on the other hand, all drinks are alike to him, pro- 
 vided they are strong, and he takes as readily to 
 drugs and poisons as to alcohol. We may, there- 
 fore, consider some cases of the passion for ether, 
 morphine, cocaine, etc., etc., as clinical varieties of 
 dipsomania. 
 
 Together with the impulsions above described the 
 following analogous ones, though less frequent, should 
 be mentioned: Oniomania, or irresistible impulse 
 to buy ; the impulsion for gambling (cubomania) ; 
 the impulsion to travel (dromomania) . Many of the 
 cases described of late years under the generic name 
 of ambulatory automatism, appear to belong to this 
 last variety. 
 
 Impulsion to Suicide and Homicide. — We have 
 here only to speak of the attacks of conscious, 
 irresistible and distressing impulsion, since impulses 
 to suicide or homicide are, more than any other kind, 
 met with in most forms of insanity. 
 
NEUKASTHEIHAS. 279 
 
 Impulse to suicide is, we are aware, especially 
 hereditary ; and it is particularly so in the cases we 
 have here in view, i. e., the neurasthenic degenerates, 
 in whom we see it transmitted in the same form from 
 ancestors to descendants (homologous heredity) and 
 sometimes manifesting itself in both at the same 
 period of life (homochromous heredity). 
 
 The impulsion to homicide proceeds in an identi- 
 cal manner by intermittent and paroxysmal crises 
 preceded by melancholic prodromata. The patients 
 are beset with the fixed idea of killing this or that 
 person, for example a child they adore ; the sight of 
 that child, of a weapon, a knife, arouses their obses- 
 sion and plunges them into inexpressible torment; 
 they realize that their will is bending that they are 
 yielding to the impulse, and filled with horror, they 
 lament, flee from home, ask aid and protection of 
 physicians, not hesitating in some cases to have them- 
 selves locked up in order to escape from their 
 morbid penchant. 
 
 Erotomania. — Under the generic name of eroto- 
 mania are included the obsessions of a sexual nature 
 described abroad by Krafft-Ebing and by Maguan 
 in France. In some subjects the fixed idea, consist- 
 ing in coarse or lascivious reminiscences, has for its 
 effect either the excitation or the suppression of the 
 sexual power ; in others it causes true impulsive acts 
 such as : indecent exposures before women and child- 
 ren, sometimes at a certain hour in any place what- 
 ever, even in churches ; rubbing of the penis, either 
 
280 DfiGENEEAClBS OB' EVOLTTTION. 
 
 hidden or openly, against the pelvis of women in 
 crowds ; thefts of feminine articles as amorous relics, 
 such as plaits of hair, handkerchiefs, shoes, jupons, 
 etc. , etc. In some instances the impulse, more grave 
 in its nature, may give rise to acts of sodomy, 
 bestiality, or even bloody deeds and violation of 
 corpses. 
 
 Reversed sexual instinct (contrare sexual Empfind- 
 ung) , characterized by an affinity, especially psychic 
 in its nature, of certain individuals for the persons, 
 the costume, the occupations, and the habits of the 
 other sex, is comparable in many respects to the 
 preceding obsessions, and, like them, is observed 
 especially among the degenerates. 
 
 2. — Aboulic Neubasthenias ok Obsessions. 
 
 The aboulic neurasthenias or obsessions are, as we 
 have seen, those in which the will is affected in its 
 power of action. 
 
 Contrary to that which occurs in the impulsive 
 obsessions, where the subject anxiously endeavors 
 to get rid of an idea which is imposed upon him, 
 here he tries vainly to transform an idea into an act; 
 his will is unable to set into action his motor system, 
 and his efforts in this direction end only in increasing 
 his trouble and distress. 
 
 Aside from this difference, the aboulic obsession 
 is, in reality, of the same nature as the impulsive one ; 
 it is connected like it to neurasthenic degeneracy, 
 and reveals itself by conscious, besetting, paroxysmal 
 
liTEUEASTHEinAS. 281 
 
 attacks, accompanied by the same physical and 
 psychic symptoms. 
 
 The impulsive obsession, it has been seen, may 
 have any idea whatever for its point of departure ; 
 so also the aboulic impulsion may betray itself by 
 the distressing impossibility of any act whatever. 
 As many varieties therefore can be made of aboulic 
 as of impulsive obsessions. Fortunately, investiga- 
 tions have not yet been pushed in this direction, and 
 there does not exist to my knowledge, any detailed 
 description of this kind of psychic neurasthenias. 
 
 One of the most frequent forms consists in the 
 inability of the patient to rise from a sitting posture 
 when he is seated. The desire of the act exists and 
 he makes efforts to accomplish it, but his power 
 of impulsion is insufficient and his most strenuous 
 attempts only end in -the characteristic emotional 
 crisis of neurasthenia. In other cases, the patients 
 can walk, rise, and sit down, but cannot mount 
 without experiencing the same inhibitory obses- 
 sion as that of the priest reported by Dr. Lichtwitz 
 and referred to by Krafft-Ebing, who could not go 
 up the altar step, in saying mass, especially if the 
 church was full of people. If supported, however, 
 even to a very slight extent, by a choir boy, he over- 
 came his obsession. I have given to the first of 
 these conditions the name of ananastasia, from 6, 
 privitive, and livdaraoig the action of rising, and 
 to the second that of ananabasia {d-dvdfiaaig, the 
 act of mounting). It will be noticed that these 
 
 Ueni. Ukd.— 18. 
 
283 DBGBNBEACIES OP EVOIiUTION. 
 
 terms, ananastasia and ananabasia are almost iden- 
 tical with atasia-abasia, a term chosen by M. Char- 
 cot to designate a special neuropathic modality, of 
 which M. Blocq gave an excellent description in 
 1888, and which is characterized by the inability of 
 certain hysterical subjects to stand erect or walk. 
 
 I ought to state that this is a pure coincidence, 
 since it was in 1886, and on the indication of students 
 of aggregation in philosophy present at my course, 
 that I first employed these neologisms, on which, 
 moreover, I lay no stress, since their utility, as I have 
 many times remarked, seems very questionable. It 
 is well to state, however, that the conditions of motor 
 inhibition to which they refer, differ sensibly from 
 those described by M. Charcot. Ananastasia and 
 ananabasia signify, in fact, inability to rise and 
 inability to climb, while astasia-abasia signifies 
 inability to stand erect or walk {A-araai^, the act 
 of standing; d-Sdatg, the act of walking). But 
 there is still another distinction which is of great 
 importance. The impossibility of standing erect 
 and of walking in astasia-abasia is a continuous and 
 constant symptom, undoubtedly due to a functional 
 impotence, a dissociation of the constituent elements 
 of progression under the influence of the neurosis ; in 
 ananastasia and ananabasia, on the other hand, the 
 inability to rise or walk only exists in the attacks 
 when the obsession is produced; in the interval the 
 patient can make whatever movements he pleases. 
 There is evidently, aside from the other peculiarities 
 
NEURASTHENIAS. 283 
 
 that may be invoked, a capital difference, which 
 shows that ananastasia and ananabasia do not belong 
 to the same category of morbid facts as astasia-aba- 
 sia. The former are phenomena of aboulic obsession, 
 the latter appear to be symptoms of dissociated func- 
 tional paralysis. 
 
 However it may be, it seenii'd to me to be worth 
 while to compare them, if only to establish the dis- 
 tinction between pathological conditions that might 
 otherwise lead to confusion. 
 
 Besides the impossibility of rising and climbing, I 
 have also noticed, as an aboulic obsession, the inability 
 to dress one's self (anesthia, from a-kadrii, habit). 
 This inability, like all the other inhibitions of the 
 same kind is intermittent and only occurs in attacks ; 
 further, it is not complete and is generally limited to 
 one or several articles of dress, for instance, the 
 stockings, the shoes, the waistcoat, the corsage, the 
 hat. In the intervals between the attacks the patients 
 dress themselves with ease ; when the obsession super- 
 venes they are unable to accomplish it, and are com- 
 pelled to stay in till the return of the normal calm 
 or to go out only partially dressed. 
 
 Another rather common disability consists in the 
 inability of the patients to speak, write, and, partic- 
 ularly, to sign their names (anupographia) . An 
 instance of this kind is to be found in the work 
 of Billod on the diseases of the will, and another 
 very remarkable one in that of Morel on the de'lire 
 emotif. This last is the case of an individual who 
 
284 DEGEKEEACIES OF EVOLtmON. 
 
 was unable to write to his betrothed, to sign his 
 name, or to pronounce in church the sacramental 
 "yes," so that the chaplain had to be satisfied 
 with his assent by signs. 
 
 There are many other emotional impossibilities, 
 such, for example, as the impossibility of fixing the 
 thought, already described under the name of apro- 
 sexia, the impossibility of sitting at table, of open- 
 ing doors, of entering or leaving, and many other 
 forms still, which future observations cannot fail to 
 bring to light. I limit myself here to the mention 
 of the principal ones, desiring chiefly to show that 
 neurasthenic aboulia is a special obsession, differing 
 from neurasthenic impulsion in that it has for ite 
 starting point a lesion of the will to act, while 
 the other has for the same a lesion of the will to 
 arrest action. 
 
 Diagnosis. — I need not dwell at length on the 
 diagnosis of obsessions, which constitute syndromes 
 of degeneracy with absolutely pathognomonic charac- 
 ters. I limit myself to calling attention to the pos- 
 sibility of confounding aboulic obsessions with 
 certain forms of depressive melancholia. The dis- 
 tinction is not always easy, since both conditions are 
 characterized in various degrees by motor inactivity 
 as well as by discouragement and sadness. 
 
 The analogy, nevertheless, is only in appear- 
 ance, as melancholia is a special disorder, in 
 which the symptoms of inactivity are continuous, 
 persistent and regular like all the others, while 
 
NEUEASTHENIAS. 285 
 
 neurasthenic lack of force is only a simple 
 intermittent and paroxysmal syndrome. Fur- 
 thermore the incapacity of the melancholiac does 
 not weigh upon him, he does not suffer on 
 its account and fight in vain against it; the neu- 
 rasthenic, on the other hand, wishes and endeav- 
 ors to act, whence his characteristic distress. We 
 have explained this difference already, by showing 
 that the aboulia of the melancholiac is by defect of 
 excitation, while that of the neurasthenic is from 
 default of central impulsion with retention of centri- 
 petal excitation. 
 
 It should be recognized, moreover, that the abou- 
 lia of the melancholiac is very often only an accessory 
 phenomenon of the disorder, and that it coexists 
 with other significant symptoms, such as painful 
 delusions, hallucinations, refusal of food, and sui- 
 cidal tendency, which leave no room for doubt, 
 since, with the exception of the last named, they are 
 never encountered in neurasthenic obsession. 
 
 Prognosis. — The prognosis of neurasthenic obses- 
 sions is generally, as we know, very grave, and 
 the majority of authors have insisted on the tenacity, 
 chronicity, and incurability of these syndromes, which 
 are very liable to remissions but not to recovery. 
 
 It is certain, indeed, that whenever the obsession 
 coincides with an actual and serious degeneracy, it 
 has a natural tendency to persist indefinitely. On 
 the other hand, when there is no degeneracy or when 
 it is present to only a slight extent, the obsession is 
 
286 DEGESTEEACIBS OF EVOLUTION. 
 
 perfectly capable of recovering. We may formulate 
 in this regard the rule that the curability of the 
 obsession is in inverse proportion to the degree of 
 degeneracy and in direct proportion to the degree of 
 acuteness of the neurasthenia. It is especially, 
 therefore, in the acute accidental neurasthenias, due 
 to severe moral or physical causes, that we observe 
 the curable obsessions. I should state also that the 
 aboulic obsessions seem to me to be less grave than 
 the impulsive ones, and that I have met them more 
 frequently in acute neurasthenias where the degen- 
 erative characters were little marked. 
 
 Treatment. — The treatment of obsessions is blended 
 with that of neurasthenia. How complex and varied 
 that is, is well known. Nevertheless, not all the ther- 
 apeutic methods proposed for neurasthenia are 
 available against obsessions, and that of Weir Mitch- 
 chell, in particular, can only be of use in cases of 
 acute neurasthenia with aboulia, which is unques- 
 tionably among the rarer forms. Isolation and con- 
 finement are hardly any more efiicacious, and the 
 rather numerous obsessed patients who have them- 
 selves admitted in asylums in hope of a cure derive 
 from them, as a rule, no decided benefit. The 
 means that seem to me most useful, apai't from the 
 pharmaceutical preparations appropriate to the case 
 (iron, phosphates, quinine, kola, strychnia, bromides, 
 hypnotics, etc.), are external agents, hydrotherapy 
 and baths of all sorts, massage, and especially elec- 
 tricity, either cerebral galvanization in large dose, 
 
PHEBWASTHEinAS. 287 
 
 as recommended by Beard, or franklinization as pre- 
 ferred by Vigouroux. It is seldom that we do not 
 obtain by the methodic and enlightened employment 
 of this latter agent, if not a cure, at least a tem- 
 porary, and sometimes a lasting, alleviation. 
 
 Finally, chiefly when all other means have failed, 
 we may have recourse to hypnotism, which will pos- 
 sibly give good results in case its application is not 
 difficult. I am well aware that many cases have 
 been reported during the past few years, of morbid 
 obsession cured by hypnotic suggestion, but I am 
 firm in the belief that all the patients are far from 
 being readily hypnotizable in spite of their good will, 
 and that many of them cannot be put to sleep, what- 
 ever care and persistence is used to effect it. Perhaps 
 it will be proper yet in this point of view to sepa- 
 rate the cases of obsession into two classes : those of 
 accidental and acute neurasthenia, hypnotizable and 
 curable; and those of constitutional and degenera- 
 tive neurasthenia, non-hypnotizable and condemned 
 to absolute incurability. 
 
 §111. PHREKASTHENIAS. 
 (Hbrbditaet Insanity or Insanity of the Db&bnbeates). 
 
 Under the name of phrenasthenias we designate 
 the vices of organization or degeneracies which 
 are accompanied by insanity. This is what is called 
 by some authors hereditary insanity or that of degen- 
 erated individuals. 
 
288 DEGENEEACIES OF EVOLUTION. 
 
 Described by Morel, studied successively by J. 
 Falret, Legrand du SauUe, Sander, Krafft-Ebiug, 
 Buccola, Morselli, Tonnini, Riva and numerous 
 foreign savants, tbis morbid condition has been 
 especially elucidated during tbe past few years by 
 Magnan and bis pupils. 
 
 Hereditary insanity is far from being universally 
 admitted as a special form of insanity, and the inter- 
 national congress of mental medicine of 1889 rejected 
 this appellation to substitute that less discussed, but 
 quite as debatable, one of moral insanity. It is 
 impossible, indeed, to give the name of hereditary 
 insanity to any one form, whatever it may be, since 
 all kinds of insanity may be hereditary. It is not 
 less the fact^ however, that the degenerates, i. e., 
 individuals suffering from vices of organization, do 
 not become insane like other people and that their in- 
 sanity presents special characters of its own. It is 
 therefore the word rather than the thing that is under 
 discussion, and the term insanity of the degenerates, 
 or better, phrenasthenia, seems to be one suited to 
 conciliate all views. 
 
 The principal character of the insanity in the 
 degenerates is that it depends upon a still graver 
 constitutional condition, the mental infirmity. In 
 ordinary lunatics the insanity is everything ; here it 
 is only a secondary phenomenon, superadded and 
 often episodic. There are therefore two distinct 
 elements to be considered in phrenasthenia: the vice 
 of organization and the insanity. 
 
PHEENASTHBNIAS. 289 
 
 The vice of organization or background we are 
 acquainted with. It is the total of the bodily 
 and mental stigmata on which we have insisted so 
 many times already, and it suifices to say that these 
 stigmata, essentially characterized by congenital devi- 
 ations and malformations, are here more pronounced 
 than they are in the disharmonies and neurasthenic 
 cases, the phrenasthenics representing a more ad- 
 vanced degree in the teratological scale. It i s in these 
 patients especially that we find the bodily anomalies 
 of the cranium, face, ear, palate, and the genital 
 organs, and, mentally, more or less profound moral 
 and intellectual lacunae, coexisting with aptitudes 
 and faculties normal or in excess. 
 
 The insanity or psychopathic epiphenomenon has 
 very complex characters and presents itself under 
 the most varied and complex aspects. Therefore it 
 is worthy of extended consideration. 
 
 Sometimes the insanity of the degenerates consists 
 in a true intellectual delirium ; sometimes it reveals 
 itself in moral and affective aberrations, without 
 delusions, properly speaking; sometimes, finally, it 
 shows itself by tendencies purely instinctive. There 
 are therefore three different varieties to be examined 
 successively : the delusional, reasoning, and instinc- 
 tive phrenasthenias. 
 
 Delusional Phbenasthenias. 
 {Delire des Degenerea.) 
 The delusional phrenasthenias represent, to speak 
 correctly, the true insanity of the degenerates. 
 
390 DEGENEEACIBS OF EVOLUTION. 
 
 Degenerate individuals may be subjects of any 
 form whatever of the common vesanias : mania, 
 melancholia, or systematized insanity. But each of 
 these has its special characters, either in the 
 symptomatology or, more particularly, in its evolu- 
 tion. The attack of generalized insanity begins all 
 at once; the delirium is more restricted and the 
 lucidity greater; remissions and intermissions are 
 almost the rule; recovery takes place suddenly, 
 but relapses are always threatened. Furthermore, 
 mania and melancholia may be intermingled, suc- 
 ceed and alternate, so that some authorities have 
 been led to consider the periodical and circular 
 insanities as belonging properly to the insanity of 
 degeneracy. As regards systematized insanity, it 
 shows itself under a still more abnormal aspect. 
 Here it is no longer the typical psychosis, evolving 
 regularly and methodically by successive and distinct 
 periods. Here the different phases are entangled 
 and confused : sometimes the ideas of grandeur and 
 persecution appear simultaneously; sometimes the 
 ambitious delusions precede the persecutory ones; 
 sometimes, finally, it is an attack of mania or melan- 
 cholia that becomes the starting point of the sys- 
 tematized delusions, in which mystical or sexual 
 conceptions {pers4eutSs g4nitaux) often predominate. 
 On the other hand, the disorder may improve or even 
 stop at any moment whatever of its existence which 
 never, so to speak, occurs in typical systematized 
 insanity. In a word, as Saury says, "the course of 
 
PHEBNASTHBNIAS. 291 
 
 hereditary insanity allows no regularity ; the lack of 
 method replaces the plan; absence of preparation 
 takes the place of progressive march. The most di- 
 verse manifestations may appear, combine, or altern- 
 ate -without any formal evolution. Far from indica- 
 ting sytematizatioTi and chronicity the ambitious 
 delusions lack all character and may disappear 
 to-day or to-morrow. " 
 
 This is the form of systematized insanity, first 
 described by Sander under the name of original 
 systematized insanity, on account of its nature and 
 precocity, that foreign authors, as was stated in the 
 preceding chapters, call paranoia primaria. 
 
 The insanity of degeneracy may, however, mani- 
 fest itself, not merely in an ordinary form, but also 
 under an aspect that is peculiar to itself. It is then 
 a special type, variable in its delusional expression, 
 but with uniform and, so to speak, pathognomonic 
 characters. The delusions are connected, coherent, 
 lifelike, starting from false or misinterpreted data, 
 but eminently logical in their deductions ; they are 
 never accompanied with hallucinations aside from 
 hypnagogic or oneiric hallucinations exceptionally in 
 certain cases ; they develop by progressive extension 
 of the parent idea, but without undergoing trans- 
 formation or losing their earlier physiognomy ; they 
 reveal themselves in nnore or less chimerical, but 
 persistent and tenacious claims, very often aggressive 
 and dangerous ; this form is incurable notwithstand- 
 ing frequent remissions, and it usually terminates in 
 cerebral complications. 
 
292 DEGENESACLES OP EVOLUTION. 
 
 The lunatics of this class have been placed among 
 the reasoning insane on account of the persistence of 
 their lucidity and the logical character of their delu- 
 sions. They have also been called persecutors from 
 their very characteristic tendency to employ violent 
 methods to advance their cause. The public, easily 
 deceived by appearances, often takes them for 
 victims embittered by injustice, and it is not uncom- 
 mon for their delusive ideas to communicate them- 
 selves to one or several persons among their friends 
 {folie d deux). 
 
 In reality they are hereditary degenerates, posses- 
 sors of very marked mental and bodily imperfections ; 
 egoists, arrogant, malicious, greedy of notoriety 
 and popular attention, and their delusions, the 
 more dangerous from their probability and lack of 
 recognition, impel them to the most striking adven- 
 tures and the most serious crimes. We are indebted 
 especially to the works of J. Falret, of his pupil 
 Pottier, and of Krafft-Ebing, for our knowledge of 
 this class of the insane. 
 
 The characters above indicated will suffice to give 
 a correct idea of the persecutors, but something 
 more will be said in regard to the principal varieties 
 of their insanity, according to which they are divided 
 into: persecutory, ambitious, litigious, erotic and 
 jealous, mystical, and political types. At bottom, 
 however, we have the same disease and the same 
 class of patients in all ; they differ only in the color- 
 ing of their predominating ideas. 
 
PHEENASTHENIAS. 293 
 
 Persecutory Oases. — Contrary to what occurs in 
 simple insanity of persecution, the delusions are 
 here immediate, without hallucinations, perfectly 
 logical and objective. A soldier, a priest, or an 
 employe, with the abnormal conditions of heredity 
 and temperament we have described, becomes the 
 subject of a reprimand or some disciplinary punish- 
 ment on account of his misbehavior or his profes- 
 sional deficiencies ; instead of accepting the correction, 
 his pride revolts, he calls it injustice and poses as a 
 victim. He is therefore persecuted, but, from the 
 first, he becomes a persecutor. He protests, makes 
 charges and appeals so loudly and energetically that 
 he is changed or loses his position. He sees in this 
 only a new grievance and his pathological spite 
 increases. Thereafter he sets no limits to his demands ; 
 he makes charges upon charges, complaint after com- 
 plaint, to the authorities ; he draws up long justifica- 
 tory memoirs, writes to the journals, posts handbills, 
 and appeals to the public in behalf of the legitimacy 
 of his cause. Often, the administration, wearied 
 with his importunities and touched by his precarious 
 situation, accords him some compensation or indem- 
 nity ; but this act of favor only renders him still iflore 
 haughty and exacting, as he considers it an admis- 
 sion and recognition of his rights, so much so that at 
 last, exasperated by his poor success, beset by pov- 
 erty, and tormented by his fixed idea, he passes 
 from complaints to threats, and from threats to 
 crime. Sometimes these individuals fire a pistol in 
 
394 DEGENBEACIES OF EVOLUTION. 
 
 the Chamber of Deputies, on the passage of a minis- 
 ter or the head of the State, declaring that they 
 want " to call attention to themselves and secure jus- 
 tice " (false regicides of R6gis) ; sometimes they 
 murder some one, perhaps their supposed enemy, per- 
 haps even some unknown person, in order to be 
 brought before the courts where they can finally ex- 
 pose their wrongs to the public gaze. If confined in 
 an insane asylum, they protest energetically against 
 their arbitrary sequestration, which is only an addi- 
 tional injury to their minds, they demand an inquis- 
 ition, endeavor to escape, to kill some one, or, on the 
 other hand, they profess to have given up their delu- 
 sions and make the most handsome promises ; but as 
 soon as they have, in one way or another, regained 
 their freedom, they commence at once again their de- 
 mands and their criminal acts. ' 
 
 Such, in brief, is the history of the reasoning per- 
 secutory cases or the persecuted persecutors. Many 
 of them have become widely known for the noto- 
 riety they have achieved, and the advocate Sandon, 
 the persecutor of the minister of the Empire, Busson- 
 Billault, will always, in the opiaion of many, be 
 remembered as an undoubted victim of the errors of 
 science, from having found in some writers, blinded 
 by political zeal, the virulent defenders of his path- 
 ological grievances. 
 
 Ambitious Cases. — The ambitious persecutors 
 differ in no respect from the persecuted persecutors, 
 except in one point : that is that their demands have 
 
PHEBN-ASTHBNIAS. 295 
 
 for their object, not the reparation for an injury, 
 but the recognition of an invention, a fortune, or a 
 title for which they are contesting. Aside from this 
 their delusion has the same evolution and mode of 
 displaying itself. "Without speaking of the cases of 
 this kind which have given rise, of late years, to 
 curious lawsuits, I will cite that of the woman of 
 Bordeaux who, after vainly demanding, with innu- 
 merable complaints and charges, but all apparently 
 logical, the property of a well known banker, ended 
 one fine day by forcibly installing herself there with 
 her son, whom she had made to share her delusional 
 convictions. I have at present under observation, 
 in the service of M. Pitres, at Bordeaux, a reason- 
 ing degenerate who calls himself the son of Jules 
 Gr6vy. His dying mother, he says, revealed to him 
 the secret of his birth. Since that time he has not 
 ceased to besiege the ex-president of the Republic 
 with his letters and his visits, calling him ' ' my dear 
 father" and demanding frequent subsidies. Con- 
 fined for two years at St. Anne, after a demand 
 without doubt a little too pressing upon the sup- 
 posed author of his existence, he has evidently seen 
 in it only one of the machinations of the individuals 
 interested in causing him to lose a part of his inher- 
 itance. He never fails on a certain day of the year, 
 that of St. Jules, and on various other occasions, to 
 write an affectionate letter to M. Grevy, and he 
 shows triumphantly, in support of his sonship, the 
 mail receipts showing that his letters reach their des- 
 
296 DEGENBEACIES OF EVOLUTION. 
 
 tination, for which he always takes care to ask. I do 
 not know whether this individual, who is in his way a 
 persecutor, since he annoys M. Grfevy with his fond- 
 ness and his filial demands, will end in raising his re- 
 quirements and energetically claiming his birthrights, 
 but this is in the order and may be considered as a 
 natural consequence of his delusion. 
 
 Litigious Cases. — The litigious persecutors have 
 been specially studied in Germany by Brosius, 
 Snell, Liebmann, and particularly by KrafEt-Ebing 
 who has described their malady under the name of 
 Querulanten Wahnsinn, or mania for disputes or 
 lawsuits. Their delusion is only a variety of reason- 
 ing persecutive insanity the characteristic of which 
 is to keep up legal proceedings. 
 
 An observation of Legrand du Saulle, unfortu- 
 nately too long for reproduction here, and to which 
 I refer (Annates medico-psychologiques, 1878), can 
 serve as an excellent description of this form. I 
 will content myself with giving, in brief, here an- 
 other interesting case reported by M. Pettier in his 
 inaugural thesis. It was that of a young woman 
 who, having had disputes with the municipal com- 
 mission of St. Ouen, in reference to the work on a 
 sewer that affected her dwelling, began suit against 
 the commune. At the same time she wrote to all 
 the ministers, had her demands printed for circula- 
 tion, and addressed them to the authorities, and 
 accused the courts, the police and the ' ' coalition of 
 dishonest persons leagued against her." On the 
 
PHEENASTHEinAS. 297 
 
 twenty-first of January, 1886, she entered the 
 Chamber of Deputies, walked up to the public 
 tribune, wrapped up in a flag and crying "Justice," 
 threw her pamphlets to the public, the members, 
 and the president. On her flag, made by herself 
 out of a piece of calico, was represented a besieged 
 house with this inscription : " Drama of St. Ouen, 
 7th July, 1884. Appeal to MM. the Deputies. Inva- 
 sion of Ballerich and a band of assassins, who have 
 overrun us. " The ushers arrested her and led her to 
 the questure. When examined, she said she wished 
 "to make a disturbance in order to call attention to 
 herself and her affairs," and that she had previoasly 
 informed M. Grevy, the president of the Republic, by 
 letter, of this manifestation. She was allowed her 
 liberty, and a month later, February 23, was arrested 
 at her home for having placarded her house with " In- 
 vasion of Ballerich, the infamous ! Justice ! " She 
 was then sent to the SalpStri^re. An interesting 
 feature of this case is that the husband of this 
 patient shared her delusions and signed with her 
 the printed protests. This fact of communicated 
 litigious insanity is, however, not infrequent, and is 
 shown even more clearly in one of the observations 
 in my thesis on the folie d deux. 
 
 Erotic and Jealous Cases. — A typical case, pub- 
 lished by M. Taguet, will enable us to appreciate 
 the erotic persecutors and will show that they are 
 similar to all the other reasoning lunatics of what- 
 ever category. 
 
 Memt. Med, — 19. 
 
398 DBGENBBACIBS OP EVOLUTION. 
 
 "M. X. . . entered one of the great houses of 
 France as a tutor. The kindly reception offered 
 him by the Princess de .... led him to hope that he 
 might gain her affection. One day when the prin- 
 cess was occupied in writing bending over her desk, 
 X . . . forgot himself so far as to imprint a kiss upon 
 her neck. The offense was great, but he could not 
 atone to her, and her husband, being informed, did 
 not disquiet himself further about it. 
 
 M. de . . . died, and the heart of the princess was 
 free. From that moment X . . . kept writing to her 
 strange, foolish letters, protesting the purity of his 
 intentions and recurring constantly to the old his- 
 tory of the kiss. 
 
 Finally he consented to leave Paris, but returned 
 almost immediately. The princess having shut her 
 doors to him, he installed himself in a house that 
 permitted him to spy her slightest movements ; dur- 
 ing the (Jay he followed her in the churches, in the 
 magazines, and in the streets. One evening he 
 forced his way into her carriage and covered with 
 burning kisses the hand of a femme de chambre 
 whom he mistook for her. At night he threw sand 
 and little pebbles against the windows of her apart- 
 ment. 
 
 On the complaint of M. le due de . . . , brother-in- 
 law of the princess, X. . . was ordered confined, 
 after an examination by Professor Lasfegue. At the 
 asylum his delusions continued and he tried to prove 
 that he was loved by the princess. How could 
 
tSEBNASTHENIAS. 299 
 
 Otherwise be explained that invincible attraction 
 that they felt for each other, those projections for- 
 ward of the pelvis and those nervous spasms that 
 Madame de. . . experienced in his presence, those 
 pressures of the foot, that fluid that ran through 
 their fingers when they met? 
 
 When restored to liberty his first care was to sue 
 MM. le due de. . . and doctors Lasfegue and Girard 
 de Cailleux for illegal sequestration, claiming one 
 hundred thousand francs damages. He lost his 
 case. 
 
 After the war in which he served as captain of 
 mohiles, X. . . appealed from the judgment that 
 had condemned him and demanded to be allowed to 
 plead his own cause. He lost in the appeal but 
 sued for a writ<of error. 
 
 X. . is, as is seen, not only an erotomaniac, but 
 also a case of persecutive and litigious insanity, 
 proving thus that the various forms we have 
 described are not distinct forms, but simple varieties 
 of phrenasthenia, capable of coexisting in the same 
 subject 
 
 The jealous persecutors are analogous in all 
 points. The following is a personal observation, 
 also interesting in this point of view. 
 
 Some years since I had occasion to examine a 
 young lady whose delusions were as follows : 
 
 This lady, a hereditary and degenerative case, al- 
 though very intelligent, became jealous of her 
 husband whom she blamed for not fulfilling his 
 
300 DEGENEEACIES OF EVOLUTION. 
 
 conjugal duties and for spending his evenings away 
 ■from home with his friends. Having been present 
 at a trial for separation in which unnatural relations 
 between a husband and his servant had been 
 charged, she was much impressed by the revelations 
 of these abnormal acts, of which she had not been 
 aware of even the existence, and this was to her 
 a beam of light. From that moment she imagined 
 that if her husband neglected her, it was because 
 he had shameful relations with one of his friends, 
 M. X . . . , and every evening, sometimes to a very 
 late hour, she followed him in the streets and spied 
 on him through the windows of the caf6 where he 
 went to play his game. Her daughter, a young 
 woman of eighteen, very virtuous and lady-like, was 
 informed by her of her suspicions add shared them 
 fully, accompanying or replacing her in her noc- 
 turnal watches. Madame X. , ., wrapped up in her 
 fixed idea, sought and found decisive proofs in 
 everything. Her husband came home late, fa- 
 tigued and with , dark rings around his eyes, that 
 was because he had been indulging in his infamous 
 vice ; he talked in his dreams, he was then calling 
 his cicisbeo. The poor woman went so far as to 
 scrutinize his soiled linen, and found in his shirts 
 and handkerchiefs traces of his illicit pollutions. 
 She showed us at our examination a shirt of M. 
 X . . . , spotted in the back in several places from 
 pimples that had suppurated, and which she had 
 preserved carefully for a month as an evidence. 
 
PHEBNASTHBNIAS. 301 
 
 deducing even that her husband in his unnatural 
 practices with his accomplice, had been the agent a 
 posteriori, i. e. , had played the passive part. 
 
 Full of this idea, and while her daughter, excited 
 by her, inserted into her '■'■cahier bleu'''' maledictions 
 against the infamy of her father, she became fully 
 a persecutor, and had encounters with the friend of 
 her husband, insulting and threatening him in public, 
 to the extent of creating a disturbance. 
 
 The mother and daughter happily decided to leave 
 for Paris, where they are living, without my 
 being able to learn exactly to what their delusions 
 have come. 
 
 Mystics. — Of all the persecuting insane the mystics 
 are the ones that present the most special physiog- 
 nomy. Mystics by temperament, often also by 
 heredity, they have an instinctive tendency to relig- 
 ious enthusiasm, and by a more or less gradual 
 process, they come to conceive a religious system 
 which they seek to spread and make prevail by all 
 possible means. Their profound conviction, their 
 enthusiastic appeals, and their exalted writings, 
 bring about sometimes surprising results, and it is 
 not uncommon for them to draw after them a crowd 
 of proselytes devoted to their cause even to the sac- 
 rifice of their lives. But the point that especially 
 distinguishes them, as compared with other reason- 
 ing insane, is the frequent occurrence of hallucina- 
 tions. These have in them characters that are 
 altogether peculiar. Thejr consist in supernatural 
 
303 DEGBlfBHACIES OF BVOHTTIOK. 
 
 revelations in the form of apparitions of the Deity, 
 the Virgin, or the saints. These apparitions occur 
 by preference in the night time, at intervals, and are 
 confused with the sleep to an extent that it is not 
 easy to distinguish whether they are genuine hallu- 
 cinations or purely oneiric phenomena, i. e., apper- 
 taining to dreams. 
 
 Whatever they may really be, these apparitions 
 have the effect of causing the delusive convictions 
 of the patients, and confirming them in their pre- 
 dominating idea that they have a divine mission to 
 fulfil. Grod, the Virgin or the saints, appear before 
 them in resplendent forms, sometimes with sounds 
 of celestial music, and after having indicated to 
 them, in a few seemingly sybilline words, what they 
 are to do for humanity and the means they are to 
 employ, disappear, leaving behind them as it were a 
 trail of light and harmony. Sustained by these 
 fantastic visions which give them the most exalted 
 ideas of their mission and which often attract to 
 them the reverence of the masses, they boldly come 
 to the front, braving punishment and death, draw- 
 ing peoples and armies after them, and it is in this 
 way that the founders of religions have been able 
 to accomplish such surprising results and stir so 
 profoundly the faiths of humanity. Without men- 
 tioning those of this class whose insanity is incon- 
 testable, I will refer, as examples, to the Swede, 
 Emmanuel Swedenborg, and Louis Riel, the Can- 
 adian agitator, hung at Rfegina, November 16, 
 
PHKENASTHENIAS. 303 
 
 1885, after having been twice confined as an insane 
 person. 
 
 The political phrenastheniacs are the same as the 
 mystics, but with their predominant ideas directed 
 to matters of government or state policy. It is not 
 infrequent, moreover, for their delusions to be at the 
 same time composed of both political and religious 
 ideas. They may show their tendencies in various 
 ways, but they are best represented by the regicides, 
 a name given here to those fanatics, who, apart frOm 
 any sect or conspiracy, have assassinated or attempted 
 to assassinate a monarch or ruler of their day. In 
 the recent work I published on celebrated regicides 
 of past and present times, I have demonstrated that, 
 identical in all countries and periods, notwithstand- 
 ing some apparent dissimilitudes, they are hereditary 
 degenerates, with a mystical temperament, who, 
 misled by a political or religious delirium, sometimes 
 complicated with oneiric hallucinations, believe them- 
 selves called to fill the double rSle of agents of justice 
 and martyrs, and, under the domain of an obsession 
 they are not free to resist, they attempt to destroy 
 some great personage in the name of God and their 
 country. 
 
 The essential ruling idea of the regicides' insan- 
 ' ity is that of their glorious mission, and, as I have 
 pointed out in regard to the simple mystics, their 
 hallucinations, when they have them, consist in inter- 
 mittent nocturnal apparitions, intimately associated 
 with dreaming and sleep. 
 
304 DEGESTEEACIES OF EVOLUTION. 
 
 FoUe d deux. — I have stated and have shown in 
 some of the cases cited, that the reasoning insanity of 
 the degenerates, whatever its form, persecuted, am- 
 bitious, litigious, erotic or mystic, is often communi- 
 cated by the patient to one or more individuals of 
 his immediate surroundings. It is indeed in these 
 conditions that the folie d deux or communicated 
 insanity, described incidentally by Baillarger and 
 extensively and thoroughly by Lasfegue, Falret and 
 Legrand du Saulle, is developed. At other times 
 folie d deux consists, not in the communication of a 
 delusion from one person to aiiother, but in its 
 simultaneous appearance, and by reciprocal influence, 
 in two predisposed individuals who are together. 
 This is what I have called simultaneous folie d deux. 
 I must mention also the imposed insanity of Maran- 
 don de Montyel, which is only a variety of commu- 
 nicated insanity, and the/o^ie gdmellaire of Professor 
 Ball and certain English authors, characterized by 
 the simultaneous appearance of a similar insanity in 
 two twins, even at a distance from each other. 
 Lastly some foreign authors have described, under 
 the name of induced insanity, the addition of new 
 delusions to the original insanity of a patient, under 
 the influence of his association with other patients. 
 
 Reasoning Phkenasthbnias. 
 {Moral Insanity). 
 
 Under the name of reasoning phrenasthenias, I 
 designate the moi-al insanity of certain authors. 
 
PHEEITASTHEiaAS. 305 
 
 Strictly speaking there is no need of giving a special 
 name to the maladies of this type, since they can be 
 included among those of the preceding class. Like 
 them, they are victims of heredity, essentially degen- 
 erates, and have clearly marked bodily and mental de- 
 fects. The distinction between the two is merely in 
 the fact that only exceptionally do they have delus- 
 ions, properly so-called, and that their vice of 
 organization reveals itself especially in perversions of 
 the sentiments and the affections. They are the 
 individuals who, with apparent full reason and 
 judgment, permit themselves, in an unconsious and 
 frequently paroxysmal manner, to indulge in errors 
 of conduct, inconsistencies, excesses, and immoral 
 acts that are really pathological, whence the term 
 morally insane that has been applied to them. Fun- 
 damentally, and although apparently less insane, 
 they are more profoundly degenerate than the delu- 
 sional cases, and they border a more marked degree 
 of mental infirmity, imbecility. 
 
 iNSTiNCTrvB Phrekasthenias. 
 {T?ie Criminal Psychosis). 
 
 What has been said above is still more true of the 
 individuals affected with instinctive phrenasthenia, 
 in whom the degeneracy shows itself particularly 
 by an innate tendency to jjerverse or criminal acts. 
 
 The born-criminals of Lombroso and the Italian 
 school unquestionably belong to this variety of the 
 degenerates. It would be indeed a mistake to believe 
 
306 DBGENBEACIES 01' EVOLTJTIOW. 
 
 that there is a special form of insanity having for 
 its symptoms a tendency to crime, i. e., a pure crim- 
 inal psychosis. The proposition should be reversed, 
 as it is more correct to say that there is a class of 
 criminals presenting clearly a more or less evident 
 vice of organization. But whatever has been pre- 
 tended, the somatic anomalies of these beings should 
 not be considered as peculiar to them. It is possible 
 and even probable that certain characters of degen- 
 eracy are met with more frequently in a determined 
 morbid variety, comparing among themselves its 
 various members, and that exaggeration of the great 
 envergure, asymmetry of the face, prominence of the 
 cheek bones and the superciliary arches, increased 
 size of the lower jaw, the presence of the sub-occipi- 
 tal fossa and the lemurian appendix, to cite only 
 these, are especially marked in criminal degenerates. 
 This, however, is no ground for seeing in the degen- 
 eracy of criminals a special teratological vice due to 
 a special cause, such, for example, as the reversion to 
 the savage ancestral condition. The degeneracy is 
 always one, and varied as may be its stigmata, it is 
 none the less identical in its origin and consequences. 
 
 The born-criminal is therefore only an instinctive 
 degenerate, just as the insane persecutor is an 
 intellectual and reasoning degenerate. 
 
 There is much to be said on such a living question 
 as that of criminal degenerates, which, under the 
 magnificent influence of Lombroso, has been the 
 
 )ject, in recent years, of so many interesting 
 
MONSTEOSITMIS. 307' 
 
 memoirs in the different countries of Europe, not- 
 ably in Italy, France and Russia. But, by a rather 
 curious scientific evolution, the study of the criminal, 
 at first purely anthropological, has gradually taken 
 a new direction, and, enlarging itself by degrees, 
 has now become plainly a sociological one. The 
 criminal, in fact, as has been well said by La- 
 oassagne, is a microbe inseparable from his culture 
 broth, the social surroundings. The complete study 
 of the criminal appertains therefore, for the present, 
 rather more to sociology than to psychiatry, prop- 
 erly speaking, and in the period of investigations 
 we are passing through, we can only refer the reader 
 to the well known works of Lombroso, Manouvrier, 
 Sergi, Garofalo, Tarde, and Laoassagne, which 
 include all the data at present known on this subject. 
 
 § IV. MONSTROSITIES. 
 
 (Imbecility, Idiocy, Ckethjism). 
 
 The monstrosities, which represent the highest 
 degree of vices of organization or mental infirmities, 
 comprise: imbecility, idiocy, and cretinism. 
 
 Imbecility. 
 
 The imbeciles may be in certain instances, well 
 formed, vigorous, and healthy: generally, however, 
 they exhibit characteristic bodily anomalies. 
 
 Their cranium, small or voluminous, is liable to 
 the most varied malformations and asymmetries; 
 
308 DEGENEEACIES OE EVOLUTION. 
 
 their physiognomy denotes their deficient intelli- 
 gence, and often suggests by its general configura- 
 tion, the appearance of an animal; the forehead 
 is low and straight, the ears ill formed and badly 
 inserted; the eyes are small, expressionless, often 
 strabismic; there are also lisping, prognathism, 
 anomalies of the velum palati, the uvula, and nearly 
 always also of the genital organs, which are some- 
 times remarkable for their rudimentary conditions, 
 sometimes, on the other hand, from their exagger- 
 ated size. 
 
 In a psychic point of view, the imbeciles possess 
 only a more or less restricted intelligence; they 
 learn to read, write, and count, with difficulty; 
 while susceptible of acquiring a slight and super- 
 ficial tincture in everything, they are incapable of 
 a correct and consecutive course of conduct and of 
 doing anything in earnest. Nevertheless, some of 
 them, notably weak-minded, though in a slighter 
 degree, have exhibited more or less brilliant artistic 
 ability, great qualities of memory or imitation, and 
 often also a certain vivacity of spirit, a promptness 
 and shrewdness of repartee which gives them always 
 the last word and puts the laughers on their side. 
 This peculiarity which is very striking in them and 
 is in marked contrast with the profound deficiencies 
 of their intelligence, explains why they were chosen 
 in former times as buffoons by kings whom they 
 brightened with their sallies and bon mots. 
 
 In a moral point of view the lacunae are perhaps 
 
MONSTEOSITIBS. 309 
 
 more marked than in the domain of the intellect, 
 and if these patients are capable of showing to 
 varying extent, sentiments and affections of a low 
 order, they are only the least elevated ones, and the 
 lower instincts that dominate them. The majority 
 are vain, gluttonous, cowardly, credulous, idle, iras- 
 cible, inclined to venereal and alcoholic excesses and 
 to acts of violence (Marce) ; nearly all are given to 
 onanism, and some even to unnatural crimes. At 
 certain times they may be seized more or less sud- 
 denly with melancholic or maniacal attacks, during 
 which they are particularly liable to commit acts of 
 obscenity, or even arson, robbery, suicide, or hom- 
 icide. When these attacks, which very often assume 
 in them a periodical or circular character, occur 
 many times, the patients soon fall into a condition of 
 dementia. 
 
 Idiocy. 
 
 Idiocy, formerly confounded with all the other 
 mental infirmities and all conditions of intellectual 
 obtunding, has been elucidated especially by 
 Esquirol, who differentiated it from dementia. His 
 classic definition is well known. " The demented 
 man," said he, "is deprived of the good that he 
 formerly enjoyed ; he is a rich man become poor: 
 the idiot has always lived in misfortune and poverty. " 
 
 Esquirol recognized three degrees in idiocy and 
 to-day also we still admit generally two classes 
 of cases in that condition of mental infirmity : (1) 
 
310 DBGEWHEACiES OF EYOLUttOl^. 
 
 idiots of the second 4egree; (2) idiots of the first 
 degree, or complete idiots. 
 
 (1). The idiots of the second degree hold the 
 middle place between the imbeciles and the complete 
 idiots. 
 
 Physically, they present very marked vices of con- 
 formation in different parts of the body. Their 
 stature is generally small; their hands those of a 
 child, and often presenting special peculiarities (idiot 
 hand). The head is usually small and irregular, 
 sometimes, on the other hand, it is enormous ; their 
 face lacks expression ; deaf -mutism, strabismus, con- 
 genital fissure of the palate, anomalies of the ear, 
 teeth, tongue, genital organs, and various bodily 
 deformities are very frequent in them ; they are sub- 
 ject to peculiar tics, to choreiform movements, to 
 rumination {merycisme) ; they often have paralysis, 
 especially infantile paraplegia or hemiplegia with 
 atrophy and contractures; their sensibility is very 
 dull and sometimes almost abolished ; and lastly they 
 are subject to neuropathic complications and epilepsy 
 in particular. 
 
 Intellectually, their faculties are extremely limited 
 and, as it were, in a rudimentary condition. Gener- 
 ally they pronounce only a few words or phrases, 
 which form their whole vocabulary; they can eat 
 alone and know how to select their food ; they recog- 
 nize those who live with them, and show some attach- 
 ment to those who care for them. But, apart from 
 some isolated artistic aptitudes, not capable of cul- 
 
MONSTROSITIES. 311 
 
 tivation, they have, properly speaking, no intelli- 
 gence; their education is nil; they hardly know 
 their age or names, and are unable to give the least 
 indication as to the course of years and months, the 
 value of money, the difference lu colors, etc., etc. 
 
 According to SoUier (1891) the psychology of the 
 idiot is summed up in the more or less complete ab- 
 sence of the primordial faculty : the will. 
 
 Morally, the sentiments and affections are alto- 
 gether absent and are replaced by the instincts. 
 The sexual instinct is particularly developed; the 
 majority of these unfortunates masturbate in public 
 and before their associates without the least appear- 
 ance of shame; others commit paederasty, run after 
 all women, or exhibit their genitals m the street. 
 Finally, these idiots, like the imbeciles and complete 
 idiots, are very often affected with epilepsy. Natur- 
 ally passionate, they may be seized with attacks of 
 maniacal agitation during which they give utterance 
 to savage and inarticulate cries, and give themselves 
 over to acts of violence that are absolutely bestial. 
 
 (3). In the complete idiots the physical and men- 
 tal development reaches its lowest limit, which is 
 shown by the total absence of intelligence, the sen- 
 timents, sensibility, and even certain instincts. The 
 majority are hideous appearing, rachitic, covered 
 with scrofula, afflicted with all kinds of vices of 
 conformation, partial paralyses, and contractures, 
 choreic and convulsive" movements, automatic tics, 
 and very often epilepsy. Many are blind, deaf, 
 
313 DEGEITERACIES OP EVOtTTTION. 
 
 dumb, deprived of the senses of taste and smell, 
 absolutely incapable of walking, dressing them- 
 selves or feeding themselves. Their physiognomy is 
 stupid, expressionless, the evacuations are invol- 
 untary, the saliva drools constantly from between 
 their half -opened lips, raucous and inarticulate cries 
 escape from their throats ; the second dentition does 
 not occur, no sign of puberty appears : at twenty, 
 these unfortunates seem only four years old. Every- 
 thing is reduced in them to the accomplishment of 
 the last vegetative functions, and the only signs of 
 life they manifest are their automatic balancings 
 and their unconscious manoeuvres of masturbation. 
 Such a condition is incompatible with any long exis- 
 tence, and these idiots of this degree hardly live 
 beyond twenty-five or thirty years. 
 
 Etiology. — Idiocy and, consequently, the various 
 arrests of development that we are studying, recog- 
 nize heredity as their principal cause, especially that 
 of mental alienation, epilepsy, hysteria, alcoholism, 
 syphilis, and>consanguinity of parents. Even when 
 idiocy is not congenital but, as has been said, 
 acquired, heredity is nearly always the primary 
 cause, not directly, but indirectly through the 
 infantile disorders such as meningitis, convulsions, 
 hydrocephalus, etc., that it causes. Together 
 with heredity, have been noted as adjuvant causes, 
 blows, falls on the head, compression of the head 
 during labor, and also, the compression practiced 
 
MONSTEOSITIBS. 313 
 
 in certain countries to give the heads of infants a 
 determined form. 
 
 PATHOLOGiCAii An ATOMY. — The lesions suscepti- 
 ble of being observed in cerebral weaknesses, and 
 notably in idiocy, usually involve the whole of the 
 head, and may be divided into external and internal. 
 
 1. There is, properly speaking, no special de- 
 formity of the cranium peculiar to idiocy. All de- 
 scribed anomalies may be encountered, from the most 
 simple which manifest themselves in a simple diminu- 
 tion of the cranial volume without changing its pro- 
 portions, up to the most complex, shown by the var- 
 ious deformities known as scaphocephaly, plagio- 
 cephaly, etc., etc. 
 
 In a general way, and apart from those cases 
 where the idiocy is connected with chronic hydro- 
 cephalus, the most constant def onnity is microceph- 
 aly, with corresponding diminution of the cranial 
 cavity. The diameters most affected are generally 
 the transverse, so that, contrary to the great major- 
 ity of cretins, the idiots are more dolicocephalic 
 than brachycephalic. The sutures sometimes ossify 
 prematurely, either throughout or by preference at 
 certain points; sometimes, on the contrary, they 
 ossify only late or not at all. In this last event 
 they are often filled with a large quantity of 
 wormian bones. 
 
 2. Excluding certain exceptional cases in which 
 the brain is more voluminous and heavy than nor- 
 
 Memt, Med,— 30. 
 
314 DEGEITEEACIES OE EVOLUTIOIT. 
 
 mal, the diminution of the volume and weight of 
 that organ is the most constant and remarkable 
 alteration in idiocy. The brain weight in idiots 
 varies from 700 to 1,100 grams. 
 
 Besides this alteration, there are others, such as 
 marked inequality of the hemispheres, atrophy of one 
 of them ; rudimentary condition of certain regions, 
 especially the anterior lobes; absence of certain 
 parts, such as the corpus callosum, the central 
 nuclei, the fornix, etc. ; various lesions, such as 
 hydrocephalus, porencephaly, atrophic, hypertrophic 
 and tuberculous scleroses, smoothness, thinning, or 
 even absence of certain convolutions, especially the 
 frontal ones, with greater or less enlargement of 
 the fissures and sulci, particularly the fissure of 
 Sylvius. Finally, in a histological point of view, 
 we find various alterations of the structure of the 
 nervous substance, softening of the gray matter, 
 presence of numerous idiot cells, and also certain 
 anomalies of the cerebral circulation, recently 
 described by M. Luys. 
 
 Bourneville distinguishes, from an anatomico- 
 pathological point of view, the following forms in 
 idiocy: (1) idiocy symptomatic of hydrocephalus 
 (hydrocephalic idiocy) ; (2) idiocy symptomatic of 
 microcephaly (microcephalic idiocy) ; (3) idiocy 
 symptomatic of an arrest of development of the con- 
 volutions; (4) idiocy symptomatic of a congenital 
 malformation of the brain (porencephaly, absence of 
 corpus callosum, etc.) ; (5) idiocy symptomatic of 
 
MOKSTEOSITIBS. 315 
 
 hypertrophic or tuberculous sclerosis; (6) idiocy 
 symptomatic of atrophic sclerosis : (a) sclerosis of one 
 or both hemispheres ; (b) sclerosis of one lobe of the 
 brain ; (c) sclerosis of isolated convolutions ; (d) scler- 
 osis chagrinde (like shagreen) of the brain (?) ; (7) 
 idiocy symptomatic of chronic meningitis or menin- 
 gito-encephalitis (meningitic idiocy) ; (8) idiocy with 
 pachydermic cachexia, or myxcedematous idiocy 
 connected with absence of the thyroid gland. This 
 last fonn is also called cretinoid idiocy, cretinoid 
 pachydermia, or sporadic cretinism. It will be 
 noticed later on in the remarks on cretinism. 
 
 Diagnosis. Peognosis. — The diagnosis of the 
 monstrosities is generally very easy, as they can 
 hardly be mistaken for dementia. The only point 
 consists in determining the exact degree of the arrest 
 of development, since, as has been said, the limits 
 between the different varieties of cerebral infirmities 
 are not clearly defined. 
 
 As to the. prognosis, it is not necessary to dilate 
 upon its gravity. Complete idiocy is incompatible 
 with a long life. Incomplete idiocy and imbecility 
 are only susceptible of a slight modification under 
 the influence of special treatment. 
 
 Teeatment. — Thanks to the efforts of Belhomme, 
 Felix Voisin, S6guin, Delasiauve, Bourneville, etc., 
 a therapeusis and a special pedagogy has been grad- 
 ually formed for idiots. This treatment, the special 
 
316 DEGENEEACIES OF EVOLUTION. 
 
 rules of which, cannot be given here, consists in the 
 wisely combined employment of hygienic, moral, 
 and intellectual agencies. 
 
 Some recent trials of craniectomy (Lannelongue, 
 of Paris) in idiots with premature synostosis of the 
 cranial bones seem to have given good results. 
 This intervention of surgery in certain special cases 
 of idiocy may possibly have a certain future use- 
 fulness. 
 
 Cbetinism. 
 
 Definition. — We designate under the name of 
 cretinism, an arrest of development of the organism, 
 with special features involving particularly the phys- 
 ical constitution, of endemic origin, and habitually 
 accompanied witli goitre. 
 
 The cretins are usually divided into three classes, 
 representing the three progressive degrees of degen- 
 eracy: 1, the cretinoid or sluggards; 3, the semi- 
 cretins; and 3, the cretins. 
 
 1. The cretinoids are essentially characterized: 
 intellectually, by the symptoms of more or less com- 
 plete imbecility ; physically, by the signs of the first 
 degree of the cachexia. These signs consist mainly 
 in the flattening of the nose, the size of the mouth, the 
 earthy color of the skin, the pufRness of the face, the 
 bad implantation and condition of the teeth, a gen- 
 eral arrest of development of the organism, more 
 or less pronounced, and lastly in the existence of a 
 goitre of varying size. The head is generally rather 
 
MONSTEOSITIES. 317 
 
 large, and clearly brachycephalic in type, as is the 
 case with most cretins. According to Cerise, the 
 cretinoids have always also a rather marked fronto- 
 occipital depression. They are apt in reproduction. 
 
 3. The semi-cretins differ especially from the cre- 
 tinoids in the much more marked degree of the ex- 
 ternal signs of the cachexia. The difference is slighter 
 as regards the mental condition ; moreover, the major- 
 ity of the cretins are not properly idiots, and in 
 some of them the intellectual deficiencies are not at 
 all proportional to the physical degeneracy. The 
 semi-cretins are generally squat in figure, their limbs 
 stumpy, the joints large and swollen, the neck short 
 and thick; at other times they are, on the other 
 hand, thin and slim ; their head is large, and partic- 
 ularly broad, their eyes bulging, and half covered by 
 the swollen lids ; their cheeks and lips are flaccid 
 and pendant, their teeth carious and badly implanted ; 
 their skin is clayey, their goitre voluminous. Their 
 gait is vacillating and irregular ; their sphincters are 
 relaxed ; their respiration stertorous and wheezing ; 
 their tongues hanging between the open lips drip 
 with saliva. Their sensibility is very obtuse, their 
 intelligence very limited, and their speech, very 
 imperfect, is limited most often to a few monosylla- 
 bles. Quite unlike the full cretins, they have vol- 
 uminous genital organs and nearly always give 
 evidence of a great salacity. 
 
 3. The complete cretins, entirely lacking in in- 
 tellectual and reproductive faculties, as well as of 
 
318 DEGENEEACIES OF EVOLTTTIOIT. 
 
 reproductive power, endowed only with vegetative 
 faculties, represent the highest degree of cretinoid 
 degeneracy (Marce) . They resemble young infants 
 and liave, like them, the chest weak, the abdomen 
 prominent, and their teeth are of the first dentition. 
 The goitre when present is slight, which is explained 
 by the absence of puberty. Their genital organs 
 are altogether rudimentary. They can hardly walk 
 and sometimes remain in a condition of absolute im- 
 mobility. All their senses are obtunded, and some- 
 times nil; their voice is reduced to rancous cries or 
 to gruntings that have nothing human in them. 
 
 Etiology. — It appears from the numerous works 
 on cretinism that this form of degeneracy recognizes 
 no single cause, but that it is the result of many 
 cumulative ones. 
 
 Some of these are found in the geological consti- 
 tution of the soil, the altitude, the topography, the 
 chemical constitution of the air and water. It is a 
 well known fact that cretinism is endemic especially 
 in certain narrow valleys of the Alps, the Pyrenees, 
 of Auvergne, Scotland, Tyrol, New Grenada, and 
 Hindostan. In France, the department of Haute- 
 Savoie is that which furnishes the most cretins. 
 These valleys are, for the most part, contracted; 
 humid, deprived of air, light and sun, and at nearly 
 an equal altitude above the sea. Their villages are 
 built against the sides of the mountains and the 
 houses are low and damp. The soil is magnesian, 
 
MONSTEOSITIES. 319 
 
 the waters coming from the melting snows is hard, 
 badly aerated, mixed with silex, charged with lime 
 salts, and lacking in bromine and iodine. Moreover, 
 in the infected villages the hygienic conditions are 
 very poor and the unfortunate inhabitants live in a 
 very repulsive state of uncleanliness. 
 
 Together with these causes which exist in all 
 countries where the cretinous degeneration prevails 
 and which make it there endemic, are to be considered 
 individual causes consisting especially in heredity, 
 consanguineous marriages, etc. Whether the goit- 
 rous and cretinous cachexias are the same or not, it 
 is none the less true that the cretins represent the 
 most degraded products of a race that begins with 
 goitre and that the goitrous and the cretins mutually 
 engender each other. 
 
 Natueb. — It is not fully agreed as to the nature 
 and the ultimate cause of cretinism. One of the 
 most accepted theories consists in considering cretin- 
 ism as a diffuse (Edematous hydrocephalus, produced 
 by the compression exerted by the thyroid or thy- 
 mus gland on the cervical vessels. This theory, 
 nevertheless, is open to many objections, the chief 
 of which is that certain cretins, the complete cretins, 
 are either not goitrous or only slightly so. It is more 
 probable that cretinism is the result, not of a mere 
 mechanical compression, but of the abolition of the 
 physiological function of the thyroid gland. 
 
 However it may be, if these theories are correct, 
 
330 DEGBNEEACIES OF BVOlUflON. 
 
 it only places the difficulty a little farther back, 
 since it will always be necessary to . explain either 
 the origin of the goitre or of the hypertrophy of 
 the thymus in the cretins. 
 
 There is nothing special in the pathological ana- 
 tomy of the cretins. It consists, the same as in 
 idiots, of decrease of volume and weight of the brain, 
 narrowing of the cranial foramina, especially the oc- 
 cipital, and atrophy of many parts, notably of the 
 convolutions. 
 
 Tkbatment. — The most important matter relative 
 to the management of cretinism is prophylaxis. 
 This consists in the application of hygienic means to 
 counteract the general causes of the degeneracy. 
 It is well known that with the opening of roads, the 
 sanitation of the villages, the procurement and control 
 of proper sources of drinking water, and lastly, with 
 the diminution of poverty in the affected villages, 
 goitre and cretinism have both decreased in frequency. 
 The same will be true as regards properly selected 
 marriages that can, in a measure, combat successfully 
 the hereditary element. 
 
 As to curative treatment, it consists in the removal 
 of cretin infants and their transfer to healthy 
 regions, in an appropriate bodily and mental train- 
 ing, and, finally, in the use of iodine and its 
 preparations. 
 
 Sporadic cretinism. Cretinoid idiocy. Idiocy 
 with pachydermic cachexia. Cretinoid pachy- 
 
MON-STEOSlTIfiS. 3^1 
 
 dermy. Myxoedematous idiocy. — Under these va- 
 rious designations there has been described a physical 
 and intellectual arrest of organic development, 
 offering the general features of cretinism, but not, 
 like it, arising from an endemic condition. The 
 only special peculiarities really belonging to this 
 condition seem to be the almost constant existence 
 of pseudo lipomatous masses located especially in 
 the sub-clavicular hollows, and in the almost pachy- 
 dermatous or myxoedematous appearance of the sub- 
 jects. 
 
 M. Bourneville, who has, in recent years, brought 
 together under the name of myxcedematous idiocy 
 the most of the known cases of sporadic cretinism, 
 attributes this form of degeneracy to the absence 
 of the thyroid gland. This opinion, which has long 
 been advanced in England, particularly by Curling 
 in 1850 and Hilton Fagge in 1871, is not absolutely 
 correct, as, in a case reported by Bucknill and Tuke 
 and in another reported by M. Arnozan and myself 
 in 1888, there was an evident goitrous hypertrophy. 
 Instead of saying with Hilton Fagge, that ' ' goitre is 
 never present in sporadic cretinism," or with 
 Bourneville that ' ' myxoedematous idiots do not have 
 the thyi-oid gland and therefore no goitre," it is 
 better to conclude, as Robinson did in 1886, that in 
 sporadic cretinism " the thyroid gland is either ab- 
 sent or affected with some organic alteration." 
 
 Formulated in these terms, the opinion that 
 attributes a thyroidian origin to sporadic cretinism 
 
323 DEGENERACIES OE EVOLUTIOIT. 
 
 i» very plausible, and has an important confirmation 
 in the probable pathogeny of certain conditions, 
 such as myxoedema, cachexia strumipriva, and ex- 
 perimental cretinism, regarded with reason by Ord 
 and some other authors ' ' as forming with cretinism 
 a single disorder, that has for its direct cause the 
 loss of the functions of the thyroid gland." 
 
 The most recent researches on this subject au- 
 thorize us to believe that the thyroid body is a 
 vascular gland, the secretion of which assists in the 
 elimination or neutralization of -certain toxic prod- 
 ucts of denutrition. Cretinism and allied states 
 (sporadic and experimental cretinism, cachexia 
 strumipriva, myxoedema), will therefore have a 
 common origin, and be due to an intoxication of 
 the organism from the absence or suppression of the 
 function of the thyroid gland. 
 
 Supporting themselves on these facts, Horsley, 
 Lannelongue, Bettencourt-Rodriguez, and some 
 others, have recently tried to graft the thyroid 
 gland of the sheep into the subjects of myxoedema 
 and cachexia strumipriva, but this operation has not 
 yet given satisfactory results.* 
 
 * Since the above was written, numerous observations have been 
 reported in which favorable results have been apparently obtained 
 by thyroid transplantation and especially by the internal and hypo- 
 dermic administration of thyroid extract in myxoedema.— (Tbams- 
 latob). 
 
SECONB GEOUP. 
 
 DEGENERACIES OF INVOLUTION. 
 
 (Disorganizations). 
 
 SIMPLE DEMENTIA. 
 
 Dementia is an acquired cerebral infirmity, charac- 
 terized by failure of the intellectual and moral facul- 
 ties. It has long been confounded with idiocy and 
 with stupor, which Esquirol considered to be an 
 acute. dementia. It is not necessary to restate here 
 that this last is due to an obtunding, and not to a 
 weakening of the intelligence. 
 
 Etiology. — Dementia is the consequence of a 
 host of different causes. It is divided into primary 
 and consecutive forms, according as it appears all at 
 once of itself, or follows another disorder of which 
 it is then the final stage. This is much the most 
 common occurrence, so much so that M. Ball has 
 said that dementia constituted a, point of arrival 
 Tabthertha,n a, point of departure. Primary dementia 
 is that which is due to age (senile dementia), or to 
 organic changes of the brain (apoplectic, paralytic 
 dementia, etc.), consecutive dementia is that which 
 forms the termination of the various insanities 
 (vesanie dementia), epilepsy, alcoholism, arrests of 
 
3^4 DEGBNEEACIES OP INVOLTTTION. 
 
 development, and, in a general way, all the disorders 
 that end at the expense of the mental and moral 
 faculties. 
 
 Description. — I must confine myself here to 
 describing simple dementia, that is, the acquired 
 cerebral infirmity constituted by intellectual enfeeble- 
 ment. This is the skeleton of dementia, the com- 
 mon basis of all its varieties ; as regards the peculiar- 
 ities, delusional, etc., that it presents in certain 
 cases, they are only superadded symptoms that wUl 
 be noticed in connection with the various patholog- 
 ical conditions of which they are the consequence. 
 The type of simple dementia is represented by senile 
 dementia without delusions. 
 
 Three periods can be distinguished in dementia : 
 (1) an initial period ; (3) a middle stage ; (3) a term- 
 inal period. 
 
 1. Initial Period. — It is exceptional to see demen- 
 tia appear suddenly. Generally its beginning is 
 insidious, and the mental weakness is already more 
 or less profound when it is recognized. First of all, 
 there is a more or less decided incapacity for work, 
 a lack of precision and lucidity in business, in the 
 ideas and judgments, also errors in figures and 
 calculations. Soon defects begin to appear in the 
 memory which is, usually, the first faculty afliected. 
 The amnesia first involves only recent, and conse- 
 quently the least adherent (Kussmaul) recollections, 
 while, on the other hand, the older ones come up in 
 
SIMPLE DEMENTIA. 335 
 
 crowds and have a special revivication. The patients 
 forget what they have done and said, they lose their 
 objects, they do not recollect what they intended to 
 do when they have their work half done. When 
 they talk, they constantly repeat, forgetting names 
 and words, the same stories in the details of which 
 they wander losing every minute the thread of their 
 discourse. Their character changes at the same time, 
 and as regards this feature, we can recognize two 
 classes : the apathetic and the excited; the ones placid 
 and good natured, the others irritable and cross- 
 grained to excess. Generally, at this time, they 
 begin to lose their good manners, their habits 
 and good tone, and to offend in their talk, their 
 gestures, and dress against the most elementary 
 rules of politeness and decency. 
 
 2. Middle Period. — After a longer or shorter 
 time, the patients become absolutely incapable of 
 serious and sustained employment, and their demen- 
 tia makes notable progress. From recent facts, the 
 amnesia extends to ideas, words, scientific or profess- 
 ional notions, to acquired languages, and spares only 
 the first acquisitions of the earliest ages, so that it 
 perfectly justifies the popular expression "to fall 
 into infancy." Hence results a puerility of ideas 
 and language, a progressive diminution of the 
 sentiments and affections which makes the dement a 
 regular infant, credulous, without will power, excess- 
 ively mobile, forgetful of the simplest matters and 
 incapable of self-control. As regards speech he 
 
336 DEGBNBEACIES OF INVOLITTION. 
 
 becomes incoherent, not like the maniacs, in whom 
 this is the effect of an excessive mental activity and 
 is purely elliptical, but in consequence of loss of 
 memory of words and expressions to employ. It is 
 verbal incoherence, a species of characteristic 
 aphasia. The same trouble as with speech occurs 
 with writing. 
 
 In a still more advanced stage the demented 
 patient is reduced to the condition of an automaton, 
 and lives in the most complete unconsciousness. It 
 is a curious fact, nevertheless, that although he has 
 forgotten everything, even to the number, age, and 
 names of his children, even his property, he can still 
 sometimes carry on perfectly well, as by a sort of 
 habit, more or less difficult occupations or distract- 
 ions, such as reading papers, playing cards, checkers, 
 billiards, etc. His speech at the same time is pure 
 nonsense without any significance whatever. 
 
 There are also some physical peculiarities to be 
 described : thus, the majority of the dements take on 
 flesh and the organic functions are carried on in them 
 with very great regularity. It appears as if the in- 
 tellectual and the physical existence have become al- 
 together independent of each other. On the other 
 hand sleep is light, short, and often hardly occurs. 
 In some cases, especially in those where the dementia 
 is connected with an organic cerebral disorder, 
 paralysis of the sphincters soon appears. 
 
 3. Terminal Period. — This is formed by an 
 almost complete obliteration of the intelligence, and 
 
SIMPLE DEMENTIA. 327 
 
 by the progress of the organic cachexia. In a mental 
 and moral point of view, the dement is at this time 
 in the same condition as the idiot ; nothing is as it 
 formerly was. At the same time he loses flesh and 
 appetite, becomes altogether untidy, and ends by 
 dying in a more or less complete state of decrepitude, 
 either from some cerebral or visceral disorder, or in 
 consequence of trophic disorders or the progress of 
 the cachexia. 
 
 Duration. Pathological Anatomy. — Simple 
 dementia may continue for a longer or shorter period ; 
 generally its evolution is very slow and continues over 
 many years. The lesions vary according to the cause 
 of the dementia. It may be said, nevertheless, that 
 in a general way the dementia corresponds to a cere- 
 bral atrophy and to degenerative changes of the nerve 
 centres. 
 
 Teeatment. — The treatment of dementia can be 
 only palliative. In simple cases it is limited to 
 hygienic and moral attentions, the employment of a 
 regular surveillance, the use of certain medicines to 
 ward ofE complications. When the mental enfeeble- 
 ment is accompanied with delusions, and especially 
 if with pathological acts, it is often needful to have 
 recourse to sequestration. 
 
SECOND SECTION. 
 
 SECONDARY CONDITIONS OF MENTAL 
 ALIENATION. 
 
 (Absociatbd ok Symptomatic Inbanitibs). 
 
 The associated or symptomatic insanities being, 
 as has been shown in our classification, only the 
 result of the combination of a simple generalized 
 insanity, mania or melancholia, w'ith any process 
 whatever, physiological or pathological, of the or- 
 ganism, we might, strictly speaking, dispense with 
 making them a special study. It is advisable, how- 
 ever, for the sake of completeness, to sketch broadly 
 their principal characters, laying stress more par- 
 ticularly on such of them as by their frequency and 
 their importance are brought especially under the 
 notice of the practitioner. 
 
 In our description we shall follow the order of the 
 table here presented, in which the symptomatic 
 insanities are grouped, according to analogies of 
 associations, under their usual designations. But it 
 must be understood that this table is only an annex 
 to our classification, that is not indispensable, a 
 synoptical list, intended simply to assist the memory, 
 and to receive in their places all the new varieties of 
 associated insanities as they are recognized. 
 
ASSOCIATED INSANITIES. 
 
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 ASSOCIATED INSANITIES. 
 
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Cbapter ITf . 
 
 INSANITY ASSOCIATED WITH PHYSIO- 
 LOGICAL CONDITIONS. 
 
 (Sympathetic Insanity). 
 
 I. — Insanity of Infancy and Puberty. II. — Insanity 
 OF Old Age. III. — Insanity of Menstruation. IV. — 
 Insanity of Pregnancy. V. — Insanity of the Meno- 
 pause. 
 
 §1. INSANITY OP INFANCY AND PUBERTY. 
 (Hebephrenia. Pubescent Insanity). 
 
 Insanity of Infancy. — Insanity is very rare in 
 early infancy and it is met with only exceptionally 
 before puberty. When encountered, it is usually 
 observed in children with a very strong hereditary 
 tendency, and it shows itself in them by terrors, 
 nightmares, nocturnal delirium, visual hallucinations, 
 especially by morbid impulses of a more or less 
 dangerous character, and only rarely by a maniacal 
 or melancholic condition. 
 
 Insanity of Puberty. — Puberty is a critical 
 period of human life, and many predisposed and 
 nervous children show various disturbances of the 
 emotions and the intellect at this time. 
 
332 nsrsAinTT with physiologic ai conditions. 
 
 The mental disorders incident to puberty are ex- 
 tremely varied, and it is not possible to include them 
 all under a single head, as has been attempted by the 
 Germans who have described them under the name of 
 hebephrenia. 
 
 Sometimes it is a simple depression, more or less 
 acute, with a tendency to solitude, moroseness, exces- 
 sive timidity, confused bashf ulness, vague longings, 
 tears and sadness ; sometimes, on the contrary, there 
 is a varying degree of excitement, showing itself in 
 an incessant activity, turbulence, insomnia, continual 
 tricks and annoyances, dissimulations and falsehoods ; 
 and in a more advanced stage the depression becomes 
 lypemania or hypochondria having for its subject the 
 novel phenomena that appear in the sexual functions, 
 which surprise, alarm, and torment the patients, 
 especially boys, sometimes to the extent of arousing 
 in them a very marked suicidal tendency. The 
 excitement when it exists may become agitation, the 
 roguishness actual viciousness with pride, presump- 
 tion, evil tendencies, cruelty, especially to animals, 
 impulses to theft, arson and, still more, to homicide. 
 With these bad tendencies there are also observed 
 occasional acts of extraordinary bravery that arouse 
 the greatest admiration, and are due to no other 
 motive than the desire to do something. Under the 
 influence of this temporary impulse, young men show a 
 disdain for danger, at which they are later themselves 
 astonished. 
 
 These, however, are only transitory disturbances, 
 
IN'SANITT OF PtTBEETT. 333 
 
 the mere oscillations of a forming character seeking 
 its equilibrium. Other more serious symptoms may- 
 appear and produce an actual condition of mental 
 alienation. These are delusive conceptions which, 
 in these cases, often take on an erotico-mystic or re- 
 ligous type, and reveal themselves by fear of the 
 devil, of hell, of demoniacal possession, of damna- 
 tion, by bizarre sexual ideas, by platonic and mystic 
 loves for imaginary beauties that often lead to habits 
 of masturbation. The mcdadie du doute may also 
 be observed. Some times there are nocturnal terrors, 
 and nightmares, and even actual hallucinations involv- 
 ing mostly the visual sense. 
 
 The insanity of puberty seems to take the depres- 
 sive rather more than the maniacal form, and it 
 manifests itself by preference, as remarked by Mairet 
 (1889), in melancholic stupor with attacks of agita- 
 tion. In all cases it localizes itself much more in the 
 moral sphere and in that of action than in the purely in- 
 tellectual one, that is it shows itself more in morbid 
 acts and impulses than in delusions. The morbid 
 impulsions in pubescent insanity impel the patients 
 to dangerous and criminal acts, and many of the 
 misdemeanors and crimes committed by young per- 
 sons at this period of their lives, have no other cause 
 than a mental disorder connected with the appear- 
 ance of puberty. 
 
 However certain German authorities consider it, 
 the insanity of puberty is not usually of serious im- 
 port, and it disappears with the cessation of the crit- 
 
334 rNSANTTT WITH PHYSIOLOGICAL CONDITIOKS. 
 
 ical period that gave it rise, unless it has its source 
 in a pronounced heredity, in which case it is only the 
 first stage of an intellectual degeneracy or an incur- 
 able dementia. 
 
 It is hardly necessary to say that the mental 
 disturbances developed under the influence of puberty 
 are manifested much more commonly in young 
 women than in boys. We know, indeed, that nubility 
 in the former is always a perilous period, and that 
 the various stages of sexual life affect the female 
 more profoundly than the male. On the other hand, 
 it appears that hebephrenia is a less serious disorder 
 in the female sex, which is possibly explainable by 
 the fact that when menstruation is once established 
 aud regular, it sets up in the girl a sort of salutary 
 derivation that contributes powerfully to the re- 
 establishment of the mental equilibrium. 
 
 Mairet considers choreic insanity as a simple 
 variety of pubescent insanity in which the delirium 
 and the chorea are both syndromes of the same pro- 
 cess : puberty. This view is certainly not appli- 
 cable to all cases ; and we will therefore continue, in 
 accordance with most of the authorities, to describe 
 choreic insanity by itself. It would be more correct 
 to refer the insanity of masturbation to the insanity 
 of puberty. According to Spitzka, who has made 
 it a special study (1888), the insanity of masturba- 
 tion is five times moi-e frequent in males than in 
 females, and occurs ordinarily between the ages of 
 thirteen and twenty. It is manifested physically by 
 
INSANITY OP OLD AGE. 335 
 
 a genera] exhaustion of the system, with ansemia of 
 the brain, and digestive and circulatory disturbances, 
 and mentally, by obtuseness, alternations of depres- 
 sion and exaltation with a permanent ground work of 
 sadness, that usually passes into profound melan- 
 cholia, and finally into dementia. 
 
 The treatment of the insanity of puberty should 
 be at once prophylactic in predisposed children, 
 moral, hygienic and medicinal. Quietness of mind, 
 the avoidance of religious subjects and of reading 
 matter capable of exciting the imagination, travel, 
 recreation, gymnastics, hydrotherapy, sedatives, 
 and, when required, emmenagogues, sum up the 
 principal resources of treatment in such cases. 
 
 § n. INSANITY OF OLD AGE. 
 
 (Senile Insahitt). 
 
 The insanity of old age, or senile insanity, is that 
 which occurs from advance of years. It recognizes 
 for its main predisposing cause, heredity, especially 
 cerebral heredity ; and as its principal exciting causes, 
 alcoholism, syphilis, great excesses, and misfortunes. 
 Filrstner, who has made a special study of the 
 psychic disorders of old age (1888), classes them in 
 three groups : (1) simple senile psychoses ; (2) senile 
 psychoses with simple dementia ; (3) senile psychoses 
 with cerebral dementia. 
 
 The simple senile psychoses are those in which 
 the insanity is not accompanied by intellectual en- 
 
336 IN-SAITITT ■WITH PHYSIOLOGICAL CONDITION'S. 
 
 feeblement. It is then a common, more or less acute 
 attack of mania or melancholia. The maniacal form, 
 much the least frequent, is essentially curable ; the 
 melancholic often due to a homologous and homo- 
 chronous heredity (R6gis), affects by preference the 
 anxious type, and almost invariably terminates in the 
 chronic form. 
 
 The senile psychoses with simple dementia are 
 those in which the insanity is associated with a i con- 
 dition of mental weakness without corresponding 
 somatic lesions. It is a combination of an ^ttack 
 of mania or melancholia with simple dementi^, such 
 as has been described in the~ preceding pages. It 
 is generally met with as a sub-acute melancholia 
 with ideas of persecution. These last are in these 
 cases, necessarily absurd and puerile from the co- 
 existing dementia. The patients almost slwma 
 think that some one has a design against theii, 
 but especially that they are to be robbed ; this is 
 their ruling idea. Under the influence of this teh: 
 they rise in the night, hide everything they have in 
 places where later they are themselves unable to find 
 them, they barricade themselves in their houses and 
 in their rooms, and go so far, as it were automatic- 
 ally, as to accumulate in thefir night vessels, their 
 sheets, blankets, and gai-ments. 
 
 There may be also hallucinations of sight or hear- 
 ing, but confused and rudimentary as they always 
 are in demented conditions. 
 
 There is very little sleep or none at all; nocturnal 
 
INSAJSriTT OP OLD AGE. 337 
 
 noisiness and excitement ai"e nearly constant in these 
 patients. Their actions all cany the stamp of de- 
 mentia. They are : absurd and infantile thefts, like 
 those of general paralytics, but even more foolish ; 
 sudden and causeless fits of passion, ridiculous and 
 heedless attempts at suicide ; there are also especially 
 libidinous actions, obscene exhibitions of themselves 
 in public, attemps at rape, unnatural crimes, all result- 
 ing from lack of conscience and absolute loss of the 
 feeling of modesty. 
 
 The senile psychoses with cerebral dementia are 
 those in which the insanity is associated, not with 
 simple mental enfeeblement, but with the bodily and 
 mental symptoms of loss of power due to a more or 
 less diffuse lesion of the nervous centres, i. e., what 
 is called organic or apoplectic dementia. This will 
 be again referred to later on when discussing this 
 last, which does not fall in any absolute fashion 
 into the category of senile dementia. 
 
 With the exception of the simple insanities, those 
 of the first class, which are curable, the maniacal 
 form in particular, senile insanity is recovered from 
 only exceptionally. It is almost always necessary to 
 have recourse to isolation of the patient in order to 
 protect him from the dangers to which his delirium 
 and his dementia expose him. The treatment, prop- 
 erly speaking, is comprised in the medication for the 
 symptoms. It consists chiefly in intestinal deriva- 
 tion and the re-estalslishment of sleep by means of 
 the appropriate agents, 
 
338 INSANITY "WITH PHYSIOLOGICAL CONDITIONS. 
 
 § III. INSANITY OF MENSTKUATION. 
 (MENSTRtTAL Insanity. Catamenial Insanity). 
 
 In the majority of women, even in the physiological 
 condition, the return of the menses is accompanied on 
 each occasion, with intellectual and moral disturb- 
 ances, the frequency of which is so great that they 
 have ceased fo attract attention. It is usually more 
 or less excitement, a tendency to loquacity, to dis- 
 putation, to susceptibility, to passion, to caprice; 
 or, on the other hand, a depressed condition with in- 
 difference and apathy that is observed. 
 
 In certain cases these alterations of character, dis- 
 position and desires of women may reach a greater 
 intensity and attain the proportions of insanity. 
 The alienation, in these cases, may take on any form 
 whatever. In general it is a matter of a transient 
 attack of acute melancholia, or more often, mania, 
 lasting only through the period with which it is con- 
 nected and ceasing with it, essentially ephemeral and 
 consequently susceptible of being classed, strictly 
 speaking, in the transitory and periodic insanities. 
 "In some patients," says M. Ball, " the religious 
 ideas predominate, in others it is demonomania that 
 fills the scene. Lastly, there are women who have, 
 at each appearance of the menses, an attack of 
 nymphomania. " 
 
 We have had in view, so far, only normal men- 
 struation in the description of these phenomena, 
 
INSANITY OP MENSTB-D-ATTON. 339 
 
 As to the disorders of this function, and notably sup- 
 pression of the menses or amenorrhcea, and dysmen- 
 orrhoea, their action on the mental condition is still 
 more marked and frequent, and quite frequently 
 gives rise to insanity. Esquirol made them out to 
 be one-sixth of all the physical causes of insanity in 
 women. Every one knows of the case cited by that 
 author, of a young girl made insane on account of 
 suppression of the menses, who, on rising one morn- 
 ing threw herself on her mother's neck, crying out 
 that she was cured, her menses flowed freely and 
 reason was immediately re-established. I have 
 many times seen at the hospital St. Andre at Bord- 
 eaux, in the service of Dr. Lande, a young hyster- 
 ical female who, following suppression of the cata- 
 menia, had every month a palpebral ha3matidrosis, 
 and with this an attack of acute mania lasting 
 from two to three days, with daily exacerbations at 
 a fixed hour. In the interval her reason was perfect. 
 
 The psychic disorder frequently reveals itself by 
 irresistible impulses, by a tendency, sometimes peri- 
 odic, to dipsomania, erotism, theft, arson, homicide, 
 and especially to suicide. 
 
 On account of all these impulsions that may occur, 
 menstrual insanity raises an important point in legal 
 medicine. We should also never lose sight of this 
 fact while the question arises of the responsibility of 
 a woman guilty of a misdemeanor or crime, or even 
 of any very extraordinary behavior, committed at 
 the time of the catamenia or during the suppression 
 of that function, 
 
340 INSAIflTT WITH PHYSIOLOGICAL COUDITIOITS. 
 
 In a general way, catamenial insanity is almost 
 always judged by the effects of the return of the 
 menstrual flow, and when that appears without any 
 improvement of the mental condition, incurability is 
 to be feared. In the great majority of cases, the 
 return of the periods is consecutive to mental im- 
 provement, leading some physicians to neglect the 
 function and treat only the mental disorder. It is 
 better, however, in principle, to treat the cause, that 
 is, the menstrual disorder. It is rare that its disap- 
 pearance is not attended with a general check in the 
 disease, and following this a cure. 
 
 §IV. INSANITY OP PREGNANCY, OF PARTURI- 
 TION. OF THE PUERPERAL CONDITION AND 
 OF LACTATION. 
 
 (Pderpebal Insanity). 
 
 We designate under the name puerperal insanity, 
 the insanity connected with the various periods of~ 
 pregnancy, i. e. , gestation, parturition, the jjuerperal 
 condition and lactation. 
 
 Puerperal insanity is not very frequent in com- 
 parison with the number of parturient women. Its 
 principal cause is heredity, and it is very often the 
 case that the daughters of insane parents become 
 themselves insane on the occurrence of so important 
 an event as pregnancy. The accessory causes are 
 poverty, debility from loss of blood or anaemia, the 
 mental torment and anguish due to a false gtep, dlf- 
 
PTTEEPEEAL IlTSANlry. 341 
 
 ficult labor, suppression of the lochia or the milk, 
 and, finally, the enfeeblement from a prolonged lac- 
 tation. It is evident that former attacks of insanity, 
 whether connected with pregnancy or not, actively 
 predispose to puerperal insanity. There is a lack of 
 agreement of opinion as to whether or not primiparse 
 are more exposed than multiparas, and vice versa. 
 
 As regards the period in which puerperal insanity 
 appears, some authorities have made two varieties: 
 that occurring before labor {ante-partum insanity), 
 and that occurring after labor (post-partum) . 
 Others, like M. Ball, divide pregnancy into four 
 periods, and, therefore, from this point of view de- 
 scribe four varieties of puerperal insanity. 
 
 The clinical form taken by puerperal insanity is 
 always mania or melancholia. Most frequently it is 
 acute; but sometimes it is manifested in a hyper- 
 acute form, that is an acute delirium in the maniacal 
 form and stupor in the melancholic type. 
 
 The characters of the mania and melancholia con- 
 nected with the puei-peral state are in all respects the 
 same as those of simple mania and melancholia. 
 Marce, who made a special study of puerperal insan- 
 ity, says that it differs in no respect in its symptoms 
 from ordinary mania. ' ' I have proved in another 
 work," says he, " that the characters assigned to it, 
 such as the peculiar appearance, the odor of mice 
 exhaled by the patients, are due solely to the accom- 
 panying puerperal state, and the erotic manifestations 
 ia this morbid condition are far from having the 
 
342 tNSANlTY WITH PfiYSlOLOfilCAi CONDltlOUS. 
 
 value and frequency assigned them by some author- 
 ities." 
 
 There is no necessity, therefore, of describing 
 puerperal mania and melancholia in detail. It will 
 suiEce to point out at each stage of the physiological 
 process the forms of generalized insanity that may 
 occur, and the more or less striking peculiarities 
 they may borrow from the coexistence of this pro- 
 cess. 
 
 1. Peegnanct. — A great many women present 
 more or less marked intellectual and moral disturb- 
 ances during pregnancy without actually becoming 
 insane. It is hardly necessary to mention the long- 
 ings, the extravagant desires, the depravations of the 
 appetite (pica and malacia), and also sometimes the 
 tendency to theft, which are sometimes observed in 
 the pregnant.female. 
 
 The insanity of pregnancy, properly so-called, gen- 
 erally makes its appearance during the last three 
 months, and habitually takes the melancholic form, 
 especially the subacute (melancholic depression) or 
 acute form. Sometimes it ends at the time of labor, 
 but more often it continues during the puerperal 
 period. 
 
 2. Laboe. — Childbed insanity or that which 
 begins at the moment of labor is rather rare. Apart 
 from heredity,. it has for its causes, either a difficult 
 delivery, or the torments of a clandestine birth, or 
 eclamptic complications, and consists in a temporary 
 
PTTEEPBEAL INSAKITT. 343 
 
 transient delirium, generally of the maniacal type, 
 with sudden impulses, and especially with a tendency 
 to infanticide. Some cases have been reported in 
 which each uterine contraction was accompanied, in- 
 stead of a pain, with a sudden spell of excitement 
 that ceased whenever the pain was over. Such cases 
 are infrequent. 
 
 3. PuEKPBEAL CoiirDiTioN. ^Insanity connected 
 with the puerperal state, or puerperal insanity, prop- 
 erly so-called, is that which appears after delivery and 
 before the return of menstruation, especially about 
 the fifth or sixth day. It is, with the insanity of lac- 
 tation, the most frequent of all. 
 
 It is usually preceded by prodromata, such as ir- 
 ritability, general malaise, excessive anxiety, and 
 when the attack occurs it takes, three times out of 
 four, the form of mania, and chiefly the acute type. 
 
 It has been claimed that erotic tendencies and 
 obscenity are more marked in puerperal mania than 
 in any other form. We have seen, with Marc6, what 
 should be thought of this peculiarity, which is really 
 only a shade of difference not easily determined. 
 
 A symptom that seems more reliable, is the fre- 
 quency, in puerperal insanity whether of the maniacal 
 or melancholic form, of the perversion of the affective 
 sentiments, and especially the excessive morbid aver- 
 sion of the patient to her husband and children. 
 
 Puerperal melancholia takes also the acute or even 
 the hyperacute, that is, the stuporous form. Apart 
 
344 IKSANITT WITH PHTSIOLOGICAL CONDITIONS. 
 
 from perversion of the affective sentiments and pos- 
 sibly a more decidedly suicidal tendency it has no 
 characters peculiar to itself. 
 
 4. Lactation. — Insanity connected with lacta- 
 tion manifests itself in general towards the second or 
 third month of nursing. It has for its chief causes, 
 anaemia, poverty, and above all, the debility due to 
 lactation. It affects by preference, the types of acute 
 or subacute melancholia (melancholic depression). 
 
 Peognosis. — In a general way, puerperal insanity 
 is rather curable, especially a first attack, but less so, 
 nevertheless, than simple generalized insanity. That 
 occurring during gestation or during labor is the 
 most curable ; that occurring during lactation is, on 
 the other hand, more serious in its prognosis. It 
 may also be said that the maniacal form of puerperal 
 insanity offers-the best chances for cure. 
 
 There is no form more subject to relapses than puer- 
 peral insanity, and a first attack predisposes almost 
 inevitably to a second. Thus there are women who 
 have an attack with each pregnancy, sometimes of 
 the maniacal, sometimes the melancholic form. At 
 each attack the prognosis becomes more grave, and 
 it is rare that after a second or third attack the dis- 
 ease does not pass into the chronic condition. 
 
 The treatment is the same as that ordinarily em- 
 ployed in simple mania and melancholia, with such 
 special indications as are required by the condition 
 of the woman, the anaemia, the suppression of the 
 milk, the return of the catamenia, etc., etc. 
 
msAJsinr of the menopause. 345 
 
 §V. INSANITY OF THE MENOPAUSE. 
 (Cx-iMACTEKic Insanity). 
 
 The menopause, so justly called a critical epoch, is 
 a dangerous period for many women to traverse, and is 
 very frequently the occasion of intellectual and moral 
 perturbations, and psychic modifications, which may 
 sometimes go so far as to cause insanity. Nervous 
 women especially, and such as are predisposed to men- 
 tal disease, incur the danger of losing their reason at 
 this period. It is not an infrequent thing to see 
 those who are thus originally predisposed, but who 
 have been able to keep this tendency latent during 
 all their active life, in spite of all the physical and 
 moral shocks they have endured, become suddenly 
 insane at this time from the sole influence of the 
 physiological suppression of the menses. In others 
 who have already had one or two attacks of insanity, 
 the change of life is the occasion of a new attack or 
 relapse. This possibility is especially to be dreaded 
 for women whose first attacks of insanity were con- 
 nected with either puberty, menstrual disorders, or 
 pregnancy, in a word, with any one of the great pro- 
 cesses of sexual life, the influence of which we are 
 studying. For them, more than others, is the last step 
 of this sexual existence a difficult one. 
 
 Like the insanity of puberty and menstrual in- 
 sanity, the insanity of the menopause does not, to 
 tell the truth, present any special clinical physiog- 
 nomy, and the symptoms may be infinitely varied; 
 nevertheless, here also it is in the impulsive sphere 
 
 JlEST, Med.— 33. 
 
346 nsrsANiTT with phtsiological conditioks. ' 
 
 that the greatest disturbances make their appearance, 
 and the tendency to dipsomania, to theft, to homi- 
 cide, to arson, but still more to suicide, forms the 
 prominent feature of this disorder which is, as a rule, 
 melancholic in its type. The delusions often assume 
 the erotic or mystic type or are those of persecution, 
 and they are, in many cases, accompanied with 
 bizarre sexual hallucinations, such as were described 
 in the remarks on these symptoms. 
 
 Tiie critical age, which seems to exert so active 
 an influence on the development of insanity, some- 
 times, in certain more or less chronic cases, plays the 
 part of a crisis. At this time, it may be said, their 
 future is decided for good, when there yet remain 
 any chances of reason being restored ; that age once 
 passed they either recover and are thereafter protected 
 from attacks of insanity, or they are sunk irrevoca- 
 bly into incurability and dementia. 
 
 Insanity of the change of life is peculiar, so to 
 speak, to the female sex. Nevertheless men appear 
 to be sometimes subject to it, since, according to some 
 authorities, they have also their great climacteric 
 between the ages of fifty and sixty. In them, even 
 more prominently than in women, the symptoms of 
 the disorder consist chiefly in a state of constant 
 dread of some misfortune, the foar of damnation and 
 tendency to suicide, i. e., in melancholia of the 
 anxious type. 
 
 Insanity of the menopause is generally curable 
 and its duration is ordinarily limited to that of the 
 
INSAinTT or THE MENOPAUSE. 347 
 
 critical period. We can only call to mind excep- 
 tional instances where the insanity came on only after 
 the menopause and then manifested itself by periodic 
 attacks occurring at the epochs of the former mens- 
 trual periods. 
 
 The treatment of climacteric insanity is often very 
 diiSoult, as there is no absolute line of conduct here 
 to be followed, as in cases where the mental disease 
 is due to amenorrhoea. The chief indication, apart 
 from hygienic and moral treatment which must never 
 be neglected, is to direct the efforts against the nerv- 
 ous disturbances, the vaso-motor disorders and the 
 accompanying aniemia. Tonics, and external modi- 
 fying agencies (baths, douches, massage, electricity) 
 are the remedies best adapted to this end. 
 
Cbapter f . 
 
 INSANITY CONNECTED WITH LOCAL 
 VISCERAL DISEASE. 
 
 (Sympathetic Insanity). 
 
 §1. INSANITY DUE TO DISEASE OF THE GEN- 
 ITAL AND GEliTITO -URINARY ORGANS. 
 
 A. — Aitections of the Uteetjs and its Appendages. 
 (^Uiero- Ovarian Insanity). 
 
 If the physiological processes that have their point 
 of departure in the generative organs, are often the 
 causes of mental trouble, this is perhaps still more fre- 
 quently the case with their diseases. On account of 
 the direct connections that unite the sexual to the 
 cerebral life, there is not a single affection of the 
 genito-urinary apparatus that may not in time affect 
 the brain and cause mental disorder. 
 
 Thus in the male we often see onanism, seminal 
 losses, and disease of the urethra, especially blen- 
 norrhagia and blennorrhoea, affect the mind, depress 
 the spirits, and gradually produce, either hypochon- 
 dria or neurasthenia, or even a delusional melancholia 
 with suicidal tendency. Nevertheless, mental disor- 
 ders due to the affections of the sexual organs are 
 comparatively rare in the male, while, on the con- 
 trary, they are quite common in the female sex. 
 
DISEASES OF THE GENITO-UEIITAET SYSTEM. 349 
 
 The majority of women suffering from organic 
 disease of the uterus, fall gradually, in fact, inio 
 depression, moroscness, and hysteria; they change 
 in their characters, and become irritable to excess, 
 sometimes even passionate and violent ; occasionally, 
 indeed, they go a degree farther and pass fully into 
 the domain of insanity. According to general 
 opinion of observers the form taken by the mental 
 disease in these cases is most frequently melancholia 
 with a tendency to suicide. 
 
 It is in this variety of alienation especially that 
 we find, together with more or less pronounced erotic 
 and mystical notions, those queer liallucinations of 
 the genital sense, in which the patients experience 
 extraordinary sensations of a painfully pleasurable 
 kind, and which give a special character to their de- 
 lusions. These are the lunatics that make charges 
 of dishonorable liberties attempted, of their having 
 to undergo disgusting tests, that all kinds of objects 
 are introduced into their parts, that they are outraged 
 and made to experience the feelings of coition at 
 night, that they are pregnant and can feel the motion 
 of the infant, that they have animals in their bellies, 
 that they are about to be confined, etc. , etc. Some 
 of these also, in order to combat with all their might 
 these imaginary outrages, devise very extraordinary 
 methods of self -protection, they fasten their thighs 
 together at night, they tampon the vulva with old rags 
 or towels, and even introduce foreign substances 
 deeply in the vagina. Sometimes it is their own 
 
350 INSANITY WITH LOCAIi VISCERAL DISEASE. 
 
 account of their sensations that attracts attention to 
 the condition of their organs, and thus reveals the 
 true cause of the mental disorder, by the discovery 
 of some of their existing morbid conditions. 
 
 Most uterine affections are capable of engendering 
 mental disease, by sympathy, and it does not appear 
 that out of the whole number, any one has any 
 special influence more than the others in this regard. 
 
 Dr. Wiglesworth (1885), who made one hundred 
 and nine autopsies of insane women with particular 
 reference to this point, has obtained the following re- 
 sults : in forty-two the sexual organs were healthy or 
 without any appreciable lesion ; in sixty-seven there 
 were found more or less serious alterations. In 
 twenty-two cases the disease seemed to have no partic- 
 cular connection with the insanity. In the other forty- 
 five there was one case of absence of the uterus ; four 
 cases of conical cervix with pinhole os ; four cases of 
 retroversion ; five of retroflexion ; and one of retro- 
 flexion and retroversion combined; one case of pro- 
 lapsus; six of increased volume of uterus; six of 
 fibroma ; six of chronic peritonitis ; one case of hyper- 
 trophy with induration of the lips of the cervix ; one 
 case of uterine cancer; nine cases of diseased ovaries 
 and tubes. Fibroid tumors and displacements of the 
 womb, together with alterations of the ovaries or 
 their total ablation, seem therefore to be the lesions 
 that have most influence on mental disorders. Sim- 
 ple ulcerations or granulations of the cervix with 
 or without leucorrhoea, however, are suflicient to 
 cause these same disorders. 
 
DISEASES OE THE GENITO-TIEINAET SYSTEM. 351 
 
 Very often, and I may say generally, the psychic 
 disorders follow exactly the phases of the utero- 
 ovarian symptoms, increasing with them or, on the 
 other hand, improving and disappearing as the latter 
 improve and disappear. There have even been cases 
 reported of the disappearance of insanity in cases of 
 prolapsus, as soon as the uterus was replaced with 
 a pessary. These facts, which are very curious, 
 establish firmly the relation existing between the 
 mental trouble and the uterine lesion, and the sub- 
 ordination of the course of the former to the pro- 
 cesses of the latter. 
 
 Nevertheless, this is not always the case, and we 
 may see either the uterine lesion disappear and the 
 mental disorder persist, or rather the intellectual 
 trouble disappearing while the uterine affection is 
 stationary. 
 
 It is none the less true that we should never lose 
 sight of the frequency of this sympathetic relation, 
 and should give attention to the condition of the 
 generative organs, not, perhaps as, Azam counsels, 
 in all cases of suicidal melancholia, but at least in 
 such patients as have delusions relating to these 
 organs or the strange sexual hallucinations which 
 have been mentioned in the preceding pages. 
 
 B. — Diseases of the Kidneys and Bladder. 
 (Bnghtie Insanity). 
 
 The relations of insanity with kidney disorders 
 have been long since observed, particularly by 
 
352 INSANITY WITH LOCAL VISCERAL DISEASE. 
 
 Las^gue, Koppen, Raymond, Pierret, and Bouvat. 
 It is, howe-\-6r, of late yearfs that attention has been 
 given to this question by several French physicians 
 who have discussed it in the Soci6te medicale des 
 hopitaux, and have recognized, vrith Dieulafoy, a 
 Brightic insanity. Unfortunately there have been 
 confounded, rather carelessly, all the psychopathic 
 conditions susceptible of coexisting with albuminuria, 
 whatever may be their form or origin. A foreign 
 alienist, Madame Alice Bennett, has recently made 
 ursemic poisoning one of the most frequent causes 
 of mental alienation, and as the starting point of 
 nearly all cases of melancholia (Amebic an Journal 
 OP Insanity, October, 1890). There is in this an 
 evident exaggeration, against which it is important 
 to protest. This is what M. Jeffrey has attempted 
 in an interesting clinical lecture which gives correct- 
 ly, from this point of view, the actual state of our 
 knowledge of the subject. {Bulletin Medical, 
 February, 1891). 
 
 According to M. Jeffrey, a capital distinction 
 must first be made between the nervous accidents of 
 acute delirious uraemia and Brightic or ursemic in- 
 sanity. 
 
 The first of these is an acute and transient delirium, 
 or to express it more correctly, a non-vesanic febrile 
 delirium occurring under the influence of an infec- 
 tious disorder accompanied by nephritis and fever. 
 
 Brightic insanity comprises the cases in which the 
 existing albuminuria is responsible alone for the in- 
 
DISEASES OP THE GENITO-trEINAEY SYSTEM. 353 
 
 sanity, and those where, by arousing a vesanic 
 predisposition, it simply brings into activity a latent 
 mental disorder. There are, consequently, two 
 species of albuminuric insanity. 
 
 In the first, albuminuria occurs in a person with 
 no antecedents of mental disease, either personal or 
 hereditary, but presenting a neuropathic predispo- 
 sition. Under its influence the brain suffers in a 
 special way from the urssmic intoxication ; nutrition is 
 vitiated and insufficient, and a quiet, mild delirium, 
 very closely allied to dementia, may appear, continue 
 as long as the albuminuria, increase or diminish with 
 it, and even disappear if the patient recovers from 
 the bodily disorder. 
 
 In other cases, always appertaining to the same 
 species, vascular lesions occur under the influence of 
 the albuminuria, such as hsemorrhagic or necrobiotic 
 lesions of the brain, and the dementia thus due to a 
 profound organic alteration may still be aggravated 
 with the fluctuations of the albuminuria, but it can- 
 not recover when that disappears. 
 
 According to M. Joffroy, there is a true Brightio 
 insanity developed, not because of a vesanic predis- 
 position, but by the long continued albuminuric in- 
 toxication disturbing the nutrition of the nej'vous 
 centres or even producing in them organic lesions. 
 These cases, however, are rare, and the insanity is of 
 an inactive type, dementia predominating. 
 
 In the second variety, we see a true insanity super- 
 vene in the course of an albuminuria, due mainly to 
 
354 IKSANITT WITH LOCAL VISCERAL BISEASE. 
 
 a hereditary vesanic taint, and only albuminuric in 
 that the kidney disorder is its exciting cause. It is 
 not albuminuric insanity but insanity aroused by 
 albuminuria. It may therefore take very different 
 forms. Some patients have hallucinations of sight 
 and hearing, others ideas of persecution and erotic 
 ideas, or religious delusions ; still others are maniacal, 
 melancholic or suffer irora.folie du doute, etc. 
 
 The distinction between these various conditions 
 is important in view of the prognosis. In acute 
 delirious ursemia, the mental symptoms generally 
 subside after a little time, and there is no necessity 
 of sequestrating the patient. 
 
 In the first variety of Brightic insanity, that 
 v^hich is due directly to the intoxication, we ought 
 not to advise asylum treatment, unless very guard- 
 edly ; the insanity, not of a dangerous type, follow- 
 ing closely the course of the albuminuria, may 
 improve as it improves, and sometimes disappear, in 
 case there are no profound organic cerebral lesions. 
 
 In the second variety, that where the albuminuria 
 is only the exciting cause, there is usually no partic- 
 ularly close connection between the evolution of the 
 psychic symptoms and the renal disease. This in- 
 sanity is, therefore, susceptible to the usual means of 
 treatment, especially isolation. 
 
 It goes without saying that in all cases, of what- 
 ever kind, milk diet used judiciously, forms an 
 important part of the treatment. 
 
 Like renal diseases, disorders of the bladder and 
 
DISOEDEES OF DIGESTIVE TEACT, ETC. 355 
 
 the urinary ducts seem to have a real influence on 
 the development of insanity. It seems established 
 that persons affected with lithiasis and particularly 
 with cystitis and retention of urine, are for the most 
 part melancholic, depressed and hypochondriacal, 
 passive and easily discouraged and sometimes even 
 driven to suicide. It is, in fact, well established 
 that the urinary function is very often the starting 
 point of morbid mental preoccupation, and that 
 chronic lesions of its organs of excretion, frequently 
 engender a more or less profound condition of sad- 
 ness, which may, after a time, end in insanity prop- 
 erly so called. 
 
 § II. INSANITY CONNECTED WITH DISORDERS OF 
 THE DIGESTIVE TRACTS, WITH DISEASE OF 
 THE LIVER AND WITH INTESTINAL PAR- 
 ASITES. 
 
 A. — Diseases of the Digestivb Tracts. 
 
 Direct relations exist between the mental condition 
 and that of the digestive functions. When the 
 latter are in any way disordered, it is rare, in case 
 the trouble persists, that it is not followed by a more 
 or less profound involvement of the intellect and 
 emotions. 
 
 Simple constipation, angina, and gastric uneasi- 
 ness are enough at times to cause depression, sad- 
 ness, melancholia with refusal of food, hallucinations 
 of taste, delusions and insanity. 
 
 Diseases of the intestines have also a very powerful 
 
356 INSASITT WITH LOCAX VISCEEAX DISEASE. 
 
 action on the development of mental alienation. 
 Esquirol, it is well known, affirmed that melancholia 
 was due to a displacement of the transverse colon. 
 Wichmann, Hesselbach and Greding have also made 
 the same observation. Bayle has also shown in his 
 thesis that enteritis and gastro-enteritis may produce 
 sympathetically cerebral disorders. Lastly Dr. Holt- 
 hof has shown that duodenal catarrh, especially after 
 it has passed into the chronic condition, gives rise to 
 a marked state of depression in the subjects ; but in 
 individuals already predisposed to neuroses, it may 
 become the source of more serious mental disorder. 
 In nearly every case the symptoms are those of 
 hypochondria; at other times it develops into a reg- 
 ular melancholia, with ideas of persecution, of unwor- 
 thiness, with morbid exaggeration of conscientious- 
 ness, etc. , etc. , or else the patients become unquiet, 
 fretful, quarrelsome and excessively irritable. 
 
 Alterations of the peritoneum and its folds, the 
 mesentery and the epiploons, may also give rise to 
 mental troubles. 
 
 The majority of the gastro-intestinal affections, 
 innocent as they may be in appearance, are therefore 
 liable to engender mental alienation. But of all those 
 that can thus react on the intelligence, the most im- 
 portant with the exception of cancer which is a gen- 
 eralized disease, is certainly dyspepsia, which takes 
 in this regard the foremost place. 
 
 All or nearly all of the dyspeptics present in some 
 degree, either nervous disturbances (gastro-intestinal 
 
DISOEDEES OF DIGESTIVE TEACT, ETC. 357 
 
 neurasthenia), or mental disturbances, such as 
 eccentricities of character, attacks of depression, 
 marked tendency to irritability, and attacks of tem- 
 per, and a propensity, often irresistible, to suicide 
 and to dipsomania. It is not uncommon to see dys- 
 pepsia bring on mental alienation, and it is especially 
 in these cases that the chronic gastric disorders 
 improve with the appearance of the insanity, to 
 reappear when it, in its turn, has passed away. 
 
 It should be added, for the sake of completeness, 
 that the dyspeptic troubles, whether they are the 
 actual cause of the insanity, or occur in persons 
 already insane, usually give rise to two mental 
 symptoms that are almost characteristic. These 
 symptoms are : (1) the refusal of food, so intimately 
 connected with dyspepsia, which is not a mere 
 sitiophobia not connected in any degree whatever 
 with gastric disoi-ders. The second symptom 
 consists in the almost constant existence of these 
 disorders of the sensibility which have been called 
 internal hallucinations and illusions, and which lead 
 the patients to believe that their stomachs and 
 abdomens are the seat of extraordinary diseases, that 
 they have been poisoned, that their food smells of 
 phosphorus and arsenic, that they have living animals 
 in their abdomens, that they smell badly, that they 
 are rotten, etc., etc. Theusualresnlt of this mental 
 condition is a suicidal tendency, which is, in fact, 
 quite marked in insanity of gastric origin. 
 
 The prognosis of the mental disease in all these 
 
358 INSANITY WITH LOCAL VISCEEAL DISEASE. 
 
 cases is entirely dependent on the nature and tlie sever- 
 ity of the organic disease that gave rise to it. It 
 is therefore only really serious in those which are in 
 their nature but slightly susceptible of cure. The 
 other symptomatic disorders yield readily, and the 
 cases of refusal of food, spoken of above, under the 
 influence of medication, cause the disappearance of 
 the visceral trouble itself. 
 
 B. — Diseases of the Livbu and Biliabt Ducts. 
 (Hepatic Insanity). 
 
 Affections of the liver and its annexes play a 
 rather important part in the production of sympa- 
 thetic insanity ; their action has been admitted from 
 all time, and the ancient theory that made the liver 
 the exclusive starting point of melancholia, is, at 
 bottom, only the exaggeration of the actual influ- 
 ence of that organ on the mind. Still in our time 
 some authors. Burrows and Hammond among them, 
 assign to hepatic disorders one of the first places in 
 the development of mental alienation. 
 
 Among the affections of the liver that appear to 
 really influence the mental condition, hypertrophy 
 and especially abscess appear in the first rank. 
 
 Without going so far as Professor Hammond who 
 attributes nearly all cases of hypochondria and mel- 
 ancholia to abscess of the liver, it ought to be recog- 
 nized that the affections of this organ may become 
 under certain conditions the starting point of mental 
 
DISOEDEES OF DIGESTIVE TKACT, ETC. 359 
 
 disturbances that usually take the characters of mel- 
 ancholia and hypochondria. 
 
 Besides hypertrophy and abscess, the principal les- 
 ions of the liver that have been noticed in the insane 
 are tubercles of various sizes disseminated in the par- 
 enchyma of the gland, fatty degeneration, hydatid 
 cysts, adhesions to the diaphragm, and finally vic- 
 ious conformation and abnormal situation of the 
 organ. 
 
 The organic affections of the gall-bladder and 
 biliary ducts act probably in the same manner as the 
 lesions of the liver itself. In some cases there have 
 been found obstructions of the duct, in others the 
 gall-bladder was atrophied and filled with a slightly 
 viscous and almost colorless liquid. 
 
 Hepatic calculi are extremely common in the in- 
 sane, especially in melancholiacs and hypochondriacs, 
 and there is no observer who has not found them at 
 the autopsies of these patients, often in considerable 
 number and of a size that surprises one at their slight 
 effect during life. 
 
 C. — Helminthiasis (Intestinal Worms). 
 ( VermiTuma Insanity). 
 
 Although worms, the presence of which is rather 
 often evidenced by various nervous symptoms, may 
 locate themselves in any portion of the body, the 
 psychic phenomena they produce seem to find their 
 natural place among the sympathetic insanities con- 
 nected with lesions of the abdominal organs, on 
 
360 INSAiaTY WITH LOCAL VISCEEAL DISEASE. 
 
 account of the marked predilection of these entozoa 
 for those organs, and also on account of their more 
 decided action on the state of the intelligence -when 
 they occupy the intestine. Moreover, the presence of 
 worms in the different portions of the digestive tracts 
 is generally associated with more or less alteration of 
 these parts, which aids in their action on the develop- 
 ment of insanity. 
 
 It was in the beginning of the present century 
 that certain authors, imbued with the ideas of Pinel 
 on insanity by consensus, began to attribute some 
 importance to intestinal worms as a factor in the 
 production of mental disease. Prost, in his " Cotcp 
 cPceil physiologique sur la folie" warmly upheld 
 their importance and, like all advocates of new views, 
 carrying things to extremes, he made insanity depend 
 in the majority of cases on the presence of intestinal 
 parasites. Generalizing on the facts he had observed, 
 and making them serve for the erection of a com- 
 plete theory, Prost held that very often the humors, 
 and particularly the bile, became altered, and that 
 it was in the bile, thus changed, that the worms 
 originated whose presence ultimately gave rise to 
 the troubles of the intelligence. This subordination 
 of the origin of the parasites to a morbid condition 
 of the abdominal organs, approached closely, as we 
 see, to the theory of the origin of insaaity by alter- 
 ations of the liver or digestive tracts. 
 
 Prost's ideas, too exclusive as they were. Were not 
 accepted, even in his own times, without some reser- 
 
DISOEBEES 01* DIGESTIYE TEACT, ETC. 3G1 
 
 vations. Since then attention has been repeatedly 
 di'awn to the subject ; some cases have been published, 
 and it is genei'ally admitted at the present time that 
 intestinal worms may, under certain circumstances, 
 develop insanity by sympathetic reaction. 
 
 Dr. Vix, who has made a special study of helmin- 
 thiasis in the insane, has ascertained that convulsive 
 nervous affections, eclampsia, hysteria, etc. , are, of all 
 nervous disorders, the most common with these par- 
 asites. When a mental disorder is produced it is gen- 
 erally hypochondria or mania. According to the 
 same authority, certain mental dispositions and impul- 
 sions are peculiar to insanity connected with hel- 
 minthiasis, and these will vary according to the 
 locality of the parasite, the reflex action on the 
 brain changing, in fact, according to the region 
 of the body infested. Thus in the insane who ex- 
 hibit these psychic peculiarities, eight out of every 
 hundred are troubled, according to Vix, with worms, 
 and among the others we do not find marked animal 
 instincts or the tendency to skatophagy, i. e. , eating 
 excrement and filth, which would appear to indicate 
 that these symptoms are more common in mental 
 disease connected with helminthiasis. 
 
 Some disturbance of the sensibility is commonly 
 met with in these cases, especially hypersesthesia, 
 and in some instances various perversions of the gus- 
 tatory sense. Genital excitement is also frequent, 
 also hemeralopia which seems to be specially con- 
 nected with the presence of oxyurus. 
 
 Mext. Med.— 33. 
 
362 INSAKITT WITH LOCAL VISCERAL DISEASll. 
 
 Helminthiasis is also sometimes accompanied with 
 nervous symptoms or such general phenomena as 
 convulsions, pupillary dilatation, palpitations, tin- 
 nitus, weakness of the limbs, cachectic pallor, etc. 
 Moreover, (always according to Dr. Vix) , it is more 
 frequently followed by insanity in the female than in 
 the male sex. Finally, in the former, trichocephalus 
 is most common, in the latter oxyurus. 
 
 Verminous insanity is not commonly obstinate, 
 and yields readily to antihelminthics. Some worms, 
 nevertheless, are very difficult to get rid of, and 
 have, moreover, a tendency to recur, which compli- 
 cates the prognosis to a certain extent and makes 
 relapses possible. 
 
 §ni. DISEASES OF THE CIRCULATORY 
 APPARATUS. 
 
 A. — Diseases of the Heart. 
 {Ccwdiac Insanity). 
 
 Affections of the heart have, rather frequently, an 
 injurious effect on the mind and are capable of pro- 
 ducing various disorders of the ideas and the 
 emotions, from simple change of character and rudi- 
 mentary morbid conceptions to confirmed insanity. 
 
 The so-called cardiac insanity is not, properly 
 speaking, a sympathetic insanity, certainly not if we 
 hold strictly to the signification of the term sympa- 
 thetic. Nevertheless, since it is hardly possible to 
 point out exactly what cerebral circulatory disorders 
 
DISEASES 01" THE CIECtTLATOR-? APPAEATUS. 363 
 
 are produced in cardiac disease, and since, on the 
 other hand, the disorders of the circulation that are 
 constant as symptoms of the heart lesions are far 
 from causing delusional or vesanic symptoms in all 
 cases, we must recognize that the nervous system is 
 a potent agent, if not the principal one in the pro- 
 duction of cardiac insanity, and this permits us to 
 continue to consider this variety of alienation as a 
 sympathetic insanity in the wider sense we have 
 given to the term. 
 
 All diseases of the heart may produce mental 
 alienation; but those whose action in this way seems 
 most frequent are mitral and aortic lesions. The 
 lesions of the other cardiac orifices may, neverthe- 
 less,- have a certain role, and M. Duplaix has re- 
 ported in VEnc4phale a case of insanity, with 
 agitation, hallucinations of sight and hearing, and 
 ideas of persecution, that was plainly connected 
 with a tricuspid insufficiency. 
 
 Cardiac insanity takes on most frequently the 
 melancholic form, at least in case of mitral affec- 
 tions, as, according to certain authors and especially 
 M. d'Astros, who has supported this view, the 
 aortic cases are those of the excited types, and the 
 mitral ones the depressed ; so that the former tend 
 rather to mania in all its forms, and the latter to 
 melancholia. 
 
 The depression in these patients reaches occasion- 
 ally the condition of stupor ; the tendency to suicide, 
 already noticed by Corvisart, is frequent; there is 
 
364 INSAKITY WITH LOCAL VISCEEAL DISEASE. 
 
 finally a marked tendency to impulsive and morbid 
 acts, such, in particular, as fits of passion and violence. 
 
 The delusions, which are very variable, have here 
 no special type, but it appears nevertheless that per- 
 secutory ideas are specially common in cardiac insan- 
 ity, or they form frequently the basis of the insanity. 
 As regards hallucinations they are very frequent 
 in this mental condition, and they may, in this case, 
 have some relations as to nature and character, with 
 the organic affection, as, for example, in the patient 
 with heart disease, I have elsewhere referred to, who 
 heard a voice speaking to him in his heart. Deventer 
 [Centralblatt, 1888) has also noted the existence in 
 cardiac patients, of auditory hallucinations synchron- 
 ous with the cardiac beats. 
 
 Cardiac insanity is a form with sudden oscillations, 
 intermittent or rather remittent in its conduct and 
 manifestations. The mental disorders are commonly 
 subordinate to the influence of the heart affection. 
 They are most pronounced at the times of exacer- 
 bation of the bodily disease. Sometimes, on the 
 other hand, we observe a sort of inverse equilibrium 
 between the somatic cardiac disorder and the intellec- 
 tual troubles. 
 
 Cardiac insanity is serious, because its cause, the 
 heart affection, is permanent and incurable. The 
 attacks of insanity, which, as has been remarked, 
 usually assume the intermittent or remittent type, 
 usually are recovered from, but as a rule they re- 
 appear and they are very liable to relapses. 
 
DISEASES OF THE CIECTTLATOET APPARATUS. 365 
 
 The mental disorders that sometimes accompany 
 the later stages of asystoly have not been mentioned. 
 In these cases we do not have a real insanity, but 
 a sort of toxic delirium analogous to that of the last 
 stages of phthisis. 
 
 In a recent clinical lecture (Bulletin Medical, 
 March, 1891), M. Huchard has shown that true 
 cardiac insanity, which he distinguishes according 
 as it occurs with or without asystoly, is compara- 
 tively rare, and that it is of importance n6t to con- 
 found it with certain deliriums that occur in patients 
 with cardiac disease, such as cardio-renal delirium, 
 due at once to asystoly and uraemia, the drug delir- 
 iums (digitalis, belladonna, etc.), and the arthritic, 
 alcoholic, hysterical and puerperal deliriums. These 
 various forms have besides a physiognomy of their 
 own that allows them to be recognized with proper 
 attention. 
 
 B. — Diseases of the Blood-Vessels. 
 
 Diseases of the blood-vessels rarely give rise to in- 
 sanity properly so-called. We have in these cases 
 more of dyscrasic disorders involving the intelligence, 
 or, more frequently still, as with arterio-sclerosis, 
 direct cerebral lesions giving rise to more or less 
 pronounced symptoms of dementia. Occasionally, 
 however, we meet with a true insanity, made up 
 usually of hypochondriacal ideas, ideas of persecution 
 and accompanied with internal hallucinations. It 
 is io cases of aortic aneurism especialljy that this is 
 
366 IN-SANITT WITH LOCAL VISCERAL DISEASE. 
 
 met with, as has been recently demonstrated by Dr. 
 Mickle {Brain, 1889). 
 
 § IV. DISEASES OF THE LUNGS. 
 
 Except in tuberculosis, the mental disorders of 
 which are studied in connection with the insanities 
 of the infectious diseases, the local aflfections of the 
 lungs are only exceptionally accompanied with insan- 
 ity, and we see in them hardly anything more than 
 transitory attacks of febrile or alcoholic delirium. 
 
Cbapter f ir. 
 
 ESrSANITIES ASSOCIATED WITH GENERAL 
 DISORDERS. 
 
 (Acute and Chronic Infectious Diseases. Diatheses). 
 
 §1. INSANITIES OF THE INFECTIOUS DISEASES. 
 
 Infectious diseases may aid in the development of 
 insanity by a triple meclianism recently explained 
 by M. Chardon in an interesting study {Thhse de 
 Lille, 1889.) They may act: (1) by the direct ac- 
 tion of the microbes, localized in the nervous 
 centres ; (3) by the action of products secreted by 
 the microbes; (3) by auto-intoxication by products 
 not duly eliminated by the patient. 
 
 Regarding them in their relations with mental 
 alienation, we may divide the infectious diseases into 
 acute and chronic. 
 
 Acute Infectious Diseases. 
 
 (VAEIOLA, MEASLES, SCAELATINA, DIPHTHEBIA, SWEATING SICKNESS, EBT- 
 SIPBLAS, CHOLEBA, TTPHOID TEVEB, HTDEOPHOEIA, INPLUENZA). 
 
 I. — Variola. 
 
 The eruptive fever most frequently complicated 
 with insanity is variola. 
 
 The times when this complication appears are by 
 preference, the time of the appearance of the eruptiou 
 
368 INSANITIES WITH GENEEAL DISOEDEES. 
 
 and that of convalescence. It may nevertheless show 
 itself during incubation and during the stage of sup- 
 puration. 
 
 The most usual clinical form at the eruptive 
 period is acute mania with violent agitation, inco- 
 herence, disordei'ed action, active fever; at conva- 
 lescence, on the other hand, the melancholic form is 
 more common, generally acute or subacute melan- 
 cholia, with profound depression and almost always 
 with suicidal tendencies. The frequency of suicide 
 in variolous delirium has been often noted. 
 
 The attacks of insanity connected with convales- 
 cence fi'om small-pox have some analogies with those 
 we obsei"ve at the decline of typhoid fever, and like 
 those, but in a less marked degree, they present, as 
 regards the accompanying delusions and hallucina- 
 tions, a stamp of absurdity and silliness with mental 
 obtuseness that imprints upon them an altogether 
 characteristic physiognomy. As to those that occur 
 in the course of the disease, it is not rare to see them 
 announced by a decrease of the febrile symptoms 
 which may be mistaken for a real amelioration. 
 
 The prognosis of insanity connected with variola 
 is generally good and the attack is commonly re- 
 covered from. Nevertheless, there may occur a fatal 
 acute delirium in the eruptive stage, and in the con- 
 valescent stage the insanity may assume a chronic 
 type and terminate more or less rapidly in dementia. 
 We need not mention here the influence of variola 
 on the course of a pre-existing insanity; that subject 
 
INSANITIES OF THE INFECTIOUS DISEASES. 369 
 
 appertains to general pathology, to that part on in- 
 cidental affections. We will confine ourselves to 
 the remark that variola, and in a general way all the 
 acute febrile disorders may, in certain cases play the 
 part of crisis and bring about the cure or the 
 amelioration of the insanity. 
 
 Measles, scarlatina and diphtheria only rarely pro- 
 voke an attack of insanity and when they are accom- 
 panied with intellectual derangement, it is, in the 
 first named, more especially a febrile, and in the 
 last a sort of asphyxic delirium that we encounter. 
 We need only refer also to sweating sickness in 
 which Brouardel has noted the possibility of maniacal 
 or melancholic disorders. (Ejjidemic of Poitou, 
 1887). 
 
 It is well known that erysipelas, especially that of 
 the face and scalp, is almost constantly accompanied 
 with a febrile or, in topers, with an alcoholic delirium 
 In a few rather rare cases it may give rise to an 
 attack of genuine insanity. 
 
 As in variola, the attacks of insanity in erysipelas, 
 occur by preference in the acute stage of the dis- 
 ease, nearly always under the form of acute mania 
 or acute delirium; or during convalescence, under 
 the form of melancholia with depression, hebe- 
 tude, various hallucinations, especially of hearing, 
 ideas of suicide, etc., etc. General paralysis itself 
 appears to be developed in certain cases, after 
 erysipelas of the face, 
 
370 msANITIES WITH GENEEAIi DISOKDEES. 
 
 The only peculiarity to be mentioned in connection 
 with insanity due to erysipelas is that, on account 
 of erysipelas being a disorder likely to recur, an 
 attack of insanity from this cause creates a trouble- 
 some precedent that makes us foresee other attacks 
 in case of the recurrence of the erysipelas. There 
 have even been cases reported of mania following 
 facial erysipelas cured by the appearance of a new 
 erysipelatous attack. 
 
 S. — Cholera. 
 
 The possibility of vesanic complications in cholera, 
 especially at the period of convalescence has been 
 often noted. The more usual clinical forms are: 
 acute mania, with or without exalted delusive ideas, 
 melancholia accompanied with vague ideas of per- 
 secution and tendency to suicide, and, lastly, stupor. 
 
 Although insanity is a complication of the cholera, 
 it usually recovers ; indeed it has been remarked that 
 it habitually occurs only in those cases of cholera 
 which should terminate in recovery. 
 
 i. — Typhoid Fever. 
 
 The insanity of typhoid fever is the typical in- 
 sanity of those due to infectious diseases. On ac- 
 count of its importance, its relative frequency, and 
 the number of papers its study has caused to be 
 written, it merits our attention. 
 
 First of all we may remark that febrile, non- 
 vesanic delirium is very common in typhoid fever, 
 and is never lacking in severe cases, It ip usually 
 
INSANITIES OP THE INFECTIOUS DISEASES. 371 
 
 easy to recognize by the febrile characters it presents ; 
 nevertheless cases have been reported, and this seems 
 rather peculiar to typhoid fever, in which this de- 
 lirium becomes systematized and made up entirely, 
 so to speak, of hallucinations, in such a way as to 
 offer some analogies to the delirium of insanity. 
 
 The genuine insanity is not altogether rare — 43 
 cases in 2,000 patients (Nasse) ; 33 cases in 500 
 (Schlager) ; 11 cases in 3,000 (Christian) — and, as in 
 most febrile affections, it may supervene either 
 during the course of the disease or during its 
 decline. 
 
 Marandon de Montyel in an interesting paper, 
 has made a classification of the deliriums of typhoid 
 fever, which he divides into pertyphic deliriums, 
 comprising those of the initial stage, the period 
 -of culmination and, that of convalescence, and 
 thspost typhie deliriums either mediate or immediate. 
 All these divisions, although they have been ac- 
 cepted by some authorities, seem to me unnecessary, 
 and I limit myself to admitting one insanity occur- 
 ring in the course of the dothienteritis, or a pertyphic 
 insanity and one of convalescene or a post-typhic 
 insanity. 
 
 Pertyphic insanity is rather rare. It consists 
 almost always in an acute or hyperacute mania com- 
 bined with phenomena of excitement and depression. 
 These attacks, as has been remarked when speaking 
 of the eruptive fevers, may announce themselves by 
 illusive symptoms of improvement. According to 
 
372 mSANITIES WITH GENERAL DISOEDEES. 
 
 Kra3pe]in they are followed by death in at least one 
 quarter of the cases. 
 
 Post-typhic insanity, or that of convalescence, is 
 more common. The time of its appearance is vari- 
 able. It may appear either at the decline of the dis- 
 ease, when the febrile movement becomes less intense, 
 or later, during convalescence. It may even shoW 
 itself after apparent restoration of health and when 
 the patient has been out repeatedly. 
 
 The appearance of insanity after typhoid fever does 
 not necessarily iudicate that the affection has been 
 very severe or that it has been of the adynamic type; 
 it may occur even after mild cases of short duration. ^ 
 As has been recently said with truth, insanity is more 
 frequent in certain epidemics of typhoid than in 
 others, which fact seems to indicate that, aside from 
 individual predispositions, certain epidemics seem to 
 be specially predisposed to this complication. 
 
 The three states of alienation that may occur in 
 the decline of typhoid are: intellectual obtuseness 
 or pseudo-dementia, mania, and melancholia. 
 
 Intellectual obtusion is only the morbid exaggera- 
 tion of the more or less marked and persistent 
 obscuration of the faculties and especially of the 
 memory, that is commonly left behind it by typhoid 
 fever. In this case it presents itself with all the 
 features of dementia, and may extend, in some 
 cases, as far as the complete abolition of the intelli- 
 gence. This is not, however, a true dementia ; it is 
 only a pseudo-dementia, an obscuration of the piind 
 
IKSANITIES OF THE INTECTIOUS DISEASES. 373 
 
 by excessive debilitation of the brain, since in al- 
 most all cases the mental faculties arouse themselves 
 more or less completely to their normal activity, 
 while the alterations of dementia are irreparable. 
 
 This intellectual obtusion or pseudo-dementia may 
 alone constitute the whole mental trouble, but it ex- 
 ists even when mania or melancholia follows the 
 fever, and it is the feature that forms one of the 
 principal characteristics of this kind of insanity. 
 
 Mania, in typhoid fever, occurs in the acute form 
 and more commonly still in the sub-acute form. The 
 frequency of more or less limited ideas of ambition 
 has been long since observed in these cases. 
 
 The special character that gives to this condition 
 and this form of insanity a special physiognomy, is 
 the constantly existing intellectual obtusion. This, 
 indeed, causes a condition of hebetude and mental 
 weakness that imprints on the whole mental dis- 
 order, the ideas and acts a stamp of characteristic 
 absurdity and stupidity. This peculiarity, together 
 with what we have said regarding the relative fre- 
 quency in these cases of ambitious and absurd con- 
 ceptions, and also the physical disorders, such as 
 muscular weakness, tremor, slowness of speech, 
 which may concurrently exist, may all together oc- 
 casionally give rise to some difficulties in the diag- 
 nosis of this condition from general paralysis. 
 
 The most frequent form of insanity in the con- 
 valescence from typhoid fever is melancholia. It is 
 commonly characterized by a more or less profound 
 
3'J'4 INSANITIES WITH GENifiEAL DISOEDBfeS. 
 
 depression, going in some cases as far as to stupor; 
 by confused hallucinations, especially of hearing ; by 
 delusions, chiefly vague ones of persecution or mys- 
 ticism ; and lastly by foolish acts and sometimes a 
 marked tendency to sitiophobia and suicide. As with 
 mania, that which gives it its special note, is the 
 character of dementia that presents itself in all its 
 symptoms and manifestations. 
 
 Summing up, the mental disorder of the convales- 
 cence from typhoid fever may be described as a con- 
 stant condition of pseudo-dementia, which forms the 
 basis of the intellectual condition, and upon which 
 sometimes supervene more or less acute attacks of 
 mania or melancholia. 
 
 Peognosis. — In spite of the bodily debility that 
 accompanies this condition and in spite of the ap- 
 parent gravity of the attacks they most generally 
 end in recovery, and it is the rule to see the insanity 
 following typhoid fever disappear. It is only in 
 rare cases that it persists and passes into the chronic 
 condition. 
 
 Pathogeny. — While nothing is absolutely certain 
 as regards this, it is probable that the pseudo-de- 
 mentia and attacks of insanity in the convalescence 
 from typhoid fever are connected with dynamic and 
 nutritive disorders of the nervous substance of the 
 brain. 
 
 Diagnosis. — Insanity following typhoid fever is 
 rather readily recognized by the character of de- 
 
mSANITlES OV VBE INFECTIOUS DISEASES. 'HtB 
 
 mentia it presents, the general obtusion of the whole 
 mental condition of the patient that is its chief 
 characteristic/ A correct diagnosis is therefore 
 comparatively easy even in the absence of any full 
 history. An important matter sometimes is to dis- 
 tinguish between the insanity from typhoid and a 
 general paralysis of the maniacal or melancholic 
 type, the more so since general paralysis may follow 
 typhoid fever. The difficulty is sometimes great 
 enough to cause some hesitation. Nevertheless, one 
 can generally rely on the fact that embarrassment of 
 sjDeech and inequality of the pupils are commonly 
 lacking in typhoid fever, and that the delusions are 
 more childish, silly, and limited, and less mobile 
 than they are in general paralysis. As to the de- 
 lirium that sometimes occurs in the beginning of 
 typhoid fever, it may be mistaken for an attack of 
 insanity, and this error has been committed. It is 
 needful as a general rule to distrust the deliriums 
 that appear suddenly complicating a fever, especi- 
 ally one with an evening exacerbation and a regularly 
 ascending temperature curve, which are usually only 
 febrile deliriums. According to Marandon de Mon- 
 tyel, the rejection with disgust of liquids is the best 
 differential sign of acute delirium from typhoid fever 
 and the beginning of maniacal delirium. 
 
 The treatment varies according to the case; the 
 chief indication is to tone up the system of the 
 patient in every way, with bitter tonics, hydro- 
 therapy, exercises, etc. 
 
376 INSANITIES WITH GENERAL DISOEDEES. 
 
 5. — Hydropliobia. 
 
 The mental disorders connected with rabies, de- 
 scribed by Brierre de Boismont, have been the sub- 
 jects of special studies of late years by Pierret, 
 Belous and Chardon. 
 
 In the beginning are observed insomnia, a special 
 form of headache (sensation of the head in a vice), 
 nightmare, general excitation pf the organism with 
 desire of locomotion, disorders of secretion and of 
 the saliva in particular. 
 
 Next appear the phenomena of agitation with hal- 
 lucinations, illusions, and delirium resembling alco- 
 holism. It is a plainly maniacal condition ; the patient 
 breaks and destroys everything, makes gestures and 
 utters cries according to his hallucinations and 
 illusions. 
 
 This period of general excitement of the nervous 
 system is followed by a period of depression and 
 paralysis. Then follow the typhoid phenomena and 
 death ends the scene. 
 
 Professor Pierret lays much stress upon multi- 
 ple paralysis, especially those of the jaws and of 
 the pharynx, as characteristics of hydrophobic 
 delirium. 
 
 6. — Oi'ippe or Influenza. 
 
 The relations of insanity with influenza were but 
 little studied prior to the late pandemic, a few 
 authors, such as Rush (1790) and Bonnet, of Bor- 
 deaux (1837), have merely noted the possibility of 
 
IKSAKITIES OP THE nSTECTIOTTS DISEASES. 37? 
 
 the appearance of mental alienation in consequence 
 of the grippe. 
 
 The epidemic of 1889-90, either because of its 
 assuming a special character, or because the facts 
 were better observed, has been noticeably accom- 
 panied by a great number of cases of neuropathic 
 or psychopathic disorders. It seems from the mem- 
 oirs published on the subject by French and foreign 
 authors, notably by Huchard, Joffroy, Krsepelin, 
 Metz, Bartels, Pick, Mairet, Ladame, etc., that 
 the insanity in influenza behaves exactly like 
 that of typhoid fever. Sometimes it appears 
 with the fever in the beginning, or even before 
 the grippal symptoms; sometimes on the other 
 hand, and this is more common, during conva- 
 lescence. In the first case we have usually a 
 violent maniacal attack with automatic agitation, 
 ordinarily of short duration. In the second case, 
 and in that form specially studied by Ladame under 
 the name of post-grippal psychosis, we have to do 
 with the j)henomena of cerebral neurasthenia, char- 
 acterized by hebetude and torpor, it may be with 
 actual melancholic or hypochondriacal attacks with 
 more or less pronounced mental obtusion. 
 
 In almost all cases the effects of the influenza are 
 combined with hereditary predisposition. Neairly 
 always also, the mental disorders, serious as they 
 appear, recover more or less quickly under the in- 
 fluence of a proper, and especially a tonic, medica- 
 tion. 
 
 Meht. Med. — 24. 
 
378 INSANITIES WITH GENEEAI, DISOEDEES. 
 
 The action of influenza on the insane themselves 
 has Leen very variable. In some asylums the 
 patients appeared altogether refractory to the epi- 
 demic, even when the personnel suffered severely; 
 in others they vs^ere attacked in great numbers by 
 the disease, without, as a rule, its exerting any action 
 whatever on the pre-existing insanity. 
 
 CHRONIC INFECTIOUS DISEASES. 
 
 (niTEEMITTENT PETEK, TUBERCULOSIS, PELLAGRA, STPaiUs). 
 
 1. — Intermittent Feveb. 
 {Paludal Insanity.) 
 
 Sydenham was the first to remark the possibility 
 of insanity being due to intermittent fever. Since 
 then, a great number of observers (Sebastian, Bail- 
 larger, Billod, Griesinger, Krsepelin, Laveran, 
 Bard, etc)., have taken up the subject, but it is 
 Professor Lemoine who has, of late years, made the 
 most complete study of it. (Lemoine and Chaumier, 
 Annales Medico-psychologiques, 1887). 
 
 We recognize with him: (1) the psychic disorders 
 of the febrile attack ; (2) those of convalescence from 
 intermittent fever; (3) those of chronic malarial 
 poisoning. 
 
 1. The attack of intermittent fever, even in its 
 least degree, may, in nervous or debilitated individ- 
 uals, be accompanied with insanity. It is then a 
 more or less noisy delirium, but essentially fugaci- 
 ous and sometimes periodic. It is in the pernicious 
 
cnnoNic rfTFECTioTrs diseases. 379 
 
 attacks that the psychic troubles are most intense 
 and dominate all other symptoms to the extent of 
 effacing them and making the diagnosis difficult. 
 After two or three febrile attacks accompanied by 
 general excitement, headache, and cries of pain, the 
 insanity makes its outbreak under the form of acute 
 mania. The agitation is excessive, the face flushed, 
 the pupils dilated, the arterial pulse strong, and 
 these symptoms increase in intensity until coma or 
 convulsions appear. Sometimes there is observed 
 a series of alternating phases of excitement and 
 stupor. When a favorable termination is about to 
 occur, general perspiration covers the body, the 
 patient becomes drowsy and goes to sleep ; when it is 
 to end unfavorably, coma supervenes and death 
 ensues. 
 
 Instead of coming on gradually the insanity may 
 break out suddenly, noisy and violent, especially in 
 the night. Finally, it may be accompanied with 
 convulsions, transitory paralysis, and aphasia, and 
 be followed by a more or less persistent condition 
 of hebetude after recovery. 
 
 2. The mental disorders occurring during con- 
 valescence from malarial fevers are better known. 
 Sometimes they appear immediately after the 
 disappearance of the malarial attacks or even 
 while they are still occurring, but more often 
 they appear only in that period of indefinite duration 
 in which the anaemic, enfeebled, and anorexic patient 
 is in constant danger of a relapse. 
 
380 ETSAOTTIES -WITH GEITEEAL DISOEDEES. 
 
 According to Sebastian and Baillarger tlie most fre- 
 quently observed form is stupor. It lasts for a varia- 
 ble period but recovery almost always occurs when the 
 patient has regained his strength, has recovered from 
 the anajmia, and has thrown off the fever. 
 
 Mania has also been observed at this period, and 
 Krsepelin has met with it alone, often accompanied 
 with exalted delusions. The prognosis here is more 
 sombre, and recovery, when it does occur, is always 
 delayed. 
 
 Sebastian finally, has described a form, character- 
 ized by attacks of insanity occurring every one or 
 two days, at the same hour and after the same fash- 
 ion as the jsreceding fever. The mania especially 
 has a character of periodicity, and is cured by the 
 use of sulphate of quinine. Since Sebastian there 
 have been no cases published in which an intermit- 
 tent insanity replaced the febrile attacks, but, as M. 
 Lemoine remarks, a certain number of cases in which 
 patients not suffering from malaria, presenting hal- 
 lucinations or insanity with regular intermissions 
 and cured by quinine, may be regarded as special 
 larvated accidents of a sensorial type. 
 
 3. The psychic disorders connected with chronic 
 malarial poisoning have hardly been studied at all 
 except by Krsepelin and Lemoine. The last named 
 has called attention to the cases where mental de- 
 rangement, although occurring in non-cachectic 
 individuals, is connected with former attacks of in- 
 termittent fever by a series of larvated phenom- 
 
CHEONIC INTECTlOirS DISEASES. 381 
 
 ena that leave no doubt of its malarial nature. In 
 some cases, moreover, as if to confirm the diagnosis, 
 the latent febrile symptoms reappear and bring with 
 them an exacerbation of the insanity. The insanity 
 of these patients is variable in type, resistent to 
 quinine, chronic and without any tendency to re- 
 covery. 
 
 M. Lemoine thinks that malaria, when super- 
 imposed on an arthritic basis, may cause in the long 
 run, the lesions and consequently the symptoms of 
 general paralysis, but the observed facts are still too 
 few to permit the settlement of the question. 
 
 2. — Tdberctjlosis. 
 {Inmnity of Tuberculosis). 
 
 Esquirol and Georget long ago remarked the fre- 
 quency of chest affections in the insane. Since then, 
 this interesting subject has led to the production of 
 numerous works, notably those of Burrows and Ellis, 
 Friedreich, Sohrcsder van der Kolk, Skae, Clouston, 
 Biaute, Ball, etc., whence it is clearly shown that 
 lung diseases, and tuberculosis in particular, have a 
 marked influence on disorders of the mind. 
 
 In many consumptives the intellect and character 
 are more or less affected. Sometimes we see an ab- 
 normal tendency to hypochondria or sadness, or on 
 the other hand, to satisfaction, to optimism, to a 
 feeling of well-being, to euphoria, as it has been 
 called. The patients become irritable, mobile to 
 excess, often also they give evidence of a remarkable 
 
383 rxsANiTiES with geneeal disoedees. 
 
 genesic excitation. Lastly they may give tliemselves 
 to the commission of morbid acts and to true impul- 
 sions, dipsomania for example. 
 
 As regards genuine insanity, it may occur in tuber- 
 culous cases in many different ways. Sometimes the 
 tubercular infection manifestly antedates the insan- 
 ity, which, once established, undergoes the same vicis- 
 situdes as the bodily disorder and follows a parallel 
 course. In other oases the appearance of the mental 
 disorder coincides with the amendment or the disap- 
 j)earance of the pulmonary symptoms and then we 
 see the two kinds of phenomena alternate and replace 
 each other. In other cases, finally, the insanity 
 breaks out suddenly without there having been any 
 prior indication to call attention to the state of the 
 lungs, the phthisis having up to the time taken on 
 the latent form it so frequently affects in the insane, 
 and to which the English have given the name 
 " florid consumption" on account of the appearance 
 of the patient and the coloration of the face, which 
 affords a striking contrast with the data obtained 
 by auscultation. 
 
 It is necessary to notice, finally, the attacks of 
 more or less transitory insanity or delirium that 
 occur in tuberculous patients in the last stages of their 
 disorder, and of which MM. Peter, Lucien, Leudet, 
 and B. Ball have reported interesting examples. 
 Here, however, as has been shown by these authors, 
 we have to do only with toxic phenomena due to 
 deficient hsematosis and to saturation of the blood 
 
CURONIC INFECTIOUS DISEASES. 383 
 
 with carbonic acid, that is to say with a delirium 
 that has nothing really to do with insanity properly 
 so-called. 
 
 Whatever its mode of commencement, the attack 
 of insanitj' connected with phthisis is variable in its 
 character. It is generally admitted, however, that 
 its most frequent form is that of lypemania. 
 
 Dr. Clouston pushing his analysis still further, 
 makes out that of all the varieties of alienation, the 
 most frequent one in consumptives is the mania of 
 suspicion (he might better say the melancholia of 
 suspicion). He adds also that this monomania of 
 distrust is more common in tuberculosis of the peri- 
 toneum than in that of the lungs. M. Ball has 
 given in his Logons a remarkable example of this 
 kind of insanity. 
 
 After this melancholia of suspicion, which often 
 presents itself under the form of lucid or conscious 
 insanity, the most common form in pulmonary 
 phthisis is acute melancholia, especially profound 
 melancholia, accompanied with suicidal tendencies 
 that persist for a long time, and refusal of food. 
 Mania and dementia follow after, and finally at the 
 bottom of the scale comes general paralysis. 
 
 Without discussing the question how tuberculosis 
 can of itself create this disorder, it is certain that, 
 whether latent or not, and it is generally latent, the 
 pulmonary affection influences the mental aspect of 
 the general paralysis. Clouston has remarked that 
 all tuberculous paretics began with a melancholic 
 
384 rNSANITlES WITH GENERAL DISOEDEES. 
 
 Stage and that it is in these especially that we 
 meet with the extravagant hypochondriacal ideas 
 described by M. Baillavger. 
 
 In those cases where the insanity presents itself in 
 its most frequent form, the following is, according to 
 Clouston, as reported by M. Ball, the usual method 
 of its manifestations. 
 
 The initial insanity appears as a mania or melan- 
 cholia. We observe excitement or depression, but 
 the acute stage soon disappears and the patient falls 
 into the chronic condition. He manifests an alto- 
 gether peculiar mental condition; he is the prey of 
 morbid irritability, a continual bad humor. He 
 is troubled with a mania of suspicion, and presents, 
 so to speak, a false insanity of persecution. There 
 is simultaneously a sort of mental weakness, a pro- 
 found aversion to work, a horror of movement. 
 
 This condition of depression is often traversed by 
 fits of passion. The patient becomes suddenly 
 angered without any reason, but his irritation does 
 not long continue. 
 
 Little by little the subject falls into a semi-de- 
 mented state, interrupted sometimes by periodic re- 
 missions, flashes of intelligence now and then appear 
 and it is in these consumptive insane, especially, that 
 we observe that singular return to rationality on the 
 approach of dissolution that has been noticed by so 
 many observers. 
 
 The cerebral lesions of phthisical insanity present 
 no striking peculiarities. According to Schtlle there 
 
CHRONIC rNTECTlOUS DISEASES. 385 
 
 is often a venous hyperasmia of the meninges witt 
 anaemia of the underljdng cortical substance. The 
 brain is pale and cedematous and shows hero and 
 there vascular irregularities. Under the microscope 
 we find fattj^ infiltration and rupture of some corti- 
 cal fibres. According to Clouston also, the specific 
 weight of the gray matter is very much diminished. 
 
 The insanity of consumptives is, as a rule, in- 
 curable. Half of the patients succumb within three 
 years from the commencement of the insanity. 
 Finally, it only very rarely has any favorable re- 
 action upon the phthisis, and in the vast majority 
 of cases, although the symptoms of phthisis remain 
 masked, the bacUlary evolution none the less pursues 
 its course. 
 
 The treatment is that of pulmonary phthisis. It 
 is needful, however, to keep iu mind that the insan- 
 ity may alternate with the lung symptoms and that 
 the disappearance of the one may cause the others 
 to disappear, which fact renders great caution ad- 
 visable. 
 
 3. — Pellagra. 
 
 {Pellagrous Insanity, Pellagrous General Paralysis). 
 
 Pellagra, as is well known, is a chronic infectious 
 malady, characterized essentially by a squamous 
 erythema, limited to the parts most exposed to light 
 and heat, by a chronic phlegmasia of the digestive 
 tracts, the principal symptom of which is an obsti- 
 nate diarrhoea, and, lastly, by a more or less grave 
 
3SG IN-SASITIES WITH GE^'EBAL DISOKDEES. 
 
 lesion of the nervous system, sometimes terminating; 
 in mental alienation and paralysis (Henry Gintrae). 
 Wc need not here take up the question of etiology 
 that has given rise to so many and so long discus- 
 sions both in France and Italy. It may only be re- 
 marked that atmospheric and geological causes, 
 heredity, and especially the use of maize altered by 
 a parasite called verderame or verdet, have all in 
 turn been charged with its origination. From all 
 the facts known, we may admit, with Lombroso, 
 that pellagra is the result of a special poisoning of 
 the organism by certain alkaloids of altered maize 
 {ma'isme). 
 
 Pellagrous Insastitt. — As far as the mental 
 symptoms are concerned, it is generally recognized 
 that the most frequent form of mental alienation in 
 pellagra, is melancholia. It exists, to a greater or 
 less degree, in most cases. It reveals itself by an 
 inertia, apassiveness, an indifference, a rather marked 
 torpidity; by insomnia, hallucinations, often of a 
 terrifying nature, of sight and also of hearing; by 
 depressive delusions and fixed ideas of despair, fear 
 and anxiety, and in particular so marked a tendency 
 to suicide and to suicide by drowning , that Strambio 
 has described the disorder under the name of 
 hydromania. In looking over the records of the 
 countries where pellagra prevails one readily notices 
 how many cases are found drowned each year. 
 This melancholic depression, which in some cases 
 
CHEOXIC IJTFECTIOtrS DISEASES. 387 
 
 may attain to stupor, has always a basis of obtusion, 
 of intellectual hebetude, that finally becomes per- 
 manent, and gradually terminates in dementia, as the 
 pellagrous cachexia progresses. 
 
 Pellagrous Gexeeal Paealtsis. — M. Baillar- 
 ger and some Italian authors have described a 
 special form of general paralysis, consecutive to the 
 pellagrous cachexia, the dominant mental symptoms 
 of which are dementia and depressive ideas. From 
 the numerous writings and discussions on this point 
 it is tolerably generally agreed to-day that we do 
 not have to do in these cases with a true general 
 paralysis, but rather with a pseudo-general paral- 
 ysis, with rather infrequent embarrassments of 
 speech; much such as is observed in the course of 
 syphilitic disease, or in certain chronic intoxications 
 such as saturnism or alcoholism (Baillarger, Annales 
 Med. psychol, 1888). 
 
 Pellagea in the Insane. — M. Billod noticed, in 
 1855, an epidemic of pellagra in the asylums of 
 Ille-et- Vilaine axidi Maine-et-Zioire, and since then in 
 numerous papers he has maintained the possibility of 
 the development of this disease during the course of 
 mental alienation. It is, however, generally agreed 
 that the erythema and various other troubles that 
 were presented by these insane are a pseudo-pellagra 
 and not a true pellagra. 
 
 Pellagrous insanity is one of the most grave vari- 
 eties, not in itself, but because it is the expression, 
 
388 mSAlTITIES WITH GEKEEAI. DISOEDEES. 
 
 in the sphere of the intelligeuce of a general disease, 
 progressive in its course, and inevitably ending m 
 cachexia and death. 
 
 The diagnosis of pellagrous insanity need not be 
 at all doubtful, on account of the other symptoms 
 of the general disorder. It presents no special in- 
 dications as regards treatment which is that of the 
 pellagra itself. 
 
 4. — Syphilis. 
 (Syphilitic Insanity, Syphilitic Paeudo- General Paralysis). 
 
 The question of the relations of syphilis and men- 
 tal alienation includes two factors : (1) syphilis and 
 insanity ; (2) syphilis and general paralysis. These 
 two parts of the problem have been long studied 
 abroad ; in France only the latter, and that of recent 
 times, has received much attention. 
 
 1. Syphilis and Insanity. — lu a rather large 
 number of syphilitic cases the morale is more or less 
 profoundly altered ; there are depression, moroseness, 
 hypochondria, melancholic prepossessions, disgust 
 with life, and sometimes even a tendency to suicide. 
 This is what we may call, from its analogy with 
 the rudimentary psychic troubles of certain diatheses, 
 the mental state in syphilis. 
 
 The insanity of syphilis, as appears from the in- 
 teresting historical studies of Morel-Lavallce and 
 Beliferes and of Parant, has been specially studied 
 during the past twenty years, by J. F. Duncan, 
 Grainger Stewart, Wille, Skae and Clouston, Hayes 
 
CHEOXIC INFECTIOUS DISBASES. 389 
 
 NewingtoD, Julius Mickle, Alf. Fourrier, Kiernan, 
 Goldsmith, Savage, Wiglesworth, Kinnier, and more 
 recently by the English and American alienists at 
 the Congress of "Washington (1887). The predom- 
 inant opinion is that syphilis may, in certain cases, 
 cause or favor the appearance of insanity but that 
 this insanity thus produced does not present any 
 special characters, that there is no syphilitic insanity 
 properly so called. Generally, moreover, syphilis 
 does not act alone in these cases, and there is almost 
 always hereditary predisposition and also other oc- 
 casional causes. 
 
 Insanity may appear either in the first stages of 
 syphilis or by j)reference during the secondary or 
 tertiary stages. 
 
 That occurring at the period of infection is very 
 rare. Goldsmith and Savage, who have reported a 
 fuw cases, attribute it rather to the moral influence 
 than to the specific effect of the disease. 
 
 The insanity of the secondary stage is more com- 
 mon. It appears especially with the accidents ac- 
 companied by fever, principally at the time of the 
 cutaneous eruptions. It is then an acute or subacute 
 attack of mania or melancholia, generally of short 
 duration and quickly yielding to specific treatment. 
 
 Its etiology may be attributed to multiple causes, 
 cachectic condition, mercurialization, poisoning, 
 hyperthermy, etc. 
 
 The insanity of the tertiary stage, or late insanity 
 of syphilis has been elucidated by Professor Fournier 
 
390 nsrsAinTiES with geneeal disoedees. 
 
 under the name of the mental type of cerebral syph- 
 ilis. It is the foi-m most frequently met with. 
 
 It ordinarily consists in a more or less acutely 
 melancholic state with various delusions, with pre- 
 dominating hypochondriacal ideas, notions of per- 
 secution" and 25oisoning, confused hallucinations of 
 taste, smell, and hearing, refusal of food, and tend- 
 ency to suicide. This is the depressive form of 
 Fournier. At other times (expansive form) it consists 
 in a maniacal condition, ranging from simple cere- 
 bral excitement to acute mania with automatic agita- 
 tion, incoherence, and violence. There is joined to 
 the vesanic condition nearly always a mental torpor 
 and obtusion of the faculties, that imprints a char- 
 acteristic stamp of hebetude on the manifestations of 
 the insanity, whatever its fonn. Often, indeed, 
 the mental disorder is limited almost solely to this 
 obtusion characterized by a sort of external stupidity 
 with apparent loss of ideas, recollections and senti- 
 ments, and which deserves, from its importance and 
 frequency, to constitute a third form of mental 
 syphilis under the name of the pseudo-demented or 
 torpid form. 
 
 The insanity of tertiaiy syphilis is usually due to 
 the action on the brain of more or less circumscribed 
 specific lesions, such as gummata, arteritis, meningo- 
 encephalitis, etc. Nevertheless, and Mickle lays 
 stress on this point, it may develop without any 
 alteration in the nerve centres and when only the 
 other organs arc seriously affected by syphilis. 
 
CHEOinC INPJICTIOtrS DISEASES. 391 
 
 In the great majority of cases the late insanity of 
 syphilis is recovered from, but there is often left a 
 more or less marked degree of mental weakness. 
 
 The diagnosis, difficult when the external man- 
 ifestations of syjshilis are lacking, must be made from 
 the antecedents which must be sought for with the 
 utmost care. In dubious cases resort should be had 
 to specific treatment, which is sometimes a veritable 
 touchstone. That is to say, the insanity of ter- 
 tiary syphilis, in spite of its apparent gravity, is 
 veiy amenable to specific treatment which should 
 in the main, consists of repeated mercurial frictions 
 and large doses of the iodides. 
 
 2. Syphilis and General Paralysis. — Here we 
 encounter the most important part of the question of 
 the relations of syphilis and mental alienation. Two 
 points require consideration: (1) Is syphilis a cause 
 of general paralysis ? (2) Does syphilis give rise to 
 cerebral conditions resembling general paralysis but 
 not identical with it, in other words, does it produce 
 a pseudo-general paralysis ? 
 
 The first of these may be left for the pi-esent as it 
 can be better discussed in connection with the causes 
 of genei-al paralysis, and we will confine ourselves to 
 saying that, in spite of the persistence of a certain 
 amount of difference of opinion as to this point, 
 syphilis tends, at the present time, to take a more 
 and more important place in the etiology of general 
 paralysis. 
 
393 INSANITIES -WITH GENEEAl DISOEDEKS. 
 
 SypJiilitic Pseudo- General Paralysis. — If there 
 is yet far from being general accord as to the i^art 
 that syphilis plays as regards genuine general paraly- 
 sis, there is nearly a unanimity in the admission that it 
 may produce morbid conditions closely resembling 
 that disorder. Even those who, like M. Magnan, 
 reject the theory of pseudo-general paralysis, recog- 
 nize fully that certain infections, such as syphilis, or 
 certain intoxications, such as alcoholism, are capable 
 of producing symptom complexes more or less similar 
 to that of the malady of Bayle, but that that is no 
 good reason they claim for the creation of the term 
 "pseudo-general paralysis." It is the word, there- 
 fore, rather than the thing that is objected to, and 
 as the term is convenient and has already passed 
 into current scientific language, it seems worth while 
 to retain it. 
 
 The expression "syphilitic pseudo-general par- 
 alysis" was proposed in 1879 by Professor Fournier, 
 but the morbid entity had been previously known. 
 Already in 1862 Zambaco remarked that "syphilis of 
 the brain may cause a general paralysis of movement 
 with also mental alienation, the paralysis resembling 
 and liable to be mistaken for paralytic insanity." 
 Later, in 1873, Lancereaux said in his turn : " Certain 
 syphilitic lesions of the brain may give rise to a 
 symptomatic total having a great resemblance to the 
 morbid conditions known under the names of general 
 pai-alysis and paralytic dementia." Finally in 1877, 
 Julius Mickle, in an important article entitled 
 
CHEONIC INFECTIOUS DISEASES. 393 
 
 " Syphilis and Insanity," affirmed that corebi-al syph- 
 ilis and general paralysis are two distinct disorders, 
 as is proven by pathological anatomy, but that the 
 difference is still more important in a clinical point 
 of view. He described, in particular, as distinctive 
 features of cerebral syphilis in its mental forms : the 
 habitual existence of hypochondriacal ideas in the 
 beginning and the rarity of exalted delusions ; less 
 pronounced dementia; absence of labial and facial 
 tremor, and slight degree of its appearance in the 
 tongue when it existed; more paralytic than ataxic 
 character of the embarrassment of speech ; obstinacy 
 of nocturnal headache ; frequency of ocular paralysis 
 with the inequality of the pupils (double optic 
 neuritis, atrophy of papillae, choroiditis, blindness, 
 strabismus, ptosis) and also of unilateral or localized 
 paresis ; physical cachexia often very marked ; irreg- 
 ularity of evolution. In his interesting Treatise on 
 General Paralysis of the Insane, (2d edition, Lon- 
 don, 1886), Mickle reproduced and developed the 
 characters of the differential diagnosis. 
 
 It was, however, the distinguished professor of 
 the Saint Louis who, in elucidating syphilitic pseudo- 
 general paralysis and in seeking to differentiate it 
 from true general paralysis, has called attention to 
 this question. According to him the principal points 
 of difference are the following : nearly always, if not 
 invariably, the delirium in syphilis is absolutely free 
 from the ambitious wanderings proper to general 
 paralysis; tremor is less common, especially of the 
 
394 HfSAIflTIES WITH GEITEEAX DISOEDEES. 
 
 tongue and upper lip, and is also less delicate ; the 
 motor disorders of a paralytic nature (hemiplegia, 
 monoplegia, facial hemiplegia, ocular paralysis) are 
 more frequent and more marked; the apoplectic 
 strokes and sudden paralyses, attesting a localized 
 lesion, often commence the trouble, while contrary 
 to the rule in general paralysis, the mental troubles 
 only appear later; the alteration of the general 
 condition, sometimes very precocious, with emacia- 
 tion, cachexia, peculiar facies (syphilitic appearance), 
 is more special to pseudo-general paralysis ; the lat- 
 ter, moreover, has a less regular and methodic evolu- 
 tion ; its progress is irregular ; its symptomatic mani- 
 festations and their succession are more variable; 
 it is impossible to determine its duration even approx- 
 imately ; finally, its cure is not usual or frequent, but 
 is possible.* 
 
 The anatomical lesions are also different in the 
 two disorders, and their difference consists especially 
 in the fact that in syphilitic pseudo-general paralysis, 
 the alterations, instead of predominating in the gray 
 substance, occupy essentially the meninges which be- 
 come adherent, through adhesive inflammation, to 
 the brain (meningo-cerebral symphysis, hyperplasio 
 meningitis, meningeal sclerosis). 
 
 Since then other authors have insisted on the 
 
 *In a more recent paper {Ann. de Payehlatrie et d'Hypnologle, 
 1893), Foumier apparently abandons Ms old views as to pseudo- 
 general paralysis. He says, In effect, that what he used to call syph- 
 ilitic pseudo-paresis' he now considers more correctly, at least inmost 
 oases, as genuine paretic doiuentia.— Tbanslatoe. 
 
CHEONIC INTECTIOUS DISEASES. 395 
 
 differential diagnosis of general paralysis and the 
 syphilitic pseudo-paralysis, notably Savage and Hurd 
 (Congress in Washington, 1887) and Motet (in Morel- 
 La\allce et Beli^res 1889). They have only con- 
 firmed the distinctive characters indicated, and nota- 
 bly the irregularity of its course and the possible 
 curability of syphilitic paralysis. 
 
 It follows from these data that the majority of 
 authorities admit under one form or another, a spe- 
 cific pseudo-general paralysis, separated from true 
 general paralysis especially by clinical differences, 
 which can be summed up as follows : dementia less 
 pronounced ; habitual melancholic delirium ; delusions 
 of grandeur less frequent, more coherent ; less embar- 
 rassment of speech, rather paralytic than ataxic; 
 tremor of lip and tongue often absent ; motor disturb- 
 ance of paralytic order more frequent; course more 
 irregular; dui'ation longer; recovery possible. If 
 we except the particular features relative to the 
 course of the disease, its duration and termination, 
 which are i)athognomoDic, we do not believe that 
 there exist any very evident differences between the 
 two conditions as regards morbid phenomena. In 
 any case, the differences are neither constant nor 
 important enough to legitimize such a purely sj'mp- 
 tomatic differential diagnosis as has been attempted, 
 and in this matter we agree with the lamented A. 
 Foville, who thought that the term syphilitic pseudo- 
 general paralysis should be reserved for cases where 
 different lesions have given rise to symptoms like 
 
396 rN'SANiTiEs -wirn gexeeal disoedees. 
 
 true paresis. To be able to say "pseudo-general 
 paralysis " there onglit in fact to be similar symptoms, 
 at least the essential ones should be the same ; and 
 lacking this the term pseudo-paralysis has no further 
 raisoii cVetre. 
 
 Without troubling one's self with more or less 
 problematical shades of difference between the symp- 
 toms of the two disorders, the designation syphilitic 
 pseudo-general paralysis may therefore be reserved 
 for those specific cerebropathies, which, while clinic- 
 ally similar to general paralysis, differ absolutely 
 from it as regards their course and prognosis, and 
 consequently in theii- lesions. True paresis has a 
 progressive course, a fatal prognosis, and incurable 
 lesions. The pseudo-paresis, whether it be infec- 
 tious as when from syphilis, or toxic as in alcoholism, 
 has a regressive course, a relatively favorable prog- 
 nosis, and curable lesions. Whenever this triple 
 condition of regressive course, favorable prognosis, 
 and curable lesions is realized in a morbid condition 
 similar in symptoms to general paralysis, we may 
 apply to it the name of pseudo-paresis. It is thus 
 we understand, for ourselves, the pseudo-general 
 paralysis in general and that from syphilis in partic- 
 ular. Although the term pseudo-general paralysis 
 itself is unacceptable, nothing is more easy than to 
 consider these conditions as general paralysis, but as 
 special forms to which may be applied the adjective 
 regressiuc, in opposition to genuine general paralysis 
 which is essentially progressive. 
 
DIATHESES. 397 
 
 However it may be considered, sypliililic pseudo- 
 general paralysis may present itself iinder any form, 
 demented, depressive or expansive. The character- 
 istic peculiarity, whatever may be their form, is tliat 
 the symptoms rapidly attain their greatest intensity, 
 and that sometimes the patients are demented and 
 filthy from the very beginning. Then, after a cer- 
 tain time, especially if under specific treatment, the 
 symptoms are observed to improve by degrees, and 
 there occurs an evident amelioration or even a gen- 
 uine recovery takes place. When we see, therefore, 
 in a syphilitic subject with or without a prodromic 
 apoplectic attack, a very rapidly appearing and pro- 
 found dementia with paresis, accompanied or not by 
 delusions, we should be on our guard for a syphilitic 
 pseudo-paresis, and institute at once an appropriate 
 course of treatment which will often be successful. 
 As to the lesions of syphilitic pseudo-paresis, they 
 cannot always be determined on account of the rela- 
 tive curability of the disorder, but from this fact 
 that they are not irremediable, we may assume that 
 they are usually neoplasms of rapid evolution, acting 
 by compression on the mass of the brain. 
 
 § II. DIATHESES. 
 (Diathetic Insanities). 
 
 The scientific conception of the word diathesis has 
 been considerably modified of late years, and its sig- 
 nification has been ma,de more precise at the same 
 
3D8 INSANITIES WITH GEWEEAL DISOEDEES. 
 
 time that it lias been limited under the influence of 
 some notable memoirs, in the first rank of which we 
 may place those of M. Oh. Bouchard. 
 
 Bouchard defines diathesis as: "a permanent dis- 
 turbance of the nutritional changes that prepares, 
 provokes, and maintains various diseases as to their 
 symptomatic forms, their anatomical locations, and 
 their pathological processes. The common bond of 
 these diflferent disorders, but of the same family, the 
 common cause that engenders and associates them, 
 is the general disturbance of nutrition, it is the dia- 
 thesis characterized by obstructed nutrition. A dia- 
 thesis is a morbid temperament." 
 
 I will speak here only of the intellectual disorders 
 connected with arthritism in general and with its 
 principal manifestations (rheumatism, gout, dia- 
 betes), and those rarer ones associated with cancer. 
 I have used to advantage in the preparation of this 
 part of the chapter the masterly article of Pro- 
 fessors Leraoine and Huyghes '■'■VArthritisme dans 
 ses rapports avec le JVervosisme." (Gaz. Mod. de 
 Paris, February, March and April, 1891), and also 
 the yet unpublished memoir of MM. Mabille and 
 Lallement on "ies FoUes diathesiques" recently 
 crowned by the Academy of Medicine, and which, 
 thanks to tlie kindness of the authors, I have been 
 able to consult. 
 
 AllTHKITISM. 
 
 Arthritism is a general vice of the organism char- 
 acterized by retardation of the nutrition (Bouchard), 
 
DIATHESES. 399 
 
 "It is made up of a host of manifestations that all 
 appertain to an arthritico-nervous cycle in which 
 we find, side hy side, migraine, epilepsy, gout, hys- 
 teria, rheumatism, diabetes, etc. It also includes 
 precocious atheromasia, and the arterites with angina 
 pectoris, all due to inflammations of special characters 
 and locations." (Pierret). 
 
 Arthritism is especially characterized by a ten- 
 dency to congestions {cUathhse congestif of Cazalis 
 and Senac). By reason of these frequent congestions 
 or on account of some yet unknown general cause, 
 the general nutrition is profoundly altered. The or- 
 ganic combustions are imperfect, whence the passage 
 frequently into the blood of acid substances, such 
 as uric acid in gout, lactic acid in rheumatism, 
 which act on the economy as toxic foreign bodies. 
 
 Thus is brought about in the end a sclerotic pro- 
 cess, first vascular, then parenchymatous, acting on 
 this or that organ according to its degree of re- 
 sistance. 
 
 On the other hand arthritic subjects are very often 
 dyspeptic; many of them have dilatations of the 
 stomach and disorder of the intestinal functions. 
 This is a source of toxic action, by way of auto- 
 intoxication, to which should be added that result- 
 ing from the non-retention in the sclerosed liver, of 
 certain physiological poisons. 
 
 It is in the frequency of the congestive rushes of 
 blood to the head and in the intensity of this double 
 auto-intoxication that the origin of the nervous 
 
400 INSANITIES WITH GENEKAL DISOEDEKS. 
 
 troubles so common in the subjects of arthritis is to 
 be sought. 
 
 I will say a word first on the mental condition in 
 arthritism in general, and then on the special intel- 
 lectual disorders of rheumatism, gout, and diabetes. 
 
 1. — Ahthhttism in Geneeal. 
 
 Arthritic subjects most frequently present a spe- 
 cial character. According to M. Lemoine, that which 
 predominates in them is a restlessness that shows it- 
 self by mobility, desire to move or change places, a 
 great psychic sensibility with indecision, anxiety 
 and sadness, a tendency to hypochondria that may 
 show itself here either under the nosophobic form 
 (worry as to health, imaginary ailments), or in the 
 so-called moral form (discouragement, pessimism, 
 lack of object in life, etc.) 
 
 Together with these, so to speak, distinctive marks 
 of the arthritic character, should be noted the men- 
 tal instability, the excessive action of objects or cir- 
 cumstances on the humor of the moment, finally also 
 the modifications of the mental state under the 
 influence of the times, the temperature, the seasons, 
 etc. 
 
 Arthritic patients are sometimes subject to illusions, 
 generally visual, consisting in the transformation of 
 shadows into animated and moving objects, such aa 
 mice, cats, dogs, etc. These fugitive and temporary 
 illusions, seem to have relation with the disorders of 
 the cerebral circulation and coincide with the fits of 
 
DIATHESES. 401 
 
 hypochondria. M. Lemoine compares them to the 
 ocular symptoms of migraine (scintillant scotomata, 
 hemiopia, muscse volitantes) , with this difference that 
 the latter ai-e purely sensorial phenomena and not 
 psycho-sensorial. 
 
 The need of air and space felt by these patients 
 produces in them the sense of oppression and want of 
 breath under certain circumstances, such for example 
 as being in a church, in halls, in closed chambers, 
 in crowds, in the dark, in water, etc. This anxiety, 
 at once bodily and mental, reaches in certain cases 
 the proportions of claustrophobia. 
 
 The sleep in these patients is usually unquiet, 
 peopled with unpleasant dreams, making a strong im- 
 pression and vividly remembered, sometimes repeated 
 more or less periodically, and having for their starting 
 point organic sensations. Or again there is only a 
 semi-slumber with vague apprehensions, startings, 
 cramps, involuntary contractures. At certain times 
 actual attacks of insomnia appear. 
 
 The mental troubles of arthritic subjects, what- 
 ever they may be, are essentially mobile and par- 
 oxystic and subject to the fluctuations of the bodily 
 condition. They may be aggravated, or on the 
 other hand relieved, and even made to disappear 
 under the influence of various derivations, such as 
 hasmorrhoidal or menstrual flux, attacks of diarrhcBa, 
 polyuria, glycosuria, hyperhydrosis, attacks of mi- 
 graine or asthma, eruptions of cutaneous exanthe- 
 mata or articular fluxions, etc. 
 
402 nrsANiTiEs with geneeal disoedees. 
 
 There is often observed a very well-marked equili- 
 brium between the psychic accidents and the other 
 diathetic manifestations, and this law applies not 
 only to the simple modifications of the mental and 
 moral condition but also, and particularly to the 
 moi'e serious neurotic or vesanic accidents, that 
 have heretofore been palled for this reason herpetic, 
 dartrous, migrainous, haemorrhoidal, asthmatic, etc., 
 insanities. 
 
 Among the neuroses related to arthritism one of 
 the most frequent is undeniably neurasthenia. Some 
 authorities, such as Axenfeld and Huchai'd, consider 
 this affection as developing itself by preference on 
 an arthritic basis, and M. Lemoine goes stiU farther 
 and does not hesitate to declare that, in most cases, 
 neurasthenia is an arthritic neurosis. This is also 
 the opinion of M. Bordaries (Th6s. de Bordeaux, 
 1890). This pathogenic conception seems the more 
 probable, since the arthritic subject is, as we have 
 seen, before all unquiet and anxious, so that he bears 
 with him in the germinal condition, in a mental 
 point of view, the elements of neurasthenic emotivity. 
 
 The symptoms and varieties of neurasthenia, to 
 which a special chapter has akeady been devoted, 
 need not be described again here. It may merely 
 be stated that in arthritis, the neurosis is observed 
 in all its forms, visceral or cerebi'al, and that gener- 
 ally it appears in its simple form and at every stage, 
 without any complication of degeneracy. 
 
 Hysteria (Huchard, Charcot), chorea (rheumatism 
 
DIATHESES. 403 
 
 mal chorea), epilepsy (B. Teissier), angina pectoris 
 (Landouzy), paralysis agitans (Pienet, Vaisselle), 
 may likewise have arthritism for theu- originating 
 cause. 
 
 The same is true of insanity, properly speaking. 
 We have generally in this event, as has been shown 
 by Rouillard, Mabille and Lallement, Lemoine and 
 Huyghes, intermittent and sometimes periodic at- 
 tacks of melancholia, especially melancholia with 
 consciousness, characterized by physical and mental 
 torpor, inquietude, fixed ideas of hypochondria and 
 discouragement, tendency to suicide and gastro-in- 
 testinal disorders, together with more or less pro- 
 nounced stigmata of neurasthenia (cephalalgia, rachi- 
 algia, weakness of the limbs, genital impotence, 
 spells of obsession, local perspirations, etc., etc.), 
 which frequently give to the disorder the aspect of a 
 neurosis rather than a vesania. We may also encoun- 
 ter, I believe, maniacal excitation or double foi^m 
 insanity. These outbreaks of insanity are accompan- 
 ied by local congestive attacks, or, on the other 
 hand, alternate with them. Mabille and Lallement 
 lay much stress on the intermittent and periodic 
 character of the mental disturbances in arthritism, 
 which are, according to them, characteristic signs, 
 to the extent that they advise the search for the ex- 
 istence of the diathesis in the ancestry and in the in- 
 dividual antecedents of every case of insanity and 
 in melancholia occurring in attacks in particular. 
 The memoirs of MM, Mabille and Lallement seem 
 
404 nrsANiTiES with general disoedees. 
 
 to demonstrate, moreover, and this is a point of 
 much interest, that the attacks of insanity in arthritic 
 cases coincide with the chemical changes of the or- 
 ganism, notably with hypoazoturia, hypophospha- 
 turia, oxaluria, with marked variations in the amount 
 of urea, and particularly with actual discharges of 
 uric acid which generally announce the end of the 
 attack. The experiments of the same authors on 
 the comparative toxicitj' of the urine during the at- 
 tack and in the intervals, have broached the invest- 
 igation but have not given any positive results. 
 They show nevertheless that at certain times this 
 toxicity falls below the normal which seems to in- 
 dicate that there is at such periods a retention of 
 toxic products in the organism. 
 
 As to general paralysis, it seems to have direct 
 relations with arlhritism. Many authorities have 
 already pointed out the frequency of heredity of 
 congestive tendencies in chronic meningo-enceph- 
 alitis (Lunier, Doutrebente, Baillarger, Ball and 
 Regis, etc.), and others have called attention to the 
 existence in paretics of some of the stigmata of 
 arthritism such as hemorrhoids, migraine, exanthe- 
 mata, diabetes, articular inflammations, local sweats, 
 etc. (Charcot, Charpentier, Lemoine). I have my- 
 self described a curious case of retraction of the 
 palmar aponeurosis (Dupuytren's disease) in a gen- 
 eral paralytic suffering fi-om hereditary arthritis. 
 
 There are evidently, therefore, frequent relations 
 between arthritism and progressive general paral- 
 
DIATHESES. 403 
 
 ysis. The nature of these relations is yet far from 
 clear, and we can only notice as to this point the 
 opinion of M. Lsmoine, according to which arthrit- 
 ism is the predisposing cause of paresis, for which it 
 prepares tlie way, by its repeated congestions and 
 its over-production of the pi-oducts of disassimila- 
 tion, for its later development by an exciting cause, 
 such as intoxication (alcoholism, saturnism) or infec- 
 tion (syphilis, malaria). 
 
 The diagnosis of the psychic disorders connected 
 with arthritism generally presents no difficulties. 
 We should remember merely that in the majority 
 of cases of emotional neurasthenia and of intermittent 
 insanity, especially of reasoning melancholia, we 
 should suspect this diathesis and look up the family 
 history and the stigmata of the patient without neg- 
 lecting the very valuable data furnished by the full 
 and frequent analysis of the urine. 
 
 The prognosis of alienation of arthritic origin, ex- 
 cepting always general paralysis, is not grave, 
 properly speaking, and the recovery is the rule. 
 We ought not, however, to forget that the charac- 
 teristic of the diathetic manifestations, mental or 
 physical, is intermittence, and that we find ourselves 
 often in the presence of an apparently curable in- 
 sanity but one that is really hopeless on account of 
 the inevitable return of the attacks. 
 
 The treatment should be addressed first of all to 
 the diathesis. The general condition of the patient 
 and his organic functions, especially the gastro-in- 
 
406 INSANITIES WITH GENERAL DISOEDEES. 
 
 testinal and hepatic and circulatory functions ; the 
 composition of the blood and perspiration, and more 
 especially of the urine; the appearance or disappear- 
 ance of habitual hsemorrhages (basmorrhoids), of ex- 
 anthemata, of asthmatic attacks, and of migraine, 
 all form so many precious indications for the treat- 
 ment. I have many times, since the pathogeny of 
 the arthritic psychosis has been, determined, been 
 able to rapidly and appreciably ameliorate their 
 symptoms by the use of large doses of the alkalines, 
 salicylates and lithates, antiseptics, repeated pur- 
 gations, lavage of the stomach, etc., and at the 
 present time I am attempting, in an obstinate and 
 hereditary case of arthritism, to break up the peri- 
 odicity, heretofore regular, of attacks of mania fol- 
 lowed by depression, i.e., a biennial attack of double 
 form insanity, by a preventive anti-arthritic treat- 
 ment. 
 
 3. — Ehetjmatism. 
 
 It is a well known fact that articular rheumatism, 
 in its acute manifestations, may give rise to menin- 
 gitic or apoplectic complications that have received 
 the name of cerebral rheumatism. These accidents 
 may, in their turn, be accompanied by delirious dis- 
 turbances, showing themselves usually in the acute 
 or hyperacute form, with incoherence, loquacity, 
 great excitement, etc. This, however, is not, prop- 
 erly speaking, a vesania ; it is only a febrile delirium 
 pushed to an excessive degree. 
 
DIATHESES. 407 
 
 The vesanic disorders of rheumatism, those that 
 form what we may call rheumatismal insanity, are 
 of two orders. They may occur in chronic rheuma- 
 tism, independently of the acute attacks of the dis- 
 ease ; or they may be intimately connected with these 
 latter. 
 
 First described by Leuret in 1845, they have 
 since then been the subject of sjDecial studies by 
 Mesnet, Griesinger, Morel, Fleming, Fraser, Simson, 
 Simon, Marechal, Ball and Faure, etc. 
 
 The mental troubles allied to chronic rheumatism, 
 consisting usually in modifications of character, fall 
 into the class already described under the name of 
 the mental state of arthritism. There is therefore 
 no necessity of redescribing them here. 
 
 The true rheumatismal insanity is that occurring in 
 connection with the acute attacks of the disease. 
 Its outbreak generally occurs during convalescence ; 
 sometimes also it occurs during the attack itself, 
 and in this case it commonly replaces the articular 
 symptoms which may re-appear again at its disappear- 
 ance. Almost always it takes on the melancholic 
 form, especially when it occurs during convales- 
 cence. Only when its onset is during the attack 
 itself does it appear under the form of acute mania. 
 
 All varieties of melancholia may be met with in 
 rheumatism, from simple melancholic depression to 
 complete stupor. Commonly there is a more or less 
 pronounced torpor, with characteristic delusions and 
 halluciaations. The patients have terrific visions; 
 
408 rRSASriTIES with GElsrEEAL DISOEDEES. 
 
 they see everything in flames (Mesnet) ; they are 
 pursued by ferocious beasts (Vaillard) ; they see 
 worms crawling on their beds (Burrows) ; they think 
 themselves to be dead. The less frequent auditory 
 hallucinations are of the same nature and usually 
 consist in curses and insults. There is generally also 
 sitioiDhobia, tendency to suicide, and sometimes 
 sudden and violent impulsions. This state is there- 
 fore, as we see, not without analogy with alcoholic 
 insanity, which fact seems to support the newer 
 theory that makes rheumatismal manifestations the 
 result of a veritable auto-intoxication. 
 
 Whatever may be the form of the insanity, the 
 basis of the mental condition is often constituted by 
 a greater or less degree of intellectual obtusion, and 
 occasionally even by a weakening of the faculties 
 that may become permanent. 
 
 Attacks of insanity in rheumatism may be accom- 
 panied with choreiform movements, and frequently 
 coexist with cardiac or pericardial disorders. 
 
 Finally they may alternate, once or repeatedly, 
 with the articular attacks, appearing when the latter 
 disappear, and vice versa. 
 
 Peognosis. — In the majority of cases, about three 
 times in five, recovery takes place. Nevertheless it 
 is rarely complete, as there very commonly remains 
 a certain obnubilation of the intelligence, and some- 
 times even decided mental weakness. 
 
 Relapses are common and an attack of insanity in 
 
DIATHESES. ' 409 ' 
 
 the course of an attack of rlienniatism predisposes to 
 others under similar conditions. 
 
 Death rarely occurs and is hardly ever due to the 
 insanity, but rather to the rheumatism or its compli- 
 cations or the general condition accompanying it. 
 
 Like simple mania and melancholia, rheumatismal 
 insanity is not attended with regular and invariable 
 cerebral lesions ; genei-ally no special lesion is dis- 
 covered and only the usual alterations of general- 
 ized acute insanity are met with. 
 
 The treatment offers no special indications, except 
 perhaps that in many cases there m.ay be some ad- 
 vantage in reviving the articular inflammation, the 
 return of which occasionally suffices to cause the 
 disappearance of the mental symptoms. 
 
 3.— Gout. 
 {Podagrous Insanity). 
 
 A large number of authors, such as Sydenham, 
 Todd, Garrod, Gairdner, Lorry, Clouston, Besnier, 
 Lecorche, Scnac, Ball, Bouchard, Charcot, etc., have 
 remarked and described the mental disorders that 
 may supervene in cases of gout. These are the same 
 as those already indicated apropos to the mental 
 states and neurosis of arthritism. The insanity of 
 gout, proj)erly so called, is rather rare and has been 
 little discussed up to the present time. 
 
 The greater part of the cases, carefully collected 
 by MM. Mabille and Lallement, belong to the class 
 
 Mekt. Med.— 26. 
 
410 nrsAJ NiTiK s wnu gekeeax disoedees. 
 
 of attacks of insanity occurring daring the gout or, 
 on the other hand, alternating with its manifest- 
 ations. 
 
 When insanity appears during a gouty attack it 
 is nearly ahvays in the form of acute mania. 
 When, on the contrary, the insanity alternates 
 with the diathetic symptoms, it usually takes the 
 melancholic form, with mental and physical torpor, 
 depression, hebetude, hypochondriacal delusions, and 
 suicidal tendency. It is in such cases that we see a 
 more or less periodic equilibrium produced between 
 the vesanic and the podagrous manifestations, the 
 dermatoses, attacks of asthma, etc. 
 
 4. — Diabetes. 
 {Diabetic Insanity). 
 
 The psychic disorders of diabetes have been espe- 
 cially elucidated by Marchal de Calvi, Legrand du 
 Saulle, de Santos, Cotard, L6corch6, Fassy, Mabille 
 and Lallement, etc. They are almost ahvays lim- 
 ited to modifications, more or less profound, of the 
 intelligence and feelings, and only seldom, reach the 
 condition of confirmed insanity. 
 
 The mental state of diabetics reveals itself in 
 general by hypochondria, toi-por, or sometimes invin- 
 cible somnolence, fears of ruin or misfortune, mo- 
 tiveless prepossessions, and tendency to suicide. 
 The hypochondria here necessarily assumes a pecul- 
 iar character; it has for its object the presence of 
 
DIATHESES. 411 
 
 sugar in the urine, and impels the patient to examine 
 it, to taste it, to multiply analyses, and to discuss the 
 proportion of glucose and the make-up of the diet- 
 ary regimen to the exclusion of all other subjects. 
 It is to be remarked that this hypochondria is in 
 direct ratio with the amount of sugar excreted, as it 
 improves as the sugar decreases. Then the patients 
 again become gay and lively, confident, less solicitous 
 about themselves and more open to outside impres- 
 sions. The fears of ruin have the effect of rendering 
 the patients miserly, parsimonious to excess; possessed 
 by the notion of inevitable failure, and by the 
 desire for death which alone can save them from 
 dishonor. The torpor is characterized by a mental 
 weariness, a fear of mental effort, " the loss -of appe- 
 tite for thought "(Lasegue). A characteristic feat- 
 ure of the mental condition of diabetics is the con- 
 cordance of the changes of the mental condition 
 with those of the sugar in the organism, and, the so 
 to speak, barometric influence of the composition of 
 the urine on the mental dispositions and emotions. 
 
 Insanity, properly so-called, is rare, as was said, 
 in diabetes. When it occurs it is habitually in the 
 form of melancholia, remittent or intermittent. 
 
 In general, the psychic disturbances of diabetes 
 appear in the beginning of the disorder. Sometimes, 
 nevertheless, they never show themselves in the later 
 stages. In some cases they precede the glucosuria 
 by a longer or shorter period and they may then be 
 aggravated by its appearance, or, on the other hand, 
 
412' IK-SASriTIES WITH GEKEEAL DIS0EDEE9. 
 
 as in the case reported by Cotard, they may disap- 
 pear when it manifests itself. 
 
 5. — Cancee. 
 (^Cancerous Insanity). 
 
 It is known that cancer has affinities that tend 
 to become more and more well established, with ar- 
 thritism. Bazin, and, more recently. Prof essor Ver- 
 neuil have made themselves the defenders of this 
 opinion. Guislain, Decorse, Sauze and Aubanel, Au- 
 zouy, Dagonet, Griesinger, Trousseau, Geoffroy and 
 Berthier have demonstrated that cases of insanity 
 connected with a cancerous affection are rather rare, 
 if we except cancers of the brain, which operate by 
 a different mechanism, as a local affection and not 
 so much as a diathesis. 
 
 The forms of cancer that most influence the de- 
 velopment of insanity are cancer of the uterus and 
 cancer of the stomach. It is an indubitable fact 
 that it is the cancer which in the majority of the 
 patients causes change of character, irritability, de- 
 pression, discouragement, and occasionally also ideas 
 of suicide. It is only in predisposed individuals that 
 an actual insanity supervenes. 
 
 The insanity connected with cancer is nearly 
 always a melancholia with hallucinations and hypo- 
 chondriacal ideas or delusions of persecution. As in 
 most of the insanities connected with visceral dis- 
 orders having painful and morbid sensations, it is 
 notable for its delusive interpretations of actual sen- 
 
DIATHESES. 413 
 
 sations that we call internal illusions. The female 
 patients claim that they are pregnant or have been 
 violated; they have frogs or serpents in their 
 abdomens, etc, etc. 
 
 Aside from this peculiarity, insanity connected 
 with cancer has no characteristic symptoms deserving 
 of notice. 
 
 Its diagnosis may often present some difficulties 
 as it resembles in all points true melancholia, and 
 the cancer often^remains latent like many other or- 
 ganic affections in the insane. 
 
 As regards prognosis, it is serious, as the melan- 
 cholic attack is never really acute ; it is a sub-acute 
 type, or, rather, an attack of delusional melancholic 
 of slow and progressive course, which may termin- 
 ate in dementia, in case death does not supervene 
 from the progress of the cancerous cachexia. 
 
Cbapter ^11. 
 
 ESrSANITIES ASSOCIATED WITH DISEASES 
 OF THE NERVOUS SYSTEM. 
 
 (Diseases op the Brain. Diseases op the SpinaIi Cokd. 
 
 Nedkoses). 
 
 §1. INSANITIES CONNECTED WITH DISEASES 
 OP THE BRAIN. 
 
 (GENEitAL Pabaltsis. Apopleptio Demehtia), 
 
 General Paralysis op the Insane. 
 
 Definition. — General paralysis is a cerebral dis- 
 order, sometimes cerebrospinal (diffuse, chronic, 
 interstitial, meningo-myelo-encephalitis) essentiallij 
 characterized by 2orogressive symptoms of dementia 
 and paralysis (paralytic dementia) with which are 
 frequently associated various accessory symptoms, 
 and especially an insanity of the maniacal, melan- 
 cholic, or circidar type (paralytic insanity). 
 
 HiSTOEicAL. — The discovery of general paralysis, 
 of which Baillarger was able to say with reason 
 that it was the greatest step in advance that is re- 
 corded in the history of mental disease, dates back 
 not more than sixty years, although attempts have 
 been made to show that it was earlier recognized, 
 
GESrEEAl PAEALTSIS (hISTOKICAI,) . 415 
 
 and more particularly that Haslam and Perfect had 
 reported cases at the close of the last century. 
 
 Esquii-ol inaugurated the movement by noticing, 
 in a general way, the extreme gravity of those cases 
 in which the dementia was complicated with paral- 
 ysis, and the evil significance that should be 
 attributed to embarrassment of articulation as an 
 element of prognosis. 
 
 It is to his students, however, that was reserved 
 the honor of actually bringing to light the disease. 
 Georget described it in 1830 under the name of 
 chronic muscular paralysis; Delaye, in 1834 under 
 that of incomplete general paralysis, which it has 
 since retained; Calmeil finally, in 1836, under that of 
 paralysis observed in the insane. All of these re- 
 garded the malady as a special form of paralysis 
 superimposed upon the insanity, that is, as the 
 complication of an ah-eady existing mental disease. 
 
 Bayle, however, had already in 1833, in his 
 inaugural thesis, formulated a new theory and 
 changed the condition of affairs. According to him 
 general paralysis is not a mere complication of 
 insanity, but is a true morbid entity. He desig- 
 nated it arachnitis or chronic meningitis, on account 
 of its predominant lesion, made the ambitious delus- 
 ions its necessary characteristic symptom, assigned 
 it a regular course, divided into three sucessive 
 periods ; one of monomania, another of mania, the 
 third of dementia. Like Calmeil ho insisted on 
 its anatomico-pathological characters, and consid-*i 
 
416 INSANITY TflTH DISEASES OE ^EAIN. 
 
 ered pathognomonic the adhesions existing between 
 the meninges and the convolutions. 
 
 The ideas of Bayle were accepted, little by little, 
 and Parchappe in 1838 went so far as to regard 
 general paralysis as a special form of insanity, 
 which he designated under the name of paralytic 
 insanitj'. 
 
 Requin, in 1846, proposed a restriction of this 
 view, and considering that general paralysis, to which 
 he applied the epithet progressive, may exist without 
 mental symptoms, he recognized two forms : the one 
 with intellectual disorders, the other without any 
 disturbance of this kind. This distinction has been 
 confirmed and made more precise by a number of 
 authors, notably by MM. Sandras, Lunier, and Bail- 
 larger. The latter has even claimed that, in a psychic 
 point of view, it is the dementia and not delusions 
 that constitute the essential symptom of the disease. 
 He also proposed for it the name of paralytic de- 
 mentia (1846). 
 
 From this date, investigations multiplied and there 
 appeared a series of important memoirs on the sub- 
 ject, among which may be especially cited those of 
 Ch. Lasfegue, J. Falret, and A. Linas. 
 
 In 1858 there took place in the Medico-Psychol- 
 ogical Society a long and interesting discussion 
 which resulted, in spite of the objections of cer- 
 tain opponents, notably of Baillarger in the en- 
 dorsement of the views of Bayle, namely, the prin- 
 ciple of the essentiality of general paralysis. Propi 
 
GEN-EEAL PARALYSIS (hISTOEICAl) . 417 
 
 that time to the present, the theory of general paral- 
 ysis has not been brought in question. 
 
 The notion of a morbid entity having been ac- 
 cepted, attention was turned more particularly to 
 the study of the characteristics of the disease. 
 
 In a first period, filled especialy with the memoirs 
 of Baillarger, the clinical analysis of the disorder 
 was taken up and its description perfected. 
 
 In a second, began the investigation of the ana- 
 tomo-pathological lesions and the application to it 
 of the microscope. It is no longer a chronic men- 
 ingitis or meningo-encephalitis that constitutes the 
 chief alteration of the disorder. According to some 
 it is a sclerosis of the connective tissue of the 
 brain, others consider it a degenerative lesion of the 
 great sympathetic, and finally, by certain individ- 
 uals, it is held to be a myelitis rather than an en- 
 cephalitis. 
 
 Next the attention is called anew to the altera- 
 tions of the meninges and the cortical layers. The 
 theory of localizations is applied to the study of the 
 symptoms of paresis, and it has been sought to find 
 in the localizations the reason of the symptomatic 
 differences of the malady (Foville). 
 
 Already, however, new clinical facts, such as the 
 remissions, latent general paralysis, general paral- 
 ysis of double form, and in particular, syphilitic, 
 . saturnine and alcoholic pseudo-general paralysis had 
 gradually overthrown the unitary theory which failed 
 to. explain them, and M..J. Falret went so far in 
 
418 nrsAiaTT with diseases of beain. 
 
 1877 as to say that the history of general paralysis 
 must be rewritten. 
 
 Thus Baillarger (1882-3) proposed, with good 
 reason, to return to the dualist theory upheld hy him 
 in 1858, which admits the existence in what we call 
 general paralysis, of two quite distinct disorders, sus- 
 ceptible of existing associated with each other or 
 separately : (1) paralytic dementia, the principal dis- 
 ease; (3) paralytic insanity, the accessory affection . 
 
 This dualist theory, upheld unceasingly by 
 Baillarger to the last days of his life, counts to- 
 day numerous partisans. Some alienists even tend 
 at the present time to consider general paralysis 
 not as a single malady, but as a group of more or 
 less distinct diseases, according to their causes or 
 their lesions, " as a genus comprising many species " 
 (Ball). 
 
 At this point ends the history of general paralysis. 
 En resume when we glance over the whole scientific 
 evolution of this disease we note that it has passed 
 through three principal stages : (1) in the first, it is 
 considered as a complication of insanity ; (2) in the 
 second, it represents a morbid unity having among 
 its other symptoms, insanity; (3) in the third, 
 finally, which is the present period, it tends to be 
 considered, if not as a group of cerebral or cerebro- 
 spinal affections, at least as a paralytic dementia to 
 which is associated more or less frequently, and 
 under various conditions, insanity. 
 
 These various changes of opinion and differing 
 
GEiS'EEAX PAEAITSIS (PAEALTTIC DEMENTIA). 419 
 
 conceptions of general pai-alysis, have had their 
 influence on the progress of its clinical study, which 
 to-day is one of the most advanced in all mental 
 medicine. 
 
 Desceiption. — As a partisan, Avith M. Baillarger, 
 of the dualist theory of general paralysis, which 
 seems to me to best correspond with the facts, I 
 believe that the disease in its most perfect, un- 
 complicated, and essential type is represented clinic- 
 ally not by this or that delusional form, but, on the 
 contrary, by general paralysis without delusions, by 
 a paralytic dementia essentially made up of a de- 
 mentia and a progressive paralysis. 
 
 Contrary to the usual practice, therefore, it seems 
 to me rational, and at the same time more profitable 
 to the study, to describe first the type of the disease, 
 that is to say, the paralytic dementia. Once 
 acquainted with this type, we can next examine in 
 the sphere of insanity, pro23erly so-called, the various 
 phenomena that are more or less habitually superadded 
 to the paralytic dementia and their different modes 
 of association. 
 
 Pakalttic Deatentia. 
 {Prodomic or Preparalytia Period). 
 
 There is perhaps no disease that begins more grad- 
 ually than general paralysis. Except when it begins 
 with a congestive ictus, its invasion is so gradual 
 and insensible that it is almost always impossible to 
 fix its real commencement and its origin is lost, so 
 
:420 OTSAKITT WITH DISEASES. OB^BEAIN. 
 
 to speak, in the darkness of the past. When care- 
 ful study is made of the life of the paretics and all 
 data obtained from their families, we find that the 
 first changes in the intellect, the feelings and the 
 organic functions which indicate the beginning of 
 the disease, date back many years before its apparent 
 outbreak. There is a true prodromal period, called 
 the pre-delirious period (Christian) or the pre-paral- 
 ytic period (Regis) , from its analogy with the pre- 
 ataxic period of tabes. 
 
 This period, of which only a few symptoms are 
 known, merits a special study. I will confine myself 
 to the brief enumeration of the principal manifest- 
 ations which chiefly are of a bodily and organic 
 nature. 
 
 The general appearance of the future paretics is 
 often modified a long time in advance. Their phys- 
 iognomy is changed, they have a dead complexion, 
 their flesh is flaccid and pale, their features drawn 
 and lacking expression, the hair and eyebrows usually 
 dry and thin, their eyes moist and lacking fire. 
 Their teeth are carious and incomplete and often 
 fall out spontaneously while the face border of the 
 gums becomes the seat of a quasi-scorbutic ulceration. 
 
 On the side of the motility and sensibility we may 
 meet with: spasms, convulsions (Jacksonian epi- 
 lepsy), paralysis, nearly always ocular (strabismus, 
 diplopia, ptosis, inequality and immobility of the 
 pupils), which are relatively very frequent in the 
 years preceding the attack of general paralysis. We 
 
GEPTEEALPAEAiTSlS (PAEAiTTIC DEMENTIA) . 4^1 
 
 also find hypersesthesias and anaesthesias of the 
 organs of sense and of the cutaneous surface, loss of 
 memory of localization of tactile sensations (Ziehen), 
 various derangements of the reflexes, especially loss 
 of the cremastic reflex with testicular insensibility 
 and atrophy. Furthermore it is not uncommon to 
 observe certain nervous disorders such as cephalalgia, 
 neuralgias, ophthalmic migraine (Charcot), gastric 
 and vesical crises analogous to those of tabes (Hurd), 
 symptoms of cerebral or spinal neurasthenia, of 
 partial epilepsy, and even of hysteria. 
 
 Sleep is one of the first functions to be disturbed 
 and it is rare if it remains altogether intact. It is 
 light, and unsatisfying, disturbed by dreams and 
 nightmares, cramps, startings, and sometimes by epi- 
 leptiform convulsions. Very frequently the respira- 
 tion takes on a special type. It is carried on by 
 short inspirations that hardly raise the chest walls and 
 that are cut off shortly, followed from time to time 
 by long and plaintive expirations. This is a charac- 
 teristic mode of breathing during sleep that I have 
 met many times in general paralysis and in all its 
 stages. 
 
 Another hitherto undescribed sign, that from its 
 frequency and ease of observation seems to merit 
 special mention, is the condition of the sternum which 
 by a slow process of periostosis finally diminishes 
 the elasticity of the thoracic cage, while at the same 
 time the xyphoid appendix, becoming ossified, is de- 
 pressed, elongated, and incurved toward the abdo- 
 
422 iK-sANiTT •vnxn diseases of beaut. 
 
 men in such a way as sometimes to produce severe 
 pains. In some cases tlie thorax tends to become 
 quite immobile and respiration consequently becomes 
 almost exclusively abdominal, especially during sleep. 
 
 The alterations as regards the organic and trophic 
 functions are not less frequent and numerous. I may 
 mention : capriciousness of the appetite, tendency to 
 dilatation of the stomach and the intestine, gastric 
 pain and vomiting simulating serious disease of the 
 organ, habitual constipation alternating with colic 
 and sudden attacks of diarrhoea, palpitations and 
 feebleness of the heart, increased sensibility to cold, 
 vaso-motor disturbances, particularly flushes of blood 
 to the head, trophic disturbances such as dystrophy 
 and spontaneous shedding of the nails, mal per for ant, 
 arthralgias, etc., alternating exaggeration and sup- 
 pression of the perspiration or of periodical fluxes, 
 menstrual or hemorrhoidal, more or less transitory 
 modifications of the quantity or quality of the urine 
 (polyuria, glycosuria, peptonuria), and lastly alter- 
 ations in various ways of the sexual power. 
 
 Mentally, the future paretic retains all the appear- 
 ances of the most complete intellectual soundness. 
 But he himself realizes that his mental energy is 
 slowly diminishing, that work is becoming painful, 
 that he has failure of memoiy, and that it is more 
 and more by a sort of professional automatism that 
 ho accomplishes approximately well his daily tasks. 
 Some observe and follow anxiously the slow process 
 of mental and physical disorganization that is going 
 
GEITERAL PAEALTSIS (PAEALTTIC DEME:JTIA). 423 
 
 on in themselves, and fully conscious of their condi- 
 tion and even foreseeing their future, they may at 
 this time announce their future general paralysis or 
 seek to prevent it by suicide. Lastly, the character 
 changes little hy little; the patients hecome moody, 
 absorbed in their condition; they are readily irri- 
 tated, have fits of passion, changes of humor; they 
 are unsettled and indifferent to everything. Some- 
 times they have true spells of neuropathic depres- 
 sion, with attacks of weeping; or rather, they be- 
 come hypochondriacal, and complain of palpitations, 
 of suffocation, of all kinds of evil feelings ; they are 
 anxious to consult about their condition, and never 
 cease to lament it, while they gorge themselves 
 with drugs. At other times on the contrary, they 
 feel active and vigorous and in good condition, they 
 have an abnormal feeling of well-being and show an 
 extraordinary ardor for work. 
 
 Such, taken altogether, is the list of signs 
 observed, either wholly or in part, in the years pre- 
 ceding the outbreak of general paralysis. Finally, 
 however, this slow incubation is completed and the 
 invasion of the malady begins. 
 
 There have been already manifested some signs 
 of mental, moral and physical failure, forerunners 
 of the coming trouble. ' ' The attentive observer, " re- 
 marks M. J. Falret, "already begins to notice mo- 
 mentary absences of memory or intelligence, and 
 true lacuncB in the conceptions, in a word, the in- 
 contestable traces of a commencing dementia, which 
 
424 nrgANlTY WITH DISEASES OF BKAIN. 
 
 are the characteristic of this mental disease, even 
 from its first beginning." 
 
 These defects may be summed up as follows : in- 
 tellectually there are strange lapses of memory, un- 
 usual mistakes in spelling or calculations, a lack of 
 sequence in combinations and projects, an absolute 
 inability to finish anything, etc. Morally, and this 
 is most striking in patients of the higher clases, we 
 see a very noticeable forgetfulness of the rules of 
 politeness and decorum, a negligence in costume; 
 sometimes also indelicacy and grossness, and finally, 
 a more or less pronounced tendency to alcoholism, 
 to a cynical erotism, to criminal acts, especially ab- 
 surd and useless theft. Physically, the patient be- 
 comes awkward, unskilful, unfit for the work of his 
 trade ; if he is a mechanic, he bungles his work, be- 
 gins it again only to do it worse, and loses more and 
 more his aptitude for careful and accurate move- 
 ments, so much so that he is dissmisscd by his em- 
 ployers and he is finally unable to find work. At 
 this same time there appear some slight disturbances 
 of speech, consisting in a certain hesitation, espec- 
 ially apparent after eating, aud sometimes also true 
 congestive attacks of the apoplectiform or epilepti- 
 form types. 
 
 In a word there have already supervened signs of 
 enfeeblement in all three of the modalities of the in- 
 dividual, and these becoming gradually emphasized, 
 attract more and more attention, and progressively 
 conduct the patient to the first period of the disease. 
 
GENEEAI, PAItAlTSIS (fIEST PEEIOD). 435 
 
 First Period. 
 
 From this time on the paralytic dementia is estab- 
 lished, and it is characterized from the first by two 
 kinds of symptoms : the ones physical, the others 
 intellectual and moral. 
 
 1. Physical Symptoms. — The physical symp- 
 toms consist in motor disorders, disturbances of 
 the organic functions. 
 
 A. DisoEDEES OF MOTILITY. — The principal dis- , 
 orders of this nature are: embarrassment of speech, 
 tremor, muscular weakness, and oculo-pupillary 
 disorders. 
 
 Embarrassment of speech is the chief pathogno- 
 monic symptom of general paralysis. When it is 
 not observed, whatever may be the other symptoms, 
 we may suspect, but cannot affirm the existence of 
 general paralysis. The importance of its study wUl 
 therefore be recognized. This hesitation in speech 
 is veiy difficult to describe, but when one is accus- 
 tomed to hear it, it becomes easy to perceive all its 
 characters, even the slightest shades of difference, ex- 
 cept in its beginning when it is only perceptible to 
 practised ears. At first this hesitancy is not con- 
 tinuous, and only manifests itself in an intermittent 
 fashion. 
 
 When the patient rises from meals or when he is 
 fatigued by reading or by a lengthy conversation, a 
 syllable is badly pronounced and repeated, there is 
 what we call an impediment; the emission of the 
 sound remains suspended on the impeded syllable, 
 
 1I£^■T. IIEC.— 27. 
 
4:26 hj-sanitt with diseases of beaut. 
 
 and then after this faux pas which lasts only a 
 second, he again becomes at ease. Or perhaps the 
 speech becomes slow, drawling, and as it were 
 intoned. Gradually this hesitancy increases and 
 becomes perceptible by every one. It assumes two 
 rather distinct types: the ataxic, consisting in a 
 species of incoordination of speech which is wander- 
 ing, confused, and precipitate and full of mistakes; 
 and the paralytic type, consisting in a staccato and 
 sing-song slowness, a regular syllableizing of words 
 and parts of words. This last is most frequent 
 in paralytic dementia and in females. 
 
 In the first type of speech each emission- of sound, 
 every beginning of a word or sentence is preceded by 
 a series of fibrillary ataxif orm startings of the lips, so 
 that there almost always elapses a certain space of 
 time between the first effort and the final enunciation. 
 To be assured of this the patient may be asked to 
 pronounce difficult words, and as it is usually the 
 labials that are worst articulated on account of his 
 inability to manage his lips from his ataxia, it is best 
 to ask him to repeat words with labials and without 
 syllables that might aid him, such as immovability, 
 incompatibility, or words with ILnguals and dentals 
 such as artilleryman of artillery. 
 
 Tremor is one of the first phenomena to appear 
 in the beginning of general paralysis ; the very first 
 according to Charles Lasfegue. It affects most the 
 tongue, the lips, the muscles of the face and of the 
 legs and arms. This tremor, especially at the 
 
GfiXEftAL paSaltsis (nfesT peeiod). 437 
 
 beginning, is not a tremor en masse, like that of 
 alcoholism, for example, it is a very fine ataxic, and 
 what is called a fibrillary tremor. It is intermittent 
 and shows itself particularly when the patient is 
 about to make an effort. If he wants to speak all 
 the muscles of his lips and even of his face enter into 
 jilay, and fibrillary twitching, more or less marked, 
 occur before and during the emission of the word. 
 Projection of the tongue out of the mouth is done 
 in a jerky manner, and its retention outside is very 
 diificult (trombone movement, Magnan). In the 
 hands the tremor is yet more pronounced when the 
 patient makes an effort to carry tliem to the mouth, 
 to button the clothing, to pick up any small object, 
 or to perform any operation requiring precision and 
 adroitness. The handwriting is changed, finely 
 tremulous, covered with erasures, full of omissions 
 and faults of grammar and spelling (dysgrammatic 
 and ataxic writing). In the lower limbs the tremor 
 is marked while walking, and is notably so when 
 the patient is made to turn around quickly. The 
 tremor of general paralysis falls into the same class 
 as those of Basedow's disease and alcoholism, the 
 vibratory or rajDid tremor of Charcot (eight to ten 
 vibrations per second). It differs therefore in this 
 respect from that of paralysis agitans,- from senile 
 and mercurial tremors, which count only four to six 
 vibrations each second. 
 
 The muscular enfeeblement is rather a paresis 
 than a paralysis. The muscular power is certainly 
 
438 TNBAm.TS -WITS diseases of braik. 
 
 diminisbed, but to a less extent than would be 
 inferred from the awkwardness and disability of the 
 patients. Indeed the dynamometer and the myo- 
 graph indicate an average muscular strength prop- 
 erly speaking up to a late period of the malady. The 
 patients are nevertheless quickly fatigued and are 
 incapable of any great effort. The myographic 
 traces obtained in them (Chambard) are character- 
 istic. The line of ascent is more irregular and the 
 line of physiological tetanus is interrupted by more 
 or less extended ataxic contractions. 
 
 The oculo-pupillary disorders consist chiefly, 
 either in an exaggerated contraction of the pupils 
 (myosis) which may become mere pinholes, or, 
 what is more common, an inequality of their dila- 
 tation. If this last symptom only is looked for, it is 
 certainly, as has been intimated, not a constant one, 
 and it is wanting in about one-third of the cases ; 
 but if all oculo-pupillary symptoms, exaggerated 
 contractions, inequality of pupils, etc. , are noted, it 
 is very exceptional that none are met with. An 
 excessive myosis may, moreover, mask an inequality 
 too slight to be apparent under such conditions, as 
 in some cases this inequality is revealed under the use 
 of belladonna. Much importance has been attributed 
 to the question as to which pupil was affected, and 
 an intimate relation has been sought for between 
 the side of the most dilated pupil and the mental 
 form of the disease. It has been said that the right 
 is larger in the depressive forms and the left in the 
 
GENERAL PARALYSIS (fIEST PEEIOD). 439 
 
 expansive forms. It is generally recognized as re- 
 gards which pupil is altered, that it is the one that is 
 most dilated, -either from some disorder of the 
 sympathetic innervation or from that of the motor 
 oculi, and tliis fact has its importance since it may 
 indicate in some measure in which hemisphere the 
 lesions predominate. Aside from their contraction 
 or unequal dilatation, the pupils may be deformed, 
 ragged, and may not react under the effect of light 
 or accommodation. Lastly, various other ocular 
 troubles may exist, such as amaurosis, ptosis, achro- 
 matopsia, erythropsia (Ladame), nystagmus, etc. 
 
 B. DisoEDEKS OF Sensibility. — Cutaneous an- 
 sesthesia, particularly of certain regions, and notably 
 in the anterior thorax, has been observed as a sign of 
 beginning general paralysis. What seems more sure 
 is that fi'om the moment the disease has fairly started 
 the tactile sensibility is dulled, although it is difficult 
 to definitely establish, this fact on account of the 
 demented condition of the patients. The same is 
 true of special sensibility which becomes less perfect. 
 Some writers indeed attribute a great importance to 
 the enfeeblement of the gustatory and olfactory sen- 
 sibility. As regards the reflexes, their condition is 
 variable. According to Bettencourt-Rodrigues the 
 cutaneous reflexes are generally diminished and the 
 tendon reflexes exaggerated. 
 
 C. DiSOEDEES OF THE OeGANIC FaNCTIO^TS. 
 
 These disorders are but little pronounced in the first 
 
430 ES-SAKITT -WITH DISEASES OP BTiATS. 
 
 psricd: digestive disturbances are the ones that pre- 
 dominate, and these consist in exaggeration of the 
 appetite and a tendency to constipation. 
 
 2. I.N-TELLECTUAL AND MoRAL DiSTDEBANCES. 
 
 The intellectual and moral disorders may be summed 
 up in a general enfeeblement of all the faculties. 
 
 The memory becomes more and more untrust- 
 worthy, the patients lose their recollections of dates, 
 names of recent events, of what they have done the 
 day previous or wish to do at the moment, while pre- 
 serving at the same time their former recollections ; 
 their imagination, their reasoning powers, theirpower 
 of attention and of will become more and more ob- 
 scured. They may still be able to fulfil their social 
 duties, and even to carry on, by a sort of acquired 
 habitude, some easy mental work that requires no 
 effort of the imagination or. initiative, but they arc 
 incapable of serious labor. They make serious errors 
 in calculation, they leave their sentences unfinished, 
 their conversation is disconnected, they lose their 
 way in the streets. 
 
 Moralli/ they become indifferent as to conduct and 
 show a progressive altei-ation of the affective feelings, 
 together with marked irritable weakness. 
 
 In a word they fail more and more and realize in 
 an intellectual and moral point of view the ordinary 
 tableau of dementia. 
 
GENERAL PAEALTSIS (SECOKD PEEIOd). 431 
 
 Second Period. (Period of Full Development). 
 
 The transition from the first to the second period 
 is an artificial one, based on no very well defined 
 symptoms. It is recognized by the progress of the 
 above described symptoms, especially the dementia 
 and the paralysis, and frequently also by an increase 
 of flesh that occurs at this time. 
 
 Apart from the epiphenomena of various kinds 
 that may supervene, it is essentially constituted by 
 the progressive accentuation of the already existing 
 symptoms. The speech becomes gradually more 
 and more embarrassed, till at the end of this stage 
 it finally becomes almost unintelligible ; the tremor, 
 the paresis, the uncertainty of the movements and 
 of progression increases; the intelligence fails, the 
 ideas are more and more circumscribed and are 
 gradually limited to the material matters of life, the 
 simple needs of existence. The patients come to 
 have no idea of what goes on around them; they 
 commit absurd, automatic and childish acts, lose 
 their sense of propriety, do not clothe themselves 
 properly, they gather up filth, pebbles and scraps of 
 paper with which they fill their pockets. They for- 
 get that they are married, that they have children, 
 they live in the monotonous repetition of the same 
 words and ideas. There is sometimes added to the 
 other oculo-pupillary disturbances diplopia, amau- 
 rosis, etc. ; and to the muscular disorders, contrac- 
 tures, particularly in the head which becomes rigid 
 
432 DfSAJSITT WITH DISEASES OP BEAIW. 
 
 and does not touch, the pillow in the dorsal decubitus. 
 Very often also there is a kind of mumbling, a 
 sort of movement of rumination or tasting, that 
 is sometimes continuous, together with a char- 
 acteristic grinding of the teeth that may go so far 
 as to wear away their surface and which is heard at 
 quite a long distance. 
 
 The muscular weakness gradually increases so 
 that walking is more and more impeded, falls are 
 frequent, the patients have difficulty in carrying 
 their food to their mouths. Nevertheless they gain 
 considerably in flesh, arid they become more and 
 more voracious and gluttonous. Finally, they have 
 a peculiar fades that has been called the paralytic 
 mask, and which consists in an earthy tint and flac- 
 cidity of the cheeks, with obliteration of the cutane- 
 ous folds, particularly the naso-labial grooves, that 
 deprives the face of all vivacity and expression. 
 
 After a longer or shorter duration of this period, 
 which, according as it is complicated or not with con- 
 gestive phenomena, may last months or even years, 
 the patient gradually passes into the terminal stage, 
 which is marked by a characteristic symptom ; the 
 relaxation of the sphincters, the result of which is 
 the "untidy" {gdteux) condition. 
 
 Terminal Period. 
 
 At the moment the patient begins to soil himself 
 he enters into the final stage of his disease. 
 
 He usually begins by wetting his bed at night, 
 
GENEEAL PAEALTSIS (TEEimj-AL PEEIOd). 433 
 
 then his clothing, first only occasionally, later, con- 
 tinuously; he gradually begins to allow his fseces to 
 escape, and at last becomes altogether filthy; his 
 vesical and rectal sphincters are paralysed. More 
 rarely this paralysis reveals itself by a retention of 
 urine or of fecal matter. 
 
 From this time on the paralytic becomes more and 
 more degraded; he walks clumsily or in an ataxic 
 fashion, is always on the point of falling, and soon 
 is unable to keep the erect posture ; he cannot di-ess 
 himself, or perform the simplest acts; he ignores 
 propriety, eats gluttonously and filthily and even 
 eats his own excrements. The physiognomy is 
 that of hebetude and absolute dementia; pupillary 
 inequality is commonly very marked ; the speech is 
 only an incomprehensible stammering, sometimes 
 complicated with true aphasia; the grinding of the 
 teeth and the mumbling when present are very 
 noticeable; the spasmodic tremors of the hands, the 
 lips and the tongue increase; the contractures, 
 especially in the neck, are very manifest; sensibility 
 is almost or quite abolished; paralysis of the pharynx 
 is added to that of the sphincters, so that the food, 
 bolted down, is often accumulated in the isthmus of 
 the throat and sometimes causes in this way asphyxia 
 which maybe fatal. Finally, failing constantly, the 
 patients become bedridden and shortly there appear, 
 under the influence of the alterations in the nervous 
 system, trophic disorders and various forms of de- 
 generation such as cachectic wasting, tendency to 
 
434 INSAKITT WITH DISEASES OF BEAIN. 
 
 fractures and luxations, although denied by Chris- 
 tian, erythemas, abscesses, mal perforant of the 
 foot, spontaneous shedding and dystrophy of the 
 nails and teeth, hcematomas of the ear, purpura, 
 sloughs of the sacral region and buttocks, and of 
 the heel, etc. Such of these complications as give 
 rise to a free suppuration, may, by the revulsion 
 thus produced, cause a temporary improvement and 
 regression of the evolution of the symptoms. It has 
 been also remarked that in spite of the general bad 
 condition of the patient, all these incidental disorders, 
 fractures, abscesses, boils, mal perforant, etc., have 
 a surprising tendency to recover. 
 
 The aural hajmatoma, the only one of these com- 
 plications that from its frequency and the discussions 
 to which it has given rise, merits our attention here, 
 may be either single or double. This form of blood 
 tumor is, it is true, sometimes met with in other 
 forms of mental disorder, especially in epilepsy, 
 idiocy, melancholia, mania, etc., as well as also in 
 professional pugilists, but it is particularly frequent 
 in general paralysis. The extravasation is often pro- 
 duced with great rapidity and develops within a few 
 hours, but in most cases it takes several days for its 
 full growth. The tumor may vary in size from that 
 of a hazel nut to that of a pigeon's egg ; it occupies 
 all the pavilion of the ear but leaves the lobule intact. 
 lu the beginning it has a crepitant feel to the finger 
 and when incised it discharges blood mixed with 
 serous fluid. In spite of its apparent gravity the 
 
GENERAL PAEALTSIS (tEEMINAL PEEIOd). 433 
 
 tumor heals almost always in the course of a few 
 weeks, but there remains a deformity that is gener- 
 ally characteristic and indelible. In an anatomical 
 point of view litematoma is formed by an extrava- 
 sation situated according to some (Foville) under 
 the perichondrium, according to others (Mabille) 
 between the cartilage and the skin ; and according 
 to some (Vallon) in the body of the cartilage. 
 
 The pathogeny is no better understood. Accord- 
 ing to some authorities hsematoma is always the 
 result of a traumatism, and of blows in particular. 
 According to others it is spontaneous and is due 
 to a disorder of innervation of the great sympathetic. 
 It is probable that its essential cause is, in fact, in a 
 disorder of the circulation, and that in consequence 
 of this preparatory state, the slightest shock, such as 
 the mere friction of the ear on the clothes, may give 
 rise to its appearance. 
 
 During this period the patient fails steadily in his 
 intelligence and moral qualities ; his ideas are grad- 
 ually contracted and abolished; he recognizes no one, 
 feels no emotion or sentiment, he remembers nothing, 
 his only manifested want is that for food, and he 
 finishes by being reduced finally, as has been said, 
 to a mere digestive tube. 
 
 Arrived at this stage the paretic presents the picture 
 of a most profound and lamentable degradation, he 
 has in him nothing more of his human nature and 
 falls actually uito the condition of a lower order of 
 being. 
 
436 ns-SAlTITY WITH DISEASES OF BEAIH'. 
 
 Death is the invariable terraination of this stage. 
 It occurs either from the advancing physical failure 
 (paralytic marasmus or cachexia) , or as the result of 
 some complication (incidental diseases, hypostatic 
 pulmonary congestion, etc.), or finally from the ef- 
 fects of congestive attacks. The frequency and im- 
 portance of these latter necessitates a word in regard 
 to them. 
 
 Cerebral congestion plays a very important part in 
 the course of general paralysis. It may announce the 
 beginning of the disorder as well as terminate it sud- 
 denly by death in its later stages. It may also man- 
 ifest itself at any stage of its course or duration. 
 This cerebral congestion reveals itself under the most 
 diverse forms, so that some authors, like Aubancl and 
 Marce have noted some six or eight varieties. In 
 reality those that occur under the form of congestive 
 attacks and constitute a true complication arc the 
 following: (1) comatose; (3) lie^niplegic ; (3) apo- 
 plectiform; (4) epileptiform. 
 
 In the comatose form the patient begins by show- 
 ing a tendency to somnolence, to hebetude, to 
 bodily and mental inertia. His face becomes con- 
 gested and in a few hours he reaches the condition of 
 complete coma with muscular relaxation and absolute 
 insensibility, without usually any appreciable diffi- 
 culty of respiration. These attacks are ordinarily 
 not serious, and pass off rather rapidly under proper 
 treatment. 
 
 In the hemiplegio form the paralysis occurs 
 
GEKEEAL PAEALTSIS (TEEMINAL PEEIOD). 437 
 
 suddenly, so to speak, without any premonitions. 
 The patient all at once drops whatever he may have 
 in his hands or one of his limbs gives way and a 
 hemiplegia or monoplegia quickly appears, which 
 lasts for a variable time but as a rule tends to dis- 
 appear or become diminished within a few days. 
 
 In the following described form we see a genuine 
 attack of the apoplectiform type. The patient falls 
 as if struck by lightning and loses consciousness ; a 
 comatose condition follows with deeply congested 
 visage, loud stertorous respiration, foam at the lips, 
 muscular resolution, and relaxation of the sphincters. 
 Death may occur at once, but generally this con- 
 dition passes oif in a few minutes, and after a longer 
 or shorter period of transition, characterized by hebe- 
 tude and somnolence, the patient comes to himself, 
 with still in some cases a transitory hemiplegia or a 
 weakness of the vesical and rectal sphincters. 
 
 The epileptiform attack, the most frequent and 
 most sei'ious of all the congestive complications of 
 general paralysis, also manifests itself by a sudden 
 loss of consciousness with initial cry, pallor, fol- 
 lowed by redness of the face, bloody foam at the 
 mouth, and finally convulsions, sometimes general, 
 sometimes and more often, limited to one side or to 
 one-half of the face, to one arm or limb, and, as a 
 rule accompanied by a rise of temperature which 
 may reach to 104° P. 
 
 In the great majority of the cases the ej^ilepti- 
 form attack is not an isolated one, others occur dur- 
 
438 nrsAifiTf tntfi diseases oe BftAiif. 
 
 ing the same day separated by a longer or shorter 
 interval of coma ; sometimes there is a regular status 
 epilepticus. These attacks, which may reappear 
 many times in the course of the disease, especially 
 in its later stages, are always followed by an aggra- 
 vation of its symptoms, and occasionally by death, 
 which may be predicted by the progressive elevation 
 of the temperature. They often leave behind them 
 various complications such as hemiplegia, contrac- 
 tures, aphasia, etc. , generally transitory and capable 
 of a certain degree of amelioration. 
 
 The epileptiform attacks of general paralysis, 
 although not differing essentially in a clinical point 
 of view from true epilepsy, are yet separated from 
 its idiopathic form in many respects, and enter into 
 the category of symptomatic epilepsies. 
 
 Insanity Connected with Pakalttic Dementia. 
 {Paralytic Insanity). 
 
 Paralytic dementia of which the description has 
 been sketched in the foregoing pages, is the most 
 simple aud uncomplicated type of general paralysis, 
 its fundamental expression. It presents itself in 
 this form more frequently than is generally sup- 
 posed, if we take account not only of the cases ob- 
 served in the asylums but also of all those that exist 
 outside institutions of this kind, especially in females, 
 and which arc more or less unrecognized. But be 
 this as it may, in a large number of cases there are 
 supei-added to the symptoms described varied con- 
 
GENEEAL PAEALYSIS (pAEALTTIC mSAlTITT). 439 
 
 ditions of insanity, that is to say, a generalized 
 insanity of the maniacal or melancholic type is as- 
 sociated with the paralytic dementia, and impresses 
 upon the latter cerebral conditions certain special 
 characters that deserve our attention. 
 
 The form of insanity that occurs most frequently 
 in paralytic dementia, at least in its beginning, is 
 maniacal excitation with ambitious delusions. This 
 maniacal condition, which usually opens the scene, 
 consists in a more or less marked exaltation of the 
 intelligence, the feelings, and the bodily functions 
 (functional dynamy), in a marked mental and physi- 
 cal hyperactivity, an exaggerated desire for move- 
 ment, ideas of ambition, of invention, of riches, with 
 tendencies to absurd thefts, to erotism, to alcoholic 
 excesses, etc. , etc. Later as the dementia increases 
 this exaltation of the faculties gradually disappears, 
 and gives place to delusions of greatness that are 
 absolutely typical, the characteristic of which is their 
 absurd, mobile, contradictory and incoherent char- 
 acter. These characters are due to the dementia 
 which forms the basis of the mental condition. 
 The delusions of the patients include all possible 
 grandeurs. They have immense wealth, millions 
 and milliards, they are princes, dukes, bishops, 
 popes; they boast to the fullest degree strength, 
 health, fortune, business, success, their family, the 
 number of their children, etc. Everything in their 
 claims is superlative. Satisfaction and happiness 
 are shown in all their being. In general, and apart 
 
440 ITfSAITITT WITH DISEASES OF BEAIN. 
 
 from theii- temporary spells of passion, they are 
 good-natured, philanthropic and generous to excess. 
 
 E"ext to maniacal excitation, acute melancholia is 
 the most frequent form of insanity observed in the 
 beginning or during the course of pai'alytic demen- 
 tia. As we know, it was long held, with Bayle, 
 that ambitious delusions were constant and pathog- 
 nomonic in general paralysis, and it required all the 
 efforts of Baillarger to establish the fact that in this 
 disease the insanity was rather frequently of the 
 melancholic type. As this author has shown the 
 delusions in these cases generally manifest them- 
 selves in absurd, incoherent hypochondriacal ideas 
 relating to the organic functions and especially 
 those of the digestive tract. The patients claim 
 that their aliments do not pass, that they have no 
 mouth, no arms, they are constipated, obstructed, 
 rotten, they are dead, etc. More rarely they suffer 
 from ideas of persecution, of culpability, of ruin, 
 dishonor, etc. , and in these cases we may meet with 
 hallucinations of hearing, sight or touch, — moreover 
 usually denied — which seem to be less common in 
 in the other forms of paralytic insanity. Whatever 
 may be the form of the delusion it is essentially ab- 
 surd, silly, and incoherent. There are also very 
 frequently added refusal of food and ideas of 
 suicide. 
 
 After these two varieties of insanity, those most 
 frequently met with in paralytic dementia are : acute 
 mania, with very active excitement, delusions of 
 
GENEEAl PAEAITSIS (PAEALTTIC INSANITY). 441 
 
 greatness, incoherence, and violence; hyperacute 
 mania or acute delirium, which then takes the name 
 of acute paralytic delirium, and constitutes the most 
 acute and rapidly fatal of general paralysis; finally, 
 simple melancholic depression and sometimes mel- 
 ancholia with stupor. 
 
 The characteristic of all these conditions, of what- 
 ever form, is the absurdity of the coijceptions due to 
 the dementia. 
 
 These forms of insanity are associated with para- 
 lytic dementia in many different ways. 
 
 In certain cases an attack of maniacal excitement 
 with functional exaltation of potency, breaks out at 
 the very beginning of the disorder, and continues, 
 in more or less acute attacks throughout its whole 
 course. (General paralysis of the expansive type, the 
 maniacal type, the ambitious type). In other cases 
 melancholia with hypochondriacal delusions accom- 
 panies the affection from beginning to end. (Gen- 
 eral paralysis of the melancholic, depressive and 
 hypochondriacal types). 
 
 Occasionally also the insanity, after having ap- 
 peared in the melancholic or, what is more frequent, 
 the maniacal form, may disappear either at the com- 
 mencement or during the course of the disorder, 
 leaving behind it only the symptoms of paralytic 
 dementia. In such a case there is produced what is 
 called a remission, a clinical feature that has been 
 variously interpreted, but which ought to be consid- 
 ered with Baillarger, as the disappearance of the 
 
 Kent. Med. — 2B. 
 
442 INSAOTTT WITH DISEASES OP BEAIN. 
 
 attack of insanity with persistence of the paralytic 
 dementia, which continues its progress whether 
 complicated or not by new attacks of maniacal or 
 melancholic paralytic insanity. 
 
 In other cases still, the ambitious mania disappears, 
 but only to give place to an attack of melancholia, 
 generally hypochondriacal in its character, an altern- 
 ation which may be many times reproduced with or 
 without intermediate remissions, but generally in a 
 less regular manner than is the case in true double 
 form insanity. This is what has been designated 
 general paralysis of double form or circular paresis. 
 According to Baillarger's theory these cases are not 
 to be explained by a modification of the paralytic 
 dementia which itself remains fixed and unchangeable, 
 but by the circular character taken on by the in- 
 sanity instead of its continuing always the same. 
 Paralytic double form insanity and the remissions 
 are observed especially among the subjects of heredity 
 and more particularly amongst those with heredity 
 of vesania. 
 
 In some cases finally, the attacks of paralytic in- 
 sanity, whether mania, melancholia or circular, occur 
 and continue for a longer or shorter period, without 
 the symptoms of paralytic dementia manifesting 
 themselves. Recovery or death may take place 
 without their appearance (latent general paralysis). 
 
 Only by thus considering the relations of general 
 paralysis and insanity by their possible disassociation, 
 are we able to comprehend the very diverse ways of 
 
GENERAL PAEALTSIS (pAEALYTIC INSANITY) . 443 
 
 manifestation of the latter, which would be inex- 
 plicable were we forced to admit, according to the 
 unitary theory, that insanity formed one of the es- 
 sential constituent elements of general paralysis. 
 
 CouESE. DuEATioN. Teemination. — General pa- 
 ralysis may be either primary or consecutive to some 
 other disease, generally one of the nervous centres, 
 like locomotor ataxia, for example. When it com- 
 mences thus with spinal symptoms, it is called as- 
 cending general paralysis, or general paralysis by 
 propagation. 
 
 Here it should be stated that general paralysis and 
 tabes are diseases absolutely similar in origin and 
 nature and that they have very close relations with 
 each other. It is not uncommon to see general paral- 
 ysis beginning or terminating with the syniptoms of 
 ataxia, and even in some cases presenting through- 
 out its whole course a mingling of spinal and 
 cerebral symptoms. 
 
 The usual course of paralytic dementia, when un- 
 complicated, is progressive and the duration of all 
 three periods averages two or three years in the male 
 and three or four in the female, the longer duration 
 in the latter being due to the less frequency of con- 
 gestive complications. Its invariable termination is 
 in death. 
 
 When paralytic: dementia is accompanied with in- 
 sanity, however, its course may be modified. When 
 the insanity is of "the continuous type and persists all 
 
444 rNSAUlTT WITH DISEASES OF BEATN. 
 
 the time, no change occurs in the progress of the dis- 
 order except in oases when it takes on the hyperacute 
 form (paralytic acute delirium) when death super- 
 venes in from ten to fifteen days. If, however, the 
 insanity is of the remittent type (remissions) or the 
 circular type (alternating general paralysis) the 
 duration will be longer and may extend over seven, 
 eight, or even ten years or more. 
 
 Finally, when paralytic insanity appears alone 
 (latent general paralysis), recovery may occur either 
 temporary or definite, the incurable lesions of para- 
 lytic dementia not having yet developed. 
 
 Pathological Anatomy. — The lesions commonly 
 encountered in general paralysis are of two kinds, 
 macroscopic and microscopic. 
 
 Macroscopic Lesions. — The dura mater is very 
 often thickened, adherent to the cranial walls, with 
 here and there osseous deposits and in certain cases 
 with false membranes. 
 
 The arachnoid is also thickened and opaque, dis- 
 tended by the engorged vessels, and it has patches 
 of granulations of conjunctive tissue particularly 
 along the great longitudinal fissure. 
 
 The pia is usually injected and covered with ar- 
 borizations. It sometimes presents whitish streaks in 
 the periphery of the vessels. 
 
 The meninges are almost always adherent to the 
 cortex of the brain. These adhesions, noticed by the 
 earliest observers, are properly considered to be the 
 
GENEEALPAEALTSIS (PAItAlTTICINSAiaTT). 445 
 
 most characteristic and constant of the macroscopic 
 lesions. In some exceptional cases they may be want- 
 ing. Sometimes they are hardly apparent, especially 
 when the patient succumbs in the early stages of 
 the disorder, the meninges then being just barely 
 attached to the cerebral cortex. Commonly the 
 meninges m being detached take with them small 
 portions of the cortical tissue, so that after their 
 removal the brain surface shows here and there 
 more or less marked erosions or ulcerations. The 
 most frequent seat of these adhesions is the super- 
 ficies of the cortical folds of the antero-lateral 
 lobes, particularly the horizon of the convolutions 
 bordering the fissure of Rolando. Sometimes, on the 
 other hand, they predominate in the occipital region, 
 occasionally they are scattered over the whole brain. 
 
 The cortical layer is thinned, there is absorption 
 and atrophy. It is softened and comes away in pulp. 
 It separates the more easily from the white substance 
 which is, on the other hand, indurated. By scratch- 
 ing with the back of a scalpel the cortical layer be- 
 comes detached and there is produced the phenom- 
 enon of crests (Baillarger), that is, we cause white, 
 firm ridges or crests, entirely deprived of gray 
 matter. 
 
 The lateral ventricles, and especially the fourth 
 ventricle, are lined with serous exudate and nearly 
 always show the so called ependymal granulations 
 (Joire, Magnan, and Mierzfejewski). These granu- 
 lations are like bits of parchment or of chicken's 
 
446 IlfSANITT WITH DISEASES OF BEAIN. 
 
 flesh ; if not at once seen they may be rendered visi- 
 ble by viewing obliquely the ependymal surface. 
 Sometimes the ventricular parietes are full of fine 
 holes. The cavity of the lateral ventricles seems 
 enlarged. 
 
 In the later stage the brain loses a noticeable part 
 of its weight, and the inequality between the two 
 hemispheres is increased. The gray matter varies 
 according to the degree of disorganization; it some- 
 times assumes a slaty color, which is due, according 
 to Baillarger, to purulent infection produced by the 
 eschars. 
 
 Microscopic Lesions. — These lesions are observed 
 at once in the vessels, in the interstitial tissue or neu- 
 roglia, and in the nerve substance proper. 
 
 The alterations of the vessels, the earliest and 
 most constant lesions, consist first in a considerable 
 increase .of the nuclei in the walls of the capillaries 
 which gradually becomed thickened and narrowed. 
 Then extravasations of blood occur, composed mainly 
 of white globules, and the adventitia, charged with 
 nuclei of new formation and deposits of pigment, 
 sometimes presents miliary aneurysms. 
 
 At a more advanced stage we observe in the ves- 
 sels various states of degeneration, such as colloid and 
 fatty degenerations. 
 
 The alteration of the interstitial tissue, which 
 begins in the inferior layers of the gray substance 
 and propagates itself from below upward, consists 
 in a morbid development of the connective tissue 
 
GENEEAL PABALTSIS (pAEALTTIC INSANITY). 447 
 
 cells, known under the name of spider cells. At the 
 same time the neuroglia increases, and according as 
 it develops, it crowds and chokes out the cerebral 
 cells. 
 
 The nerve substance proper may be relatively 
 spared, and its alterations are mainly secondary. 
 Its cells, compressed as we have seen by the pro- 
 gressive expansion of the connective tissue, undergo 
 a series of degenerative lesions; they become soft- 
 ened, lose their nuclei, and finish by a granular 
 fatty degeneration, at the same time as the intra- 
 cortical nervous fibres disappear (Tuczek, Targowla). 
 The white tissue resists longer, but finally succumbs 
 in its turn : we observe hypertrophy of the cylinder 
 axes, fragmentation of the myeline sheaths, and 
 their granular fatty degeneration. 
 
 The cerebellum, much more rarely affected, may 
 nevertheless show softening, serous induration, 
 atrophy of Purkinje's cells, etc. 
 
 The lesions of the brain extend as a rule to the 
 cord, which is in some cases profoundly altered, and 
 its posterior and lateral columns sometimes undergo 
 a sclerotic degeneration. 
 
 We also encounter lesions in the region of the 
 great sympathetic. According to Bonnet and Poin- 
 carr6, these lesions, which are very important, are 
 located in the cells of the ganglia, which first suffer 
 a pigmentary alteration and then in time disappear, 
 being replaced in part by cellulo-adipose tissue. Ac- 
 cording to the more recent researches of Popoff, the 
 
44& I]S'SAifITY WITH DISEASE8 OP BRAIN. 
 
 grand sympathetic exhibits in general paralysis two 
 kinds of lesions : (1) thickening of the vascular walls, 
 proliferation of interstitial conjunctive tissue of the 
 ganglia ; (2) diminution by half and extreme pigment- 
 ation of the cells, which undergo vacuolization but 
 never fatty degeneration. 
 
 The nerves are sometimes the seat of various alter- 
 ations. Sclerosis of certain cranial nerves, atrophy 
 of the sciatic, and also peripheral neuritis have been 
 found. 
 
 Tip to the present the nervous lesions have mainly 
 been studied in the pathological anatomy of general 
 paralysis. It is certain nevertheless that the viscera 
 are also altered and this also merits attention. It is 
 not uncommon, in autopsies, to find in one or many 
 of these organs, manifest traces of sclerosis or of 
 softening. 
 
 Diagnosis. — The diagnosis of general paralysis, 
 often easy on account of the assemblage of typical 
 symptoms accompaning the disease, may, neverthe- 
 less, in certain cases, present some real difficulties. 
 It will be most convenient here to consider separately 
 the diagnosis of paralytic dementia and of paralytic 
 insanity. 
 
 (1) . Simple paralytic dementia may be confounded 
 with apoplectic dementia. It can be distinguished 
 from the latter mainly by the fact that apoplectic 
 dementia, usually supervenes at a more advanced age 
 and ordinarily in atheromatous subjects; moreover, 
 
GENERAL tAEAtTSIS (pAEALYtIC ISTSANITt). 449 
 
 it is usually accompanied with hemiplegic symptoms 
 which are lacking in general paralysis ; the embarrass- 
 ment of speech is not the same ; pupillary inequality 
 is often wanting ; lastly, the sensibility is much more 
 marked and is sometimes charactei-istio. 
 
 Intracranial tumors (cancers, tubercles, syphilis, 
 cysticerci, echinocoeci, etc.), may give rise to enceph- 
 alopathies that are more or less analogous to general 
 paralysis. It is rare, however, for their symptoms to 
 be as diffuse and as generalized : on the contrary, 
 certain special symptoms, such as headache, amaur- 
 osis, vomiting, partial paralyses and epilepsies, are 
 very frequent. 
 
 A diagnosis is sometimes difficult between gen- 
 eral paralysis and multiple sclerosis in its imperfect 
 or its cerebro-spinal form. In some of these cases 
 there is a genuine embarrassment. As a rule the 
 signs of dementia are less marked in multiple scle- 
 rosis; moreover, certain physical signs such as 
 embarrassment of speech and tremor have different 
 characters from those in paresis. 
 
 The most important and the most delicate diag- 
 nosis, however, is beyond dispute that between the 
 true and the pseudo-general paralysis. Under this 
 latter name it is understood we include those cere- 
 bral conditions clinically analogous to general paral- 
 ysis, but differing from it in their tendency to 
 recovery. Some authorities who do not recognize in 
 principle the existence of pseudo-general paralysis 
 consider these conditions as special forms of paresis. 
 
450 llJSANITT WITH DISEASES Of BEAIN. 
 
 The greater number, however, see in them only- 
 more or less exact morbid imitations of general paral- 
 ysis. Substantially there is between these two ways 
 of viewing the subject only a simple difference of 
 the names of special general paralysis and pseudo- 
 general paralysis, all the world being in accord as 
 to the reality of the clinical facts. It is better 
 therefore to continue to accept pseudo-general 
 paralysis, just as we admit, at present, pseudo-tabes 
 and pseudo-multiple scleroses. 
 
 The pseudo-general paralyses are, for the most 
 part, the result either of an infection (syphilitic 
 pseudo-general paralysis) , or of an intoxication (al- 
 coholic, saturnine, etc.), possibly also of a neurosis 
 (hysterical, neurasthenic, epileptic pseudo-general 
 paralysis). As the lamented Baillarger insisted, up 
 to the last days of his life, it is not paralytic insan- 
 ity that they simulate (there is not and cannot be 
 any pseudo-paralytic insanity, since paralytic insan- 
 ity is itself susceptible of cure) , but the true general 
 paralysis, properly so styled, or paralytic dementia, 
 with or without delusions. They present them- 
 selves therefore with the symptoms of dementia and 
 paresis that characterize this disorder. The clinical 
 picture may be more or less identical ; it is often such 
 that any symptomatic diagnosis is impracticable 
 from the beginning. Thus it is certainly not from 
 the difference of the symptoms that the distinction is 
 made, as has been vainly attempted by the majority 
 of authors. In my opinion this distinction is only 
 
GBNEEAl PARAITSIS (PAEALYTIC INSANITY). 451 
 
 to be found in the difference of the course and prog- 
 nosis and consequently in the lesions. As I have 
 said already in reference to syphilitic pseudo-gen- 
 eral paralysis, the genuine general paralysis has a 
 progressive course, a fatal prognosis, and irremedi- 
 able lesions. Pseudo-general paralysis, whether in- 
 fectious as in syphilis, or toxic as in alcoholism, has 
 a regressive course, a relatively favorable prognosis, 
 and curable lesions. It follows therefore that the 
 diagnosis between the two depends essentially on 
 the radically different evolution in the two cases. 
 
 (3). Paralytic insanity may be confounded with 
 simple insanity in the various forms under which it 
 presents itself. 
 
 Thus the attacks of maniacal excitement of the 
 beginning of general paralysis may be taken either 
 for an attack of simple maniacal excitement or for 
 the excited period of a double form insanity, which, 
 as we have seen, often assumes this type of mania. 
 The diagnosis is, in general, very difficult and is 
 sometimes even impossible, since at this stage there 
 is not yet any dementia in general paralysis ; and, on 
 the other hand, the physical signs are but little ap- 
 parent, and also may exist to the same extent in double 
 form insanity. The two most important diagnostic 
 signs are : (1) the initial signs of mental weakening 
 which show themselves from the beginning in pare- 
 tics ; (3) the good nature and habitual generosity of 
 these patients which, at this period in particular, are 
 in strong contrast with the usual maliciousness of 
 
453 INSAiaTY WITH DISEASES OS' BEAIN. 
 
 the insane of the double form type. The history of 
 the case comes in to remove all doubts by showing 
 in the latter either prior attacks or a vesanic hered- 
 ity, often similar in kind. 
 
 When general paralysis has progressed and the 
 ambitious delusions are in full swing, it is hardly 
 possible to mistake it with the insanity of exaltation 
 (partial insanity). Aside from the fact that the am- 
 bitious delusions of paralytics have a stamp of de- 
 mentia, of absurdity and incoherence, altogether 
 lacking in the other, we know also that the exalted de- 
 lirium of partial insanity is never a primary form, but 
 that it succeeds another type of delusions, generally 
 those of persecution; it is, moreover, accompanied 
 by numerous hallucinations, while hallucinations are 
 rather rare in general paralysis, at least in its mani- 
 acal form. Finally, taking into account only the 
 insanity itself, the dilire des grandeurs of general 
 paralysis is a generalized insanity, that is to say, at- 
 tended with excitement, while ambitious delusions 
 form a partial insanity. 
 
 The acute mania of paralytic insanity may be taken 
 in its beginning for an attack of acute simple mania, 
 and in the same way the acute paralytic delirium may 
 be mistaken for simple acute delirium. The diagnosis 
 in these cases is often very difficult, and in some 
 cases can only be made at the autopsy. It is necessary 
 to take into account the age of the patient and his 
 antecedents and to particularly look for the physical 
 signs of general paralysis. 
 
GENEEAL PAEAITSIS (PAEALTTIC INSANITY). 453 
 
 Melancholia of paralytic insanity may he confused 
 with simple insanity or with the melancholic stage 
 of double form insanity. It must be kept in mind 
 that as a rule physical symptoms and mental weak- 
 ness are present in general paral/Sis. The delusions, 
 moreover, take ordinarily an absurd and often typic- 
 ally hypochondriacal form, although, as I have 
 shown, this may also be met with in certain cases of 
 simple melancholia. 
 
 Paralytic insanity may present itself under the 
 form of stupor and the patient neither speaking nor 
 moving, the diagnosis is almost impossible. The in- 
 equality of the pupils is almost the only differential 
 sign of any value. 
 
 It would seem that when paralytic insanity assumed 
 the alternating form that it ought to be hard to dis- 
 tinguish from double form insanity. This is not the 
 fact, however, since in these cases the physical symp- 
 toms are usually more or less marked ; moreover the 
 return of the attacks never occurs with the same 
 regularity as in those of double form insanity. 
 
 Etiology. — The etiology of general paralysis has 
 always been one of the points most discussed in the 
 history of this affection. The predominant opinion 
 at the present time is that which attributes it to the 
 joint action of two causes : a predisposing cause, rep- 
 resented by a congestive or cerebral tendency, usually 
 hereditary ; and an occasional cause, which is nearly 
 always syphilis. At least this is my own opinion, 
 
454 INSANITY WITH DISEASES OF BEAIN. 
 
 as well as that of a great number of authorities, 
 especially in other countries. 
 
 We must pass in review here the principal pre- 
 disposing and determining causes, both general and 
 individual, that influence, more or less, the develop- 
 ment of general paralysis. 
 
 Peedisposing Causes. — Epochs and Countries. — 
 The question whether or not general paralysis existed 
 in the past centuries has been much discussed, and 
 if it had been ever so infrequent it ought not to 
 have completely escaped the attention of our prede- 
 cessors. On the other hand there is no doubt that 
 its frequency tends to increase from day to day. 
 We may, therefore, conclude with certainty that 
 general paralysis is a contemporaneous malady and 
 especially a disease of the nineteenth century. This 
 fact should be compared with the marked predilec- 
 tion it shows for certain countries and especially for 
 the great centres. In a general way, in fact, and 
 aside from certain exceptions, it is rare in uncivil- 
 ized lands, while on the contrary it is very frequent 
 amongst the peoples who have reached theii- apogee 
 and are on their decline. 
 
 Western Europe and North America are therefore 
 the principal foci of this disease. In this regard an 
 American author has said that the frequency of gen- 
 eral paralysis in the various countries may serve in a 
 certain measure as the thermometer of the degree of 
 their civilization. It may be admitted, consequently, 
 
GENERAL PAKAITSIS (pAEAlTTIC INSANITY). 455 
 
 that the excesses of civilization and the evil effects 
 of all kinds that follow, by causing a cerebral wear 
 and tear that goes on augmenting from generation 
 to generation, gradually diminish the power of 
 resistance of the nervous system in the descendants 
 and create in them a predisposition to degenerative 
 cerebral affections, and notably to general paralysis. 
 -^ffe. — General paralysis is, as I have elsewhere 
 called it, a climacteric disease, that is, one associated 
 with a certain period of existence. This period is, 
 as we are aware, the apogee of life. M. Luys has 
 explained perfectly the reason of this by showing 
 that the interstitial framework of the brain, the 
 evolution of which is continuous, finds itself at this 
 moment in a state of critical proliferation, in " a sort 
 of preparatory physiological condition that may inci- 
 dentally become a pathological process under the in- 
 fluence of an incidental nutritive hyperexcitation. " 
 As regards the epoch of maximum frequency of gen- 
 eral paralysis, it is rather hard to fix it absolutely. 
 While it was set at forty-five, forty-eight, and even 
 fifty years in Bayle and Calmeil's times, it has cer- 
 tainly decreased since then and, for myself, I found 
 it at thirty-eight in three hundred and seventy gen- 
 eral paralytics that came under my observation at 
 the Asylum of Sainte-Anne. This lowering of the 
 average age of the malady speaks ill, according to 
 the English author Mickle, for the vitality of the 
 populations of Western Europe, at least, inasmuch 
 as general paralysis is to be considered ^.s the result 
 
456 INSANTTT WITH DISEASES OP BR4.IN. 
 
 of an exaggerated expense of vital force and of a pre- 
 mature senility. Besides this reduction of the age 
 at which general paralysis most generally manifests 
 itself, it is certain that we tend to observe cases oc- 
 curring prior to the culminating point of life. In a 
 recent study of these oases, which I have called pre- 
 mature general paralysis, I showed that it is possible 
 to find cases under twenty years of age. Since then 
 new facts have been published, and it is generally 
 admitted now that there is a premature or precocious 
 general paralysis, which commonly appears in the 
 form of simple paralytic dementia, and which seems 
 to be the result of a precocious syphilis, personal or 
 hereditary. On the other hand there may occur 
 cases of late general paralysis, occurring after the 
 age of sixty or sixty-five years. This form of gen- 
 eral paralysis, called senile, also bears the name 
 atheromatous, since it is nearly always accompanied 
 with lesions of the heart or arteries. 
 
 Hbkbditt. — As, we have said above, the most 
 important predisposing cause of general paralysis is 
 the congestive or cerebral tendency, usually the 
 result of heredity. For a long time the heredity of 
 the insanity and that of general paralysis were con- 
 fused, and some authorities still hold, with Marc6, 
 that these two affections have a common origin and 
 reciprocally engender each other. But this is an 
 error. General paralysis has its source in an heredity 
 ^hat is not vesanic but cerebral arthritic or congestive, 
 
GENEEAIi PAEALTSIS (PAEALTTIC LNSANITT). 457 
 
 as Jias Ibeen shown by the memoirs of Lunier, Dou- 
 trebente, Baillarger, Ball and R6gis, Lenioine and 
 Pierret. We may, it is true, meet with paretics, the 
 issue of insane parents, but I have noticed that this 
 particularity shows itself in the vesanic, remittent or 
 circular form, in a word, that it is imposed upon the 
 general paralysis by the predominance in the subjects 
 of the paralytic insanity over the paralytic dementia. 
 
 I have many times consecutively found consan- 
 guinity in the ancestors of general paralytics. 
 
 Sex. — It has always been remarked that general 
 paralysis is more frequent in the male sex, and also 
 that it becomes more common in the male according 
 as we rise in the social scale, while the contrary is 
 true of the female. The special study I have 
 given to the disease as it occurs in the latter has en- 
 abled me to reach the following conclusions which are 
 evidently only applicable to France: (1) In the pop- 
 ulation of the rural districts general j)aralysis of the 
 insane is hardly one and a half times more common in 
 men than in women, and is very rare in either sex ; 
 (2) among the laboring population of the large cities 
 it is three times more common in men than in 
 women, and is relatively frequent in both; (3) 
 in the higher classes of society it is nearly 
 thirteen times more frequent in men than in 
 women, and is very common in the former while 
 it is rare in the latter. In proportion to the whole 
 number of the insane, it was found: (1) 3 male 
 paralytics in 100 insane males in the country, and 
 
 LlEHT. UBO. — 29. 
 
458 INSANITY WITH DISEASES OP BEAIK. 
 
 2.13 female paralytics in every 100 female insane; 
 (3) in tlie working classes of the large cities 23 par- 
 alytic males in 100, and 7.7 paralytic females; (3) 
 finally, in the higher classes of society, 33. 33 paralytic 
 males and 2.58 paralytic females. My investigations 
 were made on 7,552 insane of both sexes, including 
 868 general paralytics. These figures approach very 
 nearly those of MM. Christian and Ritti and those 
 of M. Plants. It is also generally agreed that at the 
 present time the increase in the number of cases of 
 general paralysis is much more noticeable in the 
 female than in the male. Of late years there have 
 been observed a certain number of cases of conjugal 
 general paralysis, i. e., affecting husband and wife 
 at the same time. These cases seem to be due to 
 the reciprocal syphilization of the two partners. Not 
 only is general paralysis less frequent in the female, 
 but it presents in her some special features. It 
 occurs sometimes in the prime of life, sometimes, on 
 the contrary, later and especially at the critical age ; 
 it usually takes the form of simple paralytic dementia, 
 and, lastly, it persists for a longer time. 
 
 Professions. — It is the liberal professions, the 
 intelligent classes and generally those that labor 
 most with their brains that furnish the greatest con- 
 tingent to general paralysis, at least in men. This 
 has been recently contested, but not with reason, by 
 M. Arnaud. It is in fact sufficient to fix the com- 
 parative ratio of general paralysis to the other forms 
 of insanity in the different establishments for the 
 
GfiNSEAt PAEALTSIS (p ANALYTIC INSANITY). 459 
 
 insane, to demonstrate that this proportion is higher 
 in the private than in the public institutions of the 
 same centre, and also, what is very significant, that 
 it is greater in the private asylums of the provinces 
 than in the public asylums of the great cities and of 
 Paris. In the higher society general paralysis is 
 particularly frequent among savants, lawyers, phy- 
 sicians, politicians and business men, artists, the 
 military (especially the oflScers). 
 
 OccAsiONAi. Causes. I — It was said in the beginning 
 of the remarks on etiology that the most potent oc- 
 casional cause of general paralysis is syphilis. This 
 is at present the common opinion abroad, as is 
 demonstrated by numerous statistics published on 
 all sides. In France this is not the case, and it is 
 hardly two years since I, with MM. Morel-Lavall6e 
 and Beli^res, was almost alone in supporting this 
 opinion. It must be said that, imbued with the opin- 
 ion that syphilis is rare in general paralysis and that 
 it can only produce a pseudo-form, the majority of 
 alienists of our country remained indifferent to the 
 question and abstained from any personal investi- 
 gation in this direction. Since, however, a certain 
 interest has been aroused in the matter, this 
 indifference has decreased, and already many 
 statistical contributions have appeared that indicate 
 that when one takes the trouble of investigating with 
 the needful perseverance it is found that syphilis 
 exists, as I have held, in seventy to ninety cases out of 
 
460 IS-SAHITY W-IlH DISEASES OF SEAUf, 
 
 a hundred in general paralysis (Bonnet and Anglade, 
 Theses, 1891). There is reason to believe that these 
 statistics, absolutely conclusive as they ai-e, will not 
 delay multiplying and that in a short time a very 
 large majority of French alienists will be fully con- 
 verted to the opinion of the extreme frequency of 
 syphilis in general paralysis. When this point is 
 reached, and, I repeat, I have no doubt in regard to it, 
 it will then be in order to find out whether general 
 paralysis is a disease due to syphilitic lesions, known 
 or unknown, or a cerebral entity indirectly devel- 
 oped under the influence of syphilis ; in other words, 
 whether it is a syphilitic or a Para-syphilitic dis- 
 order. The question is now at this stage in other 
 countries; the chances of its solution will only be 
 increased when we take it up ourselves. 
 
 Aside from the eilect of syphilis, which, I repeat, 
 seems to be preponderant, the other occasional causes 
 of general paralysis that may be cited are : mental 
 overstrain, venereal excesses, and the various intoxi- 
 cations (nicotinism, alcoholism, saturnism, pellagra, 
 etc.), which themselves especially give rise to pseu- 
 do-general paralysis. There have been noted also, 
 as more or less active causes, the effect of insolation 
 and of sojourns in an overheated temperature, the 
 menopause, the suppression of hemorrhoids, or men- 
 struation, cranial injuries, erysipelas of the face, 
 typhoid fever, and lastly, locomotor ataxia and even 
 diphtheria. General paralysis does not favor certain 
 conditions like the hysterical tendency. It only 
 
GENERAL PAEALTSIS (PAKALTTIC INSAJTITt). 461 
 
 develops in such but rarely and when it exception- 
 ally does occur, it may cause, as I have indicated, a 
 kind of antagonism between the neurosis and the 
 general paralysis, from which results a suspensory 
 action or an inhibitory action of the first upon the 
 second. It is also this antipathy of general paralysis 
 for the nervous diathesis that forms, according to 
 my opinion, one of the principal reasons of the less 
 frequence of general paralysis in females. 
 
 Treatment. — In the majority of cases general 
 paralysis is only recognized after it has clearly mani- 
 fested itself. It is therefore nearly always impossi- 
 ble to institute any preventive treatment. 
 
 It is very important to know in what conditions 
 of general paralysis sequestration becomes necessary. 
 Although it is perhaps impossible to establish any 
 fixed rule in this regard, it may be said that in a 
 general way confinement is needed in every case 
 attended with insanity, whatever may be its 
 character, maniacal or melancholic, while it is 
 not absolutely necessary in cases of simple par- 
 alytic dementia. Sequestration should be ad- 
 vised especially in the beginning of the disorder, 
 when maniacal excitation exists, as it is in this 
 stage, so justly called by Legrand du Saulle the 
 medico-legal period, that the patients are led to 
 commit criminal acts, particularly absurd thefts, or 
 to launch out in adventurous projects and imperil 
 ^beir fortupes, fn case of remissions iii tjae course 
 
462 INSAITITT WITH DISEASES OF BEADT. 
 
 of the disease, it is needful to exercise great pru- 
 dence as to setting the patients at liberty, as these 
 remissions are commonly only temporary, and gen- 
 erally dependent on the sojourn of the patients in 
 the establishment for the insane. 
 
 The medical treatment, properly speaking, of gen- 
 eral paralysis includes an infinite number of agents, 
 none of which, unfortunately, has up to this time, 
 afforded any really favorable results. Those from 
 which the best effects have been obtained are 
 revulsives applied to the nucha, especially setons, 
 permanent vesication, fine cauterization of the pos- 
 terior cervical region; unfortunately these are efii- 
 cient only early in the disease and are, moreover, 
 borne only with impatience by the subjects. Large 
 and repeated paintings with iodine may also be tried 
 as recommended by Pritchard Davies, and cautious 
 suspension with a modified Sayre apparatus from 
 which good results have been obtained by M. Fri^se 
 and myself. As to irritant frictions of the scalp, re- 
 commended by some authors, and trepanation, recent- 
 ly tried by Shaw and Batty Tuke, they should be 
 rejected as too painful and without any real action. 
 The same is the case with mineral waters, sea bath- 
 ing, and especially hydrotherapy, very often pre- 
 scribed for paralytics in the early stages of their 
 malady, but which are hurtful rather than useful and 
 too often have only the effect of augmenting the 
 already existing tendency to cerebral congestion. 
 One should also be very cautious as to abstraction of 
 
GENERAL PAEAIYSIS (APOPLECTIC DEMENTIa). 463 
 
 blood and have recourse to it only in exceptional 
 cases. Some authors have obtained good effects 
 from the use of galvanic currents to the spinal cord. 
 In the way of medication, antisyphilitic treatment 
 may be tried, which unfortunately is almost always 
 without any decided effect, the iodide of potash alone, 
 in moderate doses and according- to the case, sedatives, 
 opium, morphine, veratrine, hyoscyamine, hyoscine, 
 chloral, sulfonal, hypnal, bromides, digitalis, er- 
 gotine, bitter tonics, iron preparations, but especially 
 the evacuants, which, administered at proper times, 
 may have a salutary effect on the course of the 
 malady and may even prevent the congestive com- 
 plications. In case of congestive attacks, sinapisms, 
 repeated purgative enemas, alkaline bromides, asso- 
 ciated or not with chloral, and finally subcutaneous in- 
 jections of ergotine, recommended by Christian and 
 Girma, should be employed. Other complications, 
 such as refusal of food, incoercible agitation, retention 
 of urine, untidy condition, eschars on the sacrum, 
 incidental diseases, etc., etc., call for appropriate 
 hygienic and therapeutic attention. 
 
 Apoplectic Dementia. 
 
 Circumscribed lesions of the brain rarely give 
 rise to attacks of insanity properly so-called; they 
 oftener produce a variety of dementiaj known 
 under the name of apoplectic, organic, or^^hemiplegic 
 dementia, to differentiate it from the simple or 
 senile forms. Among these ^lesions, focal softening 
 
464 DiTSAlinTT WITH DISEASES OF BEAIN. 
 
 is the one that produces the most pronounced mental 
 symptoms. 
 
 There is a prodromal period of more or less 
 duration, with symptoms of depression or, on the 
 other hand, of excitement, continual desire to sleep, 
 hallucinations, particularly visual ones, obtusion of 
 intelligence, followed hy hemiplegia of the left or 
 right side, and with this last almost always aphasia. 
 There are cases where the mind is intact, but these 
 are rare, and the patient generally continues worse 
 in this respect after the attack; sometimes even 
 the mental enfeeblement becomes progressive and 
 terminates in complete dementia, with which may 
 be associated more or less acute attacks of mania 
 and, even more probably, melancholia. 
 
 The most salient clinical feature of apoplectic de- 
 mentia is the tendency to emotional disturbance 
 which is particularly shown by these patients in 
 spells of crying on the occasion of their being asked 
 the slightest question. According to M. Luys, this 
 emotionality is more marked with left than with 
 right hemiplegia, and he recognizes as its anatomical 
 localization a lesion of the cortex which corresponds 
 with the upper part of the right temporal lobe at 
 the inside of the Sylvian fissure. 
 
 In other respects, apart from bodily symptoms, 
 apoplectic dementia is almost analogous to senile 
 dementia. 
 
LOCOMOTOB ATAXIA. 465 
 
 §n. msAmxiEs connected with diseases 
 
 OF THE SPINAL CORD. 
 
 (Locomotor Ataxia. Mitltiplb SctEEoais). 
 
 LocoMOTOB Ataxia. 
 
 Since attention has been especially called to the 
 mental state of Jabetic patients, it has been recog- 
 nized that mental disorders are very common in them. 
 Usually these are limited to simple modifications 
 of the intellect and character that show themselves 
 in irritability, distrustfulness, low spirits, hypo- 
 chondria, discouragement and tendency to suicide. 
 In some cases, and this may occur in the beginning, 
 in the pre-ataxic period, sensory disturbances make 
 their appearance, consisting in illusions and hallu- 
 cinations, more or less conscious, principally in the 
 domains of vision, of audition and of general 
 sensibility. 
 
 The psychic disorders, however, are not always 
 thus limited and in certain cases they reach genuine 
 insanity. Pierret and Rougier, who have made a 
 special study of this insanity, have shown that it is 
 usually a lypemaniacal condition, with vague ideas 
 of persecution and confused hallucinations. The 
 patients accuse persons about them of wishing to 
 poison them, of burning them, they complain of 
 hearing insults, of having a bad taste in their food 
 and in their mouths, and of feeling tingling and 
 other disagreeable sensations all over their bodies. 
 The insanity may likewise reveal itself under tixQ 
 
466 INSANITY WITH DISEASES OE SPINAL COED. 
 
 hypochondi-iacal or the ambitious form as in general 
 paralysis. 
 
 Moreover, tabes may be accompanied with an 
 intellectual enfeeblement which occasionally causes a 
 decided difficulty in the diagnosis between it and 
 general paralysis. There are also cases, as we have 
 seen, where the disorder becomes complicated, so to 
 speak, hybrid, and has at the same time the char- 
 acters of tabes and general paralysis. 
 
 MXTLTIPLB SOLBEOSIS. 
 
 Disseminated sclerosis, like locomotor ataxia, may 
 induce a condition of mental failure that, on account 
 of the concomitant tremor and embarrassment of 
 speech, suggests more or less strongly paralytic 
 dementia. The facts on which the sometimes diffi- 
 cult diagnosis is to be based have been already 
 pointed out. The less constant and less pronounced 
 mental weakness, the more paralytic than ataxic 
 embarrassment of speech, and, lastly, the intention 
 tremor, particularly mark multiple sclerosis. 
 
 It is rare that insanity complicates multiple scle- 
 rosis ; on the other hand, rudimentary psychic disturb- 
 ances, alterations of the intelligence and changes of 
 character are rather frequent, but do not offer any 
 point of special interest. 
 
EPILEPTIC IKSAKITT. 467 
 
 §111. INSANITIES CONNECTED WITH 
 NEUEOSES. 
 
 (Epilbpst, Hysteeia. Chobea, Pabalysis Aoitahs, Exophthalmic 
 Goitke). 
 
 The mental disorders connected witli the neuroses, 
 especially those complicating epilepsy and hysteria, 
 are described in most works devoted to nervous dis- 
 eases and are consequently known to all. I will here 
 only review their principal features. 
 
 EpII/BPSY. 
 
 {Epileptic rasanity). 
 
 We here have to notice successively: (1) the men- 
 tal condition of the epileptics ; and (3) epileptic in- 
 sanity properly so-called. 
 
 1. The Mental Condition op Epileptics. — 
 When epilepsy is not engrafted upon some mental in- 
 firmity, such as imbecility or idiocy, epileptics are 
 often very intelligent. It is only in the long run 
 that the mental faculties are altered or enfeebled. 
 The mental disturbances are mainly shown in the 
 character. In regard to this there are two classes 
 of epileptics, the ones sombre, taciturn, distrustful, 
 quick to take umbrage, always ready to quarrel, to 
 wound, to strike ; the others, on the contrary, are obse- 
 quious, obliging, cajoling, full of effusiveness and 
 goodness, but a goodness that is only in appearance 
 ap4 that hides their claws, In fact, epileptics 
 
468 INSAinTIES CONNECTED WITH NETTEOSES. 
 
 are subject to fits of choler, and to violent and furi- 
 ous passions, during which they are not masters of 
 themselves and would readily commit homicide. 
 They are often vicious and have perverse instincts; 
 they are gluttonous, thieves, masturbators, falsifiers, 
 etc. They often have a tendency to a morbid piety, 
 a sort of outer religiousness mixed with hypocrisy 
 which is never so marked as at the time of their at- 
 tacks. The note of their character is therefore irri- 
 tability. 
 
 The intellectual disorders often remain at this 
 stage, either constantly or during the intervals of 
 the attacks, which themselves may be accompanied 
 or followed by short delirious or impulsive attacks. 
 Frequently also epileptics become fully insane. 
 
 2. Epileptic Insanity. — We must distinguish in 
 epileptic insanity the insanity of the intervals from 
 the attacks and the insanity of the convulsive crises. 
 
 The insanity of the intervals between the attacks 
 is rather rare, as epileptics are not ordinarily in a 
 state of permanent derangement, the insanity is gen- 
 erally remittent or intermittent. This form may 
 occur, nevertheless, and in this case it assumes any 
 form whatever, maniacal or melancholic, sometimes 
 melancholico-maniacal. Its special characters are 
 that it is most frequently accompanied with ideas of 
 persecution, with a tendency to fits of passion, and 
 especially to irresistible impulsions (homicide, 
 suicide), and finally its co-existence with terrifying 
 balluciuations, 
 
EPILEPTIC IHSANrfY. 469 
 
 The insanity connected with the epileptic attack 
 itself may supervene : A, before; B, during; and C, 
 after the attack. 
 
 A. — The pre-paroxysmal epileptic insanity may 
 show itself either by maniacal excitement or, on the 
 contrary, by a more or less profound depression, 
 preceding the attack for several days ; but it is much 
 more common to see the attack itself preceded by 
 hallucinations, especially of sight and of a terrify- 
 ing character. These hallucinations may be of 
 spectres, of wheels, of gigantic objects, of wild 
 beasts, and there may be also disagreeable or nau- 
 seous odors, or, more rarely, auditory hallucinations. 
 As a rule the hallucination reproduces itself in con- 
 secutive attacks. It is very common to see the 
 patients make always the same gesture or pronounce 
 the same words at the moment of'^alling. 
 
 Sometimes the fall occurs at the moment the hal- 
 lucination appears ; if this is not the case the patient 
 has time to perform some insane or strange action, 
 or to give himself up to a more or less noisy 
 delirium. 
 
 B. — From the moment the cry is uttered or the 
 attack begins, the patient loses his consciousness, 
 and the characteristic of the insanity which is pro- 
 duced with the epileptic attack is the absolute loss 
 of consciousness and memory that attends it. This 
 is so characteristic a symptom that it is not met 
 with, with the same evidences, in any other form of 
 insanity. 
 
470 msA]SfI*IBS COtTNECi'fiD WlTtl NEUftOSES, 
 
 During the attack itself the insanity cannot occur 
 except when the convulsions are lacking and are re- 
 placed by an attack of insanity (larvated epilepsy). 
 The attack of insanity in this case commonly consists 
 in a violent spell of mania, lasting for one or for 
 several days, and succeeded by a greater or less de- 
 gree of prostration, this last sometimes going so 
 far as to stupor. But still oftener the attack is re- 
 placed, by a sudden instantaneous impulsion, nearly 
 always the same, to homicide, suicide, arson, exhi- 
 bition of the genital organs, obscene acts, theft, some 
 wild prank, etc., etc. On each new occasion the 
 convulsions are replaced by an impulse almost 
 invariably the same and producing itself under the 
 same conditions. These cases are commoner than is 
 generally supposed, since epilepsy is not suspected 
 by reason of the absence of the convulsions. When 
 he comes to himself the patient has not the least 
 consciousness of what he has done. Frequently it 
 happens that he starts off during the attack and is 
 astonished to find himself, at the end of a day or 
 two, very far from his home, without knowing how 
 he came there (comitial ambulatory automatism). 
 
 C — The insanity consecutive to the attack is of 
 all varieties the most common. 
 
 It may manifest itself by a spell of melancholic 
 depression, sometimes going as far as stupor, with 
 prostration, immobility, hebetude, terrifying hallu- 
 cinations, etc. It may, and this is more often the case, 
 be constituted by a period of excitement, sometimes 
 
EtlLEPTlC IlSrSANITf . 4')'1 
 
 very acute, with loquacity, choler, spells of passion, 
 impulsions and furor. Usually there supervenes 
 an attack of acute mania that breaks out sud- 
 denly within a longer or shorter period after 
 the convulsions, and is accompanied by a noisy 
 incoherent delirium or sudden impulsions to 
 destructiveness, homicide, or arson. This is the 
 time when epileptics are most dangerous. They 
 have no control of themselves and assume a terrible 
 appearance. With flushed and swollen countenance, 
 staring eyes, and strength multiplied, they smash, 
 destroy, and strike, with a blind fury, everything 
 that is before them. 
 
 These spells are not often of long duration ; after 
 a few days the symptoms gradually subside, to 
 reappear in subsequent attacks, generally with the 
 same characters and peculiarities. 
 
 Epileptic insanity terminates after a longer or 
 shorter time in mental enfeeblement and dementia, 
 which, in some individuals, may assume, more or less 
 closely, the aspect of paralytic dementia in its cachec- 
 tic period. There are even cases where the diag- 
 nosis may, at this stage, present some difficulty. 
 
 Diagnosis. — The diagnosis of epileptic insanity is 
 not usually difficult when the mental symptoms ac- 
 company the paroxysm. It is sometimes very diffi- 
 cult when the epUepsy is larvated. 
 
 The sudden and instantaneous impulsions, the 
 repetition of the same symptoms with identical 
 
472 INSANITIES CONNECTED WITH NEtTEOSES. 
 
 peculiarities, and lastly and particularly the absolute 
 unconsciousness of the attack, are characteristic of 
 epileptic insanity. 
 
 Peosnosis. — Very grave. We are ordinarily 
 without resources in epilepsia vera. 
 
 Tebatmbnt. — The treatment of epileptic insanity 
 is the same as that of epilepsy in general. It con- 
 sists therefore in the prolonged usage of sedatives 
 and antispasmodics. 
 
 The chief indication when epilepsy is accompanied 
 with insanity is to sequestrate the patients. On ac- 
 count of the unconscious and generally dangerous 
 impulsion to which they are so often subject, it is, in 
 fact, very imprudent to leave them at liberty. Even 
 in establishments for the insane they almost al- 
 ways require special supervision, and as we are 
 aware the [French] law requires the separation 
 from the other insane of epileptics when they are in 
 excess of a certain number. 
 
 Htstbria. 
 {Hysterical Insanity). 
 
 As in the case of epilepsy we must here examine 
 successively the hysterical mental state and hysteri- 
 cal insanity. 
 
 1. Mental Condition of Htsteeia. — The 
 future hysterical subjects reveal, in a mental point 
 of view, their peculiar characters at a very early age, 
 
HTSTEEICAl INSANITY. 473 
 
 They are, for the most part, young girls of great 
 mental vivacity, excessively precocious, impres- 
 sionable, coquettish, fond of attention, skilled in 
 deception and falsehood, subject to more or 
 less marked disorders, especially to night terrors, 
 dreams, nightmares, and often also to palpitations 
 and ansemia. Hysteria once established, the mental 
 and moral condition of its subjects is characterized 
 principally, as regards the intellect, by an excessive 
 mobility so that the patients have no spirit of order, 
 no fixed idea, and while able to show on occasion, 
 a cultivated, brilliant and often caustic wit, they are 
 absolutely unfit to follow any serious business. 
 With this there exists a very marked tendency to 
 contradiction and controversy, and also to imitation, 
 and to paradoxical ideas and to opinions that may 
 distinguish them and make them conspicuous. Mor- 
 ally, their condition is the same. Their character is 
 bizarre, capricious, fantastic, mobile to excess, their 
 sensibility very lively and out of proportion to 
 occurrences ; there are perpetually sudden changes of 
 the feelings and affections, ill-judged enthusiasms ; 
 duplicity, falsehood, abominable deceitfulness, sud- 
 den and violent propensities to the most perverse and 
 criminal actions, as well as to acts of humanity 
 and bravery of the most praiseworthy kind; they 
 exhibit a constant desire for movement, for being ob- 
 served, of keeping .themselves before their neighbors, 
 the public and the press, and consequently of caus- 
 ing surprises or of weaving the threads of an inex- 
 
 Mbnt. Ubd.— 30. 
 
474 rsrsANiTiEs connected with nbtteoses. 
 
 tricable romance : such are the chief characters of 
 the moral condition of the hysterical subjects, whicli 
 may he summed up, that in them everything is mo- 
 bility and contrast: sentiments, affections, instincts 
 and acts. As regards the sexual tendencies that 
 have been considered a pathognomonic sign of hys- 
 teria, it must be admitted that their exaggeration 
 is not constant, and that here also there is mobility 
 and excess, sometimes in one direction, sometimes in 
 another. . 
 
 All these disturbances which reveal, taken alto- 
 gether, an absolute lack of equilibrium of the 
 psychic personality in the patients, and which are 
 exaggerated almost always by the events of life, 
 more especially the great processes of the sexual life, 
 such as pregnancy, menstruation, the menopause, 
 may in certain cases end in confirmed insanity. 
 
 Htstbeicai. Insanity. — ^As in epilepsy, we have 
 to distinguish in hysteria the attacks of insanity 
 connected with the paroxysms, and that of the in- 
 tervals. The first are commonly known under the 
 name of hysterical delirium, the second constitutes 
 hysterical insanity, properly so-called. 
 
 A. Htsteeicai Dblieium. — Hysterical delirium, 
 that is, the attack of temporary insanity, connected 
 with the convulsive attack, may appear before, 
 during or after the paroxysm. 
 
 When before the attack, it shows itself the few 
 
HY8TEEICAL INSANITY. 4^5 
 
 days preceding by a change of character, by an ex- 
 cessive tendency either to excitement or to depres- 
 sion. As the crisis approaches these phenomena 
 become exaggerated and there is added to them, a 
 veritable agitation with confused ideas, incoherent 
 propositions, disordered actions, perhaps torpor, 
 often accompanied with hallucinations of sight and 
 of hearing, or with false tactile sensations which oc- 
 casionally are unilateral. When the paroxysm com- 
 mences there is produced a sort of arrest and these 
 symptoms disappear. 
 
 During the attack the delirium manifests itself 
 either in the beginning or, rather, toward the close, 
 by a sort of acted dream that begins suddenly and 
 reveals itself in a rapid and changing succession of 
 the most various thoughts uttered aloud in the form 
 of an unconnected monologue of images ; this delir- 
 ium is the result of the multiple hallucinations ex- 
 perienced by the patient at the moment and it causes 
 the gestures, attitudes and acts in accordance with 
 the conceptions that compose it. The crisis over 
 the reason ^returns. 
 
 The hysterical attack itself may be replaced by a 
 more or less acute phase of delirium of the maniacal 
 or melancholic type. 
 
 After the paroxysm there is usually a period of 
 excitement with loquacity and noisy laughter, or 
 more often a period of torpor and depression 
 with more or less complete mutism, tears and 
 sobbing. 
 
476 INSANITIBS CONNECTED WITH NBtTROSBS. 
 
 B. Htstebical Insanity. — Hysterical insanity, 
 proper, is that whicli occurs in hysterical subjects, 
 apart from the convulsive attacks, under the influ- 
 ence of any exciting cause whatever, either moral or 
 physical, and sometimes without any apparent cause. 
 According to some authorities it is an insanity of 
 degeneracy. (Colin, 1891). 
 
 This insanity may show itself under the form of 
 more or less acute attacks of mania or melancholia 
 with their usual symptoms. It is rather more com- 
 mon to see it assume the reasoning type. This 
 marked predilection of hysterical insanity for the 
 reasoning variety explains its principal characteris- 
 tics, which are : the semi-consciousness of the patients 
 of their condition; the limitation of their delu- 
 sive conceptions, of whatever nature, erotic, mystic, 
 hypochondriacal, of pride, or of persecution, to the 
 sphere of things possible and realizable, also the mo- 
 bility of these conceptions ; the predominance of the 
 psychic disorders in the passional sphere, in the in- 
 stinct and in the acts, thus giving rise to affective 
 perversions, to calumnies, to false accusations and 
 denunciations, simulations of suicide or of violation, 
 foolish erotic and platonic affections, fits of passion, 
 and finally to morbid impulsions to theft, incendiar- 
 ism, suicide and homicide, that always have the ear- 
 marks of the hysterical basis on which they are 
 superadded. 
 
 Less frequently there is produced an attack of 
 stupor, with mutism, refusal of food, irresistible ten- 
 dency to suicide, etc. 
 
CHOEEIC INSANITY. 477 
 
 The diagnosis of hysterical insanity generally 
 offers no difficulties, as, even when the convulsive 
 attacks are lacking, the stigmata of the neurosis are 
 so numerous and varied, that enough of them are 
 always existing to demonstrate the true origin of 
 the mental alienation. 
 
 The prognosis is comparatively favorable, partic- 
 ularly when the attacks of insanity are plainly acute. 
 Recovery then takes place, according to Moreau (de 
 Tours), in one-half of the cases. The reasoning type 
 of insanity is much more serious and much more tena- 
 cious. It must be remembered, finally, that when 
 hysterical insanity is pi'olonged, it terminates almost 
 invariably, after a longer or shorter time, in de- 
 mentia. 
 
 As regards treatment, it is much the same as that 
 of hysteria in general, and like that it calls for the 
 employment of the alkaline bromides, opium, mor- 
 phine, antispasmodics, hydrotherapy, etc. Confine- 
 ment is often necessary on account of the predomin- 
 ance of the psychic disorders in the sphere of 
 action. 
 
 Chokba. 
 {Choreic Ima/rdty). 
 
 If disturbances of the intelligence are common in 
 epilepsy and hysteria, they are, on the contrary, much 
 more infrequent in chorea, where they are met with 
 in only two-thirds of the cases according to Marc6. 
 The age and sex of the patients, as well as the 
 
478 INSANITIES CONNECTED WITH NBUEOSES. 
 
 acuteness or intensity of the neurosis, seem not to have 
 any special action on the production of these troubles, 
 for which only an original predisposition appears to 
 be accountable. However this may be, it is necessary 
 to study both the mental condition and the insanity 
 of chorea. 
 
 The Mental Condition of Chobeics. — In an 
 intellectual point of view the chief disturbances met 
 with in choreic subjects are the defects of memory 
 and attention, the mobility of the ideas, the lack of 
 consistency in the recollections, the mental hebetude. 
 What however is most characteristic in the patients, 
 in this point of view, is the existence of special hallu- 
 cinations on which Marcd has justly laid stress. 
 These almost always involve vision, very rarely taste, 
 smell, tact, or hearing. They are especially common 
 in females, and rarely appear before fourteen years 
 of age. They occur chiefly in the evening, in the 
 drowsy condition between waking and sleeping, and 
 are very often continued in dreams. 
 
 They always are of a painful nature, terrifying, 
 fantastic, and consist in scenes of death, burials, of 
 hell, butcheries, and conflicts, which pass before the 
 subject as in a kaleidoscope (kaleidoscopic hallucin- 
 ations). They cause the patients much discomfort 
 and arouse a terror of going to sleep that causes them 
 to keep awake and to try j;o hide themselves under 
 the coverings. When these hallucinations are con- 
 tinued into the dreams they cause awakening, 
 
CHOEEIC IKSANITT. 479 
 
 Starting, cries and nightmares. This symptom is 
 sometimes a premonitory sign occurring many days 
 prior to the appearance of the convulsive movements ; 
 sometimes, and more commonly, it appears at the 
 time the choreic paroxysms show themselves. It 
 may persist, moreover, for many months. Its dis- 
 appearance is generally a favorable prognostic ; while, 
 on the other hand, its exacerbation may become the 
 starting-point of a true maniacal delirium. Morally, 
 the predominant disturbances in chorea affect the 
 character, which is modified and altered. The major- 
 ity of the patients become impressionable, emotional, 
 irascible, impatient, disputative, passionate, and even 
 violent. These disorders are more marked in patients 
 whose phonator muscles are involved in the chorea, 
 and who find food for their irritability in the super- 
 fluous efforts they make to express themselves dis- 
 tinctly. 
 
 Choeeic iNSANirsr. — Choreic insanity, which is 
 rather rare, may appear in either the maniacal or 
 the melancholic form. 
 
 The maniacal form shows itself ia attacks that 
 sometimes appear in the beginning of the disorder, 
 but more often only occur many days after the ap- 
 pearance of the convulsive movements. In either 
 case it may take on the character of acute mania 
 with incoherent delirium, noisy excitement, hoarse 
 inarticulate cries, disconnected words, or it may 
 even present itself under the form of acute febrile 
 
480 INSANITIES CONNECTED WITH NEUBOSES. 
 
 delirium with pulse at 120, hot skin, dry tongue, 
 mumbling, sputation, violent and uncontrollable agi- 
 tation, and sometimes even choreic convulsions 
 coming on in spells. 
 
 The melancholic form sometimes appears as a 
 delusional melancholia, based on already existing 
 hallucinations and consequently accompanied with 
 ideas of persecution and poisoning, anxiety, tend- 
 encies to sitiophobia and suicide, sometimes as 
 stuporous melancholia with profound hebetude, fits 
 of weeping, immobility, terrors, and amnesia. 
 
 The above description applies especially to ordi- 
 nary or Sydenham's chorea. But the other forms of 
 chorea may also be attended with psychic disorders 
 (Digoy, TMses de Paris, 1890). 
 
 Thus in the rhythmic choreas may be mentioned 
 the chorea of pregnancy which is sometimes associated 
 with a maniacal type of insanity, and especially 
 hereditary, or Huntington's chorea, which very fre- 
 quently gives rise to a progressively increasing en- 
 feeblement of the mental faculties, accompanied in 
 some cases with melancholia, suicidal ideas, or more 
 often irritability and violence, less frequently ideas 
 of persecution and of grandeur, and hallucinations 
 (Charcot, Clarence King, Peretti, Digoy). Chorea 
 of old age also terminates in dementia in the major- 
 ity of cases. As to the mental disorders of hemi- 
 chorea, they are analogous to those of hemiplegic 
 dementia, and have the same cause. 
 
 In the rhythmic or systematic choreas the moral 
 
CHOREIC INSANITY. 481 
 
 and mental disturbances assume the excessive mobil- 
 ity pathognomonic of the mental condition of hys- 
 teria. There may also be a true insanity, mania or 
 melancholia, with visual and auditory hallucinations 
 and also hallucination of the general sensibility, 
 usually temporary and following the attacks but sus- 
 ceptible also of being continued during the intervals 
 and then assuming the reasoning type of hysterical 
 insanity. 
 
 The pseudo-choreas such as the tic de Salaam 
 which belongs rather to epilepsy and is frequently 
 seen in the lower grades of degeneracy, and the con- 
 vulsive tics (Grilles de la Tourette's disease) already 
 alluded to under the head of neurasthenia, need only 
 be mentioned here. 
 
 The peculiar convulsions that accompany these 
 various conditions of insanity leave no doubt as to 
 their nature, hence the diagnosis of choreic insanity 
 presents usually no difficulties. 
 
 The prognosis is variable. While not serious 
 when the psychic troubles do not exceed those we 
 have indicated as the mental condition of chorea, or 
 when the insanity is confined to an attack of acute 
 mania or mild melancholia, it becomes very grave in 
 the stuporous form or in that of acute delirium. 
 
 The treatment is that of the neurosis, and there- 
 fore consists chiefly in cold affusions, sulphurated 
 baths, valerian and antispasmodics, prolonged warm 
 baths, opium in increasing doses, strychnia, iron and 
 tonics. In case of acute excitement, sequestration 
 is, moreover, almost always necessary. 
 
483 INSANITIES CONNBCTBD WITH NEITEOSBS. 
 PABAIiYSIS AGITANS. 
 
 M. Ball, and still more recently other authors, 
 Parant, Bergerio, Roger, and others, have given es- 
 pecial attention to the mental troubles attending 
 paralysis agitans. It results from their studies that 
 while nearly all the subjects of this ailment have 
 more or less marked disturbances of the ideas, char- 
 acter and feelings, these may in some cases attain to 
 the dimensions of real insanity. This, in sach cases, 
 appears usually under the melancholic form, either 
 with the symptoms of delusional melancholia accom- 
 panied with anxiety, ideas of persecution and poison- 
 ing, and with hallucinations, or with those of stupoi- ; 
 the insanity is not permanent, and usually follows 
 the changes of the malady itself, generally disap- 
 pearing whenever the tremor ceases. It may be 
 added that the majority of the cases of paralysis 
 agitans terminate in dementia. 
 
 Exophthalmic Goitkb. 
 
 It has long been known that sufferers from ex- 
 ophthalmic goitre are erratic, irritable, changeable 
 and unequal in their characters and mode of life. 
 
 In a very interesting lecture recently published 
 {Bull, mddical, 1890), Professor Peter has called 
 special attention to a symptom that approaches to 
 being a capital and pathognomonic one in this dis- 
 ease: a morbid, neuropathic emotivity, revealing 
 itself not only in the most intense psychic sensibil- 
 
EXOPHTHALMIC GOITRE. 483 
 
 ity and unrest, but also by very marked somatic 
 phenomena in the domain of the great sympathetic ; 
 palpitations, choking sensations, precordial pain, 
 flushes of heat and pallor, spells of sweating and 
 of diarrhoea, etc., etc. It is easy to see from this 
 short enumeration that the predominating neurotic 
 symptoms in Basedow's disease very closely resemble 
 those of neurasthenia. In fact I believe that neu- 
 rasthenia, chiefly in its emotional form, accompanies 
 many cases of exophthalmic goitre; and I have 
 found, on the other hand, that, in a large number of 
 obsessional neurasthenias, the disorder commenced 
 at puberty with palpitations, and that it was later 
 complicated with swelling of the neck and prom- 
 inence of the eyes, recalling more or less clearly the 
 malady of Basedow. These facts show that an in- 
 timate relation exists between these two diseases, and 
 it will be of interest to foUow out further the inves- 
 tigations as to this point. 
 
 While exophthalmic goitre is never, so to speak, 
 without some mental and moral disturbances, it is 
 accompanied in some cases with actual insanity. 
 
 This insanity, as has been remarked by M. Ray- 
 mond Martin {TMses de Paris, 1890), may supervene 
 either after, or with, or even before the appearance 
 of the exophthalmic goitre. 
 
 It follows from numerous facts published of late 
 years by Savage, Meynert, Charcot, Rendu, Ballet, 
 JofEroy, Debove, and Landouzy, and summed up by 
 M. Martin in his thesis, that the types of insanity 
 
484 INSANITIES CONNECTED WITH NBUBOEBS. 
 
 observed in Basedow's disease are rather variable. 
 Acute maniacal conditions seem nevertheless to pre- 
 dominate ; but we also meet with hypochondriacal or 
 anxious melancholia, and especially with vaguely 
 systematized delusions of persecution or mysticism, 
 with almost constant visual and auditory hallucina- 
 tions such as are observed in hysteria. 
 
 Exophthalmic goitre is, in fact, very frequently 
 connected with this neurosis ; which makes it impos- 
 sible to state precisely to which of the two affections 
 the insanity is to be attributed {Soo. ni4d. des 
 hdpitaux, 1890). 
 
 As M. Martin well says, in these mixtures it is 
 hard to state the part that is played by one or the 
 other morbid condition. Moreover, exophthalmic 
 goitre, like hysteria, has its origin in a neuropathic 
 heredity, and it is not demonstrated, as was said 
 above in speaking of hysteria, that there are not 
 direct relations existing between these different ex- 
 pressions of the same diathesis. 
 
Cbapter f iFfl. 
 
 INSANITIES CONNECTED WITH INTOXI- 
 CATIONS. 
 
 (Toxic Insanities). 
 
 I. ALCOHOLISM. 
 
 (Inebbiett, Alcoholic Insanity, Alcoholic Dementia, Alcoholic 
 Pseudo-Gbneral Paralysis). 
 
 The term alcoholism, originated in 1856 by 
 Magnus Huss, is applied to the whole range of dis- 
 orders caused by poisoning by alcoholic liquors. 
 According as the toxic action is sudden or prolonged, 
 the alcoholism is called acute or chronic. 
 
 The psychic disorders of alcoholism, the only ones 
 that will occupy us here, may show themselves in 
 either acute or chronic alcoholism. We find them 
 occurring by preference, in subjects who are, by 
 heredity, profession, or conditions of debility, pre- 
 disposed to cerebral or vesanic disorders and who 
 are given to immoderate use of alcohols of bad qual- 
 ity or liquor of absinthe ( absinthism) . 
 
 The most of the states, of mental alienation may 
 be met with in alcoholism, from ordinary drunken- 
 ness, the incomplete and temporary loss of reason, 
 to simple dementia and paralytic dementia. Those 
 that are most common, however, are acute general- 
 ized insanities of the maniacal or melancholic type. 
 
486 TOXIC iNSAiinnBS. 
 
 On each of these conditions of insanity certain special 
 characters, more or less striking, are impressed hy 
 alcoholism, which compel us to pass them in review. 
 We will therefore describe successively : (1) drunk- 
 enness; (2) acute alcoholic insanity (maniacal or 
 melancholic) with its subacute and hyperacute vari- 
 eties; (3) simple alcoholic dementia; (4) alcoholic 
 pseudo-general paralysis. 
 
 1. — Inbbbibtt. 
 
 Inebriety comprises three distinct periods. The 
 first is that of excitation ; it is characterized by an- 
 imation of the' face and expression, increase of the 
 pulse, the perspiration, the urinary secretions and 
 especially by a feeling of well being, with loquacity 
 and expansive tendencies. Those who are, as they 
 say, merry in their liquor, are full of life and spirit, 
 of gaiety and movement ; those who are maudlin in 
 their cups are depressed, inclined to relate their mis- 
 fortunes ; weep and lament without motive ; some 
 become benevolent, tender, affectionate, much in- 
 clined to erotic manifestations ; others become iras- 
 cible, easily disturbed and have a marked tendency 
 to quarrel and come to blows. At this stage the 
 man still is semi-conscious of his condition and re- 
 tains the power of self-control, at least to a certain 
 extent. But there exists already a sort of moral 
 anaesthesia ; nothing shocks him. 
 
 The second stage or drunken period is character- 
 ized by more pronounced disturbances. There is 
 
AlCOHOLIC mSAKITT. 487 
 
 no longer merely exaltation, but also perturbation 
 of the intelligence; the ideas are confused, uncon- 
 secutive and excessively variable ; the language is in- 
 coherent and disconnected; the tongue is thick, the 
 speech embarrassed, sexual power usually abolished, 
 the walk vacillating, and the sensibility much 
 obtunded. Simultaneously there exist sensory dis- 
 turbances, such as confusion of vision, diplopia, tin- 
 nitus, illusions of taste and general sensibility, and 
 occasionally true delusions with impulsions. 
 
 The third period is the comatose stage. It is 
 marked by long and profound sleep, with profuse 
 sweating, during which the individual is exhausted, 
 inert and completely unconscious. On awaking 
 there is more or less pronounced general malaise, an 
 uncomfortable feeling of, lassitude, a feverish thirst, 
 great dryness of the mouth, and severe headache. 
 
 Besides this simple inebriety as we call it, there 
 are other more serious forms, notably the convulsive 
 form, described by Percy, and amnesic inebriety. 
 
 3. — Alcoholic Insanity. 
 
 Alcoholic insanity may present itself under either 
 the maniacal or the melancholic form. 
 
 As regards its intensity, it is met with in three 
 different degrees: a. — the subacute attack; b. — the 
 acute attack, properly so-called; c. — the hyperacute 
 attack. Whatever the intensity, the attack of alco- 
 holic insanity is liable to occur either in a,cute alco- 
 
488 TOXIC INS/lBTITIBS. 
 
 holism following a sudden and transient intoxication, 
 or at any moment whatever in the course of a chronic 
 poisoning. Its appearance may follow great excesses 
 {delirium a potu nimio) as well as, on the other 
 hand, the suppression of habitual stimulation {delir- 
 ium a potu suspensd). It is also a common thing 
 to see the attack of insanity occur suddenly as the 
 effect of a moral or physical shook (moral or physical 
 traumatism), and, especially of an intercurrent dis- 
 order. Thus alcoholic delirium develops in a pneu- 
 monia for example, or after surgical operations 
 (nervous delirium of the wounded). Any trifle is 
 enough in individuals intoxicated and saturated with 
 alcohol, to call up or awaken the cerebral disorder. 
 
 A. Subacute Insanity. — The most frequent 
 form of insanity in alcoholism is the subacute type 
 that ordinarily occurs as a transient episode in the 
 course of chronic alcoholic poisoning. Its manifest- 
 ation is almost always of the melancholic type. 
 
 The attack usually begins with disturbances of 
 sleep which become unsatisfactory and troubled with 
 dreams. LasSgue, whose description I reproduce, 
 says that the subject of alcoholism, before becoming 
 insane begins by sleeping ill, and that his delirium 
 is only a waking dream of the day that follows, as a 
 consequence, a sleeping dream of the night, and 
 continues not only in a psychic sense, but also 
 chronologically. The dreams of these subjects are 
 especially dreg,ms of action, drawn from familiar sub- 
 
ALCOHOLIC nrSANITT. 489 
 
 jects of events of the time, dramatic displays, and 
 in wMcli hallucinations of sight play the principal 
 part. A time arrives when these dreams prolong 
 themselves into the waking moments, and this it is 
 that constitutes the alcoholic delirium. This painful 
 change from sleeping to waking follows an excessive 
 agitation preventing, like a nightmare pushed to ex- 
 tremes, the possibility of sleep, or some external ex- 
 citation, or any cause whatever. The passage from 
 dormant to waking delirium is made without trans- 
 ition, the insanity does- not follow some distance 
 after the dream, it becomes simply its intensification 
 and maximum. The condition as regards the nature 
 of the abnormal phenomena is the same, the delusions 
 are the continuation of the dreams. The same fan- 
 tastic combinations and thrUling situations, the 
 same strange or sinister adventures, the same 
 disordered and changing scenes occur. In the alco- 
 holic insanity, as in the dream, visual hallucinations, 
 that usually assume a terrifying character and con- 
 sist mainly in visions of animals, thieves, assassins, 
 battles, fires, deaths, etc. , play a chief part and to 
 the almost complete exclusion of any others. Audi- 
 tory halluciaations, in fact, are reduced, as a rule, to 
 merely confused impressions, sounds of steps or blows, 
 mufl3.ed cries and a few interjected phrases. On the 
 other hand, like all dreamers, the alcoholic subject 
 is constantly undergoing some physical and moral 
 change, during his attack. Bis speeches are lengthy 
 but made up of detached phrases without logical con- 
 
 USNT. JUBD. — 31. 
 
490 TOXIC INSAliTITlES. 
 
 nection. Mere facts without reflections and' still 
 less of wonder and criticism. What is past is past, 
 and that is all. A last peculiarity common to dreams 
 and alcoholic delirium is the possibility of these con- 
 ditions being suddenly and temporarily suppressed 
 by shaking the dreamer or the patient and accom- 
 panying the act with some strong expression. 
 
 Basing himself on these peculiarities Las^gue is 
 able to say that subacute alcoholic insanity is not an 
 insanity but a dream. 
 
 With these psychic symptoms, to which must be 
 added the rather frequent tendency to suicide, are 
 joined the habitual bodily symptoms of alcoholism, 
 such as generalized tremor, cramps, formications, 
 dyspeptic disorders, analgesia or hyperoesthesia of 
 the limbs, convulsive hysteriform or epileptiform 
 accidents, etc., etc. 
 
 The subacute f oim of alcoholic insanity is of vari- 
 able but generally of short duration, at least when 
 the patient stops drinking. It is rare that thei-e is not 
 an amelioration after five or six days ; little by little 
 the dream disappears and the reality returns. Just 
 as the loss of sleep marked the beginning of the dis- 
 order, so its return marks its termination. 
 
 B. Acute Insanity.— Acute alcoholic insanity 
 occurs under the same conditions as the subacute 
 form, and it manifests itself sometimes under the 
 form of melancholia, sometimes and more often, that 
 of mania. The melancholic variety differs from that 
 
AlCOMOLlC tNSAU-lTT. 49l 
 
 of the subacute type, only in its higher degree of 
 intejisity. It is preceded by prodromata such as 
 feeliiigs of malaise, oppression, gastric uneasiness, 
 cephalalgia ; the insomnia is more complete, the hal- 
 lucinations more terrifying, the fearfulness becomes 
 a genuin e panophobia, and the patients believe them- 
 selves surrounded by enemies, ferocious beasts, 
 flames, cadavers, they fly in affright and are the 
 prey of unspeakable terror. There is added, more- 
 over, to this condition, a true delirium that revolves, 
 as a rule, around ideas of hypochondria and persecu- 
 tion especially. The victim of alpoholism believes 
 he is full of worms, rotten, that he has no stomach or 
 head, that he is dead, that people are mocking him, 
 his wife deceives him, that it is sought to poison 
 him, that persons of suspicious mien follow him in 
 the streets, that they wish to make way with him, 
 accuse him of theft, of murder, of psederastj, they 
 come to his house to arrest him, to shoot him, etc., 
 etc. It is in this form and when such ideas of per- 
 secution exist that we can recognize more or less 
 perfect hallucinations of hearing in the patient. A 
 tendency to suicide is almost the rule, and often 
 shows itself by a sudden unpremeditated attempt. 
 There is here, as in all attacks of alcoholism, a very 
 marked tremor of the extremities, cramps, formica- 
 tions, partial ansesthesias or hypersesthesias, various 
 hallucinations of taste or smell, and, lastly, more or 
 less pronounced gastric troubles. 
 
 The maniacal form is nothing else than what is 
 
49^ *oiic lirsANlTiiis. 
 
 commonly known as delirium tremens. It begins 
 with insomnia, incoherence of ideas, . and various 
 general phenomena. Excitement soon appears and 
 rapidly increases. The face is red, swollen and con- 
 gested, the eyes glittering, the pulse frequent, the 
 temperature elevated, the skin burning and covered 
 with sweat, the thirst excessive. Hallucinations and 
 more especially illusions supervene ; the patients be- 
 lieve they recognize those about them ; they take a 
 window for a door, an object for an animal, a piece 
 of furniture for a person ; they find a new taste and 
 odor to what they eat or drink, and, lastly, they 
 have fantastic visions, especially of animals, but 
 these are less terrifying than they are in the melan- 
 cholic form, and rather frequently they consist in 
 lewd representations and obscene tableaux that unroll 
 themselves before the eyes of the patient. In a very 
 short time the agitation is at its height and the indi- 
 vidual cries, vociferates, walks and runs without 
 cessation. 
 
 The tremor is so excessive and so generalized that 
 it has given its name to this variety of alcoholic in- 
 sanity. The whole body is in vibration, as is readily 
 demonstrated by placing the hands on the patient's 
 shoulders. The hands and arms are agitated with an 
 extended uncontrollable motion, the whole head 
 oscillates visibly, the tongue is so tremulous that 
 it is drawn convulsively out of the mouth; and, 
 finally, the tremor may sometimes extend to the lips 
 and vocal muscles so as to cause a certain embarrass- 
 
ALCOHOLIC IKSANITT. 493 
 
 ment of speech. There may also be an apparent 
 inequality of the pupils, which is rather common, as 
 we are aware, in chronic alcoholism. 
 
 Finally, we may mention various more or less 
 constant disorders, such as profuse perspirations, 
 accelerated pulse, epileptiform attacks, and lastly 
 the usual disturbances of alcoholic intoxication in 
 the organic functions. As to the temperature, it is 
 not sensibly modified, and is rather diminished than 
 increased, especially in the periphery. 
 
 Recovery is the usual termination of the attack of 
 acute alcoholic insanity, and it takes place rather 
 rapidly in from eight to fifteen days, from the effect 
 of the simple suppression of the habitual stimulation ; 
 it is evidenced by the return of sleep and the pro- 
 gressive diminution of the symptoms of the attack. 
 
 C. Htpeeacute Insanity. -^In the hyperacute 
 alcoholic insanity the attack attains a very high 
 degree of intensity. In the melancholic form there 
 is an actual condition of stupor. Immovable, stupid, 
 incapable of answering or moving, with terrified 
 visage, and wild eyes, the patients are plunged into 
 the most profound prostration ; they seem to be 
 taking part in horrible spectacles, the sight of which 
 terrifies them, and they only arouse themselves out 
 of this state of prostration to make some sudden 
 attempt at suicide. It is in this form in particular, 
 that they retain only an extremely vague idea of 
 ■^fhat has taken place during their attack, and al] 
 
494 TOXIC INSAITITIBS. 
 
 they have seen, heard, or done, even their attempts 
 at suicide, seems to them like a confused and remote 
 dream. Nevertheless these stuporous attacks usually 
 disappear and end in recovery, hut with a certain 
 slowness and often leaving behind them various dis- 
 orders, especially a state of dullness and intellectual 
 obtusion. 
 
 In the maniacal form the agitation reaches its 
 maximum and exhibits all the symptoms of acute 
 delirium, from which, moreover, it derives its name 
 (alcoholic acute delirium) . Analogous in all respects 
 to simple acute delirium, the attack presents, like it, 
 an elevation of temperature, which may attain 108 
 or 109 degrees or even more (febrile delirium tremens), 
 typhoid symptoms, profuse perspiration, fuligin- 
 osities, subsultus of the tendons, smallness of the 
 pulse, convulsions, adynamia, etc. Like it also, it 
 usually terminates fatally, and this occurs either 
 suddenly from syncope, or in coma. 
 
 The cerebral lesions met with most frequently in 
 acute attacks of alcoholic insanity, and apart from 
 the habitual lesions of chronic alcoholism, such as 
 arterial atheroma and fatty degeneration of the ves- 
 sels, are hemorrhagic pachymeningitis, thickening of 
 the membranes and their serous infiltrations, san- 
 guine suffusions, adhesions of the meninges to the 
 cortex, m.ore or less marked coloration of the gray 
 matter, punctation of the white substance, serous 
 effusion in the lateral ventricles, and lastly, hemor- 
 rhagic foci in various regions, especially in the ter- 
 ritorv of the Sylvian artery of the left 8i,4?, 
 
ALCOHOLIC INSANITY. 495 
 
 The diagnosis, generally easy, may present some 
 difficulty, in oases, for example, of an acute attack of 
 the melancholic type and with ideas of persecution. 
 We have seen that these cases are frequently mis- 
 taken for incipient delusions of persecution, and 
 vice versa. Here, nevertheless, the ideas of perse- 
 cution are more confused and more terrifying, and 
 are accompanied with a panophohia that does not ex- 
 ist in partial insanity. 
 
 As to the alcoholic stupor and alcoholic acute de- 
 lirium, they differ from the simple forms of these 
 disorders only in their history and the concomitant 
 characters of alcoholic intoxication. 
 
 The treatment of acute alcoholic insanity, is 
 blended with the ordinary treatment of alcoholism, 
 and, like it, consists essentially in the suppression of 
 the customary stimulants. It is needful, neverthe- 
 less, to reach this suppression by easy stages, 
 and to gradually wean the patient from alco- 
 hol by daily diminution of the dose. Insomnia 
 being the most constant result of alcoholism, the 
 chief indication is to re-establish sleep ; and for this 
 reason sedatives, and chloral, especially in full doses, 
 combined or not with morphine (Laneereaux) , are the 
 therapeutic agents that have the beat effect, partic- 
 ularly in the excited forms. Strychnia has also been 
 recently recommended for the accidents of acute 
 alcoholism. 
 
 Many authors, notably Laneereaux {Bulletin 
 medical, 1891), have tried to differentiate the alco- 
 
496 TOXIC INSANITIES. 
 
 holism according to the nature of the drink ingested 
 (wine, rum, cognac, and eaux-de-vie, absinthe, 
 vulnSraire, bitters, aperatives, etc.) The distinc- 
 tion is less psychical than physical and consists either 
 in the great frequency of convulsive accidents 
 (absinthism), or in the different types of disorder of 
 sensibility, analgesic in the intoxication from wine, 
 and hyperalgesic in that from the essences. 
 
 M. Magnan, and his pupil, Legrain, have also de- 
 scribed separately the alcoholism of hereditary pre- 
 disposed subjects and that of degenerates. 
 
 3. — AicoHOLic Dementia. 
 
 After chronic alcoholism has continued a certain 
 time it, at last, causes a progressive decay of the in- 
 dividual, both in an intellectual and moral and a 
 physical point of view. In the physical sphere the 
 tremor, the dyspnoea, the alphonia, the epUeptiform 
 convulsions, the thicknesi of the tongue, the mus- 
 cular weakness, the anaesthesia and hypersesthesia, 
 the oculo-pupillary disorders, the fatty degener- 
 ations, loss of appetite, bilious vomiting, circulatory 
 troubles, the congestion of the liver, etc. , etc. , are 
 the most important of all symptoms. 
 
 As to the mental enfeeblement, it begins slowly and 
 like all the conditions of dementia, first manifests 
 itself by the progressive failure of memory and other 
 faculties and also by indifference and loss of the sen- 
 timents and the affections. The special characteris- 
 tic of this dementia is the almost invariable insomnia 
 
ALCOHOLIC PSBUDO-GBNBBAL PABALTSIS. 497 
 
 that accompanies it, and the more or less marked 
 hallucinations that may complicate it either continu- 
 ously or in an intermittent fashion. 
 
 By a process of gradual degradation the patients 
 reach the untidy {gdteux) stage and end in maras- 
 mus, being generally carried off by an apoplectic 
 attack. In some cases they recall more and more 
 the general aspect of paralytic dementia, so that the 
 diagnosis is soinetimes rendered difficult. The 
 tremor, the hallucinations, the character of the 
 speech embarrassment, and the co-existence of all 
 the other signs of the alcoholic cachexia, neverthe- 
 less permit generally the distinction of these two 
 conditions of dementia from each other. 
 
 At the autopsy we find the lesions of alcoholism 
 mentioned in the description of the acute form of 
 alcoholic insanity, to which is sometimes added a 
 more or less pronounced atrophy of the cerebrum. 
 
 4. — Alcoholic General Paralysis. Alcoholic Psbitdo- 
 Gbwekal Pakaltsis. 
 
 Tip to within recent years alcoholism was consid- 
 ered as one of the most important causes of general 
 paralysis. Nasse, in 1870, called attention to cases 
 of alcoholism with all the mental and bodily symp- 
 toms of general paralysis, but differing especially 
 in their curability under the influence of rest and 
 the deprivation from alcoholic drinks. Like Hoff- 
 mann, who had called them pseudo-paralysis, he pro- 
 posed to give these cases the name of pseudo-parai- 
 
498 TOXIC INSANITIES. 
 
 ysis e potu. The memoir and the ideas of the Ger- 
 man author were rather overlooked, and we contin- 
 ued to make no distinction between alcoholic and 
 ordinary general paralysis, or rather to continue to 
 admit the preponderating influence of alcoholism in 
 the production of this affection. 
 
 M. Moreau, in 1881, without accepting com- 
 pletely the idea of Nasse, sought to show that alco- 
 holic general paralysis has a peculiar course, charac- 
 terized by the frequency and distinctness of its 
 remissions. This difference, nevertheless, although 
 important, does not seem sufficient by itself alone to 
 prove that there does not really exist an alcoholic 
 general paralysis. Having already studied the pre- 
 ceding year the relations of saturnine encephalopa- 
 thy and progressive general paralysis, and having 
 demonstrated, contrary to the received opinion, that 
 lead poisoning usually causes, not a true general pa- 
 ralysis, but a pseudo form essentially curable, I 
 was struck, at the time, with the analogy existing 
 between the cases of so-called alcoholic general 
 paralysis and those I had studied under the name of 
 saturnine pseudo-general paralysis. I was therefore 
 led to accept fully the opinion of Nasse and to ad- 
 mit the existence of ao alcoholic pseudo-general 
 paralysis, in regard to which I published some con- 
 siderations which were soon reproduced and devel- 
 oped in the thesis of M. Lacaille. 
 
 Since then a number of cases have been published 
 and many authors have admitted the existence of an 
 
ALCOHOLIC PSEUDO-GBNEEAL PAEALTSIS. 499 
 
 alcoholic pseudo-general paralysis. Among these 
 should be cited M. Ball, who, by taking up in one of 
 his clinical lectures the subject of alcoholic pseudo- 
 general paralysis, has, so to speak, officially declai-ed 
 its existence. 
 
 The question of the relations of general paralysis 
 and alcoholism was agitated anew at a late Congress 
 of Alienists (1891) by a remarkable report of M. 
 Rousset. Various opinions were expressed, but it 
 seemed to be generally admitted that alcoholic paral- 
 ysis, whether called pseudo-general paralysis or not, 
 presented special features. 
 
 The pseudo-general paralyses, syphilitic, saturn- 
 ine, and alcoholic, have characters in common, and 
 the two last especially present the same clinical 
 physiognomy. They differ chiefly from general 
 paralysis in that they are essentially curable, or at 
 least susceptible of amelioration under appropriate 
 treatment. 
 
 In a symptomatic point of view their analogy 
 with true general paralysis is nearly perfect, and 
 they differ from it only in a few peculiarities with- 
 out real importance. 
 
 The special characters of alcoholic general paral- 
 ysis, according to my own observations and the 
 memoir of M. Lacaille, are as follows : 
 
 Alcoholic pseudo-general paralysis always is found 
 only in clearly established cases of cerebral alcohol- 
 ism, which is not usually true of the genuine form. 
 It begins in them in \,wQ different wa.js. In some 
 
500 TOXIC INSANITIES. 
 
 cases it is announced and preceded by apoplectiform, 
 or more particularly, epileptiform attacks, which 
 differ in certain respects from those observed in the 
 beginning of general paralysis. At other times, and 
 this is most frequently the case, the pseudo-paralysis 
 is consecutive to a subacute attack of alcoholism. 
 It is in the course of this attack and on account of 
 the insane acts caused by it, that the patients are 
 sequestrated, but, and this is a remarkable fact, they 
 do not, at this time present any of the symptoms of 
 paresis, and these latter only appear when the sub- 
 acute attack is over, or is on the point of disappear- 
 ing. In all cases, and this is important to note, 
 instead of being insensibly progressive like true gen- 
 eral paralysis, the symptoms 'in pseudo-paralysis 
 attain at once their greatest intensity. 
 
 Symptomatically alcoholic pseudo-general paral- 
 ysis differs from general paralysis in two ways : (1) 
 it has symptoms peculiar to itself ; (2) the symptoms 
 common to it and general paralysis present in the 
 former some special features. 
 
 Its own peculiar symptoms are no other than those 
 that belong to chronic alcoholism and these are too 
 well known to require their recital here. We may 
 add that local paralytic accidents, such as permanent 
 hemiplegia and aphasia, are more frequent and more 
 persistent than in true general paralysis. 
 
 The following are the principal differences in the 
 symptoms they share in common : 
 
 (/ontrarjsr to what occurrs in true general paralysis. 
 
AliCoaoLtC PSEUDO-GBNEEAL PARALYSIS. 501 
 
 the inequality of the pupils is scarcely ever lacldng 
 in alcoholic pseudo-general paralysis. In it, more- 
 over, the pupils are invariably very paretic, and in 
 some cases absolutely immobile, especially the one 
 that is most dilated. Besides this the pupillary 
 aperture is very often misshapen, oval, notched on its 
 borders ; the coloration of the pupil loses its sparkle 
 and transparency ; it is usually dull and cloudy ; and 
 lastly, the visual acuteness is ordinarily diminished. 
 These last peculiarities are exceptional in general 
 paralysis. 
 
 On the part of the intellect, aside from the delu- 
 sional and hallucinatory manifestations that usually 
 mark the beginning of their malady, and which may, 
 moreover, reappear at any moment of its progress 
 under the influence of various causes, the pseudo- 
 paralytics are specially characterized, not by a pro- 
 gressive enfeeblement of the mind, such as occurs 
 in general paralysis, but by a false dementia, an in- 
 tellectual obtusion and stupidity, sometimes carried 
 to the extreme, by an actual brutalization. 
 
 That, however, which most particularly distinguish- 
 es alcoholic pseudo-general paralysis is its course. 
 While in true general paralysis, which has for this 
 reason been called progressive, the symptoms gradu- 
 ally become more and m.ore aggravated and progress 
 almost invariably to the fatal termination ; in the 
 pseudo-paralysis, on the other hand, their course is 
 regressive, that is to say, that however marked they 
 may have been in the beginning, they gradually 
 
50^ toxic lisrslsrltiES. 
 
 diminish and may disappear entirely in a compara- 
 tively short time. It is a remarkable fact, moreover, 
 that the disappearance of these symptoms follows an 
 altogether different course from that observed in the 
 remissions of general paralysis. While in the latter 
 the pupillary inequality is one of the first symptoms 
 to be effaced, while the embarrassment of speech 
 always remains to a greater or less degree, in the 
 pseudo -general paralysis, on the contrary, the in- 
 equality of the pupils is the most fixed and durable 
 of all the symptoms, while the speech disturbance 
 diminishes from the beginning of the amelioration. 
 
 In a prognostic point of view we may say that 
 general paralysis never, or only very exceptionally, 
 ends in recovery, while pseudo-general paralysis 
 habitually does so. It is also a common thing to 
 see alcoholic pseudo-paralysis reproduced repeatedly 
 after new excesses, and each time with recovery, 
 until the patient finally falls into alcoholic dementia, 
 or is carried off by an apoplectic stroke. M. Ball 
 and I have reported the case of a patient who re- 
 covered sixteen times in thirteen years from alcoholic 
 pseudo-general paralysis. 
 
 As regards the lesions of alcoholic pseudo-general 
 paralysis, the one fact that the disease may occur 
 and pass off many times is sufficient to prove a 
 priori that they must be purely functional. I have, 
 in fact, published the case of an alcoholic paralytic 
 who died from an accidental cause, in whom we 
 found at the autopsy none of the usual lesions of 
 
geiiet-al paralysis. The changes commonly met 
 with in the brain are those already noticed of 
 chronic alcoholism, especially atheroma of the cere- 
 bral arteries (arterio-sclerosis) , and circumscribed 
 lesions such as hemorrhagic pachymeningitis. 
 
 The treatment of alcoholic pseudo-general paral- 
 ysis offers nothing absolutely special. It consists in 
 aiding the tendency to recovery by the removal of 
 the customary stimulants, and appropriate medica- 
 tion, and especially the endeavor, by moral hygienic, 
 and therapeutic agencies, to prevent the relapses so 
 frequent in these cases. It is for this purpose in 
 particular and for the patients, that the inebriate 
 asylums, half hospitals and half homes, such as exist 
 in England, may be of real value. 
 
 II.— SATURNISM. 
 
 (Satuknine Insanity, Sattibnine Dementia, Saturnine Pseudo- 
 General Paralysis). 
 
 Saturnism is the result of poisoning by lead, as 
 alcoholism is that of poisoning by alcohol. But 
 while the mental disorders due to alcoholism have 
 been the subjects of many interesting memoirs, very 
 little has been done as regards saturnine insanity, 
 probably because it is rarer and less frequently ob- 
 served. Apart indeed from the relations of lead 
 poisoning to general paralysis, the study of which 
 has been begun by several authors, there are still, 
 as regards the insanity caused by lead, only some 
 
504 Tone INSANITIES. 
 
 vague references left us by Tanquerel des Planches 
 and Grisolle. 
 
 If it is correct to say that all the toxic insanities 
 preisent great resemblances to each other, it is need- 
 ful to recognize that these analogies should not he 
 pushed too far as regards the mental disturbances 
 of alcoholism and lead poisoning. Errors are often 
 committed in this regard. When the saturnine cases 
 come to the asylums, suffering from nightmares, ter- 
 rifying hallucinations, and ideas of persecution with 
 also very marked tremor of the limbs, the physician, 
 accustomed to look upon these morbid phenomena 
 as pathognomonic, does not hesitate to consider 
 them from the beginning as suffering from the com- 
 bined action of alcohol and lead. Thus the usual 
 form of medical certificate in these cases is as 
 follows: "Alcoholic and saturnine insanity." Here 
 is a confusion that it is important to notice, since 
 these patients have often been guUty of no alcoholic 
 excess and all their symptoms are imputable to lead 
 intoxication. 
 
 This enables us to dispense with any long details 
 of the mental troubles of saturnism, which fall into 
 the same divisions and answer the same description 
 as those of alcoholism. 
 
 There are therefore : (1) a saturnine insanity, 
 maniacal or melancholic, with its subacute, acute, 
 and hyperacute varities; (2) a saturnine dementia; 
 and (3) a saturnine pseudo-general paralysis. 
 Strictly speaking, another still lighter form, may be 
 
SATURNINE INSANITY. 505 
 
 admitted, lead inebriety, more or less analogous to 
 alcoholic drunkenness. 
 
 1. — Satubnine Insanity. 
 
 a. Subacute Insanity. — Subacute attacks of in- 
 sanity in saturnism, are rarer than the acute variety, 
 contrary to the rule in alcoholism. Moreover, as in 
 the latter, the subacute attack almost always as- 
 sumes the melancholic form, and is characterized by 
 the same symptoms, especially by insomnia, temfy- 
 ing hallucinations of sight, nightmares, suicidal 
 tendency, generalized tremor, etc. The only differ- 
 ence consists in the co-existence of the usual stig- 
 mata of saturnine intoxication, and notably the line 
 of Burton, which enable us to make the diagnosis. 
 Still this diagnosis is made more ■ difficult when the 
 patient, as often happens, is at once charged with 
 lead and alcohol. 
 
 h. ActTTB Insanity. — Acute saturnine insanity al- 
 most always manifests itself under the maniacal 
 f oiin. Usually it is announced by prodromata, such 
 as cephalalgia, depression, somnolence, acceleration 
 of the pulse, vertigo, tremor, and, in some cases, 
 albuminuria. At other times its onset is abrupt. 
 Like the alcoholic attack it may come on after a 
 rapid intoxication, or from the suppression of an 
 habitual poison, sometimes, finally, from the effect of 
 a physical or moral traumatism. 
 
 However this may be, the first symptom is dis- 
 turbance of sleep, which becomes agitated and full 
 
 M&NT. Med.— 33. 
 
506 TOXIC ixsANirrES. 
 
 of dreams. Little by little excitement appears and 
 increases, and delirium supervenes, accompanied 
 with illusions and more or less terrifying visual hal- 
 lucinations; a very marked tremor appears; the 
 patient's face is flushed and swollen and he gives utter- 
 ance to cries, acts with violence, utters obscenities; 
 in short, he is an absolute picture of the alcoholic 
 subject in an acute attack of insanity from drink. 
 
 The duration of these attacks is usually short, 
 hardly extending beyond one or two weeks ; recov- 
 ery is the most frequent termination, and shows it- 
 self by the restoration of sleej) and the progressive 
 disappearance of the symptoms. Sometimes, never- 
 theless, the patient may die suddenly during the 
 attack. 
 
 c. Htpeeacutb Insanity. — Hyperacute insanity 
 is a little more rare in saturnine intoxication, and 
 when it occurs it nearly always presents itseK in the 
 melancholic, that is, the stuporous form. As in the 
 corresponding form of alcoholic insanity, the pa- 
 tients are stupid, immobile, in a condition of fixed- 
 ness and complete stupor from which they arouse 
 themselves only to make some attempt at suicide. 
 This form is serious, and when it does not cause 
 death, it always leaves behind it an obtusion of the 
 intelligence that may persist for a long time. 
 
 The lesions found at the autopsy do not generally 
 account for the symptoms observed. At most we 
 find in some cases an anaemia of the brain with more 
 
SATTrENrtiTB PSEtrDO-GENEEAl PAEALTSIS. 507 
 
 or less pronounced oedema. It is rare that we can 
 discover traces of lead in the hrain, especially in 
 acute intoxication. 
 
 3.— Satubnine Dementia. 
 
 Just as long-continued alcoholic intoxication will 
 produce at length a progressive physical and moral 
 decay, so slow poisoning by lead may give rise to 
 an analogous degradation, traversed or not as in 
 alcoholism by more or less acute delirious or con- 
 vulsive episodes. It is to be remarked that in 
 chronic saturnism the dementia is precocious and 
 more prpfound, the cachexia more marked, the local 
 paralysis and epileptic or eclamptic convulsions more 
 frequent, the marasmus and the untidy state more 
 rapid, and that after a time of varying length the 
 patients either succumb from the progress of the 
 bodily cachexia or are carried off by a convulsive 
 attack. 
 
 It is usual in this form to encounter more evident 
 alterations, such as softening of the brain, cerebral 
 atrophy, presence of lead in the nervous centres, etc. 
 
 3. — Sathrkestb Psbtjdo-Genbbal Paralysis. 
 
 Tanquerel des Planches had already noted the 
 embarrassment of speech in the saturnine encephal- 
 opathy, but it was not until 1851 that M. Delasiauve 
 showed that certain forms of this encephalopathy 
 might so closely resemble general paralysis as to 
 simulate that disorder, whence the name of saturn- 
 
508 TOXIC INSANITIES. 
 
 ine pseudo-general paralysis given to them by him. 
 Nevertheless, a year later, M. Delasiauve seemed to 
 modify his opinion and admitted the existence of a 
 true saturnine general paralysis. 
 
 In 1857 the work of M. Devouges appeared, sanc- 
 tioning the existence of a saturnine general paral- 
 ysis identical with the ordinary form. 
 
 Since that time the question has not been advanced, 
 and, except in a few scattered published observations, 
 the ideas of M. Devouges have been generally ac- 
 cepted. 
 
 Having been struck by the surprising recoveries of 
 numerous cases of saturnine general paralysis in my 
 own observation, I published in 1880, a paper, in 
 which, supporting my views on my own experience, 
 I tried to show that saturnine general paralysis did 
 not really merit the title, and that it was in reality 
 only a pseudo-general paralysis of which I sketched 
 the principal features. From that time the idea of 
 saturnine pseudo-paralysis has gained ground simul- 
 taneou sly with those of syphilitic and alcoholic pseudo- 
 general paralysis, and some authors have published 
 accounts of cases. 
 
 Like alcoholic pseudo-paresis the saturnine pseudo- 
 general paralysis most generally develops in the 
 course, or rather as the result, of a subacute attack 
 of saturnine insanity. Contrary to what occurs in 
 true general paralysis, its beginning is abrupt, it 
 breaks out noisily and reaches its apogee at once. 
 As soon as the hallucinatory and delirious symptoms 
 
SATUENINE PSEUDO-GENERAL PAEALTSIS. 509 
 
 that constitute the lead intoxication have passed off, 
 the pseudo-general paralysis appears, not with the 
 mild symptoms of the period of invasion, but with 
 the gravest characters of the full-fledged disorder. 
 In most cases the patients are plunged from the be- 
 ginning into the most profound cachectic marasmus. 
 They are untidy, paralyzed, demented, incapable of 
 making a movement or uttering a syllable , and seem 
 to be on the point of snccumbing. At the same time 
 they present the usual symptoms of lead intoxication, 
 such as the blue line on the gums, clayey complexion, 
 cephalalgia, dizziness, cramps, various neuralgias, 
 partial anaesthesias or hypersesthesias, arthropathies, 
 paralysis, epileptic or eclamptic disorders, etc. 
 
 The symptoms common to true general paralysis 
 and saturnine pseudo-paralysis, present in this last 
 some special shades of difference. Thus the pupil- 
 lary inequality is often lacking, the tremor, while 
 more intermittent, is also more marked and spas- 
 modic, and the embarrassment of speech is occasion- 
 ally so marked at the beginning that the voice is 
 unintelligible. The patients, as has been stated, are 
 often untidy and completely paralyzed on their first 
 admission to the asylum. Mentally, besides the de- 
 lirious and hallucinatory manifestations we have de- 
 scribed and which speedily disappear, they show a 
 type of depression very different from that of general 
 paralysis. While, in ordinary paretics the enfeeble- 
 ment of the intelligence, at first slight, follows a pjo . 
 gressive course and finally terminates in complete de- 
 
510 TOXIC INSAUITIKS. 
 
 mentia, in the case of saturnine pseudo-paralytics, this 
 enf eeblement, which appears at once in its greatest in- 
 tensity, is much more apparent than real. The patients 
 seem often from the very beginning to be suffering 
 from a complete abolition of the intellect, they ap- 
 pear absolutely stupid, disconnected in their words, 
 hardly able to speak their own names. Neverthe- 
 less there is no abolition, but merely a suspension of 
 their faculties, an obtusion pushed to its extreme 
 limits. Thus, after sometimes a very short lapse of 
 time, the intelligence reappears, and one is surprised 
 at being able to witness the rapid awakening of the 
 patients who appeared to be fated to an incurable 
 dementia. As regards the delirium, gay or otherwise, 
 of saturnine j^seudo-general paralysis, there is little 
 of special importance to note. Nevertheless we 
 may say that it is less apparent than in general paral- 
 ysis, as the obtunding of the faculties that dom- 
 inates the scene does not favor its explosion, but 
 that, on the other hand, it is more frequently accom- 
 panied by sensory disorders. Lastly, it may be said 
 that, as a rule, the saturnine patient, at least when 
 not in a torpid state, is querulous, coarse and 
 troublesome, while the paralytic is, at least super- 
 ficially, pleasant, humane, generous and benevolent. 
 It is especially as regards its coui'se and prog- 
 nosis, that saturnine pseudo-paralysis is distinct from 
 true general paralysis. In fact, however little differ- 
 ent the symptoms may have been, they quickly im- 
 prove and finally disappear as the poison is eliminated 
 
MOEPHnac htsanttt. 511 
 
 from the system by the natural excretions, which 
 fact makes this form an essentially curable one. It 
 should be stated, however, that, like alcoholic pseudo- 
 paralysis, it has a decided tendency to recur under the 
 influence of the same causes. 
 
 It is only in this last event, and after many suc- 
 cessive relapses, that the patients become incurable 
 and fall into a condition of cachectic dementia, 
 during which they are generally carried off by a 
 comatose or convulsive attack. We find then at 
 the autopsy the usual lesions of saturnine dementia, 
 and sometimes also some non-cortical meningeal 
 lesions. 
 
 The treatment consists chiefly in favoring the 
 elimination of the poison. It is necessary therefore 
 to use sulphur baths, and iodide of potash combined 
 with the bromides. It is necessary, in order to pre- 
 vent a return of the symptoms, to formally pledge 
 the patient to change his occupation. 
 
 m.— MORPHINISM. 
 
 (MOEPHINIO INSAHITT). 
 
 Morphinism is the sum of the accidents due to 
 poisoning by morphine. It may be medical, that is, 
 the result of a more or less prolonged medication 
 with morphine, but almost always it succeeds mor- 
 phinomania, that is, the passion of the patient for 
 morphine. 
 
 There is no need here of giving the history of 
 
51iJ I'oxic msANiTias. 
 
 morphinism or of morphinomania or of explaimng 
 how subcutaneous injections of morphine, recom- 
 mended by a physician to calm the sufferings of his 
 patients, have become in a short time the fashionable 
 poison in certain classes of society, among whom 
 they are already making the greatest havoc. What 
 is of interest for us to know is that, like all other 
 toxic agents, morphine is capable of provoking 
 mental disojjders of various kinds, and the history of 
 certain recent criminal trials shows that the medico- 
 legal chapter of morphinism has been opened. 
 
 A number of works have already appeared on 
 morphinism and piorphinomania, but the course of 
 lectures of M. Ball on this subject was one of the 
 earliest studies that particularly discussed the psychic 
 disorders of this intoxication. Since its appearance 
 the question has been treated fully and at length in 
 many works (Jennings, Pichon, GuimbaU, etc.) 
 
 In a general way the insanity caused by morphin- 
 omania resembles in all points all the other toxic in- 
 sanities, and like them manifests itself in more or 
 less acute attacks of mania or melancholia, with 
 insomnia, terrifying visual hallucinations, tremors, 
 etc. Morphinomania, however, causes insanity more 
 rarely than the other intoxications, and usually gives , 
 rise to intellectual disorders that confine themselves 
 to the domain of semi-alienation. 
 
 It is useful, therefore, to make a distinction between 
 the accidents due to the abuse of morphine and those 
 caused by its suppression, as both may be the origin 
 
MOEPHINIC mSANlTT. 513 
 
 of mental disorder, which, as we have seen, was also 
 the case with alcohol and lead. 
 
 1. Effects of Abuse. — The first effects of the ab- 
 sorption of the poison are generally agreeable, and 
 this period of stimulation may last, according to the 
 eases, from a few weeks to some years. Dating 
 from the moment that the passion becomes tyran- 
 nical, or the morphine habitue becomes a morphino- 
 maniac, the disorders appear more or less rapidly, 
 and the following intellectual and moral symptoms 
 may present themselves : 
 
 The first effect, as has been said, is a feeling of 
 well-being and happiness — a sort of stimulation of 
 the faculties. Soon, however, the will becomes paral- 
 yzed and the patient has not enough energy to rouse 
 himself from his torpor and renounce his habit. 
 Often indeed he lacks the force to leave his couch 
 (manie leatuaire) . Memory and judgment do not 
 seem seriously affected, but they may show a certain 
 degree of obtusion. The moral sense is nearly always 
 profoundly blunted; the morpliinomaniacs commit 
 indelicate acts, sometimes also misdemeanors or actual 
 crimes. Finally, their instincts may be depraved, and 
 they frequently indulge in all sorts of excesses, even 
 to debauchery that is actually pathological. Sleep 
 is always disordered and sometimes almost abolished ; 
 at the most there is then produced a tendency to 
 diurnal somnolence, but not supfjying the needed 
 rest. When all these disturbances attain a certain 
 degree of intensity, there are usually added some 
 
514 TOXIC INSAinTIES. 
 
 more serious symptoms such as panic terrors, hallu- 
 cinations, mainly visual, but possibly also of taste 
 and smell. Occasionally there is a true melancholic 
 state, with prostration, delusions of persecution, 
 suicidal tendency, etc. Acute mania is less common, 
 though it may be observed ; thus in the opium resorts 
 of Indo-China, we may see Malays, in a paroxysm 
 of fury from having lost at play, rush into the street, 
 knife in hand. 
 
 Finally, the prolonged abuse of morphine may at 
 last cause a state of dementia, more or less anal- 
 ogous to the other toxic dementias. 
 
 With these purely psychic disorders occur the 
 array of physical symptoms of the poisoning, such 
 as anaesthesia or hyperaesthesia, diminution of the 
 reflexes, increased appetite, obstinate constipation 
 with tenesmus, dysuria, hoarseness of the voice, in- 
 duration of the skin, tendency to local accidents at 
 points of puncture, and lastly the aged and wrinkled 
 appearance of the face. 
 
 3. Effects of Abstinence. — These effects are pro- 
 duced in morphinomaniacs who, either voluntarily or 
 involuntarily, find themselves suddenly deprived of 
 their habitual stimulants. Among the effects of 
 abstinence there are some identical with, and others 
 opposed to, those that result from abuse. Mentally 
 we see the euphoria disappear and be replaced by 
 irritability, inequalities of character and humor, and 
 tendency to criticise and see evil in everything. To 
 this is joined a greater or less degree of sentiment- 
 
MOEPHINIC INSANITY. 515 
 
 ality, incapacity for work, mental weakness, somno- 
 lence, and weakness of the will. In some instances 
 the patients are inert and torpid, they will not leave 
 their beds ; in other cases, on the contrary, they are 
 excessively agitated, go and come, vmable to remain 
 in iLuj one place, they weep and groan and lament on 
 all occasions. Sometimes they also have hallucina- 
 tions of sight, smell, and taste. Insomnia is gen- 
 erally complete. In some cases a genuine attack 
 of insanity declares itself, commonly maniacal in 
 form, and occasionally even a true trembling 
 delirium. 
 
 The concomitant physical disorders in the sensory 
 and motor and organic functions are much more pro- 
 nounced than in case of the abuse of morphine, and 
 may terminate in a very serious condition, such as 
 collapse, capable of causing death. The best treat- 
 ment in these cases is the retura to the morphine in- 
 jections, which often causes the symptoms, serious 
 as they seem, to disappear as if by magic. 
 
 The diagnosis of morphinio mental alienation, 
 consists essentially in detecting the morphinomania, 
 often sedulously concealed by the patients. Beside? 
 the usual symptoms of morphinism, the appearance 
 of the skin with traces of punctures, and the exam- 
 ination of the urine, which contains the alkaloid 
 even after many days' abstinence, will suffice to re- 
 lieve all doubts. 
 
 The prognosis is grave, as there is no passion 
 more tyrannical than that for morphine, and if we 
 
516 TOXIC INSANITIES. 
 
 cannot vanquisli it or at least attenuate it by a pro- 
 gressive diminution of the dose, the patients gener- 
 ally succumb finally to marasmus or phthisis. 
 
 The treatment consists either in the gradual or 
 the abrupt discontinuance of the drug, the latter be- 
 ing the more dangerous and capable of producing 
 the serious effects of abstinence. A third method, 
 intermediate between these two, that of Erlenmeyer, 
 consists in the sudden suppression of the ration de 
 luxe, and the gradual diminution of the dose until 
 complete suppression is attained. Isolation in an 
 asylum is often necessary, and some authors do not 
 hesitate to make this the basis of the treatment. It 
 is, in fact, almost the only means — and yet some- 
 times insufficient — of preventing the morphinoma- 
 niac from deceiving, and obtaining by easily plotted 
 ruses, his customary excitant. In order to avoid 
 their seclusion in insane asylums, there have been 
 some special establishments founded abroad {Seil- 
 anstalten fiXr MorphiumsiXchtige) for these cases, 
 where the plan consists, as at Gratz, in the ab- 
 rupt and complete discontinuance of the poison, 
 without other treatment than immediate interven- 
 tion, but without morphine, in case any compromis- 
 ing accidents supervene. 
 
 In the early stages of treatment by gradual dimi- 
 nution of the dose, other treatment may be limited 
 to the administration of some sedatives, such as 
 bromide of sodium, chloral, and picrotoxine. In the 
 second period, if phenomena of cardiac and general 
 
MOEPHINIC INSANITY. 517 
 
 depression show themselves, it is necessary to stim- 
 ulate the organism. We may proceed in this hy 
 substitution, replacing the morphine by some other 
 agent, such as opium, alcohol in full doses, cocaine 
 (a very dangei-ous agent), atropine, hasohisch, nux 
 vomica, caffeine, and lastly, phosphate of codeine, 
 in the dose of ten to fifty centigrammes by hypoder- 
 mic injections, that was specially recommended as a 
 basis of treatment by M. Guimbail. As a stimu- 
 lant, strophanthine may be utilized (half a milli- 
 gramme hypodermically), sulphate of spartein, nitro- 
 glycerine or trinitrine (Jennings), fluid extract of 
 kola, etc. 
 
 When the hypodermics are discontinued, that is, 
 in the third stage of the treatment, one must combat 
 the accidents that may occur. For the vomiting, iced 
 or very warm drinks, quiet horizontal position, alco- 
 holized black coffee, extract of belladonna. For the 
 diarrhoea, naphthol, salol or salicylate of bismuth in 
 full doses, extract of opium. For the accidents 
 of collapse, energetic cutaneous revulsives, douches, 
 cold affusions, warm baths, sinapisms, urtication, 
 faradization of the skin and especially of the phrenic 
 nerves, injections of ether, and, finally, in very se- 
 vere cases, the injection of morphine, which, nine 
 times out of ten, is sufficient to arouse the organism 
 from near the point of extinction, or again, as a last 
 resort, transfusion of blood. 
 
 The adjuvants to this treatment are numerous, and 
 vary according to the case : hydrotherapy, Turkish 
 
518 Tono nrsAinTiES. 
 
 baths, massage, static electricity, heat, valerian, 
 bromides, chloral, alkalines, milk, mechanical stimu- 
 lations, and exercise and amusements when prac- 
 ticable. 
 
 Hypnotism, highly praised by some physicians, 
 may give good results, but only in certain special 
 cases. The same is true of all the agencies that act 
 by strongly impressing the feelings and imagination 
 of the patients, such as violent emotions, religious 
 ceremonies, pilgrimages, etc. 
 
 IV.— OTHEE INTOXICATIONS. 
 
 (AbSINTHIBM, EtHEKISM. CHLORALISM, COCAINlSMt GXYCARBONISM, BTC.) 
 
 Alcohol, lead, and morphine are not the only 
 substances capable of causing cerebral disorders. 
 There are very many others that have more or less 
 analogous effects on the organism. The description 
 of all the toxic deliriums, useless here, finds its proper 
 place in a special study of the subject, such, for 
 example, as that of M. Pichon {Les maladies de 
 Vesprit, 1888), or that of M. Legrain {Les poisons 
 de Vintelligence, 1891). We wUl content ourselves 
 vrith recapitulating very briefly, at the end of this 
 chapter, the principal characters of certain intoxi- 
 cations to which attention has been more specially 
 directed of late years. 
 
 AbsMithism. — Absinthism differs, by some peculi- 
 arities, from alcoholism. Instead of the ansEsthesia 
 of the analgesic type observed in the former, there 
 
ETHBEISM, CHLOEAIilSM. 519 
 
 is hjrpersesthesia of the feet (Lancereaux) and very- 
 marked exaggeration of the patellar and plantar re- 
 flexes. Moreover the accidents have in this intoxi- 
 cation a much more rapid evolution to dementia. 
 
 The conscious, irresistible impulsions are much 
 more violent than in alcoholism. In chronic absinth- 
 ism, or in the intervals between the attacks, it is 
 not uncommon to see a sort of conscious melancholic 
 state (Gilson). Finally, the epileptiform attacks, 
 which are very frequent, resemble the comitial 
 attacks. 
 
 Etherism. — This intoxication is comparable to 
 that from morphine, but is rarer and less grave. 
 The passion for ether, ether omania, is not accom- 
 panied with the same degree of irresistible craving for 
 the stimulant. The deprivation, also, of the drug 
 produces quite a different condition from the state 
 of distress of the morphinomaniac, and is not accom- 
 panied with the same serious accidents. 
 
 Chloroformisw,, which is very uncommon, also 
 presents analogous characters. Dr. Savage has cited 
 cases where surgical ana3sthesia with chloroform, 
 ether, or protoxide of nitrogen, has been sufficient to 
 provoke in persons who had been formerly Insane or 
 those predisposed to insanity, either a temporary 
 toxic delirium or the return of a vesanic alienation. 
 
 Chloralism. — Chloralism is characterized, like 
 morphinism, by an irresistible tendency to the ab- 
 sorption of progressively increasing doses of the 
 
520 TOXIC INSANITIES. 
 
 drug, and by a genuine state of distress that is pro- 
 voked by the abstinence after its long continued 
 employment, but with less serious symptoms. The 
 bodily symptoms seem to consist mainly in gastro- 
 intestinal disturbances. Psycho-sensorial accidents 
 are rare, but there is usually some mental 
 enfeeblement. 
 
 Haschischism, llieism, Vanillism, and Nico- 
 tinism cause analogous effects on the system to those 
 passed in review. 
 
 Cocainism. — Erlenmeyer, Magnan and Saury, 
 Pichon, S6glas, Chalmers da Costa, Hallopeau, 
 Chouppe, and some other authors, have called atten- 
 tion of late years to the cerebral disorders engen- 
 dered by cocaine. In most of the cases observed, 
 the intoxication was from morphine and cocaine 
 simultaneously, thus complicating the distinction of 
 the symptoms. The special effects of cocaine have, 
 nevertheless, been observed in patients free from 
 morphinism or alcoholism. According to Magnan 
 and Saury, the leading symptom is found in the ex- 
 istence of special cutaneous impressions (sensations 
 of worms, insects, microbes, vermin around the body, 
 in the skin or in the wounds of the punctures) ; next 
 come hallucinations of sight, hearing, or smell, and, 
 finally, delirium composed of hypochondriacal ideas 
 and those of persecution. There are also sometimes 
 ocular disturbances (diplopia, amblyopia, dyschro- 
 matopsia) and, even after small doses as in Chalmers 
 
OXT-CAEBONISM, ETC. 531 
 
 da Costa's case, tetaniform condition, collapse, hys- 
 tero-epileptiform convulsions and violent agitation. 
 
 Cocaine niay be considered as the agent of a grave 
 intoxication and as causing in the system rapid and 
 serious ravages. It is a drug that should be entirely 
 abstained from, at least in the form of hypodermic 
 injections. 
 
 Oxy-carbonism. — The vapor of oxide of carbon 
 may give rise to an intoxication, either chronic and 
 professional, as in ironers, or accidental and acute as 
 in poisoning by movable stoves. This intoxication 
 has been specially studied of late years by Woelcken, 
 Lancereaux, Briand, Moreau (de Tours), etc., etc. 
 
 The dominant psychic symptom and the one that 
 constitutes the characteristic phenomenon in acute 
 cases, is amnesia, usually retrograde and going back 
 more or less beyond the poisoning. We also observe, 
 especially in the slow intoxication, other phenomena, 
 such as vertigo, oppression, syncope, mental obtu- 
 sion, hallucinations of sight and hearing, delusive 
 conceptions (notions of persecution). 
 
 If these symptoms are not of too long standing 
 the removal of the action of the deleterious gas 
 causes them all to disappear. If the case is other- 
 wise, rapid and incurable dementia ensues. 
 
 The treatment should consist mainly in hygienic 
 measures, tonics and reconstituents. In the acute 
 stage alkaline bromides, bromohydrate of quinine, 
 prolonged warm baths, and vertebral affusions, 
 
 MENT. UEO.— 33. 
 
SECOND PART. 
 
 APPLICATIONS OP 
 
 MENTAL PATHOLOGY 
 
 TO PEACTICE, 
 
 FIRST SECTION. 
 MEDICAL PRACTICE. 
 
 DIVISION. 
 
 The practical part of mental alienation divides 
 naturally into two sections: (1) medical practice, 
 ■which relates to the treatment of the insane, and the 
 various matters appertaining to it ; (3) medico-legal 
 practice, vrhich includes the medical study of the 
 forensic questions in regard to the insane. 
 
 The medical practice is, unquestionably, the one 
 that chiefly interests the physician, as it treats es- 
 pecially of the relations of eveiy kind that he may 
 have with the insane, either during the course of 
 their disease, whUe they are at liberty, or up to the 
 moment of their entry into the asylums when they 
 are destined to sequestration. But the various 
 points that make up this practice have never been 
 
DIVISION. 523 
 
 formulated in any precise manner, and there does 
 not exist, properly speaking, any professional code 
 destined to guide the physician in the current prac- 
 tice as regards mental alienation. Without in any 
 way pretending to fill up this lacuna, I have thought 
 that in a Manual intended especially to be practical, 
 and which addresses itself more particularly to phy- 
 sicians who are not specialists, these practical pro- 
 fessional questions ought necessarily to occupy an 
 important place. I have therefore attempted to 
 formulate some general precepts relative to the prin- 
 cipal situations in which the physician may find 
 himself in his practice in relation to the insane. 
 
 These situations seem to me to be summed up in 
 a general way in the following indications : 
 
 1. The physician is called to see a patient 
 supposed to be insane. His task is to find out 
 whether the individual is really insane or not and 
 what is the form of the malady. This is what 
 may be called the practical diagnosis of mental 
 alienation. 
 
 2. The existence of mental alienation and its 
 form being determined, it remains to say what 
 measures are to be taken in regard to the case, the 
 necessity or otherwise of internement. This second 
 point therefore consists essentially in the medical 
 judgm.ent as to the need of sequestration. 
 
 3. These points settled, the duty of the phy- 
 sician varies according to whether or not confine- 
 ment is ordered. In case it is directed, the 
 
524 Medical practice. 
 
 physician should proceed to make use of the 
 formalities prescribed by the law in such cases, 
 and from that moment the patient is submitted to 
 the authority of those who have the care and treat- 
 ment of the inmates of special establishments for the 
 insane. There are here therefore two distinct things : 
 (1) the commitment of the insane ; (2) the situation 
 and treatment of the insane in confinement. 
 
 4. If confinement is not found to be necessary or 
 is for any reason impracticable, the patient is left 
 at liberty and the physician adopts an appropriate 
 treatment suited to the ease. This is the treatment 
 of the insane. 
 
 5. Finally, the physician may be called on to act 
 in certain conditions, either in regard to the insane 
 themselves, or for their friends: for example, to lay 
 down rules for a prophylactic treatment for the 
 patients or their children, and especially to give 
 opinions on the matter of heredity, as regards tlie 
 future of their children, or in regard to a proposed 
 marriage by a member of their family. This is 
 what may be called tnedico -mental deontology. 
 
 We shall now study briefly, in different chapters, 
 these various points of medical practice in mental 
 alienation, viz. : 
 
 1. The practical diagnosis of mental alienation. 
 
 2. Medical estimation of the necessity of seques- 
 tration. 
 
 3. Placing the insane in special establishments. 
 
 4. The treatment of the insane. 
 
 6. Medico-mental deontology. 
 
Cbapter H. 
 
 THE PRACTICAL DIAGNOSIS OF MENTAL 
 ALIENATION. 
 
 Just as diagnosis in ordinary medicine is com- 
 posed of two distinct elements: the study of the 
 history of the case and the examination of the 
 patient, so also and even more so in mental medicine 
 it is absolutely indispensable that we should inform 
 ourselves as to the antecedents of the case before 
 proceeding to the interrogation and direct exam- 
 ination of the patient. 
 
 But while in ordinary medical clinics the patient 
 can usually give the facts needed by the physician 
 for his diagnosis, even better than anyone else, in 
 the mental clinic it is almost always impossible to 
 proceed in this way, and it becomes necessary to get 
 the history from another source. The majority of 
 the insane, indeed, cannot furnish the slightest 
 serious indication as to their past, some, like the de- 
 generates and the dements, because they are incapa- 
 ble; others, like the excited and incoherent cases, 
 because it is impossible to fix their attention ; some, 
 like the melancholiacs, from their more or less abso- 
 lute mutism; and others, finally, like the victims of 
 persecutory delusions, on account of their reticence 
 and because they think they see a trap in the ques- 
 tions asked them, 
 
626 PRA.CTICAX DIAGNOSIS OF INSANITY. 
 
 It is, therefore, usually inexpedient to begin 
 directly with the patient without previously ac- 
 quired information, and before obtaining this it is 
 needful to interrogate the members of his family or 
 some one very closely associated with him. By 
 thus doing we can obtain valuable information that 
 will give important aid in examination and 
 diagnosis. 
 
 History. — The facts to be obtained from the rela- 
 tives or intimate associates include : (1) the family 
 history ; (2) the personal antecedents of the patient. 
 As these very often include matters of extreme deli- 
 cacy, the physician should in questioning, show him- 
 self to be discreet, reserved, should use the greatest 
 circumspection and make the persons he interrogates 
 understand that all these details, far from being 
 superfluous, may have, on the contrary, a very great 
 importance. And after all we must not forget that 
 the information thus obtained is far from being the 
 exact expression of the truth. Either from honest 
 ignorance or more often still from a feeling of repug- 
 nance or false shame very common in society, the 
 members of the patient's family very frequently fail 
 to give the physician the truth as regards hereditary 
 antecedents. We may also, in a general way, ac- 
 cept as under the reality the semi-admissions we 
 obtain in this regard. 
 
 1. Family History. — In investigating the family 
 history one must not limit himself to obtaining da(* 
 
HISTORY. 527 
 
 as to the patient's father and mother, that is to say, 
 to his direct ancestors. It is equally necessary to 
 learn in regard to his collateral heredity and his de- 
 scendants, and particularly to go back in the direct 
 heredity to the grand-parents. We have seen, in- 
 deed, that heredity in certain families sometimes 
 jumps one generation to appear again in the suc- 
 ceeding one, so that the insanity of an individual, 
 leaving his immediate descendants intact or at least 
 existing in them only in a latent condition, may 
 break ont in his grandchildren. It is well therefore 
 to obtain information whether there have not ex- 
 isted in the paternal or maternal ancestors, or in the 
 collaterals or descendants, well defined cases of men- 
 tal disorder, spinal disease, neuroses, alcoholism, 
 suicide, abnormal vices or criminality, deaf -mutism, 
 consanguineous marriages, diatheses in general (tu- 
 berculosis, arthritism, cancer, syphilis), or simply 
 cases of eccentricity, or defective psychic organiza- 
 tion; since, as Morel has justly remarked, insanity 
 is very frequently not the direct result of in- 
 sanity, but is rather that of a predisposition 
 that is shown in the ancestors only by some 
 simple oddity of character, or by an isolated 
 tendency to sadness or excitement. In addition to 
 these facts there are some others the knowledge of 
 which may be of interest. Thus it is well to know, 
 when we can, if the patient is not illegitimate, if at 
 the time of his presumed conception his parents 
 were young or old, if they were under the influence 
 
528 PEACTICAL DIAaNOSIS OF INSAIflTY. 
 
 of alcoholic excitemelit, were recovering from any 
 long or serious illness, or gufEerLng from any kind of 
 exhaustion, etc., etc. It is, in fact, very important 
 to specify the nature of the diseases or the morbid 
 peculiarities that may have existed in the family, 
 since all kinds of alienation do not have the same 
 origin or recognize the same heredity. Thus at the 
 present time the tendency is to admit that general 
 paralytics do not usually descend from insane parents 
 buf from subjects of tendency to other cerebral dis- 
 orders, while the heredity of the insane properly so- 
 called, is from vesanio ancestors. We know also 
 that certain varieties of insanity such as double form 
 insanity, and hereditary suicide, are inherited from 
 ancestors similarly affected, while in the other types 
 the heredity is dissimilar as a rule. It will be un- 
 derstood that these indications, drawn from heredity 
 and its form, may be of importance in cases where 
 the diagnosis presents difficulties, for example, when 
 we are endeavoring to establish or reject the exist- 
 ence of general paralysis. In such case the assured 
 proof of vesanias in the progenitors would be a fact 
 against the presumption of general paralysis, which 
 on the other hand would be supported by a history 
 of apoplexy or hemiplegia of the parents. 
 
 The important question of heredity settled, not 
 only as to its existence, properly speaking, but also 
 as to all its characters of multiplicity, complexity, 
 form, etc. , it is of importance to study the family of 
 the patient, as to its general constitution, the prin- 
 
HISTOET. 
 
 529 
 
 cipal manifestations of its life, in that which we 
 have studied, with M. Ball, under the name of the 
 biological characters of the family. The principal 
 of these characters are : the longevity, or duration 
 of life, usually rather long in the families of the 
 insane; the natality, or average number of births, 
 also high in families of the mentally alienated, es- 
 pecially in those subject to cerebral accidents; the 
 vitality or vital power, less in early life on the con- 
 trary in these families. We may find here certain 
 indications, certain peculiarities that betray the 
 hereditary taint, and show clearly the degeneracy 
 and the form of degeneracy that weighs upon the 
 race. 
 
 3. Antecedents of the Patient. — The family of 
 the patient known, both as to the ascendants and the 
 descendants, it is needful to become informed as to 
 himself, and this from the period of his birth up to 
 the time we are called to examine him. This in- 
 quiry therefore includes two distinct parts : A. — the 
 history of the life of the patient up to the disorder ; 
 B. — ^the history of his disease. 
 
 A. — In regard to this first point we should inquire 
 rapidly as to all the main points of the patient's life, 
 his age, civil condition, physical, mental and moral 
 constitution, his resemblance in these respects to this 
 or that of his progenitors, his degree of mental cul- 
 ture, his character, tastes, religious sentiments, in- 
 stincts, habits and penchants j should inquire if he 
 
530 PEACTICAL DIAGNOSIS OF INSANITY. 
 
 is nervous and impressionable ; at what epoch puberty 
 appeared and how ; if the patient is a female, inquire 
 as to the catamenia, whether suppressed, difficult, 
 or normal, whether or not their return is accompanied 
 with psychic or nervous disturbances, whether there 
 have been any pregnancies and how many, how they 
 have been endured ; one should learn whether the 
 patients have not been or are not still affected with any 
 serious disorder (meningitis, convulsions, typhoid 
 fever, visceral disease, or any diathesis whatever, 
 especially former attacks of insanity) ; if they have 
 not received injuries, particularly blows on the head ; 
 if they have been guilty of alcoholic or sexual ex- 
 cesses ; if they have not used tobacco excessively, or 
 morphine or any other poison ; if their occupation has 
 exposed them to any intoxication or other deleterious 
 influences ; if they have had domestic difficulties, re- 
 verses of fortune, unexpected joy ; if they have passed 
 suddenly from an active life to one of repose, or vice 
 versa, etc., etc. In short no point must be left io 
 the dark, and every effort must be made to search 
 out fully the patient's past life. 
 
 B. — ^Passing next to the malady the nature of which 
 is to be determined, one must demand of the rela- 
 tives what, in their opinion, is the cause or probable 
 cause, moral or material; what was the date and 
 manner of its beginning, its first mental and bodily 
 manifestations, the course it has taken since its be- 
 ginning ; inquiry should be made as to the present 
 conduct of the patient, the nature of his ideas, his 
 
EXAMINATION OP THE PATIENT. 631 
 
 conversation, sentiments, the acts lie has committed, 
 the state of his organic functions, especially his di- 
 gestive and genital functions, and, above all, his 
 sleep. 
 
 Whenever possible, the writings of the patient 
 should be seen and compared with other similar pro- 
 ductions of various previous dates. The autographs 
 of the insane deserve all the physician's attention as 
 they often bear the direct evidence of the disorder of 
 their faculties, either in form as a graphic represent- 
 ation, or fundamentally as a mode of expression of 
 delusional ideas. 
 
 The interrogation of the family having been com- 
 pleted, we find ourselves in possession of valuable 
 data that permit us to proceed profitably in the 
 examination of the patient himself. 
 
 Examination of the Patient. — -It may happen 
 that we have to deal with a patient, with more or 
 less fever, or one suffering from an acute visceral 
 disease complicated with delirium ; in such cases the 
 first steps should be as with an ordinary sick patient, 
 and the diagnosis consists in determining the exist- 
 ence of the organic affection and specifying the 
 nature of the febrile or vesanic delirium that accom- 
 panies it. We have seen, in the first part of this 
 work, on what basis rests this distinction, generally 
 easy to establish. 
 
 Generally we have to do with an insane person, 
 who continues, in a measure, to go and come, to liv^ 
 
532 PftACTICAL DIAGNOSIS OF INSANITY. 
 
 Ms usual life, and who is still semi-capable of under- 
 standing wliat passes around Mm and of carrying on a 
 conversation. These are the oases therefore we must 
 have in view in our study. 
 
 First, how to begin with the patient? — This is, in 
 its way, a very important question, and one that 
 presents certain difficulties. In ordinary medical 
 practice, the patient, instead of fearing the physician's 
 visit, desires it with impatience, he looks to him 
 sometimes as to a saviour, so the relations between 
 the two are very satisfactory. The peculiarity of 
 insanity on the other hand, is non-recognition of 
 itself, and the majority of the insane, ignorant of 
 their condition, believe themselves perfectly sound in 
 mind. To begin therefore as a physician, at least 
 in cases other than those of profound dementia or of 
 violent maniacal excitement rendering the subjects 
 indifferent to everything about them, is to incur a 
 great risk, not only of spoiUng everything and of 
 reaching no result, but also of having the patients fall 
 into a passion, become violent, and sometimes receiv- 
 ing insults, threats, and regrettable violence. 
 
 How shall this difficulty be avoided? Some authors 
 have proposed, when it is not possible to meet the 
 patient as a medical advisor, to make use of any 
 knowledge one may have as to Ms delusions to intro- 
 duce one's self in a character in accordance with them. 
 Is the patient a megalomaniac who believes himself 
 possessor of an immense fortune, a general, prince. 
 
EXAMINATION 01' THE PATIENT. 533 
 
 or potentate? Then begin as a man of business, -wish- 
 ing to propose a purchase, a banker, or an ambassador 
 from a friendly power. Is he, on the other hand, a 
 case of delusions of persecution? Then present your- 
 self as a police officer, a magistrate charged with 
 making an inquiry into his persecutions and obtain- 
 ing for him justice. And so on, each form of delu- 
 sion serving as a basis for the part the physician is 
 to play. Other authorities, Dr. MacDonald among 
 others, affirm that all these disguises are un- 
 worthy of the physician, and should in no case be 
 resorted to; all the more, since the insane often 
 detect the imposition, and take a malicious pleasure 
 in making the doctor ridiculous in his assumed char- 
 acter: as, for example, the insane mystic to whom 
 Dr. MacDonald was introduced as a Protestant 
 clergyman, and who mischievously compelled the 
 poor doctor to say grace at meals and to answer the 
 most difficult theological questions. In fact, we can- 
 not lay down any fixed rules in this regard. On princi- 
 ple, it would be better to present oneself squarely as a 
 physician were it not for suffering the first fire of the 
 patient's anger ; it is rare that with skill and patience 
 one does not speedily master his spirit. It is only 
 when it is impossible to act otherwise that the physi- 
 cian ought to hide his real personality under any 
 disguise; he should also guard against giving way to 
 all the fancies of the relatives, who under the foolish 
 pretext of not disturbing the patient, sometimes in- 
 vent the most ridiculous comedies, even going so far 
 
534 PRACTlCAl, DIAGNOSIS OP INSANITY. 
 
 as to demand that the physician should announce him- 
 self as a tailor come to take his measure, or as some 
 sort of merchant soliciting trade. The most simple 
 rdles are always the best. One of the better methods 
 is to appear as a doctor calling to see some other 
 member of the family (wife, children, etc.) ; the 
 health of such person is a convenient subject to open 
 upon with the patient and conduct the conversation 
 naturally, and then lead him unconsciously to the 
 subject of his own health. 
 
 Once in the presence of the patient, whom it is 
 always well to know how to distinguish amongst 
 those about him when seen in company and for the 
 first time, under penalty of otherwise making regret- 
 table mistakes, one should avoid a direct attack of 
 asking inconsiderately in regard to his delusions. 
 Sight should not be lost of the fact that in this situ- 
 ation one is before a place to be taken, there is a 
 veritable siege to be laid. 
 
 The discourse ought, therefore, to be at first con- 
 fined to matters of light importance, and it is by a 
 series of skilfully managed transitions, taking ad- 
 vantage of every hint dropped by the patient, that 
 it is, unconsciously to him, directed to the patholog- 
 ical conditions. It is profitable, moreover, to utilize 
 these first few minutes in the inspection of the pa- 
 tient, to form a judgment on the total and the de- 
 tails of his physique, which may furnish valuable 
 indications, and in some cases be alone sufficient for 
 the diagnosis. Thus microcephaly, prognathism, lack 
 
EXAMINATION OF THE PATIENT. 535 
 
 of folds in the ear, deaf mutism, lisping, and all mal- 
 formations and arrests of development are signs of 
 intellectual and moral degeneracy ; excessive asym- 
 metry of the face should put us on our guard for epi- 
 lepsy ; hemiplegia indicates an apoplectic dementia ; 
 embarrassment of speech by itself alone, and with 
 much more reason when it is accompanied with tre- 
 mor and inequality of the pupils, is often sufficient 
 to cause the recognition of general paralysis ; very 
 marked tremor of the hands reveals alcoholism ; ag- 
 itation, disordered acts, incessant cries, incoherence, 
 animation of the face and eyes, denote mania ; de- 
 pression, grief, immobility, hanging head, viola- 
 ceous tint of the skin, infected odor of the breath, 
 cicatrices of special localities, notably the head and 
 neck, evidences of one or more suicidal attempts, 
 indicate melancholia; a gloomy, haughty, distrust- 
 ful attitude with eyes open and threatening in appear- 
 ance indicates persecutory hallucinations; oddity 
 of costume, a special arrangement of the headgear, 
 hair and beard, colored ribbons, medals and chap- 
 lets worn conspicuously, and a proud and majes- 
 tic attitude, betray a systematized insanity, especially 
 megalomania; and so on, the physical inspection 
 alone, that is too often neglected, frequently reveals 
 interesting particulars that, aided by information 
 already obtained, are sometimes sufficient to make 
 matters completely clear to the observer. It is well, 
 at the same time, to cast a glance about the apart- 
 ment of the patient, which by its general arrange- 
 
536 PSACTICAL DIAGNOSIS OF INSANITY. 
 
 ment or that of certain parts, of certain pieces of 
 furniture or accessories, sometimes affords character- 
 istic indices of insanity. 
 
 During this time conversation opens the way, 
 and one gradually obtains control of the patient's 
 mind so that the point is reached of progressively 
 leading the discourse on to the subject of his delu- 
 sions. This arrived at, there is no invariable rule 
 to be followed any more than there is a methodic 
 order of questions to be asked. Everything is sub- 
 ordinated to the nature of the disease and the attitude 
 of the patient. Therefore it may be settled as a 
 principle that the course of the conversation, instead 
 of being laid out in advance and consisting in a series 
 of pre-arranged questions asked in a definite order, 
 should rather be guided by the patient himself. 
 The physician, without losing for an instant his 
 object in view, should let the patient talk, listen 
 without interrupting, even although he relates 
 tedious details, limiting himself to recalling him to 
 his subject whenever he wanders, and narrowing it 
 more and more. In this way we are able to eluci- 
 date all the points of the problem and to penetrate 
 more and more deeply into the intimate and secret 
 feelings of the insane. 
 
 In any case whatever it should never be forgotten 
 that there are two essential and quite distinct things 
 to be determined: (1) the condition of the intel- 
 lectual capital, that is to say, the intelligence in a 
 quantitative point of view ; (2) the state of intellect- 
 
EXAMINATION OF THE PATIENT. 537 
 
 iial functioning, that is to say, the intelligence in a 
 qualitative point of view. The study of the first 
 point will serve to indicate if the psychic faculties 
 of the patient are normally developed or preserved 
 in their integrity, or in other words whether there is 
 or is not any congenital or acquired cerebral infirm- 
 ity; the study of the second point will make certain 
 whether the faculties, whether normally constituted 
 or not, function incorrectly, or whether there exists 
 any insanity and, if so, of what kind. 
 
 In order to estimate in a quantitative point of 
 view, the psychic level of the subject, we should use 
 for comparison, what we know from previous in- 
 formation of the former condition of his faculties, 
 and compare with that the state of affairs we find 
 existing, using as means of measurement various 
 questions, recollections recalled, dates and calculations 
 skilfully demanded, making the patient write some 
 lines, calling out some literary, philosophical or 
 moral appreciations on his part, all of which permit 
 an estimation as to the fund of intelligence, and 
 especially of the state of the memory, ideation, rea- 
 soning power, judgment and moral sense. This 
 important part of the problem being settled, and it 
 is generally easily managed, at least when the degree 
 of dementia or mental weakness is slight, we seek 
 to solve the second question which consists in ascer- 
 taining whether the patient is a victim of insanity 
 and of what form. 
 
 The information obtained from the famUy, added 
 
 Ment. Med.— 34. 
 
538 PEACTICAL DIAGNOSIS OF INSAHITT. 
 
 to that obtained from inspection and questioning of 
 the patient, has already sufficed to assure us that he 
 is affected with some mental disorder. As regards 
 the question whether the mental trouble amounts to 
 an actual insanity or not, it is one which, while easily 
 solved in most cases, may in some others give rise to 
 very serious difficulties ; there is not indeed, properly 
 speaking, any absolute criterion of insanity. It 
 should be based mainly on the condition of the will 
 power, because the thing of most supreme importance 
 is to find out if the patient is still his own master and 
 controls himself or, on the contrary, if he has lost the 
 free control of his actions and is more or less com- 
 pletely under the dominion of his morbid tendencies. 
 In a case, moreover, where we have to do with one of 
 the exceptionally dubious instances of semi-insanity, 
 the exact estimation of which is so difficult, one ought 
 always to either claim a supplemental inquest, or to 
 utilize in consultation the skill of a brother physician. 
 The existence of insanity established, it yet re- 
 mains to determine its form and, when we have to 
 do with a generalized insanity, to ascertain whether 
 it is a simple or a symptomatic or sympathetic form. 
 This is the indispensable complement of the diag- 
 nosis, which can only be settled satisfactorily by hav- 
 ing clearly before the mind the primary elements 
 of mental alienation and the manner in which they 
 are associated together to constitute the various types 
 of insanity. Thus a general disorder of the activ- 
 ity, excitement or depression, denotes a condition of 
 
EXAMINATION 01" THE PATIENT. 539 
 
 mania or of melancholia, while the absence of this 
 general disturbance indicates partial or systematized 
 insanity ; in the same way, mobility of the ideas, inco- 
 herence, sensorial and mental illusions, disordered 
 excitement of speech and actions, characterize acute 
 mania ; gloomy delusive conceptions, ideas of culpa- 
 bility, of humility, of ruin, damnation, perdition, 
 hallucinations, refusal to speak, to eat, or to move, 
 together with suicidal tendency are characteristic of 
 melancholia ; systematized, coherent delusions, either 
 of persecution or of mysticism, hallucinations of 
 hearing and disturbances of the general sensibil- 
 ity, reticence and impulsions, appertain to systema- 
 tized insanity, etc., etc. ; in a word, in order to be 
 able to distinguish in practice the different forms of 
 insanity from each other, it is needful that one 
 should be acquainted with the principal symptoms 
 of each special form. 
 
 Not losing sight of this objective point we can 
 proceed to the interrogation of the patient and the 
 determination of the peculiarities of his mental- con- 
 dition; that is, according to the ease, the nature 
 and intensity of his delusive conceptions, his hallu- 
 cinations, his intellectual, moral, and affective aber- 
 rations, his prepossessions, desires, projects, path- 
 ological hopes, his temptations and impulsions. 
 
 It is understood that it may not be possible to lay 
 down fixed rules relative to formulas to be adopted 
 in the interrogation, nor consequently to indicate 
 any made-up list of questions. What it is import- 
 
540 PRACTICAL DIAGNOSIS OF INBANITT. 
 
 ant to keep in mind is, that whatever may be his 
 condition, it is needful to always treat the patient 
 with the greatest politeness and consideration, since, 
 however profoundly disordered they may be, the in- 
 sane are always capable of appreciation of politeness 
 and consideration shown them. It is, besides, by 
 such means that we are able, in great part, to obtain 
 their good will and ascertain their mental condition, 
 the principal aim of our proceedings. It is well un- 
 derstood that we should never speak to a lunatic as 
 to a patient, or let him suspect that we consider him 
 affected with any mental trouble whatever; so it is 
 important to weigh all one's words with care, and 
 particularly to guard against any evidently medical 
 interrogations, like those addressed to other classes 
 of patients, such for example as, — "Have you any 
 ideas of persecution? " ' ' Since when have you had 
 this embarrassment of speech? " " Have you always 
 had these hallucinations ; " etc. , etc. The condition 
 of the patient and the peculiarities of his disorder 
 must be ascertained without any technical word hav- 
 ing been pronounced, and without his suspecting 
 that he has undergone a scientific examination to 
 find out whether or not he is deranged. I need not 
 add that in no case should the chief part of the ex- 
 amination consist in the queries and methods of in- 
 quiry, without any real import, to which the public 
 and some magistrates wrongly attribute the value of 
 a real criterion, and which consists in simple inter- 
 rogations on the course of time or the respective 
 
EXAMINATION OF THE PATIENT. 541 
 
 value of different pieces of money. As is well 
 known, with some people, the ability of the patient 
 to tell his age, the month it happens to be, and to 
 give correctly the money value of a piece of silver 
 or a note is to clearly prove that he is not insane. 
 
 It occasionally happens that the physician encoun- 
 ters a patient who continues voluntarily mute to all 
 questions, so that after having exhausted all his re- 
 sources he is compelled to acknowledge himself van- 
 quished and to give up the interrogation. But this 
 absolute mutism is, in medical practice, nothing es- 
 pecially surprising or discouraging, as it has, by 
 itself, a clinical value, and if it prevents the obtain- 
 ing of valuable points furnished by the patient's 
 replies, it is, on the other hand, a genuine symptom 
 which, though a negative one, has still a very import- 
 ant signification. 
 
 Mutism, in fact, is a special feature of some forms 
 of insanity which its occurrence therefore tends 
 consequently to reveal. 
 
 Thus, if we observe a very depressed, woe-begone, 
 immovable individual, with eyes cast down and head 
 bent on his chest, whom nothing seems to move, we 
 have here almost certainly an insane person affected 
 with profound melancholia, more or less closely ap- 
 proaching stupor. The diagnosis will be assured if 
 we find at the same time in the patient disorders of 
 the peripheral circulation, that violaceous coloration 
 of the skin and coldness of the extremities that are 
 the external indices of the melancholic condition. 
 
543 PEACTICAL DIAGN^OSIS OF rN-SANITT. 
 
 If, on the contrary, the silent patient is one that 
 meets the approach of the physician with a suspicious, 
 offensive manner, who' recoils from him as from a 
 serpent, or, on the other hand, views him arrogantly 
 mth fixed gaze, we may be almost certain that in 
 this case we have an hallucinated lunatic suffering 
 from systematized insanity, more particularly with 
 delusions of persecution. Generally, moreover, in 
 spite of his purposed reticence, there will escape from 
 him some significant, insulting, or typical phrase 
 somewhat of the following order, that perfectly clears 
 up the diagnosis: "You know better than I." "I 
 have nothing to say to you." " It is my affair." 
 
 The j)hysician who examines a lunatic ought 
 never to be discouraged by rebuffs he encounters, 
 nor break off the conversation at the leaft refusal to 
 respond that he meets with. As a general rule, the 
 examination of the insane, especially that of rea- 
 soning and systematized cases, ought to be prolonged, 
 as these patients have to be mastered gradually ; the 
 first quarter of an hour seldom reveals much, then 
 one minute of the second may alone be of much 
 greater value ; an hour is not too much sometimes. 
 Contrary to the advice of most authors, I believe, 
 therefore, that it is necessary to tire out the patient. 
 When he is compelled, he yields, confesses without 
 evasion or restriction and gives himself completely 
 to his interrogator. Thus when one has, after much 
 trouble, gained his confidence, he should never aban- 
 don the conversation and put it off tUl another day, 
 
EXAMINATION OF THE PATIENT. 543 
 
 for -with, an insane person, at least when he has 
 not fully revealed himself, it is hardly possible to 
 take up the conversation at the precise point where 
 it has been left off ; usually it becomes necessaiy to 
 recommence the whole examination and to obtain 
 anew the former admissions before pushing the 
 investigation farther. It is only in exceptional 
 cases, and when the examination needs to be fol- 
 lowed up and renewed, as in medico-legal examina- 
 tions, that we can thus abandon the interrogation 
 half done, to be continued again later. 
 
 The examination of the patient finished, we should 
 proceed, whenever it is not impossible, to a rapid 
 examination of the great organic functions, insisting 
 more especially on this, if there is any reason to sus- 
 pect any visceral disorder capable of having some 
 relation with the mental trouble. It is in melan- 
 cholic forms and particularly amongst females 'with 
 internal illusions, or sexual sensations, that it is 
 necessary to give a minute study to the great appa- 
 ratuses of the organism. 
 
 When the examination and interrogation of the 
 patient is completed, the physician should politely 
 and amicably take leave, with a pleasant word or a 
 promise soon to see him again. 
 
Cbapter iTir. 
 
 MEDICAL ADVICE AS TO THE NECESSITY 
 OF SEQUESTRATION. 
 
 The diagnosis settled and the form of mental de- 
 rangement once clearly defined, it remains for the 
 physician to give his opinion as to what is next 
 advisable, that is, to pronounce in regard to the 
 question of confinement of the patient or not. 
 Before stating the considerations that may pei-mit 
 him to decide with thorough knowledge in this 
 regard, it wiU be of utility to call attention to two 
 fundamental points, that seem to be only imperfectly 
 understood in practice. 
 
 The first is that isolation in a special establishment 
 being a part of the medical treatment, a veritable 
 therapeutic agency, it is to the physician and to him 
 alone, that the right to prescribe it belongs, it being 
 in this like the prescription of any other method of 
 treatment or medication. It may be said in reply 
 to this that, as regards iasanity, every member of 
 the community believes he knows well enough what 
 to do, and that in families where there is an insane 
 member, the relatives will not leave to any one out- 
 side of their own number, the responsibility of de- 
 ciding whether sequestration is or is not necessary. 
 To oppose this will therefore be for the physician to 
 
GSI^EBAti COKSIDEEATIONS. 545 
 
 pitHmself against established opinions and to raise a 
 thousand objections. They are well aware, they 
 say, that the patient is a little depressed or excited 
 or even seems eccentric, his nerves are out of order, 
 but as for his being insane, it is impossible, there is 
 clearly an exaggeration here; there are physicians 
 who see insanity everywhere. Moreover the disorder 
 is not yet sufficiently advanced, it will be time 
 enough to act later, if it is needed. They fear the 
 poor man would rather lose his head altogether 
 than be placed in an insane asylum and deprived of 
 his liberty, whei-e he could only become more excited 
 in contact with raving maniacs. It should be consid- 
 ered how he will lose in reputation if the report of 
 his sojourn ill an asylum should get out, the whole 
 family would suffer, and he has daughters to get 
 married ofE. They do not want to take the respons- 
 ibility of his confinement without consulting all 
 the members of his family, since they fear he would 
 never forgive them if he should be restored to health. 
 They reiterate finally all the old stereotyped tales 
 about asylums that are extant amongst the masses, 
 who believe fully that patients are there submitted 
 to violence and to all sorts of bad treatment. The 
 above are the objections raised usually by the fami- 
 lies, to the proposition of the physician, and the 
 reasons why they object to the asylum. But it must 
 be admitted that if errors and prejudices still exist 
 on the part of the public relative to the insane and 
 to the methods of treatment suitable for them, this 
 
546 NECESSITY OF SEQtJESTEATIOK. • 
 
 is, in great part, due to the fact that medical men 
 have too long lacked interest in the matter and have 
 voluntarily abdicated all initiative as regards these 
 patients. When the time comes when every phy- 
 sician is versed in the study of mental alienation, and 
 can testify from his own observation as to the bene- 
 ficial effects of isolation in the treatment of insanity, 
 when he will assume his proper function in cases 
 where he is called and explain, with full knowledge 
 of the subject, to the friends the therapeutic effi- 
 ciency of asylum treatment, then the public will be 
 quickly educated and will abandon its errors as to 
 insanity, as it has already abandoned those in regard 
 to other medical and scientiiic questions. It is im- 
 portant, therefore, that the physician should never 
 lose sight of the fact that to him, and him only, 
 belongs the right to judge as to the net-d of confine- 
 ment of an insane person, and that, if it is allowable 
 to discuss the possibility of this measure with the 
 families, or even, at a pinch, to yield and make 
 some concessions, he should never abdicate his place 
 to the extent of becoming a mere figurehead, charged 
 only with the responsibility of endorsing with a 
 medical opinion a measure the initiative of which 
 appertains to others. 
 
 The second fundamental point that seems to me 
 so important to keep in mind, is that establishments 
 for the insane ought not to be considered solely as a 
 refuge, intended to prevent the dangerous acts of 
 lunatics, or as simple asylums serving to protect the 
 
GENEKAL CONSIDEEATIOIirS. 547 
 
 friends, the public and the patients themselves 
 from scandals and pathological crimes. It is unde- 
 niable that the guaranties they afford are, in fact, 
 one of their advantages ; but their chief utility, that 
 which renders them indispensable, is that they real- 
 ize in principle and in details all the moral and 
 material conditions of isolation, the most efficaceous 
 and fruitful method of treatment of insanity in our 
 knowledge. 
 
 " The insane asylum," says Esquirol, " is an instru- 
 ment of cure." It is not necessary at this day to 
 discuss at length the advantages of isolation in the 
 treatment of mental diseases. This therapeutic method 
 has proved its value and is proving it every day, and 
 it is recognized at the present time that there is no 
 better means with which to meet insanity. When 
 we compare, as regards the results obtained, the cases 
 treated outside and similar cases treated in special 
 establishments, it cannot but be recognized that 
 sequestration, far from being injurious, offers by 
 itself alone the best opportunity for recovery that is 
 available to the patient: It is this double usefulness 
 of isolation, not only as a protective measure, but 
 also and especially as a precious therapeutic resource, 
 that the physician should keep in mind when called 
 on for his opinion in this regard. 
 
 We will now see what are the principal consider- 
 ations that should occur to the practitioner in forming 
 his medical opinion as to the necessity of this measure. 
 
 These considerations are of two orders: (1) those 
 
648 NECESSITY OP SEQTTESTRATION. 
 
 relative to the patient; (2) those relative to the 
 disease. 
 
 (i) Considerations Relative to the Patient. — ^As 
 regards the patient, it is first necessary to consider 
 his situation as regards his family, and especially as 
 regards his social position. If he has no relatives 
 really attached to him and ready to devote themselves 
 to caring for him to the extent of meeting the tre- 
 mendous difiiculties incident to his care at home, if 
 he is alone or surrounded only with indifferent 
 or mercenary people, it is evident that, whatever 
 may he his condition, his confinement in a special es- 
 tablishment is necessitated as the most favorable 
 measure for the treatment of his disorder. On the 
 other hand, if the patient belongs to the middle or 
 poorer classes, we are also compelled in most cases, 
 apart from all other considerations, to have him sent 
 to the asylum, since he is an expense and trouble to 
 his friends who, busied with their daily occupations 
 would find it an impossibility to properly watch over 
 and care for him, and who besides this, deprived as 
 they are of resources, could not undergo the large 
 expense entailed by methodic home treatment. In 
 the wealthy class, on the contrary, the social condi- 
 tion of the patient may necessitate outside treat- 
 ment, when it is practicable. Then, on account of 
 these various social differences, we may say a priori, 
 that all the poorer class of patients ought to be sent 
 to asylums, and that the treatment at home can only 
 be realized when it is practicable amongst the upper 
 classes of society. 
 
SITUATION OP THE PATIENT. 549 
 
 (2) Considerations Deduced from, the Disease. — 
 The considerations deduced from the disease, mainly 
 relate: A. — to its degree of curability; B. — to 
 the more or less dangerous character of the morbid 
 tendencies it produces. 
 
 A. — In every case of acute derangement, espe- 
 cially an attack of mania or melancholia, that is of a 
 curable form, isolation should be practiced as early 
 as possible, because it has been irrefutably demon- 
 strated by experience and proven that the insanity 
 has not only ten times less chances of recovery at 
 home than in a special establishment, but also that 
 an attack of insanity, not specially treated but left 
 to itself in an asylum, recovers more quickly than 
 would the same case treated and watched outside of 
 an institution. 
 
 In the interest of the patient, which should 
 be above all other considerations, the physician 
 ought therefore to advise isolation in any case that 
 affords chances of cure, and should endeavor to over- 
 come the opposition of the famUy, who, from very 
 natural but iU advised sentiments of affection and 
 devotion, are always hesitant about separation, and 
 have, moreover, very frequently unjustifiable preju- 
 dices against asylums, which they think in their ig- 
 norance wiU aggravate the patient's condition. It is 
 certainly very hard with members of the family who, 
 making no difference between insanity and ordinary 
 ailments, are prepared to devote themselves to the 
 patient and to surround him with the tenderest and 
 
550 NECESSITY OF SEQUESTEATION. 
 
 most affectionate care, to make them understand that 
 their own influence and contact are themselves the 
 greatest obstacles to his recovery. Nothing is more 
 true, notwithstanding, and every one acquainted 
 with the treatment of the insane is well aware of the 
 injurious influence usually exercised on the patient's 
 disorder by the intercourse with friends, in spite of 
 their intelligence and manifest devotion. The phy- 
 sician ought therefore to formally counsel the placing 
 of the patient in an institution, in every case suscep- 
 tible of cure or at least of amelioration. It is 
 important to add, however, that this step should be 
 taken, not after the lapse of some time or after more 
 or less prolonged delay and temporizing, but imme- 
 diately, as soon as possible after the beginning of the 
 disorder, as asylum treatment is the more effective 
 the earlier it is resorted to. The friends almost al- 
 ways object to this view ; they wish to gain time, to 
 have, so to speak, their hand forced by the progress 
 of the disease; a detestable practice, which, although 
 originating in a kindly feeling, does an irreparable 
 wrong to the patient, and every day peoples the 
 asylums with incurables who might readily have 
 recovered had they been sent there sooner. In the 
 face of this almost general opposition the medical 
 adviser ought therefore to insist, to plead the 
 patient's cause, and, if necessary, to call in the aid 
 of counsel whose formal opinion may add its weight 
 to his own advice. 
 
 In cases of chronic and incurable alienation, isola- 
 
CTTEABILITT OF THE DISEASE. 551 
 
 tion is not so absolute a necessity, at least in a 
 therapeutic point of view, but the need exists in these 
 cases also on account of considerations of family and 
 social order arising from the nature of the case which 
 may render this measure necessary. In the first rank 
 of these may be reckoned the more or less dangerous 
 character of the morbid tendencies. 
 
 B. — Whatever may be, indeed, the degree of 
 curabUity of the mental disease, or whatever the 
 social condition of the patient, it is absolutely neces- 
 sary to have recourse to sequestration whenever 
 there exists any evident tendency to dangerous acts. 
 In such cases, no matter what opjDosition the friends 
 may offer, it is the strict duty of the physician to 
 assert the urgency of isolation. It is, therefore, very 
 important as we see for him to be able to recognize 
 the dangerous forms of mental derangement. In 
 theory this distinction seems rather easy, but noth- 
 ing is more difficult practically, and in the long and 
 brilliant discussions that have taken place on this 
 subject in the Medico-Psychological Society, accord 
 was had on only one point, namely : the difficulty in 
 determining absolutely whether a lunatic is or is not 
 dangerous. 
 
 In fact it is hardly agreed on the one hand as to the 
 signification to be given to the woi-d "dangerous," 
 and on the other hand every lunatic, whatever his 
 mental condition may be, is capable of becoming 
 dangerous at any moment. All are agreed that an 
 individual who has tendencies to murder, suicide, 
 
552 NECESSITY OF SEQI7ESTEAT10N. 
 
 theft, arson, or excessive prodigality, is a dangerous 
 person, but all will not say the same of one who 
 limits himself to, for example, refusing medicine 
 prescribed for him, or who unconsciously exhibits 
 his genital organs in public, or utters in society and 
 before children obscene words and indecent remarks. 
 There is much matter for discussion here, but we 
 must limit ourselves to showing how difficult it is to 
 specify clearly whether a lunatic is or is not dangerous, 
 either to society, to property, to his family or himseK. 
 
 Nevertheless, this distinction, which lacking a 
 precise criterion cannot be formulated in practice in 
 an absolute manner, is rendered possible to a certain 
 extent by the attentive study of the habitual ten- 
 dencies in each form of derangement. 
 
 In the mental types we have studied under the 
 head of infirmities, and which include the dis- 
 harmonies, neurasthenias, phrenasthenias, mental 
 weaknesses, imbecility, idiocy, cretinism, and simple 
 dementia, the patients are usually inoffensive, and 
 consequently do not absolutely require sequestration. 
 
 It must not be forgotten, nevertheless, that a 
 certain number of them are inclined, from their 
 impulsiveness, and their lack of consciousness to 
 certain illegal acts, such as criminal assaults, theft, 
 arson, and that they sometimes come before the 
 courts to answer more or less serious charges. 
 
 Most general paralytics, — I speak of those suf- 
 fering from simple paralytic dementia, — are also 
 inoffensive, like the ordinary dements, with whom 
 
CTTEABILITT OF THE DISEASE. 553 
 
 they have, ia this point of view, many analogies. 
 But the case is different with those in whom the 
 paralytic dementia is associated with a more or less 
 pronounced maniacal condition. These patients, 
 it is true, only exceptionally commit assaults or 
 make attempts at homicide ; but if in their insanity 
 they respect human life, they have on the contrary 
 no regard for the property of others or their own 
 interests. Some, especially in the beginning, in what 
 we call the medico-legal period, waste their fortune 
 and that of their family on all sides in foolish specu- 
 lations, inconsiderate purchases, excessive prodigal- 
 ity, and donations of every kind ; others, erotic to 
 the highest degree, exhibit their genital organs in 
 public, and commit the moat obscene acts; many, 
 finally, are guilty of indelicacies and petty thefts. 
 It is noteworthy that the majority of general para- 
 lytics legally confined in the great cities have been 
 arrested in the streets for not having paid for the 
 use of a carriage they have been riding in for many 
 hours, or for having stolen from a shop, without 
 precaution and with the candor of unconsciousness, 
 some trifling object, such as a cheap umbrella, a 
 pair of shoes or trousers, a bunch of cabbage, an 
 egg, or some sweetmeat of little value. When 
 general paralysis is accompanied by insanity of the 
 melancholic type, the danger is less great, at least 
 to the public, but the patient may be more or less 
 suicidally inclined. 
 
 Uekt. Msd,— ^. 
 
554- NECESSITY or SEQUESTKATIOU. 
 
 In simple melancholia also the patients are gener- 
 ally inoffensive, especially those who do not react 
 actively and whose depression is very profound. 
 It should not be forgotten, nevertheless, that some 
 of them are dangerous, not so much perhaps to 
 others, but to themselves, and that it is sometimes 
 very hard to prevent them attempting to carry out 
 their suicidal ideas. 
 
 Besides these mental disorders in which we find 
 the patients often inoffensive but susceptible of be- 
 coming dangerous at times, there are others, on the 
 contrary, where the proposition is reversed, where 
 the patients are usually dangerous and only excep- 
 tionally harmless ; of this class are : mania, princi- 
 pally some of its varieties, double form insanity, 
 hysterical insanity, alcoholic insanity, and particu- 
 larly the systematized insanities and epileptic insanity. 
 
 In acute mania, the patients excited and propelled 
 by an irresistible desire for movement and action are 
 generally disorderly and dangerous. It is mainly 
 violence and sudden destructive behavior that is to be 
 feared on theit part, rather than tendencies to homi- 
 cide which they are incapable of planning. But 
 maniacal excitation, or subacute mania, still more 
 than acute mania, renders its victims dangerous. 
 One has only to refer to the description given of this 
 form of mental disease to realize all the intelligence, 
 astuteness, and knavery that these patients employ 
 in the service of their perverse instincts. With ap- 
 parent sanity or, at least, with apparent conservation 
 
THE DANGEEOtrS IITSANE. 555 
 
 of their intellectual faculties, they make out to 
 pass for sane individuals with the public and thus 
 finding means to make their calumnies and their 
 Machiavelian inventions seem true, they are, per- 
 haps, with the moral lunatics, the worst of all the 
 insane. 
 
 It is precisely, moreover, because hysterical and 
 double form insanity in the periods of excitement, 
 are frequently made up of maniacal excitation and 
 reasoning mania, that the patients suffering from 
 these forms are in the same way so dangerous. 
 
 In acute and subacute alcoholic insanity the tend- 
 encies to violence, homicide, and especially to sui- 
 cide are very frequent. It is known, in fact, that 
 under the influence of hallucinations causing in 
 them a panic terror, the most of these patients flee 
 wildly from imaginary enemies and often end in 
 thtowing themselves out of an upper window or into 
 the river to escape them. 
 
 It is especially, however, in the systematized in- 
 sanities and in epileptic insanity that we meet with 
 the really dangerous lunatics. 
 
 As regards the systematized insanities, whatever 
 the form of the delusions, really oilensive tendencies 
 are, so to speak, constant in them. The mystics, 
 besides their practices of fasting, asceticism, and self 
 inflicted violence even to the extent of more or less 
 serious mutilations, often attempt the life of others 
 in obedience to the duty that inspires them. Some 
 believe they have received from heaven a mission to 
 
556 NECESSITY OF SEQUESTRATION. 
 
 Strike down some great personage, who they believe 
 represents the evil on the earth ; others, always with 
 the idea of pleasing God, renew the sacrifice of 
 Abraham and destroy their own children. 
 
 The megalomaniacs, those systematized insane who 
 believe themselves to be kings, dukes, princes, or 
 possessors of immense fortunes, are often equally 
 dangerous. It is not at all rare, in fact, to see them 
 urgently claim their supposed riches and titles, 
 either from the public authorities or from well 
 known bankers, and to commit violence when refusal 
 is made to their morbid pretensions. 
 
 Of all the cases of systematized insanity those 
 with delusions of persecution are the most danger- 
 ous. The greater part of the pathological crimes 
 reported in the journals of the day are, in fact, com- 
 mitted by these patients. This is readily under- 
 stood. So far as their delusions are not yet fully 
 systematized, so far as they limit themselves to such 
 indefinite locutions as the following: "Some one 
 wishes me ill," they are but little to be feared. At 
 the most they then confine themselves to complain- 
 ing to the police or magistrates of the persecutions to 
 which they are subjected. But from the time their 
 delusion becomes systematized, from the day when 
 they give features and a name to the person who does 
 them harm, from that day they become essentially 
 dangerous. As Lasfegue says, they are no longer 
 persecuted but persecutors. They are infuriated 
 with their self-styled enemies and have no rest until 
 
THE DANGEROUS INSANE. 557 
 
 they have smitten them. They continue to be es- ' 
 sentially dangerous in the asylums ; usually their ill 
 will is directed against the_ physicians, whom they 
 accuse of confining them illegally, of tormenting 
 them, subjecting them to the action of electricity 
 etc., etc. The list of asylum physicians killed or 
 attacked by these patients is already lamentably 
 long, and no year passes without this sad martyr- 
 ology being increased by some new name. We 
 should never lose sight therefore of the fact that the 
 persecutory insane are essentially dangerous, there 
 should be in their case no hesitation, they should 
 be rigorously sequestrated. 
 
 Many of the epileptics, at the time of, and partic- 
 ularly after, their attacks are likewise seized with a 
 blind furor during which they unconsciously attack 
 anyone near them, or commit criminal acts, having 
 afterward no memory of what they have done, 
 which is, as we are aware, the peculiarity of this 
 convulsive neurosis. 
 
 I stop with this enumeration, which though im- 
 perfect, may serve to practically show in what classes 
 of cases a patient is or is not dangerous. It seems 
 to me, however, that it is possible to be still more 
 exact, and that there is one symptom, which, without 
 being an absolute criterion, yet indicates nearly 
 always when it exists, the dangerous forms of mental 
 alienation. This symptom is hallucinations, espe- 
 cially those of hearing. In my opinion, — and I believe 
 it is hardly possible to forip.ulate any indication mor^ 
 
558 NECESSITY OF SEQUESTEATION. 
 
 applicable in practice, — every insane person who has 
 clearly defined auditory hallucinations is a danger- 
 ous lunatic, and should accordingly be put in 
 confinement. 
 
 To sum up, the medical opinion as to the neces- 
 sity of sequestration should be based on a certain 
 number of considerations the chief of which are: 
 
 (1) the social condition and situation of the family; 
 
 (2) the degree of curability of the disease ; and (3) 
 the more or less dangerous character of the morbid 
 tendencies. 
 
dbaptet iriFil.* 
 
 THE TREATMENT OF INSANITY. 
 
 The treatment of insanity comprises the prophy- 
 lactic or preventive treatment, and the direct or 
 curative treatment. 
 
 I.— PREVENTIVE TREATMENT. 
 
 The prophylactic or preventive treatment consists 
 in the prevention of insanity in individuals who are 
 predisposed to it. Precise rules in this regard cannot 
 be laid down ; it consists mainly in the resources of a 
 proper hygiene and a judicious moral direction. To 
 specially watch over the infancy of the predisposed, 
 to manage them with kindness and firmness, not to 
 spoil them, to avoid in their education any excessive 
 mental application, the more since they often exhibit 
 a marvellous precocity ; to combat their bad tenden- 
 cies and their evil instincts, their nascent passions ; 
 to choose for them, by preference, the calm and 
 quiet life of the country ; to prescribe bodily exercise 
 and the avoidance of violent moral emotions ; later, 
 
 * Chapter III of the original work, on the placing of the insane in 
 asylums, is mainly made up of practical statements and comments 
 on the law of commitment in France, which are of especial value to 
 French readers only. It has accordingly been omitted, together with 
 the closing chapter on the clvU code in its bearings on insanity. In the 
 present translation, 
 
560 TEBATMENT OF IHBANITY. 
 
 to fortify them against their first passional impulsions, 
 against their tendencies to excess, irregular living, 
 or debauchery ; to put off marriage, or, on the other 
 hand, to hasten it in some rare cases where heredity 
 is not to be feared in the descendants ; to watch at- 
 tentively, in females, the evolution of the great 
 events of sexual life, puberty, menstruation, preg- 
 nancy, menopause; finally, to lessen as much as 
 possible the evil effects of degeneracy, to interdict 
 certain unions and to favor happy crossings of blood ; 
 such are the general principles that should guide us 
 in the preventive treatment of insanity. Every 
 case, moreover, has its own special indications of 
 which it is necessary to take account. 
 
 II.— CUBATIVE TREATMENT. 
 
 We will divide the curative treatment into gen- 
 eral agents or systems and special agents. 
 
 1. — Genbral Agents. 
 iBolation. 
 
 The fundamental principle of the treatment of the 
 insane is isolation. This consists in separating 
 the patient from his habitual surroundings, from 
 contact with persons and things famiUar to him, 
 amongst whom he lives, and where his disorder had its 
 birth and development. Nothing is worse than the 
 retention of the patient in his own dwelling, and the 
 continuation of his stay amidst his family. There 
 
SPBCIAL ESTABLISHMENTS. 561 
 
 is, in such case, the influence of the family on the one 
 hand, an influence that is injurious and prevents or 
 delays the cure ; and on the other hand the influence 
 of the patient upon his family, which is not less 
 hurtful, and sometimes, when there are children, 
 actually dangerous. Moreover we must take into 
 account the danger from au insane person, either to 
 himself or to society, against which his situation 
 with his family affords only very insufiicient guaran- 
 tees. Isolation is, therefore, a measure of security 
 and a powerful therapeutic agency. 
 
 Isolation may be in a special establishment, in an 
 agricultural colony, or a stranger family, in a 
 country house or in a hydrotherapeutic establish- 
 ment. Travel is also a means of isolation. 
 
 Special Establishments. — Isolation should, as a 
 rule, be secured in a special establishment, either a 
 public or private asylum, and in the great majority 
 of cases, recourse must be had to this radical meas- 
 ure as preferable to any other. The asylum, "that 
 instrument of cure " as Esquirol calls it, unites, in 
 fact, all the conditions of the care of the insane, for 
 whom it was constructed. There the patient under- 
 goes, almost in spite of himself, from the moment 
 of his entrance, the salutary effects of appropriate 
 organization, good hygiene, fixed rules, discipline, of 
 a hierarchy of which he has constantly under his eyes 
 the examples, and at the same time he is under an 
 active surveillance and placed in the hands of expe- 
 
562 TREATMENT OF INSAOTTY. 
 
 rienced specialist physicians, more able than anyone 
 else to direct in a rational manner the treatment of 
 his disease. 
 
 Farm Colonies. Family System. — Confinement 
 in a special establishment cannot be made, neverthe- 
 less, an absolute rule, and in some cases recourse 
 may be had to other modes of isolation, such, for 
 example, as the so-called family care. This mode 
 practically presents itself under three forms: the 
 colony annexed to an asylum; the independent 
 colony ; and the private residence. 
 
 Colonies attached to asylums (German system) 
 exist chiefly in Germany (Alt Scherbitz in Prussian 
 Saxony ; Slup, near the asylum at Prague ; Ellen, near 
 that of Bremen; Ilten in the vicinity of Hanover). 
 These colonies are designed to afford the insane open- 
 air life and -work in the fields. In some of them, 
 as at Clermont-sur-Oise in France, the patients live 
 together in a sort of farm asylum; in others, as at 
 Ilten, they are placed singly among the country 
 people who lodge and board them for a moderate 
 compensation. This system evidently is applicable 
 only to certain classes of the insane, carefully selected 
 by the physicians mainly from among the chronic 
 cases and the convalescents. The nearness of the 
 asylum moreover permits them to be readily secluded 
 on the least outbreak, and watchfulness is not 
 relaxed. 
 The independent or autonomous colonies (Belgian 
 
FAMILY SYSTEM. 563 
 
 system) differ from the above only in tliat they are 
 not connected with asylums. The type of these in- 
 stitutions is realized in the old Belgian colony of 
 Gheel which dates from time immemorial, and which 
 has been justly called the Mecca of Alienists, on ac- 
 count of visits for study that it is constantly receiv- 
 ing. There the insane, to the number of nearly two 
 thousand, are scattered through a commune of over 
 ten thousand hectares, the chief village of which 
 alone has five thousand inhabitants. These insane 
 are divided into pensionnaires who live with hdtes 
 (boarding masters), and indigents who are cared for 
 by nourriciers. A central infimiary is used for 
 patients under observation, also for such as 
 require watching and special attention. A similar 
 colony was founded in 1884 at Lierneux in the Belgian 
 Ardennes, and became very p:fosperous within a 
 short time. The autonomous colonies, excellent as 
 establishments of refuge, leave much to be desired 
 as places for treatment. 
 
 In the private house or individual family isolation 
 (Scotch system) the insane are also placed out among 
 families of a farming community ; but here this is 
 purely individual, and there is nothing that recalls 
 the reunion of the insane in agglomerated colonies. 
 This method is little known in France. In England 
 it forms a part of the cottage system, but is scarcely 
 used except for patients in easy circumstances. In 
 Scotland, on the other hand, it is practised on a 
 large scale under the name of the "private dwelling 
 
564 TEBATMENT OF INSANITY. 
 
 system," and it was there extended on Jan. 1, 1888, 
 to 3,270 pauper insane, and to 132 non paupers, or to 
 22.8 percent, of all the insane in Scotland. The 
 private dwelling system, in spite of its real advantages 
 in point of view of the material and moral conditions 
 of life of the patients, as well as in that of economy 
 to the staite, can hardly be applied, except to inof- 
 fensive and incurable lunatics. Even under this 
 restriction its extension in> the various countries 
 would have good results in clearing the asylums of a 
 multitude of incurables that encumber them, and in 
 restoring these establishments to their true 
 function, — that of hospitals for treatment. The 
 interesting work of M. Ffer6 (Paris, 1889) may 
 be consulted profitably with reference to all the 
 questions relative to the isolation of the insane out- 
 side of the asylums. 
 
 Hesidence in the Country. — Isolation in a country 
 house is still the preferable mode of treatment, in 
 default of internement. It is also that most willingly 
 adopted by the friends, in order to avoid at once the 
 formalities and disagreeable consequences of entry 
 into an asylum and of living with an insane person. 
 Unfortunately, it is a difficult system of treatment 
 to realize in a perfectly satisfactory way, and is, 
 moreover, very expensive. The rule to follow in 
 such case consists essentially in organizing the 
 country house on the basis of a private asylum, of 
 which it is practically the application for a single 
 
HTDEOTHEEAPEUTIC ESTABLISHMENTS. 565 
 
 patient. To the specialist physician therefore belongs 
 the right of disposing and choosing, both in total 
 and in details the future residence of the patient. 
 He must not lose sight of the following three 
 principal points : (1) not to permit the family to live 
 with the patient and to separate them as much as 
 possible from each other, either in the same house or 
 in different dwellings; (2) to keep exclusively to 
 himself the moral and material direction of the 
 treatment in all its details; (3) to insure for the 
 patient, together with competent and devoted eare, 
 a strict surveillance, continuous and intelligent, by 
 individuals really skilled in this work, which demands 
 numerous and especial qualifications. With such an 
 organization a certain number of insane melancholiacs, 
 paralytics, degenerates, etc., can, without doubt, be 
 treated in a house in the country, either from the 
 beginning or after a prior sedative sojourn in a 
 special establishment. 
 
 Hydrotherapeutic Establishments. — The insane in 
 the beginning of their disease, or those considered as 
 non-dangerous, are sometimes taken and treated in a 
 water cure establishment. In theory, this treatment 
 has nothing objectionable in itself, and it is in any 
 case preferable to treating the patient at home ; but 
 it must be kept in mind that it is hardly applicable 
 except to nervous and semi-deranged cases, and not 
 to lunatics properly so-called, for whom the lack of 
 control and discipline, the too great liberty, the fre- 
 
566 TKEATMEl^T Of iNSA'ini'Y . 
 
 quent contact with relatives, and the absence of a 
 methodical surveillance, render the situation an ob- 
 jectionable one and not free from danger. Neuras- 
 thenics, hysterical cases, certain melancholiacs, and, 
 in a general way, the peaceable and inoffensive luna- 
 tics whose malady may be favorably influenced by 
 hydrotherapy, may nevertheless derive real benefit 
 from this method of treatment. 
 
 I will limit myself to merely mentioning the 
 placing of the insane in the care of a religious com- 
 munity, a measure resorted to by some families in 
 case of female patients of harmless character. 
 Without exception this mode of isolation offers noth- 
 ing but inconveniences. 
 
 Travel. — Travel is an efiicacious therapeutic 
 agency in mental derangement, and at the same time 
 is a salutary means of diversion. By removing the 
 patient from his usual surroundings it corresponds 
 indeed to the very principle of treatment, isolation, 
 while at the same time it causes moral and physical 
 distractions that react favorably on the mind of the 
 patient. Specially recommended by Esquirol and 
 some of his students, who had obtained good results 
 with it, it is less utilized at the present on account 
 of its inconveniences and the dangers to which it 
 may give rise. Without rejecting it in principle, it 
 is well to use it only with prudence, and surrounded 
 with sufficient precautions. Thus certain morbid 
 forms, notably those in which the patients are 
 
TEAVEt. 567 
 
 usually dangerous, are absolutely incompatible with 
 this mode of treatment. It suffices to say, that save 
 in rare exceptions, we should never take on journeys 
 maniacs in their acute stage, epileptic insane, cases 
 of persecutory insanity, and hallucinated cases in 
 general. On the other hand, traveling is very suit- 
 able in melancholic cases, especially the beginning of 
 subacute melancholia, not only because it affords a 
 greater freedom for the patients, but also because 
 they are the more susceptible of being favorably 
 affected by moral treatment. With them the trip 
 acts as a curative agency and may itself cause a cure 
 or at least a notable improvement in the symptoms. 
 We may employ it also in some chronic insanities 
 with subjects more or less inoffensive, but in these 
 cases it is only a means of diversion capable at the 
 most of producing a relative sedation. Whatever the 
 morbid form and the end proposed, the physician 
 ought never to advise or permit an insane person to 
 travel except on condition that the patient should not 
 be accompanied by any of his nearest friends ; and that 
 the direction of the trip should be by an experienced 
 person in preference to a young physician ; finally, 
 that all precautionary measures should be taken to 
 prevent, as far as possible, any disagreeable events 
 or accidents. It is well also to take the patient a 
 sufficient distance, often even out of the country, 
 and also to frequently change his residence; and, 
 finally, it is needful that the trip should be long 
 enough, some months or even years, according to the 
 
568 TEEATMSHiTT 01" TSBATSITY. 
 
 case, and if it seems to produce any good effect, it 
 is advisable, to prolong it till convalescence is 
 firmly established. 
 
 Non-Bestraint. 
 
 Among the general systems that have been pro- 
 posed in the treatment of the insane, it is well to 
 cite those designed to modify whatever there may 
 be of rigor in the regime of special establishments for 
 the insane. 
 
 The system of open door asylums is of this kind. 
 As its name indicates, it consists in the suppression, 
 in the asylums, of guards and enclosing walls. Prac- 
 ticed only in Scotland, the country par excellence 
 of reforms and innovations of this kind, it is still far 
 from having had its last word. 
 
 Non-restraint proposed in England by ConoUy 
 and Gardiner Hill, and imported into France by 
 Morel and Magnan, consists in the complete sup- 
 pression among the insane of means of physical re- 
 straint, and especially of the camisole. Long main- 
 tained as an absolute principle by its partisans, this 
 system is tending to gradually lose its ground, even 
 in the country of its origin (V. Parant, 1890). 
 Circumstances exist, in fact, such as too violent ag- 
 itation, propensities to voluntary mutilation, suicide, 
 homicide, etc. , when it becomes necessary to restrain 
 the patient. The camisole, used skilfully, without 
 roughness, and in such a way as not to at all 
 
HTGrENB. 569 
 
 embarrass the respiration, is the only prooedure to 
 which we should have recourse. 
 
 The physician, moreover, and he alone, should be 
 the judge as to the need of the use of the camisole 
 and the length of time it should be employed. In 
 no case should it be left to the attendants to decide, 
 since such a course necessarily tends to cause abuse. 
 
 When it is not absolutely necessary to confine the 
 patient's arms, but only his hands, as, for example, 
 in cases of extreme tendency to onanism or destruc- 
 tion of clothing, the camisole may be replaced by a 
 mufiE of leather or canvas which confines the hands 
 to the level of the belt. 
 
 It is in only very exceptional cases, and when ab- 
 solutely necessary, that we may, for a short time 
 only, have to fasten the limbs of a patient to the bed, 
 by means of specially designed straps, well padded, 
 and moderately tightened around the ankle. 
 
 3. — Special Agents. 
 A.- 
 
 The hygienic treatment of insanity includes the 
 usual sanitary regulations in regard to clothing, 
 habitation, food, sleep, etc. 
 
 The clothing of the insane calls for no special 
 remark except that it ought to be ample and free, 
 and especially that it should not be too tight around 
 the neck, on account of the possible congestive 
 tendency of many of the patients. The dwelling, 
 
 SISST. SlED.— .36. 
 
570 TEEATMENT OF INSANITY. 
 
 being usually an establishment for the care of the 
 insane, or at least, as we have seen, a house arranged 
 for this purpose, there is no need here to point out 
 the rules that ought to guide its construction and 
 management ; it need only be said that the patients' 
 rooms should be wholesome, well secured, well ven- 
 tilated and, as far as possible, on the ground floor. 
 The food should be wholesome, tonic and nourishing ; 
 excitants, wine and alcoholic liquors in particular, 
 without being absolutely forbidden, ought to be used 
 only in moderation. Milk, eggs, soup, white meats 
 and fresh vegetables should form the general basis 
 of the nourishment. For general paralytics, espe- 
 cially in their later stages, the food should be given 
 cut small, and the meat hashed, to avoid asphyxia. 
 Finally, the hours of meals should be as regular as 
 possible with the insane. As to their sleeping quar- 
 ters there is nothing special to note, except with un- 
 tidy patients who need special arrangements for 
 cleanliness. 
 
 The best bed for untidy patients is an iron bed- 
 stead with straight sides, but with the bottom formed 
 by a double inclined plane, sloping toward the centre, 
 which is perforated, and thus permits liquids to pass 
 into a vessel underneath. The bed is filled with sea 
 wrack or dry turf (Cuylits) which is covered with 
 a cloth. Changing the cloth each day and remov- 
 ing every morning that part of the sea- weed or turf 
 that is soiled, we have a clean and perfectly dry bed. 
 Instead of this bed we may use an ordinary bed 
 
MOEAl TEEATMBNT. 571 
 
 with, in place of one large mattress, three small 
 ones. The one in the middle may be filled with sea- 
 weed, straw, oat chaff, etc., and is intended to be 
 soiled and replaced each day. Above these, on the 
 tick or mattress a waterproof rubber cloth may be 
 used. Air or water mattresses may also be employed. 
 The best arrangement, however, when a proper 
 bed for untidy patients cannot be had, is made 
 by using a large and thick rubber blanket made 
 with a tunnel-like tube in its centre, which, passing 
 through the mattress, carries the drainage into 
 a vessel underneath. With this practical ar- 
 rangement any bed whatever may be utilized, and 
 I have always employed it for untidy patients whom 
 I have had to treat in private houses. 
 
 In these ways we contrive to secure a wholesome 
 and dry bed for the patient, and to prevent, to a 
 considerable extent, with the use of the usual means 
 of cleanliness, the occurrence of bedsores and sloughs. 
 
 B. — Psychic Agencies. 
 
 Under this head we take up the subjects of moral 
 treatment and suggestion, which form the two prin- 
 cipal elements of the psychic treatment of the insane. 
 
 Moral Treatment. — Moral treatment, together 
 with isolation, is one of the most important agencies 
 in the cure of insanity. Its direction should belong 
 to the physician alone, by virtue of his situation, his 
 profession, his authority, and his character. Moral 
 
573 TEEATMBNT OF ENSAXITT. 
 
 direction therefore consists essentially in the psychic 
 influence exercised on the patient for the purpose of 
 cure by the physician himself or under his direction. 
 All mental disorders do not act in the same manner in 
 this regard, and some are particularly susceptible of 
 being influenced by this kind of treatment. Melan- 
 cholia is one of these. 
 
 The medical action is exercised in very different 
 ways according to the case, and it demands a tact, 
 skill, and knowledge, that is only acquired after long 
 practice. It may be said, without exaggeration, 
 that the physician, by his mere presence and the 
 influence which he exercises when with the patient, 
 is a potent agency for the cure. It is only neces- 
 sary to see in asylums with what impatience the 
 doctor's visit is expected, what good impressions his 
 encouragement and advice produce in some melan- 
 choliacs, to recognize his influence. As a general 
 rule the physician ought to show the greatest polite- 
 ness to and sympathy for his patients. However 
 absorbed they may be in their delusions, the insane 
 are always sensible of kindnesses and marks of inter- 
 est in them, and this is one of the best means of 
 gaining their good will and gaining control of them. 
 It is needful to listen to them, treat them with 
 authority, although with kindness ; to make them feel 
 that in their physician they have an adviser and a 
 moral support ; not to openly ridicule their ideas, 
 even the most unreasonable ones, nor to contradict 
 too flatly ; to take care, nevertheless, not to approve 
 
MOEAL TEEATMEIfT. 373 
 
 of them or to considei- their delusions as the expression 
 of the truth ; to direct and regulate with care and 
 judgment the interviews with relatives and friends, 
 the correspondence, the occupation, the diversions 
 (manual and mental employment, promenades, paint- 
 ing, designing, music, singing, entertainments, relig- 
 ious exercises, etc., etc.); to encourage them when 
 they begin to doubt their delusions and help them to 
 gradually appreciate the reality ; and in certain cases, 
 where their obstinacy, indocility, and persistence in 
 their fixed ideas or morbid acts necessitate it, to 
 change the attitude, to act with authority, be severe, 
 and use intimidation, never however going so far as 
 to use violence. All these means are excellent 
 and have a great value in the hands of experienced 
 physicians; but they are two-edged weapons that 
 should be employed only wittingly and with prudence. 
 As is well known Leuret has made argument and 
 intimidation the basis of a systematic treatment, 
 which he calls moral treatment. This consists prac- 
 tically in convincing the lunatic of his errors either 
 willingly or by force. As the one principle of treat- 
 ment this system is evidently not acceptable and is, 
 moreover, hardly capable of producing satisfactory 
 results. The patients are shocked and humiliated, 
 they are embittered by these methods, they are com- 
 pelled to admit their insanity without being con- 
 vinced ; they are, in short, placed in the situation of 
 those who in former times were forced by torture to 
 confess crimes of which they were innocent. It is 
 
574 TEEATMETJT OF INSANTTT. 
 
 not necessary to be acquainted with the insane to 
 know that their errors are not such as can be up- 
 rooted by force, and that it is needful to leave them 
 to wear away and disappear spontaneously. 
 
 Suggestion. — Therapeutic suggestion maybe prac- 
 ticed, as we are aware, in two ways ; either during 
 the waking state or in the hypnotic condition. The 
 first of these is as old as medicine itself, and numer- 
 ous remedies owe to it, either wholly or in part, their 
 virtues. (See Dr. Hack Tuke's "Influence of the 
 Mind upon the Body.") As Doutrebente well re- 
 marked at the last International Congress of Mental 
 Medicine, the moral effect of the physician on the 
 insane is especially a suggestive action, a suggestion 
 in the waking state. As to hypnotic suggestion, 
 although previously known, it has only within the 
 past few years been studied experimentally and ap- 
 plied to the treatment of disease. 
 
 In the domain of neuro-pathology therapeutic 
 suggestion has already produced undeniable results. 
 It is effective especially in dynamic disorders, 
 or those without recognized anatomical lesions of the 
 nervous system, chiefly in neuralgias, hystero-epileptic 
 attacks, paralyses, contractures, hysterical anses- 
 thesias and vomiting, rebellious cephalalgias, chorea, 
 etc. 
 
 Its action on the psychoses is much more question- 
 able. A priori it is logical to think that an agent 
 of this kind, capable of modifying the ideas, the 
 
STTGGESTION. S'I'S 
 
 feelings and even the personality of an individual, 
 might be able to construct what it has undone, that 
 is, to call back the ideas to their normal condition, 
 and the feelings and personality to the one who has 
 lost them. Unfortunately experience has given only 
 a negative answer up to the present, at least in the 
 majority of cases. 
 
 M. Auguste Voisin was the first who attempted 
 the application of hypnotic suggestion to the treat- 
 ment of mental disorders. Since then a great many 
 authors, French and foreign, have reported the re- 
 sults of their own experience in this regard. I will 
 cite among them: Benedikt (of Vienna), Forel (of 
 Zurich), Ladame (of Geneva), Castelli and Lom- 
 broso, Bernheim, Bremaud, Fontan and Segard, 
 Peyronnet, Ventra, Amadei, Dumontpallier, Ober- 
 steiner, Vizioli, Bottez and Mall, Herter, B6rillon, 
 Algeri, Percy Smith, and A. T. Myers, and 
 lastly Seppili, whose recent remarkable study 
 is, at the present, the best we have on the subject. 
 [Archivio italiano, Sept., 1890). It appears from 
 the whole of these memoirs that, — as Bernheim has 
 shown, and as I pointed out very clearly in 1884, 
 in reply to M. Auguste Voisin (Ass. for Advanccm. 
 of Sciences, meeting at Blois), — the insane are most 
 frequently refractory to hypnotism, and only hys- 
 terical, epileptic, dipsomaniac, and obsessed cases 
 seem to be susceptible to hypnosis and benefited by 
 suggestion. The following are the very judicious 
 conclusions of Seppili's paper: 
 
576 TEEATMENT OP INSAXHTf. 
 
 (1) Hypnotic suggestion cannot be employed as 
 a means of treatment in mental diseases, on account 
 of the difficulty of hypnotizing the insane. 
 
 (2) The best results of therapeutic hypnotic sug- 
 gestion have been obtained so far in the psychoses 
 dependent on hysteria and dipsomania. 
 
 (3) Hypnotic suggestion may be employed when 
 the patient takes to it kindly and is profited by it. 
 The practitioner should employ it only with great 
 caution and note any injurious effects which, in cer- 
 tain cases, may be produced. 
 
 (4) Therapeutic suggestion in the waking state is 
 the most useful and efficacious agency in the treat- 
 ment of insanity, and to it alone are due the salu- 
 tary effects of the asylum, which has a really sug- 
 gestive character. 
 
 (5) In cases of melancholia without delusions, 
 fixed ideas, alcoholism and the milder forms of 
 stupor, repeated methodical suggestion in the waking 
 state, employed to combat the morbid phenomena, 
 may be very useful. 
 
 (6) In the chronic forms of insanity, and in paral- 
 ysis, suggestion has never afforded any good results. 
 
 Physical Agents. 
 
 The principal physical agents in the treatment of 
 insanity are : hydrotherapy, electrotherapy, and mas- 
 Eotherapy. 
 
aTDROTHEEAPY. 6'J'7 
 
 Htdeotheeapt. — Hydrotherapy, readily em- 
 ployed in mental medicine, has, nevertheless, been 
 thus far hardly utilized except in an altogether 
 empirical fashion. In tolerably complete medical 
 studies of the subject, I can only cite the interesting 
 general review by my friend Jules Morel of Gand 
 {Bulletin de la Soc. de Med. Mentale de Belgiqice, 
 Dec, 1889), and the chapter on hydrotherapy of 
 Kovalewsky's recently translated work on the 
 treatment of mental and nervous diseases. 
 
 The hydrotherapeutic methods utilized in psychi- 
 atry are the same as those ordinarily employed. I 
 will state h6re those that are best known, such as are 
 indicated by my distinguished confrere and friend, 
 Dr. Delmas (of Bordeaux) in his excellent Manuel 
 d''hydrotherapie. 
 
 The apparatuses, formulas, and hydrotherapeutic 
 methods vary according as they involve the appli- 
 cation of heat or of cold. 
 
 1. — Among the caloric methods I will mention the 
 dry pack. The patient is laid naked on a mattress 
 and is covered with one or two blankets tightly ap- 
 plied and kept thus by an outer cloth, with the 
 purpose of provoking perspiration. 
 
 The wet pack. Two woolen blankets are laid 
 over an ordinary bed, and over these is laid a cloth 
 previously dipped in water of from 8*^ to 12° C. 
 (46.4° to 53.6° F.) and then thoroughly wrung out. 
 The patient is placed naked on this cloth, which is 
 then wrapped around him with folds inserted be- 
 
578 TEEATMENT OP INSANITY. 
 
 tween the thighs and between the arms and body so 
 that the whole surface of the skin is in contact with 
 the moist cloth. Then the blankets are wrapped 
 around the patient and securely fastened. If a tonic 
 sedative effect is wanted the patient should remain 
 enveloped from ten to twenty minutes ; but it should 
 be continued for from an hour and a half to three 
 hours, as with the dry pack, if a sudorific action ie 
 sought. Other methods of inducing perspiration 
 are used, such as stoves, both of the ordinary kind 
 or those special for this purpose, hot air baths, fumi- 
 gations, and embrocations. The name of Russian 
 bath is given to a sudation followed by cold im- 
 mersion, and Turkish bath to the same succeeded by 
 massage. Foreign alienists, especially the English 
 and Americans, praise these methods very highly, 
 and constantly make use of them. 
 
 I will mention further, as methods of employing 
 heat, the warm bath, the piscina, the vapor douche, 
 the warm douche, the Scotch douche and the altern- 
 ating douche. The Scotch douche is a warm douche 
 followed suddenly by a cold one. The alternating 
 douche is the Scotch douche repeated many times in 
 succession. 
 
 2. — The application of cold is also made by numer- 
 ous methods, among which may be mentioned, partial 
 or general envelopment. Partial envelopment bears 
 the name of cincture, from the region to which it is 
 most frequently applied. It is applied by means of 
 a towel soaked in cold water and wrung out more or 
 
HTDEOTHEEAPY. 579 
 
 less completely, surrounding the body and covered 
 with dry linen or water-proof so as to produce a 
 local vapor bath. The wet cloth serves for a general 
 envelopment. Dipped into cold water and partially 
 wrung out, it envelops the whole body, and then 
 energetic friction with the flat of the hand is employed. 
 
 In immersion the body is plunged into cold water. 
 The immersion is total (bath tub, tank, swimming 
 basin) or partial (half bath, sitz bath, arm, hand 
 and foot baths). In the affusion bath, the body 
 plunged in water of a bath tub, of moderate temper 
 ature, receives from the sprinkler of a watering-pot 
 a shower of a more or less lowered temperature. 
 
 The projection of cold water on the body con- 
 stitutes the douche. This is general or local. The 
 general douche is called, according to its form, 
 shower, circle, jet, sheet, needle, palette, lance, 
 column, direct, and broken. Local douches in their 
 turn, according to the case, receive the names of 
 hepatic, splenic, epigastric, hypogastric, ascending, 
 vaginal, uterine, lumbar, anal, etc., douches. 
 
 Hydrotherapy, in its principal therapeutic effects, 
 is sedative, stimulant or tonic. In a general way 
 the sedative effects follow the use of warm and the 
 stimulating or tonic effects the use of cold water. 
 This is, nevertheless, not an absolute rule, and 
 the duration as well as the mode of the application 
 act, as well as the temperature, on the final result. 
 As a rule the best method is that using moderately 
 cool or temperate douches 20° to 30° C. {^= 68° 
 
580 TEEATMEKT OP INSATnTT. 
 
 to 86° p.) as a beginning of the treatment, taking 
 due note of the season, the temperature of the atmos- 
 phere, and the condition at the time. As regards 
 duration it ought not to exceed ten seconds at the 
 beginning, with water at l'Z° C. (= 53.6° F.), 
 and half a minute at the maximum, if the water is 
 raised to a temperature of 18° to 24° C. (= 64.4° 
 to 75.2° F.) (Delmas). 
 
 There is no need here to describe the apparatuses 
 of hydrotherapy, every one is now acquainted with 
 them. I will limit myself to saying that institutions 
 for the insane ought to possess a hydrotherapeutio 
 outfit suited to the varying needs of practice. For 
 the treatment of patients at home, we may use the 
 so-called shower bath. I prefer a simple copper ir- 
 rigating pump, which, placed in any kind of a vessel, 
 suffices at all times and places, for the administra- 
 tion of warm, cold, Scotch, and alternating douches. 
 
 I need not pass in review here all the mental dis- 
 orders in which hydi'otherapy is useful, but will con- 
 fine myself to stating the chief ones. 
 
 Neurasthenia. — In cases of nervous excitement, 
 temperate plunge baths, affusions, wet pack, douches 
 of slight force, moderately cool, and of short du- 
 ration, general friction with a wet cloth, lotions, 
 etc. In cases with symptoms of exhaustion we 
 should not at once have recourse to the cold douche 
 but should begin with a mixed douche. Later when 
 the patient is acclimated to hydrotherapy, use ex- 
 
HTDEOTHEItAPT, 681 
 
 citant applications, such as shower baths, and short 
 forcible cold jets, brief immersions in cool water, 
 frictions with wrung out wet cloth, etc., etc. If 
 cerebral symptoms break out and there is hyper- 
 excitement of the brain, cold lotions with sponges or 
 cold compresses applied to the head and frequently 
 changed, moderately cool showerings with slight 
 force, warm affusions when pain is produced by 
 cold ones. If, on the contrary, there is cerebral 
 adynamia, the local treatment should be excitant, 
 but the hydriatic applications should be closely 
 watched and should be mild, short and progress- 
 ively cooled (Beni-Barde). 
 
 Melancholia. — The hydrotherapeutic treatment 
 is very simple. It should first of all be tonic and 
 reconstituant. Douches of moderate pressure, short, 
 general and cool. Proceed with judgment using 
 first water of 82° to 8o.6°(F.) according to the sea- 
 son and gradually reduce the temperature. A re- 
 vulsive action may be needed in the course of the 
 treatment; it can be had by the use of shower 
 baths. The tonic action is increased by the use of 
 the plunge bath, when it is not contra-indicated. 
 If a tonic, and a still more energetic disturbing 
 action are both wanted at the same time, this 
 end is best attained by the Scotch douche. If 
 instead of a depressed, we have to treat an excited 
 or anxious form of melancholia, general warm baths 
 with affusions to the head, or a warm shower bath, 
 should be ordered. 
 
582 TEBATMBNT OF INSANITY. 
 
 Mania. — Here the warm bath of from 82°to 93° 
 F. is the hydriatic treatment par excellence. This 
 may be prolonged sometimes for several hours, care 
 being taken to keep cold compresses applied to the 
 head or the cold cap of Leiter or Wintemitz. Schille 
 also uses in subacute mania cold baths of from 59° 
 to 68° F. lasting eight to ten minutes, together 
 with the application of ice to the head followed by 
 friction and rest in bed. Briand has also employed 
 cold baths as antithermics in acute delirium. Svetlin 
 recommends the use of prolonged packs with towels 
 dipped in water of 60° to 68° F. , to combat excite- 
 ment : the calmative and hypnotic effects, he claims, 
 will never fail. Krsepelin, Krafft-Ebing, Schille, 
 Arndt, Salg6, have had good results with this 
 method, especially in feeble patients. The Russian 
 and Turkish baths also have excellent effects, ac- 
 cording to certain foreign authors, in mania as well 
 as in other forms of insanity. 
 
 General Paralysis. — "In this disease," says 
 Delmas, " hydrotherapeutic measures should be em- 
 ployed only with great caution. Extreme temper- 
 atures should be avoided, also douches with great 
 pressure and especially of long duration. ' When the 
 disorder assumes the congestive form and the alter- 
 ations are yet but slightly advanced there is yet hope 
 of retarding the final explosion. Aside from these 
 cases, however, the physician should abstaia from 
 all promises, and generally consent to use the treat- 
 
ELECTEOTHBBAPT, 583 
 
 ment only with the fullest reservations." These 
 wise words of a specialist are profoundly true. I 
 will, for my own part, go still farther, and declare 
 that, after numerous experiences, apart from simple 
 bathing, properly so-called, hydrotherapy in all its 
 forms, is useless and even dangerous in progressive 
 general paralysis. 
 
 Electeothebapt. — Electrotherapy, that potent 
 method of treatment, hitherto too much neglected, 
 seems destined to play a very important part in the 
 therapeutics of insanity. We sum^ up here some of 
 its indications according to the memoirs of Erb, 
 Kovalewsky and Morel, and, according to the 
 advice of our excellent friend, Professor Bergenia. 
 
 "We use in psychiatry the usual eleotrotherapeutic 
 procedures : the constant current or galvanization, 
 the LuteiTupted current or faradization, and static 
 electricity or franklinization. 
 
 Constant Current or Galvanization. — The con- 
 stant current for medical applications by means of 
 elements of piles connected in series. It is indis- 
 pensable to measure the amount of the current 
 utilized. This is done by means of galvanometers 
 graduated in milliampferes (the milliampfere being 
 the unit of quantity of current employed in med- 
 icine) . For therapeutic purposes of the constant cur- 
 rent, the battery should furnish at least a current 
 of 15 or aO milliampferes. The current is applied by 
 
584 TEEATMENT OF INSAJUITT. 
 
 means of electrodes, the form and surface of which 
 vary with the applications intended. The electrode 
 connected with the positive pole of the battery is 
 sometimes called the anode, that connected with the 
 negative pole is called the cathode. The intensity 
 of the current at any electrode is the quotient of the 
 intensity of the current by the surface of the elec- 
 trode. When the density of the current is very fee- 
 ble, that is, when the surface of the electrode is very 
 great, the action of that electrode is veiy slight, 
 and it receives the name of the indifferent or inact- 
 ive electrode. When, on the contrary, the surface 
 is small, the current density at that electrode is 
 great and it takes the name of the active electrode. 
 Sometimes the indifferent electrode may be formed 
 by all the water of an ordinary bath, the active 
 electrode being applied on some non-immersed part 
 of the body of greater or less extent. This is what 
 is called the galvanic bath when the constant current 
 is employed, and the faradic bath when the faradic 
 current is used. The human body interposes a 
 greater or less resistance to the passage of the cur- 
 rent, the greater part of which is due to the skin. 
 The unit of resistance bears the name of ohm. The 
 greater or less degree of dryness of the skin has a 
 great influence on the resistance. In order to dimin- 
 ish it as much as possible the part on which the 
 electrode is placed should be moistened with warm 
 water, or still better the fatty matter should be 
 removed by fjiction with alcohol, A rheostat is 
 
ELECTROTHERAPY. 585 
 
 an instrument that introduces progressively increas- 
 ing resistances into the circuit. It will be seen that 
 in this way we can vary the intensity of a current 
 from the same number of elements, since the in- 
 tensity of a current is inversely proportional to the 
 resistance of the circuit it traverses. A commutator 
 or current-reverser is an apparatus that serves to 
 change the direction of a current in the body, by 
 which manoeuver the positive becomes the negative 
 pole, and vice versa. The collector of elements (or 
 switch board) is the apparatus for introducing into 
 the circuit or cutting out the different elements of 
 the battery. In some cases an interrupter is added 
 by which the current is broken and set in action 
 again. 
 
 The constant current is used for the electrization 
 of the head, the spinal cord, the great sympathetic 
 and the peripheral nerves. 
 
 Cerebral galvanization has a sedative action on 
 the nervous system, and is therefore indicated in 
 cases of motor or intellectual excitement. It is very 
 useful in neurasthenia (Hughes, Althaus), epilepsy, 
 the premonitory period of general paralysis (Arndt, 
 Hitzig, Schtlle), lyperaania, mania (Schiile, Tigges, 
 Von Heyden, Wiglesworth, etc.) It should be 
 commenced with a current intensity of zero, very 
 slowly increased. Ordinarily the electrodes are 
 applied longitudinally, and they are applied obliquely 
 only in very exceptional cases. The patient should 
 not see sparks or wink if the apparatus is properly 
 
 Mbnt. MBD.— 37. 
 
586 TEEATMKNT OF rNSANrTT- 
 
 managed. The average duration of each seance is 
 from five to ten minutes. 
 
 Spinal galvanization is designed to pass the current 
 through the spinal cord. It may be followed by 
 excellent effects in medullary disorders and in myelas- 
 thenia, but it is scarcely used in mental diseases, 
 except occasionally in psychoses with excitement 
 (Arndt and Newth). A rather strong current, 
 fifteen to twenty milliampferes, for ten to fifteen 
 minutes, is permissible. In functional disorders the 
 length of the sittings ought to be less than in 
 organic affections. 
 
 Galvanization of the sympathetic has been so far 
 insufiiciently studied and has been much criticized. 
 It seems, nevertheless, to have before it a certain 
 future, since we can act on the caliber of the blood- 
 vessels by way of the sympathetic and regulate the 
 circulation toward the various organs, — ^notably 
 toward the brain. As yet we know only the action 
 of galvanization on the superior cervical ganglion as 
 it is the one most accessible to the current. When 
 speaking therefore of galvanization of the sympa- 
 thetic, it is therefore understood that we refer to this 
 ganglion only. To apply the current the active 
 electrode is usually placed in the auriculo-maxillary 
 fossa, and the indifferent on the chest, the occiput, 
 or the vertebral column. If the galvanization is 
 made on both sides simultaneously a double electrode 
 is employed. The current, feeble at first, is gradu- 
 ally increased, and for this reason a rheostat is 
 
fiLECTKOTHEIiAPT. 587 
 
 convenient in the circuit. The action of the different 
 poles is not well determined as yet, though clinical 
 ohservations show that the application of the positive 
 pole to the ganglion rapidly causes redness of the 
 face, flow of blood to the head and a feeling of weight 
 and slight vertigo. The negative pole, on the other 
 hand, causes pallor of the face and sometimes a 
 sensation of emptiness in the head and vertigo. 
 These facts sufficiently indicate the choice of poles 
 in the different disorders. Thus we should employ, 
 subject to later change if necessary, the positive pole 
 in neurasthenia, Basedow's disease, lypemania, hypo- 
 chondria, and dementia, and the negative pole in 
 general paralysis. 
 
 Galvanization of the peripheral nerves is hardly 
 utilized in mental medicine. Central galvanization 
 and general galvanization as recommended by Beard, 
 are of limited application and rather difficult. 
 
 Interrupted, or Induced Ciirrent or Faradiza- 
 tion. — This current is produced by means of a 
 Rumkhorff coil specially constructed for medical 
 use. We recommend a sliding apparatus giving as 
 regular a current as possible, on which we may use 
 either a fine or a coarse wire bobbin. The same 
 electrodes are employed as in galvanization. 
 
 Cerebral or spinal faradization are hardly used at 
 the present time on account of the uncertainty as to 
 their action, and peripheral faradization is the 
 method almost always employed. This acts not 
 
588 TEEATMETSrT OF INSANITY. 
 
 only locally, but in a reflex way on the nervous 
 centres. On account of this reflex action it has been 
 recommended by Benedikt and Arndt in certain 
 psychoses, notably in cases of psychic depression 
 and melancholic stupor. The results obtained seem 
 very satisfactory. There are two kinds of faradi- 
 zation : the deep and the superficial. Superficial 
 faradization affects particularly the nerve endings 
 in the skin, consequently the sensory nerves. It is 
 applied with a dry electrode or a metallic brush. 
 In order to make the current penetrate more deeply, 
 into the muscular structure, it is necessary that the 
 electrode and the part of the body over which it is 
 passed should be sufficiently moistened. 
 
 Static Electricity or FranMinization. — Static 
 electricity is produced by friction or influence 
 machines. The ones most used in France are those 
 of Carr6, Voss, Vigouroux, and Wimshurst. The 
 necessary accessories are an isolated stool on glass 
 feet, and a series of excitors with glass or ebonite 
 handles. The patient is connected by a conductor 
 with one or the other of the poles of the machine. 
 The excitor, held in the physician's hand by an in- 
 sulated handle, is connected with the other pole. 
 Static electricity is used in the form of baths, the 
 electric breeze, the aigrette, the electric friction 
 and the spark. 
 
 To give the static electrical bath, the patient is 
 made to sit on the stool connected with one pole of 
 
BLECTEOTHBBAPT. 589 
 
 the machine by means of a chain, a stem, or an iso- 
 lated wire conductor. The machine having been set 
 in action the patient feels in all unclothed parts of 
 his body a peculiar sensation, something between 
 that of a current of air and that of cobwebs. 
 Vigouroux attributes to this bath a feeble sedative, 
 chieflj'^ useful in the neurosis. 
 
 The souffle or electric breeze, is produced in the 
 following manner : the second electrode, in the form 
 of an excitor with points, is brought near the patient 
 who has been already charged with electricity by 
 the preceding method. There then pass from him 
 electric breezes which give a sensation of a draft or 
 current of air and appear in the darkness like lumin- 
 ous radiations. Vigouroux attributes to them 
 a sedative action that is very effective against the 
 symptom of pain. The frottement or electric fric- 
 tion, and the spark, are produced by a spherical or 
 bulbous excitor. In order to obtain the friction it 
 is sufficient to pass the bulb over the patients body 
 lightly. If the part to be electrized is bare, the 
 bulb should be covered with silk, without which, at 
 the moment of contact the body becomes a con- 
 ductor, and no sensation is produced. To draw out 
 the spai'ks, the bulb, uncovered by the silk, should 
 be held a short distance from the body. 
 
 Franklinization, especially recommended by 
 Charcot and Vigouroux, gives excellent results in 
 certain neuroses, notably in hysteria, Basedow's dis- 
 ease, and neurasthenia. It merits to become of 
 
590 TEEATSEBrNT OF INSANITY. 
 
 common use even in the psychoses, especially mel- 
 ancholia and hypochondria. Its use is, in certain 
 cases, combined with that of galvanization and 
 faradization. 
 
 Massothekapt. — Thus far massage has been very 
 little utilized in mental medicine, at least in France. 
 It has been more employed in certain foreign coun- 
 tries, associated with hydrotherapy or otherwise. 
 
 I will say that the manipulations of massage, are 
 the effleurage, and the rubbing, frictions, petrissage, 
 tapotement, hachage, and passive motion. I need 
 not describe them here. 
 
 The different varieties of massage find their spe- 
 cial indications in the various forms of mental disease. 
 
 Frictions and effleurage, associated or not with 
 cold baths, are very useful in stuporous melancholia. 
 
 A general massage, under the form oi petrissage, 
 is indicated in the various neuroses, hysterical, 
 hypochondi'iacal, and neurasthenic psychoses (Kov- 
 alewsky) . 
 
 Other Physical Agents. — Other physical agents 
 may be employed, though less important in the treat- 
 ment, as adjuvants. Of these I will mention, gym- 
 nastics, equitation, billiards, canoeing, swimming, 
 and especially bicycling, which, from its availability 
 and its freedom from danger, is suitable for many of 
 the insane. The English, always first in these mat- 
 ters, have already noted and utilized its advantages 
 
OPKEATIOirS. 591 
 
 (C. Theodore Ewart, " Cycling for the Insane." 
 Jour. Ment. Science, 1890). I have also had re- 
 course to it at once as a physical stimulant and a 
 psychic derivative, in some cases of neurasthenia, 
 hypochondria and melancholia. 
 
 Surgical Agencies. 
 
 Surgery is rarely invoked in the treatment of men- 
 tal disorders. Occasionally, nevertheless, its inter- 
 vention may be useful if not necessary. 
 
 Trephining, Gerehrotomy, Craniectomy. — Tre- 
 phining has been f oiinerly tried, it seems, for insan- 
 ity. Some foreign surgeons seem to wish to revive 
 this method at the present time, and even to carry 
 it farther than before. Thus Batty Tuke and Shaw 
 (1889) practiced trephining with excision of the dura 
 in general paralysis, with the view of relieving the < 
 intra-cranial pressure, due to the disease. So also 
 Burkhardt, Horsley, and Althaus (1890) have car- 
 ried out a series of operations ( trephining, excision 
 of parts of the cortex, ligatures of cerebral arteries, 
 extirpation of neoplasms) with the view of curing 
 or ameliorating certain psychoses. The results thus 
 far, however, have hardly been satisfactory. 
 
 More logical and assuredly more profitable, is the 
 craniectomy proposed and practiced recently by Prof. 
 Lannelongue in certain cases of arrest of psychic de- 
 velopment from primitive synostosis of the skull, 
 with the idea of making it practicable for the brain 
 
592 TEEATMBNT OF INSAKITT. 
 
 to reacli its normal expansion. There are, as yet, too 
 few facts to enable one to deduce any definite con- 
 clusion, but this operation seems destined to have a 
 certain future. 
 
 Hevulsion. — This is an excellent therapeutic 
 method in mental disorders that has not been suf- 
 ficiently resorted to. The happy results of sponta- 
 neous suppurations in the insane enable us, indeed, 
 to conclude a priori, as to efiicaciousness of artificial 
 revulsion, and numerous clinical facts support this 
 opinion. General paralysis itself, refractory we 
 may say to all other treatment, can, nevertheless, be 
 influenced by spontaneous or provoked suppuration, 
 and not infrequently when taken in its beginning, 
 the disease is seen to give way temporarily under 
 the influence of energetic revulsive measures. 
 • The best method of revulsion is a seton in the 
 back of the neck. We may also employ permanent 
 vesication, punctate cauterization with the thermo- 
 cautery, and lastly irritant frictions; but these 
 methods are generally either insuflicient or too 
 painful. 
 
 Thyroidectomy. Thyroid Grafts. — It is well 
 known that for some years past various foreign 
 surgeons, following the lead of Reverdin (of 
 Geneva), have attempted the cure of goitre by ex- 
 tirpation of the thyi-oid gland, or thyroidectomy. 
 After this operation there has been observed in a 
 
oPBKATioiirs. 593 
 
 majority of the cases, a particular condition of de- 
 generation, analogous to cretinism (cachexia strumi- 
 priva, or operative cretinism). Hence it was 
 naturally deduced that the suppression of the thy- 
 roid function was the immediate cause of cretinism 
 and pseudo-cretinism, and later physiological and 
 experimental researches seem to confirm this. The 
 cretinism following operations is, moreover, avoided, 
 as we are aware by the substitution of partial for 
 total ablation of the organ. Such being the case, 
 it is naturally asked whether the artificial re-estab- 
 lishment of the thyroid function in those deprived 
 of it could not, if successful, more or less sensibly 
 modify their condition. Experiments of grafting 
 the thyroid gland of a sheep, or of subcutaneous 
 injections of thyroid juice, have been recently made 
 by various experimenters (Horsley, Lannelongue, 
 Bettencourt-Rodrigues) , but the results are as yet 
 insuificient for us to speak confidently in regard to 
 the method.* 
 
 Together with thyroidectomy I will mention cas- 
 tration and clitoridectomy, which have been practiced 
 abroad, but without marked success, in a certain 
 number of insane females, especially in cases of 
 hysterical or climacteric insanity. In this connec- 
 tion, we are reminded of the fact that in sympa- 
 thetic insanity, and particularly in that connected 
 
 * since the above was written numerous cases have been reported 
 in medical publications, of favorable results in myxoedema from 
 injections of thyroid extract, and from thyroid transplantation or 
 grafts, 
 
594 TEBATMENT OP INSANITY. 
 
 with genito-urinary aflEections, an appropriate sur- 
 gical intervention (ablation of tumor, cauterization, 
 application of a pessary, etc.), has often caused the 
 disappearance of the concomitant psychic symptoms. 
 
 Blood-Letting . Transfusion. — Bleeding, for- 
 merly much resorted to, has to-day, as we are aware, 
 fallen into disuse, and if it was carried to excess 
 then, we may say that it is now too little employed. 
 In certain eases when the congestive condition of 
 the brain is manifest, there should be no hesi- 
 tancy in practicing bleeding or of applying leeches 
 either to the head or the arms. 
 
 Transfusion has hardly been employed, so far as 
 I know, in the treatment of insanity. The operatioo 
 is too complicated and the indications for its use too 
 restricted for it to be of advantage in any but very 
 exceptional conditions. 
 
 Hypodermic Injections. — The hypodermic method 
 that has rendered such great service to ordinary 
 medicine, tends to come more and more into use in 
 mental medicine. Already for a long time M. Aug. 
 Voisin has recommended morphine injections in full 
 doses almost as a regular treatment of insanity. 
 We also use subcutaneous injections of cocaine in 
 melancholia (Morselli and Buccola) ; injections of 
 ergotine and ergotinine in the congestive attacks of 
 general paralysis (Christian, Girma, Descourtis); 
 and finally injections of hyoscyamine, hyoscine, and 
 
OPBEATIOKS. 595 
 
 duboisine against the agitation of mania. The 
 hypodermic method is the better for the insane in 
 that it overcomes their very frequent refusal to take 
 medicine. 
 
 Before closing the subject of the hypodermic 
 method I will say a word as to the application to 
 mental medicine of Brown-Scquard's procedure, that 
 is, the subcutaneous injection of the testicular extract. 
 This procedure is at the present time very actively 
 criticized and even ridiculed, but it would be rash, 
 nevertheless, to affirm that it can never give any 
 positive results. As regards psychiatry in particu- 
 lar, it appears from the experiments of Professor 
 Mairet of Montpellier {Bull. Medical, 1890), that 
 the testicular liquid has a favorable influence in 
 melancholia by the excitant or especially the tonic 
 action of this fluid on the nervous system. I believe, 
 for my own part, that, if the revivifying effects 
 attributed to this method are real, it is in neurasthe- 
 nia, the malady ^ar excellence of nervous exhaustion, 
 and in psychic and physical asthenia, that they 
 ought to appear, and I have considered the possibil- 
 ity of making trials in this direction, with of course 
 all due cautions and reservations. 
 
 Lavage of the Stomach. ^La 1880 I recommended 
 the washing out of the stomach for the relief of 
 sitiophobia, or refusal of food on the part of the 
 insane, and this measure has given good results to all 
 those who have tried it with me. Since then I have 
 
596 TEEATMBNT OF IWSANITT. 
 
 endeavored to extend this metliod to the treatment 
 of the melancholia itself, which arises, as we are 
 aware, very frequently from digestive disorders, 
 especially from a gastro-intestinal auto-intoxication, 
 and in very many cases I have been able, while 
 relieving the bodily symptoms, to concurrently amel- 
 iorate the mental condition. The capital indication 
 that domiaates this method is to find out by pre- 
 vious chemical examination the exact composition of 
 the gastric juice, and consequently the nature of the 
 co-existing dyspepsia. This prior investigation in- 
 deed should guide us as to the liquid to be injected. 
 Since most of these liquids, especially the antiseptics, 
 are insoluble, my friend, M. Martial, has been kind 
 enough to furnish a series of formulse, forming, so 
 to speak, the posology of gastric lavage. They will 
 be found further on, in the list of therapeutic re- 
 ceipts which terminate this chapter. 
 
 Forced Alimentation or " Gavage'''' of the 
 Insane. — It has been said already that some of the 
 insane, mainly of the melancholiacs, hypochondriacs, 
 and the cases with delusions of persecution, obstin- 
 ately refuse all nourishment. This is what we have 
 designated as sitiophobia. In these cases we are 
 compelled to make them take food, and for this 
 purpose have recourse to forced alimentation. 
 
 Forced feeding of the insane includes a host of 
 methods of every kind and order. The most prac- 
 tical, and we may say the only one used in rebellious 
 
OtEEATlOXS. 597 
 
 oases, is oesophageal catheterization. I will not 
 describe this in detail, but will confine myself to 
 stating here the principal peculiarities of the 
 manipulation. 
 
 (Esophageal catheterization in the sitiophobes 
 should always be practiced by the nasal fosssB and not 
 through the mouth, on account of the difficulties 
 met with in the latter method. The patient should 
 be seated or laid on a bed, the head sufficiently ele- 
 vated by means of pillows. If he is too violent he 
 can be restrained with a camisole or held by 
 attendants. 
 
 The instrument that should be employed as best 
 for the purpose is a thick-walled rubber tube of a 
 callibre of 30 to 24 millimeters and of considerable 
 length. After dipping it into warm water the 
 operator takes it like a pen in his right hand at a dis- 
 tance of some centimeters from its lower ex- 
 tremity, and introduces it gently and gradually 
 into the nostril ; with the left hand he covers the 
 patients eyes to prevent his watching the movements 
 and thus preventing to some extent his voluntary 
 resistance. 
 
 The principal difficulty in catheterization is the 
 arrest of the tube at the base of the tongue, which 
 the patient frequently holds applied against the pos- 
 terior wall of the pharynx. This is a very serious 
 obstacle. The difficulty is overcome by suddenly in- 
 jecting a little water into the free nostril : the reflex 
 movement of swallowing thus produced, opens a 
 
598 TKEATHtEN* OP INSANITY. 
 
 passage for tte tube which then glides down if the 
 favorable moment is taken advantage of. 
 
 As regards the diagnosis of the tube taking a false 
 route into the air passages, its necessity, fortunately, 
 does not often occur. Nevertheless it may happen. 
 We may be sure that the tube is in the (Esophagus, 
 when it passes without effort and smoothly in a 
 smooth passage free from asperities, and is passed, 
 in spite of its considerable length, clear to its end ; 
 when there is no embarrassment of respiration nor 
 raucousness of thfi voice even when we obstruct the 
 tube; and finally when we hear the peculiar noise 
 of the exit of the gas from the stomacli at the open- 
 ing of the tube. For greater safety, and too much 
 precaution cannot be employed, we may, before the 
 injection of food, turn a few drops of water into the 
 tube and notice the effect. If no spasm of coughing 
 and nausea is produced with congestion of the face 
 and efforts to get rid of the liquid, we may be almost 
 certain that the sound is in the oesophagus. A la 
 rigueur, we may use either the sound I proposed 
 under the name of sonde d^dpreuve, or the more 
 recent one of M. Raspail, but this method, I admit, 
 is not as practical as might be wished. 
 
 The catheter introduced, the alimentary liquid is 
 injected, but is preceded each time, accoi'ding to the 
 indications laid down, by washing out of the stomach. 
 Formerly I employed a stomach pump for this pur- 
 pose, but have long since replaced this slightly 
 complicated apparatus, with a simple Faucher tube. 
 
MEDICAMSSTS. 599 
 
 fitted at its loose end by means of a glass tube to 
 oesophageal sound and by its other to an ordinary 
 funnel. I thus successively and conveniently do 
 first the washing out of the stomach, and then the 
 injecting of the alimentary fluid. 
 
 The nutritive liqvuds, prepared in advance and 
 ■warmed to the temperature of the body, should be 
 made up of varied mixtures of milk, bouillon, eggs, 
 peptones, and meat powders, Adrian's complete food, 
 chocolate, wine, cod liver oil, etc., to which we 
 may add, according to the case, tonics, preparations 
 of iron and other drugs that seem necessary. I 
 give, further on, from Lailler, a formula for alimen- 
 tary liquid for the feeding of the insane. 
 
 The operation should be repeated, at least twice 
 a day. 
 
 PHAKMACBUTICAi AoENTS. 
 
 The medicines used in the treatment of insanity 
 are very numerous, and their number increases daily. 
 Instead of giving here a dry and necessarily incom- 
 plete list, it seems to me preferable to give first a 
 word as to the chief classes of these medicaments, 
 and then to add a short therapeutic formulary of the 
 better preparations suited to each type of the disease. 
 
 Purgatives. — Purgatives have been always em- 
 ployed in the treatment of insanity. They are used 
 either to combat constipation, so frequent in the 
 insane, or to act by a salutary derivation on the in- 
 testinal canal. We may employ indiscriminately all 
 kinds of purgatives and the best are only those that 
 
600 TEBATMBNT OF INSANITY. 
 
 are easiest administered ; in many cases, nevertheless, 
 it is advisable to employ drastics, and especially 
 pills with a basis of aloes, which have the effect to 
 congest the rectum and occasionally may even re- 
 establish a suppressed hemorrhoidal flux. 
 
 Sedatives. Hypnotics. — Hypnotics and sedatives 
 are, with purgatives, the drugs most frequently em- 
 ployed in the treatment of insanity. Formerly hardly 
 any others than opium and morphine were in use, 
 but of latter years therapeutics has been enriched 
 with a number of different agents, at once less dan- 
 gerous and more efficient. Of this number I will 
 cite the alkaline bromides, choral, paraldehyde, sul- 
 fonal, methylal, hypnal, hyoscyamine, hyoseine, etc. 
 
 loonies. Antiperiodics. — Tonics, such as quinine, 
 arsenic, alcohol, iron, bitters, are of great value in 
 the insane, who are often subjects of ansemia. Sul- 
 phate of quinine has been recommended in certain 
 periodical psychoses, notably in double form in- 
 sanity and in malarial insanity where it seems to 
 have had good effects. 
 
 Diffusible Stimulants. Haschisah. Mnmena- 
 gogues. — Among other drugs suitable for more 
 or less frequent usage in the treatment of insanity, 
 I will mention the stimulants, alcohol, coffee, tea, 
 certain special products, such as haschisch, to which 
 has been attributed from the first, a special action on 
 hallucinated subjects, and finally emmenagogues, 
 which succeed very well in certain cases of insanity 
 due to ameuorrhoea or dysmenorrhoea, etc. 
 
THERAPEUTIC rOKMULAET. 601 
 
 THERAPEUTIC FORMULARY.* 
 
 It seemed well to me to bring together here, in 
 such a way as to be of use to the practitioner, some 
 of the prescriptions best suited for the treatment of 
 mental diseases. Some of them are taken from books, 
 others have been given me by my friends MM. 
 Carles, Cathusier, and Martial, to whom I wish to 
 express my thanks. These formulas are classified 
 according to the mental disorders in which they are 
 especially indicated, but it is needless to say that 
 they may be used, according to the case, in any 
 other morbid forms. 
 
 MANIA. 
 Sedatives and Bypnotics.\ 
 
 1 
 Chloral. 
 
 ■ ■ •,". !• aa 4 grams. 
 
 sodium S " 
 
 Bromide of 
 
 Syrup of orange flowers or morphine . 30 
 
 Distilled water 100 " 
 
 Fifty centigrams each of bromide and chloral in a table- 
 spoonful. 
 
 1' (TVON). 
 
 Hydrate of chloral 5 grams. 
 
 Bromide of sodium 5 " 
 
 Syrup of codeine 15 " 
 
 Note.— The preparations here prescribed are largely those of the 
 French pharmacopoeia. The prescriptions are, however, all intel- 
 ligible and it will be easy for the physician, who wishes to use them, 
 to make any such unimportant changes as may be required before they 
 can be filled in this country.— Tkakslatob. 
 
 tThe best of the known hypnotics for the insane are: sultonal, 
 chloral, bromidia, hyoscine, hypnal, methylal, and ohloralamide. 
 Uent. Ued.— 38. 
 
602 TEBATMENT OP INSANITY. 
 
 Syrup of cherry laurel 15 grams. 
 
 Distilled water 130 " 
 
 Fifty centigrams each of chloral and bromide in a table- 
 spoonful. 
 
 2 
 
 Paraldehyde 10 grams. 
 
 Alcohol 48 " 
 
 Tincture of vanilla 3 " 
 
 Water 30. " 
 
 Simple syrup 60 " 
 
 One gram of paraldehyde to each tablespoonful. From 
 one to six spoonfuls. 
 
 2' (YvoN). 
 
 Paraldehyde 1, 3. 3, or 4 grams. 
 
 Simple syrup 30 " 
 
 Water 70 " 
 
 Tincture of cloves 20 drops. 
 
 2" (Kbeaval and Nebcam). 
 
 Paraldehyde 3 grams. 
 
 Yolk of egg 1 
 
 Marsh mallovc vrater 130 grams. 
 
 For an injection, 
 
 3 
 
 Methylal 4grams. 
 
 Raspberry syrup 30 " 
 
 Distilled water 100 " 
 
 Fifty centigrams of methylal to a tablespoonful. Two 
 spoonfuls. 
 
 3 
 
 Methylal 1 gram. 
 
 Mucilage and water 135 " 
 
 For an injection, 
 
 4 
 
 Sulfonal 1 gram. 
 
 For one powder. From 1 to 3 powders. 
 
THEEAPBUTIC POEMULAEY. 603 
 
 4' 
 
 Sulfonal, finely pulverized 6 grams. 
 
 Powder of gum arable 6 " 
 
 Sugar 6 " 
 
 Distilled water 60 " 
 
 One-half gram of sulphonal to each teaspoonful. From 
 one to three teaspoonfuls. 
 
 5 (Bkomidia). 
 
 Chloral hydrate , 10 grams. 
 
 Bromide of potassium 10 " 
 
 Extract of hyoscyamus 10 c'grams 
 
 Extract of cannabis 10 " 
 
 Distilled water 30 grams. 
 
 One teaspoonful every hour till sleep is produced. Give 
 in one-half glass of sweetened water. 
 
 6 
 
 Urethan 10 grams. 
 
 Syrup of orange flowers 30 " 
 
 Distilled water 130 " 
 
 One gram of urethan to a tablespoonful. From one 
 to four. 
 
 7 
 
 Chloralamide 10 grams. 
 
 Elixir of Garus 50 " 
 
 Distilled water 100 " 
 
 One gram of chloralamide to the tablespoonful. From 
 1 to 4. 
 
 8 (Laillbb). 
 
 Hypnone 30 drops or 50 centigrams. 
 
 Alcohol 30 grams. 
 
 Cherry laurel water 5 " 
 
 Syrup of orange flowers 375 " 
 
 Sixty grams contain 4 drops of hypnone. 
 
 8' (Laillbb). 
 
 Hypnone 40 drops or 1 gram. 
 
 Alcohol 40 grams. 
 
 Cherry laurel water 5 " 
 
 Syrup of orange flowers 355 " 
 
604 TEEATMENT OP LNTSAIOTT. 
 
 Sixty grams contain 8 drops of hyphone. If only a few 
 drops of liypnone, from 1 to 4, use formula number 8, if 8 
 drops is prescribed, use formula number 8'. The syrup is 
 poured out in tbe required dose into a 150 gram vial whicli 
 is then filled with water. 
 
 9 
 
 Ural 1 gram. 
 
 For one powder. From 1 to 4 
 9 
 
 Ural 10 grams. 
 
 Alcohol 10 " 
 
 Syrup of punch 30 
 
 Distilled water 100 " 
 
 One gram to the tablespoonf ul. From 1 to 3. 
 10 
 
 Hypnal 1 gram. 
 
 For one powder. From 1 to 2. 
 
 10' 
 
 Hypnal 10 grams. 
 
 Alcohol 10 " 
 
 Syrup of orange flowers 30 " 
 
 Distilled water 100 " 
 
 One gram to the tablespoonful. From 1 to 3. 
 11 
 
 Hyoscyamine 10 milligr. 
 
 Distilled water 10 grams. 
 
 For hypodermic injections. One syringeful or more in 
 a day. 
 
 12 
 
 Chlorohydrate of hyoscine 10 milligr. 
 
 Distilled water 10 grams. 
 
 From i to 1 syringeful. Commence with i or ^ and keep 
 it up till 3-5 or f of a milligram is reached. The amount of 
 1 miUigr., IJ or even 3 milligrams may be gradually 
 reached,'^but extreme caution should be employed in the use 
 of these large doses. 
 
THEKAPEUTIC POBMULAEY. 605 
 
 13 
 
 Sulphate of duboislne 10 milligr. 
 
 Distilled water 10 grama. 
 
 Maximum dose 1 to 3 milligrams. 
 
 MELANCHOLIA OR LTPEMANIA. 
 14 
 
 TVeatmeni of Anxiotis Lypemania (Belle and Lemoine). 
 
 a. — Rest in bed, in complete dorsal decubitus, and as 
 prolonged as possible. 
 
 b. — Each morning, on awaking and before eating, a glass 
 of purgative water. 
 
 0. — Tincture of nux vomica in the dose of five drops, each 
 day, divided into tw3 portions and taken five minutes before 
 each of the two principal meals. 
 
 d. — Laudanum in increasing doses, starting with five 
 drops daily and increasing by five drops each day. Given 
 in two doses, morning and evening. 
 
 e. — Douches with interrupted jet, of very short duration, 
 and only after the bodily health has become good. 
 
 15 OMOESELLI AND BuCCOLA). 
 
 Hydrochlorate of cocaine 1 gram. 
 
 Distilled water 100 " 
 
 For hypodermic injections. From 3^ to 10 milligrams. 
 
 16 
 
 Tonic Wine. 
 
 "Wine of Kola 1 
 
 :: "ITntT ^^«g™-- 
 
 " " columbo J 
 
 Fowler's solution 10 " 
 
 Tincture of nux vomica 5 
 
 M. S. One liqueur glassful twice a day at meal times. 
 
606 
 
 TBEATMEITT OP IKSANITT. 
 
 17 
 
 Tonic Pills. 
 
 Extract of cinchona 5 grams. 
 
 "Kola 5 " 
 
 " "rhubarb 2^ " 
 
 " " nux vomica SO centigrams. 
 
 Arseniate of iron 30 " 
 
 Powder of Kola 9.5 " 
 
 For 100 pills. Four pills per diem. 
 
 18 
 
 Gastro-Iniestinal Antisepsis. 
 
 Beta-napthol (precipitated) 10 grams. 
 
 Salicylate of bismuth 10 
 
 For 30 powders. Two a day. 
 
 19 
 
 Medical Washes for the Stomach. 
 
 a. — Cases of hyperacidity. First antiseptic washing out 
 of the stomach with: 
 
 Creoline 1 gram. ) 
 
 Bicarbonate of soda 6 " [-Emulsion. 
 
 Water 1,000 " ) 
 
 Or : Phenic acid 1 gram. ) 
 
 Glycerine 10 " [Solution. 
 
 Water 990 " ) 
 
 Or; Thymic, acid 1 gram. ) 
 
 Glycerine 10 " [-Solution. 
 
 Water 990 " ) 
 
 Or: Corrosive Sublimate 10 c'gr's. I a„i„i.;„„ 
 
 Water 1,000 gr'ms. \ Solution. 
 
 Then wash out with alkaline water, or simple alkaline 
 lavage without antiseptics. 
 
 b. — Cases of anachlorohydria and of dyspepsia from fer- 
 mentation. First, antiseptic lavage of the stomach with : 
 Salolorpulverized naphthol. 4 grams. I Q,,„„o„„)n„ 
 Water 1,000 " \ »uspension. 
 
 Or : Resorcine 3 to 5 grams. ) a«i„«r,r, 
 
 Water 1,000 " ^ »ol"tion. 
 
 Or: Oxygenated water. 
 
THBEAPBTTTIC FOEMTTLAET. 607 
 
 Or: Iodoform, or pulverized iodol 1 gram. )«,„„„_„;„„ 
 Water 1,000 " \ Suspension. 
 
 Or: Permanganate of potasli. . . 10 cen'gr. | a„i„t)„„ 
 Water "^ 1,000 grams. \ Sol^t^'i- 
 
 ^'' ^f^3^P^^^°|(Pl^«°^t«°f«°'i«'\ qI^^'T'- [solution. 
 
 Or: Salicylic acid 3 grams. ) a„i.,HnTi 
 
 Water 1,000 " \ Solution. 
 
 Or: Boric acid 6 errams. ) a ■, .■ 
 
 Water 1,000 " [Solution. 
 
 Or: Sulphate of copper (pure). . 35 cen'gr. ) a„i„j.- „ 
 Water *.': . .:':...'... 1,000 grams. \ Solution. 
 
 Then washing out with acid wash : 
 
 Hydrochloric acid 4 grams. ) □„,„+,• 
 
 Water 1,000 " \ So^ion. 
 
 Or; Lacticacid 30 grams. / a i i- 
 
 Water 1,000 " \ Sol^t^o"- 
 
 Or acid drink with : 
 
 Hydrochloric acid 2 grams. 
 
 Simple syrup 100 " 
 
 Alcoolature of oranges 40 drops. 
 
 Water 890 grams. 
 
 Or: Lactic acid 10 grams. 
 
 Simple syrup 100 " 
 
 Alcoolature of oranges 40 drops. 
 
 Water 890 grams. 
 
 20 (Laillbr). 
 
 Alimentary Liquid for Forced Feeding. 
 
 Eggs 4 
 
 Milk 3 litres. 
 
 Claret 350 grams. 
 
 Meat powder 30 " 
 
 DOUBLE FORM INSANITY. 
 
 21 (HUBD). 
 
 a. — In the excited stage, hyoscyamine or hyoscine hypo- 
 dermically. (See numbers 11 and 13). 
 
608 TEBATMENT OF INSANlTf . 
 
 b. — In the depressed stage: 
 
 Citrate of Caffeine 1 gram. 
 
 Syrup of codeine 30 " 
 
 Distilled water 90 " 
 
 Tablespoonful every hour. 
 
 Or : Caffeine 3^ grams. 
 
 Benzoate of soda 3j " 
 
 Distilled water 6 " 
 
 For hypodermic injections. 
 
 PARTIAL INSANITIES. 
 Insomnia of Mallueinated Cases. 
 
 22 (LuTs). 
 
 "Julep gommeux " 160 grams. 
 
 Syrup of chloral 50 " 
 
 Ergotine 30 centigrams. 
 
 Tablespoonful every hour. 
 
 NEURASTHENIA. 
 23 (Dujardin-Beatimbtz). 
 
 Ferro-potass. tartrate ) „„ in ™_„™„ 
 
 Extract of cinchona f ^- ^° S"^*"^- 
 
 Strychnia 5 centigrams. 
 
 For 100 pills. 3 to 4 daily. Use also tonic preparations 
 (Nos. 16 and 17). 
 
 Sexual Neurasthenia (Beabd and Rockwell). 
 
 24 
 a. — Tonic: 
 
 Strychnia 15 milligrams. 
 
 Phosphorus 15 " 
 
 Extract of Indian hemp 13 centigrams. 
 
 Porphyrized iron 3 grams. 
 
 Powder of rhubarb 4 " 
 
 M. Make into 35 pills. 3 daily. 
 
tHEEAPEUTIC FOEMULAEY. 609 
 b.- 
 
 Bromide of zinc ) 
 
 Valerianate of zinc >■ aa. 1 gram. 
 
 Oxide of zinc ) 
 
 Conserve of roses q. s. 
 
 For 30 pills. 3 each day. 
 
 GENERAL PARALYSIS. 
 
 For the Congestive Attacks. ' 
 
 25 (Tauket). 
 
 Ergotinine 5 centigrams. 
 
 Lactic acid 10 •' 
 
 Distilled water 5 grams. 
 
 Syrup of orange flowers 995 " 
 
 Contains J- milligram of ergotinine to each teaspoonful. 
 
 25' (Tauket). 
 
 Ergotinine 1 centigram. 
 
 Lactic acid 3 "• 
 
 Cherry laurel water 10 grams. 
 
 About one milligram of ergotinine to a hypodermic syringe. 
 Dose : from J milligram to 1 milligram. 
 
 26 
 
 Treatment of the Deeubitibs: 
 
 a. — Erythematov^ period. — Classic application of diachylon 
 plaster to prevent contact of the skin with the surface of the 
 bed. Billroth advises soap plaster as follows: 
 
 Soap plaster 50 grams. 
 
 Spread on a piece of soft leather or fine cloth. 
 ft. — Gangrenous period. — The separation of the slough is 
 facilitated by tampons of wadding soaked with antiseptic 
 applications like the following : 
 
 Phenic acid 5 grams. 
 
 Olive oil 300 " 
 
 Or we may dust the surface with finely pulverized iodo- 
 form and cover with iodoform gauze, or we may employ 
 compresses saturated with : 
 
 Permanganate of potash 60 centigrams. 
 
 Distilled water 500 grams. 
 
Cbapter \D. 
 
 MEDICO-MENTAL DEONTOLOGY. 
 
 It sometimes happens in professional practice that 
 the physician is consulted in regard to certain deli- 
 cate questions bearing especially on the heredity of 
 alienation and the results that may follow ia the 
 families of the patients. The r&le of expert is not 
 always an agreeable one in these cases, nor is his 
 intervention altogether easy. It seems worth while 
 therefore to indicate some of the points the knowledge 
 of which may facilitate his task in such a case. The 
 principal questions to be answered in this connection 
 are the following: (1) That of the sexual relations 
 between an insane person and his or her consort; (2) 
 The chances of heredity of the different members of 
 the family of an insane person ; (3) The marriage of 
 the insane and of those related to them. 
 
 1. Sexual relations between the insane individ- 
 ual and his or Tier married partner. — The solution of 
 this question, which is often very embarrassing, may 
 be imposed upon the physician under two quite differ- 
 ent conditions: a. — during the existence of the dis- 
 order itself; b. — after its cure. 
 
 a. — In the first case we have to deal either with 
 an individual who is being treated in some way or 
 
CONJtrflAL RELATIONS OF THE INSANE. 611 
 
 Other at his home and who lives in more or less close 
 contact with his family, or with a patient confined 
 in a special establishment, and who, for various 
 reasons, is permitted interviews and promenades 
 with his or her consort. As a rule the physician is 
 not consulted in regard to their conjugal relations, 
 which take place or not without his intervention ; 
 occasionally, nevertheless, he is called upon to give 
 his opinion as to their safety and the inconveniences 
 to which they may give rise. The response of the 
 medical adviser in such cases should be positive ; it 
 is self-evident that he ought to formally prohibit all 
 sexual relations between the parties, not only as a 
 cause of excitement or exhaustion of the patient, but 
 also as dangerous in view of possible procreation ; it 
 being, in fact, admitted that children of a parent 
 deranged at the time of conception are especially 
 exposed to become insane. This, moreover, is one 
 of the thousand reasons why isolation is necessary in 
 cases of this kind, as, while the insane person con- 
 tinues to live with his family, difficulties of every 
 kind are met with and it becomes less easy to suc- 
 cessfully oppose his desires and inclinations. In 
 any case it is the correct thing to absolutely forbid 
 sexual relations between two persons, one of whom 
 is at the moment suffering from an attack of 
 insanity. 
 
 b. — The case is different after the patient has re- 
 covered, and it seems to me altogether arbitrary to 
 oppose, as has sometimes been done, and recently in 
 
612 MBDICO-MBNTAL DEONTOLOGT. 
 
 a case under my own observation, the legitimate de- 
 mands of an individual restored to reason, and con- 
 sequently in full possession of his conjugal rights. 
 I certainly do not ignore the fact that sexual rela- 
 tions of ex-insane individuals are dangerous in a 
 social point of view, but in spite of all considera- 
 tions, it is not evident that we have any right to 
 restrain them, any more than we have in the case of 
 a consumptive or any other individual the subject of 
 a diathesis transmissible to his descendants. If 
 mental derangement has its dangers, the constitu- 
 tional diseases of a physical order have theirs also, 
 and we cannot make an exception as regards the 
 former, which shares the common rights. The 
 physician should bear this in mind when called to 
 give his opinion on this point. It is his duty, never- 
 theless, to act .with prudence and to try to attenu- 
 ate, to some degree, the possible consequences of 
 sexual approaches in such conditions, by delaying 
 them till the cure is absolute, and by advising the 
 patient in the interest of his future health, to use 
 the greatest moderation in the accomplishment of his 
 desires. As to those methods of rendering the con- 
 jugal relations without effect as regards procreation, 
 too much employed at the present time, I do not 
 believe that it appertains to the physician to inter- 
 vene in regard to them, still less to advise their use, 
 in these cases ; since here we touch a very delicate 
 point and one that is completely outside of the 
 medical jurisdiction. 
 
CHANCES OF HEEEDITT. 613 
 
 3. Chances of Heredity of various members of the 
 Family of an Insane Person. — In a session of the 
 Medico-psychological Society, Billod judiciously 
 brought up the following question of medico-mental 
 practice : " What should be our conduct when con- 
 sulted by a person who believes himself threatened 
 with insanity because he is the offspring of insane 
 parents? " This communication and the succeeding 
 discussion resulted in the rather general conclusion 
 that the duty of the physician in such a case is to 
 reassure his client, while at the same time maintain- 
 ing a great reserve. It is true that this is, in fact, 
 the position the physician ought to take, and that he 
 ought no more to increase the fears of a child of an 
 insane person than he should, for example, those of 
 the offspring of a consumptive who fears that he in 
 turn may become tuberculous. This, however, is 
 only a general indication, and the question has other 
 aspects that have been passed over in silence, but 
 which, nevertheless, it is useful to solve. Thus we 
 may be consulted not merely by the descendant of 
 an insane person : it may not be the interested party 
 himself, but one of his near relatives or his wife ; by 
 a mother, for example, who is disquieted about the 
 future of her child, or by a wife who wishes to know 
 the dangers that threaten her husband. In short, 
 cases may happen where the physician is compelled 
 not to reassure but to speak with freedom and to 
 make the reasons for his opinion appreciable. On the 
 other hand, it seems to me that his answer should not 
 
614 MEDICO-MBNTAJL DEONTOLOGY. 
 
 be indiscriminately the same for all cases, and that 
 he ought not, for example, to apply the same path- 
 ological probabilities to the descendant of a general 
 paralytic as to the son of a lypemaniac or a subject 
 of delusions of persecution, for the simple reason 
 that the different forms of derangement do not 
 expose all to the same degree or type of heredity. 
 It is right, therefore, when called upon to decide the 
 question of the chances of heredity in mental aliena- 
 tion, to not limit oneself to the task of allaying more 
 or less well founded apprehensions, but to formulate 
 a scientific and rational opinion based in particular 
 upon certain considerations relative to (a) the person 
 inquiring ; (b) the one about whom inquiry is made ; 
 and (c) the form of mental derangement that exists. 
 
 (a). — ^As regards the person making the inquiry, 
 there are, properly speaking, no special considera- 
 tions to be kept in mind and the general principles of 
 propriety that apply in ordinary medical practice are 
 equally applicable in mental medicine. It suffices to 
 say that when one is consulted by the interested 
 party himself, it is frequently necessary to dissimu- 
 late and to avoid darkening the future, since even 
 the distant prospect of dreaded evU may be, so to 
 speak, fatal. On the contrary, when we are dealing 
 with another than the one directly involved, we can 
 express ourselves more unreservedly, especially if the 
 object is to institute a preventive treatment capable 
 of lessening to some extent the chances of insanity. 
 
CHANCES OF HBREDITT. 615 
 
 (b). — The considerations relative to the person 
 whose chances of heredity are involved are derived 
 chiefly from his degree of relationship with the 
 insane person or persons existing in the family line, 
 and also from his bodily and mental constitution. 
 It is clear that the closer the relationship is the 
 greater are the chances of heredity. The son and 
 daughter are therefore more exposed than the brother 
 and sister, these again more than the nephew and 
 niece, and these last more than the cousins in all 
 degrees. The children also are more exposed when 
 insanity exists in the mother than when it is in the 
 father, and among the children of the same insane 
 parent, those born at a period nearest the parents 
 insanity have also the more chances against their 
 future. Lastly, it is claimed that insanity of the 
 father is more frequently transmitted to the daugh- 
 ters and that of the mother to the sons, a fact that 
 is far from being demonstrated ; neither is it estab- 
 lished sufficiently that the children who physically 
 resemble one of their parents also take after that 
 one in a psychic point of view, and in consequence 
 have a more marked tendency to inherit his or her 
 mental disorders. 
 
 As regards temperament, the bodily and mental 
 constitution of the party interested, it is clear that we 
 have here an important element and one that should 
 be duly estimated in the calculation of the morbid 
 probabilities for the individual. We are well aware 
 that all the members of the families of the insane are 
 
616 MEDICO-MENTAL DBONTOLOGT. 
 
 not alike doomed to become insane, and that, together 
 with ill-balanced or insane members, there are others 
 whose mental make up is normal and not in the 
 least degree affected. But among these different 
 types of which these families are composed, it is, as 
 a rule, rather easy to distinguish those of healthy 
 mental constitution from the candidates for insanity. 
 These last may be marked, even at a very early age, 
 by an absolute lack of equilibrium in their faculties, 
 by a lack of balance and harmony, the absence of 
 sequence in their ideas and of logic in conduct, by a 
 manifest predominance of the nervous temperament, 
 a morbid impressionability, a marked tendency to 
 excitement or depression from the slightest causes, 
 sometimes alternations of excitement and depression. 
 The others, on the contrary, are always well poised 
 and masters of themselves, and we realize in their 
 presence that they are normal individuals, sharing 
 little or none of the pathological heritage. The 
 difference will be stUlmore pronounced if the children 
 of the insane already arrived at adult age have their 
 temperament clearly marked ; the ones have already 
 given evidence of some cerebral trouble either at an 
 early age or, what is more frequent, at puberty or 
 the first serious emotions of life ; the others, on the 
 contrary, have already passed the various stages 
 without having felt the least mental disturbance or 
 undergone the slightest moral shock. In a word, it 
 is necessary to submit the individual in regard to 
 whose future we are consulted, either directly or 
 
CHANCES OF HEEEDITT. 617 
 
 indirectly, to a minute psychological analysis, just as 
 we would submit to an attentive pulmonary exam- 
 ination any descendant of a consumptive who might 
 be disturbed as to his lungs. 
 
 (c). — The most important element however in this 
 question is, without dispute, the study of the type of 
 mental alienation in the case. 
 
 First of all, is it an isolated case, unique in 
 the family, or, on the other hand, are there many 
 similar ones, giving evidence that the evil is already 
 deep-rooted and that the taint is destined to be trans- 
 mitted from generation to generation? Does the 
 mental alienation exist on one side only, or on both, 
 paternal and maternal, at the same time ? Are 
 there already in the existing generation to which 
 the suspected person belongs, any examples of ec- 
 centricity, neuroses, insanity, mental degeneracy, or 
 on the contrary are the signs those of a normal con- 
 stitution? Was the disease of the ancestor purely an 
 unforeseen accident, occasioned by powerful causes 
 altogether personal in their nature, or, on the other 
 hand, did it appear under the influence of some 
 trivial cause, acting on an already existing predis- 
 position? All these are so many important points 
 which call for close attention. 
 
 Lastly, and this is a capital point, in my opin- 
 ion, although it was not taken into account in the 
 discussion cited above, it is important to specify 
 clearly, before pronouncing an opinion, the charac- 
 
 MeNT. Mcd. — S9, 
 
618 MBDICO-MBNTAL DfiONTOLOGT. 
 
 ters and the form of the mental derangement that 
 existed in the ancestors. We are not to think, 
 in fact, that it is a matter of indifiference, as 
 regards morhid consequences, whether we have 
 to deal with this or that form of insanity, 
 and the memoirs on heredity and on the biol- 
 ogical constitution of families that have followed 
 those of Lucas, Morel, Moreau (deTours) have al- 
 ready clearly laid down the fundamental distinctions 
 that are usefully applicable in this point of view in 
 practice. 
 
 "We know, in the first place, that certain forms of 
 mental alienation predispose more than others "to 
 heredity, and that suicide, double form insanity, 
 the reasoning insanities, intermittent or periodical 
 insanities, to mention only these, almost inevitably 
 expose the descendants, while certain others, like 
 acute mania and melancholia compromise the future 
 of the family to a much less degree. We are also 
 aware, and this is what M.Bali and I have especially 
 endeavored to show in our work on the biological 
 characters of the families of the insane, that hered- 
 ity, in mental alienation, presents itself under three 
 morbid types with clearly defined characteristics, 
 although similar in appearance: (1) the neurotic or 
 neuropathic type which originates in the neuroses, 
 and gives rise to neuroses and neuropathic insanity; 
 (2) the cerebral or congestive type, originating in 
 cerebral disorders, properly so-called, and giving 
 rise to cerebral affections, complicated or otherwise 
 
CHANCES OF HEEEDITY. 619 
 
 Vnth insanity; (3) the vesanic type, originating in 
 the vesanias or insanities, properly so-called, and 
 giving rise also to vesania, that is, to pure 
 insanity. The special evolution of the morbid man- 
 ifestations of each of these hereditary types, per- 
 mits therefore, to a certain extent, the foretelling 
 to what category of mental disorders the members 
 of a family are particularly exposed. Thus, for 
 example, when the individual in any special case 
 of inquiry is a descendant of a general paralytic, the 
 answer of the physician will not be the same as 
 when questioned in regard to the son of a vesaniac. ' 
 The following are the terms in which M. Ball and I 
 formulated our opinion in this regard : ' ' Thus gen- 
 eral paralysis does not arise from insanity and does 
 not engender insanity. Like the cerebral diseases, 
 it is born of cerebral affections and gives rise to the 
 same." 
 
 "It follows that general paralytics, not being 
 descendants of the insane nor producing lunatics, the 
 children of these patients escape vesanic heredity, and 
 that if they are doomed to a special class of diseases 
 by reason of the general paralysis of their father or 
 their mother, it is evidently not to insanity but to 
 cerebral affections of all kinds. 
 
 " Thus, when consulted, and this happens daily, 
 in regard to the future of a child of a general para- 
 lytic, the opinion of the physician should be the 
 direct opposite to that usually given by practitioners 
 or even by specialists more acquainted with these 
 
620 MBDICO-METTTAL DEONTOLOGY. 
 
 subjects, namely, that the child of a general paralytic, 
 by the mere fact that he is a general paralytic is in 
 no way predisposed to insanity, that he has only to 
 fear from predisposition cerebral disorders, and that 
 therefore the two critical periods of his life are 
 infancy, on account of the tendency to infantile 
 cerebral disorders at this time, and adult age, the 
 period for cerebral paralysis and for general paralysis 
 itself. 
 
 "Altogether the future is thus much more re- 
 assuring, with the more reason since, very different 
 'from the families of vesaniacs in which cases of insan- 
 ity are constantly on the increase, the families of para- 
 lytics rid themselves in infancy of their worse con- 
 tingent and are purified, so to speak, under the 
 influence of infantile brain disorders ; so that these 
 families are thus regenerated, if we can so express it, 
 by a sort of morbid selection, and what remain of the 
 descendants of the paralytics may be considered as 
 almost normal." 
 
 On the other hand, if we have a family in which are 
 many cases of insanity, properly so-called, or vesania, 
 we have also to fear vesania in the descendants, from 
 the fact that in vesanio heredity it is the repeated 
 aptness to insanity that constitutes in each generation 
 the characteristic of its morbidity. The same is true 
 of the families of the neuropaths or neurotics, in whom 
 the type of neuropathic heredity reveals itself with 
 its special characters. 
 
 It is sometimes possible, however, to carry scien- 
 
MABKIAGBS OF THE INSANE. 621 
 
 tific induction still farther in the calculation of the 
 morbid probabilities. It is not only possible to almost 
 certainly determine in advance to which of the three 
 types of heredity the individual in question belongs, 
 but also, in special cases, to just what variety of 
 insanity he is most likely to succumb. Thus, for 
 example, the children of suicides are often impelled to 
 suicide themselves, and the children of subjects of 
 double form insanity are also liable to have the same 
 form as their progenitor in preference to any other. 
 It wUl thus be seen what interesting consider- 
 ations arise from these questions of medico-mental 
 deontology. Also, although the biological study of 
 the family history of the insane of these different 
 types has hardly been more than touched upon, 
 the practical conclusions we can deduce from the 
 facts gained are already very important, and enable 
 the physician, in the cases we have in view, to form- 
 ulate a scientific and rational opinion, and not 
 merely a response, empirical so to speak, and made 
 solely to reassure the interested parties. 
 
 3. Marriages of the Insane and Relatives of 
 the Insane. — The physician may be consulted as to 
 the propriety of marriage, in psychiatric practice, 
 either relative to the insane themselves or their 
 relatives. 
 
 a. — As regards the insane, it is mainly with those 
 that have recoyered from their insanity that we have 
 
623 MEDICO-MENTAL DEOKTOLOGT. 
 
 to do, since the marriage of a lunatic during the 
 existence of his disorder could hardly be suggested 
 except under very unusual circumstances. Some 
 oases have occurred, nevertheless, where the mar- 
 riage of insane persons confined in special establish- 
 ments has been authorized and recognized as valid, as 
 was shown in the interesting discussion that occurred 
 on this subject in 1876 in the Society M6dico-psy- 
 chologique. As regards non- sequestrated lunatics, 
 their marriage presents much fewer difficulties, 
 and cases exist, as, for example, a union in extremis 
 intended to correct an abnormal situation, and, as 
 under some other circumstances still, where the doc- 
 tor can give his approval to such a marriage. But, 
 apart from these altogether exceptional cases, the 
 practitioner should be prudent and should keep him- 
 self apart from marriages of lunatics, which often 
 conceal interested motives and unavowable specula- 
 tions. 
 
 The question of the marriage of a recovered luna- 
 tic occasionally comes before us, and Morel says, 
 in this connection, that he has been able to decide 
 boldly in favor of it, when the individuals concerned 
 had no case of insanity in their ancestors and when 
 their disorder broke out under the influence of a 
 moral cause personal to themselves. 
 
 It should be added that the marriage can hardly 
 be approved of in these cases, except when the in- 
 sanity was^merely an acute attack of melancholia or 
 especially of mania, the only forms of mental S^UeB' 
 
MAEEIAGB8 OF THB IKSANB. 633 
 
 ation of wMch recovery may be sufficiently certain to 
 not compromise the future of tlie ex-lunatic. Never- 
 theless, however accidental the attack of insanity, 
 and however little hereditary it may appear, the 
 physician ought conscientiously to formulate some 
 reservations even while giving a favorable opinion. 
 
 It is chiefly in regard to the marriage of the rela- 
 tives of the insane, however, that the question is raised 
 in medico-mental practice. Usually it is the descend- 
 ant of an insane person who inquires, or for whom a 
 relative asks whether or not he can marry with 
 impunity, and, still more commonly, a strange lady 
 who wishes to know in behalf of one of her family 
 whether she can seek an alliance with the descendant 
 of a lunatic. Here is a delicate matter, and one in 
 which the physician cannot exercise too much circum- 
 spection and too much reserve. As in case of the 
 preceding question, he ought to chiefly base his 
 answer on considerations relative to the person inquir- 
 ing, the party interested, and the malady in question. 
 
 When the person chiefly interested is the one who 
 consults, the condition is frequently embarrassing, 
 since the physician cannot have with him his full 
 liberty of action. He ought, therefore, to try, under 
 some pretext or other, in this case, to consult with 
 some other member of the family, with whom he will 
 find himself in a more independent situation. In 
 case, moreover, where this is impossible and the 
 physician finds himself obliged to advise against mar- 
 riage to a descendant of a lunatic, he should support 
 
624 MEDICO-MENTAIi DEONTOLOGT. 
 
 his opinion with the argument that although alto- 
 gether free from the disorder of his father or mother, 
 the individual runs the risk of transmitting the pre- 
 disposition to his own offspring by a fact of atavism, 
 and that in consequence it would be better for him to 
 abstain from marriage. He may also try to induce 
 him to defer his marriage when it is possible, and to 
 wait till the period when mature age has placed him to 
 a certain extent beyond the risk of acute attacks 
 of insanity, which are much most frequent in 
 youth. Finally, when the case requires it, he can 
 base his prohibition on some other morbid peculiar- 
 ity, for example, a too feeble physical constitution, 
 or a moral temperament ill fitted for domestic life. 
 
 When it is a father or mother or some more dis- 
 tant relative that consults in behalf of the party in- 
 terested, we can be more frank, whUe still maintain- 
 ing some reservations. It will be permissible, 
 nevertheless, to express one's opinion with more 
 freedom. 
 
 Finally, it may happen that strangers come to de- 
 mand of the physician an opinion as to whether they 
 can, without peril, permit for one of their family an 
 alliance with the offspring of a lunatic. It is under- 
 stood that I do not refer here to any strangers that 
 might ask the practitioner to commit an indiscretion 
 or violate medical confidence, but to persons already 
 in relations with the family of the interested party, 
 and who come with its authorization to inquire in 
 regard to a matter in which they are deeply inter- 
 
MABEIAGES OF THB INSANE. 625 
 
 ested. In this ease the physician is free to act since 
 he has permission to express himself freely, preserv- 
 ing of course all the reserve and delicacy that should 
 never be lacking in matters of this nature. 
 
 As to the considerations relative to the interested 
 party himself and to the form of derangement exist- 
 ing in his family, they are exactly the same as those 
 brought out in the preceding question, since here 
 again it is the estimation of the chances of heredity 
 that is asked for. We will pass therefore in review 
 the degree of the relationship of the individual with 
 the insane patient, his constitution, his temperament 
 and his antecedents, as well as the characters of 
 multiplicity, of intensity of origin, and of form of 
 the mental derangement that existed in the ancestor. 
 Especially will we not forget the distinction we have 
 made between the three diiferent forms of heredity 
 nor to deduce the consequences that follow from it. 
 Thus, for example, — I again quote from our memoir 
 — "if one is consulted on the subject of a union to be 
 contracted by or with a descendant of a general para- 
 lytic, he may boldly give to that union his medical 
 and scientific approbation, by aifirming that general 
 paralysis is solely a cerebral disease, and for that 
 reason does not create a predisposition to insanity 
 in the descendants." 
 
 And, if it is required of me, in concluding, to sum 
 up in a few words the practical consequences of 
 this biological study we have made, I would say : 
 
 "If one wished to save his children from the sad 
 
626 MEDICO-MENTAX DEONTOLOGY. 
 
 inheritance of insanity he might with impunity, I 
 believe, enter into the family of a general paralytic, 
 but it is always dangerous in this case to espouse the 
 daughter of a lunatic." 
 
 It is not a matter to be neglected when we come 
 to pronounce 'in regard to the safety or propriety of 
 the marriage of the descendant of an insane person, 
 to study, as far as possible, the family with which 
 he thinks of allying himself, and especially the tem- 
 perament of his future consort. It is clear, in fact, 
 that the union will offer much fewer dangers, as re- 
 gards the offspring, in cases where the marriage 
 produces a happy crossing, while the existence of a 
 like predisposition in the future married pair will, 
 on the contrary, be a formal indication for the scien- 
 tific opposition of the physician. 
 
 Such are the principal questions of medico-mental 
 deontology that the physician is called upon to solve 
 in practice. Still others might be presented, but 
 their importance is less great, and they therefore do 
 not seem to me to call for a special study. 
 
SECOND SECTION. 
 
 MEDICO-LEGAL PBACTICE. 
 
 While the medical practice of mental alienation has 
 not, prior to the present period, been the subject of 
 special works, medico-legal practice on the other hand 
 has always attracted the attention of observers, and 
 there exist in this department a considerable number of 
 very important works, from the treatises of Zacchias, 
 Hoffbauer, Fod6r6, Mittermaier, Georget, Marc, 
 Casper, down to the more recent ones of Bonnucci, 
 Tardieu, Legrand du Saulle, and Krafft-Ebing, 
 without mentioning the articles scattered through 
 the cyclopedias and reviews, among which I will cite 
 only those of M. J. Falret, of Linas, of M. Motet 
 and M. Ritti.* 
 
 Also, without entering into historical develop- 
 ments or scientific discussions, for which we refer 
 the reader to the works already cited and to the 
 majority of the general treatises on legal medicine, 
 we confine ourselves to summing up in a practical 
 
 •Consult also, for the general questions relative to the legal med- 
 icine of insanity; Maudsley, Orime and Insanity; Max Simon, Orimen 
 et Selits dans la Folie; CuUerre, les FronWires de la Folle; Parant, la 
 Baison dans la Folle; Ball, Lefons aur les Maladies Mentales, 2d edition; 
 FiT6, Set/enerescence el Oriminaliie; Lombroao, L'Somme Criminel; 
 Tarde, Criminalite Oomparil; Coutague, la Folie au point devuejudl- 
 dare et administratif; the works of Qarofalo, Ferri, Sergi, lastly the 
 Comptes Eendus of the International Congress of Legal Medicine, 
 jifental AUenation an4 Criminal Anthropolo^, 
 
638 MEDICO-LEGAL PRACTICE. 
 
 point of view, the principal points in legal medicine 
 of insanity that are likely to interest practitioners 
 and magistrates as well as specialists themselves. 
 
 The legal medicine of insanity divides itself 
 naturally into twft parts, corresponding to the two 
 great divisions of the law : (1) the part relative to 
 the criminal law ; (2) the part relative to the civil law. 
 
 The first two chapters which f oUow are devoted to 
 the study of the more important questions of crim- 
 inal legal medicine, the third and last chapters to 
 those relating to civil law. 
 
 Note. — This chapter on the Civil Code, referring as it does exclu- 
 sitely to French law and practice, as well as a former chapter on the 
 French law of commitment for insanity are omitted, by permission 
 of the author, from this translation. 
 
Cbapter jffrst. 
 
 CRIMINAL CODE. 
 
 I.— PENAL EESP0N8IBILITY OF THE INSANE. 
 H.— CRIMES AND MISDEMEANORS OF THE INSANE. 
 
 I. — Penal Responsibility op the Insane. 
 
 Absolute Ieeesponsibilitt. Paktial Respons- 
 ibility. — Every crime or misdemeanor is composed, 
 says the legislator, of the act and the intention, but 
 no criminal intent can exist in an accused person who 
 has not the exercise of his moral faculties; and 
 freedom from penalty of the law should be granted 
 any man when disease has enervated his intelligence, 
 obscured his judgment, perverted his conscience, 
 disordered his reason, and deprived him of his free 
 will. A single article of the Penal Code (French) lays 
 down in unmistakable and vigorous language these 
 eternal principles of moral justice, and preserves the 
 lunatic from the rigors reserved for the criminal. 
 Article 64: '■'■There is no crime or misdemeanor 
 when the accused was in a state of dementia at the 
 time of the act, or when he has been under the com- 
 pulsion of a force he was unable to resist." It is 
 not necessary to add that, under the generic term of 
 dementia, the law understands not only the form of 
 
630 MEDICO-LEGAL PEACTICE. 
 
 mental derangement that bears that name, but all 
 mental alienation, whatever maybe its form. "By 
 dementia" say MM. Adolphe Chauveau and Faustin 
 H61ie, " we must understand, since no text has limited 
 its meaning, all the diseases of the intellect, idiocy 
 and dementia, properly so-called, delusional mania 
 and mania without delusions (that is affective mania), 
 even when partial. All the varieties of mental 
 disease, whatever the name science may apply to 
 them, whatever their classification, carry with them 
 the power of excusing the act, and acquit the ac- 
 cused, provided that their influence on the act can be 
 presumed." 
 
 The French law, therefore, absolves the lunatic 
 from responsibility for his actions. All legisla- 
 tion, moreover, since the morbid nature of insanity 
 has been recognized, has admitted the criminal 
 irresponsibility of the insane, and it is, therefore, 
 needless to discuss here the great principle of human 
 freedom and the conditions of the loss of free will in 
 beings deprived of reason. We must, nevertheless, 
 notice the disagreement of late years relative to the 
 degree of responsibility in some forma of mental de- 
 rangement : many authorities admitting, with M. Le- 
 grand du Saulle, that if certain of the insane are com- 
 pletely irresponsible for their acts, others are only so 
 in part, whence the names of partial, proportional, 
 and attenuated responsibility given to this latter con- 
 dition ; other authorities maintain vigorously, on the 
 contrary, with M. J. Falret, the absolute principle 
 
RESPONSIBILITY OP THE INSANE. 631 
 
 of entire irresponsibility in insanity, whatever may 
 be its form. 
 
 The arguments presented by these last and espe- 
 cially those of M. J. Falret, who has supported his 
 opinion with rare talent, seem to me to settle the 
 question and to clearly establish that in law as in fact, 
 every individual affected with confirmed mental de- 
 rangement, is on that account, irresponsible. Beyond 
 the fact that this doctrine, as just as it is positive, 
 closes the door to all quantitative and individual 
 valuations of moral capacity, and consequently to 
 those psychological subtilties that deserve no place in 
 legal medicine, it has still the immense advantage 
 of substituting for those arbitrary and contra- 
 dictory elements of appreciation, such as those based 
 on the degree of knowledge of right or wrong, on 
 the pathological nature or otherwise of the act, a 
 positive criterion, entirely medical in character, 
 namely, the existence or non-existence of mental 
 derangement. With this principle of total irrespons- 
 ibility, everything is reduced, in fact, to ascertain- 
 ing whether or not there is insanity, and not to 
 measuring the degree of discernment and conscious 
 responsibility of a patient. 
 
 But if the doctrine of attenuated responsibility 
 cannot be admitted in any case of well marked insanity, 
 properly so-called, we often find its application, on 
 the other hand, in certain cases of semi-alienation, 
 where the responsibility for acts, although persisting 
 in different degrees, is nevertheless manifestly dim- 
 
633 MBDICO-LBGAt PRACTICE. 
 
 inished. The most convinced partisans, moreover, 
 of the absolute' irresponsibility of the insane, have 
 themselves admitted in formal terms partial respons- 
 ibility in certain pathological conditions, and M. J. 
 Falret himself says in this regard: " But if we do 
 not admit the partial responsibility of the insane, thus 
 understood, that is to say, as regards certain things 
 and not in others at the same time, we are all dis- 
 posed to admit it at different times. We are all 
 compelled to say that there are moments in the life 
 of individuals in which we must admit either their 
 entire responsibility, as in the periods of predispo- 
 sition, intermissions, or lucid intervals, or their 
 incomplete or lessened responsibility, as in the periods 
 of incubation, of more or less complete remission, or 
 of convalescence. We admit also that the question 
 of complete or incomplete responsibility may be dis- 
 cussed in certain states of mental disorder apart from 
 insanity, properly speaking, such as apoplectic 
 dementia and aphasia, hysteria, epilepsy, and alcohol- 
 ism. It is within these narrow limits, apai*t from 
 mental alienation or confirmed insanity that we 
 admit partial, incomplete, or attenuated respons- 
 ibility." 
 
 The principal morbid conditions in which M. 
 Falret admits this graduation of penal responsibility, 
 are the following : 
 
 1. The first stages of mental disease; the pro- 
 dromic period or stage of incubation ; 
 
 2. Apoplectic dementia and aphasia; 
 
EESPOXSIBILrrT 01" THE IXSAIJE. 633 
 
 3. The conditions of lucid interval, of intermission, 
 and of remission ; 
 
 4. The periods of predisposition to insanity; 
 
 5. Hysteria, to which may be added somnambu- 
 lism and hypnotism; 
 
 6. Epilepsy; 
 
 7. Alcoholism; 
 
 8. Conditions of imbecility or natural mental 
 weakness. 
 
 "These," says M. Falret, " are mixed states, inter- 
 mediate between reason and insanity, and in which 
 it is permissible to discuss the degree of respons- 
 ibility, to admit entire responsibility or attenuated 
 responsibility, according to the case, and in which 
 there is no room to apply the criterion of absolute 
 irresponsibility, which, for our part, we recognize in 
 all cases of really confirmed or clearly character- 
 ized mental alienation." 
 
 It seems to us difficult not to agree with the 
 opinion so clearly stated by M. Falret, and not to 
 admit, with him, that, in cases of pronounced 
 mental alienation, there can be no question as to the 
 absolute irresponsibility, partial responsibility being 
 reserved for those conditions of mental disorder 
 that hold a place midway between reason and 
 insanity. 
 
 It will be understood that it is impossible to 
 discuss here successively the degree of responsibil- 
 ity appertaining to the different states of semi- 
 alienation of which we speak, not merely because 
 
 nygM T llBj>.-^0. 
 
634 MEDICO-LEGAIi PEACTICE. 
 
 the question allows of excessive amplification, but also 
 because we cannot lay down any general rules appli- 
 cable to all cases, and tbat it is before all necessaiy to 
 judge from particular facts. We must not forget that 
 partial responsibility is delicate ground, a sort of com- 
 promise between science and justice, as M. Lutaud 
 says, and that consequently the physician should use 
 this implement only with reserve, if he wishes to ex- 
 tract from it all the good of which it is capable.* 
 We will say only a word on the degree of respons- 
 ibility in remissions, intermissions, and lucid inter- 
 vals. 
 
 Responsibilitt in the Conditions of Remission, 
 Inteemission, and Lucid Intervals. — In the states 
 of remission, which form, as we have seen, an atten- 
 uation of the symptoms of the mental disease, the 
 degree of penal responsibility may be discussed. 
 But, as M. J. Falret says, the legal question is 
 hard to decide in these cases. " Here, indeed, doubt 
 is permissible, the question to be solved becomes one 
 of degree, and, in consequence, the answer cannot be 
 absolute; it cannot be formulated by regular rules 
 and necessarily depends upon each particular case." 
 In these cases the most resolute partisans of abso- 
 lute irresponsibility can admit an attenuation of the 
 
 *We would refer more particulai'Iy, for the study of the questions 
 of responsibility and capacity in the mixed condiiions to the worlis 
 of Charcot, Legrand du SauUe, Huchard, Pitres, Colin, on Hysteria; 
 to those of Christian and ¥6c6 on Epilepsy ; to those of Motet and 
 Vetault on Alcoholism ; and to those of Liegeois, Charcot, Brouardel, 
 Pitres, Bemhcim, Gilles de la Tourette, B^rUlon, etc., on Somnam- 
 bulism and Hypnotism. 
 
EBSPONSIBILITT OF THE INSANE. 635 
 
 responsibility proportional to the intensity of the 
 disease or the remission. But as I have already said 
 many times, this responsibility is not partial and 
 complete at the same time ; it does not exist for 
 certain acts while it is suppressed for certain others ; 
 it is variable according to the times and not at the 
 same instant ; it is absent during the attacks and may 
 be considered as complete or as simply attenuated 
 during the periods of remission, which can be de- 
 termined and pronounced by the clinical physician. 
 The study of these remissions and their degrees, in 
 the different forms and periods of mental derange- 
 ment, is one of the most interesting subjects in the 
 legal medicine of insanity ; but this chapter is yet to 
 be written in a clinical and scientific point of view. 
 This study has been chiefly made in regard to the 
 remissions of general paralysis (Baillarger, Sauze, 
 Legrand du Saulle, Doutrebente). 
 
 As regards intermittences or intermissions, that is, 
 the complete return to reason between two attacks 
 of insanity, such as occurs in intermittent mania, 
 double form insanity, etc. , the question of responsi- 
 bility appears under another form, since here we no 
 longer have to do with a simple amelioration, the 
 degree of w^hich is to be estimated, as is the case in 
 the remission, but with a veritable return to the nor- 
 mal condition. " But," says M. Falret, "in these so 
 frequent cases, which are met with as well in the 
 melancholiac as in the maniacal forms, the question 
 of responsibility offers itself naturally in all its dis- 
 
635 MEDICO-LEGAL PRACTICE. 
 
 tinctness and all its rigor. A true intermission is, 
 in reality, a temporary or momentary recovery. 
 We ought, therefore, to apply to it the same rule 
 as to recovery, i. e., to consider the individual in 
 this condition as possessing all his faculties, and there- 
 foi-e his full penal responsibility and civil capacity. 
 The only difficulty in these cases (and it is often a 
 very serious one) is a clinical difficulty, a question 
 of diagnosis. The expert has to show by positive 
 proofs that the individual examined was sound of 
 mind at the time of the act, in a true period of inter- 
 mission, in a real and not merely an apparent re- 
 covery, and not in a state of simple remission, more 
 or less marked, or in a state of voluntary conceal- 
 ment of delusions such as often occurs, for example, 
 in the remissions of insanity of persecution. This 
 clinical problem is often very hard to solve, and ia 
 one of the most delicate points in the legal medicine 
 of insanity. But, in principle, we cannot deny 
 that true periods of intermission often occur in 
 mental disorders, and that during these periods the 
 individual should be considered as having recovered 
 his moral responsibility and his civil capacity." 
 This is also the opinion of most authors, and of 
 M. Doutrebente in particular, who says himself, in 
 this regard : ' 'From all that precedes it is easy to con- 
 clude that during the intermission the intermittent 
 lunatic can and should be likened to a recovered 
 patient or to a man of sound mind, and that conse- 
 quently he is in possession of his civil capacity and is 
 
CEIMES AUD MISDEMEAITOES OF THE nSTSANE. 637 
 
 responsible for Ms actions; we will nevertheless, make 
 some reservations in the case of intermissions of 
 short duration alternating with frequent attacks of 
 mental derangement, since, in these cases, the inter- 
 mission approaches closely to simple lucid moments. " 
 
 This last restriction of M. Doutrebente can be 
 applied, for example, to double form insanity of 
 short attacks, separated from each other only by an 
 interval of a day or a few days of intermission. 
 
 The question is quite different as regards lucid 
 moments, since, in these cases we have solely to do 
 with a complete but altogether temporary suspension 
 of the symptoms of the disease, in the course of the 
 same attack. Here the lucidity has, so to speak, 
 only the duration of a flash of lightning and the 
 usual irresponsibility of the patient may be con- 
 sequently considered as not being suspended.* 
 
 II. — Ckimbs and Misdembanoks of the Insane. 
 
 We do not pretend to give here any complete study 
 of the crimes and misdemeanors of the insane. We 
 desire only, in enumerating the chief of them, to indi- 
 cate their general characters and their special char- 
 acteristics in each of the great forms of mental 
 alienation. 
 
 A. — General Chaeactees. — All the crimes and 
 all the misdemeanors, of whatever kind, may be met 
 
 ♦One may also consult with benefit, on this subject, the work of Max 
 Simon: Ci'imea and Misdemeanors in Insanity. 1886. 
 
638 MEDICO-LEGAL PEACTICB. 
 
 with in mental alienation, in such a way that, as 
 regards their nature itself, they difEer in no respect 
 from any others. The most frequent, however, are: 
 homicide and attempts at homicide, criminal assault 
 and rape, thefts, arson, forgery, slander, libel, simu- 
 lation, etc., etc. 
 
 In certain oases the act itself and the circumstances 
 accompanying it, bear the manifest stamp of the state 
 of derangement of the individual who has committed 
 it. Thus certain homicides or attempts at homicide 
 are committed by lunatics in a condition of 'delirious 
 agitation and maniacal fury that leave no doubt as to 
 their mental condition. At other times they are the 
 result of a sudden, instantaneous impulse, the violence 
 and unexpectedness of which are sufficient to reveal 
 their pathological nature. Frequently also, the mis- 
 demeanor, criminal assault or theft is so silly, ridicu- 
 lous, and witless, that it bears in itself the mark of 
 dementia. Or the lunatic takes no precaution to 
 conceal it, and seems to choose for the accomplish- 
 ment of his project a moment when he cannot fail to 
 be caught. In other cases again, he may denounce 
 himself, boasting of his crime or misdemeanor as if 
 it were a perfectly natural or even a meritorious 
 thing. In some cases he will completely forget the 
 fact and have no recollection of his act. Finally, the 
 crime may have no semblance of an end or excuse, 
 as when a lunatic all at once attacks in the street 
 some one whom he does not know, or steals some 
 article of no possible utility to him. 
 
CRIMES AND MISDfiHEAKOES OV THE INSAITE. 639 
 
 But if the crimes and misdeeds that have the in- 
 sane as their authors carry sometimes the special 
 characters of their diseased origin, this is far from 
 being always the case. Indeed, some of the insane 
 act from perfectly determined motives, prepare and 
 plan their misdoings long beforehand with a patience, 
 a fixedness of purpose, an address, a consecutiveness, 
 a talent for combination, and an amount of precau- 
 tion, ruses, and calculations that might deceive the 
 most skilful and clearsighted. Sometimes even, like 
 the true criminals, they may deny the commission 
 of the act or give it an appearance of reasonableness, 
 explaining it by plausible and almost sensible mo- 
 tives. Nothing therefore is more incorrect than the 
 notion, held by the majority of the public, that the 
 criminal and unlawful acts of the insane are always 
 characterized by want of foresight and the greatest 
 spontaneity and absurdity. There are cases, on the 
 other hand, where nothing at first sight betrays the 
 morbid nature of the criminal act, and this is why 
 the medico-legal valuation of certain acts is often so 
 difficult to fix. 
 
 B. — Paeticulae Chahactees est the Peikcipal 
 MoEBiD FoEMS. — One very important element of the 
 inquiry is found in certain special characters which 
 the crimes and misdemeanors of the insane borrow, 
 not only from their pathological nature, but also 
 from the form itself of the disorder in which they are 
 observed. 
 
640 MEDICO-LEGAl PEACTICE. 
 
 We have already, in discussing the reasons that 
 may necessitate sequestration, stated in the preceding 
 pages the principal characters of the morbid acts in 
 the great varieties of mental alienation, laying espe- 
 cial stress on those acts that most frequently caused 
 the patients to be dangerous. We will therefore 
 content ourselves here with pointing out certain pe- 
 culiarities relating to those acts that may constitute 
 in legal medicine an indication of some value. 
 
 Degeneeacies. — The degenerates, from the sim- 
 ple neurastheniacs with obsessions to the imbeciles 
 and idiots, are, above all, subjects of impulse, on ac- 
 count of their greater or less feebleness of wUl. 
 In the higher degenerates, as Magnan calls them 
 (ill-balanced, neurastheniacs, phrenastheniacs), there 
 is still resistance and consciousness; in the inferior 
 degenerates, the act becomes instinctive and, so to 
 speak, automatic, it approaches a reflex. 
 
 The more common impulsions in neurasthenias are 
 those to drink, arson, murder, theft, suicide, and 
 sexual aberrations of every kind (hair cutters, col- 
 lectors of female objects, rubbers, exhibitionists, 
 platonio lovers, etc.) These impulsions take the 
 character of emotional and conscious obsessions, and 
 it is only after a more or less lively resistance that 
 the patient finally gives way to them. 
 
 In the delusional and reasoning phrenasthenias the 
 dominant morbid tendencies are, on the one hand, the 
 tendency to private murder (reasoning persecutory 
 
CEIMES AND MISDEMEANOES OF THE INSAITE. 641 
 
 insanity), to religious or political murder (regicides), 
 and on the other to moral perversion. Nowhere is 
 the conception of the act more clear, more calculated, 
 more logical in appearance and more premeditated 
 than in this class of patients. Those more particu- 
 larly affected with moral perversion, the morally 
 insane as we call them, rarely attempt a criminal act; 
 they are dangerous rather to the reputation and honor 
 of individuals, since they use falsehood, dissimulation, 
 and calumny with a consummate art, and there is 
 nothing, in this line, that they will not invent to 
 injure those who have gained their ill will. It is in 
 regard to these that the medico-legal question presents 
 perhaps the greatest difficulties, as the absence of 
 delusion on the one hand, and the incredible skill 
 with which they have framed their plots on the other, 
 render the estimation of their mental condition a very 
 delicate matter, and make the excuse of insanity very 
 difficult of acceptation by the judges. To these 
 patients it is necessary to compare the double form 
 lunatics, and especially the subjects of hysteria, who 
 resemble them closely in that their insanity is very 
 frequently manifested under the reasoning form. 
 
 Special mention should be made of the instinctive 
 phrenasthenias, which constitute what we call the 
 criminal psychosis, and in which should be ranked 
 the born criminals of Lombroso. All crimes and 
 misdemeanors are met with in this class. The char- 
 acters of the born criminals, in both a physical and a 
 psychical point of view, have been many times 
 
643 MEDICO-tEGAl PBACTICSl. 
 
 pointed out by Lombroso and his disciples, but, as 
 we have said, they are in no way absolutely specific 
 and do not materially differ from the other characters 
 and stigmata of degeneracy.* 
 
 In the states of mental weakness, properly speaking, 
 either congenital or acquired (imbecility, idiocy, 
 dementia), the criminal or unlawful act, is usually 
 puerile, unconscious, absurd, sometimes automatic. 
 Murder is rather rai-e, at least when native infirmity 
 of the intelligence is uncomplicated with any neuroses 
 or acute attack of insanity. It is with offenses 
 against decency, rape, and thefts that we have to do 
 with in these cases. The indecent acts of these weak- 
 minded patients may be the result of a greater or 
 less degree of genesic excitement, in which case they 
 bear the stamp of this super-excitation, and some- 
 times even of bestial violence, but more often stiU 
 they are silly, absurd, and purposeless. It is, in 
 fact, among these patients that are principally to be 
 found the exhibitionists of Lasfegue, i. e., patients 
 who, without knowing why they do so, content them- 
 selves with displaying their genital organs in public. 
 
 After offenses against decency, come thefts, more 
 frequent in dementia and absurd as in general paral- 
 ysis ; lastly, we may observe arson, especially among 
 imbeciles. 
 
 Maniacal Conditions. — Crimes and misdemean- 
 ors are rare in mania, although this is the form of 
 
 ♦See Corre, Us Orlmlnds, (1889) ; Dortel, P Anthropologie CHminelle et 
 la SesponsabUite Medico-legale, (.Thise, Parie, 1891). 
 
CRIMES AND MISDEMBASTOES OP THE INSANE. 643 
 
 insanity that seems most terrifying ; this is because 
 the patients are absolutely incapable of conceiving 
 any act whatever, and they are rather destructive 
 than really dangerous. Nevertheless, v^hen the agit- 
 ation is pushed to paroxysms of fury, it may be the 
 cause of a homicide, accomplished under conditions 
 of violence and hyper-excitement that leave no doubt 
 as to their true character. 
 
 Melancholic States. — Crimes and misdemeanors 
 are rare in states of melancholia, where we observe 
 almost exclusively, as we have stated, the tendency 
 to suicide. Nevertheless, homicide may be seen in 
 exceptional cases of certain forms of acute lype- 
 mania, but then, far from having hatred or malice 
 for its motive, it results nearly always, on the con- 
 trary, from an excess of affection or a deluded sym- 
 pathy for the victim. Thus, I have seen at Saiute- 
 Anne a woman in a condition of acute melancholia 
 who, when she threw herself into the river with 
 suicidal intent, took with her her two young children, 
 so as not to leave them on earth exposed to the mis- 
 eries of existence. In this case we might almost say 
 that the insane person commits the suicide of other 
 individuals, as with herself, in order to protect them 
 from the torments and punishments which, she thinks, 
 threaten them also. We may also see in melancholia 
 indirect suicide, that is to say, an act of homicide 
 committed for the purpose of bringing about the 
 death of the one committing it, either on account of 
 
644 MEDICO-LEGAI- PEACTICE. 
 
 dread of killing himself, or in order that he may have 
 tune for repentance. 
 
 Paktial oe Ststematized Insanities. — In the 
 systematized insanities, homicide is the leading 
 offense, and we may say that it is most frequent in 
 this type of mental disorder. 
 
 The deluded mystics, as we have seen, often 
 believe they have received a commission from heaven 
 to kill some more or less prominent personage, who 
 they think represents the cause hostile to God on 
 earth, and then they coolly, with calculation and 
 premeditation, assassinate that individual ; more fre- 
 quently they immolate in sacrifice their own children ; 
 or even the first persons they meet, pei'suaded that 
 in so doing they are in some way pleasing the Deity. 
 Their prophetic and inspired attitudes, their delusions, 
 and even the circumstances of their act are enough, 
 as a rule, to cause the recognition of their insanity, 
 although their apparent lucidity, and the calmness 
 and the reticence behind which they intrench them- 
 selves, sometimes make the forming of an opinion 
 somewhat difficult. 
 
 The subjects of persecutory delusions, as we have 
 not ceased to reiterate, are, of all the insane, the 
 most dangerous. With them, homicide is chiefly to 
 be feared ; because, believing themselves the butt of 
 their imaginary persecutions and considering them- 
 selves the victims of an organized conspiracy into 
 which enter a more or less considerable number 
 
CEIMES AND MISDEMEANOES OF THE INSAlinE. 645 
 
 of persons, they finally come to act, against their 
 supposed enemies, as persecutors and as aggressors. 
 
 There are in this respect, two great classes of 
 patients. The first, the most numerous class, base 
 their ideas of persecution on various sensory disturb- 
 ances, and especially on hallucinations of hearing, 
 which become the fundamental element of their ex- 
 istence, and finish in directing and misleading them 
 more and more into their delusions. These are the 
 hallucinated persecutory cases. The others, appar- 
 ently rational, build up on some more or less salient 
 circumstances of their lives a whole system of per- 
 fectly coherent delusive conceptions, based on a 
 semblance of truth, and which, defended with as 
 much skill as conviction, are almost invariably very 
 logically combined. These patients, usually free 
 from hallucinations, and more partially affected in 
 their faculties, are the reasoning persecutory cases. 
 They fall into the category of the degenerates. 
 
 Whether hallucinated or reasoning, these persecu- 
 tory cases are, we cannot too often repeat, the most 
 dangerous of the insane, and a large portion of all 
 pathological crimes can certainly be attributed to 
 them. Still more, perhaps, than the hallucinated 
 cases, who kill chiefly from an impulsion, under the 
 influence of an hallucination or under that of a 
 transitory exaltation, the persecuted degenerates are 
 to be feared, and this because they reason out their 
 delusion and carry out in cold blood, so to speak, 
 the crime they have conceived. It is a curious fact, 
 
646 MEDICO-LEGAX PEACTIQE. 
 
 nevertheless, and one that seriously complicates the 
 r6le of the medical expert before the courts, that it 
 is just these patients, the worst of all without any 
 dispute, whom^ it is most difficult to make accepted 
 as such by the magistrates and by the public. 
 
 Persecutory cases, moreover, do not confine them- 
 selves to merely attacking their enemies, sometimes 
 their victims are those they have never before seen ; 
 they may also, though much more rarely, commit rape 
 or arson. 
 
 Hebephrenia. — In hebephrenia, and in a general 
 way, in all the disorders of intelligence that mani- 
 fest themselves in children, the criminal or unlawful 
 acts assume generally the character of a sudden, 
 instantaneous and unreflecting impulse. There are 
 motiveless murders committed often under circum- 
 stances of astonishing cruelty and ferocity, thefts, 
 and incendiarism. It is rare in these cases that the 
 precocity itself of the criminal, added to the impul- 
 sive nature of the act, the lack of thought, and the 
 cruelty of which it gives proof, do not put one 
 readily on the track of his real condition. 
 
 PtTERPEBAL iNSAsriTT. — In puerperal insanity the 
 most frequent crimes and misdemeanors are theft 
 and homicide : the theft under the form of an impul- 
 sion, a sudden instigation, a desire to satisfy, chiefly 
 in ante partum insanity; the homicide, and more 
 especially infanticide, also under the form of an 
 impulsion, chiefly m post partum insanity and, more 
 yet, in the insanity of childbed, properly so-called. 
 
CEIMES AND MISDEMEANOES OF THE INSAITB. 647 
 
 In the latter case it is sometimes very difficult 
 to appreciate the pathological nature of the 
 act, the more so from the fact that childhed 
 insanity may be absolutely transitory, not lasting 
 beyond a few hours or a few days. 
 
 Toxic Insanities. — In the toxic insanities, and 
 particularly in alcoholic insanity, the form most 
 often in question in a medico-legal way, suicide 
 dominates as a morbid tendency, at least in the sub- 
 acute form. In the acute form, on the contrary, 
 homicide is not uncommon, and the patients im- 
 pelled by their terrors and their agitation throw them- 
 selves upon their victims whom they butcher with an 
 indescribable fury. They resemble in this point of 
 view maniacs and epileptics, and their state of 
 agitation itself, usually tremulous, is commonly suffi- 
 cient to reveal the toxic influence. They may also, 
 either simultaneously or each by itself, commit arson, 
 theft, or offenses against decency. 
 
 Geneeal Paealtsis. — The prodromic period of 
 general paralysis, when it assumes the excited form, 
 is very often the theatre of pathological acts, among 
 which misdemeanors, in the place of crimes, hold a 
 large place. In this respect this period has been 
 made the subject of a special study by M. Legrand 
 du Saulle, under the name of the medico-legal period 
 of general paralysis. The most frequent mis- 
 demeanor is theft, next comes indecent behavior, 
 lastly forgery, breach of trust, and rarely homicide 
 or attempt at homicide. 
 
648 MEDICO-LEGAL PBACTICB. 
 
 Whatever the act committed may be it presents 
 special characters which are generally sufficient to en- 
 able us to refer them a priori to their true origin. 
 The thefts of general paralytics, which have been 
 the subject of special study and analysis, are, indeed, 
 characteristic. The paralytic takes from a store, 
 without precaution and with the candor of innocence 
 some insignificant object, such, for example, as a 
 worthless umbrella, a pair of shoes, or trousers, a 
 bunch of cabbage, an egg, or some delicacy of little 
 value. He has no idea of what to do with the ob- 
 ject stolen, and almost immediately gives it away for 
 charity to some beggar. He is so unconscious of the 
 nature of his act that he commits it without conceal- 
 ment, before everybody, and often even calls in the 
 help of a stranger to help him in his larceny, like the 
 paralytic mentioned by M. Magnan who, wishing to 
 carry off a cask of wine called in the aid of a police- 
 man, who, deceived by his candor, aided him to roll 
 his cask. The theft of the paretic, like the other 
 crimes he commits, is an absurd, silly theft, the theft 
 of a demented person, since it is clearly to his de- 
 mented state that is due his action, as is also the 
 equally absurd and silly character of his delusions. 
 It is more than is required for the diagnosis of even 
 incipient general paralysis, and experts do not usually 
 hesitate when they have to judge upon a theft com- 
 mitted under these conditions by a man of some forty 
 years of age, even when the physical signs of the 
 malady are not yet very pronounced. 
 
CEIMES AND MISDBMEAlSrOES OF THE INSANE. 649 
 
 Epilepsy. — Witli the cases of delusions of perse- 
 cution, it is epilepsy that furnishes the largest con- 
 tingent pathological crimes and misdemeanors. 
 The special character that these acts borrow from 
 the great neurosis to which they are due, have been 
 thoroughly studied and shown during late years. 
 These characters, moreover, are so distinct that they 
 make it possible to refer the act committed to epilepsy, 
 even when the outward signs of this disorder and 
 particularly the convulsive attacks, are wanting, as 
 in case of larvated epilepsy, epileptic vertigoes, and 
 petit mal. These distinctive peculiarities consist 
 chiefly in the fact that the act of the epileptic, which 
 is generally a crime, especially murder or incendiarism, 
 is committed under the form of a sudden, instan- 
 taneous, violent impulsion, frequently reproducing 
 itself at more or less regular intervals, and of which 
 the patient retains no recollection after the attack. _ 
 This profound amnesia that makes the assassin or 
 the incendiary remember absolutely nothing of what 
 is passed and of what he has done, is peculiar to 
 epilepsy and is met with under the same characters 
 in no other condition. It is often possible for expe- 
 rienced physicians, in the presence of an act of this 
 kind, not only to recognize its pathological nature, 
 but also to make it the starting point of a complete 
 diagnosis, and to suspect a hitherto ignored epilepsy, 
 which in fact reveals itself after a longer or shorter 
 period. 
 
 Meni. Med.— 41. 
 
Cbaptcr irir. 
 
 CRIMINAL CODE {Continued). 
 
 MEDICO-LEGAL EXAMINATIONS. 
 
 We have laid down in the preceding chapter the 
 principle of the irresponsibility of the insane, and 
 shown the nature and character of the more frequent 
 crimes and misdemeanors in mental alienation in 
 general, and in each of its principal types, in particu- 
 lar. It now remains, in concluding the subject of the 
 criminal portion of legal medicine, to state briefly 
 the rdle of the physician when he is intrusted with 
 a medico-legal examination relating to insanity. 
 
 This rdle has been fully described by numerous 
 authors, notably by my eminent and lamented rela- 
 tive, Dr. Linas, in his article in the Diotionnaire 
 encyclopMique, from which I borrow the chief 
 paragraphs that follow. 
 
 Definition OP Expertise* {V Expertise). — When, 
 in a civil or a criminal suit, the question of dementia 
 is raised, men of skill are usually called in, either by 
 
 * The French term expertise has no exact English equivalent in the 
 sense in which it is here employed. I have therefore used the word 
 as an Enjflisih one to avoid an awkward circumlocution that could 
 not moreover well express its meaning, which is literally '"a survey 
 by a board of skilled examiners."— Tbassij.tob. 
 
DErnSTTION OP EXPEETISE. 651 
 
 the judges or by the parties, sometimes to confirm, 
 sometimes to refute, the presumption or allegation 
 of insanity. If the physician acts by virtue of a 
 delegation of judicial authority, he properly takes 
 the title of expert; if his employment, instead of 
 being by the court, is friendly and at the instance 
 of the parties, he is a simple employ6, not subject 
 to the rules of the code of procedure. In the first 
 case, the ■written result of his investigations is called 
 a report ; in the second case, a consultation. Which- 
 ever way it is, at base the mission is the same, 
 though different in origin ; it tends to the same end, 
 and imposes the same duties. What applies to one, 
 applies also to the other in what we are about to say. 
 
 First, what is an expert examination, and what is 
 an expert in the eyes of the law, and in the sense of 
 jurisprudence? 
 
 Expcrtism is a method of instruction ; its aim is to 
 enlighten the judges in difficult, dubious, or obscure 
 cases, and to furnish from special knowledge what 
 they need in order to solve the question and make a 
 definite judgment possible. 
 
 The expert is a man of skill charged with supply- 
 ing these elements of the judgment. 
 
 In Prussia, as well as in some other countries, the 
 law makes it a duty of the court to call in the as- 
 sistance of a medical legist to determine the mental 
 condition of an individual. In France it is optional 
 with the magistrates to order an examination by 
 experts, either of his own motion or on the deiaand 
 
652 MEDICO-LEGAL PSACTICE. 
 
 of the parties ; they are the sovereign judges as to 
 the expediency of this measure. The obligation to 
 resort to experts is imposed upon the tribunals only 
 in certain special matters designated by the law, 
 amongst which we regret not seeing mental alienation 
 figure, as is the case in Prussia. 
 
 The expertise necessarily presumes on the part 
 of the judge, one or several definite questions 
 addressed to the man of skill, and on his part an 
 answer, a personal and reasoned opinion. 
 
 The rdle of an expert in all its simplicity and 
 clearly defined is this : The expert is less than a 
 judge ; he is more than a mere witness ; he diflEers 
 from the first in that his decision has iu it nothing 
 imperative, from the second in the extent, the import- 
 ance, and the scientific character of his testimony. 
 In no case should the medical expert step out of the 
 boundaries of his proper attributes to usurp the rdle 
 of an advocate, still less that of a judge. He should 
 not pretend to interpret or apply the law, and should 
 be on his guard against making dangerous encroach- 
 ments. Fixed animus and vain declamation fit ill in 
 the mouth of a man who should speak exclusively in 
 the name of science and verity. His language should 
 be severe, cold, free from any artifice, disengaged 
 from all interests and prepossessions. He should 
 work for but one end ; to instruct the conscience of 
 the judges and to provide impartial decisions for the 
 court. 
 
 In a criminal case, the first and generally the only 
 
DEFINITION OF EXPEETISE. 653 
 
 question for the expert to answer is this : Was the 
 accused in a state of dementia or sound of mind 
 when he committed the act with which he was 
 charged? 
 
 Everything is therefore reduced to a question of 
 diagnosis. 
 
 Thus fixed on the ground of pathology and of med- 
 ical observation, the problem simplifies itself, frees 
 itself from metaphysical uncertainties, and reduces 
 itself into two correlated, conjoined and inseparable 
 terms, which should equally share the examination 
 of the physician ; the morbid state and the subiect, 
 that is the fact and the agent, the act and its author. 
 
 The remarks already made relative to the crimes 
 and misdemeanors of the insane make it unnecessarv 
 to again recur to the subject. We will confine our- 
 selves to saymg that, as regards the tact or tiie act, 
 save in certain cases where its conception and execu- 
 tion bear the plain imprint of mental alienation, we 
 may accord to this element of the examination taken 
 singly, only a secondary and, as it were, an accessory 
 importance ; it certainly deserves consideration by the 
 medical legist, but it ought, in order to acquire all 
 it§ prominence and medico-legal value, be considered 
 only in an abstract way and never be separated from 
 its agent. 
 
 As regards the individual, the author of the act, it is 
 evident that he should be the principal object of the 
 physician's investigation. And this investigation to 
 be complete should be carried into not only the pgy- 
 
654 MEDICO-LEGAL PEACTICE. 
 
 chological phenomena, but also into the external 
 api^earance and the whole of the organism ; should 
 include not only the actual conditions and existing 
 appearances, but also the past conduct of the sub- 
 ject, his antecedents and his previous acts. 
 
 Wats and Means of the Expeetise. — The 
 medico-legal expertise to be well conducted should 
 be based on the three following methods of diagnosis : 
 the inquest, the interrogation, the direct and con- 
 tinued observation. 
 
 The Inquest. — The inquest consists in collecting all 
 the data that can enlighten the expert in regard to 
 the condition of the insane person, and on the nature 
 of his delusions ; in making inquiry as to his hered- 
 itary predisposition, and his morbid antecedents, his 
 tastes and inclinations, his habits and mode of life, 
 before and after the outbreak of his insanity ; the 
 known or presumed causes of the disorder, the date 
 of its beginning, its manner of invasion and develop- 
 ment, its most striking phenomena and most char- 
 acteristic symptoms, and finally the circumstances 
 and particular details of the act of which he is 
 accused. 
 
 These data may be obtained from various sources ; 
 from the relatives, friends and neighbors of the 
 individual ; by visiting the places where he has lived, 
 and by examining his writings ; from the remarks, 
 attestations and certificates of physicians; in the 
 papers of _^the^court. 
 
WATS AND MEANS OF THE EXPEETISB. 655 
 
 The legal documents and medical testimonies have 
 a special character of authenticity which gives them 
 in the eyes of an expert an exceptional value. This 
 is not always true on the contrary with the data ob- 
 tained from kinsmen and friends, and the expert 
 cannot be too much on his guard against the hyper- 
 bolic statements and erroneous interpretations of some, 
 and the studied reticence and systematic assertions 
 of others. 
 
 We wiU not dwell here upon the inspection of the 
 dwelling of the subject and the analysis of his 
 writings, in regard to which we have already spoken 
 in the chapter on the practical diagnosis of mental 
 alienation. 
 
 Interrogation. — ^In the same way, as regards the 
 interrogation of the individual, we can refer to the 
 same chapter on practical diagnosis, where this 
 question has been treated in full detail. We will 
 limit ourselves to mentioning here some particular 
 points relative to medico-legal interrogations. 
 
 There is nearly always a real advantage in not 
 having recourse to the personal interrogation untU. 
 after the inquest, that is, when numerous accurate 
 data have already made known the habitual and dom- 
 inant ideas of the lunatic, and have made it possible 
 to suspect the form of his disease and shown the best 
 method to be followed in questioning him. We 
 avoid thus having to grope our way and useless loss 
 of time, and are possessed of the necessary facts to 
 
656 MEDICO-LEGAL PEACTICE. 
 
 impress a more methodic and efficacious direction 
 upon the interrogation. 
 
 It is essential, when in the presence of an insane 
 person, to hanish all apparatus, all solemnity and all 
 appearance of harshness. The attitude of the expert 
 should be that of a physician, and not that of an 
 examining magistrate. All his efforts should be to 
 dispel the distrust or fears of the patient, to gain his 
 entire confidence, to quiet his distracted or pre- 
 occupied mind. Preciseness and clearness in the 
 questions, simplicity in language, kindness and 
 gentleness in words and manner, plenty of skiU, tact, 
 and finesse, firmness when required, in rare and 
 exceptional cases ability to use intimidation and 
 menace ; such are the qualities and disposition that 
 it behooves the expert to bring into the medico-legal 
 interrogation of the insane. 
 
 In the periodic, intermittent or transitory forms 
 of insanity, the subject may have recovered his 
 reason at the time of the examination. Such a test 
 would then be of no value, and wUl even entail the 
 risk of drawing false conclusions. The fact must 
 not be lost sight of that in certain cases the delir- 
 ium decreases rapidly and disappears suddenly when 
 the transports of morbid furor are, so to speak, 
 satiated. In such case, however, it is not uncom- 
 mon for a new attack to appear during or after the 
 Judgment, and thus prove the genuineness of the 
 former one. Hence the rule for the expert to pro- 
 ceed to the interrogation as soon as possible, during 
 
WATS AND MEANS OF THE EXPERTISE. 657 
 
 the active period of tlie insanity; hence also the 
 necessity for him to have frequent recourse to the 
 third method of investigation, direct and continued 
 observation. 
 
 Direct and Continued Observation. — Whenever 
 the inquest and personal interrogation have failed to 
 dissipate the doubts of an expert and settle his 
 opinion, he is, after a fashion, compelled to supple- 
 ment it by personal observation. Many of the 
 insane have sufficient self-control to impose upon the 
 public, and to contain themselves before the magis- 
 trates and the physicians. But left to themselves, 
 they throw off the mask and loosen the rein to all 
 t-heir extravagant ideas. By the aid of an assiduous 
 persevering surveillance skilfully managed and prac- 
 tised without their knowledge, one is enabled to ascer- 
 tain the truth and take them, as it were, in the act 
 of mental derangement. 
 
 It is especially, however, in the co mplicated cases, 
 and those presenting difficulties in their diagnosis, 
 that the direct and continuous observation of the 
 patient becomes most useful in enabling the expert to 
 completely enlighten himself. The chief difficulties 
 met with in this regard are : dissimulation, simu- 
 lation and allegation of insanity. We will say a 
 word on each of these. 
 
 Dissimulated Insanity. — There are certain forms 
 of insanity, the systematized or partial insanities in 
 
658 MEDICO-LEGAI PEACTICB. 
 
 particular, in which the patients are naturally in- 
 duced, by a sort of pathological tendency, to main- 
 tain reticence, and to conceal their delusions with 
 sufficient skill, occasionally, to impose upon those 
 not forewarned. The expert must not confine him- 
 self to questioning these lunatics. Such a method 
 of investigation could, in these cases, only produce 
 unsatisfactory or misleading results. It is needful 
 to submit them to the test of a personal and pro- 
 tracted observation, to scrutinize their sentiments 
 and instincts, to apply to their actions an attentive 
 control and scrupulous surveillance; to make, if 
 possible, the inventory of their lives ; to question the 
 wife, the children, the relatives, that is to say, all 
 the habitual witnesses and neglected victims of their 
 extravagances and madness. 
 
 Simulated Insanity. — An accused person, a con- 
 script, or a soldier presents himself with the apparent 
 symptoms of insanity : all three have a like interest 
 in passing themselves off as insane, the one in the 
 hope of gaining freedom form punishment, the others 
 in the hope of escaping militaiy service. Is the 
 insanity feigned or genuine? Such, under these cii'- 
 cumstances and others similar to them, is the question 
 to be answered by the medical expert. Following 
 Tardieu, we will examine successively; a. — the 
 forms of insanity simulated; h. — the methods of 
 simulation ; and c. — the means of detecting fraud. 
 
 a. — Forms of Insanity Simulated. — Not aU the 
 
SIMTTLATED mSAOTTT. 659 
 
 forms of insanity favor simulation equally, and there 
 are some which, on account of the special facility 
 they seem to offer, are most frequently tried hy im- 
 postors. Of this number are : acute mania, of which 
 the state of excitement, the loquacity, and the dis- 
 ordered gesticulation seem, indeed, very easy to 
 counterfeit ; dementia, of which the essential element, 
 the loss of intelligence and memory, it appears to be 
 merely play to realize ; melancholia, and especially 
 melancholia with stupor, which apparently only de- 
 mands of the simulator, a mask of immobility and 
 inertia ; ambitious insanity, and in general, all the 
 partial insanities, which, for the fact that they 
 turn on a more or less fixed and limited num- 
 ber of ideas, offer a less complex theme and 
 a less difiicult r6le to sustain. We may mention 
 also the toxic insanities in this connection, 
 and alcoholic insanity in particular, often sim- 
 ulated of late years by certain criminals who hoped 
 thus to escape the rigors of the law by trying to 
 throw the blame on an act committed under the tem- 
 porary effects of intoxication. Finally should be 
 added epilepsy and epileptic insanity which always 
 hold one of the first places when we are treating 
 of simulation. 
 
 b. — The Methods of Simulation. — "I do not 
 believe," says Georget, "that an individual who has 
 not studied the insane could so imitate insanity as to 
 deceive a physician well acquainted with the disease, " 
 
660 MEDICO-LEGAL PEACTICK. 
 
 In fact nothing is more difficult to counterfeit than 
 is mental alienation. Imbued with the common 
 notion that all the acts of lunatics are extravagant, 
 that all their discourse is lacking sense, those who 
 borrow the mask of insanity, make excessive gestic- 
 ulations, perform ridiculous actions and utter inco- 
 herent speeches. They invariably give silly and 
 absurd answers to questions addressed to them, with- 
 out consecutiveness or connection, in which they 
 misconstrue all that is asked of them, so that instead 
 of giving a faithful likeness of insanity, they make 
 an outrageous burlesque and parody of it. In the 
 instance of Derozier, reported by Morel, when asked 
 his age, the impostor, after hesitating, replied 245 
 francs 35 centimes, or rather 5 metres, 75 centimetres ; 
 to a question in regard to his family, his brothers, 
 his childi'en, he answered, ' ' I am well supplied with 
 coupons." In a second questioning, Derozier was 
 asked if it was day, he answered that it was night ; 
 his age, he replied that he was king of Beauvais ; 
 when asked to give his right hand, he invariably 
 gave his left ; the left, and he gave his right hand. 
 There is in all the answers and in all the acts the 
 evident and calculated intention to deceive, and to 
 seek the absurd, which fits poorly with the characters 
 of true insanity, so natural, so logical aiid so true 
 in all its manifestations, even those that are most 
 extravagant. 
 
 Thus, and it is an important fact to keep in mind, 
 the genuine lunatic is a patient in whom all the 
 
SIMtTLATED mSANITY. 661 
 
 various symptoms of insanity reveal themselves with- 
 out effort and without parade; the simulator is a 
 comedian who plays a part and who can never re- 
 frain from exaggerating and grimacing under the 
 mask he has assumed. 
 
 Another important peculiarity of simulation is the 
 lack of exactness of the clinical picture presented by 
 the subject, who, if he attempts to offer certain 
 symptoms of the type of insanity adopted, omits 
 certain others just as essential, or replaces them by 
 others not reconcilable with this form. Further, the 
 impostor, incapable of realizing in its successive 
 steps the regular process of the affection he coun- 
 terfeits, persists indefinitely in the same attitude and 
 the same role, or on the other hand he modifies his 
 behavior and speech according as he feels himself 
 watched, or as he believes he can do better by the 
 change. The case reported by Montegya is well 
 known in which the physicians charged with the ex- 
 amination of an individual suspected of simulation, 
 said in his presence, so as to be heard, that they had 
 doubts of the genuineness of the insanity of the ac- 
 cused for several reasons : first, because he scattered 
 the food given him ; second, because he did not sigh ; 
 and third, because he did not look fixedly on any 
 object. The ruse succeeded, the simulator modified 
 his comedy in such a manner as to instantly relieve 
 the doubts of the physicians. 
 
 c. — Methods of Discovering Simulation. — Al- 
 though, properly speaking, there is no particular 
 
663 MEDICO-LEGAL PEACTICE. 
 
 method of discovering simulation, there are, never- 
 theless, certain rules, the knowledge of which may 
 be under such circumstances, very useful to the 
 physician. 
 
 "A first principle," says Tardieu, "that should 
 never be ignored in these cases, is, to give no opin- 
 ion until after prolonged, repeated, persevering, 
 and, so to speak, incessant observation, carried on, 
 if not directly, at least indirectly, by persons sufii- 
 ciently experienced and familiar with the insane." 
 It is for this reason, that it is always preferable to 
 transport the subject, as is usually done, to an in- 
 sane asylum where he can be more efiiciently ob- 
 served, or where he may in contact with genuine 
 lunatics, change his behavior in a way to betray 
 himself, or where he sometimes, tiring of his sojourn 
 in such surroundings, at last gives up his simulation. 
 
 It has, from all time, been recommended, as a 
 proper procedure to unmask simulation, to use meth- 
 ods of harshness and repression toward the sus- 
 pected individual, such as the employment of chloro- 
 form or ether, blisters, moxas, scarifications, the 
 actual cautery, energetic douches, etc., etc. With 
 Tardieu, who raised his voice against these painful 
 and sometimes even dangei'ous tests, we proscribe 
 all these truly inhuman methods, and only accept, 
 in this line, such really inoffensive procedures, like 
 the sojourn oi the accused in a ward of disturbed or 
 untidy patients, to weary his patience, and like a 
 sham medication composed of water with some dis- 
 
SIMULATED HTSANITT. 663 
 
 agreeable or nauseous substance added, to disgust 
 him. 
 
 In reality, it is chiefly on his own experience and 
 sagacity that the physician must rely in discovering 
 simulation. By multiplied and well conducted in- 
 terrogations, strict observation, a surveillance with- 
 out relaxation, carried on night and day without 
 the knowledge of the party observed, by methods 
 skilfully adopted to put his distrust to sleep, nets 
 carefully spread to provoke inconsiderate words, 
 imprudent writings, or compromising actions : such 
 arc the more correct methods for reaching this 
 result. 
 
 One of the principal rules in an expertise of this 
 nature consists in submitting to a careful examina- 
 tion the different bodUy functions of the individual. 
 In fact it is especially in this regard that simulation 
 is difficult, and of certain symptoms impossible. 
 There is insomnia which pseudo-lunatics hardly at- 
 tempt; analgesia so frequent in genuine lunatics; 
 irregularity of the appetite, constipation, and above 
 all the disorders of the circulation and respiration, so 
 characteristic in the generalized insanities, and which 
 it is clearly impossible to counterfeit. Thus the sham 
 melancholiac, however easily he assumes the mask 
 of torpor, never succeeds in presenting the lowering 
 of the bodily temperature, the slowness of pulse and 
 respiration, and especially the violaceous chilling of 
 the extremities, that are so manifest in true melan- 
 cholia. If necessary the thermometer and sphygmo- 
 
664 MEDICO-LEGAI PEACTICE. 
 
 graph can be employed, as has been done by M. 
 Voisin in simulated epilepsy. 
 
 Another sign is the facial expression, on which 
 M. A. Laurent has judiciously laid stress in his excel- 
 lent monograph on simulation of insanity. "The 
 aspect of the simulator," says that author, " is 
 furtive, changeable, and sly. The countenance 
 indicates forced expression, an unpleasant and sig- 
 nificant lack of harmony. The criminal simulator 
 cannot give to his face the wild and excited appear- 
 ance that belongs to the maniac. We -recognize 
 there only effrontery, and not mental aberration. 
 Neither can he assume the genuine, indifferent and 
 enfeebled expression of the dement and paretic, fixed 
 gaze of the stuporous patient, the proud and haughty 
 look of the monomaniac, etc. He cannot conceal 
 the attention he gives to every word and motion of 
 him who is charged with studying his words and 
 gestures; and very often he casts down his eyes, 
 distrusting the expression his looks might betray." 
 
 A difference still to be noted between the genuine 
 and the false lunatic is that the former is generally 
 rather inclined to conceal his insanity and in any case 
 to deny it and defend himself from the imputation, 
 while the simulator, on the contrary, seeks constantly 
 to give evidence of his insanity, he plumes himself 
 on it, so to speak, and is never so extravagant as when 
 he finds himself in the presence of those called to 
 examine and judge him. 
 
 Finally, it must not be forgotten, in expertises of 
 
AllKGED rsrsANiTT. 665 
 
 this kind, that the insanity may have broken out 
 after the commission of the act of which the person 
 is accused; that the subject, already more or less 
 truly insane, may simulate or rather exaggerate his 
 delirium, a phenomenon noticed many times by 
 numerous observers, and it has even been said by 
 some that it is necessary to be more or less insane to 
 simulate insanity; finally, that the prolonged simu- 
 lation of insanity may, in the long run, have an 
 injurious effect on the faculties of the subject, and 
 even disorder more or less profoundly the intellect. 
 Many exposed simulators have admitted that they felt 
 they were becoming insane, and that they would not 
 again begin to play such a part, even to save their 
 lives. "You cannot believe what I have suffered," 
 said the unmasked Derozier to Morel, "I believed I 
 was really becoming insane, and I have more fear of 
 becoming a lunatic than of going to prison. " 
 
 Alleged Insanity. — A misdemeanor or crime has 
 been committed ; the accused person is in the grasp 
 of the law ; he does not pretend to be now insane, 
 but he protests, either personally or through his 
 counsel, that his mind was astray at the time of the 
 act, that he was under the influence of this transient 
 delirium, dream or hallucination, when he committed 
 the act. Undoubtedly, in cases of this kind, a 
 minute analysis of the circumstances that preceded, 
 accompanied or followed the act, may furnish useful 
 indications ; nevertheless, the expert should remember 
 
 Mbht. HEED.— 43. 
 
6G6 MEDICO-UJGAI, PEACTICE. 
 
 expressly that cases of sudden and transitory insanity 
 are rarely obsei'ved, not to say never, in persons ab- 
 solutely sound in mind and body, but tbat such con- 
 ditions are generally the sign or the result of an 
 ignored hereditary predisposition, unrecognized ver- 
 tigo, a threatening meningo- encephalitis, or of a 
 larvated mental derangement, or one in the period of 
 incubation. It is, therefore, indispensable that aU 
 the investigations should be guided by these consider- 
 ations. 
 
 Medico-legal Repoets. — ^His examination fin- 
 ished, it remains for the physician to formulate the 
 result and to make known his conclusions under the 
 form of a written document, which bears, as we 
 have stated, the name of a medico-legal report. It 
 seems unnecessary to reproduce here models of these 
 reports, as I did in the previous edition of this work. 
 I refer those who wish it to the remarkable report 
 of my friend. Dr. Parant, on the murderer of Dr. 
 Mai-chant, to the reports of Blanche, Lasogue, and 
 Legrand du SauUe, and particularly to the acute and 
 excellent reports of my master and friend, M. Motet, 
 some of which are veritable clinical and literary 
 masterpieces, and which unhappily remain always 
 unpublished or scattered in the pages of special 
 reviews. 
 
 Asylums foe Insane Ceiminals. — When, after 
 a medico-legal expertise, the accused, declared irre- 
 
ASTLTJSrS FOE INSANE CEIMINALS. 6G7 
 
 Bponsible, has been the object of an ordinance of 
 non-suit, it yet remains to be asked, what shall be 
 done in regard to this unfortunate. 
 
 Is it necessarj'^, assimilating him with the ordinary 
 insane, to simply confine him in an insane asylum, 
 without having his retention there and his release 
 conditioned by some sjjecial regulations ? Or, on the 
 contrary, is it necessary to separate him from the 
 other insane, and to confine him in a special asylum, 
 like that of Broadmoor in England (criminal lunatic 
 asylum), or in an annex to a prison like that existing 
 in the Maison centrale of Gaillon, France, and to 
 subject his detention and his restoration to liberty 
 to specially devised rules ? 
 
 Such is the important question at present* under 
 discussion in France, in a scientific point of view by 
 the savants, and in a legislative point of view by the 
 commission charged with the elaboration of the new 
 law. 
 
 Without taking sides in this important question 
 we will confine ourselves to saying that the majority 
 incline to the creation of special State asylums for the 
 insane, not criminals, since the two terms are incom- 
 patible, but for lunatics whose tendencies are espe- 
 cially vicious and dangerous. Among the numerous 
 reasons of divers orders which have provoked this 
 solution, there should be specially mentioned the need 
 felt, on account of the present tendency to increase 
 more and more the liberty of the patients in tlie asy- 
 
 *1S01. 
 
668 MEDICO-LEGAL PEACTICB. 
 
 lums, of separating inofEensive insane from those 
 really dangerous, whose presence with the former 
 would suit poorly with the increase of freedom that 
 is proposed. I may add that in the ordinary asylums 
 the criminal insane mingled with the others recover 
 their liberty with a deplorable facility, and that it is 
 not uncommon to meet before the courts irresponsi- 
 ble, incorvigihle recidivistes, who, leaving an asylum 
 for the fifth, sixth, or the tenth time, are arrested at 
 once for a new misdeed, often the same as before, 
 and it is only too fortunate if their morbid tendencies 
 are not found aggravated at each arrest. 
 
 THE END 
 
TABLE OF CONTENTS. 
 
 PAET FIRST. 
 
 MENTAL PATHOLOGY. 
 
 HISTOEICAL. 
 
 First Epoch (Primitive Epocb). Second Epoch — 1. Hippo- 
 cratic period; 2. Alexandrian period; 3. Grseco-Roman 
 period; Asclepiades; Celsus; Aretaeus; Soranus; Ocel- 
 lus Aurelianus; Galen. Third Epoch — 1. The Middle 
 Ages ; 3. The Renaissance ; Paul Zacchias ; Sydenham ; 
 Willis; Bonet; Vieussens; Boerhaave; Sauvages; Lorry; 
 OuUen. Fourth Epoch (Modern Epoch), Pinel, etc. . 1-38 
 
 FIEST SECTION. 
 
 GENERAL PATHOLOGY 
 
 Chaptek I. 
 § I. — Definition 39 
 
 Distinction between Insanity and Mental Alienatioii. 
 Synonymy, Terminology 39-33 
 
 § n.— Etiology 83 
 
 PKEDisposiNa Causes. Civilization, Race. Religious 
 Ideas. Political Events. Wars. Heredity. Age. 
 Sex. Climate. Seasons. Lunar Phases. Civil Condi- 
 tion. Profession. Education 32-44 
 
 Occasional Causes. 1. Moral Causes. Passions, Emo- 
 tions, Imitation. Solitary Confinement. 3. Physical 
 Causes, a. Local Causes. Direct. Sympathetic. 
 b. General Causes. Anaemia. Cachexia. Diatheses. 
 Fevers, c. Physiological Causes, a. Specific Causes, 44-48 
 
670 TABLE OP COXTEKTS. 
 
 § III.— PnoQRESS 48 
 
 Distinction of Insanity into Acute and Clivonic. Begin- 
 ning of Insanity. Passage to tbe Chronic Condition. 
 Different Types of tlie Evolution of Insanity. Kemis- 
 sion. Intermissions. Lucid lutervals 48-51 
 
 § IV.— Duration 51 
 
 Duration of Subacute Insanity. Transitory Insanity. 
 Duration of Acute Insanity. Duration of Clironic In- 
 sanity ^ Dl-53 
 
 § V. — Termin.\tions. — Complications 52 
 
 Recovery. Incurability. Death. Complications. Inci- 
 dental" Disorders. Crises 53-54 
 
 § VI.— Prognosis 54 
 
 Prognosis from tbe Character of the Disease. Prognosis 
 Deduced from the Patient Himself. Relapses 54-57 
 
 § VII. — P.\Tno LOGICAL Anatomy 57 
 
 Pathological .^natomy of Mental Alienation in General. 
 
 Pathological Anatomy of Insanitj'. a. Acute Insanities. 
 
 6. Chronic Insanities 57-60 
 
 Chapter II. 
 
 Symptomatic Elemekts of Mental Alienation. 
 
 §1. Functional Elements 61 
 
 \. Disorders of General Activity. (Excitement, depression) 63 
 3. Disorders of the Psychic Sphere: delusive conceptions; 
 hallucinations (definition, division, nature, hallucin- 
 ations without insanity, hypnagogic hallucinations, 
 hallucinations of lieariug, of sight, of smell and taste, 
 of general sensibilit}', genital hallucinations), illusions 
 (detinition, division, characters, internal illusions, 
 mental illusions), insanity of the sentiments, of the 
 instinct, of acts, impulsions 63-78 
 
 3. Disorders of the Physical Sphere, disorders of nervous 
 functions (sleep, sensibility, motility), disorders of the 
 vegitative functions (circulation, respiration, nutrition 
 and assimilation, secretions, temperature, trophic and 
 vaso-motor functions, appendix 78-111 
 
TABLE OF coNTE:;rrs. C71 
 
 § IL— COKSTITTJTIONAL ElEJIEKTS Ill 
 
 1. Lesions of Organization : psycliic stigmata, physical 
 stigmata (stature, limbs, cranium, face, enceplialon, 
 eyes, vision, cars and hearing, mouth and teeth, genital 
 organs, skin, larynx, voice) 111-119 
 
 2. Lesions of Disorganization 119 
 
 Chapter ni. 
 
 Classification op Mektal Diseases. 
 
 Division of classifications: classification of M. Baillarger, 
 classification of M. Hall, classification of M. Magnan, 
 classification of Hack-Tuke, classification of KrafEt- 
 Ehing; international nomenclature of the Congress 
 of 1889 ; the author's classification 131-144 
 
 SECOiro SECTION. 
 
 SPECIAL PATnOLOGT. 
 
 CnArTEE IV. 
 Mania. 
 
 § I. — Acute Mania (typical mania) 146 
 
 Definition, etiology, symptomatology, termination, course 
 and duration, pathological anatomy, prognosis, diag- 
 nosis, treatment 146-157 
 
 § II. — StJBACTJTE Mania (maniacal excitation) 157 
 
 Definition, etiology, course, duration and termination, 
 
 prognosis, pathological anatomy, diagnosis, treatment, 
 
 157-163 
 
 § III. — Hyperacute Mania (acute delirium) 163 
 
 Definition, etiology, description, pathological anatomy, 
 
 diagnosis, treatment , 163-165 
 
 § IV. — Chronic Mania 165 
 
 § V. — ^Remittent and Intebmittent Mania 166 
 
673 TABLE OF CONTENTS. 
 
 Chapter V. 
 Melancholia oh Ltpehania. 
 
 § I. — Acute Melancholia (typical melancliolia) 170 
 
 Definition, etiology, symptoms, termination, forms, 
 course and duration, pathological anatomy, prognosis, 
 
 diagnosis, treatment 170-183 
 
 § 11. — Subacute JIklancholia, (melancliolic depression) 182 
 Etiology, description, course, duration, termination, 
 
 pathological anatomy, diagnosis, treatment 183-185 
 
 § III. — Hypbkacutb Melancholia (melancholia with 
 
 stupor) 185 
 
 Definition, etiology, description, course, duration, ter- 
 mination, pathological anatomy, treatment 185-187 
 
 § IV. — Chhonic Melancholia 188 
 
 § V. — Remittent and Intermittent Melancholia. . 189 
 
 Chapter VI. 
 
 DoTTBLE Form Insanity. 
 (Circular Insanity, Insanity of Alternating Forms). 
 
 Definition, etiology, description, course, duration, ter- 
 mination, pathological anatomy, prognosis, diagnosis, 
 treatment 191-300 
 
 Appendix. 
 Graphic representation of the generalized insanities. . . . 201 
 
 Chapter VII. 
 
 (Pabtial or Essential Insanities). 
 
 § I. — Generalities 213 
 
 § n. — Progressive Systematized Insanity 218 
 
 Definition, etiology; 1, period of subjective analysis 
 (hypochondriacal insanity) ; 2. period of delusional ex- 
 planation (delusions of persecution or LasSgue's dis- 
 ease), mystic insanity (religious insanity), erotic, 
 political, jealous insanity ; 3. period of transformation 
 of the personality (ambitious insanity), course, dura- 
 tion, termination, prognosis, pathological anatomy, 
 diagnosis, treatment 318-240 
 
TABLE OF CONTENTS. 673 
 
 Chaptbb VIII. 
 
 Degeneracies of Evolution. 
 (Vices of Organization). 
 
 § I. — Disharmonies 243 
 
 111 balanced individuals, original, eccentric individuals, 
 
 243-346 
 
 §11. — Neurasthenias (fixed ideas, impulsions, aboulias) 246 
 
 Generalities, cerebral neurasthenia (obsessions), impul- 
 sim neurasthenias or obsessions (general characters), 
 maladie du doute, fear of objects, agoraphobia, crem- 
 nophobia, acrophobia, potamophobia, claustrophobia, 
 astrapliobia, nosophobia, anthropophobia, mono- 
 phobia, onomatomania, arithmomania, convulsive tics, 
 kleptomania, pyromania, dipsomania, impulsion to 
 suicide and homicide, erotomania) aboulic neurastlienias 
 or obsessions, (general characters, ananabasia, ananas- 
 tasia, anesthia, anupographia, aprosexia,) diagnosis, 
 prognosis, treatment 346-287 
 
 § III. — Phbenasthenias (hereditary insanity, or insanity 
 of the degenerates) 387 
 
 General characters, delusional plirenastJienias or insanity 
 of t7w degenerates (persecuted, ambitious, litigious, 
 erotic and jealous; mystics, regicides, folie a deux), 
 reasoning phrenast/tenias or moral insanity, instinctive 
 phrenastJienia or criminal psychosis, 387-307 
 
 § IV. — Monstrosities 307 
 
 Imbecility, idiocy (division, description, etiology, path- 
 ological anatomy, diagnosis, prognosis, treatment,; 
 cretinism (definition, division, cretinoids, semi-cretins, 
 complete cretins, etiology, nature, treatment, sporadic 
 cretinism or cretinoid idiocy) 807-333 
 
 Degeneracies of Involution. 
 (Disorganization). 
 
 Simple Dementia , 333 
 
 Definition, etiology, description, duration, pathological 
 
 anatomy, treatment 333-837 
 
 Secondary Conditions of Mental Alienation. . 338-330 
 
C74 TABLE OF CONTEXTS. 
 
 CHArTER IX. 
 
 Insanities Associated with Phtsiological Conditions. 
 (Sympathetic Insanities). 
 
 § I. —Insanity of Childhood and Pubeett (hebe- 
 phrenia) 331 
 
 § II. — Insanity of Old Age (senile insanity) 335 
 
 § III.— Insanity op Menstruation (menstrual insanity) 338 
 
 § IV. — Pderper.vl Insanity 340 
 
 1. Insanity of pregnancy 342 
 
 2. Insanity of cliildbed 342 
 
 3. Insanity of the puerperal state 343 
 
 4. Insanity of lactation 344 
 
 Prognosis, treatment 344 
 
 § V — Insanity op the Menopause (climacteric insanity) 345 
 
 Chapter X. 
 
 Iksantties Associated witu Local Viscekal Disease. 
 (Sympatlietio Insanities). 
 
 §1. — Insanity Connected' with Disorders op the Gen- 
 ital and Genito-ukinaky Organs 348 
 
 1. Utero-ovarian insanity 348 
 
 2. Brightic insanity 351 
 
 §11. — Insanity Connected with Disorders op the 
 Digestive Tracts, Diseases of the Liver and 
 Intestinal Worms 355 
 
 1. Insanity connected with diseases of the digestive 
 organs 355 
 
 2. Insanity connected with diseases of the liver and bil- 
 iary passages 358 
 
 8. Insanity connected with helminthiasis (verminous 
 insanity) 359 
 
 § III. — Insanity Connected with Diseases op the 
 Circulatory Appabatus 383 
 
TABLE 01' CONTENTS. 675 
 
 1. Insanity connected with disease of tlxo heart (cardiac 
 insanity) 363 
 
 2. Insanity connected witli diseases of tlic vessels. . . . 365 
 
 § IV. — Insanity Connected with Disease of the 
 Lungs 366 
 
 Chaptee XI. 
 
 Insakities Connected with Genekal Diseases. 
 
 § I. — Insanity of the Infectious Diseases 367 
 
 1. Insanity mnnectedwithncuteinfeclious diseases (variola, 
 erysipelas, cholera, typhoid fever, hydrophobia, grippe 
 
 or influenza 367-878 
 
 2. Insanity connected with climnic infectious diseases, 
 intermittent fever (malarial insanity), tuberculosis, 
 pellagra (pellagrous insanity and pellagrous general 
 paralysis), syphilis (syphilitic insanity, and general 
 paralysis) 878-397 
 
 § II. — Insanity of the Diatheses (diathetic insanity) . 897 
 
 1. Arthritism in general 400 
 
 2. Rheumatism (rheumatic insanity) 406 
 
 3. Gout (gouty insanity) 409 
 
 4. Diabetes (diabetic insanity) 410 
 
 5. Cancer (cancerous insanity) 413 
 
 Chapteh XII. 
 
 Insanities Associated with Disease of the Nehtous Ststem. 
 
 § I. — Insanity Connected with Brain Disease 414 
 
 1. General paralysis 414 
 
 Definition, history, paralytic dementia, prodromic or pre- 
 paralytic period, primary stage, second stage, terminal 
 stage, insanity associated with paralytic dementia 
 (paralytic insanity), course, duration, termination, 
 pathological anatomy, diagnosis, etiology, treatment, 
 
 414-463 
 3. Apoplectic dementia 463 
 
676 TABLE OB" CONTENTS. 
 
 § n. — Insanities Associated with Diseases of the 
 
 Spinal Cord 465 
 
 1. Insanity associated with locomotor ataxia (tabetic 
 
 insanity) 465 
 
 3. Insanity associated with multiple sclerosis 466 
 
 §111. — Insanities Associated with the Neuroses. .467 
 
 1. Insanity associated with epilepsy 467 
 
 a. Epileptic mental condition ; S. Epileptic insanity 467 
 
 2. Insanity associated with hysteria 473 
 
 a. Hysterical mental condition ;S. Hysterical insanity 473 
 
 3. Insanity associated with chorea 477 
 
 a. Choreic mental state ; h. Choreic insanity 477 
 
 4. Insanity connected with paralysis agitans 483 
 
 5. Insanity connected with exophthalmic goitre 482 
 
 Chapter XIII. 
 
 IirSAHFTIES AbSOCIATEB ■with the iNTOXIOiTIONS. 
 
 (Toxic Insanity). 
 
 § I. — Insanity due to alcoholism 485 
 
 Inebriety, subacute alcoholic insanity, acute alcoholic in- 
 sanity, hyperacute alcoholic insanity, alcoholic demen- 
 tia, alcoholic general paralysis and pseudo-general 
 paralysis 485-503 
 
 § II. — Insanity dub to Plu.mbism 503 
 
 Subacnte saturnine insanity, acute saturnine insanity, 
 hyperacute saturnine insanity, saturnine dementia, 
 saturnine pseudo-general paralysis 503-511 
 
 § III. — Insanity due to Morphinism 511 
 
 a. Effects of abuse; b. Effects of abstinence 511-518 
 
 §IV. — Insanity DUE TO Other Intoxications 518 
 
 1. Intellectual disorder's of absinthism 518 
 
 2. " " " etherism 519 
 
 3. " " " chlornlism 519 
 
 4. " " " cocainism 530 
 
 5. " " " oxy-carbonism 531 
 
TABLE OF CONTENTS. 677 
 
 SECOND PART. 
 
 PRACTICAL APPLICATIONS OF MENTAL 
 PATHOLOGY. 
 
 First Section — Medical Pkacticb 533 
 
 Chapter I. 
 
 The Peactical Diagkosis of Mental Alienation. 535 
 
 1. Commemorative 536 
 
 Study of the family, antecedents of the patient 536 
 
 3. Examination of the patient 539 
 
 Chapter II. 
 Medical Opinion as to Necessity or Sbquestbation. 
 
 General considerations, consideration relative to the 
 patient, considerations drawn from the disease, danger- 
 ous lunatics 544-558 
 
 Chapter HI. 
 
 Treatment of the Insane. 
 
 1 1. — Preventive Treatment 559 
 
 § II. — Curative Treatment 560 
 
 1. Oeneral agents: a. Isolation (special establishments, 
 agricultural colonies, family system, county residence, 
 hydrothcrapeutic institute, travels); b. non-restraint 
 (open door asylums, non-constraint). 3. Special agenU: 
 a. Hygienic; J. psychic (moral direction, sug- 
 gestion); c. Physical, (hydrotherapy, electrother- 
 apy, massotherapy, other physical agents, bicycling); 
 d. Surgical (trephining, cerebrotomy, craniectomy, 
 revulsion, thyroidectomy, thyroid grafts, bloodletting, 
 transfusion, hypodermic injections, washing of the 
 stomach, forcible feeding or gavage, drugs (purgatives, 
 sedatives, hypnotics, tonics, antiperiodics, diffusible 
 
 stimulants, emmenagogues, 560-600 
 
 8. T herapeutic formulary 601-609 
 
678 table of contents. 
 
 Chapter IV. 
 Medico-Mentai, Deoutoloot. 
 
 Sexual relations between a deranged person and consort, 
 cLances of heredity of the different members of tlic 
 family of an insane person, marriage of the insane and 
 the relatives of the Insane 610-626 
 
 SECOND BBCTION. 
 
 MEDICO-LEGAL PRACTICE. 
 
 Chapteh I. 
 
 Penax Eesponsibilitt of the Insane. Crimes and Misdemeanobs 
 OF the Insake. 
 
 1. Penal respondMUty of the insane : absolute iiTCspons- 
 
 ibility, partial responsibility, responsibility in the 
 states of remission, intermission, lucid intervals. . 639-637 
 
 2. Crimes and misdemeanoi-s of the insane: general char- 
 
 acters, special characters in the principal morbid 
 forms, in tlie degeneracies, in maniacal states, in 
 melancholic states, in systematized insanity, hebe- 
 phrenia, puerperal insanity, toxic insanities, general 
 paralysis, epilepsy 637-649 
 
 Chapter II. 
 
 Medico-Legal Expebtise, 
 
 Definition, ways and means, inquest, interrogation, direct 
 and continued examination, concealed insanity, simu- 
 lated insanity, alleged insanity, asylum for insane 
 criminals 650-668 
 
INDEX. 
 
 A 
 
 Abonlias (neurasthenias or 
 obsessions). ........ 356, 280 
 
 Absiutliism (mental state 
 
 in) 518 
 
 Acrophobia 360, 370 
 
 Activity, general (disorders 
 
 of) 128, 145 
 
 Adherences, meningo-on- 
 cephallc in general pa- 
 ralysis 444 
 
 Age, general etiology .... 41 
 
 Age, critical 34r) 
 
 Agoraphobia 360, 370 
 
 Aiclimophobia 260, 267 
 
 Alciat 17 
 
 Alcoholic Insanity, 487 ; 
 subacute, 488 ; acute, 
 
 490; hyperacute 493 
 
 Alcoholic dementia 496 
 
 Alcoholic general paral- 
 ysis 497 
 
 Alcoholism 485 
 
 Alexandrine period 1-9 
 
 Alienation, mental, 29; 
 definition, 30 ; different 
 
 from insanity 29 
 
 Alimentation, forced or 
 
 gavagc 596 
 
 Aliments, refusal of in 
 acute melancholia, 178; 
 in gastrointestinal in- 
 sanity 357 
 
 Althaus 585, 091 
 
 Amadei 575 
 
 Ambitious delusions, 234; 
 
 iu general paralysis. . . .439 
 Ambulatory automatism . 278 
 
 Amelung 26 
 
 Amenorrhffia, (insanity in)839 
 
 Anauabasia 381 
 
 Ananastasia 381 
 
 Anatomy, pathological, of 
 mental alienation, 57; of 
 insanity, 58; (acute, 58; 
 
 chronic) 59 
 
 Anffimia (general etiology) 47 
 
 Anesthia 383 
 
 Anosmia 63 
 
 Anglade 460 
 
 Anthropophobia 373 
 
 Anupographia 383 
 
 Apoplectiform attacks in 
 
 general paralysis. .436, 437 
 Apoplectic dementia. .. . 463 
 
 Aprosexia 384 
 
 Aretaeusof CappadocialO, 11 
 Argyll Robertson pupil. . 86 
 
 Arithmoraania 375 
 
 Arnaud 458 
 
 Aruozan 100 
 
 Arnozan and Regis 321 
 
 Arndt 585, 588 
 
 Arthritism (mental state in) 
 400; and general paral- 
 ysis 404 
 
 Arthritic insanity 403 
 
 Asclcpiades 4-5 
 
 Asclcpiades of Bythinia. . 10 
 
680 
 
 DTDEX. 
 
 Asylums, open door 568 
 
 Asylums for criminal in- 
 sane 666 
 
 Asphyxia from food in 
 
 general paralysis 433 
 
 Assimilation and nutrition 96 
 
 Astraphobia 260, 271 
 
 Asystoly (delirium of). . .365 
 Ataxia, locomotor (mental 
 
 state in) 465 
 
 Aubanel ., 436 
 
 Auditory hallucinatians . . 67 
 Autointoxication in in- 
 sanity 108 
 
 Anzouy , . . . .412 
 
 Avicenna 16 
 
 Axenfeld and Huchard. .402 
 Azam 351 
 
 B 
 
 Baillarger, 27, 39, 66, 122, 
 191, 199, 378, 380, 384, 
 
 414, 499, 441 
 
 Baillon 17 
 
 Ball, 44, 64 122, 217, 262, 
 271, 304, 323, 338, 341, 
 
 381, 407, 483 
 
 Ball and Faure 407 
 
 Ball and Regis 404, 457 
 
 Ball and Ritti 64 
 
 Ballet 67, 483 
 
 Bannister and Hektoen ... 36 
 
 Bard 378 
 
 Bartels 377 
 
 Bayle 27, 415 
 
 Bazin 413 
 
 Beard 352, 273, 387 
 
 Beard and Rockwell 608 
 
 Belhomme ; 315 
 
 Bgliferes and Morel-La- 
 
 vallee 395, 459 
 
 Belle and Lemoine . . 182, 605 
 
 Belonephobia 267 
 
 Belous 376 
 
 Benedikt 90 
 
 Bgni Barde 581 
 
 Bennett (Alice) 353 
 
 Bergerio 483 
 
 Bergonie 583 
 
 Berillon 575 
 
 Bernheim 575, 634 
 
 Besnier 409, 437 
 
 Bettencourt - Rodrigues, 
 
 108, 323, 439 
 
 Biaute 381 
 
 Billed 383, 387 
 
 Blanche 666 
 
 Bladder, mental disorder 
 
 from disease of 354 
 
 Blasphematory (mania). .375 
 Bleeding, in treatment of 
 
 insanity 594 
 
 Blocq... 382 
 
 Blood, state of in insanity. 100 
 
 Boerhaave ' 19 
 
 Bonet 17, 18 
 
 Bonnet 376, 460 
 
 Bonnet (H.) andPoincarre447 
 
 Bonnucci 636 
 
 Bordaries 403 
 
 Bouchard.. 107, 108, 898, 409 
 
 Bourneville 315, 331 
 
 BournevUle and SoUier . . 118 
 
 Bouvat 353 
 
 Bouvet 376, 460 
 
 Brain in the insane, 59 ; in- 
 sanity connected -with 
 
 disease of 414 
 
 Briand , 531 
 
 Brierre de Boismont 376 
 
 Brightic insanity 351 
 
 Brosius 396 
 
 Brouardel 369 
 
 Brown-Sequard., 595 
 
 Buccola 388 
 
 Buccola and Morselli, 181, 
 
 594, 605 
 
 Buchanan 35 
 
 BuckniU and Tuke 321 
 
rcTDBX. 
 
 681 
 
 Burkhardt 591 
 
 Burrows 381 
 
 Burrows and Ellis 381 
 
 C 
 
 Cachexia (general etiol- 
 ogy) 47 
 
 Calmeil 27, 417 
 
 Camisole 569 
 
 Cancer 413 
 
 Cardiac insanity 363 
 
 Casper 637 
 
 Castration 593 
 
 Catatonia 186 
 
 Catrou 375 
 
 Causes of insanity, predis- 
 posing, 38 ; occasional, 
 44; physical, 46; local, 
 46: general, 47; physio- 
 logical, 48; specific, 48 ; 
 
 moral 44 
 
 Celsus 9, 10, 11 
 
 Cerebrotomy 591 
 
 Cerise 317 
 
 Chalmers da Costa 530 
 
 Chamhard 438 
 
 Charcot... 375, 409, 480, 483 
 Charcot and Magnan.374, 383 
 
 Chardon 108,367 
 
 Charpentier 110 
 
 Chaslin 80 
 
 ChasHQ and Seglas 186 
 
 Chevalier-Lavaure 109 
 
 Chiaruggi 34 
 
 Childbed, insanity of 343 
 
 Chloralism (mental state 
 
 in) 519 
 
 Chlorof ormism (mental 
 
 state in 519 
 
 Cholera (insanity from) . . 370 
 Chorea (insanity from) . . . 477 
 Chorea, Huntington's (men- 
 tal state of) 480 
 
 Ment. Hbd.— 43. 
 
 Choreic insanity 477 
 
 Ohouppe 530 
 
 Christian 463 
 
 Christian and Ritti 458 
 
 Circular insanity 191 
 
 Circulation (disorders of in 
 
 insanity) 93 
 
 Civilization (general etiol- 
 ogy) 33 
 
 Civil condition ( general 
 
 etiology) 43 
 
 Classification, 131 ; of 
 Baillarger, 133; of Ball, 
 133; of Magnan, 133; of 
 Hack Tuke, 134; of 
 Krafit-Ebing, 134; of the 
 
 author 136, 139 
 
 Claustrophobia 371 
 
 Climateric (insanity of) . . . 345 
 Climate (general etiology) 41 
 
 Clitoridectomy 593 
 
 Clouston 381, 409 
 
 Clouston and Skae 388 
 
 Cocainism (mental state 
 
 in) 530 
 
 Coelius Aurelianus..3, 10, 13 
 
 CoUn 476 
 
 Colonies, agricultural .... 563 
 Complications of insanity 53 
 Conceptions, delusive. 63, 333 
 
 Congestive attacks 436 
 
 Conolly 38 
 
 Convulsibility, reaction of 90 
 
 Coprolalia 375 
 
 Cordes 370 
 
 Corvisart 363 
 
 Cotard 188, 410 
 
 Cranium in the insane. . . . 113 
 
 Craniectomy 316 
 
 Cremnophobia 370 
 
 Cretinoids ...316 
 
 Cretinism, 317 ; endemic, 
 319; sporadic, 330; ex- 
 perimental 333 
 
 Cretinoid idiocy 330 
 
683 
 
 mDEX. 
 
 Crimes of the insane, 637 ; 
 general cliaracter of, 637 ; 
 special characters of in 
 the principal morbid 
 types, 639; in degenera- 
 tions, 640; in mania, 642; 
 in melancholia, 643; in 
 systematized insanity, 
 644: hebephrenia, 646; 
 in puerperal insanity, 
 646; in toxic insanity, 
 647 ; in general paralysis, 
 
 647 ; in epilepsy 649 
 
 Criminal psychosis 305 
 
 Criminals, insane, asylums 
 
 for 666 
 
 Criminal born 305 
 
 Crises in insanity 53 
 
 Crystallophobia 267 
 
 CuUen 20 
 
 CuUerre 627 
 
 Curling 321 
 
 Cuylitz 114 
 
 B 
 
 Dagonet 412 
 
 Dangerous lunatics 555 
 
 Daquin 24 
 
 d'Astros 363 
 
 Davies, Pritchard 463 
 
 Death in insanity 53 
 
 Debove 483 
 
 Decorse 412 
 
 Duplicated hallucinations 65 
 Duplication of personality 69 
 
 Defect of equilibrium 242 
 
 Definitions of insanity ... 29 
 Degenerates, insanity of. . 287 
 Degeneracies of evolution, 
 133, 241; of involution, 
 140, 323; crimes, &c. in, 640 
 Degeneracy, stigmata of. 112 
 
 Delasiauve 315, 507 
 
 Delaye 27, 415 
 
 Delirium, acute 162 
 
 Delirium tremens 492 
 
 Delmas (of Bordeaux) 677 
 
 Dementia, simple, 323 ; 
 maniacal, 439 ; melan- 
 choliac, 440; ambitious, 
 439; alcoholic, 496; sat- 
 urnine 507 
 
 Dental stigmata 118 
 
 Deontology, medico-men- 
 tal 610 
 
 Depression 63 
 
 Descourtis 72 
 
 Deux,folie A. 393 
 
 Deventer 364 
 
 Devouges 508 
 
 Diabetes, insanity of 410 
 
 Diagnosis of mental aliena- 
 tion 525 
 
 Diatheses, 397; general 
 etiology, 47 ; insanity 
 
 of 397 
 
 Dieulafoy 353 
 
 Digestive disorders in the 
 
 insane 97 
 
 Digestive tracts, insanity 
 
 due to troubles of 355 
 
 Disharmonies 134, 343 
 
 Digoy 480 
 
 Diphtheria, insanity due 
 
 to 869 
 
 Dipsomania 377 
 
 Double form insanity. . . .191 
 
 Doubting insanity 261 
 
 Doutrebente 51 
 
 Dreams 79 
 
 Dujardin-Beuametz 608 
 
 Dumontpallier 575 
 
 Duncan, J. M 888 
 
 Duplaix 863 
 
 Dupuytren's disease in gen- 
 eral paralysis 404 
 
 Duration of insanity. .... 50 
 
nojEx. 
 
 683 
 
 Dynamy, functional, in 
 general paralysis 439 
 
 Dysmenorrhoea, insanity 
 from 339 
 
 E 
 
 Ears in the insane 117 
 
 Echo of thought 69, 333 
 
 Echolalia 376 
 
 Echomatism 876 
 
 Eckokinesis 376 
 
 Education (general etiol- 
 ogy) 44 
 
 Electrotherapeutics 583 
 
 Elements, fear of 360 
 
 Elements, symptomatic of 
 
 mental alienation 61 
 
 Ellis and Burrows 381 
 
 Emotionalism in apoplectic 
 
 dementia 464 
 
 Emotional insanity 74 
 
 Emotions (general etiol- 
 ogy) 74 
 
 Ependymal granulations in 
 
 general paralysis 445 
 
 Epidemics of religious in- 
 sanity 303 
 
 Epilepsy (legal medicine 
 
 of) 649 
 
 Epileptiform attacks 437 
 
 Epileptic insanity 467 
 
 Epileptics, mental state of 467 
 
 Equilibrium, sense Of 85 
 
 Erasistratus 9 
 
 Erb 583 
 
 Erlenmeyer 530 
 
 Erotic insanity 833 
 
 Erotomania 879 
 
 Erysipelas, insanity from . 369 
 Esquirol 3, 86, 87, 65, 
 
 363, 856, 308, 415 
 Establishments, special.. 561 
 Etherism, mental state in. 519 
 Etiology, general 33 
 
 Evolution, lesions of.. 133, 341 
 
 Ewart, (C. Theo) 591 
 
 Eccentricity 343 
 
 Excitation 63 
 
 Excitement, maniacal 157 
 
 Exhibitionists 379 
 
 Expertise, medico-legal, 650; 
 definition of, 650; ways 
 and means of, 654; in- 
 quest, 654; interrogation, 
 655; direct observation, 
 657; concealed insanity, 
 657; simulation, 658; 
 forms simulated, 658 ; 
 methods of simulation, 
 659 ; means of detection, 
 661; alleged insanity. . .663 
 Eyes, condition of, in the 
 insane 84 
 
 F 
 
 Face in the insane 113 
 
 Fagge, Hilton 331 
 
 Falret, Sr 87, 191, 198 
 
 Falret, Jules 38, 353, 363, 
 
 388, 304, 415 
 
 Falret. Jules, and LasSgue304 
 
 Faradization 5S7 
 
 Fassy 410 
 
 Faure 407 
 
 Fears, morbid 360 
 
 Fere 66, 109, 117 
 
 Perri ,.637 
 
 Ferrus 38 
 
 Feyal 108 
 
 Fevers, (general etiology). .47 
 Fever, intermittent, insan- 
 ity from 378 
 
 Fever, typhoid 370 
 
 Fleming-. 407 
 
 Fodere 38 
 
 Folie d deux 40, 45, 304 
 
 Fontan and Segard 575 
 
 Forel 575 
 
684 
 
 INDEX. 
 
 Fournler 389 
 
 Poville, Sr 37 
 
 Foville, Achille 239 
 
 Franklinization 588 
 
 Fraser 407 
 
 Friedreich 26, 381 
 
 Friese and Regis 4H2 
 
 Frigerio 117 
 
 Fiirstner 335 
 
 G 
 
 Gairdner 409 
 
 Galen 3, 15 
 
 Galvanization, 583 ; cerebral 
 585 ; of the sympathetic . 586 
 
 Gamier 316 
 
 Garofalo 307 
 
 Garrod 409 
 
 Gardiner Hill 38 
 
 Gavage 596 
 
 Gemellary insanity 304 
 
 Genital organs, state of, in 
 
 insanity 118 
 
 General etiology 33 
 
 Geoflroy 413 
 
 Georget 27, 38, 415 
 
 Gheel 563 
 
 Gilles de la Tourette 375 
 
 Giacchi 117 
 
 Gintrac 386 
 
 Girma 463 
 
 Glycosuria, insanity from. 410 
 Goitre, exophthalmic, men- 
 tal state of 483 
 
 Goldsmith 889 
 
 Gout, insanity from 409 
 
 Gouty insanity 409 
 
 Graphic representations of 
 generalized insanities. .301 
 
 Greding 356 
 
 Greenlees, Duncan 93 
 
 Griesinger, 36, 378, 412 
 
 Grinding of teeth in general 
 paralysis 433 
 
 Grippe, insanity from. . . .376 
 
 GrisoUe 504 
 
 GrUbelsucht 263 
 
 Guirabail 513, 517 
 
 Guislain 28, 413 
 
 Gynephobia 373 
 
 H 
 
 Haschischism, mental state 
 
 of 530 
 
 Hallopeau 530 
 
 Hallucinations, 65 ; without 
 insanity, 67; of hearing, 
 67; of sight. 70; of smell 
 and taste, 71 ; of general 
 sensibility, 71 ; genital. . . 71 
 
 Hammond 358 
 
 Haslam 415 
 
 Heart disease, insanity of. . 363 
 
 Hebephrenia 331 
 
 Heinroth 36 
 
 Hektoen and Bannister. . . 36 
 
 Hellebore 8 
 
 Helminthiasis, insanity 
 
 from 359 
 
 Hsematoma auris 434 
 
 Heinroth ' 36 
 
 Hematophobia 367 
 
 Hepatic insanity 858 
 
 Hereditary insanity 387 
 
 Heredity, general etiology, 
 38 ; in general paralysis, 
 
 456; chances of 613 
 
 Herophilus 9 
 
 Hesselbach 356 
 
 Heyden (von) 585 
 
 Hippocrates 1, 5 
 
 Hitzig 585 
 
 Hoflbauer 637 
 
 Hoffmann 497 
 
 Holthof 356 
 
 Homicidal, impulse 378 
 
 Horsley 333 
 
 Huchard 865, 877 
 
INDEX. 
 
 685 
 
 Huchard and Axenfeld. . .402 
 
 Hughes 585 
 
 Hurd 300 
 
 Hydrophobia 376 
 
 Hydrotherapy , 577 
 
 Hydrotherapeutic insti- 
 tutes 565 
 
 Hygienic agents 569 
 
 Hy pnogogic hallucinations 67 
 
 Hypnotism 574 
 
 Hypochondriacal insanity. 319 
 Hypochondria in general 
 paralysis 440 
 
 Ideas, fixed 346 
 
 Ideler 36 
 
 Idiocy 308 
 
 111 balanced Individuals . . 343 
 
 Illusions 73, 73 
 
 Imbecility 807 
 
 Imitation 44 
 
 Imprisonment, solitary. . . 45 
 
 Impulsions 77, 346 
 
 Incurability 53 
 
 Indecisions (obsessions). ..361 
 
 Induced insanity 304 
 
 Inebriety 485 
 
 Infectious diseases, insanity 
 
 of 367 
 
 Infectious diseases, acute. 367 
 
 " chronic. 378 
 
 Influenza, insanity of. . . .376 
 
 Infancy, insanity in 331 
 
 Insanity, intellectual.. 63, 313 
 Insanity of feelings, emo- 
 tions 62 
 
 Insanity, of instinctive ... 75 
 
 " acts 76 
 
 " double form.. 191 
 
 " definition 31 
 
 ' ' etiology 83 
 
 " course 48 
 
 " duration 51 
 
 Insanity, of termination ... 33 
 " " complications. 53 
 " " prognosis .... 54 
 Insanity, pathological an- 
 atomy 57 
 
 Insanity, generalized. .. .145 
 Insanity, partial or system- 
 atized 313 
 
 Insomnia 79 
 
 Intermissions 51 
 
 Intermissions, responsi- 
 bility in 634 
 
 Intervals, lucid 51 
 
 " " responsi- 
 bility in 634 
 
 Intoxications, insanity 
 
 from 485 
 
 Involution, lesions of . . . .333 
 lophobia 360 
 
 Jacoby 36 
 
 Jealous insanity 333 
 
 Jennings 513, 517 
 
 JofEroy 353,377, 483 
 
 K 
 
 Kahlbaum 186 
 
 Kaleidoscopic hallucina- 
 tions 478 
 
 Kandinsky 67 
 
 Keraval and Nercam 603 
 
 Kiernan 389 
 
 King 480 
 
 Kinnier 389 
 
 Kleptomania 276 
 
 Koppen 103, 352 
 
 Ko valewsky 577, 590 
 
 Krojpelin 372, 377, 380 
 
 Krafft-Ebingl22, 279, 288, 296 
 Kussmaul 324 
 
686 
 
 INDEX. 
 
 Lacaille 498 
 
 Lacassagne 307 
 
 Lactation, insanity of . . . .34:4 
 
 Ladame 877 
 
 Lailler 603 
 
 LallementandMabille. . . .409 
 
 Laucereaux 393, 495, 531 
 
 Lande 339 
 
 Laadouzy 483 
 
 Langermann 36 
 
 Lannelongue 316, 333 
 
 Lannois 117 
 
 Lasfegue. .38, 314, 334, 353, 
 
 415, 436, 488 
 
 LasSgue and Falret 304 
 
 Laurent (A.) 664 
 
 Laurent (Eraile) 118 
 
 Laveran 378 
 
 Lecorche 409 
 
 Legoyt and Ogle 43 
 
 Legrain 496,518 
 
 Legrand du Saul le. ..303, 
 
 388, 396, 304, 410, 461 
 
 Leiter 563 
 
 Leioyer 17 
 
 Lelut 45 
 
 Lumoinc. 378,381,400, 401,405 
 
 Lemoine and Bulle 183 
 
 Lemoine and Chaumier. ..378 
 Lemoine and Huyghes, 
 
 398, 403 
 
 Lepois, Nicliolas 17 
 
 Leudet (Lucien) 383 
 
 Leuret 407 
 
 Lichtwitz 381 
 
 Liebmann 396 
 
 Liegeois 634 
 
 Lierseux, colony of 563 
 
 Linas 415 
 
 Litigious insane 396 
 
 Liver, disease of 358 
 
 Lombroso 305 
 
 Lorry 20, 409 
 
 Lucas 618 
 
 Lucid intervals 50 
 
 Lunier 415 
 
 Lunar phases, influence 
 
 of 41 
 
 Lutaud 634 
 
 Luys 353, 314 
 
 Lypemania (see melan- 
 cholia) 170 
 
 M 
 
 Mabille 435 
 
 Mabille and Lallement, 
 
 403, 409 
 
 MacDonald 533 
 
 Magnan, 133, 131, 313, 
 
 358, 377, 388, 393 
 Magnan and Charcot. . . .374 
 
 Magnan and Saury 530 
 
 Mairet 103, 333, 377 
 
 Maladies, incidental 58 
 
 Mandragora 8 
 
 Maniacs, crimes of 643 
 
 Mania, acute 146 
 
 " subacute 157 
 
 ' ' hyperacute 163 
 
 " chronic 165 
 
 " remittent, &c 166 
 
 Manouvrier 307 
 
 Marandon de Monty el, 304, 
 371, 375 
 
 Marc 38 
 
 Marce, 28, 33, 96, 341, 436, 
 
 456, 477 
 
 Marchal de Calvi 410 
 
 Marechal 407 
 
 Marriages, of insane, &C.631 
 
 Marro 103 
 
 Martin (Raymond) 483 
 
 Mask, paralytic 433 
 
 Massotherapy 590 
 
 Maudsley 637 
 
 Measles, insanity connect- 
 ed with 369 
 
INDEX. 
 
 687 
 
 Medico-legal practice 627 
 
 Melancholia 170 
 
 varitiesof....l70 
 Melancholiacs, crimes of. 643 
 
 Mendel 103 
 
 Menopause, insanity of.. 345 
 
 Menstruation 338 
 
 Mesohede 271 
 
 Mesnet 407 
 
 Metallo therapy 367 
 
 Metz 377 
 
 Meynert 483 
 
 Mickle (W. J.) 86, 366, 388 
 
 390, 455 
 Myers (A. T.) and Percy 
 
 Smith 575 
 
 Mierzejewski 445 
 
 Migrators (insane) 336 
 
 Misdemeanors 637 
 
 Misophohia 387 
 
 Moment, lucid 50 
 
 Monoideism 258 
 
 Monophobia 373 
 
 Monstrosities 134, 307 
 
 Montaigne 17 
 
 Montigya 661 
 
 Moon, phases of 41 
 
 Moral insanity 304 
 
 Moral treatment 571 
 
 Moreau(de Tours).. 477, 618 
 Moreau (de Tours) Paul. .531 
 
 Moreaux 498 
 
 Morel, 27, 131, 213, 255, 
 
 283, 388, 487 
 
 Morel, Jules 122 
 
 Morel-Lavallee and Beli6res, 
 
 388, 295 
 
 Morgagni 30 
 
 Morphinism 511 
 
 Morphinomacia 513 
 
 Morselli, 78, 100, 136, 353, 
 387 
 
 MorseUi and Buccola 181 
 
 Motet 395 
 
 Mobility, disorders of. .. . 89 
 
 Mystics, insanity of 329 
 
 Mystics 301 
 
 Myxoodema 333 
 
 Myxoedematous idiocy. . .331 
 
 Nasse 26, 497 
 
 Negroes, insanity in 34 
 
 Nercamand Keraval 603 
 
 Nervous system, insanity 
 
 in diseases of 414 
 
 Neurasthenias, 246 ; gener- 
 alities, 346 ; cerebral, 
 348 ; on impulsive obes- 
 sions, 358; on aboulic 
 obessions, 380 ; acute, 
 
 347; and arthritism 403 
 
 Neurosis, insanities due to. 467 
 
 Newington (Hayes) 389 
 
 Newt 586 
 
 Nicotinism 520 
 
 Nomenclature, internation- 
 al 125 
 
 Noorden, van 98, 110 
 
 Non-restraint 568 
 
 Nosophobia 371 
 
 Nutrition, disorders of. . . 96 
 
 O 
 
 Obersteiner 575 
 
 Objects, fear of 267 
 
 Obsessions, 348, 358; im- 
 pulsive, 274; aboulic. .380 
 Oculo-pupillary disorders 
 in general paralysis. . . .438 
 
 Ogle and Legoyt 43 
 
 Oniomania 378 
 
 Oneiric hallucinations 308 
 
 Onomatomania 374 
 
 Ord 333 
 
 Originality , . . .343 
 
 Oxy-carbonism 531 
 
688 
 
 INDEX. 
 
 Pachoud 98, 110 
 
 Paludism, insanity from. 378 
 Paralysis, general, 414; def 
 initions, 414 ; history, 
 414 ; paralytic dementia, 
 419 ; prodomic, 419 ; first 
 stage, 425 ; second stage, 
 431; terminal stage, 432; 
 insanity of, 438; expres- 
 sive, 439; melancholiac, 
 depressive, hypoclion- 
 driac, 440; latent, 444; 
 course, duration, termina- 
 tion, 443 ; ascending, 443 ; 
 pathological anatomy, 
 444; diagnosis, 448; eti- 
 ology, 453 ; treatment, 
 461 ; conjugal , 4 5 8; 
 syphilitic, 460 ; prema- 
 ture or precocious, 456 ; 
 late, senile or atheromat- 
 ous, 456 ; crimes, &c. , in. 467 
 Paralysis, pseudo-general, 
 pellagrous, 387; syphil- 
 itic, 391; alcoholic, 497; 
 saturnine, 507 ; diag- 
 nosis 509 
 
 Paralytic dementia. .419, 438 
 Paranoia, 217; secondary, 
 318 ; rudimentary, 137 ; 
 
 primary 218 
 
 Parant 388, 482 
 
 Parchappe 28, 415 
 
 Passions (general etiology), 44 
 Pathophobia (in noso- 
 phobia) 271 
 
 Paulof Egina 16 
 
 Pellagra, insanity of 386 
 
 Pellagrous general paral- 
 ysis 387 
 
 Peretti 480 
 
 Perfect 415 
 
 Persecutors, insane, 226 ; 
 persecuted, 223; ambi- 
 tious, 234 ; litigious, 296 ; 
 erotic and jealous, 397 ; 
 mystic, 301; political. ... 303 
 Persecution, insanity of, 
 or Lasfegue's disease . . . 221 
 
 Pertyphic insanity 371 
 
 Peter 383, 483 
 
 Phlebotomy 
 
 Phrenasthenias, 387 : delu- 
 sional, {delire des degen- 
 ires), 389; reasoning, 
 (moral insanity), 304 ; in- 
 stinctive, (criminal psy- 
 chosis), 305; political... 303 
 
 Phrenitls 6 
 
 Phthisis, insanity of 381 
 
 Physiological states, insan- 
 ity associated with 331 
 
 Pichon 512, 518 
 
 Pick 377 
 
 Pierret 110, 352, 376, 465 
 
 Pinel 2, 23, 24, 25 
 
 Pitres 295 
 
 Places, fear of 270 
 
 Planes 458 
 
 Plater, Felix 17 
 
 Poincarre and Bonnet. . . .447 
 
 Political insanity 232 
 
 Political events (general 
 
 etiology) 37 
 
 PopofE 447 
 
 Post-typhic insanity 373 
 
 Potamophobia. , 370 
 
 Pettier ; 296 
 
 Pulse in insanity 94 
 
 Practice, medical, in insan- 
 ity, 533; medico-legal... 627 
 Pre-delusional period of 
 
 general paralysis 420 
 
 Pregnancy, insanity of. . .340 
 Preparalytic period of gen- 
 eral paralysis 419 
 
INDEX. 
 
 689 
 
 Professions (general etiol- 
 ogy)... 43 
 
 Prognosis of insanity. ... 54 
 Propensities (obsessions).. 274 
 
 Prost 360 
 
 Psycho-motor hallucina- 
 tions 66 
 
 Puberty, insanity of 831 
 
 Puerperal insanity, 340; 
 
 crimes in 646 
 
 Purgatives in treatment of 
 
 insanity 599 
 
 Pussln 28 
 
 Pyromania 277 
 
 Q 
 
 Querulanten - "Wahnsinn, 
 (see litigious insanity).. 296 
 
 R 
 
 Race (general etiology). . . 33 
 Rabies, insanity connected 
 
 with 876 
 
 Reports, medico-legal. . . .666 
 
 Raymond 352 
 
 Recovery 53 
 
 Relapses in insanity 56 
 
 Reflexes, disorders of, 86; 
 in general paralysis, 421 
 
 Regicides 303 
 
 Regis 100, 303 
 
 Regis and Arnozan 100 
 
 Regis and Ball 404 
 
 Regis and Friese 462 
 
 Reinhardt 98 
 
 Religious insanity 229 
 
 Religious ideas (general 
 
 etiology) B7 
 
 Remissions, 50 ; responsi- 
 bility in, 684 ; in general 
 paralysis, 444; in alco- 
 holic pseudo-paralysis. 502 
 Renaissance 2, 17 
 
 Rendu 488 
 
 Requin 415 
 
 Respiration, disorders of in 
 
 insanity 95 
 
 Responsibility, penal, of 
 the insane, 628; partial 
 or attenuated, 628 ; in re- 
 missions, intermissions 
 and lucid intervals. . . .634 
 
 Reverdin 592 
 
 Revulsion 592 
 
 Rhazes 16 
 
 Rheumatism, insanity con- 
 nected with 406 
 
 Ribot 74, 137, 255, 258 
 
 Riel 303 
 
 Ritti., 191 
 
 Ritti and Christian 458 
 
 Riva 288 
 
 Robinson 831 
 
 Roger 482 
 
 Rougier 465 
 
 RouiUard 403 
 
 Rousset 499 
 
 Rupophobia or miso- 
 phobia 267 
 
 Rush 28, 376 
 
 S 
 
 Salgo 582 
 
 Sander 288, 291 
 
 Sandon 294 
 
 Sandras 415 
 
 Santos, de 410 
 
 Saturnism, insanity from . 503 
 Saturnine insanity (sub- 
 acute) 505; acute, 505; 
 hyperacute, 506 ; dement- 
 ia, 507 ; pseudo-general 
 
 paralysis 507 
 
 Saury 520 
 
 Saury and Magnan 520 
 
 Sauvages 20 
 
690 
 
 nJDEX. 
 
 Sauze and Aubanel 413 
 
 Savage.... 389, 394, 483, 519 
 Scarlatina, insanity from. 369 
 
 Schlager 371 
 
 Schrffider van der Kolk, 
 
 26, 381 
 
 Schule 384 
 
 Sclerosis, multiple (mental 
 state in) 466; diagnosis 
 of, 466; with general 
 
 paralj'sis 466 
 
 Seasons (general etiology) 41 
 
 Sebastian 378, 880 
 
 Secretions (disorders of) in 
 the insane, 97 ; salivary, 
 97; gastric, 98; biliary, 
 99; sudral, 99; sebace- 
 ous 100 
 
 ;las...67, 83, 330, 284, 520 
 
 jlas and Chaslin 186 
 
 Seguin 815 
 
 Semal(of Mons) 46 
 
 Senac 409 
 
 Senile insanity 335 
 
 Scnnert 17 
 
 Sensibility, (disorders o^ 
 in the insane, 80; cuta- 
 neous, 80; electric, 83; 
 magnetic, 82; metallic, 
 82; meteoric, 82; gusta- 
 tory, 83; olfactory, 83; 
 auditory, 83 ; visual, 84 ; 
 muscular, 84; organic, 
 86; in general paralysis. 429 
 
 Seppilli 489 
 
 Sequestration (medical opin- 
 ion as to need of) 551 ; 
 motives of, 548 ; of dan- 
 gerous lunatics 551 
 
 Sergi 807 
 
 Sex (general etiology). .. . 41 
 Sexual relations of the in- 
 sane 610 
 
 Shaw 462 
 
 Simon ..,,,,,,,, , . . .407 
 
 Simon (Max) 637 
 
 Simson 407 
 
 Simulated insanity 658 
 
 Simultaneous insanity (folie 
 
 d deux) 292 
 
 Sitophobia, 98; in acute 
 
 melancholia 175 
 
 Skae 381, 388 
 
 Skae and Clouston 388 
 
 Skatophagia 76 
 
 Skin, in the insane 99 
 
 Sleep, (disorders of) in the 
 
 insane 79 
 
 Smith, Percy, and A. T. 
 
 Myers 575 
 
 Smyth, Johnson 101 
 
 Snell 396 
 
 Solbrig 35 
 
 Sollier 311 
 
 Soranus of Ephesus 18 
 
 Speech, embarrassment of 
 
 in general paralysis. . . .425 
 Sphincters, relaxion of in 
 
 general paralysis 433 
 
 Spinal cord, insanity in. 465 
 
 diseases of 465 
 
 Spitzka 334 
 
 Stahl 35 
 
 Stewart, Grainger 388 
 
 Stigmata, psychic, 113; 
 physical, 118; stomach, 
 
 lavage of 
 
 Strambio 886 
 
 Strump riva, cachexia. .322 
 Stupor, melancholia with. 185 
 Suette, miliary, insanity in. 369 
 Suggestion, in treatment 
 
 of insanity 574 
 
 Suicide in acute melan- 
 cholia, 175; in neuras- 
 thenia, 278 ; indirect 643 
 
 Surgical treatment of in- 
 sanity 
 
 Svetlia 583 
 
 Swedenborg 302 
 
moBz. 
 
 691 
 
 Sydenham 18, 378, 409 
 
 Sylvius de la B8e 17 
 
 Sympathetic (causes) gen- 
 eral etiology, 47 ; insan- 
 ities, 145, 328, 331. 
 Syphilis (insanity connect- 
 ed with) 388; and gen- 
 eral paralysis 392 
 
 Systematized insanity, pro- 
 gressive, 132; original.. 291 
 
 T 
 
 Tabetic insanity 465 
 
 Taguet 297 
 
 Tamburini 66, 252, 255 
 
 Tanquerel des Plahches, 
 
 504, 507 
 
 Tanret 609 
 
 Tarde 307, 627 
 
 ■Tardieu 
 
 Targowla 447 
 
 Teissier 403 
 
 Temperature in insanity . . 104 
 
 Thyroidectomy 592 
 
 Thyroid grafting 322 
 
 Tics, convulsive 275 
 
 Tigges 585 
 
 Todd 409 
 
 Tonnini... 288 
 
 Toucher, delire du 262 
 
 Toxic insanities, 485 ; 
 
 crimes, &c., in 647 
 
 Treatment of insanity, 559; 
 preventive, 559; curat- 
 ive, 560; in a special 
 hospital, 561 ; in farm 
 colonies (family system) 
 563 ; in country houses, 
 564; in water cures, 562; 
 by travel. 566 ; by non-re- 
 straint, 568; by hygienic 
 agents, 56'9; by psychic 
 agencies, (moral treat- 
 ment) 571; suggestive, 
 
 574; by physical agencies 
 (hydrotherapy 576; elec- 
 trotherapy) 576 ; by sur- 
 gical agencies (trephin- 
 ing, cerebrotomy, crani- 
 ectomy) 591 ; revulsion, 
 593; thyroidectomy, 593; 
 thyroid grafts, 593; cas- 
 tration, 593; clltoridect- 
 omy, 593 ; bleeding, 
 transfusion, 594; hypo- 
 dermic injections, 594: 
 lavage of stomach, 695; 
 by pharmaceutical 
 agents (purgatives, 599; 
 sedatives and hypnotics, 
 600 ; tonics, antiperiod- 
 ics, emmenagogues, 600 ;) 
 therapeutic formulary . 601 
 
 Transfusion of blood 594 
 
 Trelat 27 
 
 Tremor in general paraly- 
 sis 436 
 
 Trephining 591 
 
 Tricophobia 367 
 
 Trophic disorders, in the 
 insane, 105; in general 
 
 paralysis 433 
 
 Trousseau 413 
 
 Tuberculosis 381 
 
 Tuczek 447 
 
 Tuke ("William) 24, 105 
 
 Tuke (Hack) 122 
 
 Tuke ahd Bucknill 132 
 
 Tuke (Batty) 462 
 
 Typhoid fever, insanity 
 in 370 
 
 U 
 
 Unilateral hallucinations. 66 
 
 Uraemia (delirious) 352 
 
 Urine in the insane 102 
 
 Utero ovarian insanity... 348 
 Untidy patients 570 
 
692 
 
 Vessels, psychic disorders 
 
 in diseases of 365 
 
 Vaisselle 403 
 
 Vallon 435 
 
 Van Swieten 19 
 
 Variola, insanity from. . .267 
 VasD-motor disorders in in- 
 sanity 105 
 
 Vegetative functions, dis- 
 orders of 73 
 
 Velocipeding 590 
 
 Verga 370 
 
 Vering 26 
 
 Verminous insanity 359 
 
 Verneuil 413 
 
 Vesanias 139 
 
 Vetault 634 
 
 Vieussens 19 
 
 Vigouroux 387 
 
 Viscera, insanity from local 
 
 disease of 348 
 
 Vix 361 
 
 Vizioli 575 
 
 Voisin (Felix) 37, 815 
 
 Voisin (Auguste) 83, 575, 
 
 594, 664 
 Voyages 566 
 
 W 
 
 Wars (general etiology). . . 37 
 
 Weir-Mitchell 286 
 
 Westphal 370 
 
 Wichmann 356 
 
 Wier 17 
 
 Wiglesworth 350 
 
 Wille 308 
 
 Willis 18 
 
 Winternitz 583 
 
 Woelcken 531 
 
 Wolf 94 
 
 Writing of insane, 93 ; in 
 general paralysis, .... 437 
 
 Tvon 601, 603 
 
 Z 
 
 Zacchias, Paul 17 
 
 Zambaco 393 
 
 Ziehen 81 
 
 Zoophohia 374 
 
I 
 
 I 
 
 i 
 
 i