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A TEXT-BOOK OF INSANITY 
 
A TEXT-BOOK OF 
 
 INSANITY 
 
 AND OTHER MENTAL DISEASES 
 
 BY 
 
 CHARLES ARTHUR MERCIER 
 
 M.D., F.R.C.P., F.R.C.S. 
 
 lATE LECTURER ON INSANITY AT THE MEDICAX SCHOOLS OV 
 
 THE WESTMINSTER HOSPITAL, CHARING CROSS HOSPITAL 
 
 AND THE ROYAL FREE HOSPITAL 
 
 Author of ^'Sanity and Insanity" ; " Psychology, Normal and Morbid' 
 " Conduct and Its Disorders " ; "A New Logic " ; " Criminal 
 EesponsiMlity " ; " Crime and Insanity," etc. 
 Swlney Prizeman for 1909 
 
 SECOND 
 
 EDITION 
 
 ENTIRELY BE-WEITTEN 
 
 NEW YORK : THE MACMILLAN COMPANY 
 
 LONDON 
 GEORGE ALLEN AND UNWIN, LTD- 
 
 19U 
 
First Edition . Feb. 1902 
 Second Edition . Sept. 1914 
 
 
TO 
 
 SIR THOMAS CLIFFORD ALLBUTT, K.C.B., 
 
 M.A., M.D., LL.D., D.SC, F.R.S. 
 
 REGIUS PROFESSOR OF PHYSIC IN THE UNIVERSITY OF CAMBRIDGE 
 
 IN RECOGNITION OF HIS EFFORTS 
 
 TO PROMOTE THE SCIENTIFIC STUDY OF INSANITY 
 
 DURING HIS TOO BRIEF TENURE 
 
 OF THE OFFICE OF 
 
 COMMISSIONER IN LUNACY 
 
PEEFACE 
 
 TO THE FIEST EDITION, 1902 
 
 Year by year the students to whom I lecture ask me 
 what book on insanity they ought to study, and year 
 by year I have to recommend books which I know to 
 be excellent in themselves, but which I feel are of such 
 bulk and volume as to be out of proportion to the time 
 which students can profitably give to an outlying 
 subject, and to the vast mass of other material which 
 they have to assimilate during their brief curriculum. 
 Before that important event which took place in the 
 year B.C. 2348,* medical students might have spent 
 forty or fifty years in preparing for examination, and 
 have looked forward to commencing practice when 
 they were entering their second or third century, but 
 nowadays it seems incumbent upon their teachers to 
 avoid discursiveness, and I think that our knowledge 
 of insanity has reached a point at which its various 
 forms and varieties, like those of bodily disease, can be 
 described as types, without having recourse to descrip- 
 tions of illustrative cases, which bulk so large in most 
 text-books on the subject. Moreover, I was anxious to 
 put forward the distinction that I have drawn in this 
 book between forms of insanity and varieties of insanity, 
 a distinction which I think goes far to solve the difficulties 
 of classification which have been so great a stumbling- 
 block to successive writers on insanity for generations. 
 
 * According to Usshcr, but the Septuagint has it B. c. 3246. 
 
 vii 
 
viii A TEXT-BOOK OF INSANITY 
 
 In giving a preliminary sketch of the normal pro- 
 cesses of which insanity is the disorder, I have followed 
 a course which is very unusual, but which I have pursued 
 for many years in lecturing on the subject, and have 
 found to be a very useful foundation on which to build 
 a knowledge of insanity. Special stress is laid upon 
 observation of conduct, which is in my opinion the key 
 to the subject. The causes of insanity have also been 
 separately dealt with, and as I hold that there are not 
 insanities, but insanity only, this course is at once 
 convenient and logical. 
 
 C. M. 
 
 Flower House, Catford. 
 
PEEFACE 
 
 TO THE SECOND EDITION 
 
 This book was primarily intended for tlie use of students 
 of medicine, as an introduction to the study of insanity, 
 to give them a general notion of" the subject without 
 going much into detail, and incidentally to be of use 
 to them in examinations. In this object it succeeded 
 so far that it became, I am told, the text-book in use 
 in most of the Universities. It was not intended as an 
 advanced book for those who make a special study of 
 insanity, and in this respect also it has not disappointed 
 its author, for the novel doctrines contained in it do 
 not appear to have become known to them yet. 
 
 In preparing a second edition, I have addressed a 
 rather wider audience. The book will still, I hope, give 
 the novice a general idea of the elements of the subject, 
 but if he is reading merely for the purpose of preparing 
 for a qualifying examination, there is much that he 
 will be well-advised to omit. It is never advantageous 
 to an examinee to know more than his examiners about 
 his subject. The considerable additions that have been 
 made to the book are intended, not for the general 
 student of medicine, who has enough subjects in general 
 medicine to load his memory with without adding the 
 superfluous burden of a knowledge of the constitution 
 of mind ; but for those, now much increased in number, 
 who devote themselves temporarily or permanently to 
 the special study of insanity. 
 A 2 ix 
 
X A TEXT-BOOK OF INSANITY 
 
 Insanity is a subject but little understood. When I 
 began to study it there was no systematic knowledge of 
 it at all ; and even now it is considered, both by alienists 
 and in legal phraseology, equivalent to disorder of 
 mind, or unsoundness of mind. So regarding it, as I 
 was taught to regard it, and as everyone but myself 
 still regards it, I urged in my early days that the study 
 of insanity — the disordered mind, as I then considered 
 it — should be preceded by the study of psychology — the 
 mind in health. The argument was logical and reason- 
 able, and unlike most of my recommendations this was 
 successful, but the experience of many years has made 
 me sorely regret my success. We are all psychologists 
 now. Many examining bodies grant degrees and 
 diplomas in psychological medicine, and all that do so 
 require of the candidates a knowledge of psychology, by 
 which they mean the psychology of the text-books ; 
 but as a knowledge of text-book psychology is of no 
 more value to the student of insanity than a knowledge 
 of cuneiform inscriptions, I now contemplate the result 
 of my well-meant efiorts with rueful dismay ; but still, 
 though my argument led to this disastrous result, I 
 yet maintain that it was right in principle. Insanity is 
 of course not the same thing as disorder of mind, but it 
 contains a considerable ingredient of disorder of mind ; 
 and of mind, as of everything else, disorder cannot be 
 understood until order is known. I have therefore 
 considerably enlarged the chapter on Mind, and it now 
 contains an analysis and description of the normal 
 mind specially adapted to the purposes of the student 
 of the disordered mind and the alienist. The scheme 
 appears to be an elaborate one, but it is the irreducible 
 minimum necessary for the comprehension of disorders 
 of mind ; and though the divisions are numerous, the 
 
PREFACE xi 
 
 plan of division is simple, and imposes no great burden 
 on the memory. Certain faculties of mind — self- 
 estimation and caution for instance — which are often 
 disordered, are here distinguished for the first time, and 
 many disorders that have hitherto been confused 
 together are now discriminated. For instance, euphoria 
 and exaltation, dysphoria and abasement, have never 
 been discriminated, though each of them may occur 
 alone, and some of them often so occur. The disentangle- 
 ment of the highest level of thought from its inferiors 
 is alone a justification for the scheme, for it is disorder 
 of this limited constituent that distinguishes insane 
 from sane disorder of mind, and that constitutes the 
 criterion of insanity. It has taken a quarter of a century 
 to obtain practical recognition of the principle that the 
 study of the physiology of mind should precede the 
 study of its pathology, and it will probably take another 
 quarter of a century to substitute a fruitful scheme of 
 the constitution of mind for a useless one. I shall not 
 live to see the substitution, but as we grow older we 
 grow more patient and more resigned. 
 
 The doctrine that insanity is disorder primarily of 
 conduct and not of mind, manifestly and blatantly true 
 though it is, has made little or no progress towards 
 acceptance in the twelve years since this book was 
 published. My alienist colleagues understand, when I 
 speak of disorder of conduct, that I mean disorderly 
 conduct in the police-court sense. The difierence seems 
 to me as plain as the difierence between, say, a horse 
 chestnut and a chestnut horse, or between £3 10s. and 
 3 lbs. 10 oz., or between A and a bull's foot, but I cannot 
 get my colleagues to appreciate it, and it must wait for 
 acceptance until a new generation takes their place. 
 
 Every writer on insanity has his own classification of 
 
xii A TEXT-BOOK OF INSANITY 
 
 insanity, and I am no exception to the rule. I am 
 exceptional, however, in paying some regard, in the 
 classification I propose, to the accepted canons of classi- 
 fication. In the first edition of this book I formulated 
 a scheme in which an approximation was made to the 
 separation of insanity the symptom from insanity the 
 disease, though the distinction was not at that time 
 clear in my mind. I was convinced that insanity could 
 not be classified in a single scheme, because there is 
 more than one kind of fundamental difference between 
 different cases, or more than one kind of kinds ; and 
 that the two series must be separated from one another 
 before any satisfactory classification could be made of 
 either. The resulting arrangement was an advance on 
 previous classifications, but it was not wholly satis- 
 factory, and no one recognised this more clearly than 
 myself. It was unsatisfactory because I did not at 
 that time recognise, what has since become clear to me, 
 that the series is not double, but triple, and that no 
 classification of insanity can be satisfactory, or free 
 from cross-classification and confusion, that does not 
 recognise the three concurrent series : — symptom, type, 
 and disease. 
 
 Tried by all the tests that I have been able to apply to 
 it, the classification now proposed is watertight. There 
 is no inclusion of anything that is not insanity. Insanity 
 is clearly distinguished from everything else, including 
 unsoundness of mind. There has been no attempt to 
 divide any class on three or four principles at once : 
 principles of division have been applied one at a time ; 
 consequently there is no cross-classification. Moreover, 
 I think the alienist will find, as I have found, that the 
 kinds of insanity brought together in this classification 
 are such as, from their natural affinities, we think of 
 
PREFACE xiii 
 
 together as alike, and those that are separated are 
 separated by a distance that corresponds with the 
 number and importance of the differences between 
 them. If a classification does these things it is a valid 
 classification, and does all that is wanted of a classifica- 
 tion. 
 
 The clinical descriptions of the various kinds of 
 insanity have been slightly elaborated, but not much ; 
 for in the first place, our knowledge has not much 
 advanced in this respect since the first edition appeared, 
 and in the second, I kept in view the primary object of 
 the book as a text-book for students. For examination 
 purposes I am afraid the book will be to some extent 
 vitiated by the exclusion of the fashionable titles of 
 dementia praecox and manic-depressive insanity that 
 have of late become so popular. I think I was the first 
 to point out that mania and melancholia could not be 
 distinct diseases, since they were often correlated in the 
 same case ; but I did not consider this the epoch- 
 making discovery that it is known to be now that these 
 cases are called manic-depressive insanity ; nor do I 
 think that the disease well known in my youth as 
 primary dementia was fiirst discovered when it was 
 agglomerated with other disorders and called dementia 
 praecox. Of the alternatives of conforming to what I 
 trust is a passing fashion in nomenclature — there are as 
 many fashions in medicine as in woman's dress — and 
 giving what I believe is a true account of insanity, I 
 have chosen the latter, even though by so doing I 
 prejudice the sale of the book. 
 
 Certain hitherto unrecognised kinds of insanity are 
 described for the first time in this book. The form of 
 stubbornness or resistiveness was described in the fiist 
 edition. Some allusion to it may be found in other 
 
xiv A TEXT-BOOK OF INSANITY 
 
 books that have been published since, but its importance 
 as a distinct form of insanity has met with no recog- 
 nition. Its importance lies first in its clinical signifi- 
 cance, as a very irrecoverable form of insanity, and 
 second in its remarkable pathological affinity with para- 
 noia, an affinity that is pathological only, and does not 
 seem to extend to its clinical aspect. I was perhaps ill- 
 advised in not giving to it a fancy title. If I had called 
 it "dementia recalcitrans " or "manic-recalcitrant in- 
 sanity " it might by this time have been accepted as a 
 great discovery. The other kinds that are here described 
 for the first time are the two kinds of insanity of child- 
 hood. The very important distinctions between the 
 various defects of memory have never been described 
 before. 
 
 The definitions of idiocy and imbecility proposed in 
 this book have been adopted by the Eoyal College of 
 Physicians, by the Eoyal Commission on the Feeble- 
 Minded, and in substance by Parliament, but they have 
 not yet found their way into books on insanity ; nor 
 has the origin of these defects from lapse of the 
 developmental impetus yet been accepted. It will be 
 seen that alienists are not precipitate in adopting 
 novelties that originate in this country, but in time — 
 in five-and-twenty years or so — we may hope that 
 what is manifest to everyone else will be accepted by 
 them. Meantime, as Dr. Johnson said, I can wait. 
 
 CHAS. A. MERCIER. 
 
 August, 1914. 
 
CONTENTS 
 
 PA01? 
 
 Introduction , . . . . . xvii 
 
 PART I 
 THE INSTITUTES OF INSANITY 
 
 CHAPTER 
 
 I. The Causes of Insanity . ... 3 
 
 11. Conduct . . ... 27 
 
 III. Mind . . . . . 47 
 
 PART II 
 FORMS, TYPES, AND KINDS OF INSANITY 
 
 IV. The Classification of Insanity . . .115 
 V. Forms of Insanity . . . . 126 
 
 "VI. Types of Insanity . . . .174 
 
 Acut« and Chronic Insanity 
 VII. Kinds of Insanity . . . . 209 
 
 Insanity of Involution 
 VIII. Kinds of Insanity . . . . 232 
 
 Insanity of Dissolution 
 Symptomatic Insanity 
 IX. Insanity of Dissolution . " . . . 243 
 
 Symptomatic Insanity 
 General Paralysis 
 X. Symptomatic Insanity . ... 269 
 
 Traumatic Insanity . ... 269 
 
 Insanity of Epilepsy . . . . 271 
 
 XV 
 
XVI 
 
 A TEXT-BOOK OF INSANITY 
 
 CHAPTER 
 
 XL Idiopathic Insanity 
 
 PAGE 
 
 . 278 
 
 Cyclical Insanity 
 
 . 278 
 
 Fixed Delusion . 
 
 . 280 
 
 Dementia 
 
 . 292 
 
 XII. Idiopathic Insanity 
 
 . 298 
 
 Alcoholic Insanity 
 
 . 299 
 
 Sequelar Insanity 
 
 . 305 
 
 Insanity of Times of Life 
 
 . 305 
 
 Insanity of Keproduction 
 
 . 311 
 
 PART III 
 THE LEGAL RELATIONS OF INSANITY 
 
 XIII. 
 
 The Legal Relations of Insanity 
 
 . 317 
 
 
 Certifiability 
 
 . 319 
 
 
 Placing and Keeping under Care . 
 
 . 323 
 
 
 Testamentary and Contracting Capacity 
 
 . 339 
 
 
 Criminal Responsibility . 
 
 . 340 
 
 
 APPENDICES 
 
 
 A. 
 
 —Model Certificate 
 
 . 342 
 
 B.- 
 
 —Letters of Insane Persons . 
 
 . 345 
 
 Index 
 
 . 
 
 . 347 
 
INTRODUCTION 
 
 When the student of medicine passes to the study of 
 insanity, he crosses a scientific frontier, and enters an 
 entirely new province of knowledge. Hitherto his pur- 
 view has been limited to the processes that go on within 
 the body, and whatever references he had to make beyond 
 that field were indirect and of secondary import. He 
 needs to know the structure and functions of the several 
 organs of the body, and, when any function is disordered, 
 his calling is to take measures to readjust the bodily 
 processes to one another so that they may work in 
 harmony again. He has, in short, to maintain the 
 organism in a fit state to do its work, whatever that 
 may be, but with the doing of the work he has no con- 
 cern. What the work may be, and with what efficiency 
 it may be performed, is no concern of his, except in as 
 far as these things may afiect the general capability of 
 the organism to continue its existence. His position 
 towards the patient is the position of the shipwright 
 and the engineer towards the vessel on which they are 
 engaged. Like them, he must be thoroughly acquainted 
 with the structure and function of every part, and, like 
 them, he must be upon the watch to repair the structure 
 and correct the function, when the one is damaged or 
 the other is at fault ; but with the ship's course he has 
 nothing to do. That is a matter altogether beyond his 
 province. When the student oversteps the bounds of 
 medicine to enter upon the study of insanity, he leaves 
 
 xvii 
 
xviii A TEXT-BOOK OF INSANITY 
 
 the engine-room for the quarter-deck. He is no longer 
 directly concerned with the integrity of the structure or 
 the efficiency of the engines. His function now is to set 
 the ship's course, to note the way in which she comports 
 herself in wind and weather, to study charts and tides, 
 stars and clouds, to watch the barometer and to sound 
 the lead, and generally to relinquish the observation of 
 the ship herself, and to take up that of her relations to 
 the world in which she moves. This is the function of 
 the student of insanity — to study the individual, not 
 per se, or simpliciter, but in relation to the world in 
 which he exists, and in which he has to maintain his 
 existence. 
 
 Insanity is often called disorder of mind, and this 
 it is, but it is much more than this. Were it disorder 
 of mind alone, we should not be called upon to treat 
 it ; for we should know nothing about it unless we 
 happened to be subject to it ourselves. What goes 
 on in the minds of other people we can never know, 
 unless and until it is revealed to us by their conduct. 
 Only by disorder of conduct can we infer the existence 
 of disorder of mind, and when conduct is disordered, 
 we may safely and immediately infer, we are irre- 
 sistibly compelled to infer, the existence of insanity, 
 without stopping to investigate the condition of the 
 mind. If a general officer goes on parade in flannels 
 and practising the banjo ; if a parson goes into the 
 pulpit and plays cup and ball before the congregation ; 
 if a hostess comes down to a dinner party in her night- 
 dress and curl-papers ; if a smith pulls a glowing 
 horse-shoe out of the fire with his naked hand ; if a 
 navvy tries to break up the road with a saucepan ; we 
 do not need to sit down and investigate the state of 
 their minds before we pronounce them insane ; the 
 
INTRODUCTION xix 
 
 state of the mind is left on one side and does not enter 
 into our consideration. We say at once that such 
 conduct is itself insane, and needs no further evidence to 
 establish the insanity. It is true that there are cases, 
 many cases, in which we do investigate the state of 
 mind, and in which we should not pronounce an opinion 
 on the sanity or insanity of the patient until his 
 mental condition has been investigated ; but these are 
 cases in which a portion, it may be a very large portion, 
 of the conduct exhibits no disorder ; in which the dis- 
 order of conduct is only occasional, and afiects only a 
 small, though it may be an important, department of 
 conduct ; and in which we have, perhaps, no oppor- 
 tunity of witnessing any disorder of conduct. In such 
 cases we investigate the state of mind in order to dis- 
 cover whether conduct is likely to exhibit disorder ; 
 and it is an index to the Likelihood of disorder of con- 
 duct, not as in itself exhibiting disorder, that disorder 
 of mind is important. If we discover a disorder of mind 
 that has no influence upon conduct, we cannot regard it 
 as an indication of insanity. 
 
 Mind and conduct are not the only things disordered 
 in insanity. The former is a sign, the latter is a symptom, 
 of disorder of the highest nerve processes, whose function 
 it is to actuate conduct, and whose activity is the con- 
 dition under which mental states arise. These highest 
 nerve processes have a double function. Not only do 
 they actuate conduct, and thereby regulate the whole of 
 the commerce between the organism as a whole and the 
 universe which environs it, but they regulate also the 
 whole of the internal processes of the body with respect 
 to one another, harmonise and balance and preserve 
 due relations amongst them. When the highest nerve 
 processes are disordered, therefore, there is disorder 
 
XX A TEXT-BOOK OF INSANITY 
 
 among these bodily processes — disorder which is often 
 inconspicuous, but which, in the deeper degrees of 
 insanity, is often very pronounced, and exhibits itself 
 in anomalies of skin, hair, nails, sweat, etc. — superficial 
 and conspicuous examples of a disordered metabolism 
 which is doubtless present in the deeper tissues also. 
 
 Conduct, however, is the main thing that is dis- 
 ordered in insanity. It is disorder of conduct that 
 gives to insanity its whole significance. Disorder of 
 mind without disorder of conduct, if it were possible, 
 would be unimportant, if it were important, would 
 be unrecognisable ; and thus the first essential to a 
 knowledge of insanity is an enumeration of the main 
 features of conduct, and of the ways in which conduct 
 may be disordered. 
 
PART I 
 THE INSTITUTES OF INSANITY 
 
CHAPTER I 
 
 THE CAUSES OF INSANITY 
 
 Whenever a meclianism fails to perform the duty 
 demanded of it, the reason must be either that the 
 work is too heavy for the mechanism or that the 
 mechanism is not strong enough for the work ; and 
 the two things are not exactly the same. When a 
 human organism breaks doT;vTi under the stress of life, 
 in a way that the majority of men do not break down, 
 it is because either the person who fails is weaker than 
 his fellows, or the stress brought to bear on him is 
 greater. For every person, as for every beam and every 
 rope, there is a breaking strain. Load a beam or a rope 
 with sufficient weight, and, whatever its strength, it will 
 break at last. Subject a man to sufficient stress, and 
 however well he may be constituted, he will become 
 insane. In estimating the factors that go to produce 
 insanity in any case, we have to consider, first, the 
 person who becomes insane, and, second, the stresses to 
 which he is subject. 
 
 The fact that the majority of people are sane, indi- 
 cates that they possess a nervous organisation of suffi- 
 cient stability and strength to withstand the stresses 
 to which it is subject ; and if here and there one becomes 
 insane, it is because either his nervous organisation 
 was not strong enough to withstand ordinary stresses, 
 or he has been subjected to stresses of extraordinary 
 severity. The great majority of cases of ordinary in- 
 
 3 
 
4 A TEXT-BOOK OF INSANITY 
 
 sanity belong to the former class ; cases of insanity of 
 drunkenness, and of general paralysis, belong to the 
 latter. 
 
 We have no means of gauging the efl&ciency of a 
 person to withstand stresses, except by observation of 
 his behaviour under their incidence ; but, since every 
 person is the outcome and product of his ancestry, we 
 may make a rough guess at his efficiency by investi- 
 gating his heredity. That heredity has a very impor- 
 tant part in the production of insanity is proved, not 
 less by clinical experience than by the considerations 
 just dealt with ; but what it is that is inherited in cases 
 in which insanity " runs in the family " it is difficult to 
 say. Insanity is manifested in conduct, and it is 
 evidently absurd to speak of what a man is now doing 
 as an inheritance from his forefathers. The only thing 
 that can be clearly conceived as transmitted by inheri- 
 tance is structure ; and if a son " inherits insanity " from 
 his father, what is transmitted from father to son must 
 be some structural peculiarity of nerve tissue. There 
 are several such peculiarities that may conceivably be 
 derived by inheritance. In the first place, the process 
 of development may be deficient in impetus ; it may 
 come to a premature close ; and in that case the part 
 of the body which will remain undeveloped will be the 
 part which is the last to be completed — that is to say, 
 the highest regions of the brain. The degree of de- 
 velopment which is reached by these regions varies 
 much in difierent persons, according to the strength and 
 persistence of the developmental impetus. When these 
 are exceptionally great, the highest nerve regions be- 
 come exceptionally well developed, and the person 
 attains to a high level of intellectual development. 
 When the process of development is feeble, and comes 
 
INHERITANCE OF INSANITY 5 
 
 to a premature close, the brain never attains full develop- 
 ment, and the person never reaches the normal intel- 
 lectual standard. 
 
 But there are other forms of insanity than idiocy 
 and imbecility, and many of the insane whose insanity 
 " runs in the family " are of average, and even of more 
 than average, ability. How can we suppose that, in 
 such cases, the insanity is " transmitted " ? Or rather, 
 what is it that is transmitted by inheritance in such 
 cases ? The analogous case of tubercle may help us 
 to understand. That inheritance has a large share 
 in the production of phthisis is as indisputable at the 
 present day, when the tuberculous process is known to 
 be due to the invasion of a micro-organism, as it was 
 before bacilli were discovered ; but, though it is known 
 that phthisis is influenced by heredity, it is known also 
 that the bacillus is not inherited. What is inherited 
 is a " delicacy of constitution," a " vulnerability," a 
 " feebleness of resistance," such that, when the organ- 
 ism is invaded by bacilli, it has less power to attack 
 and destroy them, they more easily efiect a lodgment, 
 establish themselves and multiply, than they do in the 
 tissues of a person of stronger constitution. And some 
 cases, at any rate, of insanity are closely analogous. 
 Among the stresses that do unquestionably produce 
 insanity is that of poison circulating in the blood, and 
 supplied in the pabulum presented to the nerve tissue. 
 There is indisputable evidence with respect to some 
 of these poisons that the nerve tissue of different people 
 has different power of exclusion or of counteraction. 
 No observation is more trite than the amount of alcohol, 
 for instance, which will make one man beastly drunk, 
 will leave another but slightly elevated, and have no 
 appreciable effect upon a third. And these differences 
 
6 A TEXT-BOOK OF INSANITY 
 
 in the power of the nerve tissue to exclude or to neutralise 
 the alcohol that is supplied to it are derived from inheri- 
 tance. They are part of the innate constitution which 
 the person derives from his ancestry. There is there- 
 fore nothing inconsistent with experience in sup- 
 posing that similar innate and inherited differences 
 exist in the power of the nerve tissue to exclude or 
 neutralise other poisons ; and if, as is probable, many 
 cases of insanity are due to the action of poisons upon 
 the nerve tissue, the influence of inherited quality of 
 nerve tissue is easy to understand in such cases. 
 
 But although poisons are among the most powerful 
 stresses that the higher nerve regions have to with- 
 stand, and among the most frequent, they are not the 
 only ones. As we shall presently see, there are many 
 other stresses that are provocative of insanity ; but the 
 way in which inherited incapacity renders the person 
 obnoxious to the action of poisons helps us to under- 
 stand the way in which incapacity, similarly inborn, 
 may facilitate the occurrence of insanity on other 
 provocation than that of poisonous food. We see 
 similar differences in the power of the nervous system 
 to resist disturbing agents, and to maintain equable 
 action, in other respects. We see that the disaster 
 which will reduce one man to despairing impotence 
 will stimulate another to energetic activity. We see 
 that the same insult which will provoke one man to 
 uncontrollable rage will be treated by another with con- 
 temptuous indifference. And these differences, again, 
 are innate, and are derived from inheritance ; so that 
 we can dimly understand how it is that a set of cir- 
 cumstances which will produce insanity in one man 
 will have no such effect upon another. 
 
 ^0 widely spread and so strong is the belief in the 
 
INHERITANCE OF INSANITY 7 
 
 hereditariness of insanity, that proposals are frequently 
 made to limit by law the marriage, not merely of 
 persons who have been insane, but of those who have 
 insanity " in the family " ; and the expediency of such 
 marriages is a matter on which medical practitioners 
 are frequently consulted. Such proposals are imprac- 
 ticable. If marriage is to be prohibited in all cases in 
 which a clean bill of health cannot be shown for all the 
 individuals in, say, three generations, the practical 
 result would be to prohibit marriage altogether ; and 
 although the offspring of those who have been insane 
 are more likely to be insane, and to have children who 
 become insane, than are the offspring of normal persons, 
 yet it by no means necessarily follows that such ill 
 results will accrue. The children of any individual 
 who errs from the general standard of the race in any 
 respect exhibit, in the great majority of cases, a return 
 towards the standard. The children of giants are not 
 so tall, nor are the children of dwarfs so short, as their 
 respective parents ; and very many of the children of 
 the insane are as sound in mind as they are vigorous 
 in body. Even when insanity is strongly prepotent in 
 a race, and when four or five brothers or sisters are 
 insane, there is usually at least one brother or sister 
 who never shows a sign of insanity. The influence of 
 inheritance in producing insanity is great, but it should 
 not be exaggerated ; and it would be a gross exaggera- 
 tion to suppose that the children of an insane person 
 must necessarily be insane. 
 
 There is a widespread opinion that the children of 
 cousins german are more prone to insanity, and es- 
 pecially to weakness of mind, than other people. The 
 very thorough investigations of Mr. Huth into the 
 marriage of near kin have not sufficed to dispel this 
 
8 A TEXT-BOOK OF INSANITY 
 
 opinion, in the face of the occasional occurrence of 
 idiocy or insanity in the offspring of persons so related. 
 That such cases do occur is indisputable, but that 
 in very many cases the offspring of cousins german 
 are as normal and as well endowed as other people, 
 shows beyond question that it is not the mere existence 
 of blood relationship between the parents that pro- 
 duces this effect. The truth seems to be that if there 
 is any heritable disposition in the common family, 
 whether this disposition be to phthisis, gout, cancer, 
 insanity, or what not, the inheritance in the child is 
 intensified by its derivation from both parents. The 
 same intensification would be produced even were 
 the common grandparents destitute of any such heri- 
 table disposition, if such disposition existed in both 
 of the unrelated parents of the cousins. Whether 
 the person gets his morbid inheritance from the common 
 ancestor of his parents or from unrelated ancestors 
 makes little difference. The important consideration 
 is whether he gets the same kind of inheritance — 
 inheritance of the same disposition or defect — from 
 both his parents. In such a case the gravity of the 
 inheritance is more than doubled. 
 
 The stresses that produce insanity are of three 
 kinds. The first consists of those in which a disturbing 
 agent acts directly upon the nerve tissue of the highest 
 regions of the brain ; in which they are bruised by 
 violence, compressed by tumours, damaged by in- 
 flammation, or vitiated by the supply of a poison in 
 the blood. These we will call " direct stresses."* 
 
 * It should be mentioned that the term " stress " has of late years 
 been used in a sense diiferent from that in the text, which was first 
 applied by me in 1890 to the agents that provoke insanity. It is 
 used to mean exercise, fatigue, exhaustion of nervous tissue. The 
 former meaning has been restored in the text. 
 
DIRECT STRESSES 9 
 
 Gross lesions of the brain, in their active stage, are 
 seldom attended by insanity in the clinical sense. 
 Meningitis, cerebral abscess, cerebral tumour, con- 
 cussion, fracture of the skull, wounds, lacerations of 
 the hemispheres, are attended, not by active insanity, 
 but by various depths of coma ; and coma, though 
 scientifically it is a form of insanity, and though it is 
 the form which all insanities assume at last, if they 
 go on to the end, yet, since it is not clinically regarded 
 as insanity, need not be dealt with here. Although, 
 however, in their active stages, gross lesions do not 
 produce clinical insanity, yet, if they damage or destroy 
 convolutions, this damage may be evidenced in insanity 
 when the coma is sufficiently cleared up for the defect 
 of sanity to become recognisable. In every large 
 asylum there is a proportion of weak-minded inmates 
 whose defect of mind is owing to gross structural 
 defect of brain, the result of previous active process. 
 
 By far the most important of the direct stresses, 
 perhaps the most important of all the stresses which 
 contribute to the production of insanity, is alteration 
 in the composition of the blood by which the highest 
 nerve regions are nourished. 
 
 Simple deficiency of nutriment reduces the efficiency 
 of the function of the nerve tissue, which exhibits 
 itself in deficiency of sanity. In starvation the mind 
 is weakened according to the degree of the starvation, 
 the attenuation of mind reaching to actual uncon- 
 sciousness when the starvation is extreme, and when 
 the deprivation of nourishment is complete and pro- 
 longed. Even when it is neither, but the heredity is 
 bad, the weakness of mind may be accompanied by 
 active insanity. In a large proportion of the cases 
 of acute insanity that we have to treat, a greater 
 
10 A TEXT-BOOK OF INSANITY 
 
 or less degree of starvation Las been one of the factors 
 in its production ; and copious feeding is one of the 
 most important modes of treatment of acute insanity. 
 
 The deficiency in the nutritive supply of the brain 
 may be due, not to starvation, but to haemorrhage, 
 or to any other condition in which the blood is im- 
 poverished ; and whatever the cause of the impoverish- 
 ment, the deterioration of sanity is the same, provided 
 the impoverishment is the same in degree, and the 
 resistive power of the nerve elements is the same. 
 Hence we sometimes meet with insanity, usually of 
 a very intractable type, after severe haemorrhage ; 
 and in all exhausting disease there is some deteriora- 
 tion of mind — deterioration which, in persons whose 
 nervous system was originally badly organised, may 
 attain to actual insanity. 
 
 More potent even than attenuation of the nutritive 
 supply to the brain is its vitiation. By introducing 
 a poison into the blood, we can produce insanity at 
 will. We can regulate the degree of the insanity by 
 the amount of poison that we administer, and we 
 can maintain the insanity as long as we please by 
 continuing the administration of the poison. Proof 
 of these statements is exhibited by every case of drunken- 
 ness, b}^ every case in which chloroform or ether is 
 administered. The insanity of acute alcoholic poison- 
 ing is extremely instructive. From it we learn that 
 the rapid administration of a very large dose of the 
 poison will produce rapid death by coma ; that the 
 rapid administration of a smaller dose will produce a 
 madness of short duration, passing, in a few hours, 
 through coma into recovery ; that a more gradual 
 administration of several smaller doses, extending 
 over some hours, will produce an exalted delirium of 
 
ALCOHOL AND INSANITY 11 
 
 a milder type, passing presently into sleep, and so to 
 recovery ; that in those who have been accustomed to 
 take alcohol in great excess, the sudden deprivation of 
 alcohol will produce an attack of acute insanity of 
 very different form, characterised neither by maniacal 
 fury nor by jovial exaltation, but by suspicion, misery, 
 and prominent hallucinations of vision, a form of 
 insanity which is of longer duration than the others, 
 and lasts for several days ; and, lastly, that the ad- 
 ministration of alcohol prolonged for years, will give 
 rise to yet another kind of insanity, a kind in which 
 the exaltation of the third phase is often combined 
 with the suspicion of the fourth, and to them are 
 added pronounced defects of intelligence, and especially 
 of memory, and. in this form the duration is still further 
 prolonged. It lasts for months and years, and is often 
 irrecoverable. 
 
 The different efiects of different dosage, and of 
 greater or less prolongation of the administration of 
 the poison, are not all that we learn from the adminis- 
 tration of alcohol. We learn also that the manner in 
 which the insanity is manifested depends not only 
 on the dosage and the mode of administration, but 
 upon the nature of the person to whom the poison 
 is administered. One person becomes hilarious, jovial, 
 and braggart in his cups ; another becomes sentimental, 
 maudlin, and confidential ; a third becomes suspicious 
 and morose ; a fourth is cantanl^erous and quarrel- 
 some, a fifth merely stupid, and a sixth, under the same 
 administration of the same amount, becomes furiously 
 maniacal, violent, and destructive. 
 
 Alcohol is very important, because it is not only 
 one of the most frequent, but the most manageable, 
 p^ all the poisons which produce insanity. The number 
 
12 A TEXT-BOOK OF INSANITY 
 
 of these poisons is very large, and their constitution 
 most diverse. They include such simple substances as 
 carbonic acid, whose intoxicating effect is seen in the 
 delirium of heart disease, and perhaps in that of pneu- 
 monia, and substances so complex as the toxins produced 
 by the specific organisms of zymotic disease. They 
 include foreign substances introduced into the body 
 from without, as well as toxins produced within the 
 body by variation of its own metabolism, and, perhaps 
 most deadly of all, toxins produced by invading 
 microbes. Seeing how readily and how frequently 
 insanity is produced by the administration of alcohol, 
 and how very familiar we are with the delirium of 
 fevers, a form of insanity that has for many years been 
 recognised as due to the action of poisons, it is a little 
 surprising that the influence of poisons in producing 
 insanity has only recently had its due importance 
 assigned to it ; but it is not at all surprising that as 
 soon as the toxic origin of insanity is fully recognised 
 it should be exaggerated, and that the claim should be 
 made that every case of insanity is of toxic origin. This 
 is certainly not the case ; but still, the part of blood- 
 poisoning in producing insanity is a very important 
 one. It is probable that it accounts for all, or nearly 
 all, cases of acute insanity ; and it is now certain that 
 it has a very large share in the production of general 
 paralysis of the insane. The nature and mode of 
 origin of the poison are often very obscure. It is 
 no doubt often produced within the body by some 
 fatal variation of its own chemistry, while often it 
 is introduced from without. Disease that is due to 
 poisoning, whether the poison is introduced into the 
 body or produced within it, is usually febrile in character; 
 it is usually accompanied by raised temperature and 
 
INSOMNIA AND INSANITY 13 
 
 other signs of fever ; but the poisons that produce 
 insanity do not usually produce fever. In the delirium 
 of zymotic disease there is, of course, fever. There is 
 fever in acute delirious mania, which is probably a 
 disease of the same class. In some cases of puerperal 
 insanity there is fever from absorption of the decom- 
 posing contents of the uterus ; but in the great majority 
 of cases of acute insanity, which are in my opinion due 
 to intoxication, the temperature is not raised. This 
 is a very important clinical observation, for occasionally 
 the invasion of zymotic disease — of smallpox, scarlet 
 fever, typhoid or other fever — is marked by an outbreak 
 of acute delirium which is indistinguishable from the 
 acute insanity due to other toxins, except by the 
 temperature. A raised temperature in acute insanity 
 should, therefore, always arouse suspicion of zymotic 
 disease. ^ 
 
 This is the most appropriate place in which to enu- 
 merate sleeplessness among the provocations of insanity. 
 As with several other factors in the malady, it is difiB.- 
 cult to determine how far it acts as a cause and how 
 far it is a symptom merely. That there are very many 
 persons who habitually sleep very badly — lightly, 
 intermittently, and for an insufi&cient number of hours 
 — and who yet never come within measurable distance 
 of insanity, is certain. Equally certain is it that acute 
 insanity is often preceded for days or weeks by a great 
 and unusual degree of insomnia, and that the induction 
 of sleep often marks the first step toward recovery ; 
 but whether the sleeplessness is a cause or a sign of the 
 oncoming insanity is uncertain ; nor is it very im- 
 portant, since in either case it is a warning, and in 
 either case it is to be dealt with in the same way. 
 
 The indirect stresses that tend to produce insanity 
 
14 A TEXT-BOOK OF INSANITY 
 
 are of two kinds — those which arise within the limits 
 of the organism, and those which arise in the com- 
 merce between the individual and his circumstances. 
 
 In the first class are included all those bodily pro- 
 cesses which make large draughts upon the stored 
 energy of the nervous system, whether the demand 
 is made by the process of growth and development, 
 by that of reproduction, by bodily or mental exertion, 
 by the processes of disease, or for recuperation after 
 illness. Any process, in short, that is generally ex- 
 hausting, may contribute to the production of in- 
 sanity, and a fortiori the concurrence of two or more of 
 these processes is eminently provocative of insanity. 
 
 Close observers of the development of children know 
 that their mental development proceeds, on the whole, 
 alternately with their bodily development ; that they 
 have periods in which their bodily growth is stationary, 
 while their minds develop apace, alternating with 
 periods in which their bodily growth is rapid and 
 their mental development ceases, or seems even to 
 retrograde. If, during the latter period, an injudicious 
 attempt is made to force the mental development by 
 close application to mental work, the consequence will 
 be a serious " nervous breakdown " of the nature of 
 insanity. The demand upon the energy of the brain 
 is greater than it can supply ; it becomes so depleted 
 that it cannot carry on its current function, and the 
 depletion exhibits itself in some form of insanity. 
 The same condition may result, though more rarely, 
 from excessive addiction to athleticism when the mental 
 development is very active. If the combined effect of 
 concurrent physical and mental development is ex- 
 haustive, still more exhaustive is the additional demand 
 upon the energies of the organism which is made by the 
 
REPRODUCTION AND INSANITY 15 
 
 evolution of the reproductive function at puberty, and 
 when to this is added the further drain of frequent 
 masturbation, we can understand how it is that insanity, 
 or a minor disorder of the same nature, is so frequent 
 in adolescence, and how it is that that is the period of 
 life when stupor and hysteria are most frequent. 
 
 The dominant role of the reproductive function in 
 the life of every organism will be pointed out in sub- 
 sequent chapters. It has now to be noted that not 
 only is reproduction the aim and end to which all 
 life is subservient, but that reproduction and life are 
 mutually antagonistic — that is to say, the full and 
 complete life- worthiness of the individual is incom- 
 patible with reproduction ; and reproduction diminishes 
 the life-worthiness of the parent so as in some cases 
 to destroy him or her altogether ; and in all cases to 
 render the parent, for a time at any rate, less capable 
 of living, less apt and less competent to maintain the 
 struggle for existence. Seeing that the motive of 
 existence is the reproduction of the race, it is to be 
 expected that, when this aim is attained, existence 
 should cease, or at any rate should approximate to 
 its close. 
 
 In the first place, the addition of the reproductive 
 function to the powers of the previously unproductive 
 organism is itself an occasion of disorder. The infertile 
 organism consists of a large number of organs and 
 functions co-ordinated together and acting one with 
 another in due correlation as one harmonious whole. 
 When a new set of organs and functions of dominant 
 importance has to be added to those already in existence, 
 has to be correlated with them, to be assigned their 
 place in the economy, and to be allotted their share in 
 the life, of the organism, it is evident that so far-reaching 
 
16 A TEXT-BOOK OF INSANITY 
 
 and delicate a process of equilibration will be very apt 
 to fail in exactitude, especially if the great co-ordinating 
 agent, the brain, is lacking in power. Hence the period 
 of the assumption of the reproductive function is always 
 a period of danger, and very frequently of disorder. The 
 liability to disorder is, in the early stage of the assump- 
 tion, but small, and insanity at puberty is rare ; but 
 the reproductive function is not then fully acquired. 
 It is not until after seventeen that the female is fully 
 nubile, not until after twenty that the male is fully 
 virile, and it is not until these ages that the incidence 
 of insanity becomes serious. It is then only that the 
 individual becomes, not merely capable physiologically 
 of continuing the species, but awake to the responsi- 
 bilities of life. It is then only that the real dangerous 
 stress begins to bear upon the highest regions of the 
 brain ; and while insanity before these ages is rare, it 
 then begins to be frequent. 
 
 The reproductive act is a great exhauster of energy. 
 It is always and of necessity inimical to life. In many 
 of the lower animals it is if so facto destructive of life. 
 In man, while it is not thus necessarily fatal, it is 
 yet detrimental. It is exhaustive ; it renders the 
 organism less fit and less capable of resisting adverse 
 circumstances ; and, if it is repeated with undue 
 frequency, its ill- effects become conspicuous. The 
 woman who has children in rapid succession becomes 
 enfeebled, anaemic, hysterical, the prey of neuralgia 
 and of many nervous maladies, an easy victim to 
 tubercle and other bacilli. The man who repeats 
 the sexual act with great frequency becomes similarly 
 etiolated and enfeebled ; and both are apt to give 
 evidence of the exhaustion of energy in neurasthenia 
 or in insanity. The connection of masturbation with 
 
MASTURBATION AND INSANITY 17 
 
 insanity is very close. A few years ago masturbation 
 was looked upon, it is scarcely too mucli to say, as 
 the most potent cause and the invariable accompani- 
 ment of insanity ; but nowadays masturbation is not 
 regarded as the prime and sole cause of insanity. I 
 may take some credit for exploding a belief which was 
 once universal. In males, and especially in unmarried 
 adolescent males, occasional masturbation is so ex- 
 tremely common that it is scarcely to be considered 
 abnormal. The same is true of older men who have 
 no opportunity for the normal gratification of the 
 sexual passion. And by those who are becoming insane, 
 or are liable to become insane, it is no doubt practised 
 more freely, it may be to great excess. But insanity 
 does not occur in people who are of sound mental 
 constitution. It does not, like smallpox and malaria, 
 attack indifierently the weak and the strong. It occurs 
 chiefly in those whose mental constitution is originally 
 defective, and whose defect is manifested in lack of 
 the power of seK-control and of forgoing immediate 
 indulgence ; and when it attacks those who were 
 originally normally constituted, the breaking down of 
 the power of self-control is among its first efiects. It 
 would be wonderful, therefore, if masturbation were 
 not practised, and practised freely, by those who are 
 liable to become, or are becoming, insane. And since 
 the sexual act is in all cases a very efficient cause of 
 exhaustion and depletion of energy, it cannot fail to 
 assist the deteriorative process, to hasten the onset 
 of insanity where this is impending, and to retard and 
 impede recovery where insanity is established. But 
 to look upon masturbation as the sole, or even the 
 chief, agent in the production of insanity is to take a 
 very exaggerated view. 
 
18 A TEXT-BOOK OF INSANITY 
 
 In the female, indulgence in this vice is very much 
 less common than in the male, and the mere fact that 
 it is practised is 'prima jade evidence that the girl 
 or the woman who indulges in it has not attained 
 to the normal standard, but is congenitally abnormal. 
 In the female, however, the sexual act is less exhausting 
 than in the male, and while the significance of mastur- 
 bation as an indication of an abnormal mental constitu- 
 tion is greater, its importance as a contributory cause 
 of insanity is much less. 
 
 While the female is less obnoxious to the deteriora- 
 tive influence of masturbation than in the male, she 
 is liable to other stresses of reproduction from which 
 he is exempt. Upon her fall the stresses of pregnancy, 
 parturition, and lactation, each of which may be the 
 occasion of insanity. The " longings," and equally 
 the aversions, of the pregnant woman are aberrations 
 of mind so usual that they scarcely attract attention ; 
 but any occasion on which disorder of mind, however 
 trifling, occurs in healthy and well-constituted people 
 is an occasion on which insanity may occur in those 
 who are less healthy and less well constituted. Indeed, 
 considering how considerable are the mental disorders 
 that often accompany pregnancy, the aversion to the 
 husband, the excessive caprice, the restlessness and 
 *' nervousness," it is remarkable that insanity is not 
 more frequent in pregnancy, for on the whole it is an 
 infrequent occasion of insanity, only about one per 
 cent, of all the cases of insanity that occur in women 
 being associated with this condition. 
 
 The puerperal state is a much more frequent occasion 
 of insanity, about six per cent, of all the cases among 
 women occurring in connection with childbirth — that 
 is to say, within a month or so of parturition — and 
 
CHILDBIRTH AND INSANITY 19 
 
 when we consider all that childbirth implies, we find 
 no cause for surprise that this should be so. In the first 
 place, when the child is born, an immense readjustment 
 of physiological processes has to be made in the maternal 
 organism. The great supply of pabulum that has 
 hitherto been made to the uterus is now no longer 
 needed there, can now no longer be dealt with there, 
 and has in part to be drafted ofi to the breasts, in part 
 to be dispensed with. The continual stream of efiete 
 products from the nutrition of the foetus is suddenly 
 cut off, all the arrangements for dealing with them are 
 deprived of their material from this source. No doubt 
 the rapid involution of the uterus supplies their place 
 in so far as quantity goes, but the quality is probably 
 very different, and needs further readjustment of 
 excretory processes to enable it to be dealt with. Then 
 the process of labour is itself a very severe drain upon 
 the great reservoir of bodily energy, and thus diminishes 
 its capacity to bring about these adjustments just at 
 the time when they are needed. In addition to this, the 
 haemorrhage, frequently excessive, is of itself a cause 
 of serious stress ; and when to all these stresses is 
 added the absorption of septic matter from the decom- 
 posing contents of the uterus, the wonder is, not that 
 puerperal insanity is frequent, but that it is not much 
 more frequent. In a certain proportion of cases of 
 puerperal insanity, about one-fourth, the temperature 
 is raised, and in these cases the suspicion that the 
 insanity is dependent upon sepsis is often confirmed by 
 the result of local measures directed to emptying the 
 uterus of decomposing matter and sweetening its 
 contents. But on the one hand, the adoption of these 
 measures in such cases does not always produce im- 
 provement in the insanity, showing that even where the 
 
20 A TEXT-BOOK OF INSANITY 
 
 temperature is raised, the origin of the insanity is not 
 wholly septic ; and on the other, we know that there 
 are poisons which produce insanity without raising the 
 temperature, so that we cannot be sure that where the 
 insanity is not septic it is not toxic. 
 
 Puerperal insanity is most frequent in the first 
 fortnight after labour, and when more than a month 
 has elapsed before the outbreak, it is no longer called 
 puerperal. At this period insanity is infrequent, and 
 it is not until the later months of lactation that the 
 liability again increases. The insanity of lactation is 
 a disease of exhaustion. It occurs in women who 
 have suckled long and freely, who have had insufficient 
 food, and who have perhaps had to work hard ever 
 since they rose prematurely from their lying-in. It is 
 therefore much more frequent among poor women 
 than among the well-to-do. 
 
 The climacteric is another of those periods of physio- 
 logical adjustment which make so severe a call upon 
 the powers of the highest co-ordinating organ. The 
 deprivation of function, no more than the addition 
 of function, can be effected without disturbing the 
 general balance among the various functions of the 
 body. This balance has to be readjusted, and the 
 equilibration is sometimes beyond the power of the 
 organism to effect, and the result is disorder of the 
 highest nerve regions on which the strain falls. The 
 climacteric period is always a period of some disorder 
 in women. They are troubled with sleeplessness, 
 irritability of temper, despondency, loss of energy, and 
 lackadaisicalness ; and in exceptional cases these 
 aberrations are exaggerated into actual insanity. A 
 similar affliction may occur in men at about the age of 
 sixty, which is sometimes attributed to a climacteric 
 
BODILY DISEASE AND INSANITY 21 
 
 in them, though it is more usually associated with the 
 total change of habits and loss of interests arising from 
 retirement from business. 
 
 The other stresses of this class are those which arise 
 from bodily disease. In these cases the stress no doubt 
 very often belongs to the previous class, and is a poison 
 produced by the morbid process, or perhaps, as in the 
 case of myxoedema, a poison not so much produced as 
 permitted. The poison is not actually produced by 
 the morbid process, but owing to this process, it is no 
 longer neutralised, and so produces its efiect. Generally 
 it may be stated that every bodily disease has its effect 
 upon the sanity, even if it is only, by diminishing the 
 full efficiency of the cerebral action, to produce a mild 
 and inconspicuous weakening of the mental power ; 
 and in many cases of bodily disease the disorder of the 
 cerebral processes is considerable enough to amount 
 to actual insanity, as the frequency of delirium shows 
 us. In the majority of cases, such insanity may be 
 attributed either to starvation, or to poisoning of the 
 convolutions ; in some cases these two causes co-operate, 
 as in bronchitis, asthma, and heart disease ; in some 
 cases we trace the origin of the insanity to exhaustion 
 of the cerebral energy, as in epilepsy ; and in others we 
 are unable to offer a probable explanation of the mode 
 in which the insanity is brought about. Among the 
 starvation insanities may be instanced those which 
 occasionally occur in anaemia and chlorosis, and post- 
 febrile insanity, as well as that weakening of mental 
 power which is observable in every illness of long 
 standing — a weakening which often escapes notice, 
 since persons so situated are not often called upon 
 for severe intellectual effort. Among the insanities 
 due to poisoning may be instanced those which occur 
 
22 A TEXT-BOOK OF INSANITY 
 
 in Blight's disease, in gout, in lead poisoning, in diabetes, 
 as well as the delirium of fever, and perhaps also the 
 gloom, often deepening into melancholy, of chronic 
 dyspepsia and intestinal torpor. 
 
 Bodily disease is often connected causally with 
 insanity in the sense that the bodily malady supplies 
 the localisation, as it were, of the delusions which are 
 part of the insanity. Tinnitus aurium supplies the 
 provocation for aural hallucinations ; intestinal ulcer 
 co-exists with the delusion that the bowels are ob- 
 structed ; chronic dyspepsia may suggest that there 
 is a live weasel or lobster in the stomach ; some uterine 
 affection may be at the root of a delusion of pregnancy ; 
 some vaginal irritation may so direct the delusion that 
 the patient believes she is frequently raped, and so forth. 
 
 Lastly, as old age comes on, it may be attended, 
 not by a gradual and equable decline of the faculties, 
 but by a breakdown more or less catastrophic in 
 character, which may take the form of depression, 
 of excitement, of persistent delusions, of rapid dementia, 
 or of several other forms of insanity. 
 
 Stresses of the third class are those which arise out 
 of the relations between the organism and its sur- 
 roundings, and may be dealt with in the order proposed 
 for the activities of conduct in the next chapter. The 
 circumstances under which these stresses arise are those 
 which arouse emotion, and the more powerful the 
 emotion aroused, and the greater the suddenness with 
 which it is aroused, the more effectual is the stress in 
 producing insanity. Stresses of this class are, upon the 
 whole, much less potent than those of internal origin, 
 which in their turn are less effectual than those which 
 have been termed direct. The stresses with which we 
 are now dealing do not produce insanity except in those 
 
INDIRECT STRESSES 23 
 
 who are already predisposed to become insane by tbeir 
 heredity. 
 
 In the relations which directly concern the physical 
 safety of the organism, the only circumstances that 
 are capable of provoking insanity are those of fright, 
 or " nervous shock." The stress is not a fertile cause 
 of insanity, but a certain small proportion, about one 
 per cent, of all the cases that come under treatment, 
 are assigned to this cause. 
 
 Stresses arising in the circumstances under which 
 the livelihood is earned are more important. It does 
 not appear that extreme poverty is of itself provocative 
 of insanity, for we do not find that it is very prevalent 
 among those who live in penury, nor among the victims 
 of what is known as the " sweating system." But the 
 apprehension of poverty, the fear of losing the means 
 of livelihood, and the descent from more prosperous to 
 less prosperous circumstances, are very efficient occa- 
 sions of insanity among those who are already predis- 
 posed by constitution to become insane. In about 
 five and a half per cent., or nearly as large a proportion 
 as can be assigned among women to parturition, in- 
 sanity is traceable to the stress of difficulty in main- 
 taining the standard of living. 
 
 Among the circumstances which have a certain 
 efficiency in occasioning insanity is change in the 
 mode of livelihood. \\Tien a man gives up one career, 
 and embarks upon another, when a medical man turns 
 journalist, or a solicitor is called to the Bar, the revolu- 
 tion in the mode of life, added to the anxiety as to the 
 success of the venture, is occasionally a source of 
 insanity ; and the complete revolution of habit involved 
 in retirement from business when mind and body are 
 still active, and no provision has been made for their 
 
24 A TEXT-BOOK OF INSANITY 
 
 employment in other directions, is also an occasional 
 source of disorder. The form that the insanity takes 
 in such cases is usually that of depression with delusions 
 of poverty. 
 
 Stresses arising in connection with the family cir- 
 cumstances are a frequent source of disorder amount- 
 ing to insanity. First in order among these come 
 disappointments in love and other troubles arising in 
 the course of courtship, which account for about one 
 per cent, of the occurring cases of insanity. Now and 
 then the circumstance of becoming engaged to be 
 married will so agitate a nervous girl as to render her 
 actually insane ; and if this occurs upon engagement 
 only, a fortiori it may occur upon the occasion of 
 marriage. There are innocent girls who are totally 
 ignorant of what marriage implies ; who are coerced 
 into marriage with men for whom they have no affection, 
 whom perhaps they positively dislike ; and who learn 
 for the first time on their wedding night what marriage 
 really means. Such cases are rare, no doubt, but 
 they actually occur, and are responsible for a very 
 small number of cases of insanity. As few are the 
 cases in which connubial excess produces insanity in 
 the husband, but such cases also occasionally present 
 themselves. 
 
 No case has been recorded, so far as I am aware, 
 of extreme unhappiness in married life being provoca- 
 tive of insanity, although it would seem a priori as 
 if few stresses of the order that we are dealing with 
 could be more severe. Cases have occurred, however, 
 in which the discovery of the unfaithfulness of a wife 
 has been followed by her insanity, and other cases in 
 which it has been followed by the insanity of the injured 
 husband. 
 
SOCIAL STRESSES 25 
 
 The parental relationship is full of occasions of 
 anxiety, which are stresses that may contribute to 
 the production of insanity. Anxiety over the illness of 
 children, the strain and exhaustion of nursing them, 
 the grief over their profligacy or crime, worries as to 
 the means of supporting them, are all stresses which 
 help to produce insanity in parents who are not by 
 nature constituted to withstand exhausting emotions. 
 
 The stresses that arise out of the social relations 
 are not often sufficiently severe to provoke insanity, 
 but sometimes they have this effect. Man is a gregarious 
 animal, and cannot live a healthy life in solitude. If 
 he is compelled to live alone, there is much danger to 
 his mental health, and even if he does not live alone, 
 but his social circle is greatly restricted, the integrity of 
 the mind suffers. People who live in a very narrow 
 social environment, especially if their time is insuffi- 
 ciently occupied and their interests are restricted, are 
 extremely apt to exhibit morbid traits of mind and 
 conduct. They attach a monstrous consequence to 
 trifles ; they become fretful, irritable, and quarrelsome ; 
 and they are extremely apt to take to drink. Drink is 
 the curse of small communities. Prisoners who are 
 kept in solitary confinement have often become insane, 
 and although the causative influence of the solitude has 
 been repeatedly denied, no one who has been deprived 
 of congenial companionship for long stretches of time 
 can doubt that the deprivation has a serious effect upon 
 the mental health. When, as in the case of many 
 criminals, the man who is subjected to the deprivation 
 is originally a feeble being without mental resources, 
 its effect is necessarily more severe ; and, in practice, 
 solitary confinement for long periods has been in most 
 civilised countries abandoned. 
 
26 A TEXT-BOOK OF INSANITY 
 
 Not only is companionsliip of his fellows necessary 
 to the mental health of man, but it is of prime necessity 
 that he should secure their good opinion ; and the 
 loss of esteem, the knowledge that he is reprobated 
 and held in contempt and aversion, is a stress of so 
 severe a character that we might expect to find it a 
 frequent occasion of the onset of insanity. In practice, 
 however, we do not find it so. The Jabez Balfours and 
 Benjamin Lakes do not appear to be more prone to 
 insanity than are other criminals ; and the reason may 
 be that they are secluded from all actual experience 
 of the expression of this reprobation, and find themselves 
 but units among a crowd of others who are similarly 
 treated. 
 
 The religious circumstances in which a person lives 
 have not, at any rate nowadays, much influence upon 
 his sanity. The tumultuous emotional experiences of 
 a " revival," as it is termed, do, not infrequently, upset 
 the mental equilibrium of the feebler folk ; and we hear 
 of their falling in trances and being subject to con- 
 vulsions under the influence of the minatory preaching 
 of some eloquent enthusiast, and cases undoubtedly 
 occur in which such experiences are provocative of 
 insanity in persons previously disposed to become 
 insane ; but, in this country at least, the number of 
 such cases is insignificantly small. 
 
CHAPTER II 
 
 CONDUCT 
 
 Conduct is the pursuit of ends ; and an investigation 
 into the several activities that together constitute 
 conduct resolves itself into an analysis of the ends 
 which mankind pursue, and the apportionment to each 
 of its relative importance. 
 
 The outcome of the stupendous biological discoveries 
 of the latter half of the last century is to show that 
 all life is teleological, and that the great and ultimate 
 end to which all life is directed, towards which every 
 living being strives, for which every living being exists, 
 and to which all other ends are but means, is the con- 
 tinuation of the race to which the individual belongs. 
 To each individual, life is not a gift but a trust, to be 
 employed in transmitting life to a new generation ; 
 and, this purpose effected, the reason for the existence of 
 the individual is at an end. This is very clearly indicated 
 in the lives of many of the lower animals, in which re- 
 production is followed at once by death. Hence the 
 whole scheme of existence centres around the repro- 
 ductive function, and the first, the greatest, the most 
 important, the most fundamental group of activities 
 of which human, in common with all other living, 
 beings are capable, consists of those which directly 
 subserve the reproductive function, activities which in 
 mankind begin with the first approaches of courtship, 
 and do not cease until the last child is established in 
 
 27 
 
28 A TEXT-BOOK OF INSANITY 
 
 the world, and capable, in its turn, of handing on the 
 sacred fire of life to a succeeding generation. 
 
 Although, however, the reproductive activities are 
 the fundamental activities and the reproductive instincts 
 the fundamental instincts out of which the whole vast 
 fabric of human conduct has grown, yet these are not 
 the only activities of which human beings are capable, 
 nor are these the only desires they experience. We see 
 in nearly all the lower animals that the instincts of 
 reproduction, fundamental as they are, become active 
 for short periods only of their lives, and in some, such 
 as worker bees, ants, and wasps, the cruder desires are 
 altogether evanescent, and have no part in their lives. 
 In human beings also the instinctive desires of reproduc- 
 tion only occasionally obtain dominance, and in some 
 are as evanescent as they are in worker bees. In spite 
 of this very obvious fact, a new school has recently 
 arisen which looks upon crude sexual desire as not 
 only the fundamental desire, but also the dominant 
 desire, and as not merely occasionally asserting itself, 
 but as practically the one only continuous desire which 
 dominates the whole of human life. Every act, however 
 pure and remote from sexuality, even a day's shooting 
 or the keeping of a pet cat, is regarded by this school as 
 the expression of lust, so true it is that to the impure all 
 things are impure. 
 
 Before considering disorder of conduct in detail, it 
 should be noted that conduct of any kind is susceptible 
 of four different kinds of disorder, according as the 
 instinctive desire which prompts it is excessive, defective, 
 perverted, or reversed. Excess and defect need no 
 explanation, but I must explain that by perverted 
 conduct I mean conduct which tends or is calculated to 
 defeat the very instinct by which it is prompted. The 
 
REPRODUCTIVE CONDUCT 29 
 
 normal desire for food, for instance, prompts us to eat 
 things that are nutritious, and therefore appetising to 
 the normal man. When the appetite for food is per- 
 verted, it prompts the consumption of substances like 
 coals or clay, that are manifestly innutritions, and un- 
 appetising to the normal man. By reversal of instinctive 
 desire I mean the experience of a desire to do the very 
 reverse of what is prompted by the normal instinct. 
 The normal instinct of self-preservation prompts us 
 to avoid pain and bodily injury and discomfort ; above 
 all to avoid death. Reversal of this instinct prompts to 
 self -mutilation and suicide. The reproductive activities 
 fall naturally into three groups — those of courtship, of 
 reproduction proper, and of parentage. 
 
 The activities of courtship need not detain us, since 
 they are not very important, and are but little liable 
 to disorder. We witness in them, however, the same 
 curious phenomenon of reversal that we shall have to 
 notice in the manifestation of other instincts ; that is 
 to say, we witness conduct directed, not to the attain- 
 ment, but to the defeat, of the instinctive end. We 
 see women, instead of decking themselves in colours 
 and endeavouring to make themselves attractive by 
 becoming costume, assuming the trappings of a nun, 
 and adopting elaborate devices to make their appearance 
 repellent. 
 
 The reproductive function proper is subject to 
 several morbid aberrations. The commonest of these 
 is masturbation, to which a great deal of factitious 
 importance has been ascribed. There are few diseases 
 of the nervous system whose causation has not at one 
 time or another been attributed to masturbation, and, 
 in insanity, both the physician and the patient are 
 accustomed to regard it as a factor of the greatest 
 
30 A TEXT-BOOK OF INSANITY 
 
 importance. It is probable, however, that its share in 
 the production of insanity has been much exaggerated. 
 As far as it is possible to judge, it seems most likely 
 that very few lads pass through the period of adoles- 
 cence without sporadic and occasional indulgence in 
 this vice ; and it is certain that in many cases it is 
 practised with considerable regularity and frequency 
 without producing insanity. There is no doubt that 
 it is practised before the outbreak of the insanity by 
 a considerable proportion of those who become insane, 
 and by all who become insane before the age of twenty- 
 five ; and although it has unquestionably an influence, 
 varying with the person by whom, and with the extent 
 to which, it is practised, in precipitating the outbreak 
 and increasing its severity, yet it is to be regarded 
 upon the whole rather as a symptom than as a cause 
 of insanity in such cases. The excess with which it is 
 indulged in is due to that inherent lack of self-control 
 which is an inseparable part of insanity, and which is 
 so often conspicuous in its early stages. 
 
 Perversion of the sexual passion, or its direction 
 towards abnormal objects — towards the same sex, for 
 instance — and its gratification in abnormal ways — with 
 accompaniments of brutality and blood-thirstiness — are 
 subjects which have of recent years been treated by 
 certain writers with a lingering solicitude and a minute- 
 ness of detail out of all proportion to their importance. 
 It is true that cases of such perversion are not extremely 
 rare, but they are not usually attended by any other 
 symptom of insanity, and the question whether this 
 perversion in itself constitutes insanity is one which 
 can scarcely be considered here at length. It is cer- 
 tainly not so in law, and the abnormal gratification of 
 the sexual passion being a criminal ofience, the persons 
 
PABENTAL CONDUCT 31 
 
 who are addicted to these practices are convicted and 
 sentenced as sane people at every session of the Central 
 Criminal Court, excuse or mitigation of the offence, 
 upon the ground of the insanity of the act, being un- 
 known. 
 
 Disorder of parental conduct is not infrequent. 
 Among the lowest class of the population in large 
 towns the obligations of paternity are frequently 
 neglected or altogether ignored ; and the occasional 
 desertions of infants and young children are instances 
 of defect in maternal conduct, defects which are some- 
 times paralleled by parents in higher social strata. 
 Excess of parental solicitude, to the extent that the 
 health of the parent is damaged, and even the life 
 sacrificed, by devotion to the offspring, is not very 
 uncommon, but is not a wide departure from the 
 normal, for parenthood of necessity implies self-sacrifice. 
 Nor can that diversion of the parental instinct which 
 leads an old maid to lavish attention upon a pug-dog, 
 a cat, or a canary-bird, in the absence of any more 
 appropriate object, be looked upon as abnormal. There 
 are, however, perversions of the parental instinct which 
 evince manifest disorder. Chief of these is the rage 
 of destruction, directed against the new-born offspring, 
 which is such a frequent and terrible feature in the 
 insanity of child-bed. It is remarkable that this re- 
 version of the parental instinct occurs in connection 
 with parturition among the lower animals also. Dogs, 
 pigs, and rabbits frequently kill and devour their new- 
 born offspring ; and ewes will often repel, and leave to 
 perish of starvation, the weaklier of their twin lambs. 
 The parallelism does not explain the occurrence, how- 
 ever, though no doubt it indicates the direction in 
 which an explanation is to be sought, and at present 
 
32 A TEXT-BOOK OF INSANITY 
 
 this strange aberration of conduct remains inexplic- 
 able. 
 
 Next in importance to the reproductive activities 
 are the directly self-conservative — those activities 
 whose performance is necessary to the maintenance 
 of life from hour to hour and from moment to moment 
 — those by which obvious physical dangers to life are 
 averted. These are the activities by which a person 
 avoids falling into pits ; collisions with moving, and 
 eke with stationary, objects ; falling into fire or water ; 
 drinking scalding fluids ; running into dangers of 
 ferocious or poisonous animals ; and, generally, those 
 obvious dangers which prohibit us from leaving young 
 children without supervision. Defect of the activities 
 of this class is presented by all young children, and in 
 them the defect is normal ; but when it is prolonged 
 beyond the stage of childhood, the defect is morbid, 
 and is characteristic of that class of the insane that is 
 connoted by the term " idiot." Defect of these activities 
 is not always original. It may be acquired. While 
 idiots never attain to the degree of intelligence that 
 enables them to guard themselves against these obvious 
 dangers, there is another large class of the insane who 
 have acquired the activities of this class in full, but 
 who have subsequently lost them, and these activities 
 are among the last to be lost in the deeper degrees of 
 dementia. Deeply demented persons, no more than 
 young children, can safely be trusted to be alone. They 
 are apt to fall downstairs ; to set their clothes on fire ; 
 to lie naked and shivering with cold, for want of sense 
 enough to pull the bedclothes over them ; to trip over 
 steps, or buckets, or what not, and fall ; and to incur in 
 other ways dangers that arise from want of the simplest 
 care and forethought. 
 
FAULTY HABITS 33 
 
 Among these primitive modes of activity, which are 
 acquired at a very early age and are lost only when 
 the later stages of dissolution are reached, is that 
 which mankind shares not only with the great majority 
 of mammals and birds, but with bees and ants and 
 other social insects, of depositing his excrement at a 
 distance from his habitual haunts, and in such a manner 
 that it shall not soil his person and render it offensive 
 to himself and his fellows. This mode of conduct is 
 very often defective in insanity, and very often affected 
 out of its turn, as it were, and at a much earlier stage 
 of dissolution than we should expect. It is common 
 to find insane persons in good physical health, capable 
 of acts of considerable elaborateness, able not only to 
 feed themselves, to undress themselves, to converse 
 with some intelligence, to find their way from place to 
 place in their customary abodes, who yet, without any 
 paralysis of sphincters, pass their water and motions 
 under them as they sit and lie. Considering at what a 
 very early stage of development this faculty is attained, 
 it is remarkable that it should so often be lost long 
 before other faculties of much later attainment ; and 
 its loss is very significant and of very unfavourable 
 import. Whatever the form of the insanity, an insane 
 person who lapses from cleanliness in this respect rarely 
 recovers. Usually the first appearance of this symptom 
 marks the beginning of the end. In acute cases it 
 very often means that the patient is going to die; in 
 chronic cases it means that he is settling into hopeless 
 dementia. 
 
 This phase of conduct is susceptible not only of 
 defect, but of perversion. There are many insane 
 persons who not only soil their clothes with their 
 fseces, but who revel in paddling in their filth. They 
 
34 A TEXT-BOOK OF INSANITY 
 
 wasli their hands in it ; they knead it ; they take it 
 in their hands and plaster it about the walls and fur- 
 niture of their rooms, on their persons, on their faces, 
 and in their hair. Such reversal of the ordinary normal 
 conduct of mankind is difficult to account for, but 
 though it is not in all cases explicable, there are many 
 in which an explanation can be conjectured. There 
 a.^e some lunatics who are so lazy, whose detestation 
 of distasteful exertion is pushed to such an extreme 
 that they will wet the bed from sheer dislike of the 
 trouble of getting out to make water. Others there are 
 who are possessed by an impish spirit of malignity, and 
 whose desire to give trouble and to outrage the feelings 
 of those around them will manifest itself in this way ; 
 and finally — it is an extraordinary fact, but one that 
 cannot be doubted by those who have had much ex- 
 perience of the insane — that in some cases pleasure of 
 a sexual character is derived from these practices, and 
 they are undertaken with that end in view. 
 
 The other directly self-conservative activities are 
 likewise frequently perverted, and even reversed. 
 Instead of conduct being directed to the preservation 
 of life and the quest of pleasure, it is directed by a fury 
 of self-destruction and an unquenchable desire for the 
 self-infliction of pain and suffering ; and one of the 
 commonest of the forms which is exhibited by the 
 perversion of the self-conservative activities is the 
 unwillingness, often amounting to obstinate refusal, 
 to take food. The refusal to eat may be due to a con- 
 viction that all the food is poisoned, or it may be 
 deliberately adopted as a suicidal expedient ; and 
 both of these motives are frequent. But often it 
 is exhibited by patients who have not sufficient in- 
 telligence to form either the hypothesis or the inten- 
 
SUICIDAL CONDUCT 35 
 
 tion, but in whom it is part of a brutish resistiveness 
 which leads them to oppose every mode of activity 
 that is proposed to them. They struggle against being 
 fed with the same mulish obstinacy that they struggle 
 against being dressed, against being undressed, against 
 being sat down or stood up, against walking about, 
 against standing still, against every form of activity 
 that they are desired to undertake ; and their struggles 
 are varied by endeavours to injure those who have 
 care of them. The conduct that they exhibit reminds 
 us, on the one hand, of a wild animal that resents its 
 capture, and on the other of a jibbing horse ; and a 
 plausible explanation is to regard it as a resuscitation 
 of such obsolete instincts as these. 
 
 The craving for suicide and self-injury exhibits itself 
 in many other ways besides that of refusing food, and 
 perhaps its commonest expression is in a leap from a 
 window. Persons without experience of insane people 
 usually consider that if a window is shut and fastened 
 so that it cannot be opened, the precaution against a 
 suicidal leap through it is complete ; but a patient 
 who is determined upon suicide takes no account of the 
 obstacle of a mere pane of glass, and will jump through 
 a shut window as readily as through an open one. The 
 craving for suicide often exists without the pluck to 
 carry the intention into execution, and even among the 
 insane, many are saved from suicide by the lack of 
 courage ; but, on the other hand, in many cases the 
 determination is so fixed and obstinate that the most 
 unlikely means are employed for the purpose, the 
 greatest ingenuity and industry are exercised in finding 
 an opportunity, and nothing but unceasing vigilance 
 will suffice to prevent the act. A fragment of cup or 
 tumbler, of window-pane or chamber-pot, will furnish a 
 
36 A TEXT-BOOK OF INSANITY 
 
 cutting instrument which will serve to open a vein or an 
 artery. A ligature will be found in a garter, an apron- 
 string, a shred of clothing or sheet, or of unravellings 
 twisted together to form a string. A couple of inches 
 of water in a ditch or bath will suffice for drowning ; 
 the back of a chair or the rail of a bedstead is high 
 enough for a gallows ; a handkerchief squeezed into a 
 ball may be stuffed into the throat ; petroleum, or 
 furniture polish, or anything that seems nasty and 
 unwholesome, may be swallowed ; and thus the re- 
 sources of the would-be suicide are always at hand, and 
 the only efficient preventive is incessant and vigilant 
 watchfulness. 
 
 Short of suicide, the melancholic, who is deeply 
 impressed with his own unworthiness, will endeavour 
 to diminish and obviate his comfort as far as he can. 
 If he will eat food at all, it must not be savoury or 
 daintily served ; his bed must be hard, his clothing 
 coarse, his occupation distasteful. He insists upon a 
 morbid and unreasoning asceticism. 
 
 The third class of activities of which conduct is 
 made up comprises those which Spencer has termed 
 indirectly self-conservative — those by which the liveli- 
 hood is earned and the means are administered ; and 
 these also are often defective and sometimes perverted. 
 When defective, the defect, as in the previous class, 
 may be either original or acquired ; the activities 
 may never have been attained, or, once attained, they 
 may be lost. 
 
 Original defect of the indirectly self-conservative 
 activities is seen in two forms : the first, in which the 
 general level of intelligence is low, and the defect is but 
 a part and a manifestation of a general defect implicating 
 all forms of conduct ; the second, in which the defect 
 
ECONOMIC CONDUCT 37 
 
 is either confined to this particular division of conduct 
 or is in it much more pronounced than in any other, 
 the remaining divisions being comparatively complete, 
 and the general level of intelligence up to the normal. 
 The first of these classes is constituted by the imbeciles, 
 by those who attain to the directly self-conservative 
 activities, but fail to progress further ; or who attain 
 to some degree of conduct of this second class, but who 
 can never attain to the skill in any occupation that 
 is necessary to give their labour sufficient market 
 value for their support. They can do simple work, 
 but they cannot, unless carefully supervised, do even 
 the simplest work without making such blunders as 
 deprive the work of all value ; and when the cost 
 of the supervision is deducted from the value of the 
 labour, the balance is too small for them to live on. 
 If they are set to weed a garden, they will pull up 
 weeds and valuable plants indiscriminately ; if they 
 are set to beat a carpet, they will vigorously beat 
 it into a hole at one spot and leave the remainder un- 
 touched ; tools they will either break or injure them- 
 selves with ; letters they lose, or deliver to any one 
 but the addressee ; and so forth. 
 
 Inability to earn a living may be due to a totally 
 different defect. To earn a livelihood requires moral 
 as well as intellectual qualities. It needs steady in- 
 dustrj^. It requires such self-control, such self-denial, 
 such a degree of self-abnegation, as will allow of the 
 steady pursuit of an uninviting and perhaps repellent 
 employment, in spite of the solicitation of others by 
 which immediate pleasure may be gained. It means, 
 in short, the postponement of immediate pleasure and 
 the suffering of immediate pain, for the sake of greater 
 pleasure to be enjoyed in the future. And this ability 
 
38 A TEXT-BOOK OF INSANITY 
 
 of self-control differs very widely in different people, 
 and is by no means a function of the intellectual ability. 
 Either may be highly developed while the other remains 
 distinctly below the average ; and we frequently meet, 
 on the one hand, with stupid people whose sense of duty 
 is highly developed, and in whom self-control increases 
 into self-denial, and self-denial is pushed to asceticism ; 
 while, on the other hand, it is as frequent to meet 
 with clever people, persons of nimble intellect and 
 many accomplishments, who are so deficient in this 
 moral quality that they are incapable of continuing 
 any mode of occupation after it has ceased to be 
 pleasant and congenial to them. Such people are 
 deficient in the activities of the class now under con- 
 sideration. They are incapable of earning their live- 
 lihood, and incapable by reason of a defect, which 
 we may term mental or moral as we choose, but which 
 is a defect, not in the direction of idiocy or imbecility, 
 but of a totally different kind. 
 
 The ability to administer the means, when gained, 
 is of equal and even of greater importance than the 
 ability to earn a livelihood ; for, while the first is 
 obligatory upon every one, there are many people who 
 are relieved by the exertions of their predecessors from 
 all need to earn their own livelihood. Defect in the 
 administration of the means may take either of the 
 forms exhibited by defect in the earning of the liveli- 
 hood. It may be due to general defect of intelligence, 
 so that the subject of it is imable to appreciate the 
 amount of his income, unable to grasp the relative 
 values of different commodities, unable to appreciate 
 the different purchasing power of different sums of 
 money ; so that he is at the mercy of any dishonest 
 person who ohppses to ^sk hm half ^ sovereign for an 
 
FACILITY 39 
 
 ounce of tobacco or a box of matches, or to palm ofi 
 upon him a German lithograph as a genuine Raphael, 
 a broken-winded screw as a certain winner, ormolu 
 and glass as gold and diamonds ; so that he expends 
 his income and sinks into debt from sheer inability 
 to appreciate the relation between income and outgo. 
 Few persons are brought to ruin by this defect, how- 
 ever, for it is recognised in early life, and they are 
 usually made wards of court before they come of age, 
 so that the administration of their means is never in 
 their own control. 
 
 But the next defect is a very frequent one, and 
 brings scores of spendthrifts to ruin every year. It is 
 the moral defect of inability to postpone immediate 
 pleasure for the sake of a greater future benefit. The 
 spendthrift knows and appreciates the amount of his 
 income ; knows that the rate of his expenditure cannot 
 be maintained without inroad upon his capital ; knows 
 that he is living at a rate at which his capital will be ex- 
 hausted in a few years ; and yet the prospect of certain 
 ruin is insufficient to check his immediate indulgence. 
 
 Allied to this defect is that which is known in Scotch 
 law as " facility " ; that which is characterised by 
 an inability to say " No " ; and this defect may be 
 original or acquired. Often it is congenital. There 
 are very many persons of weak character who are 
 unable to withstand solicitation, who give to every 
 beggar and lend to every " sponge " money which they 
 know they cannot well afford, from lack of the moral 
 courage, force of character, or strength of will to refuse. 
 These are the people who are ruined by endorsing 
 bills and becoming security for their friends. Again, 
 there are people who, while in the vigour of health, 
 are able to repudiate such proposals, but who weakly 
 
40 A TEXT-BOOK OF INSANITY 
 
 accept tliem when enfeebled by illness or in the decay 
 of old age. These are the people whose wills are dis- 
 puted upon the ground of undue influence, who make 
 wills or deeds of gift in favour of their nurses or land- 
 ladies, to the exclusion of their own near relatives. 
 
 The administration of the means may be perverted. 
 The instinct of accumulation may be present in such 
 excess that expenditure is grossly inadequate. A man 
 who is well able to afford a house and a decent estab- 
 lishment will live in a single room, cook his own food, 
 go without such decencies of life as table-linen, carpets, 
 clean crockery, or change of clothes, deny himself the 
 use of artificial light, restrict to a dangerous extent 
 his fire, live a stranger to soap, comb, blacking, and 
 clothes-brush. When economy is pushed to such a 
 degree of miserliness as in the cases of Daniel Dancer 
 and John Elwes, the perversion of conduct in itself 
 constitutes insanity. 
 
 The next class of activities are those by which the 
 individual maintains his relations with the community 
 to which he belongs, and these, like other activities, 
 are susceptible of defect and perversion. 
 
 Communities exist by virtue of the self-restraint of 
 the component individuals, by which self-regarding 
 activity is limited so that the activities of the other 
 members of the community shall have free play within 
 similar limits ; and in order that the community may 
 hold together and continue, each individual must do 
 things for the common welfare which, if he lived in 
 solitude, he might without detriment leave undone. 
 When he lives in a community, he must so restrain 
 and regulate his activity as not to impair, nor even 
 to jeopardise, the safety, the property, and the self- 
 respect of his neighbours ; and more than this, he 
 
SELF-RESTRAINT 41 
 
 must take his share of the common burdens. He must 
 contribute to its security and defence both from in- 
 ternal and external dangers ; he must contribute to its 
 solidarity and cohesion, not only by abstinence from 
 disintegratory conduct, but by an active execution of 
 such deeds as draw closer the bonds of fellowship and 
 knit more securely the strands of society. He must 
 abstain from violence, dishonesty, and slander ; and, 
 above and beyond this abstinence, he must exercise 
 self-restraint in those hundred little ways by which the 
 conduct of a person in the presence of others is shorn 
 of indulgences which he allows himself when alone. 
 He must pay taxes, serve on juries, and contribute 
 by similar exercises to the common welfare ; and, in 
 addition to this, he must perform those acts of cere- 
 monial and small benevolence which, under the name 
 of politeness and courtesy, diminish repulsion and 
 increase cohesion among the units of which the society 
 consists. Thus each form of conduct, whether in- 
 hibitory or active, is divisible into a major and a minor 
 section ; and while the opportunities and occasions for 
 the exercise of the activities of the major section are 
 comparatively infrequent and few, the opportunities 
 and occasions for the exercise of the minor activities 
 are frequent and, so long as the individual is in the 
 presence of his fellows, continuous. Each major section 
 may be dealt with separately, while the minor may be 
 considered together. 
 
 The exercise of self-restraint, when it is directed to 
 the forgoing of whatever advantage may be gained by 
 injuring others in person, or property, or feeling, is 
 termed " morality " ; and the doing of such injurious 
 acts is " immorality," and may or may not be crime, 
 according as it is or is not pimishable by law. Im- 
 
42 A TEXT-BOOK OF INSANITY 
 
 morality and crime, while they are disorders of conduct 
 in the sense that they are departures from what the 
 universal consent of mankind admits that conduct ought 
 to be, are not necessarily disorders in the sense that they 
 partake of the nature of insanity. They may be sane 
 or insane according to circumstances, and the reader 
 who is interested in the circumstances which dis- 
 tinguish the sane from the insane variety of immorality 
 and crime should consult the article on *' Vice, Crime, 
 and Insanity " in Clifford Allbutt's " System of 
 Medicine," and the present writer's book on *' Criminal 
 Kesponsibility." 
 
 The ability to serve the community in active ways, 
 whether by partaking in its defence against internal or 
 external foes, or by undertaking municipal or political 
 duties, is precisely the same kind of ability as is re- 
 quired for the furtherance of the welfare of the indi- 
 vidual himself, and the same act which is undertaken 
 for the one end often serves the other ; so that no 
 separate treatment of the defects and disorders of this 
 division of conduct is needed. 
 
 It is in the minor activities of social life, in matters 
 of politeness, of convention, of ceremony, of courtesy, 
 that defect and disorder of conduct first exhibit them- 
 selves in those cases in which insanity comes on slowly, 
 or in which it does not advance far. As these are the 
 latest activities to be acquired, so they are the earliest 
 to decay in those cases in which an order of decay can 
 be discerned. When the defect of conduct is merely 
 quantitative — when, that is to say, there is a general 
 diminution of the amount of energy available for 
 expenditure in conduct, as in the gradual advance 
 of age — then defect is first and most perceptible in 
 those forms of conduct that denxand for their actua- 
 
GENERAL FAILURE OF CONDUCT 43 
 
 tion the largest amounts of energy, and activities are 
 abandoned in the order of the vigour which they need 
 and of the fatigue which they entail. Athletic exercises, 
 jumping, running, climbing, rowing, and so forth, are 
 the first to go ; and the acts of politeness and courtesy 
 which make so small a demand upon vigour and energy 
 are retained to the last. But when, as in insanity, 
 conduct suffers what may be termed a qualitative 
 defect — when activities are lost without respect to the 
 amount of energy needed for their execution, but in the 
 inverse order of their acquirement — then these little 
 offices are the first to show defect. In a large pro- 
 portion of cases of insanity defect of these qualities 
 is unnoticed, for the insanity comes on so rapidly that 
 the more fundamental and important activities of self- 
 conservation are reached at the outset, or very early in 
 the course of the malady ; and the disorder or defect 
 of these is such an important and such a conspicuous 
 factor in the case that the loss of the others passes 
 unnoticed. When a house is shaken by an earthquake, 
 we are too apprehensive of the collapse of the roof and 
 walls to notice the breakage of the crockery. Thus it 
 happens that, in a large proportion of cases of insanity, 
 defect and disorder of these qualities do not need to 
 be considered. But there is a numerous and very 
 important class of cases — cases that are the most 
 difficult of all to deal with in practice — in which these 
 minor activities alone exhibit disorder, and then it is 
 often difficult to recognise that insanity exists ; diffi- 
 cult, when one has satisfied oneself, to convey the con- 
 viction to others ; and often impossible to establish 
 a sufficient degree of insanity to set the law in motion 
 and sequestrate the individual from the management 
 ol himself and his affairs. 
 
44 A TEXT-BOOK OF INSANITY 
 
 When the minor social activities are disordered, 
 then the minor activities among the self-conservative 
 and reproductive activities are usually disordered along 
 with them ; and disorder of the whole group of minor 
 phases of conduct may now be considered together. 
 
 The beginnings of insanity, when insanity begins 
 slowly, are often very slight. The irritable man shows 
 such an increase of irritability as makes his family 
 stare ; the talkative man monopolises conversation 
 more completely than usual ; the uxorious man becomes 
 even more demonstrative ; the egotist brags more 
 audaciously ; the querulous complains more bitterly ; 
 the moody man has longer and more frequent periods 
 of deeper gloom ; any little peculiarity of conduct 
 which is native and not assumed becomes exaggerated. 
 In this stage insanity is not recognised ; indeed, in 
 this stage insanity does not exist. It needs a wider 
 departure from the normal to justify us in diagnosing 
 insanity, but yet this is the beginning of the malady ; 
 the difference between this state and recognisable 
 certifiable insanity is a quantitative difference, a 
 difierence of degree only, and a further advance of 
 the malady is marked at first by an exaggeration of 
 the same defects. 
 
 But if the most conspicuous features in the man's 
 normal conduct were artificial and assumed, if they 
 were the expression, not of deeper and more funda- 
 mental peculiarities of nerve structure, but of characters 
 of late acquirement, and therefore of little fixity and 
 endurance, then the mark of the onset of insanity 
 is a " change in the nature " of the man, and the change 
 is always in the direction of degradation. The kindly 
 and forbearing man becomes irritable and quarrelsome ; 
 the reticent man becomes expansive, and expatiates 
 
PLAUSIBLE INSANITY 45 
 
 to strangers and servants upon the misdeeds of members 
 of his family ; the refined and gentlemanly man con- 
 sorts with artisans and labourers, and frequents low 
 public-houses ; the man of cleanly life visits brothels, 
 and chums with loose women ; the cautious, prudent 
 man of business launches out in wild speculations ; 
 the modest, retiring man thrusts himself forward into 
 all kinds of society, writes long and familiar letters to 
 persons with whom he has only a bowing acquaintance, 
 asking favours, offering benefits, and making appoint- 
 ments ; the parsimonious man becomes lavish, and 
 the generous man parsimonious. 
 
 In this early stage of the malady no intellectual 
 defect may be apparent, or if there be any intellec- 
 tual defect, it is displayed only in the inability to 
 recognise and realise the impropriety of the conduct. 
 If you remonstrate or reason with him, you will be 
 astonished at the astuteness with which he justifies 
 and accounts for his conduct. You adduce instances 
 of his irritability and quarrelsomeness, and he admits 
 that he lost his temper, but, then, consider the pro- 
 vocation ! and he gives you an account of the incident, 
 not wilfully garbled, but highly coloured, and such 
 as, if you admit that it appeared so to him, you must 
 admit that his retaliation was not excessive. Does 
 he consort with labourers in low public-houses ? He 
 was unable to sleep, and at four o'clock on a summer 
 morning he dressed and went abroad. He has always 
 been interested in the lives of the labouring class, has 
 held night-schools for them, and started slate clubs, 
 and so forth. On this morning he met some of his 
 former pupils going to their work, and naturally began 
 to talk to them ; the conversation became so interesting 
 that he accompanied them to the house where they 
 
46 A TEXT-BOOK OF INSANITY 
 
 took their breakfast, and then could do no less than 
 stand them beer all round. Tell him that he is 
 squandering his means, and he will almost convince you 
 in spite of yourself that his expenditure was justified ; 
 that, in the first place, he could afford a flutter ; and, 
 in the second, the chances of success in his venture were 
 so great as to justify the speculation. 
 
 Disorder of other divisions of conduct is scarcely of 
 sufficient importance to need separate consideration. 
 Defect of religious conduct is common enough without 
 carrying with it any implication of insanity ; but 
 excess and disorder are occasionally seen, and are 
 more decidedly abnormal. When a girl passes whole 
 days and nights upon her knees in prayer, and cannot 
 be prevailed upon to rise, even to eat and drink, or 
 to take her fair share in the duties of the household ; 
 when a youth enters his father's office, harangues the 
 assembled customers upon their sins, prays aloud for 
 them, and finally dismisses them with his blessing ; 
 the morbid degree of the excess is no longer in doubt ; 
 but such disorder of the religious portion of conduct is 
 rarely the most important, is rarely even the most 
 conspicuous disorder. It is not so much the time 
 spent in prayer as the neglect of all other and more 
 urgent duties that is the important disorder in the 
 first case ; it is not so much in the second case the 
 prayer, as the inability to appreciate the inappropriate- 
 ness of his conduct, that is the important element in 
 the conduct of the youth. 
 
 The whole subject of Conduct and its Disorder is dealt 
 with fully and elaborately in my book so entitled, which 
 is the foundation of the study of insanity for the 
 advanced student. 
 
CHAPTER III 
 
 MIND 
 
 Although, as lias been said, insanity is not exclusively, 
 nor even primarily, disorder of mind, and although there 
 are many disorders of mind that are not insane, yet 
 some part of mind is always disordered in insanity, and 
 no account of insanity, or of the institutes or pro- 
 legomena of insanity, would be complete in which the 
 constitution of mind and the disorders of mind were 
 ignored. 
 
 It is many years since I first urged that since mind is 
 always disordered in insanity, and since the study of 
 order and of the normal should always precede the 
 study of disorder and of the abnormal, therefore an 
 indispensable preliminary to the study of insanity is the 
 study of the normal mind, and every alienist should 
 prepare himself for the study of insanity by acquiring 
 a competent knowledge of psychology. This doctrine 
 has at length been accepted, and to adopt a saying of 
 the late Sir Vernon Harcourt, we are all psychologists 
 now ; but the result has been not a little disappointing. 
 The study of normal psychology, as taught in authorita- 
 tive text-books, has proved of very little use, I may say 
 of no use at all, in assisting us to comprehend insanity. 
 I can scarcely recall a single instance in all the writings 
 of alienists of any application to insanity of any doctrine 
 taught in any text-book of psychology, nor do I find that 
 
 47 
 
48 A TEXT-BOOK OF INSANITY 
 
 a knowledge of psychology, as taught in any book on 
 the subject, has been of the slightest use to myself or 
 to anyone else, either in the investigation of any indi- 
 vidual case of insanity, or in the systematic study of 
 insanity at large. 
 
 If we compare this result with the result of the 
 corresponding study of the pathology of the nervous 
 system, we are struck by the discrepancy. Knowledge 
 of the pathology of the central nervous system has 
 proceeded fari passu with knowledge of its physiology ; 
 and our knowledge of both has advanced by leaps and 
 bounds in the last thirty years, while our knowledge of 
 the physiology and pathology of the mind has been 
 almost stationary. The moment we inquire into the 
 reason of this discrepancy we are struck by the fact that 
 our knowledge of the physiology of the central nervous 
 system is derived very largely from a study of the 
 changes produced by disease. It was by studying the 
 effects of disease on the central nervous system that 
 Hughlings-Jackson made those discoveries that after- 
 wards received experimental corroboration from the 
 researches of Hitzig and Ferrier ; and ever since then 
 the study of disease has gone hand in hand with ex- 
 perimental research in elucidating the physiology of 
 the central nervous system. In psychology, the experi- 
 mental method is not open to us, for the mind of man is 
 so immeasurably superior to the minds of even the most 
 intelligent animals, that conclusions cannot be carried 
 across from the one to the other ; and moreover, as I 
 have so often insisted with so little efiect, we cannot 
 observe directly the mental states and processes of 
 others. But for the study of mind we have at our service 
 a method that is not available for the study of the 
 central nervous system. We have the method of intro- 
 
PSYCHIATRIC PSYCHOLOGY 49 
 
 spection, by which each one can investigate his own 
 mind, and observe what passes therein. This method 
 takes the place, in the study of mind, that is taken by 
 experiments on animals in the study of the central 
 nervous system ; but whereas in the latter the results 
 of experiments are perpetually collated with the results 
 of disease in the human subject, in the former the 
 results of introspection have never been collated with 
 the phenomena of disease ; and consequently the two 
 methods of research have afiorded no assistance to 
 each other, and their results have diverged so widely 
 that, until some effort is made to collate them, they can 
 afford no assistance to each other. 
 
 It is found by the physician that certain faculties of 
 mind are frequently disordered, and the disorder of 
 them is a prominent and important symptom in the 
 cases that come before him ; but when he turns to 
 psychology for a description of these faculties, he finds 
 that they are not mentioned, and that psychologists 
 do not know of their existence. For instance, Self- 
 estimation, which undergoes such extremely important 
 disorders in insanity, is not so much as mentioned in 
 any book of psychology known to me. Nothing is 
 more important to the student of insanity, and to the 
 student of sane disorders of mind, than the grading of 
 the several mental faculties into their several evolution- 
 ary levels or strata, without which it is quite impossible 
 to understand, much less to localise, the different 
 disorders of mind, or to distinguish those that are 
 compatible with sanity from those that are insane ; 
 yet no attempt to distinguish any evolutionary grade 
 except the lowest is made in any book on psychology. 
 While these factors in mind that are so important to 
 the student of the disordered mind are omitted from 
 
 E 
 
50 A TEXT-BOOK OF INSANITY 
 
 every treatise on psychology, these treatises devote a 
 very large proportion of their space, and assign a very 
 prominent position, to matters that are to the alienist 
 utterly unimportant and useless. The whole analysis. of 
 Sensations, in as far as it is of value at all in medicine, 
 is relegated to the province of the physiologist and the 
 general physician, and does not concern the alienist as 
 such ; nor need he ever consider, except as an academic 
 exercise, the association of ideas, the nature and varieties 
 of attention, the relation of thought to language, 
 imagination, conception, or a hundred other topics 
 which the psychologist treats at length. The difierences 
 between Analysis and Synthesis, between Affirmation 
 and Negation, between Association and Suggestion, 
 are naught to the alienist ; what may be the basis of 
 Time perception, or Space perception, or of apprehension 
 of Form, is a matter of utter indifference to him ; the 
 various laws discovered by psychologists — the laws of 
 Eelativity, of Suggestion, of Association, Weber's Law, 
 Fechner's Law — are not violated in insanity, or if they, 
 are, the violation has no significance whatever for the 
 alienist ; and if he ever learns what is meant by Apper- 
 ception, he finds, when he enters the wards of a lunatic 
 asylum, that the sooner he forgets all about it the better 
 he will understand the disorders of mind from which 
 his patients suffer. 
 
 In order to understand disorders of mind, to dis- 
 tinguish the disorders of mind that are sane from those 
 that are insane, to analyse disorders of mind, and to 
 localise and identify the faculty and grade of mind that 
 are disordered in any particular case, it is necessary to 
 forget all the teachings of psychologists, and to formu- 
 late a scheme of mental faculties ad hoc. I do not say 
 that the text-books of psychology are wrong ; I only say, 
 
MENTAL FACULTIES 51 
 
 what every alienist will corroborate, that for the purpose 
 of the alienist they are useless. For this purpose it is 
 necessary to make such a division and explication of 
 the various faculties of mind as shall throw into pro- 
 minence those that are liable to be disordered, any others 
 not so liable, or whose disorder cannot be discovered, 
 being neglected ; and it is of even greater importance 
 to grade these faculties into what Hughlings-Jackson 
 called "evolutionary levels," that is to say, into degrees 
 of elevation from the simple to the complex, from the 
 crude to the elaborate, from the fundamental to the 
 accessory, from the primitive to the derivative, and 
 from that which was earliest in origin to the most 
 lately acquired product of evolution. Dr. HughHngs- 
 Jackson marked of! in the nervous system three such 
 grades or levels, lowest, middle, and highest, but he 
 would have been the first to admit and declare that 
 such levels are but arbitrary divisions of a series that 
 is, in fact, continuous, just as the horizontal bars of a 
 window divide the gradual tints of the sunset sky. In 
 such a continuous gradation it is a matter of mere 
 convenience and of arbitrary convention how many 
 divisions we make and where we place them, and 
 therefore I have no hesitation in substitutins for the 
 three levels into which Hughlings-Jackson divided the 
 nervous system, a fourfold division of grades or levels 
 of mind, which enables us to localise disorders with 
 greater minuteness and accuracy. 
 
 I first divide the mind into certain primary faculties, 
 each of which is found in experience to be subject to 
 disorder. These are seven in number, and five of them 
 are then redivided into four evolutionary grades or 
 levels, so that if we range the faculties side by side, and 
 regard the horizontal division into levels as cutting 
 
52 A TEXT-BOOK OF INSANITY 
 
 across them, we obtain, as it were, a series of pigeon- 
 holes, vertically four deep, and numbering horizontally 
 as many as the faculties that we choose to constitute. 
 Into one of these pigeon-holes every disorder of mind 
 should be placeable. Perhaps it is as well that I should 
 declare that I do not regard the mind as composed of 
 pigeon-holes, nor do I suppose that it is actually con- 
 stituted on any such plan, any more than I suppose 
 that the surface of the earth is truly represented by a 
 map on Mercator's projection. Nevertheless, maps are 
 useful helps to finding our way about the country, and 
 estimating the relative positions of places on the surface 
 of the earth ; and such a Mercator's projection of the 
 topography of the mind as I propose will be found 
 useful in understanding the intricacies of the mind, 
 and in estimating the relations of the several parts that 
 participate or do not participate in any disorder. 
 
 The plan by which I represent the constitution of 
 mind is a complicated one, but then the mind of man 
 is extremely complex, and any simpler plan would not 
 represent that constitution with any approach to 
 correctness. I do not say that the plan that I propose 
 represents the true relations of the several faculties 
 of mind, for it is obvious that that which is not in 
 space can scarcely be accurately represented by spacial 
 relations. My scheme does, however, provide a 
 systematic plan of a large area of mind, a plan such 
 as has not hitherto been in existence ; and although 
 some departments of mind will not go very comfort- 
 ably into my pigeon-holes, and others are advisedly 
 omitted altogether, and although the scheme is ad- 
 mittedly crude and imperfect, and will no doubt be 
 found susceptible of improvement in the future, yet I 
 submit that even a crude and imperfect plan is better 
 
MENTAL FACULTIES 53 
 
 than no plan at all ; and I have myself found it of such 
 great assistance in investigating and classifying mental 
 disorders that I camiot think it will be useless to others 
 who are engaged in the same pursuit. 
 
 The primary faculties into which I divide the mind for 
 the purpose of studying and locaHsing mental disorders 
 are five : — Desire, Will, Feeling, Thought, and Memory, 
 or, since I divide each into grades or levels, they may 
 be termed, Desires, Volitions, Feelings, Thoughts, of 
 which the most important are Beliefs, and Memories. 
 Two of these, Feelings and Thoughts, are split down 
 vertically into an objective and a subjective side, so 
 that in all there are seven primitive faculties of mind. 
 All these, with the exception of Memory, are again divided 
 horizontally into grades or evolutionary levels, of which 
 I make four, so that altogether there are twenty-five 
 pigeon-holes or compartm^ents, in one or more of which 
 every disorder of mind can be placed. 
 
 Let me again declare, though no doubt I shall be 
 taken to task just as if the declaration had never been 
 made, that although the mind is rightly and naturally 
 divisible on this scheme, yet the distinctions and divisions 
 are arbitrary, conventional, and made more for the 
 purpose of practical convenience than of scientific 
 accuracy. Emotion, for instance, is classed among the 
 objective feelings, though it contains large ingredients 
 not only of subjective feeling, but of thought also. 
 Ingenuity is classed on the objective side of thought, 
 though it contains a large subjective element. 
 
 The second principle of division, into evolutionary 
 grades or levels, should be familiar to every student of 
 neurology, and should need little explanation. I take 
 it that there is a continuous series of desires, from the 
 crude desire for food to the refined desire for justice ; 
 
54 A TEXT-BOOK OF INSANITY 
 
 that there is a continuous series of volitions, from the 
 elementary choice of this potato out of the dish, or this 
 cigar out of the box, to this rather than that career in 
 life ; of thoughts, from the simple perception of an 
 object to the highest flights of speculative genius ; of 
 feelings, from the crude pleasure of eating and the 
 crude pain of bodily injury to the refined pleasures of 
 benevolence and sympathy and the refined pain of 
 bereavement and indignation. In each of these con- 
 tinuous series I draw, at arbitrary distances, three 
 transverse lines, dividing them into four levels or 
 strata ; and thus the skeleton outline of my plan is 
 complete. It now remains to fill it in. 
 
 Before doing so, however, it will be well to state 
 generally, what will be abundantly illustrated in par- 
 ticular cases, that in practice we find that any one of 
 these faculties may alone be subject to disorder, the 
 others remaining normal, or with only such errors in 
 action as are strictly consequential to the disorder of 
 their erring colleague ; and not only this, but any level 
 of any faculty may suffer disorder without implicating 
 the level of that same faculty above or below the level 
 that is disordered. It is this possibility and this occur- 
 rence of limited disorder that gives to the plan of mind 
 here elaborated most of its validity and usefulness. It 
 is quite true that several faculties may be simultaneously 
 disordered on the same or on difierent levels, and it is 
 true also that any one faculty may be disordered on 
 more than one level ; and it is the occurrence of these 
 single or multiple disorders that constitute the various 
 types and kinds of disorder of mind and the various 
 forms of insanity ; but the important thing is that 
 when we have a plan of this kind before us, it constitutes 
 a system on which the mind may be investigated ; and 
 
DESIRE 55 
 
 it constitutes also a plan upon which the disorders can 
 be mapped out, so that we can see at a glance in any 
 case what faculties are disordered, upon what levels, 
 and how far the disorder extends in this direction or in 
 that. 
 
 DESIRE 
 
 Insanity is disorder of conduct, and conduct is 
 prompted and actuated by desire. Without desire to 
 achieve ends, without aversion to. certain experiences, 
 there would be no motive to conduct, and therefore 
 no conduct. All conduct is undertaken for the satis- 
 faction of some desire or the avoidance of some aversion, 
 which is the complementary antithesis to desire, and 
 the first department or faculty of mind, the faculty 
 that lies at the base of mind and constitutes its founda- 
 tion, the faculty to which all conduct is due, is Desire. 
 
 The several grades of desire correspond with the 
 several departments of conduct that have been already 
 enumerated and examined. It has been pointed out 
 in a previous chapter that all Hfe is teleological — is 
 inspired by a purpose — and that the prime purpose 
 of every living thing is to continue the stirp to which it 
 belongs. In the human being this primary purpose is 
 so overlaid and obscured by a multitude of secondary 
 and subsidiary purposes, many of which have become, 
 by a process explained in my book on Conduct, ultimate 
 purposes pursued for themselves alone, that the primary 
 end of the life of man is apt to be forgotten or to remain 
 unrecognised, but in him it is the same as in all living 
 beings ; and since animate beings do not strive to efiect 
 a purpose unless they are prompted and urged to do 
 so by desire, the central fact in mind is the existence 
 of the desires of reproduction and of maternity. These 
 
56 A TEXT-BOOK OF INSANITY 
 
 desires, therefore, form the lowest stratum or level of 
 the series or stack of Desires. Reproduction cannot 
 be effected unless life is preserved to the reproductive 
 age, nor can the offspring be reared, nor reproduction 
 be repeated, unless life is preserved after reproduction 
 is effected ; and hence self-preservation is a necessary 
 preliminary and accompaniment of reproduction, and 
 the corresponding desire for self-preservation, the dread 
 of death, of bodily injury, and of illness, are immediately 
 necessary and subservient to the racial desires. The 
 desire of self-preservation from injury and death forms, 
 therefore, the second level or stratum in the stack of 
 desires. But immunity from bodily injury is not the 
 only condition necessary for the survival of the indi- 
 vidual. If he is to survive and to reproduce his kind, 
 it is necessary, as human life is now carried on, that he 
 should be fed, clothed, housed, and employed to 
 advantage ; and in order that he may do the things 
 necessary to secure these requisites, he must have a 
 further set of desires — for occupation, of accumulation, 
 and so forth, and these form the third stratum in the 
 stack of desires. Lastly, struggle for life with cir- 
 cumstances, inorganic, organic, and super-organic, has 
 led to the desire, so powerfully effectual in securing 
 survival, of living together in communities ; and the 
 exigencies of social life have given rise to another 
 large and important group of desires, which prompt 
 and urge to conduct tending to preserve and consolidate 
 and advance the community to which the acting indi- 
 vidual belongs. These form the topmost level of 
 desires, and complete the four grades into which this, 
 in common with the other compartments of mind, is 
 divided. 
 The disorders of desires are for the most part ex- 
 
OBSESSION 57 
 
 pressed in corresponding disorders of conduct, and 
 what has been said in a previous chapter of disorders of 
 conduct need not be repeated here ; but there is one 
 disorder of desire that often struggles to express itself 
 in conduct, but that is usually overborne by will, and 
 prevented from finding expression. This disorder is 
 Obsession, a term that like other terms in psychology 
 is constantly misused. It is employed to mean delusion, 
 imperative idea, prejudice, and other mental states. 
 The true meaning of obsession is . a morbid desire to 
 do some act which the would-be actor discountenances, 
 struggles not to do, and can usually, probably always, 
 succeed in refusing to do. Most of us have experienced 
 at one time or another a minor and trivial form of 
 obsession. We find some familiar form of words — a 
 proverb, a line of verse, a text from Scripture, or what 
 not — " running in the head." We say it over and over 
 again silently to ourselves, and as we do so we ex- 
 perience a more or less urgent desire to say it aloud. 
 This desire can be resisted. Very often it is not re- 
 sisted, for the whole afiair is so trivial that it is not 
 worth while to summon up the will to overpower the 
 desire ; so at length the words get themselves uttered 
 aloud. Or it may be that in walking along the street, 
 we have the absurd and irrational desire to step upon 
 the divisions between the flagstones, or to avoid step- 
 ping upon them, as the case may be, and here again, 
 the desire is often not resisted because it is not worth 
 while to resist it. It is allowed to have its way, and we 
 regulate our footsteps accordingly. But we feel all the 
 while that we could resist if we pleased, and could if 
 we chose disregard the desire, and pursue our walk 
 without reference to it. Sometimes, however, the 
 obsession is not of this innocent nature. The words 
 
58 A TEXT-BOOK OF INSANITY 
 
 that arise in the mind and clamour for utterance may 
 not be mere innocent proverbs or texts ; they may be 
 objurgatory, or obscene, or blasphemous. The act that 
 suggests itself and demands execution may be not the 
 innocent act of stepping on or avoiding the divisions 
 between the flagstones : it may be the act of cutting 
 a throat or throwing a child out of window. In such 
 cases it is urgently necessary to summon up the will to 
 inhibit and prevent the execution of the act ; and in 
 experience it is found that the will has almost always 
 sufficient power and authority to keep order in the 
 mental household and prevent the perpetration of the 
 act. There are, indeed, a few cases on record in which 
 the will has been felt incapable of resisting, and external 
 aid has been sought. The unfortunate sufferer has given 
 himself up to the police, or sought the shelter of an 
 asylum, andbegged to be physically restrained from carry- 
 ing out a purpose that he felt was not his purpose ; and 
 now and then a case has occurred in which some minor 
 obsession, such as that to steal objects of a certain class, 
 has been yielded to. But it is still doubtful whether the 
 will would have been ineffectual to restrain these acts 
 if it had been sufficiently appealed to. No doubt, when 
 the obsession is unusually intense and persistent, such 
 sufferers do become after a time weary of the struggle, 
 but in the cases in which they place themselves under 
 restraint, it is clear that their wills are competent to 
 overcome the morbid desire up to the time of so placing 
 themselves, and my own opinion is that such persons 
 place themselves under restraint, not so much because 
 they feel their wills giving way, but in order to obtain 
 relief from the fatigue of the conflicts between will and 
 desire. In the rare cases of stealing under obsession, I 
 believe that the appeal to will was ineffectual because 
 
VOLITION 59 
 
 it was half-hearted — in other words, that the thief 
 could have resisted, but did not. 
 
 In all cases of obsession, what happens is a conflict 
 between a lower desire and one that is more elevated, 
 an occurrence that is frequent enough in the experience 
 of us all. WTiat stamps the obsessive desire as morbid, 
 and removes the conflict from the class that is so 
 frequent with us all, is its unprofitable character. The 
 desire, if carried out into action, would do the actor 
 no good. He would not benefit, nor would anyone else 
 benefit by the accomplishment of the purpose represented 
 by the desire. This is true even of obsessions to steal, 
 for the objects on which the obsession fixes are not 
 usually objects whose possession would materially 
 benefit the obsessed. 
 
 In obsession, then, we witness a disorder of desire, 
 whose nature is a rebellion of a lower desire, a desire 
 whose purpose is always useless, and is sometimes 
 highly pernicious to the person by whom it is felt, 
 against the higher desires for his own welfare and that 
 of those who are near and dear to him. It is the rebellion 
 of a lower level against a higher level, the like of which 
 we shall witness again and again in the other faculties, 
 and thus, although it is always regarded as a unique, 
 a bizarre, and an unaccountable disorder, we find that 
 it ranges itself along with others, and belongs to a class 
 of mental disorders that is by no means uncommon. 
 
 WILL 
 
 As has been said, Desire is the motive of all conduct, 
 and without the prompting and urging of desire, animate 
 beings would undertake no action, and display no 
 conduct ; but between desire and action there inter- 
 
60 A TEXT-BOOK OF INSANITY 
 
 venes a second mental factor, without which desire, 
 however urgent and overwhelming, would never find 
 expression in action. This factor is Will, or Volition, 
 the immediate antecedent, and as far as we know, the 
 immediate cause, of action. In the experience of us 
 all, desires often conflict. One desire pulls this way, 
 another pulls that : one desire prompts to a certain 
 course of action, another to the opposite. It seems 
 that in such a case the stronger desire will and must 
 prevail, but examination of our own consciousness does 
 not support this view. It seems, if we watch the 
 turmoil in our own minds, that on some occasions will 
 intervenes, and gives the weaker desire dominance over 
 the stronger. However that may be, it is as certain 
 as universal experience can make it that whatever the 
 urgency of a desire may be, it can to some extent be 
 checked and controlled by the will, and in no case does 
 it find expression in conduct until will gives its sanction 
 and exerts itself to produce the outward act. Volitions, 
 then, constitute the second of the great faculties of 
 mind, the second nest of pigeon-holes into which mind 
 is for convenience divided; and volitions, like other 
 mental processes, may be graded into levels. 
 
 On the highest level are those volitions which deter- 
 mine our conduct in the gravest and most important 
 affairs of life — ^in those matters which determine our 
 general success or failure — affairs whose success gives 
 rise to exultation, and whose failure causes despondency. 
 On the upper middle level are those volitions by which 
 choice is made and action determined of the means 
 that should be employed to attain the important 
 results determined on by the highest class of volitions. 
 The lower middle level is constituted of volitions on 
 matters less important and subsidiary to the last, the 
 
DISORDERS OF VOLITION 61 
 
 daily decisions about daily affairs ; and the lowest level 
 by choice on trivial matters of momentary import, 
 such as which shoe or stocking to put on first, which 
 book to amuse an idle hour with, which peach or which 
 potato to select out of the dish, and so forth. 
 
 Vohtion is subject to several disorders, which fall 
 naturally into two kinds, the spontaneous and the 
 reflective. By a spontaneous disorder of will, I mean 
 a disorder of will which is manifested spontaneously 
 by the person affected, and does not need the incidence 
 of circumstances to call it out. By a reflective or elicited 
 disorder of will, I mean one which is not manifested 
 except under the influence of the wills of other persons. 
 
 The spontaneous disorders of will are three — ^Delay, 
 Vacillation, and Precipitation. Whenever the will is 
 exerted, whenever a volition is effected, the mental 
 operation is preceded by an interval, which may be 
 prolonged, or may be so brief as to be inappreciable, 
 and which is called hesitation. The duration of this 
 preliminary interval varies with the level of the volition 
 that is being exercised. Volitions of the uppermost 
 level may normally be preceded by a prolonged period of 
 hesitation. When the choice to be made is on a m^atter 
 that will influence the whole of the subsequent life, 
 when, for instance, it is the choice of a calling, or of 
 adhering to or abandoning a calling, or when it is 
 whether the calling should be followed at home or abroad, 
 whether an appointment of less but certain advantage 
 shall be sought rather than one of greater but less 
 certain advantage, when it is whether some important 
 offer shall be accepted, or some important step shall 
 be taken, it is legitimate, normal, and desirable to 
 hesitate long, and to ponder deliberately, it may be 
 for weeks or months, before the volition is exercised 
 
62 A TEXT-BOOK OF INSANITY 
 
 and the final decision taken ; but when the matter in 
 question is of the means to carry out an end already 
 determined upon, when it is not whether we shall spend 
 the greater part of our life in India or South Africa or at 
 home, or whether we shall leave the Church of our 
 fathers and our upbringing and join another, or enter 
 into partnership with Jones or not, or some such mo- 
 mentous decision, but is whether we shall take a house 
 in this suburb or that, or an office in this street or that, 
 or invest a spare thousand in this security or that, a 
 hesitation of weeks or months would be manifestly 
 inappropriate and excessive. Hours or days would be 
 long enough to hesitate over such matters as this. 
 Decisions on the lower middle level may properly be 
 still more brief. Minutes would be enough time to 
 consume in hesitating whether to send for Dr. Smith 
 or Dr. Brown for the baby's illness, whether it is 
 necessary to go in person from London to Birmingham 
 to transact the business, or whether a letter will not 
 suffice ; whether to buy this picture or that bracelet 
 would or would not be unjustifiable extravagance. 
 Finally, volitions on the lowest level are normally made 
 without appreciable hesitation. In novels, it is true, 
 the characters always " carefully select " a cigar out of 
 the box, but anyone who did so in real life would be 
 stared at. A choice of this kind is made instantaneously, 
 and even in buying a pipe or a walking-stick, no normal 
 person would hesitate more than momentarily ; and so 
 with the decision whether to walk or take a cab ; whether 
 to go to church or stay at home, whether to play billiards 
 or cards, whether take the short and muddy path across 
 the fields or the longer and cleaner way by the road, 
 may admit of momentary hesitation, but not of a hesita- 
 tion that is more than momentary. 
 
EXCESSIVE HESITATION 63 
 
 No doubt other considerations than the importance 
 of the decision do enter into the determination of the 
 length of hesitation, and such determinants as the 
 number of the alternatives among which the choice is 
 to be made, and the equality in advantage of the 
 difierent alternatives, have an important efiect ; but 
 for the present purpose all that we need take into 
 account is the importance of the decision, or the evolu- 
 tionary level of the volition concerned. 
 
 The first of the spontaneous disorders of voHtion is 
 the undue prolongation of the period of hesitation. In 
 this disorder there is abnormal delay in "making up 
 the mind," and it seems that even when the mind is 
 made up, and the course of conduct decided upon, there 
 is some obstruction to the exercise of the will, so that 
 the action is delayed. In such cases not only is some 
 choice of the lowest level, such as which shoe or which 
 stocking is to be put on first, preceded by a period of 
 hesitation that may run on for ten or fifteen minutes, 
 but when some simple act, such as pouring out the 
 tea, is decided upon, an unaccountable delay occurs 
 before the hand can be stretched out and the teapot 
 grasped and lifted. In the latter case the interval is 
 usually occupied in giving way to the obsession of 
 counting. Before every action of the most trivial 
 kind the patient is obsessed, and yields to the obsession 
 of counting, usually up to ten, or some multiple of ten. 
 Before the teapot can be grasped, ten must be counted ; 
 before the tea can be poured into the cup, ten more 
 must be counted ; before the milk can be added, ten 
 must be counted again ; and yet again before the 
 sugar is dropped in. In other cases there is merely 
 excessive hesitation without obsession. 
 
 Closely allied to excessive hesitation is Vacillation, 
 
64 A TEXT-BOOK OF INSANITY 
 
 a disorder which occurs at a slightly later stage, after 
 the action is begun, and consists in repeated interruption 
 and renewal of an act. In this disorder the patient will 
 not, as in hesitation, sit contemplating his shoes, 
 unable to make up his mind which to put on first, but 
 will seize first one, with the intention of putting it on, 
 and will instantly abandon it and take up the other. 
 He will get the right shoe half on and kick it ofi again 
 in favour of the left, and so he will go on with other acts 
 throughout the day. He decides to go and buy some- 
 thing — starts and comes back half a dozen times. He 
 gets to the shop at last, enters it — and comes out again 
 without making his purchase. He goes back and selects 
 the pair of gloves he wants — ^rejects them in favour of 
 another pair — ^rejects these and takes the first pair — 
 rejects these again for the second, and so on ; and so 
 throughout the day. Undue hesitation often exists 
 alone, without a trace of vacillation, but vacillation, 
 which seems to be a more advanced stage of hesitation, 
 rarely exists without hesitation. 
 
 The third variety of the spontaneous disorder of 
 volition is the reverse of undue hesitation. It is 
 precipitation in volition. It is the sudden and precipi- 
 tate willing of an act whose advantage and disadvantage 
 have received no adequate consideration, or have not 
 been considered at all. Some degree of precipitation 
 is common enough, and does not transcend the limits 
 of the normal. There are plenty of people who act 
 impulsively upon occasion, and who suffer the conse- 
 quences of doing so, without the impulsiveness reaching 
 the degree of actual disorder of mind. The impulsive- 
 ness that constitutes disorder is very rarely precipitation 
 pure and simple ; that is to say, it rarely or never 
 consists in the precipitate choice of one out of several 
 
IMPULSIVENESS 65 
 
 sane and reasonable alternatives. Such impulsiveness 
 is frequent enough, and may be supremely sane, for 
 there are a few rare spirits, of whom Napoleon Bona- 
 parte is the most conspicuous, who appear to seize 
 instantly and intuitively, even in the most important 
 and most complicated afiairs, upon the course of conduct 
 that proves in those circumstances the most advan- 
 tageous. The impulsiveness that marks disorder of 
 mind is the precipitate willing of some act that is itself 
 on the face of it unreasonable and disadvantageous, and 
 that it is dijB&cult to believe that even the disordered 
 intellect would have sufiered the person to choose if 
 time had been allowed for a deliberate choice to be 
 made. Precipitate volitions that are morbid are morbid 
 not only in their precipitation : they are morbid also 
 in the character of the act that is done, but still, the 
 impulsiveness of the act is its leading and most dis- 
 tinctive quality. Morbid impulsiveness may show 
 itself in a sudden leap from a window, and then the 
 impulsiveness may be so extreme that no time is taken 
 even to open the window ; or it may show itself by a 
 sudden tearing of the cloth ofi the table with all the 
 covers and viands upon it ; or it may show itself in any 
 other sudden act, which may be self-destructive, or 
 destructive of others, or destructive of things merely ; 
 but which is usually destructive of something. 
 
 The reflective or elicited disorders of will are, as the 
 title implies, not exhibited except in circumstances that 
 call them forth ; and these circumstances are the ex- 
 pression of the will of others. It is a common observa- 
 tion that different persons differ normally both in the 
 power of impressing their wills on others, and in the 
 power of resisting the will which others seek to impress 
 on them, or do impress on them without seeking to do 
 
66 A TEXT-BOOK OF INSANITY 
 
 so. Here we do not consider the power of impressing 
 the will on others, but solely the power, and aptitude, 
 and practice of resisting the will or the suggestion of 
 other people. This power, normally variable, attains 
 in disease to extremes that are in themselves mani- 
 festly morbid. There are persons in whom it is so 
 deficient that they are at the mercy of those around them, 
 or more usually of one person of their acquaintance, 
 and fall in, with canine obedience, with every suggestion 
 that these others or this other may make to them. Such 
 suggestibility is recognised by Scotch law as an occa- 
 sional feature in human nature, and certain provisions 
 of that law are specially designed to protect the Facile 
 person from plunderers who would take advantage of 
 his facility. 
 
 The opposite attitude of Stubbornness or Kesistive- 
 ness, though not very frequent, is sufficiently frequent 
 in insanity to render it remarkable that it was never 
 described until the description appeared in the first 
 edition of this text-book. That description may be 
 repeated here : — Patients of this type do not speak. 
 They make for the door, the window, or the fire, and 
 when restrained will continue for hours the same silent, 
 dogged, determined effort to reach the desired destina- 
 tion. They, too, undress themselves, but they do so, 
 not, as the acute maniac does, from the mere exuberance 
 of their activity, which must find some vent, it matters 
 not what, and which, when restrained from taking oJS 
 the coat, begins to unbutton the waistcoat or trousers. 
 A patient of the resistive type undresses himself with 
 the same blind dogged obstinacy that he does every- 
 thing else. He persistently, again and again for hours 
 together, attacks the same button, or tries to remove the 
 same garment in the same way. He, too, refuses food, 
 
SUBJECTIVE FEELING 67 
 
 but he refuses it not, as far as can be judged, with 
 suicidal intent, but with the same resistiveness with 
 which he stubbornly opposes everything that is done 
 for him, and everything that is suggested to him to do 
 — refuses to be dressed and to be undressed, to sit down 
 or stand up, to go to the closet or come away from it, 
 to walk about or to stand still. Stubbornness seems 
 to rest, in the last resort, upon excessive suspicion, and 
 it is probably on account of the suspicion, or more, the 
 conviction, that everyone is antagonistic towards him, 
 that the stubborn person adopts his attitude of 
 stubbornness. At present, however, we are not con- 
 cerned with the combinations of disorders, but solely 
 with single disorders of single faculties, and of these 
 Stubbornness is one of the most pronounced and 
 remarkable. 
 
 FEELING I. SUBJECTIVE 
 
 Under this heading I include two difierent groups of 
 mental states, each of which is susceptible of division 
 into the four evolutionary levels into which the other 
 faculties have been divided. I call the two groups 
 respectively Subjective and Objective, names that have 
 been so abused and are so generally misapplied that I 
 hesitate to use them, but no others are as appropriate. 
 
 By a Subjective Feeling I mean a feeling of pleasure 
 or pain ; and it is easy to see that there are several 
 grades or evolutionary levels of pleasure and pain. On 
 the lowest level are those crude pains, often miscalled 
 bodily pains, that arise from structural damage to the 
 tissues of the body and from many functional disorders. 
 Such are the pains of wounds and burns, of colic and 
 cramp, of inflammation and cancer ; the corresponding 
 
68 A TEXT-BOOK OF INSANITY 
 
 pleasures being those of warm or cool and soft contact, 
 of stroking and rubbing, of normal functions actively- 
 performed. On the second, or lower middle level, are 
 those general and voluminous feelings of well-being 
 or ill-being, of buoyancy or depression, of high spirits 
 or low spirits, euphoria or dysphoria, that do not admit 
 of analysis, of division into parts, or of description. 
 Everyone knows what they are : everyone has experi- 
 enced them at one time or another. The aspect of them 
 that is important to the alienist is that in the normal 
 they correspond with and depend upon our estimate 
 of our circumstances and achievements, as favourable 
 and successful or the reverse. If and when circumstances 
 are such as to fulfil or favour our aspirations, and 
 especially if we are successfully approaching the achieve- 
 ment of any task or aim, or have actually just attained 
 it, then we experience a feehng of elation, high spirits, 
 and buoyancy ; but when circumstances frown upon 
 us and oppose to our efiorts difficulties that appear 
 insuperable, or when we recede from the end we have 
 in view instead of approaching it, or when we fall short 
 or fail completely in attaining any desired object, then 
 we experience depression, low spirits, misery, in pro- 
 portion to the importance to our general welfare of the 
 aim toward which we were striving. In such circum- 
 stances, and such being our experience, the feeling of 
 buoyancy or depression is justified, legitimate, and 
 normal so long as it is in proportion to the importance 
 of the aim or end concerned ; but when the proportion 
 is disturbed or faulty, and especially when the elation 
 or depression is felt in the absence of any justifying 
 circumstance or experience, then it is morbid in propor- 
 tion to the width of the discrepancy. Such unjustified 
 elation or depression is frequent enough, and is sane or 
 
DYSPHORIA , 69 
 
 insane according as it is or is not recognised by the 
 subject of it to be unjustified. 
 
 Normally, the affection, that is to say, the feehng of 
 elation or depression, is a consequence of the circum- 
 stances or the experience, and therefore follows the 
 appreciation and knowledge of the circumstances or 
 experience. However adverse our circumstances may 
 actually be, we do not feel depression until we know of 
 the adversity. Many of the passengers by the ill-fated 
 Titanic did not know, for an hour or more after the 
 event, that the ship had suffered such damage as must 
 speedily consign them to a watery grave ; and till that 
 knowledge was brought home to them they were free 
 from the depression that overwhelmed them when they 
 appreciated the circumstance. In disease, this order is 
 frequently, if not invariably, reversed. The depression 
 is felt first, and after a longer or shorter interval some 
 circumstance or experience is imagined that would, if 
 it existed, justify and account for the depression, and 
 this imagination speedily assumes the form of a belief, 
 which in this instance is a delusion. In some cases no 
 such imagination is formed. The depression is felt, but 
 no fictitious circumstance is imagined to account for it. 
 Usually in such cases when the depression is deep, some 
 actual circumstance or past experience of an unfavour- 
 able character is fixed upon as accounting for and 
 justifying the depression, but the depression is out of 
 proportion and excessive with respect to the experience, 
 and this excess may even be recognised by the subject 
 of the depression. It seems, however, that whenever 
 depression is felt, there is a very strong tendency to find 
 in circumstances or in past experience a provocation 
 and justification for the depression ; that some actual 
 circumstance or experience will be selected if one caa 
 
70 A TEXT-BOOK OF INSANITY 
 
 be found, and if intellect participates but little in the 
 disorder ; but tbat if, as is usual, intellect as well as 
 Subjective Feeling is disordered, some circumstance or 
 experience of sufficiently disastrous character will be 
 imagined and believed in to account for the depression. 
 And the same is the case, mutatis mutandis, with 
 euphoria or exhilaration. To take a concrete case : 
 a man who feels deeply depressed will, if his intellect 
 remains unafiected, or but little affected, dwell upon 
 some pecuniary loss that he suffered some time ago, 
 and that did not greatly concern him at the time, and 
 will worry and fret over this loss as if it were a justifica- 
 tion for his present depression ; and if he were asked 
 he would say that he is depressed because of his loss. 
 If, however, he has had no such loss, and if his intellect 
 participates, as it often does, in the disorder of feeling, 
 then he will imagine disasters, either past or impending, 
 sufficient to account for the depression, and will believe 
 these imaginations represent the true state of his affairs. 
 He has lost all his money ; his business is ruined ; his 
 wife has run away from him ; he has committed some 
 crime ; he is the unpardonable sinner ; or if these things 
 have not already happened, they are about to happen, 
 and no effort of his can avert them. 
 
 Since, in the normal, appreciation of circumstances 
 or of experiences, favourable or the reverse, always 
 precedes exhilaration or depression, it is natural to 
 suppose that the same order would be followed in disease, 
 and that morbid exhilaration and morbid depression 
 would always depend upon misappreciation of circum- 
 stances or misrecollection of experience : and this view 
 is often taken by alienists. They find depression or 
 exaltation accompanied by a deluded belief in facts that, 
 if it were true^ would go far to justify the eixhilaration 
 
.ESTHETIC PLEASUKE AND PAIN 71 
 
 or depression ; and they assume that the normal order 
 has been followed, and that the state of affective feeling 
 is a consequence of the delusion. Careful study of the 
 history of such cases would show them that this is not 
 the sequence of events. In every case the history shows 
 that, where there is an appreciable order in the events, 
 the afiective feeling alters first, and the delusion is 
 subsequent and consequential. 
 
 Rising now from the lower middle to the upper middle 
 level of pleasures and pains, we may constitute this level 
 of the pleasures and pains of aesthetics. On the one 
 aspect are the pleasures experienced in appreciating 
 beauty, whether of form, of colour, or of sound, of 
 nature or of art, and on the other aspect are the corre- 
 sponding pains produced by the appreciation of harsh- 
 ness and ugliness. How much the appreciation of 
 beauty and ugliness varies in difierent people is suffi- 
 ciently notorious, and it is well known, though scarcely 
 as well recognised, that it varies very widely in the same 
 person for di:Serent impressions. Those who keenly 
 appreciate beauty and ugliness of form are not always 
 equally appreciative of the same qualities of colour, 
 and those who can appreciate both may be very in- 
 appreciative of beauty and ughness of sound. 
 
 To the student of disorder of mind, these subjective 
 feelings of the upper middle level are of httle impor- 
 tance, and their disorders have attracted little attention, 
 though instances in which they have sufiered disorder 
 will not have escaped the vigilant student of insanity. 
 In a treatise like this, however, which does not profess 
 to be exhaustive, but gives only a bare outline of dis- 
 orders of mind, it is unnecessary to pursue further a 
 matter of minor importance. 
 
 The topmost level of pleasures and pains is consti- 
 
72 A TEXT-BOOK OF INSANITY 
 
 tuted by those of the moral order, or what is much the 
 same thing, those that arise out of our social circum- 
 stances and the fulfilment or neglect of our social 
 obligations. On the active side there is the pleasure 
 of duty well done, of happiness conferred, of services 
 rendered, of benefits bestowed, with the corresponding 
 pain of remorse for abstention and neglect, and it may 
 be, alas ! for active misdeeds ; on the passive side are 
 the pleasures of receiving approbation and applause, 
 the signs of being liked, respected, admired, with the 
 corresponding pains of receiving the marks of disappro- 
 bation and reproof, of being disliked and despised. 
 
 The subjective feelings share in the general degrada- 
 tion of mind that takes place in many cases of insanity, 
 and not infrequently the whole of the topmost level 
 of pleasures and pains is completely wiped out ; indeed, 
 it is the rule in insanity that these mental qualities, 
 which are among the last to be acquired, both in the 
 race and in the individual, are among the first to suffer 
 diminution and obliteration in the dissolution of insanity. 
 Duties are neglected, the welfare of others is regarded 
 with indifference, occasions of conferring benefit, 
 especially those trifling but valued benefits that ordinary 
 politeness and good breeding dictate, are ignored, 
 without any remorse or regret following the omission ; 
 and correspondingly there is no sensibility to either 
 approbation or reprobation, to applause or reproof ; 
 and the tributes of love and admiration no more arouse 
 pleasure than the expression of dislike and contempt 
 excite pain. 
 
 It happens often enough that the pleasures and pains 
 of the moral level are experienced inappropriately, 
 when there is no justification for them in the experience 
 of the person who feels them ; but in such cases the 
 
OBJECTIVE FEELING 73 
 
 disorder is not in the faculty of feeling, which faithfully 
 responds to the information it receives from intellect. 
 When remorse is felt for sins that have never been 
 committed, when complacency is felt at liking and 
 approbation that have never been expressed or felt, 
 what is at fault is not the feeling, but the belief to 
 which the feeling responds. If the information that 
 reaches the Faculty of feeling were correct, if the sin 
 really had been committed, or the applause or token of 
 afiection really had been received, the corresponding 
 feeling of remorse or complacency would be justified 
 and normal. Feeling acts normally on the information 
 supplied to it, and if the information is erroneous, the 
 fault lies at the door of intellect, which supplies it, not 
 of feeling, which does the best it can with the material 
 at its disposal. 
 
 FEELING II. OBJECTIVE 
 
 By Objective Feehngs I mean the residue that 
 remains of compound feehngs when the pleasure or 
 pain that accompanies them, or enters into their com- 
 position, is abstracted and removed. In actual ex- 
 perience, the pleasure or the pain is in many cases 
 inseparable from the rest of the feeling, is in many 
 cases an integral component of the feeling ; but in 
 many cases also some element of thought, or desire, or 
 will enters into a complex mental state, and yet we have 
 no difficulty in abstracting that element and giving to it 
 a separate consideration, as if it occurred alone ; and 
 there is no more difficulty in disregarding the pleasure or 
 pain of an emotion, and contemplating separately the 
 other constituents of the compound mental state so 
 denominated, than in disregarding the reasons why we 
 
74 A TEXT-BOOK OF INSANITY 
 
 come to a certain determination, and fixing our attention 
 on the determination alone. 
 
 All feelings are identified more or less completely witli 
 the Self, or the subjective side of mind, but with the 
 feelings of pleasure and pain the identification is 
 especially close and inseparable, and therefore to them 
 the title of Subjective applies with great appropriateness. 
 The feelings of the present class, which I call in contrast 
 Objective, are slightly more detachable, and although 
 the term must appear a contradiction, it may perhaps 
 be allowed to pass. 
 
 The lowest level of Objective Feelings is occupied by 
 Sensations. By a sensation we understand a state 
 arising in the mind in response to an impression received, 
 a quasi-passive state, into the composition of which no 
 responsive activity of mind enters. When a sensation 
 is received or aroused in the mind, a responsive activity 
 does in fact take place. The mind seizes upon the 
 new content and elaborates it into something more 
 than a sensation, as we shall presently find ; but for the 
 purpose of description and of understanding the com- 
 position of the mind, it is necessary to analyse its 
 processes and make distinctions that are to a certain 
 extent arbitrary. One of the least arbitrary of these 
 distinctions is the separation of sensation from percep- 
 tion. Sensations are divided according as they are or 
 are not brought into being by bodily activity ; and the 
 latter class according to the sense organ by which the 
 impression is received. The sensations that are pre- 
 ceded or accompanied by bodily activity to which they 
 owe their existence are those of Eesistance and Freedom 
 and of Effort. The sensations of the passive order are 
 the Visual, including Light and Colour, the Auditory, 
 the Tactile; the Olfactory, the Gustatory, the Sense of 
 
EMOTION 75 
 
 Temperature, and perhaps some others. The whole 
 realm of sensation, together with its disorders, is in the 
 province of the physiologist and the physician, and has 
 no bearing on the work of the alienist. It is a very 
 large and a very interesting field, and is cultivated 
 with much assiduity in most books on Psychology, but 
 it need not be traversed here. 
 
 The two middle levels of Objective Feelings are 
 occupied by the emotions, divested of their ingredient of 
 pleasure or pain. An emotion is a mental state of 
 considerable complexity, and has been analysed with 
 great skill by William James and others ; but the 
 composition of emotions is not a matter of any concern 
 to the alienist, and there is no need to examine it here. 
 What the alienist is concerned with is the circumstances 
 under which emotions normally arise in the mind, and 
 the alterations that occur in disease in the relations 
 between emotions and circumstances. In my book on the 
 Nervous System and the Mind is an elaborate classifica- 
 tion of Feelings, and amongst them of Emotions, based 
 upon the difierences in the circumstances that normally 
 call them forth. Anyone who is sufficiently interested 
 in the subject will there find a complete enumeration 
 of the emotions, together with a description of the 
 circumstances in which they severally arise ; but such 
 a complete enumeration is not needed in such a mere 
 outline as this. All that is necessary for the student of 
 alienism to bear in mind is that every emotion is aroused 
 by a certain appropriate circumstance, which must be 
 cognised and appreciated by the intellect before the 
 emotion can come into being ; and that emotions may 
 be broadly divided into two groups, one of which is 
 aroused by circumstances, or events or experiences that 
 are, or are believed to be, antagonistic or beneficejat 
 
76 A TEXT-BOOK OF INSANITY 
 
 towards the person, or towards others with whom he 
 is iu relation, while the emotions of the other group are 
 aroused by circumstances and experiences that are 
 neutral in this respect. The first group, consisting of 
 the Emotions of Antagonism, Repugnance, and Kindli- 
 ness, and including such emotions as Anger, Fear, 
 Triumph, Contempt, Disgust, Horror, Anxiety, Sorrow, 
 Joy, and their associates and congeners, I place on the 
 lower middle level ; the upper middle level of Objective 
 Feelings being constituted by the ^Esthetic Sentiments 
 of Admiration, Awe, Wonder, Surprise, and so forth, 
 which are called forth by circumstances and experiences 
 that have no direct effect on the welfare either of the 
 subject himself or of those with whom he is in relation. 
 The topmost level of Objective Feelings is occupied by 
 those which are aroused exclusively by social circum- 
 stances and experiences, and which comprise the feelings 
 of Approbation and Reprobation, Pride, Dignity, Shame, 
 Guilt, Martyrdom, Sympathy, Pity, Benevolence, and so 
 forth, in as far as these feelings can exist free from the 
 pleasure or pain which enters so largely into their 
 composition. 
 
 Disorder of any of these feelings exists when the 
 feeling is entertained apart from the special circum- 
 stance or experience which normally calls it forth and 
 justifies it ; and disorder of less degree exists when the 
 emotion is out of proportion to the justifying experience 
 or circumstance. Fear, for instance, should normally 
 arise only when we are threatened with injury by some 
 agent superior in power to ourselves ; and in order for 
 fear to be justified there should be no mistake in our 
 estimate. It should be a fact that we are threatened, 
 and that we are threatened by an agent of power 
 superior to our own, and if these two conditions are 
 
DISORDER OF EMOTION 77 
 
 fulfilled, tlie emotion is a normal emotion. It may be, 
 however, that we have made a mistake — that we are 
 not really threatened, or that if we are, we can easily 
 evade or antagonise the action that is threatened, and in 
 this case the emotion is unjustified, but it is not neces- 
 sarily disordered. It is not disordered if the mistake 
 can be corrected upon trial, or upon other sufficient 
 evidence. If, however, fear is still felt when there is no 
 antagonistic agent, or no threat, or if the threat is 
 manifestly idle, then there is disorder. It may be that 
 the agent is purely imaginary ; or that, a real agent 
 existing, its antagonism and threatening are imaginary ; 
 or that a real agent, actually antagonistic and threaten- 
 ing, its power of harm is imaginary, as when an earwig 
 cocks up its tail ; in either case, and especially in the 
 former, there is disorder, but in all these cases the dis- 
 order is manifestly not disorder of emotion, which 
 faithfully follows the facts as the facts are supposed to 
 be. The disorder is in the intellect, which chooses to 
 misapprehend the circumstances, and to give to emotion 
 a false representation of them. It sometimes happens, 
 however, that fear, anger, or some other emotion 
 arises in force without the excuse of even an imaginary 
 circumstance to justify it, and in such a case it is 
 emotion itself that is disordered. Both kinds of disorder 
 occur, but in the majority of cases there is an erroneous 
 belief as to the facts, and if the facts were as they are 
 erroneously or deludedly beUeved to be, the emotion 
 would be justified. Even in these cases, however, it does 
 not follow that the mistake or the delusion as to the 
 facts is the first event in the order of time. Not in- 
 frequently it can be found that an unreasonable and 
 unjustified emotion of fear, or anger, or what not, was 
 first experienced, and that subsequently circum- 
 
78 A TEXT-BOOK OF INSANITY 
 
 stances were imagined to fit in with and justify the 
 emotion. 
 
 The whole Faculty or group of Feelings may be 
 stated in tabular form thus : — 
 
 FEELINGS 
 
 Subjective (Pleasure and Pain). Objective. 
 
 Moral. Moral Sentiments. 
 
 iEsthetic. Esthetic Sentiments. 
 
 Euphoric and Dysphoric. Emotion. 
 
 Crude. Sensation. 
 
 INTELLECT OR THOUGHT 
 
 The word Thought, like innumerable other words in the 
 English language, is used in two senses, as a verb, to 
 mean the doing of a thing, and as a noun, to indicate the 
 thing done. It may mean the process or operation of 
 thinking, or it may mean the result of this process, the 
 thought that results from the operation. With the 
 process of thought the alienist is not much concerned, 
 and in fact no allusion whatever is made, to my know- 
 ledge, in any book on insanity to error or disorder of the 
 process of thought. This is not because such errors or 
 disorders are infrequent in insanity, for in fact they are 
 frequent enough. The attention of alienists has been 
 concentrated upon Belief, one of the results of thought, 
 and it does not seem to have occurred to them that if 
 the result is erroneous, the cause is to be sought in error 
 of the process that leads to this result. This is probably 
 because the process of thought is transient and cannot 
 be easily traced, while the belief that results from it is 
 enduring, and is usually as easy to identify and examine 
 as the process is difficult; and in the second place 
 
INTELLECT OR THOUGHT 79 
 
 because the process of reasoning has been completely 
 misunderstood, and the only description of it that has 
 been at the service of alienists has been the crude, 
 erroneous, and imperfect description of Aristotle, which 
 is ludicrously inadequate and ineffectual. 
 
 The true reason for the superior importance that has 
 always been attached by alienists to disorders of belief 
 or delusion is that upon belief all conduct is founded ; 
 and although alienists have neglected and scorned 
 the systematic study of conduct, and although they 
 refuse to admit in words that insanity is primarily dis- 
 order of conduct, yet conduct is so manifestly of para- 
 mount importance in insanity that a blind but sure 
 instinct has compelled them to pay special attention to 
 that factor in mind by which conduct is mainly guided. 
 Every act of every human being is determined by belief. 
 We should not walk across a room to get a book unless 
 we believed that the book was at the other side of the 
 room, and that the floor would bear our weight. 
 
 There is another good reason why the intellect should 
 have been looked upon as of paramount importance in 
 insanity, a reason which has never been formulated or 
 discovered by any alienist, but which in some dim and 
 inchoate form has probably been at the back of their 
 minds. This is that disorder or defect of the highest 
 level of intellect is a necessary ingredient in insanity. 
 Mind may be disordered in any faculty and on any level 
 of any faculty, but unless the disorder implicates the 
 highest level of thought, objective or subjective, this 
 disorder of mind is sane and not insane. It is by virtue 
 of the highest level of thought that we recognise and 
 gauge our own mistakes and disorders, and as long as 
 this highest level is intact, so that we can and do recog- 
 nise that our mistakes are mistakes, and our disorders, 
 
80 A TEXT-BOOK OF INSANITY 
 
 whether of mind or conduct, are disorders, so long 
 sanity is unafiected, and our mistakes and disorders are 
 sane. As soon, however, as we become incompetent to 
 make this adjustment, and proceed to act on the supposi- 
 tion that our disordered mental processes and states are 
 valid and correct, and make no attempt to correct our 
 mistakes, the Kubicon is passed, sanity is left behind, 
 and insanity is established. 
 
 It is not on this account, however, that alienists have 
 confined their study of the disorders of mind exclusively 
 to disorders of thought. It is because disorders of 
 thought are so conspicuous, dramatic, and impressive, 
 that it was for long held universally, and is still held by 
 some, that the disordered belief that is termed delusion 
 is the only disorder of mind, and is co-extensive with 
 insanity. Delusion was for long the sole criterion of 
 insanity: without delusion there was no insanity; and an 
 insane person meant a deluded person and no one else. 
 Once held universally, and formally laid down in Courts 
 of Law, this doctrine still lingers, not only amongst the 
 laity, but even amongst medical practitioners, some of 
 whom to this day refuse to certify a person as insane 
 unless they can discover in him evidence of delusion. 
 This long identification of insanity with delusion was 
 no doubt largely answerable for the blunder, which 
 should now be considered an anachronism as well as an 
 absurdity, of identifying insanity with unsoundness of 
 mind. 
 
 To give here a complete account of the normal process 
 of reasoning and of the normal conditions of belief would 
 be to interpolate a treatise on Logic and a treatise on 
 Epistemology ; and although either would be of more 
 value to the alienist than learning to fiddle with the 
 ergograph, and the other instruments that make up the 
 
INTELLECT OE THOUGHT 81 
 
 armentarmm of tlie '' experimental psychologist," and 
 although an alienist can scarcely be considered expert 
 in his profession without some knowledge of both, yet 
 their direct bearing upon the study of individual cases 
 of insanity and other mental disorders is not sufficient 
 to warrant the space being given to them here. Those 
 who wish to follow up this line of study should read 
 " A New Logic " and the sections on Truth, Certainty, 
 Likelihood, etc., in my book on Psychology. 
 
 Intellect has two sides, of which one only has hitherto 
 been recognised. By means of Intellect or Thought we 
 judge or estimate the nature and bearings of our sur- 
 rounding circumstances, and devise methods of dealing 
 with them in such ways as to turn them to our advan- 
 tage. This is the external or objective side of intellect, 
 and it is the only aspect of intellect that has received 
 any attention, or is recognised or known to psychologists. 
 But there is another side to intellect, and one that is 
 of the utmost importance to the alienist, for it is the 
 seat of frequent and grave disorder. By means of 
 intellect we judge not only of external circumstances, 
 but of our own powers and capacities and other quahties ; 
 and a moment's consideration will show that in dealing 
 with circumstances, and in devising methods of dealing 
 with circumstances, it is quite as important to form a 
 just estimate of our own powers as to judge accurately 
 of the circumstances without. If I find an obstacle in 
 my way, it is important to discover its nature, and its 
 mobihty or immobility ; but it is evident that its mo- 
 bihty or immobility is relative to my own strength. 
 What I mean by the mobihty or immobility of the 
 obstacle is whether I have or have not the strength to 
 move it ; and it is evident that what appears to be a 
 quality in the obstacle is really dependent on a quahty 
 
82 A TEXT-BOOK OF INSANITY 
 
 of my own. If I liave to catch a train, it is very neces- 
 sary that I should estimate the distance of the station 
 and the time at my disposal ; but these are no use to me, 
 however accurately I may estimate them, unless I 
 estimate also the rate at which I can walk or run. It is 
 impossible to deal with circumstances, or to devise ways 
 of dealing with circumstances, unless we take into con- 
 sideration and estimate our own powers and capacities. 
 This side of intellect, which I call the Subjective side, 
 does not appear to have been discovered by psycholo- 
 gists, but the disorder that it frequently sufiers 
 makes it very conspicuous to the alienist, and very 
 important to him. I therefore treat of Intellect on two 
 aspects ; first the Objective aspect, or the Estimation of 
 Circumstances, and second the Subjective aspect, or 
 Self-estimation. 
 
 OBJECTIVE INTELLECT 
 
 There are three processes of Reasoning, two of which, 
 or rather parts of two of which, are known, very 
 imperfectly, to Logicians. They are Induction, Deduc- 
 tion, and Analogy, but the last two of these may be 
 neglected, for neither of them leads directly to Belief, and 
 therefore neither is of direct importance to conduct. 
 Induction is the reasoning process with which the 
 alienist is most concerned, and fortunately for him the 
 process of Induction is a simple one. Induction rests 
 upon this simple principle — that if two things resemble 
 each other in some material respects, they will resemble 
 each other in other material respects ; or to put it other- 
 wise, if two things have certain qualities in common, 
 they will have in common certain other qualities that 
 have been found in experience in constant association 
 
OBJECTIVE INTELLECT 83 
 
 with, or to depend upon, the first common qualities. 
 For instance, if a certain fruit resembles in material 
 respects another fruit that has been found in experience 
 always wholesome or always poisonous, the first fruit 
 will be found wholesome or poisonous as the case may 
 be. "What respects are material cannot be stated gener- 
 ally. That is a matter for experience in each case as it 
 arises ; but granted that there is similarity in material 
 respects, the induction will be sound and the resulting 
 belief justified. 
 
 The simplest beliefs result from those simple inductions 
 that are, as it were, forced upon us by sensation. The 
 sensation of a small patch of brown colour on the green 
 grass arrests my attention, and instantly arouses the 
 remembrance of innumerable patches, similar in 
 material respects, that I have seen before. These other 
 patches of colour I have found in experience to possess 
 certain qualities. I have submitted them to examina- 
 tion by various senses, and have found that they indicate 
 thin, brittle, light, fragrant, rustHng laminse, that they 
 are in fact dead leaves ; and I reason or induce that this 
 new patch that I see before me, since it is similar in the 
 material respects of light and shade and outline and 
 mobility in the wind, is similar in other material respects 
 also, and would, if I examined it closely, prove to be a 
 thin, brittle, light, fragrant, rustling lamina, similar to 
 others that I see hanging on the tree. The result of this 
 induction is the belief that this patch of colour represents 
 a dead leaf, and beliefs of this class, that are initiated, 
 and in a measure forced upon us, by an impression on 
 the senses, are called Percepts ; and the process of 
 induction by which they are reached is called Perception. 
 The process is the simplest and most rapid instance of 
 induction — is so simple and so rapid that its nature is 
 
84 A TEXT-BOOK OF INSANITY 
 
 obscured, and by most psychologists it is considered not 
 to be induction ; but this is merely an instance of the 
 familiar fact that wide superficial differences often conceal 
 a deep and fundamental similarity or identity. Percepts 
 vary, of course, according as the sensation that initiates 
 them is visual, auditory, tactual, or what not, but all 
 are arrived at by the same simple process, and all are 
 beliefs of the same simple character. 
 
 The process of perception may be ill-performed, and 
 the resulting belief may be erroneous ; and in this case 
 the error may be corrigible or incorrigible — sane or 
 insane. Mistakes in perception of greater or less degree 
 are not very infrequent. We see an aneroid barometer 
 of the shape and size of a watch, and on a casual glance 
 we perceive that it is a watch. The percept is a mistake. 
 The belief is erroneous. Such a belief is, however, 
 corrigible. If we examine the thing more attentively, 
 we shall perceive that it is not a watch, and if we are 
 already familiar with barometers we shall perceive that 
 it is an aneroid. 
 
 Graver mistakes are frequent in disease. In some 
 states of disease, a man seeing a piece of string lying on 
 the floor, will read into it the qualities of a worm or a 
 snake. He will perceive it, not as a piece of string, but 
 as a worm or a snake ; and this percept may be cor- 
 rigible or incorrigible. If he has the courage and pre- 
 sence of mind to pick it up and examine it attentively, 
 he may correct his percept and arrive at the valid 
 belief that it is a piece of string ; or he may be unable to 
 make the correction, and still perceive it as a snake. In 
 the first case the mistake is a sane mistake, and is an 
 example of a sane disorder of mind that is by no means 
 infrequent. In the latter case the mistake, being in- 
 corrigible, is insane, and is an example of insane 
 
DISORDERS OF PERCEPTION 85 
 
 illusion, an insane disorder of mind that is frequent 
 enough. 
 
 Similar mistakes occur in interpreting or perceiving 
 auditory sensations. We hear a voice, and perceive that 
 it is the voice of A. It is in fact the voice of B ; and if B 
 is before us and we see as well as hear him speaking, we 
 may be able to correct the process and arrive at the 
 valid belief that we had been mistaken, and that the 
 voice was in fact the voice of B. If, however, we cannot 
 make the correction, but continue to beheve that B is 
 speaking with the voice of A, the belief is no longer sane. 
 It is an insane illusion. Still graver is the disorder when 
 some inarticulate sound, such as the song of birds or 
 the wind in the trees, is perceived as spoken words. 
 In such a case the mistake is nearly always incorrigible, 
 and the illusion is therefore insane. 
 
 A still wider departure from the normal takes place 
 when a percept is perceived without any provocation or 
 basis in the shape of a sense impression to justify it, or 
 any percept. Whether such an event ever really takes 
 place I take leave to doubt. The sense organs are 
 never wholly free from stimuli, internal or external. 
 Even in the dark and with closed eyes we see clouds and 
 rings of colour. Even in the silence of the dead of night 
 we hear the rush of blood in the cerebral arteries ; and a 
 very trifling sense impression is enough to form the 
 nucleus of a percept in certain morbid states of mind. 
 However, whether this is so or not, it is manifestly a 
 wider departure from the normal to found a percept on 
 a sensation, if sensation there be, that no one else can 
 appreciate, than on one of a grosser character ; and 
 percepts of this nature are distinguished from other 
 illusions and receive the title of hallucinations. 
 
 Perception is the most rudimentary process of thought, 
 
86 A TEXT-BOOK OF INSANITY 
 
 or intellect, and Percepts are the simplest of Beliefs. 
 These then constitute the lowest level of Objective 
 Intellect. 
 
 The next step upwards in Objective Intellect after 
 perceiving an object is to form an estimate of the 
 beneficence, the maleficence, or the neutrality of that 
 object with respect to one's own life-worthiness or 
 welfare. The lowest and most rudimentary process of 
 thought answers the question. What is this ? What 
 manner of object is it that produces this impression on 
 my senses ? Immediately following the determination 
 of this problem comes the further question. Now that I 
 know what this object is, is it potentially harmful or 
 beneficial to me ? Is it dangerous, and in what way ? 
 Can I utilise it, and in what way ? The estimation of 
 beneficence or maleficence is often almost as instan- 
 taneous as perception itself ; but it is difierent from the 
 perception, and the difierence is well brought out by 
 the discrimination of disease. A housewife who has had 
 abundant experience of the kettle and the wash tub, 
 and whose experience of the destructive and painful 
 effect of boiling water on the skin is ample, becomes 
 demented to a certain depth, such that while she retains 
 the power of perception, and can perceive that the vessel 
 before her contains water, and by the abundant steam 
 that rises from it, scalding water, yet has lost her power 
 of estimating the harmful quality of scalding water, and 
 immerses her hand in it, well perceiving that it is 
 scalding hot, but not estimating that it has the power to 
 scald. Similarly, a man accustomed to the traffic of the 
 streets may perceive that the object which approaches 
 him is a two-horse van, but he fails to estimate that this 
 object possesses lethal qualities, so that if he gets in its 
 way it will knock him down and injure him. This power 
 
DISORDER OF CAUTION 87 
 
 of estimating tlie harmful or benej&cial quality of 
 perceived objects or appreciated circumstances I call 
 for want of a better title, Caution. Thus characterised, 
 the power or process of estimating the beneficial or 
 harmful quality of familiar objects constitutes the 
 lower middle level of Objective Thought. 
 
 Defect of caution is not the only disorder of the lower 
 middle level of thought. A frequent disorder of this 
 level is an exaggerated estimate of the potential noxious- 
 ness and maleficence of surrounding agents, an esti- 
 mate that results in a general attitude of suspicion. The 
 estimate may be thus general, or it may be concen- 
 trated upon certain specific things or persons. The most 
 exaggerated instances are seen in the disease of paranoia, 
 of which exaggerated and unreasonable suspicion, 
 unjustified by circumstances, is one of the most promi- 
 nent features. Usually in paranoia there is more than 
 suspicion : there is settled and deep conviction of the 
 hostility and noxiousness of some one or more persons, 
 who may be real or may be imaginary, but in any case 
 the settled belief in the noxiousness and hostihty of this 
 person or of these persons is but the nucleus of a cloud 
 of suspicion that spreads far beyond them, and is apt to 
 become almost universal. The most innocent acts of 
 the most utter strangers are enveloped in the suspicion. 
 The casual greetings of strangers in the street, the pubHc 
 utterances of public men, the leading articles in news- 
 papers, are all suspected ; and subtle references, ofiensive 
 references, to the suspicious person are found in them 
 all. 
 
 The upper middle level is constituted by inductions of 
 a more elaborate character, dealing with more general 
 circumstances, and may fitly be represented here by the 
 means which are devised to meet circumstances whose 
 
88 A TEXT-BOOK OF INSANITY 
 
 quality, as beneficial or otherwise, lias been determined 
 on the level below. This faculty, which we may term 
 Ingenuity or Cleverness, takes cognisance not of mere 
 objects that can be seen, heard, or touched, but of 
 whole situations, constituted by a complete set of 
 circumstances, such, for instance, as those embodied in 
 the terms of an agreement, the lease of a house, or a deed 
 of partnership. Caution advises us that our informant 
 is not trustworthy, and ingenuity sets to work to sift 
 his information and compare it with that from other 
 sources. Caution tells us that a storm is imminent 
 and ingenuity looks about for shelter. Caution shows 
 us the danger of a conflagration, ingenuity devises means 
 to prevent and to extinguish it. 
 
 The highest level of Objective Intellect is the faculty 
 of Wisdom, which estimates by and large the important 
 circumstances of life, and thinks out what our conduct 
 should be in order to secure the main purposes of life. 
 If ingenuity settles the terms of an agreement, wisdom 
 determines whether an agreement shall be made or no. 
 Ingenuity may settle the terms of a lease, but wisdom 
 decides whether or no the house shall be taken. In- 
 genuity governs the clauses of the partnership deed, 
 but wisdom decides whether or not it is expedient to 
 enter into the partnership. Shall I make a public 
 proclamation of my opinion and attitude on this vital 
 question ? Wisdom ponders the pros and cons, and 
 lays them before the highest level of Will for determina- 
 tion. Cleverness or ingenuity devises the method by 
 which the position is to be stated. Caution estimates 
 the appropriateness of the words and phrases. Percep- 
 tion sees to the spelling. Or we may illustrate the 
 several levels thus : Ought I in these circumstances to 
 bring an action at law ? Wisdom, in the person of 
 
WISDOM AND INGENUITY 89 
 
 counsel, gives tlie opinion. That being decided, In- 
 genuity, in the person of the solicitor, takes the proofs 
 of the chief witnesses and devises the means for putting 
 the decision into force. His clerk, who represents 
 Caution, sees the formal witnesses and attends to 
 details ; and the office boy, who personifies the lowest 
 level, takes the names of the witnesses and shows them 
 in. Shall I or shall I not go to that place 1 Wisdom 
 discusses the alternatives. How shall I get there ? 
 Ingenuity finds the way. Shall I go by train or motor? 
 Caution dictates the choice. Is that a taxi or a private 
 carriage ? Perception makes the judgment. Wisdom 
 settles the strategy of the campaign ; Ingenuity devises 
 the tactics of the battle ; Caution directs the opera- 
 tions of the units ; Perception is the Tommy who 
 makes the firing line and comes into contact with the 
 enemy. 
 
 Objective Thought may be disordered on any of its 
 levels, but before examining actual disorder, I may draw 
 attention to the disproportion that frequently exists 
 between the highest and the second level. It is a 
 frequent occurrence to find ingenuity developed out of 
 proportion to wisdom, and vice versa. When cleverness 
 is in excess with respect to wisdom, the resulting charac- 
 ter is that of the clever fool — the man who is full of 
 ingenious devices to do that which is not worth doing. 
 To say that he will invent a machine for turning fresh 
 eggs into stale ones is no doubt an exaggeration, but 
 many of his devices are not much more useful. He will 
 scheme and plot to save sixpence — at an expense of 
 half a crown. He is full of schemes and devices which 
 make us wonder that so much ability is incompetent to 
 recognise the uselessness of them all, or at least how 
 much better such ability would pay if it were turned 
 
90 A TEXT-BOOK OF INSANITY 
 
 into other channels, and expended in attaining other 
 ends. But wisdom being deficient, the choice of ends is 
 injudicious, for it is the function of wisdom to select the 
 main ends to be sought. It sometimes happens that 
 wisdom is conspicuously deficient while ingenuity is 
 highly developed, and the consequence of this combina- 
 tion is the " sane lunatic," who is such a puzzle and such 
 a trial to those who have charge of him. His conduct is 
 such that it is difficult, and may be impossible to lay 
 one's finger on any act or speech that is certainly insane. 
 We caimot say of any one thing he does or says " This 
 is insane : this is a thing that no sane man would do or 
 say," and yet, when viewed by and large, the whole 
 trend of his conduct leaves no doubt upon our mind that 
 he is insane, and enables us, with more or less difficulty, 
 even to convince a court of law that he is insane. We 
 are all familiar with such cases, and it is extremely 
 difficult to formulate in words what the peculiarity in 
 mind or conduct is that justifies us in finding insanity, 
 and compels us to find insanity. Such persons are the 
 despair of their families, and are insoluble problems to 
 the general practitioner, who may be for years convinced 
 that they are insane, and yet may be wholly unable to 
 state in a certificate any single *'fact indicating insanity 
 at the time of examination." Yet if we keep in mind the 
 different levels of intellect, and especially the difference 
 between wisdom and cleverness, we shall have little 
 difficulty in discovering where the disorder is, and not a 
 great deal in putting it into words. 
 
 Such a patient is for ever plotting and planning and 
 scheming ; and his plots and plans and schemes are 
 very ingenious, very clever, and very often successful 
 in achieving their immediate purpose ; but when they 
 have achieved their immediate purpose, the success is 
 
THE CLEVER LUNATIC 91 
 
 worthless to the actor. It does not advance him in the 
 least towards any ultimate goal : on the contrary, it 
 retards him and baffles him in attaining what he most 
 desires. He is, we will say, a lunatic so found by 
 inquisition, and the main, the ultimate purpose of his 
 life is to get his supersedeas. He is for ever contriving 
 dodges, tricks, and devices to outwit those who have 
 charge of him, and he is often successful in outwitting 
 them. He gets letters that he has no business to post 
 posted on the sly. He tempts and bribes the attendants 
 and others to commit faults, and then rounds upon them, 
 accuses them, and may succeed in getting them punished. 
 He obtains goods here, credit there, and money in 
 another place ; in spite of all our care and vigilance he 
 succeeds in a score of subtle devices ; but put all these 
 successes together, and what do they amount to ? Do 
 they carry him a hair's-breadth nearer his ultimate 
 object of proving his sanity ? Not a bit. The more he 
 succeeds in his malicious tricks and dodges, and the 
 more he gives himself up to them, the more you recognise 
 the ingrained insanity of a really able man squandering 
 his ability on such unworthy ob j ects . Many of the things 
 that he seeks to obtain by cunning and underhand 
 devices he could have for the asking if he chose to be 
 straightforward, but the defect of wisdom prevents him 
 from seeing this; and owing to the same defect he 
 cannot appreciate, even when he is told, that by thus 
 acting he is demonstrating, not his fitness, but his 
 unfitness to be at large. It was just such a succession of 
 impish tricks that brought him to the asylum, and yet 
 the defect in his wisdom prevents him from under- 
 standing that the continuance of these impish tricks is 
 keeping him there. He cannot understand this because 
 the highest level of his intellect is disordered and 
 
92 A TEXT-BOOK OF INSANITY 
 
 inefficient. He can act with abundance of cleverness 
 because tbe second level of intellect, originally highly 
 developed, retains its integrity : he is incapable of 
 directing his ability to the highest service of his own 
 welfare because the highest level, wisdom, is out of order 
 and incapable of utilising the cleverness and ingenuity 
 that are at its service. 
 
 On the other hand, there are plenty of dull people, 
 more or less lacking in cleverness or ingenuity, who are 
 nevertheless successful in life, and prove by their suc- 
 cess the possession of a normal quantum of Wisdom. 
 Realising the limitation of their own cleverness, they 
 take such places in the world as do not require clever- 
 ness to fill capably. They set before themselves no aim 
 that they are incapable of attaining, and therefore do 
 not fail. Deficient as they are in ingenuity, which is 
 the capacity of meeting new circumstances in new 
 ways, they are careful to keep to old ways, and never 
 to adopt a new device until it has been well tried and 
 found successful by others. The determination of the 
 main ends in life is the function of Wisdom, and in 
 wisdom they are not deficient ; hence their lives, while 
 never strikingly or brilliantly successful, are never 
 arrant failures. Of such characters the great bulk of 
 the population in every country is composed. 
 
 It has been said above that disorders of Objective 
 Intellect have received from alienists a monopoly of 
 importance to which they are not entitled. This is true, 
 for, as is now being explained, mind may be disordered 
 in many ways and in many departments without dis- 
 playing any of those erroneous beliefs that were once 
 supposed to be necessary to render a person insane. 
 But at the bottom of the practice of alienists there was 
 a residuum of truth. Mind may be disordered in many 
 
DEFECT OF INGENUITY 93 
 
 departments without disorder of intellect ; insanity 
 may include many disorders of mind that are not dis- 
 orders of intellect ; but whatever the disorder of mind 
 may be, it does not amount to insanity unless the 
 highest level of intellect is defective, so that the disorder 
 of mind is not recognised and known to be disorder ; 
 and whenever this highest level of intellect is disordered, 
 then the disorder is insanity, whether or no other levels 
 and other faculties of mind are implicated in the dis- 
 order. The consequences of this doctrine are of the 
 highest importance, as will be seen as we go 
 along. 
 
 When the second level, the level of ingenuity, is dis- 
 ordered or defective, the result is dullness, stupidity, and 
 confusion of thought ; but these defects are by no means 
 necessarily insane. If the highest level remains un- 
 affected, the subject of the disorder recognises and 
 admits the disorder, and adapts himself to it as far as he 
 can. Eecognising that his mind is unequal to the 
 performance of his daily work, he rests from it. He 
 does not attempt the ordinary tasks that are now 
 beyond his power, and he consults his doctor for the 
 malady that he knows is attacking him. In so doing he 
 proves the sanity of his mind, disordered though it is. 
 As long as the highest level of intellect is intact, any 
 disorder that occurs on the inferior levels is recognised 
 as disorder, and measures are taken to counteract and 
 correct it. Illusion is known to be illusion ; hallucination 
 to be hallucination; groundless suspicion, fear, panic, 
 depression, are known to be groundless ; imperative idea 
 is known to be absurd. All these are then sane disorders 
 of mind, and such sane disorders are frequent enough. 
 Every book on psychology expatiates at length on sane 
 illusions. Sane hallucinations, that are known and 
 
94 A TEXT-BOOK OF INSANITY 
 
 recognised by the subjects of them as hallucinations, 
 though not frequent, are well known to occur ; and 
 frights, panics, depression, suspicion, as well as many 
 other states of mind that are unjustified by circum- 
 stances, and are known and recognised by the subjects of 
 them to be unjustified, are of frequent occurrence. 
 Such disorders are quite sane. There is no trace of 
 insanity in them. They are not described in books, 
 for they rarely come before writers on insanity, and if 
 they did, the writers on insanity, holding as they all do 
 that insanity is disorder of mind, and that disorder of 
 mind is insanity, would of course regard them as 
 insane ; and if they come before neurologists, as they 
 probably do, the neurologist gets what knowledge of 
 disorder of mind he has from the alienist, and takes the 
 same view. 
 
 SUBJECTIVE INTELLECT 
 
 Subjective Thought is a department of mind that has 
 not hitherto been described or even recognised. It 
 consists, as already explained, in the estimation of our 
 own qualities, and its extreme importance to conduct, 
 and therefore to the estimation of insanity, is plain. 
 Intention or determination to do this or that depends 
 on several factors, some of which — desire, estimation of 
 circumstances, etc. — ^have already been examined ; but 
 it is clear that no course of conduct will be determined 
 on that is not believed to be within our powers, and this 
 belief must rest upon the estimate that we form of our 
 powers. We may desire to get from Dover to Calais, 
 and we may correctly estimate the distance to be 
 about twenty miles, but in casting about for means to 
 compass the journey we shall not take into practical 
 
SUBJECTIVE INTELLECT 05 
 
 consideration the project of jumping across. Why not ? 
 Clearly because we estimate our own powers of jumping, 
 and have a settled belief that twenty miles is more than 
 we could manage. If the gap of water that we want to 
 traverse is not twenty miles, but twenty feet, the 
 difficulty for most of us is still insuperable ; but still, in 
 this case it is not so utterly and outrageously beyond our 
 powers that we do not give it at any rate a momentary 
 consideration. If it is but ten feet, we may seriously 
 consider it, and if only five, many would try it without 
 hesitation, and many would succeed ; but in any case, 
 whether an act is to be attempted or not depends, 
 among other things, upon our own estimate of our own 
 ability to accomplish it; and therefore this field of 
 estimation is a very important department of the 
 province of thought. It is the more important to the 
 alienist since it is very liable to disorder. 
 
 The four levels of Subjective Thought are determined 
 by the grade of the power, capacity, ability, or other 
 quaHty that is the subject of the estimate. On the 
 lowest level are the estimates of mere physical capacity. 
 Everyone can tell, with a more or less close approxima- 
 tion to accuracy, what his physical powers are — 
 whether the ditch is or is not too wide to leap ; whether 
 the stile is or is not too high to jump ; whether he can 
 reach up to this object, or Lift that one ; what distance 
 he can walk, and in what time ; how far he can throw 
 this ball or that stone ; his powers of endurance, his 
 manual dexterity, and so forth. Such estimates are 
 perpetually being made, and conduct is perpetually 
 being regulated in accordance with them. Another 
 branch of the estimates of this character are those 
 concerning the magnitude, weight, and other statical 
 attributes of our own bodies, and of parts of them. 
 
96 A TEXT-BOOK OF INSANITY 
 
 Lying, as they do, at the base of subjective estimation, 
 estimates of this level are disordered late in disorder of 
 mind, and show that the disorder is profound. They are 
 therefore not nearly so frequent as disorders on the 
 higher levels, but still we sometimes witness them. We 
 see patients with the most exaggerated estimates of 
 their own powers, and of the magnitude of their own 
 bodies or limbs. This one can jump over a house, that 
 can lift a ship out of the water by his own unaided 
 strength. The feat of jumping across the straits of 
 Dover appears to another well within his powers. One 
 patient of an amorous disposition assured me that his 
 penis was fifteen miles long, and his testes as big as 
 castles. 
 
 The next level is constituted naturally by estimates of 
 mental capacity, and the estimates that we form of our 
 own ability are of two kinds — ^relative and absolute. 
 Everyone in his progress through life, and his constant 
 intercourse with his fellows, measures himself more or 
 less deliberately against them, and estimates his own 
 intellectual capacity relatively to theirs, gets to know 
 whether he is above or below the average, not only 
 generally, not only with respect to his wisdom, cleverness, 
 or caution, but also with respect to special accom- 
 plishments. He learns to rank himself as indifferent, 
 fair, good, or excellent, as a linguist, as a bargainer, as 
 a musician, an organiser, a judge of character, a chess- 
 player, or what not. Besides this relative estimate, he 
 learns to form also an absolute estimate of his intellec- 
 tual powers. He knows what he can understand at 
 once, what he can by application learn to understand, 
 and what is wholly beyond his comprehension. He 
 learns what mental capacities he possesses, what occupa- 
 tion is suitable and what unsuitable for him, what 
 
DEFECT OF WISDOM—INSANITY 97 
 
 problems lie can solve unassisted, and for what he must 
 ask for assistance, and so on. 
 
 These estimates are liable to err, and the error may- 
 be within or without the limits of sanity. Some people 
 are so happily constituted that they habitually overrate 
 their own capabihties ; and although this leads them 
 to undertake tasks for which they are incompetent and 
 in which they fail, the failure has not the same efiect in 
 producing depression and despondency that it has on 
 other people. Others, unduly modest, underrate their 
 own capabilities, and shrink from tasks that they are 
 well able to perform. In such cases, however, the defect 
 is often not so much a mistaken underestimate of their 
 own intellectual powers as a lack of courage, a shrinking 
 from responsibihty, an unwilHngness to incur the risk of 
 failure ; and the fear of failure is often itself a source of 
 failure. 
 
 In all this, however, there is no insanity. Insanity 
 does not exist unless the estimate of mental capacity is 
 grossly and exorbitantly excessive or defective ; and 
 gross and exorbitant error in either direction is frequently 
 witnessed. One person will cover reams of paper with 
 wretched doggerel, and boast of it as glorious poetry ; 
 another will be certain of selHng for enormous sums 
 mere unintelligible scribbling ; others, again, will lay 
 claim to supernatural acuteness and ability in the most 
 various directions — acuteness and ability of which 
 there is no evidence beyond their own claim. They can 
 square the circle, and demonstrate the flatness of the 
 earth ; they can read the thoughts of persons a 
 thousand miles away ; they know what song the Sirens 
 sang, and will sing it to you in a voice that they declare 
 is comparable only to a seraph, but that seems to the 
 hearer a discordant noise ; they can penetrate the 
 
98 A TEXT-BOOK OF INSANITY 
 
 secrets of all the Chancelleries of Europe, and tell exactly 
 how each of them ought to act ; there is, in short, no 
 limit to their capacity. 
 
 On the other hand, there are unfortunates whose 
 underestimate of their own powers is certainly great, 
 but cannot be proved, and for the moment may even be 
 not very inaccurate. They stand appalled and helpless 
 before problems and difficulties that in health they 
 could meet and solve easily enough, but that now are 
 beyond their capacity ; so far their own estimate of their 
 own powers is not perhaps inaccurate, but they extend 
 this inability into the future and the past, and declare 
 that they have always muddled everything they ever 
 undertook, and will never be competent to transact the 
 simplest business. In this the limits of sanity are 
 passed. 
 
 The upper middle level of Subjective Thought is 
 composed of estimates, not of physical or mental 
 capacity, but of powers more extended — of the powers 
 arising from the possession of wealth, influence, and 
 honour. Of course, these are not, strictly speaking, 
 altogether subjective estimates, or estimates of subjec- 
 tive powers. They involve and require as antecedent 
 conditions certain estimates of external circumstances. 
 They are, however, so closely bound up with the purely 
 subjective estimates ; they so surely, or at least so com- 
 monly, suffer disorder when the purely subjective 
 estimates are disordered, the disorder is so invariably 
 in the same direction, and the recovery from the one so 
 regularly accompanies recovery from the others, that it 
 would do violence to evident natural affinities to place 
 them anywhere but in association with these others. 
 The estimates of this class are estimates of possession : 
 they refer to wealth, power, influence, honour, titles, 
 
DISORDER OF SELF-ESTIMATION 99 
 
 possessed by, or due to, the estimator. Normally there is 
 little room for error in estimates of this class. A man 
 of great wealth may not know the whole of his posses- 
 sions, but he knows that he is a very wealthy man. A 
 poor man whose afiairs are very complicated may not 
 know whether he is actually solvent or insolvent, but 
 he knows quite well that he is near the border line. A 
 man can scarcely make a normal mistake as to his 
 position in the world, or the title by which he has a right 
 to be addressed ; and though he may not have a very 
 accurate estimate of the esteem in which he is held by 
 his neighbours, he knows pretty well if they are pre- 
 pared to acclaim or to execrate him when he appears 
 in the street. 
 
 When this faculty is disordered, these estimates are 
 erroneous, and are often grossly erroneous. The poor 
 man, or the man of moderate means, believes that he is 
 possessed of wealth beyond the dreams of avarice ; the 
 humble dweller in a back street fancies that he can 
 determine the fate of cabinets, and influence the destinies 
 of nations ; the city clerk or the bricklayer's labourer 
 arrogates to himself the highest titles in the peerage, 
 monarchy, popedom, godhead itself. The ordinary titles 
 are not enough to satisfy his overweening and grotesque 
 self-estimation, and he invents new ones of which no 
 one has heard the like. In the opposite direction of 
 self -depreciation the exaggeration is never so enormous. 
 He who is near the ground has not far to fall, though the 
 boundless expanse of heaven is above him to soar into. 
 The man of substantial means, or even of great wealth, 
 often beheves that he is ruined, but never, in my ex- 
 perience, that he is groaning beneath a load of inex- 
 tinguishable debt. He looks upon himself as despised 
 and rejected of men, as insignificant, of no account, as 
 
100 A TEXT-BOOK OF INSANITY 
 
 neither possessing nor deserving of influence or power, 
 but lie does not often invent for himself titles of ignominy 
 and disgrace. One patient, however, stigmatised himself 
 as the Awful of Awfuls. 
 
 Lastly, the highest level of self-estimation is consti- 
 tuted by estimates of our own moral worth. This is a 
 matter that in the normal does not much occupy our 
 thoughts unless we have unhappily some fault to regret ; 
 and when the faculty is disordered, the disorder is 
 seldom in the direction of exaggerating our own moral 
 excellence, or if it is, the exaggeration of this quality is 
 swamped and concealed beneath the exaggeration of the 
 estimates on the second level — of wealth, power, and 
 honour. Self-depreciation with respect to the moral 
 quahties is, however, a frequent symptom of disorder, 
 and may take the form of self-accusations either of crime 
 or of sin. False but conscientious self -accusations of 
 crime are frequent enough, both in the transient insanity 
 of drunkenness, and in cases of more enduring alienation ; 
 and, without any definite self-accusation of a specific 
 crime, a general feeling of moral delinquency, and a belief 
 in a past of criminal actions that can no longer be 
 individually remembered, is not very infrequent. More 
 frequent still are ungrounded self-accusations of sin, 
 often culminating in confession of the unpardonable sin, 
 an expression that, for the sake of these unfortunates, 
 one could wish to see expunged from the authorised 
 version. "What men mean by the expression is usually 
 the practice of masturbation, to which the laity attach 
 such exaggerated importance, taught so to do, no 
 doubt, by the medical profession, which held the same 
 view until I ventured to question it five-and-twenty 
 years ago. When women confess to the same inexpiable 
 offence, its nature is not usually to be ascertained. It 
 
EXALTATION 101 
 
 is certainly not, as one miglit perhaps have expected, 
 inchastity, but is usually a vague conviction of moral 
 turpitude of no specific character. Sometimes, however, 
 it is a specific act. One poor girl, described to me how, 
 when her lover jilted her, she lay upon her bed and 
 cursed the Almighty, who had suffered him to do so ; 
 and this was, to her conscience, the unpardonable 
 sin. 
 
 The exaggerated estimate of our own powers and 
 worthiness, upon whatever level the estimate is made, 
 may fitly be called Exaltation, and should be dis- 
 tinguished from Exhilaration, or unjustified joyousness 
 or gaiety, with which it is always confused by alienists. 
 Similarly, Abasement, which is the morbid under- 
 estimate of our own powers and worthiness, is confused 
 with Depression, which is lowness of spirits or misery. The 
 two are manifestly different. One is a state of feeling, 
 the other is a belief, the result of a judgment or estimate. 
 The behef that constitutes abasement may be a logical 
 ground for depression, but it is not the same as depres- 
 sion, though it often accompanies depression. The very 
 fact that depression occurs apart from abasement is 
 enough to show that the two things are not the same. 
 I do not know that abasement occurs apart from 
 depression, but exaltation occurs often enough without 
 any exhilaration, and exhilaration apart from ex- 
 altation. The exalted person is rarely depressed, but he 
 may be depressed, and I have witnessed the combina- 
 tion, though it is certainly unusual ; but he is very often 
 little or not at all exhilarated by his exaltation ; and 
 the queen may be found at the wash-tub and the emperor 
 carrying coal, neither exhilarated by their exalted 
 rank, nor impressed by its incongruity with their 
 present occupation. 
 
102 A TEXT-BOOK OF INSANITY 
 
 The structure of Intellect on the plan here proposed 
 will be as follows : — 
 
 THOUGHT OR INTELLECT 
 Objective Thought Subjective Thought (Self-Estimation) 
 
 Wisdom. Moral. 
 
 Ingenuity. Possessive. 
 
 Caution. Mental. 
 
 Perception. Physical. 
 
 MEMORY 
 
 The last constituent of mind that needs consideration 
 at the hands of the alienist is Memory, and as already 
 said, memory differs from the other constituents of mind 
 in as much as it is not, as they are, susceptible of 
 division into grades or levels. It has, however, different 
 aspects, which the alienist must bear in mind. 
 
 That memory varies much in different persons, so that 
 some have a good memory and others a bad memory, is 
 sufficiently notorious ; but what is insufficiently ap- 
 preciated is that memory differs much in the same person 
 for different things, so that the same person remembers 
 some things well and other things badly ; and the 
 person who is noted for the wonderful retentiveness and 
 accuracy of his " memory," meaning thereby what is 
 usually meant, viz. his verbal memory, may have an 
 exceptionally bad memory for other things that cannot 
 be, or do not happen to be, expressed in words ; and may 
 in this respect be vastly inferior to the person with 
 a reputed " bad memory." For instance, two men 
 who are commonly singled out as the possessors of 
 extraordinarily good m^emories — Dr. Johnson and Lord 
 Macaulay — ^had, indeed, wonderful verbal memories, 
 
MEMORY 103 
 
 so that they could repeat accurately whole pages of 
 books that they had recently read but once, and quote 
 accurately passages that they had read but once and 
 that years ago ; but they both had exceptionally bad 
 memories for musical sounds and melodies. Of Macaulay 
 it is reported that he once recognised '' God Save the 
 Queen," but no similar instance is recorded of Dr. 
 Johnson, and it is unlikely that if such a starthng event 
 had occurred, it would have remained unrecorded. 
 
 It is not necessary to discuss here the various factors 
 that help or interfere with the tenacity of memories ; 
 they are fully described in my book on Psychology, 
 and elsewhere. It is, however, necessary to insist here 
 that it is as normal to forget as to remember, and that 
 it may be as abnormal to remember as to forget. It 
 depends upon what is remembered and what is forgotten. 
 To have enduring memories of all the details of the 
 domestic day, every petty act and movement, every 
 sound that is heard, every thing that passes under the 
 eyes, every trivial word that is interchanged, would be 
 intolerable. All these things are remembered momen- 
 tarily, can be recalled after a short interval, but are 
 obliterated by the first sleep, and thereafter are remem- 
 bered no more. On the other hand, there are certain 
 things that, either for their importance in our lives, or 
 from perpetual repetition, are never forgotten unless the 
 memory is obliterated by disease. No one normally 
 forgets the way about the house or the neighbourhood 
 in which he has lived for any length of time, unless, 
 indeed, he is bedridden. No one normally forgets the 
 name of wife, husband, or child, the nature of his 
 business, or the matters of daily routine ; and of single 
 events, no one forgets the church in which he or she 
 was married, no woman forgets the style and material 
 
104 A TEXT-BOOK OF INSANITY 
 
 of her wedding-dress, tlie place in which she spent her 
 honeymoon, the time and place at which her first child 
 was born ; no man forgets the nature of his first paid 
 employment, the place to which he went on first leaving 
 the parental roof, and so forth. These things, and such 
 things as these, are indelibly impressed upon the mind, 
 and not to remember them is clear evidence of morbid 
 forgetfulness. 
 
 Morbid defect of memory is of three main kinds, which 
 are quite distinct, occur in different people, and are 
 different morbid conditions. 
 
 The first defect is that in which those things are 
 forgotten which are enumerated above, and which it has 
 been said that no one normally forgets. From time to 
 time persons are found wandering in the streets and 
 unable to give any account of themselves, to say who 
 they are, or where they live, or to give any information 
 about their past lives. They have forgotten not only 
 the names of their nearest and dearest, but even their 
 own names, and the whole of their past lives seems to 
 be completely obliterated from their memories. Such 
 people are not always found wandering. The lapse of 
 memory sometimes takes place in their own homes ; and 
 curiously enough, they may recognise the famihar faces 
 and figures of those about them, though they are unable 
 to remember their names. Sometimes, however, they 
 are unable to remember whether the husband or wife is 
 the husband or wife. Some such cases are allied to, if 
 they are not indeed identical with, post-epileptic auto- 
 matism on the one hand, and alternating personality 
 on the other, two conditions that in my opinion are 
 variants of one another. 
 
 The second defect of memory is an exaggeration of the 
 senile defect. In this condition the events and experi- 
 
DEFECTS OF MEMORY 105 
 
 ences of the moment are forgotten as soon as they occur, 
 while the events of the remoter past are remembered 
 with full, and it may be with much exaggerated, vividness 
 and detail. In extreme cases of this kind, an experience 
 is instantly forgotten the moment it has occurred. 
 The patient has no sooner written a letter and laid it on 
 one side than he starts to write it again, oblivious that it 
 has been written already. Has daughter has no sooner 
 left the room than he begins to whimper and complain 
 that she never comes near him — ^has not seen him for a 
 month. His dinner is no sooner cleared away than he 
 rings to know why it is so late ; and so forth. The com- 
 monest and mildest example of this defect is seen in the 
 practice of elderly people to tell the same story again and 
 again at short intervals to the same person, oblivious of 
 having told it before. This, with a difficulty in recalling 
 proper names, is the first mental sign of oncoming 
 seniHty. Together with this lapse of memory for the 
 most recent afiairs is apt to go an undue vividness of the 
 memories of things long past. The incidents of youth and 
 childhood pass before the mind with a vividness and 
 persistence that may make them seem more real than 
 the state of things actually existing. The old man passes 
 into a veritable second childhood, and calls his grand- 
 children by the names of school-fellows with whom he 
 has not associated for sixty or seventy years, mistakes 
 his daughter for his first love, and his wife for his mother, 
 and seems to live in a world that has long passed away. 
 
 The third defect of memory is of a totally difierent 
 kind. Having stated once in the witness-box that the 
 plaintifi suffered from defect of memory, I was asked 
 in cross-examination whether he had not shown in his 
 evidence that his memory of the events he described 
 was very good ; and I admitted that he had, but these, 
 
106 A TEXT-BOOK OF INSANITY 
 
 I said, were past events. " And would you expect him," 
 said counsel with something of a sneer, " to remember 
 future events that have not yet happened ? " and he 
 was considerably taken aback when I answered, *' Pre- 
 cisely. It is for future things that his memory is so 
 defective." The statement is paradoxical, but it is 
 quite true. Among the things that we have to remember, 
 and that it is most important for us to remember, are 
 things that are going to happen. We should not often 
 catch a train unless we remembered at what time it is 
 going to start. How often do we not — some of us — 
 find our visit to a shop fruitless because we have for- 
 gotten the hour at which it was going to close ! What 
 is more important to a business man than to remember 
 the appointments that he has to keep ? The whole 
 efficiency of men in many occupations lies in remember- 
 ing correctly what things have to be done at what times. 
 What is the value of a nurse who forgets when dressings 
 are to be changed, when food is to be given, when 
 remedies are to be administered, when the doctor's 
 visits are to be expected ? This is a special form or 
 mode of memory, quite different from the memory of 
 what one has read or heard or seen, which is what usually 
 comes into the mind when memory is spoken of. It is 
 the form of memory which is by far the most useful in 
 the practical affairs of life, and is by no means necessarily 
 developed in proportion or in association with the 
 memory of what has been read in books. Rather there 
 seems to be a certain antagonism between them, so that 
 the most learned man is the man least likely to remember 
 an appointment, and the practical man, who never 
 forgets to perform in due order any of his multifarious 
 duties, is the man least able to acquire knowledge from 
 books. Defect of what may be called the practical 
 
MNEMONIC DELUSION 107 
 
 memory is a frequent disorder of mind. In many people 
 it seems to be either originally defective, or to be 
 defective from want of cultivation, and in these people, 
 who are called absent-minded, it is not serious ; but 
 when it becomes defective in those in whom it has been 
 cultivated to a high pitch, the defect is a serious one, not 
 only on account of its practical inconvenience, but 
 because it may mean grave disease. It is among the 
 earliest signs of one form of general paralysis. It is 
 sometimes the consequence of injury to the head. And 
 it is usually accompanied by confusion of thought. 
 
 The last disorder of memory, and the last disorder of 
 mind with which the alienist need concern himself, is 
 not a defect. It is rather an excess. It consists in what 
 I have called mnemonic delusion ; that is to say, an 
 event which never occurred at all is remembered, or 
 appears to be remembered. It is imagined and pro- 
 jected, or retrojected, back into the past, and is to the 
 subject of it a memory. Such false memories, or mne- 
 monic delusions, occur chiefly in chronic alcoholism ; 
 and the vividness, detail, and particularity of the 
 memory are often remarkable. A single instance will 
 suffice. I was driving one day with an old gentleman, 
 the subject of alcohohc insanity, when all at once he 
 tried to get out of the carriage while it was going rapidly. 
 I forcibly prevented him from getting out, and in the 
 struggle one of his fingers was dislocated. The disloca- 
 tion was reduced and the finger put up in a splint, and a 
 few hours afterwards, when he was asked how the 
 accident happened, he gave the following account of it : 
 " I was going upstairs," he said, " and one of the stair- 
 rods had been taken out, leaving the stair-carpet in a 
 loose fold. It slipped under my feet, and I fell forward, 
 catching the tip of my finger against the edge of the 
 
108 
 
 A TEXT-BOOK OF INSANITY 
 
 stair above. The finger was bent quite back, and put 
 out of joint." To this account he adhered for a time; 
 but it was subsequently changed for another, equally 
 imaginary, and related in equally good faith. Fortun- 
 ately the delusion was innocuous, and implicated no one 
 in any fault ; but it is manifest that the imaginary 
 memory might have been of an unjustifiable assault ; and 
 in any case my old friend would have been quite prepared 
 to go into the witness-box and swear with a clear 
 conscience that his account was the true one. Such 
 delusions are therefore not free from danger to others. 
 
 SUMMARY 
 
 The total constitution of Mind, as far as the alienist 
 needs to take it into his consideration, that is to say, 
 the regions of mind that are subject to such flagrant 
 disorder as to enter into insanity, or otherwise to call for 
 the services of the physician, may be tabulated in the 
 following manner : — 
 
 Desire. 
 
 Will. 
 
 Main Ends 
 Subordinate 
 Sub-subordinate 
 Trivial 
 
 Feeling. 
 
 Thought. 
 
 Memory. 
 
 
 Subjective 
 
 Objective 
 
 Subjective 
 
 Objective 
 
 Social 
 Selfish II 
 Selfish I 
 Racial 
 
 Moral 
 Esthetic 
 Euphoric 
 Crude 
 
 Social 
 Esthetic 
 Emotion 
 Sensation 
 
 Moral 
 Possessive 
 Mental 
 Physical 
 
 Wisdom 
 Ingenuity 
 Caution 
 Perception 
 
 This Table is complicated and elaborate, no doubt, 
 but it is less complicated and elaborate than the constitu- 
 tion of Mind. There is no faculty, and no level of any 
 
CONSTITUTION OF MIND 
 
 109 
 
 faculty, that is enumerated in the Table that is not 
 subject to disorder of such consequence as to call for the 
 investigation of the physician ; and the physician for 
 mental diseases who has not them all at his fingers' 
 ends, and cannot immediately relegate a disorder to its 
 proper compartment, is not equipped for his profession, 
 and, to put it bluntly, does not know his business. It 
 would be easy to simpHfy the Table by omitting some 
 faculties, but then it would not serve its purpose. As 
 it is, it does not pretend to be an exhaustive account 
 of the constitution of mind ; it is merely a convenient 
 plan of so much of mind as is found in the consulting 
 room to be subject to disorder. 
 
 Blank forms of this diagram should be inserted in the 
 case book of the physician for mental diseases, and the 
 faculty and level that are disordered in any case can be 
 indicated by shading. A few specimen diagrams of 
 various forms of disease are here inserted as models. 
 
 Anoia in deep dementia. — All the highest and upper 
 middle levels are lost. Memory also is for the most part 
 absent. The lowest level remains — sexual and crude self- 
 preservative desires, simple efiorts of will, feelings of 
 effort are left-, but some sensations are diminished. The 
 
110 
 
 A TEXT-BOOK OF INSANITY 
 
 lowest level of subjective thought is damaged, so that 
 the patient does not know of what exertion he is 
 capable. Perception remains, but the estimation of the 
 harmful action of things perceived is diminished. 
 
 II 
 
 Destre 
 
 Will 
 
 FeeUitg 
 
 TK-ou/^Mi 
 
 Menwn/ 
 
 
 
 6uXj. 
 
 Olj. 
 
 3ixhj. 
 
 Olj. 
 
 
 
 
 
 
 g//m 
 
 
 
 
 
 
 im 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Exalted delusion without elation. — Delusion shows 
 disorder of thought. Exaggeration of his own pos- 
 sessions, titles, etc., shows disorder on the upper middle 
 level of subjective thought. Inability to correct shows 
 defect of the highest level of both subjective and 
 objective thought. 
 
 Ill 
 
 DeiL}*e 
 
 Will 
 
 Fe eltn^ 
 
 Tlioatjk/fc 
 
 Mem/Oftj 
 
 
 
 Sitbj. 
 
 oy. 
 
 3uJ^. 
 
 oy. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 '4'il!''. 
 
 Sane hallucination. — The only disorder is of per- 
 ception. As the patient is able to correct his perception, 
 
CONSTITUTION OF MIND 
 
 111 
 
 and knows that it is erroneous, the highest level of 
 thought is unaffected, and there is no insanity. 
 
 
 
 
 IV 
 
 
 
 
 DesiKe 
 
 Will 
 
 Feeling 
 
 Tkou/Cjlit 
 
 Wiciiiori) 
 
 
 
 Siilj- 
 
 oy. 
 
 5al;j. 
 
 OOj. 
 
 
 
 
 
 
 'f& 
 
 fk 
 
 
 
 
 
 
 m 
 
 f 
 
 
 
 
 
 '''9/A 
 
 
 
 
 
 
 ■''% 
 
 Paranoia with grandiose delusion and hallucination. 
 Shading of the lowest level of objective thought indicates 
 the disorder of perception. The lower middle level of 
 the same faculty — estimation of the harmful quality of 
 circumstances — also is disordered. The patient over- 
 estimates his own ability and his rank, shown by shading 
 of the two middle levels of subjective thought. The 
 inability to correct these errors indicates defect of the 
 highest level of both sides of thought. Cleverness is but 
 slightly diminished. 
 
 Acute insanity of melancholic type with suicidal 
 
112 
 
 A TEXT-BOOK OF INSANITY 
 
 desire {lower middle level of desire). — Dysphoria is 
 shown by shading of the lower middle level of subjective 
 feeling. The disorder spreads to the highest level as 
 shown by feeling of wickedness. Uncalled-for fear 
 shows disorder of emotion (lower middle level of objec- 
 tive feeling) and spreads up to the highest level of this 
 faculty, where it exhibits itself as remorse. Both 
 subjective and objective thought are disordered on the 
 upper three levels, as shown on the subjective side by 
 underestimation of moral worth and mental ability, on 
 the objective side by delusions of misfortune in circum- 
 stances, by diminished intelligence and by loss of 
 wisdom and of the power of estimating self and circum- 
 stances correctly. 
 
 VI 
 
 Desive 
 
 Will 
 
 Feelintj 
 
 TfioagKt 
 
 Mentori^ 
 
 
 
 Su/ly. 
 
 06j. 
 
 .Su/Iaj. 
 
 Obj. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 m. 
 
 
 ^- 
 
 
 
 
 
 
 
 Agorophohia or Claustrophobia. — Malestimation of 
 the power of perceived circumstances to harm (lower 
 middle of objective thought) and unjustified fear (lower 
 middle of objective feeling). 
 
PAET II 
 
 FORMS, TYPES, AND KINDS OF 
 INSANITY 
 
CHAPTER IV 
 
 THE CLASSIFICATION OF INSANITY 
 
 The classification of insanity is admitted by everyone 
 to be unsatisfactory. Every writer on tbe subject has 
 his own classification, which is different from that of 
 every other writer. Various schemes have been drawn up 
 by committees and official bodies, but, I say it after 
 examining a very large number of classifications, the 
 results both of individual and of collective effort, there 
 is not one that does not violate the fundamental rules 
 of classification. 
 
 In the year 1905 a strong Committee of the Medico- 
 Psychological Association drew up a classification which 
 has since been adopted by the Lunacy Commission, and 
 owing to this official approval has superseded, in this 
 country at least, all previous classifications. To that 
 Committee I was Secretary, and I am therefore without 
 antagonistic bias when I say that, having taken into 
 consideration all previous classifications, it produced a 
 scheme which is almost as faulty as any of its pre- 
 decessors — a scheme which violates every canon of 
 classification ; which does not define or delimit the group 
 of things to be classified ; which fails to find a place for 
 some of these things ; and which admits things that are 
 outside the boundary of insanity. The several classes 
 of equal rank are founded upon different principles of 
 division, and therefore the scheme allows of abundance 
 
 115 
 
116 A TEXT-BOOK OF INSANITY 
 
 of cross-classification. These objections are common to 
 this and to every other scheme of classification of 
 insanity that has ever been proposed, and it is suf- 
 ficiently clear that no classification can possibly be 
 satisfactory to which any one of these objections can be 
 justly made. It is clear that no previous classifier has 
 ever been at the trouble to acquaint himself with the 
 rules or canons of classification, still less to make any 
 attempt to abide by them. It may be well, therefore, to 
 set them forth here, in order that critics may judge 
 whether they are observed or not. 
 
 The first step towards forming a valid classification is 
 to delimit the group of things to be classified — to draw 
 a line round them, including them all, and excluding 
 all other things. The second requisite is that each step 
 in the classification must be made according to the 
 presence or absence of one single quality, or according to 
 the modes or degrees of one single quality and no more. 
 If these conditions are observed, the classification will 
 include all the things that ought to be included in the 
 classification, and nothing that ought not ; and the 
 classes will be mutually exclusive, so that nothing that 
 is in any one class can possibly be placed in any other 
 also. In other words, the classification will be a valid 
 classification. If either of these conditions is violated, 
 the classification will be faulty in one or other of the 
 respects mentioned, and will not be a valid classification. 
 In every classification of insanity hitherto proposed they 
 have both been violated. 
 
 The first step in making a classification is to settle 
 what it is that we have to classify — to set out the limits 
 of the class of things that we propose to subdivide, so 
 that the classification may include them all, and may 
 exclude everything else. In other words, the first step 
 
THE CLASSIFICATION OF INSANITY 117 
 
 in making a classification is to define the group of things 
 to be classified. 
 
 The things to be classified are cases or instances of 
 insanity, and one reason for the utter failure of every 
 classification of insanity hitherto proposed is that 
 insanity has never been satisfactorily defined. It never 
 could be satisfactorily defined, and for this reason, that 
 the name insanity has always stood for more than one 
 concept. We have been and are in the habit of speaking 
 of insanity as if by this name we meant only one thing 
 and always the same thing ; whereas, in fact, the name 
 insanity stands for more than one thing — ^has more 
 than one meaning — and when we use the name we 
 mean sometimes one thing and sometimes another. 
 This would not matter in the least if we knew and 
 recognised that the name has more than one meaning, 
 and if we always kept the meanings distinct in our 
 minds. No confusion arises from our habit of calling a 
 beam stuck upright in the ground by the same name as 
 is used to denominate a delivery of letters ; but to a 
 person who did not know these two meanings of the 
 word *' post " the use of it alternately in the two senses 
 would be puzzling. No confusion need result from 
 using the name insanity in more than one sense, but 
 confusion does result because the meanings are not 
 distinguished, and we do not know that we are using 
 the word in more than one sense. 
 
 We found in a previous chapter that insanity is a 
 quadruple disorder of (1) Conduct, (2) Mind, and (3) 
 Metabolism, all dependent on (4) disorder of the action 
 of the highest region of the brain. This is one concept 
 of insanity, but it is not the only, nor even the usual 
 concept. I do not think that anyone but myself includes 
 disorder of metabolism in the concept of insanity, though 
 
118 A TEXT-BOOK OF INSANITY 
 
 it is often a very conspicuous factor in the concept to 
 me ; and it is certain that we can think and often do 
 think of insanity as disorder of conduct and mind, not 
 only without connecting these disorders with disorder of 
 metabolism, but also without at the moment taking up 
 into the concept the disorder of brain process. Here, 
 therefore, are three different concepts all called by the 
 name insanity — the fourfold disorder of conduct, mind, 
 metabolism, and brain-process ; the threefold disorder of 
 conduct, mind, and brain-process ; and the twofold 
 disorder of conduct and mind. There are alienists who 
 deny that disorder of conduct forms any part of their 
 concept of insanity, but those who make this denial have 
 peculiar notions of conduct and of disorder of conduct 
 which put their views outside the pale of the present 
 discussion. What they mean by conduct I do not know, 
 except that they, or some of them, consider it a part of 
 mind. It is clear that they do not mean by it what I 
 mean by it, that is to say, the way a person acts and 
 talks, for if they did mean this, they could not fail to 
 admit that erroneous ways of acting and talking do 
 enter into the concept of insanity. Others evidently 
 think that disorder of conduct means disorderly conduct 
 in the police court sense, and I do not think this view 
 merits serious refutation. Everyone who understands 
 ordinary familiar English words in their ordinary 
 familiar meanings must admit that it is impossible to 
 think of insanity without including in the concept 
 disorder or error in what the insane person says and 
 does. 
 
 The necessity of including disorder of mind in the 
 concept is a little more doubtful. Insanity is already 
 complete when conduct is disordered, and in many 
 cases no more need be considered : in many cases no 
 
VARIOUS CONCEPTS OF INSANITY 119 
 
 more is considered, for a time, at any rate ; and in 
 those cases in which disorder of mind does enter into 
 the concept, the nature and extent of the disorder is 
 always somewhat conjectural, and is often largely or 
 entirely conjectural. It is quite true that insanity is 
 always called disorder of mind, and is never called 
 disorder of conduct, but this is merely an instance of the 
 common tyranny of the word. When we say that a 
 person's mind is disordered, what we mean is that he 
 acts or talks strangely and abnormally ; and if he did 
 not so act and talk we should never know and never 
 care whether his mind was disordered or not. Still, apart 
 from the mere use of the terms mental disorder and 
 disorder of mind, which are used as equivalents of 
 insanity without any necessary reference to actual 
 mental states or processes that are working in a dis- 
 orderly manner, no doubt we do in many cases of 
 insanity look behind the disorder of acting and talking, 
 and infer from them some disorder of mind ; and no 
 doubt we always ought to regard the disorder in acting 
 and talking as representative and significant of disorder 
 of mind, and so bring mental disorder into our concept 
 of insanity. We may take it, therefore, that the very 
 minimum concept that is in our minds when we speak 
 or think of insanity is the twofold disorder of conduct 
 and of mind. 
 
 Although we can, and often do, thus conceive insanity, 
 we do not often allow this concept to remain in our 
 minds in its simplicity. We usually bring it into 
 relation with disorder of brain function, and bring it 
 into relation in one of two ways. In the first way, we 
 keep the disorder of brain function separate from the 
 disorders of conduct and mind, and regard the latter as a 
 symptom of the former. In the second, we combine 
 
120 A TEXT-BOOK OF INSANITY 
 
 tlie three disorders together into a single concept, and 
 regard this threefold disorder as a disease. In the first 
 case, there are two concepts, the disorder of conduct 
 and mind on the one hand, and the disorder of brain 
 function on the other, and these are regarded in the 
 relation of symptom and basis. In the second case there 
 is but one concept, of disorder of conduct, mind, and 
 brain, amalgamated into a disease. 
 
 It is as well to state here exactly what I mean by a 
 symptom and by a disease, since there are no authorita- 
 tive definitions of these terms, and until they are defined 
 it is difficult to make my meaning clear. By a 
 symptom I mean a sign or manifestation of disorder of 
 some function. The sign may be perceptible to the 
 patient alone, as in the case of pain ; or it may be 
 perceptible to the bystander alone, as in the case of coma ; 
 or it may be perceptible to the skilled examination of 
 the physician alone, as in the case of a cardiac murmur 
 or a water-hammer pulse ; or it may be perceptible to 
 both the patient and the bystander, as in the case of 
 tumour or rash ; but in any case a symptom is a sign 
 or manifestation, perceptible to someone, that some 
 function is gone wrong. Disorder of conduct is a sign 
 or manifestation that the higher function of the brain is 
 gone wrong, and we often infer so directly from disorder 
 of conduct and from altered demeanour, which is, of 
 course, a part of conduct, to disorder of mind, that we 
 seem to observe the disorder of mind ; and no doubt 
 uneducated and untrained persons think they do 
 observe the disorder of mind. So that, by a little 
 straining and stretching of the meaning of the words, 
 we may regard the disorder of mind that we do not 
 observe, but infer, as a symptom of disorder of brain- 
 function, just as we regard the endocarditis that we do 
 
THE MEANING OF DISEASE 121 
 
 not observe, but infer, as a symptom of acute rheumatism. 
 The expressions are not strictly correct, but they are 
 convenient fictions. 
 
 By a disease I mean the whole group of correlated 
 disorders from which the patient suffers. The whole of 
 the disorders from which a patient suffers need not be 
 a single disease. A person may suffer from two or more 
 diseases at the same time. He may suffer from curva- 
 ture of the spine and psoas abscess, and since these are 
 correlated together by their dependence upon a single 
 cause — tuberculosis of the vertebrae — they are not 
 different diseases, but parts of a single disease. But he 
 may suffer also from chilblains, or from scarlet fever, 
 or from rickets, and since these cannot be correlated 
 together by dependence on a single cause, since they are 
 not different manifestations of a single disorder, they 
 are not one disease but several diseases. Cough, dys- 
 pnoea, hvidity, dropsy, and a cardiac murmur are all 
 symptoms of mitral disease. Taken together with the 
 distortion of the mitral valve, and with any other 
 disorder produced by this distortion, such as alteration 
 of the pulse, they constitute the disease from which the 
 patient suffers, the disease being the whole group of 
 correlated disorders — the whole group of symptoms 
 together with the underlying disorder to which they are 
 all due. 
 
 In the light of this definition, is insanity a disease ? 
 If we mean by insanity disorder of conduct and mind 
 only, then insanity is not a disease, but a symptom of 
 disorder of brain. But if we mean by insanity 
 disorder of conduct and mind plus disorder of brain, is 
 such insanity a disease ? Clearly it is, if these constitute 
 the whole of the group of correlated disorders from 
 which the patient suffers. Thus in many cases dysphoria 
 
122 A TEXT-BOOK OF INSANITY 
 
 with its expression is a disease, and in many cases excited 
 conduct is a disease. But there are also many cases in 
 which the disorder of conduct, mind, and brain do not 
 constitute the whole of the group of correlated disorders 
 from which the patient suffers. We frequently see this 
 group correlated with specific fevers — with typhoid, 
 scarlet fever, measles, small-pox, and so forth. When 
 so correlated, insanity is not a disease, but a symptom 
 of the wider disease. So well is this recognised that in 
 such circumstances insanity is not called insanity. It 
 is called delirium, and regarded as a symptom of the 
 fever. But if insanity can be a symptom of fever, it 
 can be a symptom of other diseases, if it is correlated 
 with those diseases and due to the same underlying 
 cause. Now insanity as a symptom — disorder of con- 
 duct and mind — is found associated with some other 
 diseases, such as myxoedema, gout, Graves' disease, 
 and so forth, sufficiently often to lead us to suppose that 
 it is correlated with them, so that whatever poison or 
 other agent produces the other symptoms of these 
 diseases produces the insanity also. In such cases the 
 insanity is not a disease, for it does not constitute the 
 whole of the correlated group of disorders, and is there- 
 fore one of the symptoms only of the disease. It would 
 be a great improvement in our nomenclature if the 
 symptom insanity were always called delirium, as it is 
 when it is a symptom of specific fever. We are accus- 
 tomed to think of delirium as a symptom, just as we are 
 accustomed to think of insanity as a disease ; and if the 
 separate names were allotted severally to the distinct 
 things, it would save a good deal of confusion of thought. 
 I have said that in one concept of insanity, and that 
 which I regard as the only complete concept, the dis- 
 order is fourfold, and includes disorder of metabolism, 
 
SYMPTOM AND DISEASE 123 
 
 disorder which shows itself sometimes in conspicuous 
 alteration in the integuments, in the skin, sweat, hair 
 and nails, and in chilblains and other cutaneous change. 
 If these are correlated with the insanity, if, that is to say, 
 they depend on the same disorder of the brain as that 
 to which the insanity is due, then according to the 
 doctrine here laid down, they are part of the disease. 
 The whole disease may still be called insanity, and of 
 this disease the structural change in the integuments is 
 a part and a symptom. If the symptom insanity occurs 
 in the course of some specific fever, then the insanity is 
 similarly accompanied by a structural change in the 
 skin — by a rash — but we do not now call the whole 
 disease insanity and regard the rash as a symptom of 
 the insanity, and the reason is plain. The disease is not 
 insanity because the disorder of conduct, mind, and brain 
 is not the whole disorder from which the patient suffers ; 
 and the remaining disorder is not part of the insanity, 
 because it is not due to the disorder of brain function 
 which is the central disorder in the insanity and to 
 which the other disorders of the insanity are due. On 
 the contrary, the factor which correlates the whole of 
 the disorders, causes them all, and constitutes them one 
 disease, is the microbe of small-pox, or scarlet fever, or 
 measles, or what not. 
 
 Now apply this principle to the case of general 
 paralysis of the insane. Is it a bodily disease, of which 
 insanity is a symptom, or is it insanity of which bodily 
 disease is a part ? Certainly, the symptom insanity — 
 the disorder of mind and conduct — is far from being the 
 whole of the disease. The physical symptoms also are 
 conspicuous and important, and of these the patient at 
 length dies. From the pupillary disorders and the 
 altered knee jerks of the early stage of the disease to the 
 
124 A TEXT-BOOK OF INSANITY 
 
 contractions and bed-sores of its final stage, physical 
 symptoms are of high importance throughout. The 
 question is, Are these physical symptoms produced by 
 the very sam^e changes in the brain that produce the 
 delirium, or do they, as in the case of specific fever, own 
 some other and deeper cause, to which the brain change 
 also is due ? The puzzle is that both questions may be 
 answered in the affirmative. The whole of the disorders, 
 brain change and all, are due to the poison of syphilis, 
 just as the whole of the disorders in delirious small-pox, 
 brain change and all, are due to the poison of small-pox ; 
 but the difference is that, in small-pox, the rash on the 
 skin and the other symptoms are produced directly by 
 the local action of the poison on the skin and other parts 
 displaying the symptoms, while in general paralysis the 
 whole of the physical symptoms are produced in- 
 directly by the action of the poison on the brain, and it 
 is the impairment of the trophic and other functions of 
 the brain to which the physical symptoms are due. In 
 general paralysis, therefore, all the symptoms are cor- 
 related by the brain disorder ; in small-pox we must go 
 behind the brain disorder to the widespread action of the 
 poison in order to discover the correlating agent. Hence, 
 general paralysis may be regarded as an instance of the 
 disease insanity, in which the disorder of metabolism, 
 which I say is part of the disease, is unusually profound, 
 widespread, and severe. 
 
 It is of the greatest importance, therefore, in dealing 
 with insanity, to remember that insanity may be a 
 symptom or a disease ; and it is expedient, when we are 
 speaking of disorder of conduct and mind alone, that is of 
 the symptom insanity, to call it delirium, or some other 
 title than insanity, and to reserve the name insanity for 
 diseases. Since, however, delirium has an old and 
 
SYMPTOM AND DISEASE 125 
 
 prescriptive right to characterise that peculiar form of 
 the symptom that occurs in specific fevers and in some 
 other bodily diseases, I shall here call the symptom 
 insanity by the name of the form of insanity, and the 
 difierent diseases that insanity includes — for it does 
 include difierent diseases — by the title of kinds of 
 insanity. 
 
CHAPTER V 
 
 FORMS OF INSANITY 
 (insanity the symptom) 
 
 A FORM of insanity is therefore a correlated couple of 
 disorder of conduct expressing disorder of mind, or of 
 disorder of mind expressed in disorder of conduct, pro- 
 vided the disorder is not recognised as disorder by the 
 subject of it. For instance, grievous expression and 
 demeanour, accompanied, it may be, by lamentation, 
 express dysphoria, or misery of mind. If this misery is 
 manifestly unjustified by the circumstances in which 
 the patient is, it is disorder of mind ; and the grievous 
 expression and demeanour which express the disorder of 
 mind are disorder of conduct. If the sufferer recognises 
 that his misery is unjustified by his circumstances, and 
 looks upon it as disorder, then, although it is disorder of 
 mind, it is sane disorder. If, however, he does not 
 recognise that it is unjustified, and especially if he 
 attributes his misery to misfortunes or other circum- 
 stances that are imaginary, and for which there is no 
 sufficient evidence, then the misery is insane disorder of 
 mind, and the grievous demeanour and lamentation are 
 insane disorders of conduct. This correlated couple of 
 insane disorder of mind plus the insane disorder of 
 conduct that expresses it, I call a form of insanity. The 
 correlated couple may also be called a symptom of dis- 
 order of the brain. 
 
 126 
 
MELANCHOLIA 127 
 
 Of course, strictly speaking, the disorder of mind is 
 not a symptom, since it cannot be observed. We cannot 
 observe the patient's misery, but we can observe the 
 expression of it in his conduct, and we infer so directly 
 from this expression to the state of mind that it ex- 
 presses, that we may, without much straining of 
 language, speak of them both as symptoms, or at least 
 of the combination as a sjnnptom. It is quite clear from 
 the language used by many ahenists that they think 
 they do observe the state of the patient's mind. 
 
 Misery, expressed in grievous demeanour and un- 
 justified by the patient's circumstances, is called by 
 ahenists melancholia, and this word is a good example 
 of the confusion of our nomenclature, and of the 
 ideas expressed by our nomenclature. These are some 
 of the meanings for which the term melancholia 
 stands : — 
 
 1. Unjustified misery, known by the patient to be 
 unjustified, and therefore sane. 
 
 1 2. Unjustified misery, not recognised to be unjustified, 
 and therefore insane. 
 
 3. Unjustified misery plus the expression of it in 
 demeanour and other conduct. 
 
 4. Unjustified misery and its expression plus disorder 
 of brain. 
 
 5. Unjustified misery, together with its expression in 
 conduct and the disorder of brain on which it is supposed 
 to depend, plus gastro-intestinal and other bodily 
 disorders. 
 
 6. Unjustified misery together with the elements 
 previously mentioned, or some of them, 2^?W5 delusion 
 and its expression. ** 
 
 7. Some or all of the previous elements plus abase- 
 ment. 
 
128 A TEXT-BOOK OF INSANITY 
 
 8. Suicidal conduct, with or without some or all of 
 the elements above mentioned. 
 
 9. Silence and resistiveness. 
 
 It would be absurd to dispute, and I do not dispute, 
 that it is useful, and indeed necessary, to characterise 
 definite clinical pictures by specific terms ; but I protest 
 against the application of a single term to such a hetero- 
 geneous collection of difierent disorders, some simple, 
 some very complex ; some sane, others insane ; some of 
 them mere symptoms, others complete diseases. Our 
 nomenclature is to a great extent a measure of the stage 
 to which our thought has progressed, and as long as our 
 nomenclature is as confused as this, our thought will be 
 equally confused. 
 
 Although when mind is disordered, the disorder is 
 always expressed in some disorder of conduct, and but 
 for the disorder of conduct we should not know that 
 disorder of mind exists ; and although when conduct is 
 disordered, this disorder is always the expression of 
 some corresponding disorder of mind ; yet it happens in 
 some cases, and often in dysphoria, that we infer so 
 directly and immediately from conduct to mind that we 
 are apt to forget the disorder of conduct, and to con- 
 centrate our attention on the mental disorder alone. 
 
 In other cases, as in excited conduct and in destructive 
 conduct, the disorder of conduct is conspicuous, and it is 
 difficult to interpret, or to infer with any confidence, 
 what disorder of mind is expressed by the disorder of 
 conduct. In such cases we speak of the insanity as 
 disorder of mind, but we think of it as disorder of 
 conduct. 
 
 In a third class of cases the disorder of mind 
 cannot be definitely known except by the verbal 
 confession and description given by the patient. 
 
FORMS OF INSANITY 129 
 
 which, of course, is a part of conduct ; but even 
 then, though we witness disorder of other parts of 
 conduct, and though we have the patient's own descrip- 
 tion of the disorder, or some of it, that is present in his 
 mind, yet it is impossible to interpret the disorder of 
 conduct by the disorder of mind, or to connect the one 
 with the other. It is difficult to see, for instance, what 
 connection there can be between exaltation and delu- 
 sions of grandeur and of increased consequence on the 
 one hand, and such conduct as washing the face in the 
 pan of the water-closet or throwing the bed-clothes out 
 of the window. No doubt these acts were prompted by 
 some other disorder of mind that was not discoverable. 
 
 Still, when allowance has been made for these difficult 
 cases, we must assume that every disorder of conduct 
 expresses a corresponding disorder of mind which 
 prompts it, and that every disorder of mind finds 
 expression in corresponding disorder of conduct ; and 
 though it is in many cases difficult to trace the connec- 
 tion between the one disorder and the other, yet in a 
 wide range of cases we can discern a connected couple of 
 disorder of conduct and disorder of mind, afiording a 
 symptom of a more or less hypothetical disorder of brain. 
 
 In a previous chapter I showed that mind is divisible 
 for the purposes of the alienist into five principal 
 divisions or faculties : — ^Desire, Will, Feeling, Thought, 
 and Memory, and the first four of these are further 
 divisible into grades or evolutionary levels, and having 
 regard to the further division of Feeling and Thought 
 into subjective and objective sides, there are altogether 
 five-and-twenty departments, in any of which mind may 
 be disordered ; and in some of these departments mind 
 may be disordered in various ways. Each department 
 was taken singly, and the disorders to which it is 
 
130 A TEXT-BOOK OF INSANITY 
 
 subject were described, but the several departments 
 of raind are not, as a rule, disordered singly. Sometimes 
 they are so, and instances of such localised disorders are 
 witnessed in simple dysphoria, sane hallucination, 
 imperative idea, excessive hesitation, facility, obsession, 
 vertigo, claustrophobia, and other disorders. Usually, 
 however, the disorder implicates more than one level of 
 a faculty, it may be more than one faculty, either on the 
 same or on different levels, and some disorders are so 
 widespread as to impUcate every level of every faculty. 
 In describing any large number of objects of the same 
 kind, it is manifestly desirable to begin with the simplest 
 and gradually proceed to the most complicated, but in 
 the case of disorders of conduct and mind, that which is 
 simplest from one point of view is the most complicated 
 when viewed in the reverse direction, and vice versa. 
 In other words, we may pay attention either to what 
 is taken away or to what is left. The less the area 
 of mind that is disordered, the more of normal mind 
 remains, and the cases in which but a very small area of 
 mind is disordered are, from one point of view, the 
 simplest ; but these have always appeared the most 
 puzzling and the most difficult to account for, as appears 
 when it is remembered that they include such maladies as 
 imperative idea, obsession, and claustrophobia. On the 
 other hand, the greater the area of conduct and mind 
 that is removed, the less remains as an object of study, 
 and such maladies as stupor and coma, in which every 
 level of every faculty of mind and conduct is abolished, 
 are, in spite of the extreme extension of the disorder, the 
 simplest to study, because little or nothing remains to 
 observe. Here it will be advisable to regard those cases 
 as simplest in which the disorder is most limited, 
 and the complementary area of the normal largest, for 
 
DISORDERS OF DESIRE 131 
 
 these have been described in the last chapter, and their 
 description forms a starting-point for that of the more 
 complicated disorders. In each case I shall take the 
 leading disorder, the most conspicuous disorder, and 
 show what other disorders are commonly associated 
 with it. 
 
 I. DISORDERS OF DESIRE 
 
 When these are primary, they are usually single, that is 
 to say, they are uncomplicated with disorder of other 
 faculties or of other levels of desire. Keeping always in 
 mind that no disorder of mind is insane unless it includes 
 disorder of the highest level of thought, so that the 
 subject of it is unable to recognise that the disorder is 
 disorder, we come first, on the lowest level of desire, 
 to sexual perversion. This is undoubtedly disorder of 
 mind, but with equal absence of doubt it is not insanity, 
 for it is uncomplicated, and unaccompanied by disorder 
 of the highest intellectual level. It is undoubtedly 
 disease. Should it then be punished ? Certainly not. 
 A man should no more be punished for experiencing a 
 desire that he cannot help than for suffering a pain in 
 his head that he cannot help. We ought not to punish 
 the sexual pervert for entertaining a morbid desire — 
 and we do not punish him for it. But if he acts in 
 pursuance of his desire in such a way as to gratify it, 
 then we punish him, and rightly, granting that it is 
 expedient for the welfare of society that such acts 
 should be punished. It is right that he should now be 
 punished, for the act is the product of his will, to which 
 the disease does not extend. 
 
 It will be unnecessary to go through all the mani- 
 festations of morbid desire, since these have been suf- 
 ficiently described in a previous chapter, but something 
 
132 A TEXT-BOOK OF INSANITY 
 
 must be said about defect and disorder of the highest 
 level of desires, those, namely, that affect our relations 
 to our fellows. Ninety-five per cent, of the crimes that 
 are investigated by the courts are crimes of dishonesty ; 
 that is to say, they are due to the improper preponder- 
 ance of desires of the upper middle level — desires of 
 acquisition and of livelihood — over those social desires 
 for the welfare of others and the good of the community 
 at large which keep honest men honest. 
 
 It is often said, by those who have no clear notion of 
 what crime is or of what insanity is, that all crime is in- 
 sane — that criminality is a disease of the nature of in- 
 sanity. There are those who hold that all crime is ipso 
 facto insanity ; but I do not know that anyone who holds 
 this opinion has any clear notion of what he means by 
 crime or of what he means by insanity, and until he is pre- 
 pared with some sort of justification for his opinion, it is 
 scarcely worth while to discuss it. It is certain that the 
 general opinion, which holds the field, which has pre- 
 vailed among all nations and in all ages of which we 
 have any record, is that insanity and crime are distinct ; 
 and if anyone holds the opposite view, the onus is upon 
 him to justify his opinion and prove his case. Up to the 
 present he has made no attempt to do so. On the other 
 hand, there are some, among whom I reckon myself, 
 who hold that there are such things as moral imbecility 
 and moral insanity ; in other words, that there are not 
 only criminals who are insane and criminal acts that are 
 insane — everyone is agreed upon that — but that there 
 is a certain form of criminality that is insane, although 
 the great bulk of criminality and the great majority of 
 criminals are sane. I now proceed to elucidate these 
 propositions and to show cause why they should be 
 accepted. 
 
CRIME IS NOT INSANITY 133 
 
 Crime consists of acts that are destructive or detri- 
 mental to society, and arises from the preponderance of 
 selfish over social desires, that is to say, of the preponder- 
 ance of desires on the three lower levels over those of 
 the highest level, which should prevail over the lower 
 whenever they are in conflict. I do not here labour to 
 establish this theme, which I have treated at sufficient 
 length in my book on Criminal Responsibility. The 
 doctrine is generally accepted as true, and has never, as 
 far as I know, been contested. Insanity, on the other 
 hand, is disorder of conduct and mind of a certain kind. 
 No doubt criminal conduct may be called, with a certain 
 stretching of the meaning of words, disordered conduct, 
 but even if it were disordered conduct, it would not 
 necessarily be insane conduct, for, as already stated 
 with repetition that is, I fear, becoming wearisome, 
 disorder of conduct and mind is not necessarily insane. 
 If it were, the reeling and clutching of thegiddy man would 
 be insane. As already explained, that conduct only is 
 insane which is unregulated by the highest level of 
 intelligence. Criminal conduct is the expression of a 
 mind in which the highest level of desire is defective ; 
 but the highest level of desire may be defective without 
 any accompanying defect or disorder of the highest level 
 of intellect, and unless this level of intellect is disordered 
 there is no insanity. Criminal conduct may be not only 
 ingenious in a very high degree, witness the operations 
 of the accomplished burglar, or the long firm expert, but 
 also regulated by a competent wisdom or prudence as 
 far as the welfare of the criminal himself is concerned. 
 For what manner of man is the criminal ? More than 
 ninety per cent, of recorded crimes are crimes of dis- 
 honesty. They are committed by persons who have an 
 aversion to steady industry, who desire to enjoy the 
 
134 A TEXT-BOOK OF INSANITY 
 
 fruits of labour without undergoing labour to secure 
 them, who estimate the risks they incur, and face them 
 for the sake of the advantage they secure. And the 
 advantage is often great, and the risk not prohibitive. 
 We hear much of the habitual criminal, who is convicted 
 time after time, and spends the greater part of his life in 
 gaol or under sentence ; but these are the unskilful or 
 unsuccessful practitioners, and for very good reasons we 
 do not hear of the successful expert, who contrives, not 
 only to keep out of prison, but to accumulate wealth, 
 or at least to keep himself in comfort by his depredations. 
 Crime not only exists but is increasing, and crimes of 
 dishonesty would scarcely exist, and would certainly not 
 increase, if they were uniformly unprofitable. In the 
 very long run, and if we take into account the necessity 
 to each individual of preserving the community of 
 which he is a part, and the tendency of crime to de- 
 teriorate the community, no doubt there is unwisdom 
 in crime ; but as far as the individual himself is alone 
 concerned, there is, or may be, no unwisdom in crime. 
 He may, by a life of crime, achieve a degree of success in 
 preserving his own life and securing the amenities of 
 life that he could not achieve, or could not achieve so 
 quickly, in any other way. Criminality is therefore not 
 inconsistent with a good development of wisdom, or 
 with the integrity of the highest level of intelligence ; 
 in other words, it is consistent with sanity. 
 
 But some crimes are undoubtedly insane. What these 
 are, I need not here discuss, for the whole subject is 
 thrashed out exhaustively in my book on Criminal 
 Responsibility, but here I may point out that not only 
 are some criminals insane, but also there is a form of 
 criminality that is itself insane, and I have made a 
 certificate of lunacy, stating, as facts indicating insanity, 
 
MORAL IMBECILITY 135 
 
 criminal conduct of this description. Criminals of this 
 type are criminals from birth, and the peculiarity of 
 their criminality is that it is unprofitable. They are 
 often — usually — of good birth, and of good prospects — 
 and good abihties. Ingenuity or cleverness is often in 
 them so highly developed as to mask the insanity to an 
 unskilled observer. Their crimes, it is true, are often 
 clumsy enough, but their subterfuges to escape the 
 consequences of their crimes are often extremely 
 ingenious, and their lies have a plausibility and veri- 
 similitude that would deceive anyone who has not had 
 experience of them. The quality that distinguishes their 
 criminality and marks it as insane is the conspicuous 
 want of prudence and wisdom. The crimes are com- 
 mitted often for gain which is manifestly not worth the 
 risk, often for objects which could be obtained equally 
 well and with equal ease by honest measures, and are 
 often committed T^dth such lack of precaution as renders 
 speedy detection certain. Moreover, the whole crimin- 
 ality is unnecessary and supererogatory. With their 
 birth, their start in life, their opportunities, their family 
 influence, their education and social advantages, it 
 would be easier to make an honest living than to make 
 a Hving by crime ; and the life that they could live 
 honestly would be far more advantageous in all ways 
 than that to which they condemn themselves. Such 
 criminality is insane, and is insane by reason of the 
 defect in the highest level of intellect, 
 
 II. DISORDERS OF ^^LL 
 
 Of these, Obsession is almost always uncomplicated, 
 at least, I have never seen a case in which any other 
 disorder of mind except hesitation was associated with 
 
136 A TEXT-BOOK OF INSANITY 
 
 obsession. It is never, in my experience, insane ; for I 
 have never seen a case in which, the patient did not 
 recognise and deplore his disorder, and do his best to 
 restrain it and correct it. The obsessed are, it is true, 
 often depressed, but the depression is thoroughly 
 justified by their experience of their malady, and is in 
 no sense abnormal. 
 
 Morbid impulsiveness, on the other hand, is always 
 associated with insanity, at any rate at the time the 
 impulsive act is committed. In some cases, especially 
 those in which the impulsive act is unsuccessfully 
 suicidal, the patient does recognise shortly after the 
 commission of the act, that it was insane ; but he never 
 realises this at the time ; and in most cases impulsive 
 acts are utterly irrational, and are committed by persons 
 already certified on other grounds to be insane. 
 
 Morbid hesitation and morbid vacillation are never, in 
 my experience, insane. The patient always recognises 
 and deplores his malady. Morbid hesitation is some- 
 times accompanied by the obsession to count, as has 
 already been described, but this is the only disorder 
 with which it is associated. 
 
 Facility occurs as a symptom both in the sane and in 
 the insane. 
 
 Stubbornness never occurs except as the most 
 prominent symptom of a widespread and deep insanity. 
 The obstinate silence of the patient renders it difficult to 
 investigate his mind, or to ascertain with any confidence 
 the range and extent of the disorder, but there is strong 
 reason to suppose that the three uppermost levels of 
 objective intelligence are disordered, and possibly the 
 lowest level, that of perception, also is disordered. 
 Certainly the highest level — Wisdom — is gone, for the 
 whole conduct of the patient, regarded from the point 
 
DISORDER OF SUBJECTIVE FEELING 137 
 
 of view of his own welfare, is unwise in the extreme. 
 Cleverness also gives scarcely any manifestation of its 
 existence, the few stratagems and subterfuges of the 
 patient being childish and transparent. It is the third 
 level of intelhgence, however, that which estimates the 
 beneficence or maleficence of surrounding agents, that 
 is most impaired. As far as can be judged, the stubborn 
 person lives in a pervading atmosphere at first of 
 suspicion, and at length of rooted conviction of the 
 animosity and mahgnity of all around him. Only by 
 this supposition can we explain his extreme recalcitrancy 
 to every suggestion, to all persuasion, his determination 
 to do the opposite of everything that he is advised, and 
 his occasional unprovoked violence to those around him. 
 The natural expression of suspicion is by taciturnity, and 
 the stubborn are taciturn to complete silence. 
 
 III. DISORDER OP SUBJECTIVE FEELING 
 
 The chief disorders of this faculty are on the lower 
 middle level, and consist of the opposite states of 
 dysphoria and euphoria. 
 
 Dysphoria, or misery in various degree, is perhaps the 
 most frequent and most widespread of all disorders of 
 mind, and that with the most numerous associations 
 with other disorders. As previously stated, it may exist 
 alone, and is then, of course, sane ; and a transient 
 depression of spirits, usually associated with some 
 digestive trouble, is one of the commonest of mental 
 disorders. The most frequent mental accompaniment 
 of dysphoria is abasement, or underestimation of self, 
 on any or every level — physical, mental, possessive, or 
 moral. With this underestimation on the subjective 
 side of thought there often goes overestimation of the 
 
138 A TEXT-BOOK OF INSANITY 
 
 maleficent influence of circumstances, a disorder which 
 may afiect any level of objective thought, even the 
 lowest, in which case it produces terrifying or depressing 
 hallucinations and illusions. 
 
 In consequence of the universal prevalence of the 
 doctrine that insanity and disorder of mind are con- 
 vertible terms, it is necessary to emphasise again in this 
 place that depression of spirits is not necessarily insane. 
 
 It is, of course, completely normal when it is due to the 
 appreciation of adverse circumstances that really exist, 
 of failures and disappointments that have actually been 
 experienced ; but when quite unjustified by circum- 
 stances, it is still not insane, though it is disorder of mind, 
 when it is known and recognised by the patient who 
 experiences it to be morbid. Nor is it necessarily insane, 
 nor even morbid, when it accompanies disorder of mind 
 in other departments. Persons with obsession, or with 
 imperative idea, or with agoraphobia, are often de- 
 pressed, but their depression is a normal and justified 
 consequence of the discomfort and inconvenience which 
 their malady inflicts upon them. 
 
 When disorder of mind begins in dysphoria and 
 spreads, the departments of mind next involved are 
 usually the other levels of intellect, both objective and 
 subjective. Disorder of the corresponding — the lower 
 middle — level of objective thought produces misap- 
 preciation of circumstances, such that they are invested 
 with maleficent and terrifying qualities that are purely 
 imaginary. Spread of the disorder to the upper middle 
 level of the same faculty gives rise to delusions of past 
 and future experiences of depressing character ; and 
 invasion of the highest level prevents the correction of 
 these errors by the judgment. Invasion of subjective 
 thought results in abasement, and depreciation of some 
 
ABASEMENT AND SUICIDE 139 
 
 or all of the powers of the patient, physical, mental, 
 possessive, and moral. Dysphoria is, however, some- 
 times accompanied by a very peculiar form of abase- 
 ment which paradoxically partakes of the nature of 
 exaltation. The patient exalts his own powers — for 
 evil. He overestimates his influence for harm. He 
 believes that the sin with which he debits himself will 
 ensure, not only his own damnation, but the ruin of his 
 family, of his country, it may be. of the whole human 
 race ; that his financial ruin will bring penury on all 
 connected with him ; that his personal uncleanliness 
 contaminates everything he touches or everything he 
 comes near. It is when the moral worth of the patient 
 is underestimated by himself, when he erroneously 
 attributes to himself crime, sin, and moral worthlessness, 
 that the disorder spreads into the lower middle level of 
 desire, and the tendency to self-destruction, self-mutila- 
 tion, and self-injury appears. In my experience, which 
 I give for what it is worth, suicidal desire and suicidal 
 attempts do not appear unless and until moral abase- 
 ment is reached. I have not found that underestimation 
 on the second level, that is to say, delusion of poverty, of 
 loss of consequence, is associated with the desire for 
 death unless there is also depreciation of the moral 
 character ; and this is the more remarkable since the 
 sane motive for suicide is almost always pecuniary ruin. 
 If this exclusive association should be corroborated by 
 general observation, and found to be a universal rule, 
 it will be of the highest cHnical importance, for it will 
 enable us to expect attempts at suicide in cases in which 
 no intention is expressed, and it will free our minds from 
 anxiety and render precautions unnecessary in a large 
 number of cases that now give us great solicitude. 
 AU the different disorders into which dysphoria enters, 
 
140 A TEXT-BOOK OF INSANITY 
 
 and some others, such as stubbornness, are lumped 
 together by alienists under the title of melancholia, a 
 name that comes down to us from the time of Hippo- 
 crates, and signifies black bile. It is, perhaps, fitting 
 that a name derived from an extinct pathology should 
 be applied to an agglomeration of disorders, some sane 
 and some insane, some simple and others extremely 
 complex, some attended by excitement and others by 
 lethargy, and it is about time that the agglomeration 
 was analysed into its component parts and the name of 
 it discarded for ever. 
 
 Dysphoria is expressed in conduct by a sad and 
 grievous demeanour, which is the only feature in conduct 
 common to all cases. In certain cases other features are 
 added, the most frequent of which are lamentation, more 
 or less bitter, and self-accusation. The activity of 
 conduct varies much, from lethargy, from which the 
 patient can be aroused only temporarily and with 
 difficulty, to considerable excitement, which is always of 
 a character consonant with the dysphoria, and is dis- 
 played in pacing up and down, in wringing of the hands, 
 in loud lamentations, or it may be in determined effort 
 at self-destruction or self-mutilation. 
 
 The older alienists divided madness into two kinds, 
 melancholia and mania ; and although this division is 
 no longer sustained, yet the two states are still con- 
 trasted and considered antithetic of each other. This 
 view is absurd. If there is any antithesis to dysphoria, 
 the only element, if there is any element, common to all 
 cases of melancholy, it is euphoria, the antithetic state 
 of unjustified elation. Mania, as far as it means any- 
 thing definite, which is not very far, means excited 
 conduct, or over- action, and the true antithesis of over- 
 action i§ under-actjon, or lethargy. Dysphoria may, 
 
EUPHORIA 141 
 
 as has been said, be accompanied and expressed by 
 over-action, and therefore cannot be antithetic to over- 
 action, even if, in any case, a disorder of mind could 
 properly be compared with a phase or mode of con- 
 duct. 
 
 The antithesis of dysphoria is, of course, euphoria, or 
 elation, high spirits, gaiety, which may be justified by 
 the favourable circumstances of the patient, just as low 
 spirits may be justified by the circumstances of the 
 patient, and in either case the state of mind is wholly 
 normal. Like dysphoria, however, euphoria or elation 
 may exist without any justification from circumstances, 
 and when the circumstances, truly considered, would 
 rather justify unhappiness. In such circumstances, 
 elation is a disorder of mind, and this disorder of mind 
 is frequent. Like dysphoria, morbid elation may be 
 sane or insane, but it is to the disadvantage of humanity 
 that morbid but sane elation is very much less frequent 
 than morbid but sane dysphoria. The former is indeed 
 rare. It is natural that it should rarely come under the 
 notice of the physician, for people are not likely to seek 
 relief from undue happiness, even if they recognise that 
 it is undue ; a case has, however, come under my own 
 notice, in which a young man declared that he could 
 not account for feeling so happy. 
 
 There is, however, a pretty common case of euphoria 
 w^hich may be considered morbid, and which is, at any 
 rate, in its early stage, quite sane, and that is the 
 temporary elation that is produced by alcohol, and to 
 some degree doubtless by opium, and other drugs. It 
 is in order to experience this elation that, in a large 
 number of cases, alcohol is taken to excess ; and there 
 is in very many cases, before the intellect becomes dulled, 
 an interval in which an euphoria, which is well known to 
 
142 A TEXT-BOOK OF INSANITY 
 
 be unjustified by circumstances, is experienced by the 
 drinker. 
 
 Such uncomplicated elation is exceptional, however. 
 Usually elation is accompanied by exaltation, by which 
 is meant, as already explained, overestimation of one's 
 own powers and qualities, physical, mental, or moral. 
 The distinction between elation and exaltation has never 
 hitherto been made, partly because they usually, though, 
 as we have seen, not always, occur together, and partly 
 because psychological analysis of the disordered mind 
 has never hitherto been attempted. The exaltation 
 that accompanies elation is less often confined to a 
 single level of subjective thought, or self-estimation, 
 than the abasement that accompanies dysphoria. 
 Abasement is often limited for a time, or throughout 
 the malady, to underestimation of possession, and 
 delusions of poverty may exist for years unaccompanied 
 by underestimation of mental, physical, or moral 
 qualities ; but overestimation is rarely limited to one 
 level. The megalomaniac who believes that he pos- 
 sesses millions of money and extravagant titles, 
 believes also that he has superhuman strength, perhaps 
 that he has several bodies, hundreds and thousands of 
 children, intellectual genius such as the world never 
 saw, and moral worth unspeakably great. Even the 
 euphoria of drunkenness is pure in the early stage only 
 of drunkenness. As the drunkenness progresses, 
 exaltation is soon added, and the drunkard boasts of the 
 qualities, physical and mental, with which drink invests 
 him. The exaltation of drunkenness rarely extends, 
 however, to the upper middle level. Drunkards do not 
 often exaggerate their wealth, though they may spend 
 and bet recklessly as if they did. Their profligacy 
 arises not so much from overestimation of their 
 
EUPHORIA AND EXALTATION 143 
 
 wealth as from confusion of mind and recklessness, 
 and inability to realise that they are spending beyond 
 their means. 
 
 Objective as well as subjective thought is usually 
 disordered in euphoria if this is considerable. It is on 
 the lower middle level that disorder is most conspicuous, 
 so that the euphoric overestimates the propitiousness 
 and good fortune of his circmnstances, and their benefi- 
 cence towards him; but the highest and the upper 
 middle level also are defective, for the exalted euphoric 
 is always wanting in cleverness and ingenuity, and is 
 sadly lacking in wisdom. He is quite unable to order 
 his life with prudence, and is invariably insane. 
 
 Objective as well as subjective feehng always partakes 
 in the disorder in exalted euphoria. Sympathetic joy 
 at the good fortune of others is freely expressed ; 
 benevolence is boundless ; and gifts are scattered in 
 profusion upon all and sundry ; admiration is evoked by 
 quite commonplace spectacles ; and all the joyous 
 emotions — freedom, self-reliance, power, dignity — are 
 expressed to the full. 
 
 Disorder of the lowest level of desire is a frequent 
 accompaniment of euphoria with exaltation, and persons 
 so affected are often amorous to excess. 
 
 Volition also shares in the disorder, though not very 
 conspicuousl}^, and the exalted euphoric is usually facile 
 and easy to manage, though he may be subject to out- 
 breaks of rage, which are usually shortlived. 
 
 Though euphoria is nearly always accompanied by 
 exaltation, and euphoria, when considerable, is never 
 seen without exaltation, the converse is not true. 
 Exaltation is often seen without elation, and every 
 large asylum contains its kings and queens and million- 
 aires who are by no means elated at their exalted 
 
Ui A TEXT-BOOK OF INSANITY 
 
 position or wealth, but pursue their menial occupations 
 with contentment, but without extravagant joy. 
 
 Exaltation alone may exist without a trace of excite- 
 ment in conduct, but exalted euphoria is, as long as 
 bodily strength is maintained, usually accompanied and 
 expressed by over-action in conduct. The patient 
 teems with plans for the benefit of others as well as of 
 himself, and in his endeavours to carry out these plans 
 he exhibits over-action on a high level of conduct. He 
 is restless and animated ; he talks incessantly except 
 when he is writing, and he writes incessantly except 
 when he is talking. 
 
 IV. OBJECTIVE THOUGHT 
 
 The lowest level of Objective Thought is perception, 
 and the disorders of perception, illusion, and hallucina- 
 tion have already been described. They sometimes 
 occur alone, without any other mental disorder, and are 
 then, of course, sane. It is a commonplace among 
 alienists that hallucination indicates deep disorder, and 
 usually irrecoverable disorder, of mind, and is present 
 only in severe cases of insanity. This is a mistake. 
 Hallucination or illusion may occur alone without any 
 discoverable disorder of any other department of mind, 
 and since without disorder of the highest level of thought 
 there is no insanity, such hallucinations and illusions are 
 not insane. The subjects of them know and appreciate 
 quite clearly that their morbid percepts are morbid, that 
 they answer to no objects in the external world, and 
 that any objects that they think they perceive are 
 imaginary. Indeed, those who are deeply insane usually 
 recognise a difference between the normal and the 
 abnormal percepts. They speak of their hallucinatory 
 percepts as *' voices " and sometimes express a doubt of 
 
SUSPICION 145 
 
 their reality. When other disorder of mind does 
 accompany hallucination, this disorder may be of the 
 most varied character, and may be very widespread. 
 The reason why hallucination is looked upon as a grave 
 symptom is that, being a disorder of the lowest level, it 
 naturally appears late and at an advanced stage, when 
 the disorder has begun in the highest level and has 
 gradually spread downwards until the lowest level is 
 reached. In such cases it is a serious symptom, for in 
 such cases it means that the disorder has struck deep ; 
 but when it occurs as an early symptom, and especially 
 when it occurs without other disorder, it has no such 
 grave significance. 
 
 The lower middle level of objective thought is that by 
 which we estimate the beneficence or maleficence of 
 those circumstances which the level next below acquaints 
 us with ; and when that function of estimation is 
 primarily disordered, the disorder is always in the 
 direction of exaggerating the maleficence of the circum- 
 stances. This exaggerated estimate may express itself 
 merely in suspicion, or may develop into definite beliefs 
 of malevolent action, either of certain agents, specified 
 or unspecified, or more often of mysterious agencies, or 
 it may be of circumstances in general. 
 
 Suspicion, like other attitudes of mind, may be 
 justified or unjustified by circumstances, and in the 
 latter case may be sane or insane. A general attitude of 
 suspicion or confidence is, in the normal, a matter partly 
 of temperament, partly of experience. Some persons 
 are by nature confiding and apt to impute beneficence 
 rather than maleficence to others and to circumstances 
 generally. Some have been well treated by others and 
 by fortune, and have had no occasion to suspect ; others 
 have been betrayed, ill-treated, unfortunate, and expect 
 
 L 
 
146 A TEXT-BOOK OF INSANITY 
 
 to meet in the future experiences similar to those of the 
 past. All these are within the limits of the normal. 
 But suspicion may be carried to excess, and whether it 
 remains within the limit of the normal or surpasses it 
 is a matter of degree. Those who see in every stranger a 
 possible enemy do but reproduce an ancestral attitude 
 of mind, for in many languages the name for a stranger 
 and the name for an enemy are the same. When, as in 
 this case, and as in the case of failure of memory, the 
 transition from the normal to the morbid is a matter of 
 more or less, it is not possible usually to draw a sharp 
 line between the two, but in the case of suspicion we 
 have in many cases the aid of a qualitative difierence, 
 for suspicion may be fastened upon circumstances that 
 plainly cannot be maleficent, or that cannot be male- 
 ficent in the manner that is suspected. A man who 
 suspects that he is robbed by some person whom he has 
 never seen, and of whose existence he has no evidence 
 whatever, exhibits suspicion which is insane by reason 
 of its degree : a man who suspects another of imparting 
 diseases to him from a distance by means of a system of 
 mirrors and lenses, shows suspicion which is insane by 
 reason of its quality. Robbery is a possible mode of ill- 
 treatment : the production of disease from a distance 
 by means of mirrors and lenses is not. 
 
 Insane suspicion rarely exists for long as an isolated 
 disorder. The suspicion usually soon becomes con- 
 firmed into belief, and the disorder spreads up to the 
 higher middle level and invokes the aid of ingenuity to 
 concoct beliefs of the most extraordinary and far- 
 reaching character. Some mysterious agency — any- 
 thing the operation of which is to the patient mysterious 
 or unfamiliar — steam, electricity, telephones. X-rays, 
 wireless telegraphy, mesmerism, hypnotism, or what 
 
INSANE SUSPICION 147 
 
 not — is invoked to account for the occurrence of events 
 untoward to the patient, and of bodily uneasiness that 
 they suSer, and in addition, suspicion or conviction, as 
 the case may be, fastens upon certain persons, real or 
 imaginary, as the agents who utilise these means of injury. 
 
 To these disorders of objective thought the malady is 
 in many cases confined; but in many other cases it 
 spreads across to the upper middle level of subjective 
 thought, and implicates self- estimation with respect to 
 rights, honours, titles, position, and perhaps money. 
 The person who is insanely suspicious of hostile agency 
 often attributes the hostility to the fact, which soon 
 becomes a fact to him, that he is entitled to some high 
 position which the hostile agents are keeping him out 
 of. He is heir to a dukedom or a throne, or is the rightful 
 tenant of one or the other, and is deprived of them. If 
 the over-estimation of self came first, the belief that he 
 was rightfully entitled to a certain position which he 
 has sense enough to know he does not actually possess 
 might logically lead the patient to the belief that he was 
 being wrongfully deprived of them by some hostile 
 agent, and this may be the origin of the suspicion in 
 certain cases ; but when intellect is disordered, its 
 deductions are not necessarily logical, and as far as we 
 can judge it would seem that in some cases the belief in 
 hostile agency comes first, and the belief in an over- 
 estimated self-importance second. 
 
 The chief modes in which suspicion is expressed in 
 conduct are reticence, reserve, and recalcitrancy, and on 
 these follow precautions against the dangers that are im- 
 agined, and retaliation on those who are suspected. We 
 find, therefore, that the paranoiac, — the symptoms just 
 described are those of paranoia — is reserved, reticent, 
 and recalcitrant ; that is to say, he suspects, but he 
 
148 A TEXT-BOOK OF INSANITY 
 
 does not readily express his suspicions ; attempts to 
 draw him out and lead him to express them are apt to 
 deepen his suspicion and increase his reserve ; and he 
 is recalcitrant to advice. He sees in every suggestion a 
 sinister motive, and is with difficulty persuaded to do 
 things that are, it may be, obviously proper and bene- 
 ficial. In paranoia the second level of objective thought 
 — ingenuity or cleverness — though it is disordered in 
 such a way as to elaborate delusion, and though it is 
 usually the seat of confusion, yet may retain consider- 
 able efficiency. The paranoiac is often clever and 
 ingenious, and exhibits his cleverness and ingenuity in 
 elaborate precautions against the plots that he believes 
 are being contrived against him. He changes his 
 residence furtively and frequently, so as to throw his 
 enemies of! his track. He hides himself. He appeals 
 to magistrates and other persons in authority for pro- 
 tection. At length, finding all precautions fruitless, and 
 receiving no protection, he is apt to retaliate either upon 
 someone to whom he attributes his persecution, or 
 upon someone who is, he thinks, in a position to protect 
 him and has failed to do so, or upon anyone in a 
 prominent position, for the purpose of drawing atten- 
 tion to his case. 
 
 Such are the manifestations in conduct of a belief in 
 hostile agency when the belief is in an agency that, 
 however hostile, and however widespread, is yet not 
 universal. The paranoiac imagines usually a highly 
 complicated system of persecution by some agency 
 that is to him mysterious, but there is always a part, 
 sometimes a large part, of his circumstances that is 
 outside the system of persecution. Though there are 
 many persons of whom he is suspicious, yet there are 
 always some in whom he has confidence, at any rate 
 
PARANOIA AND STUBBORNNESS 149 
 
 temporary confidence. Though he is reserved, yet by 
 tact and judicious handling his reserve may be invaded. 
 Though he is recalcitrant to advice and persuasion, his 
 recalcitrancy may be overcome. Though he is reticent 
 and with difiiculty drawn into revealing his suspicions, 
 he can always be drawn, and is then apt to become 
 voluble about them. But there is a deeper depth. 
 Imagine all these pecuUarities exaggerated. Imagine 
 the reserve and reticence exaggerated into complete 
 taciturnity ; imagine the suspicion and the belief in 
 hostile agency to become universal ; imagine the con- 
 fidence to be withheld from everyone ; imagine the 
 recalcitrancy to increase into what has been described 
 on a previous page as stubbornness ; and we have a 
 picture of the malady so styled. The paranoiac is 
 reticent, the stubborn is dead silent. The paranoiac is 
 recalcitrant, the stubborn is mulishly resistive. The 
 paranoiac trusts but few, the stubborn trusts no one. 
 No matter whence or from whom a suggestion comes, 
 he always resents and resists it, and if possible does the 
 opposite. As he speaks but rarely or not at all, it is 
 not easy to investigate the state of his mind and the 
 behefs that he entertains, but his whole conduct and 
 demeanour indicate that he is convinced of the hostility 
 of everyone around him. There is no evidence that he 
 is capable of imagining the highly complicated system 
 of persecution in which the paranoiac believes. His 
 conduct is much more crude and simple than that of 
 the paranoiac, and it is evident that his mind is much 
 more deeply affected, but it is affected in the same 
 direction. His imaginings, as far as we can penetrate 
 them, are of the same character, but they are on a 
 much lower level. He exhibits no cleverness, no 
 ingenuity. When he retaliates by violence upon those 
 
150 A TEXT-BOOK OF INSANITY 
 
 about him, as he often does, his retaliation has none of 
 the elaboration of the paranoiac. Instead of an assault 
 with fire-arms or other weapons, carefully devised and 
 long considered, it is a blow with the fist ; but the root 
 elements of taciturnity, recalcitrance, and retaliation 
 are the same in both cases, and we cannot doubt that 
 the mental disorder in both cases is the same in nature, 
 though difierent in degree, and consists in rooted belief 
 in the hostility of those around them. 
 
 This being so, it would seem that stubbornness is but 
 a more advanced stage of paranoia, and that we might 
 expect paranoia to merge and deepen into stubbornness 
 as the case proceeds, and the invasion of the brain 
 becomes more profound. This, however, does not 
 conform with clinical experience. Stubbornness is an 
 acute malady : paranoia a very chronic one. However 
 long it lasts, and however severe the symptoms, paranoia 
 never, in my experience, merges into stubbornness. 
 Indisputably allied as they are in nature, and due, it 
 cannot be doubted, to greater and less degrees of the 
 very same change in the very same regions of the brain, 
 yet clinically they seem to be quite distinct. Stubborn- 
 ness is not a very frequent form of insanity, and when it 
 does occur is often fatal, which paranoia never is ; but it 
 would be both interesting and important to observe 
 whether the cases of stubbornness that recover do not 
 pass through a stage of paranoia on the way to recovery. 
 It would be odd if they did not. As far as my observa- 
 tion goes, stubbornness is always confused with melan- 
 choly, and has never been discriminated or described 
 except in this book, and therefore no observations on 
 its course have been made except by myself, and as the 
 malady is not frequent, the cases I have seen have been 
 but few. 
 
DISOKDERS OF CLEVERNESS 151 
 
 Disorder of the upper middle level of objective 
 thought is coDimon enough. This is the locus of the 
 great majority of delusions, those that affect the 
 relations of the patient to the world in which he lives, 
 and such delusions may be combined in multitudinous 
 ways with disorder of other levels of objective thought 
 and of other faculties, or maybe combined only with that 
 defect of the level immediately above them which con- 
 stitutes them delusions. Distinct from delusion is 
 confusion or mere dullness, defect of ingenuity or clever- 
 ness, which often exists ah initio, the patient never 
 attaining to the normal standard, and often is a degrada- 
 tion from a normal degree that has been attained, but 
 that has been lost. Insanity in which there is not some 
 lack of cleverness and clearness of thought is rare, and 
 is seen, if at all, only in the case of the " sane lunatic," 
 or clever lunatic, already described. In every other 
 case of insanity the defect or disorder of the highest 
 level of objective thought, which constitutes the in- 
 sanity, spreads down to a gTeater or less depth in the 
 level immediately beneath, and produces confusion of 
 thought, or inability to receive and appreciate evidence 
 contradictory of the delusions. In many cases, as in 
 that of paranoia, the confusion extends beyond what is 
 necessary to ignore the evidence against the delusions, 
 and is apparent in other matters, but only in matters 
 connected with the delusions. Deluded persons of all 
 classes are many of them very clever in matters uncon- 
 nected with their delusions, so much so that it is a 
 standing wonder that they should be so incredibly 
 stupid in matters that do concern their delusions. 
 
 As already explained, it is disorder of the highest 
 level of thought — wisdom or prudence — that constitutes 
 insanity. Disorder of mind in any other faculty and 
 
152 A TEXT-BOOK OF INSANITY 
 
 on either level is sane unless and until it is combined 
 with such disorder of the highest level of thought as 
 prevents the subject from knowing and recognising that 
 the disorder is disorder, and we have seen that sane 
 disorders of mind are numerous enough. There are, in 
 fact, several disorders of mind that in my experience are 
 never insane. Most people would, I suppose, admit 
 that giddiness is not necessarily insane, but then most 
 people, alienists as well as others, would, I suppose, not 
 admit that giddiness is disorder of mind. To such 
 people this book is not addressed. Until they are able 
 to distinguish the mental from the physical, anything 
 that is said here will be of no service to them. Agora- 
 phobia is not very rare, and claustrophobia is frequent 
 enough, but I have never seen either of them in an 
 insane person, and there is no reason to suppose that 
 they are akin to insanity. The same may be said of 
 obsession ; but it is curious that imperative idea, 
 which is so similar to obsession in its persistent striving 
 to assert itself against the control of the superior level, 
 does sometimes, though in my experience not often, 
 succeed in establishing itself and becoming a delusion. 
 The idea, such as that of a man that he is pregnant, 
 is for long recognised to be absurd and irrational, and 
 is scorned and rejected, but at long last it is accepted, 
 and becomes delusive. Various 'phobias, such as the 
 fear of dirt and of contamination, which lead the 
 subjects of them to perpetual washing and changes of 
 clothing, are sometimes insane, but their irrational 
 character is in other cases quite recognised by the 
 subjects of them, and the same is true sometimes of 
 what appear at first sight to be delusions of poverty. 
 The patient when pressed and confronted with proof 
 will sometimes admit, " I hnoiv I am not ruined, but I 
 
DISORDERS OF SUBJECTIVE THOUGHT 153 
 
 feel that I am." In other words, he suffers, not from 
 delusion, but from imperative idea, which may or may 
 not subsequently become delusion. 
 
 V. SUBJECTIVE THOUGHT 
 
 The lowest level of subjective thought, that depart- 
 ment of thought in which we estimate our own physical 
 powers and structure, is not very infrequently dis- 
 ordered in such a way as to produce what may be called 
 Somatic delusions, that is to say, delusions with respect 
 to the composition of our own bodies. Such delusions 
 as that the legs are made of glass, that the back of the 
 head has been removed, that the brain has been taken 
 out or otherwise tampered with, that there is a weasel 
 in the stomach, or a tapeworm in the head, are common 
 enough, and are usually isolated disorders, accompanied 
 of course by disorder of the highest level of thought, or 
 they would not be delusions ; accompanied no doubt by 
 disorder of the second level, or evidence of their existence 
 would be required ; but otherwise unaccompanied by 
 mental disorder. In other cases they are but features 
 in a widespread disorder. Under and over- estimation 
 of the physical powers are always parts of a wide- 
 spread disorder, and are always accompanied by 
 dysphoria and euphoria respectively. 
 
 The second level of subjective thought is that which 
 concerns our estimation of our own mental constitution 
 and powers, and here again we must distinguish between 
 sane mistake and insane delusion. It would be quite 
 erroneous to suppose that all the bizarre notions about 
 the constitution of the mind that we find in text-books 
 of psychology are insane delusions. They are merely 
 sane mistakes, and though some of them may be 
 
154 A TEXT-BOOK OF INSANITY 
 
 evidence of disorder of mind, the disorder is within the 
 pale of sanity. It is otherwise, however, with such 
 notions as some persons entertain, that other people are 
 thinking their thoughts, or controlling their thoughts 
 or their wills or their desires or feelings. It is true that 
 there is a considerable body of persons who believe, or 
 profess to believe, that some persons can communicate 
 their thoughts to other persons at a distance from them 
 by other than physical means, but those who entertain 
 this belief are not necessarily insane. They do not, as 
 the insane do, reject positive evidence that tells against 
 their belief : they merely entertain the belief on no or 
 on very insufficient evidence, and are thus less irrational 
 than the insane, though they are more irrational than 
 the behevers in witchcraft, for which there was at one 
 time a great deal of evidence of considerable cogency, 
 including many confessions of suspected witches. 
 Under and over- estimation to a morbid degree of the 
 mental powers are, like those of the physical powers, 
 combined with dysphoria and euphoria respectively, 
 and are parts of a widespread disorder. 
 
 There is, however, one very common instance of over- 
 estimation, which is not actually insane in degree, 
 though it borders on insanity and sometimes oversteps 
 the line. This is the overweening vanity of adolescence 
 and youth. Young people within a few years on either 
 side of twenty are apt to entertain a confidence in 
 their own mental abilities and judgment which is quite 
 unwarranted by the academic success at school or at 
 college which they may have achieved, and in fact their 
 achievements, even of this small kind, are not usually 
 considerable, and the airs they give themselves and the 
 dogmatism with which they assert their opinions, as if 
 they were of importance, show a strange ignorance of 
 
MORAL IMBECILITY 155 
 
 Lord Bowen's celebrated dictum that we are none of us 
 infallible, not even the youngest of us. This is the 
 normal, or quasi-normal degree of a mental peculiarity 
 that sometimes transcends the normal, and then becomes 
 a familiar type of adolescent insanity. 
 
 Disorder of the upper middle level of subjective 
 thought, that is to say, mal- estimation of means, 
 position in life, rank, titles, and so forth, is not com- 
 patible with sanity, and therefore never exists as an 
 isolated disorder. It may, however, exist without any 
 other disorder except that of the highest level of thought, 
 which renders its correction impossible ; and, as already 
 stated, exaltation of this character is not at all in- 
 frequent. On the other hand, abasement on this level 
 is never seen without dysphoria as an accompaniment. 
 
 Mal- estimation on the highest level of subjective 
 thought, that is to say, mal- estimation of our own 
 moral character and acts, does in some rare cases exist 
 as an isolated or almost isolated malady, and very 
 puzzling such cases are. There are persons who are 
 born apparently without the rudiment of a moral sense 
 with respect to their own acts, and who never acquire 
 one. They begin to steal as soon as they have pockets 
 to put stolen goods into, and they continue their maraud- 
 ing throughout life. It is not that they are brought up 
 in criminal surroundings and never have a chance to 
 learn the difierence between good and evil. They are 
 of gentle birth, and have the same bringing up and 
 education as their brothers and sisters who live honour- 
 able and upright lives. Their peculiarity is that they 
 do not recognise the turpitude of their acts. They 
 recognise, indeed, that stealing is frowned upon, and 
 that their thefts, if discovered, will bring them into 
 trouble ; and therefore they steal secretly and with 
 
156 A TEXT-BOOK OF INSANITY 
 
 precautions against discovery ; but their precautions 
 are often but slight and ineffectual, and when confronted 
 with their crimes they exhibit no shame, and seem to be 
 incapable of understanding that they have done wrong. 
 Punishment they regard as unjust vindictiveness and 
 unmerited injury, and resent it as undeserved. I have 
 said that the defect is almost isolated. It is usually not 
 quite an isolated defect, for the precautions against 
 detection are often so flimsy that it is manifest they 
 must be ineffectual, and that discovery and its conse- 
 quences must speedily follow ; and this shows a defect 
 of wisdom or prudence so great that it raises the ques- 
 tion, if indeed it does not settle the question, of insanity 
 in the ordinary sense. Moreover, there are indications 
 of other mental disorders. There is sometimes a 
 malignant vindictiveness against those relatives who 
 have suffered most by their depredations ; and who 
 have taken endless trouble and made many sacrifices 
 to keep them out of prison and to save them from the 
 natural consequences of their misdeeds. If there is 
 such a being as an " instinctive criminal " persons who 
 satisfy this description are best entitled to the appel- 
 lation. 
 
 Children who steal are not necessarily of the kind of 
 born criminal just described. Many children steal 
 repeatedly in spite of repeated punishment for stealing, 
 and often are very ingenious in their thefts. They steal, 
 however, without precaution against discovery ; they 
 steal when they know that discovery will be speedy 
 and punishment sure ; they steal, it appears, from 
 weakness of will to resist desire. They fully know and 
 appreciate the turpitude of their acts. They do not, 
 as the children of the previous class do, regard them- 
 selves as innocent victims when they are punished. 
 
DEFECTS OF MEMORY 157 
 
 They know how wrong it is to steal ; but they cannot 
 resist temptation. Unlike the children of the previous 
 class, they always, in my experience, grow out of their 
 thievish proclivities, and grow into normal men and 
 women. 
 
 VI. MEMORY 
 
 Defect of memory, even when distinctly morbid in 
 degree, is not necessarily insane, although when it is 
 extreme it must impair the judgment, by reason of the 
 impossibility of holding together the two ideas, com- 
 parison of which constitutes judgment. Less degrees 
 of defect of memory are quite compatible with sanity. 
 The common senile defect, which begins with difficulty 
 of recalling proper names, then extends to forgetfulness 
 of substantive names, and gradually extends to forget- 
 fulness of recent daily events, together with over- 
 recollection of the events of a time long past, remains 
 quite sane until it becomes very extreme, and in its 
 milder degrees is quite compatible with shrewd business 
 capacity, and not infrequently accompanies it. When 
 the defect becomes extreme, it necessarily impairs the 
 judgment, and is often attended by petulance, querulous- 
 ness, outbreaks of temper and of childish violence, 
 which show that the limits of sanity are passed, for 
 they arise on very inadequate occasion, and exhibit a 
 conspicuous lack of appreciation of circumstances and 
 of wisdom. 
 
 The other main defect of memory, the inability to 
 remember at the right time things that have to be done, 
 is also quite compatible with sanity, for the subject of it 
 usually appreciates and deplores his defect, and seeks 
 medical advice for aid to overcome it. It is true that it 
 may be an early symptom of brain disease which subse- 
 
158 A TEXT-BOOK OF INSANITY 
 
 quently becomes profound, and deprives the patient 
 of sanity, but in its early stage, and as an initial 
 symptom, it is by no means necessarily insane. Its 
 earliest mental concomitants are confusion of mind, 
 dullness, and generally, defect of cleverness and in- 
 genuity ; and in the natural progress of the disease 
 these soon become accompanied by such inability to 
 appreciate circumstances and form the ordinary adjust- 
 ments of prudence, as amounts to insanity. 
 
 VII. GENERAL DISORDERS 
 
 In the foregoing accounts some one disorder of mind 
 has been taken because it is the most prominent and 
 conspicuous disorder present in the case, and the sub- 
 ordinate disorders, or those that are less conspicuous, 
 with which it is found in combination have been 
 described in connection with it. There are, however, 
 other disorders of mind which spread over the whole 
 mental area, affecting all the mental faculties upon some 
 or all of their levels with such uniformity that it is 
 impossible to select any department, or even any faculty 
 of mind, as more prominently or more conspicuously 
 disordered than any other. These disorders demand 
 separate consideration. 
 
 Anoia 
 
 One of the most frequent of these disorders is a more 
 or less uniform obUteration or ablation of all the 
 faculties of mind, proceeding from above downwards, 
 and extending in different cases to very various degrees, 
 until, when the limit is reached, conduct and mind are 
 completely abohshed, and that state is reached which is 
 known as coma. Coma is not usually regarded as 
 insanity, but of course it is insanity, or it includes 
 
ANOIA 159 
 
 insanity. In spite of the very prominent and con- 
 spicuous loss of conduct and mind, coma is not re- 
 garded as insanity because it usually comes on pre- 
 cipitately, and we are so preoccupied with the physical 
 basis of the coma that we forget its other relations. But 
 coma does not always come on precipitately, and when 
 it is the culmination of a gradual process that has been 
 going on for months and years, as it is, for instance, in 
 those cases of general paralysis that go on to the end, 
 and are not cut short by inter- current pneumonia or 
 other disease, we see clearly that it is insanity pushed 
 to the extreme. Conduct and mind have been gradually 
 failing, gradually diminishing, gradually departing, for 
 months and years, until they are completely lost ; but 
 the final loss is not a new feature in the case, it is merely 
 the long-existing feature pushed to the extreme ; and 
 if coma is insanity when it is the culmination of a process 
 that has been going on for months and years, equally is 
 it insanity when it occurs suddenly. 
 
 In coma, as usually pictured, there is something more 
 than loss of conduct and unconsciousness. There is 
 besides, at any rate in deep coma, universal paralysis 
 of the voluntary muscles. This universal paralysis is 
 quite apart from any local paralysis that may be due 
 to a local lesion, as for instance unilateral cerebral 
 haemorrhage, a local paralysis which remains when the 
 general paralysis is cleared away. This universal 
 paralysis is due to the great depth to which the lesion 
 suddenly implicates the central nervous system. When, 
 as in general paralysis, the lesion is very gradual in its 
 reset, the universal paralysis is replaced by universal 
 spastic contraction. There are cases, however, in which 
 the depth of implication is less than this ; in which the 
 muscles are neither paralysed nor spastic, and in which 
 
160 A TEXT-BOOK OF INSANITY 
 
 some rudiment of conduct and some glimmering of 
 consciousness still remain. In such cases the patient 
 is not necessarily prostrate. He may be able to sit up, 
 or to stand. He may even be capable of a few voluntary 
 movements. He does not pass his urine and faeces 
 involuntarily or inappropriately. If he is shouted at, 
 we may get some response from him, if only a look or a 
 movement. If pushed along he does not fall, but 
 performs a shuffling walk. Such is the clinical picture 
 of a case of deep stupor. Stupor may be deeper than 
 this, so that the patient does not even walk or stand, or 
 it may be shallower, so that he feeds himself, and per- 
 forms other simple acts when he is told to do so ; but in 
 any case the characteristic of stupor is simple defect 
 of conduct and mind, usually deep defect, uniformly 
 distributed over all the faculties of mind and all the 
 phases of conduct, and uncomplicated with over- 
 action on any level. The stuporose patient experiences 
 neither desire, pleasure, nor pain, and exercises neither 
 volition nor thought, except on the lowest levels. As 
 recovery takes place, the several levels gradually resume 
 their functions in their order from below upwards, until, 
 when recovery is complete, wisdom resumes its sway, 
 the moral and social desires and feelings are again 
 experienced, and volition comes into full force once 
 more. 
 
 In stupor, the defect extends to the very lowest level in 
 all the faculties. Even the crude sexual desire is not 
 felt, even the most trivial vohtions are impossible, 
 objects are scarcely perceived, impressions scarcely 
 produce sensations, even the crude pains of bodily 
 injury may be unfelt ; and as has been said, there is 
 scarcely any conduct of any grade. In a far larger 
 number of cases the defect of conduct and mind is not 
 
ANOIA 161 
 
 as deep as tliis. The great bulk of the inmates of lunatic 
 asylums are persons who are known as '' chronic 
 dements." They are persons in whom the highest level 
 of all the mental faculties is lost, and for the most part 
 the second level also is gone. The third level may or 
 may not be invaded, and the lowest level of all is usually 
 intact. Such persons display no social conduct. Their 
 conduct is quite selfish, and consideration for others is 
 no part of their mental equipment". Of wisdom they 
 have none. So incapable are they of directing their 
 conduct in the major affairs of life, that they must be 
 placed under the care of others, and have these things 
 managed for them. They feel neither the pleasures of 
 sympathy nor the pains of remorse, and the moral 
 estimates that others form of them are wholly indifferent 
 to them. On the second level the faculties are almost 
 equally deficient. They are as destitute of the desire to 
 earn their livelihood as they are of capacity to do so. 
 They are as impervious to beauty as they are to disgust. 
 To the charms of wealth, of social standing, of power 
 they are as indifferent as they are to poverty, to the 
 manifestations of dislike and contempt. Often this 
 defect is deep enough to invade the third level, and 
 render them insensible to common dangers, and to the 
 fear and anger that common dangers and crude antagon- 
 ism evoke in normal persons. Their spirits are never 
 raised or depressed. It may be that the defect invades 
 even the lowest level, so that they become insensible 
 even to the crude pain of bodily injury and their sensa- 
 tions are dulled. Precisely the same defects of the 
 same varying extent may be discerned in those who 
 have not, indeed, lost the uppermost levels, but who 
 have never acquired them. The imbecile and the 
 dement are mentally on a par. What differences they 
 
 M 
 
162 A TEXT-BOOK OF INSANITY 
 
 manifest are due partly to the greater activity in conduct 
 of the young, in whom imbecility is usually seen, and 
 partly to the more irregular extension upward in 
 imbeciles of normal acquirement. The imbecile who is 
 generally dull and amented may surprise us by a dis- 
 proportionate development of some isolated faculty, 
 such as music or calculation. 
 
 Dementia — literally unmindedness, or deprivation or 
 lessening of mind — may, as a form of insanity, be of 
 any degree, from the slight blunting of intelligence and 
 feeling and the slight diminution of conduct that we all 
 experience at the end of a tiring day to the complete 
 obliteration of mind and conduct that we witness in 
 coma and in the deepest depths of stupor. The title 
 dementia is also given to the kind of insanity in which 
 the form dementia is the main symptom, and is limited 
 by the Scotch school to those cases of dementia that are 
 irrecoverable. This confusion of nomenclature is un- 
 fortunate, and leads to a great deal of confusion of 
 thought. 
 
 In every case of insanity of every sort, kind, and 
 description there is some degree of unminding — some 
 loss or defect of mind — and therefore some degree of 
 the form dementia. As already shown, the one character- 
 istic of insanity that is never absent, and that constitutes 
 insanity, is loss of the highest level of thought, with of 
 course corresponding loss of the highest level of conduct. 
 This defect is in many cases, and especially in acute 
 insanity, so swamped and overborne by excess of activity 
 on a lower level, that the defect is overlooked, but it is 
 always there. When a patient is ramping and raving, 
 stripping himself and tearing up his clothes, hammering 
 at the walls and breaking the furniture, or when he is 
 wringing his hands and lamenting his crimes and sins, 
 
ANOIA 163 
 
 our attention is so much absorbed by these active 
 manifestations that we are apt to overlook and forget the 
 loss of wisdom and prudence, the inability to appreciate 
 circumstances and to guide conduct aright, that are 
 at the bottom of the symptoms and are the funda- 
 mental elements in the malady ; but these elements 
 are always present, these qualities are always absent, 
 and it is their absence that constitutes the insanity. 
 The more active symptoms are but the consequences of 
 the loss. When the active symptoms subside, they 
 leave the defects outstanding as the most conspicuous 
 features in the disease, but the defects were there all 
 the time. They are not new. They now become 
 apparent by the subsidence of those that masked them. 
 When I have pointed out that these defects of mind 
 and conduct, to which the name of dementia is given, 
 exist in every case of insanity, I have been met, especially 
 by Scotch critics, with the reply that this is absurd, 
 because dementia is irrecoverable, and many cases of 
 insanity recover. They meant by dementia a kind of 
 insanity : I meant by it a form of insanity common to 
 every kind. In order to remove this misunderstanding, 
 I now call the defect of mind and conduct that consti- 
 tutes insanity by the name of Anoia, a name that has 
 unfortunately been used before in another sense, but 
 that has not been generally adopted in that sense, and 
 that is in fact but little known. In fact I am sure that 
 the majority of my readers will be unfamiliar with it. 
 By anoia I mean, then, that defect of conduct and mind 
 that begins at the top, in the highest level, and may 
 remain limited to a mere shaving off that level, as in 
 the case of the clever lunatic, or may extend down- 
 ward to any depth until at last it touches the bottom in 
 coma. Whether it invades a person who has reached 
 
164 A TEXT-BOOK OF INSANITY 
 
 the full stature of conduct and mind, and takes some of 
 it away, or whether it is congenitally absent and has 
 never been attained, makes no difference to the form of 
 the insanity. It is still anoia. The name applies to 
 every such case, for the deficiency in each is the 
 same except in degree as a whole, and in the degree 
 to which the different levels are invaded. Thus under- 
 stood, anoia of some degree is present in every case 
 of insanity, and it is the anoia that constitutes the 
 insanity. 
 
 In other words, the real, the important, the crucial 
 feature in every case of insanity is defect. In no case 
 does disease make a real, a fruitful, addition to function. 
 The affection of function is always in the direction of 
 loss, of defect, of diminution. In inflammation, tissue 
 change is increased in activity, it is true, but it is 
 carried on upon a lower level. There is increase of 
 process, but there is diminution of function. In 
 glycosuria there may be increased production of sugar 
 by the liver, but there is no real elevation of the 
 function of this organ, and the general functions of the 
 body are not increased, but diminished. And so it is in 
 active insanity. In mania there is great increase of 
 activity ; in melancholia and in exaltation there is 
 great increase of feeling ; in delusion there is increase 
 in the ability of mental states to enter into coherent 
 combinations. But none of these states of increased 
 activity indicate real operative increase or elevation of 
 function. On the contrary, they are accompanied by, 
 and they indicate, diminution of function. For with 
 all the vivacity of thought that obtains in mania, there 
 is always an inability to appreciate the circumstances 
 in which the individual is, and his true relations to 
 these circumstances. With all the increased activity 
 
ANOIA 165 
 
 of conduct, the conduct is on a lower level ; it is not, 
 and cannot be, adapted to the circumstances, for the 
 power of adapting conduct to circumstances, the 
 highest function of the brain, is defective. With all 
 the increased intensity of feeling, with the depression 
 or the exaltation, there is still the mal-adjustment of 
 this feeling to the circumstances, and there is still the 
 inability to bring the feeling into correspondence with 
 the circumstances. And the important, the vital 
 disorder, is not so much the increase of activity, as the 
 degradation of activity to a lower level ; is not so much 
 the excess as the defect ; is not so much the mania, or 
 the melancholia, or the exaltation, or the delusion, 
 as the inability to appreciate the mal-adjustment of 
 conduct and thought and feeling to circumstances, and 
 to bring about readjustment. So that, in all cases 
 of insanity, the real and important aberration is not 
 necessarily the most conspicuous feature — the over- 
 action — which may be regarded as adventitious, and to 
 a certain degTee as accidental, but the degradation of 
 activity to a lower plane ; and it is this degradation 
 that is indicated by the term " anoia," 
 . Allowing that in all forms of insanity this degradation 
 of conduct exists, then the cHnical kind of insanity will 
 depend upon whether the defect is simple — that is to 
 say, upon whether the activity of mind and conduct 
 are merely degraded and diminished, and upon the 
 lower plane to which they are reduced no excess of 
 activity takes place, in which case it is simple anoia ; 
 or upon the kind and degree of inferior and debased 
 activity that goes on at this lower level. When the 
 debased activity is marked by excess of feehng, we call 
 it melancholia or exaltation, as the case may be ; when 
 it is exhibited jn excess of low-grade conduct, we call 
 
166 A TEXT-BOOK OF INSANITY 
 
 it mania ; when it occurs in the formation of beliefs, 
 we call it delusional insanity. In any case of simple 
 anoia, over-action may occur at the low level to which 
 the nervous organisation is reduced, and then we call 
 it a case of dementia with outbreaks of excitement, 
 or of dementia with delusions, and so forth. Even 
 when the anoia is deep, when the level to which the 
 nervous organisation has been degraded is very low, 
 some over-action upon this lower plane is usual, and 
 then we witness those forms of anoia in which the 
 patient is excessively voracious, in which he eats all 
 kinds of filth and rubbish without distinction ; in which 
 he collects stones and sticks and bits of string and 
 other rubbish ; in which he tears and destroys his 
 clothing and anything he can get hold of ; in which he 
 exhibits for many hours every day, and every day for 
 years together, some simple and inappropriate form of 
 conduct ; in which he shouts and screams, or pats his 
 leg, or rubs his clothes together as if in the wash-tub, 
 or rocks himself backwards and forwards in his chair, or 
 repeats the same form of words. 
 
 The degrees of anoia are practically infinite. They 
 range from the trifling decadence of intelligence, feel- 
 ing, and conduct that is exhibited by anyone after 
 an enfeebling illness, or at the end of a tiring day, 
 down to the almost total obliteration of consciousness 
 and movement in the latest stage of such a disease as 
 general paralysis, in which the patient lies a mere log, 
 insensible to all that is passing around him, passing 
 his motions and urine as he lies, allowing the flies to 
 walk over his face and into his open mouth without 
 showing the least sign of disturbance, indifferent to 
 the sight and smell of food when placed before him, 
 incompetent even to chew the food placed in hjs mouthy 
 
GRADES OF ANOIA 1G7 
 
 and exhibiting only sufficient intelligence to swallow 
 the pulp with which he is fed. 
 
 In this long and uniformly diminishing series we 
 may mark off separate grades where we please, and 
 whatever divisions w^e make will be wholly artificial ; 
 but there is a practical convenience in distinguishing 
 between grades of anoia, and the first grade that we 
 may distinguish is that in which the social activities 
 alone, or chiefly, are defective. In this respect all the 
 insane, \Ndthout exception, are deficient. As the higher 
 social quahties are the last to be acquired, so they are 
 the first to be lost when complete sanity begins to fail. 
 We never find an insane person who is quite polite. 
 Ceremonious they often are in an exaggerated degree, 
 but polite, in the sense of exhibiting those little 
 benevolences which are as oil in the running of the 
 social machine, they never are. Even the sanest of the 
 insane are deficient in courtesy. They may bow you 
 into their room wdth an exaggerated afiectation of 
 ceremony, but they fail to offer you a chair ; or, if 
 they go as far as this, they exhibit their want of civility 
 by engrossing the conversation, and in talking ex- 
 clusively about themselves ; in their naive boastfulness ; 
 their engrossment in their own affairs ; their indiffer- 
 ence to the little ordinary duties of hospitality ; in the 
 absence of all effort to entertain. In the next gTade 
 of dementia the indifference to social obligations is 
 greater. The subject of it will receive you in his 
 shirt-sleeves, he will go about the streets in his 
 dressing-gown and slippers, he will go to a funeral in 
 a shooting suit. If a woman, she will be indifferent to 
 her personal appearance, be untidy, slovenly, and dirty 
 in her dress, will go about with tangled hair, loose 
 stockings, and shoes down at heel. If a man, he swears 
 
168 A TEXT-BOOK OF INSANITY 
 
 freely before ladies and strangers, and introduces 
 objectionable topics of conversation without discerning 
 any impropriety in so doing ; or lie may go further, 
 and introduce loose women, perhaps his own mistress, 
 to his wife and daughters, and even bring her to live 
 in the same house, obUvious to the objectionable 
 character of his conduct. He loses reticence, and 
 speaks familiarly of his family affairs, of his income, of 
 his differences with his wife, of his son's misconduct, 
 and his daughter's epilepsy, before strangers, in railway 
 carriages, in hotel smoking-rooms, in his club. If a 
 woman, she will talk with similar want of reticence of 
 her confinements and miscarriages, of her husband's 
 unfaithfulness, or her own amours. 
 
 The grades of anoia described above may co-exist 
 with full ability to earn the livelihood and administer 
 the means, but in the next grade these modes of 
 conduct also are affected, and the patient becomes 
 either incapable of appreciating the importance of 
 continuing his regular employment and of regulating 
 his expenditure according to his income ; or, while 
 recognising the importance of doing so, incapable of 
 appreciating what his income is, and therefore what 
 his expenditure should be ; or deficient in ability to 
 follow his employment. In conjunction with these 
 defects we meet with many forms of excessive action 
 upon a lower level, which will be alluded to in other 
 connections. 
 
 The lowest grade of anoia is exhibited by those 
 who have not only wholly lost their ability to ad- 
 minister their means, but who are deficient also in 
 that primitive group of activities by which existence 
 is preserved from day to day and from hour to hour. 
 If their food is not brought to them, they will make 
 
MANIA 169 
 
 no efiort to provide it for themselves. They have 
 not sense enouoh to come in out of the rain. If the 
 house were on fire they would not know which way to 
 go to get out of it, even if it occurred to them that 
 it was desirable to escape. Conduct is reduced to 
 finding the way from the bedroom to the sitting- 
 room, from the fireside to the meal-table, and back 
 again ; or even this modicum of intelhgence is lost. 
 Even in this lowest grade of anoia degrees or sub- 
 grades are apparent. The most intelligent of these 
 anoiacs are clean in their personal habits. The next 
 lower grade is when they pass their urine under them, 
 but go to the closet to defsecate. Then this is also lost, 
 and their motions are passed in their clothes. Then 
 they become incapable of dressing and then of un- 
 dressing themselves ; and the last acquirement to be 
 lost is the art of carrying the food to the mouth when 
 it is placed before them. Even in this accomplishment 
 there are degrees, for some can use a knife and fork, 
 some a spoon only, and last of all, this implement is 
 abandoned, and the fact that fingers were made before 
 spoons is practically exemplified, since their use is 
 retained longer. 
 
 Thus understood, anoia of some degree is present in 
 every case of insanity, and it is anoia that constitutes 
 insanity. 
 
 Mania 
 
 In anoia, we concentrate, our attention on the defect. 
 It is the loss or absence of a part of conduct and mind 
 that constitutes the form ; but defect rarely exists 
 alone. It is usually accompanied and often obscured, 
 either continuously or from time to time, by over- 
 action on a lower level. The removal of the higher 
 
170 A TEXT-BOOK OF INSANITY 
 
 levels, and it is the higher levels that are first and most 
 defective in anoia, removes from the levels beneath 
 them the control to which they were subject by the 
 higher, and permits the lower to act in excess, provided 
 they contain the store of energy necessary for action. 
 In coma, all the levels are placed out of action, and there 
 is no over-action, except perhaps of the purely vegetative 
 functions. Respiration, for instance, may be exces- 
 sive. When the anoia is deep, but is not so deep as this, 
 and but little energy is left in store, even this little may 
 be expended excessively, and we see that idiots and 
 dements indulge to excess their lower appetites. When, 
 however, abundance of energy is contained in the lower 
 levels of the nervous system, and the control of the 
 higher levels is removed, we witness over-action in 
 great excess ; and all such over-action undirected by 
 wisdom or prudence receives the common name of 
 mania. Mania is not a kind of insanity ; it is not a 
 disease ; it is a form or symptom only, and may exist 
 in many diseases. However enormous and portentous 
 activity may be, even if it reaches the superhuman 
 activity of Napoleon Buonaparte, and wears out 
 ministers, secretaries, amanuenses, and subordinates of 
 all grades, it is never excessive so long as it is informed 
 by wisdom — so long, that is to say, as the highest level 
 of mind is intact. Only when the highest level is out 
 of action, it may be but the thinnest film removed 
 from its surface, can over-action be properly said to 
 exist. The question at once presents itself, Why, if 
 over-action results from loss of control, and the higher 
 levels control the lower, is there not always over-action 
 when the higher levels are destroyed, as in dementia, 
 or in abeyance, as in stupor ? The answer is not far to 
 ^eek. The nervous system is an apparatus for the 
 
OVER-ACTION 171 
 
 storage and expenditure of motion, and each level can 
 expend only up to the amount that is in store. If it is 
 in a state of general repletion, and if then control is 
 suddenly removed, motion will be set free in great excess. 
 If control is removed but gradually, time will be given 
 for readjustment to take place, and for inferior levels 
 to assume the function of inhibition, and in this case 
 the outburst of over- activity will be kept within limits ; 
 and if control is removed from levels that have little or 
 no motion in store, little or no motion can escape. 
 However suddenly we draw the cork of a bottle of ginger 
 beer, there will be no overflow if the beer is flat. In 
 stupor, the central nervous system appears to be 
 emptied of its store of motion, and its capacity of 
 restorage to be in abeyance. In quiet dementia the 
 head of pressure is but low, and little escapes because 
 there is little within ; but given a great head of pressure, 
 and a sudden removal of control, and a great outburst 
 of excessive activity is certain. 
 
 Over-action may take place on any level except the 
 very highest. The description of the " sane lunatic " 
 given on a previous page is a description of moderate 
 over-action upon a high level, due to removal of the 
 control of a still higher level ; but instances of much 
 greater over-action — much greater excitement — on the 
 same level are not infrequent. The clever lunatic is a 
 busy man. He is seldom idle, and keeps his time pretty 
 fully occupied ; but his industry is methodical. When 
 he is engaged upon a task he keeps at it until it is com- 
 pleted ; and he has his intervals of rest and recreation. 
 But the sufierer from what may be termed high-level 
 mania knows no rest. He is eagerly and incessantly 
 active, and his activity knows no continuity and no 
 patience. He is engaged in a dozen pursuits at once^ 
 
172 A TEXT-BOOK OF INSANITY 
 
 and he follows them all with the same impatient avidity. 
 He sleeps little ; he is down before anyone else in the 
 house ; he bolts his meals to get back to work ; he 
 writes innmnerable letters, he sends innumerable tele- 
 grams, he makes innumerable appointments. He is as 
 full of schemes as an egg is full of meat, schemes in his 
 profession or business, schemes for the reconstruction 
 of national and political affairs, schemes of social 
 regeneration, schemes for the welfare of his family and 
 friends, for rebuilding his house and resettling his 
 household affairs — schemes for anything and every- 
 thing, schemes that may not be without plausibility, 
 but that are vitiated by want of proportion between 
 ends and means, if not by total want of practicability 
 or even of desirableness. 
 
 Over-action on a low level shows itself in equal eager- 
 ness, activity, and versatility, but the activity is crude, 
 and the aims are immediate. In the place of schemes 
 for future benefit, and action directed, however unskil- 
 fully, towards carrying them into effect, no aim can be 
 discovered beyond the immediate intention. There is 
 shouting, but the shouting is without purpose of attract- 
 ing attention or warning, there is hammering at the 
 door and walls, but without the purpose of escaping ; 
 there is tearing of clothing and destruction of furniture, 
 but only with the purpose of expending energy. There 
 is incessant walking, but not with the purpose of 
 arriving anywhere. There is abundant over-action, 
 but it is over-action on a low level, the higher levels 
 being in abeyance. Excitement in conduct must be 
 presumed to correspond with excitement of mind ; and 
 no doubt in elaborate over-action on a high level, excite- 
 ment of mind shows through the excited conduct ; but 
 in the erude low-Jevel excitement that has just been 
 
EXCITEMENT 173 
 
 described, excitement of mind is inconspicuous just 
 because so much of mind is in abeyance. The higher 
 levels are altogether out of action, and what excitement 
 there is is on so low a level that, when the higher levels 
 resume their sway, even the memory of it is lost. It is 
 lost because on these higher levels there was no excite- 
 ment, and therefore there can be in them no memory 
 of excitement. 
 
CHAPTER VI 
 
 TYPES OF INSANITY 
 
 So far, the classification has extended to the symptom 
 only of insanity. No attempt has been made to con- 
 sider insanity the disease, or to show of what different 
 diseases insanity consists. This is the task that must 
 now be undertaken, and undertaken with all the 
 trepidity and circumspection that are naturally in- 
 spired by the failure of innumerable predecessors. 
 
 It was said at the beginning of the last chapter that 
 two conditions are necessary to the validity of a 
 classification ; first that the things to be classified 
 must be delimited and separated from all other things, 
 and second that there must be one fundamentum 
 divisionis or principle of division, and no more, for each 
 act of dividing. It is now to be added that there is 
 a third condition that must be satisfied by every classifi- 
 cation, if it is to be of any value. It must be adapted 
 to its purpose. If a classification satisfies the two 
 conditions mentioned above, it will be a valid classifi- 
 cation, but a classification, even though completely valid, 
 may be completely useless for the purpose in hand. A 
 classification of coins according to their value is a valid 
 classification, and for the purpose of a bank cashier, a 
 useful classification ; but valid as it is, it is utterly 
 useless to the numismatist. A classification of coins 
 according to their date is a valid classification, and for 
 
 174 
 
CLASSIFICATION 175 
 
 the purpose of a numismatist a useful classification, 
 but it is utterly useless to the bank cashier. So the 
 following classification of cases of insanity is a valid 
 classification, and is for the purpose of the asylum 
 manager a useful classification : — 
 
 "&' 
 
 Able-bodied 
 
 tractable 
 turbulent 
 
 ( epileptic. 
 ( not epileptic. 
 J epileptic, 
 [not epileptic. 
 
 Not able-bodied- 
 
 rfrail /employable. 
 
 \not employable. 
 
 fof infectious disease. 
 
 1 of non-infectious disease. 
 
 sick 
 
 But valid as this classification is, it is utterly useless to 
 the alienist who desires to organise his knowledge of 
 insanity. To produce a valid classification is not 
 enough. We want a classification that shall be adapted 
 to its purpose ; and for this we must settle for what 
 purpose the classification is desired. Why do we want 
 to classify cases of insanity ? Why do we want generally 
 to classify things ? Mainly for three objects : To aid 
 description ; to refieve the burden on our memories ; 
 and to organise our knowledge. The two former may 
 without much straining be included in the latter. 
 The root of all thought and the root of all knowledge 
 is comparison ; and the aim of comparison is to discern 
 likeness and unlikeness, to group together in thought 
 the things that are alike, and to separate in thought the 
 things that are unlike. In one aspect, all thought is 
 classification ; all knowledge is of classified things. 
 
 To classify and to know are, from one aspect, the 
 same ; and as we crave to know, so we crave to classify. 
 
176 A TEXT-BOOK OF INSANITY 
 
 When we speak of a classification of cases of insanity, 
 we usually mean a classification, not for the purpose 
 of putting like cases with like in the wards of an asylum, 
 but for the purpose of thinking together of those that 
 have the most nurderous, far-reaching, fundamental, 
 and important similarities, and separating those that 
 have corresponding differences. 
 
 Bodily diseases are not difficult to classify. They are 
 classified according to the agent that produces them, 
 or according to the organ that is first and most affected ; 
 but madness cannot be thus classified, for the agent 
 that produces it is in most cases unknown, and the 
 organ first and most affected is usually the same. 
 There are, however, bodily diseases which we cannot 
 or do not classify thus. The agent that produces gout 
 is unknown, and so are the agents that produce certain 
 other diseases ; and we do not classify gout as a disease 
 of the big toe, though this is the organ that is usually 
 first and most affected. If we refer to our definition of 
 a disease — that it is the whole of the correlated disorders 
 from which the patient suffers — we shall see that what 
 we have in our mind when we speak of diseases and of 
 classifying them is a certain clinical picture that we 
 actually witness, that is to say, always a correlated 
 group of symptoms, to which is usually added disorder 
 of function, known, inferred, or postulated, of some 
 organ, on which disorder all the symptoms depend, and 
 by which they are correlated. The concept of the 
 disease is not complete until we add to these elements 
 a certain course, more or less variable, that it will take, 
 and, when possible, the cause to which it is due. The 
 whole of these elements, or as many of them as we can 
 ascertain, are combined into a single concept which we 
 call a disease. All that is strictly necessary to our concept 
 
CLASSIFICATION 177 
 
 of a disease is a group of symptoms which we have 
 reason to believe are correlated together by some 
 miderlying disorder, and a specific course. If we can 
 assign an underlying organic disorder, and a cause, all 
 the better. Our concept is the more complete ; but 
 a correlated group of s3rmptoms runriing a certain 
 course is all that we need to constitute our concept of 
 a disease. 
 
 Bodily diseases are comparatively easy to classify, 
 because the symptoms by which they are known are 
 all, with one exception, of the same order. With the 
 exception of pain, they are all physical symptoms that 
 can be observed ; and facts of one order are not difl6.cult 
 to classify. But the symptoms by which insanity is 
 known are, if we may caU mental disorder a symptom, 
 of three different orders, which are not comparable 
 inter se. The S3niiptomatology of insanity is threefold 
 • — physical, mental, and praxic. It consists, or may 
 consist, of disorders of the body, disorders of mind, 
 and disorders of conduct. And of these, disorders of 
 body are often imperceptible ; disorders of mind are 
 never perceptible, and it may be difficult or impossible 
 to discover their exact character ; and disorders of 
 conduct, though always present, are often elusive and 
 difficult to seize and to describe in specffic terms, 
 and are often overshadowed by the preponderant value 
 of the mental disorder, which clamours insistently for 
 relief. Hence it follows that some cases of insanity, for 
 instance mania, are recognised and described by the 
 disorder of conduct ; others, such as melanchoHa, by 
 the disorder of mind ; and yet others, such as the 
 insanities of myxoedema, of cretinism, and of acute 
 specffic fevers, by the bodily symptoms ; and it is clear 
 that a classffication founded upon three principles, 
 
 N 
 
178 A TEXT-BOOK OF INSANITY 
 
 used simultaneously as principles of first division, 
 cannot be a valid classification. 
 
 There is yet another difficulty. In some cases of 
 madness there is a definite group of correlated symptoms, 
 the like of which we see again and again in successive 
 cases, which runs a certain course, and satisfies all the 
 conditions that are required to constitute the concept 
 of a disease ; but in a large number of cases we meet 
 with a group of symptoms, which, since they are dis- 
 orders of conduct and of mind, we must suppose to be 
 correlated, and to these may be added disorders of 
 bodily health, as to whose correlation with the others 
 we may be in doubt ; but whether they are so correlated 
 or no, the whole group of symptoms is like nothing we 
 have ever seen before, or is like one fairly constituted 
 group in some important aspects, and like another 
 fairly constituted group in other material respects, 
 and perhaps like a third group in some still other 
 material respects. Where are we to place such a case ? 
 Two or three diseases have equal claims to accept or 
 to reject it, and if we constitute each such case a 
 separate disease, the accumulation becomes too great 
 for the mind to grasp, and classification is virtually 
 abandoned. 
 
 Still, however great the difficulties may be, they 
 must be met. Insanity must be classified, or our 
 knowledge is at a standstill, and the classification, 
 to be a valid classification, must conform to rule ; 
 that is to say, its primary groups must be consti- 
 tuted upon one single fundamentum divisionis and no 
 more. 
 
 As far as I know, two attempts only have been made 
 to classify insanity upon a single principle. The first 
 of these is Sir G. Savage's classification according to 
 
CLASSIFICATION 179 
 
 the age at which it occurs, and the other is the classifi- 
 cation on the principle of dissolution. 
 
 Sir George Savage's classification is a valid classifica- 
 tion, and is not badly adapted for a certain purpose, 
 that, namely, of readily referring to its place in the 
 classification those cases that are seen in practice by 
 the physician ; but as what is sometimes called a 
 scientific classification, that is to say, an arrangement 
 constituted so as to accord with important, far-reaching, 
 and fundamental resemblances and differences, it will 
 not do ; for though the symptoms of insanity are 
 probably always coloured by the age at which the 
 insanity appears, yet some diseases of insanity, such as 
 general paralysis, may occur at any age, and present 
 no material difference at several ages. 
 
 To the orderly mind, a classification according to 
 the principle of evolution and dissolution is most 
 attractive, and, were it practicable, would undoubtedly 
 be preferred, but unfortunately its practicability does 
 not extend very far. According to such a classifica- 
 tion, insanity would be divided first into cases due to 
 imperfect or defective evolution, and cases due to dis- 
 solution ; and so far the scheme is practicable. But 
 the division of the insanities due to dissolution presents 
 insurmountable difficulties. It should proceed by 
 dividing insanities due to uniform or general dissolution 
 from those due to local or partial dissolution ; but in 
 our experience general dissolution, such as we see in 
 stupor, in dementia, and in general paralysis, begins 
 locally, and not often in the same locality twice running ; 
 and the cases of local or partial dissolution form a 
 heterogeneous and unclassifiable group. This principle, 
 therefore, fascinating as it is, must be rejected, except 
 for the primary division. There is no reason, however, 
 
180 A TEXT-BOOK OF INSANITY 
 
 why for the primary division it should not be utilised. 
 It is after this stage that the difficulties begin. 
 
 Since what we are now endeavouring to classify 
 are diseases, and since it has already been shown that 
 by a disease we mean a clinical picture, consisting of at 
 least a group of correlated symptoms, it is natural, and 
 it is justifiable, to turn to the clinical pictures and ask 
 whether in them there cannot be found some junda- 
 mentum divisionis which can be applied to the dissolute 
 class of cases and can serve to divide them into groups. 
 Such a fundamentum there is, and although it does not 
 afford a very sharp-cut distinction between two classes, 
 it is easily applied, and it does enable us to divide the 
 dissolute class into two, and the division, though not 
 absolute, is not only easily made in a great number of 
 cases, but is of great practical importance. It is the 
 division into acute insanity and chronic insanity, and 
 I must explain what I mean by these terms. 
 
 By acute insanity I mean insanity in which the 
 symptoms are of recent onset, are intense, and are 
 never absent, so that it would be impossible to observe 
 the patient for even a few moments during his waking 
 life without discovering that he is insane. There are 
 many cases in which the symptoms are intense and 
 remain intense for years, but these are excluded by the 
 definition from acute insanity ; and there are many 
 cases in which the symptoms are of recent origin and 
 intense, but which we know will last for years, and these 
 are in a sense cases of chronic insanity ; but they are 
 for the time cases of acute insanity in the sense in 
 which that term is used here. When the symptoms are 
 no longer of recent onset, the case is no longer one of 
 acute insanity. It then merges into chronicity. To 
 those who object that this is not a valid division, 
 
CLASSIFICATION 181 
 
 because it is not a sharp division, I reply that a division 
 may be quite valid though it is not sharp, and though 
 we may not be able to indicate with accuracy where to 
 put the dividing line. The distinction between night 
 and day is quite a valid distinction, though we cannot 
 draw any precise dividing line between them. I refuse 
 to be tied down to any precise number of days as the 
 duration of recency, but if I were compelled to give 
 some indication, I should say that anything less than 
 six months is recent, and anything more than six 
 months is scarcely recent. 
 
 By chronic insanities I mean all those that are not 
 acute according to this definition. It is evident, there- 
 fore, that the chronic insanities constitute an extremely 
 heterogeneous class, and that many of them have once 
 been acute. It is difficult, and would be scarcely worth 
 while, to divide them on any useful principle, but 
 certain of them must be described. The acute insanities, 
 however, form a practically well-defined class, and one 
 that is of great clinical value. For clinical purposes it 
 matters little, except for prognosis, which cannot always 
 be made with any confidence, whether an acute insanity 
 will be transient, or whether it is the initial stage of a 
 chrc'uic insanity that will endure for years or for life. 
 
 It may seem that a classification by dichotomy 
 which results in one small and well-defined class and 
 one large, heterogeneous class, insusceptible of further 
 division, cannot be a very useful classification. It is 
 useful, however, as far as it goes. It gives us one class 
 of practical value which can be studied apart from the 
 other. It selects certain cases having a common 
 quality, and enables us to study them free from the 
 confusion and embarrassment of the remainder. It is 
 analogous to a classification of flowering plants into 
 
182 A TEXT-BOOK OF INSANITY 
 
 orchids and other plants. It is not an exhaustive 
 classification, but it does distinguish orchids from other 
 plants, and enable us to make a separate study of them. 
 So this mode of classifying dissolute insanity enables 
 us to distinguish acute insanity from other insanity, 
 to make a special study of it, to enumerate the features 
 common to all cases of acute insanity, and to sub- 
 divide the class into its varieties. Moreover, the two 
 sub-types of chronic insanity that will be described 
 are well-characterised and useful tjrpes. 
 
 ACUTE INSANITY 
 
 Acute or intense insanity is insanity of recent onset, 
 in which the symptoms are intense in that they are 
 exaggerated in degree, and dissolution proceeds rapidly, 
 until conduct becomes crude, and manifestly, often 
 grossly, insane, so insane that its insanity cannot be 
 missed by the most negligent onlooker. Acute insanity 
 is susceptible of dichotomous division first into hyper- 
 acute insanity and insanity that is merely acute. 
 The merely acute insanity is divisible into several 
 varieties according to the feature, mental or praxic, 
 that predominates. They are as follows : — 
 
 Acute Insanity 
 
 1. Hyper-acute insanity. 
 
 2. Acute insanity. 
 
 {a) Excited or maniacal. 
 
 (b) Dysphoric or melancholic. 
 
 (c) Suicidal. 
 
 (d) Resistive or Stubborn. 
 
 (e) Sexual. 
 (/) Stuporose. 
 
ACUTE DELIRIOUS MANIA 183 
 
 HYPER-ACUTE INSANITY, OR ACUTE DELIRIOUS MANIA 
 
 This is one of the most definite and clearly dis- 
 tinguished clinical varieties, as distinguished from 
 forms, of insanity — one of the few varieties of in- 
 sanity which runs a very definite course. No other 
 variety of insanitj^ exhibits such extreme and con- 
 tinuous excitement as acute delirious mania. Even 
 in acute insanity the patient has his moments of 
 tranquilUty ; has snatches, perhaps prolonged periods, 
 of sleep ; will occasionally answer questions intelli- 
 gently ; will regulate his conduct with some reference, 
 however distorted, to surrounding circumstances ; 
 will sometimes recognise his friends, and will have 
 some regard to the decencies of life ; but in acute 
 delirious mania the ahenation is more profomid. The 
 raving is continuous. It goes on incessantly, day 
 and night, the whole twenty-four hours round. It 
 is quite incoherent and meaningless, a torrent of un- 
 intelligible utterance. And as is the vocal movement, 
 so are the other bodily movements. The restless 
 activity is extreme and incessant ; the patient roams 
 about with ceaseless restlessness, he is never still, he 
 never lies down, he never sits down, he is always on 
 his feet, always in movement. He neither eats nor 
 sleeps ; sometimes he will drink, sometimes not ; but 
 in any case he never eats voluntarily, and is with 
 the greatest difficulty induced to do so. The length of 
 time that he goes entirely without sleep is astonishing. 
 Day after day and night after night he keeps up his 
 incessant movement. You cannot engage his attention ; 
 he takes no notice when spoken to. He is indifierent 
 whether he is dressed or naked ; heat and cold he does 
 not notice : the calls of nature he does not answer ; 
 
184 A TEXT-BOOK OF INSANITY 
 
 his bladder becomes full, and over-full, until his urine 
 dribbles away. Withal his temperature is raised : it is 
 seldom much raised, but it is two or three degrees 
 above normal, and this feature alone distinguishes this 
 from almost every other variety of insanity. Such 
 excessive and continuous waste of tissue and of energy 
 cannot endure long without producing exhaustion. 
 After a few days of this extreme restlessness and sleep- 
 lessness, the patient is no longer able to remain on his 
 feet ; he sinks to the ground, but still he continues to 
 rave in a voice hoarse and wellnigh inaudible from in- 
 cessant use ; still he continues to toss about his weary 
 limbs ; and when this stage is reached, the end is not 
 far off. His mouth becomes dry, sordes accumulate 
 on his lips and teeth, his heart's action fails, his pulse 
 flutters, his breathing becomes a succession of sighs ; 
 but still he mutters in a hoarse whisper his unceasing 
 babble, until, at the end of seven or eight days he dies 
 of exhaustion. Such is the course of a typical case of 
 acute delirious mania, the " brain fever " of older 
 writers, the most rapid and most terrible variety of 
 insanity. 
 
 It affects both men and women, and usually those 
 who are in the prime of life — from twenty-five to forty 
 — and is usually preceded by some prolonged and 
 efficient debilitating occurrence, such as an exhausting 
 illness, deficiency of food, rest, and sleep, anxiety, dis- 
 appointment, or excessive intellectual labour. 
 
 Acute delirious mania is practically always fatal. 
 If a case is so mild as to admit of recovery, it would 
 be one of acute insanity rather than of acute delirious 
 mania. As to treatment, a padded room is essential. 
 In no other surroundings can the restlessness of the 
 patient lead to so little bruising and other injury. 
 
ACUTE INSANITY 185 
 
 Abundance of food must be given by the stomach 
 tube, and mingled with it should be given brandy, 
 strychnia, and large doses of hypnotics — paraldehyde, 
 sulphonal, and trional being the best. For all that 
 we can do, however, the patient will almost surely die ; 
 and in the rare cases in which the bodily health recovers, 
 the patient remains a mental wreck, a hopeless dement 
 for the rest of his days. 
 
 ACUTE INSANITY 
 
 The boundary between this and the previous variety 
 of insanity is not always well defined, but generally, 
 the whole course and symptoms of acute insanity are 
 less acute, less rapid, less exaggerated and fulminating, 
 than those of acute dehrious mania ; recovery is not 
 infrequent ; and what difierentiates them more sharply 
 is that in the latter disease the form of insanity is always 
 that of mania, while acute insanity is of several types. 
 
 The causes and antecedents of acute insanity are 
 those of insanity in general. It may occur at any 
 age after sixteen, and in very rare cases before that 
 age, but is most frequent in the most vigorous period 
 of Hfe — from twenty to forty-five. 
 
 Acute insanity is rapid, sometimes sudden, in its 
 development. The very first thing to attract attention 
 and to indicate insanity may be a determined attempt 
 at suicide — a leap from a window, a cut throat, or a 
 dose of poison, or it may be some outrageous or violent 
 act directed against other people. But usually there 
 is some warning of what is going to happen. For 
 days, or even weeks, beforehand, the patient sleeps 
 little, dreams much and vividly, eats little, finds himself 
 unable to attend to his business, feels ill, and perhaps 
 seeks medical advice. Headache is rare, but often the 
 
186 A TEXT-BOOK OF INSANITY 
 
 mind is confused, and the patient dreads lest he should 
 be going out of his mind ; or he gets restless, talks too 
 much, pays too many visits, writes unnecessary letters, 
 sends unnecessary telegrams, neglects or mismanages 
 his own business, and meddles with that of everyone 
 else. 
 
 After a few hours, days, or weeks of these initial 
 symptoms, the disease becomes fully established, and 
 then exhibits several forms distinguished by the follow- 
 ing characters : — 
 
 (a) Excited or Maniacal 
 
 In the first form the patient is excited — that is to 
 say, his movements are in excess ; he talks with rapid 
 fluency and disconnectedly ; he utters sometimes a 
 stream, of words in which each suggests the next by 
 sound or meaning, but which are not connected into 
 sentences, such as " window, wind, blow, thrashing, 
 smashing," or they may be connected into sentences 
 which are similarly irrelevant to each other, as " open 
 the vdndow, give me a glass, drink your brandy, isn't 
 he handy ? what a dandy ! fine feathers make fine 
 birds," etc. Together with verbal utterance, other 
 movements are in excess, and are similarly disconnected. 
 The patient roams about the room, he rushes to the 
 door or the window, he picks up every movable object 
 and throws it down again, or throws it about the 
 room, or converts it to some use for which it was never 
 intended. He upsets the water- jug and the chamber- 
 pot, he overturns the furniture, he breaks the windows, 
 he throws the chairs about, he assaults those who 
 endeavour to control him, he tears his clothes off, he 
 or she swears, blasphemes, and talks obscenely ; and 
 all this he does, not with any settled or intelligent or 
 
ACUTE INSANITY 187 
 
 enduring purpose, but aimlessly, erratically, and out of 
 the mere exuberance of his energy. 
 
 (b) Depressed or Melancholic 
 
 A second type is the melancholic. In this type the 
 activity is less, and there is a dominant delusion. 
 The patient believes that he is ruined, or that he is 
 damned, or that he has some frightful bodily disease, 
 or that he is morally a hopeless outcast, and to his 
 belief he gives utterance all day long. He is usually 
 still over-active, though his over-activity is less. But 
 he does not sit down, he does not rest ; he shuffles 
 about the whole day long, giving vent, not with shouts 
 and outcries, as in the previous type, but in a mutter- 
 ing, plaintive, miserable voice, to his conviction of 
 his own ruin, his unworthiness, his incapacity. He 
 weeps, he moans, he wrings his hands, he tears his 
 hair, he beats his breast ; he importunes you for a ray 
 of hope, a glimmer of comfort ; but he refuses to be 
 comforted. He repeats the same formula over and over 
 again a thousand times a day : " Oh ! my poor soul." 
 *' I am so wicked ! " "I can't pay you ! " " My poor 
 wife and children ! " ^' Oh ! dear; oh! dear." *' Oh ! 
 my God," and so forth. He is less inclined to the im- 
 pulsive outbreaks that are so common in the previous 
 type, but he is very likely to commit suicide, and he 
 is more persistent and obstinate in his refusal of food, 
 while he is less neglectful of personal cleanliness and 
 less apt to pass his motions and water beneath him. 
 
 (c) Suicidal 
 Acute insanity of suicidal type often displays as much 
 restlessness and over-activity as is seen in the first type 
 — that of acute mania. In every form of acute insanity 
 
188 A TEXT-BOOK OF INSANITY 
 
 attempts at suicide are common events, but in this form 
 the whole attention and energy are concentrated upon 
 the single purpose of suicide. The sufferer from acute 
 mania will try to jump out of the window, or will take 
 up a knife or a razor and cut himself with it, not, as far 
 as can be judged, with any deliberate intention of 
 suicide, or of anything else, but out of pure restlessness 
 and meddlesomeness, combined with inability to appre- 
 ciate the nature and quality of his acts. In this, as in 
 every other type of acute insanity, there is sure to be, 
 at some time, refusal of food, but the refusal does not 
 appear to be the expression of any deliberate intention 
 of suicide. But in this third variety the whole power 
 of the mind is absorbed in, and devoted to, the single 
 object of suicide. The mind is far more alert than in 
 the other types ; the power of adapting means to ends 
 is retained to a far greater extent ; and the end which 
 is sought with inflexible determination, and with the 
 most flexible adaptation of means, is suicide. To effect 
 this end they are continually on the watch. In every 
 object they see a possible means, and they set them- 
 selves with much ingenious contrivance to reach it, 
 and possess it. They will promise to eat if they may 
 eat by themselves, hoping thereby to be left alone. 
 They will break glass and crockery to get a cutting 
 instrument ; they will ravel out the threads of their 
 clothing to make a cord which they can tie round the 
 throat ; they will swallow anything that seems un- 
 wholesome ; will bite a piece out of a tumbler or a cup, 
 and try to swallow the fragment ; will batter the head 
 against the wall or floor, and try by the most unusual 
 as well as by the most obvious means to effect their 
 purpose. If they find suicide impracticable, or while 
 they are waiting for a favourable chance to efiect it, 
 
ACUTE INSANITY 189 
 
 they will occupy the time with efforts to reduce their 
 comfort and give themselves pain, or even mutilate 
 themselves. They will try to gouge their eyes out 
 with their fingers, to tear the cheek with the finger in 
 the mouth, to tear out the testes or to cut off the penis. 
 Prevented from tying a ligature round the neck, they 
 will endeavour to tie it round the leg or the penis. 
 Prevented from knocking their heads against the wall 
 they will take the skin off their knuckles by the same 
 means, and so on. 
 
 (d) Stubborn 
 
 A fourth type is the silent, obstinate, resistive. 
 Patients of this type do not speak. When spoken to 
 they do not answer. They make for the door, the 
 window, or the fire, and when restrained will continue 
 for hours the same silent, dogged, determined effort 
 to reach the desired destination. They, too, undress 
 themselves, but they do so, not, as the acute maniac 
 does, from the mere exuberance of their activity, which 
 must find some vent, it matters not what, which, when 
 restrained from taking off the coat, begins to unbutton 
 the waistcoat or trousers. A patient of this type 
 undresses himself with the same blind, dogged obstinacy 
 that he does everything else. He persistently, again 
 and again for hours together, attacks the same button, 
 or tries to remove the same garment in the same way. 
 He, too, refuses food, but he refuses it, not, so far as 
 can be judged, with suicidal intent, but with the same 
 resistiveness with which he stubbornly opposes every- 
 thing that is done for him — refuses to be dressed and 
 to be undressed, to be sat down or stood up, to go to 
 the closet and to come away from it, to walk about or 
 to stand still. 
 
190 A TEXT-BOOK OF INSANITY 
 
 (e) Sexual 
 
 A fifth type of acute insanity is the sexual. A 
 sexual proclivity is usually perceptible, as is the 
 suicidal proclivity, in every case of acute insanity ; but, 
 in the one matter as in the other, there are cases in 
 which the proclivity becomes so pronounced, assumes 
 such dominance, is by so much the most prominent 
 and conspicuous feature, as to constitute a distinct 
 type of the malady. The sexual type is exhibited 
 by women almost exclusively. Few things are more 
 surprising in insanity than the obscenity and filth that 
 are uttered by women, and even by young girls, well 
 bred and carefully brought up, of pure lives, and 
 previously innocent conversation and behaviour. They 
 curse and swear like troopers ; they use expressions 
 of obscenity and blasphemy of which a costermonger 
 would be ashamed. Nor is it only in their speech that 
 they display lewdness and indecency. Insane women 
 of this type make shameless overtures to every man to 
 whom they have access. Not the gardener nor the 
 footman ; not the waiter in the hotel in which they 
 are taken ill ; not the medical man who attends them ; 
 not even their own brothers or fathers, are exempt 
 from their libidinous advances. They ogle and leer, 
 they throw themselves into unseemly and indecent 
 attitudes, they expose their breasts and legs, and, when 
 all this is ineffectual, they do not hesitate to ask in 
 plain terms for what they want — to call out of the 
 window to a passer-by to come to bed with them, or 
 even, in plain Saxon, to have intercourse with them. 
 As the melancholic and suicidal varieties of acute 
 insanity are often called acute melancholia, so the 
 sexual type is often called nymphomania ; but all are 
 
ACUTE INSANITY— STUPOR 191 
 
 really varieties of the same malady, in which the 
 one or the other feature, common to all, becomes 
 exaggerated and assumes unusual preponderance. 
 
 (/) Stuporose 
 
 This is as nearly a distinct and separate form, as 
 well as variety, of insanity as there is. In pronounced 
 cases it is quite unmistakable, but it is not always 
 pronounced, and an element of stupor may often be 
 distinguished in cases of dementia that would not 
 be called stuporous, and especially in the young, for 
 stupor occurs usually, though not exclusively, in early 
 life. It exhibits the signs of exhaustion of nervous 
 energy, as though the highest regions of the brain 
 had been emptied of motion and had ceased to act ; 
 and it is usually preceded by experiences which are 
 calculated to drain these regions of their energy, and 
 especially by a combination of several such drains. If 
 we wished to produce a case of stupor, we should take 
 a young man between the ages of eighteen and twenty- 
 five, subject him to severe and exhausting bodily 
 fatigue, let him at the same time work hard in pre- 
 paring for an examination, let him work too many 
 hours a day, and have insuflB.cient food, and especially 
 insufficient sleep ; and above all, let him masturbate 
 freely, and at the end of a month or two he will become 
 insane, and his insanity will take the form of stupor. 
 If he is so exceptionally strong that these measures fail 
 to break him down, the last efiort of resistance can be 
 overcome by subjecting him to some severe shock. 
 Let him be involved in a railway or other accident, or 
 let him even witness one, or let him come suddenly upon 
 a dead body, or see his schoolfellow dragged drowned 
 
192 A TEXT-BOOK OF INSANITY 
 
 out of a river, or let him be assaulted and robbed, or 
 set his house on fire in the night. By such means may 
 stupor be produced even in a strong nature ; and a 
 weak nature will not require such an aggregation of 
 causes. Any one of them will suffice sometimes, any 
 two of them or three of them will usually suffice, especi- 
 ally if excessive masturbation be among them, though 
 this last factor is by no means essential to the causation 
 of stupor. 
 
 Whatever the causation, the insanity may be 
 stuporose from the outset ; but more usually to the 
 exhausting conditions that have been mentioned the 
 further exhaustion of a few days of acute insanity is 
 added, and then the stupor comes on. The charac- 
 teristic of the stuporose patient is his stillness. He 
 stands with drooping head and hanging arms, with 
 open mouth and staring lack-lustre eyes, with a face 
 void of expression, in an attitude void of vigour, and 
 thus he stands all day. Speak to him, shout at him, 
 fire a pistol behind him, flick your fingers within an 
 inch of his eyes, you evoke no response ; he exhibits 
 no reaction. Saliva hangs in long ropes from his open 
 mouth, his face is sweaty and greasy, his pupils large, 
 his tongue flabby, his hands blue, his pulse feeble. Of 
 food placed before him he takes no notice, but if it is 
 put into his mouth he will chew and swallow it. Yet, 
 stupid as he is, and destitute of most ordinary reactions, 
 except in the most extreme cases he does not let his 
 urine dribble, nor does he allow his bowels to act inap- 
 propriately. He retains both urine and fseces until 
 he is taken to the closet, and when he is there he passes 
 them. As he passes his days in a state closely allied to 
 profound slumber, so he sleeps well at night. 
 
 Such is the appearance and such are the habits of 
 
STUPOR 193 
 
 a well-marked case of stupor. But the condition is 
 not always as well marked as this, and indeed the 
 degrees of stupor are very various. In milder cases 
 the patient moves from place to place of his own 
 accord, though his movements are seldom and slug- 
 gish. He may answer when addressed, but the 
 answer is long in coming, is brief, and is uttered in 
 a faint, monotonous voice. He may keep his mouth 
 shut, exhibit palpebral reaction, and even look about 
 him from time to time ; in short, he may exhibit a 
 less degree of the same condition ; or, in rare cases, 
 the symptoms are not less, but more pronounced. 
 The patient does not stand, does not move under 
 any provocation. He lies like a log ; he passes his 
 motions and urine beneath him. He does not even 
 chew his food. His extremities are not only blue, 
 but deathly cold, and the circulation in them is so 
 defective that sometimes sloughs form. His only 
 spontaneous movements are breathing and swallowing. 
 While spontaneous movement is absent or mini- 
 mised, the reaction to " passive " or imposed move- 
 ment presents three well-marked variations. In the 
 first class, every attempt to move the hmbs or the 
 body is met with obstinate and intense resistance, 
 which is the same to every variety of movement and 
 in every part of the body. It is as pronounced in the 
 jaw as in the arm or leg ; it is as obstinately opposed 
 to flexion as to extension. It is as difl&cult to make 
 such patients change their attitude from standing to 
 sitting as to make them change from sitting to stand- 
 ing. The same resistance that is opposed to every- 
 thing else is opposed to the administration of food ; 
 and of course this is a serious matter, and influences 
 the prognosis, which is worse than in the other forms, 
 
 
 
194 A TEXT-BOOK OF INSANITY 
 
 tkough not necessarily hopeless. This obstinate resist- 
 ance to imposed movement, when present in stupor, is 
 always associated with melancholic delusion ; it is 
 present in many cases of acute insanity, and then also 
 is usually associated with melancholy. 
 
 The second and most frequent variation in the 
 reaction to imposed movement in stupor is the " cata- 
 leptic " condition, in which there is no resistance to 
 the imposition of movement, and in which any atti- 
 tude that we choose to impose upon the patient is 
 retained by him. When the stuporose condition is not 
 very pronounced, the attitude is maintained for but a 
 short time, it may be only a moment or two ; but 
 when the stupor is deep, the attitude will be main- 
 tained for long. We raise the patient's arm over his 
 head, and there it will remain for several minutes. 
 Dr. Clouston relates a case in which a stuporose patient 
 was got out of bed, the chamber-pot was put into his 
 hands, so that he held it under his penis, and then the 
 attendant went away and forgot him. He remained 
 in this attitude for several hours. In stuporose cases, 
 in which this cataleptic condition exists, the prognosis 
 is usually favourable. 
 
 The third variation is that in which there is neither 
 resistance to, nor retention of, an imposed attitude, but 
 a flaccid facility. The limbs can be moved with ease, 
 and fall back after movement into such positions as 
 require the least exertion to maintain. This is the 
 condition to which the term " anergic stupor " has 
 been given by Dr. Hayes Newington. 
 
 The mental condition in stupor may be in one of 
 two extreme conditions, or in any intermediate state 
 between them. In simple stupor, of exaggerated 
 degree, consciousness is altogether absent ; at least, 
 
STUPOE 195 
 
 we can get no manifestation of consciousness while 
 the state continues, and when it is past, no memory 
 whatever remains of the experiences of the stuporose 
 state. In the minor degrees, consciousness is pro- 
 portionately diminished. Some sign of consciousness 
 can be elicited, some slight reaction can be obtained ; 
 after a question has been many times repeated, some 
 answer will be given ; after an order has been many 
 times insisted on, some attempt will be made to carry 
 it out ; and when recovery takes place, some glimmer 
 of remembrance will be retained of what occurred 
 during the illness. 
 
 The other form of stupor is called melancholia cum 
 stupore, or melancholia attonita, or melancholy stupor, 
 since in it there is always misery, and sometimes the 
 depression is profound. The depression is somewhat 
 difierent from that of ordinary melancholia, and is 
 more of the nature of panic or horror. The sense of 
 personal unworthiness and incapacity which accompanies 
 dysphoria is, indeed, present, but in addition to this 
 is an overwhelming horror at something that the 
 patient deludedly believes to have occurred, or to be 
 about to occur. Unlike the previous form of stupor, 
 consciousness is not only present, but seems, as it were, 
 to be intensified. The patient is keenly alive to every- 
 thing that is going on around him, but everything that 
 happens is woven into his dream, and goes to corroborate 
 and intensify it. If he is compelled, for instance, to 
 take food, to dress or to undress, to sit down or to walk, 
 this interference is interpreted by him to be the actual 
 beginning of that terrible torture to which he is to be 
 submitted, and the attendants who so interfere with 
 him are his executioners. Hence his stubborn resist- 
 ance. 
 
196 A TEXT-BOOK OF INSANITY 
 
 The treatment of stupor may be summed up in two 
 words — feeding and rest. The state is one of exhaus- 
 tion, and the treatment must be directed to restore 
 the exhausted energy. To this end feeding must be 
 copious. Such patients must have much more than 
 the ordinary full diet which would suffice for a healthy 
 person of the same age, and, in young people at any 
 rate, it should be highly nitrogenised — plenty of eggs 
 and plenty of meat, with a moderate quantity of 
 alcohol. When solid food cannot be administered, 
 of course slops must be given, but essences and extracts 
 are useless. Milk is always valuable, and when food 
 cannot be given in solid form, it should be given, not 
 as liquid, but as thin porridge, that is to say, mth 
 plenty of finely divided solids suspended in it. Bread 
 sauce is an excellent food, and may be mixed with 
 pounded meat. 
 
 Rest is the complement of feeding. Since energy 
 is exhausted, every demand upon energy must be 
 minimised, and therefore the patient should be kept 
 warm, and usually he should be kept in bed. He must 
 be vigilantly watched to prevent masturbation, which 
 often goes on in a quasi- automatic manner ; and sleep, 
 the great restorer of exhausted energy, should be en- 
 couraged, and if necessary induced by hypnotics. 
 
 The same indications govern our administration of 
 drugs. Cod-liver oil, Easton's syrup, and other pre- 
 parations of iron, quinine, strychnine, and phosphorus 
 all appear to assist recovery. Baths and friction are 
 useful, but massage is not advisable. 
 
 In simple stupor, the prognosis is usually favourable. 
 It occurs commonly in young people, in whom recupera- 
 tive power is active, digestion good, and sleep easily 
 induced ; and, moreover, in this form there is neither 
 
STUPOR 197 
 
 refusal of food nor exhaustion from struggling during 
 its administration. In melancholy stupor the prospect 
 is much less favourable. It may occur at any age ; 
 sleep is usually difficult to induce, and the strenuous 
 resistance to feeding and other necessary offices keeps 
 a perpetual drain upon the strength. Hence recovery 
 is in this form less frequent, it is longer delayed, and a 
 much larger proportion of the cases end either in death 
 or in permanent insanity. 
 
 In other characters, as well as in those mentioned, 
 melancholic stupor shades off by insensible degrees 
 into other forms of acute insanity, and many cases 
 which would usually be classed as melancholy insanity 
 exhibit the panic and horror that are so prominent in 
 this form of stupor. When, as not seldom happens, the 
 subject of melancholic stupor exhibits sudden out- 
 breaks of impulsive violence, directed either against 
 himself Or against others, or similarly impulsive out- 
 breaks of destructiveness, the case approaches in 
 character to ordinary acute insanity ; and the affinity 
 of the two forms of insanity is further exhibited in the 
 occasional transition of the one into the other. The 
 stuporose patient loses his apathy, his outbreaks of 
 excitement become more frequent, and he passes, on 
 his way to chronic quiet dementia, through a period of 
 acute maniacal insanity. 
 
 Whatever the type of the acute insanity, there are 
 certain features common to them all. All, as we have 
 seen, are potential suicides. In all there is at one time 
 or another refusal of food, alternating, it may be, with 
 wolfish voracity. In all there are sexual proclivities, 
 showing themselves in frequent shameless mastur- 
 bation, as well as in other ways. In all there is in- 
 attention, not only to ordinary tidiness and clean- 
 
198 A TEXT-BOOK OF INSANITY 
 
 liness, but to the calls of nature. They pass their 
 urine and motions under them, either occasionally or 
 habitually, according to the gravity of the case. Their 
 clothes soon become ragged, dirty, stained, and caked 
 with spilt food. In all cases of acute insanity, sleep- 
 lessness is a very prominent and very important 
 symptom. It has usually existed for days or weeks 
 before the insanity declares itself, and it is aggravated 
 when this takes place. The length of time for which 
 they will maintain their excessive activity without 
 sleep, or with only an hour or two of sleep per night, 
 is astonishing. They are always constipated, and the 
 tongue is usually foul, and the breath stinking. They 
 have usually lost a great deal of weight before the 
 insanity declares itself. When they are sufficiently 
 rational to give an account of themselves, they are 
 found to be suffering from delusions. In the melan- 
 choly type these are the ordinary delusions of melan- 
 cholia, sometimes combined with delusions of perse- 
 cutory type. In the excited or maniacal type the 
 delusions are of a very extravagant character. The 
 patient has visited heaven and made the personal 
 acquaintance of the Almighty, or he has attended his 
 own funeral, or he has some other equally extravagant 
 belief. Hallucinations are rarely prominent, and often 
 not present in acute insanity, and when present are 
 usually visual. It is rare for patients with acute in- 
 sanity to " hear voices," and those who do are usually 
 of the resistive type. 
 
 Acute insanity is very variable in course and duration. 
 In a few cases it is very evanescent, and clears up 
 completely and permanently in twenty-four or forty- 
 eight hours ; and such cases constitute what has been 
 called mania transitoria. Usually it lasts in full 
 
ACUTE INSANITY— TREATMENT 199 
 
 intensity for from one to four or five weeks, and if the 
 longer term is reached, it then terminates fatally from 
 exhaustion. The earlier improvement begins, the more 
 favourable the chance of recovery ; the longer the full 
 intensity of the malady lasts, the graver the prognosis. 
 Four or five weeks of really acute mania will kill the 
 strongest man, and a shorter term, even if not fatal 
 to life, is very apt to leave irreparable damage to the 
 brain and mind. Of the five types described, the 
 resistive is the most unfavourable to life, and the 
 suicidal is the most apt to leave permanent insanity. 
 When recovery takes place, it often takes place 
 suddenly. The patient has a night of long, sound 
 sleep, and wakes up well, or so nearly well that a few 
 days completes the recovery ; but this can only happen 
 when the malady has been of sudden onset and short 
 duration. In other cases, improvement is gradual, the 
 excitement subsides, the melancholy clears away, and 
 the patient passes into a state of slight, or it may 
 be of grave, dementia, from which he may gradually 
 emerge, or which may remain permanent for the rest 
 of a long life. In other cases the subsidence of the 
 excitement is simultaneous with fixation and systema- 
 tisation of the delusions, and the acute insanity merges 
 without break into paranoia. Even when recovery is 
 rapid and appears complete, the patient should not 
 return to the active duties of life for at least a third 
 or half a year, and he will always be liable, on a recur- 
 rence of the conditions, to a recurrence of the malady. 
 
 The effective treatment of acute insanity may 
 be summed up in two words — food and sleep. In 
 the rare cases in which a patient has been eating 
 and sleeping fairly well up to the time of the outbreak 
 of insanity, the prognosis is extremely unfavoui-able ; 
 
200 A TEXT-BOOK OF INSANITY 
 
 and the more confidently we can attribute the outbreak 
 to deficiency of food and sleep, the more confidently 
 may we expect that the administration of food and 
 the procurement of sleep will be followed by recovery. 
 As the sleeplessness depends very largely upon the 
 inanition, our first care must be to administer abund- 
 ance of food. The patient must not merely be fed, 
 he must be over-fed. He must have food in super- 
 abundance and excess ; he must have twice or three 
 times as much as would sufiice for a healthy man of his 
 age and weight. What he needs is not extract of meat 
 and Brand's essence, and Bovril and Valentine's meat 
 juice, and similar concentrates, but bulky, ordinary 
 food — meat and potatoes, bread and butter, rice 
 pudding, and such like viands in great quantity. 
 And here we are met at the outset by two serious 
 difficulties — ^first, that digestion is very frequently 
 disordered, and, second, that the food is very frequently 
 refused. 
 
 The first difficulty we may often disregard. The 
 stomach has perhaps been pampered and humoured for 
 months by discarding first one food and then another 
 that has been thought to disagree with it, and if it is 
 taken firmly in hand and compelled to receive all 
 kinds of bland food, it will do its duty uncomplain- 
 ingly. A more serious matter is that when food has 
 for months been taken in small quantity only, the 
 stomach has become contracted, and till it has been 
 educated to receive larger quantities, it will resent 
 over- distension by vomiting. In such cases we must 
 be content to feed very frequently, and gradually to 
 increase the amount given at each meal. 
 
 The other difficulty is far more serious. Refusal of 
 food, obstinate resistance to the administration of food, 
 
ACUTE INSANITY— TREATMENT 201 
 
 is a common feature of all the types of acute insanity, 
 and unless it is overcome, the patient will certainly die. 
 It must therefore be dealt with promptly and vigor- 
 ously. The patient must be forcibly fed. There are 
 degrees of persistence of refusal. Some patients will 
 not feed themselves, but if the food is put to the 
 mouth, they will take it with docility, chew and 
 swallow it. Others will take it only if spoon-fed ; 
 the rest — and these are the majority — will refuse and 
 resist every attempt to feed them. Various methods 
 of forcible feeding are in use for such cases, but I 
 have no hesitation in condemning all but one. The 
 nasal tube, a small tube of soft rubber introduced into 
 the nostril, has been used very largely, but it is so 
 easy for a suicidal patient, or even a greatly demented 
 patient, to inhale the food thus administered ; and so 
 many cases of gangrene of the lung have followed the 
 use of the method ; that it ought to be abandoned, and 
 the oesophageal tube used in every case. 
 
 Of course, in this case, solid food cannot be given 
 in solid form ; but the same food can be given if it is 
 first pounded up in a mortar and made into a thin 
 pulp with milk, and then there is the advantage 
 that the appetite and palate need not be consulted, 
 and food, stimulants, and drugs can be administered 
 together. If a really copious and excessive amount of 
 food is introduced, the dijB&culty about sleep is already 
 half overcome ; but there are few cases, though there 
 are a few, in which food alone is sufficient to procure 
 sleep. In most cases hypnotic drugs have to be em- 
 ployed. Our choice of these has greatly extended o£ 
 late years. There was a time when opium was the 
 only soporific ; then chloral and bromide of potassium 
 were added ; now all these are abandoned in the 
 
202 A TEXT-BOOK OF INSANITY 
 
 treatment of acute insanity, and newly discovered 
 drugs are found to be more efficacious and attended 
 by fewer disadvantages. 
 
 The question often arises, what is to be done upon 
 the instant to control a patient who has suddenly 
 become acutely insane in his own house, or in an hotel, 
 or elsewhere ; who is tearing up his clothes and smash- 
 ing the furniture, who has worn out his friends and 
 the ex-policeman who has been called in to help in 
 controlling him ? In this state of things we have in 
 hyoscin an agent of the utmost value. It is made up 
 for hypodermic use in minute tabloids, and one of these 
 can be dissolved in a cup of tea or a glass of wine, or, 
 if needs must, it can be given hypodermically, and its 
 action is very speedy and very effectual. The usual 
 doses — -^ho and -^t oi a, grain — are of no use in acute 
 insanity, and at least -^ should be given under the 
 skin, or -srV by the mouth. I give -^ hypodermically, 
 and have never seen any ill-effects from its use. Ill- 
 effects, and fatal effects, used sometimes to attend its 
 use when the drug was first introduced, but no case 
 has been reported of late years, and I cannot help 
 thinking that when it has been fatal, either the drug 
 was impure, or it was insufficient^ mixed, and larger 
 doses were given than were intended. At any rate, 
 if there is any risk attached to its use now, it is a risk 
 that ought to be run, for the danger of the drug is in 
 any case not so great as the danger of allowing the 
 patient to die of exhaustion ; and therefore it should be 
 given. In this way a breathing-time may be obtained, 
 during which the friends are freed from the absorbing 
 task of immediate attendance on the patient, and are 
 at liberty to take the necessary steps to have him 
 removed to an institution. For this course is essential 
 
ACUTE INSANITY— DRUGS 203 
 
 in every case of acute insanity, except, perhaps, wKen 
 the patient's friends are very wealthy, and can arrange 
 for at least three attendants and a medical man to 
 reside in the house with him, and even then the con- 
 ditions for his control and recovery are not so favour- 
 able as they would be in any well-conducted institution. 
 It is scarcely justifiable to keep up a full administration 
 of hypnotics merely for the purpose of facilitating the 
 control of a patient, and unless this is done, there will 
 be times when two, and even three, attendants will be 
 insufficient to control an acute maniac. He should be 
 in a place where practically unlimited help can be 
 brought to bear to get him undressed, or dressed, or 
 fed, as the case may be. There is nothing so likely to 
 produce bodily injuries as insufficiency of help in these 
 operations. 
 
 There is a practical measure of great value, which is 
 much insisted upon by Dr. Savage in the management 
 of acute insanity so long as the patient is kept at 
 home, and this is to remove the patient at once to the 
 ground floor, bag and baggage, bed and bedding. 
 Then if he jumps out of the window he can do himself 
 but little harm. 
 
 Useful as hyoscin is as a calmative and controller of 
 excitement upon emergency, it is not a drug to be used 
 as an hypnotic, nor is it suitable for prolonged adminis- 
 tration, for tolerance is soon established, and the dose, 
 to be effectual, has to be increased. When we desire 
 an hypnotic effect, the most efficient drug for ordinary 
 use in acute insanity is sulphonal, a drug that has the 
 great advantage that it not only induces sleep at night, 
 but has a calmative influence upon the patient for the 
 following day. Its disadvantages are various. In the 
 first place, its action is delayed, and it varies much in 
 
204 A TEXT-BOOK OF INSANITY 
 
 the period after administration at which its effects 
 begin to be felt. Sometimes it will act in an hour, 
 sometimes not for two, three, six, or as much as twelve 
 hours. It is therefore manifestly inappropriate when 
 we desire an immediate effect. Trional, upon the 
 other hand, is a drug whose action is far more speedy, 
 almost as effectual, and much less lasting. It has none 
 of the delayed calmative effect that is so characteristic 
 of, and important in, sulphonal. The best effect of 
 both drugs is obtained by a combination of the two. 
 A combination of about | trional with f sulphonal is 
 most valuable. The trional puts the patient to sleep, 
 and the sulphonal keeps him asleep — ten grains of one 
 to fifteen grains of the other, or better, fifteen grains of 
 the one to twenty-five of the other. If this is given 
 the first night, a less dose will suffice for the second, a 
 still smaller for the third, and on the fourth night the 
 patient will usually sleep without drugs. The same 
 hypnotic should not be given for long together. They 
 are much more effectual when changes are rung upon 
 them. In the melancholic form of acute insanity, and 
 when there is cardiac weakness, paraldehyde is a very 
 valuable hypnotic. 
 
 Mention has already been made of the disorder of 
 digestion that is so frequent in acute insanity. In any 
 case in which it is ascertainably present, it must be 
 treated. There are cases in which the contents of the 
 stomach undergo putrefactive or fermentative changes 
 which render them unspeakably foul and offensive, and 
 when this is the case, or whenever the breath is very 
 foul, or especially when foul gases are expressed from 
 the oesophageal tube when the end reaches the stomach, 
 benefit will be derived from washing out the stomach 
 at regular intervals. 
 
CHRONIC INSANITY 205 
 
 In all cases of acute insanity, certainly in all which 
 are severe or prolonged, institution treatment is essen- 
 tial. In many cases it is far better for the patient 
 to have the comparative freedom of a padded room 
 than to be perpetually checked and interfered with by 
 attendants. 
 
 The first favourable symptoms are the establishment 
 of natural sleep, the voluntary taking of food, sub- 
 sidence of excitement, and commencing appreciation 
 by the patient of his circumstances. If all these are 
 concurrent with a gain of weight, and occur within the 
 first fortnight, there is reasonable hope of complete 
 recovery. But if sleep is established, food taken, and 
 weight gained, while still the mind does not improve, 
 the prognosis, while improved as to life, is very gloomy 
 as to recovery of reason ; and if improvement is 
 delayed beyond the first fortnight, every day's delay is 
 of consequence. 
 
 CHRONIC INSANITY 
 
 By chronic insanity is meant here insanity that is 
 either not of recent origin or that, if of recent origin, is 
 not intense. It is, of course, true that chronic means in 
 the literal sense of long duration, but in the first place 
 there is no one word which connotes the alternative of 
 long duration or lack of intensity, and in the second, the 
 term chronic insanity has never been appropriated to 
 any particular class, and in bringing it for the first 
 time into use I imagine I am at liberty to give it any 
 signification I please. I therefore consider that the 
 definition I have given is quite justifiable. 
 
 Thus defined, chronic insanity may be divided into 
 two important classes or sub- types, and a rabble of 
 
206 A TEXT-BOOK OF INSANITY 
 
 others which need not be considered here. The two 
 sub-types that stand out with clear characterisation are 
 fixed delusion and dementia. The sub-type fixed 
 delusion happens to coincide with the kind of insanity 
 similarly entitled, and is more conveniently described 
 among the kinds, where it will be found. The other 
 clear sub-type, dementia, is also well characterised, and 
 as it does not coincide with any kind, but like the type 
 acute insanity is witnessed in several kinds of insanity, 
 it falls to be described here. 
 
 DEMENTIA 
 
 Dementia is that type of chronic insanity in which 
 there is no such outstanding predominant feature as 
 fixed delusion or a cyclical course, but the insanity is a 
 general degradation affecting in various degree, and to 
 various depths in the different cases, all the faculties 
 of mind. Although it is a general defect, it is not neces- 
 sarily a simple defect. It is complicated in most cases 
 with over-action on the lower levels that the defect has 
 not yet reached, as has been explained in the description 
 of anoia. Anoia is a form of insanity, that is to say, a 
 group of symptoms made up of disorder of conduct and 
 mind, that may be present in any kind of insanity — in 
 any of the different diseases of which insanity consists — 
 and that is in fact present in some degree in every such 
 disease. Dementia is that particular kind or disease of 
 insanity in which the symptoms are those of anoia only, 
 and in which no single accompaniment of anoia — no 
 delusion, no excess of feeling, no excitement in conduct, 
 — is so predominant as to obscure the anoia, which now 
 stands out as the predominant symptom. 
 
 But though anoia, or simple deficiency of conduct and 
 
CHEONIC INSANITY— DEMENTIA 207 
 
 mind, is the predominant symptom, it is not necessarily 
 the only symptom. In many cases there are from time 
 to time outbreaks of excitement, in some there may be 
 from time to time fleeting delusions, in others there is 
 continuous excess of some low grade of conduct, as has 
 been described in treating of anoia ; but in all the pre- 
 dominant feature is the anoia — the defect of mind and 
 conduct. 
 
 As has already been stated, the Scotch school of 
 alienists look upon dementia as an irrecoverable disease, 
 and would deny the name to any case of insanity, 
 however characteristic the symptoms of anoia, if the 
 patient were to recover. I cannot agree that the way 
 in which a disease terminates forms a satisfactory basis 
 for classifying it. Even the school of Kraepelin, 
 though it constitutes the disease of dementia prsecox 
 mainly on the basis of the irrecoverabihty, or as they 
 call it the incurability, of the disease, yet admit that 
 some cases do recover. The admission knocks the bottom 
 out of their classification and leaves them in chaos, but 
 this does not trouble the minds of those who think they 
 have got hold of something new, and have all the 
 enjoyment of playing with a new toy. 
 
 The indisputable fact is that though in a great many 
 cases anoia may be the expression of actual structural 
 deterioration of the brain, and in these cases the 
 dementia is irrecoverable, yet in some cases there is 
 little or no structural damage of the brain, and a 
 minority of the cases, a lamentably small minority, do 
 recover. We do not yet know whether the structural 
 deterioration which is found after death in cases in 
 which dementia has been of long standing is the cause 
 or structural basis of the dementia, or whether it is not 
 atrophy resulting from long disuse. However this may 
 
208 A TEXT-BOOK OF INSANITY 
 
 be, a certain number of cases of dementia recover, and in 
 these cases the symptoms of the disease, while it lasted, 
 are indistinguishable from those of other cases that go on 
 for many years and never recover. I do not think that 
 the different termination of a disease in recovery or 
 death constitutes a sufficient basis for regarding the 
 cases that recover as suffering from one kind of disease 
 and those that do not recover as suffering from another. 
 The difference is not made a basis for classification in 
 any other disease, and there seems no good reason for 
 making it a basis of classification in insanity. 
 
 Dementia is a sub-type of disease that is presented by 
 several kinds of insanity. We see it in youth, in middle 
 age, and in old age, and at each time of life it has 
 peculiarities that are fairly distinctive ; and when the 
 dementia constitutes the whole of the correlated dis- 
 orders from which the patient suffers, it is properly 
 considered a disease, and reappears under that title 
 among the kinds of insanity hereafter considered. But 
 there are cases, advanced general paralysis for instance, 
 in which the dementia constitutes not the whole, but a 
 part only of the correlated disorders from which the 
 patient suffers, and in such cases the dementia is not 
 the whole disease. The disease is general paralysis, of 
 which one symptom or group of symptoms is insanity 
 of chronic type, the sub-type being dementia. 
 
CHAPTER VII 
 
 KINDS OF INSANITY 
 
 The mode that was adopted in the last chapter of 
 classifying the disease insanity, the classification into 
 acute insanity and chronic insanity, is, as far as it goes, 
 a useful classification ; but it does not go far, and it is 
 not the only mode of classification. As has already 
 been pointed out, it is a mistake to suppose that there 
 is but one ideally perfect mode of classifying anything, 
 and that all other modes are wrong. Things can be 
 classified in as many ways as they have difierent 
 qualities to serve as a means of classification, and in 
 fact must or ought to be classified in difierent ways for 
 difierent purposes. There may be a best way of classify- 
 ing for each purpose, but there will be at least as many 
 ways of classifying as there are purposes to be served by 
 the classification. For clinical purposes the classifica- 
 tion of insanity into acute and chronic is a very useful 
 and suitable and valid classification, but for the purpose 
 of organising our knowledge it is unsuitable because it 
 results in classes one of which is a heterogeneous mixture 
 of dissimilar cases. For this purpose we must seek 
 another basis of classification. In most books on insanity 
 it will be found rather dogmatically stated that the 
 only true and satisfactory classification of insanity 
 p 209 
 
210 A TEXT-BOOK OF INSANITY 
 
 must be that which has a pathological basis, in other 
 words that in which the fundamentum divisionis is the 
 kind of structural change in the brain that underlies the 
 symptoms of insanity and enters into the constitution 
 of the disease of insanity. I cannot find any rational 
 foundation for this doctrine. Even in bodily diseases it 
 is not true that the classification is always founded on 
 the structural change that underlies the symptoms. 
 Many diseases are classified by the agent that produces 
 them. Such are syphilis, tuberculosis, hydatids, and 
 many others. And it is demonstrable that all insanity 
 cannot be classified by the structural change in the 
 brain, because in some cases of insanity there is no such 
 change, as is shown by complete recovery. We may 
 therefore put aside the ideal of a pathological classifica- 
 tion as both unnecessary and impracticable ; but it does 
 not follow that there is no practicable classification, and 
 some classification is, as we have found, necessary. I 
 do not say that the classification I am about to propose 
 is the only practicable classification. What I have 
 already said shows that it is not ; but it is at any rate 
 a valid classification, made in accordance with the 
 accepted canons of classification, and therefore free from 
 cross- classification, which is more than can be said of 
 any of its predecessors. 
 
 Taking the principle of Evolution as the first funda- 
 mentum we get the two main classes already indicated 
 according as evolution is imperfect and has been 
 arrested at an incomplete stage, or according as evolution 
 has been complete and has subsequently been reversed. 
 Thus the primary division is into — 
 
 I. Insanity of undevelopment or Involute Insanity. 
 II. Insanity of dissolution or Dissolute Insanity. 
 
INVOLUTE INSANITY 211 
 
 Insanity of undevelopment, in its various degrees 
 of idiocy, imbecility, and feeble-mindedness, is rationally 
 divisible into three kinds according to the reason of the 
 undevelopment. This may be due to : 
 
 A. Defect of the developmental impetus communi- 
 cated by the sperm cell to the germ cell at conception, 
 so that the process of development comes to a premature 
 end from mere lack of vigour. 
 
 B. Defect of some chemical product of metabolism, 
 the presence of which is necessary to normal develop- 
 ment. Undevelopment due to this cause may be recog- 
 nised by the presence of many co-ordinated or correlated 
 defects, forming a recognisable group that occurs again 
 and again in difierent cases. In one case, that of 
 cretinism, the defective chemical has been identified, 
 and is known to be the secretion of the thyroid gland. 
 In other cases, e.g. microcephaly and mongolian idiocy, 
 the defective chemical has not yet been identified, but 
 the presence of a number of correlated defects compels 
 us to conclusively presume that the undevelopment is 
 due to such a deficiency, either absolute or relative. 
 
 C. In a third class of cases arrest of development is 
 due to the action upon the brain of some extraneous 
 agent, which may be either of two main kinds : 
 
 1. Mechanical violence applied to the head, either in 
 the natural passage of a large head through a narrow 
 passage at birth, or by instrumental delivery, or by a 
 fall or a blow in infancy. 
 
 2. The action of a microbe, or of the toxin produced 
 by a microbe, which may be that of syphilis, measles, 
 scarlet fever, small-pox, etc., and may act directly upon 
 the brain, or indirectly through inflammation of the 
 meninges. 
 
212 A TEXT-BOOK OF INSANITY 
 
 DISSOLUTE INSANITY 
 
 In every case of insanity we postulate disorder of the 
 brain, and this disorder of brain, taken together with 
 the disorders of conduct, mind, and metabohsm that 
 depend on it, constitute the disease of insanity in those 
 cases in which insanity exists alone — in which it includes 
 the whole of the correlated disorders from which the 
 patient suffers. But in many cases the insanity, thus 
 understood, does not include the whole of the correlated 
 disorders from which the patient suffers. In many 
 cases the disorder of brain is itself but a part of a more 
 widespread disorder, affecting also other organs, or the 
 whole of the body, and due, it may be, to disorder of 
 some other organ, such as the thyroid, or to the invasion 
 of a microbe, as in the delirium of specific fever, or to 
 some generally distributed poison, such as that of gout. 
 In these cases, the form of insanity — the disorder of 
 mind and conduct — is a symptom, directly of brain 
 disorder, and indirectly, through the brain disorder, of 
 the disorder of the thyroid, or of the specific fever, or of 
 gout. We must therefore recognise that the disease 
 insanity — the threefold disorder of conduct, mind, and 
 brain — may be an independent disease or a symptomatic 
 disease, according as it does or does not include all the 
 correlated disorders from which the patient suffers ; 
 and the first division that we make of the insanity of 
 dissolution is into symptomatic insanity and idiopathic 
 insanity. 
 
 In symptomatic insanity, the prominence and im- 
 portance of the insanity varies much in different cases. 
 When delirium occurs in specific fevers, the bodily 
 symptoms usually preponderate. They precede the 
 delirium hj days or weeks, and persist after the delirium 
 
SYMPTOMATIC INSANITY 213 
 
 subsides ; and throughout the delirium the bodily 
 symptoms take rank of it in importance and prominence. 
 The delirium is but an incident in the course of the 
 disease. The same thing may occur when insanity 
 occurs as a symptom of gout. But sometimes the 
 insanity is for the time being more prominent than the 
 bodily disease, and the bodily disease may even be 
 overlooked. The same may be the case in myxoedema 
 and in other diseases. Sometimes the insanity is the 
 more prominent, and the bodily disease may escape 
 notice unless the observer is on the alert to look out for 
 it : in other cases the bodily disease preponderates, and 
 the insanity may be but a transient and unimportant 
 interlude. 
 
 Symptomatic Insanity may be logically divided 
 according to the kind of disease of which it is a symptom, 
 and thus falls naturally into the following classes : 
 
 A. Insanity symptomatic of what may be termed 
 intrinsic diseases, by which I mean diseases due to 
 errors of metabolism and the faulty action of glandular 
 bodies. Under this head fall the insanity of gout, of 
 myxoedema, of Graves' disease, of uraemia, and so 
 forth. 
 
 B. Insanity symptomatic of what may be termed 
 extrinsic diseases, by which I mean diseases due to 
 poisons invading the body from without. These are 
 subdivisible according as the poison is a toxin, produced 
 by a living microbe within the body, or a chemical 
 poison ingested as such. 
 
 1. To the first sub-class belongs the insanity or 
 delirium of acute specific fevers, of tuberculosis, probably 
 of pellagra, and so forth. 
 
214 A TEXT-BOOK OF INSANITY 
 
 2. To the second sub- class belongs the insanity pro- 
 duced by alcohol, by opium, by cocaine, and by other 
 drugs. 
 
 C. Insanity symptomatic of gross brain disease, by 
 which I mean structural disease that is manifest to the 
 naked eye. This class includes general paralysis, post- 
 hemiplegic insanity, insanity symptomatic of tumour of 
 whatever character in the brain, and insanity due to 
 mechanical injury to the brain from violence. 
 
 D. Insanity symptomatic of epilepsy, or rather of the 
 disorder of brain of which epilepsy is a co-ordinate 
 symptom. What this disorder is we do not know. It 
 may perhaps in some cases be an intrinsic poison ; it 
 is in some cases mechanical injury, or the result of 
 mechanical injury ; but whatever its nature may 
 ultimately be discovered to be, in the present state of 
 our knowledge it must be placed in a separate class. 
 
 Idiopathic Insanity is that w^hich is not at present 
 known to be symptomatic of any bodily disease. It is 
 quite probable that some of the cases, and even some of 
 the classes, that we must now consider idiopathic, may 
 by the progress of our knowledge be ultimately dis- 
 covered to be symptomatic of the invasion of some 
 toxin. If and when this happens these cases or these 
 classes will be removed from the class of idiopathic 
 insanity to the class of symptomatic insanity ; but the 
 fact that they were wrongly classed will not invalidate 
 the scheme of classification, any more than the dis- 
 covery, that certain organisms at one time believed to 
 be animals are really plants, invalidates the division of 
 organisms into plants and animals. The scheme of 
 classification will still hold good, even though some of 
 its contents may be shifted from one place to another. 
 
IDIOPATHIC INSANITY 215 
 
 Idiopathic insanity is primarily divided into cyclical 
 insanity and non- cyclical insanity. By cyclical insanity 
 is meant insanity that runs a cyclical course, such that 
 the form that it once displays is departed from, and 
 replaced by some other form, or perhaps by an interval 
 of sanity, but at length the original form reappears, to 
 be followed by the same phases in the same order as they 
 followed its first appearance, and the cycle may be 
 repeated again and again. Non-cyclical insanity is, of 
 course, that in which no such cyclical course can be 
 detected. 
 
 Cyclical insanity may be divided into several kinds, 
 according to the phases that occur, and to the order in 
 which they occur. When the several phases or forms 
 of insanity are separated by intervals of sanity, the 
 disease is called recurrent insanity, but there are other 
 cases of cyclical insanity in which there are no such 
 interruptions. These are clearly allied very closely to 
 recurrent insanity, but to call them recurrent insanity 
 would be a misnomer : they may appropriately be 
 called circular insanity, but this name is often given to 
 recurrent insanity. All these allied varieties may 
 properly be included under cyclical insanity. 
 
 Non-cycUcal insanity is primarily divided according as 
 we are or are not able to correlate it with a causal stress, 
 to which it is in part attributed. Some cases of riion- 
 cyclical insanity arise apparently spontaneously, in- 
 dependently of any assignable causal stress. The term 
 stress was imported by me about five-and-twenty years 
 ago from the science of engineering into the science of 
 alienism, and was used by me in a certain restricted 
 meaning which is explained in the chapter on causation 
 supra. The term has since been used by others in 
 difierent senses, but is here used in the same sense as 
 
216 A TEXT-BOOK OF INSANITY 
 
 that which I originally gave to it. Other cases of 
 non-cyclical insanity arise in circumstances that we may 
 regard as productive of stress ; and these cases we may 
 separate from the others and put in a distinct class. 
 
 A. Of the cases of non-cyclical insanity to which we 
 can assign no stress as a contributing cause, there are 
 two main classes, viz. those that exhibit in some fixed 
 and enduring delusion or delusions a predominant 
 feature, and those that exhibit no such predominant 
 feature, but consist in a general degradation of conduct 
 and of mind. 
 
 1 . The first kind of non-cyclical insanity in which there 
 is no assignable causal stress is distinguished by the 
 predominance of enduring delusion or delusions, which 
 is compatible with a high general level of intelligence. 
 It is divisible, according to the character of the pre- 
 dominating delusion, into three sub- classes. 
 
 (a) The predominating delusion is of a persecutory 
 plot against the deluded person. This is the character- 
 istic feature of paranoia. 
 
 (h) The predominating delusion is of the exalted 
 rank or position of the patient. These cases have no 
 name, but are called cases of fixed exalted delusion. 
 The term megalomania might with advantage be 
 restricted to them. 
 
 (c) The predominating delusion is of some bodily 
 change or infestation, of which examples have been 
 given on a previous page (p. 153). They may be appro- 
 priately called cases of somatic delusion. 
 
 2. The second kind of non-cychcal insanity in which 
 there is no assignable causal stress exhibits no delusion 
 as a predominant feature, though delusions of some 
 
DEMENTIA 217 
 
 kind or other may be entertained. The insanity con- 
 sists in a general degradation, though not necessarily a 
 uniform degradation, of all the faculties of mind and all 
 departments of conduct, and the general and appro- 
 priate name is Dementia, of which there are the following 
 sub-classes. 
 
 {a) The disease begins in an attack of acute insanity, 
 which may be of any type, and may or may not have 
 belonged to the second great class of idiopathic insanity, 
 that, namely, to which a causal stress can be assigned. 
 This is the kind of insanity known as terminal dementia. 
 
 (b) The second kind of dementia is that which does 
 not follow an attack of acute insanity, but begins 
 slowly, it may be very insidiously, and gradually 
 progresses. Many years ago the appropriate name of 
 Primary Dementia was given to these cases. They 
 would now all be called Dementia Prsecox, and would be 
 included with an omnium-gatherum of other cases 
 under this title. 
 
 This sub-class is again divisible into two distinct 
 varieties according as it begins in early life or middle 
 life. The latter variety has peculiarities which mark 
 it of! from the former. 
 
 B. The second main class of non-cyclical idiopathic 
 insanity consists of those cases which occur at a time of 
 stress, and in which the stress may reasonably be assigned 
 as a causal factor. Stresses are of three kinds ; the first 
 is a direct stress, the second we may call physiological, 
 since it is an incident in the progress of the life of 
 everyone, and the other we may call reproductive, since 
 it arises out of the function of reproduction. 
 
 1. The direct stresses that may be assigned as causes 
 of idiopathic insanity exclude, of course, those which 
 
218 A TEXT-BOOK OF INSANITY 
 
 co-exist with the insanity. In such cases the insanity 
 is symptomatic, and we are here concerned with idio- 
 pathic insanity. In idiopathic insanity the stress must 
 have ceased to act, and in this sub-class is the insanity 
 that is left behind by previous stresses that are now 
 absent, such as the insanity that follows acute specific 
 fevers, and that which is left by long continued alcoholic 
 excess. 
 
 2. The second sub-class of the second kind of non- 
 cycHcal insanity consists of those cases which occur at 
 the time of some physiological stress, and to which we 
 can reasonably assign this stress as a causal agent, 
 seeing that case after case of the same kind occurs 
 in the same connection. Physiological stresses are 
 three. 
 
 (a) A certain number of cases of insanity or of 
 " nervous breakdown " of the nature of insanity, 
 though less in degree, occur in connection with unduly 
 rapid growth in children, usually about the age of 
 fifteen. 
 
 (6) The period of adolescence, that is to say, from 
 seventeen to four or five-and-twenty, is a period of 
 stress, and a time of life at which many cases of insanity 
 occur. 
 
 (c) The third period of physiological stress is the 
 climacteric, the period of involution of the sexual 
 function in women, and occurs between the ages of 
 forty-five and fifty-five. 
 
 3. The third sub-class of the second kind of non- 
 cycUcal insanity consists of the cases that occur in 
 connection with the stress of reproduction. They also 
 may be divided into three. 
 
KINDS OF INSANITY 219 
 
 (a) Insanity during, and presumably due to, preg- 
 nancy. 
 
 (6) Insanity at or soon after childbirth, 
 (c) Insanity during lactation. 
 
 Set out as a complete scheme, the classification of 
 insanity the disease, as distinguished from insanity the 
 symptom, and from the type (acute or chronic) that the 
 insanity may assume, is as follows : — 
 
 Kinds of Insanity 
 (insanity the disease) 
 
 I. Insanity of undevelopment, or Involute Insanity — 
 
 A. Developmental : 
 
 General. 
 Moral only. 
 
 B. Metabolic : 
 
 Cretinism. 
 
 Microcephaly. 
 
 Mongolism. 
 
 C. Accidental : 
 
 Toxic. 
 Traumatic. 
 
 II. Insanity of Dissolution — 
 
 A. Symptomatic : 
 
 1. Of intrinsic disease. 
 
 2. Of extrinsic disease. 
 
 (a) Toxic. 
 (h) Poisonous. 
 
 3. Of gross brain disease. 
 
 4. Of mechanical injury. 
 
 5. Of epilepsy. 
 
220 A TEXT-BOOK OF INSANITY 
 
 B. Idiopathic : 
 
 1. Cyclical. 
 
 2. Non-cyclical. 
 
 A. Without assignable causal stress. 
 
 (a) With predominating delusion. 
 a. Of persecution, 
 yg. Of exaltation. 
 y. Of bodily change. 
 
 (h) With no predominating de- 
 lusion. 
 
 a. Beginning in acute insanity 
 ^. Beginning gradually. 
 
 (a) In early life. 
 
 (h) In middle life. 
 
 B. With assignable causal stress, 
 
 which is : 
 
 (a) Pathological. 
 a. Alcohol. 
 p. Specific toxin. 
 
 (h) Physiological. 
 
 a. In childhood. 
 ^. In adolescence. 
 y. At the climacteric. 
 S. In old age. 
 
 (c) Keproductive. ^ 
 
 a. Pregnancy. 
 /3. Childbirth, 
 y. Lactation. 
 
 This is the classification of the disease of insanity ; 
 but it is to be remembered that this table is to be read 
 and used in connection with the forms of insanity 
 
FOKMS, TYPES AND KINDS 221 
 
 already described in a previous chapter, and with the 
 type of the insanity as acute or chronic. It is the 
 endeavour to combine the form, the type and the kind, 
 variety, or disease of insanity in a single scheme, and to 
 divide insanity simultaneously on all three principles, 
 that has vitiated and rendered invalid every previous 
 scheme of classification ; but though the three principles 
 cannot be used simultaneously for the purpose of 
 classifying insanity, this is no reason why each disease 
 or variety should not have its ow^n form or forms, and 
 should not be of one or other type. Some varieties, such 
 as paranoia, are of the same form and the same type 
 throughout, and never vary in these respects. General 
 paralysis, on the other hand, may begin as an acute 
 insanity, or may begin gradually and insidiously. Its 
 form may be at first euphoric and exalted, or dysphoric 
 and abased, or merely confused and amnemonic ; and 
 subsequently its type becomes chronic and its form 
 anoiac. In every case the form is easy to observe, the 
 type may be readily ascertained, but the variety may 
 be long in doubt ; the reason being that the form and 
 type are chiefly to be ascertained by observation, while 
 the variety rests upon induction, the data for which are 
 not always to be had. There are varieties of insanity 
 that have but one form : such are paranoia and acute 
 delirium ; and there are forms that are never seen but 
 in one variety: such are stubbornness and somatic 
 delusion, or even in only one sub- variety, such as the 
 delirium of belladonna poisoning ; and, on the other 
 hand, there are forms, such as the combination of 
 dysphoria and abasement, that appear in many varieties, 
 and are not characteristic of any. This combination is 
 one of the many insanities that go by the name of 
 melancholia, and we may see from its distribution over 
 
222 A TEXT-BOOK OF INSANITY 
 
 many varieties how much confusion the name melan- 
 cholia is responsible for. Mania also is not an inaccurate 
 term as applied to a form or symptom of insanity, and 
 as a symptom may appear as a phase of many varieties, 
 but to regard it as itself a variety is to court confusion. 
 It is repeating the error of the old physicians who 
 regarded cough and dropsy as diseases. 
 
 INSANITY OF INVOLUTION 
 
 By this is meant those varieties of insanity that 
 result from imperfection in the process of evolution or 
 development. The process of development, instead of 
 going on to produce a brain of full adult development 
 in a body of adult stature, for some reason ceases pre- 
 maturely, and produces only an infantile or childish 
 brain in a body of normal stature, or it may be that the 
 bulk of body also is deficient, and the result is a childish 
 or infantile brain in the body of a dwarf. It is known, 
 and a good many examples are on record of the reverse 
 mal-development, in which the brain reaches adult 
 development while the body remains childish. In- 
 fantilism, as it is called, is manifestly the reverse of 
 imbecility, and as infantilism is believed to be due to 
 defect of that potent and mysterious agency, the secretion 
 of some ductless gland, it might be supposed that 
 imbecility, and its extreme degree idiocy, is due to the 
 excess of the same. There is no evidence that it is not, 
 but it is safer to assume, for it accords better on the 
 whole with the facts, that it is due to mere premature 
 extinction of the process of development. 
 
 The zygote is the product of the fusion of a sperm 
 cell with a germ cell. To this compound the germ cell 
 contributes the matter or substance, the sperm cell 
 
INVOLUTE INSANITY 223 
 
 contributes the energy that animates the matter. The 
 one is the mass of coals in the grate, the other is the 
 match that sets them alight ; or rather, the one is the 
 dough in the kneading trough, the other is the yeast 
 that, minute in quantity as it is in comparison, yet 
 permeates the dough throughout and sets it all ferment- 
 ing. Once started by the impetus given by the sperm at 
 conception, the zygote continues on its predetermined 
 course of development until adulthood is reached, and 
 even then, the brain continues to develop until late in 
 life. If the dough is insujficiently kneaded, there will be 
 parts of it to which the yeast does not penetrate, and 
 when the bread is baked, these will be recognisable as 
 lumps of " sad " bread embedded in the loaf. It seems 
 as if in some cases parts of the germ similarly escape the 
 energising process set going by the sperm cell, and in 
 these parts development ceases before it is complete. 
 Thus we account for spina bifida, for hare lip, cleft 
 palate, and some other local failures of development. 
 But when the total impetus given by the sperm is lacking 
 in vigour, there will be a general failure of development, 
 and this may show itself in imperfect development of 
 either of the two main branches of development, or in 
 both. Of course, in either case it will be the last part of 
 development that will fail. When a ball is hit with the 
 bat, the distance that it goes will depend on the strength 
 of the impetus it receives from the bat. A powerful 
 impetus will drive it far, a feeble impetus will drive it 
 less far. So with the impetus the germ receives from the 
 sperm. A powerful impetus will drive it to the boundary 
 of the normal ; a more powerful impetus will drive it 
 beyond the normal to giantism on the one hand, or 
 genius on the other, according as the body at large or 
 the brain alone receives the chief share of driving 
 
224 A TEXT-BOOK OF INSANITY 
 
 power. In exceptional cases, genius and giantism may- 
 go together, as in Charlemagne, who was seven feet 
 high. More often the brain develops at the expense, to 
 some extent, of bulk ; and most men of high intelligence 
 have been men of small stature. But when the impetus 
 is deficient, it is the brain that will fail to reach full 
 development, and it may cease to develop after infancy, 
 when the result will be idiocy ; or after early childhood, 
 when the result will be imbecility ; or after late childhood 
 or adolescence, when the result will be f eeble-mindedness 
 in its various degrees. Such cases form the class of 
 genetous idiots and imbeciles of Bucknill and Tuke. 
 
 The developmental impetus which the germ receives 
 at conception does more than merely carry on develop- 
 ment to completion of structure. It also gives that 
 constitutional vigour to which no more definite name 
 can be given, which enables the product to withstand 
 fatigue and to preserve all its organs in balance and in 
 vigour. At conception the clock of life is wound, and 
 the number of years it shall run is determined by the 
 amount of the winding. Some are so wound that the 
 clock runs down before birth, or shortly after, and the 
 foetus perishes in utero or the child soon after birth, 
 from no definite malady, but from mere insufficiency of 
 " vital power." It is '' not viable." In others the 
 clock is wound to go for a hundred years or more, but 
 sooner or later the developmental impetus is exhausted, 
 and then the organism dies, of old age, as we say. I 
 think there is good evidence to show that the develop- 
 mental impetus, if by this we mean the energy that 
 sui!uses the organs of the body and enables them to 
 perform their functions and to preserve the integrity of 
 their structure, never fails quite equally, so that all 
 the organs and tissues grow old together and simul- 
 
IDIOCY AND IMBECILITY 225 
 
 taneously fail in the performance of their functions. In 
 one the arteries go first ; in another the heart is the first 
 to fail under the stress of life ; and in a third the brain 
 fails in its functions while the rest of the body is still 
 vigorous ; but this thesis will be more appropriately 
 resumed in a later chapter. 
 
 This is the appropriate place to explain the difference 
 between idiocy and imbecility, by a distinction that I 
 first put forward five- and- twenty years ago, but that is 
 only now become accepted in consequence of its em- 
 bodiment in the Mental Deficiency Act. It had long 
 been agreed that imbecility and idiocy are two degrees, 
 less and greater, of the same defect, but no definite line 
 was drawn between them. The line of division that I 
 proposed was this : that imbeciles are capable of 
 acquiring, and do acquire, those modes of conduct that 
 I have described in the first chapter under the heading 
 of directly self-conservative activities, but are incapable 
 of acquiring those indirectly self-preservative activities 
 by which the livelihood is gained and the means are 
 administered. Idiots are incapable of acquiring even 
 the first and simplest and most elementary modes of 
 conduct. Supposing that there is enough of inherent 
 energy to keep the machine going for a few years, there 
 may yet not be enough to carry on the process of 
 development to its normal conclusion. The whole of 
 what energy there is is exhausted in the effort to keep 
 life going, and none is left available for the increase of 
 life. Idiots of this origin — " developmental idiots " or 
 " genetous idiots," as they are called — give evidence of 
 their defect in other ways. They are always short-lived. 
 For the contest between integration and disintegration, 
 of which every life consists — a contest in which integra- 
 tion at first predominates, at first with increasing and 
 
 Q 
 
226 A TEXT-BOOK OF INSANITY 
 
 then with slackening vigour, then for a long while 
 maintains an equal footing, and at length yields with 
 ever diminishing vigour to disintegration — the idiot is 
 so inadequately equipped that the turning point occurs 
 long before his full equipment is attained. The taper of 
 his life burns so feebly that it is only by sedulous 
 care that it can be maintained even for a few years ; 
 and before he reaches his teens some of the many 
 maladies, which healthy children live through without 
 difficulty and without detriment, extinguish his little 
 flame. The idiot never develops more intelligence 
 than is possessed by the normal infant. Even at ten 
 or twelve 5^ears. if he live so long, he may not be left 
 alone without immediate danger to his life. Even 
 physically, it is long before he emerges from babyhood. 
 He lies helpless in his cradle for years after other 
 children of his age are running about and at boisterous 
 play. In many cases he never attains, in no case does 
 he attain until several years old, the command over his 
 sphincters and the intelligence to pass his excrements 
 appropriately ; and the ability to prehend his food and 
 carry it to his mouth is similarly delayed, or similarly 
 unattained. 
 
 Idiots are always short-lived, though they not in- 
 frequently reach adult age. They are always lacking 
 in general and sustained vigour of movement, and as the 
 simplicity and want of development of their conduct 
 expresses the simplicity of structure and want of de- 
 velopment of their brains, so, we may well suppose, does 
 the feebleness of their conduct and movement generally 
 indicate a want of vigour in their cerebral processes. 
 The same want of vigour characterises the action of all 
 their organs and tissues. They are feebly compacted 
 and, as it were, only half finished. All their functions 
 
IDIOCY AND IMBECILITY 227 
 
 are debilitated and easily deranged. Consequently they 
 have little power of withstanding the action of adverse 
 agents, and early fall a prey to disease. 
 
 In imbeciles the vigour of development is greater, 
 often much greater. Their brains are arrested in de- 
 velopment in childhood, but their bodies may be 
 vigorous, and they may live to old age. Imbecile 
 conduct has been described on a previous page (169) 
 and the description need not be repeated here. 
 
 Why the union of sperm and germ should result in a 
 zygote lacking in developmental vigour is not easy to 
 determine, and is for the most part matter of speculation, 
 but a few causes may be assigned with some degree of 
 probability. 
 
 I have seen a good many cases that have convinced 
 me that children conceived near the limit of the age of 
 reproduction in either parent are apt to be imbecile, if 
 not idiotic. Weismannites will declare that this is 
 a priori impossible, but a priori impossibilities must go 
 down before clinical experience. There seems some 
 reason to suppose that great intemperance on the part 
 of either parent may be a cause of imbecility in the 
 offspring, but there is no proof of this. On a priori 
 grounds it seems likely that the reproductive cells 
 become enfeebled after long and exhausting illness of 
 those who contain them ; but facts in support of this 
 view are wanting. 
 
 In many cases, probably in most cases, of involute 
 insanity, development does not expire from mere want 
 of impetus, but is cut short prematurely by some inter- 
 ference of a quasi-accidental character. 
 
 A. The first of these is deficiency of some glandular 
 secretion, the presence of which in sufficient quantity is 
 necessary to normal development. The peculiarity of 
 
228 A TEXT-BOOK OF INSANITY 
 
 this defect is that its incidence leads to a number of 
 correlated changes in different parts of the body, to a 
 peculiar physiognomy, in which all the cases resemble 
 one another so closely that they might pass for brothers 
 and sisters of each other. There are three such cor- 
 relative changes, in only one of which, cretinism, has 
 the substance whose deficiency causes the change been 
 identified. 
 
 In cretinism the stature is stunted, the features are 
 bloated, the belly large, the limbs thick and clumsy, the 
 skin coarse, thick, and pale, the hair scanty, short, and 
 brittle, and the whole aspect so characteristic that, 
 once seen, it is easily recognised. The condition is due 
 to deficiency of the secretion of the thyroid. 
 
 The second kind of correlated change that exhibits 
 idiocy is microcephaly, the most characteristic feature of 
 which is the extreme smallness of the cranium, indicated 
 by the name, a defect which is the more conspicuous 
 since it is not shared by the face, which is of normal 
 size except the forehead. The hair is unusually coarse 
 and thick, the stature diminutive, the nose aquiline, the 
 eyes are rather large, the movements are lively, and 
 usually very mimetic. They imitate the attitudes and 
 gestures of those around them ; and they are subject to 
 outbreaks of rage on slight provocation. The secretion 
 to whose defect these peculiarities are due has not yet 
 been identified — perhaps because it has not been sought 
 for. When it is sought and found, microcephaly will be 
 as amenable to treatment as cretinism now is. 
 
 The third of the sets of correlated changes is seen in 
 what the late Dr. Langdon Down termed mongolian 
 idiocy, minor degrees of which are far from rare. In 
 this form also the stature is low. The fades is peculiar, 
 and easily recognised by the small, obhque, widely 
 
IDIOCY AND IMBECILITY 229 
 
 separated palpebral openings, the rounded ears, the 
 depressed nose, and the large and fissured tongue. In 
 addition the fingers are stumpy. Like the microcephalics 
 they are imitative, though to a less degree, and for 
 idiots they are unusually teachable. Since the same 
 group of characters is seen again and again in case after 
 case, we are warranted in correlating them, and attribut- 
 ing them to a common cause, which is, it cannot well be 
 doubted, the want, or perhaps the excess, of some 
 chemical product of metabolism. 
 
 B. The second cause of premature arrest, as dis- 
 tinguished from premature cessation, of development 
 may be termed accidental, in that it takes its origin 
 outside the body, and is of the nature of an interference 
 from without. The earliest in point of time is an intra- 
 uterine infection, and the classical example is syphilis. 
 It seems probable that small-pox, which is known to 
 occur in utero, and perhaps other specific fevers, may 
 have the same effect, but evidence is wanting. That 
 congenital syphilis may cause youthful general paralysis 
 is now a commonplace, and a certain small proportion 
 of idiots and imbeciles present the stigmata of syphiHs. 
 In such cases we assume, perhaps on insufficient grounds, 
 that the non-development of the brain is due to the 
 syphilitic poison. Idiocy and imbecility not very 
 infrequently appear to date from an attack of some 
 acute specific fever — measles, scarlatina, whooping 
 cough, or perhaps typhoid — in childhood. Allowance 
 must be made for the difficulty of determining with 
 precision when a gradual process lilvc the development 
 of the brain ceases to progress. When noisy machinery 
 suddenly stops we can time the stoppage to a moment, 
 but a slow, silent, gradual process like cerebral develop- 
 paent is less accurately timeable ; and we must remember, 
 
230 A TEXT-BOOK OF INSANITY 
 
 too, the insatiable craving of the human mind to find 
 an explanation and a cause for every event. When it is 
 found that a child's mind has ceased to develop, search 
 will naturally be made in its history for anything that 
 can plausibly be considered a cause, and an attack of 
 specific fever will naturally be fixed upon. Innumerable 
 children do suffer from such attacks without any inter- 
 ference with the ultimate development of their brains, 
 and therefore we must be cautious in admitting such 
 illnesses as causes of the insanity of involution ; when, 
 however, the fever is attended by meningitis, we need 
 not be sceptical. Meningitis is undoubtedly a sufl&cient 
 cause of damage to the cerebral convolutions. 
 
 Mechanical injury also is certainly an efficient cause, 
 and is the cause in many cases. Prolonged pai'turition, 
 with the pressure on the yielding bones of the head that 
 it involves, sometimes produces such structural damage 
 to the brain that it never recovers ; and instrumental 
 delivery undoubtedly produces local injury in some 
 cases, resulting in non-development of the motor area 
 on one side, and consequent paralysis, with imperfect 
 development of the limbs, upon the opposite side. Cases 
 of congenital hemiplegia, with stunted growth of the 
 affected limbs, paresis, and very often with choreiform 
 movements of the affected side, spreading, it may 
 be, to the rest of the body, are very common, and 
 are always associated with corresponding imperfection 
 in intelligence, amounting to imbecility and some- 
 times to idiocy. Some of these cases can be assigned 
 with certainty to injury to the head during birth, 
 while in others the non-development of the convolu- 
 tions seems to be due to arterial obstruction in early 
 life. 
 
 The condition just described is frequently associated 
 
IDIOCY AND EPILEPSY 231 
 
 with epilepsy, and often epilepsy without such gross 
 structural damage begins in early Hfe, and is then 
 associated with mental defect. It is common to speak 
 of the idiocy or imbecility associated with epilepsy 
 as epileptic, and if all that is meant is a convenient 
 clinical description, the term may be allowed ; but if 
 by " epileptic idiocy " be meant idiocy dependent on 
 epilepsy as a cause, the appellation is unwarranted, 
 for we do not know whether the mental defect is due 
 to the epilepsy, or whether, as seems much more likely, 
 both are manifestations of the same organic defect in 
 the brain. 
 
CHAPTER VIII 
 
 INSANITY OP DISSOLUTION 
 
 SYMPTOMATIC INSANITY 
 
 Dissolute insanity, or insanity the result of dissolution 
 of a completely evolved nervous system, we have found 
 to be of two main orders — Symptomatic insanity, or 
 that in which the disease from which the patient suffers 
 is not solely disorder of conduct, mind, and brain, but 
 is a wider disorder, of which these three disorders may 
 be regarded as symptoms ; and Idiopathic insanity, in 
 which the disorder is, as far as we know, limited to 
 disorder of conduct, mind, and brain, and to such other 
 disorder, as of metabolism, as is consequential to the 
 disorder of brain that produces the insanity. It is the 
 diseases of the first order, that of Symptomatic insanity, 
 that are now to be described. 
 
 Symptomatic insanity we have found to be of four 
 main kinds, according as the disease of which the 
 insanity is a symptom is what I have called an intrinsic 
 disease, an extrinsic disease, gross brain disease, or 
 epilepsy. 
 
 insanity symptomatic of intrinsic diseases 
 By intrinsic diseases I mean diseases of faulty 
 metabolism, either general, as in gout, or local, as in 
 failure of the thyroid. 
 Insanity of gout. — Gout is common : insanity of 
 
 232 
 
INSANITY AND GOUT 233 
 
 gout is rare. Still rarer is it for insanity to accompany 
 an acute attack of podagra. On the contrary, it some- 
 times happens that an attack of insanity suddenly 
 disappears at the very time that gout appears in the 
 toe, and this is the foundation of our belief that the 
 insanity was due to the action on the brain of the poison, 
 whatever it is, which we suppose is diverted from the 
 brain to the toe ; and thus we account for the simultaneous 
 disappearance of the insanity and appearance of the 
 podagra. The reverse change, subsidence of the podagra 
 and simultaneous occurrence of insanity, has not, as far 
 as I know, been observed. Without being insane, gouty 
 people are said to be unusually irritable and irascible 
 when an attack of gout is impending, and to resume 
 their normal equanimity when the poison becomes 
 localised in the toe or elsewhere, and produces its 
 characteristic inflammation. As a sufierer from gout 
 myself, I am able to say that this prodromal change of 
 temper is not universal, but the beUef in it could scarcely 
 have become such a commonplace as it is if there were 
 not good ground for it. We should naturally expect 
 from this notorious sequence that gouty insanity which 
 is relieved by an attack of gout would be of the same 
 character, but exaggerated; but experience does not 
 bear out this anticipation. In the few cases that have 
 been observed, the insanity was of the form of great 
 depression. 
 
 Disease of the thyroid body produces two difierent 
 diseases, myxoedema and Graves' disease, both of which 
 may have insanity as a symptom. 
 
 The insanity of myxoedema is anoia. The patient 
 subsides into great sluggishness of mind and conduct. 
 Thought is slow and simple, memory is impaired, 
 speech and all movements are very deliberate. This 
 
234 A TEXT-BOOK OF INSANITY 
 
 placid sluggish condition is sometimes varied by fretful- 
 ness and irritability, going on sometimes to actual 
 mania, with delusions, usually of suspicion, and hallu- 
 cinations. Myxcedema is greatly improved by thyroid 
 feeding, and the insanity improves along with the bodily 
 symptoms ; but both usually relapse if the thyroid 
 feeding is discontinued. 
 
 Graves' disease is common enough, but it rarely 
 presents insanity as a symptom, and as insanity is no 
 protection against Graves' disease, nor Graves' disease 
 against insanity, it is certain that in the long run the 
 two will be found associated in the same case. They 
 may then be of independent origin, and if so it would 
 of course be erroneous to speak of the insanity as sympto- 
 matic of the Graves' disease. We should not be justified 
 in regarding the insanity concomitant with Graves' 
 disease as symptomatic of this disease unless either the 
 two undergo concomitant occurrence, recovery or fluctua- 
 tions, or unless the same form of insanity is found in a 
 considerable number of cases associated with Graves' 
 disease. It can scarcely be said that up to the present 
 either of these conditions has been satisfied. 
 
 INSANITY SYMPTOMATIC OF EXTRINSIC DISEASES 
 
 By an extrinsic disease I mean, as already explained, 
 a disease that is not a gross disease and that is due to the 
 invasion or ingestion of a toxic agent from without the 
 body. Of such agents there are two kinds : living 
 microbes and chemical poisons. 
 
 INSANITY SYMPTOMATIC OF SPECIFIC MICROBIC DISEASES 
 
 Of these there are two main classes, the acute specific 
 fevers and the chronic specific diseases. Any of these 
 
INSANITY AND FEVER 235 
 
 may, it seems, present insanity as a symptom in some 
 part or other of their course. 
 
 The list of acute specific fevers is a long one, including, 
 besides those indigenous to this and other European 
 countries, a considerable number of others that are 
 peculiar to the tropical climate. Dealing here with 
 those only with which English experience makes us 
 familiar, we may take them together, since their features 
 are for the most part common. 
 
 Insanity may appear as a symptom of specific fever 
 at three periods in the course of the fever : at the 
 invasion, at the height, and as a sequel. 
 
 That insanity may occur as a symptom of the invasion 
 of a specific fever, such as small-pox or typhoid, does 
 not seem even yet to be generally known, in spite of the 
 number of times that I have called attention to it in the 
 last twenty-five years. At least I find little or no 
 reference to the fact in the most recent text-books of 
 insanity. Yet it is a very important possibility to bear 
 in mind, for if it is not recognised, a patient in the 
 incubation or invasion stage of typhoid fever may be 
 sent to a lunatic asylum, and there not only receive 
 treatment inappropriate to typhoid fever, an event 
 which has actually occurred, but also may be the focus 
 of an epidemic of fever in the asylum. The form of 
 insanity that occurs at the invasion stage of a specific 
 fever is always, I believe, acute excitement on a low 
 level — mania, as this is called. It may be preceded by 
 a few days of malaise, or it may be quite the first 
 symptom that is noticed. 
 
 Insanity at the height of the fever, that is to say, 
 when the temperature has been high for some days, 
 and the patient is, as a rule, very exhausted, is called 
 (ielirium. The mind is much confused ; there is what is 
 
236 A TEXT-BOOK OF INSANITY 
 
 sometimes called disorientation, that is to say, the patient 
 does not realise where he is, or recognise familiar persons 
 and things ; there are often hallucinations, mostly of 
 vision ; and there are agitated movements, which, since 
 the patient is extremely exhausted, are not violent, 
 but are limited to picking at the bed-clothes, and 
 similar small movements. If the patient were physically 
 stronger, no doubt he would gabble and rave ; as it is 
 his utterance is reduced by weakness to a mutter, and 
 *' muttering delirium " or " busy delirium " are the terms 
 usually applied to his insanity. If he is strong enough 
 he tries to get out of bed, but he is not often strong 
 enough to succeed, and if he does succeed he usually 
 falls and lies on the floor. Cases have been known, 
 however, in which patients in the delirium of fever have 
 gone about the house, and even out of doors, in their 
 night-clothes, and have wandered some distance. When 
 I first pointed out that the delirium of fever is insanity, 
 the assertion met with a good deal of ridicule, but I do 
 not know that anyone disputes it now. 
 
 There is one acute specific fever of which the 
 symptomatic insanity is the most conspicuous and most 
 important symptom, and which is therefore not included 
 among specific fevers in any book on that subject, and 
 is included in insanity in every book on this subject. 
 This is the fever known as acute delirium or acute 
 delirious mania, which has been described as a type of 
 insanity. In this case, as in the case of stupor, the 
 type is coincident with the kind. 
 
 Post-febrile insanity is not at all rare, especially 
 after influenza, but post-febrile insanity is not sympto- 
 matic insanity, for when it appears the fever is over 
 and gone, and the insanity is no more symptomatic of 
 the fever that is past than valvular disease of the heart 
 
INSANITY OF CHRONIC INFECTION 237 
 
 is a symptom of the acute rheumatism that has passed 
 away and left the valvular disease behind it. The heart 
 disease is now raised from the status of a symptomatic 
 disease to an independent primary disease, and so is 
 the insanity that is left behind by a fever. Post- febrile 
 insanity will therefore be considered infra among idio- 
 pathic insanities. It will be noted that this classification 
 corresponds strictly with clinical methods, for we think 
 of pre-febrile insanity and of febrile insanity in con- 
 nection with the fevers of which they are symptomatic, 
 and treat them accordingly for the fever, in fever 
 hospitals or in their own homes ; but in dealing with 
 post- febrile insanity, we take note of the fever as causa- 
 tive, and then dismiss it from our minds, and treat the 
 patient, often in an asylum, on the basis that he suffers 
 from idiopathic insanity. 
 
 INSANITY SYMPTOMATIC OF CHRONIC MICROBIC DISEASE 
 
 This group includes the insanity symptomatic of 
 syphilis (except general paralysis) and of tuberculosis, 
 which are the chief chronic invasions seen in this 
 country, and in addition of sleeping sickness, of malaria, 
 and as it now appears of pellagra, and doubtless of other 
 chronic infections. General paralysis is excluded from 
 this group and placed in the next because, although it is 
 due to syphilis, the insanity is symptomatic of gross 
 brain disease. For the same reason the insanity that 
 may attend cerebral hydatid is similarly placed. If 
 anyone is aggrieved by this arrangement, it is open to 
 him to shift general paralysis from the position in which 
 I have placed it into this group, and I don't know that 
 any particular harm will be done. For the same reason 
 the insanity, if any, that is symptomatic of tubercular 
 
238 A TEXT-BOOK OF INSANITY 
 
 tumour of the brain is classed among those due to gross 
 lesions, to which it belongs clinically. It seems to me 
 that there is a clear difference between the insanity 
 symptomatic of the poisoning of the brain by a toxin, 
 and the insanity symptomatic of a gross lesion, even 
 though the toxin and the gross lesion may both be due 
 to the same kind of microbe. 
 
 INSANITY SYMPTOMATIC OF TUBERCULOSIS 
 Not every insanit}^ occurring in persons who are also 
 tubercular is symptomatic of tuberculosis. Phthisis is 
 so frequent among the insane that there is little danger 
 of this fortuitous concomitance being overlooked ; but 
 alienists are not always on their guard to distinguish causal 
 correlation from fortuitous concomitance. For instance, 
 every case of insanity that occurs in a woman about the 
 climacteric age is called climacteric insanity, which it 
 may not be, and often is not. 
 
 Phthisis is common among the insane, but apart 
 from this there is a variety of insanity often associated 
 with phthisis, and assuming much the same form in 
 the phthisical patients w^ho become insane. The 
 insanity often precedes the physical signs of phthisis, 
 and it is quite possible to predict the onset of phthisis 
 from the form that the insanity assumes, together with 
 the general bodily condition. The form of the insanity 
 is always that of sub-acute insanity with depression, 
 and delusions of suspicion. The common form that 
 the suspicion takes is that of being poisoned. The patient 
 refuses food, and when the case is investigated, it is 
 found that the refusal is based upon suspicion that the 
 food is poisoned. The patient is feeble, languid, idle, 
 and in addition is irritable, morose, and suspicious to an 
 insane degree. All that is done for her (it is, I think. 
 
INSANITY OF SYPHILIS 239 
 
 more frequent in the female) is misinterpreted and 
 attributed to evil motives and machinations. The 
 physical signs of phthisis are often not present in the 
 lungs at first, but there are loss of weight, feeble circula- 
 tion, coldness of the extremities, chilblains, deficiency 
 of sleep, from the beginning ; and when the physical 
 signs do appear, they usually progress rapidly. In 
 many cases, however, the course of the disease is pro- 
 tracted. The prognosis is bad, but patients occasion- 
 ally recover from the insanity. 
 
 INSANITY SYMPTOMATIC OF SYPHILIS 
 
 Syphilis and insanity are connected in many ways, 
 which have been enumerated very completely by Sir G. 
 Savage, but here we are concerned with that insanity 
 only which is symptomatic of syphilis, excluding general 
 paralysis and the insanity that results from cerebral 
 gumma, which, as gross diseases of the brain, fall in a 
 subsequent class. It was Sir Jonathan Hutchinson who 
 first pointed out that syphilis is a specific fever, difiiering 
 from the acute specific fevers only in the prolongation 
 of its stages ; and this general similarity may be supple- 
 mented by the further similarity that in the eruptive 
 stage of syphilis, as in the eruptive stage of acute specific 
 fevers, the brain may be so poisoned by the toxin 
 produced by the microbe that insanity results. Such 
 insanity differs from the delirium of acute specific fevers 
 in the absence of the great bodily prostration that they 
 produce. In the eruptive stage of syphilis the patient is 
 not necessarily so weak as to be confined to bed, and his 
 insanity, if he is insane, is correspondingly of more 
 vigorous character. Like the delirium of acute specific 
 fever, however, it is an acute insanity of excited form, 
 
240 A TEXT-BOOK OF INSANITY 
 
 and accompanied by hallucination. It may have any 
 of the features and lead to any of the terminations of 
 excited acute insanity. 
 
 INSANITY SYMPTOMATIC OF THOSE EXTRINSIC 
 DISEASES THAT ARE DUE TO CHEMICAL POISONS 
 
 Insanity symptomatic of alcoholic poisoning. — The 
 chief of these poisons is alcohol, and alcohol pro- 
 duces insanity in several ways and of several kinds, 
 according to the quantity taken, to the length of time 
 over which it has been taken, and to the character of 
 the person by whom it has been taken. When once it is 
 recognised that drunkenness is insanity, a proposition 
 that was received with incredulous amazement when I 
 first made it five-and-twenty years ago, the experimental 
 insanity that is produced by drinking alcohol throws a 
 flood of light upon the incidence of insanity generally. 
 From it we learn, in the first place, how wide are the 
 variations in liability to become insane, or, to put it 
 another way, how various are the degrees of resistance 
 to insanity under the same stress in different persons. 
 Some persons become uproariously drunk after taking 
 two or three ounces of spirit, others never become 
 drunk, however much they may take. There are men, 
 and women too, who drink from a bottle to a bottle and 
 a half, say from thirty to forty-five ounces, of whiskey 
 a day without any immediate effect upon conduct or 
 mind, or with such slight effect as can be recognised 
 only by those who are intimately acquainted with them, 
 and so can recognise small shades of variation. In the 
 second place, we learn how much the form of the insanity 
 depends on the character of the person who becomes 
 insane. The same amount of the same form of alcohol 
 administered to several members of a party will perhaps 
 
INSANITY AND ALCOHOL 241 
 
 make them all drunk, but the insanity of drunkenness 
 will show itself in each one in a form different from that 
 of the others, as set forth on a previous page, on 
 which the various effects of different quantities on the 
 same person are also described. From these diJSerent 
 effects of the same quantity of the same agent on 
 different persons we may justifiably infer the material 
 identity of the different forms of acute insanity. Whether 
 this shall exhibit itself as depression (acute melancholia), 
 or excitement (acute mania), or stubbornness (acute 
 melanchoha), or stupor, or some other form is a matter 
 of quasi-accident, depending in part on the nature and 
 character of the person who becomes insane, and in part 
 on other conditions of which we are ignorant. Certain 
 it is that the same person may exhibit, in different 
 attacks, or on different occasions, acute insanity of 
 different forms, showing first, how easily one form 
 replaces another ; and second, that the character of the 
 person affected is not the only factor in changing the 
 form of the insanity. 
 
 Alcohol is responsible for two very different kinds of 
 acute insanity. The first is the insanity of ordinary 
 drunkenness, the second is delirium tremens, which has 
 been shown by Dr. Francis Hare to be due to the sudden 
 withdrawal of the whole or a great part of the customary 
 daily quantum of alcohol of those who are accustomed 
 to take regularly a large quantity. Delirium tremens 
 is a very w^ell characterised form of acute insanity, of 
 short duration and favourable issue, which it is unneces- 
 sary to describe here, since a description will be found in 
 the ordinary text-books of general medicine. All that 
 is necessary to add here is that an attack of dehrium 
 tremens can be cut short with certainty at an early 
 stage by the administration of the customary dose of 
 
 R 
 
242 A TEXT-BOOK OF INSANITY 
 
 alcohol ; and that an attack can infallibly be produced 
 in anyone who has for some time been accustomed to 
 take large doses of alcohol, by cutting ofi, or materially 
 diminishing, the customary quantity. 
 
 Alcohol is responsible also for at least two types of 
 chronic insanity, but as these are not due to the presence 
 of the poison in the brain, but are effects of its previous 
 action, persisting long after all the alcohol has been 
 cleared out of the body, they are not Symptomatic in- 
 sanity, but are Idiopathic, and fall to be described later 
 on. This division corresponds with a clinical severance, 
 for we do not think of together, nor treat in the same 
 way, the acute insanity produced by the presence of the 
 poison in the brain and the chronic insanity due to the 
 damage that alcohol has inflicted in the past. 
 
CHAPTER IX 
 
 SYMPTOMATIC INSANITY CONTINUED 
 
 GENERAL PARALYSIS 
 
 There is no variety of insanity more distinct or more 
 important than this. It is so distinct that some years 
 ago a very able writer on insanity divided this malady 
 into two varieties only — ordinary insanity and general 
 paralysis. Its importance lies in its frequency, in its 
 progressive and incurable character, and in the frequent 
 difficulty of its diagnosis. 
 
 In the main, general paralysis is a disease of middle 
 life and of the male sex. It seems to affect by preference 
 vigorous, energetic, successful men, who have lived full, 
 active, busy lives in cities ; who are married ; who have 
 indulged freely in eating and drinking, and in sexuality ; 
 and in whom an hereditary disposition to insanity is 
 absent. While this is the character of the majority of 
 persons who become the victims of general paralysis, 
 the malady is not strictly limited to such persons. It 
 does occur also in those who have an insane inheritance, 
 and about 10 per cent, of general paralytics are thus 
 characterised. It does occur also in women, about 
 19 per cent, of the occurring cases affecting this sex ; 
 and in rare cases it occurs in early Hfe, in children in 
 the early teens, and then it is invariably found to be 
 associated with hereditary syphiHs. So singular and 
 invariable an association in these early cases led to 
 
 243 
 
244 A TEXT-BOOK OF INSANITY 
 
 strict inquiry with respect to the antecedents of general 
 paralytics of mature age, and it was then found that 
 in a very large proportion of these also syphilis was 
 antecedent to the disease. It was found that in 80 per 
 cent, there was conclusive proof of syphilis, either in the 
 history or in stigmata existing in the body. In the 
 remaining 20 per cent, no history or sign of syphilis 
 could be found, but then it is found that, with respect 
 to other lesions which are unquestionably syphilitic, but 
 which occur long after the infection, there is a residue 
 of 20 per cent, in which no history of syphilis and no 
 other stigmata of syphilis exist. We are therefore 
 driven to the conclusion that syphilis is a very constant 
 if not an invariable antecedent of general paralysis, and 
 certainly the most important factor in the causation of 
 the disease. 
 
 It is certainly not the sole factor, however. Only a 
 very small proportion of the persons who are syphilitic 
 become general paralytics ; and in almost all cases of 
 general paralysis we find that the patient has recentty 
 passed through a period of mental or other stress, which 
 has seemed to determine the onset of the disease. He 
 has had great anxiety in his business or in his family ; 
 he has indulged too freely in alcohol ; he has had 
 influenza ; he has had a blow on the head ; or he has 
 su.ffered from some other form of stress ; and it seems 
 that it is this provocative occasion, acting upon a person 
 already syphilised, that determines the disease. It is 
 to be remembered that general paralysis is closely allied 
 to tabes ; that tabes sometimes culminates and termi- 
 nates in general paralysis ; that true tabetic symptoms 
 occur in general paratysis ; and that the affections of the 
 oculo-motor apparatus in the two diseases are closely 
 allied. Hence we have additional reason for expecting 
 
GENERAL PARALYSIS 245 
 
 that the causes that produce the one will be closely 
 similar to those that produce the other. 
 
 General paralysis may begin quite suddenly, with a 
 fit, or with an outbreak of acute insanity of which no 
 warning has been given ; but usually, after the disease 
 has declared itself, it is remembered that for days, 
 weeks, or perhaps even months, the patient had been 
 failing in certain assignable ways. It is rare, however, 
 for these warnings to be sufficiently pronounced and 
 sufficiently definite to enable us to predict, or even to 
 suspect, what is coming. When it is not sudden, the 
 onset of the disease is usually rapid. 
 
 The prodromes may be divided into four groups, 
 and are, in the order of their frequency, moral, intel- 
 lectual, sensory, and motor. 
 
 The most frequent of the early changes of general 
 paralysis is a change and a degradation of the moral 
 tone of the individual. His character changes. Always 
 a busy, energetic man, prone to take risks, to keep late 
 hours, to live freely, all these characteristics become 
 accentuated. His energy becomes overpowering ; he 
 undertakes more than he can get through, and his 
 affairs become more and more involved and entanoied ; 
 he speculates more rashly ; he goes about more ; he 
 takes long journeys upon slight inducement ; he drinks 
 more ; he is less particular about his associates and 
 companions ; he goes among loose women ; he talks too 
 much, and chatters among strangers about his private 
 affairs ; he becomes effusive ; he gives presents with- 
 out sufficient justffication ; he brags. He is like a man 
 always a little under the influence of drink ; and, as he 
 does drink a good deal, his peculiarities are attributed 
 to drink alone. When this phase of conduct is but 
 slightly marked, it may be considered as a prodrome 
 
246 A TEXT-BOOK OF INSANITY 
 
 of the disease, but when it is exaggerated, it constitutes 
 the first stage of the malady in one of its forms. 
 
 The prodromes on the intellectual side, in addition 
 to those included in the above description, consist of a 
 want of mental efficiency, more or less marked, and 
 existing for a longer or shorter time before the outbreak 
 of the disease. The patient becomes stupid. He cannot 
 concentrate his attention ; he forgets things ; he makes 
 mistakes ; he is confused in his mind, and it is apparent 
 that he is less capable in business and less able to 
 transact all the affairs of life than he was. When these 
 symptoms are but slight, they are looked on as pro- 
 dromes. When pronounced, they constitute the 
 demented form of the disease. 
 
 Neither the pupillary abnormalities nor the articu- 
 latory troubles, however slight in degree, are counted 
 among the prodromes of general paralysis. If they 
 exist at all, we regard the disease as established ; but 
 then the pupillary changes are not seen until they are 
 looked for, and they are not looked for until some more 
 prominent symptom suggests general paralysis. The 
 articulatory defect, again, is never a very early symptom. 
 Often the patient has been consigned to an asylum for 
 months before the defect of articulation shows itself, 
 and it never appears before the mental symptoms. 
 But before the definite outbreak of the disease there 
 may be transient motor troubles. A limb may become 
 weak, or an eyelid may droop, or there may be transient 
 aphasia or transient strabismus, which, with a history 
 of syphilis, may give rise to a suspicion of gumma. The 
 handwriting sometimes becomes sprawling or shaky, 
 but it does not, in this early stage, show the character- 
 istic changes that will be presently described. In those 
 cases in which the morbid change first attacks the cord, 
 
GENERAL PARALYSIS 247 
 
 ataxy of the gait may be properly looked upon as a 
 prodrome of general paralysis ; but until the insanity 
 declares itself, there is nothing to distinguish such 
 cases from ordinary tabes. Li rare cases there may, in 
 the early stage, be a transient ataxy of gait, comparable 
 with the transient aphasia ; or there may be attacks 
 of giddiness, fainting, or purposeless vomiting. It will 
 be seen from this description that although, when the 
 disease declares itself, we can recognise that such motor 
 symptoms as these were its earliest manifestations, yet, 
 until the malady is otherwise recognisable, there is 
 nothing in them to point to an oncoming general 
 paralysis, or to lead us to anticipate its occurrence. 
 
 On the sensory side, the warnings, if warnings they 
 can be called, are similarly transient, similarly isolated, 
 and usually similarly sudden. When a patient is brought 
 to us with definite general paralysis, we may learn that 
 during the previous twelve or eighteen months he has 
 been treated for a sudden deafness of one ear, or blind- 
 ness of one eye, or for neuralgia, or severe headache, or 
 for local numbness or anaesthesia ; but it is not possible 
 at the time these symptoms occur, to predict that they 
 will be followed by general paralysis. 
 
 The onset of the disease may be sudden, and is usually 
 rapid. Often it is possible to assign the very day upon 
 which the malady declared itself, either by a fit of some 
 kind, or by an outbreak of acute mania. Often the 
 symptoms, which have been described as moral or 
 intellectual prodromes, become rapidly exaggerated 
 in intensity until, in the course of a week or so, the 
 apprehension that the patient may be going out of his 
 mind becomes a fact only too patent. In any case, the 
 definite invasion of the disease is usually an attack of 
 acute insanity, and in the majority of cases the acute 
 
248 A TEXT-BOOK OF INSANITY 
 
 insanity is of the maniacal type. In a minority of cases 
 the acute insanity of the onset is melancholic or resistive. 
 It is scarcely ever suicidal. It is usually very acute, and 
 marked by aggression and violence. Sometimes it is so 
 acute as to be taken for acute delirious mania. It lasts 
 for a few days, or more often for several weeks, and then 
 subsides into a sub-acute insanity which exhibits one 
 of the following types : — 
 
 1. The maniacal or classical type. 
 
 2. The melancholic type. 
 
 3. The demented type. 
 
 4. The fulminating type. 
 
 5. The circular type. 
 
 6. The spinal or tabetic type. 
 
 1. The maniacal or classical type of general paralysis 
 is the most distinctive and most striking of all forms of 
 insanity. In no other form do we witness such exag- 
 gerated hyperbolical exaltation. The patient owns 
 millions and millions ; he is thousands of years old ; he 
 has hundreds of wives, thousands of children ; he has 
 such titles as were never heard of ; he is the greatest 
 inventor, artist, poet, warrior, statesman, pitch-and-toss 
 player, the world has ever seen. He is lavishly benevo- 
 lent ; he will give cheques for millions, written on dirty 
 bits of newspaper, to all bystanders. He talks inces- 
 santly, save when he is writing ; and he writes inces- 
 santly, save when he is talking. He corresponds, still 
 on margins of newspapers, or dirty scraps picked up in 
 the road, with all the crowned heads of Europe and all 
 the celebrated people he can think of. His writing is 
 characteristic. It is sprawling and shaky ; it is unrecog- 
 nisable as his ordinary handwriting. He omits letters ; 
 he fails to finish his words ; he omits syllables, and often 
 
GENERAL PAKALYSIS 249 
 
 whole words. He runs the words together in writing 
 just as he does in speech, and often he repeats the same 
 word or syllable twice or oftener. 
 
 In this stage he sleeps little, he is up early and late, 
 he is full of eager, busy, futile activity. In whatever 
 is going on he must take part, and principal part. If 
 anything is being discussed, he lays down the law ; if 
 anything is being done, he takes the command. He 
 appropriates everything he has a mind to, and when 
 his pockets are turned out, they are found to contain 
 as miscellaneous a collection as a magpie's nest — other 
 people's pipes, handkerchiefs, and pencils, one or two 
 playing-cards, bits of string, bits of bread, sticks, stones, 
 dead leaves, and bits of paper innumerable. 
 
 At the same time, with all his grandeur and majesty, 
 he is singularly weak of will and easily influenced. In 
 his own house he is obedient to his own servants, if they 
 are at once authoritative and judicious. He does what 
 he is told. He is full of preposterous schemes, but he is 
 diverted from their pursuit with the utmost ease ; and 
 even if left alone, he does not pursue any one of them 
 for more than a few moments together. He is subject 
 to outbursts of temper, rising often to fury, but they 
 are short-lived and easy to control. Sent to an asylum, 
 he accepts the situation without murmur and without 
 question. He does not resent his removal from home ; 
 he sees nothing worthy of protest or remark in the 
 control to which he is subjected. 
 
 In this excited and grandiose condition he remains 
 for a few months, becoming gradually calmer and more 
 demented, until at the end of a variable time, usually 
 about a year after the onset of the disease, he has a fit, 
 and then the course of the disease follows the order that 
 will be presently described. 
 
250 A TEXT-BOOK OF INSANITY 
 
 2. The demented type. — In common with other insane 
 persons, all general paralytics are anoiac in every 
 stage of their malady ; but what is meant by the 
 demented type of general paralysis is a form of the 
 disease in which the dementia is simple, and is miaccom- 
 panied by the active symptoms so characteristic of the 
 other forms. In the second stage of the disease — that 
 is to say, after the first fit — the more active symptoms 
 subside in every type of the disease, and the case 
 approaches to one of simple dementia ; but in the type 
 now under consideration the symptoms are never very 
 active. The patient is from the first heavy, stupid, 
 lethargic, inactive ; whatever activity there is in the 
 mind is of the same cast as in the classical type, and the 
 patient often surprises us by evincing out of his dullness 
 some extravagant delusion ; and just as in the other 
 types the period of simple dementia sets in with the 
 fits, so in this type fits occur early in the course of the 
 malady and are frequent during its progress. This is 
 the form that general paralysis usually takes when it 
 begins with a fit. As might be expected, the course of 
 the disease is more rapid than in the classical type. 
 
 3. The melancholic type. — General paralysis usually 
 begins with an attack of acute insanity, and, as already 
 stated, the acute insanity of the commencement is 
 sometimes melancholic or resistive in type. When this 
 is so, the tinge of melancholia usually remains through- 
 out the progress of the disease. Not infrequently a 
 case that has begun with acute mania becomes sub- 
 sequently melancholic. The patient then presents the 
 physical signs of general paralysis together with the 
 ordinary mental symptoms of melancholia. But the 
 melancholic symptoms are not quite ordinary ; they are 
 often combined with an element of grandiosity in excess 
 
GENERAL PARALYSIS 251 
 
 of what is seen in ordinary melancholia. The ordinary 
 melancholic believes that his bowels are obstructed, and 
 that he has had no motion for a month ; the melancholy 
 general paralytic has had no motion for thirty years. 
 The ordinary melancholic has a ton weight resting on 
 his body ; the melancholy general paralytic is crushed 
 under the weight of the whole earth. The melancholia 
 of general paralysis may be ordinary dysphoric abase- 
 ment or may be of the resistive type. It may be asso- 
 ciated with stupor, and it may be attended with suicidal 
 attempts, though these latter are not common in general 
 paralysis. In the melancholic form there are not the 
 remissions and periods of improvements that take place 
 in the classical form, or if they occur, they are much 
 less pronounced. 
 
 4. General paralysis of the fulminating type is a terrible 
 malady. Whereas the other types of the disease begin 
 with acute insanity, this type begins with the acutest 
 form of insanity — acute delirious mania. Whereas the 
 other types pass through the various stages in the course 
 of two or three years ere they terminate in death from 
 exhaustion, the fulminating cases run their course in 
 six months, in four or three months, or even less. The 
 symptoms are those of the classical form, but they are 
 much more acute, and the course of the disease is very 
 much more rapid. 
 
 5. The circular type of general paralysis is rare. It 
 begins in the ordinary way with an outbreak of sub- 
 acute, culminating in acute, insanity, with the exalta- 
 tion, braggadocio, extravagance, and immorality of the 
 classical form. After a few months, the acute symptoms 
 subside, as they usually do in the classical form ; but 
 instead of the relapse that takes place in the other types 
 of general paralysis, the patient continues to improve 
 
252 A TEXT-BOOK OF INSANITY 
 
 until he is practically well, and it is thought that the 
 diagnosis was wrong, and that the case was not one of 
 general paralysis at all. After a few months of sanity, 
 the patient begins to be depressed, and gradually sinks 
 into profound melancholia, for which he is again sent 
 to an asylum, and from which he again recovers and 
 returns to active life. Then, after an interval, occurs a 
 new outbreak of acute mania, and the circle is complete. 
 The circle may be renewed more than once before the 
 physical signs exhibit themselves, and the case then 
 follows the usual course of the classical type of general 
 paralysis. 
 
 6. The spinal type. — General paralysis always in- 
 volves the spinal cord sooner or later ; spinal paralyses 
 are present during life, and spinal-cord degeneration 
 is found after death. In the ordinary types, the brain 
 is affected first and most ; and symptoms due to disease 
 of the spinal cord appear late in the course of the 
 disease, when the patient is already a wreck, and con- 
 sequently do not attract much attention. But there 
 are cases in which the spinal cord is first attacked, and 
 the malady begins as tabes or as spastic paraplegia, 
 upon which the mental and other symptoms of general 
 paralysis are subsequently grafted. The brain and 
 spinal cord form one continuous organ, and a morbid 
 process in one easily spreads to the other. The wonder 
 is that tabes and general paralysis are not more often 
 associated. 
 
 In addition to the six forms described, general paralysis 
 exhibits certain peculiarities when it occurs in women 
 and in the young. 
 
 The disease is less frequent in women than in men, in 
 the proportion of less than one to five. The symptoms 
 in women are less aggravated, less pronounced. All 
 
GENERAL PARALYSIS 253 
 
 the manifestations are milder. The type is usually the 
 elemented, but unlike the demented type in men, the 
 course of the malady is prolonged. It is more " chronic " 
 in character than it is in men. It usually sets in earlier 
 in life — nearer thirty than forty, — and the physical 
 symptoms are less pronounced. The tremor, the articu- 
 latory defect, the involvement of pupils, appear later 
 and are less pronounced, and fits are less frequent. 
 
 In children also, the symptoms and the course of the 
 disease are sub-acute, and the general character of 
 the malady is similar to that in women. It is always 
 associated with hereditary syphilis. 
 
 Physical Signs. — These are of extreme importance, 
 for until they are recognised the diagnosis cannot be 
 made. The earliest are the pupillary changes. Next 
 come defects in articulation ; then the manual move- 
 ments, and especially the handwriting, are affected ; 
 and lastly the gait deteriorates. This is the usual 
 course, but, as already noted, there are cases in which 
 tabetic symptoms precede the mental changes by months 
 or even years. 
 
 The pupils are usually unequal, and often deviate 
 from circularity and become oval or irregular in outline, 
 and they fail to react to light, or in accommodation, or 
 both. In ninety-nine cases out of a hundred, when 
 unresponsive pupils co- exist with any form of mental 
 disorder, the case is one of general paralysis. As far as 
 my experience goes, the pupillary symptoms are not 
 only the earliest of the physical signs, but they are 
 never absent in commencing general paralysis. Hence 
 their extreme importance. 
 
 The articulatory defect comes later, and is highly 
 characteristic. It is exactly the same as that of a 
 drunken man. The speech is " thick." The words are 
 
254 A TEXT-BOOK OF INSANITY 
 
 clipped and run together. The patient often speaks 
 with extreme deliberation, so as to overcome the defect, 
 of which he is conscious ; but if he speaks at all quickly, 
 the words are blurred and fused together, and syllables 
 are omitted. The labials and dentals are first affected ; 
 and when the disease is further advanced, the voice 
 itself becomes involved and assumes a very character- 
 istic peculiarity. It becomes monotonous. Cadence is 
 lost ; and in addition there is often a peculiar bleat, 
 w^hich can always be recognised after it has once been 
 heard. 
 
 The face is remarkably expressionless. It looks puffy, 
 and the normal lines and folds fill up and disappear. 
 The cheeks and alw nasi are often shiny with grease, and 
 when the patient speaks, there is tremor, not only of 
 the lips and of the tongue, but of the muscles of the 
 cheeks as well. 
 
 The peculiarities of the handwriting have already 
 been described. Other movements of the hands are 
 often defective. The patient has difficulty with his 
 buttons, and cannot pick up a pin from a plate or 
 other smooth surface. 
 
 The gait does not become defective until the later 
 stages of the disease, and then the defect is not very 
 definite. It is not ataxic ; it is not a reel ; it is a 
 general inefficiency which is scarcely describable other- 
 wise. The patient walks slowly, turns with difficulty, 
 and is apt to fall ; but there is no localised or differen- 
 tial paralysis. It is a generally diffused weakness and 
 incompetency. 
 
 The knee-jerks are usually exaggerated in the early 
 stage of the malady. Subsequently they may dis- 
 appear and reappear, and may be different in the two 
 sides. 
 
GENERAL PARALYSIS 255 
 
 Stages and Fits. — General paralysis is a progressive 
 disease, and it is usually described as marked off into 
 three stages, the first extending from the outbreak of 
 the disease until the first fit ; the second from the first 
 fit till the patient becomes bedridden ; and the third 
 the bedridden stage. It is not always possible to mark 
 these distinctions, nor are they very important. But 
 the occurrence of the fits is a very important incident 
 in the progress of the malady. 
 
 As already stated, the disease may begin with a fit ; 
 and whether it does so or no, fits, or sudden exacerba- 
 tions allied to fits, invariably occur in the course of the 
 disease, usually beginning about midway in its duration. 
 In different cases the fits are very different in character, 
 but in the same case the fits usually are closely ahke. 
 In the classical type of the disease, the fit is a universal 
 convulsion, indistinguishable from those of epilepsy. It 
 begins less suddenly, it is true, than epileptic paroxysms 
 usually begin, but in other features it is the same. The 
 head and eyes deviate to one side, the spasm becomes 
 universal, may be accompanied by evacuation of the 
 bowels and bladder, and is followed by a period of coma. 
 Fits of this kind may succeed one another rapidly, so 
 that the patient passes into the status ejnlepticiis, which 
 is far more common in general paralysis than in idio- 
 pathic epilepsy ; and in this condition a certain pro- 
 portion of general paralytics die. 
 
 Very commonly the fit is not of this definite character. 
 Often it is '' apoplectiform," but, in this case again, it 
 rarely has the very rapid onset of haemorrhagic apoplexy. 
 The patient becomes duller and duller, more and more 
 stupid, until in the course of an hour, or two or three 
 hours, he is comatose. The coma is not usually deep — 
 rarely so deep as to be stertorous — and often it is found 
 
256 A TEXT-BOOK OF INSANITY 
 
 to be combined with rigid deviation of head and eyes to 
 one side, so that it partakes of the nature of epilepsy. 
 
 In very many cases, the character of the fit is less 
 definite than this. There is no convulsion, nor is there 
 actual coma, but the patient becomes for a few hours 
 unusually dull, lethargic, and stupid. He lies about ; 
 he does not answer, or he answers slowly and at random ; 
 he cannot be got to take his food ; he seems dazed ; he 
 is muscularly weak and incapable of exertion ; and 
 when this condition passes of!, he is found to have under- 
 gone the deterioration which, as will be presently noticed, 
 invariably follows the fits of general paralysis. These 
 attacks are sometimes called " congestive " — it is hard 
 to say wh}^. 
 
 At the stage of the disease at which fits are customary, 
 there sometimes occur causeless attacks of bilious vomit- 
 ing, or of profuse diarrhoea, which are sometimes followed 
 by fits, and sometimes seem to take the place of fits, or 
 to be a variety of them. In yet other cases, the fit is 
 replaced by a local paralysis, or by a general loss of 
 power, which, by its sudden or rapid onset and its 
 gradual recovery, exhibits its community of nature with 
 the more easily recognised fit. 
 
 It is sometimes said that fits do not occur in all cases 
 of general paralysis, and if by a fit is meant an epileptoid 
 or apoplectiform seizure, this is true ; but I have never 
 seen a case of general paralysis in which periodical 
 crises of some kind have not occurred ; and if we include, 
 as I think we should, all periodical crises of every kind 
 under the term ''fit," then I think there is no case of 
 general paralysis in which fits do not occur. 
 
 Whatever the nature of the crisis or fit, it has a very 
 marked effect upon the condition of the patient. When 
 he emerges from it, he is found to be greatly deteriorated. 
 
GENERAL PARALYSIS 257 
 
 His delusions are, perhaps, less prominent, but this is 
 because he is too stupid to entertain them. He is much 
 weaker in body, and he is much more demented in mind. 
 As the days and weeks pass by, he gradually improves. 
 He climbs the hill again ; he recovers a great part of 
 his mental and bodily aptitude, but invariably, before 
 he has completely regained the ground that he lost by 
 the fit, he has another fit ; and when he emerges from 
 this, he is found to be on a lower level of capacity, both 
 bodily and mental, than he was after the previous fit. 
 Again he climbs the hill. Again, after the lapse of weeks, 
 or it may even be months, he regains a great deal of his 
 lost ground, but he never regains it all. Invariably, 
 before he has attained to the condition that he reached 
 after the first fit, a third occurs, which reduces him to 
 a still lower depth, and so the malady progresses, each 
 fit leaving behind it a greater wreck, from which recovery 
 is less complete. 
 
 This effect of the fits upon the course of the disease 
 is an instance of the periodicity which is discernible 
 more or less distinctly in the course of every case of 
 general paralysis. General paralysis has been called 
 progressive paralysis, but its course is never continuously 
 progressive. While its general course is steadily down- 
 ward if sufficient intervals are taken, yet, when minutely 
 examined, it is found that this downward progress is 
 not continuous, but is always remittent, a rapid or 
 sudden decline being followed by gradual improvement, 
 and this alternation being continued throughout the 
 disease. This character is discernible from the very 
 first. The outbreak of the malady is, as we have seen, 
 sudden or very rapid, and is followed by a gradual 
 recovery, which may be so complete that the patient 
 is able to return to his business, and to resume his place 
 
258 A TEXT-BOOK OF INSANITY 
 
 in the world for several months ; and this is called a 
 complete remission. But when careful observation is 
 made, it is found that the remission is not complete, 
 but that it conforms to the rule by which the recovery 
 from every crisis culminates in a state, which is never 
 so near a return to the normal as the pre-critical state. 
 In these " complete remissions " it is found that the 
 character of the patient is a good deal deteriorated, 
 and that his intelHgence is less keen. He goes back 
 to his work and his family, it is true, but he can no 
 longer do his work capably, and his family remarks a 
 decided change in his disposition. Thus the circular 
 type of general paralysis is no departure from the type 
 of the malady, but merely an exaggeration of a feature 
 which all cases present in some degree. 
 
 With each recurrence of the crisis, the patient be- 
 comes more and more demented, and more and more 
 paralytic. At length he becomes incapable even of 
 sitting up, and is confined entirely to bed ; and at the 
 same time lapses of the control of his bladder and 
 bowels, which have been occasional since the crises 
 began, now become habitual. The patient ceases to have 
 the character of an intelligent being. He lies in bed 
 in the extreme stage of dementia, his arms crossed, his 
 legs drawn up, all his limbs gradually becoming more 
 and more rigidly contracted. He passes his urine and 
 motions under him. He is incapable of conveying food 
 to his mouth or of brushing away the flies that crawl 
 over his face and into his open m-outh. It is with the 
 greatest difficulty that he is saved from getting bed- 
 sores, and at length he dies, either in a fit, or in coma, 
 or from diarrhoea, or pneumonia, or some other disease 
 of exhaustion. This bedridden condition is called the 
 third stage of the disease. 
 
GENERAL PARALYSIS 259 
 
 The general bodily condition presents characteristic 
 peculiarities in the three stages of the disease. In 
 the first, the maniacal stage, the patient is usually 
 remarkably "fit." He is in fine " condition." He 
 is muscularly strong, and he is wanting in superfluous 
 fat. His condition is much as if he had been well trained 
 for some athletic contest. In the second stage, as he 
 becomes stupid he gets fat. The lines on his face fill out 
 and are obliterated, and his face becomes more greasy, 
 pulpy-looking, and expressionless. In the last stage, 
 he emaciates, and the emaciation is often extreme. 
 
 A very remarkable and very unfortunate nutritive 
 anomaly, that may take place at any time after the 
 first stage of general paralysis, is a change in the struc- 
 ture of the bones, by which they become unusually, 
 and in some cases surprisingly, brittle. This change is 
 so great in some cases that a rib can be easily broken 
 with a thumb and finger, and as general paralytics 
 become very helpless, and often at the same time very 
 restless and apt to fall about, the brittleness of the bones 
 becomes a source of great danger. A certain number of 
 general paralytics die every year from pneumonia 
 following fractured ribs, or from shock and exhaustion 
 following fracture of other bones. 
 
 Diagnosis. — When once the physical signs are 
 decided, there is no difficulty whatever in diagnosing 
 general paralysis. The defect of articulation is patho- 
 gnomonic, and the pupillary signs, when conjoined with 
 mental disorder of any kind, are equally so. But before 
 the physical signs are established, the difficulty of 
 deciding whether a case is or is not one of general 
 paralysis may be very great — may, indeed, be insuper- 
 able. Cases not seldom occur in which a diagnosis is 
 for the time impossible, and we must wait the 
 
260 A TEXT-BOOK OF INSANITY 
 
 further development of the disease before giving an 
 opinion. 
 
 Generally, any rapid or sudden outbreak of insanity, 
 of any form, in a middle-aged man, in whose family 
 there is no history of insanity, should put us on our 
 guard, and lead us to suspect general paralysis. Even 
 a definite family history of insanity does not exclude 
 general paralysis, but it is much more frequent in men 
 with a sound family constitution. General paralysis 
 sometimes begins with a fit, and the fits are very varied 
 in character ; hence any cerebral crisis, for which no 
 adequate cause can be found, should raise a suspicion 
 of general paralysis when it occurs in middle age. 
 
 Acute mania with grandiose delusions and the 
 scattering of cheques for millions, even when occurring 
 in a man of middle age and a fast liver, does not always 
 mean general paralysis. It may be simple acute insanity 
 and may recover. But if any of the physical signs of 
 general paralysis are present, the diagnosis is no longer 
 in doubt. 
 
 Dr. Savage lays stress upon the gain of weight in 
 the melancholy type of general paralysis, as against 
 the loss of weight or the continued meagreness of the 
 ordinary melancholic. This gain of weight is a very 
 important sign if the pupillary and articulatory defects 
 are absent, but usually, by the time the patient has 
 entered upon the fattening stage, these motor defects 
 are already conspicuous. 
 
 The greatest difficulty in the diagnosis of general 
 paralysis is in deciding, in a doubtful case with a 
 history of alcoholic excess, whether the disease is 
 general paralysis or alcoholic insanity. The difficulty 
 is the greater, since general paralytics often take to 
 drink in the early stage of the malady, and often have 
 
GENERAL PARALYSIS 261 
 
 habitually indulged too freely ; and it is the greater 
 since alcohol itself produces motor disorder allied to 
 that of general paralysis. The main reliance must be 
 placed on the pupillary changes. These are not present 
 in alcoholic insanity, but they may be absent also in 
 the early stage of general paralysis. The history of 
 morning vomiting is important. There are only two 
 conditions with which regular morning vomiting is 
 associated — pregnancy and alcoholism. But we must 
 be careful to ascertain that the vomiting is regular, 
 and is not a sporadic crisis. The general paralytic 
 sleeps well, though his sleep is short ; the alcoholic 
 patient sleeps badly, and is apt to suffer from terrifying 
 dreams. The memory does not present in general 
 paralysis the characteristic defect in recent matters 
 that is so conspicuous in alcoholism. The defect of 
 gait and the tremor of hands in the two maladies 
 may be closely alike, and in alcoholism the articulation 
 may be defective, but the defect is not of the same 
 character. 
 
 We have now in the Wasserman reaction, in the 
 estimation of leucocytosis in the cerebro-spinal fluid, 
 and in the estimation of the globulin in this fluid, tests 
 of the presence of syphilis that are of the utmost value ; 
 and since general paralysis is a syphilitic disease, the 
 determination that syphilis is present in a doubtful case 
 of mental disease goes far to corroborate a diagnosis of 
 general paralysis ; but it is important to insist that 
 even if all three tests yield a positive result, the proof of 
 general paralysis is not conclusive. Syphilis is a very 
 common disease. It is estimated that at least 16 per 
 cent, of the population of this country are infected with 
 it. Mental disease of other kinds than general paralysis 
 is by no means rare ; and the doctrine of chances showg 
 
262 A TEXT-BOOK OF INSANITY 
 
 that there must be a small number of cases in which 
 both maladies coexist in the same case independently, 
 and without any causal nexus. While, therefore, proof 
 of syphilis goes far to confirm a diagnosis of general 
 paralysis in a case otherwise doubtful, it is not con- 
 clusive proof of general paralysis. I have seen cases in 
 which syphilis coexisted with mental disease without 
 being the cause of the mental disease, and such cases 
 cannot be very rare. 
 
 Prognosis. — General paralysis is always fatal, and 
 usually is rapidly incapacitating. Cases are not very 
 uncommon, however, in which, after the acute attack 
 of insanity which marks the onset of the disease, the 
 patient recovers sufficiently to return to his family and 
 his business for three, six, or twelve months, or even 
 longer. Sooner or later, however, the malady recurs, 
 and although it always runs a remittent course, it is very 
 rare for a second remission to be so complete as to allow 
 of a return home. The average course of the disease 
 is about three years, but it is often less than this, and 
 occasionally it is prolonged for four or five years. The 
 circular type is that of longest duration. I have left 
 this paragraph as it stood in the first edition, but I 
 should not now express my opinion so unconditionall}^ 
 I have seen cases of general paralysis that have lost all 
 signs of the malady, and have remained well for years, 
 until I lost sight of them ; and I have seen other cases 
 that have lasted in a state of anoia, not very deep, for 
 ten and fifteen years. 
 
 Treatment. — There is at present no curative treat- 
 ment of general paralysis. Seeing how intimately 
 it is associated with syphilis, it is natural that anti- 
 syphilitic remedies should have been extensively tried, 
 but they h^ve never been found of the least use, 
 
GENEEAL PARALYSIS 263 
 
 Removal to an institution is always necessary. In no 
 class of cases do we witness outbreaks of such frantic 
 violence as in general paralysis, and, as they take place 
 without any warning, and in cases that have previously 
 been quiet and tractable, it is necessary that the patient 
 should be in a place where a sufficient stai! is available 
 at a moment's notice to deal with him in his outbreak. 
 For the rest, treatment must be of symptoms, and it 
 is important to remember that general paralytics are 
 very amenable to the action of drugs, and that their 
 allowance of tobacco should be very limited, for it is 
 very apt to prostrate them. Sulphonal is the best 
 calmative of excitement, and paraldehyde the best 
 hypnotic ; but the former easily produces a great 
 effect upon the gait by its paretic effect on the muscles. 
 Trephining has been tried, to diminish an imaginary 
 intra - cranial pressure, but without any beneficial 
 effect ; and the same may be said of paracentesis of 
 the spinal canal. Blistering of the scalp and setons 
 have been tried, but with no appreciable beneficial 
 effect. In the second stage of the disease the patient 
 becomes extremely voracious, and is apt to choke 
 himself if allowed to feed himself. His food must 
 be cut up, and no implement larger than a teaspoon 
 allowed, and if necessary he must be fed. The brittle- 
 ness of the bones is a source of great anxiety ; and 
 every care must be taken to prevent the patient falling 
 about, or getting into quarrels with other patients. In 
 the final stage, the prevention of bedsores must be 
 managed secundein artem, and the status epilepticus 
 treated in the usual way with rectal injections of chloral. 
 Since the first edition of this book was published, the 
 trifonema faUidum has been found in the brains of 
 general paralytics, and by the discovery some of the 
 
264 A TEXT-BOOK OF INSANITY 
 
 mystery that enveloped the pathology of general 
 paralysis has been dispersed. Since it has been recog- 
 nised that general paralysis and tabes are manifesta- 
 tions of syphilis, the great difficulty has been to account, 
 not so much for the appearance of these diseases as for 
 their non-appearance for so many years. They occur 
 neither in the primary, in the secondary, nor in the 
 tertiary stages of syphilis. They are post-tertiary in 
 their occurrence, and the remedy, iodide of potassium, 
 that is so effectual in tertiary syphilis, has no effect at 
 all on these diseases, which have therefore been called 
 para-syphilitic, and have been conjectured to be due, 
 not directly to the triponema, but to some toxin produced 
 by it. Why tabo-paralysis is so late an occurrence in 
 syphilis is still unexplained. It might be conjectured 
 that the brain and cord were too remote and inaccessible 
 to the triponemce were it not that gumma of the brain 
 and cerebral nerves is not infrequent in the tertiary 
 stage of syphilis ; but some inaccessibility there 
 certainly is in these organs, for the impotence of 
 mercury and the iodides to relieve tabo-paralysis 
 certainly does seem to depend upon the difficulty they 
 have in penetrating to the seat of the micro-organism. 
 This being so, it would appear that a remedy directly 
 applied to the seat of the disease might be expected to 
 be more efficacious ; and we have now in our hands, in 
 salvarsan and neo-salvarsan, microbicides far more 
 effectual than the iodides. Attempts have therefore 
 been made to treat tabes by direct injections of sal- 
 varsan and neo-salvarsan into the spinal theca, and 
 general paralysis both by such injections and by 
 injections, through trephine holes in the skull, into 
 the membranes of the brain and the cerebral substance. 
 This mode of treatment is at present in an early stage, 
 
GENERAL PARALYSIS 265 
 
 and the cases in which it has been tried are compara- 
 tively few ; but of them few have been thus treated 
 without some improvement, and in some the improve- 
 ment has been great, so much that patients with 
 exorbitant and extravagant delusions have so far 
 recovered that they have returned to business and 
 transacted it capably. There is no doubt that it is in 
 this manner that the treatment of general paralysis will 
 be conducted in future. 
 
 The PatJwlogical Anatomy of general paralysis is very 
 characteristic. There is, it is true, no single change 
 which may not be found in other maladies, but there 
 is no other malady in which the same combination of 
 changes is found. 
 
 The skull is usually thick and heavy ; the dura 
 mater, too, is usually thickened and adherent to the 
 skull. Sometimes a meningeal haemorrhage, or the 
 remains of such a haemorrhage, in the shape of cyst 
 or membrane, is found between the dura and the 
 arachnoid. The brain is manifestly shrunken, and 
 in consequence the sub-dural and sub-arachnoid fluid 
 is copious, so that the arachnoid and pia have a 
 thickened, semi-opaque, jelly-Hke appearance. When 
 the membrane is stripped off, it is found to be strongly 
 adherent along the summits of the convolutions of the 
 frontal lobe, so that in these positions a portion of the 
 brain substance is torn off along with the membrane, 
 and a streak is left in the middle of the gyrus, in which 
 the brain appears as if it had been nibbled by a 
 mouse. 
 
 The brain is shrunken in all its dimensions ; the gyri 
 are thin and the sulci wide, this change being most 
 conspicuous in the frontal lobe, and diminishing 
 backwards. The ventricles are large, and the basal 
 
266 A TEXT-BOOK OF INSANITY 
 
 ganglia small, and foci of softening are common in 
 various parts of the brain. Histologically, the nerve 
 elements are diminished and the connective tissue is 
 increased, but, as is evident from the general atrophy, 
 the former process is greatly in excess of the latter. 
 Both cells and nerve fibres suffer, and suffer together, 
 and the morbid change has the characters, in as far 
 as they are distinct, of primary rather than of secondary 
 degeneration. The cells lose the definition of their 
 outline, and not only of their external contour, but 
 of their internal organisation also. The Nissl bodies 
 break up (chromatolysis), the nucleus becomes indistinct, 
 its outline is lost, and at length it disappears. The 
 cell loses its shape, and approaches more and more to 
 the shape of a sphere, by an apparent retraction of the 
 substance that is prolonged into the fibres, and by the 
 bulging of the contour between the origin of the fibres. 
 At first increased in size, in later stages it shrinks, 
 breaks up and disappears, leaving a pigmented detritus 
 which is subsequently absorbed. The processes partake 
 in the destruction of the cells. As the cell-body alters 
 in form, the processes, from being manifest prolonga- 
 tions of the substance of the cell, appear as if stuck 
 into it, or to project from it like the root of a 
 turnip. The finer ramifications disappear, the main 
 processes shrink, dwindle, break up first into lengths 
 and then into granules, which are absorbed and 
 disappear. The same process affects the association 
 and other fibres. 
 
 The connective-tissue element in the brain shows 
 great relative increase, owing to the disappearance of 
 so much of the nerve tissue proper. Whether it is 
 upon the whole increased in bulk is doubtful, but 
 certain of its constituents are undoubtedly larger, 
 
GENERAL PARALYSIS 267 
 
 more prominent, and relatively, if not absolutely, 
 more numerous. The glia takes the stain more 
 deeply than in the normal brain, and as the cells 
 are smaller and wider apart, from the absorption of 
 so many, it constitutes, in any one section, a much 
 larger proportion of the field. The glia cells appear 
 to be more numerous, they are more deeply stained, 
 they are larger, and their visible processes are more 
 numerous and more pronounced. Where the nerve 
 cells are most affected, the spider cells are very numer- 
 ous, and exhibit a large and well-marked process passing 
 to the wall of the nearest vessel, where it ends in a plate 
 of nucleated protoplasm. A number of other processes 
 surround and envelop the degenerating nerve cell. 
 As the nerve cell disappears, the body of the spider 
 cell shrinks, and what remains of it at last is a network 
 of fibrils. 
 
 The blood vessels are numerous, large, tortuous, and 
 dilated at intervals along their course. Their coats 
 are thickened, the endothelial nuclei are increased in 
 number, and around the vessel are groups of extrava- 
 sated leucocytes mingled with hsematoidin crystals. 
 The wall of the vessel exhibits hyaline or fatty change, 
 the perivascular lymph spaces are large, and contain 
 masses of lymph-corpuscles here and there. 
 
 In the pia-arachnoid the vessels are unusually 
 numerous and prominent, and the whole of the con- 
 nective tissue apparently increased in amount, and 
 permeated throughout with exudation and with 
 nuclei. 
 
 In a large proportion of cases changes are found in 
 the spinal cord similar to those in the brain. The 
 theca is similarly thickened and adherent, with evidence 
 ot blood extravasation within it, and occasionally 
 
268 A TEXT-BOOK OF INSANITY 
 
 grey degeneration of the columns is discernible by the 
 naked eye. Microscopically, the changes are the same 
 as are found in the brain, and are most marked in the 
 posterior columns, less in the lateral, and least in the 
 anterior. 
 
CHAPTER X 
 
 SYMPTOMATIC INSANITY CONTINUED 
 
 INSANITY OF GROSS BRAIN DISEASE 
 TRAUMATIC INSANITY 
 INSANITY OF EPILEPSY 
 
 INSANITY OF GROSS BRAIN DISEASE 
 
 Meningitis and tumour of the brain do not often exhibit 
 active insanity as a symptom, but meningitis if diffused, 
 and intra-cranial tumour when rapidly increasing, or 
 when Vory large, always give rise to coma, and coma is, 
 of coarse, insanity. AVhen coma comes on slowly, there 
 is a precomatose hebetude, slowness in answering and 
 in making other adjustments, loss of power to think, 
 with general mental dullness and general defect of con- 
 duct, that amount, or may amount, to insanity, though 
 it is not usually so styled, nor even so thought of. In a 
 few cases, however, when the tumour is situated in the 
 anterior lobes, an unusual place for tumour, the insanity 
 is of an active kind, and is what anyone would recognise 
 as insanity. One case has been published in which 
 tumour of the anterior lobes produced symptoms so 
 closely resembling general paralysis as to be mistaken 
 for this disease. 
 
 traumatic insanity 
 Insanity that can be definitely traced to injury to 
 the head and to no other assignable cause is rare, but 
 
 269 
 
270 A TEXT-BOOK OF INSANITY 
 
 cases are occasionally seen. It is indeed frequent for 
 an attack of insanity, especially in the young, to be 
 assigned by the relatives of the patient or by the patient 
 himself to a blow or a fall on the head, but this arises 
 from the craving of the human mind to find and assign 
 a cause for every event ; and when critically examined, 
 the traumatic origin of the insanity rarely appears even 
 plausibly likely. The superabundant activity of children 
 and young people perpetually leads to accidents, and 
 in them falls and other accidents in which the head is 
 struck are frequent enough, and are pretty often severe 
 enough to lead to temporary unconsciousness ; but the 
 very frequency of such accidents compared with the 
 relative rarity of insanity shows that they are not a 
 necessary cause ; and every practitioner of experience 
 must have met with cases in which the head has been 
 severely struck and prolonged unconsciousness has 
 followed, without any appreciable damage to the sanity 
 of the patient ; and when the blow on the head is not 
 followed by any sign of insanity until after the lapse of 
 years, we may safely dismiss any casual agency in the 
 blow. 
 
 It is otherwise when insanity follows, as it sometimes 
 does, immediately upon a serious injury to the brain. 
 There are now many cases on record of penetrating and 
 lacerating wounds of the brain, even bullet wounds, 
 which have been followed by recovery as far as bodily 
 health is concerned ; and some of these have left sur- 
 prisingly little effect upon the sanity. It seems, indeed, 
 probable that in many persons a portion, it may be a 
 considerable portion, of the cerebral convolutions is 
 never brought into use, and may be lost without appre- 
 ciable defect. It is difficult otherwise to account for the 
 enormous differences of mental capacity in persons 
 
INSANITY OF EPILEPSY 271 
 
 whose brains are approximately equal in weight. In 
 other cases, however, severe injury to the brain is 
 followed by defect and disorder of mind of various 
 kinds and degrees, and in some of these cases there is 
 insanity. Since the injury to the brain may be of very 
 various degree and in very various locality, there are no 
 symptoms characteristic of traumatic insanity except 
 that, unhke other kinds of insanity, it is usually accom- 
 panied by headache. 
 
 INSANITY OF EPILEPSY 
 
 Insanity is associated wdth epilepsy in many ways. 
 We have seen that idiocy is often associated vdth. 
 epilepsy, and is often said to be due to it when the 
 epilepsy begins in very early life. But we have no 
 warrant for concluding that the idiocy is the result of 
 the epilepsy, which is itself but a symptom of some 
 grave irregularity in the mode of working of the nerve 
 elements. It is more likely that the same defect in 
 the constitution of the nervous system, which displays 
 itself in idiocy, has in epilepsy another of its mani- 
 festations. And similarly, when it is said that long- 
 continued epilepsy at length brings about insanity, we 
 are arguing post hoc, ergo propter hoc, without sufficient 
 warrant. Long-repeated epilepsy indicates a long-con- 
 tinued morbid condition of nerve tissue, and increasing 
 frequency of fits indicates increase of this morbid 
 condition, whatever it may be ; and the insanity that 
 at length occurs may well be due to the same advance 
 of this morbid change that underlies the progress of 
 the epilepsy. So that, closely as epilepsy and insanity 
 are often associated, it is no more justifiable to regard 
 the epilepsy as the cause of the insanity, than to regard 
 the insanity as the cause of the epileps}^ in those numerous 
 
272 A TEXT-BOOK OF INSANITY 
 
 cases in which epileptic convulsions occur in the final 
 stage of insanity. All that we are justified in saying is 
 that insanity and epilepsy are very closely associated. 
 
 Epileptics may be permanently insane, or their in- 
 sanity may occur only in connection with their fits. 
 The permanently insane epileptics are those whose 
 epilepsy has begun in early life, and who have never 
 been mentally sound, or those who, after lifelong 
 epilepsy, have become demented. In the former, the 
 epileptic idiots and imbeciles, the depth or severity of 
 the imbecility or idiocy bears a general relation, not so 
 much to the severity of the fits, as to their frequency ; 
 and not so much to the frequency of the fits, as to the 
 earliness in life at which they began. The earlier the 
 epilepsy begins, and the more frequent the fits, the deeper 
 the idiocy. Epilepsy (by which we now mean, not only 
 the periodic convulsions, but the tissue change which 
 underlies it) which does not make its appearance until 
 puberty or later in life, does not, of course, affect the 
 mental development until it appears, and the later it 
 appears, the more complete the development of brain 
 and mind before they begin to be interfered with. 
 
 The epileptic idiot is not different from other idiots 
 in any important respect except the fits, bat the epileptic 
 imbecile differs much from other imbeciles. He is usually 
 more robust in body. He is taller, bigger, more muscu- 
 lar, more energetic than other imbeciles ; he is often 
 more intelligent, and he is usually more industrious. 
 Like most other imbeciles, he is heavy, clumsy, slow, 
 and awkward in his movements ; and withal he is 
 irritable, passionate, and quarrelsome. Epileptics are a 
 turbulent, excitable race, prone to quarrelling and 
 violence. 
 
 The epileptic dement is usually very demented. His 
 
EPILEPTIC INSANITY 273 
 
 forehead and nose are often scarred from the results of 
 his falls ; his aspect is heavy and dull ; his movements 
 are slow, clumsy, and ineffectual. Like other epileptics, 
 he is Hable to outbreaks of impulsive violence. 
 
 Other forms of chronic insanity — fixed delusion, per- 
 secutory delusion, mania, melancholia — are not often 
 seen in epileptics as a permanent condition in the inter- 
 vals of the paroxysms. The form of the insanity is 
 simple defect or deprivation, is what I have called 
 anoia. 
 
 In connection with the fits, insanity may declare 
 itself before the paroxysm or after it — pre-paroxysmal 
 or post-paroxysmal insanity. It has been described 
 also as replacing the fit, as an outbreak of rage or acute 
 mania taking place at the time the fit is due, and un- 
 accompanied by any fit. It is probable that this out- 
 break is usually either pre-paroxysmal or post-paroxys- 
 mal, the fit having been slight and unnoticed ; but it 
 seems as if a periodical outbreak does sometimes occur, 
 at a time and of a character that is regarded as pre- 
 paroxysmal, an outbreak which rises to a climax and 
 passes away without the actual occurrence of a fit. 
 
 Pre-paroxysmal Insanity. — Epileptic fits often occur 
 with electric suddenness, and with no preceding or 
 premonitory symptoms to warn us of what is about 
 to happen ; but usually there is a warning, and the 
 warnings are of two kinds. The first kind of warning 
 is the aura, which is a part of the fit itself, and which 
 need not be described here, as it is fully dealt with 
 in works on general medicine . It lasts but a few moments 
 and is soon superseded by, and lost in, the other occur- 
 rences of the fit. The second kind of warning is of 
 much longer duration. It consists of a general altera- 
 tion of disposition, always in the same sense in the 
 
274 A TEXT-BOOK OF INSANITY 
 
 same case, which enables those who are familiar with 
 the patient to foretell the advent of a fit for several 
 hours, and often for several days, before its onset. He 
 becomes more and more irritable, captious, ill-tempered, 
 and apt to violence ; or he becomes sullen, morose, silent, 
 and very dangerous, breaking out into frantic rage if 
 interfered with ; or he gets more and more stupid, 
 heavy, dull, and lethargic, until he may sit motionless 
 for the greater part of the day, and be scarcely reusable 
 to take his meals ; or he is gay, excitable, talkative, 
 and buoyant. But whatever the condition, it is one 
 foreign to his usual and normal state, and it gradually 
 becomes more and more pronounced up to the time 
 when the fit occurs. Or, as has already been noted, it 
 may culminate without any observable fit, in some out- 
 break of violence which is characterised by suddenness, 
 and especially by extreme, savage, reckless ferocity. 
 Every few months the country is startled by some 
 crime of horrible violence, in which the victim is not 
 merely killed, but the attack is pursued and continued 
 after life is extinct, until the body is mutilated almost 
 out of the semblance of humanity. The head is smashed 
 and battered into a pulp, or the body and Umbs are 
 hacked and hewed with blind and revolting fury. When 
 the matter is investigated, it is found that either there 
 was no provocation at all, or that what provocation 
 was given was utterly and grotesquely out of proportion 
 to the terrible vengeance inflicted. Then, upon still 
 further investigation, it is found either that the criminal 
 is a confirmed epileptic, or more commonly that he has 
 " suffered with his head " ; that he has been " very 
 strange in his manner at times " ; that other members 
 of his family have been epileptic ; that he has been 
 subject to fainting fits ; that he has done odd and un- 
 
EPILEPTIC INSANITY 275 
 
 accountable things ; and, in short, that he has given 
 evidence by which we can conclude that he has suffered 
 from epilepsy, and that the crime that he has committed 
 was done towards the end of the pre-paroxysmal stage 
 of epilepsy. In such cases there is not usually any 
 actual fit. The maniacal violence seems to take the 
 place of the fit and to bring the occurrence under the 
 description of epilepsie larvee of French writers. 
 
 Post-paroxysmal Insanity. — When the alteration of 
 conduct and demeanour of the prcr-paroxysmal stage is 
 prolonged and is well marked ; when there is a pro- 
 longed warning that a fit is coming on ; w^hen the modi- 
 fication of character gradually and continuously in- 
 creases up to the time of the fit ; then, when the fit 
 does occur, it entirely clears all such symptoms away, 
 and the patient emerges from it in his normal condition 
 — a condition which may not be one of wholly sound 
 mind, but which is normal to him. The time immediately 
 after the paroxysm is the time at which he is at his best. 
 His intellect is then clearest, his temper least objection- 
 able, his conduct most orderly. Moreover, in the pre- 
 paroxysmal state, in which he is in some degree alienated, 
 he is yet as fully conscious as he is at other times. Post- 
 paroxysmal insanity is the reverse of all this. The 
 patient as a rule preserves his usual conduct and de- 
 meanour up to the very moment of the fit. There is 
 usually no w^arning at all in the strict sense, though 
 there may be an aura. The fit is often very slight — 
 indeed, elaborate automatism is not common after 
 severe fits. After a fit, which may be indicated merely 
 by a momentary pallor, or an instant of deviation of 
 the eyes and head, or a slight sinking at the knees, or 
 some similarly trivial manifestation, the patient enters 
 upon a period of action, which is distinguished by 
 
276 A TEXT-BOOK OF INSANITY 
 
 certain striking peculiarities. In the first place, of 
 whatever acts he then does, he retains not the slightest 
 trace of recollection afterwards ; and hence it is assumed 
 that when he does them he is wholly unconscious, an 
 hypothesis which gains corroboration from the nature 
 of the act. This is usually an habitual act. It is some- 
 thing which the patient is in the habit of doing, and 
 which he can do with a minimum of deliberation and 
 attention ; or, rather, it is the caricature of some such 
 habitual act — a caricature which is often nullified or 
 vitiated by want of appreciation of the circumstances 
 under which it is done. For instance, one of the most 
 frequent of these automatic acts is that of undressing ; 
 and the patient will start to undress himself wherever 
 he may happen to be — in the street, in a railway train, 
 at a dinner-party, anywhere. Or he will make water, but 
 instead of proceeding to a urinal, he will micturate in a 
 corner of the room or out of the window, or he will use 
 his hat or his beer- jug for a chamber-pot. Or he will 
 wind up his watch, but will stick the key in anywhere 
 it will go, or will use for a key any small object that 
 comes to his hand, or he will go on winding until he 
 breaks the works. Usually, whatever act a patient 
 does after one fit, that same act he will repeat after 
 every fit, but this is subject to a very important modifi- 
 cation — viz., that if he find any implement in his hand 
 or handy, he will be very apt to put that implement to 
 its common use, or to some caricature of its common 
 use. If he happen to be holding a pen, he will make 
 marks on the surface before him. If he happen to 
 be holding a gun or pistol, he may load and fire it. 
 If he happen to be holding a knife, he may cut some- 
 thing with it. Thus it happened that a woman was 
 cutting bread and butter for her children's tea when 
 
EPILEPTIC AUTOMATISM 277 
 
 she had a fit, and in the subsequent automatism she 
 cut the arm of one of her children, so that it died ; 
 and in a similar way other quasi-crimes have been 
 committed. Usually the period of automatism after 
 the fit lasts for a few minutes only, but in instances 
 not very rare it is prolonged for hours ; and there are 
 cases in which, after a fit, the patient lives, as it were, 
 a new life, lasting for days, weeks, and even months. 
 It is quite a usual occurrence for a patient in post- 
 epileptic automatism to show some appreciation of 
 surrounding circumstances. I have seen one in this 
 condition walk for several hundred yards, getting over 
 a stile and a gate, and deviating from his course when 
 shouted at. But there are cases, recorded upon un- 
 impeachable authority, in which the patient has taken 
 a ticket, has travelled a long distance, put up at hotels, 
 bought, sold, and transacted other business ; and at 
 length, after days or weeks, has woke up to a recollection 
 of all his former life up to the moment of the fit, after 
 which his mind was an utter blank as to every experience 
 that he had undergone. The case then merges into one 
 of double or alternate consciousness. 
 
 In treatment, epileptic insanity requires nothing in 
 addition to the treatment of epilepsy and of insanity. 
 For the first, the main reliance is upon the careful 
 regulation of meat in the diet, and the prolonged adminis- 
 tration of as large doses of bromides as the patient is 
 able to endure. In the dangerous outbreaks, the ad- 
 ministration of hyoscin will be found very effectual, and 
 the status e^pile'pticus demands treatment secundem 
 artem by rectal injection of chloral hydrate. 
 
CHAPTER XI 
 
 IDIOPATHIC INSANITY 
 
 CYCLICAL INSANITY — FIXED DELUSION — DEMENTIA 
 
 Idiopathic insanity has been divided first into that 
 which is cyclical and that which is not. 
 
 cyclical insanity 
 
 Insanity, like every other organic process, exhibits 
 periodicity. In every case of insanity that is at all 
 prolonged, a certain rhythm of exacerbation and 
 subsidence can be detected. Epilepsy, and the in- 
 sanity associated with it, are conspicuous instances of 
 periodicity, more or less regular. In general paralysis, 
 the alternation of periods of excitement and of calm 
 is usually a conspicuous feature of the disease. In 
 dysphoria, the depression is most intense in the 
 small hours of the morning. In mania, the excitement 
 is often greatest in the early hours of the night ; and 
 more or less of periodicity of the most various length 
 of cycle can be detected in all cases of insanity. There 
 are certain cases in which different forms of insanity 
 follow one another in regular series, which is repeated 
 again and again, and to this variety of insanity the 
 names folie circulaire, circular insanity, and folie a 
 double forme have been given. It is usually described 
 as a period of depression, or melancholia, followed by 
 
 278 
 
CYCLICAL INSANITY 279 
 
 a period of excitement approaching, or attaining to, 
 acute mania, from which recovery takes place, to be 
 followed in time by melancholia again, and the cycle is 
 then repeated. The events do not always follow this 
 order, however. Sometimes the excitement precedes 
 the period of depression. Often the period of recovery 
 is not one of complete recovery, but one of mild 
 dementia, and the degree of dementia may be so 
 considerable as to necessitate the permanent detention 
 of the patient in an institution. Then the case becomes 
 one of ordinary dementia, with the periodical outbreaks 
 of excitement which are so common in dementia, and 
 with periods of depression of only slight degree sand- 
 wiched between them. In many cases the patient 
 recognises the nature of his malady, and, when he 
 feels it coming on, he voluntarily seeks the protection 
 of an institution, from which he returns, when the attack 
 is over, to resume the business of life. The most difficult 
 and unhappy cases are those in which the degree of the 
 excitement is just insufficient to allow of the certifica- 
 tion of the patient, and he remains at large in a state 
 of sub-acute mania, dissipating his property and 
 bringing scandal upon his name, until the period of 
 depression sets in, to plunge him into agonies of remorse. 
 
 There is a variety of circular insanity in which the 
 period of depression is replaced by a period of stupor, 
 usually of the resistive type, and to this variety the 
 name of Katatonia has been given. 
 
 The symptoms of cyclical insanity at any given 
 time are the symptoms of the particular form of insanity 
 that the patient then exhibits, and the treatment 
 corresponds. The prognosis is very unhopeful. The 
 interval of lucidity or of sanity does not usually become 
 shorter, but the recovery therein becomes less and less 
 
280 A TEXT-BOOK OF INSANITY 
 
 complete, until a definite state of dementia takes its 
 place in the cycle. 
 
 The period of the cycle varies much in difierent 
 cases. In many of the chronic inmates of asylums a 
 periodicity of a few weeks can be recognised in the 
 outbreaks of excitement ; but in what would be called 
 folie circulaire the intervals may be equal or unequal, 
 the rule being for the period of tranquillity and com- 
 parative mental health to be considerably longer 
 than those of depression and excitement, which are 
 approximately equal, and may be one, two, or three 
 months or more in duration. 
 
 INSANITY OF FIXED DELUSION 
 
 The three kinds of insanity that are next to be de- 
 scribed constitute a natural group, for they have certain 
 features in which they resemble each other and difier 
 from all other kinds of insanity. They all belong to that 
 larger class of idiopathic insanity to which no provoking 
 cause can be assigned, and they are distinguished from 
 the other sub-group of this class by presenting, in a 
 fixed or enduring delusion, a predominant outstanding 
 feature to which all the rest of the insanity can be 
 referred. By a fixed delusion is meant, as its name 
 implies, a delusion that endures in much the same form 
 for years ; that is never absent from the mind of the 
 patient except when his attention is temporarily 
 distracted from it ; that instantly resumes its dominance 
 when the attention is set free, and that even when the 
 patient is attending to other things is not quite absent 
 from his mind, but is merely relegated temporarily to a 
 subordinate position. Of such delusions there are three 
 main kinds, which characterise respectively the three 
 diseases in this sub-group. 
 
PARANOIA 281 
 
 PARANOIA 
 
 In the first of these, the delusions are called systema- 
 tised, not a very happy term, but one that is fixed in use. 
 
 By a systematised delusion is meant a delusion which, 
 to use the language of modern psychology, constitutes 
 an *' apperceptive system." It is an organised body of 
 (false) knowledge, and it difiers from other delusions in 
 the fact that it colours the whole life of the patient ; it 
 regulates his daily conduct ; it provides him with an 
 explanation of all his experiences that are otherwise 
 inexplicable ; it is his theory of the cosmos. 
 
 For instance, his delusion is that he is influenced by 
 telephones. Whatever he does, and whatever happens 
 to him that is in the least out of the ordinary course, 
 is due to the telephones. He sees a pretty flower, and, 
 forgetful of the regulations in that case made and 
 provided, he plucks it ; then he remembers the rule 
 against picking flowers. It was the telephone that 
 made him pick it. Intent upon the beauty of some 
 floral gem, he trips over a grass verge ; it was the 
 telephone that made him trip. He sits down to write, 
 but finds his mind confused ; telephones again. He 
 plays whist, and revokes ; the telephone made him do 
 so. He plays bilhards and loses ; the telephone kept 
 his balls out of the pockets and put his adversary's in. 
 His nose begins to bleed ; the telephones did it. He 
 gets annoyed and throws his book across the room ; the 
 telephone prompted him, or possessed him and threw 
 the book for him. He sees two strangers meet and 
 chat on the opposite side of the street ; the telephone 
 is talking to them about him, or they are talking to 
 him through the telephone, or the telephone is mixed 
 up with them in some mysterious way. 
 
282 A TEXT-BOOK OF INSANITY 
 
 The precise character of the systematised delusion is 
 very widely different in different cases, but in all there 
 are several features in common. Through every 
 systematised delusion there runs the thread of perse- 
 cution, which connects them all together in a single 
 well-characterised group. Every systematised delusion 
 is a delusion of persecution. The influence, whatever 
 it be, that acts upon the patient, is always an influence 
 adverse to him. Secondly, the delusion is a fixed 
 delusion ; it endures without material change, often 
 without appreciable change, for years and years. 
 Thirdly, it is associated more closely and more con- 
 spicuously than any other form of delusion with con- 
 fusion of thought. Fourthly, more often than any other 
 delusions it is associated with hallucination. 
 
 The character of the delusion is very various, though, 
 as has been said, the idea of persecution runs through 
 them all. The persecutor may be a specific individual, 
 and in that case may have a real existence or be wholly 
 imaginary. In a certain case, e.g., the patient was 
 annoyed by a man whom he had never seen, but whose 
 presence he felt, whose name was Girardot, and who 
 haunted the lanes and fields about the patient's resi- 
 dence, armed with an apparatus of mirrors and lenses 
 by which he was enabled to see at all times what the 
 patient was doing, and to locate him so accurately 
 that he could pour upon him without fail a stream of 
 electricity, which produced baleful effects. Not in- 
 frequently the persecutor is identified as the super- 
 intendent of the asylum, or the governor of the gaol, in 
 which the patient has been detained, and who still, 
 by his emissaries, torments the patient, years after the 
 latter has been transferred to other care. They haunt 
 the neighbourhood ; they are under the floor, in the 
 
PARANOIA 283 
 
 cellars ; they are in rooms above, or on the roof ; they 
 are in adjoining rooms ; every mishap, every incon- 
 venience, every disappointment that happens to the 
 patient is ordered by them. Or the persecutors are not 
 specifically identified, but pervade the community. 
 The people in the streets talk to each other about him ; 
 they look at him in meaning ways ; if they smile or 
 laugh, it is in contempt or derision of him ; if he catches 
 scraps of their conversation, this also has reference to 
 him. He sees two men meet who are total strangers 
 to him ; they shake hands, they smile, and ask each 
 other how they do ; the shake of the hands is a Masonic 
 grip by which each recognises that the other is in the 
 plot ; the smile is an expression of triumph that they 
 have succeeded in their nefarious design against him ; 
 the question and answer, while seemingly innocent, 
 really refer in some way to him, and means that he is a 
 blasphemer, a murderer, an adulterer, or what not. 
 In some cases the delusion is of bodily disfigurement ; 
 for instance, the nose is too large, is so large as to 
 attract attention, and the universal topic of conversa- 
 tion, wherever the patient appears, is the size of his nose. 
 
 Very often the delusion is of being followed about 
 and watched, it may be by the police, but more often 
 by unofficial watchers. Sometimes the vigilant enemy 
 is a single specific individual, sometimes two or more, 
 sometimes a number of unspecified individuals. 
 
 Perhaps the commonest of all the forms of perse- 
 cutory delusion is that of being acted upon by some 
 unseen influence ; and usually the latest conspicuous 
 discovery in physics is pressed into the service, and 
 becomes the prosecuting agent. In the early part of 
 the last century, paranoiacs were persecuted by steam- 
 engines ; later, the telegraph was the means of their 
 
284 A TEXT-BOOK OF INSANITY 
 
 persecution ; then, as successive discoveries were made, 
 electricity, hypnotism, mesmerism, animal magnetism, 
 telephones, the Rontgen rays, and wireless telegraphy 
 were made responsible for their sufierings. The 
 majority still ascribe their persecution to electricity, 
 and the " electrics " constitute the largest class of 
 paranoiacs. But they are assiduous readers of the 
 newspapers, for they see in the daily prints references 
 to themselves in the items of news and in the leading 
 articles ; and whenever a new physical discovery is 
 announced, it is appropriated by them as a means of 
 persecution, and the more obscure it is in its nature, 
 the less they are able to understand of the new process, 
 the more it commends itself to them as a persecuting 
 agent. This seems to be the ground upon which 
 electricity is so often selected. Sometimes, however, 
 nothing sufficiently mysterious exists among the known 
 natural agents, and then a new agent is invented to 
 account for the sufferings. Dr. ConoUy Norman gives 
 an instance of a patient who ascribed his persecution 
 to a '' typhone," and of another whose thoughts were 
 " read by a hypophone and translated into logarithms." 
 A patient complained to me that he was persecuted 
 by " infernal traces mystery " ; another was annoyed 
 by " injury stuff like smoke " ; and another by micro- 
 scopical glasses. 
 
 While it is not very uncommon for the centre of the 
 persecution to be some bodily peculiarity — the large 
 nose or the deformed mouth, which attracts the atten- 
 tion of bystanders, and sets them talking about it, 
 and nudging each other as the patient goes about the 
 streets — it is more common for the mysterious influence 
 to be exerted upon the mind. Other people read their 
 thoughts, or think their thoughts, or put thoughts into 
 
PARANOIA 285 
 
 their minds, or deprive them of the power of thinking, 
 or say or do things through them which they would 
 not say or do of themselves. 
 
 Delusions of persecution are always associated with 
 confusion of mind. No doubt with all delusions there 
 is more or less confusion, or the delusion would not 
 continue ; but in no case is the confusion of mind so 
 conspicuous and complete as it is in cases of paranoia. 
 The delusion is in no case so clearly defined, so sharply 
 cut, so definite in expression, as it is in the delusions, 
 for instance, of abasement and of exaltation. The 
 confusion is often conspicuous in the very statement 
 of the delusion itself, as in the case of the man who 
 was persecuted by " infernal traces mystery," or when a 
 man is referred to in terms which he cannot repeat, by 
 persons whom he has never seen, under circumstances 
 that he cannot identify ; but if the delusion itself 
 appears to be definite, as when the persecution is the 
 utterance of specific expressions by a specified person, a 
 little conversation, a little questioning of the patient, 
 will nearly always elicit a statement which is a 
 mere farrago of nonsense, an unintelligible jumble of 
 words. 
 
 Hallucinations are more constant and more promi- 
 nent in paranoia than in any other variety of insanity. 
 They may be referred to any of the senses, and are by 
 far most frequently auditory, and least often olfactory. 
 Visual hallucinations rank next in frequency to auditory, 
 gustatory come next, but are rare, and the olfactory 
 and those of common sensation rarest of all. 
 
 Auditory hallucinations are the most frequent of all, 
 and are of serious import in three ways. In the first 
 place, the " voices " are often minatory, abusive, and 
 objurgatory, and when this is the case they may lead 
 
286 A TEXT-BOOK OF INSANITY 
 
 the patient to retaliate with violence upon some inno- 
 cent bystander or passer-by to whom he attributes 
 them. In the second place, the " voices " are often 
 mandatory and imperative, or persuasive and urgent. 
 They command or they incite the patient to do things, 
 and the acts thus proposed to him are often objection- 
 able, criminal, or even murderous in character. They 
 are usually resisted and repelled, but if they continue, 
 as they usually do, for a long time, the resolution of 
 the unfortunate patient at last breaks down, and he 
 commits the act to which he has so long been urged. 
 In the third place, the existence of auditory hallucina- 
 tions gives a very unfavourable colour to the prognosis 
 of any case in which they are well established. This is 
 true, however, in increased degree, of other forms of 
 hallucination. Auditory hallucinations are occasionally 
 heard on one side only. Sometimes the voice is always 
 the same, sometimes two or more voices are heard, 
 and in some cases they argue with one another, and 
 in that case one may abuse and the other defend the 
 patient. The sufierer usually recognises completely at 
 first the unreal character of the voice, and that it is not 
 produced by any external agent ; and afterwards, even 
 although he may attribute the voice to bystanders, 
 there is evidently some quality by which he distinguishes 
 it from the voices of real people, for he always speaks 
 of it as " the voice " and " the voices." Deafness is, of. 
 course, no bar to the occurrence of auditory hallucina- 
 tions. 
 
 Visual hallucinations are much rarer, upon the whole, 
 than auditory, though they are much commoner as 
 epileptic aurse, which stand on quite a different footing 
 from the hallucinations of paranoia. These are usually 
 quite elaborate, and may consist of faces or figures — - 
 
PARANOIA 287 
 
 those of delirium tremens have often been described — 
 or sometimes they consist of words or sentences, 
 luminous or not, standing out as if printed upon the 
 surface of whatever the patient is looking at. In such 
 cases the words are usually of the same character as the 
 " voices " in auditory hallucination — that is to say, 
 they are blasphemous or objurgatory or obscene. 
 
 Evil tastes and smells are sometimes, but rarely, 
 complained of. The taste is always disagreeable, 
 usually metallic, and the smell ofiensive. One patient 
 complained to me that he *' smelt blood." 
 
 How far the frequent sexual delusions of the paranoiac 
 are dependent upon hallucinatory common sensation it 
 is impossible to say, but if they are so dependent, 
 hallucinations of this class would be among the most 
 frequent, for nothing is more common than for female 
 paranoiacs to complain of being raped and outraged in 
 complex and horrible ways, and for male paranoiacs to 
 complain of sodomy and various sexual tamperings 
 being practised upon them. 
 
 The conduct of the paranoiac is dominated by his 
 delusion. In this is the marked and conspicuous 
 difference between paranoia and mere fixed delusion. 
 In the latter, the patient goes about his work like an 
 ordinary mortal, and refers to his delusion at intervals 
 only, between which there is nothing to distinguish 
 his conduct from that of a sane person. But the de- 
 lusions of the paranoiac dominate his whole life. They 
 are with him every hour and every minute of the day. 
 They keep him from his work, they interfere with what- 
 ever he tries to do. However he is occupied, he feels 
 the electric shocks, he hears the voices abusing him or 
 conspiring against him, he is conscious of the vapours 
 pouring upon him, and under these circumstances he 
 
288 A TEXT-BOOK OF INSANITY 
 
 cannot work, he cannot maintain any steady employ- 
 ment. If we watch him, we see him twitch, start, and 
 jump, as the shocks affect him, or we notice his expec- 
 tant attitude ; we see him absorbed in contemplation 
 of his visions, or we hear him answer and expostulate 
 with his hallucinatory voices. Another thing that pre- 
 vents him from pursuing his business is the necessity 
 of avoiding his persecutors. To this end, he eschews 
 going out in the daytime ; he cannot remain long in 
 one residence ; he frequently and suddenly changes his 
 lodging ; if he is well-to-do, he travels from country to 
 country to escape from the annoyances, hoping in each 
 to find more efficient police, able to give him protection. 
 But the most important character of the conduct in 
 persecutory delusion is the tendency to violence and 
 to homicide that so often exists. The continuance of 
 the persecution, the futility of all measures taken against 
 it, the refusal of the authorities to interfere, the general 
 neglect of, and disbelief in, his trouble, at last generate 
 a degree of exasperation which prompts, it may be to 
 violence, it may be to murder. When the persecutor 
 is identified with any specific person, the violence is, 
 naturally, directed against that person ; but when, as 
 so often happens, no accessible person or no specific 
 individual is identified as the persecutor, then the 
 violence may be directed against anyone, and is usually 
 directed against some person in a prominent position, 
 the avowed motive being " to draw attention to the 
 case." In some cases the hallucinatory voices prompt 
 the patient to commit some deed of violence ; he 
 resists for weeks or months, but at last, in a fit of 
 exasperation, his resistance gives way, and he does 
 what he is told. In rare cases, the violence thus insti- 
 gated may be directed against himself ; but, intolerable 
 
PARANOIA 289 
 
 as the life of the paranoiac is made by his persecution, 
 he very rarely finds refuge in suicide. 
 
 The bodily state of the paranoiac offers nothing 
 remarkable. There is no doubt that they do suffer 
 torments from abnormal sensations of various kinds, 
 but we can never discover any justification for these 
 sensations in an altered bodily process. 
 
 The whole frame of mind of the paranoiac usually 
 differs from that of the melanchohc. The melanchohc 
 often complains of persecution, and pities himself with 
 deep commiseration, but he is not resentful. Often he 
 regards his persecution as deserved, and when he does 
 not, he tries to escape, but never to retaliate. The 
 paranoiac is almost always resentful, and is incHned to 
 retaliate and avenge himself. Formerly I thought the 
 paranoiac was never self- condemnatory, but I have now 
 seen cases in which delusions of persecution by means 
 of a plot, delusions unquestionably paranoiac in charac- 
 ter, have been associated with abasement, with con- 
 viction of personal unworthiness and sin. 
 
 Paranoia is sometimes a sequel to an attack of acute 
 insanity, but often it is an original malady, arising 
 gradually and becoming gradually intensified for months 
 or years before it is recognised. Usually a family history 
 of insanity can be traced, but this is far from invariable. 
 It is an incurable and irrecoverable malady. As age 
 advances, the prominence of the delusion subsides, and 
 in rare cases the patient can be trusted to resume his 
 place among his fellow-men, but such cases are very 
 few indeed. The broad general rule is that paranoia is 
 irrecoverable. Curative treatment there is none. AMien 
 we find syphilis among the antecedents of the disease, 
 the syphilis should be treated, but we must not expect 
 the treatment to affect the insanity, 
 u 
 
290 A TEXT-BOOK OF INSANITY 
 
 The need of restraint in an institution is more im- 
 perative in paranoia tlian in any other form of insanity, 
 and the rule is stringent that no paranoiac should be 
 allowed at large. If he is so allowed, his perpetration 
 of a murder is merely a matter of time, and is certain 
 to take place if time be allowed. Scarcely a week, and 
 never a month, passes in which the newspapers do not 
 report a murder committed by a person sufiering from 
 this form of insanity and one who obviously ought to 
 have been placed in an asylum years before. 
 
 MEGALOMANIA. SOMATIC DELUSION 
 
 These two kinds of insanity may be taken together 
 They are both idiopathic insanities that occur without 
 assignable cause, and both are distinguished by the 
 predominating feature of a fixed delusion. In megalo- 
 mania the delusion is a delusion of exaltation, in somatic 
 delusion it is a belief in some alteration or infestation 
 of the patient's body. There are, it is true, patients 
 who entertain delusions that their minds are altered 
 and acted upon by others, but these, as far as my 
 experience goes, are paranoiacs. To this variety of 
 insanity belong practically all the kings, queens, em- 
 perors, and millionaires who are not general paralytics, 
 and to this also belong the people who have weasels, 
 wolves, or crabs in the stomach, glass legs, no backs 
 to their heads, whose brains have been taken out, and 
 who suffer from other changes of the personality. 
 
 The distinguishing feature of the insanity is that the 
 delusion has practically no effect upon conduct. The 
 kings and emperors are content to pass their lives in 
 the most menial occupations, scrubbing floors and 
 carrying coals ; the queens and duchesses work con- 
 
MEGALOMANIA. SOMATIC DELUSION 291 
 
 tentedly in the laundry ; the millionaires see nothing 
 inconsistent with their wealth in holding a horse for 
 a copper, or begging for a bit of tobacco. What in- 
 capacity they have for more intelligent employment — 
 and the incapacity is often considerable — they owe to 
 their dementia, and not to their delusion. The delusion 
 is not often prominent. It does not absorb much of 
 the attention of the patient. He does not obtrude it, 
 and make himself a nuisance by worrying about it in 
 season and out of season, as the paranoiac does. He is 
 often rather reticent about it, and has to be questioned 
 and cross-examined before he will confess to it ; but 
 once started on the subject, he is usually difficult to 
 stop. In any case, not only does it not influence his 
 conduct, but it does not much affect the rest of his mind. 
 The king and the millionaire do not appear particularly 
 elated by the knowledge of their exalted position or 
 their wealth. The man whose legs are of glass, or whose 
 stomach is tenanted by an unbidden guest, does not 
 worry about his crural fragility or his parasite. The 
 delusion forms a small and unimportant part of his 
 mental life, and he pursues the tenour of his way with- 
 out regarding it. A large number of the inmates of 
 lunatic asylums exhibit this variety of insanity. 
 
 The bodily state exhibits nothing characteristic. The 
 malady is chronic, unchanging, and irrecoverable. 
 The patients remain in the same state of dementia and 
 delusion for the rest of their lives ; liable, like other 
 dements, to outbreaks of excitement from time to time ; 
 subject to the common ailments of humanity, of one 
 of which, in the fulness of time, they die. 
 
292 A TEXT-BOOK OF INSANITY 
 
 DEMENTIA 
 
 Dementia, the type of insanity, is always of the form 
 anoia. Dementia, the disease, is always of the type 
 dementia. It would be better, no doubt, if we could 
 give a third name to the type, and keep the name 
 dementia for the disease. The application of the same 
 name to the disease and the type is confusing, but 
 there need be no confusion if we remember that when 
 the type constitutes the whole of the correlated dis- 
 order from which the patient suffers, the type is co- 
 extensive with the disease ; but when, as in general 
 paralysis, the type dementia is only part of the corre- 
 lated disorder, it is a type only, and the disease is more 
 than the insanity. 
 
 There are many cases, however, in which dementia 
 constitutes a disease of itself and is correlated with no 
 other disorder, and in these cases the dementia is a 
 kind of insanity. 
 
 Clinically we may classify cases of dementia accord- 
 ing to the way they begin. A certain number of cases 
 of acute insanity recover, and recover to all appearance 
 completely, and as far as we know permanently. The 
 remainder do not recover. The acuteness, that is to 
 say, the intensity, of the symptoms abates ; the active 
 symptoms disappear, more or less completely, and leave 
 the anoia, which has existed throughout the acute stage, 
 as the only outstanding feature of the malady. The 
 case then becomes clinically a case of dementia. In my 
 opinion almost every case of acute insanity that recovers 
 passes through a stage of dementia between the subsi- 
 dence of the acute symptoms and complete restoration 
 to sanity. As a rule, we are so relieved and so thankful 
 
DEMENTIA 293 
 
 when the actual symptoms subside and signs of recovery- 
 appear that we cease to observe, or cease to interpret 
 our observations correctly. We neglect to notice the 
 anoia that the patient now exhibits, an anoia that may 
 be but mild, and that is of course transitory, and we 
 neglect to notice it because our attention is fixed upon 
 the patient's improvement. We are so intent upon 
 noticing the absence of the symptoms that are gone 
 that we neglect to notice those that are present. Some 
 cases of acute insanity are so transient that the stage 
 of dementia, if it exists, lasts a few hours only and 
 escapes notice on that account. In other cases the stage 
 is prolonged, and we may be for some time in doubt 
 whether it will clear up or not. In many cases it does 
 not clear up, and the patient remains for the rest of his 
 life, which may be long, permanently demented. When 
 the dementia thus follows an attack of acute insanity 
 of any form it is called terminal dementia. 
 
 But dementia does not always follow or begin in an 
 attack of acute insanity. It sometimes comes on gradu- 
 ally, and is then known as primary dementia. I am 
 not sure that it is much more justifiable to take as a 
 basis of classification the way a disease begins than to 
 take the way it ends. The former has this advantage 
 over the latter, however, that we usually know, or can 
 find out, how the disease has begun, but we can never 
 be sure during its progress how it is going to end. If, 
 therefore, we adopt the termination as our basis of 
 classification, we cannot be quite sure that we have 
 diagnosed the disease correctly, or given it its proper 
 title of dementia prsecox, or what not, until the patient 
 appears on the post-mortem table. This is inconvenient 
 clinically, and I am not sure that the advantage gained 
 by the use of a comparatively new title, un(^uestionably 
 
294 A TEXT-BOOK OF INSANITY 
 
 fashionable as it is, compensates altogether for the 
 clinical inconvenience. For my part, when I am asked 
 by the friends of my patients the familiar question, 
 *' What do you call it, doctor ? " I feel reluctant to 
 say, "Wait until he is dead; I cannot tell you until 
 then." 
 
 Primary dementia may come on at any time of life. 
 It is frequent in the young, rare in middle life, and not 
 very infrequent in old age. It is called primary, or it 
 may be so called — the name is become unfashionable — 
 because it begins as anoia, continues as anoia, and ends 
 as anoia ; that is to say, the enfeeblement and degra- 
 dation of conduct and mind predominate over more 
 active and positive symptoms, though more positive 
 symptoms are seldom absent. Since primary dementia 
 does not begin in an attack of acute insanity, it comes 
 on gradually ; and as it comes on, so it proceeds. In 
 other words, it is a progressive disease, and in this 
 respect it differs from terminal dementia. Dementia 
 that is consequent on an attack of acute insanity may 
 fluctuate and alter for some months, but after some 
 months the patient settles down into a permanent con- 
 dition in which he remains with little change for the 
 rest of his life. Primary dementia on the contrary is a 
 progressive disease. It is not regularly progressive ; it 
 need not be rapidly progressive ; for intervals it is 
 apparently stationary ; but on the whole, its course is 
 not a level course, but tends downwards, at first more 
 rapidly, afterwards more slow^ly. 
 
 Although, as has been said, primary dementia exhibits 
 few active and positive symptoms, and what active or 
 positive symptoms there are are subordinate features 
 in the case, and are but unimportant incidents in the 
 clinical picture, yet often, it may be said usually, the 
 
MIND IN DEMENTIA 295 
 
 anoia is not quite simple, but is complicated by over- 
 action on some lower level. In the faculty of Desire, 
 the sexual desire is often unduly and disagreeably 
 prominent. In young dements, at any rate in young 
 male dements, masturbation is a constant feature. This 
 does not necessarily mean that desire is augmented ; it 
 means that self-control is diminished. Desire on the 
 lower middle level is often disordered. The patient is 
 not determinedly suicidal, but he is apt to do impulsively 
 acts of a suicidal character — to throw himself out of 
 window, for instance. On the upper middle level he is 
 altogether deficient, the desire as well as the ability to 
 earn his living and administer his means being absent ; 
 and of course the social desires are the first to go. 
 
 Will is often disordered in the direction of impulsive- 
 ness ; sometimes in the direction of increased hesitation, 
 sometimes in the direction of facility. 
 
 Self- estimation is usually exaggerated, especially in 
 the early stage and in young people. This is the exag- 
 geration of a normal phase that most young people pass 
 through. When they first begin to feel their feet and 
 realise that they have powers of their own, they over- 
 estimate their own importance and their own abilities ; 
 and in the primary dementia of young people this over- 
 estimate is often still more exaggerated. The opposite 
 condition of self-depreciation is not infrequent, however, 
 and when it exists is accompanied by dysphoria. 
 
 In the faculty of objective thought, delusion is not 
 very unusual, and the delusion is often that of suspicion 
 and persecution which so often goes with exaggerated 
 self-importance. The highest level of thought is of 
 course abolished, and on the lowest level hallucinations 
 testify to the great depth that the destructive process 
 has attained. 
 
296 A TEXT-BOOK OF INSANITY 
 
 Feeling, both subjective and objective, shares in the 
 general deterioration. Early in the case there may be 
 euphoria or dysphoria, but at a later stage these are 
 replaced by apathy and indifference. Emotion may at 
 first be excessive on slight provocation, but at length can 
 be evoked with difficulty or not at all. 
 
 The primary dement sometimes recovers, and but little 
 trace is left of the disease, but more often it progresses 
 to a certain considerable depth, at which it remains 
 during the lifetime of the patient. 
 
 PRIMARY DEMENTIA IN MIDDLE LIFE 
 
 Primary dementia in the middle-aged is not a frequent 
 malady, and when cases do present themselves they are 
 often very puzzling. A man in vigorous health and in 
 full business employment finds his capacity failing ; he 
 becomes stupid ; he loses his grip over his afiairs ; he 
 forgets important appointments and other matters ; he 
 becomes slovenly in dress and address ; his letters are 
 rambhng, and omit the subject they are meant to refer 
 to ; but he has no delusions, his conduct is not bizarre 
 or outrageous. He is merely stupid and incompetent. 
 This is the way that one form of general paralysis begins, 
 and such an alteration in a man of middle age raises a 
 suspicion of general paralysis ; but no confirmation of 
 this suspicion is obtained from physical signs, nor 
 from the subsequent progress of the case. The man 
 becomes more stupid. He is obliged to retire from 
 business, and he settles down at home, cared for by 
 his women folk like a child, prematurely and primarily 
 demented. 
 
 Primary dementia of middle life is not the kind of 
 insanity characteristic of that time of life, and therefore 
 
PRIMARY DEMENTIA 297 
 
 is described here as a type, modified by age. Senile 
 dementia, however, is the insanity characteristic of that 
 time of life, and is therefore described as the insanity 
 of old age with the other kinds of insanity characteristic 
 of times of life. 
 
CHAPTER XII 
 IDIOPATHIC INSANITY CONTINUED 
 
 INSANITY FOR WHICH THERE IS AN ASSIGNABLE CAUSAL 
 
 STRESS 
 
 Idiopathic insanity for which a cause can be plausibly 
 assigned is of three kinds, according to the nature of 
 the stress that has operated as a cause. For reasons 
 already stated I do not include in this class insanity 
 that is part of a coexisting bodily disease. Such insanity 
 is symptomatic, and has already been described. In 
 the present class I include those cases only with which 
 no existing bodily disease is correlated. The insanity 
 may, however, have originated in a bodily disease that 
 is past and gone, and is then analogous to the valvular 
 disease of the heart that is left as a substantive disease 
 after the rheumatism that produced it is past and gone. 
 Or it may be that the insanity is like the adherent 
 pericardium that is due to a pericarditis that is past and 
 gone. At no time during the existence of the pericarditis 
 was the pericardium adherent ; the adherent pericardium 
 is a sequel to the previous disease. And similarly, it 
 may be that at no time in the course of influenza was 
 the patient insane, but yet the influenza may leave the 
 insanity behind as a sequel. 
 
 Insanity due to such direct stresses as the poison of 
 influenza constitutes the jirst sub-class of those with 
 
 298 
 
ALCOHOLIC INSANITY 299 
 
 which this chapter is concerned. The second sub-class 
 consists of those in which the causal stress that we 
 assign is incidental to the time of life to which the 
 patient has attained, and in the third sub-class the 
 stress is that incidental to the production of offspring, 
 and is confined to the female sex. 
 
 IDIOPATHIC INSANITY DUE TO DIRECT STRESS 
 
 The chief of these stresses is the long-continued use 
 of alcohol. The poison of alcohol produces by its direct 
 action acute insanity, as has already been described. 
 The long-continued use of alcohol so damages, or may 
 damage, the structure of the brain as to produce chronic 
 insanity, which remains even though the use of alcohol 
 is discontinued. It may be, of course, that a person 
 who is accustomed to exceed in alcohol may present a 
 combination of both types, part of his insanity being 
 due to the alcohol now circulating in his brain, and part 
 to the permanent damage done by previous doses. In 
 such a case, if the alcohol is discontinued, the insanity 
 is always mitigated by the disappearance of that part 
 which is due to the actual presence of alcohol in the 
 brain, and what insanity is left is that which is due to 
 permanent damage. Of this permanent insanity there 
 are two kinds. 
 
 In the first kind there is a general degradation of 
 most or all of the faculties of mind, but especially a 
 moral degradation. The habitual drunkard almost 
 inevitably sinks in the social scale. His habits at table 
 become disgusting. His conduct generally deteriorates 
 until his family become ashamed of him and shrink 
 from allowing him to associate with their friends. He 
 geeks companions fa? belpw him in social position. He 
 
300 A TEXT-BOOK OF INSANITY 
 
 becomes a liar and a sponge, indifferent to the means by 
 which he gets his drink, so that he gets it. A man or 
 woman of good birth and social position frequents low 
 pot-houses and boozes with low companions. He 
 becomes a byword and a reproach. With this degrada- 
 tion of conduct and mind — he does not recognise hia 
 own degradation, and is therefore insane — go usually 
 certain physical symptoms. On first rising in the 
 morning he retches violently ; his eyes become watery, 
 his hands tremulous, and sometimes, but not often, he 
 resembles Bardolph in his bottle nose. 
 
 The second kind of chronic alcoholic insanity exhibits 
 some of the moral degradation of the first, but these 
 symptoms are swamped and overcome by others — by 
 suspicion, delusion, a peculiar disorder of memory, 
 hallucinations, and various sensory disturbances and 
 motor defects. 
 
 Suspicion is usually a prominent feature in alcoholic 
 insanity. The patient believes that his food is poisoned, 
 that his wife is unfaithful, that his children are con- 
 spiring against him, that he is to be tortured and 
 destroyed ; and, combined as this attitude of mind is 
 with hallucination, it is apt to be confused with paranoia, 
 which it often closely resembles. It is important to dis- 
 criminate between the two, for the insanity of alcohol 
 is far more improvable than paranoia, and the prognosis 
 therefore much better, and the treatment is different. 
 The diagnosis is not usually difficult, the defect of 
 memory and the motor disturbance of alcoholic insanity 
 being sufficient, apart from the history, to establish the 
 difference. 
 
 The delusions are often those of pure suspicion and 
 persecution, such as have been instanced ; but there is 
 often a strain of vainglory and boastfulness running 
 
ALCOHOLIC INSANITY 301 
 
 through them in addition. The patient believes him- 
 self to be rich, to be a great personage, but at the same 
 time people are conspiring to rob him of his money or 
 his rank. He has not the confident security of the 
 ordinary megalomaniac, the general paralytic, or the 
 man with fixed delusion. 
 
 The disorder of memory is usually a prominent feature 
 in alcoholic insanity. There is usually marked defect, 
 and the defect is the same in character as the defect in 
 old age — that is to say, the memory of long-past events 
 is tenacious and faithful, but the current events of daily 
 life are swept out of the memory as soon as they have 
 happened. The patient receives a visit from his wife, 
 who spends an hour with him, and ten minutes after 
 she has gone he has forgotten all about the visit, and 
 vows that she has not been near him. He worries 
 because he has not written a letter, which he has written 
 and delivered to be posted a dozen times or more. He 
 has very little notion of the lapse of time, and if he does 
 remember a recent event, he cannot tell whether it 
 occurred to-day or yesterday, or a week or a month ago. 
 Together with this defect, there is a peculiar delusion 
 of memory which is not so pronounced or so frequent 
 in any other variety of insanity. The patient remembers 
 vividly and in detail events which have never occurred 
 at all. He will describe visits that he thinks he has 
 paid, will repeat conversations that he believes he has 
 taken part in, scenes that he thinks that he has witnessed, 
 none of which have ever taken place at all. It some- 
 times happens that the imaginary events which he 
 describes, and fully believes that he has witnessed, are 
 assaults upon himself or others, and he then becomes a 
 dangerous person. 
 
 Hallucinations occur more constantly in alcoholic 
 
302 A TEXT-BOOK OF INSANITY 
 
 insanity than in any other variety of insanity except 
 paranoia. They are usually aural, sometimes visual, 
 and not infrequently affect the sense of smell or taste. 
 They are always unpleasant and disconcerting, and 
 usually work in with and corroborate the delusions of 
 suspicion. The evil taste or smell that he experiences 
 confirms his opinion of poison in his food. The voices 
 that he hears, the texts that he sees written upon the 
 walls, corroborate the suspicion of persecution to which 
 he is subject. 
 
 Of the motor disturbances, which are rarely absent 
 in alcoholic insanity, the chief is tremor, which is 
 usually pronounced. It occurs first and most in the 
 hands, but it subsequently afiects the lips and articula- 
 tory organs generally. It is present both in rest and 
 during voluntary movement, but is more pronounced 
 in the latter. Following on tremor of the hands comes 
 a peculiar gait, which is neither a reel nor ataxy, but 
 a kind of stringhalt ; and the patient wavers in hia 
 walk so that his course is not a straight line but an 
 irregular zig-zag. Cramp in the calf of the leg is often 
 frequent and severe in alcoholic insanity, and occasion- 
 ally convulsions occur in its course. Shght irregularity 
 of the pupils is not uncommon in alcoholic insanity, as 
 in many other morbid states, and the reactions are apt 
 to be sluggish, but they are never absent. 
 
 Alcoholic insanity often simulates paranoia, from 
 which it may be distinguished as already described. 
 Its symptoms are often closely similar to those of 
 general paralysis, and there are cases in which the 
 diagnosis cannot be made, and we have to wait for the 
 course of the case to clear up the difficulty. The history 
 is not to be depended upon, for drunkards very often 
 deny their habit, and general paralytics have often been 
 
ALCOHOLIC INSANITY 303 
 
 intemperate. The tremor is closely alike in the two 
 cases. In the early stage of general paralysis it is never 
 so marked as it sometimes is in the early stage of alco- 
 holic insanity ; but sometimes in the latter there is 
 little or no tremor. If the peculiar mnemonic delusions 
 of alcoholism are present, their presence is almost 
 decisive, but the delusions of general paralysis often 
 approach them in character. The chief reliance must 
 be placed upon the pupillary reactions. It has been 
 said that these reactions are sometimes lost in alcoholic 
 insanity, but this is not my experience. If either the 
 reaction to light or that to accommodation is lost, or is 
 seriously defective, then I believe that general paralysis 
 may be diagnosed without hesitation. The difficulty is 
 that in the early stage of general paralysis there is some- 
 times no such sufficient defect in these reactions as to 
 enable us to make a diagnosis, which must then remain 
 in doubt. The importance of clearing up the matter as 
 soon as possible is very great, for general paralysis is 
 almost certainly fatal, while alcoholic insanity is very 
 improvable, and is compatible with considerable dura- 
 tion of life. 
 
 Since the various reactions characteristic of syphiHs 
 have been discovered, it has been usual to accept a 
 positive reaction as conclusive evidence of general 
 paralysis in a doubtful case. This practice is fallacious. 
 Drunkards are not immune from syphilis, and it may 
 well be that a person who is both syphilitic and a 
 drunkard may suffer from alcoholic insanity but not 
 from general paralysis. Every syphilitic does not be- 
 come a general paralytic^ and this is true whether he is 
 a drunkard or not. 
 
 In the treatment of alcoholic insanity, the first thing 
 to be done is to deprive the patient of his alcohol, and 
 
304 A TEXT-BOOK OF INSANITY 
 
 this can only be done by sending him to an institution. 
 It is quite futile to attempt to treat such cases in their 
 own homes, for there they will always find means to 
 obtain their poison. It does not matter what vigilance 
 is exercised, they will endeavour to corrupt their nurses 
 or servants, and they will succeed at last. They are 
 sure to have a secret store bestowed somewhere about 
 the house to which they will get access at times. The 
 only possible chance of completely depriving them is 
 to place them in a lunatic asylum. The Jfirst week 
 of their deprivation will be a terrible time for them. 
 They will suffer agonies of depression and misery, will 
 become perhaps riotously maniacal, and will give 
 endless trouble by their false accusations and general 
 perversity. The alcohol need not be absolutely with- 
 held, and by withdrawing it suddenly we may produce 
 an attack of delirium tremens. Sleep is often better 
 obtained if a dose of whiskey in hot milk is given 
 at night ; and when the misery becomes very great, 
 the same remedy will give relief. So long as the 
 patient is in the institution, we have him under 
 absolute control, and we need not fear the result of an 
 occasional dose of stimulant. He probably suffers from 
 gastritis, more or less, and this must be treated, espe- 
 cially as it is important in this, as in acute insanity, to 
 feed copiously. Iron and bitter tonics will be found 
 useful, but the chief reliance is to be placed upon 
 deprivation of alcohol, copious feeding, regular hours, 
 and fresh air. In these circumstances the improvement 
 that takes place is often surprising. The patient in 
 a few months becomes so well that it is very dijB&cult 
 to detain him in an institution ; and yet, if he is dis- 
 charged, he will certainly return to his drinking habits 
 and relapse. 
 
SEQUELAE INSANITY 305 
 
 SEQUELAE INSANITY 
 
 The second direct stress that leaves insanity behind 
 it as a sequel is the poison of specific fever. We have 
 already seen that this is probably an efiect in some 
 cases of acute specific fevers occurring in childhood. 
 They appear to arrest the development of the brain, 
 and the child does not advance, or does not much 
 advance, in mental capacity after the attack. In adults 
 an attack of specific fever may be followed by insanity, 
 and though such an event is rare, it does sometimes 
 happen after smallpox, typhoid fever, and perhaps other 
 acute specific diseases. The fever which leaves this 
 result behind it with the greatest frequency is influenza, 
 perhaps because the occurring cases of influenza are far 
 more numerous than those of any other specific fever. 
 Post-influenzal insanity has no constant form or type. 
 It is sometimes acute, sometimes chronic. In the 
 acute type it is usually melancholic, in the chronic it is 
 usually dementia, but I have seen a case with delusions 
 of persecution, indistinguishable from paranoia, follow 
 upon influenza. 
 
 INSANITY OF TIMES OF LIFE 
 
 The next stress that may be assigned as a cause of 
 insanity is that incident to the time of life at which the 
 patient has arrived. How this may be supposed to act 
 as a stress has already been considered under the causes 
 of insanity. Certain it is that insanity does occur 
 definitely in connection with the time of life at which 
 the patient is, and is often of such constant form and 
 type that we must suppose that the connection is 
 causal. 
 
306 A TEXT-BOOK OF INSANITY 
 
 INSANITY OF CHILDHOOD 
 
 In the previous edition of this book I followed authority 
 in saying that insanity, apart from idiocy and less 
 extreme forms of congenital weak-mindedness, is very 
 rare in childhood. Wider experience leads me to give 
 a different opinion. I have now seen many cases of 
 insanity in childhood, cases in which there was no reason 
 to suspect that the insanity was congenital. The cases 
 I have seen have been in two classes, in one of which 
 the insanity comes on about the age from six to eight, 
 and in the other about fifteen. 
 
 Children, both boys and girls, well born and well 
 brought up by careful mothers in moral surroundings, 
 sometimes become, about the age of six to eight, in- 
 corrigible thieves. They are usually intelligent, and 
 sometimes precociously clever. It is not that they do 
 not understand the moral lessons conveyed to them, 
 but that they are unable to profit by them. They 
 usually deny their thefts, even when the evidence against 
 them is overwhelming ; and the mark of this kind of 
 thief is that punishment has no deterrent effect upon 
 them whatever. " I have beaten him," one mother said 
 to me, " until I am tired." They do not usually take 
 much care to escape detection, and they will steal under 
 circumstances in which detection is certain and punish- 
 ment speedy. They will steal even if the cane is up- 
 lifted over them, ready to strike the moment they have 
 completed the theft. Such children occasionally grow 
 up into criminals — stupid, vindictive criminals — who lie 
 and steal, and are guilty of impostures that do not 
 benefit them, of frauds that bear the character of fraud 
 upon their face, criminals who will take more trouble 
 to get a precarious and insufficient living by dishonesty 
 
ADOLESCENT INSANITY 307 
 
 than it would cost them to earn an honest living by an 
 honourable life. But such cases are very exceptional. 
 The great majority of such children grow out of their 
 dishonesty and develop into honest and honourable men 
 and women. 
 
 The second class of children become insane at a later 
 age, usually at about fifteen, and in them the insanity 
 is always in my experience associated with excessively 
 rapid growth. They shoot up in height and they fill out 
 in bulk with extreme rapidity, and children who are 
 thus growing should always be watched with vigilance 
 and their studies interrupted until they have done grow- 
 ing. The form that disorder of conduct takes in these 
 cases is a peculiar one. I have not seen it in girls, but 
 in boys it takes the form of ordering from tradesmen 
 goods that they cannot pay for and have no intention 
 of paying for. One will order a motor-car, another will 
 stay at expensive hotels, live on a royal scale, and depart 
 without paying his bill. A third ordered a magnificent 
 gold watch, and instructed the tradesman of whom he 
 purchased it to place upon it a laudatory inscription 
 stating that it was presented to the boy by his admiring 
 school-fellows. The phase passes away in a few months 
 when bodily growth comes to an end, and the energy 
 drafted off for this purpose is again at the service of the 
 brain. 
 
 ADOLESCENT INSANITY 
 
 Adolescence is, for reasons stated in a previous 
 chapter, a time of life at which insanit)^ is frequent — 
 perhaps more frequent than at any other. By adoles- 
 cence I mean from about eighteen to about twenty-five. 
 Any insanity occurring at this time of life is coloured by 
 the mental peculiarities that prevail at this time of life, 
 
308 A TEXT-BOOK OF INSANITY 
 
 but there is no insanity that is peculiar to adolescence. 
 The kinds of insanity most often seen at this early time 
 of life are acute insanity and primary dementia. The 
 stuporose form of acute insanity is rarely seen at any 
 other age. 
 
 CLIMACTERIC INSANITY 
 
 Not every case of insanity that occurs at the time 
 of the menopause is climacteric insanity. Women at 
 the climacteric are not exempt from the causes that 
 may produce insanity at other times of life, except of 
 course to those incident to child-bearing ; and when 
 they become insane from these other causes their 
 insanity is not climacteric insanity. True climacteric 
 insanity has certain specific features by which it may 
 be recognised. It begins as an acute or sub-acute 
 insanity, becoming acute, of gradual onset, and always 
 of melancholic type, associated with suspicion and 
 terror, and with attempts at suicide. The patient is 
 very apt to have delusions of suspicion, as distinguished 
 from delusions of persecution. She thinks her food is 
 poisoned, that something dreadful is going to happen, 
 or has happened ; that she has lost all her money, and 
 perhaps been robbed of it. Sometimes the delusions 
 have a sexual colouring. An old maid thinks she has 
 been seduced, she has been unchaste, she is engaged to 
 this man or that, to whom perhaps she has never spoken. 
 There is nothing special in the treatment. The prog- 
 nosis is not unfavourable, but the duration of the disease 
 is likely to be longer than in the insanities connected 
 with child-bearing. In these we expect recovery to 
 take place, if at all, within a year, and often within six 
 months. In the insanity of the climacteric it is unwise 
 to expect recovery under eighteen months or two years. 
 
SENILE INSANITY 309 
 
 SENILE INSANITY 
 
 Dementia is one of the terminations of life. In the 
 vast majority of cases life is cut short by accident, or 
 by the quasi-accident of bodily disease ; but when it 
 goes on until it ceases from pure exhaustion of the 
 quantum of energy that it received at conception, it may 
 pass through dementia on its way to the end. Some 
 degree of dementia, some diminution of the vividness 
 of feeling, of the capacity of thought, of the range and 
 variety of conduct, is the natural and inevitable accom- 
 paniment of the decay of the bodily power in old age ; 
 and it often happens that the decay of the highest 
 regions of the brain outstrips that of the body, so that 
 the dementia sets in earlier, is more pronounced in 
 degree, and is more irregular in its manifestations than 
 is usual and normal in old age, and is out of proportion 
 to the decay of the bodily capacity. The condition 
 then presented is the clinical condition of senile dementia. 
 
 In senile dementia the most conspicuous feature is 
 defect of memory ; the most conspicuous fault is the 
 outbreak of ill-temper. The defect of memory is peculiar, 
 and is characterised by the evanescence of the memory 
 of passing experiences while the memories of long-past 
 experiences are not only retained, but are increased in 
 their prominence, in their intensity, and in the frequence 
 with which they are present in consciousness. The first 
 approaches of senility, which are perceptible between 
 forty and fifty, are marked, as has been said, by an 
 inability to recall newly acquired names, whether of 
 persons or of things, and generally by a want of nimble- 
 ness in the use of substantives. As age advances, 
 experiences produce impressions that are less and less 
 enduring, and, in the dementia of old age, become so 
 
310 A TEXT-BOOK OF INSANITY 
 
 transient that events are not remembered from hour to 
 hour, and often not from minute to minute. A senile 
 dement will declare that he has not seen for months a 
 person who spoke to him, and whom he recognised and 
 answered, five minutes before he makes the declaration ; 
 and no matter how important or impressive the event, 
 its memory is equally evanescent. While he thus forgets 
 with abnormal celerity and completeness current events, 
 he retains with punctual fidelity the memories of 
 experiences that he underwent in youth, and is able 
 to give accurate descriptions of events that happened 
 fifty or sixty or more years ago. Nor is this all ; the 
 memories of long-past experiences are not only faithful, 
 often surprisingly and unusually faithful and detailed, 
 but they thrust themselves forward and occupy a much 
 larger share of consciousness than is usual. People in 
 Doiddle life, and normal people in old age, are occupied 
 mainly with the current experiences of their daily life ; 
 and the reminiscences of childhood are before the mind 
 but seldom, and for short periods. But in many cases 
 the senile dement lives his childhood over again. He 
 is perpetually maundering about things that happened 
 before his hearers were born, about the events of his 
 school life and his early love affairs, and not very 
 infrequently these memories of bygone experiences 
 take such hold upon him that he actually mistakes 
 the people about him for the companions of his early 
 life. He addresses his grandchildren by the names of 
 his schoolfellows, and takes his daughter for his first 
 sweetheart. 
 
 Together with this peculiar defect of memory there 
 is usually in senile dementia an irritabihty of temper, 
 a petulance and impatience, which reproduce the 
 peculiarities of a spoilt child. If they want a thing, 
 
INSANITY OF PREGNANCY 311 
 
 they must have it on the instant ; they cannot wait 
 until it is prepared or until it is fetched ; they must 
 have it now, this moment ; and if it is not forthcoming 
 they fly into a rage, they stamp, they shout, they 
 swear, and they often offer such feeble violence as 
 they are capable of. Like the child, too, they are 
 easily coaxed into a good humour again ; their ill- 
 temper is transient, and its occasion soon forgotten. 
 Another characteristic is the wearisome iteration with 
 which they will repeat the same thing, their defect 
 of memory rendering them oblivious to the frequency 
 of the repetition. Indeed, the repetition of the same 
 story at short intervals to the same person is as common 
 an indication of the advent of senility as is the difficulty 
 of dealing with substantives that has already been 
 mentioned. 
 
 INSANITIES OF REPKODUCTION 
 
 Insanity of Pregnancy 
 
 It is remarkable that although all women are so 
 liable during pregnancy to emotional disturbances, un- 
 provoked " hysterical " laughing and weeping, " long- 
 ings," caprices of all kinds, and other mental disturbance, 
 yet disturbance to the point of actual insanity is rare in 
 pregnancy. When it does occur, it occurs either about 
 the third month, as an exaggeration of the longings and 
 caprices that normally appear then, or about the sixth 
 month, or later, it comes on gradually as the foetus 
 grows. The latter variety is the more frequent and the 
 more severe, the first variety sometimes recovering in 
 the later months of pregnancy, while the latter never 
 recovers until after delivery. 
 
 The form of the insanity of pregnancy is an acute 
 
312 A TEXT-BOOK OF INSANITY 
 
 or sub-acute insanity of melancholic type, with suicidal 
 inclination. The delusions are often coloured by the 
 condition of the patient, who imagines that she herself 
 or her husband has been unfaithful, or has other de- 
 lusions in which the husband is concerned, as that she 
 has ruined him. 
 
 As already said, when the insanity comes on about 
 the third month after the pregnancy, it may recover 
 before delivery ; but when it comes on in the later 
 stages, it never recovers till the child is born. In a 
 minority of cases the birth of the child, whether pre- 
 maturely or at term, is followed by rapid recovery ; 
 in other cases the insanity continues without change ; 
 and in yet a third class it undergoes an exacerbation 
 a few days after labour, as if puerperal insanity were 
 added to that of pregnancy. Hence the rule is not to 
 bring on premature labour in the hope of terminating 
 the insanity by that means, but the rule ought by no 
 means to be slavishly adhered to in all cases. In some 
 cases, and especially when the insanity is very acute 
 and severe, it is justifiable, and is followed by speedy 
 recovery. 
 
 The treatment of the insanity of pregnancy is that 
 of acute insanity of melancholic type, but with this 
 difference — that since whatever drugs are given to the 
 woman are given to the child in her womb also, the 
 administration of drugs is to be cautious, and is to be 
 minimised. As in other varieties of insanity connected 
 with reproduction, the prognosis is not unfavourable. 
 About three-fourths of the cases recover. 
 
 PUERPERAL INSANITY 
 
 The puerperium is a common occasion of insanity 
 in women, insanity occurring in about a quarter per 
 
PUERPERAL INSANITY 313 
 
 cent, of all confinements, and being responsible for 
 about seven per cent, of all cases of insanity in women. 
 It is most common in primiparae and within the first 
 week after labour, it is less common in the second week, 
 and after that time it is rare ; but insanity occurring 
 within six weeks of labour is called still puerperal, and 
 partakes of the character of puerperal insanity. Should 
 insanity occur after this period, it is the insanity of 
 lactation. 
 
 Puerperal insanity is always an acute insanity, and 
 may be of any of the types of that malady that have 
 been described, or of some intermediate grade between 
 two or more of them, but usually it is maniacal-melan- 
 cholic in character. In addition to the description that 
 has already been given of acute insanity, there are 
 certain characters special to the puerperal variety. The 
 impulsive violence so often seen in acute insanity is, 
 in puerperal insanity, usually directed against the 
 infant, which should be immediately removed to a place 
 of safety. Often, but by no means always, there is a 
 septic element in the disease. The lochia become ofien- 
 sive, the uterus is tender, the temperature is raised, the 
 pulse rapid and weak, the lips are dry and the tongue 
 foul. In such cases the uterus must be examined, 
 and, if necessary, cleaned out, and the usual sanitary 
 precautions taken. In other respects the treatment is 
 that already prescribed for acute insanity. 
 
 The treatment is usually successful, perhaps because 
 the patients are always got under treatment early. It 
 is usually necessary to remove the patient to an institu- 
 tion, and here she commonly recovers. The recovery is 
 often interrupted by relapses, sometimes serious, though 
 usually slight, and for this reason, and because the 
 relapse is likely to be much more serious at home 
 
314 A TEXT-BOOK OF INSANITY 
 
 than in an institution, and especially because, even 
 wlien recovered, the patient ought not for several 
 months to resume marital relations, the stay at the 
 institution ought to be prolonged. The subjects of puer- 
 peral insanity often recover with apparent completeness 
 in three months ; but they should rarely be allowed 
 to go home before the child is six months old. A rough 
 practical rule is not to discharge the patient until men- 
 struation is re-established ; but this will not always work, 
 although the re-establishment of menstruation is often 
 the sign of complete recovery, and a considerable mental 
 improvement occurring at the same time is of excellent 
 augury. But when no improvement accompanies the 
 occurrence of a menstrual period, the prognosis is bad. 
 
 Puerperal insanity is remarkable as being the only 
 form of insanity, except acute dehrious mania, in which 
 the temperature is raised except from accidental causes. 
 
 INSANITY OP LACTATION 
 
 This is an insanity of starvation, of exhaustion. It 
 occurs mainly in the later months of suckling, and 
 among women who suckle their babies freely and long, 
 work hard, and are perhaps, in addition, insufficiently 
 fed ; and is rare among the well-to-do. Agreeably to 
 its causation, it is an acute insanity of melancholic 
 type (which see), and is very amenable to treatment. 
 Fully three-fourths of the cases recover. 
 
PAET III 
 THE LEGAL EELATIONS OF INSANITY 
 
CHAPTER XIII 
 
 THE LEGAL RELATIONS OF INSANITY 
 
 Insanity differs from all other diseases in this respect, 
 that the patient may retain all his physical ability, but 
 yet is incapacitated by his disease from being a normal 
 constituent of a social body. The disease always affects 
 his social relations, and diminishes his usefulness as a 
 social unit, and it may make him noxious to the social 
 body to which he belongs — noxious either passively by 
 rendering him a burden on it for his support, or actively 
 by reason that the disorder of his conduct is dangerous 
 to the lives, or harmful to the property, or outrageous 
 to the feelings of his fellows. In addition to this in- 
 capacity to take his place as a normal and useful social 
 unit, he usually presents also an incapacity to manage 
 his own life profitably. The disorder of his conduct is 
 of such a nature that it menaces not only the lives, well- 
 being, or comfort of others, but also menaces his own 
 life, either directly, or through the loss or perversion 
 of his means of livelihood. For these reasons, firstly 
 for its own welfare, and secondly for the welfare of the 
 lunatic himself, society has always, and rightly, con- 
 cerned itself about the treatment of the lunatic in a 
 way that it has never, until very lately, concerned itself 
 about the treatment of those whose illness does not 
 directly affect their conduct. 
 
 The first duty and the first necessity of society is to 
 
 317 
 
318 A TEXT-BOOK OF INSANITY 
 
 protect itself ; and the element in insanity that first 
 attracted the notice of society was the noxiousness of 
 the lunatic to itself. Early legislation for lunatics was 
 therefore directed exclusively to safeguarding society 
 by locking them up. If the lunatic was not noxious 
 to society he was left alone, and there was scarcely a 
 village in this kingdom that had not its harmless idiot, 
 who was the butt of the children and the recipient of 
 charity from their elders. With the immense develop- 
 ment of sympathy and charity that has distinguished 
 the last hundred years above any other period in the 
 history of the human race, a new view is taken of the 
 duty of society to the lunatic, and he is now taken out 
 of the body of society and locked up in an asylum not 
 only when he is noxious to society, but when, and 
 because, he cannot sufficiently safeguard himself from 
 the common ills of life. 
 
 Whether to safeguard itself, or whether to safeguard 
 the lunatic, society, through the medium of the law, 
 has provided that he shall be placed and kept under 
 control, and in order that this placing and keeping 
 under control shall be restricted to lunatics and not be 
 improperly applied to sane persons, the law requires 
 certain formalities, which will presently be explained, 
 to be observed. Statute law, however, is necessarily 
 too rigid to adapt itself perfectly to the infinite varia- 
 bility of human affairs, and there are on the one hand 
 certain cases for which it does not provide, and on the 
 other certain cases for which it provides needlessly. 
 
 The formalities required for placing a lunatic legally 
 under control necessarily take time ; and there are 
 cases in which time cannot be afiorded. If a lunatic is 
 at large with arms in his hands and threatening or 
 actually taking the lives of his fellow-citizens, urgent 
 
CERTIFIABILITY 319 
 
 necessity supersedes the statute law, and the common 
 law, the organised common sense of many generations, 
 authorises us to deal with him in the best way we can, 
 even if we have to shoot him to stop his depredations. 
 Short of shooting him, we may maim him or tie him 
 down, or do anything that seems on the spur of the 
 moment the most effectual and judicious thing to do. 
 
 On the other hand, there are many cases for which the 
 law provides needlessly. In strict law it would be 
 necessary for every patient in a nursing home who is 
 dehrious from fever, or from the effect of an anaesthetic, to 
 be promptly certified as insane, which he is ; but this 
 is never done unless the delirium is very prolonged and 
 becomes the dominant feature in the case. Similarly, 
 there are many general paralytics in whom, towards the 
 end of their malady, the bodily incapacity is by far the 
 most prominent and important feature, and the mental 
 incapacity subsides into relative insignificance. There 
 is no sort of necessity for keeping them under legal 
 control, for they are already sufficiently under control 
 by their bodily incapacity. There are other reasons 
 why it may be inexpedient to place or keep under legal 
 control a lunatic to whom the law in strictness applies. 
 It by no means follows that a person who is legally 
 certifiable as a lunatic ought to be certified, and for- 
 tunately the lunacy law is administered by a commission 
 of enlightened men who recognise that what is legally 
 requisite is not always expedient, and who will not 
 enforce the strict provisions of the law if they are 
 satisfied that it is better for the patient that they should 
 not be enforced. 
 
 Again, a patient may be insane without being certi- 
 fiably insane — that is to say, although, by prolonged 
 observation of his conduct, we may be convinced that 
 
320 A TEXT-BOOK OF INSANITY 
 
 his mind is disordered, and that he is no longer fully 
 responsible for his acts, yet we may be unable to de- 
 scribe in words any specific " fact indicating insanity 
 observed at the time of examination," and so to place 
 him under control. Such persons are extremely difficult 
 to deal with ; and though they often eventually become 
 certifiable, they contrive, before this stage is reached, 
 to run through large sums of money, often to ruin them- 
 selves, and often to commit criminal acts. 
 
 But supposing a patient to be certifiably insane, the 
 first questions that have to be decided are whether he 
 may properly be allowed to remain uncertified, whether 
 he should be placed in private care, or whether he should 
 be sent to an institution. These are questions that 
 depend partly upon the nature and degree of the malady, 
 and partly upon the age, wealth, and other circum- 
 stances of the patient. 
 
 The character of the malady is the most important 
 consideration. It may be stated categorically that 
 every case of acute insanity should be at once placed 
 in an institution, to whatever type the acute insanity 
 conforms, and to whatever variety of insanity it may 
 happen to belong. Every patient with acute insanity 
 is a potential suicide, and suicidal patients can only be 
 prevented from effecting their purpose by asylum treat- 
 ment. It is only in an institution specially constructed 
 for the purpose that the habit of incessant supervision 
 is maintained, and that the appliances for heating and 
 lighting and ventilation, the staircases, water-closets, 
 bedsteads, and other arrangements are specially con- 
 structed with a view to minimise the opportunities for 
 suicide. Moreover, patients who are acutely insane 
 need the presence of a medical attendant always within 
 call, for contingencies requiring instant medical treat- 
 
LEGAL RELATIONS 321 
 
 merit are of frequent occurrence ; and it is obvious that 
 this condition can be secured in an institution only. 
 
 For a somewhat similar reason, general paralytics 
 invariably require to be detained in an institution. 
 They are subject, throughout the whole of the first, 
 and often the second stage also, to sudden outbreaks of 
 violence, to deal with which the continued presence of an 
 adequate stafi of attendants is necessary, and this abun- 
 dance of attendants is only obtainable in an institution. 
 
 Lastly, all paranoiacs ought to be detained in insti- 
 tutions. All such patients are potential homicides, 
 and scarcely a month passes without the commission 
 of a murder by a patient of this description, who had 
 given abundant evidence beforehand that he ought to 
 be under efficient control. 
 
 Patients of these three classes ought always to be 
 treated in institutions, but they are not the only patients 
 for whom institution treatment is necessary. All 
 patients who need much control ought to be in institu- 
 tions, for only in them can much control be exercised. 
 Patients who are very noisy, or who are very restless, 
 or who are sexually excited, cannot be properly managed 
 in private care. 
 
 On the other hand, there are patients w^ho ought not 
 to be sent to institutions if this course can be avoided. 
 Young girls or young lads should be kept out of insti- 
 tutions as long as possible, for the fact of their having 
 been placed under care may tell very seriously against 
 them in future life; quiet dements can very well be 
 treated at home or in private care ; and persons whose 
 insanity is recent, is of a mild and sub-acute form, 
 ought usually to have a trial in appropriate surround- 
 ings outside an asylum, before recourse is had to this 
 extreme measure. 
 
322 A TEXT-BOOK OF INSANITY 
 
 The means of the patient form a very important 
 factor in determining whether he shall be sent to an 
 asylum or no. In the case of a poor person, no other 
 alternative is possible, since, apart from the expense 
 of supervision, the mere abstention from work reduces 
 them to a condition of dependence ; while wealthy 
 men, who can afford plenty of attendants and an isolated 
 house with large grounds, can very well be treated in 
 their own homes. There are multitudes of patients in 
 pauper asylums who, if they possessed adequate means, 
 might be at large ; and there are multitudes of persons 
 at large who, if they were not fortunately in possession 
 of means, would have to seek the shelter of an asylum. 
 It is a very common occurrence for a person to have 
 sufficient intelligence to administer his means capably 
 if he happens to possess any, and yet to have insufficient 
 intelligence to earn his livelihood. If he has means, he 
 may very well live at large, but if he has none, he must 
 be cared for in an institution. 
 
 If it is determined that treatment in an institution 
 is unavoidable, or is desirable, the question will often 
 arise whether he should be placed there under a recep- 
 tion order, or whether he should go of his own free will 
 as a voluntary boarder. There are but few cases in 
 which the latter alternative is really the best, though 
 it is often practicable, and sometimes the only practic- 
 able course. In such cases the patient must not only 
 be willing to place himself under care, but he must be 
 competent to form a judgment as to the expediency of 
 doing so, and he must be to such an extent of sound 
 mind that, even if it were desirable, it is not possible 
 to make a certificate of lunacy with regard to him. He 
 must be uncertifiable. 
 
 Neurologists, who are frequently consulted about 
 
PLACING UNDER CONTROL 323 
 
 cases of insanity, though it is a subject of which they 
 have no special knowledge, almost invariably advise 
 that the patient should travel, and are particularly 
 fond of recommending a sea voyage. Travelling is, 
 however, almost always detrimental in the early stages 
 of insanity ; and a sea voyage is probably the very 
 worst course that could be adopted. As already 
 stated, all cases of acute insanity are potential suicides, 
 and on board ship the opportunity and temptation to 
 suicide are constantly present and constantly obtruded, 
 and effective supervision is almost impossible. 
 
 There are four occasions on which a medical prac- 
 titioner may be brought into contact with tke law in 
 dealing with insane persons : — 
 
 1. In the placing of an insane person under control. 
 
 2. In the keeping of an insane person under control. 
 
 3. In connection with the validity of wills and con- 
 tracts. 
 
 4. In connection with responsibihty for criminal acts. 
 The legal formalities necessary for depriving an 
 
 insane person of the management of himself and his 
 afiairs, and for detaining him under care and treatment, 
 differ much in different countries, and in each country 
 in different cases. The procedure is different in England 
 and Wales, in Scotland, and in Ireland. 
 
 PLACING UNDER CONTROL 
 m ENGLAND AND WALES 
 
 The procedure varies in the following circumstances : — 
 
 I. According as the patient is a mentally defective 
 person or a lunatic. According to the Lunacy Act, 
 1890, a lunatic is equivalent to a person of unsound 
 mind ; hence the law dravrs a distinction between a 
 
324 A TEXT-BOOK OF INSANITY 
 
 person who is mentally defective and a person whose 
 mind is unsound. More than this, by the Lunacy Act, 
 1890, it is enacted that a lunatic means an idiot ; but 
 by the Mental Deficiency Act an idiot is one class of 
 mentally defective persons. The practical effect of this 
 double enactment is that an idiot can be placed under 
 control under either Act, but this privilege does not 
 extend to his brother who is an imbecile. The intention 
 of the Government in bringing in the Mental Deficiency 
 Bill was to codify the old law as well as to add to it the 
 new, and the first Bill was drafted accordingly. This 
 Bill had to be dropped, and the subsequent Bill, which 
 is now the Mental Deficiency Act, leaves the old Lunacy 
 Law in force, and is in many respects, of which the 
 enactment with regard to idiots is one, incongruous 
 with the old law. The Mental Deficiency Act applies 
 to those persons only who satisfy the definitions in the 
 Act of the several degrees of mental deficiency, leaving 
 all other classes of the insane under the old law ; and 
 instead of one, there are now two central bodies who 
 supervise the working of the Acts relating to the insane. 
 The Commissioners in Lunacy continue their old 
 functions, and the Board of Control, of which the Com- 
 missioners are members, administer the law with 
 respect to those who satisfy the definitions of defectives. 
 The arrangement is clumsy, and cannot be permanent, 
 but no doubt it will be years before it can be altered, and 
 in the meantime I must give an account of it as it is. 
 
 The following classes of persons are mentally defec- 
 tive within the meaning of the Mental Deficiency Act, 
 1913 :— 
 
 (a) Idiots ; that is to say, persons so deeply defective 
 in mind from birth or from an early age as to be unable 
 to guard themselves against common physical dangers ; 
 
MENTAL DEFECTIVES 325 
 
 (h) Imbeciles ; that is to say, persons in whose case 
 there exists from birth or from an early age mental de- 
 fectiveness not amounting to idiocy, yet so pronounced 
 that they are incapable of managing themselves or their 
 afiairs, or, in the case of children, of being taught to 
 do so ; 
 
 - (c) Feeble-minded persons ; that is to say, persons 
 in whose case there exists from birth or from an early 
 age mental defectiveness not amounting to imbecility, 
 yet so pronounced that they require care, supervision, 
 and control for their own protection or for the protection 
 of others, or, in the case of children, that they by reason 
 of such defectiveness appear to be permanently in- 
 capable of receiving proper benefit from the instruction 
 in ordinary schools ; 
 
 (d) Moral imbeciles ; that is to say, persons who from 
 an early age display some permanent mental defect 
 coupled with strong vicious or criminal propensities on 
 which punishment has had little or no deterrent efiect. 
 
 A mentally defective person who comes under any 
 of these definitions may be placed in an institution or 
 under guardianship 
 
 (a) at the instance of his parent or guardian, if he is 
 an idiot or an imbecile, or at the instance of his 
 parent if, though not an idiot or imbecile, he is 
 under the age of 21 ; or 
 
 (h) if in addition to being a defective he is a person 
 
 (i) who is found neglected, abandoned, or without 
 visible means of support, or cruelly treated ; 
 
 (ii) who is found guilty of any criminal offence, or 
 who is ordered or found liable to be ordered 
 tp be ^ent tp a certified industrial school • 
 
326 A TEXT-BOOK OP INSANITY 
 
 (iii) who is undergoing imprisonment (except im- 
 prisonment under civil process) or penal 
 servitude, or is undergoing detention in a 
 place of detention by order of a court, or in 
 a reformatory or industrial school, or in an 
 inebriate reformatory, or who is detained 
 in an institution for lunatics or a criminal 
 lunatic asylum ; or 
 
 (iv) who is an habitual drunkard within the 
 meaning of the Inebriates Acts, 1879 to 
 1900; or 
 
 (v) in whose case a certain notice has been given 
 by the local education authority ; or 
 
 (vi) who is in receipt of poor relief at the time of 
 giving birth to an illegitimate child or when 
 pregnant of such child. 
 
 The parent or guardian of a defective who is an idiot 
 or an imbecile, and the parent of a defective who is not 
 an idiot or an imbecile but is under 21, may place the 
 defective in an institution or under guardianship. Two 
 medical certificates are necessary, one of which must 
 be signed by the medical practitioner approved for the 
 purpose by the local authority. In the case of an idiot 
 or an imbecile these are all that is necessary, but in the 
 case of a feeble-minded person or a moral imbecile 
 there must be in addition the signature to both certifi- 
 cates of a judicial authority and a statement by the 
 parent or guardian. 
 
 If the defective has been found guilty of a criminal 
 offence, he may be dealt with under an order of the 
 court or of the Secretary of State, but if he has not been 
 convicted and if there is no parent or guardian, or if for 
 a^ny reason the parent or guardian does not act, theri 
 
MENTAL DEFECTIVES 327 
 
 any relative or friend of the defective or any ofi&cer of 
 the local authority may obtain an order by a petition 
 to a judicial authority. 
 
 The petition must be accompanied by two medical 
 certificates, one of which must be by the approved 
 medical practitioner, and must be accompanied also by 
 a statutory declaration made by the petitioner and at 
 least one other person, stating 
 
 (a) That the defective is a defective within the 
 meaning of the Act, and to which class of 
 defectives he belongs ; 
 
 (6) That the defective is subject to be dealt with 
 under the Act, and the circumstances that 
 make him so subject ; and 
 
 (c) whether or not a petition under the Act or under 
 
 the Lunacy Acts has previously been pre- 
 sented, with the date and result ; and 
 
 (d) If the petition is accompanied by a certificate 
 
 that a medical certificate is impracticable, the 
 reasons that render it impracticable. 
 
 It will be seen by comparing these provisions with 
 those set out below as required by the Lunacy Acts, 
 that the difierences are that under the Mental Defectives 
 Act the petition must be accompanied by a statutory 
 declaration, and one of the medical certifiers must be 
 approved by the local authority, but neither need be 
 the regular medical attendant of the defective. Under 
 the Lunacy Acts there is no statutory declaration, there 
 are no approved medical certifiers, and as we shall 
 presently see, one medical certificate must be made, if 
 possible, by the regular medical attendant of the 
 patient. 
 
328 A TEXT-BOOK OF INSANITY 
 
 II. When the patient does not come under the 
 description of an idiot or imbecile from birth or from 
 an early age, but has become insane in later life, pro- 
 cedure varies according to the following circumstances: — 
 
 1. If the patient is wandering at large, he may be 
 arrested by the police and taken before a justice. 
 
 2. If the patient is not wandering at large, but either 
 is not under proper care and control, or is cruelly treated 
 or neglected by the relative or other person having 
 charge of him, then it is the duty of the police and the 
 parish authorities to give information on oath to a justice, 
 who will then take the necessary legal proceedings. 
 
 3. In the ordinary case, in which the patient is living 
 at home with his friends, the procedure differs according 
 as he is or is not a pauper, by which is meant according 
 as his means allow of his being treated as a " private " 
 patient and of his support being paid for, or as his 
 malady must be treated at the public expense. It does 
 not mean that he must be a pauper at the time of his 
 certification as a lunatic, but that he becomes one by 
 being certified at the expense of his parish. 
 
 If he is in this sense a pauper, the ai!air is managed 
 by the relieving officer, and the only duty of the medical 
 practitioner is to make a certificate, which is in the 
 same form whether the patient is a pauper or a private 
 patient. 
 
 If, however, the patient does not satisfy any of the 
 foregoing descriptions, but is a private patient, not 
 wandering at large and not cruelly treated or neglected, 
 then there are three ways of placing him under control, 
 viz. : — 
 
 The Judicial Reception Order, 
 
 The Urgency Order, and 
 
 The Inquisition. 
 
CEETIFICATES OF INSANITY 329 
 
 The first is the ordinary and normal procedure. In 
 order to procure a judicial reception order, a petition 
 must be presented by the nearest relative of the patient 
 to a magistrate specially appointed under the Lunacy 
 Act, 1890 ; and the petition must be accompanied by 
 a statement, also made by a relative, and by the certifi- 
 cates of two medical practitioners made independently 
 of each other — that is to say, the certificates must be 
 on separate sheets of paper, and the examination made 
 for the purpose of certifying must be made " separately 
 from any other practitioner." 
 
 The requirements of the certificates are simple and 
 easily satisfied, but it is seldom that they do not con- 
 tain some gross defect that could have been avoided 
 by a little ordinary care. The majority of certifjdng 
 practitioners do not even trouble to refer to all the 
 marginal notes and to see that all are satisfied, nor do 
 they read through the certificate when made, to delete 
 redundant words, and see that it reads grammatically 
 and logically from beginning to end. 
 
 In making a certificate, its purpose must be con- 
 stantly borne in mind. It is to satisfy the mind of the 
 magistrate, a third person, who has never seen and 
 knows nothing of the patient, that the patient is insane 
 and a proper person to be detained imder care and 
 treatment as an insane person. Students usually make 
 a certificate as if it needed to contain a diagnosis, or as 
 if it were a clinical description of the case, and accord- 
 ingly they put among the " facts indicating insanity " 
 their observations on the knee jerks and the pupillary 
 reflexes, and the age and complexion of the patient. 
 If they would only pay attention to the terms of the 
 document, and remember that what is required of them 
 are " facts indicating insanity observed by myself at 
 
330 A TEXT-BOOK OF INSANITY 
 
 the time of examination," they would be saved from 
 many absurdities. A medical certificate of lunacy has 
 by statute the force of a statement made upon oath, 
 and therefore should be drav/n with the same punctilious 
 care as an affidavit. The essentials of a good certificate 
 are three : — 
 
 1. It should he sufficient — that is to say, the facts 
 stated as indications of insanity should be such as to 
 carry to the mind of the magistrate, who has never seen 
 the patient and knows nothing of him, a conviction 
 that the patient is insane. It is not enough for the 
 certifying practitioner to satisfy himself on this point. 
 He must so state his facts as to satisfy the magistrate, 
 and he must remember that the magistrate has not the 
 knowledge of the patient that he himself has. To the 
 doctor, who knows well the circumstances of his patient, 
 it is a fact indicating insanity when the patient deplores 
 his own poverty and ruin, or declares that his wife has 
 deserted him. But to the magistrate, who knows 
 nothing of the patient or his circumstances, these state- 
 ments do not carry insanity, for, for aught he knows, 
 they may be true. When the " fact indicating insanity " 
 does not carry insanity upon the face of it, it should 
 be supplemented by a statement that it is incorrect, 
 and, if need be, by a further statement that the patient 
 continues to hold it in spite of plain evidence to the 
 contrary. That " he thinks his wife has deserted him " 
 is of itself no evidence of insanity ; but that " he thinks 
 his wife has deserted him, although she was in his room 
 ten minutes ago, and left it for the avowed purpose of 
 posting a letter " is evidence. 
 
 2. The certificate should he definite. It should give 
 " facts indicating insanity," not opinions which the 
 certifier mistakes for facts. To say that the patient 
 
CERTIFICATES OF INSANITY 331 
 
 " feels miserable," that he " believes he has committed 
 the unpardonable sin," that " he thinks he is king of 
 the world " are not observed facts, but inferences from 
 observed facts. What is actually observed is that the 
 patient says this or the other. Whether his mind 
 is in accordance with his statement is a matter of 
 inference, not of observation, and hence the statements 
 in a certificate should be limited to what the patient says 
 and what he does, and should not ramble into w^hat he 
 thinks and feels. Neither has the certifier any business 
 to aver that the patient " cannot remember " this or 
 *' will not answer " that. All that he can observe is that 
 the patient does not do what is required of him. Whether 
 this defect is defect of ability or defect of will is beyond 
 his power to determine. When you are giving evidence 
 upon oath you must distinguish carefully between what 
 you observe and what you infer, and the observation 
 alone can be legitimately stated as a fact. 
 
 3. Lastly, the certificate must he clearly expressed. 
 Unless you are a master of English composition, keep 
 your sentences short, and do without qualifying clauses. 
 Above all, avoid entanglements with the personal pro- 
 nouns. You are not bound to give any " facts com- 
 municated by others." If the facts that you yourself 
 observe are sufficient to prove your case, there is no 
 need of facts communicated by others. But if your 
 own facts are weak and need corroboration, then you 
 must reinforce them by communicated facts ; and never 
 forget, what is usually forgotten, to give the name, 
 Christian names, address, and description of your in- 
 formant. By the " description " is not meant, by the 
 way, the complexion, colour of eyes and hair, etc., of 
 your informant, but his rank in life, occupation or pro- 
 fession. Having given these particulars with respect to 
 
332 A TEXT-BOOK OF INSANITY 
 
 your informant, state the information that he gives you 
 in as unambiguous terms as possible, making it clear 
 to whom your pronouns refer. Here is a specimen of 
 the kind of statement that ought to be avoided : "The 
 patient states that he knew Mr. M. in AustraUa, and 
 that he has often visited him at his house there, and 
 that on one occasion he went into his house and ate the 
 dinner that had been prepared for him." Who was 
 the visitor, whose was the house, and whose the dinner 
 are here left in uncertainty ; and it is obvious that, 
 on one reading of the statement, the fact that one man 
 went into his own house and ate his own dinner is 
 alleged as a reason why another man is to be considered 
 insane. 
 
 The second method by which a " private " patient 
 may be placed under control is by means of an urgency 
 order, but this method is purely a temporary expedient 
 to obtain immediate control of a patient while the usual 
 order by judicial authority is being obtained. It takes 
 time to obtain a judicial reception order, and there are 
 cases in which it is expedient that a patient should be 
 placed under control at once. For these exceptional 
 cases the urgency order is provided. By its means a 
 patient can be placed under control within an hour or 
 two, and the urgency order will remain in force for 
 seven days, or if within seven days a petition for a 
 judicial reception order is presented, then until that 
 petition is disposed of. 
 
 The urgency order must, like the petition, be signed 
 if possible by a near relative of the patient, and in any 
 case the person who signs it must be of full age, and 
 must within two days have seen the patient. It must 
 be accompanied by one medical certificate, and by a 
 statement of particulars sirailar to th^t which accogi- 
 
UBGENCY CEBTIFICATES 333 
 
 panics a petition. In addition to the medical certificate, 
 which is in precisely the same form as those which 
 accompany the petition, a further certificate must 
 be given by the medical practitioner in the following 
 form : — 
 
 I certify that it is expedient for the welfare of the 
 said A. B. [or for the public safety, as the case may be] 
 that the said A. B. should he forthwith placed under 
 care and treatment. My reasons for this conclusion are 
 as follows : [State them]. 
 
 By this means a case of acute mania can be got 
 under control at once ; a patient who is taken ill in an 
 hotel or a lodging-house, or who arrives insane on board 
 ship, can be immediately taken to a place of safety. 
 
 The inquisition is a purely legal procedure, and the 
 only function of the medical practitioner in connection 
 with it is to make an affidavit and to give evidence 
 when called upon. It results in the appointment of a 
 committee of the estate to administer the financial 
 affairs of the patient, and of a committee of the person 
 to direct how the patient shall be cared for, and to be 
 responsible for his personal welfare. 
 
 IN SCOTLAND 
 
 Idiots and imbeciles under eighteen years of age may 
 be received into training schools in Scotland without 
 even the small formalities which are needed in England 
 and Wales ; but in practice all such cases are sent to 
 such institutions as lunatics, with the usual formalities 
 required for lunatics, in order that thereby the Govern- 
 ment grant may be obtained. When above the age of 
 eighteen and when sent to institutions other than train- 
 ing schools, idiots and imbeciles are classed as lunatics, 
 and are subject to the same formalities. 
 
334 A TEXT-BOOK OF INSANITY 
 
 Insane persons whose malady is not confirmed may be 
 placed in private care for a period not exceeding six 
 months, under the certificate to that effect of one 
 medical practitioner. 
 
 Insane persons, whether pauper or non-pauper, can 
 be placed in institutions upon an order of the sheriff, 
 which is obtained by petition, accompanied by a state- 
 ment of particulars and the certificates of two medical 
 practitioners. In the case of a pauper, the petitioner is 
 the inspector of poor. 
 
 The English urgency order is paralleled by a certificate 
 of emergency given by a single medical practitioner, 
 and accompanied by a request from the person in the 
 position of petitioner, to the superintendent of the 
 institution, to receive the patient. 
 
 By interdiction a person who is prodigal or facile — 
 that is, too easily influenced by others — can be restrained 
 from alienating his property without the consent of 
 guardians, called interdictors, who are appointed by 
 the court. This provision has no parallel in English 
 law. 
 
 The English inquisition is paralleled in Scotch law 
 by the proceedings of cognition and curatory. The 
 curator appointed by the court administers the estate 
 of the lunatic, but there is no functionary corresponding 
 to the committee of the person. 
 
 IN IRELAND 
 
 The formalities differ according as the patient is to 
 be taken to a district asylum or to a licensed or un- 
 licensed house. 
 
 Pauper patients vjJio are not dangerous require for their 
 admission into a district asylum four documents : — 
 
PRACTICE IN IRELAND 335 
 
 1. Declaration before a magistrate stating that the 
 patient is insane and destitute, and giving the names, 
 addresses, and descriptions of two relatives of the 
 patient. 
 
 2. The certificate of a magistrate and of a clergy- 
 man or poor-law guardian that they have personally 
 inquired into the case. 
 
 3. One medical certificate. 
 
 4. An engagement by the applicant to remove the 
 patient when called upon to do so. 
 
 Paying ^patients who are not dangerous require for 
 admission into a district asylum even more documents 
 than the foregoing, viz. : — 
 
 1. A declaration before a magistrate that the patient 
 has not sufficient means to pay for his support in a 
 Licensed house, and has no friend who can do so ; and 
 stating how long the patient has been resident in the 
 country. 
 
 2. The certificate of a magistrate and a clergyman 
 that the case has been investigated. 
 
 3. One medical certificate signed by two medical 
 practitioners. 
 
 4. An engagement to remove the patient when called 
 upon to do so, and to pay a specified sum for his support. 
 
 5. The sanction of an inspector of lunatics. 
 
 As might have been expected, proceedings so cum- 
 brous are in practice never employed, and practically 
 all the patients in the district or public asylums of 
 Ireland are admitted as dangerous lunatics^ having been 
 apprehended " under circumstances denoting derange- 
 ment of mind, and an intention of committing an indict- 
 able offence," and removed by warrant from gaol to 
 the asylum. 
 
336 A TEXT-BOOK OF INSANITY 
 
 Into licensed houses^ charitable institutions, and single 
 care in Ireland patients are admitted upon the following 
 documents : — 
 
 1. An order by a relative or connection of the lunatic. 
 
 2. A medical certificate signed by two medical 
 practitioners. 
 
 In cases of urgency the signature of a single prac- 
 titioner is sufficient, provided that a second be added 
 within fourteen days of the first. 
 
 The proceedings under inquisition are practically 
 the same as in English law. 
 
 In connection with the placing of an insane person 
 under control, and generally in connection with the 
 examination and investigation of cases of insanity, a 
 warning must be given to the medical practitioner 
 never under any circumstances to lend himself to 
 deceit, or subterfuge, or cunning devices, in dealing 
 with his patients. There is a practice, unhappily still 
 too common, of regarding persons who are in any degree 
 of unsound mind as if all the ordinary canons of truth 
 and honesty were dissolved and obliterated in as far 
 as dealings with them are concerned. They are apt 
 to be looked upon as beings to whom everything may 
 be lightly promised, and with whom no promise need 
 be kept ; who may be shamelessly deceived without 
 the natural consequences of deceit being incurred. 
 Such practices are utterly inexcusable, and ought on 
 no account whatever to be resorted to. When a patient 
 is to be examined with respect to his state of mind, the 
 only fair and proper course to pursue is to explain to 
 him, if he is sensible enough to understand the explan- 
 ation, what the object of his visitor is in subjecting 
 
KEEPING UNDER' CONTROL 337 
 
 him to examination. And if it becomes necessary to 
 remove him to an institution, the necessity should be 
 pointed out to him, and he should be told where he is 
 going, and why. If he objects, he should be reasoned 
 with, and if reasoning and persuasion are of no avail, 
 he must be told that, if necessary, force will be em- 
 ployed. Of course, if he is not sensible enough to under- 
 stand, this procedure need not be adopted, but even 
 then, no deceit should be employed to gain a temporary 
 advantage at the certain cost of much subsequent 
 trouble. 
 
 KEEPING UNDER CONTROL 
 
 The law with regard to the custody of insane persons is 
 extremely stringent, and in these days, when every 
 medical practitioner, while waiting for his practice to 
 grow, seeks to eke out his income by taking a resident 
 patient, it is important that this should be known. The 
 terms of the Lunacy Act, 1890, are as follows : — 
 
 " Subject to the exceptions in this Act mentioned, a 
 person . . . shall not be received or detained as a 
 lunatic . . . as a single patient, unless under a reception 
 order made by a judicial authority," etc. 
 
 " Every person who, except under the provisions of 
 this Act, receives or detains a lunatic or alleged lunatic 
 in an institution for lunatics, or for pajonent takes 
 charge of, receives to board or lodge, or detains a lunatic 
 or alleged lunatic in an unlicensed house, shall be guilty 
 of a misdemeanour, and in the latter case shall also be 
 liable to a penalty not exceeding fifty pounds." 
 
 "Except under the provisions of this Act, it shall 
 not be lawful for any person to receive or detain two or 
 more lunatics in any house unless the house is an 
 institution for lunatics or workhouse." 
 
 "Any person who receives or detains two or more 
 lunatics in any house except as aforesaid shall be guilty 
 of a misdemeanour." 
 
338 A TEXT-BOOK OF INSANITY 
 
 It is unlawful, therefore, to receive into residence a 
 lunatic or alleged lunatic without a reception order, 
 and only one such patient can be received into a private 
 house even with such an order. It matters not whether 
 a profit is made or no. Last year a medical man was 
 prosecuted for having, for payment, taken charge of 
 his brother, an " alleged lunatic," for having, for pay- 
 ment, received him, and for having, for payment, de- 
 tained him in an unlicensed house. It was proved that 
 the Master in Lunacy was aware of and approved the 
 arrangement, and it was proved that the income that 
 the medical man received for his brother's keep did not 
 cover the charges for him, but nevertheless the de- 
 fendant was convicted of the technical ofience. The 
 important question, upon which the whole of the section 
 practically hangs, is, What is an " alleged lunatic " ? 
 Without presuming to decide a legal point, it may be 
 stated that, as far as can be at present ascertained, an 
 '' alleged lunatic " probably means a person who is 
 certifiably insane. 
 
 If, therefore, a medical practitioner — or, indeed, any- 
 one else — desires to receive, for payment, a patient who 
 is certifiably insane, it is absolutely necessary that he 
 should refuse to receive the patient except upon a judi- 
 cial reception order, otherwise he may find himself 
 liable to severe penalties. He must remember, more- 
 over, that when he does receive a patient under a 
 judicial reception order, he is at once responsible for 
 keeping statutory books and sending statutory notices 
 and reports, that he must submit to have his house 
 periodically visited and inspected, and his domestic 
 arrangements criticised and reported upon, and generally 
 that he will be under supervision, and responsible, it 
 may be to more than one authority, for every detail in 
 
TESTAMENTARY CAPACITY 339 
 
 the treatment of his patient. The numerous duties of 
 record and report cast upon the person who has charge 
 of a patient in private care are far too lengthy to set 
 out here, and will be found in detail in " Lunacy Law 
 for Medical Men " (Churchill) by the present writer. 
 
 TESTAMENTARY AND CONTRACTING CAPACITY 
 
 It may happen to any medical practitioner to be called 
 upon to give evidence as to the capacity of a testator 
 to make a valid will. It is not infrequent for the family 
 medical attendant to be called upon to witness a will, 
 and when he does so he should remember that he does 
 not do so as an ordinary witness, whose attestation means 
 merely that the signature of the testator was attached 
 to the will in the witness's presence. When a medical 
 practitioner attests a will, his attestation means, not 
 only that the testator executed the will in his presence, 
 but it means in addition that the testator was at the time 
 of sound and disposing mind, and fit to make a will. 
 The attestation of the medical witness is a certificate 
 of competency given to the testator. 
 
 When there is any question of the capacity of a testa- 
 tor, the following are the points to which the examining 
 practitioner should give his consideration : — 
 
 L Does the testator understand the nature of his 
 act ? — that is to say, does he realise that he is making 
 a disposition of his property to take effect after his 
 death % Does he know whom he is benefiting and 
 whom he is excluding from benefit, and the extent to 
 which his legatees severally benefit under his will ? 
 
 2. Does he understand and appreciate the nature 
 and extent of his property ? It is not essential, of 
 course, that he should be acquainted vvith every detail if 
 
340 A TEXT-BOOK OF INSANITY 
 
 lie is a man of large property, but he should have a 
 general knowledge sufficient for the purpose. 
 
 3. Does he comprehend and appreciate the nature 
 of the claims to which he ought to give effect ? — that is 
 to say, has he a clear knowledge and recollection of the 
 existence of the persons that he excludes from his will, 
 and of the relation in which they stand to him 1 Has 
 he sufficient intelligence to compare the claims of 
 different people upon his bounty ? And lastly, has he 
 any such disorder of mind as shall " poison his affections, 
 pervert his sense of right, or prevent the exercise of his 
 natural faculties " ? Has he such insane delusion as may 
 " influence his will in disposing of his property, and 
 bring about a disposal of it which, if the mind had 
 been sound, would not have been made " ? To vitiate 
 the disposing power, it is not sufficient that the testator 
 should suffer from delusion. Many insane persons 
 suffering from delusions have made wills which have 
 been upheld by the court. To destroy the " disposing 
 mind," the testator must not only suffer from delusions, 
 but the delusion must be of such a character as to in- 
 fluence him in the disposal of his property. Contracting 
 capacity requires the same conditions mutatis mutandis 
 as testamentary capacity. 
 
 Ceiminal Responsibility 
 
 The third occasion upon which a medical practitioner 
 may be brought into contact mth the law in dealing 
 with an insane person is in connection with criminal 
 responsibility. When the plea of insanity is raised in 
 a criminal case, the question left to the jury is. Did the 
 prisoner, at the time the crime was committed, know 
 the nature and quality of the act that he was com- 
 
CRIMINAL RESPONSIBILITY 341 
 
 mitting and that it was wrong ? What amount of light 
 the medical witness will be allowed to throw upon this 
 question, supposing that he can throw any, will depend 
 upon the discretion of the judge who tries the case, 
 but the practice nowadays is for the judge to allow a 
 very wide latitude to the medical witness, and for the 
 latter to state his opinion very freely. In doing so he 
 should, however, not allow himself to be influenced by 
 any sentimentality or professional prejudice in favour 
 of the plea of insanity, and there are certain practical 
 precautions which it is his duty to take. In his inter- 
 views with the prisoner he should furnish himself with 
 writing materials and take down the prisoner's state- 
 ments in the prisoner's own words and in the prisoner's 
 presence. He will then be entitled to refer to his notes 
 in the witness-box in order to refresh his memory. He 
 is, of course, entitled to record anything that the 
 prisoner may say about the crime and his share in it, 
 and to ask him consequential questions arising out of 
 these statements, but he must most carefully avoid 
 asking the prisoner whether he committed the crime, 
 or putting to him leading questions implying that the 
 crime was committed by him. The matter comes too 
 rarely into the practice of the general practitioner to 
 need explanation at length here, and those who desire 
 to pursue it will find it treated in detail in any book 
 on Criminal Responsibility. (Clarendon Press.) 
 
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APPENDIX B 
 
 LETTERS OF INSANE PERSONS 
 
 In many forms and varieties of insanity letters are 
 never written. In other forms the writing of letters 
 forms one of the chief occupations of the patient, and 
 the letters are often very characteristic. 
 
 The two varieties in which the writing of letters is 
 most characteristic are general paralysis and paranoia. 
 In sub-acute mania also, the letters written are often 
 very numerous. 
 
 In the early stage of general paralysis, the letters 
 are very numerous, and have the characteristics already 
 described. They very often contain orders for the 
 purchase of goods in great quantity. In paranoia, the 
 writing of letters is usually a very prominent symptom, 
 and the letters are often of an extremely insane character 
 when Little or no indication of insanity can be obtained 
 from the conversation of the patient. The letters some- 
 times, but by no means always, contain references to 
 the persecution from which the patient believes that he 
 suffers. They are sometimes neat and tidy, but more 
 often are written anyhow — first a body of writing down 
 the middle of the page, then the margins are utilised, 
 then the writing is crossed, and perhaps recrossed and 
 interlineated. When all the paper has been occupied 
 in this way, ragged scraps are added, old envelopes are 
 
 345 
 
346 A TEXT-BOOK OF INSANITY 
 
 utilised, margins of newspapers, pages torn out of books, 
 bits of paper bags, anything in the shape of paper, and 
 finally the letter is concluded on the flap of the con- 
 taining envelope, and often on the outside of it also. 
 The handwriting is usually very bad, often illegible, and 
 when deciphered, the confusion of thought so character- 
 istic of paranoia is very conspicuous — more so, usually, 
 than it is in the conversation. Often there are long 
 strings of words from which no meaning whatever can 
 be extracted. Sometimes the manuscript is varied by 
 sketches, or by mysterious symbols and diagrams. The 
 letters are usually written to prominent people with 
 whom the patient has no acquaintance — to the sovereign, 
 to the Secretaries of State, to foreign potentates, to 
 prominent politicians, philanthropists, actors, athletes, 
 to anyone whose name is mentioned in a newspaper. 
 
INDEX 
 
 Reviewers will rejoice greatly to find no index to this book, for 
 its absence will save them the trouble of reading the book to discover 
 whether they ought to award to it praise or blame. It was Carlyle 
 who first erected the index into the most important feature in a book, 
 and made the presence or absence of an index the criterion of literary 
 excellence ; and subsequent reviewers have followed him with a 
 unanimity of imitation that I will not call slavish, but that certainly 
 lacks nothing in faithfulness. Why the absence of an index should 
 always rouse a reviewer to fury I have never been able to understand. 
 It is no necessary adjunct to a book, and many books that were 
 published before the day of Thomas Carlyle are allowed to have 
 merits, even though they have no index. There is no index to the 
 Iliad, to the dramas of Sophocles or Euripides, to Euclid's Elements, 
 or to CiBsar's account of the Gallic War. There is no index to 
 Shakespeare's Plays, to Don Quixote, to the Pilgrim's Progress, or to 
 the Novum Organon. Even the Bible is without an index. AVhy, 
 then, should the absence of an index be such a damning fault in the 
 eyes of the modern reviewer ? I am far from asserting that no 
 book should have an index : there are many books whose usefulness 
 would be sadly impaired if an index were wanting. Such are BradshaAv's 
 Railway Guide, the Stores Catalogue, Whittaker's Almanack, books 
 on Case Law, and other hiblicc ahihlia ; but to add an index to a book 
 on a single subject — a book which treats that subject systematically 
 and orderly, so that each topic is in its proper place, and can be found 
 at once by anyone who is familiar with the plan of the work — seems 
 to me nothing short of an insult to the intelligence of the reader. 
 Apart from its use as an infallible guide to the judgment of the 
 reviewer, an index is no use at all in any book but those of the kind 
 mentioned above. In no other book is the index ever consulted ; 
 at any rate, I have never myself consulted an index, nor in any of 
 the books that I have in past years borrowed from my friends, and 
 supported gratuitously ever since upon my own bookshelves, have the 
 pages containing the index ever been opened, either before or after my 
 benevolent assumption of their care. 
 
 347 
 
348 A TEXT-BOOK OF INSANITY 
 
 For what is an index ? It is an apparatus to enable a reader to find 
 any given topic in the book. To add an index to a book that is 
 logically arranged is to take it for granted that the reader is not 
 intelligent enough to appreciate a logical arrangement, but must have 
 the topics arranged alphabetically before he can find them. When, 
 therefore, a reviewer complains that such a book as this has no index, 
 he carries his complaint to the wrong quarter ; he lays the burden on 
 the wrong shoulders. His grievance lies, if he did but know it, not 
 against the author of the book, but against his own parents. 
 
 WILLIAM BRENDON AND SON, LTUi 
 PRINTERS. PLYMOUTH 
 
COLUMBIA UNIVERSITY LIBRARIES 
 
 This book is due on the date indicated below, or at the ' 
 expiration of a definite period after the date of borrowing, as 
 provided by the rules of the Library or by special arrange- 
 ment with the Librarian in charge. 
 
 DATE BORROWED 
 
 DATE DUE 
 
 DATE BORROWED 
 
 DATE DUE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 C2b(M4i)m100 
 
 
 
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