Columbia ®mber!^it|> ^^^. ^cJjooI of Bcntal antj O^ral burger? ^tttvmtt Hibrarp PSYCHOLOGICAL MEDICINE Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/psychologicalmedOOcrai PSYCHOLOGICAL MEDICINE A MANUAL ON MENTAL DISEASES FOE PEACTITIONEES AND STUDENTS P7 MAURICE CRAIG M.A., M.D. (CANTAB.), F.R,C.P.(LOND.) PHYSICIAN FOR AND LECTDEER IN PSYCHOLOGICAL MEDICINE, GUY'S HOSPITAL EXAMINER IN PSYCHOLOGICAL MEDICINE FOB DIPLOMA IN PSYCHOLOGICAL MEDICINE, CAMBRIDGE UNIVERSITY EXAMINER IN PSYCHOLOGY AND PSYCHOLOGICAL MEDICINE, LONDON UNIVEESITT LATE CLINICAL TEACHER OF PSYCHOLOGICAL MEDICINE, ROYAL ARMY MEDICAL COLLEGE, LONDON LATE SENXOB ASSISTANT PBYSIOIAN, BETHLEM ROTAL HOSPITAL, LONDON THIRD EDITION WITH 27 PLATES, SOME IN COLOUR PHILADELPHIA P. BLAKISTON'S SON & CO. 1012 WALNUT STREET 1917 n V I h i.. VI- L ^(^-^^^ -^•■Printed in Great Britain. L'l'Vv'.lO'^ VA T\.}JS.'d ,' PREFACE TO THE THIRD EDITION As almost all the European countries have been involved in war for the past two and a half years, research in psychological, medicine, like many other studies for the advancement of know- ledge, has had to make way for more pressing needs ; conse- quently there has not been as much new work to embody in this edition as on the last occasion. Nevertheless very steady progress is being made, and the war, entailing as it has done great strains upon a large number of men and women, has been the means of bringing in new observers who are opening up fresh fields of study, and consequently the great developments in this branch of medicine which were foreseen and referred to in the Preface to the Second Edition will take place even more rapidly than one could have hoped. A new era in the study and treatment of functional nervous diseases is beginning ; the former attitude towards mental disease will be changed ; antiquated terminology and superstitious beliefs will be replaced by scientific terms and a proper understanding of the subject.- There are still no facihties for the treatment of poor persons who are showing signs of nervous exhaustion ; these continue to be allowed to drift on until many of them can be certified as insane. Public opinion is beginning to appreciate the state of affairs and will shortly demand attention to this matter. During the last three years the Mental Deficiency Act has been added to the Statute Book and it is fully referred to in this edition. A new chapter has been devoted to the functional neuroses and psycho-neuroses occurring in those exposed to the stress of war. Psycho-analysis has been more fully VI PREFACE described in the present edition, and other subjects have been added to and brought up to date. Once again I have to express my grateful thanks to Colonel Mott, Director of the Laboratory and Pathologist to the London County Asylums, for supplying me with most of the illustrations found in this book. To my Secretary, Miss Brameld, I owe a special debt of gratitude for her careful revision of the proofs and the preparation of the Index. M. C. 87 Habley Street, April 1917. PREFACE TO THE FIRST EDITION The object of tins book is to lay before the student a short account of the principles and practice of Psychological Medicine. Several years of teaching have fully convinced me that for his future usefulness the student must be thoroughly taught the underlying principles of disease, whether that disease falls within the province of Medicine or Sm'gery. It is not sufficient to know that certain symptoms will be found to exist in certain maladies ; the cause of their presence and their relative importance are subjects requiring intelligent study. The keen and thoughtful observer will succeed in healing disease when a superficial physician fails, although the latter may have a thorough knowledge of his bookwork. Once the fundamental principles of insanitj^ have been learnt, the disorders of mind will at least be intelligible, and no longer a mere concatenation of strange symptoms. Throughout the foUo"v\dng pages the student will be con- stantly reminded to look upon Inental disorders in the same way that he views disease in general. This warning is very necessary, as so many men regard the insane as if they were the victims of some strange visitation, and not sufferers from ordinary illness. Antiquated terms, such as ' mad ' and ' lunatic,' are strongly condemned, and are never used in this book, except when quoting Acts of Parliament or legal authorities. The retention of these words is harmful in many ways and retards progress. It IS therefore incumbent on the physician not only to discon- tinue using them himself, but to discountenance the employ- ment of them by others. VUl PREFACE I have not cited cases illustrative of the various disorders ; to have done so would have made the book more cumbrous, with no commensurate advantage. The descrijjtion of isolated cases may be very misleading, disorders being largely coloured by the individual characteristics of the patient. I have also decided not to reproduce photographs of patients suffering from various diseases. In the majority of instances it is impossible to give a typical photograph of a sufferer from anj^ disease until that disease is confirmed. The earliest symptoms of mental disorders rarely, if ever, show themselves by changes in the facial expression or attitude of a patient. Photographs, therefore, do not assist the diagnosis of mental disorders in their earliest forms, the point upon which I desire to lay especial stress. It is during the initial stages that disease lends itself most readily to treatment. Unfortunately, the early symptoms of mental disorder are commonly overlooked, as frequently neither the physician nor the laity attach sufficient importance to slight changes of character or symptoms of nervous fatigue. The question of treating minor symptoms, such as restlessness and irritability, is a point to which the reader should give attention. As regards the general scheme of the book, an attempt has been made to meet the requirements both of the general practitioner and of the student. The opening chapter is devoted to a short description of normal psychology, as it is difficult for a physician to investi- gate or accurately gauge symptoms of the diseased mind if he is totally ignorant of normal mental processes. No new classification of insanity is olTered, but I have endeavoured to hold an even balance between the old and the new school of Psychiatry, If we cannot accept the whole of Kraepelin's classification of mental disease, we can by no means ignore it, forming as it does the most important contri-- bution of recent years to the literature of insanity. I do not disguise from myself the many imperfections of my attempt at readjustment, but crave the clemenpy of the critics on the ground that the remodelling of old ideas is ever difficult. A chapter has been devoted to the subject of law in its relationship to insanity, and matters such as testamentary PREFACE ix capacity and criminal responsibility have been especially dealt with. As sleeplessness is both a frequent caase of, and an im- portant symptom in, most forms of mental disorder, a chapter has been reserved for its consideration. The subject-matter throughout the book has been broken up into sections for the benefit of those who wish to refer to special matters only. This book is designedly simple in both arrangement and language, and is, to a great extent, a summary of many years' asylum experience digested for the student. If it in any way helps the student to a better understanding of insanity, or assists the general practitioner in the early diagnosis and treatment of mental disorder, it will have fulfilled its purpose. I owe my gratitude to many friends, who have given me invaluable assistance. To Dr. F. W. Mott, Director of the Laboratory and Pathologist to the London County Asylums, I am deeply indebted for supplying me with most of the illus- trations found in this book ; and also for his many kind sugges- tions and ever ready help. I accord my thanks to the members of the Asylums Committee of the London County Council for their kindness in allowing me to reproduce several illustra- tions from the ' Archives of Neurology.' I am also under no small obligation to my friend and former colleague. Dr. E, Goodall, Medical Superintendent of the Joint Counties Asylum, Carmarthen, not only for the loan of several photomicrographs, but also for his kindly assistance in the reading of a large portion of the manuscript, and for many useful suggestions and correc- tions. To my brother, Norman Craig, barrister-at-law, I am indebted more than I can well express for devoting much time and thought to the revision and correction of the whole manu- script. I also owe my grateful thanks to my colleague. Dr. Stoddart, for several kind suggestions, and to Dr. J. S. Bolton and Dr. G. Watson for the very kind loan of microscopic preparations and photomicrographs. M. C. March 1905. CONTENTS CHAP. PAQE Pbefaoe . . . . , .V I. NoBMAL Psychology 1 II. What is Insanity ? .19 III. Causation of Insanity . . . . , . . . 26 IV. Classification of Insanity .39 V. General Symptomatology ....... 45 VI. Mania 99 VII. Melancholia and States of Depeession . . . . 115 VIII. Stupor .133 Catatonia 138 [IX. Chronic Delusional Insanity (Paranoia) ... 141 X. Dementia PB^aEOox . . 156 XI. Secondary Dementia 166 Organic Dementia ...... . . 170 XII. Epochal Insanities : Puerperal Insanities 173 Climacteric Insanity .181 Senile Insanity and Abtbeiopathio Dementia . . 186 XIII. Intoxication Psychoses: Alcoholism 196 KoBSAKOw's Disease 213 mobphinism 214 cocainism 218 Plumbism 220 XIV. Gbneeal Pabalysis of the Insane (Dementia Pabalytica) 222 XV. Exhaustion Psychoses : Nbbve Exhaustion and Nbubasthenia ... 254 Anxiety Nbubosis 260 Acute Hallucinatory Insanity ..... 260 zi Xll CONTENTS CHAP. XVI. General Neuroses : Epilepsy and Insanity Hysteria and Insanity . Traumatic Neuroses , XVII. Psyohasthenia and Obsessions XVIII. The More Common Neuroses : Psycho-neuroses occur- ring IN Men exposed to Shell Shock and Strain 265 277 287 293 XIX. UJJ- VVAU ...... Insanity and Physical Diseases : . . . ouu Phthisis and Insanity .... 312 Diabetes and Insanity . 315 Influenza and Insanity . . 315 Chorea and Insanity . 317 Insanity of Myxcedema . . 320 Exophthalmic Goitre . 324 Cretinism . . 325 Gout and Insanity .... . 328 Rheumatic Fever and Insanity . . . 330 Heart Disease and Insanity . . 331 Sunstroke and Insanity . . 331 Malaria and Insanity . 332 Syphilis and Insanity .... . . 332 XX. Defective Mental Development : Idiocy and Imbecility . 340 Moral Imbecility . .' . . . 364 XXI. Feigned Insanity . . . . . . 373 XXII. The Relationship op Insanity with Law . . . 380 XXIII. Sleeplessness . 400 XXIV. Case-taking . . 412 XXV. Treatment' ..... . .433 INDEX . . 479 Plates I. and II. ..... . between pages 164 and 165 jj III.— XXVII f 252 and 253 PSYCHOLOGICAL MEDICINE CHAPTEE I NORMAL PSYCHOLOGY Although it may be outside the province of a treatise on Mental Diseases to discuss Psychology and Psychological Pro- blems, nevertheless it must be helpful, if not absolutely neces- sary, for the student to Imow something of the. workings of the normal mind in seeking to understand the mind which is disordered. For this reason a few preliminary pages may be usefully devoted to a brief review of normal mental processes. Mind is composed of processes which are constantly changing, therefore the ' ego ' of one moment is not the ' ego ' of the next. It is this constant and rapid changing that makes the study of mind so difficult. Further, a mental process is purely subjective, whereas processes dealt with by other sciences are largely objective and can form part of the experi- ence of others. Psychical and physical processes are intimately connected, and our study of mind is largely assisted by observ- ing its influences on the body. For centuries philosophers and scientists have from time to time promulgated various theories as to the relation of mind and body. There are the ideahsts, who make body dependent upon mind ; and the materialists, who postulate that mind is dependent upon matter. But the psychologist of to-day prefers not to dog- matise in either direction, and the theory of psychophysical parallelism is that which is largely held. This theory neither makes mind dependent upon matter, nor the body dependent upon mind, but states that throughout life there is a chain of 1 •2 PSYCHOLOGICAL MEDICINE psychical events which runs parallel to another chain of phy- sical events. Others hold the theory of inter-actionism, in which it is believed that inter-action takes place between the spiritual or mental processes and those which are material or nervous. The close relationship between mind and body is evident to all observant physicians. There is a mental aspect to all physical disease ; but this mental aspect is too frequently overlooked, wdth consequent failure to recognise a symptom the treatment of which would tend greatly to the relief of a patient. The mental depression with gout, and the hopefulness of a patient with phthisis, are symptoms which are apparent to the most careless of observers. On the other hand, how frequently we see such a symptom as the irritability of fatigue, so often an indication of the approach of more serious trouble, either misconstrued or overlooked. In the same way, if due attention were given to such physical changes as loss of weight and irregularities of the action of the bowels in unstable individuals, much mental disorder might be averted. For the moment it is enough to impress upon the reader that the mental aspect of the organism cannot be separated from the physical, and that if the symptoms of the one appear to be more urgent than the other, the lesser must not be overlooked. Sensation. — ' Sensation ' is the term used to express the most elementary of all conscious processes, and is the result of the stimulation of some bodily organ. Sensations are of two kinds, viz. (1) Special sense sensations, (2) Organic sen- sations. The former are due to stimulation of one of the special sense organs, and the latter are sensations w^hich are derived from the ]\Iuscles, Tendons, Articular Surfaces, Ali- mentary Canal (hunger, thirst, nausea, etc.), and the Circu- latory, Respiratory, and Sexual Organs. The organic sensations differ from the special sense sensa- tions by being more diffusible and more closely connected with the feelings. They are not so well defined, and tend more quickly to die out of memor3^ The attributes of sensation are : (1) Quality, (2) Intensity, (3) Duration, and (4) Extent. Quality is the attribute by which we distinguish one sensation from another ; for instance, a colour is always the same colour no matter how intense or for what lenath of time it lasts. NORMAL PSYCHOLOGY 3 I'urther, every sensation differs in intensity, and, according to Weber's Law, ' if sensations are to increase in intensity by equal amounts, their stimuli must increase by relatively equal amounts.' That is to say, the intensity of a stimulus must increase by a certain definite amount before any appre- ciable difference in the sensation can be detected. The other attributes of sensation apply to time and extent, the latter being present only in the cases of sight and touch. The sense of position and movement is largely made up of sensations derived from muscle, tendons and articular surfaces. Affection. — Affection has been defined by Titchener in his ' Primer of Psychology ' as an ' elementary conscious process which may be set up by the stimulation of any bodily organ. There are only two affections, (a) Pleasantness, (t) Unpleasant- ness. To quote the same author again : ' Now, when we have in consciousness a complex process composed of sensations and pleasantness or unpleasantness, and when the affective side strikes us more forcibly than the sense side, we call the total process feeling.' Affection differs from sensation in several ways. The more we attend to a sensation the clearer it becomes, whereas if we direct our attention to an affection it fades at once. Habituation weakens affection, but not sensation, for we _find that after weak sensations have lasted for some time they may even become painful. Affections which have been almost unbearable, in course of time, if they continue, may be scarcely noticed ; this is especially noticeable in disorders -such as melancholia. Both with feeling and affection there are certain bodily changes which accompany them. They are not so marked as the changes found with emotion, but consist of alteration in the state of pulse, breathing, bodily volume, and muscular strength. These changes clearly show the close relationship between mental and physical processes. Attention. — Attention is the sustained and continued con- centration of the mental faculties on some particular object or idea. Mental processes do not all flow along at the same level ; some we encourage, others we endeavour to inhibit. Thus attention consists partly of reinforcement and partly of inhibition. The perceptions which we encourage become clearer, last longer, and are more useful. Among the bodily 4 PSYCHOLOGICAL MEDICINE aspects of attention we find that the muscles, especially of the neck and eyeballs, are fixed, expiration is prolonged, or the breath may be held altogether. The head is often turned to one side and fixed. Probably the tension of the tendons and muscles in action largely accounts for the sensation of effort (Conation) which is occasioned by active attention. Attention is constantly fluctuating, and cannot be fixed for more than a short time together. The range of attention varies, and although probably one cannot concentrate the mind on more than one complex idea at a time, one can, as has been shown by experiment, attend to several simple stimuli at the same moment. In addition to active attention there is a state of passive attention, at times spoken of as instinctive attention. Certain things have to be attended to, whether one wishes it or not ; for instance, loud sounds or bright lights. One is largely indebted to passive attention for warning of any sudden danger. Attention is an attribute of fairly late development. Some cliildren never acquire it, and at all times it is easily lost ; attention fails with fatigue, and is affected in all forms of mental disorder. Attention is the basis of action, for in the primitive organism without attention there would be total inaction. Conation. — Closely connected with Attention is found a condition known as Conation, or Feeling of Effort. All con- sciousness is more or less conative, but some states of con- sciousness are far more conative than others. In prolonged active attention there is a strong feeling of effort. Some authorities beheve conation to be central in origin, and directly due to brain activity ; others hold that it is purely the result of tension and strain in the muscles and joints, and ^is thus produced by peripheral changes. Perceptions and Ideas. — By origin perceptions and ideas are alike ; but, for the sake of clearness, a distinction between them may be drawn. Perception may be spoken of when sensation is actually aroused by the presence of some external stimulus ; idea, when the mental image of a former sensation is intended. For instance, I see a book in front of me : that is a percept ; while if I close my eyes I have a mental record of the former sensation derived from seeing the book : that is an idea. NORMAL PSYCHOLOGY 5 Perceptions and Ideas are divided into three classes, viz. (1) Qualitative, (2) Extensive, and (3) Temporal. What has been said of sensations can be said of perceptions, so far as quaHty is concerned. Further, one is aware of locality and position ; one recognises a definite arrangement of things in space. This knowledge in early life is largely acquired from tactual sensation ; a child will stretch out its hand to reach things far beyond its grasp. As evolution goes on, the visual sense develops, and in adult Hfe it is on this sense that chief reHance is placed for information as to size, position, and distance. Binocular vision is far more accurate in measuring the third dimension than monocular vision. There is no inborn sense of the position of things in space ; it is derived from education, and by such data as the size of the object, its outhne and distinctness, the uniformity of colouring, by the accom- modation and movement of the eyes, and by comparison with surrounding objects. Sterognosis is a term which is applied to the perception of form and consistency as derived from the tactile and kin- sestbetic senses. This sense becomes disordered under certain conditions. Rhythm. — Temporal perceptions and ideas include rhytlim. Now rhythm is found to accompany both mental and physical processes. Sleeping and waking occur, or ought to occur, at regular intervals. Walking is rhythmical^ Marked periodi- city is present in the reproductive functions, especially in those of the female. Allusion has already been made to the fact that attention waxes and wanes : it does so in a rhythmical manner. The aesthetic sentiment is found to favour rhythm, as is shown by melody and dancing. Ehythm also plays a prominent part in many forms of mental disorder. The insanity known as folie circulaire is markedly rhythmical. Dipsomania and other impulsive forms of mental disease may be periodical in onset. There are several disturbances of the process of perception, such as Illusions and Hallucinations, but it will be more convenient to describe them in a subsequent chapter. Association o£ Ideas. — Let consideration next be given to Association of Ideas ; that is to say, the tendency of every idea to bring into the mind its associated ideas. This may occur 6 PSYCHOLOGICAL MEDICINE by simultaneous association ; a presented idea may bring up without any appreciable delay another idea. Or the associa- tion may be successive, as instanced by reverie or train of thoughts. The association of ideas plaj-s a far larger role in an in- dividual's life than many persons appreciate. If it were not for this process we should never get beyond the most rudi- mentary state of thought and action. This power of associa- tion is the basis of habit, and habit directs and dominates om' whole life. Habit. — Habit, as akeady stated, is an example of the law of association. Broadly speaking, there are two great divi- sions of habits : (1) Those wliich are inborn in us, and which may be looked upon as instincts ; (2) Those which have been acquired in the lifetime of the individual. It is over the latter that v\-e have the greatest control. Professor James states, ' The phenomena of habit in living beings are due to the plasticity of the organic materials of wliich our bodies are composed. Our nervous system grows to the mode in which it has been exercised. Habit simplifies the move- ments to achieve a given result, makes them more accurate, and diminishes fatigue.' Watch, for instance, the beginner leaiTing to play the piano ; at first the energy employed seems to spread all over the body, but the more easily the special movement occurs, the shghter the stimulus required to produce it ; and, the slighter the stimulus, the more its effect is confuied to the fingers alone. Dr. Maudsle}^ puts the matter very tersely when he says, ' If an act becomes no easier after being done several times, if the careful direction of conscious- ness were necessary to its accomplishment on each occasion, it is evident that the whole activity of a lifetime might be confined to one or two deeds — that no progress could take place in development — a man might be occupied all day in dressing and undressing himself ; the attitude of his body would absorb all his attention and energy ; the washing of his hands or the fastening of a button would be as difficult to him on each occasion as to the child on its first trial, and he would furthermore be exhausted by his exertions.' Again : ' Habit diminishes the conscious attention with which our acts' are performed.' We automatically learn to do the right thing NORMAL PSYCHOLOGY 7 at the right moment, as in walking, jumping, fencing, etc. but we may also learn to do the wrong things habitually ! Once again, to quote Professor James, ' We all of us have a definite routine manner of performing certain daily offices connected with the toilet ; our lower brain centres know the order of these movements, and show their sm'prise if the objects are altered so as to oblige the movement to be made in a different way. But our higher thought centres know hardly anything about the matter. Few men can tell off- hand which sock or shoe thej^ put on first.' I cannot tell the answer, but my hand never makes a mistake. Now in action gi-own habitual, that which instigates each new muscular con- traction to take place in its appointed order is not a thought or a perception, but the sensation occasioned by the muscular contraction just finished (in doing a thing, if one fails one often has to start again at the very beginning) ; a strictly voluntary act has to be guided by idea, perception and volition throughout its w'hole com'se. In an habitual action, mere sensation is a sufficient guide, and the upper regions of the brain and mind are set comparatively free. For example, the knitter keeps on with her knitting, even while she reads or is engaged in a conversation. Habits we must form, so that the importance of forming right ones cannot be over-estimated. Let me remind you once again that we acquii'e habits by means of actively at- tending to that which we are learning ; and, having ofttimes accomplished it, the action, mode of thought, or whatever it may be, passes out of the realm of consciousness and becomes automatic. Throughout life we are constantly putting by (packed up, as it w^re, all ready for use) judgments and actions which for the future will be available for immediate require- ments. Thus again you will see how^ important it is that these bundles of habit should be built carefully up whilst in the conscious stage ; for once they pass beyond this stage they will remain, maybe for many years, as attributes for good or ill. The importance of habits cannot be over-estimated and in treating mental disorder their significance is constantly compelling attention. Take sleep : it is largely habit, and if confidence be lost and the association between bed and sleep be 8 PSYCHOLOGICAL MEDICIKE broken, this may become a serious obstacle to the successful treatment of insomnia. Similarly delusions of persecution may be originated and confirmed by the habit of treating those around us with suspicion. The emotions should be kept under control and any "wide sweeps from excitement to depression should be corrected. The physician and those whose work lies in the training of the young should never forget to encourage the development of good habits and the eradication of bad ones, whether in the matter of physical functions or in the attri- butes of mind. And, when we turn to disease, it must always be borne in mind that bad habits may seriously jeopardise the chances of recovery and therefore must be corrected, for, as we shall point out later, bad habits may be formed during the illness which will in future militate against the patient's usefulness in life. Emotions. — Emotions are more complex than feelings. In the former the organic sensations take a prominent place ; so prominent, indeed, that some authorities go so far as to say that organic sensation is the basis of emotion. In emotion the same bodily changes occur as in the case of feeling ; but in addition there are changes in the secretory organs and in the involuntary muscles. The surface of the body may be bathed in perspiration, the mouth may be dry, and the eyes wet with tears. Extreme emotion is spoken of as Passion, and when an emotion has lasted for some time it usually calms down into a mood, which denotes a weaker emotive state. The feelings and the emotions are a useful barometer by which the mental state and even the physical condition of individuals may be judged. Disturbance of the emotions is frequently an early symptom in all forms of disease, whether bodily or mental ; and, in some insanities the symptoms may be chiefly confined to emotional alterations ; or it may be that the affective changes are the concomitants of a more complex insanity. Sentiment. — A sentiment differs from an emotion in that with the former there is a state of active attention. It is by this means that we judge and say, ' This is right or wrong,' * This is true or false.' Belief and disbelief are common forms of sentiments, and it must not be forgotten that disbelief is just as positive a state as belief. Doubt is the state of un- NORMAL PSYCHOLOGY 9 certainty which Hes between two behefs. In such a condition as that of folie de doiite, which will be considered later, it will be found that the active weighing of motives, and the fear of doing wrong, are the determining factors in the inaction of a fair proportion of the insane. The aesthetic sentiment is one that has no small interest to those who have to treat the insane, for it undergoes alteration in most forms of mental disorder. The acute maniac is often decorated to an extravagant extent, and as a rule sees beauty in objects which in sanity he would condemn as vulgar or commonplace. Conversely, the melancholiac will deplore that things which he formerly thought beautiful now appear gloomy and ugly. Untidiness and want of personal cleanliness are characteristics of many of the insane. Instinct. — ^Instinct is purposive action without foresight or education, and instinctive action differs from reflex action in that it has psychical concomitants. Instincts are developed for the benefit of the race. In the lower animals instincts rule supreme ; but m^an is also pos- sessed of instincts probably even more than animals. The two fundamental instincts are desire to live and desire to reproduce, and from these many of the other instincts are derived. The infant smiles in the fifth week, and by the sixth week eye movements are complete. By the ninth week perception is being established and objects are recognised, and with the eleventh week movements which were previously aimless begin to assume purpose, owing to the myelinisation of the pyramidal tract. At this time surprise and fear begin to develop and there is an attempt to imitate sounds. Fear further develops during the next few weeks, and in the fifth month it shows itself by an instinctive shrinking from strangers. At six months there is some idea of space and distance ; compare this with a chick which has this attribute when hatched from its shell. Crawling begins about the tenth month and also pleasure is evinced in making a noise. The instinct to stand appears about the eleventh month and this is shortly followed by a desu-e to walk. Instinctive language of the * bow-wow ' order appears between the ninth and tenth months, bat voluntary language is usually not attempted 10 PSYCHOLOGICAL MEDICINE until about the sixteenth month. Curiosity appears about the nineteenth month, and from the twenty-first to the tAventy-fomih months cleanHness is developed. The mstmct of make-believe is usually present by the beginning of the thnd year. Destructiveness is most marked dming the fourth and fifth years, and by the end of the sixth year constructiveness should take its place. Modesty and shame appear at the time of puberty. Memory. — Memory is so large a subject that it is difficult to condense it into narrow limits ; but it must be here described in as few words as are compatible with clearness. Kiilpe defines that which is understood by memory in the following words : ' That an impression which has been produced in the past by a particular stimulus does not disappear outright with the cessation of that stimulus, but is somewhat con- served, and, under certain conditions, has the power of again becoming a noticeable part of conscious contents, without any renewal of the original peripheral stimulation.' In other words, memory means the tendency of the nervous elements to fall into a similar state of commotion to that in which they were when the original stimulus acted upon them. Cognition is the dii'ect apprehension of an object, it is association by similarity, one sees an object and at once cognises what it is. Recogfiition consists of three processes : there is an object before us (Percept) ; and this percept calls up by association other ideas and with this there is a feeling of familiarity. Memory differs from recognition in that the percept is replaced by an idea. There is no object before us, there is merely the mental image of a former sensation ; otherwise the process is the same, for memory stands in the same relationship to recognition as ideation does to perception. There are many types of memory, varymg in different individuals. Memories may be mainly visual, auditory, tactual, or a mixed variety ; other memories consist largely of word-ideas. Mental constitutions vary, and to this fact are due the very diverse ways in which different persons remember things. Two persons may see the same incident, and yet afterwards may describe it in such a manner that it is difficult to conceive that they are relating the same story. This is accounted for when it is remembered that the one may record what he saw, and NORMAL PSYCHOLOGY 11 what especially fell in with his tendencies; while the other, with tendencies widely different, reproduces the incident from what he heard or from some other standpoint. Thus memory, although not exact, is a partial reproduction, the accuracy of which largely depends on the mental constitu- tion of the individual, and the degree of his attention when the impression was received. Events that created a strong impression, social habits of everyday recurrence, and recent events, are all easily remembered. The power of being able to forget useless things is of great importance in relieving the memory. The marks of a good memory are : (1) The rapidity mth which the power of recalling is acquired ; (2) the length of time during which the power of recalling lasts without being refreshed ; (3) the rapidity and accuracy of actual revival ; and (4) the power of forgetting those things which are of no value or have ceased to be of value. To cultivate a good memory it is necessary to have (1) a keen observation ; (2) a power of concentrating attention .; (3) a method of arranging in a systematic way things to be remembered ; (4) a power of forming association. For prac- tical clinical purposes memory may be divided into two classes — recent, and distant or organised memory. The former is the first to go in amnesic states, as it has a lesser hold on the nervous system. Imagination. — Imagination is closely alhed to memory, and yet differs from it in several important particulars. A memory is more or less a recall or reproduction of a former perception or group of perceptions, whereas imagination is usually derived from a number of former perceptions. More- over, memory has with it a consciousness that the revival is. more or less familiar and has been experienced before. This is not the case with imagination, for with it there is no such feeling of familiarity. Imagination is entirely dependent upon memory for its existence ; for, if the power to recall past experiences be lost, the data necessary for imagination are absent. Movement and Action. — Four forms of action are usually described, viz. reflex, instinctive, volitional and automatic Keflex actions have no psychical concomitants and they are all. carried out by the lowest level of the nervous system, i.e. fronr 12 PSYCHOLOGICAL MEDICINE the oculo-motor nucleus to the end of the spmal cord. Instinc- tive actions differ from reflex actions in that they have psychical concomitants. Professor James in his ' Prmciples of Psychology ' describes instinct as follows : ' Instinct is the faculty of actmg in such a %vay as to produce certain ends, with foresight of the ends and without previous education in the performance.' Volitional or Voluntary Actions differ from the actions already described in that they have conscious antecedents and conscious concomitants. They are actions which occur after dehberation, and first appear in mfants about the age of seven- teen or eighteen months. Yokmtary action takes place when there is a conflict of motives ; and so long as this confhct lasts we call this dehberation, and the mdividual remams mactive. In other words, in vohtional and selective actions which only take place dming active attention there is an active weighing of motives, and the period between the thought of action and the movement is termed deliheratioji. Im'pulse is defined as an action which occurs without delibera- tion ; i.e. it follows immediately upon the presentation of a percept or idea. It is also described as the simplest form of voluntary action. Automatic Actions are vohtional actions which originally were consciously performed but which, through repetition, have lost their psychical concomitants. Walking, knitting, etc., are examples of this class of action. Tuke defines mental automatism as ' a state in which a series of actions are performed ^\-ithout cerebral action or conscious wiU, as dm-mg reverie or in certain morbid conditions.' Microkinesis. — Certain spontaneous and micontrollable movements (microkinesis) are seen in the infant. Warner infers that in the infant brain the centres act more or less separately and mdependently, and that it is only as evolution advances and the centres act in conjmiction that the move- ments become controlled. These fidgety or microkinetic move- ments are of marked interest, for in states of dissolution they reappear. The micontroUed actions of dehrium and mania and other fidgety movements are reversions to microldnetic movement of early hfe. Judgment and Reasoning. — Titchener, m his ' Outlines of Psychology,' defines judgment as ' the most elementary form NORMAL PSYCHOLOGY 13 of intellect,' and reasoning as ' the name given to a successive association of judgments. ... In every association two ideas are brought into connection. When the connection itself has become the object of attention — when, i.e., we have found an idea of connection, as distinct from the ideas which are con- nected — we speak of it as Helation. Eeasoning implies an idea of relation ; an idea which guides us in our argument, as the idea of movement guides us in the performance of an action.' Hyslop, in his book on ' Mental Physiology,' writes that the degree of perfection of judgment depends on — 1. Its clearness, and this is interfered with by — (a) Imperfect observation. (&) Defective conditions of memory. (c) Imperfect use and conception of words. {d) The presence of emotional disturbances. (e) Traditions — attending to the notions of others. 2. Its accuracy, interfered with by — (a) Imperfect understanding of propositions. (h) Imperfect observation. (c) Imperfect recall. {d) Emotional states, strong feelings. (e) Instability of mental action. (/) Kapidity of formation of judgments. Judgment and reasoning, being so complex, must very easUy be affected by emotions, attention, memory, and even perception. It is not, therefore, surprising that errors and disturbances of reasoning should be common symptoms in all forms of mental disorder. Delusions faU under this heading ; these are fully dealt with in the next chapter. Belief. — Hume says that belief is nothing more than having a clear idea ; when we have a clear idea, we are believing. Belief is a subjective variety of sentiment. Disbelief is as much a belief as belief, doubt being the intermediate state. Both belief and doubt are important and common symptoms in mental disorder. Doubt and the active weighing of motives are one of the chief causes of inaction in certain forms of insanity. Doubt is a state of oscillation between belief and disbelief, 14 PSYCHOLOGICAL MEDICINE and brings with it disagreeable sensations and emotions derived from muscular tension and restlessness. Apart from definite mental disease there is a large class of persons whose usefulness in life is constantly being hampered by doubts as to whether they ought to do this thing or that ; and who, even when they have formed a decision, are disturbed in mind, considering that perhaps they ought to have acted otherwise. SeU-Consciousness. — By ' self ' we mean the ' ego ' composed ■Of a complex of sensations, perceptions, and affections. In early life the idea of self is largely developed from kineesthetic sensations. By kinsesthesis is meant the sense of movement, and the sense by which we appreciate direction and extent of movement. Kinsesthetic sensation is derived from voluntary muscles in action, joints, tendons, and skin. As time goes on, the visual centres assist in the production of an idea of self, and also a certain amount, is learned about oneself from the remarks that others make. All through life sensation is the important factor in our idea of self ; for greatly diminish sensation and you have to a large extent, if not completely, taken away the consciousness of self. There is no doubt that this fact is not as fully realised as it ought to be, and yet it is the basis of nmnj delusions in the insane. Patients who have the belief that they are dead will usually be found to have an almost complete anaesthesia of the body. One patient, whose sensation is markedly affected, believes that he can fly, while another will state that he ' weighs tons.' Self-con- sciousness is defined by Titchener as ' a consciousness in which the concept or idea of self, or some phase or part of it, is present in the state of attention, and thus serves as a centre of association for other ideas.' A person who is self-conscious is an individual who is eminently introspective. Subject-Consciousness and Object-Consciousness. — Subject - .Consciousness and Object-Consciousness are terms frequently used in text-books on mental disorder. They are words which were introduced by Bevan Lewis, and are very useful in expressing ' self ' and its relationship to its surroundings. Subject-consciousness is what I know, what I feel ; while .object-consciousness is the knowledge of things of the external world. The ' ego ' is therefore conjoined subject- and object- consciousness. Bevan Levis, in his excellent work on Mental NORMAL PSYCHOLOGY 15 Disease, lays much stress on the rise of subject-consciousness and fall of object-consciousness in mania and melancholia, and explains many of the mental symptoms from this stand- pomt. No doubt he is perfectly correct in his deductions, but it is probably true that in all disease, physical as well as mental, there is a rise of subject-consciousness and a corre- sponding fall in object-consciousness. Even the patient with a severe toothache takes little interest in his environment, but his subject-consciousness is decidedly raised. Farther reference will be made to this subject when dealing with ' General Symptomatology,' for it certainly explains and largely accomits for several important symptoms usually present in such disorders as melancholia. Reaction Times. — Until comparatively recent times psycho- logists relied chiefly upon introspection for the study of mental processes. The tendency of later years has been more in the direction of experimental methods. The exponents of purely introspective psychology object to experimental study on the ground that, by placing an individual under standard con- ditions, the ordinary mental state of that individual is altered. This is probably true, and must be always borne in mind when doing experimental work. On the other hand, in the older psychology, far too much was left to the personal equa- tion of the observer ; and this, no doubt, is the reason why the older psychologists differ so much in their results. No control could be kept on their observations, and each recorded what he considered to be the workings of his own mind. Experiment cannot take the place of introspection, but it can usefully supple- ment it. By experiment we mean the placing of an individual under standard conditions. The same experiments can be repeated, and control experiments made. The most common form of experiment is reaction-time observations. These re- action-time experiments may be either (1) simple, or (2) compound. The methods of procedure are these : The in- dividual who is being tested, for the purpose of convenience here called the reactor, is told to make a certain pre-arranged movement on receiving a certain sensory stimulus, given and controlled by the experimenter. The time elapsing between the application of the sensory stimulus and the execution of the., movement is accurately measured. 16 PSYCHOLOGICAL MEDICINE A simple reaction-time experiment may be of two kinds : (a) sensory, and (&) motor. In the case of the former, the reactor directs his attention to the sensory stimulus, whether it be a Mght or sound of a bell, which he will receive, and not towards the movement he has to make, commonly the pressm'e on the bottom of an electric apparatus. In the motor reaction, the reactor attends to and thinks of the movement he has to make when he receives the stimulus. Thus it will be seen that the motor reaction more nearly resembles a reflex action, and is therefore a more rapid re- action than the sensory one. With these reactions as a base, it is possible to add to their complexity in a number of ways, and such complex reactions are known as compound reactions. They can be made very compHcated, in which case the dura- tion of the reaction will be correspondingly longer. The reactor may have several known or unknown stimuli to which he is to react, and be told only to react when he has fully cognised the stimulus. For instance, in a choice reaction, he may have choice of signal and choice of reaction, as when letters are spoken to him or exhibited on a photographic shutter, and he is told to react with his right hand for all vowels and with his left for consonants. Munsterberg has done much work on association reactions. His method was to call out a word aloud to the subject, who then had to give his first clear idea associated with the word. He found that persons could be fairly classified into three types : (1) those who associated heneatli — e.g. ' hand ' called out and ' finger ' given by the subject ; (2) those who answered by giving a ivhole of which the word was part — e.g. ' hand ' called out and ' arm ' given by the subject ; and (3) those who gave an analogue — e.g. ' hand ' called out and ' foot ' given by subject. These Munsterberg considered corresponded to types of intellect ; Class No. 1 tending to deal with detail, Class No. 2 tending to generalise, and Class No. 3 tending to be witty. Experimental psychology may prove to be of great use in the training of children ; it may be possible in this way to discover what faculties are most acute in each child. So also in mental disease diagnosis ; reaction times are longer in the insane, and they give more premature reaction ; i.e. they react too soon, be- fore the sign or stinmlus has been given. Premature reactions NORMAL PSYCHOLOGY 17 are also common in fatigue states. In experimental work among the insane it is of interest to observe the influence of distraction, the power of estimating time, etc. Memory, too, may be tested by such methods as those employed by Ebbinghouse. Dream States. — Dream states must ever be of intense interest to the physician whose work is devoted to the study of mental disorder. Some forms of insanity seem to be closely allied to a condition of dream-consciousness, and the dreams of the sane often show a marked resemblance to the hallucinations of the insane. We probably dream, if the word can be used in this sense, in all stages of sleep ; but it is only during light sleep that we can remember the fact that we have been dreaming. Dreams may be set up by any stimuli ; some authorities consider that visual dreams are not uncommonly started by changes in the circulation of the retina. Aristotle pointed out that as in sleep the senses are no longer occupied with external objects, internal operations are therefore more easily perceived. During dreams, inattention is extreme ; every stimulus has an equal chance, free from the influence of reinforcement or the control of inhibition. Prob- ably this extreme inattention largely accounts for the grotesque arrangements of ideas during sleep. To a certain extent the laws of habit and association regulate ideas in dreams ; but the association is constantly being interrupted by a fresh stimulus, starting fresh ideas. The sensory centres are active during sleep, so that things are commonly seen and heard. Ideas may be very clear and vivid in dreams, a fact which has been advanced as an argument in explanation of the ready manner in which they are accepted as realities. Periods of time are greatly abridged, and in the space of a few moments a dreamer will pass through what seem to be the events of hours. The dreamer usually is indifferent to the presence of others in the drama of his dream, and he will do all kinds of ridiculous things without a thought of the criticism of those who are witnesses of his folly. If reasoning and judg- ment are weak, as in dreams they clearly are, conscience may be as active as in the daytime. We again refer to dreams when describing the method of investigation known as psycho- analysis. 2 18 PSYCHOLOGICAL MEDICINE Tui'mng fi'om the study of dreams to insanity, the points of similarity are apparent. A brief recapitulation of the chief characteristics of the state of the dreamer, and a com- parison of these ^vith the state of insanity, wUl demonstrate the justice of this observation. Attention fails in both ; and in some forms of mental disorder ideas are fantastic in arrange- ment, as in the case of dreams, the laws of association and habit only having partial control. The ideas in the insane seem to be equallj^ vivid and impressive Avith those of the dreamer and to carrj- with them the force of conviction. Time is not uncommonly abridged in insanity as in dreams, and days seem to be years. The maniac and many other insane persons are, hke the dreamer, entirely indifferent to the presence of others, subject-consciousness being in the ascendant and object-consciousness correspondingly lessened. The powers of reasoning and judgment are in abeyance, whereas conscience may be stronger than ever. Aristotle might have explained certain mental states as he explained dream-consciousness ; for there can be no doubt that many of the insane have their attention constantly directed to the workings of their internal organs, but at the same time their special senses are found to be less occupied with their sur- roundings and the affans of others. The psychology which has been described in this chapter is of a very rudimentary nature. The end in view has been merely to show the student some of the workings of the human mind, in order that he may more readily recognise mental disease in its earliest forms. But this is not all ; some know- ledge of normal psychology will make him a more successful physician, for he will no longer look upon mental disorder as a hopelessly obscm-e disease in which the symptoms are outside the limits of human understanding;. 19 CHAPTEE II •WHAT IS INSANITY ? Insanity, Like sanity, is indefinable. Insanity connotes the absence, whether by non-acquisition or loss, of some of the elements which go to make up what we miderstand by sanity. Sanity is, however, not to be ascertained by any definite .standard. Sanity and insanity are both relative terms. Insanity is a negation of the state of sanity, while sanity is measured by an approximation to the normal, as kno\\Ti in the experience of the human race. Sanity, as appUed to cer- tain persons, does not connote mental perfection, nor insanity something less than mental perfection. It is impossible to find a person with so healthy and perfect a body that some shght deformity or degeneracy cannot be observed. So, it is impossible to find a perfect mmd. But it is not by perfec- tion that sanity is measured, and insanity is not determuied b}^ relation to perfection, but by relation to sanity. It is by no means uncommon in cases involving an issue of sanity to hear counsel ask a witness to define what he means by insanity ; but woe betide that witness if he tries to give an answer in the terms of the question, that is to say, in the form of a definition. There is no definition possible which would not include in its Hmits a large number of persons accredited to be sane, and fail to include a goodly number of those whom it was intended to comprehena. Premising, therefore, that it is impossible to define insanity, it is nevertheless necessary, for educational purposes, to be dogmatic even at the risk of being wrong. The student must have something definite, something tangible, around which he may centre his ideas. A working rule must be found, and for practical pm'poses the following is probably the best that can be given : A person may be considered of unsound mind if from some mental cause 20 PSYCHOLOGICAL MEDICINE (1) he is miable to look after himself and his affairs, (2) he is dangerous to himself or others, or (3) he interferes with society. In considermg mental disorder three questions most be borne in mind and separately considered. In the first place, there is the ' self,' which is composed of the sum-total of subjective sensations, perceptions, feehngs, and ideas at any given moment. We depend largely upon kineesthetic (kinsesthesis = sense of movement) sensation for our know- ledge of self, for by means of it we know of our relationship to our environment. Now, kinsesthetic sensation is derived from (1) the muscles in action, (2) joints moved, (3) tendons, fasciae, and skin. Accordmg to Bastian, the so-called motor area is the centre of kinsesthesis in the brain. Every time a movement is made we receive a group of sensorial impres- sions occasioned by and pecuhar to that movement. Diminish sensation, and you have, to a certain extent, taken away the consciousness of self. That disordered sensation has a marked effect upon the individual ideas of self is clearly seen in several forms of mental disorder, where altered sensation is a promi- nent symptom. A patient in Bethlem Hospital had the beUef that she was dead, and upon examining her sensations it was found that she had a general and well-marked anaesthesia. The second factor we must consider in dealing with mental disorder is enzironmeni. There are different grades of society, and the customs and habits of those grades vary. Omitting for the present degeneracy, as it is found in all divisions of society, we find that the lower we go in the social scale the less we expect to see such attributes as moraUty and control fully developed. In the lower grades of society education is of a more rudimentary nature, and therefore less is expected of a man who belongs to this class. Likewise, in dealing with crime and insanity, the question of environment must always be con- sidered ; but this subject is dealt with in a subsequent chapter. The third factor is, m many ways, the most important of all, and that is the adjustment of the first and second factors, which is the * adjustment of self to surroundings.' Mercier, in his excellent work entitled ' Sanity and Insanity,' has defined conduct as ' the adjustment of self to surroundings,' and no better definition can be conceived, as this adjustment seems to be the very essence of conduct. In msanity we have to deal WHAT IS INSANITY ? 21 with failure of adjustment of self to environment. Now this failm'e may show itself in many ways. The sufferer may neglect the most rudimentary and necessary requirements of life. Food may neither be sought nor eaten, even when it is placed within reach. The ordinary laws of self-conservation may be neglected : he may fail to protect himself from perils which endanger his very life. The rules of personal cleanliness may be unobserved. The ability to earn a living may be absent. Acts of violence against themselves or others may be a prominent symptom in the conduct of some persons. We are born into a community, and have to adapt ourselves to a social and moral code of laws. This code of laws deter- mines what we may do and what we may not do ; it lays down rules as to personal property, and creates the distinction between meum and iuum. Some persons fail to adjust them- selves to these laws, and their conduct is disordered in that they fail to distinguish between their property and that of others. Others neglect to conform to the laws of decency and propriety as dictated by society. These are a few examples of the ways in which disordered conduct may show itself. Although a judgment of a person's sanity may be formed either by noting his conversation or observing his conduct, it is largely the state of the latter that decides whether he is to retain his liberty or not. Society rules that the liberty of the subject is only possible so long as that liberty is not used to interfere with the liberty of others. From this it is clear that it is society which demands that such persons who fail to adjust themselves to their surroundings, and whose conduct is dangerous either to themselves or others, should be placed under care. Some persons are much more insane in their conversation than they are in theii' conduct, while in others the mental aberration is more noticeable in theu' conduct than in their conversation. When a man's conversation is wild and rambling, or replete with strange fancies and delu- sions, there is no difficulty even for the lay mind to diagnose that he is suffering from some mental disorder. But the difficulty to the lay mind is much greater when it is the con- duct that is chiefly at fault, especially when the vagaries of conduct are slight ; and yet the patient with disordered conduct is usually the more dangerous person. 22 PSYCHOLOGICAL MEDICINE The insane usually keep to themselves ; they feel that they are not in touch with the thoughts and feelings of others, either because they believe that they are of such a nature as renders them unfit to associate with the world, or that mankind, by hint or persecution, has clearly shown them that they are not wanted. The healthy-minded man is gregarious : the insane is solitary. This is one of the symp- toms by which the physician knows when a patient with mental disorder has returned to health. During his illness he keeps to himself and is self-absorbed ; but when he recovers he associates with others. There are exceptions to this rule, for some persons during their insanity devote them- selves to an almost extravagant extent to helping others ; but nevertheless their mental aberration is usually clearly indicated in other ways, and is even evidenced by the manner in which they render theii- assistance. Another character- istic of the disordered mind is the defect of judgment usually evinced. Some of the insane are ready to believe any state- ment, however extravagant or improbable ; others only believe their own opinion to be correct, notwithstanding that it is unsupported by evidence and contrary to the ideas of every- body else. The question of delusions has been fully gone into elsewhere, and therefore it is unnecessary to detain the reader fm'ther than to emphasise the fact that insanity can exist without delusions, and delusions may occur in persons who are not insane. Some people would have us believe that false beliefs are the very essence of insanity, and, indeed, would almost hesitate to certify a man as a person of un- sound mind if no delusions could be discovered. A truly dangerous doctrine, for some of the most homicidal and im- pulsive patients have no delusions. When present, delusions may be most valuable data, in conjunction with other evidence, in conclusively proving the trae mental state of a patient. •For further information on this topic the reader must refer to the passage on delusions which Avill be found in the chapter on General Symptomatology. Again, insanity is not proved by the presence of hallucina- tions or other sensory disorders, for they, like delusions, may exist apart from certifiable mental disorder. Clearly they indi- cate disturbances of nervous functions, but such disturbances WHAT IS INSANITY ? 23 may take place within the realm of sanity. Nevertheless, in any given case, hallucinations may be one of the factors which go to prove the insanity of the patient, and may even be the symptom which determines the line of treatment. Insanity is not evidenced by one symptom, but a group of symptoms. A man may be depressed, a man may have a delusion, a man may have an hallucination, a man may be emaciated and in bad physical health, and yet not be insane ; but if he has all these he is almost certainly insane. Disorders of the normal feehngs and emotions frequently connote insanity. A man may hear of the death of a near and loved relative without evincing the slightest concern. Now, if such a man has been in the past one who has not only keenly felt domestic losses, but has exhibited emotion, the present apathy and apparent callous behaviour are probably indicative of severe mental disorder. In health we react to pleasure and pain, and those about us observe the effect of those sensations upon us. But in insanity this is altered, and unusual reactions follow these stimuli. Again, the healthy mind sees good in all men ; to hate is almost alien to it, and even dislike is kept within narrow bounds. But the converse is equally true : in sanity love is bestowed only on a chosen few, who, by ties of relationship or exceptional friendship, are its proper recipients. The insane are often bound by no such limitations, and are ready to thrust their affections upon any who will receive them. The girl who in health is reserved and maidenly in her attitude, frequently becomes forward and immodest when insane. The study of the moral sense, even in the apparently healthy-minded, is most complex. We see men who are possessed of exceptional intellectual powers, men who have within them the fire of genius, men who are endowed with brilliant talents, but whose moral sense is most rudimentary. Are their shortcomings to be considered under the head of vice or disease ? Such men may be capable of writing prose or verse, every line of which glows with lofty ideals or subhme thought, and then, laying aside the pen, they prepare to do some action which, maybe, entails doing grievous wrong to some fellow-creature. If a number of the mental attributes of such a man were as shallow as his moral sense, he would have to be classed 24 PSYCHOLOGICAL MEDICINE as insane ; but %Yhen the degradation is partial, it is usually- spoken of as vice. In determining a question of insanity where the moral or some other sense is involved, the present conduct must be compared with the past. Slow deterioration extending over years is more difficult to treat as insanity than some sudden change. All change of habit connotes an altered mental state, and the nature of the variation, as shown by thought and action, marks whether it is the result of higher evolution or dissolution. In this connection the words of Maudsley ^ may be usefully quoted as well summarising the position of the insane unit in relation to the social whole : * By insanity of mind is meant such derangement of the lead- ing functions of thought, feeling, and will, together or separately, as disables the person from thinking the thoughts, feeling the feehngs, and doing the duties of the social body in, for, and by which he lives. . . . Insanity means essentially, then, such a want of harmony between the individual and his social medium, by reason of some defect or fault of mind in him, as prevents him from hving and working among his kind in the social organisation. Completely out of tune there, he is a social discord of which nothing can be made.' Mental dis- order may be due to a failure of evolution ; such an organism is not endowed with those intellectual attributes with which nature usually equips a man. Eeason and judgment, purpose and control, have been denied him. Small wonder that as he grows up he finds himself out of touch with his fellow-men, and unable to compete on an equality with them in the battle of life. He drifts, swayed by his lower instincts, which lack the control of higher attributes. On the other side we see the effects of dissolution ; here the once intellectual man loses the attributes he originally possessed, or, if not losing the attributes, loses the proportion and correspondence between them which are necessary to an even and balanced mind. Disordered sensation or strong emotion may usurp the whole attention, to the detriment of other faculties. Sensory illusions may deceive the man and bias his conduct, or profound depression may paralyse both thought and movement. But, let it be remembered, insanity is not revealed by one symptom : the change can be seen in everything, physical or mental. ^ Patholofjy of Mind, ch. i. WHAT IS INSANITY ? 25 Decay is not limited to one organ, but affects the body as a whole. The dissolution may be uneven, and the degeneration in one part may far exceed that of another ; nevertheless, the whole is affected. In determining insanity the evidence to establish it cannot be derived from one symptom. The symptoms present may be regarded much in the same way as pieces of circumstantial evidence are during a trial. Each individual piece denotes nothing, but the chain formed by welding the separate pieces together may be so strong as to compel one conclusion. So with the symptoms of insanity. Each of them present alone might be consistent with sanity, but taken together they may form so strong a body of evidence as to forcefthe inference of insanity. 26 PSYCHOLOGICAL MEDICINE CHAPTEE III CAUSATION OF INSANITY Much has been written and much will continue to be written upon this subject, a subject so full of interest and importance to the human race ; but before entering upon it one word of warning may usefully be given. It is not always safe to accept either the apparent cause of a mental breakdown or the cause to which the friends of the patient may attribute it. Causes and early symptoms of disorders are constantly being confused, and, although there may be no intention to mislead, if the physician is careless or too readily accepts data, his deduction may be entirely erroneous. Take, for instance, the question of alcohol ; this may be given as the cause of the mental disorder, and yet inquiry may elicit that the intem- perance was of recent development, being in fact the first sign that the patient was losing control. In all matters appertaining to our daily life, each of us is constantly seeking for explana- tions of this or that phenomenon, and may determine upon a solution which is, in fact, entirely erroneous. A person who develops an ordinary cold in the head is not satisfied until he finds out how he got it, and having allocated it to coming out of a heated theatre, or sitting by an open window, he is perfectly satisfied with his conclusions, however mistaken they may be. In determining causation, the physician cannot be too careful in his inquiry or too guarded in his conclusions. Many classifications of causation of mental disorder have been from time to time drawn up, but all of them are more or less unsatisfactory. The system of dividing the causes up into predisposing and exciting is perhaps as confusing as any, for factors such as syphilis and alcohol may be either predisposing, or exciting, or both. The student will be wiser to take a much wider scheme to liegin with, CAUSATION OF INSANITY 27 and then, if he so wishes, subdivide afterwards. The system used by Mercier, whereby the main causes are divided under two heads, Heredity and Stress, is one which, at any rate, commends itself by its simphcity. By inheritance it is meant that the child tends to inherit every attribute of the parent. Our nervous system, like any other system of the body, bears in all probability the stamp of our ancestors upon it. If our parents or grandparents have had an unstable nervous system, the tendency is that we shall be unstable in the same direction. We would especially emphasise the word tendency, for, after all, it is nothing more. Because our ancestors were of unsound mind, it is no reason why we should become insane ; all we inherit is a tendency, not a certainty, to be unstable, so far as our own nervous system is concerned. Now this is very important to fully realise and remember, for so many persons spend their life worrying about their future because their inheritance is not sound. After all, it is a great advan- tage to know the weak point in one's armour, so that that part may be guarded against undue stress. Moreover, it is this knowledge of tendencies that is practically the keynote of preventive treatment, and the guide by which life should be regulated. Degeneracy in the parent may be evidenced by insanity of all kinds, epilepsy, alcoholism, moral perversion, and the like — and the presence of any such element of degeneracy in the parent is apt to engender in the offspring similar defects-, or a state of general instability. On the other hand, the children of such a parent may be apparently healthy, but in turn their offspring may exhibit symptoms of mental disorder. In this case the elements of insanity are apparently latent in the second generation, but in the third there is a reversion to the original condition. This reversion is known as Atavism. Further, it has been noted that where we find insanity appear- ing in several generations, the tendency is for it to appear earlier in each successive generation ; this is probably only true in families where the taint is exceptionally strong. It must also be remembered that the danger of insanity to the offspring is greater as the begetting of the child is nearer to the insanity in the parent. On the other hand, from time to time one finds an insane family whose parents are not insane, 28 PSYCHOLOGICAL MEBICTNE and in whose relatives no marked insanity can be ascertained. Before leaving this question of Inheritance, reference may be made to one other law which Mercier calls the ' Law of San- guinity,' and which he explains in the following way : ' There is a certain degree of dissimilarity (sanguinity) between parents, which is most favom-able for the production of well-organised offspring ; and parents who are more similar (consanguinity) or more dissimilar (exsanguinity) t\^11 have offspring (if any) whose organisation will be inferior in proportion to the distance of the parents from the most favourable point.' In other words, this means that the more dissimilar, up to a certain point, parents are, the stronger and better the off- spring, but that individuals whose constitutions and tem- peraments are ahke will either have no children or degenerate children. Now, this law largely decides the question of the marriage of first cousins. If the parties who are contem- plating marriage are of blood-relationship, and if in both families the stock is markedly degenerate, and if this degeneracy is exhibited by instability or neurotic symptoms in the individuals in question, then it is extremely probable that the offspring of such a marriage would be degenerate. Conversely, if there is no such similarity of constitution, notwithstanding the blood-relationship, the offspring would in all probability be healthy. We will now pass on to the stresses, which may be of two kinds : (1) Direct, (2) Indirect. The direct stresses include factors such as Brain Tumours, Cerebral Haemorrhage, Injuries to Cranium or Brain, and Inflammation of Meninges or Brain itself. Among the direct stresses we must also include poisons circulating in the blood ; these may be autotoxins or toxins derived from external agents. Every year brings more and more convincing evidence of the importance of recognising that autotoxins derived from the alimentary tract play no small role in the production of insanity. Blood changes, in- cluding poisons circulating in the blood, have for some time past been placed in a prominent position among the various factors to be considered when studying physical disease. The case is no different in insanity, and it may fairly be said that the advantages to be gained by a careful study of the blood in cases of mental disorder cannot be over-estimated. CAUSATION OF INSANITY 29 Constipation is not only a common symptom in the insane, but it is the rule rather than the exception to find a history of prolonged constipation before the mental disorder supervened. For years the blood may have been loaded with effete material, and is it to be wondered at that the nervous system, together with other systems of the body, finally becomes disorganised as a result ? Much valuable work is being done in the in- vestigation of this subject, and it is undoubtedly a field of study which will amply repay the worker. Perhaps, after all, the causation of much mental disorder is not so intricate and com- plicated as has been supposed ; and it may be that while we have been groping in the dark with metaphysicians, the key to the problem has been lying under our very hands. Let there be no misapprehension ; the suggestion is no new one ; it may well be that its revival, assisted by later scientific methods, may discover much that escaped those who have gone before. May it not be that much of the growing increase of mental disorder is to a certain extent due to our mode of living : no time for proper meals, no time for necessary exercise, no time for attending to health ; the race for life is too keen, until finally we perish in the product of our own metabohsm ? The subject of direct stresses need not be further pursued, as clearly, if the damage to the brain is severe enough, there will be some mental disorder as a result, no matter how stable the nervous system of the patient may originally have been. With the indirect stresses the matter is different, for they act much more readily on the unstable than on the individual with a sound nervous system. These are of varied kinds, and include such factors as anxiety and worry, financial and domestic difficulties, misdirected education, intemperance, syphiUs, sexual excesses, etc. Certain occupations seem more favourable for the development of mental disease than others, and especially highly speculative businesses. Successful work, so long as it is not too successful, seldom leads to mental disorder ; but unsuccessful work shows a very different record. Metabolism. — This subject is of intense interest in connection with the study of mental diseases, but at the present time Uttle or no work has been done. We are still in doubt whether mental disorder is the primary condition and that the physical disturbances follow, or whether the mental aberration is the 30 PSYCHOLOGICAL MEDICINE result of metabolic changes in the body. Probably both conditions may arise, but it seems more likely that in the majority of cases we shall find the physical changes arise first. For example, in women, menorrhagia or metrorrhagia is frequently followed by exhaustive nervous symptoms, and this may result from the loss of some constituents of blood, such as the calcium salts. One of the best examples of metabolic dis- order, giving rise to mental distm'bances, is seen in myxcedema. Goodall, in his Presidential Address, delivered in the section of Neurology and Psychological Medicine of the British Medical Association, in 1911, referred to the probable toxic origin of some kinds of insanity. Eeferring to the bacteriological work in insanity, he states : ' Summarising the work of the past twenty years I should affirm that there are no adequate grounds for believing that the organisms which have been found in the tissues in any case of insanity play more than a secondary role. At the same time, they frequently cause death. (We fall victims, it has been said, most often to om- secondary infections.) Though not shown to be of prime pathological significance, they may yet be shown to be the cause of some of the symptoms. Much more work is required in this field, and better methods of cultivation of organisms are needed.' Passing on to discuss leucocytosis in mental disorders, he says : ' The outstanding pathological fact which indicates a toxic pathogenesis for some of the psychoses is leucocytosis. The condition is found very commonly in acute and recent mental disorder, and in states of exacerbation dui'ing chronic insanity. The most recent workers in this field are Dide and Chenais, Klippel and Lefas, Lepine and Popoff in France ; Lewis Bruce and C. MacDowall in this country ; Heilemann in Germany ; Graziani in Italy. I believe the following statements are justified by much personal study of thi* question for the past three years, and by the work of these investigators. The total leucocyte count is increased in varying amounts from 11,000 to 30,000 per cubic milHmetre in acute and recent mania and melancholia (senility excluded), and in the periodic exacerba- tions of chronic cases of the same. Should the count fall in the course of the disease it rises agam to rather above normal towards the close of the attack in cases which recover, and CAUSATION OF INSANITY 31 remains fairly high on recovery. In acute mania and melan- choHa, the percentage proportion of the neutrophile cells is increased in the early phases of the disease, also towards the close of the attack when recovery is to take place. In these disorders a low total count and a fall in the normal percentage of neutrophils, if maintained, are of bad recovery, and point to the onset of dementia. As regards dementia prsecox, in the active phase there is some (but no considerable) increase. in the total number of leucocytes ; neutrophils are diminished, and lymphocytes, mononuclears, and eosinophiles increased. Cases of systematised delusional insanity do not exhibit leuCocytosis. ' As a generalisation, in the acute and recent mental disorders there is leucocytosis with percentage increase of the polynuclear cells ; id the subacute and chronic ones there is little or none, and the proportion of large mononuclears and lymphocytes is increased. In acute mental disorders, absence of leucocytosis and a fall in the percentage proportion of polymorphs go with deficient reaction, and are an unfavourable indication, as is the case in those infectious fevers in which leucocytosis is observed. This, from the standpoint of toxaemia, is significant.' Over- work. — Over- work is a cause which must be received with extreme caution. No doubt some individuals, either from necessity or from choice, spend their days in steady work, and seldom take exercise or indulge in holidays. In pre- disposed persons, this may end in a mental break-down. Again, it is not uncommon to meet persons of humble origin, who by means of incessant work manage to raise themselves into some position higher in the social scale. They reach their ideal only to find that they must be failures, as they lack the attri- butes which are necessary for success. Governesses, to some extent, belong to this class. The calling of a governess is always precarious, her' salary is often a mere pittance ; and, as years go by, she finds herself with no savings, her ac- complishments out of date, and nothing but the workhouse before her. There are no factors so prone to produce insanity as worry and constant anxiety. Domestic troubles perhaps fall more heavily upon women, whereas financial difficulties and pecuniary losses chiefly affect the male sex. 32 PSYCHOLOGICAL MEDICINE Education. — The question of education and its relationship to insanity is constantly being inquired into with varying results, hi educating a child we must remember that the mind and body should be developed together. The close rela- tionship of mind to body is fully recognised in theory, but in practice it is all too frequently overlooked. How common it is to see a brilliantly intellectual child being forced along to •pass high examinations, while the developments of the physical side are, for the time being, forgotten ! When it is realised that this very brilliancy probably indicates nervous and mental instabihty, that it is the product of too rapid evolution, its grave import will be better understood. Brilliancy ought to be the warning note to the parent and the teacher that the mental side must be kept back until the physical is developed. One of the main reasons of mental failure in the young is too rapid evolution, in which case the child matures too quickly. The danger here is instabihty and a tendency to decay early. Throughout the natv.ral world we find that those organisms which develop rapidly, and reach maturity in a comparatively short time, tend likewise to degenerate early, and that their life-history is a short one. Exactly the same process takes place in the nervous system of a human being. For stabiUty it is requisite that the growth and development should be slow and steady ; and if from any cause this development is too rapid, it indicates a tendency to mental instability, and not uncommonly early failure. How often parents might be saved from disappointment if this fact were only grasped and understood ! It is by no means an uncommon sight to see a child, who is considered to be a mathematical genius or a marvel in some other subject, being exhibited before an assem- blage of admiring friends. The outlook for development in such a case is not too hopeful, as the very relations seem to be hurrying on the child to intellectual ruin. Every endeavour should be made to retard rapid development ; the physical side should be fully attended to, as it is largely upon the bodily condition that the stabihty of the mental faculties will depend. Wise education, where the mind and body are developed to- gether, but neither at the expense of the other, is rmdoubtedly one of the best preventives of insanity. Religion. — Kehgion, according to the popular view, is one CAUSATION OF INSANITY 33 of the chief causes of insanity. This error^for never was there a greater one — has been brought about by confusing cause with effect. No doubt it is very common to find rehgious subjects playing an important part in many cases of insanity, but it is not the cause of the mental disorder, but rather the explanation the patient gives of altered feelings and thoughts. Take, for instance, an insane mother, who, from her very mental disorder, is no longer able to attend to and look after her children, and who, for the same reason, neglects all her household duties ; sooner or later she will begin to accuse herself of being unnatural, and allege as the reason that God has forsaken her, and that she is lost for ever. After this, if she reads her Bible at all, she notes and emphasises all the verses which condemn her, and ignores the chapters which might lead to her comfort. Eeligion deals with the ' unknown,' and it is to the * unknown ' we appeal for explanation when a disorder which we fail to recognise as an illness overtakes us. It is usually the conscientious individual who looks to religion for his explana- tion ; others turn to hypnotism, mesmerism, electricity, and the like. Thus we see that in the vast majority of cases religion, fer se, does not produce insanity. Nevertheless there are a few patients whose mental break-down dates from an attendance at some emotional rehgious revival. In the enthusiasm of conducting a mission it is apt to be forgotten that there are certain unstable inidividuals who will be attracted by the services. Emotional excitement is either encouraged or not checked, with the result that this excitement passes on to acute mania in these predisposed persons. Eeligion is a powerful factor in the life of most individuals, but it wants careful and judicious handling ; otherwise that which ought to generate good may be the exciting cause of an illness which may terminate in dementia. Alcohol. — Alcohol stands in the first rank as a factor in the production of insanity. It is not only marked intem- perance that has to be considered, for the quantity of alcohol that any given person can take without producing intoxica- tion varies enormously, but constant ' nipping ' is far more damaging to the nervous system than bouts of drunkenness. In the individual alcohol acts as a direct poison, and sooner or later leads to impairment of the mental faculties, or maybe 3 34 PSYCHOLOGICAL MEDICINE definite brain disorder. Further, in the famihes of alcoholic parents nervous diseases of all kinds appear ; the child may be imbecile from birth, or may early develop epilepsy, and in time may help to swell the already large number of insane. Children of alcoholic parents are not uncommonly vicious in their habits and criminal in their tendencies. This subject will receive more detailed consideration in a subsequent chapter, for as an individual cause of mental disorder alcohol stands a long way in front of any other. Syphilis. — Syphilis may be a predisposing or exciting cause of insanity, and will be fully dealt with in a subsequent chapter. Sexual Excess. — With regard to sexual excesses, these pro- duce varying results in different individuals, for that which is excess in one person may not be so in another. Nevertheless, it is an important factor in the production of nerve exhaustion and its usual concomitants. Masturbation. — ^Masturbation in both sexes is closely con- nected with insanity ; in certain unstable individuals it may be the exciting cause, but, generally speaking, excessive self- abuse is more commonly a symptom of mental disorder than a cause. It is frequently found in quite young children, and requires most careful treatment. Physical Disease.' — Physical disease may so interfere with the nutritional economy of the organism that insanity results. The delirium of fever may develop into a true mania ; in fact, a temporary insanity or mental aberration may pass on to a more permanent mental disorder. This is seen with fever, intoxication from alcohol, with anaesthetics, and in other conditions. Sex. — Sex plays a certain part in the causation of mental disorder, as the stresses vary in men and women. Males suffer chiefly from worry and anxiety and excesses of all kinds, whereas the stress in the case of the female is largely connected with the reproductive functions. The onset of menstruation at puberty, the monthly nisus, pregnancy, lactation, and the climacteric are all periods of severe stress, and in unstable women may be the determining factors in bringing about' a mental breakdown. There are more insane women in the world than insane men, but this is in some way accounted for by the female population being greater CAUSATION OF INSANITY 35 than the male ; and further, fatal disorders, such as general paralysis of the insane, are more rife among men than women. Periods of Life. — We now pass on to consider the various periods of life, and in what way they may play a part in pro- ducing mental disorder. Throughout the early years of a child's life it ought to acquire certain attributes in a fairly definite order. In the first place, the microkinetic or spon- taneous uncontrolled movements of infancy slowly disappear, the child's movements are regulated and controlled, and are adapted to its wants and the requirements of its environ- ment. As months and years pass along we see the develop- ment of the emotions, memory, attention, control, morality, and reason taking place. Hughlings Jackson has pointed out that as evolution in the brain advances there are ' increasing complexity ' (differentiation) and ' increasing definiteness ' (specialisation). Now, anything which interferes with this evolution tends to produce mental disorder by arresting mental development. For example, an unstable child, whose parents are of the neurotic type, may suffer from convulsions during the process of teething. These nerve storms may become a habit, and if occurring frequently may interfere with the mental evolution, and imbecility may result. Some children grow up without acquiring such attributes as control and morality, and when they reach puberty, if not before, their deficiency may give rise to grave breaches of the social code of laws. Thus in early life mental disorder may result from failure of evolution ; the child never acquires its full complement of faculties ; the body develops, but the mental growth does not keep pace with it. On the other hand, insanity may arise through dissolution taking place in the highest centres. The law of dissolution of the nervous system is that the latest acquired, that is to say the least organised, attributes dege- nerate first. This law holds good whether one is dealing with the motor, sensory, or intellectual attributes. The powers of reasoning, control, and attention are early lost in insanity. Mental dissolution may take place at any period of life, and may be rapid or slow in its course ; but, if it persists, it ulti- mately ends in weak-mindedness. In early life the mental disorder may be due to congenital defects. The child may 36 PSYCHOLOGICAL MEDICINE lack the sense of sight or hearing, or both, and in consequence has difficulty in acquiring knowledge. Puberty is a period of exceptional stress, especially in the female, and the appear- ance of the reproductive functions in certain predisposed persons may prove too severe a strain on the organism, and an attack of insanity results. At the climacteric, again, when the power of reproduction disappears, profound changes take place. The bodily and mental functions are slowed, and life is less active, but before this takes place there is a period of peculiar stress which may lead to a mental breakdown. With old age the brain, together with the rest of the bodily organs, begins to atrophy, and in some persons the degeneration of brain substance seems to be more rapid than in the tissues elsewhere. As in all forms of dissolution, it is the highest control that fails first, so that with senility it is not uncommon to see defects of the moral sense. With old age the insanity may be of any kind ; some individuals suffer from a pro- gressive dementia, while others have a temporary mental disorder similar to that which may occur at any other period of life. To sum up, we shall find that as a general rule the more marked the neurotic inheritance in the parents, the greater is the instability in the offspring, and the more likely the child is to have symptoms of mental disorder early in life. Curiously in some families there seems to be an inherited ten- dency always to break down at the same period of life. While on the subject of inherited tendency, a moment's consideration should be devoted to the question whether there is such a condition as an Insane Diathesis ; that is to say, whether there are individuals who from their constitution, psychical or physical, show that they are more than commonly liable to mental disorder. The terms * temperament ' and ' diathesis ' have been used variedly by different writers, so care must be exercised in noting the meaning here attached to them. Habit. — In some instances insanity is secondary to some mental change ; in other words, it may be a terminal state. Elsewhere we have pointed out the influence of habit and the important part it plays in the mental and physical life of the individual. Throughout fife we are acquiring habits, and once formed CAUSATION OF INSANITY B7 thej automatically influence our thought and conduct in the future. Some young persons foster the idea that those about them sHght them, give them the cold shoulder and generally neglect them. Slowly, over extended years, they build up the pernicious habit of looking for insults ; more and more they distrust the intentions of others, until the day comes when they find themselves totally out of touch with their fellow-men. The habit of indecision is another example which in time may be difficult to eradicate and yet if uncorrected may seriously affect the judgment. In all illness there is a tendency for the patient to form habits of thought and action during the acute or sub-acute stages of that illness. Now these habits are apt to persist long after th6 illness has passed away and may in time so alter the person's outlook in life as to render him incapable of adapting himself to his surroundings. Diathesis. — Dr. Eayner, in Tuke's ' Dictionary of }?sycho- logical Medicine,' defines Insane Diathesis as a ' deterioration of hrain, inherited or acquired, indicated hy peculiarities of functions, hy tendencies to mental disorder, and often associated icith hodily stigmata.'' There are two varieties of Insane Diathesis : (1) shown by eaxlj and precocious mental and physical evolution, frequently met with in persons of genius ; (2) indicated by late and defective evolution with some moral and intellectual weakness. In the latter class the physical stigmata are, as a rule, more marked. One cannot fail to recognise that there are persons whose natures are highly hyper-sensitive, to whom a look is as painful as a severe rebuke to a more phlegmatic individual. Sensi- tiveness is an attribute of extreme value, for it is largely by it that we keep in touch with those about us ; and a sensitive person is constantly adapting himself to his environment. Nevertheless, when carried to extremes, sensitivity may form the basis of delusions ; a sneer may be seen when no such expression was intended, or a smile may be distorted into a look of scorn. Another temperament which is constantly met with is the over-active, restless individual, never quiet for one moment, but often capable of doing a large amount of work. Such a person wants longer hours of repose than his phlegmatic and apathetic brother ; he runs through his stock of energy at a 38 PSYCHOLOGICAL MEBICINE rapid rate, and, if he neglects to take proper rest, the end is disaster. Again, how common it is to see a man whose thoughts and actions are always tinged with suspicion ! Doubt of the motives of others seems to be the fundamental idea which dominates his life. As years pass, this tendency to suspect everybody and everything grows, and in time begets delusions of persecution. Other forms of constitution might be men- tioned if any useful purpose were served ; but at the moment it is enough to show that there are variations of temperament, and that there are temperaments which maybe called dangerous, as predisposing to mental disorder. Insanity in such cases seems to grow insensibly out of the normal condition, and it is often very difficult to say when the line that divides sanity from insanity has been crossed. Observe, for example, a young man, whose conceit and self-complacency, though remarkable and far exceeding those of his fellows, are put down to the affecta- tion of youth. Unfortunately, as evolution takes place, this egotism is not tempered by the wisdom of increasing years, but becomes more and more offensive and overbearing, until finally the man is consumed by the vanity of his own import- ance. Such an individual, sooner or later, frequently develops delusions of grandeur. Probably a good deal might be done in the early training of these individuals in the way of prophylaxis, and we will refer again to this subject when dealing with treatment. The causes of mental disorder are so numerous that it is impossible to review them fully in so short a chapter. All that can be done is to refer to those factors which seem to be the most powerful in producing insanity. These agencies may act on the developing nervous system, and impede or entirely check the mental evolution, or they may operate on the matured brain and destroy it. The principles of the causation of disease must be learnt, and the student is then able to note for himself the innumerable conditions which are detrimental to a healthy organism. 39 CHAPTEE IV CLASSIFICATION OF INSANITY This is a subject which has exercised the minds of many writers, and dm-ing the past century numerous classifications have been drawn up. Unhappily each of them must be con- sidered to be more or less unsatisfactory. Some writers endeavour to classify from the psychological standpoint, and to name insanities according to whether the malady touches more closely the emotions or the will. For example, Heinroth's classification rested on the threefold analysis of the mind into — 1. Intellectual Faculties, -i 2. Moral Dispositions. -fc 3. The Will (including the propensities). Other authorities have tried to form a classification based upon the most prominent symptoms of each disorder. Pinel had merely four divisions — (a) Mania. (fe) Melancholia. (c) Dementia. (d) Idiocy. Esquirol, who came later, made five divisions : (a) Lypemania. This is a disorder of the faculties with respect to one or a small number of objects, together with feelings of depression. (&) Monomania. This is similar to the first group, but in the place of depression there is excitement. (c) Mania. In this the insanity extends to all kinds of objects, and is accompanied by excitement. 40 PSYCHOLOGICAL MEDICINE (d) Dementia — weak-mindedness. (e) Imbecility and Idiocy. Griesinger recommended a very small classification, which consisted of three divisions — 1. Mental depression or melancholia. 2. Mental exaltation. 3. Mental weakness. Other writers have endeavoured to classify mental dis- orders from the oetiological point of view, i.e. naming the insanity after its causations, sach as Phtliisical or Alcoholic. At the Paris Congress of 1889 Morel drew up a classification which was partly symptomatological and partly setiological ; and the Statistical Committee of the Medico-Psychological Association of Great Britain and Ireland have dra\vn up a classification upon the same hues. During recent years Kraepelin's classification has been largely used. It is a comprehensive scheme, and one that deserves careful study. It may be somewhat compHcated in some of its divisions, but it certainly is qaite one of the best classifications which we have at the present time. His scheme is as follows ; I. Infection Psychoses. (a) Fever delirium. (&) Infection delirium. (c) Psychoses characteristic of the post-febrile period of infectious diseases. in. Exhaustion Psychoses. (a) Collapse dehrium. (&) Acute confusional insanity. (c) Acute dementia and hypochondriasis. {d) Acquired neurasthenia. III. Litoxication Psychoses. A. Acute Intoxications. 1, Alcoholism. •/ CLASSIFICATION OF INSANITY 41 B. Chronic Intoxications. ' (a) Acute alcoholic intoxi- cation. (6) Chronic alcoholism. (c) Delirium tremens. (d) Alcoholic delusional in- sanity. (e) AlcohoUc paranoia. ^ (/) Alcoholic pseudoparesis. 2. Morphinism. 3. Cocainism. IV. Thyroigenous Psychoses. A. Myxoedematous Insanity. B. Cretinism. , . , V. Dementia Prsecox. (a) Hebephrenic form. (&) Catatonic form. (c) Paranoid form. . . , VI. Dementia Paralytica. VII. Organic Dementia. (a) Diffuse lesion. (&) Locahsed lesion. VIII. Involution Psychoses. (a) Melancholia. (&) Senile dementia. IX. Maniacal-depressive Insanity. (a) Maniacal states. (6) Depressive states, (c) Mixed states. X. Paranoia. XI. General Neuroses. (a) Epileptic insanity. (fe) Hysterical insanity, (c) traumatic neuroses. 42 PSYCHOLOGICAL MEDICINE XII. Constitutional Psychopathic States. (a) Congenital neurasthenia. (6) Obsessive insanity. (c) Impulsive insanity. (d) Contrary sexual instincts. XIII. Defective Mental Development. (a) Imbecility. (6) Idiocy. Some authors have attempted to divide insanity into two classes ; namely, curable and chronic. This is not a very useful classification, as at the present time the term ' chronic ' is used in a sense which appears to the writer to be incorrect. Most authorities in mental disease use the word ' chronic ' as indicating that an insanity has lasted a certain time. The term ' chronic ' as apphed to disease does not, however, necessarily imply that it has lasted through some given antecedent period. It suggests rather incm'abihty. Some disorders, such as dementia prsecox, paranoia, certain cases of mania and melanchoha, and many other insanities, are chronic from the first, and it is only a question of diagnosis to recognise that this is the case. In dealing with physical diseases we do not hesitate to affirm that a patient ex- hibiting certain symptoms is suffering from chronic inter- stitial nephritis, notwithstanding that he has only recently complained that he is out of health. Why should a different test be apphed to mental disease ? Experience teaches us that there are some cases of mania which at the very outset exhibit marked symptoms of degeneracy ; and sm'ely, correctly speaking, being incurable, these ought to be classed as chronic from the very beginning. At first many mistakes wiU be made ; patients who were considered to be incm'able will sometimes recover. Every physician must make mistakes, but probably the use of the term ' chronic ' in the manner above suggested wiU induce keener observation and greater accm'acy in the examination of patients. It need hardly be added that it is often neither necessary nor advisable to inform the friends of a patient that their relative is thought to be chi'onically insane. Chcumstances must guide action in this respect ; CLASSIFICATION OF INSANITY 43 indeed, the physician will seldom err if he regulates his attitude and action in cases of mental disorder by the same con- siderations as would be applicable to a case of physical disease. Several attempts have been made to formulate a scheme of classification on a pathological basis, but the results have been most disappointing. Still, the student must be given some system upon which he may work, some scaffold upon which he may build. The writer does not wish to add any new classification to the aheady large number, but wUl use the following general scheme, which he has drawn up from the classifications of other authors : 1. Mania and States of Excitement. 2. Melancholia and States of Depression. - 3. Mental Stupor. 4. Chronic Delusional Insanity (Paranoia). 5. Dementia Praecox. 6. Dementia, secondary and organic. (Puerperal. Climacteric. Senile. Arteriopathic. f Alcoholism. Intoxication Psychoses. Morphinism. Cocainism. Plumbism. 9. General Paralysis of the Insane. 10. Exhaustion Psychoses. Acute Hallucinatory Insanity. Neurasthenia. Chronic Nerve Exhaustion. (Epilepsy and Insanity. Hysteria and Insanity. Traumatic Neuroses. 12. Obsessional Insanity. Psychasthenia. 13. Insanity associated with Physical Diseases. (Moral Insanity, Imbecility, and Idiocy. This scheme has the great objection that it is partly symptomatological and partly aetiological. The writer is 44 PSYCHOLOGICAL MEDICINE aware that this method of arrangement is condemned by some authorities ; for to name a disease after its supposed cause is in many ways unscientific, as we may be describing over and over again the same complaint under a different name. For example, under puerperal insanity, mania and melancholia are again referred to, notwithstanding that . they have been aheady described elsewhere. Gn the other hand, provided that care is taken to point out that no new disease is being recounted, from a clinical aspect this method has its advan- tages. The practitioner or student can more readily refer to the disorders which may occur at any special period, and the course of the illness can more easily be depicted. Mania associated with senility differs in some respects from the mania of early life ; some symptoms which might have been neglected in the adolescent are of great importance in the aged. Every classification of insanity is apt to confuse the student unless he carefully studies the basis on which it has been drawn up. The most simple, and in many ways the most scientific, form of classification of mental disorder would be one consisting of three divisions : '-1. Failure of evolution. . 2. Derangement of normal mental functions. ^3. Dissolution or Dementia. Many persons are insane because their brain is not equipped with a sufficient number, of nerve-cells or a proper complement of association-fibres. Others start life with a normal supply, but either from disease or decay they become reduced in number or activity. Between this state of amentia and dementia there are many stages. The nervous mechanism may be damaged temporarily and recover, or it may slowly degenerate during a period of months or years. Now, we might give a different name to every phase of this disintegra- tion, according to the clinical aspect. Buch are the difficulties which he in the path of the man who seeks to devise a scientific classification. It is on these grounds that the writer prefers to use a purely utilitarian arrangement, one that is useful to the teacher and comprehensible to the student. 45 CHAPTER V GENERAL SYMPTOMATOLOGY Before passing on to consider distinct forms of mental disease, it may be helpful to the student to devote some pages to the study of those various symptoms which are commonly met with in the insane. In this way much repetition will be avoided, and the advantage gained of famiHarising the student with the general aspects of the subject, and so facilitating for him the diagnosis of mental disorder, always a difficult duty to the novice. Once more — a wearisome but necessary re- iteration — let the beginner be encouraged to approach the study of mental disease in the same attitude of mind as he would engage upon the study of medicine or surgery. Let the principles of the subject first be grasped and thoroughly mastered ; afterwards the acquisition of detail will be found to be comparatively easy. There are fundamental principles which must be learned before the student can hope to under- stand mental disease ; it is the ignorance of these principles which makes insanity appear so obscure and incomprehensible a subject. In the early stages one must not expect to find too pro- found a mental change. Insanity, like everything else, has a beginning ; and, as a rule, it develops by degrees so slow and subtle that the physician who only recognises glaring symp- toms of mental aberration will fail to recognise the disorder while in its most curable state. Minor symptoms must receive their due amount of attention, and not be brushed aside, as they frequently are, or ignored as being of little consequence. The student can study mild forms of mental disorder in himself, and he will find such introspection of great assistance in comprehending the more advanced dis- orders of others. . For example, we all have experienced days on. which we have had feelings of malaise and mild 46 PSYCHOLOGICAL MEDICINE depression, when small troubles have seemed vast, when mole- hills have become mountains. On such days the business man feels that ruin is staring him in the face ; the worker feels that, no matter how hard he may work, success is not to be his. Accompanying these feelings there is a restlessness and loss of attention ; the sufferer derives temporary consolation from the sympathy of others, but relapses into despondency when solitude returns. Picture yourself always in this state, and imagine your worst moments as about equal to the better moments of the acute melancholiac ; you will then have some idea of what despair really means. Or, when much fatigued — if quiet introspection is at such a time at your command — ^try to read a scientific book or write a letter, observing your mental state when a word or question is addressed to you. Or, again, when you are distracted by the fear of some impending disaster, when your thoughts seem confused, and constant walking about seems your only relief, try to sit down for an hour or two ; you will then in a feeble way realise what the insane man has to bear when he tries to control his feehngs. Thus we learn that what we term mental disorder is not so much the development of something new as the persistence of certain symptoms which in the normal mind appear but seldom and for a short space of time. If a man gives way to an outburst of temper, his friends may regret it, but they do not consider it a symptom of insanity ; but suppose that his bad temper becomes chronic, and he is persistently irritable, the probability is that a physician will be called in to examine his mental condition. We may all at some time in our life conclude, rightly or wrongly, that the disposition of a particular person is un- friendly towards us ; yet no one would think of casting a doubt on our mental state if we suggested our suspicions to him ; but if we continually suspect the motives and intentions of others, and shape our conduct accordingly, it will not be long before we are looked upon as of unsound mind. Unless a physician is on the watch for symptoms, he will either over- look or misconstrue them. Eemember the possibility of mental disorder in examining your various cases. No one can diagnose what is not present to his mind ; and, after all, unsoundness of mind is not an uncommon condition. More GENERAL SYMPTOMATOLOGY 47 cases of mild disorder of the mind are to be met with in general practice than is commonly imagined, and it is as important to diagnose and treat mild distm'bances as the more ad- vanced stages. Indeed, in many ways it is more important ; for the earlier condition is more curable, and prompt treat- ment may arrest its development. It is a mistake, and im- proper, to apply the term ' insanity ' to these mild disorders ; but, as a rule, there is no objection to informing the patient and his relatives that the symptoms complained of are nervous in their origin and require very decided treatment. Again, it must not be forgotten that certain symptoms standing alone may be of no diagnostic value, but when asso- ciated with others they may be of great importance. For instance, a condition of general exaltation may indicate merely a mental state which is common to many forms of insanity ; but associated with marked pupillary changes, and hesitancy of speech, it, in all probability, points to some organic disease of the brain. There are physical as well as mental symptoms to be considered when diagnosing or treating insanity, and it will be convenient to divide symptoms under these two heads. The writer always adopts this plan, and it will be found of practical value in examining cases of mental disorder ; other- wise important symptoms may be overlooked. Always carry out your examination in a methodical manner. Investigate each case separately, carefully noting the presence of disease in any organs of the body. It is usually advisable to ask the patient regarding his physical health first, for in this way the suspicious person may be thrown off his guard and become more confidential ; and, in any case, questions regarding his body do not provoke surprise in a patient who might be much alarmed if the interview began by an examination pointing to hallucinations or delusions. Eemember, also, that the physi- cian has not merely to determine that a man is insane — a layman can usually do that — ^he has also to endeavour to find out the cause of the malady. Insanity is not uncommonly the result of some physical disease, in which case the prognosis largely depends on the curability of that disease. Thus we see how important it is to be thorough in our examination, and to ascertain, if possible, whether the mental symptoms are secondary to the physical or vice versa. 48 PSYCHOLOGICAL JMEDICINE ^ Disorders o£ Sensation.-^Disorders of sensation are of three kinds : anaesthesia, hyperaesthesia, and paraesthesia. The cuta- neous surfaces can be tested by response to the prick of a pin. Stoddart has pointed out that cutaneous anaesthesia occurs most commonly in stuporose and confusional states. A very exten- sive anaesthesia is generally fomid in patients recovering from acute mania, but it is usually only of a temporary nature and may disappear in a few days. The sense of liearing is deficient in some cases of insanity, especially in patients with arterio- sclerotic changes. The deaf are more prone to mental disorder, and even in the sane this symptom tends to produce suspicion in the sufferer. The visual sense may be lessened and the visual field contracted. The colour sense is usually normal, except in the exhaustion psychoses and in arteriosclerotic disease when it may be defective, especially for some shades of blue and possibly green. The senses of taste and smell are dimin- ished in dementia, idiocy and in the exhaustion psychoses, and at times in general paralysis. The acuteness of taste may be lessened or taste sensations may be altered ; this is seen in the voracious appetite of some patients (Boulimia). These persons may consume ah manner of filth. ^\Tien it is possible to ehcit why these things are eaten, the reason sometimes given by the patient is that he has a constant feeling of faintness or nausea and that matter of all kind allays this sensation. The taste is best tested by solutions of salt, sugar and quinine. The visceral sense may be affected, as observed by changes in the ahmentary tract. The appetite may be changed or there may be an actual dislike to all food. Hypercesthesia, especially of the sense of hearing, is very marked in the nerve exhaustion cases ; even slight noises may be intolerable. The pelvic organs may be hypersensitive, or owing to anaes- thesia of the hmbs and other parts of the trunk there may be a relative hyperaesthesia. Increased acuteness of sensation in these parts not uncom- monly leads to delusions regarding them. Parcesthesice are more readily considered under illusions and hallucinations. In conclusion, w^hatever may be the cause of perverted sensa- tions, whether they are peripheral or central, it must always be remembered that altered sensations are a very potent factor in the production of delusions. They lead to an altered GENERAL SYMPTOMATOLOGY 49 idea of self, and the tendency is for the person so affected to endeavour to account for the changed state of things. This is especially the case when the organic sensations are disturbed. A word of warning may be useful : do not be too ready to class all complaints of disordered sensations as delusions. Fre- quently patients will misinterpret their sensations, and it is the duty of the physician to find out, if possible, whether there is any organic disease to account for the symptoms. A good example of this is the mental aspect met with in some cases of locomotor ataxy. .Tabetic patients may misinterpret the ordinary physical symptoms, and may explain the gastric and other crises by extraordmary delusions. Disorders of Perception^l^Disorders of perception are met with in many types of mental disorder. They are of the following Varieties : (a) Imperception, {b) Hallucinations, and (c) Illusions. Imyerceftion occurs most commonly in arteriosclerotic condi- tions. By imperception we mean a state in which, although the individual is able to sense objects either by hearing, seeing, feel- ing, tasting or smelling, he cannot state what these objects are ; past experience seems to be obhterated. At times the patient may be able to show you what to do with a thing, but he cannot tell you what it is. Give him a knife and he may tell you it is a thing to cut with, or even if he is unable to give you this information he may show you for what it is intended to be used. There are various degrees of imperception, total or partial. The dissolution that is taking place closely resembles in the inverse order the imperception of childhood, but with this difference, that tbe child has potentiahties of acquiring know- ledge, whereas the patient with arteriosclerotic changes is degenerating and is losing the memory of experience which he once possessed. Imperception or agnosia, as it is sometimes called, can be tested in many ways, either by single articles such as a key, pen, knife, coins, etc., for visual imperception ; bells, tapping on wood or china, rmining water, etc., for auditory imperception ; giving the patient objects to hold and describe (with eyes blindfolded) for tactual imperception ; and tests for taste and smell for imperception of these senses. If these are successfully recognised a more comphcated series of tests can be made, such as giving the patient pictures to describe, and for the finest degrees of imperception Stoddart recommends 4 50 PSYCHOLOGICAL MEBICINE a children's book in which proverbs are clearly depicted in picture form — ' Proverbs old newly told.' Another condition which occurs in the same disorders as imperception, and which is closely allied to it, is that which is known as ideational inertia, or by some authorities as agnostic perseveration. It is a state of fatigue and is best explained by means of an illustration. If a patient is shown a key he will answer correctly ; next show him, for example, a penholder, and this he again describes cor- rectly ; then give him a knife and he will say that it is a penholder, and to each article now shown he will say penholder. He has passed into a state of fatigue, and is now unable to get away from the idea and word penholder. Hallucinations and Illusions Definition. — An hallucination has been defined as * a false perception of the senses without an external stimulus,' i.e. we see, hear, feel, taste, or smell something which has no apparent external origin. If a face or light is seen in an absolutely dark room, this would be spoken of as an hallucination. An illusion is a false perception of the senses with an ex- ternal stimulus. For example, a pattern is seen on the carpet, and is taken for ^vriting ; or the wind howling in the chimney is interpreted into the sound of a voice. It is frequently difficult to decide whether the sensory distm'bance is in reality an hallucination or an illusion, but illusions are probably more common than pure hallucinations. As the study of illusions is somewhat simpler than that of hallucinations, their various forms may first be enumerated and described. There are two main divisions of illusions : (1) Passive, (2) Active. The Passive Illusions arise from without, and are largely suggested by external or physical factors ; whereas the Active Illusions arise from within and are due to expectancy. Professor SuUy classifies illusions in the following way : Passive Illusions 1. Exoneural, determined by — ■ (a) Exceptional external arrangements, e.g. a stick immersed in water appears to be bent. GENERAL SYMPTOMATOLOGY 51 (6) Exceptional relation of stimulus to organ, e.g. objects appear smaller, and at greater distance, when one eye is used than when we use both eyes. (c) Illusions of art. — Stereoscopic effects are instances of this type of illusions, for by means of the stereoscope we get the appearance of solidity and depth. {d) The "particular forms of objects. — The limbs or head may seem enormously enlarged or greatly contracted under certain conditions. Drugs such as hashish will produce this effect. (e) Tlie points of similarity of objects. — An illustration of this is seen in errors of identity. A person sees a resemblance to his friends or relatives ia the faces^of strangers. Probably all differences and defects in the likeness are corrected by imagina- tion, just as, when we are examining printed proofs of manu- script, we are apt to pass over wrongly spelt words, for we intuitively correct the error in our own minds. Mistaken identity is very common in the insane, and may be due to some error of refraction, which causes a blurring of outline of the features, and the result is an illusion. if) The reverse illusions of orientation. — When travelling by train at night it is often very difficult to decide in which direction we are moving, and by an effort of imagination we can persuade ourselves that we are moving either backwards or forwards. 2. Esoneural, determined by — (a) The limits of sensibility : (1) Degree of stimulus. (2) Number of stimuli. (3) Fusion of stimuli. (4) After-sensations. (5) Specific energy of nerves. (6) Eccentric projection. After-sensations are a good example of this form of illusion. For instance, we may feel the rolling of a ship for hours after we have landed ; or, in the case of eccentric projection, there may be apparent feeling in the toes, notwithstanding the fact that the hmb has been amputated. This latter condition can 52 PSYCHOLOGICAL MEDICINE be explained by ' the law of eccentricity,' which affirms that we refer our sensations to the peripheral endings of nerves. (b) By the variatioii in sensibility : (1) Transient. — Illusions due to the exhaustion of the various sense organs. (2) Comparatively permanent conditions. — Colour-blindness, conditions of more or less permanent hyperaesthesia, anaesthesia, or parsesthesia. Active Illusions In active illusions there is a state of expectancy. For instance, when standing in a crowd waiting for a procession to pass, we may fancy we hear the music of the band long before it is possible for it to reach our ears. The phenomena seen by various individuals at seances are commonly illusions of this type. It is certainly the most frequent form of sensory disorder met with in the insane. In describing the symptoms of melancholia, reference will be made to the part played by active illusions. In fact, in all forms of mental disease expectancy is the forerunner of many sensory disorders. The maniac sees beauty in everything, while to the melancholiac all is gloomy and ugly. What we expect to see we are apt to see, whether it is a smile or a scornful look. If we believe the world is saying things against us, we are prone to hear disparaging remarks. In a word, we are ready to be deceived by our senses. Before leaving the subject of illusions, mention must be made of another class of illusions which have been termed secondary sensations. Some individuals never see a colour without having the sensation of a distinct smell which always seems to accompany that particular colour. In the same way sounds may be associated with colours, or colours with smells. Bleuler has divided these secondary sensations into : 1. Sound fhotisms. Sensations of colour accompanying sensations of sound. 2. Light fhonisms. Sensations of sound from perception through light. j3. Taste fhotisms. Sensations of colour from perception through taste. GENERAL SYMPTOMATOLOGY 58 4. Odour fhotisms. Sensations of colour from perception through smell. 5. Pain fhotisms. Sensations of colour from perception of pain, temperature, and touch. Certain of the insane are found to have these secondary sensations, and hitherto no satisfactory explanation has been given of the phenomena. To revert to the consideration of hallucinations and illu- sions. As already stated, it is frequently very difficult to decide whether we have in a given case to deal with an hallucination or an illusion, for it is often by no means easy to say whether there is any recognisable external stimulus. Professor Ball believes that even an illusion involves an ■hallucination, and that there is no fundamental difference between the two. Therefore, from the clinical point of view, it is more convenient to consider them together. It will perhaps be as well to state that the presence of hallucinations and illusions does not, 'per se, constitute insanity. Many sane persons suffer from hallucinations — in fact, they may be able to produce them at will ; and similarly with illusions, no one is exempt from the risk of being in this way deceived by his senses. Hallucinations and illusions are common in dreams and in half-asleep and half-awake states (hypnagogic states). Head also lays stress upon their presence in associa- tion with certain types of visceral disease. But if we are not to rely too much on the presence of hallucinations as a test of mental disease, we must not under-estimate their importance when associated with other symptoms of insanity. Hallucina- tions are not only valuable corroborative evidence, but may prove very helpful when we have to give a prognosis. As a general rule persistent hallucinations may be a grave symptom, and a physician should be on his guard not to give too favourable a prognosis regarding a patient who is thus afflicted. Further, it must be borne in mind that the majority of the insane who suffer from hallucinations treat them as if they were realities ; for, after all, how can they distinguish between normal special sense sensations and the abnormal ? It is true that, if the illusions are indistinct and fleeting, it may be possible to get the patient to ignore them ; but if they are vivid and oft-recurring, he will almost certainly be ;S4 ' PSYCHOLOGICAL MEDICINE infltienced by them. He has trusted his senses in the past, and why should he discredit them now ? Auditory Hallucinations. — Auditory hallucinations are the most common variety, probably owing to the fact that we use the sense of hearing by night as well as by day. It is also the most liighly developed sense. Auditory hallucinations usually begin as indefinite sounds, and later become more organised — into whisperings and definite ' voices,' or they may remain as rushing or roaring sounds, or even be musical in character. If they become organised into ' voices,' commonly single words are heard at first, and at a later stage sentences. They may be confined to one ear or heard in both : the voice may be that of a friend or a stranger, male or female. The soimd may appear to come from above or below, or even from the abdomen. The conversation may be of a pleasant or unpleasant character ; the words may be persuasive or com- manding. Another point of interest regarding auditory hallu- cinations is that they are very frequent in deaf persons. Visual Hallucinations. — Visual hallucinations are very com- monly met with in many types of insanity, and more especially in those forms of mental disorder due to fatigue or to drugs such as alcohol and cocaine, and in delirious states they vary greatly in character ; they may appear merely as lights or shadows, or may be more complicated. Faces of friends or foes, faces with horrible and distorted expressions, angels or devils, animals or vermin, spectres or ghosts, are some of the forms that these hallucinations may assume. The objects seen may be fiat or may stand out in rehef. In the matter of colouring the most common type is black or white ; a certain percentage are blue, but bright colouring is rare. They may be stationary or floating about in the air ; others keep moving from left to right, or right to left, according to whether the patient is a right or left-handed individual. Homonymous hemiopic hallucinations have also been observed, and are usually but not invariably associated with a corresponding hemianopsia. Hallucination of vision may occur in the blind. Gustatory Hallucinations. — Gustatory hallucinations are also common and of importance, as they frequently lead to refusal of food by patients on the ground that the food has been tampered with. In these hallucinations the taste is GENERAL SYMPTOMATOLOGY 55 usually described as ' bitter,' or it may be some compound taste such as that of filth. Hyslop in his ' Mental Physiology ' briefly sums up the various perversions of taste as follows : ' (1) Hypergeusia, exaltation of the sense of taste, i.e. there is a morbid exaggeration of all gustatory sensations, as seen in some forms of neurasthenia, extreme nervousness, and sometimes even in conditions of mania and melancholia. ' (2) Hypogeusia, diminution of the sense of taste ; at times met with in acute maniacal or melancholic states, in cases of stupor with general blunting of the sensibility. ' (3) Ageusia, absence of sense of taste, met with in some organic conditions. * (4) Parageusia, perversion of the sense of taste, as seen -in nearly every form of insanity. Gustatory hallucinations are frequently associated with perversion of smell.' Olfactory Hallucinations. — Olfactory hallucinations are of varied kinds. They may be sweet and pleasant, but are more commonly offensive. Savage believes that perversions of smell are closely connected with uterine and ovarian disorders. Tactual Hallucinations. — Hallucinations of common cuta- neous sensibility are frequently electrical in character. Sen- sations that insects are crawling over the skin, feelings of dirt, dryness or moisture are also met with. The so-called epigastric sensation is very common, the feeling being described in varied ways as a fullness, sinking or actual pain. Among these perversions of tactual sensation must be mentioned those which lead a patient to affirm that his sexual organs are being tampered with ; these are especially common in some cases of paranoia. Psycho-motor Hallucinations is the term given to the sense of movement when no actual movement is taking place. Hal- lucinations of this type may occur in any part of the body ; one patient may feel his brain swinging to and fro, another may believe that he has struck some one near him, whilst another may feel that he is saying blasphemous words. Examples of these various types of hallucinations might be given in infinite variety if space permitted, but no good purpose would result. 56 PSYCHOLOGICAL MEDICINE The physician must always consider what effect any halUi- cinations may have on a given case. In the first place, it is not alwaj's easy to diagnose the presence of hallucinations in an individual who is suspicious and uncommunicative. Watch the patient's movements and general conduct, for in this way much may be learned. Commanding auditory hallucinations are dangerous, for ' voices ' of this kind may lead a patient to commit acts of violence against himself or others. Belief that food is being poisoned results in refusal of food, except in those cases where the patient is able to cook all his own meals. To sum up : hallucinations of the various senses account for many of the vagaries of conduct in the insane. Some persons are greatly influenced by their presence, and may act upon their promptings. Hallucinations frequently confirm pre-existing delusions. The patient, at first merely suspicious that others are against him, is at length confirmed in this belief by hearing the disparaging remarks, or by tasting the poison which he believes to have been pre- pared for him. For this reason persistent hallucinations are apt to indicate chronic mental disorder, as the patient bases his life and actions on these altered conditions, not realising that he is being deceived by his own senses. To explain the development of hallucinations is by no means easy. Some are no doubt peripheral in their origin, while others appear to be central. External ear disease may pro- duce auditory hallucinations in the same way that disorders of the eye or of the skin surfaces may give rise to other sensory perversions. Other common causes are peripheral neuritis and distm'b- ances of the circulatory system. Hallucinations may be fantastic in their arrangement, but are not absolutely new creations : the devil seen by the melancholiac is the goblin of the fairy tale or the Mephistopheles of ' Faust.' They are all memory-types, and more or less follow the laws of association. Auditory and visual illusions or hallucinations may be set up by any form of stimulus acting on nerve-endings and thence upon the centres of sight and hearing in the brain. On the other hand, can the centre act independently of any external stimulus ? Can it in a sudden and unprovoked way pass into a state of commotion, and cause the reproduction of memory- GENERAL SYMPTOMATOLOGY 57 ideas wliich may have been latent for years ? This question must be answered in the affirmative, as there seems increasing evidence to prove that such is the case. After all, why should it not be possible for the centres to be irritated and set in action by the very blood in which they are bathed, especially when the blood contains toxins or other irritants, as in all likehhood is the case in many forms of mental disease ? The effect of drugs in the production of hallucinations is variable, some drugs acting directly on the centres, others on the peripheral ends of nerves. Hughlrngs Jackson has ingeniously suggested that illa- sions and hallucinations may arise in the following way. "When any area of the brain is damaged, or becomes func- tionally deranged, there will in consequence be two sets of symptoms in evidence — ^the negative symptoms, due to the non-activity of the damaged portion of the brain ; and the positive symptoms, due to the over-activity of the lower centres, which are now no longer controlled by the higher centres, which have become disorganised. Hughhngs Jackson suggests that illusions and hallucinations may result from the over-activity of the lower centres. Stoddarfc ^ considers that there is practically no psychical difference between perception, ideation, illusions, and hallucinations, and there- fore the differences must be sought among the physical bases of these processes. He states that ' the most obvious difference is that, while in perceptions and illusions there is a stimulus to the peripheral end-organs, in ideation and hallucinations there is no such stimulus ; in visual perceptions and illusions the stimulus to the angular gyrus arrives by way of the optic radiations, occipital lobe, and occipito-angular association- fibres ; but in the case of ideation and hallucination, the stimulus reaches it by way of other association-fibres than the occipito-angular bundle. Confirmation of this proposition is afforded by the existence of visual hallucinations in the blind, auditory hallucinations in the deaf,' etc. Now, when a patient has an hallucination of vision, there is a negative as well as a positive side to the process. The positive side is that he sees the hallucination image, the negative is that he does not ^ ' The Psychology of Hallucinations,' Journal of Menhd Science, October, 1904. 58 PSYCHOLOGICAL MEDICINE see objects in the neighbourhood of the image. Stoddart considers that hallucination depends upon two factors — - diminution of sensation, and disturbance of association ; and further that these factors vary inversely in the several conditions in which hallucination occurs. For example, with delirium of fever and in the excited stage of acute mania there is little diminution of sensation and great disturb- ance of association ; in cases of nitrous oxide or chloroform inhalation there is little disturbance of association and great diminution of sensation. The ' reflex hallucinations of Kahlhaum ' are supposed to arise in another way. An ordinary sensory stimulus acting on a hypersensitive sensory centre may set up reflex hallu- cinations. As already stated, a deaf or blind person may suffer from hallucinations of the senses in which he is defec- tive ; on the other hand, the congenitally deaf never have auditory hallucinations, neither do the congenitally blind have visual hallucinations. This clearly shows that, whether the excitation be central or peripheral in origin, hallucina- tions are the reproduction of former memory-images. Delusions. — A delusion is a false belief. But here we are met with a difficulty at the very outset. Who is to deter- mine what is a delusion ? We are born into a community, and have to conform to its social laws and dictates, and even if we disagree with the rules which it prescribes, we must not actively disobey them. Society, to use the word in its broadest sense, permits a certain amount of latitude in obedience to its regulations ; but, in the main, the views of the majority are paramount. Now, beliefs are largely the tradi- tions and ideas which have been handed down by parents and teachers ; they are ready-made and must be accepted. The normal evolution that is ever taking place in all things permits the adaptation of the older ideas to the latter-day demands. So, in considering the question of delusions, we must bear in mind certain ascertained or ascertainable facts. Among the most important of these are the traditions of the country in which we live. For example, if a person were to adopt some of the habits of life in vogue in distant lands, and were to conduct himself in Kegent Street as Kaffirs or Basutos do in their country, he would unhesitatingly be pronounced insane. GENERAL SYMPTOMATOLOGY '59 The degree of education and the social status of a person, whose conduct is under consideration, are also important facts, for habits which would be regarded as decidedly eccen- tric in educated members of the upper classes, might pass unremarked in the lower grades of society. It is obvious that any one may have a false belief, but the sane man corrects his ideas and conclusions by his reasoning power, he applies his past experience, and listens to the argu- ments of others. In this way he differs from the insane man, whom no force of reasoning will convince, but who prefers to be guided by his own feelings and sensations. Defendorf i writes on this subject as follows : ' Delusions are iiiaccessible to argu- ment, because they do not originate in experience ; experience .therefore is unable to correct them as long as they remain delusions. Only in convalescence, when they become a mere memory of delusions, can they , be recognised as false. At the height of the disease they are as firmly established as reason herself. So long as the morbid conditions which give rise to them persist, the delusions are unchanged. If they are relinquished or modified, the change is not due to argu- ment, but to a change in the morbid condition. Our arguments may drive the patient to admit non-essential points, but the delusion serenely reasserts itself notwithstanding the most evident self-contradiction. Even when the external object of reference or support is destroyed, a new one is quickly found. The delusion needs no other support than the absolute con- viction of the deluded.' ' I feel that I am lost for ever ! ' is the cry of the clergyman, notwithstanding that he has taught the way of salvation to his parishioners for years. Altered feel- ings and sensations outweigh all arguments and reasoning. Strong emotional states tend to the production of delusions. Some writers believe that the ' clouding of consciousness ' is an important factor in their development. This may be so, but perhaps it would be more accurate to say that in some mental states there is loss of power of com'parison. Memory and attention may be defective, and thus the ideas of the moment may be misleading. Especially is this the case when ideas are vivid and impressive. Probably some of the delu; sions observed in general paralysis and certain delirious states ^ Clinical Psychiatry. 60 PSYCHOLOGICAL MEDICINE originate in this way. A general classification of delusions may be helpful to the student, and no better can be given than that drawn up by Mercier.i I. Disorders of the Consciousness of Self. A. Disorders of self-conscious feeling. B. Disorders of thought. A. There are three subdivisions of the disorders of feeling of self. (a) Elevation of self-consciousness. Exaggerated feelings of well-being and vigour. Buoyancy and general exaltation. {h) De'pression of self-consciousness. Depression and misery. (c) Alteration of consciousness. This is a condition separate from either elevation or depression, in which the feeling of self is altered. B. Delusions of the thought, as distinguished from the feeling, of self. These may be general or local. They may include the knowledge of the body as a whole, or the knowledge of parts only. 1. Delusions of knowledge of whole of self. 2. Delusions of knowledge of parts of self. 1. (a) In some cases the old self is found to be replaced by a new ; a man loses his own identity, and believes that he is something else. (b) In others the old self and the new self alternate. A person passes through alternating phases of existence of days' or weeks' duration. (c) Further, in other cases the old self and the new self coexist, and the patient believes himself to be two persons at once. This is met with in those persons who suffer from a double hallucinatory condition, e.g. where the auditory hallucinations of the right side quarrel with those of the left. 2. (a) Partial disorder of the knowledge of the whole self is seen in those persons who, while preserving a knowledge of their own identity, believe that they are changed in some im- portant particular, as, for instance, in sex, or that they are composed of glass or iron. ^ Tuke's Dictionary of Psychological Medicine, GENERAL SYMPTOMATOLOGY 61 {h) Cases of disorder of the knowledge of parts of self are also common ; for example, a man may believe that his head is open, and that his brains have been removed, and replaced by some other material. 11. Disorders of the Consciousness of the Relation of Self to Surroundings. This is further divided into — (a) Delusions of the relation of self to surrou7idings. — These are of two kinds, delusions either of increased welfare or diminished welfare. Under the first head fall delusions of power, of wealth, of influence, including the delusions of those who think themselves millionaires, kings, etc. Under the second head fall self-accusatory delusions. {h) Delusions of the relation of surroundings to self. — These are similarly divisible into delusions of beneficent relation and delusions of inimical relation. The former include the delusions of those who believe honours or commands are conferred upon them ; the latter, an exceedingly common and in practice a most important group, include the delusions of those who believe themselves to be the victims of per- secution. Substantially all classes of delusions are included in the above classification. Delusions are found to be present in nearly every form of mental disorder. In some conditions they seem to be the outcome of the insanity ; in others they seem to form its very basis. For example, some delusions are merely the explana- tion offered for altered feelings ; these are common in the case of emotional insanities such as mania and melancholia. The patient feels miserable, and, as Savage tersely puts it, ' explains his condition from the standpoint of mind, body, or estate.' These delusions may be fleeting and transient, or may become more organised. On the other hand, in the ideational forms of mental disorder, delusions are slow in development, and may for years pass almost unnoticed. Delusions of grandeur and pride may spring from a haughty nature ; jealousy and suspicion may be the forerunners of definite delusions of persecution. Delusions are the outward and visible sign of an altered mental state. Lawyers and jurymen feel that they have some 62 PSYCHOLOGICAL MEDICmE tangible proof of mental disorder when a definite delusion can be instanced ; but to the physician its presence is of httle importance, except as lending some assistance in indicating the line of treatment. A question of far greater importance is, * Why is the delusion there ? ' Delusions are merely symp- toms, and the physician must endeavour to discover the reason for their presence. This sounds Hke emphasising the obAdous, but it is the obvious that often is overlooked. Many a physician thinks that he has discovered everything about a patient when he has dejQnitely detected a delusion. He has not : the delusion may be here to-day and gone to-morrow, while the mental disorder may persist. In some cases delu- sions are ever changing, and are merely the audible reflection of a passing thought. The term ' fixed delusion ' has been appHed to that class of delusion which is more or less per- manent, and which is a dominating factor in the hfe of the patient. There are also so-called ' fixed ideas ' and ' obses- sions,' but these will be dealt with elsewhere. The presence of delusions does not necessarity argue mental weakness, and clinically it will be found that many who suffer in this way are perfectly capable of transacting business, provided their delusions are not such as to obscure judgment in matters to which then- business relates. Delusional states are frequently associated mth hallucinations, and may be secondary to the sensory disturbances. In alcohohc insanities and those forms of mental disorder due to poisons, the delusions are, as a rule, the result of haUucinations, while in other types of in- sanity the hallucinations are usually secondary to the delusion. Delusions occm- both in the sane and the insane. Taken by themselves, they do not necessarily indicate insanity, but their presence is strongly indicative of mental disorder when they are found in conjunction with other evidence, such as failure of general conduct and neglect to conform to the ordinary rules of life and society. Disorders of Attention. — The disorders of attention are of two kinds : (1) Hyperattention ; (2) Inattention. The normal mind ought to be polyideational and should be capable of concentration on any subject which demands GENERAL SYJIPTOMATOLOGY 63 its attention ; but when there is a reduction from general intellectual activity to concentration upon one idea, we get hyperattention. Fixed ideas are found in several conditions ; they may be due to a pm'ely intellectual change, or may be accompanied by emotion. The most common variety of fixed ideas is seen in oft-recurring imperative ideas, usually spoken of as obsessions. Inattention is due either to absence of power of reinforcing an idea, or to the impossibility of inhibiting accidental external influences w^hich have no relation to the needs of the moment. Inattention may be due to failure of evolution — the power of concentration of mental faculties on a subject never having been acquired — or it may be due to dis- solution. Failure of attention is seen in fatigue, in mental states after serious physical illness, in intoxication, and in many forms of mental disorder. Dream consciousness is an example of an extreme degree of inattention ; and to this is largely due the fantastic arrangement of ideas in dreams, in that there is no governing idea upon which attention is centred, but every idea has an equal chance. The im- portance of inattention as a symptoln is very great. It usually occurs in every form of mental disease, and accounts for much of the inaction exhibited by the insane. A person who is preoccupied in considering his o^tl thoughts and feelings cannot apply himself to the wants of others ; it is largely for this reason that the insane keep so much to themselves. As mental improvement takes place they become more altruistic, and more attentive to the requirements of their fellow-patients. Attention is of late development, and therefore goes early ; and inattention, or easy distractabihty, is frequently one of the earhest symptoms which are noted in the onset of mental disease. Inattention also plays an important part in the question of memory ; perceptions and ideas to which attention has been given are remembered, whilst an inattentive individual wiU often seem to have a bad memory. Subject-Consciousness and Object- Consciousness. — Closely con- nected with hyperattention and inattention are the rise of subject-consciousness and the fall of object-conscious- ness, which are such prominent symptoms in mental disease. The meaning of these terms has been already described in a former chapter. As Bevan Lewis shows, the rise in 64 PSYCHOLOGICAL MEDICINE subject-consciousness is the 'positive aspect of the patient's mental state, and is that which attracts the most notice. This is very markedly the case in melancholia, where every thought and action of the patient is colom'ed by his miserable feelings. Similarly the decline in object-conscious- ness represents the negative aspect. ' The decUne in object- consciousness which occurs in states of pathological depression presents us with the following features : (a) enfeebled re- presentativeness ; (&) a lessened seriality of thought (weakened attention) ; (c) diminution or failure in the muscular element of thought.' 1 Muscular Element of Thought. — Bevan Lewis points out that, in addition to the five special senses, there is a sixth sense, the muscular sense, which tells us of size, position, and form. He goes on to show that the full perception of things about us is largely due to the proper and vigorous working of this muscular sense. Now, if this sense undergoes any diminution, correspondingly the space attributes of the body become less vividly conceived. Proper vision is largely dependent upon the" muscular mechanism involved in our perception of objects. Bevan Lewis also observes that * we must distinguish between that portion of the muscular element which enters into our higher intellectual concepts, and that grosser factor of the larger musculatm'e of the limbs, etc., which subserves the pm^pose of locomotion and coarse move- ments. The sense of muscular contractions which forms the basis of the primordial ideas of form, size, and position, lapses eventually in consciousness as a pure sense of muscular contraction. With the larger musculature this is not so ; it is essential that the movements of the limbs, their contraction and tension, should be exquisitely registered centrally, as thereby alone can we gain an idea of their position in space apart from the sense of sight, and appreciate the relative weight of objects and the resistance offered by them. The unrestrained action of these muscles signalises to our minds the absence of external resistance, and the rise in the muscular sense which accompanies any resistance opposed is the direct measure of such resistance. Similarly with the " Muscularity of Thought," which in the normal state is of free and easy ^ A Text-book of Mental Diseases. Bevan Lewis. GENERAL SYMPTOMATOLOGY 65 play, the rise into consciousness of its primordial muscular element means effort, and at once suggests to the mind the same notion of resistance in the environment.'' Now, with failure of object-consciousness there is a sense of resistance in the environment ; thus the melanchohac does not gi'asp his relation with the external world. Again, if a man fails to do a thing on account of loss of object-consciousness, he is annoyed, and there is a fm'ther rise of subject-consciousness ; his idea of self alters, and delusions result — ^usually by way of explain- ing the altered conditions. Another example of the effect of muscular contraction on thought and feeling can be demon- strated by the voluntary relaxation of the facial and limb muscles when the mind is in a state of tension or irritability. The reader can test this for himself and he will notice how rapidly this tension is replaced .by a sense of repose. Disorders of the Association of Ideas. — The power of associating ideas may be disordered in two ways : (1) The flow of ideas may be retarded ; this is to be observed in states of mental enfeeblement, in exhaustion states, in melancholia, and in organic disease where there is destruction of the cortical neurons, in disease such as general paralysis, and in local lesions of the brain. (2) The flow of ideas may be accelerated in delii'ious and maniacal states, and is often spoken of as the ' flight of ideas.' Disorders of Memory. — Disorders of memory fall into three main classes : (1) Amnesic States, or loss of memory ; (2) Hypermnesic States, where there is exaltation of memory ; and (3) Paramnesic States, or illusions of memory. 1. Failure of memory follows the ordinary law of disso- lution of the nervous system — ^that is, that the latest acquired and consequently the least organised attributes disappear first, the failm'e being in inverse order to the order of acqui- sition. The patient is no longer able to store fresh impres- sions, and the events of long ago reappear with the vividness of an event of yesterday. How often is it said, ' Oh, his memory is excellent ; he remembers events which happened years and years ago which I have long forgotten ! ' But such a memory is of little use in comparison with the memory which is retentive of events of recent occurrence, and is indeed consistent with and sometimes symptomatic of impending 5 66 PSYCHOLOGICAL MEDICINE failure. Eibot in his ' Diseases of Memory ' gives the follow- ing classification of Amnesic states : 1. Congenital defects. 2. Conditions of tem'porary loss : (a) In epilepsy. (&) Following injury or shock. (c) In acute mental disorders. 3. Conditions of 'periodic loss : {a) In states of double consciousness. {h) In somnambulistic states. 4. Conditions of frogressive loss : (a) In general paralysis of the insane. (&) Associated with various brain lesions, (c) In senile dementia. 5. Conditions of 'partial loss (as seen in loss of memory for names, aphasia of all kinds, music, etc.). Defects of memory may be due to failure of evolution or to a temporary or progressive dissolution. A true amnesia is always a factor of great importance in considering the prognosis of a case of mental disorder. As a general working rule, when the memory is found to be bad or progressively failing, the outlook for recovery is not good. The memory is not very defective in acute functional forms of mental disorder ; and, if it is found to be lost or progressively failing, it generally indicates some organic change. Care must always be taken in testing the memory, as it may appear to be defective when the condition is really only due to lack of observation ; this is often the case in melancholia. Further, memory must be tested for both recent and remote events, and it is the failure of memory for recent events that is of most diagnostic value. Loss of memory is often most marked in persons suffering from arteriosclerotic and senile changes in the brain. It is frequently a matter of great difficulty to decide whether a person with loss of memory, and with no other marked mental disturbances, should be placed under care. It is largely a question of the financial position of the patient. If his circumstances are sufficiently affluent GENERAL SYMPTOMATOLOGY 67 to insure his receiving careful attendance at his home, it is rarely necessary to send him away. If, however, his means do not enable such provision to be made, it may be expedient to place him in safe keeping. Loss of memory may seriously affect conduct. An amnesic person may seriously contravene moral and social codes. He may relieve his bladder in some public place in entire ignorance that he is offending, or he may wander away from home and be totally unable to account for himself. Frequently, loss of memory leads to inability to provide means of livelihood either for the patient himself or his dependants. There is little doubt that patients afflicted with loss of memory are in many cases happier and better cared for in asylums than they can be elsewhere. There is certainly ah increasing tendency to send senile amnesiacs of the pauper class into asylums ; and this, to a certain extent, accounts for the great increase in the insane population in these in- stitutions. Though this is well for the patients, it is bad for the ratepayers. It would be a wise economy if suitable infirmaries could be established for cases of this type, as it would relieve the costly machinery of the regular asylum. As already observed, if there is marked loss of memory, the prognosis is usually bad ; but there are notable exceptions to this rule. In certain cases of alcoholic insanity, and in some forms of stupor and exhaustion states, the memory is bad, and yet there is a fair chance of recovery. Loss of memory is most marked in the following forms of mental disorder : (1) general paralysis of the insane ; (2) chronic alcoholism ; (3) progressive mental disorder ; (4) stupor and nerve exhaustion states ; (5) senility ; (6) organic dementia. 2. Hypermnesic States. — These may be : (1) Congenital. (2) Temporary. (3) Periodic. (4) Partial. This condition of exaltation of memory is seen not in^ frequently in acute fevers, and notably with poisoning by drugs — such as hashish. It is a symptom which is not 68 PSYCHOLOGICAL MEDICINE uncommonly present in some cases of excitement. Partial hypermnesia is sometimes fomid in imbecile and weak- minded persons. Some such patients may remember the names of all individuals whom they meet, even casually, others remember dates in an extraordinary way. 3. Paramnesic States, or illusions of memory. Incidents which never occurred seem to be famihar, in fact so familiar as to have been part of past experience. As already stated in a former chapter, an essential factor in a memory-idea is the feeling-tone of famiharity which accompanies that idea. Therefore, should this feehng-tone arise with any sensation or perception, the result will be similar to that of ordinary recognition or memory. A common instance of paramnesia in a sane person is when he has told a story of some event a number of times, and each time tells it as if it happened to himself, until finally he becomes firmly convinced that he was really present when the incident took place. The feehng-tone of famiharity is supplied by the description he has given on former occasions. Paramnesia is common in chronic alcohohc disorders, especially in the variety known as Korsakow's disease, a polyneuritic psychosis. Disturbances of the Emotions. — Disturbances of the emotions are very common in the insane, and, in certain instances, may form the chief symptom of the mental disorder. In the early stages of general paralysis of the insane, and in several varieties of insanity, the emotions may be in an exaggerated state of irritability. Small annoyances may cause outbursts of passion and temper. At one moment the patient may be laughing and at the next weeping. The emotions seem to be poised in a condition of unstable equiHbrium, and are ever ready to respond violently to shght stimuli. This condition is very commonly seen in states of excitement apart from organic disease. The alcohohc is at times very emotional ; and this is true both in the acute and chronic variety of alcohohsm. In dementia prsecox, one of the earhest symptoms is a tendency to outbursts of laughing for no apparent reason. On the other hand, the emotions may appear dull and fail to respond to even strong stimuh. This is observed in some cases of melancholia ; a patient may be told of the death of a near and much-loved relative, and be apparently unaffected by the news. GENERAL SYMPTOMATOLOGY 69 Emotional deficiency may result from imperception, as in old age, in arteriosclerosis, dementia, myxoedema and in states of mental enfeeblement. Again, fear and constant anxiety are symptoms frequently met with in many types of mental disorder. Morbid emotional states may be temporary or per- manent. With progressive mental deterioration the emotions fail, together with the other attributes of the mind. Disorders o£ Volition. — The layman is apt to lay much stress on the want or weakness of will-power in the mentally afflicted. Usually this conclusion is erroneous and there is no real absence of voHtion, but for the time being it is misdirected or swayed by disordered sensations or ideas. There are several disorders of volition : (1) A'praxia, or paralysis of the will. Apraxia may be either (a) sensory or (6) motor in character. In the former, the disturbance is due to failure on the part of the patient to recognise a thing. For example, give him a match and tell him to light a candle ; but he makes no movement, as he fails to appreciate that he has a match in his hand. If he has motor a'praxia he recognises the match, but he cannot go through the movements required to light it. Apraxia is a common symptom in cases with cerebral dege- neration, in Korsakow's disease, and other types of alcoholism, and at times in the exhaustion states. 2. Negativism is another form of disordered action ; in this condition any suggestion made to the patient at once sets up a counter suggestion, and this makes him resist everything done for him. It is a common symptom in certain types of dementia prsecox. The reverse of this is echopraxia and automatic ohedience, in which the patient tends to imitate movements made in front of him. These are also symptoms common to dementia praecox. Stereotyped movements are movements which are monotonously repeated, such as swinging an arm or leg. Defendorf in his text book on ' Chnical Psychiatry,' which is an adaptation of Kraepelin's work, classifies morbid disturhances of volition in the following way : (1) The energy of the volitional impulse can be diminished or increased ; (2) its release facilitated or impeded ; (3) or the direction can be modified by external or internal influences ; (4) morbid impulses can forcibly suppress the normal will; (5) or natural impulses can assume morbid forms ; (6) finally, 70 PSYCHOLOGICAL MEDICINE the conduct of the insane is naturally influenced by all those disturbances which occur in other spheres of their mental life, although the volitional process itself presents no disturbance. Eibot, in his ' Diseases of the Will,' divides the disorders of the will into two principal groups, according as the will is impaired or abolished. ' Impairment of the will may be due to (1) lack of impulse, or (2) excess of impulse.' The former variety is called ahoulia : meaning that the patient knows what he ought to do, but lacks the power to bring his will into action. This condition is common in some forms of melancholia. In the second class, the difficulty is lack of inhibition and control. Volitional actions are dimiuished with fatigue, intoxication, and with certain drugs — such as morphia — and in several forms of mental disorders. There is increase of voHtional impulse in conditions of motor excitement. The so-called latent period, or period of inaction before making the movement, may be lengthened ; and, according to some authorities, this lengthen- ing is due to a certain amount of resistance which has to be overcome. This is well seen in melancholia. Attention has much to do with action ; inattention may play an important part in disorders of the will. For this reason certain children are always inactive. Obsessions (compulsive acts or imperative ideas) are another variety of disorder of the will ; these will be fully dealt with in a subsequent chapter. Movements. — In an earlier chapter it has been shown that movements are the muscular expression of mental action. It has been shown that in infancy movements are spontaneous and uncontrolled, and that these movements gradually become controlled as childhood advances. With dissolution there is a reversion to this former state. The restlessness of delirium and mania belongs to this class, and even the fidgety move- ments so common with fatigue must be regarded as falling into the same category. All through the day we are slowly passing from a higher to a lower state of evolution, and it is only with rest and sleep that the equilibrium is re-established. With the agitated melancholiac there is often constant movement. Stoddart has drawn attention to a marked difference in the movements of persons suffering from mania as compared with those of the melancholiac. He has pointed out that the maniac's movements are chiefly from the large joints, while GENERAL SYMPTOMATOLOGY 71 those of the melancholiac are principally connected with the fingers and smaller joints. This is a very important observation and when considered with the microkinesis of infancy it shows how strong the relationship really is between the movements in the early states of evolution and those of dissolution. Ehyth- mical movements are also common in the insane, notably in catatonic and some depressed states. Delusions may be shown by movements, for some patients constantly mirror their thoughts by their actions. Impulsive Acts. — Impulsive actions take place during pas- sive attention, and have to be distinguished from voluntary or volitional acts, which occur during active attention. Obses- sions or imperative ideas are largely associated with active attention, and may in time monopolise the whole attention. Thus a difference is to be observed between a purely impulsive act and an imperative idea. Below, we refer to the common forms of impulse met with in the insane. These are very varied, and may result in injury to self or others. Morbid impulses may be exhibited in sexual desires, or in an irresistible impulse to steal or set fire to everything. Excessive greed and a desire to eat all manner of disgusting things belong also to this category. Impulsive acts are numerous. The following are the types given by Clouston : (1) General impulsiveness, or the tendency to react immediately to all sorts of external or internal stimuli. (2) Epileptiform impulses which are unconscious in character ; or in which, at any rate, the patient is unable to recall the reason for, or the nature of, the impulsive act. (3) Sexual impulses of all kinds. (4) Morbid appetites, in which the patients are unable to resist eating and drinking all sorts of filth. (5) Homicidal impulses. (6) Suicidal impulses. (7) Dipsomania, kleptomania, pyromania, etc. (8) Impulsive conditions which alternate with forms of intellectual and moral insanity. Exaltation. — In mental disease, the term ' exaltation ' denotes delusions of grandeur, wealth, and importance ; it must be distinguished from excitement, which is quite a different mental state. The tendency of the casual observer is to diagnose an exalted person as suffering from general paralysis. Consideration of this disease will show that it is a physical derangement, and that the mental symptoms are to 72 PSYCHOLOGICAL MEDICINE a certain extent accidental, and referable to the ravages of the disease upon the brain. In some cases of general paralysis there are no marked mental changes for a long time, and then merely a progressive dementia. Any form of mental dis- order may be encountered in general paralysis, depression being almost as common as exaltation. The student must therefore be careful not to fall into the common error of diagnosing general jjaralysis from the symptom of exaltation, which is common to many forms of insanity. Exaltation is merely a mental state, and it is to be found frequently in the following varieties of mental disorder : (1) simple mania ; (2) chronic mania ; (3) paranoia ; (4) de- lusional insanity ; (5) certain forms of alcoholic insanity ; (6) some varieties of epileptic insanity ; (7) some cases of de- mentia ; and (8) general paralysis of the insane. Exaltation, at times, seems to grow out of a natural tendency to be ego- tistical, and later passes on to inordinate conceit and self- complacenc}^ The patients are, as a rule, youthful in such cases ; nevertheless they believe themselves to be possessed of wonderful powers. They consider themselves to be talented beyond their fellows, especially in subjects such as poetry, drama, or composition. In others, the exaltation has developed after a varying period of delusions of persecution. The patient begins to ask himself why every one stares at him, why he is always recognised in the street, why he is talked about ? Sooner or later the answer comes — ' It must be that I am some one great.' There are some cases in which exaltation is merely an exaggerated sense of well-being ; in others it is, as Bavage graphically puts it, ' the mast sticking up when the ship has gone down ' — in other words, the last remnant of a mind now completely disorganised. Habits. —It has already been observed that the law of habit is a form of the law of association. If, for example, we begin to doubt the intentions of those around us, in time it will become second nature to us to treat with suspicion every one with whom we come in contact. The insane are very liable to develop bad habits, and these frequently interfere with (he prospect of recovery ; for a patient may learn to base the workings of his whole life on these habits, and in such a case their eradication will be found to be almost impossible. GENERAL SYMPTOMATOLOGY 73 On the other hand, there are a number of habits which it is possible to break down, and those in charge of the insane should constantly endeavour to encourage the patient to correct them. Biting the nails is a sign of irritability and restless- ness. Some patients are constantly removing their clothing, not necessarily with the intention of exposing themselves, but rather from a desire to be free from all covering, which seems to irritate the skin. Others will dress themselves in an extravagant way, and decorate themselves with flowers or bright-coloured ribbons. In certain forms of insanity the mental state seems to revert to the early schooldays, when all manner of rubbish was collected and stowed away in the pockets. The aesthetic sentiment may be diminished or lost, the patient may become careless of dress and general appear- ance, or he may show great extravagance and squander money in a reckless manner. Destructiveness of all kinds is common in the insane. Some destroy with the intention of constructing something new out of the remnants, but they never get further than the destruction of the original article. Others destroy in a reflex impulsive manner and often will tell you that it is a great relief to throw things down or break something. Eavenous eating is another habit which should be corrected. This symptom may be due to irritability and loss of control — the patient not giving himself time to eat a meal — or it may be the result of an inordinately large appetite. Eating all kinds of rubbish and picking pieces of food from the waste-bowl is a habit of some patients — this is usually a symptom of degeneracy, and few of those who practise it recover. Some patients will not attend to the calls of nature— this may be wilful neglect, or due to general mental confusion. Sexual malpractices are also common in the insane. Mas- turbation is a frequent symptom both in the male and in the female. It is a practice that is often looked upon as a cause of mental disorder. Probably this is the case in a certain percentage of neurotic individuals, but it is far more often a symptom of mental disease. Masturbation may be merely a vice learned at school, or in some cases a child first begins to practise it as it finds that it relieves tension when pressed with work, the writer has seen several cases of this kind. No 74 PSYCHOLOGICAL MEDICINE definite age can be fixed for talking to young persons on sexual matters, as some children are more precocious than others ; but it is most important for those who have the charge of them to be very watchful, and not hesitate to speak if they observe any suggestive symptom. With care, it is quite easy in a conversation to see if a boy understands what is being referred to ; and if it is noticed that he is ignorant, the subject can be changed at once. Many youths are greatly relieved at having a chance of being able to speak to some one on the subject, as not infrequently they have already been frightened by reading quack literature. It should be clearly pointed out to the boy that to contmue masturbation is to run the risk of midermining his whole constitution and ruining himself in mind and body. On the other hand, his mind should be set at rest by telling him that up to the present no permanent harm has been done, and that if he conquers the habit he will soon be strong and well again. Except in the case of very neurotic subjects, masturbation does not cause mental disorder ; it chiefly produces apathy and general Hstlessness, and at times leads to tremor of the face dming speech. If carried to excess there are marked symptoms of fatigue and the pupils are usually widely dilated. In the insane, masturbation is a very trying symptom, and most difficult to treat. Other sexual malpractices are not uncommon in very degenerate types of mental disorder, and especially in some forms of paranoia. These cases are important from a medico-legal aspect, as the sufferers may place themselves within reach of criminal law. It is often very difficult to defend these persons, as, with the exception of inordinate conceit, it is often impossible to find any other symptom. Their mental aberration is shown entirely by disorders of conduct, and they are therefore hardly distinguishable from the ordinary ci'iminal. Nevertheless it is the duty of the physician to defend these persons if he considers them to be victims of nervous dcgonoracy and not degraded criminals. Suicide. — Suicidal tendencies are so very common in the insane that the subject must be included in a chapter on General Symptomatology. The question of suicide is a very large one, and has exercised the minds of men since the very earliest times. In some periods of history suicide was not only permitted under certain circumstances, but was even expected GENERAL SYMPTOMATOLOGY ' 75 as the natural sequel of some events. Formerly the ' happy despatch ' was the customary end of a Japanese who had compromised himself either ojBicially or socially. Space will not permit a general review of this subject, nor is such a survey required in a book of this kind, where the study of the relation- ship of suicide to insanity is all that is relevant. The tendency to suicide varies in different forms of mental disorder, but it is most rife in states of depression — indeed, it is not too much to say that every melanchohac must be looked upon as a potential suicide. Suicide may be accidental or intentional. A maniac or general paralytic may accidentally kill himself in an attempt to perform some impossible feat. Another patient may actually destroy his Hfe when his intention was merely to attract the sympathy of others or to draw attention to his case. Patients suffering from the extreme forms of nerve exhaustion are peculiarly hable to commit suicide. The more fatigued they become, the more marked the mental compulsion and the greater the danger of impulsive acts. Many of the suicides in nursing homes are by patients of this type. The reasons given for attempts at self-destruction are so varied that it would be impossible to enumerate them. Among the common reasons assigned by would-be suicides the following may be recorded : (1) that they are unfit to live ; (2) that they are ruined morally or financially ; (3) that they are a source of danger or contamination to the rest of the community ; (4) that they may avoid constant persecution ; (5) that they are impelled to do so by ' voices ' urging suicide ; (6) that various delusions compel suicide ; f7) sleeplessness ; (8) during mental confusion (exhaustion states) ; (9) continual worry ; (10) that others may be saved, etc. A certain number of patients act purely on impulse ; suicide suggests itself in some form, and is at once carried into effect. Similarly, a man may destroy himself in a fit of passion — this is at times met with in the case of epileptics. Children frequently commit or attempt suicide, and the triviahty of the motive given is often extraordinary. The methods employed for self-destruction vary in different individuals. The most dangerous class are those who spend their time in devising numerous plans, and who would avail themselves of any possible means of carrying out their mten- tions. The average person prefers some particular method which 76 PSYCHOLOGICAL MEDICINE specially appeals to him. For instance, a man has been known to swim a river to reach a railway, in order to throw himself in front of some passing train. This peculiarity is of great importance in the treatment of suicidal persons, though it is dangerous to rely on the patient adhering absolutely to his chosen plan. There is Uttle doubt that a far larger number of persons contemplate self-destruction than are actively suicidal. After all, it is not surprising that suicide should suggest itself to the depressed and worried mind. It is natural that the troubled soul should seek that portal which, once passed, ends for ever the sufferings of mortahty ; for the truly depressed person usually feels that he has nothing to hope for in this world or the next. The physician need never fear that by asking a person whether he has suicidal feelings he may be making the first suggestion of self-destruction to the patient's mind. Not only is there no such risk, but it is the duty of the physician to talk to a depressed patient on this question. It is a subject fi'om the discussion of which most persons recoil, and to which they will not initiate any reference ; but it is often a great reUef that it should be opened by another. The thought of suicide is one which is accompanied by intense suffering ; not merely the suffering which has suggested suicide as a means of escape, but also that which is engendered by the feeling that even the contemplation of self-destruction is a grievous sin. If the physician explains that the desire to commit suicide is quite a common symptom with depression, and tells his patient that he should speak as freely about any suicidal impulse as he would about any physical symptom, he will almost sm'ely relieve both his patient and help those who look after him. Suicide is most likely to occm- in the early morning, between 5 a.m. and 10 a.m. Between those hom'S the melanchoUac is most depressed and ought to be kept under strict supervision. In patients with nerve exhaustion the latter part of the day is equally dangerous from the suicidal standpoint. With regard to the question whether a suicide fully realises the nature of his act, it is probable that the majority of persons attempt to destroy themselves when in a confused condition of consciousness — in fact, almost in a dream state. GENERAL SYMPTOMATOLOGY 77 Probably the idea of suicide has been uppermost in their minds for a long time ; maybe they have been fighting against the feeling ; and ultimately, in a semi-confused state, the act, is done or attempted. It is interesting to note that immediately after a would-be suicide has committed the act, he may, if a fatal result does not at once ensue, try to save himself ; and, if he be successful in so doing, the incident often proves the turning-point in the illness, and from that moment he may make an uninterrupted recovery. Homicide. — There is probably no insanity in which the desire to kill stands as the only symptom. Homicidal feelings are by no means as common as the lay mind would suppose, and the percentage of dangerously homicidal patients is decidedly low in any asylum, save in the criminal asylum at Broadmoor. On the other hand, impulsive violence is common, but only a small percentage of patients with this symptom can be looked upon as homicidal. The really dangerous man is he who quietly awaits his chance, plotting and scheming for days before he carries his intentions into execution. The writer has heard a patient say that, owing to the continual persecution to which he had been subjected, he felt perfectly justified in killing the man whom he believed to be his persecutor. Many homicidal persons are fully aware that it is against the law of the land that they should murder, and may even recog- nise that they may have to pay the penalty society exacts. Another patient told the writer that he intended to kill two persons who had wronged him, adding, ' I know that I may be hanged myself, but after all it will be two lives for one.' Perhaps the most dangerous type of insanity is the mental disorder which follows a major or minor attack of epUepsy, and more especially the latter, acts of violence being very common dm-ing the automatic stage which follows the fit. The melancholiac may murder his whole family before he commits suicide, as he will not leave them to starve. In some cases the homicidal impulse seems to be of the nature of an obsession, for the idea to kill usurps the whole attention. With these persons the attack is generally very sudden and determined. * Voices ' may urge a man on to murder. Some years ago when a gentleman was walking up Begent Street he heard a ' voice ' telling him that he must 78 PSYCHOLOGICAL IklEDICINE kill some one at once. He ignored it for some time, but the commands became more urgent and the phenomenon being so extraordinary, he began to lose confidence in himself. As matters were nearing a crisis, the ' voice ' gave him an alter- native, and the order was, ' You must at once kill some one or go to an asylum.' He was relieved to find any way of escape, and at once hailing a hansom, told the man to drive to the nearest asylum. He reached Bethlem in an agitated condition and begged that he might be taken in as a voluntary boarder. The patient remained in the hospital for about six weeks and was then discharged recovered. At times the desire to kill may take the form of a periodic impulsive insanity and may resemble dipsomania in its manner of onset. These patients may confide their troubles to their friends or medical attendant, and it is important to remember that these confidences must not be treated too hghtly. The very fact that a man will own to such terrible thoughts proves the intensity of them in his mind. Many a murder might have been prevented had some one only given the patient the assistance which he sought. There is another point which is worth remembering regarding the treatment of would-be mm'derers. If an insane man has a grievance, listen to him and argue with him in a liberal manner if yo.u hke, but never turn away and refuse to hear what he has to say. A sane man is intensely annoyed if he is treated in what he considers to be a high-handed way ; but the insane man may lose all control and make a violent assault, which would probably not have been made had he received what he regarded as a fair hearing. You are perfectly at liberty after the interview to inform the man's friends or the police that 3-ou consider him to be a danger- ous person. Many fatal assaults might have been avoided if people would remember to treat the man with a grievance in a courteous manner. The question of homicide will be further dealt with in the chapter on the Eelationship of Insanity to Law. Fatigue. — Fatigue states are of vast importance to the student who studies mental disorder, as they are his great oppor- tunities for investigating mental disturbances in their earliest form. The time when fatigue symptoms first appear varies in different individuals ; one man wearies more readily on the GENERAL SYMPTOMATOLOGY 79 muscular side, another on the intellectual. Some persons, as they fatigue, at first exhibit a greater capacity for work and may ultimately collapse suddenly ; others progressively fail. Fatigue m&j be ushered in by some disorder of sensa- tion in a feeling of lightness or heaviness of the limbs, or the special senses may evince disturbances — such as illusions or hallucinations of sight or hearing. With fatigue there is loss of power of attention ; association is diminished, and the hearing is defective. Weak stimuli, which in a normal state would have been unnoticed, now become painfully unpleasant. Every one has probably experienced how annoying the ticking of a clock or the rattling of a window may be when he has been exceptionally tired. With fatigue the reaction time is longer, and the subject will give a large number of premature reactions — that is to say, he will react before the signal has been given. The pupils may be found to be widely dilated, and the deep reflexes are usually exaggerated. Fine muscular adjustment, such as writing, fails ; the handT\Titing is changed and shows mental irritability. With fatigue we find both increasing irritability and restlessness. With irritability, muscular movements will be found to be irregular and spasmodic. The judgment is inaccurate and unreliable, and there are outbursts of temper on the slightest provocation. Irritabilit}^ is to be observed in the early stages of many forms of mental disorder and ought to be the warning note that rest is necessary. Quick temper and great irritability are often the earliest mental changes in general paralysis. Restlessness is a very important symptom, and one that does not always receive the attention due to it. With mental fatigue there is almost always restlessness ; the student reading for an examination will note this, for no sooner has he sat down to read than Ms attention wanders, and he gets up and does something else. The weary busy man paces up and down his office trying to concentrate his thoughts, and the more exhausted he is the more energetic he seems to become. Few seem to realise that this morbid restlessness is almost, if not actually, within the danger-zone which separates sanity from insanity. There is no symptom which requires more immediate attention. When we finally cross the line and enter the realms of insanity, restlessness is a common 80 PSYCHOLOGICAL MEDICINE and prominent symptom, especially in such disorders as mania and agitated melancholia. Jealousy. — In primitive life jealousy is closely associated with sex. The male is jealous of the female, and the female for the welfare of her offspring. As society becomes more complicated, jealousy is found in many other phases ; but it is still in sex relationship that it plays the most prominent part. As a symptom of mental disorder it is by no means uncommon, and a very trying symptom it is to those who may be the objects of its attention. It is far more common among women than men, and in the mental disorder of some unmarried women and in widows jealousy frequently plays an important part. These women generally select some man, commonly a clergyman or some young physician, and continually dog his path. If there is any obstacle in the form of another lady in the way, murder has been known to result. Women of this type have no shame ; indifference and even definite objection on the part of the victim make no difference. The devotion is steadily maintained. This form of mental disorder is often most difficult to treat. There is nothing to which one may point except their extraordinary conduct ; and even this may not be so marked as might be expected, as they show much cunning in preventing attention being drawn to their actions. Their conversation, though foolish and extravagant at times, cannot be considered as more than eccentric. Many a man has been seriously compromised by a woman of this type, notwithstanding every effort on his part to escape her devotion. These cases are not understood by the lay mind. There is always a strong disposition to champion the cause of a woman ; the charitable pubUc is ever ready to point the finger of scorn and to hound a man out of society, without even hearing his defence. No more trying fate can befall a young man than to find himself the object of regard of an insane woman of this kind. The friends of such a woman should at once be told of the annoyance which her conduct occasions ; letters received and copies of all letters written should be carefully kept. Further reference will be made to jealousy in the descrip- tion of the mental disorders of the climacteric period. A mother may be jealous of her children ; and an insane parent has been known to murder a child in order to spite his wife GENERAL SYMPTOMATOLOGY 81 or her husband, as the case may be. Cases at tnnes occur where a young man is insanely jealous of some girl who refuses to marry him, and she not infrequently falls a victim to his jealousy. Jealousy may occur alone or associated with other symptoms of mental disorder. In any case, it is useless to attempt home treatment if the patient is jealous of any relative residing in the house. The only prospect of recovery is in getting the patient away from the customary surroundings. Heart and Vascular System. — Heart disease is not more common among the insane than the sane, and the causes are the same in both. If a person with aortic regurgitation becomes insane, the form the mental disorder takes is usually that of excitement and restlessness — as in mania or agitated melancholia. In the case of mitral disease, especially during ■the early stages, the mental state is usually one of depression. The arterial tension varies in different forms of insanity, and is a symptom of much diagnostic value. The writer made a careful study of the blood-pressure in the insane. The results of this work were published in the ' Lancet,' June 25, 1898, and the following were the deductions arrived at : — ■ 1. That the blood-pressure varies in certain forms of insanity. 2. That the blood-pressure is raised in persons who are depressed, or who are suffering from melancholia. 3. That the blood-pressure gives varied results in persons suffering from melancholia with motor excitement, so-called agitated melancholia. (The writer has made further investiga- tions in this form of insanity and has found that the blood- pressure is almost invariably low, and for this reason he considers that agitated melancholia ought to be classed with mania.) 4. That the blood-pressure is found to be normal upon the recovery of a patient whose blood-pressure has been raised during the period of depression. 5. That the blood-pressure is lowered in persons suffering from excitement or acute mania. 6. That the blood-pressure is found to be normal after the excitement has passed off and the patient has recovered. 7. That the blood-pressure tends to fall as the day advances ; hence the melancholiac tends to improve throughout the day, and the excited patient to become more excited. 6 82 PSYCHOLOGICAL MEDICINE 8. That the depression following on an attack of acute mania is not necessarily an active depression but rather a reaction and condition of exhaustion, and that the blood- pressui'e in these cases may remain low, until it finally on recovery returns to normal. 9. That the blood-pressure is low in stupor. 10. That the blood-pressure is not always altered in delusional insanity, except in those cases where there is also some emotional disturbance. 11. That the blood-pressm'e in healthy, active, and excitable persons is low compared with the healthy but apathetic individual. 12. That from the above it would appear that the blood- j)ressm"e is chiefly affected in the emotional insanities, in contradistinction to the ideational forms of mental disorder. 13. That the blood-pressure is raised in general paralysis of the insane when there is depression, but that in the excited types of this disease the blood-pressure is low, as it is also in the later stages of all types of general paralysis. 14. That there is evidence to prove that the altered blood- pressure may in certain individuals induce mental aberration, but that it is so far not complete enough to justify a definite statement that mental disease is usually caused by altered blood-pressure. 15. That the altered blood-pressure in different forms of insanity suggests the line of treatment which may be adopted in the various kinds of mental disease. 16. That the feeling of weight and pressure on the top of the head, so common a symptom in melancholia, is apparently vascular in origin, and is lessened or disappears when the blood-pressure is lowered. 17. That certain depressed patients improve with treatment by nitro-glycerine, Ijut that there is difficulty in keeping the blood-pressure down with this drug, as its action is so evanescent. 18. That the action of erythrol tetra-nitrate is more pro- longed and rehable and is more powerful in lowering the blood-pressure in melancholia than nitro-glycerine. 19. That the prolonged bath raises the blood-pressure, and hence is of more value in the treatment of excited patients. GENERAL SYMPTOMATOLOGY 83 Since publishing this I have noticed that in all exhaustion states, no matter whether the patient is excited or depressed, the blood-pressure is low, and this factor is frequently of great assistance in differentiating between depression in maniacal- depressive mental disorders and depression in the exhaustion psychoses. Also in chronic melanchoHa the blood-pressure may fall after some months of depression, and it is of interest to note that with the fall of blood-pressure the feeling-tone of depression is less marked. The frequency of the heart-beat is increased in several forms of mental disease, and most notably in acute mania, in which disorder the pulse-rate is not uncommonly as high as 140. On the other hand, with profound depression, the frequency of the heart-beat may be lessened and the general circulation found to be very sluggish. The condition of the blood is also at times markedly affected, diminution of the red blood-corpuscles and deficiency of haemoglobin being commonly observed, and, what is of even greater interest, a large increase of the white corpuscles is present in some forms of insanity. The coats of the blood-vessels are found to be atheromatous and degenerate in a certain percentage of cases, and all the changes due to former syphilis may be observed. Blood. — Bruce has kindly given me the following epitome of some of his work on leucocytosis in mental diseases : — ' A series of observations made upon the leucocytosis of attendants and nurses in asylums shows that in such persons — aU of whom were well-developed men and women under thirty years of age — there may exist considerable variations in the total number of leucocytes and in the percentage of the different leucocytes present. In the women the total leucocytosis varied between 5,600 and 14,000 per cubic millimetre and the percentage of polymorphonuclear cells ranged from forty-six to seventy-four. In the men the leucocytosis varied between 4,000 and 10,000 per cubic millimetre and the polymorphonuclear percentage between forty-nine and seventy-one. The differences between the maximum and the minimum in these cases are very con- siderable, and yet they are quite insignificant when compared with the variations which occur in certain cases of insanity. 84 PSYCHOLOGICAL MEDICLNE ' All the observations recorded below are the results of continuous blood examinations — in several cases extending over a continuous period of six months or longer ; isolated observations being, in my experience, quite worthless. ' For purposes of description I divide my cases of mania into two classes : (1) Confusional Mania — conditions of excitement with confusion and hallucinations, dm'ing the acute period of which the patient is not mentally accessible, and which is never complicated by alternating states of depression. (2) Mania of the maniacal-depressive type. ' During a iirst attack of confusional mania there is always a hyperleucocytosis, which may rise as high as 40,000 or 50,000 per cubic millimetre, with a high polymorphonuclear percen- tage, and an absence of eosinophiles. In a typical case, as the excitement subsides the leucocytosis gradually falls, and within a few days eosinophiles appear. As recovery sets in, the leu- cocytosis rises again and the total number of polymorpho- nuclear cells is also increased, while there is a temporary rise of eosinophiles which fall again as recovery is completed. In all the cases which recover, there is a persistent hyper- leucocytosis and high polymorphonuclear total. How long this persists it is impossible to say, as recovered patients have to be discharged ; but in one case which I kept under obser- vation for six years after discharge, there was still a hyper- leucocytosis with a polymorphonuclear percentage of seventy or over. In two other cases these symptoms were still present for two years after discharge. ' If the patient does not recover, the leucocytosis falls to 10,000 or below 10,000 per cubic millimetre, with a faU in the polymorphonuclear cells and an increase of large and small lymphocytes, and there is no increase in the eosinophiles. Such cases generally pass into dementia. On the other hand, if the patient becomes a case of chronic mania, the leucocyte chart presents a series of waves of hyperleucocytosis cor- responding to periods of exacerbation of excitement, and there are frequent increases in the eosinophiles generally corresponding to the periods following upon the exacerbations of excitement. ' In second, third, and fourth attacks of the disease the hyperleucocytosis tends to become less pronounced. In GENERAL SYMPTOMATOLOGY 85 recurrent cases of the disease, it is the rule to find a tendency to hypoleucocytosis immediately preceding a relapse. ' In mania of the maniacal-depressive variety, at the onset of the attack there is always a hyperleucocytosis, which may vary between 14,000 and 30,000 per cubic millimetre, with a high polymorphonuclear percentage. It is a noticeable featm-e that the polymorphonuclear cells and the blood plaques, in the very earliest days of the most acute attacks, present a well- marked iodophile reaction. As the excitement lessens the leucocytosis falls, and the polymorphonuclear cells diminish in number. If recovery follows upon the period of excite- ment the cell-changes are similar to those which occur in the recoveries from confusional mania, but after recovery is complete the hyperleucocytosis gradually disappears. If, on .the other hand, depression follows immediately upon the period of excitement, the onset of depression is marked by an increase in the leucocytosis and the polymorphonuclear percentage. Throughout the period of depression there is an ii-regular hyperleucocytosis, with frequent transient increases of the eosinophile cells. As the attack passes off, the mono- nuclear and large lymphocyte cells increase at the expense of the polymorphonuclears. WhUe, when recovery is com- plete, the leucocytosis falls to about 10,000 or 12,000 per cubic millimetre, or even lower. In no case which I have been able to examine, was there any abnormal leucocytosis during the periods between the attacks. ' Cases of catatonia follow very closely the leucocyte changes of confusional mania. During the early acute stages of the disease there is always a hyperleucocytosis, with an actual increase in the polymorphonuclear cells. Just prior to the onset of stupor, the polymorphonuclear leucocytosis may rise as high as 50,000 per cubic millimetre. Dm'ing the period of stupor there is a more or less continuous hyperleucocy- tosis, and if recovery takes place there is a rise in both the polymorphonuclear and eosinophile cells. If the patient does not recover, the leucocytosis gradually falls, the polymorpho- nuclear cells diminish ; while the lymphocytes, and, to a lesser degree, the mononuclear cells increase. ' In general paralysis there is a sHght hyperleucocytosis in both the first and second stages of the disease, and 86 PSYCHOLOGICAL MEDICINE in acutely excited cases the hypeiieiicocytosis is always marked. In the third stage of the disease there is an irregular hyperleucocytosis due to an increase chiefly of lymphocytes, while the poh^morphonuclear cells are actually and relatively diminished.' Respiratory System. — The respiratory system is not markedh^ affected in patients suffering from mental disorder. In mania, and in certain cases where the frequency of pulse- rate is increased, it will be found that the normal ratio between heart-beat and respiration is lost, as the breathing is not accelerated to any appreciable extent. In some forms of insanity, and more especially in stupor and catatonia, the respiration is very shallow and the movements of the chest are slight. This is of importance, as it may tend to the development of phthisis in predisposed persons. Some TNTiters have given the name of ' respiratory hallu- cinations ' to certain abnormal sensations complained of by some patients, of which the following are the more common — a feeling of inability to breathe, or being made to breathe too quicklj^ or too slowly, whereas in reality the respiration is normal. Secretory Disorders. — In melancholia and allied condi- tions all the secretions are diminished in quantity. Stoddart has done some very instructive and valuable work on this subject. He found that the sensible perspiration was greatly diminished or absent in these cases, and further that the patient, when treated with jaborandi or subcutaneous injection of pilocarpine, usually gave no reaction. On the other hand, he observed that with maniacal patients a similar dose produced profuse perspiration and salivation. It is further interesting to note that Stoddart found that, if a melancholiac were treated with erythol tetra-nitrate for some days, it was then possible to get a reaction to pilocarpine or jaborandi. The saliva is diminished in melancholia, and this, together with insufficient secretion of the digestive juices, may account for the indi- gestion and anorexia experienced by a certain proportion of melancholiacs. The hydrochloric acid in the gastric juice varies and may be either increased or lessened. Salivation in the insane may result from several causes. Nevertheless, it may be merely apparent and not real when GENERAL SYMPTOMATOLOGY 87 saliva is seen'' to be constantly dribbling out of the corners of the mouth. In these cases the saliva is probably not swallowed owing to diminished reflexes in the jDharynx. Excessive and continual masticatory movements may, by purely mechanical means, jDroduce a very copious flow of saliva. Salivation may be due to disease of the central nervous system and is seen in certain cases of epilepsy. The urine is diminished in quantity in melancholia and seldom reaches more than thirty ounces per diem, whereas polyuria is common in general paralysis and hysterical cases.- The reaction is usually acid, but the urine may contain a large amount of phosphates in cases where there has been great cerebral excitement. The quantity of urea excreted varies, being diminished in depressed states and increased to a small extent in mania. The chlorides, sulphates, oxalates, and glycero-phosphates all vary in amount in different forms of mental disorder. Indican is rarely found, but should always be looked for, as it usually indicates auto-intoxication. Albu- minuria is far from being a common symptom in mental disorder, but it is met with in a certain proportion of alcoholic patients and following seizures in some cases of general paralysis and epilepsy. Glycosuria is not so frequently found as some writers would indicate, but the question of diabetes will be dealt with elsewhere. Menstruation. — The catamenia are usualty disordered in most forms of insanity. Menstruation is, as a rule, absent in melancholia and in many other types of mental disease. Amenorrhoea must, in the vast majority of cases, be con- sidered a symptom in the course of the insanity, and not the cause. This is important to remember, and the physician would do well to inform both the patient and friends of the true state of affairs, as the former is apt to be worried and anxious, whereas the latter may be over-energetic in their attempts to re-establish the function, under the belief that its absence is the cause of the mental trouble. In some cases — notably certain forms of mania — there may be metrorrhagia or menorrhagia, and the continued and profuse loss of blood may seriously interfere with chances of recovery. Again, menorrhagia and metrorrhagia are probably the most common cause of exhaustion in women, and any tendency to these in 88 PSYCHOLOGICAL MEBICINE neui'otic subjects should at once be treated. As a general rule the absence of the catamenia is a favourable symptom in mental disease, and their reappearance not uncommonly indicates general mental and physical improvement. On the other hand, re-establishment of all the functions when unaccompanied by mental improvement greatly increases the gravity of the prognosis. Constipation. — Reference has already been made to con- stipation as a cause of insanity ; it must now be considered as a • symptom in mental disorder. Stress has been fre- quently laid in these pages on the fact that the physical health always suffers to a greater or less degree in every form of insanity. Constipation is probably the most com- mon of all sj^mptoms. In melancholia it is scarcely ever absent and requires constant attention. Constipation may result from sluggishness of functions or deficiency of intestinal secretions. In some cases there is found to be at post-mortem actual narrowing of the bowel, more especially in the ex- haustion psychoses. In other cases the fault may lie in defect of innervation and lessened peristalsis. Whatever may be the cause — and the physician should discover the fault, if possible — constipation is a symptom which should never be forgotten, as it is a cause of anaemia, sleeplessness, and general discomfort, and may even form the basis of delusions. Its treatment will be dealt with elsewhere. Trophic Disorders. — Nutritional changes take place in all the tissues of the body in patients suffe)-ing from mental dis- order. One of the earliest symptoms of acute insanity is loss of body weight. Too much stress cannot be laid on this point, as careful attention to the weight of the body is the keynote of both preventive and curative treatment. Trophic changes take place in the hair and nails, both of which become brittle ; the skin in many of the insane will be found to be dry and harsh, and pustules and small abscesses may develop. Bed-sores may occur in some patients in an almost incredibly short space of time. Trophic changes in bones may render them liable to fracture. Haematoma Auris. — An effusion of blood may take place between the cartilage of the ear and its perichondrium. This condition is known by the term Hsematoma Auris or Othaema- GENERAL SYMPTOMATOLOGY 89 toma. Some persons speak of it as Insane Ear, but this is a misnomer for the condition is fomid also in the sane — as, for example, in some Bugby football players. It is very com- mon among the chronic insane and general paralytics, and its presence is usually considered to indicate incurable mental disorder. It is almost always due to some slight injury. Holding a patient's head with one arm whilst feeding is one of the commonest ways of producing a haematoma auris. Probably it is owing to this mode of origin that it is more frequently found in the left than in the right ear, as most nurses hold the patient with the left arm while they feed with the right hand. No violence nor even rough handling need have taken place, as very slight manipulation is necessary to produce the condition : patients may even cause it themselves by rubbing the ear with their hands or against the pillow. When first seen it is a smooth tense swelling, usually bright red in colour, which occupies the anterior and outer surfaces of the auricle and is limited to the cartilaginous parts of the ear. It is tender to the touch. The hsematoma may rupture or slowly become organised ; in any case the result is great wrinkling and puckering of the ear. Ford Eobertson has shown that hsematoma auris is brought about by degeneration of the cartilage of the ear, the first change being in the cartilage cells and later the elastic fibres, which become fluid. Cysts then form near the surface and new vessels appear ; in time these latter degenerate and the cysts become filled with blood. As the haemorrhage con- tinues the perichondrium becomes stripped off, and soon the swelHng gradually increases in size, until the pressure is sufficient to arrest further oozing out of the blood. The proper treatment for this condition is blistering the cyst with Hquor epispasticus, and if this is done early very little deformity may result. Anomalies of the Ear. — There are many deformities of the pinna, and these, taken with other stigmata of degenera- tion, may be of importance. Peterson describes the following twenty-two varieties : — 1. Abnormally implanted ears : they project too far or lie too closely, are placed too high or too low, too far forward or too far backward on the head. 90 PSYCHOLOGICAL MEDICINE 2. Excessively large ears : (a) absolutely too large ; (&) relatively too large in small or microceplialic individuals. 3. Ears which are too small. 4. Too marked conchoidal shape of the ear : the details of the ear (anthelix and crura, etc.) are but slightly marked, while the helix outlines the ear like the rim of a funnel. 5. Ears which have a general ugly shape : the breadth of the upper part may exceed that of the lower, and vice versa ; excessive length ; ears without lobules ; unusually short ears. 6. Ear not uniform in width ; usually a long ear with one or more constrictions in its breadth. 7. The Blainville ear : asymmetry of various kinds of the two ears. In most cases the asymmetry is due to an anomaly of the left ear. 8. The ear without lobule : there are usually other de- formities of this ear besides the absence of lobule — such as too large a concha, prominence of the anthelix, etc. 9. The ear with adherent lobule : the lobule is enlarged, adherent, and inclines downward toward the cheek. 10. The Stahl ear. No. 1 : a series of anomalies of the helix. The helix is broad, hke a band, and coalesces with the cartilages of the crura furcata ; the fossa ovahs and fossa scaphoidea are scarcely to be seen ; the lower half of the helix is obli- terated. There are occasionally slight variations from this type. 11. The Darwin ear : helix interrupted where its trans- verse portion passes into the descending, and at this point is a projection of the rim above and outward, like the pointed ear of lower animals. 12. The Wildermuth ear, No. 1 : the anthelix projects so far as to form the most prominent part of the auricle. 13. The ear without anthelix or crura furcata. 14. The Stahl ear, No. 2 : multiplication of the divisions of the crura furcata, so that there are three instead of two crura. 15. AYildermuth's Astec ear : lobule wanting ; the whole ear seems pushed forward and downward ; the crus superius of the anthelix coalesces with the helix, while its crus anterius is scarcely perceptible. 16. The Stahl ear, No. 8 : onlv the crus anterius of the GENERAL SYMPTOMATOLOGY 91 crura furcata is present, while the auricle seems divided into two halves by a ridge from the antitragus. 17. The ear with double helix. 18. The ear with too large or too small a concha. 19. The ear with continuous fossa scaphoidea : the fossa passes down into the lobe. 20. The Morel ear : a form marked by abnormal develop- ment of the helix, anthelix, fossa scaphoidea, and crura furcata, so that the folds of the ear seem obliterated, and the ear is smooth, larger than usual, often prominent, and with thin edge. 21. Ear misshapen by abnormal cartilage development : here belong all irregular cartilaginous growths and thicken- ings, except those caused by hsematoma of the ear. ■ 22. Various peculiarities, difficult to classify, are included here — such as abnormalities of the semilunar incisure of the tragus and of the meatus, coloboma of the lobule, hairiness of the different parts of the auricle, accessory ears, clefts, etc. Cranial Deformities.— Asymmetry. — If slight, this may be of no importance, but if to a marked degree and associated with other stigmata of degeneration, it is important. The normal circumference of the skull is about twenty-two and a half inches, and a deviation of more than two and a half inches in either direction must be regarded as abnormal. Nevertheless, there are cases on record of persons having abnormally large or small heads who are apparently intellec- tually sound. The anterior-posterior diameter should be about seven and three-quarter inches, and the greatest trans- verse diameter is normally about six and one-eighth inches. Stoddart states that the binauricular diameter (calliper measurement from one auditory meatus to the other) and the length of the face from the root of the nose to the lowest part of the chin should each be about five and a quarter inches ; and the binauricular arc and naso-occipital arc (root of nose to occipital protuberance measured over the highest point of the skull) should each be about fourteen inches. Broadly speaking, an individual is to be regarded as ab- normal if his measurements differ more than fifteen per cent, from the above, and as a degenerate if the measurements are more than fifteen per cent, below the normal. 92 PSYCHOLOGICAL MEDICINE The cephalic index or index of breadth is arrived at by multiplying the breadth by 100 and dividing by the length. Peterson describes eight well-known cranial deformities : — Chemocephalus is flat-headedness. In this there is flat- ness at the top of the head. The condition is also called platicephalus. Leptocephalus. — Early synostosis of the frontal and sphenoid produces leptocephalus, or narrow-headedness. Macrocephalus is a large head, usually due to hydro- cephalus. Microcephalus is a small head, due either to aplasia of the brain or premature synostosis of the sutures (rarely the latter). Oxycephalus, or steeple-shaped skull, is due to synostosis of the parietal with the occipital and temporal bones, with compensatory development in the region of the bregma. Another name for this is acrocephalus. Plagiocephalus, or oblique deformity of the head, is due to unilateral synostosis of the frontal with one of the parietal bones. Scaphocephalus is probably caused either by too early union of the sagittal suture, or by the development of both parietal bones from one centre. The top of the head is keel-shaped. Trigonocephalus. — Premature union of the frontal suture, resulting in very narrow forehead and great width behind, giving rise to the term trigonocephalus. Peterson regards all indices between seventy and ninety as within normal hmits. Deformities of the Palate.— The Normal Heart Palate is large and wide and moderately arched. Whereas the palate of the degenerate is usually high and narrow. Peterson describes the following varieties : — 1. The Palate with Gothic Arch. Tliis may have a high or low pitch and may be short or long. 2. The Palate with Horse-shoe Arch. Here the alveolus projects into the cavity of the mouth. GENERAL SYMPTOMATOLOGY 93 3. The Dome-shaped Palate. This may be high or low, and is often combined with asymmetry, 4. The Flat-roofed Palate. This includes such palates as are nearly horizontal in outline, as well as those with inclined- roof size to flattened gable. 5. The Hip-roofed Palate. In this the anterior-posterior arch is greatly accentuated. 6. The asymmetrical Palate. This is usually associated with asymmetry of the face and skull. 7. The Torus Palatinus Palate. In this there is a projecting arch or swelling below the palatine suture. Deformities o£ the Limbs. — Although these do not all belong to the stigmata of degeneration, nevertheless there are some which must be considered to come under this heading, e.g. the supernumerary fingers or toes, missing fingers or toes, or fusion of fingers or toes, or in the abnormally short or long hmbs. Deformities of the Body. — In this class we may place dwarf or giant growth. Disorders of Speech. — Stuttering and stanimering are com- monly found in the relatives of the insane, but not so frequently in those who are actually of unsound mind. The speech may be incessant, rapid, and incoherent, or it may be slow and laboured. By incoherence is meant an apparent want of connection in the sequence of language. In other words, it is an inabihty on the part of the hearer to foUow the thoughts of the speaker. There is a difference between wandering conversation and true incoherence, for in the former, notwithstanding that the speaker strays from subject to subject, his thoughts can be followed. A patient once said to the writer, ' Maternal, paternal, infernal, Dante.' In this case his thoughts could be easily followed, as the first three words rhymed and the last was an association of ideas. The mania has an accelerated flow of ideas, while the thoughts of the melancholiac are slow and laboured. Mutism is present in a certain number of the insane, and may be due to the absence of ideas or the result of a delusion. It is a prominent symptom in catatonia and other stuporous states and is present, of course, in the congenitally deaf. Hesi- tancy and slurring of speech are defects which may indicate 94 PSYCHOLOGICAL MEDICINE serious cerebral disease. Tremulousness in articulation occurs in the exhaustion psychoses and may be toxic in origin, but it is a symptom which may also point to organic disease. These symptoms will be more fully considered when dealing with general paralj^sis. Aphasia of all kinds is met with in the insane. Sudden and transient aphasia is very suggestive of general paralysis. There is an interesting variety of speech, met with in cata- tonia and some other types of mental disorder, known as Verbigeration. This is a monotonous repeating of words or phrases. In conclusion, it may be mentioned that in con- versation many of the insane repeat the question put to them (echolalia) ; this is often done in an automatic manner and as a means of gaining time and is the result of slow ideation. Insomnia. — Sleeplessness plays such a very important part both as a cause and symptom of mental disorder that a short chapter has been devoted to its study. Temperature. — The temperature of the body in the insane varies in the different forms of mental disorder, but, broadly speaking, it is not commonly raised in mental disease. It is imjDortant to make a habit of taking the temperature of these patients, as fever is frequently the first indication that we may have that the patient is physically ill. Insane persons do not, as a rule, complain of subjective sensations, therefore in treating them it is ever necessary to be observant. For instance, in general paralysis, fever not infrequently precedes ' seizures,' and in many forms of mental disorder it connotes some lung complication or other bodily ailment. Subnormal temperatures are usually found in stuporous states and in melancholia, and raise temperatures in acute delirious states and in some cases of puerperal insanity. There may be hyperpyrexia in conditions such as status epilepticus. To sum up, fever in the insane generally indicates some physical disease in the same way as it does in the sane. Reflexes, Disorder of. — The superficial reflexes are not con- sidered to be very important factors in insanity. They are use- ful in the diagnosis of hysterical conditions, as the plantar reflexes are usually lost. The deeper reflexes are affected in many forms of mental disorder ; they may be exaggerated, diminished, or lost. The knee-jerks are often very exaggerated GENERAL SYMPTOMATOLOGY 95 in states of excitement or extreme exhaustion. Too much weight must not be attached to the condition, but, on the other hand, they are common in general paralysis. Loss of knee- jerk is a symptom of far greater importance, as it frequently points to a tabetic form of general paralysis. The physician must, however, bear in mind that it may be due to peripheral neuritis. The changes in the pupillary reflexes will be described in the chapter on General Paralysis. Expression. — The facial expression is not a very reliable indicator of the emotions in the highest and lowest mental states, for in the highest the emotions can be concealed, and in the lowest there is a general lack of expression. Still, facial expression is probably a truer index of action and thought in the insane than in the sane. There are certain points to be noticed in examining the face and expression. The face may appear lengthened and toneless, the result of general muscular relaxation ; this is commonly seen in melancholia and some cases of general paralysis. Terror and anxiety are shown by the facial muscles, the emotional tremors being caused by strong and intermittent nerve currents transmitted to the various muscles. Pain, to a great extent, is shown in the lower part of the face ; this is especially the case with visceral pain. Mental stress is usually indicated by over-tone of the corrugator supercilii, which causes knitting of the eyebrows. Twitching of the supra-orbital muscles is said to be common in forms of mental disorder due to alcohol. I It is important to note the shape and size of the head, whether it is symmetrical, or whether there is lack of development on one side, as is seen in some cases of traumatic idiocy. A head with a circumference of less than seventeen inches is incom- patible with intellect. Note also the eyes, whether there is any drooping of eyelids ; whether the eyes work together or the eyeballs are prominent. Exophthalmos is a common symptom in some maniacal patients, and is probably due to congestion of the venous circulation at the back of the orbit. The size and various reactions of the pupils should be exam- ined, mydriasis being commonly found in nervous and fatigued persons. Note the movements of the eyeballs in their sockets as distinguished from the various movements of the head, as the former indicate a higher state of evolution than the latter. 96 PSYCH0L0C4ICAL MEDICINE An infant usually turns its head when its attention is attracted by a sound, the independent movement of the eyeballs being of later development and sometimes never acquired. Observe also the quickness of expression and the rapidity of reaction to stimuH, and further observe whether the two sides of the face act together and to an equal extent. The presence or absence of hair on the face is a point worthy of attention, for it must be borne in mind that degeneracy in the male may be shown by absence of the customary hair on the face, whereas a female degenerate is often hairy. Posture. — We are ever moving our position, and every posture is temporary and may be looked upon as a balance of muscular action. Warner i describes four principal postures of the head : ' (a) Flexion, (b) Extension, (c) Kotation to one or other side in a horizontal plane, the head remaining erect, but the face being turned to the right or*left. {d) In- cHnation to one or other side, lowering one ear so that the two do not remain on the same level.' Flexion of the head and a general flexion of the body are seen in most cases of melanchoha and in certain forms of stupor. Extension of the head may be due to spinal irritation or merely the result of a delusion. Eotation usually suggests an hallucinatory condition. Persons may throw themselves into positions of prayer or other ecstatic postures. The reader need not be detained longer on this subject, except to remind him that much may be leamt by observing the posture of a patient. The exalted man will appear proud and self- complacent ; the depressed man flexed and drooping ; the persecuted man suspicious and anxious. Handwriting. — The handwriting, being the production of highly developed and co-ordinate muscular movements, is often of great diagnostic value in the study of disease. Hand- writing is of comparatively late development, and therefore is early affected in every form of nervous disorder. Even with fatigue the clearness and character of the writing are found to be altered. In studying handwriting in its more highly developed forms, it will be observed that there is a great difference between the up- and the down-strokes, for the latter are bolder and stronger and show greater weight of the hand ^ ' Posture,' in Tuke's Dictionary of Psychological Medicine. GENERAL SYMPTOMATOLOGY 97 on the pen. With dissolution this difference between up- and down-strokes disappears, and every stroke will be heavy. The pressure of the pen on the paper is of interest, for a child learning to write cannot even use a pen without covering itself and the paper with ink, and owing to the weight of the child's hand it is necessary for a pencil to be used. So again with increasing dissolution the writing will once more be found to be blotty and untidy, and the day comes when a pencil alone can be used. In the early stages of any nervous disorder the up-strokes of writing will be observed to be shaky, indicating tremor of muscles when Hghtly stimulated. With increasing age a general shakiness becomes very evident, though, as a rule, the character of the writing is not markedly affected. Tremulousness is also noticeable in the handwriting of patients convalescing from any serious illness. A keen observer can glean a great deal as to the health of a relative or friend by noting his handwriting. If the corre- spondent is weary and tired, the handwriting shows irritability and uncertainty, and further it is usually smaller and more cramped, as is the case in the writing of the aged. There are several other points to be observed in dealing with the handwriting of the insane. Some patients write slowly and with great effort, either from difficulty in thought or effort in the production of the various letters. If the latter is the case, the letters will usually be found to be separate and not run together. In some forms of mental disorder, and in general paralysis, there is a tendency to drop out letters or syllables, showing constant irritability and failure of attention. On the other hand, words may be reduplicated. Some patients write an enormous amount, either of prose or poetry, and the correspondence of these individuals is frequently very large. Further, much can be learned as to the mental state of a person by studying the contents of the letters he writes. The melanchohac's notes are filled with gloomy thoughts about the present and fears for the future ; the hypochondriac fills his letters with descriptions regarding his bodily health ; the exalted man with grandiose ideas and extravagant schemes. The moral pervert may spend his time in writing libellous post-cards : this symptom of mental disorder is rather more common in women. Suspicions and delusions of persecution 7 98 PSYCHOLOGICAL MEDICINE may first shoT\- themselves in the contents of a letter. Before leaving the subject of handwriting, an interesting variety kno^Ti as mii'ror--^Titing must be named. It is found in certain degenerates and may be a symptom in some persons suffering from mental disorder. Mirror-^Titing is usually effected by the left hand and is written from left to right and can only be read by means of a looking-glass, or if the paper on which it is written is very thin, by holding it up to a strong Hght. In reading the following accounts of the various forms of mental disorder, it will be well for the student from time to time to refer back to this chapter on General Symptomatology, so that he may keep clearly before him the exact significance of the symptoms recorded. 99 CHAPTEE VI MANIA Excitement in its various degrees is much more readily recognised than depression, and it is easier to say when the hne which divides sanity from insanity has been crossed, for the reasoning power is, as a rule, lost quite early. On account ■of this, acute mania is one of the few forms of insanity recog- nised by the lay mind ; for if a man is noisy, destructive, or violent, it does not require a physician to diagnose that such a person is insane. On the other hand, it is not enough to say that a patient is suffering from mania ; the question further arises as to what is the cause of this excitement. Excite- ment, Uke depression, may be the whole visible evidence of the condition ; or it may, on the other hand, be associated with other symptoms which coimote gross brain disease, or the grouping of symptoms may be such as to indicate a disorder such as maniacal-depressive insanity. jffiJtiology.- — Excitement may occur at any period of hfe, but is more common in the earlier epochs. It is almost physio- logical in its mildest forms during childhood, but as evolution takes place the emotions become more and more controlled. Again, with senihty the highest levels may degenerate first, with the result that the power of inhibition is lessened and outbursts of excitement or other symptoms, due to loss of control, ensue. Mania is by no means so commonly met with as depression, but in many ways it is a more serious disorder. It must be borne in mind that delirium is temporary mania, and in certain neurotic subjects it may pass on to a definite acute attack of excitement. Sex is not an important factor, but women are somewhat more liable to attacks of mania than men. A definite neurotic inheritance is found in a fairly large proportion of cases, and especially in patients who 100 PSYCHOLOGICAL MEDICINE break down early in life. The instability may have shown itself previously by too rapid or too slow evolution, or a ten- dency to night terrors or other psychoses. Phthisis or other exhaustive types of disease may be found in the family history. Exciting and anxious forms of occupation predispose to mania in some persons, and this fact should be remembered when advising concerning the education of a neurotic youth. Ill- health and starvation are potent factors in the production of mania. There are certain toxic conditions which may in predisposed persons tend to produce excitement ; more especially may be instanced alcohohsm, plumbism, uraemia, and drugs — such as belladonna. Mania may arise from a defective blood-supply to the brain, or from a vitiated condition of the blood. During the febrile stage of specific fevers excitement may develop — in short, anything which produces delirium may engender acute mania. Epileptic furor is a very violent form of excite- ment which sometimes follows a fit of epilepsy. In the female, childbirth may be followed by an attack of mania of the exhaustive type ; and, finally, sleeplessness is also a factor which must not be forgotten. Varieties. — There are several types of mania which must be recognised. Attacks of mania may occur periodically throughout the hves of some people, or mania and melancholia may alternate with periods of health. The terms 'periodical, recurrent, and circular insanity are used by some writers to denote these cases, but Kraepelin has pointed out that where mania and melanchoha occur, under such conditions, the symptoms are not accidental, but should more properly be considered as phases of one disease. He describes these cases under the head of maniacal-degressive insanity, for, as he rightly shows, the disorder follows a definite course, which is usually repeated in each succeeding attack. Kraepelin recognises three forms of maniacal-depressive insanity, viz. the maniacal, the depressive, and the mixed. Older writers would describe these as recurrent mania, recurrent melancholia, and folie circulaire. As mania may exist apart from these periodic or circular conditions, it would be more convenient to describe the state under the following heads : — - MANIA 101 1. Simple Mmiia, in which there are usually no delusions or hallucinations. It frequently occurs early in life and has a tendency to recur periodically or may alternate with a phase of depression. 2. Acute Mania. — Some authorities consider this to be a more intense form of simple mania. Others make a distinction between them. This disorder may appear at any age but is more common in adolescence and in early middle life. 3. Recurre7it Mania (Maniacal-Depressive). — This may be either simple or acute mania in the character of symptoms. 4. Chronic Mania. — The symptoms in this condition are very similar to those found in acute mania, though there is usually greater degeneracy present. 5. Acute Delirious Mania. — At one time this was considered a separate disorder from other types of excitement, but in recent years the evidence seems strongly to indicate that it is merely a later type or more advanced stage of acute mania of the exhaustion type. In addition to these varieties of mania, the student must bear in mind that excitement may be the mental state of a certain proportion of persons suffering from general paralysis or other forms of organic disease. Prodromata. — The onset may be gradual or sudden, but the former is more common. A sudden outburst of excitement may occur in recurrent cases or may be secondary to an epileptic seizure or due to drugs — such as alcohol or bella- donna. As a rule there is a period of malaise or depression, during which time the patient is sleepless and loses weight ; this may last for some days or weeks before the over-activity and restlessness of mania appear. As the excitement develops, the patient talks incessantly ; he rises very early in the morning and retires late to bed. His conduct becomes as erratic and uncertain as his conversation. He dresses in an extravagant fashion and spends money rapidly. He is irritable and refuses to be controlled. Loss of control is the prominent feature of both his actions and his conversation. The power of attention fails rapidly, and he becomes unable to hold a connected conversation or carry out any of his usual duties. Judgment and reasoning are soon affected, and it is on this account that 102 PSYCHOLOGICAL MEDICINE there is but little difficulty in deciding when the bounds of sanity have been passed. Mental Symptoms. — (1) Simple Mania. — This is the mildest type of mania. The patient has an exaggerated sense of well- being. He is buoyant and in the best of spirits. He is ex- travagant in his dress and squanders money. He may be very exalted as regards both his wealth and his social rank. In this connection a word of warning is needed. These cases are frequently diagnosed as general paralytics from their mental symptoms alone. Once again let emphasis be laid on the point that general paralysis is a physical disease and may be accompanied by any form of mental disorder. Exaltation per se does not connote general paralysis. The patient with simple mania is garrulous and talkative and much that he says is unconventional and bizarre. He is exceedingly quarrelsome and often throws up his occupation with the intention of going on the stage or following some other pursuit which is more suited to his exceptional mental powers. He usually gets engaged to be married to several young women in quick succession, as his ideas of marriage are ever changing. He will generally be found to be boastful ; loss of control stamps his every thought and action. The memory is not markedly affected, but the attention is easily distracted. The emotions constantly vary ; more commonly the patient is exuberant in spirits, but he is always liable to outbursts of passion, and sometimes will lapse into tears. He may change his creed, and from being an indifferent Protestant he may become a devout Eomanist. As a rule there are no hallucinations, and delusions, if any, are tem- porary and fleeting. Patients suffering from simple mania are generally sleepless, waking, as a rule, early in the morning. There is a tendency to indulge in sexual excitements. The appetite is capricious ; the patient may at different times eat largely or go without food for many hours. The physical health is fairly good, though it may fail if the illness goes on for some months. Patients of the class are by no means always certifiable and many of them can be treated by rest at home. Others are so difficult to control that asylum treatment is absolutely necessary. 2. Acute Mania. — In this disorder both the mental and MANIA 103 physical symptoms are more marked than in simple mania. There is greater loss of control in speech and action. These patients are constantly on the move and never rest ; they may sing, dance, laugh, or shout continuously. Speech is very incoherent, and, though the attention may be attracted for a moment, the thoughts will soon wander. Patients of this class are very quick both in sight and hearing, and their senses are hypersensitive in their acuteness. Perception is normal. They are careless of the presence of others and for the time being seem to live in a world of their own. They are frequently considered brilliant in their conversation; this is not actually the case, for when analysed this seeming brilliancy will be found in large measure to be due to the unconventional character of their chatter ; they say smart things, which s.trike the hearer who is not used to home truths and person- alities as amusing. These patients are often more entertaining when ill than during health, for through loss of control they will make remarks in illness which they would in health perhaps think but forbear to utter. Association of ideas is more active than in normal conditions, and it is for this reason that the patient is incoherent, as he is unable to find words quickly enough to express his thoughts. (Flight of Ideas.) The acute maniac may rhyme, or his ideas may be sug- gested by objects round about. These patients are usually very impulsive and destructive and at times may be violent. They are often considered almost superhuman in their strength, but in reality they are weaker than in health. They appear to be strong, for they have singleness of purpose and use all their strength in one direction, and in this way they differ from the sane person, as the latter is constantly inhibiting his actions. For example, a maniac would use all his strength to remove an annoying person from his room, heedless of whether in carrying out his intention he either damaged himself or his persecutor. Their actions are in keeping with their mental state. They collect all manner of rubbish, filling their pockets with worthless articles after the manner of schoolboys. Young women tie bits of string round their fingers to replace any rings that have been removed and decorate their hair with ivy and flowers. They are often irritable, and may quickly lose their temper and strike 104 PSYCHOLOGICAL MEDICINE and may accidentally kill, but intentional homicide is rare. Usually these patients are happy and cheerful, but the emotions may undergo a sudden change and the tears of one moment may give way to the laughter of the next. It is by no means uncommon to iind that they mistake identity and will address those about them either as relatives of their own or as celebrities of the day. Memory is fairly good, but at times uncertain. It is, however, remarkable how many details of his illness a patient of this type will remember after recovery. The habits vary greatly, according to the severity of the attack. Some patients are very degraded and will eat all manner of filth, while others will strip off their clothing. The sexual instincts are exalted and give rise in both sexes to immodest actions and speech and at times to shameless masturbation. Delusions are ever changing and are usually exalted in character ; the maniac may adhere to a delusion for some time, but, as a rule, if contradicted he will abandon his belief or replace it by another. Similarly hallucinations are tem- porary and fleeting. Music and other sounds may be heard, or faces and lights may float across the room. Auditory hallucmations are more common than visual sensory disorders, except in cases of mania due to some drug-poisoning. Sleep is very deficient and may be absent for weeks, and profound insomnia is very characteristic of this disorder. In the severe forms of acute mania a patient will spend his nights and his days in constant movement and continual laughter and speech. Such patients are apt to wear themselves out, and some die from exhaustion. Attempts at suicide are rare, but a maniacal person may kill himself by accident in trying to do some im- possible feat. To sum up : all maniacs are capricious and are swayed by their constantly changing thoughts and ideas ; continued occupation is impossible, and employment depends on the fancy of the moment. 8. Recurrent Mania {Maniacal-Depressive).- — The periodic or recurrent forms of mania or the mixed variety of Kraepelin's maniacal-depressive insanity usually appear during the earlier epochs of life. The excitement varies in intensity, and the type may be that already described under ' Simple ' or ' Acute MANIA 105 Mania.' In many instances each succeeding attack leaves its effect on the intellect of the patient, who may progressviely lose the capability of doing work. The intervals between the attacks vary in length, but the tendency is for them to grow shorter as age advances. The attacks frequently begin with a period of depression which is followed by a period of excitement, and this, in turn, is succeeded by a stuporose state which some authorities have named ' Anergic-stupor.' 4. Chronic Mania. — In this condition the symptoms are usually less marked than in acute excitement, otherwise they are very much the same, except that there is usually some mental enfeeblement accompanying it and the memory tends, on the whole, to fail, though at times one may observe that the patient evinces an extraordinary memory in certain directions — such ■as names, dates, etc. 5. Acute Delirious Mania. — There is usually an insane inheritance in these cases and, in addition, some definite exciting cause which may be either physical or mental. It is more commonly found in the exhaustion type of excitement, though it may be a later stage of ordinary acute mania. The symptoms closely resemble those of the dehrium observed in acute specific fevers. Insomnia is profound, restlessness is intense. Speech is very incoherent and the patient may become noisy. It is very difficult to attract his attention, even for a moment, and the sufferer wdll sit up in bed, constantly chattering to himself and swaying about. Memory is almost entirely obliterated for the time being. Hallucinations, especially of sight, are very common ; delu- sions of all kinds occur, but they are very fleeting and con- stantly changing. The face is flushed, and th3 pulse is very frequent and low-tensioned. Food is refused and has to be given artificially by means of an oesophageal or nasal tube. The tongue is furred, and sordes form on the hps and mouth. The temperature is nearly always raised two or three degrees, and in this it differs from acute mania. The urine is scanty and high-coloured ; the excretions are passed under the patient. He rapidly develops a typhoid condition, lying in bed in a state of low muttering dehrium. He differs from the sufferer from enteric in that he resists all attempts at nursing. Bed-sores frequently form in spite of every care. 106 PSYCHOLOGICAL MEDICINE Physical Ssnnptoms. — Physical symptoms differ greatly according to the severity of the attack. In simple mania they are slight and, except for some loss of weight, may not be well-marked. On the other hand, in the more severe types of mania, the plwsical conditions may occasion grave cause for anxiety. Gastro-Mtestinal System. — The tongue is usually furred, and there may be sordes about the hps and mouth. There is an increase of the hj^drochloric acid in the gastric juice, which has been found to be more toxic than normal. The appetite is, as a rule, bad, but the maniacal patient is very capricious in the matter of food ; he may eat one meal ravenously and refuse the next two or three. It is often necessary to feed these cases by means of the nasal or oesophageal tube, otherwise rapid loss of weight with serious results may ensue. Con- stipation and general irregularity of bowel action are common but not as constant as in melanchoHa. Circulatory System. — The pulse is frequent and low-tensioned. The frequency may reach as high as 140-150 beats a minute. Bespiratory System. — The rate of breathing is not materially increased ; the usual ratio between heart-beat and respiration is lost. Genito-Urinary System. — The quantity of urine secreted in some cases is greater than normal, while in others it is less. The menstrual functions in women are always disordered. The catamenia may be scanty and irregular, or entirely absent, throughout the attack ; on the other hand, there may be menorrhagia or metrorrhagia. Some patients have exacerba- tions of excitement either before or immediately after the catamenia, wliile for a fortnight between the periods they may to all appearances be well. Nervous System. — Except for a general hypersesthesia of the special senses, the nervous system does not exhibit any special symptoms. Maniacal persons will constantly strip off their clothing, but it is not clear whether this is due to altered bodily sensations. After an attack of mania it is common to find a temporary general anaesthesia which passes off rapidly. Stoddart has drawn attention to the striking differences MANIA 107 in the movements of the maniac as compared with the melan- chohac. The movements of the maniacal patient take place for the most part at the large proximal joints, whereas in melancholia these are weak or rigid. The body weight usually falls rapidly, and there is general emaciation. The skin and appendages suffer from nutritional changes. Small pustules may develop ; the nails are friable, furrowed, and contain opaque patches ; the hair is dry and brittle — ^it loses its lustre and sometimes falls out. The patient may become very anaemic as the illness proceeds. The temperature is usually about normal, except in cases of acute delirious mania, when it is often raised. There is a tendency to salivation in some cases, but this is not a constant symptom. Stoddart found that the maniac reacted readily to pilocarpine and jaborandi. Sleep is very bad and its continued absence may lead to very serious consequences. Maniacal patients not uncommonly develop some intercurrent affection, especially disorders of the respiratory system. Course. — Mania may run a very rapid course, the acute symptoms passing off within a few days. Mental excitement of this type is often spoken of as mania transitoria ; it occurs in certain alcoholic and epileptical cases and is seen also at the time of labour in some very neurotic subjects. It is a violent attack of excitement that passes off as rapidly as it appears. Eecovery usually takes place more slowly — com- monly after eight or nine months. The disease reaches its height after five to ten weeks ; after which the physical health tends to show signs of improvement. Food which has pre- viously been refused is now taken, the appetite being abnor- mally large. The mental excitement fluctuates from day to day, but shows an improving tendency. The hair and the general appearance of the patient become more tidy. Sleep improves, but slowly. There is a greater tendency to help in the domestic work of the wards of the hospital, and the rest- lessness is less marked. Some patients become quarrelsome and fault-finding as they progress towards health, and are a sore trial to nurses and those in authority. They make all kinds of false accusations of rough treatment, assaults, and the like, which, on careful inquiry, prove to be baseless. More 108 PSYCHOLOGICAL MEDICINE commonly, patients who are recovering from mania pass into a confused and apathetic condition, in which they take httle or no interest in their smToundings and rarely occupy them- selves. These patients, as a rule, steadily improve in their phj^sical health. The condition is not one of true depression, but is rather one of general fatigue resulting from the intense excitement through which they have passed. It resembles the feeling of malaise and apathy experienced by some persons after several evenings of dancing and social excitements. In other cases this confused apathetic condition passes on to a more definite state of stupor and is called by some authorities post-maniacal stupor and by others anergic stupor. But it will be more convenient to describe this condition in a subsequent section. After passing through these various stages, recovery may take place. On the other hand, a patient may reach a certain point towards recovery, yet the final recovery does not take place till some months later. Persons in asylums and under care, as a rule, appear to be much better than they really are, and to allow them too early freedom has a bad effect and is apt to cause a relapse. Many patients, who have apparently recovered, are found to be defective in one or more respects. Savage aptly describes the condition as the scar that is left after the illness has passed off. The scar may show itself in many ways — as, for example, in mental or moral defects. A man, previously energetic and keen, may become idle or indolent. He may develop habits of drinking or gaming, which show a lack of control. From being jDlacid and easy-going, he may become irritable and passionate. There may be either complete or partial recovery. Recovery may be partial, but sufficiently well marked to render the patient capable of earning his own living. On the other hand, a number of cases never recover, but steadily pass into a weak-minded condition. All insanities tend to dementia, but mania more strongly than others. The patient may improve physically and his weight increase ; sleep may retm-n ; and the bodily functions, which were formerly deranged, may be normally performed. Nevertheless, with all this improvement he may remain weak- minded, noisy, and destructive. The term ' Secondary De- mentia ' is frequently used to describe this condition. Death MANIA 109 supervenes in about five per cent, of the cases. The cause of death may be some intercurrent disease, but exhaustion alone is by no means infrequent, for there is httle doubt that acute excitement leads to serious defects in the nutrition of the brain. An autopsy on the body of a patient who has died from acute mania reveals no signs of organic disease. In some of these cases the conclusion that death has resulted from exhaustion is irresistible ; and this conclusion is supported both by the clinical and post-mortem evidences. Diagnosis.^ — Excitement itself is not difficult to diagnose, but care must be taken not to confuse the delirium of some fevers with acute mania. Carelessness in this respect has led to patients suffering from pneumonia or some specific fever being sent to an asylum as insane. Delirium is temporary insanity, but it is not proper or usual for ordinary delirious patients to be certified as of unsound mind. A raised tempera- ture should always put a physician on his guard, as fever is rare in mania except in its more severe forms. Examine the patient carefully for any rash. UraBmia has also been mistaken for mania. Try and determine whether the excitement is purely functional in character, or whether it is the mental aspect of some organic disease. Never forget to look for symptoms of general paralysis. The mental excitement of the latter, when it occurs, is usually very acute, and the patient is most unreasoning and more insane than is the case with ordinary mania. Alcohohc conditions are at times difficult to differentiate from simple maniacal states, and it is hard at times to distinguish delirium tremens from acute delirious mania. The temperature is raised in the latter, and is subnormal, as a rule, in delirium tremens ; also in acute delirious mania the patient is flushed, while in the alcoholic deliiium he is pale and of anaemic appearance. The alcoholic is afraid of his hallucinations, but the ordinary maniacal patient shows no such fear. Drug-poisoning must also be borne in mind in making a diagnosis. Epilepsy and seizures should also be considered. Hysterical cases at times are difficult to diagnose, but they exhibit, as a rule, the symptoms common to hysteria and will be fully dealt with elsewhere. Dementia prsecox may be confused with mania, but patients with the former disorder 110 PSYCHOLOGICAL MEDICINE are usually more childish. The history will assist in arriving at a proper diagnosis in those cases of paranoia which are accompanied by maniacal outbursts. Prognosis. — The immediate prognosis is good in cases of simple mania, but the ultimate is by no means so hopeful, recurrent attacks being common. In acute mania the outlook is faii'ly good, so long as the general physical condition remains satisfactory, rapid emaciation pointing to an unfavourable prognosis. The presence of auditory hallucinations makes the outlook more grave. The same is true of marked degeneracy, indicated by the eating of filth or total disregard of the calls of nature. As a general rule, a maniacal outbreak in the early epochs of life indicates that there wUl be subsequent attacks. This is more likely to be the case if there is definite cause for the illness, or if there is a marked nem'otic inheritance. The prognosis is bad in many cases of acute delirious mania and probably only careful feeding and good nursing will give a patient any chance of recovery. Pathology and Morbid Anatomy. — The pathology of mania is stUl somewhat obscm'e. Eeference is made to change in the blood in mania, in the chapter on General Symptomatology. Delirium is usually caused by infective toxic agents. Micro- organisms have been found in the blood of patients with acute delirious mania, but most of these organisms appear to be the common pathogenic bacteria usually found with suppuration. Bianchi and Piccinino reported that they had found a special bacillus in the blood of persons suffering from acute delirious mania, and on this ground they concluded that there must be a special form of delirium, which they named Acute Bacillary Delirium. Auto-intoxication from the gastro-intestinal canal is a theory which continues to gain support. Marro has reported several recoveries from the treatment of washing out the stomach of such patients ; this is a very strong corroborative evidence that — at any rate, in some cases of maniacal excitement — absorption of deleterious matter from the ahmentary canal may give rise to mental disorder. The question of altered blood-supply to the brain is one that still requires further investigation ; but a confident belief may be entertained that it plays no small part m the production of mania. In support of this view the MANIA 111 writer has known an attack of acute mania to result from liga- ture of the internal carotid artery ; again, delirium is a common sequel to starvation. In considering the bearing that changes of the blood-pressure may have upon mania, it may be usefully observed that mental disorder associated with aortic disease is almost always maniacal in character. It is interesting, too, to note that even the ordmary physiological fall of blood-pressure, which occurs in the latter part of the day, is accompanied by mild excitement when compared with the mental state of the early morning. In acute dehrious mania, and even in other forms of mania, the quantity of blood in the system is found to be greatly decreased, and infusion of a saline solution leads to a rapid and marked improvement in the patient's mental condition. Whether the actual disorder is the result of altered blood-states or not, it is most probable that the feeling of well-heing, so commonly experienced in states of mania, is due to altered blood-pressure. The morbid changes which are found in the brains of persons dying from acute mania show, in varying degrees, degeneration of the neuron. It is certain that the nerve-cells ultimately suffer in their entirety, but in all probabihty the condition is secondary to something else. Treatment. — Many points regarding the treatment of mania win be found in the special chapter on Treatment ; and sugges- tions will here be limited to those matters which are especially connected with mania. The physician must decide where he considers it best for the patient to reside during his iUness. The milder forms of excitement seldom come under treatment, as the symptoms of mania are not usually recognised as such, but are taken rather to indicate good spirits and exuberant health. StiU, if a medical attendant see such a patient, he should warn the friends of the risks they are running in allowing their relative to waste his strength in restless excitement. If the case is at all acute, it is very difficult to treat it out- side an asylum, unless ample means are available. Continual restlessness and loss of control are awkward symptoms to cope with in a private house, and, when shouting and singing are superadded, removal to an institution is almost imperative. Wherever the patient is, all unnecessary furniture should be removed ; and a room on the ground floor is preferable to one upstairs. Cases of simple mania do not always call for certifica- 112 PSYCHOLOGICAL MEDICINE tion, provided that the patient can be controlled ; but where there is much arrogance and general exaltation, effective manage- ment is almost impossible at home. Kest in bed is the most valuable form of treatment and best tends to promote recovery. Added to this, partial isolation, good and liberal feeding, and attention to the sleep and bowels are important points in the treatment of mania. Massage is not recommended. Some phj^sicians recommend plenty of exercise for their maniacal patients, believing that physical exhaustion will promote natural sleep. Such a practice is full of danger and seems to be directly opposed to all experience. To exhaust the body impHes an equal exhaustion of the nervous elements ; the greater the fatigue, the wilder the excitement. Strength must be conserved during the early weeks of mania, for in this way the attack is shortened. Further, it must be borne in mind that fatigue is not registered in the maniac as it is in the sane person, and in consequence it is very easy to overtax his strength. Eest engenders rest ; the more it is indulged in, the greater is the desire for repose. When the excitement is very intense it is frequently difficult to persuade a patient to keep in bed, but if left he will usually sit covered up in blankets. Plenty of fresh air is very important in the treat- ment of these cases, and the tendency of recent years has been to keep them in bed in the open air, if possible ; the beds in some of the acute mental hospitals being placed on verandas. The bowels must be carefully attended to, and a dose of mineral water, or some other purgative, may be given with advantage three or four times a week. Many excited patients are troublesome in taking food ; some are very capricious, and will take one good meal and then refuse the next, but in the end they will average a fair amount of nourishment daily. Others refuse everything that is brought to them, or will only drink a small cupful at a time. A minimum standard must be fixed, and the patient must be forcibly fed if he does not take this allowance. Many of these patients will swallow only fluid food ; but as this may consist of several pints of milk, four to six eggs, soup, etc., enough nourishment can be taken. Never delay forcible feeding if it is considered necessary, as states of excitement tend to produce exhaustion, which may terminate fatally. All struggling with patients MANIA 113 must be avoided as far as iDossible. Nothing must be under- taken unless sufficient help is at hand to carry it out without injuring the patient, if he should offer resistance. The insomnia of acute mania is most difficult to overcome. Patients will lie awake laughing and talking night after night, in spite of the hypnotics which are given. Chloral, amylene hydrate, and sulphonal are the most useful sedatives in these cases. During the day hyoscin may be given with advantage. Stimulants may be necessary in all the more acute forms of mania, but alcohol should be avoided if possible. The writer finds that, if it is possible by any means to raise the blood- pressure of these patients, a distinct lessening of excitement is at once produced. Unfortunately, it is not always easy to bring this about. The drugs which will be found most useful are acid, hydrobrom. dil. and liq. adrenalin and pituitrin ; but the period during which the blood-pressure is raised after administration is usually very short. As a rule, better results can be obtained by employing the prolonged bath — the descrip- tion of which will be found elsewhere. Patients are placed in this bath daily. The duration of the first bath should be half an hour, with a gradual increase from day to day, until a duration of six or eight hours is attained. Often an excited patient will be found to be quiet and rational during the bath and for a short time after. In many ways the use of the bath tends to promote recovery. In acute delirious mania and other forms of very acute excitement, where there is a tendency to collapse, much can be done towards saving a patient's life by the services of a good, conscientious nurse. From the nursing standpoint these cases resemble those of typhoid, and consequently it is a matter of the utmost importance to have a thoroughly conscientious and experienced nurse. Food must be ad- ministered, if necessary, by means of a nasal or cesophageal tube every four hours, and, as a rule, six ounces of alcohol should be given during each twenty-four hours. In these acute cases it is very necessary to watch carefully for local redness or other signs which may indicate the forming of bed-sores. The passing of urine must be regularly recorded. A tem- perature chart should be kept, as a sudden accession of fever may be the first warning of some intercurrent disease. 114 PSYCHOLOGICAL MEDICINE The administration of chloroform is of great value in the treatment of the very acute forms of mania, the anaesthetic being given for an hour a day for two or three days. When convalescence has set in, plenty of time must be given for the patient to recover his physical health. The nervous system will require many weeks of rest, and it is very unwise to remove the case from the institution or house in which it has been treated until sleep has fully returned and all the physical functions are re-established. The period of convalescence is frequently very trying, both to the patients and his friends, and unfortunately it is by no means common for the latter to decide upon some rash step, which ultimately ends in disaster. This question is so fully dealt with in the chapter on Treatment that it is unnecessary further to discuss it here. In conclusion, it should be pointed out that if there is any special cause for the excitement, this must be treated in addi- tion to attending to the various symptoms as they arise. The treatment must be directed towards improving the bodily condition, as well as quietening the mind, and in many ways the former may be said to be the more important of the two. When the patient has recovered, tell him how he must live in the future so that he may avoid any recurrence of his illness. If he should have a second attack, he and his friends should recognise the symptoms earlier than on the first occasion and thus reduce the risk of a serious break- down by taking immediate action. If the patient is suffering from the mixed form of maniacal- depressive insanity, his rela- tives must be warned to watch for symptoms of depression. In no case should a patient be allowed to go back to work for some months after his illness, and it should always be remembered that it is the method of treatment during the next few years which will go far towards confirming the nervous system and re-establishing health. 115 CHAPTEE VII MELANCHOLIA AND STATES OF DEPRESSION Formerly all states of depression were included under the generic term Melancholia ; any attempts at differentiating various types were chiefly confined to whether the patient was resistive or agitated, or, in other words, whether there was motor restlessness associated with the mental depression. During recent years there has been a growing tendency to differentiate states of depression according to the grouping of the symptoms and the general type of the case. As with other forms of mental disease, a disorder which was at one time considered an undivided whole is now found to be an aggre- gation of disorders, for the mistake was made of naming the disease according to its most prominent symptom. Depression is common to many types of insanity, but to call all these types Melancholia is a misnomer and tends to confusion. At the present day the study of mental disease is still in its infancy, and change in nomenclature is to be expected as from time to time it is found that diseases formerly regarded as distinctive are in reality compound. Many forms of insanity are still necessarily named after their most prominent mental symptom. The student should clearly understand that such terms as Mania and Melancholia merely designate growps of symptoms. From a diagnostic point of view this state of things is unsatisfactory ; groups of symptoms are apt to change, and not infrequently the name of the disease, which is really descriptive of the condition of the moment, has to be altered with the variation in the condition. Thus the melan- choliac of to-day may be the maniac of to-morrow and the dement of six months hence. All this is very confusing to the student ; but though the advance is slow, progress is taking 116 PSYCHOLOGICAL MEDICINE place, and more accurate diagnosis can be made to-day than was possible some years ago. Differences are more clearly distinguished, and differentiation between types of mental disease is more minute than in the past. Kraepelin has done a very great deal to further more accurate diagnosis and prognosis, correctness in the latter depending largely on accuracy in the former. States of depression are found associated with many forms of insanity. A layman can diagnose that a man is melan- chpHc, but the physician should try to find out why his patient is depressed. Depression may be the whole or para- mount condition, or it may merely be a symptom in a grave disease such as general paralysis. It may be a symptom merely indicative of a mental state, or it may be associated with other symptoms which, when taken together, connote progressive mental deterioration. Melanchoha has been defined by Mercier as a ' disorder characterised by a feeling of misery, which is in excess of what is justified by the circum- stances in which the individual is placed.' This definition, it should be remembered, deals only with the mental state and in no Avay explains the origin of the depression. etiology. — Some forms of melancholia occur only in the j'"ears of decadence and not before middle life, but the varieties of depression formerly known as Eecurrent Melanchoha and Folie Circulaire usually show themselves earlier. Depression is rather more common among women than men. An unstable inheritance is found in a fairly large proportion of cases, especially in those in which the break-down occurs early in life. Phthisis is often found in the family history, and, if combined with any neuroses, it increases the liability to insanity in the offspring. Monotonous and anxious occu- paHons are factors which may predispose to depression. Certain types of mental constitution are more liable than Others to lead to melancholia. Long-continued periods of insomnia are frequently followed by a depression of a more or less severe kind. Many melancholiacs will tell you that they seldom drink water and will also give a long history of Severe constipation. Certain periods of life, when stresses are Apt to weigh heavily on the organism, must also be classed among the commoner cases of depression. In the female we MELANCHOLIA AND STATES OF DEPRESSION 117 find the following: pregnancy, lactation, climacteric, and senility. Lastly, there are the so-called mental shocks — -such ,as loss of relatives and financial failure. Varieties,- — There are several recognised forms of mentiil disorder in which, depression is the most marked symptom. Attacks of melancholia may occur periodically throughout the life of soma persons, in the same way that; others may suffer from cyclic attacks of excitement. Many writers prefer to use . the old term ' periodic ' ^ or ' recurrent ' melancholia for these cases, or,^ if the mental disorder is an alternation betWeeii depression and mania, the terni Circular Insanity or Folie Circulaire is employed. Kraepelin has introduced the nam^ Maniacal-Pepressive Insanity for these cases. He considers that -disorders of this kind are not accidental in character, but that they, are a definite grouping of symptoms which _ are quite distinguishable from other forms of depression— and in this the writer entirely agrees. Kraepelin is undoubtedly a keen observer, and he shows that these recurrent disorders follow .a! definite course, which is. usually repeated in each succeeding attack. He describes three varieties of maniacal-depressive insanity : the Maniacal, the Depressive, and the Mixed. Older writers would describe these as Eecurrent Mania, Eecurrent Melancholia, and Folie Circulaire. Melancholia, for the present purpose, may be classed under the following heads : — 1. Simple Melancholia. — A condition in which there arp usually no delusions, and in which the physical health is not seriously affected. This disorder usually first appears early in life, and has a tendency to recur periodically, or may alternate with a. cycle of excitement. Patients suffering froim the simple form may have repeated attacks, alivays of this mild type, but' they never become weak-minded, or the attacks may tend to become more severe. In the more serious variety the melancholia and the alternat- ing mania, when it occurs, are of a severe nature, and there is a greater tendency for the patient to pass into dementia. 2. Melancholia and Hypochondriacal Melancholia. — This .disorder more commonly occurs after middle life. .. S. Eecurrent Melancholia (Maniacal- Depressive). — -This may be either simple or acute Mania in. the character of ^.symptoms. 118 PSYCHOLOGICAL MEDICINE 4. Chronic Melancholia. — This condition usually appears after middle life. The symptoms are very similar to those found in acute melancholia, though of a more sub-acute type, and there is often a tendency to motor restlessness. Some authorities describe other varieties of melancholia — such as agitated melancholia, where there is an excess of move- ment, and resistive melancholia where there is resistance to nursing, etc. ; stuporous melancholia where there is defective voluntary movement. Depression also occurs in other con- ditions, and, in fact, may be a symptom in many diseases. It is therefore all the more incumbent on the physician to be careful in his diagnosis. The mental state of a fair propor- tion of general paralytics is one of depression, but dementia paralytica must not be diagnosed from the mental symptoms alone ; this disease is physical, the mental disorder being secondary. A prudent physician will always seek for physical signs of organic disease before committing himself to a diagnosis. Prodromata. — Melancholia usually develops slowly, though in its recurrent forms subsequent attacks may be sudden in onset. As a general rule the patient gradually becomes more and more depressed. He may have weeks of sleeplessness, and there is a slow but steady loss of the body weight. He loses interest in his work and surroundings, attention fails, and everything becomes a burden. It is often very difficult to say when the line of demarcation between sanity and insanity has been crossed, as the reasoning power is not lost so early as it is in mania. Mental Symptoms. — (1) Simple Melancholia. — In this con- dition there is merely a general feeling of depression and slowing of mental action. Savage defines the state as being a * saturated solution of grief.' These patients are self- absorbed, and there is a rise of subject-consciousness and fall of object-consciousness. They feel a sense of resistance to their environment, and lose interest in all their former pursuits. Thought is difficult, and there is a general sense of inability to do their daily work ; thus they become unoccupied. Speech is slow and betrays effort. They become untidy and careless in dress and personal cleanliness, and food is distasteful to them. These patients must always be treated as potential suicides ; but with simple melancholia it is not common to find serious MELANCHOLIA AND STATES OP DEPRESSION 119 attempts at self-destruction. Depression is more acute in the early hours of the morning, and often by evening the patient is able to take interest in the affairs of others. Hallucinations and delusions are not present ; a patient may have a vague fear that he will be unable to work again. After some weeks or months these cases usually recover, but the tendency is for them to have recurrent attacks of a similar kind. 2. Melancholia and Hypochondriacal Melancholia. — In this disorder all the symptoms mentioned under the head of Simple Melancholia are present but more marked. There is greater evidence of dissolution, both physically and mentally. The onset is usually slow and steady, with short periods of remis- sion, during which the patient appears brighter and more cheerful. It is largely owing to this gradual onset that so many patients are left untreated, and the condition is not un- commonly chronic before the physician is called in. When the disorder is fully developed there is severe mental depression ; there is a very great rise of subject consciousness, and the patient is more and more introspective. Attention fails for external things, and is centred on subjective thoughts and feelings of a dismal kind. With all this, there is a profound loss of interest in environment and inability to do the daily work. The melancholic mother neglects her house and children, and to her everything seems to be confusion. Self- accusation very soon appears as a prominent symptom, for the tendency of human nature is to explain new feelings and thoughts. It is this tendency to explain and desire to account for everything that leads to the production of so many delusions. Symptoms and circumstances are all viewed from the gloomy side, and the patient turns to the ' unknown ' for his explanations. To the conscientious person there is no subject so fraught with possibilities for this purpose as reUgion, as there the melancholiac can find the condemnation which he seeks. As has been already stated in the chapter on Causation of Insanity, religion is far more closely connected with the explanation of unaccustomed symptoms than an actual factor in the production of melancholia. The layman would have us believe that rehgious excitement is the cause of the mental 120 PSYCHOLOGICAL MEDICINE disorder ; in a vast proportion of cases this is not so, the religious element being purely secondary to the insanity. It seems at times almost incredible that the patient really beheves all he says, so trivial are the matters upon which his self -accusation is based ; but these delusions, it must be remembered, are not founded on past experience, but upon behef. Some persons seem capable of making themselves believe anything ; and, once the belief is present, plenty of evidence in support of it is readily forthcoming, no matter how absurd the original idea may be. For the same reason argument is of no avail, since the belief is a faith, and not based on fact or experience. A patient may even go back to his early hfe in his endeavour to find a cause, and may ultimately accuse himself of having stolen two stamps when he was young or in his first position of trust. He distorts earty indiscretions into gigantic sins, and even the ordinary incidents of life may be misconstrued into vice. Some patients say and believe that they are ' lost ' for ever, and that they have committed some ' unpardonable sin ' ; and, when pressed to state what the sin is, cannot do so. They feel that they have sinned, and that is sufficient, just as another feels that he is ruined, notwithstand- ing that he has a large balance at the bank. Fear of being sent to prison is another common delusion. Extreme apprehension of some impending harm fills many melanchohacs with alarm ; they misinterpret every sound and action into the movements and preparations of their persecutors. ' The world is changed, and everyone in it,' is the cry of some, faiHng to realise that the change is in themselves. Hallucinations do not usually occur in acute melancholia ; if present, they usually indicate that there is a tendency to exhaustion, or that the case is not purely one of depression. A certain proportion of patients develop exhaustion symptoms during an illness of this type, and it is when this takes place that sensory disturbances appear ; when present, they usually tend to confirm the patient in his beliefs, etc. The unpardonable sinner hears the ' voice of God ' proclaiming that he is ' lost,' and constantly sees ' devils ' around him ; he may even go so far as to smell brimstone. The hallucina- tions which are associated with melancholia frequently reflect the type of the patient's education and training. He believes me;