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A TEXT-BOOK 
 
 ON 
 
 MENTAL DISEASES 
 
 FOR THE USE OF 
 
 STUDENTS AND PRACTITIONERS OF MEDICINE 
 
 BY 
 
 THEODOEE H. KELLOGG, A.M., M.D. 
 
 LATE MEDICAL SUPERINTENDENT OF 'WILLARD STATE HOSPITAL, EORMER PHYSI- 
 CIAN-IN-CHIEF OF NEW YORK CITY ASYLUM FOR THE INSANE, FORMER 
 PHYSICIAN - IN - CHARGE OF SANFORD HALL PRIVATE ASYLUM, 
 FORMER FIRST ASSISTANT PHYSICIAN OF HUDSON RIVER 
 STATE HOSPITAL, AND OF NEW YORK CITY ASYLUM 
 
 Mitb miustrationa in tbe ^eit 
 
 NEW YOEK 
 WILLIAM WOOD & COMPANY 
 
 1897 
 

 COPTKIGHT, 1897, BT 
 
 WILLIAM WOOD & COMPANY 
 
 TROW DIRECTORY 
 
 PRINTINQ AND BOOKBINDING COMPANT 
 
 NEW YORK 
 
GEOKGE F. SHKADY, A.M., M.D. 
 
 IN SPECIAL APPRECIJATION OP IIIS PEKSISTENT AND ABLE ABVOCACT OF 
 PROGRESSIVE AND SCIENTIFIC METHODS OF TREATMENT OF THR IN- 
 SANE; IN RECOGNITION OF HIS USEFUL AND DISTINGUISHED 
 PROFESSIONAL CAREER AS MEDICAL EDITOR, MANAGER 
 OF A STATE HOSPITAL, AND VISITING AND CON- 
 SULTING HOSPITAL SURGEON ; AND AS A PER- 
 SONAL TRIBUTE TO HIS STERLING 
 TRAITS OF CHARACTER 
 
 ^bis TKIlork (0 2)eDicateD 
 
 THE AUTHOR 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/textbookonmentalOOkell 
 
PEEFACE. 
 
 The Science of Mental Diseases advances so rapidly that there is 
 no apology needed for new treatises. All modern English;, French, 
 and German hooks on the suhject have proved highly instructive, 
 and have served to educate the profession in a most important 
 branch of medical knowledge. An endeavor is here made to set 
 forth in a condensed but comprehensive manner the present state 
 of the Science of Mental Diseases. The book is made to embrace 
 the wide range of the history, statistics, nosology, etiology, clinical 
 course, symptomatology, pathology, diagnosis, prognosis, and treat- 
 ment of Mental Disorders. 
 
 An attempt has been made to introduce such clear and sys- 
 tematic subdivisions as would best tend to facilitate the compre- 
 hension of the whole subject and render the work available for 
 students and practitioners of medicine. The book aims to be a 
 practical guide to the diagnosis and treatment of all the various 
 types of Insanity with which the physician has to deal in public 
 hospitals or private practice, and also to serve as a work of ready 
 reference for psychiatrists, in the emergencies of their specialty. 
 Parts of the treatise may merit the attention of psychologists and 
 of all interested in the study of mental pathology. 
 
Tl PREFACE 
 
 The wlaole work is written independently of leading philosopli- 
 ical or medical hypotheses, and is the clinical rendition and general 
 outcome of the writer's experience in psychiatry while in charge of 
 public or private hospitals for the insane, or in practice in New York 
 City. A full table of contents and a complete alphabetical index 
 will render the book of ready service to the busy professional man. 
 
 Neiv York City, 3Imj, 1897. 
 
TABLE OF CONTENTS. 
 
 PART I. 
 
 GENERAL MENTAL PATHOLOGY. 
 CHAPTEE I. 
 
 PAGE 
 
 The Histoey of Insanity, 3 
 
 The earliest historical mention of Insanity — Egyptian, Gre- 
 cian, Roman, and Biblical records of Insanity — Historical sketch 
 of the general condition and treatment of the insane from the 
 earliest to the present time — Summary survey of the evolution 
 of the Science of Psychiatry and of the early literature of the 
 subject. 
 
 CHAPTER II. 
 
 The Statistics of Insanity, 19 
 
 General principles of statistics as applied to Insanity and er- 
 rors to be avoided — Correct basis of tabular returns from institu- 
 tions for the insane — Total numbers of insane ; European, Brit- 
 ish, and American figures — Reasons for percental increase of 
 insane to general population in civilized countries — General sta- 
 tistics as to sex, age, nativity, civil condition, occupation, form of 
 insanity, heredity, sensorial defect, degree of education, recover- 
 ies, relapses, and mortality in Insanity — Rules for correct calcula- 
 tion of statistics. 
 
 CHAPTER III. 
 
 The Nosology of Insanity, 36 
 
 General nosological principles applicable in Insanity — Former 
 accepted classifications — Nosological divisions of recent standard 
 writers — The author's classification of Insanity. 
 
 CHAPTER rV^ 
 
 The Etiology op Insanity, 69 
 
 Predisposing causes — The predisposing circumstances — The he- 
 reditary group of causes — Exciting causes — The bodily causes of 
 mental diseases — The reproductive organs — Gastro-intestinal dis- 
 orders — Cardiac disease — Pulmonary affections — Vascular and cir- 
 
Vlll TABLE OF CONTE]S"TS. 
 
 PAGE 
 
 culatory disorders. — The pliysiologlcnl crises as etiological factors — 
 Intra-uterine life, birth, dentition, puberty, menopause, and se- 
 nility — The neuroses in the light of causes : Chorea, epilepsy, hysteria, 
 hy]30chondria, and neurasthenia — The toxic origin of Insanity — 
 Vegetable, animal, and mineral poisons most productive of Insan- 
 ity — Auto-intoxications causing mental disorders — The psychoses 
 from infectious disorders and acute affections of internal organs — 
 The diatheses in their causative relation to the psychoses — Dis- 
 eases and traumatic lesions of the cerebro-spinal nervous centres 
 ^followed by Insanity — The reflex and sympathetic origin of men- 
 tal disease — The psychical causes of Insanity — Fear the basis of a 
 great generic group of emotional causes — Loss of mind as the im- 
 mediate result of emotional shock — ^Moral contagion and epidemics 
 of Insanity — Individual infection and communicated Insanity — 
 Mental disorder as the result of simulation. 
 
 CHAPTEE V. 
 
 The EvoLmox, Stadia, Clixical Progression, and Terminatigns of 
 
 Mental Disorders, . . .127 
 
 CHAPTER Yl. 
 
 Psychical Sx51ptgmatology, . 142 
 
 Section I. — Bisorclers of the Intellect — Presentaiive Faculties — 
 Perception and Conscioiisness — Pathological states of the muscular, 
 tactile, gustatory, olfactory, auditory, and visual senses — Illusions 
 and hallucinations — Disorders of consciousness— Changes in iden- 
 tity — Double personaKty — The representative faculties — Memory 
 and imagination — Lesions of memory — Amnesia — Hypermnesia — 
 Paramnesia — Disease of imagination — Phantasmagoria — The ra- 
 tional processes — Thought and reasoning — Disordered thought — 
 Incoherence — Quickened and retarded thought-rate— Eeasoniug — 
 Definition and description of the origin and nature of delusions. 
 
 Section II. — Disorders of the Emotions. — The organic sensations 
 and the resultant coensesthesis — The j)hysiological basis of the pre- 
 vailing emotional mood in Insanity — The rationale of the funda- 
 mental emotional tone in states of exaltation and of depression — 
 Cortical disease and the spasmodic liberation of emotions — Gen- 
 eric division of emotions as manifested in Insanity — Egoistic and 
 altruistic feelings — Fear resulting from psychical disintegration 
 the i^redomiuant emotion — Other emotions considered in the rela- 
 tive order of their frequency. 
 
 Section III. — Disorders of Volition. — Abulia, hyperbulia, para- 
 bulia, impellent ideas — Irresistible im]pulses — Nature of the loss 
 
TABLE OF CONTENTS. IX 
 
 of inliibition of ideas and actions in special types of Insanity — The 
 appetites and instincts in their basic relation to the will and their 
 perversion in Insanity — Sitophobia, polydypsia, polyphagia, pica, 
 coi^ropliagy, anthropophagy — Sexual perversions — Insomnia — Ar- 
 tificial appetites in mental disorders — The volitional sequelae of 
 mental disorders — The psychic stigmata degenerationis. 
 
 CHAPTEE VII. 
 
 Somatic SYJiPTOMATOiiOGY, • • 199 
 
 Section l. — The Osseous iS'?/si!ewi.— Microcephalic, macrocephalic, 
 and asymmetrical cranial defects — Facial, dental, and palatine 
 malformations— Other physical stigmata degenerationis— Fragili- 
 tas et mollities ossium, ankyloses, arthritis deformans, necroses. 
 
 Section 11.— The Muscular ^'j/s^ew.— Changes in general nutri- 
 tion and in the electro-muscular reactions— Dynamometric and 
 dynamographic variations— Hyperkineses, spasms, tonic and clonic, 
 parakineses, pareses, paralyses, contractures, and atrophies — Mus- 
 cular inco -ordination, tremors — Ataxic, pseudo-paralytic, cata- 
 leptoid, and tetanoid states— Jacksonian epilepsies— Changes in 
 the reflexes — Automatic acts and characteristic attitudes — Disor- 
 ders of speech in Insanity — Changes in gait and other highly 
 specialized acts— The chirography of the insane— The physiog- 
 nomy of Insanity with illustrationiS of the various types. 
 
 Section 111.— The Vascular System.— 'Fu-nciiorxdl and organic 
 cardiac affections— Anomalies of structure and degeneration of ves- 
 sels — Functional and organic vascular affections — General and 
 partial antemias and hypertemias- Capillary stasis, varicosity, vari- 
 ations of blood-pressure, abnormal pulsation— Angiospastic and 
 angloparetic conditions and general vasomotor disorders — The 
 pulse in Insanity — Descriptions and illustrations of sphygmo- 
 graphic tracings in the various forms of mental disorders. 
 
 Section IV. — Changes in the Cutaneous and Other Epithelial Struct- 
 ures. — Pigmentations, desquamations, eruptions, herpes, pemphi- 
 gus, decubitus, cyanosis, oedema, anidrosis, hyperidrosis, chromo- 
 drosis, seborrhoea, hirsuties, canities, anomalies in growth and 
 coloration of hair— The nails and their trophic affections, cutaneous 
 anaesthesias, hypersesthesias, and paresthesias, changes in cutane- 
 ous reflexes — Superficial temperature changes. 
 
 Section Y .-Splanclmological Disorders.— Pulmonary diseases 
 and modifications of respiration — Gastro-intestinal symptoms — 
 The genito-urinary disorders— Biliary, splenic, pancreatic affec- 
 tions. 
 
 Section Yl.— Nutritive, Secretory, and Trophic Disturbances. — 
 Changes in total weight of body in Insanity— Disorders of second- 
 
X TABLE OF CONTENTS. 
 
 PAGE 
 
 ary assimilation — Aiito-iutosications— The blood in Insanity — The 
 ■urine in mental disease— The saliva — Tropliic tissue clianges — 
 Hsematoma auris — Temperature in mental disorders. 
 
 Section VII. — Disorders of the Cerebral, Spinal, and Peripheral 
 JS'ervous System. 
 
 CHAPTER VIII. 
 
 Pathology op Insanity, 269 
 
 Section I. — The Pathogenesis of Mental Disorders. — Physiologi- 
 cal facts and pathological records — The inherited insane diathesis 
 — The acquired neurotic constitution — Functional brain exhaus- 
 tions — The earliest nutritive lesions and biochemical cerebral 
 changes — Insanity from circulatory disorders of the brain — Quali- 
 tative changes in cerebral blood-supply — Toxic states — Origin of 
 mental disorder from lesions of cerebral, spinal, or sympathetic 
 nervous system — Eeflex or sympathetic Insanity from disease of 
 internal organs — Epochal systemic changes— Cerebral, thermic, 
 chemical, or mechanical traumatism — Emotional traumatism. 
 
 Section IL — The Pathological Anatomy of Insanity. — The MacrO' 
 scopical Changes. — The cranium — The brain — Lobes, lobules, con- 
 volutions, sulci — The nei-ve-fibre systems : centrum ovale, central 
 ganglia, ventricles — Pons medulla — The membranes : Dura mater, 
 pia mater, arachnoid, ependyma — Cerebral anaemia, hypersemia, 
 atrophy, hypertrophy, oedema, inflammation, sclerosis, abscesses, 
 tumors, hemorrhages — Cerebral vessels — Embolism, thrombosis, 
 arteriosclerosis, aneurisms— The spinal cord — Investing mem- 
 branes — Descending system-fibre lesions, and cellular degenera- 
 tions. 
 
 77^6 Microscopical Changes. — The cortical cells and their various 
 disintegrations — Changes in nuclei, nucleoli, apical and basilar 
 processes of cells — Granular, fatty, moniliform, and pigmentary 
 degenerations — Cellular vacuolation — Colloid bodies — Miliary 
 sclerosis — Phagocytes — Neuroglia fibre-cells — Protoplasmic glia- 
 cells — Changes in the commissural, association, and projection 
 nerve-fibres — The cerebral membranes — The cerebral vessels — 
 Perivascular lymph-spaces — Cellular degenerations of spinal col- 
 umns, vessels, and membranes. — General principles explanatory of 
 microscopical lesions in the genesis of Insanity. 
 
 CHAPTEB IX. 
 
 The Diagnosis of Insanity, 296 
 
 Technical difficulties and legal responsibilities — The essmtial 
 elements of diagnosis — The history of the case antecedent and subse- 
 quent to the attack — Medical lines of inquiry and laws of evidence 
 
TABLE OF CONTENTS. XI 
 
 involved — Complete outline given for the record of histories — The 
 personal examination of the patient — Diagnostic, psychic, and so- 
 matic symptoms — Standards of comparison in the determination of 
 Insanity. 
 
 The average sane mental standard of mankind, as affected by his- 
 toric epoch, national crises, degree of civilization, race, caste, oc- 
 cupation, and general environment. 
 
 The sane mental standard of the special individual. — Its fluctua- 
 tions within physiological limits — The determination of its patho- 
 logical departures — Conditions of unusual difficulty of diagnosis in 
 childhood, senility, eccentricity, imbecility, deaf-mutism, volun- 
 tary mutism, aphasia, habitual drunkenness, and other forms of ex- 
 cessive indulgence of natural or artificial appetites, and supi^osed 
 recoveries from psychoses. 
 
 Feigned Insanity and the detection of various forms of malingering. 
 
 The differential diagnosis of m,ental disorders. — Insanity differen- 
 tiated from acute brain diseases, from the deliriums of fevers, 
 acute internal inflammations, inanition, sudden losses of blood, 
 commotio cerebri, surgical and other forms of traumatism, acate 
 alcoholism, toxic states, violent emotions, and extreme functional 
 exhaustion of mental powers. 
 
 The points to he determined hy the diagnosis. — The prime fact of 
 Insanity — The special type — The question of institutional or home 
 treatment — The degree of responsibility in legal cases — The setio- 
 pathology and the general indications for treatment — Complete 
 formula for the mental and physical examination with reference to 
 diagnosis. 
 
 CHAPTEE X. 
 
 The Pkognosis of Insanity, 342 
 
 The substance of the prognostic inquiry — The possibility of 
 death — The hope of recovery — The probable duration and mode of 
 termination — The chances of recurrence — The essential elements 
 of prognosis in individual cases — Age, sex, constitution, heredity 
 of the patient, and the form, duration, course, and cause of the 
 attack — Special symptoms of bad prognostic import — Special 
 symptoms of favorable prognostic nature. 
 
Xll TABLE OF CONTENTS. 
 
 CHAPTEE XI. 
 
 PAGE 
 
 The Tkeatsient of Insanity, . . 367 
 
 Section I. — The Prophylaxis of Insanity. — The early life and 
 education of children— Advice about marriage and the adult rela- 
 tions of life — State-medicine and regulations for the prevention 
 of mental disease. 
 
 Section II. — General Mode of Treatment. — Private and public 
 hospitals and their relative advantages — Practical directions for • 
 the treatment of cases in private practice. 
 
 Section III. — First Attentions to Urgent Syinptonns. — Traumatic 
 accidents — Inanition, insomnia, obstipation, retention of urine, 
 gastro -intestinal disorder, exhaustion of vital powers, heart failure 
 — Psychomotor excitement, hallucinatory delirium, acixte organic 
 affections, infectious disease. 
 
 Section IV. — Certain Specially Troublesome and Responsible 
 Cases. — Destmctive i^atients — Violent and homicidal cases — The 
 actively and passively filthy cases— Feeble, helpless, or bed-ridden 
 patients — Masturbatic and suicidal cases. 
 
 Section V. — The Treatment Based on Diagnostic Conclusions 
 and Etiological and Pathological Indications. 
 
 Section VT. — Pharmaceutic Remedies. — IIyi3notics, anodynes, de- 
 pressomotors, vascular sedatives, vascular stimulants, nervous 
 sedatives, nei'vous stimulants, anaesthetics, laxatives, jDurgatives, 
 emetics, digestives, tonics, alteratives, eliminators, anti-periodics, 
 emmenagogues, anaphrodisiacs, antiseptics, disinfectants, organic 
 extracts — Their chief uses described in the order above given. 
 
 Section VII. — Surgical Procedures. — Trephining — Craniectomy, 
 craniotomy, laminectomy, vertebral puncture, thyroidectomy, 
 hysterectomy, oophorectomy, clitoridectomy, orchidectomy, phle- 
 botomy, transfusion, hypodermoclysis, revulsion, vesication, 
 thermocautery, electrocautery, setons, aquapuncture, acupunc- 
 ture, hepatic aspiration, enteroclysis, cataphoresis, ansesthetic con- 
 gelation, gastric lavage — Gynecological local treatment — Electro- 
 therapy and its uses in Insanity. 
 
 Section VIII. — Hygienic Measures. The Hygiene of the Resi- 
 dence. — The hygiene of the person — The open-air cure — The rest- 
 cure— Forced recumbence versus forced exercise — Gymnastics- 
 Calisthenics— Swedish movement — Out-door games, horseback and 
 bicycle exercise — Hydrotherapy in Insanity — Ice-cap, spinal bags, 
 sunlight, sun-bath, colored light and its effects — Massage and its 
 ajjpHcation in special cases — Climato-therapy in mental disorders 
 — Mineral springs. 
 
TABLE OF CONTENTS. xiii 
 
 Section IX. — The Dietetics of Insanity. — General instructions as 
 to quality and quantity of food — Dietetics of acute mental disor- 
 ders — The diet of the chronic insane — Figures given for physio- 
 logical rations required — Formulae for liquid and solid food prep- 
 arations — Diet in special forms of Insanity — Predigested foods — 
 Ercctal alimentation — Artificial feeding — Special directions for the 
 forced feeding of patients and illustrated descriptions of the best 
 apparatus for the purpose. 
 
 Section X. — Psychotherapy — General principles of mental thera- 
 peutics and the means for enforcing the same — Isolation from fam- 
 ily and friends — Institutional environment — Trained nurses — So- 
 cial readjustment — Conduct of physician toward patient — Influence 
 of the opposite sex — Occupation — Diversions — Power of music — 
 Travel and change of scene — Certain intellectual and emotional 
 effects — Appeals to the reason, to the self-respect, and to the emo- 
 tions of the patient — Discipline, rewards, and punishment — Seclu- 
 sions—The question of mechanical restraint — Hyianotism — Sug- 
 gestion — Placebos. 
 
 Section XI. — The Coyivalescent Period. — Eemoval from institu- 
 tional care — The cessation of all treatment — The danger of pro- 
 longed treatment — Eeturn to business and social rights — Class of 
 cases in which only a partial or tentative restoration to civil rights 
 is advisable — The final advice of the physician to the jpatient. 
 
 PART II. 
 
 THE SPECIAL GROUPS AND THE TYPICAL FORMS 
 OF INSANITY. 
 
 CHAPTEE I. 
 
 PAGE 
 
 Insanity feom General Organic Abrest of Development, . . 519 
 
 Idiocy, cretinism — Imbecility — The definition, clinical delinea- 
 tion, causes, stadia, symptoms, pathology, differential diagnosis, 
 prognosis, and treatment of the above forms. 
 
XIV TABLE OF CONTENTS. 
 
 CHAPTEE n. 
 
 PAGE 
 
 iNSAijnTY from: CoKSTiTUTiONAii Netjropathic States, . . . 540 
 
 Insanity of cliildhood — Primary monomania — Moral insanity — 
 Periodical Insanity — The definition, clinical delineation, causes, 
 stadia, symptoms, pathology, differential diagnosis, prognosis, and 
 treatment of the above forms. 
 
 CHAPTEE III. 
 
 Insanity with Established Neuboses, 573 
 
 Epileptic, hysterical, hypochondriacal, choreic, and neurasthenic 
 Insanity — The definition, clinical delineation, causes, stadia, symp- 
 toms, pathology, diflerential diagnosis, prognosis, and treatment 
 of the abcfve f orifis. 
 
 CHAPTEE IV. 
 
 Insanity with PHYSioiiOGicAL Ckses, ...... 609 
 
 Pubescent, puerperal, climacteric, and senile Insanity — The defi- 
 nition, clinical delineation, causes, stadia, symptoms, pathology, 
 differential diagnosis, prognosis, and treatment of the above forms. 
 
 CHAPTEE V. 
 
 Insanity -with Geneeal SxsTEino Moebid States, .... 637 
 
 Toxic Insanity — Alcoholism, plumbism, morphinism, hydrargy- 
 rism, cocainism, nicotinism. 
 
 Diathetic Insanity — Phthisical, podagrous, rheumatic, pella- 
 grous, limopsoitosic, paludal, ansemic, j)ost-febrile, cancerous, and 
 myxoedematous Insanity — The definition, clinical delineation, 
 causes, stadia, symptoms, pathology, differential diagnosis, prog- 
 nosis, and treatment of the above forms. 
 
 CHAPTEE YI. 
 
 Insanity with Definite Lesions of the Cebebeal, Spinal, Vaso- 
 motor OR Peripheral Nervous System, .... 654 
 
 General jiaresis — Syphilitic Insanity — Organic dementia — Ty- 
 phomania— Traumatic and sympathetic Insanity — The definition, 
 clinical delineation, causes, stadia, symptoms, j)athology, differen- 
 tial diagnosis, prognosis, and treatment of the above forms. 
 
TABLE OF CONTENTS. XV 
 
 CHAPTEE VII. 
 
 PAGE 
 
 Psycho-Traumatic Insanity, 707 
 
 Insanity from Pathological Psycliic Influences. 
 
 CHAPTER \T:II. 
 
 States op Depression, 712 
 
 Coenaesthetic depression — Melancholia simplex — Melancholia 
 agitata — Chronic melancholia— Secondary monomania with de- 
 pression — The definition, clinical delineation, causes, stadia, symp- 
 toms, pathology, differential diagnosis, prognosis, and treatment 
 of the above forms. 
 
 CHAPTEE IX. 
 
 States of Exaltation, 720 
 
 Coensesthetic exaltation — Mania simplex — Mania transitoria— 
 Chronic mania — Secondary monomania with exaltation— The defi- 
 nition, clinical delineation, causes, stadia, symptoms, pathology, 
 differential diagnosis, prognosis, and treatment of the above forms. 
 
 CHAPTEE X. 
 
 States of Mental Weaelness, 733 
 
 Primary mental enfeeblement — Terminal dementia — The defini- 
 tion, clinical delineation, causes, stadia, symptoms, pathology, dif- 
 ferential diagnosis, prognosis, and treatment of the above forms. 
 
 CHAPTER XI. 
 
 States of Stupor, 740 
 
 Acute primary dementia, sequential stupor — The definition, 
 clinical delineation, causes, stadia, symptoms, pathology, differen- 
 tial diagnosis, prognosis, and treatment of the above forms. 
 
 CHAPTEE XII. 
 
 States of Impaired or Suspended Volition, 750 
 
 Abulic and somnambulistic Insanity — The definition, clinical de- 
 lineation, causes, stadia, symptoms, pathology, differential diag- 
 nosis, prognosis, and treatment of the above forms. 
 
PART I. 
 
TEXT-BOOK ON MENTAL DISEASES. 
 
 PART I. 
 
 GENERAL MENTAL PATHOLOGY 
 
 CHAPTER I. 
 
 THE HISTORY OF INSANITY. 
 
 It is a universal law that the most highly integrated functions 
 of vital organisms are the most apt to suffer derangement. The 
 human mind, as the highest evolved function of the most wonder- 
 fully complex of all organisms, has always been subject to partial 
 or total disintegrations. Historical note of these mental disorders 
 has been made from the earliest to the present time by various 
 writers, and by the careful chronological arrangement and inter- 
 pretation of the known facts an attempt will here be made to present 
 a brief liistory of Insanity. 
 
 The whole subject is divided, according to chronological order 
 and with reference to the general history of medical science, into 
 four periods. 
 
 The first period extends from 1700 B.C. to 400 B.C. — from the 
 first recorded mention of Insanity to the dawn of psychiatric science 
 in the Greek school of medicine. 
 
 The second period is from 400 B.C. to 200 a.d. It is the first 
 scientific evolutionary period of psychiatry, ending with the decline 
 of the Greek school of medicine. 
 
 The third period, from 200 a.d. to 1500 a.d., is the dormant 
 period of psychiatric science continuing through the Middle Ages 
 to the Renaissance. 
 
4 TEXT-BOOK ON MENTAL DISEASES. 
 
 The fourtli period, from 1500 a.d. to 1800 a.d., is the second 
 evolutionary period of psychiatry from the Eenaissance to the pres- 
 ent day. 
 
 The actual treatment of the insane as well as the existing knowl- 
 edge of Insanit}" during the above periods will he simultaneously 
 considered. 
 
 First Period {1700 B.C.—JfOO B.C.). 
 
 The modern study of Egyptian antiquities and papyri reveals 
 indications of a knowledge of mental disease even at that prehistoric 
 time. It is not to he understood that it has heen possible to decipher 
 from Egyptian hieroglyphic records that at that remote period In- 
 sanity was recognized in the sense that it is now known to exist. 
 The conception of Insanity, such as jjrevails in modern times, would 
 have been a moral impossibihty in an Egyptian mind. 
 
 All learning was then confined to a caste, to Egyptian priests, 
 whose ideas on all subjects were tinctured largely with a species of 
 niystical religious philosophy. 
 
 The obscuration of htmian intellect did not escape their keen 
 perception, but it was interpreted by them to mean a divine afflic- 
 tion which was to be averted by sacrifices. 
 
 The mentally afflicted in those days were therefore taken to the 
 Egyptian temples, and they were there treated by the priests, accord- 
 ing to the manner of their peculiar religious practices, by oblations, 
 incantations, purifications, and sacrifices. 
 
 Some simple truth of wide application has always formed the 
 basis of philosopMc ideas, wliich have governed the world at all 
 periods of its history. The truth that good and evil exist in the 
 world, when elaborated in the highest Egyptian religious philosophy 
 and apphed to the insane, signified that they had become possessed 
 by a good or an evil spirit. This may be said to have been the only 
 principle of classification of Insanity at that time, and it was not 
 without decided indications for treatment. 
 
 If the spirit was diagnosed as an evil one it was to be driven out 
 by the most active religious proceedings, and the patient passed 
 through a heroic ordeal. On the other hand, if the spirit was a 
 good one, non-interference was the order of the day, and the patient 
 was treated with deference and even at times regarded as inspired. 
 
 Some of the earliest authentic cases of Insanity are related at 
 considerable length in the Bible. The histor\' of King Saul, 1063 
 
THE HISTORY OF INSANITY. 5 
 
 B.C., is probably the first recorded instance of homicidal mania. It 
 is related that he removed his clothes, and that he remained naked 
 by day and by night, and that he attempted to kill David by throw- 
 ing his javelin at him. David liimself, according to biblical account. 
 may be regarded as the first instance of feigned insanity, for when 
 he appeared before King Achish of Gath, according to the words 
 of the Bible, " he scrabbled on the doors of the gates, and he let 
 his spittle fall upon his beard," and the King ordered him from his 
 presence, exclaiming that he had no need that a fool should appear 
 before him. 
 
 Another remarkable case of Insanity was that of King iSTebu- 
 chadnezzar, who became insane 569 B.C. His disease took the form 
 of chronic mania of lycanthropic turn, and for years he wandered 
 in the woods and ate herbs, and his body became covered with an 
 extraordinary growth of hair, and his finger-nails grew to an ex- 
 treme length. The most astonishing point in the biblical history of 
 this case of Insanity is that ISTebuchadnezzar recovered his reason 
 after an attack of seven years' duration, and he was restored to his 
 throne as King of Babylon in the year 563 B.C. 
 
 Numerous other instances of mental disease are to be found 
 am.ong biblical records, but those above cited are sufficient to show 
 that at that earl}'' historic period Insanity was recognized in types 
 not essentially different from those of a later day. The Jewish idea 
 of the genesis of Insanity was theistie, and the priests were the 
 physicians of the soul, as they alone could intercede in behalf of 
 those inflicted from on high as an indication of divine wrath, or 
 possessed by a demon avenging some sin supposed to have been com- 
 mitted by the sufferer or by his progenitors. 
 
 In cases of Insanity complicated with epilepsy demoniacal pos- 
 session was almost invariably the diagnosis. 
 
 Among the early Hebrews the general treatment of the insane, 
 under the direction of the priests, was more humane than at many 
 subsec{uent periods. 
 
 The Oriental Indians, 1100 B.C., possessed considerable tradi- 
 tional medical knowledge. Their learning, however, Avas confined 
 strictly to a certain order of priests, and it was professedly of an 
 occult and mystical nature, so that it has been difficult to learn what 
 their belief and treatment were as regards mental disease, but it is 
 safe to presume that it did not diifer materially from the theories 
 and practices already mentioned as prevalent among the Egyptians. 
 
6 TEXT-BOOK ON MENTAL DISEASES. 
 
 The history of Insanity among the ancient Greeks takes a wide 
 range, and there is not space to recount here the numerous cases of 
 the disease mentioned by Greek poets, philosophers, and historians. 
 Sophocles and Euripides, Aristotle and Plato, Herodotus and Thucy- 
 dides, all refer in their writings to cases of Insanity. The poets 
 mention Ajax, Orestes, ffidipus, Hercules, Bellerophon, and Ulys- 
 ses, who feigned insanity. Then again, there was Cleomenes, King 
 of Sparta, probably the first recorded case of alcoholic Insanity, and 
 King Lycurgus, likely the first hmatic on record as having slain his 
 own son. Herodotus recounts at length the history of three sisters, 
 princesses and the daughters of Pretus, King of Argos, who became 
 insane simultaneously. They were cases of leprous Insanity, and 
 the mental symptoms took the form of lycanthropy, so that they 
 ran wild through the woods, making animal-like noises. Herodotus 
 further relates that they Avere cured by Melampus by the use of 
 veratrum album, and by bathing in a mountain-stream after they 
 had been chased by youths until they were in a state of profuse 
 perspiration. 
 
 The insane among the Greeks were still treated, as among the 
 Egyptians, by priests. The yEsclepiades constituted an hereditary 
 order of priesthood among the Greeks, and they had sole charge of 
 the temple of iEsculapius, to which the insane were conveyed for 
 curative purposes. 
 
 Solon (500 B.C.) made laws with reference to the insane, and he 
 defined those lunatics who were to be confined. 
 
 With the advance of Greek civilization at this period some of the 
 grosser superstitions with regard to lunatics were dispelled, and it 
 became recognized that they were still human and had certain rights 
 to be respected. 
 
 The Eomans, at a somewhat later period, made wise and complete 
 laws for the control of lunatics, and for the appointment of guard- 
 ians of their persons and estates, and they defined the insane to be 
 treated in thei^* awn hoiuses, and such as were to be confined " pro 
 bono publico." In lunacy, as in other matters, the Roman law was 
 so perfect a model as to have served as a basis of all subsequent legis- 
 lation on the subject. 
 
 During the long ages embraced in this first period of the history 
 of Insanity there had been a gradual evolution of medical knowl- 
 edge. Egyptians, Oriental Indians, Turks, Persians, Greeks, and 
 ]iomans had all contributed something to the common fund of med- 
 
THE HISTORY OF INSANITY. 7 
 
 ical lore which, at the close of this first period (400 B.C.), may be 
 said to have attained to the respectable dimensions of a science of 
 medicine. The most crude part of this science, however, was psy- 
 chiatry, in spite of the fact that in all ages it had been studied by 
 the most learned men, by philosophers, priests, and physicians. 
 
 The nomenclature of Insanity was limited to the three terms, 
 phrenitis, mania, and melancholia. Phrenitis applied to mental dis- 
 order with inflammation of the brain or other internal organs. The 
 etiology of Insanity was based on vague views of changes in the bile, 
 nmcus, and other secretions. The treatment was by hygienic means, 
 outdoor games, baths, mineral waters, and a few simple therapeutic 
 remedies, apart from the religious practices on the part of the 
 priests. 
 
 Second Period {JfOO B. G.—200 A.D.). The First Scientific Evolutionary 
 Period of Psychiatry, Ending with the Decline of the Greek School 
 of Medicine. 
 
 The beginnings of psychiatry having been made by many peoples 
 in various lands, the time was now ripe for some master hand to 
 mould the crude material thus contributed into some definite shape, 
 and the genius for the work arose in no less a person than Hippoc- 
 rates, the Father of Medicine, himself, who laid the first founda- 
 tions of the science of psychiatry. 
 
 Hippocrates was born 460 B.C., in the island of Cos. His teach- 
 ings as to Insanity are not given collectively, but they are to be 
 found scattered throughout his wonderful clinical descriptions of 
 diseases in every domain of medical practice. 
 
 With but slight knowledge of the anatomy of nervous centres, 
 he still conceived that the brain was the seat of Insanity. He recog- 
 nized acute and chronic forms of mental disease. He spoke of the 
 latter under the use of the terms mania and melancholia, and 
 to the former he applied the word phrenitis, which he also used to 
 describe Insanity with cerebral or visceral inflammation. 
 
 It is evident from his clinical descriptions that he was familiar 
 with puerperal, alcoholic, and epileptic forms of mental disorder. 
 His depictions of insane symptoms bore the stamp of everlasting 
 truth, so that to-day, twenty-three hundred years after they were 
 written, they might be applied to cases of mental disease with truth- 
 ful fitness. 
 
8 TEXT-BOOK ON MENTAL DISEASES. 
 
 In liis views of the nature of Insanity he was a humoral patholo- 
 gist. Though descended from the ^sculapian order of priests 
 he completely emancipated himself from their superstitious views. 
 Ht: keenly ridiculed their religious observances in the treatment of 
 Insanity, and he boldly declared that epilepsy was not a sacred dis- 
 ease (mal sacer), or an infliction by the gods, as was then believed. 
 His genius did not enable him, however, to rise above philosophic 
 heights, for, though he ignored the priests, he agreed with the phil- 
 osophers in locating Insanity sometimes as a disease of the soul 
 ■wliich resides in the head, and at other times as a disorder of the soul 
 which, it was taught, had its habitat in other parts of the body. It 
 is to be borne in mind that philosophy at that time embraced and 
 controlled all branches of human knowledge. 
 
 Hippocrates employed in the treatment of Insanity bleeding, 
 purging, emetics, counter-irritants, mineral waters and baths, gym- 
 nastics and outdoor games, together with music, travel, and change 
 of climate. 
 
 In general, it may be said that Hippocrates had humane and, for 
 his time, remarkably advanced ideas of the treatment of the insane. 
 
 Following Hippocrates, the physicians for the next two centuries 
 would seem to have simply pursued imperfectly the maxims of the 
 Father of Medicine in psychiatry. 
 
 During the Alexandrian period of medicine, judging from sub- 
 sequent citations by Galen of the writings of Herophilus and Erasis- 
 tratus (300 B.C.), no special additions would seem to have been made 
 to the knowledge of mental disease. It would appear, however, that 
 Erasistratus was gifted with perspicacity in defending the doctrine 
 that the superficial parts of the brain were especially concerned in 
 intellection, and might be taken as a measure of the degree of indi- 
 vidual intelligence. 
 
 Asclepiades of Bithynia (circa 100 B.C.) was a bold and original 
 writer, and he did not even hesitate to differ from the views of Hip- 
 pocrates in certain respects. He had just conceptions of the deriva- 
 tion of disease from bad water, food, and air, and he attached much 
 importance to hygienic conditions in treatment. He made a clear 
 distinction between mental disease with and without fever. He 
 observed the transformation of one form of Insanity into another, 
 and he made a special study of the deranged perceptions of the in- 
 sane. In his treatment he discarded dark rooms and bleeding; and 
 he used poppy, henbane, sun baths, inunctions, and water-cure — es- 
 
THE HISTORY OF INSANITY. 9 
 
 T3ecial]y cold baths. His enthusiasm in the doctrine of the transfor- 
 mation of one type of mental disease into another led him into some 
 inconsistency in the use of intoxication to convert incurable into 
 curable forms of Insanity. He seems to have made a somewhat free 
 use of mechanical restraint, and he added nothing to the terminol- 
 ogy of the subject, but employed the terms phrenitis, mania, and 
 melancholia, then in common use. 
 
 Titus Aufidius of Sicily (44 B.C.) was a student of Asclepiades, 
 though he does not appear, to say the least, to have improved upon 
 his master's teachings. He seems to have believed that the insane 
 retained, to a considerable degree, their free will and responsibility, 
 and that their efforts at self-control might be materially aided by 
 se^'ere measures. He accordingly favored deprivation of food and 
 drink as punishment, and he even prescribed flagellation in extreme 
 cases. In order to make a pleasurable change in the organic emo- 
 tions he occasionally recommended sexual indulgence in melan- 
 cholia. 
 
 Celsus (25 B.C. — 45 a.d.) considered Insanity to be due to perver- 
 sion of the secretions. The doctrine of heredity had not yet come 
 into vogue. He distinguished between Insanity with and without 
 fever, and divided it into acute and chronic forms, which were par- 
 tial or general in type. He was acquainted with the hallucinations 
 of the insane and described them. He attached great importance to 
 individual differences in patients and the treatment to be given 
 them, and he gave complete instructions for the hygienic and moral 
 measures to be employed. Exercise in the open air, bathing, music, 
 reading, the removal of fear by kindness or by deceit, if necessary, 
 were some of his resources. Other measures which he deemed reme- 
 dial were decidedly harsh, and consisted in restraints and even severe 
 punishments of various kinds, to subdue violent cases of mental dis- 
 ease. 
 
 Aretfeus of Cappadocia (30 — 90 a.d.) gave remarkably correct de- 
 scriptions of alienation under the terms mania, melancholia, and 
 chronic insanity, all of which he regarded as forms of one disease, 
 the melancholia forming the introductory stadium. He differen- 
 tiated Insanity from the effects of drugs, and he distinguished paral- 
 ysis of sensation from paralysis of motion. He described the height- 
 ened recollection of some acute maniacs, the fixed ideas of the insane, 
 and the erotic forms of mental disorder, especially satyriasis. He 
 advocated the use of emetics, bleeding, and a variety of drugs, and 
 
10 TEXT-BOOK ON MENTAL DISEASES. 
 
 he regarded the moral treatment as of much importance, and change 
 of scene and climate as beneficial to convalescents. His therageusis 
 related particularly to the bodily functions, the perversions of which 
 in Insanity he described with the greatest precision. 
 
 Coelins Aurelianus (100 a.d.) had most humane and enlightened 
 views as to the moral treatment of the insane. He is the first his- 
 torical defender of the system of non-restraint, and of the control 
 of patients by nurses instead of by mechanical means. He de- 
 nounced the iron chains and other crude apparatus then in use for 
 the restraint of lunatics. He studied, with considerable success, the 
 false beliefs of the insane and the relation of visceral disease to 
 mental depression. He conceived melancholia to be most often due 
 to gastric disorder and mania to cerebral disease. He clearly differ- 
 entiated the delirium of fevers from true Insanity. He believed in 
 a generous diet for the insane and in occupation of a dustomary kind, 
 such as agriculture for farmers and boating for seafaring patients. 
 It is not improbable that he borrowed largely in his ideas from 
 Soranus of Ephesus, whose works he translated. 
 
 Menodotus of Mcomedia (100 a.d.) appears to have been a good 
 clinical observer of Insanity, and of the relations between causes 
 and symptoms. He seems to have been about the first author to 
 comprehend and definitely state the relation between traumatic in- 
 juries and mental disease. His observation was that trauma capitis 
 gave rise to mania. 
 
 Galen (131 — 201 a.d.) represented the culmination of the science 
 of medicine in the Greek school, and, next to Hippocrates, he was 
 the greatest of the medical writers of antiquity. He made a noso- 
 logical division of mental diseases into mania, melancholia, demen- 
 tia, and imbecility. He made a decided advance in the definition 
 of Insanity with native defects of mind. 
 
 The pathology of mental disorders, according to him, was by 
 sympathy and in connection with disease of internal organs chiefly. 
 He gave lengthy and often most excellent descriptions of the sjrmp- 
 toms of Insanity. He described the insane temperaments, the differ- 
 ent forms of lycanthropy, and the difference between fever deliriums 
 and Insanity. He had an extensive armamentarium of drugs for 
 the treatment of mental diseases, and a great variety of baths, also 
 gymnastics and massage, with inunctions, after the manner of the 
 Romans. He also recommended music, poetry in recitations, theat- 
 rical performances, and in general humane moral treatment. 
 
THE HISTORY OF INSANITY. 11 
 
 Like all the medical men of his day, he was imbued with the 
 prevailing philosophic ideas, and he shared Aristotelian views as to 
 two souls symbolic and correlative of the two great elemental con- 
 ditions of heat and cold, which he believed to be accompanied by 
 corresponding disordei"S of mania and melancholia. In fine, it may 
 bo said of this remarkable man that he fully reflected in his writings 
 all the most advanced knowledge of his times, and also made some 
 real additions to psychiatric science as it then existed. 
 
 Third Period {200 A.D.—1500 A.D. The Dormant Period of Psychia- 
 tric Science Continuing Through the Middle Ages to the Renaissance. 
 
 Psychiatry under the Greek school had attained to the dignity 
 of a science, so far as the knowledge of the symptoms, diagnosis, 
 prognosis, and treatment of mental diseases was concerned, but after 
 the decline of the Greek school much of that which was known was 
 forgotten or perverted. Pneumatists, dogmatists, empiricists, meth- 
 odists, and other medical sects arose and discussed with partisan 
 feelings such worthless technical theories as have always been the 
 bane of true medical science. 
 
 With the invasion of Eome by the Goths, and of the centres of 
 civilization by hordes of northern barbarians, there was a general de- 
 cline of all lands of learning. Forms of pseudo-science arose and 
 began to exert an influence on medical beliefs and practice, such as 
 alchemy and astrology, and, much worse still, theosophy and necro- 
 mancy and every form of charlatanrj' came to abound in all parts 
 of the earth. To complete the misery of mankind, plague, pesti- 
 lence, and famine spread in different sections of the world, and the 
 number of lunatics was increased. The insane wandered or were 
 driven from place to place, and many of them perished by the way, 
 of neglect and starvation. Some of them found shelter in convents, 
 where they were free from persecution, but not always from severity 
 of treatment, which had again come to be regarded as a necessity in 
 dealing with the more excited cases. 
 
 In the midst of the darkness of ignorance and superstition which 
 had overspread the world there were still here and there individuals 
 who carried the true knowledge of a past medical science, and some 
 of these will now be named. 
 
 Oribasius of Pergamus (circa 370 A.D.), who was physician to the 
 Emperor Julian, appears to have had considerable knowledge of In- 
 
12 TEXT-BOOK ON MENTAL DISEASES. 
 
 sanity and to have written some upon the subject. He described 
 especially an epidemic of melancholia which had symptoms of a 
 lycanthropic type. 
 
 Alexander of Trolles (560 a.d.) wrote some commendable things 
 about Insanity, but he seems merely to have copied some of the tra- 
 ditions of the Greek school, and to have added nothing of special 
 value to the subject. He considered the moral treatment to be of 
 great importance, and he maintained ingenious ways of combating 
 the delusions of the insane, and resorted to emotional shocks, and 
 practised various forms of deception for the sake of the moral effect 
 which could thus be produced. He deemed abstinence from food 
 and mineral waters to be efl&cacious means of treatment. 
 
 Paul of Egina (630 a.d.) was a physician of original talent, and 
 distinguished through his writings upon diseases of women. He 
 would seem to have had a very good knowledge of the mental dis- 
 turbances which attend the puerperal state. 
 
 Eliazes (850 — 923 a.d.), like many of his predecessors, regarded 
 visceral disease as the chief source of Insanity. He had the aptitude 
 of the Arabian medical school for the selection of a great diversity 
 of drugs in the treatment of mental disorders. The only novelty 
 in the moral treatment which he introduced was the game of chess, 
 which he considered a mental discipline as well as a diversion par- 
 ticularly useful in melancholia. 
 
 Ali Abbas (obiat 994 a.d.) added nothing new to psychiatric 
 knowledge, with the single exception that he described clearly the 
 depressive forms of mental aberration which arise at the age of 
 puberty. 
 
 Mondini de Luzzi of Bologna (1315 a.d.) made anatomical 
 demonstrations on animals, and stimulated others to research in the 
 same direction in a way which tended to throw future light on the 
 study of mental disease. It was one of the first rays of ligl^ which 
 foretold the coming dawn of another era of medical science. 
 
 Antonio Guaineri (obiat 1447 a.d.) rose above the superstition 
 of his day in regard to lunatics and rejected their treatment by 
 exorcism and the idea of demoniacal possession. He was a physi- 
 cian of remarkable diagnostic acumen, and was the first to de- 
 scribe aphasic conditions. He also made the perspicacious observa- 
 tion that imbeciles, during attacks of acute mania, manifested 
 unwonted intelligence and astonishing activity of memory. He fur- 
 ther noted the clinical connection between gout and Insanity. He 
 
THE HISTORY OF INSANITY. 13 
 
 made a free use of caustics and counter-irritants in the treatment 
 of mental disease. 
 
 To turn once more from the writers on Insanity to the actual 
 state of the insane during these dark ages of the world, it is to be 
 remembered that the enlightened views of the Greek school as to 
 the origin and treatment of mental disorders died out gradually 
 after the third century of the Christian era, and the reign of ig- 
 norance and superstition in regard to lunatics had become general. 
 The insane were regarded everywhere as afflicted by the gods or pos- 
 sessed by the Devil or his attendant imps, their symptoms were 
 mistaken for wilful demonstrations of wickedness, and they were 
 treated accordingly in prison cells, or in cells attached to the cloisters 
 under the care of the priests. The Middle Ages were the dark ages 
 of psychiatry. Epidemics of Insanity occurred, and thousands of 
 lunatics wandered about in neglect and terrible suffering, as all doors 
 were closed and all hands were raised against them, since they were, 
 as taught and believed by many, deserted of God Himself and de- 
 livered over to evil spirits as a punishment for imaginary sins which 
 they often confessed. To complete this chapter of horrors there 
 arose anew, out of the cruel animal depths of human nature, the 
 fanatical and diabolical belief in witchcraft, and an eagerness to 
 persecute and kill those accused of it. It was not all witchcraft. It 
 was the opportunity to seek revenge upon enemies — it was the grati- 
 fication of a brutal and instinctive delight in the infliction of suffer- 
 ing — it was the vicarious escape of that pent-up and unformulated 
 feeling of injuries sustained and wrongs unrighted which is ever 
 latent in the heart of the populace, and always ready to be poured 
 forth upon any suspected victim. The same tendency to fix upon 
 some person the responsibility for present evil, and to cause the 
 selected victim to suffer in proportion to the general amount of 
 wrong supposed to have been done, has existed in all ages and among 
 all peoples. In this sense the Egyptians, the Indians, the Persians, 
 the Arabs, the Greeks, and the Eomans had their belief in sacrificial 
 victims, sorcery, and witchcraft, which was handed down by tradi- 
 tion, like an evil heirloom, to the Middle Ages. It is estimated that 
 not less than 100,000 persons were tormented or burned to death 
 as witches from 1400 to 1700 a.d., and that of this number not less 
 than 30,000 were insane at the time they were accused and executed. 
 
 Perhaps the earliest record of special places for the accommo- 
 dation of the insane is to be found among the Turks, before the 
 
14 TEXT-BOOK ON MENTAL DISEASES. 
 
 f ourteentli century. At Eome and other places in Italy, as early as 
 1300 A.D., places for -the conhnement of lunatics had existed. It 
 was during the fourteenth century that structures for the reception 
 and treatment of the insane were set apart in Italy at Florence, 1389 
 A.D., and from 1400 — 1500 a.d. at Feltre, Seville, Padua, and also 
 several in Spain — 1408 a.d. at Valencia, and at Saragossa 1425 a.d. 
 
 In 1403 A.D., lunatic patients were first received at Bethlehem 
 Hospital, London, England, though that hospital was first formally 
 devoted to the care of the insane in 1547 a.d. 
 
 In 1472 there was a special place for lunatics in Ghent, in Bel- 
 gium, and at Gheel the insane were cared for at a very early period. 
 
 It is true that all these places were custodial rather than curative, 
 and that they were not conducted with a true understanding of 
 Insanity as a brain disease, to be treated and cured like other dis- 
 eases, but they represent the crude beginnings of that better system 
 of hospitals for the insane which has since been inaugurated in all 
 parts of the civilized world. The darkest hour in the history of the 
 insane had now passed and the dawn of a better day was approa;Ching. 
 
 Fourth Period {1500 A.D. to 1800 A. D.). The Second ScientHic Evolu- 
 tionary Period of Psychiatry, from the Renaissance to the Present 
 Day. 
 
 Medicine as a science has always been dependent for its advance 
 on the allied sciences and on the development of general knowledge. 
 At the period here mentioned it underwent a rapid evolution, in sym- 
 pathy with the general revival of knowledge, science, art, and liter- 
 ature. The dormant period, the night of the dark ignorance of the 
 Middle Ages, had passed, the Eenaissance was the dawn — and the 
 reawakened human intellect once more resumed its onward march. 
 All branches of medicine were investigated with great zeal, and 
 prominent physicians in all the principal European countries stud- 
 ied and wrote about mental diseases. 
 
 The mention of the chief writers and the leading points in their 
 teachings will suffice to sketch the evolutionary course of psychiatry 
 during this period. 
 
 F. Platter (1536 — 1614) made a profound study of mental dis- 
 eases and wrote a treatise on the subject. He was the first systematic 
 nosologist, and made a complete classification of mental disorders, 
 
THE HISTORY OF INSANITY. 15 
 
 and he added much to the knowledge of symptoms and to orderly 
 methods of their study. 
 
 Paul Zacchias (1584 — 1659) wrote the first complete treatise on 
 the medico-legal relations of Insanity, and he discussed therein the 
 responsibility of the insane, their civil capacity, the question of lucid 
 intervals, and a great variety of subjects of juridical interest in con- 
 nection with mental disorders. 
 
 Prosper Alpin (1553) studied the symptoms of Insanity with 
 much care and described them well in his writings, which contain 
 some good suggestions as to water-cure in mental diseases, especially 
 the warm bath with cold effusions to the head in acutely maniacal 
 cases. 
 
 V. Chiarrugi (1759) advocated humane treatment of the insane 
 and the non-restraint system. He wrote good clinical descriptions 
 of Insanity in his treatise, which appeared in the year 1794. 
 
 Stahl (1660 — 1734), the originator of the theories of the German 
 Psychological School, was largely influenced by metaphysical and 
 philosophic ideas in his belief as to Insanity, which he held to be 
 an affection of the soul, which, as the immortal part of man, could 
 not be subject to physical disease. Insanity was, according to his 
 teachings, a spiritual disorder. Langerman and Ideler, his followers, 
 elaborated these theories at length in their writings on Insanity. 
 
 Heinroth (1773 — 1840), the most representative writer of this 
 psychological school, taught in Leipzig to enthusiastic students that 
 all Insanity was the result of the violation not of physical but of 
 spiritual law; that the influence of spirit upon matter was supreme; 
 that conscious sin causes all the sjTuptoms of mental disorder, which 
 could only be cured by faith, hope, forgiveness sought from the 
 Divine source whence the disordered spirit first emanated. Heinroth 
 ignored completely the etiological influence of heredity in mental 
 diseases. On the other hand, he analyzed, with great precision, 
 the mental faculties and the various disorders which they undergo 
 in Insanity. 
 
 In contradistinction to the Psychological School there arose 
 about this time in Germany the Somatic School, with notable ad- 
 herents like l!Tasse, Friedreich, Vering, Jacobi, and other prominent 
 medical men. They taught, in diametrical opposition to the spir- 
 itualistic theories, that Insanity was of purely physical origin, and 
 that it sprang from disease of internal organs, and some even went 
 to the extreme of the grossest materialism in declaring that the 
 
16 TEXT-BOOK ON MENTAL DISEASES. 
 
 mind was little else than a functional secretion of tlie brain, as the 
 bile was of the liver. 
 
 The teachings of this Somatic School led to a much more thor- 
 ough research for the bodily causes of mental disorder, and also 
 resulted in more scientific study of somatic symptoms and of the 
 morbid anatomy of the disease. 
 
 Thomas Willis (1622 — 1675) did much to lay an anatomical basis 
 for mental science. He recognized Insanity to be the result of brain 
 disease. He also observed stupor and cyclical mental disorder. He 
 employed heroic treatment by powerful drugs and mental shocks, 
 and unfortunately did not hesitate to use severe punishment in vio- 
 lent cases. 
 
 Yieussens (1641 — 1720) also did much to advance the idea of 
 anatomical study in psychiatry. He wrote upon the neuroses and 
 ranked Insanity among them. 
 
 Boerhaave (1668 — 1738), whose writings had a wide influence, 
 taught the humoral pathology of Insanity, and described the stupor- 
 ous forms of mental depression and gave good directions for the 
 hygienic treatment of mental disorders. 
 
 Denis, in Paris, 1667, practised transfusion with success in a case 
 of melanchoHa. He tried transfusion of lamb's blood in a ease that 
 had been excessively bled in 1668 without success. 
 
 Bonet (1700) resorted to a like surgical remedy in Insanity and 
 aided in the study of the pathological anatomy of mental disease. 
 
 Sauvage (1706 — 1767) made the most complete classification of 
 Insanity thus far attempted according to natural history meth- 
 ods of division, and made a decided scientific advance in treating 
 Insanity as a neurosis. He well illustrated the pertinacity of philo- 
 sophic ideas, for, although he was of a thoroughly scientific turn 
 of mind, he still harbored many of Stahl's animistic and metaphysi- 
 cal theories. 
 
 Cullen (1712—1792) occupied in England a place corresponding 
 to that of Sauvage in France as a systematic nosologist. He also 
 contributed much to the pathological anatomy, etiology, and symp- 
 tomatology of mental diseases. 
 
 Brown, a student of Cullen's, particularly developed the idea of 
 the asthenic nature of Insanity'- '^nd classed most cases under this 
 single term — aesthenic. 
 
 Andrew Marshall (1742 — 1813) drew attention in his writings to 
 the etiology of Insanity from vascular and cerebral lesions. 
 
THE HISTORY OF INSANITY. 17 
 
 Mason Cox (1762 — 1822) described cerebral hypersemia as the 
 chief pathological factor in mental disorders. 
 
 Cricliton (1763 — 1856) wrote of the psychosomatic origin of In- 
 sanity from powerful passions, as well as from bodily disease, and 
 justly enlarged upon the influence of heredity. 
 
 Haslem (1764 — 1844) deserved credit for his autopsical studies 
 and his contributions to the subject of the morbid anatomy of men- 
 tal disorders. 
 
 Arnold (1786) wrote a treatise on Insanity from the point of 
 view of mental philosophy, giving especially logical descriptions of 
 the psychical symptoms of the disease. 
 
 I Thus it is seen that active and able men had studied the subject 
 of Insanity from many points of view. They had practically ex- 
 hausted every resource of human knowledge in endeavors to solve 
 its difficult problems. They had summoned to their aid the highest 
 religious and spiritualistic doctrines, the most thorough clinical 
 study of mental and bodily symptoms, philosophic theories, chemi- 
 cal, physiological, and anatomical researches, the sympathy of the 
 nervous system, disease of internal viscera, post mortem appear- 
 ances, changes in the blood and other secretions, malarial disease, 
 heredity, and a host of other considerations, in their strenuous efforts 
 to build up a science of psychiatry. Individual contributions to this 
 common end have been now sketched as far as space for this purpose 
 will permit, and if the reader, seeking fuller information, will turn 
 to the chapter on Nosology, he will find further facts and an analysis 
 of the nosological part of the works of the more recent authors. 
 
 Throughout this fourth period (1500 — 1800) there had been a 
 gradual amelioration in the general condition and treatment of the 
 insane. In the year 1660 wards were set apart in the Hotel Dieu, 
 Paris, for the care of the insane. A large lunatic asylum was built 
 at Moorfields, England, in 1675, and another one at Avignon, 
 France, in 1681. 
 
 In 1751 the act creating Pennsylvania Hospital, Philadelpliia, 
 Pa., was passed, providing for a department for the reception and 
 care of lunatics. 
 
 In 1773 the first American asylum for the insane was constructed 
 at Williamsburg, Va. 
 
 Daquin, in France, 1792, strongly denounced restraint and harsh 
 treatment of lunatics. 
 
 William Tuke, of the Society of Friends, in England, 1792, ad- 
 2 
 
18 TEXT-BOOK OX MENTAL DISEASES. 
 
 vocated humane methods, and founded the York Eetreat, which was 
 not formally opened until some years later, in 1796. 
 
 Phillipe Pinel (1?55 — 1826) worked his great reform in behalf 
 of lunatics at the Bicetre in 1793. 
 
 Benjamin Paish at this date also spent some of the force of his 
 genius in attempts to better the condition of the insane in America. 
 
 Dr. Fricke, 1793, is said to have reduced the amount of restraint 
 and to have improved the condition of patients in the asylum in 
 BrunswicJc, and at a somewhat later date Langerman reformed the 
 asylum at Bayreuth, and Dr. Glawnigs is credited with exertions at 
 this time to ameliorate the treatment of the insane and to employ 
 them in agriculture. 
 
 Esquirol made his appeal to the French ^linistry in behalf of 
 the insane and worked his renowned reform in 1818. 
 
 Guislain labored to better the state of the insane in Belgium at 
 Ghent in 1828. 
 
 Gardiner Hill, practically through his single efforts, abolished 
 restraint in the Lincoln Asylum, England, in 1837. 
 
 Conolly followed, with his bold and wholesale abolition of every 
 kind of restraint, and he deserves, and has always received, credit 
 for his uncompromising combat in this direction. 
 
 In England much wise and humane legislation for the welfare 
 of the insane was brought about by the Earl of Shaftesbury. 
 
 In Germany Hayner made a pubhshed appeal for the abolition of 
 the more cruel forms of restraint in 1817. 
 
 Since the events above mentioned there has been in Europe, 
 Great Britain, and America a gradual but constant improvement in 
 the general condition and treatment of the insane. In all these 
 countries large numbers of special hospitals, thoroughly appointed 
 for the care and cure of the insane, have been constructed, and they 
 are now administered in accordance with the most modern ideas. 
 
 It is, of course, a most complicated and difficult question for 
 political economists, and for social and medical scientists, to decide. 
 whether the present hospital system is the best and final solution 
 of the problem of provision for the constantly increasing numbers 
 of the insane requiring public care. It is the author's belief that 
 some radical innovations and changes in the present system will 
 ultimatelv be made. 
 
CHAPTER IL 
 
 THE STATISTICS OF INSANITY. 
 
 General Principles of Statistics as Applied to Insanity and 
 Errors to be Avoided. — The difficulty in the application of the statis- 
 tical principle to the solution of the problems of psychiatry lies not 
 in any inherent deficiency of the science of statistics, but in the 
 erroneous methods of its use in the study of mental disorders. 
 
 Uniform methods of statistical returns have not been employed 
 in the various institutions for the insane throughout the country, 
 and the difficulty of obtaining comparable data for statistical de- 
 ductions is the obstacle to the student of mental science from a 
 statistical point of view. Thus the recovery-rate has been variously 
 calculated on the total numbers treated, on the discharges, on the 
 supposed curable cases, and on the average number resident for the 
 year, and on the number of admissions. Like differences exist in 
 the methods of calculating the death-rate. These discrepancies be- 
 come still more marked in attempts to compare the statistical infor- 
 mation of different countries. 
 
 The prime question of the relative amount of Insanity in differ- 
 ent countries cannot be accurately determined, because the returns 
 are much more complete in some countries than in others. 
 
 In order to determine the actual increase or decrease of Insanity 
 in a countr}'- it does not suffice to compare the total numbers of 
 insane at two different periods with the total general population 
 at those periods. 
 
 The improved care in modern institutions for the insane tends 
 to prolong life and to diminish the annual mortality, so that there 
 is a constant accumulation of chronic cases of mental disease to be 
 carried forward in all calculations of this kind. The true principle 
 for the calculation of the actual increase of Insanity is to determine the 
 ratio of the neio cases of mental disease to the mean of the general popu- 
 lation living at the time of the occurrence of these first attacks. 
 
 19 
 
20 TEXT-BOOK ON MENTAL DISEASES. 
 
 In the application of this principle in returns from institutions 
 for the insane^ first admissions and not readmissions should be con- 
 sidered, and persons must be distinguished from cases, and it is to be 
 borne in mind that first admissions do not invariably accord with 
 first attacks, which may have occurred prior to admission. 
 
 In comparing the existing number of cases of Insanity, in differ- 
 ent countries or different sections of the same country, with the 
 general population a common error has been to determine simply 
 the percentage of the occurring cases to the general population in 
 the two localities, but a wide difference in the mortality of the cases 
 which have occurred may vitiate the conclusion. To avoid error the 
 number of deaths must first be taken out of the total number of 
 cases arising during the period in question, in order to determine 
 the total remainder of existing cases and the true terms for com- 
 parison. 
 
 Correct Basis for Tabular Returns from lastitutions for the In- 
 sane. — The rate of recoveries has been calculated upon the average 
 number resident in some English institutions, and in applying this 
 method to a series of years the annual percental recovery-rate mul- 
 tiplied by the average length of residence in all cases admitted dur- 
 ing the time gives a percentage of recoveries not greatly different 
 from that calculated upon the total admissions during the same 
 period. The length of time patients are under treatment must be 
 taken into account in this method, and if this average length of 
 residence were the same for all institutions there would be less objec- 
 tion to this mode of calculation. The proportion of recoveries has 
 also been calculated on the discharges, but this gives a slight excess 
 over the percentage of recoveries estimated on the admissions during 
 a series of years, and this excess is most marked in the early periods 
 of institutional existence. The recovery-rate may be calculated upon 
 the supposed curable cases, but in the long run this does not give 
 a very different result from that based on the total admissions. 
 
 The correct basis for this return of recoveries is the percent- 
 age obtained from the total annual admissions. It is true that 
 this percentage of recoveries calculated on the admissions is too 
 small in the first period of an institution's history, and naturally 
 increases with its age, and that patients admitted and practically 
 cured toward the close of the year are often not credited as recoveries 
 of the year, but eventually it is the most correct method of calculat- 
 ing the recoveries. 
 
THE STATISTICS OF INSANITY. 21 
 
 The mortality has been calculated incorrectly by some on the 
 admissions or discharges. The element of time, which is all impor- 
 tant in a chronic disease like Insanity, is here left out of the calcu- 
 lation; whereas, in any community the death-rate is only indicated 
 by the total deaths among a given number of people living a given 
 length of time, as, for instance, the percental number of deaths in 
 10,000 inhabitants during a year. 
 
 ^_ The correct calculation of the mortality must be bafied on the an- 
 nual average number resident. Even this method leaves the ques- 
 tion of age out of consideration, and it is well known that the mor- 
 tality-rate increases decidedly with advancing years, and the average 
 ages of patients in different institutions might vary sufficiently to 
 affect the mortality-rate. A still more correct estimate, therefore, 
 might be based on the proportion of deaths at each age compared 
 with the average number living at that age. 
 
 The average number resident during the year should be calculated 
 from a census book giving the number present for each day of the 
 year, and the grand total or sum of the numbers for the year divided 
 by 365 will give the average number resident. In the absence of 
 such a census-book a weekly or monthly record, showing the num- 
 bers present, will suffice; the divisor in this case will be 52 or 12 
 respectively; and where no census or other record of numbers pres- 
 ent has been kept by the week or month the average for a series 
 of years may be nearly ascertained when calculated on the total num- 
 bers remaining at the end of each year. 
 
 Thurnam, on " Statistics of Insanity," p. 18, says: "Where no 
 register of the number of patients at intervals not exceeding a month 
 or a quarter of a year has been regularly kept, the only method of 
 ascertaining the average number is the laborious one of extracting 
 from the register of patients and adding together the exact duration 
 of time passed in the house during the entire period by each person 
 admitted, and then dividing the total by the number of which such 
 period consists." 
 
 Tuke says that by the multiplication of the average number resi- 
 dent in an asjdum by the number of years it has been opened the 
 years of insane life passed therein are calculated; and he gives the 
 following formula for calculating the average duration of residence, 
 viz.: Average number resident, x years of operation -j- number ad- 
 mitted = average duration of residence. 
 
 As the recovery-rate and the death-rate tend to increase with 
 
22 TEXT-BOOK OX MENTAL DISEASES. 
 
 the lapse of years in hospitals for the insane, it is evident that only 
 statistics extending over a considerable period of time in any one 
 institution from the time of its first opening are fnlly reliable. 
 
 As age is such an important factor in both the recoveries and 
 the mortality, and also in order to institute comparisons Avith the 
 general population, all the returns mentioned should be calculated 
 by quinquennial periods as well as by the average of the total age 
 periods. 
 
 Every hospital for the insane should keep the most complete 
 records of all patients and furnish, for statistical or other purposes, 
 tables as to date of admission, causes of Insanity, forms of mental 
 disease, percentage of recoveries and deaths, causes of death, num- 
 ber of admissions, hereditary tendency, civil condition, degree of 
 education, duration of Insanity previous to admission, and the period 
 under treatment of the recoveries and of those discharged not re- 
 covered, and of those who died, ages of all discharged or died, dura- 
 tion of Insanity previous to admission, occupations, nativity of pa- 
 tients and of their parents, sex, color, and personal description, 
 bodily diseases, and bodily weight. All such extensive and accurate 
 individual records are of great value for special statistical studies. 
 
 The main object of statistics is to present, however, information, 
 condensed by the exercise of special judgment and sldll, for objects 
 of general comparison on a broad scale, and for the deduction of 
 general conclusions, and any attempt to improve their value by the 
 introduction of largely specialized particulars will alwaj^s defeat 
 its own object. Where vast numbers of cases, accurately re- 
 corded by skilful observers, are concerned individual exceptions 
 and particular differences equalize themselves and disappear before 
 the force of grand averages, and do not impede the discovery of 
 general laws, which are the real objects of statistical research. 
 
 Total Numbers of Insane — European, British, and American Figuns. 
 
 The statistical figures and information under this head are de- 
 rived chiefly from the latest United States census report prepared 
 by Dr. J. S. Billings, expert special agent of the Census Office. 
 The number of insane and idiots to 100,000 of the general popula- 
 tion was: For the IFnited States (1890), .323; for England and Wales 
 (1891), 336; for Scotland (1891), 384; for Ireland (1891), 450; 
 
THE STATISTICS OF INSANITY. 23 
 
 for Austria (1890), 217; for Prussia (1880), 243; and for France 
 (1S79), 252. 
 
 Omitting idiots, the actual number of the insane to 100,000 of 
 the general population, reported by census in different countries, has 
 been as follows: For United States (1890), 170; for England and 
 Wales (1881), 199; Scotland (1891), 259; Ireland (1891), 317; Austria 
 (1880), 135; Hungary (1880), 81; France (1876), 124; Italy (1871), 
 98; Prussia (1871), 87; Bavaria (1871), 98; Saxony (1875), 84; Den- 
 mark (1871), 138; Norway (1865), 185; and Sweden (1870), 176. 
 There has been a constant increase of the proportion of the insane 
 to the general population in all civilized countries, but whether this 
 is due to more complete census reports, to a gradual accumulation 
 of chronic cases, to diminished death-rate, and to the wider recog- 
 nition of cases of Insanity by medical men, or to a veritable increase 
 in the total amount of Insanity is difficult to determine positively. 
 There can be but little doubt, however, that there has been a posi- 
 tive increase in the proportion of Insanity in most countries, to be 
 etiologically ascribed in the main to alcoholic excess, specific disease, 
 and general paresis. There can be no question but that the increase 
 in Ireland is real if there be no mistake about the figures reported 
 as per 100,000 of population in 1881, 188; and in 1891, 317. The 
 total number of insane reported in the United States, June, 1890 
 (including Chinese, Japanese, and Indians, ^31 in all), was 106,485^ 
 or a ratio of 170.0 to each 100,000 of living population at that date. 
 In 1880 the total number was 91,959, and the ratio per 100,000 
 183.3. In 1880 physicians made special reports of seventeen per 
 cent, of the total numbers, but for the census of 1890 they failed td 
 make special returns, and this accounts for the apparent decrease in 
 the ratio. Of the total 106,254 insane (exclusive of 231 Japanese, 
 Chinese, and Indian insane) 99,719 were white, and 6,535 were col- 
 ored. Among the whites 64,419 were natives, and 35,300 were for- 
 eign born. Out of every 1,000 of the insane whites in 1890, 581,1 
 were born in the United States of native parents; 64.9 had one or 
 both parents foreign bom, and 354.0 were born foreign. 
 
 The ratio of the insane for 100,000 of the living population, 
 1890, was 387.0 for the foreign born whites, 140.5 for the native 
 whites, and 86.6 for the colored. It is thus evident that the propor- 
 tion of insane is much less among the colored and very much greater 
 among the foreign than the native white, in part due to the excess 
 of adults at the viilnerable age among the foreign population. It 
 
24 TEXT-BOOK ON MENTAL DISEASES. 
 
 is of interest to note that the proportion of insane to the colored 
 population is double among the colored living in the North than 
 that among the colored living in the South. 
 
 In cities having over 50,000 inhabitants the ratio of the insane 
 to 100,000 of the general population was in 1890 343.9, as compared 
 with 170.0 for the whole country, showing apparently that the sup- 
 ply and the demand for institutions for the insane is greater in large 
 cities. On the other hand, the feeble-minded, deaf and dumb, and 
 blind are found in greater proportions in the country and in small 
 towns. 
 
 Out of the total population of 03,633,250 in the United States in 
 1890, about 500,000 had some defect or disorder of mind or of the 
 special senses. The exact ratio per 1,000 of the general population 
 in 1890 was, for the insane, 1.70; for the feeble-minded, 1.53; for the 
 deaf and dumb, 0.65; for the blind, 0.81. 
 
 Counting the lame, the deformed, the sick, and permanently 
 infirm, one person in every fifty in the general population, including 
 the classes previously mentioned, is mentally or physically disabled. 
 
 The reason for the giving of these figures is that it is not easy 
 to separate the nosological relation between the insane and the 
 feeble-minded, and that there is in all countries a certain propor- 
 tion between the sensorially and physically defective and the men- 
 tally defective classes. These figures also give numerical force to 
 a general law (broader than that of heredity), which is the law of 
 chances of organic failure traceable at every grade in the rising scale 
 of animal intelligence. This law will be again mentioned more fully 
 under etiology, and it is sufficient to cite the above figures as showing 
 in general the percental chances of organic failure as regards the 
 intellectual and special sensorial functions. 
 
 Eeasons for the percental increase of the insane to the general 
 population in civilized countries may be given in brief as follows: 
 There has been a decided increase in the amount of hospital accom- 
 modations and better quality of medical care given to the insane and 
 a prolongation of insane life. The diminished mortality has led to 
 an accumulation of chronic cases. The increased confidence in in- 
 stitutions for the insane has brought into them many cases formerly 
 kept hidden in private families. There have been more complete 
 returns made of the existing insane, and the education of the med- 
 ical profession generally concerning mental disorders has extended 
 the limits of diagnosis as regards Insanity. More persons are living 
 
THE STATISTICS OF INSANITY. 25 
 
 in large cities crowded together under bad hygienic surroundings, 
 and the total conditions of life are more highly artificial and neces- 
 sitate a keener competition and a greater mental strain, and intem- 
 perance and specific disease and general paresis account for an actual 
 increase of Insanity in connection with the above considerations. 
 Some of those formerly classed among the feeble-minded are now 
 returned as insane. This is an important point, as this combined 
 class of feeble-minded and idiots is very numerous, and it numbered 
 in 1890, in the United States, 95,609. 
 
 The proportion of first attacks of Insanity to the general pop- 
 ulation is not to be reliably determined except in England during 
 certain periods, and this is the needed information to determine ac- 
 curately the question of actual increase of Insanity in different coun- 
 tries at sequent periods. Thus in England and Wales in 1859 the 
 ratio of the pauper insane to the population was 1 in 578, whereas 
 in 1889 it was 1 in 384. The number of first attacks to the popula- 
 tion does not indicate so large an increase of Insanity, taking the 
 following figures given by Tuke: For each 10,000 of the population 
 the number of the first attacks was, in 1878, 3.33; in 1879, 3.34; 
 in 1880, 3.22; in 1881, 3.25; in 1882, 3.25; in 1883, 3.43; in-1884, 
 3.33; and in 1885, 3.10. Since 1885 there has been an increase 
 in the annual average number of first attacks. For the five years 
 from 1881 to 1885 inclusive the. average annual number of first 
 attacks per 10,000 of the population was 3.29. The corresponding 
 figure for the proportion of first attacks to the population from 1886 
 to 1890 was 3.46. These figures relate to certified cases only. 
 
 General Statistics as to Sex, Age, Nativity, Civil Condition, Occiqjation, 
 Form of Insanity, Heredity, Sensorial Defeat, Degree of Educa- 
 tion, Recovery-rate, Relojyses, and Mortality -rate. 
 
 Sex. — Esquirol, from statistical research, came to the conclusion 
 that more women than men were insane. The researches of Thur- 
 nam and of Dr. Jarvis would tend to show that men are more ex- 
 posed and more liable to become insane. It is probable that in 
 France there is a greater numerical liability to Insanity among 
 women. It also appears tbat in England more males than females 
 were formerly admitted to asylums, but of late years the reverse 
 is the case. From 1886 to 1890 in England the average of male 
 admissions was for each 10,000 of the population 5.24, while for 
 
26 TEXT-BOOK OlSr MENTAL DISEASES. 
 
 females the corresponding average was 5.26. In England and 
 Wales, from 1878 to 1887, there were admitted to public and pri- 
 vate asylums 69,560 women and only 66,918 men. The proportion 
 of male idiots, on the other hand, is greater in all countries, and in 
 the United States in 1890 the total feeble-minded reported were 
 52,963 males as against 42,647 females, and the ratio per 100,000 
 of the general population was 165.2 for males and 139.6 for females. 
 Exclusive of 231 Chinese, Japanese, and Indians, of the 106,254 
 insane reported June, 1890, 53,264 were males and 52,990 were 
 females, or 100.52 males to 100 females, which is a relatively high 
 proportion of males. This ratio of male insane to every 100 female 
 insane was, in the United States in 1880, 93.32; in England and 
 Wales (1881), 81.27; in Scotland (1881), 88.18; in Ireland (1881), 
 98.77, and in 1891, 99.74; in Prussia (1871), 91.51; in Bavaria 
 (1871), 86.16; in France (1876), 86.89. Among the native whites 
 horn of native parents this ratio was 102.46 males to 100 females, 
 w^liile among the native wliites born of foreign parents the corre- 
 sponding figure was 126.94. 
 
 It is to be borne in mind that there are one and a half million 
 (1,513,510) more males than females in the United States, and there 
 were reported in 1890, in each 100,000 males, 167 insane, and in 
 each 100,000 females, 174 insane. This greater actual proportion 
 of female than male insane to the general population may be due 
 to a smaller mortality and an accumulation of females, and to the 
 modern competition of women mth men in the various walks of Hf e. 
 Tlie numerical returns of the sexes insane in the United States have 
 not varied greatly for the last five censuses. Thus, out of every 
 1,000 insane in 1890, 502 were males and 498 female^; in 1880, 483 
 were males and 517 females; in 1870, 487 were iiiiiies and 513 
 females; in 1860, 493 w6re males and 507 were females; and in 
 1850, 506 were males and 494 females. 
 
 In 1890, 74,028 were reported as inmates of as ns for the 
 insane, or 697 out of every 1,000 of the total nuni ^ported as 
 
 insane. Out of this 74,028 in asylums for the ins; .330 were 
 
 males and 35,698 females, or a proportion of 107 ;._ o 100 fe- 
 
 males. In cities having 50,000 inhabitants or over rage ratio 
 
 of the male insane to 100,000 of the general popr /as 229.3 
 
 in ]890, and the ratio for females 256.6. 
 
 The differences of sex in regard to the reco-- and the 
 
 mortality-rate will be mentioned later under tho^ igs. 
 
THE STATISTICS OF INSANITY. 
 
 27 
 
 Age. — The folloTvnng figures from the last census report give in- 
 formation on a large scale as regards age and Insanity, In 1890, 
 of the total number of insane (106,254) reported, the age was not 
 given for 2,308, but for all the others the quinquennial age-periods 
 were as foUo-^vs: From ten to fifteen there were 311; from fiiteen to 
 twenty, 1,691; from twenty to twenty-five, 5,131; from twenty-five 
 to thirty, 8,863; from thirty to tliirty-five, 12,386; from thirty-five 
 to forty, 12,857; from forty to forty-five, 12,879; from forty-five to 
 fifty, 12,207; from fifty to fifty-five, 10,719; from fifty-five to sixty, 
 7,931; from sixty to sixty-five, 6,641; from sixty-five to seventy, 
 4,708; from scA^enty to seventy-five, 3,502; from seventy-five to 
 eighty, 2,055; and eighty and over, 2,005. 
 
 Table Shmcingfor each 100,000 of Papulation of ctrtaiii Groups of Ages the JSl'um- 
 ber of the Insane of Corresponding Groups of Ages, but excluding those under 
 Fifteen Tears of Age. 
 
 \ Total.* 
 
 i 
 
 15-ao 
 
 years. 
 
 20-25 
 years. 
 
 25-35 
 years. 
 
 35-45 
 years. 
 
 45-55 
 years. 
 
 55-65 
 years. 
 
 65 years 
 and over. 
 
 Total 
 
 263 
 
 26 
 
 28 
 23 
 
 83 
 
 94 
 
 72 
 
 218 
 
 230 
 
 204 
 
 367 
 359 
 375 
 
 455 
 
 417 
 495 
 
 467 
 417 
 521 
 
 508 
 
 Male 
 
 Female 
 
 257 
 
 270 
 
 448 
 571 
 
 ■ Fifteen years and over inclndiiig unknown. 
 
 This table shows that Insanity steadily increases with advancing 
 years; and especially among women is this the case. 
 
 The proportion of the insane of certain ages found in institu- 
 tions for the insane in 1890 is as follows: Of those from twenty-five 
 to forty-five years of age, over 75 per cent.; of those from forty-five 
 to fiity-five, 71.5 per cent.; of those from fifty-five to sixty-five, 64.6 
 per cent.; of those from sixty-five to seventy-five, 52.6 per cent.; 
 and of those more than seventy-five years, 33.3 per cent. 
 
 The age-periods at wliich Insanity first appeared in 79,274 cases 
 reported in 1890 were as follows: From ten to fifteen, 1,548 (male, 
 772; female, 776); fifteen to twenty, 5,902 (male, 3,163; female, 
 2,739); twenty to twenty-five, 11,935 (male, 6,608; female, 5,327); 
 twenty-five to thirty, 13,061 (male, 6,826; female, 6,235); thirty to 
 thirty-five, 11,617 (male, 5,731; female, 5,886); thirty-five to forty, 
 9,536 (male, 4,655; female, 4,881); forty to forty-five, 7,781 (male, 
 
28 TEXT-BOOK ON MENTAL DISEASES. 
 
 3,562; female, 4,319); forty-five to fifty, 5,787 (male, 2,600; female, 
 3,187); fifty to fifty-five, 4,271 (male, 2,064; female, 2,207); fifty- 
 five to sixty, 2,658 (male, 1,339; female, 1,319); sixty to sixty-five, 
 2,024 (male, 1,062; female, 962); sixty-five to seventy, 1,275 (male^ 
 636; female, 639); seventy to seventy-five, 931 (male, 451; female, 
 480); seventy-five to eighty, 539 (male, 244; female, 295); eighty 
 to eighty-five, 262 (male, 120; female, 142); eighty-five to ninety, 
 109 (male, 49; female, 60); ninety to ninety-five, 26 (male, 9; fe- 
 male, 17); ninety-five years and more, 12 (male, 3; female, 9). 
 
 Of the 79,274 insane above mentioned, 93.98 ^ev 1,000 were 
 under twenty years of age when the Insanity first appeared. From 
 twenty to forty-five years, 680.29 per 1,000; from forty-five to sixty- 
 five years, 185.94 per 1,000; and among those sixty-five years and 
 more, 39.79 per 1,000 of the 79,274 insane mentioned first bfecame 
 mentally disordered. 
 
 Sixty-eight per centum of the first attacks of mental disorder 
 occur between twenty and forty-five years of age. The greatest pro- 
 portion of first attacks in any quinquennial period occurs from 
 twenty-five to thirty years of age. The greatest proportion of first 
 attacks in any decennial period falls between twenty and thirty 
 years. More first attacks are to be enumerated from twenty to 
 twenty-five years than from thirty to thirty-five years, counting the 
 total of both sexes, but among the women alone there is a slight 
 preponderance of first appearance of Insanity in the quinquennium 
 . thirty to thirty-five years. In order to furnish statistical proof of 
 the actual tendency to Insanity at certain ages, it would be neces- 
 sary to compare the number of cases occurring at those ages with 
 the mean of the living population of like age at the time of the oc- 
 currence of the mental disease, and such complete information is 
 not to be had. The data given, however, clearly indicate points 
 above mentioned, and also that the tendency to first attacks is 
 gi'cater among males under twenty years than among females, but 
 after that age the reverse is true. 
 
 Natiritij. — =In 1890, for every 1,000 of the general population 
 the number of the insane was, for the native-born in the United 
 States, 1.40; for the foreign born, 3.87; and for the colored, 0.87. 
 The proportion of Insanity among the foreign-born population is 
 thus seen to be vastly greater than among natives, and in some de- 
 gree this is to be attributed to the fact that there were relatively 
 more adults of an age liable to mental disorder among them. It 
 
THE STATISTICS OF INSANITY. 29 
 
 also appears that tlie proportion of Insanity is much less among the 
 colored people. 
 
 Among the same classes the figures for the feeble-minded per 
 1,000 of the general population were, for native born, 1.66; for 
 foreign born, 1.00; for colored, 1.42. There is a less decided differ- 
 ence between the white and colored race in this instance, and the 
 native white number exceeds the foreign white because the actual 
 proportion of children was less among the latter. Sensorial defect, 
 at least as regards blindness, was greater numerically among the 
 colored than among the native whites, and it was still greater among 
 the foreign-born whites. This fact is given on account of the causa- 
 tive relation between deprivation of the special senses and Insanity. 
 Amcng the Chinese, Japanese, and Indians the proportion of In- 
 sanity and of other defects, such as idiocy, deafness, and dumbness, 
 excepting blindness, was less than among the white population. 
 The proportion as regards blindness was only slightly excessive. 
 
 ]n 1890, out of every 1,000 insane reported, 581.1 were natives 
 of native-born parents, 64.9 were natives with one or both parents 
 foreign barn, and 354.0 were foreign born. The ratio of the insane 
 per 100,000 of the living population was 387.0 for the foreign-born 
 whites, 140.5 for the native whites, and only 88.6 for the colored. 
 The ratio among the Chinese was 182 insane for 100,000 of the liv- 
 ing population, which is almost entirely adult, and hence propor- 
 tionately more liable to Insanity; and the ratio, though small rela- 
 tively to the general average, is more than double that found among 
 the negroes. 
 
 The ratio among the Indians of the insane per 100,000 living 
 was only 12.8, and, after making due addition for probably defective 
 reports, the proportion would still be very much less than among 
 the other races. 
 
 Civil Condition. — In 1890, out of 99,257 insane whose ages and 
 civil condition were reported there were 49,463 males, of whom 
 29,793, or 602 per 1,000, were single; 16,227, or 328 per 1,000, were 
 married; 3,010, or 61 per 1,000, were widowers; and 433, or 9 per 
 1,000, were divorced. Of the 49,794 females, 19,401, or 390 per 
 1,000, were single: 21,665, or 435 per 1,000, were married; 8,171, or . 
 164 per 1,000, were widows; and 557, or 11 per 1,000, were divorced. 
 The corresponding ratios in the general population were: for males, 
 single, 416 per 1,000; married, 542 per 1,000; widowed, 40 per 
 1,000; divorced, 2 per 1,000; and for females there were: single. 
 
80 TEXT-BOOK Oi^ MENTAL DISEASES. 
 
 318 per 1,000; married, 568 per 1,000; widowed, 110 per 1,000; 
 and divorced, 4 per 1,000. 
 
 The conclusions to be drawn from these statistical data are that 
 tlie tendency to Insanity is considerably greater among the single 
 than among the married, and this is specially marked as regards 
 males; that the proportion of mental disease among the divorced is 
 even greater than among the unmarried, and that the proportion of 
 Insanity among the widowed is also greater than among the married 
 or the single. 
 
 In England the proportion of married to single in the general 
 population is greater than in the United States, but the same pre- 
 ponderance in the numbers of single persons admitted to asylums 
 holds there, as here, to support the view that single life favors In- 
 sanity. 
 
 In an article on Insanity, written some years ago for Wood's 
 " Eef erence Handbook of the Medical Sciences," the writer pointed 
 out a possible fallacy as regards the large number of single insane 
 who, it was suggested, did not marry perhaps because they were 
 physically or mentally weak or defective. It is also possible, on 
 account of the difficulty of gaining accurate information, that on 
 admission to hospitals for the insane some who have been married 
 are enumerated as single. 
 
 Occupation. — It is a question whether the comparison of the 
 number of the insane of given occupations with the total numbers 
 of the same occupations in the general population furnishes reliable 
 data as to the degree to which the various occupations favor Insanity. 
 
 If the proportion of law^^ers reported insane in 1890 to the total " 
 number of lawyers in the general population in that year be com- 
 pared with the proportion of physicians reported insane the same 
 year, to the total number of physicians in the general population, 
 it appears that the ratio of insane is considerably greater among 
 the lawyers than among the physicians. And if a like comparison 
 on a like statistical basis be made between physicians and clergymen 
 it appears that fewer relatively among the latter than among the 
 former become insane. By thus comparing those fed, clothed, and 
 housed somewhat alike, and doing brain work, the sole influence of 
 occupation may perhaps be more nearly determined than by the 
 comparison of classes living under totally different hygienic condi- 
 tions and engaged variously in manual and intellectual labor, l^o 
 attempt, however, will be made to pursue this subject in a statistical 
 
THE STATISTICS OF INSANITY. 31 
 
 WAY through the complexities with wliich it is surroimded as regards 
 the various pcciipations. 
 
 Form of Insanity. — Of the 106,354 insane reported in the United 
 States in 1890, the form of Insanity is unknown or not specified in 
 the following data in 15,237: in 17,481 the form was acute mania; 
 in 21,511, chronic mania; in 2,286, acute melancholia; in 11,847, 
 chronic melancholia; in 2,258, monomania; in 1,615, paresis; in 
 29,218, dementia; in 4,104, epileptic Insanity, and in 697, dipso- 
 mania. The following are ratios as to these 106,254 insane, taken 
 from the census report of 1890. The average ratio of cases of acute 
 mania is 192.1 per 1,000 of all cases of Insanity. The same ratio is, 
 in native white women of native parents, 199.1; in colored males, 
 21S.0; in colored females, 246.2; in males with French mothers, 
 250.0; in females with French mothers, 276.8. 
 
 The average ratio of cases of chronic mania is 236.3 per 1,000 
 of all cases of Insanity, and it was, in foreign-bom females, 257.5, 
 and in colored females; 260.5. 
 
 The average ratio of cases of acute melancholia was 25.1 per 
 1,000 of all cases of Insanity; in native females of foreign-born 
 parents, 35.1; in colored males, 12.4; in colored females, 13.1. 
 
 The average ratio of chronic melancholia is 132.2 per 1,000 of 
 all cases of Insanity; in females, 137.8; in colored males, 71.7; in 
 colored females, 89.6. 
 
 The average ratio of monomania is 24.8 per 1,000 of all cases 
 of Insanity; and in foreign-born males it was 30.1; in the colored 
 males. 14.2; colored females, 15.4. 
 
 The average ratio of general paresis was 17.7 per 1,000 of all 
 cases; in males, 27.8; in females, 7.3; in colored males, 18.4; in 
 colored females, 7. It was much above the male average here given 
 in those males whose mothers were foreign born. 
 
 The average ratio of cases of dementia was 321 per 1,000 of all 
 cases of Insanity; in males, 319.8; in females, 322.3. 
 
 The average ratio of epilepsy was 45.1 per 1,000 of all cases of 
 Insanity, being 50.6 in males and 39.4 in females. It was highest 
 in the colored — males, 94.8; females, 73.0. 
 
 The average ratio of cases of dipsomania was 7.7 per 1,000 of all 
 eases of Insanity, being 12.2 in males and 3.0 in females. It was 
 highest in males Avhose mothers were born in Scotland, being 19.8, 
 and in Ireland, 19.1. 
 
 The greatest number of cases of acute mania at any quinquennial 
 
32 TEXT-BOOK ON MENTAL DISEASES. 
 
 period was from 30 to 35 years both for males and females; of 
 chronic mania, from 35 to 40 for male, and 40 to 45 for females; 
 of epileptic Insanity, from 35 to 40 for males, and 30 to 35 for fe- 
 males; of chronic melancholia, from 30 to 35 for males, and 35 to 40 
 for females; of dementia, from 30 to 35 for males, and 40 to 45 for 
 females. Acute mania, chronic mania, and chronic melancholia 
 increase in numerical proportion to each 100,000 of population of 
 like age up to fifty-five years of age, and they then diminish, hut 
 after fifty-five years dementia continues to increase (in the ratio 
 of cases relative to each 100,000 of like ages in the general popula- 
 tion) to the end of life. 
 
 Heredity. — In the census returns of 1890, as to 70,340 insane in 
 point of heredity, it was reported that 22,077, or 314 per 1,000, had 
 insane relatives. The number having, insane fathers was 2,531, and 
 insane mothers, 3,159. The number having insane grandfathers 
 was 784, and the number having insane grandmothers was 810. 
 
 The number having insane uncles was 2,408, and the number 
 having insane aunts was 2,034. The number having insane cousins 
 was 1,708. 
 
 The number having insane brothers was 3,630, and the number 
 having insane sisters was 3,704. 
 
 The number having insane sons was 465, and the number having 
 insane daughters was 480. The ratio of the insane having insane 
 relatives was greater among females (being 337 per 1,000) than 
 among males (being 289 per 1,000). 
 
 The number having insane uncles on the father's side was 243 
 as against 206 on the mother's side, and the number having insane 
 aunts on the mother's side was 289, as against 179 on the father's 
 side, which apparenth'' points to heredity in the same sex. Before 
 hereditary influence as an etiological factor can be determined, sta- 
 tistics must be made to embrace every memher of all tainted families 
 affected with not only Insanity, but with idiocy, epilepsy, and other 
 nearly allied neuroses which appear vicariously with mental disorder. 
 The members not affected must be reported as well as those mentally 
 diseased in a family, for it is just as important to determine the num- 
 ber having insane parents who are not insane, as to fix the ratio of 
 those having insane parentage who are insane, and until statistics 
 are made to include these additional particulars they cannot aid 
 greatly in the solution of the problem of direct heredity. The 
 broader law of the probability of organic failure, which will be dis- 
 
THE STATISTICS OF INSAiSTITY. 33 
 
 cussed under etiology, as previously mentioned, is of first importance 
 in this connection. 
 
 Sensorial Defect. — In 1880 the total insane reported in the 
 United States as deaf and dumb were 268, and in 1890 there were 
 409 thus reported, so that there has probably been a real increase 
 of Insanity in this class. The number of insane reported as blind in 
 1880 was 528, and in 1890 582. The number of the insane deaf, 
 dumb, and blind was 30 in 1880 and 62 in 1890. 
 
 The total number of insane having sensorial defect has increased 
 beyond the relative additions to the general population in the last 
 ten years. 
 
 Degree of Education. — Information on this point in the census 
 returns of 1890 was given as regards inmates of institutions in 65,- 
 065 cases, out of which 51,362, or 785 per 1,000, could read and 
 write; 1,681, or 26 per 3,000, could read but could not write; and 
 11,833, or 182 per 1,000, could neither read nor write. 
 
 Eecovery-raie. — The rate of recovery diminishes with age, and 
 it is slightly more favorable among women than among men. It av- 
 erages from thirty per cent, to forty per cent., calculated on admis- 
 sions in hospitals for the insane in the United States. Of those 
 thus enumerated as recovered, a certain number relapse into In- 
 sanity, and it is probable that Thurnam's estimate (" Statistics of 
 Insanity," p. 123) is about correct, as follows: " In round numbers, 
 of ten persons attacked by Insanity, five recover, and five die sooner 
 or later during the attack. Of the five who recover not more than 
 two remain well during the rest of their lives; the other three sus- 
 tain subsequent attacks, during which at least two of them die.'"' 
 
 After a study of returns from hospitals for the insane in the 
 United States, and of all other available statistical information, the 
 following estimate is given as probably very nearly the average re- 
 sult to be anticipated in mental disorders, by striking an average as 
 regards age, sex, and form of mental disease: Of one hundred per- 
 sons attacked for the first time by Insanity, seventy will eventually 
 die insane; thirty will recover and die sane; twenty will recover, 
 but will relapse and will be among the seventy to die insane; fifty 
 will not recover and will, with the twenty just mentioned, make out 
 the seventy to die insane. This estimate is based on experience in 
 the treatment of Insanity in private practice as well as in hospital 
 practice, and, if it did not relate to Insanity in general as well as 
 to cases in institutions for the insane, it would be too favorable as 
 3 
 
34 TEXT-BOOK ON MENTAL DISEASES. 
 
 regards the permanent recoveries, and it would have to be reduced 
 considerably in this one particular if applied solel}'- to cases in public 
 hospitals for the insane. 
 
 Relapses. — Eelatively more females than males relapse. The 
 proportion of relapses given in reports of hospitals for the insane 
 is relatively too large, because the recoveries are too favorably 
 judged, and in the estimate above given the relapses have reference 
 strictly to complete recoveries, and not to recoveries of a defective 
 nature. Taking hospital recoveries as they average, more than 
 twenty per cent, of them are followed by relapses. Of 74,183 cases 
 of Insanity reported in 1890, the number of attacks was as follows: 
 One, 63,390 (male, 32,683; female, 30,707); two, 7,127 (male, 3,560; 
 female, 3,567); three, 1,820 (male, 886; female, 943); four, 730 
 (male, 344; female, 386); five, 300 (male, 135; f empale, 165); six 
 to ten, 405 (male, 163; female, 242); eleven and more, 401 (male, 
 160; female, 241). 
 
 A separate return should be made by hosjDitals for the insane as 
 regards the number of relapses in strongly hereditary cases, and the 
 length of the lucid intervals should be stated, and this, like all other 
 returns, should be by quinquennial age periods. 
 
 Moriality-rate. — The mortality-rate is higher among insane men 
 than women, and it increases after fifty years more rapidly than in 
 the general population, and it is greater in the early than in the later 
 period of institutions for the insane, and it is from four to five times 
 greater than among the sane. Mr. Noel Humphreys, for inmates of 
 asylums in England and Wales, gives the following average death- 
 rates on average numbers resident for the year, viz., 1859-1868, 10.31 
 per cent; 1869-1878, 10.17 per cent; 1879-1888, 9.55 per cent. 
 
 In an aggregate of 36,517 patients treated in hospitals for the 
 insane in 1890, the last census report gives an average death-rate 
 of 65.0 per 1,000, which is nearly five times above the average for 
 the general population above fifteen years of age; and from the 
 same source is derived the following table, in which is calculated 
 the expectation of life from. 7,875 insane and feeble-minded of 
 known ages above fifteen years who died in institutions. The table 
 shows also, for comparison, the corresponding figures for the pop- 
 ulation of Massachusetts m 1880. 
 
THE STATISTICS OF INSANITY. 
 
 35 
 
 Table Showing Expectation of Life in the Insane. 
 
 Ages. 
 
 15 years 
 25 years 
 35 years 
 45 years 
 55 years 
 65 years 
 75 years 
 85 years 
 95 years 
 
 Expectation of Life in 
 Yeaks. 
 
 35.78 
 
 28.51 
 
 23.14 
 
 18.80 
 
 14.87 
 
 10.37 
 
 7.33 
 
 5.79 
 
 2.00 
 
 PopulatioH of 
 Massachusetts. 
 
 46.85 
 39.81 
 32.96 
 26.01 
 19.02 
 12.95 
 8.31 
 5.82 
 
 Statistics for special forms of Insanity will be given in the clinical 
 part of this work. 
 
CHAPTER III. 
 
 THE NOSOLOGY OF INSANITY. 
 
 From time immemorial writers on Insanity have given special 
 appellations to the various pathological departures from mental 
 health, and they have endeavored to group the varieties of mental 
 disorder with some show of logical consistency according to one 
 or more principles of division. Their endeavors in this direction 
 were perfectly natural, and they constituted a necessary step in the 
 development of the subject, which, like all branches of research, 
 absolutely required some sort of division for purposes of study. 
 
 It is the Avorst form of obstructive ignorance to oppose the use 
 of working theories and provisional classifications, which are indis- 
 pensable in all departments of human knowledge and have served 
 a useful purpose in the evolution of all kinds of sciences. What, 
 then, are the general nosological principles applicable in the study 
 of Insanity? The reply to this question will be given seriatim under 
 the following terms, which define the principles deemed available 
 for the classification of mental diseases; viz., psychological, symp- 
 tomatological, etiological, pathological, anatomical, physiological, 
 and combinative. 
 
 The psychological principle is one which would naturally com- 
 mend itself to a reflective student seeking some means of dividing 
 the disorders of the mind. It is the natural order of science to study 
 the normal before the abnormal activities of organs, and it would 
 seem appropriate to determine the physiological activities of the 
 brain, as the organ of the mind, and to make a corresponding psy- 
 chological division of its separate functions, as the only scientific 
 basis for a study of the pathological disturbances of these functions 
 in Insanity. A clear idea of the separate faculties of the mind, and 
 of their actions in health, would seem to be a prerequisite of their 
 study in disease. 
 
 86 
 
THE NOSOLOGY OF INSANITY. 37 
 
 The derangement of one or more of these mental faculties is al- 
 ways the most striking feature of Insanity, which has no social or 
 legal recognition without psychical symptoms, even though the med- 
 ical expert may determine its existence without mental manifesta- 
 tion. 
 
 There have been two extreme attitudes maintained toward the 
 use of this psychological principle in psychiatry. One has been the 
 extreme refinement of the principle in metaphysical directions, 
 leading to useless theories and subdivisions in mental diseases, 
 and the other has been the utter negation of the value of the 
 principle, and the consequent neglect of a most useful adjunct 
 in the study of mental alienation. The fact is that mental 
 states, whether normal or abnormal, will always require to be 
 studied from a metaphysical as well as from a physical side. The 
 most ultimate fact yet attained by human science is that a physical 
 and a psychical process coincide to form every mental event. The 
 pathological mental events in Insanity have their physical and their 
 concomitant psychical processes, which must be studied coincidently 
 as correlatives, which constitute the two sides of a subject otherwise 
 indivisible. A wise empirical psychology should go hand in hand, 
 therefore, with experimental physiology in the study of psychiatric 
 science. 
 
 The symptomatological principle has been more constantly em- 
 ployed for nosological purposes in Insanity than any other. It is 
 natural and customary in all branches of medicine to classify diseases 
 by objective symptoms, and this principle is equally appropriate in 
 mental medicine, and it is the one which has best stood the test 
 of time. The division of Insanity by mental symptoms into mania, 
 melancholia, and dementia has stood for twenty-five hundred years 
 and will probably remain forever. 
 
 The symptomatological principle is extremely flexible, and ad- 
 mits of endless subdivisions in mental diseases, and some nosologists 
 have abused it in this particular, making tiresome and trivial sub- 
 classifications of pathological mental phenomena. When used with 
 discretion, however, it may safely be ranked as one of the foremost 
 and almost indispensable nosological principles in the study of In- 
 sanity. 
 
 The etiological principle in the nosology of Insanity consists in 
 the classification of mental diseases according to the causes which 
 have been most active in their production. It is beyond all com- 
 
38 [ TEXT-BOOK ON MENTAL DISEASES. 
 
 parison the most useful principle of division for practical purposes 
 of treatment. It is manifestly more irdportant to the practitioner 
 to know that the Insanity is puerperal, alcoholic, or syphilitic, than 
 to know that it is of the melancholic, maniacal, or demented form. 
 
 The etiological principle is also mostly decisive for diagnostic and 
 prognostic purposes. It is not a sufficient principle for the complete 
 classification of mental diseases, which, as a rule, proceed not from 
 one, but from several causes, and from sources often not to be clearly 
 ascertained, but so far as it is available for the scientific division of 
 pathological psychical affections it should be employed preferably 
 to principles thus far described. 
 
 The pathological principle of classification, when completely car- 
 ried out, is the most scientific in Insanity and in all other diseases. 
 Unfortunately, the knowledge of the pathological conditions which 
 underlie morbid mental states is not yet sufficiently advanced to 
 serve as a basis of division, except in a few of the types of Insanity. 
 It will appear presently how premature efforts at pathological clas- 
 sification have been made by certain able writers on Insanity. 
 
 It can only be said, therefore, that this principle should be em- 
 ployed to the exclusion of all others, so often as the pathological 
 lesions which occasion the mental disease are definitely known. In 
 the distant future, when pathological anatomy shall have advanced 
 vastly beyond its present limits, this principle will become the sci- 
 entific basis. of a division of brain diseases with accompanying mental 
 disorders. Mental diseases will then be scientifically grouped and 
 causatively understood, but they will not be philosophically or ra- 
 tionally explained, for the intimate relation between anatomical 
 structure and physiological function will still be a mystery. The 
 absolute nature of mind, like that of life, will always be beyond the 
 ken of mortal man. 
 
 The anatomical principle in mental pathology seeks to assign 
 definite limits to the cerebral structures affected in mental diseases. 
 The day will doubtless come when this clear demarcation between 
 anatomical structures and physiological mental functions can be 
 determined. Of late years a vast amount of labor has been expended 
 on cortical localization and a hopeful advance in the knowledge of 
 the subject has been made. It is also a fact that improved technical 
 methods of research in the finer anatomy of cerebral structures has 
 added greatly to existing scientific data. It is reasonable to believe, 
 therefore, that in course of time the anatomical principle will be 
 
THE NOSOLOGY OF INSANITY. 39 
 
 employed in mental pathology, as it now is in neurology, for the 
 classification of various types of disease. To this very end the la- 
 mented Meynert, among other noted collahorators, expended some 
 of the best eif orts of his genius. 
 
 The physiological principle is the counterpart of the one just 
 mentioned. Cerebral activity and psychical manifestation corre- 
 spond in both health and disease. Functional activity of the health- 
 ful brain is attended by nomial mental manifestations, while the 
 action of the diseased brain develops corresponding morbid psychical 
 reactions. The nature of the functional cerebral process invariably 
 determines the character of the objective psychical symptom. The 
 physiological standard of mental activities would seem to be, there- 
 fore, a true principle for the comparison and classification of the 
 morbid variations of mental functions in Insanity. The new sci- 
 ence of physiological psychology, it is to be trusted, will in due sea- 
 son furnish some valuable principles of use in the nosology of In- 
 sanity. The psychologist also looks expectantly to physiological 
 chemistr}" for revelations as to biochemical tissue changes and re- 
 sultant perversions of brain function and of corresponding morbid 
 psychical manifestations. 
 
 The combinative principle in the nosology of Insanity arises 
 out of the fact that none of the principles heretofore described are 
 adequate separately for the classification of the different varieties 
 of mental alienation, so that an eclectic or combinative procedure 
 becomes necessary. Classification is simply the orderly arrange- 
 ment according to some given principles of the known facts of a 
 science. When nothing but the objective symptoms was known of 
 Insanity, the symptomatological principle was all that was required 
 in its nosolog}', but with the advent of anatomical, physiological, 
 etiological, and pathological facts, other principles of grouping the 
 known data became essential. 
 
 The limits of psychiatric science have become so extended, and 
 the facts pertaining to it so numerous, that none but a combinative 
 principle will suffice for a complete nosology of Insanity at the pres- 
 ent day. This preliminary analysis of nosological principles will 
 assist in the review of some of the chief classifications of authors 
 which will now be presented in condensed form. 
 
 Former accepted classifications will first be passed in review, as 
 they are highly instructive, and have served as models for the 
 more recent nosological schemes, in comparison with which they are 
 
40 TEXT-BOOK ON MENTAL DISEASES. 
 
 in some instances of equal value, and the simple chronological order 
 here observed of course excludes any intentional precedence of one 
 classification over another on the ground of comparative worth. 
 
 Stahl (1660 — 1734) has already been mentioned under another 
 head, but, as he represents in nosology a school which had predom- 
 inant influence in Germany for many years, his teachings must be 
 here noticed. Stahl was the founder of the Psychological School 
 in Germany, which was based on animistic, philosophic views, and 
 it had as its followers men of note like Ideler, Langerman, Hoff- 
 bauer, Eeil, and Heinroth. The teachings of this Psychological 
 School were that in man material changes are governed by spiritual 
 influences, and Insanity was only an indication of a disease of the 
 sou], as the result of sin. Insanity was classified in accordance with 
 metaphj'^sical distinctions, which were again elaborated, in keeping 
 with animistic philosophy. The forms of mental disease were classed 
 under one of three heads; viz., the spiritual faculties, the moral 
 powers, and the vohtion, including the instincts and propensities. 
 
 The Somatic School in Germany, contemporaneous with and a 
 rival of the one just mentioned, taught diametrically opposite views, 
 and it was represented also by prominent men like Nasse, Vering, 
 Friedreich, and Jacobi. 
 
 Jacobi reflects the doctrines of the school, which rapidly found 
 followers in all parts of Germany. He declared that Insanity was 
 a purely physical disease, arising through sympathy with visceral 
 affections or from gross lesions of the nervous system, and that it 
 might spring from disease of an abdominal viscus just as well as from 
 the brain. The only classification he admitted was as follows: 1. In- 
 sanity without delirium. 2. Insanity with delirium or incoherence 
 and without delusion. 3. Insanity with delusion. 
 
 Sauvage (1706 — 1767) was the first systematic nosologist who 
 employed natural history methods, and grouped general diseases 
 and the special affections of Insanity by classes, orders, genera, and 
 species. In thus systematically classifying all the facts then known 
 about Insanity, he conferred a great service on psychiatric science, 
 for some logical arrangement of a heterogeneous mass of empirical 
 observations is the first step toward evolution in any branch of 
 knowledge. 
 
 Sauvage, in his " ISTosologia Methodica," grouped mental diseases 
 in his eighth class and third order, under the general term, " Yesan- 
 iae,'' which was redivided into: 1, Hallucinations; 2, Morosities; 
 
THE NOSOLOGY OF INSANITY. 41 
 
 B, Deliriums; 4, Abnormal aberrations; and these were again sub- 
 divided to include every manner of mental symptomatic disturb- 
 ance which had been recognized up to that time. His descriptions 
 alike of separate symptoms and of clinical forms of Insanity were 
 especially good and true to the most minute details, showing the 
 painstaking genius of the author. 
 
 Pinel (1793), great as the champion of the rights of the insane, 
 and as an author of the widest influence in France, taught that the 
 symptoms of Insanity as a whole should be studied by aid of mental 
 philosophy, inasmuch as they represented psychical phenomena, but 
 that when a large number of these symptoms had been separately 
 analyzed they should finally be classified, like the facts of natural 
 history. He did not attach much importance to lesions of material 
 structures in relation to psychical disturbances nor to materia med- 
 ica remedies for mental disorders, which were to be dealt with by 
 hygienic and moral means and by isolation, and he insisted that the 
 psychic derangement coincident with acute diseases was not In- 
 sanity. 
 
 He classified diseases of the mind under the f olloAving simple but 
 comprehensive division according to mental symptoms, viz.: Mania, 
 Melancholia, Dementia, Idiotism. 
 
 Esquirol, the student of Pinel, celebrated alike in the annals of 
 lunacy reform and of psychiatric science, was the author of a classic 
 treatise on Insanity translated into modern languages and read the 
 civilized world over. 
 
 Esquirol was loyal to the views of his great teacher, and he did 
 not depart essentially from Pinel's classification, to which he added, 
 however, a knowledge of partial insanity with gayety or with sadness, 
 and also a clear distinction between congenital and acquired states 
 of weakness of mind. Esquirol's classification is as follows: 1, Lype- 
 mania; 2, Monomania; 3, Mania; 4, Dementia; 5, Imbecility and 
 Idiocy. 
 
 Cullen (1772), in his general nosology (on natural history lines) 
 of diseases, includes Insanity among the neuroses as Order TV., un- 
 der the term "vesanias," and the subdivisions were: 1. Amentia, 
 which included congenital or acquired mental affections. 2. Mel- 
 ancholia, which embraced eight sub varieties, erotomania, and demon- 
 omania being among them. 3. Mania, which had three divisions, ac- 
 cording as the cause of the mental disorder was psychical, physical, or 
 unknown. 4. Oneirodinia, or derangement of sleep, somnambulism. 
 
42 TEXT-BOOK ON MENTAL DISEASES. 
 
 A condition pertaining to all of these forms was that they were 
 free from fever and coma. 
 
 Cullen deserved credit for calling attention to and introducing 
 for the first time in nosology the Insanity of disordered states of 
 sleep under the term oneirodinia. 
 
 Arnold (1806) treated of the symptoms of Insanity with clinical 
 discrimination and excellent descriptions of the psychical manifes- 
 tations;, but unfortunately in classification he was governed com- 
 pletely by metaphysical ideas. His division of Insanity was: 1. Ideal, 
 which had four subdivisions. 2. Notional, which had twenty vari- 
 eties, according to the mental complexion of symptoms. 
 
 Benjamin Eush, who showed a touch of genius in all the diversi- 
 fied topics upon which he wrote, published in 1812 his " Medical 
 Inquiries and Observations," with an article on mental diseases, 
 which he divided simply in accordance with the psychical symptoms^ 
 much as did Esquirol, using the new term amenomania to denote 
 monomania with expansive feelings. 
 
 Isaac Eay, whose " Medical Jurisprudence of Insanit}^," like its 
 author, is so widely known, classified Insanity also in simple form 
 according to the mental features of the disease. 
 
 Guislain, of Belgium, who worked such important lunacy re- 
 forms at Ghent in 1828, classified Insanity under a new nomencla- 
 ture of Greek derivation according to a psychological principle of 
 divisions as follows: 1. Phrenalgia (melancholy). 2. Phrenoplexia 
 (ecstasy). 3. Ilj-perphrenia (mania). 4. Paraphrenia (folly). 
 5. Ideophrenia (delirium). 6. Aphrenia (dementia). Conolly, the 
 great English lunacy-reformer, at this date admitted no further 
 classification of Insanity than Mania, Melancholia, and Dementia. 
 
 Noble, some years later, offered nothing new as a basis of division, 
 wliieh he made with reference to mental symptoms and metaphysical 
 ideas into: 1. Emotional. 2. Notional. 3. Intelligential disorders. 
 
 Griesinger, in 1845, published his "Mental Pathology and Ther- 
 apeutics,'' which, in view of the fact that it was a quarter of a century 
 in advance of contemporary psychiatric science, qnd gave a masterly 
 analysis of the bodily and mental symptoms of Insanity, and pre- 
 sented, with laborious care and the most skilful clinical interpreta- 
 tion, all the physiological and pathological facts relating to mental 
 diseases, was the most remarkable work which has ever adorned 
 the literature of Insanity. Griesinger employed the psychological 
 principle in the classification of Insanity, not by exclusive prefer- 
 
• THE NOSOLOGY OF INSANITY. 43 
 
 ence, but of necessity, for, as he Justly affirmed, anatomical, physio- 
 logical, and pathological knowledge were not sufficiently advanced 
 at the time to serve as a basis of nosology. 
 
 His nosological arrangement was the following: 
 
 States of Mental Depression — Melancholia. 
 
 I. Hypochondriasis. 
 
 II. Melancholia in a more limited sense. 
 
 III. Melancholia with stupor. 
 
 IV. Melancholia with destructive tendencies. 
 
 (a) Melancholia with suicidal tendencies. 
 (h) Melancholia with murderous tendencies. 
 y. Melancholia with persistent excitement of the will. 
 
 States of Mental Exaltation. 
 
 I. Mania. 
 
 II. Monomania. 
 
 States of Mental Weakness. 
 
 I. Chronic Mania. 
 
 II. Dementia. 
 
 III. Apathetic Dementia. 
 
 IV. Idiocy and Cretinism. 
 
 (a) Idiocy in general. 
 
 (b) Endemic Cretinism. 
 
 To the above was added the " Complications of Insanity," which 
 included general paralysis and the major neuroses. 
 
 Schroeder van der Kolk, influenced by the Somatic School of 
 Germany, but avoiding its extremes, in 1852 made a decided effort 
 to classify mental diseases by the etiological principle, tracing their 
 causation largely to affections of the thoracic and abdominal viscera, 
 through sympathetic action. While retaining some customary terms 
 indicative of the mental phases of the disease, he still held that the 
 symptoms were too variable, and that the causes alone were suffi- 
 ciently stable for the classification of Insanity. 
 
 He divided it into two main groups, idiopathic and sympathetic. 
 The first term included mental disease from intra-cerebral causes, 
 and the second term embraced mental disorder from extra-cerebral 
 sympathetic causes. His nosological scheme was formulated thus: 
 
44 TEXT-BOOK ON MENTAL DISEASES. 
 
 Genus A^ 
 
 1. Acute Idiopathic Mania, 
 
 2. Chronic Idiopathic Mania. 
 
 3. Obtuseness. 
 
 4. Dementia and Idiotism. 
 
 Genus B. 
 
 1. Sympathetic Mania, from disease of the colon. 
 
 2. Sympathetic Mania, from disease of the sexual organs. 
 
 3. Sympathetic Mania, from diseases of the chest. 
 
 4. Sympathetic Mania, from erethica senilis. 
 
 5. Intermittent Mania. 
 
 Morel (1860) strongly advocated the etiological principle of 
 division, which he labored assiduously to perfect, and his nosology, 
 published in the year here mentioned, contained several important 
 additions to the subject, viewed in the light of causes, and was 
 substantially as follows: 1. Insanity from hereditary transmission. 
 2. Toxic Insanity. 3. Insanity from the transformation of other 
 diseases. 4. Idiopathic Insanity. 5. Sympathetic Insanity. 6. De- 
 mentia. 
 
 Skae, in 1863, propounded a classification in which the etiological 
 principle was carried to its extreme hmit, as is evident in this, his full 
 arrangement of mental diseases: 1, General Paralysis. 2. Paralytic 
 Insanity. 3. Traumatic Insanity. 4. Epileptic Insanity. 5. Syph- 
 ilitic Insanity. 6. Alcoholic Insanity. 7. Eheumatic and Choreic 
 Insanity. 8. Gouty Insanity. 9. Phthisical Insanity. 10. Uterine 
 Insanity, 11. Ovarian Insanity. 12. Hysterical Insanity. 13. Mas- 
 turbatic Insanity. 14. Puerperal Insanity. 15. Lactational Insan- 
 ity. 16. Insanity of Pregnancy. 17. Insanity of Puberty. 18. Cli- 
 macteric Insanity. 19. Senile Insanity. 
 
 Skae described, in addition to the above, some exceptional forms 
 of mental disorder in connection with affections of the thoracic vis- 
 cera, with goitre and fevers, and occurring in the delirium of young 
 children, and in relation to the disturbances of sleep, and also fol- 
 lowing the excitement of marriage. 
 
 Laycock, in 1864, in his " Medical Observation and Eesearch," 
 endeavored, with ingenious ability, but rather prematurely, to con- 
 
THE NOSOLOGY OF INSANITY. 45 
 
 struct a complete nosology by the physiological and anatomical prin- 
 ciple of division of mental diseases. 
 
 His nosological attempt consisted in the demarcation by anatom- 
 ical lines of cerebral centres, which subserve in function: 1. The 
 Instincts and Propensities. 2. The Emotions and Sentiments. 
 3. The Intellectual Faculties and Special Senses. 
 
 The normal and abnormal activities of these cerebral centres, 
 explained by the laws of mental physiology and mental pathology, 
 afforded, in his opinion, the best basis of explanation and of classifi- 
 cation of mental phenomena, both in health and in disease. 
 
 Space will not permit the insertion here of this complete noso- 
 logical scheme, nor of that of Parchappe, also based on the anatom- 
 ical principle, nor of that of A. Yoisin, relating to morbid anatomj'-, 
 especially vascular patholog}^, nor of that elaborated on anatomical 
 lines somewhat later by that original and industrious worker, Luys. 
 
 It will not do to omit, however, the nosology from an ana- 
 tomical standpoint, of that great psychiatric genius and brain anat- 
 omist, Meynert, whose grouping in the original text not being at 
 hand is here quoted from Tuke's " Dictionary of Psychological Med- 
 icine: " viz., " 1. The clinical forms which arise from anatomical 
 changes caused by injury to the skull and brain during pregnancy, 
 parturitions, or infancy (idiocy, deaf-mutism, etc.); those which 
 arise from changes caused by focal or coarse brain disease, as tumors, 
 hemorrhages, sclerosis, and syphilis (delirium, paralysis, organic 
 dementia); thirdly, those caused by diffused changes, as atrophy, 
 hypertrophy, and meningitis (senile dementia, epilepsy, general 
 paralysis), etc." 
 
 '•' 2. ])isorders of nutrition, involving cortical excitement (mania, 
 melancholia, exalted ideas, etc.), or subcortical localized irritation 
 and feebleness (delusions, hallucinations, mental stupor, hypochon- 
 driasis, hysteria, partial insanity, persecution mania; disorders of 
 the subcortical vascular centres — epilepsy, hystero-epilepsy, circular 
 insanity, ascending paralysis, goitre, etc.). 
 
 " 3. The last group comprises ' intoxications.' " 
 
 In 1867 the International Congress of Alienists, held in Paris, 
 adopted the following classification of Insanity, prepared by a com- 
 mittee especially appointed to draft the same: 1. Simple Insanity 
 (mania, melancholia, monomania, moral Insanity, and dementia). 
 2. Epileptic Insanity. 3. General Paralysis. 4. Senile Dementia. 
 5. Organic Dementia. 6. Idiocy. 7. Cretinism. 
 
46 TEXT-BOOK ON MENTAL DISEASES. 
 
 Delirium from trauma, alcohol, or fever, was mentioned as not 
 pertaining to the typical forms of Insanity. 
 
 Maudsley (1868), in his " Pathology of Mind," admits the ne- 
 cessity of the psychological principle in psychiatric nosology, while 
 he at the same time deplores its insuificiency. He seems to think 
 that there is greater stability in the objective character of the psy- 
 chical symptoms than in the actual causes of the mental disease, 
 which, he claims, varies infinitely in outward manifestation, even 
 in cases having the identical same cause. He therefore gives this 
 psychological classification: 
 
 Affective Insanity, or Insanity without delusion, 
 
 (a) Instinctive. 
 
 (b) Moral. 
 Ideational Insanity. 
 
 Melancholia. 
 
 Acute. 
 
 Chronic. 
 Mania. 
 
 Acute. 
 
 Chronic. 
 Monomania. 
 Dementia. 
 
 Acute. 
 
 Chronic. 
 Amentia. 
 
 Imbecility. 
 Idiocy. 
 
 Moral and Intellectual. 
 
 The inconsistencies of this arrangement of mental diseases are 
 harmonized through the great ability of the author. 
 
 Blandford, writing with all the tact and skill of an accomplished 
 clinician, suggests classification primarily according to the general 
 psychical and somatic state of the patient, and secondarily in keep- 
 ing with the mental complexion of the malady, while he at the same 
 time takes into consideration the etiological factors when clinically 
 grouping patients for purposes of treatment. 
 
 Hammond makes a division of mental diseases in strict accord- 
 
THE NOSOLOGY OF INSANITY. 47 
 
 ance with the psychological principle. He classifies under three 
 main groups, denominated Intellectual, Emotional, and Volitional, 
 and he then subdivides, hy clinical peculiarities and mental features 
 of the disease, reflecting the partitions of the human mind regularly 
 established in mental philosophy. The practical delineations of the 
 forms and the versatile style atone for the misconception that a no- 
 sology of Insanity can be constructed by the psychological principle 
 alone, or from any one point of view. 
 
 The nosological divisions of recent standard writers will now be 
 presented. 
 
 The earnest student of mental diseases will nowhere find more 
 general and condensed information than in these classifications of 
 Insanity, representing, as they do, the best efforts of the ablest 
 alienists to portray, with a few strokes of the pen, the salient feat- 
 ures of the whole subject. 
 
 Bucknill and Tuke, in their " Manual of Psvchological Medi- 
 cine,^^ which is the standard English treatise on Insanity, recog- 
 nize fully the fact that no complete classification can be made from 
 any one exclusive principle, inasmuch as the mental symptoms are 
 for didactic purposes, at least, the very essence of the disease. The 
 students of the manual are supplied with the following classification 
 of Insanity by Tuke: 
 
 Disorders of the Mind. 
 
 Class I. — The Intellect or the Ideas. 
 
 Order 1. Development incomplete. 
 
 Idiocy. 
 
 Imbecility. 
 Order S. Invasion of disease after development. 
 
 Dementia. 
 
 Delusional Insanity. 
 
 Monomania. 
 
 Mania. 
 
 Class U. — The Feelings and the Moral Sentiments. 
 Order 1. Development Incomplete. 
 
 Moral Imbecility. 
 Order 2. Invasion of disease after development. 
 
 Moral Insanitv. 
 
48 TEXT-BOOK ON MENTAL DISEASES. 
 
 Melancholia. 
 
 1. Eeligious. 
 
 2. Hypochondriacal. 
 
 3. Nostalgic. 
 Exaltation, regarding 
 
 1. Religion. 
 
 2. Pride. 
 
 3. Vanity. 
 
 4. Ambition. 
 Order 1. General. 
 
 Mania. 
 Order 2. Partial. 
 
 Homicidal mania. 
 Suicidal mania. 
 Erotomania. 
 Dipsomania. 
 
 Bucknill, viewing the whole question from all standpoints, and 
 with a happy combination of all the principles, has evolved the fol- 
 lowing classification in which the psychical phenomena form the 
 classes, the pathogenic relations the orders and the genera, and 
 the pathological conditions the species. 
 
 1. Melancholia (simple, with excitement, with stupor, alternat- 
 ing with mania). 
 
 3. Mania (simple, with depressing emotions, intercurrent with 
 melancholia or with dementia, alternating with sanity). 
 
 3. Dementia (simple and primary, consecutive to mania or mel- 
 ancholia, congenital). 
 
 1. Simple Insanity. 2. Allied Insanity. 3. Sequential Insan- 
 ity. 4. Concurrent Insanity. 5. Egressing Insanity. 6. Metas- 
 tatic Insanity. 7. Climacteric Insanity. 
 
 The genera of pathogenetic relations and the species are too 
 numerous to be quoted in full, but they embrace substantially the 
 following points: Heredity, overwork, cerebral injuries, visceral dis- 
 eases, fevers, cachexias, neurotic aifections, epochal crises, influences 
 of the reproductive organs, and hasmic and trophic changes in the 
 general system. 
 
 In this nosological attempt Bucknill conceived the true idea. 
 
THE NOSOLOGY OF INSANITY. 
 
 49 
 
 which is first to make a summation of all the known facts, and then 
 to arrange them in some consistent order, and to allow no clinical 
 truth to be crowded out by fancied logical necessity, or any other 
 preconceived theoretical notion, since the object of any such attempt 
 is not to teach perfect methods of nosology, but to convey complete 
 information about mental diseases. 
 
 Ball (1880), in his " Le9ons sur les Maladies Mentales," written 
 in a most accomplished style, takes a comprehensive view of mental 
 disorders, as will be seen by a glance at his schematic arrangement 
 here given in full: 
 
 f 1. Vesanic or essential (without lesion), 
 circular and partial. 
 
 2, Neuropathic 
 
 3. Diathetic 
 
 Insanities i 4. Sympathetic 
 
 5. Toxic. 
 
 6. Organic or cerebro-spinal . 
 
 7. Congenital or Morphologic. 
 
 Hj'steric. 
 Epileptic. 
 Choreic. 
 
 Gouty. 
 Rheumatic. 
 Tubercular. 
 Cancerous. 
 L Anaemic. 
 
 Genital. 
 Cardiac. 
 
 Gastro-intestinal. 
 Pulmonary. 
 
 Alcoholic. 
 Saturnine. 
 Morphinic. 
 
 General paresis. 
 Aphasia. 
 
 Delirium acutnm. 
 Hemiplegic dementia. 
 
 Idiocy. 
 
 Imbecility. 
 
 Cretinism. 
 
 Clouston (1883), following the teachings of his talented master 
 Skae, recognizes the great importance of the etiological factors of 
 Insanity, but he still classifies, by a combined psychological and 
 symptomatological principle, as follows: 
 
 1. States of Mental Depression. — a. Simple melancholia, h. Hy- 
 pochondriacal melancholia, c. Delusional melancholia, d. Excited 
 melancholia, e. Eesistive melancholia, f. Convulsive melancholia. 
 g. Organic melancholia, h. Suicidal, homicidal melancholia, 
 
 2. States of Mental Exaltation. — a. Simple mania, h. Acute 
 mania, c. Delusional mania, d. Chronic mania, e. Ephemeral 
 mania. /. Homicidal mania. 
 
60 TEXT-BOOK ON MENTAL DISEASES. 
 
 3. States of Regularly Alternating Conditions. — a. Periodic In- 
 sanity. 
 
 4. States of Fixed and Limited Delusion. — a. Monomania of 
 pride and grandeur. &. Monomania of unseen agency, c. Mono- 
 mania of suspicion. 
 
 .5. States of Mental Enfeellenient. — a. Secondary dementia. 
 l. Idiocy, imbecility, cretinism, c. Senile dementia, d. Organic 
 dementia. 
 
 6. States of Mental Stupor. — a. ]Melancholic stupor, l. Anergic 
 stupor, c. Secondary stupor. 
 
 7. States of Defective Inhihition. — Impulsive Insanity, epileptic, 
 sexual, homicidal, suicidal, destructive, dipsomaniac, kleptomaniac 
 impulses. 
 
 8. The insane diathesis. 
 
 Ea-afft-Ebing (1883), in his " Lehrbuch der Psychatrie," hav- 
 ing scientific methods, and a thorough practical acquaintance with 
 all the facts of mental diseases, made one of the best classifications 
 ever given to the patienth^ expectant medical world. It is thus 
 worded: 
 
 A. Psychical Diseases of the Developed Brain. 
 
 I. Psychoneuroses. 
 
 1. Primary curable conditions. 
 
 a. Melancholia. 
 
 (a) Melancholia simplex. 
 
 (6) Melancholia attonita. 
 h. Mania. 
 
 (a) Maniacal exaltation. 
 
 (h) Acute delirious mania. 
 
 c. Stupor or Curable Dementia. 
 
 d. Hallucinatory Delirium. 
 
 2. Secondary incurable conditions. 
 
 a. Secondary Monomania. 
 h. Terminal Dementia. 
 
 (a) Agitated Dementia. 
 
 (&) Apathetic Dementia. 
 
 II. Psychical Degenerations. 
 
 a. Constitutional affective Insanity. 
 1). Moral Insanity. 
 
THE NOSOLOGY OF INSANITY. 51 
 
 c. Primary monomarda. 
 
 (a) With primordial delusions of persecution. 
 (&) With primordial delusions of ambition. 
 
 d. Mental disorder with impellent ideas. 
 
 e. Insanity sequential of constitutional neuroses. 
 
 (a) Epileptic. 
 (&) Hysteria, 
 (c) Hypochondriacal. 
 /. Periodic Insanity. 
 III. Brain diseases with predominant psychical disturbances. 
 a. Dementia paralytica. 5. Lues cerebrales. c. Alcoholis- 
 mus chronicus. d. Dementia senilis, e. Delirium acutum. 
 
 B. Psychical Arrests of Development. 
 Idiocy and cretinism. 
 
 Spitzka (1883), with his wonted quickness of perception, seizes 
 on the psychological, symptomatological, etiological, and patholog- 
 ical principles, and applies them very aptly in this, his classifica- 
 tion: 
 
 Group First. — Pure Insanities. 
 
 Sub-Group A. — Simple Insanity, not essentially the manifesta- 
 tion of a constitutional neurotic condition. 
 
 First Class. 
 1st Division, attacking the individual irrespective of the physio- 
 logical periods. 
 
 Order of primar}- origin: 
 
 Genus 1. Simple mania. 
 
 Genus 2. Simple melancholia. 
 
 Genus 3. Katatonia. 
 
 Genus 4. Transitory frenzy. 
 
 Genus 5. Stuporous Insanity. 
 
 Genus 6. Primary confusional Insanity. 
 
 Genus 7. Primary deterioration. 
 
 Genus 8. Secondary confusional Insanity. 
 
 Genus 9. Terminal dementia. 
 
52 TEXT-BOOK ON MENTAL DISEASES. 
 
 2d Division, attacking the individual in connection with devel- 
 opmental or involutional periods. 
 
 Genus 10. Senile dementia. 
 Genus 11. Insanity of pubescence. 
 
 Second Class. 
 "With demonstrable active organic changes of the brain. 
 Genus 12. Paretic dementia. 
 Genus 13. Syphilitic dementia. 
 Genus 14. Dementia from coarse brain disease. 
 Genus 15. Delirium grave. 
 
 Sub-Group B. — Constitutional Insanity, the expression of a con- 
 tinuous neurotic condition. 
 
 Third Class. 
 Dependent on the great neuroses. 
 1st Division. The toxic neuroses. 
 Genus 16. Alcoholic Insanity. 
 2d Division. The natural neuroses. 
 Genus 17. Hysterical Insanity. 
 Genus 18. Epileptic Insanity. 
 
 Fourth Class. 
 Independent of the neuroses. 
 Genus 19, Periodical Insanity. 
 Order: Arrested development. 
 Genus 20. Idiocy and imbecility. 
 Genus 21. Cretinism. 
 Genus 22. Monomania. 
 
 Group Second. — Complicating Insanities. 
 
 Traumatic, Choreic, Postfebrile, Eheumatic, Gouty, Phthisical, 
 Sympathetic, Pellagrous. 
 
 Bevan Lewis (1889) presents mental diseases in a most scientific 
 light, from a pathological point of view by preference, though all 
 the clinical phases of the subject are dealt with in a masterly man- 
 ner. He treats of Insanity under the following heads: 
 
 1. States of Depression. 2. States of Exaltation. 3. Fulmi- 
 
THE NOSOLOGY OF INSANITY. 
 
 53 
 
 nating Psychoses. 4. States of Mental Enfeeblement. 5. Eecurrent 
 Insanity. 6. Epileptic Insanity. 7. General Paralysis of the In- 
 sane. 8. Alcoholic Insanity. 9. Insanity at the Periods of Puberty 
 and Adolescence. 10. Insanity at the Puerperal Period. 11. Insan- 
 ity at the Climacteric Epoch. 12. Senile Insanity. 
 
 The International Medical Congress, at Paris, 1889, adopted 
 the following classification of Insanity: 
 
 1. Mania (acute delirious mania also). 3. Melancholia. 3. Pe- 
 riodical Insanity. 4. Progressive systematized Insanity. 5. De- 
 mentia (Vesanic, organic, senile). 6. General Paralysis. 7. In- 
 sanity from neuroses (Hysteria, Epilepsy, and Hypochondriasis). 
 8. Toxic Insanity. 9. Moral and impulsive Insanity. 10. Idiocy. 
 
 This is not complete as a classification of Insanity, but it may 
 be deemed a very useful worldng formula for grouping patients in 
 the wards of the insane hospitals. 
 
 Regis (1891), in his " Manual of Mental Medicine," which teems 
 with modem ideas, gives the following as his classification: 
 
 Partial or Essential In- 
 sanities. 
 
 /. Functional Alienations. 
 
 Generalized or Sympto- J 
 matic Insanities. I 
 
 2. Melancholia 
 
 Subacute mania. 
 Acute mania. 
 Hyperacute mania. 
 Chronic mania. 
 j_ Remittent or intermittent mania. 
 
 Subacute melancholia. 
 
 Acute melancholia. 
 
 Hyperacute melancholia, with stupor. 
 
 Chronic melancholia. 
 
 Remittent or intermittent melancholia. 
 
 •3. Insanity of double form . -j 
 
 Systematized progressive in- 
 sanity.^ 
 
 Continuous. 
 Intermittent. 
 
 First stage — hypochondriacal. 
 Second stage — persecutory, religious, 
 
 etc. 
 Third stage — ambitious. 
 
 //. Constitutional Alienations. 
 
 ( Disharmonies -{ Originality ; eccentricity. . 
 
 Neurasthenics -{ Fixed ideas ; abulias. 
 
 i Delusional. 
 
 Degeneracies of Evolution . -j Phrenasthenias < Reasoning Insanity ; moral Insanity. 
 
 ( Instinctive Insanity. 
 
 ( Imbecility. 
 
 Monstrosities < Idiocy. 
 
 ( Cretinism. 
 
 Degeneracies of Involution, -j Dementias -{ Simple dementia. J 
 
 In this nosology the symptomatological principle is seen to be 
 most skilfully elaborated. Had the other nosological principles been 
 
64 TEXT-BOOK ON MENTAL DISEASES. 
 
 brought to bear upon the subject with equal originality, the classifi- 
 cation would have been extraordinarily successful, instead of only 
 partially complete. 
 
 Stearns (1893) regards a complete classification of Insanity in 
 the present state of knowledge as extremely difl&cult. 
 
 He employs the symptomatological and the etiological principles 
 of classification in his tabular presentation of the chief forms of 
 mental diseases, which he divides into two main groups, as follows: 
 
 A. Symptomatological. 
 
 1. Melancholia. 2. Mania. 3. Primary Delusional Insanity. 
 4. Folie Circulaire. 5. Dementia. 
 
 B. Etiological. 
 
 1. Epochal. 
 
 Insanity of puberty. 
 Climacteric Insanity. 
 Senile Insanity. 
 
 2. Sympathetic. 
 
 Puerperal Insanity. 
 Masturbatic Insanity. 
 Ovarian Insanity. 
 
 3. Toxic. 
 
 Alcoholic Insanity. 
 Syphilitic Insanity. 
 
 4. jSTeuropathic. 
 
 Epileptic Insanity. 
 Hysterical Insanity. 
 
 5. Pathological. 
 
 General Paralysis. 
 
 Insanity from coarse brain disease. 
 
 Acute Delirium (Typhomania). 
 
 6. Other less frequent genera and species. 
 
 Phthisical Insanity. 
 Kheumatic Insanity. 
 Postfebrile Insanity. 
 
 The descriptions of the clinical forms are written with the truth- 
 ful assurance of one long familiar, by actual observation, with the 
 
THE NOSOLOGY OF INSANITY. 55 
 
 diYersified phases of every type of mental disease, and they are pleas- 
 urable reading to one likewise versed in clinical minutiae. 
 
 Ziehen (1894), a very competent writer, after much considera- 
 tion, concludes, finall}'', that the nosology of Insanity is best accom- 
 plished by a combination of the psychological and the symptomato- 
 logical principles. He bases his chief division, therefore, on the 
 clinical and psychical fact that some cases present disturbances of 
 the intellectual faculties from the very first, wdiile in otlier cases the 
 intellect is not thus involved. His classification is as follows: 
 
 I. Psychoses Without Intellectual Defect. 
 
 A. Sim|)le Psychoses: A single chief stadium. 
 
 1. Affective Psychoses. — Primary chief symptoms in the 
 emotional domain. 
 
 a. Mania. 
 
 &. Melancholia. 
 
 c. Neurasthenia. 
 
 2. Intellectual Psychoses. — Primary chief symptoms in the 
 intellectual domain, 
 
 a. Primary Dementia. 
 &. Paranoia. 
 
 (a) Paranoia simplex. 
 
 (&) Paranoia hallucinatoria. 
 
 (c) Flighty and changeable form. 
 
 {d) Stuporous form. 
 
 {e) Incoherent form. 
 c. Insanity with impellent ideas. 
 
 B. Compound Psychoses, several chief stadia. 
 
 U, Psychoses With Intellectual Defect. 
 
 A. Congenital mental weakness. 
 
 a. Idiocy. 
 
 h. Imbecility. 
 
 c. Feeble-mindedness. 
 
 B. Acquired mental weakness or dementia. 
 
 a. Dementia paralytica. 
 
 1). Dementia senilis. 
 
 c. Dementia secondary to functional psychoses. 
 
56 TEXT-BOOK ON MENTAL DISEASES. 
 
 d. Dementia secondary to focal brain diseases. 
 
 e. Dementia epileptica. 
 /. Dementia alcoholica. 
 
 Sohmer (1894), on the other hand, resorts exclusively to the 
 anatomical and pathological principle of division. 
 
 He claims that mental affections are simply diseases of the nerv- 
 ous system, and that there is a perfectly plain ground for their clas- 
 sification into those which have, and into those which have not, 
 demonstrable lesions of nervous tissues. His nosology, in keeping 
 with this anatomo-pathological idea, is the following: 
 
 I. Mental Diseases With Demonstrable Lesions of Brain Substance. 
 
 A. With anatomical and morphological demonstrable lesions. 
 General paralysis, cerebral tumor, senile atrophy, microcephaly, 
 
 porencephaly, cretinism. 
 
 B. With chemically occasioned lesions: 
 
 a. Insanity from alcohol, morphia, cocaine, hydrophobic 
 virus, auto-intoxication, and myxcedema. 
 
 1). Infection-deliria from typhus fever, erysipelas, and 
 acute inflammatory rheumatism. 
 
 II. Mental Diseases Without Demonstrable Lesions of Brain Substance. 
 
 a. Epileptic, hysteric, hypnotic, melancholia, mania, hallucina- 
 
 tory delirium, hallucinatory delusional Insanity, katatonia. 
 
 b. Degenerative forms: 
 
 1. Congenital feeble-mindedness. 
 
 2. Congenital partial moral defect. 
 
 3. Primary mental weakness. 
 
 4. Periodic Insanity. 
 
 5. Original monomania (paranoia). 
 G. Paranoia tarda. 
 
 7. Hypochondriasis. 
 
 8. Impellent ideas. 
 
 Thus, at no small expense of patient endeavor, the chief classi- 
 fications of writers on mental diseases have been reproduced, and 
 commented upon for the information of the reader, who has been 
 
THE NOSOLOGY OF INSANITY. 57 
 
 made acquainted with the principles applicable in the nosology of 
 Insanity, and with the manner in which they have been employed 
 by the best authors, and also with the inherent difficulties of the 
 whole subject, and there only remains a final topic to complete this 
 chapter. 
 
 The author's classification of Insanity, and the reasons for the 
 same, will now be given to conclude the subject. 
 
 The physician, in his practical dealings with cases of mental 
 disease in hospitals or in private practice, when the fact of Insanity 
 is once established, seeks first and most eagerly for the causes of the 
 disease, knowing that they will most aid him in the understanding 
 and in the treatment of the case. 
 
 He directs his inquiries somewhat in the following order: He 
 first desires to know whether there has been congenital defect or 
 early acquired mental weakness, or whether there is native singular- 
 ity and distinct hereditary tendency to Insanity; whether there has 
 been anything like chorea, hysteria, epilepsy, or other neuroses; and, 
 receiving only a negative answer to these questions, he still con- 
 tinues liis search for causes, seeking to know if the mental disorder 
 might not arise in connection with puberty, menopause, or senility, 
 according to the age of the patient: or whether it might have sprung 
 from fevers, syphilis, consumption, gout, rheumatism, or from some 
 excess in the use of alcohol or opium, or from accidental poisoning, 
 or severe falls, or blows on the head. If these inquiries bring him 
 no positive information, he turns his search for causation in another 
 direction, and tries to learn whether there has been worry and men- 
 tal strain, domestic unhappiness, business losses, grief from death 
 in the family, great disappointments or sudden shocks from fright, 
 or other moral cause for the Insanity. Now this line of inquiries 
 is perfectly natural, and is a scientific procedure on the part of the 
 physician, who, as soon as he finds a definite and decided cause for 
 the mental disorder, at once assigns it a clinical position in the 
 category of mental diseases and proceeds to treat it accordingly. In 
 other words, the etiological principle is the one in general use and 
 most esteemed in actual daily practice by physicians, and it is here 
 given a foremost position in the clinical arrangement of the different 
 types of mental disorder. 
 
 But, to observe the skilful physician still further, when he fails 
 to find in the history any definite cause, it will be seen that he next 
 resorts to scientific research and personal examination of the patient 
 
58 TEXT-BOOK ON MENTAL DISEASES. 
 
 with instruments of precision, to determine pathological conditions 
 of the brain, spine, vasomotor or peripheral nervous system, and, 
 having discovered organic disease to account for the mental dis- 
 turbance, he classifies and treats it on pathological grounds. 
 
 Such is the difficulty of exact diagnosis, however, that the patho- 
 logical principle, though first in point of actual science, is here ac- 
 corded a secondary position in the nosological arrangement, since 
 it only admits of occasional application. 
 
 But, to take the clinical expert in mental diseases as a mentor 
 once more, it will be found that when the etiological and patholog- 
 ical principles fail him completely and he can find neither bodily 
 nor mental causes, nor a pathological state of the nervous system, by 
 which to class the Insanity, he then makes a careful study of the 
 nature and course of the mental symptoms, and he classifies and 
 treats the patient solely on symptomatic lines. 
 
 Here, then, is the third or symptomatological principle as it oc- 
 curs in regular order in the nosology of Insanity about to be given. 
 This classification is drawn on the identical clinical lines above 
 traced, and in keeping with the principles mentioned, and it is prac- 
 tical for everyday use, and sufficiently complete to include every 
 case that the student or practitioner will ever meet. Class I. cor- 
 responds to the physician's inquiry for congenital defects. Class II. 
 answers to the question about degenerate eccentricity and hereditary 
 taint. Class III. responds to the clinical query as to actually devel- 
 oped neuroses. Class IV. embraces a reply to the examining physi- 
 cian as to the physiological crises. Class V. contains such farther 
 causes as the clinical expert naturally seeks as a means by which 
 to class and treat his patients. Class VI. is the pathological order 
 in which the clinician sometimes classes his cases by precise scien- 
 tific diagnosis. Class VII. contains Insanity from psychical causes, 
 to which the practitioner refers some of his cases, and the remaining 
 classes are symptomatological, and furnish a natural means of clas- 
 sification to the ph}' sician when, in any particular case, he finds that 
 the etiological and pathological factors are not to be discovered or as- 
 signed. 
 
 In one word, insane patients are classed in this nosology, first, by 
 bodily and mental causes; second, by the exact nature of the physical 
 morbid process underlying the Insanity, and, third, by the form of 
 the mental symptoms. The facts included in the nosology are 
 necessarily numerous, but they are grouped by the above simple 
 
THE NOSOLOGY OF INSANITY. 59 
 
 principles, as will be seen by a moment's study of the different 
 classes. 
 
 The natural history method of subdivision is employed as the 
 most convenient means of clearly indicating certain natural affili- 
 ations and subordinate relations in the classes, orders, and genera. 
 There is no failure to recognize the difference in the nature of the 
 material with which natural science and mental science has to deal. 
 Pathological mental phenomena, however, are based on changes in 
 physical structures, and they are often not more variable than 
 changes manifested in lower types of animal organisms, and in some 
 regards the laws of the human mind are as immutable as those of 
 natural science, and admit of an equally clear classification. 
 
 To proceed, then, to a somewhat broader and naore scientific ex- 
 planation of the nosology here given, it will be noted that there are 
 two main groups. Group A is made in accordance with the etiolog- 
 ical and pathological principles, and it is hence briefly defljied as 
 etio-pathological, and as having definite assignable etiological and 
 pathological relations. 
 
 Group B, on the contrary, consists of the simple psychoses, with- 
 out definite assignable etiological and pathological relations, and 
 hence classifiable by the psychical symptoms alone, and hence the 
 group is briefly denominated " psycho-symptomatological." 
 
 In Group A, by the application of the etiological principle, 
 the lines of division of the classes are caused by organic ar- 
 rest of development, by constitutional neuropathic states ordi- 
 narily hereditary, though occasionally acquired by the established 
 neuroses, by the physiological crises, by general systemic morbid 
 states, either toxic or diathetic, and, finally, by the direct action 
 of powerful psychical causes; and through the use of the pathological 
 principle there appears a class with definite pathological conditions 
 of the encephalo-spinal, vasomotor, or peripheral nervous system^ 
 
 In Group B, by the symptomatological principle, the classes, 
 based on the fundamental division of the human mind into feeling, 
 intellect, and will, are subdivided in accordance with the universally 
 admitted states of depression, states of exaltation, and states of weak- 
 ness, and the only farther distinction made is as to whether these 
 states are primary or secondary in origin. 
 
 Here, then, is a S5^stematic nosology drawn on practical and nat- 
 ural clinical lines, utilizing, primarily, the etiology and the pathol- 
 ogy, and secondarily the mental symptomatology of Insanity for the 
 
60 
 
 TEXT-BOOK OlSr MENTAL DISEASES. 
 
 purpose of the subdivisions of the various classes. It serves to show 
 the relations between different orders of facts, and that is the object 
 of all classification, which is necessarily more or less artificial; for, 
 in nature there are nowhere hard and fast lines of division, but 
 everything merges, by the most gradual evolution, into something 
 else by such gentle transitions that no lines of division are anywhere 
 perceptible. This is no less true in the animal and vegetable king- 
 doms than in the domain of human mental diseases. 
 
 With these preliminary remarks the classification is now given 
 and commended to the careful consideration of the reader. 
 
 Classification of Insanity. 
 
 Growp A. {Etio-pathological.) 
 
 With Definitely Assignable Etiological and Pathological Relations. 
 
 Class I. From general organic 
 arrest of development. 
 
 Order 1. Idiocy. 
 Order 2. Cretinism. 
 Order 3. Imbecility. 
 
 Class II. Emerging from con- f Order 4. Instinctive Insanity 
 stitutional neuropathic | of childhood, 
 
 states, usually hereditary, -J Order 5. Primary monomania, 
 though occasionally ac- | Order 6. Moral Insanity. 
 quired. L Order T. Periodical In.«anity. 
 
 f Order 8. Epileptic Insanity. 
 I Order 9. Hysterical Insanity. 
 I Order 10. Hypochondriacal In- 
 sanity. 
 Order 11. Choreic Insanity. 
 Order 12. Neurasthenic Insan- 
 ity. 
 
 Order 13. Pubescent Insanity. 
 Order 14. Puerperal Insanity. 
 Order 15. Climacteric Insanity. 
 Order 16. Senile Insanity. 
 
 Class III. With established 
 neuroses. 
 
 Class IV. In connection with 
 the physiological crises. 
 
 f 
 
 Order 17. Toxic . 
 
 Class V. With, general sys- , 
 temic morbid states. ' 
 
 Order 18. Diathetic 
 
 f Genus 1. 
 
 Genus 2. 
 
 Genus 3. 
 
 Genus 4. 
 
 Genus 5. 
 I Genus 6. 
 J Genus 7. 
 
 Genus 8. 
 
 Genus 9. 
 
 Genus ](]. 
 
 Genus 11. 
 
 Genus 12. 
 
 Genus 13. 
 [ Genus 14. 
 
 Genus 15. 
 
 Genus 16. 
 
 Genus 17. 
 
 Genus 18. 
 
 Genus 19. 
 1 Genus 20. 
 I Genus 21. 
 
 Genus 22. 
 I Genus 23. 
 [_ Genus 24. 
 
 Alcoholism. 
 
 Morphinism. 
 
 Plumbism. 
 
 Hydrargyrism. 
 
 Oxy-carbonism. 
 
 Cocainism. 
 
 Bromidism. 
 
 Etherlsm. 
 
 Chloroformism. 
 
 Chloralism. 
 
 Nicotmism. 
 
 Auto-intoxications. 
 
 Lyssa humana. 
 
 Infectious diseases. 
 
 Phthisical. 
 
 Cancerous. 
 
 Podagrous. 
 
 Rheumatic. 
 
 Pellagrous. "'" 
 
 Limopsoitosic. 
 
 Malarious, 
 
 Anaemic. 
 
 Po«t-febrile. 
 
 Myxoedematous. 
 
THE NOSOLOGY OF INSANITY. 
 
 61 
 
 Class VI. With definite patho- 
 logical conditions of the 
 encephalo - spinal, vaso- 
 motor, or peripheral 
 nervous system. 
 
 Order 19. With organic lesions 
 of cerebral tissues. 
 
 Order 2U. With lesions of the 
 vasomotor and peripheral 
 nervous system. 
 
 Class VII. From pathological f Order 21. P s y c h o - traumatic 
 psychic influences. \ Insanity. 
 
 Genus 25. General paresis. 
 Genus 2H. Syphilitic Insanity. 
 Genus 27. Organic dementia. 
 Genus 28. Typhomania. 
 Genus 29. Traumatic Insanity. 
 
 Genus .30. Sympathetic Insanity. 
 
 Group B. The Psyclwses {Psycho-symptomatological). 
 Without Defiiitely Assignable Etiological and PatJiological Relations. 
 
 Class IX. Intellectual. 
 
 Class X. Volitional. 
 
 r 
 
 r 
 
 Class VIII. Emotional. - 
 
 Order 22. States of de- 
 pression. 
 
 Order 23. States of ex- 
 altation. 
 
 Genera primary . . 
 
 Genera secondary. 
 
 Genera primary . . 
 
 Genera secondary . 
 
 r3i. 
 
 32. 
 33. 
 
 .34. 
 35. 
 
 f 86. 
 
 137. 
 i 38. 
 
 39. 
 40. 
 
 Order 24. States of J Genus primary .. . { 
 weakness 
 
 Genus secondary. 
 
 Coensesthetic d e pres- 
 
 sion. 
 Melancholia simplex. 
 Melancholia agitata. 
 
 Melancholia chronica. 
 
 Secondary monomauia 
 
 with depression. 
 
 CoeniEsthetic exalta- 
 tion. 
 Mania simplex. 
 Mania transitorin. 
 
 Mania chronica. 
 Secondary monomania 
 with exaltation. 
 
 Primary mental en- 
 feeblement. 
 
 ■{ 42. Terminal dementia. 
 
 Order 25. States of J Genus primary .. . 
 stupor. I 
 
 [_ Genus secondary. . 
 
 ^'"^ uti^n.^'"^'*'''"^ ""^ \ <^«""^ p^'^^'^y • ■ 
 
 ! Order 27. Suspended ( o™,,, ;™o„. 
 
 L volition. }■ Genus primarj 
 
 ( 43. 
 1 
 
 -I 44. 
 
 -! 45. 
 
 \ 46. 
 ( 
 
 Acute primary demen- 
 tia. 
 
 Sequential stupor. 
 Abulic Insanity. 
 
 Somnambulistic I n - 
 sanity. 
 
 In reg^ard to the nomenclature of the classification, a word may 
 be said to advantage. Words, of course, are only signs of ideas, 
 hut they are accustomed signs, and for that very reason they should 
 not he changed without good reason when they have once i)assed 
 into general use and been accepted as technical labels in special 
 branches of science. No innovations have been made, therefore, 
 but the terms in current use have been continued, and a new des- 
 ignation has only been employed in one or two acute and chronic 
 types of Insanity to mark distinctions not already clearly made. 
 
 In the second or clinical part of this treatise all the typical 
 forms of Insanity named in this classification will be. separately de- 
 scribed, and it is only deemed necessary here to define the main feat- 
 
62 TEXT-BOOK ON MENTAL DISEASES. 
 
 iires of the generic types and the reasons for their relative positions 
 
 in this nosology. 
 
 The main grounds of the first division into the two groups have 
 already been mentioned. Group A contains the degenerative and 
 hereditary forms of Insanity and all such as have a definite and 
 assignable etiology and pathology. Group B represents the simple 
 psychoses, without degenerative type or hereditary form, and having 
 no assignable pathological basis, and also having no direct derivative 
 relation to other separately existing diseases of the nervous systeni, 
 or to any established neurosis. Some authors, considering simple 
 Insanity of the character here described as a neurosis, have applied 
 the term " psychoneuroses " to these simple psychoses. It is im- 
 portant to grasp the clinical idea, but the terminology is a matter 
 of little importance, for, as a matter of fact, all Insanity may be 
 considered to be a neurosis, and properly to be classed among the 
 neuroses. 
 
 In order to further unfold the rational method in accordance 
 with which this nosological system was constructed, let a moment's 
 explanation be given in regular order to each of the classes with its 
 subdivisions. Class I. is characterized by general organic arrest of 
 develoimient of mind and body. It represents, in the highest de- 
 gree, degenerate types and congenital defects. Between the lowest 
 idiocy and the slightest imbecility there is a sliding scale of intelli- 
 gence, with every conceivable degree of mental defect actually illus- 
 trated in different patients. ISTor does this gradation of intelligence 
 stop with imbecility, for, between a person distinctly imbecile and 
 an individual of average mental ability, there are to be sometimes 
 seen those of only intermediate intelligence, sometimes spoken of 
 as feeble-minded. To avoid unnecessary terms and limit their num- 
 ber when possible, the feeble-minded are here included under im- 
 becility, which is extended to embrace all beneath the average of 
 intelligence. Cretins, who, as a rule, are the endemic hereditary 
 victims of unfortunate elemental conditions of earth, air, and water, 
 are more nearly allied to idiots than to imbeciles, though the pa- 
 thology of their affection is not that of ordinary idiocy, and they 
 are here classed intermediately between idiots and imbeciles. Class 
 II. comprises forms of mental disease which emerge from constitu- 
 tional neuropathic states usually hereditary, though occasionally 
 acquired. The degeneracy is not necessarily structural, and it is 
 often only functionally manifested, and to be traced as hereditary 
 
THE NOSOLOGY OF INSANITY. 63 
 
 taint in the history of the patient. The stronger the degenerate 
 taint, the earlier it is apt to reveal itself, and hence the " Instinctive 
 Insanity of childhood '*' is placed in sequence next to the generic 
 types of the first class. Next in order of constitutional heredity is 
 primary monomania, which is synonymous here with original mono- 
 mania, or paranoia, as it is more commonly, but less properly, 
 termed. 
 
 Moral Insanity comes next in this degenerate class, for, although 
 it raises a vexed question, it has heen admitted on the ground previ- 
 ously indicated, that no type encountered in actual clinical practice 
 is to be excluded on theoretical considerations. 
 
 Periodical Insanity is the final type in this class, and in it the 
 constitutional neuropathic state is revealed intermittently as aber- 
 ration of mind. 
 
 Class III. is a division based upon the established neuroses. It 
 is one of the degenerative classes, and in it are mentioned neuroses 
 most nearly allied to mental alienation, and later it will be explained, 
 in the clinical part of this work, how vicarious transformation be- 
 tween Insanity and these neuroses actually occurs. 
 
 Class IV. is the final distinctly degenerative class, and it contains 
 types in which the mental aberration only appears when the organ- 
 ism is undergoing evolutional or involutional changes, or passing 
 through some crisis, during which the inherited instability reveals 
 itself. Attention is here called to the methodical foresight in this 
 nosological system, by which the degenerative types are given a fore- 
 most place, such as they occupy in clinical observation, and that not 
 only the first four classes, but the genera contained therein, are ar- 
 ranged in the order of the prevailing degeneracy or hereditary taint, 
 which diminishes gradatim from the first genus of the first class 
 to the last genus of the fourth class, now under consideration. Any 
 exception to this which may be occasionally met will only serve to 
 prove the rule, which will always hold good when applied to num- 
 bers of cases. With this fourth class is exhausted, as a basis of di- 
 vision, the transmitted, degenerative instability of nervous centres, 
 and some other etiological principle of v\^ide application is next 
 sought and found in general systemic morbid states, such as appear 
 in the next class. 
 
 Class V, is replete with toxic and diathetic states, accompanied 
 by mental disorder. The writer was among the first, in a monograph 
 published some years ago, to call attention to the toxic origin of 
 
64 TEXT-BOOK ON MENTAL DISEASES. 
 
 Insanity. At that time it was Ms impression, from the observation 
 of more than five thousand cases of Insanity that had come under 
 his personal charge, that something more than thirty per cent, were 
 toxic or diathetic in origin. It is now believed that this source of 
 Insanity was underestimated, and that a much larger percentage 
 of cases than that then stated will be found to be classifiable under 
 this head. 
 
 With the genera in the first five classes of this nosology once 
 assigned to their respective positions, the value of the etiological 
 principle in classification is chiefly exhausted, and the pathological 
 principle is then brought into use as it here appears in the following 
 class: 
 
 Class YI. is the pathological group, with organic lesions of cere- 
 bral, and often of spinal, centres, or of the vasomotor and periph- 
 eral nervous system. The psychic scourges of mankind, general 
 paresis and syphilitic Insanity, are in this class, and organic de- 
 mentia, into which some of the brightest minds the world has ever 
 known have finally sunk, and typhomania, which, by the Conti- 
 nental writers more especially, is termed delirium acutum, but, as 
 Dr. Luther Bell first described it in 1844 and called it typhomania, 
 the original name is preserved. Sympathetic Insanit}'' is here more 
 limited than the term as used by many German writers, as will be 
 described later. 
 
 Class VII. shows a final application of the etiological principle 
 to include the psychical causes of Insanity. The injury inflicted by 
 repeated mental shocks is here justly classed in the category of 
 psychic traumatism, which it virtually is, and it is sometimes fol- 
 lowed by actual lesions of nervous tissues, which in this sense are 
 traumatic in origin. 
 
 Group B having no definite pathological basis, and being drawn 
 on p&ycho-symptomatological lines, it was necessary that the dehm- 
 itation of the classes should be in accordance with some comprehen- 
 sive and established division of the human mind, and the one adopted 
 is probably more universal in character than any other. 
 
 Class YIII. is composed of orders of mental disease characterized 
 by depression or exaltation of feeling, which constitutes a continu- 
 ous fundamental tone. The genus termed coengesthetic depression, 
 and also that called coenresthetic exaltation are important innova- 
 tions to denote an initiatory form of mental disease first described 
 by the writer. The genera in this class are both primary and sec- 
 
THE NOSOLOGY OF INSANITY. 65 
 
 ondary as regards their mode of origin. The inclusion of mania 
 transitoria in this class is open to criticism, if the etiology of the 
 affection is, as some suppose, uniformly epileptic. Of this some- 
 thing will he said when this form is cHnieally descrihed. 
 
 Secondary monomania with depression, and secondary mono- 
 mania with exaltation, are forms of chronic Insanity descrihed 
 some years ago by the writer. They are distinct clinical types 
 wliich had previously been merged indiscriminately in chronic 
 mania or dementia. They are not to be confounded with secondary 
 forms of paranoia, and they will be fully written about in the second 
 part of tliis book, along with the other typical forms. 
 
 Class IX. is subdivided into general states of weakness and states 
 of stupor. The genus " Primary mental enf eeblement " is admit- 
 tedly very rare, but it is the professed object of a classification to 
 provide a place for every distinct type, and hence the provision for 
 this form. 
 
 The states of stupor are of great importance, and other forms 
 might have been admitted, but they can all be classed without any 
 undue straining of clinical points under the two genera here named, 
 as it is best, so far as possible, to limit the terminology of Insanity. 
 Class X. contains mental alienations in which the volitional ac- 
 tivities are especially involved. The admission of " Abulic Insan- 
 ity " is open to discussion, in the opinion of some alienists, but, as it 
 is only possible to judge of mind, either in health or disease, by 
 outward manifestations, this type, which corresponds to the morbid 
 psychical symptoms sometimes seen in actual practice among the 
 insane, is here classed separately. 
 
 Somnambulistic Insanity, too, is a rare form, but it has forensic 
 importance, as crimes have been committed not infrequently by 
 patients in pathological sleep-states, while the volitional energies 
 were completely suspended. This final genus of this classification 
 provides that such criminal cases, whose highest form of mental 
 energy, the will itself, is in complete abeyance, are to be classed 
 as in a state of Insanity none the less real because transitory. 
 
 The objections which may be urged against tliis classification 
 will not be anticipated, nor answered in advance, as they are just 
 such as in the present state of knowledge may be -made against all 
 the nosologies of Insanity that have been or are to be constructed. 
 It would not have been difficult to formulate a more highly pliilo- 
 sophie scheme of classification — one with a greater display of scien- 
 5 
 
66 TEXT-BOOK ON MENTAL DISEASES. 
 
 tific facts, and perhaps fewer vulnerable points of criticism — ^but 
 it would not have had the value of the present one for clinical work- 
 ing purposes. The theoretical perfection of a classification is no 
 test of its real worth. All classifications in every branch of knowl- 
 edge are artificial, and in themselves of no inherent value, merely 
 serving as a means to an end, as provisional arrangements of facts, 
 and as working formulae, to be changed as often as the evolution of 
 science demands it. The Linnaean system was a revelation to the 
 scientific world, and of incomputable value to workers in all branches 
 of natural science, but it was by no means perfect as a system of 
 nosology. Linnseus elaborated a nosology of mental diseases with 
 great success, considering the material out of which he had to con- 
 struct it. He was practically without any etiological and patholog- 
 ical facts, and his chief divisions, " Ideales, Imaginarii, and Pathet- 
 iei," were subdivided and complexly compounded by refined meta- 
 physical and psychological distinctions, such as have usually formed 
 the " stock in trade " of metaphysicians in all ages of the world. 
 
 In concluding this chapter on classification, it may be well to 
 state what facts are actually still needed for the construction of a 
 rational and complete nosology of Insanity, and to suggest such lines 
 of medical research and of clinical inquiry as in time may, if assid- 
 uously pursued, lead to the acquisition of at least some of these 
 needed facts. 
 
 It is to be granted as sufficiently proven that the brain is essen- 
 tially the organ of the mind, though it is also highly probable that 
 the whole nervous system is subservient, to some degree, in the 
 same functional direction. If, then, the cerebral structures are the 
 physical mechanism of mind, the first needed facts are the minute 
 details of the component parts of this thinking machine — the ana- 
 tomical facts, in other words, which correspond to the physiological 
 mental functions. When the methods of Golgi and Cajal, of Dejer- 
 ine and Ketzius, and a hundred others still more perfect, shall hr.ve 
 evolved, in the distant future, the complete microscopical anatomy 
 of cerebral structures as they exist in health, and when experimental 
 physiology shall have connected with these structures the correlative 
 psychical functions as they exist in health, two important kinds of 
 facts now needed will have been supplied. The morphological facts, 
 however, must extend beyond those supplied by microscopical re- 
 search, and must embrace all those to be discovered by a perfected 
 physiological chemistry, which will eventually reveal the complex 
 
THE NOSOLOGY OF INSANITY. 67 
 
 biochemical changes of tissues through which nervous energy is 
 simultaneously transformed and conserved. 
 
 With all the needed facts to be supplied by applied microscopical 
 aDatomy, biochemistry, and mental physiology, the first scientific 
 step will have been taken in the true knowledge of mind as based 
 on material structures in health. Then another class of facts will 
 be required of a pathological nature, and an independent order of 
 clinical observations must be recorded before positive inferences 
 can be drawn as to the actual nature of Insanity. 
 
 The changes which these nervous structures undergo in disease, 
 and the corresponding alterations in mental functions, as seen in 
 mental disorders — facts to be supplied by a new pathological anat- 
 omy and a new mental pathology — are the additional classes of data 
 to be sought by the following generations of students of mental 
 science before a truly scientific nosology of Insanity can be con- 
 structed. 
 
 In the meantime, as the skilled natural scientist infers correctly 
 the unknown from the known, and arrives at many things from a 
 few definite things, or, as the zoologist reconstructs an extinct spe- 
 cies out of the partial discoveiT of its geological remains and as- 
 signs it a relative position on the scale of animal intelligence, so the 
 mental scientist, by inferential methods, must for the present be 
 satisfied to infer mental functions from partial knowledge of actual 
 physical structures, and he must " learn to labor and to wait." A 
 vast amount of labor essential to the evolution of psychiatric science 
 must be performed in the field of clinical research, which has never 
 been thoroughly cultivated by alienists, who have been over-occu- 
 pied by routine duties. Many of the psychic phenomena, and almost 
 all of the somatic symptoms, have yet to be scientifically studied. 
 The blood and the urine and all the secretions and excretions must 
 be analyzed exhaustively in laxge numbers of cases of the various 
 types of insanity in like stadia of the disease. The whole question 
 of toxic and auto-toxic Insanity presents an immense field for chem- 
 ical research. The modifications of all the physiological functions 
 in mental disease are yet to be studied. The application of instru- 
 ments of precision to the exact determination of the accompanying 
 neurological affections of Insanity has still to be performed and re- 
 corded. 
 
 Even the gross disorders of the muscular system, and of the spe- 
 cial meclianisms of speech and gait, have only been partially ana- 
 
68 TEXT-BOOK ON MENTAL DISEASES. 
 
 lyzed, and the perversions of the functions of the special senses in 
 mental disease, if properly investigated by psycho-physical and psy- 
 chometrical research, would yield data of the utmost value. 
 
 The intercurrent affections of all the internal viscera,, some of 
 -which bear direct relations to the Insanity, are yet to be investi- 
 gated. 
 
 The causative relations of the diathesis to the psychoses have 
 never been a subject of extended rational inquiry. 
 
 The pathogenetic relations of vasomotor disturbances to mental 
 disease have only just begun to receive due notice, and the changes 
 in intravascular blood-pressure and sphygmographic variations in 
 large numbers of cases in the various phases of Insanity are yet tp 
 be duly recorded. 
 
 A thoroughly reliable and scientific system of statistics in all 
 branches of the clinical study of mental diseases has yet to be de- 
 vised, and reliable statistical data in all the lines of medical inquiry 
 above indicated have yet to be made. 
 
 Such, then, are the scientific foundations still to be laid, and such 
 is the material still needed by the medical architect who would build 
 a nosological superstructure, with appropriate compartments for 
 every order of psychiatric facts, which are all to be labelled by a com- 
 plete terminology and confirmed by the logic of figures and by a 
 perfect system of statistical records. 
 
 Let the student of psychiatric nosology not be discouraged, for 
 the light of coming knowledge already illumines the darkness which 
 surrounds some points of mental pathology. 
 
CHAPTEE lY. 
 
 THE ETIOLOGY OF INSANITY. 
 
 Insanity, when traced to such final causes as are best known to 
 science, is a disease of the nervous system, and it is to be classed 
 among the neuroses. Hence it is, from the broadest point of view, 
 that all those thermal, chemical, mechanical, and perverted biologi- 
 cal influences which are active in the production of general diseases 
 of the nervous system are those most fundamentally involved in the 
 causation of Insanity. 
 
 The chief customary division of the etiology of Insanity into 
 predisposing and exciting causes is convenient for descriptive pur- 
 poses, though, as a logical matter, the two classes of causes are some- 
 times interchangeable, or blend in the same case inseparably, or are 
 to such a degree interdependent that they can hardly be said to 
 have a separate existence. As a clinical fact, also. Insanity is usually 
 the result of a series of causes, which may act sequentially or sim^ul- 
 taneously, and in contributive degrees not to be ascertained by even 
 the most careful subsequent study of the case. 
 
 Predisposing Causes. 
 
 The predisposing causes, or those conditions, internal or external, 
 which favor, without actually causing, the development of Insanity, 
 will first receive attention. Heredity, as the chief predisposing 
 cause, will be considered at some length under the next heading, and 
 there will first be noticed the following predisposing circumstances. 
 
 The consanguinity of parents is generally deemed a circumstance 
 predisposing to deterioration in the offspring. This opinion has pre- 
 vailed from the earliest times, and both the Mosaic and the Eoman 
 law forbade marriages of certain degrees of consanguinity, as does 
 at the present day the legislation of most civilized countries. Pop- 
 
 69 
 
70 TEXT-BOOK ON MENTAL DISEASES. 
 
 ular prejudice in this regard is not based on instinctive repugnance 
 alone, and there is doubtless some good reason to be found in the 
 nature of the results themselves that consanguineous marriages 
 should be discouraged. Defects of the special senses and intellect- 
 ual deteriorations have resulted from such unions so frequently that 
 it has become a medical dictum that they are to be forbidden. The 
 experience of the breeders of animals is that " inbreeding," if car- 
 ried too far, results in loss of stamina, and finally in practical extinc- 
 tion of all the finer traits of the race. The intermarriage in English 
 and European aristocracies has afforded numerous instances of re- 
 sulting deteriorations, and like examples are also to be found in the 
 history of the Jewish people. 
 
 On the other hand, the law of physical inheritance is that the 
 qualities of the parents, when alike, are intensified in the offspring. 
 Theoretically, therefore, the sound bodily constitutions of two vig- 
 orous and nearly related parents should be transmitted with double 
 certainty to the offspring, and doubtless this is practically the result 
 in the majority of instances. 
 
 It would not be a logical inference from this that a uniformly 
 good result would follow the marriage of two first cousins free from 
 all known tendencies to disease as regards the common family, as 
 decided neurotic taint of like kind might perchance exist in the 
 separate families, and might be inherited by the children in intensi- 
 fied form. Near relatives, also, when married, may be in perfect 
 physical condition, but they are more apt than those not related 
 to become affected with like diseases during life, and to transmit, 
 with increased probability, the greater tendency to the same to their 
 children. 
 
 All things considered, there is no doubt that consanguineous 
 marriages between those as nearly related as cousins of the first de- 
 gree favor the direct transmission of a heightened tendency to neu- 
 rotic family traits, and that such marriages should be discouraged 
 by the physician as often as positive instances of Insanity have been 
 known to exist in the common family of either of the contracting 
 parties. The arithmetical insignificance of consanguinity of parents 
 as a predisposing cause of Insanity may be surmised from the fact 
 that in this countr}'-, with its floating and heterogeneous population, 
 there are relatively fewer intermarriages than in old and perma- 
 nently located communities, as in England, for instance, where it 
 has been estimated that not more than three or four per cent, of 
 
THE ETIOLOGY OF INSANITY. 71 
 
 the marriages are consanguineous, and hence, judged by the law of 
 chances, the actual proportion of cases of mental disease from this 
 source would be very small. 
 
 Civilization is to be numbered among the circumstances predis- 
 posing to Insanity. 
 
 So far as any reliable information is to be had, it appears that 
 Insanity increases as man departs from the savage and semi-civilized 
 states and approaches the highest civilization. 
 
 The brain of the savage is a psychical organ of primitive simplic- 
 ity, responding to sensorial stimuli, and moved by few emotions, 
 wliich spring chiefly from animal instincts. There are no pent-up 
 mental energies, since, as fast as generated, they find a ready exit 
 through muscular action, and tension of mind is thus avoided. The 
 daily wants of the man are simple and easily gratified, and nature 
 is not cheated of her own demands, and, as night comes on, the 
 child of nature sinks upon the bosom of Mother Earth in sweet and 
 natural slumber, during which there is a perfect restitution of brain 
 forces, and successive days are but the prolonged satisfaction of the 
 natural needs of a healthy organism. 
 
 On the other hand, the brain of the highly civilized man is an 
 exceedingly complex instrument, and as such liable to derangement. 
 It differs structurally, as well as functionally, from that of the sav- 
 age. It generates more highly specialized energies, and it is sur- 
 charged from earliest childhood with an ever-increasing burden of 
 knowledge, and it is played upon by a thousand stimuli unknown 
 to the savage, and it acts and reacts to environmental infiuences 
 innumerable times more frequently in the course of the day, and, 
 as night comes on, continued unconscious cerebration prevents its 
 perfect reparation during sleep. The highly civilized man lives in a 
 state of compound thoughts and emotions, provoked by the necessity 
 of rapid and varied adjustments to most complicated environments, 
 and every day evolves a host of petty battles, which have to be 
 planned and fought out to complete success or defeat, and each suc- 
 cessive morrow 1)rings but the renewal of the camp£iign. The ten- 
 sion of mind is continuous, wants are many and ungratified, artificial 
 desires multipl)', ambition fires the overworked brain, and the eager 
 hand reaches to grasp the prize which is plucked away by some other 
 one of the numerous competitors, and bitter disappointment is 
 added to mental overwork and nervous strain. 
 
 It has been argued that the increase of Insanity in civilized com- 
 
72 TEXT-BOOK ON MENTAL DISEASES. 
 
 muni ties is due largely to the fact that there is a more complete 
 enumeration of cases, that better methods of care prolong the lives 
 of patients and lead to a gradual accumulation of the same, and that 
 the increased confidence of the people in institutions for the insane 
 has brought to light many cases formerly hidden from statistical 
 notice. 
 
 According due weight to these arguments, it is still an unques- 
 tioned fact that there is a marked increase of mental diseases at- 
 tendant upon civilization, which, if more closely studied as a pre- 
 disposing cause, resolves itself into a series of somewhat widely dif- 
 fering questions, which will now be cursorily reviewed. 
 
 In the first place, civilization implies the massing of people in 
 large cities and all the hygienic abominations resulting therefrom. 
 Immense numbers of poor people live in crowded and badly venti- 
 lated apartments, many in damp and malarious underground rooms, 
 and it is the exception that even the middle classes have well- ven- 
 tilated dwellings. The well-to-do class abandons the overheated 
 and mephitic air of the city in summer, but the masses must endure 
 the debilitating atmosphere and the reeking odors of superficial 
 drainage and decomposing garbage. In -winter the same class suffers 
 from cold and from want of fuel and clothing. It is not alone the 
 filth and squalor of the dwelling, but it is the lack of food, which is 
 defective both in quantity and quality, which predisposes to physi- 
 cal and mental disease. 
 
 Then, again, this overcrowding leads to petty miseries and per- 
 sonal discomforts, to humiliating and demoralizing infiuences in 
 adults, and to the contamination of children, and successive gen- 
 erations bred in this way cannot escape degeneration of body and 
 mind. 
 
 But there is another attendant evil of civilization which is worse 
 than poverty, and that is crime, which bears a most intimate relation 
 to Insanity. When the conditions of life become extremely com- 
 plex, and the highest forms of self-control and prolonged efforts 
 are essential for success, there will always be numbers of unfort- 
 unate ones who will not or cannot conform to them, and they will 
 necessarily sink into poverty or drift into crime. In fixing a high 
 standard and in forcing the pace of civilization, society may thus be 
 said to make her own paupers, lunatics, and criminals. Possibly, 
 when a more perfect height of culture and wisdom shall have been 
 attained, these dismal failures may be avoided, but, in the present 
 
THE ETIOLOGY OF INSANITY. 73 
 
 state of sociological science, no remedy is known, and the evolution 
 of the many seems to proceed at the expense of those who are physi- 
 cally, mentally, or morally incapable of elevation to that higher 
 plane of existence termed civihzed life. 
 
 The question of age as a predisposing circumstance is one to be 
 determined largely by statistical inquiry. Taking the figures of 
 hospitals for the insane, it will be found that Insanity is relatively 
 rare in childhood and old age, and that the greatest number of pa- 
 tients are attacked during adult life. The decade of the maximum 
 frequency of Insanity, procured by comparing the number of those 
 attacked at a given age with the total number of those in the gen- 
 eral population of the same age, varies somewhat in different coun- 
 tries, and, while it falls between twenty and thirty years in this 
 country, it is found between thirty and forty years in England. 
 
 Facts which will be adduced in the clinical part of this work to 
 show the large amount of mental disease unrecognized as such in 
 children would tend to fix the maximum decade of the frequency 
 of the occurrence of Insanity at a still earlier period than the one 
 here named, and, on the contrary, the fact that the age of admission 
 to hospitals to the insane is, on the average, later than the actual 
 age of the attack, would, if given due weight, advance the period 
 of maximum frequency. The general pathological law is that the 
 mind is most subject to derangement during the period of its great- 
 est functional activity, and in those having a distinct neurotic taint 
 this period occurs earlier than in those free from all hereditary de- 
 gene]-acy, and it is also found at an earlier average age in women 
 than in men. 
 
 Sex, as a predisposing cause of mental disease, has been discussed 
 with divergent views by different authors, who have held, sometimes, 
 that men, and at other times that women, were more disposed to 
 become insane. Formerly, more men than women were found in 
 hospitals for the insane, but now there is not much diiference in 
 the sexes in this regard. It is probable that men are more exposed 
 to hardships and bodily injuries, to syphihs and alcoholic excess, 
 and that more of them suffer some mental disturbance, but that 
 women, as inmates of hospitals for the insane, have a lower rate of 
 mortality and tend to accumulate. In short, it would appear that 
 more men the world over are attacked and die, and that, of the 
 fewer women attacked, more survived a longer period in hospitals 
 for the insane, and that the residuum of the two sexes will be about " 
 
74 TEXT-BOOK ON MENTAL DISEASES. 
 
 equal. With a general population presenting no special disparity 
 in the original number of men and women, it would be expected 
 that the above rule would apply to special communities when suffi- 
 ciently large numbers are considered. 
 
 Civil condition, in its relation to Insanity, is another mooted 
 question. It appears, from figures gathered on this point, that more 
 single than married persons become inmates of asylums, in propor- 
 tion to the number in the general population, and the natural in- 
 ference is that celibacy predisposes to Insanity. It is just possible, 
 as the majority of asylum admissions are from the poor classes, that 
 single persons, having no one to care for them and no homes of their 
 own, would be sent to asylums more invariably than married persons, 
 who might be cared for during brief attacks by husband, wife, or 
 children in their own homes. Then, again, the stronger and more 
 capable, as a rule, would be more likely to assume the responsibili- 
 ties of married life, which impecunious or sickly, incompetent or 
 dissipated persons, who are already tending to Insanity, would nat- 
 urally avoid. For woman, who has so few agreeable possibilities 
 in life outside of marriage, which brings her the surety of a perma- 
 nent home and the only environment for which nature has physi- 
 cally and mentally endowed her, it would seem that celibacy might 
 be an evident predisposing cause of Insanity. But for man, whose 
 natural sphere of action is the outside world, and whose every wish 
 and ambition can best be attained when he runs the race of life 
 free of all encumbrances, it is difficult to conceive that celibacy, per 
 se, should constitute a predisposing cause of Insanity. 
 
 Occupation sometimes favors the development of mental disease 
 to a very marked degree. 
 
 The army and the navy contribute more than the average quota 
 to the numbers of the insane in all civilized countries. Some of the 
 influences which are most injurious in the lives of soldiers and sailors 
 are physical exposures and hardships, insufficient quantity or variety 
 of food, alcoholic and sexual excesses, malarious, luetic, and trau- 
 matic affections, separation from home and relatives, death of com- 
 rades, capture or imprisonment, and, on the part of officers, great 
 responsibilities in time of war and idleness and disappointed ambi- 
 tions in time of peace. 
 
 Then, again, there are occupations which are inseparable from 
 influences directly deleterious to nervous centres. Some of those 
 who follow these occupations are exposed continuously to a high 
 
THE ETIOLOGY OF INSANITY. 75 
 
 degree of heat, and others to metallic poisoning, and still others 
 to the inhalation of noxious gases or a dust and germ laden air, 
 and there results not infrequently ill health, nervous disease, or men- 
 tal disorder. Other occupations, less unhealthful in themselves, 
 favor nervous and mental disease on account of the tender age and 
 the long hours of work of those employed, and it has been found 
 necessary to legislate against prolonged hours of labor for young 
 children. 
 
 The broad question as to whether those engaged in agricultural 
 pursuits are more subject to Insanity than those occupied in large 
 cities has been decided, seemingly, by English statistics showing a 
 considerably larger percentage of mental disease in agricultural pop- 
 ulations. The fallacy lies in the fact that the figures were made 
 from those living in comparative poverty, such as exists in certain 
 rural districts of England and Ireland, and a very different result 
 would be obtained from the tabulation of the facts as they exist 
 among farmers in this country, or even the French peasantry, which 
 is much more prosperous than the English tenantry in their mode 
 of life. 
 
 Another wide question, as to whether brain-workers are more 
 subject to mental disease than those engaged in manual occupations, 
 may receive a general affirmative answer. The learned professions 
 seem to contribute more than their proportionate share of cases, and 
 physicians, lawyers, and clergymen, about in the order named, make 
 frequent additions to the ranks of the mentally afflicted. 
 
 There are other callings which involve an intensification of the 
 imagination and of the emotions at short and daily recurring inter- 
 vals, which, in the long run, notably generate nervous, psychic insta- 
 bility, and there is undoubtedly, among artists and actors, an unusual 
 amount of mental alienation. Musicians often present a nervous 
 and emotional erethism, which passes into a distinctly pathological 
 mental trouble in many instances. 
 
 In vocalists and players upon wind instruments, the inhibition 
 of normal respiration and hyperaimic cerebral conditions thus in- 
 duced, Avith sudden fluctuations in cerebral blood-pressure, bear 
 causative relations to the resulting nervous troubles which are some- 
 times manifested as pneumogastric disorders. In pianists who prac- 
 tise long hours daily, and in other kinds of musicians, there is also 
 fixation of respiratory muscles on execution of difficult passages, 
 and, through vibration, the nervous centres would seem to suffer 
 
76 TEXT-BOOK ON MENTAL DISEASES. 
 
 a species of mechanical traumatism, which may become as real as a 
 " railway-spine/' and not very rarely one is compelled, by nervous 
 affections, to abandon the profession. 
 
 Again, no occupation, or the loss of one, or the sudden change 
 of calling, or the abrupt retirement from business, predisposes to 
 mental derangement. 
 
 The pursuit of questionable and illegitimate callings, as in the 
 case of prostitutes, gamblers, desperate speculators, and a whole 
 parasitic and reckless set who live by their wits at the expense of 
 the public, favors the outbreak of mental disease. A large con- 
 tingent of insane cases is furnished by the ever-increasing predatory 
 tribe of inferior politicians, who, without truth, honor, self-respect, 
 or other motive than greed of gain, are employed as the tools of 
 their superiors in ofdce, and, having served the base uses to which 
 they are put, and having been cast aside by the successive masters 
 whom they follow, often end their careers in poverty, crime, or in- 
 sanity. 
 
 Those who professedly and continuously make of crime a means 
 of livelihood are by inheritance frequently degenerate, and become 
 insane more frequently than others. It is not alone that criminals 
 are so often naturally allied to the insane, but it is also because a life 
 of crime is unavoidably attended with hardships and constant .fears 
 and anti-social emotions which tend to undermine mental health, 
 and sooner or later imprisonment and solitary confinement may de- 
 velop the Insanity to which their calling predisposes. The profes- 
 sional criminal undergoing sentence feels no stings of conscience, 
 but occasional or accidental offenders often suffer the torments of 
 shame and remorse which may induce mental disorder, especially 
 during the early months of imprisonment. 
 
 Nationality, in its etiological relations to Insanity, is a complex 
 subject. jSTo one doubts that there are distinct national types of 
 character, and that a man's mental constitution is derived not alone 
 from his immediate ancestors, but aiso from the race whence he 
 sprang. If it were possible to place all races as they now exist 
 under like physical and moral conditions, and to expose them to like 
 causes of mental disease, very disproportionate morbid results would 
 doubtless follow, and the strong mind of the man of superior race 
 would survive the shocks which would dethrone the reason of the 
 individual of inferior race. Even among the most highly civilized 
 peoples there is a national difference of reaction to powerful emo- 
 
THE ETIOLOGY OF INSANITY. 77 
 
 tional shocks, whicli in one instance may provoke despair and suicide 
 more frequently, as recent study of suicides in different nationalities 
 has shown. That there is a difference in the amount and kind of 
 Insanity in various nationalities admits of little doubt. That gen- 
 eral paresis was rare among Eastern nations and among negroes in 
 this country before they were emancipated is not to be questioned, 
 any more than at the present time in Europe the J ews are especially 
 prone to certain degenerative types of mental disease. The Chinese, 
 according to the most reliable account, have fewer insane among 
 them than the other nations of a like degree of civilization. Among 
 the Swiss goitrous Insanity prevails; among Italians pellagrous In- 
 sanity is common; among Swedes, Danes, and Norwegians alcoholic 
 and syphilitic mental disease predominates; and amon^ Anglo- 
 Saxon races, more especially Americans, who are relatively temperate 
 as regards alcohol, psychical causes most powerfully predispose to 
 mental disorder. 
 
 Although the predisposing conditions and the types of mental 
 disease differ in the various nationalities, there are still no sufficient 
 data from which to draw conclusions as to the relative and actual 
 liability of different races to Insanity. 
 
 Climate is a circumstance of some importance in relation to men- 
 tal disorders. Great extremes of heat or cold are most damaging 
 to the nervous system, and they have often caused most obstinate 
 forms of Insanity, which, both in symptoms and course, is of the 
 traumatic type. Sufficient importance has not been attached to 
 the effect of heat upon the infantile nervous system, and the " f ons 
 et origo mali " in many children exhibiting symptoms of nervous 
 and mental disorder has been undue exposure to the sun or to arti- 
 ficial heat. 
 
 Sudden and extreme changes of climate are especially deleteri- 
 ous, and whenever a higher temperature than 100° F. is reached in 
 large cities a long list of fatal cases occurs among children, and some 
 adults suffer insolation, which often results in incurable mental af- 
 fections. 
 
 The general ill health and frequent mental disturbances of Euro- 
 peans in tropical regions are largely the result of climate, and their 
 only hope of recovery lies in a prompt escape from the high tempera- 
 ture. 
 
 Prolonged exposure to a high degree of cold, in those not ac- 
 climated, is undoubtedly both a predisposing and an active cause , 
 
78 TEXT-BOOK ON MENTAL DISEASES. 
 
 of insanity, as appeared among Napoleon's soldiers after the retreat 
 from Moscow, and in other well-known instances, and the case of 
 a strong young man insane from exposure on a Polar expedition, and 
 other cases that have come under the writer's observation, are in- 
 stances to the point in question, though it is to be understood that 
 cold 16 not as deleterious to the nervous centres as heat. 
 
 It is a significant fact, as shown by asylum statistics, both in this 
 country and in Europe, that the bulk of the quarterly admissions 
 occurs not during autumn, winter, or spring, but during summer. 
 It is during this latter season that agricultural populations are ex- 
 posed in the harvest-fields to the direct and uninterrupted rays of 
 the sun, and that those resident in cities suffer from heat accumu- 
 lated and reflected from sidewalks and walls of dwellings. 
 
 Unfortunatel}^, there are no statistics to permit a differentiation 
 of the effects of climate from other endemic active causes in different 
 parts of the world, or to institute international comparisons of cli- 
 mates as predisposing causes of Insanity. 
 
 There can be little doubt that the tliin, wiry, and nervous consti- 
 tution of the American people, taken as a whole and compared with 
 Europeans, or residents of the British Isles, is due chiefly to clijnatic 
 influences, which imprint like bodily characteristics on the very 
 first generation born of foreign parents in this country.* 
 
 As the presence of the sun is the prime source of variable climatic 
 influences, so, too, its diurnal absence from parts of the earth is 
 attended by a rhythmical ebb of both the physical and psycliical 
 forces of the human organism. There is even in sane persons at 
 night a relatively unstable emotional equihbrium and a less firm 
 mental inhibition, and the ignorance of this fact has led alienists, 
 in all ages, to attribute the nocturnal intensification of insane symp- 
 toms to the coincident appearance of the moon, which there is no 
 reason to believe has ever any other influence upon insane patients 
 than that of a sensorial stimulus of a mild and customary kind. As 
 a matter of fact, sidereal influence is more considerable than lunar 
 effects. 
 
 Education may strengthen or weaken character and may increase 
 or diminish any inherent tendency to mental disease. The term is 
 
 * Steams, in his Lectures on Mental Diseases, page 244, in speaking 
 of "folie circulaire," says : "It is qnite possible that climatic inflnences 
 are operative in rendering the system more susceptible and liable to take 
 on such periodic changes in its mental activity." 
 
THE ETIOLOGY OF INSANITY. 79 
 
 here used in its widest sense, and ii signiiies not mere routine knowl- 
 edge derived from books, but all those social and moral influences 
 wliich enlighten the understanding and mould the disposition of the 
 individual. It is well known that a person may be trained for a 
 trade or business without book-learning of any kind and may be 
 so well educated in a knowledge of men and things as to become 
 eminently successful in his special calhng, and that a college gradu- 
 ate with lofty ideals often makes such an egregious failure in prac- 
 tical life as to suffer from wounded pride and disappointed ambi- 
 tion, and perhaps be driven to suicide or Insanity. 
 
 The best education is that which best fits one for the work which 
 one is to perform in the world, and the choice of a calling should 
 be made early, and all energies should then be forcibly directed to 
 the end in view, and all processes of education should be shaped 
 accordingly. 
 
 One of the prime conditions of advanced civilization is the divi- 
 sion of labor, and, as competition is becoming ever more keen in all 
 special lines of human endeavor, the only hope of success, without 
 mental strain or worry, is an early, definite aim, with systematic and 
 well-directed efforts to attain it. Gross errors prevail and have been 
 disseminated by educators themselves in regard to this whole sub- 
 ject. Instead of the fact that the study of a lifetime would not 
 suffice to learn a minute fractional part of that which is known in 
 one science, the public is allowed to believe that their sons are im- 
 bibing the essentials of all the sciences in four years of collegiate 
 study. Instead of the truth that this length of time would scarcely 
 lead to proficiency if well applied solely in one special branch of art, 
 the idea is permitted to prevail that the classical curriculum fits the 
 youth to grapple with the difficulties and intricacies of any or all 
 of the sciences, arts, professions, or business callings. The family 
 may be somewhat impoverished to educate the young man, whose 
 eyes are finally opened to the bitter deception; for, after college 
 graduation, he must struggle in adversity to acquire the real educa- 
 tion needful for his success in life. 
 
 Present systems of education are especially faulty as regards 
 children, who are of such plastic material as to become permanently 
 warped from the standard of mental health by forced and premature 
 efforts at instruction. The child's mind is crammed with a mass 
 of facts unrelated among themselves and uncorrelated with any- 
 thing practical, and hence retained by sheer force of memory, which 
 
so TEXT-BOOK ON MENTAL DISEASES. 
 
 is thus surcharged, like a beast of burden to which, if not the whip, 
 some equivalent goad of reward or punishment is apphed to spur 
 drooping energies. J^o wonder that at the end of a few years the 
 child looks prematurely old, has headaches and frightful dreams 
 • nightly, and grows to be a nervous youth, with possibly chorea, or 
 even symptoms of Insanity, which is much more common among 
 children than is supposed, and is favored by precisely such educa- 
 tional ordeals as here named. But there are other dangers than the 
 gauntlets of over-ambitious pedagogues set for the child to run, amd, 
 if not injured in the public school, he may be spoiled in the more 
 important school of the home circle. The child's inmost character 
 is moulded more permanently by parental example than by any 
 other means. Habits are thus formed by imitation and repetition 
 01 the acts of parents, who, if they are selfish, harsh, untruthful, 
 and dishonest in their dealings, will inevitably develop like traits 
 in their children. 
 
 Parents, also, who are not vicious may have spoiled children 
 through over-indulgence, for the naughtiness of the child is the 
 making of the wickedness of the man, even as " the child is the 
 father of the man.'' 
 
 There is another extreme, and that is heartless severity on the 
 part of the parent, which may imbitter the child against the whole 
 world and ruin the moral nature, or, in very susceptible children, 
 result in suicidal attempts or in actual Insanity. 
 
 The best education for young people is that which will promote, 
 first, physical health and strong bodily development, and, second, 
 a firm and compact moral nature, fashioned by the habitual practise 
 of obedience, truthfulness, sincerity, love of others, self-denial and 
 self-control, and respect for superiors. When this primary founda- 
 tion has been firmly laid, there may be superadded the learning of 
 a profession, the mastery of such knowledge as is essential to success 
 in a special calling, and of such practical points of ethical science 
 as will best guide the social relations of life. It is best to make 
 haste leisurely, for the battle of life is half won if well begun. 
 
 Education, then, is a predisposing cause or a prophylactic means 
 as regards mental diseases. 
 
 The time is ripe for a great educational reformer to appear and 
 lead the way to wiser and better methods, and the peoples of all 
 civilized lands shall rise up and call him blessed, and in that future 
 day the human intellect shall be expanded, and not weakened, and 
 
THE ETIOLOGY OF INSANITY. 81 
 
 the crowning faculty of reason shall be fortified and not dethroned 
 by that wliich is denominated education. 
 
 National crises and public calamities are to be viewed in the light 
 of predisposing causes of Insanity. Wars, pestilence, famine, polit- 
 ical revolutions, great conflagrations and floods, earthquakes and 
 vohranic eruptions, with loss of life and violent perturbation of emo- 
 tions among many people, render some insane at once and are fol- 
 lowed by permanent nervous disease in others, and by one or both of 
 these affections occasionally in the generation " in utero " at the 
 time. 
 
 It is true that European authors have not reported any notable 
 accession to admissions to hospitals for the insane attendant upon 
 the wars of this century. It does not seem to have been sufficiently 
 considered, however, that some insane perish from war, and that ,a 
 large class of intemperate, impoverished, and worthless individuals, 
 who are " the insane in the making," are also eliminated by war, 
 and that thus is diminished the very class whence the insane popu- 
 lation is largely recruited. The writer has seen many cases of In- 
 sanity immediately due to the civil war in this country, and if all 
 those cases directly or indirectly springing from it were marshalled 
 together, they would constitute an array of living examples of the 
 point in question which would settle it beyond all cavil. 
 
 Financial crises, bringing business ruin to large numbers, may 
 excite mental disorder at once or lead to general ill health and pre- 
 disposition to Insanity in the afflicted persons or in their offspring. 
 Frevious attachs of mental disease, apart from heredity, consti- 
 tute the most important of all predisposing causes. The relative 
 numerical value of this etiological factor has already been given 
 under the head of statistics. It is theoretically possible that a pre- 
 vious attack might arise from depressed bone, or some foreign body 
 in the nervous centres, and that, when the source of irritation was 
 removed, the Insanity would cease, and no real predisposition to a 
 recurrence could be said to exist as the result of the first attack. 
 The hereditary group of causes consists in certain congenital 
 structural defects, in functional weaknesses, and in a transmitted 
 tendency to nervous or mental disease. 
 
 This group of causes is found in what are conventionally termed 
 the degenerative insanities, ranging through the degrees of idiocy, 
 imbecility, feeble-mindedness, instinctive Insanity of childhood, 
 6 
 
82 TEXT-BOOK ON MENTAL DISEASES. 
 
 moral Insanity, paranoiac aberrations, and mental disorders emerg- 
 ing from the established neuroses. 
 
 The structural defects in the forms of organic arrest of develop- 
 ment just mentioned are cranial asymmetries, macrocephalic and 
 microcephalic formations, atrophies of cerebral hemispheres and 
 convolutions, hydrocephalic and parencephalic states, inequality 
 and simplicity of convolutions, sclerotic changes in pyramidal tracts 
 and lesions of other spinal tissues. The organic arrests of develop- 
 ment mark the highest degree of degeneracy, as in idiocy, and in the 
 order of the mental affections above named there is a diminishing 
 intensity of deterioration until the opposite end of the degenerate 
 series is reached in the alienations with the major neuroses, and, 
 in the main, the gross structural defects above mentioned disappear 
 rapidly in this serial order, so that when the paranoiac degeneracies 
 are reached, the stnictural anomalies consist chiefly in cranial asym- 
 metries, facial peculiarities, and bodily stigmata, which will be de- 
 scribed at length under Somatic Symptomatology. 
 
 The functional weaknesses referred to are revealed in childhood 
 as general irritabihty, reaching the point of convulsibihty in many 
 instances, and in adult hfe they are displayed in general instabihty 
 of nerve centres, and in a special tendency to various forms of ner- 
 vous disease. 
 
 As gross anatomical lesions, therefore, are not to be found in the 
 majority of the degenerative insanities, and as the essential thing 
 in the hereditary group of causes is the transmitted tendency to 
 neurotic and psychic disorders, it becomes necessary at this point to 
 fully present the subject of heredity in its relations to Insanity. 
 
 Heredity, generally speaking, is a theory to fit the observed fact 
 that like comes from like in the vegetable and animal world. Hered- 
 ity in man is the conservative force of nature which supposedly re- 
 produces the organic structure and functional activity of the parents 
 in the offspring with uniform regularity. 
 
 Theoretically, the offspring should be the exact reproduction 
 of the parent, and in the simpler forms of organisms there is in this 
 regard a striking repetition of individual likeness. In man genera- 
 tion is dependent on the union of sexual elements furnished by 
 parents who are seldom alike in age, general vigor, or bodily and 
 mental traits. Consequently there is usually a preponderance of the 
 influence of one of the parents, and, other things being equal, of the 
 younger and stronger progenitor. In this way the correction of 
 
THE ETIOLOGY OF INSANITY. 83 
 
 morbid inheritance is sometimes accomplished, for, if a feeble, old, 
 degenerate, insane man were to marry a young woman of sound 
 stock and vigorous in mind and body, the diseased tendency in the 
 offspring might be overcome by the preponderant influence of the 
 younger parent. 
 
 As a rule, then, children receive much in common from both 
 parents, but they resemble one more than the other. This resem- 
 blance is not infrequently between the sexes, the daughter resem- 
 bling her mother and the son his father, and this is true as to morbid 
 as well as physiological traits in many instances. There are, on the 
 other hand, numerous examples showing that this hereditary resem- 
 blance is crossed, so that the son resembles the mother and the 
 daughter the father, and, in accordance with this principle, of 
 course, in the second generation there would be a return of resem- 
 blance as regards the sexes, the granddaughter resembUng the 
 grandmother, having received the likeness of nature from her father, 
 and the grandson resembling his grandfather, having got the simi- 
 larity from his mother. This principle is known as crossed heredity, 
 and it is found to' be frequently exemplified in the transmission of 
 nervous and mental diseases. 
 
 Direct heredity is inheritance immediately from father or mother, 
 grandfather or grandmother, from great grandparents, or from an- 
 cestors removed to any degree in direct parental line. 
 
 As regards the common fund of attributes possessed by the race, 
 direct heredity is always double or derived from both parents, but, 
 as to special attributes, it may be single with reference to either 
 parent. If the special peculiarities are alike in both parents, they 
 may be heightened in the offspring, and this is especially frequent 
 in the transmission of morbid peculiarities. It is not improbable 
 that the child inherits the qualities of both parents, but only mani- 
 fests those of the parent he is said to resemble and under whose 
 special influence he may be during certain years of his life. So long 
 as a boy is under the constant care of his mother he may fail to 
 display paternal characteristics, which may appear strongly later 
 in life. It is well known that qualities received by direct heredity 
 may remain latent, and finally manifest themselves at certain epochs 
 in the offspring, as in the parent before him. This is frequently 
 the case with morbid defects reappearing at certain times of life 
 through successive generations of the same family. It is not un- 
 common in women, after the menopause, to have certain appear- 
 
84 TEXT-BOOK ON MENTAL DISEASES. 
 
 ances of latent masculine traits, and it is well known that bodily 
 defects of the maternal grandfather appear in the grandson after 
 being latent in the mother. 
 
 The offspring, then, inherits largely from both parents-, but only, 
 a part of the quahties thus derived are manifested, and the rest re- 
 maia latent until special circumstances favor their development, and 
 this leads to the question of reversional heredity, which is of special 
 importance in Insanity. 
 
 Atavism is the inheritance from more or less remote ancestors 
 of resemblances, qualities, or tendencies to disease which have re- 
 mained latent in the immediate parents. Insanity, for instance, 
 often skips a generation, and the son of a sane father inherits mental 
 disease from an insane g-ranHfather. The disease is then said to be 
 atavistic and to have remained latent in the father, and to have been 
 inherited by the son from the grandfather. It may be well to say 
 here that diseases are never inherited, but only tendencies to disease. 
 In the case of Insanity it is the instability of nervous centres, the 
 tendency to vasomotor and nutritional disorder, and the susceptibil- 
 ity to functional mental disturbance which are inherited. 
 
 It will frequently be found that Insanity thus derived by ata- 
 vism is between members of the same sex, in accordance with the 
 fact that the son often takes after the mother, and the daughter after 
 the father, and that atavistic transmission between grandparents and 
 grandchildren would in this way be from grandfather to grand- 
 son and from grandmother to granddaughter. The largest percent- 
 age of diseased inheritance is from parents or grandparents, because 
 nature does not favor, but ever tends to eliminate, accidental and 
 morbid peculiarities, which seldom survive the third generation in 
 direct line; and this introduces another important principle of he- 
 redity, which is the preservation of the normal type. 
 
 The normal type is continued by the constant inheritance from 
 both parents of a certain sum of characteristics which are typical 
 of the race to which the individual belongs. Qualities which are 
 not thus typical, but which are accidental or acquired, are only ex- 
 ceptionally transmitted, and they only tend to become permanent 
 when they are in the nature of special adaptations to the environ- 
 ment. Such acquired qualities, when frequently transmitted, gain 
 strength and may become permanently fixed, and their chance of in- 
 heritance is then much greater. Morbid peculiarities occasionally 
 become in some degree fixed and transmitted in certain families, but, 
 
THE ETIOLOGY OF INSANITY. 85 
 
 as before said, it is seldom for more than a few successive genera- 
 tions, for so strong is the principle of return to a normal type that 
 the ftimily is more apt to die out than tliis principle to fail. It 
 would be impossible, by selection and inbreeding of a certain num- 
 ber of the most confirmed lunatics, to permanently propagate a race 
 of lunatics, as there would be in part a return of the normal type and 
 in part extinction of the race through degeneracy. 
 
 The child issuing from an insane father and a sane mother has 
 more than an even chance of escaping mental disease. Even when 
 there is insanity in both parents the conservative force of nature 
 may preserve the normal type in the offspring. An insane degen- 
 erate, once under the writer's care, after he had entered the de- 
 mented stage of paranoia, begat five children, all of whom have 
 grown up and remain in ordinary good health. Large numbers of 
 instances of the failure of transmission of Insanity from immediate 
 progenitors to children have come within the writer's observation, 
 and it is perhaps time to collect extensive statistics on this score to 
 aid in arriving at just conclusions as to the laws of inheritance of 
 mental disease. It would seem as if statistics were only recorded in 
 instances confirming the view of heredity, to which is constantly 
 attributed a more and more important influence as a cause of In- 
 sanity. The subject is of great importance and complexity, and it 
 must be studied with scientific impartiality; but, before further con- 
 sideration of it, there is another mode of heredity to be mentioned. 
 CoUaieral liei^edity is the appearance of common family traits, 
 qualities, or morbid affections in relatives not in direct line of de- 
 scent. Thus the same anomalies of character or the same disorders 
 manifest themselves in the uncles and nephews, in the aunts and 
 nieces, in cousins, or in more remote collateral branches of the fam- 
 ily. The supposition, then, is that the disease, which thus appears 
 among relatives, existed in some remote common ancestor, and that 
 it has been latent in some and apparent in other members of the 
 family. The finding of Insanity in collateral branches of a family 
 is circumstantial evidence, but not satisfactory proof, therefore, 
 that the disease is inherited. In studying the etiology of a case of 
 Insanity this mode of heredity is to be taken into careful considera- 
 tion, especially in the absence of any evidence of direct heredity. 
 If collateral heredity is found on both the father's and the mother's 
 side, the probabilities of the hereditary nature of the Insanity are 
 very much heightened, and the presumption would be that the men- 
 
86 TEXT-BOOK ON MENTAL DISEASES. 
 
 tal disease was the result of combined latent tendencies on the part 
 of both parents. 
 
 Having now described the chief forms of heredity, it is necessary 
 to consider more exactly what is meant by the term in relation to 
 mental diseases, and especially the wide extension which modern 
 writers are wont to give it. It has already been said that in cases 
 of heredity it is the tendency and not the disease which is inherited, 
 and that it is instability of nervous centres and susceptibility to 
 mental disorder which descend from the insane parent to the off- 
 spring. Now, as this instability of nervous centres is characteristic 
 of chorea, hysteria, hypochondria, epilepsy, and allied nervous con- 
 ditions, writers are inclined to embrace all these affections as the 
 transformed equivalents of Insanity, so far as evidence of the hered- 
 itary nature of the mental disease is concerned. Some writers go 
 still farther, and add phthisis pulmonalis, syphilis, alcoholism, dia- 
 betes, Graves's disease, and other afl'ections, to this group of hered- 
 itary equivalents, with an apparent determination to establish, so 
 far as possible, the hereditary character of mental disease in all cases. 
 
 It is time to draw the line somewhere, and to enter some protest 
 against this wholesale manner of the hereditary derivation of In- 
 sanity; for, if the same course were pursued with other diseases, 
 " confusion worse confounded " would soon reign in our general 
 ideas of etiologj'^ and pathology. 
 
 It is one thing to recognize the etiological relations of many dis- 
 eases to Insanity, and it is another thing to represent these diseases 
 as constituting the heredity of Insanity. The practical point is 
 to be boi'ne in mind that every insane patient has two parents, four 
 grandparents, eight great-grandparents, to say nothing of collateral 
 relatives, any or all of whom may have had some of the diseases 
 above enumerated, and to make a direct search for heredity under 
 such circumstances is to enter a maze of pathological conditions 
 through which no scientific line of inquirj^ can be clearly traced. 
 If statistics are to have any definite value, therefore, in recording 
 the heredity of insane patients, only the most closely allied neu- 
 roses, and such as the history of the family shows to have appeared 
 interchangeably with the Insanity should be taken into account as 
 constituting the hereditary equivalents of the disease. Any excep- 
 tion to this rule may be left to the unbiassed judgment of the skilful 
 physician, who, if he finds, on extended inquiry, that in different 
 individuals or generations of a certain family, phthisis pulmonalis 
 
THE ETIOLOGY OF INSANITY. 87 
 
 and Insanity have appeared interchangeably, may consider every 
 case of consumption as a link in the hereditary chain of the mental 
 disease; but by the same rule he Avould have to accept the Insanity 
 as constituting the heredity of phthisis pulmonalis. 
 
 In estimating the intensity of the heredity in any given case of 
 mental ahenation, it is necessary to consider the character as well 
 as the number of the direct and collateral instances of the disease 
 in the family history. Two or three eases of epileptic, periodical, 
 or other degenerative types of Insanity would imply a much more 
 decided heredity than the same number of simple psychoses from 
 accidental causes. General paresis, though the most hopeless form 
 of Insanity, is less hereditary than other forms, in the opinion of 
 most writers, and Eegis, in his " Manual of Mental Medicine," says 
 that the child of a general paretic has no predisposition to Insanity, 
 but to cerebral disorders. 
 
 Other things being equal, the nearness of the kinship determines 
 the degree of the heredity, counting first in direct line parents and 
 grandparents, and then in indirect line uncles, aunts, and cousins. 
 A child bom after the parents' Insanity will be affected more likely 
 than one born before the attack. 
 
 The heredity will be strongest in those born nearest and after 
 the attack, provided the parent's recovery is complete, but the chil- 
 dren of imperfectly recovered patients may have decided heredity. 
 Heredity is apt to be intense in children begotten in the acute 
 incubatory stage of mental diseases. 
 
 Convergent heredity, that is to say from both parents and of 
 like kind, is apt to be very strong. Some authors think predisposi- 
 tion is greater derived from the mother than from the father, and 
 this is no doubt true for daughters, though an insane father is more 
 apt to transmit the tendency to his sons, who closely resemble him 
 in mental constitution. 
 
 Children sometimes derive their outward appearance and physi- 
 cal organization from one parent, and their mental and moral nature 
 largely from the other, and it is from the latter source, in these 
 instances, that morbid psychic abnormities are more likely to be 
 received. Again, a daughter, for instance, may resemble the father 
 strongly in early life, but in middle age may become like her mother 
 in body and mind, and she would then probably develop the ma- 
 ternal neurotic predisposition, especially if it were of a kind wont 
 to appear late in life, as at the menopause. 
 
S8 TEXT-BOOK Oj^ MENTAL DISEASES. 
 
 Heredity tends, in a general way, to appear at the same time 
 of life in the offspring as in the parent, and at the critical points 
 of puberty, menopause, and senility, and at earlier periods in pro- 
 portion to the degree of its intensity. Morbid heredity during in- 
 crease, and while being Ired in, appears earlier in successive genera- 
 tions, but, while being Ired out, shows itself at later and later periods 
 of Ufe. 
 
 Families rise ^nd decay, like nations, and heredity in a rising fam- 
 ily and in a degenerating family might have a numerical sameness, 
 and still an absolutely different value. The history of the patient 
 and of the family to which he belongs may clearly show this de- 
 generacy and determine the relative strength of the heredity, but 
 in many instances it is not possible to get sufffcient evidence that 
 the family has entered a stage of deterioration. 
 
 Thus far attention has been directed to diseased ancestral heri- 
 tage through direct and collateral lines, but there is a less remote 
 " foils et origo mali." Morbid heredity may be generated, de novo et 
 ah ovo, by the unsuitability of the spermal and germal elements of 
 the immediate progenitors. 
 
 The spermal force acting on the germal substance, to attain its 
 best result, must be favored by a certain similarity between the 
 paternal and maternal sexual elements, and great dissimilarity leads 
 to sterility or monstrosity. The Arabs, in the preservation of a 
 pure, inbred strain of horses, seem to have practically adjusted to 
 a nicety this required degree of similarit}^ and at the end of a thou- 
 sand years they continue to breed these beautiful animals with uni- 
 form success. 
 
 On the other hand, if this double parental similarity in devel- 
 opmental cells is too great, there result feeble or defective offspring, 
 as has been repeatedly shown in families which, for wealth, caste, 
 or religion, or other motive, have too closely interbred for too long 
 a period. 
 
 Here, then, is a source of hereditary mental defects which may 
 extend even to idiocy, received by the child from his parents, who 
 may have neither open symptoms nor latent tendencies of mental 
 disease. 
 
 A somewhat similar direct origin of morbid heredity proceeds 
 from physical or psychical influences active in the parents at the 
 moment of the conception of the child. These influences may be 
 exhausting diseases, toxic, and specially alcoholic, conditions, and 
 
THE ETIOLOGY OF INSANITY. 89 
 
 powerfully distressing emotions, wliich, like the maternal impres- 
 sions of gestation, may be followed by bodily or mental abnormities 
 in tlie offspring. 
 
 Knowing full well the cellular lesions which may be the sequels 
 of sudden fright in children, even in compact dental tissues, it is 
 probable that to powerful and untoward mental influences during 
 the maturation of the spermal and germal elements in parents is to 
 be attributed many pathological results in the offspring. 
 
 Then, again, nature has her freaks as well as her eternal lawful 
 sameness, and, as naturalists have been compelled to admit the fact, 
 if not the theory, of spontaneous variations, so psychologists must 
 admit startling exceptions to the hereditary law that like produces 
 like in the mental sphere, as when a moral monster springs from a 
 saintly family, or a genius from the most humble origin. Thus the 
 psychiatrist, in his studies of mental pathology among his patients, 
 will meet with occasional astonishing exceptions, which only go to 
 prove the rule of heredity. 
 
 In degenerative families heredity is only exceptionally similar 
 in the parent and offspring, in whom, as a rule, dissimilar mental 
 disease appears. One child of a degenerate lunatic may be suicidal, 
 another dipsomaniac, another criminal, another epileptic, and an- 
 other imbecile. This appearance of a variety of pathological states 
 in the same family is polymorphic heredity, which especially char- 
 acterizes the degenerative group of insanities. 
 
 The progressive heredity, so well observed and described by Mo- 
 rel and others, in which there may be, for instance, chronic alco- 
 holism in the first generation, simple psychoses and neuroses in the 
 second generation, paranoia, periodical, and other degenerative 
 forms of Insanity in the third generation, and in the fourth gen- 
 eration imbecility, idiocy, and, finally, extinction of the family, is 
 as interesting as it is rare. Serial family degeneracies partly ex- 
 emplifying the above observations are occasionally encountered, but, 
 if they are traced far enough, it will be found that, finally, part of 
 the family reverts to the normal type, and especially will this be 
 found to be the rule when the histories of large numbers of degen- 
 erative families are traced completely. 
 
 In tracing these degenerate insanities, numerous pathological 
 states have been treated by writers as hereditary equivalents, such 
 as hysteria, chorea, epilepsy, apoplexy, chronic alcoholism, con- 
 sumption, and organic arrests of development. 
 
90 TEXT-BOOK ON MENTAL DISEASES. 
 
 In the absence of all these conditions there are certain bodily 
 and mental anomalies which may mark the individual as degenerate, 
 and these signs, termed stigmata degenerationis, will be described in 
 the chapter on sj^mptomatology. These psychic and somatic stig- 
 mata may exist to some degree in normal persons, but, when typi- 
 cally grouped in one patient, they serve to diagnose the degenerative 
 psychopathic constitution. 
 
 In attempts to decide the actual proportion of cases of Insanity 
 due to heredity, recourse must be had to statistics including only 
 cases of direct heredity in some, and of indirect also in other in- 
 stances, and in others still embracing allied neuroses and hereditary 
 equivalents, both in direct and collateral lines. Statistics made thus 
 differently have necessarily led to widely divergent conclusions, 
 which may be stated, in a word, as varying between standard authors 
 so widely that twenty per cent, and eighty per cent, represent the 
 extreme estimates of the numerical value of heredity as a cause of 
 Insanity. In my Annual (1895) Eeport, as Superintendent of the 
 Willard State Hospital, there were recorded, out of a past total of 
 2,G45 admissions, direct and collateral hereditary influences as causes 
 of the Insanity in 345 instances, or a percentage of 13 + . Dr. Hack 
 Tuke * reports, out of a grand total of 136,478 admissions to hospi- 
 tals in England and Wales, a percentage of 20.5 set down to heredi- 
 tary influence ascertained. He deems this a low proportion on ac- 
 count of the unwillingness of relatives to give full information. Most 
 modern writers fix the percentage between twenty-five and fifty, 
 and they seem inclined to increase the importance of this cause. 
 
 It is the writer's opinion that not more than twenty-five per cent, 
 of cases of Insanity are strictly due to heredity, and that as science 
 advances and reveals the true causes of Insanity, the number of 
 cases attributed to heredity will constantly diminish. 
 
 And now, having accorded due respect and weight to heredity 
 as a cause of Insanity, and having treated it in conventional man- 
 ner as a sort of constitutional affection frequently transmitted in 
 ways above mentioned, let there be ventured some broader views of 
 this whole subject, that the student of mental pathology may not 
 be overawed by heredity as the cause of causes of Insanity, and that 
 he may not too readily commit to this convenient and enlarging re- 
 ceptacle cases which scientific research might show to be due to def- 
 inite special agents or to wide general causes. 
 
 * Dictiouary of Psychologic Medicine, p. 1205. 
 
THE ETIOLOGY OF INSANITY. 91 
 
 What is, in the broadest sense, man's nature, which is modified in 
 Insanity, and what broader law than family heredity may there be 
 to account for human degeneracy? In the first place, man is an 
 animal, a mammalian vertebrate, and his fundamental nature is ani- 
 mal and is ever inherited as the substance out of which humanity 
 is moulded. What more striking proof of this can there be than that 
 afliorded by mental disease, which denudes man of the veneer of 
 civilization and of all self-control, and lays bare his brute nature, 
 alike in man and woman, in youth and advanced age? Turning 
 from the naturalistic to the ethnological view, man is born white," 
 yellow, or black, with radically different ethnic traits, and varying 
 tendencies to psychic anomalies. Then, again, he has a national 
 character, which stamps him with typical peculiarities, both in 
 health and in disease of mind. Again invoking the past, there arise 
 scores of unknown or forgotten beings who labored consecutively^ 
 and with predestined certainty of result, on one ancestral line to 
 lay firm or loose foundations of mind and character for the indi- 
 vidual. Then comes the family heritage for good or evil, with 
 strength or decay of mind and body, and, finally, the impetus given 
 by the immediate parents toward evolution or degeneracy, and, last 
 of all, the personal modifications effected by good or bad environ- 
 mental influences. Thus every individual has a racial, national, re- 
 motely ancestral, and near parental character, in addition to funda- 
 mental, animal, and special individual nature. As the resultant of 
 of all these compound forces, mind in turn is manifested through 
 the channel of the cerebral centres, which are the most highly 
 evolved and the most complex of all organized structures, and the 
 most subject, therefore, to derangement; and the wonder is not that 
 mental disorder appears, but that it is not more frequent. 
 
 Then, again, there is a broader law than family heredity, and 
 that is the universal law of organic failure in all living creation, of 
 outward and temporary individual variety, but inward and perma- 
 nent racial sameness, of personal imperfections and abnormities, 
 but racial perfection and trueness to type. Nature conserves the 
 species, but cares not for the individual. Enter any of her fields in 
 the vegetable or animal world, and study the rank individual fail- 
 ures. Ask the breeder of animals the proportion of successes to fail- 
 ures, and how long he must labor to produce a perfect specimen. 
 Man, as the king of animals, enjoys no immunity from general laws. 
 A certain proportion of mankind is by the universal law of organic 
 
92 TEXT-BOOK ON MENTAL DISEASES. 
 
 failure doomed to physical and mental imperfections, even to tlie 
 lowest grade.* 
 
 The definite special agents to which Insanity may be due, and 
 which were above referred to, together with the exciting physical 
 
 causes of the disease, will now be studied. 
 
 Exciting Causes. 
 
 The exciting causes of Insanitij are those which form not the fa- 
 voring tendency, but the immediate occasion of the attack, and it 
 has already been said that in actual practice the conventional line 
 of division between them and predisposing causes is sometimes plain 
 and at other times not to be distinguished. Thus, intemperance 
 may cause general ill health or special disease of nervous centres 
 and strongly predispose to Insanity, or it may excite an outbreak of 
 alcoholic mania. In the same way syphiUs and its attendant dys- 
 crasia may be a predisposing cause of mental disorder, or the excit- 
 ing cause of the most incurable form of the same, general paresis. 
 Likewise, powerfully depressing emotions may predispose to or im- 
 mediately excite acute melancholia. 
 
 In a perfectly sound individual, absolutely free from any insta- 
 bility of cerebral centres, and with all the vital organs in a perfect 
 state of health, there can be, strictly speaking, no such thing as 
 an exciting cause of Insanity, for the simple reason that nothing will 
 disorder the reason of such a person, unless it be actual partial de- 
 struction of the brain, as the organ of the mind, and even then there 
 might be diminution rather than derangement of intellect in pro- 
 portion to the extent of the destructive process. 
 
 It is granted that in such a person chemical agents might pro- 
 duce sensorial disorder, and drugs in large doses might cause delir- 
 ium, which is to be differentiated from Insanity proper, but which 
 would terminate with the action of the poison. 
 
 In other words, it has come to be known that some persons are 
 
 * The numerical chances of this law of organic failure are, that in the 
 reprodnction of the human species there will once in two hundred times 
 be organic failure shown as monstrosity, idiocy, imbecility, deafness, 
 blindness, dumbness, Insanity, or the allied neuroses. Heredity in mental 
 disorders is only a coincidence in this more universal law to which atten- 
 tion has not been directed so as to lead to the making of confirmatoiy 
 statistics. 
 
THE ETIOLOGY OF INSANITY. 93 
 
 susceptible to the action of exciting causes of mental disease, and 
 that others are not, and that in those who are vulnerable there is 
 some inherent weakness or peculiarity of the nervous system which 
 may be inherited or may be acquired. There is nothing new or 
 strange in tliis doctrine, for there are in general medicine some 
 analogous, though not strictly parallel, facts which show that causes 
 sufficient to excite various diseases in some persons are entirely in- 
 effective in others, and that certain individuals have an immunity 
 even from the most virulent affections, while others are attacked 
 on the slightest exposure to infectious disorders, some suffering even 
 a second and a third time from the same special contagious com- 
 plaint. Mechanical causes of identical nature may have widely dif- 
 ferent sequels. Thus, trauma of the sole of the foot may heal kindly 
 by first intention in one person and occasion tetanus and death in 
 another, and, in like manner, " trauma capitis " may have no un- 
 toward result in one case, and in another may be the exciting cause 
 of incurable Insanity. This much is said in a general way in re- 
 gard to the exciting causes of mental disease, which will now be 
 considered separately under the further customary division into 
 bodily and psychical factors. 
 
 The lodily causes of mental disorder are dependent upon the close 
 sympathy which unites all the organs of the body under the special 
 influence of cerebral centres. The influence of diseases of any one of 
 the internal organs may thus be radiated through nervous channels 
 to other viscera, to spinal centres, to subconscious cerebral centres, 
 or to the highest seat of conscious mental activity, thus causing in 
 turn sympathetic visceral disturbance, automatic sensory or motor 
 symptoms, variations of organic consciousness, or disorder of emo- 
 tion and intellection. 
 
 That such bodily causes are active in some cases and inefficient 
 in others, as already intimated, can only be explained on the ground 
 of intrinsic instability existing in the nervous organization of one 
 person and not in that of another, and also through a native differ- 
 ence in the acuteness of the visceral sympathies. One child may 
 have no objective manifestations of the presence of intestinal worms, 
 and another may, as reflex symptoms of the same, have convulsions, 
 hallucinations, or active mental disorder. One man may have but 
 slight symptoms of any kind with organic disease of the stomach, 
 while another may be deeply despondent or acutely melancholy from 
 functional congestion of the gastric mucous membrane. Bearing 
 
94 TEXT-BOOK ON MENTAL DISEASES. 
 
 these general considerations in mind, the special etiological rela- 
 tions of certain bodily to mental diseases will now receive attention. 
 The reproductive organs, when diseased, may cause mental disor- 
 der, but it is a popular error, as well as a professional fallacy, to at- 
 tribute a large percentage of Insanity to this source. It is granted 
 that there is no more intimate relation between the physical and 
 psychical part of man than that between the reproductive organs 
 and the mental sphere, which have a simultaneous evolution and 
 involution at the ages of puberty and senility. The mistake has 
 been in taking a concomitant symptom for an antecedent cause 
 in the overestimate of the sexual origin of mental derangement. 
 The fundamental instincts are, as a rule, disordered in Insanity, and 
 especially is this true of the instincts of self-propagation and of self- 
 preservation, which are the two most powerful basic propensities 
 of man. The disorder of the former instinct in Insanity reveals 
 itself in masturbatic and perverted indulgence, and of the latter in 
 suicidal attempts, and the mistaking of the symptoms for the cause 
 is the error here indicated that it may be avoided. Masturbation 
 is a symptom of maniacal states in two-thirds of all cases in both 
 sexes, and at all ages, not excepting the extremes of youth and senil- 
 ity. Masturbation may be said to be almost a universal vice, exist- 
 ing among animals with instinctive persistency, common among sav- 
 ages, and equally frequent among civilized peoples; appearing in 
 children too young to know what impels them, and in single adults 
 of both sexes, and even in married persons as a matter of choice 
 in the mode of indulgence, and if it caused Insanity as often as some 
 claim, the whole race would long since have passed into masturbatic 
 degeneracy of mind. Masturbation does cause Insanity in a small 
 percentage of cases, and it is especially injurious as a habit in the 
 YQTj young and in all who have weak nervous systems. In such it 
 may cause physical and mental arrest of development, as well as 
 moral peiTcrsion. It is probably because it is a despicable habit 
 that it causes such disastrous moral effects, and not because it is 
 physically more exhausting to brain centres than sexual excess of 
 the natural kind. The latter is much more apt to produce general 
 paresis, while unnatural indulgence favors spinal disease rather than 
 cortical degeneration. There is considerable evidence that mastur- 
 bation is transmitted as a strong tendency in certain families, and 
 that it is only one of other neurotic traits in these instances. This 
 accounts for the general neurotic appearance of many who are given 
 
THE ETIOLOGY OF INSANITY. 95 
 
 to the habit, which does not, as some suppose, readily impress a 
 characteristic physiognomy and general outward appearance, such 
 as pseudo-experts claim they can recognize at a glance. These phys- 
 ical traits attributed to the habit are common to thousands of neu- 
 rasthenic and neurotic individuals. It is not denied that these traits 
 may be exaggerated by excessive addiction to the habit, and that 
 in an occasional extreme case a degree of physical and mental degen- 
 eracy may finally be reached which may picture in some degree the 
 special effects of the habit, and may admit the true expert to make 
 a positive physiognomical diagnosis. On the other hand, if two 
 men of ordinary good health and like physical appearance were to 
 indulge once a day, the one in masturbation and the other in married 
 intercourse, for two or three successive years, they would at the end 
 of that period present like symptoms of general debility and nervous 
 exhaustion, and no expert could place them side by side and diag- 
 nose, from outward appearances alone, the solitary sinner from the 
 married offender against the laws of health. This much is said to 
 correct popular error, which calls upon the physician in the major- 
 ity of cases of Insanity to decide whether the cause of the trouble has 
 not been masturbation. 
 
 The differential pathological fact which science offers the in- 
 quiring physician as to the effects of natural and unnatural sexual 
 excess is indeed a most remarkable one, and it is fully confirmed by 
 clinical observation of results, since probably fifty cases of general 
 paresis are caused by indulgence with women to one occasioned by 
 masturbation. The presence of the woman heightens the emotional 
 excitement, and there is a more diffused cortical liberation of ner- 
 vous energy, with angioparesis of cortical capillaries, and the shock 
 falls upon cortical centres, which eventually undergo the paretic 
 changes. In the other instance the normal stimulus to cortical emo- 
 tional centres is absent, and it is the automatic lumbar sexual centre 
 which is chiefly concerned, and the nature of the resulting disease 
 is essentially spinal. In rare instances, however, in persons with 
 vivid imaginations, who cultivate the habit of evoking by efforts of 
 phantasy the simulacrum of a woman, and thus succeed in exciting 
 cortical loss of nervous force, there may be developed finally a 
 pseudo-general paresis. '^ 
 
 Disease of the reproductive organs in women may become a 
 cause of Insanity, which may be relieved by local treatment or by 
 operative procedure. The results of gynecological treatment in 
 
96 TEXT-BOOK ON MENTAL DISEASES. 
 
 American and Canadian hospitals for the insane within the past few 
 years fully confirm this general statement. When a woman who is 
 a great sufferer from uterine disease becomes insane and undergoes 
 gynaecological treatment and is cured at once of her local disease and 
 of her mental disorder, and remains well, it is a fair inference that 
 there was a causative relation between the local and mental trouble. 
 This sequence of events has occurred repeatedly, and has been duly 
 reported in large numbers of cases of insane women, who have been 
 thus operated upon, and have been promptly restored to their right 
 mind. 
 
 There is a counter-statement to be made in this connection, and a 
 diametrically opposite series of cases to be adduced in order to lay 
 bare the whole truth. Not a few women suffering from disease of 
 pelvic organs, but not rendered insane by the same, have undergone 
 operations Avhich have been followed by Insanity, and here again 
 it is equally fair to infer the nature of cause and effect as between 
 the operation and the mental disorder. 
 
 Furthermore, women have suffered surgical ablation of their 
 uterine appendages, which were not diseased, and have become in- 
 sane as a sequel of the operation. The disturbance established by 
 the operation and the readjustment required in the whole nervous 
 economy is probably greater in the latter than in the former cate- 
 gory of cases. 
 
 Briefly summarizing conclusions on this subject, it may be safely 
 affirmed that both functional and organic diseases of the sexual or- 
 gans are sometimes adequate exciting causes of mental disorder — 
 that the partial or complete removal of the uterus and its appendages 
 or surgical operations upon the same may cause Insanity, or may 
 relieve it when it exists; that superadded disease of pelvic organs 
 uniformly aggravates the existing mental trouble; that even the 
 rhythmical and functional activity of these organs is attended, as a 
 rule, by exacerbations of the mental symptoms, but, as a marked 
 exception, cases of Insanity, presumably due to chronic hypersemic 
 cerebral states, relieved by the local derivation of blood to pelvic 
 regions, enjoy comparative lucidity only during menstruation and 
 gestation. 
 
 In men, genito-urinary diseases are, in rare instances, the ex- 
 citing cause of mental disturbance. 
 
 In neurasthenic cases subacute inflammatory conditions of the 
 urethral mucous membrane, with reflex sexual weakness, may act in 
 
THE ETIOLOGY OF INSANITY. 97 
 
 this way, and in senile cases urethral strictures, enlarged prostate 
 gland, and chronic cystitis may be the immediate cause of melan- 
 cholia, as may also be stone in the bladder, with its distressing train 
 of symptoms. 
 
 Renal disease is frequently associated with Insanity, and the two 
 affections are sometimes the common symptom of general vascular 
 degenerations. Occasionally the kidney disease precedes the mental 
 trouble, and may be regarded in the light of a cause. In several 
 hundred autopsical examinations of the insane the writer has found 
 renal disease in a considerable percentage of cases, and in one in- 
 stance a remarkable cystic degeneration of both kidneys would seem 
 to have been the cause of the Insanity. Several writers have re- 
 ported cases of mental disorder from Bright's disease of the kidneys, 
 and Dr. Bennett, of Pennsylvania, has made an extensive contri- 
 bution in this direction. It is, of course, important to know the 
 time of the systemic vascular degenerations and the general path- 
 ological order of events in these cases before logical conclusions can 
 be drawn, but it is safe to admit Bright's disease among the etiolog- 
 ical factors of mental disorder. If there appears, on close inquiry, 
 a history of previous alcoholic excess in these cases, it is more con- 
 sistent to regard both the renal and mental trouble as resultant 
 symptoms of this antecedent cause. 
 
 Kidney disease, with prolonged ursemic conditions, is attended 
 by occasional maniacal or stuporous states, and likewise Insanity 
 is sometimes an epiphenomenon or an interchangeable condition 
 with the diseases of the nervous system, which gives rise to continu- 
 ous diabetes. The writer has had one well-marked case of Insanity 
 with Addison's disease, and it is not improbable that there is some 
 causal connection between the two affections. 
 
 Gasiro-intesf.inaJ disorders may be the occasional cause of Insan- 
 ity. The irritability and depression of .dyspeptics and the immedi- 
 ate changes in emotional tone produced by affections of the gastro- 
 intestinal mucous membrane show the intimate sympathetic rela- 
 tion between the whole intestinal tract and organic consciousness. 
 This reflex relation is evident also in modification of the symptoms 
 of Insanity by intercurrent disease of the stomach or intestines, and 
 in delusions or illusions corresponding to such disease of this nature 
 as is usually present in all acute cases of mental disorder. 
 
 When Insanity appears as a sequel of a troublesome gastric or 
 intestinal disease and disappears when this disease is relieved, it is 
 7 
 
98 TEXT-BOOK ON MENTAL DISEASES. 
 
 natural to recognize the causal connection, though it is possible that 
 both affections might be symptoms of a more general cause, which 
 is probably to be sought in the nervous system. It is a fact that 
 gastric and duodenal catarrh are frequent prodromata of mental dis- 
 order, and that skilful treatment occasionally gives simultaneous 
 relief to both the gastric and psychic trouble. 
 
 The, liver, which the ancients regarded as the chief source of 
 Insanity, is not without causative relations to mental disease. There 
 are to be considered in this connection the frequency of icterus and 
 of gall-stones in the insane, the changes in the quantity and the 
 quality of the bile, the obstruction of the portal circulation, the well- 
 known despondency attending hepatic affections in general, and seri- 
 ous systemic conditions resulting from organic diseases of the liver. 
 
 Hammond attributes much importance to the liver as a cause, 
 more especially of melancholia, for the cure of which he has aspi- 
 rated hepatic abscess. 
 
 The pancreas and the spleen have no well-recognized etiological 
 relations to Insanity, but they may have a reflex influence, like other 
 viscera, and it would not do to deny that they might disturb the 
 action of cerebral centres. What the influence of the enlarged spleen 
 may be in malarial Insanity is open to conjecture. 
 
 Cardiac diseases have a direct relationship to mental disorders, 
 which they aggravate, modify, and sometimes cause in the first in- 
 stance, through defects of circulation and nutrition of cerebral tis- 
 sues. There is more than am average proportion of cardiac disease, 
 apparently, among the insane, who have hypertrophy, dilatation, and 
 valvular lesions of the heart very frequently. Mitral lesions are spe- 
 cially common, and aortic valvular disease is by no means rare, and 
 is apt to be found in the more confirmed insanities. 
 
 One writer has even gone so far as to describe the special types 
 of mental disorder to which the different cardiac lesions give rise. 
 It is enough to name anxiety, depression, and irritability as common 
 mental symptoms in these cases. Certain cases of organic dementia 
 resulting from embolism proceed primarily, no doubt, from cardiac 
 disease, just as heart disease and Insanity arise as common symptoms 
 of rheumatism. 
 
 It is a question how far the feeble and fatty hearts of terminal 
 dements determine in any degree the mental weakness of the 
 patients, and what favoring relation there may be between the 
 atheromatous degeneration of the aorta and the dementia of seniHty, 
 
THE ETIOLOGY OF INSANITY. 99 
 
 for special symptoms of general morbid processes may still have 
 causal connections among themselves, and all the senile vascular 
 degenerations often antedate the mental decline and in part occa- 
 sion the nutritive cerebral lesions. 
 
 Pulmonary diseases are among the etiological elements of mental 
 alienation. Phthisis pulmonaHs, which is foremost in this regard, 
 will be mentioned later under the group of diathetic causes. The 
 statistical fact that pulmonary affections are much more common 
 among the insane than in the general population, and that they 
 uniformly constitute the causes of large mortalities in hospitals for 
 tJie insane, is significant in this connection. There is the further 
 fact that an important part of the somatic derangement in Insanity 
 is referable to the pulmonary organs, as will be seen in the chapter 
 on somatic symptomatology. 
 
 Pneumonitis occasionally develops mild forms of mania, and in 
 alcoholic subjects fatal forms of acute delirious mania. 
 
 Pleuritis has been the exciting cause of melancholia, and in 
 chronic pleuritis and empyema unfavorable forms of Insanity, ap- 
 parently dependent on organic brain lesions, may arise. Chronic 
 bronchitis and emphysema favor the development of melancholia,, 
 particularly in senile cases. 
 
 The various forms of spasmodic asthma have certain etiological 
 relations to Insanity, of which they may form the prodromes or- 
 sequels. In other instances the pulmonary disease and the Insanity- 
 appear together, as the result of previous organic brain disease, and 
 of this something more will be said under the head of pathology. 
 
 Vascular disease and circulatory disorders are among the possible 
 exciting causes of Insanity. Vascular degenerations axe very com- 
 mon in mental disorder, which they sometimes precede and provoke 
 by depriving the brain of its customary blood-supply and by the pre- 
 vention of the elimination of the waste products of cellular activity. 
 This is the immediate and practical relation of vascular disease to 
 Insanity, though it is freely admitted that there is a previous link 
 in the etiological chain of events, and that, adhering strictly to the 
 pathological order of things, the vascular disease is secondary to cel- 
 lular tissue changes. Cortical nerve-cells, surcharged with waste 
 products or suffering from toxic exposure, demand and attract more 
 blood, and the cerebral hypersemia thus occasioned, if long con- 
 tinued, leads to vascular changes, which in turn act in the manner 
 above mentioned; but, as there is no sufficient knowledge of these 
 
100 TEXT-BOOK ON MENTAL DISEASES. 
 
 biocheimcal changes in cortical nerve-cells, it is more practical to 
 avoid a theoretical search for the final reason, and to accept the 
 vascular disease as the proximate cause of the mental disturbance. 
 The special vascular degenerations will be described in the chapter 
 on pathology. 
 
 Vasomotor disorders not only form prominent symptoms of many 
 forms of mental ahenation, but they essentially constitute the con- 
 necting link in the causation of Insanity by visceral affections and 
 peripheral nervous disease. 
 
 The vasomotor centre of the medulla is under the reflex control 
 not alone of the cerebral cortex, but of the entire peripheral dis- 
 tribution of the sensory nervous system, so that not only emotional 
 stimuli, but peripheral irritations, may effect circulatory changes and 
 variations in blood-pressure which stand in proximate relation to 
 mental disorder. Thus, through the intervention of vasomotor ac- 
 tion, is explained the mental derangement which supervenes im- 
 mediately from an overwhelming emotion, or the sudden maniacal 
 outbreak attendant upon the continued pain of intense peripheral 
 irritation. 
 
 Unhygienic conditions, such as are numerously created by present 
 modes of civilized life, and not yet prevented by modem science, 
 deserve notice among the physical causes of Insanity. 
 
 The food which man consumes, the liquids which he imbibes, 
 and the air which he respires, largely determine his physical welfare 
 or misery. 
 
 If all these elements are highly artificial, the consumer will in- 
 evitably pass by slow degrees into an abnormal state of health. 
 Unhygienic points in the dietary of the average resident of towns 
 and cities are numerous. Meats are often poor in the first place, are 
 kept too long, and exposed to various temperature changes, and after 
 reaching the consumer are placed in ill- ventilated refrigerators, or 
 they are salted, pickled, potted, smoked, desiccated, in crudely arti- 
 ficial ways. Vegetables are seldom fresh, and are chiefly canned, and 
 unhealthful often through secondary changes. Cereals of all sorts 
 are usually kept too long exposed to all kinds of atmospheric germs. 
 Milk is conveyed a distance under varying temperature, or passes 
 from one receptacle into another, and is often condensed poorly, and 
 is seldom good, if not positively bad. Eggs are packed, and, through 
 absorption and other influences, are often distinctly bad articles of 
 diet, but necessarily enter largely into the cooking. No more favor- 
 
THE ETIOLOGY OF INSANITY. 101 
 
 able accoimt could be given of other staple articles of diet did space 
 permit. Drinking-water is seldom healthful, and tea, coffee, and 
 artificial drinks are substituted from earliest childhood, so that the 
 craviag for stimulants increases until some form of alcohol is reached. 
 
 Houses are ill-ventilated and usually overheated. The indoor 
 air breathed da,y and night is charged with germs and simmers with 
 organic dust-particles, as seen by sunlight. 
 
 It is no wonder when continuous generations are bred under 
 these unhygienic conditions that they have nervous dyspepsia, neu- 
 rasthenia, functional neurosis, and finally mental disorder, especially 
 when it is considered that excessive functional activity of brain- 
 centres is superadded, and that exhausted cortical regions are often 
 not restored for want of sufficient sleep. 
 
 It might be profitable to divert some of the universal ardor with 
 which heredity and " stigmata degenerationis " are studied to the 
 investigation and scientific prevention of the conditions which make 
 heredity, which has by voluminous writing been erected into a for- 
 midable sort of an entity, whence emanates a full-blown tendency to 
 all the ills to which flesh is heir. As a matter of fact, this tendency 
 proceeds from a thousand little commonplace unhygienic influences 
 which escape the study of the scientist and the remedy of the prac- 
 tical hygienist, and perpetuate themselves through generations of 
 beings, who become weak and nervous, and have children who re- 
 semble their parents, because they live under the same unhealthful 
 and highly artificial circumstances, and hence have no chance of 
 reversion to the normal type. 
 
 The physiological crises as etiological factors deserve consideration. 
 Life is ever a conflict between natural elementary forces, which tend 
 to disintegrate, and vital forces, which sustain the human organism, 
 and there are critical periods in this battle through which every 
 human being is destined to pass. 
 
 In this unequal conflict, in which the natural environing forces 
 always prevail, and which always ends by nature claiming her own, 
 some with compact vital forces present an unwavering front to the 
 enemy and pass through all the crises unshaken, and only yield at 
 the bitter end, while others show signs of disorder at the first critical 
 moment, and are demoralized and completely disordered at each 
 successive crisis of life. 
 
 The contest between the vital integrating and the environing 
 disintegrating forces may begin before embryonal life, and chemic 
 
102 TEXT-BOOK ON MENTAL DISEASES. 
 
 and toxic forces acting on the germal or spermal elements may cripple 
 the being which is to he. The moment of conception is also a critical 
 one, and should either or both of the parents be suffering from acute 
 incubatory disease, or toxic, especially alcohohc, influence, or great 
 mental strain, the die may be cast then and there for the future 
 misery of the offspring. 
 
 Intra-uterine hfe is a period replete with dangers, for the embryo, 
 although safely surrounded by muscular walls, is vulnerable through 
 the maternal circulation and nervous system, and it suffers not only 
 from untoward " maternal impressions," but also shares the fate of 
 the mother as regards general diseases, and traumatic, toxic, and all 
 inimical external forces. 
 
 The clubbed feet, withered limbs, compressed and distorted 
 crania, and other physical mishaps of embryonal life have received 
 much attention, but the cerebral accidents and fatal mental shocks 
 of this critical period have yet to be studied. 
 
 The first independent crisis of existence is birth, and as the little 
 being, hard pressed on all sides, struggles forth upon the stage of 
 life's miseries, and suddenly presentient, as it would seem, of all the 
 ills before him, utters that first long cry of distress, he vocally typifies 
 the echo which comes back at the other end of life in the dying moan, 
 the first and the last sound alike struck in the dominant key of 
 average human suffering. 
 
 The most imminent danger at birth is the narrowing of the bony 
 pelvic canal, through which the fetal head has to pass, and the 
 prolonged pressure to which it is thus exposed, and which results 
 not infrequently in idiocy and lesser grades of intellectual defect. 
 Primiparous children naturally suffer more than others from cranial 
 pressure during parturition, and males more than females, inasmuch 
 as the average diameter of the male fetal head is greater than in the 
 female, and this fact may alone in part explain the excess of male 
 over female congenital mental defects. 
 
 Premature birth may also account for mental deficiencies, though 
 in nothing like the same degree as primogeniture. 
 
 Difficult and prolonged labor and instrumental delivery are also 
 to be here enumerated among the perils of this first crisis, which, 
 brief though it be, is often fraught with the issues of life and 
 death, and though the child survive the parturient injury, it is with 
 an intellect " nipped in the bud." 
 
 Illegitimate and unsuccessful abortive attempts upon the life of 
 
THE ETIOLOGY OF INSANITY. 103 
 
 the cMld may likewise have lasting ill results, and the general physi- 
 cal tendency of civilization to enlarge the fetal head relatively while 
 contracting the pelvic outlet may be accorded some weight in this 
 connection, as well as multiple birth and asphyxia and other acci- 
 dents of this crisis. 
 
 The second physiological crisis through which the child has to 
 pass is dentition. Peripheral irritations in dental nerves act with 
 peculiar force on unstable cerebral centres at all times of life, and 
 especially is this the case in early childhood. 
 
 The congestions of this period are not confined to dental regions, 
 but extend to encephalic centres, and the continued pain has, as a 
 reflex result, disturbed digestion and intestinal irritations and diar- 
 rhoea, which aggravate the general irritabihty of the patient, and 
 may reach the point of general convulsibility. The dentitional 
 eclampsia thus developed may, if severe and often repeated, perma- 
 nently damage the organ of mind, or pass into more confirmed forms 
 of convulsive seizures, which will then in turn be followed by the cus- 
 tomary unfavorable mental sequels. 
 
 Puberty is a physiological crisis of great import, arriving during 
 the period from twelve to sixteen years, and the age of its occurrence 
 varies somewhat with ethnic peculiarity and climatic influence, as 
 well as with inherited idiosyncrasy. The complete evolution in the 
 emotional and intellectual spheres at this epoch is as remarkable as 
 the changes in the reproductive organs. The psychological evolution, 
 however, is not accomplished until some time after the physiological 
 changes have been perfected. Both the psychic and somatic devel- 
 opmental changes are much more rapid in the female than in the 
 male, being completed in a decennium in the former, and requiring 
 a decade in the latter before full maturity of mentaland bodily 
 powers is attained. There are correlative functional changes in the 
 cortical regions at this epoch, and dormant emotions and latent 
 hereditary tendencies are for the first time aroused into full activity. 
 Any transmitted instability of cortical centres is very apt to appear 
 at this time as emotional disorder, loss of self-control, and impulsive 
 violence, which symptoms are the analogues of motor disturbances 
 iu neurotic childhood. The stupendous work of nature at this period 
 in perfecting all parts of the individual organism, while providing 
 for reproduction of the race, and adjusting the highest nervous 
 centres to the complex relations of adult life, is often attended by 
 
104 TEXT-BOOK ON MENTAL DISEASES. 
 
 uutritive insufficiences, through, actual want of constructive material 
 for these varied purposes. This defect of nutrition of brain-centres 
 is manifested as mental disorder whenever there is a predisposition 
 in this direction. In woman especially there is apt to be scant form- 
 ative material and impoverished blood, and in this state of unstable 
 nutritive equilibrium the rhythmical diversion from cerebral to re- 
 productive tissues of even a small amount of nutrient fluid at the 
 " nisus generativus " is sufficient to renew the mental disturbance. 
 
 When the constructive changes in the vascular, muscular, osseous, 
 and reproductive systems have been accomphshed, and the correla- 
 tive transformations in the eerebro-spinal nervous system, and more 
 especially in the psychomotor regions, have been completed, there 
 is re-established a metabohc equilibrium, and the chief danger of 
 psychic disorder may then be said to have passed, and in woman, if 
 periodic mental disturbance does not then cease, the prognosis is 
 unfavorable. As important complications and morbid epiphenomena 
 of this physiological crisis are to be mentioned constitutional neu- 
 roses, cranial developmental defects, neurotic cutaneous afCections, 
 and functional sexual disorders, which heighten and complicate the 
 action of this epoch as an exciting cause of Insanity. 
 
 The next physiological crisis to be considered is maternity. 
 
 The functional burden of the perpetuation of the race falls largely 
 upon woman, and it is full of risks for both the mind and the body. 
 In this crisis heredity plays a much less prominent role than in that 
 of puberty, but it is still a complicating factor, which, as reason hangs 
 in the balance, tips the scales of mental destiny on the side of disease. 
 During gestation, especially in" the last three months, there are im- 
 portant circulatory changes, and constantly augmenting reflex uterine 
 influences, which react upon brain-centres which have to accom- 
 modate themselves to a host of new physical sensations, tinged with 
 emotional ideas, maternal, apprehensive, and painfully depressing in 
 case of illegitimacy. The crisis is apt to be somewhat more severe 
 in primiparse than in multiparse, and it is certain that mental aber- 
 ration is more hable to occur in primiparous parturition after the 
 age of thirty-five. 
 
 It is thought by some that the sex of the embryo bears a more 
 constant relation to the general degree of suffering of the mother 
 than can be accounted for by coincidence or idiosyncrasy. Heredity, 
 when it does appear, is often homologous and a repetition in the 
 daughter of similar Insanity under like circumstances in the mother. 
 
THE ETIOLOGY OF INSANITY. 105 
 
 Previous attacks of mental disorder on the part of the mother are 
 strongly predisposing elements. 
 
 Albuminuria, uraemic states, and eclampsia are complicating 
 causes in occasional instances of the Insanity of gestation, which 
 may be attended also by defects of nutrition and excretion, wliicii 
 are to be regarded in the same light as contributive etiological 
 factors. 
 
 Parturition endangers mental stability through moral shock, 
 which is greater in cases of illegitimate birth; through intense and 
 prolonged pain, which may rise to the height of frenzy, and pass at 
 once into continued maniacal delirium; through sudden and profuse 
 hemorrhages eventuating in anaemic maniacal attacks; and through 
 retention of excretory products in the system and infectious proc- 
 esses, or as the immediate sequel of eclamptic convulsions. 
 
 Contributory causative circumstances in this parturient crisis may 
 be prolonged labor, the administration of anaesthetics, and instru- 
 mental delivery, and combined toxaemic and renal affections. 
 
 Post-partum causes of mental disturbance are hemorrhages, septic 
 reabsorptions, lochial and lacteal suppressions, uterine inflammation, 
 general infections, and toxaemic states, and, in mothers longing for 
 off'spring, grief in case of death of the child. 
 
 Finally, the forms of Insanity connected with lactation are due 
 to general nervous exhaustion, malnutrition, anaemia and other patho- 
 logical states of blood, uterine subinvolution, prolonged lactation 
 and loss of sleep and undue solicitude as to the child, and, in case of 
 hereditary tendency, phthisis pulmonalis is specially wont to develop 
 at this lactational period. 
 
 The menopause is the most decided of the physiological crises. 
 In all women, at the grand climacteric, there is more or less mental 
 instability and moral variance similar to such as generally character- 
 ize the evolution and cyclic activities of the reproductive organs. 
 The involutional changes are cerebral as well as sexual, and in this 
 fact lies the explanation of the mental disturbances. The cerebral 
 readjustment to the new order of things involves ideational, emo- 
 tional, and coengesthetic adaptations of a wide nature, and there is 
 a complex equilibration of sensory motor and vasomotor functions 
 to be brought about. That these involutional changes are accom- 
 plished with difficulty, and even open disorder, there is abundant 
 s^^mptomatic evidence in the paraesthesias, local hyperasmias, hemi- 
 spastic, and general vasomotor disturbances, in the emotional and in- 
 
106 TEXT-BOOK ON MENTAL DISEASES. 
 
 stinctive perversions, and in sensorial and intellectual aljerration in 
 those hereditarily predisposed. 
 
 Heredity is less active in this crisis than in the physiological 
 epochs heretofore mentioned, though in occasional instances it is 
 singularly repetitive in the precise similarities of symptoms of 
 daughter and mother at this critical age. Acquired predisposition 
 from previous attacks of Insanity is frequently to be taken into ac- 
 count in mental alienation at the change of life, and other elements 
 of causation occasionally attendant upon the climacteric are toxic 
 influences (especially alcoholic), confirmed nervous diseases, and ex- 
 ceptionally premature arterial degeneration and cerebral senile 
 changes. Strictly speaking, the climacteric and the senile involution 
 are perfectly distinct in women, but in some degenerate families 
 there is a late appearance of the catamenia and an early disappearance 
 of menstruation with all the signs of premature old age, and a merg- 
 ing of the two classes of involutional changes. 
 
 It is probable that in most chmacteric mental disorders senescent 
 failure of the vasomotor system is causative in some degree, and the 
 syncopal, epileptiform, and congestive cerebral attacks common at 
 the menopause tend to confirm this view. The vasomotor failure 
 and the consequent prolonged circulatory disturbances of brain- 
 centres are more potent etiological agencies than ovarian disease, 
 local hemorrhages, and uterine displacements, occurring at this epoch. 
 
 Analogous to the menopause in women during the fifth decen- 
 nium, but resting upon a narrower physiological basis, is the climac- 
 teric in man in the sixth decennium of life. In man it is not a ques- 
 tion of the extent of tissue-changes or of a balancing anew of cerebral 
 and peripheral organic relations so much as it is of the disappear- 
 ance from the higher representative centres of desires and varied 
 emotional phases of mental life, springing originally from the sexual 
 instinct, which is predominant in indirect influences upon the mind. 
 
 Intellectual prime coincides with the full height of sexual vigor, 
 and any marked permanent decline of sexual power has a decided 
 psychic effect. 
 
 It is the physiological rule, that there is in the sixth decennium 
 a sexual involution, manifested in some men by diminution of de- 
 sire, in others by loss of appetite and ability, and in neurotic sub- 
 jects by complete impotence, which may be the immediate cause of 
 suicidal melancholia. The physiological fact of climacteric sexual 
 involution is not to be denied, but the etiological value of the fact 
 
THE ETIOLOGY OF INSANITY. 107 
 
 may be cautiously interpreted to mean simply that it may be a de- 
 termining factor of mental disorder favored by strong hereditary 
 predisposition. 
 
 The final physiological crisis of life is senility. The involutional 
 changes are universal at this epoch, involving osseous, muscular, 
 nervous, and glandular tissues. 
 
 The whole significance of the epoch as regards the organ of mind 
 lies in excess of waste over repair, and progressive brain-atrophy, 
 more especially of cortical elements, which eventuates in mental 
 decay. The usual changes of mind in old age are too well under- 
 stood to be mistaken for Insanity, but when there is a rapid decline 
 of mental powers and sudden alterations of character, it becomes 
 difficult to draw the line between physiological and pathological 
 involution. 
 
 The most important etiological influence of this epoch in its 
 bearings on mental disease is the general atheromatous degeneration 
 of cerebral vessels, also particularly of the carotid, vertebral, and 
 basilar arteries, which with narrowed lumen fail to furnish a due 
 supply of nutrient fluid. In the absence of atheroma of these large 
 vessels pathological states of the arterioles and miliary aneurisms 
 may exist. Eupture of cerebral vessels, coarse brain-disease, and 
 focal lesions are mentioned by some writers as causes of senile In- 
 sanity, but they pertain rather to organic dementia. 
 
 Heredity is not as important as in the developmental epochs, but 
 in some families Insanity only appears as the result of senile degen- 
 eration. On the other hand, general exciting causes, such as mental 
 strain, business worry, and general unhygienic influences, and ex- 
 cesses of all kinds, act with unusual effect on a brain without re- 
 sistive power, and which has already entered upon a natural de- 
 cadence. 
 
 The neuroses in tJie light of causes next require a brief review. 
 Chorea., h}q30chondriasis, hysteria, neurasthenia, and epilepsy are 
 pathological states of the nervous system allied in some degree to 
 Insanity, into which they sometimes pass abruptly, and at other 
 times by gradual transition. 
 
 Such indeed is the intimacy of pathological relation that these 
 functional neuroses and the psychoses may precede, follow, or mu- 
 tually replace one another by vicarious transformation. These in- 
 timate pathogenetic relations will be dealt with in the clinical part 
 of the work, and it is only necessary to note here the farther fact 
 
108 TEXT-BOOK ON MENTAL DISEASES. 
 
 that these neuroses vicariate with the psychoses hereditarily, as well 
 as in the same generation and individual. Patients suffering from 
 these neuroses beget insane children, who in turn have offspring 
 afflicted with these neuroses. The most hopelessly insane, general 
 paretics, do not heget paretic but epileptic children. 
 
 Epilepsy, as an independent and permanent neurosis, is followed 
 by mental deterioration in more than fifty per cent, of all cases. 
 The various forms of Insanity in which it results will be later de- 
 scribed. 
 
 In all the established neuroses there is a gradual but persistent 
 psychical degeneration, which effectually prepares the way for 
 Insanity. 
 
 Taking a more comprehensive view of the whole subject, it may 
 be said that these neuroses consist essentially in a pathological reduc- 
 tion of the higher nervous centres in the same direction but less in 
 degree than that present in Insanity, and that they constitute the 
 preliminary degenerative processes of which the mental disorder is 
 the final stadium in the individual, or the final hereditary outcome 
 in the course of generations. 
 
 TTie toxic origin of Insanity is of numerical and substantial im- 
 portance. 
 
 In a monograph published four years ago by the writer, on " The 
 Toxic Origin of Insanity," it was estimated that thirty per cent, of 
 aU cases of mental disorder were due to toxic causes, and subsequent 
 study has confirmed the view that this was not an over-estimate, 
 and that in all truth and probability a considerable addition might 
 be made to the numerical strength of this statement. It is variously 
 estimated by different authorities that alcohol alone, through its 
 toxic action, accounts for from ten to fifteen per cent, of all cases 
 of Insanity, regarding simply its direct, and ignoring its much wider 
 indirect, effects. 
 
 It would be out of place to enumerate at full length the toxico- 
 logical substances which are capable of exerting a causative influence 
 in mental disease. 
 
 The toxic agent may be animal, vegetable, or mineral; it may 
 be ingested in fluid or solid form; it may be respired and enter 
 the system through the lungs, or it may gain access through the 
 cutaneous or mucous surfaces. 
 
 The poison, once in the circulation, has a pathological action 
 upon nutrition and upon the vasomotor system, and then its bane- 
 
THE ETIOLOGY OF INSANITY. 109 
 
 ful efPect falls next upon the cerebral yascular system and upon 
 ganglionic and cellular structures. The promptness and the per- 
 sistency of the various poisonous effects and the nature of the re- 
 sulting mental aberration will be described in later cUnical chapters. 
 The poisons most productive of Insanity, and the toxic states to 
 which they give rise, may be briefly enumerated as follows: Alco- 
 holism, hydrargyrism, plumbism, arsenicism, atropiaism, morphin- 
 ism, cocainism, haschischism, chloralism, bromism, nicotinism, ether- 
 ism, chloroformism, oxy-carbonism, iodinism, iodoformism, hyoscy- 
 aminism, and phosphorism. 
 
 It is important to remember that any drug, not excluding stand- 
 ard pharmacopceial remedies, if pressed too far, may damage the 
 nutrition of brain-tissues, and become the exciting cause of mental 
 ahenation in eases with hereditary or acquired predisposition. The 
 individual resistance to toxic influences varies greatly, as is con- 
 stantly to be seen in those exposed by occupation to carbon disul- 
 phide, turpentine, aniline, and other poisons, and there is a like' 
 individual variation in the resulting mental disorder. 
 
 Auto-intoxications causing mental disorders demand attention in 
 this connection. The toxic agents thus far considered have had an 
 external origin, but there are poisons generated within the system 
 capable of deranging the mind. 
 
 The mental disturbances of ursemic intoxication are familiar to 
 the general practitioner, 'and they sometimes pass into confirmed 
 Insanity. Prolonged diabetic conditions may also be direct etio- 
 logical factors of mental disease. Diabetes mellitus also bears in- 
 direct and hereditary relations to the psychoses, with which it may 
 in the same individual form also a distinct alternation. 
 
 Septic reabsorption is a causative element in certain cases of 
 puerperal mania, and the perverted secretions of many acute insani- 
 ties suggest the toxsemic origin of the disease. 
 
 In other cases of Insanity the highly morbid secretions and ex- 
 cretions, and the generally defective metabolism, and the frequent 
 obstipation favoring intestinal reabsorption of waste products, all 
 tend to the view of autointoxication, as at least a fitting and rational 
 explanation of the mental disturbance, and the relief afforded by 
 antiseptic treatment in such cases would seem to confirm this idea. 
 Modern chemistry has revealed the highly complex constitution of 
 brain-tissues, and if the varied biochemical products of cortical cel- 
 lular disintegration accumulate, it is possible that there may be 
 
110 TEXT-BOOK ON MENTAL DISEASES. 
 
 generated cerebral toxins, in situ, and that there may be an actual 
 brain auto-intoxication. 
 
 The study of experimental intoxications in animals and bacterio- 
 logical researches in toxaemias of the nervous system is too broad a 
 subject for discussion here, but there is much therein to support the 
 hyiDothesis of auto-intoxication as a cause of Insanity. 
 
 The psychoses from infectious disorders and acute affections of 
 internal organs are not uncommon. The infectious disorders to be 
 here enumerated are scarlatina, variola, rubeola, cholera, influenza, 
 diphtheria, and erysipelas; and pneumonitis and acute inflammations 
 of viscera are the afEections to be noticed. 
 
 The mental disturbance may appear in the prodromal stage of 
 the infectious disorders, or at the height of the febrile movement, 
 or in the convalescent stage, or as a more or less distant sequel. 
 
 The mental aberration of the incubatory stage is to be attrib- 
 uted to the action on cerebral centres of the virus already in the 
 circulation, and at the acme of the infectious disorder it is due to 
 the specific virus, to high temperature, to waste products and micro- 
 organisms in the blood, and to hypersemia of cerebral centres, and 
 in the convalescent stage it results from nervous exhaustion, pro- 
 found nutritional defects, cortical deteriorations, heart-failure, and 
 cerebral anaemia. It occasionally happens at the height of the in- 
 fectious disorder that the meningeal membranes are acutely in- 
 flamed or extensive cortical lesions occur, as the writer has repeat- 
 edly (on autopsical examination) found in insane patients dying 
 from epidemic influenza. 
 
 Exposure to cold or other cause of sudden repression of the acute 
 exanthemata has also been known to occasion an acute maniacal 
 outbreak. 
 
 Pneumonitis and other acute inflammations of internal organs, 
 tonsillitis, gonorrhoea, and cutaneous eruptions may be the immedi- 
 ate cause of mental disorder, and the hydrophobic virus may lead 
 to acute mental aberration in the fatal termination. The patho- 
 genetic relations of these various affections will be fully discussed 
 in the clinical chapter on general systemic morbid states. 
 
 The diatheses, in their causative relations to the psydhoses, naturally 
 appear in this connection. The diatheses more especially concerned 
 in the etiology of Insanity are the phthisical, rheumatic, podagrous, 
 pellagrous, malarious, anaemic, cancerous, limopsoitosic, postfebrile, 
 and myxcedematous. 
 
THE ETIOLOGY OF INSANITT. Ill 
 
 The immediate causative, as well as the hereditary relationships 
 of Insanity and phthisis pulmonalis have long been recognized. 
 Mental disorder arising during rheumatism and gout has been ex- 
 plained by metastasis, but there is no longer any doubt that actual 
 lesions of nervous centres, sufl&cient to account for the psychic dis- 
 turbance, do occur in the course of these diseases in certain cases. 
 The endemics of Insanity in various parts of Europe, more especially 
 in Spain, Italy, and France, due to the action of diseased maize, are 
 already matters of medical history, and the mental disorder is only 
 one among many groups of symptoms of the pellagrous disease which 
 provokes similar psychic disturbances to those produced by ergot- 
 ism. 
 
 Insanity not only arises from malarious poisoning, but it may 
 appear vicariously of other symptoms of intermittent fever and 
 during apyrexia. Aneemia always predisposes to mental disturbance, 
 of which it may also be the exciting cause, if sufficiently profound to 
 deprive the brain of such nutrient fluid as is essential to its normal 
 action. 
 
 Cancer, as an etiological factor in mental alienation, is rare, but 
 undoubted examples of it are on record. 
 
 Starvation during sieges in war times and in cases of shipwreck 
 gives rise to mental disorder, and it is an important element of the 
 causation of morbid h&emic and neural alterations and of mental 
 disorder in many instances in which extreme inanition persists in 
 spite of efforts at forced alimentation. A minor degree of the limop- 
 soitosic diathesis, lowering vitality and nervous force and the power 
 of resistance to the inimical influences of the environment, is among 
 the poverty-stricken masses the world over the most universal and 
 deep-seated cause of mental disorder, as of disease in general. 
 
 Postfebrile diathetic states occasion mental alienation through 
 general malnutrition, and special forms of wasting of cortical tissues, 
 and enfeeblement of cardiac and vasomotor action, and continued 
 defects of digestion and secondary assimilation, and the imperfect 
 elimination of the products of retrograde metamorphosis. The myx- 
 oedematous diathesis results in mental disorder in many cases, and 
 the relations of the thyroid gland to mental integrity are very re- 
 markable. It has been suggested that one function of the thyroid 
 gland is h^mic depuration, and that, therefore, through loss of its 
 action, toxins accumulate in the system and occasion Insanity. 
 Whatever hypothesis be admitted, the fact remains that in atrophy 
 
112 TEXT-BOOK ON MENTAL DISEASES. 
 
 and morlDid (goitrous) states of the thyroid gland, and after its sur- 
 gical removal, defects and disorders of intellect often appear. Thus 
 certain forms of idiocy, sporadic cretinism, cachexia strumipriva, 
 and myxoedema are attributed to functional or organic disease of the 
 thyroid gland, and what has long been known as the Insanity of 
 Graves's disease belongs in the same pathological category, proba- 
 bly, though exophthalmic goitre has been described as causing a dis- 
 tinct form of mental disorder. The cutaneous anomalies, convul- 
 sive states, and general mental enfeeblement in cachexia strumipriva 
 following thyroid ablation, and causal glandular relations in acro- 
 megaly, as well as the facts above mentioned, show the importance 
 of the glandular system as regards elimination and neutralization of 
 toxic waste products in the blood, as well as its direct influence on 
 normal metabolism, and the immediate bearings of this system in 
 Insanity will doubtless be understood with the advance of science. 
 
 Diseases of the cerehro-spinal nervous system and traumatic le- 
 sions are direct etiological factors of occasional mental disorder, to 
 which they may bear the relation of exciting or of predisposing 
 causes. The presumption that diseases of the nervous system, more 
 especially of the brain, would affect the mind is so natural that it 
 is necessary to guard against -the inference of cause and effect from 
 mere sequence alone. The eerebro-spinal disease and the Insanity 
 following it may be only common symptoms of some general path- 
 ological process due to syphilitic or alcoholic degeneration of nerve- 
 tissues, and the '" post hoc ergo propter hoc " -view of the case would 
 not be correct. 
 
 In some instances, however, the Insanity is clearly the sequel of 
 the nervous disease. 
 
 Encephalitis is a common cause of idiocy and imbecilitj;, and in 
 its subcortical forms later in life it often determines mental disorder. 
 Multiple sclerosis not infrequently results in aberration of mind, 
 and, in general, diffused lesions are more apt than focal disease to 
 cause Insanity. 
 
 Tumors exerting pressure on cells, fibres, and vessels of the 
 brain, and causing irritation, are also a source of alienation, espe- 
 cially when multiple. 
 
 Arterio-sclerosis, embolism, thrombosis, necrosis, aneurisms, ab- 
 scesses, hemorrhages, and hydrocephalus are brain diseases followed 
 by occasional mental disorder. 
 
 Meningitis is often causative of active mental aberration, which 
 
THE ETIOLOGY OF INSANITY. 113 
 
 may succeed the ordinary form of delirium. Middle-ear disease is 
 important because followed by meningitis. Locomotor ataxia not 
 rarely precedes mental disorder, and in ascending cases of general 
 paresis it may be the initial process. 
 
 Paralysis agitans and hereditary chorea are often followed by 
 Insanity, which is also occasioned by polyneuritis, especially of alco- 
 holic origin, though in a marked case in the writer's practice it was 
 due to arsenical poisoning. 
 
 Commotio cerebri may be the direct occasion of serious mental 
 aberration. In one case observed, the mental disturbance followed 
 promptly cerebro-spinal concussion, with great confusion of ideas 
 and almost total amnesia. 
 
 Trauma capitis may excite mental disorder by the direct cerebral 
 shock, or by the secondary resulting changes in cortical tissues, as 
 well as by accompanying hemorrhages into brain-tissue, or depres- 
 sion of bone exerting permanent pressure and acting as a constant 
 source of encephalic irritation. 
 
 Insolation is an important cause of mental disease, either from 
 the reflected or the direct rays of the sun, or from artificial heat 
 to which many are unavoidably exposed by occupation. It is a slow 
 but sure cause in those predisposed hereditarily and compelled by 
 business to reside in hot foreign climates. Permanent mental weak- 
 ness or instability is developed readily in infants by thoughtless ex- 
 posure to artificial or solar heat. A very hot day in a very large city 
 always kills some infants and makes mental cripples of others. 
 
 " Coup de soleil " has an etiological action, sometimes of a trau- 
 matic nature, and. again it is provocative of toxic changes, and of 
 general nutritive lesions, and mental disorder is the remote result, 
 following sometimes at an interval of several years. Surgical opera- 
 tions with prolonged anaesthesia may be the exciting cause of In- 
 sanity, and the extraction of several teeth at one sitting has been 
 followed by an acute maniacal outbreak, and in one instance within 
 the writer's observation this happened when anasstheties were not 
 employed. 
 
 There are certain lesions of brain membranes or of brain tissues 
 which result frequently in Insanity, such as those provoked by the 
 alcoholic poison or syphilitic virus, or by general involutional corti- 
 cal atrophy, or by pachymeningitis hemorrhagica interna, or by 
 tubercular basilar meningitis or cerebro-spinal meningitis. 
 
 Substantially, it may be affirmed that disease which simultane- 
 8 
 
114 TEXT-BOOK ON MENTAL DISEASES. 
 
 ously affects many or large tracts of the ideational or emotional 
 centres is causative of mental disturbance. Thus cysticerci, if suf- 
 ficiently numerous, may constitute such wide brain-lesions as to 
 occasion Insanity, though hydatid cysts and ecliinococci and brain 
 parasites in general may exist without any psychic derangement, and 
 the same rule applies to intracranial exostoses. 
 
 Again, the suddenness of development of the cerebral tumor or 
 other disease, "rapidly increasing cerebral pressure and giving no 
 time for compensatory adjustment of the brain circulation, is espe- 
 cially dangerous. It may be said of brain diseases in general that 
 they tend to produce mental disorder in the same degree that they 
 interfere A^dth the circulation or nutrition of the cortical centres. 
 
 Ansemia and hyperemia of the brain, if intense and long contin- 
 ued, however produced, become decided and direct etiological ele- 
 ments of mental disorder, of which the indirect factors are the dis- 
 eases causing the circulatory derangement. Extensive arterio-scle- 
 rosis, leading to renal and cardiac disease, and finally brain-anasmia 
 and nutritive cerebral lesions and Insanity illustrates a clinical chain 
 of causal events, which may be much shortened if, as sometimes oc- 
 curs, the cerebral blood-supply is directly diminished by arterio- 
 sclerosis of the internal carotid arteries. 
 
 The pathogenesis of Insanity from syphilis shows the variety 
 of ways in which the same cause may act. Thus s}^hi1is may act 
 though periostitis or exostoses involving the membranes or exerting 
 pressure on the brain, through chronic basilar meningitis, or en- 
 cephahtis, through periarteritis and aneurismal dilatations, and en- 
 darteritis and occlusion of middle cerebral and basilar arteries; 
 through luetic tumors and obstructed cerebral circulation; through 
 cellular degenerative changes in both superficial and deep cortical 
 layers; through pathological changes in the blood and general nu- 
 tritional defects; through the immediate dyscrasia and effects of the 
 luetic virus; through disease of internal organs and of the organs 
 of special sense; through the resulting epileptic, ataxic, or paretic 
 disease; through congenital forms of the affection, and, finally, 
 through its psychical morbid influences. 
 
 Furthermore, when it is borne in mind that syphilis frequently 
 acts in conjunction with excesses, " in venere et baccho," some idea 
 is gained of the complexity of the etiology of mental disorders, even 
 in the presence of a known prime factor. Alcohol, as a causative 
 agent, has similar and equally varied pathogenetic relations. 
 
THE ETIOLOGY OF INSANITY. 115 
 
 The reflex and sympathetic origin of mental disease is next to be 
 considered. 
 
 The higher nervous centres are intimately connected with spinal 
 centres, with the entire peripheral nervous distribution, and through 
 the sympathetic nervous system with all the organs of the body, 
 and the reflex relations thus established form the physiological and 
 anatomical basis of what are term^^d reflex or sympathetic mental 
 disorders. It is no more remarkable that the cerebral centres should 
 respond to reflex influences than that the spinal centres shordd thus 
 react to peripheral stimuli. In infancy the cerebrum is especially 
 prone to disturbed functional action from eccentric irritation, as 
 seen in delirium from intestinal disorder, or convulsions from 
 worms; and the vomiting of pregnancy, and hke visceral sympathies, 
 show the reflex connection of the internal organs among themselves. 
 That the brain as the highest organ should suifer sympathetically 
 from disease of other organs with which it is in intimate relation 
 and over which it presides is a natural supposition. 
 
 If, as has been recorded by good authority, a patient with tape- 
 worm suffers from confirmed melancholia, and is relieved completely 
 of the worm and of the Insanity by a vermicide, it goes far to con- 
 firm the reflex nature of the mental disorder. Helminthiasis is by a 
 consensus of opinion of many writers a common cause of Insanity. 
 The motor, sensory, and psychic disturbances of dentition are also 
 reflex, and the convulsive seizures, continued pain, and mental dis- 
 order have a common origin in the peripheral irritation. 
 
 Gastro-intestinal disease of a functional nature is usually at- 
 tended by mental irritability and gloom, which readily pass into 
 pathological states of mind. 
 
 Irritations of cutaneous as well as mucous surfaces may occasion 
 mental disturbance, as is seen in herpetic and other neurotic erup- 
 tions, and likewise pruritus vulvae has given rise to maniacal excite- 
 ment. It would appear that there is a great individual difference 
 in the keenness of organic sympathies, and in the susceptibility to 
 mental disorders of peripheral origin, and it becomes largely a ques- 
 tion of the relative explosiveness of the higher nervous centres and 
 the intensity of the acting peripheral irritation. Irritating ingesta 
 may provoke despondency in one case, epileptic seizure in another, 
 and have no effect in a third instance. Idiosyncrasy it may be which 
 determines that one out of many women suffering from prolapsus 
 uteri should become insane, and be relieved by the replacement of 
 
116 TEXT-BOOK ON ME^'TAL DISEASES. 
 
 the organ, as has been reliably reported. The same idiosyncrasy pre- 
 vails as regards the pathological conditions of the pelvic organs as 
 causes of Insanity cured by operations. It is observed that the 
 psychic result sometimes varies diametrically in different cases, the 
 same surgical procedure causing or relieving the psychosis in dif- 
 ferent patients, just as the exceptional woman is rendered insane by 
 gestation, or, if already insane, as an equal rarity, may be rendered 
 rational by it, only to relapse after the birth of the child. 
 
 The ancient writers observed that the sudden suppression of 
 hemorrhoidal flux or other chronic discharges was followed by men- 
 tal disturbance, and various instances of this have been recorded in 
 modern times. " Menstruatio suppressa " may provoke mental dis- 
 order, which is not merely a coincident symptom, but the result of 
 the intense cerebral hypersemia caused directly by the menostasis. 
 
 Likewise, the mental disorder with metastasis in gout, rheuma- 
 tism, or suddenly suppressed acute exanthemata, is due to active 
 cerebral congestion or actual inflammation. 
 
 Clouston ("Mental Diseases," p. 416) says: "I have seen more 
 than one case where the healing of an old ulcer was followed by an 
 attack of Insanity. I have seen instances of erysipelas of the face 
 ' striking inwards ' and causing an attack of acute mania." 
 
 The widespread disorder of nervous functions from local irrita- 
 tion is well illustrated in the presence of some small foreign body 
 in the sole of the foot, giving rise to tetanic seizures and a possible 
 fatal termination, or, if there be psychic convulsibility, maniacal 
 symptoms may appear. 
 
 Cicatrices involving sensory nerves may be the painful points of 
 reflex irritation exciting disorder of the cerebral centres, and cases 
 have been recorded in which pressure on these painful points height- 
 ened the mental disturbance, just as pressure on hysterogenic zones 
 may provoke hystero-epileptic seizures. 
 
 Severe neuralgias are to be included among the reflex exciting 
 causes of mental disorder, which they may replace or precede, as is 
 the case also with migraine. In fact, prolonged and severe pain 
 of any kind is, in those predisposed, a competent exciting cause of 
 Insanity, which, it is true, may be due to loss of sleep and disturb- 
 ance of nutrition caused by the pain, or to the cerebral vasomotor dis- 
 turbance which it provokes. Visceralgias often precede for years, and, 
 as far as the substantial form of the psychic disorder is concerned, 
 constitute the " materies morbi " of hypochondriacal Insanity. 
 
THE ETIOLOGY OF INSANITY. 117 
 
 In a paper published two years ago the writer described the 
 intimate relations of the pneiimogastric functions to forms of psy- 
 chic derangement, and it can no longer be doubted that pneumo- 
 gastric disorders may have direct pathogenetic bearings upon mental 
 disease, and that they should be numbered among the reflex causes 
 of the same. 
 
 The irritating and radiating source of the mental disturbance 
 may be in the sensorial peripherj'^, in the eye, ear, or nose, following 
 operations, injuries, or diseases of these organs. The exceptional 
 nature of this source of mental disorder is not a reason for its ex- 
 clusion, and it is presumed that a predisposition to Insanity exists- 
 in these instances, of which the writer has seen several. In Hke; 
 manner, but not to the same degree, traumatic injuries, or painful 
 affections of the extremities, or of any portion of the nervous periph- 
 eral distribution, may determine a reflex psychosis. 
 
 Peritonitis, hepatic abscess, larvae of frontal sinuses, Meniere's- 
 disease, and numerous other affections might be mentioned under 
 this head of the sympathetic and reflex origin of mental disorder,, 
 bat enough has been said to convey the idea that disease, not of the- 
 organ of the mind, but of distant organs, or of parts of the nervous 
 organism, may become the reflex cause of psychoses. 
 
 The further discussion of the mode of origin of these psychoses 
 would surpass the due limits of this chapter. 
 
 The 'psychical causes of Insanity remain to be considered. They 
 are also termed moral, as distinguished from physical, causes, and 
 they are usually classed among the exciting rather than the predis- 
 posing factors of mental disorder, though, as a matter of fact, these 
 are arbitrary, though, for didactic purposes, convenient, distinctions. 
 
 Psychical causes, if prolonged and severe, determine physical 
 lesions, and they not only predispose to, as well as excite, mental 
 disease in the individual, but, contrary to usual teaching, they are 
 a constituent element in the formation of hereditary predisposition. 
 A little study of the present and the past science of the human mind 
 shows that the modem man, like the historic man, is completely 
 governed by ideas which, issuing from the highest and innermost 
 recesses of his being, assume authoritative control and wield the 
 sceptre of destiny over his future physical and mental welfare or 
 miser5\ Many of these ideas are the natural germinations of con- 
 ceptual seed sown by ancestral acts, and predestined to bring forth 
 fruit after its kind. The hereditary suicide, having purposely, per- 
 
118 TEXT-BOOK ON MENTAL DISEASES. 
 
 chance, been kept in ignorance of his fatal heritage, struggles in 
 vain against the demon-idea, which culminates in self-destruction, 
 accomphshed, as by his parent, in a certain way and at the same age. 
 In like manner, one with alcoholic, libertine, or criminal heredity 
 may struggle through life against the tyranny of innate ideas. It 
 can be readily understood that certain classes of ideas, whether 
 emotional or instinctive, have by repeated transmission gathered 
 hereditary inertia, and act, therefore, in some persons with much 
 greater force than others. The individual equation in the patient 
 under examination is of great importance as to the actual force or 
 value of any particular psychical cause. Every patient has his own 
 vulnerability through some particular ideal area. The mother 
 clings to her young, the miser to his gold, the king to his throne, 
 the maid to her lover, the general to his renown, the poor man to 
 his cottage, the nobleman to rank and title, the author to literary 
 fame, the actor to popularity, the man to his family and success 
 in the world, the physician to his reputation, the business man to 
 his credit, the Croesus and mammon-worshipper to his millions, and 
 the impoverished masses to the helping hand that doles them out 
 a scant supply of the necessaries of life. Psychical vulnerability, 
 therefore, is as varied as inherited peculiarities, individual tempera- 
 ment, and acquired habits of mind, and the multitudinous external 
 relations of life. It is altogether a question of the potential rela- 
 tionship between the particular psychical cause and the individual 
 mind upon which it acts. Some psychical causes, which become di- 
 rect excitants of mental disorder, are astonishingly inadequate, such 
 as practical jokes, " hazing " in college, failure upon examination, 
 the reprimand of a child by a parent, the death of a pet animal, all 
 of which have been known to lead directly to suicide or insanity. 
 One young man of temperate habits and previous good health, poor 
 and economical, bought a lottery ticket, which won for him several 
 hundreds of dollars, which threw him into great hilarity for twenty- 
 four hours and then into boisterous mania, from which he recovered 
 at the end of some weeks under the writer's treatment. 
 
 When an idea strikes the mind with great force, particularly 
 if it impinge directly upon the most vulnerable psychical area, it 
 liberates a large amount of nervous energy, which may be trans- 
 muted into associated ideas, or transformed into related emotions, 
 or spent in motor demonstrations; but, if it find no appropriate 
 outlet, as is frequently the case with powerfully depressing ideas, 
 
THE ETIOLOGY OF INSANITY. 119 
 
 it then reacts •banefully upon the glandular system, upon secretion 
 and nutrition, or, finding no channel of escape, it results in painful 
 mental tension, which, if prolonged or repeated, ends in acute melan- 
 cholia. 
 
 The following are the modes of pathological action of psychical 
 causes which eventuate in Insanity. 
 
 In the first place, there is the direct dethronement of reason by 
 the immediate action of an emotional idea. 
 
 Syncope upon the reception of the news of a calamity is a fre- 
 quent occurrence, and death, though rare, is an equally well au- 
 thenticated result. In other instances there is an arrest not of vital 
 and cardiac functions, but of intellectual functions. The patient 
 is struck dumb, is motionless and speechless, and there is absolute 
 inertia in the emissive sphere of mind, and primary dementia ensues 
 at once. Sudden fright, likewise, may be followed by partial or 
 complete loss of consciousness, and dementia appearing immediately 
 or at the end of a few days. Anger, too, may pass directly into 
 maniacal frenzy in those free from any epileptic tendency, and in 
 this instance there may be confusion, but no actual loss of conscious- 
 ness. This widely diffused, radiatory, and perturbatory action of a 
 single emotion, which finally involves the whole psychic sphere in 
 disorder, is a remarkable psychological phenomenon. 
 
 Secondly, Insanity results from the cumulative action of psy- 
 chical causes. The patient may react manfully against loss of fort- 
 une, and, by an effort of will, may retain his mental equilibrium 
 under a rapidly succeeding loss of position, but the following death 
 of an only child may furnish the cumulative pathological action 
 from which the Insanity results. This mode of origin of the psy- 
 choses is constantly encountered in psychiatric practice, for there 
 is much truth in the saying that " misfortune never comes single- 
 handed,'' and only the most soundly and compactly fashioned minds 
 can withstand the blow upon blow which foul and cruel Fate often 
 deals an unfortunate victim. 
 
 Thirdly, there is another form of psychical traumatism, less 
 sudden than those above described, and resulting from the constant 
 daily repetition of lesser moral shocks, such as the sensitive wife of 
 a drunkard, or a speculative financier, or numberless persons in the 
 endless trying situations of life might have to endure. These con- 
 stantly repeated and prolonged psychical causes produce cardiac and 
 circulatory derangement, cerebral vasomotor disturbance, and cor- 
 
120 TEXT-BOOK ON MENTAL DISEASES. 
 
 tical niitritiYe lesions, disordered disgestion and changes in the 
 blood, neurasthenic and neurotic conditions, and, finally, distinct 
 psychoses. 
 
 The manner of reaction to these minor forms of psychical in- 
 juries varies much in individual cases. In some the psychical shock 
 provokes continued diabetes, which, in fact, may at first precede 
 and then alternate with the psychosis. In other cases the sequence 
 of pathological events is psychical injury, albuminuria, and a psy- 
 chosis which is recoverable; but another sequence is psychical 
 shocks, repeated and long continued, albuminuria, vascular degen- 
 eration, renal disease, and incurable Insanity. 
 
 Among the customary psychical causes, grief at the loss of chil- 
 dren, husband or wife, brother or sister, or devoted friend, is spe- 
 cially potent. It works all the more surely when combined with 
 personal attendance upon the departed one through continued sick- 
 ness. It is common in aged couples to see the loss of a life-companion 
 followed by death or insanity of the survivor. 
 
 Domestic trouble among women includes the thousand petty 
 worries of a wife, mother, and housekeeper, which recur daily and 
 hourly, and, like the constant dropping which wears the stone, con- 
 sume the nervous forces and result in mental disaster. There is a 
 corresponding cause in men, known as business worry, which in- 
 cludes the responsibilities, annoyances, and distressing occurrences 
 of active professional or commercial conflicts with the inevitable 
 misgivings as to future success. 
 
 Mental strain and overwork is an often-mentioned cause. Intel- 
 lectual exertion alone, unattended by any moral perturbation, is 
 seldom an element of causation, but mental labor performed as a 
 matter of necessity and during emotional suffering is an efficient 
 factor. Indeed, prolonged contrariety of feeling and action is ever 
 a strong provocative of mental alienation. The forced action con- 
 trary to feelings, the outward appearance of joy with inward sorrow, 
 the compulsory line of conduct against judgment, the force of cir- 
 cumstances which enslave and bind the free spirit of man, these are 
 influences which strain the strongest moral fibres. 
 
 Love and jealousy are complex emotions, and the subject of them 
 always presents an area of intense vulnerability. Disappointed love 
 is, in women, an occasional cause of a psychosis, but this occurrence 
 in men, is very rare, and it is then to be attributed to wounded pride 
 rather than to unrequited love. Jealousy is a veritable demon among 
 
THE ETIOLOGY OF INSANITY. 121 
 
 emotions, and there is probably no keener torment than the fiendish 
 rack of jealousy, to which the sequel is not infrequently suicide, 
 homicide, or Insanity. 
 
 Disappointed ambition, among men, is a much more efficient 
 cause than disappointed love, and here, too, the nature of the influ- 
 ence is more nearly alhed to wounded self-love. 
 
 Fear is the basis of a great generic group of emotional causes. 
 This emotion does not need definite form to work harmful effects, 
 for fear of evils which have not assumed specific shape is equally 
 disastrous to mental health. The element of uncertainty and the 
 possibility of all kinds of evils only gives the greater room for the 
 play of a panphobic phantasy. Space will not permit the naming 
 of the great variety of fears in neurasthenic individuals. The etio- 
 logical importance of fear lies in the fact that it is the most univer- 
 sal and primordial emotion, and directly allied to the fundamental 
 instinct of self-preservation. 
 
 Loss of property and social standing is mentally survived by men 
 of ordinary vigor, but if, as often happens, contrary" to the rules 
 of civilized warfare, the man fallen in the battle of life is, in addi- 
 tion to other misfortunes, trampled upon by the united vindictive- 
 ness of former opponents, mental disorder will result, except in the 
 instance of rare courage and endurance. 
 
 " Man's inhumanity to man, 
 Makes countless thousands mourn," 
 
 and the ruin of men wrought by enemies and persistent persecution 
 of individuals has in all ages been a prolific cause of Insanity. 
 
 The wholesale exhibition of brute passion and national enmity 
 and deeds of blood and iron, euphemistically termed war, abounds 
 in i^sychical causes of widespread mental disorder. 
 
 Persecutions of individuals, also, conducted in the name of re- 
 ligion, ever have driven and ever will drive more men into Insanity 
 than into Heaven. 
 
 Imprisonment, and particularly solitary confinement, not in the 
 professional, but in the accidental criminal, is a cause of mental 
 aberration. One element of causation in tliis case is analogous to 
 deprivation of the special senses, for it is not the withdrawal alone 
 of social intercourse, but of accustomed sensorial impressions, which 
 causes the psychical distress. The loss of the special senses, espe- 
 cially of the intellectual senses of sight and hearing, is a recognized 
 
122 TEXT-BOOK ON MENTAL DISEASES. 
 
 psychical cause of Insanity. The arrest of the constant ingoing cur- 
 rent of specialized impressions received by the brain cortex from the 
 acoustic and optic periphery is the deprivation of a sensorial pabu- 
 lum essential to a normal state of mind, and intellectual starvation, 
 pain, and aberration may follow. 
 
 Another psychical cause is the sudden cessation of business activ- 
 ity for a life of idleness, and any forced changes in the habits of old 
 persons act in like manner in disturbing mental equilibrium. 
 
 Dreams have important causative relations to mental disorder. 
 They have always had much influence on relatively ignorant or 
 superstitious minds, and they sometimes arise directly from organic 
 sources and may be truthful harbingers of coming disease; and, 
 again, by constant repetition, they become a sort of mental habit, 
 and may form the prodromal psychic phenomena of Insanity. 
 
 The dream-state is one in which all voluntary mental acts cease; 
 the power of attention and of comparison is lost and the absurdities, 
 therefore, of the ideas are not realized; judgment and self-conscious- 
 ness are in abeyance; the accidental association of ideas and the 
 association of ideas with organic and special sensorial impressions 
 remains; phantasy and organic memory are active; conscious per- 
 sonal identity is lost, but ccensesthetic personal identity — the sum 
 of subconscious organic impressions, which is the material basis of 
 personality — ^remains and constitutes in a dream the only real thing, 
 and the one fixed point about which phantasy plays, from which it 
 ever departs, and to which it ever returns. 
 
 The impressions of the dream-state are so vivid in neurotic per- 
 sons that they may be mistaken for realities, and they thus form 
 the starting-point of insane delusions. 
 
 In very exceptional instances the delirium of Insanity may be 
 the direct continuation of hypnagogic hallucinations and a case 
 of this kind is related by Maudsley (" Pathology of Mind," p. 41). 
 
 In the insane the line between dream-life and real life may 
 completely disappear, and there will then be no distinction between 
 the impressions of dreams and illusory impressions of the waking 
 state, just as in a still deeper state of mental decay there is no dif- 
 ferentiation between the real and the unreal. 
 
 There are certain disorders of sleep which are of etiological im- 
 portance. The brain repairs its daily waste only during normal 
 sleep, -without which nutritive deficiency is sure to result in cortical 
 centres. Insomnia is the most constant prodrome of Insanity. 
 
THE ETIOLOGY OF INSANITY. 123 
 
 There is a considerable individual variation in the amount of sleep 
 required, but the average of seven hours out of twenty-four admits 
 of no wide departure without risk to mental health, and the logical 
 sequence of prolonged insomnia is mental disorder. 
 
 Somnambuhsm is an expression of a neurotic constitution, and, 
 in various cases which have come under the writer's treatment, it 
 would seem to have constituted a prolonged preparation for Insan- 
 ity. It not infrequently involves the sufferer in ridicule, in mental 
 distress, and at times in real difi&culties, and becomes, finally, a direct 
 exciting cause of mental alienation. 
 
 Hypnotism is in itself a pathological nervous state, and, if it be 
 too frequently induced, it may be the direct means of establishing 
 a psychosis. Individual infection and communication of Insanity is 
 occasionally witnessed in psychiatric practice. 
 
 The influence of those clearly recognized to be insane upon the 
 sane persons about them is very slight, and is limited chiefly to 
 unconscious imitations, by attendants, of the mannerisms of the 
 insane. There are instances on record of paranoiacs who inoculated 
 large numbers of persons with their religious delusions, but, as soon 
 as these paranoiacs were recognized as insane and placed in seclusion, 
 their devoted followers ceased to believe, and the endemic folly was 
 at an end. Communicated Insanity, strictly speaking, is that which 
 is produced in the sane by the insane, and the different ways in 
 which this may occur are best made known by illustration. A mem- 
 ber of a family has paranoiac ideas of persecution, and, having nat- 
 urally a strong influence, persuades other members to believe in his 
 delusions and to act upon them. Insanity is communicated in this 
 way, as a rule, from older to younger persons, from stronger to 
 weaker minds, between those already alike in neurotic disposition 
 and accustomed by habit to trust in each other, and usually only to 
 one person at a time. A rare and interesting variety of contagion 
 of latent mental disorder is Insanity hy mutual infection. Thus, 
 two neurotic sisters of intense feelings and flighty imagination, by 
 mutual suggestions and fortifications of false ideas, persuade each 
 other into belief in the most absurd delusions. If kept separate they 
 may not become insane. After recovery from a first attack, if thrown 
 together, mutual reinfection will probably occur again. 
 
 Apart from imposed infection by a stronger on a weaker intel- 
 lect, and mutual infection — ^the combined outcome of two neurotic 
 minds — there is Insanity by sympathetic suffering. A nervous and 
 
124 TEXT-BOOK ON MENTAL DISEASES. 
 
 sympathetic woman nurses an insane relative (who is passive as an 
 agent of infection), and, partly through suggestion and imitation, 
 but chiefly through sympathetic suffering, becomes insane herself. 
 The communication of delusions between insane patients may some- 
 times be observed, but it is not a full exemplification of the type in 
 question. There is also the exposure, under hke circumstances, of 
 two or more persons who, from the same cause, become deranged 
 at the same time, and this is known as simultaneous Insanity. 
 
 Mental disorder as the result of simulation is of rare interest, and 
 it accords with known psychological reaction in normal minds. 
 
 It is well understood among tragedians who have to play the 
 same part through a prolonged engagement that no small volitional 
 effort may be required to resist temporary emotional perversions, 
 or even permanently disagreeable frames of mind engendered by 
 their oft-repeated role. There is also the analogy of the imitation 
 by nervous persons of neurasthenic symptoms, which thus become 
 confirmed and real. 
 
 Mental disorder as the result of simulation is presumably a pos- 
 sibility only in those having a psychopathic disposition. 
 
 Einallj', moral contagion and epidemics of Insanity remain to be 
 noticed among the psychical causes of alienation. 
 
 Comparative psychology furnishes the prototype of the principle 
 here involved, in the imitation of example and in the contagion of 
 emotions, and in the swiftly spreading epidemic influences among 
 animals. There is a wide field for the study of contagion of minor 
 nervous affections among children in public schools, in which habit- 
 chorea, balbuties, sneezing, coughing, and many neurotic peculiari- 
 ties show an epidemic tendency. There are instances of the more 
 serious nervous disorders developed by contagion; and syncope, 
 chorea, hysteria, epilepsy, and other convulsive disturbances have 
 been known to appear in epidemic form. The transition from epi- 
 demic neuroses to epidemic psychoses is natural and not difficult to 
 understand. Thus there is the principle of imitation and the con- 
 tagion of example typified in comparative psychology, especially 
 active in the lower forms of human intelligence, appearing in phys- 
 iological psychic activities, and characterizing minor pathological 
 symptoms of the nervous system, and finally manifested in epidemic 
 neuroses and psychoses. 
 
 There never has been a time in the history of the world when a 
 century has elapsed unmarked by endemic or epidemic diseases of 
 
THE ETIOLOGY OF INSANITY. 125 
 
 the nervous system, including sensory, motor, and intellectual dis- 
 orders. The historic period which most continuously abounded in 
 these epidemics was the Middle Ages, but there are Egyptian, Greek, 
 and Eoman records of similar psychological anomalies. The moral 
 and intellectual aberrations which have been most widely epidemic 
 have usually been strongly tinged with peculiar religious beliefs 
 and practices. Among the Greeks and Romans there were endemic 
 lycanthropic manias, and in the early centuries of the Christian era 
 demonomanias were epidemic. In the fourteenth century there 
 appeared in Germany the dance of St. John, in which thousands of 
 people joined, dancing until they fell exhausted to the ground, and 
 having often hallucinations, ecstatic states, and convulsive seizures. 
 A similar epidemic was St. Vitus's dance, in 1420 A.D., which con- 
 tinued to appear remittently for nearly a century. 
 
 Tarantism in Italy exemplified in epidemic form, for more than 
 two centiiries, a like mental aberration, with motor and intellectual 
 disturbances. Another instance is the epidemic madness, which 
 reigned for many years in France among those termed " Convulsion- 
 naires de St. Medard." A more modern example of epidemic con- 
 tagious diabolism was the fanatic, cruel, and monstrous delusion of 
 witchcraft in Europe and America during the two last centuries, 
 which led to self-immolation or to persecution to death of nearly 
 a hundred thousand human beings, a large percentage of whom were 
 driven insane by the persistent false accusations of neighbors that 
 they Avere in league with the Devil, The strong-minded went to 
 their death protesting their innocence, but the weak-minded be- 
 came deranged, and, filled with hallucinations and delusions, con- 
 fessed the personal relations with the Devil of which they were ac- 
 cused, and also all manner of imaginary crimes, for which, in their 
 profound dejection, they felt that they deserved the death to which 
 they were put. Never before in the history of the world had there 
 been such widespread production of Insanity by suggestion and ac- 
 cusation practised with fanatical cruelty. 
 
 The element of contagion was active in the propagation of the 
 popular delusion of witchcraft, but it was not the direct etiological 
 factor of the Insanity here mentioned, which is to be attributed to 
 the causes above named. Did space permit, further instances of 
 epidemic insanities would be adduced as interesting studies in path- 
 ological psychology, but enough has been said to give full weight 
 to this point in the etiology of mental disorders. 
 
126 TEXT-BOOK ON MENTAL DISEASES. 
 
 Finally, the psycliical causes of Insanity in general, as compared 
 with the physical causes, are numerically estimated very differently 
 by the opinion of different writers. French authors, from the time 
 of Esquirol, have, like that great authority, considered that psy- 
 chical causes play a more important role than physical causes, and 
 some placed the figure of causation as high as from fifty to sixty- 
 seven per cent. 
 
 The personal estimate among German authorities varies consid- 
 erably, for some, like Griesinger, regard the psychical, and others, 
 like Kroeplin, believe the physical causes to predominate in the total 
 causation of Insanity. 
 
 English psychiatrists, as a rule, seem disposed to consider the 
 physical causes the more important, judging from the etiology as- 
 signed in reports of hospitals for the insane in England, in which the 
 physical causes the more important, judging from the etiology as- 
 tion of tliree to one in cases admitted. 
 
 This same statement holds good for causation upon admissions 
 to hospitals for the insane in America, in which, including heredity 
 among the physical causes, twenty-five per cent, of admissions only 
 remain as attributable to psychical causes. 
 
 The writer has already expressed his view that psychical influ- 
 ences are of active importance in the determination of morbid hered- 
 ity. This fact, conjoined to the further fact that psychical causes 
 co-operate largely in the causation of the acquired psychopathic con- 
 stitution, must, if given due weight, add greatly to the relative etio- 
 logical importance of psychical causes, which, if it were possible 
 to correctly estimate them inclusively of these facts, would consti- 
 tute a very much larger percentage of the causation of Insanity than 
 that customarily accorded them in hospital reports for the insane 
 in America and Great Britain. 
 
CHAPTER V. 
 
 THE EVOLUTION, STADIA, CLINICAL PROGRESSION, AND TERMI- 
 NATION OF MENTAL DISORDERS. 
 
 Inasmuch as mental disorders are manifested through anomalies 
 of the nervous system, through functions varying so far from the 
 physiological norm as to have passed into pathological limits, and 
 as these wide departures from health are usually more gradual in 
 origin and more continuous than those of ordinary diseases, it be- 
 comes important to make a special study of their evolution, stadia, 
 clinical progression, and termination. 
 
 The general rule as to these particulars is deduced from the ob- 
 servation of large numbers of cases, and, when understood, it facil- 
 itates greatly a general insight into the clinical course and nature 
 of Insanity, and also into its many exceptional varieties. The rule 
 with regard to the special forms of Insanity will be in each instance 
 given separately in the clinical part of the work, and the effort will 
 bo here to portray only the broad clinical features of the subject. 
 
 Evolution. — The evolution of Insanity is gradual, and, from the 
 incipient perversion of organic functions until the first open mental 
 disorder, there is usually a lapse of several months. Generally speak- 
 ing, the temporal limits of the evolutionary stage do not vary greatly 
 from those of the acute stage, and a slow development usually indi- 
 cates a slow course of the disease. The evolutionary stage is char- 
 acterized by a feeling of general malaise, by disturbances of sleep, 
 digestion, and circulation, and by perverted nutrition and mental 
 unrest and forebodings of evil. These incubatory sjrmptoms become 
 more and more marked, until they culminate in the acute mental 
 disorder. This organic evolution may be completed in a week, a 
 month, or not before a whole year, but the usual lapse of several 
 months has been mentioned, and, in the simple psychoses, if an av- 
 erage for ten thousand cases were made, from the time of the first 
 perceptible disturbance of vegetative and other organic functions 
 
 127 
 
128 TEXT-BOOK OK MENTAL DISEASES. 
 
 to tlie outbreak of the mental disorder, it would not probably vary 
 far from three months. This time limit applies to the active evolu- 
 tion, through progressive pathological changes in all the physical 
 functions, which in turn are followed by alterations of organic con- 
 sciousness, by a sense of ill-being and depression of the fundamental 
 emotional tone. But in some cases there is a pre-incubatory period 
 of very gradual systemic changes, which may precede this active or- 
 ganic evolution of mental disease by months or years. Thus alcohol 
 or other toxic agent for one or more years continues to effect changes 
 in the glandular, vascular, and nervous tissues, and to diminish vital 
 powers of resistance; and then comes the active evolution of symp- 
 toms of disordered digestion, nutrition, and circulation, with in- 
 somnia and depression of mind, which at the end of two or three 
 months culminates in acute Insanity. 
 
 Psychical causes, likewise, such as constant domestic worry or 
 business anxiety, may, through a pre-incubatory period of years, 
 gradually accomplish vasomotor and nutritive disturbances of the 
 higher nervous centres, and lower general vitality, before the evolu- 
 tion of the active perturbations of the entire organism, ending in 
 mental disorder. 
 
 But, however varied the duration of the pre-incubatory period or 
 the number of the etiological elements co-operative during the same, 
 the stage of active evolution still appears, with such clinical features 
 and time-limits on the average as have been mentioned. 
 
 And now, having stated the law of the active organic evolution 
 of mental disease, it may be well to consider some of its chief appar- 
 ent exceptions. 
 
 Puerperal, toxic, and post-febrile Insanity sometimes appears 
 abruptly, but it will be* found, on closer study, that there were secre- 
 tory, excretory, nutritive, circulatory, or nervous disorders previous 
 to the Insanity, but that they may have escaped attention, and, when 
 this is not the case, it will be learned that there had been previous 
 attacks of mental disorder, or that there were such active hereditary 
 transmitted tendencies that a stage of preparatory evolution had 
 virtually been accomplished. In all strongly hereditary cases the 
 abrupt occurrence of the mental disorder may appear to be an ex- 
 ception, but, even in these instances, parsesthesia, neuralgia, angio- 
 spastic or angioparetic states, migraine or other neurotic symptoms 
 will be discovered, on closer research, to have been prodromal to the 
 mental aberration. Even in Insanity with the established major 
 
THE EVOLUTIOTT OF MENTAL DISORDEES. 129 
 
 neuroses there will be found the active evolutionary stage preced- 
 ing the first attack, as well as the separate attacks in recurrent mania, 
 in Insanity with the physiological crises, with the diatheses, and with 
 gross organic lesions of the nervous system. The law that Insanity 
 is developed at the height of a previous evolution of morhid func- 
 tional changes in the organism seems to have a glaring exception 
 in transitory mania, which may attain to its maximum within an 
 hour. But, as nothing happens without a cause in nature, so noth- 
 ing occurs "without a cause in mental pathology. A careful scientific 
 inquiry into cases of mania transitoria, as it will be seen later in 
 chapters on chnieal description, does not fail to discover the latent 
 occurrence of previous pathological changes in brain-tissues, through 
 alcoholic, febrile, epileptic, and other influences productive of the 
 very explosive state of the cortical centres, which alone admits of 
 this sudden form of Insanity. Whatever be the exciting cause of an 
 abrupt outbreak of mental disorder, therefore, careful investigation 
 will reveal the morbid preparatory processes fitting the system to 
 take on the final pathological change, except in rare instances, in 
 which it is presumable that there is a latent evolutionary stage which 
 escapes the closest scrutiny. 
 
 Whether monomania constitutes an actual exception to the gen- 
 eral law of development of mental disease is a matter of some doubt. 
 It certainly does not in those instances in which monomania is de- 
 veloped out of the acquired psychopathic constitution. It ap- 
 proaches the nearest to an exception in the degenerative form known 
 as original monomania, in which the Insanity would seem to be a 
 gradual intensification of eccentricities of character. In tracing 
 back the histories of several of these cases, which seemed to be typ- 
 ical of their kind, the writer has found an evolutionary stage of the 
 morbid systemic changes at puberty or in connection with fevers 
 or injuries or exposure to heat about the time the first peculiarities 
 began to be noted, and the memories of which were only revived 
 by much cross-questioning or letter-writing. So that, if the whole 
 trutli were known, it would be a question whether there be an orig- 
 inal monomania as the gradual hypertrophy of native eccentricity 
 or the outgrowth merely of inherited peculiarities of mind, and 
 which has attained its acme, without any corresponding systemic 
 changes or organic disturbances at any period. So that even the 
 exceptions to the rule of the organic evolution of Insanity become 
 doubtful. Since the brain is not only the organ of the mind, but 
 
130 TEXT-BOOK ON MENTAL DISEASES. 
 
 presides over and sympathizes with the functions of all organs of the 
 body, it is safe to assume that, when it has reached the highly patho- 
 logical state of which Insanity is the symptom, correlative systemic 
 changes have already taken place. But it is not necessary to predi- 
 cate this upon theoretical grounds or from a priori reasoning, since 
 clinical and pathological observation has already established the 
 fact. There is one more apparent exception to be noticed in the 
 sudden outbreak of impulsive Insanity, as some term the homicidal 
 and suicidal attacks and other impulsive insane actions, which de- 
 velop without premonitory symptoms in rare cases. 
 
 The instances of impulsive Insanity here noted will, on investiga- 
 tion, be found to be connected with puberty, alcoholic excess, meno- 
 pause, or emotional shock, and to have had ample time and cause 
 for a latent evolution of systemic pathological changes, and, when 
 such previous conditions are wanting in the history of the case, the 
 sudden explosion of violent aberration can be traced to an epileptic 
 origin. 
 
 The rapid development in some cases of periodic and recurrent 
 Insanity is due to a morbid state of the cerebral nervous centres, 
 which is hereditary, organic, insane evolution, virtually, since it 
 determines the tendency to rapid nutritional defects of cortical 
 centres, which constitute the latent systemic changes in these cases. 
 
 The organic evolution of mental disease takes place, therefore, 
 first, through a relatively long pre-incubatory stage during the ac- 
 tion of few or many causes, which gradually undermine the founda- 
 tions of the mental superstructure; and, secondly, through a com- 
 paratively short stage of active systemic disturbances, which initiate 
 the mental disorder. 
 
 The temporal divisions of the mental disease thus initiated, and 
 the general order of its psychic and somatic phases will next come 
 under consideration. 
 
 Stadia. — Insanity is ordinarily a prolonged pathological process 
 with many symptomatic phases, and its division into stadia, in ac- 
 cordance with clinical facts, aids materially in its study, In fact, 
 such is the complexity of mental diseases that a systematic analysis 
 is absolutely necessary to their perfect comprehension. 
 
 Physicians who for some years see much of Insanity and read 
 much about it, remain in doubt and confusion still, for want of a 
 scientiiic method in mental pathology. The student is urgently 
 advised to make an attentive study of the following analysis of this 
 
THE EVOLUTION OF MENTAL DISORDERS. 131 
 
 subject, which is a practical key to the scientific comprehension of 
 mental disorders, and a true method to the study of their various 
 clinical forms. 
 
 Insanity is divided into stadia in accordance with the clinical 
 phases of the disease, as will appear later. A stadium is part of an 
 attack of Insanity. Stadia are composed of psychopathic states, 
 which will be presently described. 
 
 Psychopathic states are made up of characteristic morbid symp- 
 toms, of which a definite description will follow. These morbid 
 symptoms are divided into psychic and somatic. Also, these morbid 
 symptoms in turn have component elements, which will be analysed 
 in the chapters on symptomatology, as they are not requisite to the 
 present didactic dealing with this subject. 
 
 The stadia in regular order in Insanity running a complete 
 course are as follows: 1. Stadium coensestheticum. 2. Stadium 
 acutum. 3. Stadium debilitatis. 4. Stadium terminale. 
 
 The initial stadium is determined in type by the ccensesthesis, 
 and hence it is in fact a stadium coencestheticum. Ccensesthesis is 
 the state of organic consciousness arising as the resultant of all the 
 organic sensations of the body, whether from visceral, muscular, 
 osseous, vascular, cutaneous, or glandular sources. This coenses- 
 thetic state maj'' be pleasurable or painful. It is painful, as a rule, 
 in Insanity as well as in other conditions of disease. 
 
 This stadium coensestheticum accords, in the main, in point of 
 time with the general pathological systemic changes described un- 
 der the head of organic evolution, and naturally the resultant of all 
 the organic sensations is disagreeable or even painfully depressive. 
 To such an extent is this true that some writers have mistaken this 
 coenffisthetic stadium for a genuine stadium melancholicum, which 
 they have declared to be the initial stadium, even in cases of mania. 
 Knowing that this initial stadium is based physiologically on the 
 ccensesthesis, which is painful on account of the general morbid 
 processes active in the system at this time, the psychopathic state 
 of depression wliich prevails during this stadium coensestheticum is 
 readily understood, and the incongruous supposition of melancholia 
 as the prodromal stage of mania is avoided. 
 
 As a rule, then, this first stadium coensestheticum has a single 
 clinical phase and is composed of a single painful psychopathic 
 state, which gradually attains its height. The psychic and somatic 
 symptoms are: Loss of interest in the outside world and painful in- 
 
132 TEXT-BOOK ON MENTAL DISEASES. 
 
 trospection, vague fears, perverted feelings and instincts, hallucina- 
 tions, irritability and loss of self -control, impulsive tendencies, in- 
 somnia, anorexia, disorders of digestion, circulation, and nutrition, 
 and gradual loss of weight. It is the altered and painful coensesthesis 
 which causes the field of consciousness to be narrowed to self and 
 self-suffering, giving a strong hypochondriacal tinge often to this 
 initial stadium, and withdrawing attention almost entirely from out- 
 ward things. 
 
 The duration of this stadium ccensestheticum is from one to 
 three months on the average. The exception is that this stadium is 
 marked by an agreeable and exalted, instead of depressed, tone of 
 feeling. This agreeable coengesthesis is the most marked feature 
 of general paresis, and the initial stadium is in this case pleasurable 
 and exalted, as it is also in an occasional case of mania. 
 
 It is difB.cult to say why this agreeable and expansive feeling 
 prevails in disease, but it is due in some cases to the action on cortical 
 centres of toxic products generated in the general system or in the 
 disintegrating cellular tissues themselves, a cellular auto-intoxica- 
 tion, varying with the intensity of the pathological cortical process, 
 and hence most marked in general paresis. An analogous euphoria 
 is to be witnessed in the cheerful and hopeful f eehng of the patient 
 with lungs completely disorganized by phthisis. 
 
 The transition from the stadium ccensestheticum to the stadium 
 acutum following is ordinarily gradual, occupying a week or more, 
 but exceptionally it is accomplished in a day or a night, the patient 
 awakening, as it were, out of one state into the other. 
 
 The stadium acutum is the full bloom of the mental disorder. 
 It ordinarily consists of a single psychopathic state, continuing from 
 one to three months. This psychopathic state is either the maniacal 
 state or the melanchohc state, which will be fully studied under symp- 
 tomatology, but the outlines of which must be sketched here at once. 
 Tlie maniacal state is made up of the following psychic and so- 
 matic symptoms: Loss of inhibition of ideas and actions, greatly in- 
 creased thought-rate, flight of ideas too rapid for utterance and con- 
 sequent incoherence of speech, spontaneous Hberation of emotions 
 rapidly changing and expressed in pantomime, hallucinations of 
 sight and hearing, illusions of the special senses, delusions of swiftly 
 varjdng nature, powerful impulsive tendencies, increased muscular 
 activity and co-ordination, perpetual motions and apparent inco- 
 herence of actions, diminished arterial tension, turgor vitaHs marked 
 
THE EVOLUTION OF MENTAL DISOEDEES. 133 
 
 in some cases, insomnia persistent, loss of weight, anorexia or poly- 
 phagia, menostasis, increased secretions, and vasomotor disturbances. 
 When the maniacal state, thus symptomatically composed, prevails 
 as the characteristic psychopathic state of the stadium acutum, the 
 latter is termed stadium maniacale. 
 
 The melanclwlic state is made up of the following psychic and 
 somatic symptoms: Inhibition of ideas and actions, a narrowing 
 of consciousness to self and painful introspection, retarded thought- 
 rate, diminished association of ideas, concentration of attention, 
 mutism, general emotional depression, suicidal impulses, halluci- 
 nations of the special senses, insomnia, frightful dreams, sombre 
 delusions of a hypochondriacal or persecutory kind, sitophobia, di- 
 minished secretions, obstipation, disordered digestion, malnutri- 
 tion, angiospasm and increased arterial tension, diminished turgor 
 vitalis, and general loss of weight. 
 
 This psychopathic state sometimes characterizes the entire sta- 
 dium acutum, which is then designated stadium melancholicum. 
 
 ISText in regular order after the acute stadium comes the stadium 
 debilitatis. 
 
 The stadium dehilitatis is appropriately named, in that it ex- 
 presses precisely the general physical and mental condition, which 
 is present after the violent storm of mental disorder. This general 
 condition is one of debility of mind and body as the direct sequel 
 of the exhaustion of nervous centres, and of the whole system from 
 the acute pathological processes which have been survived. 
 
 The prevailing psychopathic state is characterized by negative 
 rather than active symptoms. There is feebleness of memory and 
 attention, paucity of ideas, loss of spontaneity of thoughts and ac- 
 tions, enfeebled volition, general apathy or great emotional weak- 
 ness, diminished muscular activity with exceptional muscular rigidi- 
 ties, capillary stasis and angioparetic tendencies, enfeebled cardiac 
 action, hsemic alterations, and general asthenia. 
 
 This stadium, after a very severe acute stage, more especially, is 
 marked by a stuporous character, and the psychopathic state through- 
 out may be that of sequential stupor, and in the latter case it is 
 termed stadium stuporosum. 
 
 The stadium debilitatis is of relatively brief duration, and at the 
 end of from one to four weeks it merges into the stadium terminale. 
 
 The stadium terminale presents three distinct typical forms, hav- 
 ing radically different durations and results. 
 
134 TEXT-BOOK ON MEKTAL DISEASES. 
 
 When it leads to recovery it is a stadium convalescens, and it has 
 a duration of from one to four months, dependent in the main on 
 the length and severity of the stadium acutum. 
 
 When it terminates in chronicity of the mental disorder it is the 
 stadium dementise, and endures for lifetime. 
 
 When the Insanity is destined to a fatal termination, it is the 
 stadium lethale, and ends in a variety of ways, according to the 
 immediate determining cause of death, usually within three months. 
 
 The stadium convalescens is characterized by pathological rem- 
 nants of the acute stage, such as emotional weakness^ odds and ends 
 of delusions, confusion as to places and persons, an occasional false 
 sensorial representation, remaining antipathies to those of the im- 
 mediate environment, and some disturbance of vital functions. 
 Gradually all these disappear and give place to a return of normal 
 emotional equilibrium, natural tastes and affections, a correct orien- 
 tation as to localities and identification of individual acquaintances, 
 an insight into the true nature of the past mental disorder, a desire 
 for former occupations, and a restitution of individuality and of 
 general physical health. 
 
 This general advance toward recovery is sometimes marked by 
 periodical recessions of all the symptoms for a day or a week at a 
 time, which is what the nurses call " good days and bad days," but 
 the good turns become longer, and the bad ones shorter, until com- 
 plete convalescence is established. 
 
 In rare exceptions there is a sudden recovery, and the writer has 
 seen several instances in which patients, after a good night's rest, 
 awoke from a state of Insanity in their right mind. The oscillations 
 of reason from the upright standard had gradually diminished, and 
 a plentiful supply of the balm of sleep had started the mental mech- 
 anism to running smoothly again. 
 
 The stadium dementice is the period of dissolution of all outward 
 forms of higher intellectual life. Gradually memory fails, speech 
 becomes verbally incoherent or impossible, inability to construct sen- 
 tences or simple phrases appears, there is passivity or automatic 
 restlessness, there may be automatic repetition of set phrases, grimaces 
 or gestures, vegetative functions are active, and there is first a great 
 increase and finally a loss of flesh, there are filthy habits and neglect 
 of the wants of nature, and there is complete apathy, which may be 
 interrupted occasionally by a return of brief emotional excitement, 
 and finally the patient comes to represent only the outward and 
 
THE EVOLUTION OF MENTAL DISORDERS. 135 
 
 physical form of a being with an animal existence, but without emo- 
 tional or intellectual life. This stadium dementias ends only with 
 the life of the patient, who may survive to old age, but the mortality 
 of the insane is six times greater than that of the sane at most ages. 
 
 The stadium letTiale may follow at once the stadium acutum, and 
 death may then be the result of general exhaustion from the acute 
 pathological processes, as in cases of delirium acutum, general paresis, 
 and acute alcoholic mania. Ordinarily, though, death follows from 
 coarse brain disease, diseases of the lungs or some acute intercurrent 
 affection. 
 
 Clinical Progression. — The clinical manner in which an attack 
 of Insanity progresses is more readily traced when a knowledge of 
 stadia, psychopathic states, and the special symptoms composing 
 them has been attained, and hence a description of these things has 
 preceded clinical progression. 
 
 The clinical progression of an attack of Insanity is the relative 
 order which the stadia bear to one another, and to certain other 
 features of the disease known as intermissions, remissions, recur- 
 rences, lucid intervals, and the varied commingling of all these in the 
 production of special types of mental disorder. 
 
 The clinical progi'ession of an attack of recoverable mania may be 
 in regular order, thus: 1. Stadium coenffistheticum. 2. Stadium 
 maniacale. 3. Stadium debilitatis. 4. Stadium convalescens, but, as 
 an exception, the patient may have, as cook or fireman, been exposed 
 to excessive heat, and may have sought relief from alcoholic stimu- 
 lation, and under the conjunction of toxic and thermic influence 
 may have, without initial stadium, developed suddenly acute delirious 
 mania, which from its very severity passes from its full height to 
 death. The clinical progression then would be: 1. Stadium mani- 
 acale. 2. Stadium lethale. These stadial exceptions to the regular 
 order are constantly encountered, but they are more apparent than 
 real. In the case Just mentioned, it is more than probable that there 
 would be a coenaesthetic stadium of depression and suffering, which 
 would drive the patient to drink, but, being brief, would fail to be 
 recognized. A stadium may be of only a few hours' or days' duration 
 and yet be an important reality. Many suicides are provoked by the 
 general organic suffering of the stadium coensestheticum, and a vain 
 search is then made for motives for the act. 
 
 The progression of curable melancholia is: 1. Stadium coenaes- 
 theticum. 2. Stadium melancholieum. 3. Stadium debihtatis. 4. 
 
136 TEXT-BOOK ON MENTAL DISEASES. 
 
 Stadium convalescens. But if a neuropatMc woman were to learn of 
 the death, of her husband or children by an accident in travelling, 
 she might pass at once into profound melancholia, and die of ex- 
 haustion and inanition in a short time. The progression would then 
 be: 1. Stadium melancholicum. 2. Stadium lethale. In nearly all 
 these cases, however, there has been a latent evolutional stadium of 
 organic changes, which has developed the instability of brain-centres, 
 which admits of the sudden onset of the mental disorder. Many 
 persons pass through the stadium ccenasstheticum, and heed its timely 
 warnings, and the further progression of the Insanity is thus avoided 
 by hygienic means. There is seldom any arrest of the progression 
 after the stadium acutum has once been entered, but there occur, 
 as the convalescent stadium approaches, more especially, remissions 
 of the acute symptoms in some cases. 
 
 A remission is the diminution of the symptoms of mental dis- 
 order, but not the cessation of the same. A remission may occur 
 during or between stadia, or may intervene between attacks not 
 really separate. In recoverable mania and melanchoha these remis- 
 sions of a few hours or days are commonly observed as the stadium 
 acutum nears its end. These remissions of the mental symptoms 
 are also occasioned sometimes by acute inflammatory intercurrent 
 diseases, such as fevers or infectious disorders. 
 
 An exacerhation is the antithesis of a remission — it is the intensi- 
 fici'tion of the symptoms of mental disorder, and it marks a quanti- 
 tative rather than a qualitative variation. 
 
 Both remissions and exacerbations may have a periodical char- 
 acter in Insanity, just as in nervous diseases in general, and in 
 women this is observable in connection with the catamenial molimen, 
 which ordinarily coincides with exacerbations of all the mental 
 symptoms. 
 
 In the stadium debilitatis the exacerbation of the emotional weak- 
 ness characteristic of this period may be antithetical to the dominant 
 tone of feeling of the stadium acutum, which has just passed, whether 
 it be expansive or depressive. This is an apparent exception to the 
 rule that exacerbations do not furnish qualitative variations of 
 symptoms. 
 
 In the stadium acutum remissions exceptionally occur at a certain 
 hour of the day, or every other day, or every few days or weeks, and 
 they are not to be confounded with lucid intervals. 
 
 A lucid interval is a temporary restoration of right mind, but not 
 
THE EVOLUTION OF MENTAL DISORDERS. 137 
 
 often a complete removal of the physical conditions of mental dis- 
 ease. A lucid interval may occur during or between stadia, or be- 
 tween separate attacks of mental disorder, and it may have a duration 
 of an hour, a week, a month, or even of several months, though it is 
 better to confine the term to the shorter periods of lucidity, and to 
 the longer ones to apply the word intermission. 
 
 An intermission is a complete cessation of all the symptoms of 
 mental disorder, and it may vary from weeks to many months in dura- 
 tion, and it occurs between separate attacks of Insanity. 
 
 A recurrence is an independent attack of Insanity in a patient 
 who has previously suffered from mental disorder and has a latent 
 tendency to the same. 
 
 Eecurrences facilitate and approximate one another, and they 
 usually occur in those having a transmitted psychopathic tendency. 
 
 Having thus defined the prominent exceptional features which 
 interrupt the clinical progression of Insanity, it is necessary to show 
 in what way they modify the typical course of the disease. 
 
 It will be observed, in patients with inherited taint chiefly, that 
 at regular intervals of weeks, months, or years, an attack of mania 
 or melancholia will occur, and disappear during an intermission of 
 definite length, only to reappear with precisely the same character 
 and sequence of symptoms. This periodic return of like attacks and 
 similar intermissions is known as periodical Insanity. 
 
 If the stadium acutum appears abruptly in the form of the 
 maniacal state and is followed by an intermission, and then by another 
 maniacal state and intermission, and this sequence continues, the 
 Insanity is periodical mania. 
 
 If the stadium acutum begins as the melancholic state, and is fol- 
 lowed by an intermission, and then another melancholic state and 
 intermission, and if this sequence continues, the case is one of peri- 
 odical melancholia. 
 
 The apparently abrupt stadium acutum and the intermission are 
 the salient features of periodical Insanity, which may continue for 
 years or for a Hfetime, but it is a mistake to suppose that the mental 
 disorder originates in this exceptional sequence without an initial 
 stadium. On the contrary, this mental disorder, which usually begins 
 at puberty, has invariably a stadium ccenaestheticum, often of long 
 duration and of decided character. Moreover, there is before the 
 stadium acutum of every periodic return an initial stadium of vaso- 
 motor, sensory, or trophic disturbances, which will not escape the 
 
138 TEXT-BOOK ON MENTAL DISEASES. 
 
 close student of nervous diseases. Even the patients come to recog- 
 nize this initial stadium hy the return of neuralgias, severe head- 
 aches, gastralgias, or other prodromal symptoms, which are often as 
 uniform in character as the stadium acutum and the intermissions 
 which follow. The clinical progression of periodic Insanity is, there- 
 fore, to outward appearance: 1. Stadium acutum. 2. Intermission. 
 1. Stadium acutum. 3. Intermission, etc. But in reality it is: 1. 
 Stadium coensestheticum. 2. Stadium acutum. 3. Intermission. 
 1. Stadium ccenastheticum. 2. Stadium acutum. 3. Intermission, 
 etc., and it is only through the gradual shortening of the intermis- 
 sions with the lapse of years, or the actual final disappearance of the 
 same, that this sequence is hroken. 
 
 There is a variety of periodical Insanity, known as circular In- 
 sanity, which originates thus: 1. Stadium melancholicum. 2. Sta- 
 dium maniacale. The initial stadium is, contrary to general rule, the 
 fully developed melancholic state, and as the diseased process deepens 
 the maniacal stage appears, and is followed by a lucid interval. 
 
 The clinical progression of circular Insanity is, therefore, as fol- 
 lows: 1. Stadium melanchohcum. 2. Stadium maniacale. 3. Inter- 
 vallum lucidum. This constitutes a complete cycle, and each suc- 
 cessive cycle is an exact repetition of the same order of clinical 
 progi'ession, which characterizes the original or intermittent type of 
 circular Insanity. In occasional instances the primary cycle and all 
 subsequent cycles have the following cHnical progression: 1. Stadium 
 maniacale. 2. Stadium melancholicum. 3. Intervallum lucidum. 
 This also is intermittent circular Insanity. 
 
 In circular, as in all periodic Insanity, the general tendency is 
 for the lucid intervals to shorten or disappear, and in cases once com- 
 pletely developed they may form no part of the progression, and the 
 maniacal and melancholic stadia succeed one another directly. This 
 is confirmed circular Insanity without intermission. 
 
 Space will not, in this connection, permit a review of the clinical 
 progression in the various types of Insanity, and for complete infor- 
 mation of this kind reference is again made to the second part of the 
 work, but sufficient has already been said to show the impossibility of 
 a clear understanding of mental disorders without a knowledge of 
 the stadia, intermissions, remissions, and lucid intervals, and of the 
 order in which they combine to constitute the clinical progression 
 of the typical forms of Insanity. 
 
 To the physician who ignores the psychopathic states which 
 
THE EVOLUTION OF MENTAL DISORDERS. 139 
 
 compose the stadia, who mistakes the separate stadia for attacks of 
 melanchoha, mania, and dementia, who knows naught of the laws of 
 sequence established by clinical observation, mental disorders will 
 ever remain an incomprehensible jumble of disconnected symptoms. 
 
 The evolution, stadia, and clinical progression, as here portrayed, 
 are to be accepted by the student as clinical facts, to be daily verified 
 by study in hospital wards, and as an orderly and scientific means 
 of insight into all cases of mental disorder. 
 
 Terminations. — The terminations of attacks of Insanity are as 
 follows: 1, Complete recovery. 2. Incomplete recovery. 3. Trans- 
 formation into other forms. 4. Chronicity. 5. Death. 
 
 Complete Recovery. — Complete recovery is usually gradual, and a 
 sudden return to reason is seldom permanent. In mania, for instance, 
 the stadium convalescens is usually marked by remissions and ex- 
 acerbations of symptoms, and gradually the remissions lengthen and 
 the exacerbations disappear, and then comes a distinct lucid interval, 
 followed by signs of irritability or emotional weakness perhaps, and 
 finally complete recovery at the end of several months from the first 
 appearance of the convalescent stadium. 
 
 Exceptionally, the intervention of inflammatory or infectious 
 disease, producing profound nutritional changes and alterations in 
 the functional conditions of the entire organism, leads to a simul- 
 taneous complete recovery both of the intercurrent disease and of 
 the mental disorder. 
 
 The powerful revulsion of severe traumatic accidents has been 
 known to be followed by a prompt recovery from Insanity, but this 
 is an extremely rare termination of mental disorder. 
 
 Other exceptional terminaitions in recovery ^\dll be noted under 
 the special types of Insanity. 
 
 Incomplete Recovery. — ^Many patients are discharged from hos- 
 pitals for the insane as improved, and they return to their customary 
 occupations and discharge all their duties as useful members of the 
 community for years or possibly for the remainder of their life. To 
 the world at large they are practically recovered, but to the alienist 
 they are known to be only incompletely recovered. The incomplete- 
 ness of the recovery consists not in any renmant of delusions or of 
 other active signs of mental disorder, but in a permanent impair- 
 ment of the higher mental processes of the affective faculties, of 
 general powers of endurance, and in an instability, which exposes 
 them, on slight provocation, to subsequent attacks of Insanity. 
 
140 TEXT-BOOK ON MENTAL DISEASES. 
 
 Transformation of Attack. — An attack of Insanity may terminate 
 by transformation into another form of mental disease. Thus a case 
 of original monomania or paranoia, at the end of some years, may 
 terminate in general paresis. Acute mania or melancholia sometimes 
 terminates in secondary forms of monomania. In other exceptional 
 instances there is simply a reversion to the original type, of which 
 the acute attack is an epiphenomenon, as in imbecility, with an attack 
 of acute mania, upon the termination of which there is a return to 
 the status of original defect of mind. 
 
 CJironicity. — The vast majority of all cases of Insanity terminate, 
 sooner or later, in chronicity of the mental disorder. 
 
 The chronic terminations of mental disease are too varied to 
 admit of description here, but as a practical and ultimate fact the 
 stadium terminale of most forms destined to chronicity is a stadium 
 dementia3. 
 
 This terminal dementia is the common goal toward which all 
 mental disease tends and to which most Insanity attains. This ter- 
 minal dementia is not reached suddenly, except after a severe acute 
 attack, but after repeated attacks, or after various secondary forms 
 of mental disorder have been traversed. 
 
 Occasionally, however, the mental disorder retains for a decade 
 of years, or even for life, the form of chronic mania, chronic melan- 
 cholia, secondary monomania, or even of primary monomania. If 
 life were sufficiently prolonged in these cases they would doubtless 
 all end in dementia. Insanity arising at the grand climacteric or later 
 in life may, by way of exception, terminate in senile dementia. 
 
 Senile dementia is itself an independent type of the disorderly 
 involutional terminatioin of mental life, and it illustrates the nature 
 of some Insanity as simply a functional departure from the norm. 
 The atrophic brain-changes and the orderly failure of all the powers 
 of mind in typical senile dementia pertain normally to senility, and 
 it is only the disorderly involutional changes that constitute the 
 pathological process of this terminal form of Insanity. 
 
 Death. — The termination of Insanity in a considerable percentage 
 of the cases is in death. The mortality of the insane in general is 
 more than five times greater than that of the general population of 
 like age. The chances of the preservation of life varies according 
 to the age, sex, and constitution of the patient, and the cause, form, 
 and duration of the attack, and the prognosis as to life will be dis- 
 cussed under the special types of Insanity. 
 
THE EVOLUTION OF MENTAL DISORDERS. 141 
 
 There are certain forms of mental disorder which ordinarily ter- 
 minate in death, such as general paresis, organic dementia, and de- 
 lirium acutum. 
 
 There are diethetic insanities uniformly destined to a fatal issue 
 from the somatic rather than the psychic disorder. 
 
 All terminations of mental disorder, whether in complete or in- 
 complete recovery, in transformation, or chronicity, or death, are 
 most instructive subjects for study on the part of the student of 
 mental pathology, for in psychiatric practice the physician is always 
 called upon to express an opinion as to the probable manner of the 
 termination of the Insanitv. 
 
CHAPTER TL 
 
 PSYCHICAL SYMPTOMATOLOGY. 
 
 Section I. — Disorders of the Intellect. 
 
 The differences of the action of the mind in health and in In- 
 sanity can only be studied by means of some systematic division of 
 the subject^ which will accordingly be presented under the disorders 
 of the intellect, of the emotions, and of volition, with practical rather 
 than philosophic subdivisions. 
 
 The morbid psychical phenomena, which are the pith and core 
 of mental disease, cannot be separately analyzed without a conven- 
 tional recognition of distinct mental faculties, and of their presum- 
 ably independent action. It is substantially afhrmed in advance, 
 however, from a philosophic point of view, that the mind acts as a 
 unit, and that intellection, emotion, and volition are interdependent 
 phases of the action of an undivided psychic force. 
 
 The topic of this special section — Disorders of the Intellect — 
 will be treated under the Presentative Faculties of Perception and 
 Consciousness, the Eepresentative Faculties of Memory and Imag- 
 ination, and the Piational Processes of Thought and Pieason. 
 
 The Presentative Faculties. — Perception is the conscious recog- 
 nition of sensorial stimuli, and it is accompanied ordinarily by an 
 effort of definition and of localization of the special sensorial stim- 
 ulus. 
 
 Perception is very constantly disordered in Insanity, and even 
 in the sane there are analogous though minor degrees of like per- 
 ceptional disorder. Everyone knows that things are not always 
 what they seem, and that the senses sometimes deceive, and that op- 
 tical illusions do occur. 
 
 The part of a straight stick thrust into water appears bent at an 
 angle; to a person rapidly progressing in one direction objects ap- 
 pear to recede; the railway passenger mistakes between the motion 
 of his own and of the adjoining train; a small round body rolled 
 
 142 
 
PSYCHICAL SYMPTOMATOLOGY. 143 
 
 under the tips of the large finger crossed over the forefinger seems 
 like a double object; the rapid revolution of a luminous object pro- 
 duces the effect of a continuous circle; a few perspective lines make 
 that which is flat appear round and solid; stereoscopic effects are still 
 more perfect illusions; similar persons, things, or places are con- 
 stantly mistaken, through lack of close attention; the ground rocks 
 under the recently landed sea voyager, and in musically susceptible 
 minds a catching tune may resound for days; and almost endless 
 examples of errors of perception might be adduced. In mental dis- 
 order the customary correction of the percej^tual error of one sense 
 by aid of the other senses, or by other processes of comparison, does 
 not take place, owing to preoccupation of mind, or to lesion of at- 
 tention or memory, or failure of the power of discrimination, or to 
 the fact that the false perception chances to be in accord with ex- 
 isting morbid emotions or delusions. 
 
 The most common technical form of erroneous perception in the 
 insane is termed illusion. 
 
 An illusion is the misapprehension of a sense-impression, or the 
 false interpretation of a sensorial stimulus. The patient who mis- 
 takes a post for a man, or the noise of the wind for the human voice, 
 has an illusion of sight or hearing. The sense-impression does not 
 correspond truly to the external object, and there is no exact phys- 
 ical outward equivalent for the psychic image produced. There is, 
 therefore, always a previous and real peripheral source of illusions 
 as well as a uniform failure of corresj)ondence between the sense- 
 presentation and the antecedent reahty. It is important to grasp 
 this point, which differentiates illusions from other errors of per- 
 ception to be presently considered. 
 
 Illusions of all the senses are found in mental disorder, and those 
 of sight and hearing are most frequent. Visual illusions, both in 
 sanity and insanity, are somewhat more common than auditory. 
 More than sixty per cent, of all insane patients have decided illu- 
 sions, which may be either visual, auditory, tactile, gustatory, ol- 
 factory, or kinoesthetic. 
 
 Illusions are rarely constant, but they ordinarily recur at brief 
 intervals, and they are bilateral or unilateral. They are more fre- 
 quent in the acute stage of mental alienation, but they may exist 
 at any period of the mental disease, even in the convalescent stage, 
 and they also persist in modified form in certain cases after recovery. 
 
 The fact that the sensorial impression from which the illusion 
 
144 TEXT-BOOK ON MENTAL DISEASES. 
 
 originates is transformed by the association of ideas or by imagina- 
 tion has led some modem writers to comprise all illusions under 
 hallucinations, which are admittedly purely imaginative psychic 
 products. 
 
 The distinction between these two classes of disordered percep- 
 tion is sufficiently valid to warrant its continuance, as illusion re- 
 lates to real objects, springs from actual peripheral stimuli, and has 
 an environmental counterpart, which does not exist in the instance 
 of hallucinations. There is a decided temporal distinction also 
 between the two classes of phenomena, as illusions are the product 
 of the immediate present and of its coincident peripheral stimuli, 
 while hallucinations are chiefly evolved from the indefinite past and 
 from its stores of sensorial residua. As the origin and nature of 
 illusions varies with the special sense affected, it will be necessary 
 to give a brief separate notice to visual, auditory, tactile, coenses- 
 thetie, gustatory, olfactory, and kinsesthetic illusions. 
 
 Visual illusions correspond to all objects anterior to the retinal 
 expansion, and they may be entoptic and dependent on corneal opac- 
 ities, muscse volitantes, retinal pulsation, and circulatory blood-cor- 
 puscles, lenticular disease, or affections of the vitreous humor. Illu- 
 sions of color may thus arise, and the size of objects may be magni- 
 fied (megalopsy) or minimized (micropsy), and various illusive ef- 
 fects may spring from astigmatism, defects of accommodation, and 
 existing pathological conditions of the visual apparatus. All ex- 
 ternal objects furnish material for illusions, especially in a dim 
 light, so that, among the insane, twilight and moonlight are the 
 fruitful occasions of the f orinal misinterpretation of the outer world. 
 
 To the diseased imagination of the insane patient looking out 
 of the window in obscure light the bushes, trees, and all external 
 objects are wont to assume the forms of living things or of human 
 beings, which are interpreted in the special direction of the dom- 
 inant emotions or delusions of the patient. 
 
 The anatomical basis of illusions is the pathological irritability 
 of the cortical centres of memorial residua and of associative proc- 
 esses, and of the sensorial cells, which are aroused by the physiolog- 
 ical stimulus of the peripheral excitation. There is a preparedness 
 for a discharge from such pathological cortical centres, and the 
 sensorial impression only determines, in a measure, the direction 
 and the nature of the discharge. 
 
 The patient who thinks that he is constantly persecuted by those 
 
PSICHICAL SYMPTOMATOLOGY. 145 
 
 about him sees in everj' movement of their features derisive or mock- 
 ing expressions, or through some superficial resemblance he mis- 
 takes them for farmer enemies; or, if prepared by expectant delu- 
 sion for the visit of friends, he mistakes them for old acquaintances. 
 
 Illusions of sight are sometimes fortified by illusions of other 
 senses, as when a patient mistakes shrubbery swayed by the wind 
 for movements of a human form, and the rustling of the leaves for 
 the whispered voice of persecutors, and the odor of the shrub's blos- 
 som for the noxious gas with which his enemies afflict him at night. 
 A patient with a flowering shrub near his window, and thus af- 
 flicted with combined illusions, might be temporarily relieved by 
 a change of locality, but the morbid cortical centres would soon re- 
 ceive some other sensorial provocation to discharge, and new forms 
 of pathological transformation of sense-impressions would result. 
 
 Auditory illusions arise from all external or internal causes of 
 sound-waves which impinge upon the organ of hearing. Entotic 
 illusions may spring from noises within the ear, from affections of 
 the membrana tympani, of the labyrinth, of the semicircular canals, 
 from arterial pulsation, from anaemic bruit, and from all forms of 
 tinnitus aurium. Cardiac sounds, pulmonary rales, borborygmi, 
 aneurismal bruits, stomachal succussions, tendinous and arthritic 
 nojses are all likewise occasional sources of auditory illusions, having 
 an immediate source in the personal organism rather than in the 
 extcT'nal world. As regards the environmental source of illusions, 
 morbid expectancy on the part of the patient has much to do with 
 the localization and transformation of sounds proceeding from near 
 or distant surroundings. The fearful and expectant patient, await- 
 ing at night the coming of his executioners, will locate the most dis- 
 tant noises in his immediate vicinity, and transform the most dis- 
 similar sounds into the sharpening of knives and the dragging of 
 ropes, which are to be used in his destruction. In this state of fear- 
 ful expectancy also there is a dislocation of near sounds, so that the 
 crealdng of the bed, or the fluttering of an insect on the wall, may 
 be referred to the distance, and at the same time there is often a 
 gross amplification of the sense-impression, v/hich in rare instances 
 may spring from actual hypercesthesia acustica, but ordinarily is 
 due to the effect of expectant imagination. The absurd disparity 
 between the illusion and the reality was well illustrated in a case 
 of acute melancholia, in this painful state of deluded expectancy, 
 in which the falling of drops of water on the window-sill was mis- 
 10 
 
146 TEXT-BOOK ON MENTAL DISEASES. 
 
 taken for the repeated blows of a hammer in the making of a coflOn 
 for the patient's burial. This instance illustrates the general fact, 
 also, that auditory illusions are sensorial presentations misinter- 
 preted in keeping with emotional or intellectual phases of the mental 
 disease. To the expansive paretic the most commonplace humming 
 sounds are like the voices of the heavenly choirs, and to the suspi- 
 cious patient Hstening to the conversation of those about him words 
 which might possibly favor are mistaken for those fully in accord 
 with his prevailing delusion. 
 
 Patients sometimes tliink that animals or birds or inanimate ob- 
 jects give forth articulate sounds, which convey distinct ideas, and, 
 in listening to a language of which they are ignorant, they receive 
 like definite impressions favoring their insane behefs. 
 
 Unilateral auditory illusions are apt to be entotic, and in all 
 cases of illusions of hearing the ear should be carefully examined. 
 
 Qualitative and functional variations in the sense of hearing 
 have some modifying influence upon auditory hallucinations, for 
 both intensification and diminution of hearing is found among the 
 insane, and complete loss of the faculty does not exclude the possi- 
 bility of entotic illusions. Hyperacusia is most common in hysteri- 
 cal and neurasthenic Insanity, and hypacusia is to be found in gen- 
 eral paresis, organic dementia and terminal Insanity. 
 
 There is also a genuine paracusia in the insane independent of 
 actual illusions. Patients with this form of paracusia complain 
 that their own voices and the voices of their friends are strange, 
 and that music and all customary sounds are unnatural. A patient 
 with this perversion of hearing denied the identity of her brother 
 because he had a stranger's voice. Delusion thus arising is different 
 from similar false beliefs growing out of changes of conscious self- 
 identity and the resultant strangeness of external things. 
 
 Tactile illusions follow in point of frequency those of sight and 
 hearing among the insane. It is important to first mention changes 
 in cutaneous sensation present in Insanity. 
 
 Diminution of sensation in the skin, known as anaesthesia, is 
 found both in organic and paretic dementia, and in hysteric, epi- 
 leptic, and toxic Insanity. Hemiansesthesia may also occur in hj's- 
 teric and epileptic cases, and involve a loss of touch, of heat and 
 cold, or of pain. Hyperesthesia, which is less frequent, is sometimes 
 a symptom of neurasthenic cases and of paretic Insanity in the early 
 stage, and of alcoholic cases with spinal sclerotic lesions. 
 
PSYCHICAL SYMPTOMATOLOGY. 147 
 
 Increase of sensibility to pain (hyperalgia) is present in neuras- 
 thenic and hypochondriacal cases, and hypalgia is common to many 
 forms of Insanity, while analgia is most pronounced in the terminal 
 stage of general paresis, though occasionally characteristic of acute 
 phases of mental disorder, during which extensive self -mutilations 
 may be inflicted without pain. All those perverted sensations em- 
 braced under the general term parsesthesia are prominent symptoms 
 of Insanity, especially of that which is toxic in origin. 
 
 AU the foregoing pathological variations of sensibility in the 
 insane are to be referred to increase or failure of attention and of 
 conscious recognition, and to altered states of consciousness rather 
 than to actual anomalies of the peripheral nervous system, except 
 in those cases in which there are positive organic lesions of nervous 
 structures. 
 
 Excitations of nerves are by force of habit uniformly referred 
 to their periphery. This projection of subjective sensations is de- 
 termined by irritation of any part of the sensory conductory tract 
 or of the cortical representative centre. A familiar example of 
 this outward projection of sensation is witnessed in feelings referred 
 to hands or feet of hmbs long ago amputated. 
 
 Tactile sensations in the insane are thus vividly projected, and 
 at the same time misinterpreted to be electric effects, and the appli- 
 cation of all sorts of ingenious mechanical devices designed for their 
 persecution. These tactile illusions are sometimes described as foul 
 air blown upon the body, or irritant gases, or magnetic currents, or, 
 as some mysterious power of enemies by which the vital force of the 
 body is drawn off through the pores of the skin, or the injection 
 during sleep of poisonous fluids under the skin. 
 
 The sexual class of tactile illusions is important from its fre- 
 quency and persistency. The consciousness of some patients is con- 
 tinuously flooded with sexual illusions due to perverted sensations 
 arriving from the nervous periphery of the generative organs. 
 
 The tactile illusions of alcoholic Insanity and of general paresis 
 fully developed are remarkable. In alcoholic cases the formication 
 and crawling mistaken for insects, and the burning, pricking, and 
 shooting pains are perversions of tactile sensibility due to sclerotic 
 central lesions, and to changes in the sensory nerve-trunks, and the 
 illusions may proceed from paralgic zones, and may assume the most 
 intense forms of h}^eralgia. The modification of tactile sensibil- 
 ity in these cases, known as polysesthesia, belongs to the same order 
 
148 TEXT-BOOK ON MENTAL DISEASES. 
 
 of pathological sensorial disturbances as monocular polyopia in hys- 
 terical Insanity. 
 
 In full-blown cases of general paresis, with expansion of feeling, 
 tactile illusions of an exaggerated character are sexually located, 
 and also extend in most cases to the entire cutaneous periphery, and 
 they furnish the raw material for many of the megalo-maniacal de- 
 lusions of the second stage of the disease. 
 
 In this connection is to be mentioned a most important class of 
 illusions located sometimes in the cutaneous periphery and at other 
 times in the nervous sensory distribution to internal organs. 
 
 Clinically, there is an intimate relation between painful visceral 
 and cutaneous sensations, though the central anatomical connection 
 does not yet admit of demonstration. In mental disorder tliis nu- 
 merous class of illusions, which shift interchangeably from internal 
 organ to outward surface, and comprise at times the combined ef- 
 fects of visceral and cutaneous perverted sensations, are here em- 
 braced under the general term of coensesthetic illusions. 
 
 Ccencesthetic illusions abound in acute forms of the psychoses, 
 and they form the essential " materies morbi " in hypochondriacal 
 Insanity. They are typical also as sensorial phenomena of the first 
 stage of certain types of general paresis, and of some cases of con- 
 firmed epileptic and alcoholic Insanity. 
 
 In neurasthenic Insanity there is also a profuse illustration of 
 the frequent vicarious character of ccengesthetic illusions, which 
 fluctuate from visceral regions to hyperalgic cutaneous spots, for 
 which some definite law of nervous relationship may yet be discov- 
 ered by future clinical research. 
 
 Gustatory Illusions. — Taste and smell are the emotional senses, 
 as distinguished from sight and hearing, which are the intellectual 
 senses. When illusions combine they ordinarily show this natural 
 partition between the special senses, so that sensorial perversions 
 of sight and hearing appear together, and illusions of taste and smell, 
 too, are superimposed. As a physiological fact, tasting is smelling 
 to a considerable extent, especially for the more delicate shades of 
 gustation. The gustatory illusions of the insane have a painful 
 emotional tinge in the vast majority of cases, and it is only in the 
 most exceptional states that they have a pleasurable emotional qual- 
 ity. The agreeable gustatory illusions of the general paretic are 
 real only in the first stage of the disease, and subsequently they are 
 purely the effects of coensesthetic exaltation. 
 
PSYCHICAL SYMPTOMATOLOGY. 149 
 
 Among the insane the illusions are favored by increase or dim- 
 inution of the gustatory faculty. Hypergeusia, or exaggeration of 
 the gustatory sensations, is found in neurasthenic and hysterical 
 cases. Patients afflicted with this unfortunate hypersesthetic taste 
 detect the most minute variations in food supplies, and the earhest 
 preliminary changes of fermentation in meat, butter, milk, eggs, 
 and vegetables, and from this real source of peripheral irritation 
 they derive the most exaggerated gustatory illusions interpreted to 
 match their delusive conceptions. 
 
 Hypageusia, or diminution of the sense of taste, is common in 
 the acute as well as chronic stage of the psychoses. It is a frequent 
 negative source of positive illusions, for the patients, finding that 
 food has lost its natural taste, readily infer that it is mixed with 
 foreign material, and they begin to supply imaginary substances 
 which best fit their illusory idea, such as that the sugar is ground 
 chalk, that the corn-meal is sawdust, that the butter is colored lard, 
 and, as there is of ten a corresponding loss of smell, they soon become 
 confirmed in their illusions. 
 
 Ageusia, or complete loss of taste, is found in some cases of or- 
 ganic and syphilitic dementia, and in the final stage of general 
 paresis. Even in the second stage some paretics eat anything and 
 everything with absolute indifference. Ageusia is occasionally pres- 
 ent also in senile and in alcoholic dementia. Gustatory illusions 
 have their origin often in alteration of the buccal secretions, in dry 
 or coated tongue, in dental caries, in pharyngeal disease, in gastric 
 disorder, in toxic states of the system, and in the resultant perver- 
 sions of taste due to the administration of drugs. 
 
 Gustatory illusions may also proceed from central nervous le- 
 sions before the organic changes have resulted in ageusia. 
 
 The gustatory illusions with the most decided perversions of 
 taste (parageusia) usually result in delusions of poisoning of food, 
 which is also frequently declared to contain stercoraceous and other 
 disgusting substances. 
 
 Gustatory illusions are somewhat more common than those of 
 smell, and they have about the same, though probably somewhat 
 less, numerical importance than tactile illusions. 
 
 Olfactory Illusions. — The sense of smell is occasionally much 
 heightened in neurasthenic, hysterical, and epileptic Insanity, and 
 is known as hyperosmia, while hyposmia, or diminution of this 
 sense, is common in syphilitic, alcoholic, and paretic cases. Anosmia, 
 
150 TEXT-BOOK ON MENTAL DISEASES. 
 
 or loss of smell, is common in senile, paretic, syphilitic, and organic 
 dementia. 
 
 Olfactory illusions are of painful character in most cases, and 
 thej'^ are especially common in developmental and involutional men- 
 tal disorders. The relation between sexual and olfactory illusions is 
 of clinical frequency, though this close connection does not admit 
 of any satisfactory physiological explanation. 
 
 Olfactory illusions may spring from nasal or pharyngeal disease, 
 or from actual odors resulting from disease of internal organs, or 
 they may be the simple transformation of external olfactory stimuli 
 from any and all outward sources. 
 
 Illusions of smell are not infrequent in acute melancholia; they 
 often lead to refusal of food and to delusions of poisoning. They 
 are often associated with illusions of taste and of common sensation. 
 
 Kincestlietic Illusions. — Kinaesthesis is the sense of movement, 
 also termed the muscular sense. Through this sixth, or kinassthetic, 
 sense are perceived the various single and combined movements of 
 the body and the extremities, and their relative position in space. 
 Through this sense also is estimated the weight of bodies and the 
 degree of muscular effort necessary to overcome the resistance of 
 the same. It is probable that cutaneous, muscular, tendinous, and 
 aiiicalar impressions are complementary to the kinajsthetic sense, 
 which is also intimately associated in action with visual space-im- 
 pressions. 
 
 The diminution and perversions of the muscular sense which 
 lead paretic, syphilitic, and alcoholic insane patients to illusory per- 
 ception of the movements of their extremities is due in some in- 
 stances to angesthesia of the articular surfaces. 
 
 In other cases there is a certain inco-ordination of movement 
 due to disturbance of the kineesthetic sense, independent of any 
 angesthetic conditions or of any interference with the spinal reflex 
 mechanism. 
 
 In somnambulistic Insanity there may be increase of the kinaes- 
 thetic sense, which is also heightened in acute mania and diminished 
 in acute melancholia and in choreic and paretic Insanity. 
 
 Kinaesthetic illusions in the insane may relate either to the spe- 
 cial mechanisms of locomotion or of speech, and they are inter- 
 preted in various delusional directions, chiefly of a persecutory kind, 
 such as that their persecutors misplace their limbs in bed and pre- 
 vent them from having the customary use of their arms and legs. 
 
PSYCHICAL SYMPTOMATOLOGY. 151 
 
 Most of these perversions of the nrnscular sense among the insane 
 are more correctly and technically to be classed in the category of 
 kinaesthetic hallucinations, under which head some further allusion 
 will be made to this type of perceptional disorder. 
 
 Hallucinations. — An hallucination is the vivid conscious revival 
 of a sense-impression without a physiological peripheral stimulus. 
 
 There may be a pathological peripheral stimulus having a direct 
 causative relation to the hallucination, as will presently appear. 
 Hallucination may be further defined as a forceful representation 
 of a sensorial image without a corresponding physical reality. While 
 illusion is the distorted perception of a real object, hallucination 
 is the real perception of an object which does not exist. Hallucina- 
 tions are purely subjective, while illusions are partially objective 
 in origin. 
 
 The perception of a picture on a wall which had no picture upon 
 it would be an hallucination, and the mistaking of a real picture for 
 some other object would be an illusion. A patient who hears music 
 in tfee absence of all tones is the subject of hallucination, but he 
 has an illusion if he mistakes common noises for music. 
 
 Hallucinations may exist in the various senses separately or si- 
 multaneously, and they are more common at night than in the day- 
 time among the insane. 
 
 Visual hallucinations are more frequent among mankind in gen- 
 eral than any other form, but in mental disorder auditory halluci- 
 nations predominate, and those of the other senses appear in the fol- 
 lowing numerical order: Gustatory, tactile, olfactory, and kinses- 
 thetic. Space will not admit the mention of the numerous anatom- 
 ical theories advanced to explain the origin of hallucinations. 
 
 AH perception is dependent on a special sense-organ, a conduct- 
 ing nerve-tract, central ganglia, and a higher representative brain- 
 centre. The anatomical origin of hallucinations may be pathologi- 
 cal irritation (from any and every form of disease) of the special 
 sense-organ, of the conducting nerve-tract, of the central ganglia 
 (more especially of the thalami optici), or of the representative cor- 
 tical areas. The essential point is the pathological instability of 
 these higher nervous centres, the cortical areas which are the stor- 
 age-regions of sensory images, so that it matters not through what 
 conducting paths of association or through what special irritation 
 these higher nervous centres are provoked to a discharge, or to an 
 outward projection of the sensory image which is the hallucination. 
 
152 TEXT-BOOK ON MENTAL DISEASES. 
 
 The special irritation which arouses this morbid action of me- 
 morial and sensory cortical areas may proceed from any of the ana- 
 tomical points mentioned, or may consist in toxic agents circulating 
 through these cortical centres, or may come from diseased internal 
 organs, or from general diathetic conditions, from qualitative and 
 quantitative changes in the blood, from ccenassthetic sensations, from 
 reflex sympathy of the reproductive organs, or from the perverted 
 activity of the special sense-organs themselves. The main patho- 
 genic fact is that the sensory image is aroused in the higher brain- 
 centres Avith such unnatural force as to be projected outwardly as 
 an objective reality. 
 
 It is true that the hallucination is of varying degrees of conscious 
 reality, that it is sometimes of a shadowy and fantastic character, 
 which does not inspire firm belief on the part of the patient, but at 
 other times it is invested \\dth intensely real physical attributes of 
 form and color, and startles the patient into the most sudden and 
 violent demonstrations of feeling and action. This latter result is 
 wont to occur when the hallucination is aroused by deep organic 
 sensations, and springs from subconscious regions with sudden 
 dramatic effect upon the stage of conscious intellectual operations, 
 which are often disordered or suspended momentarily by the high- 
 colored and fully fledged apparition. At such moments the patient 
 often screams with terror, or attempts a suicidal or homicidal trag- 
 edy to escape from the horrors of the situation. 
 
 A few words will be said about each of the special types of hallu- 
 cinations in the order of their numerical frequency in mental dis- 
 ease, viz., auditory, visual, gustatory, tactile, olfactory, and kinass- 
 thetic. 
 
 Auditory Hallucinations.— The local pathogeny of aural hallu- 
 cinations may be disease of the Eustachian tube, of the tympanum, 
 of the bones of the ear, of the labyrinth, of Corti's organ, of the 
 auditory nerve at any point of its course between periphery and cen- 
 tral ganglia, and of the corresponding cortical sensory regions. 
 There is also to be mentioned vascular variations in the parts above 
 named, toxic effects, functional aural disorders, tinnitus aurium, 
 after-vibrations, and morbid entotic conditions too numerous to 
 name, as well as tumors and other intra-cranial diseases. The irri- 
 tations thus peripherally or centrally initiated and acting on cortical 
 sensory areas pathologically excitable determine the hallucination. 
 
 There is a purely psychical origin of auditory hallucinations 
 
PSYCHICAL SYMPTOMATOLOGY. 158 
 
 which correspond to an idea, which, through its morbid intensity, 
 revives the correlative acoustic image. Normally, the peripheral 
 stimuli of the organs of special sense arouse centripetal currents 
 to sensory cells, and from thence to cortical areas of ideation, but 
 pathologically there may be a reversal of this order with a centrifu- 
 gal current from ideational cortical areas to sensory cells in which 
 in this instance the acoustic image is revived. The auditory hallu- 
 cinations in this case correspond directly to the ideas or emotions 
 which precede them, and to the insane delusion which is uppermost 
 in the mind of the patient. The patients subject to this type of 
 hallucinations are surprised to hear their innermost thoughts men- 
 tioned by the hallucinatory voices, and they are thus soon confirmed 
 in the delusion that people read their minds. Such patients some- 
 times, while reading or writing, hear some of the words repeated 
 by the voices. 
 
 The ideational origin of hallucinations is proved by the close 
 correspondence of the hallucinations to the customary habits of 
 thought, to the level of intelligence, and to the special views and 
 behefs of the individual affected. To such an extent is this true 
 that the account of hallucinations in ages past has truthfully re- 
 flected the main features of the intellectual life of the people, and 
 especially of their current rehgious beliefs. 
 
 Sensitive hallucinatory patients are influenced by their reading 
 and by conversation, and it is possible in this way to have hallucina- 
 tion by direct suggestion. There is a great difference not only in 
 different persons, but in the same individual as to the ease or force 
 of action of imagination in the production of sensory images of the 
 various senses. The facility of fantastic imagery of any special sense 
 depends largely upon the perviousness of that special sensory chan- 
 nel afl'ected by the force of previous customary discharges. The 
 painter is already prepared for visual and the musician for auditory 
 hallucinations, and a patient with a dominant delusion in one sen- 
 sory direction will eventually have a corresponding hallucination. 
 Hallucinations and delusions, therefore, are reciprocally causative, 
 just as the prevailing emotional tone and the hallucination may be 
 the mutual offspring of each other, sometimes one and then again 
 the other being the primary and parental phenomenon. 
 
 Auditory hallucinations are sometimes reflex and arise seconda- 
 rily to perversions of some of the other senses, and they are combined 
 with hallucinations of sight, in many cases, and with those of com-. 
 
154 TEXT-BOOK ON MENTAL DISEASES. 
 
 mon sensation occasionally, and more rarely with sensory disorders of 
 taste and smell. They are unilateral or bilateral. When unilateral, 
 they are most frequently entotic. This one-sided kind of hallucina- 
 tion may possibly be due to one-sided brain-action, or to a pathologi- 
 cal state of one cerebral hemisphere, to opposite cortical lesions, 
 but it is also possibly occasioned through some defect in the process 
 of localization of sound through disorder of the differential sensa- 
 tions of movement, and of the normal variance of sensory intensity 
 in the two ears, for patients having an intact auditory apparatus 
 persistently refer all hallucinations to the right or left of the median 
 line. The hallucinations also come from behind rather than from 
 in front, and from below more frequently than from above, and more 
 exceptionally from within rather than from without the body. 
 
 Bilateral hallucinations may be double in character and have 
 uniform differences in loudness and quahty of sound on the opposite 
 sides, and they may have dissimilar emotional associations, being 
 agreeable on one side and disagreeable on the other, or the voices on 
 the two sides may contradict each other. In this latter instance the 
 repartee which patients often carry on with the voices is suppressed, 
 and, through the patients' hallucinated concentration of attention, 
 the voices reflect immediately in their consciousness their own silent 
 argumentations, and it is only when the two-sided debate does not suit 
 them that they make a loud interruption. Auditory hallucinations 
 are most common in melancholia and in chronic delusional Insanity, 
 and they are among the unfavorable symptoms, and when they are 
 permanently organized in relation to delusions they are absolutely 
 among the very worst prognostic signs. The epigastric voice and 
 other distinctly located internal hallucinations are of decidedly bad 
 omen. 
 
 Hallucinations having the worst prognosis are near in spatial 
 relation, distinctly articulate, fixed in direction, and permanent in 
 character and combined with delusion. 
 
 The less unfavorable auditory hallucinations are remote in dis- 
 tance from the patient, indistinct and inarticulate, shifting in direc- 
 tion, changing in character, and irrelevant to any fixed idea or delu- 
 sional conception. Auditory hallucinations may simulate the voices 
 of friends or strangers, and they may speak in foreign tongues and 
 may also issue from animate or inanimate things, and may represent 
 every conceivable sound known to the patient, or even new and 
 strange combinations of sounds. They are most often painful, and 
 
PSYCHICAL SYMPTOMATOLOGY. 155 
 
 arouse strong impulsive tendencies to violence; and this point is 
 to be borne in mind in practical dealing with hallucinated patients. 
 
 Visual Hallucinations. — A visual hallucination may originate in 
 a morbid irritation at any anatomical point from the expansion of 
 the optic nerve to the cortical visual centres — i.e., in the course of 
 the optic nerves, in the corpora quadrigemina, in the corpora gen- 
 iculata, in the optic basal ganghon, in the optic thalamus, and in 
 the optic radiations to the occipital and temporo-sphenoidal lobes. 
 
 Hallucinations of sight arise also from a pathological state of 
 the visual cortical centres, due to the virus of infectious diseases, 
 to inanition and "anaemia, to toxic agents in the blood, and to exten- 
 sive hemorrhages. 
 
 The bulk of visual hallucinations among the insane, however, 
 are central rather than peripheral in origin. They are simply in- 
 tense visual images revived through ideational or emotional asso- 
 ciative paths by a morbid activity of memory and imagination. The 
 abnormal state of consciousness in mental disorder prevents the 
 differentiation through comparison and reflection of these memorial 
 images from actual sense-impressions aroused through the custom- 
 ary channels by peripheral excitation of the special sense-organ. 
 
 These centrally initiated hallucinations may depend on diseased 
 activity of the ideational cortical areas of the frontal lobes, or on 
 pathological excitability of the sensory cells of the occipital visual 
 areas, which may be provoked to discharge, not as in health, from 
 peripheral ingoing stimuli, but from reverse stimulation from idea- 
 tional centres. This latter origin of hallucinations from downward 
 currents proceeding from ideational areas to sensory ganglia was 
 clearly announced in 1868 by Maudsley, in his masterful treatise 
 on the " Pathology of Mind," p. 266. Ziehen has recently elaborated 
 a similar theory in accordance with the present knowledge of sen- 
 sory cortical areas, the stimulation of which, by reverse currents 
 from memorial centres, he holds to be the real source of hallucina- 
 tions (vide " Psychiatric," p. 32). Independently of all peripheral or 
 central anatomical theories there are functional states of patholog- 
 ical action of the intellectual faculties which adequately account 
 for hallucinations in Insanity. 
 
 There is the altered consciousness which causes all objects to 
 seem strange; there is a disturbance of the association of sensory 
 concepts and inability to compare them with past sense-data; there 
 is further confusion from disordered memory; there is morbidly 
 
156 TEXT-BOOK OlS" MENTAL DISEASES. 
 
 heiglilened imagination, which causes entirely new sensory images; 
 there is powerful and suggestive emotion; there is loss of voluntary 
 control of ideas; and, finally, there is inability of calm reflection 
 and of the power to differentiate between the imaginary and the real. 
 These are the essential alterations of intellect which render halluci- 
 nations possible under any circumstances, and from whatever local 
 source of irritation derived. 
 
 Visual hallucinations are sometimes entoptic and due to retinal 
 shadows, retinal pulsation, and the movement of blood-corpuscles, 
 pressure, and accommodation-phosphenes, muscse volitantes, and to 
 changes in the macula and in the refracting media.' Entoptic hallu- 
 cinations are apt to be more distinct when the eyes are closed, and 
 they respond to the movement of the ocular muscles, and they have 
 distinctions of color as well as of form. The hallucinated image 
 due to spastic or paretic accommodation may appear magnified or 
 minimized. 
 
 Hemiopic hallucination, which probably arises from disease of 
 the sensory visual areas of the occipital cortex, is found in hysteric 
 and epileptic Insanity, and it may also exist independently of hemi- 
 anopsia. 
 
 Visual hallucinations are bilateral or unilateral, and for the lat- 
 ter there is the simple test of alternate closure of the eyes and the 
 cessation of the abnormal symptom, with the exclusion of the af- 
 fected eye. Unilateral hallucination may also be the result of 
 expectant delusion, as when a patient has a fixed idea that one eye 
 is diseased and keeps his attention focussed upon it until hallucina- 
 tion results. 
 
 Fixed delusion often determines the direction of hallucinations 
 when they have been located, as to a particular object which can 
 only be seen on one side of the position the patient habitually occu- 
 pies. Thus, a patient always saw her imagined friend on a partic- 
 ular walk as she sat at the window, but never at any other time or 
 place. A^'isual hallucinations may have definite or indefinite pro- 
 portions; they may seem as on a flat surface or solid and rounded; 
 they may have changing or fixed outlines, and advance or recede, 
 or move across the field of vision; they may be colorless or have 
 various prismatic tints; they may be larger (megalopsy) or smaller 
 (micropsy) than life; they may be single or multiple; and they may 
 even be of panoramic character. 
 
 Visual hallucinations sometimes disappear on closing the eyes. 
 
PSYCHICAL SYMPTOMATOLOGY. 157 
 
 or in the dark, and, on the other hand, these are precisely the con- 
 ditions which, together with pressure of the ej'eball, favor entoptic 
 hallucinations. 
 
 Hallucinations, again, may be diplopic or polyopic and seen 
 on a plain background, as on the water or the sky, or among other 
 objects only, either superimposed, depressed, or in relief and cameo- 
 like. The masklike hallucination is very real and leads patients 
 to believe that their acquaintances change their features frequently. 
 
 Other forms of visual hallucinations are those of the dreamlike 
 and hypnagogic states of the morphio-maniac, the aura of the epi- 
 leptic, the phantasmagoria of the hystero-maniac, those of retinal 
 origin, moving with the eye like visual spectra, and luminous after- 
 images, or flitting in nystagmic cases, the processional array of ani- 
 mal forms of the alcoholic patient, the bright and complex visions 
 of religious ecstas}'', and the illumined outlines of kaleidoscopic ob- 
 jects in certain epileptic states. 
 
 The hallucinations of mental disease are painful or pleasurable 
 usually in accordance with the dominant emotional tone, but excep- 
 tionally they axe transformed to a directly opposite kind, for a brief 
 period, favoring the inmost desires of the patient; just as a ship- 
 wrecked mariner sees ships of rescue, or the thirsty and heated 
 traveller in the desert sees green oases and fountains of fresh water, 
 so the patient persecuted with painful hallucinations may have an 
 expansive change in them as well as in his del^isions. 
 
 Visual impressions are, in the exhausted and toxic dream-states 
 of Insanity, pathologically vivid, and they then persist after waldng, 
 as hypnagogic hallucinations. In fact. Insanity may spring directly 
 out of the hypnagogic hallucinatory state, as well as out of the hallu- 
 cinatory condition of artificial anaesthesia. 
 
 Visual hallucinations are common in the acute stages of mental 
 disorder and in general paresis, and they are more frequent during 
 the vital reductions of the night season than in the daytime; they 
 are favored by perceptional disorder of the other senses, and they 
 are not uncommon in eye diseases, and in hemianaesthesia are on the 
 affected side, and they appear in the blind, and after entire re- 
 moval of the eyes, and after atrophy of the optic nerve. 
 
 Visual hallucinations are less unfavorable than hallucinations 
 of hearing as regards recovery of the mental disorder. 
 
 Gustatory Hallucinations. — Gustatory perception, strictly speak- 
 ing, is confined to substances which are acid, saline, bitter, or sweet, 
 
158 TEXT-BOOK ON MENTAL DISEASES. 
 
 acting on mucous membranes supplied by the glosso-pharyngeal and 
 lingual nerves. All the more delicate shades of taste dependent on 
 odoriferous qualities are perceived by the olfactory organs. 
 
 As tasting, therefore, is smelling to a great extent, it is difficult 
 to separate the pathological action of these two senses in hal- 
 lucinations. 
 
 The anatomical limits of normal gustatory sensations are the 
 tip, the edges, and the back of the tongue, the soft palate and the 
 posterior hard palate, and the anterior pillar of the fauces, but these 
 limits are considerably narrowed in most cases of acute mental dis- 
 ease through local affections of the membranes as well as from gen- 
 eral toxic and diathetic states which influence these sensory parts. 
 When a patient suffering from toxic Insanity complains that his 
 food has a metallic taste, it is not easy to know whether it is reality 
 or imagination — whether it is illusion, hallucination, or normal re- 
 action to a poison actually in the system. 
 
 There is a like uncertainty as to anomalies of taste in the acute 
 psychoses, with dry or heavily coated tongue, or morbid salivary 
 secretions, or nasal or pharyngeal catarrh, or the various alterations 
 of innervation of the parts in question known to exist in Insanity 
 with syphilis, tubercle, and other cachexias. The administration of 
 drugs also complicates the question of the nature of perversions of 
 taste in the insane. 
 
 These difficulties of differentiation do not change the clinical 
 fact of the frequency of gustatory hallucinations in Insanity from the 
 major neuroses, in general paresis, in acute melancholia, and in hal- 
 lucinatory monomania. The gustatory hallucination is emotional 
 and arouses the resentment of the patient, and leads to refusal of 
 food and violent delusions of poisoning, and it frequently arouses 
 reflex hallucinations of the other senses, and the hallucinated sub- 
 stances will soon be seen as well as tasted in the food. In the con- 
 valescent stage gustatory hallucinations, like those of sight and 
 heai'ing, become less distinct until they disappear, but it will be 
 found that they usually survive the secondary and associated per- 
 versions of perception. 
 
 AVhen a therapeutic or accidental toxic agent is in the patient's 
 system the various nutrient fluids taken into the mouth, or even solid 
 ingesta well mixed with saliva, produce a variety of chemically re- 
 sulting combinations of morbid tastes which are to be taken into ac- 
 count in the diagnosis of gustatory hallucinations. Iodide and bro- 
 
PSYCHICAL SYMPTOMATOLOGY. 159 
 
 mide of potassium, in sypliilitic and epileptic Insanity, act in this 
 way, and in morphinism, coeainism, santoninism, plumbism, and 
 other toxic states there are like chemical resultants in gustatory 
 regions. It is worthy of note that the gustatory sense, which is a 
 continuous source of pleasure in health, is almost invariahly pain- 
 ful in the hallucinatory states of mental disorder. 
 
 Tactile Hallucinations. — Anomalies of touch in mental disorder 
 take the form often of anassthesia, hypersesthesia, or parsesthesia, 
 and it is difficult to distinguish between illusory and hallucinatory 
 symptoms when patients complain that they have creeping, prick- 
 ling, sticking, and burning cutaneous feelings, which are readily 
 transformed into delusions of persecution by electricity and mechan- 
 ical appliances devised by enemies. 
 
 Tactile hallucinations are most common in toxic Insanity, in 
 general paresis, in hypochondriacal, hysteric, epileptic, neurasthenic, 
 and climacteric cases. Thermic and algid sensations are associated 
 often with the tactile hallucination, which may correspond to sub- 
 conscious coengesthetic excitations in internal organs, to vasomotor 
 cutaneous variations, or to morbid states of spinal and cerebral sen- 
 sory centres determining the direction of the pathological action 
 of imagination. Thus, skin diseases in Insanity give rise to illu- 
 sions through misinterpretation of the conscious cutaneous sensa- 
 tions, but they may also be the physical substratum of a variety 
 of tactile hallucinations, just as pruritus vulvge may be the origin 
 of sexual hallucinations as well as illusions. In aboUtion of sensa- 
 tion, as when a hemiangesthesic patient believes a second person to 
 be attached to his body, the major part of the symptom is hallu- 
 cinatory inference rather than illusion. 
 
 In the main, however, it is difficult to distinguish between hallu- 
 cinations and illusions of touch, which merge indistinguishably and 
 are complicated in many cases with perversions of the other special 
 senses. 
 
 Tactile hallucinations from extensive loss of cutaneous sensation 
 lead to delusions of changed identity or of altered material struct- 
 ure of limbs or other parts of the body. Tactile hallucinations in 
 hypochondriacal patients are very numerous, and referred to vis- 
 ceral or cutaneous regions they become the source of the most ex- 
 traordinary delusions. Sexual hallucinations are mainly a complex 
 variety of the tactile order. Women especially are subject to them 
 at the climacteric, and think that they are pregnant, that they bring 
 
160 TEXT-BOOK ON MENTAL DISEASES. 
 
 forth children, that they are shamefully abused by men at night, and 
 they often accuse those about them of indecent conduct toward them. 
 
 Anfesthetics develop these tactile hallucinations of a sexual kind, 
 and they have led not a few physicians and dentists to be falsely 
 accused by women not insane. 
 
 Hypnagogic tactile hallucinations of this same nature are very 
 common among the insane, and, as they have a tendency to recur, 
 they soon establish a corresponding delusion of nocturnal outrages 
 usually recounted in detail in the most realistic manner. They are 
 extremely real to the patients, who occasionally resort to the most 
 ridiculous and elaborate means for local protection of the genital re- 
 gions at night, using sheets and towels, or even having special guards 
 constructed for the purpose. 
 
 Tactile hallucinations, like those of all the other special senses, 
 may constitute the epileptic aura. 
 
 Olfactory Hallucinations. — The normal stimuli of olfactory per- 
 ception are infinitesimal particles reaching the rod-shaped cells of 
 the nasal membranes by inspiration through the lower and upper 
 nasal chambers, and the specific sensation is derived from the ol- 
 factory nerve, while the fifth nerve supplies common sensation to 
 the membranes. 
 
 Abnormally, chemical or mechanical stimulation of the olfactory 
 nerve may cause hallucination, which has been known to have been 
 persistent in connection with tumors causing pressure and final de- 
 struction of the nerve, abscess in temporosphenoidal lobe and coarse 
 brain lesions, necrosis of the bones of head or face, dental caries, and 
 nasal and pharyngeal diseases. The fact that illusions of smell are 
 peripherally initiated does not exclude the possibility of hallucina- 
 tion from the same source, though it complicates the differential 
 diagnosis. After atrophy of the olfactory nerve in senile Insanity, 
 and disorganization of the bulbs in general paresis, there may be 
 hallucinations of smell of cortical origin. Intra-cranial pressure 
 from syphilitic tumors or any other cause may occasion anosmia or 
 even parosmia. 
 
 Olfactory hallucinations are common in involutional and evo- 
 lutional Insanity. The evolutional type, as in pubescent cases, is 
 associated often with masturbation; and hallucination with involu- 
 tion, as at the climacteric, is related to disease of the uterus or its 
 adnexa. 
 
 The intimate connection between the perversions of the olfactory 
 
PSYCHICAL SYMPTOMATOLOGY. 161 
 
 sense and disease of the reproductive organs is only a clear revelation 
 of man's latent and evolutionary animal nature, for, in the lower 
 animals, smell is the direct excitant of the sexual appetite, and orig- 
 inally the olfactory sense, which was specifically differentiated from 
 the primordial sense of touch, was very largely perfected in animals 
 through sexual incitations. 
 
 Olfactory hallucinations are intensely emotional in character in 
 many cases, and painful with few exceptions, and they often produce 
 great delusional excitement. This fact only corresponds to the 
 powerful physiological action of odors, which are overwhelming 
 sometimes, and may even cause sj^ncope in susceptible persons. The 
 powerful odor of the epileptic's aura is hallucinatory. 
 
 Olfactory hallucinations are found both in acute and chronic 
 cases, and they are frequent in general paresis, in toxic, epileptic, 
 hysteric, neurasthenic, and syphilitic Insanity, and they are ordi- 
 narily elaborated in keeping Avith the dominant delusion. 
 
 KincustJietic Hallucinations. — The perception of movements per- 
 formed takes place through the kingesthesis, or muscular sense, and 
 the centrally registered kinsesthetic sensations come largely from 
 the joints, though also from the cutaneous and muscular periphery. 
 
 In the absence of all muscular action there may be a false per- 
 ception of movement, which constitutes a kiuEesthetic hallucination. 
 This hallucinatory feeling of movement leads patients to declare 
 that they feel themselves during the night wafted in the air; that 
 their limbs move when they do not will it; that the influence of 
 their invisible persecutors compels them to strange movements and 
 positions of their head, body, and extremities. These false sensa- 
 tions of movement are centrally initiated in cortical centres and are 
 the product of a morbidly intense imagination. Kinsesthetic hal- 
 lucinations relate not only to such past movements as admit of re- 
 vival in memory, but embrace such new combinations of muscular 
 action as a diseased fantasy may suggest. Thus sometimes general 
 paretics, and epileptic, hysteric, neurasthenic, and toxic cases, in 
 the acute stages, complain of the most remarkable distortions of 
 their limbs and body, of gyrations, of flight through the air, and 
 precipitations while revolving. Heightened kinesthetic sensations 
 add to the exaltation in acute mania and the early stage of general 
 paresis before the actual hallucinations of movement arise. 
 
 Any of the more highly specialized muscular actions, such as 
 speech, handwriting, gait, playing upon musical instruments, may 
 11 
 
162 TEXT-BOOK OX MENTAL DISEASES. 
 
 form the material of the kinsesthetie hallucinations, and the patients 
 may fancy that they speak or write words or play upon the violin 
 or the piano. 
 
 E^ven in normal ideation there are always nascent and correlative 
 motor impulses of speech, and it is the intense revival of these latent 
 motor elements of thought which gives rise to the kinsesthetie hallu- 
 cination of speech in the insane. 
 
 KmaBsthetic hallucinations of the ocular muscles lead to false 
 conceptions of direction and of the spatial relations of objects, and 
 of required movements to reach them, and may modif}'-, in a meas- 
 ure, the co-ordination of muscles. Kinesthetic hallucinations are 
 also intimatel}^ related to impellent ideas, which are nascent motor 
 impulses aroused with such morbid force as to issue at once in action, 
 which may be both involuntary and irresistible. Kinsesthetie hallu- 
 cinations, therefore, may have such pathological intensity as to be 
 transformed directly into impellent ideas or irresistible impulses, and 
 they thus have a certain clinical and also medico-legal importance. 
 
 Having now considered the chief disorders of perception in In- 
 sanity, there are next to be described the changes in consciousness 
 which mark the progress of mental disease. 
 
 Ccnsciousness. — It is best for the practical purposes of psychiatry 
 to consider consciousness, not metaphysically, but physiologically, 
 and as the concomitant of the action of the physical environment on 
 the nervous structures of the human organism. 
 
 The action of an environmental stimulus on the peripheral ner- 
 voiis sj'stem is attended by tactile sensation, which is the simplest 
 state of consciousness. If a sound-wave follow immediately and 
 impinge on the tympanum, there is instantly an acoustic sensation 
 and a corresponding change in the state of consciousness, and at 
 once, if the reflected light of some object strikes upon the retina, 
 there is another sensation and another change in the state of con- 
 sciousness. All consciousness is likewise constituted of a continuous 
 series of active states of feeling and of passive states of change, 
 alternating so that every state of feeling is followed by a state of 
 change and every state of change by a state of feeling, and this al- 
 ternation continues ad infinitum. The states of feeling vary in 
 length chiefly according to the intensity of the excitant, but states 
 of change are so brief as to have no appreciable duration, though 
 the transition from one state of feeling to another is always noted 
 in consciousness, however rapid the change. 
 
PSYCHICAL SYMPTOMATOLOGY. 163 
 
 The states of feeling are as diversified as the infinite combina- 
 tions of tlie varions spec'ial sense-impressions, but the states of change 
 are on]}' of two kinds, such as connect similar and such as connect 
 dissimilar states of feeling. The conscious recognition of the rela- 
 tion of similarity or dissimilarity between states of feeling is thought, 
 and when two states of feeling are thus for the first time juxtaposed 
 and consciously recognized as similar or dissimilar, it is reasoning 
 by comparison, and when the same recognition of similarity or dis- 
 similarity between the same recurrent states of feeling is repeated 
 it is memory. 
 
 The continuous succession of states of feeling, of which con- 
 sciousness is thus composed, corresponds to processes in the nervous 
 structures provoked by correlative influences in the physical en- 
 vironment. States and changes of consciousness never occur but 
 as the reflection of corresponding changes in nervous structures, so 
 that the nervous system co-ordinates all parts of the human organ- 
 ism and its bearings to the physical environment, and determines 
 the relations of states of consciousness in this sense, that they never 
 can arise except in connection with active processes in the nervous 
 centres. The active nervous process, which is the physical counter- 
 part of the conscious state, takes place in the cortical centres of the 
 brain, but it may have been elaborated in lower centres prior to its 
 arrival there, and the entire nervous system is in some way subservi- 
 ent to consciousness, though Meynert held that the fore-brain was 
 the essential organ of consciousness, and this is largely the truth, 
 though probably not the whole truth. 
 
 The active nervous processes occurring for the first time are at- 
 tended by vivid states of consciousness, which become less and less 
 vivid, and finally cease, after prolonged repetitions of the same ner- 
 vous processes. Thus the nervous process of co-ordination of new 
 modes of action is painfully conscious at first, but is finally unat- 
 tended by consciousness when the action becomes automatic, as in 
 the musician. The active processes attended by vivid consciousness 
 are supposed to be the opening up of new channels of communica- 
 tion in the higher nervous structures, and in automatic actions the 
 flow of nervous energy is presumed to be through the old and well- 
 worn channels. Thus, in the course of long generations, habitual 
 actions become organized in the nervous system and are not only 
 unconscious and automatic, but instinctive. All nervous processes 
 are not attended by conscious states, therefore, for, in the evolution 
 
164 TEXT-BOOK ON MENTAL DISEASES. 
 
 of the race certain nervous activities have become permanently 
 organized and are on an unconscious basis, ^ch as those which pre- 
 side over all the trophic, vascular, and vital functions, and co-ordi- 
 nate the relations of muscular, glandular, and nervous systems. 
 The more permanently organized activities are those of the spinal 
 cord, medulla oblongata and cerebellum, and basal ganglia, and the 
 more recent and highly evolved are those of the brain cortex, which 
 is for this very reason the chief seat of consciousness. It follows, 
 therefore, that there are going on in the various levels of the nervous 
 system nervous processes of all degrees of newness or habitualness, 
 and of intensity or levity, attended by conscious states of correspond- 
 ing degrees of feebleness or vividness. There is the vast aggregate 
 of sensations from muscular, cutaneous, vascular, osseous, visceral, 
 and other organic sources, which constitute coengssthetic conscious- 
 ness. Any decided change in this continuous form of organic con- 
 sciousness, as in hypochondriacal Insanity, is attended by a change 
 in the higher form of intellectual consciousness. 
 
 It has been claimed that during sleep consciousness is broken 
 off, or that for about one-third of existence there is a complete inter- 
 ruption of consciousness. The truth is, that consciousness is an un- 
 broken continuity throughout life, but that it is carried on at differ- 
 ent levels, and during sleep it is preserved at the level of coengesthetic 
 consciousness. It is only after profound anassthesia by artificial 
 means that an intelligent and introspective person experiences for 
 the first time the shock of an actual break in his conscious existence. 
 The dawn of consciousness takes place " in utero,"' and there can 
 be no doubt that, if not microkinetic, at least adaptive, movements 
 of the embryo in the last months of gestation are, in a measure, con- 
 scious. Infantile consciousness rises to a higher level than embry- 
 onic consciousness within a few days after birth, on account of the 
 greater variety and complexity of the environmental influences act- 
 ing upon the nervous structures and arousing corresponding states 
 of feeling, so that consciousness is rapidly educated, so to speak, 
 but it is essentially a ccenasthetic consciousness for the first few 
 months. It is then conducted at higher and higher levels, until 
 there has been a complete evolution of personal identity. In old 
 age, again, there is a decline of consciousness as to the environment 
 and as to self, and a reversion even to the level of childhood, or of 
 camffisthetic consciousness in senile dementia. In apathetic and 
 terminal dementia, and in low forms of idiocy also, the total life 
 is carried on at the level of coenassthetic consciousness. 
 
PSYCHICAL SYMPTOMATOLOGY. 165 
 
 Among the insane sleep is at a lower or higher level often than 
 that of coensesthetic consciousness and partakes of a semi-comatose 
 nature from exhaustion or of the dream-state, during wliich there 
 is association of ideas and fantasy, with hypnagogic hallucinations. 
 
 There is a disorder of consciousness, not infrequent in Insanityj 
 consisting in somnolence prolonged for weeks at a time, and, as often 
 as reawakened, the patient relapses into this state of partial aboli- 
 tion of consciousness. 
 
 In somnambulistic states there is a partial ecHpse of conscious- 
 ness and of special sensations, though there is an exaltation of the 
 muscular sense, and there is most elaborate automatism. 
 
 A more total eclipse of intellectual consciousness takes place in 
 the automatic states of epileptic Insanity, during which the patient 
 may appear to others fully conscious and may commit violent deeds 
 of which he has subsequently not the remotest memory. 
 
 Artificial hypnotic states represent various degrees of abeyance 
 of consciousness, and they have this characteristic, that during their 
 continuance the contents of consciousness may be varied by sugges- 
 tion. 
 
 In the hypnagogic states of the insane occasionally suggestion 
 may act in like manner, even in those who have not been somnilo- 
 quists. 
 
 Another change and partial loss of consciousness occurs in mental 
 disorders in catalepsy, with impaired sensibility and muscular rigid- 
 ity, and the latter symptom usually becomes marked in proportion to 
 the degree of impairment of consciousness. 
 
 In ecstatic conditions there is limitation of consciousness within 
 certain delusional and hallucinatory spheres, to the exclusion ordi- 
 narily of all other peripheral or central impressions, and the emo- 
 tional tone is highly agreeable. 
 
 Another kind of disorder consists in a limitation of consciousness 
 to some frightful delusion or hallucination, with inhibition of men- 
 tal activities and reduction of all the vital functions, as in melan- 
 cholia attonita, or primary dementia. There are other sequential 
 states of stupor from exhaustion of the higher nervous centres, with 
 feeble consciousness and weakness of all the psychic processes. 
 There are also the gradual reductions of consciousness in the transi- 
 tion to terminal dementia in all the incurable forms of Insanity. 
 
 In all acute states of mental depression there is a circumscribed 
 and concentrated consciousness which seldom passes the limits of a 
 circle of painful delusions and false sensory perceptions. 
 
166 TEXT-BOOK ON MENTAL DISEASES. 
 
 In states of mental exaltation, on the other hand, there is a dif- 
 fusion of consciousness, .due to the rapid influx of sensorial impres- 
 sions and the loss of voluntary attention, so that consciousness is in- 
 cessantly changing with the multitude of peripherally and centrally 
 initiated excitations. In the initial stadium of Insanity the great 
 changes in the coengesthesis force themselves into consciousness and 
 arouse distressing presentiments of loss of reason or of impending 
 dissolution. At a later stage continuous changes in coensesthetic 
 consciousness lead to the belief of complete change of identity. 
 
 The most remarkable of all the changes of consciousness in In- 
 sanity are these transformations in personality, and, before their 
 description, some analysis of personal identity is required. 
 
 It would seem to be a simple matter that a child should learn to 
 distinguish its own body from other objects, and that with advanc- 
 ing yeai"s he should have a clear recognition of habitual physical and 
 mental states known to be his own, and that he should feel his united 
 physical and mental being to be his own self, and that this conscious 
 feeling of personal identity should remain firmly fixed so long as 
 life endured. 
 
 Personality, however, is a complex psycho-physical compound, 
 which readily undergoes dissolution in mental disease. 
 
 The component elements of personality are as follows: 
 
 1. Coengesthesis is the central substance of conscious personal- 
 ity, which is based on the sum of all sensations from every organ 
 and every tissue in the body. Coenassthesis varies widely in different 
 individuals, and in two persons of very different constitutions, if 
 there could possibly be during sleep a substitution in the one of the 
 coena3sthesis of the other, there would probably be, on awakening, 
 a complete failure of self -recognition. Disorder of the cosnassthesis 
 in Insanity is a cause of changed identity. 
 
 2. A simultaneous nucleus of ideas, emotions, or volitions at the 
 actual moment of realization of self-identity must exist. A nuclear 
 delusive idea, to which' all memories and incoming impressions are 
 referred, causes alteration of personality in mental disease. The 
 immediate nucleus of consciousness, which is the present link bind- 
 ing old memories and new impressions, and the inner man and the 
 outer world, embraces the individual's relations in time and space, 
 and when this suddenly drops out of the immediate contents of con- 
 sciousness there is confusion of identity, as often witnessed in mental 
 disorders. 
 
rSYCHICAL SYMPTOMATOLOGY. 167 
 
 The present nucleus, or immediate contents of consciousness 
 upon which the mental vision is focussed, is in reality the only clear 
 and illumined consciousness which man possesses, and it is ever un- 
 dergoing instantaneous changes and is never absolutely the same at 
 any two successive points in time. Psychologically speaking, per- 
 sonality, as a synthetic whole, is never brought completely within 
 the focus of illumined consciousness at any one moment of an indi- 
 vidual's existence. 
 
 3. The mnemonic residua of all concepts, sensations, emotions, 
 or actions which have been experienced during the whole life and 
 admit of recall in the mind of the individual. Amnesic disorder, as 
 favoring change in personality, will presently be described. 
 
 4. Eecognition of the relations, interactions, and motives of 
 .conduct between self and the environment. There is ordinarily 
 
 much confusion among the insane in this field of conscious life. 
 
 5. The emphatic reference to self of any of the above compo- 
 nents, which more especially associates the individual with any new 
 event. The normal strong and positive feeling that it is my bodily 
 being which is affected, my immediate ideas which are concerned, 
 my past experience which is in question, my relation to surrounding 
 events which is at issue, is often so feeble as to be a contributive 
 cause of change in identity in Insanity. 
 
 This analysis of the component elements of personality shows 
 that the latter is not a simple, but a complex, affair, and there has 
 from this fact resulted a variety of explanations of the phenomena 
 of double personality witnessed in Insanity. 'No theory thus far 
 advanced by authors on the subject explains satisfactorily all cases 
 of this distinct cleavage of self-consciousness, which takes place 
 in the following different ways, according to the writer's opinion. 
 
 In original monomania it is the second component of personal 
 identity above mentioned which is immediately concerned in the 
 evolution of a new personality. It is the immediately conscious 
 nucleus of morbid feelings and delusive conceptions about wliich, 
 by gradual accretions, a new personality is formed. It is the nuclear 
 delusion and the central fixed idea which is the backbone of the 
 second personality in the transformation stage of monomania. This 
 is an evolutional phenomenon, and differs from the dissolutional 
 change of identity in the secondary vesaniae. In secondary mono- 
 mania the most decided change is in the third component, in the 
 mnemonic residua, part of which have been lost through anmesia, 
 
168 TEXT-BOOK ON MENTAL DISEASES. 
 
 and the rest changed in their relations b}^ new habits of association 
 with diseased concepts and fixed ideas, which come finally to consti- 
 tute also the persistent and immediate contents of consciousness. 
 There is also a partial alteration of the ccensesthesis and a change 
 in the fourth component of identity, which is in this instance a com- 
 ]3lete loss of the recognition of the relation between self and the 
 environment, and of the normal motives of reaction to environmen- 
 tal influences. In the above forms of mental disorder there is, for a 
 time, a struggle for existence of the two forms of personality, and 
 the morbid and secondary form finally survives as the fittest under 
 the circumstances. 
 
 There is seen, as a rare exception in Insanity, a double self-con- 
 sciousness with somnambulism. 
 
 The component element of identity, which consists of mnemonic 
 residua, is distinctly different in. the two states of consciousness, and 
 the memories of the somnambulistic condition recur only with this 
 condition and never in the more permanent state of consciousness. 
 This is^ the only real basis of a claim of double personality in this 
 instance, for the remarkable muscular co-ordinations and the whole 
 series of perfectly adapted actions are only such as have been pre- 
 viously acquired and are executed under the guidance of heightened 
 muscular sense and hypnagogic ideas. 
 
 The most perfect examples of double personality are found 
 among epileptics, in whom there is complete amnesia, in the more 
 permanent state, of the occurrences in the secondary state of con- 
 sciousness. The whole conduct of the secondary state may to the 
 onlooker appear to be that of a person in full possession of his 
 faculties, as the special senses are active, the motor adjustments are 
 perfect, and all the actions are in complete accord with surrounding 
 circumstances. 
 
 This secondary morbid state, during which the second person- 
 ality is said to exist, may continue for days or weeks together, and 
 it is nothing more nor less than an elaborate instance of epileptic 
 automatism. Explained in the terms of the analysis of personal 
 identity, the secondary personality is simply the primary personality 
 minus the second component, i.e., consentaneous ideas in full focus 
 of clear consciousness essential to attention and memory, which 
 therefore fails of all the events of the automatic condition. 
 
 It happens occasionally in mental disorders that in certain recur- 
 rent phases of the same attack there is an apparent change of per- 
 
PSYCHICAL SYMPTOMATOLOGY. 169 
 
 sonality. The patient has the same ideas, feelings, and actions in 
 each of the recurrent phases, of which no clear recollection is re- 
 tained in the regular course of the disease. Thus, in melancholia 
 with maniacal exacerbations the patient may be subjectively and ob- 
 jectively an entirely different person during the exacerbations. The 
 mental change here rests on a physical basis, and it is the uniform 
 and recurrent change in the coenjesthetic consciousness which under- 
 lies the temporary change in personality. 
 
 In mental disease a prominent symptom often is a confusion as 
 to time, place, and identity of persons, which is usually considered 
 to be a disorder of consciousness. This symptom is more frequently 
 due to deranged association of ideas and amnesic disorder, except in 
 cases with complete transformation of personality. 
 
 Having completed the study of perception and consciousness, 
 attention will now be directed to the disorders of the representative 
 faculties of memory and imagination. 
 
 Memory. — Memory is the mental revival of things recognized 
 to have previously occupied a place in consciousness. The physical 
 condition correlative to memory is a fundamental quality of nervous 
 tissues which are supposed to retain a permanent trace of impres- 
 sions once experienced. The physical substratum of memory is more 
 especially the brain cortex upon which presumably are impressed 
 images of all sensory presentations, which may subsequently be re- 
 vived in consciousness by suggestion or by voluntai-y effort, and in 
 the latter case the process is termed recollection. 
 
 Readiness of recollection depends on the strength of the first 
 impression and the number of times it is repeated, and the extent 
 and character of its associations. 
 
 Cerebral localization has led to the belief that the various cor- 
 tical sensory areas are concerned in the registration of the mnemonic 
 images of the special senses, and this theory is applied in the ex- 
 planation of partial memories and their loss in disease. Space will 
 only permit a review of the chief disorders of memory in Insanity. 
 
 Amnesia, or loss of memory, is very common among the insane, 
 and in some cases the remembrance of past events, during certain 
 periods, is only partial, and in others it is completely lost. 
 
 In epileptic Insanity the complete loss of memory may be for 
 periods of a few hours or of some weeks. 
 
 In the cases of somnolence, mentioned under consciousness, there 
 may be total amnesia for certain periods. 
 
170 TEXT-BOOK ON MENTAL DISEASES. 
 
 In delirium acutum there is total amnesia, often not only for tlie 
 acute stadium but for the first part of the convalescent stadium. 
 
 In general paresis there may be total loss of memory in the ter- 
 minal stage, and temporary but total loss of memory following the 
 epileptoid seizures. 
 
 In apathetic and terminal dementia the amnesia is practically 
 total in character, though there may be recurrences to states of 
 partial restoration of memory. 
 
 In acute mania, in profound melancholia, and in primary de- 
 mentia there are sometimes complete lapses of memory for hours, 
 days, or weeks at a time. In sequential stupor and in toxic and dia- 
 thetic Insanity, with extreme exhaustion of vital powers^ and malnu- 
 trition of cortical structures, there may be not only actual amnesia, 
 but positive loss of organic memory, of the possibility of the regis- 
 tration of sensory impressions in molecular tissues. 
 
 The alternate memory of double personality, which Ireland as- 
 cribes to unequal or alternate action of the cerebral hemispheres, 
 is to be here mentioned, as well as the alternations in natural and 
 induced somnambulism. Finally, there is the total amnesia of 
 diffused cortical lesions, and of coarse brain disease in organic de- 
 mentia and of the atrophy of senile dementia. Partial amnesias are 
 also common in mental disease, and they may involve the memory 
 of sight, hearing, touch, taste, smell, or of the muscular sense, and 
 they are due to cerebral lesions which may be located with a certain 
 definiteness. 
 
 Aphasia, which is common in organic dementia, may consist in 
 loss of the memory of written words or musical notes, so that reading 
 is impossible, and this is word-blindness, or of the meaning of spoken 
 words, which is word-deafness, or of the motor memory of words 
 as articulated, which is termed aphemia. 
 
 All forms of ataxic and amnesic aphasia are to be met with in 
 mental disorders. 
 
 Agraphia, or loss of the images of the co-ordinated movements 
 of writing, is also common in many forms of Insanity. In the 
 progi-essive forms of amnesia the more recent acquisitions of knowl- 
 edge and of motor skill first disappear, and the older and more per- 
 manently organized memories and motor attainments, which have 
 become automatic, are the last to disappear. 
 
 Hypermnesia is not as rare in mental disease as has been sup- 
 posed, and the history of the patient not infrequently embraces an 
 
' [psychical symptomatology. 171 
 
 account of remarka"ble activity of the memory at some early period 
 of the alienation. 
 
 In hysterical, neurasthenic, and maniacal cases there is not very 
 uncommonly hypermnesia, which is also found in the initial stadium 
 of the toxic insanities and of the psychoses from infectious disease. 
 
 Partial hypermnesia may also arise in connection with the action 
 of the virus of infectious disorders in Insanity, or it may be due to 
 intense and localized cortical hyperaamias, as in general paresis. It 
 is well known to exist to a surprising degree in states of arrested 
 mental development, either in idiots or imbeciles, who become known 
 as mathematical or musical geniuses. 
 
 There is an apparent partial hypermnesia in demented patients, 
 whose memory is almost a blank, except that they recollect the best 
 modes of play at games like chess or cards, which phenomenon 
 admits of no easy explanation, though it is more likely cerebral au- 
 tomatism than partial hypermnesia. 
 
 Paramnesia, which is a term applied to illusions of memory, is 
 sometimes to be witnessed in paretic and alcoholic cases, who mis- 
 take revived sensory impressions for the actual experiences of life. 
 A paretic recalls a champagne dinner and enjoys it in imagination, 
 and is positive that he has enjoyed it in reality; or from some revived 
 resemblance mistakes the place and the people about him for a part 
 of his past experience, and he mistakes a present sensory impression 
 for a recollection. 
 
 When the imaginary experience has absolutely no basis in the 
 past facts of the patient's life, it is, more properly speaking, an hallu- 
 cination of memory, but, when a real and correct perception of 
 a present reality is transformed, by the addition of fantastic remin- 
 iscences, until it is mistaken for an actual part of the patient's past 
 experience, it is perhaps more correctly to be termed an illusion of 
 memory. 
 
 Imagination. — The revival in consciousness of mnemonic im- 
 ages which are combined in some new way is imagination. 
 
 Past sensory impressions form the plastic material out of which 
 imagination constructs the new forms which stand out so hfelike 
 in consciousness. 
 
 In the higher forms of constructive imagination, as in the painter 
 or musical composer, there is a certain voluntary element in the 
 selection of the plastic material, and a clear recognition of the final 
 product, as a creation of the imagination, but among the insane there 
 
172 TEXT-BOOK ON MENTAL DISEASES. 
 
 is no realization of the source or nature of the imaginary product, 
 which springs full-formed into consciousness and is therefore mis- 
 taken for a substantial reality. In some patients the auditory, and, 
 again, in others the visual, mnemonic residua present themselves 
 most promptly and abundantly for the plastic operations of imag- 
 ination, and it is probable that this fact determines, in some measure, 
 the character of the hallucinatory phenomena. Some persons, in 
 sanity or Insanity, are so neurally constituted that the revival and 
 recombination of sensory residua do not take place vividly, and, 
 being practically without imagination in health, they remain with- 
 out hallucinations in mental disease. 
 
 The true creative imagination of genius is absolutely different 
 from the low forms of imagination displayed in Insanity. The 
 modern idea that the constructive imagination of genius is akin 
 to madness is a travesty of scientific truth. Great genius always 
 rests upon the solid foundations of brain-structures of rare assim- 
 ilative qualities, which register with absolute truthfulness to nature, 
 of the exact and voluntary reproduction in consciousness of these 
 rich stores of memory, arrayed in order and correspondence with 
 past external realities, of great power of discrimination and compar- 
 ison of the internal combinations and external bearings of these data 
 of memory, which are held with an extraordinary grasp of attention 
 in the full illumination of a consciousness of great intensity, until 
 there is a clear perception of their new and inspiring relations — an 
 actual revelation of genius. 
 
 Such physical and psychical conditions as these never exist in 
 their totality in Insanity, in which there is only a pathological sus- 
 ceptibility of the reception and revival of ideas under the diseased 
 activity of imagination. 
 
 The display of imagination in mental disease is almost exclu- 
 sively of the lower form, more correctly termed fantasy. 
 
 Fantasy is the inco-ordinate reproduction in consciousness of 
 loosely combined sensorial images. There is probably some physical 
 reason for the disorderly combinations of sensory images in mental 
 aberration, and that there is some law of uniform cause and effect 
 in the fantastic display is seen in toxic Insanity, in which alcohol, 
 for instance, calls forth a certain array of reptiles and insects with 
 almost uniform certainty. States of extreme inanition also have 
 characteristic phantasmagoria, which may spring from visceral and 
 ccensesthetic sources, as from gastric and sexual regions, and there 
 
PSYCHICAL SYMPTOMATOLOGY. 173 
 
 can be no doubt but that in Insanity the fantasy largely reflects or- 
 ganic sympathies. 
 
 In acute mania there is one continuous play of fantasy, and in 
 many states of mental disorder patients live in a world of their own 
 fantastic creation, which reflects the prevailing emotional tone, 
 whether sad or gay, and often the delusional contents of the mind. 
 In general paresis, especially, it is difficult to distinguish between 
 hallucinations and delusions, and the incessant working of fantasy 
 in the early stage of the disease. 
 
 Hysterical and hypochondriacal patients indulge in fantastic 
 reveries, and paranoiacs have a sort of a dream-life for months to- 
 gether, and the outcome in chronic mania is a steady play of fan- 
 tasy, and the senile dement reverts to a childish action of fantasy, 
 which disappears, however, in the terminal stage of dementia. 
 
 Fantasy often survives the decay of the other mental faculties, 
 and becomes the final flickering light in the extinction of intellectual 
 
 Having now summarily surveyed the chief anomalies of memory 
 and imagination, it will be necessary, in order to complete the sub- 
 ject of disorders of intellect, to consider the disturbances in the ra- 
 tional processes of thought and reasoning. 
 
 Thought. — Thought, logically considered, consists in a triple 
 process of conception, judgment, and reasoning. 
 
 General concepts are formed by analogical inference, by the com- 
 parison of objects sensorially presented, or imaginatively represented 
 in consciousness. 
 
 Judgment consists in the comparison of general concepts, in the 
 detection of similarity between them, and in the statement of their 
 points of agreement in propositional or syllogistic form. 
 
 Eeasoning is the derivation of inferences from the comparison 
 of judgments. 
 
 Thus thought, in the inverse order of its complex elements, is 
 resolvable into reasonings, judgments, and general concepts, and 
 the latter are in turn resolvable into mnemonic images and sensa- 
 tions. Sensation itself, as the basic element of mind, is not such 
 an ultimate fact as to defy further analysis, for the sensation of a 
 single musical note must correspond in some measure to the com- 
 pound nature of the simultaneous vibrations of the fundamental 
 tone and of the harmonic over tones, which compose the note, and 
 a like idea is true of visual and tactile sensations. 
 
174 TEXT-BOOK ON MENTAL DISEASES. 
 
 The pathological nature of thought in mental disease is due 
 to the defects of formation of concepts or judgments, or to disturb- 
 ance in the reasoning processes. 
 
 The formation of clear concepts depends upon attention, which 
 is the concentration of consciousness upon a particular object, which 
 act is effected by voluntary effort, or involuntary through force, 
 novelty, or other quality of the object itself. 
 
 In mental disease there is failure of attention from preoccupa- 
 tion of the mind by dominant ideas or feelings, or from exhaustion 
 of cortical centres, or from the rapid flight of ideas in excitement, 
 which renders attention impossible, or from original cortical defects, 
 as in idiocy. In terminal dementia there is complete failure of atten- 
 tion and of the formation of new concepts, as well as an obliteration 
 of past concepts, so that thought finally ceases completely for want 
 of crude material. 
 
 The force, novelty, and persistence of certain emotional concepts 
 in the insane fill consciousness to the exclusion of all other ideas, for 
 days or weeks together, and some term this a reduction of con- 
 sciousness from the general to the particular. 
 
 As voluntary attention diminishes and passive attention prevails 
 the patient becomes a prey to all sorts of sensorial impressions and 
 incongruous notions, and there is disorder in the association of ideas, 
 which become incoherent. 
 
 Judgment is deranged through the detection of strange and 
 fanciful similarity in concepts, and hence arise odd conceits and 
 insane conclusions. 
 
 Through the feebleness of some concepts and the undue force 
 of others, and the disorder in the association of the same, the first 
 terms of comparison, on which judgment rests, are falsified, and 
 the inferences become the evident product of an insane mind. 
 
 In mania there is first an accelerated flow of concepts, which lead 
 to facilitated and even brilliant thought, but later there is a tumult- 
 uous flow, Avhich neither voluntary effort nor the most powerful im- 
 pression can arrest, and the result is entire incoherence of thought. 
 
 In melancholia the opposite condition of a retarded series of 
 concepts is present, and the succession of ideas may be so tediously 
 slow as to become a cause of incoherence of thought. There is also 
 the constant repetition of a single concept, which leads to verbiger- 
 ation, which is the monotonous repetition of words or phrases, and, 
 if it is a motor concept as to some particular action, it leads to con- 
 
PSYCHICAL SYMPTOMATOLOGY. 175 
 
 stant repetition of the same. There is also a form of verbigeration 
 associated witli extremely rapid and incoherent thought, with repe- 
 tition of words having some similarity of sound. The form of in- 
 coherent thought with tendency to rhyming is not rare, and is de- 
 pendent entirely on similarity in the sound of words without regard 
 to their sense, which is the direct antithesis of onomatopoeia. 
 Thought is carried on in mental disorder largely under the influence 
 of prevailing emotions, hallucinations, or delusions. The character 
 of the thought does not create in this instance the emotional tone, 
 but is determined by it. It has been supposed that rapid thought- 
 rate creates expansive feeling in mania, but both are the outcome 
 of common conditions of disease. There is a rapid thought-rate 
 with painful emotional states in certain hypochondriacal and hyster- 
 ical cases, and in some paretics with expansive tone of feeling there 
 is a greatly retarded thought-rate, which also exists in some ecstatic 
 conditions. 
 
 Greatly increased or retarded thought-rate renders recognition 
 difficult, and the mistakes in persons and things in acute mania are 
 chiefly due to such rapidity of thought that the comparison of the 
 present with past concepts is impossible. The disturbance in the 
 association of concepts and general incoherence of thought leads 
 to like defects of recognition, and to the mistakes in time, place, 
 and identity so common among the insane. 
 
 These failures in recognition are distinct from similar disorders 
 of recognition mentioned under perceptive and mnemonic disturb- 
 ances. The inhibition of thought through the force and persistence 
 of emotional concepts has already been mentioned, and it is only 
 necessary to add that when a frightful concept takes the halluci- 
 natory form it may give rise to inhibition of movement as well 
 as of thought, so that the patient becomes statuesque and falls 
 into a stuporous state, which is not organic stupor, which has a 
 wider basis of physical disorder. In these states of inhibited thought 
 there is a slow and labored formation of judgments, which are cor- 
 rect in the main, and this fact distinguishes this sort of stupor from 
 actual dementia, in which no judgments can be formed, as the mate- 
 rial for the same has faded from the memory. 
 
 Incoherence, which, as regards thought, may be due to tumultu- 
 ous ideation, to violent emotions, to amnesic defects, and to changes 
 in thought-rate, also affects the movements of the body and limbs, 
 and of the special mechanisms of speech, gait, and handwriting in 
 
176 TEXT-BOOK ON MENTAL DISEASES. 
 
 the insane. The flighty thought leads to flighty action, and the 
 absence of clearly purposive and definitely directing ideas leads to 
 incoherent and contradictory speech, looks, and acts — to pseudo- 
 paraphasia, paramimia, and parapraxia. 
 
 Reasoning. — The power of reasoning is almost constantly af- 
 fected in Insanity, for, as the highest evolution of intellect, it is 
 naturally the first to suffer in disease. The mode of reasoning 
 peculiar to the individual in health is the same in kind, though 
 not in degree, in mental disease. Thus some more naturally reason 
 by the detection of a relation of likeness between the differing things 
 compared, and others by discerning the difference between things 
 generally alike. But whether the latter analytic method or the 
 former synthetic method be the habit of the patient's mind, the 
 disorder of reasoning comes about in much the same way. 
 
 In the first place, the mnemonic residua may have been falsified 
 by disordered perception, or the general concepts which they compose 
 may be unnaturally grouped from defects of association, or the nexus 
 of ideas forming the immediate contents of consciousness may be 
 illusory, so that the unlike terms between which a relation of simi- 
 larity is to be discovered already contain the source of error, and 
 the premises being false the conclusion must be erroneous. 
 
 False reasoning in mental alienation may proceed not only from 
 imperfect registration of impressions, from weak memory, poverty 
 of general ideas, and lack of association of the same, but also from 
 the immediate influence of strong emotion, and controlling insane 
 ideas. The bias of preconceived and expectant ideas is sufficient 
 to warp the processes of reasoning in some cases, and in others ratio- 
 cination is impracticable from amnesic failure of words, from re- 
 tarded and inhibited mental action, or from too rapid and tumultu- 
 ous ideation. 
 
 This study of the rational processes in mental disorder leads nat- 
 urally to the consideration of those false inferences of the insane 
 known as delusions. 
 
 Delusions. — The belief in a state of things which does not in 
 reality exist is by no means confined to the insane. The erroneous 
 beliefs which have guided the actions of mankind form one of the 
 most instructive and humiliating chapters in human history. 
 
 Wise men have been mistaken for fools, great geniuses for luna- 
 tics, benefactors of the race for impostors — scientific truth has 
 fought its way continuously against erroneous belief firmly en- 
 
PSYCHICAL SYMPTOMATOLOGY. 177 
 
 sconced in high places — the most abominable wholesale persecu- 
 tions, the most terrible revolutions, and the most cruel wars have 
 been carried on under the influence of delusions. 
 
 The active conflict of business relations and of social life is con- 
 ducted in no small measure under false beliefs of the motives of 
 action of others, and the attempts of immediate adjustment of people 
 to their personal environments is often a comedy of errors. Sane 
 delusions are of varied origin, and they result from ignorance, super- 
 stition, personal prejudice, national, political, social, religious or sci- 
 entific bias, and they are in some instances direct heirlooms. 
 
 This general liability of mankind to delusions is a prototype of 
 the same liability in the insane mind still active, though diseased, 
 and sane and insane delusions are sometimes derived from exactly 
 the same sources of error by the same mental processes, and in these 
 instances they admit of no practical distinction except the coincident 
 fact of Insanity. 
 
 In the vast majority of instances, however, the nature and origin 
 of the delusion and the insane mental process whence it is derived 
 are to be traced, and the derivation of delusions in mental disorder 
 will now be the immediate subject of inquiry. 
 
 An insane delusion is the belief of a diseased mind in a state of 
 things which does not exist. 
 
 This simple but comprehensive definition is applicable to false 
 notions as to internal states of mind or body, as well as to all other 
 erroneous conceptions. 
 
 When the delusion relates to things of the external world, a 
 definition like the following is widely appropriate: 
 
 An insane delusion is the belief in a relation between self and one's 
 surroundings lohich is unreal and unjustified under the circumstances. 
 
 If it be desired to emphasize the fact that the patient does not 
 admit of conviction of the falsity of the delusion, the following 
 defijiition may be adopted: 
 
 An insane delusion is a false belief renting from, brain disease, and 
 contrary to eocisting facts and incapable of correction by adequate proof 
 of its falsity. 
 
 As regards the latter point, the rule is that insane delusions 
 do not admit of removal by appeals to reason, but it is a common 
 mistake to suppose that this is always the case. There are delusions 
 which appear above the plane of consciousness from organic sources 
 and disappear again with the rise and fall of the tide of nervous 
 12 
 
178 TEXT-BOOK ON MENTAL DISEASES. 
 
 energies^ just as delusi-ve views may arise during the rhythmical 
 reduction of nervous force at night and be recognized as absurd on 
 awakening in renewed vigor. 
 
 The physician may arouse the patient from anenergy and delu- 
 sive collapse by a strong appeal to his feelings and better judgment, 
 and stimulate nervous currents to the point of activity essential to 
 the correction of delusion. Well-planned and well-timed stimula- 
 tions of this sort in the convalescent stage may abridge the duration 
 of delusions, and they are not to be contemned at certain other strat- 
 egic points in the combat with the disease, as will be described under 
 the head of treatment. 
 
 It is to be noted that delusions spring from fluctuations in ner- 
 vous force as well as from organic lesions. In the latter instance 
 the delusions are more apt to assume the form of permanent reality, 
 but in the former case they vary in distinctness in every degree, from 
 mere psychic shadows to real mental substances. In the acutely 
 melancholic consciousness the same delusion may be substantial to 
 the point of suicidal incentive in the small hours of the morning, 
 or shadowy to the degree of doubtful existence in the fuller flow of 
 nervous energy in the evening hours. 
 
 The duration of a delusion may be momentary, like the illusion 
 from which it springs, or of the gradual growth of a lifetime in orig- 
 inal monomania. 
 
 In the main, delusions vary greatly in duration in states of mental 
 exaltation and in states of mental depression, so that in the former 
 hours, and in the latter weeks, may be taken as the average unit of 
 measure of duration. 
 
 The derivation of delusions from hallucinations and illusions is 
 very frequent, and the process is in the nature of suggestion. 
 
 The fearful melancholiac has an hallucination or illusion of 
 footsteps in his room at night, and at once has the delusion that his 
 enemy has come to kill him, or he has an illusion of taste and be- 
 lieves that his food is poisoned, and the alcoholic patient has a 
 complete array of frightful delusions, all of direct sensorial origin. 
 
 When the hallucinations are multiple the delusion attains irre- 
 sistible force, for the melancholiac not only hears the footsteps, but 
 sees his enemy approach, and may even feel his grasp, or he may 
 smell and see, as well as taste, the poison in his food, and the alco- 
 holic patient may hear, see, feel, and smell the frightful objects 
 about him. 
 
PSYCHICAL SYMPTOMATOLOGY. 179 
 
 A delusion, from whatever source derived, can never occupy 
 consciousness as a reality but for the briefest period, except there 
 be loss of discriminative power. This loss may be due to amnesic 
 disappearance of standards of comparison, or disordered association 
 of the past concepts required for the correction of present error, 
 or to enfeebled attention and failure to grasp the terms of relation 
 by which the delusive idea is to be tried in judgment. 
 
 The basis of delusions among the whole class of imbecile insane 
 is the organic feebleness of the representative and discriminative 
 powers, and among idiots the sensorial falsifications do not rise 
 to the dignity of delusions. 
 
 It is to be borne in mind that delusions may evoke hallucina- 
 tions, and through the prime belief of poisoning the corresponding 
 hallucination of taste of the toxic agent may arise, and this is true 
 of perversions of all the special senses in their mutual relations to 
 delusions, so that either class of phenomena may be primary and 
 causative as regards the other. 
 
 Delusion may arise, apart from the association of past ideas or 
 of present impressions, from subconscious regions and fill the field 
 of consciousness. Delusions springing up thus fully formed in the 
 mind, though recognized as strange, may still greatly influence con- 
 duct, and they sometimes strike the patient as directly imposed by 
 some higher power, or as immediate revelations for the guidance 
 of their actions. Such delusions often reflect the inner tendencies 
 and deeper impulses of the patient, and hence they are more readily 
 accepted as realities, though they have never been challenged by at- 
 tention at the gate of consciousness, like other incoming impres- 
 sions, and have never undergone customary critical examination 
 and assignment to temporal position among mnemonic residua. 
 
 Another class of false beliefs originating outside of the limits 
 of conscious and attentive discrimination are hypnagogic delusions. 
 A dream often repeated or of great vividness is accepted by the 
 patient as a reality. A mother longs to see her son; she dreams 
 intensely that he comes to see her and is denied the privilege, and 
 the next day, under the full force of delusion, she accuses the physi- 
 cian of preventing the visit which her son came to make her. Hyp- 
 nagogic delusions are not all thus simple, and they may be enlarged 
 by subsequent dreaming, and what is of peculiar interest is that they 
 may embody the substance of dreams habitual in the precedent state 
 of health. Thus a patient had for years dreamed of falling down 
 
180 TEXT-BOOK ON MENTAL DISEASES. 
 
 precipices, and when he became insane had frightful delusions of 
 this same precipitation. 
 
 Ccena3sthetic delusions are also of a subconscious origin, and 
 they proceed from all parts of the periphery, and more especially 
 from visceral sources. They constitute the prevailing symptom 
 in hypochondriacal Insanity, and they are often permanent and 
 incorrigible. They may correspond to actual organic disease of 
 some internal organ, and then a very elaborate delusion may be con- 
 structed out of the morbid and constant sensations. 
 
 Many delusions arise under the organic influence of the repro- 
 ductive organs at pubestence and the menopause, and they not in- 
 frequently have a strong religious tinge of unpardonable sin, or of 
 ecstatic certainty of divine favor. 
 
 These delusions, involving two of the deepest elements in human 
 nature, the sexual and religious feelings, are apt to incite violent 
 actions. . Thus many cases have come under the writer's care having 
 attempted or accomplished sexual mutilations to improve their 
 morals, or from like motives, and following the Scriptural text, " If 
 thine eye offend thee, pluck it out," had literally carried out the 
 injunction. One unfortunate creature conceived some guilt of im- 
 modest feeling on her part in contemplating the figure of the Sa- 
 viour on the cross, and not only plucked out her right eye, but bit 
 ofE part of her tongue as another offending member, because it had 
 repeated the sacrilegious feeling which she fancied she had enter- 
 tained. 
 
 An important general division of delusions is into those which 
 are the outcome of depressed or of expansive states of feeling. 
 
 There is no question but that the fundamental emotional tone 
 detei-mines, to a great extent, the character of the delusions. This 
 view is sustained by the vast majority of all delusions in states 
 of depression and exaltation, for the acute melancholiac rarely has 
 an expansive, or the acute maniac a depressive, delusion, and the 
 character of the delusions only alters with the change of the emo- 
 tional ground-tone. 
 
 When the dominant key of emotion has once been changed, de- 
 lusions tend actively to swell the new tone of feeling, and the fact 
 that they thus heighten pleasurable or painful states has led to 
 the idea that they create such states which are primarily based solely 
 upon the coenassthesis. 
 
 The expansive delusions are in general more sudden in origin 
 
PSYCHICAL SYMPTOMATOLOGY. 181 
 
 and more changeable in nature than the depressive ones, and they 
 correspond more directly to sensorial impressions. They abound in 
 all maniacal states, and in general paresis they take the form of de- 
 lusions of grandeur, and in monomania also they are sometimes of 
 the megalo-maniacal type, which is very common in imbecile mania, 
 as a reflection of the exaggerated boastfulness of imbeciles in gen- 
 eral. They relate to superior powers of mind or body, to the pos- 
 session of great wealth, or to any and all ideas which favor the im- 
 portance and general welfare of the individual. 
 
 The depressive delusions are more gradual in development and 
 more permanent in duration and more completely systematized or- 
 dinarily. 
 
 They include delusions of suspicion in which the general atti- 
 tude of the whole world is inimical and personal conspiracies abound, 
 delusions of persecution, which take every imaginable form and 
 are confirmed by hallucinations of the various senses, and delusions 
 of sinfulness and self-accusation, and endless varieties of painful 
 notions of every conceivable relation of self to one's surroundings. 
 
 The importance of this division into expansive and depressive 
 delusions lies in its correspondence physically to states of ill-being 
 and well-being, and mentally to states of pleasure and pain. 
 
 A psychological division of still greater importance is into sys- 
 tematized and unsj'stematized delusions. 
 
 A systematized delusion consists of a central fixed idea around 
 which is grouped a whole system of other secondary delusions by 
 a logical process of inferences. This dominant delusive idea is for- 
 tified by all the possible coincidences of the patient's life, which can 
 by the most strained construction be brought to sustain it, and it 
 finally becomes the controlling principle of the patient's motives 
 and actions. 
 
 • Some delusions are very much more systematized than others, 
 and the degree to which a delusion is organized depends simply on 
 the strength of the imagination and of the logical powers. For this 
 reason, in all the chronic terminal insanities, systematized delusions 
 are not found, except as remnants of former delusions, while they 
 may exist in any kind or stage of mental disorder in which the ra- 
 tional processes are still performed, and they are found in their 
 most elaborate form in original monomania. 
 
 Systematized delusions in the first stage of their existence most 
 frequently accord with the general emotional tone, but later they 
 
182 TEXT-BOOK ON MENTAL DISEASES. 
 
 are modified by the evolution of changes in the personality of the 
 patient presently to be mentioned. They ordinarily originate with 
 a depressive ground-tone of feeling, as shown by the usual inimical 
 and persecutory attitude of the environment, and later there is a 
 complete transformation of delusions of persecution into delusions 
 of grandeur. 
 
 This transformation takes place with the change in personality 
 by logical efforts of explanation and by the natural antitheses of 
 thought, so that the patient comes to think that if he is treated as 
 insane it is because he is a genius, if regarded as inferior it is because 
 he is great, if hated it is because he is so esteemed as to be an object 
 of envy, and if confined as a pauper lunatic it is to prevent his Just 
 claim to a great estate or his marriage to a lady of title and wealth. 
 During this transformation the fittest expansive and depressive de- 
 lusions survive and undergo mutual readjustment, and the active 
 phase of this psychic process is then at an end. 
 
 The unsystematized delusions exist in forms of Insanity in which 
 the thought-rate is too rapid to admit of logical comparisons, as in 
 acute mania, or where the raw material of judgments is lacking, 
 as in the amnesic failure of general paresis or in melancholia with 
 inhibition of rational processes and greatly retarded thought-rate^^ 
 and in all secondary states with permanent logical deficiency. 
 
 The unsystematized delusion is an isolated phenomengn without 
 any particular relation to other delusions, and without special logical 
 bearings of any kind, and it ordinarily appears in connection with 
 some expansive or depressive feeling or sensorial perversion, and 
 it is seldom of long duration and is readily supplanted by some other 
 delusion. 
 
 Delusions which arise in connection with changes in personality 
 are of considerable importance. Under the head of consciousness 
 the chief forms of changes in personality were described, so that 
 it is only required to record here some additional particulars of the 
 manner of alteration of the component elements of self-identity. 
 
 In health the incoming impressions are discriminated by com- 
 parison with past experiences, and they are then stored in memory 
 and may serve in turn as standards of comparison, if they have been 
 correctly perceived and truly registered in accordance with external 
 relations. But in Insanity the incoming impressions are subject 
 to great sensorial perversion, but they are registered in memory as 
 if they corresponded to'actual realities, so that in time the mnemonic 
 
PSYCHICAL SYMPTOMATOLOGY. 183 
 
 residua are largely falsified, and a most important component of per- 
 sonality is thus altered and new and false standards of comparison 
 are substituted, and by them all the current experiences are judged, 
 and a host of delusive concepts are formed completely at variance 
 with the real external relations of the patient. 
 
 While this pathological change in mnemonic residua is going on 
 there is an alteration of ccensesthetic consciousness, and these two 
 new and morbid components are the basis of the second personality, 
 while the remnant of the sound memory and understanding repre- 
 sent the old personality now rapidly fading from clear conscious- 
 ness. The old and the new personalities may alternate, each with 
 its own set of delusions, or may even exist simultaneously. Finally, 
 however, the new personality, with its attendant delusions, survive 
 as the fittest to the pathological state of things. 
 
 It is at the time of this metamorphosis of personality that the 
 transformation of delusions of persecution into delusions of gran- 
 deur, as above mentioned, usually takes place. 
 
 Before the old self has been supplanted by the new self, and 
 while they exist simultaneously, the patient may cease a habit of 
 monologue, and talk aloud to himself in dialogue, the old person- 
 ality answering to the new in argumentative form. When the new 
 self has prevailed the old self seems very vague, like a thing of the 
 distant past, and, finally, like a very old memory, it may only be 
 revived at rare intervals with diminishing distinctness. It some- 
 times happens that the old personality is replaced by an abortive 
 personality, defective in physical or mental parts, without certain 
 internal organs, or one-sided only, or composed in part of some 
 other material than human structures, or devoid of memory and 
 having different senses, so that everything looks, sounds, feels, and 
 tastes differently, or, finally, cadaveric, the patient insisting that 
 death has taken place, and that the apparent body is only a corpse. 
 In the latter instance the nihilistic delusion may extend to the whole 
 environment, the patient ignoring the existence of self and of the 
 whole world, and disclaiming the reality of the objects presented 
 to his senses. 
 
 Delusive states of doubt are very common in the degenerative 
 insanities, and they usually run a chronic course and are of a very 
 annoying nature. The patient doubts what is said or done by others 
 or by himself, doubts his recollections, doubts his senses, looks at a 
 thing and turns to look a second and a third time to see if it is really 
 
184 TEXT-BOOK ON MENTAL DISEASES. 
 
 as it appears^ does a thing and returns to see if he has done it, and 
 still donbts if there be not some mistake about it. These states of 
 doubt are in one sense delusions, for to doubt the very recent con- 
 tents of one's consciousness or the evidence of one's senses is to dis- 
 believe prime facts, which is equivalent to a false belief, since dis- 
 belief is as positive a symptom as belief. 
 
 These delusive states of doubt are ordinarily of a painful char- 
 acter, and they are not to be mistaken for amnesic or paramnesic 
 conditions, nor are they analogous to normal states of suspended 
 judgment due to real difiFiculties of inference, but they are of the 
 pathological nature of impellent ideas and of morbid impulses. 
 
 Delusions may relate to the past, present, or future. When they 
 are referred to the past they may spring from perverted memories 
 largely embellished by morbid imagination, and when projected in 
 the future they often embody the fears or desires of the patient. 
 
 It is possible to engender delusions by suggestion, particularly 
 in states of suspicion, and delusions also arise by contagion, by in- 
 oculation with the false beliefs of other patients. 
 
 History furnishes instances of widespread epidemic delusions. 
 Delusions are of medico-legal importance and they are commonly re- 
 garded as crucial tests of Insanity. The precise form of the delusion 
 is not of such importance as its origin, its influence on the thought 
 and actions of the patient, the degree to which it is systematized, the 
 length of time it has existed, the ratiocinations by which it is re- 
 tained and defended, and the persistency with which it is held in 
 the presence of adequate proof of its falsity. 
 
 Insanity may exist without delusion, and delusion may exist 
 without Insanity. When delusion alone constitutes the sympto- 
 matic gravamen of mental disorder, a diagnosis without a most 
 searching inquiry into the circumstances of the case is unjustified^ 
 since, to avoid medical error in such a case, it is essential to exclude 
 the possibility of a basis of facts for the delusion. In such a case, 
 also, it is to be borne in mind that illusions and hallucinations of 
 memory exist in sanity as well as in Insanity, and that a great many 
 persons of lively imagination continue to repeat and embellish an 
 account of certain occurrences, until they finally come to believe 
 that which is absolutely untrue. 
 
 The natural course of all delusions is that they lose, with lapse 
 of time, their original intensity, their emotional connections, and 
 their influence over the actions of the patient, and, with the cortical 
 
PSYCHICAL SYMPTOMATOLOGY. 185 
 
 disintegrations of the terminal stages of Insanity, they fade com- 
 pletely from consciousness. The patient is then once more at rest 
 and at peace with himself and the imaginary world, as these perturb- 
 ing spectres of a deluded mind 
 
 " Fold their tents like the Arabs, 
 And as silently steal away." 
 
 Section II. — Disorders of the Emotions. 
 
 Emotions are pleasurable or painful modes of consciousness re- 
 sulting from diffused discharges of nervous energy through brain 
 structures specifically integrated and molecularly modified by indi- 
 vidual or ancestral experiences. 
 
 It is probable that the ancestral and racial transmitted tendencies 
 are more important in determining the general trend of the emo- 
 tions than the immediately acquired individual experiences. The 
 racial differences of emotional manifestations are as great in In- 
 sanity as in health, but space will not permit their study here. 
 
 As regards mental disorders, it is of the first importance to con- 
 sider the physiological basis of the prevailing emotional mood which 
 in turn exerts a general modifying influence over the emotions. In 
 states of mental exaltation the resultant of the cutaneous, muscular, 
 vascular, glandular, and other organic sensations is highly agreeable, 
 while, on the other hand, it is painful in states of mental depression, 
 and of a negative character in states of mental weakness, especially 
 in those known as terminal dementia. 
 
 Now, this aggregate of organic sensations from every external 
 and internal peripheral source, excluding the current sum of the 
 special sense-impressions, constitutes the ccensesthetic consciousness, 
 which is the physiological basis of the prevailing emotional mood 
 in mental disease. 
 
 This, then, is the rationale of the fundamental emotional tone, 
 v/hich is agreeable in states of exaltation, painful in states of de- 
 pression, and negative in dementia; and it is a clinical fact in all 
 these forms of Insanity that the emotions are agreeable, painful, or 
 absent, in correspondence with the general organic tone of feeling 
 here mentioned. 
 
 This division of emotions in Insanity into pleasurable and pain- 
 ful, according to the prevailing states of ccensesthetic consciousness, 
 is the widest primary grouping possible. 
 
186 TEXT-BOOK ON MENTAL DISEASES. 
 
 Emotions may be further divided according to tlieir degree of 
 complexity. 
 
 Thus various agreeable or disagreeable feelings may attend the 
 organic sensations of activity and repose, of hunger and thirst, and 
 of changes of temperature. 
 
 The emotions connected with the olfactory and gustatory senses 
 are simple relatively, and are very numerous and much perverted 
 in mental disease, since taste and smell are the emotional senses. 
 The emotions arising from the intellectual senses of sight and hear- 
 ing are more complex, and are likewise subject to great alterations 
 in Insanity, corresponding to anomalies of these senses described 
 under perception. Then there are endless varieties of emotions 
 springing from revived experiences, as to which sense-impressions 
 do not act in their direct renewal in memory, and, being largely 
 ideational, are still more complex in nature, and they are pathological 
 in keeping with all the morbid alterations mentioned under the head 
 of memory in mental disease. The more numerous the ideational 
 elements which enter into emotions, the more complex they become. 
 The more abstract and complex feelings are termed sentiments, and 
 some of them are more highly intellectual than others, as, for in- 
 stance, the sentiment of justice. 
 
 These higher intellectual sentiments are the first to suffer de- 
 rangement in Insanity, not only because disorder of feeling uni- 
 formly precedes that of intellect, but because they represent the 
 most highly evolved forms of feeling. Thus patriotic, aesthetic, 
 benevolent, and the higher moral feelings very seldom fail to dis- 
 appear in mental alienation at an early period. 
 
 Then, again, there is in mental disorders the spasmodic libera- 
 tion of emotions from cortical disease in acutely maniacal and toxic 
 states and in general paresis. These emotions are independent of 
 sensorial impressions and of the laws of the association of mnemonic 
 ideas, and they may be contradictory of. the general law that emo- 
 tions accord in character with the prevailing emotional tone. Thus 
 the acute maniac or paretic, with a dominant expansive and agree- 
 able tone of feeling, will have occasional spells of spasmodic libera- 
 tion of mixed emotions, shown by laughing, crying, anger, and other 
 antithetical feelings, which subside in a few minutes or hours, and 
 leave the patient again in his customary emotional mood. 
 
 The spasmodic and automatic display of emotions is often mis- 
 taken for highly co-ordinated and intellectual feelings. Thus the 
 
PSYCHICAL SYMPTOMATOLOGY. 187 
 
 busy social performances of the maniac, or the profuse and incoher- 
 ent generosity of the paretic, who gives with one hand and steals 
 with the other, are in no sense evidence of the higher social or benev- 
 olent sentiments, and even the appropriate words accompanying 
 these social demonstrations are in many cases automatically associ- 
 ated and absolutely insignificant of deliberative intent or of intel- 
 lectual sentiment. 
 
 The emotion which is spasmodically liberated with the greatest 
 frequency and force in Insanity is anger, which is attended by de- 
 cided changes in respiration and circulation and secretion, with inco- 
 ordination of ideas and actions at the height of the feeling. There 
 is arterio-spasm of cortical arteries, and the resulting cerebral an- 
 aemia may end in syncope, and in the meantime the patient may 
 have blindly vented his fury on things animate or inanimate. 
 
 There is also a prevailing angry mood, which, in a minor degree, 
 is manifested in a continuous tone of irritability, which consists in 
 an extreme readiness of reaction to disagreeable impressions. All 
 these emotional symptoms are especially frequent in the degenera- 
 tive insanities. 
 
 In the early stage of mental disease there is sometimes a general 
 increase of emotional excitability, so that the simplest sensations 
 or ideas are morbidly pleasurable or painful, and there is an emo- 
 tional shading of every passing event, even of the most common- 
 place occurrences of life. In the later stages of mental disease there 
 is often a general decrease of emotional excitability, even to the 
 point of complete apathy and entire absence of all emotions. 
 
 There is also an antithetical perversion of the emotional reac- 
 tion, so that pleasurable impressions are painful, and normally dis- 
 agreeable feelings become agreeable. 
 
 This is very different from another anomaly witnessed in Insan- 
 ity, by which, through habituation, disagreeable emotions become 
 agreeable, so that patients come finally to cradle their most frightful 
 feelings of persecution because it gives them morbid delight. 
 
 Paranoiacs and maniacs and paretics in the initial stage unques- 
 tionably derive pleasure in creating imaginary situations and in mak- 
 ing voluntary surrender to emotions. These histrionic performances 
 are often carried on for hours in the patient's room at night, with 
 boisterous demonstrations of song and laughter, and, when called 
 to account, the patient may answer that he is amusing himself, and 
 may cease the . performance. A paretic minstrel used to reply on 
 
188 TEXT-BOOK ON MENTAL DISEASES. 
 
 such, occasions that he was having a show, and a circus actor used 
 to relate stories to imagined audiences, and applaud and laugh at 
 his own stories. 
 
 The most characteristic emotional alteration in mental disorders 
 is the concentration of conscious feelings upon self, and the entire 
 disregard of all other external relations except those which concern 
 the prevailing selfish and narrow circle of feelings. In other words, 
 the egoistic emotions abound and the altruistic emotions are ex- 
 cluded. The incubatory stage is marked by loss of interest in friends 
 and family, and later there is complete disappearance of affectionate 
 feelings for the nearest relatives, and, finally, there may arise anti- 
 thetical feelings of hatred instead of love for parents, children, hus- 
 band, or wife. Melancholiacs thus remain concentred in self 
 throughout the attack, and the harbinger of recovery is a renewal 
 of normal emotions toward their family. 
 
 The absence of altruistic sentiments is a rule with very few 
 exceptions in mental alienation. There is seldom any sympathetic 
 response for the sufferings of other patients in melancholia, or, in- 
 deed, reaction to any new painful idea, not even to death in the 
 family of the patient. On the other hand, the anti-social emotions 
 of suspicion, hatred, and fear abound. 
 
 In the later stages the narrowing of consciousness to self some- 
 times takes the form of an exaggerated feeling of self-importance, 
 so that self seems at all times to fill the whole field of mental vision. 
 
 Emotions are evoked and in some measure determined by de- 
 lusions and hallucinations, especially those of a fearful character. 
 
 The generic group of emotions based on fear is more prominent 
 in Insanity than any other class of feelings. 
 
 Psychical disintegration is the prime factor in this group of emo- 
 tions. Some patients in the incubatory stage become clearly con- 
 scious of the impending mental disaster, and early fall into a state 
 of dread, while most patients only have a vague foreboding of evil, 
 but still become anxious and fearful. In a few highly intelligent 
 and susceptible individuals the fully conscious feeling of psychical 
 disintegration ends in extreme panic, which readily passes into 
 maniacal excitement. In all the active forms and stages of Insanity 
 fear, as a reflex of the instinctive feeling of self-preservation, in some 
 of its multitudinous forms, is the predominant emotion, which is 
 reflected in the majority of insane delusions, particularly in states 
 of mental depression. 
 
PSYCHICAL SYMPTOMATOLOGY. 189 
 
 There is a state of extreme anxiety and acute anguish with dis- 
 tressing epigastric sensations and cardiac irregularities of action, 
 known as precordial anguish. 
 
 This precordial anguish is of cortical origin, hut only as the reflex 
 conscious expression of deep-seated ccentesthetic disturbances, and it 
 varies greatly in intensity. The milder form is confined to vague 
 fear, anxiety, restlessness, and epigastric distress. The full attack 
 of precordial anguish presents the additional symptoms of spastic 
 arterioles and capillaries, rapid cardiac action, accelerated respira- 
 tion, great motor restlessness, painful emotions, and not infrequently 
 violent or suicidal impulses and acts. 
 
 As in the milder forms, the anguish and the painful emotions 
 are without physical accompaniments, the phenomenon is ranked 
 among the disorders of feeling, though in certain cases, with great 
 vascular disturbance, it might with equal propriety be classed as a 
 vasomotor symptom. 
 
 In paranoiac, hysteric, neurasthenic, and degenerative insanities 
 generally, there are to be found cases in which there is no definite 
 emotional tone based on a depressed or expansive coenEesthesis, but 
 there is a pathological state of fluctuation of emotions occasioned by 
 slight sensorial or ideal provocation, so that the patient may pass 
 through the whole gamut of the emotions in the course of a few 
 hours. 
 
 This susceptibility and changeabihty of the emotions may con- 
 tinue for weeks at a time, but depth of feeling is wanting, and cor- 
 responding delusions are rarely formed. Other emotions common in 
 mental disorders are self-reproach and remorse for imaginary crimes, 
 disgust at hallucinatory objects of loathing, revenge for persecutions, 
 vanity, pride, exaggerated hope, excessive religious feeling, perverted 
 sexual feelings, suicidal and homicidal feelings. 
 
 Disordered emotions precede, attend, and follow mental disease. 
 The return to a normal state of feeling being a necessary accompani- 
 ment of recovery, it is to be understood that there are residua of 
 morbid emotions attached to remnants of former delusions, which do 
 not disappear at once on restoration of a right mind, but they recur 
 from force of inertia and habit, and only fade out completely with 
 course of time; but it would be an injustice to allow them to exclude 
 the diagnosis of complete recovery, as they may persist in memory 
 Avithout credence or influence on conduct for many months after 
 perfect mental equilibrium has been restored. 
 
190 TEXT-BOOK ON MENTAL DISEASES. 
 
 . Section III. — Disorders of Volition. 
 
 It is not the intention here to touch upon the momentous question 
 of free will, to broach mechanistic theories, which explain all mind 
 in terms of motion, or to enter into idealistic hypotheses which pose 
 the will as the supreme principle of mind and the prime reality in 
 the universe. It suffices, for psychiatric purposes, to suppose that 
 things are what they appear in the realm of volition, that man has 
 a will of his own, and that the modes of its manifestation are altered 
 in mental disease. 
 
 To assist in the study of disorders of volition in Insanity it is well 
 to resolve the act of volition into psychical components. The voli- 
 tional process, "in toto," is composed as follows: 1. Attention to 
 ideas differing in degrees of pleasure or pain. 2. Deliberate com- 
 parison of such ideas. 3. Fixation of choice upon one of the ideas 
 which is the conscious edict of will. 4. Eecall of motor images for- 
 execution of the idea. 
 
 It will appear a little later to which one of the terms of this 
 volitional process certain defects of will in mental disorders are to 
 be more especially referred. 
 
 As the will is chiefly concerned in the active adjustment of the 
 relations of the human organism to its environment, its chief mani- 
 festations are co-ordinated movements consciously adapted to some 
 special purpose. 
 
 When these voluntary movements have been repeated a sufficient 
 number of times they become involuntary and automatic. In health 
 the number of acts which are thus automatic and performed with 
 unconscious facility are very numerous, and they are the cause of 
 the perfect freedom and readiness of actions as adjusted to all the 
 external relations of life. 
 
 In mental disease many of these acts cease to be automatic, and 
 have again to be performed with voluntary effort, and the restriction 
 and awkwardness in customary actions thus arising are often at- 
 tributed to loss of will power. There are various other instances in 
 which the essential elements of will, desire, and choice tend to a 
 definite action, which is not performed from defects in the nervous 
 mechanism, and here again the failure is falsely attributed to volition. 
 
 There are undoubted disorders of volition, however, in mental 
 disease, and they will be considered chiefly under the heads of abulia, 
 hj'-perbulia, and parabulia. 
 
PSYCHICAL SYMPTOMATOLOGY. 191 
 
 Abulia is impairment or loss of will, and it is due to defects in 
 some of the components of will, not to any uniform failure in any- 
 one of the essential antecedent conditions of volition. In health it 
 is the pleasurable or painful quality of the ideas arising in conscious- 
 ness which attracts attentive comparison and leads to a choice, but 
 in melancholia the ideas have sometimes lost all pleasurable quality, 
 and are all equally indifferent or painful, so that they no longer 
 incite to a choice of action, and there is then a defect in the first 
 component of the volitional process, which is attention to ideas dif- 
 fering in degrees of pleasure or pain. 
 
 In a case of degenerative Insanity constant suspicion and doubt 
 often prevent the third step in the volitional process, the fixation of 
 choice, and absolute indetermination is the impairment of will. 
 Such patients, before deciding the simplest action, are in a painful 
 state of doubt and hesitation, and a cold perspiration may reveal the 
 agony of an edict of will on their part. There is no failure in these 
 cases in attention, in the painful or pleasurable qualities of the ideas, 
 or in the comparison essential to a choice, but there is a decided 
 impairment of will. 
 
 In toxic maniacal states with tumultuous actions and ideation 
 the failure is precisely in the impossibility of deliberate comparison 
 of ideas essential to a choice of action, and hence no distinct volitions 
 are formed, and all the actions are automatic in response to sensorial 
 stimuli or incoherent ideas and emotions. 
 
 There is the same failure in the element of comparison in the 
 ccenaesthetic exaltation of the general paretic, who has no motive for 
 choice, since all courses of conduct are equally pleasurable and every- 
 thing is rose-color, and it is like a choice between colors on the part 
 of a color-blind patient. Hence comes the impaired volition, and the 
 childish and fickle conduct varying with every passing impression 
 in the exalted paretic. 
 
 In certain cases of severe mental depression there is loss of clear 
 conceptions of spatial relations of objects, and of the ideal reproduc- 
 tions of movement, and the resulting impairment of will is due to 
 a failure in the fourth factor of the volitional process, the inability to 
 clearly recall the motor images for the execution of the idea. A like 
 failure in the volitional actions attends the loss of the muscular sense 
 in mental disease. In organic dementia the loss of volitional speech 
 and writing is well known to be due to ataxic aphasia, and all the 
 organic lesions, which prevent the transition from volitional fiat to 
 the performance of the action, are too numerous to mention here. 
 
192 TEXT-BOOK ON" MENTAL DISEASES. 
 
 In some cases of melancliolia there is no manifestation of will- 
 power tecause there is absence of such emotions, desires, or senti- 
 ments as are the mainspring of conduct. 
 
 In all states of dementia will is greatly impaired from loss of 
 attention, memory, and discrimination, so that neither a comparison 
 nor a resolve is any longer possible. 
 
 In states of great exhaustion following the acute stage of mental 
 disorders there is impaired volition from sheer want of nervous en- 
 ergy, essential to this highest form of psychic action. 
 
 In other cases of Insanity there is an intense emotion or dominant 
 painful delusion, which prevents the action of vohtion. In neuras- 
 thenic and other forms of Insanity the emotion of fears in its various 
 special forms inhibits vohtion, and it is not necessary to name here 
 the endless varieties of phobias to which special names have been 
 given. 
 
 There are numerous temporary states in mental aberration in 
 which the ^411 is overwhelmed by the number and force of the emo- 
 tions, which completely dominate the actions of the patient for the 
 time being. 
 
 The will is seriously impaired also during the prolonged periods 
 of mental inhibition in certain states of mental depression and in all 
 conditions of profound stupor, and in primary dementia and melan- 
 choha attonita vohtion is practically abolished, as well as in terminal 
 dementia. 
 
 Hyperlulia is an intensification of the volitional process, and it 
 has been supposed by some writers to exist in Insanity. There is 
 certainly a crude display of wilful conduct in mental disease, but the 
 brutal force of the maniac's action, or of a patient impelled by power- 
 ful delusion or emotion, is by no means a sign of heightened will- 
 power. The highest power of will is that which restrains, co-or- 
 dinates, and inhibits ideas and actions, and it is precisely this exercise 
 of volition which is wanting in those cases which have the appearance 
 of great force of will. 
 
 The deluded patient may make the most persistent and deter- 
 mined efforts to injure himself and others, and he may require the 
 combined force of several nurses to prevent his violence, but the 
 automatic epileptic will act in the same way, and in both cases it is 
 the manifestation of disease and not of increased strength of volition. 
 
 The nearest approach to hyperbulia is in the initial stadium of 
 mania, but the inhibitory element of will is slightly impaired, though 
 
PSYCHICAL SYMPTOMATOLOGY. 193 
 
 ideation and emotion may be intensified, so that it must be con- 
 cluded that in mental disorders a positive increase of volitional 
 power does not exist. 
 
 Parabulia is a designation for perversions of will, and under it, 
 for want of a better general term, will be described a variety of mor- 
 bid manifestations, which in appearance are directed by will, but in 
 reality escape volitional control. 
 
 It is to be considered that will does not exist in the child, that 
 self-control is a gradual attainment, and that the highest form of 
 inhibition of ideas and feelings is only evolved. at maturity. The 
 normal adult can inhibit one group of sensory stimuli and its asso- 
 ciated ideas by fixing attention upon an opposing set of sensations 
 and concepts, and in this way can control the direction of his con- 
 duct, for all sensations and ideas tend to issue in actions of some 
 kind. As often as ideas clearly present themselves in consciousness 
 they arouse faintly or vividly the motor-images and impulses neces- 
 sary to their execution, and when a special idea has greater force 
 and persistence than others it will certainly be expressed in action if 
 not voluntarily inhibited. 
 
 Impellent ideas are precisely those which have such morbid inten- 
 sity and persistence as to escape inhibition and issue in actions, 
 which are not willed, and they are common symptoms in the degen- 
 erative insanities. 
 
 These intense impellent ideas arouse equally vivid motor-images 
 and impulses, which issue immediately in action, and by their ex- 
 treme rapidity or great force they escape or overcome impaired voli- 
 tion. They impel the patient to make a certain motion, to touch 
 a certain object, to speak a foolish word, to do a silly act, to shout, 
 to strike or to break something, and they result in all kinds of 
 absurdity or violence of conduct. Sometimes they are associated 
 with or suggested by other ideas, and then they may be manifested in 
 ideational or emotional as well as in motor directions. 
 
 These impellent ideas are to be distinguished from morbid im- 
 pulses which spring from the appetites and instincts. 
 
 Morbid impulses are powerful tendencies to actions without any 
 adequate motives, and they differ greatly in their nature and origin. 
 
 In acute mania the inhibitory control of actions is absent, and 
 the sensorial and emotional incitives to action are intense, and the 
 result is extreme impulsiveness of conduct. 
 
 The mental reflex excitability and the strength of the sensorial 
 13 
 
194 TEXT-BOOK OTT MENTAL DISEASES. 
 
 stimuli explain tlie morbid impulses, which are constantly changing 
 in character and lead to destructive and violent acts for which there 
 is no motive. 
 
 Morbid impulses abound in alcoholic Insanity. It is known that 
 alcoholic cases are subject to convulsive seizures ; and some of the 
 morbid impulses are the psychical equivalents of such seizures, and 
 in general the sudden and irresistible impulses of alcoholic patients 
 may be regarded as the result of cortical discharges. There are, 
 however, violent impulses attending in these cases the withholding 
 of the customary stimulus, and they are connected immediately \\dth 
 the artificial appetite, and are akin to those springing from inanition 
 or thirst. 
 
 In acute melancholia the irresistible impulses are related to a 
 frightful delusion or hallucination, or they are the outcome of pre- 
 cordial anguish, or of the perversion of the instinct of self-preserva- 
 tion, and they then take the suicidal form. 
 
 Irresistible impulses in epileptics are merely manifestations of 
 "the general convulsibility, which may express itself in co-ordinate 
 just as well as in inco-ordinate movements, in adapted actions as well 
 as in convulsive motions. 
 
 The coengesthetic impressions, embodying the systemic needs of 
 hunger, thirst, and the sexual appetite, rising to cortical representa- 
 tive centres, are at once liberated spasmodically in the most brutal 
 forms of violence in these epileptic cases. 
 
 It is to be remembered that the appetites in mental disorder are 
 almost inconceivably intensified, and that the brute ferocity of a 
 hungry animal is only a normal degree of a feeling, which in disease 
 ■may reach the height of absolute frenz}^, and that which is true of 
 hunger in Insanity is equally applicable to all the other appetites. 
 
 Thus an epileptic patient in a state of appetitive frenzy may 
 violate a woman, and after homicide partially devour the body, and 
 such cases are on record also in other forms of mental disorder. 
 
 Anthropophagy is therefore to be regarded in such cases as one 
 of the symptoms of the Insanity. 
 
 It is necessary to say something here of the appetites and in- 
 stincts in their basic relations to will and of their perversions in In- 
 sanity. 
 
 The appetites are the crude source of almost all desires, which 
 in turn become the chief motives of conduct, for volition in general 
 follows the desire for things pleasurable or the desire to avoid ac- 
 tions painful in results. Parabulic symptoms in mental disorder 
 
PSYCHICAL SYMPTOMATOLOGY. 195 
 
 therefore have their ultimate genesis in the perversion of the appe- 
 tites in very many instances. 
 
 The appetites, or organic cravings for activity and repose, for 
 food and drink, in health are proportionate to the actual needs of 
 the sj^stem, and by heeding these physiological warnings the nutri- 
 tional balance is preserved, but in mental disease there may be in- 
 crease, decrease, or absence of these feelings of systemic need. 
 
 Thus there is a morbid increase of the need of activity, which 
 leads to ceaseless movements, or absence of normal desire for action 
 and complete inertia. 
 
 The need of repose may be increased so that the patient feels 
 tired constantly without having exercised, or it may be so decreased 
 that the normal feeling of fatigue is absent after hours of maniacal 
 violence of action. Thus the patient, though exhausted to a dan- 
 gerous degree by incessant activity, feels no need of rest, and may 
 die for want of it if it is not enforced. 
 
 Somnolence and insomnia are common symptoms, and they con- 
 tinue for weeks together. 
 
 Bulimia is an intensification of the need for nourishment, and it 
 attains to an incredibly morbid height in certain phases of mental 
 disease, and it bears in part a direct relation to the extensive and 
 rapid waste of tissues. 
 
 In epileptic, paretic, senile, and maniacal cases there is often an 
 excessive appetite for food and drink, termed, respectively, poly- 
 phagia and polydipsia. There is also loss of appetite for food known 
 as anorexia, and for drink, adipsia, and also active dislike for nour- 
 ishment, termed sitophobia, which is often a very troublesome symp- 
 tom. There is also active perversion of the appetite for food which 
 leads the patient to devour even the most disgusting substances. 
 The milder forms of this perversion of appetite seen in hysterical, 
 climacteric, pubescent, and puerperal Insanity are termed pica, and 
 consist in the eating of chalk, earth, plaster, and similar things, but 
 the more decided forms are the devouring of insects, worms, carrion, 
 and not infrequently human excrement, to which latter symptom 
 the word coprophagy is applied. There is not only a loss of natural 
 disgust for offensive things, but there is a diseased craving for them. 
 ' The artificial appetites in Insanity, therefore, are readily acquired 
 arid have an abnormal force and persistence. Patients become ad- 
 dicted to stimulants and all kinds of drugs, quickly learn the tobac- 
 co-habit, and are fond of strong condiments, and they are greatly dis- 
 
196 TEXT-BOOK ON MENTAL DISEASES. 
 
 turbed when deprived of the gratification of their artificial appe- 
 tites. 
 
 All these morbid appetites become the basis of abnormal desires, 
 and of perverted volitional attempts to gratify them, and insane con- 
 duet is thus largely the outcome of diseased cravings and impulses. 
 The changes in the sexual instinct are in this regard of great im- 
 portance. In maniacal states the sexual appetite is often increased, 
 while it is diminished in states of depression. In toxic Insanity it 
 is ordinarily increased in the early stage, and diminished or lost in 
 the later stages. Sexual anaesthesia is frequent in hysterical Insan- 
 ity, and is almost universal in terminal dementia after severe attacks 
 of mental disorder, and it is also found in idiots and cretins occasion- 
 ally, as well as in all states of great exhaustion in Insanity. 
 
 Sexual hypergesthesia is an occasional symptom in most forms of 
 mental disease, not excepting senile dementia, in which there is not 
 infrequently a final flame of passion before the last extinction of the 
 appetite. 
 
 When the sexual desire attains the height of open indecency and 
 entire loss of control, it is termed nymphomania in women, and 
 satyriasis in men, and this symptom is not very uncommon in 
 acutely maniacal states. 
 
 Sexual parsesthesia is also a symptom witnessed occasionally in 
 mental disease, and it assumes a variety of forms. 
 
 In one kind of perverted sexual appetite the gratification is 
 sought in many partial or unnatural ways, and it may be attended 
 with brutality and violence toward the object of lust. 
 
 In another form there is sexual passion for the same sex, taking 
 the shape of Lesbian love in women, or the specially beastly direction 
 of pederasty in men. 
 
 All these perversions of the sexual instinct are necessarily at- 
 tended by very decided volitional anomalies, and by conduct 
 markedly insane in proportion as self-control is lost. The same sex- 
 ual abnormalities may exist in persons not insane, and may be inhib- 
 ited, so as not to become irresistible impulses, and if the intellectual 
 sphere is not otherwise involved, they do not in themselves consti- 
 tute mental alienation. 
 
 Also the gratification of other artificial appetites, to the extent 
 of debasement of the physical or moral being, can only be regarded 
 as proof of Insanity when volitional control of ideas and actions re- 
 sults, so that the patient is manifestly irrational in speech or con- 
 
PSYCHICAL SYMPTOMATOLOGY. 197 
 
 dnct, for the majority of persons, in some degree, impair health by 
 indulgence of natural or artificial appetites. 
 
 It is of clinical importance, as regards diagnosis and prognosis, 
 to have a knowledge of the volitional sequelae of mental disorders. 
 
 It is a discouraging fact that, in cures deemed perfect, a close 
 study in most instances w^ill reveal a permanent sequel as regards 
 volition, which remains impaired in the highest forms of inhibition 
 of emotions and of ideas. If the patient be highly intelligent he will 
 probably recognize that he no longer can direct by force of will at- 
 tentive studies of difficult questions, that he does not control as 
 formerly the general current of thought by volitional selection of 
 objects of attention, that emotions invade more decidedly his mental 
 life, that voluntary choice is less prompt, and that there is a larger 
 element of irresolution in conduct. These volitional sequelae in 
 many patients lead to a permanent loss of self-confidence and to a 
 certain air of indecision in emergencies calling for self-assertive ac- 
 tion, and to a ready persuasion against one's will, and to a yielding 
 to emotional desires and instinctive propensities which were for- 
 merly easily inhibited. 
 
 It is but natural that volition, as the supreme force of mind and 
 the culmination of psychic evolution, should present these residual 
 changes, which, in the degree above mentioned, are not to be re- 
 garded otherwise than customary sequels of mental disease. 
 
 Finally, to conclude this chapter on psychic symptomatology,. 
 there remains to be noticed certain abnormal and peculiar traits of 
 mind found in persons of a neurotic and degenerative type, and asso- 
 ciated ordinarily with anomalies of bodily structures termed stig- 
 mata, which reveal a congenital tendency to mental instability and 
 aberration. The bodily stigmata will be described in the next chap- 
 ter, and only the psychic stigmata will be here enumerated. They 
 do not in themselves constitute mental disorder, but they show the 
 innate tendency, and in doubtful cases they furnish cumulative evi- 
 dence which aids in diagnosis. 
 
 The psychic stigmata degenerationis are : 1. Precocity, or re- 
 tarded evolution of intellect and of the instinctive propensities. 
 2. Emotional changeability and irritability. 3. Exaggerated con- 
 scientiousness or absence of moral sense, with fanatic religious zeal, 
 or great depravity. 4. Intense egoism, selfish disregard of others, 
 and cruelty to animals. 5. Morbidly heightened imagination and 
 tendency to confuse the real and unreal. 6. Eccentricity of ideas 
 
198 TEXT-BOOK ON MENTAL DISEASES. 
 
 and, of feelings, odd conceits and novel emotions. 7. Extravagant, 
 capricious, and cranky motives and desires. 8. Disproportionate 
 development of mental faculties, one-sided talents, display of fantas- 
 tic. genius, and defect of higher rational processes. 9. Loss of the 
 higher forms of inhibition of ideas, emotions, and actions. 10. Gen- 
 eral lack of harmonious co-ordination of the intellectual, emotional, 
 and volitional elements of mind. 
 
 Some other degenerative traits and tendencies, such as vivid 
 dreaming, night-terrors in children, and somniloquism in adults, 
 and the numerous psychic anomalies of the imbecile and feeble- 
 minded classes might be mentioned, but the foregoing are the chief 
 psychic '^ stigmata degenerationis." 
 
CHAPTER VII. 
 
 SOMATIC SYMPTOMATOLOGY. 
 Section I. — The Osseous System. 
 
 Among the anomalies of the osseous system, associated with de- 
 fects or disorders of the mind, the most important are changes in the 
 dimensions and conformation of the cranium. In idiocy the cra- 
 nium on the average is smaller than normal, but there are great ex- 
 tremes in size above and below the norm, and also extraordinary 
 shapes of the head. 
 
 Microcephaly exists when the head measures less than sixteen 
 inches in circumference, and it is uniformly attended by diminished 
 intelligence. The convolutions of the brain in microcephaly have 
 the main sulci and gyri, though showing gross morphological defects 
 and asymmetries, and even brains with the most rudimentary arrests 
 of development are still distinctly human and not simian in type. 
 The chief loss of size is in the hemispheres, though all parts of the 
 brain, and often the spinal cord as well, are diminished as the result 
 of inflammatory, trophic, and vascular disorders, increased pressure 
 from eerebro-spinal fluid, and premature closure of cranial sutures. 
 
 The microcephalic cranium is greatly contracted in the frontal 
 regions, with narrow and retreating forehead, and is cone-shaped or 
 oxycephalic. 
 
 The cranium in idiots may be enlarged frontally and occipitally 
 and have an increased antero-posterior diameter, and scaphocephaly 
 then exists, and brachycephalic and dolichocephalic conformations 
 with partial asymmetries are also common. 
 
 Macrocephaly arises in idiocy from chronic hydrocephalus with 
 enlarged temporal regions and a globular shaped cranium, and from 
 hypertrophy of the brain with a square shaped skull, said to be en- 
 larged chiefly above the superciliary ridges. Rickety shapes of the 
 skull, calvaria smaller on the side of hemispherical atrophy, trau- 
 
 199 
 
200 TEXT-BOOK ON MENTAL DISEASES, 
 
 matic asjTnmetries from mechanical violence in delivery, cretinoid 
 malformation from premature synostosis basilaris, spinal caries, and 
 curvatures, anterior and lateral, are to be named among the osseous 
 anomalies. 
 
 Dr. Clapham, in Tuke's "Dictionary of Psychological Medicine," 
 reports some unexpected conclusions from the measurements of sev- 
 eral thousands of insane heads, which he found larger than among 
 sane individuals of the same class doing a certain amount of brain- 
 work. Including all classes of the insane, together with idiots, the 
 average size of head was smaller than among the sane, and as regards 
 the relation of diameters the type was in general that of Broca's sub- 
 brachycephali. Chronic mania had the highest and idiocy the lowest 
 average skull value, and epilepsy ranked next to chronic mania in 
 this regard of size. As to the shape of the head, the special insane 
 type was considered that having the largest diameter in the anterior 
 third of the circumferential outline, though the majority have the 
 largest diameter in the middle third, just posterior to the median 
 transverse line, and females had more symmetrical heads than males, 
 and imbeciles had the most symmetrical heads of all the classes of the 
 insane. The majority had the left side of the head larger than the 
 right side, and the right half of the skull was generally pushed for- 
 ward in advance of the left half. 
 
 Sepilli also reports a volumetric increase of the insane over the 
 sane cranium both in males and females. 
 
 There are also facial osseous malformations and disproportions 
 het"\veen the size of the head and face, and asymmetry between the 
 two sides, and deflections of nose and chin, prognathism, abnormal- 
 ities of dentition; large, small, double, deformed teeth; cleft, dome- 
 shaped, flat, median-ridged and uneven palate, and other peculiar 
 shapes of palatine vault; wide separation of the orbital cavities, 
 great prominence of malar bones, variations in frontal sinuses, ex- 
 cessively large or small inferior maxillary bone. The skeleton as a 
 whole may be small and variously deformed, as in cretins, or there 
 may be scrofulous or rickety malformations, or there may be giant- 
 ism as well as dwarfism. 
 
 " Fragilitas ossium " is a common symptom in Insanity, and it 
 accounts for the facility of fractures of the ribs in general paretics 
 and other patients. It is due to trophic disorder and to absorption 
 and porosity of bony structures, and it is not confined to the ribs but 
 may exist in the vertebrae, giving rise to curvature of the spine. 
 
SOMATIC SYMPTOMATOLOGY. 201 
 
 '•' Mollities ossium " also exists, not as an osteoporosis, but rather 
 as a decalciiication of bone, which approaches a genuine osteoma- 
 lacia, and also results frequently in injuries from the weakness of the 
 various parts of the bony framework. 
 
 There are both false and true ankyloses in rheumatic, syphilitic, 
 and hysterical Insanity, thickening of the Joints in neurasthenic 
 cases, arthritis deformans in general paresis, and necrosis of bones 
 in the toxic and diathetic Insanities. 
 
 It has already been said that there are in idiots, imbeciles, crim- 
 inals, lunatics, and highly neuropathic individuals generally certain 
 signs of degeneration, consisting in abnormities of mental and 
 physical organization, and the psychical stigmata have already been 
 mentioned, and it is thought best to group here the somatic stigmata 
 rather than to isolate them in the sections of this chapter. 
 
 Occurring singly, these somatic stigniata are of no special sig- 
 nificance, but when a number of them are well marked in the same 
 individual they afford cumulative evidence of a degenerative taint, 
 especially if there are corresponding psychic stigmata. 
 
 Like other scientific novelties, they have excited in some minds 
 too great credulity, and as tests of mental disease they are not de- 
 cisive of any diagnostic point further than the fact of individual 
 origin from a degenerative source, and they do not even warrant this 
 conclusion unless the structural anomaly has attained such a degree 
 as in some measure to impair the functional activity of the organ 
 or part in question. Men of vigorous minds and great talent often 
 have some stigmata with asymmetrical heads and faces, while im- 
 beciles not infrequently present a singular symmetry of cranial and 
 facial conformation, so as to furnish an actual type of physical 
 boauiy. 
 
 There is no intention to underestimate the value of the stigmata 
 degenerationis, which have not yet been studied comparatively on a 
 sufficiently large scale among different races and classes of men 
 in health and disease to warrant any broad conclusions, but it is 
 very essential for the student of mental disorders to know and to 
 weigh well these signs of degenercy. 
 
 The somatic stigm.ata degenerationis are as follows : The whole 
 stature excessive or diminutive, giantism or dwarfism ; spinal curva- 
 tures, lordosis, scoliosis, spina bifida, prolongation of coccyx ; tho- 
 racic malformations ; pigeon-breast ; disproportionate length or 
 breadth of stature. 
 
202 TEXT-BOOK ON MP]NTAL DISEASES. 
 
 Lower extremities excessively long or short, great volume of limbs 
 (megalomelus), splay-foot, or club-foot, absence of part of limb (pho- 
 comelus). 
 
 Upper extremities abnormally long or short, congenital luxations, 
 fingers grown together (syndactylism), or missing (ectrodactylisni), 
 or supernumerary (polydactylisni), or club-hand. 
 
 Cutaneous abnormalities, atrophy and hypertrophy, deep wrin- 
 kles, adipose hypertrophy or absence of subcutaneous fat, pigmenta- 
 tions, hirsuties, absence of hair on genital and other regions, canities. 
 
 Anomalies of general nervous system and of its motor aiid sensory 
 functions, defects of co-ordination, tremors, convulsive ties, general 
 convulsibility, asymmetrical innervation of face, late acquisition of 
 gait and speech, and permanent peculiarities of the same; per- 
 versions of general sensibility, anaisthesias, neuralgias, pavor noc- 
 turnus, migraine and hemispastic, hemiparetic and other vasomotor 
 affections, reversional appetites and instincts. 
 
 Cranial and facial deviations, microcephaly, macrocephaly, hy- 
 drocephaly, brachycephaly, dolicocephaly, scaphocephaly, asym- 
 metry of facial bones, prognathism, recession of lower jaw, very 
 large or small mouth, and negroid lips. 
 
 Ears too large or too small, too long, short, or wide, placed too 
 high or low, too far front or back, too close to the head or lop-ears; 
 large, small, absent, adhered, or deformed lobule, helix, antihelix, 
 tragus or antitragus; reversional ear with Darwin tubercle on helix, 
 and ears with greatly enlarged or contracted concha, and difference 
 between the ears. 
 
 Eyes congenitally defective in function, albinism, congenital cat- 
 aracts, Daltonism, astigmatism, congenital blindness, coloboma iri- 
 dis, nystagmus, strabismus, ptosis, misshapen pupils and unlike color 
 of irides. 
 
 Anomalies of the huccal cavity, macrodontism, mierodontism, ab- 
 sence of second dentition, widely separated and misplaced teeth, 
 canines and incisors misdirected, macroglossus and other lingual 
 peculiarities. 
 
 Palate too short from before backward, too flat, broad, high, oi' 
 narrow, ridged in the middle, dome-shaped. Cleft palkte and hare- 
 lip, and deviations in size, shape, position, and motor innervation 
 of soft palate. 
 
 ' Abnormities of reproductive, organs, retarded puberty, impo- 
 tence, false hermaphroditism, epispadias, hypospadias, microrchidia, 
 
SOMATIC SYMPTOMATOLOGY. 203 
 
 monorchidia, anorcliidia, cryptorcliidia, very small or large penis 
 or scrotum^ phimosis, varicocele, hernia (congenital), azoospermia, 
 absence of sexual appetite, rudimentary or hypertrophied labia, cli- 
 toris, or mammae, polymastia, absence of vagina, double vagina, va- 
 ginal atresia, absence of uterus, infantile uterus, uterus bicomis, 
 amenorrhoGa, sterility, and hypertrichosis partialis in form of beard 
 in women, and masculinism. • 
 
 The foregoing are the principal somatic stigmata degenerationis, 
 though in cretinoid degeneracy, atrophy, or absence of the thyroid 
 gland, is to be included among the stigmata. 
 
 Section II. — The Muscular System. 
 
 The manifestation of mind is made by movements of some part 
 or organ of the body, and the muscular system is the means of the 
 expression of mental states and of the adjustment of the human 
 organism to its environment. When the nervous system which con- 
 trols the muscles becomes diseased in mental disorders there is a cor- 
 responding derangement of the intricately combined movements by 
 which mind is normally manifested. The maniac has a disorderly 
 series of movements, of gestures, bodily contortions, strained atti- 
 tudes, purposeless acts, and a wild play of features never seen in 
 health; and every type of Insanity finds some form of expression 
 through muscular channels. Muscular disorders are therefore an 
 important part of the semeiology of mental disease, and they will 
 be considered at some length, as they are also of practical impor- 
 tance in diagnosis and in prognosis. 
 
 There is in acute mental disorders a change in the nutrition of 
 the total muscular system, which largely accounts for the rapid loss 
 of total weight, and in special muscles this trophic disturbance as- 
 sumes different forms presently to be described. 
 
 It happens, also, that there is an abnormal reaction to external 
 stimuli, so that slight blows upon the body of muscles cause un- 
 wonted contractions, or there may be loss of normal reaction to 
 mechanical .stimuli. 
 
 The mechanical muscular excitability is sometimes increased and 
 at other times diminished in epileptic, hysterical, and paretic cases, 
 and in phthisical Insanity a slight tap on the body of a muscle may 
 cause continuous contraction. 
 
204 TEXT-BOOK ON MENTAL DISEASES. 
 
 There is sometimes a change in the electric reactions of muscles 
 in Insanity. 
 
 The electro-muscular excitability is diminished in melancholia, 
 with stupor occasionally, and also in dementia of toxic origin, and 
 it has sometimes a unilateral variation in epileptic and hysterical 
 Insanity and in organic dementia. It is in some cases of alcoholic 
 dementia with lateral spinal sclerosis at first increased and finally 
 lost, while it is retained in all the pareses of general paresis of cor- 
 tical origin. 
 
 The electro-muscular excitability is at times increased in melan- 
 cholic, neurasthenic, and hysterical cases, while it may be lost in 
 epileptics, and it is frequently absent in idiots and in profound 
 stupor and dementia. 
 
 The reaction of degeneration is sometimes present in toxic In- 
 sanity, and especially in alcoholic cases. The sensibility to pain 
 from electric stimulation may be increased or impaired, and in 
 neurasthenic and hysterical Insanity the electric sensibility for the 
 galvanic current may be retained while it is impaired for the faradic 
 current. 
 
 In all the paralyses of the various forms of Insanity the electro- 
 muscular reactions are, as a rule, normal, except in cases with pe- 
 ripheral neuritis or degenerative muscular atrophy with reaction of 
 degeneration. 
 
 The dynamometric tests are not in certain cases of much reli- 
 ance, but, by repeated and careful trial, the relative degree of failure 
 of muscular power can be determined in most instances. In general 
 paresis there is an early failure of muscular power, and the loss of 
 strength will be found to increase continuously in most eases, and 
 it is often unilateral from the very beginning, and the relative dif- 
 ference continues into the third stage. There is also marked uni- 
 lateral variations in hysterical and epileptic cases, and the average- 
 test for the evening hours shows a higher rate of innervation than 
 that of the morning hours in melancholia, while the reverse is true 
 iu mania. The average dynamometric tests are below the norm in 
 Insanity, but there are temporary maniacal states and conditions 
 of precordial anguish in which the muscular innervation and the 
 actual effort put forth are far above the normal degree of power. 
 
 The dynamographic tests are probably more reliable, upon the 
 whole, in reflecting the variations of muscular innervation in the 
 different forms of Insanity, and in determining the rhythm and 
 force of the efferent impulses. 
 
SOMATIC SYMPTOMATOLOGY. 205 
 
 The Jiyperkineses are among the most eommon disorders of tlie 
 "voluntary muscular system in Insanity. 
 
 In acute mania there is a heightened muscular sense, an irre- 
 sistible tendency to muscular action and a general hyperkinesis 
 which may attain almost the degree of general convulsibility seen 
 in hysterical Insanity. 
 
 Spasms, clonic or tonic, are to be mentioned under this head. 
 
 The grinding of the teeth, so often observed, is a bilateral mas- 
 ticatory spasm of muscles supplied by the motor branch of the tri- 
 geminal nerve, and it is found in general paresis chiefly in the final 
 stage, and also in the choreic insanity of children, in organic de- 
 mentia, in syphilitic and epileptic cases. The result of this spasm 
 is wasting of the teeth by friction, and sometimes wounding of the 
 tongue or membranes of the mouth. 
 
 In alcoholic Insanity there is a hyperkinetic state of the mimic 
 facial muscles, which twitch spasmodically, and wrinkles and con- 
 tortions of the features result. In these cases also there are fascic- 
 ular contractions and spasms of separate bundles of muscular fibres 
 in the flexor groups of the extremities chiefly, and they are gener- 
 ally due to local irritation and to peripheral neuritic processes. 
 
 In neurasthenic and hysterical cases there are also continuous 
 and rhythmic fibrillary spasms in facial or fore-arm muscles for 
 weeks together, and ceasing only during sleep, and these tT\"itchings, 
 like the isolated fibrillar spasms in general paresis, are probably 
 due entirely to irritation of cortical motor cells. 
 
 Automatic spasmodic action of the facial muscles, established 
 as a chronic habit of grimacing, is an unfavorable symptom, as is 
 also nictitation, divergent strabismus, and nystagmus arising late 
 in the course of the mental disease. 
 
 On forced attempts to interrupt insane mutism the only result 
 is often a series of clonic spasms of orbicular and facial muscles, arid 
 any unusual emotion in states of painful inhibition may provoke 
 spasmodic muscular action as the only mode of escape of the ner- 
 vous discharge. 
 
 Subsultus tendinum and painful spasms of the gastrocnemius 
 and stemoclidomastoid muscles, and various convulsive tics are com- 
 mon in Insanity. Clonic spasm of the diaphragm is found in organic 
 dementia, and it sometimes presages death in general paresis. 
 . , Tonic spasms of muscles supplied by the external branch of the 
 spinal accessory nerve are common, and oesophageal and gastric 
 
206 TEXT-BOOK ON MENTAL DISEASES. 
 
 spasms sometimes cause vomiting and interfere with artificial feed- 
 ing. Pliaryngeal spasm and blepharospasm are especially frequent, 
 as well as the tonic contraction of the corrugator supercilii and of 
 the orbicularis oris, and laryngeal spasm premonitory of general 
 paresis has come within my observation, and saltatory cramps in 
 acute delirious mania, and tonic pedal spasms in alcoholic dementia, 
 are also to be witnessed. 
 
 The pareses in mental disease have a varied etiology. They ap- 
 pear in monoplegic form in hypochondriacal cases from fixed delu- 
 sions, or in hemiplegic form in hysterical Insanity, at first from 
 emotional or delusional inhibition, and later as the result of habit, 
 which can onl}'^ be interrupted by some powerful psychic influence. 
 
 Hysterical hemiplegia is rather in the nature of a paresis also, 
 and may disappear suddenly with a change in the mental disease, 
 such as a maniacal exacerbation. The hysterical aphonia and aphasia 
 are less permanent also than in persons not distinctly insane 
 
 In neurasthenic and hypochondriacal Insanity the pareses of the 
 palatal, pharyngeal, and laryngeal muscles are apt to escape obser- 
 vation. Prolapsed and deviated palate, feeble voice, and dysphagia 
 are common from this cause, and in states of secondary exhaustion, 
 as well as in neurasthenic conditions, the functional defects of 
 speech may be mistaken for those springing from organic lesions. 
 Indistinct or faulty articulation is sometimes the result of enfeebled 
 cortical centres to evolve the motor impulses of speech, and this 
 paresis of the muscles of speech is seen in the stadium debilitatis 
 after severe acute stages in mania or melancholia. Pareses from 
 force of imitation are to be seen in epileptic and hysterical cases, and 
 in the liistorical epidemics of Insanity all forms of muscular dis- 
 order were from the contagion of example prominent symptoms. 
 
 Paralyses in mental disorders arise from organic lesions in cor- 
 tical regions, in internal capsule, in pyramidal decussation, in cells 
 of the anterior cornua or spinal nerve-roots, or in the spinal nerves 
 and their distribution to peripheral regions. They are chiefly due 
 to encephalitic processes in idiocy, to gross brain lesions in organic 
 dementia, to peripheral neuritis in the toxic insanities, to cerebro- 
 spinal sclerotic processes in alcoholic dementia, and to basal gUm- 
 mata in syphilitic Insanity in which the cranial nerves are involved. 
 
 Thus there are hemiplegias in epileptic and paretic dementia, 
 monoplegias in organic dementia, paraplegias in hysterical and al- 
 coholic Insanity, and a combination or succession of these paralytic 
 affections occasionally in general paresis. 
 
SOMATIC SYMPTOMATOLOGY. 207 
 
 Contractures occur from the predominant action of the flexors, 
 adductors, and pronators over the extensors in mental disease, and 
 from flexed posture habit and disuse of limbs as the result of which 
 tissue degeneration occurs, and the final outcome is permanently 
 fixed positions of the extremities. 
 
 There is contracture from tetanoid action of the muscles for 
 weeks at a time, until the fixture of the limb becomes permanent, 
 and the final appearance is practically the same as in posture habit 
 contractures. The fingers may be buried in the palms of the hands 
 and the arm bent, or the legs firmly flexed upon the abdomen. 
 
 In hysterical and epileptic cases there are characteristic contract- 
 ures of limbs, and in organic dementia structural contractions result 
 from descending degenerations of the motor tracts, and a like result 
 follows in alcoholic dementia from sclerotic spinal lesions. In 
 paretic and rheumatic Insanity contractures are occasionally sec- 
 ondary to arthritic afi'ections, and in toxic cases they may follow 
 multiple neuritis. 
 
 Atrophy of muscles is an important symptom in Insanity. 
 
 The most widespread atrophy of the voluntary muscular system 
 in the psychoses is due to disease of trophic centres, and in delirium 
 aeutum it happens within the brief space of a few days, and in the 
 acute melancholic and maniacal conditions it is to be observed to 
 some extent. In toxic, and especially alcoholic Insanity, it arises 
 in some eases from sclerotic degeneration of the motor cells of the 
 anterior cornua of the spinal cord, and also from polyneuritis. In 
 rheumatic cases it may be secondary to arthritic disease, and it is 
 not seldom a sequel of myositis, which is a relatively frequent symp- 
 tom among the insane. 
 
 Premature muscular atrophy is found in senile Insanity with or 
 without neuritic degenerations, and it also results from accidental 
 trauma and from forced positions long retained through delusions, 
 and as the direct result of the paralyses already mentioned. 
 
 Muscular inco-ordination is found in general paresis and delir- 
 ium aeutum from organic lesions of cortical regions. 
 
 In alcoholic and tabetic cases the muscular inco-ordination is 
 of spinal origin, and in ascending cases of general paresis it is chiefly 
 the sequel of the degenerative changes in the posterior columns of 
 the spinal cord. 
 
 In toxic and syphilitic cases the inco-ordination may be the 
 combined result of cerebro-spinal and cerebellar sclerotic processes 
 
208 TEXT-BOOK ON MENTAL DISEASES. 
 
 and vascular degenerations. Muscular inco-ordination may also re- 
 sult from a loss of the kinsestlietic sense, and, further, from a loss of 
 the clear conceptions and of the motor images of movements, and 
 also, as in acute delirious mania, from an active incoherence of the 
 motor representations of adapted movements. 
 
 There is in exhausted states and in neurasthenic Insanity mus- 
 cular inco-ordination from failure of the motor centres to generate 
 adequate motor impulses essential to uniform action of groups of 
 muscles, and this type of inco-ordination is seen in the special 
 mechanisms of speech and gait, and it is often mistaken for that 
 which springs from organic lesions of an incurable nature, as it 
 gives rise to static ataxia as well as to locomotor unsteadiness. 
 
 There is a species of inco-ordination of this character from une- 
 qual and deficient innervation of facial muscles Avitnessed during 
 the emotional play of the featiires, and, as a consequence of their 
 unequal action, there are strange expressions of countenance. 
 
 The muscular tone, which is the physiological and permanent 
 tonicity of muscles which are never in a state of absolute repose, is 
 increased in states of exaltation and diminished in states of de- 
 pression, and lost in profound stupor and the final stage of general 
 paresis. 
 
 The tonus muscularis of facial regions in apathetic dementia 
 may be so far lost that the countenance becomes a perfect blank. 
 Further instances of loss of tone of muscles will be described in the 
 section on vascular disorders. 
 
 Tremors are coarse or fine, constant or interrupted, and they 
 usually cease during sleep, and their pathogenesis varies greatly in 
 the different forms of Insanity. 
 
 In general paresis there is a fine and rapid tremor, a coarser and 
 typical intention-tremor, and a gross tremor especially manifest 
 under emotional excitement, and a variety of fibrillar tremors in 
 lingual, facial, and manual muscles, and in some cases like tremula- 
 tions are to be detected in the larger voluntary muscles, and they 
 all spring from the active progressive lesions of cortical motor 
 centres. 
 
 In alcoholic Insanity there are fine and rapid oscillations of 
 facial and brachial muscles from defective generation of nerve- 
 force or from increased resistance of nerve-conduction; also tremors 
 from sclerotic lesions of nerve-centres of a coarser kind, and general 
 muscular tremors of the extremities or of the whole body, siraulat- 
 ing, in some instances, convulsive seizures. 
 
SOMATIC SYMPTOMATOLOGY. 209 
 
 In all the toxic and in many of the diathetic insanities there 
 may be tremors, varying somewhat with the special poison causa- 
 tive in the case, that of mercury extending from facial to manual 
 regions, that of lead affecting the unparalyzed muscles of the arm, 
 that of arsenic implicating the flexors in extensor paralysis, and oth- 
 erwise assuming a general character of fine and quick oscillation of 
 muscles, while that of nicotinism is more evident in the hands, and 
 that of narcotics in general is like the tremor of general debility, 
 and is increased on intentional efforts. 
 
 The asthenic tremors form a complete group, and are present 
 in the stadium debilitatis, and in all states of great exhaustion of 
 vital powers in post-febrile and diathetic Insanity, and a similar 
 tremor may exist in the Insanity of childhood and in states of mental 
 arrest of development. 
 
 There are also the tremors from complications with tabes, paral- 
 ysis agitans, chorea, insular sclerosis, exophthalmic goitre, and cere- 
 bellar tumors. 
 
 Hysterical Insanity has a variety of tremors, both coarse and 
 fine, and some are emotional and others are distinctly of the inten- 
 tional type, and greatly exaggerated on voluntary effort. 
 
 Tremor is found in organic dementia, and may be post-hemi- 
 plegic in nature or due to descending degeneration of pyramidal 
 tracts, and there are tremors in epileptic Insanity, with hemiplegic 
 symptoms; also in the epileptic maniacal states and following the 
 status epilepticus. There is also a tremor of auto-intoxication, of 
 the puerperal state, of acute delirious mania, of precordial anguish, 
 and a coarse tremor of delusional origin. 
 
 The tremor of senile dementia visible in the hands on attempts 
 at specialized acts, such as writing, may extend to the head and 
 become constant on all intentional efforts, and it is then of very 
 bad prognosis, pointing to an extension of organic atrophy in cor- 
 tical centres or to degenerative changes in spinal regions. 
 
 Ataxic states are more general conditions of muscular inco-ordi- 
 nation than the affections already described under the latter head. 
 Thus, in alcoholic Insanity, the gait which is generally paretic may 
 bo distinctly ataxic, and there may be a decided static ataxia in 
 these cases, and from inco-ordinate action of facial muscles there 
 may be remarkable facial distortions. 
 
 In general paresis the ataxic state attains its height, and the f ail-- 
 ure in all the highly purposive movements is ataxic. As the rapid 
 14 
 
210 TEXT-BOOK ON MENTAL DISEASES. 
 
 degeneration of the motor cortex advances the defects of speech, 
 due to decline of cortical impulses, become very decidedly ataxic 
 in nature, and so remain until descending lesions involve bulbar 
 regions and fiacial and hypoglossal nuclei. The true paretic gait is 
 essentially ataxic from disease of cortical motor cells, and it is only 
 when the posterior or lateral spinal columns are later involved that 
 the tabetic or spastic gait appears. 
 
 There is a sudden and fully developed ataxic state in delirium 
 acutum, and in Insanity from acute infectious disorders, and in 
 occasional cases of acute mania of toxic origin. 
 
 The pseudo-paralytic states are characterized by the appearance 
 and disappearance of various forms of paralysis of voluntary muscles, 
 not to be confused with those already described, and for which 
 organic lesions exist in many cases, for the pseudo-paralyses here 
 in question are doubtless chiefl}'^ functional, as they are often of 
 very brief duration. 
 
 In hysteric and neurasthenic Insanity these pseudo-paralyses 
 abound as crural or brachial monoplegias, or even as paraplegias, 
 and occasionally facial or ocular muscles will be affected for the 
 brief period of a few hours or days. These pseudo-paralyses also 
 appear in epileptic cases, and it is probable that they are then not 
 purely functional, as they follow severe congestions of the brain, 
 being post-convulsive ordinarily. They are found likewise in al- 
 coholic and paretic Insanity, either sequent to or independent of, 
 convulsive seizures, and they may disappear completely within a 
 few hours, and are probably due to intense and brief irritative or 
 congestive states of spinal centres, or to purely functional defects 
 of innervation. They seem sometimes to be due to the frightful 
 delusions and hallucinations, which may relate immediately to the 
 part affected, and in hypochondriacal cases these pseudo-paralyses 
 are apt to be of a more continuous kind, on account of the perma- 
 nency of the delusions. In female pubescent Insanity there is often 
 a fully developed pseudo-paralytic state, with rapid variations in 
 the loss of muscular power in the various extremities and parts of 
 the body, even the spinal muscles being involved, so that the erect 
 posture may be an impossibility for the time being, and in these 
 cases the pseudo-paralytic state may give place suddenly to a mani- 
 acal exacerbation with increased motility of the affected parts, which, 
 in this instance, it is reasonable to presume, may have been under 
 intense inhibition from painful delusion. A plausible supposition. 
 
SOMATIC SYMPTOMATOLOGY. 211 
 
 also, to explain these brief pseudo-paralyses is vasomotor spasm of 
 cortical motor regions. 
 
 Cafaleptoid states are characterized by cutaneous and muscular 
 aufesthesia, by impaired consciousness, and by a general state of the 
 voluntary muscles known as " flexibilitas cerea," by which they re- 
 tain, for a considerable time, the positions in which they may be 
 placed. There is a loss of the natural sense of fatigue, and, contrary 
 to the law of gravity, the arms extended or placed in constrained 
 attitudes may remain in the unnatural positions longer than it is 
 well to continue the experiment. 
 
 There would appear to be a loss of the kinsesthetic sense, or of 
 the normal innervation of antagonistic muscles, and the frontal cor- 
 tical regions are evidently involved, as shown by the impaired con- 
 sciousness. The pathogenesis is probably hot always the same; and, 
 in states of stupor with capillary stasis, cold and livid extremities 
 and greatly impaired consciousness, the cataleptoid state is probably 
 due to brain-oedema, increase of fluid in ventricles, and intracerebral 
 pressure. The cataleptoid state may be slightly or fully developed 
 and have a duration of hours or months together, and there is every 
 degree of impairment of consciousness and of rigidity of muscles. 
 There is sometimes a transition from the cataleptoid to the tetanoid 
 states, and when the rigid fingers or limbs on displacement spring 
 back to their original position, instead of retaining the new position 
 given them, Krafft-Ebing terms the condition " catalepsia spuria,*' 
 fis distinguished from '^ catalepsia vera." The cataleptoid state is 
 an epiphenomenon in hysterical paretic, epileptic, stuporous, melan- 
 cholic, and maniacal Insanit}'', or it may constitute one of the phases 
 of circular Insanity. Although it is an intercurrent symptom in 
 states of sequential stupor, it differs from it and also from primary 
 stupor, in which consciousness is concentrated on painful delusions 
 or liallucinations instead of being largely suspended. 
 
 The ecstatic state also is a concentration of mind upon highly 
 elating delusions rather than a suspension of active attention and 
 consciousness, and thus differs also from the cataleptoid state. The 
 cataleptoid states are also to be differentiated from the lethargic 
 states and from states of prolonged somnolence. 
 
 The tetanoid states are marked by some limitation of conscious- 
 ness and by the permanent rigidity of the flexor, adductor, and 
 j)roriator muscles, which obstinately retain the positions in which 
 they are found. In the complete tetanoid state the extremities and 
 
212 TEXT-BOOK OX mp:ntal diseases. 
 
 head are bent upon the body, which is in turn bent upon itself, and 
 the utmost force is required to extend the Hmbs, which return to 
 their original position when released. In genuine tetanus conscious- 
 ness is not impaired as in true catalepsy, but in the tetanoid states it 
 is disordered variably, according to the form of Insanity, but it is 
 not ordinarily so much obscured as in the cataleptoid states. There 
 is every degree of incompleteness of the tetanoid state, and often 
 the head alone may be firmly bent, or the fingers of one hand pressed 
 into the palm of the hand, but even in these partial states there is 
 a certain stiffness and passive resistance of the muscles to imposed 
 movements of all kinds. The eyes are often firmly closed and the 
 eyeballs rotated upwards and convulsively moved on forced efforts 
 to separate the eyelids. 
 
 The tetanoid states are common in mental depression, and in 
 stuporous conditions of all kinds, and in alcoholic, epileptic, and 
 paretic cases, and their duration is from a few hours to many months. 
 
 A mild tetanoid state often precedes the cataleptoid state, which 
 it also follows in the same cases. When the tetanoid state is at- 
 tended with dementia it usually points to deep-seated central or- 
 ganic lesions and is of bad prognosis as regards mental recovery. 
 
 Jacksonian Epilepsies. — In paretic and alcoholic Insanity, and 
 occasionally in organic and syphilitic dementia, there are convulsive 
 seizures, which are not to be ranked as epileptic, inasmuch as they 
 occur without loss of consciousness in most instances. 
 
 These Jacksonian epilepsies begin as spasms ordinarily in the 
 fingers and hand and extend to the arm and then to the face and 
 to the leg on the same side without loss of consciousness, and they 
 may recur very frequently in the same case during the day. They 
 may cross to the opposite side of the body, and consciousness may 
 at last be lost, but they difi'er in toto from genuine epilepsy, in which 
 consciousness is abolished at the onset of the seizure. 
 
 These localized convulsions are wont to observe a certain. orf"!or 
 in their recurrence in syphilitic and paretic dementia, but in the 
 latter afEection the customary order of protospasms is apt to be in- 
 terrupted. 
 
 Hughlings Jackson attributes these seizures to discharging le- 
 sions in the lower or in the middle level of the nervous S3^stem, and 
 it is only when the higher level becomes involved that there is finally 
 loss of consciousness. 
 
 These Jacksonian epilepsies are to be differentiated from the 
 
SOMATIC SYMPTOMATOLOGY. 213 
 
 true epileptiform and apoplectiform seizures in alcoholic, syphilitic, 
 and paretic dementia. 
 
 The Muscular Reflexes. — The changes in the muscular reflexes 
 are of great diagnostic importance in Insanity, and they are present 
 in most of the psychoses. 
 
 The changes in the iridial and ciliary muscles are first to be 
 considered. 
 
 Inequality of the pupils may be due to unilateral contraction or 
 dilatation, or to abnormal smallness of one and largeness of the 
 opposite pupil. 
 
 Paralytic mydriasis (dilatation of pupils) is found in general 
 paresis, in phthisical Insanity with basilar meningitis, and in syph- 
 ilitic Insanity with basal gummata, and in organic dementia with 
 cerchral hemorrhage. Mydriasis is also an occasional symptom in 
 acutely maniacal and melancholic states, and it is then probably 
 of the irritative and spasmodic variety. 
 
 The cycloplegia of general paresis is unilateral and appears in 
 the third stage, and it is also present in the final stage of some cases 
 of organic dementia. 
 
 Myosis (contraction of the pupils) of the paralytic form is found 
 in goitrous and paretic Insanity, especially when complicated with 
 locomotor ataxia, and in the latter case the Argyll-Robertson symp- 
 tom of loss of light-reflex and reaction to accommodation may be 
 found. 
 
 Spasmodic myosis is to be seen in acute maniacal conditions, and 
 in the early stage of alcoholic, paretic, and syphilitic Insanity, and 
 is generally unilateral. The permanent inequality of pupils in men- 
 tal disorders is a most unfavorable symptom, and prolonged and 
 extreme myosis (pin-head pupils) is also a very bad sign. 
 
 Very slow reaction to light is also of evil augury when perma- 
 nent, as in paretic and syphilitic dementia, in which there is occa- 
 sionally complete loss of the light-reflex. 
 
 The reflex closure of the eyelids on the sudden approach of an 
 object is lost in stuporous conditions, and the test for this reflex 
 should be made, as it may lead to the discovery of hemianopsia. 
 The conjunctival and corneal reflex may be lost in post-epileptic 
 stupor and in hysterical somnolence, and in various semi-comatose 
 states following paretic and toxic convulsions. 
 
 The 'palatal reflex is lost sometimes or greatly diminished in hys- 
 terical and paretic Insanity. The epigastric, testicular, and cremaster 
 
214 TEXT-BOOK OIS^ MENTAL DISEASES. 
 
 reflexes may be absent in paretics, and the entaneoiis reflexes gen- 
 erally are greatly diminished in all states of stupor, and often in the 
 early stage of general paresis. The cutaneous reflexes in neuras- ■ 
 thenic and hysterical cases may be greatly exaggerated. 
 
 Tlie plantar reflex is frequently diminished in the functional 
 psychoses, and it may be lost on one side in hysterical and paralytic 
 cases. It is generally absent in stuporous states. 
 
 The Jcnee-jerlc is diminished often in states of depression, and not 
 infrequently exaggerated in states of exaltation. 
 
 In general paresis the knee-jerk is usually increased in the early 
 stage, then diminished, and finally lost. At the time of the increase 
 of the knee-jerk in general paresis there is often abolition of cutane- 
 ous reflexes, and generally there is an inverse relation between the 
 superficial and deep reflexes in general paresis. 
 
 The knee-jerk is often lost in tabetic and syphilitic dementia, 
 and in toxic Insanity with multiple neuritis. One-sided difference 
 of the knee-jerk is found in organic dementia with descending de- 
 generations of tlie pyramidal tract, and in alcoholic and epileptic 
 cases with some loss of power on one side. 
 
 The knee-jerk is absent in some cases of stupor and in epileptic 
 somnolence, and in the comatose states following seizures, and in 
 severe states of collapse. It is exaggerated sometimes in cases of 
 organic dementia with internal capsular lesions, and in paretic cases 
 with irido-plegia and descending spinal lesions. 
 
 Automatic Acts and Characteristic Attitudes. — The muscular ac- 
 tivity of Insanity is largely automatic. In cretins, idiots, and im- 
 beciles there are many oft-repeated movements of a purposeless 
 character, and bearing the outward appearance of awkwardness cor- 
 responding to the inward deficiency. There is the inco-ordinate 
 motion of the arms and hands wandering aimlessly over the body 
 and face, the clumsy lateral movements of the body, the festinating 
 gait on the balls of the feet, the rolling of the eyes and head, and 
 many other insignificant and automatic acts. The Insanity of child- 
 hood, independent of choreic complications, is marked by muscular 
 automatism and active disorder of muscular movements in seventy- 
 five per cent, of all cases. These persistent movements are largely 
 a reversion to the microkinesis of infancy, and a maniacal child 
 displays only more exaggerated microkinetic motions with such 
 automatic acts as have been fully acquired. In chronic mania and 
 terminal dementia, not of the passive type, there are simple, com- 
 
SOMATIC SYMPTOMATOLOGY. 215 
 
 plicated, or rhythmical automatic acts (the remnants of those ac- 
 quired by habitual delusion or hallucinations), which persist during 
 the entire waking hours for months or years together. Purely au- 
 tomatic acts in these cases are the rotary movements of the head 
 and body, and the to-and-fro motion of the same, the friction of 
 some part of the body or clothing, the constant rubbing of the 
 hands or scalp, the change of weight from one foot to the other 
 while stationary, the rocking step forward and back or from side 
 to side, the advance and retreat with numbered stride of two or 
 three paces without turning, the progression which turns at right 
 angles or walking in a circle, and rhythmical gestures and time- 
 beating, and other motor manifestations devoid of definite purpose. 
 These instances of active automatism are simple as compared to 
 the highly co-ordinated and special acts performed in epileptic 
 cases. In post-epileptic automatism the whole conduct of the pa- 
 tient may be perfectly adapted to circumstances, and yet uncon- 
 scious and unattended by subsequent memory. 
 
 In acutely maniacal conditions there are automatic ideation, and 
 incessant movements of the sensori-motor type. Inhibition of 
 thoughts and motions is absent, and there is a prompt succession of 
 motor responses to all sensorial stimuli, and the central motor mech- 
 anism reacts automatically to every passing impression. The move- 
 ments at the height of the excitement not only are incoherent and 
 conflicting, but there may be also automatic laughing and crying 
 and other automatic emotional antitheses. 
 
 The characteristic attitudes are, many of them, instances of pas- 
 sive automatism. Thus, in dementia the predominant action of the 
 flexors and pronators determines the bent position of the head and 
 body, which may be retained for years,. 
 
 Some unusual postures are with the forehead held in one hand 
 and with the elbow supported by the opposite hand, or with the 
 fingers interlocked over the knee, or with one foot flexed and sat 
 upon, or with the face buried in the crossed arms, or with one foot 
 crossed under the opposite knee and held by the opposite hand, 
 or with one hand thrust between the crossed legs and held with the 
 clasped fingers of the opposite side. 
 
 These are attitudes often persistent for months, for a whole 
 attack of Insanity, or for the life-time of the patient. 
 
 Disorders of Speech. — The movements which give expression to 
 ideas and feelings through oral channels are variously modified in 
 
216 TEXT-BOOK ON MENTAL DISEASES. 
 
 Insanity. The defects of oral expression are not muscular alone, 
 and the intellectual source of speech-disorders will necessarily be 
 embraced in this description of the anomalies in question. 
 
 ■ The speech-rate is greatly increased in maniacal states from a 
 rapid flight of ideas. The heightened muscular sense favors rapid 
 articulation, and a rate of nearly three hundred words per minute 
 may be attained, but, as the surging tide of ideas rises faster than 
 possible utterance, there results elliptical speech, which may convey 
 to the listener the impression of incoherence of ideas, which does 
 not exist. Finally, there may be fatigue of the vocal organs and 
 imperfect articulation of words, consisting in the omission of final 
 syllables or the partial pronunciation of a word before the rapid 
 passage to another. In delirium acutum there is first logorrhoea, and 
 finally a complete jumble of words and of syllables; and in all acute 
 inflammatory conditions of brain-membranes and cortical regions 
 an incoherence of the motor-images of speech movements and a 
 correspondingly confused articulation arises. 
 
 Speech-rate is greatly retarded in stuporous, demented, and mel- 
 ancholic states. The greatly retarded speech of the melancholic 
 patient is due to painful inhibition, while the drawling utterance 
 of the demented proceeds from feeble ideation as well as from slowed 
 motor impulses, and the delayed response of stupor comes from pre- 
 occupation by active delusion or frightful hallucination, or from 
 the impaired state of the automatic speech reflexes. 
 
 In epileptic dementia and in the dementia of imbeciles there is 
 remarkable retardation of speech-rate, so that in some cases not 
 more than twenty words in a minute may be pronounced in a co- 
 herent phrase. 
 
 In post-febrile cases and in secondary states of great nervous 
 exhaustion the delay of response to questions is due to absence of 
 cortical energy essential for the formation of phrases, and after 
 visits from friends there are temporary states of this kind induced by 
 the loss of nerve-force, which leaves the patient in a pseudo-aphasic 
 condition. 
 
 Insane mutism is of importance from a diagnostic point of view, 
 as it is one means of the feigning of Insanity. The possibility of 
 deaf -mutism, and of idiotic or imbecile mutism, is to be remembered 
 in Judging a case without a history. 
 
 Insane mutism is often due to extreme inhibition of ideas in 
 acute melancholia, or to the loss of the motor conceptions of speech 
 
SOMATIC SYMPTOMATOLOGY. 217 
 
 moYements in dementia, or to amnesic aphasia in organic dementia, 
 or in tke final stage of general paresis to motor aphasia. 
 
 Mutism also exists in cataleptoid, tetanoid, ecstatic, and hysteric 
 states, and in the latter instance there may be paralytic aphonia. 
 
 Hypochondriacal patients are mute from delusions, and emo- 
 tions, if yery powerful and prolonged, as in Insanity, may he the 
 cause of mutism, which is also present in all those states of impaired 
 consciousness which do not admit of consecutive thought. 
 
 There is in many cases a prolonged state of whispered voice, 
 which is scarcely audible, and the words uttered are so few that the 
 symptom is practically a form of mutism. 
 
 The timbre of the voice reflects the melancholic or maniacal tone, 
 and also the A'arious intercurrent emotions, and, in a measure, the 
 predominant delusion. It is subdued and indistinct in melancholia; 
 loud and harsh in mania; husky in boisterous cases; nasal or muf- 
 fled in advanced paresis; a grave monotone generally in chronic 
 Insanity; imitative of animals in lycanthropy, or of some personage 
 in exalted change of personality; pitched in foreign accents or highly 
 artificial tone in invented language; almost universally lowered in 
 relative pitch and in musical quality and inflection. This absolute 
 loss of musical tone through the disappearance of the harmonic over- 
 tones of the sustained vowel sounds is highly diagnostic, but the 
 rh}i;hm of speech is retained both in speech and song, and the accent 
 of syllables and of sentences is correctly placed long after the most 
 severe disturbances of articulation have occurred. Occasionally 
 there is a certain dramatic intonation sustained for weeks together, 
 and exceptionally a brief display of histrionic efi^ort which is truly 
 pathetic and even remarkable. There is the rhyming tendency and 
 the chanting and intoning which is continued for hours together; 
 the mysterious tone adopted toward hallucinatory persons in para- 
 noiac dialogue; the prayerful and sermonizing tone, and the ex- 
 tremely trivial and childish intonation, as well as the pompous voice 
 of the weak-minded megalomaniac. 
 
 The use of old words in new senses, or the creation outright 
 of new words, is common among the insane. Such new words are 
 used continuously for the same thing, or they are displaced by still 
 more recently coined words and then forgotten. Other patients 
 merely pronounce a long series of strange syllables having a general 
 similarity of sound, terminating usvially with a vowel, and pretend 
 that they are speaking a foreign tongue, but they attach no clear idea 
 
218 TEXT-BOOK ON MENTAL DISEASES. 
 
 to the jargon which is differently improvised on each occasion. The 
 new words are sometimes agreeable to the ear and have a certain 
 orotund quality, and are retained for years and often repeated by 
 the patient, who is pleased with the sounds to which he assigns no 
 meaning. 
 
 The insane not infrequently invent names for their persecutors, 
 or for the strange feelings which they have, or for the imaginary 
 and mysterious influences exerted over them. Among imbeciles 
 there are childish words (such as are peculiar to children of one 
 family), or, like some chronic insane patients, they speak of them- 
 selves in the third person (akataphasia). 
 
 There is also the repetition of words spoken in the presence of 
 the patient termed echolalia, which is purely automatic, or the mo- 
 notonous repetition for hours of the same phrase ordinarily ac- 
 cented in some peculiar manner, and this is verbigeration. 
 
 Patients sometimes make the same answer to every question, 
 or respond affirmatively or negatively to every interrogation, or 
 they repeat the question asked before giving the appropriate reply, 
 or they never answer except by asking another question. 
 
 Involuntary exclamations of an obscene or profane character 
 (coprolalia), under the influence of impellent ideas, are to be wit- 
 nessed, and there are hallucinations of the motor images of speech 
 which result in automatic vocal utterances. There is also, in senile 
 dementia, a correct series of well-worded answers often when con- 
 secutive thought is impossible, and this is a purely reflex and auto- 
 matic phenomenon: and a mistaken estimate of the degree of in- 
 telligence remaining is often made, owing to this automatism of 
 speech in various forms of Insanity. 
 
 The incoherence of the insane relates to the ideas, which are 
 without natural sequence and contradictory of the laws of the asso- 
 ciation of ideas, or to the separate words of the sentence. Verbal 
 incoherence denotes a deeper degeneration than the loss of logical 
 sequence in thought. Ignorant and uneducated persons are even 
 in sanity often disconnected in speech, and the grade of education 
 is to be considered in judging of the degree of incoherence in any 
 case of Insanity. 
 
 There is a whole chapter of anomalies of speech connected with 
 psycho-motor hallucinations, which impel the patient to repeat 
 aloud certain utterances or to attach a peculiar meaning to words. 
 In other instances the revival in consciousness of the nascent motor 
 
SOMATIC SYMPTOMATOLOGY. 219 
 
 impulses of the images of words leads to their pronunciation aloud 
 without volitional effort, and the patient then declares that words 
 are put in his mouth by his persecutors. If the nascent motor im- 
 pulses issue in the automatic and unconscious pronunciation of the 
 words, the patient often comes to believe that an internal voice 
 speaks the words. In other cases of deluded self-absorption the pa- 
 tient utters an idea aloud, and the sound dies from his ear, but the 
 auditory memory of the words is, a few moments later, so forcibly 
 revived that he hears the words distinctly repeated, and he then de- 
 clares that he hears his thoughts read aloud. 
 
 Other disorders of speech in mental disease are due to lesions 
 of the nervous system. 
 
 The degeneration of cortical cells and nerve-fibres causes the 
 ataxic disorder of speech in the first stage of general paresis, and 
 later the bulbar lesions give rise to loss of motility in speech- 
 muscles and -to the more decided defects of articulation. The nasal 
 tone comes from paresis of the soft palate, the husky and lowered 
 tone from imperfect innervation of the vocal cords, and the vibra- 
 tory voice from intention tremor of the same, and later from motor 
 failure in the expiratory muscles. There is great retardation, also, 
 and, finally, amnesic and aphasic defects of speech from cortical 
 disease, and forms of balbuties and paraphasia. 
 
 In a word, therefore, disorders of speech in Insanity are due to 
 defects of memory and of the association of ideas, to loss of the 
 motor images of words, to the immediate effects of hallucinations 
 and delusions, to impaired consciousness, to cortical and bulbar dis- 
 ease, and to derangement of the motor mechanism of speech. 
 
 Changes in gait and other highly specialized acts are among the 
 motor anomalies of Insanity. These muscular disorders arise from 
 psychical and physical causes. 
 
 The gait varies with the exaggerated or depressed delusions and 
 hallucinations, and it reflects the ruling emotions. In hypochon- 
 driacal cases hemiparetic gait exists sometimes purely as the result 
 of delusion, and intention-pareses are to be seen from the same 
 cause in such cases, and also crural monoplegia. 
 
 In hysterical Insanity there is the dragging gait, the exagger- 
 ated tremulous gait, and forms of affected locomotion, all of psy- 
 chical origin. In dementia there is an awkward shuffling gait, and 
 in senile cases short steps greatly retarded in depressed moods or 
 taken in confused haste t© no purpose in melancholia agitata. The 
 
220 TEXT-BOOK ON MENTAL DISEASES. 
 
 free, elastic, and at times bounding or dancing gait of the maniac 
 is in striking contrast to the restricted and labored progression of 
 the melancholiac. There is backward walking, the rhythmic step, 
 the oblique progression, the mincing gait, the walk with inverted 
 or everted toes, the sidelong advance with one leg extended, the 
 f estinating gait on the balls of the feet, the walking zigzag or with 
 complete bodily rotations, and other oddities of gait too numerous 
 to mention in the various types of Insanity, and due to insane 
 caprice. 
 
 Then there are the changes in gait from physical lesions of the 
 motor mechanism. 
 
 There is the tremulous gait of alcoholic cases from sclerotic proc- 
 esses, and of senile dementia from cortical atrophy; the spastic gait 
 in the same cases from lateral sclerosis of the cord, the ataxic gait 
 from affections of the posterior columns in syphilitic dementia and 
 in ascending cases of general paresis, inco-ordinate locomotion in 
 toxic Insanity from cerebro-spinal lesions, various forms of paralytic 
 gait from gross brain disease in organic dementia, and the stiff and 
 resisting walk of patients with bulbar sclerosis. 
 
 The true paretic gait is ataxic from degeneration of the cortical 
 motor regions and of the association of fibres to the pyramidal tracts 
 and from descending spinal lesions. 
 
 In general paresis, also, locomotor ataxia and tabetic gait may be 
 an epiphenomenon, and spastic gait from sclerosis of the lateral col- 
 umns of the spinal cord is another complication. The tetanoid and 
 hemiplegic states attending the seizures modify, to a great extent, 
 the locomotion of the patient in the later periods of the disease. 
 
 The loss of the kinesthetic sense and of the motor conceptions 
 of complex movements, as well as organic lesions, lead to the disap- 
 pearance of the aptitude required in the highly specialized acts of 
 playing upon instruments. The manual dexterity of mechanics is 
 likewise lost, and acrobats, dancers, and singers detect an early fail- 
 ure of their special skill in their highly co-ordinated acts. In mani- 
 acal states there is a form of motor incoherence from confusion and 
 a rapid flight of the motor images of movements to be performed, 
 Just as there may be ineo-ordination in depressed states from re- 
 striction of the muscular elements of thought and great retardation 
 of the nascent motor impulses, which are not fused, therefore, into 
 associated movements. Hence changes in highly specialized acts 
 are a part of the muscular disorders of Insanity. 
 
SOMATIC SYiMPTOMATOLOGY. 221 
 
 The cliirography of the insane undergoes some modifieations of 
 practical interest, as they precede often tiie speech defects and have 
 diagnostic bearings. The handwriting is altered from psychical dis- 
 order or from physical disease, and it reflects, accordingly, the men- 
 tal phases or the motor disturbances of the psychosis. 
 
 The writings of the insane reveal, therefore, delusions, dominant 
 feelings, morbid impulses, and dangerous intentions, but more es- 
 pecially they are an index to the state of the memory for the con- 
 struction of language, and give an insight into the general condition 
 of integrity or decay of the mental faculties. The same phases of 
 the mental disease are shown often in recurrent attacks, both in 
 the incubatory and convalescent stages, by the written compositions 
 of the patient, and they may thus serve as a warning of the ap- 
 proaching danger as well as a sign of recovery. Space will not per- 
 . mit a description of the peculiarities of handwriting corresponding 
 to the incoherence of ideas, the amnesic failure, the grandiose feel- 
 ings, or the fantastic conceits of the various types of Insanity. Pa- 
 tients not only forget the motor images of chirographic movements, 
 but they have an incoherence of the kinsesthetic impulses essential 
 for writing and misplace letters in words apart from amnesic failure 
 for orthography. 
 
 The alteration of handwriting from physical disease is seen 
 chiefly in the form of tremor and muscular inco-ordination, which 
 exist in acute mania, melancholia, and in all states of great nervous 
 exhaustion at any time intercurrent in mental disorders. 
 
 The tremor in senile, alcoholic, syphilitic, and paretic dementia 
 may be so similar that the handwriting will not serve any purpose 
 of differential diagnosis. 
 
 The chirographic inco-ordinations occur also in acute and 
 chronic forms of the various types of Insanity, with cortical, bulbar, 
 or spinal lesions, and they have such common points of resemblance 
 that they serve no differential purpose of diagnosis as regards the 
 form of psychic disorder, but they are valuable indices of the degree 
 of functional miiscular disturbance referable to organic lesions of 
 nervous centres. 
 
 Even in general paresis, tremor, and inco-ordination of special- 
 ized movements, like those involved in handwriting, spring from 
 cortical, bulbar, and spinal lesions in varying order in different 
 cases, and the amnesic failure is equally variable in its appearance, 
 so that no uniform statement as regards the handwriting is possible. 
 
222 TEXT-BOOK ON MENTAL DISEASES. 
 
 Ordinarily the degree of degeneration of the motor and sensory- 
 cortex determines the relative and corresponding defects of chi- 
 rography, and when, through cortical disease, the motor images of 
 letters and words are lost, writing becomes impossible. 
 
 The handwriting in aphasie states shows, to a considerable de- 
 gree, the nature of the psychic defects, as well as the lesions of mus- 
 cular innervation. 
 
 Mirror-writing, from right to left, and often left-handed, is very 
 exceptionally present in degenerative forms of mental disease. The 
 cross-writing, fanciful flourishes, odd marks and cabalistic signs are 
 trivial distinctions of insane handwriting, except that they usually 
 characterize the writings of chronic degenerations of mind. 
 
 The fliysiognomy of Insanity is a positive phenomenon easily 
 perceived but difficult of description. The modifications of the 
 countenance in mental disorders are most decided and numerous, 
 and they spring from very complex causes, both mental and physical. 
 Certain modifications occur so frequently that they may be termed 
 types of insane physiognomy, but the individual variations are so 
 multiform that only general pathological traits of countenance can 
 be here described. Although the general rule is that great changes 
 in the facial appearance occur, there are exceptional eases so free 
 from derangement of expression that the most skilful expert could 
 detect no insane traits of countenance, and the physician who pre- 
 tends to invariably diagnose Insanity from outward appearances has 
 very limited experience or unlimited self-confidence. 
 
 In a large percentage of insane cases the features have some of 
 the actual " stigmata degenerationis," and unilateral asymmetries 
 and defects of innervation and congenital peculiarities pointing to 
 a degenerative origin. 
 
 There are also tremors, spasms, pareses, and paralyses of orbicu- 
 lar and facial muscles, from a diversity of causes, modifying greatly 
 the countenance and completely interrupting natural expressions 
 of face. 
 
 As a first type of insane physiognomy the countenance of the 
 acute maniac furnishes an interesting study. The face may be 
 flushed, but it is more often pallid, with wide pupils, the facial 
 muscles are extremely mobile and quickly respond to the rapid 
 succession of feelings of joy and sorrow, anger and mirth, laughter 
 and crying, and there are mixed expressions of these antithetical 
 feelings, which are more swift than muscular movements, and hence 
 
SOMATIC SYMPTOMATOLOGY. 223 
 
 arise the paramimic effects and the momentary blending of opposite 
 emotional manifestations very strange to behold and very charac- 
 teristic of acute mania. 
 
 The direct contrast to this is the physiognomy of acute melan- 
 cholia, with immobility of countenance, dull, sunken, downcast eyes, 
 slightly convergent; bent head, forehead with vertical central wrin- 
 kles and occasional horizontal folds, corners of the mouth depressed, 
 eyelids partially closed, eyebrows downwards inclined at the outer 
 angle, compressed lips, and a generally pinched and painful expres- 
 sion of face. 
 
 Another type in states of mental depression is the countenance 
 under the inhibition of some frightful delusion or hallucination, 
 as in melancholia attonita or primary dementia from fright. The 
 head is fixed and slightly inclined forward, the eyes are open wide 
 and stare intently in one direction, the occipito frontalis acts so 
 as to cause central and horizontal lines in the forehead, the nostrils 
 are slightly everted, the lips are a little separated, and the lower 
 jaw may drop a little, the eyebrows are overarched in the centre, 
 and the whole physiognomy is immovably set in dull but painful 
 outlines. 
 
 The type of the terminal dement is a common form of facial 
 appearance in Insanity. The lines of the face are obliterated, and 
 the physiognomy is a complete blank, the jaw sometimes droops, 
 the eyes are dull and the axes parallel, the orbicular muscles of the 
 eyelids relaxed, the naso-labial folds effaced, the features are gross, 
 and the whole countenance is lifeless and stupid. 
 
 There is another type of physiognomy in states of stupor. The 
 face is pale and sometimes swollen in appearance, the lower Jaw 
 relaxed, and, from the open mouth, saliva drools; there is slight 
 action of the occipito frontalis with fine horizontal wrinkles, giving 
 a dull forehead; the long-drawn face is immobile, the eyes are closed, 
 but they respond to light reflex when the lids are opened, the par- 
 tially dilated pupils contracting and thus distinguishing the state 
 from sopor, in which the contracted pupils dilate when the lids are 
 separated and the patient aroused. 
 
 The physiognomy in tetanoid stupor furnishes another type. 
 The facial muscles are in a spastic state, the forehead has central 
 vertical wrinkles, the chin is firmly drawn downward and inward, 
 the lips are pressed together and the corners of the mouth retracted, 
 the naso-labial fold is well marked, the eyelids are firmly closed 
 
224 TEXT-BOOK ON MENTAL DISEASES. 
 
 and when forced apart there is spasmodic oscillation of the eyeball,, 
 the nostrils are firmly set, and the general expression of countenance 
 is that of discomfort and tension. 
 
 There is another spastic type of countenance in ecstasy. The 
 fixed and upturned face, the widely opened eyes focussed upon the 
 hallucinated object, the elevated eyebrows, the lips slightly parted 
 but actively innervated, with gentle elevation of the angles of the 
 mouth, all point to the intense but pleasurable 'preoccupation of 
 mind. 
 
 There are facial types, also, not connected with the clinical 
 forms of mental disease, but purely the reflex manifestation of con- 
 stitutional disorders, or of the primary causes of the Insanity. 
 
 The diathetic and toxic factors thus leave their special imprint 
 on the countenance, and the neuroses as causes permanently mould 
 the face, and in epileptic Insanity there is ordinarily a distinct 
 fades epileptica. In alcoholic dementia there is the "'•' facies pota- 
 torum/' which is blank and expressionless. In organic dementia 
 the obliteration of the lines of expression is confined more especially 
 to the lower zone of the face on the side opposite to the brain-lesion. 
 
 There are a series of progressive changes in the countenance of 
 the general paretic. After the first stage, in which the face reflects 
 in the main the maniacal or hypochondriacal tone of feeling, there 
 is unilateral variation in the frontal WTinkles, in the angle of the 
 mouth, and in the orbicular and corrugator supercilii muscles, and, 
 finally, the naso-labial folds and all the chief lines of the physiog- 
 nomy are obliterated and the whole countenance becomes an inert 
 mass of flesh devoid of all intelligent expression. 
 
 Paramimia is occasionally witnessed in general paresis, as the 
 manifestation of joyiul feeling by tearful facial expression, and a 
 like phenomenon is found in other states of great mental weakness. 
 
 There is a superannuated appearance in many cases of Insanity; 
 ugliness is almost a universal trait, and the return of good looks 
 is one of the sure signs of recovery, and the change for the better 
 is so great that the patient may be hardly recognizable. 
 
 The old and anxious type of countenance from a painful coenas- 
 thesis is common in the Insanity of children, and also in the dia- 
 thetic insanities. 
 
 In terminal forms of mental disorder there are to be witnessed 
 the after effects of strong emotional delusions, usually of a frightful 
 or disagreeable kind, and the corresponding habitual expression of 
 
SOMATIC SYMPTOMATOLOGY. 
 
 225 
 
 countenance becomes permanently organized and may remain as 
 long as the patient lives. 
 
 It is important to know that hereditary types of expression are 
 wont to appear at certain ages, and the history of a ease of Insanity 
 should embrace the fact of any peculiar family cast of countenance. 
 
 Physiognomt No. 1. 
 
 This represents terminal dementia after twenty-four years of Insanity. The acci- 
 dental attitude of upturned eyes might suggest some emotion -which in fact does not 
 exist. It illustrates an automatic remnant of devout expression, which has absolutely 
 no intellectual counterpart, and similar automatic traits of facial mobility are not un- 
 common in 'dementia. 
 
 Chronic types of insane physiognomy represent feelings of pride, 
 disgust, anxiety, mock benevolence and condescension, hatred, and 
 brutal ferocity, and there are unquestionably animal-like reversions 
 of physiognomy to be detected when the more human forms of 
 expression have been effaced by disease. 
 
Phtsiognomt No. 2. 
 
 A type of chronic mania is here illustrated in a very confirmed mood of suspicion 
 and angry excitability, with vituperation of enemies whom delusions and hallucinations 
 led him to suppose were about him on all occasions. The expression is characteristic 
 of this type of chronic mania. 
 
Physiognomy No. 3. 
 
 This is illustrative of chronic mania of many years' duration, with prevailing ex- 
 pansive delusions, and pleasing ^emotions with paramimic expression. The paramimia 
 is so decided that the laughing might be mistaken for crying. 
 
228 
 
 TEXT-BOOK OlSr MENTAL DISEASES. 
 
 The composite type of physiognomy is not uncommon in the 
 psychoses, and it is not a question here of asymmetry between the 
 two sides, but of complete disparity between the upper, middle, and 
 lower zones of the face. This disparity may consist in permanent 
 
 passive phases, which are incongruous, or in active difierences, such 
 
 ^w35SSSl!5^«W 
 
 Physiognomy No. 4. 
 
 This was a case of acute melancholia reaching the grade of stupor eventually. The 
 painful tension of melancholia is here blended with a certain stuporous fixity of counte- 
 nance, which accords with the actual course of the sj-mptoms. 
 
 as frowning wrinkles in the upper zone and a continuous grimacing 
 smile in the lower zone. 
 
 All coarse brain disease is manifested chiefly in the lower zone 
 of the face, and this is especially true of unilateral lesions, and in 
 syphilitic, paretic, and organic dementia there are repeated instances 
 of this fact. 
 
 The knowledge of insane physiognomy is acquired by the expert 
 
SOMATIC SYMPTOMATOLOGY. 229 
 
 alienist after long years of close observation of many cases as they 
 pass through the successive stages of the disease, and the student 
 
 Physiognomy No. 5. 
 
 The type here shown is terminal dementia of the active form, -ndth occasional ex- 
 acerbations of excitement. The vestige of mental activity is revealed in a certain 
 resistive determination of countenance, and was further illustrated during the exacerba- 
 tions by actions. 
 
 of this branch of psychiatric symptomatology must not he content 
 with photographs and descriptions, but he should seek occasion to 
 study carefully the facial outlines and the peculiar expressions of 
 many cases of mental disorder. In the absence of such an opportu- 
 
Physiognomy No. 6. 
 
 It would be difficult to conceive of a more typical insane physiognomy than is here 
 presented. The case is one of chronic mania of twenty years' duration, with hsematoma 
 auris on both sides. The forward inclination of the head, the open mouth, the deep 
 frontal lines, are all characteristic of terminal mental deterioration. And still there 
 was considerable automatic activity of mind and body, comical speech and action, and 
 occasional excitement. 
 
SOMATIC SY3IPT0MAT0L0GY. 
 
 231 
 
 Physiognomy No. 7.. 
 
 This was'a case of acute mania attributed to religious excitement. The momentary- 
 pose here shown likely corresponded to some passing devout emotion, and contrasted 
 with his usual maniacal actions. 
 
 nity the above descriptions and the accompanying photographs may 
 serve as an introduction to the subject of the physiognomy of In- 
 sanity. 
 
 Section III. — The Vascular -System. . 
 
 The serious disturbances of the vascular system in Insanity are 
 to be viewed in the light of causes, symptoms, or sequels. A weak 
 vascular mechanism predisposes to mental disorder, which in turn 
 tends to develop vascular disease, which clinical observation shows 
 to be of unusual frequency among the insane, in whom vascular 
 degenerations also form permanent sequels, and sometimes lead 
 to a fatal termination. 
 
 There are congenital defects of the vascular system in states of 
 arrested development of mind, such as contraction of the cerebral 
 vessels from narrowing of the cranial foramina, anomalies in the 
 
232 
 
 TEXT-BOOK ON MENTAL DISEASES. 
 
 Physiognomy No. 8. 
 
 This illustration of acute mania is given more especially to show the hfematoma 
 auris in the third month of its appearance. It may be compared with hsematoma in 
 Physiognomy No. 6 of this series. 
 
 structure and distribution of the carotid and vertebral arteries, and 
 in the heart itself patency of the foramen ovale. 
 
 In cretins, too, with premature synostosis basilaris, there is nar- 
 rowing of the lumen of vertebral and basilar arteries, and great 
 dilatation of venous and lymphatic vessels. 
 
 In degenerative insanities there are sometimes native vascular 
 deficiencies in the calibre or in the coats of vessels, or thin and 
 feeble cardiac walls. 
 
 The proportion of deaths from heart disease is greater among the 
 insane than among the sane, and it varies, according to reports of 
 hospitals for the insane, from five to fifteen per cent. Oat of eleven 
 
SOMATIC SYMPTOMATOLOGY. 233 
 
 hundred and twenty-two deaths in the Willard State Hospital, heart 
 disease was the assigned cause in a fraction over nine per cent. 
 
 Heart disease is unquestionably more frequent in chronic In- 
 sanity than in sanity. Some form of cardiac hypertrophy is to he 
 found in at least twenty per cent, of the insane, chiefly on the left 
 side, and sometimes atrophy and fatty degeneration is present, and 
 pericardial adhesions, and various microscopic alterations of cardiac 
 fibres. In toxic Insanity, and especially in alcoholic eases, there is 
 compensatory hypertrophy of the left ventricle, and in maniacal 
 cases exceptionally right-sided cardiac hypertrophy. 
 
 Fatty heart is more common in terminal dementia, and degen- 
 eration of cardiac muscles and general venous stasis often follows 
 attacks of pericarditis and endocarditis in the diathetic and toxic 
 insanities. i 
 
 Both aortic and mitral lesions are frequent, but the latter are 
 the more common. In general, valvular aortic disease is found to 
 be associated with maniacal and mitral valvular lesions with melan- 
 chohc conditions, and in organic and coarse brain disease there are 
 often both aortic and mitral deficiencies and resulting dementia. 
 
 Dilatation of the heart and aorta, and degeneration of cardiac 
 muscles and atheroma of the aorta, are ordinarily attended by states 
 of mental depression or of mental weakness. 
 
 It has also been observed that mitral regurgitation is more apt 
 to be associated with depression, and aortic regurgitation with ex- 
 altation, but the emotional tone is more often determined by the 
 diathetic or toxic state of which the heart disease is a sequel. The 
 rheumatic, phthisical, podagrous, syphilitic, alcoholic auto-toxic, 
 and general toxic influences are to be borne in mind in this connec- 
 tion, and the essential causative relation is the degree of cardiac 
 insufficiency which results in imperfect supply of nutrient fluid to 
 the brain. 
 
 The determination of organic lesions of the heart among the 
 insane is rendered more difficult by the fact of frequent functional 
 disorders of the heart, such as loud second sounds of heart-beat 
 from overaction of aortic valves in chlorotic cases, and aortic bruits 
 in maniacal eases without lesions of valves, and violent palpitations 
 and rhythmic irregularities. 
 
 The degenerative changes in the vessels in Insanity are very 
 important. Atheroma of the aorta and of the large arteries, and 
 especially of the cerebral vessels, is a common symptom. In alco- 
 
234 TEXT-BOOK ON MENTAL DISEASES. 
 
 liolic Insanity the increase of the muscular coat of arteries^, which 
 are thus greatly narrowed, is accompanied by atheromatous and 
 fatty changes in the intima. There is in toxic Insanity generally 
 a tendency to arterio-scierotic degeneration, and this arterio-sclerosis 
 is more marked in the cerebral vessels, and is most frequent of all 
 in the internal carotid. 
 
 These degenerative changes are present in most luetic, alcoholic, 
 senile, and paretic cases, in which the vessels become tortuous, nar- 
 rowed in calibre, and there result aneurismal dilatations, thrombosis, 
 embolism, rupture and hemorrhages into brain-tissues. 
 
 The involutional changes in the entire vascular system account 
 for many of the symptoms, not alone in senile dementia, but in cli- 
 macteric cases and in premature senescence, and in women the 
 vascular alterations are often fully initiated at the time of the meno- 
 pause. 
 
 The part of the mechanical problem of the circulation which 
 concerns the distribution of blood within the cranial cavity is of 
 the utmost importance, for states of cerebral anemia and hyper- 
 lemia have the most intimate relations to mental disorders which 
 arise when the variations of blood-pressure within the cranium are 
 so great that the brain is not properly nourished or depurated of 
 its waste products. 
 
 The medullary and cerebral vaso-constrictor and vaso-dilator 
 centres control the blood-supply to the cortex cerebri, and, as a 
 greater quantity of blood enters or leaves the cranium, there is a cor- 
 responding decrease or increase in the intra-cranial amount of cere- 
 bro-spinal fluid, which normally amounts to two or three ounces, 
 and intra-cerebral pressure is thus uniformly regulated. The cere- 
 bro-spinal fluid is displaced into the lymph spaces and cisterns, 
 which are in communication with the cerebral ventricles and with 
 the basal cisterns, which connect with the larger spinal spaces. 
 
 The variations of intra-cerebral blood-pressure shown by symp- 
 toms of intense cerebral hypersemia and anaemia are among the im- 
 portant vascular phenomena of mental disorders. They are found 
 in all acute stages and in some chronic conditions of alienation, and 
 they may even attain the extreme forms of syncopal or apoplectiform 
 attacks, as well as of delusional and hallucinatory manifestations. 
 
 Local variations of blood-pressure from tumors and cortical apo- 
 plexies and cerebral hemorrhages may or may not derange mental 
 functions, but, acting as sources of irritation, they usually deter- 
 mine some symptoms of mental disorder. 
 
SOMATIC SYMPTOMATOLOGY. 235 
 
 The disturbances of the vasomotor system in Insanity are prom- 
 inent symptoms. The cortical hypersemias and anaemias which un- 
 derlie maniacal and melancholic attacks are often of vasomotor ori- 
 gin. The sudden intercurrences of acute excitement in many cases 
 of mental disorder, and even mania transitoria as an independent 
 affection, may be attributed to vasomotor spasm or paresis of cortical 
 vessels, and, in general, cerebral angioneuroses are common in In- 
 sanity. 
 
 The cerebral cedematous conditions in states of stupor are largely 
 the result of vasomotor paresis, and the defects of brain nutrition 
 in chronic Insanity arise from permanent damage to the vasomotor 
 centres, and in all the degenerative insanities anomalies of vasomotor 
 innervation are to be witnessed. " Eaptus melancholicus " and 
 certain kinds of precordial panic are due to vasomotor spasm. An^ 
 giospasm of peripheral capillaries accounts for the increased blood- 
 pressure in melancholia, and angioparesis for the diminished arterial 
 pressure in mania. 
 
 Meynert attributed the maniacal and melancholic phases of cir- 
 cular Insanity directly to variations in vasomotor innervation. In 
 hysterical and paretic cases unilateral angiospastic and angioparetic 
 conditions are common, and also local cutaneous ansemias and hy- 
 persemias. 
 
 There are large numbers of stuporous and demented patients 
 with cold and livid extremities from defective vasomotor innerva- 
 tion, and there is also in paretics the striking symptoms of dermato- 
 graphia and well-marked cases of digiti mortui occur exceptionally. 
 
 The most rapid fluctuations in vasomotor innervation are seen 
 in hysterical Insanity, which is more common in women, who nat- 
 urally have an increased excitability of the vasomotor nervous sys- 
 tem, as shown by blushing and fainting, and at the menopause the 
 disturbances are largely referable to the vasomotor system. Space 
 will not permit the description here of vasciilar symptoms of pneu- 
 mogastric origin, which were set forth at some length in a paper 
 on " Frequent Disorder of Pneumogastric Functions in Insanity," 
 read May 17, 1894, before the American Medico-Psychological As- 
 sociation, and published in the " Transactions " of the Society. A 
 mere word of mention must be given to local cortical anaemias and 
 hypersemias which occasion hallucinatory and other sensorial phe- 
 nomena, to capillary stasis in limited cutaneous areas, to very fre- 
 quent varicosities, to hsematoma auris, when of vasomotor origin, 
 
236 
 
 TEXT-BOOK ON MENTAL DISEASES. 
 
 to the abnormal pulsations in large veins, and in the abdominal 
 aorta and in other large arteries, to cyanosis and oedema of the 
 extremities, to capillary spasm and local asphyxia of cutaneous tis- 
 sues, even to the point of gangrene in pellagrous Insanity, and to 
 the sudden and sometimes syncopal spasm of cortical vessels follow- 
 ing a severe emotional shock. 
 
 Among vascular disorders the anomalies of the pulse are of 
 sufficient clinical importance to require special description, and for 
 fuller particulars than the present limits will permit reference is 
 made to " The Pulse in Insanity," a paper read by the writer before 
 the American Neurological Association, June 5, 1895. 
 
 The following table of pulse frequency is taken from a studj 
 of 2,172 patients under the writer's charge at the Willard State 
 Hospital, and they were of all ages and forms of mental disorder. 
 
 The records in this table are arranged by decades of frequency, 
 beginning with that from 40 to 50 beats per minute, and ending 
 with that from 130 to 140 beats per minute. 
 
 Pulse Frequency by Decades in 2,172 Patients. 
 
 
 DECADES. 
 
 
 
 40 
 to 
 60 
 
 50 
 to 
 60 
 
 60 
 to 
 70 
 
 70 
 to 
 80 
 
 80 
 to 
 90 
 
 90 
 to 
 100. 
 
 100 
 to 
 110. 
 
 110 
 to 
 120. 
 
 120 
 
 10 
 
 130. 
 
 130 
 to, 
 140. 
 
 Totals. 
 
 Women 
 
 Men 
 
 3 
 
 9 
 14 
 
 96 
 120 
 
 307 
 365 
 
 344 
 294 
 
 217 
 150 
 
 103 
 
 70 
 
 33 
 
 12 
 
 21 
 12 
 
 2 
 
 1,132 
 
 1,040 
 
 Grand totals . . 
 
 3 
 
 23 
 
 216 
 
 672 
 
 638 
 
 367 
 
 173 
 
 45 
 
 33 
 
 2 
 
 2,172 
 
 It becomes evident from this table that a very much larger pro- 
 portion of women than men had a pulse record in the decades above 
 80 beats per minute, that there are contained in the decade of fre- 
 quency 70 to 80 thirty-five per cent, of the men and only twenty- 
 seven per cent, of the women, while, on the contrary, in the decade 
 80 to 90 there are thirty per cent, of the women and only twenty- 
 eight per cent, of the men. 
 
 It also appears that for both sexes the percentages contained 
 were relatively larger in the four decades immediately above eighty 
 than in the four consecutively below it. 
 
 The male, female, and total pulse curve by decades of frequency 
 
SOMATIC SYMPTOMATOLOGY. 
 
 237 
 
 is gTaphically shown in the following diagram for the whole number 
 of 2^173 patients: 
 
 Diagram Shoicmg Pulse-curve and Frequency in 2,172 Patients. 
 
 
 40-50 
 
 50-60 
 
 60-70 
 
 70-80 
 
 80-90 
 
 90-100 
 
 100-110 
 
 110-120 120-130 
 
 
 
 
 , 
 
 
 
 
 
 
 
 -600- 
 
 
 
 -4 
 
 
 
 
 
 
 
 -500- 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 
 
 
 
 
 
 
 / '^• 
 
 
 
 
 
 
 
 
 
 / / -'^<" 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / /■'' 
 / // 
 
 \ 
 
 \ \ 
 \ \ 
 \ 
 
 
 
 
 
 
 
 
 // 
 
 
 \ 
 
 \ \ 
 
 
 
 
 
 
 / / 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / /' ^ 
 
 ' 
 
 
 
 N 
 
 ^■<-\ 
 
 
 
 
 --rr::::^^^ 
 
 v 
 
 
 
 
 
 
 j"~-^>5;;,^ 
 
 
 
 FEMALE PULSE CURVE. 
 MALE PULSE CURVE. 
 TOTAL PULSE CURVE. 
 
 PER-CENTUM LINES ARE HORIZONTAL 
 
 (THEY NUMBER PATIENTS) 
 
 DECADE LINES ARE VERTICAL. 
 
 (THEY NUMBER PULSE BEATS) 
 
 The total average pulse-rate in the 1,132 women examined was 
 84.8 per minute, and the total average pulse-rate for the 1,040 men 
 was 80.8, and the grand tqtal average pulse-rate for the 2,172 pa- 
 tients examined was 82.8 beats per minute. 
 
 Admitting the average normal pulse-rate in adult males to be 
 seventj'-two and that of females to be seventy-eight, the above study 
 of pulse-frequency shows that there is a decided average increase 
 of pulse-rate in Insanity amounting to 6.8 beats per minute for 
 females and 8.8 for males. 
 
 Some of the chief sphygmographic characters of the pulse, as 
 studied among the same patients, are now to be enumerated, and 
 several of the tracings taken with a Marey's sphygmograph are 
 shown on page 240 et seq. 
 
238 TEXT-BOOK ON MENTAL DISEASES. 
 
 It is to be affirmed, in general, that it is upon the physical con- 
 stitution of the patient, the etiology of the case, and the stadium of 
 the mental disorder, rather than upon the form of the Insanity, that 
 the sphygmographic type of the pulse is to be predicated. 
 
 The division which is most widely applicable in mania is into two 
 classes of cases having totally different pulse-tracings. 
 
 The first class of maniacal patients has active cutaneous circu- 
 lation with warmth and color of skin, and the pulse is about normal 
 in frequency. The sphygTaogram in these cases has a vertical ascent, 
 a sharp apical angle, the predicrotic wave and notch almost disap- 
 pear, and the aortic notch and dicrotic wave are strongly marked. 
 
 The second class of maniacal patients has pallor and coolness 
 of the cutaneous surfaces, and a pulse of much higher tension. 
 The percussion-wave has a less sudden ascent, a less acute angle, 
 and the descent is more gradual with a distinct tidal wave and an 
 obscure aortic notch, and a scarcely perceptible dicrotic wave. 
 
 Even these two types of pulse are not permanent throughout an 
 attack of mania, and they may succeed each other in the same case. 
 
 In the first class of cases, when the excitement is very great, 
 the pulse may become tricrotic, and in the second class of cases, when 
 exhaustion is very decided, the pulse becomes monocrotic. 
 
 Puerperal maniacs, having lost a considerable percentage of their 
 vital fluids by hemorrhage, may present the pulse of empty arteries, 
 and post-febrile maniacs may have subnormal temperature and an 
 exaggerated tricrotic pulse. Anacrotism is found in alcoholic mania 
 with atheromatous arteries and in mania Avith G-raves's disease. 
 
 The toxic manias ordinarily have a high-tension pulse, the .tidal 
 wave rising to form a plateau with the apex of the primary wave. 
 
 In phthisical cases the relation between pulse and temperature 
 may be lost, or there may be a typical pyrexial pulse-tracing, and, 
 as mental disorder is often most active when pulmonary disease is 
 stationary, there may be a high-tension pulse and dicrotism only on 
 advance of the pulmonary lesions. 
 
 In auto-intoxications there is usually a j)ulse of high tension 
 with a sustained rectangular apex formed by the blending of the 
 percussion and predicrotic waves, while the dicrotic wave disappears 
 and the smaller diastolic elastic vibrations may be present. 
 
 Melancholia is, in the majority of cases, attended by hypertrophy 
 and high-tension pulse. The ascent is not high, there is an early 
 tidal wave, and the descent is gradual, vdth. scarcely a perceptible 
 trace of the aortic notch or dicrotic wave. 
 
SOMATIC SYMPTOMATOLOGY. 239 
 
 In great physical depression, with f ee'ble systole, the percussion- 
 Avave is small and the catacrotic elevations completely disappear. In 
 senile melancholia the high-tension pulse is due to atheromatous 
 changes rather than to spastic states of the arterioles, and in alco- 
 holic melancholia the sphygmographic signs of peripheral resist- 
 ance arise from arterial degeneration rather than from angiospasm. 
 
 Melancholia from cerehral exhaustion and of neurasthenic ori- 
 gin or hypochondriacal in nature, gives a pulse-tracing of low ten- 
 sion, and a dicrotic tracing also characterizes tubercular melancholia 
 with basal meningitis. 
 
 Melancholic anguish and precordial panic present a small, fre- 
 quent pulse of high tension with low ascent and sustained descent 
 with elastic vibrations, or a slight percussion-wave and complete dis- 
 appearance of catacrotic elevations. 
 
 In stuporous and cataleptoid states a similar tracing is often 
 found with loss of the diastolic features and the substitution of a 
 simple line of descent, as in slowed pulse from pneumogastric irri- 
 tation. 
 
 In the demented and in terminal forms of Insanity with cir- 
 rhosed liver, granular kidneys, and peripheral obstruction to the 
 circulation from vascular disease there is apt to be a pulse of high 
 tension, either dicrotic or monocrotic. The ascent is gradual and 
 below medium height, the apex is rounded or formed in variously 
 sustained shapes by the help of an early and imperfectly developed 
 tidal wave, the descent is gradual and shows some wavelets, but 
 no distinct aortic notch or dicrotic wave. One cause of the gradual 
 line of descent in the tracings of dementia is permanent exhaustion 
 of the sympathetic nervous system and resistance from venous stasis, 
 as shown in the cyanotic extremities. There is early high tension 
 in paretic dementia. The pulse is sometimes tricrotie in the first 
 stage, but there is rapid failure of systolic force, and angioparesis 
 begins in the second stage, and capillary stasis offers sufficient re- 
 sistance to cause forms of high-tension pulse, which may also arise 
 from endarteritis, so that the percussion-wave is usually low with 
 rounded apex, and the descent has numerous wavelets and vibrations 
 peculiar to the disease. 
 
 The apex in other tracings is rectangular, the plateau being 
 formed by help of the tidal wave, and the aortic notch and dicrotic 
 wave do not appear. With rise of temperature after paretic seizures 
 the tracings may be dicrotic or even hyperdicrotic. In the fin"al 
 
240 
 
 TEXT-BOOK ON" MENTAL DISEASES. 
 
 stage of general paresis the monocrotic type of pnlse prevails^ tliongli 
 bedridden cases sometimes give anacrotic tracings^ and variations 
 are due also to the way in which the cerebral vasomotor and the 
 23nenmogastric centres are involved by the progressive lesions. In 
 ascending cases the tracings continue to show high tension even 
 to the final stage. 
 
 Accidental features in the sphygmograms of the cases examined 
 were due to cardiac abnormities, and the cardiac affections actually 
 diagnosed in the 2,172 cases of Insanity may be briefly summarized 
 in the following percentages: There were irregu.larities of the heart's 
 action in five per cent., intermittance of heart-beat in two per cent., 
 heart murmurs and valvular lesions in eight per cent. 
 
 The general conclusion as to the abnormal sphygmographic 
 tracings is that they are to be observed at some stage of the disease 
 in the vast majority of cases of Insanity, and that they are occa- 
 sioned by the cerebral, bulbar, and spinal organic lesions, by anom- 
 alies of the vasomotor system, by pneumogastric disorder, by central 
 and peripheral vascular changes, by disease of internal organs, by 
 toxic and auto-toxic and diathetic influences, and by actual organic 
 cardiac lesions. 
 
 These abnormal tracings vary much in different kinds of Insan- 
 ity, and in variously constituted individuals suffering from the same 
 form of mental disorder, and they are best classified according to 
 the actual physical status of the patient, the special etiology of the 
 case, and the stadium rather than the nosological form of the mental 
 disease. 
 
 The following sphygmograms represent a few of the more com- 
 mon types, and they were among many others taken with a Marey's 
 sphygmograph among the writer's patients: 
 
 Sphtgmogram No. 1. 
 This is a tracing m acute melancholia with a pulse-rate of 72 per minute and a 
 pressure of two ounces. It shows the vascular hypertony of melancholia with corre- 
 sponding tension of pulse. The line of ascent is not high and the descent is gradual, 
 with scarcely a trace of the normal aortic notch or dicrotic wave. 
 
SOMATIC SYMPTOMATOLOGY. 
 
 241 
 
 Sphtgmogram No. 2. 
 
 This is a tracing in chronic melancholia with a pulse- rate of 78 and a pressure of 
 three and one-fourth ounces. It indicates feeble heart action, and peripheral resistance 
 and high tension. There is a low ascent with a sustained descent, with slight elastic 
 vibrations. It is not unlike certain tracings in precordial panic. 
 
 Sphygmogram No. 3. 
 
 This tracing in an epileptic imbecile with a pulse-rate of 84, pressure three and 
 one-fourth ounces, shows low tension and cardiac irritation, and the tracing is similar 
 to some found in delirium acutum. There is a vertical line of ascent, a sharp apex, and 
 a rapid descent to the level of the aortic notch. 
 
 Sphtgmogram No. 4. 
 
 This tracing in epileptic dementia, pulse 72, pressure three and one-fourth ounces, 
 is the more common tj-pe in the physical deterioration of epileptics, in which the pulse 
 is slower and the tension higher from capillary stasis. Here the line of ascent is less 
 vertical and there is a rounded apex, and there is a long-sustained line of descent. 
 
 16 
 
242 
 
 TEXT-BOOK OK MENTAL DISEASES. 
 
 SPHrGMOGRAM No. 5. 
 
 This tracing, taken in the second stage of general paresis, pulse 90, pressure four 
 ounces, shows a full-length line of ascent, with an apex approaching a plateau, and a 
 rather rapid descent to the aortic notch, and the pulse is one of considerable tension 
 from obstructed flow in the arterioles. 
 
 Sphtgmogram No. 6. 
 
 The pulse-rate in this instance was 72 and the pressure two ounces. It was a case 
 of chronic mania with tension of pulse, often present in this form of mental disorder. 
 There is a low percussion-wave and a descent with all the usual features obscured, and 
 still it is a tracing very common in chronic mania. 
 
 Sphygmogram No. 7. 
 
 This tracing in epileptic mania, with a pulse of 120 and two-ounce pressure, illua- 
 trates an interesting variety of low-tension dicrotic pulse with vertical ascent, acute 
 apical angle, rapid descent, and dicrotic wave, often found in both epileptic and acute 
 delirious mania. 
 
SOMATIC SYMPTOMATOLOGY. 
 
 243 
 
 Sphtgmogram No. 8. 
 
 As a contrast to the preceding tracing here is one taken in epileptic dementia, 
 pulse 72, pressure two and one-half ounces, with high tension due to peripheral ob- 
 struction, a very slight percussion-wave and a sustained line of descent without any 
 other features. This is characteristic in degenerative forms of dementia. 
 
 Sphygmogram ISTo. 9. 
 
 A tracing in chronic mania with exophthalmic goitre, pulse 90, three-ounce press- 
 ure, illustrates a type of pulse found in chronic alcoholic or other toxic states. With 
 the vertical line of ascent a distinct right angle is formed at the apex, and the arterial 
 tension is considerable. 
 
 Sphtgmogram No. 10. 
 
 This sphygmogram is taken in fully developed general paresis. There was a pulse 
 of 100, and three ounces pressure were employed in tracing. It shows a slightly oblique 
 line of ascent, the tendency to form a plateau at the apex, a certain degree of tension 
 from obstructed outflow through capillaries, and a frequent type of tracing seen in 
 general paresis. 
 
244 TEXT-BOOK OX MEXTAL DISEASES. 
 
 Section IV. — CJianges in tlie Cutaneous and Other Epithelial 
 
 Structures. 
 
 It is natural that tlie cutaneous and epithelial structures should 
 reveal the general defects of nutrition and circulation common in 
 mental disorders. 
 
 Pigmentation of the skin is due to erethism of the papillai and 
 to angioparesis of the special papillary vessels and to quahtative 
 changes in the blood. In toxic and diathetic Insanity, especially 
 in syphilitic, cancerous, and malarial cases, the deposit of pigment 
 may occur in internal organs as "^'ell as in cutaneous regions. The 
 bro^vn patches in facial parts are very extensive and permanent in 
 arsenious, pellagrous, and malarious cases, and in the latter there is 
 sympathetic paresis of splenic vessels and great increase of pigment 
 with enlargement of the spleen and pigmentation of vascular as well 
 as glandular tissues. 
 
 Pimientation of skin is verv conmion in melancholic states, and 
 unquestionably painful emotions are sometimes causative in these 
 cases, as their dystrophic effects are well known, and pigmentation 
 is often a trojjliic disturbance. 
 
 Climacteric cases and all other instances of involutional defects 
 of nutrition are subject to this s^rmptom of discoloration of the 
 skin, which is most marked in the senile dementia of women. 
 
 Yellow and icteric pigmentation is not so frequent, though oc- 
 casional in alcoholic and syphilitic cases. 
 
 Bronzing is also rare, though fully developed Addison's disease 
 does occttr, both as a concomitant and as a sequential symptom. 
 
 Extreme pallor and waxy skin is not infrecjuent in diathetic 
 Insanity, and Spitzka (" Insanity," p. 78) records a case of bleaching 
 of the skin in patches in a negro. Congenital discolorations and 
 pigmentary nsevi are found among the physical stigmata hereditatis. 
 
 Desquamations are partial in the acttte psychoses of toxic origin, 
 and sometimes general in mental disorder from acute infectious dis- 
 eases. 
 
 In post-febrile Insanity there is often extensive desquamation. 
 
 This is a symptom which readily escapes observation, and in 
 many cases of melancholia there is abnormal and furfuraceous 
 desquamation for months together, and pit}Tiasis is a part of the 
 process. 
 
SOMATIC SYMPTOMATOLOGY. 245 
 
 Atrophy of the cutaneous tissues is not uncommon. The " pan- 
 niculus adiposus " early disappears, and the skin becomes extremely 
 thin, and, as a result, abrasions are apt to occur. This tenuity of 
 the skin is so great in senile dementia that the rupture occurs, as if 
 in wetted brown paper, upon the slightest force exerted in the 
 handling of the patient, and unjust blame may be attached to the 
 nurse in these cases. 
 
 Cutaneous eruptions most frequently observed are prurigo, ec- 
 zema, herpes zoster, urticaria, psoriasis, and pemphigus, and they 
 are evolved chiefly under the direct influence of a diseased nervous 
 system. Herpetic eruption sometimes follows violent emotions as 
 a direct sequel, and artiflcial urticaria may follow mechanical irri- 
 tation of the skin in certain neurasthenic cases. Pemphigus is most 
 often seen in general paresis and psoriasis in syphilitic dementia. 
 Furunculosis is common in alcohohc dementia, and carbunculosis 
 is found in various toxic and diathetic insanities. 
 
 Acute decubitus is a troublesome complication in bedridden de- 
 ments, and it arises, without regard to neglect, as an independent 
 and sudden afl'ection of trophic origin, and involves the cutis vera 
 in extensive sloughs, which may prove fatal even under skilful treat- 
 ment. 
 
 G-angrene of the skin, and cellulitis, and scorbutic and purpuric 
 effusions and cutaneous hemorrhages with abscesses are also en- 
 countered frequently among insane patients. 
 
 Unilateral and local ischsemias and hfemic stigmata have been 
 seen in hysterical Insanity. 
 
 CEdema of the extremities is a common symptom in stuporous 
 cases, with cold and livid skin from angioparesis, and there is in rare 
 instances a violet shade of the cutaneous surfaces and also local ery- 
 themas in facial regions. 
 
 Cutaneous excretions are more abundant in mania than in melan- 
 cholia. In the latter the skin is often dry and harsh, and in the 
 former it is most frequently moist. 
 
 Anidrosis is found in stuporous as well as in melancholic condi- 
 tions, while hyperidrosis is a common symptom in maniacal states. 
 Hemianidrosis and hemihyperidrosis are to be witnessed in epileptic 
 and paretic and hysteric cases, and also chromidrosis and hsmidrosis, 
 though the latter symptom is rare. There is a distinct effluvium 
 from the perverted cutaneous excretions, which, with the increased 
 seborrhoeal secretion and macerated epithelium, undergo rapid chem- 
 
246 TEXT-BOOK ON MENTAL DISEASES. 
 
 ical dianges, giving acid;, rancid^, musty, and indescribable odors. 
 There is in acntely maniacal patients a sexual odor, a menstrual odor, 
 and an axillary jDerspiration in women, which stains the clothes 
 and is very ofEensive, especially if they be suffering from- obstipation, 
 and in negroes at such times the effluvium is so powerful as to be 
 perceptible at some distance. Seborrhoea is frequent in pubescent 
 and other kinds of Insanity, and acid hyperidrosis in rheumatic 
 Insanity causes a miliary eruption, which in warm weather is com- 
 mon in maniacal eases from the same cause. There is also increased 
 diaphoresis in diathetic Insanity, and also suj)pression of perspira- 
 tion in toxic cases, and emotional influences and spinal affections 
 common in Insanity modify considerably cutaneous excretions. 
 
 Otlter epithelial structures also occasionally present various anom- 
 alies. 
 
 Tlie hair in acute melancholia is dry and bristling, and may fall 
 out in places or become much thinner, and it may become gray in 
 part. 
 
 The hair often turns gray in places, and in rare instances over 
 the whole head, but the sudden bleaching of the hair is so exceptional 
 that few authenticated cases are on record from reliable sources. 
 
 There is an erection of the hair from emotional influences in 
 Insanity, and also a permanent state of partial erection of the hair 
 in chronic states of mental disorder, as well as an actual increased 
 growth of the hair which tends to stand out irregularly from the 
 head. 
 
 The natural color of the hair may be restored on recovery, but 
 this is rarely the case when the hair has turned completely gray 
 during a prolonged attack of Insanity. 
 
 Hirsuties appear not only as a stigma degenerationis but as an 
 intercurrent symptom during Insanity of chronic course, ^nd it is 
 also found in climacteric cases in women, and occasionally in pubes- 
 cent eases there is a failure of growth of hair on customary parts of 
 the body, and premature baldness is common among male patients, 
 and also alopecia in syphilitic Insanity. 
 
 Bald spots are common from the habit of friction of the scalp, 
 and the hair-follicles may be thus permanently destro5'^ed by the 
 mechanical violence. Bald spots also come from the constant pluck- 
 ing out of the hair, and even complete baldness will occur in this 
 way if the patient is not prevented from the constant picking, which 
 becomes automatic finally, and may result in lesions and permanent 
 cicatrices of the scalp. 
 
SOMATIC SYMPTOMATOLOGY. 247 
 
 There are, perhaps, some relations between temperaments, color 
 of the hair, and depressed or exalted forms of mental disorder. It 
 has been claimed that forms of mental depression are more prevalent 
 in persons with dark shades of hair, and some statistical observations 
 sustain this view. 
 
 Tlie nails are also subject to alterations in mental disease. They 
 may be large, thick, and incurvated, or thin, small, and brittle. They 
 are frequently bitten off to the very quick by the patient, or they 
 may be tliickened by constant friction. There are troublesome forms 
 of hang-nails and of ingro-wing toe-nails; also very frequent onyxia, 
 with furrowed, ridged, and variously deformed nails indicative of 
 trophic disorder. 
 
 Tlie cutaneous reflexes are generally increased in states of excite- 
 ment and diminished or lost in states of stupor and of severe mental 
 depression. They are often heightened in alcoholic cases and les- 
 sened in senile dementia. 
 
 In general paresis and epileptic dementia they may be lost on one 
 side, and there is also a unilateral difference in some hysterical cases. 
 In neurasthenic Insanity there is often a considerable increase of all 
 the cutaneous reflexes. 
 
 TTie cutaneous sensory 'disturtances consist in a loss of the sense 
 of temperature, loss of tactile discrimination of points touched, or of 
 the linear direction of an object drawn across the skin, loss of the 
 sense of weight or pressure and of the position of the limbs in space, 
 and absence of response to tickling. Cutaneous ansesthesia may be 
 confined to limited areas, or it may be unilateral in epileptic, paretic, 
 and hysteric cases. Hypersesthesia is found in pressure-points, supra- 
 orbital, infra-orbital, sternal, intercostal, dorsal or coccygeal, and in 
 hypertesthetic zones over ovarian and other cutaneous regions. 
 
 Pargesthesia is a symptom in most acute stages of Insanity, and 
 it may relate to almost any part of the cutaneous surface, and it is the 
 constant source of delusions of persecution. 
 
 Superficial temperature changes have not been very thoroughly 
 studied in mental disorders, but they are so frequent as to be noticed 
 upon casual observation. The cold extremities of melancholic and 
 stuporous cases, the heated skin of some maniacs, the high cutaneous 
 temperature in paretic seizures, and in the flushed faces of climacteric 
 patients, and in some hysteric cases, are very evident symptoms. 
 
 The cutaneous temperature varies on the two sides in some 
 paretics, and there is a similar unilateral variation in some epileptic 
 cases. 
 
248 TEXT-BOOK OlS" MENTAL DISEASES. 
 
 Tliermometric tests liave determined that there are decided dif- 
 ferences of temperature in the scalp, and that powerful emotions 
 cause a rapid rise, and that in general the frontal region has a higher 
 degree of warmth than the middle region, which is in turn warmer 
 than the occipital region. 
 
 Apart from variations of temperature from extreme cerebral ac- 
 tivity there are in the scalp those due to lesions of the sympathetic, 
 so common among the insane, in whom one side of the face is often 
 seen to be highly flushed, and the patients complain sometimes of 
 these irregularities of temperature, which reach their greatest ex- 
 treme in paretic dementia and in delirium acutum. On the other 
 hand, algid cutaneous conditions are found in stuporous and ex- 
 hausted states following severe acute stadia both of mania and 
 melancholia. 
 
 Section V. — Splanclmological Disorders. 
 
 The affections of thoracic and abdominal viscera in mental dis- 
 orders are frequent from general malnutrition, impaired innervation, 
 and special causes about to be described. 
 
 Pulmonary diseases are vastly more common among the insane 
 than the sane, and in all large hospitals for the insane they constitute 
 the chief factor in large mortahties. The most frequent of these 
 diseases, phthisis pulmonalis, is found in the ratio of three to one 
 in the insane as compared with the sane, and this is due to lowered 
 vitality, and to the general trophoneurosis, and to defects of pneu- 
 mogastric innervation of pulmonary tissues, which present a soil in 
 which bacilh readily thrive and multiply. There is also a hereditary 
 relationship between phthisis pulmonalis and Insanit}*, which appear 
 vicariously in successive generations. 
 
 The mental disease may appear a year or two before the lung 
 complaint, or the latter may cause the former, or the two affections 
 may progress in cyclical order, first one and then the other furnish- 
 ing the predominant symptoms. 
 
 Sometimes the pulmonary symptoms are latent until the close 
 of life, and then develop rapidly as the direct cause of death. The 
 objective signs of the lung disease are often absent, even when the 
 lesions are far advanced, and a fatal termination is then reached 
 without cough or expectoration, and the customary variations in 
 temperature are also sometimes wanting. 
 
 AstJima is associated with Insanity sometimes as a cause modify- 
 
SOMATIC SYMPTOMATOLOGY. 249 
 
 ing the type of alienation, and as an intercurrent affection. There 
 are also observed pseudo-asthmatic attacks, with labored breathing, 
 in hypochondriacal and neurasthenic cases. 
 
 Pneumonitis is an epiphenomenon in alcoholic dementia, to 
 which it often puts a rapid lethal termination, and typho-pneu- 
 monia is a frequent cause of death in states of acute exhaustion from 
 mental disease. 
 
 Pneumonitis is an accidental result in the artificial feeding of 
 patients more often than is supposed, and also from the escape of 
 food into the air-passages while eating, and this arises from paresis 
 of the muscles of deglutition and from defects of sensory innervation 
 of pharyngeal membranes. 
 
 In bed-ridden dements and other very feeble patients there is 
 a hypostatic pneumonia, which not infrequently brings about the 
 fatal end, and gangrene of the lungs is not very rare among the 
 insane. 
 
 (Edema of the lungs is another common symptom and a frequent 
 cause of death among old and debihtated patients. 
 
 In the status epilepticus and in prolonged paretic seizures there 
 is vasomotor paresis of pulmonary vessels and an oedematous infiltra- 
 tion of the lungs, which is the customary cause of death on these 
 critical occasions. The autopsical examination in these cases shows 
 that the infiltration is not pneumonic, and the rise of temperature 
 is antilethal and points to involvement of heat centres by central 
 lesions and not to pulmonar}^ inflammation. 
 
 There is in epileptic, alcoholic, and paretic dementia a special 
 type of oedema of the lungs caused by pneumogastric lesions. The 
 physical signs are moist rales and dulness on percussion, extending 
 rapidly upwards from the lower lobes of the lungs, with rapid respira- 
 tion, but only slight rise in temperature. The auscultatory signs of 
 pneumonia are wanting, and death results with unexpected sudden- 
 ness, and bloody serum with rarely a few pus-cells is found through- 
 out the lung-tissues, which are not hepatized. This form of oedema 
 is due to failure of pneumogastric innervation, and actual degenera- 
 tion of the nuclear origin of the nerve will sometimes be found. 
 
 Pulmonary crises, with painful and labored respiration lasting 
 for some hours, are to be witnessed in tabetic, alcoholic, and paretic 
 cases, arising from the advance of degenerative changes in the pneu- 
 mogastric and accessory nuclei. 
 
 Modifications of respiration in the insane are so frequent that 
 they demand some special description. 
 
250 TEXT-BOOK OX MEXTAL DISEASES. 
 
 Eespiration is more frequent in states of mental exaltation and 
 less frequent than normal in states of mental depression. The fre- 
 quency of respiration may range as high as forty or fifty per minute 
 in maniacal exacerbations, and as low as eight or ten in inelancholic 
 attonita, and in some stuporous conditions, and in hysterical somno- 
 lence it may sink still lower, so as to he scarcely percepiiule. 
 
 The depth of the respiratory movements is inhibited in melan- 
 cholia in striking contrast to the freedom of respiration in maniacal 
 cases. In ecstatic and cataleptic states there is superficial respiration, 
 which becomes deep and full under the influence of strong emotions. 
 There is a voluntary inhibition of respiration under the control of 
 delusions, which may continue for hours together, so that the patient 
 only breathes when absolute!}' necessary; and, on the other hand, 
 in delirious mania, very rapid blowing at hallucinatory objects may 
 continue to the point of complete exhaustion of the patient, and 
 there are few acutely maniacal patients in whom some modification 
 in depth or frequency of respiration does not occur. 
 
 In epileptic, hysteric, and paretic Insanity there are frequent 
 changes in the rhythm of respiration, with prolonged or shortened 
 expiration or inspiration and undue pause between the respiratory 
 acts. 
 
 In paretics there may be rhythmical variations consisting in rapid 
 breathing for a few minutes and then retarded respiration continuing 
 for about the same length of time, and this phenomenon may last 
 for several hours following paretic seizures. Typical Che}me-Stokes 
 respiration is occasionally present in the " status epilepticus " and 
 in fatal eases of delirium aeutum. In cataleptoid states there is 
 momentary suspension of respiration, which is continuously retarded, 
 and this symptom persists for days together. 
 
 Prolongation of expiration is present often during the sleep of 
 the insane, who also voluntarily prolong the expiratory movement 
 in shouting and whistling, thus preventing the return of venous 
 blood from the brain and causing passive cerebral congestions and 
 chronic lar3mgeal troubles, and after the patient becomes too hoarse 
 to make an audible noise the expiration continues prolonged with 
 panting muscular effort. 
 
 Aiitomatic laughter is a spasmodic expiratory modification of 
 respiration, which escapes the control of the patient and may con- 
 tinue for hours. It sometimes begins as an emotional reflex partly 
 under voluntarv control and then becomes automatic, but usnallv it 
 
so:matic symptomatology. 251 
 
 springs from active pathological changes in encephalic centres, and it 
 is more in the nature of a convulsive action in epileptics, in whom it 
 may be vicarious of a seizure. The latter seemed to be the case in 
 a young male epileptic under the writer's care, in whom the auto- 
 matic laughter was followed by such stuporous exhaustion as is the 
 frequent sequel of convulsions. Crying-laughter without hilarious 
 expression and with free lachrj-mation is common in organic and 
 paretic dementia, and laughter with closed lips, and violent explosive 
 noises after efforts to suppress laughter, are to be heard. Paramimic 
 laughter, as above mentioned, renders it difficult to tell when the 
 patient is crying or laughing. 
 
 Sneezing, ordinarily caused by excitation of the nasal distribution 
 of the fifth nerve, appears as " sternutatio convulsiva '" among epi- 
 leptic and hysteric insane, like the spasmodic cough in women as 
 a uterine reflex, or like the barking cough of chorea. Dry and ex- 
 aggerated spasmodic cough is common in men as well as women, and 
 the fact of laryngeal angesthesia and absence of cough in walking 
 cases of pneumonia is to be obser^^ed among the insane. There is 
 also a cough of delusional origin in hypochondriacal cases and a 
 suffocative cough in the final stage of organic dementia. The modi- 
 fications of respiration should not escape clinical notice during hours 
 of sleep in which there is a diurnal reduction of vital force, dimin- 
 ished oxidation, and suspension of cerebral inhibition. 
 
 The exhaustion of motor and emotional excitement in the insane 
 is followed by deep sleep, during wliich the jaw drops, mouth- 
 breathing and various forms of snoring occur, with labial vibrations 
 pointing to a pathological depth of somnolence. The sleep of general 
 paretics in the dorsal decubitus from prolapse of the palate and of 
 the base of the tongue gives an alarming obstruction of respiration, 
 which is sometimes increased by the collapse of the al^ nasi, and 
 even the vocal chords in some cases furnish the obstacle to breath- 
 ing, and their spasmodic adduction may result in vibrations and a 
 variety of inarticulate sounds. 
 
 In the soporous condition of epileptic and paretic patients posi- 
 tive stertor is ]3resent, and the sleep always has a pathological char- 
 acter. 
 
 The singvlhis of the insane often presents, not atmospheric clos- 
 ure of the vocal chords on diaphragmatic spasm, but spasmodic glottic 
 closure with loud inspiratory sound, and the whole phenomenon is 
 often prolonged for hours from pneumogastric irritation occasion- 
 
252 TEXT-BOOK ON MENTAL DISEASES. 
 
 ally, though ordinarily from excitation of the phrenic nerve. In 
 tabetic and paretic cases this phrenic irritation arises from ceryical 
 spinal lesions involving the roots of the nerve. 
 
 In toxic Insanity liiccough probably springs from direct toxic 
 effect on the respiratory centre. It is often a fatal symptom in 
 organic dementia and in the final stage of general paresis. In one 
 case it lasted three days, and the autopsy revealed thrombotic oc- 
 clusion of the basilar artery and no other cerebral lesion to account 
 for the symptom. 
 
 Oscedo in the insane is sometimes attended by exaggerated action 
 of the extensor muscles of the trunk and limbs, and the yawning may 
 finally pass beyond voluntary control in hysterical hypochondriacal 
 and paretic cases, and in paralytic cases certain tremors attend the 
 act. In hysterical Insanity chasmus hystericus may be as purely 
 spasmodic as globus hystericus, and it sometimes continues for days 
 together. 
 
 Sobbing sometimes takes the place of crying among the insane. 
 It is a spasmodic noisy interruption of inspiration, and during the 
 pathological liberation of intense emotions it becomes very difficult 
 to arrest except by powerful sedatives, and it may continue day and 
 night if not brought under artificial control. These sobbing seizures 
 usually continue until the patient sinks exhausted into a deep sleep. 
 In tabetic cases imperfect abduction of the vocal cords gives rise to 
 labored inspiration, and a like difficulty in paretics springs from 
 sclerotic changes and irritation of the lar3mgeal branches of the pneu- 
 mogastric. Finally, there are dyspnoeic modifications of respiration 
 in the acute psychoses for which there is no assignable pathogenesis, 
 and those disorders of respiration which attend the diathetic forms 
 of mental disease will be noticed in the clinical part of the work. 
 
 Gastro-intestinal symptoms are almost universal in the acute 
 psychoses. The gastro-intestinal secretions are diminished in melan- 
 cholia and more abundant in mania. In melancholia also there is 
 absence of normal peristalsis, as well as lessened excretions, and the 
 result is obstinate constipation. The impaction of fecal masses in 
 the large intestine is a very troublesome and at times dangerous 
 symptom, and in dementia there is also sometimes the most per- 
 sistent obstipation, and when the rectum is completely impacted 
 mechanical delivery may become the only means of relief. 
 
 Irritative or destructive lesions of spinal reflex centres, through 
 which the intestinal tract is innervated, lead to a variety of symp- 
 
SOMATIC SYMPTOMATOLOGY. 253 
 
 toms. ThuSj paresis of the muscular coat of the intestines increases 
 obstipation, or there may be spastic action of the muscular coat and 
 greatly increased peristalsis with pseudo-diarrhcea and borborygmi 
 and false tympanites through spasm of abdominal muscles. 
 
 Quantitative and qualitative changes in the gastric juice occur, 
 and there is frequently continuous gastro-intestinal catarrh, and 
 indigestion is seldom absent in the acute stages of Insanity. The 
 tongue is heavily coated and the breath is offensive, and there is 
 anorexia, or absence of the feeling of satiety. Gastric dilatation 
 and sarcinous fermentations, regurgitations, pyrosis, loud eructa- 
 tions, and vomiting are frequent. Emesis is sometimes due to gastric 
 spasms without nausea, and also to pneumogastric irritation, and to 
 hypochondriacal delusions. The most violent spasmodic affections 
 of the stomach are found in hysterical and paretic cases, and gastral- 
 gia and other sensory troubles are among the symptoms to be noted. 
 
 Gastric crises are found in general paresis, and in mental dis- 
 order in connection with locomotor ataxia. 
 
 Merycism in congenitally feeble-minded and in the chronic in- 
 sane is not very rare, and the food may be repeatedly regurgitated 
 and remasticated either voluntarily or automatically as in true ru- 
 mination. Some insane patients have, or acquire, the power of com- 
 pletely emptying the stomach at will, and this gastric control renders 
 artificial alimentation almost an impossibility, and deliberate starva- 
 tion almost a certainty. Imperfect mastication is the rule among 
 the insane, who are apt to bolt their food in large masses and also 
 to swallow all sorts of substances, so that gastro-enteritis is not in- 
 frequent. There are also ulcers of the stomach, hsematemesis, intes- 
 tinal displacements and involution, hernias, and inflammatory affec- 
 tions of the gastro-intestinal tract. 
 
 The chief significance of these gastro-intestinal disorders is the 
 fact that they heighten the impairment of nutrition of the nervous 
 centres, and sympathetically influence to a surprising degree the in- 
 tellectual disorder, which in hypochondriacal cases is often due 
 directly to the disease of the primse vi^. There are occasionally the 
 further influences of helminthiasis, of stasis of the portal vein, and 
 extensive hemorrhoids, of tubercular peritonitis, and of cancerous 
 disease of the stomach or rectum, and of other severe organic diseases 
 of the primse vise. 
 
 Genito-urinary symptoms demand attention, and they spring 
 from diseases which may be causative, concomitant, or consecutive 
 
254 TEXT-BOOK OX MENTAL DISEASES. 
 
 as regards tlie Insanit}'. Their importance is great oil account of 
 the direct reflex sympathy between the genito-nrinary organs and 
 the cerehrum^ as shown not only at pnherty and the menopause, hut 
 throughout hfe and during the phases of mental disorder. 
 
 Both organic and functional uterine disorders are present more 
 frequently among insane than sane women, and they modify the 
 mental disease, which may sometimes he best treated by a relief of 
 the local affection. Uterine displacements, tumors, and chronic dis- 
 charges, and inflammatory conditions are especially common at the 
 chmacteric. Amenorrhoea is the rule in the acute psychoses, and it 
 may continue after recovery, but the return of the catamenia is or- 
 dinarily one of the signs of convalescence or of transition to a chronic 
 stage of the mental disorder. 
 
 Masturbation, pruritus vulv^, the passage of foreign bodies into 
 the vagina, sexual mutilation, furor uterinus, irresistible impulses 
 of sexual origin, and suicidal attempts from sexual delusions, and 
 false accusations, and even homicidal attempts from the same source, 
 are not uncommon symptoms. 
 
 Delusions of pregnancy, childbirth, and of nightly assaults upon 
 virtue are favored by genital paresthesia and by spasmodic vaginal 
 and titerine afi'ections, or by other local diseases. 
 
 In men masturbatic strictures, and self-inflicted injuries of the 
 sexual organs, and chronic inflammatory states of the membranous 
 portion of the urethra, with pollutio diurna and sexual hypochon- 
 driac symptoms, are found with parassthesia and neuralgic genital 
 affections, which become the fruitful source of sexual delusions. 
 Impotence or satyriasis may exist, but the ordinary symptom is sex- 
 ual anaesthesia in melancholic and stuporous states, and sexual hy- 
 peragsthesia in maniacal conditions. 
 
 Coitus may be painful, or there may be long-continued erection 
 and erethism without orgasm, and various forms of sexual perversion. 
 
 A^'esical s}Tnptoms are of clinical importance, and they require 
 active attention. The bladder often becomes enormously distended 
 and there is then incontinence of urine with overflo-u'. There is also 
 retention of urine with vesical paralysis in organic and paretic 
 dementia. 
 
 Paresis of the bladder is also found in epileptic, syphilitic, 
 tabetic, and hysteric eases. There are irritable and spasmodic vesical 
 states and frequent vesical catarrh and nocturnal incontinence of 
 urine. The latter symptom can be overcome in a measure by habitual 
 
SOMATIC SYMPTOMATOLOGY. 255 
 
 education of the patient. The cerebral inhibition oi the spinal reflex 
 control of the bladder and rectum is completely lost in many cases, 
 and there is then involuntary passage of the contents of the bladder 
 and rectum, and tliis also occurs from hebetude in dements, and in 
 tabetic and paretic cases from paresis of sphincter muscles. 
 
 When the above conditions do not prevent, it is possible to estab- 
 lish automatic habits of attention to personal needs, even in dements. 
 In hysterical cases, more especially, there is temporary anuria and 
 polyuria, and in epileptics vesical spasm, and the passage of urine is 
 often a part of the convulsive seizure. 
 
 Voiding urine involuntarily is also in some epileptics a precursory 
 symptom, or an automatic sequel, or an equivalent of the seizure. 
 
 Biliary, splenic, and pancreatic affections have sympathetic rela- 
 tions to mental disorders. Liver disease is sometimes the cause of 
 melancholia, and the ancients were not altogether wrong in their 
 black-bile theory of this form of mental disease. Hypochondriacal 
 Insanity also springs from hepatic disorder. Abscess of the liver has 
 been known to cause great mental depression, which has been relieved 
 by operative procedure. In hypochondriacal cases there is duodenal 
 catarrh, occasionally extending to the bile-duct and leading to partial 
 occlusion of the same and to mild forms of icterus and increase of the 
 melancholy. Hepatic calculi are common, especially in women, and 
 are found post-mortem of unusual dimensions, and their passage 
 constitutes a painful intercurrent symptom. In alcoholic and syph- 
 ihtic Insanity there are organic lesions of the liver. Fatty degenera- 
 tion and cirrhosis are the most usual forms, and the latter is often 
 followed by ascites and progressive emaciation, which render the 
 prognosis of mental recovery hopeless. 
 
 Atrophic processes are also found in the liver in chronic In- 
 sanity, and Bucknill and Tuke (" Manual of Psychological j\Iedi- 
 cine,'^ p. 594) report some instances of shrunken and flabby hver 
 resembling splenic tissue. 
 
 The spleen in chronic cases of mental disease is often atrophic, 
 but in malarial Insanity it is greatly enlarged. In toxic Insanity there 
 is often distinct atrophy of the spleen, and in diathetic Insanity there 
 is sometimes hypertrophy and secondary atrophy. Functional hyper- 
 trophy is by no means rare, and the extended limits of the organ can 
 readily be recognized on percussion, and pain located over the organ 
 is an accompan5dng symptom in some of these cases. The extensive 
 pigmentations in the insane, not alone of cutaneous regions, but of 
 
2oQ TEXT-BOOK ON ^IEjSTTAL DISEASES. 
 
 internal organs and of rascnlar tissues^ are attended sometimes with 
 splenic disorders. 
 
 The pancreas has been found altered in size and in its tissues in 
 Insanity, and the loss of abihty to digest fats is a very common symp- 
 tom among the insane, and it is doubtless in part due to disorder of 
 pancreatic functions. 
 
 Finally, bihary, splenic, and pancreatic affections modify the 
 ccenEesthesis and the preraihug emotional tone in mental disorders. 
 
 Section VI. — Nutritive, Secretory, and Trophic Distiirhanccs. 
 
 Changes in the total iveight of the lodij in Insanity correspond to 
 the pathological fact that the psychosis is only an expression of a 
 general tropho-neurosis. Loss of weight often begins in the pro- 
 dromal stage and progresses rapidly during the acute stage, and is 
 greatest at the full height of the mental disorder. There is then a 
 stationary period during the stage of secondarj- exhaustion, and then 
 the weight increases suddenly during convalescence beyond the aver- 
 age of health, and as the cure hardens there is again a slight con- 
 traction of total weight to the physiological and normal average of 
 the patient in health. This is the course the curve of bodily weight 
 pursues in the simple psychoses, with a rapid fall and a rapid rise 
 at the beginning and end of the acute attack. 
 
 But in Insanity with the major neuroses and in strongly degen- 
 erative eases the weight-cujwe, after a rapid initial decline, often 
 oscillates irregularly beneath the norm and rises more gradually to 
 the customary height on recovery; or it rises to the full norm of 
 health during remissions of the mental s}Tnptoms, and sinks again 
 during exacerbations. In the hereditary form known as circular In- 
 sanity the weight sometimes rises nearly to the average during the 
 maniacal period, and sinks rapidly during the melanchohc period. 
 
 The actual full gain in weight upon recovery may range from 
 twenty to twenty-five i3er cent, of the normal total weight in women, 
 and from fifteen to twenty per cent, in men. In puerperal mania 
 with great loss of vital fluids it may attain as high a figure as thirty 
 per cent. There is also a gradual and exaggerated gain in weight 
 upon the passage of the Insanity from the acute to a chronic and 
 incurable state, and increase of weight without a corresponding men- 
 tal improvement is always a bad symptom. 
 
 Loss of weight in the terminal forms of mental disorder almost 
 
SOMATIC SYMPTOMATOLOGY. 257 
 
 always precedes the fatal end, and there is extreme malnutrition in 
 the final stage of toxic and diathetic cases, and excessive emaciation 
 in melancholia, and some cases of refusal of food in spite of forced 
 alimentation. 
 
 Disorders of secondary assimilation exist in those insane patients 
 who eat voraciously and apparently are free from digestive disorder, 
 and still continue to grow more and more emaciated. The whole 
 muscular system diminishes in size and in contractile power, the in- 
 ternal organs appear atrophied post-mortem, and the central nervous 
 system partakes in the general atrophic process. This marasmus 
 is found in both acute and chronic cases of mental disease, as well as 
 in senile cases and in instances of premature senescence. 
 
 The essential defect would seem to be in secondary assimilation, 
 in the inability of the tissues to appropriate that which is essential 
 to their renewal. The result of this trophic disturbance is progres- 
 sive emaciation, which may finally attain to the most extreme degree 
 in the absence of any diathesis or acute disease, and wliile the appetite 
 is good and the amount of food consumed more than normal. 
 
 Auto-intoxications are found in puerperal cases with reabsorption 
 of septic material, and also in those forms of puerperal Insanity with 
 uraemic blood-poisoning. 
 
 In all cases with chronic nephritis mental disorder from ursemic 
 intoxication is liable to occur. 
 
 Diabetic auto-intoxication gives rise to another form of mental 
 derangement, and several of the diatheses, such as the podagrous 
 and the rheumatic, are attended by mental disorder from auto-intox- 
 ication. 
 
 Myxoedematous Insanity in connection with degeneration, or 
 surgical removal, or abnormal growths of the thymus gland is prob- 
 ably due to retention in the system of substances which should be 
 eliminated, and it is nearly related to, if not actually to be enumer- 
 ated among, the auto-intoxications. 
 
 There is no longer room for doubt that putrefactive alkaloids 
 exist in the human system through the action of bacteria on or- 
 ganic matter, that these ptomaines are highly poisonous, that basic 
 substances formed from metabolic changes in the bodily tissues, 
 known as leucomaines, may act as autogenous poisons, and that in 
 insane patients with generally perverted secretions and excretions 
 auto-intoxications are of frequent occurrence. For fuller details 
 than present limits will permit reference is made to an article by the 
 17 
 
258 TEXT-BOOK ON MENTAL DISEASES. 
 
 writer, on " The Toxic Origin of Insanity," Journal of Nervous and 
 Mental Disease, October, 1893. 
 
 The Hood in Insanity undergoes changes in quantity and quality. 
 It may be diminished from profuse hemorrhages in puerperal cases, 
 or charged with uric acid, biliary constituent, specific virus, toxic 
 agents, and autogenous poisons. The proportion of serum fibrin 
 and globules may vary in the diathetic and toxic insanities, as chlo- 
 rotic, anaemic, and leucocythsemic conditions prevail. 
 
 Variable points in the composition of the blood in Insanity of 
 special importance are the number of red blood corpuscles, the pro- 
 portion of white blood corpuscles and the amount of red coloring 
 matter (haimoglobin) in the various forms of mental disorder. 
 
 In mania it is exceptional to find any great deviation in the rel- 
 ative quantity of the white or red corpuscles or haemoglobin. In 
 maniacal women the proportion of white corpuscles is greater than in 
 men. 
 
 In melancholia there is a considerable diminution in red blood 
 corpuscles and in haemoglobin, and a slight increase in specific grav- 
 ity. 
 
 In the epileptic insane there is a still greater deficiency of red 
 corpuscles and of haemoglobin and a higher specific gravity. 
 
 In terminal dements there is a very great decrease in the haema- 
 cytes and also in the red coloring matter, and a decided increase in 
 specific gravity of the blood. The deterioration is usually more 
 decided in women and those advanced in years. In general paretics 
 the blood is sometimes more deteriorated in males, however, and 
 there is a diminution, both in red blood corpuscles and in haemo- 
 globin and a small increase of specific gravity, and a leucocytosis 
 which steadily advances to the terminal stage of the disease. Pa- 
 retic remissions are characterized by a partial restitution of healthy 
 conditions of the blood. 
 
 In malarial Insanity the blood contains pigment granules in 
 large amounts, so that pigmentary obstruction of capillaries may 
 occur. In some of the toxic insanities the proportion of white to 
 red blood corpuscles is increased, but the rule is in the simple psy- 
 choses that there is no abnormity in this particular. 
 
 The quality of the blood returns to a normal standard upon 
 complete recovery, or it deteriorates still more decidedly as Insanity 
 passes into an incurable state. 
 
 The urine in mental disease presents a variety of changes from 
 
SOMATIC SYMPTOMATOLOGY. 259 
 
 the normal standard in quantity, specific gravity, reaction, and 
 chemical constituents, but investigators do not agree as to the spe- 
 cial abnormities in the separate forms of Insanity. The compo- 
 sition of the urine varies in the same type of mental disease accord- 
 ing to the quantity of fluid and solid ingesta, the degree of mental 
 excitement, the amount of muscular effort, the condition of the 
 vasomotor innervation, and the state of the central nervous system. 
 
 The problem of the determination of the abnormal variations in 
 the chemical composition of the urine is very complex, but there 
 are some general facts which may be considered as sufficiently de- 
 termined. 
 
 The quantity of urine excreted in twenty-four hours is dimin- 
 ished in melancholia and in secondary dem-entia, and in mania with 
 excessive perspiration or excitement, but in other cases of mania it 
 is normal. 
 
 In general paresis the quantity of urine is increased in the first 
 stage, except when it is one of depression, and diminished in the 
 demented stage, but there may exceptionally be bulbar lesions giv- 
 ing rise to continuous polyuria. The latter symptom is present in 
 epileptic and hysterical Insanity occasionally, and also in luetic and 
 organic dementia. In neurasthenic cases there is both oliguria and 
 polyuria arising from changes in psychical influences. 
 
 The specific gravity of the urine is a little above the norm in 
 melancholia, somewhat increased on the average in mania, and de- 
 creased in terminal dementia rather than increased, and slightly 
 above the normal figure in general paresis, upon the whole, but 
 subject to many fluctuations. 
 
 The specific gravity is increased in hysteric oliguria and dimin- 
 ished in epileptic polyuria following convulsive seizures. In gen- 
 eral, the solid constituents are increased according to tlie degree 
 of emotional perturbation and miiscular activity. 
 
 The urine is usually high-colored in the acute stages of mental 
 disorder and light-colored in hysteric and epileptic polyuria, and 
 with less than normal color in dements in a quiescent state. 
 
 The reaction of the urine is acid in melancholic and maniacal 
 states, and especially so in the latter during great muscular exer- 
 tions. In dementia it is less decidedly acid in reaction, and when 
 the urine is long retained it often gives in dements an alkaline re- 
 action. 
 
 Urea is relatively increased in acute mania and melancholia. 
 
260 TEXT-BOOK ON MENTAL DISEASES. 
 
 though in the latter form with anorexia and refusal of food it may 
 be diminished. It is in excess in the early stage of general paresis, 
 and evidently diminished in terminal dementia. 
 
 The excretion of urea is increased, as a rule, in most of the dia- 
 thetic and toxic insanities in the early stage, and diminished in the 
 terminal demented stage. 
 
 Uric acid fluctuates above and below the norm in mental dis- 
 orders. It is often increased in paretic, epileptic, and acute toxic 
 Insanity, and diminished in diabetic Insanity and in some chronic 
 diathetic mental disorders. 
 
 Albumin is occasionally present in the urine of the insane in the 
 absence of kidney disease. Albumin is found in states of great 
 excitement in mania and melancholia, in the acute delirious mania 
 of alcoholic cases, in delirium acutum, and in general paresis. 
 
 Albumin also exists in the urine following epileptic convulsions, 
 and apoplectiform and paretic seizures, and also in cases with or- 
 ganic diseases of the kidney, especially in alcoholic and syphilitic 
 Insanity. It is found that peptonuria occurs in general paresis and 
 in states of great motor excitement. Peptone may be found in the 
 urine even in the terminal stage of paresis, and acetone is reported 
 to be present in the urine of epileptics and paretics, and also in 
 states of inanition. 
 
 Sugar is not confined to diabetic cases, but appears in connection 
 with gross brain disease in organic dementia, and also is frequent 
 in syphilitic and paretic Insanity, and it also attends tumors or other 
 lesions in the neighborhood of the fourth ventricle. 
 
 Phosphoric acid appears to be excessive in states of extremely 
 active excitement and to be diminished in chronic brain diseases 
 with Insanity. 
 
 Casts, epithelial cells, mucus, pus-globules; leucocytes, and 
 haematuria are occasionally to be found in the urine of the insane. 
 
 Through inadvertence, or under the influence of delusion, or as 
 the result of spasm of the neck, or paralysis of the muscular coat of 
 the bladder the urine is long retained and ammoniacal decomposition 
 may occur. In hysteric and paretic cases there may at times be 
 considerable escape of blood from the mucous coat of the bladder 
 and various forms of vesical calculi are occasional symptoms. 
 
 Saliva is secreted in abnormal quantity and quality in Insanity. 
 It is either thin and watery, as in the idiotic and feeble-minded 
 class, or it is thick and tenacious, under the influence of the sym- 
 
SOMATIC SYMPTOMATOLOGY. 261 
 
 pathetic, as in states of maniacal excitement, in which the active 
 movements of the month and lips produce, mechanically, a foam out 
 of the viscid saliva, and this is the explanation of the popular idea 
 that madmen foam at the mouth. Excessive flow of saliva may 
 occur in any form of Insanity as an intercurrent symptom, and it 
 sometimes indicates the beginning of terminal dementia, and in 
 other cases it is a critical sign of approaching convalescence from 
 depressed or stuporous conditions, pointing to more active cortical 
 innervation and circulation, 
 
 Ptyalism may proceed from organic lesions of cerebral centres, 
 from bulbar disease, from cortical affections, from disease of the 
 facial or sympathetic nerves or of the salivary glands, and from 
 emotional influences, and it is conjectural in many cases of mental 
 disorder to which one of these factors the increased flow of saliva 
 is due. In organic dementia ptyalism is to be attributed to the 
 central brain lesion, and organic lesions of nervous centres usually 
 determine it in syphilitic, paretic, and alcoholic dementia. Ptyal- 
 ism is more apparent than real in depressed and stuporous states in 
 which the lower jaw falls inert and allows the saliva to dribble from 
 the mouth. In these cases there is inhibition of all motion or ab- 
 sence from hebetude of mouth-closure and customary deglutition, 
 and the escape of saliva is not to be mistaken for actual increase of 
 the same. In other cases of this class there is mouth-closure, but 
 not deglutition, and the saliva accumulates in large quantities in 
 the mouth and undergoes a species of decomposition from admix- 
 ture of epithelium, mouth germs, dental decay, and macerated food 
 particles, and it then becomes very offensive. 
 
 Saliva is not swallowed, and may be retained in the mouth under 
 the influence of hallucinations or delusions, which in other cases 
 cause a constant spitting, which may be mistaken for real salivation, 
 
 Sialorrhoea may reach an astonishing degree, as in acute delirious 
 conditions of toxic origin, and also in typhomania, alcoholic mania, 
 and epileptic and paretic cases in which the flow of saliva may be 
 almost incessant. 
 
 There is actual diminution in the amount of saliva secreted in 
 some acute maniacs, with dry and parched lips and tongue, and also 
 in many cases of acute melancholia in which all the secretions are 
 diminished. 
 
 In some idiots the escape of saliva comes not from an open-mouth 
 habit, but from real ptyalism. 
 
262 TEXT-BOOK ON MENTAL DISEASES. 
 
 Trophic tissue changes have already received considerable notice 
 under the various sections of this chapter, but there are certain 
 points yet to be described. 
 
 In organic dementia there are trophic changes in the joints 
 of the paralyzed side, sach as thickening and inflammatory efEusion, 
 giving rise to albuminous crepitus; and in hysterical Insanity there 
 is pseudo-ankylosis from subinllammatory joint affections with con- 
 traction and partial atrophy of tendons and muscles. In hysterical 
 cases, also, the paralyzed limbs, which pit on pressure, present the 
 peculiar symptom which has been described as " blue oedema." 
 There is also cutaneous atrophy in senile dementia and a tendency 
 to death of tissue, so that troublesome ulcers may form upon the 
 lower limbs, the heel or sole of the foot, or at the elbow. In general 
 paresis there is increased trophic activity in the early stage and 
 unusual facility of the healing of wounds and abrasions, but in the 
 final stage there is a loss of trophic function and open sores, and 
 deep-seated abscesses and decubitus, which may extend to the bone 
 in spite of every surgical or antiseptic measure. 
 
 In neurasthenic Insanity complicated with neuralgia, herpetic 
 blebs arise in the region of the cutaneous distribution of the nerve, 
 leaving a superficial abrasion, and in climacteric Insanity the par- 
 sesthedc symptoms are in part due to actual trophic changes in the 
 skin. 
 
 Changes in the marrow of bones in the insane are of a trophic 
 nature and are more common than is supposed, and are yet to be 
 fully investigated. The trophic changes in the teeth are more easily 
 studied, and consist in falling off of the enamel, ulcerations at the 
 root, alveolar abscesses, tartarous concretions extending under the 
 gum toward the root of the teeth, which are painful and very trouble- 
 some and require extraction in these cases, and also loosening and 
 falling out of the teeth before actual decay. The latter affection 
 occurs without scorbutic taint and the patients often pick the teeth 
 out with their fingers. 
 
 Beard first called attention to the premature loss of teeth in 
 neurasthenic cases. 
 
 The excessive formation of adipose tissue and the deposit of rolls 
 of fat about the neck in dements and imbeciles, and the general 
 fatty degenerations of the visceral and vascular systems in Insanity, 
 are to be regarded as trophic changes, and in the same category are 
 to be included the general malnutrition of the terminal forms of 
 
SOMATIC SYMPTOMATOLOGY. 263 
 
 mental disorders and the fatal marasmus of melancholia and de- 
 mentia. The atrophy of internal organs so generally revealed post- 
 mortem in chronic dements is a trophic result, and the general 
 relation of tropho-neuroses and psychoses is shown in the extreme 
 frequency of scrofula in idiocy, and of phthisis in mental disorders. 
 
 There is the symptom of the insane ear, which is sometimes of 
 trophic origin, and it is therefore to be described in this connection. 
 
 Hmmatoma auris is a tumor formed by the effusion of blood 
 between the cartilage of the ear posteriorly and the perichondrium 
 of the ear anteriorly. The blood escapes from the rupture of peri- 
 ehondrial arterioles, and then a cyst is formed of sero-sanguinolent 
 fluid contributed by the cystic surface of the perichondrium. The 
 tumor forms rapidly within a few minutes or hours, and lasts for 
 several weeks or months, and then disappears, leaving the ear shriv- 
 elled and contracted in bad cases with a loss of one-fourth of auric- 
 ular dimensions. 
 
 The tumor varies in size from a marble to a hen's egg, and gen- 
 erally occupies the helix and schaphoid fossa, but it may extend over 
 all the fossae and cartilaginous portions of the ear and occlude the 
 meatus externus, but the lobule of the ear is not involved. The 
 sldn over the tumor is livid or reddish, with purplish veining, and, 
 when tense, is shining in appearance; and spontaneous rupture an- 
 teriorly through the perichondrium and its cutaneous coverings may 
 take place in one or more places, allowing the escape of bloody 
 serum. The cyst thus partially empties itself and refills, or it con- 
 tinues to ooze a fluid composed of serum, fibrous and cartilaginous 
 flakes, leucocytes, and red blood corpuscles, until there is an adhe- 
 sion of the cystic walls by a new formation of fibrous and cartilagi- 
 nous tissues. If incised it pursues much the same course as after 
 spontaneous discharge, refilling and, if much pressed, rupturing 
 vessels anew and prolonging the natural course of cure. 
 
 The symptom of hsematoma auris is most common in acute mania 
 and melancholia and in general paresis, but it is also found in epi- 
 leptics and cases of chronic mania, and in all cases with violent ex- 
 citement and cerebral congestion. The tumor may occur simul- 
 taneously or successively in the two ears, but it is far more frequent 
 on the left side, and more often met with among men than women. 
 It occurs in the sane among boxers and gymnasts, circus clowns and 
 contortionists, and in all specially subject to mechanical violence 
 to the external ear, but it is far less frequent than among the insane. 
 
364 TEXT-BOOK ON MENTAL DISEASES. 
 
 The chief cause of h^ematoma auris in paretic, alcoholic, syph- 
 ilitic, and chronic maniacal cases is a trophic degeneration of the 
 auricular vessels of the ear, and in some instances, also, trophic 
 changes in the cartilaginous tissues which lose their normal flexi- 
 bility, and the result is that the most trifling mechanical impres- 
 sions upon the ear occasion rupture of vessels. 
 
 The vasomotor theory of disease of the cervical sympathetic 
 is probably the true explanation in some instances of hematoma 
 auris, as it accords with local hypersemias of vasomotor origin in 
 various parts of the system among the insane. 
 
 Mechanical violence is an undoubted cause of hsematoma auris 
 in the falls of epileptics, and in violent maniacs who beat their heads 
 with their fists or against the wall, or receive injuries during violent 
 assaults upon others, or rub the side of their heads vigorously against 
 the bed at night, or pull their ears, under the influence of delusions. 
 
 The mechanical theory, however, is totally inadequate to ac- 
 count for all cases of h^ematoma auris, which arises in quiet bed- 
 ridden cases under the constant supervision of trustworthy nurses 
 and independently of all violence. 
 
 Temperature in mental disorders by classic teaching is supposed 
 to be normal, but, as a clinical fact, it is subject to very frequent 
 changes. 
 
 In able-bodied patients of full habit the bodily temperature is 
 increased as often as there is great mental excitement and motor 
 activity. This rise in temperature may be counteracted by con- 
 tinuous perspiration and evaporation in maniacs. In acute exacer- 
 bations of mental and motor excitement in epileptic, alcoholic, and 
 paretic mania there is a customary increase in temperature of one 
 or two degrees. Even in acute exacerbations of excitement in melan- 
 cholia there is a rise in temperature. 
 
 There is an increase of temperature attendant upon emotional, 
 hallucinatory, and delusional excitement, without regard to the 
 amount of muscular effort put forth, and, though it is most evident 
 in cranial areas, it is also appreciable in axillary regions, though it 
 seldom surpasses one degree Fahrenheit. 
 
 Slight functional disturbances of internal organs in the insane 
 give rise to abnormally great fluctuations of bodily temperature, 
 varying from 2 to 3° F. in bronchial, gastric, or intestinal catarrh. 
 or obstipation in women, or menstrual irregularities, or slight cu- 
 taneous affections. High temperature in hj'sterical Insanity is com- 
 
SOMATIC SYMPTOMATOLOGY. 265 
 
 mon without inflammatory disease of any kind, and it may be of a 
 few hours' or days' duration, and there is a similar symptom in 
 epileptics. In general paresis there is often an evening rise of tem- 
 perature, or there may be consecutive days during which the bodily 
 heat is above the normal. Attending or following the paretic seiz- 
 ures the temperature may rise as high as 106° P. In epileptic con- 
 vulsions there may be a rise of temperature and it may reach a high 
 degree in the status epilepticus. 
 
 There is an enormous increase of bodily heat in some cases of 
 acute alcohohc mania and in delirium acutum. Occasional high 
 temperatures are found in organic dementia and in the acute stage 
 of toxic Insanity. There may be a marked difference between the 
 two sides of the body, both in cutaneous and axillary measurements 
 of the degree of heat in paretic and organic dementia. 
 
 The cases in which there is a reduction in bodily heat are still 
 more numerous in^Insanity. 
 
 The temperature of maniacs, who lose heat by respiration and 
 cutaneous evaporation while very active, is kept about normal, but 
 after prolonged muscular exertion, as exhaustion sets in, there is 
 often a decided reduction of bodily warmth from one to three de- 
 grees, and the fall in temperature in cases of complete prostration 
 may considerably exceed this limit. 
 
 In states of great mental depression or stupor the bodily tem- 
 perature is habitually subnormal for weeks at a time. Also, in 
 terminal dementia there is subnormal temperature in many cases. 
 
 The most extreme reduction in temperature is found in the ter- 
 minal stage of general paresis, in which there are exceptional algid 
 conditions with surprisingly low records of temperature. In puer- 
 peral cases of Insanity, after extensive post-partum hemorrhages, 
 there are also very low temperatures, which may also be observed 
 as antelethal symptoms in cases of exhaustion from acute mental 
 disorder. There is also an antelethal rise of temperature in paretics 
 and cases of organic dementia. 
 
 The variations of temperature here mentioned are all inde- 
 pendent of inflammatory affections of internal organs. The inter- 
 current changes of temperature in the diathetic, toxic, and infec- 
 tious diseases which give rise to Insanity are too numerous to be 
 noted in this connection, but they will be separately mentioned un- 
 der the separate forms of mental disease. 
 
266 TEXT-BOOK ON MENTAL DISEASES. 
 
 Section VII. — Diseases of the Cerebral, Spinal, and Peripheral Ner- 
 vous System. 
 
 Diseases of the nervous system are more common among the 
 insane than among the sane, and they precede, accompany, or follow 
 the mental disorder. 
 
 The nervous disease and the Insanity may occupy to each other 
 the relation of prodroma or of sequel, or both affections may be but 
 the common symptoms of a general diathetic or toxic disorder, or the 
 common result of mechanical injuries or of widespread pathological 
 tissue changes in nervous centres. 
 
 It is not the intention to name all the nervous affections which 
 are encountered among the insane, which would be equivalent to a 
 review of the whole domain of diseases of the nervous system, but 
 it is proposed to point out the immediate symptomatic relations 
 of certain nervous diseases and certain forms of mental disorder. 
 
 General paresis presents tremors, spasms, pareses, convulsions, 
 trophic affections, angioneuroses, and a host of nervous maladies 
 which are symptomatic of the progressive cerebro-spinal lesions 
 characteristic of this type of mental disorder. 
 
 Syphilitic Insanity is often accompanied by neuritis, paralyses 
 of cranial nerves, hemiplegia, convulsive seizures and spinal nervous 
 affections. 
 
 Alcoholic dementia is marked by tremors, spasms, multiple neu- 
 ritis, paralyses, and sensory nervous anomalies. 
 
 Cerebral tumors, abscesses, hemorrhages, and other gross brain 
 lesions which cause organic dementia are also attended by hemi- 
 plegia, optic neuritis, epileptic seizures, paralysis of cranial nerves, 
 and other nervous diseases. 
 
 The major neuroses, epileps)^ hysteria, chorea, and hypochon- 
 driasis may be symptomatic as well as causative as regards Insanity, 
 and this is true also of exophthalmic goitre, which is nearly allied 
 to the neuroses. The latter affection sometimes recurs with succes- 
 sive attacks of mental disorder. 
 
 Cerebral traumatism may give rise to mental disorder and to 
 a simultaneous train of nervous affections, both motor and sensory, 
 which persist as prominent symptoms throughout the whole course 
 of the mental alienation. 
 
SOMATIC SYMPTOMATOLOGY. 267 
 
 Severe forms of neuralgia are both causes and symptoms of men- 
 tal disease, and the same is true of epilepsy following trauma capitis. 
 
 Locomotor ataxia sometimes precedes and at other times follows 
 as a symptom of general paresis. It is probable that the mental dis- 
 order due to the cortical lesions, and the locomotor ataxia, are to 
 be regarded as having a common relation, and as symptomatic of 
 a general trophoneurosis, which may be manifested first by either 
 the tabetic or the mental disease. In regular cases of general paresis 
 the mental sjrmptoms always precede the spinal, but in ascending 
 cases the reverse is the order of symptoms. 
 
 Insanity not of the paretic type may also follow tabes dorsalis. 
 
 In toxic Insanity of alcoholic origin there may appear the sen- 
 sory and motor symptoms of ataxia when the leptomeningitis in- 
 volves the posterior nerve-roots, and secondary sclerotic lesions occur 
 in the posterior spinal columns, and in some cases complete ataxic 
 paraplegia results. 
 
 In the same class of cases there may be pareses of the upper 
 extremities, and atrophic wasting of the muscles secondary to le- 
 sions of the anterior cornua of the cord. 
 
 In toxic Insanity there is interstitial sclerosis of spinal columns 
 in a large percentage of all cases, and the spastic gait in these cases 
 is due to sclerosis of the lateral columns, and paralyses also arise 
 in connection with multiple neuritis, and cramps, amaurosis, and 
 convulsions are further symptoms of disease of the nervous system in 
 this form of Insanity. A case of Insanity in which arsenic was the 
 toxic factor came under my care, and had multiple neuritis and loss 
 of muscular power confined to the lower extremities. 
 
 It is true that in toxic Insanity multiple neuritis is relatively 
 rare, but it would be a mistake to suppose that it does not occur 
 among the insane. It is, of course, not a coincidence, but a natural 
 sequence, that Insanity should result chiefly in those cases in which 
 the central and not the peripheral nervous system is attacked by 
 the toxic agent. 
 
 Labio-glosso laryngeal paralysis is another nervous disease hav- 
 ing symptomatic relations to Insanity, and also paralysis agitans, 
 and hereditary chorea, and disseminated cerebro-spinal sclerosis. 
 Cerebral tumors and thromboses modify the Insanity which they 
 cause, and give rise to symptomatic anomalies of the nervous sys- 
 tem, according to the sensory or motor cortical areas which they 
 involve by pressure, reflex irritation, or secondary inflammation. 
 
268 TEXT-BOOK ON MENTAL DISEASES. 
 
 Finally, it becomes evident, from the study of mental disorders 
 and of the array of diseases of the nervous system so constantly 
 associated with them, that both classes of phenomena have in most 
 cases a common pathogenesis, and that the point of symptomatic 
 attack is always the hereditary or acquired point of organic weak- 
 ness. Thus the selective points of attack in the human organism 
 exposed to the toxic effect of alcohol or the ravages of the syphilitic 
 virus may be the kidney, the liver, the vascular system, or the cere- 
 bral centres, according to individual immunity or vulnerability. 
 This view has some explanatory value in its application throughout 
 the entire field of the somatic symptomatology of Insanity. 
 
CHAPTEE VIII. 
 
 PATHOLOGY OF INSANITY. 
 
 Section I. — The Pathogenesis of Mental Disorders. 
 
 The present theories of the pathogeny of mental disease are based 
 on the scientific behef that mental manifestations arise from phys- 
 ical changes in nervous structures, and that in man the encephalon 
 is the material seat of all intellectual activity. 
 
 Physiological facts and pathological records not only support the 
 theory that the brain is the organ of the mind, but they show a cor- 
 responding and constant relation between mind and brain in nor- 
 mal evolution and in pathological decline. 
 
 First there are the broad physiological facts of the origin of mind 
 in the evolution of species, showing that throughout the whole ani- 
 mal kingdom the nervous system increases in complexity with the 
 corresponding rise in intelligence, that there is a correlative differen- 
 tiation among the higher animals of special faculties and of cerebral 
 structures, and that the maximum of complex brain-conformation 
 is attained in man as the most supremely intelligent animal. 
 
 Ethnological studies of past and present races of mankind, as 
 well as of teratological and individual degeneracies, confirm the fact 
 of a constant relation of degrees of intelligence to perfection or fail- 
 ure of brain development. 
 
 Naturally the physiological and psychological facts, that mind and 
 cerebral structures advance in complexity together, and that every 
 psychical process is attended by a corresponding change in the physical 
 substratum of mind, precede the further facts, confirmed by experi- 
 mental methods, that certain parts of the brain subserve certain men- 
 tal activities, and that the motor and sensory elements of mind have 
 in some degree been localized in cortical areas. Then there is the 
 further order of facts, that as the nervous structures of the brain 
 degenerate, from whatever cause, there is a pathological decline of 
 intelligence; that when vascular occlusion limits the morbid process 
 
 269 
 
270 TEXT-BOOK ON MENTAL DISEASES. 
 
 to definite cortical areas there may be corresponding limitation of 
 mental function in verbal or sensorial directions. 
 
 In a word, physiological experimentation and patliological ob- 
 servation sustain the present theory, that the mind and the brain 
 have inseparable correlations in health and in disease, and that no 
 mental derangement exists without corresponding cerebral disorder. 
 
 In view of these facts the pathogeny of Insanity is limited directly 
 to those factors which give rise to organic or functional cerebral dis- 
 orders. 
 
 In the fi-Tst place, then, a word must be said about the positive 
 and inherent differences of brains and of nervous constitutions with 
 which classes of individuals are natively endowed, and which deter- 
 mine largely the nature of the pathological result when tlie brain 
 is subjected to such factors of disease as are supposed to cause 
 Insanity. 
 
 The inherited insane diathesis exists in every degree of imperfect 
 or full development, and it is to be recognized by the presence of the 
 physical and psychical " stigmata degenerationis," which were de- 
 scribed under the head of symptomatology. 
 
 It is an undoubted fact that some individuals are endowed with 
 such stably constituted brains that the ordinary factors of mental 
 disorders produce no lasting effect on their cerebral functions, and 
 that others have inherited such instability of nervous centres that 
 slight inimical influences cause cerebral and mental derangement of 
 a permanent type, and to this latter class belong those who have the 
 inherited insane diathesis. The structural defects of cerebral mech- 
 anism found in idiots and imbeciles are not encountered in this class, 
 nor are the physical stigmata just alluded to always present, but, on 
 the contrary, as in the higher order of imbeciles, there may be an 
 exceptionally symmetrical conformation of face, body, and brain. 
 
 The inherited obliquity reveals itself through psychical channels, 
 often in connection with a considerable degree of unbalanced talent 
 displayed spasmodically in various directions, without well co-or- 
 dinated efforts, which lead to any decided results. Such individuals 
 usually have great egotism and intense imagination and much vain 
 ambition, and they make and lose friends, take and abandon posi- 
 tions, turn from one business or profession to another, and they have 
 many disappointments in life and become misanthropical and sus- 
 picious, and finally insane. The inherited insane diathesis also shows 
 itself in those who pass for eccentric in manners, dress, and modes 
 
PATHOLOGY OF INSANITY. 271 
 
 of thought and speech, in those noted for one-sided talents, and in 
 the numerous class known as odd, peculiar, and " cranky."' 
 
 This inherited insane diathesis is found in families in which epi- 
 lepsy, hysteria, chorea, consumption, and nervous diseases generally 
 abound, and it appears vicariously with these affections in the course 
 of generations in the same family, in which some members are found 
 to be insane, others epileptic, and others eccentric, and others a prey 
 to neuralgias, neurasthenias, and a host of minor nervous complaints. 
 
 Apart from those who inherit unstable brains are those born 
 sound in mind and body, who acquire instability of nervous centres. 
 
 T1ie acquired neurotic constitution may develop at any period of 
 adult life as the result of mechanical, thermal, or chemical injuries 
 to the nervous sj^stem, or as the sequel of acute infectious diseases, 
 or of prolonged illness from any cause. 
 
 The acquired neurotic constitution difEers from the inherited in- 
 sane diathesis through the absence of physical and psychical stigmata, 
 and in the fact that it is much less liable to be transmitted to off- 
 spring, or to assume the form of the major neuroses. It is char- 
 acterized on the other hand by weakness and instability of nervous 
 centres, by neuralgic complaints, spasmodic muscular disorders, and 
 minor nervous diseases, and diminished resistance to the causative 
 influences which directly develop Insanity. 
 
 In the study of the pathogenesis of mental disorders it is of prime 
 importance to bear in mind the pathological categories of individuals 
 here described, since they constitute a large contingent of all who 
 become insane, whatever the immediate exciting cause may chance 
 to be. 
 
 Functional hrain-exhaustion is a common source of mental dis- 
 order. Men may be worked to death as well as other animals, and 
 when a man breaks down from over- work he gives out in his weakest 
 organic point, which may chance to be the brain. All brain activity 
 takes place at the expense of waste of cerebral tissue, and if time is 
 not given for repair brain-exhaustion must result. Sleep restores 
 and repairs the worn cerebral tissues, but the intense activity of the 
 brain leads to hypersemia, which is inimical to sleep, and so much 
 blood and energy go to the brain that digestion and nutrition suffer. 
 An ill-nourished and over-worked brain has already lost its potential 
 equilibrium, and Insanity will follow this brain-exhaustion if rest, 
 which for the brain means sleep, is not quickly procured. 
 
 Brain-work never produces Insanity so long as the balance be- 
 
272 TEXT-BOOK ON MENTAL DISEASES. 
 
 tween waste and repair is maintained, and provided ordinary routine 
 work, however long the hours may be, is interrupted by reasonable 
 length of sleep. But original brain-work and unaccustomed mental 
 occupation demanding close attention and active thought, and the 
 discharge of functions of great responsibility much disproportionate 
 to the actual ability of the individual, may readily produce brain- 
 exhaustion, which also is apt to result when excessive mental labor 
 is combined with emotional strain. 
 
 Powerful emotions, painful anxiety, bitter disappointments, finan- 
 cial losses, and domestic misery are additional factors of brain-ex- 
 haustion, and they suffice to sunder mental fibres which are not 
 firmly knit. The strain which the mind will bear varies precisely with 
 such inherited or acquired strength or weakness as has already been 
 described, but even in the most firmly constituted individuals there 
 is a limit of human endurance, which cannot be surpassed by a cumu- 
 lative weight of miseries without a severance of the normal ties 
 which bind the mental functions in co-ordinate relations. "Witness 
 the inco-ordination of thought and action of the man upon whom a 
 series of calamities has fallen, the veritable distraction which is the 
 precursor of an acute psychosis. 
 
 Behold the dreamlike confusion, the staring and vacant look, 
 the vacillating gait and mien of the financier who has suddenly lost 
 his entire fortune. He may recover from the blow or he may suffer 
 from brain-exhaustion and Insanity, It is the suddenness and the 
 severity of the shock which form the chief danger in the latter in- 
 stance. The commotio cerebri in such a case is as real as if it had 
 been inflicted by direct physical violence, and the sequence of symp- 
 toms not infrequently resembles that of trauma capitis, or of spinal 
 concussion, as regards confusion of ideas, loss of memory, and in- 
 somnia. 
 
 It becomes evident, therefore, that brain-exhaustion, from what- 
 ever source it proceeds, plays an important role in the pathology of 
 Insanity. 
 
 The earliest nuiritive lesions and liochemical cerebral changes con- 
 stitute the prime pathological departures in incipient mental disease. 
 
 The first lesion is a defect of nutrition in brain-cells, which results 
 in a change in their chemical and molecular composition. It may be 
 a trophic excess, decrease, or perversion by which the brain-vessels 
 become surcharged with detritional products. After prolonged emo- 
 tional strain it is probable that excessive cellular metabolism ae- 
 
PATHOLOGY OF IXSANITY. 273 
 
 counts for this surcharge of effete material, which accumulates more 
 rapidly than it is removed, and in other cases there is an arrest of 
 retrograde metamorphosis and a retention of tissues which should 
 be renewed, and in a third and important class of cases there are 
 perverted biochemical changes in cerebral tissues, and the cellular 
 waste may have irritant or even toxic properties. It is true that auto- 
 toxic products are ordinarily conveyed to cerebral cells through the 
 circulation from distant systemic parts, but there is reason to pre- 
 sume that there may also be a genuine cerebral auto-intoxication. 
 
 By reason of these perverted biochemical changes there is irrita- 
 tion and increased flow of blood to cerebral tissues, and finally stasis 
 of the circulation of lymph, which becomes acid in reaction and 
 charged with toxic waste material and irritant to cerebral tissues, 
 which soon take on a subinflammatory condition. The result is 
 obstruction to circulation in cellular capsule and in perivascular 
 lymphatics, with deposit of pigment, leucocytes, and epithelial 
 debris, and, finally, cellular degeneration. 
 
 Insanity from circulatory disorders of the train arises chiefly in 
 intense hypergemic or anaemic forms. The cerebral supply of blood 
 is under the control of a complex vascular mechanism regulated 
 by vasodilator cerebral centres and by a vasoconstrictor medullary 
 centre. 
 
 Meynert taught that the brain-cortex itself has inhibitory and 
 vasomotor influences; and the direct supply of vasomotor nerves 
 to the cerebrum is from the cervical sympathetic ganglia, and the 
 distribution is to be the adventitial and muscular coat of arteries, and 
 also to the veins and capillaries. Quantitative variations of blood 
 within the cranial cavity and relative changes in pressure are regu- 
 lated largely by the entrance and escape of cerebro-spinal fluid from 
 the cranium. The displacement of the cerebro-spinal fluid is pri- 
 marily into the lymph-spaces as the volume of the cerebrum is in- 
 creased under intense hypersemia. There is also, under pathological 
 conditions, a direct vasoconstrictor or vasodilator influence locally 
 exerted on arterioles by the lymph charged with toxic exudates, and 
 as often as venous, capillary, or lymphatic stasis results from too 
 great intra-cranial pressure, there is impairment of cerebral nutri- 
 tion. 
 
 Cerelral hypercemia, of such severity as to cause Insanity, may 
 be of sudden origin from emotional shock, or of gradual develop- 
 ment, and it may be due to influences above enumerated or to vaseu- 
 18 
 
274 TEXT-BOOK ON MENTAL DISEASES. 
 
 lar degenerations, though the latter are usually sequels of the hyper- 
 semia. The congestion of the brain may be so intense that acute 
 maniacal delirium and death may result, but the more common se- 
 quel of chronic hypersemia is a series of degenerative changes in cells 
 and vessels and a terminal form of Insanity. Autopsical records 
 show evidences of chronic inflammatory engorgement of cerebral 
 vessels in confirmed forms of mental disease in about thirty-five per 
 cent, of the cases, irrespective of the lesions of general paresis and 
 of syphilitic dementia. 
 
 Cerebral ancemia is the cause of the nutritional impairment which 
 ends in melancholia, both acute and chronic, in very many instances. 
 
 The brain is deprived of its nourishment, and there is general 
 organic depression of vegetative as well as of intellectual functions. 
 There is a species of arrest of all vital processes as the direct result 
 of the diminished trophic energy and reduced vitality of cerebral 
 centres, which are no longer able to preside over nature's feast by 
 which all the organic tissues are daily nourished to satiety. The 
 result is disordered digestion and assimilation, reduced metabolism, 
 rapid wasting of tissues throughout the organism, the abeyance of 
 motor and sensory functions, and, in fine, melancholia fully devel- 
 oped. 
 
 If the cerebral anaemia is intense and prolonged, the brain-star- 
 vation ends in degenerative changes both in the vascular and ner- 
 vous tissues. It is true that the circulatory defect does not precede 
 the nutritive disturbance in all cases, and that in some states of 
 mental depression the cerebral malnutrition may be the antecedent 
 condition and causative of the ansemia, or the two factors may coin- 
 cide and contribute to the final pathological result. The distinction 
 between the two classes of cases is sufficiently marked, however, in 
 many instances in which the Insanity evidently has its pathogen- 
 esis in the circulatory disorder of the brain, 
 
 Qualitative changes in cerebral blood-supply, as well as the quan- 
 titative alterations Just mentioned, have pathological relations to 
 mental disorders. 
 
 The qualitative changes of the blood in the diiferent types of 
 Insanity were described under symptomatology. They appear often 
 in the earliest stages and even prior to the mental disease of which 
 they are the nearest pathological factor in some undoubted cases. 
 It is a physiological axiom that brain function is dependent on a 
 supply of blood proper, in quality as well as in amount, and it must 
 
PATHOLOGY OF INSANITY. 27o 
 
 be admitted that blood greatly altered in constitution, acting on 
 hereditarily unstable cerebral centres, may cause mental disorder. 
 Blood surcharged with biliary constituents may give rise to melan- 
 cholia, or when loaded with uric acid it may determine an attack 
 of gouty mania. 
 
 Blood deficient in corpuscles and in haemoglobin in cancerous 
 and malarial cases, and not only deteriorated but conveying direct 
 to cerebral tissues icherousand poisonous material, micro-organisms, 
 and pigment in large amounts, ma}^ derange cerebral functions. The 
 profound qualitative alterations, as well as the presence of micro- 
 organisms in the blood in pellagrous, tuberculous, syphilitic, and 
 other diathetic cases, have pathological relations to the mental dis- 
 order. 
 
 J'oxic states are to be mentioned in this connection, and in them 
 is to be sought the direct pathogeny of a considerable percentage 
 of all cases of mental disease. 
 
 The toxic agent may enter the system in gaseous, liquid, or solid 
 form by the lungs, skin, or primae visB. It may be animal, vege- 
 table, or mineral, taken voluntarily as stimulants or drugs, or ap- 
 pearing as a necessary evil attending certain occupations, or enter- 
 ing into the accidental adulterations of foods, or an admixture in a 
 staple article of diet of large classes of the community, as in ergot- 
 ism and pellagra in Europe. 
 
 The toxic principle, again, may be engendered in the organism, 
 as in the auto-intoxications, or it may consist in the specific germs 
 of the infectious diseases. The virus of the acute exanthemata may 
 give rise to disordered intellection before the appearance of high 
 temperature or of the eruption. The post-febrile psychoses are to 
 be attributed less to toxic influence than to profound anjemia and 
 nutritional anomalies. 
 
 The morbid anatomical changes which take place in the vessels 
 and nervous strictures of the brain in the toxic states will presently 
 be described in detail under the head of microscopic changes, which 
 in this instance constitute the organic lesions of the psychosis. 
 
 There are two toxic principles alone, which in their direct and 
 indirect pathogenic relations account for thirty-three per cent, of 
 all cases of Insanity. One of these is alcohol in its immediate and 
 remote causative effects, and the other is the luetic virus, including 
 its etiological bearings to general paresis. 
 
 Lesions of cerebral, spinal, or sympathetic nervous system are of 
 importance in the pathogenesis of mental disorders. 
 
276 TEXT-BOOK OX MENTAL DISEASES. 
 
 Diffused lesions of cerebral structures and those which involve 
 the cortical associative and intercellular fibres are especiallj'' effec- 
 tive causes of derangement of intellection, while disease at a lower 
 level affecting the projection sj^stem of fibres is of minor importance. 
 Hence disseminated sclerosis, widespread atrophy of cortex, and 
 periencephalitis are highly efficient factors of mental disease, in- 
 volving at once cortical cells and associative fibres, which are the 
 relational elements of mind. 
 
 Focal train diseases may disturb intellectual processes through 
 pressure, or by acting as a centre of reflex irritation, or by exciting 
 extended inflammation and secondary degeneration of cerebral 
 structures. 
 
 Tumors of the train may exert such pressure as to disturb the 
 circulation and nutrition of cortical centres, or they may cause epi- 
 lepsy and then Insanity. Extensive intra-cerebral hemorrhages are 
 not infrequently the cause of dementia, which also may proceed from 
 a great variety of coarse brain diseases, such as abscesses, encepha- 
 litic processes, cysticerci, hydatid cysts, aneurisms, and thrombosis. 
 As regards local softenings from embolic and thrombotic' affections, 
 the middle cerebral artery and its areas of distribution are the most 
 often involved, and then the posterior and anterior cerebral in the 
 order named. Secondary inflammation and oedema are superadded 
 to the primary focal disease, which may modify largely the nature 
 of the mental disorder, which usually is characterized by sensory 
 disturbances and amnesic failure, and great emotional irritability. 
 
 The disseminated atrophy of senile involution being a widely 
 diffused lesion of the cortical organ of the mind, is naturally attended 
 by a general impairment of all the mental faculties which may at- 
 tain the degree of absolute fatuity. 
 
 Softening of the brain is found in some degree, post-mortem, 
 in more than one-half of all chronic cases of Insanity, and unques- 
 tionably it exists at a relatively early stage in a certain proportion 
 of cases. 
 
 Atrophy of the train is one of the most universal of chronic 
 lesions among the insane. It is sometimes limited to the special 
 areas of terminal arterial distribution, and in other cases it is gen- 
 eral as regards cortical regions, though, when thus widely diffused, 
 it is never entirely uniform in degree in different localities. 
 
 Lesions of the spinal nervous system precede or follow mental 
 disorders, to which in some instances they stand in immediate path- 
 ological relation. 
 
PATHOLOGY OF INSANITY. 277 
 
 Thus locomotor ataxia may be the initial degeneration which 
 is destined to end in mental disorder, and there are other extensivb 
 organic spinal diseases which may be viewed in the same light. The 
 broadest pathological view, however, is to regard descending cerebral 
 lesions, ascending spinal lesions, and mental disorder in tabetic and 
 paretic eases as common symptoms of a general trophoneurosis with- 
 out regard to the order of appearance of the morbid processes. 
 
 Lesions of the sympathetic nervous system probably play an im- 
 portant role in the pathogeny of mental disorders, but there is an 
 element of obscurity yet to be removed by further research before 
 positive statements can be made as to the pathological relations 
 of the sympathetic diseases to Insanity. 
 
 That the vasomotor system is under sympathetic control accounts 
 for some of the vascular disturbances which are recognized as fac- 
 tors of mental disease. 
 
 In melancholia attonita as the immediate result of a sudden emo- 
 tional shock, or in primary dementia from a like cause, the patho- 
 logical nervous process is best explained when the sympathetic ner- 
 vous system is recognized as immediately involved in the stasis of 
 the cerebral circulation which is the direct sequel of the violent 
 excitement. The prime symptom of syncope in such cases from 
 angiospasm is a sympathetic phenomenon. Cerebral angioneuroses, 
 however, in relation to Insanity, have yet to be thoroughly studied. 
 
 Reflex or sympathetic Insanity from disease of internal organs 
 deserves a mention in pathological connections, and, in the opinion 
 of former writers, it held a very prominent place in the pathology 
 of mental disease. 
 
 Whatever theories may be held as regards the subject, the clinical 
 fact remains that Insanity is a direct sequel of inflammatory affec- 
 tions of viscera, of heart disease, of gastro-intestinal disorders, and 
 of affections of the reproductive organs. 
 
 For full particulars under these heads reference is made to the 
 chapter on etiology. The pathology in these cases may be indirect, 
 as in rheumatic inflammation of the heart, giving rise to cerebral 
 embolism and softening and dementia, or in other acute inflamma- 
 tions of viscera resulting in vascular disorder and malnutrition of 
 cerebral centres. But in other cases the psychosis follows the vis- 
 ceral affection so directly that its reflex origin would seem to be 
 the only pathological explanation, especially as recurrences of the 
 two affections may coincide, and the relief of the mental disorders 
 
278 TEXT-BOOK ON MENTAL DISEASES. 
 
 may follow directly upon the cessation of the disease of the internal 
 organ. 
 
 Epochal systemic changes are active at the age of puberty and at 
 the grand climacteric. The epoch of the development of the repro- 
 ductive function and of its attendant mental and moral changes is 
 especially critical for those having hereditary predisposition to In- 
 sanity. This pubescent Insanity is more common in women, and 
 adolescent Insanity, which is also a developmental type, occurs more 
 frequently in men at a somewhat later period in life. 
 
 The epoch of the menopause in women also calls forth any latent 
 tendency to mental disease, and here again, occurring at a more ad- 
 vanced age, is an involutional type of Insanity in men, presenting 
 usually vascular degenerations and slight atrophic cerebral proc- 
 esses, such as initiate the senescent period. 
 
 The forms of mental disorder proceeding from the epochal sys- 
 temic changes are ordinarily termed involutional and evolutional 
 Insanities. These epochal systemic changes must be included, there- 
 fore, in this general pathological review. 
 
 Cerebral traumatism, thermic, chemical, or mechanical, holds 
 a positive place in the pathogenesis of mental disorders. 
 
 Thermic traumatism may arise either as insolatio, from the direct 
 heat of the sun, or from artificial heat of a high degree, to which 
 some are necessarily exposed by their occupations. 
 
 In either case, if the heat is sufficiently extreme and the exposure 
 long continued, pathological lesions of cerebral centres follow, as 
 the direct result, or as a remote sequela, and Insanity or death may 
 likewise be an immediate or indirect result. 
 
 Chemical traumatism is most surely and suddenly produced by 
 the inhalation of toxic gases, which are conveyed in the blood di- 
 rectly to cortical centres, which may be thrown by the shock into 
 permanent functional disorder. 
 
 The inhalation of illuminating gas and of various poisonous 
 fumes in chemical works may determine this form of cerebral trau- 
 matism, which may also be occasioned by the prolonged adminis- 
 tration of anaesthetics, which have caused a large number of cases 
 of Insanity. 
 
 In one case of this kind which came under the writer's care the 
 patient passed directly from the anaesthetized state into acute mania 
 of some weeks' duration. It is true that the ansesthetic in probably 
 all of these cases is only an efficient cause when there is great insta- 
 bility of cerebral centres. 
 
PATHOLOGY OF INSANITY. 279 
 
 Mechanical traumatism may occur in a great -variety of forms. 
 Tlie injury may implicate cranial bones, or membranes, or the cere- 
 bral substance. 
 
 Commotio cerebri without laceration is common from falls or 
 blows upon the head, or from " contre coup," the violence being 
 transmitted in some cases by the spinal column. 
 
 The Insanity may follow the cerebral concussion in a few hours 
 or at distant intervals. In certain cases of trauma capitis the men- 
 tal disorder is the instantaneous product of the violence, so that the 
 patient is literally, as expressed in common parlance, "knocked 
 crazy." 
 
 Ordinarily, trauma capitis leads to mental disorder through a 
 series of chronic secondary lesions of vascular and nervous struct- 
 ures dependent in nature on the original site and character of the 
 injury. Progressive cortical atrophy as one of the sequels may 
 give rise to a train of sjrmptoms like those of general paresis. The 
 cerebral lesions more often involve the gray than the white matter, 
 and the disintegration of cells and fibres is of the most varied nature, 
 and there are not infrequently descending system-fibre degenera- 
 tions. 
 
 In one class of cases the psychosis is secondary to the epilepsy 
 caused by the trauma capitis. 
 
 The severity of the traumatic injury does not determine the 
 probabihty or the serious nature of the ensuing Insanity, which 
 may be a sequel of relatively trivial accidents. 
 
 Surgical traumatism may be followed by Insanity, and the hered- 
 itary tendency to mental disorder is to be taken into consideration 
 in all capital surgical operations. Even minor surgical operations 
 in alcoholic cases may evoke maniacal symptoms. This is a rare 
 source of mental disease, but it is not without real importance. It 
 is also to be recognized that the traumatic origin of Insanity em- 
 braces the whole nervous system, and is not confined simply to in- 
 juries of the head. 
 
 Emotional traumatism includes all the repeated moral " shocks 
 that flesh is heir to," which may disturb the functional equilibrium 
 of the mind. If severe emotional vibrations are frequent they may 
 derange nutrition and the molecular structure of the brain. The 
 pathogenesis of Insanity is often found in violent passions and over- 
 whelming emotions. 
 
 The most decided instance of emotional traumatism is the power- 
 
280 TEXT-BOOK ON MENTAL DISEASES. 
 
 ful passion, the anger, which transports the sufferer into the realms 
 of rage, or into a maniacal paroxysm, or the horror which transfixes 
 the person and paralyzes muscular and intellectual action at one 
 blow. The paralysis of intellect may be instantaneous and complete, 
 and the patient may pass through the stages of primary dementia 
 before recovery. 
 
 Keference is made to the chapter on Etiology to avoid the repe- 
 tition of much which was there said of the setio-pathology of mental 
 disorders, and after this general survey of the chief pathological 
 factors, attention will now be directed to the morbid anatomy of 
 Insanity. 
 
 Section II. — The Pathological Anatomy of Insanity. 
 
 The macroscopical changes will first be described. 
 
 The cranium has congenital malformations, volumetric varia- 
 tions, and asymmetries, which were described in the chapter on So- 
 matic Symptomatology. 
 
 The bones of the skull in some cases are greatly thickened by 
 an increase and rarefaction of the diploe, as the result of inflamma- 
 tory action, and they are still relatively light in weight. There are 
 chronic adhesions of the dura mater to the inner table with local 
 points of osseous thickening from the oft-repeated vascular engorge- 
 ments. In other cases the diploe is encroached upon by the thick- 
 ening of both the outer and inner tables of the skull-cap, which is 
 exceedingly dense in structure and of great weight. The osseous 
 sclerosis and the extent of the thickening in some cases is remark- 
 able, especially in shrinkage of the brain from early encephalitic 
 processes with compensatory thickening of the calvaria. This type 
 is common in chronic cases of Insanity. 
 
 The cranial bones in other instances are extremely dense, but 
 not of unusual thickness. This is the eburnated tj^pe of skull also 
 found in terminal forms of Insanity. The skull-cap may be ex- 
 tremely thin and even diaphanous at the vortex. The osseous hy- 
 pertrophy is most common in frontal regions, and exostoses are rare. 
 The vascular channels of the vitreous table are more frequently 
 deepened than obliterated, and the Pacchionian depressions are often 
 exaggerated. 
 
 Spiculae of bone and osteophytes are exceptionally found. The 
 calvarium in senile Insanity often shares in the general atrophic 
 
PATHOLOGY OB INSANITY. 281 
 
 processes, and is usually thin in advanced cases, and it is also modi- 
 lied by toxic and diathetic influences, with exostoses or necrosis in 
 syphilitic cases. In general, hypertrophic processes of cranial bones 
 are twice as frequent as atrophic anomalies. 
 
 The brain among the insane presents post-mortem vascular 
 microscopical appearances according to the mode of death, the 
 cadaveric position of the body, and the order of autopsical exam- 
 ination. 
 
 Thoracic obstructions to the return of the venous cerebral supply 
 intra vitam favor venous congestions post-mortem, as does also a 
 lowered recumbent position of the head, while the opposite effect 
 is produced by the opening first on autopsy of the large thoracic 
 vessels, which deplete the cerebral regions of fluid. 
 
 In about twenty-five per cent, of all cases there are adhesions 
 of the pia mater, so that minute ragged bits of the external cortical 
 layer are removed with the pia, exposing in the torn cortex pin-point 
 and bleeding lumina of severed vessels. In other instances there 
 are bright-red hemorrhagic patches of irregular size and outline, 
 indicative of a certain grade of inflammatory action. 
 
 Extreme vascularit}' of the brain is not as common as the op- 
 posite state of angemia. In a certain proportion of perhaps one- 
 third of the autopsies the brain is found greatly congested, the 
 puncta vasculosa well marked (though they are not a reliable index), 
 and general signs of inflammatory engorgement. In about one- 
 half of the cases there is every sign of cerebral anaemia, which is 
 heightened in diathetic, and especially phthisical, disease. The 
 surface of the brain is then extremely pallid, and the whole sub- 
 stance may have a water-soaked appearance. This exsanguinated 
 look may be present whenever there is great ventricular distention 
 or intra-eranial pressure from foreign growths or from hemorrhages, 
 or any other cause of exclusion of blood from the peripheral cere- 
 bral parts. Local hypersemias and anaemias dependent on occlusion 
 of cerebral vessels, and the various stages of the resulting inflamma- 
 tion, cedema and softening, are to be seen. 
 
 Cerebral atrophy is the most constant pathological change found 
 among the insane. It is present in some form in about two-thirds 
 of all cases, and both the cellular and medullated structures are 
 affected, and, in fact, the atrophic process is general rather than 
 local, and it extends even to the central ganglia. It may result from 
 vascular degenerations, from connective-tissue proliferation and 
 
282 TEXT-BOOK ON MENTAL DISEASES. 
 
 subsequent contraction, or from trophic cellular degenerations. It 
 is usually a sequel of acute Insanity, but in its most extensive form 
 it may follow early encephalitic processes, and in other instances 
 it is only an exaggeration of the involutional changes of senescence. 
 
 The frontal lobe of the brain suffers most uniformly in atrophy, 
 and the convolutions have a flattened appearance, especially when 
 compressed by compensatory effusions. Organic, senile, and paretic 
 dementia, in the order named, afford the most decided degrees of 
 atrophic diminution of brain-weight. Local atrophies of cortical 
 areas from embohc or thrombotic affections are common, and Bevan 
 Lewis reports the order of frequency of localized atrophies to he 
 as follows: Postero-parietal lobule, central gyri, frontal gyii, oper- 
 culum, temporo-sphenoidal gyri, occipital gyri. 
 
 Softening of the train is a frequent result of Insanity, and it is 
 found in about one-half of those dying insane. It arises from in- 
 flammatory affections, especially of the vessels, and from oedema, 
 or intra-cranial hemorrhages, or senile fatty degenerations of cere- 
 bral tissues. 
 
 On the removal of the brain from the cranial cavity there is 
 evidence of oedema, often, and the whole brain feels limp and de- 
 void of normal firmness, and it flattens out, by its own weight, in 
 whatever position it is placed, and the sulci are separated and the 
 tissues may rupture, especially the commissures, which are also soft- 
 ened in many instances. 
 
 There are various degrees of softening, which may be general, 
 or partial from vascular occlusions, especially of the middle cerebral 
 artery. When much softened the medullated substance yields to 
 slight pressure of the finger and washes under a stream of water, 
 falling a few inches, and the corpus callosum tears as the hemi- 
 spheres fall apart when the brain is placed on its base. Some parts 
 of the brain may be cream-like in consistence, and the basal ganglia 
 and the medulla, in exceptional instances, are involved. 
 
 Inflammatory degenerations of vessels give rise to hemorrhages 
 and softening, but the latter follows thrombosis more frequently. 
 
 Ganglionic ' softening, according to Bevan Lewis, is most fre- 
 quent in the following order: Intra-ventricular nucleus, optic thala- 
 mus, lenticular nucleus, and external capsule. 
 
 Circumscribed softening about tumors, hemorrhages, and throm- 
 botic clots is the result of inflammation excited by the focal disease, 
 and it is especially common in organic dementia. 
 
PATHOLOGY OF INSANITY. 283 
 
 The most diffused cortical softening is found as the result of 
 periencephalitis in general paresis, in which it is most marked in 
 the frontal lobe. 
 
 As regards pathological lesions of cortical regions among the 
 insane, it would seem that the frontal lobes suffer most, and then 
 the parietal and the occipital, and this is especially true as regards 
 atrophic processes. The convolutions most often involved in local- 
 ized softenings from focal disease are the superior temporo-sphe- 
 noidal and the occipital. The posterior portion of the inferior fron- 
 tal convolution is frequently diseased in organic dementia. 
 
 As to the central ganglia, Charcot long ago called attention to 
 the frequency of lenticular hemorrhage, and Bevan Lewis has found 
 that the intra- ventricular nucleus suffers most frequently from focal 
 disease among the insane, and lesions of the basal ganglia are sup- 
 posed by some to be pathological factors in choreic Insanity. 
 
 'The nerve-fibre systems are degenerated not infrequently in 
 toxic, diathetic, tabetic, and paretic cases. 
 
 The centrum ovale is sometimes softened, and at other times 
 it has a firmer consistence than normal. It is frequently the site 
 of miliary sclerosis, and also of focal lesions. 
 
 The ventricles are often greatly distended with fiuid, and they 
 sometimes contain hemorrhagic effusions, and their lining mem- 
 branes are granulated, and this pathological change is common on 
 the floor of the fourth ventricle in epileptic ' and chronic cases of 
 Insanity. 
 
 The pons Varolii is occasionally implicated in the diffused le- 
 sions of toxic Insanity. 
 
 The medulla oblongata may suffer in either descending or as- 
 cending lesions of brain or spinal cord, as in paretic or tabetic eases. 
 It is also the seat of softening and of tumors in exceptional cases. 
 The bulbar lesions which determine in part the speech defects in 
 general paresis are relatively constant. The softening in the floor 
 of the fourth ventricle will occasionally be found associated with 
 atheroma and thrombosis of the basilar artery and pathological le- 
 sions in this locality often occasion sudden death in Insanity. 
 
 Tlie membranes of the train are very generally involved in the 
 pathological processes. 
 
 The dura mater is normally adherent to the calvarium at the 
 basal foramina, but in about twenty-five per cent, of the autopsies 
 made among the insane some abnormal adhesion exists apart from 
 
284 TEXT-BOOK ON MENTAL DISEASES. 
 
 sutural and foraminal connections. The adhesions may be unilat- 
 eral, but they are more frequently bilateral and partial, being most 
 frequent over the greatest convexity of the frontal and parietal 
 bones and at sutural points. Occasionally the adhesions are very 
 general, and so firm that great force is required to tear the mem- 
 brane from the bone, and in rare instances the separation is impos- 
 sible. 
 
 Many of the severe neuralgic pains of the head among the insane 
 are doubtless due to inflammatory exudation and compression of the 
 dural filaments of the fifth and twelfth nerves, an affection first 
 pointed out by Duret, as quoted by Bevan Lewis (" Mental Diseases," 
 p. 435). 
 
 The dura mater is occasionally thickened in cases of adhesions, 
 and it is sometimes the seat of chronic internal pachymeningitis 
 with formation of new vessels and adventitious membranes, and in 
 rare instances it presents points of ossification. 
 
 Tlte pia mater, macroscopically viewed, is thickened and opaque 
 in the majority of chronic cases of Insanity. The opacity is chiefly 
 over vertical regions, and it is most marked along the course of ves- 
 sels, and it points to previous inflammatory conditions whenever ac- 
 companied by adhesions to cerebral substance, but in senile cases 
 it would seem to occur as the natural result of repeated congestions 
 and of involutional changes. The pial vessels are often lengthened, 
 dilated, and varicose in appearance, and distended with blood, pig- 
 ment, and debris. The pial adhesions which give the eroded aspect 
 to the surface of the brain after the removal of the membrane have 
 already been mentioned. The choroid plexuses are sometimes en- 
 larged and contain cystic dilatations. 
 
 In general paresis the pia mater is ordinarily deeply implicated 
 in the pachymeningitis interna hemorrhagica, and likewise in syph- 
 ilitic and alcoholic dementia it is the seat of chronic inflammatory 
 changes. 
 
 The arachnoid is thickened by chronic inflammatory processes in 
 many cases, and the arachnoidal space is distended with fluid. The 
 opacity and oedema are most marked in vertical regions, and the 
 amount of the subarachnoid fluid is often very great. 
 
 There are also arachnoid cysts, in paretic cases, which have usu- 
 ally been regarded as of inflammatory origin, but Bevan Lewis thinks 
 they are hemorrhagic in nature. The Pacchionian bodies are some- 
 times enlarged in alcoholic cases, and at other times they are dimin- 
 
PATHOLOGY OF INSANITY. 285 
 
 ished in size without relation to morbid processes in other parts 
 of the arachnoid. When large they may indent the skull. 
 
 The ependyma is often thickened in chronic Insanity, as well as 
 in cases of congenital mental defect. There are sometimes granu- 
 lations to be seen in the lateral ventricles as well as in the fourth 
 ventricle. 
 
 In epileptic Insanity this granulation of the ventricular epen- 
 dyma is very marked, as well as in alcoholic and paretic cases. 
 
 Cerebral anemia is the most common naked-eye appearance of 
 cerebral tissues in those dying insane. Few vessels are to be seen, 
 puneta vascvilosa are not apparent on section, and both the cortical 
 and medullated tissues are pallid. HyperEemia, on the other hand, 
 is striking in some cases in which the gray matter is highly colored 
 and the white substajice pinkish on section, and the puneta vascu- 
 losa extremely numerous. 
 
 Cerebral atrophy is also readily appreciated by macroscopical 
 appearances. The convolutions in extreme cases are plainly wasted, 
 the cortical gray is very thin, the sulci gape, and there is compensa- 
 tory effusion of fluid, and the ventricles are often found distended, 
 and there are alterations in the firmness of cerebral tissues, which 
 may be either harder or softer than normal, and there are also 
 changes in color in both gray and white substance. Apparent cere- 
 bral hypertrophy, due to extreme congestion of the brain, is a state 
 which exists before and after death in Insanity. The whole brain 
 appears too large for the skull-cap. The convolutions are pressed 
 and flattened against the bony walls, the sulci partially obliterated, 
 and superficial vessels may be emptied of their contents by the 
 intra-cranial pressure, though cortical layers often appear extremely 
 congested, as well as the entire white substance. Connective-tissue 
 hypertrophy in epileptic Insanity is very exceptional, and in imbe- 
 ciles it is more often found. The brain, when removed, cannot again 
 be contained by the skull-cap, and the general appearances are such 
 as those just described, except that the superficial vessels are uni- 
 formly anaemic in appearance, as well as the gray and white matter, 
 through expulsion of the blood by pressure. 
 
 (Edema of the 'brain is a sequel of atrophic and inflammatory 
 processes, and it may be evident in the gray or the white substance 
 following vascular engorgement. The tissues, on section, have a 
 watery and shining appearance and are reduced in consistency. 
 There are also local cedemas about focal lesions. 
 
286 TEXT-BOOK ON MENTAL DISEASES. 
 
 Infiammation of the brain among the insane usually affects lim- 
 ited portions about embolic lesions, or tumors, or hemorrhagic effu- 
 sions, but in paretic and some toxic cases it may implicate extensive 
 cortical areas, and in traumatic Insanity there may be a wide ex- 
 tension of the inflammatory process from the original seat of injur\\ 
 
 Sclerosis of medullated tissues exists in a disseminated form in 
 toxic Insanity, but the most frequent type of miliary sclerosis will 
 be noticed later. 
 
 Abscesses are exceptionally found in the brain, and they may 
 be present in organic dementia. 
 
 Tumors are often surrounded by inflamed or softened tissues, 
 and they can usually be distinguished by the unaided eye from nor- 
 mal brain-structures; they are common in syphilitic Insanity. 
 
 Hemorrhages into cerebral tissues are not infrequent among the 
 insane. They may occur from rupture of capillaries or of arteries, 
 and the effused blood may occupy the most various localities. 
 
 Blood sometimes escapes into the ventricles or into the cavity 
 of the arachnoid. Secondary hemorrhages, from the rupture of 
 newly formed vessels, is also common in cortical membranes in 
 pachymeningitis among general paretics. 
 
 The cerebral vessels are more frequently diseased in the insane 
 than in the sane. The general vascular system may appear normal 
 while the cerebral arteries are clearly diseased. The vertebral and 
 the internal carotid arteries are very frequently affected. Fatty de- 
 generation and atheromatous changes are the most frequent lesions 
 of the cerebral arteries. The basilar artery is also involved in many 
 eases, as well as parts of the circle of Willis, in which a glance or a 
 touch will often reveal atheromatous patches. 
 
 The coarser forms of embolism, thrombosis, and aneurism are 
 to be detected on maeroscopical examination, and the expert pathol- 
 ogist will also, by skilled sight and touch of dissected vessels, sur- 
 mise, with a certain accuracy, the degree of arteriosclerosis and of 
 atheromatous degeneration of arteries in syphilitic, alcoholic, and 
 paretic cases. For the middle cerebral artery most frequently af- 
 fected, the areas of distribution most often invaded by embolic and 
 thrombotic softening are, according to Bevan Lewis, in order of 
 precedence of the arterial branches involved, as follows: Parieto- 
 sphenoidal, ascending frontal, ascending parietal, external and in- 
 ferior frontal arteries. 
 
 The spinal cord often presents morbid appearances. 
 
PATHOLOGY OF INSANITY. 287 
 
 The membranes are sometimes the evident seat of inflammatory 
 action and are thickened and adherent to each other or to the cord 
 with serous and hemorrhagic effusion. There may be opacity as well 
 as thickening of the arachnoid, and local firm attachments of the 
 membranes to the cord, especially posteriorly. 
 
 Descending system-fibre lesions of the cord are doubtless deter- 
 mined somewhat by the cortical areas primarily degenerated, though 
 they may arise through vasomotor influence as well as by direct con- 
 tiguity of pathological processes, in toxic and paretic cases. In some 
 instances the presence of disease in spinal regions may be recognized 
 upon autopsy by the naked eye. 
 
 Atrophy and sclerosis, and even softening, are to be encountered. 
 The posterior and lateral columns are the most often affected, and 
 the pyramidal tracts furnish the most common instance of descend- 
 ing system-fibre degeneration. The spinal cord in toxic, tabetic, 
 and paretic cases may be the primary seat of pathological changes, 
 and there may then be ascending lesions by direct extension of the 
 morbid processes or by the propagation of the disease under vaso- 
 motor influence. 
 
 It is not unlikely that the point of greatest vulnerability and 
 of first attack of pathological changes is determined by personal 
 idiosyncrasy. 
 
 It is not impossible, even when the trophoneurosis is fully devel- 
 oped, that the point of its first manifestation may be decided by 
 relatively fortuitous circumstances, such as cerebral exhaustion in 
 brain-workers, or spinal exhaustion from specially laborious occu- 
 pation, combined with sexual excess. 
 
 The Microscopical Changes. — The cortical cells in different forms 
 and stages of Insanity undergo various disintegrations, which are 
 to be recognized upon fresh frozen sections, or in those prepared 
 from brain-substance preserved and hardened by various reagents. 
 In the description of morbid changes the term neuron is synonymous 
 with axis-cylinder process and its medullated prolongation, and 
 dendron is applied to the subdivisions of all other processes, which 
 end in arborization more or less complete. 
 
 The order of disintegration of individual cells and of the cellular 
 layers of the cortex varies much in different types of Insanity, but 
 in general it may be said that the larger cells are the first to suffer, 
 and that the processes and the protoplasmic body of the cell degen- 
 erate before the nuclei and the neurons. As an exception to this 
 
288 TEXT-BOOK ON MENTAL DISEASES. 
 
 observation, in epileptic Insanity, more especially, there may be a 
 primary fatty degeneration of the nuclei of cells, and, as in some 
 way the nucleus is supposed to exert an influence over the nutrition 
 of the entire cell, it is possible that often primary change, not read- 
 ily recognized, takes place in the nucleas before further disintegra- 
 tion of other cellular parts. There are certain modes of disintegra- 
 tion relatively important and distinct in their nature. 
 
 One is a trophic disintegration, beginning primarily in the cellu- 
 lar elements, as an intimate disturbance of nutrition. 
 
 Another is secondary to vascular disease, through which the 
 nerve-cells are deprived of due nourishment. 
 
 And a third form of disintegration follows an excessive prolifera- 
 tion of connective-tissue elements, leading to the final destruction 
 of the nerve-cells. 
 
 It is not improbable that there are originally defective cells, 
 which have such native imperfections of constitution that even se- 
 vere functional strain suffices to cause their disintegration. 
 
 The apical processes of cells not infrequently undergo granular 
 degeneration before the basilar processes, which in turn usually dis- 
 appear before the nerve-fibre process is affected. One of the most 
 deferred changes is that by which the neuron is deprived of its 
 medullary sheath. 
 
 The nucleoli of the large cells may disappear, while the nuclei 
 still remain in situ, and this exceptional change has been observed 
 in the pyramidal cells of the cortex. 
 
 The granular degeneration of cells is one of the most constant 
 pathological changes in Insanity. The whole body of the cell and 
 the larger processes first become enlarged, and may even present 
 an oedematous appearance, and their angular outlines disappear and 
 they assume a rounded contour. The protoplasm of the cell is re- 
 placed by minute grantiles, which are also to be seen in the apical 
 process, and the nucleus of the cell-changes shapes and gradually 
 disappears as the cell-body shrinks, and, with the general reduction 
 in size of the cell, the processes diminjsh and fade from view, and 
 all that remains to be seen finally is a rounded collection of gran- 
 ules with the basal process devoid of medullary covering. In some 
 specimens the nucleus, much degenerated, is still to be detected in 
 the midst of the grannies representing the cell, and spread out in 
 loose and irregular outlines. The smaller cells as well as the larger 
 undergo this form of disintegration. 
 
PATHOLOGY OF INSANITY. 289 
 
 Fatty degeneration describes more accurately the morbid state 
 in which the cells are found, in some instances filled with fat-gran- 
 ules, while the vessels have also undergone fatty degeneration. 
 Even the nuclei of cells suffer this fatty change, especially in alco- 
 hoUc and epileptic cases, and even fat-emboli may be an associ- 
 ated condition. 
 
 Pigmentation of nerve\cells is another common pathological ap- 
 pearance. 
 
 The normal pigment of cortical cells sometimes disappears com- 
 pletely in granular forms of degeneration, but in the present affec- 
 tion there is not merely an increase of the normal pigment, but an 
 active invasion of the protoplasm of the cell by yello\\ash or brown- 
 ish pigment, which may be found to vary much in color and amount 
 at diff'erent stages of the morbid process. 
 
 Pigmentation would seem to be a sequel of vascular congestions 
 and excessive brain activity, and it is found in various confirmed 
 types of Insanity, in alcoholic, epileptic, and paretic cases. 
 
 The first change is a swollen and rounded appearance of the 
 larger cortical cells, which most distinctl}'' show the invasion of pig- 
 ment. The nucleus of the cell is displaced and deformed, and may 
 itself be pigmented and diminished in size. The processes disap- 
 pear, with the exception of the apical and basilar, which may be both 
 pigmented and atrophied. The non-pigmented protoplasm of the 
 cell about the nucleus is clearly demarcated from the invaded por- 
 tion. As a final morbid change, the granular pigment is replaced 
 by a light-refracting fatty material and the cell wastes into a granu- 
 lar debris. 
 
 Vacuolation of cells is another frequent pathological change, 
 which may be imitated readily by artificial means of chemical and 
 mechanical treatment of specimens, but it is also an undoubted 
 product of disease. It appears most uniformly in connection with 
 granular degeneration in senile and alcoholic and other forms of 
 toxic Insanity. Various experimenters have by toxic agents pro- 
 duced this lesion in the nerve-cells of animals. 
 
 Vacuolation is the appearance within the cell of oval or rounded 
 fatty particles, which disappear and leave in the cellular protoplasm 
 minute openings having the size and contour of the particles men- 
 tioned. 
 
 One or several vacuoles may be present in the same cell, and the 
 protoplasm of the larger cells may present numerous punctures of 
 19 
 
290 TEXT-BOOK ON MENTAL DISEASES. 
 
 this nature. In epileptics vaciiolation also occurs in the small cells 
 of the second cortical layer as described by Bevan Lewis, who, in 
 general, attributes vacuolation to '' the accumulation of hydrocarbon 
 in the tissues from defective oxidation." 
 
 J. Batty Tuke and Woodhead mention the occurrence of vacuo- 
 lation in idiopathic mania in connection with both pigmentary and 
 granular degeneration. 
 
 The vacuolation of the body of the cell is more common in the 
 motor areas of the cortex and in the anterior cornua of the spinal 
 cord, in which locality it has been produced by artificial experimen- 
 tation also in animals. 
 
 There is also a nuclear vacuolation in which fatty deposit first 
 takes place in the nucleus of the cells. 
 
 The nucleus disappears, leaving in the cell a puncture of its own 
 size and shape, and this change also appears in connection with 
 pathological conditions of the entire cell, which ultimately degener- 
 ates. 
 
 Colloid degeneration is found in the brain or spine among those 
 dpng insane, and the morbid change is closely allied to miliary 
 sclerosis, and it has been reported in cases of traumatic injury of 
 the nervous centres. 
 
 It consists in the presence of small oval or rounded bodies, which 
 are translucent, colorless, and scattered through medullated tissues 
 of the brain, medulla, or cord. It is a degeneration of nerve-fibres, 
 and it has an inflammatory origin, or m-ay be due to the loss of the 
 trophic influence of the cortical cell over the fibre. J. Batty Tuke 
 connects it directly with " change occurring in the hyaline sheath," 
 and reports the presence of colloid bodies beneath the visceral pia 
 and the epithelium of the ventricles in senile dementia. 
 
 Whatever may be the origin of colloid bodies, they are found 
 intimately connected ^vith the axis-cylinders and nerve-fihres, and 
 are a trophic lesion often present in chronic Insanity. 
 
 Miliary sclerosis is a common lesion of the medullated structures 
 of the brain and spinal cord of the insane. It appears as white, shin- 
 ing, lobular granules, irregularly distributed amid the fibres or ag- 
 gregated in sclerotic patches found most often in the lateral spinal 
 columns, in the pons, medulla, or white substance of the brain. 
 
 Its intimate nature, according to J. Batty Tuke, who first de- 
 scribed it, is " altered myelin exuded in droplets from the medullated 
 tubes," and the idea is accepted in view of researches by Bevan 
 
PATHOLOGY OF INSANITY. 291 
 
 Lewis, who pointed out this mode of origin, which he attributed to 
 vascular implication and exudation, causing swelling of the myelin 
 and rupture of the surrounding sheath. 
 
 The sclerosis would appear, therefore, to be secondary to chronic 
 inflammatory vascular changes with proliferation of connective-tis- 
 sue corpuscles, known commonly as Deiter's cells. The axis-cylin- 
 ders are displaced and in some instances ruptured as the result of 
 the miliary sclerosis. 
 
 Moniliform change in medullated fibres is present, consisting 
 in uniform constrictions of the neuron, giving to the fibre a knotted 
 appearance, which, in speaking of the basal nerve-fibre process, Lewis 
 describes as " spherical masses of medulla strung upon the axis- 
 cylinder like beads upon a string." 
 
 Phagocytes are connective-tissue cells concerned in removal of 
 waste-tissue products or of degenerated nerve-substance. They are 
 represented as actively consuming such effete material or of trans- 
 forming it and conducting it into vascular channels. 
 
 Thus, in all established forms of Insanity with chronic vascular 
 inflammation and obstruction of lymph circulation, there is a pro- 
 liferation of connective-tissue cells which, acting as phagocytes, re- 
 move the degenerated nerve-cells. 
 
 It would seem that these protoplasmic glia-cells, as Andriezen 
 terms them, are not the only brain-phagocytes, as J. B. Tuke re- 
 ports that leucocytes have played a phagocyte role toward the large 
 motor cells of the cortex. 
 
 If nerve-cells, which are the ultimate organic elements of mind, 
 are liable, when diseased, to be fully destroyed or removed in toto 
 by overaction of phagocytes, it is plain that these scavenger cells 
 are of the greatest pathological importance in many forms of In- 
 sanity. Hence it becomes desirable to consider at some length the 
 elements of the neuroglia in their pathological relations. 
 
 The smaller cell-elements of the neuroglia, described by An- 
 driezen as the fibre-cells, are of two kinds. The fibre-cells found 
 in the first layer of the cortex send smooth, long, and fine fibrils 
 downward into the subjacent layers of gray matter. These same 
 cells also send out long lateral fibrils, which would seem to be with- 
 out anastomotic or vascular connections. The other minute fibre- 
 cells are situated in the white matter and have fine, long fibrils, 
 radiating in all directions, but without vascular attachments. 
 
 The most important neuroglia elements are the protoplasmic 
 
292 TEXT-BOOK ON MENTAL DISEASES. 
 
 glia-cells which abound in the cortex of the brain and are rarely 
 present in the medullated substance upon the confines of the deepesc 
 cortical layer. These protoplasmic glia-cells, from which, in all di- 
 rections, extend branching processes, are regarded by Bevan Lewis 
 as a " lymph-connective system," and they are always found in abun- 
 dance in the immediate naighborhood of vessels, and they have at 
 least one large process which ends in a protoplasmic expansion on 
 the lymph-sheath of a blood-vessel. Any stasis of the lymph-cir- 
 culation in the cortex of the brain is attended by a rapid prolifera- 
 tion of these cells, especially when the obstruction to the escape 
 of perivascular lymph has had an inflammatory origin. 
 
 The important phagocyte-action of these cells has already been 
 alluded to, and the chief point is that they complete the destruction 
 of diseased nerve-cells, which might otherwise have been regener- 
 ated. It is true that this only occurs when the protoplasmic glia- 
 cells have excessively multiplied and taken on pathological activity. 
 
 But there is a further destructive action exerted by these cells, 
 which, after multiplying at the expense of surrounding tissue, seize 
 upon nerve-fibres and minute vessels by means of their fine processes, 
 and finally come to occupy the position of the higher elements of 
 nervous structures. 
 
 These connective-tissue cells, accordingly, in severe chronic cases 
 of Insanity, partially replace the cellular elements, the neurons, and 
 dendritic expansions, and thus a permanent and hopeless patholog- 
 ical change is established. The lateral processes of the nerve-cells, 
 the arborization of the dendrons, and the nerve-fibres which unite 
 the nerve-cells in their associated activity, are those first implicated, 
 and hence arises the special significance of these protoplasmic glia- 
 cells in the pathogenesis of mental disorders. 
 
 The protoplasmic glia-cells, after throwing out innumerable fine 
 fibrils and fully undergoing fibrillation, pass through a fatty degen- 
 eration and the body of the cell thus disappears. 
 
 Changes in the commissural association, and projection nerve- 
 fibres, are chiefly due to thrombotic and atrophic processes, or to the 
 pressure of tumors, or to intra-cerebral hemorrhage, or other gross 
 brain disease, as in organic and syphilitic dementia. In traumatic 
 Insanity also there is destruction of nerve-fibres from mechanical 
 injury and descending lesions. 
 
 In general paresis, after degeneration of cortical cells, there is a 
 secondary atrophy of projection fibres. There is colloid change and 
 
PATHOLOGY OF INSANITY. 293 
 
 miliary sclerosis of fibres, as already described, and in toxic Insanity 
 there are descending sclerotic lesions of nerve-fibres. 
 
 The most important nerve-fibre degenerations are, first, that 
 of the apical processes of cells by granular or pigmentary change; 
 second, that of the arborizations of the dendritic processes by the 
 action largely of protoplasmic glia-cells; and third, the destructions 
 of the neurons after the loss of the myelin-sheath. 
 
 The cerebral membranes in Insanity present, under microscopical 
 examination, niany morbid appearances. The dura mater shows the 
 engorgement of its minute vessels, and the effusion of plastic mate- 
 rial and the nuclei of osseous formations. The pia mater reveals 
 the formation of new vessels, the proliferation of epithelial cells, 
 the multiplication of connective-tissue corpuscles, by which it is 
 bound to the cortex, and the plastic exudates of inflammation along 
 the most minute vessels, and not infrequently leucocytes, pus-cor- 
 puscles, and capillary hemorrhages. 
 
 The cerebral vessels are distended, engorged with blood, athero- 
 matous, distorted and variously bent, varicose or with aneurismal 
 dilatations. Proliferation of the nuclei of the sheath, hypertrophy 
 of the tunica muscularis, the escape of leucocytes through the vas- 
 cular tunics, epithelial and pigmentary collections in the minute 
 arterioles, and the transudation of inflammatory material are to be 
 observed. 
 
 The perivascular lymph-spaces are occluded by cellular and fatty 
 debris in the chronic inflammatory states of Insanity. There is a 
 nuclear proliferation and a distention of the perivascular lymph- 
 channels, and also an invasion by the processes of the rapidly multi- 
 plying Deiter's cells already described. 
 
 The cellular degenerations of the spinal columns may arise as 
 a system disease of the cord in tabetic cases, in which the posterior 
 columns, more especially, are involved and the posterior root-zone 
 is one of the first points of attack, but in pseudo-tabetic cases 
 it may escape, while the columns of Goll are more especially impli- 
 cated, or the lateral columns may also become involved in the dis- 
 eased process. The lesions in combined paretic and tabetic cases 
 are much varied and by no means typical, as in uncomplicated tabes 
 dorsalis. 
 
 The primary pathological process is ordinarily in posterior com- 
 missural regions, consisting in inflammation of membranes and en- 
 gorgement of vessels with exudation and adhesions, and a great pro- 
 
294 TEXT-BOOK ON MENTAL DISEASES. 
 
 lif eration of connective-tissue cells, which interfere with conduction 
 in nerve-fibres by pressure. Later there may be a genuine sclerosis 
 and destruction of nerve-fibres in posterior columns. 
 
 In ascending cases of general paresis bulbar symptoms become 
 more evident as the lesions advance, but in many cases of paresis 
 in which there is pronounced disease of other parts of the cerebro- 
 spinal system the bulbar symptoms remain in abeyance. 
 
 In alcoholic and some other toxic cases the lateral columns of 
 the cord are diseased, even to a greater extent than the posterior col- 
 umns. There is meningitic disease in many of these toxic cases. 
 There is effusion of fluid and partial adhesions along the median 
 raphe, great increase of connective-tissue corpuscles, leucocytes, and 
 sometimes formation of new vessels, and hypertrophy of the tunica 
 muscularis of arteries, and sclerosis involving both posterior and lat- 
 eral columns. 
 
 The degenerations are not continuous, but are at irregular in- 
 tervals and heights in the cord, and implicate even the anterior cor- 
 nua in some regions, and unilateral deviations in the pathological 
 processes are common. The posterior nerve-roots may be aifected, 
 and in alcoholic cases this may be a sequel of the multiple neuritis, 
 but it is more likely that both the latter and the spinal lesions are 
 common symptoms of the toxic state. 
 
 Sensory and spasmodic affections of the muscles may indicate 
 whether the cervical or -lumbar regions are especially involved. 
 
 After fatty and atheromatous disease of vessels and sclerosis of 
 nervous elements in toxic cases there may be extensive atrophy of 
 nerve-cells and fibres in the columns of the cord, and in some in- 
 stances amyloid degeneration. In alcoholic cases, however, all the 
 lesions would seem to be secondary to vascular changes, which only 
 express the general trophoneurosis induced by the presence of the 
 toxic agent throughout the system. The action of the syphilitic 
 virus would seem to be primarily not confined, like alcohol, to vas- 
 cular tunics beginning with the intima, but of a more general nature, 
 extending to the nervous elements at an early day and inducing a 
 more general and diffused pathological process, chiefly of a sclerotic 
 nature. 
 
 General principles explanatory of microscopical lesions in the 
 genesis of Insanity may be briefly summarized. 
 
 All diffused lesions which involve the protoplasmic body of cor- 
 tical cells attack the immediate centre of intellectual activity, and 
 
PATHOLOGY OF INSANITY. 295 
 
 they are, of all others, the most immediately destructive of intellec- 
 tual existence. 
 
 Degenerations which involve the intercellular association-fibres 
 and fibrillary network, the dendritic arborizations and the protoplas- 
 mic lateral extensions of cortical cells are likewise subversive of co- 
 ordinate mental function when they implicate extensive areas of 
 the fronto-parietal cortex. 
 
 Involutional atrophic processes which widely involve all the cel- 
 lular elements of the fore-brain directly effect a general diminution 
 of intelligence. 
 
 Developmental insufficiencies and early encephalitic and sclerotic 
 disease of cortical cells and of medullary substance perpetually limit 
 the degree of intelligence. 
 
 Atrophy of cells or fibres limited to the area of anatomical dis- 
 tribution of single cerebral arteries are much less liable to produce 
 disorder of mental functions. 
 
 Embolic and thrombotic softening of limited areas likewise are 
 of secondary importance in the pathogenesis of Insanity. 
 
 Toxic agents which enter the blood and are carried directly to 
 the cortical centres, though causing only slight granular changes in 
 cells, are effective causes of mental disorder in that they simul- 
 taneously attack the ganglionic elements of the brain as a whole, 
 and the same principle is explanatory of the acute outbreaks of In- 
 sanity from the action of the virus of infectious diseases in which 
 the only microscopic lesions to be detected may be slight granular 
 pigmentation of cortical cells. 
 
 General proliferations of the protoplasmic glia-cells, which, 
 through fibrillation, finally fail to remove the detritional products 
 of cortical cells and interfere with the nutrition of nervous struct- 
 ures, are among the frequent pathological alterations which give 
 rise to mental disease. 
 
 Diffused vascular degenerations of cortical regions and fatty 
 epithelial and pigmentary obstructions of the perivascular lymph- 
 spaces, which prevent the nutrient supply of plasma to the gangli- 
 onic cells and the escape of lymph, and produce prolonged stasis in 
 the cerebral circulation, are also pathological factors of mental dis- 
 order. 
 
CIIAPTEK IX. 
 
 THE DIAGNOSIS OF INSANITY. 
 
 Technical DifficuUies and Legal Responsibilities Involved. — ^In 
 about a third of the eases to which medical aid is summoned for 
 mental trouble, the disease has so far advanced that friends or near 
 relatives have already recognized the nature of the affection, and 
 only a perfunctory duty falls to the physician in the confirming of 
 the diagnosis. In another third of the cases the general practitioner, 
 without much experience in mental disorders, will, by careful and 
 methodic study, be able to avoid gross error in the diagnosis and 
 to determine the fact, if not the form, of the Insanity, though he 
 will act wisely in calling expert advice to share the responsibility. 
 In a final third of the cases there will be great technical difficulties 
 to which medical experts alone are equal, and in the solution of 
 which the full height and breadth of psychiatric science is barely 
 sufiicient. 
 
 The technical difficulties reside in the infinite variety of the 
 phases of the human mind, both in health and disease; in the fact 
 that the true state of the inner mind is only revealed by words and 
 actions for which the motive is not always apparent, and hence 
 becomes a matter of inference; in the discontinuous nature of 
 the mental symptoms, which are not always manifested at the visits 
 .of the medical examiner; in the further fact that the diagnosis must 
 rest in part in some cases on evidence which requires judicial as 
 well as medical skill for its interpretaiion, and is liable to be ig- 
 norant or prejudiced. 
 
 The physician must bear in mind the complete possibilities and 
 worst frailties of human nature, such as are daily revealed in courts 
 of law, for the first case to which he is called may constitute the 
 exception and not the rule. He must not forget that intense per- 
 sonal feelings and financial motives may prevail among near rela- 
 tives, whom he will often find completely divided in opinion as to 
 the existence of the suspected Insanity. 
 
 296 
 
THE DIAGNOSIS OF INSANITY. , 297 
 
 The attitude of the patient toward the physician is often that 
 of suspicion, readily converted into open hostility, and subjective 
 symptoms will then be concealed rather than communicated, thus 
 heightening the inherent difficulties of the case. 
 
 The physical signs of the disease may be thus, in a measure, in- 
 accessible through the refusal of the patient to submit to a physical 
 examination. 
 
 The responsibilities in diagnosis are still greater than the diffi- 
 culties mentioned. 
 
 In vain do medical men inculcate that mental disease is like any 
 other disease, and not an opprobrium; for, in the public mind, the 
 dread and the stigma of Insanity will ever remain an ineradicable 
 idea. To pronounce the diagnosis of Insanity is to affix this stigma 
 of popular prejudice to the individual, and to the family indirectly. 
 The individual may recover his mental health and the confidence of 
 his near relatives, but he will never be fully reinstated in the same 
 public estimation, nor in positions of professional responsibility and 
 business trust. Incipient and mild cases of Insanity judiciously 
 treated and cured as cases of neurasthenia escape this opprobrium. 
 
 The sufferer to whom the physician is called may be technically 
 and medically in the initial stage of mental disorder and yet not 
 legally insane. Should the physician commit such a patient to a 
 hospital for the insane, and recovery follow without any further 
 development of symptoms, the physician might find liimself in- 
 volved in a suit for damages, which it might be difficult for him 
 to defend. Several cases for the commitment of patients to hospitals 
 for the insane have of late years been decided against physicians, 
 who have acted in good faith, but have still been mulcted in dam- 
 ages. A mistake outright in the diagnosis of Insanity, of course, 
 renders the physician liable the same as in cases of malpractice in 
 general. 
 
 The present law of commitment of the insane in Kew York State 
 has in some degree shifted the responsibility of the deprivation of 
 personal liberty from the physicians to the judges who approve of 
 the certificates of Insanity ordering the confinement of the patient. 
 
 In other cases the patient may have been indicted for capital 
 crime, and the diagnosis, once pronounced, may carry with it the 
 responsibility of life and death. 
 
 There are also many minor offences committed by the insane, and 
 the physician may have in these instances to protect individual rep- 
 
298 TEXT-BOOK ON MENTAL DISEASES. 
 
 utation and family honor by pointing out the diseased source of the 
 derelict action. 
 
 The medical man, then, must approach the diagnosis of cases 
 of Insanity forewarned and forearmed as to the difficulties and re- 
 sponsibilities involved. 
 
 The Essential Elements of Diagnosis. — In mental disorders, as 
 in general diseases, the elements of diagnosis are, first, the previous 
 history; and, second, the present symptoms of the malady. The dif- 
 ference in Insanity lies in the fact that the previous history, on 
 account of the chronic course and gradual development of the af- 
 fection, must often extend over very prolonged periods, and the 
 present symptoms include a double order of phenomena, on the one 
 hand most essentially psychical, and on the other somatic, but so 
 general as to involve motor, sensory, and trophic functions of the 
 entire organism. 
 
 The first, element, therefore, of diagnosis in a case of Insanity 
 becomes virtually a life history of the patient, and the second ele- 
 ment is an epitome of all the physical signs of existing bodily dis- 
 order, embracing not only the motor, sensory, and trophic, but also 
 the special sensorial disturbances. 
 
 The first element of diagnosis or the complete history of the case 
 is to be obtained from different relatives or members of the immedi- 
 ate family of the patient; and, in order to save valuable time, the 
 physician must have a definite formula for questions to be answered, 
 and he must thus elicit information quickly upon essential points, 
 which are very numerous, but they can all be passed in review 
 promptly if the system of categoric replies is adopted in some defi- 
 nite and comprehensive order. 
 
 When the complete history has been obtained in its full medical 
 outlines, it is then well to hear at length what the different mem- 
 bers of the family have to say about the case, especially if there 
 be differences of feeling and belief in regard to the patient's In- 
 sanity. 
 
 TTie History of the Case Antecedent and Subsequent to the At- 
 tack. — The first element of diagnosis resolves itself into two distinct 
 parts, which are the history of the case antecedent to the Insanity 
 and the full account of the case subsequent to the attack. 
 
 These two parts of the history are radically distinct, in that one 
 relates to a period of sanity and the other to a term of Insanity — 
 one is supposed to accurately portray the life, habits, and character- 
 
THE DIAGNOSIS OF IISrSANITY. 299 
 
 istics of the individual in health, and the other to record all the 
 changes wrought in the patient by the mental disease. If both parts 
 of the history are well drawn the departures from normal modes 
 of thought and feeling will stand out in bold relief as salient points 
 in the diagnosis. 
 
 Both the antecedent and the subsequent history as regards the 
 attack is to be obtained, as far as possible, before the patient is seen, 
 and a great advantage will then be gained to the physician at his 
 first visit, which may thus be abridged so as to spare the patient 
 unnecessary length of examination and fatigue. It is rare that any 
 portion of the history should be taken from the patient directly, 
 and yet, if the patient be relatively intelligent, the information thus 
 furnished, especially as to the symptoms of the attack, is not always 
 to be ignored, for past subjective feelings may be revealed to the 
 physician and not to the family. 
 
 It is true that in many cases a momentary and informal examina- 
 tion may show that the patient is insane, but there are other points 
 besides the mere fact of Insanity to be determined by the diagnosis, 
 and even in a self-evident case the physician should not dispense 
 with a systematic mode of diagnostic procedure and a complete study 
 of the case, which may assume a new phase in a short space of time, 
 to the surprise of the physician, who should keep a full written 
 memorandum of all patients examined, and more particularly of the 
 dates and results of the personal examination of the patient. 
 
 The Medical Lines of Inquiry and the Laws of Evidence Involved. 
 — It has been pointed out thus far that the essential elements of 
 diagnosis are a personal history and a personal examination — that 
 the former consists in a history previous and subsequent to the at- 
 tack, and that the latter is composed of the determination of the 
 psychical and the physical condition. It now becomes necessary 
 to show fully the medical lines of inquir}% first, in the direction of 
 the personal history, and, second, in that of the personal examina- 
 tion, and to develop all the essential points as to which it is the duty 
 of the medical examiner to inform himself. 
 
 To begin with, the physician must first go to the parental source 
 of the patient and learn his inherited nature, which is the founda- 
 tion of the individual. The first line of medical inquiry, therefore, 
 is that of parental history. The object of the inquiry must be to 
 determine the nativity and age of the parents, their general mental 
 and physical status, and, if not surviving, the disease of which they 
 died. 
 
300 TEXT-BOOK ON MENTAL DISEASES. 
 
 One of the first questions will naturally be whether the parents 
 have suffered from any form of mental disorder, or from brain disease 
 of any kind; whether they have been subject to any disorder of the 
 nervous system, and, if such be the case, whether it was previous 
 or subsequent to the birth of the patient. This line of inquiry as to 
 heredity is to be carried, both in direct and collateral directions, 
 to grandparents and to uncles and aunts on both the paternal and 
 maternal side. It is important, also, to embrace in the inquiry 
 all diseases supposed to be hereditary in the family, instances of in- 
 temperance or drug habit, suicides, and depravity or eccentricity 
 among near relatives, and the question of consanguinity of parents, 
 
 Having completed the parental history, the medical examiner 
 is ready to enter next upon the direct line of inquiry of the personal 
 history of the patient, and here, too, he must begin at the beginning. 
 The foetal life of the patient and exposure to injury through mechan- 
 ical or psychic traumatism of the mother while bearing the child 
 in utero; then the crisis of birth, which may have been multiple 
 or with instrumental delivery and cranial damage, are the first lines 
 of inquiry. Then infancy, with the question as to dentition, con- 
 vulsions, precocity or delayed mental development, is next in order, 
 and then should follow the history of childhood, with its infectious 
 diseases, accidents, and injuries to head or spine, the premature or 
 imperfect expansion of the mental faculties, and the record in 
 school. 
 
 Puberty and its evolutionary changes in mind and body, sexual 
 vices and menstrual irregularities, choreic or other nervous com- 
 plaints, one-sided talents or eccentric tendencies, retarded or exces- 
 sive growth, spinal curvatures or other physical deformities, are to 
 be ascertained in this natural order of the personal history. 
 
 Adult life is then in regular sequence, and the inquiry is first 
 as to the customary bodily condition of the patient and the state 
 of the various vital organs and organic functions in what is deemed 
 the ordinary and normal condition of the patient. Then all the 
 diseases, bodily injuries, peculiarities of physical conformation, and 
 the history of reproductive activities in married women are to be 
 recorded, and mental or nervous disease in the children of the pa- 
 tient is to be noted as possibly circumstantial evidence of heredity. 
 
 Then the natural character, disposition, habits and mental en- 
 dowments of the patient are to be made the object of the most 
 searching inquiry, which must also include all the damaging mental 
 
THE DIAGNOSIS OF INSANITY. 301 
 
 influences to which the patient may have been exposed, such as busi- 
 ness worry, financial losses, over-work and worry, domestic grief and 
 prolonged anxiety of every kind. If there have been fully devel- 
 oped attacks of mental disorder, their date, duration, symptoms, 
 and supposed causes, treatment and manner of complete recovery 
 are to be fully ascertained. 
 
 This is the general scope of the antecedent history, and then 
 comes the history subsequent to the beginning of the Insanity, with 
 a detailed account of all the psychic and somatic symptoms in the 
 order of their occurrence. 
 
 The earliest changes in character, manner, and speech which ex- 
 cited suspicion as to Insanity are to be the first object of inquiry, 
 as they sometimes indicate a much longer duration of the complaint 
 than that marked by an open outbreak of the disease. The date at 
 which the Insanity was clearly recognized by the friends, however, 
 is also important. 
 
 The prevailing emotional tone, whether expansion or depression; 
 or, of like importance, the fact of apathy or stupor is to be learned. 
 Then the personal habits and tendencies, such as noisy, untidy, 
 destructive, violent, or suicidal symptoms are to be sought for with 
 close questioning, as they are not always readily revealed by the 
 relatives, who are often less inclined to state simple facts than they 
 are to give their interpretation of occurrences. 
 
 The question of the delusions which the patient may have had, 
 and of the hallucinations and illusions to which he has been subject, 
 requires very skilful investigation, and the physician will often be 
 surprised at the confiicting testimony given on this score by the 
 different members of the family, and at the not infrequently puerile 
 nature of the testimony furnished in this regard. 
 
 Other psychical symptoms to be sought for are confusion or 
 incoherence of ideas or speech, defects of memory for recent or old 
 events, changes in personal identity, the state of consciousness 
 as to the Insanity itself, and the general changes in the feelings of 
 the patient toward his near relatives. 
 
 The somatic symptoms are to be ascertained by repeated inter- 
 rogations as to loss of sleep, appetite, or weight, as to the state of 
 the skin, pulse, respiration, digestion, condition of the bowels and 
 of menstruation, and of the sexual functions or their perversions. 
 
 Eesearch must be extended to the muscular system, to the ques- 
 tion of tremors, spasms, convulsions, defects of gait, speech, or of 
 
302 TEXT-BOOK O'S MENTAL DISEASES. 
 
 other highly specialized mechanisms. The chirography and the 
 ability to play on musical instruments, or the mechanical skill re- 
 quired in manual occupations, may have been impaired. 
 
 Finally, the supposed causes of the disease and the manner in 
 which it has been treated, as to the use of drugs, restraint, confine- 
 ment, or moral influences, are to he made the subject of close in- 
 quiry. 
 
 The fact as to any improvement or continued failure or sta- 
 tionar}' state of the mental condition is also to be recorded, and in 
 some cases still further lines of medical inquiry will have to be fol- 
 lowed out, but the above are the essential ones to be pursued by the 
 medical examiner. 
 
 In gaining the above facts of personal history the physician must 
 liave a practical knowledge of the laws of evidence — he must be able 
 to weigh the credibility of the testimony given, and to judicially 
 interpret the value of the facts alleged hy parties whose feeUngs and 
 interests are often at variance, and who are not giving evidence un- 
 der the solemnity of an oath. It is well to examine the members of 
 the family separately when there is conflict of f eehng and statement 
 in regard to the symptoms, and then to listen to mutual discussion 
 of the question hy the various parties after the completion of the 
 history of the case. 
 
 Ordinarily, older persons are more rehahle than the younger, 
 who know little in general about disease or the motives of conduct 
 or the affairs of life. The physician will discover that delusions are 
 common among the sane as well as the insane, and that they arise 
 from ignorance, prejudice, and self-deception, and, as before inti- 
 mated, he must skilfully weigh the evidence adduced to prove the 
 patient's delusions. The psychology of the family as well as of the 
 patient will be a part of the prohlem to he solved in not a few 
 instances, and the study of the relatives will often throw a clear 
 light on special phases of the patient's mental malady. 
 
 If the physician have a knowledge of mankind in general, and 
 of women and children in particular, he will arrive at the true facts 
 of the history of the patient by tactful questioning, but if he be not 
 gifted with great knowledge of human nature, and also disregards 
 the laws of evidence, his personal history in many instances will be of 
 little value when completed, and he will have to rely on the personal 
 examination, which may be inconclusive as to the Insanity of the 
 patient. 
 
THE DIAGNOSIS OF INSANITY. 303 
 
 Complete Outline for the Record of Histories. — It is deemed well 
 to give here a complete outline for the record of the history of cases 
 of Insanity, but the details, it is thought, will be suggested readily 
 by the leading headings of the outline, which does not pretend to 
 be exhaustive, by any means. It is purposely not technical, but 
 simplified in form and language, such as may be of most practical 
 use in gaining information by questions from relatives of the patient. 
 
 Outline of History in Cases of Insanity. 
 
 A. Personal Description. 
 
 Name Sex Age 
 
 Color of hair and eyes .... Height .... Weight 
 
 Education Eeligion. . . Occupation .... 
 
 Civil condition Nativity . . Eesidence 
 
 B. Parental History. 
 
 1. Nativity of parents — native or foreign grandparents. 
 
 2. Age of parents. If parents are not living, the cause of death. 
 
 3. If father, mother, grandparent, uncle, aunt, brother, or sister 
 has been insane, relate all that is known of the date, duration, cause, 
 and termination of the Insanity. 
 
 4. Special tendency to diseases of brain, lungs, heart, kidneys, 
 or other organic affections, scrofula, rickets, spinal disease, cranial 
 deformities, epilepsy, idiocy, deafmutism, chorea, or hj'Steria. 
 
 5. Intemperance in alcohol or drugs. 
 
 6. Cases of suicide or criminality. 
 
 7. Consanguinity of parents. 1 
 
 C. Personal History. 
 
 1. Fetal Life. — 1. Severe illness or bodily injury or great mental 
 strain of parents a year or so before the birth of the child. 
 
 2. Sickness, trauma, or emotional shock of the mother while 
 bearing the child. 
 
 II. Childbirth. — Premature or multiple birth, mechanical deliv- 
 ery, cranial injury. 
 
 III. Infancy. — 1. Infantile diseases, first dentition, convul- 
 sions. 
 
 2. Age of walking, talking, precocity, or delayed mental gro^vth. 
 lY. Childhood. — 1. Diseases of childhood, sequels of infectious 
 disorders. 
 
304 TEXT-BOOK ON MENTAL DISEASES. 
 
 2. Nature and history of convulsions at this age, chorea, night- 
 terrors, incontinence of urine at night, somnambulism, hallucinations 
 at night, deliriiun upon slight rise of temperature. 
 
 3. Physical development and bodily functions. Second denti- 
 tion. 
 
 4. Mental development. Studies in school. Precocity or arrest 
 of mental functions. 
 
 5. Mental shock, fright, or severe injuries to head or spine. 
 
 v. Puberty. — 1. Early or late puberty, unusual physical or men- 
 tal states at this epoch, sexual vices, menstrual irregularities. 
 
 2. Diseases of the nervous system at this age, chorea, hysteria, 
 convulsive tics, night-talking or walking, convulsive seizures. 
 
 3. Eetarded or excessive growth and general bodily function, 
 spinal curvatures, cranial or other malformations. 
 
 4. Mental status, one-sided talents, eccentricities, success in 
 school or business. 
 
 VI. Adult Life. — 1. Customary bodily condition, fat or lean, 
 muscular or thin, strong or weak, state of the vital organs and vege- 
 tative functions, endurance in work. 
 
 2. Diseases of adult life, nervous affections, fevers, toxic or spe- 
 cific disorders, gastro-intestinal troubles, bodily injuries, deformities 
 of head, chest, spine, or limbs, defects of special senses, loss of teeth, 
 hernia, varicocele, or sexual peculiarities. 
 
 3. In women, menstruation, uterine diseases, age and number of 
 children, miscarriages, duration of lactation, date of last pregnancy. 
 
 4. The natural mind, character, and habits of the individual, the 
 disposition and prevailing mood, whether cheerful or gloomy, the 
 relative intelligence to educational advantages, industry and suc- 
 cess in business or profession, habits, tastes, likes and dislikes, social 
 or anti-social tendencies, oddities of conduct or speech, peculiarities 
 of manner and dress, desires and appetites, natural or artificial. 
 
 D. History and Symptoms of the Insanity. 
 
 1. The earliest changes in character, manner, or speech which 
 excited suspicion of Insanity, and the date of the first decided symp- 
 toms of mental disorder recognized. 
 
 2. The mental symptoms in the order of their occurrence. Illu- 
 sions, hallucinations, change in identity, incoherence of ideas, loss 
 of memory, nature of the delusions. 
 
THE DIAGNOSIS OF INSANITY. ' 305 
 
 3. Emotional disorder, the prevailing mood of depression, ex- 
 pansion, or apathy, or stupor. 
 
 4. Loss of self-control, suicidal, homicidal, violent or destructive 
 tendencies, morbid appetites, alcoholic excess, or sexual vices. 
 
 5. Loss of bodily weight, wasting of muscles, muscular tremors, 
 spasms, contractions, changes in gait, handwriting, in facial inner- 
 vation and expression, abnormal muscular reflexes. 
 
 6. General circulation, changes in the pulse or temperature, 
 rush of blood to the head, or paleness and fainting, state of the 
 heart, palpitations. 
 
 7. Eruptions and discolorations of the skin, turning gray of the 
 hair, cold and blue extremities. 
 
 8. Disorders of digestion, constipation or diarrhoea. 
 
 9. Asthmatic attacks, consumption, diseases of the genital or- 
 gans, especially in women. 
 
 10. Delirium, convulsions, loss of consciousness, choreic or epi- 
 leptiform symptoms, loss of power of limbs, changes in the pupils 
 or in the special senses. 
 
 11. General course of the Insanity, tendency to improvement 
 or the opposite. 
 
 E. Treatment of the Disease to Date. 
 
 1. General treatment of the Insanity to date of this history. 
 
 2. Home treatment or institutional treatment, dates. 
 
 3. Medicines employed, hygienic or hydrotherapic measures 
 used, restraint, if employed, forced feeding, seclusion. 
 
 4. Surgical measures employed, cups, blisters, local applications 
 in women, electricity, operations. 
 
 The above outline for the personal history in cases of Insanity 
 will be found not only highly suggestive, but fully adequate for the 
 clinical use of the medical practitioner, who can dispense with any 
 portion of it in cases of a chronic type and of a foregone conclusion. 
 
 The Personal Examination of tJie Patient. — ^Having now fully 
 dealt with the historical elements of diagnosis, the remaining lines 
 of medical research are confined directly to the existing mental and 
 bodily condition of the patient, to be determined by personal exam- 
 ination. 
 
 The physician must have a clear idea of the scope of the personal 
 examination which he is about to make. He is to discover the true 
 20 
 
306 TEXT-BOOK ON MENTAL DISEASES. 
 
 state of all the physical and mental functions, so that he may be 
 able to state those which are normal and those which are abnormal. 
 He will necessarily traverse some of the points already considered 
 under the personal history, which he is now to confirm by personal 
 examination, and to record additional points on his own responsible 
 observation. Relatives can no longer be of any service, and the phy- 
 sician is now thrown entirely upon his scientific resources. It is 
 now a contest between science and the great difficulties to be over- 
 come, and often the cunning of the patient to be circumvented by 
 fair superiority of knowledge, and not, as some have suggested, by 
 trickery, rude shocks, prolonged espionage, or personal examinations 
 carried to the point of complete exhaustion of the patient. Such 
 devices are unworthy, unless it be to expose the feigning of convicted 
 criminals. The contest is to be open, gentlemanly, and humane, 
 and this necessitates, on the part of the medical examiner, perfect 
 familiarity with the line of investigation to be pursued, so that his 
 full presence of mind and tact may be devoted to the emergencies 
 of the occasion. 
 
 The bearing of the physician toward the insane should be the 
 same as toward any other sufferer from disease, sincere and intelli- 
 gently sympathetic, with the firm resolve of professional duty to be 
 performed, and a perfect equanimity not perturbed by the diseased 
 irritability or even open abuse by the patient. In any patient pre- 
 senting special difficulty of diagnosis there will be a quick percep- 
 tion of subterfuge on the part of the physician, as well as an appre- 
 ciation of honesty and kindness shown by him during the personal 
 examination. The medical examiner has no new role to play or 
 character to assume, but he is simply to employ his entire knowl- 
 edge of human nature, to rise to the full height of the situation, 
 to have his wits about him, to be prompt to decide and act, and in 
 some instances his physical courage may be put to the test, and he 
 may recall with practical effect the scriptural saying, " A quiet an- 
 swer turneth away wrath," especially if it remain accompanied by 
 a quiet and self-possessed mien. An attempt to overawe the insane 
 by severity of looks, as wild animals are supposed to be kept in 
 subjection by the human eye, would in most cases result in disaster 
 to the medical examiner for practising a popular theory. The in- 
 sane, enraged and dominated by delusions and violent impulses, 
 know no fear and are deterred by no threat of punishment. 
 
 If the patient to be examined be strong and homicidal or violently 
 
THE DIAGNOSIS OF INSANITY. 307 
 
 inclined, the physician is culpable if he risk an assault upon himself, 
 or expose the patient to the force he might have to exert to resist 
 an attack without the presence of a sufficient number of persons 
 to control the patient. The regular order of the personal exam- 
 ination will have to be varied according to the nature of the case. 
 It often happens that the physical examination serves as a good 
 introduction to the more trying mental probing, which may so dis- 
 turb the pulse, respiration, and temperature as to be an obstacle to 
 later physical observations, but the converse is sometimes true. If 
 there is evident perturbation it is well to suspend the examination 
 until the heart is quiet and there is a return of self-control. 
 
 It often reassures the patient to examine the presumably healthy 
 organs first, and to announce the favorable facts as the examination 
 progresses. Pent-up nervous feeling is most quickly relieved by 
 muscular effort on the part of the patient, who may be asked to 
 walk briskly a few times across the room, to stand on one foot with 
 the eyes closed, and while so standing to describe a circle on the 
 floor with the toe of the free foot, to grasp the physician's hand with 
 full force, first with one and then the other hand, to walk backward 
 with closed eyes. The physician will know the real value of these 
 tests of muscular strength and co-ordination better than the patient, 
 who may doubt their serious nature, and the physician may then en- 
 courage the performance by first executing the movements himself. 
 The dynamometer and assthesiometer may be employed in this con- 
 nection, and when it is evident that the mental tension is somewhat 
 relieved the thoracic organs may be examined, and for some reason 
 this part of the research is often very trying to the patient, so that 
 the examination should be as quickly performed as practicable, and 
 indeed, this should be the rule throughout this ordeal, which is not 
 to be dispensed with except for good reasons. The physical exam- 
 ination helps often to determine the form and the pathology and 
 the indications for treatment of the Insanity. It may seem ridicu- 
 lous to the members of the family to see the physician feeling a pa- 
 tient's shins to determine the nature of his mental trouble, but this 
 humble act may reveal more than the whole history derived from 
 the combined knowledge of the relatives, for, if tibial nodes are 
 found, the syphilitic origin of the case and the nature of the treat- 
 ment are indicated. In mental depression the former may be ob- 
 scure until the physical examination clearly shows the paretic nature 
 of the disease. It is rare that the physician can do justice to him- 
 
308 TEXT-BOOK ON MENTAL DISEASES. 
 
 self or the patient without a physical examination, but the nature 
 and extent and order of the same will vary in different cases. 
 
 It is the object to indicate here the full extent which the exam- 
 ination may have to take in all essential directions, and to leave to 
 the medical examiner to select from this necessarily lengthy outline 
 the points most directly indispensable in individual instances. As 
 the expert morbid anatomist will within a half hour perform a com- 
 plete autopsy and examine every organ of the body as to their macro- 
 scopical appearances, so the expert medical examiner can pass in 
 review all the essential points of the physical and mental condition 
 as here noted within the space of an hour in cases presenting no un- 
 usual obstacles. The physician must renew his visits, if need be, 
 until he has satisfied himself as to the true physical and mental 
 status of the patient. 
 
 The pliysical examination must cover the following main lines of 
 inquiry : 
 
 The bony frame-work, as the solid basis of the individual, is the 
 first object of attention. The conformation of the chest, spinal 
 curvatures, rickety formations, the state of the long bones and theii 
 relative length to the trunk, exostoses and mollities ossium are to 
 be ascertained. Cranial circumference and diameters, as}Tnmetries 
 and traumatic injuries and the relative size of the cranium to the 
 stature are to be determined, and excessive or defective total growth 
 of body is to be observed. 
 
 All the " stigmata degenerationis " described under somatic 
 symptomatology are to be here noted. 
 
 The general muscular development is to be considered and tests 
 as to the muscular functions are to be applied. Some of these tests 
 have already been mentioned as to strength and co-ordination. The 
 electric reactions are to be tested in disease of the muscles as an 
 aid to diagnosis. 
 
 Muscular tremors, spasms, atrophy, contractures, and other dis- 
 orders are to be detected, as well as cataleptoid and tetanoid states. 
 The muscular reflexes are important, and the deep, if not the super- 
 ficial, should always be examined. The most significant deep re- 
 flexes are the patella-tendon reflex, or knee-jerk, and the ankle 
 clonus, and in some cases the Avrist, elbow, and chin reflexes should 
 also receive attention, together with the superficial reflexes, the 
 plantar, cremaster, epigastric, and abdominal. The gait and its 
 alterations, disorders of speech, especially those of a paretic nature, 
 
THE DIAGNOSIS OF INSANITY. 309 
 
 changes in hand-Amting, in manual skill in various occupations and 
 in the playing of instruments, characteristic attitudes and gestures, 
 movements of the tongue and deflections of the palate are all points 
 to be observed. The physiognomy, the youthful or aged look, the 
 prevailing expression, laughter or crying or an indiscriminate min- 
 gUng of both, defects of facial innervation, and the absence of all 
 expression, are to be noted. 
 
 The heart and vascular structures, valvular lesions, the state of 
 the arteries and veins, the pulse and its variations, indicated by the 
 sphygmograph in some cases, are to be examined. 
 
 Observation is to be extended to the skin, to eruptions, oedema, 
 cyanotic conditions of extremities, pigmentations and excretions, 
 and to the state of the hair and nails. 
 
 The internal organs come within the examination, the lungs, 
 the stomach, liver, spleen, kidneys, and reproductive organs and 
 their disorders form a part of it. 
 
 Special attention is to be given to the nutritive, secretory, and 
 trophic functions, to the changes in total weight of the body, to 
 excess of adipose tissues or emaciation, to the secretions and excre- 
 tions, to the state of the blood, of the urine, of the saliva, to tem- 
 perature changes, cranial, axillary, and oral. The state of the ner- 
 vous system is to be examined as to brain diseases, spinal affections, 
 disorders of the sympathetic and peripheral nerves. 
 
 In the presence of diseases of the nervous centres all the cus- 
 tomary tests, including electric reactions, are to be employed. 
 
 The Psychical Uxaiiiination must Embrace the Following Points. 
 — Perception and the special senses of touch, taste, smell, sight, 
 hearing, and the muscular sense are to be tested. Taste and smell 
 will naturall}^ be tested together, but delicate and brief tests of smell 
 first used do not impair taste, but after the use of salt, sweet, sour, 
 and bitter solutions for testing taste, odors may not be normally per- 
 ceived. If special instruments are not at hand, some substitutes 
 can be improvised to deliver a minute portion of the solution to dif- 
 ferent parts of the tongue. 
 
 Touch is best tested by the sesthesiometer, or, in its absence, 
 by sharp-pointed scissors or a hairpin, and by tracing letters or fig- 
 ures on the skin, by the direction of lines drawn lightly on the skin, 
 and by the locating of points touched. The muscular sense for 
 weights and for the position of the limbs is to be tested, and also 
 the temperature and pain-sense. It is well in this connection to have 
 
310 TEXT-BOOK ON MENTAL DISEASES. 
 
 the patient identify objects touched with his hands behind his back, 
 to test promptness of recognition and tlie association of ideas and 
 sensorial impressions. 
 
 The simpler tests of ^dsion and of the action of the ocular muscles 
 are to be made. The presence of strabismus^ arcus senilis, color- 
 blindness, and especially anomalies in the pupils and their reflexes 
 are to be noted. 
 
 Hearing, as to promptness, distance, cranial conduction and the 
 recognition of objects by sound, is to be carefully examined. By 
 moving objects and executing movements behind the patient's back 
 and requiring him to tell what is done, the association of ideas and 
 of acoustic impressions can be readily determined, and also, if the 
 patient is in a familiar room, his memory of objects and their cus- 
 tomary location, and before beginning this test it is well to blindfold 
 the patient or have him seated at one end of the room with back 
 turned. 
 
 Hallucinations and illusions of all the special senses are to be 
 diagnosed, if present. 
 
 The state of consciousness, impairment or epileptic loss of the 
 same, changes in identity, and double consciousness are to be ascer- 
 tained. 
 
 Memory and its partial or complete loss for recent or past events 
 may be tested in various ways by comparing the patient's knowledge 
 with dates given in the personal history for past occurrences, and 
 for recent ones questions at the close of the examination as to things 
 done in the early pai't of it may be used. The degree of education 
 must be considered in the questions, which may embrace the repeti- 
 tion of the alphabet, of the days of the week, and of the months of 
 the year and the number of the days in each, followed by more and 
 more difficult tests in arithmetic, geography, and simple Enghsh 
 branches of study. The chronological order of events already learned 
 in the history will furnish tests on this score, as to places and dates 
 of residence, and changes in occupation, and other events of the 
 patient's life. In case of a woman, the names and ages of her chil- 
 dren and the birthday of each is a fair test-question, which is rela- 
 tively more difficult for men, who, without any real loss of memory, 
 often fail to tell the day of the month on which their children were 
 born. A surer test for men is their memory of financial matters 
 in which much loss of memory usually points to serious impairment 
 of mind, and yet even here business men are relatively more accurate 
 
THE DIAGlSrOSIS OF INSANITY. 311 
 
 than professional men. The medical examiner must be able to gauge 
 the value of the tests according to the individual and the general 
 fact that people do not remember that to which they pay no atten- 
 tion and in which they have no interest. There is a great natural 
 difference of memory as to names, places, and numbers. Some in- 
 telligent persons do not always remember the names or the street 
 appearance of their friends well enough to recognize them. Labor- 
 ing men often know their house by its location in the block and by 
 its outward appearance, and do not know its number, especially if it 
 happens to be a large one. Facts are remembered, but their order, 
 in time, is not impressed upon the memory very clearly in many per- 
 sons, who cannot tell without considerable reflection when any par- 
 ticular event of a few weeks previous occurred. Only thorough, 
 all-round tests of memory, therefore, are reliable. 
 
 The thought-rate, association of ideas or incoherence, the atten- 
 tion and presence of mind, confusion of time, place, or persons, the 
 appreciation of present surroundings and of patient's personal rela- 
 tion to the same, and self-knowledge of the patient's rights and du- 
 ties in general are to be examined, and also Ids consciousness of his 
 own mental trouble, and, above all, his delusions. 
 
 There are also to be determined the fundamental emotional 
 mood, the ruUng emotions, hkes and dislikes, personal animosities, 
 disposition as to his own family, and altruistic and egoistic feelings 
 in general. Constancy or alternation of depression, exaltation, ap- 
 athy, or stupor is to be noted. 
 
 Volitional control of ideas and actions, homicidal, suicidal, irre- 
 sistible impulses, destructive habits, anomalies of appetites or in- 
 stincts, sexual perversions and impellent ideas are to be closely in- 
 vestigated. 
 
 For a tabular outline of the personal examination of patients, 
 reference is made to the close of this chapter, but the foregoing are 
 the main points in both the physical and psychical examination. 
 
 Diagnostic, Psychic, and Somatic Symptoms. — There are some 
 symptoms which are much more highly diagnostic than others, and 
 the mental and bodily signs which have special, if not pathogno- 
 monic, value are now to be mentioned. 
 
 A fundamental mood of depression or of exaltation, whep. pro- 
 longed and out of proportion to any external events or causes in 
 the life of the patient, is highly diagnostic. 
 
 Coenassthetic depression from physical and temporary suffering 
 
312 TEXT-BOOK ON MENTAL DISEASES. 
 
 or prodromal of infectious diseases or sequential of the same is to 
 be excluded, as well as the normal fluctuations in the tenor of the 
 emotions from over-work or untoward circumstances of life, and 
 also the temperamental variations of brief but extreme degree in 
 certain individuals. 
 
 Even when there has been an occasion and a real motive for the 
 emotional change, if the latter be disproportionate to the actual 
 cause and remain greatly exaggerated, the significance of the symp- 
 tom continues still as regards diagnosis. 
 
 The presence of a delusion in spite of evidence of its falsity, pro- 
 vided the conduct of the individual is unreasonable as the result 
 of the influence of the false belief, is a diagnostic symptom. 
 
 Actions speak louder than words, and some persons express ex- 
 traordinary false beliefs, which they never put in practice, and 
 which, in truth, are not a vital part of their mentality, but when the 
 delusion is carried out in disregard of the conventions of society, 
 exposing the person to resultant penalties, it is proof that it is a 
 constituent of the inmost life of the individual. A man might 
 declare the amount of clothing worn in the heat of summer to be 
 a foolish convention, and he might have a belief that it would be 
 more healthful and a better adaptation to the environment to re- 
 main like the savage in the summer months, and if he put this 
 belief in practice, even in the limits of his own household, remaining 
 in a state of nature during the summer, it would be symptomatic 
 of Insanity to the same degree as a more irrational belief professed 
 but not practised. Sane people have delusions in great variety, but 
 they also have a sane amount of inhibition, which prevents the prac- 
 tice of anti-social beliefs and a sane appreciation of their obligations 
 to society, and of the severe punishment of violation of conventional 
 usages. The delusion which crowds out all these considerations and 
 becomes the guiding motive of conduct, and is not inhibited, is 
 highly diagnostic, and, in fact, pathognomonic of Insanity. 
 
 Irresistible impulses to perform destructive or violent acts, when 
 arising irrespective of ordinary motives of conduct, are highly diag- 
 nostic psychic symptoms. The question of motive and of the mode 
 of origin of the irresistible impulse is of great importance in this 
 connection. It is known to be within the limits of normal psychol- 
 ogy for a man moved by the deep passions of love or revenge to 
 destroy life or property, and there are occasionally aggravating cir- 
 cumstances under which these motives attain a force irresistible, 
 
THE DIAGNOSIS OF INSANITY. 313 
 
 except to those schooled to life-long self-control. There are also 
 in young persons lacking the full realization of the gravity or nature 
 of their acts^ and deficient in the self-control brought by age and 
 experience, examples of overt acts from the irresistible contagion 
 of example or from the over-firing of the imagination, as witnessed 
 among youths after reading of noted highwaymen, whose lives and 
 adventures they proceed to imitate, usually in some foolish attempt 
 at highway robbery. 
 
 Exclusive of all like instances, there are impulses which arise 
 irrespective of all sane motives and of all normal reactions of mind 
 to external influences, and these are pathognomonic of a diseased 
 mind. Of like kind, but not of the same degree of diagnostic im- 
 portance, are impellent ideas, which lead the sufferer to the per- 
 formance of aimless or absurd acts, which may even be of an ille- 
 gitimate nature. 
 
 Conduct widely different from that customary in the individual, 
 provided it is not in the nature of an adjustment to some actual 
 change in his environment, is diagnostic of Insanity. Some persons 
 show their mental disorder in their acts rather than in their words, 
 just as others are rational in conduct and evidently insane in con- 
 versation, while others still reveal their mental alienation only in 
 their writings. There are even patients who cunningly inhibit the 
 issue of their Insanity through any of these channels, and are still 
 betrayed by an insane physiognomy. In judging of the conduct of 
 a person in this relation the class, profession, degree of education, 
 and previous habits of life have to be taken into consideration. 
 
 If a man, reared in wealth and having abundant means, were to 
 suddenly adopt the petty economics of a person brought up in rela- 
 tive poverty, it would raise doubt as to his sanity; or if a clergyman 
 were to assume the attire or freedom of conduct of a layman it would 
 excite suspicion; or if a highly educated and refined man were to 
 show the ignorant and coarse conduct which might be normal in 
 a laborer, the question of alienation might arise; or if a person were 
 to at once ignore the habitual polite usages of the society in which 
 he moves he would furnish grounds for belief in his mental de- 
 rangement. 
 
 In all very large cities are sectional differences of class, wealth, 
 education, and race, so great that if the standard of the habits and 
 life of one of these quarters of the city were suddenly to appear in 
 the other it would be so out of adjustment to the environment as to 
 
314 TEXT-BOOK ON" MENTAL DISEASES. 
 
 signify Insanity. These and other like considerations are to be 
 taken into account in judging of the change of conduct which must 
 be independent of motive or provocation furnished by unusual and 
 novel alterations in the environment. 
 
 Double consciousness and changes in personal identity are diag- 
 nostic symptoms, and usually indicate a deep and permanent mental 
 deterioration. 
 
 Among the somatic symptoms the progressive inco-ordination 
 of speech and gait and of other specialized movements, if combined 
 with gradual diminution of mental power, is diagnostic of general 
 paresis. Or, in the absence of disturbance of special muscular mech- 
 anisms, if there be gradual impairment of intellect without any ac- 
 tive disorder, the loss of the patella tendon reflex and of the pupil- 
 lary reflex to light are not only diagnostic, but pathognomonic of 
 general paresis, provided the presence of locomotor ataxia is first 
 excluded. 
 
 In the absence of all mental symptoms the concomitance of fixed 
 pupils, loss of knee-jerk, and tremulous hesitancy of speech are path- 
 ognomonic of general paresis. 
 
 There is a characteristic intonation combined with tremulous- 
 ness of the vocalized sound which, in the absence of the other phys- 
 ical and mental symptoms, is still pathognomonic of general paresis, 
 but any exact knowledge of this sign cannot be conveyed in words, 
 but when it is once acquired by experience of the ear it is unmis- 
 takable. It is well to know that this highly diagnostic somatic 
 symptom may, with long familiarity and practice, be perfectly 
 feigned, so as to deceive even an expert. 
 
 The symptoms of gross brain disease, when followed by diminu- 
 tion of mental powers, are diagnostic of organic dementia. If there 
 be failure of various kinds of memory alone after gross brain lesions, 
 without diminution of the other powers of mind, the diagnosis of 
 Insanity is not to be made. 
 
 Standards of Comparison in the Determination of Insanity. — All 
 things about which there is any question are tested by some unit 
 of measure or tried by some standard of comparison. All persons 
 have general similarities of physical organization, and yet no two 
 persons are exact physical counterparts, and in the same way no 
 two persons are precisely alike in mental constitution, and yet such 
 is the general conformity to a universal standard that it is possible 
 to formulate general laws of mind and conduct, to which there may 
 
THE DIAGNOSIS OF INSANITY, 316 
 
 be numerous individual exceptions. It is possible, therefore, to 
 know, ninety-nine times out of a hundred how persons will react 
 to certain influences, and yet the hundredth case reacting in an 
 eccentric way might not be insane, but the individual exception 
 which is ever occurring in the world of organized beings. There 
 are, therefore, two standards of mind and conduct: one is the gen- 
 eral average standard of mankind, and the other is the particular 
 standard of the individual, and both of these terms of comparison 
 must enter into the general conclusion as to the Insanity of a person 
 under given circumstances and modes of reaction to environmental 
 influences. The student of history and of the human mind is struck 
 with the fact that the general mental standard of mankind has 
 varied widely at different periods of time and in distant parts of the 
 world, and that various factors greatly influence tlie present wide 
 differences, which it is well to consider for a moment, in both the 
 general and individual mental standard. 
 
 The Average Sane Mental Standard of Mankind as Affected by Historic 
 Epoch, National Crises, Degree of Civilization, Race, Caste, Occupation, 
 and General Environraent. — If an ancient Egyptian, Greek, or Eo- 
 man could be revived for comparison, there would be found an an- 
 achronism and a total disparity between the man and the age, be- 
 tween the adjustment and the environment, between the individual 
 mental standard and that of the people about him. Even at the 
 present day the average mental standard varies greatly among differ- 
 ent races, and, if a physician were to determine the mental condition 
 of a Turk by the average American standard of thought, feeling, 
 and action, there would be room for great error, and the same wide 
 difference of character and conduct exist between many other na- 
 tionalities. 
 
 The average sane mental standard of mankind at national crises, 
 and during wars and epidemics of emotional ideas, has betrayed 
 some remarkable fluctuations, such as was seen at the time of the pil- 
 grimages, when hundreds of thousands started on foot for the Holy 
 Land without any means of supporting life by the waj'', and perished 
 by the thousand like migrating animals, or as witnessed during the 
 pandemoniacal scenes of the French revolutions in Paris, or during 
 the witch-hanging epoch in America. 
 
 At the present day the degree of civilization makes the most 
 general differences of sane mental standards, which thus have wide 
 geographical demarcations, as existing between civilized, barbarous^ 
 
316 TEXT-BOOK ON MENTAL DISEASES- 
 
 and savage nations. In India, caste, and in civilized countries in gen- 
 eral, degree of education, makes the most marked variation in the 
 average sane mental standard of mankind. Eacial differences, as 
 between the colored and white in the United States, the effects of 
 general extremes of environment as between the serfs and the nobles 
 in Eussia, widely divergent occupations as that of the cowboy and 
 of the university professor, affect the code of morals and of conduct 
 and of manner of reaction to given influences and events in every- 
 day life. If one of the standards above mentioned were suddenly to 
 be exchanged for the other, even under like circumstances, it would 
 be a manifestation of mental derangement rather than of mental 
 adjustment to the environment. If the learned college professor, 
 enjoying his vacation on his summer-place, were to mount his horse 
 in reckless abandon, rifle in hand, pursue some thief who had driven 
 off one of his cows, and shoot him dead at sight, he would likely 
 be deemed insane. If a cowboy performs likewise while in pursuit 
 of his occupation, he simply reacts in a cusfomary way, and the 
 question of Insanity would never be raised, and his courage would 
 more probably be called in question if he failed to take the law in 
 his own hands. 
 
 The average sane mental standard varies, therefore, with factors 
 above indicated, and the skill of the psychologist must accurately 
 weigh the force of environmental circumstances in this regard. 
 
 The Sane Mentai Standard of the Special Individual. — The diag- 
 nostic value of a comparison of the person supposed to be insane 
 with his former self is very great, for there is nothing more charac- 
 teristic of Insanity than a prolonged departure from the individ- 
 ual's customary modes of thinking, feeling, and acting. It is essen- 
 tial, therefore, to know what his usual standard in health has been in 
 these respects. Some persons are naturally cheerful, hopeful, or 
 even enthusiastic in temperament, with social and communicative 
 habits, while others are apathetic or even gloomy by nature, looking 
 on the dark side of things, hoping little and doubting much, and 
 having no social tendencies. If these individual mental standards 
 were suddenly to be exchanged without any adequate external 
 causes, both classes of these persons would furnish grounds of sus- 
 picion of their Insanity. It is to the medical examiner of such im- 
 portance to know the individual standard that he will be without 
 it unjustified in making a diagnosis in difficult cases, whatever may 
 be his wide knowledge of mankind in general. 
 
THE DIAGNOSIS OF INSANITY. 317 
 
 Even when the habitual mode of mental being of the special in- 
 dividual is known, it is still further to be considered that there may- 
 be brief fluctuations within physiological limits in the mental status, 
 and that an observed departure is only pathological when prolonged 
 or .disproportionate to the exciting cause. It is necessary also to 
 eliminate changes from great emotion and functional exhaustion, 
 and the coena3sthetic alterations of the incubatory stage of all acute 
 bodily diseases. 
 
 Conditions of Unusual Difficulty of Diagnosis. 
 
 Childhood. — The fact that in childhood the general mental stand- 
 ard has not yet been attained, and even an individual standard of 
 mind and character has not been fully developed, makes the diag- 
 nosis very difficult. The child is then to be compared with the 
 average sane mental status of children born and reared under like 
 circumstances of life. The wide individual differences in the rapid- 
 ity or tardiness of mental development are to be taken into con- 
 sideration. The degree of instability of nervous centres, which 
 would result in mental disorder in the adult, is more apt to reveal 
 itself in muscular disorders or in convulsions in children, and delu- 
 sions and other fully developed symptoms, as in grown persons, are 
 seldom present in like degree, and the diagnosis is to be made in 
 their absence in most children. The diagnosis in young children 
 must rest on symptoms like the following: Night terrors, hallucina- 
 tions of sight and hearing, inattention to what is said or done and 
 to sensorial appeals, irritability, prolonged anger, which may end 
 in syncope, general dislike shown to all persons, including nurse 
 and mother, prolonged spells of crying and violent actions, loss of 
 interest in all objects or in playthings or in other children, unpro- 
 voked change of emotions, signs of fear, facial distortions, spas- 
 modic muscular affections and convulsive seizures. In older children 
 there will be found other diagnostic signs, such as great boldness 
 or shyness, extremes of vain pride or absence of self-esteem, loud 
 mirth or silent sadness, general wickedness or painful over-conscien- 
 tiousness, heartless cruelty or crying pity, disobedience, impudence, 
 lying, destructive habits, filthy ways, precocious or perverted sexual 
 tendencies, impulses to steal or to do bodily violence to others or to 
 self, or to burn or destroy property, brief attacks of uncontrollable 
 rage or fright, night-walking and talking, nocturnal enuresis, ne- 
 
318 TEXT-BOOK ON MENTAL DISEASES. 
 
 gleet of natural needs, loss of sleep and appetite, convulsive ties and 
 loss of weight. A special difficulty in diagnosis will be found in the 
 variability of the symptoms, and in the fact that there are often re- 
 missions and recurrences in the mental disorder of children. 
 
 Senility. — The age of the natural decline of all the mental func- 
 tions presents the difficulty of diagnosis between involutional and 
 pathological mental changes. 
 
 There may be premature old age or the senile involution may 
 be sudden instead of gradual, or family peculiarities not necessarily 
 indicative of Insanity may appear by force of hereditary tendency 
 late in life. There are numerous personal oddities of manner and 
 expression, which do not make their appearance as transmitted bod- 
 ily or mental traits until the decline of life, and there are usually 
 few living to identify them with common features possessed by an- 
 cestors, and these peculiarities are hence mistaken for new develop- 
 ments of disease, whereas they are ancestral tendencies which have 
 been latent or have been inhibited during life, and occasionally they 
 are atavistic in nature. 
 
 The psychology of old age, like that of early childhood, is seldom 
 specially studied by the medical examiner, who feels an uncertainty 
 when called upon to diagnose the mental state of an old person. 
 Loss of memory, indifEerence to people and events, egotism, penuri- 
 ousness, garrulity, slovenliness, and selfishness are common traits in 
 senility, even in those who have possessed opposite traits in early 
 life, but the transition to these lower characteristics is normally 
 gradual. If the above traits, then, appear suddenly, and, above all, 
 if they are accompanied by an outbreal^ of scandalous immorality 
 or dishonesty in one previously having led an exemplary life, they 
 become diagnostic of mental alienation as well as of mental failure. 
 
 In proving loss of testamentary capacity in old age, perversion 
 of affection for children or some other near relative is often alleged 
 as a proof of Insanity. It is to be remembered that the possession 
 of property and the right to bestow it is often all that commands re- 
 spect and obedience toward these very old persons, who punish cru- 
 elty, neglect, or other wrongs by cutting off the offender from his 
 share of property, and the charge of insane antipathy is to be, in 
 these instances, admitted as a genuine symptom of mental disorder 
 only after the most careful inquiry. As to the somatic symptoms, 
 also, the diagnosis is difficult, for loss of weight, impaired diges- 
 tion, and insomnia are very frequent accompaniments of senility. 
 
THE DIAGNOSIS OF INSANITY. , 319 
 
 It is necessar}^ to learn the parental history as to the age of senile 
 involution, and the general manner in which the changes are wont 
 to occur at this epoch in the family. In some families the somatic 
 involution is the more rapid, and in others the mental decline is 
 first in order and most marked long before even arterial degeneration 
 is to be detected. 
 
 Concern about property and the apprehension of its loss is com- 
 mon among the aged as the result often of their experience or ob- 
 servation in life, and the fear that they may yet be deprived of their 
 possessions through some unexpected turn in fortune, is not always 
 evidence of delusion, unless, indeed, it influence their conduct and 
 lead them to deny themselves the necessaries of life, as is not infre- 
 quently the case. 
 
 There is an automatic habit of adjustment to the routine ways 
 of life, and also an automatic propriety of response to customary 
 questions on the part of senile cases far advanced in dementia. 
 This deception, as to the relative amount of intelligence retained, 
 is readily detected by the introduction of some subject new to the 
 patient requiring attention and judgment on his part, and his psy- 
 chical defect will at once become evident. 
 
 A senile lawyer, for instance, may talk with considerable show 
 of legal lore, and yet may not be able to tell the day of the week, 
 the place where he is, or the names of his nearest relatives, or to 
 name the street or the number of the house in which he lives. 
 
 The mental depression of the aged has not the same intensity 
 of manifestation as in younger persons, and the physician has to be 
 on his guard in these senile cases of melancholia, which may end in 
 suicide while he is debating in his mind over the diagnosis, which 
 is often not facilitated by the presence of any delusion, since melan- 
 cholia sine delirio is one of the characteristic senile forms of Insanity. 
 
 Eccentricity. — The presence of decided eccentricity may create 
 some difficulty in the diagnosis of mental disorder. 
 
 There are two kinds of eccentricity. Some eccentric persons are 
 strong-minded, self-reliant, independent thinkers, taking original 
 and often correct and advanced views of general affairs, and such per- 
 sons are far removed from the danger of Insanity. They are more apt 
 to control persons and events than to be influenced by them, and 
 they rise superior to the untoward circumstances of life, and they 
 are not easily cast down by misfortunes. 
 
 The other kind of eccentric persons are weak, vacillating, pecul- 
 
320 TEXT-BOOK ON MENTAL DISEASES. 
 
 iar, often witli one-sided talent, and deficient mentally and physi- 
 cally in general development. They are often timorous, suspicious 
 of others, and without confidence in themselves, strange in manner 
 and dress, shy and reticent, sensitive and having a silly vanity in 
 certain directions. They also have native mental deficiency in many 
 instances, and they are prone to Insanity. These strange weaklings 
 often become more and more eccentric with the advance of life, and 
 there is often real difficulty in determining the point at which they 
 are to be regarded as " non compos mentis." The diagnosis in these 
 cases can only be made by a careful study of the life-history of the 
 patients as compared with the actual mental status in which the 
 medical examiner finds these eccentric persons. 
 
 Imbecility. — It is difficult to say, in cases of partial arrest of 
 mental development, what is due to native defect and what may be 
 due to subsequent mental disease. There is every grade of mental 
 deficiency and of resulting absurdities of conduct in complex and 
 difficult situations of life. Imbeciles also are easily disconcerted by 
 emotional influences, and they may indulge in imbecile rage or de- 
 structive or violent actions, wliich may spring from Insanity in some 
 cases, and from simple defect of self-control in the other. It is 
 diflficult to determine whether there is in a given case of imbecility 
 capacity for control of property, as some imbeciles have special facil- 
 ity in figures, though they are generally defective in Judgment. 
 
 Some imbeciles Kve on the border-line of mental disorder, and 
 have frequent recurrences of mental aberration from shght exciting 
 causes. There is often some difficulty in deciding what their normal 
 mental status has been, as people have generally failed to distin- 
 guish their weak-minded vagaries from actual insane symptoms, and 
 their repeated mild attacks of mania are occasionally not recognized 
 as such, but are simply termed " bad spells " by the family. The 
 melancholia to which they are so subject is also not of a very pro- 
 nounced type, and readily escapes recognition, by the relatives, as 
 an actual form of Insanity. 
 
 A complete personal history and a careful personal examination, 
 "vvith tests of the various mental faculties, are the only practical aids 
 to the diagnosis in these cases of imbecility, and, as wide variations 
 in the mental symptoms are liable to occur, a number of visits may 
 be necessary, among the higher order of imbeciles especially. 
 
 Not a few imbeciles find some simple routine occupation and go 
 through life unrecognized as belonging to the defective class. The 
 
THE DIAGNOSIS OF INSANITY. 321 
 
 phj'sician must be able to diagnosticate the grade of mental defect 
 and the Insanity which may be superadded. 
 
 Deaf -mutism. — The number of insane deaf-mutes has increased 
 of late years in hospitals for the insane, chiefly through the ability 
 of physicians to detect Insanity when existing in this defective class. 
 The difficulty of diagnosis varies in inverse proportion to the degree 
 of education of the deaf-mute. Among the highly educated deaf-- 
 mutes the Insanity is revealed in a variety of ways, but chiefly in the 
 form of insane delusions and of irresistible and dangerous impulses. 
 
 In the uneducated deaf-mute the difficulty lies in ascertaining 
 the natural degree of intelligence, and the changes which have oc- 
 curred in it from the effects of disease. 
 
 The actions of the patient alone furnish an index as to his men- 
 tal condition, and it is seldom that the real motives of his conduct 
 can be learned. If the mental excitement interferes with the meagre 
 sign-language which he possesses, the task is almost hopeless, but 
 even then a homicidal or suicidal attempt, or the discovery of epi- 
 leptic symptoms, may throw light on the diagnosis. Maniacal states 
 and acute melancholia are, of course, recognized. 
 
 Delusions of suspicion and suicidal tendencies have been the most 
 constant symptoms in insane deaf-mutes who have come under the 
 writer's care. The diagnosis of malingering in a deaf-mute would 
 doubtless present unusual difficulties. 
 
 Voluntary Mutism. — Peculiar difficulty of diagnosis arises in 
 case of absolute silence, and refusal of the person examined to com- 
 municate with anyone. Voluntary mutism is itself a symptom of In- 
 sanity in an occasional case, in which it may continue for years under 
 the influence of insane delusion. Convicted criminals have been 
 known to feign this type of Insanity, and this is in some respects 
 the easiest form of simulation, though it eventually becomes very 
 trying to the malingerer. 
 
 It sometimes happens that the nature of the physician's visit 
 to the supposed insane person is understood by the latter, who, for 
 the time being, maintains a silence which cannot be broken by any 
 device. In such an instance the physician must obtain information 
 through the medium of other persons with whom conversation will 
 be carried on by the patient. If this be not practicable, and if a 
 physical examination is refused, the physiognomy and the personal 
 history of the case can alone be relied upon for the diagnosis. If 
 the personal history be meagre, the elements essential to a diagnosis 
 21 
 
322 TEXT-BOOK ON MENTAL DISEASES. 
 
 are wanting and a conclusion cannot be reached. In the latter case 
 it will be necessary to resort to continued personal observation of the 
 supposed insane person until sufficient cumulative evidence of In- 
 sanity can be had. 
 
 It is not to be recommended that the physician resort to means 
 to provoke, surprise, or intimidate the person who is obstinately si- 
 lent under examination, unless it be in the case of a convict sus- 
 pected of malingering. 
 
 Painful electric currents and similar means are seldom neces- 
 sary or justified even in prisons. Scientific observation, and the 
 determination of somatic signs and bodily functions, and of per- 
 sonal conduct during a certain period of time, are sufficient even 
 in cases of prolonged voluntary mutism, and the physician who is 
 not competent to make a diagnosis without crude or questionable 
 measures should call the skill of a speciaHst to his assistance. 
 
 Aphasia. — The question of the mental status of an aphasic per- 
 son often has important medico-legal bearings, as, for instance, in 
 the case of the validity of wills executed during aphasic conditions. 
 The cerebral lesions which cause aphasia often result in organic de- 
 mentia. A close study of every individual case of aphasia is required 
 to determine the mental functions affected and the general degree 
 of impairment ,of mind. 
 
 Cases of motor aphasia, having lost the memory of movements, 
 of speech (aphemia), or of writing (agraphia), or of gestures 
 (amimia), are not from that fact alone to be regarded as insane, and 
 if the will and understanding are otherwise sound, the testamentary 
 capacity cannot be questioned on the ground of Insanity diagnosti- 
 cated by these cerebral symptoms. 
 
 Cases of sensory aphasia, having lost the visual memories of words 
 written or printed, or of gestures and manual signs executed, or the 
 auditory memories of words spoken, are not to be considered insane 
 from the mere fact of this word-blindness and word-deafness, for 
 they may still have a clear understanding of themselves and of their 
 surroundings, and they may judge correctly of events about them 
 and may be free from actual disorder of mind. 
 
 If, in addition to symptoms of motor and sensory aphasia there 
 be incoherence of ideas and of speech from lesions of the associative 
 fibre-system (paraphasia), the intellect is evidently so far impaired 
 that the diagnosis is extremely difficult, and the probability is that 
 the sufferer is at least medically insane. If such a case be recent, only 
 
THE DIAGNOSIS OF INSANITY. - 323 
 
 a guarded and provisional opinion is to be given, and the element 
 of time is to be claimed as essential to the diagnosis, as both the 
 paraphasia and incoherence with excitement may shortly disappear, 
 leaving the alexia or aphemia, which in turn may slowly diminish. 
 On the other hand, the intellectual impairment may progress to 
 fully developed organic dementia. 
 
 In these cases the somnolence, emotional weakness, and irrita- 
 bility of temper are not diagnostic of Insanity, as they are symp- 
 toms common to all coarse brain disease. The prevailing mood in 
 cerebral focal lesions is that of irritable depression, even in the ab- 
 sence of symptoms of active Insanity, and a fundamental tone of 
 exaltation in one of these aphasic cases, therefore, has considerable 
 significance as to Insanity, as it is highly abnormal. 
 
 AlcoJiolic Intemperance. — Nothing is more difficult than to de- 
 termine the real mental condition of an habitual drunkard, who h^s 
 become a public nuisance and a menace to the personal safety of his 
 own family. In the first place, it is not easy to obtain a personal 
 examination at a time when the individual is free from the direct 
 effects of alcohol, and then the personal history and alleged insane 
 acts are known to be in part the result of alcoholic influence. The 
 habitual drunkard assumes something in his manner and speech 
 beyond that which springs directly from the alcohol; he usually 
 exaggerates the effect of the stimulant, both as to its mental and 
 bodily influence. In the early history of the drunkard this is a 
 species of histrionic performance of a clownish nature, but eventu- 
 ally the drunken manner and speech become habitual, along with 
 a sort of stupidity, which is sometimes more apparent than real. 
 
 If such a drunkard is put to the test of an examination as to his 
 sanity, he will often inhibit even the above-mentioned habitual bear- 
 ing, and he will talk " as sober as a judge," and no delusions will 
 be discovered, and the lapses of memory will be surprisingly few. 
 This effort of inhibition in those in whom serious cerebral lesions 
 have taken place cannot be continued usually for an hour at a time 
 without affording the medical examiner glimpses of the true state 
 of mental impairment, especially if the intemperate person can be 
 taken at a time when he is not sustained by his customary stimulus. 
 If the person can be induced to abstain from drink even for one day 
 the examination may then be renewed with success, and, by plying 
 the person with questions upon subjects in which his feelings are 
 known to be enlisted, delusions of conjugal infldelity, hallucinations, 
 
324 TEXT-BOOK ON MENTAL DISEASES. 
 
 and other characteristic symptoms of alcoholic Insanity may he dis- 
 covered. In otlier instances, however, no positive symptoms of In- 
 sanity will be found even after repeated examinations, and the phy- 
 sician can only declare that the case is not yet ripe for a diagnosis, 
 however sure he may he that cerebral lesions have so far advanced 
 that it is only a question of time when the mental disorder will make 
 its appearance. 
 
 Excessive Indulgence of Appetites. — The most abject addiction 
 to sensual indulgence is not per se proof of Insanity. Men are found 
 the world over making the gratification of their beastly appetites 
 a chief source of pleasure. Some of these appetites are natural and 
 others are" artificial or acquired. Both savage and civilized peoples 
 addicted to the use of animal, vegetable, or mineral poisons, of which 
 the most widely used are arsenic, opium, and tobacco, are known to 
 indulge to the extent of serious damage to their physical and mental 
 state. When the mind is undergoing, with the rest of the organism, 
 deterioration in this way, it becomes a diflicult question often to 
 fix the point at which Insanity may be said to exist as the result 
 of the excess. Some opium-eaters live to advanced years and retain 
 their mental faculties intact to the last, just as do some life-long 
 alcoholic tipplers, but others, through idiosyncrasy or transmitted 
 instability of nervous tissues, suffer serious lesions after compara- 
 tively slight indulgences. 
 
 . As far as the Insanity is concerned, therefore, it is not a question 
 of length or degree of indulgence, as the individual standards vary 
 so widely in these particulars, but of the actual damage which the 
 nervous system has sustained and of the resulting degree of mental 
 impairment or disorder of the faculties of body and mind. The dis- 
 order of physical functions is here mentioned because the mental 
 disease follows in a reflex way in some of these cases as a sequence 
 of the physical disturbances. 
 
 The diagnosis of Insanity, therefore, in these cases of excessive 
 indulgence of appetites, natural or artificial, cannot be based on the 
 fact of gross sensualism, or on the individual's deliberate choice of 
 continued indulgence to the extent of damage to health or fortune, 
 and it cannot be made at all unless there be positive disorder of men- 
 tal faculties or decided impairment of mind. 
 
 The ability to make a diagnosis in these cases implies a famil- 
 iarity with the effects of all sorts of drugs and self-indulgent habits, 
 in addition to a knowledge of the psychic and somatic symptoms of 
 
THE DIAGNOSIS OF INSANITY. 325 
 
 Insanity. The difficulty of diagnosis will also be found to be in- 
 creased often by the extreme reticence and cunning of the patients, 
 who hide their true state of mind and body from the physician. 
 
 Supposed Eecoveries from Psychoses. — Patients who have recov- 
 ered from an attack ,of Insanity treated at home or in hospitals for 
 the insane are subject to relapses, which it falls to the lot of the 
 general practitioner to recognize. It is a trying thing for a general 
 practitioner to oppose the expert opinion of hospital ofi&cers who 
 may have discharged a patient from their care as recovered from 
 Insanity, yet the family physician must be equal to this emergency. 
 
 The patient may, in the quietude and regularity of hospital life, 
 have ceased to show any signs of Insanity for some weeks before his 
 discharge, and yet the cares and responsibilities of active life may 
 soon cause a return of symptoms, which it is the duty of the family 
 physician to recognize. 
 
 There is usually pressure brought to bear for the- release of pa- 
 tients from hospitals for the insane before their cure has had time 
 to harden, and the officers of such institutions may yield to the 
 persistent demands of the relatives when the symptoms of Insanity 
 have disappeared completely for a certain period, and before the 
 danger of relapse has ceased to exist. 
 
 The person supposed to have recovered has gained much experi- 
 ence as to Insanity and the views of physicians about it, and is able 
 often to practise deception as to his real mental condition. The 
 diagnosis of a return of symptoms in a supposed case of recovery is 
 therefore very difficult in many instances. On the other hand, the 
 physician has to guard against the tendency of expectant attention 
 on the part of acquaintances or interested parties, who are apt to 
 see strangeness in the conduct or speech of a patient when it does 
 not exist. The change in the bearing of the patient toward those 
 friends whom he knew before his first Insanity is often only a reflec- 
 tion of the altered mental attitude and feeling of the friends toward 
 the patient, who, after an attack of mental disorder, is seldom re- 
 stored to the complete confidence of any but his nearest relatives. 
 The physician must possess much astuteness, therefore, to deter- 
 mine whether the changed conduct and feeling does not exist more 
 largely in the patient's personal environment than in the patient 
 himself; whether the patient is simply reacting normally to the 
 changed bearing of others, or is showing altered and morbid conduct, 
 irrespective of the changed conditions just mentioned. 
 
326 TEXT-BOOK ON MENTAL DISEASES. 
 
 In order to arrive at the truth it may be necessary for the phy- 
 sician to gain the confidence of both the relatives and of the patient. 
 If there was in the first place a contest of opinion and feeling about 
 the patient's mental condition, it will very likely be renewed among 
 the relatives in the second instance, and the physician must be at 
 great pains to act with judicial impartiality in the case, and he must 
 be prepared, if need be, to incur the ill-will of the family in order 
 to protect the best interests of his patient. 
 
 Feigned Insanity and the Detection of Various Forms of Malin- 
 gering. — Accounts of feigned Insanity abound in history and litera- 
 ture, and the same motives exist to-day for the simulation of mental 
 disease. In military and naval service, or to escape from the same; 
 in prisons, or to avoid punishment for crime committed; and to evad6 
 the responsibility of contracts or of financial undertakings, and for 
 various other motives. Insanity may be feigned. 
 
 Many attempts at the feigning are absurdly crude, but others 
 are so premeditatedly perfect or accidentally successful as to de- 
 ceive an expert, so far as a diagnosis from the personal examination 
 alone is concerned. 
 
 The fact that the person to be examined has a motive for the 
 feigning of Insanity is of no service in the formation of opinion in 
 the case, but the fact of heredity and of previous attacks of Insan- 
 ity is of importance. A complete personal history of the individual 
 is of the utmost importance before an attempt is made to detect the 
 supposed simulation. The fact that the insane feign symptoms of 
 Insanity other than those which constitute their mental disease is 
 not to be forgotten, otherwise the physician might be betrayed into 
 the declaring of a lunatic a malingerer. 
 
 A difficult complication arises when the person feigning Insanity 
 is in reality affected with some neurosis, such as hysteria, neuras- 
 thenia, or epilepsy, and the general ill-health of prisoners interferes 
 in some degree with the value of somatic signs, since there may be 
 constipation, coated tongue, indigestion, and other bodily symptoms 
 as in Insanity. Another relevant fact is that prolonged simulation 
 sometimes ends in actual Insanity, as already described in the chap- 
 ter on Etiology. 
 
 The points to which special attention is to be given in the de- 
 tection of cases of malingering are, in the main, as follows: First, 
 does the history of the case accord with the ordinary course and mode 
 of development of Insanity, and is there any prevailing tone of de- 
 pression or exaltation, or is there any real continuous stupor? 
 
THE DIAGNOSIS OF INSANITY. 327 
 
 Secondly, are there delusions, illusions, hallucinations, and real 
 impairment of any of the mental faculties, and are the apparent 
 symptoms of a kind found in ordinary cases of Insanity? 
 
 Are there any somatic symptoms such as are found in Insanity, 
 and are they in accord with the mental symptoms displayed? 
 
 Is there a general likeness to any special type of Insanity in 
 the manifestations, or is there an inconsistent mixture of symptoms 
 of several forms? 
 
 The first question covers the point that there are almost always 
 preliminary symptoms for weeks or months before an attack of 
 Insanity, and that there is usually a certain order of appearance 
 of both the bodily and mental signs of the coming mental disorder. 
 There is also, in the vast majority of cases, preliminary mental de- 
 pression and a permanent emotional tone of exaltation or depres- 
 sion, or the presence of stupor, after the Insanity has once declared 
 itself. If all these signs fail and the preliminary features have none 
 of them been present, there is a first ground for doubt. 
 
 The second question relates to the very essence of the mental 
 disorder, and it will be found almost impossible for a malingerer 
 to feign delusions, hallucinations, and illusions consistently with 
 any form of Insanity with which he is not very familiar. He will 
 either have too many delusions about many subjects, or a few gross 
 delusions out of keeping with the general intelligence present; or 
 he will change his delusions and forget about them and get them 
 confused on different occasions in a way not found among the insane. 
 
 If loss of memory be feigned it will likely be for those things 
 forgotten last in true amnesia. Even the names of the months of 
 the year, the multiplication-table, the names of near relatives, and 
 like automatic memories may appear to have been forgotten, which 
 is only the case in almost total amnesia. The malingerer readily 
 falls into such absurdities and greatly exaggerates his role in most 
 cases. 
 
 The somatic symptoms of Insanity cannot be feigned success- 
 fully. Even the melancholy caste of countenance is not to be long 
 retained, and the facial wrinkles of depression cannot be imitated 
 at any time, nor the unhealthy hue of the skin, nor the slow or rapid 
 pulse, nor the foul breath, coated tongue; nor, indeed, any of the 
 decided bodily symptoms of Insanity. 
 
 It is still more difficult to imitate the rapid flight of ideas, the 
 wild looks and the haggard mien of mania, with the constant activity 
 
328 TEXT-BOOK ON MENTAL DISEASES. 
 
 and, above all, the insomnia and tlie general bodily symptoms. The 
 swift facial changes of an emotional nature, and the automatic grim- 
 aces in mania cannot be feigned even by the most skilled facial con- 
 tortionist. 
 
 The third point, which is the choice of form of Insanity, or, 
 rather, in many instances, the ignorance of the types of Insanity 
 and the mingling of various forms in the simulation, is one of the 
 most constant signs of malingering, and the simulator may reverse 
 the natural order of the stadia of depression, excitement, and stupor. 
 The stuporous physiognomy cannot be feigned, nor can the cutane- 
 ous ansisthesia, if the patient be pricked with a pin when unprepared 
 for it, and the absence of certain reflexes cannot be imitated if tests 
 are unexpectedly made. 
 
 The primary symptoms which are followed by stupor will also be 
 wanting, unless melancholia attonita, or primary dementia, or some 
 like impossible form of stuporous Insanity be simulated. The men- 
 tal symptoms of general paresis may be imitated with some success 
 by one very familiar with them, but this is not true of the physical 
 symptoms of the disease, except as to the hesitancy and tremor of 
 speech and the exaggerated knee-jerk. By long acquaintance and 
 practice in imitation the speech of the paretic may be very perfectly 
 simulated, and some of the one-sided seizures are far more readily 
 feigned than epileptic seizures. The writer once had to pass an opin- 
 ion on a person who feigned epileptic convulsions and subsequent 
 maniacal excitement for a few hours on several occasions, but at the 
 end of a few weeks gave up the role (which was remarkably well 
 done) on being assured that the fraud was very evident. Another 
 case feigned simple melancholia with hatred of relatives and sus- 
 picion of conspiracy against his life by poisoning, and the only fail- 
 ure was that the facial melancholy was a trifle overdone, and secret 
 observation showed a completely diiTerent expression when the pa- 
 tient was alone in his room. 
 
 Primary monomani,a cannot be well simulated, and the system- 
 atized delusions and the whole ingenious system of reasoning about 
 them can only be well feigned by those having very special knowl- 
 edge. 
 
 The personal history of some criminals corresponds in the main 
 with what is termed moral Insanity, but the latter is too technical 
 a type of Insanity to come within the range of the simulator's at- 
 tempts. 
 
THE DIAGNOSIS OF INSANITY. 329 
 
 Insane mutism is almost too negative a form of Insanity for the 
 simulator, though less difficult than some which are attempted. Ab- 
 ject dementia cannot be feigned, as the fraud is exposed by the phys- 
 iognomy and the intelligent look of the eyes and the state of facial 
 innervation and general attitude and bearing of the patient. 
 
 The easiest form for the simulator is simple melancholia, and, 
 if he confine the manifestations to delusions of persecution, hatred 
 of family, suspicion of poisoning, and wear a sad countenance, and 
 is never betrayed out of his gloomy taciturnity, it will be very diffi- 
 cult for the medical examiner to form an opinion as to the simula- 
 tion. 
 
 This form of simulation may also be reinforced by suicidal prep- 
 arations or attempts made with sure chance of prompt interruption, 
 or in the weak way common among many really insane, and in the 
 latter instance it does not aid the simulator. "Well-timed and well- 
 executed attempts at self-destruction are very effective means of 
 feigning, and they are always to be investigated in a most searching 
 manner, since attempts may, if stupidly undertaken, furnish the 
 most convincing proof of malingering. 
 
 The most effectual means for the detection of feigning is pro- 
 longed observation of the simulator. Practically there is no possibil- 
 ity of successful feigning under secret observation, and all the other 
 tests which may be applied in a hospital for the insane, where the 
 person is continuously under the espionage of skilled attendants. 
 
 It is fully possible for persons to feign Insanity so as to remain 
 inmates of hospitals for the insane. The ordinary attention given 
 to patients by medical officers is not sufficient to penetrate the mask 
 of the simulator at all times, and especially where there is no cause 
 to suspect the extraordinary conduct of one who feigns Insanity 
 simply for the purpose of seeing the inside life of a hospital for the 
 insane. This has been done repeatedly, however, and it is mentioned 
 as of incidental interest in this connection, and as showing that 
 feigning by inexperienced persons is by no means self-evident, even 
 to the eye of experts, and that it requires special attention for its 
 detection. 
 
 Feigning may be discovered by the administration of anaesthetics 
 when more customary and less heroic measures have failed. By 
 tempting the simulator to indulgence in alcoholic stimulants, or by 
 the artificial feeding of the same by nasal tube in milk, the feigning 
 may be exposed in some cases. 
 
330 TEXT-BOOK ON MENTAL DISEASES. 
 
 Eidicule, sudden surprise, intimidation by the announcement 
 that a surgical operation to the patient's head may be necessary, and 
 the exciting of the emotions in various ways may be justified and 
 successful means of exposure of the fraud of feigning in criminals, 
 but, as a rule, these measures are not to be employed, except as a 
 dernier ressort. 
 
 Strong electric currents sometimes have a demoralizing effect 
 on the simulator, and they are then a prompt means of detection, 
 but, like the other questionable measures, they are seldom necessary 
 or justifiable, and the same may be said of the surprise-douche and 
 various means of infiicting physical shock. The quiet but decided 
 assuring of the simulator that his fraud is very evident will some- 
 times lead to the abandonment of his role when other means have 
 failed. 
 
 The gaining of the confidence of the simulator by persons about 
 him or by former friends may be a successful way of arriving at the 
 true mental condition of the person under observation, and the 
 secret facial study of the simulator when he is alone with his most 
 confidential friend may decide the question. All these detective 
 means are rarely required, and the same scientific procedure as to 
 personal history and personal examination described for the diag- 
 nosis of Insanity in general will be all that is essential for the vast 
 majority of all cases of feigned Insanity. 
 
 The Dijferential Diagnosis of Mental Disorders. — In the making 
 of a diagnosis of Insanity a variety of affections, which in some re- 
 spects resemble it, have to be excluded. The differentiation between 
 mental disorder and some of these affections is not always eas}'-, from 
 the fact that there is real disorder of the faculties of mind in both 
 instances, but in the one it is arbitrarily called Insanity and in the 
 other it has a different designation. The sufferer from acute brain 
 diseases may have excitement, incoherence of ideas, and great motor 
 activity, and, for the time being, is beside himself or delirious. If 
 like symptoms follow epileptic attacks they are said to be symptoms 
 of epileptic mania, and if they follow upon toxic conditions, the}'- 
 are recognized as toxic Insanity. If alcohol happens to be the toxic 
 agent, the patient is said to have delirium tremens, or intoxication, 
 or chronic drunkenness, which are not regarded as symptoms of In- 
 sanity unless certain psychical sjTnptoms happen to appear in addi- 
 tion to those found in the above affections. 
 
 Now, as a matter of fact, there is mental disorder in all the above 
 
THE DIAGNOSIS OF INSANITY. 33^1 
 
 instances, and it is a purely conventional distinction to apply the 
 term Insanity to some and not to other conditions in which tliere 
 is real disturbance in the action of the mental faculties. It would 
 be a broader and more philosophical view to recognize every genuine 
 disorder of the mental faculties as Insanity from whatever cause 
 produced, and to admit the clinical fact that every possible degree 
 and every conceivable duration of the Insanity may occur. If a pa- 
 tient is beside himself from drugs, alcohol, trauma capitis, diathetic 
 poisons, infectious diseases, or any other causes, whether it be for 
 hours or days or months, the Insanity should be recognized if it 
 really exist. The only brief form of Insanity, of a few hours' full 
 duration, admitted, is mania transitoria, which, as it is now under- 
 stood, could not be applied to any of the conditions above mentioned. 
 
 The arbitrary usage of authors on Insanity, after the above quali- 
 fication, must necessarily be followed here in speaking of the differ- 
 ential diagnosis of mental disorders. 
 
 In the first place, then, Insanity is to be differentiated from acute 
 brain diseases. 
 
 If the patient be suffering from meningitis and be in a iiighty 
 condition, the mental disorder is not to be designated or treated as 
 Insanity. The patient is to be guarded against accident and to be 
 treated for meningitis. The physician would render himself liable 
 to censure if he were to send such a patient to a hospital for the 
 insane for treatment. If permanent symptoms of mental disorder 
 were to attend chronic meningitic processes, the Insanity would be 
 recognized as the chief affection, or, if melancholia followed or at- 
 tended basilar meningitis in a tubercular patient and both affections 
 were prolonged results of the tubercle, the patient might be diag- 
 nosed and treated as insane. Meningitic metastasis in acute rheu- 
 matism may cause active delirium for hours or days at a time, and the 
 joint becomes less inflamed often and other symptoms may be less 
 marked while the delirium lasts. This delirious state is not termed 
 Insanity unless the hallucinations and disorder of mind continue 
 after the acute inflammatory symptoms have disappeared and high 
 temperature has subsided. A like conventional usage applies in all 
 acute brain diseases attended with delirious conditions, or brief al- 
 terations of consciousness, perception, or intellection. 
 
 Insanity is to be differentiated from the delirium of fevers during 
 either the stage of high temperature or of exhaustion. Some persons 
 are always delirious when the bodily temperature rises more than 
 
332 TEXT-BOOK ON" MENTAL DISEASES. 
 
 five degrees Fahrenheit from any cause. The delirious symptoms 
 in the exhausted stage of fevers are sometimes prolonged. There 
 may eventuate a mental disorder termed post-febrile Insanity. In 
 typhoid fever delusions of suspicion and melancholia may arise at 
 any stage of the disease, and forms of stuporous Insanity are common 
 sequels of the fever. In acute infectious- diseases of all kinds there 
 is apt to be delirium from two causes: first, from the hyperpyrexia, 
 and, second, from the specific virus in the blood. In all these acute 
 infectious diseases impaired consciousness, sensorial disorder, inco- 
 herent ideation, muttering, and restless movements are not termed 
 Insanity, even though they may be present for a week at a time. 
 
 If the patient has no active disturbance of consciousness and is 
 fully aware of the nature of his surroundings, and is connected in 
 his memory of events, persons, and places, and still has persistent 
 delusions, it is conventional to recognize the Insanity, even during 
 the course of the infectious disease. 
 
 It will be found useful, by graduated baths or the application 
 of ice to the surface, to reduce the temperature in all diseases in 
 which there are delirium, hallucinations, and excitement, and if the 
 mental disorder subsides the conclusion is that it is due to the hyper- 
 pyrexia. 
 
 Insanity is to be differentiated from the delirious symptoms in 
 inflammation of internal organs. Pneumonitis is very constantly 
 attended with delirium, and it is sometimes followed by Insanity, 
 especially in those of intemperate habits. 
 
 Cardiac inflammatory affections, peritonitis, and intestinal in- 
 flammations, nephritis, and hepatitis are sources of temporary men- 
 tal disorder of a delirious nature not to be recognized as Insanity. 
 At the same time, in one predisposed to a psychosis, any of the above 
 affections may act as the exciting cause of permanent Insanity, 
 which is to be recognized without hesitation, even though it develop 
 in direct sequence of the delirium. The differential points in the 
 conventional distinction between delirium and Insanity are as fol- 
 lows: In delirium consciousness is much impaired; tliere is con- 
 fusion of time, places, persons, and past events, which are not recog- 
 nized in their relation to immediate surroundings, of which the 
 patient has no clear conception, and the muttering is an incoherent 
 jumble of past memories and hallucinatory images, with picking at 
 illusory objects, and the muscular movements are purposeless, and 
 the excitement is usually motiveless, and manifestations are very 
 
THE DIAGNOSIS OF INSANITY. 333 
 
 largely of a reflex and automatic nature. In Insanity the supposi- 
 tion is that the patient is conscious of his relation to his environ- 
 ment, he knows what he is doing, and acts from some motive, even 
 though it be insane, and his restless activity in excitement is to some 
 purpose, and his delusions bear some relation to actual events, as a 
 rule, and there is some effort to reason and explain them, and his 
 hallucinations are not such incoherent sensorial mixtures of real, and 
 imaginary things, and, in a word, the general reduction of conscious- 
 ness and of the mental faculties is not as general as in delirium. 
 These differential points, arbitrary though they be, usually suffice 
 for practical purposes of diagnosis in cases in which the physician 
 has to act. 
 
 Insanity must also* be difEerentiated from the fiightiness of in- 
 anition from whatever source it may proceed. There are many dis- 
 eases, both acute and chronic, in which the patient falls into a state 
 of extreme inanition, which may be attended by disorder of sensorial 
 perception and wandering speech and actions. Forced alimenta- 
 tion, with a generous amount of predigested foods, if need be, may 
 relieve the mental disorder and assist in the diagnosis. Extensive 
 losses of blood following accidents, childbirth, or operations may be 
 followed by temporary delirium not to be mistaken for Insanity. 
 The same may be said of the delirium following physical injuries, 
 and surgical and all other kinds of traumatism. 
 
 Commotio cerebri and spinal concussion may give rise to confu- 
 sion of ideas, loss of memory, inability to fix the attention, and to 
 other symptoms of mental impairment, which, as it is often of a 
 temporary nature, is not ordinarily recognized as Insanity. It is a 
 fact, however, that these symptoms sometimes remain and gradually 
 assume a more serious nature, and end in permanent Insanity. 
 
 Insanity is to be differentiated from acute alcoholic intoxication 
 and from the immediate effects of drugs. If the odor of the breath 
 reveals nothing, the general appearance and actions of a drunken 
 person are so well known as hardly to require description here. 
 Delirium tremens, it is well known, arises when drink has not been 
 taken, and it is often provoked by physical shock or some acute dis- 
 ease, especially pneumonitis in the chronic inebriate. The mental 
 disturbance caused by drugs varies considerably, and the chief diffi- 
 culty lies not in the distinction between their immediate cfiects and 
 Insanity, but in the determination of the point at which the habitual 
 addiction to some drug has developed sufficiently general or perma- 
 
334 TEXT-BOOK ON MENTAL DISEASES. 
 
 nent mental disorder to justify the diagnosis of Insanity. When 
 the abuse of a drug has led to permanent perversion of the affective 
 faculties^ to impairment of memory and reason, and has resulted 
 in positive delusions, the diagnosis of Insanity must be made. The 
 direct tendency of many drugs is to develop the above symptoms, 
 and alcohol acts in the same way, and yet, when a tippler is perverted 
 in affection for his family, whom he abuses, is forgetful and stupid, 
 and gets suspicious, false ideas about things and people in general, 
 he is often not recognized as insane. Both the popular and profes- 
 sional standard of sanity in this instance favors a very large class 
 of the community, coming by force of bad habit more or less dis- 
 tinctly in the above category. The physician, therefore, is com- 
 pelled, against his scientific opinion, to diagnosticate Insanity in 
 alcohoHc patients with unusual circumspection if he wishes to es- 
 cape legal actions and personal trouble. 
 
 All toxic states are to be judged by the rule above given for drugs 
 as to the presence of Insanity. Malarial intoxication has a delirium, 
 usually in the pyrexial stage, not to be confused with the actual In- 
 sanity which sometimes results from the malarial cachexia. 
 
 Insanity is to be differentiated from the effects of violent emo- 
 tions. It is well known that there is a great individual difference 
 as to the effects of emotions, and that some persons are completely 
 prostrated for the time being by anger, fright, or injured pride, and 
 that even sudden death may result from severe emotions in those 
 affected with cardiac disease. Eeaction to real emotional causes may 
 therefore be extreme, but it does not indicate Insanity unless it be 
 greatly prolonged. 
 
 Finally, Insanity must be differentiated from great functional 
 exhaustion of mental powers. Some persons are capable of such 
 severe mental exertions as to completely exhaust their powers of 
 mind for the time being. They may not be able to remember, or to 
 exert their reasoning faculties, or to do customary work, or to solve 
 simple problems, or to concentrate their attention. Tliis temporary 
 state of brain-exhaustion is not Insanity. There may even be asso- 
 ciated with this functional exhaustion defects of speech and inco- 
 ordination of highly adaptive movements from deficient innervation, 
 which might favor a mistake in diagnosis. The writer has known 
 such cases to be mistaken for general paresis. In all cases of severe 
 strain and over-work a chance for r3st should be had, if practicable, 
 before the final diagnosis in doubtful instances. 
 
THE DIAGNOSIS OF INSANITY. 335 
 
 The interdifEerential diagnosis of the various types of Insanity 
 will be discussed in the clinical part of the work under the special 
 forms of mental disorder. 
 
 Mai7i Points to he Determined hy the Diagnosis. — The main points 
 to he settled hy the diagnosis are the existence of mental disease, the 
 special type of the Insanity, the question of institutional or home 
 treatment, the degree of responsibility of the patient in medico- 
 legal cases, and the setio-pathology and general indications for the 
 treatment of the case. 
 
 To determine the fact of the existence of Insanity is to make 
 the minor diagnosis in the case. The medical examiner may reach 
 the conclusion that the patient is insane long before he is able to 
 determine the other points in the case, but it is just as well to re- 
 serve his opinion until he has made up his mind about the full 
 nature of the disease, for, as soon as he announces the prime fact 
 of mental disorder, he will have many other questions to answer. A 
 second visit, therefore, may be wise before the minor diagnosis is 
 made. 
 
 The major diagnosis determines not only that the patient is in- 
 sane, but decides the special type of Insanity from which he is suf- 
 fering. As certain types of Insanity are practically incurable, the 
 major diagnosis in some cases also includes an opinion that the dis- 
 ease is without hope for the future. The physician must use his dis- 
 cretion in the announcement of this fact, which had better be com- 
 municated only to those having a natural right to know, as it may 
 prejudice the best interest of the patient, and, if there should be 
 subsequent lengthy remissions of symptoms, as in some cases of 
 general paresis, it may throw doubt on the original diagnosis. 
 
 The diagnosis of the special types of Insanity will be discussed 
 under the separate forms in the clinical chapters, but the general 
 principle involved is to be here mentioned. 
 
 The first thing is to determine whether there be a prevailing tone 
 of depression or of exaltation, and, in their absence, whether mental 
 weakness or stupor be present. The question whether the depres- 
 sion, exaltation, mental weakness, or stupor be primary or secondary 
 is next in order, and whether one of these conditions has alternated 
 with the other, and, if so, what the sequence has been. 
 
 These are the broadest grounds upon which a diagnosis by exclu- 
 sion can be approximated, for, if mental depression has constantly 
 prevailed, and the examination shows no marked impairment of 
 
336 TEXT-BOOK ON MENTAL DISEASES. 
 
 faculties, all forms of mania, dementia, and stupor are excluded. 
 In the same way, if stupor lias prevailed and was primary, all forms 
 of mania are excluded, and all forms of melancholia, unless it be 
 melancholia attonita, and all forms of dementia except primary de- 
 mentia. Likewise, if mental exaltation has been continuously pres- 
 ent, all forms of melancholia, stupor, and dementia are excluded, 
 and it becomes a question between general paresis and some form 
 of mania. The personal history and the actual psychic and somatic 
 symptoms present will then be sufficient additional evidence to settle 
 the question of the form of the Insanity. 
 
 If the prevailing emotional tone has varied, and the sequence 
 has been depression and exaltation, and then a repetition of the same, 
 the form is probably circular Insanity. If there has been depression, 
 then exaltation and then mental weakness, there is in all probability 
 a simple psychosis pursuing the course of the customary stadia. 
 
 The elements of diagnosis of the special form of Insanity, there- 
 fore, are the presence of depression, exaltation, mental weakness, 
 or stupor, and the sequence or alternation of these conditions, the 
 personal history, the 'actual psychic and somatic symptoms present, 
 and in some cases the cause, when well known, and the general order 
 in which all the manifestations have progressed. The full applica- 
 tion of these principles in special forms will be made in the second 
 part of the work, in which differential diagnosis of forms will also be 
 treated. 
 
 The question of institutional or of home treatment is of great 
 importance, and it is to be embraced in the diagnosis, as it is de- 
 pendent largely on the form of Insanity recognized to be present. 
 
 The popular stigma of Insanity, and the loss of standing of those 
 who have been inmates of hospitals for the insane, has already been 
 mentioned. It is better in general to avoid institutional treatment 
 if the patient can be cured equally well in his own home. The 
 simple fact that the person did not have to go to an asylum favors 
 the idea that his mental trouble was not serious, and it often largely 
 avoids the popular prejudice as to one upon whom the ofRcial seal 
 of Insanity has been stamped by commitment to an institution for 
 the insane. While protecting the interest of his patient against this 
 popular feeling of mistrust, the physician has other considerations 
 to guide him in his decision. The effect of the home treatment upon 
 the members of the patient's family is one consideration. It is the 
 duty of relatives to suffer inconvenience and some hardship even 
 
THE DIAGNOSIS OF INSANITY. 337 
 
 to nurse sick members of the family. Insanity presents no new feat- 
 ures which change the moral obligation of relatives, though the 
 physician must not in this, any more than in other sickness, allow 
 the health of the family to be seriously jeopardized. 
 
 The financial consideration often settles the question. The ex- 
 pense of home treatment is greater, unless there be members of the 
 family suitable for nurses, one for the day and the other for the night, 
 and, except in mild cases, specially experienced attendants are re- 
 quired, and a certain part of the house must be properly prepared for 
 the accommodation of the patient. 
 
 The main consideration is the best chance of cure for the patient, 
 whether at home or in a hospital. If the patient be suicidal, homici- 
 dal, destructive, or very noisy, institutional treatment is strongly 
 indicated. It is the safest resort in the vast majority of cases of 
 Insanity, unless the physician can conform to all the directions for 
 home treatment mentioned in the chapter on Treatment, to which 
 reference is made to avoid repetition. 
 
 One thing must be avoided, and that is the temporizing policy, 
 which sacrifices the chances of cure of the patient, who is not ac- 
 tively treated, either at home or in a hospital, until he is finally rele- 
 gated to an institution as incurable. 
 
 The diagnosis often has to be made with reference to the degree 
 of responsibility of the patient in medico-legal cases. 
 
 The degree of responsibility in mental disease is the most diffi- 
 cult of all the questions which the expert physician has to decide. 
 Medically speaking, personal responsibility ceases right at the point 
 of the recognition of Insanity in the patient. This would be a 
 simple, just, and satisfactory solution of the medico-legal difficul- 
 ties, but neither the legal practice nor the popular view will allow 
 this medical standard of responsibility to serve as a defense in court 
 for overt acts committed or financial liabilities incurred. 
 
 The individual, though insane, may contract reasonable debts, 
 for which his estate will be held; he may make a will, which, if not 
 the direct outcome of his Insanity, will be valid, and he may exercise 
 his civil rights and incur responsibilities in various directions; and, 
 when it comes to the commission of illegal acts, the courts will hold, 
 him responsible according to the degree of his knowledge of the 
 nature of the deed committed and of his supposed power of self- 
 control to do or to refrain from doing the act in question. The 
 physician will be called upon to decide the knowledge of right and 
 23 
 
338 TEXT-BOOK ON MENTAL DISEASES. 
 
 wrong, and the degree of self-control possessed by the patient, and 
 the modified responsibility which existed at some particular time in 
 the patient's history. If the physician simply replies in coiirt that 
 Insanity, to his mind, excludes all responsibility on the part of the 
 patient, he will be supplanted by other experts, who will discrim- 
 inate and define the relative responsibility, under hypothetical con- 
 siderations, of the state of the mental faculties of the patient and 
 the nature of the ofl'ence which he committed. 
 
 The diagnosis of the special form and of the particular phase 
 of the Insanity at the time of the act in question will be important 
 in these medico-legal cases. Irresponsibility would be more readily 
 admitted in epileptic automatism, in maniacal and melancholiac 
 furor, in advanced general paresis and terminal dementia, than in 
 paranoia, subacute mania or melancholia, hypochondriacal or neu- 
 rasthenic Insanity. 
 
 The diagnosis, finally, has to extend to the jetio-pathology and 
 the general indications for treatment of the Insanity. 
 
 If the patient be suffering from syphiHtic Insanity it is a part of 
 the medical examiner's task to discover the fact of the true nature 
 of the mental disorder. 
 
 If the patient has been secretly addicted to a drug, and has un- 
 dermined his physical and mental health, the pathology of the 
 mental disorder should come within the scope of the diagnosis, as 
 well as the effectual means of preventive treatment of the Insanity 
 in the future. The physician must extend his diagnostic research 
 from the fact to the cause of the mental disease, and he will be 
 surprised often that the setio-pathology is simply the abuse of drugs 
 or alcohol unknown to relatives in many cases. If Insanity be the 
 result of nocturnal epilepsy, not known to the patient or family, the 
 medical examiner must, if possible, arrive at the true nature of the 
 case and of the indications for its treatment. The case may be one 
 of phthisical Insanity, and the lesions may be found far advanced 
 without cough or expectoration, greatly to the astonishment of the 
 family. 
 
 The lines of the diagnosis and of the pathology of Insanity often 
 run parallel and close together, and the diagnostician must extend 
 his research the full length of pathological knowledge, if need be, 
 to discover the real source of the disease and the corresponding 
 course of treatment indicated. 
 
THE DIAGNOSIS OF INSANITY. 
 
 339 
 
 Complete Formula for the Mental and Physical Examination with 
 Beference to Diagnosis. — No effort has been made to present a tech- 
 nical or exhaustive formula for the personal examination of patients 
 supposed to be insane, but a condensed and practical array of points 
 to be canvassed by the medical examiner in attempts at diagnosis, 
 are here brought together in systematic order, and it is thought that 
 they may prove highly suggestive and useful to the general prac- 
 titioner. 
 
 Formula for Diagnostic Examination of Patients. 
 A. Psychical Examination. 
 
 I. Perception. 
 
 Sight . 
 
 II. Conscionsnessi. 
 
 III. Memory 
 
 IV. Intellection . . . 
 
 V. The Emotions. 
 
 VI. Volition . 
 
 1. Test all the senses. 
 
 r Anaesthesia, analgesia, thermo-anses- 
 i thesia. Test the sense of pressure. 
 
 Touch -j contact, locality, temperatuie. pain, 
 
 I and the time rate of the reactions 
 
 [ of the skin in the.ie directions. 
 
 ( Test for sweet, sour, salt and bitter 
 
 Taste < solutions. Ageusia, hyperageusia, 
 
 { parageusia. 
 
 1 Various tests best made before testing 
 
 Smell <^ taste. Anosmia, hyperosmia, par- 
 
 1 osmia. 
 
 Anomalies of vision, color-blindness. 
 Ophthalmoscopic examination. Pu- 
 pillary reflexes. Action of ocular 
 muscles. 
 
 Hearing \ Distance, cranial conduction, electri- 
 I cal tests, otoscopic examination. 
 
 Muscular sense -{ Sense of weight. Position of limbs. 
 
 . 3. Hallucinations and illusions of all the senses. 
 
 Degree of impairment. Changrs in identity. Realization of 
 present surroundings. Consciousness of mental disease. 
 
 ( 1. Test of memory. ( Amnesia. Special loss in aphasic con- 
 
 ( 2. Disorders of memory, j ditions. 
 
 ( Tests for thought-rate, power of attention, association of ideas, 
 I incoherence of speech, reasoning, delusions. 
 
 r 1. The fundamental emotional tone, depression, exaltation, apathy, 
 
 ! mental weakness, stupor. 
 
 J 2. Egoistic feelings, animosities. Dominant emotions of fear, hatred, 
 
 I anger, suspicion, pride. 
 
 3. Altruistic feelings. Affection for parents or relatives. Social 
 
 1. tendencies, religious and erotic sentiments. 
 
 f 1. Loss of control of ideas and of actions, as shown in general bear- 
 I ing and conduct. 
 
 2. Irresistible impulses and impellent ideas. The tendency to de- 
 
 stroy or burn property. 
 
 3. Suicidal and homicidal impulses and sexual perversions, and 
 I. morbid instincts or appetites. 
 
 I. O.sseous Strnctures. 
 
 B. Physical Examination. 
 
 1. Cranial conformation, measurements, asymmetries, size relative 
 
 to stature, injuries, cranial thermometry. 
 
 2. Stature — excess or defect of growth, spinal curvature, abnormal 
 
 joints or long bones, exostoses, moUities ossium. 
 
 3. Stigmata degenerationis. 
 
340 
 
 TEXT-BOOK ON MENTAL DISEASES. 
 
 f 1. General muscular development. 
 
 2. Tests of muscular functions. Strength, co-ordination, dynamo- 
 meter and electric tests. 
 
 3. Paralysis, atrophy, contractures, tremors, ataxia, cataleptoid 
 _, ,, , J n, ■ a,nd tetanoid states. 
 
 TOc*i"^r» tneir _j ^ Tests of muscular reflexes : Knee-jerk, ankle clonus, etc. 
 
 5. Special movements : Gait, speech, and handwriting, 
 ii. Characteristic attitudes and gestures. Automatic actions. 
 7. Physiognomy : Innervation of facial musclep, paradoxical expres- 
 sions, laughing, crying. Dominant expression. 
 [ 8. Lingual movements : Pi.latal muscles and innervation. 
 
 Disorders. 
 
 III. The Heart and Vessels 
 
 IV. Epithelial Structures . 
 
 ]l 
 
 1. Cardiac dilatation or hypertrophy. Valvular lesions. 
 The large vessels, degenerations, aneurisms. 
 The pulse : Sphygmographic tracings. 
 
 V. Internal Organs 
 
 VI. Nutrition, Secretions, 
 and Excretions, and ■ 
 Vasomotor Functions, 
 
 1. The skin : Eruptions, pigmentations, cyanosis, state of the cu- 
 
 taneous excretion. 
 
 2. The hair : Baldness, grayness, alopecia. 
 
 3. The nails : Bitten nails, trophic changes. 
 
 1. Lungs: Phthisis, asthma, modifications of respiration. 
 
 2. The stomach : Digestive disorders, gastralgia. 
 8. The spleen : Malarial enlargement. 
 
 4. The intestines : Parasites, catarrh, obstipation, hemorrhoids. 
 
 5. The liver : Abscess, cirrhosis, icterus, giill-stones. 
 
 6. The kidneys : Chronic degeneration. Examination of urine. 
 [ 7. Supra-renal capsules : Addison's disease, 
 
 f 1. Total bodily weight : Subcutaneous fat, emaciation. 
 
 2. Disorders of nutrition : Anorexia. 
 
 3. The blood : Toxic conditions, hsemoglobin, corpuscles. 
 
 4. The saliva : Quantity, quality. 
 
 5. The urine : Chemical and microscopic examination. 
 
 6. Temperature : Changes morning and evening. Difference be- 
 tween head ard armpits. 
 
 L 
 
 7. Trophic changes -[ Epithelial, muscular, osseous structures. 
 
 Hsematoma auris. Local hyperaemias, 
 cedema of skin, cyanotic extrem- 
 ities. 
 
 8. Vasomotor functions 
 
 ■] 
 
 VII. Nervous System . . . 
 
 1. Diseases of the brain. . -{ Anaemia, hyperseraia, focal lesions. 
 
 2. Spinal affections : Alcoholic, and syphilitic lesions. 
 
 3. Diseases of the peripheral nerves : Electric reactions. 
 
 4. The major neuroses. 
 
 5. The acquired neuroses. 
 
 6. Congenital defects. 
 
 In the above formula for the examination of patients with refer- 
 ence to a diagnosis it has not been thought worth while to mention 
 many modern contrivances for testing the special sensorial func- 
 tions, registering thought-rate and voluntary reaction time. 
 
 Even in testing the tactile sense, if an aesthesiometer is not at 
 hand, a pair of sharp-pointed scissors or a hair-pin may be used, or 
 a knitting needle may be employed to trace letters or figures on the 
 skin. Contact may be tested by drawing a feather over the skin, 
 and sense of locality by requiring the patient to point to the places 
 touched, and the direction of lines drawn on the skin is to be told. 
 Temperature-sense is easily tested with test-tubes, or with coins in 
 the absence of a thermo-sesthesiometer. 
 
 In testinff the muscular sense it is to be borne in mind that an- 
 
THE DIAGNOSIS OF INSANITY. 341 
 
 sesthesia of Joints and tendons causes loss of the sense of position 
 of the limbs and static ataxia. 
 
 All the usual tests are practicable in many cases of Insanity, 
 though the physician must resort to ingenious expedients, and be 
 prepared to vary the routine-tests to suit the particular case under 
 examination. 
 
CHAPTER X. 
 
 THE PROGNOSIS OF INSANITY. 
 
 The Substance of the Prognostic Inquiry. — There are a number 
 of substantial points to be embraced in the prognosis. In the first 
 place, there is the question of life or death. Are the chances, all 
 things considered, that the patient will survive or perish during the 
 attack of Insanity? 
 
 If the patient live, will he recover from the mental disorder? 
 and about how long will it be before the cure will be complete? and 
 if he recover will he be liable to have another attack? The family 
 physician will be called upon to answer these questions, and he will 
 require great skill, if he have many cases of Insanity, to uniformly 
 acquit himself successfully on these categorical occasions. There 
 are still other questions which he will have to answer, but the above 
 is the chief substance of the inquiry upon which he must form an 
 opinion. The whole subject of prognosis, being very complex in its 
 bearings, is best discussed seriatim as to its substantial points, and 
 first in order of magnitude is the matter of life or death. 
 
 The Possibility of Death. — It was estimated in the chapter on 
 Statistics that out of every one hundred persons attacked for the 
 first time by Insanity seventy eventually die insane, either during 
 the first or subsequent attacks. Another broad statistical statement 
 is that the average mortality-rate among the insane is from four to 
 five times greater than among the sane. In European, British, and 
 American hospitals for the insane the mean annual death-rate varies 
 from eight to twelve per cent, on the average numbers resident. 
 
 The expectation of life of an insane person, therefore, at any 
 given age is very much less than that of a sane person of the same 
 age. 
 
 The mortality-rate is, in general, somewhat less among women 
 than among men. 
 
 The danger of death is greatest during the first month of the 
 
 342 
 
THE PROGNOSIS OF INSANITY. 343 
 
 attact, and it decreases each month during the first year of the In- 
 sanity. 
 
 Among the insane in general the seasonal influence on mortality 
 is that more die in winter than in summer, and more in the spring 
 than in the autumn or at any other time of the year. 
 
 Other things being equal, the chances of the survival of an attack 
 of Insanity are much greater among the young than among those 
 advanced in life. The immediate causes, which lead to a fatal issue 
 in the acute stage of the mental disorder, are impaired nutrition, 
 insomnia, and cardiac failure. The general vitality of the patient 
 becomes reduced and he dies of exhaustion from acute mental dis- 
 ease, often without visible organic lesions of any kind. In other 
 cases the patient succeeds in taking his own life, or he meets with 
 injuries or surgical accidents which are treated with great difficulty 
 and may eventuate fatally. 
 
 In melancholic and emaciated cases phthisis pulmonalis not in- 
 frequently results, and pneumonia or oedema of the lungs sometimes 
 leads to the fatal result. 
 
 All cases complicated with chronic organic diseases of the heart, 
 kidneys, and lungs have an unfavorable prognosis as to life, which 
 seldom extends beyond the duration of the Insanity. 
 
 There are certain forms of Insanity which uniformly have a bad 
 prognosis as to life. General paresis ends fatally so constantly that 
 some authors question the genuineness of any case said to have re- 
 covered. The average duration of life in general paresis is three 
 years from the first appearance of symptoms. 
 
 Delirium acutum is another fatal type in which the death-rate is 
 variously estimated by writers at from fifty to seventy-five per cent. 
 of all cases attacked, and the average duration of life in the fatal 
 eases is from one to three weeks. 
 
 Syphilitic and alcoholic dementia usually terminate fatally with- 
 in a tew years from the date of their full development. 
 
 The expectation of life is greatly reduced in cancerous, tubercu- 
 lar, pellagrous, and myxoedematous cases of Insanity, and also in 
 other severe cachexia. 
 
 Mental disorder from focal brain diseases is unfavorable as to the 
 chances of life, and in the majority of cases it terminates fatally 
 in from two to five years. In hemiplegic dementia from intracerebral 
 hemorrhage there may be a considerable prolongation of life in oc- 
 casional cases. On the other hand, Insanity from brain tumors 
 
344 TEXT-BOOK ON MENTAL DISEASES. 
 
 usually terminates fatally within less than two years, and has a more 
 prompt average mortality even than general paresis. 
 
 The prognosis as to life and death, therefore, in any particular 
 case, must be judged by the above principles, and also by the careful 
 estimate of the individual strength of constitution and general vital- 
 ity and powers of recuperation, and also by considerations of the 
 age, sex, stage of the mental disorder, and by the more or less com.- 
 plete facilities for the good nursing and thorough medical treatment 
 of the case. If the patient be too poor to afford good nursing and 
 abundant supplies of nourishment, and the family have an unreas- 
 onable prejudice against the removal of the patient to a hospital 
 for the insane, the chances of life are greatly diminished, and such 
 cases are constantly sent to hospitals in a final stage of reduction, in 
 which no amount of forced alimentation or medical skill can avert 
 the fatal termination. 
 
 The Hope of Recovery. — The recovery-rate, calculated on the 
 total number of admissions in European and American hospitals for 
 the insane, varies from thirty to fifty per cent. This is rather more 
 favorable than the real facts of recovery would warrant, as relapses 
 and second recoveries of the same patients are not eliminated from 
 this estimate. On the other hand, it is to be considered that the 
 more unfavorable cases usually find their way to hospitals, so that 
 the general chance of recovery above stated is not far from correct. 
 The writer's opinion, based on experience in both hospital and pri- 
 vate practice, is, as already stated under Statistics, that out of every 
 hundred patients attacked for the first time by Insanity, thirty re- 
 cover and remain well the rest of their lives, and twenty recover, 
 but relapse and die insane, and fifty do not recover at all. The 
 chances of recovery among women are, on the average, greater than 
 among men, as shown by statistics on a large scale. 
 
 The percental chances of recovery from first attacks of Insanity, 
 therefore, are not very different from those found in severe organic 
 diseases of internal organs, and the individual prognosis in both in- 
 stances is specially modified by the age, constitution, and direct 
 hereditary tendency to the disease. 
 
 The patient who has had pneumonia, pleuris}^ or pericarditis 
 is Hable to have subsequent attacks, and the insane patient once 
 recovered is still more apt to have a recun-ence of mental disorder. 
 
 The hope of recovery diminishes rapidly with each successive 
 attack, and, although a dozen recoveries have been recorded excep- 
 
THE PROGNOSIS OF INSANITY. 345 
 
 tionally in cases, it may be practically assumed that not more than 
 three recoveries are to be admitted as complete in any case. In strict 
 accordance with scientific truth the majority of first recoveries even 
 leave the keen edge of the intellect somewhat dulled, and a slight 
 impairment of the higher intellectual and moral qualities. These 
 sequels in recoveries from first attacks are imperceptible, however, 
 except to experts, and, for all the intents and purposes of life, the 
 patient is as well as he ever was. 
 
 The prognosis as to recovery, as greatly modified by the fori» 
 of the Insanity and other factors in individual cases, will be found 
 discussed under a later heading. 
 
 TTie Probable Duration and Mode of Termination. — It is impor- 
 tant for the family to know how long the large expense of the care 
 and treatment of an insane relative will probably have to be borne. 
 Insanity pursues a longer course than most diseases, and it presents 
 greater extremes in time-limits than other maladies, as it may last 
 from an hour to a life-time. It has been estimated that the average 
 life of the insane is about twelve years. 
 
 Fortunately the immediate danger of death, as well as the hope 
 of recovery, is decided during the first year. If actively and skilfully 
 treated within the first month, seventy per cent, of those attacked 
 may be cured, but if not treated until the sixth month of the dis- 
 ease only fifty per cent, can be cured, and for each subsequent month 
 the hope of cure diminishes, and after the first year not more than 
 ten per cent, recover, and after the second year and until the twen- 
 tieth year of the Insanity an exceptional recovery may occur. Prac- 
 ticall)'-, however. Insanity may be regarded as having little hope of 
 recovery after the first year, and the family should not be expected 
 to suffer financial distress to support an insane relative, who at the 
 end of a year's treatment shows no signs of improvement. 
 
 Seventy-five per cent, of cures in hospitals for the insane occur 
 within eight months from the date of admission of the patients. 
 The above statements will enable the ph5^sician to form a correct 
 general opinion of the curable prospects of the case, judged by the 
 actual and by the prospective duration of the attack. 
 
 The form of the Insanity will also influence the opinion given 
 'as regards duration. Insanity of the menopause is often prolonged 
 for several years before recovery, while typhomania runs its course 
 Av-ithin a few weeks, and many of the acute psychoses terminate with- 
 in a few months. 
 
346 TEXT-BOOK ON MENTAL DISEASES. 
 
 The expansive forms of mental disorder are more apt to run a 
 prompt course than the depressive forms. Thus, in adolescent In- 
 sanity the melancholy type rather than the maniacal runs into 
 chronic mental disease. The maximum recovery-rate in this form 
 is from the fourth to the eighth month, and fully three-quarters of 
 the cases recover before the latter date, the most recoverable period 
 being earlier in males than in females in this instance, being prior 
 to six months in the former and subsequent to that time in the latter. 
 
 In all the incurable forms of Insanity the question of duration, 
 of course, is equivalent to the determination of the expectation of 
 life in each case, and this is often in turn dependent upon some 
 organic disease of internal organs, or upon some diathetic state. 
 
 The Mode of Termination of an attack of Insanity is a question 
 about which the physician will surely have to give an opinion. The 
 demand will be not alone as to the possibility of death or the hope 
 of recovery, but also, in case of neither of those events, just what 
 the state of the patient will be. Will the patient be able to attend 
 to any business or to have any voice in the management of his af- 
 fairs? will he be well enough to live at home, or must he remain an 
 inmate of a hospital for the insane? 
 
 The prognosis as to the mode of termination requires a more 
 extensive experience in mental disorders than is required to give 
 an opinion as to the ciiances of recovery. 
 
 In hereditary cases there is a tendency to make repeated sudden 
 and partial recoveries, which are less and less perfect after each 
 successive attack. Outside of this general rule the physician will 
 do well to bear in mind in these cases that the unexpected always 
 happens, and he will often be astounded to see a patient in abject 
 craziness one month and to find him clothed and in his right mind 
 and successfully at his business the following month. Such a pa- 
 tient has entered upon a degenerative line of life graphically repre- 
 sented by abrupt descents into the depths of Insanity and sudden 
 ascents to planes of mental health, sinking successively lower after 
 each recurrence. 
 
 There is another hereditary tendency to a special mode of ter- 
 mination in certain families at certain ages. Thus, active suicidal 
 Insanity appears about the age of forty-five in certain families, and 
 then subsides into a mild form of mental impairment for the rest 
 of life, while in other cases it takes the form of premature senile 
 decline of mental faculties from the very first and is absolutely hope- 
 
THE PROGNOSIS OF INSANITY. 347 
 
 less and progressive in nature. It is well, therefore, to carefully 
 study the family tendencies, which so often repeat themselves in 
 mental disorders. 
 
 A common mode of termination is partial recovery, with no re- 
 maining disorder but general weakness of mental faculties. There 
 is about one chance in four that an ordinary acute psychosis will 
 terminate in this way. Such partially recovered patients may often 
 live at home, and be engaged in some light business, and manage 
 their own affairs, if they demand only a modicum of business ca- 
 pacity. 
 
 In other cases of alcoholic, syphilitic, paretic, and toxic nature, 
 in which hopeless lesions have evidently resulted, the physician will 
 be able to prognosticate permanent dementia, even if life be spared 
 for years. The physician must recognize these cases, which bear 
 the stamp of incurability from the beginning, in order that the fam- 
 ily may not be impoverished by expenses of cure undertaken in the 
 false hope of a favorable termination of the mental disease. To this 
 incurable category belong general paresis, senile dementia, mental 
 disorder as a sequel of tuberculosis or cancer, the periodical and 
 circular Insanities, mental alienation resulting from chronic epi- 
 lepsy, primary monomania, hereditary alcoholic Insanity, terminal 
 dementia, and organic dementia. 
 
 The Chances of Recurrence. — There is a certain tendency to recur 
 in all forms of Insanity, and one attack always increases the proba- 
 bility of a subsequent one. There is not only a special form, known 
 as recurrent Insanity, which is almost hopeless in prognosis as to 
 the prevention of the return, but there is also direct heredity to this 
 particular form, and this is still more unfavorable. This recurrent 
 form is especially common during middle age, and at a somewhat 
 later period still in women. 
 
 The general average chance of relapses has already been stated 
 in the estimate that, out of one hundred attacked by Insanity for 
 the first time, thirty recover and remain well, while twenty others 
 who recover relapse and finally die insane. 
 
 If the patient be without special heredity and become insane 
 from great exposure, hardships, fevers, or other active cause, and 
 make a good recovery of his original strong physical condition, the 
 chances are that he will not have a relapse. 
 
 The* danger of a relapse is avoided sometimes by prophylaxis as 
 regards the original cause of the Insanity. Thus, if childbearing 
 
348 TEXT-BOOK ON MENTAL DISEASES. 
 
 be the cause of the mental disorder in a woman free from heredity, 
 the probability is that there will be no relapse if a second puerperium 
 is avoided. 
 
 The same would be true of Insanity from alcoholic excess and 
 drug habits if prophylaxis were less diflScult, but the physician may 
 safely prognose a relapse in seventy-five per cent, of tliis intemperate 
 class of patients, simply because there will be re-exposure to the 
 original cause. 
 
 In estimating the chance of recurrence the total environment 
 of the patient is of the utmost importance. 
 
 If the recovered woman is again to be exposed to hardships, the 
 care of children, the loss of sleep, unhygienic surroundings, and 
 perchance the abuse of a drunken husband, there is almost a cer- 
 tainty of a relapse. In the same way a recovered business man, re- 
 turning to the fight of life, working against fate, and hoping against 
 desperate chances to better his financial condition, and living again 
 on the keen edge of anxiety, will almost inevitably have a recurrence 
 of mental aberration. For the statistical chances of relapse, this 
 heading in the chapter on Statistics may be consulted. 
 
 The Essential Elements of Prognosis in Individual Cases. — The 
 individual elements of prognosis are age, sex, constitution, and 
 heredity of the patient, and the form, duration, course, and cause 
 of the attack. 
 
 Age, — Youth is favorable to survival and recovery from attacks 
 of acute Insanity, and old age diminishes the hope of life and of 
 cure. The greatest number of recoveries takes place between twenty- 
 five and thirty-five years of age. The individual exceptions to this 
 rule are found chiefly in particular transmitted neuropathic ten- 
 dencies to epochal Insanity followed by recoveries. For instance, 
 in certain famihes such a tendency exists to climacteric or senile 
 mental disorder followed by recovery, and even a tendency to re- 
 lapse and final recovery may exist. 
 
 The damage done to cerebral tissues and vessels during the acute 
 stages of the psychoses are not readily repaired, and the recuperative 
 powers are much greater in early life than in advanced years. The 
 more perfect nature of the cures, as well as their greater proportion, 
 is to be noted during the earlier part of life. The fact of recovery 
 in a patient between fifty and sixty is by no means the equivalent 
 of a recovery between twenty and thirty. The clinical proof of this 
 is the constant relative numerical increase of relapses a.s age ad- 
 vances from the period of maximum recoverability named. 
 
THE PROGNOSIS OF INSANITY. 349 
 
 It is to be borne in mind that age is relative, and not absolutely 
 measured by lapse of years, and the fact of involutional changes in 
 the vascular system, and in the tissues generally, is the true gauge 
 of senile decline, which is present in some families at forty and in 
 others not before sixty years, just as adolescence is complete in some 
 before twenty, and in others not until after twenty-five years. The 
 period of greatest recoverabihty falls at a later period in long-lived 
 families in which maturity is slowly reached, and at an earlier date in 
 those exhibiting precocity at one end of life and at the other senium 
 precox. The general hope of recovery is greater in the former fam- 
 ilies than in the latter. All forms of juvenile Insanity in which 
 there is a basis of congenital defect are unfavorable, and this is true 
 of Insanity at any age in those having inherited mental deficiency. 
 
 The bearing of age on the chances of life in mental disorder is 
 sufficiently expressed by the fact that the expectation of life dimin- 
 ishes with advancing years much more rapidly in the insane than in 
 the general population. 
 
 Sex. — The relation of sex to prognosis may be summed up in the 
 statement that there is, as shown by statistics, a slight advantage on 
 the side of women, both as to recoverability and mortality. 
 
 The fact of a larger proportion of recoveries among women is 
 offset, however, by the secondary fact that there are among them 
 more relapses than among men. 
 
 As to the sexual difference in the mortality-rate, it only tallies 
 with that which exists in the general population, for in the long run 
 the death-rate is smaller among females than males, according to 
 both British and American statistics. The truth probably is that 
 men have greater strength of resistance to the shocks of life which 
 cause Insanity, and that, were women equally exposed to alcoholic 
 excess and all the hardships of the battle of life, the statistical rela- 
 tion now in their favor would be reversed. The greater mortality 
 in males is largely acepunted for by the syphilitic, alcoholic, and 
 paretic cases. The greater frequency of relapses among women is 
 probably to be attributed to a greater preponderance of hereditary 
 influences among them. 
 
 Constitution. — It is intended to express by the word constitution 
 both the physical and mental organization, and the general distinc- 
 tions implied in the word temperament. The skilful physician learns 
 to judge with considerable accuracy of the general strength or weak- 
 ness of the constitution of his patients, and to recognize certain traits 
 
350 TEXT-BOOK ON MENTAL DISEASES. 
 
 implied in common parlance by the terms nervous, sanguine, bilious, 
 and lymphatic temperaments. The differences in individuals above 
 mentioned certainly have importance, and are to be given due weight 
 in prognosis. There are individuals so constituted that expansive 
 forms of mental disorder prevail with them, while in others depres- 
 sive types result, and with the lymphatic temperament stupor is 
 more often associated. 
 
 The strength of constitution required to recover well from acute 
 maniacal Insanity is very considerable, and this favorable issue is 
 certainly not to be anticipated in those of distinctly feeble constitu- 
 tion. The latter are much more apt to succumb to maniacal ex- 
 haustion or to pass into secondary dementia. The family physician 
 who has had an opportunity to watch the individual through the 
 infectious diseases of childhood and the disorders of later life, often 
 has valuable knowledge as to the inherent strength or weakness of 
 the constitution, which is to be subjected to the severe strain of an 
 attack of acate Insanity. The stress during an acute psychosis is 
 greater and m^ore prolonged than that of an acute infectious disease, 
 and the direct sequela of the mental disorder is often the develop- 
 ment of any latent tubercular or other constitutional tendency to 
 disease. The individual constitution, therefore, becomes one of the 
 elements of prognosis. 
 
 Heredity. — The hereditary element in a case of Insanity modifies 
 the prognosis, more especially as to the ultimate result. The chances 
 of a first recovery are not greatly impaired by heredity, but the rule 
 is that relapses follow until the mental deterioration is complete. 
 
 The different degrees of heredity are to be skilfully weighed in 
 giving an opinion as to the prospect in a case of mental disorder. 
 The derivation of a neuropathic constitution in direct line, both 
 from the paternal and maternal sides, reduces the ultimate chances 
 of cure to a minimum. Chronic alcoholism on the paternal side is 
 v^ery frequent, and in the light of heredity it is equivalent to open 
 mental disorder. Alcoholism of the father and active mental dis- 
 ease of the mother during the full gestation of the child is a hope- 
 less form of heritage. Confirmed epilepsy in one parent and chronic 
 intemperance in the other is as unfavorable as direct linear heredity 
 to Insanity. 
 
 Fully developed mental disorder in both parents prior to the 
 birth of the patient precludes all favorable views for the future of 
 the sufferer. Advanced phthisis pulmonalis in the father or in the 
 
THE PROGNOSIS OF INSANITY. 351 
 
 mother tefore the birth of the patient is tantamount to mental 
 disease, when combined with direct heredity to Insanity in the other 
 parent. 
 
 General paresis is held by some French authorities as simply 
 a brain disease, which directly constitutes no heredity to Insanity 
 in the children of the paretic. The writer cannot indorse this view, 
 and holds that all forms of the neuroses, as well as Insanity, are 
 found among the children of paretics. Direct heredity to Insanity 
 derived from grandparents on both the father's and mother's side 
 of the house is just as unfavorable as if it existed in the immediate 
 parents, and the fact of atavistic transmission shows the strength 
 of the latent tendency. Idiocy or imbecihty, when congenital, shows 
 a stronger degenerative tendency than Insanity itself. The type 
 of the mental disorder among ancestors is also to be considered. 
 
 Primary monomania would signify a much stronger neuropathic 
 tendency than puerperal or senile Insanity. The degree of degen- 
 erative taint is to be judged, also, not alone by the cases of Insanity 
 in the family, but by the total of all neurotic affections in the direct 
 and collateral branches of the family. If the history of the family 
 for several generations had shown cases of epilepsy, chorea, migraine, 
 asthma, spinal degenerations, myopathies, and feeble-mindedness, 
 the heredity would be stronger than if actual cases of Insanity alone 
 had appeared in the ancestry. 
 
 Above all, the physician must not fail to discover specific forms 
 of heredity to definite types of mental disorder at certain ages to 
 which allusion has already been made. The course and mode of 
 termination of Insanity in ancestors of the patient will also afford 
 often valuable aids in prognosis. There are instances of desperate 
 and fatal suicidal mental disorder in successive generations of the 
 same family at about the age of middle life. In some families hypo- 
 chondriacal melancholia begins about fifty years of age and ter- 
 minates only with life. In other families phthisis pulmonalis ap- 
 pears about a certain age, with mental disease as a sequel. Every 
 tendency to a special heritage of this kind is of the utmost value in 
 prognosis. 
 
 Direct heredity to Insanity is somewhat more constant through 
 the maternal than through the paternal line, and the daughter who 
 nearly resembles an insane mother will likely become insane in a 
 similar manner. 
 
 Other principles of heredity in relation to Insanity are discussed 
 
352 TEXT-BOOK ON MENTAL DISEASES. 
 
 under this head in the chapter on Etiology. The principle of 
 reversion to a healthy type is not to be forgotten. The history of 
 one family shows that it is constantly and surely degenerating. In 
 another family there is a steady process of regeneration and of return 
 to a healthy type. In the former instance heredity, as indicated 
 by the presence of actual cases of Insanity, Justifies a much more 
 unfavorable prognosis than in the latter case. 
 
 Hereditary syphilitic taint is to be looked out for as an unfavor- 
 able prognostic element, and in Europe goitrous and pellagrous 
 parentage is almost as bad as transmitted specific taint. In France 
 alone it is estimated that there are 420,000 goitrous persons. 
 
 In cases in which no heredity can be ascertained by inquiry the 
 existence of the same may still be revealed by the well marked 
 periodicity of the attacks, or by both psychic and somatic stigmata. 
 
 Form of the AUaclc.—-T\i.Q form in which the mental disease pre- 
 sents itself is a valuable element in prognosis. There are certain 
 forms which imply incurability from the very beginning. 
 
 When the diagnosis of general paresis has once been made be- 
 yond doubt, there need be no hesitancy in declaring the prognosis 
 hopeless. Doubtful cases of alcoholic origin chiefly are to be given 
 the benefit of the doubt in prognosis. 
 
 Cures have been reported in cases of general paresis, but the 
 diagnosis is questionable in such cases, and there is also the possi- 
 bility of mistake through the extraordinarily prolonged remissions 
 which exceptionally characterize general paresis. Primary mono- 
 mania, the gradual outgrowth of neurotic taint, with fixed and sys- 
 tematized delusions, is absolutely without hope, and yet, on account 
 of the amount of reasoning ability retained by the patient, it is diffi- 
 cult to impress the relatives of the patient with the truth of the 
 bad prognosis, which may even cost the medical adviser the loss of 
 his patient and of the good-will of the family. Moral Insanity, ap- 
 pearing in very youthful subjects with decided depravity, criminal 
 propensities, sexual perversions, and other signs of neurotic degen- 
 eration, is almost as hopeless as the form of original monomania just 
 mentioned, and, in fact, they belong to the same degenerative group 
 of Insanities. The early appearance of the mental obliquity shows 
 the high degree of the transmitted taint. 
 
 Congenital mental deficiency is, of course, irremediable, except 
 in so far as some amelioration is practicable through minor degrees- 
 of education. 
 
THE PEOGNOSIS OF INSANITY. 353 
 
 Goitrous inheritance is fatal to hopes of complete mental devel- 
 opment, except when the patient is removed at a very early age from 
 the endemic region and submitted to the most systematic means of 
 physical and mental training. The prognosis is more favorable in 
 children born of goitrous parents, who have emigrated to parts of 
 the world where goitre is unknown, before the birth of the child. 
 
 The prognosis in Insanity emerging from confirmed neuroses, 
 epilepsy, hysteria, and hypochondria is uniformly bad. 
 
 Mental disorder from coarse brain disease and focal lesions, tak- 
 ing the form of dementia, is to be counted among the incurable 
 forms. In embolic processes giving rise to amnesic disorder a 
 guarded opinion is to be given, and time becomes a necessary ele- 
 ment in the prognosis. The prospect is always bad in periodical and 
 circular Insanity, though long lucid intervals may be enjoyed. 
 
 Delirium acutum, if the patient survive, admits of an occasional 
 recovery. 
 
 Senile dementia from involutional brain-atrophy is incurable, 
 though there are senile forms of mania and melancholia which re- 
 cover. 
 
 Terminal dementia is without hope of cure, and epileptic, al- 
 coholic, and syphilitic dementia have an equally bad prognosis. 
 
 Melancholia is, according to statistics of many hospitals for the 
 insane, the most curable of the forms of Insanity. This statement 
 holds not only for the acute forms, but for all types of melancholia 
 entered in tabular reports as acute, subacute, and including also 
 chronic forms of melancholia, as compared in the aggregate with 
 corresponding forms of mania received in the same hospitals. 
 
 This is statistically confirmatory of the fact that mania is a more 
 profound disorder of mind than melancholia. Out of a total of 
 2,165 cases of melancholia treated in three of the largest Kew York 
 State hospitals 639 recovered, while out of 2,259 cases of mania 
 treated in the same hospitals during the same period 635 recovered. 
 In European hospitals for the insane some statistics show mania to 
 be the more curable form. 
 
 There can be no doubt, however, if the large number of mild 
 cases of melancholia cured outside of institutions be taken into ac- 
 count, that melancholia is the more curable form of Insanity, It 
 is probable that the greater urgency for the admission of maniacal 
 cases to institutions^ and the advantage of early hospital treatment 
 thus obtained, favors recovery in the maniacal forms. 
 23 
 
354 TEXT-BOOK ON MENTAL DISEASES. 
 
 In the United States acute mania is seven times more frequent 
 than acute melancholia, and chronic mania nearly twice as frequent 
 as chronic melanchoha, according to total figures given by institu- 
 tions for the insane. The total number of cures from mania, there- 
 fore, vastly outnumber those from melancholia, and the general 
 impression as to the more curable nature of mania may be based on 
 the greater frequency with which the physician meets the recovered 
 maniacal cases after their discharge from institutions. 
 
 There is a slight numerical preponderance of females over males 
 in both the maniacal and melancholic types of simple psychoses, 
 which is offset in the total enumeration by an excess of males in the 
 paretic and alcoholic types of Insanity. In terminal dementia, on 
 the other hand, males slightly preponderate in about the percental 
 proportion of the greater recoverability of females over males in 
 general. 
 
 These general facts as to mania and melancholia are given, since 
 nearly all favorable prognostication has to do with one of these two 
 recoverable forms of Insanity, in which the rate of cures ranges from 
 fifty to sixty per cent, in hospitals, according to the duration of the 
 mental trouble at the time of admission, which is usually much 
 deferred. 
 
 Duration of Attach. — The duration of the mental disorder is an 
 indispensable element in the prognosis. Insanity is curable in in- 
 verse ratio to its duration. From seventy to eighty per cent, of cases 
 of the acute psychoses may be cured if treated within one month 
 of the inception of the disease, fifty per cent, are curable at the end 
 of six months, and during every subsequent month there is a rapid 
 decline in the recovery-rate to the end of the first year, after which 
 not more than ten per cent, of cures are to be made, and after two 
 years' duration only five per cent, of recoveries occur, and still later 
 there may be a very exceptional recovery, but, practically, the prog- 
 nosis is then absolutely unfavorable. 
 
 The duration is to be calculated from the very first manifesta- 
 tion of mental disorder. 
 
 The lapse of time in the incubatory stage is usually not taken into 
 consideration, though it has an important bearing on the prognosis, 
 for long-continued action of the determining causes and a prolonged 
 initial stadium of the Insanity are highly unfavorable for recovery. 
 The man who breaks down under the stress of business anxiety after 
 long years of worry has fewer chances of recovery than if he had sud- 
 
THE PROGNOSIS OF INSANITY. 355 
 
 denly suffered a great loss of fortune causing acute disorder of mind. 
 The woman who has a bad husband and a number of sickly children, 
 and has her maternal and conjugal feelings harrowed up every day 
 of her life, until, worn out by years of misery, she sinks into de- 
 spondent melancholia, is less apt to recover than if she had developed 
 puerperal mania or some other acute type. 
 
 The critical point in duration of the attack is the question of 
 the period of maximum recovery-rate, which is limited to certain 
 months, which are not the same for every form of Insanity, and even 
 vary somewhat in the two sexes. Comparatively few recoveries from 
 acute Insanity fully developed are made during the first or second 
 month of the attack, or, as before said, after the first twelve months. 
 The period of the maximum recovery-rate for the average of acute 
 and curable forms of Insanity is from the fourth to the eighth month. 
 
 The question of duration of attack in prognosis must have refer- 
 ence to this period. If the mental disorder has been treated from the 
 onset for eight months, without decided change for the better, the 
 most curable period has elapsed, though considerable percental 
 chances of cure still remain. In the acute psychoses, in those aged 
 fifteen to twenty-five, the maximum recovery-rate in maniacal types 
 generally seems to be attained at an earher period than in the melan- 
 cholic forms, and also somewhat earlier in men than in women. In 
 puerperal Insanity the highest recovery-rate is reached before the 
 sixth month. 
 
 Chmacteric Insanity has an exceptionally long duration, and the 
 average period of curability is greatly deferred, and the same may be 
 said of certain toxic forms of mental disease. 
 
 Neglect of treatment not only postpones the recovery, but renders 
 it less complete. The prognosis in a case neglected for eight months 
 must reflect not only the fact that the main chance of cure has 
 passed, but also the probability that the recovery -nail be very im- 
 perfect, if, fortunately, it be brought about finally. 
 
 The recovery is later in recurrent attacks, on the average, than 
 in the first Insanity, and this delay is at the expense of the lucid in- 
 tervals, which become shorter. The temporal limits are often de- 
 fined by inherited tendency to run a certain course, which the physi- 
 cian will do well to ascertain by close inquiry. In certain families 
 pubescent and climacteric Insanity makes a comparatively good re- 
 covery after a very long duration. If no special tendency can be 
 ascertained, the physician must prognosticate according to the gen- 
 
356 TEXT-EOOK ON MENTAL DISEASES. 
 
 eral law of average duration of attack and chances of recovery as 
 above given. 
 
 Course of the Attack.. — The prognosis is more favorable in a reg- 
 ular attack than in one which pursues an exceptional course. If 
 incubatory depression is followed by prompt and acute mania and 
 then a natural stage of exhaustion and a convalescent stage, the re- 
 covery will probably be good. If there is not a frank maniacal stage, 
 but an irregular mixture of excitement, depression, and stupor by 
 turns, and no distinct stages of the mental disease at any time, the 
 prognosis is not good. Even if the physician fail to learn of any 
 heredity in the family, he can set these nondescript cases of irregu- 
 lar course down as belonging to the degenerative types nine times 
 out of ten. A prolonged incubatory stage is of bad omen for a prompt 
 recovery, and the patient who has been becoming insane for a year 
 or more will probably take the same length of time to recover, if, 
 indeed, restoration ever occurs. 
 
 A very brief convalescent stage is likewise unfavorable, and the 
 transition within a fortnight from acute Insanity to recovery is to 
 be regarded with suspicion. The current of recovery sets in like 
 the tidal advance, with gentle recessions, but a steady onward move- 
 ment to the full height of reason, and the convalescent process 
 takes, on an average, two and one-half months, varying more espe- 
 cially in length with the severity and duration of the acute stage. 
 A good prognosis, then, demands regularity in the course of the 
 attack, even in the convalescent stage. There is one exception, 
 which will probably come within the physician's observation in this 
 convalescent period, which still admits of a good prognosis, and 
 that is found in eaaes of violent mania, in which the advances toward 
 recovery and the recessions partake of the same turbulent nature, 
 amounting to successions of lucidity and maniacal relapse of brief 
 duration. A subacute course of the attack is unfavorable, and a 
 circular course of the Insanity justifies a bad prognosis. The physi- 
 ician must make careful research for any signs of periodicity of symp- 
 toms, and even though the intensified return be at the menstrual 
 -molimen, it renders the prognosis bad if a periodic tendency is once 
 (established. 
 
 The regular course of the attack may be interrupted by an acute 
 infectious disease, or by a traumatic accident, and recovery may then 
 follow in a sudden and exceptional manner. The writer has thus 
 seen some unexpected recoveries following inflammatory intercur- 
 rent diseases and bodily injuries, self-inflicted or accidental. 
 
THE PEOGNOSIS OF INSANITY. 357 
 
 When called upon for a prognosis in the instance of the inter- 
 ruption of the regular course of the Insanity hy a complicating dis- 
 ease, the physician can only state the favorable possibility of a hast- 
 ened cure, hut it is well to know the rule that severe intercurrent 
 affections only postpone the recovery. Among the writer's patients 
 in the New York City Lunatic Asylum, during the epidemic of Asiatic 
 cholera, out of more than a hundred cases attacked, only one sur- 
 vived in whom it could he said that a favorable mental crisis seemed 
 to have been established by the bacillary scourge; but several ap- 
 peared to undergo a critical mental change for the better after the 
 typhoid fever epidemic in the same institution, and, in suffering 
 from the disease, they seemed to have undergone a constitutional 
 alteration, especially of trophic functions favorable to mental recov- 
 ery. 
 
 The interruption of the course of acute melancholia by an inlil- 
 tration of mihary tubercle robs the prognosis completely of all favor- 
 able chances. 
 
 Whenever the regular course of the attack is unaccountably ar- 
 rested or changed, the physician must suspect some insidious dis- 
 ease for which he must institute a careful physical search, as the 
 usual physical signs are often absent, and walking cases of pneu- 
 monia are common, and phthisis pulmonalis may run its full course 
 without cough or expectoration. 
 
 In malarial Insanity the intermittent course of the mental 
 trouble being due to the nature of the intoxication is not necessarily 
 of bad prognosis if the cachexia be not too far advanced. An alter- 
 nating course of the Insanity with one of the major neuroses always 
 justifies a bad prognosis. 
 
 In the course of a regular psychosis there may appear a distinct 
 transformation of type of the mental disorder, and in all transfor- 
 mations of this kind the prognosis is unquahfiedly bad. The reg- 
 ular stadia of the attack must, of course, not be mistaken for such 
 transformations, and there can be no danger of this after a careful 
 perusal of the chapter on the evolution, stadia, and clinical progres- 
 sion of Insanity. 
 
 Caiise of the Attack. — There is no more important element in 
 prognosis than the cause of the attack, and in not a few cases it is 
 at once decisive of the question of curability or incurability. 
 
 The most irremediable cause is congenital deficiency, and by this 
 is not here implied general arrest of mental development, but more 
 
358 TEXT-BOOK ON MENTAL DISEASES. 
 
 especially those hopeless defects of character and of balance of mind 
 which doom the unfortunate one to failure in life, and to a succes- 
 sion of trials which end in mental disorder. These ill-balanced cases 
 of moral obliquity and mental weakness may undergo a first recov- 
 ery and a species of restoration to their original state of weak eccen- 
 tricity, but relapse is absolutely certain, and terminal dementia fol- 
 lows in ninety-nine cases out of a hundred. 
 
 The cause of Insanity among Juvenile delinquents is usually this 
 inherited deficiency of mind, which may escape recognition by the 
 neighbors of the patient, who is simply regarded as odd or perverse 
 in youth, but as soon as he undertakes the complicated relations 
 of life as a man, his hopeless defects are at once evident. An attack 
 of Insanity in these originally deficient cases signifies " the begin- 
 ning of the end," and the prognosis must be made accordingly. In 
 this category belong cases of moral Insanity, which is unquestionably 
 associated with inherited deficiency, and cases of original mono- 
 mania, as the outgrowth of native defects of mental organization. 
 
 A lesser degree of degenerative taint is shown as a neurosis, which 
 becomes permanently established as a constitutional habit, like hys- 
 teria, hypochondria, or epilepsy, and, when Insanity is developed 
 out of these neurotic conditions, the prognosis is decidedly unfavar- 
 able. 
 
 Involutional changes at the climacteric give rise to a doubtful 
 prognosis because the Insanity is frequently protracted, and in most 
 cases which end in recovery the treatment is instituted at an early 
 period. 
 
 Fifty per cent, of climacteric cases admit of cure if taken under 
 skilful treatment from the beginning of the attack, but, as this is 
 seldom done, there is, on the average, scarcely an even chance be- 
 tween recovery and chronicity of the attack, which, in about ten 
 per cent, of the cases, has a fatal termination sooner or later. The 
 mortality of climacteric cases is considerably greater than the aver- 
 age death-rate among the insane. 
 
 The prognosis of Insanity from senile involution is to be based 
 on the degree of degenerative tissue changes in the brain and ar- 
 teries, and on the presence or absence of organic afEections of tho- 
 racic or abdominal organs. Without regard to the cerebral atrophic 
 lesions, if there be found atheromatous radial and tortuous temporal 
 arteries, arcus senilis, and fatty heari, the prognosis must be unfa- 
 vorable. Or, if there be renal disease, cardiac hypertrophy, or dila- 
 
THE PROGNOSIS OF INSANITY. 359 
 
 tation, and chronic asthmatic or bronchitic trouble, the hope of 
 recovery is almost nil. In the absence of all physical complications 
 of this kind the mere fact of advanced years does not prevent a 
 favorable prognosis as to a first attack. 
 
 The prognosis in toxic Insanity varies considerably with the 
 toxic agent, and the question of a brief accidental exposure or of a 
 prolonged voluntary addiction to the poison. Insanity from mor- 
 phinism, as a confirmed habit, has a bad prognosis, not on account of 
 the physical damage sustained, but because experience has shown 
 that four out of five cases cured relapse through subsequent return 
 to the habit. 
 
 Mental aberration fi'om alcoholic tippling is likewise unfavor- 
 able for the same reason. 
 
 In chronic alcoholism the prognosis is bad on account of actual 
 lesions in cerebral tissues and vessels. It is of importance to know 
 that spinal lesions in female alcoholics are the equivalent often of 
 cerebral changes in men, so far as their prognostic significance in 
 Insanity is concerned. A woman insane from alcoholic excess, with 
 symptoms of spinal sclerosis, is as hopeless a case as a man with 
 cerebral sclerotic lesions from the same cause. 
 
 Eeeovery from some metallic poisons causing Insanity is tedious 
 and doubtful, especially in long and gradual intoxication from lead 
 and arsenic. Mental disorder from certain vegetable toxic agents 
 is equally unfavorable in prognosis, as found in cases of pellagra 
 and chronic lathyrism. Nicotinism is capable, in the aged, espe- 
 cially, of establishing permanent organic lesions, and it is more un- 
 favorable in prognosis than is generally admitted to be the case. 
 
 Youthful cases of Insanity from excessive cigarette smoking 
 usually make a good recovery, but readily relapse on exposure to the 
 toxic agent. Carbon monoxide and common illuminating gas may 
 permanently damage the organ of the mind and the general health. 
 
 In Eastern countries a large percentage of Insanity of bad prog- 
 nosis arises from the abuse of hashish. 
 
 In toxic Insanity, if anatomical lesions have not resulted, and 
 if no deep-seated habit has been formed, the prognosis is not bad. 
 Eecoveries from minor degrees of poisoning and from auto-intoxica- 
 tion are very common. 
 
 Prolonged moral causes, such as worry or sorrow, in combination 
 with toxic influences, give a bad outlook, and the man who suifers 
 distress of mind and drowns sorrow in drink, and finally becomes 
 insane, does not often make a good recovery. 
 
360 TEXT-BOOK ON MENTAL DISEASES. 
 
 A favorable opinion cannot be given in severe trauma capitis, 
 or in decided eases of insolation followed by Insanity, which is often 
 insidiously progressive, and not infrequently attended by epilepti- 
 form seizures in the more advanced stages, as meningeal and cor- 
 tical lesions extend. 
 
 Prognosis is favorable in mental disorder immediately following 
 commotio cerebri in a large perceiitage of cases, but the resulting 
 slow and gradual development of Insanity after this sort of trauma- 
 tism is unfavorable, and the same rule is applicable to mental aliena- 
 tion following spinal concussion. 
 
 Insanity from sexual excess is favorable in the young, less curable 
 in the middle-aged, and of bad prognosis in senile cases. Sexual 
 excess of men with women causes cerebral lesions and general paresis 
 in some instances, which is not the case with masturbatic indulgence, 
 which gives rise in extreme cases to spinal lesions and paraplegic 
 symptoms, but never to general paresis. 
 
 The prognosis is only good on the supposition that the cause 
 is to be removed, but in neurotic and degenerative cases, often, self- 
 control cannot be restored, and the cure cannot be effected. In very 
 many neuropathic patients the masturbation is symptomatic rather 
 than causative of the Insanity. 
 
 The physician must guard against the vulgar error of mistaking 
 the masturbatic manifestation for the cause of the mental disease, 
 for not one insane case in a hundred is to be attributed solely to 
 self-abuse, and one-half of the insane at some time during their 
 Insanity masturbate. Among the insane, women are more secretive 
 than men in the practice of self-abuse, but the evil habit is equally 
 prevalent in both sexes. Indulgence of a sexually perverted instinct 
 points to a degenerative taint, and the resulting Insanity is without 
 hope of cure. 
 
 Mental disorder from inanition during forced and temporary 
 deprivation of food may be cured, but years of semi-starvation, such 
 as fall to the lot of the impoverished masses in large cities, result 
 in permanent cortical changes of an atrophic nature, and this type 
 of inanition is one of the most universal causes of incurable Insanity. 
 
 The prognosis in general paresis, as already stated, is always bad. 
 
 Cases of pseudo-paresis, especially those of alcoholic origin, re- 
 cover with permanent partial and minor defects not perceptible 
 except to experts. 
 
 There is a tendency to extend the limits of general paresis, and 
 
THE PEOGNOSIS OF INSANITY. 361 
 
 to embrace cases which do recover, after syphilitic and alcoholic at- 
 tacks of a pseudo-paretic nature, but it is not very difficult to differ- 
 entiate these cases from genuine instances of general paresis, which, 
 in the writer's experience out of several hundred cases, have never 
 permanently recovered. 
 
 Lucid intervals of months or more than a year may throw doubt 
 on the prognosis, but they finally yield to the typical and fatal symp- 
 toms of general paresis. 
 
 A chance of recovery in puerperal Insanity exists in the excep- 
 tionally favorable ratio of three out of four cases attacked, and the 
 more promptly the mental disorder declares itself after parturition, 
 the better is the prospect of a quick return to reason. 
 
 The prognosis in lactational cases is considerably less favorable, 
 and the duration is greater. The Insanity of gestation treated in 
 private practice is fully as favorable as the other forms, but in hos- 
 pitals for the insane only the most unfavorable cases ordinarily are 
 received, with suicidal or troublesome symptoms, which prevent their 
 treatment at home, and a ratio of recoveries based on such cases does 
 not furnish a fair standard of comparison. Not a few of these ges- 
 tational cases are very mild and occur during the first three or four 
 months of pregnancy and terminate probably in some instances with- 
 out being formally recognized as insane. 
 
 Mental disorder caused by acute infectious diseases is favorable 
 in the young and less so in those of advanced years. Epidemic in- 
 fluenza (grippe) gives rise to some very serious forms of Insanity, 
 lingering and uncertain as to recovery, and this is particularly the 
 case in elderly persons. 
 
 Among so-called moral causes of Insanity some justify a more 
 unfavorable prognosis than others. 
 
 Loss of property and business failure may be considered one 
 of the most common moral causes of mental ahenation among men. 
 The prognosis is not favorable because the cause is a constant one, 
 hanging like a dark cloud over the pa:tient, acting as an obstacle 
 to convalescence, and favoring a relapse. This cause is especially 
 unfavorable in those too far advanced in years to hope to re-enter 
 business or to recover their financial losses. 
 
 Among women, grief at the death of a child or other dear rela- 
 tive is a cause of Insanity, from which recovery usually takes place, 
 but it not infrequently happens that during long nursing of the 
 departed one the patient suffered loss of sleep for months, as well 
 
362 TEXT-BOOK ON MENTAL DISEASES. 
 
 as sympathetic distress of mind, and that the general health was 
 seriously impaired, so that sufficient powers of recuperation are not 
 left for recovery from the psychosis. 
 
 Young persons, more particularly, may be rendered suddenly 
 insane by severe emotional shock, usually from fright. The type 
 is primary dementia in most cases, and the final result is recovery 
 in the majority of the instances, unless there be native weakness of 
 mind, and then reason is apt to remain shattered for all time. 
 
 Disappointment in love is a real cause of Insanity, which is more 
 enduring in women than in men. The latter are more apt to com- 
 mit suicide and to have active symptoms and a prompt recovery, 
 while the former are more wont to sink into chronic melancholy of 
 a religious or erotic nature. This form of mental aberration per- 
 tains more naturally to youth, and has, in general, a good prognosis. 
 
 As a rare exception, some retired elderly person, never having 
 had an object upon which to expend the full force of a naturally 
 loving disposition, becomes desperately enamoured and disappointed, 
 and sinks into hopeless melancholy for the rest of life. 
 
 Finally, it may be said that a combination of both physical and 
 moral causes gives a bad prognosis, whereas a single removable cause 
 always admits of a favorable opinion in the absence of organic le- 
 sions as the basis of the mental disorder. 
 
 Special Symptoms of Bad Prognostic Import. — Among the host 
 of symptoms which may appear in cases of mental disorder there 
 are some which are uniformly very grave in prognostic bearing. If, 
 upon the examination of an insane patient, the physician should 
 find loss of the patella-reflex, persistent myosis with loss of response 
 to light and accommodation, the prognosis would at once assume 
 a very grave aspect, even in the absence of any characteristic mental 
 symptoms of general paresis. If, in addition, there were present 
 tremulous and drawling speech, the elements of a bad prognosis 
 would be sufficiently complete to justify the expression of an opin- 
 ion in the case. Epileptiform and apoplectiform seizures are of evil 
 omen, pointing, in toxic Insanity, to the depth of the pathological 
 processes, and foreshadowing, in organic dementia, a rapid decay 
 of intelligence. 
 
 The congestive and convulsive seizures in malarial Insanity must 
 not be mistaken for apoplectiform attacks, as they have not the 
 same evil significance. Muscular inco-ordination is a bad symptom, 
 whether it appear as static or locomotor ataxia, or as disorder of the 
 
THE PROGNOSIS OF INSANITY. 363 
 
 special mechanism of speech, gait, handwriting, or affect any other 
 highly specialized muscular performance. 
 
 The patient who cannot stand erect, with eyes closed and feet 
 together, without loss of balance, who cannot with closed eyes touch 
 with the forefinger the tip of his nose, or any other indicated part 
 of himself, who cannot walk without looking at the floor, or cannot 
 walk a straight line, has a degree of anaesthesia of muscles and joints 
 arising generally from serious lesions of the central nervous system. 
 
 Paralysis of limbs, persistent tremors other than those of debil- 
 ity, senility, and emotion, permanent muscular contractures, masti- 
 catory spasm and wasting of the muscular structures, are all unfa- 
 vorable symptoms. 
 
 Continuous vasomotor disturbances, such as cyanosis, cutaneous 
 oedema, haamatoma auris, and monocrotic or very infrequent pulse, 
 forbid a favorable prognosis. 
 
 Loss of facial innervation and the dropping of the lower jaw 
 are often precursors of terminal deinentia, and the disappearance 
 of all intelligent expression from the face and eyes accompanies 
 profound cerebral alterations. 
 
 Large gain in bodily weight after the acute stage of the mental 
 disorder, if not accompanied by any corresponding improvement 
 in mental condition, is a bad sign, as it often presages terminal de- 
 mentia. 
 
 Prolonged trophic disorders after the acute stage of the psychosis, 
 such as cutaneous pigmentations, disappearance of subcutaneous fat 
 in women, muscular atrophy, progressive emaciation, and trophic 
 changes in joints or long bones are very unfavorable. 
 
 The psychic symptoms which are of bad prognostic import are 
 systematized delusions, which do not change in character, the per- 
 sistence of hallucinations after the acute stage of the disorder, long- 
 continued verbal incoherence, confusion of places, persons, and 
 tilings, changes in personality, fantastic attire and self-diecoration, 
 the filling of the pockets with rubbish and the accumulation of 
 worthless things, inability to fix attention and self-muttering, auto- 
 matic laughing or crying, the picking of the flesh in sore spots and 
 the plucking out of the hair, automatic swaying of the body and 
 movements of friction of clothing, walking in circle and automatic 
 angular progression, and grimacing and inarticulate vocalization. 
 
 Loss of the sense of modesty in women, when not resulting from 
 active erotic impulses, shows a high degree of mental impairment, 
 
364 TEXT-BOOK ON MENTAL DISEASES. 
 
 and it is only in the most profound mental reductions that they 
 cease to be conscious of indecent exposure of themselves. 
 
 The coinage and constant usage of new words, the claiming of 
 titles, the attempt to impersonate in manner, dress, or speech, some 
 great person, or the habitual acting of any part absolutely foreign 
 to the nature of the person, are all equally bad as to prognosis. 
 
 The failure to recognize relatives, and the absence of natural 
 affection, as of a mother who remains indifferent to the visits of her 
 young children, are likewise bad signs, if present after the acute 
 stadium of the mental disease has passed. 
 
 Symptoms of Favorable Prognostic Nature. — The return to nor- 
 mal weight after the acute stage of the Insanity is a constant and 
 reliable symptom in perfect recoveries. The weight-curve at this 
 period often rises a little above the normal, only to return, as the 
 cure hardens, to the usual stationary point as influenced by season 
 in the special Individual. 
 
 It has already been indicated that a parallel improvement in 
 mind must attend this bettered condition of general nutrition. 
 Superactivity of vegetative and torpor of mental functions, as al- 
 ready pointed out, are highly unfavorable. 
 
 A restitution of normal facial innervation is one of the most 
 positive objective signs of recovery. Eelatives familiar with the 
 customary looks of the patient in health may even anticipate the 
 prognosis of the physician in announcing the coming cure from the 
 return of natural expression of face. 
 
 With the advent of good looks in women there goes a renewed 
 interest in their personal appearance and in their toilet. The physi- 
 cian will often be astonished at the great change for the better in 
 physiognomy, and, as his experience with these cases multiplies, 
 he will tend to regard this beautifying of countenance as the surest 
 harbinger of the coming recovery. The delicate lines of symmetry 
 wliich constitute the handsome traits of a countenance are invariably 
 obliterated by mental disease. 
 
 Another favorable symptom is the renewal of natural intonation 
 of voice, and of the mode of speech habitual in health, even though 
 stuttering or some other defect reappear. In recovery from shouting 
 mania huskiness of the voice often persists for many months, and 
 in the worst cases of this laryngeal over-strain the prime quality 
 of the voice is never regained. 
 
 Normal gait, gestures, and general bearing of th.e patient are 
 
THE PEOGNOSIS OF INSANITY. 365 
 
 among the essential preliminary symptoms of recovery, and even 
 manifestations of former peculiarities of manner are to be hailed 
 as favorable signs. 
 
 Among the somatic signs of approaching recovery the most im- 
 portant are good, sound sleep, normal appetite, and a general sense 
 of well-being. In convalescence from melancholia, especially, the 
 return of an agreeable coensesthetic consciousness is the surest sub- 
 jective symptom of recovery. In this connection the physician is 
 reminded that not only the ccenspsthesis, but the entire frame of 
 mind, may be modified by the continuous influence of drugs, and 
 that it is always well to suspend medication long enough to see the 
 true condition due solely to the disease before a final prognosis is 
 made. From the neglect of this precaution the writer has known 
 some serious errors in prognosis to be made. 
 
 A hopeful sign of some prognostic value is the revival of natural 
 affection for family and friends, and so long as this is absent, espe- 
 cially in women, whose role in life is so largely dependent on a 
 healthful action of the affective faculties, there is no certainty of 
 recovery. There are personal dishkes formed toward nurses and 
 others, by the insane, which need not be abandoned, but antipathies 
 to wife, children, or husband are to be given up, and such relinquish- 
 ment of morbid animosities is among the early signs of returning 
 reason. 
 
 Self-consciousness of past mental disease, and an insight into 
 the nature of the delusions entertained, is surely prognostic of ap- 
 proaching recovery. 
 
 Some authors have gone so far as to estabhsh this conscious in- 
 sight on the part of the patient into his own mental malady as a 
 necessary criterion of recovery. This is a mistake, for some patients 
 have only a confused realization of their attack, and they have a 
 clear consciousness only of those things of which they are assured 
 by the physician. On the other hand, the capacity to view the events 
 of the past disease in their true light implies a normal readjustment 
 of the patient's mental mechanism. 
 
 This subject of prognosis has been thus fully studied from vari- 
 ous points of view on account of the great responsibihty often in- 
 volved in the giving of an opinion. There is to be decided a question 
 of great financial expense on the part of the family of the patient, 
 as well as the entire disposition of the case, and the physician can 
 ill afford to make a mistake in the prognosis. 
 
366 TEXT-BOOK ON MENTAL DISEASES. 
 
 It is hoped that the analysis of the essential elements of prog- 
 nosis, under the head of age, sex, constitution, and heredity of the 
 patient, and the duration, course, and cause of the attack, will stand 
 the physician in good stead when called upon to decide the all-im- 
 portant question of the future results to be expected in a case of 
 Insanity. The physician is advised to take time for a decision, to 
 ponder well all the points of the case, and, in event of doubt, to 
 call upon some expert in mental diseases for assistance before ren- 
 dering a final decision, for a greater need of a gift of prophecy 
 never exists than in the prognosis of intricate cases of mental dis- 
 order. 
 
CHAPTER XI. 
 
 THE TREATMENT OF INSANITY. 
 
 Section I. — The Prophylaxis of Insanity. 
 
 The highest function of medical science is the prevention of dis- 
 ease. There is not one of all the known diseases in which there is 
 a greater need of prophylaxis than in Insanity, which completely 
 incapacitates a citizen for all the duties of life, and often makes him 
 for a long series of years an expensive burden to his family or to 
 the State. There is also no widespread disease which permits of more 
 effectual limitation by wise preventive measures than certain im- 
 pending forms of mental disorder taken in the early formative stage. 
 The most radical and far-reaching prophylaxis is that which nips the 
 evil in the bud, and fortification in the earliest periods of life against 
 the approach of the dreaded disease is doubly preventive, and the 
 prophylaxis of Insanity in childhood will, therefore, first be noticed. 
 
 The Early Life and Education of Children. — ^In neurotic children 
 springing from parents having strong psychopathic tendencies, the 
 whole of childhood should be a continuous period of fortification 
 against the mental disease liable to first declare itself at puberty. 
 Such children early present signs of instability of nervous centres 
 by irritability and restlessness, extreme sensitiveness of the gastro- 
 intestinal tract, convulsibility on slight rise of temperature, inabil- 
 ity to bear the pain of ordinary dentition, and a tendency to night 
 terrors and hallucinations. When a few years of age, such children 
 are often precocious, wilful, mischievous, and morally deficient in 
 understanding, while displaying wonderful cunning in selfish and 
 perverse conduct. Other children of this class will be found weak 
 in mind and body, averse to play or companionship, moping stu- 
 pidly by themselves, slow to learn and disobedient continuously 
 through seeming stupidity, or forgetfulness of that which is told 
 them. Now, these and other types of neurotic children, too numer- 
 
 367 
 
368 TEXT-BOOK OX MENTAL DISEASES. 
 
 ous to admit of description here, are the very material out of vhiclj 
 insane persons are formed, unless wise and systematic preventive 
 measures are adopted and carried out from the earhest period of 
 life. 
 
 The earhest prophylaxis, in fact, in these neurotic families is 
 the hygiene of the mother during the gestation of the child. These 
 neurotic mothers are wont to resort to drugs and stimulants during 
 the cravings of pregnancy, to the detriment of the embryo. 
 
 Unquestionably, the earhest damage of a toxic nature may be 
 sustained by the child in utero through the alcoholic indulgence 
 of the mother, who daily takes free potations of wine or beer, in 
 hopes of sustaining her strength; or of necessity, if in poverty, she 
 lack a wholesome supply of food. If the family can afford a strong 
 and healthful nurse, the child should not be nursed by a neurotic 
 mother. And here, too, the prophylactic regulation of the diet and 
 habits of the nurse are by no means to be neglected. 
 
 In well-to-do famihes nurses are sometimes allowed ^vine. and 
 this simple and thoughtless indulgence may convey to the suscep- 
 tible nervous centres of the nursing infant a daily deleterious alco- 
 hohc influence. 
 
 Other infants suffer from the pernicious habit of drugs given to 
 procure sleep. These neurotic children should be reared, if pos- 
 sible, in the country and in the open air, on a generous but simple 
 diet of fresh milk and eggs, with good bread and butter, and roast 
 beef once a day and ripe fruits in season. They should play out-of- 
 doors and have very long hours of sleep, taken in part, in certain 
 cases, in the form of a daily siesta. If the best thing can be af- 
 forded in the way of education, these children may learn languages 
 from native nurses, or music to some degree, but all regular studies 
 should be deferred until the eighth or ninth year, and should then 
 be taken up very gradually. The forcing of school children in rou- 
 tine classes, without regard to their natural degree of development 
 of mind, is often very harmful, and the severe taxing of the brain 
 with over-study is a sure preparation for future mental trouble. 
 
 There are extreme cases in which only a common school educa- 
 tion should ever be allowed in order to fit the person for some active 
 occupation. The emulation of neurotic and often precocious chil- 
 dren in competition for school prizes is especially dangerous from 
 overstrain, excitement, and disappointment. 
 
 As these children grow older they must be judiciously trained 
 
THE TREATMENT OF INSANITY. 369 
 
 to the most systematic and orderly habits of eating, sleeping, and 
 working. Continuous long hours of occupation must be avoided, 
 and work must be interspersed with frequent respite. Manual train- 
 ing to the use of tools, moulding, modelling, turning, gardening, 
 and many like useful occupations, should interrupt brain work, 
 which should never be carried on for more than one hour at a time. 
 Special schools for neurotic boys are needed, and in their absence 
 such boys should be taken from their parents, who cannot enforce 
 the necessary discipline and retain the affection of the child or 
 their own peace of mind, and placed under the direct control of 
 some judicious person, who will devote himself to their education 
 and continued training. This course, if faithfully pursued, will 
 often prevent failure in life and final Insanity. 
 
 Girls may be managed better at home, but there are often those 
 who must also be sent to special schools, or be placed under special 
 tutelage, from the fact that their mothers have not the time or the 
 force of character to work out their salvation. The methodical 
 habits and the force of good example and orderly life in schools is 
 often the only available influence to save certain girls from develop; 
 ing into cases of moral Insanity. These cases, deficient in moral 
 understanding, require a very special system of training for a series 
 of years, and, in fact, until the crisis of puberty has been passed with 
 the immediate danger of an open outbreak of mental disorder. 
 Training, in the direction of music or of some one-sided talent, to 
 the neglect of general education, is especially to be shunned. The 
 effort must be to equally develop the physical and mental powers, 
 and to round out the character evenly in all useful directions. In 
 these psychopathic young women attempts to widely expand the 
 intellect will defeat their own purpose and lead to mental break- 
 down, but the aim must be to establish automatic habits of industry 
 and usefulness in all-round womanly occupations, while laying firm 
 foundations of physical health. 
 
 Advice About Marriage and the Adult Relations of Life. — All of 
 the learned professions are attended with too severe brain work and 
 too much responsibility for neurotic persons, who should choose less 
 difficult and more automatic callings, and such by preference as 
 lead to out-of-door life. Psychopathic young women are not fitted 
 to become teachers or governesses, and many become insane as the 
 result of this mistake in the choice of an occupation, which drains 
 their sympathy and their nervous forces. These neurotic young 
 24 
 
370 TEXT-BOOK ON MENTAL DISEASES. 
 
 women often have abnormally quick memories, gain some prize in 
 school, and are fired with the false idea that they can distinguish 
 themselves in intellectual pursuits. Male adolescents become pos- 
 sessed of a hke false ambition and vain pride of intellect, which 
 they are allowed to pursue like an " ignis f atuus," overtaxing their 
 brains with study until they break out into adolescent Insanity. 
 
 It should be the duty of the family physician, with tlie aid of 
 an expert in mental diseases, to make a special study of the members 
 of neurotic families, and to decide in each individual instance the 
 character of the occupation which it might be safe for the person 
 to adopt. 
 
 One of the surest means of the prophylaxis of Insanity is the 
 prevention of the marriage of those constitutionally unfitted for 
 the reproduction of their kind. The question of marriage in hered- 
 itarily tainted families is one about which the physician Avill often 
 be consulted, and upon which he must be prepared to give an 
 opinion. 
 
 IsTeurasthenic young women, who have been mere or less under 
 the physician's care, who have perhaps had attacks of hysteria and 
 other nervous symptoms, sometimes form an attachment and wish 
 to marry. The parents may be glad to be released from the burden 
 of such a daughter, and they may have planned the match, believing 
 that it would benefit their daughter's health. The latter result 
 sometimes follows such a marriage, but the physician should dis- 
 courage the marriage, as such young women do not make good 
 wives or good mothers, and it is from the offspring of such mar- 
 riages tha,t the contingent of the insane is largely recruited. 
 
 Marriage, for the same reason, should be forbidden instead of 
 advised remedially in the case of weak young men, partially un- 
 manned by the habit of masturbation. The physician cannot trifie 
 with the interests of the coming generation, the serious responsi- 
 bilities of the married state, or the honor of his calling by adding 
 matrimony to the list of his remedies. 
 
 How far marriage in families tainted with heredity is to be 
 allowed must be decided separately in each individual case. A man 
 born of such a family may marry a strong and healthy woman, 
 devoid of any hereditary tendency to mental disease. A woman 
 born of such a family had better not marry under any circumstances. 
 Those who have hereditary taint and have already developed 
 symptoms of Insanity should not enter the married relation. 
 
THE TREATMENT OF INSANITY. 371 
 
 Those who have recovered from a hrief simple psychosis result- 
 ing not from degenerate inheritance, but from some single powerful 
 cause, which has been removed, may marry into some family known 
 to be soundly constituted. Such a marriage should not take place 
 for at least two years after the recovery from the mental alienation. 
 If the cause of the mental disorder was epidemic influenza, a still 
 longer period should elapse, as there is a lurking tendency to relapse 
 in these cases. 
 
 Consanguineous marriages, mth taint on both sides, should never 
 take place, as the diseased tendency is sure to be greatly heightened 
 in the offspring when it exists alike in both parents. 
 
 Consanguinity alone in parties both of sound stock is no contra- 
 indication to marriage, though there is still an increased probability 
 that in subsequent years such parties will suffer from similar dis- 
 eases, which they may eventually transmit to their children. This 
 contingency is so remote as to practically form no vahd objection 
 to the union, though it cannot be denied that an unusually large 
 percentage of sensorial defects appear among the offspring of con- 
 sanguineous marriages. 
 
 A person whose parents were both inoane before his birth should 
 not marry, nor should one wed whose mother was insane during 
 the time she bore him " in utero." 
 
 Cumulative tendency to nervous diseases appearing in the fam- 
 ihes of both the intended parties to the marriage is a strong objec- 
 tion of the same weight as direct tendency to Insanity in one of the 
 parties. A double tendency to epilepsy on the part of the would-be 
 contractors of marriage is a serious objection, as the hiajority of epi- 
 leptic children undergo mental deterioration. 
 
 Those who have suffered from prolonged Insanity of more than 
 one year's duration, or who have had relapses of the disease, should 
 - not marry under any conditions. 
 
 A woman who remains well until the menopause, and then suc- 
 cumbs and makes a good recovery from climacteric Insanity,, may 
 wed and have the comforts of her own home; but a man who develops 
 mental disorder during the involution of the sixth decennium had 
 better shun wedlock if he does not wish to sap the foundation of his 
 mental integrity, which he may have apparently regained fully, but 
 which, once unsettled by senile retrograde changes, always rests on 
 a precarious basis. 
 
 Persons without known hereditary tendency to mental disease. 
 
372 TEXT-BOOK ON MENTAL DISEASES. 
 
 who have still acquired instability of cerebral centres, and who for 
 years have been recognized as living on the border-line of Insanity, 
 should be strongly advised against marriage. 
 
 So far as the happiness of an intended wife or the degenerate 
 heritage of prospective children might be involved, all forms of 
 chronic alcoholism in men should, as decidedly as Insanity itself, 
 debar all idea of marriage. 
 
 The physician must give prophylactic advice as to the conjugal 
 relations of married persons who may be insane, or who may have 
 recently recovered from an attack of mental disease. 
 
 A person, while insane, should never be allowed to propagate, 
 and the risk of reproduction should not be incurred for at least one 
 year after complete recovery, and not at all if one of the parents be 
 not of sound mental constitution. Even long lucid intervals furnish 
 no exception to this rule. The physician cannot interfere with 
 the conjugal rights of a husband restored to reason, but he must 
 still give sound medical advice, even though he know that it will not 
 be heeded. 
 
 So long as the physician can in any way prevent Insanity, it is 
 his duty to give the most uncompromisi'ng advice, and to adhere to 
 the strictest interpretation of hereditary laws, but there may be 
 occasions for an opposite tone of opinion when consulted by certain 
 parties. 
 
 Some persons, who have inherited directly a tendency to Insan- 
 ity, live in ever-increasing dread of the disease, and it would be worse 
 than cruelty to fail to speak with hopeful reserve when consulted 
 by such a person. The advice given on such an occasion might be- 
 come the exciting factor of mental disorder, or a psycho-therapeutic 
 preventive of the impending attack. The most hopeful view con- 
 sistent with truth must be expressed to weak wives nursing husbands 
 on the verge of mental disorder, and to neurotic young women affi- 
 anced to lovers in precarious mental condition, and occasionally the 
 physician, when consulted by such parties, will do wisely to with- 
 hold his opinion. 
 
 A physician, knowing the degenerative taint in a family, may 
 believe that a certain man is liable to become insane any day, but, 
 if consulted on this point by someone having a natural interest in 
 the man, as a business partner, the physician would not be free to 
 openly express his opinion, which might seriously damage the pros- 
 pects of the man with hereditary taint. In this and many similar 
 
THE TREATMENT OF INSANITY. 373 
 
 situations which may arise the physician should avoid personalities, 
 and express his opinion on a hypothetical case embodying the facts 
 furnished him by others, and not on those supplied from his own 
 professional knowledge of persons. 
 
 State Medicine and the Prevention of Insanity. — The state would 
 be less burdened with the support of a rapidly increasing number 
 of insane if wise public measures were instituted for the prevention 
 of Insanity. The following are some of the means which might 
 be taken by the state for the prophylaxis of mental disorders. 
 
 1. The state should disseminate sound medical knowledge 
 among all classes as to the common causes of Insanity and the 
 modes of its avoidance, and this should be accomplished by free 
 lectures and the distribution of reliable medical literature on this 
 subject. 
 
 3. The state should make it compulsory on all medical schools 
 to establish a professorship of mental disorders, and to hold not a. 
 nominal, but a full course of lectures on this subject, demonstrated 
 fully by cKnical material. The state examination for the degrea 
 of Doctor of Medicine should always embrace the subject of mental, 
 diseases, with chnical and practical, as well as theoretical, tests. 
 
 3. The state should establish voluntary reception hospitals- in. 
 which sufferers from incipient symptoms of mental disease could, 
 receive prompt, skilful advice and relief, which would prevent at- 
 tacks of Insanity. 
 
 4. The state should establish a Bureau of Protective Aid for 
 those discharged recovered from hospitals for the insane, as well 
 as for those under some great temporary stress of mind or body 
 liable to end in Insanity. Eecovered patients often fail to find 
 employment and suffer hardships which cause relapse. There are 
 critical periods in the life of the poorer classes which develop In- 
 sanity, which a little timely aid would often prevent. It would be 
 wise economy on the part of the state to forestall such attacks of 
 mental disorder. On an average, every case of confirmed Insanity 
 implies an expense to the state of thousands of dollars, and a fraction 
 of this amount judiciously expended would prevent many cases of 
 Insanity. 
 
 Section II. — General Mode of Treatment. 
 
 The physician, after he has made the diagnosis of Insanity, must 
 decide on some general mode of treatment, and, in order to choose 
 
374 TEXT-BOOK ON MENTAL DISEASES. 
 
 some general plan Lest suited to the case, he should be familiar 
 with the systems of treatment most in vogue at the present day. 
 
 The Colony System. — This system is chiefly adapted to the more 
 confirmed cases of Insanity, or to those convalescing from prolonged 
 attacks. The most celebrated colony is at G-heel, in Belgium, where, 
 since the seventeenth century, the insane have been cared for in 
 private families. There are now about two thousand insane pro- 
 vided for in this way among the six thousand residents of Gheel, 
 and new cases are under observation in a central infirmary for a few 
 days before they are assigned to family care. At Alt-Seherbitz, in 
 Saxony, is another noted colony furnishing provision for about six 
 hundred insane in cottages, with a central hospital for the special 
 treatment of emergencies. 
 
 At Clermont-sur-Oise, in France, has long existed a thriving agri- 
 cultural colony of the insane. The colony plan is also carried out at 
 Ellen, near Bremen, and Slup, near Prague, and at Ilten, near Han- 
 over, where the patients are cared for in private families. This fam- 
 ily system has long been in vogue in Scotland, where yearly several 
 thousand cases of Insanity have been boarded out in private fam- 
 ilies, in which not more than one patient can be received at a time 
 v/ithout a special license. This system of boarding-out has also been 
 tried in several hundred cases annually in Massachusetts for ten 
 years past, and for a shorter period of time in Wisconsin. 
 
 Institutions for the Insane. — These institutions are distributed 
 all over the United States, somewhat in accordance with the num- 
 bers of the insane and the actual need for them, though the supply 
 is never fully equal to the demand in the public institutions, which 
 almost uniformly labor under the disadvantage of overcrowding. 
 
 The best of these institutions are under state control and are 
 thoroughly equipped as hospitals for the care and treatment of the 
 insane. Others are more custodial than curative, and are known 
 as county asylums, or as departments of poorhouses. There are 
 also large numbers of private asylums, bearing the names of homes, 
 retreats, or lodges, and these are sometimes well appointed and 
 sometimes less commendably organized for the treatment of the 
 insane. 
 
 Furthermore, there are numerous places designated as " sanita- 
 riums," in which cases of mental disorder are received, and still 
 others, of a more nondescript variety, in the nature of hotels, vvith 
 arrangements for the medical treatment of guests. 
 
THE TREATMENT OF INSANITY. 375 
 
 Then, again, there are water-cure and bathing establishments, 
 with Turkish or Eussian baths, in which incipient mental trouble 
 and neurasthenic cases are sometimes treated. 
 
 Out of the one hundred and six thousand of insane in the United 
 States, at the time of the last census, seventy-four thousand were 
 in some kind of institution for the insane. 
 
 Relative Advantages of Public and Private Hospitals. — The phy- 
 sician, four times out of five, will have to choose between a public 
 and a private asylum for the case to be treated, and hence something 
 is here said about their relative advantages. 
 
 The best public hospitals for the insane have experienced medi- 
 cal officers and attendants, wholesome food, and fair hygienic con- 
 ditions. In them the patient enjoys the benefit of a systematic and 
 orderly life, of perfect regularity of hours for eating, sleeping, exer- 
 cise, and reasonable diversion and occupation. The force of the 
 example of large numbers living in strict conformity to rules is a 
 salutary and unobtrusive form of discipline. The medical officers 
 in such hospitals are without pecuniary bias or any other considera- 
 tion except the best interest of the patient, and they are more free 
 to disregard the ill-advised interference of relatives and to act in ac- 
 cordance with scientific judgment in behalf of the patient. 
 
 Even the sceptical public must understand that it is for the best 
 reputation of the physicians in charge of these hospitals to get as 
 inany and as prompt cures as possible, and that there can be no 
 conceivable motive for the retention of a patient after recovery, es- 
 pecially as the discharge of a patient tends to diminish the incon- 
 veniences of overcrowding, which is found in nearly all these public 
 hospitals for the insane, and which, in fact, is one of their chief dis- 
 advantages. 
 
 Finally, there is the great pecuniary advantage in the public hos- 
 pital, that the actual expense to the patient is, on an average, only 
 about one-eighth that of a private institution having a relatively 
 good organization. 
 
 The well-appointed private hospital, on the other hand, ofiers 
 all the comforts of a home, and there is avoided, in elderly patients 
 especially, that wide departure from customary surroundings on 
 which they are so dependent for their happiness. The individual- 
 ized treatment is more fully carried out, and the patient receives 
 more constant attention from the physician and from attendants. 
 The patient thus derives the great benefit of the direct influence 
 of the sane upon the insane mind. 
 
376 TEXT-BOOK ON MENTAL DISEASES. 
 
 Tlie diet is presumably of a superior quality, and the patient 
 enjoys many of the luxuries of life, including the use of carriages 
 and a variety of diversions. The patient has greater liberty of action 
 and retains more fully his sense of freedom and his self-esteem, and 
 isolation or companionship are at once more optional and more 
 practicable. 
 
 In some of these private hospitals voluntary patients are received 
 without legal form of commitment, and this saves the feelings of 
 the patient and of the relatives in some instances, and may even 
 make a difference in the public sentiment toward the patient after 
 his return to society again. 
 
 There is also an escape from occasional sights and sounds of a 
 disagreeable nature, inevitable in the wards of a large hospital, and 
 to a refined and sensitive patient this is a desirable point. 
 
 The greatest of all advantages presented by private hospitals 
 is the daily personal influence of a skilful physician ever at hand to 
 advise, comfort, and sustain the patient through all the changing 
 phases of the mental disease, requiring constant new adaptation of 
 remedies to the symptoms as they arise. 
 
 Directions for the Treatment of Cases in Private Practice. — It has 
 already been said that in the vast majority of cases institutional 
 treatment is the best for all parties concerned. 
 
 It will sometimes happen that the patient or the relatives, or 
 both of them, have an insurmountable dread of all institutions for 
 the insane, and they will not consent to this mode of treatment. 
 It will then devolve upon the physician to devise some plan of pri- 
 vate treatment, which, though apparently simple, is extremely diffi- 
 cult to manage with safety and success. 
 
 If the case be one of acute mania, which will run a course of 
 several months, it will not do to keep the patient confined in a house 
 in a town or city, since walking in the open air is essential. A house 
 in the country should be rented and especially arranged for the treat- 
 ment of the case. It should have at least one spacious sleeping 
 apartment on the ground floor, large enough to accommodate the 
 patient and one attendant, and a water-closet and bath-room in 
 the immediate vicinity. 
 
 It is taken for granted that the patient will present the usual 
 symptoms of acute mania, and that he will by turns be noisy, vio- 
 lent, destructive, and filthy in his habits. Two attendants at least 
 will be required, one for the day and one for the night. One of 
 
THE TREATMENT OF INSANITY. 377 
 
 these nurses must be in constant attendance upon the patient, who 
 is never to be left alone to himself, not for even a few moments, if 
 he have violent, destructive, or suicidal tendencies, as is usually the 
 case. 
 
 Everything is to be removed from the large room, including 
 carpet, curtains, and tapestry. Strong outside folding blinds are 
 to be left open or closed at the windows, as occasion may require. 
 The windows are to be screened inside if the patient develops a con- 
 stant tendency to break the window-panes, if the room be heated 
 by an open fireplace, a strong locked wire screen must guard the 
 hre. The floor, after the cracks have been calked, should have a 
 coat of water-proof filling, so that it can be washed and kept abso- 
 lutely clean and free from absorption of saliva or excrementitious 
 material. Carpets are totally impractical for this class of cases, but 
 mats may be used and be daily shaken, aired, and replaced or not, 
 as the changing emergency of the case may indicate. If the floor 
 is very poor, it is best to have a smooth, hard-wood, dovetailed, and 
 blind-nailed floor laid right over the old one. This is not very ex- 
 pensive, and a proper floor is of hygienic importance. To have a 
 maniacal patient constantly stirring about on a carpet and inhahng 
 the dust which arises is very bad. 
 
 The room should contain nothing but an iron bedstead with a 
 comfortable spring bottom, and a first-class heavy hair-mattress, 
 a settee long enough for the patient to recline at full length, and 
 one large easy-chair, so heavy that the patient cannot use it suddenly 
 as a weapon of offence or destruction. 
 
 A commode, with night-vessel and wash-basin, towels, and like 
 tilings should be in an adjoining room, or in the bath-room. All 
 clothing should be kept in a separate room. 
 
 Most maniacal patients are indifferent to assthetic things, but if 
 the patient can appreciate it, pictures without glass coverings may 
 be hung in the main room, which, with a hard polished floor, a few 
 Turkish rugs, and a bright open fire may be cheerful in its hygienic 
 simplicity. 
 
 It must be so arranged that the nurse who is resting will be re- 
 moved from disturbance by the noise of the patient, and still there 
 must be some signal by which he can be readily summoned in emer- 
 gency by the nurse on duty with the patient. In maniacal cases rela- 
 tives do not often do well as nurses, for there is too great a revulsion 
 of feeling on their part, and the patient is often more excited by their 
 presence, and it becomes very trying for both parties. 
 
378 TEXT-BOOK ON MENTAL DISEASES. 
 
 The nurses must keep a written account of the pulse, tempera- 
 ture, excretions, food consumed, medicines taken, and of the hours 
 of sleep and exercise out-of-doors and of all new symptoms. If the 
 patient be active or tend to escape, two attendants must always go 
 with him in his walks, and one of them at least must be more active 
 and fleet of foot than the patient. It is seldom safe in any case of 
 mania to allow a single attendant to take the patient out to walk un- 
 less there be great physical superiority on the part of the attendant. 
 The patient should not be at such a distance from medical aid, that 
 it could not be promptly procured in case of need. 
 
 The case may be one of acute melancholia, and the friends may 
 insist upon home-treatment in town. 
 
 It may be that only a second-story room is available for the case. 
 The windows of the room must then be secured, so that they will not 
 open more than six inches at the top or bottom, and if the panes 
 are very large they must be of such heavy glass that they cannot be 
 broken, or smaller ones must be used. The only safe theory to act 
 upon in all eases of melancholia is, that the patient is suicidal or may 
 at any hour be seized with an impulse to self-destruction. 
 
 All glass and china-ware, and every conceivable article which 
 could be suddenly used for self -injury, should be removed from the 
 room. Two attendants, one for the day and one for the night, will 
 be indispensable. The objection to relatives as nurses does not exist 
 to the same degree as in mania, but trained nurses and entire 
 strangers are always preferable. The outings of the patient in 
 crowded streets would have too many elements of danger, if the 
 patient were suicidal, but carriage drives could be taken with the 
 nurse sitting in control next to the single exit from the vehicle, and 
 a second person should be in attendance. The patient, under some 
 delusion or impluse, may attempt to plunge head first out of the 
 carriage window. This has happened not only in a carriage, but in 
 a railway car, in the twinkling of an eye, with two attendants beside 
 the patient. 
 
 With the patient on the second story of a private house the stair- 
 ways or balusters are always dangerous points. The patient is never 
 • to be lost to view while in a bath-tub, and must be attended at the 
 water-closet, and indeed, is never to be left alone, night or day, during 
 the acute stage of melancholia. Matches and coal-oil lamps, which 
 can be suddenly overturned, are to be kept at a safe distance from the 
 patient. 
 
THE TREATMENT OF INSANITY. 379 
 
 With these precautions, and minor ones too numerous to mention, 
 and with two reliable trained nurses the physician may undertake to 
 treat a case of melancholia at home, but if the expense of these 
 arrangements cannot be met he would do well to refuse the responsi- 
 bility of the case. 
 
 The brief maniacal attacks following within a few days of parturi- 
 tion may be, for special reasons, undertaken at home, in accordance 
 with general directions above given. The woman in this instance 
 should be treated in bed, and excited attempts to leave the bed and 
 to interfere with local antiseptic treatment will demand restraint, 
 which, on acount of abdominal pressure and liability to other in- 
 convenience in these cases, can seldom be carried out well by the force 
 of attendants, and the restraining sheet will be found a much more 
 comfortable means, with occasional full doses of sedatives in great 
 excitement. 
 
 General paresis, when the diagnosis is once established beyond 
 all doubt, is better treated in hospitals. There is no longer any ques- 
 tion of damage to business reputation or professional standing by the 
 residence in a hospital for the insane, as it is only to be considered 
 how long the patient will live; and he can be cared for at home in 
 the demented stage if the relatives do not wish him to die in an in- 
 stitution. 
 
 In the early stages of the disease paretics are often difficult of con- 
 trol and not suited for home-treatment. 
 
 Brief attacks of alcoholic mania may be treated in private or in a 
 general hospital if the authorities will receive the patient. 
 
 Temporary Insanity, in connection with fevers and other in- 
 fections, may sometimes be treated outside of hospitals for the in- 
 sane. 
 
 Stuporous forms of mental disorder, resulting from sudden emo- 
 tional shock in young people, are often appropriate cases for treat- 
 ment in their own homes, as all element of danger to themselves or 
 others is eliminated by the nature of the malady, which only calls for 
 attentive nursing and appropriate medication. 
 
 There are acute delirious cases of Insanity, with extreme ex- 
 haustion of vital powers from the very onset, which should as a mat- 
 ter of humanity be treated at home, and should never be transferred 
 any great distance to a hospital, as the question of life or death is of- 
 ten settled within a few days in these eases, which require immediate 
 and active sustaining treatment and absolute repose, and even the 
 loss of a few hours may be fatal. 
 
380 ' TEXT-BOOK ON MENTAL DISEASES. 
 
 Finally there are cases known as mania transitoria, which neces- 
 sarily are treated out of hospitals for the insane, as the duration of 
 the mental troubles is too brief to admit of the slow formalities of 
 leffal commitment. 
 
 Section III. — First Attentions to Urgent Symptoms. 
 
 In both hospital and private practice the first approach to a case 
 of Insanity often reveals the necessity for immediate attention to 
 urgent symptoms. The emergency may be all the greater because the 
 patient may suffer extremely without calling attention to it. It de- 
 pends upon the physician to discover the latent urgencies of the case. 
 
 Attention is, therefore, directed in this section to the chief urgent 
 symptoms with which the physician will have to deal preliminarily to 
 the regular treatment of the case. 
 
 Traumatic Accidents. — It is a very common thing for patients to 
 arrive at hospitals for the insane with injuries undiscovered by 
 friends or by the physician, who has been in attendance upon the 
 case, especially if the patient be acutely maniacal. These injuries are 
 sometimes extensive bruises, fractures of ribs, genital self-mutila- 
 tions, foreign bodies forced into the vagina, threatened sloughing of 
 penis or scrotum from ligatures tied by the patient, loosened teeth, 
 fractured jaw, contusions of the scalp, dislocation of the sterno- 
 clavicular articulation, broken nasal bones, rupture of muscular 
 fibres and of tendons and sub-luxations. 
 
 In assuming charge of a case the physician should make a com- 
 plete physical examination, and it may be necessary to trust a part of 
 the personal inspection to a skilful nurse or to a woman physician. 
 The administration of a warm bath affords a good opportunity for the 
 inspection. The possibility of internal injuries is not to be forgotten. 
 
 Inanition. — The enormous waste of tissues in acute mental dis- 
 orders is rarely understood and the large supply of nutriment re- 
 quired is not taken, and the result is more or less extreme inanition 
 often betrayed first by a " sudden sinking," which leads to a hasty 
 summons of the physician. If the patient be of strong muscular 
 development, as a man, or have natural rotundity, as a woman, the 
 point of dangerous inanition may have been reached before sufficient 
 time has elapsed for emaciation. There is in these cases a pathog- 
 nomonic starvation-odor as unmistakable as it is indescribable. The 
 urgency for forced alimentation in these cases is extreme, and not 
 
THE TREATMENT OP INSANITY. 381 
 
 one hour is to be lost, for when a certain point is passed the func- 
 tion of digestion and assimilation is reduced to a minimum. Concen- 
 trated beef-essence, fresh eggs, and milk should be freely admin- 
 istered. If the patient will not take nourishment voluntarily it 
 should be at once given by the soft nasal tube, or by the assophageal 
 feeding tube, as later described in this chapter, under the head of 
 " Dietetics of Insanity." If the stomach is found already too weak 
 to perform its function, and too irritable to retain the nutriment, 
 small and oft-repeated quantities of predigested foods must be given, 
 and in extreme cases rectal alimentation is an auxiliary means of 
 sustenance. 
 
 For food-formularies and full directions as to artificial feeding 
 reference is made to the heading just mentioned. 
 
 Insomnia. — The most universally urgent symptom in acute 
 mental disease is insomnia, but occasionally it attains such an ex- 
 treme that the patient may literally be said to be dying for want of 
 sleep. The peculiar haggard look of insomnia, and the length of 
 time passed without sleep, and the general state of the vascular sys- 
 tem, will decide the degree of urgency and the hypnotic to be em- 
 . ployed. A full dose of chloral hydrate (20 grains) is as prompt and 
 reliable as any remedy of the kind, when cardiac disease does not 
 contra-indicate. Trional, though quicker than sulphonal, is too slow 
 for this special emergency. 
 
 If the patient is very feeble, whiskey in hot milk, with a dry and 
 warm blanket-pack, and a warm w^ater-bag to the feet, and a cool 
 room may procure sleep and obviate the use of a drug. 
 
 For the list of hypnotics and their uses, reference is made to the 
 section on " Pharmaceutical Eemedies," in this chapter. 
 
 It will not infrequently be found that the insomnia is an attend- 
 ant symptom of inanition, and when the latter is relieved, sleep 
 returns more effectually than by any other means. In all acute In- 
 sanity sleep and food are the two most urgent needs. 
 
 Obstipation. — Obstinate constipation is common in mental dis- 
 ease, and more especially in melancholia, from diminished peristalsis 
 and intestinal secretions. Not infrequently there are dangerous ex- 
 cremental accumulations of some weeks' standing, during which time 
 there may have been repeated partial evacuations. The urgency will 
 be found still greater in certain cases with fecal impactions in the 
 large intestines. The relief of these conditions will often modify 
 at once the distressing excitement of the patient. The only prompt 
 
382 TEXT-BOOK ON MENTAL DISEASES. 
 
 remedy is mechanical delivery of the impacted rectum. Ordinary 
 syringes and enemas are of no avail. In the absence of a gynaeco- 
 logical chair or table the patient may be treated on a bed, spread with 
 a rubber sheet drawn on one side of the bed into a vessel. The 
 patient is drawn crosswise of the bed, in the dorsal recumbent posi- 
 tion, with the knees held bent apart by assistants, the heels and but- 
 tocks together at the edge of the bed and the operator seated directly 
 facing the patient at the edge of the bed. The effect of glycerine and 
 warm water, or of soap and warm water may be tried, but they are sel- 
 dom of any avail. Warm olive-oil or cotton-seed-oil injected through 
 a soft Irish linen catheter, passed gently by obstructions, may facil- 
 itate the operation. Eectal speculum and other appropriate instru- 
 ments may be used with great care not to injure the parts, but fingers 
 are often more effectual and less dangerous than other instruments. 
 In the worst cases anaesthesia may be advisable, or necessary, on 
 account of the resistance of the patient. 
 
 If the accumulations are in the large intestine it becomes neces- 
 sary to use a long flexible tube and to practise intestinal lavage. 
 
 The physician will often be surprised at the relief of the general 
 condition of the patient afforded by prompt attention to this urgent 
 symptom of obstipation, after purgatives have been used to no pur- 
 pose. 
 
 Retention of Urine. — The bladder will often be found immensely 
 distended, and reaching almost as high as the gravid uterus at full 
 term, and this is especially apt to be the case in general paresis and 
 organic dementia. Vesical rupture may occur from over-distention. 
 
 Catheterization should be practised at once if the patient will 
 not or cannot make a successful effort to empty the bladder. 
 
 In males old strictures may offer obstruction, and a warm bath, 
 and filiform bougies may become necessary. 
 
 Obstinate resistance on the part of the patient, and urgency of 
 the vesical symptoms, is a sufficient indication for anaesthesia, pro- 
 vided no thoracic contra-indication is found on auscultation, and 
 that the feebleness of the patient is not too great. Vesical puncture 
 may become a final necessity. 
 
 Attempts at urination while in the prolonged warm bath are often 
 successful, and this simple measure should always be tried before any 
 operative procedure is undertaken. 
 
 Gastro-intestinal Disorder. — Aggravated forms of gastro-intes- 
 tinal catarrh will demand early attention. A very distressing condi- 
 
THE TREATMENT OF INSANITY. 383 
 
 tion is often due to dilatation of the stomach and long retention of 
 food due to defective innervation of the gastric musculature, as well 
 as to altered secretions. Even in the absence of these conditions, 
 s'arcinic and acid fermentations, with pyrosis and gastralgia, will oc- 
 casionally call for immediate attention. The gastralgia may be in- 
 tense, in neurasthenic cases particularly, and accompanied by severe 
 tonic spasms of gastric muscles. A full dose of sulphate of morphia 
 by hypodermatic administration is the best remedy. 
 
 The most ready means of relief of the other gastric troubles above 
 mentioned is the thorough washing out of the stomach. A long 
 flexible soft rubber sesophageal tube with a funnel attached at one 
 end is to be employed. When it has been oiled and passed into the 
 stomach the fluid is poured into the funnel, which may be slightly 
 elevated, and then, when sufficient liquid has passed and while the 
 tube is still full, by lowering the funnel end, the tube, acting as a 
 sjrphon, will empty the stomach. This procedure may be repeated 
 without removing the tube until the stomach is completely cleansed. 
 It is best to use boric acid, or salicylic acid in a -J per cent, solution 
 for the cleansing, and if the stomach is acid vichy water or bicar- 
 bonate of sodium in a 2 per cent, solution may follow for the final 
 washing out of the stomach. This antiseptic lavage will sometimes 
 give prompt good results. The tongue in these cases is heavily 
 coated, and the buccal and pharyngeal cavities have an offensive 
 odor, and a mouth wash of glycerine and biborate of sodium in solu- 
 tion may be used. 
 
 Exhaustion and Heart-failure. — A considerable percentage of all 
 cases of acute mental disorder die from exhaustion and heart-failure. 
 The heart-failure may arise from general arterio-sclerosis and cardiac 
 degenerations or valvular lesions, or from focal brain disease and or- 
 ganic lesions involving the origin of the pneumogastric nerve, or it 
 may only be a symptom of the general exhaustion of nervous centres, 
 or it may result from a toxic diathesis or auto-intoxication. 
 
 The general exhaustion springs from a vast expenditure of 
 nervous and muscular force, which is not restored by adequate sleep 
 and nutrition. The actual danger in these exhausted cases is often 
 masked by an appearance of strength which is not real, and may lead 
 to neglect of active treatment until the approaching fatal issue 
 demonstrates the hopeless degree of general exhaustion. There is in 
 these cases an ominous fall of temperature and feebleness of the pulse 
 which announces the approaching danger. When the physician is 
 
384 TEXT-BOOK OX MEISTTAL DISEASES. 
 
 called to a case of acute Insanity and finds the restless patient -.vith a 
 subnormal temperature and a feeble and irregular or intermittent 
 pulse he may know that there is no time to he lost. The patient is at 
 once to he put to hed, and is not to he allowed to leave the recumhent 
 posture, and is to he kept warmly covered, and if the extremities are 
 cool artificial heat is to he applied. The administration hourlj', dur- 
 ing waking hours, of small doses of whiskey in concentrated beef- 
 tea and in milk is to he continued, and the tincture of digitalis in 
 certain cases is useful in small and repeated doses. Sleep is to be 
 encouraged in every way, and is not to be interrupted for the purpose 
 of nourishment or stimulation, for as the pat French proverb well 
 says, " Qui dort, dine." This treatment is to be supplemented by 
 small doses of quinine, and of dilute phosphoric acid. 
 
 It is best to carry out a sj'stematic rest cure for some weeks in 
 these cases, in which passive movements and massage are to be sub- 
 stituted for exercise. 
 
 When the first urgency of the s}Tnptoms has passed it is better 
 to keep the room cool at a temperature not exceeding 65° F. The 
 special pathology of the heart-failure as above noted may give varying 
 indications of treatment. 
 
 Psycfio-motor Excitement. — All forms of intense excitement, 
 whether continuous or paroxysmal, are urgent symptoms, as they 
 lead often to exhaustion of vital powers. The patient will be found 
 shouting, grimacing, spitting, gesticulating, beating the air, and 
 sometimes jumping continuously or running about in a circle. The 
 effect of a graduated bath with cold to the head may first be tried. 
 If this does not answer the purpose, and the patient be a strong 
 person, the subcutaneous injection of hyoscine (gr. y|o, Merck's) is 
 as efficient as any remedj^ known for allaying the excitement. This 
 remedy is powerful and not without danger of cumulative effect. 
 Conium is efficient, but as ordinarily dispensed is of uncertain 
 strength, which may give rise to disagreeable symptoms. In mus- 
 cular men free from cardiac trouble tartar emetic, gr. ^, often acts 
 as effectively as hyoscine, and tends to relieve the hoarseness and 
 congestion of lar}Tigeal, tracheal, and bronchial membranes, which 
 results often from constant shouting and mouth-breathing. If the 
 patient has been isolated in a closed room and only partially clad for 
 some time, the expedient of dressing him completely and taking him 
 out into the open air for a walk in comparative freedom will some- 
 times surprise him into temporary quietude. Ordinarily, though, all 
 
THE TREATMENT OF INSANITY. 385 
 
 element of self-control is lost and the excitement is the direct result 
 of cortical irritation. If the excitement become continuous, and 
 tend to a chronic nature, the electric cautery or blisters ad nucham 
 may prove advantageous. 
 
 Acute Organic A-ffeciions. — Inflammatory affections of thoracic 
 and abdominal organs run an obscure course often among the acute 
 insane, and they will not be discovered except by the closest observa- 
 tion, and the physician will often have to treat symptoms of this kind 
 more urgent than those of the mental disease. Auscultation and 
 percussion should be performed at the earliest practicable moment, 
 and the urine should be examined. All acute organic diseases in the 
 insane are best treated in bed. In these cases the effort of attendants 
 to retain the patient in the recumbent posture is often more exhaust- 
 ing than chemical restraint. The choice of evils, therefore, is be- 
 tween the latter and the restraining sheet, for it will not do to have 
 a patient running about with pneumonitis, pleuritis, pericarditis, 
 acute nephritis, or any of the acute organic affections common among 
 the insane. 
 
 The physician at his first visit to a case of Insanity, therefore, is 
 to settle the treatment of urgent symptoms of this nature. 
 
 Infectious Diseases. — Zymotic fevers in the primary stage may be 
 ushered in by Insanity, and delirious mania of toxic origin sometimes 
 presents eruptions, and a differential diagnosis, owing to a rash and 
 a rise of temperature in both cases, may require a little time. All 
 doubtful cases should be treated as if of infectious nature until the 
 diagnosis is settled beyond a doubt. All hospitals for the insane 
 should have an isolation hospital, built in pavilion form, at a distance 
 from other buildings, for the treatment of cases of Insanity with 
 contagious diseases. The family physician is to isolate these cases 
 completely, and to treat the infectious disease as if the Insanity did 
 not exist, though the restraining sheet may become a necessity. 
 The intercurrence of Insanity in infectious diseases after their full 
 development is seldom a justification of the commitment of the pa- 
 tient to a hospital for the insane during the course of the infectious 
 malady. 
 
 Section IV. — Certain Specially Troublesome and Responsible Cases. 
 
 There are certain cases which tax the resources of a well-equipped 
 hospital for the insanCj and are still more difficult of treatment in 
 private houses. 
 25 
 
386 TEXT-BOOK ON MENTAL DISEASES. 
 
 The endeavor here is to point out the modes of dealing with the 
 most troublesome cases which occur either in hospital or private 
 practice. 
 
 - Destructive Patients. — Destructiveness, as a part of the aimless 
 and general incoherent violence of acute delirious mania, is best 
 controlled by prolonged warm baths and cold affusions to the head, 
 and if the patient be strong by the subcutaneous use of hydrobromate 
 of hyoscine, gr. y-^^. The general automatic destruetiveness of epi- 
 leptics, following or preceding the seizures, is sometimes avoided 
 by large and repeated doses of bromide of potassium, conjoined in 
 extreme cases with chloral. 
 
 Ordinarily, medication for the control of destructive tendencies 
 alone is not to be recommended. 
 
 The simplest expedient in maniacal destructive patients is the 
 complete removal from their reach of everything which they can de- 
 stroy. This implies isolation of the patient in an empty room with 
 guarded windows. 
 
 The next most effectual means is the incessant watching of the 
 patient by attendants, who must exert sufficient manual restraint to 
 prevent any destructive acts of the patient. This amounts to con- 
 stant holding of some patients who are quick and bent on mischief. 
 Patients who kick holes in the plaster of the walls may be given slip- 
 pers or felt shoes. Many of the most destructive patients are oases 
 of chronic mania, who have fixed habits and studied ways of destroy- 
 ing property. They use pins, buttons, hairpins, splinters of wood 
 from the floor and sharp bits of stone to do an incredible amount of 
 damage to walls, doors, windows, and furniture in a brief space of 
 time. The only way to deal with these cases is to keep them under 
 constant supervision, to search them and their clothing night and 
 morning, to teach them some manual occupation if possible, and to 
 get them tired with out-of-door labor, so that they will rest at night, 
 and to have them sleep in an associated dormitory under the eye of 
 the night-attendant, if in hospital. Eestraint, as a remedy for de- 
 struetiveness, is not to be practised by mechanical appliances. 
 
 Another class of destructive patients is of the impulsive variety. 
 They know the nature of their act perfectly well, but they have an 
 irresistible tendency to perform it. Fortunately the tendency usu- 
 ally takes some definite form, such as breaking glass, setting fire to 
 things, turning the table over, or throwing things out of the window. 
 The apartment must be arranged with special reference to the avoid- 
 
THE TREATMENT OF INSANITY. 387 
 
 ance of the particular impulse, and of those things which suggest it, 
 and the nurse knowing the constant direction of the patient's weak- 
 ness can foresee and prevent it. 
 
 Chronic cases of insanity, which more or less automatically pick, 
 bite, and ruh their clothes to pieces, and are past all hope of teaching 
 any manual employment, are provided with strong quilted, or can- 
 vas, suits, which can be washed. An expedient occasionally successful 
 in these cases is to give them something to tear or pick to pieces, and 
 thus to direct their activity in a harmless direction. The task of 
 breaking the automatic habit in these cases by constant prevention 
 by the hands of nurses is wellnigh hopeless. Patients thus pre- 
 vented for weeks together will at once return to their old destructive 
 ways. In the formative stage the habit may be broken. Among 
 comparatively intelligent patients with impulsive tendencies to de- 
 stroy, mental therapy and counter-suggestion are of some avail, and 
 possibly hjrpnotic influence might have some application in these 
 cases, which are ordinarily of an impressionable nature. In some of 
 these cases the type is degenerate and beyond hope of cure. 
 
 Violent and Homicidal Cases. — During the play of emotions in 
 acute mania anger may prompt to violence, which is occasional and 
 of brief duration, and not usually very dangerous. 
 
 Such maniacal patients may be violent one mom^ent and laughing 
 the next, and the skilful nurse can always manage with these cases 
 with tact and kindness. 
 
 Certain cases of mania assume a chronic irascible and violent 
 form, and if there be a certain degree of physical strength, and at 
 the same time combined with it in men a certain knowledge of the 
 pugilistic art, the patient becomes very dangerous. It is fully pos- 
 sible for a person to be killed by a single blow with the fist. Patients 
 of this class who are habitually violent should be kept isolated, or 
 duly guarded by a sufficient number of nurses, 
 
 A single attendant should not be left alone with such a patient 
 against whom he may be thus compelled to use great force in self- 
 defence. If there be a temporary insufficiency of nurses it is better 
 that the patient should have one hand restrained than to incur the 
 risk just mentioned. It is in this way that nearly all injuries to 
 patients or nurses occur through inadequate assistance in the con- 
 trol of violent patients. 
 
 There are some patients who are persistently homicidal, either 
 from delusions of persecution, or from irresistible homicidal im- 
 
888 TEXT-BOOK ON MENTAL DISEASES. 
 
 pulses. Some of them are fully aware of their condition, and may 
 even beg to he restrained, that they may injure no one. The physi- 
 cian must decide in each case according to all the circumstances 
 how long restraint is justifiable in these cases, in which bodily signs, 
 not unlike epileptic aurse, may give forewarning of the culminating 
 impulse. 
 
 In attempts to carry out non-restraint in dealing with these 
 eases the writer has known nurses and medical officers to be badly 
 hurt, and has himself sustained injuries from attacks which might 
 have proved fatal to a person less able to sustain them. The first 
 onslaught of such a patient upon the physician may be so rapid that 
 the attendants cannot prevent it. 
 
 The treatment of homicidal patients should never be undertaken 
 in private, and isolation is the proper measure until the removal to 
 a hospital for the insane is effected. 
 
 In the chronic irascible violent cases mentioned the writer has 
 seen good results from the insertion in the back of the neck of a seton, 
 which seemed to relieve the cortical irritation and the explosive nat- 
 ure of the anger. 
 
 Epileptic violence, which is blind and furious, occurs chiefly in 
 certain definite relations to the seizure, and with prodromes whigh 
 come to be recognized and guarded against by the habitual attendant 
 of the patient. 
 
 These violent outbreaks in epileptics are sometimes vicarious of 
 the seizures, and they may be in certain instances prevented by the 
 use of nitrite of amyl or by anaesthetics. 
 
 Passively and Actively Filthy Cases. — ^Maniacal, demented, and 
 stuporous cases soil themselves frequently both during the daytime 
 and at night. 
 
 The cases of terminal dementia, so long as there is a minimum of 
 intelhgenee left, can be trained to go to the water-closet. They 
 should be taken there every hour during the day, for weeks together, 
 to estabUsh the habit of attention to nature's wants, which they 
 finally come to heed. 
 
 A night-habit of cleanliness may be taught by the same means in 
 the same class of patients. The beginnings of this method are dis- 
 couraging, but the result repays the trouble taken. 
 
 Paralytic dements cannot be taught, but by regulating the 
 amount of the fluid taken, and by the use of the catheter and enemas 
 and bed-pan, they are readily managed. The latter are the only 
 
THE TREATMENT OF INSANITY. 389 
 
 means also to be employed in profoundly stuporous cases, which 
 cannot be led to make any effort when taken to the closet. 
 
 Maniacal patients are often actively filthy, daubing themselves 
 and the walls with excrement, and they are sometimes coprophagists 
 as well as daubers. Such patients should be given concentrated 
 meat diet and little liquid, should be taken to the closet the last thing 
 at night, and if the visit is without result, the lower bowel should be 
 emptied completely by enemas. Some chronic maniacs are ex- 
 tremely troublesome, and have an insane cunning in reserving them- 
 selves for the smearing nightly performance. These may be given 
 the restricted diet, a full dose of opium one night, and a complete 
 rectal clearance by enemas the next night on retiring to their room, 
 as they are usually too noisy to sleep under surveillance in an asso- 
 ciated dormitory. In general paretics in the final stage the rectal and 
 vesical incontinence from paresis of sphincter-muscles is best met by 
 constant changes of the under sheet drawn over a rubber sheet to pro- 
 tect the bed. Some use a diaper in these cases, and others attach a 
 funnel to the centre of the rubber sheet to deliver the urine through 
 a tube extending directly through the centre of the bed into a vessel, 
 and others use rubber apparatus such as is worn in chronic incon- 
 tinence of urine, and if the patient is quiescent some form of urinal 
 can be adjusted in these cases. 
 
 In both actively and passively filthy cases the education of the 
 patient, and the tact and perseverance of the nurse, are the main 
 reliance, and the prevention of the formation of uncleanly habits in 
 the first place is of great importance, and calls for constant watch- 
 fulness on the part of the nurse. 
 
 Feeble, Helphss, and Bedridden Patients. — Some of the most 
 responsible and troublesome cases with which the physician has to 
 deal are very feeble insane patients, and especially senile dements. 
 Such patients are often restless and constantly tottering about at the 
 risk of falhng and striking against things. They often sustain 
 bruises and rents of the skin, which is so atrophied in some instances, 
 that it tears like wetted paper. The slightest firmness of grasp of the 
 nurse in efforts to restrain them causes capillary rupture and dis- 
 colorations showing the imprint of the fingers, and giving rise tn the 
 suspicion of unnecessary violence. Very often they fall and sustain 
 intra-capsular fracture of the neck of the femur or CoUes's fract- 
 ure of the radius. 
 
 In all hospitals for the insane there should be special qttarters pro- 
 
390 TEXT-BOOK ON MENTAL DISEASES. 
 
 vided for the treatment of these eases on the ground floor to avoid 
 going up and down stairs. The floors should not be smooth polished, 
 the bedsteads should be lower than usual, and provided with an ad- 
 justable side-board in eases tending to fall out of bed. An active 
 night service is required. 
 
 In private practice the physician cannot do better than to treat 
 these cases in bed, having them warmly clad and taken into the open 
 air daily. 
 
 The helpless insane, who are hemiplegic or paraplegic, from focal 
 brain disease or spinal degenerations, usually do better dressed and out 
 of bed in the daytime, seated in easy-chairs. The best appliance for 
 these cases is a comfortable arm-chair mounted on noiseless wheels 
 with rubber tires, so that they can be quietly conveyed back and forth 
 on the long wards of hospitals, or wheeled into the open air daily. 
 In certain cases in private practice a tricycle adjusted for propulsion 
 by the arms of the patient is a desirable arrangement, furnishing 
 exercise and diversion in paraplegic cases. Hygienic measures, and, 
 instead of sedatives, open-air exposure for some hours daily to pro- 
 cure sleep is in the long run the best treatment in these helpless cases. 
 
 The bedridden cases are made up largely of general paretics in 
 the final stage, of tabetics, or of cases of organic dementia, or of al- 
 eohohe or syphilitic dements with sclerotic spinal lesions. From 
 lesions of the lumbar cord arise troublesome symptoms in the bladder 
 and rectum. Irritative lesions here give rise to spasm of the urethral 
 sphincter and retention of urine and overdistention of the bladder, 
 which may rupture in paretics, especially from atrophic disease of the 
 muscular coat of the bladder. The catheter should be passed every 
 few hours in these cases. Destructive lesions of the lumbar cord 
 cause paralysis of the bladder and overflow of urine often highly 
 alkaline if not frequently drawn. Exposure of the skin to urine is 
 promptly followed by eruptions and bed-sores. Benzoated lard with 
 a little admixture of white wax freely applied in anticipation of ex- 
 posure is an effective preventive, and much better than attempts to 
 bai'den the skin with applications of alcohol, tannin, and like things. 
 The real preventive should be constant changes of linen, as often as 
 required, and the use of the catheter. In many of these bedridden 
 cases there is paralysis of the sphincter ani and escape of the rectal 
 contents. Astringent suppositories at first may be of some use, but a 
 retention pad of patent lint, retained by a perineal elastic attached to 
 a waistband, does still better, but nothing finally sufiices but frequent 
 
THE TREATMENT OF INSANITY. 391 
 
 changes of cloths evenly folded and smoothly drawn beneath the 
 patient to save the sheet. The secret of this part of the treatment 
 has to be taught to the nurse, who nine times out of ten will ivipe the 
 patient clean a dozen times a day, and will within a week have 
 abrasions, small furuncles, celluhtis or bed-sores as the result of 
 mechanical irritation. Xo friction is to be allowed, and the whole 
 knack hes in the use of a bed-pan, of a syringe with warm water to 
 effect the cleansing, which must be complete, and then simply press- 
 ure with absorbent lint to dry the parts, and finally the application 
 of an unguent of refined lard, spermaceti, and white wax over all the 
 parts liable to subsequent exposure to the discharges. 
 
 Suicidal and Masturhatic Cases. — The danger of suicide in- 
 creases greatly the responsibility of the physician in the treatment 
 of mental disorders. The means of self-destruction are almost in- 
 credibly easy and near at hand. A small piece of glass, tin, or china- 
 ware, or a strong pin may be used to open the vessels of the arm. A 
 patient can fill a wash-basin with water, place it on a chair at the side 
 of the bed, and lying across the bed with his face in the basin drown 
 himself. 
 
 A patient sitting at table, in the presence of attendants, eating 
 without knife or fork on account of known suicidal intentions, may 
 take his hfe with no other weapon than a piece of bread. This oc- 
 curred in the writer's hospital practice. A patient who had been 
 under the closest surveillance sat eating with the nurse standing be- 
 hind him. The patient fed himself with the right hand and with his 
 left hand in his lap kneaded slyly the moistened soft part of bread 
 into a doughy mass nearly the size of his fist, and in an instant he 
 carried it to his mouth and jammed it forcibly down his throat with 
 his fingers. The nurse at once noticed the unusual action of the 
 patient placing his fingers in his mouth, and springing forward 
 seized his hands, and then seeing signs of suffocation, properly used 
 his finger to free the pharynx from the mass. In five minutes' time 
 the physician with instruments was at the patient's side, but the 
 patient was dead, and resuscitation could not be brought about by 
 artificial respiration or any other means. The autopsy revealed that 
 part of the doughy mass had passed not only into the larynx, but also 
 into the trachea. 
 
 The failures and accidents of medical and surgical practice are 
 often more instructive than the successes, but they are unfortunately 
 seldom published, and one more is, therefore, here made known to 
 
392 TEXT-BOOK ON MENTAL DISEASES. 
 
 illustrate the facility and danger of suicide, and this was also a hos- 
 pital case. A woman with a suicidal tendency made known in the 
 history was placed the night of her arrival in a dimly lighted room 
 with the door ajar and with a nurse seated so that she could see if the 
 patient attempted to rise from the bed at any moment during the 
 night. By special order the nurse searched and removed the patient's 
 clothes from the sleeping-room, and stripped and searched the patient 
 just before putting her to bed. The patient managed with insane 
 cunning to secrete about her person, in spite of this search, either in 
 perineal regions or more hkely in the vagina itself, a cord the size of 
 a goose-quill and more than long enough to go around her neck. She 
 lay quietly in bed on her back, drew the bed-clothes well up around 
 her neck, adjusted the cord about her neck with an ingenious sHp- 
 knot, which would stay at the point to which it was pulled, and evi- 
 dently with one supreme effort drew it so taut that it stopped res- 
 piration, and she died without the slightest noise or struggle, or with- 
 out even a change of position in bed. 
 
 The nurse on guard in the hall-way, only the distance of the 
 length of the room from the patient, was astounded when after some 
 hours she discovered how the fatal deed had been done. 
 
 Patients may commit suicide by suddenly plunging head first 
 against the wall causing vertical or basal fracture of the skull, or 
 they may seize and swallow things dangerous to life, and any oppor- 
 tunity for precipitation or drowning is almost sure to provoke an 
 attempt. 
 
 Ocular enucleation with the forefinger and sexual mutilation 
 by male and female patients are performed at times with suicidal 
 intent. 
 
 The only safe treatment of suicidal patients is to be conducted 
 on the supposition that they are bent upon " felo de se " at every 
 moment of their lives. Such patients are never to be left alone for 
 one minute day or night, and eternal vigilance on the part of the 
 nurses is the only condition of safety of the patient. 
 
 Opiates may alleviate mental depression, but no drugs will re- 
 move suicidal impulses except as they produce delirious excitement 
 or stupefaction. A combination of opium and bromide of sodium 
 may be used to blunt the keenness of precordial anxiety, which 
 sometimes leads to suicide. Frightful hallucinations of sight prompt- 
 ing to suicide are sometimes relieved by isolation in a darkened room. 
 Special effort is to be made to ascertain and remove any delusion 
 
THE TREATMENT OF INSANITY. 393 
 
 which, may he driving the patient to self-destruction. If a man wishes 
 to die hecause his wife has been murdered, as he supposes, by his 
 enemies, it is well to have the wife visit the patient. 
 
 The impulse to suicide may disappear temporarily with the 
 delusion, but the lurking tendency is apt to reappear with a new 
 delusion to justify its execution. 
 
 Some suicidal patients have a sense of relief when wearing some 
 form of restraint which precludes the possibility of injury inflicted 
 by their own hands, but except in the most desperate cases, with 
 impulses to self -mutilation, mechanical restraint is not to be recom- 
 mended. The writer has had days together to bit and bridle cer- 
 tain patients determined and partially successful in attempts to de- 
 stroy both lips and tongue by biting them. 
 
 The modes of dealing with masturbatic patients are numerous, 
 and the practice can usually be prevented, but the tendency cannot 
 often be eradicated. In women it is sometimes the result of pruritus 
 vulvae or of other local disease, which should be treated for the relief 
 of this symptom. In acute Insanity it is often a manifestation of 
 hyperaesthesia sexualis, which subsides with the acute stage of the 
 malady. In confirmed cases the habit has become an organized 
 part of cortical associative relations, and even castration will not 
 remove the deep-seated tendency to the habit, and clitoridectomy is 
 likewise without curative result, and oophorectomy itself does not 
 eliminate the psychical sexual erethism, which has become an or- 
 ganized habit of mind. Hereditary masturbatic tendency is like- 
 wise incurable. 
 
 The prevention of masturbation as an inter-current symptom of 
 acute Insanity is accomplished in men by blistering with cantharidal 
 collodion. Pain then prevents erethism and erection. A stitch with 
 silver wire may pass from the base of the gland through the skin 
 enclosing the prepuce, or the latter may be 'drawn forward and 
 stitched through from side to side. These methods prevent tur- 
 genscence by the pain they cause, and are only to be used in ex- 
 treme cases. In women it is more difficult to limit the effects of 
 blisters, and improvised dressings with bandages to prevent friction 
 of the thighs are required. Temporary resort to mechanical restraint 
 may be justifiable in these cases, and various forms of local pre- 
 ventive apparatus are used but with indifferent success. The most 
 effectual prevention is a day and night surveillance by nurses ac- 
 customed to this class of patients, and having experience of their 
 
394 TEXT-BOOK ON MENTAL DISEASES. 
 
 cunning ways of indulgence in their habit. Sitz baths and forms 
 of hydro therap3^, including the shower bath, are useful adjuvants. 
 Anaphrodisiacs, especially the bromides, are of some service. A 
 trial may be made of Gokhru, the East Indian remedy, which is the 
 fruit of Pedalium Murex. Lupulin, salix nigra, and camphor are 
 sometimes of benefit. Urethral hypercesthesia, which favors ereth- 
 ism, may be relieved by application, cautiously made, of nitrate of 
 silver. Strychnia, phosphorus, and quinia are the best tonics in these 
 cases, and general hygiene, physical fatigue, and mental occupation 
 are indicated. Spinal galvanization is sometimes useful. On re- 
 covery of the patient from the mental disorder, if sexual hyper- 
 ffisthesia be a sequel, marriage is not a preventive of the possible re- 
 turn of self-abuse, which is also common among the married, to whom 
 the constant presence of the opposite sex may only prove a provoca- 
 tive to artificial indulgence. 
 
 Masturbation in climacteric Insanity is due to parsesthetic local 
 conditions, and it usually recovers by self-limitation of the meno- 
 pause. 
 
 Section V. — Treatment Based on Diagnostic Conclusions, and Etio- 
 logical and Pathological Indications. 
 
 The complete survey of the history and of all the symptoms of a 
 case of Insanity often leads to diagnostic conclusions, which consti- 
 tute the broadest grounds of treatment. 
 
 If the case be that of a child, and the diagnostic conclusion be 
 mental arrest, the whole treatment must be based on the central idea 
 of educational training, continued for years by those specially skilled 
 in these cases. If the mental weakness be the sequel of acute in- 
 fectious disease in the child, who has failed to recover its former 
 natural mental status, the same educational treatment is to be pur- 
 sued as in the first ease mentioned. If the developmental arrest 
 is congenital, and the child has reached the age of ten or twelve 
 years without treatment, the physician must inform the parents 
 that the hope of benefit to be derived from any curative afctempts 
 is almost nil. 
 
 If the child before the age of ten has shown monstrous de- 
 pravity and uncontrollable wickedness, the treatment must also be 
 of a corrective educational nature, carried out for years under some 
 judicious person, not a parent of the patient, who in this way some- 
 
THE TREATMENT OF INSANITY. 395 
 
 times may be rescued from life-long Insanity. Certain forms of 
 imbecility, not moral but intellectual, are to be treated in accordance 
 with the degree of mental deficiency diagnosed. Such patient? in 
 early life are misunderstood, and they are punished by parents for 
 supposed neglect of duties, and disciplined by teachers, until they 
 are driven out of their minds finally by continuous little hardships 
 of life, which would not thus affect a person of stronger mind. The 
 treatment must depend completely on the degree of native enfeeble- 
 ment established by the diagnostic conclusion founded on a review of 
 all the anamnestic data. If it be concluded that there is decided 
 mental deficiency, the young person, temporarily unbalanced by the 
 petty trials and severities of life, should be placed in the care of one 
 known to be Mnd and gentle, and should never be again sent to a 
 common school, and should be taught some simple manual or out- 
 of-door occupation to be followed for the remainder of life. 
 
 If the patient in this degenerate group is adolescent, and has 
 developed the symptoms of original monomania by a gradual out- 
 growth of perverted traits, the treatment can only consist in sur- 
 veillant and expectant methods, without hope of cure. The patient 
 is best removed from large cities to agricultural pursuits, and a life in 
 the open air under good regimenal conditions will in the course of 
 years effect such amelioration of the general constitution as is possi- 
 ble in inherited psychopathies. 
 
 If the psychopathic tendency manifests itself in a periodical way, 
 or a definite cyclic character has already been established, the treat- 
 ment in the lucid interval is to be confined to hygienic means of rein- 
 forcing the whole physical constitution, and then the most vigorous 
 therapeutical measures are to be employed to ward off the attack. 
 The recurrence in women often coincides with the catamcnial period, 
 and in such instances as the molimen approaches absolute rest in 
 the recumbent posture is to be enforced. Prolonged sleep, light but 
 nourishing diet, warm baths, gentle massage, intestinal lavage in 
 obstipation, and galvanism through sacro-pubic regions in delayed 
 menstrual flow are the indications. If this course is not successful 
 at the next coincidence of mental and menstrual trouble, the patient 
 is to be quickly brought under the full physiological effects of bro- 
 mide of potassmm and to be kept in this artificial state of sedation for 
 five days previous and five days subsequent to the menstrual flux. 
 
 In men the cyclic approach of mental trouble, according as exal- 
 tation or depression is in order, is to be treated actively with seda- 
 tives or with tonics, stimulants, and general faradization. 
 
396 TEXT-BOOK ON" MENTAL DISEASES. 
 
 If the diagnosis establish the sequential relation between the 
 mental disorder and an established neurosis the latter is to be treated. 
 Thus choreic Insanity is best dealt with by remedies to control the 
 convulsive affection, which once reheved in children is followed by 
 a return to sanity of mind. Epileptic mental disorder is hkewise 
 dealt with by active therapeusis directed against the neurosis. The 
 treatment in the latter instance is only effective before mental de- 
 terioration has actually occurred. 
 
 If the diagnostic conclusion is that the Insanity is the direct re- 
 sult of the crisis of puberty, the menopause or senility, the chief idea 
 must be to conduct the case expectantly and safely through the 
 natural evolutional or involutional changes, and to meet intercurrent 
 symptoms with special remedies as the occasion requires. There is 
 undoubtedly a good application of the bromides in climacteric cases 
 to allay nervous irritability, and of opiates in senile cases for a relief 
 of the persistent agrypnia. The treatment of the pubescent eases 
 naturally calls for such drugs, nervines, and tonics as best combat 
 sexual neurasthenia in men, and amenorrhoeal troubles in' women, 
 and such other symptoms as hysteria, tetanoid, and cataleptoid states, 
 hysteroid seizures, stuporous and fasting conditions, and temporary 
 maniacal outbreaks. In some cases the rest cure, with massage and 
 hydrotherapy, bromides for insomnia, nux vomica and iron as tonics, 
 and complete isolation are very effective. In hysterical patients 
 valerianate of zinc, asafoetida, and turpentine are of some service, 
 and bromides in large doses control the crises in some instances, and 
 an emetic may cut short the seizures, and for prompt action apo- 
 morphine (grain ^V) injected under the skin is used. In the second 
 part of the work, under the special types, the details of treatment in 
 these cases will be given. 
 
 The etiological conditions shape the course of treatment very 
 largely in mental disorders. The general systemic morbid states, 
 out of which spring the various toxic and diathetic insanities, usually 
 afford the most direct indications for treatment. 
 
 The prime object is the elimination of the poison from the sys- 
 tem through the bowels, kidneys, and skin, and hence cathartics, di- 
 uretics, and sudorifics come into use in recent cases. Acute alcoholic 
 mania, breaking out during a drinking bout, the writer has found, 
 benefited by the Turkish bath, with copious draughts of water, 
 acidulated with dilute phosphoric acid, and followed by the use of 
 strychnia, and a combination of bromides and chloral as a hypnotic. 
 
THE TREATMENT OF INSANITY. 397 
 
 There are certain remedies, as in saturnism, whicli also assist in the 
 elimination of the toxic agent, and still another class of direct anti- 
 dotal nature which should be promptly administered. Unfortunately 
 the toxic insanities are often not early symptoms of the action of the 
 poison, and organic lesions may result in muscular and nervous tis- 
 sues before the case comes under treatment. In the latter instance 
 time is essential to a cure, which is to be perseveringly sought with 
 electricity systematically used for the atrophied muscles, and mild 
 tonics, a generous regimen, and the avoidance of powerful drugs, 
 which the damaged nervous centres ill support. 
 
 Arsenicism, with resulting multiple neuritis, will be found tedious 
 of treatment, and mental disorder from plumbism has a chronic 
 course in many cases, but treatment is to be pursued even after de- 
 mentia is fully developed, as partial recovery is still possible. 
 
 The diathetic etiology of Insanity also furnishes indications of 
 treatment which call into use the whole armamentarium of drugs. 
 Here again the diathesis, rather than the resulting symptom of 
 mental disorder, is to be treated, and if the former is relieved the 
 latter usually disappears; except in those instances in which one ia 
 the vicarious or larval representative of the other. Thus, in malarious 
 Insanity, the usual remedies are directed against the paludal diathesis, 
 but if the mental disorder appears without the intermittent fever, in 
 one known to have suffered much from the malaria, the conclusion is 
 that the mental disorder is vicarious of the fever, and the correctness 
 of the theory is proved by the readings with which the Insanity 
 yields to the use of quinine. Likewise gouty and rheumatic Insanity 
 suggest appropriate remedies for the systemic rather than the mejital 
 trouble, and myxoedematous Insanity is met with the modern specific 
 in form of thyroid extracts. 
 
 In the tubercular diathesis the contagionist theory has not yet 
 impressed medical officers of hospitals so far as to lead to isolation 
 in treatment of the insane. The customary drugs are not well borne 
 by the tuberculous insane, and apart from stimulants, cod-liver oil and 
 quinine, the treatment best adapted is the open-air cure, with gentle 
 exercise and prolonged hours of sleep. Vicarious phases of the 
 pulmonary and mental symptoms are often very marked, and almost 
 discourage treatment. Thus in some cases successful attempts to 
 limit the pulmonary disease are followed by aggravation of the men- 
 tal symptoms, and upon a new invasion of pulmonary tissue the 
 mental disorder temporarily ceases. 
 
398 TEXT-BOOK ON MENTAL DISEASES. 
 
 There is a distinct ansemic diathesis giving rise to Insanity, and 
 calling for not only ferruginous remedies, but also arsenic, cod-liver 
 oil, the most concentrated nourishment and peptonized foods, as both 
 primary digestion and secondary assimilation are impaired. 
 
 Alienation of mind arising in the post-febrile diathesis usually 
 presents a variety of sequels for treatment, such as renal and cardiac 
 disorder, muscular atrophy, and diseases of the organs of special 
 sense. The visual and aural disorders require active attention as a 
 source of hallucinations and delusions, to be removed if possible by 
 local treatment. The sequel of deafness in scarlet fever may cause 
 permanent arrest of mental development if special educational 
 methods are not employed. 
 
 But there are pathological as well as etiological conditions on 
 which is to be based the treatment of mental disorders. 
 
 The insanities wdth organic lesions of cerebral centres have special 
 indications for treatment. Traumatic affections of the head often 
 demand direct surgical interference for the ablation of depressed 
 bone. Foreign bodies or growths in other parts of the nervous sys- 
 tem, acting as centres of peripheral irritation, may demand removal. 
 
 Syphilitic gummata and other cerebral lesions of luetic origin 
 call for active specifi.c treatment. 
 
 The various forms of coarse brain disease, which give rise to 
 organic dementia, are not without indications for treatment. The 
 paralyzed limbs and secondary degeneration of muscles are best 
 treated by massage and electricity. 
 
 The diffused cerebral lesions of delirium acutum prove fatal in 
 a few days if active treatment is not forthcoming. Isolation in a 
 darkened room, forced alimentation, and sustaining measures, the 
 reduction of temperature by tepid baths, the procuring of sleep, and 
 the control of motor excitement by hyoscin, stimulants, especially in 
 those cases of alcoholic origin, judiciously employed, are in the main 
 the remedial measures. 
 
 The above are the chief general indications for treatment of In- 
 sanity as based on diagnostic conclusions and etiological and patho- 
 logical conditions, and attention wiU next be directed to the special 
 uses of drugs in mental disorders. 
 
 Section VI. — Pharmaceutic Remedies. 
 
 It is thought best to consider the uses of pharmaceutic remedies 
 in their application to the symptomatic treatment of Insanity under 
 
THE TREATMENT OF INSANITY. 399 
 
 one heading. The classification of remedies here adopted is not ex- 
 haustive, but it embraces all the chief drugs employed in psychiatry. 
 The therapy of the separate types of Insanity will be described in the 
 second part of the work, but it is the intention in this section to dis- 
 play the entire therapeutic armamentarium which the physician has 
 at his command to combat the symptoms of mental disorders. 
 
 The same drug, like opium for instance, may be stimulant or sed- 
 ative, according to the dose in which it is given, and hence it may 
 appear under more than one heading, according to the purpose for 
 which it is administered. 
 
 Hypnotics. — First on the list of pharmaceutic remedies are those 
 which relieve insomnia, known to be the most constant and one of the 
 most urgent symptoms of mental disorder. 
 
 Chloral. — This is as sure in its hypnotic effects as any drug used 
 in the treatment of mental diseases. It is not an anodyne, and if pain 
 be the cause 'of the insomnia it must be combined with opium in some 
 of its forms. 
 
 Chloral hydrate is given in doses of from ten to twenty grains, 
 largely diluted for internal use, or it may be used in an injection, 
 which will be expelled from the rectum if not retained by compress. 
 
 On account of its disagreeable taste some patients will not swal- 
 low a second dose of it, and it may be necessary to give it in milk by 
 the feeding-tube or in an enema as mentioned. Acacia and high- 
 flavored syrups help to mask the taste. 
 
 A full dose of chloral in maniacal insomnia is usually followed 
 by four or five hours of refreshing sleep. 
 
 The drug loses its efficacy by repetition, and larger doses become 
 necessary. 
 
 The long-continued use of the drug causes an eruption, vascular 
 paresis, and heart-failure, digestive disiturbances, and vasomotor dis- 
 orders. 
 
 Chloral is not to be given in cases with atheromatous disease of 
 the aorta, fatty heart, or cardiac valvular lesions. 
 
 Chloral is especially effective in acute hallucinatory excitement, 
 and when combined with morphia (chloral, grain 10; morphine, 
 grain -J), its effect is much heightened. 
 
 Bromides. — The bromides of potassium, sodium, and ammonium 
 are chiefly used, and they tend to produce sleep by lowering reflex 
 excitability and diminishing cortical activity in mental disorders. 
 
 Bromide of sodium is better tolerated by the stomach, and is to 
 
400 TEXT-BOOK ON MENTAL DISEASES. 
 
 be preferably employed as a soporific, though in an occasional case 
 bromide of potassium seems to act more effectually. Either of them 
 may be given in doses from one-half drachm to a drachm, though 
 twenty grains at first may cause sleep. 
 
 The bromides in general are more adapted as hypnotics in states 
 of excitement than in states of depression, and they are especially 
 useful in insomnia from parsesthetic states and tactile illusions, and 
 hypnotic hallucinations, and in the wakeful conditions in alcoholic 
 and neurasthenic eases with subsultus tendinum and frightful dreams, 
 out of which the patient awakens suddenly every few moments. In 
 patients with evident cerebral congestion ergot may be combined 
 with the bromides, and in acute melancholia cannabis indiea is some- 
 times given with the bromides to good advantage. 
 
 Anmesia, stupor, emaciation, fetid breath, and other symptoms 
 follow the excessive use of the bromides. On the other band, the 
 patient does not form a habit, as in the use of other hypnotics. 
 
 The anaemic diathesis is a contra-indication for the bromides. 
 
 Hydrobromic acid is too irritant to the stomach to take the 
 place of the bromides of potassium and sodium. It has been used 
 largely diluted in half-drachm to one drachm doses to procure sleep. 
 
 Opium. — Insomnia due to psychical or physical pain is relieved 
 most completely by opium. In phthisical Insanity, with cough and 
 pain, it is effectual as a soporific. In states of acute mental depression 
 it relieves agrypnia and soothes the emotional irritability. It may 
 be given in mental disorders associated with cardiac disease in which 
 other hypnotics are contra-indicated. 
 
 The objections to its use are the readiness with which the opium- 
 habit is contracted, the constipation and impairment of digestion 
 which it causes, and the rapid tolerance of the drug, which requires 
 to be given in constantly increasing doses. 
 
 Opium deodoratum may be given in doses of one-half to one 
 grain. 
 
 Tinctura opii deodorata the writer has for many years found 
 to be one of the most eligible preparations in hypnotic doses from 
 twenty to forty minims. 
 
 Morphine has largely supplanted other preparations of opium 
 in the treatme^nt of mental disease, as it has a uniform strength and 
 readiness of administration by the hypodermic syringe. 
 
 Sulphate of morphine, by the mouth, may be given in one-eighth 
 or one-quarter grain doses in women, and in still larger doses in 
 
THE TREATMENT OF INSANITY. 401 
 
 men. It is less apt to cause gastric disorder when used subcutane- 
 ously, but even then nausea is an occasional result and it may be in 
 part prevented by the use of bromide of potassium, and strong coffee 
 relieves the depression. The hypodermic use of morphine is not 
 without decided danger, and a first dose given subcutaneously should 
 not exceed grain ^, on account of idiosyncrasy, which may exist. 
 
 The indications and contra-indications for morphine are, in the 
 main, the same as for opium, but the morphine-habit is more readily 
 contracted. 
 
 Paraldehyde. — This is a prompt and valuable hypnotic in doses 
 of one-half drachm to two drachms. It is best given in high-flavored 
 syrup, or in wine, or in powdered sugar, just after a teaspoonful of 
 clear whiskey has been swallowed, or in salad-oil flavored with vola- 
 tile oil. 
 
 Xothing fully masks the disagreeable taste, and the odor of the 
 breath and of the stools is the greatest objection to the continuous 
 use of the drug, which becomes a positive affliction to some sensitive 
 patients. 
 
 It procures sleep in from five to ten minutes ordinarily. It is 
 to be avoided in phthsical cases. It may be given in enema, but 
 when administered per rectum the dose must be nearly doubled. It 
 has few dangerous effects, but in large and prolonged doses it may 
 become toxic and give rise to tremor and stupor. 
 
 SulpJwnal. — The dose of this hypnotic is from twenty to forty 
 grains. It is practically insoluble in cold water and is without odor. 
 It is dissolved in twenty parts of hot water, and it may be given 
 in hot tea, soup, or milk. The drug may be shaken up in a little 
 syrup and water and swallowed and the warm soup then taken to 
 efl'eet solution in the stomach, or a dose may be dissolved in eight 
 ounces of hot water, which is to be taken before it cools. Sulphonal 
 in solution acts in about twenty minutes, but sleep is sometimes 
 delayed for hours, and this is one of the uncertainties of the drug, 
 which, given in repeated doses, has a cumulative effect which may 
 be dangerous. The writer has used it in many forms of Insanity, 
 but can only commend it in strong maniacal patients. In large and 
 prolonged doses it produces diarrhoea, vertigo, ataxic symptoms, 
 and hffimatoporphyrinuria. 
 
 Sulphonal has the advantage that tolerance is seldom created 
 by continued use, and that a sulphonal-habit is extremely rare. 
 
 Amylene Hydrate. — This hypnotic may be given in beer, or in 
 26 
 
402 TEXT-BOOK OlS" MENTAL DISEASES. 
 
 mucilaginous solution diluted very greatly, in doses from ten to tliirty 
 minims. It may also be used per rectum in a mucilaginous enema 
 diluted twenty times. 
 
 It sometimes disturbs digestion, and it is not as reliable as sopo- 
 rifics already named, though less disagreeable than some of them 
 in its effects. 
 
 Urefhane. — This is said to be a safe hypnotic in doses of thirty 
 grains, to be repeated if need be, and administered in aromatic 
 syrup to cover the saUne taste. It is represented as free from disa- 
 greeable after effects. The writer has had no experience in the use 
 of the drag, which is recommended -as being free from depressant 
 results and adapted for use among children in ten-grain doses. 
 
 Trional and Tetronal. — These drugs are closely allied to sul- 
 phonal and have a similar physiological effect, and about the same 
 soporific value. They are not free from toxic tendencies and are to 
 be employed with caution. 
 
 Trional or tetronal may be given in doses of from ten to tliirty 
 grains in hot soup, tea, or whiskey. 
 
 8omnal. — ^In doses of from twenty to thirty minims, given in 
 flavored syrups, the drug produces several hours' deep sleep, followed 
 by lassitude in some cases. It is still on trial as a new drug. 
 
 Methylal. — This drug has been experimented with by various ob- 
 servers, and is said to be a decided hypnotic in doses from one to 
 three drachms. It has also been given hypodermically, but it does 
 not seem to have come into use, and it is expensive and probably less 
 reliable than many other remedies already known. 
 
 Hypnone, chloralimide, piscidia erythrina, chloralose, duboi- 
 sine, hypnal, ural, and other modern hypnotics do well in an occa- 
 sional case, but they are not to be compared in reliability to those 
 established drugs already mentioned. 
 
 Sulphate of duboisine is nearly the same thing as hyoscine, but 
 there is no reason in its substitution for the latter drug. It is given 
 hypodermically in grain -ji^-, as a hypnatic, and it is safe to begin 
 with grain j^-. 
 
 Hyoscine. — This powerful alkaloid of hyoscyamus must be used 
 with great caution. It is a sure hypnotic in the great majority of 
 violent maniacal cases in doses of from grain y^^ to grain ^, hypo- 
 dermically administered, and it produces sleep usually within one- 
 quarter of an hour when thus given. By the mouth it may be given 
 in one-third larger dose, but it has a dangerous cumulative tendency 
 
THE TREATMENT OF INSANITY. 403 
 
 in some instances. It is very widely used in psyeMatry, and, being 
 without taste and very effective in minute doses, it is more conven- 
 ient in administration than any other drug of like power. There is 
 something more than an idiosyncrasy as regards its use in mental 
 disorders, for there are numerous patients who suffer from its effects 
 even in small repeated doses. 
 
 In strong and muscular maniacs there is no other remedy which 
 so effectually subdues motor excitement and produces quiet slumber 
 in the brief space of a few minutes. In a word, it is a sure hypnotic, 
 powerful for good or evil, and never to be used in feebly constituted 
 patients, and not to be administered hypodermatically except by the 
 physician himself. Merck's preparation of hyoscine is considered 
 reliable, and no uncertain article should be used. 
 
 The officinal drug is Hyoscinse Hydrobromas (IT. S.). 
 
 Eyoscyamine. — This drug is like the foregoing in most of its 
 effects, but it is less decidedly soporific, and it may be given in 
 larger doses. 
 
 Subcutaneously, it is well to begin with grain -g-V as a hypnotic. 
 Its effect is heightened greatly when combined with small doses of 
 morphine. 
 
 Cannabis Indica. — This drug was formerly used much more than 
 at the present day as a soporific. 
 
 Extractum Cannabis Indicse is given in doses of grain i to -|, 
 the fluid extract from ten to twenty minims, and the tincture in one- 
 half drachm to one drachm doses. 
 
 It is very important to procure a reliable preparation, otherwise 
 constant disappointment will result. 
 
 Cannabinon, a resinoid from Indian hemp, has also been em- 
 ployed in doses of one grain as a hypnotic. It is best to begin with 
 small doses in all instances. 
 
 In senile and alcoholic cases and in certain cases of melancholia 
 cannabis indica acts favorably. 
 
 The chief objection is that it is impossible to predicate the action 
 of the drug in any given case, and the first use of the remedy must 
 therefore be experimental. 
 
 When combined with bromides, cannabis indica becomes a much 
 more uniformly reliable hypnotic. 
 
 Anodynes. — ^In psychiatric practice there is constant need of 
 remedies which relieve physical pain and distressing sensations due 
 to anomalies of the sensory nervous system. 
 
404 TEXT-BOOK ON MENTAL DISEASES. 
 
 Psychical pain also is a prominent symptom, and there are cer- 
 tain drugs which dull the keen edge of suffering and distinctly mod- 
 ify the prevailing emotional tone. 
 
 Under this head of anodynes, therefore, is described the appli- 
 cation of pharmaceutic remedies used in mental disease to relieve 
 physical or psychical pain. 
 
 Antipyrine. — This drug, in doses of from five to twenty grains, 
 has a wide application in the treatment of the neuralgic symptoms 
 which are so prominent in many forms of Insanity. 
 
 The lancinating pains in paretic, tabetic, and certain alcoholic 
 eases are well controlled by antipyrine, which is also useful in the 
 neuralgic pains of the joints and muscles in rheumatic and podagrous 
 Insanity. 
 
 Many melancholiacs, tormented with neuralgic pains about the 
 head, face, and neck, and which often furnish the material for delu- 
 sions of persecution, are relieved by the judicious use of antipyrine 
 as an analgesic. 
 
 Peripheral parsesthesise, which are the persistent source of hallu- 
 cinations and delusions, are in some cases temporarily abolished 
 by the remedy. 
 
 The constant peripheral neuralgias of neurasthenic Insanity oc- 
 casionally yield to small and repeated doses of antipyrine. 
 
 The severe migraine of the generative types of mental disorder 
 is sometimes checked by the drug. 
 
 Antipyrine is best given in the smallest dose which will prove 
 effective, and it has frequent disagreeable results. 
 
 Bromides. — The painful paresthetic states in climacteric Insan- 
 ity are best controlled by the bromides. The occipital boring pain, 
 which is a reflex of uterine origin, so common in these cases, yields 
 to this drug. 
 
 The distressing pharyngeal and laryngeal parassthesia, which is 
 the source in hypochondriacal melancholia of the delusion of foreign 
 bodies lodged in the throat, may be relieved by the bromides in some 
 instances. Distressing paroxysmal cough in hysterical Insanity from 
 laryngeal hypersesthesia is also checked by the bromides. 
 
 In depressed cases at the menopause, when bromides are given 
 to relieve cutaneous paraesthesia}, they should be combined with 
 citrate of caffeine. In tabetic and paretic cases the distress of larjm- 
 geal crises may be mitigated by the bromides. 
 
 CHmacteric melancholia agitata presents a restless variety, which, 
 
THE TREATMENT OF INSANITY. 405 
 
 like some other states of psychical pain, is favorably modified by the 
 bromides. 
 
 Even in states of depression the bromides may occasionally be 
 employed with stimulants to correct their depressant action. 
 
 Opium. — The anodyne action of opium, as a modifier of psychal- 
 gia, has led to the opium treatment of melancholia. 
 
 Small and continued doses of the drug are given for weeks to- 
 gether to modify the emotional tone. The mental distress is greatly^ 
 mitigated and the attack apparently abridged in some cases, which 
 go on to complete convalescence under the influence of the remedy. 
 
 The chief objection to this procedure is the risk of the formation, 
 of an opium-habit. 
 
 Morphine is not employed for the purpose just mentioned, but 
 it is given hypodermically to control the precordial panic of melan- 
 cholic cases manifesting this culmination of mental and physical 
 suffering. 
 
 Painful hallucinations in exhausted states of mental disorders, 
 are in some cases checked by opium. 
 
 Painful sensory disturbances of pneumqgastric origin, to which 
 the writer has called special attention, are often relieved by opium. 
 
 The cardiac crises, in ataxic cases, which take a dyspnoeal form,, 
 are alleviated by morphine subcutaneously given. The deodorized 
 preparations of opium disturb the stomach less and should be pre- 
 ferred. 
 
 Cannabis Indica. — This drug has several anodyne applications 
 in the treatment of mental disorders. 
 
 In exceptional instances psychical pain in melanchoKa is remark- 
 ably alleviated by cannabis indica in small and repeated doses, but 
 it is also to be stated that nothing but a trial will decide in what 
 cases it will act thus favorably. 
 
 In painful forms of hemicrania cannabis indica is of value, and 
 in headaches arising from uterine reflex channels in climacteric 
 cases it is often an efficient remedy. 
 
 There is no danger, among Anglo-Saxons, at least, of a drug- 
 habit from the continued use of cannabis, though in oriental coun- 
 tries eannabism is the cause of a considerable percentage of all cases 
 of Insanity. 
 
 Spiritus Athens Compositus. — In the precordial anxiety of 
 senile and feeble cases one drachm of this anodyne mixture repeated 
 as occasion may require gives marked relief. 
 
406 TEXT-BOOK ON MENTAL DISEASES. 
 
 In the painful pseudo-angina pectoris, which, as a symptom of 
 pneumogastric disorder, is very common in melancholic conditions 
 and is mist-aken for precordial panic, this remedy is specially effi- 
 cient and does equally well to relieve cardiac distress in Insanity 
 from nicotinism. 
 
 Depresso-motoes. — Incessant motor excitement in mental dis- 
 ease is a common symptom, which calls for a remedy, for in maniacal 
 states, especially, the patient becomes exhausted by constant violent 
 action. 
 
 In patients who are wearing themselves out by uncontrollable 
 exertions, depresso-motors are occasionally of great service. When 
 restrained by the hands of attendants, such patients may exhaust 
 both themselves and the nurses, and resist so desperately as to be- 
 come covered with bruises and finally sink into a dangerous state 
 of collapse. Chemical restraint in certain cases is a less evil than 
 restraint by the hands of nurses. 
 
 Conium. — This is a powerful drug, and in controlling motor 
 excitement it is best to begin its use by small doses, on account of 
 the uncertain strength of many of the preparations in the market. 
 
 Extractum conii may be given in one-half grain doses, tind the 
 fluid extract in four-minim doses, increased until the physiological 
 effect is obtained, or until the motor excitement partially subsides. 
 The physician must watch the effect of the drug and promptly sus- 
 pend its use at the right point, and if the effects are excessive, re- 
 course must be had to cardiac stimulants or to strychnine subcutane- 
 ously employed. 
 
 Gelsemium. — In powerful and persistently violent and destruc- 
 tive men, who brook no control by the hands of nurses, this drug 
 may be employed to prevent the muscular expenditure of energy, 
 and to control the dangerous actions of the patient. 
 
 Extractum Grelsemii Fid. (U. S.) may be given in five-minim 
 doses, or the tincture in ten-minim doses. It is best to begin with 
 small doses, and to carefully observe the action of the drug, which 
 is too powerful to use in any but very strong patients. 
 
 Veratrum Viride. — In maniacal men, whose muscular strength 
 renders manual control impossible without a dangerous amount of 
 force brought to bear upon the patient, this drug exerts a less harm- 
 ful control of motor waste of nervous energies than the prolonged 
 and desperate struggle between patient and nurses. It is so pow- 
 erful that it must be closely observed and the dose gradually in- 
 
THE TKEATMENT OF INSANITY. 407 
 
 creased during its employment on different occasions in the same 
 patient. 
 
 Tinctura Veratri Viridis (U. S.) may be used in doses of two 
 minims, to be increased as the occasion demands. 
 
 In puerperal mania it may be indicated as a remedy for the 
 eclamptic seizures. 
 
 TJie Bromides. — In the blind motor violence of epileptics large 
 doses of the bromides are indicated. 
 
 The motor explosions often occur in a definite relation to the 
 seizure, and they are to be anticipated by full doses of the bromides, 
 which thus obviate much dangerous activity and conserve the 
 strength of the patient and avoid serious accidents. 
 
 The " anxietas tibiarum " and aimless rushing about in climac- 
 teric melancholia is well controlled by the bromides. 
 
 Vasculae Sedatives. — There are occasional indications in men- 
 tal disorder for remedies which control cardiac and vasomotor ac- 
 tivity, and lower the intra-arterial blood-pressure. 
 
 Aconitum. — ^In sthenic maniacal cases, with bounding pulse, 
 strongly pulsating carotids and evident signs of cerebral hyperaemia, 
 the judicious employment of aconite may be of great benefit. 
 
 Tincture of Aconite (U. S.) should be given, one drop hourly, 
 until some vascular sedative effect has been produced. 
 
 In the maniacal outbreaks during acute infectious diseases it 
 also has some useful applications. 
 
 In chronic maniacal states with cardiac hypertrophy and con- 
 tinued violent cardiac action the drug may be used advantageously, 
 unless the cardiac enlargement be compensatory of renal disease 
 or other organic obstruction. 
 
 Aconite should never be employed in asthenic cases, and always 
 demands watchfulness in its administration. 
 
 Antimony. — Tartar emetic was formerly in general use in psychi- 
 atric practice, but other remedies, of which some are less effectual, 
 have supplanted it. 
 
 It is a valuable vascular sedative in maniacal excitement imme- 
 diately associated with intercurrent inflammatory affections. 
 
 In prolonged states of vascular and cerebral excitement it modi- 
 fies most favorably the general condition of perturbation, restoring 
 quietude in a brief state of time, and, if then followed immediately 
 by a hypodermic injection of morphine, the patient may remain 
 composed for a day or two. 
 
408 TEXT-BOOK ON MENTAL DISEASES. 
 
 Pilocarpus. — Insanity with Bright's disease of the kidneys af- 
 fords an opportunity for pilocarpine, which lowers the blood-press- 
 ure, and relieves the renal troubles and assists in the elimination of 
 urea. 
 
 In phthisical Insanity it may be used instead of atropine for the 
 relief of night-sweats. It has been recommended in cretenoid In- 
 sanity on account of its action on the skin. It is apt to have de- 
 pressant effects and it is best employed hypodermatically in the form 
 of the alkaloid pilocarpine f roni grain gV *o grain ^■^. 
 
 Vascular Stimulants. — As all acute forms of mental disease 
 tend to exhaustion and to failure of cardiac action, there is a positive 
 necessity in psychiatry for vascular stimulants. 
 
 Digitalis. — In ordinary medicinal doses digitalis is a cardiac 
 stimulant, but in larger and toxic doses it is productive of cardiac 
 stasis in diastole. The customary use of the drug increases both 
 the volume and the force of the pulse-wave. 
 
 In asthenic cases of mania, tending to dangerous exhaustion, dig- 
 italis as a cardiac stimulant is a valuable remedy, which always, in 
 conjunction with generous and, if need be, forced alimentation, hast- 
 ens a return of strength and of equalized circulation. 
 
 The asthenic maniacs here mentioned have pallid faces, dilated 
 pupils, and evidently cerebral anaemia, and, after they have been fed 
 with milk, eggs, and one ounce of whiskey, they should be given ten 
 drops of the tincture of digitalis every hour until there is some in- 
 crease in the force of the heart's action. After the third dose, or 
 sooner, if a favomble reaction in the circulation occurs, it is well 
 to suspend the medication for the day and continue artificial nour- 
 ishment if the patient does not take food freely. Under this treat- 
 ment, as a larger supply of blood is sent through the brain, the 
 change for the better is sometimes very rapid. 
 
 In many forms of mental disorder associated with cardiac dis- 
 ease, as a cause or concomitant, digitalis is a palliative, and it has 
 its special application also in Insanity with renal disease. In ex- 
 haustion from acute mental disease it can be combined with alco- 
 holic stimulants to good advantage in all cases where there is not 
 aortic aneurism, focal brain disease, or like contra-indication in vas- 
 cular degenerations. 
 
 Alcohol. — By the term alcoholic stimulants whiskey or brandy 
 is designated, unless some other specification is made. A good old 
 whiskey is the best form of alcohol for medicinal use in mental dis- 
 
THE TEEATMENT OF INSANITY. 409 
 
 orders. Sufficient care is not taken to employ a standard brand of 
 whiskey of definite strength. It is as important to know the per- 
 centage of alcohol in the whiskey used as to know the strength of 
 any other drug. The tendency is to give too large doses of whiskey 
 used as a vascular stimulant in mental disorders. No alcoholic stim- 
 ulant should ever be given in Insanity on the vague general idea that 
 it is strengthening and nourishing, and not one drop of alcohol in 
 any form should be administered in mental disorders except to fulfil 
 definite therapeutic indications. The best stimulant in maniacal 
 exhaustion is concentrated nourishment. Alcohol is apt to interfere 
 with digestion, which is already impaired in acute cases of Insanity, 
 and it is best given in milk, and only at times when the stomach is 
 not digesting solid food. 
 
 In acute exhaustion from mental disease alcohol may be employed 
 to stimulate cardiac action when there are signs of impaired circu- 
 lation. It causes the heart to act with greater force and frequency, 
 and by stimulation of the vasomotor system it brings about increased 
 arterial tension, which is readily demonstrated by the character of 
 the sphygmographic tracings. To procure any prolonged benefit 
 from the agent as a vascular stimulant it should be given in small 
 and repeated doses once in two hours, or more frequently if the 
 emergency demands it. . Some patients convert and eliminate the 
 ingested alcohol much more rapidly than others. In melancholic 
 exhaustion, when taken in amounts larger than are converted in 
 the system by oxidation, it is eliminated chiefly by the lungs and kid- 
 neys, but in maniacal cases it is also partly excreted by the skin 
 and intestines, and the latter ordinarily bear larger doses than the 
 former without digestive disturbance. It is a mistake to mix alco- 
 holic stimulants with predigested foods. 
 
 If an emergency demands immediate vascular stimulation, 
 brandy or whiskey must be given hypodermatically, and in hot 
 drinks they act more promptly than in cold. It is not well to mix 
 the forms of alcohohc stimulants in the same case in close succes- 
 sion. The insane very readily contract an alcohol-habit. 
 
 The cases of Insanity in which more than four ounces a day of 
 whiskey are to be given are very rare, and in very large doses alcohol 
 becomes a vascular depressant rather than a stimulant. Alcohol is 
 contra-indicated in most inflammatory affections. 
 
 Caffeine. — This is a very convenient vascular stimulant in as- 
 thenic and depressed forms of mental disease. It not only stimulates 
 
410 TEXT-BOOK ON MENTAL DISEASES. 
 
 the heart's action, but it relieves the " sinking feeling " common in 
 melancholia and referable to epigastric regions, and which is, in fact 
 due to defect of pneumogastric innervation. 
 
 Caffeine is also valuable in mental disorder associated with car- 
 diac disease, and it is borne in some cases better than digitalis, 
 though it has not the permanent effects of the latter drug. In the 
 neuralgias which prevail in so many forms of mental depression it is 
 effective combined with antipyrine. 
 
 It is through its vascular stimulant effect, probably, that it re- 
 lieves the giddiness, which is a troublesome symptom in many forms 
 of mental depression. An average dose of calteine (U. S.) or of caf- 
 feine citrate is three grains. The popular preparation of effervescent 
 citrate of caffeine may be given in three-drachm doses. 
 
 Caffeine should not be given in the evening, as it produces wake- 
 fulness. 
 
 Ergota (U. S.). — Ergot is classed among the vascular stimulants, 
 not so much on account of its influence on the heart as upon the 
 vasomotor centres, which, stimulated by the drug, cause contraction 
 of the arterioles. 
 
 In maniacal conditions of cerebral congestion the vasomotor 
 stimulation by ergot effects vascular contraction and relief of cere- 
 bral hypersemia, and for this purpose it may be combined to advan- 
 tage with the bromides as hypnotics at night, and the ergot is to be 
 given in divided doses every two hours during the day-time. 
 
 In climacteric Insanity, with troublesome menorrhagia, and in 
 the night-sweats of phthisical Insanity, it fulfils certain indications. 
 
 In cephalalgia of the congestive type, so common in general 
 paresis, and in some other forms, ergot gives relief, and it is also 
 useful in the congestive vertigo often encountered in psychiatric 
 practice. 
 
 The fluid extract is an ehgible form of the drug, but ergotin 
 had better be given subcutaneously where a prompt action of the 
 drug is indicated. 
 
 Belladonna. — In toxic Insanity, especially following the abuse 
 of opium, belladonna is a useful vascular stimulant in the exhausted 
 states often bordering on collapse. 
 
 It is both a cardiac and vasomotor stimulant. It is a useful 
 substitute for morphia in many of the neuralgic affections in neuras- 
 thenic cases, and it also has its uses in epileptic cases combined with 
 the bromides. As a vascular stimulant in primary dementia from 
 
THE TREATMENT OF INSANITY. 411 
 
 emotional shock and in melanoholia attonita it relieves the capillary 
 stasis by vasomotor stimulation. 
 
 The tendency to syncopal attacks in post-febrile Insanity is best 
 met by prompt stimulant doses of atropine. 
 
 Nervous Sedatives. — There is a frequent need of nervous seda- 
 tives which stop short of actual hypnotic effect in mental disorders. 
 The hypnotic use of certain drugs here mentioned has already been 
 considered under another heading. 
 
 Opium. — As a nervous sedative opium is the most useful drug 
 to combat the distressing anxiety, which is such a prominent symp- 
 tom in most acute forms of mental depression. It is to be given in 
 small and repeated doses to relieve acute mental suffering, and in 
 large doses to meet the emergency of precordial panic and of fright- 
 ful states of hallucinatory aberration. 
 
 The restless perturbation of senile cases is relieved by it, and 
 the exacerbations in the depressed type of general paresis are best 
 treated by it. 
 
 In maniacal excitement it has a less general application, but 
 there are cases free from cerebral hyperasmia in which it is a most 
 effective nervous sedative, and it may be used with special success 
 in exhausted patients in whom the psychomotor activity is extreme. 
 
 Opium may also be effectually employed to abridge one of the 
 cycles in periodical Insanity, by full doses on the first appearance of 
 the acute symptoms of mental depression, and in the same way the 
 melancholic exacerbations of climacteric melancholia of a periodical 
 nature may be anticipated, as they usually correspond to the dates 
 of the menstrual mohmen. 
 
 In the painful state of mind of subacute melancholia, opium, 
 more favorably than any other drug, modifies the ccengesthesis, which 
 is the organic basis of the depression. 
 
 In alcoholic mania with active hallucinations, and in delirium 
 tremens, opium is a valuable nervous sedative. 
 
 Calabar Bean. — Some observers have claimed good results de- 
 rived from the use of this drug in the treatment of general paresis. 
 Small doses, continued daily for several months, is the mode of its 
 use in these cases. 
 
 Valerian. — The senile insane, who are restless and fidgeting at 
 all hours, may be benefited by this drug, which also relieves the 
 nervous agitation of neurasthenic cases. 
 
 Valerian is also of occasional value in hysterical Insanity, and 
 
412 TEXT-BOOK ON MENTAL DISEASES. 
 
 if used as a sedative during the seizures it must be given in large 
 doses. 
 
 Camphor Monohr ornate. — This drug may be given in emulsion in 
 doses of five grains in nervous and spasmodic conditions in choreic 
 or hysterical patients. One objection to it is that it is a gastric 
 irritant. 
 
 Lupulin. — This is a mild nervous sedative and antispasmodic, 
 which is sometimes of service in mental disease, especially in neuras- 
 thenic and hysterical cases. 
 
 Chloral. — Chloral as a nervous sedative is confined chiefly to 
 doses less than hypnotic given to control maniacal excitement. 
 Chloral is one of the best remedies to limit spasmodic seizures in 
 the " status epilepticus." When used for this purpose it is given in 
 form of suppository. 
 
 Strontium. — The bromide of strontium has some advantages 
 over the bromide of potassium, and may be used in from twenty- to 
 sixty-grain doses in the irritable epileptic cases, in nervous instabil- 
 ity of climacteric cases, in the aimless activity of senile dements, 
 and in the excitement of all forms of mental exaltation. 
 
 Nervous Stimulants. — There are in mental disorders lethargic 
 states of the nervous centres, and also certain conditions of exhaus- 
 tion in which there is need of nervous stimulants. The use of this 
 class of drugs calls for skill in diagnosis and judgment in the gTad- 
 uation of the doses given. 
 
 Nux Vomica. — The complete anergia, which follows the acute 
 stage of mental disorders, is best treated by tincture of nux vomica 
 used as a nervous stimulant in doses of five drops, given after meals, 
 and increased in some cases to treble the amount named. Certain 
 conditions of primary stupor are benefited by a like treatment. 
 
 There is a critical period at the beginning of the convalescent 
 stage, a turning point at which there is a tendency to sink into de- 
 mentia, when strychnine as a nervous stimulant is most advanta- 
 geous. 
 
 Insanity from nicotinism presents indications for relief of de- 
 pressed respiratory and circulatory nervous centres, best fulfilled by 
 strychnine used as a nervous stimulant in small and continuous 
 doses, which, in some cases, are by preference administered hypo- 
 dermatically, beginning with grain ^V of strychnise sulphatis. 
 
 In toxic Insanity from lead-poisoning strychnine is most bene- 
 ficial in addition to the appropriate eliminatives. 
 
THE TREATMENT OF INSANITY. 413 
 
 In mental disorder resulting either from psychical or surgical 
 traumatism the stimulant effects of strychnine are, if Judiciously 
 procured, of great value. 
 
 There is much tact and close watchfulness required in admin- 
 istration of nux vomica as a nervous stimulant, to stop the remedy 
 at the right point, and to graduate the dose to the case in continued 
 use of the drug. 
 
 ErytTiroxylon Coca. — In states of mental torpor and of mental de- 
 pression, as a temporary nervous stimulant, this drug is of some 
 service. It stimulates the cortical functions remarkably, and it may 
 be employed to break the beginning of a habit of lethargy to which 
 the patient is inclined to yield in the debility of mind following all 
 severe attacks of mental disorder. The drug should never be con- 
 tinuously given for long periods on account of the danger of the 
 drug-habit. This same danger exists in the treatment by this drug 
 of morphinism, which is thus converted into cocainism, if the use of 
 the remedy is prolonged. 
 
 As a nervous stimulant in the general depression of post-febrile 
 Insanity, coca is a good means of temporary relief. 
 
 Anesthetics, — There are occasions for the employment of an- 
 esthetics in Insanity, though in general they have a very limited role 
 in psychiatry. 
 
 In extreme instances chloroform has been employed to control 
 the spasmodic movements in choreic Insanity, and also the seizures 
 of the status epilepticus and the serial convulsions of general paresis. 
 
 During the Insanity of child-bed the puerperal convulsions have 
 also been controlled by this anaesthetic. 
 
 It is possible to check hysterical convulsions in like manner, and, 
 by previous subcutaneous injection of morphine, to get a continued 
 sedation. 
 
 Ether. — It becomes necessary to anesthetize the insane for a 
 great variety of surgical procedures, on account of obstinate re- 
 sistance, and as a subsequent period of quietude is advantageous, 
 it is sometimes advisable to precede the anaesthetic by the hypoder- 
 matic use of morphine that sleep may succeed the narcosis. In 
 strongly resistant patients catheterization or a necessary gynecologi- 
 cal examination may require anaesthesia, and this is also the case 
 often in examination for suspected fractures, and in the differential 
 diagnosis of scrotal tumors, and for many surgical reasons. 
 
 Ether is also a valuable final resort in criminals who feign symp- 
 toms of mental disorder. 
 
414 TEXT-BOOK ON MENTAL DISEASES. 
 
 Anesthetization may also be justified in hysterical Insanity to 
 determine the real condition of tendinous and articular parts. 
 
 Ethyl Bromide. — If a pure article of this anaesthetic can certainly 
 be had;, it is recommended for purposes of brief anaesthesia on ac- 
 count of the great rapidity with which it acts, thus obviating a 
 struggle with the patient. 
 
 It has been used to overcome the violent excitement of maniacal 
 patients. The chief objection to this anesthetic is the disagreeable 
 odor of the breath and the bad taste which it leaves in the patient's 
 mouth. 
 
 Cocaine. — The employment of cocaine as a local anaesthetic has 
 too wide a range to admit of description in these pages, but a word 
 of warning is here spoken against the danger of systemic poisoning 
 from its local use in minor surgical operations. 
 
 Laxatives. — In all states of mental depression there is a diminu- 
 tion of peristalsis and a resulting constipation, for which the thera- 
 peutic remedies alone are to be here mentioned. 
 
 Rhamnus Pershiana. — This remedy, known as cascara sagrada, 
 is the most reliable laxative which can be employed in the intestinal 
 atony of melancholic patients. In laxative doses of from twenty 
 to thirty drops of the fluid extract, in aromatic syrup, it relieves the 
 bowel of its contents without any disagreeable effects. Preparations 
 agreeable relatively, and known as cordials, are now in the market, 
 but not of uniform strength. 
 
 Phosphate of Sodium. — The Sodii Phosphas (U. S.) is given in 
 drachm doses as a laxative. This dose is to be repeated until the 
 desired effect is obtained. The remedy is of value in liver com- 
 plaints, apart from its laxative quality. 
 
 Aloe Socotrina. — As a laxative this drug is best given in pill-form, 
 combined with extract of belladonna and nux vomica. 
 
 Podophyllum. — This laxative should be given with reference to 
 its special action upon the liver in melancholia, and it is also well 
 to combine it with belladonna to prevent griping. The dose of the 
 Eesinas Podophylli (U. S.) is grain j\. It is well to use small doses 
 in women, and also in men, on first trial, as some are much more 
 readily affected by it than others. 
 
 Mineral Waters. — Sometimes cases derive benefit from laxative 
 mineral waters, which are never to be given continuously as laxa- 
 tives. Appropriate waters for this purpose are Hathorn (Saratoga), 
 Hunyadi Janos, Carlsbad, Friedrichshall, and some other waters 
 
THE TREATMENT OF INSANITY. 415 
 
 bottled in this country, which, taken in the morning before break- 
 fast, usually have a laxative effect within a few hours without dis- 
 turbing the stomach or appetite. 
 
 Purgatives. — The day of continuous purgation as a derivative 
 remedy in Insanity has gone by. Nevertheless an active purge in 
 a strong and constipated maniac of plethoric habit is a most appro- 
 priate therapeutic measure, often followed by notable amelioration. 
 
 Oleum Tiglii. — This is one of the most prompt and reliable pur- 
 gatives known. It has the advantage that one drop placed on the 
 back of the tongue, with a few drops of olive-oil as a medium, will 
 cause a full watery passage from the bowel. In unconscious patients, 
 in apoplectiform conditions, in the status epilepticus, in stuporous 
 patients, and in cataleptoid states, it can be thus employed; and 
 it usually acts when large doses of other purgatives have failed to 
 produce their customary effect, owing to intestinal atony. 
 
 Hydrargyrum. — Out of respect to the traditional use of calomel 
 as a cholagogue, and because, as a matter of clinical experience, it 
 seems to clear up a foul tongue and stomach, so common in acute 
 mental disorders, it is often given with good results as a purge, com- 
 bined with bicarbonate of sodium. 
 
 Blue mass, acting more mechanically, will also, when given in 
 full doses, produce watery evacuations. 
 
 In default of due action of these remedies, it is well that they 
 be followed by a saline cathartic without delay. 
 
 Ilagnesii Sulphas. — Full-blooded maniacs, evidently suffering 
 from cerebral congestion, with red faces, suffused conjunctiva, 
 and heavily pulsating carotids, are well bled through their in- 
 testines by a concentrated solution of sulphate of magnesiumd ij.), 
 which abstracts serum the length of the primse vise, and results in 
 profuse watery stools. When this intestinal derivation of the serum 
 of the blood is not desired, the larger the amount of liquid in which 
 the drug is dissolved, the smaller need be the dose, and the quicker 
 will be the evacuation. 
 
 Elaterium. — For depletive purposes there is no surer hydragogue 
 cathartic than elaterium, which may be given in the form of the 
 neutral principle elaterin, grain -^^^ or the officinal trituration of elat- 
 erin. 
 
 ColocyntMs (U. S.) is an another well-known hydragogue cathar- 
 tic, which is given in combination with other drugs, and forms one 
 of the chief ingredients in Pil. Cathart. Co. (U. S.). 
 
416 TEXT-BOOK ON MENTAL DISEASES. 
 
 Colocynth is only to be employed occasionally for the purpose 
 mentioned, and not continuously to break a habit of constipation. 
 It is capable of producing severe gastro-intestinal irritation. The 
 extracts of colocynth and belladonna combined make a good purge. 
 
 In the use of purgatives in mental disorders there will be en- 
 countered surprising intestinal inertia, which is due to paresis of 
 the muscular coat of the intestines, or to anaesthesia of the mucous 
 membranes, and to absence of normal reflexes. 
 
 In the failure of response to strong remedies, such purgatives 
 should not be repeated, but recourse must be had to other means, 
 such as massage, electricity, and intestinal lavage. 
 
 Emetics. — Hippocrates gave emetics to limit the course of In- 
 sanity, and they have been used in all ages in the treatment of mental 
 diseases, and even within the present century they have been thus 
 ejnployed, but within the last twenty-five years they have gone com- 
 pletely out of use, except in the emergencies of mental disorders. 
 
 Purging, vomiting, and bleeding are apt to be numbered among 
 the 'heroic and mistaken remedies of the last generation, but the 
 powerful alkaloids and extracted active principles of poisons which 
 have replaced them may possibly be regarded in the same light by 
 the coming generation. There are cases of strong maniacal men, with 
 foul and overloaded stomach, much benefited by a full emetic dose 
 of ipecac, which improves the gastric condition and may restore 
 quietude for a whole day, and even result in refreshing sleep; and 
 if, as is often the case, there be laryngo-trachitis from loud shouting, 
 it will also be favorably influenced by the emetic. 
 
 The chief indication for emetics, however, in psychiatry is in 
 emergencies demanding the immediate evacuation of the stomach. 
 On such occasions the patient is often resistive in the extreme to 
 the employment of the stomach-pump or oesophageal tube, and more 
 danger and delay may attend the mechanical than the therapeutic 
 means of emptying the stomach, 
 
 Apomorpliince Hydrocliloras (U, S.), — This is the best drug for 
 emetic use, and is to be given subcutaneously, in doses from grain 
 ■jJ^ to grain -g-. Emesis is produced in a few moments without special 
 nausea, but if the doses have been large there may be some depres- 
 sion. The solution used must be fresh and reliable. 
 
 Digestives. — In most forms of acute mental disease there are 
 disorders of the digestive processes and a corresponding need of arti- 
 ficial aids to digestion. 
 
THE TREATMENT OF INSANITY. 417 
 
 The subjective symptoms of gastric indigestion may not be ob- 
 tained from the patient, but in patients requiring gastric lavage the 
 nature of the contents of the stomach can be studied, and valuable 
 information may be thus gained as to the appropriate remedy to 
 be employed in the case. 
 
 Pancreatin. — The pancreatic juice contains four ferments hav- 
 ing special digestive power, and pancreatin is supposed to represent 
 effectually at least the chief elements of the pancreatic secretion 
 in this regard. In the predigestion of foods it is the most valuable 
 of the animal extracts. For pancreatized and predigested foods in 
 general reference is made to the section on Dietetics in this chapter. 
 Pancreatin, in dose of from ten to thirty grains, should be given 
 immediately after a meal, that it may act before the gastric acids 
 are present in such quantity as to interfere with its action, or not 
 until gastric digestion is ended and the contents of the stomach are 
 passing into the intestine for further digestion. It is theoretically 
 probable that it is most efficient employed in pancreatized prepara- 
 tions of food for the insane, and especially in melancholia, in which 
 hyperchlorydria is a very constant symptom. 
 
 ' Pepsinum. — This digestive principle of the gastric juice in the 
 presence of the normal hydrochloric acid converts albuminous sub- 
 stances into peptones. 
 
 Owing to the feeble state of the gastric glandular apparatus in 
 mental disorders there is a defective supply of this digestive ferment, 
 which can be artificially furnished to good advantage in many cases. 
 
 Pepsin is best given at the time of eating, in dos^ of from fifteen 
 grains to a drachm. Pure pepsin of a reliable kind is the best form 
 to employ, and hydrochloric acid may usually be of service given 
 at the same time. Peptonized foods are also valuable. 
 
 Acidum Hydrochloricum. — When the normal hydrochloric acid 
 of the stomach is deficient the bicarbonate of sodium or alkaline 
 mineral waters taken in small quantities before meals may remedy 
 the defect, but in some insane patients the deficiency is to be sup- 
 plied artificially. 
 
 The acidum hydrochloricum dilutum (U. S.) in doses of from 
 ten to twenty minims may be given largely diluted and taken through 
 a glass tube to avoid injury to the teeth. The acid is also to be 
 combined with pepsin to aid the digestive action of the latter in 
 the stomach or in the peptonizing of foods previous to their ad- 
 ministration. 
 27 
 
418 TEXT-BOOK ON MENTAL DISEASES. 
 
 Papain.— The juice of carica papaya, or, rather, the ferment ob- 
 tained from the same, has remarkable artificial digestive properties, 
 but how far it will in the future prove itself available in the actual 
 therapy of digestive disorders remains to be seen. The dose of 
 papain is from one to ten grains, to be given in form of pills. The 
 writer has had no experience with the drug, but if it possess the 
 virtues claimed for it, it ought to be an addition of some value to 
 the rather meagre Hst of digestives at present known to be of any 
 real service. 
 
 Tonics. — The general debility which is present in many forms ' 
 of mental disorder is due to a variety of causes and calls for different 
 kinds of tonics. 
 
 During the stadium debilitatis, which follows the stadium 
 acutuni of mental disorders, there is urgent need of tonics, which 
 may even prevent the passage into chronic Insanity. 
 
 Cinchona. — The various kinds of cinchona bark, and the several 
 alkaloids which they contain, are among the best tonics for general 
 use in mental disease. 
 
 Quinine in small doses stimulates the circulation, respiration, 
 and the cerebral centres. It congests the cerebrum in full doses, 
 and is contra-indicated in inflammatory states of the brain or of its 
 membranes, or of the eye or ear. It increases tinnitus aurium 
 when the latter is not due to anaemia, and may render the aural hal- 
 lucinations more troublesome. Apart from these inconveniences 
 in psychiatry, it is one of the best tonics, and is conveniently given 
 in soluble capsules, that it may act while in the stomach, as it is 
 usually ineflB.cient in the intestines. 
 
 Quinine is not only a bitter tonic, but it also has haematinic qual- 
 ities. 
 
 When patients get delusions about its extreme bitter taste, which 
 may not always be hidden even by capsules, which they sometimes 
 bite upon, it may be used hypodermically in form of the bisulphate 
 of quinine with the addition of tartaric acid, one part to six of the 
 drug, or five grains of the hydrochlorate of quinine with a half 
 drachm each of glycerine and distilled water, may be injected in 
 gluteal regions, or an enema may be used, though rectal irritation 
 will result from repetitions of this mode of administration. 
 
 The tannate of quinine, though tasteless, is much less efficient 
 than other preparations. 
 
 In large hospitals, as a matter of economy, some of the other 
 
THE TREATMENT OP INSANITY. 419 
 
 alkaloids of cinchona may be employed, such as cinchonidine, qiiin- 
 idine, or chinoidiniim. Sulphate of cinchonidine is an eligible prep- 
 aration, according to some authorities. 
 
 Tinctura cinchona composita (D. S.) is an old and reliable tonic 
 mixture, and of this Huxam's tincture is a most agreeable preparation. 
 
 Strychnine. — As a remedy in the types of mental disorder of 
 toxic origin strychnine may almost be called a specific tonic. In 
 the alcoholic form of toxic Insanity no other tonic can be compared 
 with it. In mental disease from lead-poisoning it is of the utmost 
 value. In morphinism, cocainism, chloroformism, etherism, and in 
 mental disease from addiction to other toxic agents, it is an indis- 
 pensable tonic. It is best to begin its use with grain -g^o; to be in- 
 creased until its physiological effects are obtained, and then the 
 remedy is to be discontinued, and to be renewed at the end of a 
 few days. It is contra-indicated in inflammatory affections of the 
 central or peripheral nervous system. 
 
 Acidum Arsenosum. — Arsenic, next to strychnine, is the most 
 useful tonic in Insanity. In choreic forms of mental disorder it has 
 a very special value, and in phthisical Insanity it often gives remark- 
 able relief when other remedies have failed. 
 
 In malarial mental disease it is of great value, and in all the psy- 
 choses complicated with well-marked leucocythsemia it has a very 
 special application. 
 
 Syphilitic Insanity and the chronic forms of mental disease, with 
 various cutaneous eruptions, are also types in which arsenic is a val- 
 uable tonic remedy of special utility. 
 
 Liquor Potassii Arsenitis, beginning with two-minim doses on 
 a full stomach, is the best form for administration, and the blood 
 should be tested every few days for increase of red blood-corpuscles. 
 Gastro-intestinal irritation is a sign that the remedy is to be stopped 
 for the time being, at least. 
 
 Phosphorus. — In consideration that phosphorus is a natural con- 
 stituent in osseous and nervous tissues, it would appear to be a phys- 
 iological tonic in wasting nervous diseases like the depressed forms 
 of acute mental disorder. 
 
 It certainly is a vahiable tonic, not only in melancholic types, 
 but especially in post-febrile Insanity, in the mental disorders of 
 children of rickety conformation, in the sexually exhausted insane, 
 and in the various types of neurasthenic Insanity. 
 
 In organic dementia and forms of mental aberration from focal 
 
420 TEXT-BOOK ON MENTAL DISEASES. 
 
 brain disease of a ehronic nature, phosphorus may be advantageously 
 employed, but in all acute inflammations of nervous structures it is 
 well to avoid its use. 
 
 The initial dose of phosphorus should not be more than grain 
 yJ^, to be cautiously increased. 
 
 Phosphide of zinc, in the dose of grain j^q, in pillular form, is 
 a convenient preparation. 
 
 Calumha. — This may be taken as a type of vegetable bitter tonics 
 than wliich few are better. 
 
 It is a good stomachic as well as a bitter tonic, and is usually 
 given in form of an infusion with an aromatic adjuvant. 
 
 Ferrum. — Iron is a tonic because it is a blood-food, and it should 
 not be indiscriminately used in mental disorder, and should only 
 be given for anaemia or to meet some distinct indication. 
 
 In scrofulous young persons the Syrupus Ferri lodidi is a good 
 form of the drug. Tinctura Ferri Chloridi is used in Insanity with 
 Bright's disease, and is generally one of the most reliable prepara- 
 tions of iron, but it is injurious to the teeth if not taken through a 
 glass tube. The pyrophosphate of iron is sometimes of special use 
 in angemic forms of mental depression. 
 
 Acidum Nitro-hydrocMoricum. — In melancholia and other forms 
 of mental disease, witlh chronic hepatic congestion, this acid, in 
 doses of from one to three drops, largely diluted and taken after 
 meals through a glass tube, is a most valuable gastro-hepatic stim- 
 ulant and tonic. 
 
 Alteratives. — In diathetic Insanity, and especially in that 
 w^hich springs from the luetic virus, the therapeutic treatment is 
 based largely on the use of alteratives. 
 
 Hydrargyrum. — ^In mental disorder arising after sypliilitic in- 
 fection it is safest to regard the latter as the etiological factor of the 
 disease and to treat it accordingly. 
 
 It is best not to wait for the appearance of secondary symptoms, 
 if there has been a distinct primary lesion, as the eruption of the 
 mental disorder may itself constitute the first secondary sj-mptom of 
 the specific disease. 
 
 So soon, therefore, as the diagnosis is established beyond any 
 doubt, the mercurial treatment should be commenced as the best 
 means of relief for the acute symptoms of the mental disorder. 
 
 No opinion is here expressed as to the relative merits of the 
 expectant treatment, of the mixed treatment, or of any particular 
 
THE TREATMENT OF INSANITY. 421 
 
 order in the use of mercury and the iodides in the cure of luetic dis- 
 ease in general; but the writer's experience is very decided that in 
 syphilitic Insanity, if specific remedies are to be used, they should 
 be employed so soon as the diagnosis is made with certainty as to 
 the fact of infection. 
 
 The protiodide of mercury is the best form in these cases, in- 
 creased from grain ^|- ter in die, but in urgent instances a rapid in- 
 unction-cure is indicated. 
 
 As the mental symptoms are sometimes the first to appear, so, 
 too, they are often the first to yield to the treatment mentioned, and 
 a combination of the iodide with the mercury is, in most cases, 
 advisable from the very first, together with cod-liver oil and tonics. 
 
 Insanity resulting from tertiary syphilitic disease of nervous 
 centres calls for the most decided treatment, beginning with an ac- 
 tive use of mercury and followed by large doses of the iodides. 
 
 Without regard to luetic disease, the alterative action of bi- 
 chloride of mercury in mental disease must be recognized. When 
 given in small and continued doses, the haematinic action in ansemic 
 Insanity, and in the paludal cachexia, and in mental disorder with 
 Bright's disease is remarkable.' 
 
 In traumatic Insanity the extending meningitic lesions are best 
 limited by the administration of the bichloride of mercury. 
 
 In luetic cases the hypodermic use of the bichloride, and the 
 employment of mercurial baths, as well as inunctions, play an im- 
 portant role in the antisyphilitic treatment. 
 
 Iodine. — The alterative value of this drug resides largely in its 
 stinmlant action upon tissue changes. 
 
 In exophthalmic goitre and its associated form of Insanity it has 
 been used with success, and it is the most efficient remedy for the 
 reduction of the hypertrophied gland. 
 
 In mental disorder arising from chronic phthisis pulmonahs it 
 sometimes renders good service, and the same may be said also of 
 its value in scrofulous diathetic Insanity of the young. 
 
 The Iodides of Potassium and Sodium. — The use of these drugs 
 in syphilitic Insanity has already been considered under the head 
 of mercury. 
 
 As alteratives in various cachexias they are of much service in 
 mental disease. In rheumatic Insanity the iodide of potassium 
 is of value sometimes, and in malarial Insanity with enlarged spleen, 
 and in the atheromatous vascular degenerations of both syphilitic 
 
422 TEXT-BOOK ON MENTAL DISEASES. 
 
 and alcoholic Insanity it serves a good purpose given in continuous 
 alterative doses. The gastric irritation can be largely avoided by 
 giving the drug only after meals and never upon an empty stomach. 
 In chronic maniacal conditions due to persistent subacute menin- 
 gitic affections, the iodides are often of great benefit. The patient 
 should be given a specially generous diet while under their influence 
 and should be encouraged in long hours of sleep. 
 
 Oleum Morrhuoe. — This remedy is active not on account of its 
 oleaginous material, but of its varied chemical constituents, among 
 which are iodine, phosphorus, and bromine. It may be ranked as 
 an alterative on account of its effects on general nutrition. 
 
 It is useful not only in most diathetic Insanities, but in all states 
 of malnutrition in which it can be borne by the stomach. None 
 of the elegant emulsions are as efficient as the pure oil, which may 
 be given with an equal amount of whiskey, or in strong coffee, which 
 liides the taste, or in capsules. 
 
 Morrhuol is an extractive of cod-liver oil and contains its chief 
 active principles, and it may be given in doses of from three to five 
 grains in cases in which the crude oil does not agree. 
 
 IcMhyol — Ichthyol is here recommended merely for its beneficial 
 effects in the many skin diseases which abound among the insane. 
 It is to be used topically in form of ointment, which may contain 
 from ten to twenty per cent, of the drug, or as a solution in equal 
 parts in glycerine. 
 
 Colchicum. — The only application of this drug in psychiatry is 
 in gouty Insanity, in which the remedy doubtless has a decided bene- 
 ficial influence, though it is always a powerful irritant and must 
 be used most guardedly. 
 
 Sarsaparilla. — Out of respect for the belief of thousands of 
 practitioners, it may be well to mention the supposed alterative ef- 
 fects of this drug when combined with others in the treatment, more 
 especially of specific disease. 
 
 Arsenic. — Arsenic in small and continued doses is possessed of 
 remarkable alterative effects on general tissue changes. 
 
 In the oachexias and diatheses out of which Insanity often arises, 
 it has a wide application as a modifier of faulty nutrition. 
 
 In malarial and marasmatic cases of Insanity drifting into 
 chronic states of mental enfeeblement, it sometimes works wonders 
 in both the mental and physical state, when given with cod-liver 
 oil and a generous regimen, including out-of-door life. 
 
THE TREATMENT OF INSANITY. 423 
 
 Eliminators. — The toxic origin of Insanity in a vast number of 
 cases create the need of remedies which serve to eliminate the toxic 
 agents from the system, and, for want of a better term, drugs which 
 tlius act are here classed as eliminators. 
 
 Iodide of Potassium. — In mental disorder from plumbism, hy- 
 drargyrism, or from other metallic poisoning, a part of the treatment 
 consists in the use of iodide of potassium, which forms soluble salts 
 with the toxic metals, and thus aids in their elimination from the 
 system. When employed as an eliminator in toxic Insanity, the 
 iodide of potassium should be given in large doses of from ten to 
 twenty grains, repeated three times a day. 
 
 In lead-poisoning aromatic sulphuric-acid lemonade, and sul- 
 phate of magnesium may be given, and sulphuret of potassium baths 
 administered. 
 
 Jdborandi. — In the Insanity of Bright's disease this drug is of 
 service in the elimination of the uraemic poison by its action on the 
 kidneys and the skin. It is best given in the form of its alkaloid 
 pilocarpine. 
 
 Lithium. — The carbonate and citrate of lithium are good elim- 
 inators in gouty and in diabetic Insanity in doses of from five to 
 twenty grains. 
 
 Antiperiodics. — Insanity as the result of malarial intoxication 
 is not rare. In other cases the mental disorder is a sequel of the 
 more permanent malarial cachexia with its varied changes in in- 
 ternal organs and in the vascular system. The indication is to treat 
 the malarial affection in order to relieve the mental symptoms. 
 
 Quinine. — This is the most reliable remedy in malarial Insanity. 
 
 When the paroxysms of mental excitement are vicarious of thb 
 malarial access, and have a distinct periodicity, they demand the 
 same therapeutic treatment as the malarial access itself. Quinine 
 in this form of Insanity is to be given in one large dose, so that it 
 will have its maximum effect just before, and in time to check the 
 return of the malarial access or its equivalent mental excitement. 
 
 Eucalyptus. — The writer has employed this drug with indifferent 
 success in malarial cases bearing quinine badly. Still, eucalyptus 
 and its derivative, eucalyptol, are to be named among the antiperi- 
 odics. 
 
 Warburg's Tincture. — A trial may be made of this decided anti- 
 malarial mixture in malarial Insanity. 
 
 Hare, in his " Practical Therapeutics," advises its antimalarial 
 
424 TEXT-BOOK ON" MENTAL DISEASES. 
 
 use in two half-ounce doses three hours apart, after a saline purgative. 
 Mention is also made of spurious preparations sold as Warburg's 
 Tincture. 
 
 Arse7iic. — The writer has derived more good results from arsenic 
 than from any other antiperiodic in Insanity from the malarial ca- 
 chexia. The periodicity consists in ment-al exacerbations and 
 markedly long intervals of comparative lucidity in many of these 
 chronic malarial cases. Quinine may be used to ward off the imme- 
 diate exacerbation, but in the interim the only effectual remedy 
 is arsenic. 
 
 Emmenagogijes. — There is a critical period at puberty, and the 
 prophylaxis of Insanity may then depend on the prompt interven- 
 tion of emmenagogues to establish the menstrual function and re- 
 store mental stability. 
 
 Menstruatio suppressa may in itself constitute a cause of the In- 
 sanity to be treated by remedies addressed directly to the restoration 
 of the function. 
 
 In the convalescent stage of Insanity the menstrual molimen may 
 be tardy in reappearance, and emmenagogues are then indicated 
 to restore the natural order of things. 
 
 Mangani Dioxidum (U. S.). — The binoxide of manganese, in 
 doses of from three to five grains two or three times a day, for ten 
 days previous to the menstrual epoch, is one of the best enmiena- 
 gogues. 
 
 Potassii Permanganas. — This is a good emmenagogue, and D. 
 Hack Tuke cites it as the most effectual, in his " Dictionary of Psy- 
 chological Medicine," p. 1291. It may be given in from three to 
 five-grain doses three times a day, some days prior to the catamenial 
 period. 
 
 Apiol. — Given in capsules containing from three to five minims 
 ter in die for ten days before the expected menstrual return, this 
 is a remedy which may be tried with occasional success. 
 
 Aloes. — ^Among the insane, in whom anaemia and intestinal atony 
 are such constant symptoms, the writer has had the most uniform 
 success with aloes combined with iron in amenorrhoea. In addition, 
 hot sitz-baths and electricity at the right time will provoke a re- 
 sponse on the part of nature if there is a physiological readiness, and 
 if not, it is worse than useless to attempt to force things. 
 
 Tincture of aloes and myrrh is also an old but reliable prepara- 
 tion for this purpose. It should be given tliree times a day for two 
 
THE TREATMENT OF INSANITY. 425 
 
 weeks before the date of menstruation, in drachm doses, increased 
 to two drachms two or three days before the expected return. 
 
 Sabina. — The oil of sabine is a very active remedy, not without 
 considerable danger. It has decided oxytocic properties, and it has 
 been abused to produce miscarriages. 
 
 Tanacetum. — Tansy-tea has long been a favorite domestic rem- 
 edy for amenorrhcea and for dysmenorrhoea. The oil, in doses of 
 from one to four drops, is an active emmenagogue. 
 
 Cimicifuga. — In neurotic women with angemic neuralgia and a 
 general hyperaesthetic state of the reproductive organs, this remedy 
 with iron may relieve amenorrhcea and other symptoms at the same 
 time. Only the officinal forms of the drug should be employed. 
 There is an active principle, cimicifugin, too powerful to be em- 
 ployed as an emmenagogue. 
 
 Anapheodisiacs. — There is abundant occasion for remedies to 
 diminish and control sexual desire, which is pathologically height- 
 ened in acute mental disease. Unfortunately, there are no very 
 reliable anaphrodisiacs, though many poisons given to the point of 
 great vital depression will, for the time being, abolish sexual passion. 
 The most effectual means of dealing vnth. morbidly intense sexual 
 appetite are not therapeutic, and will be mentioned elsewhere. 
 
 Oamphora Monobromata. — This drug is a sedative which seems 
 to influence the spinal sexual centre, and to have some anaphrodisiac 
 action. It is to be given in pillular form in doses of from three to 
 ten grains, or in mucilaginous solution. 
 
 Bromide of Potassium. — In large doses, continued as the occa- 
 sion may require or the strength of the patient may permit, this 
 drug is an anaphrodisiac. 
 
 Small doses are of no avail in nymphomania or satyriasis, and 
 doses large enough to control these symptoms usually produce brom- 
 ism if continued any length of time. 
 
 There are numerous reputed anaphrodisiacs, but they are not 
 as reliable as those above mentioned. 
 
 Antiseptics. — The insane are subject to abscesses, abrasions of 
 the skin, bruises, furunculosis, and a variety of accidents which de- 
 mand the resources of minor surgery. For this reason, as well as on 
 account of the care of the sick-room and of the discharges and un- 
 cleanly persons of the insane, the use of antiseptics is an important 
 point in psychiatric practice. 
 
 The list of agents having power to prevent putrefaction, or to 
 
426 TEXT-BOOK ON MENTAL DISEASES. 
 
 destroy the putrefactive germs, is veiy long, but only the most ap- 
 proved substances are here mentioned. 
 
 Bichloride of Mercury. — This drug is the most powerful anti- 
 septic and germicide in solutions of from 1 to 500 to 1 to 1,000 for 
 cleansing the skin, and of from 1 to 2,000 to 1 to 10,000 for direct 
 application to open wounds. The solution should contain several 
 parts of tartaric acid or of sodium chloride to one of the bichloride 
 to prevent decomposition by albumen in the water or in the blood- 
 serum of the parts treated. 
 
 Great care is required in working about the insane with poison- 
 ous solutions lest they suddenly swallow them or the 'antiseptic 
 dressings if left alone long enough to remove and tear them in bits. 
 The danger of toxic absorption from large open wounds is consid- 
 erable. When applied in strong solution to disinfect wood-work 
 in rooms used for infectious diseases, it should not be allowed to 
 soak into the floors. It acts in a short time as a germicide, and it 
 is the strength and thoroughness of the application of the solution 
 which is important, and hot water and soap should then be used to 
 scrub the floors and wood-work. For the removal of bacteria painted 
 or papered walls may be rubbed down with fresh baked bread, and 
 plastered walls may be treated with lime wash, according to a recent 
 authority. In bed-pans and spit-cups, for alvine evacuations and 
 for tuberculous sputa, bichloride in solution is effectual. 
 
 Carbolic Acid. — This is a most reliable antiseptic, used in solu- 
 tion 1 to 30 for cutaneous cleansing and 1 to 50 for surgical instru- 
 ments, sponges, and the hands of the operator, and its chief objec- 
 tion is its toxic effects, which must be carefully guarded against. 
 It should not be applied directly to the open tissues. It evaporates 
 readily and should not be kept about sick-rooms in quantities, either 
 for disinfecting stools or sterilizing bed linen. In strong solution 
 it is a deadly poison, and acts so quickly after ingestion that anti- 
 dotes are seldom of any avail. 
 
 Carbolic acid, combined with the bichloride of mercury in solu- 
 tion, makes a reliable antiseptic for surgical purposes, uniting the 
 advantages of the two germicides. 
 
 Carbolic acid is used largely in the sterilizing of gauze for sur- 
 gical purposes. 
 
 Double Cyanide of Mercury and Zinc. — Lister introduced this 
 antiseptic, which is used in surgery and in the preparation of gauze. 
 It is not soluble by the serous discharges. Solution of bichloride 
 
THE TREATMENT OF INSANITY. 427 
 
 of mercury was used in the preparation of the gauze, but it is said 
 that more recently a carbolic-acid solution has been employed for 
 this purpose (Gould, " Dictionary of Medicine," p. 697). 
 
 SulpJiocarholate of Zinc. — This is a good antiseptic for surgical 
 purposes; it is comparatively free from toxic danger, and is also em- 
 ployed for intestinal antisepsis, 
 
 Creolin. — Creolin is a most valuable antiseptic, which is not ir- 
 ritating and has very slight toxic properties. It is not soluble in 
 water, but in from one to five per cent, strength in emulsions it is 
 employed in surgery and in gynaecology, and as a general disin- 
 fectant. 
 
 Peroxide of Hydrogen. — In solution, bottled for ready use, this 
 is a very convenient and efficient antiseptic, which may be diluted 
 ten times or less, or employed in full strength in foul sinuses. It 
 is a deodorizer as well as a germicide. In hospital use the chief 
 objection to it is its expense. It is useful in decubitus among the 
 insane. 
 
 Iodoform. — This drug is not germicidal and must be sterilized 
 before being applied to cut surfaces. It is used as an antiseptic in 
 surgery. Its odor is penetrating and disagreeable, but it is still veiy 
 extensively employed. 
 
 Boric Acid. — This is useful in boiling saturated solution for the 
 preparation of borated lint. It is used for throat, nose, eyes, and 
 other mucous surfaces, and for skin diseases, and to correct the 
 foul perspiration of feet arising from bacterium foetidum. It is 
 antiseptic, but not germicidal. 
 
 Permanganate of Potassium. — Owing to its affinity for oxygen, 
 this is a good antiseptic and deodorizer. It is a good wash for foul 
 ulcers in solution of one drachm to the quart of water. Hare, in 
 his " Practical Therapeutics," says it is the best disinfectant wash 
 for the hands- of the operator, followed by oxalic-acid solution. 
 
 Disinfectants. — Some of the chief substances used to destroy 
 the germs of disease and of putrefaction must be constantly used 
 in hospitals for the insane, and only the more important are here 
 mentioned. 
 
 Dry heat, if carried to nearly300° F., will kill all forms of patho- 
 genic bacteria and spores. 
 
 Every public hospital should have an apparatus large enough to 
 disinfect clothing and bedding by dry heat. 
 
 Steam at a temperature of 200° F. will kill infectious germs, and 
 
428 TEXT-BOOK ON MENTAL DISEASES. 
 
 an apparatus for this purpose should be provided in all well-ap- 
 pointed hospitals. Steam-Jets are specially effective. In the ab- 
 sence of any apparatus, boiling clothing is the best means of disin- 
 fection. Exposure to extreme cold and sunlight will destroy some 
 disease germs, and fresh air is nature's universal disinfectant. 
 
 Chlorinated Lime. — This is a powerful disinfectant on account, 
 of the chlorine gas which it gives off. Chlorine has an affinity for 
 hydrogen, which is a constituent of foul odors, which are thus chem- 
 ically broken up by the chlorine gas. Much of the chlorinated lime 
 sold is useless because it contains so little chlorine. The addition 
 of hydrochloric acid causes a liberation of chlorine from the chloride 
 of lime. Chlorinated lime is a useful disinfectant in privies and 
 urinals and sewers, but it should never be placed in open dishes in 
 sick-rooms, and it may become too irritant when placed under the 
 patient in bed-pans to receive the discharges. 
 
 Labarraque's solution is far superior to carbolic acid as a deodor- 
 izer of foul bed-sores and decomposing tissues, on account of the 
 chemical disinfectant action of chlorine above mentioned. In bed- 
 pans it disinfects alvine discharges. 
 
 Sulphur Dioxide. — For fumigating a room after the doors and 
 windows have been made air-tight, if possible, sulphur, to the 
 amount of from three to five pounds, is placed in an iron vessel set 
 upon bricks in a tub partly filled with water, in the middle of the 
 room. A Httle alcoihol is poured over the sulphur, a match lights 
 the flame, and, the door being locked, the fumigation takes place; 
 at the end of twenty-four hours the room is opened and thoroughly 
 aired. 
 
 Chlorine Gas. — Fumigation of apartments by chlorine gas is ef- 
 fective as a disinfectant measure after infectious disease has been 
 treated in them. Everything is first to be removed from the apart- 
 ments. 
 
 Bichloride of Mercury. — The use of this drug as a surgical anti- 
 septic has already been mentioned. 
 
 In solution 1 to 1,000 it is the best disinfectant for soiled bed- 
 linen before it is boiled. The discharges of the patient suffering 
 from contagious disease are best disinfected by a solution of the bi- 
 chloride, 1 to 400, in which they are allowed to remain for a half 
 hour, and the bed-pan is then emptied, scalded, and provided with 
 another portion of the disinfectant solution. All these poisonous 
 solutions should be locked in the wash-stand or closet or in a trunk 
 
THE TREATMENT OF INSANITY. 429 
 
 placed in the room, if there be no other place, in the treatment of 
 the insane, who from suicidal or deluded motive, may make a sud- 
 den effort to swallow the fluids. 
 
 Sulphate of Iron. — On account of its cheapness, sulphate of iron 
 in strong solution, mixed with crude coal-tar products, has often 
 been used for wholesale disinfection of large sewers in times of epi- 
 demics. It certainly is of some value thus employed, though much 
 reliance is not to be placed on this mode of disi'nfection. 
 
 Chloride of Zinc. — It may be employed in solution as a disin- 
 fectant in water-closets, but it is vastly inferior to chloride of hme. 
 
 Sulphate of Copper. — Tins is useful for disinfection, on a large 
 scale, of privy vaults and sewers, and collections of decomposing 
 refuse. 
 
 Eor the disinfection the rough proportion is an ounce each of 
 the sulphate of copper and of sulphuric acid to the gallon of the 
 contents of the privy. 
 
 Oeganic Exteacts. — ^In closing this therapeutical chapter, it 
 is thought best to give a little space to organo-therapy, about which 
 many physicians in many lands have of late much concerned them- 
 selves. 
 
 The history of medicine shows that the idea of using parts of 
 the organs of ammals as special means of cure for disease is one of 
 the oldest and most constant of medical theories which have pre- 
 vailed in both the professional and popular practice of the healing 
 art. There are, in fact, few organs or tissues of animals, and no 
 excretion or secretion of man, which has not been at some time 
 applied to the cure of human ailments. 
 
 The most recent impetus in organo-therapy was given by Brown- 
 Sequard in 1888, when he announced the beneficial effects of orchic 
 fluid used by injections to impart renewed vitality in senile decline. 
 
 Testin. — Testicular extract has been employed by many physi- 
 cians, who have given characteristically divergent views of its use- 
 fulness or worthlessness. It certainly is not an inert remedy, and 
 there can be no doubt but that it is a nervous stimulant, which 
 would be more generally employed were it not for certain practical 
 difficulties and also uncertainties in its preparation and in its use. 
 It has been employed in general paresis and in ataxic cases, and 
 it would seem to be indicated, if of any real value, in the senile 
 cases of mental disease. 
 
 Thyroid Extract. — Murray, of England, in 1891 used the extract 
 
430 TEXT-BOOK ON MENTAL DISEASES. 
 
 of sheep's thyroid in myxoedema, and there has since been wide- 
 spread employment of the thyroid extracts in myxoedematous In- 
 sanity, in sporadic cretinism, and in cachexia strumipriva, and in 
 Graves's disease. Going outside of these theoretically legitimate 
 cases for the use of the extract, physicians have empirically applied 
 it in the treatment of all sorts of cases of mental disorder, and, with 
 an inconsistency of results demonstrating the honesty of the ex- 
 perimenters, have reported decidedly for and against the utility of 
 the extract in the treatment of Insanity. 
 
 After a careful perusal of the literature of the subject, conjoined 
 to the writer's experience, the following opinion is given: 
 
 The thyroid extracts are of some real value in cretinous and 
 myxoedematous Insanity, and they may be employed to advantage 
 in mental disease complicated with Graves's disease, sporadic cretin- 
 ism, and cachexia strumipriva. Thyroid extract, in the vast major- 
 ity of cases of mental disorder, is harmful, but in an occasional in- 
 stance, from idiosyncrasy or some unknown pathological peculiarity 
 of the patient, it has a beneficial effect, which can never be predi- 
 cated in advance and can only be determined by experimental use 
 of the remedy. It is of some value in skin diseases in psychiatry. 
 It matters Httle whether hquid extracts are injected, or dry extracts 
 are given per oram, or the fresh gland is given slightly cooked. 
 Abscess may follow the hypodermic use of the extracts. 
 
 Cerebrin. — This extract from the gray matter of brain may be 
 tried in neurasthenic Insanity. It has been considerably used. 
 
 Fancreatin. — This organic extract of pancreas is theoretically 
 adapted to the Insanity of Bright's disease, in which it is known 
 that there is often disease of the pancreas. It has already been tried 
 with dubious results in diabetes mellitus with pancreatic disease, 
 
 Ovarin. — Experimental use could only be made of this extract 
 in climacteric cases, and in those complicated with special troubles 
 of the reproductive organs. 
 
 Cardin. — This extract is said to increase the force of the heart's 
 action in neurasthenic cases. 
 
 Tuberculin. — This ptomainic derivative from tubercle bacilli, 
 has been extensively tried. It is applicable, if at all, in phthisical 
 Insanity. Its proved value thus far is chiefly as a diagnostic means 
 in the tuberculosis of cattle. 
 
 Medulla of Supra-renal Capsules. — The organic extract from 
 the supra-renal capsules is one of the latest and most remarkably 
 
THE TREATMENT OF INSANITY. 431 
 
 powerfal known. It has a very decided cardiac influence, rapidl}^ 
 slowing the heart's action, while increasing systolic force. It con- 
 tracts the arterioles like ergotine, and in very minute doses raises 
 the intra-arterial blood-pressure. It might be of some temporary 
 benefit in Insanity through its effect on cerebral blood-supply. 
 
 Section VII. — Surgical Procedures. 
 
 In the treatment of Insanity it becomes advisable in certain cases 
 to resort to surgical procedures, which may be radical for the re- 
 moval of the cause of the mental disease, or palliative and in the 
 nature merely of symptomatic surgery. 
 
 Most of these surgical procedures pertain to minor surgery, but 
 some of them are capital operations, and, in any case, they are only 
 to be undertaken under all modern antiseptic precautions. 
 
 Trephining. — This is one of the most ancient operations, which 
 has been practised for the cure of nervous and mental disease, at 
 times, for more than three thousand years past. 
 
 Within the last ten years this operation has again been utilized 
 for the relief of special types of Insanity, and renewed interest has 
 been centred in the results obtained by the recent extensions of tliis 
 surgical procedure. Space will not permit a review of the recent 
 literature of this subject, nor of the technique of the surgical opera- 
 tion, but an attempt is made to summarize very briefly the patholog- 
 ical conditions which justify surgical interference of this nature. 
 
 In the first place, traumatic injuries of the cranium, of the mem- 
 branes of the brain, or of the cerebrum itself may cause Insanity, 
 which may be relieved by the operation of trephining. 
 
 Cases of this kind have been reported by Skae, Horsley, Althaus, 
 Bacon, Talcott, Burckhardt, Mickle, Hartmann, and others. 
 
 Insanity complicated with any of the following pathological con- 
 ditions may demand a decision as to the advisability of trephining, 
 which will be deemed all the more justifiable if the mental disease 
 be the direct sequel of the morbid affection in question. 
 
 The conditions which may indicate the operation are: Simple 
 cranial fracture with firm cicatrix, fracture with evident depression 
 of the skull, fracture compound and with penetrating spicula of 
 bone, extensive cranial exostoses, neoplasms of the membranes of 
 the brain, large extradural hemorrhages and cystic formations, ac- 
 cumulation of pus in meningeal cavity, cerebral tumors, cerebral 
 
432 TEXT-BOOK ON MENTAL DISEASES. 
 
 abscess, bullets and other foreign bodies in the brain, and continu- 
 ous cortical irritation from localized lesions. 
 
 The earlier the operation is undertaken, generally speaking, and 
 the more thoroughly all diseased parts are removed, the better will 
 be the result to be anticipated; for, when secondary lesions and 
 degenerations have taken place, the hope of benefit from operative 
 interference is reduced to a minimum. 
 
 In the second place, traumatic injuries of the cranium may give 
 rise to epilepsy, which in turn is followed by Insanity, or the con- 
 vulsive neurosis and the psycho-neurosis may be simultaneous re- 
 sults of the trauma capitis. 
 
 In such cases the precedent of successful surgical interference 
 already frequently practised encourages a judicious employment of 
 the operation of trephining. 
 
 French, German, English, and American writers have reported 
 cases of trephining for epilepsy with more or less favorable results. 
 If the case be hopeless without operative procedure, the responsibil- 
 ity of a decision is at least much diminished if surgical treatment fail 
 in the end. 
 
 There is this favorable feature to be recorded, that in epileptic 
 cases the operation, though not a success in regard to the seizures, 
 has in several instances been followed by decided improvement in 
 the mental condition of the patient. It is not easy to assign a physi- 
 ological reason for this, though it accords with observation of cases 
 of Insanity cured by accidental traumatism, probably on the prin- 
 ciple of powerful revulsion. 
 
 Finally, the pathological condition which prevails in the intra- 
 cranial pressure and pachymeningitic lesions of general paralysis 
 have, in the opinion of some prominent psychiatrists, justified the 
 operation of trephining and of still further surgical procedures. 
 Batty Tuke and Claye Shaw resorted to this surgical measure in 
 general paresis, with at least temporary success, in 1889, but sub- 
 sequent experience has failed to establish trephining as an accepted 
 part of the treatment of general paresis. 
 
 What the future may bring forth in these days of rapidly ad- 
 vancing antiseptic brain-surgery remains to be seen. Burckliardt has 
 even gone so far as to propose and to practise with some success, 
 judging by reports, the excision or surgical severance of the medul- 
 lated connections of certain sensory cortical areas, known to be the 
 seat of irritation and the source of constant hallucinations. 
 
THE TREATMENT OF INSANITI. 438 
 
 Craniectomy. — This operation consists in the removal of linear 
 strips of the cranium so as to permit of expansion, and more ready 
 growth of the cerebrum. It has usually been practised in the vicin- 
 ity and direction of the vertical sutures, but it has been modified and 
 so adapted as to give necessary freedom to any contracted portion 
 of the brain too closely confined by bony walls. 
 
 The operation of craniectomy has been employed for the relief of 
 microcephalus, in which, as Virchow first pointed out, there is often 
 synostosis basilaris and premature closure of other cranial sutures, 
 and also of the fontanelles and subsequent thickening of the tables 
 of the skull by which the limited cranial capacity is still further 
 diminished. 
 
 Lannelongue, of Paris, in 1891, first gave an extended account 
 of craniectomy in microcephalus, and at the Surgical Congress in 
 that year there were reported twenty-eight cases thus treated with 
 good results. Pain and cephalalgia were relieved and the mental 
 improvement was rapid after the operation. Subsequently, within 
 two or three years, craniectomy was performed in most countries, 
 and successful cases were reported by numerous operators in America 
 as well as in Europe. 
 
 The opponents of the operation have denied that premature 
 closure of sutures occurs, and they claim that the arrest of cerebral 
 growth is primary and due to a variety of causes other than com- 
 pression by cranial walls, all of which is only a continuation of a dis- 
 cussion now historical. The operation must be judged by results 
 and not by theories, and it will doubtless continue to be performed. 
 It seems to promise most success at a very early period of infancy, 
 and in fact, within the first year of life in cases of premature closure 
 ■of the fontanelles. It is doubtful whether much benefit could be 
 expected from craniectomy in any case after the tenth year, as tlie 
 fit time for educational methods in microcephalic cases of that age 
 has already passed, to say nothing of anatomical reasons. 
 
 Craniotomy. — This is only a broader term for the great variety of 
 excisions of portions of the skull for the purposes above mentioned. 
 Craniectomy is regarded as one form of this operation and is spoken 
 of as linear craniotomy. Circular craniotomy completely loosens the 
 vertex of the skull. 
 
 Crescentic excision in parietal region corresponding in direction 
 to the temporal ridge is also made, and a second and lower excision 
 in the same ease may be made, following in the general line of the 
 squamo-parietal suture. 
 
 28 
 
434 TEXT-BOOK ON" MENTAL DISEASES. 
 
 Trap-door exoisions are also made, preserriiig the attacliment of 
 soft parts to the bone to continue circulation and nutrition. After 
 the use of the trephine, the bone-forceps are used by some in prefer- 
 ence to revolving saws with electric motor for excision of bone. 
 Many prefer limited and repeated operations as being less severe and 
 equally good in final results. 
 
 Craniotomy must be varied in each case to suit the asymmetry 
 and the special cause of it. 
 
 Thus the indication is very plain, for instance, in plagiocephaly, 
 which is one of the most common cranial deformities, caused by 
 closure of the fronto-parietal suture on one side only. In general, 
 cases of acquired arrest of development are more favorable for opera- 
 tion than congenital cases. In the latter there is more apt to be rad- 
 ical defect of anatomical structure of brain-mantle and of medullary 
 tracts, as well as the results of compression. 
 
 Even in the most favorable event craniotomy can only remove- 
 obstruction to educational training, which will have to be persistently 
 pursued for many years in order to reap the benefit of the operation. 
 
 Laminectomy. — This operation consists in the excision of parts 
 of the posterior vertebral arches, and one danger arises from anaes- 
 thesia of the patient in the prone position. The necessity of the 
 operation may occur in insane patients with Pott's disease of the 
 spine, or in syphilitic Insanity \\dth spinal caries. In young hydro- 
 cephahc patients with tubercular meningitis it has been practised, 
 and in general paresis spinal drainage also has been thus effected. 
 
 In simple or compound fractures of the spine the operation may 
 also become advisable, but as a means of relief of pressure from 
 cerebro-spinal fluid, even in cases of vertebral disease, it has been re- 
 placed by vertebral puncture in some instances. 
 
 Spinal Drainage. — The reUef of the pressure of the cerebro- 
 spinal fluid in disease has been accomplished by a variety of opera- 
 tions. At one time the occipital bone was trephined and the sub- 
 arachnoid space was reached under the cerebellum. The other ex- 
 treme in direction is the comparatively recent spinal drainage by 
 pancture between the last lumbar and the first sacral vertebra in the 
 lumbo-sacral space. 
 
 Vertebral puncture for some years has been practised by Quincke, 
 Von Ziemssen, Lichtheim, and others for several purposes, and also 
 by Furbinger, Morton, Paget, and by John Turner in general paresis, 
 and likewise by W. L. Babcock. It has been utilized in cerebro-spinal 
 
THE TREATMENT OF INSANITY. 435 
 
 meningitis^, in hydrocephalus, in eases with brain-tumors, and in 
 tubercular meningitis with, puncture between the third and fourth 
 or between the fourth and fifth lumbar vertebrffi. It has also been 
 employed for diagnostic purposes. The normal cerebro-spinal fluid 
 has a specific gravity of from 1.007 to 1.009, and contains from 
 .005 to .01 per cent, of albumen, and has a pressure under 150 mm. 
 which often has a pathological increase to more than 500 mm.; and 
 in inflammatory conditions the specific gravity and albumen may be 
 greatly increased, and in special affections bacilli may be found. 
 Vertebral puncture, both in Europe and America, has been used as 
 a palliative measure in general paresis. It usually causes severe 
 cephalalgia and other distressing symptoms as the immediate result 
 of the diminution of cerebro-spinal pressure, but it is claimed that 
 in an occasional case there has been established a species of remis- 
 sion of some of the manifestations, in the motor and mental sphere 
 alike, as the final outcome of the surgical intervention. Knowing, 
 however, that in general paresis the excess of fluid is only compen- 
 satory, it is hardly to be supposed that its partial withdrawal by 
 puncture would amount to much more than a species of depletion, 
 which, if repeated often, would only be the equivalent of vene- 
 section. 
 
 The operation is simple, and cocaine injected is best for local 
 angesthesia. It may be necessary to use aspiration if the fluid does 
 not escape in sufiicient amount upon puncture. The patient may be 
 recumbent or seated and Inclined forward to increase the facility of 
 puncture in the lumbar region. The danger of wounding the cord 
 or the breaking of the needle is to be guarded against. 
 
 No permanent spinal drainage has been practicable by this opera- 
 tive measure, which, independently of all theoretical objections, 
 should be given a fair trial, and impartially judged by its final results. 
 
 Thyroidectomy. — Mental disorders are frequently complicated 
 and sometimes caused by thyroid disease, or by operative procedures 
 upon the thyroid gland. Extirpation of the whole gland is followed 
 in many instances by myxoedema or tetanus, and the latter affection 
 may arise from even partial resection of the thyroid. 
 
 Cachexia thyreopriva results in thirty per cent, of all total thy- 
 roidectomies. 
 
 Predisposition to Insanity renders operations for the removal of 
 goitres all the more serious. 
 
 In addition to partial or complete removal of the gland there is 
 
436 TEXT-BOOK ON MENTAL DISEASES. 
 
 incision of cystic growths, and enucleation of pathological nodules 
 of the thyroid, which is less dangerous. Graves's disease is often as- 
 sociated with Insanity, to which it may bear a direct causative rela- 
 tion. About seventy per cent, of all cases of Graves's disease occur 
 in women, in whom there is a physiological relation between the 
 thyroid gland and the reproductive functions. 
 
 The chances of thyroidectomy in Graves's disease are shown in a 
 review of one hundred and eighty-seven cases by Kinnicutt. ■ Out of 
 one hundred and eighty-seven oases operated upon sixty recovered, 
 forty-seven improved, eleven were unimproved, thirteen died, and the 
 result in others was unknown. 
 
 In Insanity with exophthalmic goitre it becomes a serious ques- 
 tion, therefore, as to the value of operative interference. 
 
 In all thyroidectomies the use of thyroid extract as a part of the 
 after-treatment promises some prophylaxis against untoward sequels. 
 
 Degenerations of the thyroid gland give rise to myxoedema and 
 subsequent Insanity with the same certainty that cachexia strumi- 
 priva results from thyroidectomy. 
 
 The chief value of thyroidectomy, if performed in time for the 
 arrest of thyroid disease, would be in the nature of prophylactic treat- 
 ment of Insanity. 
 
 Hysterectomy. — Insanity may be caused by pathological growths 
 and diseased states of the uterus, and hysterectomy may offer the 
 only radical means of deliverance from the uterine disease and of 
 cure for the mental disorder. The fact that hysterectomy is known 
 to be one of the possible factors of Insanity is a matter of serious 
 consideration for the gynaecological surgeon before operation in cases 
 having hereditary predisposition to mental disease. 
 
 On the other hand, Insanity, already confirmed, does not contra- 
 indicate, but may favor hysterectomy, which is to be advised or dis- 
 couraged according to the general principles of gynaecological sur- 
 gery. 
 
 Oophorectomy. — The operation for the removal of the ovaries 
 has now been performed extensively in all parts of the world for fif-. 
 teen years past, and the literature of the subject is too large for re- 
 view in this connection. Oophorectomy, in its relations to mental 
 disease, is also a subject too extensive for discussion here, and the 
 most varied opinions are held as to its advisability either for the 
 prophylaxis or cure of mental disorder. 
 
 From the writer's experience in the treatment of insane women, 
 
THE TREATMENT OF INSANITY. 437 
 
 who have undergone the operation, and from a careful study of all 
 sides of the subject, the following summary of conclusions is reached 
 in regard to this surgical procedure: 
 
 1. Oophorectomy has occasionally caused Insanity. 
 
 2. Battey's operation in climacteric Insanity may hasten the 
 menopause, and limit the duration of the psychosis. 
 
 3. In ovario-mania from organic ovarian disease demanding 
 Tait's operation, relief of the mental s}Tnptoms has followed the 
 surgical procedure. 
 
 4. Oophorectomy, as regards Insanity, is curative or causative 
 through its psychic as well as physical effects. 
 
 Clitoridectomy. — The excision of the chtoris has been done to 
 relieve sexual erethism in neurotic women, and as a cure for mastur- 
 bation among the insane. It is a temporary check to the masturbatic 
 habit, whicii in rare cases may be permanently cured by it. 
 
 When masturbation has been carried so far as to become a part 
 of cortically organized habit, neither clitoridectomy nor oophorec- ' 
 tomy are of any permanent benefit. 
 
 In cases of moral Insanity in young girls given to the habit, the 
 prepuce of the clitoris might perhaps be with some benefit stripped 
 off under cocaine angesthesia, just as circumcision in boys under like 
 circumstances is sometimes curative. 
 
 At the present time clitoridectomy is rarely advised in psychiatric 
 practice, and is completely out of vogue. 
 
 OrcMdedomy. — Castration in mental disease has been done some- 
 times by physicians, and at other times by the patients themselves, 
 acting under delusions which led to self-mutilation. The results of 
 the operations thus performed upon the insane have been various. 
 
 Double and complete orchidectomy does not remove all sexual 
 desire, and will not cure a chronic habit of cortical masturbation, 
 though it may terminate other forms of sexual self-abuse. 
 
 Orchidectomy, self-inflicted, like other traumatic accidents, may 
 be followed by prompt recovery from the Insanity. Unilateral cas- 
 tration produces no appreciable change in adult sexual appetite, but, 
 like complete emasculation, it may terminate an attack of mental dis- 
 order by force of venesection and physical and mental revulsion when 
 it is self-inflicted. 
 
 Orchidectomy at the senile involutional epoch has never been sug- 
 gested, so far as the writer knows, by any enthusiastic performer of 
 oophorectomy at the menopause, and it is not used at present in 
 
438 TEXT-BOOK ON MENTAL DISEASES. 
 
 psychiatry, except in malignant or other organic affection of the 
 testes, which require ablation on surgical grounds. 
 
 Phlebotomy. — General bloodletting was almost universal with the 
 last generation of psychiatrists, but for forty years past it has not 
 been recognized as useful in the treatment of mental disorders. 
 
 Still local bloodletting is practised by leeching and cupping in 
 marked cerebral congestion to the extent of some ounces of blood; 
 and there should be no prejudice against venesection should there be 
 a positive indication for it. Accidental injuries in sthenic mania fol- 
 lowed by immediate improvement 'after the sudden loss of blood can- 
 not but cause reflection. It is not reasonable to suppose that all the 
 distinguished medical men who relied upon bloodletting were merely 
 following a fashion. It is a fact, that Insanity has become more 
 asthenic and neurasthenic within a generation, and if the great Eush 
 were now living he doubtless would see less indication for his favorite 
 remedy of phlebotomy, which it is probable might still be of occa- 
 sional service. 
 
 Transfusion. — According to Dr. Hack Tuke, transfusion was 
 practised in Paris, in 1667, by Denis upon an insane patient who re- 
 covered his reason soon after the operation, and in 1879 Roussel, of 
 Paris, performed transfusion at Bethlehem Hospital, London, in one 
 case without success. 
 
 It would seem as if this procedure might be of great service in 
 cases of Insanity with impoverished and deficient blood-supply, and 
 there is here at least an open field for reasonable experimentation. 
 
 In post-paitum Insanity with profuse hemorrhage immediate 
 benefit might be expected. In the absence of a donor of fresh blood, 
 a properly prepared saline solution is almost equally effective, as the 
 serum, and not the corpuscles, is accepted for immediate use from 
 the donor. The writer, who served through the Asiatic cholera epi- 
 demic of one hundred and fifty cases in the New York City Lunatic 
 Asylum, was struck with the temporary improvement in the patients 
 upon whom transfusion was practised, even though the method was 
 not direct but abdominal. One and one-half drachms of chloride of 
 sodium to one quart of boiled and filtered water at 100° F. is the 
 strength of the solution employed in transfusion. 
 
 Ilypodermoclysis. — A sterilized solution of seven parts of chloride 
 of sodium to one thousand parts of water is introduced by means 
 of a trocar into the subcutaneous tissues of the thighs or abdomen. 
 
 This method has already been used to replace lost fluids in cholera 
 
THE TREATMENT OF INSANITY. 489 
 
 and hemorrhages, and also to depurate the system of toxic material 
 which is eliminated by the kidneys so long as the hypodermoclysis 
 is continued and not carried to excess. 
 
 It is probable that it might be used to advantage in Insanity in 
 post-partum hemorrhage, in diabetic, UKemic, and other toxic con- 
 ditions. 
 
 Revulsion. — This surgical procedure is based on a very important 
 principle of medical practice in mental disorders, w'hich have been 
 observed to improve remarkably after eruptions and suppurations, 
 carbuncles on the neck, and severe attacks of hemorrhoids, and other 
 causes of decided derivation from central to peripheral regions. The 
 principle, therefore, is to imitate nature and to estabhsh by artificial 
 means peripheral irritation of some kind in order to influence the 
 processes of disease through reflex nervous channels. Just as in gen- 
 eral medicine neuralgic affections and inflammatory diseases of in- 
 ternal organs are treated by counter-irritants, so in psychiatry path- 
 ological states of cerebral centres are influenced by revulsives. 
 
 As in eye disease the blister is applied behind the ear, and in in- 
 tercostal neuralgia over the spine, and in inflammations of thoracic 
 or abdominal organs at certain points of selection, so in mental dis- 
 orders the scalp, the nape of the neck, and the central spinal region 
 are the preferable points for local attack by revulsion. 
 
 Vesication. — Various kinds of vesicants have been employed in 
 the treatment of mental disorders. Tartar emetic ointment has been 
 largely used to the shaven scalp, and although there is much severity 
 in its use, curative results have been claimed for it. 
 
 Oleum Tiglii rubbed into the scalp for vesication is favorably 
 mentioned by Bucknill and Tuke. 
 
 The writer has found blisters to the nape of the neck to have 
 about the same effect as when applied to the scalp, while being free 
 from some of the inconveniences of the latter. 
 
 A cantharidal blister is the most ready form for the nape of the 
 neck. Frequent superficial blisters are more efficacious than one deep 
 bhster, since the object is to affect the peripheral distribution of 
 nerves to cutaneous and not to deeper tissues. In patients tending 
 to dementia after acute Insanity, and in maniacal states assuming a 
 chronic type, a good lively course of vesication ad nucham some- 
 times has a happy effect. 
 
 Also in melancholia there is an occasional tedious phase, tinged 
 with hypochondria and self-pity, in which a bhster to the neck is valu- 
 able for its psychic as well as derivative effect. 
 
440 TEXT-BOOK ON MENTAL DISEASES. 
 
 The use of moxa affords a still more decided means of counter- 
 irritation. 
 
 Thermo-cautery. — In cases which demand a deeper counter-irri- 
 tant, Paquelin's cautery or the thermo-cautery may be employed. 
 The effect will vary somewhat with the red or white heat at which it 
 is applied, as the former is more irritant. It is sometimes of benefit 
 in incipient Insanity and also in delayed convalescence with stupor- 
 ous tendency after acute symptoms have subsided. 
 
 Electro-cautery. — This is a still more convenient and readily 
 regulated form of cautery for use among the insane. 
 
 The back of the neck is a good place for cauterization in chronic 
 maniacal cases, in sequential stupor, in certain cases of primary de- 
 mentia, and in an occasional case of melancholia in the first stage. 
 
 Setons. — The writer has used setons in the treatment of different 
 forms of mental disease, and is inclined to regard them as the most 
 useful form of prolonged counter-irritation. In turbulent maniacal 
 patients with chronic meningeal infiammations they afford remark- 
 able relief. In eiaileptic mania they are valuable, and in some cases 
 of melancholia tending to dementia they prove useful. The seton 
 for a fortnight in the back of the neck of an acute maniac will some- 
 times act as a surer sedative than many drugs, and will do more to 
 relieve the cerebral trouble. 
 
 Aquapuncture. — As a final very convenient means of counter- 
 irritation in the insane, aquapuncture ds mentioned. It consists in 
 a very fine jet of water, hot or cold, directed with some force against 
 the sldn. It is readily applied while the patient is bathing, and may 
 not be objected to by patients, who would oppose other forms of 
 counter-irritation. 
 
 Acupuncture. — The piercing of the skin or muscles with fine- 
 pointed instruments has been practised with some success for the 
 relief of muscular and sciatic pain and for other neuralgic troubles. 
 
 Acupuncture should be done under antiseptic precautions. The 
 neuralgic pains of hypochondriacal and neurasthenic patients may 
 be relieved by this measure, in part, through psychic effect. 
 
 Hepatic Aspiration. — Dr. W. H. Hammond attributes importance 
 to hepatic abscess as a cause of melancholia, which he has relieved 
 by hepatic aspiration. Possibly the ancient doctrine of the liver as 
 the seat of melancholia may have been due not so much to black 
 bile as to pus undiagnosed. 
 
 Enteroclysis. — This operation consists in the cleansing of the 
 
THE TREATMENT OF INSANITY. 441 
 
 lower part of the intestmal tract by means of water or slightly saline 
 solutions, which for special purposes may also be medicated. The 
 water is allowed to pass into the intestines by its own weight, wliich 
 can be regulated by elevation of the water-bag or vessel. The press- 
 ure should not exceed five pounds at any time, and a small and steady 
 stream is alone permissible, and an outflow tube should be provided 
 large enough to allow small solid particles to pass, and the fluid em- 
 ployed should have a temperature of not less than 100° F. and not 
 more than 103° F. . The object is to irrigate the large intestine and 
 even to pass the ileo-csecal valve in certain cases. A Davidson syr- 
 inge should never be used to force the water, which, if used in large 
 amounts, should contain one drachm of chloride of sodium to the 
 pint. The indications which may exist for this operation in mental 
 disorders are intestinal atony and fecal accumulations, foul state 
 of the alvine evacuations, and toxic conditions and reabsorption of 
 toxines from intestinal surfaces. In the latter instance a little boric 
 acid may well be added to the warm vi^ater. 
 
 Four years ago a patient, who had been treated for melancholia 
 until deemed probably incurable, came under the writer's care ema- 
 ciated, with offensive stools, perverted secretions, and evidently 
 suffering from toxic intestinal reabsorption. 
 
 Enteroclysis was practised and was practically the main treat- 
 ment. The patient improved from the very first, gained fifteen 
 pounds in four weeks, and had completely recovered at the end of six 
 weeks. 
 
 Cataphoresis. — The introduction of drugs into the system may 
 be accomplished by the galvanic current, ten to fifteen milliam- 
 23eres by anodal diffusion. An effect is thus procured in cases un- 
 willing or unable, for any reason, to take medicine by the mouth. 
 
 The drugs are used in solution applied on absorbent cotton on 
 the positive electrode. 
 
 In goitrous patients iodine may Ije locally used. Chloroform 
 irritates the skin, but in neuralgia a ten per cent, solution of cocaine 
 may be locally employed. 
 
 AncBsthetic Congelation. — There are many occasions for local an- 
 esthesia in minor surgical operations among the insane, and anaes- 
 thetic congelation is often preferable to cocaine in the cutting opera- 
 tions. A mixture of one part of salt and two parts of ice, quickly 
 pulverized, mixed, and applied in gauze to the skin, will produce 
 local anai^sthe&ia sufficient for incision for the release of pus, or for 
 
442 TEXT-BOOK ON MENTAL DISEASES. 
 
 the use of the cautery to the neck. Ether spray with an atomizer, 
 and rhigolene, likewise act as frigoric anaesthetics for operations, 
 and are also used for the relief of neuralgia. Methyl chloride is still 
 more rapid, and care is to be taken not to prolong the congelation, 
 which is complete at the end of a few seconds, and, if carried too 
 far, may result in sphacelation of the part. 
 
 Gastric Lavage. — In gastric dilatations and fermentation, and 
 for other reasons, it may become desirable or necessary to wash out 
 the stomach before the introduction of food. The proper apparatus 
 for this is a flexible red-rubber tube, about four feet in length, with 
 a blind end, and two large lateral end openings, large enough to 
 admit the entrance of some solid particles of food and of the mucus 
 of the stomach. The inside diameter of the tube should correspond 
 to catheter sizes 20 to 23 American system, or 30 to 35 !French, and 
 the length of the tube inserted, measuring from the hps downward, 
 will vary with the size of the patient, which is to be estimated in each 
 case, and which, on the average, is sixteen inches. 
 
 For children a tube thirty inches long and with an inside diam- 
 eter of a catheter 14, will answer the purpose. The tube should 
 not be cold, and is simply moistened, as the mucus lubricates it; 
 it is introduced within the grasp of the pharyngeal constrictors, 
 and it is then swallowed involuntarily; in children it may disap- 
 pear completely if care is not taken to aittach the external end. A 
 funnel is adjusted, either before or after the passage of the tube, 
 to the outer end; fluid is poured into the stomach to the desired 
 amount, and then the funnel is suddenly lowered; by siphonage 
 the stomach is emptied, and by a repetition of this process until the 
 flxdd comes away clear the stomach is thoroughly cleansed. If the 
 funnel end of the tube is not lowered while there is still fluid in the 
 tube, siphonage may not be established unless suction is used. 
 
 If the stomach contain much solid material the stomach-pump 
 may be necessary, but it is very rare that the tube will not answer 
 every purpose. 
 
 The water used for gastric lavage may contain a little boric acid 
 for antiseptic purposes. 
 
 In resistant patients a wooden mouth-piece with a central open- 
 ing for the passage of the tube may be necessary, and the head of the 
 patient is carefully held by an attendant. 
 
 Oyncecological Local Treatment. — It has already been pointed out 
 that disease of the uterus and of its adnexa is an occasional cause of 
 
THE TREATMENT OF INSANITY. 443 
 
 Insanity, and in such, an instance the gynsecological local treatment 
 may. remove the continuous etiological factor of the psychosis. The 
 gynaecological affections which may bear a causative relation to the 
 mental disorder are uterine displacements, endometritis, parametji- 
 tis, tumors of the uterus or ovaries, and functional disorders of the 
 reproductive organs. 
 
 The question of resort to gynsecological surgery in mental disor- 
 ders turns on the relation of cause and effect, as between the local 
 disease and the psychosis. It is to be considered also that ana3mia, 
 general disorder of nutrition and reflex disorder of the whole ner- 
 vous system may arise from the gynsecological affection, and that 
 until it is removed the first step toward the cure of the Insanity 
 cannot be taken. 
 
 On the other hand, existing uterine disease may not have con- 
 tributed to the mental disorder, which may be known to be due to 
 other definite causes, and gynsecological treatment might only add 
 another source of irritation to a suffering nervous system. 
 
 It becomes necessary, therefore, to weigh closely in each indi- 
 vidual case the indications and eontra-indications for gynsecological 
 operations among the insane. 
 
 Insanity per se is not a contra-indieation to gynaecological sur- 
 gery, provided the latter eventually prove remedial. Most all rad- 
 ical measures of treatment impart some new phase to the Insanity 
 which they finally tend to cure. The delusions which local treat- 
 ment may favor have been illogically cited as an argument against 
 gynsecological treatment, but the same reasoning would exclude all 
 medicines and other decided measures enforced in Insanity. 
 
 The gynsecological question, therefore, will ever remain the same 
 in all cases of mental disease, and it is summed up in two brief 
 phrases, viz.: Is the gynsecological operation indicated on etiological 
 grounds? Does the general physical condition of the patient admit 
 of the operation? Otherwise the sensible practitioner would never 
 think of an attack of Insanity as an opportune occasion for any kind 
 of surgical procedure. 
 
 Galvanism, Faradism, Franklinism. — The application of elec- 
 tricity to the bodies of insane patients should be regarded as a sur- 
 gical procedure, and it should never be intrusted to any but medical 
 nands. 
 
 Electricity is only of advantage in psychiatry when skilfully 
 administered, and it is a betrayal of science and of the best interests 
 
444 TEXT-BOOK ON MENTAL DISEASES. 
 
 of the patients to tolerate nurses to wield this powerful instrument 
 of physical and mental good and evil. The fact is that there are 
 few physicians, be they even psychiatrists and neurologists, who 
 possess sufficient skill to select the best form of electricity in the 
 varying conditions of mental disorder, to manipulate the currents 
 to the best advantage in each case^, and to regulate the dosage so that 
 the patient may derive the greatest benefit and sustain the least 
 shock from the operation. 
 
 Electro-therapy cannot be learned practically from books, and 
 those who have had no special opportunity to acquire skill in elec- 
 trization will do well to dispense with this technical surgical pro- 
 cedure in the treatment of the insane. 
 
 Galvanism. — Of the three forms of electricity, galvanism is un- 
 questionably the most generally useful in the treatment of mental 
 disorders. It is stimulant, sedative, electrolytic, and more deeply 
 influences nutrition than the frictional or interrupted forms of 
 electricity. 
 
 The galvanic current is sedative when used with the anode as 
 the active electrode, and with the cathode with a large surface as 
 indifferent, and the reversal of these conditions and the interruption 
 of the current gives a stimulant effect. The mode of the application 
 of the current and its strength and duration have much to do with 
 the nature of the effect produced. The insane do not bear large 
 doses of electricity well, generally speaking, but light and prolonged 
 currents are most commonly applicable. There are certain disorders 
 of the muscular system and some spinal applications which require 
 currents of from fifty to one hundred milliamperes, and with, these, 
 of course, very large electrodes are used to the spine. Every hospital 
 for the insane should be supplied with reliable electrical apparatus, 
 giving every variety and strength of current. The operator must 
 not rely upon his milliamperemeter entirely, but must test the 
 current upon himself and watch the effect upon the patient, as idio- 
 syncrasy is common and exceptional action will often be seen among 
 the insane. Seances vary from ten to twenty minutes ordinarily. 
 In neurasthenic and melancholic cases central galvanization is val- 
 uable for its effect on the general nervous system, and the cervical 
 sympathetic may be cautiously submitted to the action of the current 
 in the same class of cases. 
 
 In states of cerebral anaemia the galvanization of the cervical 
 sympathetic is to be practised with the anodal action upon the supe- 
 
THE TREATMENT OF INSANITY. 445 
 
 rior cervical ganglion, and the positive pole is used, therefore, in 
 most eases of melancholia and anaemic stupor. In general paresis 
 and in maniacal cases with cerebral congestion the cathode is applied 
 to the cervical point, since the clinical experience of this method 
 shows that it relieves the cerebral hypersemia. 
 
 The general nervousness and extreme restlessness of acute men- 
 tal disorders is best treated by general galvanization with a large 
 cathoide plate at the feet and the anode sponge applied over occipital 
 regions, with slowly increased current, which is to be gradually 
 diminished at the close of the seance. 
 
 The neuralgias, hypalgias, and paraesthesias are treated with the 
 anodal application of the galvanic current, which has been known 
 to favorably influence auditory hallucinations when applied to mas- 
 toid regions. 
 
 The galvanic current is a good vasomotor stimulant in cutaneous 
 capillary stasis of the extremities, so common among the insane. 
 The cathode, in this instance, is at the neck, and the extremities 
 are stroked with the anode in the direction of the venous circulation. 
 
 Insomnia may be relieved by the galvanic bath, warm and pro- 
 longed ten minutes, with a feeble current and with the anode applied 
 to the head at the end of this time. 
 
 Cerebral galvanization is a good sedative in the acute stage of 
 both exalted and depressed conditions. The electrodes are large 
 and the anode is applied to the forehead, and the cathode to the 
 back of the neck. The current at first is very feeble and very slowly 
 increased, and never to exceed a few milliamperes, and the first 
 application should be extremely brief. A current of from one to two 
 milliamperes thus employed for ten minutes will sometimes pro- 
 duce the much-needed sleep. 
 
 Galvanization of the spinal cord is useful in ataxic and paretic 
 cases, and in some toxic insanities with atrophic muscular disorders. 
 Only strong currents of from twenty to fifty milliamperes reach the 
 cord, and a still greater strength may be used to advantage in some 
 instances. The electrodes must be very large; the anode is placed 
 at the upper part of the back and the cathode at the lower part, 
 and the currents are slowly increased and not long applied. 
 
 A descending spinal current has a sedative effect in some cases. 
 
 Faradism. — The Faradic current varies in its properties in ac- 
 cordance with the length of the coils, the size of the wire, and the 
 number of the interruptions. 
 
446 TEXT-BOOK ON MENTAL DISEASES. 
 
 Short coils, with large wires, and few interruptions, give a rough 
 current which rasps the sensory nerves and causes strong muscular 
 contractions. 
 
 Long coils, with fine wires and rapid interruptions, give a smooth 
 current, which is much less exciting. 
 
 In a battery constructed by Kidder for the writer some years 
 ago, there was an outer coil of very long and fine wire, and a secon- 
 darily induced high-tension current, which had effects more like 
 the constant current, and it would relieve the soreness of the muscles 
 caused by rough currents of low tension. 
 
 The different kinds of Faradic currents have their applications 
 in the treatment of mental disorders. In apathetic mental states 
 with relaxed muscles the rough current arouses the patient and 
 brings about the desired muscular contractions. It serves a pur- 
 pose also in the primary and sequential forms of stupor, and in those 
 dangerous moments of exhaustion after acute symptoms when the 
 IDatient is on the verge of sinking into secondary dementia, which 
 can only be prevented by roborant and excitaoit treatment. 
 
 The action of the Faradic current is also of value in vasoparetic 
 conditions, in which the patient presents livid hands and feet. 
 
 The dry electrode and the electric brush affect the sensory peri- 
 phery directly, but in a reflex way they influence other parts of 
 the nervous system. 
 
 The deeper action of the current can only be obtained by moist- 
 ening the skin and the electrodes. 
 
 General faradization, when thoroughly performed, is beneficial 
 in neurasthenic Insanity and in many states of exhaustion after the 
 acute stage of mental disorder. In general faradization the negative 
 pole is placed, in the form of a sheet of copper, at the feet, and the 
 positive pole, with a large sponge, is applied to the back of the neck, 
 and then to all parts of the surface by various attachments. 
 
 One of the most convenient electrodes is with a long wire handle 
 and flat disc covered with sponge to reach all parts of the surface 
 without removal of clotliing. The hand of the operator is the most 
 perfect electrode for adaptation and complete application of the 
 current to every inequality of the surface, and in this case the op- 
 erator holds the anode with his left hand while applying the current 
 with his right hand. This form of application is often borne better 
 than any other by sensitive patients, as the body of the operator 
 is interposed between the patient and the battery. 
 
THE TREATMENT OF INSANITY. 447 
 
 AVith strong currents and the negative plate at the feet, the 
 contractions of the ankle muscles is an objection, and it is then best 
 to use a large soft sponge at the lower end of the spine as the negative 
 pole. 
 
 The faradic bath may be employed for its sedative effect. 
 
 It is sometimes well to alternate general faradization with gen- 
 eral galvanization and with special electrization of nerve-centres, 
 and with electric massage. 
 
 Franklinism. — Frictional or static electricity has not the same 
 wide therapeutic uses in Insanity as the forms just mentioned, and 
 it is more expensive and difficult of management. On the other hand, 
 it is agreeable in some of its applications, and calculated to impress 
 the patient favorabl}'-, and to have a decided psychic influence, and 
 the static induced current might be of real value in the diagnosis 
 and treatment of muscular disorders among the insane, as it is some- 
 what similar to the secondary induced current of the faradic battery, 
 though less effective. 
 
 The static form of electricity is chiefly of value in mental dis- 
 orders as a counter-irritant, stimulant, and reflex excitant. 
 
 The depressed and stuporous may be stimulated 'and aroused 
 on the insulated stool by drawing sparks from all parts of the body. 
 Perverted sensatio'ns, occipital pains, and the cephalalgias of the 
 insane are sometimes benefited by the electrical breeze. Sparks 
 drawn from the back of the neck are useful in counter-irritant ef- 
 fects. The psychic effect is greater than with any other form of 
 electricity, and it is probable that the static electrical bath has some 
 real effect as a stimulant of the circulation, and indirectly favors 
 tissue changes by increasing cutaneous activity and capillary cir- 
 culation. 
 
 The sedative effects of static electricity are only secondary and 
 such as follow primary stimulation. 
 
 Section VIII. — Hygienic Measures. 
 
 The most skilful therapeutic, surgical, or psychic treatment is in 
 vain when it is not based on sound hygienic conditions of environ- 
 ment. 
 
 Some of the chief hygienic measures, which it is the first duty 
 of the physician to provide, will now receive separate consideration. 
 
 The Hygiene of the Residence. — The site of the residence in which 
 
448 TEXT-BOOK ON MENTAL DISEASES, 
 
 the patient as to he treated is impartant. The air in the country, 
 with the exception of malarial districts, is always purer than the 
 air of large cities or towns. 
 
 It is better that the position be somewhat elevated and partially 
 sheltered from powerful winds in winter. The southeastern slope 
 of a large hill is usually an eligible site for a winter residence. 
 
 It is of the utmost importance that the quarters occupied by the 
 patient should have an exposure to sunlight, which purifies the air 
 and is an essential element in the recovery of health. In large 
 cities the rear of houses on the south side of streets running east 
 and west often has the best exposure to sun and the greatest air- 
 space over open back yards. The plumbing of a house in cities is 
 to be carefully inquired into, and in the country the drainage is to 
 be examined, and especial care is to be taken to avoid a house with 
 a damp cellar, or a stone house with damp walls, or an old house 
 with large cesspool drainage in the immediate vicinity. 
 
 All modem hospitals for the insane are supposed to remedy any 
 defects of plumbing or drainage, even at great expense, if need be. 
 
 Ventilation of the residence is the next point to which the phy- 
 sician must attend, for the patient is sustained by the air he breathes 
 as much as by the food he consumes. The chief impurity of air 
 which has been berathed is carbon dioxide, of which a grown person 
 exhales six-tenths of a cubic foot hourly, so an adult requires three 
 thousand cubic feet of fresh air an hour to prevent the carbon diox- 
 ide from rising above the safety limit of six-tenths per centum. 
 
 In hospital structures the rule has been to allow a thousand cubic 
 feet of space per patient, with artificial renewal of the air to reach 
 the physiological quantum of three thousand cubic feet per hour, 
 as above mentioned. 
 
 Atmospheric pressure, differences of temperature, and the dif- 
 fusion of gases chiefly cause currents and renewal of air in dwellings. 
 Natural ventilation is aceomphshed by doors, windows, and the 
 chimneys of ordinary houses. The air in the patient's room should 
 be kept purer, and perhaps at a different temperature, than that 
 in the house generally, but if the door of the room is kept open 
 it may only become a passage-way for the ventilation of the lower 
 part of the house. The first thing is to make the sick-room inde- 
 pendent of the rest of the house, as far as possible, by air-tight strips 
 at the top and bottom of the door, and then by a fireplace and out- 
 side windows any desired temperature and abundant fresh air can 
 
THE TREATMENT OF INSANITY. 449 
 
 be provided. If there is only one window, it may be opened a little 
 at the top and bottom, and if there are two windows one may be 
 opened at the top and the other at the bottom. 
 
 The theory is that the warm and impure air goes out at the top, 
 and the fresh and cool air comes in at the bottom of the window- 
 openings. In the main this is so, but the forces controlling ventila- 
 tion are so complex that their resultant cannot be foretold with 
 theoretical certainty, and when a window is opened at top and bot- 
 tom there will often be at both places a double current outgoing 
 and incoming, and the vaiiious gases in the room will rise or fall, 
 according to their density, the degree to which they are heated, 
 and relative differences between outside and inside currents estab- 
 lished. The main point is to accomplish the admixture of fresh air 
 without undue draughts upon the patient. 
 
 The temperature of an artificially heated room should not rise 
 above 68° F., on the average. The flame of a candle may be sufii- 
 cient to start upward ventilation in a chimney, and a fire creates 
 a powerful exhaust from the room in this way and is a capital means 
 of ventilation, provided there is an inlet for pure air. 
 
 Artificial methods of ventilation are used in hospitals in which 
 heating-flues and separate ventilating-flues are built in each room. 
 The air is sometimes renewed by forced ventilation by large fans 
 keeping a plenum of warm air, which displaces that in the rooms, 
 and, again, exhaust-fans are used to draw the air out of rooms. The 
 modern electric fans are efficient in the latter method. Space will 
 not permit a description of the many methods of ventilation and 
 heating of hospitals. They all have advantages and disadvantages, 
 and none are perfect. The whole system of heating-flues has the 
 defect that dust and germs accumulate in them and are then blown 
 into the air which is to be breathed. 
 
 Open fireplaces are the best means of heating, but in cold cli- 
 mates they ai'e inadequate and should be supplanted by a system 
 of hot-water pipes. 
 
 Direct radiation, which heats the patient rather than the air, 
 is preferable, and the temperature of the room is not then required 
 to be kept at such a high degree as to debilitate the patient. 
 
 All kinds of thin metal stoves are unhygienic and allow gases to 
 escape into the room. The burning of gas-jets and of oil-lamps 
 is a source of impurity in the air. Every such flame consumes twice 
 as much oxygen as a person. Electricity is vastly preferable on this 
 account as a means of illumination. 
 29 
 
450 TEXT-BOOK ON MENTAL DISEASES. 
 
 Carpets, rugs, tapestry, and all articles which collect dust and 
 germs are unhygienic. Dusting a room should be done with a soft 
 rag, moistened in antiseptic solution in some instances and carried 
 from the room, and care is to be taken that dust is not simply stirred 
 up into the air instead of being completely removed. A hard-wood 
 poUshed floor is best, and strips of carpet, which can be daily shaken 
 in the open air, are cheaper and better than rugs. A room is better ■ 
 without anything of the kind, and a strip of blanket warmed at the 
 fireplace and spread beside the bed for the patient to stand upon 
 while dressing is all that is necessary for the most delicate patient. 
 
 The bed is a hygienic point of great importance, as more than 
 a third of the patient's time, on the average, is passed in bed. 
 
 The best bedstead for general use among the insane is made of 
 iron and is adjustable as to height, for which twenty inches is a 
 good standard, and the breadth should be nearer four than three 
 feet. A removable wire mattress is attached to this bedstead, which 
 is cheap, cleanly, and durable, and, if enamelled white, is also a pre- 
 sentable article of furniture. 
 
 A hair-mattress of full size, and weight not less than twenty 
 pounds, made of thoroughly cleaned and dusted hair, completes 
 the bed. 
 
 Cotton sheets and fine, medium-weight, woollen blankets, and 
 a plain cotton coverlet makes up the outfit, with the exception of 
 two pillows of feathers. A hop-pillov/ and an air-pillow may be used 
 for special cases. 
 
 Cleanly neurasthenic cases, in cold weather, sleep better between 
 blankets without sheets. In patients with deficient vital heat, in 
 winter it is well to have a blanket between the lower sheet and the 
 hair-mattress, as the latter alone admits of the ready abstraction 
 of heat. A rubber-sheet and a draw-sheet are to be used in some 
 uncleanly cases. In exceptional cases water-beds or air-beds are 
 of service. 
 
 If blinds at the windows are not sufficient, a roller-curtain may 
 be employed, with a duplicate in dark color for more complete ex- 
 clusion of light. Hanging curtains collect dust and germs. A fold- 
 ing screen is a useful article for shutting ofl! light and draughts of 
 air, but it should be removed from the room when not in use. 
 
 The, Hygiene of the Person. — The insane patient, through gen- 
 eral excitement, delusion, or stupor, is neglectful of personal hy- 
 giene, and the nurse, under the direction of the physician, must 
 
THE TREATMENT OF INSANITY. 451 
 
 provide for the sanitary condition of the person and clothing of the 
 patient. This is a difficult matter in practice, and relates to the 
 final result obtained more directly than may be supposed, and the 
 physician must concern himself with it, for it is not a mere question 
 of nursing. 
 
 The clothing of the insane must vary in different cases, and in 
 the various phases of the malady, and it demands medical judgment 
 to adapt the clothing to the hygienic requirements of the case. The 
 psychic influence of dress, especially with women, is very decided, 
 and a new gown will buoy their drooping spirits and prop their self- 
 esteem in the critical fluctuations of the malady. 
 
 Take a woman in the debihtated stage after acute mania, whose 
 reason is hanging in the balance between convalescence or hopeless 
 dementia, clothe her anew in handsome attire, let her drive out with 
 some lady friend less well-clad, let the prop remain on the return 
 from her outing, and the new suit be worn continuously, and the 
 scale of recovery may be thus turned in her favor. All convalescent 
 patients should be clothed as becomes their station in life, and some- 
 what better than has been their custom. It is a serious mistake to 
 prolong the usage of such plain dress as is appropriate in the acute 
 phases of mental disorder. 
 
 The maniacal patient who, despite the closest attendance, will 
 ruin a suit in a brief space of time, should be clad in plain, washable 
 material, which may be completely changed every few days, if need 
 be, in order to preserve a perfectly cleanly and presentable appear- 
 ance. 
 
 Strong quilted gowns and canvas suits which are indestructible 
 are, in the rarest instances, to be employed, but their frequent use 
 points to inefficiency on the part of the nurses, who are to be advised 
 to this effect by the physician. 
 
 The numerous primary dements, stuporous melanchohacs, and 
 periodical maniacs in the depressed stage are seldom clad warmly 
 enough to conserve the slight animal heat resulting from their im- 
 paired metaboHsm. After electric baths to stimulate their cyanotic 
 skin, their extremities should be clothed in woollen underwear, 
 which should only be removed in hot weather. 
 
 It is a hygienic necessity that certain neurasthenic cases of In- 
 sanity should wear fine and full-weight woollen underclothes the 
 year round, and this is true also of man}'' women not of this partic- 
 ular type, but possessed of delicate constitutions and susceptible 
 pelvic organs. 
 
452 TEXT^BOOK ON MENTAL DISEASES. 
 
 Intestinal fermentations, toxaemias, and vasoparetic states in 
 Insanity account in part for the peculiar abdominal vulnerability 
 to cold, which is best guarded against by a flannel binder, to be 
 worn about intestinal and renal regions, even in warm weather. 
 
 Strong and warm maniacs, with full turgor vi talis and roseate 
 skin, which is hypersesthetie often, actually suffer from woollen 
 wear, and they persistently strip themselves to get relief. They 
 seldom, if ever, take cold in this condition, and they should be given 
 light Knen wear, which is a comfort to them, 'and they should not, 
 by a thoughtless routine, be afflicted with the regulation under- 
 wear until they reach the stadium debilitatis. 
 
 Then, again, there are cases of toxic Insanity demanding extra 
 heavy woollen wear; not alone that it is warm, but also hygroscopic, 
 and the object is to promote elimination of the deleterious material 
 by cutaneous perspiration. 
 
 Puerperal maniacs having suffered extensive losses of blood need 
 very warm underwear, especially for the lower extremities, in addi- 
 tion to the flannel binder. 
 
 All these are instances for medical direction in dress. 
 
 The shoes are very important, and there should be supplied two 
 pairs, to be worn alternately, that they may be ventilated and dried 
 thoroughly after use. They should be of the walking-shoe pattern, 
 and as waterproof as practicable. 
 
 Indoors, house-shoes or slippers should be worn, but in winter 
 they should be warm and come well up on the ankle. 
 
 The night-dress is best of soft flannel or woollen-wove. It 
 should be one garment from neck to ankles, with full-length sleeves, 
 and should have only one straight buttoned opening, from the left 
 side of the neck to the tip of the left shoulder, and should be large 
 -in all dimensions, and it is slipped on and off over the head. 
 
 Cases of Insanity with rheumatic and gouty diathesis often do 
 best with red flannel underwear. 
 
 Coarse woollen wear, which might be intolerably irritating to 
 hyperassthetic patients, may be of benefit to apathetic cases with 
 sluggish capillary circulation and hypsesthetic cutaneous surfaces. 
 
 Cleanliness and the care of the skin in the insane is a hygienic 
 measure calling for constant attention. Hot- water baths and a free 
 use of a good toilet soap are essential. 
 
 The special uses of water-cure in mental disorders will be pres- 
 ently described. 
 
THE TREATMENT OF INSANITY. 458 
 
 The mouth and teeth must not be neglected. Caries of the 
 teeth is unusually common among the insane, and in the toxic insan- 
 ities a specially constant symptom. Dental neuralgia may be a per- 
 manent obstacle to recovery, and the constant contamination of the 
 buccal secretions by carious teeth, which taint the saliva and food, 
 should receive prompt treatment by a dental surgeon. 
 
 Irrespective of carious teeth the mouth is sometimes offensive 
 from foul secretions, sordes, and micro-organisms, and a mouth-wash 
 of biborate of sodium, chlorate of potassium, glycerine, and lemon- 
 juice is effective as an antiseptic measure. 
 
 The insane frequently rub filth into their hair, which in men 
 had better be kept close-cut, and the scalp is to be occasionally 
 shampooed. After the latter process in women great care is to be 
 taken to properly dry the hair to prevent aggravation of the neural- 
 gic pains of the scalp so common in Insanity. 
 
 Eubbish and foreign particles often get into the eyes, nose, and 
 ears of patients, who, through delusion or perversity, stuff their nares 
 and auditory canals until they develop local inflammations. The 
 otorrhcea and middle-ear disease of the insane is partly due to this 
 cause. Patients having this propensity should be examined by the 
 physician daily. The nurse may pick loose bits of paper, straw, or 
 wood from the ear, but should report at once to the physician any- 
 thing which has passed deeply into the ear. 
 
 The eye is so delicate an organ that, except to remove small for- 
 eign particles with the moistened corner of a handkerchief, the 
 nurse will do well to make known any unusual condition at once to 
 the physician, and not to go further than to evert the lid in search 
 of the irritant material. It often requires all the skill of the surgeon 
 to extract foreign bodies from eyes and ears without damage to the 
 organ, and neither fluids nor crude instruments should be used by 
 nurses. 
 
 Pruritus vulvae, among the insane, is often due to lack of clean- 
 liness, and sitz-baths and vaginal douches are to be employed. 
 
 Pruritus ani arises also from personal neglect, and even when 
 toilet paper is supplied it is not properly used by many of the insane. 
 The hemorrhoids among the insane are often the result of local irri- 
 tation from uncleanliness. 
 
 A bidet in water-closets is a very useful arrangement for deliv- 
 ering a small stream of water of graduated temperature to perineal 
 parts after stool while the patient is still seated. 
 
454 TEXT-BOOK ON" MENTAL DISEASES. 
 
 The writer long ago discovered that hot-water enemas, absolute 
 cleanliness, and cocoa-butter suppositories would cure many forms 
 of hemorrhoids in the early stages. 
 
 ■ Masturbation in insane women not infrequently arises from local 
 hypera3mias, and hyperesthesias due to uncleanliness, and by va- 
 ginal and rectal enemas and the use of the bidet the symptom may 
 be relieved. 
 
 The nurse, while bathing men, should see to preputial cleanli- 
 ness, and circumcision is often of advantage and occasionally may 
 obviate a tendency to masturbation. 
 
 The strong odor of maniacal women is due in part to axillary 
 bromidrosis and to vulvar hypersecretions, best relieved by a stream 
 of hot water to the parts, followed by an antiseptic wash of perman- 
 ganate of potassium. 
 
 There are many other minor points in the hygiene of the person 
 of the patient for which the nurse and the physician must provide 
 in order to place the patient in the most favorable conditions for 
 recovery, but space will not here permit further details on this score. 
 
 The Open-air Cure. — When the writer took charge of the New 
 York City Asylum for the Insane an unusual amount of freedom 
 and open-air Hfe was given to many of the patients, and the cures 
 which resulted proved an instructive lesson, which has been contin- 
 uously applied with profit in both hospital and private practice. 
 The provision for open-air life is the most powerful hj'^gienic meas- 
 ure for recovery. The patient is to live out of doors and to enter 
 the house only to take rations of food and sleep, or for necessary 
 purposes. 
 
 In rainy weather arbors and open-air pavilions, with secure roofs, 
 are to be utilized, and appropriate seats are to be provided, and in 
 cool weather heavy, wai-m lap-robes and cushions are indispensable. 
 In summer a pine-grove is a desirable locality, but in cooler weather 
 open exposure to the sun is to be sought. 
 
 Camping-out and life on a yacht have been tried with success. 
 In hot weather tenting-out in the mountains or at the sea-shore may 
 be a practical measure. 
 
 The open-air cure is not contra-indicated in maniacal patients, 
 who often become more composed at the end of a few days of this 
 treatment, which so strongly favors appetite and sleep. 
 
 An army-cot, with warm robes and a pillow, should afford an 
 opportunity for sleep in the open air, so often as the patient feels 
 
THE TREATMENT OF INSANITY. 465 
 
 drowsy, and eveiy hour thus spent is so much solid gain in acute 
 cases. If hammocks are used, they are to be secured against turning, 
 that there may be no falls. 
 
 On return to the house at night windows are to be left open in 
 sleeping apartments, which are not to be heated above 65° F. at 
 any time during the trial of this method, which, if perseveringly 
 carried out for some weeks, often yields surprisingly good results. 
 
 Care is to be taken that the patient is kept warm at all times, 
 and is supplied with concentrated nourishment in small amounts 
 between meals. 
 
 The Best-cure, — Dr. S. Weir Mitchell deserves the credit of this 
 method of treatment, as now practised from three to eight weeks 
 together. A large, sunny, well-ventilated room is chosen, with an 
 adjoining room for a nurse, who proceeds, by a daily time-schedule, 
 to feed, bathe, and rub the patient, who is isolated, recumbent, and 
 quiescent at all times. Massage takes the place of active exercise, 
 and dressing and undressing is done by the nurse, should there be 
 any special occasion for it. The bed-pan is used, and in most cases 
 the patient is not even allowed to assume the sitting posture in bed. 
 
 The diet consists largely of milk and concentrated beef essence. 
 The milk, in part, may be predigested. 
 
 Fresh eggs, beef, and mutton are given in generous amounts in 
 certain cases. There are three principal meals, and between times 
 some liquid nourishment. Supper is to be light, and, if need be, 
 some liquid food may be taken during the night. Massage sui!ices 
 at first, then electricity is used to contract muscles, and, finally, 
 Swedish movements are employed. Malt extract before meals and 
 tonics after meals, with special drugs if indicated, completes the 
 treatment, which is terminated by a gradual return to active habits. 
 
 The following is quoted from Professor Dana's " Text-Book of 
 Nervous Diseases," p. 519: "A typical schedule for a rest-cure pa- 
 tient, as given by Dr. John K, Mitchell, is the following: 7 a.m., 
 cocoa, cool sponge-bath, with rough rub, and toilet for the day. 
 8 A.M., milk breakfast. Eest an hour. 10 a.m., 8 ounces of pepton- 
 ized milk. 11 a.m., massage. 13 noon, milk or soup. Eeading aloud 
 by nurse. 1.30 p.m., dinner. Eest an hour. 3.30 p.m., 8 ounces of 
 peptonized milk. 4 p.m., electricity. 6 p.m., supper, with milk. 
 8 P.M., reading aloud by nurse one-half hour. 9 p.m., light rubbing 
 by nurse with drip-sheet." 
 
 The rest-cure may be used to good advantage in some neuras- 
 thenic and hysteric cases of Insanity. 
 
466 TEXT-BOOK ON MENTAL DISEASES. 
 
 This class of cases often take to bed instinctively, and the chief 
 danger is that the bed-habit will become confirmed, as in many other 
 cases of Insanity, in which the will-power is much impaired. 
 
 Forced Recumbence Versus Forced Exercise. — Many years ago 
 the writer became impressed with the idea that perfect quiescence 
 was required by the brain, as the suffering organ in mental disor- 
 ders, and, in order to favor the heart also, treated large numbers 
 of insane in bed. 
 
 Most cases thus treated in forced recumbence improved for the 
 first two weeks, and some continue to improve for six weeks, while 
 others, at the end of the fortnight, begin to lose appetite and weight, 
 and at the end of a month have suffered general vascular and mus- 
 cular debility, as well as psychical relaxation to the point of com- 
 plete abulia. Eubbing and bathing will not prevent this latter result 
 in many cases. 
 
 Forced recumbence does well in feeble senile maniacs, in mania 
 arising in puerperio, in all cases of acute exhaustion from mental 
 disease, and in acquired neurasthenic Insanity from excessive over- 
 strain of mind or body, and in choreic youthful eases. Mental alien- 
 ation as a sequel of acute infectious diseases may be attended with 
 general systemic exhaustion, which indicates the recumbent mode 
 of treatment. Post-febrile Insanity in children, severe cases from 
 trauma capitis or spinal concussion, and intercurrent surgical affec- 
 tions demand forced recumbence, but all other classes of cases, al- 
 most without exception, do better without it. 
 
 All the hereditary neurasthenics, hysterics, and hypochondriacs 
 become more abulic and get a bed-habit, and the contest with them 
 is best made in the directly opposite direction of systematic exer- 
 cise and occupation. The muscular activity of maniacs is a natural 
 channel of discharge for irritated cortical centres, and is a safety 
 valve not to be checked by forced recumbence. 
 
 Even general paretics, in the last stage, live longer and do better 
 sitting up than in bed, and this is true of organic dements, and of 
 nearly every other type of terminal Insanity. 
 
 Forced exercise is a hygienic agency which has cured many pa- 
 tients. 
 
 Most cases of Insanity from the neuroses have a constitutional 
 indisposition to exercise, which they should be forced to take daily, 
 even if they cannot be induced to engage in any useful occupation. 
 Their walks should stop just short of actual fatigue, and even a 
 
THE TREATMENT OF INSANITY, 457 
 
 little of tlie latter in those of strong musculature is of decided 
 benefit. 
 
 Strong, turbulent maniacs, upon whom drugs and other means 
 had been tried in vain, the writer has time and again cured outright 
 by putting them at farm-work, and he has seen many chronic 
 maniacs work out their own cure in this same way. 
 
 In acute mania severe muscular exertions are not to be pre- 
 scribed, ordinarily, as theoretically, at least, the state is one of cere- 
 bral exhaustion. It is a mistake, however, to suppose that this 
 is always the case. Some sane men always find most immediate 
 relief from cerebral exhaustion and mental strain by severe mus- 
 cular exercise, and in the same way some muscular acute maniacs 
 equalize their circulation, derive from congested cerebral centres, 
 discharge pent-up cortical nerve-force, and improve their nutri- 
 tion and sleep by out-of-door labor of an accustomed kind. Acute 
 maniacs have been known to rapidly recover in this very way when 
 generously fed. These same patients, if not allowed to expend their 
 force in the open air, put forth continuous muscular efforts while 
 breathing house-air, and in practice, contrary' to neurological the- 
 ories, the suppression of these same efforts is harmful rather than 
 otherwise. 
 
 Expert judgment is required to decide in what acute maniacal 
 cases out-of-door customary exercise is to be permitted. The pa- 
 tient must not be allowed to expend more force than can be daily 
 renewed. If held by attendants to suppress all activity, he may in 
 a brief hour put forth vastly more nervous energy than in a week's 
 outdoor occupation, and, on account of the suddenness of the ex- 
 penditure, may not be able to recuperate from it for weeks. 
 
 Forced exercise is essential in all stuporous and demented con- 
 ditions, and a daily walk out-of-doors should be practised, even in. 
 cataleptic cases, and in melancholic patients with complete mus- 
 cular atony. 
 
 Forced exercise is an effective means of arousing the patient in 
 the early convalescent stage following acute attacks, ait which time 
 there is danger of secondary dementia. Such patients are to be 
 taken between two attendants, if need be, and urged to a lively 
 pace. Dancing to lively music is sometimes good to overcome the 
 torpor of such sluggish patients. 
 
 The muscular inhibition of melancholic cases becomes a con- 
 firmed habit, which requires to be broken up by forced exercise at 
 the termination of the acute stage. 
 
458 TEXT-BOOK ON MENTAL DISEASES. 
 
 It requires mucii judgment to decide in what cases forced re- 
 cumbence or exercise may give the best result, and this important 
 decision is by no means to be left to nurses. 
 
 Gymnastics. — All hospitals for the insane should have a well- 
 equipped gymnasium as a hygienic resort for patients during the 
 ice, snow, and storms of winter. At such times regular classes should 
 be formed under a competent teacher, and in accordance with the 
 physician's directions in each case. The more dangerous forms 
 of exercise are to be avoided, but all the ordinary gymnastic ap- 
 paratus admit of useful and safe application in certain cases. In 
 women, of course, the range of g5minastic performances is more 
 limited, but still of much value. 
 
 Practice in classes is a distinct advantage in abulic cases, and 
 with women especially the force of numbers and of example is a 
 decided aid in gymnastics. 
 
 Light wooden dumb-bells are best for class use, and regular 
 movements should be simultaneously executed by all, the teacher 
 setting the example and standing in full view of the class. 
 
 Swedish Movements. — In the absence of gymnastic apparatus 
 Swedish movements make a very good substitu.te for use, singly or 
 in classes, among the insane. Every mascle in the body may be ex- 
 ercised by this method, which must be pursued in each case under 
 the physician's instructions. Not only passive and active move- 
 ments, but concentric movements, made by the patient while resisted 
 by the teacher, are of special value to the patient, who sometimes 
 takes pleasure in overcoming the operator, who is to be careful not 
 to tax their strength. Eeference must be had to special manuals 
 for full details of Ling's system. 
 
 CalistTienics. — Many years ago, among the writer's patients, cal- 
 isthenics were employed at the New York City Lunatic Asylum. A 
 regular 'gymnastic room was provided, a teacher was employed, and 
 music was daily furnished. The calisthenics consisted in rhythmical 
 movements of body and limbs in time to music, marching and coun- 
 termarching, the formation of pleasing figures, with long, wooden 
 wands, and a variety of motions modelled after the Swedish system. 
 
 Patients who could not be induced to perform singly learned 
 to take pleasure in calisthenics in classes, and in time to music. 
 
 Great importance in this connection is to be attached to music, 
 which fitly furnishes the necessary psychomotor impetus in those 
 devoid of spontaneity. 
 
THE TREATMENT OF INSANITY. 459 
 
 Outdoor Games. — To say nothing of the psychic efEect, outdoor 
 games supply needful exercise, which by many patients will only 
 be taken in this way. Croquet is appropriate for the less active 
 v,'omen, and lawn-tennis will satisfy those fond of more agile move- 
 ments. 
 
 Quoits are fitted for middle-aged and elderly men, and ball 
 games for the young and active. There is an element of danger in 
 baseball, but, as it is the American game and excites more enthu- 
 siasm than any other among patients, it is not to be denied them. 
 Match games between patients and attendants are often watched 
 with keen interest by hundreds of insane patients, who applaud the 
 good strokes with great promptness and gusto. 
 
 Horseback and Bicycle Exercise. — Horseback riding is beneficial 
 to certain patients with torpid livers and defective peristalsis, and, 
 in those accustomed to it, is a most exhilarating and desirable exer- 
 cise. It should never be tried with patients who are not skilful horse- 
 men, and should only be allowed under close attendance, and with 
 perfectly safe saddle-horses. 
 
 Bicycle exercise on good roads without any steep hills, when 
 the patient already possesses the necessary skill, is one of the best 
 forms of exercise. Unfortunately, there is a lurking danger in 
 bicycling, which the physician can only prescribe after a full under- 
 standing with the relatives of the patient as to the risk incurred. 
 Great moderation must be observed in the use of this hygienic agency 
 among the insane, and one hour of gentle cycling is about the ex- 
 treme limit for a single outing. 
 
 With a good maehine, a properly conformed saddle, the erect 
 posture, and with the weight equally distributed between handle- 
 bar, pedals, and saddle, most muscles in the body are brought into 
 play and a highly animating form of exercise is enjoyed. 
 
 Hydrotherapy in Insanity. — All hydro-therapeutic effects are 
 produced chiefly through the physiological action of heat and cold 
 upon the peripheral nervous system, and in a reflex way upon vaso- 
 motor and trophic centres. 
 
 Cold, widely and briefly applied to the external nervous periph- 
 ery, causes first contraction and then dilatation of cutaneous capil- 
 laries, increases the frequency and force of the heart and the num- 
 ber of the respirations, stimulates the heat centre, and increases 
 metabolism and the excretion of urea and carbon dioxide. 
 
 The temporary application of heat to the periphery of the ner- 
 
460 TEXT-BOOK ON MENTAL DISEASES. 
 
 voiTs system has similar results to t'hose mentioned, except that 
 the heat centre is not stimulated and the capillary dilatation is 
 more immediate and not secondary to blood withdrawal to central 
 organs, and hence the reaction is not felt. 
 
 The alternate use of heat and cold to the nervous periphery has 
 still more powerful effects. 
 
 Hydrotherapy in Insanity is employed to stimulate the vaso- 
 motor system, to increase tissue changes, to diminish temperature, 
 to promote cutaneous elimination, and to effect nervous sedation. 
 
 Some of the chief forms of hydrotherapy in mental disorders 
 will now be described. Thermometers must always be employed. 
 
 The tepid lath ranges in temperature from 82° to 92*^ F. It is 
 useful in maniacal patients of full habit, in whom excitement and 
 muscular exertions have raised the temperature one or two degrees. 
 In such cases a tepid bath in the evening, lasting from ten to twenty 
 minutes, with superficial friction of skin while in the water to 
 preserve capillary activity, will restore normal temperature and qui- 
 etude, and often produce several hours of refreshing sleep. 
 
 It may be employed in maniacal cases of less robust constitution 
 and having less vital warmth, but the duration must not be more 
 than five minutes. The tepid bath in delicate and neurasthenic 
 women is used for its tonic influence, as the cold bath is in strong 
 persons, and it should then be brief and followed by friction of the 
 entire surface to establish a reaction. In feeble persons with a rise 
 of temperature the tepid, rather than the cold, bath is employed to 
 abstract heat. 
 
 The warm hath varies from 92'' to 102° F., and its most custom- 
 ary use is for purposes of cleanliness, with a free use of soap. 
 
 A warm bath, from 96° to 100° F., is the safest and most uni- 
 versally applicable form of sedative in all asthenic maniacal cases, 
 and its duration must vary from ten minutes to a half hour, accord- 
 ing to its effects, which must be persoinally observed by the physician 
 in this class of eases. It is well to give an eggnog before the bath 
 in exhausted maniacal cases, and to repeat the stimulus during the 
 immersion, if need be. 
 
 Cases of melancholia do not bear tepid baths well, as a rule, but 
 warm baths have a full sedative effect when continued for a half 
 hour at a temperature not above 99° F. Cold applied after removal 
 from the bath negatives the sedative effect, and is therefore to be 
 avoided. Cold is applied to the head during the bath. Prolonged 
 
THE TREATMENT OF INSANITY. 461 
 
 warm baths have been largely employed in Insanity by both Con- 
 tinental and English physicians. The bath varies from 85° to 98° 
 F., and is prolonged from one to twenty-four hours. In fact, pa- 
 tients have been thus immersed several days at a time. Cold com- 
 presses, or a small stream of water, have usually been applied to the 
 head in the meantime. 
 
 Maniacal patients have been cured outright by this heroic treat- 
 ment, but there have also been cases of dangerous collapse, and fatal 
 results are liable to occur. The writer's experience is that all the 
 beneficial results may be obtained by baths nearer the temperature 
 of the body, and not prolonged beyond two hours, but repeated 
 during the day. 
 
 The dangers of the more heroic method are largely avoided by 
 giving repeated immersions of not more than an hour, or, exception- 
 ally, two hours, at a temperature of from 92° to 96° F. Cold appli- 
 cations to the head are essential to prevent cerebral congestion. 
 The result of such a prolonged immersion is that the maniacal pa- 
 tient is composed for four or five hours, and sometimes for a whole 
 day, and, so soon as signs of cerebral excitement reappear, the pa- 
 tient is again to have a combined bath with cold to the head. The 
 prolonged bath is applicable also to the excitement of acute melan- 
 cholia. 
 
 The hot bath has a temperature of from 102° to 112° F. 
 
 There are some patients who will not bear prolonged warm 
 baths, but do better with hot baths from 102° to 105° F., and, 
 strange to say, the effect is sedative and not excitant. 
 
 In the use of the prolonged hot bath cold affusions, or the ice-cap, 
 to the head are indispensable, and one-half hour is the usual time 
 limit. The physician should always be present to observe pulse, 
 respiration, and cerebral effects. Women may wear a cotton night- 
 dress, or a sheet may be fastened about the neck at one end and the 
 other end drawn over the foot of the bath-tub and spread out, and 
 so fastened as to cover the patient completely from view. Dr. Buck- 
 nill uses a reclining chair in some cases for prolonged baths, and 
 thus patients are lifted into a large bath-tub. 
 
 Wooden covers, with openings for the head, are not without 
 danger among the insane, and cannot be recommended, and any- 
 thing giving the impression of forced confinement while bathing 
 is specially objectionable, and often causes violent emotional or de- 
 lusional ■ excitement. 
 
462 TEXT-BOOK ON MENTAL DISEASES. 
 
 In neurasthenic Insanity the stimulant effect of brief hot baths 
 of not more than three minutes' duration, at the temperature of 
 105° to 110° F., is more decided than cold applications, which are 
 seldom well borne, and this is also true of many of the diathetic 
 and toxic melancholias. In most states of mental depression, stim- 
 ulation is better accomplished by heat than by cold. 
 
 The debilitating effects of repeated hot baths 'are avoided by the 
 momentary application of a cold drip-sheet to the whole cutaneous 
 surface immediately upon leaving the bath. 
 
 In tabetic cases, immersion of the lower extremities in a hot bath 
 often gives temporary relief from pain. A hot half bath may also 
 temporarily relieve the paraBsthesia in alcoholic and syphilitic cases. 
 
 Hot baths diminish the tactile illusions and the muscular pains 
 in toxic Insanity, and they are occasionally of service in congestive 
 dysmenorrhoeal conditions common among insane women. In the 
 choreic Insanity of children they may be employed to relieve the 
 spasmodic affection and procure sleep. 
 
 Hot sitz-haths are indicated in mental aberration from suppres- 
 sion of menstruation after exposure to cold. In the dysmenorrhoea 
 of Insanity, for their emmenagogue effect at the time of the regular 
 return, they may be conjoined to other remedies. 
 
 They relieve vulvar paraesthesia, and are more useful than cold 
 sitz-baths in hyperesthesia of the membranous portion of the ure- 
 thra in masturbatic cases. Hot sitz-baths range in temperature 
 from 103° to 122° F. 
 
 The hot wet-pack is, in patients unable to bear a full bath, an 
 efficient sedative. A blanket is spread out, and a cotton sheet wrung 
 out of water, as hot as can be borne, is quickly spread over the 
 blanket, and upon this the naked patient lies and is folded in the 
 sheet and blanket. 
 
 A cool application may be made to the head and another blanket 
 may be thrown over the patient if the room is cool and the pack 
 continued from twenty minutes to an hour. In still feebler cases 
 hot dry-packs may be given. The patient is folded in a warm dry 
 blanket and a second blanket is also employed, and the result is 
 usually perspiration and a sedative effect and sleep. In delicate 
 women patients, this is a good introduction to a hydrotherapeutic 
 course of treatment to be followed by the hot wet-pack and then 
 the wet-pack at diminishing temperatures. 
 
 The hot dry-pack is useful in exhausted maniacal or melancholic 
 patients, and in feeble senile dements. 
 
THE TREATMENT OF INSANITY. 463 
 
 The hot spinal douche may be given in a bath-tub having hot 
 and cold water connections, so as to graduate the temperature and 
 a certain pressure of the stream through a piece of rubber tubing, 
 to whidh different shaped nozzles may be adjusted so as to give 
 a stream of hot water, from the size of a lead-pencil to an inch or 
 more in diameter. The patient sits in the bath-tub and the stream 
 is directed the entire length of the spine, or immediately over such 
 portions as are especially to be influenced. A powerful counter-irri- 
 tant influence may be thus exerted with water as hot as can be 
 borne without injury to the skin, which is to be carefully avoided. 
 The spinal douche may also be siphoned dov/n upon the patient 
 through rubber tubes from vessels of known temperature placed 
 above the patient, but the impact of the falling water must be con- 
 sidered in large jets. It is possible to get very decided effects on 
 cerebral circulation, and to influence the thoracic, abdominal, and 
 pelvic viscera by the hot spinal douche. 
 
 Hot spinal hags are more convenient, but less decided than the 
 spinal douche in general effect. They are applied to any portion 
 ,of the spine at a temperature not exceeding 130° F., for periods 
 varying from one-half hour to several hours, according to the de- 
 gree of heat and the effect desired. They are specially useful in 
 melancholic oases with subnormal temperature, and in restless senile 
 dements lacking in vital heat they sometimes produce sleep. They 
 have this latter effect also in some cases when applied over epigas- 
 tric or a,bdominal regions. 
 
 Hot spinal bags often relieve the paresthetic and neuralgic 
 symptoms of neurasthenic, hysteric, and hypochondriacal cases. 
 They are useful in spinal anaemia in melancholic women, and they 
 may be applied over the sexual lumbar centre in the spinal exhaus- 
 tion of masturbatic men. 
 
 Hot-water bottles, made of rubber and covered with cloth, of all 
 shapes and sizes, for the local application of heat, are very con- 
 venient. 
 
 Fomentations are chiefly moist, but they may be dry, and they 
 are made usually by flannel wrung out of hot water and immediately 
 applied to relieve pain or inflammation or to promote suppuration, 
 and in the latter instance spongiopiline is better than flannel. My- 
 algia and muscular spasms are so common among the insane, as well 
 as ulcers, abscesses, cellulitis, arthritic troubles, and colic, that there 
 is often occasion to use fomentations, either of simple hot water 
 
464 TEXT-BOOK ON MENTAL DISEASES. 
 
 or with the addition of mustard, turpentine, or laudanuiji. Hot 
 dry fomentations are palliative in the trigeminal neuralgias of the 
 insane. 
 
 Rubber coils of small flexible tubing, which can be passed about 
 a limb like a spiral bandage, are convenient for the continuous ap- 
 plication of heat by means of hot water, which is siphoned through 
 the tubing from a hot-water vessel placed above the patient and 
 caught at the lower end of the coil in another vessel beside the 
 bed. The same tubing can be stitched to cloth, holding it in any 
 desired shape and applied to any part of the body for either hot or 
 cold water applications. A continuous coil of it thus arranged is 
 a practical means of consitant use of heat or cold 'to the head, as it 
 readily adjusts itself like a cap to vertical regions. The flow of water 
 may be started by suction at the lower end of the tubing. 
 
 In anaemic insomnia due to spastic vascular conditions in melan- 
 cholia, the hot coil to vertical regions will often give prompt relief. 
 It is to be gently removed as soon as sleep begins. The neuralgic 
 pains in the extremities arising in alcoholic and ataxic cases of In- 
 sanity are best relieved by heat, not to the limbs, but over posterior 
 spinal nerve-roots corresponding to parts affected. 
 
 Foot-baths, from 110° to 120° F., are used chiefly for their deriv- 
 ative effect on the circulation of the brain, and in this way they 
 favor sleep. Mustard may be added to the water when a more de- 
 cided local stimulation is desired. 
 
 Cold baths, varying from 40° to 70° F., are employed for their 
 tonic effect on circulation and nutrition. Eeaction must follow, 
 otherwise the tone of the system is not increased. Insane patients 
 do not react well, as a rule, after cold baths, but cutis anserina and 
 lowered temperature and increased depression result in many mel- 
 ancholic cases and also in some maniacal cases. 
 
 In sthenic mania, especially wben there is a rise of temperature, 
 the cold bath at 70° F., continued from ten to twenty minutes, is 
 both tonic and quieting. 
 
 While in the bath the surface of the patient should be gently 
 rubbed to continue capillary activity, and, if cutaneous circulation 
 is still good at the close of the bath, a cold affusion of water at 40° 
 F. may be used. 
 
 In the hyperpyrexia of acute delirious mania, provided the heart 
 and lungs are sound, a brief cold bath at 50° F. abstracts heat and 
 diminishes cerebral excitement. Eepeated cold baths are safer than 
 
THE TREATMENT OF INSANITY. 465 
 
 prolonged immersions, and five minutes in these cases is about the 
 proper duration, as there is always danger of cardiac failure. 
 
 Plunge laths, from 50° to 60° F., have a tonic influence, and 
 they are sometimes home hy patients who cannot profit by the 
 cold bath. The tub should be large and well filled, and the patient 
 has one complete immersion, and is then rubbed dry briskly while 
 standing on a warm blanket. 
 
 Reaction often follows, even in cases of physical and mental de- 
 pression, if the proceeding is promptly conducted, and a tonic result 
 follows. 
 
 Men bear the plunge better than women, and the latter should 
 be prepared for it by previous hydrotherapeutic treatment. In- 
 somnia due to cerebral anaemia is sometimes relieved by a cold 
 plunge just before bed-time. 
 
 The cold drip-sheet has less severity than cold baths or plunges, 
 and is adapted to a larger class of insane patients who need the stim- 
 ulant and tonic effects of cold water. 
 
 The nude patient, standing in a little warm water, is quickly 
 wrapped in a sheet dipped in water from 60° to 70° F. and applied 
 with friction to every part of the surface, which is then promptly 
 dried. 
 
 The water at first may be at 80° F., and the drip-sheet then 
 serves as a good introduction to more severe hydrotherapeutic meas- 
 ures in neurasthenic and melancholic cases. The temperature of 
 the water may be finally reduced to 40° F. 
 
 The cold ivet-pack has been more widely used in mental disorders 
 than any other form of water cure, though the fact that it is deemed 
 a form of restraint in England has diminished, in a measure, its 
 popularity in that country. It is prepared by a rubber sheet, over 
 wliich is spread a blanket, and over the blanket is extended a sheet, 
 which has been partially wrung out of water from 60° to 70°, F. 
 The naked patient is then stretched full length upon the sheet, 
 which is folded about every portion of the body except head and 
 feet. A cold compress is applied to the head and warmth to the 
 feet. The blankets are folded over the sheet about the patient, 
 who perspires freely and often sleeps while in the pack, which may 
 be renewed every fifteen minutes for an hour, if the object is to 
 abstract heat. The sedative effect of the cold wet-pack is the chief 
 one sought, and when sleep results the patient may be allowed to 
 remain in the pack for hours while the sleep lasts. Eenal secretion 
 30 
 
466 TEXT-BOOK ON MENTAL DISEASES. 
 
 and alvine evacuations are increased decidedly by the use of wet- 
 packs, as is the case generally in cold water continuously applied 
 to the cutaneous surface. 
 
 The wet-pack is especially indicated in overheated and sleepless 
 maniacal patients. It should never be used for purposes of restraint. 
 
 Sponge-haths are given in very feeble patients by light, rapid 
 sponging of the separate extremities with very cold water and with- 
 out exposure of the whole body at any one time. 
 
 In a full sponge-bath to reduce temperature, a double sheet is 
 folded lengthwise under the patient, who is fully gone over by light, 
 quick strokes of sponges well squeezed out of ice-water, which need 
 never drip from the surface so as to wet through to the under sheet. 
 Alcohol may be added to the water to hasten evaporation. Large, 
 fiat pieces of ice, carved perfectly smooth and slightly concave, may 
 be passed over the surface instead of the sponge in hyperpyrexia. If 
 skilfully applied, without disturbing the patient especially, sponge 
 baths are very refreshing in exhaustion from acute mental disease, 
 and they usually answer all necessary purposes in the abstraction 
 of heat in delirium acutum, in the status epilepticus, and in the focal 
 brain disease of organic dementia in which other cold baths are con- 
 tra-indicated. 
 
 Cold affusion-haths are given by means of an army cot or a single 
 folding-bed, on which is spread a rubber blanket, gathered at the foot 
 of the cot into a vessel which catches the water because the head 
 of the cot is slightly raised and the sides are higher than the middle. 
 The patient lies upon the cot and is wrapped in a sheet. Cold water, 
 from 50° to 75° F., is poUred over all portions of the body and 
 limbs, or, better still, is sprinkled over them by a flower-sprinkler. 
 A rapid reduction of bodily temperature is thus accomplished, and 
 a thermometer in the rectum should test the progress of the bath, 
 which is used in the hyperpyrexia of delirium acutum and of sthenic 
 forms of acute mania. When the bodily temperature has been low- 
 ered to 100° F. from 104° F. or more, the bath should be discon- 
 tinued to avoid the danger of collapse. 
 
 Cold aifusion-baths have also been employed for their decided 
 sedative efPeet in acute mental disease. They are almost as severe 
 as the full cold bath, and fifteen minutes is their ordinary duration, 
 and they should be terminated by friction with dry towels. 
 
 Cold sitz-hatJis, from 40° to 60° F., may be used in masturbatic 
 cases for their local tonic effect, and also for pruritus vulvae and 
 
THE TREATMENT OF INSANITY. 467 
 
 perineal paresthesia, of which patients often complain. The vas- 
 cular relaxation in scrotal regions, which is a source of delusions 
 sometimes, especially in hot weather, may be relieved by cold sitz- 
 baths night and morning. 
 
 Douches, showers, and sprays are tonic and stimulant. They 
 can only be given to advantage in rooms with central drainage and 
 water-tight walls and floor, and with apparatus for graduating the 
 force of the stream of water, and the temperature from hot to cold, 
 with instant precision, as shown by thermometers in full view of 
 the operator. 
 
 In addition to the sudden alternation of hot and cold douches 
 there is the counter-irritant effect of powerful jets of water thrown 
 eight or ten feet before striking the patient. The impact of such 
 jets exercises a decided species of massage on the various parts of 
 the body and actively stimulates the peripheral nerves and vessels. 
 The shower-bath or needle-spray may be combined well with the 
 douche in order to get the most complete effects. 
 
 Graduated haths accomplished a cure, in five days, of a violent 
 case of acute mania treated by the writer seventeen years ago, and 
 since that time experience has confirmed the opinion that they are 
 of great service in the treatment of acute mental disease. Their 
 use is attended by no disagreeable shock to the patient, w'ho is placed 
 in water at 95° F., and the temperature is gradually reduced by 
 water of a lower degree added and evenly distributed by the hand 
 of the nurse until the lowest temperature desired is attained just be- 
 fore the removal of the patient from the bath. 
 
 The graduated bath should last from thirty minutes to an hour, 
 and range from 95° to G5° F. There should be a constant and 
 steady reduction of temperature as graduated by a bath-thermometer 
 mounted in a wooden handle, which prevents breakage. As the 
 cooler degrees are reached, friction of the surface is to be gently 
 practised by the hand of the nurse, and a cold compress is kept upon 
 the head, and the bath is promptly terminated should the pulse or 
 respiration indicate the need of it. It is well to graduate the first 
 bath from 95° to 85° F., which is as low a temperature as some cases 
 will bear to advantage. Each successive bath may be graduated 
 five degrees lower, beginning always at 95° F., and not more than 
 two baths are given within twenty-four hours. In sthenic maniacs 
 with sound heart and lungs the improvement is often remarkably 
 rapid. 
 
468 TEXT-BOOK ON MENTAL DISEASES. 
 
 The graduated bath is also a useful sedative and quickly re- 
 duces high temperatures in cerebral excitement, and has even been 
 used in the pyrexia of maniacal paretics with good effect and with 
 no bad sequels. The gradual reduction of temperature, not only of 
 the first bath, but of each successive bath of the series, is an impor- 
 tant point. 
 
 The Turkish hath has been largely used in the treatment of men- 
 tal disorders. In England, Dr. Lockhart Eobertson first employed 
 and advocated it as a remedy among the insane. 
 
 In America the writer first used it extensively in Insanity, and 
 published the results of more than three thousand Turkish baths 
 administered in various forms of mental disease, in his Annual 
 Report, as Physician in Charge of the New York City Asylum for 
 the Insane, and quotations from this report, on this subject, were 
 at the same time published in the Utica Journal of Insanity. The 
 Turkish bath is unquestionably more widely applicable in the treat- 
 ment of Insanity than any other one hydrotherapeutic agency. 
 
 The Turkish bath consists in an exposure from one quarter to 
 a half hour to dry air heated from 125° to ISO*' F., until free per- 
 spiration is established, and then to a higher degree of heat, ranging 
 from 150° to 200° F. for five minutes, more or less. A thorough 
 shampooing then follows, and immediately a warm needle-spray, 
 and then a cold douche or cold plunge, and, finally, the patient 
 reclines in a cooling room for a half-hour, and the processes of the 
 bath are then complete. " Among the insane a higher degree of heat 
 than 150° F. is seldom required, and the hottest room is never to 
 be entered until there is copious perspiration, which is often pro- 
 moted by gentle friction of the surface. 
 
 The Turkish bath stimulates cutaneous functions, equalizes 
 capillary circulation, hastens tissue changes, and has a permanent 
 tonic result. 
 
 It is useful for its eliminative effect in nearly all toxic insan- 
 ities. Acute alcoholic cases derive great benefit from it. Cases of 
 melanchoHa with dry, harsh skin, impaired capillary circulation, and 
 anidrosis are promptly improved by it. 
 
 Primary dements, stuporous cases, and melancholic patients with 
 cyanotic extremities and vasoparetic conditions are, in a measure, 
 reheved by a course of Turkish baths. The pulse becomes stronger, 
 the color of the skin more natural, and the subnormal temperature 
 is restored to that of health in these cases, in whom massage is prac- 
 
THE TREATMENT OF INSANITY. 469 
 
 tised at every bath. The primary loss of weight is followed by in- 
 creased appetite and gain of flesh. 
 
 A needle-spray, Scottish douche, rain-bath, and cold tank of 
 water for a complete plunge should be attached to the Turkish bath, 
 which should be perfectly ventilated. The Scottish douche alter- 
 nates hot and cold. Pulmonary and cardiac disease are contra- 
 indications, but Insanity with Bright's disease, and gouty and 
 chronic rheumatic cases are often remarkably relieved by the bath, 
 which also is decidedly favorable in many instances of syphilitic In- 
 sanity, over the cutaneous and other local lesions of which it exerts 
 an influence. 
 
 In the absence of a Turkish bath a hot-air bath may be impro- 
 vised by an alcohol lamp, or by numerous very hot water bottles, 
 and the air is confined about the patient by blankets. 
 
 The Russian lath is a hot moist air-bath, followed by a douche 
 and massage. It is rather severe, and still it is said to be of service 
 in mental disease. The writer has never employed it. 
 
 Medicated baths are occasionally used in the treatment of Insan- 
 ity. 
 
 The mercurial hath, in urgent syphilitic cases, is a prompt means 
 of getting the effect of the drug. 
 
 The sulphur hath, in the same class of cases, is of service and is 
 also employed in Insanity from plumbism. The bath is prepared 
 by the addition of one-quarter of an ounce of potassium sulphide 
 to the gallon of warm water. 
 
 Sea-salt haths are stimulating and are made by the solution of 
 ten pounds of sea-salt or bay-salt in thirty gallons of water. They 
 may be given to advantage hot, even in the most delicate cases of 
 Insanity, to improve cutaneous circulation. When employed cold 
 they are decidedly tonic. Pine-extract haths are also tonic in effect. 
 
 The ice-cap, made of rubber, to be filled with ice-water, is con- 
 venient for the application of cold to the head in prolonged baths 
 or whenever cerebral congestion indicates it. 
 
 Spinal hags, for tonic and sedative effect, made of rubber and 
 covered with cloth, are used in neurasthenic and hysterical Insanity. 
 
 Sun-baths are a hygienic means of considerable importance. 
 The patient, partially dressed or completely nude, is exposed, in 
 a room with glass walls, to the rays of the sun for variable periods, 
 from a half hour to two hours, according to the effects desired and 
 the actual force of the solar rays, and cold sponging is sometimes 
 
470 TEXT-BOOK ON MENTAL DISEASES. 
 
 used at the close of the seance. A solarium should be provided in 
 hospitals for the insane. 
 
 Some remarkable effects have been procured by the exposure 
 of patients to colored lights, which are excitant or sedative, and 
 vary also somewhat according to the subjective mental state of the 
 patient. 
 
 Colored-light cure demands further investigation, and has a phys- 
 iological relation to photisms and suggested reflex sensations of spe- 
 cial interest among the insane. It remains to be seen whether the 
 physiological effects of colored light are sufficiently definite to be 
 utilized in the treatment of Insanity. 
 
 Massage. — The application, by the hands of an operator, or by 
 instruments, of various kinds of force, to the skin, subcutaneous tis- 
 sues, muscles, and internal organs is termed massage. There are 
 many kinds of massage. 
 
 Effieurage is light stroking with the tips of the fingers or palms 
 of the hands in the direction of the venous and lymphatic circu- 
 lation, which is thus facilitated, and a soothing effect is exerted 
 through the gentle stimulation of the peripheral nerves. 
 
 Massage a friction is practised with finger-tips, ball of the thumb, 
 or palm of the hand by circular rubbing of the parts to be treated, 
 and is usually accompanied by centripetal stroking with the oppo- 
 site hand. 
 
 Petrissage is the kneading of muscles in the grasp of one hand 
 or between two hands or thumbs, and the object is to exert force 
 on the deeper muscular tissues and vessels. 
 
 Tapotement is the delivery of quick, short blows from the wrist 
 by the palms of the hands (spatting), or with the outer edge of the 
 hand (hachage), or tips of the fingers (punctation), or with the 
 closed fist (beating), or with a variety of instruments (percussion). 
 
 These are some of the chief forms of massage, but it is needless 
 to attempt any further description, for every conceivable form of 
 force which the hand of an operator can exert on the body has been 
 practised, and the terms descriptive of the same are not uniformly 
 used by the different schools of massage. An operator should have 
 large, soft, flexible, and powerful hands. There are few who have 
 the necessary skill and strength. 
 
 The forcible effects of massage are tonic and sedative upon the 
 general system. The circulation is aided, tissue changes are hast- 
 ened, local pains are relieved, 'and the general results of active ex- 
 
THE TREATMENT OF INSANITY. 471 
 
 ercise are obtained without expenditure of force on the part of the 
 patient. 
 
 In melancholic and abulic patients who will not exercise massage 
 is most useful. It is employed to arouse patients in secondary stupor 
 and in danger of passing into terminal dementia. It is sedative in 
 the extreme restlessness of climacteric and senile melancholia. 
 
 It often alleviates the neuralgias of the insane, diminishes the 
 cutaneous parsesthesias and the tactile illusions of neurasthenic and 
 hypochondriacal patients, and procures sleep when drugs fail in 
 those continuously in bed. 
 
 It is an essential part of the rest-cure, and is well supplemented 
 by the primary faradic current applied with double electrodes over 
 the belly of all large muscles. 
 
 Abdominal massage is efficient in the constipation of melan- 
 cholic patients with impaired peristalsis. It is not without good 
 effect in chronic hepatic congestion, in splenic enlargement, and 
 in uterine troubles so common among the insane. 
 
 It is employed in primary dementia and melancholic stupor to 
 stimulate cutaneous circulation and promote metabolism in mus- 
 cular tissues. 
 
 It serves to break up tetanoid and cataleptoid rigidity, especially 
 when used in coimection with the Turkish bath, in which the rheu- 
 matic and syphilitic insane are also immensely relieved by massage. 
 
 Massage, like hydrotherapeutic treatment, should be gradually 
 and systematically apphed, according to individual needs. 
 
 General massage, for tonic purposes, is one thing, and local mas- 
 sage, for specific purposes, is another, and the physician should know 
 enough of the methods and effects of massage to intelligently pre- 
 scribe it according to the indications in individual eases. 
 
 Cardiac disease, sclerosed arteries, extensive pulmonary lesions, 
 and diffused cutaneous eruptions are contra-indications for massage. 
 
 Climato-therapy in Mental Disorders. — Climatic factors which 
 influence disease are temperature, humidity, barometric pressure, 
 winds, sunshine, and impurities of the air from telluric and organic 
 sources. 
 
 A careful study of all available statistics leads the writer to the 
 conclusion that, as regards seasonal influences upon Insanity, the 
 maximum occurrence of attacks coincides with the nisus genera- 
 tivus of the vernal trimester. 
 
 Other evidence of climatic influence in mental disorders is found 
 
472 TEXT-BOOK ON MENTAL DISEASES. 
 
 in the large percentage of suicidal and melancholic aberration of 
 Northern Europe. Endemic cretinism affords an example of bar- 
 ometric and telluric influences. 
 
 The every-day experience of patients as affected by climatic 
 changes is sufficient proof of the fact that psychical states are greatly 
 modified by conditions of the atmosphere. The choice, however, 
 of a climate adapted to any particular case of mental disorder is 
 often as complex a question as the variety of organic lesions which 
 may underlie the psychosis. 
 
 The purity of the air is greatest on small ocean islands or on the 
 tops of high mountains. The rarefied air of high altitudes is too 
 excitant for the large class of neurotic and neurasthenic insane, who 
 sleep better and do better generally in marine climates, like the 
 Bermudas, the Florida coast, the Italian Eiviera, or the Pacific coast 
 in Southern California. 
 
 The phthisical insane are divided about equally between those 
 who do best in mountain climates, like Colorado Springs, with an 
 elevation of about six thousand feet, or at a lesser altitute of twenty- 
 two hundred feet, as at Asheville, N. C, or upon the great plateau of 
 the Adirondacks, N. Y., or the White Mountains, N. H., and those 
 who thrive best in a continuously mild marine climate like that of 
 San Diego, Cal., or the Bermudas. As a rule, tubercular eases do 
 better in the mountains in the early stages of the disease and at the 
 sea-shore with fully developed pulmonary lesions. 
 
 Syphilitic and alcoholic cases of Insanity, with arterio-sclerosis 
 and renal disease and cardiac complications, uniformly, should, by 
 preference, be treated at the sea-side rather than at high altitudes, 
 and this rule also applies to mental disorders from focal brain dis- 
 ease, to general paresis, and to epileptic Insanity. In fact, when- 
 ever the cerebral and spinal centres are damaged by gross organic 
 lesions, a high rather than a low barometric pressure is indicated, 
 other things being equal. 
 
 Of course, a most essential point in all climatic treatment is sun- 
 shine and out-of-door life, and there is no disease of the nervous 
 system which is more dependent on these two elements for recovery 
 than Insanity. As mental disease runs a lengthy course, ordinarily, 
 a climate is to be preferred which admits of the open-air cure, in- 
 dependent of seasons. With absolute freedom of choice made with- 
 out regard to secondary considerations, the French or Italian Eiviera 
 Or Southern California would be selected for a mild and sunny cli- 
 mate from October to April. 
 
THE TREATMENT OP INSANITY. 473 
 
 The Mediterranean winds are more objectionable than the Pa- 
 cific winds of the Southern Californian coast. 
 
 Mental disorder from functional brain exhaustion, with angemic 
 conditions, provided the thoracic organs are sounds, may profit by 
 the dry and stimulating air of high mountain regions, which quicken 
 respiration, circulation, and nutrition, and acquired neurasthenic 
 conditions occasionally do well for many months in elevated local- 
 ities. 
 
 It is well known that a prolonged residence at high altitudes 
 an the eastern slope of the Eocky Mountains favors the develop- 
 ment of functional nervous diseases, but this is not so clearly the 
 case at high elevaitions in Switzerland, on account, per'haps, of a 
 greater amount of moisture in the air. It is the combination of dry- 
 ness and rarefaction of air which becomes over-stimulating to the 
 nervous system. 
 
 Senile Insanity almost invariably goes on better at low than 
 at high altitudes, and, in fact, the latter are directly contra-indicated 
 by the arterial degenerations and cardiac feebleness of senile invo- 
 lution. 
 
 The epileptic insane generally do better at sea-level than at high 
 elevations, but exceptions to this rule exist. 
 
 Cases of mental disorder from diathetic and toxic conditions 
 do best in a warm climate, except malarial Insanity, which recovers 
 more promptly and completely in cold and elevated climates. 
 
 Business men in large cities, who break down mentally from long 
 worry and have dyspepsia, torpid livers, and loss of appetite, do well 
 to resort for some months to mineral springs in mountain resorts. 
 For such cases Manitou Springs, Col., with an elevation of several 
 thousands of feet and alkaline and chalybeate springs, may be tried. 
 
 The prophylactic influence of climate is considerable, and pa- 
 tients who are sleepless, nervous, and emaciating in foreign countries 
 are often restored to accustomed health by a return to their nati\'e 
 air. 
 
 Even after Insanity has declared itself in the case of a foreigner, 
 a return to the native climate without other treatment may work 
 a cure. Some persons. Like plants, do not bear transplantation well, 
 and, after a certain age, acclimatization with them is a physical im- 
 possibility. 
 
 Permanent changes from cold to hot climates in mental disor- 
 ders are especially deleterious, except in snile Insanity, but a so- 
 
474 TEXT-BOOK ON IIENTAL DISEASES. 
 
 joiirn of years in a cold climate, substituted for a native liot one, 
 may prove curative. 
 
 Mineral Springs. — A hygienic measure not to be ignored is re- 
 sort to mineral springs in the treatment of Insanity. It is the purity 
 of the water wbicb is especially to be sought, and vrhich is beneficial 
 in many cases with, foul gastro-intestinal secretions and internal 
 organs surcharged with effete material, which can be hterally washed 
 out of the s3-stem by the copious use of pure water. The toxic in- 
 sanities may be thus treated, and also rheumatic, gouty, and diabetic 
 cases. The use of bottled lithia, vichy, Kissingen, and other mineral 
 waters cannot replace successfully the taking of these waters at their 
 native source. 
 
 S}'philitic cases of Insanity may go to the Hot Springs, Ark., 
 cases of saturnism to the White Sulphur Springs, "\V. Ya., or Sharon 
 Springs, jST. Y., the rheumatic and gouty to Saratoga Springs, X. Y.^ 
 the anemic insane to Bedford Springs, Penn., Eichlield Springs, 
 X. Y., or Schu3der County Springs, 111., and the dyspeptic and neur- 
 asthenic insane may try the stimulant waters of the Old Sweet 
 Springs, W. A^'a., or of the Clysmic Spring, "Waukesha, Wis., or some 
 of the more highly carbonated Saratoga waters. Treatment at min- 
 eral springs can only be of benefit when taken systematically in 
 accordance with medical advice, and the indiscriminate use of min- 
 eral waters has often hastened an attack of mental disease in the 
 incipient stage. Hydrotherapeutic facilities are provided also at 
 most of the mineral springs above mentioned, but, like the waters, 
 they should be used only under expert medical advice. 
 
 Section IX. — Tlie, Dietetics of Insanity. 
 
 The various kinds of raw material appropriated in the growth 
 and sustenance of organized beings are known as food. The vege- 
 table organisms derive an elemental supply directly from earth, air, 
 and water, and the animal kingdom lives largely upon the vege- 
 table, and is also self-devouring. Thus the carnivora consume the 
 herbivora, and man, being omnivorous, seeks his food in both the 
 animal and vegetable world, and in a primitive state of nature de- 
 vours his ovm kind by preference to all other sorts of food. This 
 anthropophagy would seem to be a brutal obedience to the evo- 
 lutionary law of sustenance, that organized creatures generally as- 
 similate most readily tissues constituted like their own, and among 
 
THE TREATMENT OF INSANITY. 475 
 
 the insane it is a question whether it is not to he regarded as a rever- 
 sion rather than a perversion of appetite. 
 
 In the light of modern physiology there is no doubt that in man 
 the nitrogenous substances indispensable as food are most promptly 
 assimilable when derived from the animal rather than the vegetable 
 kingdom. 
 
 In mental disorders and other exhausted states of the nervous 
 system, a largely nitrogenous diet is best adapted to the recuperation 
 of the patient, with certain exceptions presently to be noticed, and 
 this supply of albuminates should be tendered in the form of animal 
 food. 
 
 All foods may be divided, on a chemical basis, into inorganic, 
 containing water and salts, and metallic substances; and organic, 
 consisting of albuminates, fats, carbohydrates, and vegetable acids, 
 combined ordinarily with the salts just mentioned. 
 
 There is no one article of diet which contains all the elements 
 essential to the nutrition of the human organism. The two most 
 complete foods known for man are milk and eggs, but the former, 
 although rich in nitrogenous material, contains so little carbon that 
 about nine quarts a day would be required to supply the physiological 
 quantum. 
 
 The organic need of food is declared by increased appetite, which 
 discriminates both as to the amount and kind of food demanded 
 by the system, and in full health this is a reliable guide to the in- 
 gestion of nourishment, but in disease of the nervous system, like 
 Insanity, appetite is deranged, and science must furnish a standard 
 of the requirements of the various kinds of aliments, based on the 
 average amounts consumed daily in the organism. 
 
 Physiologists differ slightly as to the quantity of albuminates 
 or proteids, fats, carbohydrates, and salts required daily by an adult 
 male while performing ordinary work, but the following is an 
 average of the estimates of Moleschott, Pettenkofer, Voit and 
 Eanke, of the water-free food needed per diem, viz.: Proteids, 4.31 
 ounces; fats, 3.53 ounces; carbohydrates, 11.71 ounces; salts, 1 
 ounce, giving a total of 20.55 ounces average dry food. To this 
 is to be added the percentage of water contained in ordinary solid 
 food, and there results a daily ration of from 40 to 60 ounces of 
 ordinary solid food. In addition to this the estimate allows 60 
 ounces of water extra daily. 
 
 The size of the body has some relation to total amounts of a 
 
476 
 
 TEXT-BOOK ON MENTAL DISEASES. 
 
 physiological ration, w*hicli is roughly fixed at a little more than 
 one-hundredth part of the body-weight for the total water-free food, 
 and a half ounce of water for each pound of the total body- weight. 
 
 In general, then, it may be said that an adult male requires, when 
 doing ordinary work, from 40 to 60 ounces of solid food 'and from 
 50 to 70 ounces of water daily, and that during severe labor twenty 
 per cent, should be added to total allowance of both liquids and 
 solids. Women require as much less food than men relatively as 
 exists in the proportion of difference in total bodily weight. 
 
 The following table gives the percental composition of some of 
 the more ordinary articles of diet (Parkes, quoted by ISTeedham): 
 
 
 
 In One 
 
 Hundred Parts. 
 
 
 Articles of Food. 
 
 Water. 
 
 Albu- 
 minates. 
 
 Fats. 
 
 Carbo- 
 hydrates. 
 
 Salts. 
 
 Uncooked Meat 
 
 75.0 
 40.0 
 10.0 
 15.0 
 74.0 
 
 60 
 73 5 
 36.8 
 86.7 
 
 30 
 
 15.0 
 8.0 
 5.0 
 
 12.6 
 1.5 
 0.3 
 
 13.5 
 
 33.5 
 4.0 
 
 84 
 
 1 5 
 
 0.8 
 
 5.6 
 
 0.1 
 
 91.1 
 
 11.6 
 
 24.3 
 
 3.7 
 
 49.2 
 83.2 
 63.8 
 23.4 
 
 5.0 
 96.5 
 
 1.6 
 
 Wheat Bread 
 
 Rice 
 
 1.3 
 0.5 
 
 Oatmeal 
 
 3.0 
 
 Potatoes 
 
 10 
 
 Butter 
 
 2.7 
 
 Eeffs 
 
 1.4 
 
 Cheese 
 
 5.4 
 
 Milk 
 
 0.6 
 
 Sugar 
 
 0.5 
 
 
 
 Knowing the physiological ration required by an adult, it is 
 possible, by means of this table, to calculate with considerable accu- 
 racy hospital dietaries, and also to detect insufficiencies in estab- 
 lished diet lists. 
 
 In this review of food-stuffs, which must constitute the diet of 
 the insane, there are to be mentioned accessory substances known as 
 condiments, used to excite appetite, or to impart a relish, and 
 stimulants, such as tea, coffee, cocoa, and alcoholic beverages. The 
 action of tea, coffee, and cocoa on the cerebro-spinal nervous system 
 is dependent on alkaloidal substances: thein, caffein, and theobro- 
 min, nearly identical in composition. A great variety of nervous 
 and dyspeptic symptoms are due to the abuse of these domestic 
 drinks, which it is often well to dispense with completely in the 
 treatment of mental disorders, in which there is always a tendency 
 to gratify artificial rather than natural appetites. Women in par- 
 ticular are prone to appease their appetite with tea and coffee, to the 
 
THE TKEATMENT OF INSANITY. 477 
 
 neglect of the much-needed food. In psychiatric practice no form 
 of alcohol should be permitted, except when prescribed for its spe- 
 cific effect as a stimulant. The alimentary value of alcoholic drinks 
 is so slight, as compared to more assimilable forms of nourishment, 
 that it is now ignored, and even in England the beer, which for- 
 merly entered into dietary lists of hospitals for the insane, has been 
 largely abolished. 
 
 The physiological objection to these food accessories, tea, coffee, 
 and alcohol, is that they retard the tissue-changes and the renewal 
 of structures, which in Insanity are very frequently diseased, and 
 in need of elimination and reconstruction. These artificial stimu- 
 lants satiate an abnormal appetite, which needs to be restored by 
 natural means, and gratified only with concentrated nourishment, 
 which will best serve the purpose of constructive metabolism. 
 
 A first disagreeable duty, therefore, of the physician in the die- 
 tetics of Insanity is often the complete abolition of tea, coffee, alco- 
 holic drinks, and tobacco. The first struggle is like the breaking of 
 a drug-habit, but the rapid improvement which follows is often an. 
 agreeable surprise to both patient and physician. 
 
 Patients past the acute stage and entered upon the probable 
 limits of incurability may have these food-accessories in part as 
 an indulgence and in part as a means of economy in large public 
 institutions, as there is a saving of food-supplies when patients 
 retain their old tissues instead of building them up anew, and, if 
 given the choice, they invariably prefer artificial indulgence to in- 
 creased vitality without it. 
 
 Speaking generally of the dietary of the insane, it should be such 
 as they have been accustomed to in their station in life. 
 
 A brain-worker, even in health, would find the coarse food on 
 which a laborer has always thrived almost intolerable, and when 
 a professional man is treated in a public institution for the insane 
 and fed on the routine diet alone, a serious obstacle is thrown in 
 the way of his recovery, not from deficient quantity, but from defec- 
 tive modes of preparation and service of food. A short-sighted 
 dietetic economy has caused many an insane person to become a 
 life-charge to the State. It would be a public saving, in the long 
 run, to have food of the best quality prepared and served in a first- 
 class manner to all acute cases of Insanity, and to all patients who 
 have not distinctly passed into terminal and incurable states. The 
 food should be rendered palatable, on account of the very general 
 
478 TEXT-BOOK ON MENTAL DISEASES. 
 
 anorexia in acute cases; and, to offset the impaired gastric func- 
 tions which prevail, it should be presented in as digestible a form 
 as possible. There should also be a variety not only from day to 
 day, but from one week to another. Certain dietary variations must 
 be observed with the sequence of the seasons, and in very cold cli- 
 mates an increase in the fats and carbohydrates is demanded. The 
 individual peculiarities which exist as regards choice and digestibil- 
 ity of food in health should be ascertained from relatives, and pa- 
 tients should, as far as practicable, have their tastes consulted in 
 this regard. 
 
 The insane are drawn largely from a neurotic class, and often 
 have life-long dietetic idiosyncrasies, and the physician who ignores 
 these personal differences and feeds his patients by chemical for- 
 mula alone will be taught a lesson wiser than the physiolo^ of di- 
 gestion. 
 
 Turning from these general considerations of the quality and 
 quantity of food needed in Insanity, attention is next directed to 
 the dietetic indications in special stages and forms of mental disease. 
 
 The Dietetics of the Acute Stage of Mental Disorders. — ^In nine- 
 tenths of the cases of acute mental disorder, nutrition is decidedly 
 impaired. The excitability, irritability, and sleeplessness are often 
 symptomatic of the malnutrition, and disappear as soon as the pa- 
 tient becomes well nourished. 
 
 In puerperal eases there are often extensive losses of blood to 
 be made good, in post-febrile Insanity there is general wasting to 
 be repaired; in diathetic and toxic patients there are constitutional, 
 muscular, and visceral defects of assimilation, which can only be 
 compensated for by generous alimentation; in mental disease from 
 domestic worry and business anxiety there is prolonged neglect of 
 proper nourishment; and in acute Insanity from any cause there 
 is usually loss of weight and a tendency to continued emaciation to 
 be combated. 
 
 The constant and powerful muscular efforts of the acute maniac 
 lead to an enormous waste of tissues, and the loss is not much less 
 in the violent tension of the terrified melancholiac. 
 
 The actual waste of structures in these cases is greater every day 
 than in the laborer performing the most severe work. The amount 
 of food required by these cases is at least twenty per cent, greater 
 than the average daily ration already given in the case of an adult. 
 
 The gross amounts needed to sustain the nutritive equilibrium 
 
THE TREATMENT OF INSANITY. 479 
 
 are the equivalent of four pounds of ordinary solid food and about 
 five pints of fluids daily. One-quarter of this very large allowance 
 should be given in the form of nitrogenous food, preferably of ani- 
 mal origin, such as fresh eggs and milk and meats variously prepared. 
 
 Fats are very essential in these cases, and are best given as cream 
 and butter of good quality, and, if the latter is rancid, it should not 
 be served to the patients in hospitals. 
 
 Ood-liver oil, when assimilated, is a useful hydrocarbon in these 
 cases, and when not well borne glyconin emulsion may be tried, and, 
 should this not be well tolerated, two or three ounces of lipanin 
 daily is a good substitute. 
 
 The administration of cream in acute melancholia in large 
 amounts serves a triple purpose; it supplies the needed fatty food, 
 it relieves the habitual constipation, and it often has a decided som- 
 nolent effect, which meets the indication in the constant insomnia 
 of this stage. One pint a day of fresh skimmed cream may often be 
 given, with the best results. The breaking of oil-globules by the 
 mechanical process of the centrifugal churn gives a heavier cream 
 less well borne by the stomach. If haK a glass of cream at a time is 
 not acceptable to the stomach, small and frequent amounts should 
 be given. 
 
 The necessary amount of carbohydrates is supplied in wheat- 
 bread of first quality flour, in potatoes steamed by preference until 
 mealy, in a small amount of cracked wheat or oatmeal well cooked, 
 and served with cream and sugar, and in rice boiled and served in 
 the form of pudding, or plain, with cream and sugar. 
 
 The mode of preparing the animal nitrogenous food is important. 
 
 Beefsteaks are best quickly broiled on the surface and underdone 
 inside; roast beef, rare, is an excellent mode of preparation; a quar- 
 ter of a pound of beef chopped fine, pressed into a roll, and exposed 
 to heat sufficient to slightly cook it is a good dish; scraped, shredded, 
 or pounded beef, seasoned with salt, and sandwiched between slices 
 of bread, or served as a pulp in small amounts, is more readily assim- 
 ilated than cooked meat. N'one of the beef-extracts or essences sold 
 in the market are as good as those prepared directly from fresh beef, 
 and the difference is as great as that which exists between canned 
 milks and fresh milk. As a convenience and to save trouble the 
 canned articles will always continue to be used. 
 
 Beef-essence is prepared from a pound of the round of beef 
 chopped fine and freed from fat, to which is added half a pint of 
 
480 TEXT-BOOK ON MENTAL DISEASES. 
 
 water, half a dozen drops of hydrochloric acid, and half a drachm 
 of salt. The whole is well stirred and allowed to stand for a couple 
 of hours, and the liquor is then strained o2 with slight pressure and 
 is ready for use as a good form of beef-essence to be taken without 
 further dilution. 
 
 Beef-essence is also obtained from a pound of lean beef minced 
 fine and placed in a tightly covered jar with a half pint of water 
 and a pinch of salt, and exposed to a gentle heat for several hours, 
 and then strained off ready for use. 
 
 Beef-tea is a useful preparation made by mincing a pound of 
 the round of beef, to which is added a pint of water, and, after one 
 hour's exposure to a gentle heat, it is finally brought to the boiling- 
 point for a moment, and then strained and seasoned to suit the taste. 
 It should never be kept and warmed over anew for service to a pa- 
 tient, but should be freshly prepared as needed. 
 
 Eaw beef-juice is a most excellent form of nourishment in the 
 acute exhaustion of Insanity. A pound of the round of beef is 
 chopped fine and stirred with four ounces of water and allowed to 
 stand for an hour, and then strained by twisting in a strong muslin 
 cloth. The juice of finely chopped meat may also be at once ex- 
 pressed by a meat-press, or by placing the meat in the twisted end 
 of a napkind and using a lemon-squeezer. 
 
 All these liquid preparations of beef contain much less of the 
 strength of the meat than is commonly supposed, so that serious 
 error often results in patients fed entirely on these liquid prepara- 
 tions while refusing solid food. 
 
 The strongest beef-tea represents less than twenty per cent, of 
 the actual nutrient value of the beef from which it is made. 
 
 Meat-pulp is the most reliable and concentrated nourishment 
 which can be given. It is obtained by scraping, with the edge of a 
 strong knife, crosswise of the fibre, sections of the round of beef, 
 or by the reduction, by pestle and mortar, of finely chopped beef 
 to a pulp, which is then strained through a coarse sieve. It may be 
 made more palatable by being served as a salad, with a little finely 
 chopped celery or white lettuce, or hashed with freshly boiled po- 
 tatoes. It is fed mixed with various fluids in artificial feeding. 
 
 Fresh eggs are most readily taken into the system uncooked. A 
 pinch of salt or pepper may give a little aid, as some persons cannot 
 take raw eggs or raw oysters. If stimulant is indicated the egg may 
 be swallowed with a little sherry wine, or made into eggnog with 
 
THE TREATMENT OF INSANITY. 481 
 
 milk. Fresh eggs may also be beaten into a custard or into milk or 
 beef-tea in forced feeding. 
 
 Mdlk in p/htliisicai Insanity and in neurasthenic and feeble cases 
 is often most readily assimilated taken fresh milked. In other in- 
 stances^ in carrying out a milk diet, skimmed milk alone is used. 
 In large cities in which milk arrives after long travel and change 
 from one vessel to others before reaching the consumer, it is well 
 to resort to such sterilization as heating affords. 
 
 Koumiss is a very digestible form of milk. It is fermented 
 mare's milk, but in this country it is made from the fermentation 
 of COW'S milk, and it is composed, in 100 parts, as follows: Water, 
 90.0; milk sugar, 4.0; lactic acid, 0.5; albuminoids, 2.0; fats, 1.5; 
 alcohol, 1.0; carbon dioxide, 1.0. From one to two quarts a day 
 may be given in exhaustion from acute mental disease. 
 
 The koumiss-cures effected in phthisical and other cases on the 
 steppes near Orenberg are doubtless due largely to the open-air cure 
 and climatic influences. Koumiss, as made in this country, has a 
 dietetic but not a therapeutic value in phthisical Insanity. 
 
 In addition to the nitrogenous, fatty, and carbohydrate foods 
 just mentioned, there is a special need of the fresh juices of fruits 
 in acute mental disease with perverted secretions of the primas viae. 
 The tartaric acid of grapes, the malic acid of apples, and the citric 
 acid of oranges, free or combined with potassium and other salts, 
 serve a most refreshing and corrective purpose in these acute cases. 
 The fruit must be neither under or over ripe. The seeds of grapes 
 and pulp of oranges are to be rejected, and apples are often digestible 
 scraped raw with a spoon, when not well borne cooked. 
 
 An important point in the dietetics of acute mental disorders 
 is to feed early and often. Alimentation is the ever-consitant indi- 
 cation. Foul stomach, tongue, and breath are often only sympto- 
 matic of partial starvation. Many of the deaths attributed to ex- 
 haustion from acute mental disease might, with scientific accuracy, 
 be assigned to toxic inanition. While the acute case is indifferent 
 to or refuses solid food, the immense waste of tissues goes rapidly 
 on, and the qiiart of beef-tea and two quarts of milk daily which 
 are taken after much persuasion are only a fraction of the quantity 
 needed to sustain the nutritive equilibrium. A full physiological 
 ration should be at once and continuously given, by means described 
 under forced feeding, including all the essential food elements here- 
 tofore mentioned. 
 31 
 
482 TEXT-BOOK ON MENTAL DISEASES. 
 
 The Diet of the Chronic Insane. — While it is " penny wise and 
 pound foolish " to stint in any way the food-allowances of the acute 
 and curable insane, it is just to the public, heavily taxed to support 
 large numbers of chronic insane, to practise economy within humane 
 limits in the dietary of the practically incurable class. It can be 
 safely affirmed that the majority of terminal dements, whose daily 
 expenditure of energy is reduced to a minimum, can subsist in com^ 
 parative health and comfort of body on less than the physiological 
 ration already mentioned for an adult. No reduction should be 
 made, though, in those patients of this class who are daily workers, 
 but in those living a vegetative life merely the dietary of an ordinary 
 hospital is sufficient. 
 
 For piirposes of comparison the average dietaries of ten general 
 hospitals in London is given, and the same is also stated for the ten 
 New York State hospitals for the insane. The daily dietary, giving 
 the average of the ten London hospitals, is as follows: Bread, 12 
 ounces; cooked meat, 6 ounces; fish, 8 ounces (once a week); po- 
 tatoes, 8 ounces; milk, 8 ounces; porter or beer, 1 pint; tea (sweet- 
 ened), 2 pints. 
 
 In addition, there may be ordered by the physician such " ex- 
 tras " as chicken, rabbit, oysters, custard-pudding, beef -tea, gruel, 
 eggs, and fruits. 
 
 The following dietary for the ten New York State hospitals for 
 the insane is quoted from Dr. P. M. Wise's " Text-book for Nurses." 
 The daily ration is this: " Meat (including poultry and fish), 12 
 ounces; flour, 12 ounces; potatoes, 12 ounces; milk, 16 ounces; 
 sugar, 2 ounces; butter, 2 ounces; cheese, 1 ounce; rice, hominy, 
 beans, peas, 3 ounces; tea, coffee, and one egg. In addition to this 
 can be added the fruits in their season." 
 
 This daily iration is for the acute as well as the chronic insane 
 in these hospitals, in which there is no class distinction as to diet. 
 
 The same proportionate difference as to amounts in the sexes 
 holds good in mental disorders as in the ordinary physiological re- 
 quirements already stated with reference to sexual variation in bod- 
 ily weight. 
 
 It is not possible to cite broader illustrations than those just 
 given of dietaries actually provided for those who become inmates 
 of hospitals. The special practical application of these dietaries to 
 the chronic insane is that when suffering from acute or chronic in- 
 tercurrent diseases they require dietetic allowances, as in general 
 
THE TREATMENT OF INSANITY. 483 
 
 hospitals, and at other times the dietary of the New York State hos- 
 pitals above given is adequate, in so far as it embodies in full the 
 recommendations of the distinguished physiologist, Professor Aus- 
 tin Flint, as to amounts required. 
 
 As regards laboring patients of the chronic class, the physiolog- 
 ical need is not for increased albuminates, which are seldom used 
 up by such work as is done by the insane, but for more fats a*nd car- 
 bohydrates, which should be supplied in proportion to the severity 
 of the labor performed. If the patient is to derive his potential 
 energy from fats, about 350 grammes are needed daily, but if from 
 starchy foods, 600 grammes are required. In hard work continu- 
 ously performed, so that there is an actual renewal of the muscula- 
 ture, a corresponding increase in the ration of the albuminates is 
 necessary. 
 
 Diet in Special Forms of Mental Disease. — Certain forms of In- 
 sanity present special dietetic indications, which the physician must 
 observe, though the enforcing of special dietary regulations amojig 
 the insane is sometimes difficult. 
 
 Diabetic Insanity calls for the avoidance of all carbohydrates, 
 all starchy, saccharine, and farinaceous foods, such as rice, sweet 
 fruits, bread, potatoes, and any food-stuffs readily converted into 
 sugar. 
 
 The diabetic insane may have meats, cream, cabbage, lettuce, 
 spinach, gluten bread, almond cakes, or soya bread. 
 
 In the Insanity of Bright's disease a milk diet is the most advan- 
 tageous, and skimmed milk is not preferable, provided the patient 
 digests readily the cream of the milk, which is needed to sustain 
 the nutrition of nervous centres in Insanity. 
 
 In organic dementia from cerebral hemorrhage, food causing 
 gastric and intestinal irritation is to be carefully avoided, as well as 
 all stimulants, but fatty food, if digested, is advantageous. 
 
 If the patient is plethoric the allowance of fluids is to be lim- 
 ited, and laxative foods are to be employed. 
 
 In gouty Insanity, eggs, cheese, and animal food are to be cur- 
 tailed and sweet pastries and sweet drinks are to be avoided, and 
 alkaline drinks are to be allowed. Fruits, milk, chicken in small 
 amounts, and hot water instead of coffee are allowable, and alcoholic 
 beverages are to be forbidden. Koumiss may be taken freely, as it 
 contains only one per cent, of alcohol, and by its action on the kid- 
 neys tends to the elimination of effete material. 
 
484 TEXT-BOOK ON MENTAL DISEASES. 
 
 Ansemic Insanity presents special dietetic indications. The food 
 should be easily digested and palatable, and largely nitrogenous. 
 Eaw meat-juice and meat-pulp, as already described, are here in 
 order. Eggs, raw, and cream, if well borne, are useful. 
 
 Bone-marrow is a special article of food to be administered in 
 these cases, as it has hasmatinic qualities, and good results have al- 
 ready b'een reported from its use in angemic Insanity. 
 
 Fresh bullock's blood has been taken with advantage in some 
 cases, and dried preparations are also dissolved for use in the form 
 of enemas. 
 
 Fresh butter and lipanin, or cod-liver oil, if well borne, are also 
 indicated. 
 
 In the toxic insaooities with arteriosclerosis a full milk diet for 
 a time is good to eliminate toxins by the kidneys. 
 
 In puerj)eral mania, with uremic tendency and cedematous ex- 
 tremities, a milk diet also acts well by its diuretic effect. Butter- 
 milk is sometimes better borne than skimmed milk, and is recom- 
 mended in these cases. It should always be quite fresh, as it readily 
 undergoes changes and does not keep well. 
 
 In stuporous Insanity in stout patients with enfeebled heart's 
 action and cedematous infiltration of tissues, which pit on pressure, 
 a dry diet is indicated. Fluids are reduced to a minimum, and con- 
 centrated nourishment is given, and in this way the oedema is in 
 part relieved and the bulk of the fluid in the system is diminished, 
 and the heart is less overtaxed in forcing it through vascular chan- 
 nels. 
 
 Tabetic cases of Insanity require a highly nourishing diet, in- 
 cluding a large amount of fats. Fresh butter, cream, and cod-liver 
 oil are indicated, but the latter is often not well borne by tabetics. 
 During the gastric crises in these cases koumiss and buttermilk are 
 to be tried. 
 
 Scorbutus, in its less declared forriis, which are not always rec- 
 ognized, is not uncommon in large public institutions for the in- 
 sane. It is a mistake to suppose that potatoes are always preventive 
 of scorbutus, which may even result while the patient is having an 
 excess of potatoes to the exclusion of a properly varied diet. The 
 special indication in all scorbutic eases is for the vegetable acids 
 contained in fruits, and especially citric acid in lemons, always pref- 
 erable to the pharmacopoeial form of the acid. Limes are almost as 
 
 antiscorbutic as lemons. Oranges are also useful and contain citric 
 acid. 
 
THE teeat:ment of insanity. 485 
 
 The gastric irritation caused by lemonade is in part obviated by 
 using boiling hot water to make the lemonade, and by the addition 
 of a Mttle bicarbonate of sodium to neutralize the extreme acidity 
 of 'the drink to be taken on a full stomach after meals. 
 
 In general paresis food must be prepared to facilitate degluti- 
 tion, which is so defective that suffocation may occur if a large bolus 
 is present. Meats must be minced, and food in a moist, pulpy form 
 is best. The same care is often necessary in senile cases with loss 
 of teeth and inability to masticate, and in hysterical cases with 
 oesophageal spasm. 
 
 The state of the teeth, mouth, and throat must be considered 
 in all cases, and with bitten tongues, buccal ulcers, ulitis, alveolar 
 abscesses, and a variety of affections of these parts, liquid or semi- 
 solid food is to be furnished. 
 
 Epileptic insane are not to be denied nitrogenous or animal 
 food. They seem to improve, as regards the convulsions, with a 
 change of diet as with a change of drug, but eventually they do 
 best on a full mixed diet of digestible material, which leaves little 
 irritable residue in the intestinal tract, and completely sustains the 
 nutrition of the entire system. There are some anaemic epileptics 
 who for a time do best on a diet largely animal. Sweets, pastries, 
 and alcoholic beverages are contra-indicated. 
 
 The neurasthenic insane do best on an animal diet of milk, 
 fresh eggs, and meat, with butter and cream, to the exclusion of 
 cereals, coarse vegetables, axid sweets, except as contained in the fresh 
 Juices of fruits. Sweetbreads are good in some cases, especially the 
 true sweetbread, which is the thymus gland of the calf, instead of 
 the pancreas, which is served ordinarily as sweetbread. Brains are 
 thought to be a delicacy, but they are too rich for the invahd stom- 
 ach. Some neurasthenics digest fish readily. Veal and lamb are less 
 digestible than the meat of older animals, and the short fibre and ten- 
 der nature of the white meat of poultry render it appropriate for the 
 delicate stomach. The full amount of fluid needed in neurasthenia 
 is best supplied in pure spring water, and when this is not available 
 koumiss and buttermilk, if fresh made, are vastly preferable to light 
 alcoholic beverages or to bottled waters. 
 
 In melancholia the toxins of the gastro-intestinal tract and the 
 habitual constipation indicate a free use of fluids to favor elimina- 
 tion. It is to be considered that the normal constituent ratio of 
 water in the human body is fifty-nine per cent., and the diminished 
 
486 TEXT-BOOK ON MENTAL DISEASES. 
 
 secretions and general dry state of the system in melancholia is best 
 met by the plentiful ingestion of water, which relieves the intra- 
 arterial blood-pressure and wiry pulse by restoring the moisture and 
 suppressed excretion of the dry skin, and relaxing the cutaneous 
 capillary spasm, which lends the lifeless hue to the surface of the 
 melancholic patient. 
 
 Predigested Foods. — The enfeebled powers of digestion in men- 
 tal disorders creates a need for predigestion of some of the nourish- 
 ment to be administered. By Peptonizing the albuminates are di- 
 gested and the carbo-hydrates are also acted upon by the amylolytic 
 properties of the pancreatic extract. 
 
 Peptonized milk is thus prepared: One quarter of a pint of cold 
 water is shaken up in a clean quart glass bottle with the contents 
 of one of Fairchild's peptonizing tubes, and one pint of perfectly 
 fresh milk is added, and the whole is shaken, and the bottle is placed 
 for twenty minutes in water at 150° F. The milk is then digested, 
 and, to prevent further peptonizing, it is at once placed on ice until 
 used, or boiled two or three minutes, whic^h prevents further forma- 
 tion of peptones. 
 
 Peptonized gruel, in which the starch is converted into sugar 
 and the albuminates digested, is thus made: Thick gruel of oat-meal, 
 barley, or wheat, while boiling hot, is stirred with an equal amount 
 of fresh, cool milk and one peptonizing tube to each pint of the 
 mixture, and kept at 150° F. for a couple of hours and then boiled 
 three minutes or kept on ice until used. 
 
 Peptonized beef -tea is thus prepared (Yeo): Mince one-half 
 pound of lean beef, add one pint of cold water, and cook till boiUng. 
 Pour off beef -tea, rub meat into a paste, and add it to the beef -tea 
 and mix in another pint of cold water, reducing temperature to 
 140° F. Add half an ounce of liquor panereaticus or sixty grains of 
 pancreatic extract and twenty grains of sodium bicarbonatis. Stand 
 in a warm place three hours, shaking occasionally, and then boil 
 quickly three minutes and strain. 
 
 In a like manner, meats, oysters, and other articles may be pre- 
 digested, but all these articles quickly spoil if not kept on ice or 
 boiled, and they have a bitter taste if the digestion is carried too 
 far, and a little flavoring of some kind is often necessary. 
 
 Rectal Alimentation. — There are exceptional cases of Insanity, 
 in which it is desirable to take advantage of the fact that, for a brief 
 period at least, nearly one-third of the necessary noarishment may 
 be absorbed from the rectum. 
 
THE TIIEATMENT OF INSANITY. 487 
 
 There may "be thus taken up into the system from the rectum 
 albviminous and peptonoid solutions and emulsified fats. At the 
 furthest, Hfe can only be thus prolonged a few weeks. 
 
 Subcutaneous injections in these cases afford no substantial aid. 
 
 The rectum finally becomes so irritable or inflamed that further 
 alimentation through this channel is impossible. 
 
 The enemata are best delivered high up in the rectum by an 
 enema-tube, and great gentleness and care in oiling the apparatus 
 are necessary to avoid soreness of the parts. The enema must be 
 about six or eight degrees less than the bodily temperature, and is 
 given with the patient on his left side, with elevated hips, or the 
 enema may be retained by means of a compress until the first ten- 
 dency to expulsion is over. It is a mistake to use large injections, 
 ■and from two to four ounces at a time are sufficient. The rectum 
 should be thoroughly cleansed a half hour before the nutrient enema 
 is given. 
 
 Fresh eggs, milk, and beef-essence may be thus employed as nu- 
 trient enemata, but it is a decided advantage to predigest the alimen- 
 tary substances in the manner already described. 
 
 Thus, predigested milk, gruel, beef-tea, and eggs are the most 
 available articles for this purpose. 
 
 One entire fresh egg and eight ounces of fresh milk are beaten 
 together and peptonized, and thus constitute a sufficient amount 
 for two enemata. A little stimulus or a few minims of tincture opii 
 deodorata may be added. 
 
 A small, semi-fiuid and concentrated form of enema is sometimes 
 to be used. 
 
 For this purpose two ounces of fresh, raw meat-pulp, and one 
 ounce of pancreas are mixed to a fine pulp, strained through a sieve, 
 and warmed before injection through a wide-mouthed tube. 
 
 Fresh white of egg alone is sometimes used, or fresh warm milk 
 and a simple saline solution is not without some value. 
 
 It is well never to rely long on rectal alimentation, which is to 
 be regarded merely as a supplemental and emergent form of sus- 
 tentation. 
 
 Forced Feeding of Patients. — Of the necessity of forced feeding 
 there can be no question. Some patients are firmly convinced that 
 they cannot swallow, or that they are forbidden by the Almighty 
 to take food, or that the food is poisoned, and others resist food 
 desperately with suicidal intent. 
 
488 TEXT-BOOK ON MENTAL DISEASES. 
 
 Before resorting to forced feeding every persuasion and device 
 should be resorted to with these patients, who are to be entreated, 
 urged, and commanded, but in many instances all efforts will be in 
 vain. 
 
 Food may be tasted in their presence to aver the idea of poison, 
 or it may be left near them over night, or some special friend may 
 bring them some delicacy, or they may be allowed to choose from 
 a common store of provisions. 
 
 The length of time which it is safe to wait before forced feeding 
 varies according to the actual physical state of the patient, and the 
 condition of the digestive organs. After a certain time the stomach 
 loses its functional activity, and if inanition reaches a certain point 
 neither digestion nor assimilation is possible, and death will surely 
 follow in spite of forced alimentation. It is always best to be on the 
 safe side, and, if there is great exhaustion from mental disease, the 
 patient should be fed immediately. 
 
 A feeble patient, who has fasted a whole day, should be compelled 
 to take food. 
 
 A patient of a fair amount of strength should be given nourish- 
 ment at the end of the second day's fast. 
 
 A vigorous and violent maniac may be allowed to go three or 
 four days without food if it is positively known that he had eaten 
 well up to the beginning, of his refusal of food, and provided there 
 are no signs of inanition in the meantime. 
 
 There is an unmistakable odor of starvation in acute cases, and 
 it always indicates the immediate need of forced alimentation. 
 
 Of the modes of forced feeding there are many, and it is well to 
 try the simple methods first. 
 
 Some patients, from religious delusion, will not feed themselves, 
 but will swallow food placed in their mouth to save them any respon- 
 sibility in the matter. Others are to be fed with two tablespoons 
 with smooth edges, one inverted being used to depress the tongue 
 slightly, and the other for feeding the seated patient. Some patients 
 open the mouth and allow themselves to be fed, a spoonful at a time, 
 when the nose is closed to prevent breathing. In others a round, 
 tapering, wooden wedge, one-half inch in diameter, is to be inserted 
 between the molar teeth while spoon-feeding, and the head must 
 not be thrown far back, which is a common mistake, which prevents 
 swallowing. The whole body may be inclined backward. In all 
 cases the clothing is to be j)erfectly loose about the neck, chest, and 
 
THE TREATMENT OF INSANITY. 489 
 
 waist, upon which no pressure is ever to be made while holding the 
 patient. 
 
 When the teeth are held firmly closed, food may be poured be- 
 tween the cheek and molar teeth by drawing the cheek out with 
 the forefinger while the patient is recumbent. Also, a flexible tube 
 may be passed back of the molar along the side of the cheek, into 
 the mouth, and a wooden wedge is held ready at the edge of the teeth, 
 should the patient try to bite upon the tube. One nostril may be 
 closed and fluid poured through the other into the pharynx. 
 
 All these methods work in some cases, but fail completely if the 
 patient is very resistant. 
 
 Wo'oden spoons and pap-boats are also inserted between the teeth, 
 and, the opening being through the centre, the nourishment is dis- 
 charged continuously or interruptedly, by a spring, at the will of 
 the operator, into the back of the mouth. 
 
 Some use a round wooden wedge with a hole through the centre, 
 and by a syringe attached fluids are forced through the wedge, in- 
 serted between the teeth over the tongue into the back of the mouth. 
 There are other devices too numerous to mention. 
 
 All these means succeed in some cases, but they are incomplete 
 in the instance of determined patients. 
 
 The only radical operations are feeding by the stomach-pump, 
 and by oesophageal and nasal tubes. These only fail in oesophageal 
 stricture. 
 
 A physician sometimes becomes skilled in some one of the above 
 or similar incomplete methods of feeding, and thinks that the rad- 
 ical operations just mentioned are not necessary. The writer thought 
 so in the early years of his hospital practice, but, with an experience 
 embracing ten thousand insane, who have come under his charge 
 and observation, and after a trial of all methods of forced feeding, 
 he has come to regard the stomach-pump, the oesophageal tubes, and 
 the nasal tubes as indispensable. They are by no means to be used 
 indiscriminately, but with adaptation to the case in hand. Probably 
 the nasal tube meets with an easier success in a larger number of 
 cases, but with odd-shaped noses and narrow nostrils it is not prac- 
 ticable, and there are tumefied and diseased states of the nasal mu- 
 cous membranes which contra-indicate, and in some cases tubes of 
 sufficient size cannot be passed to feed thick liquid food, and this 
 is a serious objection in prolonged cases. In unskilful hands the 
 danger of entering the larynx is greater with the nasal tube. 
 
490 TEXT-BOOK ON MENTAL DISEASES. 
 
 On the other hand, the moral effect of feeding through the nose 
 is such that one operation often determines the patient to eat, for to 
 some it is disgusting and to others astounding to be fed through 
 the nose. The practical difficulties of opening the closed teeth are 
 also avoided, and the respiration is less obstructed than by the larger 
 stomach-pump tubes. 
 
 Nasal feeding-methods are, first, that already mentioned of pour- 
 ing food into one nostril while the other is closed. It is well in all 
 nasal feeding to have the patient blow the nose first, and then the 
 operator on the right of the seated patient passes his left arm around 
 the head, which he draws against his side, and with his right hand 
 he pours fluid from a spoon, shaped for the purpose, into the right 
 nostril, while closing the left with his thumb. 
 
 A funnel may be inserted into one nostril for the passage of the 
 fluid, or a soft catheter may deliver the fluid as far back as the pos- 
 terior nares or into the pharynx, and in this instance the funnel is 
 attached to the external end of the catheter by elastic tubing. In 
 the recumbent posture a feeding-cup may be inserted into one nostril 
 through which the fluid is poured. Some operators pass a tube 
 through the nose into the oesophagus about six inches and then pour 
 through a funnel attached to the outer end of the tube. 
 
 The regular nasal tube for entering the stomach should be of 
 tan rubber, flexible, smooth, and finely finished, having a length 
 of thirty inches and a gauge of from 18 to 24 French catheter sys- 
 tem. It is convenient to have a funnel of the same material at- 
 tached, the whole being one piece, otherwise a hard rubber funnel 
 is affixed after the passage of the tube. 
 
 During the operation the patient is seated or recumbent. Both 
 positions have their special advocates, and their advantages and dis- 
 advantages, and, as the methods are the same for nasal, oesophageal, 
 or stomach-pump tubes, they are here described in full. 
 
 The sitting posture is more convenient for the operator, A solid 
 wooden arm-chair fastened to the floor is best. In this the patient 
 is fastened immovably by the broad bands of sheets about the arms, 
 resting comfortably on the arms of the chair, and about the ankles 
 and the legs of the chair. Another sheet goes in front of the knees 
 and around the back of the chair, and one over the thighs is fast- 
 ened underneath the chair. 
 
 Nothing is tied about the chest or abdomen, as breathing must 
 be free and a support to the abdomen renders vomiting easy, which 
 is especially to be avoided. 
 
THE TREATMENT OF INSANITY. 491 
 
 If properly tied, the patient cannot slip down in the chair, and 
 is absolutely fixed in position and more secure than if held by half 
 a dozen persons, and much less apt to struggle. The patient can 
 still move his head freely, and it is important that it should be held 
 steadily. A nurse stands close behind the patient, wraps a soft, 
 folded towel about his head, which he grasps firmly between his 
 hands and draws against his body and there holds immovably. 
 
 The operator now measures, according to the size of the patient, 
 the length of tube to reach from the nostrils to the pharynx. The 
 nasal tube is then dipped in the warmed fluid to be fed, which lubri- 
 cates it; or smeared with vaseline, and, holding it pen-like, the 
 operator passes it rapidly but gently into the nares until the point 
 noted as sufficient to reach the pharynx is at the nostril. 'Now the 
 turning point in the whole operation has been reached. The pa- 
 tient's head has properly been held backward with his chin out, but 
 while in this position, should the operator continue to pass the tube, 
 it will strike the posterior pharyngeal wall and be deflected by the 
 atlas into the larynx in very many instances. 
 
 When this pharyngeal point is reached, therefore, the operator 
 must wait until the chin of the patient is brought in to the chest 
 by forcible flexion of the head, and then pass the tube promptly, 
 and it will not fail to go into the oesophagus, and it then provokes 
 deglutition and is carried down to the stomach, and care is to be 
 taken that it is not completely swallowed. From fourteen to eighteen 
 inches of tube are required to reach from the nostrils into the stom- 
 ach, according to the size of the patient. . The funnel being at- 
 tached to the exterior end of the tube, is held above the patient's 
 head, and the fluid poured in passes down of its own weight into 
 the stomach. The flow of fluid can be arrested at any moment by 
 pinching the tube, which should be quickly withdrawn should there 
 be vomiting, regurgitation, or choking. It is seldom well to feed 
 more than one quart of fluid at a time, and one-half the amount is 
 better in irritable stomachs. The tube should be withdrawn slowly 
 until it reaches the pharynx, when it is quickly pulled past the back 
 of the throat, that it may not excite vomiting. The patient had 
 better recline for a half hour after the operation. 
 
 Feeding in the recumbent position is thus carried out: A hair- 
 mattress is placed on the floor and the patient is placed on his back 
 on the mattress with his head on a pillow. A sheet is thrown over 
 the patient's legs and the lower part of the body, and one attendant 
 
492 TEXT-BOOK ON MENTAL DISEASES. 
 
 on each side kneels on the sheet, drawn tight to prevent the patient 
 from bending his knees. The attendants take the patient by the 
 wrists and hold the shoulders with the other hands. An attendant 
 kneels at the patient's head, which is wrapped in a towel and held 
 between the attendant's hands, reinforced by one knee on each side 
 of the head. 
 
 If the patient is very resistant, two more attendants may be re- 
 quired to place their hands above the patient's knees. 
 
 The operator then kneels at the right side of the patient's head 
 and passes the nasal tube in the manner described. 
 
 Care is to be taken that the patient is not pressed upon by the 
 attendants, and the clothing must be loose about the neck, chest, and 
 waist, as before said, and the sheet must not press upon the abdo- 
 men. The collar is to be removed in men and the corsets in women. 
 
 The food which can be fed thus through the nose must be liquid 
 and free from solid particles, which will obstruct the flow. 
 
 The tube may be obstructed with mucus when it is first inserted 
 into the nose, and it must then be withdrawn and cleansed, or the 
 fluid will not pass. While in the stomach, if fluid fails to pass, the 
 tube may be withdrawn an inch or two and the exterior part of the 
 tube must be kept straight. Milk, eggs beaten in milk, strained 
 beef-tea, beef-essence, expressed meat-juice, and gruels, koumiss, 
 and alcoholic beverages may be thus fed by the nasal tube. 
 
 Feeding ivith ossophageal tubes has the advantage that wider tubes 
 can be used, and fluids containing a larger amount of solid material 
 may be administered. The oesophageal tubes should be of soft rub- 
 ber, with a fine and soft finish, having a diameter from 27 to 35 
 French gauge (catheter system), and a length of not less than 33 
 inches, and furnished with a hard-rubber funnel, as shown in the 
 following illustration. The openings may be at the sides of the 
 lower end of the tube, but for thickened fluids a wide-open end is 
 sometimes preferable. It is well to have a tube with, as well as 
 without, a rubber bulb attachment. 
 
 The positions in oesophageal tube-feeding are the same as those 
 already described as the sitting or recumbent postures. 
 
 The opening of the mouth and the use of the mouth-piece are 
 additional features of the operation calling for the services of an- 
 other attendant to hold the mouth-piece in position while the opera- 
 tor passes the tube. There are various forms of apparatus for open- 
 ing the mouth and keeping the teeth apart during the feeding. 
 
THE TREATMENT OF INSANITY. 493 
 
 They are all open to some objection, such as danger of injnry to teeth 
 or soft parts about the mouth. The ordinary mouth-piece is a hard- 
 wood bit with a hole in the centre for the passage of the tube. Pa- 
 tients obstruct the hole with the tongue sometimes, but in other 
 cases it serves the purpose. It is better held by an attendant, and 
 tying it behind the head is insecure. 
 
 Other gags are composed of metal, wedge-shaped, and made of 
 two plates, which, after insertion between the teeth, are separated 
 by turning a screw, which forcibly opens the mouth. The force 
 required to overcome the power of closure of the mouth is very 
 great, and, although this instrument accomplishes the purpose, it 
 is necessarily not without danger to the teeth, and even to the jaw 
 itself. It requires to be held in place by an attendant, and it inter- 
 feres somewhat with the passage of the tube. The writer seldom 
 find it necessary to use the above apparatus. 
 
 The patient's head is firmly held by one attendant; a second at- 
 tendant on the right and a little back of the patient, so as to be out 
 of the way of the physician who operates, holds a mouth-piece be- 
 tween the back teeth on the right side, and a third attendant on the 
 left of the patient, whom he faces, holds a second mouth-piece be- 
 tween the molar teeth on the left side of the patient's mouth. 
 
 These mouth-pieces are eight inches long, round, and taper from 
 three-quarters to one inch, and have a circular groove, which pre- 
 vents slipping, and they are not inserted in the mouth more than 
 a half inch beyond the inner edge of the teeth, and in nowise ob- 
 struct the operator, as do other forms of gags. 
 
 In some patients bits of broad cotton bandage tightly rolled may 
 be inserted and held in like manner between fragile teeth on both 
 sides of the mouth. The expedients for separating the teeth are 
 the same in the use of all gags. 
 
 Thin wooden wedges, flat or round, are first inserted. The han- 
 dles of spoons and other metal instruments are more dangerous to 
 the teeth, which may be broken if the wedges are used as levers to 
 pry the mouth open. The knack is to press patiently and gently 
 inward, taking advantage of every relaxation brought about by such 
 devices as closing the nostrils, pouring a spoonful of water into the 
 nose to excite deglutition, closing the nose and covering the mouth 
 with a handkerchief until the patient suddenly opens the mouth 
 to breathe, or passing back of the teeth, by a catheter, a little fluid, 
 or, finally, which almost invariably succeeds, passing a nasal tube 
 as far back as the soft palate. 
 
494 TEXT-BOOK ON MENTAL DISEASES. 
 
 With a patient's head and mouth secured as above described 
 and perfectly fixed, there is no trouble whatever in passing the tube 
 into the oesophagus. Should the patient obstruct the tube with the 
 tongue in a very persistent manner, the operator takes a small 
 well-oiled rubber catheter in his left hand, holding the tube ready 
 in his right, and slipping the catheter by into the pharynx causes 
 involuntary opening of the throat and depression of the tongue, 
 which gives just the needed chance of slipping the oesophageal tube 
 back, where it is grasped by the sphincters and swallowed. If the 
 patient's head is held a httle forward instead of far backward, which 
 is a common mistake, the tube will never pass into the larynx. 
 Still, if the operator is inexperienced and fearful, he may oil and 
 place his right forefinger over the tube and conduct it as far back 
 as the esophageal sphincter. The largest tubes are less apt to 
 enter the larynx, and in passing the tube, if suffocation occurs, the 
 tube is to be withdrawn. 
 
 Eighteen inches of the oesophageal tube 'are to be passed, and 
 when this has been done the operator may know that the tube is not 
 in the trachea, especially if the tube is of the larger size. If the 
 funnel is not attached to the tube, and the latter is not held or se- 
 cured, it may be swallowed, and this may occur should it be bitten 
 in two. Such a case, attended by a fatal result, has been reported. 
 
 Even when the tube is properly passed there may be reflex dysp- 
 noea to alarm the operator, who may feel doubt as to whether the 
 tube has not entered the larynx, or doubled upon itself. There is 
 a simple auscultatory test to determine that the tube is in the stom- 
 ach, where it will be heard by the listening operator if an attendant 
 blows in the outer end of it. 
 
 The foods which may be administered by oesophageal tubes are 
 milk, eggs, beef-tea, raw beef-pulp mixed with mashed potatoes and 
 stirred to a creamlike consistence with milk, and all predigested 
 liquid foods already described in this chapter, and eggnog, cod-liver 
 oil, koumiss, and alcoholic beverages. 
 
 It is well to warm everything to be fed through the tube, which 
 is itself to be warm and dipped in the liquid to be given or lubri- 
 cated with oil or vaseline. 
 
 Some use a bottle instead of a funnel, and others attach a sjTinge 
 to the outer end of the tube. The necessity of this is obviated by 
 the bulb attachment figured in the following illustration. 
 
 Some operators do not pass the tube more than six inches into 
 
THE TREATMENT OF INSANITY. 
 
 495 
 
 the oesophagus at any time, which is more apt to excite regurgitation 
 of fluids. If there should be discovered stricture of the oesophagus 
 
 Lever stomach-pump. 
 
 it is not well to pass it with the tube until a complete examination 
 has been made. 
 
 Stomach-pump Feeding. — There is nothing in the position of 
 the patient, or in the entire technique of the operation of stomach- 
 pump feeding different from that which has already been described, 
 with the single exception of the pump mechanism itself, and as to 
 this five minutes' personal trial of the pump is worth more than a 
 page of description. The operator should use the pump for a few- 
 
 Soft rubber stomach-tube with bulb. 
 
 minutes until perfectly familiar with its action before the operation, 
 and see that everything is clean and in good working order. 
 
 The sitting posture for the patient is preferable in this instance. 
 
496 
 
 TEXT-BOOK ON MENTAL DISEASES. 
 
 No sudclen force in injecting the fluid is to be used. The stom- 
 ach-pump tubes with stiff hard-rubber ends are not without danger, 
 and the wide rubber tubes with large side openings are preferable, 
 the whole tube being of one material. An illustration of the lever 
 stomach-pump is here given. 
 
 Soft rubber oes 
 
 tube with funnel attached. 
 
 All the predigested foods, and meat ground fine or reduced to a 
 pulp in a mortar, meat- juice obtained by a regular hand meat-press, 
 which is very convenient in these cases, vegetable puree of various 
 kinds, and grated cracker and various foods mixed with milk to 
 form a thick fluid, can be given by the stomach-pump. 
 
 Same as above, with bulb adjusted. 
 
 In American hospitals for the insane the oesophageal and nasal 
 tubes have almost entirely replaced the stomach-pump in the for- 
 cible feeding of patients. 
 
THE TREATMENT OF INSANITY. 497 
 
 Finally, it is to be stated that there is a certain nervous sliocic 
 attending all methods of feeding by tabes, and the physician may 
 be called to a patient starved to such a point of exhaustion that the 
 shock of the operation might endanger life. In this case stimulant 
 enemata may rally the patient to a degree which will render the 
 passage of a small nasal tube safe, or subcutaneous injection may 
 be a final resort for the same purpose. 
 
 Patients soon fall into a habit of being fed. Care is to be taken 
 that such a habit may not be formed and not indulged. 
 
 The illustrations of feeding apparatus on pages 495, 496, were 
 furnished by John Eej'-nders & Co., of New York City. 
 
 Section X. — PsycJwtherapy. 
 
 By the term psychotherapy is signified all that was formerly em- 
 braced under the term " moral treatment," and also every means and 
 every possible agency which primarily affects the psychical rather 
 than the physical organization of the patient in a curative direction. 
 
 Psychical causes disorder the mind, in the first instance, and psy- 
 chical influences continue powerful for good or evil, as to the mind 
 thus disordered. 
 
 To control and to apply to individual cases of Insanity, in ac- 
 cordance with skilled insight into their natural character and spe- 
 cial form of aberration, the mental influences best adapted to aid 
 in the cure is the object of psychotherapy. The utility of psycho- 
 therapeutic treatment is only real in patients who react to external 
 surroundings and to personal impressions. In greatly depressed, 
 stuporous, or demented patients the application of psychotherapy is 
 out of the question. The modes and means of psychotherapy will 
 now be described, but a few words must first be said of the basis 
 of the science. 
 
 General Principles of Mental Therapeutics. — The general prin- 
 ciples 'of mental therapeutics are based on the fact that all mental 
 manifestations are but the adaptive reaction of an individual to his 
 environment, in accordance with the general laws of human mind 
 and character. A change in the individual or in the environment 
 makes a difference in the resulting manifestation. Eccentric ex- 
 ceptions do not alter the general law of uniformity of reaction to 
 definite influences, so that the conduct and feelings of most persons 
 under given circumstances can be foretold with much certainty. 
 
 In the practice of mental therapeutics the physician must create 
 33" 
 
498 TEXT-BOOK ON" MENTAL DISEASES. 
 
 the environment and arrange the circumstances which are to cause 
 the patient to react in a giyen manner, Just as the skilled chemist 
 mingles definite compounds to get certain results. The patient is 
 the fixed quantity and the environment the variable factor. The 
 patient, by inheritance, education, and life-long habit, is cast in 
 a certain mould, and it is a common error to attempt to break him 
 all up and make him over to suit the environment in which he 
 chances to be, or the ideas of the physician as to how he would like 
 to have him. 
 
 The fundamental principle of psychotherapy is to conserve the 
 original personality of the patient, which has already been somewhat 
 shattered by the shocks which have caused the Insanity. The indi- 
 viduahty of the patient, which has been home down by the weight 
 of disease and the force of circumstances, is to be lifted up and re- 
 stored. Even in case of complete psychical wreck the reconstruc- 
 tion must be on the old lines of mental being. 
 
 In the psychoses parts of the cerebral structures are functionally 
 incapacitated, but the others continue their habitual activities, and 
 the aim must ever be to sustain the old, and not to strive for entirely 
 new action of the cerebral mechanism. 
 
 The damaged brain is not like a fractured limb, to be broken up 
 at the will of the physician for a better reunion of parts. 
 
 In the incipient and convalescent stages of the mental disease, 
 therefore, when psychotherapy is most generally useful, the effort 
 must be to arouse the natural thoughts and feelings of the patient, 
 to recall former habits, tastes, desires, ambitions, social tendencies, 
 and sentiments, and to revive activity in old ways of industry. If 
 any decided changes are to be wrought in the whole life and nature 
 of the patient, they had better be accomplished as an after-cure by 
 gradual modification, when the original mental status has been 
 safely regained. The acute stage of mental disease runs its course 
 without regard to psychotherapy, which can fill only occasional 
 symptomatic indications at this period. 
 
 Another principle of great importance in mental therapeutics 
 is frankness, truthfulness, and honesty of dealing with the patient. 
 It may be possible to practise deceit with occasional success, and to 
 outwit the insane, but such subterfuges are liable at any time to 
 be detected by the patient, who then loses all confidence in the phy- 
 sician. It is impossible to create a false environment and to have 
 nurses playing fictitious roles, which will long deceive the patient. 
 
 In the incipient stage of Insanity the plots and plans and ama- 
 
THE TREATMENT OF INSANITY. 499 
 
 teur detective performances of relatives for the benefit of the patient 
 often drive the latter to desperation and suicide. The skilful psy- 
 chotherapeutist must have sufficient sympathy and imagination to 
 place himself at the patient's point of view, and to foresee the dif- 
 ferent impressions which the same event may cause in the patient. 
 
 The benevolent stupidity of relatives surmises that a prearranged 
 deception will affect the patient in a certain way, whereas a diamet- 
 rically opposite influence often results. 
 
 The psychiatrist must at once abolish all shams and deceptions, 
 and be the soul of candor to the patient swung loose from his moor- 
 ings and in dire need of some constant point to which to anchor. 
 
 The physician must furnish a personal environment for the pa- 
 tient, not of cunning actors, prevaricators, detectives, and schemers, 
 but of outspoken, truthful, and sympathetic nurses. The whole en- 
 vironment and all its influences must be real and not fictitious. It 
 is even well to instruct the nurses, in part, in the presence of the 
 patient, as to the reason for certain things to be done. The nurses 
 are to answer the patient truthfully, and to refer doubtful questions 
 to the physician for a reply. 
 
 The experimenters who attempt to practise psychotherapy on 
 other principles than these are doomed to failure, and are liable to 
 inflict secret mental torture, instead of extending relief to the suf- 
 fering patient. 
 
 Isolation from Family and Friends. — Separation from family 
 and friends is one of the most effective psychotherapeutic means. 
 There is a double reason for this measure. In the first place, the 
 disordered feelings and ideas of the patient are so completely 
 interwoven -ndth family or friends that their presence is a constant 
 source of morbid symptoms. Eemoval of all sources of emotional 
 irritation and of delusions is a first means of cure, and the sooner 
 this is accomplished the better it will be for the patient and also for 
 the family. 
 
 The second reason is that isolation thus carried out is the surest 
 way to procure the absolute rest which is demanded in the early 
 stage of the disease in many patients, who instinctively seek solitude 
 and repose of mind. The peace which comes to the patient thus re- 
 moved to perfect quietude broken only by the assistance of a cheerful 
 nurse must be witnessed to be understood. The physician himself 
 then constitutes largely the personal environment of the patient, 
 and he thus gains an opportunity to exercise the highest form of 
 
500 TEXT-BOOK ON METs^TAL DISEASES. 
 
 psychotherapy, which is the prevailing influence of a strong and 
 sympathetic person on a mind diseased. 
 
 Institutional Environment. — A well-ordered institution for the 
 insane affords a chance of removal from former influences, and it 
 furnishes the power of example of orderly obedience to rules, of per- 
 • feet regularity of life, of conformity to daily habits of exercise, oc- 
 cupation, diversion, diet, and sleep, and it secures regular medical 
 attendance, and a higher grade of care to the indigent than they 
 conld otherwise obtain. 
 
 The self-concentration and overbearing selfishness of certain 
 forms of Insanity is not encouraged in hospital life. The patient 
 is no longer the centre of attention, as in a iamilj, where everything 
 has to be regulated with reference to the demands of the sick one, 
 but the egoistic and exacting insane find that they are only one of 
 a large number, and the moral effect and disciphne of hospital life 
 is often most salutary in effect. 
 
 The force of the whole machinery of a well-appointed hospital, 
 moving like clock-work, and of large numbers of surrounding per- 
 sons conforming to the rules of the house, is one of the most irre- 
 sistible psychical means of introducing order into the disordered life 
 of the patient. This effect is the same in kind, though not in de- 
 gree, as that obtained in all industrial and educational institutions. 
 
 Trahied Nurses. — A thoroughly trained nurse is an invaluable 
 aid in mental therapeutics. Indeed, the psychical influence of the 
 trained nurse on the patient is second only to that of the physician 
 himself. 
 
 Individualized treatment, and even a moderate degree of success, 
 can only be attained by competently trained nurses. 
 
 While the modern training-schools for nurses afford every means 
 of education, they do not insure it, and some of the best nurses have 
 been trained simply at the bedside by intelligent instructions of 
 phj^slcians, which, indeed, is the highest form of teaching for the 
 nurse. As the self-made man, educated only in the school of life, 
 is more practical and successful often than the college graduate with 
 his vain pride of intellect, so the hard-working, strong, good-natured, 
 ever-ready, and quick-witted nurse, schooled by years of bedside ex- 
 perience only, is the one often chosen by preference, when the pihysi- 
 cian desires to practise psychotherapy on a difficult ease of Insanity. 
 
 There is a demand in psychiatric practice for companion-nurses, 
 who should be the educational and social equals of the patient. As 
 companions and equals of the patient in culture and refinement of 
 
THE TREATMENT OF INSANITY. 501 
 
 manner, tliey should be able to fill a higher psychotherapeutic role 
 than the ordinary nurse, whose routine duties they should not be 
 expected to perforin. The intelligent sympathy of such a compan- 
 ion is, in the incipient and convalescent stage of mental disorder, of 
 the utmost value in eases judiciously denied the society of their own 
 relatives. 
 
 Social Readjustment. — Insanit)^ practically, is loss of the power 
 of conformity to the social medium in which the patient lives. 
 
 This power is regained in convalescence gradually, and it is a 
 part of psychotherapy to furnish a normal personal environment 
 to which the patient is to practise adjustment. This social oppor- 
 tunity is a most valuable measure in mental therapeutics, and one 
 never to be neglected at the proper stage of recovery. 
 
 Hospitals for the insane should throw open their doors more fre- 
 quently, not for large receptions and balls, but for quiet little tea- 
 j^arties and gatherings to favor the social readjustment of convales- 
 cent patients. In these tentative efforts at gradual restoration of 
 the patient to the full enjoyments of social life, there is a chance for 
 the exercise of great tact and skill on the part of the physician. 
 
 To deny the confined patient the opportunity of social readjust- 
 ment is a medical eiTor like the surgical mistake of confinement of a 
 limb which should be regaining its muscular functions, and this form 
 of psychiatric malpractice has made many a social cripple for life. 
 
 The Conduct of the Physician Toward the Patient. — The physi- 
 cian must be not only a medical adviser but a friend for the time 
 being. To enforce discipline and retain the good-will of the patient 
 is no easy task. The lesion of volition in mental disease does not pre- 
 vent the insane from being extremely wilful, and if the physician has 
 not firmness of purpose he will soon cease to be master of the situa- 
 tion. It is not only practical but best to have the same sincerity and 
 directness of conduct toward the insane as toward any other class of 
 patients. Any deceptive course of conduct is a mistake. The same 
 tact, discretion, and knowledge of human nature which secure success 
 for the physician in general practice are essential in his conduct 
 toward the insane patient, but he must be consistent and uniform, 
 as he represents the sane standard and the chief part of the personal 
 environment to which the patient must adjust himself. If the con- 
 duct of the physician toward the patient is wavering and deceitful, 
 there result suspicion, loss of confidence, and complete demoraliza- 
 tion of the patient. 
 
 The physician must be the gi'eat psychotherapeutic agent, and 
 
502 TEXT-BOOK ON MENTAL DISEASES. 
 
 exercise a continuous sort of suggestive cure upon the mind diseased. 
 The hopeful view is ever to be kept before the patient by the 
 physician. 
 
 Influence of the Opposite Sex. — So fundamental is the influence 
 of sex that it is only lost in complete obnubilation of intellect. The 
 writer has known insane mutism of years' sitanding to be broken up 
 under its influence. There are certain cases sinking into secondary 
 dementia which can be aroused by no other psychical means. 
 
 The influence of sex will, in certain instances, avert impending 
 Insanity more effectually than any other agent known to psycho- 
 therapeutic science. 
 
 The application of the influence of sex in psychiatry, from the 
 very nature of all social relations of the sexes, is attended by ques- 
 tions of propriety and delicacy, which interpose practical difficulties, 
 which the wisdom of the physician can usually overcome. Some 
 superintendents of hospitals for the insane have gone so far as to 
 employ women attendants on the male wards, and they claim only 
 beneficial results from the influence of sex thus exerted. Melancholia 
 from disappointment in love has been cured by a timely intervention 
 of this psychotherapeutic agency, which is especially efficient in 
 young persons, and is seldom inert at any age in man. 
 
 The complete social readjustment of the convalescent patient 
 can only be accomplished under the influence of the commingled 
 society of the sexes. 
 
 Occupation. — Functional activity of mind and body is one of 
 the surest means of cure. The occupation is to be chosen as far as 
 possible with regard to the special taste or desire of the patient. 
 Customary employment often fatigues the patient less, and reas- 
 sures him of his ability to perform, and results in more evident suc- 
 cess with less expense of nerve-force, than attempts at new attain- 
 ments. The occupation is to be manual or mental, largely in keep- 
 ing with former habits. Professional men enjoy working with their 
 brains and laborers with their hands; but it is well that all patients 
 should have a certain amount of out-door employment. Every 
 large public hospital for the insane should have a great variety of 
 means of occupation to suit the various trades of its inmates. As 
 Physician-in-Charge of the New York City Asylum for the Insane, 
 the writer in his published Annual Eeport advocated the whole sys- 
 tem of work-shops, and manufacturing manual employments, being 
 equipped with tools and skilled attendants to supervise the labor 
 performed. 
 
THE TREATMENT OF INSANITY. 503 
 
 The object of thus employing patients at their own trades is en- 
 tirely curative, and the financial result, which is often considerable, 
 must always remain a secondary consideration. The physician who 
 allows his patients to overwork to gratify his own economical or 
 pecuniary ambition is unfaithful to his high trust. 
 
 In the main, farming, gardening, and out-of-door occupations 
 are the most beneficial to patients, and yield the most substantial 
 profit. For women, the kitchen, the laundry, the sewing-room, gen- 
 eral housekeeping, and the care of their own apartments afford the 
 most natural sort of useful work. There is great need of out-of- 
 door employment for women. The cultivation of flowers, fruits, and 
 vegetables, and the breeding of poultry are appropriate modes of 
 employment for them. The gathering of fruits, and the picking of 
 berries, and the tending of hot-house productions are also pleasing 
 occupations for women. 
 
 The principle in all occupation is, that the more useful it is, the 
 more it restores the self-respect of the patient, and the more real are 
 its benefits. For patients not capable of serious work, the lighter 
 and more pleasing occupations are to be chosen. 
 
 For many years the writer has seen the good results of a school 
 for patients. Common English branches are taught, and also 
 languages, music, modelling, drawing, and painting. Patients may 
 also teach. For men printing and the editing of a paper has proved 
 diverting, and also sufficiently serious to carry with it a lasting and 
 salutary effect. 
 
 Women may occasionally be allowed to exercise their natural 
 bent in waiting upon the sick, which is often especially gratifying to 
 them. Such nursing is to be done under observation, of course, and 
 for its psychical effect, but the promiscuous discharge of nurses' 
 duties by patients is not to be tolerated under any circumstances, 
 as it leads to gross abuses, and nurses only too quickly learn to turn 
 their work over to patients to perform. 
 
 Occupation, in a word, is the most powerful of all psychothera- 
 peutic remedies. 
 
 Diversions. — Second only to occupation in value in mental thera- 
 peutics are the various diversions, which dispel the dark clouds of 
 melancholy, enliven the drooping spirit, arouse the apathetic, and 
 restore lively tone to the convalescent. 
 
 Diversions are to be judiciously prescribed in the acute and con- 
 valescent stages of mental disorder according to the needs of the 
 case. In chronic Insanity they only form an agreeable feature of 
 
504 TEXT-BOOK ON MENTAL DISEASES. 
 
 the routine life of the patient, and are not regarded as remedial. 
 Like all efficient means of psychotherapy they may be harmful as 
 well as useful if carried to extremes. 
 
 Tastes differ greatly in amusements, and hence there is need of 
 a great variety of pastimes to suit the fancy of patients. Out- 
 door recreations are preferable, and they have alread}' been de- 
 scribed in the section on hygienic measures. Boating, fishing, and 
 coursing with dogs, and actual sports will often arouse an interest 
 when other recreations fail. 
 
 A powerful diversion, which involves continuous muscular effort 
 and hastens the circulation in an unusual manner, will sometimes 
 furnish precisely the cerebral stimulus required for a recovery. A 
 young woman settling into silent stupor after an acute attack, re- 
 sponding neither to visits of relatives nor other appeals, was dressed 
 for the occasion, taken to an evening dance, and placed in the liands 
 of a judicious gentleman waltzer. She first moved mechanically, 
 but the music, the muscular exertion, the active flow of blood to the 
 brain, and the dance of which she was once fond, banished apathy 
 at the end of an hour, and gave an impetus which from that time 
 went right on to complete and raj)id recovery. Within doors, games 
 of chance and skill, singing and dancing classes, card and tea-parties, 
 concerts, magic-lantern exhibitions, lectures, prestidigitation, im- 
 personations, private theatricals, and professional dramatic enter- 
 tainments, tableaux vivants, minstrel performances, billiards, and 
 bowling are available diversions. 
 
 Tlie power of music in mental therapeutics is very great, and as 
 yet it has never been thoroughly utilized as a remedy. The ordi- 
 nary amateur devotion to musical instruments among the insane is 
 known to be a source of great gratification to them, and they also 
 enjoy the mediocre entertainment furnished by the improvised 
 bands of hospitals. But a few old pianos and music-boxes and a 
 volunteer band cannot furnish the real first-class and varied music 
 necessary to make a fair test of the remedy, which, if it cured a few 
 cases in a year in a large hospital, would be an economical curative 
 agent. 
 
 Every large institution for the insane should have good supplies 
 of superior musical instruments and a first-class orchestra. Once 
 a week there should be a classical musical entertainment for those 
 having a cultivated taste for the art. Twice a week there should 
 be well-rendered popular musical concerts. 
 
 Perfect dance-music should enliven the weekly soiree dansante. 
 
THE TREATMENT OF INSANITY. 505 
 
 The charm of good music should be lent to the dinner hour in large 
 associated dining-rooms. The effect of particular kinds of music on 
 special cases should be studied by the physician, who should at any 
 hour prescribe music for a patient as he ^Y0uld order electricity or 
 calisthenics. 
 
 he chronic insane are often made happy and kept out of idle 
 mischief by games of checkers or cards, or by much simpler means. 
 It is well to let such patients cultivate a fancy for some particular 
 thing, which fills out the vacancy of their otherwise idle life. 
 
 It is not wise to allow diversions to crowd. out useful occupa- 
 tion, but there should be a well-proportioned distribution of work 
 and play among the insane. 
 
 Travel and Change of Scene. — As a means of psychotherapy, 
 travel and change of scene in certain cases are unsurpassed. This 
 form of treatment has been greatly abused by the sending of acute 
 cases of Insanity on a rampage from one country to another. The 
 remedy is suitable in occasional cases in the initial stage of mental 
 disease, but it is chiefly important when acute symptoms are at an 
 end, and there is need of novelty and change to hasten and com- 
 plete the mental restoration. 
 
 In intelligent patients convalescence is often marked by mental 
 dejDression, due to surging memories of the painful causes of the In- 
 sanity, and to a certain conscious feeling of loss of social standing 
 and of the confidence of friends. 
 
 Instead of a return to old surroundings and a host of disagree- 
 able recollections, travel and change of scene are of the utmost 
 benefit in confirming the cure in these cases. 
 
 Some harmless paranoiacs who, about once in a given length 
 of time, grow a new set of delusions, or transpose the old ones to fit 
 the new environment, are kept relativeh^ comfortable b}"" a life of 
 travel. But the physician should not imperil public safety by the 
 recommendation of this course in the case of a dangerous paranoiac. 
 
 Young victims of the tender passion, sunken in despondency, 
 may engage in Avcll-planned travel, meeting, by prearranged itin- 
 erary, some attractive person of their own age but of the opposite 
 sex, and be restored to a cheerful state of sanity in a few weeks. 
 There is no danger of an immediate transfer of affection on the part 
 of the affficted one, but so soon as the first keen suffering is ban- 
 ished a second companion in travel had better be substituted as a 
 psychotherapeutic agent to aid unconsciously in the cure. It is not 
 
506 TEXT-BOOK ON MENTAL DISEASES. 
 
 necessary to have any explanation or understanding, unless bet^yeen 
 parents of the invalid and of the second young person, who happens 
 to be one of the party, and unaware of the influence which ^vill 
 naturally result between self and a chance companion, allowed to 
 divert themselves under the pleasing novelties of travel. 
 
 The rich insane, partially recovered with permanent defect, and 
 without dangerous tendencies, should be allowed such pleasure in 
 life as can be derived from travel. The view that all mentally un- 
 sound should be confined is grossly unjust, and hundreds of thou- 
 sands of such persons are living in enjoyment of perfect freedom 
 and comparative happiness. 
 
 Some insane persons have a veritable mania errabunda, which 
 should be checked rather than indulged. 
 
 Travel for the sake of climatic influence has been discussed 
 under climatotherapy. Those not subject to seasickness may de- 
 rive benefit from a prolonged sea-voyage, not only on account of 
 the great purity of the air, but of removal from disturbing influ- 
 ences and a psychotherapeutic effect of the ocean itself. 
 
 Certain Intellectual and Emotional Effects. — The sudden pres- 
 entation to a patient of the visible proof of the falsity of his de- 
 lusions sometimes causes their disappearance. 
 
 The senile melancholiac, accusing the nurse of stealing his 
 glasses, is cured of his delusion when he is told to look in the mirror 
 and behold them on his own nose. The mother who believes her 
 children have been killed abandons her delusion when they appear- 
 before her. The man who is sure his house has been burned recog- 
 nizes his delusion when driven to see that it is undamaged. 
 
 Though insane delusions disappear often before ocular evidence, 
 they seldom yield to the force of argument; but it is a mistake to 
 suppose that this is never the case. A strong argument, forcibiy 
 put, will sometimes convince them against their will, and a little 
 sharp, v/ell-timed ridicule, in the early convalescent stage, abridges 
 the duration of delusions. Some comparatively intelligent patients 
 indulge in self-commiseration and in exaggerated flights of imagina- 
 tion as to daily persecutions. This persecutory day-dreaming habit 
 of mind can be largely broken up by timely severity and disapproval 
 of manner and forced exercise, if, as often happens, the patient is 
 sedentary. 
 
 The repetition of delusional complaints and the sympathy ex- 
 cited by them serves to fix them permanently. If some strong 
 
THE TREATMENT OF INSANITY. 507 
 
 impression or intellectual counter-force is constantly opposed to 
 the delusion, as often as it is on the verge of reappearance, the ten- 
 dency to its revival may eventually become very slight. Severe 
 methods unquestionably had this effect formerly, but the substitu- 
 tion of an agreeable impression is now to be tried. Most patients 
 have some degree of self-control, which personal influence may 
 stimulate them to exert. 
 
 Appeals to their reason and self-respect may arouse dormant 
 self-control, and are by no means always in vain. The proof that 
 personal influence controls the insane manifestations is seen in the 
 quiet and orderly state of patients under a skilful attendant, and 
 their disorderly condition under a poor attendant. 
 
 Disorderly actions, like disorderly ideas, are to be anticipated 
 in a measure, and this is accomplished by a knowledge of the in- 
 dividual tendencies of patients. Surprises and emotional shocks 
 are not conventionally recommended, but the good which sometimes 
 results from their accidental occurrence shows that they are not 
 without decided curative effects. Just as a patient is cured occa- 
 sionally by accidental physical injury, so may a cure follow emo- 
 tional shock. 
 
 Not only the conduct of the patient, but, in certain eases, the 
 duration of the disease, may be affected by the influence of religious 
 emotion. A maniac approaching convalescence will sometimes dis- 
 play surprising self-control if allowed to attend church. 
 
 Eeligious observances and religious administrations by clergy- 
 men are matters for medical decision in the first instance, for the 
 emotion is so deep-seated that lasting injury may result, in certain 
 patients, by its premature revival. 
 
 Chaplains of hospitals for the insane come to understand these 
 things and to exercise a wise discretion. 
 
 Eeligious administrations in the main have a most beneficial 
 effect, and among the insane appeals to the religious emotion are, 
 of all others, most potent for good or evil. Those who have become 
 insane from religious excitement, or whose symptoms have been of 
 a devout complexion, should not, until convalescent, be allowed to 
 occupy their minds with religious affairs. 
 
 Discipline, Rewards, and Punishments. — The insane from brain 
 disease have lost self-control in a measure. There are all degrees of 
 this loss and of remaining self-control. The discipline in a well- 
 ordered hospital for the insane is complete, and extends not alone 
 
508 TEXT-BOOK ON MENTAL DISEASES. 
 
 to nurses but also to patients, wlio with few exceptions learn to 
 obserre all the regulations of the house. Tliis discipline, which is 
 increased by the force of example and of numbers, is a strong psycho- 
 therapeutic agency. 
 
 There are also certain rewards which influence the conduct of 
 the insane and arouse their efforts of self-control. These rewards 
 consist in extended privileges, carriage drives, entertainments, and, 
 in fact, in such incentives as parents hold out to members of their 
 household to .bring about the desired conformity to their wishes. 
 
 The punishments consist in deprivation of these same privileges, 
 and they are rarely to be employed. It is useless to ignore the fact 
 that they have a beneficial effect, though, theoretically, they are not 
 to be advised in the light of punishments. 
 
 Discipline, rewards, and punishments are simply plain terms, 
 seldom used, for things euphemistically described and daily prac- 
 tised by all physicians, who treat the insane, some of whom are 
 recognized to be entirely irresponsible, and others to possess voli- 
 tional power and modified responsibility. 
 
 The severity of measures recommended by Leuret, though not 
 endorsed by the profession, was founded on perfectly correct ob- 
 servation of 23sychotherapeutic influences. 
 
 Seclusion. — Seclusion has a decided psychical effect. It serves 
 to remove the patient from external excitants and to quiet sensorial 
 disturbances. 
 
 The fact that this remedy has been greatly abused does not 
 detract from its usefulness. It must never be allowed to serve 
 merely as a substitute for the care of attendants, or as a convenient 
 way of disposing of a troublesome patient. 
 
 Acute hallucinatory excitement is best treated by seclusion in a 
 darkened room, when it is dependent on sensorial hypereesthesia. 
 
 Many cases of acute exhaustion from mania are to be treated in 
 seclusion and in bed. Choreic mania in the young is to be likewise 
 dealt with. 
 
 The blind fury of epileptics, and the frenzy of precordial anxiety, 
 calls for seclusion for a brief period. 
 
 There are some patients who for a time are in active dread of 
 bodily injury, and derive the greatest relief from seclusion during 
 the height of their fears. 
 
 Perfect ventilation and an even temperature are to be provided 
 in a room serving for seclusion. Padded rooms are seldom used as 
 formerly. 
 
THE TREATMEIS'T OF INSANITY. 509 
 
 Seclusion, as a means of discipline, is not to be employed. 
 
 In psychotherapy seclusion is used mainly for its calmative 
 effect. 
 
 Mechanical Bestraint.- — -The most enlightened j)hysicians believe 
 in non-restraint, so far tis it is practical and humane. 
 
 There are three forms of restraint: first, by the hands of at- 
 tendants; second, chemical, by powerful sedatives; and, third, me- 
 chanical, by a great variety of material devices. 
 
 All three forms of restraint are evils, and sometimes one, and 
 sometimes the other, is the lesser evil, according to the nature of 
 the case. ISTo physician, who successfully treats the acute forms 
 of mental disorder, can truthfully declare that he does not make 
 use of some one of these forms of restraint. In many cases they are 
 essential to the preservation of the life of the patient and to the 
 safety of those about him. 
 
 Chemical restraint often depresses the vital powers, deranges 
 digestion, and contributes to the impending exhaustion. 
 
 Eestraint by the hands of attendants is felt by many patients 
 as a personal assault, and arouses intense anger, or insane fear of 
 life, and desperate resistance, which sometimes can only be con- 
 trolled by such force as leaves the patient bruised and completely 
 exhausted by the continuous and enormous efforts to which he is 
 provoked. 
 
 Mechanical restraint, though often less outraging than the per- 
 sonal laying on of hands by attendants, and less apt to result in 
 physical injury to the patient, is open to great facility of abuse, and 
 it is only to be employed in certain extreme cases. The simplest 
 and best form of mechanical restraint is a strong sheet, fastened at 
 the head, foot, and sides of the bedstead, with free opening for the 
 neck and arms, which are unrestrained, except in desperate cases, 
 in which blind sleeves may be necessary. The cases in which me- 
 chanical restraint may be justified are: violently suicidal and self- 
 mutilating cases, desperately homicidal cases, surgical cases to retain 
 dressings, cases requiring the recumbent posture to prevent fatal 
 exhaustion from mania, and very exceptionally masturbatic cases. 
 
 The readiness of capillary rupture and the pathological state of 
 the subcutaneous tissues in some patients cause them to become a 
 mass of bruises when held by the most skilful attendants, and hu- 
 manity demands the use of the restraining sheet in these cases when 
 there is absolute need of some restraint. Mechanical restraint may 
 
510 TEXT-BOOK ON MENTAL DISEASES. 
 
 have a psychotherapeutic effect^, as when applied at the request of 
 a suicidal or homicidal patient to give relief from the fear of their 
 own irresistible impulses. A patient has also, been known to beg to 
 have his hands restrained to save the constant struggle against the 
 impulse to tear and remove his clothes. 
 
 In hospitals for the insane in the United States, as in England, 
 the occasions upon which mechanical restraint are employed are 
 recorded in a book kept for that purpose. 
 
 Hypnotism. — The popular idea of the hypnotic state as produced 
 by magnetic or other peculiar personal influence of the operator on 
 the subject has long since been abandoned by scientific inves- 
 tigators. 
 
 It is now known that hypnotism is dependent on two factors: 
 first, on a neurotic and abnormally sensitive condition of the ner- 
 vous centres, and, secondly, on the voluntary surrender of the sub- 
 ject to the hypnotic condition. No person can be hypnotized against 
 his will in the first instance, and all the modes of the induction of 
 the hypnosis are absolutely immaterial, except as suggestive aids 
 to the voluntary surrender of the patient to the hypnotic condition, 
 which can be self-induced just as well without any of the ordinary 
 passes, bright objects, or pressure on sensitive regions. 
 
 The essential point is that the subjects hypnotize themselves. 
 If they choose to go into the hypnotic state in the absence of the 
 operator they can so do. There are persons having precisely the 
 same abnormally sensitive nervous centres who can go into the hys- 
 terical state at will, and they almost invariably choose to have tjieir 
 paroxysms, not when they know they will be unobserved, but in the 
 presence of others. Some of these same persons can go into the 
 syncopal state at will. Women who have the power of fainting at 
 will are not inclined to admit it, but such cases exist beyond a doubt. 
 It is true that hysterical seizures and fainting-spells and many simi- 
 lar psychopathic and neuropathic conditions can be cultivated with 
 great facility, and that the voluntary element may gradually dis- 
 appear, and that eventually the manifestations may escape the voli- 
 tional control of the subject in a great measure. But this never 
 occurs until there has been such constant repetition that the pro- 
 ceedings have become automatic, and even then the train of actions 
 is initiated by conscious process. Just so is it with hypnotism. 
 
 Many intelligent physicians have a strange misconception still 
 that the whole train of hypnotic phenomena are involuntary on 
 
THE TREATMENT OF INSANITY. 511 
 
 the part of the subject. The subject wills not once but twice for all 
 he does at the command of the operator. He first wills to go into 
 the hypnotic state, and to do just as the operator bids him, and to 
 inhibit all other actions. When he has, by his own act of will, gone 
 into the hypnotic state, he wills to await, and does await, the com- 
 mands of the operator, and as soon as they are given he wills to act, 
 and by an effort of volition, like that in health, co-ordinates his 
 muscles to perform skilful and difficult acts, which he again arrests 
 at will, to perform other acts in accordance with his first resolve to 
 follow the commands of the operator. 
 
 Hypnotism seldom succeeds among the insane because they do 
 not choose to go into the hypnotic state, or, more accurately speak- 
 ing, they have not the concentration of will-power needed to hyp- 
 notize themselves. This is true also of children and imbeciles. 
 
 Some relatively intelligent hypochondriacal, neurasthenic, and 
 hysterical patients have the necessary sensitive nervous centres and 
 the volitional intensity required, and the willingness to go into 
 the hypnotic state, and in this class of patients some favorable re- 
 sults have been claimed for hypnotism among the insane. 
 
 The writer cannot recommend the experimental use of hyp- 
 notism in psychiatr}'. Even the sane who continuously yield them- 
 selves to this morbid nervous condition endanger their mental 
 integrity. 
 
 Suggestion. — People are governed largely by special ideas, both 
 in health and disease. Insane persons especially are under the con- 
 trol of certain ideas, which may be opposed by the suggestion of 
 counter-ideas. An idea suggested to a patient by word of mouth, 
 by look, gesture, or any other means, may have a decided influence 
 on the mind, and indirectly on the physical state. Definite ideas 
 thus suggested to influence thought, emotion, or nutrition and in- 
 nervation of parts of the body have of late years received much 
 attention. The principle is very old in medicine, but the thing 
 under its new form is termed therapeutic suggestion. The recent 
 interest in it has grown, out of hypnotic suggestion, which is an idea 
 suggested for special effect during the hypnotic state. 
 
 Therapeutic suggestion has a very wide application in the initial 
 and convalescent stages of nearly all forms of Insanity. 
 
 The suggestions should be of a hopeful, cheerful, and stimulat- 
 ing nature, and they may be heightened in effect by repetition by 
 more than one person. The whole neurotic class of patients are 
 
512 TEXT-EOOK ON" MENTAL DISEASES. 
 
 especially susceptible to suggestion. Patients sometimes detect this 
 susceptibility and play upon the morbid fears of hypochondriacs or 
 others by suggestion. 
 
 Delusions and illusions may result in the insane from suggestion. 
 
 Placebos. — An inert substance given instead of an active drug 
 may have a real effect upon the patient. If the bread-pill is given 
 as a laxative, and the patient's attention is directed to this fact, the 
 result may be similar to that which would have been produced by 
 a laxative actually administered. 
 
 This form of psychotherapy is really a mode of suggestive treat- 
 ment. 
 
 Soporific effects may be produced in this way, and also the al- 
 leviation of neuralgic pains. 
 
 The disorders of common sensation in hysterical, neurasthenic, 
 and hypochondriacal cases are also, in occasional cases, capable of 
 modification by this form of mental therapeutics. 
 
 The danger in the use of placebos is in the discovery of the 
 deception and in the consequent loss of the confidence of the patient. 
 
 Hypodermic injections, as placebos, in which distilled water 
 simply, instead of medicated solutions, is used, may perhaps be oc- 
 casionally substituted, but in general this, like all other subterfuges 
 among the insane, is not advisable. 
 
 Section XI. — The Convalescent Period. 
 
 The period of convalescence brings a variety of responsible ques- 
 tions which the physician must decide, and of the more important 
 of these something will now be said. 
 
 Bemoval from Institutional Care.— The period at which a patient 
 should be removed from a hospital for the insane should be decided 
 absolutely by expert judgment as to the future mental welfare of 
 the patient. 
 
 Unfortunatel}^, the general public does not understand the 
 gradual nature of recovery from mental disease, nor the danger of 
 relapses from premature removals. Undue pressure is thus brought 
 to bear on medical officers to discharge patients whom scientific 
 judgment would longer detain. 
 
 The physician must consider, first, the actual physical and men- 
 tal condition of the patient, and, secondly, all the environmental 
 conditions to which the patient is to be subjected on discharge. 
 
THE TREATMENT OF INSANITY. 513 
 
 Of two patients, equally convalescent, one may safely be discharged 
 to a pleasant home circle, and the other retained for further forti- 
 fication against inevitable trials, which await a return to former 
 surroundings, which might occasion early relapse and chronic In- 
 sanity. 
 
 If the physician were to act upon the legal idea, that the moment 
 reason is restored a release should follow, he would be very unwise 
 and unjust toward his patients, and he would be guilty of the same 
 mistake as a surgeon who should allow a workman to resume labor 
 and again break a limb which had already united from fracture 
 completely, but had not yet regained strength sufficient to with- 
 stand the severity of a former occupation. 
 
 In some patients the mental balance is regained somewhat in 
 advance of the true convalescence, based on a restoration of the 
 nervous centres and of general nutrition. 
 
 The physician must have the courage of his scientific convictions, 
 based on actual experience, as to the proper time for the removal 
 from institutional care. 
 
 The Cessation of All Treatment. — The cessation of all treatment 
 is in itself a form of treatment. The patient is to be untaught the 
 idea that he is sick and in need of medication, and he is to be dis- 
 tinctly given to understand, by word and action of those about him, 
 that he is a free and responsible agent again and fully restored to 
 his right mind. The patient is entitled to this assurance from the 
 physician to restore his self-confidence and self-respect. 
 
 If in hospital, the patient should be placed on parole and 
 allowed perfect freedom to go and act his own pleasure, and to cor- 
 respond and receive visits as he pleases, and to prearrange his affairs 
 for a return to his accustomed pursuits. 
 
 It is well to stop all medication for at least a short period before 
 the recovery is pronounced complete, for the double purpose of 
 seeing the patient free from the effects of therapeutic influences, 
 and also for the moral effect upon the patient, who can by no means 
 throw off at short notice the idea of invalidism, which has been 
 impressed upon him by long months of treatment. It is precisely 
 at this period, in cases of recurrent Insanity and in a few other types, 
 that a tentative sojourn at home or return to work is of advantage 
 before the final discharge from the institution. No legal provision 
 for a temporary leave of absence from institutional care has been 
 provided, and the order of the judge committing the patient iiri- 
 33 
 
514 TEXT-BOOK ON MENTAL DISEASES. 
 
 plies that the latter will be kept under treatment until restored to 
 his right mind. Still the custom of paroles has established a sort 
 of precedent which is followed in many hospitals. 
 
 The Danger of Prolonged Treatment. — There is a real danger in 
 treatment prolonged beyond a certain point. The position of a 
 patient who has been deprived of individual rights and treated as 
 insane is often keenly felt as convalescence declares itself. The 
 patient may be grateful for his recovery, but the humiliation of his 
 position cannot but be felt so long as he is under treatment as an 
 insane patient. The personality of the patient reasserts itself with 
 different degrees of strength at this period, and the independence 
 of character reacts feebly in some cases, and if once repressed at this 
 critical convalescent stage it may never reappear, and the patient 
 will sink into terminal dementia. 
 
 The danger of treatment too prolonged is but little less than 
 that of premature return to the affairs of life. 
 
 Return to Business and Social Rights. — An immediate return to 
 a responsible business is not always wise, and yet to assume less than 
 complete charge of one's affairs is in itself a cause of depression and 
 anxiety to many business men. If there is no person in whom the 
 convalescent has perfect confidence it is better that he should again 
 resume all business responsibilities. 
 
 If a committee of the estate of the patient has been appointed, 
 the physician is to aid the patient, if need be, in regaining control 
 of his property. The physician should sustain the patient in re- 
 newing the battle of life, and use his influence, if need be, to pro- 
 tect him against the greed of business partners or of designing 
 relatives. 
 
 Social rights are to be restored at once, and the father is to 
 become the head of his household, and to command customary 
 obedience and respect. Social functions are a tax on vital energy, 
 and a convalescent occupying a position in the social world should 
 gradually resume society relations, unless the latter constitute prac- 
 tically the whole of life, as in the case of some ladies. 
 
 Convalescents of the industrial and laboring class often find 
 great difficulty in regaining lost positions, or in procuring any re- 
 munerative occupation. There is the stigma and public suspicion 
 between them and the means of livelihood. The physician should 
 lend his influence, and in public or private hospitals should, by 
 previous correspondence and interviews with friends, prepare the 
 
THE TREATMENT OF INSANITY. 515 
 
 way for the patient to some early occupation which will afford a 
 living and moral strength to face a suspicious and selfish world. 
 
 The great need of charitable organizations which should under- 
 take to find employment for, and to protect and aid the convales- 
 cent insane of the poorer class, has already been described. 
 
 Cases for Partial Restoration to Civil Rights. — There are cases 
 of recurrent Insanity destined to pass much of their life under treat- 
 ment, with lucid intervals steadily diminishing in length. It is 
 not safe to completely restore to them their property and civil 
 rights, but they should be given their liberty as often as convales- 
 cence is complete, with a charge to relatives to return them to 
 hospital upon the first appearance of symptoms of mental disorder. 
 
 Many of the epileptic insane may also enjoy a partial restora- 
 tion to civil rights, and this is also true of some organic dements, 
 and certain paretics with exceptionally long intermission of symp- 
 toms, and harmless paranoiacs, and hypochondriacs, and cases of 
 recovery with defect of mind. Imbeciles, after acute attacks, are 
 also in this class, and cases of moral Insanity without active anti- 
 social tendencies, and some cases of secondary monomania. 
 
 In all these cases it is for the physician to pronounce upon the 
 exact mental status of the patient, and to determine the degree of 
 restitution of rights and responsibilities advisable. 
 
 The Final Advice of the Physician to the Patient. — The physician 
 who has conducted a case of mental disorder through all the vicis- 
 situdes of an acute attack to perfect recovery has a final duty to 
 perform. There are to be laid down definite rules of life, points 
 in physical and mental hygiene, suggestions of the best way to meet 
 social and business difficulties, and advice as to domestic relations. 
 
 Precautions will also be given from an etiological point of view 
 as to the special avoidance of a possible return of the mental trouble. 
 
 While it is not well to declare the full gloomy outlook according 
 to average percental chances of a recurrence, it is still best to keep 
 the danger of any excess or self-indulgence before the patient, and 
 to suggest an early consultation in case of any unusual symptoms. 
 
 Conjugal rights are the same after recovery as before Insanity, 
 but still the convalescent is to be advised that the nearer the birth 
 of the child to Insanity of the parent the greater is the danger of 
 heredity. 
 
 Patients recovered from syphilitic, alcoholic, epileptic, and 
 strongly hereditary Insanity are to be dissuaded from marriage 
 under any circumstances. 
 
516 TEXT-BOOK ON MENTAL DISEASES. 
 
 Young persons without heredity, convalescent from an ordinary 
 acute psychosis, may marry into some healthy family. 
 
 Patients who have had a second attack of mental disorder should 
 inever marry, even though there be no inherited taint, and though 
 the second convalescence may he apparently complete. 
 
 "With such final advice the physician bids adieu to the patient 
 in whom he has often become greatly interested, and to whom he 
 extends the privilege of correspondence for continued professional 
 consultation. 
 
 From this chapter on the general treatment of Insanity the 
 reader may turn to the treatment of the special clinical types of 
 mental disorder for more special information. 
 
PART II. 
 
PART II. 
 
 THE SPECIAL GROUPS AND THE TYPICAL FORMS OF 
 
 INSANITY. 
 
 CHAPTER I. 
 
 INSANITY FROM GENERAL ORGANIC ARREST OF DEVELOPMENT. 
 Group : Idiocy, Imbecility, and Cretinism. 
 
 All normal manifestations of mind are dependent on complete 
 structural development of the nervous system. The clinical group 
 of this chapter includes Idiocy, Imbecility, and Cretinism, in wliich 
 there are all grades of morphological defects of the nervous system, 
 and corresponding degrees of mental deficiency. Within this clin- 
 ical group might be arranged, from the lowest grade of idiocy to 
 the slightest grade of imbecility, a complete ascending scale of 
 various degrees of arrest of physical and mental development. 
 
 The mental manifestations in this clinical group are not only 
 deficient, but aberrant, and dependent largely on the absence of the 
 primordial faculty of inhibition, and hence arises the propriety of 
 their inclusion within the general term Insanity. 
 
 Section I. — Idiocy. 
 
 By a consensus of medical opinion the extremely numerous class 
 of persons recognizably below the average of intelligence is divided 
 into those of gross defects of mind, known as idiots; into those of 
 less decided mental deficiency, termed imbeciles; and into the weak- 
 minded, whose psychical inferiority is still slighter, ranking them 
 but little below the common mental average. It is useful and prac- 
 tically of both medical and legal importance to recognize these three 
 
 519 
 
520 TEXT-BOOK ON 'mental DISEASES. 
 
 grades of mental defect, and as a designation is needed for those of 
 slight psychical inferiority, it is well to follow the usage of many 
 in confining the term weak-minded to this third division of the 
 total of all the feeble-minded in the community. 
 
 Definition. — Idiocy is a state of gross mental defect, congenital 
 or acquired, accompanied by structural and functional anomalies 
 of physical constitution. 
 
 Esquirol distinguished between loss of mind from Insanity and 
 congenital absence of mind, and he graded idiots into those having 
 only inarticulate sounds, those capable of monosyllabic words and 
 brief phrases, and those having some higher power of speech. 
 
 Others are inclined to a simple psychical division of idiots into 
 teachable and non-teachable. Some group idiots according to phys- 
 ical peculiarities and abnormalities of the cerebro-spinal nervous 
 system, with teratological specimens at one end of the scale, and 
 those with only slight sensorial defects at the other. 
 
 One of the best and most recent divisions, based on morpho- 
 logical peculiarities and etiological considerations, is by a practical 
 authority, Gr. E. Shuttleworth, M.D., as follows: Congenital types — 
 1. Mierocephalus. 2. Hydrocephalus. 3. Mongol or Kalmuc. 
 4. Scrofulous. 5. Birth-palsies, with athetosis. 6. Cretinism. 
 7. Primarily neurotic. Non-congenital types: A. Developmental — 
 1. Eclampsic. 3. Epileptic. 3. Syphilitic. B. Acquired — 1. Trau- 
 matic. 2. Post-febrile. 3. Emotional. 4. Toxic. 
 
 Clinical Delineation. — The clinical forms of idiocy are so various 
 that space will permit the delineation of only the chief types. 
 
 Microcephalic Type. — Head less than sixteen inches in circum- 
 ference, contracted and retreating forehead, sharp nose, small, close- 
 set eyes, diminutive stature, quick and frequent muscular move- 
 ments, inclined and festinating gait on balls of feet, puerile repro- 
 ductive organs, occasional sensorial defects. 
 
 Eesponse quick to sensory stimuli, slight power of attention, 
 quick and lively expression, imitative memory, repetition of short 
 phrases, often some musical faculty, capability of very limited' edu- 
 cation. 
 
 Macrocephalic Type. — Head twenty-three to thirty-five inches in 
 circumference, and round in hydrocephalic, and square-shaped in 
 hypertrophic cases. 
 
 In hypertrophy of brain full face and features, dull expression, 
 slow motions, delayed co-ordination and dragging gait, stature be- 
 
INSANITY FROM ARREST OF DEVELOPMENT. 521 
 
 low the average, organs of reproduction full formed, but function 
 often absent, speech thick and limited to few sentences. Hydro- 
 cephalic cases have pinched faces and features, wide-set eyes, pro- 
 jecting foreheads, looks serious and suffering, slight muscular ac- 
 tivity, ocular inco-ordination, heavy gait, drawling speech limited 
 to short phrases usually, imitation of musical sounds, and some 
 faculty of education. 
 
 The Mongolian Type. — This interesting ethnic type of genetous 
 idiocy includes about ten per cent, of all cases. The clinical de- 
 lineation is, in brief: Short stature, wide, low head, with small 
 occiput, flat nose, eyes far apart and fissure oblique a la chinois, 
 macroglossia, cretinoid integuments, malformed extremities, loose, 
 shuffling gait with head advanced and inclined downward, deficient 
 warmth, circulation, and trophic functions; quick perception, con- 
 siderable memory, and much imitation and some teachability. 
 
 Other ethnic types are Negroid, Malay, and American Indian, 
 and the latter is said to be more frequent in the United States. 
 
 The type of idiot with remarkable one-sided talent for music, 
 numbers, mimicry, and local memory are of the congenital class 
 ordinarily and present interesting features. 
 
 Causes. — The etiology of idiocy is very largely a questionable 
 one, dependent on the interpretation of existing facts. 
 
 Thus the eclampsise so often present are by many regaided as 
 causative of the idiocy, while a broader view might consider them 
 as only symptomatic of the general abnormality of nervous centres. 
 
 The heredity of idiocy is made to include all allied and distant 
 neuroses and phthisical tendency, which may be concomitants, 
 while the active cause may be embryonic accident or incompatibility 
 between the germal and spermal elements. 
 
 Primogeniture may be a coincidence as well as a cause, for which 
 it is set down in nearly twenty per cent, of all cases by 'some author- 
 ities, and the same may be said for accidental mental influences 
 afi'ecting the mother during gestation. 
 
 By the latest census returns in the United States there are 
 95,609 feeble-minded, or a ratio of 152.4 per 100,000 of the living 
 population, which is a greater proportion than in most other coun- 
 tries. The ratio for males is 165.3 and 139.6 for females. 
 
 As to causes, out of 95,571 feeble-minded 19,530 were unknown, 
 1,214 were senile, 10,064 were miscellaneous, 4,956 were due to 
 general diseases of a febrile or infectious nature, 10,598 were due 
 
522 TEXT-BOOK ON MENTAL DISEASES. 
 
 to diseases of the nervous system, 477 to reproductive organs, 5,927 
 to accidents and injuries, such as falls, blows, sunstroke, burns, and 
 exposure, and lightning, and there were set down as congenital the 
 remaining 42,805 of the total first stated. 
 
 While the above returns are avowedly not such as to justify re- 
 liable etiological deductions, they still give a general idea of the 
 causes usually assigned in this class of cases. Percentages given in 
 Tuke's " Psychological Dictionary " in 2,380 cases in all were at- 
 tributed as follows in idiocy and imbecility: Causes acting before 
 birth — ^Phthisis, 28.31; insanity and imbecility, 21.38; epilepsy and 
 other neuroses, 20.0; intemperance, 16.38; syphilis, 1.17; consan- 
 guinity, 4.20; abnormal condition of mother during gestation, 29.87; 
 old age of parents, 0.25; illegitimacy, 1.7C. Causes acting at birth — 
 Premature birth, 3.52; primogeniture, 20.67; prolonged parturition 
 with pressure, 14.24; instrumental delivery, 3.31; accident at birth, 
 1.51; twin birth, 0.96. Causes acting after birth — Eclampsia, 27.39; 
 epilepsy, 8.11; paralysis, 0.92; injury to head, 6.17; fright, 3.06; 
 sunstroke, 0.54; febrile illness, scarlatina, whooping-cough, measles, 
 t}"phoid fever, small-pox, 5.96; overpressure at school, 0.16. 
 
 The above figures show the drift of medical expert opinion as 
 to the causes in this class of cases. 
 
 There are in most instances a great variety of predisposing and 
 exciting causes, and it is difficult to fix other than a hypothetical 
 percental relation of any one factor in idiocy. 
 
 If the remote as well as immediate effects of intemperance are 
 considered the estimate above given is undoubtedly too small. 
 
 Toxic causes are also probably greater than estimated, and of 
 the causes acting after birth infectious diseases should likely occupy 
 a more prominent numerical position. 
 
 Stadia. — In all congenital cases the pathological condition be- 
 gins and ends with life. The amelioration produced by treatment 
 is not the equivalent of a convalescent stadium. 
 
 In non-congenital cases there may be a long initial stadium 
 while epileptic or other deterioration is progressing to complete 
 idiocy. In physical or mental traumatism there may be only a very 
 brief initial stadium before complete development of the fatuous 
 state. 
 
 As the sequel of acute mental disorder in childhood dementia 
 should not be deemed the terminal equivalent of idiocy. 
 
 Symptoms. — As space will not admit a complete symptomatology 
 
INSANITY FROM ARREST OF DEVELOPMENT. 523 
 
 of the various types, a resume is given of the chief somatic and psy- 
 chical s}TTiptoms of idiocy. 
 
 The chief somatic symptoms are as follows: Diminutive and 
 malformed structure, often due to rachitic or scrofulous disease, 
 spinal curvatures, crooked long bones, and deformities of extremities. 
 
 Cranial asymmetries, microcephalus, macrocephalus, hydroceph- 
 alus, porencephalus, and raehischisis and cranioschisis. Ankyloses 
 and arthritis deformans. Muscular atrophies, paralyses, contract- 
 ures, tonic and clonic spasms, and general muscular inco-ordination. 
 Partial or complete defects in the special muscular mechanisms of 
 speech and locomotion. Anomalies in structure and distribution of 
 vessels, and defective cerebral supply from the narrowing of cranial 
 foramina. Hypertrophy of cutaneous tissues, eruptions, hirsuties, 
 cyanosis, cutaneous anaesthesia, thermo-ansesthesia, and perverted 
 excretions of the sMn, 
 
 Malformations or infantile state of the reproductive organs. 
 Amenorrhcea, aspermatism, impotence, barrenness. Cerebral hyper- 
 trophy, simplicity or absence of convolutions, atrophic and sclerotic 
 cerebro-spinal processes, and functional perversions, eclampsia, 
 chorea, epilepsy, and ataxia; all grades of structural and functional 
 imperfections of the organs of special sense; trophic and vaso- 
 motor disorders; cardiac feebleness and valvular disease; tuber- 
 culous, asthmatic, and bronchitic affections; indigestion and gastro- 
 intestinal catarrh, and general malnutrition. 
 
 The psychical symptoms, in brief, are: Loss of muscular sense, 
 impaired tactile perception, deafness, deaf-mutism, amblyopia, loss 
 of color-sense; consciousness, confused or clear only in limited di- 
 rections — imperfect or absent conscious personality; memory radi- 
 cally defective, except in limited directions, and intentional mem- 
 ory never present; imagination childish and usually mere play of 
 fantasy; incoherence of ideas, feeble power of attention, automatic 
 language, and no power of reason by comparison, Coensesthesis is 
 either depressed or expansive. Emotions are superficial and change- 
 able, alternate crying and laughing, which may become automatic. 
 Higher sentiments exceptionally present, but usually are absent. 
 Appetites instinctive and uncontrolled, and there may be reversion 
 of low types. Sleep unsound or excessive, anorexia or polyphagia, 
 sexual torpor or masturbatic indulgence; general activity is not psy- 
 chomotor but reflex and automatic. 
 
 Volition profoundly impaired. All higher forms of inhibition 
 wanting, and this is a chief characteristic of idiocy. 
 
524 TEXT-BOOK ON MENTAL DISEASES. 
 
 This symptomatic summary gives a more comprehensive view 
 than would verbal descriptions of special cases, of which some 
 nearer idea has already been conveyed in the delineation of the 
 special types. 
 
 Pathology. — All degrees of anasmia and hyperasmia of the brain 
 are found in idiocy in connection with structural cerebral lesions. 
 These abnormal vascular conditions, though, are not in themselves 
 probably ever the cause of the deficiency of intellect, but sympto- 
 matic of the deep-seated organic changes. 
 
 Hypertrophy of the brain is the true pathology of very excep- 
 tional cases of idiocy. It is chiefly a congenital affection, and may 
 or may not be associated with rickets and with cerebral sclerosis. It 
 is not due to excessive growth of cells or fibres, and is not recognized 
 as inflammatory or sarcomatous, though Yirchow long ago attrib- 
 uted it to hyperplasia of the neuroglia. The actual cranial size at- 
 tained is less than in hydrocephalic eases, and appears chiefly above 
 superciliary ridges. Cerebro-spinal atrophy may be the pathology 
 in congenital microcephaly. It also may be in some of its acquired 
 and partial forms the chief pathological factor of idiocy. 
 
 Atrophic processes are present in paralytic forms of idiocy, and 
 are due to inflammatory affections of the cortical substance or of 
 the meninges. There is often in these atrophic cases compensatory 
 thickening of the calvarium and effusion of serum and descending 
 degeneration of systemic flbres. The origin of some cases is hemor- 
 rhagic, embolic, or thrombotic. Cystic compensation sometimes 
 occurs in this form of cerebral atrophy attended by paraplegia, 
 hemiplegia, or diplegia. 
 
 Porencephalus, 'due to intra-uterine trophic arrest of brain- 
 growths, is a cause of idiocy, with paraplegic or diplegic symptoms, 
 since the porencephalus may be double and may be acquired as well 
 as congenital. 
 
 Chronic hydrocephalus is the chief pathological condition in 
 chanieal result of a vacuum, and not accounted for by obstructive 
 proves fatal within the first few years of life. The hydrocephalus 
 is probably due to trophic arrest of medullary development, and the 
 presence of fluid in the ventricles is merely a coincident and me- 
 chanical result of a vacuum, and not accounted for by obstructive 
 or inflammatory theories. 
 
 Encephalitic processes, abscesses, and local' softenings are patho- 
 logical causes of idiocy, and also sclerosis of the brain, both of cor- 
 
INSANITY FROM AEREST OF DEVELOPMENT. 525 
 
 tical and medullary substance, and of the diffused form rather than 
 multiple. Some of these affections may be of microbic origin. 
 
 Tumors of the brain, especially tubercular and gliomatous, hold 
 some position in the pathology of idiocy, and also chronic meningeal 
 inflammations. The spinal degenerations are secondary or coin- 
 cident phenomena, and causatively are of minor pathological im- 
 port, so far as the actual mental defects are concerned. 
 
 The particular form of the morbid anatomy of idiocy may be 
 said to be accidental, dependent on trophic arrest in embryonic life, 
 or on inflammatory or hemorrhagic processes at a later period of 
 infantile development. The actual formative defects are gyral, 
 commisural, ganglionic, and extend to both cortical and medullary 
 elements, and are primarily due to intra-uterine arrest of devel- 
 opment. 
 
 Differential Diagnosis. — The differential diagnosis of idiocy is 
 to be made from simple retardation of mental growth. There are 
 families in which retarded mental development is the rule and not 
 the exception, and members of such families may even attain a high 
 order of intelligence after puberty. 
 
 Idiocy is to be differentiated from the state of general debility 
 which prevents physical and psychical activity in some infants who 
 have suffered early from infectious diseases and are undergoing slow 
 recuperation. 
 
 Idiocy is to be differentiated from the secondary states of men- 
 tal weakness, which are the direct sequels of attacks of acute mental 
 disorder, or the terminal states of the major neuroses. 
 
 Finally, the differential diagnosis is to be made between idiocy 
 and the diathetic and toxic states of infantile life, from which com- 
 plete recovery is possible. 
 
 Many of those classed as idiots in strict scientific differentiation 
 are in the terminal stage of infantile psychoses, of which there had 
 been failure of diagnosis. 
 
 Prognosis. — The prognosis is not so unqualifiedly bad as was 
 once supposed. Operative procedure has brought radical relief in a 
 few instances, and pedagogic measures have ameliorated the con- 
 dition of vast numbers of cases. In idiots with gross organic brain 
 lesions only slight improvement is to be expected even from early 
 and continued treatment. About twenty-five per cent, of all cases 
 are complicated with epilepsy which is unfavorable. 
 
 Idiocy with cerebral hypertrophy is of bad prognosis, and also 
 
526 TEXT-BOOK ON MENTAL DISEASES. 
 
 hydrocephalus, with few exceptions, is a hopeless complication. Ex- 
 ternal configuration and stigmata degenerationis are not safe guides 
 in prognosis as to the actual improvement attainable by educational 
 methods, though extreme microcephaly is a uniform exception to 
 this statement. 
 
 The prognosis is bad in those idiots whose treatment has been 
 neglected during the first ten years of life, and in those in whom 
 there is double heredity and cumulative neurotic influence in both 
 parental lines. 
 
 There are unexpected possibilities of improvement in some cases 
 contradictory of the general rule of prognosis, so that it is always 
 well to continue treatment. 
 
 Treatment. — The treatment of idiocy is not a question of weeks 
 and months, but, to be of any avail, must be carried out systemati- 
 cally for years, and it may be divided into measures for strengthen- 
 ing the physical condition, and educational methods for developing 
 the intellect. 
 
 In the physical treatment hygienic means are of first im- 
 portance. 
 
 The climate, by preference, should be mild and sunny to permit 
 of continuous out-of-door life. The dwelling should be well-ven- 
 tilated, kept at an equal temperature, and, above all, free from 
 dampness. 
 
 The diet should be highly nutritious and digestible, and nourish- 
 ment is to be administered at frequent intervals. 
 
 The clothing should be warm and of fine flannel, the year around, 
 on account of impaired circulation and deficient bodily warmth, 
 with such modifications as personal peculiarities of patients demand. 
 
 Long hours of sleep are essential, and a siesta after meals is of 
 advantage in some cases of feeble digestive powers. Absolute clean- 
 liness is to be enforced at all times. 
 
 Hydrotherapy and massage in their milder forms are of much 
 use. 
 
 Exercise, by preference always in the open air, is to be taken at 
 frequent and regular intervals during the day. Systematic habits 
 regulated with daily uniformity are of the utmost importance. 
 
 The m.edicinal treatment covers a wide range of symptomatic 
 indications drawn from the etiology of the case, and corresponding 
 to toxic, diathetic,. and neurotic conditions actually present. The 
 state of the muscular system, of the cutaneous tissues, of the organs 
 
INSANITY FROM AllUEST OF DEVELOPMENT. 527 
 
 of special sense, of the thoracic and abdominal organs often present 
 special indications for treatment. There is a wise prophylaxis to 
 be exercised in a therapeutic way against known tendencies to dis- 
 ease in the patient. 
 
 Tubercular, syphilitic, and epileptic complications are treated 
 A\dth a knowledge that idiots bear drugs less well than persons in 
 liealth. 
 
 Psychical treatment resolves itself into a complete series of sys- 
 tematic means of education of the muscles, of the senses, and of the 
 mental faculties. 
 
 Co-ordination of muscles is first to be taught in simple adaptive 
 movements, and the restless activity of the child is to be utilized 
 to establish habits of puiiposive action, ils the microkinesis of 
 infancy is converted into co-ordinate motions, so the choreoid ac- 
 tions of idiots are to be brought into orderly forms of gesture, sta- 
 tion, and gait. A great variety of simple means may be used in the 
 training of the hand, which, as in the normal infant, may be effected 
 before locomotion is complete. In fact, perfect control of the mech- 
 anism of gait is acquired very late in most idiots, and in some not 
 at all. Kindergarten methods are used to cultivate the special senses 
 and the perceptive faculties. Taste, smell, sight, including the 
 sense of color, hearing, and touch, are developed slowly but surely 
 by daily object-lessons and tests. 
 
 Speech is cultivated in very methodical ways, and certain me- 
 chanical aids are of service. The simple vowel sounds are mastered 
 and then combined with consonants in words for common objects. 
 ilusic is a means in teaching rhythmical movements of speech and 
 gait, and has other important applications, as idiots are susceptible 
 and attentive to it. 
 
 When perception, attention, the special senses, muscular co- 
 ordination, articulation, and simple accomplishments have been 
 taught, som.e of the early rudiments of English branches may be 
 undertaken. A constant repetition and review of lessons already 
 acquired is necessary to further advancement. Some useful manual 
 employment is also possible, and out-door games and in-door diver- 
 sions are not without value. 
 
 The controlling effect must be personal kindness in the moral 
 treatment, and thus orderly habits may be taught, and ideas of right 
 conduct inculcated. Severity and repressive measures have a biMie- 
 ful result, and defeat all educational advance, as the beginnings of 
 mind only expand under genial influences. 
 
528 TEXT-BOOK 0:N" ilE^s'TAL DISEASES. 
 
 Persevering and skilful treatment is follo^yed by decided ira- 
 proTement in fifty per cent, of cases of idiocy. A still greater pro- 
 i3ortion of idiots are rendered cleanly and orderly, and cease to be an 
 annoyance to their relatives, as the result of proper training. In 
 the main, therefore, treatment is highly desirable. 
 
 Section II. — Cretin ism. 
 
 This is a generic term loosely applied to a large number of en- 
 demic forms of idiocy, and also to sporadic cases having accidental 
 features of resemblance. The term should be limited to cases of 
 arrested development with abnormal condition of the thyroid gland 
 and of the connective tissues in general. 
 
 Cretinism, in this sense of the word, is found in the mountainous 
 regions of Europe, Asia, and South America, and it is specially 
 endemic in Switzerland. 
 
 Genuine cases of cretinism occur sporadically in various coun- 
 tries, but some of the cases thus classed are merely jDseudo-cretinic 
 from accidental dermic anomalies. 
 
 Definition. — Cretinism is toxic and degenerative organic arrest 
 of development of mind and body with thyroid and dermoid ab- 
 normalities. 
 
 Clinical Delineation. — There are exceptional types, but the or- 
 dinary form presents the following clinical outlines: Short stature, 
 crooked back, thick, goitrous neck, broad skull, variously misshaped, 
 flat nose, sunken at root, eyes wide apart, defective and carious teeth, 
 earthy or ash-pale complexion, large mouth, thick lips, large red 
 tongue, puffy, ill-formed hands and feet, skin coarse and wrinkled 
 or oedematous, and general clumsy and helpless appearance. 
 
 The psychical aspect stuporous, dull expression, slow perception, 
 husky voice, and slight power of speech, imperfect hearing, and gen- 
 eral deficiency of intelligence. 
 
 Causes. — Governmental investigation of cretinism has only for- 
 tified the popular belief that the earth, the air, and the water and 
 poor food are the causes of the disease. The damp earth contains 
 much lime, the air is moist and enclosed by mountain-heights, and 
 the water is calcareous and has other deleterious mineral ingredients, 
 and the general food-supply is defective in quality and variety. 
 
 The endemic nature of the disease is shown strikingly in the fact 
 that healthy persons becoming residents of the district may suffer 
 
INSANITY FROM AEEEST OF DETELOPMENT. 529 
 
 finally, and may beget cretinous children, and even animals — horses, 
 cows, and cats — show symptoms of the same affection. 
 
 Some springs are avoided finally because of their goitrous influ- 
 ence, and increase or decrease of cretinism is said to have been 
 directly traxjed in certain neighborhoods to the opening or closing 
 of certain springs. The water of these springs contains a great 
 variety of mineral ingredients derived from the soil through which 
 it filters, and efforts have been made to connect the effects of geo- 
 logical formations with the causation of the disease. 
 
 The sunlight is shut out from dwellings by their defective struct- 
 ure, and by the trees and mountains. 
 
 This combination of unh3^gienic influences is supposed to gen- 
 erate the cretinous condition, but there are still other factors to be 
 considered. 
 
 Some of the cretinous regions are known to be miasmatic, and it 
 is probable that a continuous paludal influence contributes in no 
 small degree to the cretinous cachexia in many instances. 
 
 There is also the possibility of an infection of a niicrobie nature, 
 which would serve to fully explain the clinical symptoms, which 
 would seem to point to a toxic origin of the disease. 
 
 The heredity of the disease is shown by the fact that full cretins 
 almost invariably beget cretins. This heredity is endemically en- 
 gendered, as shown by the ready reversion to a normal type of off- 
 spring after removal to a non-cretinous district. 
 
 Some regard cretinism as allied to rachitis, and there is a similar- 
 ity in some of the symptoms. 
 
 Congenital cretinism might thus be accounted for on the hy- 
 pothesis of embrj^onic rachitis, but this theory is not suificient to 
 cover all congenital cretinic symptoms. 
 
 The most recent etiological theory is that cretinism is due to the 
 loss of function of the thyroid gland, which is supposed^ elimina- 
 tive, and directly irfluences biochemical changes in the connective 
 tissues. Experimental extirpation of the thyroid gland in animals 
 gives rise to cachexia strumipriva, which is characterized by stupor. 
 oedema of connective tissues, general malnutrition, and death. Sur- 
 gical removal of the thyroid gland has produced myxoedema in some 
 patients, with mucin in the connective tissues, pachyderma, and 
 cretinoid symptoms, such as arise spontaneously in atrophy of the 
 thyroid gland. According to this theor}^ cachexia strumipriva, 
 34 
 
530 TEXT-BOOK ON MENTAL DISEASES. 
 
 myxoedema, and cretinism are closely allied conditions, arising from 
 loss of thyroid functions. 
 
 This theory is based on the fact that in cretinism the thyroid 
 gland is congenitally arrested in growth, or from inflammatory ac- 
 tion undergoes atrophy, and in other instances is the seat of gpitre, 
 causing loss of function of the gland. 
 
 It may he well to add the further fact that the thymus gland, 
 which is active in fetal life and during early infancy, is also atro- 
 phied or absent in some congenital cretins at birth, and the loss of 
 the function of this gland may not be without causative influence. 
 
 It is just possible that the glandular atrophies and the whole 
 organic arrest of all parts of the organism are alike attributable to 
 a common toxic cause, and, upon the whole, this would seem to be 
 the most satisfactory hypothesis. 
 
 Stadia. — In rare instances there is an embryonic stadium of 
 cretinism, and the infant is born with all the physical signs of the 
 disease, and with absence or atrophy of the thyroid gland, and death 
 usually follows soon after birth. In another class the initial stadium 
 begins with birth, and continues for several years, during which 
 there is a very gradual development of all the symptoms, and the 
 height of the affection is attained about the tenth year, though death 
 often follows at an earlier period. 
 
 In still another class of cases the infant is born without any 
 apparent signs of cretinism, and the initial stadium does not begin 
 until the fourth year, or later, and continues during a slow incre- 
 ment of all the cretinoid anomalies for many years. The stadium 
 of complete development of all the symptoms occurs between the 
 fifteenth and twentieth year in these cases. In those mild cases early 
 removed from the endemic region to healthful surroundings there 
 is sometimes a convalescent stadium extending over some years, and 
 ending in recovery, with slight permanent defects of mind and 
 body. 
 
 In sporadic cretinism the initial stadium usually begins about 
 the age of the second dentition, and has a duration of many years, 
 and the stadium of maximum abnormalities occurs about the ordi- 
 nary age of puberty, which is often absent in these cases. 
 
 Symptoms. — There are full cretins and half cretins. The full 
 cretins are mentally to be classed chiefly as idiots and partly as 
 imbeciles. The half cretins range in intelligence among imbeciles 
 for the greater part, but occasionally they are simply weak-minded, 
 and exceptionally possess a fair amount of talent. 
 
INSANITY FEOM ARREST OF DEVELOPMENT. 531 
 
 The population in the regions of endemic cretinism are largely 
 of a low order of intelligence, and there is added the stupefying 
 elfect of miasmatic and other local deleterious influences. There 
 is, therefore, every grade of mental and bodily defect among cretins, 
 and half cretins, and among the people who inhabit the cretinous 
 region, but have not the outward signs of the disease. 
 
 The cretinous symptoms of mind and body vary in grade in keep- 
 ing with these facts, and the symptomatology here given is that of 
 the full cretinous state. 
 
 The physical symptoms of full cretinism are: Stunted growth 
 with body broad in proportion to length, prominent abdomen from 
 lordosis, often lateral spinal curvature, short neck, often goitrous, 
 brachycephalic head, frontal insufhciency, and in the most cases 
 occipital flattening, flat nose, depressed at root, dull, wide-set eyes, 
 puffy eyelids, swollen lips, defective teeth, prognathous or retreat- 
 ing jaw, tumefaction of nasal membranes, mouth-breathing and 
 maeroglossia, livid skin is hypertrophied and anaesthetic, plump and 
 clumsy hands, arrested growth or malformation of reproductive 
 organs, impotence, sterility, amenorrhosa, feeble circulation, im- 
 paired co-ordination of muscles, enlarged joints, heavy and shuffling 
 gait, sluggish digestion and respiration, and general torpor of vital 
 functions. 
 
 The mental symptoms are: Perception blunted^ feeble memory, 
 absence of reasoning power, general apathy, defective special senses, 
 slovenly habits, limited power of speech, incapability of self-care, 
 absence of sexual appetite, lack of all spontaneity, and feeble volition. 
 
 The half cretins, ranking as imbeciles in intelligence, are partly 
 capable of self-care and of some useful occupation when taught. 
 They are said to be salacious and inclined to propagate, and it is 
 observed that women cretins, more uniformly than men, transmit 
 the disease to offspring in case of marriage with healthy persons. 
 
 Goitre exists in the greater proportion of the cases, and in others 
 there is atrophy of the thyroid gland. There are some without 
 apparent thyroid disease, but with many of the physical appearances 
 of cretinism; and there are others without the bodily peculiarities, 
 but with the mental traits of the affection. 
 
 Pathology. — There are several orders of pathological facts to be 
 named in cretinism. First, there is the fact of the greatly hyper- 
 trophied thyroid gland, and the pressure which it exerts on vessels 
 and its effect on cerebral circulation. Second, there is a premature 
 
632 TEXT-BOOK ON MENTAL DISEASES. 
 
 synostosis basilaris of the cranium, and narrowing of the vascular 
 foramina, which has an influence on cerebral nutrition. Third, 
 there are such structural defects and diseases as have already been 
 described under the pathology of idiocy; and, finally, there is the 
 specific pathology of the suppression of the function of the thyroid 
 gland, which, by recent hypothesis, is regarded as the essential 
 factor in the disease. 
 
 It may be that further research will yet reveal microbic infection 
 or special toxic agent to account for all the phenomena of the disease. 
 
 Differential Diagnosis. — The symptoms of cretinism are so char- 
 acteristic, and its limitation to certain regions so uniform, that there 
 is seldom difficulty in differential diagnosis. The only practical 
 need of differentiation is between sporadic cretinism with atrophied 
 or goitrous thyroid, and simple idiocy, with accidental resemblances 
 to cretinism. 
 
 These chance-cases with hypertroiphied skin and cretinoid simi- 
 larity, but without thyroid disease, are not to be classed as cretinism 
 unless they occur in endemic regions. 
 
 Prognosis. — The prognosis is bad where there is strong heredity 
 to cretinism, also in congenital cases, and in all cases not early re- 
 moved from the endemic districts, and in all eases with atrophy of 
 the thyroid gland. There is a possibility of amelioration in cases 
 emigrating early to a healthful locality, and the prognosis is some- 
 times favorable in healthy young children, who have acquired cre- 
 tinism by residence in cretinous regions, provided they return to 
 hygienic surroundings. 
 
 The change of residence from the cretinous neighborhood is, in 
 all cases, without regard to the form of treatment, essential to a 
 favorable prognosis. 
 
 Treatment. — The broadest treatment is prophylactic, and should 
 become a part of state medicine. The endemic districts should 
 be drained, pure water should be supplied, habitations should be 
 made hygienic, and general rules of health should be enforced; the 
 diet should be regulated, and the propagation of cretins by cretins 
 should be forbidden, and marriage with healthy persons should along 
 be permitted. 
 
 The most effective means of treatment is, first, removal from the 
 endemic region, as already stated. 
 
 Other means are hygienic, with educational and symptomatic 
 therapeutic measures, as in other forms of idiocy. 
 
INSANITY FROM ARREST OF DEVELOPMENT. 533 
 
 The specific treatment is by the administration of thyroid ex- 
 tracts to substitute the lost function of the gland. 
 
 Thyroid transplantation has been undertaken, with some show 
 of success. It remains to be seen whether this heroic surgical meas- 
 ure is destined to have success in the future treatment of cretinism. 
 
 Section III. — Imbecility. 
 
 The mental defect in imbecility ranges through every possible 
 gradation, from idiocy to such slight want of intelligence as is termed 
 weak-mindedness, and the latter condition is also included under 
 imbecility by many writers. The weak-minded will not be treated 
 of as a separate pathological class. It is important that the physician^ 
 should recognize their mental status as beneath that of the average 
 of mankind, though not such as to justify the application of the 
 term imbecile. There is an arrest of mental development in utero, 
 at birth, or in early childhood in imbecility, which must be dis- 
 tinguished from the mental weakness following the developmental 
 or involutional crises or secondary to the psychoses. The failure to 
 make this distinction has led to much confusion in medical returns 
 as to the statistics of the entire feeble-minded class in all countries. 
 
 In the statistical statement as to idiocy, the total figures given 
 embraced the whole feeble-minded population, and, for want of any 
 line of demarcation, it is not possible to state the number of imbe- 
 ciles in this or any other country as distinguished from idiots and 
 weak-minded. 
 
 Definition. — Imbecility is a state of congenital or acquired func- 
 tional deficiency of mind, usually accompanied by structural defects 
 of bodily conformation and of the nervous mechanism. 
 
 Medical men specially concerned with the care of idiots have 
 failed to draw any clear dividing line between idiots and imbeciles, 
 and yet it is important that such a division should be made, and 
 there are clear grounds for such a demarcation. A full definition 
 of imbecility requires this differentiation from idiocy, and the 
 grounds for it are here given. 
 
 The power of inhibition is the first ground of distinction, and it 
 is possessed by imbeciles to a considerable degree, but not by idiots. 
 The inhibition of ideas implies the voluntary fixation of attention 
 on a different class of ideas, and of such an act of volition the idiot 
 is absolutely incapable. 
 
534 TEXT-BOOK ON MENTAL DISEASES. 
 
 The ideation of the idiot is automatic within the narrow circle 
 of the instinctive wants and of the special senses, and can only be 
 controlled by appeal to these. 
 
 The imbecile has a much wider field of ideas, and power of at- 
 tention to fix a choice between two sets of notions, and hence a 
 certain control of ideas, or, in other words, voluntary inhibition. 
 Therefore arises the medico-legal importance of this distinction, 
 which recognizes modified responsibility in the imbecile, which ex- 
 ists not at all in the idiot, for inhibition of ideas imphes inhibition 
 of actions as well, or, in other words, control of conduct. 
 
 The second ground of distinction is the acquisition of speech. 
 Idiots connect a sensorial stimulus with a vocal sign, and the former 
 provokes the latter in a purely reflex way. A few idiots are educated 
 to an automatic use of phrases, but they do not attain a constructive 
 power of language. The independent formation of sentences ap- 
 propriate to the occasions of life shows that the grade of idiocy is 
 surpassed and that imbecility exists. The grossest imbeciles have 
 only slight formative independence of language, which is cliiefly 
 parrot-like repetition, as in idiots, but in the slightest grades of im- 
 becility there is exceptionally much fluency of speech. 
 
 The third ground of distinction is the general teachability of 
 the imbecile as compared with the idiot. 
 
 The idiot has organic memory merely — the disjointed r^idua 
 of sensorial impressions — but no recollective combination of ideas, 
 and hence cannot be taught, except through sensorial stimuli, and 
 can never rise to the comprehension of abstract things or of any 
 but the simplest things. 
 
 The imbecile has both memory and comprehension sufficient to 
 be taught, and only lacks motives, perseverance, definite aim, and 
 continuous purpose. 
 
 The fourth ground of distinction lies in the fact that idiots do 
 not develop a distinct conscious personality. Imbeciles, on the other 
 hand, have a distinct ego, which invariably asserts itself as a feeble or 
 decided personality. 
 
 These points are sufficient to differentiate between idiocy and 
 imbecility in all cases. 
 
 Clinical Delineation. — Allusion has been made to the variety of 
 degrees of imbecility, and the average grade is here delineated. 
 
 The physical groT\i:h is beneath the mean for the osseous and 
 muscular systems in most cases, but there is exceptionally dwarfism 
 
INSANITY _]fROM ARREST OF DEYEL0P3IENT. 535 
 
 or giantism. There are frequently cranial malformations, but a 
 large class of imbeciles have exceptionally symmetrical heads, with a 
 circumference and a contents slightly below the average. 
 
 The physical stigmata degenerationis are present more or less 
 in a large percentage of all imbeciles. 
 
 There is apparent deficiency in the special muscular mechanisms; 
 the gait has a peculiar lack of co-ordination; and a characteristic 
 deficiency of articulation exists, independent of stuttering and spe- 
 cial defects of speech, which are common. 
 
 The whole bearing is often childish or devoid of force and 
 directness of purpose. There is often retarded development of the 
 reproductive organs. Defects of the special senses are not uncom- 
 mon. Epilepsy, chorea, and other nervous diseases are frequent. 
 The physiognomy, in spite of evenness of features, constituting im- 
 becile beauty in some cases, lacks intelligent expression. Digestive, 
 respiratory, and circulatory functions are often functionally de- 
 ranged, though in occasional cases apparently normal or even 
 vigorous. 
 
 The psychical picture varies, but the ordinary mental outlines 
 are as follows: There is apathy or livehness predominant in two 
 classes of cases. The apathetic talk little, and show little interest 
 in persons or things; they are dull of comprehension, slow to learn 
 any occupation, indolent, sleep and eat, and care for little else. 
 The hvely imbeciles are talkative, restless, mischievous, learn to 
 work, but will not apply themselves continuously to anything. They 
 have quick memories for certain things, but are incapable of general 
 education. They sometimes have talent for music, drawing, num- 
 bers, or mechanical pursuits, but are very superficial in most of their 
 knowledge. They are vain, boastful, incapable of knowing their 
 true relation to the world, and meddlesome to a degree, which keeps 
 them in constant trouble. ISTot infrequently they are given to lying 
 and thieving, and, being subject to sudden bursts of passion, are 
 liable to commit assaults. 
 
 Occasionally they have perverted or exaggerated sexual appe- 
 tites, which lead them into offences punishable by law. 
 
 They lack self-control, are governed by their feelings, and are 
 without judgment or foresight in the affairs of life. 
 
 They get very incorrect ideas of their surroundings, and reach 
 one-sided conclusions readily, and are obstinate in their mistaken 
 views of people and events. They have lively imaginations, and it 
 
536 TEXT-BOOK ON MENTAL DISEASES. 
 
 becomes impossible to know whether they are lying or sincere in 
 their delusive statements as to occurrences in which they have taken 
 part. 
 
 The less intelligent may be uniformly good-natured, but others 
 are changeful, laughing and crying and scolding by turns. 
 
 Selfishness predominates, and complete thoughtlessness or indif- 
 ference to the welfare of others is the rule in imbecility. 
 
 Irresistible impulses are common, and anger sometimes arouses 
 suicidal tendencies. 
 
 Causes. — The first important cause of imbecility is heredity. 
 Imbeciles beget imbeciles with great uniformity. If the mother is 
 imbecile and the father of average intelligence, the majority of the 
 children are apt to be imbecile. 
 
 The transformation of the neuroses and toxic diatheses in propa- 
 gation result often in imbecility. Thus the cliildren of hysteric, 
 epileptic, hypochondriac, and syphilitic or alcoholic parents are 
 liable to be imbecile. Phthisical parents frequently beget imbecile 
 children, and other cachexia tend to a like result in the offspring. 
 
 In the progressive degeneracy which leads to the extinction of 
 families imbecility is the next to the final stage, which ends with 
 idiotic incapacity of reproduction. 
 
 Consanguinity, incompatibility of germal and spermal elements, 
 embryonic accidents, physical and mental shocks to the mother 
 during gestation, primogeniture, instrumental delivery of child and 
 prolonged labor, eclampsic attacks, infantile infectious diseases, 
 physical and emotional traumatism of the child, and exposure to 
 excessive heat are the chief etiological factors of imbecility. All 
 the pathological affections of the nervous system mentioned under 
 the etiology of idiocy are occasionally present in the light of causes 
 in imbecility. 
 
 For the imbecility of semi-cretinism . the causes of the latter 
 affection are to be taken into consideration. 
 
 Stadia. — Congenital imbecility has often an acute intra-uterine 
 stadium, due to toxic or traumatic influences, and the whole of life 
 is but a chronic state of imperfect recovery from damage sustained 
 to nervous centres " in utero." 
 
 In other cases the acute stadium begins with the infectious dis- 
 eases of childhood from which there is only partial convalescence 
 of mental strength. There is also a long and gradual initial stadium 
 in cases developed from epilepsy or other chronic neuroses, of which 
 
INSANITY FKOM ARREST OF DEVELOPMENT. 537 
 
 the final outcome is imbecility, and an after-stadium of life-long per- 
 sistence. 
 
 There are cases having a fatal degenerative impetus, which cul- 
 minates in imbecility only at the crisis of secondary dentition, or 
 still more frequently at puberty. This is the stadium of hereditary 
 latency passing into complete imbecility most often at the second 
 evolutionary crisis of puberty. 
 
 A true " stadium convalescens " cannot be said to exist in any 
 case, though vast improvement may result from prolonged pedagogic 
 methods of systematic training. 
 
 Symptoms. — The mental phenomena of imbecility may be thus 
 summarized: Perception is less active than normal, and there are 
 defects of the special senses. The sense of touch is less acute, and 
 in a few cases there is tactile loss of discrimination, as shown by 
 the sesthesiometer; hearing is often defective, color sense is feeble, 
 taste and smell lack precision occasionally, the muscular sense is 
 imperfect, giving rise to general clumsiness of movements. 
 
 Conscious personality exists, but a strong individuality is 
 wanting. 
 
 Memory is good for special things, names, places, numbers, 
 music, or mechanical things, but higher forms of memory for gen- 
 eral principles and abstract truths are entirely wanting. Thought 
 is confined to limited range, and directed chiefly by sensorial impres- 
 sions, and is often childish and rambling. 
 
 Eeasoning is confined to the most simple deductions, and higher 
 abstractions are not attained. 
 
 Emotional tone is subject to sudden fluctuations, from sad to 
 gay, without cause, and depression is frequent. Irascibility and 
 reckless gayety are to be observed. 
 
 The painful emotions predominate in the majority of imbeciles. 
 
 The sentiments are egoistic in the main, and moral perversion is 
 common. 
 
 The appetites are excessive for food, and unnatural often in 
 sexual directions, and there is a craving for artificial stimulus, and a 
 ready yielding to alcohol, tobacco, and drugs. 
 
 Volition is impaired, both as to control of ideas and actions, and 
 the higher forms of self-denial in view of future good are specially 
 wanting. 
 
 The somatic symptoms of imbecility are as follows: Arrest of 
 skeletal growth is perceptible, with angular or lateral spinal curva- 
 
538 TEXT-BOOK O^N" MENTAL DISEASES. 
 
 tnre, in a considerable percentage of cases. Cranial asj^mmetries 
 in exceptional instances are found, and a diminished cranial cir- 
 enmfcrence is common. Facial, dental, palatal, aural, and sexual 
 stigmata degenerationis are found. Muscular inco-ordination, 
 spasm, atrophies, contractures and other disorders are common. 
 Peculiarities of speech and gait are very frequent. 
 
 Defects in the vital functions of digestion, respiration, and cir- 
 culation are not very uncommon. 
 
 In the grossest form of imbecility impotence and sterility may 
 exist, and arrest or malformation of the reproductive organs. Mas- 
 turbation and contrary sexual feelings are also symptoms in a cer- 
 tain class of cases. Abnormalities in convolutions, fissures, and 
 brain-structures are common. Epilepsy, chorea, stammering and 
 other neurotic affections abound. 
 
 Sensorial defects are both organic and functional. Deaf -mutism 
 is both a symptom and a cause of imbecility. 
 
 Some imbeciles attain old age, but the average of life is shortened. 
 Trophic and vasomotor disturbances are occasionally to be observed. 
 
 Pathology. — In the grosser cases of imbecility there are to be 
 found post-mortem asymmetry of the hemispheres and of the con- 
 volutions; defective formation of central ganglia or of the com- 
 missures; deficiency in cortical or medullary substance; embryonic 
 simplicity of convolutions; poverty of ganglionic elements, and in 
 some instances such gross pathological conditions as have been de- 
 scribed under the pathology of idiocy. Atavistic reversion of gyral 
 types, globose cells and arrest of ganglionic elements of the second 
 cortical layer are sometimes found. 
 
 In other instances the morbid anatomy of imbecility cannot be 
 detected by the microscope, and the lack of mental manifestation 
 must be termed a functional deficiency. 
 
 Dijferential Diagnosis. — Imbecility is to be differentiated from 
 idiocy on the grounds given under the head of Definition. 
 
 It is, on the other hand, to be distinguished from such slight 
 mental deficiency as belongs to the weak-minded class. 
 
 It is not to be confounded with the mental enfeeblement fol- 
 lowing attacks of mental disorder, from which there is recovery with 
 defect of intelligence, nor with the decline of mind as a sequel of 
 the involutional crises. 
 
 Epileptic deterioration is not imbecility, nor is senile fatuity, 
 nor the premature decline of mental faculties sometimes sequent of 
 the menopause. 
 
INSANITY FROM ARREST OF DEVELOPMENT. 539 
 
 Imbecility must also be differentiated from the psychical weak- 
 ness following .the infantile psychoses which admit of final recovery. 
 
 Prognosis. — The prognosis of imbecility is always unfavorable 
 as to complete recovery, which is an impossibility. Great improve- 
 ment and life-long usefulness and capability of self-care may result 
 from early and prolonged treatment. 
 
 Prognosis as to life is favorable, except in gross organic lesions 
 of the nervous centres, but the expectation of life at any given age 
 is diminished by the fact of imbecility. 
 
 Treatment. — The treatment as regards physical complications is 
 symptomatic and largely hygienic. The etiology of imbecility some- 
 times furnishes special therapeutic indications, as in congenital 
 syphilitic taint, and cretinous imbecility from malarial infection. 
 
 The main reliance is upon educational treatment, which must 
 be prolonged for years, and can only be carried out to advantage in 
 special institutions, or under the direction of some individual having 
 knowledge and patient skill to devote to the task. Eegularity of 
 habits, the learning of trades or manual occupations, constant dis- 
 cipline under uniform kindness, and a progressive development of 
 intelligence by easy methods are the means to final success in the 
 treatment of imbecility. 
 
CHAPTER 11. 
 
 INSANITY FROM CONSTITUTIONAL NEUROPATHIC STATES. 
 
 Group: Insanity of Childhood, Primary Monomania, Moral Insanity, 
 Periodical Insanity. 
 
 This clinical group, embracing the forms of Insanity above 
 named, is based on a strong constitutional neuropathic state, which 
 is only less marked than the gross degeneracy described in the last 
 group of organic arrest of mental development. 
 
 The constitutional instability of the nervous centres in this group 
 reveals itself early in infantile mental disorder, in primary mono- 
 mania, in moral Insanity, or in periodical outbreaks of psychical 
 disturbance. 
 
 It is of all the clinical groups the one most strongly tainted Avith 
 degenerate heredity, with the single exception of the outright failure 
 of mental development in idiocy. 
 
 The clinical types constituting this group will now receive sepa- 
 rate consideration. 
 
 Section I. — Insanity of Childhood. 
 
 The temporal limits of this type of Insanity are from birth to 
 puberty, but it is intended more especially to embrace the cases of 
 mental disorder which occur during the first decade of life. This 
 type is found before the mind has fully expanded, and individual 
 differences of age and precocity of intellect are to be borne in mind. 
 
 Definition. — The Insanity of childhood is a type of mental 
 aberration arising from a constitutional neuropathic state, and char- 
 acterized by excitement or depression, and by motor and hallucina- 
 tory disorders, and by anomalies of appetite, sleep, digestion, respira- 
 tion, and circulation. 
 
 540 
 
INSANITY FROM NEUROPATHIC STATES. 54l 
 
 Clinical Delineation. — There is an excited^, a depressed, and a 
 stuporous type to be delineated. 
 
 In the excited type of mental disorder the child is restless, mis- 
 chievous, noisy, destructive, heedless of what is said, and has bursts 
 of anger if restrained, neglects playthings and playmates, eats 
 voraciously and without choice, or throws food away, loses sleep at 
 night and has visions which keep it awake, strikes nurse or mother, 
 and fails to recognize them, laughs loudly without apparent cause, 
 has convulsive motor disturbances during sleep, and hastened or re- 
 tarded respiration and circulation. 
 
 In the depressed type the child becomes shy and furtive, seeks 
 solitude, seems in constant dread of some harm, cries and is pain- 
 fully affected by every new impression, becomes suspicious of nurse 
 and parents, shrinks from other children, has disturbed sleep and 
 night-terrors, screams when left alone in the dark, has diurnal as 
 well as nocturnal hallucinations, mistakes common objects and per- 
 sons, refuses food, has cold hands and feet, disordered digestion, 
 feeble circulation, and constipation, with headache and vertigo, and 
 occasionally syncopal attacks. 
 
 The clinical picture of the stuporous type is very different. The 
 cliild has a dull, staring look, and remains almost motionless, and 
 takes no part in play, and has no interest in anything. It forgets 
 what it is told, and does not always understand what is said: it does 
 not ask for food, and eats without relish, and sometimes lies in bed 
 in a sort of cat-aleptoid state, and has to be dressed and led about, 
 and seems only partially conscious of its surroundings, and without 
 ideas or desires or any independent initiative, and there is disorder 
 of the vital functions. 
 
 These types are the correlatives of mania, melancholia, and 
 stupor in adult mental disorders. As an exceptional type, even at 
 this early age, must be recognized also the cycle of excitement and 
 depression, alternating and forming the prototype of the periodical 
 and alternating Insanity of later life. 
 
 There is also the critical type, appearing only during the crises 
 of primary or secondary dentition, and corresponding to the aberra- 
 tion of physiological crises of more advanced years. 
 
 These are the chief types to be outlined, though there are many 
 sub-varieties and mixed forms dependent on special etiological 
 factors now to be mentioned. 
 
 Causes. — In this particular instance the cause of causes is hered- 
 
542 TEXT-BOOK ON MENTAL DISEASES. 
 
 ity, which is so strong as to declare itself as soon as the child is 
 exposed to the first untoward influences of life. It may he heredity 
 transformed from the neuroses in the parents, or from alcoholic or 
 syphilitic or phthisical degeneracy. In other cases it is direct heri- 
 tage from Insanity or imbecility in the parents, or atavistic, and 
 still in direct line of transmis'sion. 
 
 Consanguinity and parental incompatibility account for a few 
 cases, while embryonic accidents, difficult birth, mental and physical 
 shocks of parents just before the conception of the child, or dis- 
 eases of the mother during gestation, are responsible for many more 
 cases. 
 
 Thermic injury to nervous centres from direct insolation, or 
 more often from exposure to artificial heat prolonged, near stoves, 
 fireplaces, or in hot, close rooms, while the child is closely wrapped 
 in numerous coverings, is a frequent cause. 
 
 Diseases of the eyes, ears, nose, and throat, and of the gastro- 
 intestinal tract, parasitic affections, skin diseases, traumatic injuries, 
 especially of the head and spine, and the accidental ingestion of toxic 
 agents are among the exciting causes, which, acting on unstable 
 nervous centres, result in mental disorder. 
 
 Great importance is to be attributed to insufficient and defective 
 diet, and to the resulting malnutrition of the nervous system, and 
 to unhygienic conditions common among the poor in large cities. 
 
 The infectious diseases of childhood are frequent etiological 
 factors, and all forms of microbic infection are to be considered 
 under this head. There is no question that auto-intoxication is an 
 occasional exciting cause at this age, and atrophy of the thymus 
 or thyroid glands may be causative during the first year of life. 
 
 In exceptional cases irritation, or disease, or abuse of the repro- 
 ductive organs may at this early period be an exciting cause of men- 
 tal disturbance. 
 
 Moral causes are sometimes active, and fright, parental severity, 
 overstudy in school, disappointments, and religious apprehension, 
 and other emotional excitement may become a determining cause 
 of mental disturbance. 
 
 Numerous infantile insanities are due directly to organic brain- 
 lesions or to malnutrition of cerebral structures from toxic influ- 
 ences. All the pathological conditions described under the head 
 of arrested mental development may reappear in a less decided form 
 as causes of mental disorder in childhood. 
 
 The degeneracy may be more than a morbid tendency in these 
 
INSANITY FROM NEUROPATHIC STATES. 543 
 
 cases and consist in actual morphological abnormalities, and in posi- 
 tive defects of cerebral structures in extreme instances. The rela- 
 tion of epileptic, choreic, and other spasmodic disorder may be 
 causative or only symptomatic as to the mental disease. Undoubt- 
 edly the psychosis may be the equivalent of the spasmodic neurosis 
 in certain cases, in which these two pathological affections may be 
 seen to alternate even as in adults. The writer saw these cases 
 clinically demonstrated, long years ago, by Bouchut in Paris, and 
 more especially in connection with chorea. 
 
 Stadia. — The regular stadia of mental disease are seldom want- 
 ing in the Insanity of childhood, but they are much less pronounced 
 than in the regular psychoses of adult life, and more difficult to 
 recognize. The writer has treated cases in children, following fevers, 
 in which there was the usual incubatory stadium, the stadium 
 acutum, stadium debilitatis, and the stadium convalescens in cus- 
 tomary order. In Insanity of childhood from fright the stadium 
 acutum takes the place of the initial stadium, but in mental disorder 
 from falls or blows on the head there is often a long incubatory 
 stadium, corresponding to progressive meningeal or cortical changes, 
 before the stadium acutum declares itself, and instead of a stadium 
 convalescens there is in many of these traumatic cases the hopeless 
 stadium dementise. 
 
 There is also a long incubatory stadium in many cases in which 
 secondary dentition determines the appearance of the stadium 
 acutum. The latter may also suddenly follow cortical epileptic 
 discharge or choreic exhaustion of cerebral and spinal centres. 
 
 However varied the etiology of the Insanity of childhood, care- 
 ful inquiry will usually detect the customary stadia of mental dis- 
 ease, and also in some cases the stadial prototype of psychical dis- 
 order destined to endure throughout the whole life of the patient. 
 The line of psychiatric study in these cases is most interesting, with 
 an initial stadium in the cradle and a terminal stadium extending to 
 the grave, and between the two extremes the long cyclical stadia 
 of alternating exaltation and depression. 
 
 Symptoms. — The special senses are sometimes deranged, and 
 both illusions and hallucinations are common. The night-terrors 
 and frightful visions in the dark are due to cortical irritation of 
 sensory regions. The disturbances of hearing are often the result 
 of middle-ear disease, but may also have a cortical origin, or arise 
 from cerebral anaemia and other causes of tinnitus aurium. 
 
 The perversion of taste is the result of coated tongue and changed 
 
544 TEXT-BOOK ON" MENTAL DISEASES. 
 
 buccal secretions, and the loss of smell often arises from some affec- 
 tion of the upper air-passages. 
 
 Conscious personality is not strongly developed at this early age, 
 but there are still decided feelings of well-being or ill-being, and in 
 some cases very marked hypochondriacal states with absurd exag- 
 geration of the slightest ailments. The change in coenassthetic 
 consciousness is so great that the child does not recognize itself, and 
 may declare that it is changed, and may attempt suicide or inflict 
 self-injury in various ways on account of this changed and suffering 
 feeling. Anaesthesia sometimes favors this self-mutilation, which 
 may be practised with sharp instruments or by striking the head 
 against the wall. Homicidal as well as suicidal attempts are not 
 very rare. In certain cases there may be a permanent obscuration 
 of consciousness. The memory is confused, wrong impressions are 
 received, and correct perceptions are not registered, and the child 
 lives in a fantastic and unreal world, and has a constant succession 
 of false ideas, which are too changeful to become fixed delusions. 
 
 The play of fantasy is very lively in the excited types, and the 
 child often raves all day and part of the night about these fantastic 
 things, which it fails to distinguish from realities. This is not true 
 sensorial delirium, but simply complete absence of inhibition of 
 an over-excited imagination, and it only becomes delirium in the 
 maniacal state, which occasionally is present. There are confusion 
 of ideas, failure of recognition of persons, violent emotional out- 
 breaks of fear or anger, perverted appetites, morbid impulses, and 
 destructive tendencies, and well-marked hysterical attacks. 
 
 In the depressed form there are hiding away in dark corners, 
 constant dread and vague fears, nightmare and somnambulism, ter- 
 rifying hallucinations, anorexia, insomnia, and suicidal tendencies. 
 
 In the stuporous cases there are cataleptoid states, torpor of all 
 mental processes, and partial loss of consciousness, ansesthesia of 
 skin, filthy habits, loss of desire for food, and in some cases con- 
 tinued somnolence. 
 
 The physical symptoms are: Perverted secretion and excretions, 
 depraved appetites, spasmodic muscular disorders, vasomotor dis- 
 turbances, gastro-intestinal diseases, sexual precocity or perversity, 
 eclampsia, inco-ordinations and peculiarities of speech and gait, 
 strabismus and anomalies of organs of special sense, and pneumo- 
 gastric disorders, with disturbances of respiration and circulation. 
 
 Pathology. — The hereditary instability of nervous centres in the 
 Insanity of childhood is shown by the frequent association of eclamp- 
 
INSANITY FROM NEUROPATHIC STATES. 545 
 
 tic, choreic, and epileptic states. The spasmodic neurosis and the 
 infantile psychosis axe expressions of the pathological state of the 
 brain-cortex. In a large percentage of cases the pathology is nutri- 
 tive and circulatory disorder of cortical regions. Tubercular menin- 
 gitis is the pathology of a few cases of the depressed type, in which 
 there are active hallucinations. Hereditary S3rphilitic affections of 
 nervous centres are the pathological conditions in other instances. 
 
 The morbid anatomy is similar in the most hopeless cases to 
 that found in the organic arrests of nervous centres, and all the 
 pathological cerebral conditions there described may exist in a 
 minor degree in the Insanity of childhood. 
 
 Differential Diagnosis. — Cases of Insanity of childhood are to 
 be differentiated from idiocy and imbecility. If the child has never 
 shown ordinary intelligence, and becomes maniacal or melancholic, 
 it is not a case of Insanity of childhood, but of the maniacal or 
 melancholic state intercurrent during imbecility of childhood. 
 Perfect recovery is impossible in the latter instance, but might fol- 
 low promptly in the maniacal type of the Insanity of childhood. 
 When called to such a case the history, carefully gathered, will ren- 
 der the differential diagnosis possible. 
 
 The differentiation from the delirious states attendant upon 
 fevers and other acute diseases presents no special difficulties. 
 Chronic malarial intoxication may give rise to doubt, as the men- 
 tal disorder may be vicarious of the attack, but periodicity here aids 
 in the diagnosis. 
 
 Prognosis.- — The constitutional neuropathic state, out of which 
 the vast majority of the cases of Insanity of childhood emerge, ren- 
 ders the prognosis unfavorable as to complete recovery. The active 
 mental disorder is often recovered from, but the inherent weakness 
 and the tendency to relapse remain, and the result is reciu-rence 
 in subsequent life of various forms of mental alienation. 
 
 The association of mental disease with epilepsy in early life 
 ordinarily results in mental deterioration. 
 
 The rare instances in which infectious diseases occasion Insanity 
 in children free from hereditary taint permit of a favorable prog^ 
 nosis. Children becoming insane from exposure to hardships, 
 cruelty, and deprivation of suflB.cient food may recover when restored 
 to more favorable influences. 
 
 Periodicity and cyclical tendencies in Insanity of childhood jus- 
 tify a bad prognosis. 
 35 
 
546 TEXT-BOOK ON MENTAL DISEASES. 
 
 The prognosis is unfavorable in cases complicated with scrofu- 
 lous, tubercular, and syphilitic cachexias. 
 
 Treatment. — Isolation is often the first step toward cure when 
 the child is in an unfavorable environment. This is best accom- 
 plished in an institution, or, still better, in the family of some 
 skilful physician willing to undertake the care and constant respon- 
 sibility of the case. It is not a question merely of immediate relief 
 from acute symptoms of mental disturbance in these cases, but of 
 prolonged and systematic treatment, of the continued enforcement 
 of proph5dactic measures, and of educational methods to be carried 
 out under wise supervision for several years. This is the only radi- 
 .cal way of rebuilding a faulty and neuropathic constitution, and 
 the only plan of treatment which promises permanent cure. 
 
 Hygienic measures indicated are fresh air, out-door life, nour- 
 ishing food at frequent intervals, long hours of sleep, manual in 
 preference to mental occupation, regularity in all the habits of life, 
 and cheerful surroundings. 
 
 The therapeutic means employed are to be based on etiological 
 considerations largely. The hereditary, syphilitic cases, and the 
 malarial, scrofulous, tubercular, chlorotic, rickety, and epileptic 
 symptoms are to be met with appropriate remedies. 
 
 Psychotherapeutic treatment consists in unvarying kindness, 
 with firm but gentle persuasion; constant repetition of orderly ways 
 of conduct, which become established by force of habit; occupation 
 constantly sustained, but varied with hours of diversion; education 
 adapted to the individual case, and always to be carried on by easy 
 gradation and without mental stress. 
 
 This is the fundamental plan of treatment to correct the con- 
 stitutional neuropathic state. The immediate symptomatic treat- 
 ment in acute maniacal cases is often carried out best by isolation 
 and the rest-cure. The acute hallucinatory excitement may be re- 
 lieved by confinement in bed in a darkened room. The choreic 
 maniacal cases are best treated in bed also. Nutrition is uniformly 
 defective, and forced alimentation may be of advantage, and in all 
 cases the dietetic treatment must be carefully adapted to the needs 
 of the case. Hydrotherapy is of much avail, both for sedative and 
 tonic purposes, and may in some instances replace the use of drugs. 
 
 Manual trades and active occupations in the open air should be 
 chosen for these cases, and sedentary employment and literary or 
 professional work should be avoided, and in this way the threatened 
 relapse may possibly be averted in adult life. 
 
INSANITY FROM NEUROPATHIC STATES. 547 
 
 Section II. — Primary Monomania. 
 
 The effort to abolish the idea of partial Insanity has heen a fail- 
 ure, because there are cases in which mental alienation shows itself 
 onl}^ in a limited range of delusions or hallucinations. It is under- 
 stood that the mind acts as a whole, and that there must be general 
 impairment of mental faculties to permit of this state of limited 
 delusions, but the obstinate clinical fact remains that there are 
 many patients who appear rational in conduct and conversation, ex- 
 cept in connection with their monomaniaeal notions. Monomania, 
 therefore, is just as real as any other symptomatic type of Insanity. 
 The idea that every morbid impulse to steal, burn, kill, drink, or 
 indulge some passion should be termed monomania has long been 
 abandoned, and it is now recognized that such impulses are com- 
 mon to a great many forms of Insanity. This promiscuous abuse 
 of the term has given place to a more uniform application of the 
 word to Insanity having a definite origin, course, and termination, 
 such as will now be described. The term paranoia, which was at 
 one time used more or less as a synonym of monomania, has become 
 a generic term applied by continental writers to a vast number of 
 sub-varieties of Insanity, and it is no longer a specific definition 
 for any one type, and it has erased to be the equivalent of mono- 
 mania. 
 
 Definition. — ^Primary monomania is a type of Insanity emerging 
 from a constitutional neuropathic state, ordinarily hereditary, though 
 exceptionally acquired, and characterized mainly by delusional idea- 
 tion as to personal environment and by hallucinations correlative to 
 a dominant and systematized delusion. 
 
 The main definitive points are the degenerative psychopathic 
 state, the dominant delusion in the light of which all the events of 
 life are interpreted, and the confirmatory hallucinations, and the 
 apparent rationahty of the patient outside of the limited range of 
 delusional ideation. 
 
 Clinical Delineation. — Primary monomania fully developed pre- 
 sents the following clinical outlines: Perception and memory are ac- 
 tive, thought is coherent and unchanged in rate, customary processes 
 of reasoning are carried on as usual, except in relation to the domi- 
 nant delusion, capacity for business or acquisition of knowledge 
 often remains, there is no general emotional disturbance, conversa- 
 tion and conduct are in the main rational to casual observers. To 
 
548 TEXT-BOOK ON MENTAL DISEASES. 
 
 confidential friends there are known to exist eccentricities of man- 
 ner^ persistent false ideas, and egoistic preoccupation, with, per- 
 verted, mystic, or persecutory notions. 
 
 The primary monomaniac is engaged in the endless and hopeless 
 task of reconciling all the events, and even the most minute occur- 
 rences of life, with his predominant false belief. The latter is a major 
 premise in all his reasoning, and his conclusions are thus vitiated be- 
 fore they are drawn. The reasoning tendency is irresistible and a 
 constant feature in the clinical picture, which represents the per- 
 petual motion of false attempts of adjustment to one's environment. 
 
 The somatic outlines usually include cranial asymmetries, insane 
 physiognomy, and other physical stigmata degenerationis. 
 
 A considerable portion of cases arise among the hereditarily 
 weak-minded class. Though this intellectual deficiency does not 
 reach the grade of imbecility, it facilitates the comprehension of 
 those cases of youthful primary monomania which in a few years pass 
 into a fatuous state. 
 
 Causes. — In most instances the prime cause is the inheritance of 
 a constitutional psychopathic state, which may not be the direct re- 
 sult of Insanity in the parentage, but of allied neuroses, syphilis, 
 alcoholism, or phthisis pulmoralis. In these cases of direct neuro- 
 pathic heritage it will be found that the first symptom of singu- 
 larity of thought and conduct can be traced often to the earliest years 
 of childhood, and almost invariably date back to the period of pu- 
 berty at least. 
 
 In another class of cases the constitutional neuropathic state is 
 not inherited, but acquired by severe infectious disease, traumatism, 
 insolation, long mental strain in business or domestic worry, or by 
 other great stress of mind or body. 
 
 The cases developed by puberty or the grand climacteric are not to 
 be numbered in this class of acquired monomaniacal aberration, for 
 inherited taint will be found almost without exception on careful 
 inquiry. 
 
 In still more exceptional instances primary monomania is the 
 result of gross defects of cerebral structure, or of acquired brain 
 lesions of demonstrable character. 
 
 In very rare cases the deprivation of the special senses and the loss 
 of the true correspondence between the internal world of ideas and 
 the external world of realities has been the prime source of the mono- 
 maniacal delusional growth. 
 
INSANITY FROM NEUROPATHIC STATES. 549 
 
 Stadia. — In the principal degenerative t3'pe of primarj mono- 
 mania the initial stadium begins in the eccentricities of childhood, 
 evolves delusional ideation at puberty, and passes into the stadium 
 of complete development with systematized delusions and confirma- 
 tory hallucinations between the fifteenth and twenty-fifth year. 
 This second stadium (stadium acutum) of the full height of the 
 mental disease may cease only with the life of the patient, or at the 
 end of some years it is followed by a stadium debilitatis. This latter 
 stadium of mental weakness is ushered in often by a transformation 
 of delusions of persecution into delusions of grandeur. This delu- 
 sional state of mental weakness lasts the remainder of life or very 
 exceptionally passes into a final stadium dementias. 
 
 In other degenerative cases the initial stadium does not begin 
 until adolescence, and the stadium acutum is not fully developed 
 until the fourth decennium (tliirty to forty years), and in women may 
 coincide with the climacteric involution, and in these cases of late 
 development, a stadium debilitatis is the exception, and a final sta- 
 dium dementise is still more rare. 
 
 In the cases of acquired neuropathic state, out of which the mon- 
 omania arises, the initial stadium is much shorter, varying from a 
 month to a year, and the stadium acutum in these non-kereditary 
 cases is on an average shorter and may pass into a stadium debilitatis, 
 or into a stadium convalescens, which affords the surprising in- 
 stance of recovery from acquired primary monomania, for in the he- 
 reditary patients there are long remissions but no real recoveries. 
 
 Symptoms. — The psychical symptoms are first in order of con- 
 sideration. General perception of sensorial impressions is active and 
 positive sensorial defects do not often exist from organic lesions of 
 the organs of special sense, but functional disorder, tinnitus aurium, 
 loss of color sense, illusions and hallucinations, are frequent. These 
 illusions and hallucinations often arise after the appearance of de- 
 lusions, which they serve to confirm. Though this is the usual order, 
 it is a mistake to suppose that delusions always precede the sensorial 
 disorder, which yields the first symptoms during the development of 
 primary monomania in childhood. Auditory hallucinations are al- 
 ways the leading sensorial anomaly, though all the special senses, in- 
 cluding the muscular sense, are apt to become involved. Memory is 
 active, but attention finally is so preoccupied with delusive concep- 
 tions, that those things come to be best remembered which relate to 
 the false beliefs. 
 
550 TEXT-BOOK ON MENTAL DISEASES. 
 
 Thought is coherent, but largely engaged in explanatory efforts 
 of events relating to the fixed ideas. 
 
 Imagination is very active and morbid, and plays tricks with the 
 sober senses. Everything is sensorially perceived in the hght of 
 expectant attention and distorted to suit the purposes of the dominant 
 delusions. In the play of expectant imagination every look, word, 
 gesture, or motion of surrounding objects, animate or inanimate, are 
 exaggerated into special signs relative to the patient. The manner 
 in which people walk upon the street, the chance motions made with 
 their hands, the expression of their faces, the accidental position of 
 furniture in the house, the way in which the doorbell rings, the tick- 
 ing of the clock, all are imagined to signify something or to have 
 some hidden meaning. 
 
 Seasoning by comparison takes place as usual, except that reason 
 is enslaved by the tyranny of the persistent central idea, to which 
 all other ideas become subsidiary. Ideation is apt to be within a 
 narrow range and largely repetitive, and is sometimes controlled 
 from organic sources, as in the hypochondriacal type. 
 
 Consciousness is at first undisturbed, but finally personality may 
 undergo a transformation. 
 
 The delusions cluster about a central false belief, which is slowly 
 evolved and systematized. The form which this central and domi- 
 nant delusion chances to take depends upon the age, sex, education, 
 social position, occupation, and inherited tendencies of the patient, 
 and upon the personal environment in which he happens to be. It 
 is .not a scientific basis of division to classify monomanias, therefore, 
 according to the character of the delusions, which appear chiefiy 
 under the following clinical forms, which give variety to the symp- 
 tomatology, but in no way alter the essential nature of the psychical 
 disease. 
 
 Delusions of persecution are first noted as perhaps more common 
 than any other. The false interpretation of the minute events of 
 every-day life, in accordance with fear and suspicion, which are the 
 pervading emotions, give rise to delusions, which finally place the 
 patient in the position of expectant antagonism to the whole world. 
 It is precisely because the patient is fearful and suspicious and fore- 
 boding evil that he discovers impending danger and personal persecu- 
 tions in trifies light as air. The patient soon weaves a complete net- 
 work of delusions of persecution, involving his entire personal envi- 
 ronment, and toward those in most intimate relations of life with 
 
INSANITY FROM NEUKOPATHIC STATES. 551 
 
 him his persecutory delusions may reach the height of homicidal 
 violence. Others resort to litigation to right their imaginary 
 wrongs, or persecute in many ways their fancied enemies. 
 
 It would take pages to even name the endless variety of these 
 delusions of persecution, confirmed hy hallucinations of all the spe- 
 cial senses and of general sensation. Electricity, hypnotism, drugs, 
 "gases, invisible agencies, diabolical instruments of torture, sexual 
 assaults, vile abuse, the mixing of filth with food, the communication 
 of diseases, and every conceivable insane fancy form the material of 
 these delusions. The vast majority of patients suffering from these 
 delusions only seek to escape persecution, but those who try to 
 avenge it are so aggressive as to be the most dangerous of all the 
 insane. 
 
 Eeligious delusions constitute another form. Patients of this 
 type of false belief have often played the role of prophets, and have 
 converted many followers, who have usually abandoned them after 
 their incarceration in lunatic asylums. Ordinarily these patients 
 come to interpret texts of the Bible to suit their delusions; they have 
 communications from on high, believe in mystic signs, commingle 
 sexual ideas with symbols of religion, and on the ground of divine 
 authority justify acts of self -mutilation, suicide or homicide. Fort- 
 unately most of this class are harmless, but a few are merciless even 
 to their own children, whom they offer up on the altar of insane re- 
 ligious belief. 
 
 The erotic delusions form another type. The person of whom 
 patients are enamoured may have been seen only once, or not at all. 
 Some patients pursue with their attentions the object of their erotic 
 delusions. Women as well as men are aggressive in this regard in 
 various degrees, being content with seeking a distant view, or resort- 
 ing to letters or forced interviews. Several patients of this descrip- 
 tion, released from confinement after some months, persistently re- 
 newed erotic attentions, and were again placed under treatment. 
 Clergymen and physicians are sometimes annoyed by this class of 
 patients, who may with insane cunning take advantage of circum- 
 stances to make personal accusations. 
 
 Several cases of primary monomania under the writer's care mani- 
 fested only these erotic delusions for several years before wider mani- 
 festations of mental alienation occurred. In one case a respectable 
 woman declared her intuitive knowledge of the desire of a respon- 
 sible gentleman to marry her. She had exchanged a few business 
 words with the gentleman on several occasions, but had never been 
 
552 TEXT-BOOK ON MENTAL DISEASES. 
 
 socially acquainted with him and he had never called upon her, and 
 her delusion was avowedly based only on something in his manner 
 which could not be expressed in words. The diagnosis of Insanity 
 was made on the strength of the delusion, which was fixed and un- 
 alterable and had continued for more than a year, but the medical 
 conclusion was resented by all who best knew thB patient, who had 
 no other irrational ideas. In a short time the patient met the gentle- 
 man, and openly demanded an explanation of his matrimonial in- 
 tentions toward her, and her friends then recognized the nature of 
 her mental disorder. The assurance by the gentleman of her mis- 
 take only served to develop the further delusion that he was intimi- 
 dated from declaring his true feeling for her. She continued to 
 annoy the gentleman by seeking interviews, and derived no special 
 benefit from treatment, and was firm in her delusion at the end of 
 two years. Her general conduct and conversation were so rational 
 that she was not known as insane except to her intimate friends. 
 
 Hypochondriacal delusions are another form of persistent false 
 beliefs which may constitute the essence of primary monomania for 
 years consecutively. Perversions of common sensation often exist in 
 connection with this form of delusions, which may relate to any one 
 or to several of the internal organs or to the sexual functions. Delu- 
 sions of grandeur are primary in some monomaniacs, while in others 
 they appear by transformation of persecutory ideas, and they then 
 often announce the beginning of mental weakness. 
 
 In other instances the two classes of delusions, depressive and 
 expansive, exist side by side throughout the whole course of the 
 mental disorder. 
 
 The above are the chief clinical varieties of monomaniacal delu- 
 sions, but the principal characteristic is the same in all, and that is 
 the logical organization of the delusions with reference to a central 
 and dominating false belief. 
 
 There is a gradual change in personal identity in primary mono- 
 mania, and there may come a time when there is a conscious division 
 between the old and the newpersonality,a sort of double personality. 
 
 The egoistic sentiments of the monomaniac predominate over 
 the altruistic at all times. 
 
 Appetites are often perverted, and contrary sexual feeling is 
 sometimes present. Irresistible impulses and instinctive violent ten- 
 dencies are frequent symptoms. 
 
 Volition is impaired in all cases, and the loss of self-control is 
 most evident in all things which relate to the prevailing delusion. 
 
INSANITY FROM NEUROPATHIC STATES. 553 
 
 The somatic symptoms of primary monomania are cranial and 
 facial asymmetries, marked insane physiognomy, a masculine or 
 effeminate conformation at variance with the actual sex, various stig- 
 mata degenerationis, and in rare instances gross organic diseases of 
 the cerebro-spinal nervous system. 
 
 Cutaneous and visceral paresthesias and paralgesias are constant 
 sjTnptoms in some cases, especially those of the hypochondriacal 
 type. Abnormalities of vasomotor innervation are also common, 
 and also disorder of pneumogastric functions. Spasmodic muscular 
 disorders are not uncommon, and trophic disturbances of epithelial 
 structures are occasional S}Tnptoms. 
 
 AnomaKes of vital functions are not prominent symptoms, but 
 are usually present in the terminal stage of primary monomania. 
 
 Pathology. — InequaKty of cerebral hemispheres, as3rmmetry of 
 cerebral convolutions, the degenerate and criminal type of brain con- 
 formation, anomalous distribution of vertebral and carotid arteries, 
 the narrowing of basal foramina from premature synostosis basilaris, 
 poverty of ganghonic elements of cortex, atrophic congenital arrests 
 of cerebral development, and occasional gross brain lesions, have been 
 found in cases of primar}" monomania. 
 
 Neither these post mortem findings nor the present knowledge 
 of cortical locaHzations justify an attempt to define the pathological 
 anatomy of primary monomania. The pathology of this affection 
 must for the present be deemed to consist essentially in the degen- 
 erative taint transmitted, or in the acquired neuropathic state. 
 
 Differential Diagnosis. — ^Primary monomania must be differen- 
 tiated from imbecility, with eccentricities and exaggerated notions 
 of self-importance and a few narrow delusions. It must not, in its 
 hypochondriacal type, be confounded with the exceptional early hy- 
 pochondriacal symptoms of general paresis. This mistake has led 
 to the belief that primary monomania often ends in general paresis. 
 
 It must be differentiated from those chronic states of limited de- 
 lusions which are the sequels of the acute forms of Insanity. These 
 secondary states of partial and delusional mental weakness are in- 
 stances of secondary monomania, and differ " in toto " from primary 
 monomania. The differential diagnosis must be made from subacute 
 mania and melancholia, with retention of reasoning faculty and few 
 delusions. 
 
 The differential diagnosis from the mental deterioration of the 
 major neuroses presents slight difficulties. 
 
554 TEXT-BOOK ON MENTAL DISEASES. 
 
 Prognosis. — The prognosis as to recovery is unfavorable. The 
 only instances of recovery occur in the non-hereditary cases emerging 
 from the acquired neuropathic state. The prognosis as to expectation 
 of life is favorable, and in some cases the actual duration of existence 
 cannot be said to be affected by the mental disease. The prognosis 
 concerning general usefulness in life is not altogether bad. Some 
 cases discharge responsible duties for a long term of years. 
 
 The prognosis as to final mental deterioration is worse in cases 
 having an initial stadium in childhood than in those developing at 
 a later period of life, and the complication of epilepsy is especially 
 bud. A few recoveries after traumatism or fever have been reported. 
 
 Treatment. — Isolation in an institution is necessary in the anti- 
 social, dangerous, and homicidal class of monomaniacs. The harmless 
 cases with delusions of persecution find most relief often in travel, 
 since they shed the burden of their delusions with each change of 
 residence, and the more complete organization of their delusive ideas 
 in reference to their surroundings is in some measure thus prevented. 
 
 In cases beginning in childhood, prolonged disciplinary and edu- 
 cational treatment affords the only hope of establishing habits of 
 usefulness and the possibility of self-support in life. 
 
 In cases acquired later in life the etiology may furnish certain 
 tlierapeutic or surgical indications for treatment. In the main, there 
 must be palliative and symptomatic treatment. The avoidance of 
 physical and mental strain and the provision of a favorable personal 
 environment is of importance. The turmoil of large cities is a bad 
 environment for such cases. A country life or a seafaring life is 
 adapted to some patients. One case was miserable everywhere except 
 on the broad ocean or the wide expanse of "Western prairies. In 
 patients with phthisical or other cachexia there may be climatic in- 
 dications. 
 
 Psychotherapy is of no avail as regards the dominant delusion, 
 which is the essence of the mental affection. Efforts to remove the 
 delusion by the inoculation of a counter-delusion always fail, as do 
 arguments, entreaties, or threats, or even immersion to the point of 
 insensibility, which was formerly tried in vain. 
 
 Hygienic measures and general improvement of nutrition have 
 sometimes been attended by apparent remissions of the more decided 
 mental symptoms. This amelioration is only surface deep, and is to 
 be compared to the voluntary repression of deluded manifestation on 
 the part of the patient for the sake of release from confinement. 
 
AUUmf "• A.<;S0CIATION 
 
 INSANITY FROM NEUEOPATHIC STATES. 555 
 
 Let not the physician be deceived in these cases. The disease 
 •R'hich is bred in the bone will again manifest itself in the flesh. 
 
 Prophylactic wisdom for the good of the race forbids marriage 
 and propagation, but there can be but little doubt that so far as the 
 particular individual is concerned marriage may avert for some years 
 the full development of the mental disease. This fact does not justify 
 the physician in advice to this effect to the incipient monomaniac. 
 
 In primary monomania due to trauma capitis surgical procedure 
 may constitute the only rational treatment. 
 
 The administration of specific remedies is never to be neglected 
 in patients with hereditary syphilis, and stimulants are to be avoided 
 in those with alcoholic heredity. 
 
 The development of primary monomania in brain- workers calls 
 for an entire change of occupation to some active employment out 
 of doors. 
 
 Patients of this class always do best when busily occupied, and 
 by proper management most of them may still be kept within the 
 number of self-supporting members of the community. 
 
 Section III. — Moral Insanity. 
 
 No question in mental medicine has given rise to much more dis- 
 cussion and variety of opinion than the doctrine of moral Insanity, 
 which carries with it important juridical consequences. Space will 
 not permit notice here of the diverse views expressed by different 
 writers, of whom no one has grasped all the clinical facts with suffi- 
 cient analytic thoroughness to bring logical order out of confusion. 
 Let an effort then be made to briefly marshal all the facts from which 
 to deduce a medical conclusion, for theories are worse than idle. 
 I'irst, then, what is the clinical group of symptoms constituting/ that 
 which has been termed moral Insanity, and under what circumstances 
 and in what class of persons do these symptoms appear? 
 
 The clinical symptoms are that in the presence of active percep- 
 tion, memory, coherence of ideas, quickness of understanding of the 
 ordinary events of life, and the power of connected reasoning, and 
 the general appearance of rationality, there is absence of moral feel- 
 ings of right and wrong, of shame, decency, respect for self or others, 
 or for lawful observances, and in the most pronounced eases there are 
 brutal passions, cruelty, gross immorality, and criminality without 
 pity or remorse. 
 
556 TEXT-BOOK ON MENTAL DISEASES. 
 
 Some or many of these symptoms may appear in the following 
 class of persons: 
 
 1. Imbeciles may fail to intellectually grasp the complex senti- 
 ments of pity, mercy, justice, and all the higher ethical relations of 
 life. Such perverse symptoms as occur in them are due to organic 
 failure of mental and moral growth. 
 
 2. In the first stage of general paresis the sensual depravity and 
 silly and motiveless acts of criminal nature are only the first results 
 of cerebral degeneration. They are a part of general paresis and not 
 of moral Insanity. 
 
 3. In the incubatory stage of melancholia or mania., while cohe- 
 rence of ideas and reasoning power are still present, the instinctive 
 perversion may manifest itself in immoral acts or criminal attempts. 
 Such early symptoms of mania and melancholia are not moral In- 
 sanity. 
 
 4. Moral deterioration, as one of the first symptoms of epileptic 
 Insanity, must not be confounded with moral Insanity. 
 
 5. The diffused cerebral lesions, which occasion eventually alco- 
 holic Insanity, are early announced by a decided moral perversion, 
 sensuality, and brutality of conduct, which does not constitute moral 
 Insanity. 
 
 6. Gross brain disease may be followed by loss of all altruistic feel- 
 ing and shocking lapses of morality. These are symptoms of the first 
 failure of mental power ending ordinarily in organic dementia, and 
 they are not moral Insanity. 
 
 Two distinctly different things cannot be the same thing. The 
 distinct types of Insanity above named cannot be moral Insanity, if 
 the latter itself be a distinct form, nor can the one be a part of the 
 other. Such illogical theories lead to hopeless confusion, and to the 
 mistaking of symptoms for distinct types of Insanity. 
 
 Eeasoning by exclusion of all the above instances, the analysis is 
 to be carried to a conclusion if there are clinical facts to justify it. 
 Such facts do exist in sprte of all theories. Independently of all the 
 above-named conditions and patients, there are very exceptional per- 
 sons, some youthful and some adult, who manifest the characteristic 
 clinical group of symptoms heretofore mentioned as constituting 
 moral Insanity, which term must be strictly confined to these eases, 
 and which will now be studied simply in keeping with known facts 
 and without regard to special hypotheses. 
 
 Definition. — Moral Insanity is a form of alienation arising from a 
 constitutional neuropathic state, ordinarily inherited, though excep- 
 
INSANITY FKOM NEUROPATHIC STATES. 557 
 
 tionally acquired, and characterized by deficiency of moral under- 
 standing, by perversion of the emotional nature, by brutal instinctive 
 tendencies, and by shameful conduct unrestrained by any sense of 
 right or wrong, or by any fear for self or respect for others. 
 
 It is the desire in this definition of moral Insanity to lay stress 
 on the deficiency of moral perceptions, on the perverted feelings, 
 on the pressure of low instincts forcing the patient toward brutal acts, 
 on the absence of higher sentiments inhibiting the lower passions, 
 and especially on the fact that the patient is not restrained from out- 
 rageous conduct from. ill consequences to self any more than from 
 injury to feelings of others. This latter point is important as indica- 
 tive of a perversion of the fundamental instinct of self-preservation. 
 
 Clinical Delineation. — There is considerable activity of attention, 
 perception, memory, and reason. There is no incoherence of thought 
 and no special delusive idea. The positive features are low cunning, 
 selfishness, cruelty, untruthfulness, lying, stealing, sexual depravity, 
 anger, hatred, personal violence, impulses to burn and destroy and 
 maim, homicidal and suicidal tendencies, and reckless disregard of 
 punishment or other severe results to self for evil deeds performed. 
 
 There is a degenerate physical appearance often in the hereditary 
 cases, with many of the physical signs of deterioration, as expressed 
 in the entire bodily conformation, as well as in the physiognomy and 
 the organs of special sense. In the acquired cases there may be no 
 very decided changes in physical outlines, and symmetrical features 
 may wear a sort of perpetual smile strikingly at variance with the 
 general tenor of conduct. In youthful subjects the most impish dis- 
 position may be hidden beneath a childlike innocence of face, and in 
 the female patients typical imbecile beauty may mask the very incar- 
 nation of deviltry. 
 
 Causes. — The etiology of moral Insanity is greatly narrowed by 
 the elimination of types of early depravity from congenital arrest of 
 growth, and of moral perversion as an intercurrent symptom of other 
 forms of Insanity. There remains still hereditary taint as the prime 
 cause. 
 
 Criminal life, sexual debauchery, and drunkenness in the parents 
 are probably as potent hereditary factors as parental Insanity itself. 
 
 The constitutional neuropathic state out of which moral Insanity 
 emerges may be acquired by severe mental shock, or by physical trau- 
 matism, or it may be the sequel of infectious diseases. It is possible 
 that moral Insanity, in the absence of degenerative taint, may be de- 
 veloped by the prolonged strain of business or of domestic life, but 
 
558 TEXT-BOOK ON MENTAL DISEASES. 
 
 such, cases must "be extremely rare. The accidents of embryonic life 
 and the maternal influences during gestation doubtless may have some 
 causative relation. 
 
 Stadia. — Moral Insanity, in the strict sense here employed, when 
 it is the immediate outcome of hereditary taint, has an initial stadium 
 in early childhood, with a not infrequent recrudescence at second den- 
 tition, and a stadium of full development dating from puberty. Un- 
 der long-continued and judicious treatment there may be apparent 
 relief, which is, in fact, only a specious remission lasting, in a few 
 cases, during the most favorable influences, but followed by a full re- 
 turn of symptoms upon the first stress of mind or body, or upon the 
 removal of wise restraints and artificial aids to self-control. The sta- 
 dium of full development lasts for a lifetime, therefore, or is followed 
 very rarely by a terminal stadium dementias. 
 
 , Moral Insanity resulting from the acquired neuropathic state may 
 have a brief or prolonged initial stadium, according to etiological fac- 
 tors involved, and the stadium of full development may last for 
 months or years, and pass into a terminal stadium of mental weak- 
 ness, or into a convalescent stadium, wliich is exceptional. In the 
 latter instance the convalescence is very gradual and marked by occa- 
 sional lapses, but the possibility of final cure must be recognized. 
 
 Symptoms. — The chief mental anomaly is the activity of the men- 
 tal faculties and the torpor of the moral feelings. There is the cun- 
 ning quickness of perception, memory, and reason for all the ways 
 and means of immorality, and the sluggard comprehension of the 
 simplest relation of duty or of right and wrong conduct. This con- 
 trast is an the more remarkable in cases with considerable ability to 
 acquire general information and special aptitudes in certain direc- 
 tions, but absolute mental impotence to grasp the most simple moral 
 ideas. The severest punishment, or suffering inflicted by deprivation 
 of food or liberty, does not arouse the conscience or stimulate the 
 understanding of the common observances of propriety, or deter from 
 the repetition of brutal or unlawful acts. This incorrigibility may 
 appear like voluntary wickedness, but it is due to actual deficiency 
 of moral understanding. 
 
 There is also emotional perversion, and a predominance of anger, 
 hatred, jealousy, vain pride, and all the selfish over the altruistic feel- 
 iLigs. There is absence of pity, sympathy, or natural affection. The 
 animal appetites are strong and there may be sexual perversion. 
 
 Suicidal, p}Tomaniac, kleptomaniac, and homicidal impulses are 
 occasional symptoms. Volition is always impaired in the sense that 
 
INSANITY FROM NEUROPATHIC STATES. 559 
 
 there are disproportionately strong animal passions, and no higher 
 moral sentiments to inhibit the lower feelings. The failure of organ- 
 ized inhihition of thoughts and feehngs results in loss of control of 
 actions. 
 
 The somatic symptoms are confined chiefly to the stigmata degen- 
 erationis. In a few instances there are physical signs of arrested bod- 
 ily growth or of cretinoid degeneration. 
 
 In the acquired cases anomahes of the muscular system, and of 
 digestion, circulation, and respiration may appear, but ordinarily 
 the somatic symptomatology is not very pronounced. 
 
 Pathology. — The pathogenesis of moral Insanity is presumably 
 the inherited taint from degenerate parents. An evil heritage, like in 
 kind, but not so extreme in degree, is seen in the moral obliquity, 
 along with considerable mental activity, transmitted for generations 
 in criminal families. In tracing the parental history in cases of moral 
 Insanity, no instances of mental disorder or of nervous disease may 
 be found, but it may be that the parents have been mean, suspicious, 
 hypocritical, cruel, selfish, cunning, keeping within the letter of hu- 
 man law, but violating the whole spirit of the decalogue, and that 
 the just conclusion is reached that the moral Insanity of the offspring 
 is only intensified transmission of parental depravity. The greater 
 the degree of degenerate taint, the more frequent are morphological 
 rather than mere functional abnormahties. Thus, in the most degen- 
 erate cases occur cranial malformations, asymmetries of convolutions, 
 and structural deficiencies of cortical and medullary structures. 
 
 In acquired cases from trauma capitis, or from severe cerebro- 
 spinal concussion, the pathological lesions will vary with the nature 
 of the original injury. 
 
 In the present state of science no rational explanation can be 
 offered for the fact that cerebral lesions are followed by mania or 
 melancholia in some cases, and by moral Insanity in others. 
 
 Differential Diagnosis. — Moral Insanity is to be differentiated 
 from such congenital arrest of intelligence as renders the comprehen- 
 sion of any of the higher sentiments or any ethical relations or any 
 moral ideas impossible. The defect of intelligence will in this instance 
 be found to be general and not confined to moral conceptions alone, 
 as in moral Insanity. 
 
 The differential diagnosis must be made from the decline of the 
 moral powers in senility. In old age the moral faculties decline "pari 
 passu " with the intellectual powers, until eventually morality in sec- 
 ond childhood is but an automatic observance. If, as occasionally 
 
560 TEXT-BOOK ON MENTAL DISEASES. 
 
 happens^ the moral decline anticipates the intellectual involution, the 
 senile subject displays moral inconsistencies which are not to be mis- 
 taken for moral Insanity, inasmuch as they are only the advanced 
 symptoms of senility. 
 
 Moral Insanity is to be differentiated from the mere symptom 
 of moral perversion antecedent, intercurrent, or sequent, as to general 
 paresis, mania, melancholia, or other distinct forms of Insanity. 
 
 The differential diagnosis is to be made from the general mental 
 and moral impairment in gross brain disease. The emotional and 
 moral perversity will be found here to be accompanied by a general 
 reduction of intelHgence, and the general conditions differ in toto 
 from those of moral Insanity. 
 
 Finally the differential diagnosis is to be made from depravity, 
 from habitual bad associations, by the simple fact of former good 
 manners before they were corrupted by bad company. Conscience 
 may be hardened, but moral understanding is not lacking in these 
 cases. 
 
 The most difficult, and the most important in medico-legal rela- 
 tions, is the differentiation of moral Insanity from mere criminality. 
 The fact is that criminals are sometimes cases of moral Insanity, and 
 as such they are blind and reckless of their own good. They are 
 terribly punished for disobedience of prison rules, and immediately 
 repeat their offences, and are put to the rack again and again, and 
 become the despair of prison authorities, who finally come to recog- 
 nize their mental defect. They show the perversion of the prime in- 
 stinct of self-preservation. This differential diagnosis between moral 
 Insanity and criminality in certain eases can only be made by a care- 
 ful review of the entire lustory of the case, by searching physical and 
 mental examination, and by a comparison of all the facts according 
 to their combined significance in each individual case. 
 
 Prognosis. — The prognosis as to recovery is bad. Cases with 
 strong degenerate taint never recover, and the acquired form rarely 
 progresses to a perfect cure. 
 
 The prognosis is bad as to duration of life, which is shortened 
 by evil habits and various injuries sustained, and by diseases con- 
 tracted. 
 
 Treatment. — The degenerate eases demand isolation in an institu- 
 tion, or such wise disciplinary management as can only be given by a 
 medical man willing to assume constant care of a most troublesome 
 case. The acquired form is also best treated in public or private hos- 
 
Il^^SANITY FROM NEUROPATHIC STATES. 561 
 
 pitals for the insane, in order to assure isolation from evil influences, 
 and the continuous surveillance which the nature of the complaint 
 renders necessary. 
 
 The general good of the public also calls for the confinement 
 of these cases, which are in every sense of the word dangerous to them- 
 selves and to others. 
 
 Section IV. — Periodical Insanity. 
 
 Periodicity is characteristic of many forms of Insanity, for which, 
 unfortunately, there is not in psychiatric science any uniform termi- 
 nology. Periodical Insanity is here used as a generic term to em- 
 brace all types of periodic alienation, and an effort is here made to 
 analyze and apply consistent names to such periodic forms of men- 
 tal disorder as are most often met with in actual practice. 
 
 These periodic forms belong to the hereditary order, and arise 
 fjom a constitutional neuropathic state, and the subdivision of these 
 periodic types here given is based on the mode of the periodicity, and 
 is as follows: 
 
 1. Intermittent Ma/nia. — An attack of mania of some months' 
 duration, on the average, is followed by a period of perfect health 
 
 isyiio/Mmmffm 
 
 imio/MAMA 
 
 
 
 
 
 / ......I. / 
 
 / 
 
 
 J. _^.,a:......:.: 
 
 / 
 
 
 
 
 TraciBg of Intermittent Mania. 
 
 of a year or more on the average. Then another attack of mania 
 occurs, followed by another interval of health, and this form of peri- 
 odicity may continue indefinitely or for a life-time. The maniacal 
 attacks and the free intervals of health may vary in length from 
 weeks to years. Attacks gradually become longer and intermissions 
 shorter. 
 
 Intermittent melancholia occurs in precisely the same way be- 
 tween periods of health of relatively longer average duration than the 
 attacks. 
 
 A simple linear diagram here shows the level of mental health and 
 the decline of intelligence to the maniacal and melancholic level dur- 
 36 
 
562 
 
 TEXT-BOOK ON MENTAL DISEASES. 
 
 ing the course of intermittent mania and melancholia, and the average 
 length of intervals of health. 
 
 /£yMo/jms^m//A. 
 
 Tracing of Iiitermittent Melancholia. 
 
 2. 'Remittent Mania. — An attack of mania lasting for months or 
 years is characterized by remissions of all the symptoms, but the full 
 
 
 Tracing of Remittent Mania. 
 
 level of mental health is not reached at any time, as shown by the 
 linear diagram. 
 
 Eemittent melancholia, lasting months or years, with remissions 
 approaching, but never reaching, complete health, hkewise occurs as 
 here indicated to the eye by a simple tracing of the mental decline. 
 
 i£m./jmMM/A 
 
 lI/MojmMA. 
 
 -\ ~ "'": 
 
 ....L_/ \-J. 1_Z 
 
 
 Tracing of Remittent Melancholia. 
 
 The above tracings show about the average relative duration of the 
 attacks to the remissions during the first ten years in cases beginning 
 as early as the twentieth year. Subsequently the attacks become 
 longer than the remissions, and they may finally coalesce toward the 
 close of life, for remittent Insanity often lasts indefinitely and may 
 finally become practically continuous. 
 
INSANITY FROM NEUROPATHIC STATES. 
 
 663 
 
 3. Circular Insanity. — In this periodic form of Insanity the mel- 
 ancholic state is followed by the maniacal state, and the two states 
 constitute a single cycle. This cycle then repeats itself, beginning 
 with the melancholic and ending with the maniacal state, and con- 
 tinues to repeat itself in this same order for years or for a lifetime. 
 
 l£VIZfJ/MT// 
 
 XT... 
 
 Tracing of Circular Insanity. 
 
 When the cycle is short the melancholic and maniacal states are of 
 about equal length, but when the cycle is long and of more than a 
 year's duration the melancholic state has a longer duration than the 
 maniacal. This latter course of circular Insanity is shown above in 
 the tracing. 
 
 In true circular Insanity the lowered intelligence never attains 
 the level of health in the transition from the melancholic to the mani- 
 acal state, as the latter is a still deeper departure from mental health. 
 
 The various exceptions to these typical outlines of the periodic 
 forms of Insanity are purposely withheld for the present, and will be 
 fully discussed later in this section. 
 
 4. Intermittent Circular Insanity. — In this periodic form the 
 cycle, consisting of the melancholic followed by the maniacal state, 
 
 
 Tracing of Intermittent Circular Insanity. 
 
 does not repeat itself immediately, but only after an interval of 
 health. This intermission of symptoms follows every repetition of 
 the cycle. The above tracing shows the return to the level of mental 
 health between the repetitions of the cycle. 
 
 The above are the main types of periodical Insanity, and the ex- 
 
564 TEXT-BOOK ON MENTAL DISEASP:S. 
 
 ceptional features and sub-varieties will be described under the differ- 
 ent headings of this section. 
 
 Definition. — Periodical Insanity is a type of mental disorder issu- 
 ing from a constitutional neuropathic state, and marked by periodic 
 and extremely sudden departures from and returns to the normal 
 mental standard, and characterized by abrupt changes in greath'' 
 diversified psychic and somatic phenomena. 
 
 Clinical Delineation. — The clinical features vary greatly with the 
 degree of departure from the normal standard, and at the very first 
 this is seldom complete melancholia and mania, but coeuEesthetic de- 
 pression and exaltation. The first manifestations are apt to occur in 
 youth. The young person has the slightest form of melancholia, which 
 is ccenssthetic depression arising from a painful sum-total of all the 
 peripheral impressions of the organism. There are manifested no de- 
 lusions, but tension and inhibition of ideas, the painful moods, loss of 
 interest in everything and of working ability, inactivity of mind and 
 body, emotional indifference to friends and family, loss of will-power, 
 neglect of personal appearance, anorexia, insomnia, sluggish circula- 
 tion, and impaired digestion. This state of ccengesthetic depression 
 may appear intermittently or remittently, and then at the end of a 
 few years and often at the crisis of puberty be replaced by the full 
 form of intermittent or remittent melancholia, or it may constitute 
 the stadium ccengestheticum in a cycle of circular Insanity. 
 
 The state of coenassthetic exaltation, resulting from general pleas- 
 urable organic sensations with heightened vasomotor activity, is the 
 mildest form of expansive mental disorder. 
 
 There are no delusions and no incoherence of ideas, but height- 
 ened thought-rate, some exaggeration of ideas and of self-feeling, 
 great talkativeness and activity to no special purpose, facility of mem- 
 ory, vivid imagination, egotistic and mischievous behavior, impulsive 
 acts, increased sexual tendencies, and excessive animal passions and 
 active circulation, respiration, and digestion. 
 
 In youthful cases the state of ccensesthetic exaltation often inter- 
 mits or remits for some years before it passes into full intermittent 
 or remittent mania, or it forms, with ccensesthetic depression, the cy- 
 cles of circular Insanity before these two milder states give place to 
 the melancholic and maniacal states in circular Insanity. 
 
 The clinical picture is more decided when the full maniacal and 
 melancholic states appear intermittently, remittently, or in the cycles 
 of circular Insanity. In order to avoid repetition reference is made 
 to the chapter on Symptomatology for a full description of the mani- 
 
INSANITY FROM NEUEOPATHIC STATES. 565 
 
 acal and melancholic states, which here constitute the cycles, which, 
 in extreme instances, are of only two days' duration, and hence the 
 inconsistency of mistaking these states for complete attacks of mania 
 and melancholia. Ccensesthetic depression may unite with the mani- 
 acal state to make out a cycle, or coenffisthetic exaltation followed by 
 the melancholic state may form a cycle, which will then continue 
 to repeat itself in circular Insanity. 
 
 The clinical outhne changes much in certain exceptional cases 
 in which melancholic stupor and the maniacal state form the cycle. 
 In a single night the patient may lose all the mental and bodily symp- 
 toms of the maniacal state, and, passing at once into melancholic 
 stupor, be found speechless, expressionless, staring vacantly, making 
 no reply to questions, not heeding the calls of nature, moving slowly 
 and mechanically or not at all, without motive or initiative, and with 
 vasoparetic conditions, cutaneous anaesthesia, slowed pulse and res- 
 piration and torpor of the vegetative functions. In a typical case of 
 circular Insanity under the writer's care the maniacal state was fol- 
 lowed by m_elancholic stupor with well-marked cataleptoid symptoms. 
 
 Causes. — Degenerative taint is the etiology of periodical Insan- 
 ity in seventy-five per cent, of all cases. The heredity is in many pa- 
 tients direct or collateral as regards ancestral mental disorder, and 
 in a few instances it has been homogeneous as to periodical Insanity 
 itself. Still, periodical cases of Insanity by no means transmit other 
 than a direct tendency to mental aberration, which may assume sev- 
 eral types as well as the periodical one. In many instances the hered- 
 ity is transformed from .other neuroses, from sj'philitic or phthisical 
 cachexia, and especially from alcoholic degeneracy of parents. 
 
 It must be admitted that the constitutional neuropathic state may 
 result also from cerebral trauma or from isolation. It appears to 
 f oUow eclampsia in childhood, but whether it is a result or a concomi- 
 tant may be a question. Emotional traumatism, the puerperal state, 
 luetic disease, microbic infection, alcoholic excess, the evolutional 
 and involutional crises, and especially the menopause, are to be rec- 
 ognized as occasional causes of periodical Insanity. Menstruation 
 is provocative of the maniacal state merely, and is not a prime cause 
 of the alienation. 
 
 In fact, the relation of cause and effect is not very clear between 
 the coincidence of the menstrual function and the maniacal exacerba- 
 tion. Monthly periodicity of maniacal excitement is a common form, 
 and the coincidence with the menstrual molimen is accidental in some 
 cases at least. Sex would seem to be a predisposing cause, judging 
 
566 TEXT-BOOK ON MENTAL DISEASES. 
 
 from the fact that many more women than men are periodical cases 
 of Insanity. Age favors the outbreak in the decade fifteen to twenty- 
 five years, and again in the decade forty-five to fifty-five years, or at 
 least these would seem to be the more vulnerable periods, as shown 
 by the appearance of the greatest number of first attacks. 
 
 It is a question whether epilepsy and the other neuroses are to be 
 regarded as causes, or as common manifestations of the inherited in- 
 stability of nervous centres. The association of epilepsy and periodical 
 Insanity is very frequent, and hysteria is also a common complication 
 or prodrome. Malarial intoxication causes periodical mental dis- 
 turbance, but it does not originate true periodical Insanity, ao far 
 as the writer has observed. 
 
 It is possible that auto-intoxication might favor the development 
 of periodic Insanity. 
 
 Stadia. — Periodical Insanity often begins in early childhood and 
 is not recognized. The state of ccengesthetic depression or exaltation 
 runs a remittent or intermittent course in childhood, and passes for 
 unaccountable sadness or gayety. Sometimes these two opposite 
 conditions form a cycle of circular Insanity, until the full melan- 
 cholic and maniacal states are developed in their stead. 
 
 Usually, about puberty, the full remittent and intermittent types 
 of mania and melancholia begin to manifest themselves, and from fif- 
 teen to twenty-five years the greatest number of first attacks occur, 
 and the second most fruitful decade as regards this form of mental 
 disorder is from forty-five to fifty-five, as already stated. 
 
 The attacks of mania and melancholia appear and disappear so 
 suddenly that the initial stadium has been ignored, but there is a 
 brief coenaBsthetic stadium before the full maniacal and melancholic 
 state in nearly every case. This ccengesthetic stadium consists in a 
 disturbance of organic functions of circulation, respiration, digestion, 
 and in peripheral sensations, parassthesias, anesthesias, paralgesias, 
 and changed emotional tone, and it is recognized and announced 
 often, both by patients and attendants, who understand that it is the 
 precursor of the melancholic and maniacal outbreaks. The stadial 
 progression in intermittent mania, therefore, in the strictest sense, 
 is not 1, stadium maniacale; 2, intervallum lucidum; 1, stadium ma- 
 niacale; 2, intervallum lucidum; but, 1, stadium eoenffisthetieum; 
 2, stadium maniacale; 3, intervallum lucidum; 1, stadium coenaes- 
 theticum; 2, stadium maniacale; 3, intervallum lucidum. 
 
 It is of practical importance to learn to recognize this ccengesthetic 
 stadium in order to take precautions against the maniacal outbreak, 
 
INSANITY FROM NEUROPATHIC STATES. 567 
 
 and it is not difficult to do this, since the peripheral sensory disturb- 
 ances are often as uniform in their recurrence as the epileptic aura 
 before the seizure. 
 
 Circular Insanity may begin in early life with the regular cycle 
 of the melancholic followed by the maniacal state, and have a contin- 
 uous repetition of the cycle without any intermission. In other in- 
 stances it is preceded first by intermittent mania or melancholia. As 
 the particular form of circular Insanity once established usually con- 
 tinues for years or a life-time, the sub-varieties will now be stated. 
 The cycle, which continues to repeat itself, is regularly composed 
 thus: 1, stadium melancholicum; 2, stadium maniacale. The sub- 
 varieties, in order of frequency, are first: 1, stadium maniacale; 2, sta- 
 dium melancholicum; second, 1, stadium maniacale; 2, stadium stu- 
 porosum; third, 1, stadium coengesthetieum; 2, stadium maniacale. 
 The cycle once established in any of the above ways may repeat itself 
 indefinitely. 
 
 The transition between the two stadia which compose the cycle 
 may be sudden when the stadia are short, or gradual when the stadia 
 are long; or there may be fluctuations from one stadium to the other 
 during symptomatic transition. Thus, if the cycle last two weeks 
 the patient would be in the melancholic stadium a week, and in the 
 course of a night would pass into the maniacal stadium, and this would 
 be a very sudden transition. 
 
 If the cycle lasted a year, as is not infrequently the ease, the pa- 
 tient would be probably in the melanchoHc stadium eight months, 
 and in the course of a month would very gradually change into the 
 maiiiacal stadium, which would continue for three months. If the 
 cycle lasted two years the melancholic stadium would probably take 
 fourteen months, and then there would be fluctuations from the mel- 
 ancholic to the maniacal state for a month, and then the maniacal 
 stadium would continue nine months to complete the cycle of two 
 years. 
 
 In the intermittent form of circular Insanity there is an intermis- 
 sion between the repetitions of the cycle as shown in the tracing pre-^ 
 viously given. The exception to this rule is that there may be two, 
 three, or even four repetitions of the cycle before the intermission 
 occurs. The more numerous the uninterrupted repetitions of the 
 cycle the longer is the intermission of health ordinarily. 
 
 A cycle in circular Insanity may last a few days or a few years. 
 The average duration of a cycle is a few months. Monthly periodicity- 
 is common in women and often coincides with ovulation. Yearly 
 
568 TEXT-BOOK ON MEXTAL DISEASES. 
 
 periodicity, with the melanchohc stadium in autumn and winter and 
 the maniacal stadium in spring and summer, has often been observed. 
 In general, the more severe the stadia the more decided is the lucid 
 interval, and the converse' is also true. 
 
 A distinct intermission of all symptoms only occurs in intermit- 
 tent circular Insanity, and it is a misapprehension to suppose that 
 in regular cases of circular Insanity the transition from the melan- 
 cholic to the maniacal state is through a brief lucid interval. 
 
 Periodical Insanity may last a lifetime and not end in a state of 
 mental weakness, but there is finally, in most cases, a certain mental 
 impairment, and occasionally a final stadium dementise. 
 
 Circular Insanity may terminate in intermittent mania or melan- 
 cholia, but this is very exceptional, and it is questionable whether 
 there is ever a termination in a convalescent stadium. The long inter- 
 missions in periodical Insanity are often mistaken for recoveries. 
 
 Symptoms. — Periodical Insanity, Hke other degenerative types, 
 has protean and varied types of symptoms. There are the various de- 
 grees of depression, known as coensesthetic depression, simple melan- 
 choha, melancholia with stupor, and the corresponding expansive 
 states of coengesthetic exaltation, simple mania, and maniacal stupor 
 from exhaustion. Hallucinatory states are more rare, but do occur. 
 
 There is usually a self-conscious and reasoning manifestation in 
 all the principal phases of periodical Insanity, which is surprising in 
 this regard, and a memory for the whole attack is often retained, even 
 after severe maniacal exacerbations. During the maniacal stadium 
 there are what the attendants call ^' good days," during which the 
 patient seems almost rational in speech and manner. These fluctua- 
 tions and pseudo-intermissions are highly characteristic, and they 
 appear and disappear without apparent cause very suddenly. 
 
 Insanity of acts rather than of speech is common, and maniacal 
 patients will assign plausible reasons for extraordinary conduct. The 
 suicidal or violent patients display cunning and offer excuses for their 
 crafty preparation for injury to self or others, and they are often dan- 
 gerous and destructive in many ways. 
 
 Delusions are very common, and irresistible tendencies, perverted 
 instincts, and brutal passions abound in the maniacal states. Hypo- 
 chondriacal ideas, religious despondency, self-accusation, vague fears, 
 delusional apprehension, dread of poisoning, and precordial anxiety 
 are frequent in the melancholic states. 
 
 The extravagance, vanity, and acquisitive tendency of some of the 
 exalted patients may suggest general paresis, but the general weakness 
 
INSANITY FROM NEUROPATHIC STATES. 569 
 
 of mind of the latter affection is wanting. Hysterical and epileptic 
 s}Tnptoms are, like the corresponding affections, rather to be viewed 
 as complications than as a legitimate part of periodical Insanity. 
 
 Periodicity in hysteria and epilepsy is very marked, because they 
 belong to the same degenerate type as periodical Insanity, and when 
 they are superimposed upon the latter there are reduplicated periods 
 and cycles within cycles. The hysterical and epileptic discharges are 
 usually more frequent than the stadial changes of circular Insanity, 
 and during the maniacal stadium of the latter the epileptic and hys- 
 terical exacerbations recur several times, and they may render the 
 melancholic stadium difficult to recognize and introduce clinical mixt- 
 ure of symptoms and some difficulty of diagnosis in the first instajice. 
 Epileptic furor and epileptic automatism are different from anything 
 found in periodical Insanity, and differentially diagnostic, as well as 
 epileptic delirium and stupor. 
 
 The stupor of periodical Insanity is not without clear conscious- 
 ness, and often a connected memory of events. The greatest lapse of 
 attention is in the maniacal stupor sequent to the exhaustion of 
 severe maniacal exacerbations, but the stupor of the melancholic 
 stadium is ordinarily conscious, fearful, and delusional in character. 
 A close symptomatic analysis solves all other clinical difficulties of 
 differential diagnosis when epilepsy and hysteria are epiphenomena 
 of periodical Insanity. The somatic symptoms previously described 
 as a part of the melancholic and maniacal states reappear in the cycles 
 of circular Insanity and do not require further notice here. 
 
 Pathology. — The degenerative heritage or the exceptionally ac- 
 quired neuropathic state are to be regarded as the pathology of period- 
 ical Insanity. The pathological explanation of the sudden changes 
 in the melancholic and maniacal stadia, Meynert long ago gave in 
 the spastic and paretic vasomotor conditions, which respectively char- 
 acterize the depressed and exalted states. This hypothesis best ac- 
 cords with the sudden and diversified changes in both psychic and 
 somatic manifestations, and with the self-evident fact that the de- 
 rangement is functional, since it seldom ends in dementia at the end 
 of a score of years. 
 
 The morbid anatomy cannot be defined, and 'has not been shown to 
 'exist in the form of gross lesions, but in cases from cranial injury 
 some fixed and permanent cerebral changes doubtless exist. The vaso- 
 motor disturbances of cerebral centres are inevitably attended with 
 nutritional deficiencies. The pathogenesis of the cyclic explosions is 
 in the nature of cortical discharges directly analogous to those which 
 
570 TEXT-BOOK ON MENTAL DISEASES. 
 
 attend the epiJeptic neurosis. The prevailing symptom of periodicity 
 is only a revelation of the inherited tendency of the tension-storage 
 of nervous energy spasmodically liberated from cortical regions at 
 regular intervals. The pathological anatomy in the few cases recorded 
 is too meagre to justify any definite statements. 
 
 Differential Diagnosis. — The appearance in early life of ccenses- 
 thetic depression^ in the absence of delusions and with rational be- 
 havior^ if repeated at regular intervals, is diagnostic of periodical In- 
 sanity. In the same way ccensesthetie exaltation, with a reasoning 
 tendency and freedom from delusions, when periodically manifested, 
 forebodes periodical Insanity. The diagnosis can be made beyond 
 a doubt when there is periodic alternation of ccenaBsthetic depression 
 and exaltation. 
 
 The simple development of the melancholia followed by the mani- 
 acal state occurs in many psychoses, but a repetition of this sequence 
 at regular intervals signifies the periodical nature of the Insanity. 
 Time is an element in the dift'erential diagnosis in certain cases. 
 
 Exaggerated self -feeling and extravagant delusions in the mani- 
 acal stage of periodic Insanity are to be differentiated from general 
 paresis by the absence of the physical signs of the latter disease, and 
 of general mental weakness, which rarely results at any time in peri- 
 odic Insanity. 
 
 The cyclic return of symptoms in periodic Insanity is to be dif- 
 ferentiated from the periodicity of paludal intoxication, and of hys- 
 teria and epilepsy, and from the monthly exacerbations attendant 
 upon ovulation in many psychoses. 
 
 The differential diagnosis must be made between periodical In- 
 sanity and repeated attacks of alcoholic mania. It is to be considered 
 that periodical Insanity may manifest dipsomaniacal tendencies. The 
 absence of periodicity in the history of the alcoholic case, and the fact 
 that aberration is hallucinatory in a characteristic way in alcoholic 
 mania, which has more confusion of ideas and less reasoning faciUty, 
 and marked cutaneous parsesthesia, and certain delusional characteris- 
 tics, are sufficient points of differentiation. 
 
 Occupation psychoses may-repeat themselves at intervals of a few 
 years, so long as there is continued exposure to toxic agents and no 
 change of calling to avoid the same, and they are not to be classed 
 as periodical Insanity. The differential diagnosis is to be made from 
 primary monomania, in which the same reasoning tendency exists, 
 but the delusions are more systematized and slowly developed, and 
 the exacerbations have not the same regularity, and the development 
 
INSAlSriTY FKOM NEUEOPATHIC STATES. 571 
 
 of the entire mental disease is lacking the abrupt changes found in 
 periodical Insanity. 
 
 Prognosis. — The seventy-five per cent, of cases of periodical In- 
 sanity which have the pathogenesis of degenerate heredity must be 
 regarded as having an unqualifiedly bad prognosis as to recovery. 
 They may, during intermissions, enjoy some privileges in social life 
 and perform some useful duties in business relations, but they are pre- 
 destined to repeated returns of mental disorder while cerebral activity 
 endures, or until gross brain disease extinguishes all intelhgence. 
 
 Periodical Insanity, from the acquired neuropathic state, is but 
 little more favorable in prognosis. Apparent recoveries occur, but 
 the mental disorder almost invariably returns at the end of a few 
 years. Theoretically, the possibility of recovery is to be admitted, 
 and it may be deemed a matter of interpretation as to whether the 
 long intermissions are in the nature of actual recoveries. A long 
 intermission cannot consistently be considered as a recovery when a 
 return of the disease is impending with absolute certainty. 
 
 Treatment. — The earliest evidences of periodicity in the depressed 
 and exalted moods of childhood should be indications for systematic 
 treatment. Education should then be conducted with special refer- 
 ence to strengthening the entire physical constitution. Order, reg- 
 ularity, discipline with uniform kindness, and habits of self-control 
 are to be constantly inculcated in the child. Open-air life and all 
 other hygienic means are to be perseveringly tried. Some active man- 
 ual emplo}Tnent is by preference to be learned. Prophylactic treat- 
 ment thus conducted may avert for many years the complete develop- 
 ment of the disease. 
 
 When once fully declared, periodical Insanity can only be miti- 
 gated during the attacks by symptomatic treatment, and isolation 
 in an institution is usually necessary for the longer attacks, but the 
 more brief ones may be managed in private. During the intervals, as 
 the time of the return approaches, bromide of potassium in full doses 
 lessens the force of the explosions, just as in epilepsy. 
 
 Cannabis Indica has been recommended also, and some regard 
 quinine appropriate for its antiperiodic efi'ects, which certainly must 
 be admitted in cases complicated with malaria. 
 
 The writer must confess that the bromides, while controlling in 
 great measure the exacerbations, have in some cases on cessation been 
 followed by still more violent outbreaks. They require to be given 
 in large doses, and for the immediate control of symptoms are thus 
 far the best known remedy because better borne than hyoscin or other 
 
572 TEXT-BOOK ON MENTAL DISEASES. 
 
 powerful sedatives. Opium is the most generally applicable remedy 
 in the depressed stadia and the deodorized tincture one of the most 
 available preparations. 
 
 The above are the only special points to be noted in the psychiatric 
 management of periodical Insanity^ which otherwise is to be dealt 
 with on the general principles laid down in the chapter on Treatment. 
 
 When private treatment is undertaken, great precaution is neces- 
 sary to guard against the lurking suicidal tendencies which character- 
 ize the depressed stadia of periodical Insanity. Two-thirds of all cases 
 have suicidal, homicidal, or violent impulses, and about this propor- 
 tion of eases are more securely treated in institutions than in private. 
 
CHAPTER III. 
 
 INSANITY WITH ESTABLISHED NEUEOSES. 
 
 Group: Epileptic, Hysterical, Hypochondriacal, Choreic, and Neuras- 
 thenic Insanity. 
 
 Section I. — Epileptic Insanity. 
 
 The intimate relation of epilepsy and Insanity is abundantly con- 
 firmed by statistical facts. The immense majority of all cases of epi- 
 lepsy occur between second dentition and adolescence, and the nu- 
 merical maximum of cases is attained at the crisis of puberty. Of 
 the epileptic cases developing between and inclusive of the crises of 
 second dentition and puberty, fifty per cent, ultimately suffer some 
 mental or moral deterioration, which in fifteen per cent, of the cases 
 reaches the grade of Insanity. More than twelve per cent, of all 
 epileptics display distinct mental alienation. Out of 74,000 insane, 
 in hospitals and asylums in the United States, for whom the form 
 of disease was reported for the last census, the proportion of epileptics 
 for each 1,000 was, for both sexes, .45.1; for males, 50.6; for fe- 
 males, 39.4. 
 
 Epilepsy as a degenerative neurosis, and hence hereditary, is here 
 under consideration — that form usually termed idiopathic, and which 
 ordinarily pursues a chronic course. S3'mptomatic epilepsy has less 
 intimate relations to Insanity, and it may arise in connection with 
 brain tumor or other focal brain disease, syphilis, alcoholism, and 
 other toxic states, and from ura?mia, diabetes, and auto-intoxications. 
 Accidental and reflex epileptiform seizures from sensorial, visceral, 
 and peripheral irritations have also less psychiatric interest, and even 
 from a strict neurological point of view can hardly be ranked as true 
 epilepsy, any more than Jacksonian spasms of groups of muscles from 
 limited irritations of motor cortical regions. It was known as long 
 ago as tickling was a mode of torture that peripheral irritation might 
 cause convulsive syncopal attacks, just as olfactory stimuli in form 
 
 573 
 
574 TEXT-BOOK ON MENTAL DISEASES. 
 
 of certain odors will do the same thing in susceptible persons, or 
 sexual titillation, but these accidental reflex phenomena are not epi- 
 lepsy. 
 
 The epilepsy related to Insanity manifests itself in major attacks 
 (grand mal), minor attacks (petit mal), and masked attacks, known 
 as the psychical epileptic equivalent. The mental disorder precedes, 
 attends, or follows these attacks, or it may be intercurrent as regards 
 the seizures. 
 
 The t}^es of Insanity appearing with epilepsia vera will now be 
 considered. 
 
 Definition. — Epileptic Insanity is a degenerative form of mental 
 disorder having the same pathological instability of nervous centres 
 as the spasmodic nearosis to which the morbid mental manifestations 
 bear intimate temporal and genetic relations. 
 
 The psychic explosions and the general convulsibility are com- 
 mon manifestations from discharge of unstable cortical regions, but 
 this close relationship between the mental disease and the spasmodic 
 disorder does not always exist when they occur together. Thus epi- 
 lepsy may be an accidental intercurrent symptom in cases of Insanity 
 with embolic softening, or syphiUtic gurmnata, or paretic pachymen- 
 ingitis, or alcoholic cortical changes, or senile cerebral involution, or 
 the rapid cortico-meningeal lesions in delirium aeutum. In the above 
 definition of epileptic Insanity these accidental epileptic seizures, 
 having no causative relation to the mental symptoms, are excluded, 
 and it is necessary to make this exclusion in clinical practice, for the 
 diagnostic and prognostic bearings are different in the two classes 
 of cases. 
 
 Clinical Delineation. — The clinical features of epileptic Insanity 
 are so varied that they can only be presented in brief outline. The 
 mental symptoms appear in the following morbid states: 
 
 1. Coensesthetic depression or exaltation usually preceding the 
 attack. 
 
 2. The melancholic state, with suspicious, hypochondriacal, or 
 persecutory delusions. This state ordinarily precedes but may follow 
 the attacks. 
 
 3. The maniacal state, with vivid hallucinations and delusions 
 and destructive and violent tendencies. This state is most often the 
 immediate sequel of the seizure, of which it is occasionally the psy- 
 chical equivalent. 
 
 4. Epileptic furor, characterized by blind, unconscious, and brutal 
 
INSANITY WITH ESTABLISHED NEUROSES. 575 
 
 violence. The patient is suddenly transformed into a demon of de- 
 struction toward all animate or inanimate objects. Tliis f aror is most 
 often the immediate sequel of the seizure, but it may constitute the 
 larvated attack itself. 
 
 5. EjDileptic stupor, directly resulting from the complete exhaus- 
 tion of emotional and intellectual centres by the sudden epileptic 
 cortical discharge, and chiefly a post-paroxysmal state. 
 
 6. Epileptic moral perversion, which consists in a gradual deteri- 
 oration of the whole character, entire loss of the altruistic sentiments, 
 intensification of the egoistic feelings, perverted appetites, and irre- 
 sistible impulses, and loss of control of the animal passions. 
 
 This state of moral perversion is most promptly developed as the 
 sequence of epilepsia minor in youthful subjects, but it often follows 
 epilepsia major when the attacks of grand mal are frequent and re- 
 current for some years in succession. 
 
 7. Epileptic automatism, lasting for hours, days, or weeks, during 
 which the most highly co-ordinated acts or complete adjustment of 
 conduct to all the affairs of life may take place. 
 
 Personal consciousness is partially or completely abolished during 
 the shorter automatic states, of which there is no subsequent mem- 
 or}'. In the prolonged automatic states there may be loss of personal 
 identity, and of memory, so far as recollection of the events of this 
 state is concerned after recovery from it, but upon subsequent re- 
 version to this state its past memories may be revived. 
 
 Epileptic automatic states are usually sequels of the seizures, but 
 tliey may be vicarious of the same. 
 
 8. Epileptic dementia is a general enfeeblement of all the mental 
 faculties following chronic duration of the minor attacks most fre- 
 quently, though it may be also a result of grand mal at the end of 
 some years when the seizures are very near together. 
 
 The above clinical outlines portray the chief states of aberration 
 in epileptic Insanity, and the more minute features of the disorder 
 will be found under the head of symptoms. 
 
 Causes. — The psychic manifestations in epileptic Insanity stand 
 in the light of effects of the epileptic neurosis regarded as an exciting 
 cause, so that the causes of the epilepsy may be in the same\sense 
 regarded as the causes of the Insanity. A still broader etiological view 
 might be to consider both the epileptic neurosis and the Insanity as 
 parallel symptoms of the pathological instability of cortical centres. 
 
 As a matter of fact, an epileptic or insane parentage is found in 
 thirty per cent, of all cases of epileptic Insanity. Imbecihty, alcohol- 
 
576 TEXT-BOOK ON MENTAL DISEASES. 
 
 ism, debauchery and poverty, phthisis pulmonalis, and syphilis in the 
 parents are hereditary influences. Direct exciting causes in patients 
 are;, cranial injury, insolation, alcoholic excess, acute infectious dis- 
 eases, microbic infections, and auto-intoxications; and in early life 
 the crises of birth, dentition, and puberty, as well as disorders of the 
 primse via3 and of the reproductive organs. 
 
 Stadia. — The stadial progression of epileptic Insanity will first 
 be considered in its entirety, and then as regards its separate attacks. 
 The intermissions between the seizures and the accompanying out- 
 breaks of mental disorder may be so long that the latter may be re- 
 garded in some cases as independent attacks of Insanity. 
 
 In most instances, however, it is more scientific to regard the epi- 
 leptic patient as suffering from a chronic form of mental disease, with 
 remissions between the seizures; and viewing epileptic Insanity thus 
 with reference to its entire course, there can be said to be but one 
 attack having an initial, an acute, and a terminal stadium. The 
 initial stadium in this sense begins in most cases in early life, at the 
 maximum epileptic period, and is marked by youthful eccentricities 
 and perversity of conduct, by depraved appetites and irresistible im- 
 pulses, but seldom by more decided symptoms. The acute stadium 
 then develops in acute modes of mental disorder, having all the types 
 already enumerated as maniacal, melancholic, stuporous, and auto- 
 matic. This stadium may continue for years, with constant remis- 
 sions between the epileptic seizures and no very marked mental deteri- 
 oration, but in the course of time it passes into a stadium dementise. 
 This stadium dementias is terminal, and illustrates every degree of 
 mental enfeeblement, even to the most abject loss of all mind. It 
 is a typical degradation — moral, intellectual, and physical. 
 
 This is the stadial progression of epileptic Insanity viewed in its 
 entirety. 
 
 Other epileptics, with months or years between their seizures 
 causing mental disturbances, and no intellectual impairment in the 
 meantime, may be regarded as suffering from independent attacks 
 of Insanity, of which the separate stadia will now be studied. 
 
 The " stadium prodromale " may last for some hours or for a 
 fortnight before the epileptic seizure and the acute mental disturb- 
 ance. It is marked by simple coena^sthetic depression or exaltation, 
 or by hypochondriacal ideas and conduct, or by morose and irritable 
 moods and restless and anxious feelings. 
 
 The exaltation takes the form of selfish, domineering, exaggera- 
 tion of personal importance, with meddlesome interference in the 
 
INSANITY WITH ESTABLISHED NEUROSES. 677 
 
 afi.'airs of others and constant garrulity and quarrelsome tendencies, 
 and a persistent impudence of speech and manner. Neuralgias, ceph- 
 alalgias, gastralgias, vertiginous feelings, parfesthesias, and local cu- 
 taneous hypergemias and anorexia and insomnia are physical symp- 
 toms of this prodromal stadium. 
 
 The stadium acutum is often ushered in by visual, auditory, 
 olfactory, tactile, or visceral aurse, and then follows the convulsion 
 with partial or complete loss of consciousness, the spasmodic glottic 
 closure, with the tetanic contraction of expiratory muscles giving the 
 " epileptic cry," and all the muscular phenomena and circulatory and 
 respiratory changes too familiar to need description here. The psy- 
 chical equivalent replacing this seizure may assume maniacal, mel- 
 ancholic, stuporous, or automatic forms. These same types of mental 
 disorder are also post-paroxysmal and are a part of the stadium acu- 
 tum, as is also the blind epileptic furor and the continued states of 
 epileptic automatism. The epileptic mania may last for weeks or only 
 for a few hours. 
 
 This stadium acutum gradually passes off, sometimes in prolonged 
 sleep, from which the patient awakens rational. In other severe cases 
 there follows a gradual convalescent stadium of a week's duration, 
 with some mental feebleness and confusion of ideas, and clearness 
 01 intellect finally returns, and in these cases there is no interparoxys- 
 mal obscuration of mind. In other words, the attack of Insanity 
 is at an end. 
 
 When this attack develops in connection with " petit mal " the. 
 ej>ileptie psychical equivalent is more frequent, or the seizure is more 
 often overlooked, and there is sometimes the appearance of attacks 
 of Insanity independent of the epileptic seizure. The probability 
 is that the seizure takes place without muscular, but with vasomotor, 
 completeness, and with the full cortical discharge of nervous force. 
 The violence of the mental disturbance bears no relation to the sever- 
 ity'' of the convulsions, and the maniacal attacks are sometimes more 
 prolonged in " petit mal " than in cases with " grand mal." Active 
 mental disorder after the status epilepticus is extremely rare. 
 
 The status epilepticus among the epileptic insane is a very grave 
 complication, and it frequently gives a fatal termination to the sta- 
 dium acutum of the mental disorder. 
 
 Symptoms.-^-The psychic sj^mptoms in epileptic Insanity in a 
 series of cases would include the following anomalies: 
 
 Hallucinations and illusions of all the special senses and func- 
 tional excess or diminution of the same. Anaesthesias, paraesthesias, 
 38 
 
578 TEXT-BOOK ON MENTAL DISEASES. 
 
 and hypersesthesias. Visual, auditory, tactile, gustatory, olfactory, 
 and kinesthetic aura3 epilepticaB. Partial or complete losses of con- 
 sciousness, with occasional changes of personal identity and double 
 consciousness. Feebleness, confusion, and sudden losses of memory, 
 and mistakes in places and identity of persons. Distorted imagination 
 and wild play of fantasy, with characteristic phantasmagoria epi- 
 leptica. 
 
 Slowed reaction time for visual and auditory stimuli, and greatly 
 retarded thought-rate in some cases. Confusion of ideas and anom- 
 alous association of same. Delusions of both primordial and hallu- 
 cinatory character. 
 
 Changes in the coemesthesis as based on the sum total of organic 
 sensations. 
 
 A^ivid and chahgeful emotional states often tinged with religious 
 or sexual ideas. 
 
 Violent passions, continued irascibility, and explosions of anger 
 and hatred and of all the antisocial feelings. Loss of ethical sense 
 and of natural affection, and of all the higher sentiments. Perver- 
 sion of the appetites, polydipsia, bulimia, anthropophagy, and con- 
 trary sexual feeling. 
 
 Abulia, irresistible impulses, suicidal and homicidal tendencies. 
 
 The somatic symptoms which are liable to be encountered in epi- 
 leptic Insanity may be briefly summarized as follows: 
 
 Imperfect osteological formation, and often diminutive skeletal 
 growth. Cranial deformities, and deflexions of vertebral column. 
 Facial asymmetries and palatal and dental abnormalities. Muscular 
 inco-ordinations, atrophies, pareses, spasms, tonic and clonic ; tendi- 
 nous contractions, blepharospasm, strabismus, nystagmus, choreiform 
 tics, and cataleptoid and tetanoid states. Paroxysmal tachycardia, 
 vascular hypertony, cortical angiospasm, local cutaneous hypersemias 
 and ischgemias, hyperidrosis, chromidrosis, and ptyalism. 
 
 NeuMlgias, hemi crania, crossed variation of cranial temperature, 
 neuralgic herpes, scotoma, dyschromotopsia, astigmatism (seventy-five 
 per cent, cases), disturbed innervation of ocular muscles and megal- 
 opsia. 
 
 Insomnia, incubus, somnambulism, or somniloquism. Modifica- 
 tions of respiration and pneumogastric disorders, gastro-intestinal dis- 
 turbances, constipation, anorexia, and general trophic anomahes. 
 
 It is of great diagnostic importance to recognize the fact that 
 vasomotor, muscular, or sensory disturbances may be vicarious of the 
 epileptic seizure, just as much as the psychical equivalent. 
 
INSANITY WITH ESTABLISHED NEUROSES. 579 
 
 Thus, in lieu of the epileptic seizure there are sometimes wit- 
 nessed cutaneous hypergemia unilateralis, spastic migraine, paroxys- 
 mal bradycardia or tachycardia, with a pulse of 40 or 150 per minute. 
 
 The vicarious muscular symptoms are still more important and 
 consist in twitching of certain muscular groups, monospasms, clonic 
 fibrillar action, ocular spasms, and facial inequalities of innervation, 
 which resemble hemiplegic or paretic conditions. 
 
 The sensory equivalent of the seizure consists in various forms of 
 neuralgia, resistant to quinine, but yielding to bromide treatment, 
 and in paroxysmal visceralgias, which likewise are mitigated by anti- 
 epileptic rather than by anti-malarial remedies. 
 
 It would be appropriate to depict here the epileptic physiognomy, 
 but words fail to convey that which the expert eye at once detects. 
 That there is a " facies epileptica " is proved by the ability of some 
 hospital physicians to diagnose many cases at a glance. The oblit- 
 eration of facial lines of expression is as great in some epileptic de- 
 ments as in paretics. 
 
 Disturbances of speech occur after epileptic seizures in a few 
 cases. The slowed speech is due to retarded thought-rate. There 
 are actual impairments of articulation temporarily, and balbuties 
 and scanning speech may occur, and also echo-speech. Vocal tre- 
 mor may be present and due to defective diaphragmatic innervation. 
 Brief aphasic attacks are not uncommon and are post-paroxysmal. 
 
 Pathology. — Epileptic Insanity is dependent on hereditary in- 
 stability of nervous centres in very many cases. This cortical ten- 
 dency to discharge of nervous force may be acquired. The prime 
 factor is presumably an anomaly in the periodical rhythm of nutri- 
 tion of cortical cells. The morbid histological changes are, according 
 to Bevan Lewis, increase of the neuroglia and fatty change in the 
 nucleus of sensory nerve-cells of the second layer of the cortex which 
 exercise inhibitive influence over the large motor cells, which dis- 
 charge when this influence fails from disease of the sensory cells. 
 
 The nuclei of the cells later undergo vacuolation, which is the 
 characteristic change in this form of Insanity. At a still later period 
 connective tissue and vascular changes may occur. The sclerotic le- 
 sions sometimes found in cortical regions probably are secondary re- 
 sults and more apt to be found in alcoholic cases. 
 
 As hereditary taint can be traced in nearly a third of the cases, 
 it is well to know that most direct pathological relations exist be- 
 tween epileptic Insanity and alcoholism, debauchery, criminality, and 
 malnutrition in the parents. 
 
580 TEXT-BOOK ON MENTAL DISEASES. 
 
 A pathological consideration of great importance is incompatibil- 
 ity of the spermal and germal parental elements. To this is probably 
 dae the great relative excess of epileptics in half-bred races. Amon_g 
 the colored insane in institutions in the United States (as shown by 
 the last census), many of whom were half-bred, the ratio of epilep- 
 tics per 1,000 was for males, 94.8, and for females, 73.0 ; while the 
 same ratio among whites w^as for males, 50.6, and for females, 39.4. 
 
 Differential Diagnosis. — The differential diagnosis is dependent 
 in the first instance on the diagnosis of epilepsy itself. Genuine epi- 
 lepsy must here be differentiated from symptomatic attacks from 
 cerebral disease, and toxic states, or from reflex causes, and also from 
 hj'sterical seizures. The spasmodic features of true epilepsy are not 
 always sufficient for this differential diagnosis. If the whole symp- 
 tom complex of " grand mal " is present, the aura, the cry, tRe loss 
 of consciousness, the vasomotor and respiratory and muscular phe- 
 nomena, there is no difficult}^ but in cases with " petit mal " the 
 objective signs are inadequate. In doubtful cases the history and 
 the subsequent course of the disease in connection with the special 
 character of all the physical and mental signs can alone decide. With- 
 out this history and this course of the disease it would be impossible 
 to decide between certain cases of general paresis with epileptiform 
 seizures, and epileptic Insanity with the frequent symptom of ine- 
 quality of pupillary and facial innervation. 
 
 In organic dementia the differentiation is to be made on the 
 ground of absence of an epileptic neurosis, and on the intercurrent 
 nature of the seizures and on their subsequent disappearance while 
 the cerebral disease and dementia persist. 
 
 The syncopal attacks with twitchings of facial muscles in senile 
 Insanity are not to be mistaken for epileptic seizures, any more than 
 similar symptoms in climacteric Insanity marked by vasomotor anom- 
 alies and occasional cerebral angiospasm, or fainting spells, as they 
 are called. 
 
 In a word. Insanity, with accidental syncopal attacks or even 
 epileptic attacks intercurrent and due to coarse brain disease or toxic 
 agents, is not epileptic Insanity, which is alone intimately associated 
 with the epileptic neurosis and the chronic and genuine epilepsy. 
 
 Prognosis. — When the seizures of " grand mal " occur once in 
 several years and the accompanying mental disorder disappears for 
 the same length of time, recovery may be admitted once, twice, and 
 possibly a third time. This is a question of opinion. The fact is that 
 the attacks become more frequent and mental deterioration begins 
 
INSANITY WITH ESTABLISHED NEUROSES. 581 
 
 after the first few attacks of mental disorder, even though they be 
 brief. The mental decline is more rapid in "petit mal " than in 
 " grand mal/' and still more decided in the mixed forms of " grand " 
 and " petit mal/' and the prognosis is more unfavorable the earlier 
 the onset of the epilepsy, which leads to dementia in insane cases 
 epileptic before twenty years of age. 
 
 Eegarding epileptic Insanity in its entirety and from a strictly 
 scientific point of view remissions but no recoveries would be recog- 
 nized in the vast majority of all cases. 
 
 Prognosis as to general usefulness is bad, for most insane epileptics 
 are a constant menace to public safety, and seclusion in institutions 
 is usually advisable. 
 
 Prognosis as to hfe is not decidedly bad. The expectation of life 
 is lessened, but death does not often follow, except by the status 
 epilepticus, and such suicidal and other violent accidents as other 
 insane patients meet. The actual duration of life is somewhat shorter 
 than in certain other forms of Insanity. 
 
 Treatment. — Treatment should be begun early in children, and 
 continued for consecutive years, and long after the cessation of the 
 seizures; for it is only in this way that prophylaxis as to Insanity 
 can be exerted. 
 
 Cases developing in later life must undergo the same prolonged 
 treatment. Bromides of potassium, sodium, and ammonium are 
 most effective in the order named. The dose is to be carried to the 
 full physiological effect of the drug without regard to the number 
 of grains. Men bear larger doses than women, and the latter larger 
 than children. A tolerance of the drug is soon established in some 
 eases, and in others it must be gradually increased to avoid digestive 
 disorder. The bromide of sodium disturbs the stomach less, and it 
 is better to give the drug after meals, because it is then less apt to 
 derange the stomach. If there is periodicity distinctly marked in the 
 attacks the drug should be given in large antiperiodic doses just before 
 the seizures. 
 
 Bromide of ammonium is the most irritant of the bromides, and 
 should only be used in combination with other bromides. In the 
 ansemic cases bromide of iron may be given, and arsenic for its effect 
 on general nutrition is highly useful, and also to prevent acne. Digi- 
 talis, in sustaining cardiac action, is of special value in nocturnal 
 epilepsy, which occurs when circulation and other vital functions 
 are at lowest ebb, in the small hours of the morning, 
 
 Bevan Lewis commends cannabis indica in connection with bro- 
 
582 TEXT-BOOK ON MENTAL DISEASES. 
 
 mides. Chloral hydrate combined in small doses with the bromides 
 heightens the effect of the latter. Quinine should only be used in 
 malarial cases, for it increases the convulsive tendency. 
 
 Iodide of potassium is needed in syphilitic cases and in plumbism. 
 Hydrotherapy is useful in most cases. Out-door occupation and all 
 h5'gienic measures are to be tried systematically. The diet should 
 be whatever the patient assimilates most easily, and that which best 
 sustains the general strength and nutrition. All limitations of diet 
 lowering the general vigor and nutritive level are bad without regard 
 to theories as to nitrogenous food, which is not harmful per se. 
 
 Operative procedure is indicated in traumatic cases, and the surgi- 
 cal removal of sources of irritation in reproductive organs may be 
 effective. Phimosis in masturbatic boys calls for circumcision. The 
 status epilepticus may be treated by chloral per enema, croton oil, 
 two drops on the tongue, nitrite of amyl inhalation, chloroform in- 
 haled with caution, and, if cerebral congestion is intense, venesection 
 may give more prompt relief than other remedies. Cold to surface 
 to reduce temperature is indicated. Death is inevitable in many cases. 
 Of late a preliminary opium treatment has been used, and then a 
 sudden change is made to bromides in the confirmed epileptic cases. 
 Good results are claimed. 
 
 Acetanelid, antipyrine, borax, and many other recent remedies 
 are highly recommended for the treatment of epilepsy, for which new 
 cures have been discovered every year for the last two thousand years. 
 x\ny new remedy seems to have some effect on certain cases, and 
 others respond favorably to none. 
 
 Psychotherapy is by no means in vain, and cheerful surroundings, 
 occupation, and the personal influence of the physician have astonish- 
 ing effects in epileptic cases. 
 
 In children reflex sources of convulsions, such as ascarides or other 
 forms of worms, gastric, intestinal, dental, ocular, and aural irrita- 
 tions, are to be removed. Toxic and diathetic states are to be treated 
 and all prime causes removed so far as possible. 
 
 Special treatment should be continued after the disappearance of 
 the seizures for at least one year. 
 
 Section II. — Hysterical Insanity. 
 
 The term hysteria in popular use signifies every form of emo- 
 tional, extravagant, and uncontrolled actions, accompanied by a ner- 
 vous manner. It is here strictly limited to a distinct psychopathic 
 state, which is itself dependent on a pathological condition of the 
 
INSANITY WITH ESTABLISHED NEUROSES. 583 
 
 nervous system, inlierited in most instances, but exceptionally devel- 
 oped by etiological factors, which will presently be noticed. This hys- 
 terical neurosis may exist in minor or major form, and, in fact, in 
 every conceivable degree, but it is usually strongly pronounced in 
 cases which eventuate in Insanity. 
 
 It will be found in such cases that the history of great instability 
 of feelings and conduct can be traced to early childhood, that life 
 was begun on hysterical lines, and that there) was an exacerbation of 
 all the symptoms at puberty, at which time the first decided manifes- 
 tations of mental disorder often appear. 
 
 A description will now be given of the hysterical Insanity, which 
 is the direct outcome of this permanent constitutional hysterical 
 neurosis. 
 
 Definition. — Hysterical Insanity is a form of alienation springing 
 from permanent unstable equilibrium of nervous centres, and loss of 
 inhibition of the higher cortical regions, marked by loss of control 
 of ideas and actions, exaggerated impressionability, morbid self-pity 
 and desire for sympathy, emotional explosions, illusions, delusions, 
 disorders of consciousness, psychic stigmata, and transient and 
 changeful symptoms of functional disorder of the whole physical or- 
 ganization. 
 
 In this definition two facts are to be specially noted: First, that 
 the instability of cortical centres is permanent — an organized trait; 
 and second, that the inhibition of the higher cortical regions, of the 
 intellectual centres, over the emotional, sensory, and motor centres 
 is greatly impaired. 
 
 Clinical Delineation. — The hysterical stigmata, the sensory, vaso- 
 motor, and muscular disorders, and other disturbances of the physical 
 organization will receive attention under the head of symptoms, and 
 only the chief types of the protean psychic disturbances will be here 
 outlined. These typical states of hysterical Insanity may be thus 
 classified: 
 
 1. Youthful State of Perverted Feelings and Impulses. — The 
 complete hysterical neurosis is seldom developed before the sixth 
 year, but the complete prodromes often appear in early childhood. 
 There is then to be observed the morbid impressionability and ex- 
 treme reaction to slight causes which may throw the child into parox- 
 ysms of hilarity or depression, which may verge on suicide. In the 
 same way follow outbursts of anger and destructive tendencies. There 
 is often precocity of sexual feeling, or of rehgious emotion, during 
 which trance-like visions may be described. Night terrors and sleep- 
 
584 TEXT-BOOK ON MENTAL DISEASES. 
 
 talking are common. Day-dreaming and fantastic ideas and a failure 
 to distinguish the real from the unreal are characteristic. Lying 
 springs in part from this cause, and also from an actual perversity, 
 which reveals itself in mischief, cruelty, loss of natural afEection, 
 and in irresistible impulses to all kinds of evil doings. 
 
 When punished for wrong-doing the child falls into hysterical 
 spasms of rage, which may last for hours, until terminated by sheer 
 physical and mental exhaustion, followed by a stuporous state of some 
 hours. Severe anger or other emotion in these eases may also give 
 rise to syncopal attacks. Morbid love of sympathy even at this early 
 age, and exaggerated self-pity are to be witnessed. The child mag- 
 nifies slight ailments or inflicts slight self -injuries to enjoy the com- 
 miseration of others. The degree of perversion of the feelings and 
 impulses may be very great, and lead to violent, destructive, and re- 
 vengeful acts. In rare cases, both in boys and girls before the sixth 
 year, sensory as well as motor symptoms appear in full force with the 
 complete spasmodic attack. Hysterical cough, aphonia, and limited 
 spasmodic affections are also to be observed in children. 
 
 2. Hysterical Mania. — The hysterical maniacal state may precede, 
 supplant, or succeed the hysterical attacks. It may last for days or 
 weeks, during which the patient may be boisterous, destructive, hal- 
 lucinated, and deluded, but still having a keen wit and apparent com- 
 plete comprehension of surrounding events. These glim^pses of clear 
 consciousness and of reasoning tendency extend through the attack 
 and contrast strangely with the conduct, which is often of the most 
 outrageous character. Patients in this state are mischievous and 
 malicious, stick pins in other patients, pull their hair, destroy and 
 throw things out of the windows, strip themselves and make indecent 
 exposures, are profane and obscene, neglect cleanliness, and soil their 
 rooms, upset their food at table and break dishes, and require con- 
 stant watching. They come out of this mania very suddenly. While 
 in it they lose flesh and the vital functions, are more or less deranged. 
 The mania takes the place largely of the spasmodic seizures, which 
 are rare during the mental excitement. 
 
 3. Hysterical Melancholia. — This melancholic state may precede, 
 fellow, or replace the hysterical attack. It is marked by anorexia, 
 insomnia, constipation, depression of spirits, religious talk, restless 
 anxiety, wringing of hands, pulling out of hair, picking skin sore in 
 places, impulses to- self-injury, cutting of wrists with bits of glass or 
 a pin, weak attempts at suicide, which is seldom accomplished unless 
 by accidental success of the eft'ort, neglect of person and clothing, and 
 
INSANITY WITH ESTABLISHED NEUROSES. 585 
 
 by constant demands of attention from nurses and physicians, fault 
 finding with that which is done for them, and obstinacy and resist- 
 ance to that which they are advised to do. Another type of hysteri- 
 cal melancholia is marked by constant recumbence, passive resist- 
 ance to attempts to move or dress, complete mutism, flexed joints, 
 closed eyes, and neglect of food and personal needs. Such patients 
 have to be fed, which they come to enjoy, and to be waited upon 
 like children, which is also pleasing to them. They have complete 
 memory of all the events of the attack, which may last some weeks 
 or months, and is often attended by some religious delusion or hallu- 
 cination, or by a belief of inability to stand or walk. Joints may be- 
 come permanently ankylosed in these cases if passive exercise is not 
 carried out. There is usually gradual loss of weight. 
 
 4. Hysterical Somnolence. — This somnolent state may last days 
 or weeks. The patient is easily aroused to partial consciousness, but 
 relapses quickly into sleep, which is continuous, but not profound. 
 The pulse and respiration are slightly slowed. A still more rare con- 
 dition is hysterical trance, from which the patient cannot be aroused 
 ordinarily, and respiration is superficial and retarded, and circulation 
 feeble, and all the vital processes reduced to a minimum. 
 
 5. H3'sterical Stupor. — This is an acute stuporous condition se- 
 (^uent ordinarily to the severe hysterical attacks and having a dura- 
 tion of days or weeks. It is due to exhaustion, and exceptionally to 
 acute hallucinations and delusions. 
 
 6. Hysterical Automatism. — This state merits further study. It 
 is not entirely automatic, but consciousness is largely in abeyance, 
 or at least preoccupied exclusively with a certain class of ideas. It 
 is not somnambulism and is a sort of a waking dream. There is only 
 confused memory for that which occurs during this state, which 
 rarely continues but a few hours, during which the patient may 
 automatically perform curious actions with no apparent motive. 
 
 7. Hysterical Deterioration. — In the course of years there is a 
 gradual biit steadily progressive deterioration of mind and character 
 in hysterical cases. This is specially marked in those strongly hered- 
 itary cases which begin early in life. In them this deterioration fin- 
 ally reaches a high degree of mental enfeeblement. 
 
 The above are the clinical outlines of the chief types of the psychic 
 disorder in hysterical cases. 
 
 Causes. — Direct heredity is the most frequent cause, especially in 
 youthful subjects. Transformed tendency is frequent from parents 
 
586 TEXT-BOOK ON MENTAL DISEASES. 
 
 in whom there had been Insanity, epilepsy, neurasthenia, or drunken- 
 ness. 
 
 The inherited tendency may he developed by a great variety of 
 exciting causes, such as fear or other emotional shock, prolonged 
 stress of domestic or business life, traumatic injuries of brain or spine, 
 toxic and autotoxic states, the evolutional and involutional crises, in- 
 fectious diseases, hemorrhages, chlorosis, parturition, sexual excesses, 
 moral contagion, hypnotism, poverty and malnutrition, and bad edu- 
 cation and associations. 
 
 Hysterical Insanity is three times more frequent among women 
 than men, and it is most apt to appear at the age of puberty. It is 
 more common among mixed races, and among the interbred aris- 
 tocracy or the impoverished classes. Drug habits and alcoholic indul- 
 gence tend directly to develop the latent tendency to the disorder, 
 and over-study in children is also a common exciting cause. In chil- 
 dren also neglect, exposure, and cruelty are causative. 
 
 Stadia. — In marked hereditary cases beginning in childhood the 
 Insanity must be viewed in reference to its entire course. It then has 
 an initial stadium of perverted feelings and impulses, culminating 
 ordinarily at puberty in the acute stadium, which continues for years 
 wixh the various states depicted under clinical delineation. If recov- 
 ery occur, which is the rare exception, there is a gradual convalescent 
 stadium. 
 
 In most cases there is progressive deterioration, and following 
 the acute stadium a terminal stadium of dementia, which is not as 
 decided as in epilepsy, but still amounts to general mental enfeeble- 
 ment, which completely unfits the patient for the duties of life. Hys- 
 terical Insanity from traumatic injuries has a long initial stadium of 
 months on the average, and an acute stadium of one or more years 
 often, followed by a terminale stadium of mental enfeeblement in 
 most cases. The exceptional recoveries are gradual. Hysterical In- 
 sanity, in connection with hemorrhages, parturition, and the meno- 
 pause, may have a convalescent stadium, but this also is exceptional. 
 
 The single acute attacks of hysterical mania, followed by no recur- 
 rence, and by prompt recovery, and having no prodromes, are mis- 
 takes in diagnosis. 
 
 Symptoms. — The stigmata of hysteria which are deemed specially 
 diagnostic are limitation of the visual field, hemianaBsthesia, and dis- 
 turbance of the special senses on the hemian^sthetic side more espe- 
 cially. The hearing may be diminished for the lowest and highest 
 notes, and, besides concentric narrowing of the visual field, there may 
 
INSANITY WITH ESTABLISHED NEUIIOSES. 587 
 
 be loss of the color sense. Taste and smell may be affected. The 
 anaesthesia to pain may be on one side only (usually the left), includ- 
 ing the skin, mucous membranes, muscles, as well as the special 
 senses. The analgesia may be confined to zones or to very limited 
 areas. In the achromatopsia the disappearance and reappearance of 
 colors was in regular order, and influenced by magneto-therapy in 
 cases shown to the writer by Charcot many years ago. 
 
 In hysterical Insanity, with pronounced hysterical neurosis, symp- 
 toms can be created by suggestion, just as in hypochondriacal Insan- 
 ity, and artificially educated patients are not safe material from 
 M'hich to draw general conclusions. This remark applies to traumat- 
 ic hysterical Insanity, in which patients have sometimes undergone 
 a sort of education in symptoms from medical examinations and 
 interviews during years of traumatic hysteria before decided mental 
 disorder. In the study of cases this possibility of symptoms from 
 suggestibility will be constantly confirmed. The reality of the 
 symptoms in hysterical Insanity, however, cannot, for a moment be 
 doubted. There are hyperassthetic and neuralgic zones, spinal ten- 
 derness, coxalgia, clavus, arthralgia, and visceralgias. Hysterogenic 
 points are often mammary, epigastric, or ovarian, and among the 
 hysterical insane the intercostal regions are most often hyperassthet- 
 ic and hyperalgesic. Megalopsia and micropsia are by no means 
 rare, and the sensation of enlargement of the head or special parts 
 of the body or of diminution of the same is very common. 
 
 The motor disturbances consist in tonic and clonic spasms, 
 pareses, monoplegias, paraplegias, hemiplegias, contractures, atro- 
 phies, and tremors. 
 
 Vasomotor disorder is shown in one-sided or localized hypergemias 
 and ischgemias, in hyperidrosis lateralis, capillary stigmata, and vari- 
 ations in superficial temperature. Modifications of respiration, dysp- 
 noea, barking cough, oscedo, sternutation, and tremulous voice from 
 imperfect diaphragmatic innervation, and singultus are common 
 symptoms. 
 
 Gastro-intestinal symptoms, anorexia, dysphagia, emesis, eructa- 
 tions, mer}'cism, borborygmi, tympanites with delusions of false preg- 
 nancy, and emotional diarrhoeas are frequent. 
 
 Anuria, polyuria, menstrual irregularity, nutritive disturbances, 
 anomalies of sleiep, trophic derangements, and disorder of pneumogas- 
 trie functions, are also to be observed. Globus hystericus is due to 
 spasm and parassthesia. 
 
 In children and young persons, before the major hysterical symp- 
 
588 TEXT-BOOK ON MENTAL DISEASES. 
 
 toms are developed, there are chiefly such manifestations as perverted 
 appetite, frightful dreams, enuresis, neuralgic pains, cephalalgia, and 
 sexual irritation. The crises are more emotional than spasmodic, and 
 consist in automatic laughing and crying, or in demonstrations of 
 unaccountable fear or anger. Incubus and somnambulism are com- 
 mon. 
 
 The hysterical attacks in the fully developed cases are confined 
 to violent emotional outbreaks, or they take the form of acute mani- 
 acal exacerbations, which may reach the extreme of hysterical furor. 
 On other occasions these crises may be, in the main, spasmodic, con- 
 sisting in violent movements of the extremities and of the whole 
 musculature. These convulsions among the insane never have the 
 hystero-epileptic tyjDe with such elaborate performances as are de- 
 scribed under this title in writings on hystero-epilepsy. At least no 
 such instance has ever occurred among the ten thousand insane cases 
 which have been under the writer's charge. 
 
 In all completely developed cases of hysterical Insanity the condi- 
 tion between the paroxysms is one of decided hysterical perversion, 
 and the complete lucidity which follows certain epileptic seizures is 
 wanting. 
 
 The moral perversion is very pronounced, and mendacity, histri- 
 onic deception of all kinds, accusations against nurses and physicians, 
 and malicious conduct toward husband or near relatives is character- 
 istic. 
 
 The deterioration of the intellectual faculties is very gradual, but 
 general enfeeblement of mind ultimately results. 
 
 Pathology. — All the evidence points to neurotic heritage in the 
 pathogenesis of hysterical Insanity. The fundamental instability of 
 the nervous centres is due to some nutritional anomaly of the emo- 
 tional and intellectual cortical regions in the first instance, and later 
 of the whole cerebro-spinal system, as manifested by the almost uni- 
 versal nature of the motor, sensory, trophic, and vasomotor symp- 
 toms. That the fundamental nutritional defect may be favored by 
 chronic auto-intoxication is highly probable. 
 
 Differential Diagnosis. — The chronic course and highly charac- 
 teristic group of symptoms of hysterical Insanity obviate difi&culties 
 of differential diagnosis. It is true that the hysterical stigmata and 
 the sensory motor and visceral crises may be present in various de- 
 grees of completeness, but, taken in connection with the whole his- 
 tory of the case, they leave no room for doubt. 
 
 On the other hand, there may be, so far as individual symptoms 
 
INSANITY WITH ESTABLISHED NEUEOSES. 589 
 
 are concerned, serious difficulty in diagnosis between functional and 
 organic affections. This is true of the paralyses, contractures, and ar- 
 thritic affections, of the oesophagismus and organic stricture of the 
 oesophagus, of h^ematemesis and gastric ulcer, and of the hysterical 
 dyspnoea and true asthmatic attacks. The differentiation of these 
 points pertains to surgical, medical, and neurological works and is 
 beyond present limits. 
 
 The loss of consciousness in rare instances may be complete in the 
 hysterical attacks, but other features of the attack differ so widely 
 from epilepsy that no practical difficulty of differential diagnosis 
 exists. 
 
 Prognosis. — The form of mental alienation which alone merits 
 the designation, hysterical Insanity, is in the greatest number of cases 
 progressive and decidedly unfavorable in prognosis as regards ulti- 
 mate recovery of mental integrity. Individual attacks of mania or 
 melancholia may pass away, but the perversion of character remains 
 with the recurrent tendency, and the exacerbations become more 
 frequent and intellectual deterioration finally results. 
 
 In rare instances of traumatic or climacteric origin there is a 
 gradual and complete recovery from hysterical Insanity. The prog- 
 nosis as to the chances of hfe are better than in epileptic Insanity, 
 but the actual expectation of life at any given age is diminished de- 
 cidedly by hysterical Insanity. 
 
 Treatment. — ^Isolation is the basis of treatment in acute maniacal 
 or melancholic attacks, as well as in the confirmed neurosis with 
 progressive deterioration beginning in early life. In the latter case 
 prolonged disciplinar}' and educational methods carried out under 
 medical supervision are alone of any avail. In the former instance 
 the entire appointments of an institution for the insane are usually 
 essential to meet all the emergencies of the case. 
 
 Psychotherapy is of first importance in the treatment of hysteri- 
 cal Insanity, and the influence of the physician is the supreme moral 
 means of alleviation of the patient's sufferings. The rest-cure is ap- 
 plicable in many cases with massage, and forced alimentation, if need 
 be. 
 
 Hydrotherapy judiciously and persistently carried out is of de- 
 cided benefit in some cases. 
 
 Electrotherapy has very special applications as regards the mus- 
 cular disorders, the paralyses and atrophies and contractures, for 
 which static sparks and faradic applications are best adapted. 
 
 General hygienic measures are not to be neglected, and daily oc- 
 
590 TEXT-BOOK ON MENTAL DISEASES. 
 
 cupation of some kind in the open air is essential. Out-door games 
 and the cultivation of a taste for some active pastime are useful. 
 The patient should never be left absolutely idle. 
 
 Therapeutic remedies are only to be prescribed when positively 
 indicated, and the less the patient's attention is directed to drugs and 
 to his own symptoms, the better will be the final result. Bromides 
 are not as successful as valerian, asaf cetida, turpentine, monobromated 
 camphor, and valerianate of zinc. 
 
 The hysterical attacks may be controlled sometimes by ovarian 
 pressure, or by pressure of supra-orbital region, or by cold douche, or 
 by emotional shock, severe reprimands, or other sudden impression. 
 Such means are seldom of any permanent benefit. 
 
 The attacks may also be arrested by ansesthetics, chloral hydrate, 
 or the administration of an emetic. For the latter purpose the hy- 
 podermatic use of apomorphine hydrochlorate (grain yV) is the most 
 prompt means. 
 
 The ordinary hypnotics and alcohohc stimulants are to be avoided 
 in general, since a drug habit is quickly formed. 
 
 Iron and arsenic are of occasional use. The diet should be gen- 
 erous, and specially modified to suit the frequent idiosyncrasies of 
 hysterical cases. Fats in some form are necessary. Gastric crises 
 and emesis and oesophageal spasm render rectal alimentation an occa- 
 sional necessity. 
 
 In the melancholic cases the frequent fasting with suicidal decla- 
 rations is not to be allowed to lower the general standard of nutri- 
 tion, but is to be promptly met by nasal feeding with predigested 
 foods in cases with impaired digestion, and in other instances with 
 full physiological quantities of mixed foods prepared as directed in 
 the section on dietetics. 
 
 Section III. — Hypochondriacal Insanity. 
 
 In monomania the attention is often, occupied with pain delu- 
 sively interpreted, in alcoholism absurd tactile illusions may fill the 
 mind of the patient to the exclusion of other ideas, in general paresis 
 there are extravagant ideas of disease of various organs, in ordinary 
 melancholia there may be dominant delusions of disease which does 
 not exist, and all these symptoms may be termed hypochondriacal, 
 but they are not true hypochondriasis, nor do such m'anifestations 
 constitute true hypochondriacal Insanity, 
 
 Hypochondriasis vera is a distinct neurosis, and a form of neu- 
 rotic degeneracy, which may manifest itself in a characteristic group 
 
INSANITY WITH ESTABLISHED NEUROSES. 591 
 
 of symptoms from childhood to old age. This neurosis borders 
 closely upon Insanity, into which it often passes at puberty or at 
 the involutional epoch, and it has the numerical preponderance in 
 men that hysteria has in women. Some writers merge hypochondri- 
 asis in hysteria or neurasthenia, but this serves to explain nothing, 
 and only obliterates a positive chnical group of sjrmptoms, which 
 for two thousand years have been recognized as distinct facts, which 
 cannot be doubted by medical men who have seen patients incapac- 
 itated for a life-time by hypochondriasis ending in Insanity of a pro- 
 nounced type. 
 
 Definition. — Hypochondriacal Insanity is a form of aberration 
 issuing from the hypochondriacal neurosis, with perversion of or- 
 ganic sensations, persistent introspection, changes in the ccensesthesis 
 and in conscious personality, and anxious and exaggerated delusions 
 as to imaginary diseases. 
 
 Clinical Delineation. — The muscular, neural, circulatory, and res- 
 piratory sensations, which in sum total constitute the coensesthesis, 
 are in health unconscious, but in the hypochondriacal neurosis they 
 become painfully conscious. 
 
 This morbid change in the coensesthesis — this perversion of the 
 sum total of organic sensations — ^is the essence of hypochondriacal 
 Insanity. All the organic impressions, which are in health subcon- 
 scious, arise with abnormal and painful force into consciousness, and 
 determine a change in physiological personality. The organic proc- 
 esses and bodily functions become forced objects of attention on the 
 part of the patient, and furnish the' raw material of the hypochondri- 
 acal delusions. 
 
 The eoenassthesis is a prime component of personality, and its al- 
 teration here leads to partial change of identity in patients who, 
 through perverted organic sensations, come to regard part of them- 
 selves as dead, absent, or composed of foreign material. This anom- 
 aly of organic consciousness may eventuate in complete failure of 
 self-recognition, and in entire change or loss of personality. These 
 rare and extreme cases only serve to illustrate the importance of ccen- 
 a?sthetic consciousness as an element of self -identity. 
 
 The first clinical features of the hypochondriacal neurosis are 
 to be seen in early childhood in many instances. The child shows 
 an unnatural interest in its own health, thinks and talks much about 
 little aches and pains, exaggerates to a ridiculous degree petty ail- 
 ments, and deserts play to be treated for its imaginary diseases. The 
 introspective attention to the affairs of the body, the over-sensitive- 
 
592 TEXT-BOOK ON MENTAL DISEASES. 
 
 ness to slight physical impressions, the morbid love of sympathy for 
 the imagined suffering, the sickly delight in drugs and treatment, and 
 the extreme indulgence of self-pity are all to be witnessed in the 
 child as unmistakable outlines of the hypochondriacal neurosis. 
 
 At the pubescent epoch all the symptoms are wont to be aggra- 
 vated. The hypochondriacal patient, who is male in the majority 
 of cases, concerns himself at this age with the latest function which 
 has forced its way into organic consciousness. Every phase of sex- 
 ual life is watched with the usual morbid interest by the patient. 
 SKght preputial irritation or sensitiveness of the urethra becomes the 
 cause of serious alarm, and a few seminal emissions result in conster- 
 nation and the consultation of numerous physicians, until one is 
 found charlatan enough to agree with the patient that his health of 
 mind and body is in imminent danger and can only be saved by pow- 
 erful and continuous medication. 
 
 If at this age the patient chances to be female there is con- 
 stant worry about menstruation, careful study of the menstrual dis- 
 charge, and a tendency to invalidism and bed-habit between the 
 monthly epochs. Vaginal or ovarian hypersesthesia are construed to 
 mean serious local disease, for which treatment is sought persistently 
 at the hands of specialists, who in vain assure the patient of the 
 absence of organic trouble. These patients, filled with delusions of 
 uterine disease, haunt the offices of g3rnsecologists for years, hoping 
 for relief and yet fearing the worst, and refusing to believe that 
 which they are told, because their mental disease embraces in itself 
 the idea of bodily disease. 
 
 As the neurosis is with years fully developed, the ideas of disease 
 extend to the whole organism, and the brain, the stomach, the intes- 
 tines, and all the internal organs in turn may become objects of deep 
 concern, and the source of perverted sensations and insane delusions. 
 
 The neurosis by this time has passed into evident Insanity, which 
 unfits the patient for the duties of life. There is entire concentra- 
 tion in self, and in delusions of disease. Natural affection is lost, and 
 all social and business interests are neglected. The whole life be- 
 comes a deluded study of imaginary diseases about which the patient 
 will discourse for hours together, and from which the attention can 
 only be diverted for a few moments by any conceivable means. 
 
 After years of this acute stage of perverted feelings and delusions, 
 there may follow different degrees of enfeeblement of aU the intellect- 
 ual faculties, with changes in personal identity, or ridiculous fixed 
 delusions as to the actual state of the body or internal organs, and 
 
INSANITY WITH ESTABLISHED NEUKOSES. 593 
 
 a complete retirement from the vrorld to a solitary existence passed 
 in a narrow circle of ideas of disease. This is the hopeless ter- 
 mination in the majority of confirmed cases, and the above are the 
 general outlines of the clinical features of hypochondriacal Insanity. 
 The special variation of sjTiiptoms within these outlines will be de- 
 scribed directly. 
 
 Causes. — The prime cause is the degenerate neurosis, which is an 
 inherited defect of nervous organization, shown often from the earli- 
 est years of life. 
 
 The secondary causes are physical or mental stress, or any of the 
 ordinary excitants of inherent tendency to mental alienation. 
 
 The Insanity is the immediate outcome of the neurosis, just as in 
 hysteria and epilepsy developing into mental disorder. 
 
 A broader etiological view may be to regard both the neuroses 
 and their sequent mental disorders as only manifestations of the func- 
 tional deficiencies of the entire nervous organism. The heredity is 
 sometimes direct and at other times transformed. Thus hypochon- 
 driacal Insanity may be a heritage from parents suffering from any 
 of the neuroses, alcoholism, imbecility, syphilis, or other forms of 
 mental disease. Heredit}^, direct and homologous, has often been 
 seen in sons or daughters repeating the identical hypochondriacal 
 type of Insanity, and even the identical hypochondriacal delusions of 
 their parents. In other famihes there is a continuous developmental 
 origin, with a hereditary history of alcoholism and sexual excess in 
 the grandparents, hypochondriacal neurosis well developed in the 
 parents, and h3'pochondriacal Insanity in the children, who become 
 patients in hospitals for the insane. 
 
 In exceptional cases the hypochondriacal neurosis and the result- 
 ing Insanity may be acquired by physical or mental traumatism. 
 These traumatic cases are not very favorable, but they are less hope- 
 less than the directly inherited types. 
 
 The exciting causes determine rather the special form of the hy- 
 pochondriacal s}anptoms. Thus sexual excess develops the tendency 
 to aberration in sexual hypochondriasis, trauma capitis in cerebral 
 hypochondriasis, and any other real physical trouble may serve to 
 develop allied hypochondriacal delusions. In one instance the direct 
 exciting cause was the slight abrasion of the throat by a fish-bone im- 
 mediately extracted. The patient dwelt upon the idea that part of the 
 bone remained, continued to think and talk about it, and developed 
 a delusion, which no surgical skill could remove, and despite all 
 assurances to the contrary surrendered completely to the delusion, 
 39 
 
594 TEXT-BOOK ON MENTAL DISEASES. 
 
 which practically incapacitated the patient for several years, at the 
 end of which time other hypochondriacal delusions appeared to con- 
 firm the Insanity, which became chronic, with a certain reasoning 
 tendency, characteristic of hereditary types. In all similar cases the 
 essential thing is the hereditary tendency and the latent neurosis, 
 and the exciting cause and special direction of the first delusion are 
 of accidental importance. 
 
 Stadia. — In the most degenerate cases there is an initial stadium 
 beginning in childhood and culminating at puberty in a fully devel- 
 oped acute stadium of long years' duration, and ending after middle 
 life in a final stadium of mental enfeeblement, which terminates only 
 with life. 
 
 In instances of the acquired hypochondriacal neurosis there may 
 be a brief initial stadium following severe mental shock or physical 
 injury, and then an acute stadium of long years' duration followed 
 by a terminal stadium of mental deterioration. In rare cases devel- 
 oping at the menopause there may be a convalescent stadium and 
 complete recovery, and the same may occur after recuperation of the 
 nervous system from traumatic accident, but such instances are very 
 exceptional. 
 
 Sympioms. — The essential and fundamental symptoms are those 
 of the hypochondriacal neurosis, and the innumerable sequential 
 symptoms are, in a measure, casual and dependent on the age, sex, 
 constitution, education, and social station of the patient. 
 
 , The essential psychical symptoms are the appearance in the mind 
 of organic impressions normally unperceived, the heightened con- 
 sciousness to all visceral and peripheral stimuli, the morbid interest 
 in bodily functions, the gross exaggeration of organic sensations, the 
 absurd delusions of disease originating in explanatory efforts of the 
 influx of strange organic feelings, the perversion of the coensesthesis, 
 the changes in organic consciousness and in personal identity, and 
 the final incessant preoccupation with delusive beliefs of imaginary 
 physical evils of all kinds. 
 
 The changes in perception are marked. In the early stage there 
 is hypercesthesia acustica. The slightest sounds are magnified, and 
 loud noises may be very painful, so that these patients often fill their 
 ears with cotton to shut out sounds. Hypersesthesia optica exists in 
 rare cases. Photopsia, megalopsia, and micropsia are occasional symp- 
 toms. Cutaneous hypereesthesia exists in the initial stadium, but 
 later there may be hyperesthesia or ansesthesia. Parsesthesias are 
 constant symptoms. 
 
INSANITY WITH ESTABLISHED NEUROSES. 595 
 
 There are perversions of taste and smell and occasional illusions 
 and hallucinations of all the special senses. 
 
 The ordinary pleasurable physical sensations are exchanged for 
 numerous painful impressions from internal and peripheral sources. 
 The prevailing mood is depression. Social feelings are excluded by 
 selfish ideas of bodily discomfort. Natural affection and interest in 
 family is lost, and the higher altruistic sentiments disappear and are 
 replaced by dominant delusions of disease. Memory fails because the 
 attention is preoccupied with ideas of physical suffering, which ex- 
 cludes all else from the immediate field of consciousness. Conscious- 
 ness is heightened for all organic sensations, but there is a limitation 
 of objective consciousness. Thought-rate is slowed, and thought is 
 inhibited largely by the painful state of organic consciousness. 
 
 Appetite is diminished, and not infrequently there is sitophobia. 
 Sexual desire may be perverted and intercourse painful, and in women 
 aversion is common, and psychical impotence often exists in men. 
 Libido sexualis is exceptional. Abulia is universal, and impellent 
 ideas and irresistible impulses are not very rare. 
 
 Among the somatic symptoms are to be noted vascular hyperses- 
 thesia, and pulsation of temporal and carotid arteries and of the ab- 
 dominal aorta, spasmodic twitching of muscles, cramps, spasms, 
 pareses, and contractures from disuse, cutaneous pargesthesias, pruri- 
 tus, formication, neuralgias, vasomotor anomalies, precordial panic, 
 cephalalgia, cerebral hypera^mia, visceral pargesthesias, diminished 
 peristalsis and coprostasis, cardiac dyspnoea, and disorder of pneumo- 
 gastric innervation, which latter symptom is more prominent than 
 any other physical phenomenon in hypochondriacal Insanity. 
 
 There are certain types of cases constantly encountered. One 
 of the most common is the oesophageal type, in which the delusions 
 relate to some imaginary disease of the oesophagus. The patient de- 
 clares that the throat has grown together, that there is a foreign sub- 
 stance in it, that there is stricture, that it is impossible to swallow, 
 or that there is a tumor in the throat. In some of these cases there 
 may be anaesthesia of the pharynx and some spasmodic constriction 
 of the oesophagus. No treatment or argument is of any use in the 
 removal of the delusion. 
 
 Another type is gastric in origin, and the delusions centre in the 
 digestive processes, of which an incessant study is made. A lengthy 
 debate ensues before anything is eaten as to the effects which it will 
 have, and as soon as it is swallowed the deluded exaggeration of the 
 supposed dire consequences begins. There is thus one continuous 
 
596 TKXT-BOOK ON MENTAL DISEASES. 
 
 round of perverted gastric sensations and of resulting delusions, wliich 
 drive the patient to despair, and lead to refusal of food in some in- 
 stances and to suicidal tendencies in other cases. 
 
 The intestinal type is another persistent and common form of 
 hypochondriacal Insanity. The idea often takes the form of obstruc- 
 tion of the intestines, and in spite of daily stools the patient will cling 
 to the delusion that there is complete stoppage, and incessantly de- 
 mand purgatives. Other patients have the delusion that their intes- 
 tines have disappeared, that they have been passed at stool, or that 
 they have all grown together, or that they are tilled with disease or 
 with accumulations of food. Others insist that there is a foreign 
 body in the rectum, and are constantly using their fingers or various 
 things to extract the offending object. Women have similar delusions 
 about the vagina, and keep themselves sore by their manipulations 
 to dislodge the foreign material. 
 
 The pulmonary type is also a common one. The delusion takes 
 various forms — that the lungs are partly or completely destroyed by 
 disease, that something has been swallowed the wrong way and has 
 lodged in the lungs, that breathing is impossible, or that death is 
 threatened by arrest of respiration. Tliis is one of the forms of de- 
 fective pneumogastric innervation. Attacks of dyspnoea are to be 
 observed in these cases, and various modifications of respiration due 
 to pneumogastric disorder. To the same cause is to be attributed 
 the cardiac type of cases with delusions of heart disease or of cessa- 
 tion of the circulation. 
 
 The cerebral type of h3^pochondriacal delusions are frequent — that 
 the brain is fluid, or that the skull is empty, or that there is some- 
 thing alive which is felt moving in the brain. Partesthesia and neural- 
 gia of the scalp are the real origin of most of the delusions as to the 
 cranial contents. 
 
 Other types might be enumerated, but sufficient has been recorded 
 to show the character of the clinical phenomena in hypochondriacal 
 Insanity. 
 
 Pathology. — The pathogenesis is inherited defect of nervous or- 
 ganization. There may be morphological deficiencies of nervous 
 structures, such as exist in imbecility, and in other instances demon- 
 strable lesions are claimed to have been found. As yet no morbid 
 anatomy has been established on sufficient grounds, and the more 
 tenable theory is that there is a permanent nutritional defect of the 
 higher cortical system. 
 
 It is also possible that microbic infection or auto-intoxications 
 
INSANITY WITH ESTABLISHED NEUROSES. 597 
 
 may be pathological factors. The heredity in some cases is directly 
 shoxvn by the transmission in kind of this type of Insanity from parent; 
 to offspring. 
 
 Differential Diagnosis. — Hypochondriacal Insanity is to be dif- 
 ferentiated from depressed delusions of disease intercurrent in gen- 
 eral paresis^ and ordinary melancholia. In the latter the patient is 
 hopeless on all subjects and indifferent to drugs and results, while 
 the hypochondriacal patient is eager to find remedies, and over-anx- 
 ious about results, and depressed only about liis special disease. The 
 entire course and history of "the hypochondriacal case is also different, 
 and sufficiently diagnostic without regard to special symptoms. 
 
 Though accidental delusions of disease occur in various forms of 
 Insanity, the diagnostic group of hypochondriacal symptoms hereto- 
 fore given does not present itself, and the delusions in the former 
 instance do not constitute so largely the Insanity as do the grouped 
 symptoms in the latter instance. The most exact repetitions of the 
 states of h^-pochondriacal Insanity are to be witnessed in h3^steria and 
 epilepsy, vrhich are kindred neuroses, but in them other features are 
 present to establish the differential diagnosis. 
 
 Prognosis. — The prognosis as to ultimate recovery is bad. Long 
 remissions and some apparent recoveries occur, but a return of symp- 
 toms can be predicted with almost uniform certainty. The possibil- 
 ity of recovery exists in ehmacteric cases and in instances of mental 
 disorder with the acquired hypochondriacal neurosis. The prognosis 
 as to general usefulness is bad. Incapacity for self-support results 
 in most cases. 
 
 The duration of life is somewhat shortened, on the average, but 
 the extreme care given to the preservation of health in some cases 
 tends to full tenure of life. 
 
 Treatment. — The psychiatric success in case of a natural-born 
 hypochondriac depends upon vigorous and continued treatment from 
 the earhest symptoms in childhood. Systematic education to some 
 active open-air occupation is the main plan. In the meantime a judi- 
 cious discipline, enforced with gentle firmness, the simple ignoring 
 of the hypochondriacal ideas, the constant occupation of the attention 
 by work or play, leaving no time for introspection, and the cultivation 
 by personal example of a spirit of bravery to personal hardship and 
 exposure are the surest psychotherapeutic means. 
 
 Hydrotherapy is of excellent service in these cases, to be begun 
 with the most gentle forms and carried to the point of brief but 
 severe cold douches. Hot rooms and all effeminate indulgences are 
 
598 TEXT-BOOK ON MENTAL DISEASES. 
 
 to be avoided;, and sleeping apartments should be cool, and cold spong- 
 ing, quickly done, should precede dressing. The diet should be varied 
 and generous. 
 
 In fully developed cases of hypochondriacal Insanity the treat- 
 ment can only be palliative and symptomatic. Attention is to be 
 given to slight visceral disorders, which are sources of delusions. The 
 paresthesias in climacteric cases are best controlled by the bromides. 
 
 Constipation and absence of peristalsis call for massage of abdo- 
 men and laxatives. The possibility of organic disease of internal or- 
 gans is never to be overlooked, but the patient is not to be indulged in 
 unnecessary physical examinations. 
 
 In general, the less the patient's attention is directed to ideas of 
 disease by local treatment or drugs, the better will be the result. 
 There is no form of Insanity in which the treatment is more trouble- 
 some to the physician and less satisfactory in the end. 
 
 Section IV. — Choreic Insanity. 
 
 The only true chorea is that described so faithfully by Sydenham, 
 and it is this chorea which develops into Insanity, which is here in 
 question. 
 
 The same pathological conditions underlie both the neurosis and 
 the psychosis, and, although the chorea is ordinarily first in order of 
 appearance, this is not invariably the case. 
 
 Chorea is manifested by clonic spasms and inco-ordinate action 
 of the voluntary muscles, more especially of the face and extremities. 
 It has a maximum period of occurrence at the age from ten to fifteen 
 years, being nearly three times as frequent in girls as in boys. It 
 occurs rarely in adults and in senility. Huntington's chorea is an 
 adult form of the disease, which is hereditary and is attended by 
 chronic mental disorder. In adults generally both the spasmodic 
 neurosis and the psychosis are apt to be chronic in form. 
 
 Definition. — Choreic Insanity is mental alienation, having the 
 same pathological genesis as the choreic neurosis, to which it may be 
 antecedent, vicarious, or sequent, and manifested by acute or chronic 
 states of excitement, depression, or enfeeblement of mind. 
 
 Clinical Delineation. — The clinical outlines of the mental de- 
 rangement are imparted largely by the spasmodic disorder itself. The 
 chief forms which the Insanity assumes are as follows: 
 
 1. The maniacal state, which is the most frequent form, both in 
 children and in adults. In children it appears as an exaggeration of 
 
INSANITY WITH ESTABLISHED NEUROSES. 599 
 
 the spasmodic movements, with insomnia, automatic laughing and 
 crying, fits of anger and violence, tendency to mischief and destruc- 
 tion, hallucinations of sight, soiling of self and of bed, stripping 
 naked and reckless rolling about on the floor, and some speech dis- 
 turbances in many instances, and marked loss of control of ideas and 
 actions. 
 
 This mania in adults is of a more chronic form, with impulsive 
 acts of violence or destruction of property, and changeful delusions 
 and hallucinations of sight, and a gradual weakening of intelligence, 
 with shifting delusions and gross improprieties of conduct. 
 
 2. The melancholic state is shown in children by lachrymose, irri- 
 table, and morose moods, by pavor nocturnus, frightful hallucina- 
 tions, attacks of panic-fear, during which self-injury or violence to 
 others may be inflicted. In adults the melancholic state is shown 
 by ideas of persecution, by anti-social feelings, hatred and fear, and 
 by occasional violent or suicidal outbreaks, with permanent delusions 
 confirmed by visual hallucinations. 
 
 3. Stuporous states exist and are in most cases conditions of ten- 
 sion of mind, and of inhibition of mental activity from fearful delu- 
 sions or hallucinations. These stuporous states are accompanied by 
 vasomotor paresis, capillary stasis, torpor of respiratory and digestive 
 functions, and they may alternate with the maniacal or the melan- 
 choHc states. 
 
 4. Delirium acutum, with partial loss of consciousness and violent 
 jactitation, hallucinations, and incoherent ravings, is an occasional 
 state which leads to a fatal result in more than one-half the cases 
 thus affected. This delirium acutum continues some days or a week, 
 and it must not be confounded with the transient nocturnal dehrium 
 of choreic children. 
 
 Apart from these special acute states there is a continuous apathy, 
 forgetfulness, stupidity, and irritability in choreic subjects, whose 
 conduct may have the appearance of wilful wickedness while it is, in 
 fact, the direct result of disease. 
 
 The above outlines give the main ,clinical features, which will 
 be more minutely described under the head of symptoms. 
 
 Causes. — Sex is a predisposing cause in the ratio of about three 
 to one in children. Among adults there is only a slight excess of 
 women over men in numbers attacked. 
 
 Heredity is very decided in Huntington's chorea, but in most all 
 other forms it is very slight and can only be considered a factor in a 
 small percentage of cases. 
 
600 TEXT-BOOK ON MENTAL DISEASES. 
 
 Malnutrition, such as is found in tlie children of the poor, is un- 
 doubtedly a predisposing cause. 
 
 Emotional shock, and especially fright, is to he found in the his- 
 tory of a considerable percentage of all cases, and it may be that one- 
 quarter of them are due to some psychical cause, such as overstudy, 
 worry, and disappointment. 
 
 Eheumatism is very frequently associated with chorea, and it may 
 be regarded as causative of choreic Insanity in possibly one-fifth 
 of the cases. 
 
 Infectious diseases seem to be the exciting cause in some instances, 
 and toxic agents and auto-intoxications are the etiological factors in 
 a considerable number of cases. 
 
 The puerperium develops choreic Insanity in young women, and 
 in these instances there may be a toxic condition, which underlies 
 all the symptoms. 
 
 Imitation has been claimed as a cause, but it relates rather to 
 choreiform habits, to spasmodic tics, and to hysteric epidemics of In- 
 sanity. Angemia is associated often with choreic Insanity, and it is 
 to be viewed, perhaps, in some cases, as a cause as well as a concom- 
 itant. 
 
 Stadia. — There is choreic Insanity as a prodrome, as an accom- 
 paniment, and as a sequel of chorea. As a prodrome of the chorea 
 it is rare, and there is then an initial stadium of a few weeks of hebe- 
 tude and irritability combined, with night terrors and hallucinations 
 of sight, and spells of sudden causeless alarm in the day-time. There 
 then follows an acute stadium of mental disorder, usually maniacal, 
 during which the spasmodic neurosis declares itself, and there is then 
 a final convalescent stadium of both the neurosis and psychosis. 
 
 As an accompaniment of chorea, which is most frequent, the ini- 
 tial stadium is of a few days' duration, and consists in exaggeration 
 of the inco-ordinate movements, of a reckless and mischievous 
 breaking of things, and tearing of clothing and overturning of furni- 
 ture, and disregard of instructions. The acute stadium >then follows 
 during the third or fourth week of the chorea in the greatest number 
 of cases, and is of maniacal character, and it ends in a brief convales- 
 cent stadium after a few weeks' duration, and subsequent to the dis- 
 appearance of the spasmodic neurosis. 
 
 As a sequel of chorea the mental disorder has a brief initial sta- 
 dium of depression and tension of mind, followed by an acute stadium 
 of melancholia, with stupor and a short convalescent stadium. In a 
 smaller number of cases the initial and the acute stadia are more of a 
 maniacal character. 
 
INSANITY WITH ESTABLISHED NEUROSES. 601 
 
 Whether preceding, attending, or following the chorea, the Insan- 
 ity is wont to recur with the neurosis, which is known to have at least 
 one relapse in a large percentage of cases. 
 
 In chorea in adults the initial stadium lasts for months, and the 
 acute stadium, which may be depression or excitement, continues for 
 years, or until a terminal stadium of dementia sets in with advancing 
 years. 
 
 In Huntington's chorea the mental disorder would seem to form 
 a later phase of the degenerative neurosis and to have a terminal 
 stadium of mental enfeeblement. 
 
 Symptoms. — The principal symptoms in the maniacal forms are 
 restless and irritable conduct, with violence or destructiveness, hallu- 
 cinations of sight, disorder of speech and altered intonation of voice, 
 inco-ordinate gesticulation, filthy habits, insomnia, loss of weight, the 
 infliction of bruises and other personal injuries from violent jactita- 
 tion, the stripping off of clothing, and a general incoherence of idea- 
 tion and of action. 
 
 In the melancholic form there are frightful hallucinations, sud- 
 den exacerbations of panic or of violence to self and others, insomnia, 
 disorders of respiration, circulation, and digestion, emaciation, ceph- 
 alalgia, photophobia in some cases, and perversion of common sensa- 
 tion, as well as disturbances of the special senses. Yague dreads and 
 constant suspicions of others and impulsive tendencies are common. 
 Suicidal impulses are not rare, and cases of homicidal attempts have 
 been reported. 
 
 The stuporous forms seem to be attended by inhibition from fear- 
 ful hallucinations and delusions. 
 
 The sensorial disorder, as well as the spasmodic liberation of pain- 
 ful emotions in choreic Insanity, are due to active processes of dis- 
 ease in cortical regions. 
 
 Patliohgy. — There are very constant cerebral lesions in chorea, 
 but no uniform morbid anatomy has yet been established. The 
 pathology of the mental changes is the same as that of the spasmodic 
 neurosis. 
 
 Meynert demonstrated intense hypersemia of the caudatum in par- 
 ticular, as well as of the entire prosencephalon. 
 
 Eokitansky reported hyperplasia of connective tissues of the cen- 
 tral nervous system, and Golgi encephalitic processes. Broadbent 
 deemed capillary embolism of the corpora striata and optic thalami 
 as the pathology of chorea. Various writers have reported lesions 
 
602 TEXT-BOOK ON MENTAL DISEASES. 
 
 in the cortex cerebri and in the central ganglia, in the spinal cord, 
 and in the peripheral nervous system. 
 
 The conclusion to be admitted is that in chorea there are inflam- 
 matory lesions of cerebro-spinal centres, vascular changes, infiltration 
 of perivascular spaces, meningeal adhesions, connective-tissue prolif- 
 eration, changes in ganglionic cortical elements, and other morbid 
 histological appearances. 
 
 All these pathological processes point to some toxic condition 
 which gives rise alike to the choreic and rheumatic lesions. It is pos- 
 sible that there may be microbic infection in all these eases. 
 
 So far as the mental disorder is concerned, the morbid anatomy 
 consists in the irritative lesions of the cortical motor and sensory 
 centres. 
 
 Differential Diagnosis. — The group of features in chorea with 
 which the Insanity is connected renders a mistake in diagnosis im- 
 probable. 
 
 The differentiation is to be made in intercurrent choreic move- 
 ments in epileptic Insanity, in mental disease post-hemiplegic, in cer- 
 tain paretic cases, and in Insanity from arrests of organic develop- 
 ment with choreic complications. The history of both the mental and 
 motor disturbance serves the purpose for differential diagnosis in 
 these cases. 
 
 Prognosis. — The prognosis as to recovery is good in youthful 
 cases and usually takes place promptly with cessation of the spas- 
 modic neurosis. The prognosis in adult cases of chorea is bad and 
 mental deterioration is the ordinary result, a final stadium demen- 
 tise being ultimately reached. This same unfavorable termination 
 is the rule in hereditary chorea. The prospect of life is good in chil- 
 dren, in whom death is recorded in only about one per cent, of the 
 cases. In adult choreic Insanity the expectation of life is decidedly 
 diminished on account of accidents, and the progressive general de- 
 terioration of mind and body. 
 
 Treatment. — The first indication in the acute forms of choreic 
 mental disease is quietude and rest. The patient must be isolated in 
 a room specially prepared ; the recumbent posture in the maniacal 
 cases is the best, and the restraining sheet is the only practical means 
 of keeping the patient in bed. Manual restraint is out of the ques- 
 tion, as being a cause of irritation and resulting in abrasions and 
 bruises on account of the constancy of the movements, which should 
 not be forcibly restrained. The sheet allows a certain freedom of the 
 involuntary motions while retaining the recumbent posture. 
 
IN^SANITY WITH ESTABLISHED NEUEOSES. 603 
 
 The next indication is abundant nourishment and stimulation at 
 the right moments to sustain the circulation and avoid exhaustion 
 in the acutely maniacal cases. 
 
 Bromides and chloral are the best sedatives, though in the melan- 
 cholic forms opium is preferable. 
 
 Hydrobromate of hyoscin is an extreme resort in the violent jac- 
 titations of adult cases. 
 
 The most reliable remedy for the chorea itself is Fowler's solu- 
 tion of arsenic in increasing doses, beginning with ten minims daily. 
 Cimicifuga is the next best remedy. Valerianate of zinc may be tried. 
 The salicylates are indicated in rheumatic cases and iron in the anae- 
 mic states. 
 
 Warm baths at bed-time or the moist pack favor sleep. Cold 
 spinal bags give some relief in certain cases. Darkened sleeping 
 apartment in the day-time relieves from the visual hallucinations. 
 
 The avoidance of all causes of irritation and the indulgence of the 
 patient's fancies are a part of the psychotherapeutic treatment. At- 
 tempts at discipline and severity of manner are worse than useless 
 in these cases, which call for the utmost forbearance and kindness in 
 keeping with the fact that they are doubly afflicted with motor and 
 mental disorder. 
 
 Section V. — Neurasthenic Insanity, 
 
 There is a concensus of opinion among many alienists and neurol- 
 ogists that there is a neurosis which is to be termed neurasthenia. 
 There certainly are conditions of instability and weakness of the ner- 
 vous system, as shown by a variety of functional nervous symptoms, 
 which are not grouped in a manner characteristic of any of the other 
 distinct neuroses. Hence all these symptoms of debility and exhaus- 
 tion of the nervous centres are classed under the generic term of neur- 
 asthenia. According to the special nervous centre exhausted, and to 
 which the symptoms are more particularly referable, the cerebral, 
 spinal, and sexual varieties of neurasthenia are recognized. Neuras- 
 thenics do not often become insane, but they enjoy no immunity from 
 mental alienation, and their neurosis prepares the way for the psy- 
 chosis, as does every other neurosis. Whether the neurasthenia pre- 
 cedes or develops simultaneously with the mental disorder there is a 
 blending of the neurasthenic symptoms with the psychosis, which is 
 then termed neurasthenic Insanity. 
 
 The recent American, French, and German literature of neuras- 
 thenia presents a vast and incongruous group of symptoms of ex- 
 
604 TEXT-BOOK ON" MENTAL DISEASES. 
 
 Jiaustion of cerebro-spinal and vasomotor centres, and there is con- 
 spicuous failure of consistent agreement among writers upon any par- 
 ticular neurasthenic type. Neurasthenia, therefore, like paranoia, is 
 fast tending to include so much that it will soon cease to circumscribe 
 any definite group of symptoms. 
 
 Definition. — jSTeurasthenic Insanity is a form of mental alienation 
 attended by predominant symptoms of debility and exhaustion of 
 nervous centres, by general irritable weakness of all the bodily func- 
 tions, and by vasomotor anomalies, in addition to the psychical dis- 
 turbances. 
 
 Clinical Delineation. — The earhest appearance of neurasthenia is 
 in the numerous class of persons born with a highly nervous tempera- 
 ment, and it may in them appear soon after puberty. Most cases 
 occur before the thirtieth year, and the proportion of neurasthenics 
 diminishes steadily as life advances ; the gradual blunting of all 
 the sensibilities is nature's way to euthanasia, and there are few neu- 
 rasthenics after the age of fifty. In the adolescent period the clinical 
 features are, feelings of general discomfort and of fatigue on slight 
 exertion, disturbed sleep, headache and backache, paresthetic sensa- 
 tions known popularly as " growing pains," nervous dyspepsia, gas- 
 tralgia, disorders of menstruation and seminal weakness, despondency 
 and loss of all natural interest in business or pleasure, inability to fix 
 the attention, loss of memory, irritability, and impaired volition and 
 depressing delusions. In some of the more neurotic cases there are 
 to be depicted a host of vague doubts and fears, morbid fancies and 
 suspicions, impulsive tendencies to excesses followed by intense re- 
 morse and self-reproach, religious intensity of feeling, delusions of 
 imaginary diseases, and perversion of the appetites. 
 
 The clinical lines in cases more advanced in years are to be drawn 
 more decidedly, and neurasthenic Insanity is then attended by de- 
 cided vasomotor disorders, cerebral hypersemia or anaemia, vertigo, 
 cutaneous anomalies of circulation, cold hands and feet, cephalalgia, 
 intercostal pains, neuralgias and visceral parsesthesige, spinal weak- 
 ness and backache, gastro-intestinal disorders, migraine, hyperses- 
 thesia of the special senses and occasional hallucinations of the same, 
 despondency and loss of natural affection, and delusions as to busi- 
 ness or domestic relations. A prominent feature is debility of vital 
 functions, of respiration, circulation, and digestion, and fatigue of 
 the muscular system on slight exertion. The same prompt nervous 
 exhaustion follows slight mental efforts. The feeling of general de- 
 morahzation on the part of the patient corresponds to an actual phys- 
 
INSANITY WITH ESTABLISHED NEUROSES. 605 
 
 ical and mental incompetency, and is not, as in hypochondriasis, im- 
 aginary. More special delineation would only serve to accent, in cer- 
 tain cases, the cerehral, spinal, gastric, or sexual disorders of func- 
 tion. The insane delusions vary with the clinical nature of the physi- 
 cal symptoms somewhat, they are not systematized, and generally 
 change from time to time, and are not very firmly rooted. 
 
 Causes. — The predisposing cause is the inheritance of a feehle 
 constitution and nervous temperament. Women especially often re- 
 semble weak and nervous mothers in this regard, so that a neuras- 
 thenic family of daughters is often observed to be the direct punish- 
 ment inflicted on the mother for violation of nature's laws. The 
 neurasthenic state is also acquired by all the shocks to which flesh is 
 heir. The wear and tear of life, worry, and work, the stress of busi- 
 ness and the greed of gain, excitement, artificial living, selfish pursuit 
 of pleasure, excesses of all kinds, and unhygienic surroundings, act 
 as exciting causes of neurasthenia, which arises suddenly also from 
 bodily injury, great exposure to hardship, or to sudden emotional 
 shock. 
 
 Climatic influence seems to favor it, and high and dry localities 
 have more than an average proportion of neurasthenics. Toxic, auto- 
 toxic, and diathetic states are causative of neurasthenia, which may 
 proceed also from physiological crises and especially from the meno- 
 pause. Ocular disorders and reflex irritations are occasional etiolog- 
 ical factors. In this respect irritations of the primge vise and of the 
 reproductive organs are important as causes. 
 
 Stadia. — There is ordinarily a long initial stadium of months, 
 during which all the neurasthenic manifestations are heightened, and 
 then an acute stadium of mental depression with delusions, and com- 
 plete incapacity for the ordinary affairs of life. The acute stadium 
 rarely takes the form of exaltation. 
 
 There is finally a gradual convalescent stadium. 
 
 All the stadia may have a more prompt and active course in a 
 neurasthenic state acquired by some sudden and severe stress. 
 
 The writer has seen such cases following epidemic influenza, and 
 probably moral shock might produce like results. 
 
 In congenital neurasthenics, who begin toward the crisis of pu- 
 berty to pass into a psychopathic condition, it is more scientific to 
 regard the whole age of puberty as the initial stadium, and the sub- 
 sequent long years of fluctuations between Insanity and doubtful 
 sanity as a long acute stadium with remissions, and the final years 
 of relief, which age brings, as a convalescent stadium. 
 
606 TEXT-BOOK ON MENTAL DISEASES. 
 
 In several born neurasthenic cases the natural history of the whole 
 constitutional exhaustion of mind and body and the Yacillating men- 
 tal aberrations seemed to justify this view. 
 
 It will not bear the test of clinical facts to circumscribe with a 
 theoretical line of immunity from mental disorder the whole group 
 of neurasthenics in order to be able to assure patients of safety when 
 once within the neurasthenic circle. The fact is that real neuras- 
 thenics are near the border line between sanity and Insanity, and 
 make excursions into the realm of actual aberration more often than 
 is supposed. 
 
 Symptoms. — The psychical symptoms include a permanent sense 
 of fatigue, absent-mindedness, partial amnesias, impaired will, impul- 
 sive tendencies, morbid fears, insomnia, frightful dreams, despond- 
 ency, and delusions and perversions of the emotions. 
 
 The automatic repetition of ideas, which may become impellent, 
 the loss of self-confidence and tendency to self-reproach, a reasoning, 
 doubting, and panphobic character of the symptoms are present in 
 some cases. 
 
 The somatic symptoms are sensor}' disorders, parsesthesias, anses- 
 thesias, neuralgias, hyperesthesias of the special senses, cranial and 
 occipital pains, hypersesthetic points of pressure, topalgia, visceral- 
 gias, vasomotor disturbances, dermography, hyperidrosis palmaris, 
 pneumogastrie disorder, cardiac irregularities, sexual debility and 
 menstrual disturbances, hepatic torpor, nervous dyspepsia, nausea, 
 anorexia, and defective metabolism. 
 
 The muscular disorders consist in the abnormal quickness of ex- 
 haustion from slight effort, the presence of clonic spasms of strands 
 of musciTlar fibres or of single muscles, inco-ordination of the special 
 muscular mechanisms, of gait, speech, or handwriting. The inco- 
 ordination and indistinctness of speech has led to the diagnosis of 
 general paresis in more than one ease when taken together with the 
 wavering gait. Tremor of the hands is present in some cases, and 
 may be heightened on intentional effort. Muscular reflexes are ex- 
 aggerated. General nutrition is impaired, and there is loss of weight 
 in neurasthenic Insanity. 
 
 Pathology. — The most satisfactory hypothesis is that of malnu- 
 trition of the whole cerebro-spinal axis as manifested in the symp- 
 toms of irritable weakness of the functions of all parts of the nervous 
 system. Possibly this dystrophy is more decided in cortical and vaso- 
 motor centres as judged by the prominence of the psychical and vaso- 
 motor abnormalities. 
 
INSANITY WITH ESTABLISHED NEUROSES. 607 
 
 The clinical fact is that the neurasthenic is a bankrupt in nervous 
 force, either from fault of nutritional manufacture, from defective 
 storage in cerehro- spinal centres, or from a too facile discharge. 
 
 Hypersemia of cerebro-spinal centres, and less commonly anaemia, 
 exists in some severe cases, but no morbid anatomy can be said to have 
 been estabhshed for this form of Insanity. 
 
 Differential Diagnosis. — N"eurasthenic Insanity is to be dif- 
 ferentiated from simple functional exhaustion of mind and body from 
 any cause. It must be distinguished from mental disorder emerging 
 from the other neuroses, such as hypochondriasis and hysteria. The 
 whole history of the case suffices for this distinction, even if the 
 symptoms do not sufficiently permit the differential diagnosis. 
 
 It must be differentiated from primary monomania. The physical 
 symptoms afford the grounds of distinction in this ease, taken in con- 
 nection with the systematized delusions of monomania. 
 
 Neurasthenic Insanity is differentiated from melancholia by the 
 etiology and course of the latter, which is seldom so chronic, and by 
 the entire group of neurasthenic symptoms, and by the absence of 
 some of the somatic signs of the acute melancholic state in most of 
 the neurasthenic insane. 
 
 The differential diagnosis in other instances is not difficult, except 
 in the early stage of general paresis. The clear cases of muscular 
 inco-ordination of gait and speech among neurasthenics must be dif- 
 ferentiated from like symptoms in paretics, and this implies a sus- 
 pension of judgment for a reasonable period and warns against a 
 " snap diagnosis " in any given case. 
 
 Prognosis. — Prognosis as to recovery from the immediate attack 
 is good, but in the most confirmed neurasthenics there is nearly al- 
 ways a recurrence of mental disturbance. 
 
 In the acquired forms of the neurasthenic state and in the climac- 
 teric cases the recovery may be prompt and permanent. 
 
 The prognosis as to the chances of life is good, and the duration 
 of life is not greatly affected by this form of Insanity. 
 
 Treatment. — ^Isolation is essential in many cases, either in private 
 or in an institution. The rest-cure is to be tried if there is a history 
 of over-work and there has been no interval of rest. The enforced 
 idleness in other cases is bad, and a reasonable amount of occupation 
 is attended by better results. 
 
 The excessive irritabihty is best controlled by the bromides, which 
 are useful also for the insomnia. Opium is good in some cases, but 
 a habit is at once formed. Hypnotics must be used sparingly, as 
 
608 TEXT-BOOK ON MENTAL DISEASES. 
 
 they disturb nutrition, which is always impaired in neurasthenic 
 Insanity. 
 
 Strychnine, quinine, iron, and eod-hver oil are of service, in small 
 doses, for tonic purposes. The alterative effect of arsenic is to be 
 judiciously sought when other remedies fail. 
 
 Hydrotherapy is applicable, and a change of climate is of avail, 
 in the more chronic cases, from inland to seaboard, or from the latter 
 to mountainous regions. 
 
 The diet should be nitrogenous largely, and varied with fresh 
 fruits in season. A visit to fruit regions and the abundant use of ripe 
 fruit at the height of the fruit season is often beneficial. 
 
 A fresh milk diet is good in some cases, with fresh eggs and but- 
 ter in considerable amounts. Fats are essential in most cases and 
 favor sleep when taken as fresh cream. 
 
 Electricity and electro-massage are in order in connection with 
 the rest-cure. Systematic exercise and out-door life are all impor- 
 tant to harden the cure, and prophylaxis must be perseveringly en- 
 forced to avoid recurrences. 
 
 There are sometimes etiological indications for treatment, and all 
 reflex irritations should be removed by surgical interference, if need 
 be, in certain cases. 
 
 In all cases a searching physical examination is to be made that 
 no organic disease may be overlooked. 
 
 Psychotherapy is of great avail in the treatment of the neuras- 
 thenic insane. A change of occupation and diversion adapted to 
 each particular case, instead of cessation of all activity, is one of the 
 chief means of cure. 
 
 After convalescence a change from sedentary to active life in the 
 open air may be advisable. Marriage is often good for the convales- 
 cent patient, but cannot be advised on general grounds by the physi- 
 cian, whose first professional duty is to humanity in general rather 
 than to his patient in particular. 
 
 If the neurasthenic state was acquired in the instance of the pa- 
 tient, and if the family history is good, marriage may be permitted. 
 
 Traumatic cases of neurasthenic Insanity require special treat- 
 ment, according to the nature of the original injury. Such cases 
 are apt to run a chronic and unfavorable course under any plan of 
 treatment. In these cases, also, the result of properly adapted occu- 
 pation is usually better than a surrender to idleness. In the main, 
 the general plan of treatment does not differ from that described. 
 
CHAPTEE IV. 
 
 INSANITY WITH THE PHYSIOLOGICAL CRISES. 
 
 Group: Pubescent, Puerperal, Climacteric, and Senile Insanity. 
 
 Section I. — Pubescent Insanity. 
 
 Sexuality pertains to the entire system^, and there is not a con- 
 summation of sexual differences in the human kind before the full 
 development of the entire organism about the twenty-fifth year of 
 life. At this age the individual is produced in full perfection, and is 
 ripe for reproduction of the species, and at the height of sexual fe- 
 cundity. 
 
 Ovarian maturation in the female and the orgasmic reflex and 
 spermatopoietic function in the male occur, with climatic variations, 
 from the twelfth to the sixteenth year, as confirmatory signs of the 
 crisis of pubescence. This first nisus generativus arrives at a period 
 of both physical and psychical immaturity, and with this prime sex- 
 ual impetus the coming man and woman are launched upon full men- 
 tal and bodily evolution, only completed at the end of a decade. This 
 evolutionary era from pubescence to full sexual maturity, covering 
 a period of about ten years, is the epoch during which pubescent In- 
 sanity declares itself, and it predominates in the latter rather than 
 the first half of this decade, and it is then sometimes termed adoles- 
 cent Insanity. The term "pubescent" is sufficient, especially as 
 there is only one crisis, which occurs at variable points of this pubes- 
 cent epoch, just as soon as nature runs short of formative material 
 or nutritive force in the complete production of the entire physical 
 system, and of the brain as the presidial organ of the human economy. 
 
 The same general Jaw of organic failure, as demonstrated with a 
 
 certain percental uniformity in immature and defective individual 
 
 specimens throughout the whole vegetable and animal kingdom, here 
 
 yields the pubescent Insanity order of human beings, whose imma- 
 
 39 609 
 
610 TEXT-BOOK ON MENTAL DISEASES. 
 
 turity and defect is in cortical functions as the most complex result 
 of organic evolution, which is here stopped short of full perfection. 
 
 Definition. — Pubescent Insanity is mental alienation at the pubes- 
 cent epoch from failure of complete evolution of mental faculties on 
 a basis of stable equilibrium, and is characterized by sudden anoma- 
 lies of ideation, by explosive emotions, by perversion of the instincts 
 and appetites, and by maniacal, melancholic, and stuporous states. 
 
 Clinical Delineation. — The clinical features of pubescent Insanity 
 are dependent in part on the turbulent evolution of new ideas and 
 emotions in sympathetic relation with the reproductive function, and 
 on remote and direct hereditary tendencies. Neurotic ancestral traits 
 become pronounced, and there is a periodic exacerbation of symptoms 
 corresponding with the monthly period in women, and there is also 
 a larger cyclic tendency shown by recurrences of mental disorder in 
 cases apparently recovered. 
 
 The mental disturbances may be mild or severe. In the mild 
 cases there are simply gross exaggerations of youthful characteristics, 
 'egotism, boastfulness, impudence, a wild expansiveness of self-feeling 
 and conduct, cruelty and pugnacity, sexual depravity, instinctive per- 
 versions, and occasionally violent tendencies. 
 
 In the more pronounced cases there are maniacal states, in which 
 appear exalted feelings of self-importance, grandiose ideas, loud and 
 constant talking, quarrelsome and destructive outbreaks, erotic and 
 indecent conduct, masturbation, loss of sleep and flesh, and digestive 
 disturbances. 
 
 Another type contrasting with the above is melancholic with ideas 
 of persecution or of poisoning, suspicion of surroundings, hallucina- 
 tions of hearing and of smell, loss of all energy or interest, gloomy 
 depression and thoughts of suicide, insomnia and loss of appetite and 
 of flesh, masturbatic indulgence, cold hands and feet, lowered tem- 
 perature, and amenorrhoea and irregularities of menstruation in 
 women. 
 
 The stuporous states often seen are mostly continuous of the 
 melancholic conditions, with which they occasionally alternate, 
 though they are sometimes sequels of the maniacal exacerbations. 
 They are the obstinate and passively resistant states, during which 
 the patient is conscious fully of all that occurs, and they are marked 
 by cataleptoid and tetanoid phases. 
 
 These stuporous conditions may last, in rare cases, for several 
 months, and they resemble dementia terniinalis, except that the in- 
 telligent expression of the eye is not lost, and the facial lines are 
 
INSANITY WITH THE PHYSIOLOGICAL CRISES, 611 
 
 not so completely obliterated, and close observation will show gleams 
 of intelligence, which are not present in true terminal dementia. 
 
 The above are the chief outlines of the types of mental disturb- 
 ance. 
 
 Causes. — The crisis of puberty is one which develops ancestral 
 weakness of constitution transmitted to the offspring, and the neu- 
 rotic tendency can be traced directly to parental sources in one-third 
 of all cases of pubescent Insanity. The hereditary defect is numeri- 
 cally somewhat greater among women than men. 
 
 While heredity is the prime cause, there are numerous favoring 
 circumstances to be considered. 
 
 Bad educational methods, immoral example on the part of the 
 parents, vicious associations, the moral and physical degradation of 
 extreme poverty, and the nutritional defects which it entails upon 
 children, and all forms of unhygienic living and of personal excesses. 
 
 Masturbation, which has been so often regarded as the chief cause, 
 is more often a symptom of the loss of inhibition, and of the morbid 
 intensity of the sexual appetite,. and of the general demoralization of 
 the patient. The habit heightens the symptoms of vasomotor disor- 
 der, and tends to develop the stuporous and deluded states. The 
 attack of pubescent Insanity would develop in most patients, even 
 were there no masturbation, and the latter is a modifier of symptoms, 
 rather than a prime cause. 
 
 The menstrual disturbances in women are likewise symptoms of 
 the general nutritional deficiency and of anemic conditions rather 
 than causes of the pubescent Insanity. When the patient is verging 
 upon mania the menstrual disorder may immediately favor the out- 
 break. 
 
 The chief exciting cause is the crisis of puberty, with its sudden 
 and universal changes in nutritive, vascular, and nervous functions, 
 and with a vast influx of new feelings and ideas, and a readjustment 
 of the whole mental mechanism. This profound organic evolution 
 cannot take place in hereditarily unstable ner^^ous systems without 
 signs of brain disorder. 
 
 Stadia. — There is usually an initial stadium of some months* 
 duration. This stadium is often overlooked, but it is seldom absent, 
 and it consists in an expansive mood, flighty ideation and conduct, 
 disobedient and impudent bearing, and persistent obstinacy and un- 
 reasonableness. There then follows an acute stadium of a maniacal 
 or melancholic type, with intercurrent stupor, and then a prompt 
 convalescent stadium. 
 
612 TEXT-BOOK ON MENTAL DISEASES. 
 
 In very many cases the acute stadium lasts for six or eight months, 
 during which there are remissions of symptoms and then acute exac- 
 erbations and stuporous phases before the convalescent stadium. 
 
 The melancholic cases have a longer acute stadium than the 
 maniacal, and a more prolonged convalescent stadium. In rare cases 
 the acute stadium is stuporous and prolonged many months. 
 
 All the stadia are transient, in exceptional instances occupying 
 only a week or so, but the average attack of pubescent Insanity is 
 attended by recovery at the end of the fifth or sixth month. 
 
 The strongly hereditary cases present the greatest number of 
 remissions and relapses, and they sometimes graduate into distinct 
 periodical Insanity, which lasts the remainder of life. 
 
 Symptoms. — Periodicity and explosiveness characterize, in gen- 
 eral, the symptoms of pubescent Insanity. 
 
 The psychical manifestations bear also a general stamp of childish- 
 ness in the younger subjects, and in others border on the imbecile 
 order of symptoms. In older patients there are fickle, turbulent, and 
 changeful phenomena, in keeping with the revolutionary changes 
 throughout the entire system at this epoch. 
 
 In males domineering egotism, bombastic speech, quarrelsome in- 
 terference, the assuming of some religious or heroic role, impulsive 
 violence to self and others, excess in alcohol, tobacco, or venery, anti- 
 social acts and legal offences, loss of control of ideas and actions, and 
 a reckless disregard of property and of personal safety. Delusions 
 are exaggerated or depressed and confirmed by hallucinations of sight 
 and hearing. In the masturbatic cases hallucinations of smell are 
 common. In women, restlessness, talkativeness, impudence, obscen- 
 ity, mischievousness, removal and tearing of clothing, religious or 
 erotic delusions and hallucinations, and hysterical outbreaks are to 
 be witnessed. 
 
 In both sexes suicidal tendencies exist in about one-third of the 
 cases, biit the attempts at self-destruction are not very decided and 
 seldom successful. 
 
 In the melancholic state ideas of self-reproach and sinfulness, sus- 
 picions of danger to life, refusal of food, self -mutilations, and mastur- 
 bation are common. 
 
 The hallucinations of vision in a few cases are ecstatic or phantas- 
 magorial in character. 
 
 The stupor is sometimes attended by frightful visions. Amnesia 
 is partial or complete. There is always perversion of feelings, loss 
 
INSANITY WITH THE PHYSIOLOGICAL CRISES. 613 
 
 of natural affection, tedium yitse, eroticism, and sometimes, among 
 masturbatic males, gynephobia. 
 
 The somatic symptoms include automatic sighing, weeping, and 
 laughing, cardiac irregularities and palpitations, cerebral hyperemi- 
 as, epistaxis, cephalalgia, neuralgia and paraethesise, vasomotor anom- 
 alies, cold extremities, osmidrosis, oedema in the stuporous states, 
 tinnitus aurium, muscge volitantes, spermatorrhoea, dysmenorrhoea, 
 amenorrhcea, leucorrhoea, loss of weight, muscular rigidity, catalep- 
 toid states, choreiform movements, convulsive tics, fibrillar spasms, 
 hysterical joints, " growing pains," and loss of appetite and sleep. 
 
 In the stuporous states the vasomotor disorder is marked, the ex- 
 tremities are livid, there is capillary stasis, and the temperature is sub- 
 normal. The muscular sense and common sensation are involved to 
 such an extent as to cause iiico-ordination of gait. Speech is slowed 
 in these cases, and in some there is mutism or articulation with 
 scarcely audible phonation. Though vasoparetic states predominate, 
 the sphygmographic tracing in these stuporous conditions shows high 
 tension often from the obstruction created by the capillary stasis. 
 Anaemia is frequent and the percental dininution of haemoglobin is 
 very considerable. 
 
 Trophic disturbances and nutritional anomalies are also very con- 
 stant symptoms. 
 
 Pathology. — The immediate pathological conditions would seem 
 to be vasomotor and nutritional disturbances of nervous centres. 
 Looking beyond these abnormalities, it is possible to trace a vicious 
 heritage and a neuro-psychopathic tendency in a little more than 
 thirty-three per cent, of all the cases. There are strong exciting causes 
 in some of the cases, but there is a large remainder having no definite 
 pathogenesis. 
 
 For this large contingent it is necessary to seek a broader law than 
 parental heritage, and this is found in the universal law of organic 
 failure witnessed in the propagation of every species in all the domains 
 of nature. Ample provision is made for the perfect propagation of 
 the species, but there is a constant and large percental failure in the 
 perfect reproduction of individuals. These pubescent patients, free 
 from traceable heredity, are the imperfectly propagated individuals, 
 the failures in the organic reproduction of the human species. There 
 are causes more remote or more immediate than heredity, from innu- 
 merable and culminating influences beyond the grasp of biological 
 science, which will possibly some day elucidate the facts of this law 
 of organic failure, which can already be formulated according to per- 
 cental chances in various animal species, irrespective of direct hered- 
 
614 TEXT-BOOK ON MENTAL DISEASES. 
 
 ity. As regards heredity^ some writers fix it at a higher figure in 
 this form of Insanity than that above given as representative of the 
 writer's observations. 
 
 Differential Diagnosis. — Pubescent Insanity is to be differen- 
 tiated from general paresis. The same exaggeration of ideas is present 
 in the maniacal phase of both types of mental disorder, but the gen- 
 eral failure of intelligence is less in pubescent Insanity, in which also 
 the physical signs of general paresis are wanting. 
 
 The differential diagnosis must be made from Insanity with the 
 principal neuroses. The intercurrent hypochondriacal, choreic, and 
 hysterical symptoms in pubescent Insanity can only lead to tempo- 
 rary doubt as to whether one of the major neuroses is in process of 
 development. 
 
 The differentiation from periodic Insanity on account of the re- 
 missions during the acute stadium of pubescent Insanity may give 
 rise to some doubt, which time alone can with certainty dispel. 
 
 However complex the symptomatology of pubescent Insanity, 
 there are characteristic groupings of symptoms which guide to diag- 
 nosis. 
 
 The menstrual irregularities, the stuporous states, the chloran- 
 aBmia, the erotic and religious tinge of the delusions and hallucina- 
 tions, and various psychical correspondences with the evolution of 
 the reproductive functions, are highly symptomatic of the pubescent 
 crisis in women. In males there are hardly to be found in any other 
 form of Insanity the same commingling of boyish absurdities and 
 manly pretensions, such extravagance of ideas and conduct, rank im- 
 pudence and reckless disobedience of all law and order, sudden 
 changes in mood and manner, alterations of consciousness and per- 
 sonal identity, maniacal and stuporous blending of symptoms with 
 cataleptoid states and hallucinated and inhibited psychic conditions 
 with muscular tetany, and such symptoms as the Germans designate 
 hebephrenic. 
 
 Familiarity with the vagaries of these pubescent cases is soon 
 acquired by clinical observation, but the diagnostic skill required in 
 the differentiation of these cases from other types, though soon at- 
 tained in practice, cannot be fully conveyed by didactic descriptions. 
 
 Prognosis. — The prognosis as to recovery is highly favorable as 
 regards the immediate attack. Seventy-five per cent, of the eases 
 make a recovery. Of those who recover a large percentage have sub- 
 sequent attacks, and this is specially true of the cases with strong 
 heredity. 
 
INSANITY WITH THE PHYSIOLOGICAL CRISES. 615 
 
 The recovery is more prompt in the maniacal than in the melan- 
 cholic patients, and more permanent in males than in females. The 
 prognosis as to life is good. Less than ten per cent, of males and six 
 per cent, of females die. 
 
 Chronicity finally results very frequently among males, of whom 
 about forty-five per cent, eventually become chronic cases after sev- 
 eral relapses. 
 
 The ultimate proportion of females who suffer relapses and be- 
 come incurable is still greater, owing to the stronger influence of 
 heredity. 
 
 The absolute recoverability is not so great, therefore, as would 
 seem from immediate restoration from first attacks. The recupera- 
 tive power of youth accounts for these apparently perfect first recov- 
 eries, but the inherited tendency reasserts itself at a later day under 
 any accidental stress of mind or body. 
 
 The unfavorable cases terminate in dementia of the active form, 
 chiefly with exacerbations of excitement. Some cases end in sec- 
 ondary monomania with delusions of exaltation. An occasional ter- 
 mination is chronic stuporous mental enfeeblement, with automatic 
 masturbation as long as life lasts. Such patients, when aroused, show 
 a degree of intelligence out of keeping with their facial and general 
 physical degradation. 
 
 The prognosis as to life is often complicated with tuberculosis, 
 or rheumatism and cardiac affections, to which due weight must be 
 accorded. 
 
 Treatment. — The general plan of treatment must include isolation 
 in the country or in an institution, in the majority of cases which 
 last for several months. Underlying etiological or pathological con- 
 ditions, anaemia, tuberculosis, reflex irritations are flrst to receive 
 attention. Insomnia and maniacal excitement are best met with 
 bromides, which abate the sexual ardor to some degree. The hygi- 
 enic measures are of the utmost importance. The open-air treatment 
 is to be pursued as far as possible, and a change of residence and 
 climate to effect this purpose may be advisable. 
 
 In able-bodied patients active exercise in useful occupation or in 
 out-of-door sports is commendable. The more invalid patients may 
 sit or rechne during full exposure to the air and sunhght. 
 
 The diet should be fatty and nitrogenous, and should be varied 
 with fresh fruits in season. Milk, eggs, butter, fresh meats, fish, 
 fruits and vegetables in season, and a plentiful supply of pure water 
 are most essential. Hydrotherapy is of much value to promote cutane- 
 ous activity, to favor sleep, and for the local effects of heat and cold. 
 
616 TEXT-BOOK ON MENTAL DISEASES. 
 
 Electricity and massage are applicable in the stuporous cases. 
 Anemia and amenorrhoea call for iron, cod-liver oil, malt extract, and 
 a little red wine, and in obstinate cases small doses of arsenic. 
 
 Blaud's pill is an eligible preparation, and should be supple- 
 mented with tonic doses of quinine. If there be any hereditary 
 syphilitic history, bichloride of mercury in small (grain -g^) doses 
 will do good service in the angemic state. It is useless to treat the 
 amenorrhoea until the general standard of nutrition has been re- 
 stored and then tincture of aloes and myrrh, hot sitz-baths and local 
 applications of electricity at the time of the regular return are effici- 
 ent remedies. 
 
 Hypnotics are seldom essential when hygienic, hydrotherapeutic, 
 and dietetic measures are faithfully enforced. Forced alimentation 
 is often necessary in the stuporous states and in melancholia with de- 
 lusions of poisoning. In such cases, when anaemic, bullock's blood, 
 fresh or in solution from dried preparations, may be used to advan- 
 tage per rectum. 
 
 The psychotherapy of each case demands a special study, and ab- 
 solute neglect of moral agencies, even in stupor, is a mistake. Con- 
 stant efforts to occupy and to divert patients are to be continued, 
 and are to be redoubled at the critical turning point between the acute 
 stadium and the convalescent stadium. 
 
 Section II. — Puerperal Insanity. 
 
 Ten per cent, of all mental diseases in women are developed in 
 connection with the critical function of the reproduction of the spe- 
 cies. All mental disorder appearing with this physiological crisis is 
 termed puerperal Insanity, which in turn is best subdivided as fol- 
 lows: 
 
 1. The Insanity of gestation, which occurs at any time between 
 conception and the parturient act, and constitutes about 1.5 per cent, 
 of the entire numerical amount of alienation in women. 
 
 2. The Insanity of parturition and of the puerperium. The lat- 
 ter averages six weeks from the completion of labor through the 
 chief part of uterine involution. The Insanity of this crisis forms 
 six per cent, of the sum total of mental disease in women. 
 
 3. The Insanity of lactation, appearing any time from six weeks 
 post partum to the end of nursing, and having a ratio of 3.5 per cent, 
 in the total causation of mental disorders in the sex. 
 
 The percental figures here given are based on tabular statements 
 of causation in American and British Reports of Hospitals for the 
 
IlSrSAlSriTY WITH THE PHYSIOLOGICAL CRISES. 617 
 
 Insane, and they fall somewhat below those given by Continental 
 writers. 
 
 The Insanity of gestation is a small fraction here of the whole 
 amount of puerperal Insanity in hospitals for the insane, but, in fact, 
 it has a larger statistical importance. Cases of alienation at this 
 period are not fully diagnosed, on account of the frequent vagaries 
 of pregnancy, and are often not taken to institutions for various 
 reasons. 
 
 Definition. — Puerperal Insanity is mental disorder developed by 
 the critical functions of gestation, parturition, or lactation, assuming 
 maniacal, melancholic, or stuporous types in the main, and manifested 
 by hallucinations of special and common sensation, by delusions of 
 impulsive and dangerous character, by perversion of feelings, infan- 
 ticidal, suicidal, or homicidal tendencies, and by a rapid sequence of 
 psychic and somatic symptoms, which are characteristic not individ- 
 ually, but in their collective groupings. 
 
 Clinical Delineation. — During the reflex irritations and circula- 
 tory adjustment of the first half of gestation excitement of a pseudo- 
 hysterical kind, with loud complaints and unrestrained emotional out- 
 breaks, and impulsive and unreasonable conduct occurs. The mental 
 disorder during this first four months of pregnancy may also take 
 the form of depression with morbid fears, loss of conjugal affection, 
 pica and depraved appetite, or anorexia, abstinence and emaciation, 
 and tedium vitse and suicidal impulses. During the latter half of 
 gestation maniacal or melancholic phases also may appear and pre- 
 sent much perversion of f eelinsr, hatred of family or husband, suspi- 
 cious delusions, ideas of poisoning, and homicidal impulses. 
 
 The mental disturbance of the first half of pregnancy sometimes 
 disappears, when there is an end of morning sickness and quickening 
 occurs, and the first adjustment of the system to the new order of 
 things has been accomplished, just as the Insanity of the second half 
 may cease upon delivery of the child. 
 
 The mental disorder of parturition springing from powerful and 
 painful commotion of nervous centres or from direct toxic effects 
 is usually sudden and violent, of maniacal type, with active halluci- 
 nations, incoherence, and turbulent activity. The severe aberrations 
 thus provoked by the parturient act may be of hours' or days' duration 
 only, or may pass into more prolonged states of alienation. • 
 
 The Insanity of the puerperium occurs mainly within a fortnight 
 after delivery, and more frequently within the first than the second 
 week of the puerperal state, though it embraces many cases within 
 
618 TEXT-BOOK ON MENTAL DISEASES. 
 
 the first six weeks of the lying-in period. The bulk of all the cases 
 are actively maniacal, but toward the close of the puerperal state and 
 of uterine involution melancholic forms are more frequent. 
 
 The maniacal cases have a wild flight of ideas and speech, mistake 
 persons and places, are hallucinated, emotionally agitated, gesticulate 
 and rush about madly, are profane or obscene, remove or tear their 
 clothes, can with difHculty be kept in bed or in the room unless 
 restrained. There is often rise of temperature during the first few 
 days after delivery, with frequent and wiry pulse and heavily coated 
 tongue and deranged secretions, and the mania may approximate 
 acute delirium and be due to toxic influences. Consciousness is much 
 impaired in some of these maniacal conditions, and automatic de- 
 struction of life and property may occur, with complete amnesia 
 of the events on recovery of the patient. This fact is important in 
 juridical relations in instances of infanticide or homicide during the 
 attacks. 
 
 The melancholic cases, toward the close of the puerperal state, ap- 
 pear anxious, restless, gloomy, and foreboding imaginary evils to the 
 child, or danger of life from poison or from enemies. They may 
 accuse themselves or others of crime, think they have committed the 
 unpardonable sin, attempt suicide by starvation, or by more active 
 means, and may kill the child to save it from some fancied terrible 
 fate. 
 
 The Insanity of lactation may occur before or after the weaning 
 of the child, and it is ordinarily associated with general debility, dur- 
 ing which phthisical or other diathetic states may develop. The types 
 of mental disorder are maniacal or melancholic chiefly, with stupor 
 intercurrent in many instances. Delusions and hallucinations of 
 sight and hearing of a painful character abound. Fear, anger, jeal- 
 ousy, and the depressive emotions predominate. The mental depres- 
 sion may reach the degree of stupor, with frightful hallucinations. 
 
 Perversion of maternal instincts and of that of self-preservation 
 may lead to the destruction of children and of self. 
 
 Gay and happy forms of mania are rare, and the melancholic 
 types are marked by explosive violence or painful states of stuporous 
 inhibition. 
 
 In rare instances secondary monomania or general paresis is the 
 outcome of the lactational state. 
 
 The unfavorable cases of puerperal Insanity graduate into termi- 
 nal dementia, some at the end of a few months, and others only after a 
 lapse of some years. The latter cases are apt to be tainted with he- 
 
INSANITY WITH THE PH"XSIOLOGICAL CRISES. 619 
 
 redity and to pass through a succession of remissions and exacerba- 
 tions before reaching the stage of fatuity. 
 
 Causes. — Hereditary predisposition exists in a certain number of 
 the cases, who during the lesser crisis of puberty may escape only to 
 succumb at the critical epoch of parturition. Previous attacks are 
 also powerful favoring circumstances, and some women develop men- 
 tal disorder with each successive pregnancy. 
 
 In primiparse, and especially in those who have passed the age of 
 thirty-five years, the reflex irritation of the rapidly expanding uterus 
 and the necessary systemic adjustment is a sufficient cause of derange- 
 ment of unstable nervous centres. Hemorrhages may also precede 
 labor, and abortions, miscarriages, and attempts upon the life of the 
 child in utero may have causative relations. Albuminuria and uriE- 
 mic states and auto-intoxications and hfemic deteriorations ante-par- 
 tum may be exciting causes. 
 
 Severe and prolonged labor, instrumental deliver}^ the administra- 
 tion of anaesthetics, multiple birth, extensive hemorrhages, death or 
 injury of the child, disappointment as to its sex, illegitimacy of the 
 oft'spring, and eclampsia are influences operative at the parturient 
 crisis. Following delivery there are frequent septic causes from reab- 
 sorption from uterine surfaces, from suppression of lochial discharges 
 or of the secretion of milk, and there are also occasionally mastitis, 
 endocarditis, perimetritis, and phlebitis, and undoubted states of au- 
 to-intoxication. 
 
 The etiological factors during lactation are general exhaustion 
 from the hyperlactation, impoverished blood with diminished red 
 blood-corpuscles and haemoglobin, general malnutrition, which not 
 infrequently develops latent phthisical tendency, uterine subinvolu- 
 tion, leucorrhcea, metrorrhagia, and local disease of reproductive or- 
 gans. 
 
 In some cases all the untoward influences of gestation, parturition, 
 and lactation are cumulative in the production of mental disorder at 
 this critical period. 
 
 Stadia. — In all forms of puerperal Insanity there is an initial 
 stadium, however brief it may be. During gestation this initial sta- 
 dium is one of ccen^esthetic depression, with irritability and vague 
 forebodings of evil, and general malaise, and then follows the stadium 
 acutum, whether it be the maniacal or melancholic state, with hallu- 
 cinations and delusions and other active symptoms. Sometimes this 
 stadium acutum is constituted by alternations of excitement and de- 
 
620 TEXT-BOOK ON MENTAL DISEASES. 
 
 pression and by changeful manifestations of the two states, and this 
 is more particular!}^ so in cases tainted with heredity. 
 
 Following the stadium acutum is ordinarily a stadium debilitatis, 
 a state of apathy and weakness, even though flesh may be gained dur- 
 ing this stage, which has the appearance of mild stupor in some cases. 
 
 Then follows the convalescent stadium in regular order, and with 
 steady advance or fluctuating advance, with slight recurrences for 
 some weeks, but ending in recovery, which is ordinarily complete. 
 
 In exceptional cases the stadium acutum is one long continuation 
 of melanchoHc stupor with active inhibition and hallucinations of a 
 painful nature. 
 
 The sudden maniacal outbreaks at parturition are the stadium 
 acutum of attacks, which it will nearly always be found were preceded 
 by a distinct initial stadium before the parturient act. The convales- 
 cent stadium -may be more brief even than the other stadia in these 
 extreme cases, which still will be found to form no exception to the 
 rule as regards the clinical progression of the mental disorder, how- 
 ever brief it may be. 
 
 There is no difficulty in tracing distinct stadia in the Insanity of 
 the puerperium, and during lactation the initial stadium is often 
 prolonged for weeks, and the acute melancholic stadium often lasts 
 many months, and the convalescent stadium is also more gradual than 
 in other forms of puerperal Insanity. 
 
 Even in the maniacal explosions of the act of parturition careful 
 inquiry will often reveal an initial stadium previous to parturition — 
 a state of heightened expectancy and dread of the approaching crisis, 
 with insomnia and restless irritability, and other prodromes of the 
 attack, which may follow with the apparent abruptness of mania tran- 
 sitoria. 
 
 In unfavorable cases a stadium dementiae takes the place of the 
 stadium convalescens. 
 
 Symptoms. — It is not necessary to repeat the symptoms of the 
 ordinary maniacal, melancholic, and stuporous states of puerperal 
 Insanity. It is important to note that they alternate and that the 
 stuporous symptoms are almost invariable sequels of the acute 
 maniacal or melancholic states. 
 
 That a latent general paresis may be developed or possibly orig- 
 inated by the prolonged toxic conditions of the latter part of gesta- 
 tion and the early puerperium is also noteworthy. The symptoms of 
 puerperal Insanity are characteristic not singly, but collectively, con- 
 sidered at certain critical epochs. 
 
INSANITY WITH THE PHYSIOLOGICAL CRISES. 621 
 
 Thus, in a ease of puerperal mania a week after parturition may 
 be witnessed such a collective grouping of symptoms as the following: 
 The face is pale and haggard, with dark circles about the eyes, which 
 have an unnatural brilliancy and wild expression, the skin is moist, 
 the tongue coated, the breath offensive, the bowels constipated, the 
 lochia may be suppressed, there may be high temperature, restless 
 excitement, attempts to jump out of bed or out of the windows, 
 violent resistance, exposure of person, obscenity, constant calling to 
 imaginary persons, changing hallucinations and delusions, mistaking 
 of persons, rapid repetition of single words or phrases, and an inco- 
 herent jumbling of present impressions and past memories in the 
 incessant loud talking, and perversion of affection is manifested by 
 violence toward children or husband. Incendiarism, self-mutilation, 
 or general destructiveness may occur if the patient is not restrained. 
 
 In the Insanity of lactation there may be presented a somewhat 
 different group of symptoms. There is emaciation, dilated pupils, 
 subnormal temperature, anaemia, vertical headache, intercostal neu- 
 ralgias, amenorrhcea, cough and phthisical tendency, despondency, 
 religious gloom, vague fears, suicidal tendencies, delusions of poison 
 or persecution, or of danger impending to children, who may be sac- 
 rificed to save them from some terrible fate. Violence is less impulsive 
 and more delusional and premeditated than in the maniacal forms, 
 and amnesia after recovery is rare as regards the events of the attack. 
 
 The apathetic states of the stadium debilitatis, following the acute 
 stage, are due simply to exhaustion, and are not to be confounded 
 with the stuporous states, which are hallucinatory and constitute 
 often a part of the acute attack. 
 
 The local affections of the reproductive organs, the changes in 
 the blood and urine, in the secretions and excretions, in circulation 
 and general metabohsm, give a varied somatic symptomatology, 
 which, taken in connection with the psychic symptoms, furnish types 
 familiar to those who have treated many cases of puerperal Insanity. 
 
 Pathology. — Puerperal Insanity beginning within a fortnight of 
 dehvery is probably, in the majority of cases, of septic origin. The 
 sudden and violent symptoms, the changes in temperature, the inflam- 
 matory complications, the infarcted lungs, liver, and kidnej'-s found 
 in fatal cases all point to septic reabsorption from uterine surfaces. 
 
 Other toxic influences are found in the albuminuria and uremia, 
 and in kidney affections and deteriorated hsemic states. These latter 
 states prevail before parturition. During lactation the impoverished 
 blood-supply, dystrophies, uterine subinvolution, cachectic and 
 
622 TEXT-BOOK ON MENTAL DISEASES. 
 
 phthisical conditions, and a culmination of all the previous psychic 
 and physical causes form the pathological basis of the mental disease. 
 
 Differential Diagnosis. — The occurrence of Insanity in connec- 
 tion with gestation, parturition, or lactation suffices for the diagnosis 
 in most cases. The possibility of the crisis acting as an exciting 
 cause of general paresis requires to be borne in mind. 
 
 Phthisical Insanity follows the pulmonary disease, but during 
 lactation the mental disorder usually precedes the lung trouble. The 
 history of the case, and the order of occurrence and grouping of- the 
 physical and mental symptoms are sufficient for the differential diag- 
 nosis, which seldom presents any difficulty. 
 
 Prognosis. — The prognosis as to recovery is good. About sixty 
 per cent, of the cases perfectly recover. The favorable elements in 
 the prognosis are, first, age from twenty to thirty years, since the 
 ratio of recoveries in general diminishes steadily from thirty to forty 
 years. Secondly, the acute cases occurring within ten days of par- 
 turition are more favorable than those appearing at a later period, 
 and the Insanity of the puerperium is more curable than that of 
 lactation. The maniacal forms are attended by a higher recovery- 
 rate than the melancholic types' at all periods of the reproductive 
 crisis. The hope of recovery diminishes rapidly after the second at- 
 tack of puerperal Insanity. Early treatment is essential to prompt 
 recovery, and the prognosis is correspondingly bad in cases which 
 have been neglected some weeks. 
 
 More than fifty per cent, of the cases recover within the first six 
 months, and the prognosis may be considered bad after the first twelve 
 months of the mental disease. 
 
 The mortahty is considerable and increases rapidly with age, and 
 is, on the average, probably not far from ten per cent, of all cases 
 attacked. 
 
 Treatment. — The first indications are for the relief of insomnia 
 and physical exhaustion. Chloral is the most efficient remedy for the 
 former, and for the latter concentrated nourishment is the best stim- 
 ulant, though in cardiac failure alcohol is to be given. Forced feed- 
 ing without delay with predigested foods is often a necessity. The 
 secretions and excretions next demand attention. The milk, lochia, 
 urine, and intestinal discharges often present indications which are 
 urgent. Obstipation and fecal impactions especially are to be at once 
 removed. Measures are to be taken to relieve uterine disease or other 
 local causes of reflex irritation. 
 
 Concentrated food in generous quantities is all that is required 
 
INSANITY WITH THE PHYSIOLOGICAL CKISES. 623 
 
 in some cases of ansemia from post-partum hemorrhage, but iron may 
 be given sometimes to advantage, and it is always useful in the anse- 
 mia of lactation. Tonics are to be used judiciously and stimulants 
 sparingly in these cases. Hydrotherapy has its applications. Warm 
 baths replace sedatives to a great extent. Massage and electricity are 
 of some avail, and in amenorrhoea and subinvolution their local use 
 may be effective along with general treatment. 
 
 Hygienic measures are of prime importance, and isolation from 
 family surroundings is needful in the prolonged cases, though brief 
 attacks of a few weeks may be treated at home. Out-door treatment 
 is necessary in the lactation cases, and change of climate for this pur- 
 pose and to combat phthisical tendencies may be in order. The almost 
 universal defects of nutrition are best treated by small doses of arsenic, 
 in addition to a varied and easily digested diet, and cod-liver oil, if 
 well borne, along with malt extracts and peptonized foods. 
 
 In the stadium debilitatis following the acute stadium, counter- 
 irritation to the back of the neck, the electric cautery, lively attempts 
 at diversion, electricity, and other active measures are to be employed 
 to prevent the patient from sinking into secondary dementia, whigh 
 is then impending. 
 
 Section III. — Climacteric Insanity. 
 
 The involutional crisis of the menopause is a more severe consti- 
 tutional trial than puberty or parturition, and a more active cause of 
 mental disturbance. This influence is operative during the decade 
 of the menopause, forty to fifty years in the sex, and still it accounts 
 for four per cent, of all cases of mental disease in women. At the 
 Willard State Hospital, out of a total of 1,317 women, the menopause 
 was the sole cause assigned in 3.6 per cent, of the cases. The returns 
 of other State hospitals give a somewhat larger percentage. Exclud- 
 ing the concurrent etiological factors of coarse brain disease, intem- 
 perance, and recurrences of mental disorder at the climacteric, the 
 percentage given (four per cent.) approximates closely the actual pro- 
 portion of Insanity due directly to the crisis of the menopause. 
 
 It must be admitted that the decline of sexual activity and gen- 
 eral involutional changes during the decade fifty to sixty years in men 
 may be regarded in the light of a grand climacteric, as in women, 
 and that certain cases of Insanity in men at this epoch may be classed 
 as climacteric. It is true that the sum total of physiological condi- 
 tions is considerably different in the two sexes at this involutional 
 
624 TEXT-BOOK ON MENTAL DISEASES. 
 
 epoch, but the particular cause of melancholy — the sudden elimina- 
 tion from the mental life of the individual of the vast aggregate of 
 instinctive feelings and ideas correlative of the sexual function — 
 may be active in men through premature loss of sexual power and in- 
 clination at this period of life. The general systemic changes are 
 alike in both sexes at this crisis, and must be assigned some share in 
 the production of mental derangement, and the specific difference of 
 causation in the sex lies alone in uterine and ovarian involution. 
 
 Definition. — Climacteric Insanity is mental disorder developed in 
 connection with the general systemic changes of the climacteric in- 
 volution, and attended by coensesthetic depression, gloomy emotions, 
 painful perversions of sensation, marked vasomotor disturbances, al- 
 terations of the affective and intellectual faculties, and depressing 
 delusions. 
 
 Clinical Delineation. — The psychic outlines of most cases are con- 
 fined within the usual limits of states of mental depression. The mel- 
 ancholia may become so acute as to attain to maniacal exacerbations, 
 or in very exceptional instances to pass into stupor. In the main, 
 reasoning states of despondency, with a tendency to introspection 
 and self-analysis, prevail. In men, self-pity and hypochondriacal 
 exaggeration of symptoms and complete mental and physical anen- 
 ergia are to be observed. In women the restless anxiety often assumes 
 the form of melancholia agitata. There is considerable commotion 
 in the ideal and emotional spheres representatively correspondent to 
 the reproductive organs undergoing involution. There is usually 
 enough self-control to inhibit the grosser salacity of thought and feel- 
 ing, but the erotic tendencies are evident and provoke self-reproach 
 and self -mutilation in some cases, and in other instances they lead to 
 sensorial delusions and accusations of sexual outrages perpetrated at 
 night by men, or by his Satanic Majesty. In one case the latter de- 
 lusion persisted for nearly a year. There is a vicarious discharge of 
 religious feeling and intensified observances of penitence and prayer. 
 Self-accusations and the conviction of the unpardonable sin and of a 
 soul eternally lost often lead to despair and suicidal attempts. 
 
 Fifty per cent, of the cases are suicidal in feeling, but lack the 
 energy to consummate the act, but many weak and abortive overtures 
 toward self-destruction are made, and the possibility of " felo de se " 
 is always present. Homicidal impulses are rare. Sensorial perver- 
 sions are common, and delusions arise in connection with the hallu- 
 cinations of sight, hearing, and smell. One patient saw the blue light 
 and smelled the sulphurous fume, which announced that she was 
 
INSANITY WITH THE PHYSIOLOGICAL CRISES. 625 
 
 to be " burned everlastingly in hell-fire." Primordial delusions some- 
 times arise. Patients are engrossed with their hallucinations and de- 
 lusions, and are indifferent to relatives and to all the interests of life, 
 and it is almost impossible to divert them from their painful self- 
 j)reoccupation. In occasional instances insane jealousy of the hus- 
 band, or pseudo-cyesis, or perversion of the maternal instinct and 
 infanticidal impulses may appear. Morbid impulses, impellent ideas, 
 and a sense of relief after some explosive violence of action are not 
 infrequently witnessed. 
 
 Causes. — It is necessary to eliminate certain etiological factors, 
 which may be active at this period, such as alcoholic indulgence, pre- 
 vious attacks of Insanity, cerebral softening or tumors, and recur- 
 rences of mental disturbance in periodical melancholia, for such cases 
 belong to alcoholic and periodical Insanity and organic dementia. 
 
 It is to be admitted that a predisposition to Insanity may have 
 been inherited, though not previously developed, and that the con- 
 stitutional stress of the menopause itself is adequate to provoke the 
 latent tendency. 
 
 The peripheral impressions, feelings, and ideas from the repro- 
 ductive organs fill a large place in the mental sphere, and when they 
 disappear through the involution of these organs at the climacteric 
 epoch there naturally results a disturbance of the mental equilibrium. 
 This is a noticeable feature at this crisis in most persons, and in some 
 the mental perturbation reaches the point of Insanity. Just as the 
 balance of the mental faculties may be lost at the crises of puberty or 
 parturition, so the perfect co-ordination of these faculties may be 
 overthrown by the extensive changes of the climacteric. 
 
 It is not difficult to conceive that this obliteration of reproductive 
 functions and of their representative sentiments and psychical equiv- 
 alents should result in aberration in women. But it is less evident 
 that alienation is favored so directly in men, in whom the organic 
 involution of the generative system is much more gradual. 
 
 It is confirmed by clinical observation that there is from fifty to 
 sixty years in some men, especially in those who have made sexual 
 gratification a chief pleasure and aim in life, a practical loss of sexual 
 competency and a functional ablation of all sexual pleasures and 
 sentiments. When this loss of sexual power and interest is sudden, 
 existence becomes apathetic and gloomy, and any latent tendency to 
 hypochondriacal melancholia is developed. 
 
 Both in men and women some etiological weight is to be given to 
 
 the involutional changes in the entire organism at this climacteric 
 40 
 
626 TEXT-BOOK ON MENTAL DISEASES. 
 
 epoch. Psycliieal influences are also to be considered. There is the 
 fact of sterility or impotence, which is depressive, the fear in women 
 that they will cease to be objects of attention or admiration, that other 
 women may supplant them in their husband's affection. 
 
 One woman worried herself into Insanity over a slight growth of 
 hair on her face, at this period of life, since she was sure it made 
 her an object of aversion to her husband, and many women grieve 
 over the loss of good looks or obesity at this age, for to some society 
 women loss of admiration is like loss of life. The actual physical suf- 
 ferings and organic diseases developed by the involutional epoch are 
 also to be regarded as contributory causes. 
 
 Stadia. — Close inquiry will seldom fail to discover an initial sta- 
 dium of some weeks' or months' duration. The patient is restless, 
 anxious, and gloomy. The sum total of subconscious impressions is 
 painful, and coengesthetic depression forms the chief feature of the 
 initial stadium. 
 
 The stadium acutum is melancholic in three-fourths of the cases, 
 and lasts from three months to a year or more, and there is then a 
 stadium convaleseens of weeks or months, ending in gradual and com- 
 plete recovery. But in the unfavorable cases there follows a stadium 
 dementise, or some secondary and chronic mental disorder of a mani- 
 acal type. In hereditary cases secondary monomania is not an infre- 
 quent termination. 
 
 The majority of all cases terminate in recovery within the first 
 twelve months. If the psychopathic tendency is strong in the family 
 the stadium acutum may have alternating phases of excitement and 
 depression, or even intercurrent stuporous states. 
 
 Not only the stadia, but the entire clinical progression of the men- 
 tal disease may be exact repetitions of hereditary types of ahenation 
 appearing only at the menopause. In these cases morbid expectancy 
 may have causative influence, since the daughter feels that she is 
 predestined to succumb at this critical age, like her mother and her 
 grandmother before her. When the stadium acutum takes the form 
 of agitated or resistive melancholia it is apt to be prolonged for a year 
 or two before recovery, and a stadium dementige is not an infrequent 
 termination in these cases, which are generally unfavorable. 
 
 The stadia, in the aggregate, are shorter in the maniacal than in 
 the melancholic types. 
 
 Symptoms. — The most constant symptom is the painful . coenges- 
 thesis due to the abnormal impressions from the organic periphery. 
 The brain does not take cognizance of these peripherally initiated 
 
INSANITY WITH THE PHYSIOLOGICAL CRISES. 627 
 
 impressions so long as they- are customary and normal, but the invo- 
 lutional excitations from sexual sources force themselves into con- 
 sciousness in a most painful manner. This painful coensesthesis 
 forms the basis of the prevailing melanchohc mood and accounts for 
 the permanent irritability of temper. 
 
 Next in constancy and importance is the vasomotor disturbance, 
 shown in the vertiginous attacks, muscse volitantes and blurred vision, 
 cerebral hyperpemia and anaemia, flushes of heat and cold^ cutaneous 
 ischasmias and inequalities of circulation, pulmonary and hepatic con- 
 gestion, uterine engorgements, pseudo-dysenteries, persistent ceph- 
 alalgias, and profuse discharges from sexual organs. 
 
 The cutaneous paraesthesia are marked sources of delusions. The 
 sensorial anomalies are chiefly auditory, visual, and olfactory halluci- 
 nations. The delusions arise from sensorial perversions in part, and 
 are also the outcome of the predominant mood of melancholy. Their 
 erotic and religious tinge is physiologically based on the actual invo- 
 lutional changes in the sexual organs, and the cortical relations of 
 sexual and religious emotions. 
 
 Amnesia arises from apathy and inattention, and upon recovery 
 there is usually a connected memory of the main events of the attack. 
 
 The sudden gusts of emotion are the spasmodic liberations of 
 feeling from cortical centres on account of the vasomotor and nutri- 
 tional inequahties. 
 
 Alcoholic indulgence, common at the climacteric, greatly height- 
 ens the explosive nature of the symptoms. 
 
 The morbid appetite and craving for stimulants and artificial ex- 
 citants is only an instinctive longing for relief from the coensesthetic 
 depression. The violent actions are performed chiefly under the 
 influence of distressing delusions, but occasionally from actual per- 
 version of the instincts, of the love of life, and of offspring. 
 
 Trophic anomalies are not uncommon, pigmentations of the skin, 
 hypertrichosis, progressive emaciation or abnormal deposits of fat, 
 or reabsorption of the panniculus adiposus, the formation of new 
 growths in the reproductive organs, and in women a change in the 
 metabolism of the whole organism, and an occasional tendency to 
 malignant formations in uterine or mammary tissues. 
 
 When the complete physical readjustment of the climacteric has 
 been accomplished, there is a corresponding restoration of mental 
 equihbrium, but both mental and physical life is then carried on at 
 a lower level. Patients recover, but they have suffered physical and 
 psychical eviration and defemination. 
 
623 TEXT-BOOK ON MENTAL DISEASES. 
 
 Pathology. — The connection between neuroses and disorders of 
 the sexual system has long been recognized, and that the climacteric 
 changes and morbid states of the reproductive organs may excite 
 mental disturbance is not to be doubted. 
 
 Predisposition unquestionably exists in a considerable percentage 
 of all the cases, but still the involutional crisis is the exciting cause. 
 
 Considerable influence is exerted by the vasomotor and trophic 
 anomalies in the pathogenesis of chmacteric Insanity. 
 
 The general involutional changes of the entire organism are also 
 to be included among the pathological factors of the psychosis. 
 
 Differential Diagnosis. — Climacteric Insanity is to be differen- 
 tiated from periodic melanchoha by the history and mode of the devel- 
 opment of previous attacks. 
 
 It is to be distinguished from organic dementia arising at the cli- 
 macteric by the presence of coarse brain disease in the latter. When 
 alcoholic indulgence provokes the psychosis, the latter is to be classed 
 as toxic rather than climacteric. 
 
 Eecurrent mania coincident with the menopause is not to be rec- 
 ognized as chmacteric Insanity. Epilepsy first appearing at the 
 change of life subsequent to the psychosis does not modify the diag- 
 nosis, which is climacteric rather than epileptic Insanity, but the 
 reverse is true should the neurosis precede the psychosis. 
 
 Prognosis. — The general prognostic chances in climacteric In- 
 sanity may be stated in a few words. Fifty per cent, of all cases 
 treated recover. The recovery takes place, in the majority of cases, 
 within seven months, and nearly ninety per cent, of the recoveries 
 occur within the first year of the attack. The earlier the treatment 
 is begun the more ftivorable is the issue. 
 
 Climacteric Insanity developing after fifty years of age in women 
 is unfavorable in prognosis. 
 
 The presence of hereditary predisposition renders the perma- 
 nency of the recovery doubtful. 
 
 The prognosis as to Ufe is in general favorable. The mortality 
 among men is greater than among women patients, and it is among 
 the latter about twelve per cent, and arises from intercurrent disease 
 rather than from exhaustion due to the mental disorder. 
 
 Direct heredity predestines some women to recovery and others 
 to chronieity. 
 
 The chronic cases often survive many years and may attain old 
 age. Partial recovery results in about fifteen per cent, of the cases, 
 and a certain usefulness and enjoyment of home life is possible in 
 these instances. 
 
INSANITY WITH THE PHYSIOLOGICAL CRISES. 629 
 
 Unfavorable elements of prognosis are chronic organic diseases, 
 phthisis pnlmonalis, cardiac affections, uterine or ovarian tumors, or 
 the gouty or rheumatic diathesis, or a history in men of excess in 
 " venere et baccho." 
 
 Treatment.- — Home treatment is seldom successful, and isolation 
 for a time from all home influences is desirable. 
 
 The object is to conduct the patient through the crisis of the 
 change of life, and to assist nature in the readjustment in progress, 
 and active or abortive attempts at the limitation of the psychoses are 
 out of the question. Hydrotherapy suffices to procure sleep in con- 
 junction with life in the open air and a nourishing diet. 
 
 Forced alimentation is to be systematically carried out, for ano- 
 rexia and refusal of food or partial starvation is the rule in these cases. 
 When the need of a hypnotic is imperative chloral and bromide of 
 potassium, equal parts, give relief. The bromides diminish the par- 
 aesthesice and the general restlessness, but in the long run, if used 
 in efficient doses, they influence the course of the mental disorder 
 unfavorably and favor chronicity. Opium acts favorably in some 
 cases, but soon becomes a habit and a positive hindrance, and the same 
 is true of alcoholic stimulants, which are to be avoided. 
 
 Digitalis, to sustain cardiac action, is at times indicated, and ar- 
 senic, for its effect on general nutrition, and valerianate of ammo- 
 nium, for the nervous agitation. Cannabis indica may be of service 
 in the cephalalgias, which, if of the anaemic variety, are met with 
 iron and small doses of camphor. 
 
 Climatic influences are important, and the state of the heart and 
 lungs is to be considered in the choice of a climate. Out-door treat- 
 ment is the most important hygienic measure. 
 
 Occupation and diversion and other psychotherapeutic means aid 
 greatly in the cure. The mistake of a too early return to family re- 
 sponsibilities and household cares is to be avoided, for recovery after 
 a relapse is the exception. 
 
 Section lY. — Senile Insanity. 
 
 The natural decay of the powers of mind and body begins at an 
 earlier age than is usually admitted. 
 
 Muscular activity and endurance decline rapidly after the thirtieth 
 year, and after the fortieth year there is no longer fitness for competi- 
 tion in feats of strength and agility. At forty-five years a gradual 
 retroorade metabolism of the entire orsranism besrins. Fat is substi- 
 
630 TEXT-BOOK ON MENTAL DISEASES. 
 
 tilted for higher forms of tissue, and fatty degenerations of the vas- 
 cular system are already well under way at the fiftieth year, though 
 perhaps not yet interfering with circulatory functions. The heart 
 increases in size, hut diminishes in inherent force, and there is les- 
 sened vigor of the organic muscular system. The fullest facility of 
 memory and imagination, the readiness of acquisition of knowledge, 
 the chief mental endurance, the originative power of mind are 
 things of the past at the sixtieth year. 
 
 Premature senility (senium prsecox) begins in some instances as 
 early as the fiftieth year. Senile involution is generally admitted to 
 date from the sixtieth year, and this is ordinarily the critical epoch 
 at which the retrogressive changes of the muscular, vascular, and 
 nervous tissues begin to result in evident failure of functions. 
 
 Normal senile involution is a gradual decline of all the powers of 
 body and mind, ending in second childhood — a condition too familiar 
 to require description. Instead of a gradual diminution of the mental 
 powers there may be sudden failure of the faculties, or marked per- 
 turbations of thought and feeling, or turbulent commotions of the 
 whole mental and moral being. This is senile Insanity from patho- 
 logical senile involution, and it may appear at any time after the six- 
 tieth year, or after the fiftieth year in senium prgecox. 
 
 Definition. — Senile Insanity is mental aberration arising in con- 
 nection with the cerebral atrophic changes and general systemic alter- 
 ations of the involutional crisis of senility, and manifested not only 
 by general failure of the mental powers, but also by sudden melan- 
 cholic and maniacal reductions, by hallucinatory and delusional per- 
 versions, and by varied mental disorder, modified by the existing fac- 
 tors of the crisis. 
 
 Clinical Delineation. — Senile dementia presents the most typical 
 transformation of physiological into pathological changes in old age. 
 The natural diminution of appetite becomes sitophobia, the wakeful 
 habit active insomnia, the forgetfulness amnesia, the hesitancy of 
 speech aphasic trouble, the timidity morbid fear, the tardy recogni- 
 tion of persons the absurd mistaking of personal identity, the irrita- 
 bility violent passion, the indifference to personal appearance sloven- 
 liness, the talkativeness constant garrulity and reiteration, the ego- 
 tism irrational boastfulness, and diminished faculty of adaptability 
 to the environment complete helplessness. 
 
 The old man with waning powers of mind and body thus becomes 
 gradually the typical senile dement. If this transformation is very 
 gradual there is difficulty midway to mark the point at which the 
 
INSANITY WITH THE PHYSIOLOGICAL CRISES. 631 
 
 Insanity may be said to begin. In many cases the symptoms of senile 
 dementia are of sudden appearance, leaving no room for doubt as to 
 the point of inception of the pathological mental change. Senile 
 dementia is perhaps the most typical form of senile Insanity. It is 
 distinguished from other kinds of dementia simply by the totality 
 of the senile conditions under which it arises, and in the same way 
 melancholia and mania at this senile epoch are modified by the total 
 involutional changes in pathological circumstances of this particular 
 crisis. 
 
 The loss of memory, disturbances of speech, muscular tremor, and 
 childish extravagance of ideas in some senile cases suggest general 
 paresis, and in still more exceptional instances there are reasoning and 
 monomaniacal conditions. 
 
 The arterial degenerations favor hemorrhages and localized soft- 
 enings of the brain, but all mental enf eeblement resulting from such 
 coarse brain disease is to be classed as organic dementia, under which 
 head it is described. 
 
 If there be well-marked heredity, alternating states of excitement 
 and depression, and frequent remissions of symptoms become promi- 
 nent features of the senile Insanity. Heredity is presumably less at 
 this crisis than at earlier physiological epochs, and still it can be di- 
 rectly traced in about sixteen per cent, of the cases, which are wont 
 to present the varied outlines found in all other hereditary insanities. 
 Necessarily the complete phenomena of senile Insanity are complex, 
 but still there is a constant group of mental and physical symptoms of 
 the senile epoch itself, which impart a special character to the vari- 
 eties of mental disturbance at this crisis. 
 
 Causes. — There is an inherited predisposition to Insanity in about 
 sixteen per cent, of the cases. There is in other cases a predisposition 
 acquired by alcoholic indulgence, or by syphilitic taint, or by cumula- 
 tive stress of trying circumstances. In senility the power of recuper- 
 ation from all the shocks to which flesh is heir is greatly diminished, 
 and the youthful and vigorous resistance to the inimical forces with 
 which life is environed is in a great measure lost. The exciting 
 causes, therefore, of senile Insanity are both physical and mental and 
 extremely numerous. 
 
 The essential causes unquestionably are the involutional changes 
 in the vascular supply, and in the structural elements of the cerebral 
 nervous centres. Circulatory and nutritional alterations in cortical 
 regions exist previous to arterial and atrophic degenerations. Hence 
 the senile psychoses may be clinically classed into those which are 
 
632 TEXT-BOOK ON MENTAL DISEASES. 
 
 functional and those which are organic, and the frequent recovery 
 of the former and the invariable chronicity of the latter also sustain 
 this clinical division. 
 
 The epilepsy appearing at this epoch is epiphenomenal rather than 
 causative as regards the Insanity. 
 
 Stadia. — In typical senile dementia there is a long initial stadium 
 of progressive deterioration of mind, followed by an acute stadium of 
 unmistakable Insanity, during which violation of public decency, 
 or the appropriation of the personal effects of others may get the 
 patient into legal trouble. The stadium acutum is attended in these 
 cases by remissions and exacerbations of excitement or depression, 
 which become finally hardly perceptible, and there is then a fijial 
 stadium dementise senilis, which terminates only with the life of the 
 patient. 
 
 In other types of senile Insanity there is a shorter initial stadium, 
 of a few weeks' duration, presenting anxious and restless states of 
 mind, anorexia, insomnia, and morbid suspicions and fears, followed 
 by a stadium acutum of decided maniacal or melancholic character, 
 and with delusions and hallucinations and suicidal impulses. This 
 acute stadium may continue for weeks or months and graduate into 
 a final stadium dementise, or be followed by a genuine stadium con- 
 valescens. The convalescence in the functional senile psychoses is 
 sometimes surprisingly sudden and complete. The restitution nat- 
 urally is to the standard of mental health prior to the attack, and of 
 course implies no regression of the previous involutional changes. 
 
 In the hereditary cases the stadium acutum often extends over 
 one or two years, and is marked by alternations of maniacal and mel- 
 ancholic states, by semi-lucid intervals, by reasoning states of moral 
 perversion and irrestible impulses and suicidal attempts. There are 
 exceptional cases of homologous heredity at this crisis, in which there 
 is an exact repetition of symptoms of mental disorder alike in suc- 
 cessive generations, born to pass safely through other physiological 
 crises, only to succumb to mental disease at this final critical epoch. 
 
 Symptoms. — ^Allusion has already been made to the progressive 
 deterioration of mind in senile dementia. The amnesia is more espe- 
 cially for names, dates, and recent events, while past recollections 
 may remain unimpaired until the final stadium dementife. General 
 loss of impressionability and the bkmting of all the special senses 
 lead to inattention and lack of memory, so that gross errors of time, 
 place, and identity occur. Finally, there only remain childish remin- 
 
INSANITY WITH THE PHYSIOLOGICAL CRISES. 683 
 
 iscences, or a few personal facts permanently or,ganized in memory 
 by force of repetition in stories continually rehearsed. 
 
 The original and forcible use of language is early lost, but the au- 
 tomatic use of technical language by professional men may impose 
 an idea of intelligence which does not exist. A senile lawyer dement, 
 for long years incapable of self-care, by parrot-like repetition of legal 
 phraseology imposed on visitors the idea that he should be released 
 from confinement, but an examination into his mental state soon 
 revealed the absurdity of the imposition. In the same way there may 
 be an automatic appropriateness in replies to questions long after 
 independent thought has ceased, and while marked senile aphasia 
 exists. 
 
 Delusions of suspicion and persecution predominate in the early 
 stages and are fortified by hallucinations of sight and hearing. Per- 
 versions of the special senses precede their pathological diminution in 
 some cases. Thus parosmia and parageusia may precede anosmia and 
 ageusia in senile Insanity. The anosmia is often due to atrophic 
 processes of the olfactory bulb. The idea of poisoning may arise 
 from these perversions of taste. The visual hallucinations are to be 
 attributed to involutional changes and are often entoptieal, and the 
 same is true of the auditory perversions due to entotical senile con- 
 ditions. Hyp^esthesia and anaesthesia and analgia are common in 
 the terminal stage. Paraesthesis of cutaneous surfaces lead to strip- 
 ping off of clothes and to picking the skin sore in places. 
 
 The extreme restlessness, the " anxietas tibiarum " of the initial 
 stadium, has its origin in heightened muscular sense, but the latter 
 is impaired finally and favors the ataxic conditions of senile Insanity. 
 The muscular tremor is a very constant symptom, and it is increased 
 on intentional effort. 
 
 Facial hemiparesis and temporary monoplegias may appear. Mus- 
 cular atrophy extends gradually to both voluntary and involuntary 
 muscles, though there may be cardiac hypertrophy followed by dila- 
 tation. Syncope occurs from cardiac failure. 
 
 The atrophic processes involve all the tissues, though the epi- 
 thelial and glandular structures are only affected at a late day. 
 
 The final stage of this general atrophy is senile marasmus. The 
 emaciation is often extreme. 
 
 The vascular degenerations may be first evident in the carotid 
 and basilar arteries, and in the cerebral vessels before the temporal 
 and radial arteries betray atheromatous change. Cataract and arcus 
 senilis are common precursory signs. 
 
634 TEXT-BOOK ON MENTAL DISEASES. 
 
 The rhytliin of sleep is changed to somnolence in the daytime and 
 insomnia at night. Bulimia is more frequent than anorexia. Intes- 
 tinal ansesthesia enables lifelong dyspeptics to eat voraciously with 
 impunity, and the wasting of tissues is perhaps the physiological ex- 
 planation of the gluttony. The sexual desire is increased to a morbid 
 degree, and with the presence of organic impotence there is libido 
 or even satyriasis. As ethical degeneration is often complete, there 
 result immoralities and legal offences in the sexual direction. Senile 
 parapraxia are both impulsive and automatic. Indecent exposure 
 of the person, sometimes leading to arrest, is automatic in many cases, 
 and as thoughtless as the general filthiness of habits of senile dements. 
 
 Loss of natural affection, selfish concentration of f eehng, impotent 
 anger, suicidal impulses, insane acquisitiveness and miserliness, un- 
 founded hatred and suspicion, and cruelty to children and animals 
 are also symptoms often observed. 
 
 The fundamental emotional tone is melancholic, due to the pain- 
 ful alteration of the coena?sthesis by the universal degenerative 
 changes. Even the maniacal states emerge from ccensesthetic de- 
 pression. Hebetude exists, but full stuporous states are rare, except 
 in connection with focal brain lesions. 
 
 The monomaniacal exaltations precede, ordinarily, the terminal 
 mental enfeeblement in hereditary cases. 
 
 There is something exceptional to note in senile Insanity origi- 
 nating in senium prgecox. In certain families senile decay begins at 
 fifty years, and the Insanity in some instances bears a close resem- 
 blance to general paresis in S3'mptoms and pathology. 
 
 The slowed speech of the senile dement arises from mixed causes, 
 such as dulness of comprehension, retarded association of ideas and 
 thought-rate, amnesic failure, and difficulty in the emissive sphere 
 of speech. 
 
 The articulation has the same feeble deliberateness and occa- 
 sional unsteadiness as the senile gait, and tremor of the voice from 
 defective diaphragmatic innervation is not uncommon. 
 
 Modifications of respiration, dyspnoea, slowed breathing, super- 
 ficial inspiration, modified respiratory rhythm are to be observed. 
 All the vital functions are enfeebled. 
 
 Pathology. — It has already been stated that there is an inherited 
 predisposition to mental disorder in a certain percentage of the cases. 
 Still, the pathology must be admitted to be the involutional changes 
 in the entire organism. The vascular degenerations and the cerebral 
 atrophic lesions naturally are foremost in pathogenetic consideration. 
 
INSANITY WITH THE PHYSIOLOGICAL CRISES. 635 
 
 Fatty and atheromatous changes in the cardiac and cerebral arteries 
 may alone be found post-mortem, but in other cases the radial, tem- 
 poral, and brachial arteries, and even the entire arterial system, may 
 have undergone degeneration, and this is especially true in cases com- 
 plicated with alcoholic excess. 
 
 The cortical atrophy is specially marked in frontal and motor, 
 regions, certain vascular areas sufEer more than others, and both 
 ganglionic elements and associative fibres are implicated. 
 
 In many cases not only the convolutions, but the medullary sub- 
 stance and the basal ganglia, are involved in the general atrophic and 
 sclerotic processes. Chronic pachj^meningitis, compensatory effu- 
 sions, foci of softening, miliary aneurisms, ependymitis, and lepto- 
 meningitis have been reported in these cases. Cellular pigmentation, 
 proliferation of protoplasmic glia-ceils, and leucocytes in the perivas- 
 cular spaces have also been recorded in these eases of senile Insanity. 
 Prior to these extensive pathological changes in the organic senile 
 psychoses there are decided vasomotor and nutritional derangements 
 in cerebral centres to account for the functional senile psychoses pre- 
 viously mentioned. 
 
 Differential Diagnosis. — ^AU the psychoses occurring during the 
 physiological crisis of senility and modified by the sum total of the 
 psychic and somatic conditions of the senile involution are to be re- 
 garded as senile Insanity. The differential diagnosis is to be made 
 from general paresis in senile dementia, with impaired speech and 
 memory and tremor with unsteady gait. The history and mode of 
 development differ. The senile dementia has a longer and milder in- 
 itial stadium, more painful moods and depressive ideas, suicidal ten- 
 dencies, different delusions, lacks the paretic reflexes, has a depressed 
 rather than exalted coen^esthesis, has not the paretic gait, has a more 
 gradual amnesic failure, lacks the spinal and ataxic symptoms, has 
 tremulous but rarely hesitating paretic speech, and still it presents 
 many points in common with general paresis. Senile Insanity with 
 senium prascox has so nearly the same symptomatology as general 
 paresis in certain cases that the diagnosis intra vitam is not possible, 
 and even post-mortem the appearances in nervous centres may be 
 much alike. 
 
 Prognosis. — The prognosis as to recovery in the functional senile 
 psychoses is not unfavorable from the mere fact of senility. Thirty 
 per cent, of such cases recover after maniacal or melancholic attacks. 
 The general condition of the patient and of the internal organs is to 
 be considered. In the absence of distinct organic disease, and in the 
 
636 TEXT-BOOK ON MENTAL DISEASES. 
 
 presence of a fair amount of physical vigor, recovery may be expected. 
 If there be hereditary tendency a relapse will probably occur after a 
 first attack, and a recovery from a second attack is doubtful. 
 
 The prognosis in the organic senile psychoses with degenerations 
 in arterial and nervous tissues is bad. There may be remissions of 
 many months, but complete recovery is not to be expected. 
 
 The prognosis of senile Insanity complicated with epilepsy devel- 
 oping at the involutional epoch is unfavorable. 
 
 Senile Insanity with senium prascox is practically incurable and 
 often terminates fatally in from two to four years. 
 
 The prognosis as to life is good in the functional senile psychoses 
 under proper care and treatment. In the organic senile psychoses the 
 duration of life is shortened by the mental disease, on the average, 
 though the patient may survive many years. 
 
 Treatment. — Isolation is necessary in most cases. Patients are 
 dangerous to themselves, if not to others. They run about and knock 
 against things, receive bruises, falls, and fractures. They are easily 
 injured and get extensive ecchjonoses and abrasions from restraint 
 by the hands of attendants. The recumbent posture and the restrain- 
 ing sheet are most practical at night, and incessant attendance in the 
 da}'i;ime is required. Warm baths and hot alcoholic drinks at bedtime 
 sometimes procure sleep. 
 
 Sulphonal is less dangerous than chloral in these cases. Occa- 
 sionally opium and digitahs relieve the ansemic insomnia. Forced 
 ahmentation is indicated in the majority of the cases with melan- 
 choha. A generous diet and predigested foods are all important. 
 Massage relieves the restlessness in connection with hydrotherapy. 
 Warmth, sunshine, care for clothing and personal cleanliness, the 
 relief of obstipation and of a distended bladder, night-care, day- 
 nursing, feeding and exposing to fresh air in appropriate weather are 
 the main indications in the confirmed cases. 
 
 Frequent physical examinations, and the treatment of gastric, 
 cardiac, renal, and pulmonary diseases constitute the routine of 
 psychiatric proceedings in these cases. 
 
CHAPTER Y. 
 
 INSANITY WITH GENERAL SYSTEMIC MORBID STATES. 
 
 Group : Toxic Insanity and Diathetic Insanity. 
 Section I. — Toxic Insanity. 
 
 About ten years ago the writer drew attention, in his published 
 writings, to the importance of toxic agents as etiological factors of 
 mental disorders, and in June, 1893, read a paper before the Ameri- 
 can Neurological Association on "The Toxic Origin of Insanity," 
 taking the view that a large percentage of mental disease is toxic. 
 The opinions then expressed have been abundantly confirmed by 
 subsequent writers on this subject, which has at the present day a 
 voluminous literature. 
 
 The toxic agent may be vegetable, animal, or mineral, and it 
 may be solid, liquid, or gaseous in form, and it may enter the system 
 by the ahmentary canal, the respiratory tracts, or the cutaneous 
 surfaces. It may be the toxalbumins of infectious diseases, or the 
 noxious products of catabolism in the organism, as in the auto-intoxi- 
 cations. 
 
 Whatever be the poison, the microbic infection, or the animal 
 virus, the resulting toxaemic state is apt to be attended by mental dis- 
 order, which varies chiefly according to the individual mode of reac- 
 tion to the toxic agent. 
 
 Definition. — Toxic Insanity is acute or chronic vesania, caused 
 by the medium of toxic substances acting on the eerebro-spinal or 
 sympathetic nervous system, and clinically manifested by -motor, sen- 
 sory, trophic, vasomotor, and psychic disorder, varying according to 
 the individual idiosyncrasy of reaction to the toxic agencies, whicli 
 have invaded or been generated in the organism. 
 
 Clinical Delineation. — Although the clinical manifestations in 
 toxic Insanity are extremely diversified, the chief features of the toxic 
 psychoses are readily outlined. 
 
 637 
 
638 TEXT-BOOK ON MENTAL DISEASES. 
 
 In the first place, there are acute intoxications from poisons, caus- 
 ing exaltation or depression of feeling, illusions, and hallucinations 
 of the special senses, sensorial delusions, and disturbances of memor}' 
 and consciousness. The mental disorder thus provoked may cease 
 with the physiological action of the toxic agent, only to be renewed 
 upon a second acute intoxication ; or a single exposure to the poi- 
 sonous action may initiate prolonged mental disease, as witnessed in 
 idiosyncrasy of reaction to alcohol, ether, or chloroform. 
 
 In the second place, there are chronic intoxications from poisons 
 intentionally taken, as in the wide-spread drug habits, or unavoida- 
 bly absorbed in certain occupations ; and these are attended by 
 gradual physical and mental deteriorations, interpersed with exacer- 
 bations of acute mental disorder. 
 
 In other instances acute psychoses are promptly developed by the 
 presence in the system of the virus of infectious diseases, and attacks 
 iiaving the form of acute mania or melancholia pursue a course to 
 recovery or to terminal mental enfeeblement. 
 
 Again, in the numerous auto-intoxications there are maniacal, 
 melaiicJiolic, or stuporous vesanise, passing through all the phases 
 and stages to complete convalescence, or to terminal dementia. 
 
 The above are, in brief, the general outlines and the clinical pro- 
 gression of the toxic psychoses. 
 
 As to the particular features of the mental disorder, the maniacal 
 types predominate over the melancholic, and the latter are more 
 frequent than the stuporous forms. The melancholic states are more 
 common in men than in women, and age has less influence than sex 
 in this regard; but whenever heredity is a distinct factor alternation 
 of excitement and depression becomes a feature. 
 
 Idiosyncrasy as to toxic influences is directly hereditary in some 
 cases, as in the instance of alcoholic parentage, which confers exces- 
 sive vulnerabiHty upon the offspring. It is probable that the mode 
 of reaction to toxic agents may also be influenced by heredity, and 
 it would seem that psychoses from opium and haschish abuse do not 
 present the same features among Turks and Anglo-Saxons, for in- 
 stance. Whether derived from parental source or dependent on for- 
 tuitous conditions, the individual reaction to toxic agents causes the 
 chief variation in the clinical aspects of the mental disturbance. Just 
 as the physiological efl'ect of alcohol is to cause expansive and agree- 
 able feelings in one and morose and quarrelsome moods in another, 
 so the pathological action of the same agent may result in happy types 
 of mania or sullen forms of melancholia. 
 
INSANITY WITH GENERAL SYSTEMIC MORBID STATES. 639 
 
 In their physiological effects there is a specific difference in poi- 
 sons as to the prevailing emotional mood excited, but in their patho- 
 genetic relations to Insanity they result in maniacal or melancholic 
 states more in accordance with individual and constitutional peculi- 
 arity. 
 
 In some toxic cases motor anomalies, in others sensory perver- 
 sions, and in others intellectual disorder may predominate, according 
 to the vascular areas and nervous tracts involved in the pathological 
 changes initiated by the poison. The cerebro-spinal lesions may give 
 rise to a symptom complex like that of general paresis. These pseudo- 
 pareses may be distinguished from general paresis only by the fact of 
 their frequent recoverability, but, in most instances, the clinical feat- 
 ures suffice for the differentiation, as will be later described. 
 
 Causes. — The etiological factor in all instances is the toxic agent, 
 which acts in two distinct ways. In the first place, it operates, by its 
 simple presence in the circulation, through immediate influence upon 
 the ganglionic elements of the cerebral cortex. All acute infections, 
 auto-intoxications, and most of the animal, vegetable, and mineral 
 poisoiis may excite mental disorder at once in this way. In the sec- 
 ond place, the toxic agent is causative through the permanent lesions 
 which it occasions in vascular, nervous, and connective tissues. It is 
 chiefly in this way that all the chronic poisonings lead to permanent 
 organic psychoses and to pseudo-pareses. 
 
 Some of the more common toxic agents which cause Insanity are 
 here named and classified: 
 
 I. Mineral Poisons and Drugs. — 1, Lead; 2, mercury; 3, arsenic; 
 4, chloral; 5, bromide of potassium; 6, iodoform; 7, paraldehyde. 
 
 II. Vegetable Poisons. — 1, Opium; 2, belladonna; 3, cannabis 
 indica; 4, hyoscyamus; 5, stramonium; 6, tobacco; 7, cocaine; 
 8, conium; 9, erythroxylon coca; 10, astragalus hornii; 11, secale 
 cornutum. 
 
 III. Intoxicants and ISToxious Gases. — 1, Alcohol; 2, ether; 
 3, chloroform ; 4, carbonic oxide ; 5, sulphurous-acid gas. 
 
 IV. Acute Infections and Diseases. — 1, Typhoid fever; 2, small- 
 pox ; 3, scarlet fever ; 4, typhus fever ; 5, diphtheria ; 6, cholera ; 
 7, puerperal sepsis ; 8, epidemic influenza ; 9, purpura ; 10, erysip- 
 elas ; 11, bubonic plague ; 12, lepra vera ; 13, lyssa humana. 
 
 V. Auto-intoxications. — 1, Leucomains ; 2, ptomains. 
 
 Some of these toxic agents only act upon special tissues, but most 
 of them deleteriously affect the entire organism, and their evil effects 
 continue long after their elimination from the system. A single ex- 
 
640 TEXT-BOOK 01^ MENTAL DISEASES. 
 
 posure to cliloroforni, illuminating gas, and other toxic agents may 
 result in a psj'cliosis, but ordinarily mental disturbance only follows 
 repeated exposures or chronic intoxications. 
 
 In order of numerical importance alcohol heads the list of toxic 
 agents, and in its remote and direct effects is causative of a large 
 percentage of all cases of Insanity. 
 
 In Eastern countries opium and haschish take the place of alcohol 
 in this respect, and morphinism is wide-spread in all civilized coun- 
 tries. In South America the excessive chewing of the leaves of ery- 
 throxylon coca containing hygrin and cocaine sometimes results in 
 mental disorder. 
 
 In Europe epidemics of ergotism have been attended with Insan- 
 ity due to the use of rye-bread. The toxic agent in this instance is 
 the sclerotium of claviceps purpurea which grows on secale cereale. 
 
 As regards ether and chloroform, the writer has seen acute psy- 
 {?hoses resulting both from a single ansesthetic administration, and 
 also from prolonged habit of the use of these poisons. 
 
 Sepsis in the puerperium, . especially; during the first ten days, is 
 the cause of acute maniacal attacks. Ptomains are to be found in 
 the urine. Scarlatinous and variolous poison may occasion acute 
 psychoses, prior even to the eruption, though much of Insanity from 
 acute infections is due to secondary lesions in nervons centres, com- 
 plicated with parenchymatous changes in spleen, hver, and kidneys. 
 
 Epidemic influenza is a frequent cause of Insanity, and the writer 
 has found extensive meningitic and cortical lesions in insane patients 
 who succumbed to the disease. 
 
 Auto-intoxications are very common, and due to the putrefactive 
 alkaloids, formed by the action of bacteria on organic matter, known 
 as ptomains; or to nitrogenous basic substances resulting from meta- 
 bolic changes in bodily tissues and called leucomains. 
 
 The presence of these autogenous poisons is the cause of a con- 
 siderable percentage of the acute psychoses, as well as of chronic 
 mental disorder. 
 
 Stadia. — ^Insanity from acute intoxications and single exposures 
 to toxic gases has a brief initial stadium of physical distress and coen- 
 sesthetic depression, followed by a stadium acutum of variable dura- 
 tion, and often prolonged for weeks, of maniacal or melancholic 
 syjaptoms, ending in a convalescent stadium, ordinarily leading to 
 gi'adua^ recovery. The preliminary intoxication is generally expan- 
 sive or gay, but the reverse state of depression almost invariably is 
 present in the initial stadium. 
 
INSAiS^ITY WITH GENERAL SYSTEMIC MORBID STATES 641 
 
 In chronic intoxications there is a long initial stadium of remit- 
 tent depressions, following culminations of poisonous effects, with 
 gradual change in character and the evolution of sensorial and intel- 
 lectual disturbances. There then follows a prolonged acute stadium, 
 which is virtually a stadium deteriorationis, a degeneration of the 
 entire physical and mental being, reflecting the general organic le- 
 sions in progress in the vascular, glandular, and nervous tissues. Then 
 follows a terminal stadium dementise, or a gradual stadium conva- 
 lescens. 
 
 In the acute psychoses due to infections the usual clinical progres- 
 sion of the mental disease appears in an initial stadium, a stadium 
 acutum, a stadium debilitatis, and a stadium convaleseens. 
 
 The stadium debilitatis is one of great 'mental enfeeblement, and 
 often passes directly into a stadium of terminal dementia. 
 
 Symptoms. — To illustrate the multiple symptomatology of toxic 
 Insanity, the varied states of mental disorder generated by alcohol, 
 as a typical toxic agent, may well receive attention. 
 
 First there is the acute intoxication with mental perturbation so 
 brief as not to be deemed Insanity — the gay and boisterous, maudlin 
 and lachrymose, sullen and violent moods, according to individual 
 reaction. 
 
 Then there are very mild forms of mental disorder, states of ccen- 
 pesthetic depression or exaltation. The symptoms are confined to per- 
 versions of sensation, illusions and hallucinations, often recognized as 
 such by the patient, loss of sleep and appetite, gastric disorder, ceph- 
 alalgia, subsultus tendinum at night, incubus, cutaneous partesthesise 
 and changeful emotions, which escape the control of the will. 
 
 Again, there are attacks of fully developed mania or melan- 
 cholia, with frightful hallucinations and delusions of suspicion and 
 persecution, suicidal and homicidal impulses, perversions of special 
 and common sensation, variations in pulse, respiration, and temper- 
 ature, mistakes in identity of persons, great agitation and sleepless- 
 ness, tremor, and occasional connilsive seizures. 
 
 Still another form is acute delirious mania, with wild excitement 
 and complete incoherence of ideas — a genuine delirium acutum — 
 often ending fatally in a few days. There is incessant hallucination, 
 automatic jactitation and violence, and spasmodic action of the entire 
 musculature, ending in exhaustion with rapid rise of temperature, 
 emaciation, and failure of the vital powers. 
 
 Contrasting strongly with the above types is the slow but deep and 
 
 progressive degradation of the moral nature in the chronic drunkard. 
 41 
 
642 TEXT-BOOK ON MENTAL DISEASES. 
 
 Intellectual disorder may not exist, apparently, but the patient may 
 be monstrously perverted, with loss of all natural affection for wife 
 or children, with violent tendencies, homicidal or suicidal impulses, 
 pyromaniac or kleptomaniac tendencies, and dangerous sexual and 
 brutal instincts. 
 
 Then, again, there is the terminal type, resulting from physical, 
 mental, and moral dissolution under the universal toxsemic influ- 
 ences, as witnessed in alcoholic dementia. 
 
 Finally, there are the alcohohc pseudo-pareses, which so nearly 
 resemble general paresis, but differ from it in the frequent recovera- 
 bility. 
 
 All the above types and symptoms of mental disorder caused by 
 alcohol may be developed *under the influence of other toxic agents, 
 as shown in the psychoses from toxic occupations and drug habits. 
 
 In the acute infections the maniacal sjonptoms predominate in 
 the incubatory and eruptive stage of the contagious disorder, and 
 melancholic and stuporous states attend the subsidence of the acute 
 infection. The maniacal state may attain the height of acute delir- 
 ium, and the stuporous reductions often reach the grade of complete 
 torpor. 
 
 In mental disease from typhoid fever the stadium acutum is fre- 
 quently a post-febrile hebetude, with amnesia from loss of power to 
 fix attention, confusion of time, place, and persons, and absence of 
 initiative or will power. Several instances of Insanity seen during the 
 fever took the form of melancholic delusions and hallucinations in 
 the absence of all delirium. Maniacal states are said to arise during 
 typhoid infection, but they have never been observed by the writer. 
 Post-influenzal insanities are mostly of the melancholic form, with 
 depressive hallucinations of hearing and suspicious delusions. 
 
 Hydrophobic Insanity is said to be of the maniacal order, and 
 erysipelatous aberration is also of this type, though pseudo-paresis 
 has also been reported from this source. The auto-intoxications are 
 more frequently associated with the maniacal and melancholic states, 
 but it is also claimed that general paresis develops upon a toxaemic 
 basis, and this may well be granted as regards the luetic virus. 
 
 Ergotism eventuates in melancholic and stuporous states, delu- 
 sions, amnesia, sensory disorders, cutaneous gangrene, convulsive 
 seizures, cramps, contractures, circulatory and respiratory disturb- 
 ances, ataxic shooting pains, trophic lesions of epithelial structures, 
 loss of tendon reflexes, and general emaciation. 
 
 Plumbism gives rise to melancholic, maniacal, stuporous, and 
 
INSANITY WITH GENERAL SYSTEMIC MORBID STATES. 643 
 
 demented states, and also to pseudo-paretic conditions. Nocturnal 
 delirium is a symptom, and there are also hallucinations of sight, 
 terrifying delusions, tremor, comatose and convulsive attacks, ex- 
 tensor paralysis, amaurosis from atrophy of optic nerve, wrinkling 
 of the face (Tanquerel), and marasmus. 
 
 Absinthism is said to differ from alcoholism by a greater convul- 
 sive tendency and heightened reflexes, and to end more promptly in 
 terminal dementia. 
 
 Astragalus hornii causes stuporous dementia, mydriasis, facial 
 pareses, blank countenance, and fixed, staring look. 
 
 Bromism leads to stuporous states, which may end in complete 
 fatuity. 
 
 Arsenicism, if severe, may end in dementia. In one case under 
 the writer's care there was a stuporous state, anaesthesia due to spinal 
 lesions, and paraplegia, from which there was a gradual recovery. 
 
 Morphinism results in amnesic states, affective perversion, irri- 
 table, suspicious, and fearful delusions, complete moral degeneracy, 
 suicidal impulses lacking force of execution, and distressing halluci- 
 nations on cessation of the drug, with cramps and vasoparetic states. 
 
 Cocainism develops a reasoning form of mental alienation, with 
 changeful hallucinations and corresponding delusions, anxious and 
 excitable moods, attaining melancholic states of agitation on with- 
 drawal of the drug, or even attacks of stuporous collapse. 
 
 Nicotinism in young subjects treated by the writer has given rise 
 to both maniacal and melancholic states, and in one instance to an 
 entire change in character resembling the moral degradation of 
 chronic alcoholism. 
 
 Bisulphide of carbon produces disorders of speech and memory, 
 disturbed vision, tinnitus aurium, muscular spasms, depressed moods 
 and delusions, and mental enfeeblement. 
 
 Pathology. — ^In acute intoxications there is the direct action of 
 the toxic agent on cortical centres to account for the mental dis- 
 turbance. 
 
 After repeated exposure to the poisonous influence, nutritional 
 and vasomotor disorders become complicating factors in the mental 
 disease. In the chronic intoxications organic lesions of vascular and 
 nervous tissues account for the symptoms of the psychosis. There is 
 an intermediate period, during which functional mental disorder and 
 that due to structural changes blend in a variety of ways. 
 
 Taking alcohol as a type of toxic agents, the structural alterations 
 are found to be atheromatous, and fatty degeneration of cerebral ves- 
 
644 TEXT-BOOK ON MENTAL DISEASES, 
 
 sels, proliferation of the protoplasmic glia-eells of the superficial cor- 
 tical layer, fatty changes in the motor cells of the fifth layer and of 
 the subjacent spindle cells, aneurismal dilatations of the minute cor- 
 tical arteries, pigmentation of ganglionic elements and degeneration 
 of apical processes, spinal lesions and sclerotic changes from without 
 inward of posterior and lateral columns, and changes in the vascular 
 supply of the cord. 
 
 Somewhat similar lesions are found in chronic intoxications from 
 lead and some other poisons, but no toxic agents produce constant 
 or uniform lesions, and individual peculiarity, and possibly inherited 
 tendencA'', modify the result both as to the morbid anatomy and the 
 mental phases of the psychosis. 
 
 Differential Diagnosis. — The history of exposure by special occu- 
 pations or by drug habits to the deleterious effects of poisons often 
 serves for diagnostic purposes. The whole train of sensory and motor 
 symptoms, taken with the psychic manifestations, also aids greatly 
 in the differential diagnosis. In ursemic, diabetic, and other toxic 
 states the examination of the urine reveals the toxic origin of the 
 Insanity. 
 
 In morphinism and other concealed drug habits the same test can 
 be applied, for nearly all toxic agents are present in the urine soon 
 after ingestion. 
 
 The differential diagnosis of the toxic pseudo-pareses from gen- 
 eral paresis is the most diflficult, but the history of the case, mode of 
 development and progress of the mental symptoms, and the actual 
 manner in which the entire manifestations are grouped usually suf- 
 fice for the differentiation. It is seldom that the same physical and 
 mental symptoms at once coincide in the two types, one of which is 
 curable and the other practically incurable. 
 
 Prognosis. — The prognosis as to recovery is good in all the acute 
 intoxications, Judged by the general average of results. Advanced 
 age, previous attacks, hereditary predisposition, and constitutional 
 diseases are bad prognostic elements as to recovery. The prognosis 
 in the chronic intoxications which have reached the stage of struct- 
 ural alterations is bad, and jei not unqualifiedly so, for occasional 
 recoveries still occur. 
 
 In mentwal disease from drug habits the prognosis is good upon 
 entire cessation of the drug, but a return to the habit is the rule, 
 and a recurrence of the mental disorder can be predicted in the ma- 
 jority of cases. The same is true of the occupation psychoses, which 
 
INSANITY WITH GENERAL SYSTEMIC MORBID STATES. 645 
 
 relapse if a change of occupation is not made to avoid exposure to the 
 special toxic agent. 
 
 The permanency of recovery depends, therefore, largely on the 
 degree of prophylaxis exercised in these toxic cases upon convales- 
 cence. 
 
 Treatment. — In all habitual and voluntary intoxications isolation 
 at home or in an institution is required. The weak point of home 
 treatment is that servants or relations procure the forbidden drug for 
 the patient. 
 
 The gradual or sudden cessation of the drug is a question to be 
 decided in each case, in accordance with the physical state of the 
 sufferer. 
 
 In poisonous intoxications the antidotal and eliminative remedies 
 are first in order, while the patient is sustained by supporting meas- 
 ures, concentrated nourishment in frequent and small quantities, and 
 tonic treatment. Purgatives, diuretics, Turkish baths, iodide of po- 
 tassium, and sulphate of magnesium are common means of elimina- 
 tion of the toxic substance. The motor paralyses are treated by mas- 
 sage and electricity, especially the galvanic current. 
 
 The acute maniacal and melancholic symptoms demand no differ- 
 ent treatment from that fully described in the general chapter on 
 therapeutic measures. The frequent violent and suicidal impulses 
 call for close personal surveillance both night and day. 
 
 The auto-intoxications are met by gastric lavage and by intestinal 
 antisepsis, in addition to general symptomatic treatment. 
 
 Predigested foods are here of much service, and artificial feeding 
 should be undertaken at an early day. In the alcoholic cases capsi- 
 cum and strychnine are of value, and the antidotal remedies vary 
 greatly in the different toxic insanities. The general principle is the 
 same in all — to support the patient by roborant treatment during 
 elimination of the poison, and then to persevere with active measures 
 during the tedious convalescence from the chronic intoxicaitions. 
 The mental recovery cannot be deemed complete until the general 
 physical health has been re-established on a firm basis, and until all 
 toxic sequelae have disappeared. 
 
 Section II. — Diathetic Insanity. 
 
 Disorder of the mind often arises in connection with the general 
 morbid state attendant upon such diseases as phthisis pulmonalis, 
 gout, rheumatism, pellagra, malaria, anaemia, cancer, lepra and m3rx- 
 cedema, and the Insanity is then termed diathetic. The course and 
 
646 TEXT-BOGKr ON MENTAL DISEASES. 
 
 symptoms of the mental disorder in this instance are often consider- 
 ably modified by the diathetic state, which also, in some cases, occu- 
 pies the relation of a direct exciting cause to the Insanity. 
 
 Definition. — Diathetic Insanity is mental alienation in connection 
 with phthisical, podagrous, rheumatic, pellagrous, paludal, anaemic, 
 post-febrile, cancerous, leprous, and myxoedematous systemic states, 
 which impart special traits to the somatic symptoms, and also impress 
 a particular character on the changeful phases of exaltation, depres- 
 sion, and enfeeblement, in which aberration of mind is revealed. 
 
 Clinical Delineation. — The clinical features of the mental disorder 
 vary with the nature of the diathesis, and there are fluctuations in the 
 physical and mental disease, and periodicity is not uncommon in both 
 the vesanic and diathetic symptoms. 
 
 The Insanity may appear before the diathesis is fully developed, 
 and this is often the case in phthisis pulmonalis; but the diathesis is 
 ordinarily the primary affection. Alternations or vicariations also 
 exist between the psychosis and the diathesis. Thus the phthisical 
 SA^mptoms may remain latent after the appearance of the mental dis- 
 order, and the latter may disappear when the former again become 
 active. There is a vicarious heredity, also, by which Insanity and 
 phthisis pulmonalis are interchangeably transmitted from parent to 
 offspring, and this is also true of some of the other diatheses. 
 
 During the development of the diathesis the Insanity is mani- 
 fested more frequently as melancholic perversion of ideas and feel- 
 ings, with delusions of suspicion ; but, in advanced diathetic condi- 
 tions, maniacal, stuporous, and demented states are to be encount- 
 ered. It not uncommonly happens that there is a chronic melan- 
 cholic stadium, interrupted by maniacal exacerbations, which corre- 
 spond to the culminating phases of the diathetic disorder when it is 
 malarious or myxoedematous, or to retrocessions of the same when 
 it is podagrous or rheumatic. 
 
 In chronic paludal intoxication there may be stuporous states ancl 
 maniacal periodic excitement, which is really a substitute for the 
 malarial paroxysm. This larval mental access may be tertian or 
 quartan, and it may reach the extreme of acute delirious mania. 
 
 In the gouty diathesis the prevailing mood is depression, but acute 
 mania may supervene upon a sudden retrocession of the local disease, 
 and the same is true in rheumatic metastasis. In fact, maniacal 
 symptoms are the rule upon the subsidence of the arthritic affection. 
 
 The somatic conditions in most all of the diatheses are impaired 
 nutrition, hasmie deterioration, congestion or anasmia of internal or- 
 
INSANITY WITH GENERAL SYSTEMIC MORBID STATES. 647 
 
 gans, perverted metabolism, imperfect oxidation and retarded com- 
 bustion of tissues, retention of waste products, vascular degenerations, 
 gastro-intestinal, cardiac, renal, and hepatic disorder, and continuous 
 vasomotor disturbances. Muscular disorders, modifications of res- 
 piration, derangement of digestion and sleep are also frequent. 
 
 The psychical symptoms, in the main, are restlessness, suspicion, 
 morbid fears, delusions of a depressing character, hallucinations and 
 illusions of a terrifying nature, suicidal, and more rarely homicidal 
 or destructive, impulses, and a persistence of painful emotions. Even 
 in the maniacal attacks the sensorial perversions are chiefly of a dis- 
 agreeable and frightful kind. In rare instances there is an agreeable 
 coensesthesis, and expansive feelings and delusions in phthisical cases. 
 Occasionally fully systematized monomanias appear, and still more 
 rarely general paresis originates in diathetic conditions. Hypochon- 
 driacal and hysterical features are very common in the early stage of 
 the diathesis, and at a later period convulsive seizures and cataleptoid 
 states are to be observed. 
 
 The final states of mental enfeeblement in the diatheses are usu- 
 ally conjoined with organic lesions of internal organs and a general 
 condition of malnutrition, and progressive emaciation, which reaches 
 its greatest extreme in phthisical Insanity. In the rheumatic diathe- 
 sis choreic symptoms and cardiac affections are at times prominent 
 complications. 
 
 These outKnes of diathetic Insanity will be filled out under the 
 head of symptoms. 
 
 Causes. — A certain hereditary predisposition is presumably pres- 
 ent in diathetic mental disorder, but the general systemic morbid 
 state is an adequate exciting cause of the Insanity. There are pro- 
 found changes in nutrition and in the blood, and progressive emacia- 
 tion in most of the diatheses. There are retentions of uric and lactic 
 acids in the circulating medium, and reabsorptions of septic material 
 in cancerous and tuberculous cases, and micro-organisms in the palu- 
 dal diathesis to account for many of the symptoms. 
 
 It is no longer doubted that in the metastatic cases there may be 
 a direct transference of inflammatory lesions from joints to cerebral 
 regions, and that in phthisis pulmonalis there may be basilar menin- 
 gitis, which generates depressive moods opposite to the euphoria pre- 
 vailing in some other phthisical types of Insanity. 
 
 The disturbances of circulation, the active variations in tempera- 
 ture, and the bacillary auto-intoxications are further etiological fac- 
 
648 TEXT-BOOK ON MENTAL DISEASES. 
 
 tors. In almost all the diatheses there is also a profound anaemia to 
 which a certain causative influence is to be attributed. 
 
 Stadia. — In some instances the stadia of the psychosis and of the 
 diathesis have a simultaneous progression. There is then a gradual 
 initial stadium of perverted thought and feeling during the develop- 
 ment of the physical disease, and then a stadium acutum of melan- 
 cholic or maniacal symptoms at the height of the diathetic affection, 
 and a subsequent stadium dementise in the terminal stage of diabetic 
 deterioration. This is the progression of diathetic Insanity in many 
 phthisical, cancerous, leprous, pellagrous, and myxcedematous cases. 
 In other instances there is a complete evolution of the phthisical, 
 myxcedematous, podagrous, rheumatic, or paludal diathesis, and then 
 a sudden initial, acute, and convalescent stadium of the mental dis- 
 ease; and it not infrequently happens that there is a recession of the 
 diathetic symptoms during the height of the vesanic disorder. Thus, 
 in phthisical mania there is often a complete arrest of the pulmonary 
 disease. Just as in gout and rheumatism the joint affection ceases 
 wJien the mental disorder begins. There is a distinct alternation of 
 the diathetic and vesanic symptoms in some cases, and in other in- 
 stances the psychosis is vicarious of the diathesis. The stadium 
 acutum is frequently interrupted by long remissions, as in phthisical 
 and paludal Insanity. In rheumatic and gouty Insanity the initial, 
 acute, and convalescent stadia may pursue a very brief and prompt 
 course, and the entire attack may not occupy more than a few days 
 or weeks. In the paludal diathesis the stadium acutum may be con- 
 stituted by maniacal explosions coinciding with the plasmodial crisis 
 and terminating with the malarial paroxysm. These recurrent mani- 
 acal outbreaks are not to be regarded as separate attacks, but, like 
 similar manifestations occurring with miliary infiltrations of tuber- 
 cle, are to be regarded as constituent features of an interrupted sta- 
 dium acutum, which may be thus prolonged for months or years be- 
 fore a stadium convalescens or stadium dementise appears. Like re- 
 missions in the stadium acutum of the mental disorder are sometimes 
 found in cancerous, leprous, pellagrous, and myxcedematous cases. 
 The stadium dementise terminates only with the life of the patient. 
 
 Symptoms. — It may be said that mental depression prevails in the 
 early part of the diathetic Insanity, that exaltation and excitement 
 appear at a later period, and that dementia is most common in ad- 
 van (;ed stages of the diathesis, and that alternations of stupor and of 
 the painful and expansive states mentioned are frequently to be ob- 
 served in the stadium acutum. Pseudo-pareses also occur. 
 
INSANITY AVITII GENERAL SYSTEMIC MORBID STATES. 649 
 
 There are many exceptions to this general observation, and the 
 symptoms are only characteristic of diathetic Insanity when grouped 
 and considered collectively in different cases. In phthisical patients 
 there may be the " spes phthisica," and a species of expansive and 
 optimistic mood, alternating with the most decided depression and 
 suspicion, and refusal of food through fear of poison. The objective 
 signs of the lung disease — cough, pain, and expectoration — are often 
 completely suppressed. The delusions are sometimes based on or- 
 ganic perversions of sensation in connection with tubercular deposits 
 in internal organs. 
 
 General paresis arising with the phthisical diathesis has a hypo- 
 chondriacal first stage, and usually assumes a melancholic form when- 
 ever there are active phthisical processes. 
 
 Hallucinations of hearing and smell often serve to fortify the 
 delusions of persecution in phthisical cases. Tinnitus aurium and 
 vertigo, rise of temperature and emaciation, anorexia and gastro-intes- 
 tinal disorder are among the physical symptoms. 
 
 In the podagrous diathesis despondency and suicidal tendency are 
 early symptoms, and wild excitement and maniacal conduct supervene 
 on recession of the joint affection, and dementia is a late sequel. 
 Aphasic and convulsive seizures also occur in this form of mental 
 disorder, in which neuralgic affections and vasomotor disturbances 
 are prominent symptoms, and the delusions are often connected with 
 marked cutaneous pargesthesise. The stuporous states in gout are 
 toxEemic in origin, and alternate with maniacal or melancholic exacer- 
 bations. 
 
 In acute rheumatism there are simple forms of delirium, but there 
 are also attacks of acute delirious mania during the rheumatic fever. 
 There is also the alternation of articular and psychic disorder of a 
 maniacal type. Following acute rheumatism there may be stuporous 
 states, or symptoms of perversion of the affective faculties and entire 
 change of character. The resulting mental disease may be modified 
 by the choreic and cardiac troubles sequent to the rheumatism, and 
 melancholic phases with suicidal impulses are common. Hyper- 
 pyrexia and acutely maniacal states are almost invariably associated in 
 this diathesis. Active sensorial disorder and frightful hallucinations 
 and sudden violent tendencies are found in the maniacal states. 
 
 Pellagrous Insanity presents gastro-intestinal disorder, erythema- 
 tous eruptions, emaciation, heightened tendon reflexes, cramps, 
 atrophy of muscles, convulsive seizures, paraplegic attacks, impaired 
 vision, angiospastic and angioparetic states, and marasmus. 
 
650 TEXT-BOOK ON MENTAL DISEASES. 
 
 The mental symptoms are panphobia, suicidal or violent impulses, 
 delusions of poisoning, euphoria of toxic origin or painful emotions, 
 and suspicion of relatives and hallucinatory states of stupor. 
 
 Limopsoitosic Insanity, during war, famine, shipwrecks, religious 
 fasting, or any forced abstention from food, may assume mildly mani- 
 acal or melancholic forms. There are active sensorial disturbances, 
 hallucinations of sight, ecstatic states, and, finally, flighty incoherence 
 of ideas and changeful delusions. 
 
 In the paludal diathesis the mental disorder is attended by inter- 
 mittent excitement or depression, with auditory and visual halluci- 
 nations, neuralgic and vasomotor affections, convulsive attacks, and 
 paralyses or spasms of muscles, and depressing delusions and suicidal 
 tendencies. Altered reflexes, amblyopia, and pseudo-paretic symp- 
 toms are not uncommon, and stupor may pass into terminal dementia 
 in these malarial cases. Periodic exacerbations corresponding to 
 the paludal crises are also to be observed, with complete intermis- 
 sions of the mental symptoms. 
 
 The mental alienation with cancer may vary according to the 
 cerebral lesions, if the brain be the seat of the malignant growth, but 
 where the breast or uterus is attacked by the disease there is more apt 
 to be melancholic states, with delusions and perverted sensations of 
 local origin, and finally dementia as the fatal end is neared. Leprous 
 Insanity is chiefly of the melancholic type, with apathetic and stupor- 
 ous states. Delusions of persecution originating in perverted sensa- 
 tions or anaesthetic conditions attendant upon the local lesions may 
 be present. 
 
 Myxoedematous Insanity is marked by retarded perception, sen- 
 sorial deficiency, confusion of ideas, stuporous and apathetic states, 
 aphasic and amnesic symptoms, doubt, fear, and suspicion, and delu- 
 sions of a depressing kind. Dementia may be the final result, and 
 congenital mental deficiency exists with cretinous myxcedema, and 
 mental enfeeblement often supervenes in. cachexia strumipriva. 
 
 Pathology. — In the pathogeny of phthisical Insanity the heredi- 
 tary, relationship of phthisis and the psychoses is to be accorded due 
 weight. The actual pathological findings in phthisical patients who 
 have died insane are venous stasis of meningeal membranes, an cedem- 
 atous state of the cerebral tissues, which are markedly ansemic. Louis 
 reports softening of the fornix, and this is confirmed by Clouston 
 in tuberculous cases, and the latter also calls attention to the dimin- 
 ished specific gravity of the cortical matter as first observed by Skae. 
 
INSANITY WITH GENERAL SYSTEMIC MORBID STATES. 651 
 
 In melancholia from basilar meningitis of tubercular origin the 
 tubercles are to be detected in the course of the vessels. 
 
 Presumably, the direct infection by miliary tubercle and the im- 
 mediate effects of bacillus tuberculosis and resulting ptomains on 
 cortical centres suffice to account for the functional disorder of men- 
 tal faculties. 
 
 In gout}' Insanity the accumulation of uric acid and alkaline 
 urates in the blood, and the action of podagrous toxins on ganglionic 
 elements, is to be regarded as the pathogeny of the mental disorder. 
 Doubtless the vasomotor centres are involved in the toxic influences, 
 which are reflected in the abrupt metastatic changes in the joint and 
 brain symptoms. Autopsical appearances of serous effusions, intense 
 hyperfemias of cortical regions, and vascular degenerations have been 
 recorded in these eases. 
 
 A similar set of pathological factors exist in rheumatic Insanity. 
 
 In pellagrous Insanity there is infection by micro-organisms, and 
 the lesions present in cerebral centres are hypersemic and anaemic or 
 cedematous states, meningeal inflammations, and vascular degenera- 
 tions. The most characteristic changes are in the lateral columns 
 of the spinal cord, in dorsal regions, in which degeneration of fibres 
 and sclerotic processes are found. Pigmentation and atrophy of 
 nerve-cells in the anterior and posterior cornua occasionally occur 
 with proliferation of connective-tissue elements. 
 
 In paludal Insanity the pathogenetic factors are the plasmodia 
 malarise in the blood, the excess of pigment and pigmentary emboli 
 in cortical centres, the profound cerebral anaemia, and the general 
 systemic morbid state. 
 
 The pathology of cancerous Insanity may be in the nature of focal 
 brain disease, in those rare cases in which the malignant tumor is 
 situated in cerebral tissues, but it is more generally to be sought in 
 the ha^mic deterioration, and, finally, septic reabsorptions. The latter 
 considerations also apply to the pathogenesis of leprous mental dis- 
 order. 
 
 Myxoedematous Insanity is supposedly due to infiltration of con- 
 nective tissues, disordered circulation, and auto-infection from failure 
 of thyroid functions. 
 
 Differential Diagnosis. — The presence of a fully developed dia- 
 thesis renders the diagnosis easy. 
 
 In phthisical cases in which the mental disorder precedes by 
 many months the physical symptoms of tubercular infiltration, the 
 history of phthisical heredity is the chief diagnostic point. 
 
652 TEXT-BOOK ON MENTAL DISEASES. 
 
 The diathetic pseudo-paresis, also, can only be differentiated by 
 the actual fact of curability from the true general paresis, which 
 occasionally emerges from the same general morbid state as the dia- 
 thetic Insanity. 
 
 Acute delirious mania of diathetic origin is to be difEerentiated 
 from the delirium of fever, fluctuating with the change in tempera- 
 ture, and having changeful hallucinations and incoherence of ideas 
 and confusion of memory, and a wandering and muttering character. 
 In rheumatic hyperpyrexia the use of means to reduce the tempera- 
 ture will be attended by a partial or complete disappearance of delir- 
 ium, but not of delirious mania, and this same test may be applied in 
 other forms of delirium with pyrexia. 
 
 In the pyretic state the mild wandering of the mind is not usually 
 difficult to distinguish from Insanity, which has a prevailing mood 
 of depression or exaltation, and ordinarily coherence in the delusions 
 and hallucinations, and no pronounced impairment of attention and 
 consciousness, and no confusion of past and present events, as in 
 delirium. 
 
 Insanity is to be diagnosed in the phthisical diathesis when the 
 irritability, moroseness, and suspicion wliich characterize it lead to 
 irrational conduct, even in the absence of delusions. The melan- 
 cholia of the preincubatory stage of the diathesis can only be differ- 
 entiated from melancholia simplex by the subsequent appearance of 
 diathetic symptoms, and the actual history of the case can alone 
 distinguish diathetic from epileptic states of stupor. 
 
 Prognosis. — The recovery-rate in diathetic Insanity falls below 
 the average. Practically, curability cannot be said to exist in can- 
 cerous and leprous cases, and in advanced phthisis pulmonalis the 
 prognosis is also bad. 
 
 A change of residence in the malarious diathesis to a healthful 
 region lends a hope of complete recovery from the mental disorder, 
 just as a change of diet in the pellagrous diathesis may lead to men- 
 tal recovery. Eheumatic and podagrous Insanity recovers frequently, 
 but often relapses. Permanent valvular lesions of the heart in rheu- 
 matic Insanity are unfavorable elements in the prognosis. 
 
 The prognosis in myxoedematous Insanity is bad, though the use 
 of the thyroid extracts has improved the chances in these cases. In 
 the limopsoitosic and aneemic diatheses the prognosis is good. 
 
 With the exception of the phthisical, leprous, cancerous, and myx- 
 oedematous diatheses, the chances of life are godd. In general, the 
 expectation of life is considerably diminished by diathetic Insanity. 
 
INSANITY WITH GENERAL SYSTEMIC MOEBID STATES. 653 
 
 The termination of the mental disorder in incurable cases is sec- 
 ondary dementia and exceptionally paralytic dementia, or chronic 
 mania. 
 
 Treatment. — The treatment of the Insanity is the treatment of 
 the diathesis, in a great measure. Hygienic and dietetic means are 
 of prime importance. Quinine and arsenic in the paludal cases, thy- 
 roid extracts, or fresh preparations of the gland, in myxedematous 
 cases, and iron to combat the ansemia in all the chronic diathetic 
 conditions are plainly indicated. The symptomatic treatment of the 
 mental disorder must proceed on general principles already fully dis- 
 cussed in the chapter on treatment. 
 
 Maniacal outbreaks on the sudden retrocession of Joint affections: 
 may demand counter-irritants to recall the local disease. Hydrother- 
 apeutics, Turldsh baths, hot packs, and steam baths, for their elim- 
 inative effects, have a direct application in such cases, together with 
 alkalines, salicylates, and diuretic and purgative remedies. Surgical 
 procedures may be in order in the cancerous cases, and the earlier 
 the operative interference, the greater, as a rule, is the hope of relief. 
 
 The previous excessive use of medicine by the patient for pro- 
 longed periods often complicates the case and renders a suspension 
 of all drugs desirable in some instances, while dietetic, hygienic, cli- 
 matic, hydrotherapeutic, and psychic treatment is administered with 
 discrimination as to individual indications. 
 
CHAPTER VI. 
 
 INSANITY WITH DEFINITE LESIONS OF THE CEREBRAL, SPINAL, 
 VASOMOTOR, OR PERIPHERAL NERVOUS SYSTEM. 
 
 Group: General Paresis, 8yphiliiic Insanity, Organic Dementia, 
 Typhomania, Traumatic and Sympathetic Insanity. 
 
 Section I. — General Paresis. 
 
 It is probable that general paresis has existed in the past as at 
 the present time, but the conception of the disease as it now presents 
 itself is of comparatively modern origin. 
 
 There are passages in the writings of Wilhs, the anatomist (1670), 
 showing a knowledge of the association of paralysis and Insanity, and 
 at the close of the last century Haslem and Perfect described paralytic 
 forms of dementia. Esquirol noted as early as 1815 the fatal nature 
 of paralysis and failure of speech, but had no clear idea of general 
 paresis as a distinct type of Insanity. Georget (1820) recognized a 
 distinct affection, with paralysis and mental disorder and fatal ter- 
 mination, and Boyle (1832) referred both muscular and psychic symp- 
 toms in these cases to chronic arachnitis, and pronounced the disease 
 to be a distinct entity. He later (1825) described the changes in 
 speech and the motor disorders. 
 
 Calmeil (1826) pubhshed a complete description of the physical 
 symptoms and anatomical lesions in general paresis, which he con- 
 sidered as a complication of the Insanity. 
 
 Parchappe (1838) declared general paresis to be a distinct form 
 of Insanity, with characteristic symptoms of motor and mental dis- 
 order. 
 
 Later writers — Baillarger, Eequin, Lunier, Duhamel, and Prus — 
 conceived the paralysis to constitute the essential disease, to which 
 mental disorder might or might not be added as a secondary phenom- 
 
 654 
 
INSANITY WITH DEFINITE LESIONS. 655 
 
 enon, though a certain degree of dementia was admitted to be a cus- 
 tomary sequel of the paralysis. This view led to inclusion of all 
 kinds of dementia secondary to focal brain disease under the term 
 of general paresis, or paralytic dementia, as it came to be called by 
 some writers. Subsequent students of general paresis again declared 
 its unity and independence as a type of mental disease, having charac- 
 teristic motor disturbances and pathological lesions. Thus Dela- 
 siauve, and J. Falret, and Duchek, in their writings, sustained the 
 original teaching of Boyle that general paresis was a distinct entity, 
 with mental aberration determined by the same anatomical lesions 
 which gave rise to the paretic symptoms. This view is generally ac- 
 cepted at the present day, though some authors, like Ball, of Paris, 
 look upon general paresis as a generic term, embracing a variety of 
 affections differing in etiology, course of symptoms, and final result. 
 
 Definition. — General paresis is a progressive disease of the nervous 
 system, resulting in pathological changes in the encephalon, spinal 
 cord, and sympathetic ganglia, and characterized by motor, vaso- 
 motor, and psychic disorders, ending, in the vast majority of cases, 
 in rapid physical and mental deterioration, and death within three 
 years from the inception of the malady. 
 
 Clinical Delineation. — The clinical outlines of general paresis in- 
 clude, in the order of importance, psychic, motor, vasomotor, and 
 sensory disturbances, which, in very many patients, occur in the 
 sequence here named. In the majority of cases the psychic precede 
 the motor symptoms, but in other instances the progressive paresis 
 is not only the first, but the most prominent phenomenon throughout 
 the entire course of the disease. In rare exceptions the vasomotor 
 disturbances initiate the malady, and every possible exceptional order 
 of combination of the symptoms may occur. The entire average 
 duration of the malady is about three years. 
 
 The psychic phenomena consist in an early decline of ethical and 
 altruistic sentiments, in an alteration of character, in perversion of 
 the affective faculties, and loss of the higher forms of self-control. 
 
 This initial phase in the dissolution of the mental being is fol- 
 lowed by active maniacal or melancholic perturbations, with sequent 
 stuporous states, and then remissions of all acute symptoms. It is 
 evident, in these quiescent periods, that the patient is steadily sink- 
 ing to lower planes of mental existence, and in the course of a year 
 the terminal stadium of progressive dementia ordinarily begins, 
 counting from the inception of acute psychic disorder. This final 
 
656 TEXT-BOOK ON MENTAL DISEASES. 
 
 process of deterioration is more or less rapid in different cases, but 
 it usually ends in complete fatuity within a year. 
 
 The motor phenomena, in a word, are, first, a progressive ataxia, 
 and, secondly, a constantly increasing paresis. The ataxia appears in 
 the speech, gait, and other highly specialized movements acquired in 
 manual occupations, of which the patients soon become incapable 
 through loss of skilled co-ordination. 
 
 The paresis progresses at first " pari passu," with cortical lesions, 
 but later it is also the manifestation of alterations in bulbar and 
 spinal centres, and in syphilitic cases distinct paralyses are not un- 
 common. According as the posterior or lateral columns of the cord 
 are involved, there is ataxic or spastic gait. 
 
 Following the seizures of general paresis there are not infrequently 
 hemiplegias, or brachial or crural monoplegias, chiefly of transient 
 dui'ation. 
 
 Other motor anomalies are tremors, spasms, fibrillary twitchingSj 
 changes in the cutaneous and tendon reflexes, and deranged action 
 of ocular and pupillary muscles. 
 
 The vasomotor symptoms are angiospastic or angioparetic, cere- 
 bral congestions or syncopal attacks from sudden cerebral angemias, 
 cephalalgias, vertigoes, capillary stasis, h3^peridrosis, sometimes uni- 
 lateral and cyanotic states in the final stage. 
 
 The sensory phenomena are, first, a change in the sum total of the 
 organic sensations, giving a painful or hypochondria! coenaesthetic 
 consciousness, which later often assumes the peculiarly agreeable and 
 expansive character which is so constantly reflected in the megalo- 
 maniacal delusions of the general paretic. Sensory disorder of the 
 special senses is revealed as hallucinations and illusions in the major- 
 ity of cases, and there is loss or perversion of common sensation in 
 extreme degrees. Analgesia in the final stage is often complete. 
 
 The vital functions are always involved at some stage of the dis- 
 ease. 
 
 The modifications of respiration are very decided, consisting in 
 altered rhythm, which may be of the Cheyne-Stokes variety during 
 continued paretic seizures, in suffocative attacks, and in superficial 
 or labored breathing for consecutive hours. 
 
 The disorder of circulation is most often seen in advanced cases, 
 vnth. heart failure, congested or livid skin, pulsations of large ves- 
 sels, and permanent sphygmographic alterations. 
 
 The digestion is finally deranged and the entire metabolism dis- 
 turbed, so that death often supervenes in marasmus. 
 
INSANITY WITH DEFINITE LESIONS. 657 
 
 This outline of the chief clinical features would be incomplete 
 without a mention of the paretic seizures. These are syncopal, epi- 
 leptic or epileptiform, apoplectic or apoplectiform, hysteroid or teta- 
 noid, and serial in a paretic status, which may extend over hours or 
 days of convulsive seizures and he followed by paralysis of upper or 
 lower extremities. 
 
 The exceptional forms of general paresis are tabetic cases, or as- 
 cending cases, as they are termed, beginning as locomotor ataxia, to 
 which the mental disorder is secondary. Other rare instances are 
 stuporous throughout, with remissions, and still others display well- 
 marked alternations of excitement and melancholy. This latter cir- 
 cular form may have long intervals of apparent freedom from symp- 
 toms, and is seen in cases with strong heredity. General paresis is 
 less pronounced in type, and more chronic in course among w^omen. 
 
 Hypochondrial and melancholic forms, with micromaniacal de- 
 lusions and no trace of optimism or exaggeration of ideas, are also 
 among the exceptional types. 
 
 There are also " galloping " cases, which may run their course 
 to a fatal end in a few weeks, and present clinical features resembling 
 delirium acutum. On the other hand are cases having a prolonged 
 course of ten years, with lengthy remissions. The mental symptoms 
 may precede the motor a year or two, and general paresis may then 
 appear to emerge from some other type of mental disease, but this is 
 questionable. 
 
 Causes. — Civilization favors general paresis through the demands 
 which it makes on physical and mental powers, competition, reckless 
 and feverish pursuit of wealth and social position, overstudy, over- 
 work, unhygienic modes of life, the massing of people in large cities, 
 the indulgence in tea, coffee, tobacco, stimulants, and social and sex- 
 ual excess, and artificial modes of life. The disease is vastly more 
 common in urban than in agricultural populations in all parts of the 
 world, and more frequent among highly civilized than partially civil- 
 ized peoples. 
 
 Sex has definite numerical relations, which may be stated, on the 
 average, to be that there are three men to one woman attacked by 
 general paresis. The proportion of women to men is much greater 
 among the lower than among the higher classes, and it has constantly 
 increased for the last twenty-five years, according to statistics of 
 hospitals for the insane, both in Europe and America. 
 
 Age predisposes at the period of greatest functional strain from 
 
 thirty to fifty years, though exceptional cases occur, according to some 
 
 -'3 
 
658 TEXT-BOOK ON MENTAL DISEASES. 
 
 writers, as early as fifteen years and as late in life as sixty-five years. 
 The diagnosis in these extreme cases may be questioned, and, practi- 
 cally, the limits of occurrence of general paresis may be said to be 
 from the twenty-fifth to the fifty-fifth year. The cases under twen- 
 ty-five years are chiefly luetic in origin, and usually lack the typical 
 traits, and those past fifty-five years are not easily distinguished 
 from senium precox. 
 
 The age of maximum frequency of the malady is earlier than for- 
 merly, and, whereas it was once reckoned to be forty-five years, it is 
 now between thirty-five and forty years; and in European, British, 
 and American cities it tends to fall at a still earlier period of age, 
 especially among women. 
 
 Occupation is a predisposing circumstance, and military and 
 learned professions furnish the largest percentage of cases. Politi- 
 cians and artists, and those exposed by their calling to a high degree 
 of heat, also supply a large contingent, as well as gamblers, prosti- 
 tutes, and professional criminals, and speculative adventurers. The 
 disease is said to be almost unknown among the Eoman Catholic 
 clergy. 
 
 Heredity exists in direct line in only about twelve per cent, of the 
 cases. French authors incline to trace tliis heredity to epilepsy, apo- 
 plexy, and focal brain disease in progenitors, rather than to simple 
 psychoses or to general paresis itself, which is said not to be directly 
 transmitted. 
 
 In the writer's observation of cases, psychopathic tendency was 
 common, but the major neuroses are rarely prodromes in the same 
 case with general paresis; and this fact may constitute a numeri- 
 cally greater immunity in women than in men, since the sex is more 
 frequently affected with these neuroses. 
 
 The exciting causes of general paresis are headed by syphilis, 
 which all authors admit to be the most universal cause, figuring from 
 twenty to eighty per cent, in the total causality, according to the 
 widely divergent observation of writers. 
 
 Though inclined to accept the etiological importance of syphilis, 
 the writer has only been able to positively establish the diagnosis of 
 luetic infection in twenty per cent, of cases treated. 
 
 Specific disease is the cause of nearly all general paresis arising 
 before the twentieth year. 
 
 Hereditary syphilis is also to be taken into account as favoring the 
 vascular changes which underlie the subsequent pathological altera- 
 tions. 
 
INSANITY WITH DEFINITE LESIONS. 659 
 
 Mechanical injuries of nervous centres are causative in a certain 
 per cent, of the cases, and trauma capitis, concussion of brain or 
 spine, insolation, and artificial heat-stroke are to be accorded due 
 weight. 
 
 The tosic origin of general paresis is important. Alcohol is the 
 chief toxic agent, but various metallic or vegetable poisons have 
 given rise to the disease, though many of the cases thus caused are to 
 be reckoned as pseudo-pareses. Probably not less than fifteen per 
 cent, of the cases spring from alcoholic abuse. 
 
 Sexual excess, especially when combined with indulgence in 
 " Baccho," is a competent cause, but masturbation is not followed 
 by like results and leads to spinal rather than cortical disease. In- 
 fectious diseases have been etiological factors in occasional cases, and 
 locomotor ataxia is intimately allied to general paresis, and is fol- 
 lowed by it in numerous instances. 
 
 Mental strain, excessive work under trying circumstances, pro- 
 longed worry, and painful emotions are among the causes of the 
 malady, which arises in most instances from a variety of cumulative 
 influences prolonged through a series of years. 
 
 Stadia. — General paresis has been artificially divided into three, 
 four, or five stages. The general rule is that there is a long prodromal 
 period, during which a variety of causes are undermining the physical 
 and mental constitution, and a gradual deterioration of the higher 
 mental and moral powers takes place. There then follows a period 
 of active mental disorder, maniacal, melancholic, or stuporous, with a 
 great variety of somatic symptoms, and derangement of all the vital 
 functions, and more or less marked remissions of all the phenomena 
 of the disease. A third and final period of enf eeblement of mind and 
 body and of complete dissolution of the personality of the patient 
 then develops, and ends fatally within an average of twelve months. 
 
 There are exceptional modes of clinical progression, with rapid 
 or tardy fatal ending, but nothing is gained by making more than 
 three subdivisions in the general course of the malady, which is rec- 
 ognized as having three stadia, as follows: 
 
 1. Stadium prodromale, which has an average duration of one 
 year. This stadium prodromale is marked by a steady decrease in 
 higher forms of self-control, by amnesia as to recent events, and 
 inability to discharge the more difficult duties of life, by careless and 
 reckless demeanor, extravagance in purchases or business plans, a 
 loosening of the moral inhibitions, shown in improprieties or grossly 
 sensual conduct, or in acts of a criminal nature, such as petit larceny, 
 
660 TEXT-BOOK ON MENTAL DISEASICS. 
 
 perverted sexual offences, incendiarism, or wanton cruelty to animals, 
 or destruction of property, or dishonest business transactions. There 
 are also morose and irritable moods, or boisterous and expansive turns 
 unprovoked by adequate motive, or hypochondriacal and lachrymose 
 spells. Loss of natural affection at this time may assume the more 
 decided form of antipathy or suspicion of family, or there may be 
 impulsive violence toward self or others. There is a lack of prompt- 
 ness and correctness in the use of spoken and written language at this 
 period. There are omissions of words in written sentences, and hesi- 
 tancy in the construction of phrases during ordinary conversation, 
 and a certain incoherence of ideas from failure of attention. The 
 motor disturbances usually appear also during this stadium. The 
 higher forms of co-ordination of movements required by artists, musi- 
 cians, and special mechanical workers are impaired. The mechanisms 
 of speech and gait are early involved in the ataxic disorder. 
 
 The vasomotor symptoms — cerebral congestions, cephalalgia, ver- 
 tigo, syncope, hyperidrosis, local cutaneous hyperemias, cyanosis — 
 appear along with anomalies of digestion, gastro-intestinal disorder, 
 disturbances of circulation, and modifications of respiration, both in 
 depth, frequency, and rhythm. 
 
 Trophic functions are deranged, as shown by changes in the skin, 
 hair, nails, muscles, and bones, and in a gradual loss of weight. 
 Changes in the composition of the blood, urine, saliva, and perspira- 
 tion are occasionally to be observed during this stadium. 
 
 The deep reflexes are most often exaggerated at this stage, while 
 the superficial reflexes may be diminished. There is contraction, ine- 
 quality or irregularity of the pupils, or failure of response to light 
 or accommodation in the majority of cases during the stadium pro- 
 dromale. 
 
 Sensorial disorder, tinnitus aurium, deafness, diplopia, amblyopia, 
 color-blindness, photopsia, anosmia, and parageusia are occasional 
 phenomena of this stadium. 
 
 The change in the organic sensations is revealed in the depressed 
 eoenassthesis of this first stage, and later by a transformation into an 
 exalted and agreeable coenassthesis, which is one of the most charac- 
 teristic symptoms of general paresis. This coengssthetic exaltation, 
 beginning ordinarily at the close of the prodromal stadium, often con- 
 tinues throughout the entire course of the disease, though in excep- 
 tional cases it is never present at any time. 
 
 The above are, in the main, the symptomatic developments of the 
 stadium prodromale. 
 
INSANITY WITH DEFINITE LESIONS. 661 
 
 2. Stadium acutum is the period of full development of the 
 phj^sieal and mental symptoms of the malady. It ordinarily lasts 
 about a year, from the close of the stadium prodromale to the begin- 
 ning of the terminal demented stadium, and it consists in maniacal, 
 hypochondricical or depressed, stuporous or convulsive symptoms, and 
 also- in general disturbances of motor, vasomotor, sensory, and tro- 
 phic functions, and in minor and protean signs of the approaching 
 dissolution of the physical and mental organism. 
 
 The stadium acutum is ordinarily ushered in by an acute mani- 
 acal outbreak, or by a paretic seizure, followed by depression or 
 stupor. All the phenomena of this stadium correspond to progres- 
 sive lesions of the encephalo-spinal nervous system. The maniacal 
 excitement is often of a high grade, and may assume the form of de- 
 lirium acutum and lead to a rapidly fatal termination. Exaggeration 
 of ideas and megalo-maniacal delusions abound in these maniacal 
 phases, while hypochondriacal and micro-maniacal concepts are com- 
 mon in the melancholic states. 
 
 The apoplectiform, epileptiform, and paralytic seizures are most 
 frequent in this stadium, and they hasten the mental decadence. 
 
 The failure of the mental faculties is very rapid. Through defects 
 of memory persons and places are confused, past and present events 
 are hopelessly mixed, things imagined are mistaken for realities, and, 
 with a childish play of fantasy, the most extravagant and impossible 
 things are related by the patient as if they had been a part of his 
 real experience. Attention and consciousness are impaired, so that 
 there is no clear distinction of time and locality, and the relation of 
 the patient to his environment ceases to exist, practically. Cortical 
 and mental failure in the constructive and emissive sphere of speech 
 are now complicated with ataxic and paretic defects of articulation. 
 The gait is highly ataxic and spastic as the spinal lesions advance, 
 and temporary hemiplegias or monoplegias may attend the paretic 
 seizures. 
 
 Sometimes motor or amnesic aphasia arises at this period, with 
 focal brain lesions. The facial lines of expression are obliterated, and 
 tremor of facial muscles is observed on slight emotional provocation. 
 Paramimic laughing and crying are to be observed. Monospasms, 
 fibrillary twitching of muscles, Jacksonian epileptic seizures, syu~ 
 copal attacks, contractures of nuchal muscles, masticatory spasm, and 
 increasing paresis of all the muscles are now in order, and in keeping 
 with the cortical and spinal disintegrations. Throughout the organ- 
 ism fatty degenerations occur, and adipose replaces higher forms of 
 
662 TEXT-BOOK ON MENTAL DISEASES. 
 
 tissue in vascular and nervous structures, and the panniculus adi- 
 posus may be greatly increased, and patients become plump, and all 
 the more helpless on account of increased weight. Voracious appe- 
 tite is common. Insomnia finally gives place to continued somno- 
 lence. The sexual excitement, often resulting in offences against 
 public decency, is often followed by impotency and extinction of 
 desire. 
 
 Dystrophies now appear in form of mollifies ossium, muscular and 
 cutaneous atrophies, changes in the nails, hair, and glandular organs. 
 The deep reflexes are diminished, or lost in cases complicated with 
 tabes. The evening temperature is increased, and this is also the 
 case in the paretic seizures. The pulse becomes monocrotic, usually, 
 toward the close of the stadium acutum. 
 
 Although the chief points of this stadium are a steadily progres- 
 sive paresis and mental enfeeblement, there may still be remarkable 
 remissions of these and of all the other symptoms. These remissions 
 may continue for weeks, months, and, very exceptionally, for a year 
 or more, before the stadium acutum and all its symptoms are again 
 resumed. Whether the stadium acutum exceed the average duration 
 of a year or fall short of it, there is the same termination in a final 
 demented stadium. 
 
 3. Stadium dementicB is the third and final period, of an average 
 duration of one year. This stadium is reached when vesical and rectal 
 sphincters are paralyzed, when hebetude and neglect of the daily 
 wants of nature appear, or when the confusion and weakness of mind 
 and body render the patient incapable of self-care. Eemnants of 
 former active delusions and hallucinations are still present, and an 
 occasional brief attack of excitement may appear, but enfeeblement 
 and progressive decay of the entire organism are the prominent symp- 
 toms. 
 
 The ataxia is followed by decided paresis. The patient becomes 
 unable to dress himself, he has a wavering and feeble gait, falls often, 
 and is clumsy, and in the course of a few months reaches the helpless 
 and bedridden stage. 
 
 Speech is reduced to the formation of simple phrases, uttered with 
 drawling intonation, hesitation, and tremor of voice in a guttural 
 monotone. Tremors, spasms, atrophies, contractures, hemiplegic 
 symptoms, and obliteration of facial hues are pronounced. 
 
 The patient eats voraciously and indifferently all substances set 
 before him, is filthy and destructive in habits, has grinding of the 
 teeth, hsematoma auris, decubitus, paresis of phar}mx and dysphagia. 
 
INSANITY WITH DEFINITE LESIONS. 663 
 
 and is subject to pneumonitis from passage of food into the trachea 
 and to fractures from slight falls. 
 
 As the dementia becomes more abject, the patient no longer rec- 
 ognizes persons or places, has loss of special and common sensation, 
 is without conscious personality, and has a mere vegetative existence. 
 Through vasoparetie conditions, cyanotic skin, congestions of internal 
 organs, and diarrhoea occur, and subnormal temperatures are ob- 
 served. Owing to the descending bulbar lesions the circulatory and 
 respiratory functions are affected, and dyspnoea and syncope from 
 heart failure are frequent. 
 
 Dystrophic symptoms are marked, and finally a general wasting 
 of tissues ends in marasmus. 
 
 Death terminates this final stadium by oedema of lungs, pneumo- 
 nitis, intestinal, renal, or vesical inflammations, embolism or cerebral 
 effusions, or by deep bed-sores, septic infection, and infarction of in- 
 ternal organs. The duration of a typical case of general paresis hav- 
 ing the above stadia is, as stated, three years. Other cases have an 
 exceptional stadial progression, and may manifest only a progressive 
 dementia and paresis, with congestive seizures, ending early in fatal 
 exhaustion. In cases with strong heredity the stadium acutum is 
 characterized often by alternations of melancholic and maniacal 
 states, and remissions may prolong the duration of the malady for 
 many years. 
 
 In " galloping " cases all the stadia may elapse in a few months, 
 and death ensue at the end of this brief period. In women the stadia 
 are less clearly demarcated and have a longer average duration than 
 in men. 
 
 In ascending cases of general paresis the course is exceptionally 
 long, and the early locomotor ataxia is to be reckoned as a part of 
 the stadium prodromale, like initial lesions and ocular anomalies in 
 luetic cases. 
 
 In rare instances, also, the prodromal stadium is characterized by 
 signs of some infectious disease, acting as the exciting cause of the 
 general paresis, or by other symptoms, varying according to the im- 
 mediate etiological factors of the mental malady. 
 
 Symptoms. — The entire evolution of symptoms in general paresis 
 takes place in strict correspondence with vasomotor disorder, or path- 
 ological changes in the encephalo-spinal nervous system. 
 
 The mental, motor, vasomotor, trophic, and sensory symptoms, 
 and the disorder of the vital functions, will be described in the above 
 sequence, and in the order of their appearance during the progress 
 
664 TEXT-BOOK ON MENTAL DISEASES. 
 
 of the general paresis of ordinary type; and it has been already 
 pointed out that, exceptionally, almost any conceivable priority of 
 individual symptoms may exist, as the spinal lesions may precede the 
 cerebral, and the latter vary in the manner of their development 
 according to the immediate cortical regions involved in the diseased 
 processes. 
 
 Tlie mental symptoms are the outcome of the progressive atrophy 
 of the frontal cortex. The supreme function of inhibition of this 
 part of the brain cortex is lost as the first sign of the fatal malady. A 
 certain abandon in speech and conduct first appears, and soon passes 
 into open neglect of the conventions of society. All the higher and 
 more complex concepts and feelings, such as the aesthetic and altru- 
 istic sentiments, are soon lost, and there results total disregard of 
 social obligations, and often legal infraction of the rights of others. 
 The propensities and desires are intensified and lead to overt acts for 
 their gratification. The anti-social emotions, anger, hatred, and re- 
 venge, are sometimes active in the early part of the prodromal stage, 
 and the fundamental emotional tone is that of irritable depression. 
 This prevailing emotional mood is usually transformed into coenges- 
 thetic exaltation toward the beginning of the stadium acutum, but 
 prior to this change suicidal or homicidal impulses may be mani- 
 fested. 
 
 Failure of attention and memory, neglect of customary pursuits, 
 inability to transact business, foolish investments and loss of finan- 
 cial judgment formerly possessed, inability to meet the new emer- 
 gencies of life, and steadily increasing incapacity for management 
 of self and of personal affairs, are psychic symptoms of the prodromal 
 stage. 
 
 With the beginning of the stadium acutum active mental disease 
 is in order. The turbulent feelings and animal passions are not re- 
 strained, as all higher forms of volitional control are lost. The coen- 
 sesthetic exaltation is manifested in extravagant social demonstrations, 
 in prodigal entertainment of friends, in bacchanalian or sensual in- 
 dulgences, in vast business ventures, and in general extravagance of 
 words and actions highly characteristic of general paresis. As judg- 
 ment becomes more impaired, all insight into the absurdities of con- 
 duct is lost, and any attempt to check the extraordinary acts of the 
 patient provokes violent resentment. The patient is restless, sleep- 
 less, full of a wild flight of plans for self-aggrandizement, and the 
 amelioration of mankind in general. He can often not be induced to 
 take time for his regular repasts, flies from one place to another, and 
 
INSANITY WITH DEFINITE LESIONS. 665 
 
 from one person to another, to enlist converts in his social and finan- 
 cial ^Schemes. 
 
 Delusions of grandeur appear, and in his optimistic moods the 
 patient promises in advance to his friends high offices and salaried 
 positions. Hallucinations of sight and hearing confirm the delusions, 
 and anomahes of common sensation and of the kinaesthetic sense 
 favor the exaggerated ideas of personal strength and size. The liber- 
 ation of energy from the motor cortex also swells the subjective im- 
 pressions of muscular freedom and power. The patient feels giant- 
 like, and boasts of his immense proportions and Herculean strength. 
 
 Maniacal outbreaks or melancholic or' acute hypochondriacal 
 symptoms may alternate with stuporous states, following the conges- 
 tive seizures, which now complicate the case. 
 
 Amnesia steadily progresses, confusion of ideas and of time, place, 
 and personal identity arises, limitations of personal consciousness are 
 more decided, and a positive dissolution of personality is in progress. 
 
 Eemissions at this period do not restore to the patient any con- 
 scious insight into his disease, which, with the convulsive attacks, 
 usually resumes its course on lower and lower levels of mental life. 
 
 The stadium dementite inaugurates a vegetative existence and 
 automatic mental states. The patient is now the mere simulacrum of 
 an intelligent being, emotion and ideation are at an end, delusions 
 and hallucinations no longer exist, and even the animal wants are 
 no longer perceived. The patient has to be fed, clothed, and per- 
 sonally attended, like a child of the lowest form of congenital de- 
 ficiency. 
 
 All these progressive manifestations of disintegration of the organ 
 of mind are only a part of the group of symptoms essential to the 
 diagnosis of general paresis. These psychic symptoms usually begin 
 before the somatic signs are to be detected, but they may be late 
 phenomena in ascending cases of general paresis, and in other in- 
 stances they may be limited to a simple continuous failure of mental 
 faculties without any active perturbation of intellect. 
 
 The motor symptoms correspond to the pathological changes in 
 cortical, bulbar, or spinal centres, and they ordinarily attend or follow 
 closely in order of time upon the mental disorder, but they may pre- 
 cede the latter in exceptional cases by many months. 
 
 The motor symptoms, especially the speech defects, are abso- 
 lutely necessary diagnostic elements, without which general paresis 
 cannot be claimed to exist. These motor symptoms consist in ataxia, 
 and later in paresis, most observable in the more highly specialized 
 
666 TEXT-BOOK ON MENTAL DISEASES. 
 
 movements of speech, gait, handwriting, and skilled manual occu- 
 pations. 
 
 The' disorder of speech is pathognomonic, and is invariably pres- 
 ent in some form. The earliest defect of speech is ataxic, and arises 
 from cortical lesions, which prevent the delicate co-ordination of the 
 combined movements essential to clear articulation. The resulting 
 indistinctness of utterance does not include any formal defect of 
 articulation of individual letters, syllables, or words, but only a gen- 
 eral lack of clearness of enunciation, which is the first change in 
 paretic speech. 
 
 Following this indistinctness of utterance of words and sentences 
 is ataxic failure of pronunciation of labial or lingual consonants. This 
 ataxia is at first cortical, but is finally due to disease of facial and 
 hypoglossal nuclei, by which excessive or defective innervation of 
 labial and lingual muscles results, or inco-ordination between the cor- 
 tical volitional impulse and the bulbar impulse follows. Sudden over- 
 innervation leads to spasmodic closure of lips, and a hesitancy inter- 
 rupted by the explosive escape of the labial sound, and a hke delay 
 and forcible emission of lingual consonants is to be observed. 
 
 A third defect early in general paresis is the transposition of con- 
 sonants or syllables in spoken words, and it is all the more diagnostic 
 because rarely found in other brain diseases. It is especially evident 
 in test words having a long sequence of recurring lingual or labial 
 consonants, and it can be detected during reading aloud as well as 
 in conversation. 
 
 These early ataxic defects of speech later are complicated by de- 
 cided paretic conditions of the muscles of speech, so that both labial 
 and Ungual sounds are imperfectly formed, and, finally, pronuncia- 
 tion may be unintelligible. 
 
 Imperfect innervation, not alone of the muscles of the lips and 
 tongue, but of the vocal cords and of the expiratory and inspiratory 
 muscles, gives rise to a characteristic tremulousness of the voice. 
 Hence tremor, hesitancy, and drawling from retarded thought-rate, 
 and the spasmodic or reduplicated utterance of syllables come to be 
 chief traits of paretic speech. The musical quality of the voice is 
 early lost, and a hoarse monotone prevails; or, through failure of ex- 
 piratory pressure, there is whispered or inaudible articulation. 
 
 The intellectual defects of speech are amnesic, and include loss 
 of acoustic or kinesthetic word-images, or complete inability in the 
 syntactic construction of phrases. 
 
 Tremor is an early motor phenomenon, and is most evident in 
 
INSANITY WITH DEFINITE LESIONS. 667 
 
 face and extremities. It is fine and increased on intentional efforts, 
 and during slight emotional excitement the whole physiognomy may 
 be convulsively twitched or tremulously agitated, and the tongue 
 shows the fibrillar tremor when projected. These fine and rapid 
 tremors, having often ten vibrations per second, become coarser and 
 involve the larger groups of muscles later in the disease. 
 
 The handwriting betrays ataxia and tremor and amnesic defects. 
 Letters are omitted or doubled, and words are repeated, and syntactic 
 and orthographic errors abound, and, finally, written language be- 
 comes an impossibility when the graphic signs are forgotten. 
 
 The fine co-ordination in all the skilled mechanical pursuits is 
 soon lost, and the patient becomes incompetent in his special calling. 
 
 The gait is paretic, ataxic, or spastic, or mixed in character by a 
 blending of these different types. The paretic gait springs from cor- 
 tical disease, the spastic from degeneration of the lateral spinal col- 
 umns, and the ataxic from lesions of the posterior spinal columns. 
 Hemiplegic gait following the apoplectiform seizures is also to be 
 observed temporarily. Contractures and spasms of single muscles 
 or of groups of muscles are apt to occur, and also atrophies from 
 peripheral neuritis. 
 
 The changes in the reflexes are important. The knee-jerk is ex- 
 aggerated often early in the malady and then lessened or lost toward 
 the close of the disease. It sometimes differs on the two sides, and it 
 is rarely normal throughout the attack. Ataxic gait and absence 
 of knee-jerk, and spastic gait and increased knee-jerk, are often asso- 
 ciated. The superficial reflexes are usually lost in the advanced 
 stages of paresis. 
 
 The pupillary reaction to light is partially or completely lost in 
 the majority of all paretics at some time during the malady, and often 
 it is an early symptom, and response to accommodation is also often 
 absent. 
 
 Myosis is a common symptom in the prodromal stage, and is of 
 the paralytic variety in ascending eases of paresis. Mydriasis is also 
 common in the later stage of paresis, and is greater on the side of the 
 grossest hemispherical lesions in some cases. 
 
 Inequality of pupils as a persistent symptom is most often found 
 with mydriasis, and it exists in more than fifty per cent, of all cases. 
 
 Loss of pupillary dilatation upon painful peripheral stimuli is an 
 early symptom, while cycloplegia appears in advanced stages of 
 paresis. Paralytic mydriasis in general paresis is due, in some cases, 
 to atrophy of the optic nerve. 
 
668 TEXT-BOOK ON MENTAL DISEASES. 
 
 Paralyses of external ocular muscles are not infrequent in paretic 
 eases, and ophthalmoplegia externa has been recorded. 
 
 Unilateral paralysis of the external ocular muscles is not very 
 rare, and is sometimes accompanied by diplopia, or by ptosis in pa- 
 ralysis of the third nerve. 
 
 These ocular paralyses are most common in luetic and tabetic 
 cases. 
 
 Defects of facial innervation are usually present and account 
 largely for the paretic stupor of countenance. Masticatory spasm is 
 almost a constant symptom in the terminal stage. The bulbar disease 
 is followed by dysphagia, angesthesia of the pharynx favors the 
 passage of food into the larynx and trachea, and pneumonitis and 
 suffocation are sequels in some eases. Paresis of vesical and rectal 
 sphincters occurs in the final stage, and there is involuntary escape 
 of the contents of the bladder and rectum. 
 
 The vasomotor symptoms are, in the main, a progressive paresis, 
 which favors congestive states of brain and internal organs, and is 
 manifested by cyanotic and oedematous extremities. Local conges- 
 tions, circumscribed or unilateral anemias or hyperemias, are to be 
 seen, and also hyperidrosis or hemidrosis. The pulse varies much in 
 the early stage, but finally becomes a pulsus tardus, and is ordinarily 
 monocrotic in the terminal stadium. The vasoparesis at last is so 
 pronounced that hypostatic congestions and serous effusions take 
 place in intestinal, pulmonary, and renal membranes. Heematoma 
 auris is also, in certain cases, due to the same cause. 
 
 The trophic symptoms are, first, a decidedly impaired metabolism 
 during the prodromal or acute stadia, with loss of bodily weight, 
 which is only regained in the early demented stage, and emaciation 
 supervenes toward the fatal end. Dystrophies of skin, muscles, bones, 
 and internal organs are frequent symptoms. Eruptions and pigmen- 
 tations, turning gray of the hair, cutaneous atrophy, decubitus, " mal 
 perforant du pied," muscular atrophies, peripheral neuritis, and mor- 
 bid changes in cartilages have all been known to occur. 
 
 The sensory symptoms are neuralgias and hemicrania, shooting 
 pains and paralgesias in the early stage, and later anaesthesias of skin 
 and mucous membranes and decided analgesias. 
 
 The special senses are functionally disordered at first, and then 
 partially or completely impaired by atrophy of optic or acoustic 
 nerves, or of the olfactory bulb. 
 
 The vital and organic functions arc always disordered. Changes 
 in the composition of the blood, urine, and other secretions and ex- 
 
INSANITY WITH DEFINITE LESIONS. 669 
 
 cretions are often present. Temperature is higher, on the average, 
 in the evening, and increases in maniacal attacks and during the 
 paretic seizures, and reaches the highest point in the paretic status 
 after continued convulsions. Subnormal temperature is common, 
 and very low degrees may be reached in the terminal stage. Modifi- 
 cations of respiration, dyspnoea, Cheyne-Stokes respiration, and car- 
 diac failure and irregularity due to lesions of the pneumogastric are 
 often found in the stadium terminale. 
 
 Pathology. — The seat of the pathological processes in general 
 paresis may be the brain and the medulla oblongata, or the spinal 
 cord. All these parts of the nervous system may be simultaneously 
 attacked, or the cerebrum or spinal cord may be primarily affected. 
 The morbid changes usually begin in the frontal brain cortex and 
 extend downward, but in tabetic and ascending cases of general 
 paresis the converse is observed. 
 
 The essential and terminal pathological process is atrophy of the 
 brain. This atrophic process may be primary and degenerative, or 
 secondary to various inflammatory conditions. 
 
 Membranes of brain and spine, and vessels, as well as cells, fibres, 
 and connective tissues, are all involved in some progressive patholog- 
 ical changes, w^hich also invade the entire sympathetic nervous sys- 
 tem in certain cases. The posterior and lateral columns of the spinal 
 cord suffer most uniformly, but the anterior and posterior cornua 
 and nerve-roots, columns of Goll, and pyramidal tracts may be spe- 
 cially involved. 
 
 The very earliest anomalies are nutritive defects in ganglionic 
 cortical elements, and then follow local hyperemias of parietal, fron- 
 tal, or temporal convolutions, dilatation and degeneration of the coats 
 of vessels, lymphatic stasis and effusions into perivascular lymph 
 spaces, swelling and then wasting of nerve-cells and fibres, prolifera- 
 tion of neuroglia and of protoplasmic glia-cells, cortical and menin- 
 geal adhesions and the formation of neo-membranes. 
 
 Macroscopically are to be found thickened calvaria, osteophytes in 
 falx cerebri, adherent dura mater, pachymeningitis, hsemorrhagica 
 interna, thickening and adhesion of pia and arachnoid, serous effu- 
 sions, adhesions of membranes to cortex, which is torn and has a 
 mouse-eaten appearance on removal of pial membrane. The gyral 
 summits show these erosions. The cortical gray matter is thinned 
 or softened and washes under a small stream of water, or may be 
 readily scraped from the medullary substance, which is often firmer 
 than normal. The entire brain is greatly reduced in volume, the 
 
670 TEXT-BOOK ON MENTAL DISEASES. 
 
 ventricles are enlarged and filled with serous effusions, and there is 
 thickening and granulation of the ependyma. Atrophy of optic and 
 olfactory nerves and of basal ganglia are exceptionally present, and 
 the central tubular gray matter is often involved in the atrophic 
 process. The facial hypoglossal and pneumogastric nuclei are some- 
 times implicated in the pathological processes. 
 
 The spinal membranes are opaque and thickened, and occasionally 
 adherent, and cystic hematoma may be found in some cases. Valvu- 
 lar disease of the heart is common, and hyperemia of lungs, liver, 
 kidneys, and intestinal mucous membrane is often observed. Chronic 
 cystitis is also frequent, and vesical ecchymosis and splenic enlarge- 
 ment and softening are among the post-mortem findings in a few 
 cases. 
 
 The microscopical lesions are granular, fuscous, pigmentary, and 
 fatty degeneration of ganglionic elements and of basal and apical 
 processes. Yacuolation, atrophy, and complete disappearance of 
 nerve-cells also occur in the final stage of cortical degeneration. 
 
 The nerve-fibres atrophy either primarily or secondarily from 
 pressure, or as the direct sequel of cellular decay. In the cerebellum 
 there may be sclerosis or atrophy of Purkinje's cells, and vascular 
 degenerations. 
 
 The medulla oblongata is the seat of sclerotic or atrophic changes, 
 and the nerve-nuclei are specially involved in the morbid processes 
 in many cases. 
 
 The sympathetic ganglia show nuclear proliferation, sclerotic and 
 pigmentary changes, and disease of vessels. 
 
 The earlier changes in the vessels are hypertrophy of the tunica 
 muscularis, increase of the nuclei of the adventitia, and aneurismal 
 dilatation. Later, sclerotic, fatty, and colloid degenerations occur. 
 
 The perivascular lymph spaces are dilated and filled with cor- 
 puscles, pigment, and crystals. 
 
 There is hypertrophy of connective tissue, and the protoplasmic 
 glia-cells appear attached sometimes to the minute vessels. The pro- 
 liferation of glia-cells is found both in the superficial and deep cor- 
 tical layers, and also in the basal ganglia and tubercinereum. Scle- 
 rotic patches are found in the columns of the cord and there is gran- 
 ular degeneration of nerve-cells in posterior and anterior cornual 
 regions. The posterior root-zones and the spinal nerves may become 
 involved in the pathological processes. Sclerotic and atrophic lesions 
 of internal organs may also be found in a certain percentage of cases. 
 
 Differential Diagnosis. — General paresis is to be differentiated 
 
INSANITY WITH DEFINITE LESIONS. 671 
 
 from organic dementia, from tumors, or other focal brain disease. 
 The neurological diagnosis of the focal lesion is here of first impor- 
 tance, and the prominence of sensory and motor symptoms in the 
 cases of brain tumor, for ipstance, is one point of difference. The 
 hemiplegia of hemorrhagic effusion also is more permanent than that 
 found in general paresis, and the dementia is secondary to the focal 
 lesion and is marked by aphasic and amnesic disorder, and the physi- 
 cal symptoms are not the same as in general paresis as regards the 
 ocular and deep reflexes. 
 
 The prodromal stadium of general paresis must not be mistaken 
 for simple mania or melancholia. A careful research will usually 
 reveal some of the physical symptoms of the progressive disease, but 
 it is always well to bear in mind the possibility of the more hopeless 
 affection in all mental aberration beginning with depression or ex- 
 citement. A still more serious error is to mistake the simple psychoses 
 for general paresis. 
 
 ISTeurasthenic Insanity, with its muscular exhaustion and inco- 
 ordination of speech and gait, has repeatedly given rise to this mis- 
 take in diagnosis. The neurasthenic impairment of speech has even 
 led to the diagnosis of general paresis in the absence of any real psy- 
 chosis. The avoidance of undue haste in the formation of an opinion 
 will serve to avoid such gross faults. 
 
 General paresis is to be distinguished from syphilitic Insanity 
 with difficulty. In the latter the paralysis of cranial nerves, the dis- 
 tinct focal lesions, the persistent cephalalgia at night, the paralytic 
 rather than ataxic nature of impaired motion, serve to differentiate the 
 two complaints. There are cases which can only be distinguished 
 by the course and curable nature of the syphilitic disease, and in still 
 other cases the pathological lesions alone can decide post-mortem. 
 
 In alcoholic cases the tremors, sensory disorder, and suspicious 
 delusions, and the nature of the hallucinations, may, in the absence 
 of pupillary and speech defects, as in general paresis, serve to dif- 
 ferentiate the two affections. There are cases, though, of alcoholic 
 pseudo-paresis to be distinguished only by the final result, and the 
 fact of curability may alone decide the nature of the disease in cer- 
 tain syphilitic pseudo-pareses. 
 
 Multiple cerebro-spinal sclerosis may resemble general paresis, 
 .since it may be attended by a gradual mental impairment. The 
 speech defects, reflexes, and pupillary reactions, and other physical 
 symptoms, are seldom grouped as in general paresis, and the ex- 
 pansive feelings and delusions are wanting. 
 
672 TEXT-BOOK ON MIi:NTAL DISEASES. 
 
 Monomania, with delusions of grandeur, is a more systematized 
 Insanity than general paresis,_pursues a more chronic course, has a 
 longer evolution, and hicks the general weakness of intellect of 
 paresis, and also the physical symptoms. 
 
 Post-febrile Insanity may present stuporous states, and tremor 
 and speech defects from exhaustion of nerve centres, but the history 
 of the case and the favorable progress made within a few weeks will 
 usually serve to differentiate the post-febrile from the paretic state. 
 
 Senile dementia, with epileptic attacks, ma}^ excite suspicion of 
 general paresis. The age of the patient, and the lapse of some months 
 without any progression of physical symptoms, suffice to decide the 
 case, ordinarily. 
 
 General paresis in young persons, when attended by frequent 
 epileptiform seizures, may be mistaken for epileptic Insanity, but the 
 ocular and deep reflexes and speech defects usually correct the error 
 in the course of a few months. 
 
 The history of the case, and special symptoms peculiar to the ac- 
 tion of the different poisons, serve to diagnose toxic Insanity from 
 general paresis. Plumbic cases, though, are difficult sometimes to 
 distinguish from paresis, which bromic dementia may also closel}' 
 resemble. The difference in the toxic insanities is chiefly in the fact 
 that only a few symptoms are present and that pupillary and speech 
 disorders are usually wanting in the order and constancy in which 
 they appear in general paresis, and that the mental expansion and 
 exaggerated delusions are rarely prominent at any time, and that 
 the motor troubles are limited, and not general or progressive. Ex- 
 ceptionally, all differential signs fail, and time alone can decide, and 
 whenever a cure results general paresis has not existed. 
 
 Prognosis. — The prognosis of general paresis as to recovery of 
 mind is always bad. Eecoveries have been reported, but most authors 
 are inclined to doubt the diagnosis in these cases, and they hold to 
 the incurability of the mental disorder. 
 
 The prognosis seems more favorable if long remissions of months, 
 or even one or two years, are regarded as recoveries, which would 
 seem to have been the case. Severe trauma and intercurrent infec- 
 tious diseases have been known to cause a species of recovery from 
 general paresis, but mental defect remains, even though the progres- 
 sive deterioration be arrested in very rare instances. 
 
 The prognosis as to the chances of life is also bad, for general 
 paresis ends fatally, on the average, within three years. The actual 
 duration is less in men than in women, and it is greater in hereditary 
 
INSANITY WITH DEFINITE LESIONS. 673 
 
 cases and in cases with marked alternations of depression and ex- 
 citement. 
 
 Excluding alcoholic and syphilitic cases of pseudo-paresis, it is 
 safe to predict a fatal termination in a case of general paresis. The 
 extreme possibility of a prolongation of life for many years under 
 the best of care is to be stated. 
 
 Death may occur from marasmus, decubitus, suffocation from 
 food, pneumonitis, cedema of lungs, cerebral or spinal hemorrhage, 
 cardiac or renal disease, self-inflicted violence or injuries from acci- 
 dent, septic infection or bulbar sclerosis. 
 
 Treatment. — Prophylactic treatment is seldom employed, as the 
 diagnosis can seldom be made in advance of the speech defects and 
 other somatic signs. In suspected cases it is well to advise rest and 
 favorable hygienic conditions, and the avoidance of worry and ex- 
 citement. But, if this course causes loss of salaried positions and 
 financial trouble, it would only increase the stress of mind, and a 
 simple diminution of labor in customary occupation may be a wiser 
 prophylactic measure in certain cases. Some paretics are easily man- 
 aged by relatives, and do not endanger their property or the personal 
 safety of themselves or others. 
 
 Ordinarily, it is necessary to place paretics in private or public 
 hospitals for the insane to protect them against business extravagance 
 or the violence which they may inflict upon self or others, as well as 
 to secure the constant care demanded by paretics during the acute 
 stage of the disease. 
 
 With the advent of the bedridden stage home care may again be 
 resumed under competent and constant nursing. During remissions, 
 also, liberty may be allowed the patient, under certain supervision, if 
 safety require it. 
 
 Hygienic measures are of most avail in prolonging life and com- 
 fort of the patient. 
 
 Good food, specially prepared to avoid the danger of suffocation 
 in advanced cases, and given semi-fluid or cut in small pieces, is of 
 first importance. A full physiological ration of foodstuffs is best, 
 and milk and eggs may be regarded as the two most reliable articles 
 of diet. During the accumulation of flesh in the demented stage a 
 diminution of the full ration may be permitted, and later, during 
 decline, predigested foods are useful. 
 
 Fresh air, long hours of sleep at night and a siesta in the day- 
 time, gentle exercise, and the sitting rather than recumbent posture 
 43 
 
674 TEXT-BOOK ON MENTAL DISEASES. 
 
 SO long as patients are alDle to be about, is preferable in order to avoid 
 decubitus. 
 
 Therapeutic measures correspond to the causes and symptoms. 
 
 When syphilis is diagnosed, or suspected from the nature of the 
 symptoms, specific treatment by mercurial inunction and by internal 
 administration of the protiodide of mercury is to be followed by the 
 use of iodide of potassium in full doses. In case of syphilitic pseudo- 
 paresis a cure may follow, but no decided improvement will other- 
 wise result. Mercurial baths are of service in this connection. 
 
 Among the many remedies tried,* with only occasional temporary 
 benefit in general paresis, are calabar bean, digitalis, strychnine, tartar 
 emetic, quinine, nitrate of silver, zinc, arsenic, bromide and iodide 
 of potassium, veratrine, hyoscine, duboisine, and chloral. The latter, 
 as a rule, is to be avoided, since it tends to increase the cerebral 
 congestion, which is a prominent symptom of the disease. 
 
 In the terminal stadium tonics, iron, and cod-liver oil are em- 
 ployed. 
 
 Laxatives are of use, but purgatives as powerful derivatives have 
 no permanent effect, and only tend to weaken the patient for the time 
 being, except in the seizures. 
 
 Ergotine, for its vascular effect, is of some service and merits a 
 careful trial in patients of full habit with sound heart and lungs. 
 
 Surgical procedures afford temporary relief in some cases. Coun- 
 ter-irritants to the head, neck, and spine have been repeatedly em- 
 ployed, more often without than with good results, Croton-oil, 
 ung. antimon. tart., and other irritants, have been used to produce 
 blisters and suppuration of the scalp, and benefit has been claimed 
 even when necrosis of bone has resulted. 
 
 Setons, vesicants, the electric cautery and the red-hot iron have 
 been used on the back of the neck; spinal vesicants have been tried, 
 and leeching, bleeding, and blisters to the legs and feet. 
 
 Trephining of the skull has been performed in America and Eng- 
 land, without such results as justify the recommendation of the rem- 
 edy to the general practitioner. 
 
 Vertebral puncture affords a simpler means of relief from cerebral 
 pressure, but is without curative effect, though Justifiable as a pallia- 
 tive procedure. The operation has been described in the chapter on 
 treatment in the first part of the work. 
 
 Spinal suspension and stretching of the cord have been tried, as 
 is claimed, with some benefit, but too much doubt attaches to such 
 procedures as yet to permit their indorsement. 
 
i:^rsA2iriTY with definite lesions. 675 
 
 Galvanization of the head and spine may afford some relief, if 
 practised with expert knowledge and caution. General faradization, 
 combined with massage, is tonic and sedative if thoroughly done, and 
 relieves the vasoparetic stasis of cutaneous capillaries for the time 
 being. 
 
 Frequent catheterization is to be avoided so long as the patient 
 can, by voluntary effort, empty the bladder. Pressure with hands 
 may assist the complete evacuation of the viscus, which it is well 
 to effect to avoid retention and decomposition of urine. 
 
 Massage is employed to favor alvine passages, and enemata are 
 also useful. 
 
 Special symptoms to be met are as follows: Insomnia is to be met 
 with warm baths, with cold to the head after a stimulant enema. If 
 the feet are cool, hot mustard foot-baths are advisable, and cold foot- 
 baths followed by active friction of feet and legs may answer. The 
 bromides, sulphonal, paraldehyde, and other drugs, such as morphine 
 or hyoscin, may become necessary when motor excitement is com- 
 bined with the agrypnia. Cerebral galvanization may be of use. 
 
 Extreme excitement may be subdued by prolonged baths, with 
 cold to the head, but veratrum viride, bromides, duboisine, or mor- 
 phine may be lesser evils than the exhaustion from the unrestrained 
 excitement. Sensorial excitement, especially when visual, is some- 
 times relieved by seclusion in a dark room and blisters behind the ears. 
 
 The subcutaneous use of ergotine may also relieve cerebral con- 
 gestion, which often underlies the excitement. Digitalis is of some 
 use in equalizing cerebral circulation in this connection, and a saline 
 cathartic is sometimes of service. 
 
 The epileptiform seizures call for evacuation of bladder and rec- 
 tum, and the use of chloral hydrate by mouth or enema. In the sta- 
 tus epilepticus chloroform inhalation may be justified, and a drop 
 of croton-oil on the tongue may, by purgation, tend to relieve the 
 cerebral congestion. 
 
 The apojolectif orm attacks demand cold to the head by the ice-cap, 
 ergotine and bromides, heat to extremities, and active derivation 
 through the intestinal tract. For the latter purpose oleum tiglii 
 (TTl, ij.) is well adapted. Stimulant enemata of turpentine or cam- 
 phor, venesection or leeches behind the ears, and local blood-letting 
 may be employed in extreme cases. 
 
 During the bedridden stage frequent change of position and con- 
 stant attention to cleanliness are necessary to avoid bed-sores. The 
 cleansing is best done by warm antiseptic solution, and friction is 
 
676 TEXT-BOOK ON MENTAL DISEASES. 
 
 to be avoided in drying the parts, pressure alone being used. An 
 ointment of benzoated lard and a little white wax prevents subse- 
 quent contact of urine with the skin in exposed parts. 
 
 Artificial feeding may become necessary from the paralysis of 
 pharynx and cesophagus. 
 
 Water-beds and air-cushions are useful in this stage, and pro- 
 longed hot-water applications favor the healing of deep sloughs, 
 which are to be treated on antiseptic principles in general. Cystitis 
 is common in this final stage, and rupture of the bladder may occur 
 from over-distention, if care is not exercised in personal examinations 
 of the patient. Hope of life is never to be abandoned, as most unac- 
 countable remissions may occur in the terminal stadium. 
 
 Section II. — Syphilitic Insanity. 
 
 A certain psychological change takes place in a large percentage 
 of those attacked by syphilis, but positive mental disorder results 
 chiefly in the following class of cases: 1. In cases with heredity in 
 which the specific disease acts as a moral exciting cause in advance of 
 the physical lesions. 2. Mental disorder initiated by the syphilitic 
 fever and early toxic influence of the virus on unstable cerebral 
 centres. 3. Insanity provoked by the secondary symptoms, and by 
 general nutritional and constitutional disturbances. 4. Mental dis- 
 ease from tertiary changes of cerebral syphilis, resulting in a variety 
 of focal lesions, or difl'use cortical deteriorations, or vascular de- 
 generations. 5. Psychoses in children from hereditary syphilis. 
 6. Pseudo-paresis from cerebro-spinal syphilitic lesions. 
 
 While the term syphilitic Insanity is as appropriate as any other 
 etiological designation, it is more consistently applied to cases in 
 which definite cerebral or spinal lesions are the direct outcome of the 
 syphilitic infection, and the immediate factor of the alienation. 
 
 Definition. — Syphilitic Insanity is mental disorder arising from 
 the immediate or remote effects of the luetic virus on nervous, vas- 
 cular, and glandular tissues, and manifested by melancholic, mani- 
 acal, stuporous or demented states, accompanied by paralysis of cranial 
 nerves, impairment of the special senses, nocturnal cephalalgia, and 
 other clinical features of the specific disease. 
 
 Clinical Delineation. — Syphilis, acting on those predisposed to 
 mental disease, may soon after infection excite an attack of melan- 
 cholia, through dread of the future results, through fear of loss of 
 business or social standing, inability to meet marriage engagement. 
 
INSANITY WITH DEFINITE LESIONS. (577 
 
 or liability of infection of family if married, or anxiety as to the 
 probability of mental disease to which, hereditary tendency is known 
 to exist. In this way syphilis may become a powerful exciting causo 
 prior to distinct physical lesions, and the syphilophobic melancholia 
 which results is usually attended by active suicidal tendencies, insom- 
 nia, refusal of food, self-accusation or religious despondency, and de- 
 lusions of persecution. 
 
 A more genuine syphilitic Insanity is an acute maniacal outbreak, 
 sometimes witnessed during luetic pyrexia and the primary action of 
 the virus on the entire organism. Doubtless a native instability of 
 nervous centres is a predisposing cause in these sudden maniacal at- 
 tacks, which resemble other toxic manias in clinical features. 
 
 With the secondary specific symptoms — the sore throat, cutaneous 
 eruptions, mucous patches, general enlargement of lymphatic glands, 
 and nutritional disturbances — forms of melancholia rather than 
 mania arise, but states of excitement or of weakness of mind may 
 result from the primary depression, which is not infrequently in- 
 tensely hypochondriacal in the first instance. The psychosis is at- 
 tributable to the syphilitic dyscrasia, as well as to lesions of gangli- 
 onic elements in cerebral centres. There is considerable sensorial 
 disorder, and hallucinations of sight and hearing are frequent sources 
 of the depressing delusions. This sensorial disorder only foreshadows 
 the subsequent inflammatory and atrophic processes which occur in 
 the organs of special seuGe, and also specially in optic and acoustic 
 nerves. 
 
 The mental disease most deserving the designation syphilitic In- 
 sanity results from tertiary lesions of cerebral centres, from vascular 
 degenerations, focal brain disease, diffuse sclerotic or atrophic proc- 
 esses, and gross structural changes in internal organs. 
 
 The maniacal and melancholic attacks are characterized by remis- 
 sions, but a continuous impairment, in the long run, of all the mental 
 faculties; so that mental weakness is the resultant state, which, under 
 specific treatment, may still disappear in a most surprising manner. 
 In some of these cases syphilitic epilepsy leads to early stuporous 
 states; in others the mental obtuseness would seem to result from 
 syphilitic impairment of the special senses, and the hallucinatory 
 disorder has a like pathogenesis; in others still, the irritability, emo- 
 tional weakness, and amnesic aphasia is associated with unilateral 
 loss of motion of extremities. 
 
 There is sometimes a symptom-complex of syphilitic sensorial 
 disorder, paralysis of cranial nerves, and progressive moral deteriora- 
 
678 TEXT-BOOK ON MENTAL DISEASES. 
 
 tion, which may resemhle the ethical obUteration of general paresis 
 without active expansion or depression of feeling. The coensesthetic 
 exaltation of general paresis is very rarely found in syphilitic Insan- 
 ity, in which a depressed and painful coenffisthesis is the rule. 
 
 Insanity in children from hereditary syphilis most often takes 
 the form of mental deficiency, or of alienation from deprivation of 
 the special senses. Infantile psychoses arise, however, from the 
 fifth to the twelfth year as the outcome of the specific inheritance. 
 They have a depressive emotional ground-tone, and fear and sus- 
 picion are heightened by hallucinations of the special senses. 
 
 Among tainted children there will also be seen a progressive men- 
 tal and moral deterioration, beginning after a bright early childhood, 
 and ending in terminal dementia, or modified forms of idiocy or im- 
 becility. 
 
 Finally, there are syphilitic pseudo-pareses, which have a different 
 grouping of sensory and motor symptoms from general paresis, in 
 the main, but occasionally resemble it so closely that a symptomatic 
 differentiation between the two affections becomes impossible, and 
 recovery under specific treatment alone serves to clear up the diag- 
 nosis. The cliief differences in neurological and psychic features are 
 that in syphilitic pseudo-paresis there are paralytic rather than ataxic 
 muscular affections — paralysis of cranial nerves, monoplegic and hem- 
 iplegic disorders — and the motor troubles appear relatively earlier 
 than the psychic symptoms, hypochondriacal rather than expansive 
 ideas abound, tremor of facial muscles is less marked, cachexia is a 
 more prominent and earlier symptom, the sequence of all the symp- 
 toms is more capricious and changeful, and the remissions are more 
 sudden and prolonged on the average. These symptomatic differ- 
 ences correspond to actual differences in the site and nature of the 
 anatomical lesions with two affections. 
 
 Causes. — The syphilitic virus, like the alcoholic poison, produces 
 Insanity in some and not in others. The individual vulnerability, as 
 regards the psychic result, is perhaps hereditary and possibly acquired 
 instability of nervous centres. Occasionally the syphilis is only the 
 last of a long list of untoward influences, both physical and mental, 
 and it is seldom that it is the sole known factor. 
 
 Making due allowance for these facts, there still remains suffi- 
 cient proof that the mental disorder follows the luetic infection, varies 
 with its lesions, remits and recurs with its fluctuations, and deepens 
 into dementia when tertiary disease invades the cerebrum extensively. 
 
 It has ceased to be a matter of doubt that hereditary syphihs may, 
 
INSANITY WITH DEFINITE LESIONS. 679 
 
 like the primarily acquired disease, cause extensive degeneration of 
 nervous centres and physical arrest or deterioration. 
 
 It is well known that some persons are invulnerable as regards the 
 luetic virus, in the first instance, and hence may have immunity from 
 syphilitic Insanity. It is not impossible that psychopathic persons 
 are more often attacked by cerebral syphilis, and this would seem to 
 be the case among brain-workers, as compared with those engaged 
 in manual occupations, when suffering from specific inoculation. 
 
 Severe mental labor and stress of mind in syphilitic patients are 
 undoubtedly favorable to the development of syphilitic Insanity, even 
 if they do not directly determine the site of organic cerebral lesions. 
 
 Stadia. — In the early attacks of mania or melancholia there is 
 a brief initial stadium of dread and forebodings of evil, and then a 
 stadium acutum, which, with judicious specific treatment, usually 
 ends in a stadium convalescens at the end of a few weeks. 
 
 The maniacal and melancholic attacks, which tend to pass into 
 mental weakness during the tertiary lesions, often have a long initial 
 stadium of increasing moroseness, insomnia, suspicion, and tedium 
 vitas, and then a stadium acutum of active mental disorder, with de- 
 lusions, hallucinations, suicidal or violent impulses, and remissions . 
 and progressive impairment of intellect; and this stadium, if not cut 
 short by specific treatment, may continue for months, or one or two 
 years, and then end in a stadium convalescens, or, more commonly, 
 in a stadium dementias. From this latter stadium there is still a 
 surprising possibility of recovery of mind, though with some defect. 
 
 In children with hereditary syphilis at the age of four or five years, 
 an initial stadium of restless malaise, nocturnal visions, and fright 
 passes, in a few months, into a stadium acutum of complete change 
 of disposition, hallucinations, insomnia, and convulsive seizures, or 
 spasmodic muscular affections, disorder of the vital functions and of 
 nutrition, and a general reduction of intelligence. A terminal sta- 
 dium dementiro or a fully developed idiotic state follows and seldom 
 admits of amelioration. 
 
 The pseudo-pareses have a prodromal stadium of some weeks or 
 months, a stadium acutum of months or years, with a great variety 
 of mental, motor, and sensory anomalies, similar to those of general 
 paresis, and a stadium dementi^e, from which recovery may take place 
 under the influence of specific remedies, or possibly as the result of 
 self-limitation of the disease. 
 
 Eemissions may also form a prominent feature of any of the stadia 
 above mentioned. In rare instances embolism, hemorrhage, or other 
 
680 TEXT-BOOK ON MENTAL DISEASES. 
 
 focal cerebral lesion may give rise to sudden mental disorder, and the 
 initial stadium drops out of the clinical course ordinarily pursued, 
 at least so far as objective symptoms are concerned. 
 
 Symptoms. — It is a general impression that irritability, morose- 
 ness, hypochondriacal ideas and feelings, and melancholic delusions 
 and states abound in S3^phihtic Insanity. It has been the writer's 
 observation that maniacal excitement is almost equally frequent, 
 though the symptoms are limited to rapid flight and noisy expression 
 of ideas, boisterous conduct, destructiveness and angry demonstra- 
 tions, and seldom include the extreme exaggeration and expansion 
 of feeling seen in paretics. It cannot be claimed that there is any- 
 thing specific in the psychic symptoms, but the fact that they are 
 usually preceded and accompanied by the motor and sensory anom- 
 alies of syphilis serves to present characteristic grou.ps of clinical 
 phenomena. Thus, nocturnal headache, paralysis of cranial nerves, 
 optic neuritis, vertigo, somnolence and convulsive seizures^, progres- 
 sive intellectual impairment mingled with hallucinations, delusions, 
 and active emotional excitement or depression, and sudden remissions 
 of these manifestations, can hardly be said to exist in any other type 
 of mental disease. 
 
 It was long ago pointed out by Meynert that tubercular basilar 
 meningitis gave rise to melancholic conditions, and it is probable that 
 the states of depression so common in syphihs are due to gummatous 
 basilar meningitis, and that maniacal symptoms spring from menin- 
 geal inflamxmations of the convexity of the brain, involving motor and 
 sensory cortical areas. Diabetes and polydipsia are more often symp- 
 toms of the melancholic forms, while monospasms and convulsive 
 seizures are most frequent in the maniacal types. 
 
 The syphilitic lesions of the nerves of special sense are account- 
 able largely for the sensorial illusions and resulting delusions. Optic 
 and acoustic perversions are the most constant, but hallucinations 
 of taste and smell also occur. In the excited states visual and audi- 
 tory disturbances chiefly abound, and the latter seem to persist in 
 the depressed forms, while the former are observed in stuporous con- 
 ditions. The endarteritis of basal arteries, deprivation of cerebral 
 blood-supply, embolisms and local softenings account for motor pa- 
 ralyses, usually taking the hemiplegic form, but from spinal menin- 
 gitis and myelitis paraplegia is also encountered. In spinal syphilis 
 the posterior nerve-roots are apt to be involved, and painful sj'-mp- 
 toms thus arising are the source of delusions of persecutions on the 
 part of the patient. 
 
INSANITY WITH DEFINITE LESIONS. 681 
 
 The somnolent and semi-comatose states pertain to sypliilis, and 
 are not to be mistaken for the stupor of an ordinary psychosis. The 
 sudden variations and remittences in all the symptoms are also char- 
 acteristic of the specific disease. In no other form of dementia does 
 an actual recovery take place, as happens among syphilitic patients, 
 who may have been for long months in profound hebetude, apparently 
 of a terminal nature. 
 
 All types of psychic disorder of specific origin tend to a gradual 
 impairment of all the mental faculties, and some form of mental weak- 
 ness is the final result of the melancholic and maniacal attacks in the 
 majority of cases. The peculiarity of these demented conditions is 
 their recoverability under treatment. 
 
 Pathology. — The mental disorder is the result of the syphihtic 
 lesions, cliiefly in nervous centres, though there is reason to believe 
 that the general invasion of the internal organs by the virus and the 
 luetic dyscrasia are adequate causes of mental alienation, indepen- 
 dently of cerebral changes of inflammatory nature. 
 
 Definite pathological lesions exist, however, in the majority of the 
 cases of syphilitic Insanity, and they are, in brief, as follows: Syph- 
 ilitic meningitis, with specific exudation and infiltration and prolif- 
 eration of round cells. The cortex cerebri may be sclerosed or atro- 
 phied in areas of arterial distribution, or in disseminated patches, and 
 in rare instances^softening occurs. Gummata may be present, exert- 
 ing pressure and interfering with nutrition in basal regions or on the 
 convexity of the brain. 
 
 Periarteritis and endarteritis, with obstruction or complete oblit- 
 eration of arteries, may be found, and the former affection may pre- 
 cede the latter. The small arteries, as well as the basal arteries, are 
 thus affected when situated in the vicinity of inflammatory exuda- 
 tion, in wliieh instance the periarteritis is the initial lesion of the 
 vessel. 
 
 Gummata of cerebral nerves are not infrequent. Embolism, hem- 
 orrhage, and local softening of brain tissue are also found in occa- 
 sional instances. The sclerotic processes may extend into the medul- 
 lary substance, though ordinarily confined to the cortex cerebri. In 
 all instances the arteries and meninges are primarily infiltrated by the 
 specific exudate. Finally, there are paretic and tabetic degenerations. 
 
 Dijferential Diagnosis. — The symptom-complex of paralysis of 
 cerebral nerves, optic neuritis, special sensorial disorder, mental de- 
 pression or excitement, with somnolence, nocturnal headache, vertigo, 
 
682 TEXT-BOOK ON MENTAL DISEASES. 
 
 convulsive seizures or hemiplegia, and progressive mental weakness, 
 is sufficient to establish the diagnosis of syphilitic Insanity. 
 
 The dementia of epilepsy is without these differential symptoms, 
 which are to be traced in the history of syphilitic dements with epi- 
 leptiform seizures. Organic dementia following apoplectic attacks 
 most nearly resembles S3^philitic Insanity with hemiplegic symptoms, 
 but here, too, the history of the case and the absence of all the specific 
 symptoms facilitates the diagnosis. In case of paretic dementia there 
 may be no means of differentiation from syphilitic pseudo-paresis 
 except the final fact of recovery in the latter. The symptomatic dif- 
 ferences which exist in such cases have been pointed out at the close 
 of the clinical delineation. 
 
 When syphilitic Insanity arises in the absence of decisive neuro- 
 logical sjmiptoms, or cerebral affections pointing to focal lesions, or 
 other characteristic implication of the nervous system, specific treat- 
 ment leading to rapid improvement may still render the differential 
 diagnosis possible. 
 
 Prognosis. — Syphilis, which is a microbic infection, has a natural 
 history of self-limitation at the end of a term varying from three to 
 ten years, on the average. Cerebral syphilis giving rise to Insanity 
 may, without treatment, pursue this natural course, and there may 
 then be complete recovery from both the specific and the mental dis- 
 ease. The mental disorder is only one symptom of cerebral syphihs, 
 and has a shorter average duration than the specific affection. Un- 
 fortunately, the mental disease may become fixed, while the luetic 
 affection disappears, and incurable dementia or chronic mania are the 
 usual terminations. 
 
 Partial recovery, with permanent defect, is not infrequent in 
 tertiary syphilis, but complete mental recovery is to be expected 
 chiefly in the acute mental disorder of the earlier cerebral lesions. 
 
 The young recover better than the old, women suffer less 
 severely than men, and S3^philitic Insanity in senile cases is most 
 unfavorable. 
 
 The earlier specific mixed treatment is undertaken judiciously, 
 the better is the prognosis. 
 
 Excessive mercurialization and insufficient attention to hygienic 
 measures renders the prognosis much more hopeless than neglect of 
 all treatment. 
 
 The prognosis is bad in cases of Insanity from hereditary syphilis. 
 
 The duration of life is greatly shortened by syphilitic Insanity, 
 
INSANITY WITH DEFINITE LESIONS. 683 
 
 which so often passes into terminal states of mental weakness, having 
 an average duration of life of not more than six years. 
 
 Severe forms of mental disease may follow mild forms of syph- 
 ilitic infection, and the converse is equally true. The cerebropathy 
 is most severe in those originally psychopathic. 
 
 Syphilis combined with alcoholic excess renders the prognosis ot 
 mental recovery very bad. An equally bad combination of causes 
 in prognosis is prolonged worry and excessive brain-work, and syph- 
 ilis. 
 
 Treatment. — Specific treatment is to be administered so soon as 
 the diagnosis of syphilitic Insanity has been made, provided the pa- 
 tient has not already been subjected to the same. The constitutional 
 effect of mercury is to be first obtained by protiodide of mercury, 
 grain one-fourth, ter in die, and increased rapidly, if need be. In 
 urgent cases inunction, or mercurial baths, give a more prompt effect. 
 
 Iodide of potassium, five grains, ter in die, with rapid increase of 
 the dose to one ounce, is to be continued, according to the effects 
 produced, or suspended temporarily, if not borne as expected. Very 
 large doses seem to be favored especially by American neurologists 
 in the treatment of syphilis of the nervous system. It is customary to 
 continue the protiodide for a year or two, and the iodides of potassium 
 or sodium for twice that length of time, with occasional intermissions 
 in the treatment. A generous diet, exercise, and all other hygienic 
 measures, including baths, are of much importance. 
 
 In cases with hereditary syphilis specific treatment is also to be 
 recommended. 
 
 This may be considered the heroic plan of treatment, but it gives 
 better results than the expectant plan of non-specific treatment by 
 tonics and baths and hygienic means alone. 
 
 During the specific treatment other drugs are to be avoided, so 
 far as possible. 
 
 It is well to continue the iodides so long as there are any symp- 
 toms of cerebral syphilis. The third year after infection is one of 
 special danger, and it is well to treat cases occurring at this time, 
 even in the absence of specific symptoms referable to the nervous 
 system. 
 
 It is well to state that some physicians rely on tonics and hygienic 
 measures, and never employ specific treatment in syphilitic Insanity. 
 
 Statistics show that cerebral syphilis is more common in those 
 luetic cases which have not been subjected to specific treatment, and 
 
684 TEXT-BOOK ON MENTAL DISEASES. 
 
 that the latter exerts a decided prophylactic effect in this regard in 
 those infected. 
 
 All the more recent literature of the subject sustains the idea 
 of the value of specific treatment. 
 
 Alcohol, sexual excess, mental strain, and business worry must 
 be avoided. Long hours of sleep, and open-air life and plentiful 
 nourishment are essential. 
 
 Surgical interference may be justified for the removal of a large 
 syphilitic gumma of the convexity of the brain when specific treat- 
 ment is without effect and pressure symptoms are urgent. As often 
 as there are recurrences of symptoms of brain syphilis, or of mental 
 disorder, specific treatment should be renewed. Atrophic, sclerotic, 
 and other specific degenerations of cerebral and spinal tissues in 
 chronic cases of syphilitic Insanity will not be relieved by specific 
 remedies, but roborant treatment may avert, for a time, the fatal 
 termination. 
 
 Section III. — Organic Dementia. 
 
 There are certain coarse brain diseases which give rise to disorder 
 and impairment of the mental faculties. The mental disease may 
 have an acute phase of maniacal, melancholic, or stuporous aberra- 
 tion, bvit there usually results a form of dementia which is termed 
 " organic," from the nature of the brain lesions which underlie it. 
 The gross organic brain diseases which are causative of this type of 
 Insanity are hemorrhages, embolism, thrombosis, tumors, ramollisse- 
 ment, hydatids, such as ecchinococci and cysticerci, and other coarse 
 cerebral affections. The mental alienation thus resulting naturally 
 falls in the present group of insanities with definite lesions of cerebral 
 structures. 
 
 Definition. — Organic dementia is a form of mental aberration 
 from coarse brain disease, manifested in excited, depressed, or stupor- 
 ous phases, but eventuating in more or less permanent demented 
 states, characterized by amnesic and aphasic symptoms, emotional 
 weakness, confusion of ideas, sensorial perversions, and often progres- 
 sive failure of mental faculties, in addition to motor and sensory 
 anomalies caused by the cerebral lesions. 
 
 Clinical Delineation. — The features of mental aberration vary in 
 time and order of appearance with the nature of the coarse brain 
 disease. Taking cerebral hemorrhage as one of the most common 
 factors of organic dementia, maniacal excitement may appear within 
 
INSANITY WITH DEFINITE LESIONS. 685 
 
 a few days of the effusion and disappear within a fortnight; or, the 
 focal irritation may result in melancholia of some weeks' duration, 
 with morose and irritable moods, and suspicions of poisoning; or, 
 confused and forgetful, with sensory aphasic symptoms, the patient 
 may in a few months sink into a demented state, in which he is as 
 silly, weak, and childish as a general paretic. In this typical state 
 of organic dementia there is no fundamental mood of excitement or 
 depression, but great emotional weakness, shown in uncontrolled 
 laughing or crying on slight provocation. Memory is specially im- 
 paired for recent events, and for names, dates, places, and persons; 
 various forms of aphasia may exist; the sensory and motor phenom- 
 ena vary with the site of the effusion; exacerbation of brief excite- 
 ment or suicidal depression may occur, but the state is mental 
 feebleness. 
 
 In cases with insane heredity there may be alternations of melan- 
 cholic and maniacal moods, and intervals of continuous mental en- 
 feeblement for a series of years, but the termination is ordinarily 
 dementia, just as in those not originally psychopathic. 
 
 If tumor of the fore-brain be the source of trouble, headache, 
 vertigo, spasmodic affections, impaired special senses, and disordered 
 speech may be observed; also loss of attention and memory, irascible 
 or lachrymose moods, progressive hebetude and mental incapacity, 
 with intercurrent maniacal or melancholic symptoms. Brief deliri- 
 ous attacks, with pyrexia, are to be distinguished from the other 
 aberrations of mind. In the bedridden stage stupor an4 «emi-coma- 
 tose conditions also appear, and convulsive seizures are common. The 
 fatal end is attained more rapidly than even in general paresis, except 
 in the case of gummatous tumors or those of traumatic origin. 
 
 Embohsm sometimes causes brief mental disorder of the maniacal 
 type, followed by prompt recovery, but thrombosis is apt to give 
 rise to more permanent psychic disturbance, and this is also the 
 case in all vascular obstruction ending in wide ramollissement of 
 cerebral substances. 
 
 Thrombosis is associated often with obliterating endarteritis and 
 fatty heart, and the advent of dementia is favored by decubitus, hypo- 
 static congestion of internal organs, and other physical complications 
 which arise in the bedridden state, as well as by the existing cerebral 
 vascular degenerations. In ill-nourished senile cases and in post- 
 febrile exhausted patients there is also marantic thrombosis, which 
 causes stupor, and usually ends fatally in a brief period. Malignant 
 embolism, causing septic encephalitis, is too suddenly fatal to admit 
 
686 TEXT-BO.OK ON MENTAL DISEASES. 
 
 of any intervening mental disorder, as a rule, but embolism from 
 pulmonary abscesses in phthisical cases may cause maniacal excite- 
 ment. 
 
 There is no doubt that embolism from endocarditis occasionally 
 causes softening of the brain and organic dementia, though throm- 
 bosis and hemorrhage are the chief sources, in those advanced in 
 years beyond middle age, of this form of mental disease. 
 
 The aphasic symptoms are important in these cases, having med- 
 ico-legal relations, and the paraphasia may be mistaken for incohe- 
 rence, and word-deafness and word-blindness for a degree of de- 
 mentia which does not exist. 
 
 Cases of sensory aphasia are often sent to hospitals for the insane, 
 but they may still possess reasoning power and right understanding 
 of the affairs of life, and are not necessarily demented, as can readily 
 be demonstrated by appropriate tests. A very careful study of all the 
 features of hemiplegic and aphasic cases is necessary before they can 
 be regarded as instances of organic dementia, even when alexia, 
 apraxia, and paraphasia are present in connection with some emotional 
 weakness. 
 
 Causes. — Periarteritis, endarteritis, and miliary aneurisms, and 
 other vascular degenerations from alcoholism and senility, are the 
 prime causes of hemorrhages, favored also by increased blood-pressure 
 from renal disease and cardiac hypertrophy. Cerebral c'ongestions, 
 also, from whatever source, are favoring conditions of intracranial 
 hemorrhage. 
 
 Organic dementia from embolic processes may be traced, in the 
 first instance, to ulcerative endocarditis, aneurisms, microbic or py- 
 emic foci in internal organs, or malignant growths; while throm- 
 botic occlusion springs often from arterial degeneration and the 
 cardiac enfeeblement of old age or of infectious disease. The cere- 
 bral tumors which cause dementia may proceed from tubercle, syph- 
 ilis, or trauma capitis, which is a very important factor in the history 
 of many cases. Parasitic tumors are rare but authenticated causes 
 of organic dementia. Glioma and sarcoma and cancer are much 
 less common than tubercle- and specific tumors. 
 
 Brain abscess of the chronic form may cause mental weakness, 
 and active recurrences of disorder of intellect. The cause of brain 
 abscess is microbic infection from otitis media or from suppuration 
 in more distant organs, from which pyogenic micro-organisms are 
 conveyed by the circulation to the brain. Ordinarily the mental dis- 
 
INSANITY WITH DEFINITE LESIONS. 687 
 
 turbance created by suppurative encephalitis is too brief to be reck- 
 oned as Insanity. 
 
 Pachymeningitis hemorrhagica and traumatic cranial injuries, fol- 
 lowed by extensive inflammatory changes of meninges and cortex, are 
 to be enumerated among the occasional causes of organic dementia. 
 
 Stadia. — The initial stadium is very brief after apoplectic seizures 
 before the acute stadium of maniacal excitement in some cases. Thus, 
 after cerebral hemorrhage there may be a few days of confusion of 
 ideas or stupor, followed by a maniacal stadium acutum of two or 
 three weeks, and then b3^ a stadium convalescens of the mental dis- 
 order, as there may be then compensatory adjustment of cerebral cir- 
 culation, and the clot may cease to be an active source of irritative 
 disturbance. 
 
 In other instances there is an initial stadium of some months, 
 following a hemiplegic attack. The irritability and painful feelings 
 pass into an acute stadium of melancholia, which may continue for 
 a year and end in a terminal demented stadium. The stadium acutum 
 is sometimes interrupted by remissions of some weeks, or there may 
 be alternations of depression and excitement. The exacerbations 
 sometimes correspond to new hemorrhages from miliary aneurisms. 
 
 In case of tumors the initial stadium is sometimes protracted for 
 a year or more, with depression of feeling, occasional sensorial per- 
 versions, as the special senses become involved by the anatomical 
 changes and by pressure, and the stadium acutum is of a few months' 
 duration and is marked by hallucinations, delusions, stuporous or 
 maniacal attacks, convulsive seizures, loss of sensation or motion, and 
 other phj'sical symptoms due to the tumor, and then may follow 
 coma or stupor in the fatal stage; for such cases, on the average, 
 perish more promptly than paretics. Brief stadia and recurrent at- 
 tacks are to be observed in embolic processes, while in senile cases 
 thrombosis often has a lengthy stadium acutum, and ends in a de- 
 inented stadium, which terminates life, in most instances, within two 
 or three years, and the same may be said of chronic brain abscess. 
 
 Symptoms. — In the group of insanities with definite lesions of 
 the encephalo-spinal nervous system, the mental disorder is charac- 
 teristic only through the grouping of the physical and mental symp- 
 toms, and not from any specific traits of the aberration of mind. 
 The maniacal, melancholic, and stuporous symptoms are blended in 
 organic dementia with vertigo, nausea, headache, convulsions, amau- 
 rosis, optic neuritis, hemianopsia, palsies of cranial nerves, paras- 
 thesige, ansesthesise, aphasia, protospasms, hemiplegia and paraplegia. 
 
688 TEXT-BOOK ON MENTAL DISEASES. 
 
 and other somatic sequelae of various modes of invasion of nervous 
 centres by focal lesions. 
 
 Climacteric, post-febrile, and senile, alcoholic, or diathetic states 
 also modify the semeiology of organic dementia in some cases. 
 
 The two most characteristic psychic symptoms are the emotional 
 weakness, shown in childish, or even automatic, laughing and crying, 
 and the general enfeeblement of all the mental faculties. 
 
 Complete sensory aphasia is not very rare, but ordinarily there 
 are mixed forms of motor and partial sensory aphasia. When mem- 
 ory for the auditory and graphic signs of language is lost, as well as 
 for the nascent motor impulses essential to speech, dementia is inev- 
 itable, and reasoning is no longer possible. Great improvement often 
 takes place gradually in these aphasic conditions. The stupor of 
 organic dementia is not, as in the functional psychoses, due to power- 
 ful inhibition or to hallucinations, but to actual failure of association 
 of connected memories and to loss of power of attention. The de- 
 mentia itself is due not to functional but to organic impairment of 
 the cerebral mechanism. It is even possible, from the profound 
 nature of the stupor alone, to predict focal brain disease before the 
 physical signs of the latter appear. The fluctuations and recurrences 
 of the mental symptoms are also characteristic, and point to exten- 
 sion of the pathological processes, and the mental disorder through- 
 out its entire course may be regarded as subordinate to the organic 
 brain disease. The irritation of sudden cerebral hemorrhage may 
 cause mania, and, as the clot becomes encysted, melancholia may 
 supervene, and rupture of the cyst and more effusion may again be 
 attended by a maniacal outbreak, and dementia may be the sequel 
 of this second phase of the focal disease. 
 
 Almost any imaginable sequence of the psychic symptoms may 
 thus originate. Hallucinations of the special senses, perversions of 
 common sensation, disorders of the muscular system and of the vital 
 functions of respiration, digestion, and circulation, and delusions of 
 a painful nature, chiefly, are among the prominent symptoms of 
 organic dementia. 
 
 Pathology. — Coarse brain disease produces Insanity in some per- 
 sons and not in others. Bilateral lesions and diffused processes 
 cause more extensive damage of mind than unilateral or circum- 
 scribed lesions, and this is true of cortical as compared with subcor- 
 tical lesions. It would seem that very slight disease of cerebral tissues 
 excites mental disorder in some persons, already predisposed, but that 
 there are persons in whom the most extensive focal disease causes 
 
INSANITY WITH DEFINITE LESIONS. 689 
 
 simply diminution of intelligence in proportion to the cerebral struct- 
 ures actually destroyed, and never active aberration. 
 
 In organic dementia brain abscesses may be in the temporal lobes 
 from otitis media, or in the frontal, pariettil, or occipital lobes. The 
 brain-cells and fibres are destroyed, proliferation and then disinte- 
 gration of giia-cells takes place, and a fibrous envelope encloses the 
 abscess in chronic cases. Multiple abscesses of microbic origin may 
 exist, but such pya?mic abscesses are small. 
 
 Cerebral hemorrhages causing organic dementia arise from degen- 
 erations of arteries, and are favored by renal disease, cardiac hj'per- 
 trophy, and whatever increases unduly intra-arterial blood-pressure. 
 
 Diseased states of the blood itself may lead to hemorrhage. The 
 rupture is most often in the branches of the middle cerebral artery 
 into the caudate or lenticular nuclei or optic thalamus, or seconda- 
 rily into the ventricles, and the effusion is in a few weeks encysted; 
 but previously there may be irritative disturbance of brain functions 
 and maniacal symptoms. On account of pressure, large hemorrhages 
 are more decided causes of mental disorder than smaller ones. Ee- 
 peated hemorrhages are specially apt to result in organic dementia, 
 though death often terminates a third apoplectic seizure. Cases of 
 slight attacks recurring every few months for a year or two are ex- 
 ceptionally seen, and are due to miliary aneurisms, perhaps. 
 
 Thrombosis from atheroma of arteries which supply the corpora 
 striata, is common, and it may be followed in turn by embolism, hem- 
 orrhage, and softening of brain structures. 
 
 Embolism of the middle cerebral may affect cortical areas and 
 gives rise to active mental disturbance in some cases. Tumors of the 
 brain in the frontal and occipital lobes are specially wont to disorder 
 mental functions, and when large they almost always cause enfeeble- 
 ment, as well as active disturbance of intellect by irritation, pressure, 
 and by secondary rupture of vessels and hemorrhages. Apart from 
 tubercle and luetic tumors, glioma and sarcoma are most common in 
 cerebral tissues, as causes of organic dementia. Cases from ecchino- 
 cocci, cysticerci, and the micro-parasitic affection, termed actino- 
 mycosis, have also been reported. 
 
 Differential Diagnosis. — This form of Insanity is to be differen- 
 tiated from epileptic dementia from the fact that epileptiform seiz- 
 ures are never the only symptom of focal brain disease causing or- 
 ganic dementia, and the history of the two diseases is different, and 
 epilepsy pursues a more chronic course before giving rise to a de- 
 44 
 
690 TEXT-BOOK ON MENTAL DISEASES. 
 
 mentia, which, itself has a longer duration, and a much less promptly 
 fatal termination in the majority of cases. 
 
 The neurological symptoms also serve to differentiate organic 
 dementia from senile dementia, with syncopal attacks due to cardiac 
 feebleness, or with epileptic seizures. Headache, vertigo, vomiting, 
 optic neuritis, palsy of cranial nerves, protospasms, hemiplegia, the 
 history of causes of focal brain disease, and any or all the signs of its 
 actual presence, serve to make the differential diagnosis. 
 
 Should a simple melancholia or mania suddenly pass into a pro- 
 found stupor of long continuance, focal brain disease may be sus- 
 pected, and a probable diagnosis of organic dementia may be made 
 in advance of the physical signs of the focal lesions. 
 
 It is sometimes difficult to differentiate this type from alcoholic 
 dementia, in which there may be apoplectiform seizures, but rarely 
 any permanent loss of power of limbs. It is only by the history of 
 the case and a careful study of the complete group of symptoms in 
 the order of their occurrence that a correct opinion can be formed in 
 intemperate patients mentally enfeebled. If there is a history of focal 
 brain lesions prior to the dementia, it is to be assumed that the latter 
 is organic. 
 
 In the terminal stage, and upon appearances alone, it might be 
 difficult to distinguish certain paretics from organic dements, but 
 the early history of the cases and the entire course of both the psychic 
 and somatic symptoms seldom fail to furnish sufficient points of 
 difference for a diagnosis. It requires neurological sldll of high order 
 to always make a correct diagnosis of organic dementia, since it im- 
 plies the faculty of interdifferential diagnosis of focal brain diseases 
 among themselves. 
 
 Prognosis. — The hope of mental recovery is very shght, and the 
 chances of death within a few years, at the furthest, are very great. 
 This general ojsinion admits of some exceptions. 
 
 The prognosis in any particular case depends directly on the 
 nature of the brain lesion. Tumors having attained the size neces- 
 sary to cause dementia are of bad prognosis, and will generally end 
 fatally within two years. Syphilitic tumors, and those admitting 
 surgical removal, are exceptions to this statement. 
 
 The prognosis in apoplectic effusions is bad, though there may 
 be recovery, with mental defect, from a first attack. Life itself is en- 
 dangered greatly by a second hemorrhage, and a third apoplexy is 
 rarely survived. The existence of organic dementia testifies to the 
 severity of the hemorrhages, as a rule. 
 
INSANITY WITH DEFINITE LESIONS. 691 
 
 Cerebral emboli and thrombosis are but little more favorable than 
 hemorrhages. Brain abscesses are always of bad prognosis, both 
 for mental recovery and for hfe. 
 
 Senility, cardiac and renal disease, alcoholism, atheromatous and 
 sclerotic degenerations of vessels, and diathetic states are bad elements 
 of prognosis, and some of them appear in the history of most eases 
 of organic dementia. 
 
 Treatment. — The only hope of radical cure lies in precarious sur- 
 gical procedure. Antiseptic brain surgery renders the evacuation of 
 brain abscess or the removal of tumors of the convexity less desperate 
 than formerly. 
 
 Symptomatic treatment, carefully conducted, may in course of 
 time be followed by recovery, with mental defect, in cases of cerebral 
 hemorrhage with sensory aphasia. 
 
 Sustaining treatment, tonics, and all hygienic measures are in 
 order, and arsenic, the iodides of potassium and sodium, and the 
 bromides in developing epilepsy are to be employed. 
 
 Massage and electricity have some appHcation in the paralyses and 
 other muscular disorders. Strychnine, in tonic doses, is of value, 
 and digitalis to sustain cardiac action, and hydrotherapy is of some 
 avail. Cold to the head, counter-irritation, local blood-letting, and 
 remedies for the rehef of pain, especially cephalalgia, will be required 
 in the course of the symptomatic treatment. 
 
 Specific remedies should be employed whenever there is a history 
 of previous sypliilis. 
 
 In most cases it will finally become a mere question of good nurs- 
 ing of a bedridden patient. The chief constant danger to be averted 
 is decubitus. An antiseptic wash of bichloride of mercury, frequent 
 change of position, air-cushions, and a water-bed are often to be used. 
 As the rectal and vesical sphincters become paralyzed, antiseptic cath- 
 eterization and enemata at timely intervals are practical aids to clean- 
 liness which must be carefully enforced at all times. 
 
 Eefusal of food is common and calls for artificial feeding, as does 
 also impaired deglutition from various focal brain diseases. 
 
 Life will be sustained largely by careful alimentation, of which 
 predigested foods will form a part. 
 
 In all stages of organic dementia, renal, intestinal, and cardiac 
 activity are to be sustained by appropriate remedies. 
 
 Intercurrent affections of heart and lungs are common, and death 
 most often results from pulmonary complications. 
 
692 TEXT-BOOK ON MENTAL DISEASES. 
 
 Section IV. — Typliomania. 
 
 This severe form of mental disease was first described by Dr. 
 Luther Bell, in 1844, as typhomania, but it has also of late been 
 termed delirium aeutum, or acute delirious mania. 
 
 Some writers regard it as a mode of termination of acute mania, 
 but the prompt onset, violent and brief course, and fatal terminatioii 
 in most instances. Justify the opinion that it is a distinct type of 
 mental disorder of toxic or infectious origin. 
 
 Definition. — Typhomania is a form of intense mental disorder, 
 probably of infectious origin, of sudden access, turbulent course, 
 marked b}^ hallucinatory and motor excitement, and rapid exhaustion 
 of vital powers, ending in death in the majority of cases within a fort- 
 night of the outbreak of the maniacal symptoms. 
 
 Clinical Delineation. — Typhomania is not often a complication 
 or termination of other forms of mental disease, which sometimes 
 pass into a state of typhoid exhaustion. The term is to be limited 
 to those independent acute delirious manias which present the typical 
 symptoms and run the hyperacute course about to be described. 
 
 After prolonged mental strain, excessive labor, or sexual and alco- 
 holic excess for a week or two, may be observed incubatory symptoms 
 of restless anxiety, despondency, and forebodingi of evil, general ma- 
 laise, and disorder of sleep. Then follows abruptly a maniacal ex- 
 plosion of great violence of motion, incoherent flight of ideas, wild 
 gesticulation, boisterous and destructive acts, loud screaming, laugh- 
 ing and crying, and vivid hallucinations of the special senses. The 
 excitement continues unabated by ordinary sedative measures, and 
 great physical exhaustion supervenes within a day or two. The motor 
 activity becomes general, excessive, and automatic, wild delirious ide- 
 ation appears, consciousness is rapidly obscured, and speech is re- 
 duced to incoherent muttering. 
 
 The temperature now rises to 102° F., or even as high as 106° F., 
 the pulse becomes rapid and feeble, the breath is oft'ensive, sordes 
 form upon the lips, semi-comatose and convulsive states develop, 
 there is involuntary evacuation of bladder and rectum, rapid emacia- 
 tion ensues, and, on the average, death follows within fourteen days 
 from the first appearance of the maniacal symptoms. The fatal end 
 may be reached within the first thirty-six hours, or delayed, very ex- 
 ceptionally, beyond the third week. 
 
 Causes. — Psychopathic predisposition appears in the history of 
 some cases, and in others there is an acquired neurotic state from 
 
INSANITY WITH DEFINITE LESIONS. 693 
 
 business or domestic worry, severe mental shocks or prolonged stress 
 of mind from whatever source. 
 
 Other etiological factors are insolation, trauma capitis, acute in- 
 fectious diseases, puerperal sepsis, suppurative inflammations of in- 
 ternal organs, speciall}^ of the lungs and kidneys, surgical operations 
 with prolonged anaesthesia, and alcoholic excesses. The age of the 
 vast majority of patients is between thirty and fifty years. 
 
 In the writer's experience, men are more often attacked than 
 women, but an opposite observation has been made by most writers. 
 
 The sudden invasion, violent symptoms, rapid exhaustion of vital 
 energy, and extensive pathological lesions, all favor the view that the 
 entire process is of a toxic or infectious nature. In puerperal cases 
 and in suppurative inflammations of internal organs a source of sepsis 
 may be readily surmised, as well as in all acute infectious diseases; 
 but in other instances a perverted metabolism and the auto-formation 
 of toxins is a presumable source of the disease. 
 
 Stadia.— There is a brief initial stadium in all cases, but, as its 
 duration is only for a few days, it may escape observation. It begins 
 with a depressed ccensesthesis, a general painful feeling. Sometimes 
 there is referred to the head a distressing sense of weight and ten- 
 sion, and at other times a boring pain is felt in the back of the neck. 
 Profound lassiture, depression of spirits and feelings of vague dread, 
 and restless insomnia are also a part of the initial stadium, which may 
 have extreme temporal limits of a few hours or ten days, and is 
 abruptly terminated by the outbreak of maniacal symptoms. 
 
 The stadium acutum declares itself suddenly; even within the 
 space of a half hour the patient may pass from apparent lucidity to 
 the full height of hallucinatory aberration and delusional violence 
 of conduct. In exceptional cases the patient wakes from troubled 
 sleep into the maniacal state, or the latter follows alcoholic stimula- 
 tion, or some emotional shock. The full intensity of the symptoms 
 is rapidly attained, and generally the clinical progression is marked 
 by a vast expenditure of physical force and incessant psycho-motor 
 excitement. 
 
 By way of exception, remissions of a few hours occur in the tur- 
 bulence of mental and motor symptoms. There is no arrest in the 
 pathological processes, however, and resting spells are followed by 
 still more violent explosions of nervous force, and vital exhaustion 
 becomes evident in a few days, at the furthest. 
 
 Incoherent and automatic speech and movements continue, jacti- 
 tation is incessant, subsultus tendinum is continuous, even in drugged 
 
694 TEXT-BOOK ON MENTAL DISEASES. 
 
 sleep, and convulsive spasms may become general. Sleep no longer 
 exists, but sopor or comatose conditions appear, and the downward 
 course is rapid, and death from cardiac failure is a common termina- 
 tion. 
 
 If recovery is to follow, the comatose stage is not reached, but 
 remissions of a few hours arise, and the violence of all the symptoms 
 abates, and the patient is left prostrate and completely exhausted 
 in body and mind. A convalescent stadium of some weeks restores 
 the immediate balance of the mind, but a much longer period is 
 necessary to a complete restitution of mental and bodily powers, 
 which in some are never fully regained. 
 
 Symptoms. — The painful coensesthesis is the earliest expression of 
 the incipient pathological changes in the entire organism, and of 
 these the organic senses take cognizance, which is reflected in intel- 
 lectual centres as vague presentiments of coming evil, dire forebod- 
 ings, and melancholy fears. The acute hallucinations and illusions 
 of all the senses are attended by sensorial delusions, swiftly changing 
 like the sensory perversions, but in the meantime prompting to a 
 great variety of absurd, destructive, or violent actions. This stage of 
 psychomotor activity is soon passed and is followed by involuntary 
 and forced sensory and motor phenomena, due to the intense irrita- 
 tion of cortical regions and spasmodic discharge of nervous energy 
 from the same. Multiple hallucinations and illusory sensations and 
 massive emotions overwhelm the patient, while the whole muscular 
 system displays a tetanic convulsibility. The limbs are Jerked about 
 in the most purposeless manner, and the whole body seems to be rent 
 by the disjointed actions of the extremities. These violent ataxic 
 movements may give place, for a brief period, to tetanoid contractions 
 of body and limbs. In the meantime, all clear conceptions and con- 
 scious mental processes disappear. The shouting, singing, and inco- 
 herent talking give place to hoarse and whispered mutterings. The 
 patient may continue to spit a frothy, viscid saliva; the face is 
 twitched convulsively; the pulse is rapid and feeble; the tempera- 
 ture ranges from four to eight degrees above the norm; respiration 
 is frequent and superficial, and sometimes altered in rhythm; the 
 secretions and excretions are offensive; the tongue, teeth, and lips 
 are coated with sordes; the face, at first flushed with suffused con- 
 junctiva, now is pinched and haggard, with dark circles under the 
 eyes, and the whole aspect is that of profound nervous exhaustion. 
 
 There is a general wasting of muscular tissues, and a rapid loss 
 of total weight, which may be diminished twenty-five per cent, in 
 
INSANITY WITH DEFINITE LESIONS. 695 
 
 the course of a week. The uncontrollable and incessant movements 
 prevent the patient from taking food, which cannot be recognized 
 when presented, and artificial feeding is always necessary. Perspira- 
 tion is often profuse; urine is scant, high-colored, charged with 
 urates and sometimes albumen, and also blood-corpuscles; constipa- 
 tion exists at first, and colliquative diarrhoea finally. Pemphigus, 
 decubitus, cellulitis, and abscesses are common. The superficial and 
 deep reflexes are first exaggerated and then lost. Ocular and mas- 
 ticatory spasms are frequent. 
 
 The temperature may fall to the norm a few days before death, 
 and there may then be an antelethal pyrexia of twenty-four hours. 
 
 In rare instances hyperpyrexia does not exist at any time. In 
 convalescent patients sequels like those of infectious fevers are ob- 
 served, such as renewal of cutaneous epithelium, splenic enlargement, 
 hepatic congestion, and nephritic affections. 
 
 In recoverable cases remissions of all the symptoms appear before 
 the comatose stage appears. Eecovery may be prompt, but ordinarily 
 is a slow process like that from a severe fever. One mode of termina- 
 tion is dementia. Xo case under the writer's observation has ever 
 terminated in general paresis or in any other type of Insanity than 
 that just named. 
 
 Pathology. — The pathological processes resemble those in toxic 
 or septic conditions. There is at first intense congestion of cerebral 
 regions, and following the hypersemia, venous stasis and oedema of 
 the brain. 
 
 The blood in the sinuses is dark and fluid, there are effusions of 
 blood-corpuscles and leucocytes in the perivascular spaces, the gangli- 
 onic elements are swollen or in process of degeneration, and there are 
 sometimes punctate extravasations of blood in the brain substance. 
 There is lymphatic engorgement and the pial vessels present an 
 opaque appearance, and there is injection and adhesion of membranes 
 of the brain. The lungs are the seat of hypostatic congestion or 
 oedema, and the heart is lax and contains dark fluid blood. There 
 is engorgement of internal organs — of the liver, spleen, and kidneys, 
 and the muscles are atrophied. 
 
 The presence of micro-organisms in the blood and urine has been 
 reported. 
 
 There is no doubt that the intense nature of the pathological 
 processes in the whole system stands in etiological relation to the 
 acute nature of the general symptoms. 
 
 Differential Diagnosis. — The simple exhaustion of acute mania 
 
696 TEXT-BOOK ON MENTAL DISEASES. 
 
 never appears 'n'itli the sudden or severe symptoms of typhomania. 
 The rapid reduction of consciousness, the higli temperature, and the 
 general wasting are all wanting in acute mania, which rarely leads to 
 fatal exhaustion, if treated by the same means which prove of no 
 avail in typhomania. 
 
 The dehrium of fevers is not of such an intense character, and 
 there is a difference in the temperature curve, and a rash, and a se- 
 quence in the symptoms in point of time unlike that of typhomania. 
 
 Acute meningitis may resemble typhomania in confusion of ideas 
 and delirious excitement, but the motor agitation is not so great and 
 the reduction of vital forces is not so sudden. Stilly there is a near 
 resemblance in the symptomatology, which not infrequently leads to 
 mistake in diagnosis. 
 
 In pneumonitis the delirium lacks the motor violence and is re- 
 lieved by antipyretics, which are without efEect in typhomania. 
 
 Typhomania is differentiated from delirium tremens by a gen- 
 eral comparison of the whole group of symptoms characteristic of 
 the two diseases. Single symptoms are alike in many cases of the two 
 affections. The temperature is higher in typhomania, and the re- 
 duction of consciousness more complete, and the alcoholic tremor is 
 wanting, and a coarser tremor exists only in exceptional cases. The 
 difficulty of diagnosis is greatest when alcoholic excess has been an 
 exciting cause of typhomania. 
 
 Frognosis. — The prognosis is bad. The majority of the cases die 
 within the first fortnight. Of those who survive, one-half pass into 
 terminal dementia. 
 
 Apparent lueiditj" of intellect may be restored within three or four 
 weeks, but complete recovery of the forces of mind and body is grad- 
 ual and only completed after a considerable lapse of time. 
 
 Of the prognosis of typhomania as a prodrome or sequel of other 
 forms of mental disorder, the writer cannot speak, having never ob- 
 served such a case. 
 
 Treatment. — The only hope lies in prompt treatment. A large, 
 well-ventilated room, kept at a cool temperature, preferably not above 
 60° P., and darkened, is supplied with a wide, stationary, single bed, 
 accessible to nurses from both sides. The patient is to be treated in 
 the recumbent position, and is not to be held, but kept in bed by the 
 restraining sheet, which does not arrest, but prevents self-injury 
 and bruises from the violent jactitations. 
 
 The combat for life is against death from exhaustion of vital 
 powers. 
 
INSANITY WITH DEFINITE LESIONS. 697 
 
 Alcoholic stimulants are to be reserved until the first intense 
 hypergemia of cerebral centres is passed and heart failure appears. 
 Active derivation and relief of customary constipation is to be ef- 
 fected by one or two drops of oleum tiglii. Subsequently, stimulat- 
 ing enemata are to be employed. The temperature is to be reduced 
 by sjjonging with evaporating lotions and by cold packs, which en- 
 courage the activity of the skin and assist in toxic elimination. For 
 the same reason plentiful cool drinks, mildly acidulated with mineral 
 acids, are to be given to favor diaphoresis and diuresis. 
 
 Cold milk, if the patient will take it, may be plentifully adminis- 
 tered. 
 
 Whenever the temperature rises above 104° F., friction of the 
 entire surface with ice, or a bath rapidly graduated from tepid to cold, 
 with the ice cap, is to be employed, under direct medical supervision. 
 
 Second only in urgency to reduction of temperature is alimenta- 
 tion throughout the whole attack. 
 
 Forced feeding is to be begun as soon as the patient fails to take 
 the necessary supply of food. 
 
 The waste of tissues is enormous, and must be made good by a 
 full physiological ration of concentrated nourishment, predigested, 
 if need be. Eggs, milk, beef essence, meat pulp, and fresh Juices 
 of fruits are to be given at regular intervals. Fresh cream, one pint 
 daily, obviates partly the early constipation and favors sleep. 
 
 Generous alimentation is the best stimulant and the best soporific 
 in the early part of the attack. 
 
 Chloral hydrate increases the hyperemia, and hyoscin hastens 
 the exhaustion, 
 
 Ergotine is the best drug at first, and full doses of morphine may 
 be Justified occasionally to relieve the violent excitement. Bromides 
 are of no avail, and all the hypnotics fail to give satisfactory results. 
 
 Warm baths, with cold to the head, are of some service, and, if the 
 patient is kept nourished and the heart's action is sustained by digi- 
 talis, sleep will result at brief intervals, and will be of a refreshing 
 nature. 
 
 Bleeding and counter-irritants are not to be recommended. Cal- 
 omel may be of some service and serve to correct foul intestinal condi- 
 tions. 
 
 Antiseptic catheterization becomes necessary in some cases in the 
 soporous states. The mouth is to be cleansed with an antiseptic wash, 
 and constant personal attention is required to prevent decubitus. 
 
698 TEXT-BOOK ON MENTAL DISEASES. 
 
 Alcoholic stimulants become of value when cardiac weakness ap- 
 pears. 
 
 Should the patient survive, tonics are to be employed, and a long 
 period of rest and favorable hygienic conditions are essential to com- 
 plete restoration of health. Second attacks of typhomania are ex- 
 tremely rare. 
 
 Section V. — Traumatic Insanity. 
 
 It has long been known that very obstinate mental disorder re- 
 sults from injuries to the head, which give rise directly or indirectly 
 to definite lesions of cerebral tissues. It is to this form of mental 
 disorder that the term " traumatic Insanity " is more appropriately 
 apphed, though some writers give a wider use to this designation. 
 
 Definition. — Traumatic Insanity is mental alienation from dam- 
 age to the organ of mind by mechanical violence to the cranium, 
 membranes, or cerebral tissues, and it is attended by active aberra- 
 tion or chronic deterioration of mental functions. 
 
 Clinical Delineation. — Following a severe fall or blow upon the 
 head, there may result within a few hours confusion of ideas, loss 
 of memory for recent events, and a complete incapacity for the affairs 
 of life. The patient sometimes has a siUy, helpless manner, an as- 
 tonished sort of look, gives incoherent replies to questions, and con- 
 founds places and recent events, is emotional, and in a few days 
 grows restless, sleepless, and is mildly maniacal. In other cases there 
 is an interval of weeks or months between the cranial injury, which 
 may have caused shght depression of the skull, and the attack of 
 melancholia or mania, which may manifest a recurrent tendency and 
 end in secondary dementia at the end of a few years. Or, again, the 
 trauma capitis may be followed by a gradual change in character, 
 and at the end of a year or two a development of systematized delu- 
 sions and a fully developed monomania. 
 
 In other instances, secondary lesions extend from the seat of the 
 injury and involve the brain cortex, and give rise to epilepsy, which 
 in turn is followed by mania or dementia. The extent of the brain 
 injury does not bear a constant relation to the severity of the mental 
 disease, which may take on a hopeless form after slight trauma cap- 
 itis. The httle injury may be a point of departure for wide patho- 
 logical changes of the meninges and of the cortical cells. Periodicity 
 of maniacal symptoms is a prominent feature in some of the cases. 
 That general paresis results in traumatic cases has already been no- 
 ticed. 
 
INSANITY WITH DEFINITE LESIONS. 699 
 
 Some of the cases in young persons undergo a moral deterioration, 
 and resemble, in their general outlines, moral Insanity. 
 
 Causes. — The trauma capitis and its resulting lesions are the ex- 
 citing causes of the mental disease. 
 
 Predisposing causes consist in direct heredity, or existing neu- 
 roses, intemperate habits, or exhausting mental or physical labor, and 
 insufficient nourishment and loss of sleep, or a previous psychosis. 
 
 It may even be that the head injury only develops a latent psy- 
 chosis at some of the evolutional or involutional epochs or physiolog- 
 ical crises. Doubtless a variety of causes act together in some cases, 
 but in others, free from heredity and in good general health, the 
 trauma capitis, apparently by its sole influence, leads to a psychosis, 
 which may prove incurable and end in dementia. 
 
 Stadia. — The initial stadium is yerj brief in cases of mania fol- 
 lowing within some days of the injury, and it consists in loss of power 
 of attention, slight confusion of ideas, and impaired memory, and a 
 painful sense of physical being and sleeplessness. Then follows the 
 stadium acutum, of melanchoUc or maniacal form, for a few weeks, 
 and then a stadium convalescens or stadium dementiee in unfavorable 
 cases, which are much the more numerous. 
 
 In mental disorder distant a year or more from the injury, the 
 initial stadium may consist in gradual changes in disposition and in 
 ineiibaix>ry delusions, becoming systematized at the end of many 
 months, and then follows the stadium acutum of monomaniacal order, 
 lasting for years, until there supervenes a terminal stadium of de- 
 mentia. 
 
 In still another class of cases the initial stadium embraces the 
 mental changes of early epileptic states, caused by the traumatic 
 lesions and the stadium acutum, the epileptic manias, and active 
 deterioration of mind, and then follows the stadium dementias. 
 
 Symptoms. — ^In some of these traumatic cases there is, in connec- 
 tion with general failure of bodily health, a hypochondriacal or hys- 
 terical array of symptoms, spasmodic twitchings of muscles, neuralgic 
 pains, anorexia, insomnia, loss of self-control, outbreaks of anger, and 
 general incapacity for social or. business relations of life. 
 
 In other cases, delusions or illusions may arise, only to disappear 
 and be replaced by still more disagreeable ideas or feelings, which 
 culminate in some absurd act, destructive effort, direct violence, or 
 suicidal attempt. 
 
 The monomaniacal patients, especially, develop most dangerous 
 delusions and homicidal impulses. 
 
700 TEXT-BOOK ON MENTAL DISEASES. 
 
 Still another class, probably of latent epileptic character, have 
 automatic states, of which there is no subsequent memory, and during 
 which they commit theft, arson, or petit offences against the law. 
 
 In the epileptic cases hebetude or somnolence is common, and 
 sudden violence is to be feared, and is a prominent symptom in trau- 
 matic Insanity, and often takes a shockingly ferocious and treacher- 
 ous form. 
 
 Cephalalgia, hallucinations of sight and hearing, perverted appe- 
 tites, parsesthesise, suicidal impulses, animal propensities, vertigo, 
 spasms, paralyses of special nerves, convulsive seizures, syncopal at- 
 tacks, and epileptic automatism are among the symptoms of trau- 
 matic Insanity. 
 
 In occasional cases there may be spinal symptoms due to descend- 
 ing degeneration. The moral and aesthetic deterioration is not unlike 
 that in alcoholic patients, and may constitute an important part of 
 the psychic change in perfectly temperate persons, who may develop 
 delusions of conjugal infidelity, and become brutal, selfish, and in- 
 sanely cruel to wife and children. 
 
 Eeligious delusions and sexual perversions are not uncommon, 
 and in the early stage pious and sexual emotion influences the conduct 
 largely in many patients. Self-mutilation of sexual organs under 
 religious delusions sometimes occurs. 
 
 Pathology. — The lesions found upon autopsical examination are 
 adhesion of dura mater to calvaria, thickening and opacity of mem- 
 branes and cortical adhesions, exostoses, inflammatory and atrophic 
 processes extending from the original site of injury, and, if the latter 
 has been a severe blow, lesions of membranes or cortex in the opposite 
 hemisphere as the result of contrecoup. The nature of the trauma 
 determines in some degree the resulting pathological changes. De- 
 pressed fractures may have circumscribed lesions, or may give rise 
 to epilepsy, and in course of time be followed by extensive degenera- 
 tion of cortical cells, as in idiopathic cases of the convulsive affection. 
 Falls and blows, and the effects of contrecoup from spinal concus- 
 sions, may result in diffused cortical atrophy. 
 
 Even slight and circumscribed injuries may, in predisposed pa- 
 tients, serve as a point of departure for wide structural alterations 
 of cortical elements. 
 
 Differential Diagnosis. — The history of trauma capitis, with a 
 gradual development of such clinical manifestations as have been 
 mentioned under " Symptoms," serves to establish the diagnosis in 
 
INSANITY WITH DEFINITE LESIONS. 701 
 
 most cases. If the Insanity follow epilepsy developed by the trauma, 
 it is still to be regarded as traumatic. 
 
 Traumatic Insanity is to be differentiated from general paresis 
 initiated by traumatic accident. Some writers do not differentiate 
 between traumatic Insanity and mental disease caused by insolation, 
 which may give rise to similar forms of aberration, but the patholog- 
 ical lesions are not alike in the two affections. 
 
 Mental disorder as the direct sequel of brain-surgery is to be re- 
 garded as traumatic. If, though, the operation be very slight and the 
 ansesthesia somewhat prolonged, it may be more consistent to con- 
 sider the mental disturbance as toxic in origin. Considerable care is 
 necessary to learn the history of cases and the sequence of injuries 
 and insane symptoms as related in patients having both cranial dam- 
 age and epilepsy, in order to differentiate between mental disorder 
 due to the convulsive neurosis and that due primarily to the trau- 
 matic factor. 
 
 Prognosis. — A few cases, following promptly upon cranial injury, 
 have an acute attack of mental disorder and recover completely. 
 
 Traumatic cases, with a long prodromal stadium and gradual 
 changes in character, are uniformly unfavorable in prognosis. 
 
 The prognosis is bad whenever epilepsy develops from the trauma 
 capitis along with the mental disease. 
 
 There is a bad prognosis whenever the monomaniacal type is a 
 sequel of the cerebral injury. 
 
 Intemperate patients often become insane from slight blows or 
 cerebral concussions, which are not followed by secondary lesions. 
 These cases recover often, but they are not genuine instances of trau- 
 matic Insanity, 
 
 The immediate danger to life is not much greater in traumatic 
 Insanity than in other types^ since the majority of the cases pursue 
 a chronic course. 
 
 Treatment. — The radical cure may be effected by surgical treat- 
 ment. Operation for depressed bone acting as a source of cortical 
 irritation is directly indicated, unless the general condition of the 
 patient is unfavorable. 
 
 When diffused lesions have ensued, the local interference will 
 prove of no permanent service. 
 
 In all the varied cranial injuries and modes of mechanical vio- 
 lence to cerebral tissues it is a question for modern brain surgery to 
 decide as to the surgical procedure justified. Antiseptic operations 
 now succeed which would formerly have been condemned, and the 
 
702 TEXT-BOOK ON MENTAL DISEASES. 
 
 last and only hope of mental recovery often lies in this direc- 
 tion. 
 
 On account of dangerous tendencies, many traumatic cases re- 
 quire treatment in institutions. 
 
 The traumatic epilepsy calls for the usual anti-epileptic treat- 
 ment. 
 
 Apart from the surgical bearings, the psychiatric indications are 
 such as have already been fully discussed in the chapter on " Treat- 
 ment." The impdrtant point is that the surgical procedures and all 
 other active measures should be undertaken at the earliest possible 
 moment, as delay is fatal to hopes of recovery. 
 
 Section VI. — Sympathetic Insanity. 
 
 The p'ossibility of mental disease from some morbid condition of 
 other organs than the brain, and from injuries of distant structures, 
 has long been explained on the ground of " sympathy " of the cere- 
 brum with other parts of the system. The modern view is that such 
 mental disease springs from lesions of the peripheral nervous system 
 in a reflex manner, and through vasomotor disorder. Just as intes- 
 tinal worms may cause convulsions, and a foreign substance in the 
 sole of the foot may cause tetanus, so may similar irritations, acting 
 through the peripheral and vasomotor nervous system, derange the 
 action of the higher cortical regions concerned in mental manifesta- 
 tions. 
 
 Definition. — Sympathetic Insanity is disordered action of the 
 mental mechanism through reflex channels, and through disturb- 
 ances of the peripheral and vasomotor nervous system occasioned by 
 extra-cerebral irritations and lesions of distant parts or organs. 
 
 Clinical Delineation. — Sympathetic Insanity, like some other 
 types, is treated as a special form, not from any specific psychic 
 symptoms, but from the special pathogeny and mode of termination 
 of the disease. Thus a painful cicatrix of a peripheral nerve excites 
 mental disorder of a maniacal type, and the removal of the cicatrix 
 relieves the mental disorder, or the repeated presence of intestinal 
 parasites may be attended by mental aberration, which is promptly 
 terminated by the successful use of anthelmintic remedies. The pre- 
 vailing character of the alienation may be melancholic or maniacal, 
 and the hallucinations and delusions may relate to the local irrita- 
 tion, or the complexion of the mental malady may in no wise reflect 
 the topical origin of the psychic trouble. 
 
 Persecutory delusions and suicidal tendencies have been rej^orted 
 
INSANITY WITH DEFINITE LESIONS. 703 
 
 in connection with middle-ear disease, and prompt relief from the 
 same followed the cure of the aural affection. 
 
 A form of hypochondriacal melancholia sometimes results, espe- 
 cially when, in early adult life, the reproductive organs are the seat 
 of the local irritation. 
 
 Melancholia from ahscess of the liver is reported to have been 
 promptly relieved by aspiration. 
 
 Sometimes intense circumscribed neuralgic pains form a promi- 
 nent feature of the psychosis, for which they may constitute a sort 
 of direct exciting cause in other cases. In a few instances there is 
 an etiological sequence in neuralgia, herpes, and mental aberration. 
 J. Pons regards these patients with herpetic eruptions as forming a 
 distinct type of sympathetic Insanity, with delusions based on the 
 cutaneous irritations, and reports a characteristic change of person- 
 ality as chronicity appears in these cases. 
 
 When helminthiasis is the local source of the mental trouble, 
 perversions of taste and smell, pica and coprophagy, and libido are 
 among the clinical features to be noted. 
 
 Maniacal excitement followed in one case of a worm in the stom- 
 ach. Mania may be the form resulting from larvae in the frontal 
 sinuses. 
 
 Profound melancholia and emaciation from tape-worm, Maudsley 
 records cured promptly by the oil of male-fern, leading to complete 
 expulsion of the worm, and he quotes Jordens for an instance of vio- 
 lent Insanity from a splinter of glass in the sole of the foot, and the 
 immediate relief of the mental disorder on extraction of the foreign 
 body from the foot. 
 
 In fact, literature abounds in instances of active mental disorder 
 provoked by local irritations. 
 
 Causes. — Due weight must be accorded to hereditary predispo- 
 sition to mental disorder, since the exciting cause is such as does not 
 ordinarily result in aberration of mind. 
 
 A convulsive neurosis, like epilepsy, in the patient or in the im- 
 mediate progenitors, doubtless favors this form of mental disease. 
 The innate tendency may reveal itself merely in a convulsive ten- 
 dency to muscular disorders, or sensory anomalies, or neuralgic af- 
 fections. A history of some such convulsibility or instability will 
 be found in most cases of sympathetic Insanity. 
 
 Alcoholic excess and all unhygienic modes of life tending to 
 lower the general tone of the nervous system may be regarded as 
 predisposing circumstances. 
 
704 TEXT-BOOK ON MENTAL DISEASES. 
 
 As persons are born with a tendency to disease of some particular 
 organ, so others have an innate psychic vulnerability through certain 
 peripheral nervous -channels, and it is this idiosyncrasy which is the 
 real etiological factor in this form of alienation. 
 
 Stadia. — The initial stadium may be brief and consist mainly 
 in sensory disturbance, neuralgic pains, and mental depression, and 
 there may then ensue a sudden acute stadium of maniacal symp- 
 toms, and a prompt convalescent stadium on removal of the local 
 irritation. 
 
 In other cases there may be a long initial stadium correspond- 
 ing to the gradual development of a peripheral disease; a stadium 
 acutum of a melancholic nature, with illusions of the special senses, 
 and depressing delusions and suicidal impulses; and a convalescent 
 stadium ending in recovery of both the mental and local affection. 
 Should the latter prove incurable, the terminal stadium of the men- 
 tal disease will probably be secondary dementia. 
 
 Symptoms. — When the relation between the disease of special 
 organs and of the mind, and reactions of a sensory and motor kind, 
 shall have been more thoroughly studied, it will be possible to define 
 more closely the symptoms in the reflex psychoses. It would seem 
 that subacute and prolonged irritations of gastro-intestinal and he- 
 patic tissues tend to develop hypochondriacal and melancholic 
 vesaniee; that deep-seated ocular and aural irritations serve to excite 
 maniacal disturbance, and that parasites of frontal sinuses and nasal 
 disease have a like tendency; that extensive peripheral neuritis is 
 often followed by stuporous or demented conditions; that chronic 
 uterine irritations are frequently associated with restless melan- 
 choha; that diseased centres of irritation in pulmonary tissues favor 
 euphoria and excited mental states; and even that certain cardiac 
 lesions result in depression and other valvular affections in excite- 
 ment. All these apparent clinical relations demand further research. 
 
 In general, sympathetic Insanity presents hallucinations of all 
 the senses, and corresponding delusions, expansive or depressed 
 moods, convulsive seizures, muscular disorders, neuralgic and trophic 
 disturbances, and some special sensory symptoms referable to the 
 local disease. 
 
 Pathology. — It is necessary to invoke the aid of the nervous con- 
 nections of the brain with all parts of the organism to understand 
 the effects of local irritations on the higher nervous mechanism. 
 It is only thus, through reflex nervous channels, that a local affec- 
 tion can give rise to general convulsions or to a convulsive and inco- 
 
INSANITY WITH DEFINITE LESIONS 705 
 
 ordinate action of the higlier cortical regions involved in mental 
 disorder. 
 
 There is another pathogenesis possible in these cases, and that 
 is through the intervention of the vasomotor system. In this way 
 it is possible to account for the pathological anaemias and hyper- 
 gemias arising from reflex irritations, and favoring mental derange- 
 ment. 
 
 Bearing these two modes of origin in mind, sympathetic Insanity 
 has been classed among the vesanise, with lesions of the peripheral 
 and vasomotor nervous system. 
 
 Differential Diagnosis. — Although the local disease of some in- 
 ternal organ or external part may impress a special character upon 
 the delusions and hallucinations, still the differential diagnosis can- 
 not be made by the psychic symptoms, but must be based on the 
 recognition of the local irritation, and of its causative relation to the 
 Insanity. 
 
 Thus, in a case related by Griesinger of a splinter in the eye 
 causing mental disorder, or of neuralgic herpes, as already men- 
 tioned, or of middle-ear disease, the causative connection might 
 be more patent than in hepatic abscess or other local affection of 
 internal organs. 
 
 In many instances the differential diagnosis between sympa- 
 thetic Insanity and other forms of mental disorder can only be made 
 with approximate certainty upon the actual cure effected by the re- 
 moval of the local irritation. If the expulsion of a tape-worm or 
 the surgical removal of a uterine tumor or diseased adnexa results 
 in prompt mental recovery, it is safe to pronounce the diagnosis 
 of sympathetic Insanity. 
 
 Prognosis. — The prognosis is good, provided the local affection 
 is not of a serious and incurable nature, and that the cure of the 
 same is effected before chronicity of the mental disorder is estab- 
 lished. 
 
 When the local irritation springs from functional disease of the 
 special sense-organs, of the gastro-intestinal mucous membranes, or 
 of. the reproductive organs, the chance of relief from prompt treat- 
 ment is good. Malignant local disease or organic affections of in- 
 ternal organs are of bad prognosis. Helminthiasis and foreign 
 bodies admitting ready removal furnish instances of astonishingly 
 prompt recovery. 
 
 Treatment. — The treatment must be directly based on the diag- 
 nosis of the local source of the disease, and efforts to remove the 
 45 
 
706 TEXT-BOOK ON MENTAL DISEASES. 
 
 same, either "by therapeutic or surgical means. A thorough physical 
 examination, including the organs of special sense^, can alone furnish 
 the etiological grounds of treatment, since there may be more than 
 one source of local irritation in the same case. In the meantime, the 
 symptomatic treatment of the psychosis can only proceed on such 
 general principles aiS have already heen described fully in the chapter 
 on Treatment. The most brilliant success may follow surgical in- 
 tervention, including otological, ophthalmological, or gynaecological 
 operations, but the general condition of the patient must never fail 
 to receive due treatment. 
 
CHAPTER VII. 
 
 PSYCHO-TRAUMATIC INSANITY. 
 
 As a final type of Insanity to which definite etiological relations 
 can be assigned is to be recognized mental aberration as the immedi- 
 ate result of mental shock. There are well-authenticated instances 
 of persons who have been stricken dead by sudden emotion, while 
 others have been suddenly deprived of their reason by a similar men- 
 tal blow. Such an event is in the nature of a direct psycliical trauma, 
 and hence the term psycho-traumatic Insanity is employed to desig- 
 nate such cases. 
 
 Definition. — Psycho-traumatic Insanity is mental alienation from 
 cerebral commotion, resulting from single and sudden mental shocks, 
 or from repeated psychical traumata, and manifested by abrupt and 
 stuporous termination of mental activities, by profound melancholic 
 states, or by acute mainiacal excitement. 
 
 Clinical Delineation. — The psychical effects of frightful railway 
 accidents to those not physically injured may be hysterical seizures, 
 neurotic sequels, or prolonged hypochondriacal states, and perma- 
 nent traumatic neurasthenia may result, in a like manner, from the 
 mental shock alone. These well-known facts illustrate in kind, 
 though not in full degree, the damage done by sudden mental shocks. 
 A mother sees her child killed in some horrid accident and passes 
 directly into a state like melancholia aittonita. There is a complete 
 suspension of higher mental processes, and a painful limitation of 
 consciousness, and a single terrifying conception pervades the men- 
 tal sphere. Not 'only the psychic, but also the physical, functions 
 are in partial abeyance. Eespiration is superficial, circulation feeble, 
 and general nutrition impaired. A still more common example is 
 that of a child subjected to some severe fright, which develops a 
 stuporous state. The cliild is Hterally frightened out of its senses, 
 stands helpless and motionless, stares vacantly and gives no reply 
 to questions, and there is inhibition of both motion and ideation. 
 
 707 
 
708 TEXT-BOOK ON MENTAL DISEASES. 
 
 This condition^ resembling partially or fully primary dementia, may 
 continue for weeks and may be attended by terrifying hallucinations 
 -or delusions and all the disturbances of vital functions found in ordi- 
 nary psychoses. Sometimes there is ajn interval of some days between 
 the mental shock and the distinct appearance of mental disorder. In 
 still other cases the news of some great calamity results in acute mel- 
 ancholia. A still more exceptional cerebral commotion, ending in 
 maniacal excitement, is caused by joyful emotion. This is illustrated 
 by the case already mentioned of the man who drew a small fortune 
 in a lottery, and, although previously healthy and temperate, became 
 hilarious and then maniacal, simply from excess of emotion, which 
 soon reached the uncontrollable stage. 
 
 Instances are not wanting of repeated psychical traumata, such 
 as befall some persons who meet with a rapid series of tragic mis- 
 fortunes in life. The types of mental disorder which result from 
 such psychical shocks are not always in keeping with the nature of 
 the emotional event. Maniacal attacks may follow sorrowful events 
 or melancholic states excess of joy. The predominant mood of the 
 emotions peculiar to the individual in health is more apt to influence 
 the nature of the Insanity than the determining cause in this one 
 regard. 
 
 Causes. — Those wide-spread causes which create calamity on a 
 large scale and carry consternation to the hearts of men, are most 
 apt to develop occasional cases of this type of Insanity. Thus, war, 
 pestilence, famine, floods, conflagrations, shipwrecks, business crises, 
 and other disasters are among the possible etiological factors. 
 
 The cause may be trivial and out of all proportion to the result 
 effected. In children, especially, a simple reprimand may provoke 
 suicidal Insanity, and disappointment in love may suddenly develop 
 homicidal mania. The supposition is that in normally constituted 
 persons no emotional shock is adequate to provoke mental disorder, 
 and a certain predisposition is to be assumed, therefore, in cases of 
 this kind. Most persons are vulnerable in some particular thing 
 upon which their interest is strongly centred, and they may well 
 bear emotional shocks in all other directions than that of their long- 
 cherished desires. Most men are vulnerable in financial directions, 
 and the severest blow is loss of property. In one instance treachery 
 of a trusted friend, and in another failure in competition for collegi- 
 ate honors, was the cause. Psychical trauma, then, may be as vari- 
 ous in kind as the special susceptibilities of vulnerable individuals. 
 
 Stadia. — The initial stadium may be extremely brief, and it is 
 
PSYCHO-TRAUMATIC INSANITY. 709 
 
 then essentially a stadium of vasomotor disturbance^, as shown by 
 pallor, or cerebral congestion, or profuse perspiration, and then may 
 follow the stadium acutum of confusion and inhibition of ideas, or 
 of stupor, or of profound melancholia. In other cases there may be 
 an initial stadium of painful tension of mind, and insomnia for sev- 
 eral days before the acute outbreak of maniacal symptoms. 
 
 Sometimes, by a supreme effort of will, the symptoms of the 
 initial stadium are suppressed during some great emergency demand- 
 ing action on the part of the sufferer, who then sinks into complete 
 collapse when the immediate demand for action is at an end. In 
 one instance the fright was imminent danger of life from fire, and 
 the initial stadium of some weeks resembled the symptoms of a 
 traumatic neurosis, and was followed by an acute maniacal stadium 
 of some weeks, and then by a gimdual stadium convalescens. In 
 cases with hereditary taint, the stadium acutum may consist of alter- 
 nations of excitement and depression. In psychical trauma from 
 fright in young persons the stadium acutum is most often a state 
 of stupor, with cataleptoid phases. 
 
 Symptoms. — When violent emotion is pent up, it may expend 
 its deleterious force on nutrition or vital processes, and its escape 
 through motor channels is a safeguard. The blanching of the hair 
 is only one instance of changes produced by fright, and dystrophies 
 of muscular or osseous tissues, even, may like\\dse result. 
 
 The sudden alteration of vital functions in stuporous mental 
 disorder from fright is remarkable. The temperature is subnormal, 
 the pulse is slowed, there is angioparesis and capillary stasis, the 
 skin is cool, moist, and often has a bluish-gray tint, there is dimin- 
 ished peristalsis, feeble digestion, and superficial respiration. 
 
 The stupor may spring from inhibition of mental processes or 
 intense preoccupation from a few frightful hallucinations. The 
 delusions are apt to be of a terrifying nature, also, in such cases. 
 
 There is nothing special to note in the maniacal excitement, 
 which may approach to acute delirious mania. 
 
 The melancholic symptoms are also apt to be acute, and may 
 resemble in general the thunderstruck (attonita) variety. 
 
 In unfavorable cases the transition from stupor to terminal de- 
 mentia may be direct. There is only a partial recollection, on recov- 
 ery, of the stuporous stage, but memory may be good for the events 
 of the melancholic stage. The cause of emotional shock and of the 
 malady usually appears in distant retrospect after recovery, however 
 prompt the latter may be. 
 
710 TEXT-BOOK ON MENTAL DISEASES. 
 
 Patliology. — The ejffieets of profound emotion on circulation and 
 nutrition are undeniable, and yet their pathogenesis is obscure. The 
 deferred shock of purely mental origin, in which days elapse before 
 the immediate results are manifest in collapse, is specially remark- 
 able. The psychic trauma produces an interruption of the presidial 
 influences of cerebral centres over circulatory and trophic functions. 
 This severance of the relation of the higher level of the nervous 
 system to the vital functions is one of the chief pathological features 
 in psycho-traumatic Insanity; but there are other causative ele- 
 ments, probably involving the whole cerebro-spinal axis in ere'thismic 
 conditions, as judged by the nervous manifestations. The vasomotor 
 nervous system is evidently implicated largely in the pathological 
 state in some cases, while in others the trophic functions suffer most, 
 and the higher intellectual oporations are more or less deranged in 
 aJl instances. The pathogeny would seem to be exhaustive liberation 
 of nervous energy from cortical emoitional regions in certain in- 
 s'tances, and in other cases the damage is such as is effected by violent 
 pent-up emotion reacting banefully on organic functions. 
 
 Differential Diagnosis. — The history of fright serves to differ- 
 eoitiaite the stupor, from that which follows epilepsy or other neuroses. 
 The melancholia attonita from psychical shock can only be distin- 
 guished by the actual fact of emotional trauma from that due to 
 other causes. 
 
 Occasionally the clinical symptoms of psycho-traumatic Insanity 
 refledt the nature of the etiological factor throughout the entire 
 course of the mental disorder, but this guide to diagnosis is usually 
 wanting. 
 
 Eelatively, more importance is to be attributed to a history of 
 fright in the case of women and youthful persons than in that of 
 men. 
 
 Sequential stupor is differentiated from psycho-traumatic stupor 
 by the fact of the existence of a previous psychosis. 
 
 Prognosis. — The chance of mental recovery in youthful subjects 
 are good, so far as the immediate attack is concerned, but the proba- 
 bility of relapse is also great. 
 
 Adults, who succumb to ordinary emotional shocks, have some 
 hope of a good recovery, but they have given evidence of an innate 
 vulnerability which will doubtless display itself on subsequent occa- 
 sions. If the Insanity was only developed under very severe and 
 unusual psychical trauma, the prognosis as to permanent recovery 
 
PSYCHO-TRAUMATIC INSANITY. 711 
 
 is more hopeful. If epilepsy, as well as mental disorder, is simul- 
 taneously caused by the emotional shock, the prognosis is bad. 
 
 Treatment. — The treatment of psycho-traumatic Insanity is best 
 conducted in the recumbent posture, and in isolation and in perfect 
 quietude. 
 
 The vital functions are to be sustained by artificial warmth to 
 cutaneous surfaces and to extremities, by gentle friction and hot 
 baiths, and by cardiac stimulants, and artificial alimentation with 
 concentrated and predigested foods must be early undertaken. 
 
 The obstinate agrypnia is to be overcome by full hypodermatic 
 doses of morphine. Should the original emotional shock still persist 
 as a cause of psychalgia, opium in continued doses, which do not 
 interfere with nutrition, is a justifiable remedy, and more efficient 
 than any other in the alleviation of mental pain. 
 
 When the stadium acutum is over, whether it may have been 
 stuporous or simply melancholic, there is need of active stimulation, 
 tonics, electricity, and attempts at diversion and lively forms of 
 activity to prevent secondary dementia. 
 
 Following convalescence, prophylactic measures to prevent sub- 
 sequent exposure to mental shocks are of prime importance, and will 
 determine often the difllerence between permanent recovery and a 
 prompt recurrence of the malady, which is always to be feared in 
 these cases. After mental convalescence a course of physical train- 
 ing and abstinence from responsible work is desirable for some 
 months, and a judicious plan of travel or change of scene is often a 
 wise means of prophylaxis against recurrence. 
 
CHAPTER VIII. 
 
 STATES OF DEPRESSION. 
 
 Group: C cencesthetic Depression, Melancholia Simplex, Chronic Mel- 
 ancholia, Secondary Monomania with Depression. 
 
 Mental suffering, when commensurate with, the exciting cause, 
 is normal, but when it is disproportionate to the same it constitutes 
 a pathological condition termed a state of mental depression. 
 
 These states of mental depression display ceri;ain clinical vari- 
 eties, which it is necessary to now describe. 
 
 Section I.—Cancesthetic Depression. 
 
 There is a sitate of depression less pronounced than that of simple 
 melancholia, for which some designation is needed. This depression 
 is always dependent on alteration of the coengesthesis, and hence 
 arises the propriety of the term coensesthetic depression. 
 
 Definition.^Ccenxsthetic depression is the mildest form of men- 
 tal ahenation, and consists in a painful resultant of the sum-total 
 of the organic sensations, with a correlative gloom of mind, incapac- 
 itating the patient for the ordinary affairs of life. 
 
 Clinical Delineation. — The clinical features are not unlike the 
 depression of the incubatory stage of infectious diseases. There is 
 a general sense of malaise, and a restless anxiety, for which no cause 
 can be assigned. So great is the misery that there is no longer desire 
 or full capacity for, social or business purposes, though, by a great 
 effort of will, some of the duties of life may still be performed. 
 Thought is laborious, but there is no formal disturbance of mental 
 operations, and no delusions. The patient is alienated from his nor- 
 mal manner of being, and feels the estrangement, and instinctively 
 seeks seclusion and rest. 
 
 Causes. — The essential cause is the change in the coenaesth^is, 
 
 712 
 
STATES OF DEPRESSION. 713 
 
 the perversion of the organic sympathies. This painful resultant 
 of all th.e peripheral stimuli from every part of the organism is the 
 basis of the general sense of distress, referable to no one point, and 
 definable only as a general sense of misery, which is reflected as a 
 persistent emotional gloom. 
 
 Stadia. — Coensestheitic depression has a pre-incubatory stadium, 
 but the symptoms are so mild as to escape observation, and are 
 merged in the ordinary slight departures from physical health, to 
 which no special attention is directed. The stadium acutum is that 
 which is recognized as coensesthetic depression, and may last for 
 weeks or months. There is then a stadium convalescens which is 
 often a prompt return to perfect health, and in many .instances the 
 patient is not recognized as having been insane. 
 
 Very frequently there is a termination in acute mania or melan- 
 oholia, of which, in this event, the initial sitadium is constituted by 
 the coensesthetic depression. 
 
 Symptoms. — The symptoms may be briefly summarized as unac- 
 countable emotional gloom, difficult and painful mental efforts, gen- 
 eral indisposition and incapacity for customary occupations, and a 
 desire for solitude and social aversion. 
 
 There is also anorexia, insomnia, and disturbances of nutrition 
 and of circulation. Delusions do not appear, though suspicions and 
 apprehensions may arise. There is often a certain insight on the 
 part of the patient into the pathological nature of his sufferings, 
 of which a clear self-description may be given. 
 
 Pathology. — Tliis affection is not in itself fatal, and the fact of 
 cerebral lesions correlative of symptoms cannot be claimed to exist. 
 The only available hypothesis is that of circulatory or nutritive 
 lesions of- a functional nature. This type is admittedly among those 
 for which no definite etiological or pathological condition can be as- 
 cribed. 
 
 Differential Diagnosis. — The difficulty is not that of confusion 
 of this type of alienation with other forms of mental disorder, but 
 of failure to differentiate coenassthetic depression from simple forms 
 of physical illness. The mental indisposition of physical disease is 
 justified by present circumstances, which may be detected by physical 
 examination. When no such cause of depression of mind can be 
 found, and the despondency still persists, the diagnosis can be made, 
 and is of importance, since prompt treatment may avert a more 
 serious psychosis. 
 
 Prognosis. — This is the most curable of all tjpes of alienation. 
 
714 TEXT-BOOK ON MENTAL DISEASES. 
 
 The vast majority of all cases recover, and many are not diagnosed 
 until subsequent Insanity recalls the fact of previous despondency 
 on one or two occasions. 
 
 The unfavorable prognosis is in cases in which the coengesthettic 
 depression forms the initial stadium of some other form of Insanity. 
 
 Treatment. — All that is necessary is isolation, rest from active and 
 responsible labor, hygienic and dietetic treatment, and occasionally 
 an after-cure of travel or climatic change for a few weeks. Prophy- 
 laxis may demand a change of laborious or sedentary occupation, 
 or some change in personal environment, should the latter contain 
 permanent deleterious influences. 
 
 Section II. — Melancholia Simplex. 
 
 This is the classical melancholia of all ancient and modern writ- 
 ers, and presents in itself some minor symptomatological differences, 
 according to the age, sex, and temperament of the patient, but the 
 type will remain unchanged to the end of time. 
 
 It is not well to divide melancholia in accordance with simple 
 degrees of depression involving delusional or sensorial perversions, 
 but when the painful inhibition becomes so great that there is 'an 
 actual arrest of psychical processes, the advent of melancholic stupor 
 is to be recognized as a clinical division. 
 
 Definition. — Melancholia is a state of mental depression charac- 
 terized by permanent gloom, impaired attention, retarded thought- 
 ralte, self-limitation of consciousness, sensorial perversions, suspi- 
 cions and delusions, vascular hypertony, diminished secretions, im- 
 paired nutrition, general loss of weight, and agrypnia. 
 
 Clinical Delineation. — The clinical features of melancholia vairy 
 not alone with the degree of mental depression. The actual disorder 
 of intellect and the modes of its manifestations afford the chief 
 lines of clinical variety. Such is ordinarily the self-concentration 
 and reticence of patients that it is difficult to know that delusions 
 do not exist in many patients, who manifest profound depression 
 alone. This pervading distress and weight of sorrow shown in looks, 
 words, and actions or suicidal attempts, is the core of the malady 
 in some cases, but there are few instances in which loss of self-confi- 
 dence, vague dreads, and active fears of coming evils do not also 
 exist, and lead to suspicions and delusions, which are not expressed, 
 though secretly entertained. 
 
 A great variety of names have been applied to the clinical phases 
 
STATES OF DEPEESSION. 715 
 
 of the disease. If the suicidal impulses are persistent, the term 
 suicidal melancholia is used. If the delusions relate to religion, 
 the unpardonable sin, and the need of self-crucifixion, religious 
 melancholia is mentioned. Should exaggerated self-introspection 
 and false conceptions of the state of internal organs abound and influ- 
 ence the conduct of the patient, hypochondriacal melancholia is 
 recognized. Demoniacal possession and the belief of change into 
 some animal form, known as lycanthrofic melancholia, was for- 
 merly very frequent. 
 
 A common feature is passive or even obstinate, resistance to every- 
 thing done for the patient, and this has been called resistive melan- 
 cholia. 
 
 Nostalgia almost merits a place as a separate type, having oc- 
 curred in epidemic form in armies in foreign countries. The home- 
 sick patient emaciates and pines away, has visions of home, becomes 
 desperate, commits suicide, incendiarism, or homicide, or simply dies 
 in a depressed and marasmic state. 
 
 Melancholia agitata is a type initiated by active delusions ex- 
 pressed through motor channels, but when the first force of the pain- 
 ful false beliefs is spent, the motions have become automatic and 
 remain for years. This type is often encountered at the climacteric 
 involution. The patient moves about in a restless and purposeless 
 manner, bites her nails, pulls her hair out, rubs herself sore in spots, 
 moans and groans, and automatically repeats bits of delusions a thou- 
 sand times a day. 
 
 Melancholic frenzy is the counterpart of maniacal furor. It arises 
 at the full height of the melancholic distress, and has an explosive 
 violence of uncontrolled actions, which may be destructive or homi- 
 cidal. 
 
 Chronic melancholia is a distinct type, secondary to acute melaur 
 cholia. After a year or more of the acute state the patient passes 
 into the chronic state of melancholia, which may last for years, or 
 indefinitely, without the appearance of dementia. The acuteness 
 of the mental suffering no longer exists, but the delusions and hallu- 
 cination persist, and the fundamental emotional tone is that of de- 
 pression. The inhibition of thought and action is, in a measure, 
 removed, and the patient undergoes a partial readjustment to the 
 environment, and engages, to some limited degree, in light occupa- 
 tion. This type is well known to those familiar with hospital in- 
 mates. 
 
 Melancholia attonita is a type marked by extreme concentration 
 
716 TEXT-BOOK ON MENTAL DISEASES. 
 
 of atteiition upon a few painful hallucinations or delusions, with 
 greatly impaired attention and consciousness for surrounding objects. 
 The association of ideas is so inhibited, and the paucity of impres- 
 sions is such that a positive stupor is sometimes present, and the 
 attack is then termed " melancholia cum stupore." Amnesia for the 
 attack is only partial in most cases, showing that the stupor is often 
 more apparent than real. 
 
 Secondary monomania with depression is ordinarily a sequel of 
 acute melancholia. The patient retains a certain prevailing mood of 
 melancholy and some narrow range of delusions of a depressing nat- 
 ure, but talks connectedly and reasonably on most subjects. 
 
 The delusions are systematized and defended with a certain show 
 of reason, 'and in some measure control the conduct of the patient. 
 Paltients remain in secondary monomania a decade or a score of years 
 before passing into terminal dementia. These monomaniacs are in- 
 teresting types, retaining often considerable mental vigor, but are 
 absolutely without insight into their own mental derangement. 
 
 Causes. — The forms of depression for which etiological and 
 pathological conditions could be definitely assigned have been already 
 considered. There are many cases for which no definite agencies, 
 but rather a ooncatenation of unfavorable circumstances, can be 
 deemed causaitive. Heredity, as the cause of causes, is always to be 
 thought of in the absence of other ascribable sources of melancholia. 
 
 States of depression increase with age, and the greatast number 
 of chronic cases are found from forty-five to fifty-five years. Sex has 
 numerical relations in favor of men. The average ratio of cases of 
 acute melancholia is; by the last census, 25.1 per 1,000 of all cases 
 of Insanity, but for females it is 26.4. For chronic melancholia the 
 average ratio is 130.2 per 1,000 of all cases of Insanity, but for fe- 
 males it is 137.8. 
 
 Stadia. — Coengesthetic depression has a single stadium, which can 
 be distinctly recognized and then p'asses into acute mania or melan- 
 cholia, or into a stadium conval'Cscens, as before mentioned. 
 
 Melancholia has an initial stadium of weeks or months of failure 
 of vital energy, disturbed sleep and digestion, lack of interest in cus- 
 tomary calling, and then an acute stadium of some months of symp- 
 toms already mentioned, and a stadium convale&cens of some weeks, 
 or a termination in one of the secondary states of depression above 
 named, or in terminal dementia. 
 
 Chronic melancholia is to be regarded as a terminal stadium of 
 
STATES OF DEPRESSION. 717 
 
 acute melancholia, and the same may be said of secondary mono- 
 mania with depression. 
 
 In severe cases of acute melancholia there is a stadium debilitatis 
 between the stadium acutum and the stadium dementise. In melan- 
 cholia attonita the stadium acutum may be essentially a stadium 
 stuporosum. 
 
 Symptoms. — The ground-tone of emotional gloom, the arrest of 
 the free flow of ideas, the persistence of a few painful thoughts, the 
 loss of interest in everything, doubts, fears, and suspicions, desperate 
 'or suicidal feehngs, and frightful delusions are common mental 
 symptoms. The somatic phenomena are disordered digestion, obsti- 
 pation from diminished peristalsis, general loss of weight, dry skin, 
 increased intra-arterial blood-pressure, slowed circulation, subnormal 
 temperature, lessened secretions and excretions, changes in blood and 
 urine, relaxed musculature and flexure of body and -extremities, 
 agrypnia, superficial respiration, and altered metabolism. 
 
 The suicidal impulses may spring from delusions or from de- 
 spondency alone. Exaggerated hypochondriacal ideas may dominate 
 the conduct for years. Religious delusions may prompt to self-mu- 
 tilation or suicide. 
 
 Changes, in personal identity are rare, but occasionally appear in 
 the final stage. 
 
 The resistive tendency springs chiefly from vague fears of the 
 environment, which seems to encroach upon the patient, who strug- 
 gles to repel the apparent invasion of inimical forces from all sides. 
 
 The nostalgic patient has hallucinations of home and kindred, 
 sees his native 'hills rise before him, and is engrossed with the one 
 idea of home, and may be violent to those restraining his return to 
 his native land. 
 
 The motor expressions of intense mental agony may take violent 
 and destructive forms, as in melancholic frenzy, or a more auto- 
 matic restlessness, as in melancholia agitata, which soon ceases to be 
 accompanied by much mental sufi:ering In chronic melancholia a 
 morbid delight may come to be taken in delusions primarily painful. 
 
 There is often a wild, staring look in melancholia attonita, with 
 terrifying hallucinations, but, as stupor becomes more decided, the 
 face may be perfectly blank. Cataleptoid 'and tetanoid states are 
 occasionally present, with abeyance of all the vital functions, neglect 
 of the wants of nature, and absolute lack of spontaneity of movement. 
 
 Pathology. — Hypotheses to account for the entire symptom-com- 
 plex of melancholia are lowered nerve-tension, vasomotor anomalies. 
 
718 TEXT-BOOK ON MENTAL DISEASES. 
 
 nutritional defect in cortical centres, and toxsemic influences. The 
 whole economy is involved, and the cause must be universal in effects, 
 and local lesions would not account for the symptoms. No theories 
 thus far advanced offer a satisfactory pathogeny of all the clinical 
 manifestations. 
 
 Differential Diagnosis. — Melancholia is to be differentiated from 
 the normal depression of mind from adequate causes of grief. It 
 must be distinguished from all forms of sequential stu])or and from 
 terminal types of mental enfeeblement. The physiognomy, the his- 
 tory of prevailing despondency, and the clinical course of the melan- 
 cholia, as well as the nature of the delusions, usually suffice; but 
 stuporous melancholia and dementia cannot always be differentiated 
 without a knowledge of the antecedent events in the case. Hypo- 
 chondriacal melancholia in the beginning is to be differentiated from 
 the hypochondriacal stage of certain cases of general paresis, in which 
 there is nearly always an element of mental weakness, which is diag- 
 nostic, even in the absence of physical symptoms. The history alone 
 serves to diagnosticate melancholia from the melancholic phase of 
 circular Insanity, and in the primary cycle of the latter there is no 
 means of distinction, and this possibility is to be bo'me in mind in 
 prognosis. Melancholia attonita is to be diagnosed from primary 
 dementia, in which there is no painful emotional mood previous 
 to the attack, and melancholia agitata must be distinguished from 
 mania with anxious delusions. 
 
 Melancholic frenzy and maniacal furor are only to be distin- 
 guished by the type of mental disorder from which they spring. 
 
 Prognosis. — Melancholia in young persons usually recovers. It 
 is a more serious disease in those past middle life, and as the ex- 
 pression of senile involution it has an unfavorable prognosis. The 
 prognosis is bad when treatment has been delayed for many months. 
 
 Melancholia agitata points to a chronic tendency and probable 
 incurability. 
 
 Melancholia attonita often recovers, while hypochondriacal mel- 
 ancholia is usually chronic in course, and most often terminates in 
 terminal dementia. A large number of cases pass into chronic melan- 
 cholia or secondary monomania, with depression, and these are in- 
 curable types. Other cases terminate in terminal dementia. Not 
 a few of the recoveries are defective, with ethical deterioration or 
 general diminution of intellectual force. 
 
 Death results from suicide, general exhaustion of vital forces. 
 
STATES OF DEPRESSION". 719 
 
 from trophic defects and emaciation, or from phthisis pulmonaHs, 
 or chronic gastro-intestinal disorder. 
 
 Treatment. — Isolation from sources of annoyance and danger in 
 an institution or in private quarters, under the constant care of 
 trained nurses, is essential in fully developed cases of melancholia. 
 Eest, watchful supervision to prevent self -injury, forced alimenta- 
 tion and artificial aids to digestion, hypnotics when food, fresh air, 
 and baths fail to procure sleep, are the chief indications. It is often 
 well to relieve the bowels by laxatives and enemas when dietetic 
 means fail, and to stimulate the skin by Turkish baths and massage. 
 Gentle exercise in the open air is necessary after the more acute 
 exhaustion has been overcome. Eoborant treatment 'and general 
 electrization, and stimulants and tonics must be employed at the 
 close of the acute stadium to prevent transition to dementia. Occu- 
 pation and diversions are also of service at this critical stage, and 
 sometimes a temporary removal to new surroundings is of service 
 at this time. 
 
 Forced exercises and long hours of sleep are necessary. A gen- 
 erous diet, gastric lavage, intestinal 'antisepsis, predigested foods, 
 and forced feeding are often a part of the treatment in patients with 
 foul secretions and refusal of food. Opium relieves mental suffering 
 better than any other known drug. Chloral is the surest drug to 
 procure sleep, but must be used sparingly in molancholiacs. Motor 
 agitation, if extreme, is met with hyoscin subcutaneously adminis- 
 tered. The whole life is to be carefully regulated by medical advice 
 for some months after convalescence. 
 
CHAPTER IX. 
 
 STATES OF MENTAL. EXALTATION. 
 
 Group: C cencesthetic Exaltation, Mania, Mania Transitoria, Mania 
 Chronica, Secondary Monomania with Exaltation. 
 
 Section I. — C cencesthetic Exaltation. 
 
 When the resultant of all the impressions from the peripheral 
 distribution of the nervous system is pleasurable, there is developed 
 an expansive coengesthesis, which may exceed physiological limits, 
 and the mildest pathological state of exaltation then arises and is 
 here termed coenassthetic exaltation. It is of much importance to 
 name and recognize this mildest maniacal state, which may run an 
 independent course to recovery or constitute the initial stadium of 
 a more serious psychosis. 
 
 Definition.— C(&ii?B9>i\\Qiic exaltation is the mildest maniacal type 
 of ahenation, arising from a pathologically exalted coensesthesis, and 
 clinically manifested in expansive ideas and emotions, hyperaesthesia 
 of the special senses, heightened association of ideas and thought- 
 rate, hypermnesia, quickened vital functions, and motor excitement 
 of a perfectly co-ordinated kind shown in restless activity of conduct. 
 
 Clinical Delineation. — The clinical features are often not recog- 
 nized as those of mental disease, though the change in conduct does 
 not escape observation. The patient is unusually social and may at- 
 tract attention by extravagant entertainment of friends; is full of 
 new business schemes, or, if a woman, of plans for the conversion 
 of mankind; runs about and talks to acquaintances, as well as to 
 friends, of the new projects; finds no time for actual work and 
 brings nothing to pass; changes from one plan to another; is not in- 
 coherent in thought or conduct, but ill-directed in immature efforts 
 of all kinds. The patient is a source of amusing surprise to friends, 
 showing unusual quickness of thought and action, witty in speech,. 
 I 720 
 
STATES OF MENTAL EXALTATION. 721 
 
 full of reasonable explanations for imnsiial conduct, laughing, jok- 
 ing, and bustling about, hardly taking time for meals, and sleeping 
 less than usual; sometimes meeting good fortune in rash business 
 ventures, but more often failure; often exhibiting erotic tendencies 
 and indiscriminate gallantry, and tending to social dissipation and 
 alcoholic excess. 
 
 The circulation is active, the countenance has unusual color, 
 there is increased muscular tone and heightened co-'ordination, the 
 appetite is good, but sleep is diminished, the secretions and excre- 
 tions are abundant, general nutrition is not disturbed, but the great 
 activity leads to a slight loss of weight. 
 
 Causes. — The expansive coensesthesis, the exaltation of organic 
 consciousness, is the necessary accompaniment, if not the prime 
 cause, of the full sympathetic flow of cerebral energy, which mani- 
 fests itself in pleasurable emotions, lively ideas, and increased sense 
 of mental force and freedom, and the other symptoms of coen^sthetic 
 exaltation. 
 
 The absolute or final causes of states of pain or of pleasure are 
 as yet unknown, either for physiological or pathological degrees of 
 enjoyment or suffering. 
 
 Stadia. — The pre-incubatory signs 'are so slight as to escape ob- 
 servation, and there is only an acute stadium of weeks' or months' 
 duration, ordinarily recognized by friends and readily diagnosed by 
 an expert in mental diseases. There then follows a stadium con- 
 valescens, ending, in a few weeks, in full recovery. 
 
 In some eases there is a transition into acute mania, or some other 
 acute psychosis. A termination in dementia does not occur. 
 
 Symptoms. — The emotional expansion proceeds from organic 
 sources and reflex cerebral sympathy, and not from spontaneous lib- 
 eration of cortical energy, as in some other forms of mental disorder. 
 The increased flow of ideas never escapes the rate of possible atten- 
 tion, and there is a due association of ideas and no incoherence of 
 speech. 
 
 Delusions and hallucinations do not arise. The loss of inhibi- 
 tion is evident in the rapid succession of new ideas and motives of 
 conduct, and the inability to persistently follow out any one course 
 of action. There is, therefore, a distinct impairment of professional 
 or business capacity, and some excuses are found for a neglect of 
 regular occupation. Consciousness is not seriously involved, but 
 there is no self-consciousness of the real mental trouble. Eemon- 
 strance with the patient often provokes great emotional reaction, 
 46 
 
722 TEXT-BOOK ON MENTAL DISEASES. 
 
 and the loss of self-control is again shown in sudden displays of vio- 
 lent anger, or uncontrolled laughter, or crying in women. 
 
 The eroticism may be decided and lead to violation of conven- 
 tional restraints of conduct, both in women and men. Loss of sleep 
 is sometimes great, but the effects are seldom shown in the physical 
 appearance of the patient, and the loss of flesh is due to excess of 
 activity rather than to defect of nutrition. 
 
 The social feelings predominate, but anti-social emotions also 
 appear, and the optimistic mood then gives way to vicious conduct 
 toward opponents. It is possible that the patient may be dangerous 
 to himself or others through intensity of feeling and loss of self- 
 control. 
 
 Pathology. — It is admitted that the brain is in nervous connection 
 and in intimate sympathy with all parts of the organism, hut it is 
 not known how changes in ccensesthetic consciousness and in or- 
 ganic sympathies directly derange the higher co-ordination of intel- 
 lectual processes. The clinical fact is undeniable, but the patholog- 
 ical explanation cannot be made satisfactorily. 
 
 Differential Diagnosis. — The diagnosis is to be made from tem- 
 porary states of expansive feelings due to adequate emotional causes. 
 The question of individual temperament must also be borne in mind. 
 The natural buoyancy of spirits of a sanguine temperament might 
 be positively abnormal if appearing in a person of an opposite tem- 
 perament. 
 
 The differential diagnosis must be made from the expansion of 
 feeling which marks the initial stadium of toxic Insanity, and also 
 from the 'exaltation of the first stage of general paresis. The etiol- 
 ogy of the case, and the motor symptoms, including superficial and 
 deep reflexes, usually sufiice in these instances for the differentiation. 
 
 Prognosis. — Eecovery follows in most cases, if the diagnosis is 
 made in time to institute treatment and exercise prophylaxis against 
 a more severe psychosis. If neglected,- the result is apt to be acute 
 mania, since the incessant activity is itself a cause of exhaustion. 
 G-enerally speaking, the prognosis is more favorable in those under 
 middle age, as in those advanced in life this type is often the pre- 
 cursor of more serious forms of mental disorder. 
 
 Treatment. — Isolation in an institution becomes necessary if the 
 patient is not amenable to advice and persists in exhausting activity 
 of body and mind. 
 
 Eegularity in habits, long hours of sleep, removal of heavy respon- 
 sibility, either of a social or business nature, a generous and specially 
 
STATES OF MENTAL EXALTATION. 723 
 
 adapted diet, hydrotherapy judiciously employed, daily exercise short 
 of fatigue, and some occupatiou rather than idleness, are among the 
 curative measures. 
 
 The howels are to he regulated by dietetic means, and sleep is to 
 be procured every other night hy a full hypnotic, if baths and other 
 expedients fail to relieve the insomnia, which is always a dangerous 
 symptom. 
 
 The greatest skill is required in the psycho'therapeutic measures 
 employed to divert the patient from injudicious social or financial 
 plans. If the patient is not properly managed, unsuitable marriage, 
 disastrous investment of money, and unfortunate business alliances 
 may be made. Travel with a judicious companion is sometimes ad- 
 visable when both friends and patient oppose institutional treatment. 
 
 Separation from customaiy surroundings and influences is often 
 necessary. 
 
 The whole life should be carefully regulated for some months 
 following convalescence. 
 
 Section II. — Maiiia. 
 
 The term mania has been vaguely applied by some writers to all 
 active forms of Insanity; but it now signifies a distinct type of men- 
 tal disorder, the opposite of melancholia, running an acute and 
 definite course, and having well-defined symptoms. It occurs most 
 frequently in the spring and early summer, and is more common 
 among colored than wliite persons, and among females than males. 
 Acute mania has an average ratio of 192.1 per 1,000 of all cases of 
 Insanity in institutions for the insane in the United States. Among 
 women this ratio is 199.1 for white and 246.2 for colored persons, and 
 for colored males it is 273.0. The average ratio of cases of chronic 
 mania is 236.3 per 1,000 of all cases of Insanity, and in females it is 
 248.5. Mania is therefore the most common form of Insanity in 
 institutions for the insane, and tliis is also undoubtedly true in the 
 community at large. The maximum number of cases occurs in the 
 quinquennium thirty to thirty-five years for acute mania, and for 
 chronic mania thirty-five to forty years in males and forty to forty- 
 five years in females. 
 
 Definition. — Mania is an active type of mental disorder, attended 
 by loss of the higher forms of inhibition of thought and action, by 
 increased flow of ideas, quickened rate of mental processes, a tumult- 
 uous influx of sensorial impressions, expansive and pleasurable emo- 
 
724 TEXT-BOOK ON MENTAL DISEASES. 
 
 tions, mo'tor excitement, boisterous actions, insomnia, increased se- 
 cretions and excretions, and a general loss of bodily weight. 
 
 Clinical Delineation. — The clinical picture varies somewhat ac- 
 cording to the age, sex, and temperament of the patient, but certain 
 features are always prominent. The sense of well-being, the exalta- 
 tion of feeling, the rapid flight of ideas, and heightened muscular 
 activity are seldom absent. The general expansion of feeling arises 
 from the agreeable change in ccenffisthetic consciousness, and the 
 succession of ideas, though in accordance with association by similar- 
 ity, may be more swift than utterance, and hence the discourse is at 
 times disjointed. All the senses are in a hypersesthetic state, and the 
 crowds of new impressions are provocative of changeful ideation, and 
 the lesion of attention is due to this forced displacement in con- 
 sciousness of one idea by another. 
 
 The muscular activity is at first psychomotor, but at the height 
 of the maniacal access it becomes reflex and automatic, and abso- 
 lutely beyond the control of the patient. 
 
 The mimetic muscles in reflex response to swiftly changing emo- 
 tions give a surprising play of facial expressions, as the patient by 
 turns engiages in laughter, weeping, prayer, or vituperation. The 
 agreeable moods predominate, but explosive anger is almost always 
 present. 
 
 The motor excitement is irrepressible, and under manual control 
 by nurses the muscles still continue to contract, as if for purposive 
 movements, which may be repressed but not prevented, so far as the 
 correlative discharge of nerve-force is concerned. 
 
 The patient first acts in accordance with illusive perceptions and 
 hallucinatory concepts, but at the height of the sensorial perversion 
 and confusion of ideas, action becomes incoherent as well as speech. 
 The patient then cannot even dress himself, mistakes objects and 
 their uses, attempts to put his legs into the arms of his coat, and 
 takes his trousers for a jacket, overturns and misplaces things, not 
 alone out of mischief, but from misconception of their real nature. 
 These mistakes in identity extend to persons as well as things. 
 Strangers are greeted as members of the family, or near relatives are 
 denounced as enemies. 
 
 In occasional instances the patient ceases to recognize himself, 
 but permianent changes in personal identity pertain rather to chronic 
 mania. 
 
 The delusive concepts are too fleeting ordinarily to take the form 
 of permanent false beliefs, but the repetition of the same illusions 
 
STATES OF MENTAL EXALTATION. 725 
 
 sometimes gives rise to certain sensorial delusions persisting for some 
 time. The play of phantasy is extraordinary, and finally all dis- 
 tinction between the real and the imaginary world is broken down, 
 and the patient reacts extravagantly to the fantastic environment 
 of his own creation. In the milder moods the patient appears as if 
 in a waking dream, or like a child at play, to whom the fancies of 
 the moment are the only realities. 
 
 The appetites and instincts are active, sexual passion is exagger- 
 ated, and destructive or violent impulses are common. This is a 
 delineation of ordinary acute mania, but there are other types of 
 mental exaltation to be here described in brief outline. 
 
 Mania transitoria is an ephemeral aberration of mind of the ex- 
 alted type, and of extremely sudden evolution. 
 
 After brief symptoms of rush of blood to the head, suffused coun- 
 tenance, and vertigo or headache, there is an outbreak of violent 
 maniacal excitement, intense hallucinations, turbulent and destruc- 
 tive actions, and often incendiary, suicidal, or homicidal deeds. There 
 is great confusion of ideas and partial eclipse of consciousness during 
 the transitory mania, for which there is ordinarily no recollection 
 on recovery, though a vague memory of parts of the access may exist. 
 
 The whole attack varies in duration from a quarter of an hour 
 to forty-eight hours, and it terminates by long and profound sleep. 
 It is of great Juridical interest, since responsibility cannot exist when 
 consciousness is in abeyance, and of its nature something more will 
 be said under other headings in this chapter. 
 
 Chronic mania is another state of exaltation, ordinarily a sequel 
 of acute mania, and lasting for years, and constituting an average 
 ratio of 236.3 per 1,000 of all hospital cases of Insanity in the United 
 States. It is not to be confused with demented or secondary mono- 
 maniacal terminations of the psychoses, but it is distinctly maniacal 
 throughout, though it may, in the course of years, end in terminal 
 dementia. The general disturbance of vital functions, of respiration, 
 circulation, and digestion, in a measure ceases, but the psychic symp- 
 toms of mania remain. The patient is noisy, destructive, and has 
 expansive feelings, and retains hallucinations and delusions, is diffi- 
 cult of control, and sleeps at irregular intervals, diurnal rather than 
 nooturnal, is cunning and mischievous, and easily provoked to acute 
 exacerbations of excitement, and is usually a source of much boister- 
 ous disturbance in the wards of hospitals for the insane. 
 
 Secondary monomania with exaltation is another terminal type 
 to be sketched, and to be differentiated from dementia and chronic 
 
726 TEXT-BOOK ON MENTAL DISEASES. 
 
 mania. After an acute psychosis, usually of the maniacal order, the 
 patient is left with a few expansive delusions, which become system- 
 atized, with such show of logic as enfeebled reasoning powers permit, 
 and on other subjects there is coherence of conversation. There is 
 exaltation of feehng, and the delusions show the exaggeration of 
 self-importance. There is no longer the intensity of emotions of 
 acute eases, but resistance to the special delusions provokes anger. 
 In some cases there has been a change of identity, but this implies 
 a degree of mental enfeeblement which does not exist in the major- 
 ity of cases. 
 
 Patients may believe that they are heirs to large estates, that 
 they are great inventors, that they have wide political influence, that 
 they have a divine mission on earth, that they are married to titled 
 persons, or that they are to become the benefactors and social re- 
 formers of mankind. The mental enfeeblement is not of such a 
 degree as to prevent reasoning on ordinary topics, and conformity 
 to the ordinary ways of life, and a certain rational adjustment of con- 
 duct to the personal environment. 
 
 Patients do not belong to this type of mental disorder, but to 
 a lower grade of mental enfeeblement, when they have lost their 
 identity completely, and decorate themselves with bits of paper or 
 rags, and automatically repeat that they are kings or queens, and 
 have no conception of their environment. These are terminal de- 
 ments, with automatic remnants of delusions, and they may previ- 
 ously have been cases of the type under consideration. It is desirable 
 to distinguish more definitely these consecutive forms of mental 
 alienation, which have been so promiscuously grouped under chronic 
 mania and dementia, and the writer first began this task about ten 
 years ago in an article written for Wood^s " Eef erence Handbook 
 of the Medical Sciences.'^ 
 
 Causes. — Hereditary predisposition can alone be mentioned in 
 a causative relation to manias other than those for which definite 
 etiological and pathological factors have already been given. That 
 there is such a type as idiopathic mania arising without definite 
 assignable causes other than predisposition is undoubtedly true. The 
 possible contributing causes in some cases are very numerous, while 
 in other instances absolutely no unusual or trying circumstances can 
 be ascertained. 
 
 Stadia. — Ordinary acu.te mania has an initial stadium of some 
 weeks, with headache, insomnia, a general sense of ill-being, and 
 'rritable and depressed moods. This stadium may be, on the other 
 
STATES OF MENTAL EXALTATION". 727 
 
 hand, one of eoen^sthetic exaltation and expansive feelings. Then 
 follows directly the stadium acutiTm, with emotional and intellectual 
 disturbance, motor excitement, illusions and delusions, and the whole 
 train of acute maniacal symptoms. Then succeeds, ordinarily, a sta- 
 dium dehilitatis, which is one of complete exhaustion of mind and 
 hody, often approaching a stuporous nature, and, finally, there is a 
 stadium oonvalescens, or a stadium dementise in incurable cases. 
 The stadium acutum has an average duration of from three to six 
 months, the stadium dehilitatis lasts from two to six weeks, and the 
 stadium oonvalescens extends over several months to complete recov- 
 ery, and the stadium dementise continues to the end of life. 
 
 Mania transitoria has a single acute stadium. There are incu- 
 batory symptoms, doubtless, but they are not sufficiently well-recog- 
 nized to constitute an initial stadium. The acute stadium lasts from 
 fifteen minutes to forty-eight hours, and then follow many hours 
 of deep sleep, which is the equivalent of a stadium dehilitatis, and 
 directly there ensues a stadium convalescens of some weeks, or even 
 months, before perfect restitution of health. 
 
 Chriomie mania itself constitutes a terminal stadium of acute 
 mania, and it may last for an indefinite period of years. Secondary 
 monomania, with exaltation, is also a terminal stadium of the acute 
 psychoses, more especially of mania, and its duration may be for 
 years or for the remainder of life. The absolute termination, how- 
 ever, of all consecutive types of mental disorder is dementia, provided 
 life is not abbreviated by intercurrent disease. 
 
 Symptoms. — The expansive emotions, heightened thought-rate, 
 exaggeration of ideas, loss of control of thoughts and actions, in- 
 creased muscular activity, illusions of special senses, sensorial delu- 
 sions, erotic excitement, and sleeplessness, are the most prominent 
 symptoms of acute mania. The motor excitement is shown in con- 
 stant walking, talking, and gesticulating. When the flight of ideas 
 is too rapid for utterance, there exists incoherence of speech. There 
 ceases to be any parallel between ideation and feeling, when, through 
 intense cortical irritation, there arise emotional outbursts of patho- 
 logical force. The impulsive tendencies are irresistible and lead to 
 destruction of property or personal violence. The sense of fatigue 
 does not exist, and the patient puts forth astonishing exertions. 
 Superficial and deep reflexes are usually increased. The pupils are 
 wider than normal in most cases, the turgor vitahs is well-marked, 
 the sMn moist, the appetite often excessive, and still there is loss 
 of weight. Salivation is often present, the temperature rises during 
 
728 TEXT-BOOK ON MENTAL DISEASES. 
 
 violent exertions and sinks to a subnormal degree subsequently, ob- 
 stipation or diarrhoea is frequent, and vasoparetic states are common. 
 
 Hallucinations are not promineait symptoms, but exceptionally 
 they abound to such an extent that the attack is termed mania hal- 
 lucinatoria. 
 
 In mania transitoria there are the most turbulent symptoms, 
 shouting, singing, incoherent talking, violent and destructive ac- 
 tions, furious emotions, ungovernable rage, and obscured conscious- 
 ness. The patient then sinks exliausted into profound sleep, and 
 awakens into a clear state of consciousness. 
 
 Chronic mania differs in sjmiptomatology from acute mania in 
 that the active bodily disorder largely disappears, and the patient 
 eats well and may have the outward appearance of fair physical 
 condition. Most of the psychic symptoms remain, and the illusions 
 and delusions are more constant, and motor excitement continues 
 to manifest itself in violent or destructive acts. Secondary mono- 
 mania with exaltation has a narrow circle of false behefs, and exag- 
 geration of personal imjDortance, with occasionally a few fixed sen- 
 sorial perversions. 
 
 The somatic condition approximates that of ordinary health 
 again, and sleep, ajDpetite, and circulation seem to be about normal. 
 All the mental faculties are, in fact, impaired, but the loss of balance 
 of mind is not yevj apparent, except in the direction of the special 
 delusions. Upon provocation, the weakened control is revealed by 
 temporary outbreaks of wild vituperation, or delusional anger, di- 
 rected against imaginary foes, and the enormous conceit of the pa- 
 tient appears on such occasions as he asserts liis supposed rights. 
 There is a species of physical accommodation to the new order of 
 things, and the patients may have active vegetative functions and 
 the semblance of fair health. The powers of resistance are always 
 reduced in these chronic types of Insanity, as shown by the readi- 
 ness with which they succumb to acute intercurrent diseases. There 
 is not infrequently an increase of weight and fatty degenerations of 
 internal organs. Permanent angioparetic states are also common. 
 
 Pathology. — The maniacal types vdth definite pathological le- 
 sions have already been described. It must be admitted that, for the 
 remaining forms here in question, there is no assignable pathology 
 other than vasomotor or nutritional disturbances of cerebral tissues. 
 
 It has been surmised that liigh tension of nerve-force is the 
 functional correlative of the maniacal manifestations, and tliis is 
 
STATES OF MENTAL EXALTATION. 729 
 
 as plausible as any other theory to be ofEered in pathological ex- 
 planation. 
 
 Certainly, no claim of a definite morbid anatomy in these cases 
 of mania can be sustained in the present state of knowledge. 
 
 Mania transitoria is presumably of epileptic origin in the ma- 
 jority of the eases. The whole symptom-complex is in the nature 
 of a violent cortical discharge of force. 
 
 That pathological conditions arising in puerperio and from alco- 
 hoM'C excess are to be considered in this connection admits of no 
 doubt. 
 
 In the history of some cases none of the above agencies are to be 
 traced, and the pathogenesis is very obscure. Meynert advocated the 
 vasomotor origin of mania transitoria, and, of late, mierobic infection 
 has been suggested. 
 
 Chronic mania and secoaidary monomania with exaltation, being 
 consecutive forms, can only be said to have the pathology of the 
 primary psychoses from which they spring in the first instance. It 
 is questionable to what extent any correlation exists in 'these types 
 between the mental symptoms and such chronic and gradual changes 
 in cerebral tissues or meningeal membranes as are known to occur 
 in the course of a series of years. 
 
 Differential Diagnosis. — Mania is to be differentiated from the 
 early stage of general paresis. In the latter the physical symptoms, 
 and the display of beginning mental weakness, and the extravagant 
 feelings and delusions, are the chief points of distinction; but they 
 may also, in a less characteristic way, be present in mania. The 
 inter-differential diagnosis can in certain cases only be made after 
 a lapse of some Aveeks, or even months. Simple mania is to be 
 distinguished from the maniacal phase of periodical Insanity by 
 the history of the case. When mania forms the first part of the first 
 cycle of periodical Insanity, it cannot be differentiated from simple 
 mania. 
 
 Mania is to be distinguished from the intoxication of drugs or 
 alcohol, and from the delirium of inflammatory diseases, and of all 
 forms of hyperpyrexia. 
 
 Mania transitoria is not to be easily mistaken for any other type 
 of Insanity, but it may be confused with the delirium of fevers. In 
 the latter the motor agitation and hallucinatory excitement are never 
 so severe as in mania transitoria. 
 
 Chronic mania is to be distinguished from terminal dementia 
 with automatic motions and occasional exacerbations of excitement. 
 
730 TEXT-BOOK ON MENTAL DISEASES. 
 
 The mental impairment is not so great in chronic mania, and there 
 is a much wider range of symptoms of a noisy and destructive kind, 
 with expansiye ideas correspondent to actual emotions, which are 
 wanting in terminal dementia. Secondary monomania with exalta- 
 tion is to be distinguished from terminal dementia with meaningless 
 repetition of set phrases, which may suggest fixed ideas of grandeur. 
 The secondary monomaniac feels and believes in his own "greatness, 
 and can assign reasons for his false beliefs, while the dement has no 
 feeling about the matter, and no belief and no understanding of the 
 full meaning of his claims. 
 
 Prognosis. — Mania is one of the most curable of all forms of 
 Insamity. If treated within the first six weeks, seventy-five per cent. 
 of cases will recover; after six months, fifty per cent, of recoveries 
 may be expected, and then there is a rapid fall in the ratio 'of cures 
 to the end of the first year, when ten per cent, of recoveries may 
 result from treatment. The young recover better than the old, and 
 in women the chances are a little more favorable than in men. 
 
 Mania transitoria has a good prognosis, and recovery may be 
 expected if no fatal accident be met with during the attack, which 
 per se does not lead to death by exhaustion. Mental recovery, in 
 very rare instances, may be defective, but there is ordinarily apparent 
 restoration to reason within twenty-four hours. 
 
 Chronic mania is practically an incurable type of mental disorder. 
 The patient may go twenty years without passing into terminal de- 
 mentia, which is the termination, if hfe be sufficiently prolonged. 
 
 Secondary monomania with exaltation is also a hopeless form of 
 alienation, and also ends in dementia in the course of time. The 
 expectation of hfe is considerably shortened by these and all other 
 terminal forms of Insanity. 
 
 As to the ordinary type of mania, there is a mortality of about 
 fourteen per cent, of cases attacked. The chances of life are very 
 much better in the young than in those past fifty years of age. 
 After this age the mortahty-rate in mania increases very rapidly. 
 It is somewhat less in women than in men. 
 
 The causes of death are nervous exhaustion, gastrointestinal 
 disorders, suicides and accidents, heart-failure, pulmonary diseases, 
 renal and intercurrent disorders. 
 
 Treatment. — Institutional care is necessary in acute mania for the 
 . safety of the patient and of others. 
 
 If exhaustion is imminent, the recumbent posture is to be re- 
 tained. In vigorous cases out-door exercise and light occupation is 
 
STATES OF MENTAL EXALTATION. 731 
 
 desirable. The patient puts fortli fewer efforts in the freedom of a 
 walk than when secluded. The motor excitement may be quieted 
 in extreme cases by hyoscin or duboisine, or the bromides may quiet 
 the general agitation. Warm baths and chloral are the most efficient 
 means of procuring sleep. 
 
 Graduated baths, with cold to the head in hyperacute cases, are 
 specially effective. 
 
 Generous alimentation is of the utmost importance throughout 
 the entire attack. Anorexia is no contra-indication to forced feeding 
 if there is loss of weight, and neglect of food from over-excitement. 
 
 Stimulants are only to be used to sustain cardiac action. 
 
 Tonics, massage, and electricity are useful after the stadium 
 acutum in the stadium debiiitaias. 
 
 Psychotherapy is in order in the convalescent stage, and change 
 of climate and travel are then of occasional use. Gardening and 
 light farm-work, and prolonged exercise in the open air daily for 
 some months, is one of the surest means of hardening the cure. An 
 after-cure is necessary to avoid a relapse in recoveries from a second 
 attack. This is of special importance, since recovery from a third 
 attack is rare. 
 
 ]\Iania transitoria is so brief that only symptomatic treatment is 
 possible. Probably a full dose of hyoscin and morphine, if given 
 at the very onset, might be of service. 
 
 Hyperpyrexia is to be met with the cold pack, or with a cool bath, 
 with cold to the head. 
 
 The patient is to be protected from injury by constant restraint 
 by others or by the restraining sheet. 
 
 Chroaiic mania presents only indications for the feeding, cloth- 
 ing, safe-keeping, occupying, and diverting of the patient. In pro- 
 longed excitement counter-irritations to the back of the neck are 
 of some avail. In cases constantly destructive and violent, a seton 
 in the back of the neck is sometimes followed by good results. Sec- 
 ondary monomania with exaltation can be cared for out of an insti- 
 tution, provided there are no dangerous impulses, and the teaching 
 of some manual occupation is most desirable. The object is to divert 
 the patient, to establish regular habits of life, and, if possible, of 
 usefulness, and to provide comfortable quarters, regular sleep, and 
 proper clothing. If carefully managed, tliis class of patients may be 
 rendered productive, and, in part, self-supporting. In all these 
 chronic cases frequent physical examinations are necessary to detect 
 the insidious course of pulmonary, renal, and cardiac affections. 
 
732 TEXT-BOOK ON MENTAL DISEASES. 
 
 The possibility of cure is shown by an occasional recovery in these 
 consecutive forms at the end of ten or fifteen years. The continuous 
 use of sedatives and hypnotics in these chronic cases is to be con- 
 demned. Bathing and occupation, or diversion in the open air to 
 the point of fatigue, most always suffice, together with a generous 
 diet, to procure sleep and reasonable quietude. 
 
CHAPTER X. 
 
 STATES OF MENTAL WEAKNESS. 
 
 Group: Primary Mental Enfeeblement, Terminal Dementia. 
 
 Section I. — Primary Mental Enfeeblement. 
 
 There is a primary state of mental weakness involving the whole 
 intellect and in some cases progressing to dementia, independent of 
 the deficiencies of eariy life or of the senile decay of mind. This 
 prim'ary mental enfeeblement has neither the cerebral lesions of 
 paretic or alcoholic cases, nor the somatic symptoms of those forms, 
 and it differs decidedly from acute primar}- dementia, and it is there- 
 fore recognized as a special type, though it is admittedly a rare mode 
 of alienation. 
 
 Definition. — Primar}" mental enfeeblement is a progressive state 
 of weakness of intellect shown in loss of memory, impaired attention, 
 confusion of ideas, inability to pureue customar}' avocations, and a 
 general deterioration of mind. 
 
 Clinical Delineation. — After prolonged stress of inind or body, 
 there is first absent-mindedness, a disinchnation to usual labors, f or- 
 getfulness of certain duties, or mistakes in the performance of the 
 same, a desire for quietude and repose, and a loss of interest in the 
 afi'airs of hfe. There is no active disorder of physical functions, but 
 sleep is not refreshing, and there is indifllerence to food and sexual 
 indulgence, and some gradual impairment of nutrition. 
 
 There is no decided tone of feeling, either of expansion or de- 
 pression, but there is often a consciousness of a certain general indis- 
 position. If warning is taken and treatment instituted at tliis stage, 
 there may be restoration to health; otherwise, there is further pro- 
 gression of the mental malady. The errors in business are more 
 glaring, and the amnesia is so great that mercaaitile or professional 
 occupations can no longer be pursued. Confusion of dates, of events, 
 
 733 
 
734 TEXT-BOOK ON" MENTAL DISEASES. 
 
 and of identity appears, and the weakness of intellect becomes ap- 
 parent to all. The patient finally is totally incapacitated for any 
 intellectual pursuit, is simply capable of self-care, and of some simple 
 mechanical duty. This stage is reached at the end of six or eight 
 months. Eecovery is still possible, but an occasional ending is a 
 continuous decline into 'Complete dementia, which is terminal. 
 
 Causes. — This type of enfeeblement may appear in the young 
 as well as in adults after exhausting infectious diseases, or prolonged 
 physical or mental strain from any cause. It is most apt to occur 
 about middle-age in men who have been through great vicissitudes 
 in life. Predisposition to mental disease probably exists, but has 
 not appeared as an etiological factor in the history of oases. 
 
 Stadia. — The initial stadium, as shown by early loss of memory 
 and accustomed accuracy in duties, and absence of mind, may last 
 several months and give place to the acute stadium of confusion 
 of ideas, forgetfulness of the most common affairs of life, and ina- 
 bility for any occupation. This acute stadium continues for several 
 months and passes into a stadium convaleseens or a terminal sta- 
 dium dementise. The convalescence is gradual, and full health is 
 only regained at the expiration of some months. The terminal de- 
 mentia is the same as that of other types of aberration, and is of the 
 passive variety. 
 
 Symptoms. — The chief characteristic is the absence of active per- 
 turbation and the steadily advancing enfeeblement of all the mental 
 faculties. 
 
 Another peculiarity is failure of any depression, exaltation, or 
 sensorial perversions. The delusions arise from inattention and con- 
 fusion of places and persons at the height of the alienation. Con- 
 sciousness is clearl}^ impaired, but there is no loss of it and no change 
 in identity. The amnesia is marked in all cases, and is progressive, 
 and, in the end, total in the incurable cases. The somatic symptoms 
 are at first negative, but gradually there is loss of appetite, sleep, 
 and of total weight. The progressive enfeeblement may be arrested 
 at any point, and the actual degree of mental weakness reached 
 varies much in different cases, especially in adolescent cases, in which 
 recovery may follow high grades of impairment of mind. The symp- 
 toms resemble slightly those of general paresis, so far as progressive 
 deterioration is concerned, but the active disorder and the physical 
 signs are wanting, and the recover}^ shows the radical distinction be- 
 tween the two maladies. 
 
 PatJiology. — The mental weakness is connected in some way with 
 
STATES OF MENTAL WEAKNESS. 735 
 
 functional brain exhaustion, and the curability would imply that 
 there are not organic lesions, as in paresis and other forms of pro- 
 gressive mental enfeeblement. 
 
 It is not impossible, in young persons, that certain changes in 
 ganglionic cortical elements may be recovered from in this form of 
 mental weakness, but it is not probable that the disorder is other 
 than functional. In other words, the pathology is obscure. 
 
 Differential Diagnosis. — In the absence of active symptoms, and 
 of motor disturbances in the early part of general paresis, there may 
 be mental weakness of a progressive nature, like that of primary 
 mental enfeeblement, but the subsequent course of the paresis serves 
 to differentiate the one from the other. 
 
 Acute primary dementia presents mental and physical symptoms 
 of a decided nature, and fluctuations of stupor, which suffice for the 
 differentiation. 
 
 Senium praecox has some points in common^but does not recover, 
 and has organic lesions; and the mental enfeeblement in epileptics 
 is not to be easily confused with the type in question when the diag- 
 nosis of nocturnal or larvated attacks has once been made. Senile 
 dementia presents also a more active group of symptoms. 
 
 Prognosis. — The prognosis is not bad, and fifty per cent, of the 
 cases may be expected to recover if taken in the initial stadium, but 
 when treatment is delayed to the end of the acute stadium, the 
 chances are thait terminal dementia will ensue. 
 
 The prognosis is better in the young than in the middle-aged, and 
 in women than in men. 
 
 Caution must be exercised in prognosis not to mistake the mental 
 weakness of the acute stage for terminal dementia. 
 
 Treatment. — Institutional treatment is not essential in these 
 cases, which are seldom dangerous to themselves or to others. Eest 
 and freedom from all responsibility and worry are necessary, and 
 then the enforcement of hygienic measures. Idleness is to be avoided, 
 but gentle exercise and some light out-of-door occupation, like gar- 
 dening, is desirable. Diversions and social means of arousing the 
 patient from apathy must be continued perseveringly. Long hours 
 of sleep, nourishing food, and the Scotch douche, and O'ther active 
 hydrotherapeutic measures, are useful in the more robust male pa- 
 tients. The alterative effect of arsenic may be tried, and tonics and 
 alcoholic beverages, in moderation, in cases with impaired cardiac 
 action, may be used. 
 
 Hypnotics must be employed sparingly, and still sleep must be 
 
736 TEXT-BOOK ON MENTAL DISEASES. 
 
 procured, if other expedients fail. The recovery is apt to be gradual^ 
 and a renewal of therapeutic means may be necessary to complete the 
 cure. If there is danger of passage into terminal dementia, the blis- 
 tering of the neck, or Paquelin's cautery, may be a dernier ressort. 
 
 Section II. — Terminal Dementia. 
 
 All the acute psychoses, and all the mixed and consecutive ij^e& 
 of mental disorder, which prove incurable, end in terminal dementia, 
 if life be sufficiently prolonged. More cases are classed under this- 
 form of Insanity than under any other, and terminal dementia, out 
 of 74,028 cases of Insanity in hospitals for the insane in the United 
 Statbs, was the form in 19,889 instances, of which the largest num- 
 ber fell in the quinquennium forty to forty-five years. 
 
 Definition. — Terminal dementia is a consecutive state of mental 
 weakness, and consists in various degrees of loss of all the 'higher 
 mental activities, of memory, reason, attention, and consciousness, 
 and it is also attended by physical deterioration and structural alter- 
 ations of various parts of the organism. 
 
 Clinical Delineation. — As indicated by the above definition, vari- 
 ous degrees of mental weakness of a permanent kind are grouped 
 in the demented category. Some dements do not know their names, 
 their friends, their locality, or their own existence. They do not 
 exist mentally, but physically, and have lost all conception of their 
 own identity. There has not been a transformation, but an aboli- 
 tion, of personality in these cases. Some of these patients have to be 
 fed, clothed, bathed, and cared for like babes, and they would perish 
 of himger with food within their reach, having lost the prime instinct 
 of self-preservation and of the need of food. They sit or stand in 
 one position for hours, or move about automatically, with a shuffling 
 gait. Their countenance is a blank, with expressionless eyes, ef- 
 faced facial lines, open mouth, which may drool much saliva, and 
 there is entire neglect of the calls of nature. 
 
 This is the passive type of terminal dementia. The active type 
 has somewhat different features. The active dement has automatic 
 movements, walks in a circle, or sways to and fro, rubs his head with 
 his hands, grimaces, may tear or break things or pick his clothes 
 to pieces, mutters to himself or talks incoherently, and may have 
 remnants of maniacal expre^ion or habits, or traces of melancholic 
 looks and demeanor without any corresponding emotion. Types of 
 consecutive mental enfeeblement, grouped often under the general 
 
STATES OF MENTAL WEAKNP:SS. 737 
 
 term dementia, have already been described as chronic mania, chronic' 
 melancholia, and secondary monomania with exaltation or depres- 
 sion. In addition to these, and to the active and passive forms of 
 dementia, still others might be delineated, but enough has been said 
 to show the variety of the mental ruins wrought by the acute storms 
 of mental disease. 
 
 Whatever be the diversity of symptoms, in the course of time 
 the passive type of dementia is attained as the final termination of 
 mental existence. 
 
 Causes. — ISTo independent etiology can be claimed for dementia 
 wliich is the result of the acute psychoses. Neglect of treatment of 
 the acute mental disorder, or ill-advised management of the same, 
 as a matter of fact, may be regarded as a cause. 
 
 Undoubtedly, certain cases are predestined, by evil inheritance, 
 to pass into dementia, and in some families this occurs at a definite 
 period of life. The causes of congenital or acquired imbecility are 
 not to be enumerated in this connection, though it is a common error 
 to class acquired mental deficiency under the term of dementia. 
 
 Stadia. — Terminal dementia constitutes a final stadium of the 
 acute psychoses. This stadium is prolonged for the whole period of 
 life, and ends in death. That there are some changes in the psychi- 
 cal symptoms during this stadium has already been noted, and that 
 the more active manifestations finally give place to passive and purely 
 vegetative forms of existence. Exacerbations of excitement some- 
 times occur, but remissions do not exist, and in the course of time 
 complete fatuity is the termination of this stadium dementise. 
 
 Symptoms. — The lack of all initiative is due to the emotional in- 
 difference and to the diminution of sensorial perceptions, and the 
 absence of motives of conduct. The active type of dementia retains 
 some emotional ideas and sensorial perversions following acute mania, 
 and for a time there is some show of spontaneity, until hebetude fol- 
 lows. The loss of the association of ideas, and the obliteration of 
 memories, ^as well as the inability to fix the attention upon any one 
 object, is the explanation of the fatuous state observed. The repe- 
 tition of words or phrases (verbigeration) indicates no ideation, and 
 is as automatic as the motions of the patient. Even the grimaces and 
 gestures and attitudes are largely reflex and automatic, and in some 
 cases they are inherited peculiarities of manner or movement, re- 
 maining after all voluntary action has disappeared. Obscure prompt- 
 ings of animal instincts and brutal appetites may still move the pa- 
 47 
 
738 TEXT-BOOK OlS" MENTAL DISEASES. 
 
 tient to masturbation, coprophagy, or other beastly acts, of which 
 there is no intelligent conce]3tion. 
 
 The nutritive functions may seem to be good by the large gain of 
 flesh;, but fat is the lowest form of tissue, and its rapid accumulation 
 only announces the degradation of the general physical being. The 
 circulation is impaired, there is vasoparesis, and enfeebled cardiac 
 action. The skin is bluish and cool, and there is often a subnormal 
 temperature. There is angesthesia and analgesia, and the superficial 
 and deep reflexes are diminished. Mydriasis is ordinarily present, 
 and a sluggish reaction to light and to peripheral stimuh is found. 
 Finally, the trophic functions are greatly impaired, and there is then 
 a general loss of weight, and death often results in a state of maras- 
 mus. 
 
 Pathology. — The pathological changes in the cerebral tissues are 
 cliiefly of an atrophic nature. The nerve-cells undergo degeneration, 
 and their processes disappear, and association nerve-fibres also dis- 
 integrate, and this interstitial atrophy is most general in the cortical 
 .regions of the frontal lobes. 
 
 Still, no definite lesions can be cited as correspondent to the 
 psychic symptoms during life. Atheromatous degenerations of the 
 vascular system and sclerotic changes of internal organs are not in- 
 frequent, tuberculosis appears in a large percentage of cases, and 
 oedema or other pulmonary disease is a common cause of death. 
 
 Differential Diagnosis. — Terminal dementia is to be differen- 
 tiated from acute dementia, in which there is active inhibition of 
 thought and action by fearful hallucinations or delusions. It is also 
 to be distinguished from sequential stupor, epileptic hebetude, and 
 acute melancholiacum stupore. The history of a previous psychosis 
 and the general impairment of mind renders the diagnosis easy in 
 most cases. 
 
 Prognosis. — The prognosis is always bad. Cures have been rec- 
 ognized in a few cases, but there was a mistake in diagnosis, in all 
 probabiUty. The duration of hfe is shortened, on the average, but 
 existence may be prolonged almost indefinitely, or to extreme old 
 age in rare cases. 
 
 Treatment. — Curative treatment is out of the question, and the 
 object is custodial care. Much may be done to estabhsh automatic 
 habits of cleanliness. Patients are to be taught to attend to the 
 calls of nature and to avoid destructive or filthy tendencies. 
 
 Often some simple mechanical occupation in the way of farm 
 
STATES OF MENTAL WEAKNESS. 739 
 
 labor may be taught, and the patient may thus be made in some 
 measure useful. 
 
 Eegular meals, long hours of sleep, and warm clothing are neces- 
 sary hygienic means. 
 
 The active dements may be treated with occasional sedatives, if 
 very noisy at night, but exercise in the open air to the point of fa- 
 tigue is a better expedient. 
 
 It is better for the patient to be dressed and sitting up, so long 
 as the strength will permit, but many dements become bedridden, 
 and decubitus is then a constant damger to be avoided only by con- 
 stant attention to cleanliness. 
 
 Intercurrent diseases of internal organs are frequent, and often 
 escape notice if physical examinations are not frequently made. 
 
CHAPTER XI. 
 
 STATES OF STUPOR. 
 
 Group: Acute Primary Dementia, Sequential Stupor. 
 Section I. — Acute Primary Dementia. 
 
 There is a state of stupor, which does not follow acute mental 
 disorder, and is of a very decided character, and hence is termed 
 acute primary dementia. It is most common between the ages of 
 fifteen and thirty-five, and is very rarely seen after middle age. 
 
 Definition. — Acute primary dementia is a state of stupor at- 
 tended by inhibition of thought and actions, absence of association 
 of ideas and of the power of recollection, and occasionally by the 
 domination of a few sensorial delusions, and by exhaustion of vital 
 functions. 
 
 Clinical Delineation. — The degree of stupor varies considerably, 
 and with it the general features of the case. It would not be true to 
 clinical facts to picture aU eases as suffering from profound apathy, 
 which certainly is present in the most typical instances. In the 
 cases of deep stupor, which will first be delineated, there is absence 
 of all facial expression and a vacant, staring look; the jaw is re- 
 laxed, and saliva often drools from the partially open mouth; the 
 whole musculature is lax, and the extremities, when raised, drop 
 heavily of their own weight; circulation is slow and feeble, and the 
 extremities are blue and cool; perception is dull, sharp periph- 
 eral stimulations are not heeded, and the prick of a pin will excite 
 no response. Ideation is in abeyance, and sensorial stimuli excite 
 no psychic reflexes. The sense-impressions call up no associated 
 images and arouse no memorial residua. There are no emotions and 
 no motives for immediate action, and no intentional movements. 
 The patient sits or lies for hours in one position, and has to be fed, 
 dressed and undressed, and led from one place to another. When 
 
 740 
 
STATES OF STUPOR. 741 
 
 seated, the body flexes of its own weight, and when the head is 
 raised it again falls forward. ISTo words are spoken, and the bladder 
 and rectum are involuntarily emptied, and the patient is simply 
 a surviving, but totally inert, human being. 
 
 In the less pronounced cases of stupor, the patient appears ab- 
 sorbed completely, but can be aroused to a momentary appearance 
 of recognition of surroundings by some active appeal, and may reply 
 briefly to some question, and then sinks again into hebetude. At 
 intervals the patient shows some signs of mental activity, laughs or 
 cries, and may have corresponding muscular display of a brief change 
 in innervation, shown in emotional shades of expression, or in active 
 movements of the extremities. In exceptional instances there is, 
 from time to time, a brief period of excitement, and then a sudden 
 relapse into the stuporous state. There may be cataleptoid rigidity of 
 muscles in these cases, and automatic motions oft repeated, but these 
 are unusual manifestations, and it is still more rare that there is an 
 actual maniacal exacerbation of short duration. 
 
 Whenever mental activity appears, it may be demonstrated re- 
 peatedly in the direction of a few hallucinations or delusions, remain- 
 ing the same throughout the attack. This state is like that of 
 melancholia cum stupore, but in the latter the hallucinations and 
 delusions are of a frightful and painful character, while in the cases 
 mentioned the sensorial perversions during the excitement may be 
 lively, and dancing or singing may occur before the relapse into 
 stupor. It will generally be found that these cases with excited 
 intervals have hereditary taint, and the more neuropathic the patient, 
 the greater variety will there be in the entire course of the symptoms. 
 
 In unfavorable cases the stupor passes at the end, ordinarily, of 
 six months into dementia of a terminal kind; but, otherwise, intervals 
 of clear consciousness begin to appear and gradually lengthen into 
 a convalescent state, which may end in complete or incomplete re- 
 covery of mind. 
 
 Causes. — Stuporous states develop in pubescent and adolescent 
 cases of a psychopathic disposition without any assignable cause. 
 Probably, whatever lowers vitality and nervous tone favors the stu- 
 por. Thus the puerperium, severe mental effort, masturbation, large 
 losses of blood, fevers, and other exhausting affections, and great 
 physical fatigue, serve to develop any inherent tendency to acute 
 primary dementia. Sudden fright also acts in this way. 
 
 Stadia. — There is an initial stadium of general malaise, gloomy 
 feelings, and indisposition to occupation. Often there is constipa- 
 
742 TEXT-BOOK ON MENTAL DISEASES. 
 
 tion, headache, and disordered digestion during this stadium, which 
 lasts some weeks, on the average. Then follows the stadium acutum, 
 which, in this instance, is a stadium stuporosum, which lasts some 
 months ordinarily, though it may terminate in ten days or extend 
 through an entire year. This acute stadium may be interrupted by 
 semi-lucid intervals of a few days, or by mild maniacal turns of a 
 week or so, or by hysterical symptoms in psychopathic women. 
 
 There then follows a stadium convalescens of some weeks^ dura- 
 tion, according somewhat with the relative length of the acute sta- 
 dium. In unfavorable cases a stadium dementias tenninates the at- 
 tack. 
 
 Symptoms. — The symptoms in cases from sudden fright may ap- 
 pear at once, but ordinarily a week or more elapses before complete 
 stupor is developed. In the most profound cases there is complete 
 absence of ideation, of attention and perception, of voluntary move- 
 ment, and of ordinary reflex actions. The eyes do not close when 
 objects suddenly approach, tickling the neck with a feather provokes 
 no attention, superficial reflexes are abolished, muscular reactions 
 to electricity are diminished, there is anaesthesia and analgesia, the 
 pulse is slowed and feeble, respiration is superficial, cutaneous sur- 
 faces 'are livid, there is capillary stasis, temperature is subnormal, 
 and general nutrition is impaired. There is complete muscular relax- 
 ation in profound stupor, but in other instances there is muscular 
 fixity and a passive resistance to all enforced movements. This in- 
 hibition of actions is like the inhibition of ideas in the same cases, 
 which show no movements, but still belong to active rather than 
 passive stupor, and it is in such cases that certain sensorial delusions 
 persist, to the exclusion of all other ideas. There is, in these in- 
 stances, a limitation of consciousness, while in the passive cases there 
 is an obscuration of consciousness, or a total eclipse of the same. 
 Some speak of these states as anergic stupor (passive stupor) and de- 
 lusional stupor (active stupor). There is no memory of the state 
 of passive stupor on recovery, but a partial recollection may exist 
 for the events of active stupor. In the passive type the saliva drips 
 from the mouth, but in the active form it is often retained until the 
 mouth is filled, and, as swallowing is inhibited, there is a change in 
 the saliva which becomes offensive. The sphygmograph shows a 
 high-tension pulse from capillary obstruction. 
 
 Vasoparesis, autographic skin, and digiti mortui may appear in 
 some of the cases. The organic needs are not felt and hunger is 
 unknown. The patient has to be fed and food must be carried back 
 
STATES OF STUPOK. 743 
 
 in the pharynx to excite swallowing, and liquid nonrishment is hence 
 required. The patient may be unconscious of the action 'of the 
 bowels or bladder, and is inattentive, at any rate, to nature's calls. 
 The blo'od is changed and the red blood-corpuscles are greatly di- 
 minished. Trophic functions are impaired, and there is a general 
 loss of weight. 
 
 Pathology. — The fact that recovery from the stupor may be sud- 
 den points not to organic lesions, but to functional disturbance of 
 cortical regions, either from circulatory or nutritive disorder. The 
 pathology which best accords with the clinical manifestations is vaso- 
 motor disorder. The same capillary stasis evident in the general sur- 
 faces of the body probably exists in cerebral tissues, which have been 
 found oedematous post-mortem in some cases. The pathogenesis can- 
 not be definitely assigned, however, and it ma}'' differ somewhat in 
 the active and passive types and in the different degrees of stupor. 
 
 Differential Diagnosis. — It has been customary to differentiate 
 acute primary dementia from melancholia cum stupore. In the lat- 
 ter the inhibition of thought and action is dependent on frightful 
 hallucinations and delusions, and there is painful tension of mind. 
 This tension may be broken suddenly, and violent acts to self or 
 others may follow, and then, after the explosion, the stuporous de- 
 pression may be resumed. 
 
 The tension and inhibition are not so great, even in acute primary 
 dementia from fright, which most nearly resembles melancholia with 
 stupor. Whenever the reduction of consciousness is so profound 
 tliat mental tension and pain cease to exist, the state is one of acute 
 dementia rather than of melancholia with stupor. The only real 
 distinction between the two states seems to be that in one there 
 is concentrated and painful action of mind, and in the other absence 
 of such mental activity. Clinically these states may approach one 
 another so that in some cases it is an arbitrary distinction to say 
 which designation is the more appropriate. 
 
 Acute primary dementia is to be differentiated from epileptic, 
 paretic, alcoholic, and all other forms of stupor intercurrent in the 
 acute psychoses. The history of the case serves for this purpose, and 
 in the absence of all previous knowledge of a case the differential 
 diagnosis is often impossible. 
 
 The differential diagnosis is also to be made from the temporary 
 hebetude and confusion of ideas following the shock of severe emo- 
 tions, Necessary time for a reaction must be accorded before a diag- 
 
744 TEXT-BOOK ON MENTAL DISEASES. 
 
 nosis is made. Some delicately organized persons require some days 
 to recover from severe emotional trauma. 
 
 Prognosis. — Tlie prognosis is that fifty per cent, of those at- 
 tacked may be expected to recover, if promptly and continuously 
 treated. Terminal dementia follows in a considerable proportion of 
 the cases, and imperfect recovery is also common. Death results 
 from pulmonary or cerebral oedema or cardiac failure in not a few 
 instances. 
 
 Eelapses are also to be anticipated, especially in those with strong 
 heredity. The prognosis is unfavorable in those past the thirtieth 
 year, and in those predisposed to phthisis pulmonalis, which is wont 
 to develop in these stuporous states. 
 
 Treatment. — Prolonged and constant nursing renders institu- 
 tional care necessary when two nurses cannot be provided for night 
 and day attendance in private treatment. 
 
 The three immediate provisions to be made are warmth, rest in 
 bed, and continuous alimentation of the patient. Warm baths equal- 
 ize the circulation, and Turkish baths, followed by massage, are effi- 
 cient. Sleep is favored by artificial heat to the extremities, and 
 digitalis, for its cardiac effect and the relief of passive cerebral con- 
 gestion, is indicated. Galvanism of the sympathetic and of the brain 
 may be cautiously used. General electrization and electro-massage 
 assist the circulation and nutrition. 
 
 Artificial alimentation is to be persistently carried out, and a full 
 physiological ration of nitrogenous food is to be given. Meat, eggs, 
 and milk are the main reliance, and cod-liver oil, if well borne, may 
 be added. Stimulants are to be used chiefly as cardiac failure de- 
 mands. Anemia calls for ferruginous preparations, and quinine and 
 arsenic, for tonic and alterative effects, are sometimes useful. 
 
 Obstipation is to be relieved by stimulating enemata and by mas- 
 sage. 
 
 Insomnia is sometimes an obstinate symptom. Heat to the head 
 may induce sleep, and digitalis and opium act better than the usual 
 hypnotics in these cases. Hot milk, one pint, with two ounces of 
 whiskey, and hot-water bags to feet and spine, will often procure 
 sleep. In the convalescent stadium systematic but gentle exercise 
 in the open air, diversions, and a change of climate and travel are 
 often useful. 
 
 Prophylaxis as regards relapses is nec-essar}'. No serious occupa- 
 tion should be undertaken for several months following recovery, 
 which cannot be deemed complete in women until the menstrual 
 
STATES OF STUPOR. 745 
 
 function lias been re-establislied with regularity. In general, the re- 
 turn to normal weight, appetite, and sleep announce the physical 
 restoration without which recovery cannot he recognized as fully 
 accomplished. 
 
 Section II. — Sequential Stupor. 
 
 In contradistinction to the state of stupor just described as pri- 
 mary dementia, there is another state of stupor which is secondar}" to 
 some other form of Insanity, and hence termed sequential stupor. 
 This ty^e is therefore, strictly speaking, not an independent form of 
 Insanity, though it m-ay constitute an apparently distinct mode of 
 alienation, and is so frequent as to merit separate consideration. It 
 presents a variety of clinical forms, and is so important as to deserve 
 the most careful study, and is a key to the understanding of the true 
 course of certain types of mental disease. 
 
 Definition. — Sequential stupor is a mode of alienation intercur- 
 rent in other t}^es of mental disorder, and characterized by various 
 degrees of loss of memory, arrest of flow of ideas, impaired special 
 and general sensation, absence of emotions and of vohtional im- 
 pulses, and inhibition or abolition, more or less complete, of all 
 psychic activities. 
 
 Clinical Delineation. — Following acute melancholia or acute 
 mania, sequential stupor is mild or severe, and may last for weeks or 
 months. In the mild cases of stupor the patient ceases to perform 
 voluntary acts, except as prompted by hallucinations or a few delu- 
 sions, or by momentary impulsive tendencies. Questions are not 
 answered, though the patient may utter a few phrases or repeat the 
 same reply to every question asked. One position is long retained, 
 and there may be resistance of a passive kind to all attempts to move, 
 feed, dress, or undress the patient, who is entirely neglectful and 
 dirty in habits. Every few hours there may be some automatic 
 display of activity or some impulsive act, such as striking or throw- 
 ing something suddenly seized, and then there is immediate relapse 
 into apathy again. Occasionally cataleptoid symptoms appear, or 
 there may be automatic swaying to and fro, or some stereotyped 
 motion continued for shorter or longer periods. There may be repe- 
 tition of words or of short phrases, or of certain inarticulate sounds; 
 all of which shows the paucity of ideas and the escape of nervous 
 force through some particular channel, which, for the time being, 
 chances to be per^dous. Or there may be monotonous reaction to 
 
746 TEXT-BOOK ON MENTAL DISEASES. 
 
 some hallucination or persistent sensorial delusion, but this is rela- 
 tively rare. In the severe cases of stupor sequent to melancholia or 
 mania there is complete exhaustion of psychic and physical forces. 
 All mental operations are suspended, and the vital functions are 
 notahly implicated. Eespiration is superficial and feeble, circulation 
 is slow, temperature is reduced, digestion is impaired, and general 
 innervation is very imperfect. The countenance is vacant, and vol- 
 untary movements are not executed; reflexes are absent, sensation 
 is wanting, sensorial perception does not exist, consciousness is prac- 
 tically abolished, and there is no ideation. 
 
 Between these extremes of mild and severe stupor every conceiv- 
 able degree of intermediate lethargy may exist, and the variations in 
 the symptoms correspond to the fluctuations in the actual amount 
 of apathy present. It would require a vast amount of description to 
 depict all the clinical phases of these varying degrees of stupor 
 familiar to those having had large opportunities for the observation 
 of the insane. It is important to know that these types of stupor may 
 follow or even interrupt the course of mania or melancholia, or they 
 may constitute one phase of a cycle of periodical Insanity. 
 
 It is appropriate to discuss, in this connection, a manner of men- 
 tal reduction termed catatonia. 
 
 Catatonia is a group of symptoms conceived by Kahlbaum (1874) 
 to be a separate type of Insanity. He represented this type as begin- 
 ning with melancholia, passing into mania and then into catatonic 
 stupor, and ending in dementia. The only characteristic features 
 appeared in the catatonic stupor, and were, in the main, fixation 
 and resistance of muscles, repetition of movements termed stereo- 
 typed, cataleptoid conditions, mutism, or continued utterance of the 
 same words (verbigeration), and, in fact, such symptoms as are well 
 known to alienists to occur in the various forms of stupor intercurrent 
 in epileptic, hysterical, pubescent, and hereditary cases of mania 
 and melancholia. 
 
 Kahlbaum deserves credit for a most truthful study of the symp- 
 toms of stuporous states, which naturally follow the exhaustio^n of 
 mania or melancholia, and then pass into dementia or recovery. 
 
 The order of his stadia in catatonia is simply the universal natural 
 order of all psychoses, which have first depression, then excitement, 
 then exhaustion, which may reach the gTade of stupor, and then de- 
 mentia. Neurotic and hereditarily tainted patients, during the clin- 
 ical progression of an attack of Insanity, after the melancholic and 
 maniacal stage, have a stuporous stage, with symptoms like those 
 
STATES OF STUPOE. 747 
 
 described by Kaiilbaum, and seen also, in epileptic, hysterical, neuras- 
 thenic, and all psychopathic patients, when in sequential stupor, de- 
 veloped at any point of an attack of Insanity. 
 
 The special phases of melancholic, maniacal, or stuporous stadia 
 can never become a stable basis upon which to erect separate types 
 of Insanity. Such attempts only create confusion, but Kahlbaum's 
 delineation of stuporous symptoms was so excellent as to be at once 
 recognized as real by physicians who have passed many years in the 
 chnical study of large numbers of insane cases. In any form of 
 stupor, not profound, there may be a persistence of certain 
 ideas and an automatic repetition of words and of movements. 
 But, just as habit chorea, convulsive tics, repetitive impulses 
 to set movements are most common in neurotic individuals in 
 comparative health, so in them also, in mental disease and in stupor, 
 which reveals inherent nervous tendencies deprived of volitional 
 control, are to be witnessed the same repetitive tendencies in set 
 movements called stereotyped, and in words or phrases oft repeated, 
 termed verbigeration. The resistance of enforced movements by 
 stuporous patients is the siimple result of inhibition, and cataleptoid 
 rigidity is common in sequential stupor. 
 
 Stupor in epileptic cases following severe cortical discharges may 
 be very profound. Intercurrences of stupor are also seen in paretic 
 and alcoholic and syphilitic Insanity. This sort of sequential stupor 
 is often very severe, but not of long duration, ordinarily. A mild 
 type of sequential stupor in a simple psychosis follows the stadium 
 acutum and takes the place of the stadium debilitatis in some in- 
 stances, and ends in convalescence or in a stadium dementige. 
 
 Causes. — The stuporous state is the outcome of the psychosis in 
 which it occurs, and can hardly be said to have an independent etiol- 
 ogy. Still, it is possible, during an attack of Insanity, for accidental 
 losses of blood, or masturbation, or great muscular exertion, to de- 
 velop the stupor. 
 
 Stadia. — Sequential stupor is itself a stadium following the sta- 
 dium acutum, whether melancholic or maniacal, in some psychoses. 
 In other instances it is only an intercurrent staite in the stadium 
 acutum of a psychosis, or in general paresis. 
 
 As a separate stadium, taking the place of the stadium debili- 
 tatis, it may last for many weeks, and it ends in a stadium conva- 
 lescens, or in a stadium dementige in incurable cases. As an inter- 
 current state, it may last for hours, days, or weeks, and then gives 
 place to the mania or melancholia which it interrupted. In periodic 
 
748 TEXT-BOOK ON MENTAL DISEASES. 
 
 Insanity it may form one stadium of a cycle, wMcli has also a mani- 
 acal stadium, the alternation heing, 1, stadium maniacale; 3, stadium 
 stuporosum. 
 
 Symptoms. — Sequential stupor, hypothetically, is the same from 
 whatever source derived, being dependent on suppression of mental 
 acitivities, such as association of ideas, attention, memory, and sen- 
 sorial perception; but, practically, it retains clinical evidences of its 
 special origin. Thus, following an acute melancholia, there will be 
 traces of emotional distress, or facial lines of depression, or glimpses 
 of frightful hallucinations. When secondary to acute mania, there 
 will be still occasional laughter, crying, or sudden exclamations or 
 passing shades of expansive expression of countenance. Sequent to 
 epileptic mania there may be expected sudden impulsive acts of de- 
 struction or violence, and, consecutive to hysterical mania, there may 
 be also fixed attitudes for effect, peculiar grimaces, unrestrained 
 laughing or shedding of tears, erotic gestures, and cataleptoid states. 
 The prevailing state, in the meantime, is mute stupor. All special 
 features, from whatever source derived, are obliterated when the 
 stupor becomes profound. The somatic symptoms are dependent 
 on the degree in which the cerebro-spinal sympathetic and trophic 
 centres are involved. Circulation, respiration, digestion, and general 
 metabolism are impaired in all fully developed stuporous states. 
 Along with the livid skin and cyanotic extremities there goes an 
 actual reduction in bodily warmth, and, if the stupor is prolonged, 
 there is a loss of weight in spite of the most active alimentation. 
 
 Pathology. — Angiospastic and angioparetic cerebral states are, 
 in all probability, the most constant patholo'gical factors in se- 
 quential stupor. Even theories of nutritional disturbances of 
 cortical elements cannot serve to explain the sudden appearance 
 and disappearance of stupor, and the theory of inhibition due to 
 a few intense or frightful delusions, is also inadequate. Both cere- 
 bral and spinal vasomotor centres would seem to be involved, and 
 the trophic functions of anterior comual cells is evidently implicated 
 in prolonged and severe stuporous states in which there is muscular 
 atrophy. 
 
 Differential Diagnosis. — If the history of the case is known and 
 the stupor is the sequel of some regular type of Insanity, the diag- 
 nosis of sequential stupor can always be made. Without any previous 
 knowledge of a case, it would not, from the symptoms alone, be pos- 
 sible to differentiate always between sequential stupor and acute pri- 
 mary dementia. 
 
STATES OF STUPOR. 749 
 
 Exhausting diseases, acute fevers, severe cerebro-spinal concus- 
 sions, and a series of epileptic seizures in those not insane, may- 
 give rise to extreme hebetude and lethargic states, which are to be 
 differentiated from the mode of alienation now under consideration. 
 
 Prognosis. — The prognosis is good in the majority of instances, 
 but occasionally there is a termination in dementia. Eelapses are 
 very frequent during the pubescent and adolescent periods of life, 
 but stuporous states are less common in advanced years, when de- 
 mentia takes the place of stupor. 
 
 The danger to hfe is considerable, but can be averted by attentive 
 treatment. 
 
 Treatment. — Sequential stupor is best treated in bed, to preserve 
 vital warmth and to equalize the circulation. The most urgent indi- 
 cation is to sustain nutrition. Not only artificial feeding, but predi- 
 gestion of food may be necessary, owing ito entire neglect or refusal of 
 meals by the patient, and to impaired gastric functions. Diminished 
 peristalsis may cause constipation, which is to be relieved; while, in 
 the most severe stupor, vasoparetic states in intestinal mucous mem- 
 branes give rise to diarrhoea, which must be promptly treated. Iron, 
 camphor, and arsenic, for their hsematinic, cerebral stimulant, and 
 alterative effects, are of service. Galvanization of cervical sympa- 
 thetic, practised with caution, and general electrization, with mas- 
 sage, and hot baths of brief duration, are useful measures. Cardiac 
 and general stimulants are to be employed at emergent points of the 
 stuporous attack. Eelapses may sometimes be prevented by a prompt 
 use of digitalis and alcoholic stimulants at the right moment. 
 
CHAPTER XIL 
 
 STATES OF IMPAIRED OR SUSPENDED VOLITION. 
 
 Group: Abulic Insanity, Somnambulistic Insanity. 
 
 Section I. — Abulic Insanity. 
 
 There is a type of mental disease manifested chiefly in loss of 
 control of thoughts and actions^ and of the higher forms of inhihition 
 ascribed, ordinarily, to the exercise of volition, as the supreme faculty 
 of the mind. It is useless to discuss the question of will in this con- 
 nection, and it suffices to assume the axiomatic fact that normally 
 voluntary control over ideas and actions is exerted, and that when 
 this faculty of control is lost a pathological state exists, which is here 
 termed abulic Insanity. A ^mistaken conception is that there may 
 be increased volitional power in Insanitj^, and the term hyperbulia 
 has been used to denote it. The highest function of will is to inhibit, 
 and the violent actions of the insane, supposed to display increase 
 of vohtional force, would have been inhibited had there not been an 
 actual loss of vohtional control. All such violent outbreaks are 
 abulic rather than hyperbulic. 
 
 Definition. — ^Abulic Insanity is a pathological state of mind, 
 characterized by loss of higher forms of inhibition, by absence of 
 control of ideas and of actions, and by the presence of impellent ideas, 
 morbid impulses, irresistible tendencies to violent or illegal deeds, 
 and the inability to execute desired acts or to refrain from performing 
 others which are dreaded. 
 
 Clinical Delineation. — There are two chief modes of impairment 
 of volition among abuhc patients; one is the inabihty to execute 
 desired acts, and the other is the inabihty to refrain from performing 
 deeds which are dreaded. 
 
 Emotional or intellectual disorder, such 'as is common in other 
 types of Insanity, is not often found in abulic alienation. Abulic 
 
 750 
 
STATES OF IMPAIRED VOLITION. 751 
 
 patients are to be ranked as neurasthenic or degenerate, but there 
 are some independent of both these neurotic classes, and liaving 
 neither degenerate stigmata nor the phj'sical signs of neurasthenia, 
 nor the history of transmitted taint. 
 
 First, then, as to inability to execute desired acts, it will be found 
 that certain patients have a struggle to do simple things of every-day 
 hfe, and finally become impotent to execute their own wishes in 
 certain regards. They cannot rise in the morning or retire at night 
 when they desire, cannot put on or take off certain articles of dress, 
 cannot sign their names when needful, cannot follow the service in 
 church, cannot rise up or sit down, or get in or out of a carriage, or 
 swallow certain necessary articles of food, or perform other simple 
 acts. Others, having perfect freedom of thought and speech, are 
 unable to say anything when special occasion requires it, and some 
 cannot write a letter when they wish, and, when they specially desire 
 it, cannot fix their attention on any subject (aprosexia). There is 
 no limit to the variety of manifestations of this mode of volitional 
 impairment in wliich desire is present, but impulsion to action is 
 wanting. This form of abulia is connected with certain permanent 
 deterrent ideas, which are practically what the French term obses- 
 sions. These deterrent ideas take possession of the mind and dom- 
 inate it like a delusion. The patient may struggle painfully to 
 overcome the deterrent idea, but the effort is in vain, and there is 
 impotence to perform, the desired act. 
 
 In the other mode of impaired volition there is inability to in- 
 hibit certain actions which are not desired, but dreaded. The patient 
 struggles to avoid the actions which he is impelled to perform. There 
 ■are various clinical phenomena relative to and in part explanatory 
 of this mode of impaired vohtion. In the first place, there are im- 
 pellent ideas, which persist in consciousness until the undesirable act 
 is performed. There is a painful state of tension of mind, which 
 disappears for the moment upon the performance of the act, but the 
 same impellent idea returns, and with it the anxiety to shun the 
 inevitable recurrence of the same act. 
 
 There are also irresistible impulses of either an emotional or 
 instinctive nature, which result in absurd or even criminal acts, 
 which the patient cannot avoid. Thus there may be an impulse to 
 steal, to set fire to buildings, to drink, to use profane or obscene 
 language, to make indecent exposure of the person, to commit suicide 
 or homicide. 
 
 There are also emotional ideas of a persistent and absurd nature, 
 
752 TEXT-BOOK ON MENTAL DISEASES. 
 
 which the will cannot ba-nish, and which influence the conduct. 
 Most of these ideas take the form of doubts or fears, which are clearly- 
 pathological in nature. Thus there is fear of open or closed places, 
 fear of high places, fear of men or women, fear of crowds and of 
 soKtude, fear of animals, fear of insects, fear of defilemenit, fear of 
 darkness, fear of accidents, fear of fire, fear of travel, and, in fine, fear 
 of everytliing. There is no end to the absurdity of acts which may 
 be occasioned by these persistent fearful ideas, which escape all voli- 
 tional control. 
 
 The persistent ideas of doubt are equally common and ridiculous. 
 Patients having these ideas of doubt question whether they should 
 do a thing, whether they have done it right, whether they should not 
 do it over again. They seek to be reassured that the simplest acts are 
 correctly done, that they are not mistaken in what they have heard 
 or seen or done. They doubt themselves and doubt others, and live 
 in a world of doubts, and nothing reassures them permanently, not 
 even the evidence of their own senses. There is an inability to form 
 conclusions or to perform the necessary acts of hf e calling for prompt 
 decision and action. The patient may be thus incapacitated for the 
 ordinary affairs of business. Thus, patients may converse rationally 
 on most subjects and may be, in a measure, conscious of their dis- 
 ease; but they^ are still impelled or deterred in their actions by per- 
 sistent ideas and impulses or morbid doubts and fears, and they 
 exhibit an Insanity of actions due to vohtional impairment. 
 
 Causes. — The etiology of this affection is hereditary taint in the 
 vast majority of cases, which are enumerated as degenerate or neuras- 
 thenic, though some display none of the physical traits of the latter 
 class. It is very probable that, in exceptional instances, the abulic 
 state may be acquired, like the neurasthenic state. Satisfactory 
 etiological research has still to be made in regard to this type of 
 mental disease, which has not been clearly recognized until of recent 
 years. 
 
 Stadia. — There is a long initial stadium of months or years, of 
 fixed notions and eccentric ideas as to doing or not doing certain 
 things, and by friends the paitient is recognized as odd or cranky in 
 these regards. Then follows the stadium acutum of inability to per- 
 form the essential acts of daily life, or the period of doubts, fears, 
 impulses, and irresistible tendencies, ending, perhaps, in suicide or 
 crime. This stadium may endure a lifetime, but a certain mental 
 enfeeblement is apt to develop as a terminal stadium, but not as an 
 actual stadium dementiae. 
 
STATES OF IMPAIRED VOLITION. 753 
 
 A genuine stadium convalescens is not to be expected, but re- 
 missions of all the symptoms, and paroxysmal returns, are the rule 
 in abulic Insanity. 
 
 Symptoms. — The persistent escape of nervous energy through the 
 same psychic or motor channels is peculiar to degenerate or neuras- 
 thenic patients. Thus the repetition of purposeless motions, fixed 
 a;ttitudes, fingering the face or hair, restless action of hands or 
 fingers, peculiar movements of the head, odd action of the feat- 
 ures, the persistence of certain musical airs, the counting of 
 numbers before doing anything, the desire to touch certain things 
 repeatedly without motive, the placing of things in a certain re- 
 lation to each other with no assignable reason, and a thousand 
 like actions, felt to be needful to the comfort of the patient, 
 though inexphcable in the patient's own mind, are among the psychic 
 and motor tics to be witnessed in these abulic cases. The idea of 
 an action revives the motor images for its performance, and arouses 
 nascent motor impulses. In the abulic state these nascent motor 
 impulses attaching to the idea are not inhibited, but pass at once 
 into action. Such ideas are impelhnt, and cannot be resisted, and 
 after an anxious effort the patient is forced to yield to them. 
 
 The irresistible impulses are chiefly from organic sources, and 
 spring from the animal appetites or instincts, or from their perver- 
 sions. 
 
 In abulic Insanity the patient is fully conscious of the nature of 
 the impellent ideas, morbid impulses, doubts and fears, besetments 
 and obsessions, as they are sometimes called, and the mental suffer- 
 ing is extreme, until the culmination in action brings temporary 
 relief from the painful tension of mind. 
 
 Nothing cumbers science like words, and the terminology of the 
 symptoms of abuhc Insanity has reached an unreasonable extension. 
 Thus the simple fact of morbid fears among these patients has given 
 rise to such terms as agoraphobia (fear of places), acrophobia (fear of 
 heights), anthropophobia (fear of men), nosophobia (fear of diseases), 
 monophobia (fear of solitude), zoophobia (fear of animals), misopho- 
 bia (fear of defilement), 'aichmophobia (fear of sharp things), crys- 
 tallophobia (fear of glass), metallophobia (fear of metals), and a host 
 of other technical labels. 
 
 To illustrate the irresistible impulses are designations as follows: 
 Kleptomania, dipsomania, pyromania, dromomania (impulse to 
 travel), oniomania (impulse to buy), coprolalia, cubomania, onoma- 
 tomania, arithmomania, erotomania, and others too numerous to 
 48 
 
754 TEXT-BOOK ON MENTAL DISEASES. 
 
 mention. A few writers liave not been satisfied to label simple symp- 
 toms, but have confused students of mental diseases with, the im- 
 pression that these designations stood for distinct varieties of mental 
 alienation. 
 
 The morbid association of ideas in abulic patients is illustrated 
 by phonisms, wliich are auditory impressions vividly derived by the 
 action of some of the other senses. Thus certain odors or tastes may 
 be associated m'orbidly, so as to recall certain sounds, or the sight of 
 objects or persons may invariably revive certain aural hallucinations. 
 In like manner, photisms, which are sensations of light or color sec- 
 ondary to the action of the other senses, may occur and take the 
 hallucinatory form. 
 
 Phonisms and photisms, and other secondary sensations, except 
 in their hallucinatory relations, are not neeessarily pathological, 
 though they are more apt to occur in psychopathic individuals. 
 
 The somatic symptoms in abulic Insanity are not prominent, 
 and are mostly of the neurasthenic order. There is no active disorder 
 of vital functions. The habit-chorea, convulsive tics, and automatic 
 motions of neurotic patients rem-ain, in addition to the motor anom- 
 alies due to the morbid impulses and impellent ideas. 
 
 Pathology. — Apart from hereditary susceptibility and instability 
 of cerebral centres, no definite patholog}^ can be assigned. Abulic 
 symptoms may be intercurrent in various types of Insanity, and cer- 
 tain pathological factors may then be suggested in causative relation 
 to the volitional impairment; but for the abulia as a continuous 
 mode of alienation, such as here described, there is no assignable 
 pathogenesis other than the transmitted taint. 
 
 Differential Diagnosis. — Abulic Insanity is to be differentiated 
 from the higher forms of imbecility wdth feeble will-power. There 
 is rarely any native deficiency of intellect among cases of abulia. 
 
 Monomania, with certain peculiar and persistent actions or in- 
 hibitions of conduct, may resemble abulic Insanity. The mono- 
 maniac acts, however, in obedience to fixed and systematized delu- 
 sions, which is never the case with abulic patients. Impellent ideas 
 and irresistible impulses may occur in any form of Insanity, but they 
 do not constitute the gravamen of the mental disease, as in abulic 
 eases. Some patients, classed under neurasthenic Insanity, are, more 
 properly speaking, cases of abulic Insanity. 
 
 Prognosis. — The prognosis for complete recovery is uniformly 
 bad. Long intermissions may occur, but relapses are almost inev- 
 itable. 
 
STATES OF IMPAIRED VOLITION. 755 
 
 Usefulness is seriously impaired, but patients may continue for 
 many years to be seK-supporting. 
 
 The prognosis as to life is good, exclusive of tlie chances of sui- 
 cide. The average duration of life is not specially shortened. The 
 prognosis is best in youthful subjects treated by systematic education 
 for a series of years. No amelioration is to be anticipated in chronic 
 adult cases. 
 
 Treatment. — ^Isolation in institutions seldom accomplishes any 
 improvement. Change of occupation, of climate, and of surround- 
 ings, is sometimes of decided benefit. 
 
 Attention to the general health and to hygienic surroundings 
 is first to be enforced, and, when regularity of habits has been estab- 
 Hshed, the special treatment is to be undertaken. 
 
 Psychotherapy is all-important. The influence of a cheerful and 
 strong-minded person, and, by preference, a physician, if he will 
 undertake the case, is the main reliance. Discussion or opposition of 
 the patient's weaknesses are of no avail. The patient is to be kept 
 steadily occupied or diverted, so that absolutely no time for intro- 
 spection is allowed. As a crisis approaches, most active efforts are 
 to be made in horseback or bicycle exercise, or some lively diversian, 
 and, if this fails, large doses of hypnotics are to be tried at critical 
 periods, so as to break the habit and the spell by which the patient 
 is bound. 
 
 Hypnotism, if ever of decided use, may be judiciously employed 
 in certain cases, but counter-suggestion may be of service in many 
 instances. When the volitional impairment is in the performance of 
 certain acts, the patient may be systematically trained to do similar 
 acts, until the prime difficulty is overcome. 
 
 Only prolonged psychotherapeutic treatment and systematic ed- 
 ucation extending over a series of years can be expected to accom- 
 plish permanent improvement, and then a prophylaxis is required to 
 prevent relapses. 
 
 Section II. — Somnambulistic Insanity. 
 
 It is not possible to consider the many disorders of sleep in this 
 connection, although all perversions of sleep have indirect relations 
 to the present subject. 
 
 Sonmambulism, in certain persons, may be as persistently recur- 
 rent and as pathological in nature as epileptic disorders of conscious- 
 ness. If a patient in epileptic automatism commit crime or take 
 
756 TEXT-BOOK ON MENTAL DISEASES. 
 
 ihuman life, he is recognized as insane; and if, as has occurred, a 
 sufferer from somnambulistic automatism commit crime or murder, 
 it is consistent to recognize the Insanity and the irresponsibility of 
 the patient. All epileptics are not insane, and all somnambulists are 
 not insane, but there are special epileptic states and special somnam- 
 bulistic sitates of active mental disorder of a most dangerous char- 
 acter. Such states are brief attacks of Insanity, having most impor- 
 tant medico-legal bearings, 'and as such they are given a nosological 
 position and are termed somnambulistic Insanity. 
 
 Definition. — Somnambuhstic Insanity is a state of aberration in 
 which hypnagogic impressions are mistaken for reahties, and in 
 w'hich the senses may be active while volition is suspended and mem- 
 orial consciousness is in abeyance. 
 
 Clinical Delineation. — The state of somnambulism varies greatly 
 in different persons, and on different occasions in the same person. 
 Some or all of the special senses may be active in this state, or hearing 
 or touch may alone rem^ain. Sight may be specially active, and the 
 sense of touch very acute, and the muscular sense and co-ordination 
 are sometimes heightened to an extraordinary degree. The acts per- 
 formed in this state may be very simple or very comphcated, involv- 
 ing the most skilful forms of muscular adaptations and intricate 
 psychic operations. The patient is often guided by hypnagogic im- 
 pressions, and simply reacts accordingly, just as insane patients react 
 to waking illusions. VoHtion as the supreme controlling power is 
 suspended, and hence arises the danger of violent reaction to the 
 disordered fancies of the somnambulistic brain. 
 
 Thus the somnambulist Fraser, in hypnagogic violence, murdered 
 his boy, whom he dearly loved {Journal of Mental Science, 1878, 
 p. 454). 
 
 Some patients speak aloud or converse in reply to questions in 
 the somnambulistic state, or even address imaginary audiences, or 
 play upon instruments, or sing. They also, in this state, acquire 
 knowledge, solve problems, or compose and write coherently on sub- 
 jects famihar to them. The somnambulistic state may occur in the 
 daytime as weU as at night, and Prichard relates cases in his work 
 on Insanity, and similar instances have since been reported by other 
 writers. 
 
 Patients sometimes have their eyes wide open and reply to ques- 
 tions and seem to be acting a part, and this is literally the case, since 
 they are acting out the impressions and fancies w^hich have escaped 
 volitional control. "When these hypnagogic phantasms are of a nat- 
 
STATES OF IMPAIRED VOLITION". 757 
 
 "ure to provoke violence, the resulti-ng aberration may be most dan- 
 gerous. Thus patients may shoot their friends while under the im- 
 pression that they are burglars, or jump out of the window to escape 
 fancied danger, or perform various destructive or criminal acts. It 
 is also known that in coming out of the somnambulistic state there 
 may occur a sort of panic, with dangerous emotional confusion and 
 sudden violent tendencies. This resembles sleep-drunkenness, as it 
 is termed, and which, properly speaking, is a phase of somnambuhstic 
 disorder of mind, during which crimes and violent acts have been 
 known to have been perpetrated. When such patients are placed 
 upon trial for their illegal acts, there should be no hesitation in rec- 
 ognizing the fact of mental disorder, and of irresponsibility for deeds 
 of which there is no recollection. 
 
 As to the amnesia, it would seem that patients appear to remem- 
 ber in the somnambulistic state some things which occurred in a 
 previous like state, and they have been known to tell where they 
 had secreted things while previously sleep-walking, and of which 
 they could give no information in the waking state. They also re- 
 sume in somnambulism conversations of which they have no knowl- 
 edge, except in subsequent somniloquent states. 
 
 All these states of disordered mental action in partial sleep are 
 of extreme interest and juridical importance, and merit more scien- 
 tific attention and close study. 
 
 Causes. — Somnambuhsm is sometimes hereditary. It is most 
 frequent in pubescence, but may occur at any time of hfe, or, in 
 hereditary cases, throughout hfe. Like epilepsy, it is confirmed by 
 repetition, and has as an ultimate cause some unstable condition of 
 cortical centres. It is provoked by gastro-intestinal disorders, by 
 mental over-strain, by emotions, or great physical fatigue. Sym- 
 pathy or wonder entert-ained and expressed for youthful patients 
 tends to foster the disorder. The extreme pathological form of som- 
 nambuhsm to be reckoned as Insanity is probably attained only under 
 pecuhar vasomotor conditions, and possibly autotoxic influences. 
 
 Stadia. — An explosion of destructive actions or of homicidal vio- 
 lence 'in ijhe somnambulistic state may be compared to brief epileptic 
 mania. The attack may be considered as consisting of a single acute 
 stadium, like that of mania transitoria. 
 
 Symptoms. — Memory fails because voluntary attention does not 
 exist. The heightened muscular sense renders the patient capable 
 of unusual acts of co-ordination, such as walking on roofs, and the 
 unconsciousness of danger favors such performances. The pupils 
 
758 TEXT-BOOK ON MENTAL DISEASES. 
 
 axe dilated, and the eyes open as often as closed. Objects are avoided 
 by an increased tactile sense or by sight. Talking is as common as 
 walking. Hypnagogic impressions are faint or extremely vivid, and 
 they may or may not provoke corresponding motor reactions. When 
 most vivid, they are few and persisftent, and eventuate in explosive 
 actions. The amnesia following the attack is precisely similar to 
 that after epileptic automatism. In the transition from the som- 
 nambulistic state to the waking state, hypnagogic hallucinations and 
 delusions may arise. The culmination of somnambulistic phantasms 
 in motor explosions may or may not 'terminate the sleep-walking 
 state. Patients have broken furniture, set fire to things, secreted 
 stolen articles, taken horses out of bams and driven them a distance 
 while in the somnambuhstic state. 
 
 Pathology. — ^Vasoparetic states and congestion of limited areas 
 of the sensory cortex, or the presence in cortical cells of those detri- 
 tional products w'hich, in excess, may exert a toxic effect, are likely 
 theories, but a definite pathogenesis is not known to science. The 
 explosive violence in the somnambulistic state suggests actual dis- 
 charges from cortical centres as the pathology of the mental disturb- 
 ance. The hereditary tendency in certain cases has already been 
 noted. 
 
 Differential Diagnosis. — Somnambulistic Insanity is to be differ- 
 entiated from brief epileptic mania. When epilepsy and somnam- 
 bulism coincide, violent outbreaks resulting are always to be regarded 
 as epileptic in nature. 
 
 A patient may wake out of sleep and frightful dreams directly 
 into a maniacal state, but the duration of the latter would differen- 
 tiate it from somnambulistic Insanity, which is always brief and ter- 
 minates ordinarily within the hour of the performance of some vio- 
 lent act. 
 
 Prognosis. — The prognosis is that there will be a relapse, since 
 the somnambulistic habit is like the epileptic habit when once estab- 
 lished in adult life. In youthful subjects the prospect of cure of the 
 habit and of the danger of explosive violence is much better than in 
 epilepsy. The attack itself passes off with the same promptness as 
 an outbreak of transitory mania, and brings no danger of physical 
 exhaustion, but may expose the patient to fatal accidents during the 
 height of the somnambuhstic excitement. 
 
 Treatment. — The treatment is prophylactic, and consists in the 
 prevention or relief of the somnambulistic habit. In hereditary som- 
 nambulism there is Httle hope of prophylaxis, for the disorder will 
 
STATES OF IMPAIRED VOLITION. 759 
 
 declare itself with the same certainty as other hereditary neuroses. 
 The hygienic and dietetic treatment is important. Eegular hours of 
 eating, sleeping, 'and exercising must be enforced. A hard, smooth 
 bed, light covering, elevated position of the head, the relief of the 
 bladder and rectum before retiring, a cool sleeping apartment, and 
 the exclusion of artificial light from the room, are needful measures. 
 A cardiac stimulant, given at bed-time, is sometimes of service in 
 adults. General tonic treatment and hydrotherapy, especially a cold 
 sponge-bath before retiring, are useful means. The bromides dimin- 
 ish reflex irritability and favor continued sleep better than any other 
 drugs in these oases, and are iTseful in the brealdng of a somnam- 
 bulistic habit. Counter-suggestion and a certain severity in youth- 
 ful subjects act as deterrents, and are not out of place as psycho- 
 therapeutic agencies. In pubescent cases, severe mental application 
 is to be forbidden, and all unfavorable emotional influences are to 
 be carefully avoided. In confirmed cases, when other remedies have 
 failed, hypnotism might become an experimental and justifiable 
 measure. Cerebral galvanization may also be tried as a dernier res- 
 sort, and general electrization at the bed hour may also be employed. 
 
 Cold affusions, roughly practised, have long been a popular rem- 
 edy to break the somnambulistic habit, and in youths castigation has 
 not been without curative effect, though this means cannot be com- 
 mended. 
 
 All such prophylactic measures may succeed an the prevention 
 of the habitual return of somnambulism; and still the explosive vio- 
 lence of that special phase of the disease known as sleep-drunkenness 
 may appear. 
 
 When an attack of this kind has once declared itself, the patient 
 should ever afterward, as a safeguard, occupy a single bed and room, 
 and sedulously avoid alcoholic stimulants, tea, coffee, tobacco, sexual 
 excess, and exciting habits of life and night-hours of brain-work, 
 and pursue some healthful out-of-door occupation. Marriage of such 
 a patient is to be avoided for various reasons, and specially in con- 
 sideration of the heredity of somnambulism. 
 
 Indications for treatment may sometimes be based on organic 
 sources of the neurotic affection to be found in gastric or sexual 
 disorders. All such reflex sources of cerebral irritation are to be re- 
 moved by appropriate treatment. jSTeirvines and general roborant 
 treatment are always indicated. 
 
INDEX. 
 
 Abko. -ALITIES, cranial, 202 
 
 cutaneous, 202 
 
 facial, 202 
 
 of ears, 202 
 
 of eyes, 202 
 
 of nervous system, 202 
 
 of palate, 202 
 
 of reproductive organs, 202 
 Abscess, cerebral, 286 
 Abulia, 191, 750 
 Abulic Insanity, 750 
 
 causes of, 752 
 
 definition of, 750 
 
 delineation of, 750 
 
 diagnosis of, 754 
 
 pathology of, 754 
 
 prognosis of, 754 
 
 stadia of, 752 
 
 symptoms of, 753 
 
 treatment of, 755 
 Accidents, traumatic, 380 
 Accommodations for the insane, 14, 
 
 17 
 Acid, arseniosum, 419 
 
 boric, 427 
 
 carbolic, 426 
 
 hydrobromic, 400 
 
 hydrochloric, 417 
 
 nitro-hydrochloric, 420 
 Aconitum, 407 
 Acts, automatic, 214 
 Acupuncture, 440 
 Addison's disease, 97 
 Adipose tissue, 262 
 Adipsia, 195 
 ^sclepiades, 6 
 Affections, biliary, 255 
 
 cardiac, 98 
 
 organic, 385 
 
 pancreatic, 256 
 
 pulmonary, 99, 249 
 
 splenic, 255 
 
 Affusions, 466 
 Age, causative, 73 
 
 statistics, 27 
 Agents, toxic, 639 
 Ageusia, 149 
 Agraphia, 322 
 Air, open, 454 
 Albumin in urine, 120, 260 
 Alcohol, 408, 641 
 Alcoholism, 641 
 Alexander, of Trolles, 12 
 Ali Abbas, 12 
 Alimentation, artificial, 487 
 
 rectal, 486 
 Aloe Socotrinae, 414, 424 
 Alpin, Prosper, 15 
 Alteratives, 420 
 Althaus, 431 
 Alt Scherbitz, 374 
 Ambition, disappointed, 121 
 Amenomania, 42 
 Amenorrhcea, 254 
 Amimia, 322 
 Amnesia, 170 
 Amylene hydrate, 401 
 Anacrotism, 238 
 Anaemia, cerebral, 274 
 Anaesthesia, 247 ■* 
 
 cutaneous, 247 
 
 diagnosis and, 329 
 
 surgical, 413 
 Anaesthetics, 413 
 
 and feigning, 329 
 Anaphrodisiacs, 425 
 Anatomy of Insanity, 280 
 Andriezen, 291 
 Anger, 187 
 
 Angina pectoris, pseudo, 404 
 Anguish, precordial, 189 
 Anidrosis, 245 
 Ankyloses, 201 
 Anodynes, 403 
 
 761 
 
762 
 
 INDEX. 
 
 Antimony, 406 
 Antiperiodics, 423 
 Antipyrine, 404 
 Antiseptics, 425 
 • Aphasia, 322 
 Apiol, 424 
 Apomorphine, 416 
 Appetites, 195 
 
 adipsia, 195 
 
 anorexia, 195 
 
 artificial, 195, 324 
 
 coprophag-y, 195 
 
 pica, 195 
 
 polydipsia, 195 
 
 polyphagia, 195 
 
 sexual, 196 
 Aquapuncture, 440 
 Arabs, 88 
 Arachnoid, 284 
 Aretseus, of Cappadocia, 9 
 Argj'll-Eobertson symptom, 213 
 Arm, 202 
 Arnold, 17, 42 
 Arrest of development, 519 
 Arsenic, 422 
 Arsenicism, 643 
 Arterio-sclerosis, 233 
 Arthritis deformans, 201 
 Articulation, 219 
 Asclepiades, 8 
 Aspiration, hepatic, 440 
 Assimilation, disorders of, 257 
 Asthma, 248 
 
 Asylums for insane, 14, 17 
 Atavism, 84 
 Ataxia, locomotor, 267 
 Atheroma, aortic, 233 
 
 of arteries, 234 
 Atrophies, cerebral, 276 
 
 cutaneous, 245 
 
 muscular, 207 
 Attack, selective points of, 268 
 
 of Insanity, 25, 81 
 Attention, 174 
 
 Attitudes, characteristic, 215 
 Aufidius, Titus, 9 
 Aunts and heredity, 32 
 Aurelianus, Coelius, 10 
 Auris, hsematoma, 263 
 Auto-intoxication, 109, 257 
 
 cerebral, 275 
 Automatism, 214 
 of speech, 218 
 
 Baecock, W. L., 434 
 Bacon, 431 
 Bags, spinal, 463 
 Baillarger, 654 
 Ball, 49 
 
 Baths, 460 
 
 cold, 464 
 
 ■g-raduated, 467 
 
 hot, 471 
 
 medicated, 469 
 
 Kussian, 469 
 
 sun, 469 
 
 tepid, 460 
 
 Turkish, 468 
 
 warm, 460 
 Battey's operation, 437 
 Bean, Calabar, 411 
 Beard, 262 
 Beds, 450 
 Beef, 486 
 Beef-pulp, 480 
 Beef -tea, 480 
 Belladonna, 410 
 Bennett, Dr., 97 
 Besetments, 753 
 Bethlehem Hospital, 14 
 Bicycle exercise, 459 
 Billings, Dr. J. S., 22 
 Binder, flannel, 452 
 Birth, crisis of, 102 
 Bladder, 254 
 
 distention of, 254 
 
 paralysis of, 390 
 
 paresis of, 254 
 
 rupture of, 382, 390 
 Blandford, 46 
 Blepharospasm, 206 
 Blind, 24, 33 
 Blisters, 439 
 
 Blood in Insanity, 258, 274 
 Boarding- out insane, 374 
 Body weight, 256 
 Boerhaave, 16 
 Bone-marrow, 484 
 Bones, chang-es in, 199, 200 
 
 of skull, 199, 280 
 Boyle, 654 
 Boys, neurotic, 369 
 Brain, atrophy of, 276, 281 
 
 circulatory disorder of, 234, 273 
 convolutions of, 283 
 exhaustion 271 
 lobes of, 283 
 Bright's disease as a cause of In- 
 sanity, 97 
 Bromides, 399, 404, 407 
 Bromidrosis, axillary, 454 
 Bromism, 643 
 Browne-Sequard, 429 
 Bucknill, 48, 461 
 Bucknill and Tuke, 47, 255 
 Bulimia, 195 
 Bullock's blood, 484 
 Burckhardt, 431 
 Bureau of Protective Aid, 373 
 
INDEX. 
 
 763 
 
 Cachexia, malarial, 651 
 
 striimipriva, 650, 651 
 Caflein, 409, 476 
 Cajal, 66 
 
 Calamities, public, 81 
 Calisthenics, 458 
 Calmeil, 654 
 Calvarium, 280 
 Calumba, 420 
 Calx, 428 
 
 Camphor, monobromate, 412 
 Cancer, 111 
 
 Cannabis Indica, 403, 405 
 Capsules, supra-renal, 430 
 Carbohydrates, 475 
 Carbunculosis, 245 
 Cardin, 430 
 Caries, dental, 453 
 Cascara Sagrada, 414 
 Cases, troublesome, 385 
 Castration, 437 
 Catalepsy, 211 
 Cataphoresis, 441 
 Catatonia, 746 
 Catheterization, 382, 390 
 Cathode, 445 
 Causes of Insanity, 92 
 
 bodily, 93 
 
 psychical, 117, 126 
 Cautery, 440 
 
 electric, 440 
 
 Paquelin's, 440 
 Cells, cortical, 287 
 
 Deiter's, 291 
 
 glia, 292 
 
 neuroglia, 291 
 
 nucleus of, 287 
 
 pigmentation, 289 
 
 processes, 289 
 
 sclerosis, 290 
 
 vacuolation, 289 
 Celsus, 9 
 
 Centres, spinal reflex, 252 
 Cephalalgia, 410 
 Cerebrin, 430 
 Chair on wheels, 390 
 Chances in Insanity, 33 
 Changes, biochemical, 272 
 
 epochal, 278 
 
 macroscopical, 280 
 
 microscopical, 287 
 Charcot, 280 
 
 Chasmus hystericus, 252 
 Chiarrugi, V., 15 
 Childhood, Insanity of, 540 
 
 causes of, 541 
 
 definition of, 540 
 
 diagnofsis in, 317 
 
 pathology of, 544 
 
 symptoms of, 543 
 
 Childhood, Insanity of, treatment 
 
 of, 546 
 Chinese, 29 
 
 Chirography of the insane, 221 
 Chloral, 399, 412 
 Chlorine, 428 
 Cholera, Asiatic, 438 
 Choreic Insanity, 598 
 
 causes of, 599 
 
 pathology of, 601 
 
 symptoms of, 601 
 
 treatment of, 602 
 Chromidrosis, 245 
 Cicatrices, 116 
 Cinchona, 418 
 Circular Insanity, 563 
 Circulation, cranial, 234 
 Civilization, and diagnosis, 315 
 
 as a cause, 71 
 Clapham, Dr., 200 
 Classes, defective, 24 
 Classification of Insanity, 60 
 
 futiire, 66 
 Cleomenes, 6 
 Clergymen, 30 
 Clermont-sur-Oise, 374 
 Climacteric Insanity, 623 
 
 causes of, 625 
 
 definition of, 624 
 
 delineation of, 624 
 
 diagnosis of, 628 
 
 patJtiology of, 628 
 
 prognosis of, 628 
 
 symptoms of, 626 
 
 treatment of, 629 
 Climate, 77, 471 
 Climato-therapy, 471 
 Clitoridectomy, 437 
 Clothing of insane, 451 
 Clouston, 49, 116 
 Cocaine, 414 
 Cocainism, 643 
 Cocoa, 476 
 Colfee, 476 
 Coils, rubber, 464 
 Coitus, painful, 254 
 
 among insane, 372 
 Colchicum, 422 
 Cold, 78, 459 
 Colonies of insane, 374 
 Columns, of Goll, 293 
 
 lateral, 293 
 
 posterior spinal, 293 
 Coensesthesis, 166 
 Ccenffisthetic depression, 712 
 
 causes of, 712 
 
 definition of, 712 
 
 delineation of, 712 
 
 diagnosis of, 713 
 
 pathology of, 713 
 
764 
 
 INDEX. 
 
 Qcenasstlietic depression, prognosis 
 of, 713 
 
 symptoms of, 713 
 
 treatment of, 714 
 Coenffisthetie exaltation, 720 
 
 causes of, 721 
 
 definition of, 720 
 
 delineation of, 720 
 
 diagnosis of, 722 
 
 pathology of, 722 
 
 prognosis of, 722 
 
 stadia of, 721 
 
 symptoms of, 721 
 
 treatment of, 722 
 Commotio cerebri, 113, 279, 360 
 Companion nurses, 500 
 Comparison, reasoning by, 176 
 Conception, 102 
 Concepts, 173 
 Condiments, 476 
 Condition, civil, 29, 74 
 Conditions, unhygienic, 100 
 Conduct, toward patient, 501 
 Confinement, solitary, 121 
 Congelation, anaesthetic, 441 
 Congestion of brain, 281 
 Congress, Medical, 53 
 Conium, 406 
 Conolly, 18 
 Consanguinity, 69 
 Consciousness, 162 
 
 ccensesthetic, 185 
 
 in sleep, 164 
 
 in utero, 164 
 Constipation, 252 
 Constitution, neurotic, 271 
 Contagion, moral, 124 
 Contractures, 207 
 Control, self, 507 
 Convalescence, 512 
 Convulsionaries de St. Medard, 
 
 125 
 Convulsions, feigned, 328 
 
 paretic, 657 
 Copper sulphate, 429 
 Coprolalia, 218 
 Cord, spinal, 286 
 
 anterior cornua of, 294 
 
 descending lesions of, 287 
 
 investing membranes of, 287 
 Corti's organ, 152 
 Cough, 251 
 
 Counter-irritation, 439 
 Coup de soleil, 113 
 Cox, Mason, 17 
 Craniectomy, 433 
 Craniotomy, 433 
 Cranium, 199, 280 
 Cream, 479 
 Creolin, 427 
 Cretinism, 528 
 
 Cretinism, causes of, 528 
 
 diagnosis of, 532 
 
 pathology of, 531 
 
 stadia of, 530 
 
 symptoms of, 530 
 
 treatment of, 532 
 Crichton, 17 
 Crime, 72 
 Crises, 101 
 
 cardiac, 405 
 
 gastric, 253 
 
 laryngeal, 404 
 
 national, as causes, 81 
 
 physiological, 101 
 
 pulmonary, 249 
 Cullen, 16, 41 
 Cupping, 438 
 Current, electric, 443 
 
 faradic, 445 
 
 galvanic, 444 
 
 secondary, induced, 446 
 
 static, 447 
 Cysticercus, 114 
 
 Dana, Professor, 455 
 Dance, of St. John, 125 
 
 of St. Vitus, 125 
 Daquin, 17 
 David, 5 
 
 Deaf and Dumb, 24, 33 
 Deaf mutism, diagnosis in, 321 
 Deafness, 398 
 Death-rate, 34 
 Decubitus, 245 
 Defects, cranial, 199 
 
 asymmetrical, 199 
 
 macrocephalic, 199 
 
 microcephalic, 199 
 
 sensorial, 24, 33 
 Deficiency, native, 358 
 Degeneracy, serial, 89 
 Degenerations, cellular, 288 
 
 cellular, spinal, 293 
 
 colloid, 290 
 
 fatty, 289 
 
 granular, 288 
 
 moniliform, 291 
 
 pigmentary, 289 
 
 vacuolar, 289 
 Dejerine, 66 
 
 Delirium acutum, 343, 398, 692 
 Delirium and diagnosis, 332 
 Delusions, 176 
 
 as crucial tests, 184 
 
 ccensesthetic, 180 
 
 corrected, 178 
 
 definition of, 177 
 
 depressive, 181 
 
 epidemic, 184 
 
 expansive, 180 
 
INDEX. 
 
 765 
 
 Delusions, hypnagogic, 179 
 
 imbecile, 179 
 
 of grandeur, 183 
 
 of persecution, 181 
 
 sane, 176 
 
 sexual, 180 
 
 systematized, 181 
 
 transformed, 182, 183 
 
 unsystematized, 182 
 Dementia, organic, 684 
 
 causes of, 686 
 
 definition of, 684 
 
 delineation of, 684 
 
 diagnosis of, 689 
 
 pathology of, 688 
 
 prognosis of, 690 
 
 stadia of, 687 
 
 symptoms of, 687 
 
 treatment of, 691 
 Dementia, acute primary, 740 
 
 causes of, 741 
 
 definition of, 740 
 
 delineation of, 740 
 
 diagnosis of, 743 
 
 pathology of, 743 
 
 prognosis of, 744 
 
 stadia of, 741 
 
 symptoms of, 742 
 
 treatment of, 744 
 Dementia, terminal, 736 
 
 causes of, 737 
 
 definition of, 736 
 
 delineation of, 736 
 
 diagnosis of, 738 
 
 pathology of, 738 
 
 prognosis of, 738 
 
 stadia of, 737 
 
 statistics of, 31 
 
 symptoms of, 737 
 
 treatment of, 738 
 Dementia, simulated, 329 
 Denis, 16 
 Dentition, 103 
 Depression, states of, 712 
 
 coensesthetic, 712 
 
 chronic melancholia, 715 
 
 melancholia agitata, 715 
 
 melancholia attonita, 715 
 
 monomania, secondary, 716 
 
 nostalgia, 715 
 
 simple melancholia, 714 
 Depresso-motors, 406 
 Dermatographia, 335 
 Desquamation, 244 
 Development, arrested, 519 
 Deviation, cranial, 202 
 
 facial, 202 
 Dexterity, manual, 220 
 Diabetes mellitus, 120, 260 
 Diagnosis of Insanity, 296 
 
 Diagnosis of Insanity, and brain 
 disease, 331 
 
 changes in identity, 314 
 
 childhood and, 317 
 
 conduct in, 313 
 
 delirium and, 332 
 
 delusions and, 313 
 
 difficulties of, 296 
 
 eccentricity and, 319 
 
 elements, essential, 298 
 
 examination, personal, 305 
 
 examination, physical, 339 
 
 examination psychical, 339 
 
 formula, 339 
 
 history, 299, 303 
 
 legal responsibility of, 297 
 
 race and, 315 
 
 recovery and, 325 
 
 standards, mental, 314 
 
 symptoms, psychic, 311 
 
 symptoms, somatic, 314 
 
 temperature and, 332 
 Diaper, 389 
 
 Diatheses as cause of Insanity, 110 
 Diathetic Insanity, 645 
 
 causes of, 647 
 
 delineation of, 646 
 
 diagnosis of, 651 
 
 pathology of, 650 
 
 prognosis of, 652 
 
 symptoms of, 648 
 
 treatment of, 653 
 Dietary of insane, 477 
 
 of general hospitals, 482 
 
 of insane hospitals, 482 
 Dietetics of Insanity, 474 
 
 alimentation, rectal, 486 
 
 aneemic cases, 484 
 
 apparatus for feeding, 495 
 
 chronic cases, 482 
 
 diabetic cases, 483 
 
 epileptic cases, 485 
 
 forced feeding, 487 
 
 formulae, 486 
 
 of acute stage, 478 
 
 predigested foods, 486 
 
 special forms, 483 
 Digestives, 416 
 Digitalis, 408 
 Digiti mortui, 335 
 Dilatation, gastric, 250 
 Dipsomania, 31 
 Discharg'e of patients, 513 
 Discipline, 507 
 Disease, Addison's, 97 
 
 Bright's, 97 
 
 cerebral, 112 
 
 cardiac, 98, 231 
 
 focal brain, 276 
 
 gastro-intestinal, 97, 253 
 
766^ 
 
 INDEX. 
 
 Disease, Graves's, 436 
 
 infectious, 361, 3S5 
 
 of nervous system, 266 
 
 of reproductive organs, 95 
 
 of special sense organs, 117 
 
 Pott's, 434 
 
 pulmonary, 99, 248 
 
 renal, 97 
 
 thrombotic, 276 
 
 thyroid, 435 
 
 vascular, 99, 229 
 
 vasomotor, 235 
 Disinfectants, 427 
 Disinfection, 427 
 Disintegration, psychical, 188 
 Dislike, insane, 365 
 Disorders, circulatory, 99, 273 
 
 cutaneous, sensory, 247 
 
 genito-urinary, 96, 254 
 
 nutritive, 256 
 
 of consciousness, 165 
 
 of emotions, 185 
 
 of intellect, 173 
 
 peripheral, nervous, 267 
 
 pneumogastric, 117 
 
 speech, 215 
 
 spinal, 267 
 
 splanchnological, 248 
 
 trophic, 262 
 
 vascular, 229 
 
 vasomotor, 100 
 Diversions, 503 
 Doubt, 183, 752 
 Douches, 467 
 
 Scottish, 469 
 
 spinal, 463 
 Drainage, spinal, 434 
 Dream state, 122 
 Dress of insane, 451 
 Drip-sheet, 465 
 Drugs, 398 
 
 and diagnosis, 324 
 Drunkard, 323 
 Duboisine, 402 
 Duchek, 655 
 Duhamel, 654 
 
 Eae, 202 
 Eccentricity, 319 
 Echinococcus, 114 
 Echolalia, 218 
 Eclampsia, 413 
 Ecstasy, 211 
 Education, 78, 367 
 
 of boys, 369 
 
 of children, 368 
 
 of girls, 369 
 
 of insane, 33 
 Effects, emotional, 506 
 EfQeurage, 470 
 
 Effluvium, 245 
 Eggs, 480 
 Egyptians, 4 
 Electricity, 443 
 
 and feigning, 330 
 Electrocautery, 440 
 Electrotherapy, 444 
 Elements, sexual similarity of, 88 
 Eliminators, 423 
 Embolism, 282, 286 
 Emesis, 416 
 Emetics, 416 
 Emmenagogues, 424 
 Emotions, 185 
 
 altruistic, 188 
 
 anger, 187 
 
 antithetical, 187 
 
 egoistic, 188 
 
 fear, 188 
 
 liberation, spasmodic, 186 
 
 mixed, 189 
 
 painful, 185 
 
 pleasurable, 185 
 
 surrender to, 187 
 Endometritis, 443 
 Enemata, 487 
 Enfeeblement, primary mental, 733 
 
 causes of, 734 
 
 definition of, 733 
 
 delineation of, 733 
 
 diagnosis of, 735 
 
 pathology of, 734 
 
 prognosis of, 735 
 
 stadia of, 734 
 
 symptoms of, 734 
 
 treatment of, 735 
 Enteritis, gastro, 253 
 Enteroclysis, 440 
 Ependyma, of ventricles, 2^5 
 Epidemics of Insanity, 124 
 Epilepsy, and Insanity, 573 
 
 Jacksonian, 213 
 Epileptic Insanity, 573 
 
 causes of, 574 
 
 definition of, 574 
 
 diagnosis of, 580 
 
 pathology of, 579 
 
 prognosis of, 580 
 
 stadia of, 576 
 
 symptoms of, 577 
 
 treatment of, 581 
 Erasi stratus, 8 
 Erection of hair, 246 
 Ergota, 410 
 Ergotism, 642 
 Errors of statistics, 19 
 Eruptions, 245 
 Erythroxvlon coca, 413 
 Esquirol,"l8, 41, 520, 654 
 Essence of beef, 480 
 
INDEX. 
 
 767 
 
 Ether, 413 
 
 spray, 442 
 Etherism, 640 
 Ethyl bromide, 414 
 Etiology of Insanity, 69 
 
 bodily causes, 93 
 
 exciting- causes, 92 
 
 predisi)osing causes, 69 
 
 psychical causes, 117 
 Eucalyptus, 423 
 
 Evolution of mental diseases, 127 
 Exacerbation, 136 
 Exaltation, states of, 720 
 
 coenfesthetic, 720 
 
 mania, chronic, 725 
 
 m^ania, simplex, 723 
 
 mania, transitoria, 725 
 
 monomania with, 725 
 Excess, sexual, 360 
 Excitement, psychomotor, 384 
 Exclamations, involuntary, 218 
 Exercise, 456 
 Exhaustion, acute, 383 
 Expectancy, 145 
 
 Expectation of life among insane. 
 Extracts, organic, 429 
 
 thyroid, 429 
 Extremities, upper, 202 
 
 lower, 202 
 Eyes, 202 
 
 Face, 202 
 
 Facies epileptica, 579 
 
 potatorum, 224 
 Faculties, presentative, 142 
 Faeces, impacted, 252 
 Failure, heart, 383 
 
 law of organic, 91 
 Falret, 655 
 Families, degenerating, 89 
 
 rising, 88 
 Family system, 374 
 Fantasy, 172 
 Faradism, 445 
 Faradization, general, 446 
 Fathers and heredity, 33 * 
 Fats, 484 
 Fear, 121, 753 
 Feeble-minded, 26, 29 
 Feeding, forced, 487 
 
 by oesophageal tube, 492 
 
 by nasal tube, 490 
 Females, insane, 25 
 Fermentation, sarcinic, 383 
 Fever, typhoid, 642 
 Fibres, nerve, 292 
 
 atrophy of, 292 
 
 moniliform, 291 
 Flint, Professor Austin, 483 
 Fluid, cerebro-spinal, 435 
 
 Food, 100, 474 
 
 daily amount of, 476 
 
 predigested, 486 
 Forms of Insanity, 519 
 
 statistics of, 31 
 Formula for examination, 339 
 Fragilitas ossium, 200 
 Franklinism, 447 
 Frenzy, melancholic, 715 
 Fricke, Dr., 18 
 Friedreich, 40 
 Fright, 362 
 Fruits, 481 
 Fumigation, 428 
 Funnel, 492, 496 
 Furbinger, 434 
 Furunculosis, 245 
 
 Gags, 493 
 
 Gait, changes in, 219 
 Galen, 10 
 Galvanism, 443 
 Galvanization, 444 
 
 cerebral, 445 
 33 cervical, 444 
 
 general, 445 
 
 spinal, 445 
 Games, out-door, 459 
 Ganglia, central, 283 
 Gangrene of skin, 245 
 Gas, illuminating, 359 
 Gelsemium, 406 
 General paresis, 654 
 
 causes of, 657 
 
 definition of, 655 
 
 delineation of, 655 
 
 diagnosis of, 670 
 
 pathology of, 669 
 
 prognosis of, 672 
 
 stadia of, 659 
 
 sj^mptoms of, 663 
 
 treatment of, 673 
 Genius and Insanity, 172 
 Georget, 654 
 Gestation, 361 
 Gheel colony, 374 
 Glawnigs, Dr., 18 
 Goitre, exophthalmic, 112, 430, 435 
 Gokhru, 394 
 Golgi, 66 
 Gout, 111 
 
 diet in, 483 
 Graves's disease, 436 
 Greeks, 6 
 Grief, 120, 361 
 Griesinger, 42 
 Grimacing, automatic, 205 
 Grippe, 361 
 
 Groups of Insanity, 519 
 Gruel, peptonized, 486 
 
768 
 
 INDEX. 
 
 Guaineri, Antonio, 12 
 Gnislain, 18, 42 
 Gymnastics, 458 
 Gynascology, 96, 442 
 
 Habits, forced change of, 122 
 HEematoma aiiris, 263 
 Haemoglobin, 258 
 Hsemidrosis, 245 
 Hair, 246, 247 
 Hallucinations, 151 
 
 auditory, 152 
 
 entoptic, 156 
 
 gustatory, 157 
 
 tiemiopic, 156 
 
 hypnagogic, 157 
 
 kinestlietic, 161 
 
 Jiystagmic, 157 
 
 olfactory, 160 
 
 polyopic, 157 
 
 visual, 155 
 Hammond, Dr. W. H., 46 
 Hare, 427 
 Hartman, 431 
 Haslem, 17, 654 
 Hayner, 18 ' 
 
 Headache, 410 
 Head, size of, 199 
 
 shape of, 200 
 Heart disease, 98, 233 
 Heat, 427 
 Hebrews, 5 
 Heinroth, 15, 40 
 Helminthiasis, 253 
 Hemicrania, 404 
 Heredity, 32, 90 
 
 atavistic, 84 
 
 broader laAv than, 91 
 
 collateral, 85 
 
 convergent, 87 
 
 crossed, 83 
 
 direct, 83 
 
 morbid, 88 
 
 normal, 84 
 ■ polymorphic, 89 
 
 progressive, 89 
 
 statistics of. 32, 90 
 Hill, Gardiner, 18 
 Hippocrates, 7 
 Hlrsuties, 246 
 History of Insanity, 1-19 
 Hofebauer, 40 
 Horseback exercise, 459 
 Horseley, 431 
 Hospitals, 17 
 
 private, 875 
 
 public, 375 
 
 voluntary reception, 373 
 Houses, 101 
 Humphreys, Mr. Xoel, 34 
 
 Hydrargyrum, 415, 420 
 Hydrocephalus, 524 
 Hydrogen, peroxide of, 427 
 Hydrotherapj-, 459 
 Hygiene, personal, 450 
 Hypageusia, 149 
 Hypalgia, 147 
 Hyperaemia, 114, 273 
 Hj'perEesthesia, sexual, 196 
 Hyperageusia, 149 
 Hyperbulia, 192 
 Hyperidrosis, 205 
 Hyperkineses, 205 
 Hypermnesia, 170 
 Hyperosmia, 149 
 Hypertrophy, cardiac, 232 
 Hypnone, 402 
 Hypnotism, 510 
 Hypochondriasis, 107 
 
 vera, 590 
 Hypochondriacal Insanity, 590 
 
 causes of, 593 
 
 diagnosis of, 597 
 
 prognosis of, 597 
 
 symptoms of, 594 
 
 treatment of, 597 
 
 Ice-cap, 469 
 Icthyol, 422 
 Ideas, impellent, 193, 751, 753 
 
 innate, 118 
 
 physical effects of, 118 
 Ideler, 15, 40 
 Identity, personal, 166 
 
 in dreaming, 122 
 Idiocy, 519 
 
 amount of, 24 
 
 causes of, 521 
 
 definition of, 520 
 
 delineation of, 520 
 
 diagnosis of, 525 
 
 macrocephalic, 520 
 
 microcephalic, 520 
 
 Mongolian, 521 
 
 pathology of, 524 
 
 prognosis of, 525 
 
 stadia of, 522 
 
 symptoms of, 522 
 
 treatment of, 526 
 Illusions, defined, 143 
 
 auditory, 145 
 
 ccenaesthetic, 148 
 
 gustatory, 148 
 
 kinesthetic, 150 
 
 olfactory, 149 
 
 tactile, i46 
 
 visual, 144 
 Illustrations of physiognomy, 171 
 
 of pulse-tracings, 240 
 nten, 374 
 
INDEX. 
 
 769 
 
 Imagination, 171, 173 
 Imbecility, 320, 533 
 causes of, 536 
 definition of, 533 
 delineation of, 534 
 diag'nosis of, 538 
 pathology of, 538 
 stadia of, 536 
 symptoms of, 537 
 treatment of, 538 
 Impressions, maternal, 89 
 Imprisonment, 121 
 Impulses, morbid, 193, 753 
 ■Juanition, 380 
 Incolierence, 216 
 Incontinence, rectal, 390 
 
 vesical, 389 
 Inco-ordination, 207 
 Indians, American, 29 
 
 Oriental, 5 
 Infection, 110, 123, 642 
 Inflammation of brain, 281 
 Influence, sidereal, 78 
 Influenza, epidemic, 361 
 Injuries, 380 
 
 Innervation, facial, 363, 364 
 Insanity, abulic, 750 
 
 alcoholic, 641 
 
 attacks of, first, 25, 28 
 
 cancerous, 650 
 
 choreic, 598 
 
 climacteric, 623 
 
 communicated, 123 
 
 diagnosis of, 296-341 
 
 diathetic, 641 
 
 differential diagnosis of, 330 
 
 epidemics of, 124 
 
 epileptic, 573 
 
 etiology of, 69-127 
 
 evolution of, 127 
 
 feigned, 326 
 
 history of, 1-19 
 
 hypochondriacal, 590 
 
 hysterical, 582 
 
 in cities, 24 
 
 increase of, 23, 24 
 
 leprous, 650 
 
 moral, 555 
 
 myxoedematous, 650 
 
 neurasthenic, 603 
 
 nosology of, 36-69 
 
 of childhood, 540 
 
 pathology of, 269-295 
 
 pellagrous, 651 
 
 periodical, 561 
 
 podagrous, 646 
 
 prognosis of, 343-366 
 
 prophylaxis, 367 
 
 psycho-traumatic, 707 
 
 puerperal, 616 
 49 
 
 Insanity, senile, 629 
 
 syphilitic, 676 
 
 statistics of, 19-36 
 
 symptomatology of psychic, 
 142-199 
 
 symptomatology of somatic, 
 199-268 
 
 terminations of, 139 
 
 toxic, 637 
 
 treatment of, 367-516 
 Insolation, 113, 360 
 Insomnia, 122, 381 
 Intemperance, alcoholic, 323 
 Intermission, 137 
 Interval, lucid, 136 
 Intestine, muscular coat of, 253 
 Intonation, 217 
 Intoxication, 3, 333 
 Iodine, 421 
 Iodoform, 427 
 
 Iron, 420 • 
 
 Isolation, 499 
 
 Jabokajstdi, 423 
 
 Jackson, Hughlings, 212 
 
 Jacksonian epilepsy, 212 
 
 Jacobi, 40 
 
 Japanese, 29 
 
 Jargon, 218 
 
 Jarvis, Dr., 25 
 
 Jealousy, 120 
 
 Jews, 5 
 
 Joy, cause of Insanity, 118 
 
 Judgment defined, 173 
 
 Kahlbaum, 746 
 Kidneys, 97, 120 
 Kinsesthesis, 150 
 King Achish, 5 
 
 Lycurgus, 6 
 
 Nebuchadnezzar, 5 
 
 Saul, 4 
 Kinnicutt, Dr., 436 
 Knee-jerk, 214 
 Kolk, Schroeder van der, 43 
 Koumiss, 481 
 Kroeplin, 126 
 Krafft-Ebing, 50, 211 
 
 Labakraque's solution, 428 
 Lactation, 616 
 Laminectomy, 434 
 Langerman, 15, 40 
 Lannelongue, 433 
 Laughter, automatic, 250 
 
 paramimic, 251 
 Lavage, 442 
 Law, of organic failure, 24, 91 
 
 Eoman, 6 
 
770 
 
 INDEX. 
 
 Lawyers, 30 
 Laxatives, 414 
 Laycock, 44 
 Lesions, cerebral, 276 
 
 nutritiTe, 272 
 
 of spine, 276 
 
 sympathetic, 277 
 
 valvular, 240 
 
 vasomotor, 273 
 Leucomains, 257 
 
 Levs^is, Sevan, 52, 282, 283, 286, 290 
 Life, intra-uterine, 89 
 Light, colored, 470 
 Lime, chlorinated, 428 
 Linnseus, 66 
 Lipanin, 484 
 Lithium, 423 
 Liver, 98, 255 
 Love, disappointed, 120, 362 
 
 Lesbian, 196 
 Lungs,^ MS 
 Lunier, 654 
 Lupidin, 413 
 Luys, 45 
 
 Lycanthropia, 125 
 Lymph-spaces, 293 
 Lyssa humana, 642 
 
 MACROCEPHAI.T, 199, 520 
 
 Magnesium sulphas, 415 
 Males, insane, 26 
 Malaria, 646, 651 
 ^Malingering, detection of, 326 
 Mania, 723 
 
 causes of, 726 
 
 definition of, 723 
 
 delineation of, 724 
 
 diagnosis of, 729 
 
 frequency of, 354 
 
 intermittent, 561 
 
 pathology of, 728 
 
 prognosis of, 730 
 
 recover ability of, 354 
 
 remittent, 562 
 
 stadia of, 726 
 
 symptoms of, 727 
 
 transitoria, 725 
 
 treated in private, 376 
 
 treatment of, 730 
 Maniacal state, 132, 408, 416 
 Marriage, consanguineous, 70, 371 
 
 and prophylaxis, 369 
 
 and recovered insane, 371 
 Marshall, Andrew, 16 
 Massage, 470 
 jMastication, 253 
 Masturbation, 94, 360, 437 
 
 and marriage, 370 
 
 treatment of, 393 
 Maternity, 104 
 
 Maudsley, 46, 122, 155 
 Meats, preparation of, 479 
 Meat-press, 4S0 
 Meat-pulp, 480 
 Medicine, State, 373 
 Medicines, 398 
 Megalopsy, 144, 156 
 Melampus, 6 
 Melancholia, 714 
 
 agitata, 715, 718 
 
 attonita, 715, 718 
 
 causes of, 716 
 
 chronic, 715 
 
 definition of, 714 
 
 delineation of, 714 
 
 diagnosis of, 718 
 
 feigned, 329 
 
 intermittent, 562 
 
 pathology of, 717 
 
 remittent, 562 
 
 stadia, of, 716 
 
 statistics of, 31, 353, 716 
 
 symptoms of, 717 
 
 treatment of, 719 
 Melancholic, state, 133 
 Membranes, of the brain, 283 
 
 arachnoid, 284 
 
 dura mater, 283 
 
 pia mater, 284 
 
 spinal, 287 
 Memory, 169 
 
 defined, 169 
 
 fantasy and, 172 
 
 hallucinations of, 171 
 
 hypermnesia, 170 
 
 illusions of, 171 
 
 paramnesia, 171 
 
 tests for, 310 
 Menodotus, 10 
 Menopause, 105 
 Menstruatio suppressa, 116 
 Merycism, 253 
 Methylal, 402 
 Meynert, 39, 45, 163, 235 
 Mickle, 431 
 
 Microcephaly, 199, 520 
 Micropsy, 144, 156 
 Milk, 481, 486 
 Milliamperes, 444 
 Milliamperemeter, 444 
 Mitchell, Dr. S. Weir, 455 
 ]\rodesty, loss of, 363 
 Modifications of respiration, 249 
 Moleschott, 475 
 Mollities opsium, 201 
 Mondini, de Luzzi, 12 
 Monomania, primary, 547 
 
 causes of, 548 
 
 definition of, 547 
 
 delineation of, 547 
 
INDEX. 
 
 771 
 
 Monomania, diagnosis of, 553 
 
 pathology of, 553 
 
 prognosis of, 554 
 
 stadia of, 549 
 
 synaptoms of, 549 
 
 statistics of, 31 
 
 treatment of, 554 
 
 with exaltation, secondary, 725 
 
 with depression, secondary, 725 
 Monoplegias, 210 
 Moon, 78 
 Moral Insanity, 555 
 
 causes of, 557 
 
 definition of, 556 
 
 delineation of, 557 
 
 diagnosis of, 559 
 
 pathology of, 559 
 
 prognosis of, 560 
 
 stadia of, 558 
 
 symptoms of, 558 
 
 treatment of, 560 
 IMorel, 44 
 Morphine, 400, 643 
 Morphinism, 643 
 Morrhuol, 422 
 Mortality-rate, 34 
 Morton, 434 
 
 Mothers and heredity, 32 
 Mouth, care of, 453 
 
 modes of opening, 493 
 l^Iovements, Swedish, 458 
 Moxa, 440 
 ^Murray, 429 
 Muscles, 203 
 
 atrophy of, 207 
 
 disorders of, 203 
 
 electric reactions, 204 
 
 excitability, 203 
 
 spasms of, 205 
 
 tests of, 204 
 !Music, 504 
 
 Mutilation, sexual, 254 
 Mutism, 216 
 
 deaf, 321 
 
 voluntary, 321 
 Mydriasis, 213 
 Myosis, 213 
 Myxoedema, 435, 650 
 
 Natls, 246 
 ISTasse, 40 
 
 Nativity, statistics of, 28, 76 
 Needs, organic, 195 
 Negroes, 23, 24 
 Neuralgia, 116, 267 
 Neurasthenia, 603 
 Neurasthenic Insanity, 603 
 
 causes of, 605 
 
 definition of, 604 
 
 delineation of, 604 
 
 Neurasthenic Insanity, diagnosis of, 
 604 
 
 pathology of, 606 
 
 prognosis of, 607 
 
 stadia of, 605 
 
 symptoms of, 606 
 
 treatment of, 607 
 Neuritis, multiple, 267 
 Neuroses, 107 
 Nicotinism, 643 
 Night-sweats, 408, 410 
 Noble, 42 
 
 Nosology of Insanity, 36-68 
 Nostalgia, 715 
 Number, resident, 21 
 
 total, of insane, 22 
 Nurses, 377 
 
 trained, 500 
 
 wet, 368 
 Nux vomica, 412 
 Nymphomania, 196, 425 
 
 OBSERVAiirCES, religious, 507 
 Observation in diagnosis, 329 
 Obsessions, 753 
 Obstipation, 252, 381 
 Occupation, 30, 74, 502 
 
 and prophylaxis, 369 
 
 and treatment, 502 
 Odor, 246 
 
 cutaneous, 245 
 
 menstrual, 246 
 
 sexual, 246 
 
 starvation, 488 
 CEdema, 245 
 
 cerebral, 285 
 
 cutaneous, 245 
 
 pulmonary, 249 
 Oil, cod-liver, 422 
 
 croton, 415 
 Operations, surgical, 113, 116 
 Oophorectomy, 436 
 Opium, 400, 405, 411 
 Orchidectomy, 437 
 Organic dementja, 684 
 
 causes of, 686 
 
 definition of, 684 
 
 delineation of, 684 
 
 diagnosis of, 689 
 
 pathology of, 688 
 
 prognosis of, 690 
 
 stadia of, 687 
 
 symptoms of, 687 
 
 treatment of, 691 
 Organs, reproductive, 94, 202 
 Oribasius, 11 
 Oriental Indians, 5 
 Oscedo, 252 
 Otorrhoea, 453 
 Ovarin, 430 
 
772 
 
 INDEX. 
 
 • Ovariotomjr, 436 
 Ovary, 436 
 Over-strain, 120 
 laryngeal, 364 
 
 Pacchionian bodies, 284 
 Packs, 462 
 Paget, 434 
 Palate, 200, 202 
 
 reflex, 213 
 Pancreas, 98, 256 
 Pancreatin, 417, 430 
 Panic, precordial, 239, 406 
 Panniculus adiposus, 245 
 Papain, 413 
 Parabulia, 193 
 Parsesthesia, 247 
 
 sexual, 196 
 Parageusia, 149 
 Paraldehyde, 401 
 Paralyses, 206 
 
 pseudo, 210 
 Paramimia, 224 
 
 illustrated, 226 
 Paramnesia, 224 
 Paranoia, 547 
 Paraphasia, 322 
 Paraplegia, 206 
 Parchappe, 654 
 Pareses, 206 
 Paresis, general, 654 
 
 causes of, 657 
 
 definition of, 655 
 
 delineation of, 655 
 
 diagnosis of, 670 
 
 pathology of, 669 
 
 prognosis of, 672 
 
 stadia of, 659 
 
 symptoms of, 663 
 
 treatment of, 673 
 Paroles, 514 
 
 Patellar reflex, 214, 314 
 Pathology of Insanity, 269, 280 
 Patients, bed-ridden, 389 
 
 destructive, 386 
 
 filthy, 388 
 
 homicidal, 388 
 
 masturbatic, 393 
 
 suicidal, 391 
 
 violent, 387 
 Paul, of Egina, 12 
 Pemphigus, 245 
 Pepsin, 417 
 Peptone, 260 
 Perception, 143 
 Perfect, 654 
 Periodical Insanity, 561 
 
 causes of, 565 
 
 definition of, 564 
 
 delineation of, 564 
 
 Periodical Insanity, diagnosis of, 570 
 
 pathology of, 569 
 
 prognosis of, 571 
 
 stadia of, 566 
 
 symptoms of, 568 
 
 treatment of, 571 
 Periodicity, 561 
 Peritonitis, 117 
 
 Permanganate of potassium, 427 
 Persecution, 121 
 Persians, 6 
 Personality, 166 
 
 abolition of, 168 
 
 coensesthetic, 122 
 
 double, 168 
 
 elements of, 166 
 
 in dreaming, 122 
 
 in epilepsy, 168 
 
 transformation of, 183 
 Perversion, sexual, 196, 254 
 Pettenkofer, 475 
 Phagocytes, 291 
 Phantasmagoria, 172 
 Phonisms, 754 
 Phosphorus, 419 
 Photisms, 754 
 Phlebotomy, 438 
 Phrenitis, 7 
 
 Phthisis pulmonalis, 248 
 Physician versus patient, 500 
 Physicians, 30, 375 
 Physiognomy, of insane, 222 
 
 and prognosis, 364 
 Pia mater, 284 
 Pigmentation, 244' 
 Pilocarpus, 408 
 Pinel, Phillipe, 18, 40 
 Placebos, 512 
 
 Plumbism, 642 * 
 
 Pneumogastric, 117 
 Pneumonitis, 249 
 Podophyllum, 414 
 Poisons, 108 
 Polysesthesia, 147 
 Polyopia, monocular, 148 
 Polyuria, 259 
 Pons medulla, 283 
 Pons Varolii, 283 
 Potassium bromide, 399, 404, 407 
 
 iodide, 421, 423 
 Poverty, 72 
 Pretus, 6 
 
 Pride, wounded, 120 
 Procedures, surgical, 431 
 Prognosis of Insanity, 33, 342 
 
 age, 348 
 
 atavism, 349 
 
 course of attack, 354 
 
 duration, 354 
 
 environment, 348 
 
INDEX. 
 
 773 
 
 \ 
 
 Prognosis of Insanity, elements of, 
 348 
 form of attack, 352 
 general paresis, 360 
 heredity, 350 
 Infectious disease, 356 
 of death, 343 
 percental chance, 33, 344 
 puerperal cases, 361 
 pulmonary disease, 343 
 recurrence, 347 
 relative chance, 353 
 reversion to health, 352 
 sex, 349 
 
 sexual excess, 360 
 suicide, 351 
 symptoms, bad, 362 
 symptoms, good, 364 
 teniperament, 349 
 termination, 346 
 transformation, 357 
 Progression of mental disorders, 135 
 Property, loss of, 121, 361 
 Prophylaxis of Insanity, 367 
 Pruritus vulvae, 453 
 Pseudo-pareses, 360 
 Psychoses and infection, 110 
 Psycho-traumatic Insanity, 707 
 causes of, 708 
 definition of, 707 
 delineation of, 707 
 diagnosis of, 710 
 pathology of, 710 
 prognosis of, 710 
 stadia of, 708 
 symptoms of, 709 
 treatment of, 711 
 Psychotherapy, 497 
 Ptomaines, 257 
 Ptyalism, 261 
 Puberty, 103, 609 
 Tubescent Insanity, 609 
 causes of, 611 
 definition of, 610 
 delineation of, 610 
 diagnosis of, 614 
 pathology of, 613 
 prognosis of, 614 
 symptoms of, 612 
 treatment of, 615 
 Puerperal Insanity, 616 
 causes of, 619 
 definition of, 617 
 delineation of, 617 
 diagnosis of, 622 
 pathology of, 621 
 prognosis of, 622 
 syraptoms of, 620 
 treatment of, 622 
 Pulsation, abnormal, 235 
 
 Pulse in Insanity, 235 
 
 frequency of, 236 
 Pulse tracings, 241 
 
 in dementia, 239 
 
 m general paresis, 240 
 
 in mania, 238 
 
 in melancholia, 238 
 Pump, stomach, 495 
 Puncture, vertebral, 434 
 
 vesical, 382 
 Punishments, 507 
 Pupils, 213 
 Purgatives, 415 
 
 Quincke, 434 
 Quinine, 418, 423 
 
 % 
 Eanke, 475 
 
 Raptus melancholicus, 234 
 Rate of recoveries, 33 
 
 of speech, 216 
 Ratio of insane, 23 
 Ration, daily, 476 
 Ray, Isaac, 42 
 
 Reactions, electro-muscular, 204 
 Readjustment, social, 501 
 Reasons for increase of Insanity, 24 
 Reasoning, power of, 176 
 
 defined, 173 
 Recovery-rate, 20, 33, 344 
 Recovery and diagnosis, 325 
 Recumbence, 456 
 Recurrence, 137 
 Reflexes, conjunctival, 213 
 
 corneal, 213 
 
 cremaster, 213 
 
 cutaneous, 214, 247 
 
 palatal, 213 
 
 patellar, 214 
 
 plantar, 214 
 Regis, 53, 87 
 Reil, 40 
 Relapses, 34 
 Religion, 507 
 Remedies, 398 
 
 alteratives, 420 
 
 anaesthetics, 413 
 
 anaphrodisiacs, 425 
 
 anodynes, 403 
 
 antiperiodics, 423 
 
 antiseptics, 425 
 
 depresso-motors, 407 
 
 disinfectants, 427 
 
 emetics, 416 
 
 emmenagogues, 424 
 
 hypnotics, 399 
 
 laxatives, 414 
 
 pharmaceutic, 398 
 
 purgatives, 415 
 
 sedatives, nervous, 411 
 
 sedatives, vascular, 407 
 
774 
 
 INDEX. 
 
 Kemedies, stimulants, nervous, 412 
 
 stimulants, vascular, 408 
 
 tonics, 41S 
 Eemission, 136 
 
 Removal from institutions, 512 
 Eepetition of ideas and motions, 753 
 Eeport of Willard State Hospital, 90 
 Residence, hyg-iene of, 447 
 Respiration, modifications of, 249 
 
 in sleep, 250 
 
 Cheyne-Stokes, 250, 656 
 Responsibility^, in legal cases, 338 
 Restraint, mechanical, 509 
 Rest-cure, 455 
 Restoration of rights, 515 
 Returns, tabular, 20, 22 
 Retzius, 66 
 Revulsion, 439 
 Rewards, 507 
 Rhamnus Pershiana, 414 
 Rhazes, 12 
 Rhigolene, 442 
 Rhyming, 175, 217 
 Rhythm of vital force, 78 
 Rights, civil, 514 
 Riviera, Italian, 472 
 Romans, 6 
 
 Room, prepared for patient, 377 
 Roots, posterior nerve, 294 
 Rush, Dr. Benjamin, IS, 42, 438 
 
 Sabina, 425 
 Saliva, 260 
 Sanitariums, 374 
 Satyriasis, 254, 196 
 Savage, 16, 40 
 "School, for patients, 503 
 
 medical, 373 
 
 psychological, 15, 40 
 
 somatic, 15, 40 
 Scorbutus, 484 
 Seclusion, 508 
 
 Self-consciousness of disease, 365 
 Sensation, 173, 247 
 Sex, as a cause, 73 
 
 infliience of, 502 
 
 statistics of, 25 
 Sclerosis, cerebral, 286 
 
 miliary, 290 
 Seborrhoea, 246 
 
 Secretions, gastro-intestinal, 253 
 Seizures, 362, 432 
 Senility, 107, 318 
 
 diagnosis in, 318 
 Sense of smell, 160, 161 
 Senses, loss of, 121 
 Sepilli, 200 
 
 Sequelae, volitional, 197 
 Sexual excess, 95 
 
 perversion, 196 
 
 Shaftesbury, Earl of, 18 
 Shaw, Claye, 432 
 Sheet, for restraint, 509 
 
 drip, 465 
 Shock, mental, 119 
 Shuttleworth, Dr., 520 
 Simulation, 124, 326 
 Singultus, 251 
 Skae, 44, 431 
 Skin, 244 
 
 excretions, 245 
 
 sensory affections, 247 
 Skull, 280 
 Sneezing, 251 
 Sobbing, 252 
 Sodiura phosphas, 414 
 Softening of the brain, 283 
 Solon, 6 
 Sommer, 56 
 Somnal, 402 
 
 Somnambulism, 123, 755 
 Somnambulistic Insanity, 755 
 
 causes of, 757 
 
 definition of, 756 
 
 delineation of, 756 
 
 diagnosis of, 758 
 
 pathology of, 758 
 
 prognosis of, 758 
 
 stadia of, 757 
 
 symptoms of, 757 
 
 treatment of, 758 
 Somnolence, 165 
 Spaces, lymph, 293 
 
 perivascular, 293 
 Spark, electric, 447 
 Spasms, 205 
 
 Speech, disorders of, 215 
 Sphincter ani, 390 
 Spine, concussion of, 279, 360 
 Spiritus ssstheris co., 405 
 Spitzka, 51, 244 
 Sphygmograph, 237-244 
 Spleen, 98, 255 
 Spots, bald, 246 
 Springs, mineral, 474 
 Stadia of mental disorders, 130 
 Stahl, 15, 40 
 Standard, sane, general, 315 
 
 sane, individual, 316 
 Starvation, 111, 318 
 State, ataxic, 209 
 
 cataleptoid, 211 
 
 ecstatic, 211 
 
 epileptic, 577 
 
 maniacal, 133 
 
 melancholic, 133 
 
 pseudoparalytic, 210 
 
 tetanoid, 211 
 
 toxic, 275 
 State medicine, 373 
 
INDEX. 
 
 775 
 
 States of depression, 712 
 
 of exaltation, 720 
 
 of impaired volition, 750 
 
 of stupor, 740 
 
 of suspended volition, 755 
 
 of weakness, 733 
 Statistics of Insanity, 19-36 
 
 of age, 27 
 
 of civil condition, 29 
 
 of education, 33 
 
 of form of Insanity, 31 
 
 of heredity, 32 
 
 of mortality, 21 
 
 of occupation, 30 
 Stearns, 54, 78 
 
 Stig-mata degenerationis, psychic, 
 197 
 
 somatic, 201 
 Stomach, lavage, 442 
 
 pump, 495 
 
 spasmodic affections, 253 
 Strain, mental, 120 
 Stricture, of oesophagus, 495 
 
 masturbatic, 254 
 Structures, epithelial, 244 
 Strychnine, 419 
 Stupor, feigned, 328 
 Stupor, sequential, 745 
 
 causes of, 747 
 
 definition of, 745 
 
 delineation of, 745 
 
 diagnosis of, 748 
 
 pathology of, 748 
 
 prognosis of, 749 
 
 stadia of, 747 
 
 symptoms of, 748 
 
 treatment of, 749 
 Subsultus tendiniim, 205 
 Suggestion, 511 
 Suicide, 391 
 Sulphate of iron, 429 
 Sulphonal, 401 
 Sulphur dioxid, 428 
 Sun-hath, 469 
 Surgery, 431 
 
 Sympathetic nervous system, 277 
 Sym^jathetic Insanity, 702 
 
 causes of, 703 
 
 definition of, 702 
 
 delineation of, 702 
 
 diagnosis of, 705 
 
 pathology of, 704 
 
 prognosis of, 705 
 
 symptoms of, 704 
 
 treatment of, 705 
 Symptomatology, psychical, 142 
 
 somatic, 199 
 Syphilis, 114, 420, 676, 705 
 Syphilitic Insanity, 676 
 
 causes of, 678 
 
 Syphilitic Insanity, definition of, 676 
 
 delineation of, 676 
 
 diagnosis of, 681 
 
 pathology of, 681 
 
 prognosis of, 682 
 
 stadia of, 679 
 
 symptoms of, 680 
 
 treatment of, 683 
 System, disorders of nauscular, 203 
 
 of osseous, 199 
 
 of vascular, 231 
 
 Tait's operation, 437 
 Talcott, 431 
 Tarantism, 125 
 Tea, 476 
 Teeth, changes in, 262 
 
 care of, 453 
 Temperature, 264 
 
 superficial, 247 
 Terminations of Insanitj"-, 139 
 
 chronicity, 140 
 
 death, 140 
 
 recovery, complete, 139 
 
 recovery, incomplete, 139 
 
 transformation, 140 
 Testin, 429 
 Tests, dynamographic, 204 
 
 dynamometric, 204 
 Tetanus, 212 
 
 Tetronal and trional, 402 
 Thein, 476 
 Theobromin, 476 
 Therapy, organo, 429 
 Thermo-cautery, 440 
 Thought, 173 
 
 incoherence of, 175 
 
 rate, 174 
 Thrombosis, 286 
 Thurnam, 21, 25 
 Thyroid, extract, 429 
 
 gland. 111 
 Thyroidectomy, 435 
 Tics, 753 
 
 Timbre, vocal, 217 
 Tinnitus aurium, 153 
 Titus, Aufidius, 9 
 Tone, emotional, 185 
 
 muscular, 208 
 
 of voice, 217, 219 
 Tonics, 418 
 Total of insane, 22 
 Toxic origin of Insanity, 108, 637 
 Toxic Insanity, 637 
 
 causes of, 639 
 
 definition of, 637 
 
 delineation of, 637 
 
 diagnosis of, 644 
 
 pathology of, 643 
 
 prognosis of, 644 
 
776 
 
 INDEX. 
 
 Toxic Insanity, symptoms of, 641 
 
 treatment of, 645 
 Tracings, sphygmograpliic, 240 
 Training-schools, 500 
 Transformation, of attack, 140 
 
 of types, 357 
 Transfusion, 16, 438 
 Trauma capitis, 113, 369 
 Traumatism, 279 
 Traumatic Insanity, 698 
 Travel, 505 
 Treatment, of Insanity, 367 
 
 and diagnosis, 394 
 
 and etiology, 396 
 
 cessation of, 513 
 
 dietetic, 4S3 
 
 g-eneral mode of, 373 
 
 gynecological, 442 
 
 hygienic, 450 
 
 in private, 376 
 
 institutional, 375 
 
 moral, 497 
 
 of bed ridden, 390 
 
 of destructive, 386 
 
 of feeble, 389 
 
 of filthy, 388 
 
 of helpless, 390 
 
 of homicidal, 388 
 
 of masturbatic, 393 , 
 
 of suicidal, 391 
 
 of troublesome cases, 385 
 
 of violent, 387 
 
 pathology of, 398 
 
 pedagogic, 367 
 
 pharmaceutic, 397 
 
 prophylactic, 367 
 
 surgical, 431 
 
 too prolonged, 514 
 Tremor, 208 
 
 alcoholic, 208 
 
 asthenic, 209 
 
 epileptic, 209 
 
 hysteric, 209 
 
 paretic, 208 
 Trephining, 431 
 Trouble, domestic, 120 
 Tube, oesophageal, 492 
 
 nasal, 490 
 
 stomach, 495 
 Tuberculin, 430 
 Tuke, Dr. Hack, 25, 47 
 Tuke, J. Battv, 290, 431 
 Tuke, Wm., 17 
 Tumors, cerebral, 112, 276 
 Turk's, 13 
 Turner, John, 434 
 Typhoid fever, 642 
 Typhomania, 692 
 
 Uncles, and heredity, 32 
 
 Urea, 259 
 
 Urethane, 402 
 
 Urethra, 254 
 
 Urine in Insanity, 258 
 
 Uterus, disorders of, 254 
 
 Vacuolation, nuclear, 289 
 
 Yalerian, 411 
 
 Variation, spontaneous, 89 
 
 Vasomotor innervation, 335 
 
 Venesection, 438 
 
 Ventilation, 448 
 
 Ventricles, 283 
 
 Veratrum viride, 406 
 
 Verbigeration, 218 
 
 Vering, 40 
 
 Vertigo, 410 
 
 VesaniEe, 41 
 
 Vesication, 439 
 
 Vessels, 99, 229, 233 
 
 Vieussens, 16 
 
 Violence, 388 
 
 Virchow, 433, 524 
 
 Visceralgia, 116 
 
 Voice, 154, 217 
 
 and prognosis, 364 
 Voigt, 475 
 Voisin, A., 45 
 Volition, 190, 750 
 A^on Ziemssen, 434 
 Vulnerability, psychical, 118 
 
 Waebukg's tincture, 423 
 Water-cure establishments, 375 
 Water, mineral, 414 
 Weight of body, 256, 363, 364 
 A^Tiiskey, 408 
 Widowers, 29 
 Widows, 29 
 Will, free, 190 
 Willis, Thomas, 16, 654 
 Wise, Dr. P. M., 482 
 Witchcraft, 13, 125 
 Woodhead, 290 
 Words, new, 217 
 Work, at trades, 503 
 Worry, 120 
 Writing, 221 
 mirror, 222 
 
 Yawning, 252 
 
 Zacchias, Paul, 15 
 Ziehen, 55, 155 
 Ziemissen, Von, 434 
 Zinc, 420, 427, 429 
 Zones, hyperalgic, 147 
 

 
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