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 MENTAL DISEASE. 
 
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LECTURES 
 
 MENTAL DISEASE 
 
 W,. H. O. SANKEY, M.D. Lond., F.R.C.P. 
 
 Late Lecturer on Mental Diseases, University College, and School of Medicine for Women, 
 
 London ; 
 Formerly Medic-al Superintendent of Female Department of the Hanwell Asylum, and Prciii- 
 dent of Medico-Psychological Society, etc., etc.; 
 Proprietor of Boreatton Park Asylum. 
 
 SECOND EDITION, WITH ILLUSTRATIONS. 
 
 LONDON 
 
 H. K. LEWIS, 13G GOWER STREET, W.C. 
 
 1884 
 

 LONDON 
 
 PRINTED BY H . K . LEWIS 
 
 I3C JWCR STREET W.C. 
 
TABLE OF (CONTENTS. 
 
 PART I. 
 
 MENTAL SCIENCE, OK PHYSIOLOGY. 
 
 SECTION I. 
 Mental Products . . . . . . . . 1 
 
 SECTION II. 
 Mental Processes or Statics . . . . ' , 32 
 
 SECTION III. 
 Mental Processes or Dynamics ..... 59 
 
 PART II. 
 
 MENTAL DISEASE, OE PATHOLOGY. 
 
 SECTION I. 
 Ordinary Insanity, Acute Stage ..... 100 
 
 SECTION II. 
 Ordinary Insanity, Chronic Stage . . . . .140 
 
VI CONTENTS. 
 
 SECTION III. 
 
 Recurrent Insanity . . . . . . ,103 
 
 SECTION IV. 
 Varieties of Ordinaky Insanity 190 
 
 SECTION V. 
 Examples and Cases in illustration . . 199 
 
 SECTION VI. 
 
 Etiology, Morbid natomy, and Pathology of Ordinary 
 
 Insanity . ....... 21 G 
 
 SECTION VII. 
 General Paresis 250 
 
 SECTION VIII. 
 
 Etiology, Morbid Anatoihy, and Pathology of General 
 
 Paresis . . '. 280 
 
 SECTION IX. 
 States of Idiocy and Mental Weakness . . . 827 
 
 PART III. 
 
 SYMPTOMATIC MENTAL DISEASES. 
 
 SECTION I. 
 Epileptic Insanity 814 
 
CONTENTS. 
 
 SECTION II. 
 
 I'agc 
 
 Alcoholismus 855 
 
 SECTION III. 
 Spinal Cases 3G4 
 
 SECTION IV. 
 Organic Brain Diseases ....;.. 370 
 
 PAR'i^ IV. 
 
 Treatment ......... 875 
 
 PART V. 
 
 Legal Eelations of Insanity ...... 400 
 
 APPENDIX. 
 Classification of Insanity 440 
 
PLATE I. 
 
 Sections of Normal Braiu from Specimens prepared by Dr. 
 Herbert 0. Sankey. 
 
 Fig. 1. Portion of second layer of cortex. 
 
 Fig. 2. Showing giant cells fi-om Paracentral lobe. 
 
 Tissues stained with aniline blue, and drawn to the scale of \ 
 of an inch to xxrW* 
 
k : 
 
 • • % 
 
 • • , , .» fi^ 
 
 k • 
 
 
 > 
 
 
PLATE II. 
 
 Sections of Braiu in General Paresis from specimens prepared 
 and lent by Dr. Wigleswortb, M.D. Lond. 
 
 Fig. 1. Portion of upper portion of Cortex Cerebri, a vertical 
 section tbi'ougb ■v\liole of first layer, and a small portion of 
 second from middle frontal gyrus. Tbe first layer presents a 
 marked fibrillated appearance (scarcely sufiiciently marked in 
 tbe engraving), and numerous large, mucb brancbed neuroglia 
 corpuscles scattered tkrougbout. Tbere are indications of nerve 
 cells, and brancbes of vessels enveloped in byperplasic tissue. 
 
 Fig. 2. Vertical section of a deeper layer of tbe same pre- 
 paration in wbicb tbe byperplasia of connective tissue (Binde- 
 gewebewucberuug) is more apparent. See page 202 et seq. 
 
 Drawn from tbe preparations by tbe autbor to tbe scale of ^ 
 of an incb to xoVo. 
 
ai 
 
 \ 
 
 -^ 
 
 *^^ 
 
 tt^->- 
 
 Cv 
 
 ^"N 
 
 
 
 
 ^C'^ 
 
 
 d 
 
 *■ 
 
 -^ 
 
 - ■ 
 
 A 
 
 V 
 
 \ 
 
PLATE III. 
 
 Small Arteries of the Pia Mater and Cortex Cerebri, Fig. 1, 
 4, 5 and 6 prepared under a stream of water, by washing away 
 the cerebral tissue ; Fig. 2 and 3 are from sections prepared in 
 the usual way. 
 
 Fig. 1, 2, 3, 4 show the appearance of the arterioles in general 
 paresis as described at pp. 304 and 305. 
 
 Fig. 5 and 6 are vessels taken fi-om cases of Chronic Insanity 
 and ImbeciUty and show hypertrophy of the arterioles as des- 
 cribed at pp. 236 and 245. 
 
 *»* Figs. 1, 2, 3, and 4 were drawn from the preparations themselves by 
 Mr. Tuffen West and before the-author and artist met. 
 
PLA'PR 111 
 
A COURSE OF LECTURES 
 
 MENTAL DISEASE. 
 
 PAET I. 
 
 Section I. 
 
 Science of Mind — Schools of Philnsophy — History — Augusta Oomte, liis Account 
 of Positive Philosophy — Psycliolooy a Brancli of Physiology — Division of 
 the Subject — Statics ;incl Oynamifxs, or Priiducts and Processes— Products 
 considered — liocke's D(^fiiiition of Ideas — Concrete and Abstract Ideas, their 
 difference — Examples of Concrete and Abstract Ideas, Mind, Life, Ego, &c. — 
 The Products of Sensa' ion —Persistence of Sensation — Memory — Association 
 of Ideas— Consciousness— Emotions — Will— Belief— Imagination— Judgment. 
 
 I THINK it expedient in commencing a course of Lectures on 
 Mental Disease to introduce the subject witli some remarks on 
 the science of Mind. In other medical treatises the pathologist 
 may assume that the physiology of each organ, the diseases of 
 which he is about to describe, is already acquh-ed by the student. 
 This cannot be said to be the case when the disease is mental. 
 The physiology of the mental functions or psychology, is omitted 
 of late years in the text books. It is not possible therefore to 
 appeal to the student's knowledge, and besides this the subject 
 is a very wide one and is discussed by writers from very differ- 
 ent stand-points. 
 
 The study of Mind, formerly called Philosophy as though it 
 were the only subject of learning, is of very ancient date, and 
 was almost the first subject which excited the attention of con- 
 templative minds. In those early times it was of course consi- 
 dered entirely apart from the body. Mental philosophy long 
 preceded the study of anatomy. 
 
2 LECTURES ON MENTAL DISEASE. 
 
 The large amount of attention that has been given therefore 
 to this subject, through such a series of years, has resulted in 
 the formation of what is called the various schools of philosophy. 
 Each school in its turn had its own system — one school has 
 yielded to another through many changes. The history of the 
 schools is treated in two volumes by the late Mr. Lewes.* 
 
 It would be of no use to us to review these several systems, or 
 the doctrines of the Spiritualist, Materialist, Nominalist, Realist, 
 Idealist, Sensuahst, and others ; though allusion may be made 
 to some of the tenets during our course. 
 
 In England the tendency has been to adhere chiefly to the 
 practical, and transcendentalism has not found so much favor 
 with us as with the German schools. 
 
 One of the last systems of philosophy is that of Comte, a 
 French professor, and his writings have had a large influence on 
 French philosophy, and have brought it into more accordance 
 with English views — it was called by him the Positive Philoso- 
 phy. 
 
 Comte gives in a short compass an epitome of the history of 
 philosophy, and his part in the progress of it, which I will here 
 quote. 
 
 History of the Positive Philosophy of the School of Comte. — 
 Auguste Comte was born in 1798 and died in 1857. His chief 
 work is his Cours de Philosophie Positive in six volumes. 
 
 The following passage from vol. i., p. 14, of his work, gives his 
 own account of the Positive Philosophy. 
 
 " In order to explain," he says, "the true nature and real char- 
 acter of the Positive Philosophy in a convenient form, it is abso- 
 lutely necessary to cast a general coup d'oeil over the gradual 
 progress of human knowledge viewed in its entirety ; for 
 any understanding of the subject can only be gained from its 
 history." 
 
 "In studying the development of the entire human understand- 
 ing in its different spheres of activity, from its earliest soarings 
 to the present time, I believe I have discovered a grand funda- 
 mental law, to which, by an invariable necessity it is sub- 
 jected This law consists in the fact that each of our 
 
 principal conceptions, each branch of knowledge passes through 
 • Lewea' History of Philosophy. 
 
STUDY OF MIND. 3 
 
 three diflferent theoretical states : the first, theological or 
 fictional ; sccouti, metaphysical or abstract ; thii'd, scientific 
 or positive." 
 
 He goes on to point out that the mind in its first efforts, and 
 which he would also consider as the lowest point of its develop- 
 ment, simply refers all natural phenomena to the direct inter- 
 vention or operation of an intelligent agent — to God. 
 
 That from this simple and early mode of explanation the next 
 stage, which is the metaphysical, invented the hypothesis of an 
 intermediate power as Nature, Life, Vital Principle — as the 
 active cause of the phenomena of the universe — and the object 
 of philosophy at this stage was to enquire into the nature of 
 these prime causes. 
 
 This, the metaphysical stage, took as strong a hold on men's 
 minds as did the theological, and to this day it influences the 
 judgments and opinions and modes of thought of a great many. 
 As an example, there is at present no dogma more prevalent 
 perhaps than that which attributes certain phenomena of the 
 body to some distinct agent as " the Will," " Mind," " Vital 
 Principle," etc. 
 
 The positive philosophy as described by Comte has, he says, 
 been gradually extending its power during the last two centuries 
 and embraces to day every order of phenomena. All pheno- 
 mena according to him fall under five grand categories — Astro- 
 nomy, Physics, Chemistry, Physiology, and Sociology, and the 
 •chief characteristic of this philosophy, or the philosophy of 
 science, is this — "that it seeks no more to investigate the inti- 
 mate nature or character of causes, but rather occupies itself in 
 the discoveiy of the Eules or Laws which regulate the universe." 
 
 The positive school made no sudden change in the views 
 generally entertained. Opinions had been for more than two 
 centuries gradually undergoing change, and tending toward the 
 same direction. The writings of Comte perhaps merely stated 
 positive views more dogmatically, and the name of Comte is 
 now most generally associated with them ; there are many mat- 
 ters, however, in the writings of Comte which are by no means 
 accepted — views on religious and political questions, which par- 
 take rather of atheistic and materialistic views, and which, at all 
 events are quite foreign to our present purpose. More especially 
 
4 LECTURES ON MENTAL DISEASE. 
 
 was there in the later writings of Comte much of the mystical 
 and obscure, and which have given rise to an adverse opinion 
 concerning him. It should be borne in mind that much of tliese 
 peculiar doctrines form no essential part of Positivism, and these 
 views were broached only in the latter part of his life, and after 
 a severe attack of mental disease. 
 
 Mr. Lewes sums up the position of Comte in relation to phi- 
 losophy thus : — " tlie positive philosophy is novel as a j^hiloso- 
 phy, not as a collection of truths never before suspected. The 
 novelty is in the organization of existing elements. (History 
 of Philosophi/, vol. ii., p. 696J. 
 
 Psychology being, then, a section of physiology it is to be 
 stu(3ied in the same way as that pursued with other portions of 
 the subject; we may, however, take advantage of what we find 
 prepared for our use in all previous investigations by former 
 methods. 
 
 The subject may be studied, as in other physical investiga- 
 tions, from two points of view — or statically and dynamically. 
 In other words, we may examine the organ and the function — 
 or the process and the product. Only a brief review of the 
 chief matters will be attempted here. 
 
 It will be the most convenient to consider, firstly, the pro- 
 ducts, and secondly, the process. As these, however, are very 
 intimately blended it will not be possible to keep them perfectly 
 distinct thi'oughout our examination. 
 
 THE PKODUCTS OF MIND. 
 
 I. Products. It is in this division of the subject, in which the 
 earliest labours of the schools will be alone available. 
 
 A classification of mental products has been made by many 
 authorities. The division of Professor Bain, and which it 
 appears he adopted from a suggestion of Professor Sharpey, is 
 a good practical arrangement, viz., into the Senses, the Intellect, 
 the Will, and the Emotions. 
 
 These, however, are not strictly products, but rather groups 
 of processes, the products of the senses would be Sensations ; 
 of the intellect. Ideas, Beliefs, Judgments, etc. ; of the will, 
 Volitions ; of the emotions, Feelings, etc. 
 
MENTAL PRODUCTS. 5 
 
 For our purpose I think a more useful mode will be to begin 
 with the most simple product and proceed to the more complex. 
 
 Locke, whose work on the Human Understanding really laid 
 the foundations of what has since been called the positive school, 
 commenced his examination of the understanding by the study 
 of the Ideas. 
 
 Ideas may be considered the units of our investigation. 
 
 Other resultants are as it were secondary as regards Mind ; 
 for example, Sensations and Emotions are mental products 
 when they give rise to Ideas. 
 
 It is as well, therefore, to commence with the examination of 
 Ideas. Locke used this term in a very general manner. " It is 
 the term," he says, " which I think serves best to stand for 
 whatsoever is the Object of the Understanding when a man 
 thinks. [On the Human Understanding, chap, i., § 8). 
 
 Ideas are of two kinds : — 
 
 1. Concrete. 
 
 2. Abstract. 
 
 It is important that the student should thoroughly examine 
 the differences between these. Very much of the difficulty of 
 the whole subject, in my opinion, lies in the understanding of 
 what these terms signify. 
 
 1. A Concrete Idea represents only an object as it is, that is, 
 it is the first impression that is produced upon the organism 
 by the action upon it of an external object; the impression in 
 its crude state, as received, constitutes the concrete idea. In 
 this state the object with all its attributes unseparated — whole 
 — concreted — or in its compound and unanalysed condition, 
 affects the individual and gives him — produces in him — a con- 
 crete idea. This will be still more clearly seen by contrasting it 
 with the other kind of idea. 
 
 2. The Abstract Idea. — An abstract idea does not relate to an 
 object as, or in the condition in which, we see it, or know it, but 
 to some attribute only of the object or objects. Though an object 
 is acting upon our organism, the abstract idea is in relation 
 only to a particular quality, attribute, or portion of the object, 
 drawn away — abstracted from the whole or concrete object, and 
 presented to us only after analysis ; and since it relates only 
 to a portion of the idea formed, it does not correspond to any 
 object in its actual condition as found in nature. 
 
LECTURES ON MENTAL DISEASE. 
 
 To illustrate this by an example: — I have before me a table, 
 and I see it exactly as it is before me, in its entirety ; such an 
 idea thus begotten is a concrete idea. 
 
 But almost at the same moment of receiving the first positive 
 effect upon my organism, there is another process within the 
 mind which is evoked, for directly I say that the object is a table 
 it is obvious that I liken it to some other table ; beyond the 
 simple passive impression there is an action commencing, and 
 "which is a mental process. I may recognise the object as a 
 table and perceive that it has the attributes of other tables, I 
 must have, therefore, a distinct idea of "table" quite indepen- 
 dent of the one before me, or indeed, of any table in particular. 
 
 1 know tables of various shape, size, material, colour, uses, etc., 
 and yet all are to me tables, thus I have an idea of table, which 
 is an abstract idea — because it is abstracted from many tables 
 and of all kinds — I call this abstract idea " table," and in mak- 
 ing use of the term I conceive it entirely apart from, and inde- 
 pendent of the rest of the properties of tables. 
 
 As a further illustration of the attributes of the abstract idea, 
 I will take the idea " Blue." "We have undoubtedly a distinct 
 idea of that which is signified by the term "Blue." Yet when 
 used, as it most commonly is, adjectively, there is nothing in 
 existence exactly corresponding to this term — we all know blue 
 Bky, blue paint, blue books, but if we take away (abstract) the idea 
 corresponding to the terms sky, paint, books, we have only blue, 
 but it remains only in idea. We do not imagine that there is 
 anything, any entity in nature, corresponding to the idea. 
 
 The abstract and concrete ideas difl:'er then in the following 
 particulars : — 
 
 1. A concrete idea results from the action and reaction of an 
 external object on the organism, in which the organism is a 
 passive recipient of the impression. 
 
 2. The action has relation only to a single increment of time. 
 
 8. The concrete idea carries with it a conviction that it re- 
 presents a real object as it exists in nature. Consequently "a 
 concrete name is the name of an object ; an abstract name the 
 name of an attribute." (Mill's Loffic, vol. i., p. 80). " A real 
 concrete object, such as a plant could not be annihilated witbout 
 alteration to the whole cosmos. But abstracts as classes — orders 
 
MENTAL PRODUCTS. 7 
 
 genera, etc., — one and all might be annihilated and would cause 
 no perturbation in the system of things." (Lewes). 
 
 1. The abstract idea is the result of a process within the 
 organism. 
 
 2. It is not in relation only with a single increment of time, 
 but may extend over a wider field. 
 
 3. It does not represent objects in then- actual state in nature, 
 but has relation with portions, or the qualities of things. 
 
 4. The abstract idea produces conviction, or belief, but not 
 that it corresponds to any thing or things in then- actual state — 
 the conviction only is of the existence of an attribute of an 
 object. There is some difference in different writers in the em- 
 ployment of abstract and general terms as expressing ideas. 
 A general term should properly denote a class of attributes, 
 but it of course then denotes an abstract idea, and an abstract 
 term Mill would confine to denote an attribute of a single 
 object, and to mean the opposite to concrete."''' 
 
 There are certain fallacies in regard to these two kinds of 
 ideas which are very commonly met with, viz. : — 
 
 1. To attribute a real or objective existence to what is a mere 
 abstract idea. 
 
 2. To confound the one kind of idea with the other. 
 Though these are separable they may be conveniently con- 
 sidered together. 
 
 Exa'nples in illustration of the above fallacies. With the 
 double view of illustrating the above statement by examples, 
 and pointing out some of the errors which have prevailed, and 
 obscured our present subject, I will select examples bearing on 
 the Science of Mind. 
 
 1. The confusion arising from attributing an objedtive existence 
 to an abstract idea. 
 
 This error is one abundantly discussed by writers of the posi- 
 tive school. Indeed, a just appreciation of what is a mere 
 abstract idea is the distinguishing feature of this school of philo- 
 sophy. 
 
 * The nietapbysical schools believed that that which we call an abstract really 
 did correspond to a real object, whicli they named the essence; as Mill expresses 
 it, they believed in the existence of real entities corresponding to general terms, 
 for instance, they would believe in a certain general substauiive table. The 
 Anbient Doctrine of Essences, vide Mill, vol. i,, \k 123. 
 
8 LECTURES ON MENTAL DISEASE. 
 
 Comte, in fact, points out that this tendency was a distin- 
 guishing mark of one era in the history of philosophy, for while 
 in his first era man attributed the origin of all things to one, or 
 Universal, maker; in the second, or metaphysical age of philoso- 
 phy, everything was attributed to certain general agencies, as 
 gravitation, vital force, &c., and which were viewed as real and 
 existent agencies, or as actual entities. 
 
 But there is no difficulty in meeting with illustrations. The 
 word " Mind " itself affords a good example, and we may con- 
 veniently give it precedence, for a proper conception of what the 
 word really symbolizes is very necessary to the comprehension 
 of what is to follow. 
 
 Mind. I prefer, in explaining errors that have commonly arisen 
 with regard to the abstract idea, to make use of extracts from 
 authors, as such illustrate and give authority to my own state- 
 ments. 
 
 Dr. Maudsley writes* " with regard to the manifold mental 
 phenomena by observation of them, and abstraction from the 
 particular, we get the general conccpt.'o ), or essential idea of 
 mind, an idea which has no more existence out of mind, than 
 any other idea or general term. In virtue, however, of that 
 powerful tendency in the human mind to make the reality con- 
 formable to the idea, a tendency which has been at the bottom 
 of so much confusion in philosophy, the general conception has 
 been converted into an objective entity, and allowed to tyrannize 
 over the understanding — a metaphysical abstraction has been 
 made into spiritual entity." 
 
 " The mind," says Mr. Lewes, (Problems, &c.,p. 216, vol. i.), 
 " is commonly spoken of in oblivion of the fact that it is an 
 abstract term expressing the sum of mental phenomena : as an 
 abstraction it comes to be regarded in the light of an entity, or 
 separate soui-ce of the phenomena which constitute it." 
 
 " By a similar illusion Ave come to regard the process of 
 thinking apart from the product— thought; and, generalizing the 
 process, we call it Mind or Intellect, Avhich then means no 
 longer the phenomena condensed into a term, but the source of 
 these phenomena." 
 
 When we speak of mental disease, or disorder of the mind ; 
 • Maudsley'e Physiology and Pathology of Mind^ First Edition, p. 41. 
 
MENTAL PRODUCTS. 9 
 
 terms wliicli are legitimate because they represent a general 
 notion — it is not that we would intimate that Mind can be 
 separated from body ; but that the body is diseased, and gives 
 rise to alteration of those functions called mental or Mind. 
 
 Another abstract term which is often used in the same way is 
 Life. 
 
 '■^ Life is often spoken of as something independent of Living." 
 (Lewes, op. cit., p. 110). 
 
 " The analogy of Life and Mind is the closest of all analogies, 
 • if indeed the latter is anything more than a special form of the 
 former. Hence what is known of Life, is the best guide to what 
 is knowable of Mind. Both are processes, or under another 
 aspect functional products. Neither is a substance, neither is a 
 force. To speak of Vitality as a substance would shock all our 
 ideas — but many speak of it as a force. What then is meant by 
 Vitality or vital forces ? If the abstraction be resolved into its 
 concretes it will be seen that a certain process, or group of pro- 
 cesses, is condensed into a simpler expression. VitaHty and 
 Sensibility, Life and Consciousness, are abstractions having real 
 concretes. These are compendious expressions of functional 
 processes conceived in their totality and not at any single stage." 
 (p. 111). 
 
 " Co-ordination, Mind, Life, are abstractions; they are reali- 
 ties in the sense of being drawn from real concretes ; but they 
 are not realities existing apart from their concretes, otherwise 
 than in our conception : and to seek their objective substratum 
 we must seek the concrete objects of which they are the sym- 
 bols." 
 
 The terms denote generalizations and express in a convenient 
 and concise form a wide series of phenomena. But when they 
 are taken to mean something distinct — standing over and direct- 
 ing as it were the functions or actions of the body as so many 
 agents, they are grossly misapplied and lead to much confusion. 
 
 " Tke Ego.'' — The next mental product which I will mention 
 is the Idea included in the term " Ego," or " the Ego." Much 
 use has been made of this term, and it may be said to have 
 played a foremost part in metaphysical discussion generally. 
 
 What is meant by the term is the subject, as when we say 
 Ego sum, the sum is predicate of Ego, and the Ego is subject of 
 
10 LECTURES ON MENTAL DISEASE. 
 
 the sum. The word therefore signifies one's self, while Bpeak- 
 iiig of one's mental functions — it, the Self — or the " I." 
 
 Now the term is used in two ways, and hence the confusion 
 which has arisen in its employment. The error is the same as 
 already pointed out with other ideas, or the confounding the 
 concrete and the abstract ; for the word Ego, or I, is sometimes 
 the symbol of a concrete idea and sometimes an abstract idea. 
 
 It is sometimes put merely as one element in a single re- 
 action, in which case it refers also to a single increment of 
 time, as in the expression "I am writing," " I am here," it is 
 then the name of a concrete. 
 
 But it is also used, and perhaps more frequently — and espe- 
 cially when the words "the Ego" are employed — to represent an 
 abstract idea, and as such it is not confined to the signifying of one 
 increment of time, as in the following passage from Dr, Carpenter 
 " the control which the Will can exert tends to render the Ego a 
 free agent," or "the conscious Life of every individual man con- 
 sists in an action and reaction between his mind and aU that is 
 outside it, the Ego and the Non-Ego." In both these phrases 
 the word is clearly employed as a general term to signify a per- 
 sistent agent, or an agent acting throughout a life. 
 
 For illustration's sake, I may say, I know that I have existed 
 60 years and upwards, and consider myself to be the same in- 
 dividual tln'Oughout> though I have been changing during the 
 whole of that time. When I use the term I, or speak of myself 
 as the Ego — as an abstract term, I include myself throughout all 
 these changes, and in using it in this sense it is a general term 
 as much as any other already alluded to as Life and Mind— and 
 in considering its effect in analysmg any particular act this must 
 be borne in mind : for example, in the expression — I exist — the 
 signification of these words may be either, that I am existing at 
 the particular moment of time, or that I am in a continuous 
 state of existence. As this Ego, or I, is usually one term in 
 every mental analysis of ourselves, it is necessary to thoroughly 
 appreciate its exact value in each proposition. Thus, in the 
 expression "I am a free agent," this is certainly true if the "I" 
 means the abstract condition of " Self," In the expression 
 which Dr. Cai'penter quotes from Mr. H. G. Atkinson and 
 Harriet Martiueau (and with obvious pain at the sentiment 
 
MENTAL PRODUCTS. II 
 
 expressed) the Ego or I is used in its concrete sense, and as 
 regards sevei-al distinct and separate acts : " Instinct, passion, 
 thought," they write, "are effects of organised substances, all 
 causes are material ciuses, I am what I am, a creature of 
 necessity, &c., &c." What is true of these statements is this, 
 that each individual concrete act of the individual is the re- 
 sultant of the concrete Ego, at that particular time under the 
 particular circumstances. The Ego is the concrete idea of the 
 man only as he is at that one increment of time. It includes 
 unseparated all his inclinations, convictions, desires, appetites, 
 feelings, passions, and every other attribute to which a name 
 has been given, and such an Ego, under such an influence gives 
 rise of course to necessary results. If either of the two conditions 
 vary, the result will also vary. But when the expression is 
 used in the abstract sense, as the general condition of the in- 
 dividual and his inclinations, dispositions, &c., then, since the 
 conditions are no longer the same, the result will be different. 
 The proposition then becomes a different one, and the result 
 is no longer predicated as necessary but only probable. 
 
 If the surroundings change, the Ego will not be the same 
 Ego mentally. The Ego — the abstract Ego, is thus a change- 
 able not a constant quantity, and the resultant will be a contin- 
 gency and not necessary, the result changing with the change 
 of the Ego ; the action so far depends on the Ego, that 
 since the man and the Ego are one and the same, the man 
 changes according to his own bent — according to his own in- 
 clination generally, and therefore must be said to act just as 
 he chooses. 
 
 Sensation. — The next mental product which we have to con- 
 sider is Sensation. 
 
 It will be first necessary to make some remarks as to the 
 meaning of this term. The words sensory, sense, sensible, sen- 
 sibility, sensational, have become so incorporated into conversa- 
 tional language, that a considerable ambiguity as to the proper 
 application of the words sensation and sense, &c., has resulted. 
 Thus a man has been called sensible, or a man of sense — or of 
 common sense, in relation to his intellectual qualities, rather 
 than his perception. A certain school of philosophy has been 
 called sensual, because they placed a primary importance npon 
 
12 LECTURES ON MENTAL DISEASE. 
 
 the functions of the senses ; and to the same word sensual has 
 been given the meaning in common phraseology of grossness, 
 immorality, &c. But the word sensation in mental science is 
 entirely used to express the particular function of the different 
 special senses — as Vision, Hearing, SmeUing, Feeling, Tasting, 
 to which various authors would add certain other kinds which 
 may be called organic, or those on which the emotions of appe- 
 tite and desires seem to depend. 
 
 "With respect to the operation of the organs of Sensation, this 
 difference in function may be pointed out, that the idea produced 
 from the sensation is in some objective, and in others, more or 
 less subjective. We attribute the effect produ.ced on ourselves 
 through Vision, Hearing, Smelling and Tasting, to the qualities 
 of the object. We attribute the qualities derived from touch 
 and other organic sensations to ourselves — that is, subjectively, 
 but ourselves considered objectively. Thus we do not imagine 
 after an impression produced on our eye, that the object is near 
 or close to the organ, but we refer it to a distance, and the 
 same with the action of the auditory and olfactory senses — these 
 are senses for distant perception ; there are other impressions — 
 modifications of sensation from touch within the organism and 
 called organic, and whicli are subjective. 
 
 Mr. Lewes writes : " When the mental phenomena are con- 
 sidered as wholly within the mind, they are Sensation, Emotion, 
 Impulse. When passing out of the organism, they are Percep- 
 tion, Ideation, and Volition." {Problons, vol. i., p. 138, § 29). 
 
 In other words one is the passive and the other the active 
 effect. A sensation thus limited is the impression produced 
 on the organism by external objects, for a sensation to furnish 
 an idea it must become a perception, '•■ in other words it must be 
 a conscious act. 
 
 The question involuntarily arises then, what can sensation 
 furnish, and what can it not furnish ? This has been the point 
 on which the different schools have expended much argument ; 
 this part of the question will be more in its place when we come 
 to consider the mental processes, or the dynamics of mind : it 
 may be pointed out, however, that by limiting the meaning of 
 
 • Dr. Ferrier {Fundinns of the Brain, p. 4'i) suffpests the use of the word 
 sestbesis — for the sensation as above, and noesis — to signify a perception. 
 
MENTAL PRODUCTS. I3 
 
 the ■word to its proper sphere, it will be evident to every one that 
 all that the special senses can directly give us are material objects, 
 and these in the concrete. No abstract notion can be an object 
 of any of the special senses. We may see a man, but not man- 
 kind — a brave man, but not valour — a blue book, but not the 
 abstract idea blue. 
 
 If we cannot obtain the abstract idea through sensation, we 
 are naturally led to enquire how the abstract is obtained. Locke 
 answered this question thus "by the operation of our minds" — 
 this for the present must suffice until w^e come to consider the 
 processes. 
 
 There are some properties connected with sensation which 
 should be mentioned here. 
 
 Sensations vary in power, psychologists admit of two kinds, 
 which Mr. Spencer calls Vivid and Faint. 
 
 Sensation implies feeling, the word feeling, however, has been 
 employed like the word sensation very loosely — but in the sense 
 of something felt, sensation and feeling are, as James Mill says, 
 the same thing, the names are two but the things are one. 
 
 Another attribute of sensation, most peojDle would say, would 
 be that it is always accompanied by consciousness. We have 
 naturally a difficulty in understanding how the two functions 
 can be separated. We must . be conscious of what we ieel. 
 This must depend, it will be seen, however, upon the exact 
 signification that is put upon the words " feeling or sensation " 
 by those who would object to the axiom, that a sensation must 
 be accompanied by a consciousness of the act. Before we discuss 
 that point, we may add that another property of sensation 
 is, that it produces an effect on the mind of a more or less per- 
 sistent character. And the degree of persistence appears to de- 
 pend a good deal upon the force of the original impression, 
 whether it is Faint or Vivid. 
 
 This property of the persistence of the impression is one on 
 which much depends, and unless the fact of persistence is granted, 
 the explanation of many of the phenomena to be discussed would 
 fail ; it should not therefore be passed over without careful 
 examination. But if we admit the action of the object on the 
 organism at all, which is the primary axiom — we shall have no 
 difficulty in allowing that the impression may persist, and the 
 
14 LKCTURES ON MENTAL DISEASE. 
 
 property may be formulated in a second axiom " that the im- 
 pression upon the organism by its environment may show its 
 persistence in the organism." 
 
 With regard to the connection of sensation and consciousness, 
 we may now explain that some authors would include under 
 this word sensation, every effect produced on the organism 
 through the sensory nerves, in other words the whole effect 
 of the afferent nerves. It must be remembered that there 
 are no strong lines of demarcation in nature. We have admitted 
 that the impression may be stronger or weaker, faint or vivid, 
 the?e great differences are appreciable, but their limits are not 
 sharply defined, the vivid impressions produce vivid conscious- 
 ness, the faint impressions weaker effect, and the weakest produce 
 so faint an impression that consciousness is either evanescent or 
 unappreciable ; who can decide that it is absent, this will be further 
 discussed in the sequel. 
 
 The Persistence of a sensation is the basis of the faculty of 
 memory. A sensation has always a tendency to produce motion ; 
 in the primitive state of the nervous system, the whole of the 
 sensation is expended in motion, and the action called excito- 
 motor or reflex is the result ; in the higher organisms there re- 
 mains, after the motor act, a future source of energy, the whole 
 is not expended, and there is what is called a " remanent." 
 
 Another question in connection with sensation is one that has 
 been greatly discussed in different schools of philosophy, and is in 
 relation to the nature of Sensation; this will be considered rom 
 our point of view when we have to examine the genesis of mind 
 generally. But the question which the metaphysical school have 
 been occupied with is, how the object affects the subject, or the 
 mode by which a quality of an object passes from the object to 
 the subject— and whether the quality or property of an object 
 which we recognize, belongs to the object or the subject, that is 
 ourselves ; that the blue, for example, of a blue book belongs to 
 the book, or whether the idea of blue is only an effect produced 
 on persons seeing it. 
 
 The positivist school declines this discussion, and accepts as 
 real the Sensation produced on the organism by external objects; 
 by resolving sensation into feelingi it accepts that feeling as real, 
 and under certain conditions it furnishes a sufficient basis, or 
 
MENTAL PRODUCTS. 1 5 
 
 datum for our investigation. " Science is compelled," says 
 Lewes {Problems of Life and Mind), "to accept certain limits as 
 final, and these limits may be arbitrary when they suffice for 
 the immediate purpose of the research (conventional ultimates), 
 or necessary when they abut on some dead-wall of ignorance 
 which may be one day removed, or some ultimate of feeling 
 which can never be passed beyond." 
 
 With respect to the reality of feeling, Lewes remarks " that 
 the sensation, or presentation, is fitly considered real because 
 it has objective reality for its antecedent stimulus. The re- 
 presentation, whether image or symbol, is ideal, because its 
 antecedent is a subjective state. Keality always indicates that 
 antecedent which excites sensation when in direct relation with 
 the sensory organism. Hence we say that a feeling is real when 
 it is felt, ideal when it is only thought, not felt. To feel cold 
 and to think of cold are two markedly different states." [Pro- 
 bleins, vol. i., p. 149). 
 
 In this way our abstract ideas are indirectly though not im- 
 mediately based on sensation. 
 
 That the positivist school accept as real the sensation pro- 
 duced on the organism by external objects, is not asserting, 
 however, that our senses necessarily yield us real facts, the 
 organs of sense may be imperfect, and other causes may exist to 
 impede the action of the organ. 
 
 The metaphysician on the other hand, as Kant, affirms that the 
 true is only in the abstract idea, and some go so far as to main- 
 tain that every general term (or abstract idea) such as man, vir- 
 tue, has a real and independent existence, these are the realists; 
 the nominalists, on the contrary, maintain that all general terms 
 are but the creations of mind, designating no distinct entities 
 being merely used as marks of aggregate conceptions. (Lewes' 
 History, vol. i., p. 242). 
 
 Though we cannot fathom the mystery how any quality passes 
 from the object into the subject and produces what we call sen- 
 sation, we may examine some of the attributes of the sensation. 
 "We simply say it produces an effect, and this effect is intensified 
 in some cases by special mechanical arrangements, and diffused 
 by other means, but there are some laws attending these functions 
 "which have been studied. It would appear that the mode by 
 which the influence is diffused, is chiefly if not universally by 
 
iG I.KCTUKES UN MENTAL DISEASE. 
 
 vibrations, with the Kense of hearing this is capable of ready 
 proof and the fact has been utihzed in the telephone. Hermann 
 writes {Pliijsiului/jj, by Gamgee, p. 47-1), the excitation of the 
 auditory nerve is most intense when it takes place thirty-three 
 times a second, the excitation of the optic nerve is most in- 
 tense when it takes place seventeen to eighteen times in a 
 second: in what is called the " bruit musculaire " distinct and 
 regular vibrations occur, their number in tetanus have been 
 estimated at nineteen and a half per second. 
 
 But besides these the phenomena of respiration and contrac- 
 tion of the heart are instances of the kind, the heart of a 
 frog or turtle, for example, continues to contract for hours in 
 regular time after removal from the body, and even pieces of 
 the muscular tissue separated from the muscular walls will 
 continue regularly to contract. The periodicity ot many of the 
 other functions probably is due to the action of the same law. 
 In considering the effect of rhythmical excitants this fact may 
 be remembered. 
 
 It has been shown, that in the higher organisms the sensory 
 impression docs not wholly terminate in an action, but in most 
 instances, and more especially when the original impression has 
 been strong, there remains behind, or persists, or is stored, a latent 
 energy, which is liable to be callel forth in a future operation. 
 
 Memory is a faculty founded upon, or arising out of, this per- 
 sistence of a former sensation. 
 
 A thing is remembered only when a previous impression is 
 resuscitated by a new or present impression. The tendency of a 
 present impression to recall an old impression depends upon 
 what is called the association of ideas. All ideas arc associated — 
 concrete ideas are in fact an association of abstract qualities; 
 any abstract quality occurring in a new sensation recalls the 
 same quality met with before, though differently associated ; a 
 comparison of quality with quality, or idea with idea, forms the 
 genesis of Judgments. 
 
 The Association of Ideas depends of course on the faculty of 
 memory, there would seem to be a natural cohesion between 
 different ideas, so that a given idea will resuscitate another in a 
 way recognizable as normal or natural. In disease this associa- 
 tion is often disturbed and the current of ideas flows in an in- 
 coherent manner. 
 
MENTAL PRODUCTS. I7 
 
 Memory, in tlio usual way in which the term is employed, 
 would a23pear to be necessarily associated with consciousness. 
 Memory is the remembrance of a thing felt. We can scarcely 
 imagine we could remember an act, of which we had never been 
 conscious. It seems unfortunate that the term unconscious 
 memory should have been introduced, as it has been, to signify 
 certain phenomena which are observed. The question, however, 
 will be better deferred for the present ; it will be enough to state 
 here, that Memory is much stronger, the more vivid or strong the 
 original impression was, that is re-called. Hence a new sensa- 
 tion proditces more effect than an old one. An action which is 
 stale and performed in a perfunctory manner is soon forgotten. 
 Next to a strong impression an often repeated impression pro- 
 duces a greater degree of memory. As different persons are 
 affected differently through the different sense organs, so the 
 memory of one kind is easier than another in different indivi- 
 duals. One remembers things seen, another what they hear, 
 one man's memory is for form, colour, or for harmony, music, 
 &c. The question of unconscious memory will be deferred till 
 the faculty of consciousness has been considered, and which we 
 will now proceed to do. 
 
 Consciousness can scarcely be viewed as a product, and some 
 consider it rather as a faculty ; but it may require a few lines 
 of remark in this place, on account of its intrinsic importance, 
 and the difference of the views which have been expressed con- 
 cerning it. It will scarcely need a definition, for everyone is 
 aware of its existence and operation in himself; the differences 
 of opinion, which have arisen connected with it, have been owing 
 chiefly to the different systems of mental science, by which it 
 has been examined. Dr. Charlton Bastian in an article "On 
 Consciousness " in the Journal of Mental Science, Jan. 1870, 
 quotes the following passage from Sir W. Hamilton : — 
 
 " Aristotle, Descartes, Locke, and philosophers in general, 
 have regarded Consciousness not as a particular faculty but as 
 the universal condition of intelligence. Keid on the contrary, 
 following probably Hutchinson, and followed by Stewart, Eoyer- 
 Collard, and others, has classed consciousness as a co-ordinato 
 faculty with the other intellectual powers ; and as the particu- 
 lar faculties have each their particular object, so the peculiar 
 
l8 LECTURES ON MENTAL DISEASE. 
 
 object of consciousness is the operations of tlie othrr faculties 
 themselves, to tiie exclusion of the objects about ^vhich these 
 operations are conversant." 
 
 Again Dr. Bastian, quoting from James Mill, writes, " If we are 
 in any way sentient, that is, have any feelings whatsoever of a 
 living creature, the word conscious is applicable to the feeler and 
 consciousness to the feeling." 
 
 These views are not identical ; they contain probably no- 
 thing but what is true, yet scarcely make the question clear. 
 
 Every thing of which we are conscious, of course must be a 
 feeling, but does consciousness embrace every kind of feeling. 
 In the former quotation the feeling is limited to a particular 
 field of operation. The object of consciousness, according to the 
 views of the authors named, are 'the other faculties,' hence, by 
 way of illustration, as the external environment is the object of 
 sensation — sensation is one of the objects of consciousness ; 
 (an imperium in imperio) and therefore it diflfers from sensation 
 according to this view. 
 
 As regards the second quotation of Dr. Bastian, or that the 
 word consciousness is applicable to the feeling of the feeler, it 
 may be asked if feeling or sensation is nothing more or less than 
 consciousness ? A sensation as it appears to me is the impres- 
 sion produced by an external object, but consciousness is the 
 impression or recognition of the sensation, and this is the mean- 
 ing conveyed in the first quotation. In this there is this differ- 
 ence between sensation and consciousness, the special senses 
 give ITS one set of ideas, acquaint us with external objects, their 
 presence and qualities, but consciousness makes us cognizant 
 of the operations within us. 
 
 Sensation depends therefore upon the special senses. Exter- 
 nal objects are the objects of the special organs. Internal opera- 
 tions the objects of conscioiisness. 
 
 We may next ask how far it is a condition of intelligence — in 
 two ways. 
 
 In the first place our special senses may make us cognizant 
 of the physical characters around us. Everything which we can 
 see, hear, taste, smeU, or feel, can be made known to us tlu-ough 
 these organs, but we have many other cognitions than those de- 
 rived from special senses ; all the operations going on within us 
 
MENTAL PRODUCTS. IQ 
 
 nre objects of consciousness and beyond the sphere of the 
 special senses. 
 
 Secondly, there is a wide difference between the cognitions 
 obtained by special sense and through the operations going on 
 in the mind. 
 
 The ideas received by the special senses relate wholly to our 
 environment, to external things and their relations. When we 
 see an object, we receive the idea of the object external to ua. 
 It is the same with the object of hearing, the sound is attributed 
 to its producer, and even when we touch ourselves, we attribute 
 the quality to ourselves as an object : but when any idea be- 
 comes a part of our consciousness, it is viewed as belonging to 
 the organism, and to a process connected with the organism. 
 
 A sensation, it is true, becomes conscious as soon as we are 
 conscious of it, at first it is only a sensory stimulus ; but when 
 thus incorporated with consciousness it is a perception, and we 
 do not any longer consider that it belongs to the external en- 
 vironment, but to be an attribute of the internal organism ; it 
 thus becomes an idea, and, as an idea, may remain as stored 
 force. 
 
 Various degrees of consciousness are recognizable. Authors 
 speak of semi-consciousness, feeble- consciousness in all degrees, 
 to a state of complete unconsciousness. 
 
 Consciousness is a necessary part of several other mental 
 faculties ; as. Volition — which is in other words motion with 
 consciousness : Emotions — or sensations with consciousness : 
 Memory — though of late a memory without consciousness has 
 been spoken of. 
 
 Though all the voluntary movements imply the presence of 
 consciousness, it is well established that the quality of conscious- 
 ness is in no way operative in producing the motion. Hence 
 physiologists have been speaking of unconscious motions under 
 the term automatic movements. 
 
 And beyond this of late they have claimed other kinds of 
 memory -as an unconscious memory, this term is to designate 
 the tendency expressed by Lewes in the words " discharge 
 along the line of least resistance," which means that many even 
 very complex movements originally acquu'ed by such vivid im- 
 pressions along the afferent track as to produce a vivid con- 
 
 c2 
 
20 LECTURES ON MENTAL DISEASE. 
 
 sciousncss of the operation, may by constant repetition become 
 less and less conscious in their performance, in other words be- 
 come more and more mere reflex or spinal actions. Such as 
 learning to read or write, to play the piano, walk, etc., all of 
 which by practice become almost unconsciously performed. 
 Gratiolet says — " Every organ has its own memory." 
 
 Griesinger, as quoted by Lewes, says, " there is a memory for 
 all tJie central organs including the spinal cord. There is one 
 for reflex images as well as for sense images." 
 
 This to my mind is only adding another difficulty to what is 
 already considered intricate enough. Much opposed as one 
 may be to new names however, this phenomenon would cer- 
 tainly deserve a better name, and a more distinctive term to 
 denote it, than that of unconscious memory. 
 
 The tales that are told of actions performed unconsciously, 
 from result of cerebral disease or cerebral sleep, are among the 
 most wonderful histories of medical literature ; they are at the 
 same time proofs that co-ordination in no way depends on con- 
 sciousness. 
 
 M. Trousseau (Lectures, translated by V. Bazire, p. 58) gives 
 several examples of acts performed unconsciously by epileptics 
 while in their attack, and which partook of the character of acts of 
 Will, as : an architect who, when attacked by his disease, ran 
 along the planks of a high scaffold, and this he did frequently and 
 without ever falling; a musician, who in his attack continued to 
 play his part in an overture ; a priest, who continued to incense 
 the bishop from the thurible ; the president of a provincial tri- 
 bunal who would leave his seat to go into the next room and 
 perform some incongruous act, and return to continue his 
 duty. Professor Huxley, in an address at the Meeting of the 
 British Medical Association, August, 1874, related the case of a 
 man who after receiving a shot which fractured his parietal 
 bone, recovered, but was subject to attacks, in which he be- 
 came, as it were, purely automatic for two or three days in 
 every month. In this state he would appear neither to see or 
 hear ; but if the materials for a cigarette were put in his way, 
 he proceeded to fold them into proper form, but could not dis- 
 tinguish if it were sawdust or tobacco which was given him. 
 He could perform other equally comphcated acts, avoid obstruc- 
 tions in walking, &c. 
 
MENTAL PRODUCTS. 21 
 
 Emotion. — The next mental product which we may consider ia 
 Emotion. 
 
 Emotion is closely allied to the products which we have been 
 occupied upon — Sensation and Memory. 
 
 The word Emotion is an abstract term, and is used to group 
 together those effects which are produced on the organism from 
 without, and are attended with pleasure or pain. 
 
 The effect which any external object produces on the subject 
 is one, — whole and concrete. It is by a mental process, that this 
 single effect can be separated into the abstracts of Sensation, 
 Emotion, Volition, &c. 
 
 Emotion is so closely related to, as to be scarcely separable 
 from. Sensation ; the ground for separating the one fi-om the 
 other, is this quality of being attended with pleasure or pain. 
 So much of the effect produced on the organism by any external 
 object, which excites painful or pleasurable feelings is emotion. 
 It has, therefore, reference entu-ely to the mental product, or 
 the subjective effect, or the effect produced on the subject. 
 
 "Whenever the mental phenomena," writes Lewes, "are 
 considered as wholly within the organism, they are Sensations, 
 Emotions, Impulse. When passing out they are Perceptions, 
 Ideation and Volition." (Lewes, op. cit., vol. i.,p. 138, § 29). 
 
 " We divide feelings into central, called Emotions, and the 
 peripheral, commonly called Sensations," (Spencer's Principles 
 of Psychology, vol. i., § 112). 
 
 Thus the term Sensation has a somewhat more circumscribed 
 meaning than Emotion. A Sensation is the product of an 
 object in its concrete form, and is the concrete or primary effect 
 produced on the Organism. Whereas Emotions may be pro- 
 duced by ideas of high abstraction ; the highly moral actions, or 
 valiant deeds described by poets, the contemplation of virtues or 
 of the attributes of the Deity, give rise to Emotions; as the awe 
 insph-ed by grandeur, antiquity, goodness, ideal beauty and the 
 like, is Emotion, and which may eventually be traced back to 
 Sensation as the origin ; yet certainly acts upon the mind, 
 thi-ough ideas of the abstract kind. 
 
 A very slight examination will convince us that nearly every 
 idea is accompanied by some degree of emotional feeling, from 
 that of the faintest kind, to an impression of the most disturbing 
 or overwhelming description. 
 
22 LECTURES ON MENTAL DISEASE. 
 
 The following is the definition given by Prof. Bain — 
 
 "Emotion is the name used to comprehend all that is under- 
 Btood by feelings, states of feeling, pleasures, pains, passions, 
 sentiments, affections." {Emotwns and Will, p. 1). 
 
 " The fundamental proposition respecting Emotion generally 
 may be expressed in these words : — The state of feeling, or the 
 subjective consciousness which is known to each person by his 
 own experience, is associated with a Jijfusive action over the 
 system, through the medium of the cerebral hemispheres. In 
 other words, the physical fact that accompanies and supports 
 the mental act, without making or constituting that fact, is an 
 agitation of all those bodily members more immediately allied 
 with the brain by nervous communication," {Op. cit., p. 5). 
 
 The Emotions have been differently enumerated; that ar- 
 rangement of them given by Dugald Stewart is practical, and 
 will serve to give exami^les of the chief vaiieties. He enu- 
 merates five kinds: — 1. Appetites; 2. Desires; 3. Affections; 
 4. Moral Sense ; and 5. Self Love. 
 
 All kinds of Emotions play an important role in Insanity. 
 We may examine their agency and influence from two points of 
 view : 1. From their kinds ; 2. From then* degree ; but which 
 will be better deferred to the chapter on Mental Processes. 
 
 Will, Volition. — The next product which claims our attention 
 is the "Will, and their is no product of the mind of more im- 
 portance to us in the study of mental disease than this. 
 
 Will, voluntary motion, volition, free will, responsibility, and 
 irresponsibility, all are connected with the mental faculty we 
 call the Will. The question is treated by writers of all schools, 
 but scarcely with the fulness which its imi)ortance from the 
 medical point of view deserves. 
 
 Firstly, it is obvious that the term is an abstract term ; and 
 the idea of Will is an abstract idea. Plainly as this should 
 appear to anyone who knows what an abstract idea is, it has 
 been frequently overlooked. If an abstract, from what, we may 
 ask, is it abstracted? Every time we use the term I, or lie, 
 in connection with an active verb, we have iiresented to our 
 minds an action and the cause or agent (I or he). This agent 
 by abstraction is generalised into a power that initiates an 
 action, but to attiibute to this power an independent existence 
 
MENTAL PRODUCTS. 23 
 
 and call it the "Will of the agent, is simply unTvarrantable ; by 
 no niauo3uvrc can we separate the Will from the agent. 
 
 But to go more fully into this question as it is of importance. 
 In such a sentence as "I move," the meaning is intelligible, 
 and it contains two ideas which we can separate in our minds, 
 and place the one among a group of agents, and the other 
 among a group of actions. We may say of the word "move" 
 that it is of the same kind as walk, stand, run, &c., in fact it 
 is a verb. 
 
 With regard to the word "I," it is the symbol representing 
 the agent ; and it may be classified with nouns in general, as 
 far as its functions are concerned. 
 
 By considering this '• I " in conjunction with other active verbs, 
 as : I walk, I strike, I select, &c,, we become possessed with the 
 general idea of something which plays a similar part in so many 
 acts. This general idea, with such general power to act, is the 
 power we call " Will." It denotes an attribute of the " I." It 
 is purely, therefore, an abstract idea ; when used it signifies 
 only an abstract power. 
 
 It has abeady been pointed out that the word I, or the Ego, is 
 also used sometimes to denote an abstract, and sometimes a 
 concrete, idea. 
 
 The word " Will" is thus clearly the name of an abstract idea 
 and an attribute of the subject. It cannot in that sense be a 
 separate and independent agent — an attribute except in con- 
 junction with its object has no existence. 
 
 Will, then, is an attribute of Mind, it is included in the term 
 mental functions, it cannot exist separated from mind, as mind 
 cannot exist out of body. We have seen that various func- 
 tions — Emotions, Sensations, &c., are included as mental func- 
 tions, and Will is in the same category. Will, Emotion, Intel- 
 lect, are abstractions of the idea of mind, as Mind is of bodily 
 functions. Mind, is merely the grouping of all these faculties, 
 and as expressed by Dr. Maudsley in a passage already quoted, 
 *' with regard to the manifold mental phenomena, by observation 
 of them and abstraction from the particular, we get the general 
 conception or essential idea of mind, an idea which has no more 
 existence out of mind than any other idea or general term." 
 
 Will is necessarily attended by consciousness, since it is one 
 
24 LECTURES ON MENTAL DISEASE. 
 
 of the factors of consciousness, and it may be defined in the 
 words of Hermann : " The state of consciousness coincident 
 with excitation of tlie central organ, by means of the centripetal 
 fibre is called Sensation, and that coincident with excitation by 
 means of the centrifugal fibre — Will." (Hermann, by Gamgee, 
 p. 474). 
 
 Mr. Spencer says, that the mistake that persons of confused 
 conceptions make on the subject of Will "appears to consist in 
 supposing that at each moment the Ego is something more than 
 the composite state of consciousness which then exists," that is, 
 for the passage is very epigrammatic, that in speaking of our- 
 selves we mean our minds, and it is obvious in speaking of any 
 voluntary performance this is eminently the meaning, though 
 we are apt to imagine we may speak of ourselves — divorced, as 
 it were, for a time from ourselves — that we are able to put off 
 our composite state of consciousness, which is in fact our only 
 existence, — that we put this aside and sit in judgment, or as 
 outside observers, of what is going on in our mind ; whereas, 
 what is going on is our mind, and is in fact all ourselves. 
 " A man," says Mr. Spencer, " who after being subject to an 
 
 impulse consisting of a gi'oup of psychical states performs a 
 
 certain action, usually asserts that he determined to perform 
 the action," this group of psychical states being inducements 
 presenting themselves at the moment, or the result of former 
 impressions, and that he performed the action under their im- 
 pulse, "and," says Mr. Spencer, "by speakmg of himself as 
 having been separate from the group of psychical states, consti- 
 tuting the impulse, he falls into the error of supposing that it 
 was not the impulse alone which determined the action." The 
 man himself me]itally considered, or mentally constituted, was 
 nothing more than these "psychical states." When a man 
 speaks of himself as an agent in any voluntary act, he means 
 his mental self ; for his state of mind is himself, and consti- 
 tutes his Ego, or indivUlualtwss ; and, therefore, it is the same 
 thing to say that he performed the act, and that the mental im- 
 pulse performed it. " The entire group of psychical states 
 which constituted the antecedent to the action, also constituted 
 himself at that moment — constituted his psychical self, that is, 
 as distinguished from his physical self. It is alike true that he 
 
MENTAL PRODUCTS. 2$ 
 
 determined it, seeing that during its existence the impulse con- 
 stituted his tlien state of consciousness, that is himself." l^i^rin- 
 ciples of Pt^ijchuliKjij, First Edition, vol. i., p. G17, § 219). 
 
 In this example here cited from Spencer, hy viewing a single 
 act of Volition, the impulse at that particular moment was the 
 man — the Ego, and all the relations that were present around 
 the Ego, acting with the Ego, necessarily resulted in a certain 
 way. The result was as necessary as that 2 and 2 make 4 ; the 
 laws of nature being admitted to be at all thnes fixed. 
 
 That we have, however, an idea that we are not subject to 
 this fixed law in our various volitions, results from the fact that 
 most frequently we do not judge this question on the one act 
 in its concrete state, but we take a general and abstract view of 
 our entire existence, and consider the problem with a general 
 Ego, and placed in a general position of surrounding circum- 
 stances : such a problem, i.e., of the variable Ego, in a variable 
 position, gives of course but a variable and general result ; and 
 the outcome is an abstract and general idea of a power of 
 choice. 
 
 In fine, the idea of "Will considered as a faculty of mind, must 
 be always united with its subject, and that is the Ego. 
 
 The Ego, Consciousness, Emotion, Will, are abstracts of one 
 "whole conception, and as such, cannot separately determine any 
 concrete act. 
 
 Where the popular idea of a separate and distinct agent, 
 called Will, has been derived, is from the metaphysical school — 
 a school which was the most popular during a previous genera- 
 tion, and whose tenets still linger in the minds of many, and 
 which, as pointed out by Comte, invented the hypothesis of an 
 intermediate power, as "nature, life, vital principle, as the ac- 
 tive causes of the phenomena of the universe." It was this 
 source of error which led Dr. Carpenter to quote Cardinal 
 Manning, and to state his unhesitating acquiescence : " That 
 there is (in man) still another faculty — and more than this, 
 another distinct ngent, distinct from the thinking brain." (Car- 
 penter, Mental Phyniology, p. G). 
 
 This is exactly the error, I fancy, to which Mr. Spencer 
 alludes, when he wrote about men of confused mind. If such a 
 faculty, however, could be proved to exist in the sense described 
 by Dr. Carpenter, it would behove us to study it. 
 
26 LECTURES ON MENTAL DISEASE. 
 
 But if we arc to consider tlie Will a distinct agent, why are 
 we not to consider other abstract faculties as Emotions, Intel- 
 lect, Sensation, as separate agents, or indeed why stop at such, 
 and not include all abstract ideas ? 
 
 There is another product of mind, or resultant of the mental 
 functions, which it will be as well to allude to, •' Belief." This 
 of course is largely discussed in all works on Mental Philosophy, 
 and finds an important place in all treatises on Logic. It has 
 special relation to our studies, though perhaps from a dififerent 
 point of view from that on which the works alluded to discuss 
 the question. 
 
 The word "Belief," like most others in common use, is em- 
 ploj^ed in a very loose manner in ordinary writings. Thus it is 
 used to express both a doubt and a certainty ; in the expression 
 "I am not sure, but I believe so," it expresses uncertainty, 
 though in works on Logic it signifies usually a " Creed." Ori- 
 ginally, or etymologically, however, the term meant a per- 
 suasion of truth, rather than an absolute certainty ; of fact. 
 Locke says, " Belief is the assent to any proposition not made 
 out by the deductions of reason, but upon the credit of the pro- 
 poser." This is certainly one phase of the matter. 
 
 It is in this sense in which it is chieflj' of interest to us as 
 pathologists. 
 
 The various schools of philosophy treat of it, and have of 
 course their special views on the subject. Before proceeding to 
 examine any of these it will be as well to note some of the chief 
 characteristics of Behef. 
 
 Firstly. BeUef is not a voluntary act, we cannot believe or 
 disbelieve as we choose ; though the feelings may have weight 
 in biasing opinion they cannot control it. 
 
 Secondly. Belief does not depend absolutely on truth. 
 Philosophers have examined and have had discussions at great 
 length on a ' basis of certitude' ; though what a man believes is 
 what he judges to be true, this belief is no test of the truth of 
 any proposition. The agreement of the belief of many, the con- 
 sensus of opinion of many, may produce a great degree of pro- 
 bability of the truth, but can go no farther than probability. It 
 is beyond a doubt, that dififerent men truly and firmly beheve in 
 very opposite propositions. 
 
MENTAL PRODUCTS. 27 
 
 We are more concerned here on the state of mind called belief 
 than on how it is produced. 
 
 Thirdly. A belief, to be a belief, must be a certitude to the 
 believer. 
 
 Fourthly. As already stated, certitude, or the truth of a pro- 
 position, has been based by one school, upon the ultimate appeal 
 to feeling or sensation, and to an inherent faculty of the mind by 
 another. It must be allowed that feeling, or the direct evidence 
 of the senses, is often at first view deceptive, and until it is veri- 
 fied, as particularly insisted upon by Lewes ; as an example, 
 the relative movements of the Earth and Sun may be quoted, as 
 well as various other illusions of the senses. 
 
 While as to inherent evidence of certitude, as insisted upon by 
 Kant in what he calls the a priori judgments, these are often 
 disturbed in disease. The axiom, for example, " I exist, there- 
 fore I am," may be singularly disturbed by insanity. One cannot 
 refrain from remarking here, that if these innate and funda- 
 mental beliefs are independent of the organism, and their origin, 
 as Kant maintains, quite anterior to it, it is difficult to under- 
 stand how a disease of the organism can overturn them. 
 
 Fifthly. Beliefs are by no means confined to the direct sensa- 
 tions or concretes ; on the contrary our belief in abstract pro- 
 positions is equally strong. It is claimed indeed for the abstract 
 the greater power of mducing belief, this is due to the greater 
 exactness of abstract propositions, and the elimination of dis- 
 turbing conceptions on them. 
 
 Such an abstract proposition as all A is A, which is called an 
 identical proposition, produces absolute belief by the force of its 
 high abstract nature, or the conciseness to which the terms 
 are reduced. 
 
 Lastly it must be granted that in the ordinary meaning of the 
 word, belief admits of several degrees from the strongest convic- 
 tion of certitude to a degree of probability. 
 
 There is no doubt that the facility of belief exists in different 
 degrees in different individuals. This is a necessary result of 
 the different amount of experience and knowledge in different 
 individuals ; the simpler the minds, the few^er the number of 
 stored observations and judgments, the quicker is a behef ar- 
 rived at, and the firmer is it held. 
 
23 LECTURES ON MENTAL DISEASE. 
 
 In the ultimate analysis of the foundation of belief, we come 
 to that primitive reaction between the environment and the 
 organism, in other words — to sensations, as held by the positive 
 school. For though there may be a fallacy in first impressions 
 made by an object, and an illusion of the particular sense, while 
 the wrong impression is in operation, belief exists— though it be 
 a belief of error ; and belief in error, may be, as all history shows, 
 as strong as in truths. Belief may be corrected, reviewed, or 
 modified, by subsequent sensation, or by the memories of pre- 
 vious sensation, but that does not alter the fact that belief rests 
 primarily on sensation — in other terms on Feeling. 
 
 Jmafjination has been treated by some as a separate faculty or 
 power, but considered from the point of view which has been 
 pursued in all the previous pages, it must be held to be simply 
 an abstract product. We gi-oup all phenomena under the 
 word mind, and we may on the other hand separate various parts 
 of the whole by the process of abstraction, and one set of pheno- 
 mena observed — we call imagination.* 
 
 Those who would treat it as a power or an active principle, 
 would endow it with a creative power for which there is no 
 warranty. If we examine any idea which is supposed to be due 
 to this power, that is to the Imagination, and which idea has 
 characteristics, which are easily recognised and grouped, we 
 shall find it simply an abstraction, and the process of its for- 
 mation appears to depend wholly upon the process which we 
 have alluded to in speaking of the association of ideas. The 
 new idea, however high its imaginative character, will be seen 
 to be simply a result of one impi-ession upon a previous or 
 stored impression, which is called forth by association and com- 
 parison. 
 
 However grand or highly poetical the new idea is, it will be 
 found to be simply a sensation from some physical object which 
 calling up a previous sensation, forms with it a new combination, 
 and more often than not, the new idea is only the expression of a 
 simple association of ideas. 
 
 • The business of conception says Dugald Stewart is to present us with an 
 exact transcript of what we have felt or perceived. But we have also a power of 
 modifying our conceptions by conibiniDg the parts ol different uncs, so as to form 
 nevr wholes of our own creation. 
 
MENTAL PRODUCTS. 29 
 
 Poetical expressions are chiefly the expression of similes. 
 No doubt one mind is more readily impi-essed with one phase of 
 natural objects than with another. Thus one man, as Bacon re- 
 marks, is occupied with likenesses and another with the differ- 
 ences. Some men are impressed by magnitude, others with the 
 minutiae. 
 
 Imagination is thus not occupied with a present sensation, but 
 with the secondary result which a sensation calls forth. It de- 
 pends upon memory, it is wholly an abstract idea having no 
 j)hysical object. This will readily be seen by an example ; as 
 a poetical example due to pure Imagination, the following from 
 Shelley to a lady may be cited : — 
 
 " As the moon's soft splendour 
 O'er the faint cold starlight of heaven 
 Is thrown, 
 So thy voice most tender 
 To the string without soul has given 
 Its Own, &c " 
 
 The likening of the charm w^hich the human voice gave to the 
 mstrument, to the effect which the moon sheds over the cold 
 starlight, is simply the comparison of two impressions. AH 
 having originally a physical origin, the poetry probably con- 
 sists in the description of the resemblance of the two emo- 
 tions. These emotions may not be associated at first in every 
 mind, individual minds are differently sensitive, still every one 
 can trace the natural association of the emotions, produced by 
 these two sensations, the comparison of the sensation of sight 
 to that of hearing, when once put into a formula of words. 
 
 As soon as ihese ideas are associated for ns, their connexion 
 is realised and they produce in us an emotion of pleasure or 
 satisfaction, and new associations give us a wider vieAV of nature 
 and enlarge our spheres of intellect. 
 
 The point however to be insisted upon is, that the results which 
 are called imaginative ideas, are not due to any independent 
 agent or faculty, but the word Imagination includes only a j)ar- 
 ticular kind of abstract idea, whicli is the product of one idea 
 operatmg upon another. In insanity many of the ideas expressed 
 m'glit, and indeed have been attributed to disordered imagina- 
 tion, it would be more correct to say they were due to abnormal 
 
30 LECTURES ON MENTAL DISEASE. 
 
 ussociatiou of ideas. SomotirncR idt-iis in the insane exhibit 
 merely an unusual association, that is that the stored idea which 
 is aroused by a sensation, appears to a sane person to have no 
 natural connexion with the excitant — it is incongi'uous ; to us 
 the mind of the patient is simply wandering, or it may be 
 called incoherent. A still greater abnormal condition of mind 
 is observed in some when every word seems disconnected. 
 
 Judgment. The next mental product which we have to mention 
 is "Judgment." This subject has some important bearings from 
 our point, owing to the various doctrmes that have prevailed in 
 the different schools of philosophy in regard to it. More espe- 
 cially is it of interest in relation to the question of Innate 
 Ideas. 
 
 It is said that the doctrine of the independent faculty of 
 judgment is still the most accepted in Germany and the meta- 
 physical school generally, and even in this country it prevails as 
 one of the legacies of metaphysics. 
 
 If the power of judgment is a separate faculty of the mind, it 
 would of course be of primary importance to the alienist phy- 
 sician to examine it. 
 
 The definition of the word judgment is thus given by 
 Lewes {op. cit., vol. ii., p. 141) : — " The operation named Judg- 
 ment has a much more extensive sphere than the text-books 
 assign to it. Judgment is inclusion, or grouping. The operation 
 is one which connects an action with a feeling (more accurately 
 one feeling with another) and the ordinary logical process of 
 connecting a predicate with a subject is but a particular mode 
 of this operation." That is, though what is technically called 
 a Judgment, is simply predication, or the assertion that some- 
 thing is this or that, yet according to Mr. Lcwcs, the process is 
 equally concerned with Emotions or Perception, as well as to 
 Ideas, Thoughts, or to Judgments or Conception. When con- 
 cerned with Perception and Emotion he prefers the term " The 
 Logic of Feeling," and when concerned with Conception " The 
 Logic of Signs." 
 
 According to most writers, a judgment is the outcome of a 
 proposition, but the words judgment and proposition have been 
 used indiscriminately (Mill's Logic, vol. i., chap. v.). When, for 
 example, two ideas or conceptions are compared, as when we 
 
MENTAL PRODUCTS. 3I 
 
 say gold is yellow. Here a process takes place in our minds — 
 by which two ideas, namely that of yellowness and that of gold, 
 are brought together, and the result viz., that gold is yellow is a 
 judgment. It is said that yellowness is predicated of gold — 
 and the one is said to be predicate of the other. It is not, 
 however, necessary that either of the elements, the subject, or 
 the predicate, should be a material object nor the symbol of it, 
 in fact the things compared are the ideas produced by objects, 
 and they inay be abstract and very complex ideas. But the 
 judgment, Mill says, has always reference to the things, and 
 not to our conception of them. 
 
 The process it will be seen is for the purpose of grouping — or 
 inclusion. 
 
 The example, gold is yellow, groups or includes gold among 
 yellow objects. The following phrase " the breeze which 
 whispers through the lime trees is peculiarly agreeable to the 
 feeHugs of a hot and wearied pedestrian," is equally a proposi- 
 tion in which one feeling is predicated of an action and the whole 
 is also a judgment, though the subject— that is the particular sort 
 of breeze, and the predicate or the condition produced in a x^ai'ti- 
 cular kind of individual, are somewhat complex. 
 
 In as much as a judgment is grouping, in other words placing 
 the object operated on into a group of resembling objects, the 
 judgment is the expression of the quality and the predicate 
 is the name of a quality, consequently, the judgment is an 
 abstract idea ; and that whether the result has reference to an 
 object or to a feeUug or emotion. Judgment too is not confined 
 to a single increment of time, but usually it relates to the past, 
 or to the future, it compares previous feeling with the present, 
 or with still prior feeling, and in this it differs from a mere 
 definition. 
 
 When we come to speak of the processes or the dynamics of 
 mind, the subject will be further discussed from the point of view 
 of the Metaphysical school. 
 
Section II. 
 
 PEOCESSES. 
 
 Development of iriirl — Tlpflex acts, primitive effect in movement— Organs un- 
 differentiiiteJ— {Jrailu.il Evolution of Special Orffanss; for Sense; for FiOco- 
 motion — Appearance of Neural Appnr:itu8 — (Jenesis <>f Choice — ReHex 
 Actions of Simple Kiii"l — Coinpouiiil R.'H.'X Actions — Instincl — Atqiiired 
 Actions — Ek'olution nf Memory — Persistence ot Sensory linpn-spions — 
 Emotions — Sto'cd Impressions and Ili-manents; tlieir influence — Judfjment; 
 Kantian aud ilutapliysical Doctriues— Will— Keaponaibility— Cliaructer — 
 Ecsuine. 
 
 Hitherto the sul»jecfc treated has related to a consideration of 
 the nature of the chief products of mind — this may be called the 
 statics of mind ; we will next consider the processes on which 
 these products depend, or the dynamics of mind. 
 
 This portion of the subject admits of two divisions. In the 
 first portion of the following pages we will examine the genesis 
 of mind, aud in the second part the mechanism on which the 
 mental functions depend. 
 
 Pakt r. — On the Deyelopitent of Mind. 
 
 Notwithstanding a fear that it may be thought that many of 
 the facts about to be adduced are very trite and elementary, yet 
 for the sake of tracing the genesis of mind from its earliest 
 manifestations, it will be nccessai'y to commence with such. 
 
 The first indication of the reaction between the external, or 
 what is called the inorgnnic portion of creation, aud the organic 
 or living animal, is in a movement of the latter. 
 
 This simple effect of movement does not vary greatly from 
 what is seen to occur in the action between certain agents 
 wholly inorganic ; as in the expansion of inorganic bodies by 
 heat, say for example the movement of the mercury in the 
 thermometer; or from what occurs in the transference of motion 
 from a moving body to a similar body at rest. 
 
 And indeed there would seem to be no distinct line of demar- 
 
MENTAL PROCESSES. 33 
 
 cation between the movement caused by the reaction of ex- 
 ternal and physical agents upon the organism, and that between 
 two inorganic bodies, anymore than there is in nature between 
 what is organic and what is inorganic. 
 
 This, however, is our starting point in tracing the processes of 
 mind, an animal is acted upon by an external agent of some kind 
 and a motion follows. The polypes may be cited as an ex- 
 ample. When anything, whether fit for the animal's nutrition 
 or not, floats into the vicinity of the tentacles of the polype, these 
 close around it, and it is digested or rejected if not digestible. 
 
 A second stage in ascending the scale of creation is to be 
 observed when the animal is itself more composite, when it con- 
 sists of parts symmetrically arranged as in the radiata. In 
 these may be seen rudimentary organs of sense, — points which 
 are believed to be more sensitive, and on which the action of ex- 
 ternal agents is greater, the consequence of which is simply, that 
 the animal thus endowed is more easily influenced. The influ- 
 ence remains of the same general character, we must call it 
 sensation, without defining it either as tactile, visual, or other 
 kind of impression ; we are of course not in the position to say 
 whether this effect, this sensation, approaches more to one kind 
 of special sense or another, there is this evidence only — that what 
 produces in us that which we call light, and what we experience by 
 actual contact with a solid, have more effect on the lower 
 organisms than sounds or odours. 
 
 In these compound animals consisting of several distinct 
 parts we observe a decided spreading of the local excitant to the 
 surrounding parts. The influence at first affects the parts 
 adjacent. As we ascend the scale of nature we perceive that 
 the local irritant extends also to the distant organs ; and we 
 can trace distinct lines of nerves, by which we know such in- 
 fluence can be propagated. 
 
 So far, we are speaking of but very uncomplex organisms. 
 Natural history would afford innumerable grades of development, 
 each giving more and more complex functions and endowments. 
 Next to this low form of nerve function, it will suffice to 
 instance the tribe of animals, who besides having organs in con- 
 nection with each other, but all endowed with the same faculties, 
 have distinct organs for separate functions. There is clearly 
 
34 LECTURES ON MENTAL DISEASE. 
 
 no esseutial diti'ereuce between the act of seizing a floating object 
 by the polype, and the seizing of a simihii* object by tentacles 
 placed around an oral opening, and conveying it into the special 
 organ for digestion, or a stomach as may be seen in Bryozoa, etc. 
 
 Such tentacles for seizing the object or prey are clearly rudi- 
 mentary arms ; and since in the lower tribes, as in the jelly-fish, 
 such organs as well as seizing the prey act as paddles or loco- 
 motive organs, there can be little difference in principle be- 
 tween these and the limbs of some higher animals which serve 
 entirely for locomotion. The organs of locomotion, which in the 
 lowest, are mere cilia lashing the water in which the animal 
 floats, move the animal simply in an undefined direction ; but 
 when the visual organs are developed, there is a means of bring- 
 ing the movements under the control of a common principle 
 of action. In all the above examples we recognize a movement 
 in obedience to a direct excitant from the surroundings; in 
 the primitive state the impulse of the external irritant is ex- 
 pended in the immediate neighbourhood of the point of contact, 
 in the more complex it is propagated to a wider sphere. Thus 
 we have the first rudiments of a nervous system, and of a nerve 
 current. 
 
 It may be as well to stop here and ask ourselves how far there 
 is yet shown anything approaching mind, there is nothing ap- 
 parently like choice, but it is evident that all that is received 
 into these rudimentary stomachs is not digested. There is thus a 
 selection made by some part of the organism, and this kind of 
 selection is not widely difi'erent from that which is shown by the 
 caterpillar, which affects one kind of leaf rather than another. 
 
 We may cite as example of the next degree, that which we 
 observe in the larvro of moths or butterflies; the egg is in 
 the first place deposited upon a particular Icind of leaf, immedi- 
 ately the egg is hatched, the young larva commences to feed 
 upon the leaf; thus far the event is not different from the 
 seizure of the floating particles by the polype or any of the 
 zoophytes ; but if we move the larva on to a different kind of leaf 
 the animal no longer eats. Children who rear silk worms 
 obtain if possible the mulberry leaf ; if this is not procurable 
 they substitute the lettuce leaf and the worm wiU feed on this ; 
 but if a leaf of some other species is offered the animal refuses 
 
MENTAL PROCESSES. 35 
 
 it. Here we have decidedly an instance of selection or choice. 
 On closely examining the details of this experiment it is clear that 
 the result is due to the operation of two agents, the animal is 
 ready to eat, but it must he excited thereto by its proper 
 excitant or stimulant. We may be prone to attribute all the 
 selection to the animal, but this is clearly a fallacy, and one 
 arising from want of a due examination of all the phenomena. 
 In choosing, there must be the two agents, not only a chooser, 
 but a thing chosen, and for the thing to be chosen it must excite 
 the animal in a given way, it must be possessed of quaUties that 
 will attract the animal. In this way for the consummation of a 
 choice, the two agents must operate, and the act forms no ex- 
 ception to the rule of the reaction between the animal and its 
 environment, or in the words of Mr. Spencer : — 
 
 " Manifestly, if there is an entire absence of adaptation be- 
 tween its acts and surrounding circumstances, the animal must 
 quickly cease to live, and if it exhibits any adaptation, it can do 
 so only in virtue of the fact that certain impressions made upon 
 it call forth one kind of action, while others call forth another 
 kind." (Sx3encer, Principles of Psychology). There is in the 
 organisms an innate capability of acting thus or thus accord- 
 ing to the nature of the stimulus. 
 
 There are other faculties in this larva which are equally 
 excited, the animal moves in regular manner to reach its 
 food and its locomotion is very symmetrical and complex. 
 It is not only directed by its faculties of taste, its nascent 
 emotion of hunger, but its movements are in a proper dkec- 
 tion. The animal consists of distinct parts, some for directing 
 its movement, others for conveying, and storing, and digest- 
 ing its nutriment within its body. So that we find organs 
 for seeing or other special sense located in one point, organs for 
 locomotion in another, and these are brought into an unison of 
 action by a distinct nervous system. The same cause which in- 
 cited the animal to eat, excites it to move though the result is 
 brought abqut by more complex mechanism. 
 
 Now this very animal in process of time and development 
 becomes an animal with still greater and higher faculties, 
 for the insect world as a rule has a larval stage. The 
 pupa becomes a perfect insect and in some insects much 
 
 d2 
 
36 LECTURES ON MENTAL DISEASE. 
 
 higher faculties are discoverable — in the aut and the bee for 
 example. We must admit from the experiments and observa- 
 tions of naturalists, that these animals not only show mental 
 attributes in selecting and procuring food, but, as we are told, 
 they learn to store it, they are prepared to protect it, and 
 there is even a division of labour among their tribes. These 
 very wonderful tales, if admitted, would prove that nearly all the 
 higher attributes called mental, as memory, deduction, foresight, 
 contrivance or actual reasoning faculty, may be developed in a 
 very simple organism ; but it is true that there is no means of 
 verifying the actual identity of these functions in the insect with 
 those in ourselves. And is it not merely an approach and not 
 an identity of functions ? 
 
 There is a difference which must not be lost sight of between 
 the actions, however comphcated, of the lower kind of animals 
 and those of the higher as in man. Formerly, but without any 
 very stable reason, one kind was ascribed to Instinct and the 
 other to Keason. Instinct was assigned to the lower tribes which 
 could not be allowed to i^ossess a faculty of Reason without shock- 
 ing the prejudices of mankind. A close examination does not 
 show that there is anything in the quality of the act, which can 
 distinguish between acts of reason and instinct, for the act itself 
 is perfoi*med as perfectly and completely as any act of an iuteUi- 
 gent and thinking man. 
 
 We may express this in other terms and say that the result 
 which is the outcome of a given animal placed in a given posi- 
 tion, is itself a necessary result. 
 
 If we admit the intelligence of the ant to the full extent 
 claimed, there is scarcely a mental faculty, under whatever divi- 
 sion of the faculties we like to make, that has not its analogue, 
 or prefigurement in these animals. Senses, Intellect, Will, and 
 Emotion, must be allowed to them, as well as Memory and 
 Consciousness. 
 
 But it may bo admitted that the problem cannot be so well 
 examined in the insect life, and observations with the mammahans 
 would be more convincing. However, in this early development 
 we have at least this addition — the movements of the animal in 
 a concerted direction, and this excited by a complex interaction 
 between the animal and its surroundings. We have examples, 
 
MENTAL PROCESSES. 37 
 
 of the use of the special sense of sight and perhaps of smell. 
 We have no satisfactory foundation for attributing to insects 
 anything more than a very rudimentary degree of consciousness, 
 and we cannot demonstrate the faculty of memory. 
 
 In the most primitive phase of excited actions, as they are 
 called, in which we readily observe the motion to follow immedi- 
 ately on the action of an excitant, and in which the resulting 
 movement is of the simplest character, we have no difficulty 
 iji admitting the result to be due to reflex action ; there is 
 nothing in the character of the more complex actions cited of 
 the insects, to remove them from the category of excited move- 
 ments. If we observe the first movements of some vertebrate 
 animals it must be admitted that they also are the result 
 of the same dual action. A duck just hatched rushes to the 
 water, it swims and exercises all its limbs, chases the insect, 
 turns and performs complex muscular movements, in whatever 
 du'ection it appears to will. We see in such phenomena 
 the commencement of the evolution of those actions called volun- 
 tary. Closely scrutinized these actions differ only from other 
 excited actions in being of more complex character. 
 
 In the above cases, however, there is yet no evidence of the 
 faculty of memory. This faculty evidently exists in some birds as 
 in the parrot ; but it is obvious that the first act of the duckling 
 is not due to memory in any way, — the bird can have no recollec- 
 tion of being in a similar position ; in it at least it is an excited 
 action, and must be due moreover to a particular formation of the 
 organism ; all ducks in all times and places perform the same 
 acts, and the same circumstances will continue to produce the 
 same results. 
 
 We may cite the above facts as proving the same law of the 
 interaction of the environment and the organism, and as proof 
 that many acts, which have apparently aU the characteristics of 
 contrived or devised actions, are the result of the law of reflex 
 action, or the necessary outcome of the environment and the 
 organism ; and such is the cause for almost every habit in the 
 lower animals. It is seen in the various propensities of tribes 
 of animals, as the disposition to point in one kind of dog, to set 
 in another ; to watch and lay wait, and to torment its captured 
 prey in the cat ; and which propensities are alike in all in- 
 
38 LECTURES ON MENTAL DISEASE. 
 
 dividuals of the same class and variety. We may even witness 
 the same results in the propensities exhibited by children, who 
 are found to follow certain modes of play and to have disposi- 
 tions for like i^ropensities in all cHmes, in savage as well as 
 civiHzed hfc — and particularly to show an early inclination to 
 imitation, exliibitiug as Mr. Lewes would say, " organised ten- 
 dencies to particular actions." 
 
 These actions which are usually called instincts show great 
 uniformity of character, though under certain influences, they 
 occasionally present slight variations in detail, and this more 
 and more as the organism visibly shows greater and more com- 
 plex development. Since, however, they clearly depend upon 
 the original organisation for the particular features, they must 
 be admitted to be, in some sense, innate. 
 
 These instinctive actions give no intellectual superiority to the 
 individual over its fellows, though in their performance the ac- 
 tions themselves, m well observed instances, are evidently objects 
 of consciousness ; still they do not depend in any way on con- 
 sciousness, nor are they either the result of memory, nor, as far 
 as we can i^erceive, do they leave behind a memory, in the usual 
 signification of that word. 
 
 These faculties which must be considered mental, equally as 
 those of higher kind, have this peculiarity besides their tribal 
 quality or hereditary character ; that they are perfect from their 
 first manifestations, in other words do not require to be learnt 
 nor are they performed more readily by practice. The ants, the 
 bees, and the beavers of to-da}', go through the same perform- 
 ances as their ancestors of old ; their progeny will repeat what 
 they are doing now. 
 
 Acquired Acts. — But we next meet with another plienomenon, 
 which is faintly exhibited in some of the lower forms of verte- 
 brata, such as actions which are acquired or learnt by the par- 
 ticular animal, and not being born with the animal are not 
 transmitted or transmissible to then* offspring. 
 
 Birds have been taught to perform certain motor evolutions 
 and to imitate certain sounds by instruction. Besides those 
 movements which are common to the particular animal or the 
 Bong which is the natural one of the species, new combinations 
 are engrafted ah initio upon the animal, and their motor organs 
 acquu-e a wider range of action. 
 
MENTAL PROCESSES. 39 
 
 It is important to note that this is only accoini)lished after 
 long and frequent repetition. The bird can only acquire a new 
 song or a new action after much pains hestowed, but the higher 
 we ascend in the scale the more easily is the new action acquu-ed. 
 In the dog or the elephant, the power of learning is greater, and 
 in man it is in its highest perfection. 
 
 The power of acquiring actions follows in the inverse ratio of 
 the greatest perfection of the instincts. In the human infant 
 the instincts are the fewest, and the motor functions at first at 
 the lowest state of perfection. But in the human infant the pro- 
 pensity is innate or the tendency of the race may exist, but the 
 mechanism is not in a state to carry out the actions. We 
 must place in similar category the natural tastes, the appetites, 
 and even many higher qualities, or natural gifts, with which 
 we find every man more or less endowed and which each in- 
 herits. 
 
 It is, however, only the ability to perform and not the skill 
 to execute, which is innate ; this results and doubtless de- 
 pends on particular development of the organism. New func- 
 tions require even some degree of cultivation to perfect them, 
 and are intermediate and form a transition from purely in- 
 stinctive acts to the acts of reason or the higher mental attri- 
 butes. 
 
 These acts of Eeason, which are found in a limited degree in 
 very many other animals besides man, but which are by far in the 
 most perfect condition in man, seem to exist in exact ratio to 
 the degree of development of the cerebral hemispheres, and have 
 in fact an anatomical basis. In connection with them there may 
 be certain other faculties resembling them, though it is doubt- 
 ful to what extent they exist in those animals which are dependent 
 upon what ar3 called instincts. The anatomical facts on which 
 both depend, however, have all this basis, this law — the law of 
 afferent excitement and efferent motion ; for as the action in the 
 lowest kind of function depends upon the reaction of the environ- 
 ment and the organism, which in the simplest form of ani- 
 mal life is abundantly evident, so also does each variation of 
 it upward. Man himself is acted upon from without, it is the 
 environments which affect him through his special senses, pro- 
 ducing sensation and all the other train of mental phenomena ; 
 
40 LECTURES ON MENTAL DISEASE. 
 
 but in him there is a more complex machinery and a more com- 
 plicated function. 
 
 The fact that the functions are only imperfectly performed 
 in man at birth depends, however, rather upon the stage of 
 growth at which birth takes place ; the infant has all the me- 
 chanism in an imperfect condition, no new or fresh faculty is 
 needed ; but none of the functions are perfectly performed until 
 the organism has arrived at its perfect growth. 
 
 Every animal is prone to perform certain actions in prefer- 
 ence to certain other actions ; each kind has its special kind of 
 acts, and even the same kind of act is performed differently in 
 different species. The primitive actions of all animals are in 
 connection with the seizing of their prey ; the mode of seizure 
 depends on the organism; the animal is provided with organs 
 of sense for finding, organs of locomotion for approacliing, and 
 organs of prehension for seizing the prey, and these organs are 
 more and more special as we ascend the scale of animal life; but 
 still the parlicular mode in each animal differs. One animal is 
 chiefly aided by its organs of special sense — the sight and the 
 scent, one captures its prey by its swiftness of pursuit, another 
 Hes ui wait, one which feeds on vegetables reaches its food by a 
 special formation of diflerent kind ; but all, whatever mode is 
 adopted and whatever organism is applied, are impelled by a 
 desire. This desire is special, in one it is for vegetable, in an- 
 other for flesh; in one herbage, another fruit; in one for insects, 
 another for fish, another birds, &c. In other words each organ- 
 ism has as well as its special organs, its special desires, its 
 special fitness, or its choice ; and such, it may be allowed, are 
 innate, as they dejDend on the special endowment of the organism : 
 i.e. the animal is directed or impelled to one or other kind of food, 
 according to the efi'ect which one or other kind of food produces 
 on the animal. 
 
 The animal is pleasurably excited by one kind of food and 
 unpleasantly or painfully affected by another kind, and pleasure 
 and pain are terms used to signify the sum of the effects pro- 
 duced by different excitants of whatever kind, upon the organism. 
 
 The efi'ect thus produced is Emotion. 
 
 For the production of emotion, however, what is called con- 
 Bciousness is essential, and for consciousness to exist the im- 
 
MENTAL PROCESSES. 4I 
 
 pressiou produced by the excitant must have some degree of 
 persistence. 
 
 The -persistence of an impression over a distinct interval of time 
 is an important property in mental processes — the mechanism 
 on which it depends will be spoken of hereafter. It is a fact 
 founded on pure observation, and is as uncontrovertible as any 
 other fact derived from a similar source. 
 
 If every impression derived from one of our special senses — 
 if what we saw, immediately faded as an object passing a mirror, 
 mind could scarcely be said to exist : this property, therefore, 
 is a factor in all mental processes ; without it every act would 
 simply be a reflex act, that is to say, the whole force produced 
 by an object would be expended in a motion. But observation 
 and the simplest introspection of ourselves prove to us that 
 when we see any object we recognise it as a concrete, and im- 
 mediately compare it with some object previously seen — we must 
 do this to name it. It is clear, therefore, that some influence 
 of former impression had remained with us. 
 
 The persistence of the impression is, therefore, an important 
 faculty on which much depends ; as, for example, all conscious 
 acts. Emotion, Memory, and those acts attributed to Will. 
 
 As a very familiar example of the operation and property of 
 this persistence may be cited that which occurs when an artist 
 draws from nature — when he transfers the lines from the object to 
 his paper : and in many instances this is not done immediately, 
 but often after a very considerable interval of time : or when a 
 musician returning from a concert continues to hear the airs 
 passing through his mind, sometimes even to his annoyance. 
 
 Without such persistence there could be no comparison 
 of present impressions with the past, in fact, there could be no 
 store of knowledge of any kind. 
 
 Emotion. There remains the fact that each impression, and 
 the recollection of it, gives rise to pleasure or pain ; m other 
 words, to emotional feehngs of some kind, and the co-operation 
 of such emotional feelings of past and present impressions de- 
 termines often the direction of the resulting acts of life. In 
 some acts, especially the more simple, the pain or pleasure are 
 felt to give a preponderance to the direction into which the 
 action shall tend, but in the more complex cases it may not be so 
 
42 LECTURES O.N MENTAL DISEASE. 
 
 easy to recognize all the stages, by whicli the result is ultimately 
 reached. 
 
 It uncloubteiUy happens that the Emotions are more distinctly 
 called forth from a direct sensation, or by a concrete than by 
 an abstract idea. The higher the abstract the less vividly does 
 it produce emotion ; and such abstracts as mathematical prob- 
 lems are quite free from emotional feeling. Even a description 
 or narration of sensations and actions, which can be realised, 
 causes emotion. Dramatic ^^Titing, or any narration to be suc- 
 cessful should deal with facts in the concrete ; sermons by very 
 learned men often fail to interest, by dealing almost entirely 
 in abstractions ; such preachers speak of sin in the abstract 
 sense, instead of instancing some act which is sinful. 
 
 In the higher abstract reasonings — in judgments properly so 
 called — the agency of pleasure or pain forms but a minor part, 
 and should, indeed, be wholly inoperative, but into which it 
 often intrudes itself. In deciding upon any course of action for 
 oneself, of course emotional feelings will be a factor in forming 
 a conclusion, but the man who is the most able to suppress 
 (inhibit) emotion has the best judicial mind. Such a condition 
 of mind it was the object of the Stoics to cultivate. 
 
 To accomplish such a mastery of the emotional feelings requkes 
 a mind of power. It is, however, to be acquired by constant 
 cultivation, and a large experience or a large store of observation. 
 The young, and women as a rule, are less able to accomphsh 
 such mastery. 
 
 I have said that the ultimate action of a man takes the course 
 on which the preponderance of emotions weighs, there is httle 
 doubt that an impulse to act in a particular direction may be 
 suppressed. Some writers appear to believe that this alteration 
 of the former impulse is due to an " inhibition." Such inhibition 
 would seem with them to be an active process, — an action to ar- 
 rest the first impulse. I have always viewed the result to be, and 
 I beheve this is the view of former writers, that the first impulse 
 is overpowered by a second. We see, in fact, in certain cases 
 an intermediate effect (hesitation) to be produced. Such at all 
 events is felt, in coming to any conclusion, or opinion, or judg- 
 ment. 
 
 The question of inhibitory centres will be alluded to in the 
 sequel. 
 
MENTAL PROCESSES. 43 
 
 There remains the question why some emotions are painful 
 and some pleasurable, how does an excitant cause one feeling at 
 one time and another at another. 
 
 The recollection of any event which was followed by painful 
 cu'cumstances may produce a painful feeling when any reference 
 to the same event occurs through the association of ideas ; but 
 in what does the pain or pleasure consist ? How does this re- 
 realization in the mind act upon the system ? What is the 
 process by which pleasurable or painful effects are produced ? 
 The remembrance of a sad event would be a cause of remote 
 kind, the question here is what is the proximate cause or the 
 organic condition at the basis of these feehngs. 
 
 Emotion, says Professor Bain, is invariably associated with a 
 " diffusive action over the system." While there is this tendency 
 for a sensation (impression on the sensory organs) to terminate 
 in a motor act, in many instances such motor act is more 
 or less suppressed, as by a counter- action in any opposite direc- 
 tion, or by inhibition according to some views, yet there will be 
 in every case some outgoing effect on the motor or glandular 
 apparatus. If the excitant be too powerful for the inhibitory 
 mechanism there will be some manifestation of emotion, from 
 merely what Professor Bain calls a diffusive action to a more 
 violent outbreak of laughter or crying. Sometimes the efferent 
 may be expended in action of the capillaries or heart, causing 
 blushing, palpitation, or pallor, or arrest of the heart, or evacu- 
 ation of the bladder, etc., etc. 
 
 For an excitant to produce pleasurable feelings it must be 
 regulated in its force. There is a degree to which an excitant 
 produces pleasure, and beyond which the same excitation will 
 produce pain. Another thing requisite to give rise to pleasura- 
 ble emotions appears to be a certain diversity in the sensations 
 aroused, that while a repetition of the same sensation which is 
 in fact a monotony, produces a feeling of sadness, duluess, and 
 such depressant emotions, a rapid change of effect produces 
 a liveliness, joyfulness, and pleasurable ideas, accompanied with 
 a pleasurable bodily effect. A changing scene in a landscape, 
 a gradual and flowing sound, give rise to a sense of enjoyment, 
 accompanied with a gentle play in the muscles concerned in ex- 
 pression, facial or bodily ; while sudden change or break in a con- 
 
44 LECTUKES ON MENTAL DISEASE. 
 
 nected flow of ideas produces the violent and convulsive move- 
 ments of laugliter, as in the effects of epif^'rams, riddles, and such 
 jeiix lie muts. In analysing any witticism it will be seen, as 
 often pointed out, that to produce the effect of mirth, and 
 laughter, it is necessary in the recital of the stcry to lead the 
 hearer's mind along a beaten track of ideas, and suddenly, un- 
 expectedly, and abruptly to turn the whole current of thought 
 into an opposite channel ; the change must be complete and sud- 
 den as in the last word of the epigi'am — brevity is the soul of 
 wit. 
 
 Pleasurable fcehngs therefore clearly require variation in the 
 current of ideas — these ideas may be derived direct from sensa- 
 tion, as in viewing a scene of varied character or listening to 
 music of varying notes, etc., or they may be produced by the 
 description in words. There is this proviso, however, connected 
 with the production of pleasure or pain, that events of tragi- 
 cal character are often sudden and abrupt and produce pain. 
 When this is the case, it is owing not only to a continuance 
 of impressions in one line, but to the degree of the excitant, 
 for even too great pleasure of all kinds borders on the painful, 
 and may be carried to an extent to become actually so. So when 
 the excitant of a tragical character occurs, the excitant is pain- 
 ful from its intensity, and also from sympathy which is called 
 forth in our own systems — leading us almost to reahze the uijury 
 to ourselves, such at least is the effect in witnessing some tragi- 
 cal event. But some scenes even if tragical, have an element 
 of pleasure in them or people would not resort to theatres to 
 witness them as they do. 
 
 It is not meant here that pleasures and pains are mere 
 degrees in a variety of successive sensations. The different 
 kinds of emotion called forth, and which depend upon the 
 nature of the external object which causes it, have some effect, 
 thus the pleasure of music, of poetic imagination, of a land- 
 scape, of sculptures, produce different feelings ; yet the pleasure 
 derived from either requires some kind of change. 
 
 It is clear thus that to produce a feeling of pleasure a varia- 
 tion in ideas is essential ; if the variety is abrupt, the effect is 
 abrupt, if the variation flows from one change to another, the 
 mind is pleased in a less active manner, and when one can almost 
 
MENTAL PROCESSES. 45 
 
 anticipate the coming tnrn in thought, it gratifies and even 
 soothes. In Hstcning to a piece of famihar music, not too fre- 
 quently repeated, the mind is carried through the change in a 
 way which is even more pleasurable, because more soothing, than 
 to listen to a new and unknown melody : but when the same has 
 been heard so often as to produce no surprise on the mind, or 
 when a joke, is told so often as no longer to cause unexpected 
 variation of ideas, they cease to produce the same effect ; thus the 
 actor ceases to laugh at the jokes he makes, and the musician 
 to care to repeat his music ; by the repetition of the same words 
 many times, as a priest with his rosary, the process becomes at 
 last monotonous, or automatic, and causes either depression or 
 no feeling at all. 
 
 The power of external agents to act upon the organism in a 
 way to produce pleasure or pain becomes, at least, a powerful 
 agency in directing all actions. If one need not go so far as to 
 assert that everything in a man's life and conduct depends upon 
 the attributes of pleasure and pain, yet undoubtedly these are 
 important factors in all human actions, including all kind of 
 effects, and by no means limiting them to what are specially dis- 
 tinguished as psychical. 
 
 Jtidcpnent. — On no question connected with mental philosophy 
 are the differences of opinion wider apart than on Judgment. 
 
 From the positivist point of view, the matter seems simple 
 enough, the difficulties are connected with the doctrines of the 
 metaphysicians. There is one source of confusion, however, 
 which has in some way crept in among the most rigid positivists. 
 It is this that ideas are spoken of as something more than sen- 
 sations. Of course there is a distinction in the meaning of these 
 words, but there is not therefore a separate existence for both, 
 an idea is an abstract term only and its concrete is feehng or 
 sensation, whichever word best expresses the impression on the 
 organism made by an object: by making them two things we are 
 interposing another step or stage in what seems a straitforward 
 process. 
 
 This process is, that the external object affects the organism 
 producing an impression, this is the first axiom on which we 
 have been going, and secondly that the impression there produced 
 may be exliausted entirely in a motor act, or only partially used, 
 
46 LF.CTURES ON MENTAL DISEASE. 
 
 jiml tliiis there is a remanent of enerj^y ; what is left we may call 
 a sensation or an idea, but it is still part of and identical in 
 miture with the new impression. If it be more convenient or 
 clear to anyone to call it an idea there can be no objection, pro- 
 vided he does not exalt it into a faculty, power or agent. 
 
 The primary action produces an impression in the concrete. 
 This is named, and persists. By the law of association of ideas 
 (that is, of impressions), if another object presents itself, allied to 
 it in time or space, the second idea awaking the first, the two pro- 
 duce a joint effect, and two forces thus acting, the direction of the 
 outcome will be according to the diagonal. The new effect will 
 receive probably a new name, the last excitant will be jnihjed to 
 be like or unlike, similar or dissimilar — in the comparing the 
 process of judging is inaugurated. 
 
 When more objects are presented these are compared with 
 impressions made by jirevious objects, and the quahties of one 
 compared with the qualities of the other; to compare is to judge. 
 In the formation of abstract ideas the process is a judg- 
 ment. 
 
 Judgment has therefore for its basis the power of the organ- 
 ism to receive an impression and to retain a portion of such im- 
 pression, and the operation of these contending or co-operating 
 impressions produces a new result, which may be a new abstract 
 idea and a judgment. 
 
 By a further mental process and the reaction that takes place 
 between two abstract ideas, or between abstract ideas and fresh 
 concrete ideas, the higher abstract judgment results. These judg- 
 ments through the reaction of ideas have reference, however, to 
 the subject of such ideas, the result may be suppressed or formu- 
 lated in words, and when so expressed it becomes what is called 
 a proposition. 
 
 The result may or may not be reduced into language, but 
 whether it be so or not, the proposition or judjfment thus pro- 
 duced becomes the basis of all inteUectual operations — operations 
 which distinguish man from the rest of the creation by their 
 much higher development. 
 
 By this explanation of the genesis of intellect the basis of the 
 process rests ultimately upon the effect produced on the organ- 
 ism ; and as this is called a sensation, the school which advocates 
 
MENTAL PROCESSES. 47 
 
 the doctriue lias been called the sensualistic : it is stated to 
 liold the doctriue expressed in the following : — 
 
 "Nihil ill intelloctu quod non fuerit prius in sensu." 
 
 Such, however, is not the case of the modern English school, 
 nor indeed was it the doctrine of Locke to whom they are con- 
 sidered to owe their opinions. Locke's words were, as often 
 quoted; "All our ideas come from Sensation and Reflection" 
 which he explains to mean " the operation of our minds." 
 
 The operation of our minds is generally admitted to be the 
 more important factor in the intellectual process of forming 
 judgments or ideas. In every intellectual act the impressions 
 previously produced on the Emotions, in other words on the 
 mind, remain as a memory to influence, direct, divert, or arrest 
 a judgment or an act. And, as already stated, there is no doubt 
 that a man's inclinations, propensities, or biases, continually 
 modify his thoughts, words, deeds, inclinations, propensities, &c. 
 
 But the schools which are the greatest ojpponents of such views 
 of the intellectual process, and accuse those who hold such 
 opinions of being sensualists, maintain, that besides the basis of 
 sensation and reflection, there is an entirely distinct agent or 
 property in operation, namely a property inherent in mind. 
 They hold that the knowledge from this source is innate, and the 
 doctrine of innate ideas is tluis a part of their creed. This 
 doctrine belongs to the metajphysical school generally, and since 
 the ideas of this school were at one time very much in vogue, 
 so much so as to imbue the general public with their opinions, 
 and to affect even the very language of the Hterature of the times, 
 the opinion demands some attention. 
 
 The exposition of these opinions will be best stated in their 
 own words, and as one of the chief exponents of the school we 
 may take the words of Kant, which I quote from Lewes' History 
 of Philosophy, vol. i., p. 110, and vol. ii., p. 470, et seq. : — 
 
 In contradistinction to the doctrine that our knowledge is 
 wholly derived from experience, Kant affirms, that not only is 
 experience (by which he means the ideas dependent for their 
 origin on sensations) not the source of our ideas, in other words 
 not the foundation of our knowledge, beliefs, &c., but that these 
 are matters which transcend all experience, w^hich are indeed 
 
4^ LHCTUKES ON MF.NTAL DISEASE. 
 
 anterior to it iuid without which experience itself would be of 
 no avail. 
 
 In passing it may he remarked, that if this is so, it is of essen- 
 tial consequence in any study of mental diseases. 
 
 It may also be noted that the word " experience," which was 
 the word used by Locke, is here limited to sensations ; a common 
 error in Locke's foreign critics, but as already has been shown 
 a distinct misinterpretation of his words, Locke too, is consi- 
 dered the champion of the opponents of the doctrine of Innate 
 Ideas. No modern writer of Locke's school will deny the influ- 
 ence of innate propensities, of temperaments, hereditary tenden- 
 cies, &c., these help to make one factor in every mental operation, 
 or in every interaction between the external world and the indi- 
 vidual. The sun produces in the body the idea of light, but 
 both factors must combine for the idea to be produced, and the 
 susceptibility is an innate endowment, and so far there is an 
 innate faculty, but such is not the sense which Kant claims for 
 the existence of the Innate Idea. 
 
 Kantian doctrine on Judgments. — Kant divides Judgments into : 
 1. Synthetical; 2. Analytical; and he further di\ndes each of 
 these in two, a. a priori, j3. d posteriori, according to Kant there- 
 fore judgments are of four kinds : — 
 
 1. Synthetic « p?7on. 2. Synthetic a posteriori. 3. Analytic 
 a priori. 4. Analj*tic a posteriori. 
 
 As an example of a synthetical judgment Lewes gives the fol- 
 lowing : — All bodies are heavy; Acids redden litmus; which are 
 judgments which extend our knowledge. By which he means, 
 as I understand the subject, that such a judgment is a resultant 
 from a process of putting things together (synthesis) and com- 
 paring them, and the product or result is an addition to our 
 store of knowledge. 
 
 Whereas the analytical judgment is formed by analyzing the 
 existing qualities of a subject, as when we say a triangle is a 
 body xiith three sides — body is extended. This is not any addi- 
 tion to our store of facts, but it merely analyses our previous 
 observations. 
 
 Of more importance to our present inquiry is that division of 
 the subject into a prioH judgments and d posteriori judgments, 
 according to Kant's classification both the analytical and synthe- 
 tical judgments admit of subdivision into these heads. 
 
MENTAL PROCESSES. 49 
 
 A priori judgments are those, according to the metaphysicians, 
 which are 7tot derived from experience, but belong to the natural 
 structure of the mind, and which structure is one of the condi- 
 tions of experience and makes experience possible. 
 
 A posteriori judgments are those derived from experience, that 
 is to say they are the products of the mind and external objects. 
 
 As examples of judgments of the a priori kind, are given the 
 following: — A straight line is the shortest path between two j^oints ; 
 two parallel lines cannot enclose a space or can never meet ; two and^ 
 two make four ; the ivhole is greater than its paH ; that A is A, 
 The examples of a posteriori judgments are those of every day 
 occurrence, as Gold is ductile, which is a knowledge derived 
 clearly from experience. 
 
 Kant affirms that all cognition is unstable unless it is a priori. 
 The following are the five fundamental propositions respecting 
 judgments according to Kant. 
 
 1. " Experience does not furnish the whole of our knowledge." 
 
 2. " That what it does furnish has the character of contingency 
 and variabihty." 
 
 3. " That the mind also furnishes an element, which element is 
 an inseparable condition of all knowledge and without it know- 
 ledge could not be." 
 
 4. " That this element has the character of universaHty and 
 necessity." 
 
 5. " That the principle of all certitude is precisely this univer- 
 saHty and necessity." 
 
 Before proceedhag to criticise these propositions and the exam- 
 ples in detail, it may be as well to remark, that on this question 
 hinges many of the chief differences between the two schools 
 with respect to the doctrine of innate ideas, and also that of 
 nominalism, materialism, and idealism, &c. 
 
 The upshot of the dogma, as stated by Kant, is that according 
 to him there exists, independent of the senses and other inlets 
 of knowledge connected with the organism, or at all events with 
 the brain and nervous system, another element, which existed 
 anterior to the organs and continues to exist independently of 
 them ; that this in fact is the surer and safer monitor of the 
 truth. If this be so, it behoves us especially as physiologists 
 and psychologists to become acquainted with it. 
 
50 LECTURES ON MENTAL DISEASE. 
 
 This view too is favoured I think very commonly, or until 
 very lately by physiologists, who in speaking of mental functions 
 speak always of mind as quite independent of mental actions, 
 and existing as a totally separate entity. 
 
 But firstly or before we set ourselves to examine the attributes 
 of this inherent power, or a priori factor, in obtaining our know- 
 ledge, it is necessary to examine the evidence of its existence. 
 
 This seems to rest upon the following evidence. It is asserted 
 that certain cognitions which are called necessary truths, as 
 two parallel lines cannot meet, &c., cannot be given by experi- 
 ence and therefore they must be n prion of all experience. 
 
 To quote again very largely from Lewes. {History of Philo- 
 sophy, vol. i., § 7). "We have," says Mr. Lewes, "to examine 
 whether we learn necessary truths or bring them with us into 
 the world as the heritage of a higher life." That two paraUel 
 lines can never meet is a necessary truth, that is to say it 
 necessarily follows from the definition of a straight line. 
 
 To call it, however, an a priori truth, a truth independent of 
 experience, is to have a very imperfect analysis of the mind's 
 operations. An attempt is made to prove that the idea could 
 never have been gained through experience, because it com- 
 mands universal assent, and because experience itself could 
 never give necessity. Dr. Whewell's argument is, that let us 
 follow two parallel lines out as far as we can, we are still unable 
 to follow them to infinity ; and for all our experience can tell to 
 the contrary, these lines may possibly begin to approach imme- 
 diately beyond the farthest point to which we can follow them, 
 and so finally meet. Now what gi'ound have we for beheving 
 that this possibihty is not the fact ? In other words how do we 
 know the axiom to be absolutely true ? Clearly not from experi- 
 ence says Dr. "Whewell foUowiug Kant. 
 
 "We answer," says Mr. Lewes, "yes, clearly from experience. 
 For our concept of two parallel hues formed from experience 
 is precisely this, they do not enclose space, and directly we con- 
 ceive them to approach each other, they cease in our concep- 
 tion to be parallel lines." 
 
 "The whole difficulty hes in the clearness or obscurity with 
 which the mind makes present to itself past experience.... No 
 sooner do we make present to our minds the image of parallel 
 
MENTAL PROCESSES. 5I 
 
 lines, than in that very act wo make present the imiiosBibility of 
 their meeting, and only as the imago becomes obscure does the 
 idea of meeting become possible." That this is a fact therefore 
 gained from experience is clear. (Lewes, loc, cit.) 
 
 But in fact the attribute of not meeting is the distinguishing 
 property of parallel lines ; they are named from this attribute, 
 and so soon as they lose it, they would no longer answer to the 
 definition, on this depends the necessity and the certainty of the 
 cognition. 
 
 Again to take another example, if all necessary truths are 
 a priori judgments, then that three and two make five must be 
 an a priori judgment, because by no effort, or freak of thought 
 can we imagine three and two to make seven. If they are 
 d ]}riori they cannot be a posteriori, or in other words the outcome 
 of experience. " Certainly by no freak of thought," says Mr. 
 Lewes, "can Dr. Whewell believe that two and three are seven." 
 This is quite true, and that it makes five, is to him a necessary 
 truth, but that is evidently a matter of pure experience and 
 slowly acquired knowledge too. One might easily believe that 
 472 and 274 made 646 or that 365 and 365 made 720, Yet 
 when one had made an accurate calculation, he would find that 
 the first two numbers made 746 and not 646, and the latter 730 
 and not 720 ; and having once obtained the correct result, the 
 correct figures would be necessary truths, which by no power 
 could we believe to be incorrect, but the result was a labori- 
 ously acquired knowledge. 
 
 Not only therefore are these, and many similar judgments which 
 might be quoted, not a priori, though they have all the character 
 of necessity. This character of necessity is therefore not due to 
 what is attributed to some independent and innate faculty of the 
 mind. To what then can we trace it ? It will be seen that it 
 depends upon the precision of the terms used in expressing the 
 judgment ; these necessary truths consist of abstractions, and 
 the terms used to note them are free from ambiguity. " The 
 truth depends," as Lewes says, " on the exactness of the terms." 
 All A is A is true and necessary, but vary the terms as some A 
 is some B, and there is no longer any necessity. The more ab- 
 stract the term used the less does it include ; therefore the higher 
 the abstraction the greater generally is there the quahty of neces- 
 
 £2 
 
52 LECTURES ON MENTAL DISEASE. 
 
 Bity in the judgment, but it is not because these abstractions are 
 furnished as Kant says exclusively by the mind, that they are 
 necessary or free from contingency, but because the terms used 
 are more precise and exact. 
 
 There is no evidence therefore of any element furnished by 
 the mind which is prior to all experience. 
 
 The whole fallacy of these views rests on that which is at the 
 base of all metaphysical doctrines ; the operations of the mind 
 are treated as though mind were a material object or entity of 
 some kind, and pre-existed, and were anterior to and indepen- 
 dent of the organism. That is, to the metaphysical school, there 
 is the idea of mind, whether it is a concrete or abstract idea 
 would appear to be uncertain, but if an abstract idea of what is 
 it an abstract ? It is difficult to say even from the metaphysical 
 point of view. 
 
 Judgments are usually more dependent upon the influence of 
 abstract ideas than upon the more simple or concrete ideas directly 
 derived from sensations ; judgments are concerned, however, with 
 a wide scope of mental impressions; a judgment may be derived 
 from a balance between two present impressions, which would be 
 a judgment of the most simple kind, and of the kind usual with 
 undeveloped or low class of mmds, as in children and imbeciles. 
 In such, an action takes place quickly, the person is said to 
 jump to a conclusion. Such a simple, that is uncomplex condi- 
 tion of mind, has but few stored impressions to modify or divert 
 the present sensation ; the same result follows more uniformly 
 upon the same sensation and the actions following are said to be 
 instinctive. To a mind in which impressions have accumulated in 
 greater store, the process of mental weighing (deliberation) one 
 against the other, is longer. The result or outcome is dehvered, 
 not only more slowly, but with less force ; after deliberation of any 
 large number of stored impressions, the scale preponderates 
 eventually, but feebly, in one direction, so that the word delibera- 
 tion becomes to signify a slow process of coming to a conclusion. 
 
 There is no doubt that in dehberatious of all kind, from the 
 simplest to the most abstract, the emotions enter largely as 
 elements in giving a preponderance to the force of the nervous 
 cm-rent in its outward progress. The emotions are antagonised 
 by experiences gathered during a life, and they themselves pro- 
 
MENTAL PROCESSES. 53 
 
 bably are less strong as life progresses. In other words by 
 long experience, external impressions and sensations of all kinds 
 have a tendency to produce less bodily commotion, while several 
 strong excitants grow feeble from bodily or physical decay. This 
 is especially the case with all the appetites and more especially 
 of course with all connected with sex. In man certain strong 
 emotions and many higher mental faculties, poetical, imagina- 
 tive, &c., are developed, and decay at certain periods of life, and 
 they therefore have less influence in the resulting conclusions, 
 that is, such emotions act with less force in the old than in 
 the young. 
 
 The difficulty in considering any resultant, whether a cogni- 
 tion, or judgment, or act, as dependent upon the influence of 
 abstract ideas uxDon abstract ideas, is experienced by many, be- 
 cause they desire to interpose a directing agent, or independent 
 power, which is called by them the Will, Soul, Mind, the I, &c., 
 according to various views which they have imbibed. 
 
 As an example of the mode of reasoning on the metaphysical 
 doctrine in contrast to that of the positive school, the genesis 
 of the ideas of time and space may be quoted. 
 
 Spencer writes, "the abstract of all sequences is time, the ab- 
 stract of all co-existences is space," First Principles, p. 163. The 
 ideas therefore are abstract ideas formed upon obvious concretes. 
 When we observe one act or action following upon another, by a 
 simple abstraction, we arrive at the idea of time which is a neces- 
 sary part of such action, as knowledge of outward or inward 
 actions are objects of sensation, undoubtedly the basis of the 
 idea of time is in sensation. So with space, we see any body 
 before us, or many bodies, by simple abstraction we can con- 
 ceive that the space they occupy can be void. We have thus an 
 abstract idea of space which appears perfectly simple and intel- 
 ligible. 
 
 The objection which the metaphysician raises to this, is that to 
 imagine any thing existing in space we must first have the idea 
 of space to be occupied. " The Kantian formula is," says Cousin 
 " that the pure rational idea of space comes so little from ex- 
 perience, that it is the condition of all experience." Cousin 
 points out that though this may be logically the order, it is not 
 chronologically, and suggests that wc must first have the idea 
 
54 LECTURES ON MENTAL DISEASE. 
 
 of body before we can obtain the idea of space. Kant would as- 
 8ort of course that tlio idea of space was an d prion judgment. 
 
 Will. — It may be necessary to say a few words on the sub- 
 ject of Will considered as a mental process. It has already 
 been pointed out that Will is merely the expression of a psychi- 
 cal process going on in our minds just prior to the termination 
 of any excitant into a movement. 
 
 When certain impressions are produced to our minds through 
 the medium of our senses, the tendency is for such to cul- 
 minate in a motion, and in special actions, as far as we are 
 cognizant, that is all that occurs ; the stimulus passes from the 
 sense centre to the motor centre and thence to a muscle : but in 
 other actions instead of passing directly to the motor mechanism, 
 say of a limb or leg, it is controlled by passing through a 
 higher centre, where it is delayed an appreciable time. The 
 delay is due probably to a ganglionic interposition ; at which 
 centre the original impulse may be modified by a previous or 
 stored impression, or turned in some other direction ; this conflict 
 of impulses is a conscious condition. When at length the 
 primary excitant overpowers the direction of other impulses, 
 the neural discharge is felt to be emitted and to pass in the 
 dhection in which the preponderance of different forces points ; 
 these opposing forces are the man's wishes, desires, &c., when 
 the discharge is about to occur, the feeling or the consciousness 
 of the impending result we call our Will, and the act when ' 
 made a volition. Voluntary acts are therefore slower than the 
 involuntary, and it has been shown by direct experiment that it 
 is a tendency of a ganglion to arrest the neural current. 
 
 Before concluding this part of our subject, it will be convenient 
 to append a few remarks upon some matters bearing upon the 
 mental functions, which have been supposed to be in opposition 
 to the views here described, and which arise as it were incident- 
 ally, this is the more advisable as the subjects have a bearing on 
 mental disease. 
 
 I allude to the subjects of responsibility and character. 
 
 Ilespoiisibility. — If a man's actions depend so much on exter- 
 nal circumstance it may occur to any one to ask how it is that 
 men differ so widely in temper, intellect, and mental faculties 
 generally. Two men of equal mental powers, placed in the eame 
 
MENTAL PROCESSES. 55 
 
 position, according to such a view should always act alike, and 
 since a man has no control over his own organization, and not 
 often over his own surroundings, how is it, firstly, that men differ 
 60 widely, and secondly, that they can be held responsible for 
 their acts. 
 
 The answers to these questions appear to be in the first place, 
 no two men are exactly alike, and it is rare to find two men 
 exactly in the same position as to their surroundings, and there- 
 fore, any difference that is observed does not invaHdate the pro- 
 position that men's conduct may differ normally. 
 
 Secondly, since he is the object of his surroundings over which 
 he may have no control, how can a man be responsible. A man 
 is not responsible for any acts over which he has no control ; 
 but he is for those under his control, and if we analyse an act 
 we shall find that he is only responsible for such that arise out of 
 his own organic actions ; the case is put by Miss Martiueau in 
 the words I quote from Dr. Carpenter, as follows : 
 
 "Instinct, passion, thought, etc., are effects of organized substances. All 
 causes are material causes. In material conditions, I find the origin of all 
 religions, all philosophies, all opinions, all virtues, all spiritual conditions and 
 influences, in the same manner that I find the origin of all diseases, and of all 
 insanities in material conditions and causes. I am what I am, a creature 
 of necessity. I claim neither merit nor demerit. I feel that I am as com- 
 pletely the result of my nature, and compelled to do what I do, as the needle 
 to point to the north, or the puppet to move according as the string is pulled. 
 I cannot alter my will, or be other than what I am, and cannot deserve either 
 reward or punishment." 
 
 A great deal of the above sentence is superfluity; such as 
 that which asserts the causes of this and that being material, 
 etc. The gist of the sentence hes perhaps in the last paragraph. 
 " I cannot alter my will" ; of course the will is the man, if 
 altered it would make a different man ; a different man, would 
 probably do differently, at all events he would do as he willed to 
 do. If a man wills to do an act, of course he wills or elects to do 
 the act with all its consequences, and punishment might be one. 
 "I am what I am, a creature of necessity," this is mere verbiage 
 or flourish, and might be put into a more sober proposition, 
 when it would be more intelligible, it means probably only that, 
 I own that the laws of nature are definite. As to not deserv- 
 ing either reward or punishment — since, as he says he cannot 
 
56 LECTURES ON MENTAL DISEASE. 
 
 alter and control the laws of nature or change them, which he 
 admits by his proi)06ition, when he wills a certain course, he 
 wills to take all the consequences, he deserves what he invites, 
 and what he will get, and he does exactly what he wills. 
 
 The passage is scarcely worth quotmg, except as an example 
 of a mistaken idea concerning the faculty of " Will " ; which 
 the writer first '• exalts into a separate entity, and then allows 
 it to tyrannize over his understanding." 
 
 Character. — But undoubtedly there are found in different men, 
 very different powers to act, and each individual has his special 
 characteristic, or in other words the natural characters of men 
 dififer. They differ intellectually, emotionally and morally, and 
 the causes for such variations may be in the organism of the 
 man or in his cu-cumstances or envii'onmcnts. 
 
 The organic causes of difference may be due to different cere- 
 bral development — the gross weight of the organ varies, as a 
 rule, the big cerebrum gives a greater mental power, but more 
 particularly perhaps, the difference of mental power may be due 
 to shape — that is to the preponderance of particular faculties. 
 In one man the faculty of observation is large, the man is a large 
 collector or storer of facts. In another the powers of reason- 
 ing, of estimating differences and likenesses is greater. A third 
 may have both capacities large and be a more intelligent person 
 than the others. 
 
 On the other hand, one man's energies may be feeble, another 
 weak. Such a faculty added to either of the above special 
 endowments would considerable modify the result. One man's 
 emotional faculties may be over sensitive, or duller. 
 
 Especially is the character influenced by a man's appetites 
 and organic feeUngs, bj' his health and strength, etc. 
 
 A man who is possessed of good powers of observation and 
 of reasoning, who is not swayed by his animal appetites and 
 feelings to any degree, will have faculties of the highest char- 
 acter. According to my own personal experience through a 
 long life, when two men are met with who arc equal, or nearly 
 BO, in these respects the one who has the largest power of 
 digestion will prove the best man. 
 
 That on the whole the size of the brain has considerable in- 
 fluence is shown in the weights of the brain in men of great 
 
MENTAL PROCESSES, 57 
 
 mental power, cxamplee of which may be found in any class book 
 on physiology. 
 
 Again it is observed that one faculty is often developed at 
 the expense of another, as when the blind show a develop- 
 ment of musical talent ; and no one can see a body of musi- 
 cal performers without observing how many are obliged to resort 
 to glasses for some defect of sight. 
 
 The substance of the foregoing is as follows : — 
 
 SUMMAEY. 
 
 1 . The organism is acted upon by the environment, and from 
 
 their conjoint action, a movement in the organism is the result. 
 The action from the euwonment to the organism is the afferent. 
 The action at the organism is the central sesthesis. The action 
 from the centre to the environment is the efferent ; the afferent 
 is the sensitive, and efferent the motor effect ; this law pervades 
 the whole neural system, 
 
 2. The afferent may be wholly expended in the motor act as 
 in the simplest reflex act, or it may be partially expended, the 
 remainder may persist, the remanent. 
 
 3. The XDersistent remainder or remanent is dormant until 
 revived by a fresh excitant. 
 
 4. The persistent remanent is recalled by an impression or 
 feeHug of any kind previously associated with it. This property 
 is called the association of ideas. 
 
 5. The persistent remanent when recalled has power to 
 modify the fresh impression from the environment, by strength- 
 ening or weakening it, and thus give greater variety to the dh-ec- 
 tiou of the motor outcome. 
 
 6. The excitant or impression from without may cause plea- 
 sure or pain either directly, or in combination with a former im- 
 pression. Such states are the eniotions and are usually accom- 
 panied by an efferent or motor current of some kind. 
 
 7. Upon the property of the persistence of impressions is 
 founded the faculty of memory, consciousness, emotion, vohtion, 
 perception and the higher intellectual faculties. "The percep- 
 tion of any object is possible only by the classing of a present 
 
58 LECTURES ON MENTAL DISEASE. 
 
 group of attributes and relations with a past group (Spencer, 
 op, cit., p. 330), 
 
 8. The comparison of a present group with a past group is a 
 Juclgmeut. " All mental action whatever may be defined as the 
 continuous differentiation and integration of states of conscious- 
 ness." — Spencer. 
 
 9. Judgments may be influenced by the emotions and emo- 
 tions are influenced as much by the organism as by the environ- 
 ment. 
 
 10. Consciousness of the excitation which precedes the motor 
 result is Will. In the words of Spencer "the difference between 
 an involuntary movement of the leg and a voluntary one is, that 
 whereas the involuntary one takes place without any previous 
 consciousness of the movement to be made, the voluntary one 
 takes place only after it." 
 
Section III. 
 THE PKOCESSES OE DYNAMICS OF Mmi).— continued. 
 
 Dynamics — Gradual Development of Neural Functions — First Effect, Movement 
 the Genesis of a Nervous System — Nature of Neural Force, its Properties 
 — General Scheme of Nervous System — Development of Nerves — Forms of 
 Nervous Systems — the Gang-lion, its Office and Forms — Cells, varieties of 
 — Motor and Sensory — Origin of Neural Current — Nervous Mechanism in 
 Man — Spinal Cord, its Division into Motor and Sensory Columns — its Con- 
 nection with the Cerebrum — Homology of Brain and Cord — Community of 
 their Functions, as shown Anatomically, Pathologically and from a De- 
 velopmental point of view — the Gradual Controlliug Power of the Brain — 
 the Differentiation of Brain and Cord — in their Functions — iu Construction 
 — Automatic Movements — Signification of the Term — Dr. Marshall Hall's 
 views — the Control of Cerebrum showu by Experiment— Functions of Cere- 
 bral Hemispheres — Localization of Functions — Dr. Hughling Jackson's 
 views — Anatomical basis of Intellect — Persistence of Impressions — Inhibi- 
 tion — Synthetical Review of Mental Function — Retlex Acts in Childhood — 
 Subsequent Brain Development — Other Neural Functions ; Co-ordination, 
 Equilibriation, Tone. 
 
 In the next division of our subject we have to consider the 
 dynamics of the nervous system in respect to the mechanism. 
 
 We may proceed upon the same plan, namely, we may com- 
 mence at the lower, which is at the same time the simplest form, 
 and proceed toward the higher organism. I shall here only dwell 
 upon some of the principal matters connected with this subject; 
 as, the nature and operation of the nervous energy, its mode of 
 hberation, and transmission centripetally and centrifugally from 
 the centres from which it emanates, throughout the system gen- 
 erally. 
 
 In the previous pages we have traced the gradual evolution of 
 the mental processes themselves. We have now to follow the 
 mechanism by which these processes are performed. It will be 
 less necessary to enlarge on this subject, since this question is 
 treated from the same point of view in all text books, which is 
 not the case with that aspect of the subject, which we have 
 hitherto been considering. 
 
 In any comparative investigation of the animal functions we 
 assume that there is one general principle extending through 
 
Go LECTURES ON MENTAL DISEASE. 
 
 the whole scries of animals. We also, as already eubmitted, 
 take it as a law that in the gradual development from the 
 lower order to the higlier, this general principle is modified 
 only, and is perfected by a differentiation of function and by 
 specialization of organs. 
 
 We may also lay it down as a postulate, which the preced- 
 ing pages have had the object of establishing ; that the organ- 
 ism is acted upon by its environment, from whence arise the 
 phenomena which we have to consider as mental products. 
 
 We have to consider what the nature of this influence is, and 
 secondly, in what way it acts upon the organism. 
 
 The crude result of the action of the environment on the 
 organism is motion — and this is all that occurs in the lowest 
 kind of action as in a reflex movement. This effect does not differ 
 materially fi-om the action of one inorganic object upon another, 
 and is simply a mechanical distribution of force. There are also 
 like effects produced on inorganic bodies as when a body is said 
 to be expanded by heat, and when two bodies act chemically upon 
 each other, in this latter case there is an entire re- arrange- 
 ment of the molecules. The force exerted upon the organism 
 by different surrounding objects is exhibited in some cases by 
 motion only, and in other cases by molecular changes, as in 
 nutrition and waste of tissues. The acting force in one case has 
 been attributed to chemical affinity — or to be identical with elec- 
 tric force — it has also been called the vital force to mark its 
 distinct species ; and the processes have been said to be due to 
 vital force and chemical attraction. 
 
 One of the differences formerly much insisted upon, was that 
 chemical combinations, (which were considered to be electrical) 
 were necessarily binary, and that the combinations due to vital 
 affinity were. ternary. 
 
 That these forces are not identical seems to be proved by 
 their antagonism, when the vital affinities cease the organism is 
 acted upon by chemical affinity, and its elements re-arranged ; as 
 when dead animal substance undergoes decomposition, and is re- 
 solved into various other products, chemically distinct. 
 
 But the electrical force which holds the elements together in 
 chemical composition, can be isolated as galvanism, and can be 
 conducted through metallic conductors to distant parts. In this 
 
MENTAL PROCESSES OR DYNAMICS. 6l 
 
 there is both resemblance and difference between these forces ; 
 for the power, which dominates over organic combinations, is 
 found to be transmissible through special conductors, the nerves, 
 though it has not been isolated. 
 
 The problem, whether these acting forces are identical or dif- 
 ferent, has naturally become one which has occupied the atten- 
 tion of physicians ; their identity has not been proved, their simi- 
 larity, and the similarity of the laws which govern them, must 
 be admitted by every one. As we find a great difficulty in 
 drawing a line between organic and inorganic bodies, so we find 
 a similar difficulty in distinguishing the phenomena which take 
 place in organic bodies from the changes in the inorganic. 
 And for explanation of organic changes and especially all ex- 
 cretory processes, we still invoke the laws of chemistry. 
 
 The question, however, with which we are now concerned, is 
 the force that we find transmitted through the nerves ; we might 
 of course admit the fact that the nerves convey a force to a dis- 
 tant organ and look upon the enquiry as to its nature as useless, 
 and, it may be worth the while, however, to consider certain 
 opinions which have been broached concerning it. 
 
 It is generally admitted that though the force resembles 
 the electrical it is not electricity. Mr. Herbert Spencer would 
 explain the current to be due to the extreme instabihty of the or- 
 ganic colloids, or protoplasm of which the nerves largely consist. 
 This protoplasm or colloid substance, he supposes to undergo 
 isomeric changes, to which changes all colloids are jDarticu- 
 larly prone. This explanation appears to be only the substitution 
 of one unknown thing for another, and isomeric changes must 
 have somethmg to induce them. The electric current is cer- 
 tainly a good example of transmission of force without change of 
 place, as when in magnetism N — S, N — S, N — S, N — S, becomes 
 S — N, S — N, S — N, by merely reversing the poles, by the 
 approach of a more powerful magnet at the end of the series. 
 A similar change may be instanced as an example in sound in 
 the metrical arrangement of words, when iambs may become 
 trochees, by the ablation of the first syllable, thus AB AB AB will 
 become BA BA BA by removal of the first A and again changed 
 by replacing it. 
 
 The main objection to Mr. Spencer's theory is, that it is a 
 
C)2 LECTURES ON MENTAL DISEASE. 
 
 Bimple chemical change, and chemical changes are electrical, 
 and the phenomena of tlie neural current do not accord with 
 the electrical theory according to general consent of authorities. 
 
 We must in our present state of knowledge, I thhik, either con- 
 sider the nature of the neural transmission as one of those dead 
 walls, which for the present must remain as a houndary of in- 
 vestigation, or he satisfied by saying that it is called "vital 
 force. ""■'= 
 
 If, however, the nature of this neural current or transmitting 
 influence is uncertain, we may investigate its action and some of 
 its chief properties. It has been calculated that normally, the 
 rapidity of neural cun*eut varies slightly in different individuals, 
 and is according to Helmholtz at the rate of about 26 — 27 
 metres per second, or from 29 — 30 yards. The neural current 
 is initiated or started from one of its ends, peripheral or central, 
 and passes to the other. The nerve itself is passive as regards 
 the passage through it, the genesis of the current therefore must 
 be either at the periphery through the apparatus called the end 
 organ, and which has its special organization, or centrally in, as 
 it is believed, a ganglion cell. 
 
 The neural or initiating force is capable of accumulation, and 
 by action for a long time becomes gradually exhausted, this 
 occurs by its natural action ; but it is made more apparent by 
 direct experiment. It is believed also that upon undue accumu- 
 lation of force, explosion or abnormal discharge may occur. It 
 was found that in the experiments upon guinea pigs in which 
 artificial epilepsy was induced, the fit could be produced at the 
 operator's will by pinching the animal's cheek ; the first pinch 
 threw the animal into strong convulsions ; on the animal's 
 recovery, a second pinch produced a convulsion of less severe 
 
 • Lewes arguing upon this point makes the following remarks upon the ori- 
 ginal force in organic bodies (On Animal Automatism, p. 320, et seq., Pliysical 
 Basis of Mind). "Clearly the nature of the forces must be taken into account, the 
 Materialistic doctrine attempts to reduce Biology to a problem of Mechanics," 
 "But vitality and sensibility are co-efficients which must render the mechanical 
 problem insoluble. The Vitalist turns his back on all eyidonce and would explain 
 organic phenomena without any aid from physics and chemistry." " Vital facts, 
 especially facts of sensibility, have factors neither discernible in machines, nor 
 expressible in mechanical terms. "We cannot ignore them, although for analyti- 
 cal parposes we may proTisionally set them aside." 
 
MENTAL PROCESSES OR DYNAMICS. 63 
 
 character, a third still less severe, until after many stimula- 
 tions, no effect followed. 
 
 We may next consider the organism concerned in the trans- 
 mission, which consists in the end organs, the nerves and the 
 central organs. In other terms, there is the apparatus for the 
 liberation of the neural force, consisting of the organs of the 
 special senses ; the organs which convey the action from the 
 environment to the central organs ; the central nerve organs ; 
 the organs which transmit the impulse back to the periphery 
 to muscles, tissues, glandular organs, &c. 
 
 The apparatus when perfected, as in man, has all these organs 
 differentiated, but their genesis may be traced from the lower 
 grades in which, however, the same principles rule their action. 
 
 General principles or scheme of neural functions. — We may trace 
 the process briefly in the following manner: — 
 
 We find that the mechanism by which the animal is put into 
 relation with his envu'onment, and by which the several parts of 
 his organism are brought into unison with each other, is at first 
 of very simple kind ; in this primitive condition it appears to be 
 by simple extension of the impression through the tissues, so 
 that there is a communism in function. When the functions 
 are differentiated, when the organs of nutrition and motion are 
 separated, then only the development of lines of communication 
 becomes necessary. 
 
 There are three types of the arrangement of these "means of 
 inter-communication ; the cu'cular as found in the radiata ; 
 the diplo-neurose in the articulata ; spini-cerebratal as in mam- 
 malia and man ; these are examples of arrangement not differ- 
 ences of principle. 
 
 In the circular form there is uniformity of function through 
 every portion of the animal. In the diplo-neurose there are gan- 
 glions of large size at the head and these surround the cesopha- 
 gceal opening, there are ganglions in both forms placed at more 
 or less regular intervals, and fi'om these points the nerves proj)er 
 arise, thus bringing the creature's eyes and locomotive organ, &c., 
 into direct communication. Such is the apparatus which suf- 
 fices for bringing the various parts of the animal intf» harmony 
 of functions, and for performing the reflex movements which we 
 find in this low organisation. But with this form of enervation 
 
64 LECTURES ON MENTAL DISEASE. 
 
 the movements of complex character are performed and apparently 
 
 are as elaborate, or nearly so, as those which exist in the higher 
 organisms. One of the chief differences between their perform- 
 ance, and that of the higher kind, is the fixity, or as it were the 
 stereotyped character, of the acts. One individual at one period 
 goes through the same action as another, without any accumu- 
 lation of experiences or improvement in the process. The ants 
 of this epoch do what the ants in Solomon's time did. They 
 are, as it were, machines, which when once wound up, go through 
 a given set of evolutions. 
 
 In following the development of the higher functions in mam- 
 malia and in man, we find the mechanism more complex, the 
 distribution of nerves of communication and their consensus or 
 co-ordination in action requu-e other arrangements of more com- 
 plex character. 
 
 This necessity is met by the development of ganghons ; these 
 may be Hkened to stations on a railway — or in railway terms, to 
 junctions, fi-om which anew direction may be initiated in a pass- 
 ing neural current ; and the simile holds good in several respects, 
 for the train may pass through the junction or continue in its 
 original direction, or in fact it may be turned into a branch line 
 out of the primary com-se. 
 
 We have thus developed a step in the differentiation of func- 
 tion and we have the special organs of the ganghon and the 
 nerve, which we will consider briefly in succession and sepa- 
 rately. 
 
 1. Ganglion : — If we may not say it is proved, it seems pret 
 fully admitted, as had been a long time surmised, that the gan- 
 ghon is a most important or chief organ and centre in neural 
 functions. It is not meant by this that it exercises any active 
 or possesses any inherent energy, though it may have the power 
 of exciting or calling forth energy — as exhibited in its connection 
 with a peripheral organ, as muscle, gland, &c. — Its main office is 
 rather in directing, and it has also apparently the power of stor- 
 ing energy, in like manner that a Leyden jar has the property 
 of accumulating electric power. In this latter capacity, it must 
 even arrest the neural energy, for Wundt experunentally showed 
 that a stimulus is both retarded and weakened in its passage 
 through a ganglion. " He interpreted this as proving that the 
 
MENTAL PROCESSES OR DYNAMICS. 05 
 
 cells retard every impulse, whereby they are enabled to store up 
 
 latent force like locks in a canal." Lewes' Flujsical Basis, 
 
 p. 249. 
 
 This property is one on Avhich pr()l)ably much depends, and 
 it will be referred to again in the sequel. 
 
 The ganglion itself has received considerable attention from 
 the physiologist ; and its position, form, and every thing that is 
 known concerning it seem to suggest that its office is one of 
 essential character in the neural processes. 
 
 A ganglion consists of ganglionic cells and the neuroglia. In 
 such sense the whole cortex cerebri and cerebelh, thalamus opti- 
 cus, corpus striatum, and other basal gangha, as well as the 
 grey portions of spinal cord are ganglionic. 
 
 The neuroglia, as its name implies, may be looked upon as 
 the special connective medium of the more essential parts, or 
 the cells and their processes with the vessels of nutrient and 
 functional supply. 
 
 The ganglionic cell is described to consist of a body and pro- 
 cesses. The body of the cell is composed of numerous minute 
 fibrils which form a kind of network, and according to Mons. 
 Luys, the fibrillaa are interlaced " hke the wickerwork of an 
 osier basket." Each cell contains also a nucleus and nucleolus ; 
 the processes of the cell vary in number, some cells are without 
 any and are called apolar, some have one or more and are called 
 unipolar, bipolar, multipolar, &c., the rest of the contents of the 
 cell is considered to be protoplasm. The processes connected 
 with^''' the cells are both branched and unbranched. 
 
 The cells are met with singly or in groups. They also differ in 
 size as well as in shape and complexity, as for example the cells 
 of the anterior horn or motor tract of the cord are larger than 
 the cells of the posterior or sensory tract. The cells of the 
 cerebrum differ in size at different depths of the cortex ; the 
 more superficial are smaller, more ovoid, and many appear to 
 be non-caudate, those of a deeper stratum are pyramidal (or 
 
 * It is obviously a difficult microscopic feat to prove the number of poles that 
 are connected with any given cell, since in a section, -filaments may escape 
 observation by passing out of section downwards or upwards, &c. We niny 
 readily prove the positive existence of multipola;- cells ; the negative proof of the 
 number of poles is impossible. 
 
 F 
 
66 LECTURES ON MENTAL DISEASE. 
 
 parsnip-shaped?), their large extremity directed centrally, and 
 at the upper end terminating in a process or filament, that ex- 
 tends toward the pia mater. Still deeper the colls are larger, 
 and in certain positions are specially large and are known as 
 giant cells. These latter, it should be noted, exist in small 
 quantity only in very young children, hut are specially detected 
 in old people. (See plate I.) 
 
 The fact that the largest cells are found in the motor centres 
 of the cord, has been construed to signify that the tracts of 
 the cerebrum, in which the large cells are found, are motor 
 centres also, which is corroborated by the fact that they are 
 more numerously developed in mature age and in certain locali- 
 ties in the brain. 
 
 The cells of the cerebellum are of different shape from those 
 found in other parts of the nervous system ; they consist also of 
 a body and one process which is branched ; the body is of more 
 rounded form and is without angular projections. These cells 
 are also arranged in a different way, being placed in regular 
 lines between the white and grey matter ; there are also in the 
 cerebellum numerous non-caudate cells, of rather more circular 
 form than those in the cortex cerebri. 
 
 "We are therefore justified in concluding that the functions of 
 these different cells differ, and that their use is of various 
 kinds. 
 
 2. Nerves : — With respect to the nerves and their office, the 
 nerves are simply conductors through which inter-communication 
 is made between the different organs of the body ; they exercise 
 no function which may be called energy. The current through 
 them can pass either way, as shown in the well-known experi- 
 ment in which a rat's tail was first grafted by its tip into the back 
 of the animal and afterwards severed at its root, and the neural 
 current was re-established passing in an opposite direction to 
 its normal course. 
 
 There seems no doubt, however, that the amount of energy or 
 if we liken it to a current, the strength of the current may vary 
 in degree in a nerve, if we measure its power by the different 
 degrees of action that result from its influence, and there is evi- 
 dence adduced to show that energy accumulates in its onward 
 course. The neural current, however, may probably be increased 
 
MENTAL PROCESSES OR DYNAMICS. 67 
 
 in its rapidih' by rei^etitiou of its initiating stimulus, rather than 
 by its actual power. It may, however, also be wholly and per- 
 haps partially weakened by inhibitory action, to be considered 
 further on, and by this means vary in its power. The increase 
 of muscular power, or the increase in a glandular secretion, &c., 
 must be due to the muscle when the increased power is motion, or 
 to the state of the glandular organ when the increase is in that 
 dii'ection. 
 
 But since the nerves conduct in both directions or from the 
 periphery to the centre and from the centre to the periphery, the 
 fountain of this hberated energy must be either in these peri- 
 pheral end organs or in the central organ. 
 
 Dii-ect experiment has shown that the nerve current does not 
 gain strength but rather the contrary, in passing through a gan- 
 glion (see ante p. 64) ; if we accept this view of Wundt, then 
 the ganglion has no influence in the genesis of the neural force, 
 but acts more as a storage for it. It follows that we must 
 look for the genesis of the neural force in the peripheral end 
 organs. 
 
 It is also in the anatomical arrangement of just these special 
 organs that we find the apparatus for receiving and intensifying 
 external impressions ; the optical and auditory apparatus are 
 both formed on mechanical principles to collect and intensify 
 their particular excitant. So again is the dermal surface, for 
 receiving the sensory impression of touch, as is obvious to every 
 tyro in physiology. 
 
 Our review of the whole subject so far points out, how in the 
 higher animals the environment of an individual acts upon the 
 special organs of sense, and thus initiates or liberates the neural 
 force, which is propagated along the nerves to the central gan- 
 glion, from Avhence the neural force is distributed. 
 
 The neural force may be sui rjcn^ris or analogous to the chemi- 
 cal force, which performs the same function for organic opera- 
 tions that the electrical force does for inorganic combinations ; 
 in our present state of knowledge concerning it, we simply give it 
 a distinctive name and call it the neural force. It, however, is 
 clearly an attribute of the organism ; so that the proposition 
 that vital actions are due to the conjoint action of the organism 
 and the environment still holds good. 
 
 f2 
 
68 LECTURES ON MENTAL DISEASE. 
 
 Examinalion of the yerve Functions ; 1. AnaUjticalbj; 2. Syntheti- 
 cally. — J. Analytical Kxamination of Nerve Functions. We have 
 now to consider liow these general i)rinciples are speciahsed to 
 perform the various functions of hfe which we call nervous or 
 mental in man. 
 
 We shall do well in studying the centres of the higher facul- 
 ties, to commence with an examination of the spinal cord. Not 
 only because this is pursuing our prescribed course in proceed- 
 ing from the lower to the higher, but particularly because the 
 physiology of the cord has received more attention of late and 
 has been studied with much success, and the neural functions of 
 the cord may afford us a key to the brain functions. 
 
 The following functions of the cord are recognised ; for the 
 description of which I avail myself of the work by Dr. B. 
 Bramwell on Diseases of the Sjnnal Cord. 
 
 The spinal cord may be looked upon as consisting of a num- 
 ber of segments. Each being as it were a separate organ for a 
 definite area, to which its roots proceed, whether skin, muscle, 
 mucous membrane, viscus, &c. Each segment consists of a 
 double set of organs, arranged side by side ; each segment may 
 be described as a disc of nervous tissue to which a pan* of spinal 
 nerves is attached; each nerve arising by an anterior and 
 posterior root ; the halves are sepai'ated by the anterior and 
 posterior fissures. 
 
 Li this anatomical arrangement we perceive the separation 
 into the sensory and motor organs, and viewed with regard to 
 the functions, we have the primitive mechanism necessary for a 
 simple reflex action such as we find in the lower organisms. 
 
 But in a segment of the cord, there are other organs besides 
 the mechanism necessary for a reflex action. We have besides 
 the sensory and motor ganglion cells, certain fibres which form 
 the roots of the afferent and efferent nerves, and which are 
 mostly horizontal in their direction ; and other or perpendicular 
 fibres which connect segment with segment, which also can be 
 tr iced upwards and downwards. 
 
 These perpendicular fibres may be described as forming bun- 
 dles and columns which are an-anged side by side, and form 
 three principal columns on each lateral half of the cord. Each 
 of the three columns is further divisible into secondary columns, 
 as shown in the accompanying diagram. 
 
MENTAL PROCESSES OR DYNAMICS. 
 
 69 
 
 These separate portions of the cord are not only divided by 
 then- anatomical characters, but physiologically by performing 
 separate functions, as determined both by experiment and patho- 
 logical observation. The functions of the different columns are 
 as follows ; dividing each half of a segment into three parts, 
 we have the posterior third as a sensory tract, the two remam- 
 ing thirds motory. 
 
 Fig. 1. 
 
 AH Anterior Horn, ph Posterior Horn. AC Anterior Column. LC Lateral 
 Column. PEC Postero-External Column, ric Postero-Internal Column. 
 
 The sensory tract, or posterior column, or that portion situated 
 between the posterior median fissure and the posterior cornu of 
 grey matter, is further subdivided into two parts, which Dr. 
 Gowers has proposed to call postero-internal pic and postero- 
 external columns pec, (the internal being the column of Goll, and 
 the external formerly called the column of Burdach.) The 
 postero-internal portion of the sensory tract is smallest in 
 the lumbar region, and gradually increases upwards towards 
 the cervical. From this circumstance it is evidently an ascend- 
 ing tract, increasing as it reaches its destination and collecting 
 the impulses on its way. This column in its internal portion 
 has fibres connecting it with the posterior grey cornu and the 
 grey commissure. 
 
 The postero-external portion is said to bo composed of 
 
70 LECTURES ON MENTAL DISEASE. 
 
 fibres passing inwards to the posterior cornu, and of the fibres 
 of the roots of the nerves which pass through it, and conveying 
 impressions resulting in sensation " probably of touch and pain" 
 (Bramwell), and also afferent fibres for reflex, movements " in- 
 cluding probably the deep reflexes " (Bramwell), as knee-jerk, 
 and foot clonus. 
 
 Motor tracts (1 and 2), these constitute the rest of the white 
 matter of the cord, and occupy two of the three portions into 
 which the cord is artificially divided ; the motor tracts therefore 
 occupy the anterior and lateral columns. The lateral column 
 Lc is composed of thi-ee portions, or according to some four, viz. : 
 anterior lateral lc3 ; cerebellar tract lc5 ; and posterior lateral 
 Lc4, which is the crossing portion of the pyramidal tract, or 
 crossed pjTamidal tract ; the fourth enumerated hes between the 
 latter and the cornu ; the functions of the anterior lateral and 
 the fourth are uncertain. 
 
 The anterior column ac is wholly motor and consists of two 
 portions, the column is divided from its feUow by the anterior 
 fissure, which extends to the commissure where the cornua 
 meet; the trac.t which lies internal or next to the fissure, the in- 
 ternal anterior acI tract, is narrow and constitutes the uncrossed 
 or du-ect pyramidal tract, the other tract or external anterior is 
 also motor ac2. 
 
 Besides the perpendicular columns there are numerous hori- 
 zontal fibres to be obsei-ved in each segment ; some being due to 
 the course of the roots of the nerve of which they consist, and 
 others being the fibres which connect segment with segment. 
 
 Besides these white columns, an important portion of the seg- 
 ment consists of the central columns of grey matter, which on 
 these transverse sections constitute the cornua, these ai-e com- 
 posed of grey matter and contain ganghon cells imbedded in 
 neuroglia. In the anterior cornua the ganglionic cells are larger 
 and are the motor cells, those of the lesser cornua are smaller 
 and more spindle-shaped, and are considci-ed to be sensory. 
 These cells are caudate and difi"er from the cells of the cerebrum 
 principally in size, and in having a more stellate form : they are 
 collected into groups, the arrangement of those groups varies at 
 different levels of the cord ; besides gi'oups which occupy the 
 anterior horn in the dorsal and lumbar regions, there is a dis- 
 
MEiNTAL PROCESSES OR DYNAMICS. 7 1 
 
 tinct group situated near to the central canal, called the vesicular 
 column of Clarke ; the ganglionic cells are largest in the lumbar 
 region and fibres of white matter connect the columns of Clarke 
 with the cerebellar tract described. 
 
 Relations of Cord and Cerebrum considered anatomically, patholo- 
 gically and by embryology. The most interesting point connected 
 with this differentiation of the cord is in its relation to the 
 cerebrum ; these various columns of white and grey matter can 
 be traced uxDwards to their connexion w^ith different parts of the 
 cerebrum ; on tracing this relation a few words relative to the 
 medulla will be necessary. 
 
 The continuation of the cord upwards is by connexion 
 with the medulla oblongata, cerebellar, and cerebral or basal 
 ganglions, the corpora striata, thalami optici, corpora quadrige- 
 mina, and cerebral hemispheres ; which shall next be briefly 
 reviewed. 
 
 The medulla oblongata or superior termination of the cord, 
 consists of the continuation of the different columns of the cord 
 upwards. It will be remembered that after reaching the fora- 
 men magnum of the skull, the cord slightly expands and is called 
 the medulla oblongata. This increase of size being partly due 
 to the addition of fresh developments, as the olivary bodies, but 
 partly also to a spreading out laterally of the columns correspond- 
 ing to those of the cord ; these columns have unluckily received 
 different names in this part of their course and are called often 
 the anterior pyramids. 
 
 Posteriorly, or in the sensory region, the cord is, as it were, 
 sht open and the central commissure laid bare ; the postero-in- 
 ternal columns of Gowers are here called the posterior pyramids, 
 between these and by their separation a triangular space is left 
 called the fourth ventricle, which is in fact the central foramen of 
 the cord. The postero- external columns of Gowers lie external 
 to these posterior pyramids, and are here called restiform bodies. 
 The destination of these columns is doubtful, it is affirmed by 
 some that the two become blended and pass as inferior pedun- 
 cles into the cerebellum ; " but Burdach and Arnold affirmed 
 that the postero-internal ascend to the cerebrum." (Quain). 
 
 But the anterior or motor columns of the cord, at the lower 
 part of the medulla, decussate with their fellows from the oppo- 
 
72 LECTURES ON MENTAL DISEASE. 
 
 site side, and pass through the pons Yarohi where they form 
 connection %\'ith the grey matter of the pons, and with the trans- 
 verse bundles which proceed from the lateral lobes of the cere- 
 bellum ; the course of the tracts is traversed by the roots of 
 some of the cranial nerves, in their passage to the medulla 
 oblongata (Ferrier). 
 
 " Beyond the pons Varolii and reinforced by fibres derived 
 from it and its connections, the anterior tracts appear as two 
 peduncles or limbs, the crura cerebri ; these slightly diverge in 
 their upward course. On the posterior aspect of the crura, and 
 anterior to the cerebellum, are situated certain ganghonic masses, 
 termed the corpora quadrigemiua or optic lobes," (Ferrier). 
 This description from Dr. Fen-ier, it may be pointed out, is of 
 the course of the posterior spinal column, or from a back view of 
 the sensory tract, the additional developments to be mentioned 
 hereafter are necessitated by the corresponding elaboration of 
 the sensory functions. 
 
 The spinal columns, motory and sensoi-y, up to a certain 
 point, are thus united in their upward course, but on reaching 
 the interior of the cranium their perpendicular position is 
 converted of course into a more horizontal one. " In the crura 
 there is a distinct separation betiveen the sensory and motor tracts, 
 the lower or inferior (crusta or basis) being the motor, and the 
 upper or superior {tegmentum) forming the sensory tract. 
 The two being separated from each other by a layer of dark 
 coloured nerve cells called locus niucr. The teijmentwn or sen- 
 sory tracts also contain, or enclose, a mass of nerve cells called 
 the red nucleus, which is in connection with the cerebellum and 
 corpora quadriyemina." 
 
 The crura cerebri pass into the two great basal ganglions, the 
 optic thalamus, situated anteriorly, and the corpus striatum 
 behind it. The sensory tracts pass into the thalamus and the 
 motor tracts of the crura pass into the corpus striatum ; fi-om 
 these the white fibres radiate in the form of a hollow cone called 
 corona radiata, and by their expansion, when covered by the 
 grey matter of the cortex {coiiche corticale of the Fre;ich). form 
 the surface of the cerebral hemispheres. The upper part of the 
 crus connected with the sensory functions, was named by the 
 old anatomists the tegmentum, and the lower part the foot, and 
 
MENTAL PROCESSES OR DYNAMICS. "J T, 
 
 is connected with the motor functions. "Anatomically con- 
 sidered the optic thalamus is the ganghon of the tegmentum, and 
 the corpus striatum the ganglion of the base or foot." (Ferrier). 
 
 As the white fibres emerge from the thalamiis and corpus 
 striatum, they are called the diverging fibres ; besides these, 
 which are arranged m a radiating manner, there are others 
 which pass from front to back, and across or laterally, connect- 
 ing the distant parts of the same hemisphere together. 
 
 There are certain portions of the cerebral hemisphere which 
 have received considerable attention of late years in consequence 
 of their connection with certain lesions which affect both spinal 
 and cerebral functions simultaneously, and which it will be in- 
 teresting to follow, since they connect the whole neural system 
 into one common apparatus. 
 
 Before entering upon the subject of the cerebro- spinal con- 
 nections, I would remark, that physiology and that part of it 
 which has been called teratology, leads to the conclusion, that 
 the skull may be considered as a homologue of vertebrte, and 
 to consist of the elements of four vertebrae : — viz., 1. the 
 nasal ; 2. frontal ; 3. parietal ; 4. occipital ; and the different 
 cranial nerves have their analogues in the spiaal nerves. Each 
 of these segments has its corresponding portion of nerve gan- 
 glions and homologues of the cord."^- 
 
 The observation is of interest as bearing out the principle of 
 uniformity that pervades the entire animal creation, and we 
 are justified by it in viewing the cerebrum as a modified and 
 higher differentiation of the cord, and to be the elaboration of so 
 many segments of it ; thus we may look upon the white matter 
 of the cerebrum as continuation of the six columns of the cord, 
 expanded from its bulbar end. The grey columns accompany- 
 ing the crura or columnar expansion, occupy the same position 
 as locus nifjer. The posterior horns increased in size become the 
 tubercula cinerea ; the grey commissure of the cord, as the 
 white columns separate, is exposed at the back of the meduUa 
 as the floor of the fourth ventricle. 
 
 2. Emhryological evidence of the cerebro- spinal connexions. — But 
 there are certain other facts in connection with pathology 
 and embryology, which thi'ow considerable light upon the com- 
 
 * This qaestiou was treated in au article by Dr. Ilugliliugs Jackson. 
 
74 LECTURES ON MENTAL DISEASE. 
 
 munism of function between the cerebrum and cord, which will 
 well deserve attention. 
 
 The first of these is in connection with the internal capsule, 
 as it is called. 
 
 It is found that any lesion of the capsule in its anterior two- 
 thirds, causes hemiplegia on the opposite side of the body with- 
 out anaesthesia ; while rupture or lesion in the posterior 
 one-third portion, causes hemi-anaesthesia ;* thus clearly show- 
 ing that both sensory and motor fibres are contained in this 
 part, which as we know is an extension of the crura, and that the 
 tracts are distinct ; the motor occupying as in the cord the an- 
 terior, and the sensory the posterior position ; also as regards 
 this motor tract itself, physiologists are able to trace distinct 
 connections between this part of the cord with a cerebral region. 
 In the cord there are, as stated, two j)yramidal tracts — one direct 
 and the other the crossed pyramidal tract (the first 1. and the 
 second 5. in the diagram). In the new bom child, if a section 
 of the cord be treated with osmic acid, these particular tracts 
 alone are stained, the rest of the section remains clear ; these 
 tracts are thus by a histological test proved to be similar in 
 properties. In the new born infant the cerebrum is in a very 
 rudimentary condition, and the functions of the nervous system 
 are in a manner exclusively concentrated in the medulla and 
 spinal cord (Billard quoted by Charcot). At this early period 
 such acts as are accomplished, however complex (as in suckmg), 
 are purely reflex ; that such acts are spinal the case of the an- 
 encephalic infant, who will suck, proves. 
 
 . These pyramidal tracts by the action with the osmic acid 
 show an earlier development than the rest of tlie cord, and they 
 are stained because their myeloid sheaths are developed, which is 
 not the case with the other columns. The pyramidal fibres 
 may be traced through the pons to the crus cerebri ; before 
 reaching this part they decussate with their fellow of the op- 
 posite hemisphere. In the pons the nerve elements, which had 
 previously formed the bulbar pjTamids, intermingle with the 
 spinal fibres of the pons, and as it were, emerging from the 
 pons become parts of the crura cerebri. 
 
 • Charcot. Localisation of Cerehrai Diseases. Translated by Dr. Hadden, 
 New Syd. Soc, p. 85. 
 
MENTAL PROCESSES OR DYNAMICS. 
 
 /3 
 
 The crus cerebri is here composed of an upper and lower por- 
 tion, the former called the tegmentum and the latter the foot, as 
 ah-eady stated. In the foetus or newly born child, the foot may 
 be distinguished as consisting of three segments, internal, exter- 
 nal and middle ; in the two first, the medullary sheaths are not 
 yet developed, and on treating with osmic acid remain clear ; 
 the middle segment is rendered opaque, and this opaque portion 
 is according to Flechsig, the re-arranged prolongations of the 
 pyramidal tract. " This," says M. Charcot, "is unquestionally 
 important, since it seems to indicate that the development of 
 the pjTamidal tracts proceeds from the cerebrum proper." 
 
 "The pyramidal tract may be followed beyond the foot into the 
 cerebral hemisphere, and its presence can be recognised in the 
 opto-striato ganglionic masses in the region called the internal 
 capsule, which is in short, at least to a considerable extent, no 
 other than the expansion of the fasciculi which form the lower 
 layer of the crura," Charcot, op. cit., p. 177. The pyramidal 
 tract may be traced upwards even to the grey cortical matter of 
 the convolutions and terminates in what is called the motor zone, 
 " paracentral lobuli or upper extremity of the ascending frontal 
 and parietal convolutions." (See j)late I.) 
 
 The above is Flechsig's account as quoted from Charcot, who 
 adds, that his conclusion requires confirmation in more than one 
 point. Professor Parrot examined this question by testing it in 
 ninety-six autopsies of children under one year ; the only differ- 
 ence would appear to be, that the latter observer considers that 
 the development of the motor tracts of the cerebrum jiroceeds 
 from more than one centre, and proceeds gradually downwards. 
 
 ■3. Cerebro-spinal connexions as sJwicn by pathology. The same 
 connection or community of function between cord and cere- 
 brum, is shown pathologically, by what are called the secondary 
 lesions of the cord ; that is when a lesion of any kind, which 
 may affect the cerebrum, leads to a secondary degeneration 
 below in the course of the tract by which it is connected with 
 the cord ; or wiien disease of the cord or atrophy of an inferior 
 portion leads to degeneration above. It is found that these 
 secondary lesions of the cord, on the pyramidal tract, only occur 
 when the primary lesion is in the anterior two- thirds of internal 
 capsule ; they never occur when the lesion invades the posterior 
 
76 LECTURES ON MENTAL DISEASE. 
 
 third ; and this obviously is the reason, that in one case the 
 neural current is centrifugal, and therefore the function of the 
 parts below are interfered with ; in the other case, the current is 
 centripetal, and therefore it has no effect on the point below, thus 
 showing also that the differentiation of function in brain and 
 cord are similar. 
 
 The connection or identity rather, of the cord and cerebrum, ia thus 
 made clear hy anatomical and pathological investigations, as regards 
 both motor and sensory functions. 
 
 That the development of the cord advances prior to that of the cere- 
 brum. A very important question, as pointed out in the foregoing 
 quotations and remarks, is that the development of the cord ad- 
 vances prior to that of the cerebrum. Comparative anatomy might 
 have led us to suspect this. We readily admit that the higher 
 intelligence in animals corresponds with the greater development 
 of the brain. The intelligence of animals stops at a given point, 
 and the development of their brain is finished at a correspond- 
 ing degree of perfection. 
 
 We know that complexity of movements with co-ordination 
 of the various motor impulses, occur in the lowest kind of or- 
 ganisms; there are also sensori-motor developments as indi- 
 cated by expression of pain and discomforts, as well as by move- 
 ments to escape from pain ; there is also the exhibition of choice 
 of food and many very complex operations in the very lowest 
 animals. And at a certain period of the child's life we find 
 the intelligence or the mental functions on a par with such sim- 
 ple manifestations. Before the brain is developed and even in 
 the anenceplialous infant, it has been established that the child 
 is capable of performing certain complex and co-ordinated mo- 
 tions as in the operation of sucking ; it is therefore obvious that 
 such functions are performed through or by the means of the 
 spinal cord. In observing the gradual development of the child, 
 we find that all the first signs of life are of the same kind, the 
 crying, sucking, evacuation of the dejections, the rolling of the 
 ej'es, movements of the Hmbs, are clearly of the character of 
 spinal reflex motions, and excited through the usual channels of 
 sensory centres. We may note also the fact, that in the fre- 
 quent crying on any uneasiness, the sensations, especially of the 
 skin, are perfectly developed. 
 
MENTAL PROCESSES OR DYNAMICS. 77 
 
 By degrees the child begins to direct its eyes more regularly, 
 then also to move its arms and legs with gradually increasing 
 evidence of purpose ; though still we witness the predominant 
 excited or reflex movements in the contortions of the features 
 and eyes in any slight gastric disturbance. And we know that 
 up to a term of several years, a child is particularly prone to 
 affections depending on the spinal centres, as to infantile con- 
 vulsions ; while he has but feeble control in checking all ex- 
 cited actions, as by crying when hurt, in falling, or even when 
 hungry or uncomfortable in any way. 
 
 It corresponds with the period of the completion of the brain 
 centres, that these excited reflex centres are first more con- 
 trolled; that the child begins to control its evacuation to a 
 given time ; that it can wait more readily for its food ; and 
 gradually to acquire its full powers of volition. 
 
 Thus the brain becomes gradually a controlling power. 
 
 With this increase of function consciousness is also established. 
 The higher mental powers are also slowly developing, and it 
 is not till the age of puberty, that the faculties can be said to 
 reach their completion. 
 
 The Differentiation of the Neural functions into cerebral and spi' 
 nal. The foregoing facts have been chiefly brought forward to 
 show the intimate connexion that exists between the cerebrum 
 and spinal cord, both with regard to their functions and their 
 anatomical substrata. 
 
 We may now proceed to view the question from the opposite 
 point of view, and to examine the distinction between the func- 
 tions of these organs. 
 
 Facts gleaned from pathology and experimental physiology 
 abundantly show the difference of influence of these centres as 
 regards one faculty — that is, consciousness. 
 
 We may premise that states of consciousness and uncon- 
 sciousness exist in different degrees as already shown, and we 
 may also divide them into kinds arising from different causes. 
 
 Consciousness naturally is subject to a certain degree of 
 periodicity — as in sleep, when it is in greater or less abeyance. 
 During perfect sleep all functions which are performed con- 
 sciously or which when they take place are attended by conscious- 
 ness, as Volition, Emotions, Memoiy, Ideation, cease; while those 
 
7iS LECTURES ON MENTAL DISEASE. 
 
 of ^vllic•ll \vc arc uiiconsciouB, or less conscious, continue undis- 
 turbed, as the action of respiration, of blood circulation, the 
 tonic contraction of the sphincters, and certain other so-called 
 automatic actions. 
 
 Mr. Durham, taking note of what occurred in a patient, who 
 had a portion of his brain exposed by a fracture of the skull 
 found, that as the patient dozed the brain grew pale, receded, 
 and shrunk, and on waking the brain gradually swelled 
 afresh, and discharged before it a quantity of serous fluid. This 
 experiment is as satisfactory as any in experimental physiology, 
 it shows that sleep has a marked effect in the cerebral organ, 
 and that it depends upon a lessened supply of blood to the 
 brain. 
 
 Sleep then, is a natural condition of unconsciousness, having 
 for its anatomical substratum a state of anaemia, or spanfemia. 
 
 A similar state of unconsciousness is produced also by the 
 sudden abstraction of blood, especially while the patient is in the 
 erect posture, the older physicians used to prescribe venesection 
 in the standing position ad deliquium animi, the patients usually 
 recovered on being laid on their back. That the functions of 
 respiration and other spinal movements continued, showed that 
 the brain function was alone arrested, and that the cord was 
 isolated from its immediate co-operation with it. 
 
 The above instances are of two kinds, and the »wdus operandi 
 was different in them ; in normal sleep the ch-culation was arrested 
 by the vaso-motor nerves, and probably by their centres becoming 
 exhausted. The other case was due to a direct deficiency of blood 
 produced artiQcially ; this loss must be sudden to produce the full 
 effect, for a simply deficient supply, only lowers the activity of 
 the cerebral function, affecting its energy especially in its func- 
 tion of memory, or the reproduction of a former impression : as 
 when anaemia occurs in exhaustive diseases after fevers, or in old 
 age, when the neural energy or activity of neural discharge is 
 lessened. 
 
 But in certain other cases, the cerebral function is cut off by 
 distinct lesion, as by compression of the brain, and in some 
 cases temporarily by concussion also. The well authenticated 
 cases of men who have lived for years in the state of mere autom- 
 atons and have boon suddenly restored by trepliining are well 
 
MENTAL PROCESSES OR DYNAMICS. 79 
 
 known ; in these cases the brain -function has been suppressed 
 by compression on the cerebral surface. Many of those persons 
 were able, nevertheless, to perform very complicated and higlily 
 co-ordinated movements, but entirely without knowledge of the 
 fact ; and on being restored, awoke with a period of their life 
 completely a blank in memory. So that not only a lesion affect- 
 ing the blood- supply, but one acting on the nerve-tissue more 
 directly, throws the cerebrum out of action. 
 
 Even without gross lesion, or mechanical injury, we ob- 
 serve the same state of unconscious existence to be pro- 
 duced by an excessive neural discharge, as in different kinds 
 of epileptic seizure. In the cases of p^tit vial or grand vial, 
 we have in fact the different functions of the brain as it were 
 analyzed before our eye. In some slighter attacks there is, as 
 Dr. Hughlings Jackson reasons, different degrees of discharge or 
 discharges of different areas, and affecting portions of the brain 
 in different and corresponding degree, producing in some a false 
 sensation — an aura — in some, visions of colour; flashes of light; 
 in some, a taste ; and going on to motor discharge in cramps, 
 convulsions, &c., and when the discharge is from the highest 
 centres, unconsciousness. 
 
 The action of anesthetics might also be cited, but the exam- 
 ples already instanced will suffice. 
 
 The foregoing facts, at all events, show that consciousness is 
 a cerebral function, and since without consciousness all the 
 chief purely psychical functions could not exist, as Emotion, 
 Volition, Perception, Memory, they afford proof, if any were 
 wanting, that all the higher or true intellectual powers depend 
 on the brain solely. 
 
 There are, however, several functions to which we have not 
 yet alluded, which require examination, and which depend on 
 the action of the Brain and Cord conjointly or separately. 
 
 The spinal cord, besides being the centre of reflex movements 
 has, it is believed, also trophic nerves or centres to control 
 many of the vaso-motor functions. We have less to do with 
 these from our special point of view except to indicate how a 
 moral impression may act through these centres in producing 
 those perturbations that Bain points out as accompanying all 
 emotional feeling, as blushing, acceleration of pulse, palpita- 
 
8o LECTURES ON MENTAL DISEASE. 
 
 tion, micturition, &c., and which are doubtless all spinal; and 
 hence they are more prone to occur in early life than in mature 
 age, and in the woak-minded rather than what is called strong- 
 minded ; or in other words, in those in which the lower centres 
 are less under the control of the upper centres. But these in- 
 dications come chiefly under what have been called the auto- 
 matic movements, on which we must make some reference here. 
 
 Automatic Movements. — It has been the fashion of late to class 
 many of the spinal reflex movements under the head of auto- 
 matic. The term automatic has, I consider, been an unfortu- 
 nate introduction, and has come to mean in some people's 
 notions, movements without cause, or without a substratum of 
 a physiological process. 
 
 When this term was first employed I beHeve it was apphed to 
 those movements which, though at first obviously acquired by 
 conscious efforts, and only by close attention, become by fre- 
 quent practice and repetition more frequently executed without 
 attention, or scarcely with consciousness, such as walking, or as 
 in forming the letters in writing, striking the notes on a piano, 
 which people, after a long practice, are able to do while talking 
 or thinking of a perfectly different subject. 
 
 The word " automatic"* is certainly not very appropriate for 
 such performances, except it be used metaphorically, or as a 
 simile signifjdng that persons know as little of their actions as 
 would an automaton toy. It was only subsequently that the 
 term was made to include other actions, such as breathing, car- 
 diac and peristaltic movements, wdnldng, swallowing, coughing, 
 flying, and such necessary functions which have the appearance 
 of spontaneous initiation ; while the acquired movements first 
 mentioned arc called secondarily automatic. The term in my 
 opinion is a mistake and implies a power of which there is no 
 proof, the words reflex or excito-motor introduced by Marshall 
 Hall were applied or invented for these phenomena and especi- 
 ally for the primary automatic. He showed in his lectures, 
 which I attended, a frog. " You observe this frog, its voluntary 
 and sensory functions are obvious. I ddviAe the spinal marrow 
 below the occiput, with these scissors, all is still ; there is no 
 
 • Lewes in a chapter ou Automatism remarks that the word "Automatic" 
 is an unfortunate mctnplior wliicli has led to the theory of Automatism. 
 
MENTAL PROCESSES OR DYNAMICS. 8l 
 
 trace of spontaueoiis motion. The animal would remain in tins 
 very form and position without change, until all signs of vitality 
 were extinct. But now I pinch a toe with the forceps ; you see 
 how both i^osterior extremities are moved. All is now still 
 again, there is no spontaneous motion, ?io sign of ^min from the 
 wound in the neck. It is without sensibility, without vohtion ; 
 the power to move remaining, the will is extinct. I now pinch 
 the integument. You observe the result, the immediate re- 
 currence of excito-motory phenomena. I now destroy the 
 whole spinal marrow with this probe. It is in vain that I 
 pinch the toes, the animal, the limbs are motionless," (Lectures 
 on the Nervous System, § 30). Such phenomena as these, which 
 Dr. Marshall Hall quoted to explain what are now often called 
 automatic actions, clearly are excited actions. 
 
 The gradual sovereignty wliich the brain acquires, as it comes 
 to maturity, over all spinal or excito-motory actions, is shown 
 in various ways, and defective control is often exhibited when 
 the brain is diseased as in insanity, but more distinctly is this 
 action of cerebral control illustrated in certain lesions in which 
 a physical separation of brain and cord occurs, and voluntary 
 movements are annihilated, and all the reflex are in excess, 
 a condition which is found in certain affections of the nervous 
 system in which the reflexes are exaggerated. 
 
 In man not only can the cerebrum control the reflex spinal 
 movements, but it is obvious to everyone in his own person that 
 it can initiate them. In ordinary cases it is probable that 
 walking, for example, is mainly performed, as to its neural 
 force, through the lower centres and the cord, that is, when 
 one performs the feat without attending to it, when it is auto- 
 matic according to the original meaning of that term. When a 
 person in walking has to avoid certain obstructions the action 
 becomes a conscious and a cerebral act, but it is very well 
 known that in certain cases of compression of the brain, and 
 in certain states of epilepsy, that complicated actions do occur 
 quite unconsciously, as they do also in sleep-walking. But 
 direct experiment has been invoked to illustrate the same point. 
 
 By removal of the cerebral hemispheres. Dr. Ferrier found 
 in animals the result to be, that whereas an animal with 
 " brain intact exhibits a varied spontaneity of actions " not 
 
82 LECTURES ON MENTAL DISEASE. 
 
 obviously conditionetl by present impressions on the organs 
 of sense, after the removal, it moved only by excitation of 
 its aflforent nerves, that is in other •words, its actions were 
 reduced to simple reflex acts. He found that animals de- 
 prived of the cerebral hemispheres besides being able to maintain 
 their equilibrium, are also capable of locomotion in their usual 
 manner. He also inferred from experiment (p. 69) that ani- 
 mals deprived of consciousness by removal of the cerebral hemi- 
 spheres gave indications of pain : the removal, "was found to 
 have no effect on vision, nor on hearing, nor upon co-ordination 
 and maintenance of the equilibrium, (p. 64, § 27.) 
 
 It is not so, however, when certain lower centres or the cor- 
 j)ora quadrigemina are u-ritated or removed, these con-espond 
 to the optic lobes of inferior animals and constitute the chief 
 part of their encephalon. Dr. Ferrier concludes by remarking 
 that electrical irritation of the corpora quadrigemina gives rise 
 to effects mainly of reflex character which depend on the trans- 
 ference of irritation of sensory to motor centres. 
 
 At this point, therefore, may we make the anatomical division 
 between these lower centres and the higher centres existing in 
 cerebral hemispheres. 
 
 As regards the purely cerebral function the cerebral hemi- 
 spheres have been .the subject of du-ect experiment in this coun- 
 try and abroad; Dr. Terrier's work on the Brain gives the 
 results of his o-\^ai investigation and that of others. 
 
 His experiments are now well known, and speaking in very 
 general terms, they showed that irritation of given points of the 
 cerebral surface was uniformly followed by a certain motor act. 
 I am disposed to bcHcve that with regard to the centres of 
 special functions mapped out on the hemisj)heres, the proper 
 conclusion to be drawn from a consideration of all the circum- 
 stances connected with them, is that such centres are the usual 
 foci of given movements. To say that they are the real organs 
 of the particular movements, is going beyond what experimenta- 
 tion proves, and beyond what I believe is claimed for them. 
 
 For firstly, as a pi-inciple of uexwe action, it is well recognized 
 that the current is continuous, that is, a sensory nerve at the peri- 
 phery communicates through its central organ to a motor nerve 
 going to the periphery, in other terms, there is afferent centrum 
 
MENTAL PROCESSES OR DYNAMICS. 83 
 
 and efferent, and motion must follow excitations in any part 
 of this tract. Excitation of tlie peripheral termination of the 
 sensory terminates in movement, so the excitation of any part 
 of the nervous loop produces the same effect. Of course this was 
 well known to the experimenter, and all that the experiments can 
 bear out, is that certain points indicated in different parts of the 
 cex-ebral surface produce the most uniform results. 
 
 Again, the chief thing that the experiments on the lower 
 animals show, is the movement of limbs, eyeballs, ears, etc., 
 all of which phenomena together will go to form a very scanty 
 catalogue of mental functions. It is not, I am quite aware, 
 supposed that they do show psychical functions. Yet, the parts 
 connected with the limb movements, occupy a great portion of 
 the whole, while limb movements are but primitive nerve func- 
 tions compared to psychical. 
 
 These mapped out centres, therefore, can only be looked upon 
 as points on the usual paths, along which there is least resist- 
 ance, and are the mechanism by which the tendency for a nerve 
 current to travel in the paths previously traversed is shown 
 anatomically. 
 
 And that they are only such is corroborated by various well 
 known facts. It has been observed, that though destruction of 
 a centre is followed by paralysis of the particular function in the 
 lower animals, they soon re-acquire that function. 
 
 Again, if these particular points were so many centres — bo 
 many little brains, one would expect them to be symmetrically 
 placed, which, as is well known, is not the case. (Ferrier, 
 § 89). 
 
 To quote authority on the question. Dr. Hughlings Jackson 
 wi-ites {West Fading Bejwrts, vol. vi., p. 283), "I have never be- 
 lieved in what I call abrupt localisations. I do not believe, for 
 example, that there is any part where the movements of the 
 hand are solely represented ; but that there are numerous parts 
 where these movements have special or leading representations ; 
 there being in each, as the term ' leading ' implies, a represen- 
 tation of other parts serving subordiuately with the leading 
 movement. I have never acceded to the opinion that speech is 
 to be localized in any one spot, although I do believe most 
 firmly that the region of Broca's convolutions is, so to speak, 
 
 a2 
 
84 LECTURES ON MENTAL DISEASE. 
 
 the yellow spot for epoecli, as the macula lutea is the centre of 
 the greatest acutcucss of vision, although the whole retina sees. 
 
 "To take an arbitrary and Umited illustration. Supposing 
 one centre in Hitzig and Ferrier's regions to represent the 
 hand ; another, especially the face ; another, the foot ; I should 
 beheve that each one of them represented all the movements of 
 the chest." 
 
 Two main conclusions may be drawn from the foregoing: — 
 
 1. It has been well estabhshed that, as a rule, the cutting off 
 or separation of the cerebrum from the cord, as it were emanci- 
 pates the spinal cord from control ; in the lesions of the 
 motor cerebral centres, the reflex actions of the extremities are 
 increased, as in lateral sclerosis of the cord, when all the re- 
 flexes are exaggerated. This is evidence of the continuous con- 
 trol of lower centres which is exercised by the cerebrum. 
 
 2. On the other hand, the control exercised by the cerebral 
 centres over the purely spinal functions varies, not only on 
 account of the degree of development of the ccrebi-al organ, as 
 shown in the gradual perfectioning of the cerebrum fr-om child- 
 hood to manhood ; it differs also almost naturally in different 
 individuals, also in youth and in the sexes, and varies with the 
 cultivation and education of the mental faculties. 
 
 But while the control is almost complete in regard to certain 
 functions, over some other functions it is Umited, or over which 
 we can exercise control partially, as the resijfration, the move- 
 ments of laughter, of the bladder and bowels. 
 
 When we say we control an act, the act is necessarily attended 
 by consciousness ; but consciousness is no necessary adjunct to 
 movement as has been shown, though it is of vohtion. 
 
 Intellectual faculties and their phjfuical basis. Our physio- 
 logical examination of the functions performed by the nerv- 
 ous apparatus so far, has related only to two faculties — 
 Sensation and Motion, whence come then the other mental 
 faculties, as Judgment, Ideas, Thought, &c., or what are called 
 the iisychical functions. 
 
 Motion and sensation appear no more than functions of a sim- 
 ple kind, and which we have seen the spinal cord to be capable of 
 performing. No satisfactory proof exists, however, that the purely 
 spinal functions have the attribute of consciousness connected 
 
MENTAL PROCESSES OR DYNAMICS. 85 
 
 with them. It is true that the tactile surfaces of the hmhs give 
 rise to a conscious impression, but only when the way is open 
 to the cerebrum, that is, that the cord is intact, and so can 
 convey the sensation upward. And though the origin of all the 
 sensory nerves called special are within the cranium, anatomi- 
 cally they are as much spinal as those of the tactile sensations 
 of the trunk. 
 
 We may take the faculty of consciousness as the general re- 
 presentative of the psychical functions. Since it is a necessary 
 concomitant to such functions which are usually called the psy- 
 chical functions. 
 
 In all the recent investigations of the brain functions, the 
 results gleaned, and they are not few, relate, it will be seen on 
 examination, but to the two main and general functions of (1) 
 Sensation, (2) Motion. 
 
 Some psychologists, the so-called followers of Locke, have no 
 difficulty in ascribing all the intellectual attributes to sensation 
 primarily ; but Locke, notwithstanding what has been said to 
 the contrary, also admitted a subsequent operation of the mind 
 which he called reflection, and which he clearly intimated was a 
 mental jjrocess. The dual or sensori-motor process, is not dissi- 
 milar from the dual process of reflex action generally, or in fact to 
 the law that sensation is allied to motion ; or thinking to action : 
 and in thinking and acting we embrace pretty well all the intel- 
 lectual faculties. But, Nihil in intellectu quod non fuerit prius 
 in sensu, requh'es an addition to indicate the mental process 
 of "reflection," admitting the axiom that the environment 
 acts upon the organism, the effect of which is distributed 
 throughout the system, we have to explain the anatomical 
 substratum of the after mental process from which abstrac- 
 tions result. 
 
 Abstractions as explained in a previous page are composed 
 of two or more sensations, that is, of present and past effects 
 of the environment. We have to explain how the previous 
 impressions remain to form the gi-ound-work for the compari- 
 son of past with present efiects or to ascertain the seat of the 
 persistence of previous impressions. This we fix to be in the 
 cerebral hemispheres as one seat, since as ah'eady shewn, con- 
 scious impressions are thus located : is there any other organ 
 
86 LECTURES ON MENTAL DISEASE. 
 
 in wLich former impressions are Btored ? The impression, Low- 
 ever, 18 only one half of the interaction between the environment 
 and the organism. We have to take into consideration the 
 efifect (say a motion) also, and viewing the two together it seems 
 to show that spinal impressions are also stored, as well as cere- 
 bral or conscious impressions (ideas). "There is a memory," 
 says Griesiuger, "for the spinal cord." It may be confusing to 
 call the faculty a memory, but undoubtedly the impressions on 
 the spinal centres persist as well as those of the cerebral 
 centres. 
 
 The persistence of an impression is due, we may almost say 
 undoubtedly, to the action of the ganglion cell. "NVe have seen 
 how the uem-al current is arrested in passing through a gan- 
 glion. We can trace the action through various phases of 
 completion.' 
 
 In the lowest organisms, the whole of the impression is ex- 
 pended in movement, the simplest reflex action is the result, there 
 is no ganglion and no evidence of any influence left behind. We 
 next find traces of influences of former impressions — evidence 
 of memory in the animal's acts. As we proceed higher, co- 
 ordination of movements is observed in a rudimentary state, 
 and repetition of the same series of movements. Then we find 
 newly-combined movements acquired, and the fact that the 
 same are often repeated in the same order, gives evidence of an 
 effect of a former impression persisting. These may only 
 amount to a function, or disposition of the neural current or 
 efferent, to pass along lin s of least resistance, or along lines 
 previously traversed ; and that such disposition does exist as a 
 fundamental property of the organism, rests upon the same basis, 
 as that the organism is acted upon at all by the environment. 
 
 Undoubtedly these two properties have abundant proof of 
 existence from observation, viz. : — 
 
 1. The persistence of an impression, which is connected with 
 afferent current. 
 
 2. The tendency to pass in tracks previously traversed con- 
 nected with the eflerent. 
 
 The former property may be exercised consciously or uncon- 
 sciously ; in the former case it is in a function of the highest 
 centres ; in the latter, it is connected with the lower. 
 
MENTAL PROCESSES OR DYNAMICS. 87 
 
 If we admit these premises we sliall have no difficulty in allow- 
 ing that the numher of stored impressions may be limited only 
 by the capacity of the organ ; nor of understanding those curi- 
 ous phenomena called automatic actions. If we admit that the 
 impression of an object leaves on our conscious memory the 
 form and other qualities of an object, or the pleasure or pain 
 attending a previous action, we need have no difficulty in under- 
 standing how an action once performed by us may be easier 
 than an entirely new action, since the process has already 
 passed in given tracks. 
 
 Now, these two properties — the one cerebral, the other spi- 
 nal—merge into each other, the cerebral governs, and as a rule, 
 in man it is always supreme ; but in certain functions it, as 
 it were, abrogates its influence to the cord. As example, 
 with such actions as reading, writing, piano playing, and 
 the like, and even walking, the first efforts are through 
 the cerebral organ, and are therefore all conscious move- 
 ments ; but after long practice the whole process is rele- 
 gated to the lower centres. Even co-ordination of movement 
 probably passes through the same stages, especially let us say, 
 in such a case as learning to dance — and indeed, in most of the 
 motor functions, as in various games, shooting, and in manual 
 work of all kind, which come to be performed,, as it is called, 
 automatically, or from the lower centres without reaching or 
 invoking the influence of the cerebrum at all. 
 
 These functions, however, are mechanical. We have to 
 account for the process on which some that are deemed higher 
 mental attributes depend, as the reasoning faculty. Emotion, 
 Volition, &c. 
 
 In investigating these, which are called the psychical func- 
 tions, we are unable to resort to direct experiment ; but some 
 light is thrown upon the subject by the phenomena of disease, 
 and introspection of ourselves. We cannot anatomize the origin 
 of an idea, nor detect the organism which gives rise to the 
 faculty of judging ; but the examination of these various facul- 
 ties shows their close connection with sensation and motion. 
 The law seems without exception, that each sensation results in 
 a motor impulse of some kind, and in a very large number of 
 instances the motor impulse is speech — not always audible, but 
 
88 LECTURES ON MENTAL DISEASE. 
 
 still speech. " There is every reason to believe," says Prof. 
 Bain, " that there is in company with all our mental processes, 
 an unbroken material succession. From the ingress of a sen- 
 sation to the outgoing responses in action, the mental succes- 
 Bion is not for an instant dissevered from a physical succession. 
 A new prospect bursts upon the view. There is a mental re- 
 sult of Sensation, Emotion, Thought, terminating in outward 
 displays of speech or gesture." (Bain, Body and Mind, p. 131). 
 
 But with regard to those so-caUed higher mental faculties — 
 Ideas, Judgment, the power of reasoning, &c., one school have 
 no hesitation in declaring that these are wholly founded upon a 
 basis of sensation. This view, by excluding the influence of 
 innate or organic influences, is considered too restricted by 
 another school. 
 
 Much of the misunderstanding here arises probably out of the 
 inexactness of words which are employed to define the significa- 
 tion of the authors. The force of an impression is doubtless 
 considerably modified by the organism. A man's disposition, 
 inclinations, tastes, and desires, are certainly considerably in- 
 fluenced by his conformation, or variation of his organism; but 
 if these which influence a man are not through sensation, they 
 at least quaHfy or are allied to sensation. Hereditary tenden- 
 cies also modify a man's organic tendency, and in this way are 
 elements in any impression or action. 
 
 To say an impression is modified is to admit that an idea re- 
 sulting from such impression is also modified bj' the recipient 
 organism, and so necessarily must subsequent ideas in suc- 
 cession. 
 
 Idea, then, acts upon idea, and a new idea or judgment re- 
 sults. 
 
 All reasoning, writes Mr. Spencer, is definable as the classi- 
 fication of relations. 
 
 The process of reasoning has for its object the forming of 
 judgments. 
 
 Notwithstanding the more modern theory of inhibition and 
 centres of inhibition, there can be no doubt, I think, that one 
 sensoiy impression may be arrested in its consummation into a 
 motion, or say into a verbal utterance, by a stronger impression 
 in an opposite direction. Motives for and against every act 
 
MENTAL PROCESSES OR DYNAMICS. 8g 
 
 occur quickly on each other. This is oljservccl in the lowest 
 organisms, even in the caterpillar there is a choice or selection 
 of food. " The condition on "which every creature exists is that 
 it ehaU act in special ways under special stimuli ; that contact 
 with nutritive matter shall modify its actions in a manner dif- 
 ferent from that in which contact with innutritive matter modi- 
 fies them." (Spencer, Principles of Psycliology, p, 331). lu 
 other words, there is in the organism a special faculty for the 
 reception of one kind of stimulus in preference to another, and 
 also there is a variation in degi'ee of power of different stimuli 
 to effect the organism. Two stimuli, therefore, occurring in 
 close sequence may influence each other, the second may over- 
 whelm or merely modify or change the direction of the other. 
 
 The stimulus may be an external one, or internal, or the 
 remembrance of a previous excitant — as the externals are in a 
 continuous state of action on the organism, there must be a 
 continuous comparison taking place, resulting in a continuous 
 conflict of ideas. 
 
 The outcome of this weighing of one impression against 
 another (this deliberation) may be an overt act, as a bodily move- 
 ment, or an expression of speech ; or it may be a subdued act, 
 or an unspoken formula of words. The comparison thus made 
 is a process of reasoning ; the result, a judgment ; if expressed 
 aloud it becomes a statement, if logically formulated a syllogism. 
 
 But for the process to be one of reasoning, it must be at- 
 tended with consciousness — it is thus an operation of the highest 
 centres and it is mentally a comparison of impressions, and 
 quality is compared with quality, present impression with j)re- 
 vious impression — thus, abstract ideas are the result. In other 
 words, ideas are collected into groups, and thus are more easily 
 dealt with. To group is to classify. 
 
 A gi'oup, or class, forms a general idea ; all general ideas are 
 necessarily abstract, and they are composed of the abstract 
 qualities of the objects grouped. In classifying the animal 
 kingdom, itself a group of objects, into MammaUa, &c., it is one 
 quality, that of the development of the mammae. Having thus 
 enclosed a variety of objects under one class, and noted it by a 
 name, henceforth, the name becomes the symbol of a general 
 idea, and remains as an element in subsequent mental opera- 
 
go LECTURES ON MENTAL DISEASE. 
 
 tious — a stored feeling or power, to affect a motor outgoing here- 
 after. 
 
 A higher generahzation of objects is carried on by the recall 
 of a former impression for comparison : this former impression 
 appears to be recalled by a likeness or contrast in character or 
 position, in time or place of occurrence. One idea is brought to 
 mind by the process called the association of ideas — a quahty in 
 any object, which is an abstract idea, spontaneously recalls 
 the concrete of which it was an abstract — it also recalls other 
 concretes, in which the same abstract quality was associated, 
 thus is awakened, by every new product from sensation, a whole 
 series of ideas, i.e., impressions, which occupy and pass through 
 the mind, and which have a tendency, sooner or later, to ter- 
 minate in a movement of some kind of speech or action. 
 
 This law of association of ideas appears to have much to do 
 with recollection. While the persistence of the impression, 
 which appears to be attributable to the functions of the cerebral 
 cortex or ganglions, is at the basis of memory, the recall is 
 influenced by the law of association. That the impression pro- 
 duced upon the organism from without gives rise to ideas, that 
 this effect is more or less persistent, and that a former impres- 
 sion may modify the effect of a subsequent impression is readUy 
 intelhgible. The simple analysis of observations support such 
 an explanation of the formation of mental products, but our 
 present enquu-y has for its main object, to trace the mechanism 
 on which the ti'ue psychical processes depend. 
 
 Our review, hitherto, of the facts of the intellectual faculties 
 has been chiefly analytical. We may proceed to investigate the 
 question synthetically. 
 
 2. Syyithetical cxaminativn of the basis of the psychical functions. — 
 For this purpose we may examine the phenomena historically, 
 and examine their evolution in human physiology in relation 
 with that of the organism. 
 
 As already shown, the first indications of nervous functions in 
 the child are all purely reflex, in other terms spinal, and are per- 
 formed with scarcely a scintilla of consciousness ; and anatomy 
 shows us that the spinal cord is much more advanced in structure 
 than the cerebrum : nevertheless there are many complex move- 
 ments perfectly performed, showing a considerable advance in the 
 
MENTAL PROCESSES OR DYNAMICS. QI 
 
 function of co-ordination. The act of eiicldng must bring into 
 play a very complex system of actions; and we know, as already 
 quoted, that this occurs entirely independent of cerebral influ- 
 ence, and can occur without the existence of a cerebrum. The 
 same may be said of other movements ; if a finger be placed in 
 the infant's hand it is grasped, and in the respiration, crying, 
 action of sphincters, eyelids, &c., and in tonic condition of some 
 at least of the muscles. 
 
 "With the growth of the child, the connection of the cord with 
 the cerebral hemispheres gradually takes place as pointed out 
 on page 74. 
 
 I quote the following from M. Charcot's volume, translated by 
 Dr. Hadden : " The cerebrum of the young child bears little 
 resemblance to the adult, except in its external configuration. 
 It is a soft organ of uniformly grey colour, the grey and white 
 matter being intermingled ; the neuroglia predominates every- 
 where ; the reticulum is homogeneous and less distinctly fibril- 
 lated than in the adult. The nerve tubes are universally absent 
 or at any rate barely represented in outline." " To sum up, the 
 cerebrum in the new-born child is still, as it were, in a rudi- 
 mentary condition, whereas the medulla oblongata and spinal 
 cord ah-eady present the characteristic features of the adult 
 state" (p. 160). "You see, gentlemen," concludes M. Charcot, 
 " that the cerebrum at this age has, as yet, no existence ; it is 
 from a triple point of view — anatomical, functional, and patho- 
 logical, an indifferent organ." M. Parrot's researches, as quoted 
 by M. Charcot, show at seventeen days old the infant's brain in 
 its anterior and posterior regions presented an almost uniform 
 dark-grey colour. It is only at the end of the month that the 
 substance of the occipital lobe begins to grow white, and it is 
 not until four months afterwards, that is to say, towards the 
 fifth month, that the anterior regions commence to undergo 
 development, which is not completed until about the ninth 
 month. 
 
 Such being the anatomical condition of the human infant, 
 who, nevertheless, is able to perform several highly complex 
 movements, and to begin to direct such movements, though im- 
 perfectly, towards external objects. 
 
 Still the earliest indications of mental functions are confined 
 
92 LECTURES ON MENTAL DISEASE. 
 
 to movements, and as early as the seveuteenth day M. Parrot waB 
 able to trace the commencement of a motor tract through the 
 central ganglionic masses. •* The median or sub-Rolandic part 
 of the cerebrum is marked by the presence of nervous fibres en- 
 sheathed in myeline. By treating the parts with osmic acid the 
 myehne become stained, and are thus rendered apparent. These 
 tracts are the commencement of the pyramidal tracts, and their 
 development starts from two points, according to M. Parrot, 
 " the one situated in the central nuclei is the first in age, the 
 other has its starting point in the grey matter of the Eolandic 
 convolution, otherwise called the motor zones," so that, " of all 
 parts of the hemispherical cortex, the so-called motor regions 
 are developed earliest, and they are the first to enter into rela- 
 tion with the bulbo-spinal system, through the medium of the 
 pyramidal tracts." (p. 177). 
 
 In correspondence with the anatomical facts, we observe the 
 first indications of volition or cerebral acts in motor functions. 
 " In man," writes Dr. Ferrier. p. 205, " disorganisation of the 
 cortical centres, or the above parts, causes lasting paralysis of 
 voluntary motion on the opposite side of the body." 
 
 Now, though the motor functions play an important part in 
 all mental phenomena, and especially when we include speech, 
 still our examination would not be complete until we take into 
 consideration certain functions under-lying speech, as thought, 
 &c. 
 
 We must bear in mind that many of the purely reflex, that 
 is, purely spinal movements, are not perfected at once. Co- 
 ordination of the limb movements are not perfected until con- 
 siderable advance is made in the cerebral development, and 
 still later, are the directed movements. The child's arms and legs 
 have a certain amount of co-ordination soon after birth ; they 
 have a certain feature alike in all infants. Its earhest attempts 
 to seize an object are at first futile, and resemble the irregular 
 movements of lateral or disseminated sclerosis of the cord, while 
 the movements of respiration are regular, and calm, and per- 
 fectly co-ordinated ; though they are thrown into over-action 
 very readily, as when the child cries ; — the nerve-tissues are less 
 stable, and excited movements more readily induced. 
 
 This unstable condition of what is called the neural dis- 
 
MENTAL PROCESSES OR DYNAMICS. 93 
 
 charges, is ameliorated as age increases ; but childhood is the 
 period when irregular discharges, epilepsies, are frequent. 
 
 With the gradual growth of the cerebrum, we may observe 
 the gradual increase of the mental faculties ; at first, simple 
 concrete ideas are acquired — mere impressions through the spe- 
 cial senses, the organs of special sense being perfected at a 
 very early stage. The knowledge of objects seen, the power of 
 discrimination of sounds, the musical talent, is also early shown. 
 
 In certain instances, the condition may be arrested at this 
 point. By too early synostosis of the bones of the cranium, the en- 
 largement of the cerebral organ is stopped^ and the child remains 
 au idiot, and in many other instances probably the develop- 
 ment is finished at different degrees of its growth, and different 
 mental capacities result. It may be mentioned in passing, that 
 imperfect co-ordination of movements is a frequent effect in 
 idiocy. 
 
 Up to the age of puberty, the knowledge chiefly acquired is a 
 simple accumulation of facts, and ordinary education up to very 
 recent periods, in many instances did very little to cultivate 
 a faculty for comparing facts. The intellect is better brought 
 out in the children's association with their elders, which is the 
 natural mode, and we perceive the power of this in the effects of 
 the gamin or street boy. The child, however, in spite of his 
 education, acquires the power of comparing or judging in the 
 playground, and obtains there an experience, which children 
 kept more strictly perhaps seldom acquire so thoroughly. 
 
 In the human subject there are but few complex actions per- 
 fected at birth, the chief have to be acquired afterwards ; but if 
 we take two of the most important, walking and speaking, we 
 find that both of them have to be acquh-ed subsequently, and 
 learnt too by a very slow process, it is clear also that they have 
 to be acquu'ed through a cerebral process, i.e., through the organ 
 the latest in developing. 
 
 With respect to speech especially, we have clear evidence that 
 the cerebrum is the organ utilized, we know that in the majority 
 of instances the motor centre is in a x^articular convolution of 
 the frontal region as now fully established by pathology. 
 
 Speech may be viewed from many points as : — 
 
 1. Its performance as a motor act — this requires co-ordination 
 
94 LECTURES ON MENTAL DISEASE. 
 
 of Bovoral movcmonts, as of the respiration, lip, tongue, glottis, all 
 of wliicli have to be regulated and co-ordinated. "We know that 
 the ordinary movements of expiration are possible through the 
 spinal centres, as are also many movements of the lips and ton- 
 gue which are used in sucking. What then is the relation of 
 Broca's convolution to the motor spinal centres? It is evident 
 that in the first place the higher centre modifies the lower and 
 adjusts the various actions, the process is learnt ; it is a conscious 
 operation, it is only acquired by frequent trials and failures ; 
 this is one view, it may be called the efferent part of the opera- 
 tion, 
 
 2. From another point, the sound, including its tone, note, tim- 
 bre, etc., has to be predetermined, modulated according to the 
 emotions, and this may be, and at first is, an unconscious out- 
 come of all the emotions awakened by the same cause that in- 
 duces speech. When people are overcome with emotion, the 
 speech is altered ; there are in other words two causes exciting 
 the motor act, and the motor result is influenced accordingly. 
 The emotional tone can be imitated voluntarily by the actor, 
 ■when he recalls or assumes a painful incident. From both 
 aspects speech is evidently a cerebral act, at first a slow and 
 difficult motor act, each step in it making an impression 
 sufficiently strong to be 'attended by consciousness, by frequent 
 repetition the neural current passes along a line of feeble 
 resistance, the steps are easier, awaken no, or scarcely any, con- 
 sciousness, so far as the operation is concerned the motor act 
 passes quickly to the medulla and to the motor mechanism 
 through well co-ordinated tracks, so quickly as to become like a 
 reflex act, and like it especially in awakening little conscious- 
 ness, and this may occur without reference to the subject matter 
 of speech. After constant use of the same formula of words, 
 the words may be repeated in the manner called automatical. 
 It is known as a phenomenon in aphasic patients, that they are 
 capable of using phrases of simple exclamation, the priest, it is 
 said, sometimes can repeat his paternosters without a conscious- 
 ness of the meaning of the words. So perfectly is then the 
 transit thi-ough the cerebral region, that perhaps the impulse 
 never reaches the highest centre. We have diagrams in books 
 to show bow a neural current may pass, as it were by a short 
 
MENTAL PROCESSES OR DYNAMICS. g5 
 
 cut, directly through a lower centre from the afferent. These dia- 
 grams are hypothetical only, and it is difficult to say whether, 
 as it were, they pass by the higher centre, or pass through it 
 too rapidly to leave any persistent impression behind. 
 
 It would be more in accordance with other facts that have 
 been observed, to assign to the speech-centre the higher office 
 of being the centre of various neural currents collected from all 
 'sources, and to be the arena in which the ultimate struggle, 
 between contrary inducements culminate in an efferent stimulus 
 to motion ; this arena, will then be a centre, where all the 
 stored impressions converge, and are co-ordinated, and brought 
 into order. 
 
 The Broca convolution appears to be essentially the "way 
 out " for the motor action of sjDeech, not necessarily the centre 
 of thought, which probably has a wider field ; aphasic patients 
 can think or even in some cases write. Ideas are probably 
 derived from wider areas, that is from the centres of auditory, 
 visual and tactile impressions. 
 
 It would seem that in the case of speech, though the move- 
 ments all pass through a lower centre, they are never wholly 
 relegated to the class of reflex or absolutely unconscious acts. 
 
 It may be asked, are other kinds of movements ? In walking, 
 there is little doubt that a man may walk while unconscious, but 
 the power of walking, the art of walking is an wholly acquu'ed 
 power, and one which requu'es much attention. It is coeval with 
 known cerebral growth, as shown above. After a few years the feat 
 is performed entu'ely without attention, and clearly it is du-ected 
 by currents passing down the spine ; the alternation of the move- 
 ments is also first acquired by careful practice, the infant has 
 at first great difficulty in alternating its limbs, in after hfe it is 
 performed apparently entirely automatically, the co-ordination 
 appears a property of the cord, though at first acquired through 
 a higher centre, and in this again it would seem that the action 
 first performed by a purely cerebral act at length never reaches 
 the higher centres, but that the excitant by a cross or more direct 
 channel reaches the motor centres. It must be owned, however, 
 that there is no anatomical proof of this, but here again a more 
 satisfactory explanation would seem to be that the neural cur- 
 rent was direct from the brain, though from a lower co-ordinat- 
 ing centre in the brain. 
 
g6 Ll-CTURKS ON MENTAL DISEASE. 
 
 Wo know tliiit injury in the Eolandic convolutions produces 
 hemiplegia, though the co-ordination of the limb movements 
 may be still purely spinal, since in the disease disseminated 
 sclerosis of the cord, the co-ordination of the limbs is a marked 
 symptom. 
 
 But if walking is automatic, that is, reduced to an uncon- 
 scious act, it is probably also always cerebral, the track of 
 the neural current is easier in one direction than another, 
 the combination of movements have also a tendency to move 
 in old lines. Every one knows how difficult certain un- 
 accustomed actions are in comparison to the accustomed, 
 such as to rotate a leg in a different circle to the arm, to 
 button the coat with the right hand, etc., the law that the neural 
 current has a tendency to pass in a track previously traversed is 
 sufficient to explain the phenomena. So long as the track is 
 ox^en, the traversing of the current awakes no consciousness, 
 makes no impressions, recalls no associations in the cerebral 
 hemispheres, but directly this path is disturbed — if a man 
 kicks his toe against a stone in his path — the consciousness is 
 aroused, a vivid impression is made of intensity enough to ex- 
 cite attention, to bring into action all associated impressions the 
 remanents of former impressions. If disease in the motor tract 
 occur the performance of walking is difficult, in certain cases of 
 ataxy in which the afferent columns of the cord are at fault, the 
 patient must look at his feet to direct them, that is, he must 
 call in the aid of the cerebrum. 
 
 The various actions frequently performed may awaken httle or 
 almost no consciousness, but they are not therefore reflex in the 
 sense of being necessarily spinal, though the spine has func- 
 tions probably which assist in both voluntary and involuntary 
 actions. 
 
 Thus it appears probable, as suggested by Dr. Wiglesworth 
 in a paper read at Liverpool in August, 1883, '■■ that in the 
 cerebrum itself there are centres above centres, the one con- 
 trolling the other, as the cerebrum controls the spinal centres ; 
 and analogy, which bears out this fact, would also lead us to 
 conclude that some of these may form the anatomical basis of 
 certain so-called automatic acts, of those acts in other words 
 * Published in Jounuil of Mental Science, Jan., 1884, 
 
MENTAL PROCESSEvS OR DYNAMICS. 97 
 
 which are performed without consciousness, or only semi- 
 consciously, such as the formation of words in speech, &c. 
 
 Dr. Wiglesworth's words are as folloAvs : — " The nervous arc 
 consisting of afferent and efferent fibres and intervening cor- 
 puscle, shows us the unit out of which the nervous system ia 
 built up ; and it is by the combination of two or more such 
 reflex arcs, fibres from which meet in a common centre, that 
 the highest nervous centres are elaborated. The union of a 
 number of nerve fibres from a number of nerve cells in one 
 centre, permits of the action of such nerve cells being con- 
 trolled and co-ordinated by that centre ; and by the union of a 
 number of such centres of co-ordination in one higher centre, it 
 is possible for the numerous plexuses of cells and fibres in- 
 dividually combined in such lower centres of co-ordination, to 
 be all co-ordinated together in such higher centres ; and the 
 process of evolution implies a perpetual super-position of higher 
 upon lower centres of co-ordination, so that what were at one 
 stage of development, the highest centres, become at a more 
 advanced stage subject to the control of still higher centres, and 
 are therefore themselves relegated to an inferior position, so 
 that when we reach the last term of evolution at present ex- 
 pressed, we have an infinity of lower centres of co-ordination, 
 controlled and co-ordinated by one or a few higher centres. 
 These highest co-ordinating centres are of course the latest de- 
 veloped. '' 
 
 There are still some functions of the nervous system which 
 will require a few words though they do not appear to be so ob- 
 viously connected with the mental functions, viz., co-ordination, 
 equilibriation, and muscular tone. 
 
 With respect to co-ordination, from the often quoted fact, 
 that a decapitated bird when thrown into the air can fly, that a 
 headless frog can swim, and can even jump out of the water and 
 climb up the side of the tank, it would seem that the co-ordina- 
 tion of movements in them depended upon the cord. Whatever 
 may occur in these animals may be due to the deficient differen- 
 tiation of function. In the more highly developed, the experi- 
 ment is not available ; although it has been established (Ferrier, 
 op. cit., p. 64) " that animals deprived of the cerebral hemispheres, 
 besides being able to maintain their equilibrium, are also capa- 
 
gS LECTURES ON MENTAL DISEASE. 
 
 ble of locomotion in their normal manner" but this applies 
 only, of course, to co-ordination of limb movements. 
 
 Equilibriation of course must be dependent upon co-ordination, 
 the two functions therefore may be spoken of together, though as 
 Dr. Ferrier remarks, one " can conceive such a case, as an 
 animal which could maintain its equilibrium, but could not 
 sufficiently co-ordinate its movements to walk." 
 
 Disorders of equilibrium are found to follow upon lesions of 
 the cerebellum, and that in a very regular manner, which may 
 be stated in very general terms to correspond to the seat of the 
 lesion ; when the injury is on the mesial hue, the disturbances 
 are of no marked importance ; when the anterior part of the 
 middle lobe is injured, the animal has a tendency to fall forward, 
 when the posterior part is injured, to fall backward, lesion of 
 the lateral lobes, causes a tendency to turn on the axis, usually 
 towards the side injured. 
 
 Hence, the cerebellum, seems to be "a complex arrangement 
 of individually differentiated centres, which regulate the various 
 muscular adjustments to maintain the equilibrium, the action 
 being a reflex one, and the excitant or afferent the disturbance 
 of equilibrium in the various directions." (Ferrier). 
 
 This is corroborated by the observation, that the balancing of 
 the body is a much more complex act in man, and in man is 
 found the most complex cerebellum. 
 
 Though Dr. Ferrier mentions the displacement of equihbrium 
 as acting as a stimulus to the special centre which calls into play 
 the compensatory action, it seems equally well established that 
 other factors exist in the " tactile, visual and labyrinthine im- 
 pressions." 
 
 In an excito-motor or reflex act such as exists in cerebellar 
 function, a lesion of afferent centre, or efferent, may disturb the 
 equilibrium. Such occurs in cases of locomotor ataxy when 
 both co-ordination and equilibriation are frequently fouud to be 
 affected, as through a tactile lesion ; or again in cases of laby- 
 rinthine affections (Meniere's disease), producing giddiness and 
 reeling, or by rotation of the body, as familiar in waltzing, caus- 
 ing a slight staggering, attended with giddiness. The tactile, 
 visual and labyrinthine causes, however, are attended with con- 
 Bciousness, but in certain cases the disturbance is unconsciously 
 
MENTAL PROCESSES OR DYNAMICS. QQ 
 
 produced. This is evidently caused through the free cotnmuni- 
 catiou of the cerebellum and cerebrum through the peduncles. 
 
 Tone. — This word is used to signify a condition of the muscu- 
 lar system, and it depends on the spinal cord. The experiment 
 quoted from Marshall Hall in illustration of the functions of the 
 cord, in which the decapitated frog continued to respond to an 
 excitant, until its spinal cord was destroyed, is an illustration of 
 the influence of the cord in producing tone. 
 
 It will be remembered that certain muscles are normally in a 
 persistent state of contraction, while others contract only on a 
 stimulus being applied. In the muscles which keep the jaw 
 closed and the sphincters of the rectum and bladder, tonic ac- 
 tion is persistent; but when cut off from nervous influence, they 
 relax as in facial and vesical paralysis. There are other conditions 
 of tonic action which are to be seen in the state of antagonism 
 which is constant between the flexors and extensors, these also 
 are disturbed by certain spinal diseases, when the limbs become 
 contracted. "What is termed automatic action," says Dr. 
 Ferrier "is in great measure reflex action of a constantly 
 operative'nature." {Functions of Brain, ^. 21). Similarly reflex 
 operation may be invoked to explain the tonic conditions of all 
 muscles, including those of the system of the small arteries. It 
 is well estabhshed that in certain morbid conditions of the 
 spinal cord, there is a tendency to what is called the foot clonus 
 action, it appears to me that this is due to a disturbance of the 
 balanced state of tension and contraction of the antagonistic 
 muscles, the flexors and extensors for example ; and is not a 
 like cause to be found for other irregular movements as in 
 shaking palsy, tremors, etc. ? 
 
 It has been attempted to be shown that there is in muscles a 
 natural or inherent and independent condition of tone, where an 
 explanation in accordance with general laws is suflicient to ex- 
 plain a phenomenon, it is at least gratuitous to seek for an ex- 
 ceptional cause. " It is," says Mr. Lewes, " a rule always to 
 prefer the simplest hypothesis compatible with the observed 
 facta." 
 
 m2 
 
PART II. 
 MENTAL DISEASE. 
 
 Section I. 
 
 Preliminary Remarks — Definition of Disease — Necessity of Classification — Pro. 
 per basis of Classification — Classification adopted — Two classes, Idiopathic 
 and Symptomatic — Consideration of Idiopathic Disease — Subdivision into 
 two classes, Ordinary Insanity and General Paresis — Ordinary Insanity, 
 description of, preliminary view of its nature, its stages, symptoms — First 
 stage, progress and terminations, recovery, death, bodily symptoms — 
 Second stage. Acute Mania, symptoms, mode of progress, terminations. 
 
 As the first part of these Lectures has heen devoted to the con- 
 sideration of Mind, this the second part will he occupied with a 
 description of its Diseases and their Treatment. 
 
 Before entering upon the description of the different forms of 
 mental disease, it will he well to say a word concerning what is 
 here meant, by the term Forms of Disease. 
 
 By the word Disease, is meant the sum of aU the phenomena 
 which are observed in a given case, including the first indica- 
 tions of deviation from health, the evolution of the symptoms, 
 their progress, order of succession, and mode of termination. 
 
 No two cases are, it is true, exactly alike, yet they resemble 
 one another, by theu* general characters, sufficiently to be 
 grouped together. To group is to classify. We use classifica- 
 tion merely to facihtate the study of disease, or as a kind of 
 memoria technica, to assist us in obtaining a wider grasp of 
 facts. 
 
 In describing the characters of a group or class, the terms 
 used must have a general or wide signification. So that pro- 
 bably no single case, that is met with in practice, will correspond 
 in all particulars to such a general description. 
 
FORMS OF DISEASE. 101 
 
 Such liai^peus even in examples of acute disease ; two 
 cases of measles differ in many particulars, though the period 
 occupied is but short. It is not surprising, therefore, that 
 cases of insanity of the same artificial species, show consider- 
 able variation, since their duration is so much longer. There- 
 fore, in grouping cases of mental disease, a much wider latitude 
 of variation of the phenomena must be allowed. 
 
 On this account it is, perhaps, even more necessary, in order 
 to obtain a grasp of those innumerable variations, to resort to 
 a grouping of the whole into classes. 
 
 Cases of mental disease vary much in their course or pro- 
 gress. At one period, the subject will present phenomena 
 totally different from the symptoms presented at a different 
 period. I maintain, however, that the case must be considered 
 to be of one species throughout ; such is the rule in general pa- 
 thology and there are no grounds for having a different system 
 in Insanity, however long the case may last. For a case to be 
 placed under a different name, it should differ from all other 
 cases, as distinctly as acute rheumatism from typhoid fever. 
 
 The very object of investigating symptoms or groups of symp- 
 toms, such as make up what we call a disease, is to trace and to 
 follow the alterations that are going on within the organism. 
 To know the changes that have taken place up to any given 
 time is useful, but to know what is the next step, or what is 
 likely to follow, is of greater importance. So to know a disease 
 we must know its stages and its mode of progress, towards one 
 goal or another. 
 
 The study of disease must, then, be a study of a changing 
 condition ; but great confusion must arise, if we isolate the dif- 
 ferent changes or stages, and after disconnecting them, call 
 them by fresh names and look upon them as fresh species of 
 disease. 
 
 This, however, is the course frequently foUowed by writers on 
 mental disease, and which renders the hterature of the subject 
 so complicated. 
 
 The multitude of so-called diseases thus imported into the 
 question, has necessitated systems of classification, which 
 have become very various ; in reading the different treatises, 
 Enghsh or foreign, one may at once perceive that most of the 
 
102 LECTURES ON MENTAL DISEASE. 
 
 varieties of disease are called according to eome prominent 
 feature at the period ■when the case was first seen by the physi- 
 cian, irrespective of its history or probable termination. Most 
 of such varieties are in fact diseases of a day. 
 
 Thus the classification of mental diseases really has become 
 a prominent feature in the literature of our subject. 
 
 But besides a classification for a systematic arrangement of 
 insanity, as a part of a scientific pathology, every author al- 
 most necessarily divides the subject, for the purposes of his 
 own book, and to suit his own convenience. 
 
 A classification of disease, nevertheless, is by no means an 
 arbitrary matter, for the result or deductions Avill be very much 
 influenced by the basis, which is chosen for forming the classi- 
 fication upon, A multitude of facts or objects may be grouped 
 in some way, upon almost any basis ; but the result will be in 
 each case, according to the basis chosen. It is necessary, there- 
 fore, to bear in view the object for which a classification is re- 
 quired. 
 
 In illustration of this, we might group plants into trees, 
 ehrubs, and herbs ; or trees into deciduous and evergreen ; but 
 the i)roduct in one case, would be only a grouping of the habits 
 of plants, and the other, that of their vernation. The process 
 would not convey to us, any knowledge of the family of plants, 
 unless it could be shown, that a certain vernation or a certain 
 habit, was always alhed with certain essential characters of the 
 individual plant. 
 
 I maintain, therefore, that the basis of a classification of 
 disease, should be a grouping of essential characters of disease. 
 The essential characters of a disease, speaking in general terms, 
 are the symptoms and their evolution, progress, and mode of 
 termination. It Ave group a certain number of cases, Avhich re- 
 semble each other in these essential characters, it is as much as 
 we can expect to accomplish. The symjitoms may vary more 
 or less in general character, within such limits as will fairly ap- 
 jiroximate the phenomena generally ; but after all, every disease 
 must be considered in its entirety. A disease must be a single 
 process to be worthy of a separate name. 
 
 For the purpose of completing the literature of our subject, 
 it may be necessary to describe the various systemB of classifi- 
 
FORMS OF DISEASE. IO3 
 
 cation, that have been proposed by different authorities ; but it 
 will be better to defer this until the diseases themselves have 
 been described. 
 
 Of course every writer on the subject must have some kind of 
 arrangement, but from among all the various systems of clas- 
 eification proposed, I do not adopt any, for I do not consider 
 they fulfil the desired object, of giving one general survey of 
 the whole subject; and because, in my opinion, most of them 
 are formed upon a totally wrong basis. 
 
 The ground, on which I consider the classification should be 
 formed, is some essential character of the morbid process pre- 
 sent in its entirety, not, that is, upon any particular phase 
 through which a certain case may pass, but rather upon the 
 kind of morbid process which is at the root of the altered func- 
 tions. I repeat ; a case of disease must be viewed, as a single 
 process, from its first phenomena to its last. 
 
 In grouping thus all the cases met with in Asylums, it will be 
 found, that they may be divided into two grand divisions. 
 
 It will be found that the disease in some is really idiopathic ; 
 in other terms, it is distinct from all other known forms of dis- 
 ease ; while, on the other hand, in the rest of the cases the 
 mental symptoms are only a part of some other well-recognised 
 malady, such as epilepsy, or organic disease of the brain, in 
 which there happens to be much disturbance of the mental 
 faculties. In the former cases the mental aberration is an at- 
 tribute ; in the latter, an accident in the course of the disease. 
 
 We have thus two grand divisions, viz., Division A, in which 
 the mental symptoms are primary, or essential, or idiopathic ; 
 and B, in which they are secondary, or symptomatic. 
 
 This grand division (A), or the purely mental cases, may be 
 further divided into two subdivisions, viz. (a), in which the 
 cases depend upon a purely pathological change, or on what is 
 really disease ; and (b), in which the mental symptoms are due 
 rather to develojymental causes. 
 
 In the former category (a) 1 can recognise as yet but two 
 species morhi, viz. : — 
 
 I. Ordinary insanity or insanity proper ; and 
 
 II. General paresis. 
 
 In the subdivision (h) there are also two kinds of cases ; (1), 
 
104 LECTURES ON MENTAL DISEASE. 
 
 in which the developmental anomaly is in original conforma- 
 tion, or idiocy; and (2), in which it is due to decay, or senile 
 imbecihty. 
 
 This forms, therefore, the classification of all the cases of 
 primary, or idiopathic insanity, and which may be clearer in 
 the form of a table. 
 
 Class A. — Idiopathic Disease. 
 
 Subdi\'ision (aj — Pathological: 
 
 1. Ordinary insanity. 
 
 2. General paresis. 
 Subdivision (b) — Developmental : 
 
 1. Idiocy. 
 
 2. Senile decay. 
 
 The Class B — in which the mental phenomena are only 
 symptomatic, or accidents, forms, perhaps, a smaller moiety 
 of all the cases in asylums ; and the most frequently occurring 
 kind of cases are the four following : — 
 
 I. Epileptic insanity. 
 
 II. Alcoholismus. 
 
 III. Spinal disease, extending to the cerebral regions. 
 
 IV. Organic disease of brain, as the result of apoplexy, etc. 
 
 Or to arrange the .whole in a tabular form, it would be as 
 
 below : — 
 
 ^ . ,, , ., f 1. Ordinary insanity. 
 
 1.1 Morbid . . . I 2. General paresis. 
 
 (A). iniOPATHIO ■< > g TTJogy 
 
 2. ( Developmental . \ ' a.,,-?-L 
 
 (B) . — Symptomatic 
 
 \ 4. Senility. 
 
 5. Epileptic insanity. 
 
 6. Alcoholismus. 
 
 7. Spinal diseases. 
 
 8. Organic cases. 
 
 And this corresponds very closely to the result arrived at by 
 the International Committee at Paris in 18G7. 
 
 Class A. — 
 
 Subdivision (a) — Pathological : 
 
 "We commence then, with a consideration of the cases, which 
 depend upon a true pathological cause, and which will give 
 us therefore Disease in the_ purest signification of the term. 
 
FORMS OF DISEASE. IO5 
 
 According to my experience, the diseases as already stated 
 are but two in number, viz : — - 
 
 Ordinary insanity ; and 
 
 General paresis. 
 
 It will naturally occur to any one, at all conversant with the 
 literature of the subject, to ask what becomes of the infinity of 
 varieties, which one reads about. The terms in use are almost 
 numberless ; M. Guislain in describing Mania as a disease, 
 (which I do not), says: "Vingt trois formes de manie, sans 
 compter plusieurs formes composees non indiquees, voila, me 
 direz vous peut-etre, un bagage symptomalogique passablement 
 lourd pour la memoir e." 
 
 These so-called varieties, — to which distinct names have been 
 given, are merely cases having some non-essential peculiarities 
 in their course : the names attached are very arbitrarily chosen. 
 Some are coined from a prominent symptom only, as klepto- 
 mania, where the patient has a propensity to steal ; oinomania, 
 dipsomania, erotomania, nymphomania, homicidal and suicidal 
 mania, and several others of similar origin, which will be again 
 alluded to in the sequel. 
 
 There are besides, several other synonyms, for one and the 
 same condition, all of which shall be alluded to in the descrip- 
 tion of the chief variations in the course of the disease. 
 
 Symptoms of ordinary insanity. — This is the disease which in its 
 course, presents such varying phenomena, and has thus given 
 occasion for multiplying the names. Its course is of very vari- 
 able duration ; in acute cases it may last from three to six 
 months only, in other cases it may last many years and con- 
 tinue throughout the rest of a long Hfe, that is, from thirty to 
 forty years. 
 
 It is only very lately, that this disease has been differentiated 
 from General Paresis ; this separation was first made, by the 
 French pathologists, Dr. Calmeil being probably the earhest. 
 In this country, these two diseases were still generally consi- 
 dered to be mere stages or varieties of one disease, so lately as 
 1864 ; at which time I wrote a paper on the question, which 
 was translated in the Annales Medico-Fsychologiqucs, in 18GG, by 
 Dr. Koussillon. 
 
 Before describing the symptoms of either disease in detail, it 
 
I06 LECTURES ON MENTAL DISEASE. 
 
 may probably assist the memory, if I here state in a general 
 way, what I believe to be the pathological difference, between 
 the two diseases we are about to consider. 
 
 In every mental act or act of cerebration, there are two chief 
 agencies in operation; 1st, the nerve tissue; 2nd, the blood 
 supply. A careful consideration of the early symptoms tends 
 to show, that one disease commences through the first of these 
 agencies ; the second through the other. To illustrate this, as 
 briefly as possible, I will point to the well observed fact that the 
 acts of cerebration can be distinctly affected through the blood, 
 as by the injection of certain substances into the veins, and by 
 the introduction of substances, as alcohol, into the system by 
 the stomach ; and that while one agent will produce one effect, 
 another agent causes a different result ; and in most of these, 
 according to the quality of the agent employed, the effect is 
 more or less transient. 
 
 It is equally well known that disturbances of the digestion 
 produce a depressing effect on the system.* Now, the early 
 stage of ordinary insanity very closely resembles such a condi- 
 tion. In nearly every case well marked symptoms of impaired 
 digestion are present, and are the first to appear — such as 
 capricious appetite, loaded tongue, flatulence, anxious feeling 
 located at the praecordia", constipation, etc., all of which point to 
 an error in the process of blood-making, though, as the mental 
 symptoms increase, these may be lost sight of by the patient. 
 
 • "So many alterations in the constitution of the blood, account for certain 
 of the mental phases as the hypochondriacal and melancholic. 
 
 "In relation to this, we may bear in mind the mental colouring, usually asso- 
 ciated with certain states of toxa?mia, as for example, the depression attending 
 cbolaeraia; the ill temper, anxiety, and depression of chronic lithffiniia, and 
 the apathy and unconcern of pyiEinia- So also in phthisis, briglit, swift, and 
 lively, as are often the mental powers in the early periods, — yet later, and 
 when probably the blood is much altered — caprice, fickleness, variability and 
 impatience are observed for more than the so-called spes phthisica." — (Dr. 
 Mickle on General J'arahjsis, page 153). 
 
 "Drs. Bucknilland Tuke refer to the case of a lady, whose character had always 
 been distinguished for conscientiousness, whose religious education had been of 
 a sombre kind, and who after suffering an attack of small-pox, attended with 
 congestion of the brain, recovered with the natural bent of her disposition 
 greatly altered." — (Hammond, Treatise on Insanity, p. 25). 
 
 "The mental characteristics after cerebral haemorrhage, will be found to have 
 undergone a radical change." — (Hammond, p. 24). 
 
ORDINARY INSANITY. lOJ 
 
 And tlio mental symptoms at first closely resemble those of im- 
 paired digestion. The mental symptoms are at first merely 
 emotional ; they extend but slowly to the intellect and move- 
 ments, and affect the latter, only occasionally. 
 
 If, on the other hand, we trace a typical case of general 
 paresis, we can trace from the commencement, or from a very 
 early period, symptoms which embrace every artificial division 
 of nerve force, as will be shown hereafter ; intellect, emotions, 
 volitions, including also what used to be called sympathetic sys- 
 tem or the nerves of organic control. At first all is excitement, 
 and then soon all is feebleness ; while the general health, 
 digestion, &c., remain unaffected. 
 
 Ordinary insanity. — To avoid multiplying names already too 
 numerous, I prefer this name to others that have been proposed, 
 and in this term it is intended to include the disease through 
 all its stages and variations. 
 
 The disease has its well marked and definite symptoms and 
 runs its course, in a manner which observation enables us to 
 describe. It often extends over very long periods, so that it is 
 perhaps difficult, for a single observer, to watch many cases 
 from first to last; nevertheless, its course and progress are fairly 
 well known by the labours of many different investigators. 
 
 Like other diseases it may be artificially divided into separate 
 stages, and this is useful for facilitating description, but such 
 artificial divisions must not be looked upon as different species 
 of disease. 
 
 The course of ordinary insanity like every other malady, may 
 progress in three or four ways ; it may terminate in recovery, 
 in death, or by passing into a chronic condition — that is in 
 three ways ; the fourth, may be in a certain periodical variation 
 of its symptoms. 
 
 Thus, a case in the primary attack commences by symptoms 
 of melancholy ; these may, when successfully treated, pass off, 
 and the patient recover, or the melancholic stage may be aggra- 
 vated, and the patient die in this stage ; or if the patient does 
 not die, — the disease may exhibit symptoms of violence and be- 
 come acutely maniacal. There is no ground on this account to 
 say, that the patient has a new disease, any more than the 
 appearance of an eruption in an eruptive disease would be the 
 
io8 
 
 LECTURES ON MENTAL DISEASE. 
 
 inauguration of a diflereiit kind of malady. A patient, without 
 becoming maniacal Lowever, may continue melancholic, and the 
 disease become chi-onic. The case of the patient, who has 
 passed into a condition of mania, may also become chronic in 
 that stage, and he may recover or die. Next the chronic case 
 may alternate in different waj's, between a melancholic and 
 maniacal condition ; and lastly if the patient does not die in this 
 stage, or recover, the chances of which would be shght, he 
 may pass into a condition of imbecility or dementia. The 
 following table is given to render these changes more clearly 
 traceable. 
 
 DIAGRAM OF THE EVOLUTION OF ORDINARY INSANITY. 
 
 First Stage. 
 
 Melancholia 
 
 Second Stage.. .> -< 
 
 .M. 
 
 Third Stage. 
 
 Mania. 
 
 -M.. 
 
 Chronic 
 
 Chronic 
 
 
 Alternating. 
 
 
 Ma 
 
 nia 
 
 Melanc 
 
 ;holia 
 
 .1^ 
 
 Fourth Stage. 
 
 Imbecility. 
 
 and 
 Dementia. 
 
 _WJ 
 
ORDINARY INSANITY FIRST STAGE. lOQ 
 
 In adopting the usual course of dividing the disease into 
 stages, m the above diagram, I have indicated four epochs in 
 the progress of a case. It must not be inferred, however, that 
 there are well defined lines of demarcation between the stages 
 into which the case is divided. In most cases one division may 
 run into another in a manner that no separation could be 
 made. 
 
 The first stage in Ordinary Insanity, may be called the stage of 
 Acute Melancholia. It presents five sets of symptoms, namely; 
 
 1. Depression of spirits. 
 
 2. Morbid apprehensions. 
 
 3. Alteration of affections and moral instincts. 
 
 4. Illusions. 
 
 5. Alterations of motility. 
 
 These are of course general terms only, under which many 
 concrete facts are grouped; and it will be seen, as the symptoms 
 are described in detail, that they include all the phenomena. It 
 may be premised of all of them, that they are to a very large 
 degree connected with the emotions. The feelings at aU events 
 take precedence in the symptomatology of the disease in this 
 stage. 
 
 Depression of sjnrits. — This is of course an abstract and 
 general term, and serves to include a large number of par- 
 ticular phenomena. It has reference entirely to states of 
 emotion. Emotions (see ante, pp. 21 and 41) may be divided 
 into painful, and pleasurable. Depression of spirits of course, 
 is connected with the former only, and it would seem that 
 the impression of pain or pleasure is in direct ratio to the 
 variety and modifications of the sensations produced in the 
 mind, without reference to the kind or quality of the excit- 
 ant. If the organ is unimpressionable, the natural variation of 
 ideas cannot take place, the ideas will be monotonous. It does 
 not of course always require an external object to produce aU 
 the changes of thought and emotion in the mind, a memory will 
 equally act ; and from this source it is chiefly, perhaps, that the 
 variety is supplied. These stored ideas may be faulty, or there 
 may be an absence of fresh ideas from recent sensation, owing to 
 the condition of disease. 
 
 The sources of misery or depression of spirits, are thus con- 
 
no LECTURES ON MENTAL DISEASE. 
 
 nected with as great a variety of subjects as ideas themselves 
 are ; the degree of pain will vary also in degree or intensity ; 
 as from that slight state described by Sir B. Bi'odie, {Psycholo- 
 gical Inquiries, p. 120). He wrote, " On some occasions I have 
 laboured under depression of spirits, having what I call an 
 abstract feeling of melancholy, there being no external cause 
 to which it can be attributed ; and it being at the same time, 
 as far as I can judge, not connected with any derangement of 
 any of the animal factors." 
 
 A degree of depression is apt to occur after an unusually pro- 
 longed state of pleasure, after fatigue and certainly, as is well 
 known, after the exaltation produced by inebriation. 
 
 A gloomy view of every thing sometimes is felt from slight 
 indisposition and debility on first awaking in the morning. 
 Each circumstance reflects some impending harm or inconveni- 
 ence — things seem to be all " going wrong," and which after the 
 bath and breakfast, spontaneously right themselves, and the evil 
 forecasts evaporate. These are all doubtless of the same source 
 as the graver and more permanent degrees of depression, which 
 constitute true melancholia or insanity. 
 
 The ingravescence is gradual in all the cases, the descrip- 
 tion of the state of Hamlet's mind, gives a graphic and very 
 accurate picture of the mind in the early stage of mental dis- 
 ease — "I have of late (but wherefore I know not) lost all my 
 mirth, foregone all custom of exercise ; and indeed it goes so 
 heavily with my disposition, that this goodly frame, the earth, 
 seems to me a sterile promontory — this most excellent canoj^y, 
 the air, look j'ou this brave overhanging firmament, this majesti- 
 cal roof fitted with golden fire, why it appears no other thing 
 to me than a foul and pestilent congi'egation of vajiours." This 
 feeling of melancholy, also so fascinates the subject of it, that 
 he is loath to endeavour, by any voluntary eflfort, to shake it off; 
 "thus much," says old Burton, "we may say of melancholy; that 
 it is most pleasant at first, hlanda ah initio, a most dehghtsome 
 humour to be alone, dwell alone, walk alone, meditate alone. He 
 in bed whole days, dreaming awake as it were, and frame a 
 thousand phantastical imaginations unto themselves." 
 
 The depression often exists for long periods and even becomes 
 habitual, without encroaching upon the higher intellectual facul- 
 
ORDINARY INSANITY FIRST STAGE. Ill 
 
 ties. The depression is a state only of the feehngs, or moral 
 faculties ; patients exhibit even at a comparatively advanced 
 stage of melancholy, perfect mental lucidity, they can carry on 
 their affairs, perform the functions of high offices of state, or in 
 commerce, and without evident deterioration, particularly when 
 their own feeling or interests are not greatly implicated. 
 
 The characteristics of this condition may be summed up in 
 the general terms of : — 
 
 Taciturnity, and love of solitude. 
 
 Indifference to every thing. 
 
 Such is the state of mind at the commencement of the dis- 
 ease ; the consideration of the bodily symptoms, for the sake of 
 clearness, will be reserved. 
 
 Morbid apprehensions. — The second set of phenomena which 
 I have included under the general term Morbid Apprehension, 
 is of even more varied character, and it succeeds or follows 
 upon the state of depression, or rather becomes added to it, 
 for the depression persists ; both depression and apprehension 
 are alike connected with Emotions, and are but morbid states 
 of the Emotions. 
 
 Morbid apprehensions take many and often very phantastic 
 forms, they may be considered under two heads. 
 
 1. Apprehensions connected with the present life. 
 
 2. Apprehensions connected with the future state. 
 
 With regard to apprehensions of the first kind, one of the 
 most frequent perhaps, is a fear of impending ruin, of poverty, 
 or injuries ; in some cases, the patients express a sensation of 
 fear without being able to state its nature— the sensation is then 
 more of a bodily pain and is attributed to the heart, and per- 
 haps arises absolutely from irregular action in that organ ; fear 
 of bodily danger of any kind by wounds, poison, di'owning, 
 fire, will often lead patients to assert that they are to be burnt 
 alive, suffocated, &c. The fear may vary in intensity, and in 
 the degree of conviction with which it is accompanied ; often and 
 at the earliest stages, the danger is not actually believed but 
 only feared ; by degrees it becomes more and more real, but at 
 that point the disease will have passed into my next artificial 
 division of the symptoms. In this stage, now under considera- 
 tion, the fear of injury, starvation, &c., leads or induces the 
 
112 LECTURES ON MEIsTAL DISEASE. 
 
 patient to seek suicide. "Etsi mortem timent tameu plerumqxie 
 mortem conciscimt."* Tlie apprehensions are often, not only 
 fiuitiistic and absurd, but even of ludicrous character. Such 
 is the usual development of the disease, and the characters as 
 given by Burton, which he gathered from older authors, prove 
 the universality of these characters from all time. Among such 
 trivial and phantastic fears, are the following from Burton, 
 " they are afraid of some loss, danger, that they shall surely 
 lose their goods and all that they have, but why they know not." 
 One special kind of fear also given by Burton, is that of being 
 watched or followed, " semper fere vidisse militem nigrum pre- 
 sentem." This, according to the investigation of M. Thomeuf, 
 (Annales Medico-psycholor/iques, Oct., 1859, p. 574), is more par- 
 ticularly associated with Alcoholismus in its acute stage — but it 
 occurs occasionally in ordinary insanity. 
 
 Among morbid apprehensions connected with the present 
 state, are fears about the health; this is called Hypochondriasis. 
 It is a question with writers on medicine, whether hypochon- 
 driasis is insanity at all, I have no doubt of the fact myself. 
 Hypochondi'iacal fears are met with in two forms, as recent, 
 and as chronic and confirmed. All the symptoms of Hypo- 
 chondriasis resemble in general character other cases of 
 insanity, the differen-ce being merely in the form which the 
 apprehension assumes. This difference is not sufficient to 
 constitute the case a particular species of disease, for it conforms 
 to all the rest in its progress and termination. The term hypo- 
 chondriacal melancholia is, however, quite admissible as denot- 
 ing a variation which the symptoms may assume. Nearly 
 every object of fear shown in the insane, has given rise to 
 a new name, and multiplied the compound terms ending in 
 -phobia, {vide infra). 
 
 The second kind of morbid apprehensions is that connected 
 with the patient's future state ; this is an important and common 
 form, such as : — fears of eternal punishment, or loss of salva- 
 tion, of being accursed of God, of having forfeited redemption, 
 of having committed " the unpardonable sin." These fancies Hke 
 the other, commence as fears or apprehensions only, but become 
 
 • This is quoted from Burton, Anatomy of Melanclwly, who says of it, "it ia 
 Hippocrates' observation, Galen's sentence." 
 
ORDINARY INSANITY — FIRST STAGE. II3 
 
 fixed and believed when they are delusions, and come under an- 
 other section in the division of our subject. These apprehen- 
 sions appear to be attended, very often, with the same physical 
 sensation of dread at the prfecordia or region of the aortic arch. 
 They form a part and cause of depression, which is aggravated, 
 and, as it were, authorised by them. Tliey lead the sufferers to 
 resort to reading religious books in their soUtude, to be con- 
 stantly on their knees in prayer — to be attending at every avail- 
 ing religious service, regardless of fatigues, distance, hours, &c.* 
 This excess of zeal, however, may be and probably more often 
 is, due to a perversion of feeling, rather than to an apprehen- 
 sion of their reHgious state. These cases have been called Reli- 
 gious Melancholy. This leads naturally to the next division of 
 phenomena. 
 
 3. Alterations of Affections and Moral Instincts. As morbid 
 apprehension is a state or condition of the moral faculties, so is 
 this the next artificial division of our subject. Dugald Stewart, 
 as quoted — vide p. 22, divides the moral faculties, into appetites, 
 desires, afi"ections, moral sense, and self-love. The alteration 
 observed in insanity may be conveniently examined by referring 
 to this arrangement ; but the change in any of these emotions is 
 still, in some instances, a change of condition only; for example 
 a morbid apprehension is perhaps only an exaggeration of a nor- 
 mal state, but iu other cases, there is an alteration in kind. 
 
 In this section the change is a difi'erence more in kind, 
 or is a perverted state. As in the previous paragraph, we 
 have seen, that the excess of religious zeal, is at first due 
 to fears about the patient's religious safety ; this zeal of 
 the sufferer often proceeds to an exalted condition or fervour, 
 and not unfrequently the love of the deity leads to amatory feel- 
 ings towards the minister of religion. 
 
 In youth, and perhaps more frequently in females, religion is 
 more a matter of emotion than intellectual conviction. Love is, 
 
 * In connection with morbid fears and apprehensions, fresh names have been 
 introduced for almost any kind or feature that the symptom may take — as pan- 
 phobia, as well as syphiliphobia and even hydrophobophobia. Dr. Westphal is 
 credited with the invention of an Agaraphobia, but which Gelineau says should 
 be called Kenophobia or the fear of spaces. Some of these terms will bo found 
 explained in a future page. On what will not people try to erect a fame I 
 
 I 
 
114 LECTURES ON MENTAL DISEASE. 
 
 as is known, a tenet enjoined by Christian doctrine ; it is an 
 easy transition from tlie love of the Christian doctrine to a love 
 of less chastened kind ; the strong emotion of love being called 
 forth, is easily perverted by being uncontrolled. The love en- 
 couraged by rehgion is a highly abstract emotion ; it is an abstract 
 from all kinds of love. Now one of the strongest kinds, and 
 that which exerts the greatest influence on the organism, is 
 undoubtedly, the sex- love ; this kind of emotion is at one end 
 gross and debasing — and at the other extreme, it is considered 
 to be one of the highest attributes of human nature. In fact 
 this feeling forms the basis of the emotion of the highest 
 kind, in the same manner that all abstract ideas are formed 
 upon impression on the senses. It is an easy transition 
 therefore, for the disturbed mind to go from the love of pure or 
 abstract kind, to that of the less pure or absolutely sensual kind. 
 Erotism or amatory feehngs, and especially among females, 
 is a frequent symptom in the progress of melancholia. It is a 
 fact also, that this symptom is more common among the reli- 
 gious melancholies, than among others. 
 
 This erotism may have a centric origin, or it may be due to 
 eccentric ixTitation, it is difficult to decide which : and jiro- 
 bably the truth is, that the origin is difi'erent in dififerent cases. 
 Undoubtedly it does' arise as a mental perversion — though some 
 have aj)peared to consider, that it Avas brought about, by an irri- 
 tation at the periphery or in tJie sexual organs. It was proposed 
 by one surgeon to perform what he called chtoridectomy, and 
 castration also was tried in one case. The question was thus 
 brought prominently before me at one period, but I never found 
 a clear case, in which the erotic symj^toms of insanity were 
 distinctly of eccentric origin ; the subject will be referred to in a 
 subsequent page. 
 
 Connected with the sexual functions, are various illusions and 
 delusions, which may be mentioned here. Female patients as- 
 sert that they are about to be ravished — they may have at first an 
 apprehension only, then this apprehension becomes a false sen- 
 sation, passuig thus from the first stage of morbid ai>prehension 
 into that of altered sensation. 
 
 Another change as regards the affections, is pretty frequent in 
 the early stage, viz., dishke of friends or relations, as wife to bus- 
 
ORDINARY INSANITY — FIRST STAGE. II5 
 
 band, or in males, of husband to wife, and indifference to all 
 those for whom formerly they had the greatest regard — as for off- 
 spring and parents. From indifference they i)roceed to dishke, 
 and then to accusations of cruelty, unkindness, and actual 
 hatred, and fears in consequence. Connected also with the 
 alterations of the affections, must be mentioned a morbid self- 
 accusation ; examples of which are given among cases appended ; 
 patients accuse themselves of great crimes — of deserving of 
 punishment, &c ; one case referred to, was related by its author 
 as an example of hysterical insanity; it is nevertheless only an 
 example of insanity proper, it may be accompanied by the fear 
 of punishment or other kind of apprehension. 
 
 Besides the alteration in the attachment to others, or altera- 
 tions of affection, — the moral instincts, are frequently cJianged 
 in other respects or toward themselves ; the patients are perhaps 
 regardless of ordinary decency. They cease to attend to theii' per- 
 sonal cleanliness, they become neglectful of their persons, they do 
 not provide for their own wants, they will eat anything and in any 
 way ; they thus become altered and slovenly in appearance, and 
 dh-ty in habits, and are perfectly regardless of their condition ; 
 besides this want of decency, there is also an absolute indiffer- 
 ence to the opinions of others ; an absence of normal shame. 
 They not only do disgusting acts openly but use disgusting lan- 
 guage : they, even delicate females, lose all reticence before 
 the opposite sex, and show an enth-e loss of i^ropriety and 
 modesty. 
 
 Among other changes there is also often an absolute i)er- 
 version of the instincts, the most common of which is refusal 
 of food ; the instinct of appetite or hunger, appears to be 
 lost. This symptom, refusal of food, becomes often one of 
 great difficulty to deal with. It probably occurs from different 
 causes. Its precise connection with the mental function, is 
 difficult to trace ; undoubtedly it is caused in some cases, from 
 what is just mentioned, and it is a perversion of a normal desire. 
 In other cases, it appears to be connected with morbid apprehen- 
 sions, as with the fear of poison ; in others with false sensations 
 of taste, a dislike or a suspicion of impure condition of the food ; 
 the food they say tastes of canker or dirt, or other foreign ad- 
 mixture. Patients sometimes appear to desire food ordrhik.but 
 
 i2 
 
Il6 LECTURES ON MENTAL DISEASE. 
 
 are unable to command the volition to take it. One patient I 
 knew who would not take food, but would submit to the use of 
 the stomach pump, as placidly as to the barber to be shaved ; 
 another would entreat for food, but when given to him, he 
 would hold it for hours to his mouth without taking it. In 
 most cases, it seems to be due to a perversion of the normal 
 calls of appetite and instincts for taking food. Connected with 
 this question, is the perversion of instinct in eating nauseous or 
 indigestible articles, dirt, coal, or even faeces, (see Macintosh, 
 Journal of Mental Science, Jan. 18G6, p. 512). This perver- 
 sion of the instincts is met with in some cases, in regard to 
 other animal functions. It is not uncommon for a patient to 
 voluntarily retain the ejections ; the patient appears afraid 
 to evacuate the bowels. He will endeavour with great energy 
 to prevent the action, and after taking aperients will submit 
 voluntarily to all the torment, which he evidently feels, rather 
 than allow anything to pass away. Perhaps will be greatly 
 alarmed, when he no longer can retain his discharges. The 
 same alteration of ordinary instincts, occurs with respect to the 
 urinary secretion. The symptom may be founded upon an ab- 
 surd perversion of reasoning. One patient of mine asserted that 
 he ought to retain everything for strength ; but such a statement 
 may be dependent on the perversion of the instinct. 
 
 There is also the perversions of the sexual passions ; not 
 only an increase of passion but actual perversions, but the 
 state is more likely to occur in the chronic lunatic or in senihty 
 than in the early stage of iudanity, this condition has been 
 found to be due to local irritation or disease of sexual organs 
 in some instances.** 
 
 Self Love. — The next division of the moral affections according 
 to Dugald Stewart's classification is that of self love, and this 
 may be aptly considered here in connection with the perverted 
 instincts. The suicidal propensity is clearly a perversion of a 
 moral instinct, the instinct of self preservation. 
 
 The subject of suicide will be fm-ther discussed in some of its 
 relations in a future page, it must be considered here as a 
 symptom of the early stage of insanity only. 
 
 This symptom occurs quite in the first stage of the disease, 
 * Maciatosb, he. cit. 
 
ORDINARY INSANITY FIRST STAGE. II7 
 
 but in another form as will be shown hereafter, it occurs also 
 in a different stage. When the propensity is present in this 
 stage the patient makes no secret of it, and often repeatedly 
 endeavours to carry out his desire, and usually selects one 
 particular mode of achieving it : thus a patient 'who attempts 
 his life by drowning will make no attempt by hanging, or the 
 knife, and one that attempts to injure himself by fire will adhere 
 to that mode. However, of course too much reHance must not be 
 placed on this feature except to provide special care against the 
 favoured mode ; great care is of course necessary with this class 
 of patient, yet his constant attempts and his repeatedly ex- 
 pressed desire to commit suicide puts the attendants on their 
 guard, and thus it is not often that the act is effected in asylums. 
 
 Suicides in connection with insanity are said to have this pecu- 
 liarity, the insane do not leave behind any statement of the rea- 
 son why they committed the act. This is due doubtless to the 
 fact, that the act is not one of any dehberation, but more of 
 sudden impulse ; these cases have been called suicidal melan- 
 choly, but of course they are not different species of disease and 
 their pathology is the same as that of other cases.* 
 
 All the symptoms yet described, it wiU been seen, are con- 
 nected plainly with states of the emotions, they merge it is true 
 into convictions or beliefs, which would bring them into ano- 
 malies of the intellect proper, yet in the early stage all are 
 emotional. So with suicide it is sought at first as a remedy 
 or rehef from mental agony, when it continues, it becomes more 
 like a perverted instinct and borders upon an intellectual 
 anomaly. 
 
 * Suicidal propensity was reported to be present in 29i per cent, of the 
 patients admitted into asylums in 1879, according to returns of the Commis- 
 sioners in Lunacy, or 26 per cent, amoc"' males and 32 per cent, among females. 
 It occurred in greater numbers among the married (especially among married 
 women) than in any other class. 
 
 Altogether there were admitted in 1879, 3877 suicidal out of 11,758 patients 
 and it tells well for the successful care in Asylums that out of this large num- 
 ber there were only 11 actual suicides, especially as the above number does not 
 take any account of the patients that were admitted previously. 
 
 The gross number of patients in Asylums was 40,088, if the same proportion 
 of suicidal patients to admissions were taken to hold good, there must have been 
 in the Asylums 29i per cent, of the whole or upwards of 13,000 suicidal patients 
 under care, and less than one per thousand of suicides. 
 
 The moral treatment of the suicidal propensity will be found in a subsequent 
 page. 
 
Il8 LECTURES ON MENTAL DISEASE. 
 
 Ilhisions or Ilallminations or alteration connected witli tlie 
 special senses. 
 
 Illusion must by distinguished from delusion. In my previous 
 edition, I pointed out the difference and some of my critics be- 
 lieved that they had completely discomfited me on this point. 
 It seems therefore that there is room for misunderstanding. This 
 is the sum of what I ^\Tote. " A disordered sensation is called 
 an illusion or hallucination. These terms are synonymous. 
 You will find in books definitions of each, but I hold that the 
 terms are perfectly synonymous and I account for the confusion 
 that has arisen from the variation of prefix in the French and 
 English languages. In French there is no such Avord as delu- 
 sion, the French for the English word delusion is illusion and the 
 French of the English word illusion is hallucination." 
 
 Now there are but two kinds of symptom, viz., an error in 
 sensation : — 
 
 1. Known to be an error, 
 
 2. Not so known but believed to be real. 
 
 We require two names only and unfortunately illusion must 
 be one, hallucination would not exactly meet all the require- 
 ments. 
 
 Examples are the best kinds of definition of the Illusion : — 
 
 In the examination of a patient on this point, I was told that he 
 once while sitting in his drawing room, saw the figure of a white 
 dog pass across the room, he added in the same moment, "Of 
 course I knew there was no dog, yet I saw it quite distinctly; " 
 another patient, a medical practitioner, said to me once — " As I 
 was standing looking out of this window I distinctly saw the 
 figure of my wife appear above the garden wall, and in her arms 
 she carried a white bimdle and as I looked the vision disap- 
 peared," "what was that? " he asked, — I replied, " an admirable 
 example of what we call, an illusion" (or if you like a hallucina- 
 tion) it would be called hallucination at all events in French, for 
 he knew that it teas not real. 
 
 These examples seem to make "illusions" more allied to 
 imagination, say to a morbid activity of that faculty. It could 
 not be a memory or an actual recollection of a former impression, 
 for in the one case — the medical man — he could never have seen 
 his wife on the top of the wall, or in the other case the white 
 
ORDINARY INSANITY — FIRST STAGE. IIQ 
 
 <log was never seen in the drawing room, some portion of the 
 scene must have been as it were composed at the time. 
 
 The false sensation in such cases may be called hallucination, 
 the word, however, to ordinary English minds would express, I 
 think a more permanent impression. If we say a person is 
 under the hallucination, we convey an idea that the subject is 
 mistaken on some point permanently, or at least persistently and 
 during a distinct period. Such is at least the present interpre- 
 tation of the word. We do not gain much by going into origi- 
 nal or former significations, but formerly the word was used ia 
 its classical meaning as a simple blunder, a stumble in the 
 dark, ad lucem offendo. Addison as quoted in Johnson's Diction- 
 ary evidently used the word thus, or as a physical blundering 
 not a phantastical creation of the mind as we find the word now 
 signifying. " This must have been the hallucination of the 
 transcriber who probably mistook the dash of the I for a T.'"'' 
 At present it would I think be scarcely considered correct to 
 speak of hallucinations of the sense of taste. 
 
 The morbid phenomenon is clearly an error connected with 
 sensation or its concomitant, perce]3tiou. The idea formed is 
 however not so vivid as to resist the process of verification in 
 the subsequent mental process. 
 
 Illusion has been described by some, and so differentiated 
 from hallucination, by confining it to such errors of sensation 
 as are shared in by others — the cause, as it were, being in the 
 object, not the subject; in plain words, as in the tricks of con- 
 jurors and in various optical effects. In this sense illusions 
 are not symptoms of disease at all. 
 
 The term illusion is at all events intended here to represent 
 that defect in the sensations which is felt to be not the represen- 
 tation of an actual object, and it is the same which the French 
 call "hallucination." 
 
 Illusions only rarely occur, when they occur they happen 
 early in the course of a case, and they may be considered under 
 the different special senses. 
 
 Vision. — Illusions of sight, as the appearance of angels, 
 heavenly visions, and such instances as already mentioned. 
 
 Hearing. — Of voices, or various sounds. Such illusions are 
 
 * Addison. 
 
120 LECTURES ON MENTAL DISEASE. 
 
 common in other cases from various causes, as tinnitus ; but in 
 mental disease the sound takes a more definite character — as of 
 words, tunes, &c. Illusions of auditory land are less common 
 than delusions, of which mention will be made further on. 
 
 Taste. — Illusions connected with this sense are more frequent. 
 The taste of canker, of metal, or of different disagreeable charac- 
 ter occur, and like those connected with hearing eventually be- 
 come delusions. 
 
 Smell. — The smell of sulphur and various other suflfocating 
 odours are often complained of and occur as illusions. 
 
 Touch. — Examples of false sensations of touch are common. 
 Electric shooting in the limbs and various parts of the body are 
 met with ; patients in the humble class attribute them to elec- 
 tric telegraph, and I have known patients, as these false sensa- 
 tions were becoming more troublesome and pronounced, refuse 
 to sleep on a spring mattress in consequence. 
 
 Besides these, there are met with other morbid sensations, 
 which probably, like the above, commence as illusions and be- 
 come believed, and therefore are at length delusions — as a feel- 
 ing of being too tall, too short, too large or small ; patients 
 will assert that they have eateji too much, that they are dead, 
 that some member is dead, changed, &c, ; all of which will be 
 alluded to further on when we pass to the subject of delusions. 
 
 Motility. — All the above divisions of the phenomena occur 
 as a rule in the order in which they have been mentioned. The 
 depression is the earliest symjitom, the next to appear is mor- 
 bid apprehension, but the depression continues ; then occurs the 
 alteration in the moral emotions, the apprehensions and depres- 
 sion still continuing ; and the same with the illusions. If the 
 case continues to progress these are added ; but as regards the 
 alteration of motiUty it over-rides the whole and extends through 
 the entire series, even into the later stages of the disease. 
 
 Motility is altered in two ways : — 
 By excess. 
 By diminution. 
 
 1. By Excess. — In the expression of gi'ief — I mean normal 
 grief, we find the movements differently aflfectcd. One person in 
 a state of mental distress will pace the room with eye fixed on 
 the ground ; another wiU walk rapidly to and fro in a restless 
 
ORDINARY INSANITY FIRST STAGE. 121 
 
 m.anucr ; some will throw their arms about, and above their 
 head, or throw themselves down on the floor, &c. ; while, on 
 the other hand, we may see another who sits motionless. So 
 it is in disease ; one patient will show extreme restlessness, 
 will walk to and fro, frequently turning, like an animal in a cage, 
 giving utterance at the same time to some monotonous complaint, 
 as. Oh, dear ! — oh, dear, never varying the idea — and is un- 
 able to sit still. When the patient exhibits this state the dis- 
 ease has been called melancholia agitans. Other patients exhibit 
 the same restlessness by wandering to a distance, leaving their 
 homes, and sometimes conceahng their whereabouts from their 
 friends (^melancholia errabunda) . 
 
 This condition of restlessness is attended with various acts of 
 fidgetting — women unravel their apron strings, men fray out 
 then- cravats, or pull at their buttons, pluck out their hair, pick 
 their skin, bite the nails to the quick ; women make their nails 
 bleed with pins, they rock themselves to and fro, &c. 
 
 The case with excess in movements is of more favourable 
 character. 
 
 2. By diminished motility. — The case with diminished motility 
 is less common, but of graver prognosis ; while the efferent 
 stimulus seems to unduly excite in the former kind of case, in 
 this it seems not to act on the motor organs at all. In certain 
 cases in which the patient has recovered, it has been found that 
 the intellect has not been more involved than in cases with dim- 
 inished action, the patients have remembered every occurrence 
 that has taken place ; but the absence of movements gives to 
 these cases all the outward characters of extreme dementia. 
 The cases have been called acute dementia, but in my opinion 
 very wrongly. I believe the case has been also mistaken for 
 general paresis. The French more correctly have named it 
 melancholy with stupor. In Germany it is called Melancholie 
 mit Stxunpfsinn, it has also been called Melancholia attonita. 
 
 There are, however, degrees of this inactivity ; some patients 
 merely exhibit a sluggishness of movements ; and from this con- 
 dition to that of a stolid immobihty, various degrees are met 
 with ; such conditions in the most marked character belong 
 rather to the chronic stage of the case, and wiU be described in 
 a future page. 
 
122 LECTURES ON MENTAL DISEASE. 
 
 It must be understood, that most cases of insanity j)roper, 
 generally exliibit symptoms connected with all the divisions into 
 wliicli I liave classed the symptoms, but the variety is so great 
 that general terms are indispensable. " The four and twenty 
 letters," says old Burton, " make no more variety of words in 
 diverse languages than melancholy conceits produce diversity of 
 symjjtoms in several persons." 
 
 What has been given is however connected only with the men- 
 tal phenomena of the first stage, (see table p. 108) to make the 
 description more complete it remains to point out, that up to 
 this stage the intellect proper of the patient is scarcely affected, 
 and to what extent it is affected is no more than through the 
 fcehugs. The patients may take a too miserable view of life— and 
 so far are incorrect, but from then own standpoint, not illogical. 
 If got to attend, they could give as correct a judgment of any 
 business matter as ever, they are able to calculate, they remem- 
 ber, they can form a correct view on most topics, so long as the 
 result is not directly dependent on their personal feelings. A 
 banker, for instance, while in a profound state of melancholy, 
 transacted all the affairs of business for several years. A man 
 of property managed his estate, bought and sold his stock, had 
 a large number of tenants, servants, and tradesmen with whom 
 he personally carried on his affairs, and at last he shot himself. 
 
 Before passing to the next part of the progi*ess of the case. I 
 would especially note that though I have introduced various 
 terms us, melancholia relir/iosa, erotice, errahunda, ar/itaus, etc., etc. 
 I have done so merely to show on what slight gi'ounds, and 
 on what slight variations of the symptoms some have endea- 
 voured to miiltiply the kinds of insanity ; if by employing these 
 terms anyone is lead to suppose they are separate species of 
 disease they are positively confusing and mischievous. There 
 is no objection, however, to their use, combined with melan- 
 cholia, as melancholy itself is only a collective term for the 
 symptoms of a stage in the disease. 
 
 To examine into the state of the patient in this stage of the 
 disease, as regards the moral emotions, with the view, for ex- 
 ample, of signing a certificate of insanity, or for case taking, I 
 have been in the habit of recommending in my clinical lectures 
 the use of the following inemoria technica as it is called. 
 
ORDINARY INSANITY — FIRST STAGE. I23 
 
 The word " methodic " may be used to assist in the investiga- 
 tion of tlie symptoms by dividing one's questions, thus : — 
 Is the patient changed in 
 
 M manner. 
 
 E emotional feelings, as affection, etc. 
 
 T temper. 
 
 H habit. 
 
 or 
 
 D in disposition. 
 
 1 ideas or intellect. 
 C character. 
 
 A careful investigation on these heads will often greatly assist 
 in the description of the phenomena, and give well marked rea- 
 sons for a certificate. 
 
 These altered conditions are often quite transient, they have 
 no bad prognostic signification, for they belong to the early or 
 curable stage of the malady, but it must be distinctly ascer- 
 tained, that the alterations are not connected with some fixed 
 behef, when their import would be more serious, as will be shown 
 in the sequel ; for the sake of giving a collective view of this 
 stage some allusion to the state of the bodUy symptoms may be 
 advisable, but a general review of these wUl be found separately 
 further on. 
 
 Bodihj symptoms of the first stage. — In the early stage of in- 
 sanity it is rather difficult to say by which class of bodily symp- 
 toms the disease commences. When the disease has lasted any 
 time, distinct alteration of general health is apparent ; but some 
 might argue that this was due to the general neglect of care, or 
 to the interference with the usual precautious about health, the 
 refusal of food, neglect of person, etc. To the friends this seems 
 the usual course of reasoning and they attribute several of the 
 bodily ailments to the patient's own neglect. 
 
 This I am disposed to believe is a fallacy, and it arises from want 
 of sufficient observation. The patient seldom complains, and thus 
 the nature of the earhest bodily symptoms is concealed. When 
 a mental cause, as grief or anxiety has clearly been in opera- 
 tion, when the mind has been too much absorbed, that nourish- 
 ment is no longer taken or cared for, when the bowels become 
 in consequence constipated and neglected, there follows all the 
 
124 LECTURES ON MENTAL DISEASE. 
 
 consequences, as from lonj? retained faecal accumulations which is 
 followed by flatulence, indigestion, and these are perhaps aggra- 
 vated by further imprudent feeding or drinking ; while the 
 more active functions obtain no rest in sleep, for insomnia is 
 common. It is seldom that any pain in the head is to be noted. 
 The patient is often unaware of any trouble of digestion ; but a 
 shght exammation shows that the nutrient functions are much 
 interfered with. The expression of countenance is languid and 
 dull, the complexion muddy, the hair dry, the skin is harsh, 
 often the breath is foul, the tongue coated, a foxy odour proceeds 
 from the person, etc., the urine is loaded and often with excess 
 of phosphates, yet none of these are complained of. In some 
 cases I have observed in this stage, but more frequently in the 
 next, a disposition to great flushing of the face after eating. 
 
 This first stage as noted in the diagram (at p. 108) ends in the 
 following modes. 
 
 1. In recovery. 
 
 2. In death. 
 
 3. By passing into mania. 
 
 4. By becoming chi'onic melanchoha. 
 
 We have now to consider the progress in these directions. 
 
 In illustration of the foregoing general description several 
 cases are cited in the appendix. 
 
 1. Recovery. — The progress towards recovery, in primary cases 
 is gradual, and of course depends much upon external in- 
 fluences. It is to primary cases only, that what has been 
 written refers. 
 
 No doubt, those slight symptoms previously described, usually 
 not connected in the minds of anyone with insanity, frequently 
 and daily occur and pass off either through the assistance of the 
 ordinary medical adviser, or in many instances by self adminis- 
 tered medicines. The cases are considered to be dyspepsia or 
 nervous debilities, etc., and one reads of them often well indicated 
 in the advertisements of the quacks. No doubt many are cured 
 by the random shot of a quack remedy. I must not instance any 
 kind in particular lest I figure myself in their next pubhcation ; 
 but that shght heaviness, confusion of ideas, inaptitude for work, 
 uneasiness at the epigastrium, flatulence, palpitations, etc., are 
 
ORDINARY INSANITY — FIRST STAGE. I25 
 
 often removed by brisk purgation, wliicli is the nature of many 
 of these patent medicines, and thus are nipped in the bud, is 
 highly probable, but these and like symptoms already described 
 are the forerunners of actual insanity. 
 
 The specialist has seldom the case to treat until it is con- 
 firmed, when his remedies are of less avail. 
 
 But when the change in such a case does occur there are 
 certain signs which indicate the commencement of a return to 
 health. 
 
 The progress toward recovery is very gradual ; the indications 
 first shown are a growing interest towards their fellow patients 
 (I am supposing the case to be in an asylum), and an abnega- 
 tion of self — of the self which has been so over- absorbing in the 
 first stage. When I saw a patient walk with another in the 
 pleasure-grounds at Hanwell, or listen to another's tale, I used 
 to view it as a promise of ultimate recovery. Another pretty 
 sure sign is an alteration in their own personal appearance, as 
 more tidiness of toilet or dress, showing a desire, that is, for the 
 opinion or approbation of others. But another sign of improve- 
 ment, and an important one, is the return to a natural expression 
 of feature. I was once naively asked by a lady who was going- 
 round the female wards at Hanwell, whether the good-looking 
 ever went insane, as all the patients were so extremely ugly. 
 Though beauty gives no immunity, yet it seldom continues 
 during the attack. Female beauty especially, which depends 
 so much on symmetry and regularity of outline, I suppose is 
 interfered with by the contortion of feature, and untidiness of 
 toilet ; certainly it often disappears, but again returns on con- 
 valescence, and the return of beauty thus becomes a symptom 
 of a return to sanity ; but even with those who have no claim 
 to good looks, the return of the sane expression of the features is 
 equally a sign of convalescence. Another sign is a returning 
 wish for occupation in some way ; a greater order and obedi- 
 ence to the rules of the asylum, together with a cheerfulness and 
 gratitude to those who have had to nurse them. The last and 
 best sign of all is the gradually awakening of the patient to the 
 fact that he has been insane. The acknowledgement on the 
 part of the patient of having been insane, is generally looked 
 upon as the crowning evidence of recovery ; and it is a very safe 
 proof of the return to sanity. 
 
126 LECTURES ON MENTAL DISEASE. 
 
 The progress toward recovery may extend over weeks or 
 months, and be scarcely perceptible to those much vsith the 
 patient. The progi-ess, too, is not usually uniform ; the symp- 
 toms from day to day appear to go backward or forward, like the 
 waves of the retreating tide, but viewed from month to month 
 or week to week, the improvement becomes manifest. In one 
 description of case, that with muscular immobility (melancholy 
 with stupor), the change often appears to occur suddenly, but 
 the convalescence is often more in appearance than real. The 
 fact is, the motor s^nnptoms only undergo the sudden change, 
 the state of the mental symptoms remaining unchanged. The 
 sudden alteration of the motor symptoms, the return of more 
 animated expression of feature, and the great change of a dogged 
 immobihty to an ordinary amount of activity, is a great con- 
 trast, and strikes the observer, but when the mind is critically 
 scrutinised there will be found to remain much disturbance of 
 its functions. There is usually, in the former condition of the 
 patient, a great reluctance to speak, and the mind appears to be 
 more affected than it really is ; and hence, when the immobihty 
 ceases, the mind appears to undergo a greater change than 
 actually occurs. 
 
 So much for the progress of the disease in the first direction^ 
 or that towards recovery, and which usually occupies from three 
 to six mouths in primary attacks. 
 
 It is not easy to obtain exactly the proportion of recoveries in 
 these cases, because in the statistics published no separation of 
 them has been made from other forms of the disease. But re- 
 covery will take place in from 75 to 80 per cent, at least. The 
 chance of such an event, was estimated by Dr. Thurnam in his 
 work on Statistics of Insanity, to be greatly enhanced by an 
 early attention to the case. He found, in fact, that cases 
 of all lands of mental disease, if admitted within three months 
 of the commencement, recovered in the proportion of 78" 18 
 per cent. The recoveries at St. Luke's, where these cases 
 only are received, excluding those of paralysis and epilepsy, 
 are about 75 per cent., and when death occurs as will be 
 shown presently, it is often through a compUcation with other 
 forms of disease. 
 
 2. Second Mode of Tcwiinatmi. — The next mode of termina- 
 
ORDINARY INSANITY FIRST STAGE. I27 
 
 tion of a case of acute iusauity, which will be considered, is the 
 fatal termi)iation. 
 
 When death occurs, it is more frequently due to what may 
 be called the accidents of the case, rather than to the ingraves- 
 cence of the original malady. 
 
 Among these causes may be enumerated : — Suicide, in- 
 cludmg exhaustion from persistent refusal of food ; various 
 intercurrent diseases induced by exposure, &c., the principal 
 intercurrent disease is phthisis ; different forms of visceral 
 disease aggravated by the neglect and habits of the patient, 
 as pyfemia, following upon suppuration of boils, and by a 
 form of chest disease, more common among lunatics than 
 others, gangrene of the lungs ; also not infrequently by disease of 
 old standing of kidneys, heart, as well of diseases of general 
 system, anthrax, syphilis, scrofula, besides atheroma, apoplexy, 
 tubercle of other organs — which will, however, be considered 
 under the subject of morbid anatomy. 
 
 I am not aware that any very accurate calculations have been 
 pubhshed of the number of deaths that occur, and are attribut- 
 able directly to the mental disease. But I find from such calcu- 
 lations, as I have been able to make myself, that about one half 
 of the deaths that happen in acute insanity, may be attributed 
 to the disease itself, or more accurately in the proportion of 25 
 to 45. The total number of deaths in acute cases, cannot be 
 more than one-tenth of the occurring cases ; and since in 
 round numbers about 75 per cent, recover, and 10 die, it fol- 
 lows that 15 per cent, pass into a chronic stage, in which state 
 some few more ultimately recover. These proportions are how- 
 ever but rough estimates. 
 
 When death occurs from a distinct severity'of the attack, it 
 does so with all the symptoms of meningitis or encephalitis ; but 
 for details the reader is referred to subsequent chapters. 
 
 Before proceeding to the consideration of the next stage, it 
 will be as well to mention certain cases — which are more con- 
 nected with the acute than the chronic stage, and which have 
 been considered by some to be distinct kinds of disease ; I 
 allude to what is called — 
 
 Puerperal insanity. 
 Phthisical insanity. 
 Hysterical insanity or hysterical mania. 
 
128 LECTURES ON MENTAL DISEASE. 
 
 After long and careful attention to the above, or to cases com- 
 plicated by the puerperal state or with phthisical or hysterical 
 symptoms, I can perceive nothing which should constitute such 
 cases as examples of a specific disease. Doubtless the puer- 
 peral state, as well as a condition of phthisis or hysteria, may 
 modify the course of the symptoms ; but when insanity occurs 
 in subjects affected as above, the symptoms take the same order, 
 follow in the same course, and terminate in the same way, as 
 other cases. 
 
 In what way then do they modify the symptoms. 
 
 Firstly, as regards what is called puerperal insanity. It must 
 be admitted that cerebral symptoms occur in various other con- 
 ditions besides insanity, e.(j. a somewhat sudden outbreak of 
 delii-ium attended with violence, and resembling the maniacal 
 paroxysm, occurs as a symptom : — 
 
 1. In certain cases of ansemia, as during the convalescence 
 from fever, as well as after some puerperal cases. 
 
 2. Maniacal outbreak is often nearly the first symptom in 
 recurrent insanity and general paresis, and occurs also in con- 
 nexion with epilepsy. 
 
 3. In cases of delirium tremens, as an early symptom in 
 acute specific disease and in acute carditis (Watson's Lectures 
 vol. ii, p. 61, 4th edit.). 
 
 With regard to puerperal insanity, a patient may during preg- 
 nancy, at the time of dehvery, or immediately after dehvery, or 
 during lactation, be taken with the symptoms of mental disease 
 of any form. I have had patients at these epochs with or- 
 dinary insanity, and with general paresis. A patient, unmar- 
 ried, of respectable character, became pregnant, endured much 
 mental misery in looking forward to the exposure, became in- 
 sane and was admitted into Hanwell and went through all the 
 symptoms, (see cases in appendix). 
 
 Another case was sent to Hanwell during the time when the 
 admissions were confined to recent cases. In order to admit 
 her, she was certified to have been ill a few weeks ; but the cer- 
 tificate also stated that she had the delusion that she was giving 
 birth to 800 children a day. Such a behef was clearly a delu- 
 sion, and delusions do not occur in the early stage. I therefore 
 detected the fraud which was attempted, and the friends gave a 
 
ORDINARY INSANITY — FIRST STAGE. 129 
 
 history of eight years of insanity. Was this a puerperal case ? 
 The patient had gone through a mchinchohc stage, and had 
 clearly then not puerperal mania, — had the disease changed? 
 Another patient was admitted with a child at the breast, re- 
 mained in the asylum eight months, and was discharged cured. 
 Fifteen months subsequently she was re- admitted. What was 
 the second attack ? There was no puerperal cause for it. Was 
 the first case puerperal insanity, and if so, what was the second? 
 It may be argued that these cases were instances of ordinary 
 insanity, simply occurring at a particular epoch, as I consider 
 them to have been ; but as to any other cases, which have dif- 
 ferent features entirely, such I have never seen. 
 
 A puerperal woman does not enjoy any immunity from an 
 attack of mental disease, but rather the contrary. Single women 
 have often to bear considerable anxiety, and suffer in various ways. 
 Then the puerperal condition, and especially parturition, is a 
 very exhausting process, and is often attended with great loss of 
 blood. And certain cases of so-called insanity are simply cases 
 of delirium from aufemia. In my practice I have met with 
 many such, and have strongly urged the friends not to send the 
 patient to any asylum, and the cases in a large majority do well. 
 The condition resembles more nearly traumatic delirium, and is 
 relieved by the same means. 
 
 Patients with a tendency to insanity in the recurrent form, 
 are often seized with an attack in the puerperal condition, so 
 that they have an attack of insanity with each parturition. 
 Such cases obey the usual law of recurrent attacks which are 
 liable to be brought on by anything which disturbs the system, 
 (see Kecurrent Insanity, in the sequel) . 
 
 We have thus, three kinds of mental signs liable to occur in 
 connection with the puerperal condition. 
 
 1. Simple anaemic deluium. 
 
 2. An attack of ordinary insanity. 
 8. An attack of recurrent insanity. 
 
 The first is no case of insanity at aU. However, cases havG 
 been reported which eventually become so. 
 
 The second and thh'd obey the same order in their course, 
 
130 LECTURES ON MENTAL DISEASE. 
 
 as other cases of insanity, and are in no way excep- 
 tional."'' 
 
 2n(l Staije. Mania. — By referring to the diagram at p. 108., 
 it will be seen that supposing the termination of the case is not 
 by recovery or death, there remain two modes by which the 
 acute condition of melanchoHa may be continued, viz., by pass- 
 ing into mania or into chronic melancholia. 
 
 In speaking of the first stage of melancholia, it was stated 
 that about 75 per cent, of the cases terminate by recover}' ; 
 it should be rather ' ultimately recover,' because a large propor- 
 tion (but in what ratio, it is difficult for many reasons to say'), 
 of such cases before recovery, pass into the state of acute mania 
 and in that stage get well. No statistics that I Imow of, separ- 
 ate these stages ; the same cases admitted as melancholia, in 
 fact are reported as recoveries from mania. 
 
 What is meant by the term mania ? It is given in different 
 treatises in various formula) of words, but the condition is best 
 described as consisting in excitement and ■snolence. The vari- 
 ous definitions of authors amount to little more than this ; 
 Esquirol calls it a chronic cerebral aflection, ordinarily without 
 fever, characterised by disturbance and exaltation of the seusi- 
 bihty, understanding, and will. Guislaiu writes, the characters 
 are exaggeration, exaltation and agitation, and aggressive pas- 
 sions. The patient exhibits petulance, violence, and furor. 
 These characters should be considered in conjunction with M. 
 Guislain's ideas of treatment by restraints {vide Treatment, infra). 
 M. Baillarger defines it as " over excitement, general and per- 
 manent, of the intellectual and moral faculties." There appears 
 to be, at all events, a condition of abnormal impressiouabihty of 
 both afferent and efferent nerve action. 
 
 * " So-called puerperal insanity is ordinary insanity, appearing at, and only 
 elishtly modified by the cbild-bearing circumstances." Dr Thompson Dickson, 
 Journal of Mental Science, Oct., 1870,— in a paper, with cases, read before the 
 Medical Society of London. 
 
 Dr. Ripping, M.S. of the Asylum in Siopburg, Stuttgart, gives the following 
 results in 163 cases of the psychosis of pregnancy, childbed, and lactation. He 
 concludes that oliga^mia (ancemia) is at the root of all puerperal cases, and 
 found it to be strongly marked in 153 cases. He denies anything specific in the 
 nature of the cases. JoumaX of Mental Science, Oct., 1878. 
 
ORDINARY INSANITY — SECOND STAGE. I3I 
 
 Most authors, includin.i,' those cited, treat mania as a distinct 
 disc;;i,se. I consider it simply a condition, or a group of pheno- 
 mena wliicli happen together, and which may be conveniently 
 expressed in the general term " mania " ; this group occurs un- 
 di'r other circumstances than that which we are now considering, 
 which will be shown further on, at present we have to con- 
 sider the maniacal state as a stage in a case of insanity proper. 
 
 The condition of mania usually follows the melancholic stage 
 in a very gradual manner. At first it shows itself as a mere 
 exaggeration of the restlessness (in the case called melancholia 
 agitans for example) and the mental depression may still pre- 
 dominate, or a maniacal violence appears to be induced by exces- 
 sive and morbid apprehensions and fears, as though in sup- 
 posed self-defence, or to escape from injury, much more rarely 
 in my experience from malevolence as in M. Guislain's practice. 
 
 The maniacal stage in primary attacks, and which alone I am 
 at present occupied with, is seldom so completely developed at 
 once that one could fix upon the date of its commencement ; 
 and even after it has been distinctly established, it may alternate 
 with melancholic symptoms to such a degree that on many oc- 
 casions it has been impossible to say which condition predomi- 
 nates, mania or melancholy. Sometimes the patient, still greatly 
 depressed in spirits, becomes simply more energetic in manner, 
 following in this respect what is natural in the expression of grief, 
 when grief increases to a degree to become at last unbearable. 
 The excitement and the violence seem to be the result of impa- 
 tience, and one can readily imagine how by opposition, resistance 
 of force to force, the condition can be aggravated till blows, oaths, 
 rending of clothes, smashing of glass and furniture are the con- 
 sequence ; or the tormented patient seeks an outlet to his excited 
 impressions in shrieks, curses, etc. ; all this time grief and the 
 painful moral emotions may be the condition of the jiatient's 
 mind. Though of course malevolent ideas may arise in some, 
 spontaneously, especially in uncultivated minds. Still, treat- 
 ment has much to do with the amount of violence and excite- 
 ment, but where coercion and opposition most prevail, there is 
 always the most violence and excitement as the result. 
 
 That the state of mania follows in a case of insanity upon a 
 state of melancholy is no new doctrine or discovery ; and that the 
 
 k2 
 
132 LECTURES ON MENTAL DISEASE. 
 
 two conditions alternate and intermix, and are not therefore 
 easily separable lias long been known. Htill raelancholia and 
 mania continue to be described as two diseases instead of 
 grouped phenomena in one morbid chain of symptoms. A 
 writer in A.D. 1G72 says in his chapter of mania, " post Melan- 
 choliam, sequitur agendum de mania, qua isti tautum affiuis 
 est, lit hi affectus saepe vices commutent, et alteruter in alteram 
 transeat." 
 
 Griesinger quotes the following with approval and says he 
 entirely agrees with it: " the anonymous author in the Diction- 
 naire Abreye des Sciences Medicahs, in speaking of melancholia, 
 says, ' these transitions or transformations of melancholia and 
 mania are not made suddenly, the patients pass from one state 
 to another, by innumerable intermediate degrees, which present, 
 so to speak, all the states of admixture in a thousand different 
 ways.' Hence one must conclude that all those groups of 
 symptoms out of which one has striven to make several diseases 
 form degrees of the same morbid state, and that which proves it 
 is, that in an accession of mania which manifests itself in a 
 melancholic patient one observes in succession the greater por- 
 tion of the phenomena indicated." 
 
 By an analysis .of the phenomena of the maniacal stage 
 of insanity, it will be found, that with respect to both men- 
 tal and motor sj^mptoms, there is an exaggeration of them 
 in every direction ; the impressions from without produce a 
 greater excitation and the corresponding efferent results are in- 
 tensified. The sensations are sometimes even painful, tliere 
 is often distinct photophobia and intolerance of sounds as 
 well as impatience to the sense of touch, while every outcome 
 is an excess, the ideas flow more vividly, and often in the 
 greatest confusion. They are expressed in rapid and loud 
 speech, the words are stormy and vehement, there is loud shout- 
 ing and swearing, and exhibitions of considerable violence and 
 anger. The limbs are violently agitated, the patient is restless 
 and violent m conduct, and will attack the bystander, destroy 
 furniture, or glass, and smash everything around ; such is the 
 state of the acute outbreak. 
 
 But that which is the chief feature of the maniacal stage of 
 acute insanity, is that it exhibits for the first time in the case, a 
 
ORDINARY INSANITY SECOND STAGE. I33 
 
 distinct exteusion of the mental symptoms to the intellect proper. 
 Patients in the early stage have their powers of perception, and 
 thcii* reasoning faculties clear and though they have various 
 false sensations as foul smells, disagreeable tastes, in other words 
 illusions, they are able to correct the impression by an act of 
 intellect, but when this phase has passed into mania, the patients 
 exhibit distinct aberration of intellect ; they talk incoherently, 
 rambling from subject to subject, showing considerable distur- 
 bance in the association of ideas ; they begin to believe in the 
 reality of their false sensations, and from only complaming of a 
 foul taste, they begin to believe in having been poisoned ; the 
 voices they hear are now believed to be real. The patient's' 
 power of attention is lost, his replies are irrelevant. His ener- 
 gies or violence are called forth without obvious cause, and all his 
 emotions are in the same wild and uncontrolled condition. As 
 the state increases every natural instinct or feeling is thrown in- 
 to disorder, and every decency or propriety is outraged. "While 
 the actions, which are performed with ease and precision as in 
 health, are excessive and misdirected in their character, the 
 patient is wild, ungovernable, violent, dangerous, abusive, in- 
 coherent, disgusting and blasphemous in language, filthy and 
 degraded in habits, regardless of decency, cleanliness, or mod- 
 esty but not usually lewd, though frec^uently dangerous to others. 
 
 With all this some patients have distinct and special mental 
 characteristics, which run through the whole of their actions 
 resulting perhaps in vicious tendencies of a distinct character. 
 The direction of the insane acts of such patients, has lead to a 
 large introduction of fresh names and so-called kinds of insanity, 
 but since most of these peculiar characteristics form a more pro- 
 minent feature in the chronic stage, than in this which we are 
 now considering, their enumeration had better be deferred. 
 Still some few of these particular features belong to this stage 
 also, such as the tendency to hysterics, to sexual excitement, to 
 destroy articles by fire or burning, to suicide, to various dis- 
 orders of movement approaching to a state of catalepsy, to 
 walking round and round {en maneije), etc., to noise, shouting, etc. 
 
 The development of maniacal symptoms, however difficult to 
 treat, does not add any mifavourable character to the prognosis. 
 On the contrary where the melancholic stage has been prolonged, 
 
134 LECTURES ON' MENIAL DISEASE. 
 
 the change of the symptoms to those of mania yields a better 
 prospect of recovery. 
 
 The hodihj .si/i/ijdoms. — Tlie botlily symptoms of the acute stage 
 will be considered in a future page. It may be as well, 
 however, to mention that there are several states which may 
 occur and show the approach of general improvement. Besides 
 the appearance of less excitement or more rational behaviour, the 
 occurrence of boils, and falling off of the hair are of good augury. 
 "When the menstruation has been interrupted, its reappear- 
 ance is favourable, but I have known this function to occur 
 with great regularity through the entire course of maniacal dis- 
 turbance. When the function has been supijressed, as it is pro- 
 bably quite as often as not in the early stages of insanity, the re- 
 establishment of regularity is a favourable sign ; inasmuch as it 
 is a sign of returning health. I do not think it is at all certain 
 that it influences the insanity in any other way. 
 
 With respect to intercurrent diseases in the course of an 
 ordinary insanity, and the modifications which may occur in 
 different conditions of the system, as during the jnierperal state, 
 or period of lactation, etc., my remarks will be postponed to a 
 future page. 
 
 Firstlij. — Tiie pnif/rj'sii of a cane of acute mania is towards recovery, 
 as showti in tlie d^aijram , p. lOS. 
 
 Recoveri/. — The progress towards recoveiy is to be noted in 
 the gradual return of the patient to quieter habits and be- 
 haviour ; this is accompanied, especially in females witli a 
 greater disposition to cleanliness and tidiness of person. The 
 state of increased tranquility is prefigured particularly in the 
 expression of the face. The features put on by degrees a more 
 natural expression, and patients either men or women, but par- 
 ticularly the latter, change from a state of ugliuess, positively 
 repulsive, to a pleasing and even comely ajipearance, little an- 
 ticipated by their attendants, who were not acquainted with 
 the patients prior to their illness. 
 
 The general health too, improves by degrees and one particu- 
 larly good sign, and a delicate one for testing the change is a gain 
 in weight, for patients when quite convalescent often become fat. 
 The disturbed bodily functions, in fine, gradually take their 
 normal action. 
 
ORDINARY INSANITY SECOND STAGE. I35 
 
 The mental phenomena as well, show a gradual improvement, 
 delusions fade, maniacal tricks cease, the patient ceases to pick 
 himself, his sores heal therefore, the hair begins to gi-ow and he 
 takes notice by degrees of his companions. He begins to occupy 
 himself in various ways, or he will allow himself to be amused. 
 •Even in private asylums, where occupation is peculiarly difficult, 
 the patient will gradually show some bent to occupation by walk- 
 ing, reading, etc. Often as the delusions or wUd fancies dis- 
 appear, the patient appears a httle sad. He is as it were ashamed 
 at the recollections of many of his insane acts, when his self- 
 control had deserted him. 
 
 A test of recovery generally allowed, is the patient's admis- 
 sion that his acts have been those of an insane person, and that 
 he has been wandering in mind, the lunatic who was the loudest 
 in his assertion of unjust incarceration and who has demanded 
 with greatest vehemence to be discharged, gradually ceases to 
 demand his liberty, and will even go so ^far as to say, that he 
 would prefer to abide the doctor's time. 
 
 The next mode by which onUnarij insanity or insanity proper may 
 progress, is towards a fatal termination (see diagram, p. 108). 
 
 Death. Death in the acute stage of maniacal excitement, occurs 
 in a small proportion of cases ; I have no statistics on this sub- 
 ject. Most primary cases, whether melancholic or maniacal, and 
 which terminate fatally, aie reported as dying of exliaustion or 
 debility. Thus, in Sir Charles Hood's statistics of Bethlehem 
 Hospital, we find it reported, that 25 per cent, are reported as 
 dying from exhaustion and only 5 per cent, of mania. 
 
 It is, however, well ascertained, that of the deaths from all 
 causes, more than half die in the first two years, therefore 
 mostly in the acute stage, and out of these one-thu-d only, 
 would be by general paresis, so that death of the rest must 
 occur from acute insanity. So that by a rough estimate, nearly 
 a third of the patients admitted die in acute insanity. 
 
 But though they die in the course of the disease, it does not 
 of course follow, that they die by the disease, or on account of 
 the brain symptoms. Speaking from memory and general im- 
 pressions, I should put the proportion of such deaths to be much 
 fewer. 
 
136 LECTURES ON MENTAL DISEASE. 
 
 I find this to be tlie conclusion of others, Dr. ^larco, {'I'raiu- 
 des Maladies Mentales, p. 291), writes, "death occurs rarely in the 
 course of acute mania." Griesinger says, " death may happen 
 in mania through the brain disease, by excessive hyperemia — 
 more rarely by extravasation." More commonly the patient 
 succumbs to a state of collapse after the maniacal symptoms. 
 
 "When a patient dies in this early stage of mania, it is after a 
 very short stage of melancholy only, and the symptoms are 
 those ■which are given as encephalitis in works on medicine. 
 Dr. Bristowe says, "of acute general inflammation of the en - 
 cephalon, there is little to be said, the cases are rare. The 
 symptoms which they present are vague ; and the morbid 
 changes which are observed after death are, to say the least, 
 obscure." So that death from cerebral mischief is equally un- 
 common in general hospitals, as in asylums. 
 
 In making this statement, we must leave out of question, 
 local cerebral inflammation set up around apoplectic clots, or in 
 the vicinity of diseased bones, or from tubercle which may from 
 time to time occur in asylum practice. 
 
 Among my own notes I have record of several cases of death 
 occurring in the acute stage. The symptoms which I have 
 described of great excitement, raving, insomnia, and typhoid 
 type of general symptoms occurred ; the patient in two cases 
 showed well-marked cessation of celirium and comparative 
 rational state just prior to death, there was severe convulsions in 
 one and strabismus in two of them. 
 
 Death occurs more frequently in the course of the chronic stage, 
 which will be described in the sequel. But it has been shown 
 by Dr. "Wood {On the Plea of Jiisainti/, p. 83j, that "insanity after 
 the violent symptoms of the acute stage have passed oflf, does 
 not necessarily tend to shorten life ; and that the prospect of 
 an average life is greater among those, whose malady is con- 
 firmed, than among those, who suflcr from it in a minor degree." 
 This conclusion Dr. Wood arrived at from an examination of 
 the duration of life in patients at Bethlehem, and comparing 
 then* cases with the tables of the Equitable Life Assurance Com- 
 pany. Doubtless the care that is taken of the poor in our pauper 
 asylums has something to do with this result. 
 
ORDINARY INSANITY- — SECOND STAGE. I37 
 
 Recapitulation and general reviexv of the hodihj sj/mjitoHis in in. 
 sanitij ])roper in the acute stages of mclancJiulia and mania. 
 
 lu a typical case of orcliuary insanity in a primary attack, the 
 first mental symptom has been shown to be melancholia ; but 
 prior to this, the bodily health has begun to suffer. The first 
 disturbance of health is a condition of dyspepsia, not different 
 perceptibly from an ordinary disturbance of the stomach func- 
 tions. There is undoubtedly iu stomach disturbances, or what 
 is called by the public a bilious attack, a certain amount of de- 
 pression or low spmts ; such attacks are common and frequent 
 and pass off; these cases are usually the result of errors of diet, 
 but they show how a slight defect in the blood-making organs 
 may affect the spirits. A case of course is not called insanity, 
 however, until it has advanced further than this in its effects on 
 the mind, and usually the first symptoms of bodily disturbance 
 are brought about through a different course. 
 
 It is not easy in every case to find a cause for the commence- 
 ment of an attack, but many are traced distinctly to what is 
 called a moral cause, as to the loss of child or relation, to a loss 
 of property, &c. In the statistics published by the Commis- 
 sioners in Lunacy such a cause is attributed in one-third 
 to one-fifth of all the cases, but in their table all kinds of 
 cases are included. In the statistics of Bethlehem, published 
 by Sir Charles Hood, moral causes' were attributed in much 
 larger proportion. M. Georget, as quoted by Sir Charles Hood, 
 says, " that in at least 95 per cent, the causes w^ere moral," — 
 that is, from effects on the moral faculties. 
 
 As is often the case, however, it is probable that one kind of 
 cause reacts on the other ; impaired blood-making process, 
 leads to depression, the depression leads to neglect of the or- 
 dinary rules of health. The disease thus gradually increases 
 until the general depression amounts to a state of melancholy. 
 When this condition has been reached the patient is unheedful 
 of his state, often ignores his bodily symptoms, and if questioned 
 would say his bodily health is good ; and in this stage, perhaps, 
 the patient eats well ; only a physical examination can then 
 establish the fact, that the digestion process is defective. 
 
 It will usually be found, that a patient in the early stage has 
 a coated tongue ; that his breath is offensive ; his bowels are 
 
138 LKCTURES ON MENTAL DISEASE. 
 
 constipated ; lie is troubled with wind ; his appetite is capri- 
 cious ; he eats hurriedly perhaps, and suffers after each meal. 
 Females often complain of a feeling of anxiety at the heart ; the 
 hair is rough, harsh and dry, the skin di-y, and later on emits 
 a peculiar odour ; the urine is abnormal and the catamenia sup- 
 pressed. The circulation may not show any disturbance as to 
 frequency of heart's action, but the blood shows a deficiency 
 often of red globules, and a state of chlorosis, with anamic 
 murmur heard at the base of the heart, often exists. 
 
 As the disease progresses the bodily symptoms are often ag- 
 gravated by the mental. Thus, the patient from a mental 
 cause may refuse food, and thus increase the anaemia and 
 debility. One symptom is often met with, and which occurring 
 in ordinary insanity would seem attributable to defect in the 
 sympathetic system, is intense flushing after eating ; there is 
 also often blueness of the roots of the nails, chilblains, and 
 other consequences of defective circulation. To the same con- 
 dition of the system is probably due the common occurrence of in- 
 Bomnolency which is a distressing symptom, and is present 
 through the early even to the advanced stages. The general 
 practitioner, as distinguished from the mad doctor, would be in- 
 credulous if he heard that a patient never slept ; but such hap- 
 pens with the insane for very long periods. It will be seen, in 
 fine, that in this the earliest or melancholic stage, all the svmp- 
 toms point to an error in the process of blood-making ; and it 
 will be remembered, that the mental phenomena are those of 
 modified rather than perverted cerebration. 
 
 But the bodily symptoms are somewhat modified when the 
 disease passes into mania ; the debility is less or is merely 
 masked by the excitement ; there is a recklessness in all the 
 actions of the patients ; the expression of misery is now no 
 longer visible in their features, nor by their words or conduct, 
 they will eat anything that is given, and show no symptoms of 
 pain or inconvenience of dyspepsia if they exist, but the physi- 
 cal signs remain and increase. The tongue is often at this 
 stage red and glazed, the mouth clammj', especially if the 
 patient is noisy, talkative or shouts. Sordes may be present 
 on the teeth, the bowels may continue bound, or diarrhoea 
 may set in, or even dysentery, induced probably by the filthy 
 
ORDINARY INSANITY SECOND STAGE. 139 
 
 habits ; for without care the maniacal will cram their months 
 with dirt or filth, and some Avill oat their own feces, or drink 
 their urine, pick up any dirt or mud, stones, &c. It is of course 
 rare for them to transgress in this way in well managed asylums, 
 but they have the propensity, which is the symptom, and the 
 bodily symptoms may perhaps be greatly accounted for by the 
 propensity. Besides the visceral disturbance the skin is also 
 still more offensive, and emits a more decided odour of peculiar 
 kind. This too appears to be a real phenomenon of the disease, 
 still it may arise from, or at least be increased by the habits of the 
 patient. Maniacal patients, gentlemen or educated females, of 
 refined feelings during health even, may be so transformed by the 
 maniacal symptoms, that they act as the most depraved and 
 abandoned of human beings. A lady or other patient in this 
 stage, will tear off her clothing with complete disregard for 
 everything and when clothed in the dress which is put on her of 
 a kind which cannot be torn, will dance, shout, with her hair 
 dishevelled, or filled with dirt from the garden, she will grovel 
 in the mud, begrime her skin with faeces or any other filthy 
 thing she can obtain ; the skin of the patient is thus in a con- 
 dition calculated to aggravate the disease. Patients, however, 
 often on the advent of mania appear to gain strength, and fre- 
 quently in females the catamenia, which have been absent, 
 re -appear ; and I have known the function to recur regularly 
 through many months of the acute maniacal stage. They also 
 gain flesh and when this occurs it shows of course a favourable 
 turn of the disease ; and an attack of mania following on the 
 acute melancholy is always of good augury. 
 
 There is too another bodily symptom which arises at this stage 
 and is a good prognostic, the occurrence of boils ; these have 
 been very generally observed and some have called them critical, 
 these boils occur in different parts of the surface and follow in 
 succession often for a month or two, they usually pass through 
 the ordinary course. In one case in which they occurred to the 
 degree of carbuncle the patient's life was endangered by exhaus- 
 tion, in another patient the suppuration of a large boil was 
 followed by purulent poisoning and pyanuia, but usually the 
 boils, after troubling the patient for a period, gradually cease, 
 and the patient becomes convalescent in mind and body. 
 
140 LECTURES ON MENTAL DISEASE. 
 
 Death, however, occurs in the maniacal stage and when it 
 does 60 it takes place by: 1. the severity of the morbid pro- 
 cesses of the disease; or 2. through some accidental or intercur- 
 rent cause. 
 
 When death occurs in the maniacal stage under the first of 
 the above conditions the symptoms are those of other acuto 
 cerebral diseases, and the immediate cause of death appears to 
 be owing to exhaustion of the powers by the constant raving 
 and delirium and there may be all the usual symptoms of cere- 
 bral inflammation with effusion, as strabisms, convulsion and 
 the like. I have known also other more rare phenomena as 
 opisthotonus and catalepsy. 
 
 It must be mentioned, however, that there is nothing to dis- 
 tinguish the mania of insanity from the delirium of other cere- 
 bral diseases, or perhaps from the outbreak of general paresis, as 
 will be shown hereafter. It may be also readily confounded 
 with delirium tremens, unless a clear histoiy of the case is to 
 be obtained, there is seldom any of the usual prodroma of 
 meningitis of tubercular origin, seldom any vomiting. 
 
 2. It is more usual perhaps that the cause of death belongs 
 to the second category and occurs from exhaustion due to the 
 constant raving, want of sleep, and refusal of nourishment, 
 rather than to the failure of the nerve functions proper. Death 
 also occurs in this stage from the occurrence of intercurrent 
 diseases, pneumonia, going on to gangrene even, in the lung, 
 to pyfpmia or white deposits (embolus) in the lungs, spleen, etc. 
 and to marasmus. It is especially in such cases that the ther- 
 mometer affords information which is not obtainable from the 
 patient in any other way, the temperature should be carefully 
 taken during the progress of these cases, and it will afford valu- 
 able information of the real state of the morbid processes. 
 
 Treatment in the Acute Stai/es. — In order to keci) the treatment 
 distinct from the enumeration of the sjmptoms, I have preferred 
 to postpone this subject in its general aspect and especially that 
 part which relates to the moral management of the insane, to 
 the end of the history of the progi-ess of the case ; but it will be 
 necessary to consider the subject in its different stages, since 
 the management of one stage differs from that of the other, es- 
 pecially in regard to the first stages. 
 
ORDINARY INSANITY —SECOND STAGE. I4I 
 
 The case of ordiuary iusanity also differs from that of the 
 case of other forms, aud the primary case from that of secondary 
 attacks. 
 
 As ah'eady stated, the first stage of insanity is a condition of 
 melancholy ; the general review ah-eady given of the bodily 
 symptoms, points to the fact that the first stage of treatment 
 must be with the view to correct such symptoms, as occur con- 
 nected with the organs of digestion and assimi]ation. 
 
 Should the patient have restless nights or not be able to sleep, 
 I think 20 grains of chloral at night a valuable remedy, I am 
 not disposed to combine it with the bromides. I have used 
 chloral extensively and have never experienced any ill effects in 
 any case fi'om its use ; opiates, on the contrary, I have not 
 found so beneficial. 
 
 The constipation which is often obstinate and of considerable 
 duration, is in my opinion best treated, unless other things pre- 
 vent its employment, by aloes ; and the form I prefer is equal 
 parts of aloes and mastiche, taken at noon in five to ten grain 
 doses, usually five grains daily is best. The action is slow — 
 appears in fact to be as chronic as the symptoms. The stomach 
 derangement in young people will often be relieved by soda or 
 potass : when there is any gouty tendency, I prefer the latter. 
 We cannot always get our patients in asylums to persevere in a 
 lengthened course of tonics or other medicines that are indi- 
 cated, so that often the remedy must be concealed. Bitters 
 can be hidden by beer ; quarter to half grain of aloine can be 
 dissolved daily in the patient's dinner beer, aud will not be ob- 
 served. In a patient, at Hanwell, with strong apprehensions of 
 being drugged or poisoned, and whose bowels had not acted for 
 nearly a fortnight — who was suspicious of every thing brought 
 to him, as powders in his bread and butter, and who would eat 
 no meat unless he saw it cut out of the centre of a joint, and was 
 supported almost wholly on eggs, I managed to deceive with a dose 
 of elaterine, the dose of which is one-twenty- fifth of a gi-ain. He 
 kept his own beer mug or rather tin, which he polished out him- 
 self and which he saw filled from the beer jug. This small 
 quantity was with some skill poured into his tin, behind the 
 stream of beer. 
 
 In young females the bodily condition often requii-es ferru- 
 
142 LECTUKF.S ON MF.NTAL DISEASE. 
 
 giuous tonics. In cases of refusal the tartrate of iron may be 
 concealed in porter. Its taste is easily concealed by decoction 
 of liqnqrico or Knrsaparilla — or as often Avlicn the jiationt is 
 capricious, iron can be given in chocolate cake or lozenges or 
 made up with ginger-bread nuts ; in the melancholic the chloric 
 ether is useful and may bo combined with the iron. Morphia 
 in small doses, with chloric ether has been extolled ; I have not 
 found morphia useful. 
 
 These being the chief therapeutical agents for correcting the 
 altered functions, and which on speaking in such general terms, 
 only are applicable, a more important portion of the treat- 
 ment remains to be considered. The general hygienic manage- 
 ment of the patient. 
 
 In the maniacal stage supposing the case goes on to this, the 
 same tonic and hygienic means must be persevered in. In this 
 stage especially frequent baths are necessary, particularly for 
 cleanliness. In the early stages of melancholy the Turkish 
 bath has been tried but without marked effect, it is more useful 
 in the second or maniacal stage. When the patient's cutaneous 
 surface is dry and harsh and emitting a bad odour, the tem- 
 perature should be kept up until some perspu-ation is induced 
 which is often no easy thing, the body should be sham- 
 pooed to be followed by a free use of soap, this may be repeated 
 once a week or oftener according to patient's strength. Warm 
 baths are also serviceable in mania ; some physicians have pre- 
 scribed a bath to be kept at a good temperature (101° to 102' 
 Fah.) for a period of three to five or six hours. It is probable 
 that the ablution was an important part of the benefit that was 
 derived from such a process. 
 
 Cold baths in my experience are not useful in acute mania 
 unless locally applied to the head. Cold shower baths have 
 been used extensively; but it is doubtful whether purely as a 
 curative, but rather as a corrective measure, but cold shower baths 
 of one or two minutes duration in summer have been useful and 
 enjoyed by some patients. For a maniacal patient they are not 
 appUcable. 
 
 I am inclined to believe, though at one time much opposed 
 to it, that wet packing is often a remedy that is useful in a 
 maniacal outbreak, the objection to it in my mind was that it 
 
ORDINARY INSANITY — SECOND STAGE. I43 
 
 seemed to be a mode of mechanical resti'aiufc and simply a bub- 
 stitute for the discarded strait jacket. In several very fm'ious 
 maniacal outbreaks, however, I have seen it induce a profuse 
 perspiration terminating in sleep. The mode ot packing is now 
 pretty well known, a sheet is lightly wrung out of water (if the 
 patient is feeble, the water may be tepid, otherwise the water 
 is to be cold) and the patient swathed entirely in the folds, 
 the body being stripped and the arms by the side, the sheet 
 enclosing them ; in the course of a very few minutes I have 
 found that the patient ceased to resist and gradually became 
 quiet and slept after soporifics had failed. 
 
 Exercise of all kinds should be employed, the diet simple but 
 nutritious, the patient requires support if feeble ; I have seen 
 much benefit in mania from cod-liver oil. 
 
 Blisters to the nape or head, I have seen used, but in my 
 opinion they should be avoided, as they are often followed by 
 troublesome sores which from the patients' dirty propensities 
 are very difficult to heal. 
 
 Should the insomnia continue in the maniacal stage and the 
 patient be very excited, J^ of a grain of hyoscyamine may be 
 useful. Some good authorities are opposed to the use of this alka- 
 loid on the ground that it produces so great a depressive effect as 
 to amount to a chemical coercion ; this lowering effect is de- 
 pendent a good deal on the dose, ^\ or J^ of a grain, is followed, 
 in those in whom I have administered it, by an elated or satis- 
 fied condition of mind in perfect contrast to the excitement for 
 which it was resorted to. 
 
 In a very early period of my life, when the extract of hyoscya- 
 mus was made from the fresh leaves by ourselves, I have pre- 
 scribed 4 grains of the extract with uniform sedative effects, but 
 I have seen a drachm used of the drug supplied from the di-uggist 
 and no effect to follow. I have not used hyoscyamine in one 
 grain doses, as others have, but I have seen the effect of re- 
 peated doses of i grain which seemed to have a depressing 
 effect on the patient with coldness and blue condition of the 
 hands and feet. 
 
 Prognosis. — Before proceeding to describe the next stage of a 
 case of ordinary insanity, it may be as well to say a few words 
 on the prognosis of the case at this period. The disease so far 
 
144 LFCTL'Rr.S ON MENTAL DISEASE. 
 
 as our description has extended, may be considered to be in the 
 acute stage, and so far at least as its duration in time is con- 
 cerned there is notliinj^ to wairant an unfavourable prognosis. 
 
 ]Jut the artificial stages which have been adopted for the pur- 
 pose of description, are, it must be remembered, mere expedients, 
 and are not actually separated the one from the other by any 
 well defined line of demarcation. 
 
 To estimate the probable chances of a favourable or unfavour- 
 able termination for such cases as have reached this epoch, we 
 must refer to the phenomena present in each case. 
 
 As a general rule every case still in the acute stage of melan- 
 cholia or mania may be deemed curable, there are, however, 
 phenomena which would contradict such a very general conclu- 
 sion. 
 
 In the first place, when the mental symptoms appear to in- 
 clude the functions of the whole organ, the chances of recovery 
 are less than when the symptoms are confined to a portion only. 
 Next, when the phenomena themselves point to an actual or- 
 ganic change (when probably they would involve the whole of 
 the functions), the prognosis is unfavourable. On the other 
 liand, when the symptoms appear to be simply an exaggeration 
 and not an alteration of a mental function, the chance of re- 
 covery would be greater. 
 
 In explanation of this statement, it must be remembered, 
 that the division of the mental functions into classes, as into 
 emotions, intellect, volitions, etc., is a purely artificial ar- 
 rangement, and the terms denote mere abstractions. The func- 
 tions of the brain are nevertheless one and entii-e, so that when 
 the symptoms merely have reference to one of these artificial 
 divisions, as for example, with the emotions only, there is no 
 indication of organic disease. When the symptoms are con- 
 nected with two of these divisions, as with emotions and volun- 
 tary movements, the prognosis is less favourable, and when the 
 intellect proper, the volitions or voluntary movements, and the 
 emotions are all involved the case becomes less favourable still. 
 
 Evidence of any distinct brain disease is also of adverse 
 kind, as the presence of local paralysis, ptosis, aphasia, facial 
 paralysis, any affection of the movements of the eye, or deafness, 
 or disease of the internal ear, etc. 
 
ORDINARY INSANITY SECOND STAGE. I45 
 
 With respect to voluntary raovements, restlessness or excita- 
 bility of action, being merely an exaggeration of a normal func- 
 tion, is not unfavourable ; but when there is a great degree of 
 stupor, and as it were, no response in the afferent motor func- 
 tion as in severe cases of melancholy with stupor, the prognosis 
 is less favourable. 
 
 Emotional disturbances are nearly always present, their pre- 
 sence does not add therefore any distinct bias to the prognosis. 
 in one or the other direction. Not so, however, with the intel- 
 lectual anomalies. Still the mind may be considerably dis- 
 turbed, and is so in acute mania, without adding weight to the 
 prognosis. In general disease, the thoughts and ideas wander 
 in delirium without at all affecting the organ permanently, a 
 mere delirious excitement of ideas is therefore of no bad augury 
 in insanity. But when the process of ratiocination shows a per- 
 manent defect, the prognosis is different and unfavom-able. With 
 the presence of a true delusion or permanent false belief, and inco- 
 herence of ideas (or inco- ordination in the process of ideation), the 
 prognosis is bad. When such occur the emotions are also in- 
 volved, though the volitions and voluntary movements remain in 
 ordinary insanity intact. 
 
Section II. 
 OEDINARY INSANITY— THIRD STAGE. 
 
 Third Stage of Ordinary Insanity — Evolution of the symptoms in the chronic 
 stage — Addition of Anomalies of Intellect proper — Symptoms of third stage, 
 Delusions — Ocular, Auditory, Tactile, Gustatory and Olfactory — Delusions 
 connected with nutritive functions, with generative functions — Anomalies 
 in Speech — in Actions, Temper, Habits, Memory, Character, Motility. 
 
 3rd Stage. Chronic Insanity. — We arrive next at that stage 
 of the disease when it may be considered to have become 
 chronic. As regards the period at which this stage is reached, 
 this of course varies, but after nine to twelve months or at 
 furthest eighteen months we may assume that the disease is 
 chronic, a better criterion to go by, however, is the nature of 
 the symptoms which are present. 
 
 After the case has Listed the above period the original melan- 
 chohc stage will have, firstly, persisted in the form of me- 
 lancholy, or with predominating melancholic symptoms; or 
 secondly, will have developed into acute mania, that is, will 
 have exhibited symptoms of excitement and violence. 
 
 After a given time either case continues in one of three ways. 
 (See diagram, p. 108). 
 
 1. The acute melancholy may become chronic melancholy. 
 
 2. The acute melancholy, after going thi-ough a stage of acute 
 mania becomes chronic mania. 
 
 3. The case in becoming chronic alternates between a condi- 
 tion of mania and melancholia. 
 
 The symptoms of chronic mania and chronic melauchoha, 
 may be discussed together. They are, in fact, so intermixed 
 in the progress of many cases, that it is better perhaps to use 
 the term of chronic insanity for both. Eemembering always 
 that when the term chronic melancholy is used, it denotes the 
 preponderance of melancholic symptoms in the case, and when 
 chronic mania is used, it would indicate a greater tendency to 
 violence, etc. 
 
 It is to these cases occurring with such variety in the symp- 
 
ORDINARY INSANITY THIRD STAGE. I47 
 
 toms that we find attached so many frcsli names. In French it 
 is called manic, chrnnlque or monomanle. In German Wahnsinn 
 or Vcrnicktheit. There are also many other names based upon 
 a prominent symptom which will be explained in a future page. 
 
 The line of demarcation between the stages to note the 
 chronic fi-om the acute, is as usual not sharply defined. One 
 stage as it were overlaps the other, but the difference may be 
 made at the epoch, when the mental phenomena pass from the 
 category of emotional disturbance merely, to that of the intellect 
 proper also. 
 
 The description of the phenomena will be given in the same 
 order as that adopted in describing the first stage. 
 
 The order of the symptoms in the first stage was as follows : — 
 
 1. Depression of spirits. 
 
 2. Morbid apprehensions. 
 
 3. Alteration of affections and instincts. 
 
 4. Illusions. 
 
 5. Motor alterations ; to which must be added in this stage 
 
 6. Delusions and disorders of the intellect proper. The motor 
 phenomena remaining the same in both stages namely being in 
 excess or in diminution of activity. 
 
 It will be seen that No. 1. 2, 3. are connected with the emo- 
 tions. 4. and 6, with senses and intellect. 
 
 Depression. — In the chronic stage the main difference in the 
 character of the phenomena is in the greater extent to which the 
 senses and intellect are involved ; the depression may therefore 
 not show much change. "We simply say that in chronic melan- 
 choly the painful emotions predominate, and are exhibited in 
 depression of spirits and morbid aiDprehensions. On the other 
 hand in the case of chronic mania, it is the intellect and moti- 
 lity which are the seat of the most prominent symptoms. 
 
 It is difficult, however, as already explained, to say in many 
 cases whether the painful emotions are really present, and if so 
 whether they predominate, and, as will be shown presently, in 
 particular cases the opposite conditions alternate : — "Hi affectus 
 saepe vices commutent." 
 
 All that therefore can be affirmed with regard to depression 
 of spnits in cluronic cases, is that in a certain number it persists. 
 (Example, Case XII). 
 
 l2 
 
148 LECTURES ON MENTAL DISEASE. 
 
 Depression is a state, not a hind of emotion, the ground of low 
 spirits often is some delusion, for in this stage of the disease, 
 illusions will have passed into delusions. The intellect proper 
 being now involved and the morbid belief taking an uncomfort- 
 able starting point, the source of misery becomes more persis- 
 tent. The morbid apprehensions, which in the first stage are 
 fears that evil will arrive, are now a belief that the fear has a 
 real basis, that the calamity feared is a reality ; as for example, 
 the fear of death may become in them a belief that they are 
 dead ; but since the basis of each cause of dejiression is connected 
 with delusion, it will be better to describe this in conjunction 
 with that phenomena. So long as the fears of the patient are 
 illusions only, they belong to the emotional anomalies ; but 
 when they become objects of belief, they are anomahes of intel- 
 lectual faculties, and are true delusions. 
 
 Delusions. — It will be convenient to consider some of these 
 more common delusions in the same order as that adopted with 
 illusions, or as connected with each special sense, but some of 
 the patient's insane symptoms have a more complex foundation 
 and such will be reserved to be considered subsequently. 
 
 Auditory delusions. — The alterations connected with the 
 sense of hearing become more pronounced, the patient who 
 hears voices, now beheves in their reality, and the voices con- 
 stantly torment him. What the chronic patient hears is of 
 various character. Sometimes it is painful in the extreme ; 
 they hear the cries of their childi-en in danger caUing for help, 
 they hear commands to do this or that, and sometimes are im- 
 pelled to act upon such commands, however absurd or horrible 
 they may be. The sounds are not always human voices, and 
 they seem to come from various sources, from above, from below, 
 from the wall, from their own interior, etc. 
 
 One poor woman at Hauwell was tormented by what she 
 believed to be the cries of her children from below, and would 
 implore me to let her go to them. I have often indulged her by 
 accompanying her towards the supposed source of the sounds, 
 but on reaching the storey below, she still imagined the voices 
 came from below, if we followed them till we came to the base- 
 ment, the voices still spoke to her from below. 
 
 Another patient, a lady by birth and education, but reduced 
 
ORDINARY INSANITY THIRD STAGE. 149 
 
 by her malady to pauperism, heard the voice of her deceased 
 husband calling to her from the next room. She would stand 
 for hours and answer him. On my approach she entreated me 
 to open the door, if one endeavoured to reason with her no at- 
 tention could be got from her, and in complying with her request, 
 she went only to the next door, with the same endearing words 
 to the voice she believed she heard. In both these instances 
 the delusion was of painful character. The case, on account of 
 the energetic excitement attending it, might be considered by one 
 as mania, by another melancholy. In other cases the delusion 
 of the voice is of more terrible character and excites the patient 
 to fearful outbreaks of violence, and at least to violent and loud 
 denunciations. 
 
 The subject of the delusion through the auditory sense may 
 be of course connected with nearly every subject of thought, but 
 it is rare for mere abstract ideas to be the ground of false belief. 
 The delusion is not so much a result of the reasoning process 
 upon abstract propositions, but rather upon the concrete ideas 
 produced primarily on the auditory organ. 
 
 The false belief does not, however, depend upon sensation it- 
 self, but upon a mental process which is attributed by the patient 
 to a real sensation ; patients do not mistake one sound for another, 
 but having a morbid process going on within their cerebral organ, 
 they attribute the result to the organ of sense. When a patient 
 hears a voice, there is no voice or even sound perhaps to jDroduce 
 it, but the centres which are normally affected through the audi- 
 tory sense, are morbidly excited. 
 
 And not only is the direct sense centre morbidly affected, it is 
 clear that its associated ideas are also brought into play. 
 
 And since all the sense centres are closely allied together or 
 associated, a false belief connected particularly with one sense 
 involves false beliefs of most of the other senses and the judg- 
 ments founded upon them. Auditory delusions are therefore 
 generally of complex kind. 
 
 To auditory delusions may be attributed probably, the pheno- 
 mena which some years caused much wonder among the public, 
 that of the popular belief in the gift of speaking in unknown ton- 
 gues, which was caused by certain insane females, who roared 
 during a religious service, and gave utterance to a jargon of ex- 
 traordinary kind. 
 
150 LECTURES ON MENTAL DISEASE. 
 
 Ouo of tlio speakers was under my care as a chronic lunatic 
 many years subsequently. 
 
 Ocular Delusions. — As regards delusions which seem to be 
 principally dependent on the ocular centres, sucli arc perhaps 
 less frequent, and the form which these false beliefs take, is 
 founded mostly upon the reasoning or mental process following 
 upon ocular impressions. As an example of this a lady in the 
 chronic stage asserted that nothing around her was real, '• but 
 only pretence," that the leg of mutton I was carvuig, she said, 
 was only a sham one, that I pretended to carve it and those 
 around the table pretended to eat it, but all the pieces would be 
 put together agaizi, and the joint would appear again to-morrow. 
 One young lady at the table she said was not real, her teeth 
 were porcelain and her eyes glass. She politely asked an old 
 gentleman sitting near, to oblige her by taking off his head. 
 
 Tactile Pehisions or delusions connected with the sense of touch 
 or feeling ; to this category wo must attribute the delusions pro- 
 bably when patients believe that they are dead or that they have 
 lived in some former period. A gentleman, a member of the 
 medical profession, whose case was called religious melancholy, 
 who passed through a stage of manin , and was now in the condi- 
 tion of chronic mania, had this delusion (to which the name 
 of mania or iiwlancliolia uictainarjiliusis has been given.) He 
 believed that he had lived in another body. I saw him admir- 
 ing a handsome Newfoundland dog on one occasion, and asked 
 him what he thought of it, his answer was, " Oh, I knew him in 
 the other world, ho married my aunt." Such delusions as these 
 one could multiply to any extent. These and such like are 
 more than merely false beliefs, they are anomalies of the entu-e 
 intelligence, they involve every faculty, and show errors of 
 memory, association of ideas, reasoning faculty, judgment, 
 and denote of course a serious disturbance of the organ. 
 Such delusions denote a confirmed or chronic condition and 
 therefore give an unfavourable prognosis. A girl in Hanwell 
 was screaming with afii-ight one day and on asking her the 
 cause she said that they had changed her hands, " these 
 hands," she said, " are not mine, mine were pretty little hands, 
 these are too large." This was another example of delusion 
 of metamorphosis I suppose. 
 
ORDINARY INSANITY — THIRD STAGE. I5I 
 
 Gustatory and Olfactori/ Delusions. — Delusions founded on these 
 special senses are occasionally observed, but less frequently than 
 those based u^jon the other senses. Patients are sometimes an- 
 noyed by the delusion that they stink, and are offensive to others, 
 that their food has an offensive odour or bad taste. Such delu- 
 sions are usually associated with melancholic symptoms. 
 
 The above are examples of delusions connected with the 
 special senses, and of illusions passing or passed into delusions. 
 
 There is another description of symptoms which is connected 
 with the emotions and the instincts, and may be thus classed: — 
 
 1. Symptoms connected with the nutritive process. 
 
 2. Symptoms connected with the generative process. 
 
 1. Patients have innumerable delusions about eating, in this 
 stage as well as in the former, believing that they should not eat 
 at all, that they have already eaten too much, that what they eat is 
 human flesh, that it stinks, that they have no gullet, that they 
 cannot swallow, that they should retain their urine, or their 
 fteces, and that it would be death to part with them and they will 
 endeavour to seize and re-devour them. 
 
 Belonging to the same category are the following. Some 
 imagine that they are immense, that they are ten feet high, 
 that they cannot pass through the door, that they have an ani- 
 mal in their inside, that they have no inside at all, that they 
 are pregnant, and males not uncommonly entertain this delusion, 
 others that they are too small, too light and will be blown away, 
 that they can fly, that they are birds, and are covered with 
 feathers. A poor lady under my care used to stand long 
 periods under a tree making futile efl'orts to spread her wings. 
 
 Some beheve that they have no heart, no liver, no head, 
 that then- head is made of wood, that they would melt in the sun. 
 One delusion I have met several times, patients ignore their 
 children after they have grown up. One patient entirely lost her 
 identity, her real name was Stevens, all events happening before 
 her illness, she referred to the history of Martha Stevens, all that 
 happened since she referred to her new condition in wliich she 
 was Molly Dodd. On her son, whom she left a child, visiting 
 her when he was twenty, she said he was a very nice young 
 man, and was Martha Stevens'. One lady visited by her son, 
 after many years would not own him and called him an impos- 
 
152 LECTURES ON MENTAL DISEASE. 
 
 tor. Others still speak of thcii- children as infauts after years 
 of absence. 
 
 2. With respect to tlie generative system. One woman under 
 my care had the delusion that slie gave birth to 800 children a day. 
 Virgins and males believe themselves to be pregnant. Some take 
 the literal interpretation of the text, if their eye offends them 
 to pluck it out, and attempt to enucleate an eye, or men to emas- 
 culate themselves by 'mutilation. 
 
 In speaking of delusions and connecting tliem, for order's 
 sake, with the special senses, it is not meant of course that delu- 
 sion is an anomaly of the sense organ. Such alterations would 
 be called anassthesia, hyperesthesia, dysaesthesia, etc. The 
 delusion is an intellectual product and is connected with the 
 ideas based on sensation. 
 
 We have next to consider some other errors of the intellectual 
 class, which are of more complex character as regards their ori- 
 gin, and many of them as mi;ch dependent on the emotional as 
 the intellectual division of the faculties, as the anomalies of 
 language, of ideas, of association of ideas, memory, imagination, 
 consciousness, apprehension, reasoning faculty, and the still 
 more coinplex acts, behaviour, disposition, character, propen- 
 sities. 
 
 They may be arranged roughly into two classes : — 
 
 1. The more simple, as expressed through language. 
 
 2. More complex, shown by acts chiefly. 
 
 The former are the more purely intellectual, the latter are much 
 mixed with emotional faculties, not but that every idea is more 
 or less an excitant of emotion ; for though we separate the men- 
 tal faculties artificially, they are one, and intimately blended in 
 nature, we can scarcely have an idea, especially a concrete idea, 
 without at the same time a feeling, which is emotional. 
 
 Anoinallcs of the Ideas. Of course all those delusions akeady 
 considered are of this class. 
 
 Mal-association of ideas is a prominent symptom in chronic 
 insanity, whether the form be melancholic or maniacal. It 
 is shown in speech, oral or written. It is called also Inco- 
 herence ; there are two degrees or modes in which it is shown. 
 The fii'st, incomplete — or as a mere discursiveness in speech, or 
 rambling from subject to subject, the sentences being more or 
 
ORDINARY INPANITY THIRD STAGE. I 53 
 
 less formed ; and secondly, the Incoherence is complete, and 
 there is no connection between the words even. Incoherence 
 is sometimes not readily detected when it is oral, unless the ob- 
 server is well accustomed to the investigation, but when written 
 it is at once discoverable. I have known a patient to talk rapidly 
 and never finish a sentence, but be diverted at the penultimate 
 word into a fresh idea. This is partially shown in the following 
 written sx3ecimeu : — 
 
 Hanwell. 
 " My dear Son, if I can find him. 
 
 Wherever you may be— you will do well to remember me. Wisdom 
 progresses though the people stand still. I am waiting for somebody who 
 I fear is ill, to leave this place with, I shall have to prove who I am, having 
 been a dead letter so long, perhaps to all forgotten by all that is mortal. 
 Humanity, being only selfishness sincerely do I desire to be out of Hanwell. 
 I curse the day I saw it first, a lasting bondage, nothing but tolerating 
 ignorance. Wilful injustice being the vogue. Weakness the suckcumbing fool. 
 Ignorance the Master. Usurper and tyranny directors to the already oppressed 
 and grieved. Robbed and wronged. Patience insulted. Obedience rediculed, 
 made a fool of. Reason out of season at Hanwell. There is not Order nor 
 Justice of a Bawdy House, it is murder distinguished under disguise." 
 
 The writer was an educated person and had been a governess. 
 She had no son. 
 
 The letter shows a mild degree of incoherence, it is clear the 
 writer had begun the epistle in a different frame of mind from 
 that at which she arrived, or intended to arrive. The next 
 specimen is rather more incoherent, the writer was supposed 
 when she wrote it to have been wrongfully sent to Hanwell, 
 and the magistrates at the first interview called upon me to show 
 why I thought her insane, which opinion I certainly entertained, 
 and from the incoherence, adjudged her to be in the chronic 
 stage as well. The patient is still insane and in Camberwell 
 House. 
 
 Hanwell Asylum. March, 1863. 
 " My dear Dr. and Mrs. Sankey, 
 
 We have asked him, and (to-day written for the Prince of Wales' 
 grant of 1862) which we never then refused, but as a bird in the hand is worth 
 two in tho bush, we on that 5th of November day capably carried a law case, and 
 the judges judgment was "the money to be paid forthwith. Daily broad and 
 common sense depended upon the recovery of 10£ suit on hand — Ladies could 
 not encounter a London crowd thro' wh. the greater sum of 40£ or S(t£ pr. 
 annum was said to be available having received no written order how could you 
 go through a thicket without a ticket as upon all such occasions such as the 
 
154 LECTURES ON MENTAL DISEASE. 
 
 police Pass. We knew before we came here the prant was said to bo plawd at 
 the disposal of an English and Continental Lawyer in a representative Law 
 Case, of which Prince John of Saxony under reported slander of my character 
 wished to be unconsciously the respectable head of course we refused his kindly 
 desire to aid, and judicially with it, which was f^rouudless and childish — Retro- 
 spectively and prospectively, looking at our present History we say let Friend- 
 ship take the place of representation necessitation as money is our friend in the 
 King's coin." 
 
 A greater amouut of incoherence even than this is often ex- 
 hibited in the written communications of the insane. 
 
 The incoherence often is shown, or as it were produced, by a 
 pun, a play upon words, or a rhyme, the train of thought is 
 easily led oflf from its normal course ; there are instances of the 
 turn of ideas by a rhyme in both the above specimens. It may 
 be called a want of co-ordination in ideas. 
 
 Patients show often a fancy for allegorical and cabaHstic 
 writing — they quote texts, applying them as they like ; some 
 seem to have a change in their appreciation of colours ; those 
 who amuse themselves with painting, will use the most violent 
 contrasts ; vermilion skies, and bright purple trees. An artist 
 at Hanwell, whose abihty was well known before his illness, 
 produced whUe there some very eccentric effects in colours of 
 this kind. 
 
 The power of reasoning in the chronic lunatic is by no 
 means always lost, nor always materially weakened, though 
 there is some difficulty in estimating to what degree the faculty 
 is affected ; the reasoning faculty, and its result — ^judgment — 
 is of course often interfered with by the presence of delusion, 
 so that the basis of ratiocination is bad, but when this is not 
 the case, certainly in very many cases of chronic insanity, the 
 process of comparing, weighing, and concluding remains. 
 
 As regards the imagination the same diflficulty occurs. The 
 vagaries of the insane mind often seem like products of pure 
 imagination, but perhaps they are more hke strange results, 
 produced by a miscellaneous juxtaposition of ideas. The ten- 
 dency of the powers of reasoning and imagination are in all 
 toward feebleness or imbecility, to which condition all the 
 faculties gradually incline 
 
 Anomalies as exhibited in actions. — As examples of change un- 
 der tliis head the following may be enumerated as occurring in 
 the chronic stage, and therefore somewhat permanent. 
 
ORDINARY INSANITY THIRD STAGE. I 55 
 
 1. Manner. Patients sometimes assume a haughty man- 
 ner quite foreign to their natural character, but perhaps in 
 accordance with a dehision of their exalted condition, but 
 sometimes the manner is quite incongruous, A patient at 
 Hanwell, who believed liimself to be Jesus Christ, had a very af- 
 fected Dundrearyish style of speaking, and the matter was equally 
 absurd, consisting of an incongruous admixture of Christian 
 exhortation, emphasized with blasphemous oaths. A rude and 
 sneering manner, even in ladies, is quite common which dis- 
 appears on recovery. Irresolute, hesitating, vacillating man- 
 ner is often observed. One patient will go hither and thither, 
 change his mind and return, or he will do this, and then 
 think another course would be better, etc. ; others will accuse 
 themselves of causing this or that catastrophe by some trivial 
 act of themselves, such as starting to go up stairs with the 
 wrong leg first. 
 
 2. Alteration of the feellnijs and embtional anomalies are often 
 present, the patient is miserable, misanthropic, or over-joyous, 
 as will be referred to under Disposition below, or he takes a 
 violent dislike or hatred to former friends. 
 
 3. Temper. He may be impatient, peevish, morose, irritable, 
 irascible, and also as frequently very mild, easy, an optimist 
 in every thing. 
 
 4. Habits become greatly changed, and most chronic pa- 
 tients exhibit obvious change in this respect, they become 
 often slovenly, unkempt, untidy, regardless of all appearances, 
 and dirty in every way ; regardless of the calls of nature, 
 even in respect to their dejections, filthy in then- clothes or 
 in their mode of eating, or in what they eat, picking up dis- 
 gusting food. They are greedy, or hanker after drink, which 
 they did not in health ; some, and tliis is a very common pro- 
 pensity, like to deck themselves out in fantastic colours with 
 pieces of tin, glass beads, feathers, coloured worsteds, with 
 which perhaps they decorate their head ; some do the same with 
 texts or cabahstic writing. 
 
 Among Habits must be mentioned that of masturbation. 
 Though placed here among the phenomena of chronic insanity 
 there is no evidence that would fix the habit to any particular 
 period of the disease. It is, however, more evident in the 
 chronic patient and in the fourth stage or that of imbecility. 
 
156 LECTURES ON MENTAL DISEASE. 
 
 The subject will bo ngam referred to in a subsequent page as 
 an assigned cause. When earned to a great excess, as it is 
 sometimes in the chronic lunatic, both in men and women, it ap- 
 pears in some to arise from local irritation, or the abnormal m- 
 creasc of the sexual appetite. This naturally is more developed 
 in some than others, and perhaps is increased in some by special 
 disease. There is in such cases an open and shameless prac- 
 tice of the habit. One of the worst cases that I have known 
 occurred in a young woman of about 28 to 30 years of age. 
 She was sent home from India, after having been confined in 
 an asylum there. She was emaciated to a great degree, highly 
 irritable and what is called nervous. After residence in the 
 asylum and with plenty of nourishment — wine and cod-hver oil, 
 the habit disappeared. The cause in this case was due to 
 a general erethistic condition of the nervous system. In men, I 
 have witnessed the passion to be periodical, especially among 
 epileptics. I consider the practice to be due to the condition of 
 the system, which may be ameliorated by good nourishment. In 
 men, circumcision is said to be a cure. 
 
 5. Disposition. — It is also in this direction that the chronic pa- 
 tient shows his insanity. Besides the tendency to suicide which 
 occurs in the period of depression, in some cases the same pro- 
 pensity becomes chronic, and in this stage it is even a more 
 dangerous complication than in the earlier period, in that stage 
 the patient's propensity is constantly obtruded, he talks of it, and 
 makes constant attempts to carry out his purpose, thus keep- 
 ing the attendants constantly warned, and ever on the watch. 
 But in chronic cases the disposition recurs at distant intervals, 
 very frequently without warning. 
 
 It is the same with the homicidal propensity. It is fortunately 
 not a very common form ; but a less degree of it, a tendency to 
 violence or to do personal injury, is common. This too, often 
 occurs almost without warning. A young lady under my care 
 who had been insane several years was Uable to this form of 
 excitement, siiddcnly without having received the least provo- 
 cation she would Hy at tlie throat of any one near, and after 
 the attempt was fully thwarted by tlie interference of the 
 attendants, she would cry with apparent vexation and then go 
 off to sleep. This propensity will be alluded to also in a future 
 
ORDINARY INSANITY THIRD STAGE. I57 
 
 page, mid its resemblance to the epileptic seizure spoken of. 
 All these intermittent and sudden violent acts seem to be allied 
 in character, the outbreak is equivalent to a seizure (or abnor- 
 mal neural discharge). The act of violence having been car- 
 ried out, they seem relieved and relapse into a quiet and 
 resigned attitude. In the section which is now under consi- 
 deration, or the condition of chronic insanity, the disposition to 
 an outbreak seems a mere temporary paroxysm. The condi- 
 tion is a continuous one of insanity, the mind is irrational and 
 all the acts denote chronic insanity, but in the cases to be 
 spoken of the patient is often at intervals much more free from 
 mental symptoms, and the attacks appear to be recurrent. 
 Among other insane dispositions observed in the chronic stage 
 are various anomahes, perhaps more correctly coming under 
 character, for which see below. 
 
 6. Ideas, Intellect. — Disorders of this kind mostly come under 
 either illusions or delusions, but there are some which do not, 
 as the Eeasouing faculty, Judgment forming, Propositionizing — 
 a word proposed by Dr. Hughliugs Jackson, and Imagination. 
 The powers of reasoning, &c., if diminished, merely amount to 
 imbecility ; the reasoning powers are never increased, and the 
 case with imbecihty belongs to the next artificial division of our 
 subject. 
 
 Memory. — When the case has become chronic and remains ia 
 that stage without much change, or in other words, when the 
 morbid processes are at a standstill, which happens in a very 
 large number, leaving the organ implicated more or less dam- 
 aged, it often happens that the patient's memory remains un- 
 impaired ; and perhaps there is no mental faculty which re- 
 mains untouched so much as this. I cannot say that the 
 memory is at all a test for the state of mind or degree of in- 
 sanity. 
 
 I had a patient in whom the faculty appeared increased. 
 His case was one of chronic insanity which could not be easily 
 attributed to chronic melancholy or chronic mania. He was 
 the subject of very distinct delusions, however ; this gentleman 
 remembered every incident that occurred with the precision of 
 a note-book. As an example : — Once in my presence and his, 
 some one spoke of a white pony I possessed. I was remarking 
 
158 LF.CTURES ON MI-NTAL DISEASE. 
 
 that it was very old, ami perhaps 20 years, for that it was 
 ackiiowleclg[etl by the dealer of whom I bought it to be 12 years, 
 and I said that must be 8 or 10 years ago. My patient remarked, 
 " it was 12 years and 2 months and 4 days ago to-morrow." 
 All his recollections were given with the exactitude of the above. 
 "Wishing to test his accuracy, I turned to my account books and 
 found by the date of the cheque given for it, that I had bought 
 the pony 12 years 2 months, and six days, and not 4 days pre- 
 viously. I told him that I had found him very nearly correct, or 
 within 2 days. He explained: "You may be right, and no 
 doubt you are, but I should have said that the day I named was 
 the first day you made use of it," and he related the purpose 
 for which I used it, viz., to take my child for a ride to a neigh- 
 bour's. He could tell me the date that any one called upon me 
 for years back, or the conversation that occurred at the dinner- 
 table on any day for equally long periods. 
 
 The fact is of interest psychologically if not of any diagnostic 
 utility. 
 
 The cu'cumstance that idiots sometimes possess the faculty of 
 memory in a wonderful manner is of interest in connection with 
 what I have related in regard to chronic lunatics. 
 
 In certain cases in every stage memory may be affected as a 
 special symptom, and not as it were, as a regular feature of the 
 disease. The absence of memory appears to have for anatomi- 
 cal cause an antemic condition of the brain, hence it occurs in 
 the old, and after emaciating diseases, as after fever, or other 
 exhausting disease. Such a condition of circulation is not com- 
 mon in chronic insanity, but at times after long continued refusal 
 of food, patients become greatly exhausted and in that state their 
 memory is affected. 
 
 A case of almost absence of memory occured to me in a gen- 
 tleman, an officer of the army ; when I first saw him he had 
 been refusing his food and he was in a very weakly condition. 
 He had ceased to refuse food when admitted into Sandywell, but 
 he was much emaciated and anremic. This gentleman's memory 
 was so bad, he could not dress himself, he could not remember 
 the order in which to put on his clothes ; when he had put on 
 his shirt, he would continue to look for it in his room ; he would 
 call for his bath, when he had just come out of it ; he would 
 
ORDINARY INSANITY THIRD STAGE. I59 
 
 waucler out of his room and be unable to find his way back ; he 
 would get one newspaper after another under his arm, and call 
 all the while for the Times. He would set down to breakfast, 
 and call for coffee, cup after cup, and say he had never had any, 
 or after taking a hearty meal, he would say, " now I will have 
 my breakfast ;" in walking out he was always making, as he 
 supposed, for his former residence, but he could be easily 
 directed to take any turn so that he returned home, on arriving 
 at which he entered and greeted us as strangers, not recogniz- 
 ing the servants nor the house. This case, however, scarcely 
 belonged to the clu'onic stage, though he was passing into it ; 
 the history was not complete. He died I beheve of a cerebral 
 tumour, but no examination was made. 
 
 When in a chronic case the memory fails, it is to be taken as 
 an indication of approaching state of imbecility. 
 
 In illustration of the connection between memory and the 
 circulation I met with an instance in a patient, well known for 
 his literary attainments and eloquence, who found during the 
 latter period of his life, that he often could not command a flow 
 of words while erect, but if he lay down his choice of language 
 was restored. 
 
 7. Character. — In chronic insanity it is almost universally ob- 
 servable that the patient's character is changed, and propensities 
 quite foreign to their sane condition are exhibited. 
 
 It is not always, however, that the subjects are the worse for 
 the change, but most frequently such is the result. Among our 
 chronic patients we have innumerable eccentric characters. 
 The dispositions are changed in every dii-ection, the profane 
 become rehgious and the reHgious profane, the amiable become 
 captious, suspicious and capricious, the modest become im- 
 modest, and careless of decency, etc., etc. Some show a pro- 
 pensity to hoard, and collect stones, trifles, scraps, as though 
 they were treasures and rarities. Most become jealous and 
 selfish. Some neat and particular in di-ess, others deck them- 
 selves in trumpery. 
 
 Motilitij in chronic insanity. — Alterations and auomaHes con- 
 nected with the motive powers, may be considered under two 
 heads : 
 
 1. Altered movements from mental causes. 
 
 2. Altered movements connected with motor apparatus. 
 
l60 LECTURES ON MENTAL DISEASE. 
 
 By this division it is intended to separate those anomahes 
 wliicli essentially belong to mental disease, from those other 
 deviations which occur Ironi other causes as convulsion, chorea, 
 paralysis, local or general ataxy, etc. which sometimes are met 
 "with in the insane. 
 
 The anomalies of movements in insanity occur in two forms. 
 
 1. With excess, 
 
 2. With diminution of activity. 
 
 1. As regards the cases in which the movements of the patient 
 are excessive. The excess which is indicative of general excite- 
 ment, and which was observable in the patient while in the 
 acute stage may continue into this or the chronic period 
 of disease. The increase as in the previous stage may vary 
 in degree from restlessness or fidgetting to violence ; when 
 the excitement is very prominent, the case belongs to the 
 division of mania. Chronic melancholic patients will some- 
 times walk to and fro for hours together, traversing only 
 a mere corner of a room, and pacing four or five steps in 
 the garden in one direction and then in the opposite, confining 
 themselves to a few yards of ground only, till they wear a hole 
 in the carpet or polish a jjiece of the gravel walk, they will per- 
 haps continue all the while to moan and make a monotonous 
 noise. Some others will stride round and round a garden walk 
 as though life depended on their haste. 
 
 The above phenomena as well as the opposite condition of the 
 motility, appear in the first stage, they become more pro- 
 nounced as the disease progresses, and it is in this, the third 
 stage, that the symptom is best marked. 
 
 2. With regard to the other condition of motility in which 
 the patient exhibits a torpidity of all the voluntary movements, 
 the degi-ee varies to a still greater extent. In some cases it 
 seems even only a slight exaggeration of the normal state ; 
 on speaking to the patient, instead of replying, he will seem to 
 deliberate more than usual. In sitting down to dinner he will 
 not commence. He is slow in all his actions, especially in the 
 commencement of any act ; as though the cuiTcnt was not 
 passed down to the motor mechanism — a telegram delayed in 
 transmission. Others when they arc called upon to do any- 
 thing seem to be deliberating, and stand or remain motionless 
 
ORDINARY INSANITY — THIRD STAGE. l6l 
 
 for an indefinite length of time. A patient of mine taken into 
 town could be very safely left at tlie corner of any street and 
 would be found there after a considerable interval. In the gar- 
 den he allowed some tame antelopes to nibble his coat tail, and 
 to eat his pocket handkerchief which protruded from his x^ocket. 
 Some chronic patients may have a propensity to stand in a con- 
 strained position for hours, maintaining a posture which it 
 would be difficult for a sane person to assume. This feature 
 is characteristic of the case called melancholy with stupor 
 (see p. 121), the following case is taken from the first edi- 
 tion of my Lectures, and it was drawn up with the jpatient 
 present. "The patient exhibits an expression of the greatest 
 hebetude and stupor. The facial muscles are all in a state of 
 relaxation, the countenance has a dull and heavy appearance ; 
 while the tonicity of the whole muscular system seems to be 
 equally involved. The patient sits listlessly, never notices what 
 is passing around, seldom moves ; her arms dangle by her side, 
 and however awkward and constrained the attitude, she does not 
 exert herself to change it ; if addressed, at the most she raises her 
 eyes, not her head. She allows herself to be scorched rather 
 than remove from the fire. She lets the flies settle on her face, 
 or walk across her eyehds without interfering. The saliva and 
 nasal secretion dribble as she sits, the lachrymal secretion diies 
 on her cheek. She passes all her dejections. as she sits. She will 
 make, in fact, no effort whatever, either to eat, drink, or to avoid 
 discomfort or pain. To such a degree is this immobility carried 
 that the circulation is interfered with, or possibly the motor 
 functions of the cu'culation may be included. The hands are 
 habitually cold and blue, and swell with the dangling position in 
 which they are carried, till they resemble in shape gloves stuffed 
 with bran." The above was a severe case, the patient, however, 
 eventually improved sufficiently to become useful in household 
 work. 
 
 Various other anomalies in the movements also occur. I had 
 a patient who always walked in a straight line, if he came 
 against a wall he stood with his face against it ; if his attendant 
 wheeled him round, he would march in the opposite dii'ection 
 until arrested by a similar obstruction. Another had a trick of 
 touching objects or persons. Some will stand on one leg, or lie 
 
 M 
 
l62 LECTURES ON MENTAL DISEASE. 
 
 on the back or face, for loug periods ; and besides these there 
 arc met with some auomahcs known to have a distinct origin 
 in brain lesion. Such as a tendency to walk in a circle, which 
 I have seen in several cases. 
 
 Chronic lunatics have in many instances distinct organic 
 changes in the nerve centres, and exhibit therefore the various 
 forms of symptoms — local or general, due to the nature of the 
 disease. As these are not special symptoms of insanity it must 
 suffice to refer the reader to works on General Pathology for 
 the interpretation of them. 
 
 As the variations in the symptoms are so wide in chronic 
 insanity in different cases, it will be as well at tliis point to re- 
 capitulate the characters, using only general terms. 
 
 In chronic insanity then, the symptoms connected with the 
 emotions continue, and to them are added distinct lesions of the 
 intellect proper ; while the motor powers are as before, in some 
 cases lethargic, in others excited; so that each division of mental 
 faculties, as Intellect, Emotions, and Voluntary Movements, 
 are simultaneously affected. 
 
 The sympathetic system is not involved. 
 
 As regards the proportion of patients whose disease becomes 
 clu'onic, I found at Hanwell, that after five years, there 
 
 Died 31-49 
 
 Recovered 24-00 
 
 Removed 5-00 
 
 Remained 39-51 
 
 100-00 
 
 and after ten years : — 
 
 Died 39-80 
 
 Recovered 25-16 
 
 Removed 4-30 
 
 Remained 30-74 
 
 100-00 
 
 It has been shown in the foregoing, that a case of chronic 
 insanity is sometimes called chronic melanchoha, and some- 
 times chronic mania, according to whether a state of excitement 
 
ORDINARY INSANITY THIRD STAGE. 163 
 
 or depression is present. There is still another case which has 
 to be described. 
 
 There are certain well recognized variations in the progress 
 of chronic insanity, which indeed are evident in the earliest or 
 first stage, but are more pronounced in the stage under con- 
 sideration. 
 
 The state of depression or excitement, in some chronic cases 
 is not persistent, but they alternate " ssepe vices commutent," 
 and the change greatly alters the features of the case. This was 
 observed in the ancient author Willis, but it was reserved for the 
 moderns to multiply the species of disease out of this tendency. 
 Sometimes the melancholia merely alternates with the maniacal 
 state. The French call this Folie a double forme. Sometimes, 
 however, there is a lucid interval between, thus, melancholy 
 — mania — lucid interval : — melancholy — mania — lucid interval, 
 and this they call Folie circulaire. There is more excuse than 
 usual for these terms, at all events they are more useful ; but 
 their use is merely to signify a tendency of the disease in its 
 progress. The terms do not, and must not, be allowed to mean 
 tliat these phenomena mark a distinct form of mental disease. 
 
 The main point to be noted is the fact that in the course of 
 chronic insanity there is a tendency to alternation in the cha- 
 racter of the symptoms, or between a state of depression and a 
 state of excitement. This periodicity is to be observed to some 
 extent in nearly every chronic case.'-^- In some it is faintly 
 marked, in others, the alternation is well marked, and takes the 
 course pointed out by the French authors ; but the period itself 
 is liable to many variations. In some, the oscillation is a diur- 
 nal change, in others, one or other state may be the longer — in 
 some, one period may occupy weeks or months. 
 
 In the case of that variation called Folie circulaire, with 
 the triple change of character, there arises a fresh source of 
 difiiculty. 
 
 When the symptoms merely change from depression to mania, 
 there is of course no difficulty about the case, the patient is 
 considered a chronic lunatic ; nor is there any doubt about deal- 
 ing with him if he is one day melauchoHc, one day maniacal, 
 and one lucid. But when the lucid interval is prolonged, even 
 
 * Sep Recurrent Insanity, p. IfiG et seq. 
 
 m2 
 
1^4 LECTURES ON MENTAL DISEASE. 
 
 thou<^li the two other states are also prolonf^ed, and this may 
 frequently happen, it becomes a question, while he is lucid, if 
 the patient is well. The doubt is greater, of course, the more 
 prolonged the lucid interval is. I have been frequently called 
 upon to discharge a patient, on account of this lucid interval, (a 
 case in point is given in the sequel) and very many such cases 
 occur ; they will be considered by themselves under the term of 
 recm-rent insanity in the next section. 
 
 As regards these cases of folie circulaire, and folie a double 
 forme, there are some features which may require a brief notice 
 The alternation, as before observed, had been mentioned by old 
 writers, and Esquirol also distinctly mentions the fact, and 
 went 60 far as to propose binary, ternary, etc., to distinguish 
 the variations, but attention was particularly dii-ected to such 
 cases by MM. Baillargcr and Falret in 1854. The descriptions 
 all agree in the characters and also in the prognosis, which is al- 
 ways bad ; and obviously so, because these cases all belong to 
 the chronic stage. To the chronicity it is that the unfavourable 
 result should be attributed, and not to the periodicity, for that 
 feature may be observed in all cases more or less, including the 
 acute or curable. The relation, however, of these cases to what 
 I call recurrent insanity is of much interest. 
 
 Up to this point of the description of the symptoms of ordin- 
 ary insanity, the phenomena may be considered to belong to the 
 course and progress of a single case. We have traced the disease 
 from its invasion to its chronic condition. The next stage ac- 
 cording to the table at p. 108, is a stage of imbccihty and 
 dementia, but before we consider that state, there are questions 
 connected with the course of these chronic cases which will need 
 further explanation and examination. There are certain cases 
 which I call cases of recurrent insanity, which from their rela- 
 tion to ordinary insanity and to the legal relations of the disease 
 deserve special description. 
 
Section III. 
 CHKONIO INSANITY OR THIRD STAGE (Continued). 
 
 Alternation of Symptoms in relation to Kecurrent Insanity — Examples of Recur- 
 rent attacks — Their relation to Epilepsy — Their importance in Medical 
 Jurisprudence. 
 
 Recurrent insanity. — This name is not adopted to convey an 
 idea, that what is about to be described, is a distinct form or 
 species of the disease, on the contrary it is merely to carry on 
 the description of the course of ordinary insanity. Few writers 
 employ the term. In that exhaustive treatise by Drs. Bucknill 
 and Tuke the term occurs in connection with mania, but every 
 one at all familiar with mental disease will at once recognize 
 the phenomena which the title above is mtended to pourtray. 
 
 Recurrence of attacks of insanity is only too common. Out of 
 11,758 admissions in 1879, 1,499 were re-admissions or about 
 one-seventh; these numbers are from the Report of the Commis- 
 sioners in Lunacy. 
 
 The universally quoted paragraph from Dr. Thurnam's statis- 
 tics leads to the same conclusion, that second attacks are nume- 
 rous. He wrote, " in round numbers, of ten x^ersons attacked 
 by insanity, five recover, and five die sooner or later during the 
 attacks. Of the five who recover, not more than two remain 
 well the rest of their lives, the other three sustaining subsequent 
 attacks, during which at least two of them die." So that ac- 
 cording to this, of ten in 
 
 First attack : — 5 recoveries 5 deaths. 
 Second attack : — 2 ,, 2 ,, 
 
 Third attack : — ,, 1 »> 
 
 Or in other words in 100 cases of primary disease, there 
 are 30 which are second attacks. This is a higher proportion 
 than that of the Commissioners, as calculated upon the relation 
 of re-admissions to the gross admissions in one year, and it is 
 higher than my general impressions would lead me to believe. 
 
l66 LECTURES ON MENTAL DISEASE. 
 
 But after all, the Btatistics give no very accurate data, for in 
 the one case, the Commissioners' table does not take into consi- 
 deration the number of patients attacked, for the same patient 
 may be re-admitted in the same year and thus be counted twice, 
 and as regards Dr. Thurnam's cases, there is no separation of the 
 forms of insanity, nor the reason of discharge. Moreover, statisti- 
 cians vary very considerably on the question. Dr. Hood found that 
 48 per cent of his cases at Bethlehem were relapses, otherwise 
 secondary cases. I found at Hanwell 20 per cent, were second- 
 ary cases. In France in 1858, 17 per cent., and among the re- 
 admissions in the Salpetriere and Bicetre Asylums, out of 2G8 
 admissions 170 occun-ed in patients who had been discharged 
 in less than one year. 
 
 Bearing well in mind the tendency to periodicity, already de- 
 scribed, which is manifested in the progress of insanity, we may 
 readily perceive the relation of these recuirent cases to ordhiary 
 insanity. 
 
 There is no difficulty in recognizing the links that connect 
 the two phenomena, or the two descriptions of cases into one and 
 the same species morbi. 
 
 Doubtless there occur cases which are truly second attacks ; 
 that is, the patient has absolutely recovered from one attack, 
 and has been seized a second time : for there is no suspicion 
 that an attack of the disease gives, like an eruptive disease, an 
 immunity fi'om a fresh attack. I have met with a few cases 
 "which were perhaps of this kind. 
 
 Much more commonly the second attack diflfers in its char- 
 acters from a prunary attack, and is really a relapse not truly 
 a new attack, such is the view which my experience has 
 lead me to adopt, and the following are the grounds of my 
 opinion. 
 
 1. The second attack differs chiefly in the suddenness of the 
 advent of the active symptoms, and as a rule by the absence of 
 a melanchohc stage. 
 
 2. Those attacks follow at all variations in the interval that 
 has elapsed since the previous attack, and between those cases 
 of ^'folie a double forme,'' in which there is no interval of lucid 
 mmd, and those cases with short lucid interval there is no ap- 
 preciable difference, and one form often merges into the other ; 
 
RECURRENT INSANITY. 167 
 
 and again between the case of lucid interval of a week, and the 
 case in which it is a mouth no difference can be made ; so 
 neither can there be in such cases in which the lucid interval 
 lasts two or three months. The latter case, and especially if 
 the mind was very lucid, would be called a recovery, and the 
 recurrence, a second attack, and in my view the cases belong to 
 the same category, they are simple examx^les of chronic insanity. 
 8. Still further in many of these cases even with lucid interval 
 of months and years, there is generally sometliing not quite 
 correct left in the patient's mind, there is something pecuhar, 
 eccentric, changed from the primary condition, which inteUigent 
 fi'iends can perceive. 
 
 4. Another reason for considering these as simple cases of 
 chronic insanity is that the course of them is the same, their 
 progress is towards imbecility when ;,they cannot be distin- 
 guished from other cases ; though it is quite true that some of 
 them ultimately recover, as do some cases of non-recurrent 
 chronic insanity. 
 
 Illustrations of recurrent insanity. — All cases which are not pri- 
 mary may be considered to belong to this section, that is, all 
 second, third, fourth and ultimate attacks. As ah-eady stated 
 the secondary attack may commence at any interval after the 
 real or apparent termination of the first. The same patient may 
 vary also in this respect, in other words the period between the 
 attacks may be regular or u-regular. Some writers have men- 
 tioned cases in which the patient was attacked at regular periods, 
 as every month or every autumn, =•' but it is more common I think 
 for the interval to be less regular, this may be, however, that 
 the patient has overcome intervening threatenings or such have 
 I)assed unnoticed. 
 
 It was a question which I attempted to solve, but without 
 ])erfectly satisfying my own mind, whether a recurrent case 
 was of such a distinct kind, that on the first outbreak m the prim- 
 ary attack there were phenomena to distinguish it from other 
 cases, and whereby we should be able to predict that the 
 patient would be liable to recurrent attacks ; the second attacks 
 for instance occur often without a preliminary melancholic 
 stage, are they therefore on this account different in species 
 
 * Griesinycr, § 119. 
 
l68 LECTURES ON MENTAL DISEASE. 
 
 from ordinary insanit}'. As far as I have been able to trace 
 these cases I have fouuti them to obey the same law as ordinary or 
 nou-rccnrreut cases, and to go through the same stages. There 
 is a good deal of difficulty in this investigation. I have treated 
 patients in their second, others in their third, fourth, fifth and 
 sixth attacks, and some few only in their first and also in a sub- 
 sequent attack. But in all those which I have observed in the 
 first attack, and who have had subsequent attacks, the disease be- 
 gan by a stage of melancholy, and in all those of which I could 
 get a reliable history there had been melancholic prodroma. 
 
 This kind of case, however, not unfrequently has proved one 
 of very great difficulty, both legally and medically and requires 
 therefore more than usual investigation. The readiest way to 
 describe it will I think be by giving clinical illustrations of it. 
 
 One of the most perfect cases that has occurred in my own 
 l)racticc is the following which is here given in outline only. 
 
 CiSE L — B. C, married, JEt 32, wife of a naval ofiBcer, of good education, 
 
 well formed, and handsome in person. Admitted in June, 18 . Attack 
 
 reported as the second, the former attack occurred three months after the birth 
 of her first child ; the present after the birth of another. In the former attack 
 she was melancholy. Much insanity in the family. Her mother, mother's 
 brother, and the latter's son have been insane. Has a brother of feeble intel- 
 lect, the rest of her brothers and sisters are of feeble intelligence, and of very 
 inferior bodily development to the patient. 
 
 The patient, in fact, being the only capable person in the family, much was 
 left to her management, and "she had everything her own way." She con- 
 tracted a very imprudent marriage- What means she possessed were speedily 
 dissipated. She became much reduced, and had to return to her father's house. 
 These adverse circumstances it was supposed led to the first attack, and from 
 which she ultimately recovered. The note unfortunately does not give its dura- 
 tion, but since another child was born and it was four months old, it is clear 
 she had been considered well for upwards of a year. 
 
 The second attack followed immediately after a difference in the family ou 
 money matters. The family solicitor had called on that day, and she did not 
 get her own way as she expected. She became greatly excited and angry, took 
 to drinking large quantities of ale, and left the house. 
 
 The following is a copy of the certificates on which she was admitted, two 
 days subsequently : 
 
 Facts observed, &c. 
 
 " She is exceedingly violent, and obliged to be placed under restraint, is very 
 indelicate in her actions, rending her clothes and exposing her person. She is 
 at times very incoherent, and very vulgar in her conversation." 
 
 Other facts communicated, &c. 
 
 " The Porter of Workhouse states she has been twice brought to the in- 
 
RECURRENT INSANITY. l6g 
 
 firmary by the police, having on both occasions collected a mob of persons by 
 her Strang!) and violent behaviour." 
 
 It appeared that she was taken to the Station-house for knocking a police- 
 man's hat off in the street in broad daylight. 
 
 She continued for three months in a very excited condition, raving inco- 
 herently, laughing, shouting, and rushing about; exposing her legs and bosom 
 without regard to decency. Was both wet and dirty day and night, that is, 
 passed her dejections quite unheedful of decency. Bodily health was fairly 
 good. She had a blister to the nape soon after admission and there were still 
 boils and pimples around it. She took food well, menstruated regularly. 
 Pulse 84. Lost a little flesh at first which she has regained. 
 
 At the end of six months slight amelioration was reported; boils and pimples 
 continue. 
 
 Ninth month. Improvement continues ; hair falling oif ; boils still appear ; 
 menstruation rather profuse ■ 
 
 Tenth month. Improvement continues; is now free from excitement ; cleanly 
 in habits ; health improved. 
 
 Eleventh month. Converses rationally ; gained flesh. 
 
 Thirteenth month. Discharged, recovered. 
 
 In this case there was, according to the account received from 
 the friends, a primary attack with melancholy and a recovery. 
 The second attack commenced, quite suddenly, she was trans- 
 acting business with a sohcitor, and on the next day at furthest, 
 was knocking the policeman's hat off his head; it is true that 
 she took large quantities of ale, but if the first symptoms even 
 were due to intoxication, the subsequent six or nine months of 
 mania had no such cause. 
 
 Case II. — The next case which may be quoted is that of S. C. a highly accom- 
 plished governess, who had been in several asylums on previous occasions and 
 was brought to Hanwell strongly handcufi"ed, in October, 1861. She was then 
 raving, shouting, and acting in a wild and strange manner. She refused to 
 reply to questions, had a haughty manner and demanded to have brandy 
 brought to her : the outbreak lasted a fortnight, when she became orderly, 
 quiet and well-conducted. She was discharged in about three mouths from 
 admission. She would not acknowledge that she had been out of her mind, 
 said, " she knew perfectly well what she was doing." (This denial is quite 
 characteristic of these recurrent cases). 
 
 After this discharge she was employed throughout the whole of the Great 
 Exhibition of 1862, as a pianist to exhibit the power of a pianoforte maker's 
 instruments. 
 
 She was discharged in January, 1SG2, and re-admitted on December, 1862. 
 
 On this occasion she was found raving in the Park, was taken by the police, 
 and in due course brought to Hanwell as a wandering lunatic. When brought 
 the police did not know her name. Tiie account of the commencement of this 
 attack was obtained from the husband, of whose address we at the Asylum were 
 cognizant. The husband was an attorney's clerk, the present he said would 
 
170 LECTURES ON MENTAL DISEASE. 
 
 make her fifth attack, but this was only by counting the worat attacks; she had 
 had several minor seizures which did not amount to distinct outbreaks. She 
 was again oblaiuiug her livelihood by teaching music to several fumilies. I had 
 myself recommended her. It happened that she had been particularly assiduoua 
 in these duties, and had complained of headaches, for the relief of which she had 
 again resorted to brandy. The husband said she soon began to talk of the 
 Revelations and the Seventh Seal, and he knew by experience what to expect j 
 and to avert a paroxysm he persuaded her to go with him for a walk in the park. 
 While he was obliged to leave her momentarily she seized the opportunity 
 to make her escape and though he at once sought her in every direction, he 
 had been unable to find her, or hear anything about her at all the stations, 
 until he received my note about a week afterwards. 
 
 It seemed that she had sold some of her clothing, and it was supposed she bad 
 bought brandy with the money. She passed through the same changes once 
 more, but was a longer time under treatment. She was discharged in the 
 summer of 1863. 
 
 It will be observed that on each occasion related she took 
 to brandy drinking, but it will also be noted as well, that the 
 case in no respect resembled delii-ium tremens, notablj' in the 
 continuance of the symptoms so long after all supply of stimu- 
 lants was stopped. 
 
 She was once more admitted in December, 1863. She was 
 again discharged cured, but my connection with the asylum had 
 ceased. However, in 1874, or '75, while visiting Dr. Stocker's 
 Asylum, Peckham House, with some pupils of my clinical class, 
 I requested to be referred to any case of recurrent insanity, that 
 was under treatment. Dr. Stocker at the moment was unable 
 to recollect any instance, when I heard the voice of this patient 
 and recognized it. S.C. denied all knowledge of me, and be- 
 trayed herself by addressing me by name. I then learnt that 
 the patient had been in the house for some period and was con- 
 sidered an imbecUe with tendency to occasional excitement and 
 violence, in other words the termination of her case was like 
 that of ordinary insanity. It will be observed also that the at- 
 tacks followed at first with sliortcr and shorter periods of lucidity 
 and the maniacal periods gradually got longer and longer until 
 the case was wholly one of chronic insanity. 
 
 Case III. The next case is from documents published by Dr. Lockhart 
 Robertson in his annual report, and partly from notes sent him by Mr. Huxley 
 of Barming Heath Asylum. C. T. aged 25, single, admitted into Kent Asylum, 
 August, 1855. History of symptoms not given, but on admission had been nine 
 mouths insane. Had at the time of admission delusions that he was a prophet, 
 
RECURRENT INSANITY. I7I 
 
 and inspired, and beard voices ; which he was obliged to obey ; wrote numer- 
 ous letters to a married lady of amatory kind. From this brief account it 
 would seem the symptoms were those of acute insanity, with melancholia, 
 probably, and religious symptoms and delusions. He was removed by his mother 
 after two months residence, having been quite harmless, and quiet, and believed 
 to be quite under control. Fourteen months subsequently he was transferred 
 from Maidstone gaol back to the same asylum. Had been committed for a 
 breach of the peace. A note from Mr. Huxley to Dr. Robertson stated that the 
 patient was subject to attacks of impulsive homicidal mania. On admission 
 Dr. Robertson reported the patient as calm and collected in his manner. He 
 gave a most accurate account of his previous history, expressing extreme regret 
 at the misconduct of which he had been guilty. Altogether says Dr. Robertson, 
 "I failed after repeated observation and examination, in detecting the slightest 
 trace of intellectual disorder." This was dated November 6th. On November 
 19th, the Commissioners asked for a further report, which was given on 
 Jan. 6th. i860, or about two months after admission. Dr. Robertson was able 
 to report that he continued quite free from any symptoms of Mental Disease; 
 that his conduct had been most exemplary. He had mixed freely with the 
 other patients, and joined in the weekly balls. Had undertaken by request the 
 duty of chapel clerk. Thirteen days subsequent to this, after complaining over- 
 night of a little faintness, and of not feeling very well, when he had also a white 
 tongue and looked rather out of sorts, he suddenly and without the slightest 
 provocation attempted, with a sharp piece of wood he had concealed about him, 
 to destroy the Assistant Medical Officer's eye ; the blow glanced fortunately 
 off the forehead, but was so severe as to knock Mr. Gwynn down. He made the 
 attack with great premeditation, besides preparing his instalment out of wood 
 and concealing it. While Mr. Gwynn was in the Airing Court the patient came 
 up and shook hands with him as usual, and drew him aside, saying he wished 
 to consult him about some money matters of his own. 
 
 On being secured he was excited, said he always had an objection to Medical 
 Officers, he had done it and his victim had had a lucky escape. 
 
 During the time he was in the Kent Asylum he made numerous similar 
 attacks on attendants and Medical Officers. Mr. Huxley was twice attacked, 
 his assistant three times, an attendant once very seriously. He was described 
 as being very treacherous in these attacks, taking the opportunity when an 
 attendant was temporally alone, the weapon used was as above, a piece of wood 
 or bone sharpened, and once an old rusty knife, with a handle formed by him- 
 self, to increase the grasp of it, and the injury intended was the destruction of 
 his victim's eyf<. The intervals are not given, the paroxysms are five or six that 
 are mentioned, and he was four years in the Kent Asylum. 
 
 Imperfect as the above may be, yet from the point of view 
 wbich is now under discussion, there is enough to show that the 
 patient was attacked primarily with symptoms closely rcsembliug 
 ordinary insanity, and was even quiet and harmless in conduct 
 during the early period. That in his more lucid intervals he 
 was prone to justify his acts. That in the secondary attacks 
 there was a certain periodicity of the phenomena ; the character 
 
172 LECTURES ON MENTAL DISEASE. 
 
 of the relapse of paroxysm was an homicidal character of par- 
 ticular kiuil, and that the patient had distinct lucid intervals in 
 which no intellectual unsoundness could be detected. 
 
 The sequel was, the patient passed gradually into the next 
 stage, that of imbecility — in which stage I have frequently seen 
 him. 
 
 Case IV. — The case of Dr. Pownall which is given by Dr. Davey, October, 
 18G0, Journal of Mental Science, is one illustrative of recurrent mania. " At the 
 age of 22, Dr. G. Pownall suflfered from bis first attack of mental alienation 
 from which be was supposed to have completely recovered. He, it seems, re- 
 mained well for 14 years, during which time ho conducted a large and first-class 
 general practice, and became highly respected and chosen chief magistrate of 
 the town in which he resided. He was as described naturally an amiable and 
 estimable man. His second attack first showed itself by a mistrust of his 
 nearest relatives, and apprehensions of injury and poison ; followed by acta of 
 violence and attempts at suicide " {all the usual symptoms of insanity). " In the 
 second attack in 1854, he shot a person, who was out shooting with him, in the 
 leg, and the Coroner's inquiry on the fatal issue of the injury, went to prove 
 that the injury was the result of accident; but there were those who took a 
 different view of the case. In the third attack in 1859, when he must have been 
 40 or thereabouts, he made a murderous attack on his mother-in-law, whom he 
 usually respected and loved. For the last 2 or 3 months he had become an 
 altered man, was low and desponding, and made an attempt to destroy himself." 
 Dr. Davey found him, on admission into his house, calm and subdued, and he 
 expressed the deepest sorrow for the violence shown by him to his mother-in- 
 law. In a month he was trusted by Dr. Davey to walk out alone, and he joined 
 the family and children in their walks, and rode with Dr. Davey and his son. 
 No symptom of mental disturbance showed itself. 
 
 Dr. Davey could find no symptom affording the least pretext for detaining the 
 patient, and placed himself in communication with the authorities, in respect 
 to the proper mode of dealing with the case. Negociations proceeded, but were 
 not 80 far completed as to obtain the discharge of the patient until the tenth of 
 August. It must be admitted that Dr. Davey was placed in a difficult dilemma. 
 He had no evidence, from one point of view, of the patient's present insanity, 
 and therefore no authority to detain him; while in case of relapse, almost in- 
 evitable, he would render himself liable to a grave responsibility. Dr. Pownall 
 was discharged, however, to reside in the house and under the care of a medi- 
 cal man, Dr. Davey sending a note to the medical man by the hands of Dr. 
 Pownall, which was never delivered, but found in Dr. Pownall's pocket after- 
 wards. He went to reside with this medical man, ilr. Leete, on the 10th of 
 August. On the 2nd of September Dr. Pownall cut the throat of Mr. Leete's 
 female servant with a razor. It is curious that Jlr. Leete should have over- 
 looked the danger of allowing a suicidal and dangerous lunatic his razors, and 
 still more curious that the razors were sent to Dr. Pownall by his brother-in- 
 law, another medical man ; but I have frequently known men not in constant 
 care of the insane to be thus thrown off their guard. 
 
 Dr. Pownall was sent to Bethlehem under Dr. Hood's care, who thus speaks 
 
RECURRENT INSANITY. I73 
 
 of the case in July, 1860. Dr. Hood said : " 1 must confess from that, time up to 
 the present, althoufjh I have watched him with no ordinary care, and though I 
 should say he was a man with weak mind, I do not know that I could attach 
 any particular symptom to him. And supposing he was a private patient in my 
 asylum, and the Commissioners in Lunacy asked me why I detained him, I do 
 not know that I could give any definite reason for it." 
 
 This patient's mode of outbreak differs from some of the pre- 
 vious patients ; in all other characters it corresponded. 
 
 We find the phenomenon of the outbreak sometimes of one 
 sort and sometimes of another ; it is not always exactly of the 
 same kind in the same patient, but very often is so. 
 
 There was a patient at Hanwell who had outbreaks of violence 
 from time to time, with intervals of comparative lucidity ; but 
 at the best was always grumbling — accusing the authorities of 
 unjust preferences shown to others ; able, however, to argue 
 with acuteness, very rigid in sticking to his own views. He had 
 made several attacks on attendants, and was considered to be 
 dangerous. Once he found his way into the kitchen, and taking 
 up a knife swore he would kill some one, unless the girls in the 
 kitchen gave him a kiss all round. This difficulty was com- 
 promised, but not before the patient had shown much violence 
 of language ; but he kept his word, when the servants had com- 
 pleted then- part of the compact. 
 
 On one occasion the hall of my colleague which was a veri- 
 table Glyptotheca, was found strewed with fragments of broken 
 busts and works of art. For a time it remained a mystery how 
 this was caused, when it was discovered that the patient alluded 
 to had quietly concealed a hammer and had entered the house 
 unobserved, and had smashed nearly every specimen. This was 
 done apparently without much excitement. The patient, at all 
 events, had subsequently so long and so clear a lucid interval, 
 that he was at the request of his wife allowed to leave on trial, 
 and afterwards was discharged. His case had almost passed 
 into obhvion, when one day there occurred an account of a 
 sacrilege mysteriously committed in Marylebone Church, and a 
 reward of £100 was offered for the discovery of the offender. 
 There was also an iconoclastic attack made on two equestrian 
 images of the Queen and Prince Consort, which stood under the 
 portico of the Colosseum in Eegent's Park. One of the atten- 
 dants at once recalled the propensity of this patient, gave in- 
 
174 LFXTURES ON MENTAL DISEASE. 
 
 formation, and received the £100 reward. The patient was 
 convicted, found insane, and sent to Broadmoor, where, after 
 being considered a quiet patient for some time, and clearly well 
 trusted, he again became conspicuous. He was at Chapel one 
 day, and sat immediately behind Dr. Meyer, the Medical Super- 
 intendent, and from his position it is presumed he was con- 
 sidered quite harmless, but he rose up suddenly and with a bag 
 of stones in his hand, brought it down on Dr. Meyer's head, 
 fracturing his skull, of which injury the doctor eventually died. 
 
 A remarkable feature, and a very dangerous feature too, in 
 these cases, is the degree to which this lucidity arrives in some 
 of these patients. Such a state of apparent sanity is exhibited, 
 that it seems scarcely justifiable to retain these i^atients under 
 surveillance. This difficulty has occurred to everyone. M. 
 Morel, at p. 480 of his Traite des Maladies 2Ientales, thus 
 writes : — 
 
 " I have remarked for a considerable time, a certain class of 
 patients in whom the accession of the excitement, which was 
 like, and was in reahty a state of mania in the most rigorous 
 acceptation of that term, alternated with periods of remission, 
 so perfect and prolonged, that there could be no room for doubt 
 in my own mind, that the patients had completely recovered. 
 And it has been only after being painfully and repeatedly de- 
 ceived on this point, that I have been obhged to give a more 
 special attention to the course and development of the disease in 
 this class of patients. That which has struck me more especi- 
 ally has been the sudden invasion of the morbid phenomena 
 after remissions, which have varied in duration from several 
 months to intervals of years. The friends whom I have care- 
 fully questioned, have not been able to particularise any pre- 
 monitory sjnnptom or warning of the attack. On the eve of the 
 paroxysm, the patients neglect their ordinary occupations, but 
 make no complaint. There is to be observed simply an in- 
 creased activity in their movements, and a peculiar excitabihty ; 
 the patient then suddenly breaks out in the same manner that 
 characterised his former paroxysms, in extraordinary acts of 
 violence ; in exhibitions of the most dangerous propensities and 
 irresistible impulses ; so that I have had to sincerely regret that 
 I have ever authorised the discharge of these patients, so de- 
 plorable have been the circumstances attending their relapse." 
 
RECURRENT INSANITY, I75 
 
 *' On re- admission, these patients," M. Morel goes on to say, 
 " after a period of excitement equal in duration to that in the 
 former attack, suddenly return to their former quiescent con- 
 dition exactly as before, presenting the same evidences of re- 
 covery as those which led me to discharge them from the asylum. 
 My experience," he adds, "however, has made me more pru- 
 dent ; and the exhibition of a phenomenon which had remained 
 in a larval condition, has allowed me to place these cases in the 
 class to which in reahty they belong. These patients have pre- 
 sented a close resemblance to epileptics in the character of their 
 ideas and actions ; but to such an extent only as to leave me up 
 to a certain time in doubt as to the true nature of their disease. 
 It has occurred to me since to have several patients whose 
 attacks had all the character of the relapse, the intermittence 
 and periodicity that I have described, and who have subsequently 
 been the subject of well marked epileptic seizures." 
 
 I have myself had j)recisely the same experience. The fol- 
 lowing is an epitome of two cases, which occurred to me at 
 Hanwell. 
 
 Another feature in such cases, and one which has a great 
 pathological interest is their relation, and perhaps alhance with 
 true epilepsy. There is the same periodicity in the cases ; the 
 same impulsiveness, and the same ignorance or blindness to 
 then- own position ; and though the acts of violence are not 
 attended with any unconsciousness, yet they seem scarcely 
 voluntary. In the next place, certain cases of epilepsy which 
 we have to consider hereafter, resemble these cases in having 
 maniacal outbreaks, in which the patient performs acts ordi- 
 narily of purely volitional character, acts of wanton cruelty, 
 homicide, &c., as are to be referred to further on. Lastly, a 
 proportion of these very patients, become truly epileptic. Dr. 
 Morel was led to propose for these cases the name of Epilepsie 
 larvce.* 
 
 * A critic made a point as he believed against me for latinising, in my published 
 Lectures, Dr. Morel's term into epilepsia lai-valis, asserting that all that was 
 meant by Dr. Morel was " masked epilepsy." The French dictionaries to which 
 I had access have only the word larv^, a grub-larva or worm ; the latin word 
 larva is translated mask or vizard, in the sense of something put on to frighten 
 with, a ghost, etc. I suspect that Dr. Morel really meant that the disease was 
 in an undeveloped or larval condition, if ho meant masked what s^iould have 
 hindered him from writing " masqude." 
 
176 
 
 LECTURES ON MENTAE DISEASE. 
 
 Case V. — E. T., was left an orphan at a very early apo, with £200, which 
 was left in trust for her education. Her trustee entirely neglected her, allowed 
 her to play in the streets in the lowest neijjhbourhoods, and at last deserted her. 
 She was taken in by a poor neighbour. At sixteen years of affe she had an 
 illegitimate child. Tliis was felt by her eery keenly as a disfjrace. She went 
 to the workhouse, where, according to her assertion, she was ill-used and un- 
 justly treated by the master. For several years she spent her time between 
 this workhouse and the house of correction. She was a noted character in both 
 on account of her violence. A great sensation was made about her by certain 
 philanthropists, and the medical officers of the prison were requested to give 
 an opinion about her sanity. They considered tliat there was no evidence of 
 insanity in her. I was requested by the authorities also to examine her, in 
 conjunction with Mr. Marshall of Colney Hatch Asylum. We recognised at 
 that period the resemblance of the case to epilepsy undeveloped ; and my col- 
 league especially distinctly gave it as his opinion that the case would terminate 
 in well-marked epilepsy. There was not, however, at that period, such an 
 amount of proof of this, or of any mental disease, as would warrant a certificate 
 of lunacy. We were precluded, by law, from signing a certificate ourselves; 
 and we did not feel that we could, on our view of the case, recommend the 
 officer of the prison to call the case insanity. The patient was, however, shortly 
 afterwards admitted into Hanwell, under my care. Her intellect probably was 
 never very strong. Her instincts were under Little control. She was in person 
 well developed, of short and thick-set build. She endeavoured to create a 
 morbid interest about herself; but this was prevented by the measures taken. 
 She showed evident chagrin if not treated with more particular attention than 
 the rest, and accused the nurses of favouritism', etc. She made several unpro- 
 voked attacks on the attendants and female officers, and required for some time 
 great caution in treatment. These periods of excitement alternated with 
 periods of perfectly quiet behaviour, lasting sometimes a fortnight or longer. 
 The menstruation on admission was suppressed. After residence in the asylum, 
 this function was re-established, and her conduct improved. She became in- 
 dustrious. She never was untruthful, nor dishonest. She made herself very 
 useful in the Asylum, and after fourteen months of improved conduct she left 
 on trial, under the care of her early protectress. This friend happened to keep 
 
 a china shop, and E. T 's conduct at intervals during the month was such as 
 
 to keep the owner of the china in a continual fright. She was brought back to 
 the asylum, and after another period was allowed another trial, a benevolent 
 lady undertaking to employ her as a servant; for a time she beheared very well. 
 One morning, however, on coming down stairs, the mistress found E. T. sitting 
 on the stairs, she accosted her mistress rudely, and threatened -violence. She 
 was again brought back to the asylum. She again became calm and thoroughly 
 well behaved, kind and attentive to a girl patient, and was remarkable for her 
 straightforward, truthful conduct, though from time to time she changed, and 
 clearly made great efforts to control herself. She was taken into the service of 
 the asylum in the kitchen department. Soon after she was seized while at work 
 ^vith well-marked epilepsy, and the attack continued to recur at short intervals. 
 Her disposition underwent a marked change from this period; she was more 
 quiet and subdued, though rather irritable just previous to a fit, when she 
 would use very foul language. Her memory rapidly failed, her mind became 
 very feeble. She took poison, it was believed intentionally, and died. 
 
Kl'CURRENT INSANITY. I77 
 
 111 this case the dormant epilepsy was manifested at the close 
 of the case which is the more usual course. In the next case the 
 reverse order occurred. 
 
 Case VI. — E S., was taken up in Chelsea by a policeman for creating a dia- 
 turbance. She got into a doctor's brougham while it was standing at a patient's 
 house, and vociferated to the coachman to drive on. She could only with great 
 difficulty be dislodged from the vehicle; she resisted very violently, and was 
 takeu to the station, then to the workhouse, and after making a great distur- 
 bance there, was sent to prison. In prison she disobeyed the regulations and 
 was several times punished. At last she was sent to the asylum. On admission 
 she behaved well for a time, then began to make extravagant demands for in- 
 dulgences, if denied she broke the windows, and threatened and attacked 
 several of the female officers. She broke and destroyed with great dexterity 
 her rooms however strongly secured. Her violence, when it commenced, lasted 
 SL-veral d lys, and then for a corresponding period, she remained quiet and well- 
 behaved. She was at times neat and tidy in her person, and at times filthy and 
 disgusting. She had no attack of true epilepsy while under my observa- 
 vation (about eight months), it was a case which from the intellectual in- 
 tegrity and apparently wilful perversity would be unhesitatingly considered by 
 many, and indeed was by very many, to be a case of moral delinquency, and it 
 would come under the title of " Moral Insanity '' by those who consider that 
 there is such a species of disease. After having been under my care some 
 months, she was visited by her sister who related the history of the case. The 
 patient up to the age of twenty, about four or five years previously, was a quiet, 
 hard-working, well behaved girl, of retiring habit. About the age of twenty 
 she lost her mother suddenly ; she became melancholic and out of her mind, 
 and was sent to an asylum in Ireland. She was there some time, and while 
 under treatment had epileptic fits, which she continued to have regularly for 
 several years. The fits had only left her shortly before she became insane again. 
 
 The notes that I have of other cases of recurrent insanity 
 exhibit but unimportant deviations from the cases quoted : — One 
 case is that of a female, who, between the ages of 18 and 30, had 
 had as many as 9 or 10 attacks. Three or four years elapsed 
 between the first and second attack. She had been nine or ten 
 times in Bethlehem, and during the early attacks was discharged 
 alter three or four months. The duration of each attack, how- 
 ever, became longer and longer, and the last time she was at 
 Bethlehem she remained 18 months — the rules beuig that 
 patients should be discharged after one year, unless special cir- 
 cumstances existed. She was received at Hanwell from Beth- 
 lehem and recovered in three months, and was discharged ; was 
 re- admitted in twelve months, and remained there several years, 
 as long as my connexion with the asylum lasted. In this case, 
 
 N 
 
178 LECTURES ON MENTAL DISEASE. 
 
 and iu the next, it was reported that the first attack was accom- 
 panied by fever. However, thirty years had elapsed since, and 
 the memory of friends on such matters is apt to err. The other 
 case, which was reported to have begun with febrile symptoms, 
 the notes say, the first attack occurred after an illness — the 
 patient herself says, after scarlet fever ; and the informant also 
 says, she " broke out iu violence and excitement suddenly," and 
 was removed to the Oxford County Asylum. A sudden out- 
 break without premonitory symptoms would be a very excep- 
 tional course, and it rests only on the evidence of very illiterate 
 persons, who are apt to ignore such slight phenomena as de- 
 pression of spii'it and fanciful apprehensions, and if they saw 
 them, to have their impressions obliterated by an outbreak of 
 violence. However, the fact is of interest, since there was also 
 hereditary predispositions in the family. The mother was a 
 patient in the Wilts Asylum ; a brother was not quite sound in 
 mind. However, I have also had another case not very dis- 
 similar, in a young lady, the daughter of a lady subject to epi- 
 lepsy, who was quite well up to an attack of scarlet fever, when 
 on the subsidence of the fever she was found to be much altered 
 in mind, and in a state of childishness, but with a tendency at 
 intervals to outbreaks of violence. She attacked the servants, 
 her father, and a medical man with whom she was placed, and 
 who on account of her violence was unable to retain her in his 
 house. She gradually became somewhat calmer, but had seve- 
 ral slighter outbreaks of unprovoked violence. She was wet and 
 scarcely decent in behaviour, and childish in mind, and so re- 
 mains. In this case a true epilepsy may be impending. 
 
 As a general resume of the subject of these secondary or re- 
 curring cases, I consider that the examination of all the pheno- 
 mena leads to the following conclusion : — That in many or even 
 most of these recurrent cases, there has not been an interval of 
 complete recovery. The interval, however lucid, if closely in- 
 vestigated would show some indication of unsoundness. There 
 will be detected, a want of intellectual power, an infirmity of 
 temper, a change in afi'ection, slight eccentricity of character, 
 sufficient to betoken the infirmity. That there is a general 
 resemblance in these cases, though the mode in which the out- 
 break is manifested may differ. That the nature of the out- 
 
RECURRENT INSANITY. I79 
 
 break has a tendency to simple violence, or to suicide, to drink, 
 arson, murder, rape, iconoclasm, stripping naked, &c., does 
 not change the nature of the case pathologically considered. 
 That these cases, on the one hand, have relation to ordinary 
 chronic insanity, and in another direction with epilepsy. That 
 they vary from the former or chronic insanity only in the more 
 marked periodicity or trenchant character of the phenomena of 
 lucid and insane periods. Between ordinary or continuous 
 chronic insanity, and the best marked periodic cases, all shades 
 of difference are met with, from the alternation of good and bad 
 days of a patient with no actual clearness of the mind, from the 
 changes oi Folie a double fonne, or the phenomena of Folie Cir- 
 culaire, to those cases which have marked lucid intervals for 
 months or even years, and yet have an undercurrent of insanity 
 always present. While by this very character of periodicity 
 (a character of utmost importance in their pathology) they are 
 allied to epilepsy, and in certain cases actually terminate in well 
 marked symptoms of that disease ; especially when our views 
 of epilepsy include all the phenomena and variation of the petit 
 vial, now generally classed with true epilepsy. 
 
 Notwithstanding the authentic instances of recurrent insanity 
 ehewiug intervals of lucidity for very long periods, so that the 
 disease is known to be dormant for years, it is by no means to 
 be inferred that every case that is a second attack belongs to 
 such a category. 
 
 There is one very important matter with respect to these 
 cases, which has yet to be mentioned in connection with the 
 bearing they have on criminal actions. 
 
 It has already been shown that the commencement of the 
 paroxysm takes place often without warning, or with very little. 
 The patient has a little malaise, uncomfortableness, or complains 
 of not feehng quite himself —a condition easily overlooked by 
 the friends — and the act of violence occurs, and as M. Morel 
 says, it is often a very deplorable catastrophe. The outbreak 
 resembles the seizure of a fit of epilepsy, and as already men- 
 tioned, the attack of epilepsy resembles it in being sometimes 
 attended by an act of violence. The two morbid conditions are, 
 as it were, amalgamated in character. The outbreak, though it 
 may be of any kind, is not unfrequently an act of great violence, 
 
 n2 
 
l8o LECTURES ON MENTAL DISEASE. 
 
 and brings the patient within the criminal jurisdiction, and then 
 arises the question which has raised so much difficulty between 
 the lawj'ers and the medical expert. 
 
 It has already been shown that in many of these cases the state 
 of the patient that preceded the outbreak was a lucid interval. 
 Common witnesses, and not a few medical men (for insanity un- 
 fortunately forms no necessary part of medical education), are 
 puzzled to comprehend that the accused was not responsible ; 
 and this is not only from the patient's apparently lucid state 
 immediately before the criminal act, but also immediately after 
 it. Another source of confusion has arisen in the understand- 
 ing of these cases from the dogma of moral insanity, or insanity 
 without intellectual fault. The dogma of the existence of such 
 a disease, as well as of impulsive insanity or insane impulse, 
 was started by a German named Marc, who collected a series 
 of cases of these horrors, and made of them a sensational book ; 
 and the cases have been quoted from book to book ever since. 
 
 It is not only important to know that the propensity exists in 
 certain morbid conditions to break out into these criminal acts, 
 but it is equally of importance to know that when one of these 
 apparently motiveless acts is committed by a lunatic, there will 
 always be found a history of insanity in the accused's life ; for 
 Buch outbreaks in a lunatic are only met uith as phenomena of 
 second or subsequent attacks ; this fact is important. Such parti- 
 cular criminal acts, with or without apparent motives, and often 
 of the most atrocious character, are the very symptoms or man- 
 ner in which a relapse in recurrent insanity shows itself ; and 
 such acts never occur as a first or even early symptom in the 
 first invasion of the disease. There ought, therefore, to be no 
 difficulty or obscurity in the legal bearing of a case of the kind. 
 The history of the patient's Hfe ought to settle the question 
 whether the act was an insane act or a purely criminal one. 
 
 There are only two other causes which may be in operation, 
 but neither render the accused a responsible agent. 
 
 1. When the case occurs in an epileptic ; what has been al- 
 ready said of the relation of epilepsy and recurrent insanity, 
 scarcely renders it necessary to distinguish this from the cases 
 under discussion. 2. Certain cases of idiocy ; these will be 
 alluded to hereafter, but neither these nor epileptic cases render 
 the person responsible. 
 
RECURRENT INSANITY. lOl 
 
 Numerous cases are quoted by M. Brierre du Boismont, 
 Bome known to himself, aud others quoted from Mittefmaier, and 
 us far as I am able to trace then history, the criminal act was 
 sudden and apparently causeless in all of them, and was preceded 
 by evidence of previous mental disorder. I have watched these 
 cases now for years, as reported in the newspapers, and I have 
 never known a case in which the criminal act was the first 
 evidence of insanity, or rather in which the first symptom was 
 a sudden act of violence. 
 
 It may, however, be that the act of violence appears to be 
 premeditated, and a reason for it given by the accused ; but 
 the explanation is generally, in a lunatic, outrageously inade- 
 quate, and not at all like the reason for a criminal act of re- 
 venge. One lunatic killed his mother-in-law, as he never did 
 like mothers-in-law. 
 
 There are two cases reported in the Journal of Mental Science 
 in Jan. 1868. One, of Louis Bordier, whom Mr. G. Simpson, 
 Surgeon to Camberwell Workhouse, who was called, considered 
 insane, but who was nevertheless hanged, and it seems chiefly 
 because the Surgeon of Newgate had not seen any signs while 
 under his care. It must be remembered that in recurrent 
 insanity the mind appears rational often immediately after the 
 outbreak (^vide supra). Drs. Laycock, Wood, and H. Tuke, 
 considered the man insane, and wrote to that effect to the 
 Medical Journals. Dr. Maudsley, on the other hand, opposed 
 that opinion, writing that he " looked with extreme suspicion on 
 the madness which, like Jonah's gourd, comes up in the night 
 and vanishes in the morning." But this is exactly the character 
 of these recurrent cases to which kind of case it seems to me 
 that of Bordier belonged ; and it is to be noted that there was 
 evidence of a period of apparent melancholia some time before, 
 and his outbreak or seizure being sudden, and passing off like 
 an attack of epilepsy, would be quite in the usual course. 
 
 The second case in the same article is that called the Altori 
 Murder, in which a solicitor's clerk murdered a Httle girl and 
 coolly entered in his diary, "killed a little girl, it was fine and 
 hot." The deed in its details was so atrocious as to attract 
 much feeling, " in the first place, it is a libel on the beasts to 
 call such a crime brutal," wrote one commentator, " brutes do 
 
l82 LECTURES ON MENTAL DISEASE. 
 
 not violate and murder one another in that way ; " this murderer 
 Tras executed ; evidence was given at the trial that a near rela- 
 tive of Lis father was in confinement suflFering from homicidal 
 mania, and that his father had had an attack of acute mania, 
 that he himself had exhibited singular caprices of conduct and 
 that it had been necessary to watch him, for fear he might com- 
 mit suicide, so that in this instance the sudden act of atrocity 
 was foreshadowed. He had at least an organisation prone to 
 madness or what the same writer called " the tyranny of a bad 
 organisation to contend with." It may be that such cases lie on 
 the confines of both idiocy and criminahty, if not of disease and 
 crime. 
 
 Another remarkable case of recurrent insanity which is typi- 
 cal, is that of Dr. James Pownall related by Dr. Davey, (Jour- 
 nal of Mental Science, Oct. ISQOl, already given. 
 
 In illustration of some of these acts of lunatics, I extract the 
 following epitome of cases, collected by Mr. Gaskell, the com- 
 missioner in lunacy, in a paper entitled, " On the want of better 
 provision for the Labouring and Middle Classes when attacked 
 or thi'eatencd with Insanity." I give the cases as they are re- 
 corded, omitting o-ne only that has no particular bearing on 
 this question, but in all the rest it will be perceived as I 
 have already insisted on, that these homicidal or suddenly 
 violent patients are all chronic lunatics, that in very many 
 besides there existed a proof of a previous melancholic stage in 
 some part of their case. 
 
 "In a single number of the 'Timps,' of May 15th, 1857, we road tlie account 
 of a woman killing her two children and accusing her husband of the deed. 
 She had recently been discharged from an asylum, and was proved to be insane. 
 In another column of the same paper we find that a labiuring man suffering 
 under religious delusions destroyed the attendant placed by his friends to take 
 care of him." 
 
 *' In the month of January, 1858, a young man who 'for five or six years had 
 not been of sound mind,' and had lately become worse, put an end to his father's 
 life by great violence." 
 
 "In the following Slay, a journeyman printer, who according to the evidence 
 of Lis medical attendant, had, 'for some time been suffering from unsound 
 mind,' suddenly and without provocation took the life of a fellow-workman in 
 presence of his companions, and then mutilated the body." 
 
 " In August following, a farmer in good circumstances, who had been insane 
 nine years, and had twice attempted euicide, fatally assaulted the man who was 
 engaged to attend him." 
 
RECURRENT INSANITY. 183 
 
 "In the following No7ember, a seaman who had been several times ia an 
 asylum, and had twice attempted suicide, was placed on trial for killing his 
 grandmother, which he did *iu a paroxysm of mania, in the belief that he was 
 destroying a man who was attempting his capture." 
 
 "In the same month, a commercial traveller, proved to have been 'for some 
 time a raving madman,' nearly severed the head of a sick friend with whom he 
 was on good terms." 
 
 "In the next month, a wool-sorter, who 'for some years back had shown a 
 gloomy tendency of mind,' which had increased, killed his wife by ripping 
 open her abdomen ^rith a razor, and immediately committed suicide by cutting 
 his own throat." 
 
 "In the same month, a working silversmith, 'under medical treatment for a 
 nervous complaint, was suddenly seized with a violent frenzy,' and furiously 
 attacked his wife with a poker, and then committed suicide by nearly severing 
 his head from his body with a razor." 
 
 " H. B., an agricultural labourer, first exhibited symptoms of insanity in the 
 early part of 1856. In the month of June, iu the same year, he became violent 
 and uncontrollable, was tied to his bed with ropes, handcuffed by the constable, 
 and taken to the Macclesfield Workhouse as a lunatic. After remaining in the 
 workhouse a month he made his escape and returned home. He continued to 
 be manifestly insane, the money earned by him was entrusted to his wife ; and 
 in a journal kept by the patient frequent allusion is made to the temptations of 
 the devil. On the 20th of April, 1858, he went to a relation in Stockport, who 
 noticing him to be ' much worse,' procured an order for his admission into the 
 Stockport Workhouse ; on the same day the patient returned home and dashed 
 his wife's brain's out with a cleaver, saying, ' I've killed the devil.' " 
 
 The following is from "the Echo," Aug 22nd, 1871 :— 
 
 "At Stow Bedon, yesterday Mary, the wife of a labourer, cut the throat of 
 her female child, aged fifteen month.s, almost severing the head from the body, 
 and also cut the throat of a deaf and dumb idiot, aged eighteen years, a daugh- 
 ter of her husband by his first wife. The murderess complained of illness on 
 Sunday night, but said she was better when her husband left for work yester- 
 day morning. Soon after this, when her little girl of five years awoke, she saw 
 her mother cutting the throat of the infant, after which the wretched woman 
 took hold of the little girl, and attempted to murder her, but desisted ou the 
 child appealing to her as her pet. She then carried the child through the room 
 where the idiot was lying wounded, and went to a neighbour and told her that 
 she had killed the other two, but that th& one in her arms had got over her. 
 The poor woman was insane seven years ago, and attempted suicide twelve 
 months ago." 
 
 " G. E,., who 'in the year 1857 was of unsound mind, when he attempted 
 suicide', cut his wife's throat in September, 1858." 
 
 " W. G., who had been a patient in the Suffolk County Asylum, soon after his 
 discharge killed his aunt and his sister." 
 
 In all tliese instances the outbreak was an act of murder, in 
 all there was clear evidence of a pre-existence of insanity, every 
 one of the cases would be quoted doubtless, without the history 
 given by Mr. Gaskell, as proof of homicidal impulse. 
 
184 LECTURES ON MENTAL DISEASE. 
 
 Similar cases have been given as illustrations of emotional 
 insanity. In Drs. Buckuill and Tuke's Psycholugical Medi- 
 cine, at p. 193 we read : — " In 1854, a boy shot his step- 
 mother in France. He confessed the act, but said it was 
 the result of a mysterious ' irresistible impulse.' .... He ad- 
 mitted an aversion to his stepmother ; there was no disor- 
 der of the intellect apparent ; there was an hereditary predis- 
 position to insanity on both sides." (Quoted from Ayitt. Med. 
 Fsy., April, 185G.) Now I give this case from Drs. Buckuill 
 and Tuke's treatise, because it is given as an example and 
 proof of the emotional insanity, which is described as a special 
 variety of insanity. If the proof of this special disease rests on 
 no better evidence than this, how can we admit it into our 
 nosology ? Yet it is on the nun-iitive of such cases that whole 
 sections on emotional insanity are based. It will be perceived 
 that there is not one word of how long the lad had been ill, no- 
 thing about his previous symptoms. Indeed, nothing but that 
 there was no disorder of the intellect present, and that he shot 
 his mother. I quote the case from Drs. Bucknill and Tuke's 
 edition of 1858. It happens, that one knows something more 
 about this lad, for in the Annales Medico- Psifcholot/iques, for April, 
 1862, there is an account of his afterwards shooting himself. 
 He shot his stepmother on November 10, 1854, and killed him- 
 self in Februar}', 1859, on the tomb of his victim, and in his 
 pocket-book were found these words : "I am about to die close 
 to her whom I so fondly loved and so greatly deplored." 
 
 This lad was considered insane at the time of the commission 
 of the first act by several men of eminence, among whom was 
 the celebrated M. Calmeil. He had cherished this deadly 
 animosity against his relative for nine years before he shot her ; 
 he shot himself five years afterwards. 
 
 There are several pages occupied in the works quoted in the 
 narration of violent acts done by lunatics, whose cases are cited 
 as examples of emotional or moral insanit}', but in my opinion 
 these accounts do not establish the existence of such disease as 
 a distinct morbid species, as really all they show is, — that a 
 certain number of persons committed acts of great violence. 
 In nearly all these cases the mere act of violence is given, 
 there is no history ui most of the cases. In thirty-one cases in 
 
RECURRENT INSANITY. 185 
 
 wliicli the act is reported to be committed without premeditation. 
 Two were idiots, six had a history of previous insanity, twenty- 
 two no history of case is reported, and one was epileptic. Out of 
 the six in which the history is recorded the case akeady quoted is 
 one. Another was that of an artist, wlio had had a severe cerebral 
 affection of which he had been cured for several months, he at- 
 tacked a barrister a perfect stranger in the Palais de Justice. 
 He told Esquirol, " I went to the Palais de Justice as an idler, 
 as I should have gone elsewhere, I had no ill-will against this 
 advocate, he was entirely unknown to me, I might have been 
 dh'ected to any other person." Esquirol adds, " he was perfectly 
 tranquil next morning, quite calm, without anger or resentment, 
 on the same day designed a picture.'' 
 
 The question of moral insanity is examined at length in Dr. 
 Blaudford's work. Insanity and its Treatment, and the cases of 
 Dr. Prichard to whose authority the existence of such a disease 
 is due, are there fully analysed. He concludes thus (p. 317) 
 " thus I have briefly commented on all cases of moral insanity 
 related by Prichard, that in some of them insanity existed with- 
 out insane delusion for some time I admit, but that it existed 
 without alteration or defect of the intellect I deny." 
 
 The following names may be found in authors and described 
 by some of them as separate diseases, but which are simj)ly 
 case of recurrent insanity and in which the outbreak occurs by 
 different modes. As ah'eady said the attack is ushered in more 
 or less suddenly, it is sometimes by a condition of melancholy 
 and refusal of food, etc., but when the outbreak is by violence it 
 may take various characters as by murder, rape, drinking. The 
 following are some of the names founded on this basis : — 
 dipsomania, oiuomania, homicidal mania, suicidal mania, pyro- 
 mania, nymphomania, satyriasis, iconoclastic mania, etc., etc. 
 (see p. 190 et scq.). 
 
 In pursuing the history of a case by reference to the table 
 (p. 108) it will be seen that a case of chronic insanity has three 
 modes of termination, 
 
 1. By recover}'. 
 
 2. By death. 
 
 3. By passing into imbecility. 
 
 Recovery. — The chances of recovery are greatly diminished, 
 
l86 LECTURES ON MENTAL DISEASE. 
 
 obviously bo by the very duration of the disease, tlie question 
 is after what period is a case to be deemed chronic and after 
 how long a duration of insanity is recovery possible, this must 
 depend on the duration and severity of the disease ; or 1 . the 
 nature of the disease, and 2. the constitution of the patient. 
 
 1. By the form of the disease and kind of symptoms actually 
 present we may form some j)rognosis. In those cases in which 
 the w^hole range of mental faculties is not involved, there is 
 much greater reason for anticipating, or at all events hoping 
 for a favourable result, whether the duration be short or long. 
 
 Lord Brougham once said in giving a judgment " the human 
 mind is one and indivisible and if a man is mad in one point, 
 he is mad on all," undoubtedly sucli is a safe maxim for a lawyer. 
 Yet it certainly happens in practice to find a patient, Avho is 
 undoubtedly insane in conduct and in feeling, yet retain a con- 
 siderable amount of reasoning power. When there is integiity 
 of so much it is obvious that the disease must be partial as re- 
 gards its seat ; if there are on the contrary symptoms whicli im- 
 pair the intellectual faculties, the senses or one of them and the 
 motor faculties, even though partially, the chances of recovery 
 are greatly diminished. In cases where the understanding is so 
 far involved, that the powers of reasoning, the coherence of 
 ideas, and the behefs are involved and true delusion exists, the 
 case is obviously more serious. A mere raving, with a wild flow 
 of ideas and emotions, may exist in what is called delirium and 
 may pass off, but when such a calm judgment exists and is at 
 the same time faulty, as when a man believes he is a king or 
 God, it is obvious that a very deep inroad has been made into 
 the mental integrity. 
 
 There may be, however, such a state of things as is called by 
 Neiiman Ein Heilnng viit de/ekt, a cure with permanent defect, as 
 one who has broken a leg may recover, but be permanently 
 lame. One can imagine that the morbid processes may have 
 come to an end, but the damage left may be such that perfect 
 sanity cannot be restored. This is a hj'pothetical case, how- 
 ever, and a more usual condition of things found is a gradual 
 decline towards mental weakness. A state of " backening or 
 backsliding, Verriichtheit,'' of the faculties. 
 
 2. Certain considerations in the condition of the patient may 
 
ORDINARY INSANITY FOURTH STAGE. 187 
 
 modify the unfavourable prognosis, though the unsoundness may 
 
 be general as regard the faculties, if the disease occurs before 
 full growth is attained, or in females jiist prior to the climacteric 
 periods these epochs may have a favourable influence. 
 
 Cases of recovery are reported after ten years from nearly 
 every asylum, and some after eleven and twelve. I have known 
 many after seven and eight years and who have remained well 
 fifteen or sixteen years afterwards, but such are exceptional of 
 course. 
 
 Death. — As regards the termination by death, that event may 
 still occur from bodily disease arising out of the mental ; or more 
 commonly death is due to some intercurrent disease, but when 
 the mental disease has become chronic it is no longer a cause of 
 death. 
 
 It is, however, the fact that chronic lunatics are very liable to 
 disease of different kinds connected with the nervous system, to 
 apoplexy and to haemorrhages involving different portions of the 
 nerve centres causing local and partial paralysis, ataxy, etc., 
 but as these are not at all special as regards the insanity they 
 need not be more definitely stated. 
 
 When the patient's disease does not terminate by either 
 recovery or death, its next stage is imbecility. 
 
 Imbecility. — The word imbecile or imbecility is the most fre- 
 quent termed employed in asylums to denote the patient or his 
 condition in this the last stage of my scheme (p. 108). 
 
 It is true that there are degrees even in this stage of the 
 disease and some patients are called demented or the subject of 
 amentia, when the condition is at the lowest point, these terms 
 correspond to the English weak-minded and demented. In 
 discussing the morbid states, it is as well to reserve the terms 
 idiot and idiotic, for another division of our subject (Subdivision 
 Bl. page 104). 
 
 It is of course quite an arbitrary measure, where we draw the 
 hne between our two artificial stages (the third and fourth p. 
 108) . Griesinger divides his chapter Die Pathologie unci Therajne der 
 psychischen Kranhheiten into : — I. States of mental depression, II. 
 States of mental exaltation, and III. States of mental weakness, 
 and in considering the latter he makes four degrees or exclud- 
 ing the last, idiocy, three degrees of mental weakness. The first 
 
l88 LIXTURES ON MENTAL DISEASE. 
 
 of those tlirec divisions is Verriichthcit, the second Venierrtheit, 
 which he translates as dementia, and the third BUnlsin. 
 
 Verrucktheit corresponds to our word imbecihty ; but Griesinger 
 was, he says, criticised for including this, which as was said 
 above, literally means a defect in intellect, among the states of 
 mental weakness, since in certain cases according to his own ac- 
 count there remains a good deal of tendency to violence. He 
 Bays, " although the original morbid state of the sentiments has 
 considerably diminished or even entirely disaj^peared, the indi- 
 vidual does not recover, but remaius afifected in such a manner, 
 that the aberration of mind is now most strikingly exliibited in 
 certain fixed delii'ious conceptions, which are cherished with 
 special preference and often repeated." 
 
 We should in England consider such a patient a chronic lun- 
 atic, but where the line is to be drawn, as already stated is quite 
 arbitrary, one artificial division in the progress of a single case 
 is shaded off into the other, and it is not possible to say exactly 
 at what point the title of imbecility should be given or when 
 chronic lunatic is more appropriate. 
 
 In all cases of clu-ouic insanity, there is more or less rapid ten- 
 dency according to my observation toward imbecility, if not to- 
 ward recovery or death. In general the state of melancholy and 
 mania or depression" and excitement gradually cease, and even 
 when the expression of grief becomes as it were stereotyped on 
 the patient's mind, he seems usually to feel mental pain less. 
 A gentleman under my care, who for more than six years was 
 constantly bewailing his lot, at last on becoming quite imbecile, 
 repeated constantly, "I'm very comfortable I can do more." 
 Another patient who continued to bemoan her fate, in violent 
 terms, was always ready to join in amusement of any kind. 
 
 As pointed out in the passage quoted from Griesinger, though 
 the state of depression or excitement ceases, in other words, the 
 emotional disturbance has subsided, the intellectual defects re- 
 main. The delusions especially or false beliefs, the incoherence 
 of ideas, and eccentricity of conduct become more and more 
 confirmed, but with these in nearly every case there is a gradual 
 and general weakening of mind progressing. 
 
 States of imbecility. — In all asylums, and in all worldiouses 
 there are a large number of imbeciles collected, gathered from 
 
ORDINARY INSANITY FOURTH STAGE. 189 
 
 the foUowing sources : — 1. the incurables from insanity, 2. im- 
 beciles from ej)ilepsy, 3. congenital imbeciles and idiots, 4. im- 
 beciles with general paralysis, 5. imbeciles fi'om age, 6. from 
 drink and some other diseases. Each of these present particu- 
 lar characters. 
 
 1. The imbecile fi-om insanity, will generally retain some ec- 
 centricity or delusion, " an antic disposition," with a tendency 
 in most cases to excitement from time to time. 2. The imbe- 
 cile from epilepsy presents a childlike curiosity, with drawhng 
 speech, he slobbers and laughs vacantly. 3. The character of 
 idiot varies ; 4. the paralytic, has a haggard heavy expression ; 
 5. the aged imbecile is simple and garrulous and often restless. 
 
 The diagnosis is easy, but one condition is likely to be mis- 
 taken for it, viz., the apathetic condition of melancholy with 
 stupor, which some have called acute dementia. 
 
 The cases at this stage have but one mode of termination. 
 The imbecile in asylums often pass a long and not unhappy life, 
 secure from want and trials and vicissitudes, and safer from 
 the griefs and miseries the sane have to endure. In well man- 
 aged asylums, secure from exposure and alternations of temper- 
 ature, and with sufficient diet, they escape many sources of disease 
 and often live to a great age. (See Dr. Wood's calculation, On 
 the Plea of Insanity, p. 84). 
 
 Treatment. — With regard to the treatment of this stage it will 
 be the same as that of idiocy which will be considered in a sub- 
 sequent page. 
 
 Bodily disorders. — These present nothing which can be called 
 special, in speaking of the morbid anatomy the changes in the 
 organism will be mentioned. It will be seen that various con- 
 ditions need special attention as against what is called wet or 
 du-ty habits, but with proper management, there should be no 
 interference with health fi'om this cause. 
 
 Before leaving the subject of ordinary insanity it will be well 
 to allude to the various so-called kinds of insanity which find a 
 place in many works on mental disease, some of which have 
 been alluded to incidentally ; but, nevertheless, it will be useful 
 to refer to them collectively. 
 
Section IV. 
 VARIOUS SO-CALLED KINDS OF INSANITY. 
 
 General Recapitulation of TerniB to be found in different authors for so-called 
 varieties of ordinary insanity at different periods or different phases in ita 
 progress. 
 
 Certainly one of the main difficulties connected with the study 
 of insanity is the multipUcity of names which have been intro- 
 duced in the subject. This evil, for it is such, has extended to 
 an absurd length. 
 
 In my former edition I endeavoured to classify these names 
 thus : — 
 
 1. Names derived from a prominent symptom occurring in the 
 progress of the case. 
 
 2. Names derived from some presumed cause of the attack. 
 
 8. Terms founded upon the modifications of a case during its 
 course, 
 
 I wiU endeavour to enumerate some of the most common 
 terms and give a short description of each. 
 
 Amenomania (from amcenus), a pleasant or gay sort of mania 
 or insanity. There is no such disease in any sense of the word. 
 Lunatics may be gay and cheerful in the chronic stage and 
 many are so, and most chronic lunatics are cheerful on some oc- 
 casions. I have had many pleasant insane patients. The state 
 of mind in general paresis is usually more than simply cheerful, 
 the word elation of spirits describes the condition more correctly. 
 
 Aidoiomania [al^o'cc, ^uHen^st) , vide erotomania and nympho- 
 mania. 
 
 Dcemonomania. — This is of very occasional occurrence and it 
 simply means that a patient has a delusion or merely a fear that 
 he is a devil, or is possessed of a devil, or in fact has any symp- 
 toms at all relating to demons; this notion or delusion in the gen- 
 eral mental disturbance may occur in any case, and the pheno- 
 menon is a mere symptom ; it may occur in acute insanity, or it 
 may persist and be present in chronic insanity. 
 
VARIOUS SO-CALLEU KINDS OF INSANITY. IQI 
 
 Erotomania.— This word has perhaps been more employed 
 than most of these terms, writers have even discussed its varie- 
 ties and bearings ; but it is but a symptom, and is a mode in 
 which insanity occasionally shows itself, there is an exaltation 
 of the sexual passions, or an outspoken exhibition of lustful feel- 
 ings ; the passions belong to the emotions and emotional dis- 
 turbance occurs in the early stages of ordinary insanity, the 
 exaltation of the passions is also an early and prominent symp- 
 tom in general paresis. Some writers are desirous of separat- 
 ing this symptom into subdivisions, as : — erotomania (If cu; love) 
 as the word to distinguish the state when the love is pure, unsen- 
 sual, but it is more frequently meant to include all symptoms 
 connected with sexual passion ; they apply the terms nympho- 
 mania to the condition of lustful feeling in women, and satyria- 
 sis when it occurs in men. Aidoiomania was proposed for the 
 condition in women, but it is not much used. 
 
 FoJie circulaire, Folie a double forme. — These conditions are 
 found in chronic insanity, but some degree of alternation of 
 symptoms occurs in many cases in the early stage, or in general 
 paresis, but the terms apply to a well recognized condition 
 which is fully described on p. 163. 
 
 Hysterical Mania — Insanity occuring in a hysterical patient, 
 it has no special characteristic as regards the mental phenomena, 
 it may be connected with any stage. The subject of hysteria 
 has been discussed in a recent work by Dr. Legrand Du Saulle, 
 [Les Hysteriques, Paris, 1883) in which the connection of hys- 
 teria and insanity is fully treated. In examining the different 
 cases given in illustration, and a chapter is devoted to hysterical 
 mania (p. 292), I think the following results may be estabhshed. 
 There are certain symptoms shown in hysterical patients, whe- 
 ther insane or not and which are of motor kind, such as cata- 
 leptical and paralytical kind, the patients go through various 
 clonic motor conditions, as standing in some awkward position 
 for long periods, or kneehng in prayer in constrained attitudes, 
 apparently being in a semiconscious condition all the while, 
 and they may perform some unconscious movements, and after 
 a time, return to then* natural condition without being aware of 
 what has passed. Some on the other hand, exhibit various 
 bodily symptoms, as retention of urine, borborygmus, tympa- 
 
192 LECTURES ON MENTAL DISEASE. 
 
 nitos, distonsion of the abdomen, etc. These conditions are 
 probably nearly related to Jacksonian epilepsy on one hand, 
 as shown in a certain periodicity in these attacks as pointed out 
 by Dr. Du Saulle himself; but as epilepsy itself, as already 
 shown, is nearly allied to recurrent insanity, so some of these 
 hysterical cases have also all the symptoms of insanity. 
 
 Two cases are given in the sequel, in illustration of those 
 varieties. 
 
 Homicidal mania. — The best marked cases which have received 
 this name are connected with second and subsequent attacks in 
 recurrent insanity as described p. 107, the outbreak is often sud- 
 den without much warning and the exhibition of the paroxysm 
 is by a homicidal attempt. The name is derived therefore, 
 merely from the propensity of the patient, this propensity often 
 recurs in the same form, but it sometimes takes another shape ; 
 if the act of violence is to take to drink, the case has been called 
 oinomania ; if an act of suicide, suicidal mania ; to an act of 
 incendiarism, pjTomania ; to smashing of statues, etc., iconoclas- 
 tic mania ; to rape, satyriasis, etc. 
 
 Kleptomania. — A propensity to steal is particularly observed in 
 an early stage of general paresis, but it is but a transient px'open- 
 sity and it cannot, therefore, have any pretension to constitute a 
 variety of disease in such case. It may occur also in the chronic 
 stage of insanity, there is scarcely a crime or a virtue, that may 
 not be associated with this stage. It has no distinctive charac- 
 ter, as a symptom in disease. It may be a feature, and more 
 frequently is, of idiocy. It ought to have no place, however, 
 in nosology. 
 
 Moral Insanity. — This term has been applied to morbid delin- 
 quencies of various kinds, evinced generally as sudden impulses 
 in cases in which there is a certain amoiint of mental power. 
 In fact all the cases that I have read of, would come under the 
 same category as the case of homicidal mania, and connected with 
 recurrent insanity, as described in the proper place (p. 1G7). 
 The subjects of recurrent insanity retain a considerable amount 
 of mental integrity, and can argue and assert their sanity, and 
 up to a very brief period before the outbreak, act rationally, and 
 then suddenly they commit some great offence against morals ; 
 but they are, however, impelled by disease, as much as an epi- 
 
VARIOUS SO-CALLED KINDS OF INSANITY. I93 
 
 Icptic is impelled to struggle, and such cases are often actually 
 connected Avith epilepsy or terminate in that disease, and most 
 of the patients gradually become imbecile. 
 
 As examples of this kind, Dr. Hammond narrates several 
 similar cases under the term of Keasoning Insanity (Treatise on 
 Insanitij, p. 373), but the previous history of the subjects are 
 not given. 
 
 Hypochondriacal Insanity. — It is a moot question whether hy- 
 pochondriasis itself is not insanity. Cullen defines hypochon- 
 driasis, thus : " Dyspepsia cum languore, moestitia, et metu ex 
 causis non aequis in temperamento melancholico," and subsequent 
 writers have not improved on this description. Sadness and 
 fears without due cause are depression of spirits and morbid 
 apprehensions, and though the power of arguing remains, that 
 would not exclude the case from melancholia, or as a variety of 
 insanity. Hypochondrical patients are therefore insane. Hypo- 
 chondriasis may continue into the second stage of the disease. 
 
 Lycanthropy. — In the sixteenth and seventeenth centuries 
 there was an epidemic of what was probably hysteria, rather 
 than absolute insanity. It raged in different parts of the conti- 
 nent, and among the most ignorant peasantry; the subjects of 
 it asserted that they were turned into wolves at night by the 
 devil, and they left their homes and rambled in the woods, killing 
 children and it was said eating them. It chiefly existed among 
 females, who said the devil had carnal connexion with them. 
 The priests took the disease in hand, and burnt the patients at 
 the stake (see Hysteria, p. 191). 
 
 Lypemania. — This word is not often met with now. It was, 
 Dr. Tuke says, introduced by Pincl, and means simply depression 
 of spmts, it occurs in the early stage and goes on in certain 
 cases to the chronic period. 
 
 MelanchoHa has been subdivided into as many varieties as 
 there are patients under observation, it would seem the forms 
 most common have mostly been spoken of, and the terms ex- 
 plain themselves, as : — 
 
 Melancholia agitans, the patient is restless, (see p. 121). 
 
 Melancholia errabunda, he wanders away and hides, (see 
 p. 121). 
 
 Melancholia metamorphosis, the patient imagines he is en- 
 
194 LECTURES ON MENTAL DISEASE. 
 
 tirely changed, either wholly into Bome other person or into a 
 lower animal, cat, dog, etc., or that some part of his body is 
 changed. The case is not uncommon and the impression is 
 usually a persistent one, and so it constitutes a true delusion and 
 therefore occurs in chronic cases only. This term is notable as 
 having afforded a writer the opportunity, or the craze, for divid- 
 ing and subdividing into the varieties which prevail in our liter- 
 ature. Heinroth, as quoted by Neiimann, not only makes a 
 separate disease called Melancholia Metamorjihosis, but divides 
 it into sub-species, as when the patient beheves himself to be 
 changed into a beast, and this he again divides into four varieties, 
 1. when the patient beheves he is changed into a wolf, 2. when 
 he beheves he is a dog, 3. when he beheves he is a horse, and 4. 
 when he behaves he is an ox. After such a system, it is only 
 wonderful that the author of it, did not extend it a little farther, 
 as when a man may consider himself some other quadruped, an 
 ass for example. 
 
 Suicidal melancholy or suicidal mania. — The propensity to com- 
 mit suicide occurs in two kinds of cases, both of which have 
 been described in their proper places ; the propensity, however, 
 can give no just ground for separating the case from those of 
 ordinary insanity, the symptom occurs in the fii'st stage, when 
 the patient seldom conceals it, and makes numerous abortive 
 attempts and thus keeps the attendants on the watch, but sui- 
 cide is a mode in which the outbreak occurs in recurrent in- 
 sanity, the act is then often sudden without warning and when 
 the attendants are off their guard, such cases are therefore par- 
 ticularly dangerous, (see p. 117). 
 
 Melancholia xdth stupor, has been alluded to (p. 121, ct scq.). 
 
 Melanclwlia reliffiosa, (see p. 113). 
 
 Monomania. — This term has been used in different ways, by 
 some it is taken to mean that a patient was mad on only one 
 point or one subject, such was not the signification meant by 
 those who proposed it, and such a condition does not exist, most 
 writers have agreed to abandon the term.** 
 
 yijmjjhoinatiia (see Erotomania). 
 
 Oinomania, Dipsomania, Mania a yotM.— These terms are often 
 found in different works ; in my opinion they represent no dis- 
 • Griesinger, op cit, § 46. 
 
VARIOUS SO-CALLED KINDS OF INSANITY. I95 
 
 tiuctive kind of mental disease. We meet with several kinds of 
 cases in some way connected with alcohohc poisoning, and all 
 of them may be found among the inmates of asylums, but they 
 do not constitute a distinct species morbi. The cases come 
 under the three following categories. 
 
 1. Chronic alcoholismus, which will be alluded to under the 
 division B or symptomatic conditions in a future page. 
 
 2. The case of the common drunkard, who will drink when- 
 ever he can obtain the means, and which is simply a case of 
 vice or insufficient control, and more allied to idiocy than disease. 
 
 3. There is the case of the patient who is the subject of recur- 
 rent insanity, and in which the relapse is shown by a tendency 
 to excessive drinking. The patient is sometimes even, during 
 his lucid interval, a highly respectable and very temperate per- 
 son, and the drinking is a mode in which the outbreak is shown. 
 (vide Recurrent Insanity, p. 166, et seq.). 
 
 Puerperal mania (see ante p. 128). — In my opinion there is 
 no distinct disease or species of insanity, which deserves the 
 separate title of puerperal mania, or puerperal insanity. There 
 are three kinds of cases in which insanity and the puerperal 
 condition are co- existent, the ordinary symptoms may com- 
 mence during pregnancy, or after parturition. The puerperal 
 state is of course a great disturbance of the system. Firstly, a 
 patient may be taken during pregnancy with the symptoms of 
 either a primary or a secondary attack of ordinary insanity, 
 or with the symptoms of general paresis ; and in single women 
 the mental emotion caused by the impending disclosure of im- 
 morahty may induce an attack of mental disease. Such cases 
 will take pretty much the usual course in their progress. 
 Secondly, the patient may be taken subsequent to delivery, 
 in this latter case the symptoms may occur in two ways, but 
 both be brought on probably by the great stress or strain upon 
 the system incident to the circumstances. Patients who have 
 had a previous attack of insanity, or are the subject of the 
 recurrent form of the disease, may have the attack induced, 
 when it will take the usual course of that form. In the thhd 
 kind of case the symptoms are more like delirium fi-om anremia, 
 as seen after fevers, etc. 
 
 The majority of these cases do well. In recui'rent cases there 
 
 o2 
 
ig6 LECTURES ON MENTAL DISEASE. 
 
 is a natural tendency in the case to change and toward CTtre, 
 wliicb care and good nursing will expedite, and in the primary 
 or anffimic delirium, the case usually improves by good and 
 judicious feeding. The recurrent case is very liable to occur at 
 each pregnancy. 
 
 It is quite unwarrantable from a pathological point of view 
 to exalt these cases into species of disease, they go through the 
 same course of symptoms as others ; in the wards of Hanwell, I 
 could always point out cases of melancholy, mania, paresis, 
 imbecility, or recurrent insanity, cases with stupor, with 
 chronic symptoms, delusions, etc., etc., which commenced dur- 
 ing the puerperal condition. "If," writes Dr. Tuke, "insanity 
 arises in a woman who has been suckling about three months, 
 we call it a case of insanity from lactation, while if only two, we 
 perhaps call it a case of simple puerperal insanity," on such 
 grounds are mental diseases multipUed. 
 
 Phthisical mania is simply insanity in a phthisical patient. 
 In the earHer periods of phthisis sometimes that disease is kept 
 in abeyance by the insanity, and will break out after the mental 
 symptoms have disappeared, if this does not happen the course 
 of the phthisis may be hastened by the insanity. 
 
 Pyromania is when the desire to commit arson exists, it may 
 be the mode of outbreak in recurrent insajiity. 
 Satyriasis. — See supra Erotomania. 
 Stupidity. — Another term for melancholy with stupor. 
 Syphilitic mania or syphilitic insanity. This is treated as a dis- 
 tinct disease in Bucknill and Tuke's Psycholoyical Medicine and in 
 Quain's Dictionary of Medicine. That cases of true insanity occur 
 in persons affected with sjq^hihs, there can be no reason for 
 questioning, but such accident cannot afford a basis for esta- 
 bhshing a fresh kind of disease, any more than any other acci- 
 dent, as the single or married state of the patient ; unless it could 
 be shown that syphilis was either the actual cause, when the 
 symptoms would be uniformly developed in aU cases of it, or 
 that the presence of syphilis so acted upon the prime cause as 
 to divert the progress of the symptoms in a given direction ; that 
 in other words insanity plus syphihs, took a different course 
 than insanity alone, and then the case would be only entitled 
 to be called a variety. 
 
VARIOUS SO-CALLED KINDS OF INSANITY. IQJ 
 
 But no such uniform deviation does occur according to my ex- 
 perience, and the best authorities, who have greater experience 
 on syphilitic disease than I possess, are of the same opinion. 
 
 When mental disease arises in one with syphihtic taint, it 
 obeys the same laws in its evolution as other cases, the mental 
 disease may be either ordinary insanity or general paresis, and 
 perhaps more frequently the latter. 
 
 On the other hand syphihtic disease of the brain is equally 
 variable in its symptoms. Dr. Hughlings Jackson (Journal of 
 Mental Science, July, 1875, " On the syphilitic affections of the 
 nervous system"), says "the syphilitic affections of the nervous 
 system are very indirectly of nervous origin, such names as 
 syphihtic epilepsy, syphilitic insanity, though convenient (?) are 
 not scientifically accurate terms, these terms are sometimes 
 used as though they embodied clear pathological accounts, those 
 who use them evidently do not even know that they do not 
 know the pathology of the cases of which they speak so freely. 
 
 " There is nothing in any kind of nervous symptom which 
 enables us to diagnose syphihtic disease of the nervous system, 
 the pathological processes by which syphilis causes nervous 
 symptoms, simply imitate non-syphihtic morbid processes. I 
 know nothing of syphilitic diseases of the nervous system, ex- 
 cept in the sense of there being disease beginning in the con- 
 nective tissue of nervous organs or their arteries. I know 
 nothing of syphihtic changes beginning in nervous tissue." 
 
 Other terms not much used or useful. 
 
 Agoraphobia, dread of being in a large space (Westphal). 
 
 Kenophobia, dread of being in a large space (GeUneau). 
 
 Claustrophobia, dread of being in a confined space. 
 
 Astrophobia, dread of lightening. 
 
 Anthropophobia, fear of society. 
 
 Monophobia, fear of being alone. 
 
 Mysophobia, fear of polution. 
 
 Panphobia, fear of indefinable kind (morbid apprehension) , 
 
igS LECTURES ON MENTAL DISEASE. 
 
 Anxietas tibiarum, uncomfortable feeling in the legs. 
 Nostalgia, a form of depression or home-sickness. 
 Pyrophobia, dread of fire. 
 Syphilophobia, fear of syphilis. 
 Spermatophobia, fear of spermatorrhoea. 
 Hydrophobophobia, fear of hydrophobia. 
 
 (All the above quoted from Dr. Hammond's Treatise on Insanity). 
 
 Aboiilomania, paralysis of the will, iiTesolution. 
 
 Iconoclastic mania, disposition to destroy statuary (see p. 178). 
 
Section V. 
 EXAMPLES OF INSANITY PEOPER. 
 
 Case VII.— E. M. Melancholia; Religious Fears; Suicidal Propensities; 
 Delusions about the Devil " Demonomania ;" Recovery. 
 
 Blister, sedatives, saline purgatives of little use; improvement commenced 
 after taking aloes regularly. 
 
 Admitted April 29th, 1362. History from aunt. Entered by Mr. Ellis, Assis- 
 tant Medical Officer. Mt. 23; single ; for a short period a dressmaker, the last 
 few years a servant. Is reported to be suicidal ; the present attack is said to be 
 of 14 days' duration, and to be the second attack; no clear account can be ascer- 
 tained about former illness. 
 
 15th Day. Note by myself. Was admitted yesterday; says she is tormented 
 with the thoughts that she has " rejected Jesus," that " she did not believe 
 him— that she rejected him;" answers coherently and describes her condition 
 with much fervour and expression of anxiety, says she has curious sensations 
 and violent beatings of her heart, and feels that her "thinking mind" is gone ; 
 complains that she cannot sleep, and when she shuts her eyes all the events 
 of the last fortnight come before her mind; is very restless and agitated. 
 Tongue moist ; bowels open ; takes her food well ; pulse 90. 
 
 24:tli Day. Continues to be much depressed, imagines she is given over by 
 Jesus and that she cannot repent, says "it seems as if she has no control over 
 her feeling or thoughts ;" this she says in a rapid, anxious, eager manner ; is 
 continually on the move, as if she could not stand still; is moving about while 
 she is speaking to me. 
 
 35//i. Day. Says she is possessed of the devil, that she was obliged to say 
 " God preserve my body and the devil take my soul," and since that she has 
 been wretched, feels strange sensations in her inside, like something hot. 
 Countenance is more haggard, lias no headache. Eats heartily. Tongue 
 more furred; bowels act regularly. Pil. ij. and haust. cath. 
 
 43r(Z Day, The aperient has been repeated since without any benefit. Mind 
 is more distressed. Eats but little. Sleeps less. Haust. opii, hora somni 
 
 4Sth Day. Continued the opiate and slept better, has been rather less agi- 
 tated. The aperient draught has been repeated. The opiate now begins to 
 lose effect ; the strength of it was increased and vomiting occurred in conse- 
 quence, and the appetite was worse. The same feeling of wretchedness con- 
 tinues, with constant restlessness and agitation, and belief that she is tormented 
 by the devil. Mr. Ellis ordered her head to be shaved and blister to be applied on 
 following day. 
 
200 LECTURES ON MENTAL DISEASE. 
 
 49(7i. Day. Is extremely ag-itatod, lias made several attempts to seize the 
 carving knife, both yesterday and to day ; continuod to exclaim " the old devil's 
 got me," rushes about from place to place. On the following day a slight dif- 
 ference was observed in the pupils, tlio left being the larger. 
 
 52nd Day. Continues to be extremely agitated, moaning loudly and con- 
 stantly in a kind of monotonous drawl "that old devil," rushes about the ward 
 or airing court, and tries to get away, when addressed cannot stand still, rocks 
 backwards and forwards on her feet, fidgets with a part of her dress, bites her 
 fingers and nails; has a wild and anxious expression; has made several 
 attempts to injure herself, snatched at a knife again to day. Complains of pain 
 at the chest. Sleeps well. Has siss of Tr. hyoscyami at bed time, takes food 
 weU. Pulse 120. 
 
 56(/!. Day. Is more tranquil, but same delusions continue, though with rather 
 less force ; says she is prompted to evil by the devil, that the devil makes her 
 think all sorts of wicked things, says she is to live for ever. Has continued the 
 hyoscyamus, the pupils are both large and act unequally. Sleeps better. Tongue 
 clean, takes food well. 
 
 78th Day. Mental distress continues. Has always an eager and anxious ex- 
 pression and a hurried and restless manner, says she is married to the devil. 
 Has the delusion that a fellow patient is the Saviour, and kneels and prays to 
 her, the patient in question is annoyed and speaks angrily to her, which causes 
 E. M. to be greatly affected. She is thinner, but takes food well. Bowels act 
 daily. 
 
 8ith Day. Has now the delusion that another patient is the Virgin Mary 
 and a baby in the ward is the infant Jesus. The husband of the same patient, 
 who called to see his wife, she says is God. Agitation and restlessness continue; 
 lias not made such determined efforts to injure herself lately ; is still tortured 
 by various vain regrets — if she had done this, or not done the other, then certain 
 consequences would have occurred, etc., she might have been happy; frequently 
 is emploring God to pardon her, is constantly on the move, cannot sit still, bites 
 and picks her fingers and nails till they bleed. 
 
 123rcZ Day. Still with the same delusion about the devil ; follows me about 
 saying " Oh do give me another chance of getting well." The bowels of late 
 have been constipated. Has not menstruated since admission, says she feels 
 that she has no inside. Pil. aloes and mast, daily. 
 
 12Sth Day. Bowels act daily; slight general improvement, is more tranquil, 
 but begins to moan when addressed. Has gained some flesh. 
 
 laSth Day. Is improved in mind and is stronger; still cries occasionally. 
 Ordered to be taken for a long walk daily. 
 
 loith Day. Has been employed in the laundry, is still fretful, has continued 
 the pills- 
 
 182?icZ Day. Has been working regularly in the laundry, was for some time 
 still depressed, and moaned and cried as before, but worked well. Is now looking 
 better. 
 
 Continued to mend by degrees from above date, subject to periods of de- 
 pression. Went to Officer's House to work, where she was entrusted with knives, 
 etc. She continued the aloetic pills and menstruated on the 187th day for the 
 first time ; continued regular from that period; was not considered fit to be dis- 
 charged, however, for eight months afterwards, at which time she was cheerful 
 and well behaved in every respect. 
 
EXAMPLES OF INSANITY PROPER. 201 
 
 Case VIII. — Chronic Insanity. — Chronic melancholic symptoms; (Mono- 
 manie of tlie French); Symptoms: — delusions; exalted ideas of herself; 
 I'hthisis; Death. 
 
 This patient was not seen by me till the 7th year of her malady. History from 
 a brother after that length of interval. She had been discharged as incurable 
 from Bethlehem; she exhibited a mental change in nearly every particular, in 
 manaer, emotional feelings, temper, habits, disposition, intellect and char- 
 acter. The intellectual change was in the delusion that she was royal, there 
 was nothing at all like weakness present, she could read and write and under- 
 stand when she could be got to attend. 
 
 The parents of S. P. kept a boarding-house, which was much frequented by 
 theatrical people and operatic performers. The patient had therefore frequent 
 opportunities of attending different places of public amusement. She availed 
 herself particularly of the privilege of attending the opera. She was naturally 
 of very haughty and ambitious character. She was well educated, a good 
 musician, and spoke French and German, and she read much. About the 
 twenty-sixth year of her age, she wrote a ballet which was accepted at the opera 
 and was placed in rehearsal. About this time she gave birth to an illegitimate 
 child. The informant who related the circumstances to me, seven years after 
 the occurrence, did not remember whether the event of the birth of the child pre- 
 ceded her melancholy or not, but believed it did ; but she was very depressed, 
 and felt the disgrace of her misconduct keenly. The seduction had been under 
 promise of marriage. The father of the child was connected with the operatic 
 profession. He refused to marry her, and disowned the child. The ballet was 
 never produced. The patient on the birth of the child, became very greatly 
 depressed, (depression of spirits). She was disgraced — all her ambition was 
 blighted. She never suckled the infant — had no milk. She gradually became 
 altered in disposition. One of the earliest symptoms that the brother remem- 
 bered was a suspicion that some one was about to poison her (morbid apprehen- 
 sio7i). She also thought she was watched, and got bags of straw and stuffed 
 them up the chimney, to prevent people getting into her room. She refused 
 food, and was in danger of starvation. She took a great aversion to her brother 
 (alteration of affection) whom she accused of various things. She was kept 
 at home several months, and then sent to Bethlehem, where she remained a year 
 and a half and was discharged uncured. She was next in a private asylum for a 
 short time, and was admitted into Hanwell in about the fourth year of her 
 malady. 
 
 She was a patient in the asylum about six months prior to my appointment 
 there. 
 
 When I first saw her, her condition was that of a chronic lunatic, and she re- 
 mained in the same condition till her death. The notes taken at different times 
 during subsequent seven years, give the following account of her state. 
 
 She is tall, rather thin, of good figure and proportions, erect; was about thirty 
 years of age on admission. Her complexion was of an unhealthy hue ; the lips 
 rather livid ; conjunctiva injected; the eyes were weak; her hair scanty and 
 dry. She moved with ease, and walked with a certain degree of style, but rather 
 too majestically. Had a constant propensity to wear her bonnet, which she liked 
 of a date somewhat old. She usually was to be seen pacing or marching in a 
 dignified manner up and down the airing court or gallery, talking to herself 
 
202 LECTURES ON MENTAL DISEASE. 
 
 loudly, or declaiming in a theatrical and somewhat pompous tone, asserting her 
 right to the throne, (delusion and intellectual symptoms). Her languaj^c con- 
 sisted mostly of the same set form of sentences, but these were sufficiently varied 
 to give a coherence to her declamations ; these speeches continued in the same 
 form ; they were much to the following effect : — 
 
 " Miss S. P., England's royal and state prisoner, demands to know by virtue of 
 what authority her royal person is detained, fraudulently, illegally, and unjustly, 
 within these walls. Be well assured, that each and every one will have to give 
 a full and perfect account of their conduct in this matter. My lord chancellor 
 will sec that no one, who has a hand in this affair, shall go unpunished;" and then 
 perhaps, addressing some fellow-patients who approached too near, she would say : 
 " Get out, vile lunatic reprobate !" Again continuing her oration, she would ask : 
 "Where are my palaces, my equipages, my royal robes, my jewels? Where 
 are my trusty soldiers, my cavaliers ? Have they forgotten their royal mis- 
 tress ?" &c., &c. This kind of declamation continued incessantly throughout 
 the entire day. If she went into the garden, she would continue to walk in the 
 same stately way, still continuing her soliloquy, though there was no one to hear 
 it. She went regularly to chapel, but would not sit with ^the rest ; but turned 
 away with a contemptuous sneer when any of the patients spoke to her. When 
 addressed by an officer, she did not answer at all, or in a condescending tone. 
 While in chapel she made the responses in a slow and pompous style, and finished 
 every sentence long after the rest of the congregation. She read in a correct 
 manner, and with good emphasis. She could never be induced to engage in a 
 distinct conversation. I made numerous attempts to speak with her, but never 
 obtained a hearing. She was very correct and cleanly in conduct ; very peculiar 
 in her choice of food, at one time ate scarcely anything but potatoes ; always 
 refused meat; but latterly had fish daily, and wine. 
 
 No change in her mental condition occurred ; she gradually got weaker and 
 emaciated. She would allow no one to examine her, nor would she allow a nurse 
 to see her undressed. About three days before death she complained of diarrhoea; 
 but in spite of all entreaties she would get up. On the morning of her death 
 she arose and dressed herself, but lay down again, and I was allowed to examine 
 her for the first time. She had every external appearance of phthisis ; such was 
 my suspicion of her case before I examined her; she, however, died of 
 dysentery. 
 
 A prolapsus uteri of long standing was found after death, which was not dis- 
 covered during life ; it was this fact that elicited from the friends the real history 
 of the case, which had before been kept a profound secret. 
 
 There was in this case a melancholic primary stage, no distinct or acute 
 maniacal stage, as far as I could discover, and a termination in chronic mania. 
 This case, from the oneness of the delusion, would be called, it is presumed, 
 monomania. 
 
 Case IX. — Acute Insanity in a phthisical patient commencing very insidiously ; 
 by depression ; Illusions of smell and taste ; Apprehensions of injury ; Violent 
 and maniacal symptoms; Recovery ; Death by phthisis nine months subse- 
 qutntly. 
 
 A. A. H., female, set. 26, single. In a good station socially, is tall, fair, 
 slight, appears in delicate health, but has not suffered from any particular 
 
EXAMPLES OF INSANITY PROPER. 203 
 
 malady. The attack is said on the certificate to be of a few days' duration, 
 but on close investigation it appears that she had been altered and melan- 
 choly more or less for two years, and has had numerous fancies or illusions, 
 and has complained of bad smells, has imagined that she has bad things 
 given to her which have altered her taste, these symptoms were attributed 
 by her parents to " a naturally morbid temperament." About a week ago became 
 more restless and excited and began to have the idea that she was going to be 
 ravished. Dr. Kerr in the certificate reported. " She believes a nurse in attendance 
 to be a dear friend of hers, that her bed is made by God and must not be 
 touched by anyone, that a spot on her bed is a mysterious something which 
 being transferred to the wall of the room has been wished away, is violent to 
 others and attempts to injure them, she has broken a door and destroyed 
 clothing." From Dr. W. Williams certificate, "she has been in a state of 
 maniacal excitement for the past week with marked incoherence, refuses to get 
 into her bed declaring that it is God's bed and she has been greatly tempted 
 in it." Soon after admission she became very excited in conduct and manner, 
 having been tranquil the first day or two. She talked in a rambling and 
 absurd manner, was restless and unable to control herself, she mistook an 
 attendant for an acquaintance and insisted upon waiting on her. There was 
 no depression but she was irascible and excitable, very restless and fidgetty. 
 
 The bodily health very delicate, the pulse is feeble, 84, tongue is clean, 
 bowels constipated, has no cough, there is slight dulness beneath the clavicles. 
 
 9th Day after admission. Is restless, talks much and somewhat incoherently, 
 speaks of various sensations and alludes frequently to sexual feelings, as 
 though she believed she was about to be abused, becomes very excited in 
 speaking on this subject. She is neither elated nor depressed in spirits, was 
 restless during the night but had some hours of sleep, takes food well, bowels 
 confined, pulse 84 feeble. 
 
 ISth Day. Is more tranquil and rational, is excited at intervals, but ex. 
 citement quickly passes, erotic symptoms continue, has numerous fancies con- 
 nected with the sexual functions. 01. jecoris. 
 
 38f/i. Day. Has been gradually becoming more excited, is now in a maniacal 
 state, tears her clothes, endeavours to injure herself by dashing her head 
 against the wall, attempts to stand on her head, her talk is constantly about being 
 ravished, is alarmed at my visit, imagines that I am bringing people to injure 
 her, etc. ; had chloral and slept for four or five hours, 9j. Bromide of Potass, 
 twice a day. 
 
 4/8th Day. Gradual improvement again ; a few days after this, though her 
 mind was confused and she was incoherent, she was able to join the dinner 
 table, and go out walking daily, has menstruated. 
 
 60th Day. Varies from time to time, a day or two she is quiet and then rather 
 elated for the same period, when she will endeavour to injure herself; has 
 gained strength and flesh ; no cough ; excitement was rather increased during 
 the catamenial period. , 
 
 7oth Day. Is not so well ; more dirty in habits passing her faeces on the floor 
 and smearing it with her hands ; has a wild and rambling mode of talking, is 
 erotic ; takes food well ; bowels are rather constipated has passed the period 
 without catamenia. Pil. Aloes, et Mast. 
 
 85i7!. Day. Was calmer; menstruation has not occurred, but appears improved 
 in health; no elevation of temperature night or morning ; physical chest signs 
 the same, occasional cough. 
 
204 LECTURES ON MENTAL DISEASE. 
 
 112f/i Day. Is better mentally but still does strange things and imagines things 
 which are not correct ; has taken during the last 14 days, Mist, ferri co. 
 
 6 Months after admission. Improving gradually in mind ; her general health 
 is better, but she has a troublesome cough with loose expectoration ; pulse 90, 
 temperature normal, no morbid physical chest signs except slight dulnesi on 
 supra scap. region of one side ; has not menstruated, continued mist, ferri. 
 
 7th Month. Menstruated, is gaining flesh, is quiet and well behared ; tidy in 
 appearance; still has a few fancies. 
 
 8th Month. Menstruation again appears, the improvement continues; occa- 
 sional variations ; cough is less. 
 
 10th Month. Went home for a day or two from time to time; discharged on 
 trial at twelve months, discharged finally three months later ; remained clear 
 in mind but phthinical symptoms increased ; and she died nine months after 
 final discharge of phthisis. 
 
 Case X. — Acute Insanity in the first stage and passing into second epoch; 
 suicidal propensity; proecordial pain; constipation; employment of purgatives ; 
 recovery. 
 
 Mary H., admitted into Hanwell Asylum, June 21st, 18S3. History from 
 eon. She is 45, widow of a painter. Formerly resided in the country with 
 husband. She had a shop and sold bonnets. Husband involved in local 
 politics, lost his business, removed to London, became reduced and underwent 
 great anxieties , about a year ago the husband was missing, and after several 
 days was found drowned, supposed by suicide. She Avas much affected by this, 
 and at the same time had a son dying of phthisis. The son died. The patient 
 got gradually worse and worse and more depressed; some time after showed 
 alteration in her conduct towards the other children, neglected every thing, 
 and began to threaten to dBstroy herself; her mother states that she has been 
 desponding ever since the husband's death ; of late has been violent and destruc- 
 tive ; used to howl and gnash her teeth ; was sent to Marylebone Infirmary, she 
 was there three or four months and escaped and returned home, was allowed to 
 remain, but in a fortnight became unmanageable and was taken back. 
 
 Dr. Eandall certified that "she is excitable and melancholy, noisy, tears her 
 clothes, threatens to destroy herself, and says she must die, is restless and 
 dirty, sleeps but little, attempted to tie a piece of stocking, which she had torn, 
 around her neck." 
 
 Condition on admissioji. — The first symptoms commenced from eleven to 
 twelve months prior to admission. Is now in fair bodily condition, but ia stated 
 to have lost flesh, has been much stouter. Has numerous small bruises, all 
 slight; several small boils, a bald spot on the top of the head, where she baa 
 pulled out her hair. 
 
 Speaks in a melancholy and desponding tone and strain, says she must de- 
 stroy herself, answers questions freely and coherently, and states that she was 
 in the workhouse three weeks, which is correct, that she was sent to the Asylum 
 because she was too fidgetty ; says she is worried in her mind, her troubles have 
 aggravated her, that she has been drawn to desperation, points to the epigas- 
 tric region, says *'it is all here," "a working," "an agitation ;" complains that 
 she cannot sleep, she is, however, quiet during the night. 
 
 Tongue is clean, bowels stated to be open; appetite stated to bo normal; 
 poise 84; no morbid physical chest signs. 
 
EXAMPLES OF INSANITY PROPER. 205 
 
 July 7th. Fourteen days after admission. Bowels reported to be constipated. 
 Pil. Aloes et Mast, daily. 
 
 July 9th. Manner less agitated; denies that she ever attempted to commit 
 suicide or had the desire. Her son, who has just visited her, reports that his 
 mother told him she was determined to effect it. To have porter daily. 
 
 July 17th. Bowels act daily. Speaks in a more cheerful tone, and appears 
 in good spirits. Has begun to employ herself; sleeps well; says she no longer 
 thinks of suicide, and regrets what she has done. 
 
 July 25th. Continues to be cheerful and active, and assists the nurses, ia 
 looking much better in expression and condition, has shown no suicidal pro- 
 pensity. 
 
 Continued to improve. Sept. 9th, or three months after admission, discharged 
 on probation. Oct. 9th, returned to report herself. Her mother says she never 
 saw the patient in better health. That she has freely trusted her while away, 
 and feels sure the suicidal propensity has gone. Daughter expresses herself very 
 grateful for the kindness shown her, and apologizes to the nurses for the trouble 
 she caused. Discharged cured. 
 
 Case XI. — Acute Insanity.— depression ; fears on religious topics; appre- 
 hensions; maniacal symptoms; illusions of sense and smell ; suicidal attempts. 
 
 E. E., male, set. 43, single, retired merchant, admitted Oct. 2nd, 18G7, fair 
 complexion, 5 ft. 7 in. in height, well nourished, well proportioned, somewhat 
 military bearing, no hereditary predisposition. Has been living with an invalid 
 sister, very retired. Strong religious impressions; very retiring disposition; 
 has dabbled with hydropathy and homoeopathy, assisted as lay visitor in his 
 parish; has kept gradually more and more aloof from society; during the last 
 six months has been depressed, walking always alone with downcast eyes, 
 shunning observation ; went into a hydropathic establishment for a period ; has 
 lately drank more, and has taken a good deal of opium ; has been worse during 
 the past three months ; during the last week has had the idea that he was being 
 accused of incest with his invalid sister, and that people were after him ; says 
 that his body gave off offensive smells; called himself the devil; said he was 
 surrounded by fiends. A few days before admission became violent and danger- 
 ous, requiring several men to restrain him. On his way to the asylum attempted 
 to injure himself by grasping his throat. On admission was depressed, had 
 numerous morbid apprehensions; accused himself of various sins; says he 
 cannot be saved, that he is dead, and that his body stinks, is free from excite- 
 ment. 
 
 Certificate by Dr. Sherlock, Worcester County Asylum. Facts indicating 
 insanity: — paroxysms of acute maniacal excitement, asserting that he has been 
 salivated by opium draughts, that he is surrounded by fiends, that he is now in 
 hell, and tormented for millions of years, that his sister has been killed to-day, 
 and is dead, all which are unfounded and are delusions. 
 
 Six days after admission. He is depressed in spirits ; has numerous morbid 
 apprehensions ; says he is to be destroyed, that he is eternally lost, and cannot 
 be saved, that he is unworthy to live, that he is dead, that a foetid smell 
 emanates from his person. Bodily, is well nourished, good general powers. 
 Some disorder of digestion. 
 
 Ten days after admission. Bowels appear constipated. Aloe and mast, pills 
 daily. 
 
206 LECTURES ON MENTAL DISEASE. 
 
 40th Day. Sliijlit improvement, is more sociablo, bat same delusions continue 
 but less obtruJeJ. 
 
 60i/i Day, Has been more sociable, and associates with us more readily. 
 
 90</i Dai/. Wrote to bis sister, says lie has not had the heart to do so before. 
 
 120</( Day. Improves but has several morbid apprehensions, eg. will not 
 pass the churchyard. 
 
 150</i Day. Still avoids society, but dines with the family, never alludes to 
 returning home. Still appears to have some dread in connexion with it. Continued 
 to improve; was allowed to go out in the park and grounds alone; about seven 
 and a half months after admission was visited by two friends, who were very 
 injudicious. On seeing them ima!,''ined they had come to announce the death 
 of his sister, they did not understand him, and did not for a time attempt to 
 re-assure him. 
 
 Continues much disturbed since the visit, says they came to report to me 
 things concerning him, great sins and crimes that he had committed ; says he is 
 to be shot ; has refused food and medicine, says he is to be poisoned. At nine 
 months, or six weeks after this visit he again recovered somewhat, took food 
 better, and amused himself on the harmonium, which he plays with skill. 
 The friends who visited belonged to some peculiar religious sect and they wished 
 the sister to try the influence of a certain preacher, the sister wrote to him on 
 the subject. He says that he knows he is to be shot. Has been more depressed and 
 worried during the discussion of the subject. He left about eighteen months 
 after admission, and subsequently died, as reported to me, of phthisis. 
 
 Case XII. — Chronic Insanity. — Melancholia from acute to chronic stage; 
 illusions and delusions connected, with sense of smell ; morbid appreliension of 
 hypochondriacal character ; duration from, three to four years; fatal termina- 
 tion. 
 
 M. F., a dressmaker, 62 years of age, single, the present is said to be first 
 attack, no further history ; had an uncle insane. 
 
 Was treated some time in the workhouse, the only relative who visited her 
 does not know how long. Heard that she was admitted for some uterine disease. 
 In June 1860, she began to say that she was infected with disease and not fit 
 to live, that her womb was diseased and rotten. 
 
 August 1S60. Says she is dreadfully decayed, does not know what she is to 
 do, that the smell from her is detrimental to other patients, says the bowels are 
 confined. Nurse reports this not to be the case, no disease or discharge dis- 
 coverable by ocular or manual examinction of organs, all the parts of generation 
 appear perfectly normal. 
 
 Is very lestless, constantly on the move going from one end of the ward to the 
 other, or out of doors, cannot stand witliout rocking and fidgctting. Expression 
 indicative of pain and care, has gained flesh since admission and is tanned, ton- 
 gue is slightly furred, at meals will not sit to eat, but gets »ip frequently, but on 
 the whole eats sufficiently, pulse 70, skin moist, says her head ached this morning 
 but that is not the case usually. 01. ricini ad 3 vices. The bowels more freely 
 moved, though the patient continues to deny it, the same restlessness continues 
 and she worries much on trifles, e.g., on a visit from her sister, for some time 
 afterwards, said she told her sister to take the wrong turning, and could not 
 be pacified. 
 
EXAMPLES OF INSANITY PROPER. 207 
 
 Three months after admission. Is much excited and walking rapidly up and 
 down, a few strides only each way, and saying, " Oh dear !" " Oh dear !" is 
 flushed, is reported to eat ravenously, the same delusions of being rotten, 
 offensive, etc., continue. 
 
 Four months after admission. Has had several sleepless nights, says she 
 smells and infects the others, that the devil has got into her lights, loses 
 flesh, warm bath twice a week, then a few days later opiate at night, after 
 which slept several hours, says it makes her very unhappy to sleep, is very 
 restless always on the move, A few days after this says she was pushed 
 down and came in from airing court lame. Mr. Ellis, the assistant, was 
 called to her and found no injury. She continued to complain of her hip, but 
 forgot which hip was injured. 
 
 One month after continued to complain of the right leg, the leg first said 
 to be injured was the left, the same hypochondi-iacal delusion continued, still 
 the same worry about trifles, — that her niece would lose her way home, that 
 various ills would occur ; wished to see Chaplain who visited her without 
 satisfying her, no change in symptoms. 
 
 On March 10th, 1863, the following note was made: — ■ 
 
 Has been getting thinner for some time, the mental depression has even 
 increased, is morbidly apprehensive on the most trivial circumstances, says 
 on seeing me, "Oh pray dont go there it is wrong" and is painfully excited, 
 expression is of great anxiety, it is the same on my going from her, "not there, 
 not that way," continues to say she is decaying, that she is rotten and 
 offensive, not fit to be with others, frequently paces the ward, crying loudly, 
 has taken food sparingly of late and refused her wine, has taken no dinner 
 to day, tongue is furred and brown, still limps in walking, nourishment and 
 wine as much as she will take prescribed 
 
 March 12th. Is lower and refuses food altogether, is in a constant state of 
 trouble, crying out "Oh ! my God ! my God !" all day, when quitting her room 
 cries out loudly to me not to go, is weaker scarcely able to stand. 
 
 March 21st. Reports since above show gradual diminution of power, and 
 continued resistence to food, was conscious at visit, pupils equal, is still greatly 
 depressed but answers questions, powers gradually failed. Death. 
 
 Autopsy, March 23rcZ. Body much emaciated, limbs somewhat drawn up, 
 rigor mortis in all joints including fingers. 
 
 Calvaria well formed, internal measurements 6J by 5| inches. Dura mater nor- 
 mal Pia mater very moderately injected, strips readily. Cerebrum 39 ounces, 
 cerebellum 5j ounces, spaces between convolutions wide, serum in meshes of 
 pia mater to a moderate amount, no marked injection of cerebral substance, 
 the layers of grey matter not well marked, but line between grey and white 
 matter distinctly defined, specific gravity of grey matter 1'033 of "white I'O'iS 
 of cerebellum 1-043. 
 
 Thorax — Pleura normal throughout, both lungs collapsed, one or two absolute 
 tubercles in both apices. Heart weighed 6 ounces, mitral valve thickened, opaque 
 and beaded to a great extent. Ahdome^x — stomach contracted, pale, intestines 
 generally of a purplish colour externally and internally, large intestines con- 
 tained dark semi-solid feculant matter, no ulcer, coats of dark crimson, gut 
 thin and contracted, right ovary adherent to side of pelvis near to the internal 
 inguinal ring, womb and external parts normal. 
 
208 LECTURES ON MENTAL DISEASE. 
 
 Case XIII — Acute Insanity. — Mdanchohj with stupor ; depression; morbid 
 apprehensions ; convulsions ; torpor of motor functions ; cataleptoid condition ; 
 died convulsed. 
 
 A. L., at the time of admission, a;t. 32, married, wife of a fruit hawker, had 
 borne two children the youngest of whom was 12 years of age, education Tery 
 moderate, habits sober ; said to have been insane two years and a half. The 
 parents attributed the attack to the ill-treatment of her husband, who when 
 drunk (which was frequently the case) was in the habit of beaiing her savagely. 
 She had been separated from him for two and a half years. The mother, a 
 country labourer's wife, gave but an imperfect account of the early symptoms, 
 says when her daughter was first taken, she appeared tilly or simple; and 
 •oon afterwards became slovenly and neglectful, and then very timid. She 
 •'was afraid to be left in the dark, and said she was going to be killed." 
 These sj-mptoms thus described by this peasant, were probably the usual 
 first signs of melancholy — dulness, listlessness, carelessness, and neglect of 
 home, morbid apprehension of imaginary dangers. At the end of two years 
 and a half from the commencement of the symptoms, the patient fell down 
 in a severe fit "she fell, foamed at the mouth, and struggled much." She 
 began immediately afterwards to show a lurther alteration in her conduct. 
 " One Sunday she went from pew to pew and shook hands with everybody, 
 gentlefolk as well as poor people." Her morbid fears continued ; she still 
 imagined she was going to be destroyed, and became afraid to go to bed. 
 
 Note on admission. March. She was feeble. Her manner strange ; but 
 she was neither depressed nor elated; was quite quiet; appeared harmless. 
 At times, sat listlessly for some hours, and seemed disinclined to speak. 
 
 The patient continued in this condition for several weeks ; had several 
 slight attacks like syncope, at intervals of two or three days ; but without 
 convulsion. This continued through April and part of May, when she refused 
 food for several days consecutively. In June, she had several attacks of ex- 
 citement, but without any act of violence. In one of these attacks, stripped her- 
 self quite naked in the airing-court, and appeared to be in a state of ecstasy. The 
 features, however, expressed dulness and hebetude. At times stie was taciturn; 
 but at times, as it were by a sudden impulse, became talkative and voluble. 
 On one of these occasions, said, that she conversed with God ; that God told 
 her this or that; and occasionally made use of disgusting language. In some 
 of her paroxysms appeared in a semi-cataleptic state. She had several of these 
 attacks, which appeared to have at first all the characters of feigning. In one of 
 them, however, (on August 10th), their real character was placed beyond sus- 
 picion ; and she was removed back to the infirmary. The note which is brief, says 
 that on this day "she lay as she was placed, and had scarcely moved since she 
 was put to bed some hours ago. If placed in another position, she con- 
 tinued in it for long periods. When the hand was lifted up, it was slowly 
 drawn back. She drank much and had passed a large quantity of urine. Her 
 appetite was indifferent, took food as it was given, and answered questions 
 when spoken to." This state of indisposition or indifference to move lasted 
 six or seven days. It was succeeded by a state of mental excitement. She 
 made numerous frivolous complaints, and behaved with an air of contempt 
 towards the nuries. The cataleptiform seizure being at about the fifth month, 
 at the date of fire and a half months, the following change occurred. 
 
EXAMPLES OF INSANITY PROPER. 209 
 
 Became more strange in ber conduct. On my visit was excited, and jumping 
 about in a grotesque manner. Spoke in an incoherent strain, and addressed 
 imaginary persons. Her words were chietiy abuse directed against her husband. 
 She was somewhat grandiloquent, and said in a preaching kind of tone, "The 
 water follows me," and "The sun follows me," etc. 
 
 Six days later, the entry is: "puts herself into constrained postures, which 
 she maintains for long periods ; e.g , rests on her toes and knees, and on her 
 vertex ; and says it is when she prays that she does this. At times she sings 
 and repeats the words of her song correctly from memory." 
 
 Seventh month frotn admission. The same peculiarity of motility continued. 
 She usually sat in one position and in one place, and did not move till she was 
 told; moved to the dinner table only when told; began to eat when directed, - 
 but not before. Her attitude was often very obviously an uncomfortable one, but 
 she did not alter it unless bidden. Her bladder was one day found to be enor- 
 mously distended; and when questioned about it, she said no one had told her 
 to pass her urine ; and on being told, passed according to the rough estimate 
 of the nurse, nearly half a gallon. The pulse was 84. Her bowels were open. 
 She took her food well; but she was emaciated slightly. 
 
 During the eighth month but slight variation in the above condition took 
 place. About the middle of the month she complained that she could not re- 
 member her catechism, and was much annoyed and excited about it. 
 
 Ninth month. The motor symptoms continued. She sat in an awkward pos- 
 ture, like an image, and without moving for very long periods. She allowed the 
 flies to feed on her face and hands undisturbed, and said they wanted food as 
 well as she herself. She waited to be told to pass her urine, and if not told, 
 she wetted the bed or her clothes. She took her nourishment well, and assisted 
 in the household work as heretofore, but always waited to be told. 
 
 About the tenth month she was visited by her mother, who brought her a 
 bible; the patient became considerably excited about this, put the book on the 
 fire and said there were lies in it, that God was unjust, and upbraided God 
 that she had become dirty in her habits. The statue-like immobility con- 
 tinued. 
 
 About the eleventh month she fell in a well-marked epileptic fit, in which she 
 was much convulsed. One week afterwards, began to show a difficulty in articu- 
 lation; she stammered, but protruded the tongue well. This difficulty gradually 
 increased. She was quite conscious of the change, and complained of it; com- 
 plained also about this period of occasional headache, and a sensation in her 
 arm which she called " a jumping of the bone." 
 
 After this she became gradually excited, and disposed to be violent. Her 
 movements were stiff and slow. The excited conduct extended from the eleventh 
 to the fourteenth month from her admission. Her general health was not 
 greatly impaired ; she took her meals, and retained her usual amount of flesh. 
 She had no return of fit. On May 10th (fourteenth month after admission), 
 she was, after a day of great excitement, taken with vomiting. Tho bowels 
 were also confined. She would not take medicine, but was relieved by an 
 enema. A few days afterwards (May 14th), she became libidinous in her 
 actions. 
 
 May 15th. She continued very excited ; threw herself about in a wild man- 
 ner and somewhat indecently. The skin was moist, and emitted an extremely 
 offensive odour. 
 
 P 
 
210 LECTURES ON MENTAL DISEASE. 
 
 May 17th. She had a restless niffht, and had a very violent fit this morninfj. 
 At my visit about 2 p.m., she hod a second fit, from which she did not rally. 
 She died in the convulsion; the face being flushed, and the limba contracted. 
 
 Cash XIV. — Melancholy vfith Stupor. Depression ; Illusions and delusions of 
 the sense of hearing ; Erotism; QraduaZ stupor of movements ; Sudden change of 
 this; No result knoum. 
 
 A. K., primary attack, set. 34, married, was formerly a lady's maid. She 
 lived, previously to her marriage, eleven years in one place, and married the 
 the butler. This appears to have been an unfortunate match. The family 
 made frequent inquiries about the patient. The hassband took very little interest 
 about her. He attributed her disease to stubbornness ; and requested by letter 
 that she might be treated with firmness and " vyell routed." The medical certi- 
 ficate accompanying the order of admission gave the following description of the 
 patient just prior to her reception: — "She sits weeping and miserable; says 
 she has broken her husband's heart; that she is better without food. Her 
 landlord and fellow-lodgers found her in a state of complete exhaustion from 
 want of food. The children also appeared half famished. She declares she 
 heard voices forbidding her to eat or drink, or light fire, or go to bed." 
 
 In this hearing of voices there was evidence of distinct psychical disturbance 
 or illusion. It never, however, manifosted itself afterwards. 
 
 On admission (Oct. 21st, date of disease uncertain), conversed quietly and 
 correctly, though in a weak tone of voice. She said she had been living in 
 London with her children in a lodging. She had no headache. The tongue waa 
 mnch furred. Tlie bowels were confined. She took beef-tea only for dinner ; 
 had no thirst. Pulse 60,. feeble. There was no cough, nor any morbid cheat- 
 signs. She was ordered full diet, one egg, and two glasses of wine daily. 
 
 Oct. 24th. She was up ; was pale, but had considerable turgescence of the 
 vessels of the conjunctiva. The tongue was red ; bowels not open. An aloetio 
 draught twice a day was ordered. 
 
 During the first three months she continued constantly depressed; was alwaya 
 more or less indisposed to exert herself; would not dress herself. She declined 
 in strength, but made no complaint. During my temporary absence from home 
 her head was shaved and blistered without apparent benefit. The bowels con- 
 tinued obstinate; but she would seldom take an aperient; and occasionally 
 refused food. 
 
 Jan. 8th (three months after admission). She varied from day to day. One 
 day refused all food, and said she did not require it; that she could do without 
 it. Another day ate ravenously. The bowels seldom acted. She refused medi- 
 cine. Some emaciation was visible. Pulse 70, regular. There was no cough 
 or chest-symptoms. She was always listless and depressed. The expression of 
 the features was dull and heavy. 
 
 Jan. IZth. Her mind was in the same state; but she ate ravenously; would 
 gorge herself if not watched, and filched the meat from the other patients' 
 plates. 
 
 Jan. 2Mh. She again refused food. Sat moodily in one position for long 
 periods. Her features were dull and expressionless. She allowed the nasal 
 secretion and saliva to dribble from her as she sat. 
 
EXAMPLES OF INSANITY PROPER. 211 
 
 Fch. lOth (four months after admission). Motility was still more involved. 
 Slie sat for long periods in one posture, indifferent to all around, and apparently 
 too lazy to move; was like a statue in immobility, but the attitude was ex- 
 pressive of hebetude. Her head drooped ; the features were relaxed, and did 
 not change; her arms dangled by the side of the chair as she sat. The secretions 
 were dropping from the mouth and nose, and the lachrymal secretion had dried 
 upon her cheek. The breatliing was slightly accelerated. Her bowels were 
 coi)fined. She was at the present date eating largely. Three grains of podo- 
 phyllin were ordered. 
 
 Feb. 2(Mh. She was moving down the gallery at a snail's pace. Her head 
 drooping, and her arms hanging heavily by her side. Her dress neglected. She 
 had not menstruated since admission. Compound iron mixture was ordered. 
 
 March 2nd. She would not take the medicine ; was still more dull and heavy ; 
 stood about in one position, obstructing the passage, and did not move to allow 
 one to pass ; appeared motionless and statue-like. Her arms and head drooped. 
 The saliva and nasal secretion dribbled from her. She dropped her faeces about, 
 and wetted herself as she stood ; never attempted to dress or wash herself. The 
 pulse was GO; circulation appeared torpid; nose and lips were purplish; the 
 hands cold and puffy. At times she would eat, and at times she would refuse 
 food for days together; she had, however, gained flesb since her residence in 
 the asylum. 
 
 March 9th. Asked voluntarily for some note paper, and sat down and wrote 
 a letter to her sister, requesting her to send some needlework. The letter was 
 correctly worded and spelt; but rather less neatly written towards the close; 
 and it was without signature. 
 
 Great improvement in the appearance of the patient took place from this date, 
 and increased. The work was sent, and she took to it at once. 
 
 163rcZ Day (or five months). Her expression was greatly improved. She was 
 now quite animated. The features had undergone such a change that she was 
 scarcely recognisable. She was tidy, cleanly, cheerful, and disposed to be 
 rather mischievous, playing tricks upon the other patients. 
 
 The sudden amelioration of the symptoms in these cases of melancholia is not 
 uncommon. 
 
 However, from the above date, the progress towards recovery was less satis- 
 factory. The patient continued to work well at her needle. Her health im- 
 proved ; menstruation became re-established. On several occasions she exhi- 
 bited libidinous feelings, as shown in watching the workmen and following them 
 whenever she could get the opportunity. She wrote several times to her 
 relations; her letters were correctly and clearly indited. She had one or two 
 attacks of hysterical character ; and has been more than once again depressed 
 for a short period. 
 
 At about the 400th day of residence was still in the asylum, and passing 
 gradually into a state of mental imbecility. 
 
 The case illustrates the degree to which torpor may be pre- 
 sent, giving the appearance of dementia, while the intellect is 
 comparatively but little affected. It is also an example of the 
 occurrence of erotism in melanchoHa, which is the form of in- 
 
 p2 
 
212 LECTURES ON MENTAL DISEASE. 
 
 sanity with which that Byraptom is most frequently connected ; 
 and it ilhistratcH also tlie suddenness with which the symptoms 
 of melancholy or depression sometimes pass away. 
 
 CA.SI!: XV. — Acute Insanity. Melancholia with religions fears and apprehen- 
 sions about health; refusal of food; delusion (!') ; gradual recovery in twelve 
 months. 
 
 8. C, admitted May 2nd, 18G2, history from father ; tet. 28, Bingle ; barmaid ; 
 can read; Wesleyan ; first attack. Five montha prior to admission left her 
 situation to be married ; her intended was a lay missionary ; himself under very 
 strong religious impressions. He spoke frequently and ardently to the patient 
 on religious subjects, as of sin, worldlincss, &c., and succeeded in making a 
 very powerful impression upon her. After attending numerous prayer meetings 
 with her intended the parents observed that she became very much depret-sed; 
 about four months prior to admission depression was more marked ; cried fre- 
 quently; was often reading the Bible ; soon after receiTed the sacrament with 
 intended, and at once and persistently since has accused herself of receiving it 
 unworthily, and of being very guilty. Bas become much altered in conduct, 
 has sat alone, and appeared wretched, paid no attention to anything; entirely 
 ceased to occupy herself; accusingherself continually of guilt, and unworthiness, 
 &c. The parents believing the lover was the cause of her misery at length 
 denied him the house. This appeared to make no impression on her. "She 
 was too far gone for that." For two or three months has taken little food; had 
 always to be persuaded to eat; for one month has had to be fed by force. Has 
 gradually become indisposed to speak Is greatly reduced in strength and flesh. 
 Has been deaf some years, and worn ear trumpets. 
 
 Cause. Circumstances related above. No hereditary predisposition. 
 
 On admission emaciated and feeble, had to be supported into the ward, too 
 weak to be bathed. Some wine administered which she took without opposi- 
 tion; expression anxious and careworn, says "nothing can save me, they say 
 1 am not right, but I am," is restless and fidgetty, repeatedly reiterates "I am 
 right, I am sure I am." (Intellect proper not involved). 
 
 Day after admission (about 150th of case) . Expression anxious, says she has 
 no headache, pupils are large, but act readily, equal, is deaf. Complains of pain at 
 pit of stomach, says the bowels are not open, which is contradicted by the nurse, 
 tongue moist, takes food sparingly, pulao 84, brcnthing 36 and catching, says she 
 is subject to cough, both apices are slightly dull, and some puerile respiration in 
 both, more marked on left side, is very weak and walks with a feebl« gait. Pre- 
 scribed good diet. Three ivceks after above. — Depression continues, expression 
 painful and aniious ; takes food better, is very weakly. Wine added. Five 
 weeks after admission — Has occupied herself some time with needlework; now 
 assists the nurses, and is stronger, and has gained flesh; the depressions and fear 
 of "having done wrong" continue. One month later. — Has persisted in saying 
 she was constipated which is not the case. Has had several doses of castor oil. 
 Aloes and mast, pills. Still employs herself and is industrious and stronger^ 
 but says her constipation is due to an evil spirit eating her food (delusion?). 
 Shortly after this again refused food and would only cat by nurso insisting 
 upon it, makes numerous excuses, that she is depriving other poor creatures of 
 
EXAMPLES OF INSANITY PROPER. 2I3 
 
 it, says that none of the other patients cat. To have aloes and mast, pills daily. 
 Has not menstruated since admission. Three weeks after this or eight months 
 from commencement of attack, became more fretful, refused food more pertina- 
 ciously and vomited after taking it. She had to be fed, vomiting continued for 
 more than a month. She again lost flesh. Continued to say her bowels never 
 acted. Complained of a sense of oppression at the epigastrium, is constantly 
 craving for aperients. She was ordered cod-liver oil and continued the aloes 
 and mastiche pills. She kept the oil down and the vomiting entirely ceased, 
 again began to work and is disposed to do more than she should, appears over 
 anxious not to cause trouble, became once more tormented by religious scruples. 
 At the commencement of fifth month after admission {about tenth of attack). — Ex- 
 pression more anxious desires to see the chaplain, with whom she conversed in 
 an excited manner, exhibiting very great emotion and cried much after he had 
 left ; cries much to me, says it is no delusion, no disease, but wickedness, the 
 bodily health has not much changed ; she is able to assist in the ward a little and 
 was very anxious to be useful, pulse 84. Tongue still furred ; bowels act, but 
 she continues to assert the contrary, pupils equal and act readily. Has not 
 menstruated, ordered to have enemata regularly. She improved again after this, 
 but had some return of vomiting, which did not last. At the commencement of 
 eleventh month, the improvement continued, she no longer refused food. She oc- 
 casionally said she was too wicked to live. She continued the aloetic pills ; 
 went to work in an officer's house as domestic servant. Delusions and fears 
 gradually subsided ; she gained flesh. She went home on trial at the end of the 
 eleventh month j remained well at the end of the twelfth month. Eecovery. 
 
 Case XVI. — Example of rambling ideas of so-called Melancholia metamor- 
 phosis. 
 
 A patient admitted September 17th, 1863, tet. 30, slight, received from Wap- 
 ping, had been sent home from India, without history, was landed in London 
 and thus became chargeable to Wapping. 
 
 On admission was very incoherent and excited, crying and occasionally 
 shrieking with fright; while examining her health she suddenly uttered a piercing 
 cry and said " they have put a horse's head on me, and given me horse's knees," 
 is considerably disturbed at the thought. Says she is easily taken to pieces and 
 put together again; calls herself by various and very numerous names; says 
 she was left in an alms house, and she threw ofi'her limbs, that Dr. Goodeve put 
 her head together again, this is all said without pause or break in a rapid man- 
 ner, that she wedded John Locke, that these large legs that she had got on 
 were on a tall boy, she knew the legs by a mark ; her legs were nice little legs. 
 A patient approaching her she gave a shriek and said she was a bear. 
 
 On another occasion the note entered is, " says she is a poor, cracked, damned 
 thing;" hearing some music, became very angry, said it was a brutal noise made 
 by her stolen fingers. 
 
 There was no fixed delusion of what I may call a concrete kind, though the 
 general idea that she had been generally metamorphosed continued throughout ; 
 the particular change varying constantly. She was an educated person, but no 
 clue to her history could be gathered from her. 
 
 On my leaving Hanwell she was still a patient and in a chronic stage of the- 
 disease. 
 
214 LECTURES ON MENTAL DISEASE. 
 
 Cask XVIL — Example from Dr. Legrand du Savile as Hynterical mania, but 
 which I should call simple acute insanity with suicided propensity. 
 
 The following letter was written by a lady to her husband, ehe had just ex- 
 perienced a great blow in the death of Ler little daugliter. 
 
 My dear Husband, 
 
 It is Sunday, I have been to church, (one more sacrilege that I 
 have been guilty of). Since my return from the baths, I have been guilty of 
 sins by thousands, of lies and false promises. Listen to the account of my life. 
 Up to 25 years of age I believe that I was good, a good wife and a good sister, 
 and now 1 am entirely different. I was only a monster escaped out of hell, a 
 perfect hypocrite, 1 have never loved anyone but myself, I have even been a 
 coward, I have never loved to be industrious and to crown all, I shall now be 
 the death of my father, my mother and of you, dear husband. My brother too is 
 ill. If an assassin, a thief were to place himself in the hands of justice and con- 
 fess his crimes and acknowledge himself worthy only of death, they would kill 
 him. So now your wife deserves to die. You must be her judge. Human laws 
 permit those who give life to take it. Take the train, on your arrival you will 
 liud me to all appearance cured. We will purchase something at the chemist 
 which will make me die in my bed. In seven or eight hours our honour will be 
 aaved. You can believe what I say that I deserve to die. I am the most 
 wicked person on the face of the earth. After you have let me die, in a fortnight 
 you will be rid of me. The more you have done for me, the worse I have been, 
 yet I have one request to make, if I die in this house lay me near my little child. 
 Poor dear, I never loved it, its father, its grandfather and its grandmother loved 
 it, its mother only had no affection for her child, I never received her last sigh. 
 Oh, what misery for my parents in having given me life. What misery for you 
 to have asked my hand in marriage- Heaven is my witness, had I known my own 
 baseness, I would never have joined my hand to one so good and kind. Alexan- 
 der, I know that you can kill mo, without committing a crime, you know that I 
 know good and evil. You would not wish my father to die before me, hasten 
 then to come, my father, my mother and you still suffer for me. If I die here 
 
 let me be buried at C , Kisses if you will still accept them, pray to God 
 
 that your wife may die, for your happiness and the happiness of all. 
 
 I am, what I dare not say, 
 
 Your wife, 
 
 E. L. 
 
 Forgive, forgive all I have done, come quick, in a fortnight perhaps I shall 
 be no more. 
 
 Case XVIII. — Examph of hysterical mania q^toted from Dr. Legrand du 
 SauUc {Les Hysteriques). 
 
 Case from Dr. Morel. — Hysterical mania, {folie hysterique) a congenital im- 
 becile with hysterical and epileptic symptoms. 
 
 Elisa C, a child of an intelligent mother, but whose father was of feeble 
 mind and disposed to convulsive attacks. Menstruated at the age of twelve. 
 Always of sullen character, capricious, fanciful, had never shown any affection 
 
EXAMPLES OF INSANITY PROPER. 215 
 
 toward her parents. Would cry or laugh without cause; abandoned herself 
 at a very early age to all kinds of eccentricities and follies. Having been 
 placed with a dressmaker to learn the business, the mistress was unable to 
 keep her on account of her insolent and bad language. Soon after showed 
 decidedly insane acts, common to such individuals. One day she crowned her- 
 self with flowers, took a guitar and said she was going to travel the country. 
 She rose in the night and began to wash her clothes in the night utensil. She 
 had attacks of convulsive character, mewed like a cat and tried to climb up the 
 wall. She became violent and dangerous and at length sank into a stupor. 
 These attacks became periodical, and twice it became necessary to send her 
 to an asylum (p. 295), 
 
 This case I should consider bordering upon idiocy, or natural imbecility or 
 weak-mindedness ending probably in true epilepsy. 
 
Section VI. 
 
 THE ETIOLOGY AND PATHOLOGY OF ORDINARY 
 INSANITY OR INSANITY PROPER. 
 
 Etiology of Mental Disease — Remote causes, moral and physical, influence of ape, 
 sex, condition as to marriage, social position — Physical causes, hereditary 
 influence, drink, 'venereal excesses — Anatomical characters after death — the 
 pathology proper, and explanation of the phenomena. 
 
 Hitherto we have been considering the phenomena of ordinary 
 insanity or insanity proper in its various stages, and investigat- 
 ing its progress toward one or other goal. There remains for 
 ns to enquire into the true pathology of the disease, and to 
 trace the changes in the organism on which the phenomena 
 during life, or the symptoms, depend. 
 
 For a thorough investigation of tliis part of our subject, we 
 may enquire into : 
 
 I. The supposed causes. 
 
 II. The anatomical characters as found by post mortem ex- 
 amination, and 
 
 III. The explanation of the phenomena of the altered func- 
 tions or the true pathology of the disease. 
 
 I. Etiolo(jy. — On entering upon this part of the subject, I feel 
 it necessary to make a few preliminary remarks. I have already 
 alluded to the use that has been proposed of etiology in the clas- 
 sification of the forms of insanity. I imagine that there must be 
 much difference of opinion upon the exact meaning of the terms 
 used as applied to causes in general. I will therefore quote, what 
 I conceive to be the proper signification of the terms, or as I in- 
 terpret them. Dr. Gregory in his Conspectus Medicince Theoretica, 
 a work treating of the Institutes of Medicine, says, § xxxvi : — 
 " Causa multifariam dicitur apud medicos cum de morbis dis- 
 Berunt ; et sensu profecto aliquantum diverso ab eo quo hoc voca- 
 bulum usurpari solet, vel in scriptis philosophorum, vol in com- 
 miiui homiuum sermone," in brief that the medical signification 
 of the term " cause " is peculiar. Gregory divides medical 
 causes, into the proximate and the remote, and the remote into 
 predisposing and occasional, or exciting or producing. The 
 
ETIOLOGY AND PATHOLOGY OF INSANITY. 21 7 
 
 proximate cause is tliat " qiue pnescns morbum facit, nublata 
 toll it, mutata mutat. 
 
 The predisposing cause is that which renders the body hablo 
 to a disease, so that on the apphcation of the exciting cause the 
 disease is established, lastly the exciting cause is that which 
 acting on a subject already predisposed establishes the disease. 
 
 "When we speak of a disease being due to a certain cause, we 
 should know which is meant, the remote or proximate cause. 
 Nearly all the causes cited in treatises on insanity are remote 
 causes, they may be of interest to study, as throwing hght on 
 some of the characters of the disease, but it is only the proxi- 
 mate causes which can give any explanation of the phenomena 
 presented, that is, the cause " quas prssens morbum facit, sub- 
 lata tollit, mutata mutat," in other words, the real pathological 
 change in the organism. 
 
 It may be observed in passing, that a classification on such a 
 basis would be scientific, but one on the remote causes can never 
 be. 
 
 We will first pass in review the facts that have been brought 
 together by statistics connected with these remote causes and 
 which have been a favourite study among the specialty. They 
 have been further divided into physical and moral, but it is not 
 easy to divide them in this way, as some remote causes which 
 are thus divided, are of a mixed kind, for example, marriage 
 may be of either in its remote effects on the individual ; there is 
 scarcely a physical cause which may not also have a moral in- 
 fluence. 
 
 I will confess that I do not place much weight on the study of 
 these remote causes, the subject usually occupies a large space 
 in all works on insanity, but it is to be feared without producing 
 much practical good. All the lunacy official reports are filled 
 with statistical tables, but the mode in which the facts are col- 
 lected does not impress my mind with their value. 
 
 I find these remote causes divided in the tables published 
 into : — 
 
 1. Moral causes, as anxiety, grief, loss of friends, love affairs, 
 disappointments, etc. 
 
 2. The physical causes mentioned are chiefly drink and here- 
 ditary predisposition, etc. 
 
 Since all of these must more or less be of mixed ir/1uence, I 
 
2l8 LECTURES ON MENTAL DISEASE. 
 
 sliall not attempt to follow the arrangement. There must bo it 
 is true, cases in which the prominent remote cause seems to bo 
 what is called of moral kind, as when a mother goes insane on 
 the death of a child, or when a man becomes insane after a long 
 course of hard drinking. But neither the one or the other can 
 be wholly the cause of insanity. 
 
 I will endeavour, however, to epitomise the results which the 
 statistics furnish. 
 
 The following is from the table given in the report of the 
 Commissioners in Lunacy and represents the proportion of the 
 liabihty to attacks of mental disease of each social class to the 
 entire population. 
 
 Proportions 
 per 10,000. 
 
 Ofi&cers. — Persons engaged in the defence of country 27.5 
 
 Peers and Squires.-;-Persons of rank and property not 
 
 engaged in any office or occupation . . . . 17 "1 
 
 Merchants and Traders. — Persons who buy and seD, 
 
 keep or lend, money or goods of various kinds 17*8 
 
 Professionals. — Persons engaged in the learned pro- 
 fessions 10*7 
 
 Innkeepers and Actors. — Persons engaged in enter- 
 taining 9"6 
 
 The rest range about 6-0 
 
 In looking at this list it would seem that omitting the firet 
 category which includes of course soldiers and sailors of all kinds, 
 the rest follow much in the ratio of their education ; this result 
 which to me, was unexpected, seems to point to two diflferent 
 causes ; 1. sensitiveness and refinement, rendering the subject 
 more easily affected ; 2. the responsibilities and anxieties ne- 
 cessarily accompanying station and property. 
 
 I fancy the large Habihty of the first on the hst, must be at- 
 tributed to the debauching and intemperance of the mass of 
 soldiers and sailors, and also to their enforced single hfe. 
 
 The professional class are, or should be equal to the peer in 
 intellectual work, and are probably as much exposed to anxieties, 
 though not of such luxurious habits, calculated to heighten their 
 sensibihties. 
 
 Dr. Hammond says, p.- 121, that since the emancipation of 
 elaves in America the negroes have become more hable to insanity. 
 
ETIOLOGY AND PATHOLOGY OF INSANITY. 219 
 
 The results arrived at by the Commissioners were a surprise 
 to me, for if we compare the number of the insane to the sane in 
 different conditions of life by another mode, the difference seems 
 to be very remarkable, the estimated population of England and 
 Wales in 1867 was 19,408,464, and at the same date there were, 
 according to the Poor Law Commissioners a total of 843,430 
 paupers. At the same period the Commissioners in Lunacy 
 stated there existed in England and Wales 21,344 lunatics of 
 whom 16,657 were paupers, and 4,687 not paupers. We have 
 therefore the following equation : — 
 
 T^ ( Insane 16,657 1 
 
 Paupers ->' ^ — = — . 
 
 ^ ISane 843,430 50 
 
 Or in other words, a proportion of one-fiftieth of all paupers 
 insane. 
 
 On the other hand, the non-pauper class are estimated by de- 
 ducting the number of paupers from the gross population, and 
 the result will be as follows : — 
 
 Insane 4,687 1 
 
 XT f 
 
 Non-paupers -l 
 
 Sane 18,565,034 "" 3982 
 
 It is quite true that this large proportion of insane paupers 
 may consist of many persons who were made paupers by their 
 disease, and do not therefore belong to the class of habitual 
 paupers. But the question depends rather upon the social 
 status, than upon the accident of eleemosynary assistance, and 
 this perhaps can be as well shown by the degree of education 
 found in the inmates of pauper asylums as compared with those 
 in non-pauper asylums. 
 
 At Hanwell in 1855, one-tenth of the patients admitted were 
 classed as educated, and about one half of no education at aU. 
 While at the same date, of the patients admitted into Bethle- 
 hem Hospital, which is a non-pauper asylum, 87 per cent, were 
 educated and 12 per cent, uneducated (Sir Chas. Hood, Statistics 
 of Insanity, p. 28). 
 
 After making every conceivable deduction from the latter es- 
 timate, there cannot but remain the conviction that the wealthier 
 and therefore surely the more educated and civihzed class, is 
 less liable to insanity, than the middle and lower classes. 
 
 As regards the state as to marriage, table xvi of the Commis- 
 sioners' Eeport shows the ratio per 10,000 patients tc' the whole 
 
220 LECTURES ON MENTAL DISEASE. 
 
 population at the censns 1871 and fruiu ^vhit•h it appears that 
 tlio widowed arc much more prone to insanity, tlian tlie single 
 or married, as prone in fact as the single and married put to- 
 gether. The totals are : — 
 
 For the single 40 per 10,000 of the population. 
 Of the married 7*0 ,, ,, ,, ,, ,, 
 
 Of the widowed 11-7 ,, ,, ,, „ „ 
 
 The same result is thus arrived at by this enquiry, that it is 
 those obnoxious to most anxiety and trouble who are most prone 
 to attacks of insanity. 
 
 The same general conclusion may be drawn from table xii of 
 the same report which gives average annual increase of insanity 
 in nine years in different counties, the largest increase is found 
 to be in Middlesex 341, Lancaster 201, Surrey 133, York 103 ; 
 all great centres of active life ; while there has been a decrease 
 in the counties of Devon of 35, Suffolk of 18, and Pembroke of 15. 
 
 These returns from the large numbers in which they deal 
 must approximate to the truth in many particulars. I think 
 they are more subject to error, w^hen they deal with opinions 
 rather than dry facts, as when the causes are tabulated. The 
 cause of the malady is a nice point to estimate and there are a 
 multitude of ways open to error in our search for a correct con- 
 clusion. Besides the pre-conceived notion of the medical prac- 
 titioner, or a favourite conclusion of popular opinion which 
 induces relatives to lay particular stress upon one kind of fact 
 rather than another, there are in many cases inducements to con- 
 cealment of facts ; and above all it is highly propable the causes 
 set down are not entered by the medical man at all. Such was 
 the case at Hanwell in my time ; as a rule I believe, the 
 cause is assigned by the relieving officer, who has a line to fill in 
 and is not often interested in giving much attention to minutiae. 
 It is from such returns, in many instances, that the official 
 statistics are compiled. 
 
 Temperament. — This certainly deserves mention as a predis- 
 posing cause, though I do not find it alluded to among the usual 
 statistics that are published officially, probably on account of 
 the difficulty of clearly defiumg in what temperament consists ; 
 the term is an abstract one and embraces therefore a wide field 
 of facts. The older physicians mention four kinds : 1. San- 
 guineous, 2. Mclanchohc, 3. Choleric, and 4. Phlegmatic; 
 
ETIOLOGY AND PATHOLOGY OF INSANITY. 221 
 
 terms wliich have almost lost their meaning in the advance of 
 science. Still we can distingnish certain differences in the 
 general nature of different individuals for which these terms 
 were coined. 
 
 There are some subjects of greater nervous energy, more 
 readily moved to action, and whose excitment in one or other 
 direction is more pronounced, and there are others who are 
 placid, deliberate in all their actions, not easily moved to either 
 anger or mirth ; some who are disposed to take a melancholy 
 view of every circumstance, and those who are hopeful under 
 any misfortune, and certainly these variations of character have 
 theu' influence in predipposing to insanity, quite as distinctly as 
 the conditions of the married or single state, etc. 
 
 In ordinary insanity the energetic certainly appear to be more 
 prone to mental disease than the apathetic, though the latter 
 enjoy no actual immunity. But it has occurred to me to notice 
 that those patients with one resource only, persons of one idea, 
 appear to supply a large proportion of lunatics, this fact comes 
 out often in our effort to divert the patient's mind by some 
 varied kind of occupation. Too often I have found that the in- 
 sane are ignorant and uninterested in any but a single pursuit, 
 they have no conversation, no means of occupying their minds 
 on games or other diversions, once removed from their sphere 
 they become unable to take up another kind of hfe. 
 
 This, however, applies chiefly to the patient suffering from 
 ordinary insanity, the general paretic is of a different tempera- 
 ment as will be described in the sequel. 
 
 With regard to the jjhysical causes. These are also estimated 
 in the returns by the Commissioners in Lunacy in their report 
 for 1880 (p. 41), based upon the total number of admissions 
 amounting to 13,101 during the year 1879. 
 
 According to this table, 14-2 per cent, of all causes was attri- 
 buted to drink ; 18-8 per cent, hereditary influence; 12-9 per 
 cent, to previous attacks, these are the chief assigned causes ; 
 accident or injury occurs as 3-2 per cent. ; old age 3-9 per cent. ; 
 puerperal condition, including pregnancy, 4*8 per cent. ; self 
 abuse and venereal disease, or sexual intemperance conjointly 
 2'8 per cent. 
 
 Among the pauper class drink therefore appears undoubtedly 
 above all causes the most frequent. When it is remembered 
 
222 LECTURES ON MENTAL DISEASE. 
 
 that the primary eflfect of alcohol is on the cerebral organs, this 
 result is not surprising. 
 
 Heredity. — It is beyond a doubt that a certain condition of the 
 organism renders one indi\4dual more obnoxious to an attack of 
 mental disease than another ; mental individuality is trans- 
 mitted from parent to offspring as well as physical resemblances 
 and morbid tendencies as well as what is called the " constitu- 
 tion" of a man. 
 
 In particular cases it has been observed that even the pecu- 
 Har character of the case is transmitted, and the peculiar ten- 
 dency to suicide. I have myself met with cases in which 
 numerous members of one family have committed suicide, and 
 even by the same mode. Griesinger quotes an example of a 
 man and his wife aged forty-two and thirty-six, both of whom 
 became insane, and both committed suicide ; the husband hung 
 himself, and the woman committed the act by di-owning ; the 
 daughter poisoned herself at twenty- four ; the son strangled him- 
 self at twenty-one ; another daughter threw herself down from 
 the top of the house. In this case one recognizes another ele- 
 ment, which is probably not inactive in other cases, the force of 
 example. Of course there was nothing like hereditary influence 
 between the man and his wife. 
 
 Hereditary influences may act not only therefore through the 
 physical conditions, the force of example would act as a constant 
 impression on a mind and give a bias not only in health, but in 
 disease. The child whose ancestors, one after another had im- 
 molated themselves in different ways, must have ever present in 
 his mind the painful reminder of the acts. 
 
 M. Morel is disposed to believe that not only is hereditary ten- 
 dency a powerful agent in causing insanity, but that it causes a 
 pecuUar kind or form of the disease. If this could be shown to 
 be so, it would go far to separate such cases from the general 
 group and to make them a distinct form or species of insanity. 
 Before this can be admitted, much stronger proof is required 
 and my experience tends to a contrary direction. 
 
 In an investigation that I made while at Hanwell with the 
 view especially of determining the question of the identity or 
 non-identity of ordinary insanity and general paresis, I found 
 that heredity existed in one-fifth of the cases of ordinary in- 
 sanity. 
 
ETIOLOGY AND PATHOLOGY OF INSANITY. 223 
 
 Another cause, so-called, needs a few remarks on account of 
 the views which have been expressed concerning it, viz. venereal 
 causes, the total according to statistics gathered from 13,101 
 cases was 2"3 per cent., but the point on which most error has 
 arisen is on the question of masturbation. 
 
 Masturbation. — This has been spoken of as a habit which is 
 found in the insane. It is a subject on which many opinions 
 have been expressed, both in regard to its character as a symp- 
 tom, and as a cause of disease. I propose here to examine the 
 question from this double point of view. 
 
 1. It has been considered by some as a cause of insanity, and 
 Masturbational insanity finds a place in the classifications of 
 the Scotch alienists, who say that its characters are distinct. 
 This is not my opinion, and I must say that I have found in 
 several recorded cases, the cause of different neuroses attributed 
 to masturbation on very insufficient evidence. In one case (by 
 a sHp of the pen perhaps), a state of idiocy was attributed to 
 masturbation and in which there was discovered after death 
 the absence of the corpus callosum. 
 
 The fact is, the investigation is surrounded by innumerable 
 difficulties and so far from being an obvious cause I consider it 
 a most obscure one. 
 
 In the first place, it is a habit of which no one can say when 
 it exists, nor in whom it exists ; and whether it is more common 
 among one class than another, is an undiscovered fact ; we have 
 therefore no data on which to make a comparison or conclusion. 
 The habit is confessed by some, it has to be watched for very 
 closely to be detected in others, it may be suspected, but more 
 often than not, not proved. In children and idiots it is dis- 
 covered more frequently, not because it is more frequently prac- 
 tised probably, but because there is less art in concealment. In 
 males the presence of semen on the Hnen, shows of course, a 
 discharge of semen, but gives no data beyond ; we find semen 
 in urine, but the habit need not necessarily give any such evi- 
 dence. We have only in fact direct information from those 
 who are willing to confess, and in what proportion those are 
 to those who are not wilhng to confess, no one can tell. The 
 insane in the early stages are prone to self- accusation and mor- 
 bid fears of all kinds ; these fears are sometimes greatly exag- 
 gerated by imprudent accusations of all kinds, by the announce- 
 
224 LECTURES ON MENTAL DISEASE. 
 
 ments of "manhood advertisements," etc. This Bource of 
 evidence therefore or the suhjective is not available or reliable. 
 
 The objective evidence is also as weak. Among the symptoms 
 said to be observed in such cases are a look of shyness and 
 shame, an abnormal appearance of the lips, which are in my 
 belief merely phantastical imaginations of the observers, such 
 an appearance or any other may occur in a known or confessed 
 masturbator, but there is no means of knowing in what pro- 
 portion since we cannot ascertain the prevalence of the practice 
 among the general population. 
 
 If we attempt to enquire into the mode in which the practice 
 is detrimental or capable of causing insanity, it would seem that 
 the habit must act in one of two ways : either by its debilitating 
 effects or by the condition of nervous ii-ritabihty produced on the 
 system. 
 
 Mere debility would be an inadequate cause for the production 
 of insanity, and there would be no excess of irritability imless 
 the practice were carried beyond the . point of satisfying a na- 
 tural appetite. We know from observation that certain morbid 
 conditions of the nervous system do produce such sexual irritation. 
 It appears to my mind therefore, that masturbation is much more 
 frequently the effect of a neurosis, than a cause. That the habit is 
 found, however,to a great degree in the insane cannot be denied. 
 
 We meet with such cases in lunatics in the acute and chronic 
 stage and particularly in general paresis. This may be fully 
 admitted, but it leaves the question of masturbation as a cause 
 of insanity entirely unproved. 
 
 II. Pathology and Morbid Anatomy of Ordinary Insanity. 
 
 1. The anatomical characters as discovered by post-mortem e^am- 
 ination. — This division of our subject is more nearly connected 
 with the proximate causes of the disease. In a previous page 
 was given a general outline of the pathology of the two kinds 
 of mental disease, with the view of rendering the description of 
 the symptoms more readily inteUigible. 
 
 In this place the subject of the pathology wUl be considered 
 in relation to the morbid anatomy and in my exposition of this 
 part of the subject I shall adopt a mode of procedure employed 
 in legal matters, namely I will state firstly, the conclusions 
 which I consider that the facts of the case are calculated to 
 prove and then give the evidence in detail. 
 
ETIOLOGY AND PATHOLOGY OF INSANITY. 225 
 
 The main distinction between the two diseases, ordinary in- 
 sanity and general paresis, I stated (p. 100) to be in general 
 terms, tliat in ordinary insanity the disease was induced through 
 the nutrition processes, while the origin of general paresis waa 
 by a shock or dkect action on the nerve tissue. 
 
 That whereas every act of cerebration requu-ed the inter- action 
 of the two agents, that is to say, 1. the nutrition process (or for 
 brevity sake, let us say the blood), on one hand, and 2. the nerve 
 tissue on the other. That the one disease begins in the one 
 agent or the blood, and the other disease in the other agent, the 
 nerve tissue. 
 
 Hence we found that the first symptoms, or mode of attack, in 
 ordinary insanity were gradual and confined at first to the emo- 
 tions, leaving the intellect proper intact, that later in the j^ro- 
 gress of the disease the intellect shows that it is imphcated in 
 the morbid process, but that the motor faculties, and the func- 
 tions of nutrition remain unaffected, which phenomena are 
 in certain cases suddenly dissipated and the patient has a lucid 
 interval, or his symptoms undergo certain periodical changes, 
 as described, showing during hfe a varying condition of integrity 
 and impau^ment of function, such as might be explained by a 
 morbid condition of the blood- supply. 
 
 What we have now to do is to examine the changes discovered 
 after death and to interpret those appearances, to ascertain in 
 fact if there be any traces of an abnormal condition of the blood 
 in the organs generally. 
 
 Om- examination may be conducted in the following order : — 
 1. Of the cerebral organs and its ajppendages. 2. The condition 
 of the other organs chiefly concerned in the nutrition processes. 
 
 In this enquiry I must depend largely upon my own examina- 
 tions, since few of the pubhshed accounts are available, as very 
 few authors have separated the appearances found in ordinary 
 insanity from those of general paresis. 
 
 In examination of the brain and its appendages, I will first 
 enumerate the appearances gathered by unaided vision and 
 reserve the minute changes for the results yielded by the micro- 
 scope and other means. 
 
 In the Journal of Mental Science, 1 published the annexed 
 table of morbid appearances found in 36 cases (vol. ix, p. 479), 
 
 Q 
 
226 
 
 LECTURES ON MENTAL DISEASE. 
 
 The table consist firstly of acute cases of ordinary insanity of 
 which there were eight ; eecondly, of chronic insanity of which 
 there were also eight ; thirdly, five cases of imbecility and de- 
 mentia ; fourthly, fifteen cases of general paresis. 
 
 
 
 
 5 Cases o 
 
 
 
 
 
 Simple 
 
 
 
 
 
 Imbecility 
 
 
 
 8 Acute 
 
 8 Chronic 
 
 
 
 15 Cases of 
 
 
 Cases. 
 
 Cases. 
 
 Epilepsy, 
 with Imbe- 
 cility and 
 Dementia. 
 
 General 
 Paresis. 
 
 Membranes abnormal — 
 
 
 
 
 
 Dura Mater .... 
 
 1 
 
 — 
 
 — 
 
 9 
 
 Arachnoid opaque 
 
 2 
 
 3 
 
 — 
 
 12 
 
 Serum beneath it 
 
 3 
 
 3 
 
 — 
 
 11 
 
 Pia Mater 
 
 
 
 
 
 Adherent 
 
 1 
 
 — 
 
 — 
 
 8 
 
 Injected 
 
 5 
 
 4 
 
 — 
 
 15 
 
 Anffimic 
 
 1 
 
 — 
 
 2 
 
 — 
 
 Opaque 
 
 — 
 
 1 
 
 — 
 
 — 
 
 Serum eflFused 
 
 3 
 
 4 
 
 2 
 
 9 
 
 Tubercle 
 
 1 
 
 — 
 
 1 
 
 1 
 
 Bony plates . 
 
 — 
 
 — 
 
 1 
 
 — 
 
 Lymph 
 
 — 
 
 — 
 
 1 
 
 — 
 
 Brain Substance. Weight. Ratio* of '| 
 Cerebrum to Cerebellum ..' 
 
 6-49 to 1 
 
 577 to 1 
 
 6-45 to 1 
 
 6-54 to 1 
 
 Specific Gravity — 
 
 
 
 
 
 White substancet 
 
 l-041t 
 
 1-039 
 
 1-042 
 
 1-039 
 
 Gray sub8tance§ .... 
 
 l-039i| 
 
 1032 
 
 1027 
 
 1-034 
 
 General consistence of Btain — 
 
 
 
 
 
 Firm 
 
 7 
 
 4 
 
 1 
 
 3 
 
 Flabby 
 
 
 2 
 
 2 
 
 3 
 
 Altered in colour 
 
 7 
 
 — 
 
 — 
 
 — 
 
 Congested 
 
 4 
 
 — 
 
 — 
 
 8 
 
 Convolutions closely packed 
 
 7 
 
 3 
 
 — 
 
 — 
 
 ,, open 
 
 — 
 
 2 
 
 — 
 
 9 
 
 Gray Matter- 
 
 
 
 
 
 Pale 
 
 4 
 
 2 
 
 3 
 
 3 
 
 Dark 
 
 3 
 
 — 
 
 — 
 
 8 
 
 Injected 
 
 4 
 
 5 
 
 1 
 
 12 
 
 Firm 
 
 4 
 
 — 
 
 — 
 
 5 
 
 Soft 
 
 1 
 
 1 
 
 — 
 
 — 
 
 Layers distinct .... 
 
 3 
 
 7 
 
 — 
 
 5 
 
 Morbid growths .... 
 
 — 
 
 — 
 
 1 
 
 — 
 
 White Matter- 
 
 
 
 
 
 Pale 
 
 3 
 
 3 
 
 2 
 
 4 
 
 Dark 
 
 2 
 
 2 
 
 — 
 
 2 
 
 Injected 
 
 6 
 
 5 
 
 1 
 
 8 
 
 Firm ...... 
 
 2 
 
 — 
 
 2 
 
 8 
 
 Soft .• 
 
 3 
 
 1 
 
 — 
 
 6 
 
 Atrophy 
 
 1 
 
 — 
 
 — 
 
 — 
 
 Bone — 
 
 
 
 
 
 Increased in thickness 
 
 — 
 
 4 
 
 2 
 
 7 
 
 Diminished .... 
 
 — 
 
 2 
 
 — 
 
 ^^ 
 
 * Normal ration, 78 to 1. t Normal, 1-040. J Varied from 1-045 to 1-039. 
 § Normal, 1-034. || Varied from 1-029 to 1049. 
 
ETIOLOGY AND PATHOLOGY OF INSANITY. 227 
 
 The above table which I reprint here, since it illustrates seve- 
 ral facts to which reference is about to be made, shows lesions 
 occurring in various stages of insanity as well as in various 
 kinds. 
 
 It will be seen by this summary that there were well-marked 
 deviations from healthy tissue in a large proportion of these 
 selected cases. Five of the cases were primary attacks, two 
 others were second attacks, and the eighth was a case of melan- 
 choha well marked, but which continued in a melancholic condi- 
 tion from two to three years. 
 
 It is a well observed fact, however, that cases are not unfre- 
 quently met with in which no marked or discernible lesion can 
 be found, nearly every recent writer on the subject has men- 
 tioned this fact. 
 
 Griesinger remarks that many cases that terminate fatally 
 in the acute stage present pretty much the appearance of the 
 normal brain — often enough to lead to the conclusion, that the 
 symptoms during life were due to some disturbance in the pro- 
 cess of nutrition, as yet unknown to science. 
 
 M. Parchappe says, (Traite de la Folie, 1841, p. 441). " From 
 the foregoing facts it results absolutely that neither in acute 
 insanity nor in chronic is there such an essential and cha- 
 racteristic cerebral lesion which may be considered patho- 
 gnomic." 
 
 Dr. Bucknill writes (p. 559, Bucknill and Tuke's Psycliological 
 Medicine), " The form of Mental Disease which destroys Hfe in 
 the early period of its course is comparatively rare, and has 
 been thought by many modern writers to be a distinct form." 
 " In the brains of persons who have died while suffering fi-om 
 this form of insanity, (acute insanity), the strongly marked 
 characteristics of hyperaemia of the substance and the mem- 
 branes, even to the subarachnoid ecchymoses described by 
 M. Parchappe, undoubtedly exist. But in recent cases of mania 
 and melancholia of most frequent occurrence, if death were to occur 
 from some accidental cause or intercurrent disease, which did not in- 
 terfere with the state of the cerebral circulation, it is by no 
 means so certain that strongly marked signs of hyperaemia 
 would be found to exist." 
 
 In the observations of the above paragraphs, I entirely concur. 
 
 q2 
 
228 LECTURES ON MENTAL DISEASE. 
 
 It has occurred to me many times to examine the hrain of 
 patients clyiug in the asyhim, without discovering the sHghtest 
 lesion. I have also submitted many to microscopical examina- 
 tion with the same result. This tends to show that the symp- 
 toms were caused by some evanescent condition in the organ, 
 such as the interference of the circulation to which I have 
 alluded. 
 
 But the table also shows, and there is a general consensus of 
 experience to the same effect, that when any change is dis- 
 covered in acute cases, it is one of hypersemia. It must be 
 mentioned, however, that it is likely that among the earher 
 writers, some of these hypersemic cases might be cases of 
 general paresis ; about half of the acute cases of my table 
 showed evidences of hyperaemia. In those — in which the 
 patients died of the cerebral diseases, the whole of the functions, 
 the intellectual as well as the emotional, showed gi-eat distur- 
 bance. In such cases structural changes at all events had com- 
 menced, for the specific gravity of the substance white and gray 
 pointed to interstitial changes. 
 
 In chronic cases structural changes are much more obvious, 
 even to the naked eye, and are connected with every part of the 
 calvaria and its contents ; that is with bone, membranes, and 
 brain substance. 
 
 We are I think thus justified in the conclusion, that in all the 
 course of the disease the circulation has been in a state of hyper- 
 asmia. 
 
 The symj)toms also point to the same conclusion while the 
 hyperaemia is very active, there is insomnia ; where the h}-per- 
 semia has induced structural changes, there is confusion of 
 function. 
 
 Besides the state of hyperaemia or the condition of fulness of 
 the vessels, we have further evidence to be derived from the 
 state of the vessels themselves ; but this question as well as that 
 of the atrophy of the organ, will be considered under the results 
 yielded from microscopical examination. 
 
 There are shown in the table various other lesions, especially 
 in the chronic cases. Such as increased thickness of the skull, 
 diminished thickness, which are unequivocal and obvious struc- 
 tural alterations, adherent arachnoid, &c. 
 
ETIOLOGY AND PATHOLOGY OF INSANITY. 229 
 
 But SO far as this mode of examination of the brain goes, the 
 conchision which we can arrive at is, that in the early stages, 
 there is scarcely any lesion or change of structure of such a 
 degree as to leave a permanent or very obvious mark after death ; 
 while in the latter period of the disease there are to be dis- 
 covered the traces of long operating morbid changes, especially 
 connected with increased blood supply. 
 
 Other modes available for estimating the degree of cerebral 
 lesion, shew the same conclusion as the weight and specific 
 gravity. 
 
 The weight of the brain has been examined by different ob- 
 servers and particularly by the late Dr. Skae, of Morningside. 
 Dr. Skae suggested a mode of comparing the weight of one part 
 of the encephalon with another. He says in his Eejwrt of the 
 Morningside Asylum, for 1854. " This mode of estimating the 
 results appears to me, to be free from the source of fallacy aris- 
 ing from the small number of cases compared ;" it is also free 
 from error, arising from difference in the weight depending upon 
 different height or size of the entire body, and it is better than 
 comparing the weight with the entire weight of the body, since 
 obesity and emaciation would considerably disturb the propor- 
 tions. 
 
 Dr. Skae, in the Appendix to the Annual Keport of the Morn- 
 ingside Asylum, for 1854, thus sums up his conclusions: — "The 
 ratio between the cerebellum, with the pons is given at different 
 ages distinguished," and he found in almost every instance the 
 cerebellum in the insane was heavier in relation to the cere- 
 brum, than it is in the sane. This remarkable result has been 
 further investigated. It occurs naturally to our mind, however, 
 whether it was the cerebellum was heavier or the cerebrum 
 Hghter than normal. 
 
 On this point Dr. Skae says, " that whereas the relative 
 weight according to Dr. Peacock, in the sane is 1 to 7, in the 
 insane he found it to be as 1 to G-7. Mr. Clapham, West Biding 
 Reports, analyses 1200 cases with regard to this point, how- 
 ever, and his results do not agree with Dr. Skae's in every 
 respect. 
 
 He found that the average proportion at all ages to be 1 to 
 7-68. 
 
230 LECTURES ON MENTAL DISEASE. 
 
 In General Paresis 1 to 7-80. 
 
 ,, Idiocy 1 ,, 7"83. 
 
 ,, Imbecility 1 ,, l-'6('). 
 
 ,, Organic Dementia ....!,, 7'57. 
 „ Brain Wasting 1 „ 7-G4. 
 
 Normal . . 1 to 7-G8 
 
 „ Chronic Mania 1 „ 7-72. 
 
 ,, Simple Dementia ....!,, 7-72. 
 
 ,, Senile Dementia 1 ,, 7*80. 
 
 ,, Acute Insanity 1 ,, 7-81. 
 
 ,, Epileptic Insanity ....!,, 7"99. 
 
 The different conditions of disease are arranged in the above 
 table according to the relative ratios of difference. The cere- 
 brum is shown to have a less ratio than the normal in the states 
 of mental weakness, beginning with general paresis ; and 
 a greater ratio than normal, in the more active morbid 
 states. 
 
 In this the results differ in some respects from those obtained 
 by Dr. Skae, they show with him that the cerebellum is rela- 
 tively heavier in the active morbid states, but relatively lighter 
 in the states of mental weakness. 
 
 Mr. Clapham's cases, it is to be observed however, were 1,200 
 in number, which is much larger than those of other observers, 
 and he corroborates Dr. Skae's conclusions in another respect ; 
 of course a preponderance of the cerebrum in relation to cere- 
 bellum may arise from cither, an actual increase of cerebellum 
 or vice versa. Dr. Skae came to the conclusion that there was 
 an actual increase of the cerebellum. In some conditions, Mr. 
 Clapham found that this was so, and notably in cases of general 
 paresis ; and at the same time there was a decrease in the 
 weight of the cerebrum, as compared with the normal. 
 
 In epileptic insanity the contrary was found, in this the cere- 
 brum was about the normal weight and the cerebellum less than 
 normal. 
 
 These general remarks arc mentioned here because it is con- 
 venient to insert the table in this place, but our present use of 
 
ETIOLOGY AND PATHOLOGY OF INSANITY. 23 1 
 
 these data is to examiue tliem in regard to ordinary insanity and 
 it illustrates the imthology of that disease and corroborates the 
 position which has been advanced ; or that in those cases of 
 ordinary insanity, which die in the acute stage, the weight is 
 above the mean— or in the ratios of 1 to 7'8 to 1 to 7"G which 
 itself points to some interstitial change in the cerebral tissue ; 
 the relative weights at the same time show that at the subse- 
 quent stage of chronic insanity and dementia, there is a gradual 
 atrophy supervening. 
 
 Evidence of the same kind is afforded by the examination of 
 the specific gravity of the brain substance. 
 
 I published in January, 1853, a series of experiments, which 
 I instituted relative to the specific gravity of the brain. I was 
 led to undertake the investigation from the unsatisfactory result 
 which had been arrived at by taking the gross weight only in 
 different diseases, and especially in cases attended with delirium. 
 The actual weight of the brain of course varies, not only with 
 the age and height, but with the configuration of the individual. 
 On the publication of my experiments on the brains of persons 
 dying with and without cerebral symptoms, Dr. Skae, of the 
 Eoyal Edinburgh Asylum, instituted similar experiments rela- 
 tive to the brains of the insane, and the following are the con- 
 clusions at which he arrived : — In his own words " the specific 
 gravity of the gray and white substance of the brain was taken 
 in eighty cases, of which thirty-nine were males, and forty-one 
 females. A glance at his table, will show that the specific 
 gravity in the cases of insanity was almost uniformly higher, 
 and this observation applies to both the gray and white 
 matter. 
 
 " In Dr. Sankey's cases the lowest specific gravity of the gray 
 matter was 1-028, in the asylum ones the lowest was 1-030. 
 The highest in Dr. Sankey's was 1-046, in men 1-049, while the 
 average specific gravity in all the cases of both sexes was in the 
 former 1-034, in the latter 1-038, showing an increase in the 
 cases of insanity. 
 
 " The lowest specific gravity of the meduUary substance in 
 the healthy brain was 1-032, in the diseased 1-032. The high- 
 est in the healthy 1-048, in the diseased 1-053. The mean of 
 all the cases in the sane, 1-041, and 1-042 in the insane, show- 
 
232 LECTUKIiS ON MENTAL DISEASE. 
 
 iug an increase in Bpecific gravity of the white matter in cases 
 of insanity. 
 
 " The results," Dr. Skae goes on to say, "are corroborative 
 of those obtained by Dr. Sankey, in his observations at the 
 London Fever Hospital ; where in all the cases comphcated 
 with cerebral symptoms of a grave character preceding death, 
 Buch as convulsions, strabismus, paralysis, and utter uncon- 
 sciousness, the specific gravity was of higher average, being both 
 in the gray and white matter 1*041." 
 
 The cases of Dr. Skae are of mixed kinds, they do not there- 
 fore show much more, than that the cerebral substances in 
 insanity of all kinds, on the average, is higher than in health. 
 In the table (p. 226) I have separated the different kinds and 
 stages of disease, and by this mode the same result and that the 
 brain substance is involved, is shown, that in the acute cases 
 the grey matter was but slightly increased. In chronic cases 
 it went down to normal, and in imbecility it fell still lower. 
 
 Dr. BuckuiU also published his investigations on the same 
 subject — and here I must make my fiiend the proper amend for 
 in the previous edition of my lectures, I was not aware that he 
 had published a second series of experiments, in 1855, and 
 stated that he had uQt separated the gray from the white matter 
 in his experiments. In his second paper this was done, and I 
 quote here from it. 
 
 In examining his tables there are several prominent facts ; in 
 one case the specific gravity of the gray matter was as high as 
 1*048, which is much liigher than I have ever met with in my 
 cases, and it occurred in a case of mania with phthisis — and 
 there are several, some eight or ten cases of greatly increased 
 density, connected with epilepsy and general paresis ; and aU 
 the cases, as a rule, ai)pear to have a higher density than 
 normal. 
 
 But the general average of his G3 cases, shows a density of the 
 white substances rather below that which I found in sane brains. 
 Dr. Buclmill remarks, that the lowest density was found in con- 
 nection with a watery and oedematous condition of the brain. 
 He remarks, that a brain may have a low specific gravity from 
 an increased quantity of fat globules in its tissue and doubtless 
 a high specific gra\'ity is due to protein compounds, the result 
 
ETIOLOGY AND PATHOLOGY OF INSANITY. 233 
 
 of liypersemia. lu my publislietl cases from the Fever Hospital, 
 all tlie high densities separated by an abrupt line all the cerebral 
 affections from the rest of the cases. 
 
 Our argument here is thus borne out by this mode of examin- 
 ation, viz., that while little is visible often in the recent cases of 
 insanity if the patient is cut off by accident in an early stage, as 
 by suicide, and very httle is to be discovered by the naked eye 
 or ordinary modes of examination, nevertheless there is a pro- 
 cess probably going on which eventually leads, first to the 
 increased density, due to protein interstitial matter, and after- 
 wards to diminished specific gravity, caused by degeneration of 
 such deposition, an order of events observed in the diseases of 
 other organs. 
 
 The facts, it must be allowed, do not place this on such solid 
 basis as could be wished, since the cases have not been separated 
 according to their character or duration. 
 
 My own 36 cases are open to the same objection, but so far 
 as they go they show alteration in the different stages ; in the 
 acute stage the gray substance was slightly above the average, 
 in eight chronic cases it fell below the average, and in imbecility 
 it sank still lower. 
 
 The result of these experiments tend to the conclusion that 
 there is in the early stages of some cases, dying in the acute 
 stage, some increase of density in the cerebral tissues which is 
 reversed in chi-onic cases both in insanity proper and general 
 paresis. 
 
 The next mode of examining the brain and its membranes 
 which is open to us is the microscopical. A very considerable 
 amount of labour has been expended in research by this means. 
 
 In all microscopical examinations it may be frankly admitted 
 that much toil and experience are necessary, so that in admit- 
 ting the description of appearances of an observer, a consider- 
 able latitude for eclecticism is legitimate. Always remembering 
 at the same time that an observer may obtain facts from a par- 
 ticular preparation, by a close and attentive study of his own 
 specimens, which would not be obvious at first view to another. 
 Nevertheless to admit any microscopical appearance as proved, 
 it should be supported by unequivocal corroboration. I have 
 myself given much attention to this mode of investigation, and 
 
234 LECTURES ON MENTAL DISEASE. 
 
 the following is the result of my own experience collated with 
 the observations of others. 
 
 We may divide the microscopical examination of the brain 
 and appendages, in ordinary insanity, into two parts. 
 
 1. The condition of the cerebral tissues. 
 
 2. The state of the blood vessels. 
 
 1. The microscopical and morbid characters of the cerebrum 
 must obviously depend much upon the stage of the disease. 
 
 In the acute stage of the disease, I cannot say that my own 
 microscopical investigation have given any result, which I could 
 call unequivocal. It may, however, be inferred from what is 
 found in chi'onic cases, both by microscopical and ordinary ex- 
 amination, that pathological changes in their cerebral tissue com- 
 mence at an early period of the disease, but the same kind of 
 evidence negative and positive shows, I think, that the primary 
 symptoms are due to altered condition in the blood circulation — 
 a condition not yet, by our present means of examination, capa- 
 ble of demonstration. In the microscopical examination of the 
 cerebral substance in chi-onic insanity, the changes are more 
 obvious and have been specially studied by several observers, 
 particularly by Dr. Major. We may divide this enquiry into 
 the condition of the neuroglia and the condition of the cells. 
 
 As regards the neuroglia, the normal appearance of this cannot 
 be said to be settled. It is described by some to be amorphous, 
 by others finely granular ; its functions are also variously given, 
 by some as a connective tissue and by others as nerve elements. 
 
 It has been suggested that its granular appearance seen in 
 mounted preparations, is due to the hardening medium, clu-omic 
 acid, spirit, &c. It is not easy to say whether the appearance is 
 not due rather to the management of the light, at all events 
 under certain circumstances a finely granular appearance may 
 be seen as a kind of stroma (neuroglia,) in which the cells and 
 vessels are imbedded. 
 
 It has been stated that iu acute insanity the number of the 
 smaller cells are increase. Undoubtedly, in some examples 
 taken from brains of patients dying in acute insanity, the cells 
 appear more numerous than in others ; but if a section is 
 thicker in one preparation tlian in another, there would be an 
 appearance of a greater number of cells present. Besides, since 
 
ETIOLOGY AND PATHOLOGY OF INSANITY. 235 
 
 the normal distribution of cells differ in different localities, to 
 base any deductions upon degree in this respect is scarcely war- 
 rantable. 
 
 After a careful examination of the subject with specimens, 
 and comparison of my own results with the views of different ob- 
 servers, I think that all we should be justified in concluding is, 
 that in the microscopical examination of the brain, as to cells 
 and neuroglia, that in acute cases nothing as been as yet ab- 
 solutely decided. 
 
 On the other hand, it is quite true that appearances are 
 to be met with in many such cases, which indicate a possible 
 commencement of structural change ; but neither with such 
 uniformity or constancy as to enable us to fix upon any definite 
 appearance as the character of this stage of the disease. 
 
 In cases of chronic insanity, the microscopical characters 
 often seem quite normal, as regards both cells and neurogha ; 
 but when the patient has become demented and reached a great 
 age, I have seen certain changes which I formerly supposed 
 might be due to disease, but which were quite as likely to be 
 normal or due to senile decay. The change was observed in the 
 large cells. In several cases some of these were found to be 
 unusually large, and presented an inflated appearance at the 
 central extremity. On several occasions I have seen a degen- 
 eration of the ceU-body, the body containing finely granular 
 matter of dark colour, which was collected together, leaving a 
 vacuity in one angle of the cell ; in some, the cell-body instead 
 of being angular was more or less rounded in shape, and pre- 
 sented an appearance described by Dr. Major as pigmentary de- 
 generation. Dr. Wiglesworth describes similar appearances in 
 cases of melancholia with stupor (attonita), Journal of Mental 
 Science, October, 1883. 
 
 I think also that in most chronic cases the smaller and 
 more superficial cells appear particularly numerous, small, and 
 crowded. Yet my general conclusion is, that so far as I have 
 had an opportunity of examining, I could not say that any de- 
 finite or special lesion or appearance can be fixed upon as the 
 essential pathological change in either the cells or the neuroglia. 
 
 I would adopt a remark by Dr. Major, who writes {West 
 Piiding licjwrts, vol. iv.) : "After giving in detail the result of 
 
236 LECTURES ON MENTAL DISEASE. 
 
 my examination of various cases, I was driven to the conclusion 
 that in all (I would say many) I was able to discover decided 
 pathological changes ; yet that, so far as my experience had 
 gone, in none could I put my finger on any point and mark 
 it out as being constant and distinctive of the affection to the 
 exclusion of all others." 
 
 2. The state of the blood-vessels in both acute and chronic 
 cases of insanity is, I think, less equivocal, and especially in the 
 chronic case. 
 
 I have seldom had an opportunity of examining the blood- 
 vessels in an acute case of a few weeks' standing ; but in a case 
 which died after a somewhat longer interval, the vessels, all 
 the small arteries to the size of capillaries, appeared simply 
 engorged. 
 
 In chronic insanity, the condition of the small arteries is re- 
 markable, and Dr. Major's description of what he met with in 
 chronic brain wasting coincides exactly with my own experience. 
 These vessels have " acoarseness of appearance" (Plate III, fig. 
 6). They show clearly both an increased cahbre and thickness of 
 walls. When the vessels are separated, by washing out, from 
 the brain tissue, they lie in the field of the microscope like 
 rounded thongs instead of flaccid tubes, the circular fibres are 
 coarser and evidently hyi)ertrophicd, and there is, as Dr. 
 Major expresses it, an enormous multiphcation of the minute 
 nuclei scattered over the whole of the walls (see Plate III., 
 figs. 5 and G). 
 
 If examined in situ, or in their sheaths, there is often found a 
 hyaline membrane thrown out around the vessel. In cases of 
 ordinary insanity this does not appear to be afi'cctod, at all events, 
 to such an extent as is found in general paresis ; it is not ren- 
 dered opaque, nor are the amber granules to be found so fre- 
 quently ; the disease or change appears more confined to the 
 walls of the vessels themselves. I have seldom found anything 
 like varicosity or aneurism in cases of chronic insanity. In one 
 case, however, of chronic insanity which became ataxic, a vari- 
 cosity was discovered. (Plate III., fig. 8). 
 
 So far then as the microscopical examination lets any light 
 upon the true pathology, it seems in my opinion to corroborate 
 
ETIOLOGY AND PATHOLOGY OF INSANITY. 237 
 
 the view I laid down at the commencement, or briefly, that in 
 the early stages the changes may be of evanescent character, 
 and therefore are probably due to a condition of the blood snp- 
 phed to the cerebral organ ; but as the disease progresses, the 
 nutrition of the organ is affected. 
 
 The above results are obtained solely by examination of the 
 calvaria and its contents, an investigation of the other organs of 
 the body, and especially of the glandular or blood makmg 
 organs have to be considered. These may be considered in 
 the order of:— 1, the respiratory ; 2, the circulatory and the 
 digestive organs. 
 
 I must again chiefly rely upon my own cases, since the pub- 
 lished cases, and especially the tabulated cases, deal with every 
 asylum case collectively and irrespectively of the form of 
 disease. 
 
 1. The respiratory organs. — Disease of the lungs, and especially 
 phthisis, was formerly considered to be particularly prevalent 
 among the insane, and if so, the cases would all belong, or in 
 very great majority, to insanity proper. I have met with a case 
 of general paresis comphcated with phthisis, but consumption is 
 not rare in asylum practice in insanity proper. But the ques- 
 tion here is, is it more common in the insane than in the sane. 
 I have arrived at the conclusion that it is not. 
 
 There are various circumstances which must be taken into 
 consideration in examining this question, or an erroneous con- 
 clusion will be the result. 
 
 The following are the remarks on this subject in the first 
 edition of my published Lectures, p. 203 : — 
 
 "With respect to phthisis or tuberculosis, very much has been 
 written to show that it is a very common morbid appearance 
 found in insanity ; there is scarcely a writer on insanity who 
 has not apparently quietly acquiesced in the opinion that it is, 
 beyond all proportion, the most frequent pathological condition 
 met with. For example, Griesinger writes, ' The frequency of 
 tubercle in insanity has been established from observation from 
 the time of Lory to the present day ; that although strict sta- 
 tistical proof is still wanting on this head, its frequency is 
 apparently greater than any other kind of pathological con- 
 dition.' " 
 
238 LECTURES ON MENTAL DISEASE. 
 
 The following is Griesinger's summary on the point : — 
 
 Esquirol states tubercle existed among ) 
 
 the melancholic in the rate of 
 
 J 3. 
 
 
 Calmeil found tubercle in 
 
 2 
 
 or 40 
 
 Webster .... 
 
 
 h 
 
 or 25 
 
 Pinel .... 
 
 
 h 
 
 or IG 
 
 At Vienna 
 
 
 h 
 
 or 33 
 
 Prague .... 
 
 
 2 
 
 5' 
 
 or 40 
 
 Dr. Clouston 
 
 
 h 
 
 or 60 
 
 Palermo .... 
 
 
 ■ A. 
 
 or 45 
 
 Hauwell (Dr. Hitchnian), Fema 
 
 es 
 
 h 
 
 or 20 
 
 Sutherland (St. Luke's) 
 
 
 a 
 11' 
 
 or 27 
 
 or 83 per cent. 
 
 The mortality of the entire population of England from 
 phthisis has varied from 17 to 12 per cent., but since lunatics 
 are almost exclusively adults, the comparison is not a just one ; 
 the comparison should be, of course, with persons of like ages. 
 "The mortality from phthisis," says Dr. Aitken, "produces 
 nearly half of the whole mortahty among the dragoon guards." 
 Again, " The mortality numerically from consumption is much 
 higher than from ajiy other disease in this country." And 
 again he writes : " Amongst the class of society resorting to 
 Assurance Offices, the mortality (from phthisis) seems to be 
 about one half of the whole." 
 
 The above table gives an average of one-third, so that the 
 mortality by phthisis in the sane and the insane does not seem 
 to vary very gi-eatly. But there have been mixed up in this 
 matter two distinct questions, namely, death caused by phthisis, 
 and the discovery of tubercle by post-mortem examination; 
 which latter mode of estimating the frequency of tul)ercular 
 disease yields the higher average. Of course, to know the rela- 
 tive frequency of tubercle in the two states, we ought to compare 
 the same things. In a paper by Dr. Webster, pubhshed in the 
 Medico- Chirurfjical Transactions, tubercle is reported to have been 
 found after death in 29 out of G7 autopsies, or in the proportion 
 of 43 per cent. ; but he does not say that phthisis was the cause 
 of death in any. 
 
 The age most Hable to phthisis is from 20 to 35 (Bristowe), 
 
ETIOLOGY AND PATHOLOGY OF INSANITY. 239 
 
 and this approximates very closely to the age most prone to 
 attacks of insanity {Commissioners Report, 1880). 
 
 Dr. Cloustou also examined carefully into another question in 
 connection with phthisis, and which is of the utmost importance 
 in forming a correct pathology of insanity, viz., whether the 
 conditions of asylum life induce tuberculosis, or whether the in- 
 sanity induces it; and he concludes that long- continued insanity 
 does not tend to the development of tubercle. 
 
 Of other diseases of the lung, the most important are pneu- 
 monia and gangrene. Plastic pneumonia has been observed in 
 many of the insane, and chiefly in those of deteriorated constitu- 
 tion, as in patients with general paresis. Calmeil found it in 
 one-fifth of his cases, and other observers have found it in pro- 
 portions varying from one-fifth to one-ninth. Whether this 
 liabihty is a part of the essence of the mental disease or is an 
 adjunct, or epiphenomenon arising from accidental causes, such 
 as imprudent exposure to varieties of temperature, it is, of 
 course, difficult to determine, and I have no data which will 
 throw any light on the question. It is worthy of remark, how- 
 ever, that the pneumonia may arise as a sequel of a blood 
 disease. 
 
 Gangrene of the lung is certainly a more frequent disease 
 among the insane than among the sane. It is said to occur fre- 
 quently in those who refuse food. In patients who refuse food 
 for any length of time, there is a great accumulation of epithe- 
 lium, or fur, on the tongue, and this causes the breath to have a 
 most offensive odour. We must not therefore conclude without 
 a physical examination of the chest, that gangrene has occurred 
 in the lung. I have known this error of diagnosis to be made. 
 Gangrene also occurs in other organs, as the scrotum ; and it 
 also occurs, as in all exhaustive diseases, from pressure. But 
 the h-equency of gangrene of the lung is a well observed fact, as 
 a special morbid appearance in insanity. 
 
 Gangrene of the lung certainly occurs in ordinary insanity. 
 I have never seen it in connection with general paresis. Pneu- 
 monia from stasis is more frequent in the latter disease, since 
 the patients die from exhaustion, and especially since they he 
 for long periods in one position. When death occurs in acute 
 insanity with lung disease, the symptoms are of a more sthenic 
 character. 
 
240 LECTURES ON MENTAL DISEASE. 
 
 2. The circulatury and dii/estive ortjatis. — With regard to the 
 condition of the oi-gans of circulation, we may firstly cousider the 
 heart, and secondly, the vessels. 
 
 1. As regards the condition of the heart we must hear in 
 mind again the relative liability of cardiac aflfections at the 
 different ages, and ascertain in this instance whether the ages of 
 Hability are not coincident with those of sane people. 
 
 In consulting former authorities on insanity, I find great 
 difference of opinion on the condition of the heart. Thus, Dr. 
 Bucknill writes {Psychological Medicine, p. 589), "Disease of the 
 heart is common among the insane, although GriesLnger affirms 
 that the newest and most reliable statistics show only an average 
 frequency." Still earlier writers vary considerably on this 
 point; thus, Esquirol says it is found in one-fifteenth; Webster, 
 one- eighth ; Bayle, one-sixth; Calmeil, one- third ; at Vienna, 
 one-fom'th ; Guislain, one-sixth. These proportions it must be 
 remembered are calculated from all kinds of cases, are in fact, 
 the result of examinations of persons dying in asylums at all 
 ages, many of whom were doubtless very aged. 
 
 I have no means from my ovm observations of arriving at any 
 conclusion, whether these cases belong to ordinary insanity or 
 to general paresis, '■= but since the latter disease is of much 
 shorter duration than ordinary insanity, and the patients reach 
 a greater age in the latter, doubtless the heart disease was most 
 frequently found in connection with ordinary insanity. Death 
 by heart disease, unlike death by phthisis, does not coincide 
 with the average age of attacks of insanity. 
 
 The relative frequency of death by heart disease in the insane 
 and the sane, was also investigated by Su- C. Hood and is given 
 at p. 114 of Statistics of Bethlehem. He found that the relative 
 number of deaths by heart disease, in the general population for 
 1838, was 1-07 per cent. ; while the ratio per cent, in the re- 
 turns of the Eetreat at York, was G-40 ; in other words heart 
 disease occurred six times more frequently among the insane in 
 York Eetreat, than among the general population. It may 
 be concluded, that the gi-eater number of these lunatics were 
 cases of ordinary insanity, and the majority aged individuals. 
 
 * Dr. Burinan found that the weight of the heart was greater in general pare- 
 sis, than in other forms of insanity affected with dementia. 
 
ETIOLOGY AND PATHOLOGY OF INSANITY. 24I 
 
 Dr. Biu'man in an article in vol. iii. of West Riding Reports, 
 187B, p. 216, has examined the facts and analysed them in an 
 exhaustive manner. His general conclusions are, among others : 
 " Tliat there is a remarkable relation between heart disease 
 and insanity, in that co-existing with the gradual but steady 
 annual increase of insanity, there has been a similar and more 
 than pari passu increase of heart disease." 
 
 " An examination into the state of the heart in the insane as 
 found after death and during life, shows that heart disease in its 
 various forms is exceedingly common amongst them, and pre- 
 sumably much more frequently met with in asylums than out of 
 them." 
 
 As regards the condition of the other viscera, that which is 
 of most importance in connection with the blood-making organs, 
 is perhaps the state of the kidneys ; the older pathologists have 
 differed much on this point. On first entermg upon my medi- 
 cal duties among the insane, I was much struck with the fre- 
 quency with which kidney disease occurred in my autopsies. 
 The statistics on the subject available at that date, gave but 
 a small proportion of renal disease, and which results were 
 due, I think, to a want of due appreciation of what constitutes a 
 morbid condition. These statistics were most of them of a date 
 prior to the investigation of the minute anatomy of the organ. 
 I found adhesion of the capsule to occur in nearly one half of 
 my own autopsies, and besides this there existed in a large 
 number abundant evidences of disease, as atrophy of the cortex, 
 fatty degeneration, waxy disease, and general atrophy. In Dr. 
 Bucknill's review of the subject, he says, that the kidneys 
 were remarkably free from disease in Devonshire ; but quotes 
 Dr. Howden of the Montrose Asylum, who found disease of the 
 kidney in 97 out of 235 autopsies, of which 55 were fatty and 
 31 had cysts, he does not mention adhesion of the capsule. 
 
 An altered condition of the bones throughout the body has 
 not infrequently been observed in old lunatics, but not suffi- 
 ciently often for us to consider it a change connected with the 
 mental disease. Siich a state is due more likely to mal-nutrition 
 generally. An individual who has lived on pauper asylum diet 
 for many, perhaps fifty years, may be readily conceived to be 
 but poorly nourished, he is not only poorly provided with food 
 
 R 
 
242 LECTURES ON MENTAL DISEASE. 
 
 but often deprived of the nntnral instinct, in taking noiirish- 
 ment of any kind.* 
 
 There ia found in some chronic cases of long standing, and not 
 unfrequently, an increased thickening of tlie skull, as well as a 
 diminution of the thickness, but these changes are confined to 
 cases of long standing ; the same condition of increased thick- 
 ness is also occasionally found in general paresis, when that 
 disease has existed three to five years. 
 
 The general risume of all the foregoing may be thus given 
 of the morbid anatomy of insanity proper. During the earlier 
 period of the disease, the symptoms are due to an alteration 
 of the blood, in its quality and in its amount ; next, there is 
 some congestion and interstitial deposit of serum and of protein 
 compounds, then of atrophy of the brain substance, and hypertro- 
 phy of the vessels. The alteration in the vessels is the result of 
 the usual law : at first they resist the influx of the impure blood 
 by contracting, then the heart takes on an increased action to over- 
 come the resistance of the contracted vessels ; the contracted 
 vessels thus called upon to antagonize the heart, gi-aduallv 
 become hypertrophied. At first the symptoms are due to the 
 circulation of impure blood, they next are due to excessive 
 supply, then they evidence the imperfect functions of an altered 
 cerebral tissue. 
 
 On looking over my notes of microscopical appearances in 
 chronic insanity, I find the following changes mentioned. 
 
 A. M. M., Jan. 22, 1863. Chronic insanity, fatty dpgeneration of cam. colnni. 
 of heart. Arteries of the brain opaque and thick, and under microscope show 
 irregularly disposed longitudinal fibres and fibrous looking matter- On some 
 portion of the small artories this gives the artery the appearance of an elongnteil 
 aneurism, but by careful focussing it appears the lumen of the vessel is not 
 altered ; the enlargement is due to fresh matter on the exterior of the vessel- 
 There are scattered a few oil globules. Plexus choroid are studded with hard 
 rounded opaque bodies, soluble with effervescence in weak acid. 
 
 Burton. Senile imbecility. Injected with a solution of carmine. Several of 
 the capillaries coloured with injection, cerebral substance is interspersed with 
 spots of more or less oval shape, which are more transparent than the rest of 
 the substance iu which they seem imbedded. Their outline is not defined they 
 
 • The cost ut food in public asylums varies from 3s. Gd. to 4s. fid. per week, 
 or .^ay from 6d. to 8d. per day per patient, and out of which the staff of servants, 
 &c., are fed. 
 
ETIOLOGY AND PATHOLOGY OF INSANITY. 243 
 
 appear to be lost into the anrrounding brain substance (Colloid bodies), they 
 are not turned purple by iodine, but are stained brown. After soaking in ether 
 they can no longer be discovered, but the section is shrivelled and nothing posi- 
 tive can be averred about it. A second portion washed in ether and water 
 mixed, the same bodies are found but they appear less distinct — the section is 
 not corrugated. Iodine turns the whole brown. In all the sections there are 
 small aggregations of particles collected in little heaps, and are rather irregularly 
 dispersed and remain after maceration in water and iodine and ether ; on the 
 addition of acetic acid they slowly dissolve. 
 
 A portion of the brain mounted to show vessels, which are seen to be uni- 
 versally hypertrophied. (Plate III., fig. 6)- 
 
 A. K. Insane many years and in asylum 21 years. Sister also in the asylum. 
 Chronic insanity. Capillaries cleared by washing off cerebral matter under a 
 stream of water. Numerous oil globules, apparently imbedded in the walls of 
 the vessels — query fatty degeneration of the arteries. Very few branches are to 
 be met free from this appearance, here and there are a collection of similar par- 
 ticles congregated together and occupying the angle of a branch. The fibrous 
 coat of the vessels at places appears irregular; the walls are thicker and the cut 
 mouths of the vessels remain open — no bumplike enlargement found. Some of 
 the vessels isolated by washing and afterwards stained, show a thickening 
 down to the smallest branches. Some of the branches are tortuous or slightly 
 so. 
 
 Mr. H., a case of chronic insanity of many years duration. Died Dec. 25, 
 1863. The vessels of the pia mater and cortical substance are transparent, and 
 give a clear view of the interior or tube. The circular fibres are well marked and 
 are hypertrophied one fifth of the whole vossel. Seen in profile, these circular 
 fibres appear like irregular circular bodies of different size, by focussing they 
 are seen to give transverse stria on the inner coat of the vessel. Some of the 
 smaller vessels exhibit numerous nucleated cells on this surface. Sections of 
 gray matter exhibit, scattered throughout, very numerous and minute granules, 
 of uric acid colour; congregated in groups and arranged also singly. They are 
 not affected by acetic acid or soda. Some of them are iridescent. They are 
 pretty uniformly distributed to every part. None of them appear adherent to 
 vessels. 
 
 III. The fcitliology or resume and interpretation of the morbid phe- 
 nomena. — In conclusion, the question which we have to answer 
 is, what constitutes the true j)athology of ordinary insanity or in- 
 sanity proper ? It was stated at the outset, that the opinion 
 which I had arrived at was, that the symptoms and morbid 
 anatomy show that the disease consists in a morbid state of the 
 blood, or of the processes concerned in nutrition. 
 
 We have now to review the evidence which has been brought 
 forward and show how it supports this conclusion. The exam- 
 ination of this question may be divided into two parts. 
 
 1. What evidence is there that the blood is morbid ? 
 
 k2 
 
244 LECTURES ON MENTAL DISEASE. 
 
 2. How an altered condition of the blood can produce the 
 phenomena observed. 
 
 With respect to the first question, it is true that we are not in 
 a position to detect the change in the blood, whatever it is, 
 either by chemical analysis or by the microscope ; but we may 
 obtain proofs from the ravages which an altered condition of the 
 blood is known to produce. 
 
 I must quote here the words of Dr. George Johnson from the 
 Patholopical Transactions, in support of what I am about to sub- 
 rait as e-^adence of this altered condition of the blood. 
 
 Dr. George Johnson writes : — " 1st. That in advanced stages 
 of the various forms of chronic Bright's disease, there exists, in 
 association with hypertrophy of the left ventricle of the heart, a 
 true hypertrophy of the muscular arterioles throughout the 
 body. 
 
 " 2nd. That the hypertrophy of the heart is caused by an 
 impediment to the circulation resultuig from contraction of the 
 systemic arterioles, excited by blood contamination, consequent on 
 degeneration of the kidney. 
 
 "Bernard, Brown- Sequard, and others, by a laborious series 
 of experiments, established the doctrine which is now univer- 
 sally accepted by physiologists, that the function of the mus- 
 cular arterioles, under the guidance of the vaso-motor nerves, 
 is to regulate the blood supply to the various tissues and organs. 
 The contraction of the arterioles narrows their canals, lessens 
 the blood supply to the capillaries, increases the arterial tension, 
 and excites more forcible and frequent contractions of the left 
 ventricle to overcome the obstacle. The function of these con- 
 tractile tubes appears to be sufficiently well expressed by com- 
 paring them, as I some years since ventured to do, with a stop- 
 cock." 
 
 The title of Dr. Johnson's paper is "On the changes in the 
 blood-vessels and in the kidney in connection with the small red 
 gi'anulnr kidney." He goes on to explain how the cause of the 
 hypertrophy of the left ventricle of the heart is so frequently asso- 
 ciated with advanced degeneration of the kidney, and it occurred 
 to him that the explanation might be found in the state of the 
 muscular arterioles, which being stimulated to undiie contrac- 
 tion by the morbid quality of the blood, impede the circulation 
 and thus give rise to cardiac hypertrophy. 
 
ETIOLOGY AND PATHOLOGY OF INSANITY. 245 
 
 The series of events is then as follows : — Impaired function of 
 kidney ; impure blood ; resistance to its circulation by the arte- 
 rioles ; increased action and hypertrophy of the heart ; increased 
 resistance and hypertrophy of arterioles. 
 
 Taking this as established, as I believe it to be, wo may dra^\ 
 tliis conclusion, that hypertrophy of arterioles shows impurity of 
 the cii'culating fluid. The same impure state of blood induces, 
 or at least is found in conjunction with, a morbid condition of 
 certain organs connected with the blood-making processes, as the 
 heart, liver, kidneys, &c. That such impure blood also leads to 
 mal-nutrition generally is obvious. 
 
 In our examination of persons dying in the different stages of 
 ordinary insanity, we have exactly all the evidence of the same 
 changes in the system which, as Dr. Johnson says, are induced 
 by an altered condition of the blood, or that alteration of it, 
 which takes its origin in disease of the kidneys. 
 
 Doubtless, the changes in the quality of the blood-making 
 organs may be produced by other means than through disease 
 of the kidneys ; the kidneys are but a portion of the appara- 
 tus on which a purity of the blood depends. The kidneys are 
 depurative, their office is, as it were, removed from the first 
 source of the blood-making organism, and certainly they are not 
 the only organs on which a healthy cu'culatory fluid depends. The 
 alimentary canal stands, as it were, nearer to the threshold of 
 the apparatus, if the first process of assimilation is in fault, it 
 may requii-e the depurative action of the kidneys to correct the 
 fault, and doubtless theii- arterioles, and the arterioles of the 
 whole system will be affected by the presence of an impure state 
 of the blood. In our examination of the viscera in ordinary in- 
 sanity, we find the tracks of this unhealthy blood : — At first, 
 or in the earliest stages, the most we find after death is mere 
 disturbance in the quantity of blood in the different organs and 
 in the brain, and in most cases dying quite early w^e can detect 
 nothing at all. The traces of arteriole contraction ai-e obhter- 
 ated in the act of dying, no hypertrophy having as yet been 
 produced. But when the disease continues through several 
 years, then it is common, and indeed it is the rule, to find just 
 those very organs showing lesions which are affected by impure 
 blood — the kidneys and the heart, as shown in the previous 
 
246 LECTURES ON MENTAL DISEASE. 
 
 pages ; and when the dieease is old, very often the arterioles of 
 the brain arc also found variously diseased. 
 
 It is not meant that insanity is a disease of the kidneys, far 
 from this. I consider that disease of the kidneys, where it 
 exists, is only one phenomenon in the train of the morbid pro- 
 cesses ; it is not universally found to be present, though accord- 
 ing to my own observations it is very frequently. So likewise 
 the heart lesions are but consequences of long- continued de- 
 terioration of the blood. Disease of the heart or kidneys 
 is not found as a constant in recent cases, nor is the altered 
 state of the walls of the arterioles constant. The condition 
 of the blood must continue some time before it Lrings about 
 such lesions. In disease of the kidneys leading to hj^pertrophy 
 of the heart, the kidney disease is the primary affection, and 
 possibly the lesion may commence by structural change in that 
 organ, and the impurity of the blood may be the consequence of 
 such primary kidney disease. In insanity it is rather the oppo- 
 site course that occurs. The changed condition of the blood is 
 due to an error of assimilation, and when the kidney becomes 
 involved it is probably, or quite as likely, a secondary result, in- 
 duced by the state of the blood. 
 
 At the risk of seeming to reiterate the statement, I would 
 desire to say, in other words, that I do not consider the true 
 pathology of insanity to have any necessary relation to kidney 
 disease ; but when kidney disease is found it shows there has 
 been an alteration of some kind in the quality of the blood. In 
 the course of mental disease the kidneys may become struc- 
 turally altered or rather their arterioles may ; but such a con- 
 dition is not a necessary change. There may be increased 
 action for a while of the arterioles without actual hypertrophy 
 of the walls, and it seems more hkely that hypertrophy would 
 not occur till a late period, and this is what is observed on 
 examination after death. In recent cases no change is observ- 
 able in the brain or its vessels. The hypertrophy is discoverable 
 only in chi'onic cases, and degeneration in the last stage of all. 
 Plate III, fig. 4 shows the hypertrophy of the arterioles 
 in one stage, and fig. 3, in the last stage ; and tho other changes 
 of the arterioles, as atheroma, or other degeneration, are only 
 subsequent changes, and are not as in kidney disease, universal. 
 
ETIOLOGY AND PATHOLOGY OF INSANITY. 247 
 
 The Bymptoms as well as the appearances after death bear 
 out the same conclusions. In the early stage of ordmary in- 
 sanity, the mental change is one of degree, not kind. It shows 
 an inactivity of the organ and which I explain by the corrective 
 action of the arterioles ; the blood not being of healthy quality, 
 the stopcock action inhibits the supply, the patient's mental con- 
 dition is one of torpid action, the torpidity of melancholy ; if 
 roused the patient's reasoning faculties appear unaffected, though 
 they quickly relapse into apathy. So long as the arterioles can 
 thus act beneficially and control the influx of the impure 
 blood, there is Uttle fundamental change in structure or func- 
 tion, but after a period more or less brief, the activity of the cir- 
 culation may be restored in either of two ways, by a gradual 
 improvement in the quality of the blood, when the signs of res- 
 toration to health will appear : or secondly the activity of the 
 circulation may be changed, by the yielding of the muscu- 
 lar contraction of the arterioles, or a forcible impulse a tergo 
 may overcome their contraction, and thus the impure blood may 
 circulate. In this latter case, the function of the brain would 
 show a deviation from the normal and eventually the structure 
 also. Should no improvement in the blood take place, of course 
 the nutrition would be interfered with and degenerative pro- 
 cesses commence. 
 
 2. With respect to the second part of the question or how it 
 can be shown that an altered condition of the circulation can 
 produce the phenomena observed, it has already been pointed 
 out in the preliminary statement, that foreign products intro- 
 duced into the circulation produce certain known abnormal effects. 
 It is also a very well established observatien that in certain 
 cases of ordinary insanity, as in folie circulaire and in those which 
 have the lucid interval, that a state of depression alternates 
 very rapidly with a state of exaltation or excitement. If we ad- 
 mit that the act of cerebration depends on the organism at all, 
 which is our standpoint, we are driven to the conclusion that 
 the integrity of the function must rest between the nerve tissue 
 on the one hand, and the blood (or nutrition) on the other. To 
 account for the change of function we have these two factors, 
 the phenomena we are seeking to explain is a rapidly changing 
 one, its cause should therefore be a changeable agent : the 
 
248 LECTURES ON MENTAL DISEASE. 
 
 change too is not oiily rapid, but it is ofteu transient, the cause 
 therefore must bo in the function of cliaugeable kind. In the 
 circulation we have such kind of agent, nerve tissues are perma- 
 nent ; for a changing eflect we must seek a changing cause. 
 
 Admitting that the whole phenomena of the disease point to 
 an altered state of the circulation, it may yet be asked is this 
 change in the quality or quantity of the cu-culating fluid. 
 
 If the phenomena are due to a deficient amount of blood, the 
 deficiency must be only local, as a condition of general anaemia 
 is not a phenomenon observed. If the deficiency is local there 
 must be a local cause and not a general one. 
 
 The cause, however, appears to be general as proved by the 
 state of the organs found in the old chronic cases after death. 
 If therefore, the ultimate cause is general, it must be in the 
 quaUty of the blood in circulation. 
 
 The altered quality may be sui yeneris as all altered condi- 
 tions of the blood do not produce insanity ; or otherwise, the 
 nerve tissue may be more obnoxious to the action of impure blood 
 in one individual than another, and heredity is a well-known 
 remote cause of insanity. 
 
 The changes which an impure circulation would produce in 
 the organism may be, for a time more or less long, quite tran- 
 sitory, and leave no'discoverable lesion after death ; but no organ 
 can be furnished for an unhmited time with impure blood with- 
 out suffering in its nutrition. And in old cases such changes of 
 defective nutrition are found. Impure blood too, need not be of 
 uniform impurity, it would change from time to time ; it may 
 yield to inherent curative powers for a time, and from time to 
 time give the phenomena of lucid interval and the alternation 
 of states described. 
 
 It may be sufficient to say, that, with this impaii'ed condition 
 of the blood, the function of cerebration is imperfectly performed. 
 It seems highly probable that this is so in the following way : — 
 
 The earlier phenomena of the disease may be due to the im- 
 purity only, or the phenomena may be due jointly to the impurity 
 itself, and to the stop- cock action of the arterioles ; both of which 
 would be evanescent and not to be detected after death. Or 
 the disease going on towards mania, the stop-cock action 
 may be overpowered by a vis a toyv, and excessive action or 
 
ETIOLOGY AND PATHOLOGY OF INSANITY. 2 19 
 
 excitability of the cerebral tissue, would result. But, as pointed 
 out by Dr. Wigleswortb, {vide p. 97) it is highly probable that 
 there is a coiitiuous development of nerve elemeuts. If the 
 process of evolution impHes a perpetual superposition of high 
 upon low centres of co-ordination, so that those which were at one 
 stage of development, the highest centres, become, at a more 
 advanced stage, subject to the control of still higher centres, 
 and are themselves relegated to an inferior position, it would 
 result, that the younger centres developed, under unfavourable 
 ch'cumstances, would be less efficient in action. Or to adopt the 
 the mode of expression of Dr. Hughlings Jackson in his Croonian 
 Lectures for the present year on Evolution and Dissolution, 
 " As each normal act or thought is, or signifies the fittest state 
 of the topmost (or newest) layer of the highest centres, the 
 normal highest level of Evolution ; if this layer be ^ rendered 
 fuuctionless, this would be Dissolution ; to which the patient's in- 
 sanity would answer. His positive mental symptoms are still 
 the survival of the fittest states," are " survivals on the lower, 
 but then highest level of evolution," and when this inefficiency 
 was carried to great degree or extent, the state of incoherence 
 and imbecilitv would result. 
 
Section VII. 
 GENERAL PARESIS. 
 
 The term Paresis; a distiiut species ; different viewn n-latiii^,' to this — Doctrine 
 of Unity and Duality —Definition, Dr. Mickle's, Author's— Preliminary 
 statement — Symptotoatology, typical case described — First Stage, diagnosis 
 in early stage — Second stage, phenomena of— Acute progress of symptoms 
 — Chronic course — Fractures — Various symptoms, kleptomania, delire des 
 grandeurs — Physical signs, — Optic disc — Motor difficulties — Remissions — 
 Third Stage — Reflex symptoms, varieties in the disease — Disease likely to 
 be mistaken for General Paresis. 
 
 Class A. — Idiopathic Disease. 
 
 Subdivision fa) Pathological. 
 
 2. General Paresis.-^- History. — The next division of the sub- 
 ject, it will be seen by reference to the diagram, p. 108, is that 
 of General Paresis. 
 
 This form of mental disease is now pretty generaUy admitted 
 to be distinct from ordinary insanity. When I first became con- 
 nected with this special subject, the question was still a mooted 
 one. In a paper in the Juurnal of Mental Science, I reviewed the 
 question and arrived at the conclusion that the two forms of 
 mental disease were distinct; at that period the French patholo- 
 gists advocated this opinion, while the German advocated the 
 opposite and considered that the motor symptoms were merely 
 epiphenomena engrafted upon an ordinary case of insanity. As 
 the question may now be considered settled, there is less occa- 
 sion to discuss it to any extent, but a statement of the grounds 
 for the conclusion that the two are separate, will assist in the 
 diagnosis. 
 
 The question of the nature of general paresis occupied the 
 
 * The term Paresis, or General Paresis, was first proposed in this country by 
 Dr. Ernst Salomon, a Swedish physician, who visited England in 1862 and 
 wrote an article on the subject in the Journal of Montal Science. He remarks 
 that the term general paralysis is singularly inappropriate, for one who is para- 
 lysed universally is dead. He therefore suggested the term paresis (5rafi<r/,-), 
 the meaning of this word in some lexicons is given as an incomplete paralysis. 
 The word paresis has now become more common for such a condition, and by 
 joining with the term general the phenomena of the disease is correctly indi- 
 cated. It has been suggested to me that chalasis (xeiX.etrit) might define the 
 case equally well if it were wished to give the disease a special nomenclature. 
 
GENERAL PARESIS. 25^ 
 
 attention of the pathologists of France very widely, from 1822 
 to 1846 — 50. The following account is extracted from Recher- 
 ches sur hi Fvlie Parahjtiqac. of M. Jules Falret. 
 
 The subject was studied with great care in 1822 by M. Delaye 
 and in 1826 by M. Calmeil and M. Bayle. Their attention it 
 seemed Avas directed to the question by a note by Eequirol, and 
 it was found also that Haslam in England had alluded to the 
 disease in 1798.^'= (Mickle). By MM. Foville, Parchappe, 1838 to 
 1841, and M. Baillarger in 1846 to 1847. MM. Sandras, Brierre 
 de Boismont, Duchenne also wrote, and in 1853 M. Falret says : 
 As a resume of this question, there seems, at this time 1853, 
 four principal opinions upon the nature of this disease. 
 
 1. The oldest is, that the paralysis is a simple complication 
 and even a mode of termination of insanity ; this was held by 
 MM. Delaye, Calmeil, and Georget. 
 
 2. The second view held was that it was a distinct and special 
 form of mental disease, characterised both by mental and physi- 
 cal phenomena ; this was maintained by MM. Bayle, Parchappe, 
 and Duchenne de Prague, 
 
 3. The third set of pathologists considering only the paralysis, 
 confounded in one class cases with, and cases without, mental 
 symptoms, as MM. Eequin, Baillarger, Lunier, and Hubert 
 Kodriguez. 
 
 4. Another opinion advocated by MM. Sandras, Brierre de 
 Boismont, and Duchenne de Boulogne, is that there are two 
 prmcipal species of general paralysis, one with mental aliena- 
 tion and one without. 
 
 In examining this question for myself, it seemed to me that 
 
 * That the phenomena had been observed long before Haslara's time, appears 
 evident from the following taken from Willis who wrote in 1672. 
 
 " Observavi in pluribus, quod, cum cerebro primum indisposito, mentis hebe- 
 tndine, et oblivione, et deinde stupiditate et fiupuffn afficerentur, postea in para- 
 
 lysin (quod etiam praedicere solebam) iucidebant propterea enim prout 
 
 loca obstructa magis, aut minus ampla fuerunt, aut paralysis universalis, aut 
 hemiplegia, aut membrorum resolutiones qusedam partiales accidebant ... . " 
 
 "Particulse oppilativse ^ eerebro delapsse, inque medullam oblongatnm pro- 
 vectse, nervos quarundum faciei partium musculis destinatos subeunt, inque 
 ipsis spirituum vias obstruendo, linguse paralysin, mode in his, aut illis, ocu- 
 lorum, palpebrarum, labiorum, aliarumque partium musculis resolutionem 
 pariunt." 
 
252 LECTURES ON MENTAL DISEASE. 
 
 admittiug fully us we must do, that there are cases of motor 
 paresis (or incomplete paralysis), which are general as re- 
 gards the motor fuuctions, hut with complete mental integ- 
 rity, that we may at once place such cases aside, they at 
 all events do not belong to mental disease, and reserve the term 
 general paresis for the mental disease only. 
 
 And this we are fully entitled to do, for the word 'general' 
 embraces the mental functions in the paresis, and a state of 
 paresis, not including these is not ' general,' though we might 
 call it a motor paresis. 
 
 There remains after eliminating the non-mental cases, the 
 question with regard to general paresis, whether general paresis 
 is a disease, sui tjeneris, or merely a variation in the symptoms of 
 ordinary insanity. That, as we see in certain cases the mental 
 disease terminates in the annihilation of the intellectual facul- 
 ties, so, in other cases, the disease may terminate by affecting 
 the motor functions. 
 
 The following were the facts which led to my conclusion, 
 that it is a distinct species of disease, which I extract from my 
 previous edition of these lectures. 
 
 1st. It appears to me that if the paretic symptoms are mere 
 epiphenomena, then the duration of the disease should be longer 
 in general paresis than in insanity generally ; but the reverse is 
 the fact. 
 
 2nd. If the motor symptoms are merely, as it were, ingrafted 
 upon ordinary cases of insanity, then cases of second and thu-d 
 attacks should be equally liable to have the paretic symptoms in- 
 grafted upon them as first attacks. But such is not found to be 
 the fact ; at HanweU I admitted 456 patients in then- second, 
 third, or fourth attacks, and if these had motor symptoms, in 
 the same proportion as the primary attacks, there ought to have 
 been twelve cases of paresis among them ; but there was not 
 one. There were five among the general paretics who had been 
 re- admitted, but they had not been discharged as cured, so that 
 the attack was not, in fact, a second attack. 
 
 3rd. If the paretic symptoms are epiphenomena, they should 
 occur as frequently among the old inmates of asylums as among 
 the more recent cases. If, indeed, these symptoms are to moti- 
 lity what imbecihty is to the intellectual faculties, we ought to 
 
GENERAL PARESIS. 253 
 
 find general paresis more frequently developed in the old cases 
 
 tlian in the recent ; hut such in not the case. 
 
 4th. If the disease is identical with other forms of insanity, 
 and the paresis a mere accident, then the frequency of the pre- 
 disposing causes should he the same in all cases ; whereas I 
 found in my paretic cases hereditary predisposition existed in 
 14| per cent, instead of 20 per cent, among females, and 17^ 
 per cent, instead of 22 per cent, among males ; and in examin- 
 ing into the evidence of hereditary predisposition in paresis there 
 was found to be evidence of paralytic symptoms in many of those 
 from whom the predisposition came. 
 
 5th. If general paresis is one and the same disease as insanity, 
 then in those instances in which several members of a family are 
 insane it should happen that some should be found with paretic 
 symptoms and some without. There were fifty- five patients in 
 Hanwell related by blood to other patients also under treatment. 
 There was but one also who was an epileptic, with motor 
 paresis, the niece of whom was also in the asylum. The niece 
 was affected with epilepsy, but remained without motor symp- 
 toms during the time she was under my observation. 
 
 Lastly, general paresis, besides the difference which it mani- 
 fests to insanity generally, in affecting the sexes, the different 
 classes of society, and different localities to a different degree, 
 also appears to affect individuals of a peculiar temperament. 
 Among the patients affected with it, we find chiefly those who 
 have lived a fast life, reckless, imprudent individuals, who seem 
 from their history to have been swayed through life by their 
 lusts and passions. In going through the cases of these patients 
 it is remarkable how many of them had led irregular lives, and 
 especially had been guilty of sexual impropriety of some sort."'' 
 Tlie above was written in 1 863. 
 
 The question, however, will be better understood after the 
 consideration of the symptoms, course, and progress of the dis- 
 ease, and the appearances found after death. 
 
 Nearly every writer who has described the disease has divided 
 
 * My paper appeared in the Journal of Mental Science, Jan., 18f>4, and was 
 translated by Dr. Rousjselin in the Annales Medico Ps^/chologiqites, in March, 18(>o. 
 Dr. Salomon's paper On the Pathological Eletne^it^ of General Paresis, which 
 it examined, appeared in (lie same Jonrnal, Oct., 1862. 
 
254 LECTURES ON MENTAL DISEASE. 
 
 it into three or four stageR. This, it is unneceRsary to say, is 
 merely a devise for facilitating the description. The charac- 
 ters of the disease vary in different cases which raay be due to 
 various causes, such as variation in the precise sent of the lesion 
 and the different constitutions of the subjects attacked. It noed 
 scarcely again be insisted upon that the description of any dis- 
 ease can only be relatively true. We must deal in the abstract 
 to give an account, which would embrace all the important phe- 
 nomena, but our description should include the essential char- 
 acters of the disease. 
 
 Dr. Mickle, the latest writer and almost the only one in this 
 country, who has devoted a whole work to the disease, gives the 
 following description of it. 
 
 " General paralysis (paresis) is a disease of the nervous system, 
 especially of the brain ; marked clinically by : — 
 
 1. Certain general disorders of motility, viz., ataxy and finally 
 paresis, usually following a certain order, course and develop- 
 ment, and especially obvious in the apparatus of speech, and of 
 locomotion also but in less degree ; by 2, sensory disorders or 
 defects ; and marked also by 3, mental symptoms which invari- 
 ably tend to dementia, but in the earher stages often consist in 
 part, of exaltation of feeling or even expansive delusion." 
 
 Before proceeding to describe the disease, I think it will facih- 
 tate the grasping of the various details if I give a brief outline of 
 my own convictions of its pathology. 
 
 This mode would be inexcusable in an investigation, but in 
 this place I am only describing the results which investigation 
 has afforded ; the following are my conclusions as to the nature 
 of the disease. 
 
 Preb'winon/ remarks. — While ordinary insanity according 
 to the views already enunciated, commences in the organs 
 connected with the blood supply, general paresis commences 
 in the nerve tissues ; the immediate cause of the attack be- 
 ing often distinctly traced to a nerve-shock. While the pre- 
 disposing cause is often found in a naturally super-sensitive 
 temperament. The seat of the disease is mainly, if not entirely, 
 at first, in the cerebrum. The earliest symptoms are, therefore, 
 to be found in alteration of the mental faculties ; the general 
 health not being afi"ected. I would therefore give the definition 
 of general paresis in the following words. 
 
GENERAL PARESIS. 255 
 
 A disease of nervous centres generally ; involving sooner or 
 later every kind of nerve function, whether mental, emotional, 
 or the functions of voluntary or involuntary motion, includmg 
 also those which are connected with animal life ; commencing 
 by excitement and gradually progressing to paresis and para- 
 lysis of these functions. 
 
 The word ' general' is important in the definition, the disease 
 seems to spread its influence over the whole group of nerve func- 
 tions. The extent of lesion, though complete, need not neces- 
 sarily be uniform in intensity in different localities ; the differ- 
 ent parts may be variously involved originally, the morbid 
 processes may proceed unevenly, so that we might expect to 
 find some variation in the phenomena, and such is the case ; 
 but if one division of nerve function is entirely omitted, the 
 disease of course would not answer to the term general. 
 
 The most prominent symptoms for the practical man to seek 
 for, are : — 1. the mental, which are peculiar ; 2. the motor, 
 which should be general; and include not only those of the 
 voluntary kind but the involuntary. 
 
 By way of describing the disease, I will sketch a typical case. 
 
 Symptomatology. First stage. — A male of about 40 or 45 years 
 of age, single (or widower). 
 
 Physically* of robust habit and of good previous general health, 
 (with the exception in certain cases of a syphiHtic taint), and 
 without distinct hereditary predisposition to insanity, of san- 
 guine temperament. 
 
 Mentally intelligent, more rarely accomplished or highly edu- 
 cated; active and energetic in business, speculative, sanguine of 
 success, and disposed to be changeable and fickle. Fond of 
 society, a bon-"\dvant, and self-indulgent in every way with ten- 
 dency to excesses in drink and sexual indulgences. 
 
 After perhaps a sudden reverse of his hopes, preceded some- 
 times by a period of anxious expectation or other kind of mental 
 strain, the patient shows a distinct change in his character 
 and conduct, in very rare instances by great depression, more 
 frequently this alteration is first made evident by an unusual men- 
 tal excitement, often amounting to a distinct elation, and in com- 
 
 * For predisposing and ex tiling causes see the liability to the Disease, in the 
 sequel. 
 
256 LECTURES ON MENTAL DISEASE. 
 
 mnn phvflRo ' olovation ' in miml ; the patients' spirits nroliigli. 
 He exhibits in fact just that kind of cliange in manner tlint an 
 extra glass of alcohoHc stimulant produces, and viewed through- 
 out the whole course of the symptoms, there is maintained a 
 great resemblance to the effects of an inebriate. The patient 
 goes about busying himself in various matters, exhibiting a 
 constant garrulity and an entire absence of reticence with ego- 
 tistical bragging. He will stop and as it is called, button hole 
 different persons, even persons with whom he has but a very 
 slight acquaintance, and will relate matters of a delicate or con- 
 fidential kind, entirely foreign to his natural or normal char- 
 acter. 
 
 There is very little physical change at this epoch, it may be 
 that his ' elevation ' may lead him to some social indulgences, 
 and if one of the lower order, to drink, but apparently more for 
 social than physical gi'atification. But the patient may thus 
 be actually drunk ; and not unfrequently the alteration of be- 
 haviour observed in a patient, is set down to intoxication, and 
 therefore is the less heeded by the friends. 
 
 The mental character shown in this stage may be described 
 by the word ' recklessness,' to this is added by degrees mental 
 confusion. Soon the patient may be led by such state to com- 
 mit acts of stupid folly or crime, such as faux pas of various 
 kind, acts contrary to good manners, and delinquencies of all 
 sorts; making extraordinary purchases, committing thefts in the 
 most open manner, indecently exposing himself or herself, not 
 necessarily from any notions of indecent khul or libidinously. 
 
 As examples of this conduct, the following may be cited. A 
 gentleman walked into a drawing room, without removing 
 his hat, and during his visit began to light a cigar. A poor 
 woman, the wife of a prison warder, went to the window of a 
 Resident Officer, and took some plants quite openly. A woman 
 coming out of a church took a handful of silver from a plate 
 held at the door, without any attempt at concealment. A mar- 
 ried woman, sat herself by the roadside in the country and began 
 to undress herself. A woman ordered a pair of breeches for her 
 husband, a bricklayer, to be made of moire antique, etc. 
 
 When acts of this kind have been shown the friends very often 
 become aware for the first time that they are evidences of disease 
 
GENERAL PARESIS. 257 
 
 — not unfrequently the acts committed openly and publicly 
 lead to the interference of the police, and in many instances 
 the patient is committed to prison. 
 
 In this early stage even, there is often sufficient evidence to 
 diagnose the case from ordinary insanity : 
 
 Thus in General Paresis there In first attack of Ordinary 
 is — Insanity — First Stage — 
 
 Garrulity. Taciturnity. 
 
 High spirits. Depression of spirits. 
 
 Extravagance and lofty ideas. Gloomy forebodings. 
 
 Desire for company. Desire for solitude. 
 
 Eeckless conduct. Apprehension of danger. 
 
 Mental confusion. Clear intelligence. 
 
 All the above may be called the premonitory symptoms, they 
 are elicited only from the friends and after the patient has been 
 certificated, this we may call the first stage. 
 
 Second Stage. — In the second stage, that is only a little later 
 in the progress, the previous symptoms are exaggerated and 
 some fresh added. It then happens that the attention of the 
 friends is more emphatically directed to the real state of the case, 
 and this may be impressed upon them by some extraordinary 
 act, or by a distinct maniacal outbreak. The progress of the 
 disease may then take a rapid course to a fatal termination, or it 
 may proceed less acutely and run its course on to complete anni- 
 hilation of mind and motion. 
 
 1. When the disease takes the former course, the case has 
 scarcely time to develope many of the characteristic symptoms 
 of the Paresis and it is in my belief often set down as Acute 
 Mania ; the symptoms are those of acute meningitis, the pro- 
 droma are ecHpsed by the active symptoms now presented, the 
 course is more or less rapid, the symptoms are delirium with 
 raving, violence, and destructiveuess, the patient cannot be re- 
 tained in bed, is wet and dirty, the bodily symptoms are what 
 used to be called of typhoid character, that is, a di-y tongue 
 with sordes on the teeth, hot and dry skin, injected conjunctivae, 
 contraction of pupils, insomnia, the patient dies in this state, 
 
 8 
 
258 LECTURES ON MENTAL DISEASE. 
 
 covered probably ■with bruises from falling about and possibly 
 with fractured ribs, which accident will be alluded to further on. 
 
 Such cases, which I believe are not very rare go to swell the 
 column of Mania, and to establish such a disease as idiopathic 
 in our nosologies, they may be recognised, however, as being the 
 early stage of general paresis, by firstly not being a second at- 
 tack, and secondly the early history. 
 
 If the patient has distinctly had a previous attack the occur- 
 ence of maniacal symptoms thus suddenly would prove it to be 
 a case of recuiTent insanity or relapse after a remission of gene- 
 ral paresis. It is not often that this latter case presents such 
 typhoid symptoms and the remission occurs after several of the 
 peculiar characters of paresis have ah-eady been present. 
 
 2. But the commencement of the second stage is more com- 
 monly less acute, nevertheless it dates frequently from some explo- 
 sion of violence, or maniacal excitement. This is often the cause 
 for which the patient is brought to an asylum and the case consti- 
 tutes the expansive variety of the French authors. " This mode of 
 debut," says Dr. Falret, "is much more frequent and better known. 
 When the patient has arrived at that state of restlessness or 
 over activity which to a certain point may be considered not ac- 
 tually abnormal or contrary to reason, and which constitutes 
 the first stage, there' supervenes and quite suddenly an explosion 
 of delirium obvious to everyone and characteristic of the disease. 
 A patient who has perhaps evinced restlessness merely, may 
 pass in the space of one night or a few hours into a state of 
 maniacal agitation with well marked delire des grandeurs." 
 It is this abrupt outbreak of maniacal excitement, says Dr. 
 Faket, which has led to the opinion, that the disease has com- 
 menced by this violent manner, but if closely investigated he 
 beheves that certain perversions of mind or acts have always been 
 shown as prodroma, though such may be of very brief duration. 
 {Falret, Folic Parah/tique, p. 29). I have frequently observed 
 that the outbreak of violence is actuated by the apprehension of 
 impending danger of some kind. 
 
 But there need not be a display of actual violence, but only an 
 exaggeration of insane conduct which commenced in the first 
 stage ; the patient is more restless than he was, is perhaps more 
 aggressive and thus gets into various altercations ; the general 
 restlessness is increased and there is a greater eccentricity of con- 
 
GENERAL PARESIS. 259 
 
 duct, the patient perhaps drives about in cabs, or if in the coun- 
 try drives himself and drives furiously, makes long calls on his 
 friends and perhaps forgets to pay the cabman or he walks away 
 and leaves his own trap at the door ; the visits of such patients 
 are not perhaps according to the received usages of their station, 
 at such interviews they will talk excessively, perhaps make 
 several proposals of marriage to different persons in the same day ; 
 there is in all their conduct an exhibition of irreticence on every 
 subject; and in some cases even of the better class there is entire 
 absence of attention to their dress ; their clothes will be unbut- 
 toned or buttoned wrongly, the neck loose, etc., and the rest of 
 their costume untidy and unbecoming. 
 
 Among the lower class, the same abandon is shown, but in a 
 different manner. 
 
 In all there is a disposition to spend money and acquire every 
 object they see, the rich will buy pictures, plate, jewellery, and 
 wine, the lower class will show the same propensity in a differ- 
 ent style. 
 
 In both there is a great desire for company and in their in- 
 terviews with friends it thus happens that the patient, especially 
 of the lower class, is perhaps lead to some excess in drink and 
 it is to this perhaps that the excitement or maniacal outbreak 
 is immediately due. 
 
 It is, however, in this stage of the disease especially, and that 
 is while the patient is free to do as he likes and is perfectly un- 
 protected, that accidents fi'om violence often occur and especially 
 that of fracture of the ribs. It is not generally allowed that 
 those cases, in which fracture of the ribs has been the cause of 
 death in newly admitted patients, are cases of general paresis, 
 but in no case at so early a stage is there so much violence, and 
 death occurs perhaps before a distinct diagnosis of the disease 
 is made, and therefore they have not been placed to general 
 paresis. 
 
 So frequently may this accident of fracture of ribs occur and 
 be concealed by the patient's excitement, that no medical man 
 should undertake the care of a patient without a thorough search 
 for this injury. It is a rule also which I have always carried out, 
 to have every bruise or mark on the patient's body entered on 
 admission. 
 
 s2 
 
260 LECTURES ON MENTAL DISEASE. 
 
 These fractured ribf? have been explained in various ^ays, and 
 usually to the detriment of the attendant's character for care 
 and forbearance. It is not the question here of blame or the 
 opposite, but to investigate the fact of the frequency of this 
 lesion, which is a real feature of the disease. 
 
 I have known a patient to be admitted into Hanwell, with 
 nine ribs broken on one side and four on the other ; and in 
 spite of such injury, the patient has shouted, fought, and rushed 
 aboiit wildly, regardless of anything like inconvenience, such 
 an absence of ordinary feehug becomes thus a phenomenon in 
 the symptomatology of the disease, and shows clearly a condition 
 of dulness of the ordinary sensation, in this part of the disease.* 
 
 But to pursue'our examination of this second or middle stage 
 of the disease, we shall find that the nerve symptoms are con- 
 nected with every artificial division of nervous functions. 
 
 The symptoms connected with the cerebral functions may be 
 divided for our examination into those of emotions, intellect, and 
 vohtion. 
 
 Emotions. — As in every other division of the mental functions, 
 the alteration of the emotions is in the direction of weakness, the 
 patient is very self-satisfied at all times, and when the disease is 
 advanced is usually very pleased with all that is around liim. 
 Some of those expressions which have been called delire des 
 grandeurs by the French, are more appropriately perhaps also 
 named elation of spirits; the "grand ideas" (which will be 
 considered further on) have much of emotional feeling in them. 
 
 * In thinkinp upon these cases I was led to conclude that this very dulness 
 of sensibility which is remarkable might really be at the foundation of the frac- 
 tures. Not only is there evidence of dulness to pain, but I think of slowness in 
 the motor response to excitants. It is well known that a man may receive a very 
 powerful blow on the chest, if he sees it coming ; thero was the story of a man, 
 often related in Mr. Stanley's Lectures on Anatomy, who had the name of Leather 
 Coated Jack and who for a pot of beer would lie down and allow a cart to be 
 driven across his chest, which he submitted to without injury, and doubtless 
 because he erected his intercostals into a powerful arch to receive the blow. In 
 a prize-fight, the weight of a blow on the chest is often very considerable, the re. 
 ceiver has time to receive the weight with ribs well backed by the intercostals. A 
 paretic patient on the other hand makes none of these precautions and it is pro. 
 bable that the reflex movements would be too slow in their action if the 
 blow were foreseen, the catastrophe is thus a proof of the morbid condition of 
 the nerve centres. 
 
GENERAL PARESIS. 
 
 261 
 
 But on the least appeal to the patient's feelings, he will exhibit 
 the change in his emotions in various ways. 
 
 By very little difficulty, the patient's feelings can be changed 
 from grave to gay, and gay to grave again. Any slight amount 
 of compassion shown towards him will lead him to shed tears, 
 and in the next moment he can be brought by flattery into his 
 former notion of his power and happiness. 
 
 Intellect. — Under this head we may first examine the sensations, 
 there is some difficulty in estimating the changes in this direction, 
 as the patient's state of self satisfaction and bragging, leads him 
 to give a too favourable account of them, but the condition 
 appears to resemble that of a stage of drunkenness in which all 
 the impressions are benumbed, but if no subjective evidence can 
 be gathered, the objective is conclusive by itself. When a 
 patient is asked if a pinch is felt he will say in a bragging 
 tone, "No! nothing hurts me," and perhaps he will strike himself 
 roughly to show his power of bearing pain. The insensibility to 
 ordinary pain is shown in such cases as broken ribs, or other 
 bodily injury. The same dulness is evidenced in the special 
 senses, especially in the sense of taste; they will eat the most 
 nauseous things, and probably the boulimia which is a fea- 
 ture in the disease, is due to an absence of the feeling of 
 satiety. 
 
 The readiness with which the patient's feelings and emotions, 
 or his opinions may be influenced and turned from one extreme 
 to the opposite ig remarkable, and is called by the' French a 
 deficient spontaneity. It deserves to be recorded as a distinct 
 symptom of the disease, it is clearly evidence of a feeble mind. 
 
 Kleptomania is a symptom of this stage, it is pretty nearly 
 the only case in which theft of this kind is a feature in men- 
 tal disease, but it ^ does occur in certain cases of chronic in- 
 sanity. It is but a symptom, though spoken of as a form of 
 disease ; it seems to be due to a deske of acquisition, the same 
 propensity that leads the patient to make large purchases already 
 mentioned. The theft in this as in the first stage is open without 
 attempt at concealment, the symptom does not often extend 
 beyond the early part of this stage, this symptom also shows 
 true feebleness of intellect. 
 
 Delire des Grandeurs. This symptom is marked in every 
 
202 LECTURES ON MENTAL DISEASE. 
 
 typical case ; it has been called also megalomania and " elation 
 of ideas." I consider it belongs to the intellect, though it 
 may be emotional in some of its aspects ; the examples quoted by 
 every author are very striking, among my own cases I may 
 give the following. A lady insisted that she was the wife 
 of the Saviour, also of a certain Duke, that she had other hus- 
 bands, more than a million, that God gave her a large quantity of 
 jewels of the most rare kind, that she had twenty Koh-i-noors, 
 she exhibited also in these notions a good deal of erotic tendency. 
 A gentleman said he could easily run 600 miles in a minute, 
 that he could fly, that by cutting out his entrails, he should 
 make himself so light, that he could jump a mile, and by con- 
 stant springing could mount higher and higher indefinitely, that 
 he could speak all languages. He ^Y0uld mix all his food together 
 on a plate, meat, sweets, vegetables, which he called the kosmos, 
 which would make him strong, etc. Another patient was going 
 to invest a hundred pounds in a scheme which would pay 500 
 per cent, and by re-investing he should become rich enough to 
 buy up all the Insurance Companies. Another declared that he 
 was going to bring the sea up to the house, he should build a 
 town and a cathedral, etc. One patient wrote me a cheque for 
 a million pounds on an imaginary bank. 
 
 In scrutinizing these ideas of largeness one readily may per- 
 ceive an element of imbecihty in all. Far fi-om being imaginative 
 or exalted they are usually the suggestions of sm-roundings of 
 commonplace kind. A patient was saying to me that she was an 
 angel and that all the birds knew her and came to her, on look- 
 ing up I saw a sparrow seated on a branch close to the window, 
 which suggested the idea, there is in all these so called gi-and 
 ideas about the same amount of fanc)'. 
 
 Motion, voluntary and invuluntanj. — The next division of men- 
 tal faculties is that connected with will and vohtion. 
 
 With this portion of the subject we may trace the same 
 parallehsm of the phenomena with those of drunkenness. 
 
 In the previous stage there has been described a degree 
 of restless activity, this is at first increased and (as has 
 been said) often ushers in this second stage by some great 
 catastrophe of violence, with or without shouting and 
 raving. This coucUtiun is one of mania in all its force, some- 
 
GENERAL PARESIS. 263 
 
 times with evidence of vindictiveness, sometimes with high 
 spuits ami hilarity, this continues often both day and night, but 
 more frequently the patient can be appeased by quiet means, 
 and by diverting his attention. There appears no difficulty in 
 his movements at this period nor for some time afterwards, as 
 ah-eady described the case in this stage may go on to a fatal ter- 
 mination, but more frequently by care and treatment, and by 
 the rest and the isolation from exciting objects which an asylum 
 affords, the state of active violence will subside, but reappears 
 perhaps from time to time in minor outbreaks of excitement. 
 
 Involuntary motion. — It is on the subsidence of the violence 
 and raving and as the patient begins to assume a more tranquil 
 state in every particular, that the first symptoms of motor pare- 
 sis appear. 
 
 The advent may be detected : 1. In the state of the pupil and 
 optic disc ; 2. In the speech or the articulation of the labial 
 sounds ; 3. Then gradually in the gait. 
 
 The pupils will be found to show various changes, there is ir- 
 regularity in the shape of the pupil instead of being circular it 
 may be squarish, or elongated from above downward, there may 
 be difference in size of the two pupils. 
 
 Optic disc in general paresis has been examined by various 
 physicians. 
 
 Dr. Allbutt examined fifty-three cases, with the following re- 
 sults : — " 1. That atrophy of the disc occurs in nearly every case of 
 general paresis. 2. That it is not to be distinctly seen until the 
 end of the first stage, as it slowly travels down from the optic cen- 
 tres. 3. That it begins in a pinkish suffusion of the nerve with- 
 out much stasis or exudation, and ends in simple white atrophy. 
 4. That the atrophy of the nerve is not in proportion to the ataxy 
 of the muscles of the orbit. 5. That it is in relation to the state 
 of the pupil, which is contracted in the early stages and dilated in 
 the fully atrophic stage. 6. That as the symptom is not a 
 very early one, it probably has not much diagnostic value. Its 
 pathological significance is probably considerable." 
 
 I extract the above from Dr. Aldvidge's paper in the West Biding 
 Reports, p. 223. Dr. Aldridge compares the above results with 
 fresh observations made by himself; he says "it would appear that 
 the affection commences by inflammation and slight exudation 
 
264 LECTURES ON MENTAL DISEASE. 
 
 and ends in atrophy." As regards the pupils he found, they 
 were active in twelve cases, sluggish in nineteen, inactive in 
 five, and unequally active in seven. 
 
 Dr. Tebaldi found the optic discs differed according to the 
 stage of the disease, the changes consisted in hj^persemia, oedema 
 and exudation, and atrophy of the optic nerve. 
 
 Dr. Monti found similar changes. 
 
 Dr. Noyes of the State Asylum, Utica, in ophthalmic examina- 
 tion of eleven cases of general paralysis, found that in nine there 
 was hyperaemia and infiltration of optic nerve and retina {Journal 
 of Mental Science, April, 1878). 
 
 Speech. — The first symptom of the motor paresis may be de- 
 tected in the tongue and corners of the mouth ; this symptom 
 may be often found in the commencement of the second stage, 
 but perhaps requires a practised eye to discover the condition so 
 early. It is a common thing, however, to find evidence of pare- 
 sis on the admission of the patient into an asylum, that is, as 
 soon as to the ordinary observer the patient is insane. 
 
 On the protrusion of the tongue it will be seen generally to be 
 relaxed and to show a vermicular quiver on each side of 
 the mesial line, that this quiver is on both sides is a fact which 
 is of importance as it shows the universal nature of the disease 
 and the tongue does not deviate to either side ; at the same 
 early date in women, and in beardless men, there may be de- 
 tected a similar quiver in the muscles around the mouth (clonus ?) 
 more marked on attempting to speak. 
 
 At first this appearance is slight and the speciahst often has a 
 difficulty in demonstrating its existence to one not experienced ; 
 as the disease increases it becomes more and more obvious, to- 
 wards the end of what I have called the second stage, the mus- 
 cles of the face are involved in the want of action, and thus 
 give an expression 01 marked kind. While at rest the face in 
 general paresis is pecuharly blank, the lines of expression are, 
 as it were, effaced ; the folds of integuments, which are in fact 
 the coverings of the muscles of expression in tonic action, are 
 smoothed out and obhterated; there is a mask-like doughy 
 look, a " flabby appearance " about the face. A parallel 
 here also exists between the phenomena of drunkenness and 
 general paresis, but the characters are etill distinct. In 
 
GENERAL PARESIS. 265 
 
 drunkenness, when the countenance is at rest, the expression 
 approaches nearer to that of coma, there is always some degree 
 of stupor in it ; but in general paresis, there is far less sleepi- 
 ness about the expression, there is always some degree of lassi- 
 tude, but from the different state of the emotions the features 
 are more contorted ; the face owes some of its distinctness of 
 character to the abscence of turgescence, which usually is asso- 
 ciated with the drunken face. It must be remembered that the 
 muscles of the face differ much with respect to their normal ac- 
 tion, some are more constantly in tonic action than others ; 
 thus the muscles closing the jaws and lips and those opening 
 the eyes are especially in a state of tonicity or contraction ; but 
 they differ in degree, even in this respect, and the paresis appears 
 to have more effect on one set than another, and thus the state 
 of contortion alluded to arises. The following is the result of 
 my observations on this point. I find the levator menti is fre- 
 quently contracted, the chin becomes pursed or corrugated, the 
 orbicularis oris is usually more paralysed, at all events it is more 
 frequently relaxed, and the former muscles appear to be brought 
 into action to assist it, the lips become thus a little pouting ; 
 and sometimes the centre of the under lip is bent in upon the 
 incisor teeth. Again, the orbicularis palpebrarum and levator 
 palpebr® seem to require the supplementary action of the 
 occipito-h-ontalis, for often there is a very sleepy look about 
 the eyehd, but with it a raising of the eyebrow, ''■ which gives 
 an expression of a very peculiar kind — one part of the face is 
 expressive of one emotion and another part of a different ; an 
 incongrous general effect is thus produced, characteristic in its 
 entirety. It is characteristic in its unmeaniugness, and reminds 
 one of a badly executed portrait, in which the features do not 
 harmonise in their expression. 
 
 While the disease is only apparent about the mouth, and in 
 the quivering of the tongue, described, and which may be called 
 the appearance during rest. The same parts in motion show 
 even more unequivocally the motor paresis. 
 
 * M. Moreau de Tour, lias described also a certain prominence of the eyeball 
 wbicli is due probably to similar causes ; but it requires a previous acquaintance 
 with the patient's features to recognise this alteration. He found it in half of 
 the cases. 
 
266 LECTURES ON MENTAL DISEASE. 
 
 In speaking all the same muscleB are more or less twitched, 
 the hps especially appear involved, and the articulation is con- 
 fused, which is particularly to be observed in the utterance of 
 the labial sounds, this symptom commences very gradually, at 
 first perhaps the patient merely stammers on one or two words, 
 later his speech is mumbled and drawling, and still later it be- 
 comes indistinct. 
 
 Before the alteration has arrived at this marked condition of 
 paresis with regard to the mouth and face, which for convenience 
 of description is narrated above, the motor symptoms will be 
 evident in the limbs, especially in the legs, shown while at rest 
 by the position and by the gait when moving. In stand- 
 ing, the weight is poised on both legs equally — there is no 
 " standing at ease," no throwing the centre on to one Hmb 
 mainly; the hands, too, in this the second or middle stage, are 
 not placed in any easy attitude, there is the opposite of the 
 "jaunty" about the patient. In sitting, there is a square and 
 graceless pose — the head is slightly pendent, the thighs parallel, 
 and the knees bent at just a right angle, each hand resting on a 
 knee or on the elbow of the chau- ; at least such is a favorite 
 posture. 
 
 In motion, the difference is still more marked, the gait is 
 characteristic. There is naturally a particular expression in gait, 
 even in a dog, one may divine the errand the animal is upon ; 
 the expression of the paretic is that of one who is taking an 
 objectless walk, and with his attention addressed to the perform- 
 ance, it is less automatic than in health. He seldom looks to 
 the right or left, nor does he notice anything ai'ound. 
 
 lu'^the^ gait itself there is an absence of elasticity or spring, 
 the legs as^the paresis increases, are kept wider apart, giving a 
 slight straddle, there is often an appearance or expression of 
 having to poise his head carefuUy, or to keep his head accurately 
 in the centre of gravity. Each limb is called upon to do its own 
 share. When the foot is raised, it is scarcely lifted, and is 
 quickly replaced, so that the steps are short and shambhng. It 
 happens often from the tendency of the patient to brag, that he 
 is very willing to show off how well he can walk, when all these 
 characters are demonstrated. As the paresis increases the 
 patient's wulkiug becomes more a matter of business to him, he 
 
GENERAL PARESIS. 267 
 
 looks down at his feet before starting, if spoken to, he must stop 
 to attend, as though he could not walk and talk at the same 
 time. When this condition has arrived however, the patient 
 is close upon what we artificially call the last stage. 
 
 While the division of the disease into stages may give the 
 description some order, there is this disadvantage in it, that in 
 nature the different stages often run into one another, and over- 
 lap, so that it is difficult to make a line for their separation. 
 Then again the phenomena of the succeeding stage are often 
 but slight and gradual modifications of those of the preceding. 
 
 Before all the symptoms ah-eady described have reached the 
 intensity which is spoken of, it sometimes hap^Dens that the 
 patient's progress downwards is arrested, and an almost complete 
 remission of the symptoms occurs. 
 
 Remissions. — It is a well established fact, that in certain 
 cases, during the progress of general paresis, an improvement in 
 the patient's condition occurs, and gives rise to false hopes of 
 recovery, which are never to be realized. 
 
 The improvement is generally very gradual, the word "re- 
 mission " has been employed to describe this deviation from the 
 more common course of the disease. Dr. A. Sauze. physician 
 to the Asylum at Marseilles, studied these cases, and his paper 
 appeared in the Annates Medico- Psychologiques, and has been 
 translated in the Journal of Mental Science, July, 1861. He re- 
 marks that there are three modes in which remissions may be 
 found, 1. all the signs of the paralysis disappear, 2. the mental 
 symptoms improve, but the paralysis remains in statu quo, 3. 
 the two sets of symptoms undergo amehoration equally. 
 
 He insists, however, and in this my own experience entkely 
 concurs, that in the best marked cases of remission a practised 
 eye may always detect a something left of the disease. 
 
 The different writers on general paresis do not all rigidly 
 confine their nomenclature to what I consider the typical case. 
 In fact many consider that a definition of " mental imbecility 
 with paralysis of any kind " constitutes the whole phenomena of 
 the disease, in speaking therefore of the remission of symptoms 
 or improvement in the case, they may not be all speaking of the 
 same kind of case. 
 
 Period of Remission.— From my own experience I admit fully. 
 
268 LECTURES ON MENTAL DISEASE. 
 
 that in mauy cases, the disease, alter entering upon what we 
 have called its second stage, and certainly ]after the excitement of 
 this stage has been thoroughly estabhshed, a gradual improve- 
 ment may take place, very deceitful to any but a practised 
 observer. The remission, I should say, as a rule takes place be- 
 fore the motor symptoms are very obvious, not perhaps before 
 there has been any change in the action of the pupil, but before 
 any stammering or mumbling of the voice has become noticeable. 
 The delirium, with its " monomania des grandeurs " becomes 
 less and less, the patient's mind returns almost to its normal 
 state, I say " almost," on very close scrutiny the mind will be 
 found to have lost some of its former power in every case. 
 
 This condition of the symptoms may lead and has led to 
 various legal questions, and may give rise to embarrassment 
 where interests are in contention. 
 
 I had a iiatieut under my care, the principal of a legal fii-m, 
 who had been admitted with all the characters of general paresis 
 in the tj'pical form, and in the second stage, the active symptoms 
 after about 6 months gi-adually subsided, and the patient passed 
 into this condition of remission. 
 
 During the period immediately prior to his outbreak, which 
 led to my introduction to the case, this gentleman had done 
 several extravagant and insane acts, which were not fully known 
 to his friends. He had also the affau's of several cHents in his 
 hands, and which during his illness, no one could fully under- 
 stand or unravel, on account of the confusion in which they 
 were left. It became a question therefore of great moment, 
 whether the patient in his improved state, might not be able to 
 render assistance ; to do this, it was necessary that he should be 
 discharged. He was discharged ; and I believe was able to 
 afford valuable information on several important matters. Dur- 
 ing his illness my opinion was asked as to the probabihty of his 
 recovery, I gave of course a very unfavourable prognosis. I 
 considered his ultimate recovery most unhkely, and the only 
 room for doubt being, that I had mistaken the nature of his dis- 
 ease ; which of course I admitted as possible, as there were no 
 unequivocal motor signs in the case, and there had only been 
 the character of the delii'ium and the absence of a melanchohc 
 Btage of ordinary insanity. It appeared that on the strength of 
 
GENERAL PARESIS. 269 
 
 my unfavourable opinion, his friends disposed of his practice ; 
 when the patient returned home, the purchaser, who had called 
 on me previously to purchase, to take my opinion, was also 
 much disturbed, and threatened me with an action for the 
 opinion I gave to him. It was evident, therefore, that the 
 remission appeared very complete to ordinary observers. I 
 told my visitor that I adhered to the opinion I had given. He 
 replied, the "patient has recovered ; he is well ; there is nothing 
 at all the matter with his mind, and he is quite as able to trans- 
 act business as ever he was." This is evidence of the extent to 
 which the remission of the symptoms may occur. 
 
 The patient had left my care some time. I proceeded 
 then to cross-examine my visitor and to see if there was 
 any sign of mental feebleness at all, a httle examination 
 brought out certain notable changes ; he was not quite so 
 active as usual in his business. He was fond of going into the 
 room of his head-clerk, and talking of trivial matters, contrary 
 to his former custom ; and seemed to delight in matters of pru- 
 rient kind. He seemed strong and in good health, but he com- 
 plained of his legs feeling heavy. I told my visitor that these 
 were unfortunate indications for my patient, but I think his 
 successor went away relieved and in better spirits himself, though 
 he did not show any appreciation of my ability to reheve his 
 mind. The patient died in about nine months afterwards of the 
 disease. 
 
 The apparent absolute recovery of the patient was illustrated 
 in another case. I had the son of a very intelligent veterinary 
 surgeon under my care, who watched his son's case very closely. 
 The patient was first seen by me in August, 187 — ; he was 
 very excited, had well-marked delire des grandeurs, irregular 
 pupils and indications of other motor symptoms : in December, 
 cramps in the limbs ; in January, improvement began ; m May, 
 complete remission and discharge ; from June, he remained well 
 till October twelvemonth ; relapsed and died in November, i.e. 
 after a remission of about 16 months. 
 
 I had given the father my prognosis of his son's case, on the 
 admission of the patient ; the symptoms were very closely 
 watched by the father and the remission also. The father fre- 
 quently reported the progress of his son's case to me, which 
 
270 LECTURF.S ON MENTAL DISEASE. 
 
 went on improving: month by month durinpj the 16 months that 
 the remission lasted. I saw the patient from time to time in 
 the interval ; mentally he was entirely free from delirium of any 
 kind. He said he did not foci himself well enough to return to 
 the practice of his profession, and that reading soon fatigued 
 him. He attended closely to his health and was very temperate 
 in his diet. In the course of the summer following his dis- 
 charge, he complained of a feeling of weight in his limbs ; the 
 weather was hot and he took a walk early every morning in the 
 park, and he said he occasionally felt a tightness in the fascia of 
 his legs ; he was quite rational, there was no impediment in his 
 speech at my visit, biit he told me at times he had a momentary 
 stammer. It was in October, 16 months after the first remission 
 of the characteristic symptoms, that I met the father accident- 
 ally and asked after the patient, he told me he had just seen his 
 son, and added "Doctor, this time your prognosis has been wrong, 
 my son is well ; the recovery is complete." The father was a 
 more than ordinary observer, and a man of decidedly superior 
 intellect and with a good knowledge of medicine and of human 
 physiology. A few days after this report, the son was admitted 
 into Bethlehem and died in the course of the month in a con- 
 vulsive attack. 
 
 The case is interesting since the testimony of one with more 
 than ordinary observation, pronounced the entire recovery of the 
 patient, and some judges and legal practitioners would depend 
 upon such, it seems, more than on a specialist's opinion. Its 
 legal aspect, however, will be discussed hereafter. 
 
 At the Annual Meeting of the British Medical Association in 
 1883, Dr. Savage read an account of several cases, which had 
 come under his own observation, in which the remission had 
 lasted several years, and in some of these cases appeared to be 
 permanent, that is in other words, they had terminated in cure. 
 I have never seen any such in my own practice, I have read 
 of many, and several are related in diflforont authors, but on 
 very close investigation of all the phenomena, I came to the 
 conclusion that many of the patients were affected with melan- 
 choly with stupor. But Dr. Savage's experience and judgment 
 seems to be conclusive. Admitting this, we must admit at the 
 same time, that there must be some fundamental difference in 
 
GENERAL PARESIS. 27T 
 
 the pntholnfry of the cases, grouped together under the title of 
 general paresis. We can scarcely conceive that such changes 
 as are shown in Dr. Wiglesworth's preparations (Plate II) would 
 admit of recovery, unless, which is not likely, the lesions found 
 were partial or unilateral. 
 
 The relapse, which is thus almost inevitable, as a rule takes 
 place somewhat suddenly, there is sometimes some violence, 
 more frequently a return of the motor difficulties, some- 
 times convulsion. The case on relapse will then enter the 
 last stage of the disease which we will next consider; when 
 there has been a remission, the relapse if it can always be 
 so-called maybe simply a return of; the symptoms remitted. 
 It has always appeared to me that the real pathology of 
 these cases is this, that since the first stage of the disease is 
 apparently one of exaltation of the cerebral functions or an in- 
 crease in activity of the circulation, and the end of the disease is 
 the opposite when the circulation is more torpid, there must 
 of necessity be an intermediate stage in the transition, when 
 the mental condition is half way between the two poles or 
 normal, and so far as exaltation and deficiency of energy is 
 concerned, the mental condition of the patient at a stage appears 
 in a neutral state, but the mind, after the excitement has sub- 
 sided, shows a loss of power. 
 
 The relapse will be both in the mental functions and in the 
 motor. "When the motor have been ameliorated, there is a 
 gradual increase in the stammering, in the facial expression and 
 in the gait. 
 
 Mentally, the patient who has appeared improved, exhibits a 
 gradually increasing imbecility of mind. There may be no 
 return to excitement, perhaps, nor to utopianism ; but the 
 patient has a happy and contented frame of mind ; he is as 
 much inclined to brag of his prowess as formerly, or of his 
 health and strength, but in a more fatuous way. 
 
 The last stage when fully established exhibits the patient in 
 a most pitiable condition, as regards intellect, emotion and 
 motility. 
 
 Intellect is almost annihilated, special senses are dull and 
 slow, emotional feelings, &c., in the lowest condition of fatuity. 
 The patient smiles or cries by turns ; he is no longer attentive 
 
272 LECTURES ON MENTAL DISEASE. 
 
 to the calls of nature ; if his sphincters are still able to respond 
 to volition, tlie power of control is gi-adually decreased. 
 
 The motor functions in the same manner become more and 
 more impaired. The patient's expression of face is more dull 
 and stolid, all the lines of facial expression are obliterated, the 
 face is like a smoothenod mask ; if he tries to speak the muscles 
 around the mouth are thrown into spasmodic action or sardonic 
 grin ; if he attempts to protrude the tongue, at first, it is jerked 
 out and withdi-awn, or later when asked, the patient involuntary 
 raises his hand to assist in the protrusion ; but in these im- 
 paired movements it will be noticeable that they aflfect both 
 sides apparently quite equally. The patient's hand-grasp be- 
 comes more and more feeble, but in this there is often some 
 difference on the left or right side. 
 
 There is now distinct ataxy present. While the patient can 
 stiU walk the gait is more remarkable and the performance more 
 and more difficult ; at last the patient is unable to stand at all. 
 The feebleness at first is more marked after sleep or on awak- 
 ing. The process of waking is slow, in other words, the 
 change of the cerebral circulation is feebly performed. When 
 the patient's weakness confines him to bed, his power of arti- 
 culation is often so far gone as to render him unintelhgible, 
 and there is often a disposition to grind the teeth. Another 
 motor feature is the trick of rolling up the bedclothes ; the 
 patient lying on his back continues to gather up the clothes in 
 a pecuUar way, which mode may be seen in all classes of pa- 
 tients and in aU countries. At this stage, of course, the patient 
 is whoUy unconscious of his dejections, and as a rule passes 
 them involuntarily. 
 
 In the last stage of all, the patient's limbs become contracted. 
 At first there is simply a tendency shown in the patient to lie 
 with his knees drawn up. This gradually increases, the limbs 
 can be straightened and do not at first resist, but when loosened 
 by degrees they return to the same position. This contraction 
 increases till the thighs come in contact with the belly and 
 the heels with the buttocks. 
 
 Patients have, as a rule, no particular proneness to slough- 
 ing, but from their habits, if not kept scrupulously clean, are 
 very liable to excoriate. 
 
 In this last stage there is a tendency to convulsive attacks. 
 
GENERAL PARESIS. 273 
 
 As enemata generally relieves this, the attack is probably due to 
 the irritation of accumulation in the bowels. 
 
 Apoplectic seizures also sometimes occur. 
 
 As regards reflex movements the authorities differ, and for 
 this reason, the cases differ in this respect. It will be seen here- 
 after that the seat of the disease has been attributed by some 
 to the spinal cord chiefly. That, in my opinion, is going too 
 far ; but in most cases there are ataxic symptoms, that is 
 spinal as well as cerebral lesions, but to what extent, roay differ 
 in different cases. 
 
 Certainly, in certain cases and in those which I call typical, 
 in the last stage of the disease the reflex movements are 
 abolished. Dr. Bucknill stated this, and it was contradicted by 
 Drs. Falret and Brierre de Boismont. I examined several pa- 
 tients under treatment at the time I first read his remark, and 
 found that tickling of the soles of the feet produced no reflex 
 movements in any. Since that, however, I have seen patients 
 in Avhicli the reflex movements were distinctly increased, and 
 existed at other points, cremaster and epigastrium, &c. It is 
 not easy in a patient in this last stage to examine for knee-jerk, 
 as the limb is contracted ; but Dr. Mickle examined this ques- 
 tion, and in a paper in the Journal of Mental Science, the follow- 
 ing are his results, and the phenomenon is of interest, in con- 
 nection with reflex phenomena. 
 
 He found that there were cases in which this phenomenon 
 was within the normal range, others in which it was absent or 
 very much lessened, and thirdly, cases in which it was well 
 marked or exaggerated. 
 
 It must be borne in mind that the description given here is of 
 a typical case. There are of course many deviations from this, 
 almost as many as there are cases. Nevertheless, according to 
 my experience, there is found a difference in different cases of 
 other reflex movements. 
 
 It is in this last stage of the disease that the patient is liable 
 to choke while taking food. This accident is so common that a 
 probang should always be at hand in the sick room. I con- 
 sider this accident tends to show the loss of reflex movements, 
 the action of the muscles of the pharynx not responding, or res- 
 ponding too slowly to the presence of the food. 
 
274 LECTURES ON MENTAL DISEASE. 
 
 There are other phenomena which have hoen investigated 
 with gi-eat care. 
 
 Temperature has heen examined by Dr. Mickle, Journal of 
 Mental Science, April, 1872. His general conclusions, I think, 
 show that there is nothing special in regard to temperature in 
 general paresis. He found, speaking in general terms, that 
 when the disease was advancing rapidly, there was a slightly 
 higher evening temperature, and on the eve of an attack of 
 excitement or convulsion there was a rise in temperature, and 
 also as death approached. He found, however, in certain cases, 
 a difference of temperature on the two sides of the body. 
 
 With regard to the other functions as those of respiration, 
 circulation, and digestion, investigation has been equally active. 
 The organs of the chest, as a rule, are healthy, and present no 
 special lesion ; when any such exist it is accidental. The pulse 
 to the touch gives no indication of change. 
 
 Dr. Mickle {General Paralysis, p. 49), observes, "In the early 
 stages the pulse is full and hard, and the beat of the heart 
 powerful, the first sound clear and full, the second accentuated, 
 the arterial tension increased. This condition, however, is very 
 far from being always present or persistent. Voisin finds indi- 
 cations of vaso-motor paralj'sis in the full compressible pulse, 
 whose sphygmogram displays some elevation of the percussion 
 stroke, a plateau at the summit, oscillations on the hne of de- 
 scent, and a variable degree of dicrotism. This condition in- 
 creases in proportion as the malady progi-esses. In the final 
 periods the tracing is reduced to a slightly and irregularly wavy 
 line." 
 
 This is interesting in connection with the state of the arte- 
 rioles to be mentioned hereafter. 
 
 The digestion throughout the whole course of the disease is 
 seldom disturbed, but in the early portion of the disease the 
 diet requires to be regulated on account of the boulimia which 
 is nearly always present, and later in the last stage care must 
 be taken to prevent the patient from choking. Paretics have 
 often a tendency to eat largely and unless closely watched will 
 thrust large pieces of food into their mouths. The bowels are 
 usually regular and the dejections not unhealthy ; when any 
 disturbance occurs it is attributable to this propensity to gorge ; 
 
GENERAL PARESIS. 275 
 
 there is a tendency to constipation when the patient takes to the 
 bed, -which seems to he due to the paralysis and its accom- 
 panying dysfethesia. When the large intestines become loaded 
 it induces a convulsive attack. 
 
 The secretion of the kidneys has been studied by numerous 
 observers. In the early stages it does not show much change 
 either in quality or quantity. In the later stages when the 
 urine is retained or when the catheter has to be used, it is fre- 
 quently found alkaline and offensive. Dr. Meeson, West Riding 
 Reports, vol. iv., p. 93, thus sums up an examination of the 
 urine in six well-marked cases : 1. The quantity of urea varies 
 above and below the average of health, being in the majority of 
 cases considerably increased. 2. The chlorides and phosphoric 
 acids notably diminished, the sulphuric acid is normal. 3. The 
 specific gravity varies within wider limits than in health, the 
 means do not differ. 4. Absolute quantity estimated according 
 to the weight of the body is slightly in excess of normal. 
 
 In connection with this subject Mr. Wolfenden states in an 
 article on Ptomaines in the Lancet, Nov. 17, 1883, that Selmi 
 found in the urine of patients suffering from progressive paraly- 
 sis, two volatile bases, the one like nicotin, the other hke 
 coniin . 
 
 As regards the respiratory function this is usually unaffected 
 until the very last stage when hypostatic pneumonia may 
 occur. 
 
 Thus it would seem that the symptoms are confined to the 
 neural functions ; the nutrition processes are but rarely impli- 
 cated. 
 
 The early symptoms appear to be wholly cerebral and the 
 closing symptoms point to spinal complication and to disease of 
 diffuse degeneration chiefly of the lateral columns ; there is 
 usually absent any marked wasting of the limbs and not till 
 quite the close any great disorder of the sensory functions, as 
 anaBsthesia, etc. 
 
 The foregoing description, is that of an imaginary and typical 
 case, and is intended to give the phenomena, most usual in the 
 disease, but there are many variations, in the course and pro- 
 gress of actual cases. Most writers on the subject of General 
 Paresis, have attempted to describe such principal varieties. 
 
 t2 
 
276 LFXTURES ON MENTAL DISEASE. 
 
 Assuming for the present, that the disease is one clue to 
 changes in the nerve centres — or brain and cord, it is obvious 
 that the lesion may involve different portions of these organs 
 and to a different degi-ee in different cases, and again the disease 
 may commence in different parts of these centres, and proceed 
 in a different course, so that it is natural to suppose, that 
 the symptoms may vary in their progress in the individual 
 examples of the disease. The most probable, and the most 
 received opinion of the nature of the lesion is, that it is a degene- 
 ration, and if so, this may readily be supposed to be seated in 
 different degrees in different localities, and since there is a 
 certain uniformity and continuity of structure in the whole of 
 the central nerve organs, we should expect to find a general 
 spreading of the same morbid process throughout the whole, and 
 this is what appears to be the case. 
 
 Thus the French writers speak of : — 
 
 1. A congestive variety. 
 
 2. A paralytic variety. 
 
 3. A melancholic variety. 
 
 4. An expansive variety. 
 
 M. Baillarger insists upon a hypochondriacal, a melan- 
 cholic, a mouomaniacal, and a simple form. Dr. Mickle also 
 admits of the same varieties in the symptoms. It is there- 
 fore abundantly evident, that the cases of general paresis show 
 certain deviations in the course of the disease, but nevertheless 
 there will be found running through the whole of each case, the 
 symptoms more or less pronounced, which I have endeavoured to 
 depict. 
 
 Every writer upon the disease, admits that such variation also 
 in the advent of the various phenomena is not uncommon. As 
 regards the order of occurrence of the mental and motor symp- 
 toms for instance, there are described three modes of invasion as 
 possible. 
 
 Firstly, the case may commence by some disorder of the 
 mental faculties — Tisually by delirium, or maniacal excitement — 
 but in some rare cases with depression or melancholy, and on the 
 subsidence of these syiuptnras the peculiar indications of general 
 paresis, particularly those connected with the motor functions, 
 
GENERAL PARESIS. 277 
 
 manifest themselves. This is admitted by most authors to be 
 the most frequent order of invasion. Both Parchappe and 
 Calmeil admit also, that the special paretic symptoms may 
 follow the mental at any length of time, as after many years, 
 though this is exceptional, and not the usual course. 
 
 Secondly, other cases occur, in which the mental symptoms, 
 as mania, melancholia, and especially a state of dementia, are 
 manifested simultaneously with the lesion of motility. 
 
 Thu-dly, MM. Baillarger and Lunier assert that, as a rule, the 
 lesion of motility precedes the mental phenomena, and most 
 observers say that this is the case in some instances ; are not 
 these primarily ataxy ? 
 
 The sequence of one set of phenomena to the other is obvi- 
 ously a question which requires only a careful observation to 
 determine. The primary symptoms of this, and all diseases are 
 faintly marked, it is easy to overlook them, and the paretic 
 symptoms are frequently not recognisable by ordinary observers, 
 even when pointed out. 
 
 There are however cases of morbid conditions, which seem to 
 me decidedly different, and which are Hable to be mistaken for 
 general paresis, and since the prognosis of a true case of that 
 disease is so bad, it is essential, that these should be clearly 
 diagnosed. 
 
 Dr. Von Kraft Ebing gives the following list of diseases, 
 which in his belief may be mistaken for general paresis. 
 
 1. Senile dementia with paralysis. 
 
 2. Dementia fi'om cerebral disease, as apoplexy, tumours, 
 
 chronic encephalitis, sclerosis, to which we may add 
 syphilitic disease of the vessels. 
 
 3. Ataxy. 
 
 4. Dementia fi'om epilepsy. 
 
 5. Alcoholismus chronicus. 
 
 6. Hysterical paralysis. 
 
 7. Lead poisoning. 
 
 8. Paralysis from muscular atrophy and spinal disease. 
 
 9. Pellagra. 
 
 10. Phosphoric and arsenical poisoning ; to which I would add 
 
 11. Melancholy with stupor. 
 
278 LECTURES ON MENTAL DISEASE. 
 
 In the former edition of these lectures I enumerated some of 
 these, and I still consider they are the most important, as most 
 liable to be mistaken for genuine general paresis, viz.. 
 Certain spinal diseases. 
 Chronic alcoholismus. 
 Epileptic insanity. 
 Organic disease of brain. 
 
 But as these diseases come under the next division of our 
 subject, or the Symptomatic Mental Diseases they "will be 
 discussed in a future page, and then* diagnosis from general 
 paresis pointed out. 
 
 Treatment. — As in former pages, only special treatment will 
 be alluded to in this place. Eemarks on the general or moral 
 treatment, in other terms the general management, will be found 
 in a subsequent page. 
 
 There has been of course in a disease of the fatality of general 
 paresis, a great deal of attention du-ected to therapeutics, as ap- 
 plicable to the case, yet still without very consolatory results. 
 
 During the stage of great mental excitement digitahs, and 
 digitahs and opium have been strongly recommended, and I 
 consider that the effects are often good. I prefer the combina- 
 tion as recommended by Dr. Dumesnil in a j)aper in the Annales 
 Medico -Psychologiques of opium with digitalis. I have usually 
 prescribed it in the proportion of one drachm of Tr. opii to ni,x of 
 Tr. digitalis every four hours till the patient becomes more tran- 
 quil and sleeps. I have less confidence in bromine, but the bro- 
 mide salts have the advantage of being more readily concealed 
 and the patient will take them more quietly. The dose may be 
 repeated for a time without fear. I have no beUef in the anaphro- 
 disiac properties of the bromides, but if they possess any such 
 property, they might be doubly applicable. Hyoscyamine will also 
 quiet the excited patient, but I do not consider it preferable to 
 opium combined with digitalis. Ergotine has been spoken of, 
 but I have never tried it. 
 
 Counter-irritation to the spine was strongly recommended by 
 the late Dr. Boyd. It is worthy of remark that in the several 
 reported recoveries from general paresis, the patient had suffered 
 from extensive boils and carbuncles at the back of the neck. I 
 have seen blistering to the nape employed, but I saw no benefit 
 
ft 
 
 GENERAL PARESIS. 279 
 
 derived from it. If the patient is weak and emaciated, wliicli 
 would be quite an accidental circumstance, cod-liver oil or any 
 other ordinary remedy would be indicated. There is a tendency 
 in the last stage in some cases to sloughs from pressure, they are 
 not usual in typical cases, but sores from lying, and from the 
 dribbling of urine, require the ordinary care in such cases. 
 
 Prognosis. — As regards prognosis, it is invariably bad, the 
 average duration of the disease is from two to four, or four and a 
 half years, the longer periods would include a period of remis- 
 sion probably. 
 
Section VUI. 
 
 THE ETIOLOGY, MORBID ANATOMY AND PATHO- 
 LOGY OF GENERAL PARESIS. 
 
 Preliminary statement — Division of Subject — Causes, Remote, Predisposing — 
 Influence of Sex — Age — Temperament —Marriage — Social position — Educa- 
 tion — Character — Habits — Syphilis — Injuries— Epilepsy — Race — Proximate 
 causes — Morbid anatomy — Pathology proper. 
 
 It will tend to a clearer understanding of this part of the sub- 
 ject, if I pursue the course adopted in legal proceedings, that is 
 to state firstly what conclusions I consider the facts of the case 
 are calculated to prove, and then to give the evidence in detail. 
 
 In my opinion the explanation to be derived from a considera- 
 tion of all the phenomena of the disease, is as follows, that the 
 disease commences in the nerve tissue itself, and is caused by a 
 severe shock of a moral or physical kind ; that the nerve tissues 
 are primarily envoi ved and in then- entirety ; that is, that every 
 division of the nervous system, whatever artificial divisions of 
 its functions be made, particixjates in the phenomena of the 
 disease. In other words, the symptoms and the lesions are con- 
 nected with intellect, emotion, the motor faculties, voluntary and 
 involuntary, as well as those connected with trophic functions. 
 
 That the earUest symptoms are due to an excited or uncon- 
 trolled condition of the vascular system, which leads eventually 
 to interstitial changes in the tissues themselves. 
 
 The same order will be pursued in the examination of this 
 part of the subject in connection with general paresis, as was 
 adopted in relation to ordinary insanity, viz., the subject will be 
 divided into : — 
 
 I, The supposed causes or the etiology. 
 
 II, The anatomical characters of the disease or post mortem 
 appearances, 
 
 III, The pathology or the explanation of the altered func- 
 tions, 
 
 I. The Etiology. — This will be discussed in the following order; 
 
GENERAL PARESIS. 28l 
 
 A. Remote Causes. — (a) Predisposing Cause. "Ilia qu89 corpus 
 tautum morbo opportunum reddit." 
 
 (bj Exciting Cause. '* Ea qu» in corpore jam proclivi facto 
 morbum excitat." 
 
 It must be owned, however, that it is not always easy to dis- 
 tinguish between these in practice. 
 
 B. Proximate Causes. " Ilia qusB presens morbum facit, sublata 
 tollit, mutata mutat," or the real or pathological basis of the 
 disease. 
 
 A. (a) The remote and predisposing causes of ordinary insanity. 
 
 Those causes which have been considered as predisposing or 
 to give a greater liability to general paresis, are the following, 
 wliich will be considered separately in the following order : 
 
 1. Sex most hable. 
 
 2. Ages most liable. 
 
 3. Complexion or physical temperament. 
 
 4. Condition as to marriage. 
 
 5. Social position. 
 
 6. Education. 
 
 7. Character and disposition. 
 
 8. Habits as respects temperance. 
 
 9. Syphilitic taint. 
 
 10. Heredity. 
 
 11. Injuries, etc. 
 
 12. Epilepsy. 
 
 13. Eace or constitution. 
 
 1. Eelative liability of the sexes to the disease as given by 
 Dr. Algernon Chapman . 22 males to 5 females. 
 Somerset Asylum ... 8 ,, ,,2 ,, 
 
 Dr. Mickle, England . . 14-1 ,, ,, 3-2 „ 
 
 Calmeil 50 ,, ,, 15 ,, 
 
 The average of these may be taken to be in whole numbers as 
 5 to 1.* 
 
 2. Age. — Dr. Mickle from calculations, based upon Thirty-second 
 Report of the Commissioners in Lunacy, states the relative ages 
 of patients to be 14-4 per cent, between 40 and 50, and 18*5 per 
 cent, between 30 and 40. 
 
 * Journal of Mental Science, April, 1879. 
 
282 LECTURES ON MENTAL DISEASE. 
 
 I found at Hanwell among the females. 
 
 iween 16 and 20 . 
 
 . 1 
 
 20 
 
 
 25 . 
 
 . 
 
 26 
 
 
 30 . 
 
 . 6 
 
 30 
 
 
 35 . 
 
 . 7 
 
 35 
 
 
 40 . 
 
 . 7 
 
 40 
 
 
 45 . 
 
 . 7 
 
 45 
 
 
 60 . 
 
 . 6 
 
 60 
 
 
 65 . 
 
 . 2 
 
 55 
 
 
 60 . 
 
 . 
 
 60 
 
 
 65 . 
 
 . 4 
 
 65 
 
 
 70 . 
 
 . 1 
 
 
 41 
 
 These figures differ from the above, but they show that fi-om 
 30 to 60 is the epoch most liable to the disease. 
 
 3. Complexion, — Dr. Burman examined this subject, suggested 
 to him by Dr. Saunders, who had observed that general paretics 
 as a rule were of dark complexion. Dr. Biu'man found 23 dark, 
 14 medium, 3 fair. In my own practice the dark have distinctly 
 predominated ; the proportion of dark and fair in the sane, how- 
 ever, I have no means of knowing. 
 
 4. Married or Single. — Statisticians have examined the relative 
 frequency of the disease as to marriage. Dr. Mickle gives the 
 following figures which he quotes from Dr. Algernon Chapman _ 
 
 
 Per 100,000 of Population of same age. 
 
 Of General Paretics. 
 
 Males. 
 
 Females. 
 
 Total. 
 
 Sinple 
 
 Married 
 
 Widowed 
 
 30-4 
 24-6 
 29-1 
 
 5-4 
 57 
 70 
 
 16 5 
 15-3 
 15-4 
 
 This table points to the effects of other operating causes, thus 
 single men suffer more than married or widowed, while 
 widowed women suffer more than single or married. The 
 recklessness of the young men and the straitened circumstances 
 
GENERAL PARESIS. 283 
 
 and troubles of the widowed women being probably at the root 
 of the different liabilities. 
 
 5 and 6. Social Position and Education. Education.— 1 stated 
 in the first edition of these Lectures that the disease was more 
 common among the poor and uneducated, than among the 
 educated and richer class. Dr. Mickle differs from me in 
 this, I have therefore re-examined the subject. I think the 
 Commissioners' Eeport, which he quotes, shows the disease to 
 be more common in the lower than in the upper classes. 
 Dividing the Commissioners' Orders of " station in Hfe " in- 
 to three, general paresis occurred in 11-1 per cent, in the highest, 
 and 16-9 per cent, in the lowest, and 17*4 in the middle classes. 
 But there is a source of error which might be easily overlooked in 
 these tables. It is reported that the disease occurred in the ratio 
 of 24-1 per cent, of those in Order I., or of those engaged in the 
 government of the country, taking this to be made up of magis- 
 trates, judges, lords, etc., it would show a high rate of cases among 
 the upper class ; but the order also includes, and in far greater 
 number of course, all government clerks, messengers, govern- 
 ment workmen, officers of law courts, policemen, prison officers, 
 municipal, parish and union officers ; while among plutocrats 
 alone it is in the ratio of 7*9 per cent. 
 
 The records of private practice do not afford very good means 
 for investigating the causes of disease, my own private patients 
 are all of the educated class, and I find that nine per cent, were 
 affected with general paresis. Dr. Mickle found in his own cases 
 that is the ratio among the class of soldiers was 18i per cent. 
 
 In the Twenty-fifth Report of the Commissioners in Lunacy, table 
 XX., the proportion of general paralytics to total admissions in 
 the private asylums was one- twentieth of the whole, and in the 
 pauper asylums one-fourteenth. 
 
 Social Condition as to means. — As this condition is much 
 the same as that of the degree of education ; I refer to the 
 conclusion in previous paragraph, remarking only that I 
 am still of opinion that the liabiHty to insanity in general is 
 much more prevalent among the pauper than among the non- 
 pauper population. 
 
 Dr. Burman after examining the subject de novo, arrived at the 
 same conclusion. In analysing 341 cases of general paresis, as to 
 
284 LECTURES ON MENTAL DISEASE. 
 
 the Bocial position of the patients, he concludes thus: — "Pro- 
 bably Dr. Sankey is correct when he states that the predisposi- 
 tion to the disease is in the following order : — 
 
 1. Males of the lower classes. 
 
 2. Males of the upper classes. 
 8. Females of the lower classes. 
 4. Females of the upper classes." 
 
 7. Character and disposition. — Dr. Algernon Chapman, he. cit., 
 quotes cases in " a most active, pushing, energetic man," one 
 " fond of society, bon-vivant, self-indulgent in every du-ection ;" 
 and in my own experience those of sanguine, ambitious, impro- 
 vident, speculating, scheming and reckless temperament are cer- 
 tainly more x^rone to general paresis, and it is worthy of remark 
 how often this is found in these cases, whereas in cases of 
 spinal disease the cause of the disease is as a rule in a different 
 kind of individual, in whom also the immediate or exciting cause 
 is obscure. 
 
 Strong sexual propensity. — There certainly has been in most 
 of my cases evidence of this. StiD, it must be remembered, 
 that the e\idence is hkely to be equivocal as there is no 
 doubt that sexual excitement is a symptom of the disease, but 
 that is quite different from being a cause and a predisposing one. 
 There is a total absence of reticence in the patient at the same 
 epoch. So that if one at all rehes upon what the patient him- 
 self says, there would be sure to be abundant history of libidin- 
 ous character. 
 
 " Out of thii'ty-five cases, of which the history of the disease 
 was complete, eleven were known to have led an habitually ii-regu- 
 lar life, with respect to sexual indulgence ; and of fourteen onlj' 
 was the information satisfactory as to the contrary state of 
 things ; even of these fourteen, one had borne an illegitimate 
 child in early Hfe, but since, according to her mother, had lived 
 correctly ; and one other was a married woman, who left her 
 husband on the day after her marriage." 
 
 The above is extracted from my previously pubhshed lectures 
 in 1866, my subsequent experience bears out the same kind of 
 evidence of sexual irregularities. My own evidence, however, 
 does not lead me to the conclusion that the cause of general 
 paresis is excessive sexual indulgence. On the contrary, my 
 own conclusion would be, that it is the efect. 
 
GENERAL PARESIS. 285 
 
 There is much force in the remark of Dr. Mickle that the 
 period of most hability to the disease, or between 30 and 60, does 
 not at all correspond to the period of the strongest sexual pas- 
 sions, it may, however, coincide with the time when too great in- 
 dulgence would begin to show fruit. 
 
 8. Habits, as respects temperance. Drink, Intemperance, etc. — 
 Speaking of the causes of general paresis. Dr. Hack Tuke gives 
 prominence to alcoholic excesses and dissipated habits com- 
 bined; he adds in many cases with insufficiency of nourishment, 
 there is scarcely an author who does not refer to this agent, 
 and indeed many cases of general paresis are set down as mania 
 a potu. 
 
 " Intemperance, by which is meant indulgence in alcohoHc 
 drinking, appears in every statistical table as the predominating 
 cause of general paresis, above all other kinds of causes." 
 
 It is obvious that it can only be a predisposing cause, and that 
 it should be so, is not surprising since the action of all alcohohc 
 beverages is directly on the cerebral organ, and the symptoms 
 produced by alcohol in excess, are very similar to those of gen- 
 eral paresis ; the phenomena of drunkenness are a close copy of 
 general paresis, as the elation, bragging, thick speech, stagger- 
 ing gait, etc., in fact, a drunken man might be almost utihsed 
 for demonstrating the disease to a clinical class ; 19 per cent, of 
 Dr. Burman's cases of general paresis are attributed to intem- 
 perance, drink and dissipation. 
 
 Dr. Mickle after reviewing very numerous authorities who 
 concur almost unanimously in the opinion that excess in alcohol 
 is the predominating cause of general paresis concludes thus : — 
 " In my own cases alcohol though perhaps rarely acting alone, 
 has appeared to be by far the most frequent and efficacious 
 cause of general paralysis." 
 
 It must be borne in mind however that the reckless disposition, 
 the self indulgence to which the subjects are prone, in regard to 
 all kinds of sensual excesses, may give some explanation for the 
 intemperance in drink, and that the excess therefore may be the 
 effect of the disease rather than a cause. 
 
 That it is not a determining or the actual and proximate cause 
 of the disease is clear, for as M. Voisin remarks the anatomical 
 changes, and the symptoms of alcoholismus are of different and 
 well known character. 
 
286 LECTURES ON MENTAL DISEASE. 
 
 And I find that in private practice the predominance of alcoholic 
 excess as a cause is by no means so great as in pubhc and pauper 
 asylums. In my small hcensed house I have treated twelve cases 
 of general paresis, and ten of these were in temperate subjects, 
 one was decidedly intemperate and one of doubtful kind. 
 
 Drink however must be considered a very possible predispos- 
 ing cause in many cases. 
 
 9. Syphilitic taint. This may be considered from two aspects, 
 one from its moral bearing and the other from its physical. 
 
 As a moral cause however it only is an evidence of self in- 
 dulgence and recklessness of character, already considered under 
 (7) character and disposition. It may be admitted that syphihs 
 is often present in the history of a case of general paresis. 
 
 That syphihs, however, predisposes to insanity of any kind in 
 its physical operation, is not proved, the evidence tending rather 
 to an opposite conclusion. 
 
 Dr. Broadbent in the Lettsomian Lectures, 1874, remarks, that 
 the syphihtic affections of the brain would point to a different 
 set of symptoms and morbid appearances from those found in 
 insanity, such as thrombosis of the arteries and impaction of the 
 vessels, and in syphilitic deposits. 
 
 Syphihtic growths occm- in the brain and give rise to various 
 symptoms, such as headaches, not common in general paresis, 
 with other symptoms of cerebral origm, which vary in different 
 cases according to the actual seat of the growths in the brain. 
 
 I see no reason therefore to alter the opinion which I expressed 
 in the previous edition of these lectures, namely, that though 
 there is a parallchsm between these two diseases in their 
 etiology, yet at present it has not been shown that general 
 paresis is a syphilitic disease, and such appears to be the con- 
 clusion arrived at by several others. 
 
 Dr. Fo^ille in a criticism on a paper of M. Tournier, thus ex- 
 presses himself, that as yet there is no distinct origin proved of 
 general paresis in syphihs, Medico PsychohgicalJournal, January 
 1880. 
 
 M. Tournier in a paper. Annates Medico Psychologiques, January, 
 1879, designated " Pseudo General Paralysis of Syphihtic Origin," 
 attracted the attention of Dr. Fo^•ille to the subject. After 
 perusing the several cases given as examples of the syphihtic ori- 
 
GENERAL PARESIS. 287 
 
 gin of general paresis, one is compelled to the same conclusion 
 
 which I arrived at hefore, viz., that the same causes which 
 made the subject prone to syphilis, rendered him also very ob- 
 noxious to an attack of general paresis, or the peculiar disposition 
 and character of the patient. 
 
 Dr. Foville however, on the other hand remarks " that the 
 diagnosis between general paresis and syphilitic tumours of 
 the brain is extremely difficult if not impossible," He quotes, 
 M, Lancereaux, Gazette Hehdom. 1873, who however seems only to 
 say, that certain syphilitic lesions viaxj produce a symptomatic 
 ensemble greatly resembling general paresis. 
 
 The differential diagnosis between general paresis and syphili- 
 tic diseases of the brain will be found at a future page. 
 
 10. Heredity. — Has been variously estimated, usually it is 
 based upon the tendency to any kind of neurosis. On this ba- 
 sis my own calculations made : — 
 
 14+ per cent instead of 20 among females. 
 
 11 \ „ ,, ,,22 among males. 
 Or upon an average of 16 per cent of hereditary causes in 
 general paresis to 21 per cent in other cases of insanity, thus 
 showing a distinct difference in the ^predisposing causes of the 
 two diseases. 
 
 11. Cranial injury. — Dr. Mickle, Journal of Mental Science, Jan., 
 1883, says : "In the cases which have come under my own obser- 
 vation where cranial injury has conduced to general paralysis, it 
 has in the majority served to play the part of a predisposing rather 
 than of an exciting cause." I have not seen any case myself, 
 where general paresis was attributable directly to injury to the 
 head, but in the case of a gentleman who came under my care, 
 the patient had had a severe injury from a fall in a steeple chase 
 and was nearly a week insensible, but eventually recovered and 
 remained quite well for two years before the symptoms of paresis 
 set in. I also was consulted in another case of general paresis, 
 in which the patient had had an injury to his head many years 
 previously, and bore the marks of cicatrices. What the injury 
 had to do with the ultimate affection of the brain it is not easy 
 to say. Dr. Mickle gives two out of twenty cases in which cranial 
 injuries were alleged. In my experience cranial injury has been 
 
 • See also Journal of Mental Science^ April and October, 1877, and Jan. 1880. 
 
288 LECTURES ON MENTAL DISEASE. 
 
 certainly much less frequently discovered, but Dr. Mickle's 
 patients are much more exposed to injuries than mine, who were 
 mostly females. I must have treated nearly one hundred cases, 
 but cannot call to mind any case in which cranial injury could 
 be an indubitable cause of the attack, but it certainly seems to 
 be a remote cause in some. 
 
 12. Epilepsy. — The large number of cases in the return of 
 causes of death from the different county asylums, in which 
 epilepsy and general paralysis are combined, points to the 
 possibiHty of epilepsy as being predisposant, but I have no 
 evidence to show that it really is so. I should rather be dis- 
 posed to beheve that the convulsive attacks which are not un- 
 frequent in general paresis have been set down as epilepsy. 
 
 13. Race. — An opinion has been expressed that race had in- 
 fluence in the liability to general paresis and this arose from the 
 observation of many physicians that the disease was scarcely 
 known in Ireland. An investigation was therefore undertaken 
 by a committee of the International Medical Congress of 1881,"^' 
 who drew up a report on the race-relationships of general para- 
 lysis, based on repHes to the queries received from different 
 observers, from this report, I gather that the disease is scarcely 
 known, in the Irish Asylums. But the conclusion arrived at 
 was that in the most' thoroughly Saxon districts, the disease was 
 more frequent than in the more Celtic races, and that the Celtics 
 inhabiting Brecon, Kadnor and different Welsh counties had 
 also a comparative immunity from the disease. It appears also 
 that in those districts in Ireland, which had the greatest immunitj' 
 from general paresis, were those where the largest portion were 
 agi-iculturally employed. In the same districts it seems 
 established that syphilis also was extremely rare, this if fully 
 proved would make another link in the evidence of the connec- 
 tion of syphilis with the etiology of general paresis, and especi- 
 aDy as the underlying temperament which seemed to be the 
 common cause of both diseases may be considered in this case 
 as separated, for the sanguine temperament, recklessness of dis- 
 position, is not remarkably absent from the Irish. 
 
 I must admit, however, which I readily do, that the study of 
 these remote and predisposing causes throws very little hght 
 * Dr. J. J^she's Eeport. 
 
GENERAL PARESIS. 28g 
 
 upon the real nature of the disease. It seemed to me necessary 
 to consider them as they occupy the attention of most writers 
 on this subject, but after all, I fear, it has been as yet, but work 
 and industry wasted. 
 
 A. (6) The remote and exciting causes. — We next have to con- 
 sider the remote and exciting causes, the results from the con- 
 sideration of which are more suggestive. 
 
 There is much difficulty in determining in many instances 
 among the remote causes, between what is an exciting cause and 
 what a predisposing cause. 
 
 Some agents may act in either way, as drink. Notwithstanding 
 this difficulty, as I have already shown, remote causes of the 
 attack have been proposed as a basis of classification. 
 
 In considering the exciting causes of an attack of general 
 paresis we may divide them into moral and physical, and I will 
 endeavour to keep these separate. 
 
 An exciting cause must be a concrete, a predisposing cause 
 is an abstract. Thus alcohol taken in excess may be the ex- 
 citing, but intemperance is a predisposing cause. 
 
 Moral causes. — The frequency with which a distinct nervous 
 shock can be traced is remarkable. Most authors allude to it ; 
 Mr. Austin calls it a moral agony; Dr. Mickle, an emotional 
 over-strain. The Commissioners in Lunacy in their Eeport for 
 1880, found by the returns made to them that moral causes for 
 the disease occurred in about 23 per cent, of the whole in 
 general paresis. They divided these causes in the following 
 manner : — Domestic trouble, 55. Adverse circumstances in- 
 cluding business anxieties and pecuniary difficulties, 88. Men- 
 tal anxiety and overwork, 67. Rehgious excitement, 3. Love 
 affairs, 4. Fright and nervous shock, 10. That is 183 out of a 
 total of 786, or at the rateof 23-28 per cent, (34th Report, p. 42). 
 
 But these are public returns, and I fear that not much value 
 can be put upon them, and considering the very general opinion 
 concerning the incurability of the disease, the value of them is 
 not increased by the fact that out of 786 cases no less than 38 
 are set down as second attacks. 
 
 Individual testimony from those who have investigated the 
 disease pathologically is of more value, and there is a pretty 
 general agreement among these that moral causes have a large 
 
 u 
 
290 LECTURES ON MENTAL DISEASE. 
 
 share in the etiology of the disease. Dr. Burman (West Ridinrj 
 Reports, Vol. 1, p. 140), after tabulating 103 cases of general 
 paresis from the records of the Devon County Asylum, found 
 moral causes to be in excess and the ratio to be of moral 
 causes 53, physical causes 50, or about double that of the 
 Commissioners in Lunacy. Dr. Burman says, " the experience 
 of this (the Devon County Asylum) tends to confirm the asser- 
 tion of Austin, that moral agony is the cause in the majority 
 of cases of general paralysis, for, as we have just observed, the 
 the cause in the majority of cases was a moral one, and al- 
 though, as an individual cause, intemperance would seem to 
 carry off the palm, it is an open question as to whether or not in 
 many of the cases it was not rather the effect than the cause of 
 the disease, I can call to mind several cases admitted into the 
 asylum, within my own experience, in which the cause assigned 
 by an indiscriminating reheving officer or overseer was drink, 
 but in which a careful cross-examination as to the history of the 
 patient, showed that such was not really the case, but that it 
 was as I have just surmised it to have been." (p. 143, loc. cit.). 
 
 We cannot, however, include all these to be exciting causes 
 but the enumeration of them in Dr. Burman's paper shows that 
 many of them were in all probabihty the true determining cause, 
 as fright, 8 ; death or serious illness of near relative, 7; loss of 
 ship in a gale, 2 ; then it does not appear that any single case 
 had two causes assigned, so that the most obvious was in many 
 instances probably selected, as drink, a physical cause in 19, very 
 likely itself due to some " moral agony '' as well. 
 
 In resorting to my own experience I have been able to trace 
 the disease to a distinct " nerve shock " in very many instances. 
 This shock has been usually of painful nature but not invariably ; 
 as examples I may give the following. A gentleman found that 
 his son had forged his name for a large amount, the discovery 
 was sudden, on going to the bank the cheque was shown him. 
 A lady, a widow, lost her only child, by a fever in a few days, 
 while travelling abroad. An officer in the Navy became engaged 
 to a lady the adopted daughter of a bachelor uncle, a man of 
 wealth, the marriage was favoured by the uncle on condition 
 that the husband should give up his profession and reside with 
 his wife, near to the uncle, who made them a handsome allow- 
 
GENERAL PARESIS. 2gi 
 
 auce ; the uncle over seventy just before liis death, married his 
 nurse and housekeeper, and altered his will, in which he left all 
 his real property to the niece, and his personal property to his 
 new wife. It turned out that very nearly all his land, which 
 produced the chief of liis income, was copy-hold, it was supposed 
 that the testator was not aware that that ranked as personal 
 property. The niece was thus suddenly deprived of all her 
 expectations, the husband became affected with general paresis. 
 
 In this case however, the actual catastrophe probably only 
 acted as an additional or exciting cause, for the husband had 
 amaurosis at the time of the disappointment, and was thus pre- 
 disposed to the disease. 
 
 A speculator on the stock exchange on losing a very large 
 amount of money. 
 
 A gentleman a widower, was left with two sons, with then- 
 mother's property settled upon them on theu' attaining the age 
 of 21. After carefuUy, and perhaps too strictly superintending 
 their youth, he found on their coming of age, that they both, 
 one after the other, threw off their allegiance, and launched into 
 extravagance and vice. One of them speedily drinking himself 
 to death, and the other was following the same course, this 
 attack began on the death of the eldest. 
 
 A gentleman on returning from India with his wife and 
 children soon after the mutiny, first lost his wife during the 
 voyage, and then a child directly after his landing. 
 
 There are several other cases of similar character, which from 
 circumstance, I am unable to give. Among my HanweU cases, 
 the following examples occurred. A hah- dresser's wife, with a 
 family of children, had been suffering from destitution, during 
 the greater part of a winter, scarcely even being able to give the 
 children enough food, the husband earning only a few shillings 
 from time to time. One morning he returned home with the 
 news, that he had got employment of permanent kind with good 
 pay, and he gave her a sovereign which had been advanced to 
 him. She was overcome at the time, and when the husband 
 returned from his work that evening, he found her strange in 
 conduct. She had spent the sovereign whoUy in bujing carpet 
 shppers, which she said she meant to sell for a large sum. In 
 this case it was over-joy. 
 
 u2 
 
2g2 LECTURES ON MENTAL DISEASE. 
 
 A young woman of 18, living with her father, who was a bird- 
 catcher, and who had frequently to go into the country for 
 several days or a week together. On one occasion, on leaving, 
 he gave her half a sovereign for house-keeping. As she was 
 going to a shop, she dropped the money, and a man saw 
 her pick it up. He accused her of stealing it, and gave her 
 in charge ; she was taken to the station, and the money was 
 taken from her. On being taken before the magistrate, she was 
 unable to make any reply, and was sent to prison for 14 days. 
 On returning home, the father found her perfectly altered, she 
 talked of her wealth, of having plenty of money, &c., and he was 
 told, that while in prison, she had a kind of fit. 
 
 A young woman at the age of 16 or 17, of good appearance, 
 was a patient vp. St. Bartholomew's Hospital, where she attract- 
 ed the attention of a medical student. He sent her to a school 
 for a year, and afterwards married her. They Hved together in 
 great extravagance for a term, when he, pursued by his creditors, 
 deserted her. In this case, the causes where somewhat compli- 
 cated, for on her desertion, the parents of the husband aUowed 
 her some money, but on finding that she was not temperate 
 and was not as they beheved, leading a regular life, they stop- 
 ped the allowance, and she became insane, the dissolute hfe was 
 perhaps the predisposing cause, the sudden stoppage of the 
 means of living the exciting cause. 
 
 A young woman brought up in the country and a domestic 
 servant, having an excellent character, mamed a painter who 
 came from London to paint her master's house. She went to 
 London while there she had three children ; the husband turned 
 out a very drunken and dissipated character, deserted her and left 
 her almost in a starving condition. One of her children was 
 taken ill and died ; the friends said that she had never been the 
 same since ; she became loose in her conduct, was taken up for 
 pulling up the shrubs in a gentleman's garden, and had gone up 
 to two gentlemen in the road and thrown her arms round their 
 necks and kissed them. 
 
 A kept mistress, after living in gi-eat luxury, keeping her 
 brougham, etc., was suddenly deserted by her paramour, had 
 been an epileptic in childhood. 
 
 Physical exciting causes. — I believe by far the most frequent 
 
GENERAL PARESIS. 293 
 
 exciting or determining cause of general paresis is a nerve shock 
 of uon-physical kind as just described ; but it seems that some of 
 purely material kind have induced the disease, among which are 
 mentioned by different authorities, injuries and sun-stroke; the 
 latter being the attributed cause in 7 out of 50 in Dr. Burman's 
 cases, and injm'ies of various kinds in 19 out of 60. 
 
 II. Morhid Anatomy or the 'proximate cause of general paresis. 
 
 The evidence to be gathered from the appearances after death 
 may be examined in the usual mode, taking j&rstly the grosser 
 kind or such as are brought to light by the unassisted vision, 
 and secondly by aid of the microscope. 
 
 The examination by naked eye may be thus divided : 
 
 1. The appearances found in the brain and calvaria generally. 
 
 2. In the rest of the body. 
 
 The following table exhibits in detail the alterations found in 
 fifteen examinations made by myself, and they are contrasted by 
 placing them by the side of fifteen cases of appearances in 
 ordinary insanity. I think the changes bear out the con- 
 clusion that the vascular system generally is much more 
 affected in general paresis than in ordinary insanity ; and inci- 
 dentally this unaided inspection also demonstrates much graver 
 changes in the nerve elements. 
 
 The following are the most prominent differences ; opacity of 
 arachnoid, serous effusions beneath it, adhesion of pia mater, 
 increased vascularity generally. While the cerebral sub- 
 stance itself is decreased in weight absolutely, and in specific 
 gravity, the convolutions are more open, the layers of the gray 
 matter more indistinct. 
 
 Of course the fact should be also borne in mind, that death in 
 general paresis much more frequently is dii-ectly caused through 
 the nervous system ; while death in ordinary insanity is more 
 frequently due to intercurrent disease. 
 
 (-1. EXTERNAL CHARACTERS. 
 
 15 Cases of 
 General 
 Paresis 
 
 15 Cases of 
 Ordinary 
 Insanity 
 
 (A) Form of Cranium. 
 
 
 
 Profile. 
 
 
 
 Frontal region large, occipital small 
 
 1 
 
 1 
 
 Frontal and occipital equal 
 
 9 
 
 8 
 
 Frontal small, occipital large .. 
 
 4 
 
 6 
 
 Plan or Horizontal Section. 
 
 
 
 Oval form 
 
 9 
 
 10 
 
 Circular 
 
 3 
 
 
 
294 
 
 LECTURES ON MENTAL DISEASE. 
 
 HEAD-I. EXTERNAL CHARACTERS.— (Conh'nucd). 
 
 Egg shape, larger ia front 
 
 „ ,, lurger behind 
 
 Elevation. 
 Vertex low 
 
 ., bigt 
 
 Irregular in form... 
 Measurements ... . . 
 
 (B) Hair. 
 
 Much 
 
 Little 
 
 Colour. 
 
 Light .. 
 
 Eed 
 
 Dark 
 
 Gray 
 
 (C) Integuments. 
 
 Normal ... ... 
 
 Infiltrated with serum ... 
 
 (D) Periosteum. Normal 
 
 (E) Bone. 
 
 Tbiekness normal, diploe distinct 
 
 ,, increased, diploe indistinct 
 ,, diminished 
 
 Consistence spongy 
 
 (F) Vascularity of Head, generally and externally 
 
 Normal 
 
 Increased ... , ... ... 
 
 II. INTERNAL CHARACTERS 
 (A) Membranes. 
 
 1. Dura Mater. 
 
 Normal ... 
 
 Abnormal, adherent to bone 
 
 ,, ,, to arachnoid 
 
 Increased in thickness 
 
 Bony deposit 
 
 2. Arachnoid, 
 
 Normal 
 
 Abnormal. 
 
 Adherent 
 
 Opaque or thickened ... 
 Contents. 
 
 Serous efifusion 
 
 Lymph eflfused 
 
 Pus 
 
 Blood 
 
 3. Pia Mater. 
 
 On surface of Convolutions 
 
 Normal (strips readily) 
 
 Abnormal non-adherent 
 
 5 Cases of 
 
 General 
 
 Paresis. 
 
 
 
 2 
 
 13 
 
 
 
 
 
 average 6 x 6i 
 
 3 
 1 
 
 7 
 3 
 
 14 
 
 I 
 
 15 
 
 10 
 
 1 
 12 
 
 11 
 
 15 Cases of 
 
 Ordinary 
 Insanity. 
 
 
 5 
 
 13 
 2 
 1 
 
 7 
 6 
 
 2 
 
 7 
 5 
 
 15 
 
 
 
 15 
 
 3 
 
 2 
 
 11 
 4 
 
GENERAL PARESIS. 
 
 295 
 
 II. INTERNAL CHARACTERS, Pia Mater (Continued). 
 Abnormal adherent 
 
 Vascularity increased 
 
 ,, diminished 
 
 Serum in meshes ... 
 
 Blood ,, 
 
 Tubercle 
 
 4. Plexus Choroides. 
 
 Normal 
 
 Vascularity increaaed 
 
 Opaque 
 
 (B) Brain Substance. 
 
 1. General Characters. 
 To Touch. Weight. 
 
 Cerebrum average oz 
 
 Cerebellum and pons ,, 
 
 Ratio of Cerebrum to Cerebellum 
 
 Specific Gravity. 
 
 White Substance 
 
 Gray „ 
 
 Consistence generally. 
 
 Firm 
 
 Flabby 
 
 To Sight. 
 
 Colour. Congested 
 
 Form. Irregular 
 
 Convolutions open 
 
 2, Special Characters. 
 
 (a) Gray Matter. 
 Colour. 
 
 Dark 
 
 Light 
 
 Injected ... 
 Layers distinct 
 
 ,, indistinct 
 
 Consistence. 
 
 Firmer than normal 
 
 Softer ,, 
 
 Morbid growths 
 
 Torn by removal of membranes 
 
 Atrophy 
 
 (b) White Matter. 
 Colour. 
 
 Dark 
 
 Pale 
 
 Injected 
 
 Consistence. 
 
 Firm 
 
 Soft 
 
 RaraoUisement 
 
 3 Cases of 
 General 
 Paresis 
 
 8 
 
 15 
 
 
 
 9 
 
 L 
 
 15 Cases of 
 Ordinary 
 Insanity. 
 
 1 
 
 34i 
 
 H 
 
 6-54 to 1 
 
 1-039 
 1-034 
 
 3 
 8 
 
 10 
 
 351 
 
 6 45 to 1 
 
 1041 
 1-031 
 
 5 
 
 4 
 
 5 
 
 4 
 
 
 
 4 
 
 
 
 I 
 
 8 
 
 1 
 
 1 
 
 
 
 2 
 
 1 
 
 4 
 
 3 
 
 8 
 
 8 
 
 8 
 
 4 
 
 5 
 
 4 
 
 
 
 
 
296 LECTURES ON MENTAL DISEASE. 
 
 The table marks a great difference in the post mortem ap- 
 pearances in general paresis and in ordinary insanity ; and 
 though the cases are few in number they are distinguished from 
 all other forms of disease ; and the appearances given by most 
 of the previous writers have consisted of all cases without such 
 separation. 
 
 Such is not the fact, however, with all. Dr. Mickle in his 
 valuable monograph on this disease is an exception, he writes, 
 " the pia mater itself is thickened, coarse, usuaUy hyperaemic 
 either universally or in irregularly distributed patches." There 
 is shown in the whole of the cases in the above table, some 
 change in the pia mater, the vascularity was increased and in 
 seven out of fifteen cases it was adherent to the cortex beneath. 
 This condition of adhesion of the membranes has been supposed 
 by some to be peculiar to this disease and to be universally 
 found, this is not the case as the table shows, there was adhe- 
 sion in eight only out of the fifteen. On attempting to strip off 
 the membranes when they adhere, small portions of the gray 
 matter are torn away, the reason of this will be readily under- 
 stood when we examine the gray matter. Sometimes at least* 
 wlien the membranes strip readily it is found to be due to an 
 effusion of serum which bathes the surface beneath. 
 
 Dr. Crichton Browne (West Fading Reports, vol. ^^), more par- 
 ticularly examined the seat of these adhesions of pia mater, for 
 this purpose the membranes were removed by a chemical sol- 
 vent, " by steeping the brain for a few weeks in a mixture of 
 one part of strong nitric acid to eight or ten of water," the pia 
 mater by this mode was destroyed, and the " convolutions left 
 entire and bearing the marks of the adhesions," which were left 
 rough, eroded and readily recognisable. 
 
 He found that the adhesions were confined to the anterior 
 three-fourths of the brain and were not found on the posterior 
 fourth. 
 
 Dr. Browne found that in other cases of insanity in which the 
 membranes showed any signs of disease the same locaUty, the 
 occipital region, was exempt from changes. The island of Reil 
 he also found exempt fi'om adhesions of membrane. 
 
 " The favourite site of these is undoubtedly the frontal lobe 
 and no subdivisions of this lobe was exempt fi-om adhesions. In 
 
GENERAL PARESIS. 297 
 
 this locality the pia mater is often attached to the gray 
 substance, not in scattered parts and patches, but over the 
 whole of the summits of the convolutions, and tears away 
 when removed, to what is apparently half the depth of gray sub- 
 stance." 
 
 In the majority of cases adhesions are found on the slightly 
 concave surface of the orbital lobes. 
 
 On the surface of the parietal lobes, adhesions are commonly 
 found and occur in this locality oftener than in other districts 
 of the cerebrum, except the frontal lobes. 
 
 It will be observed that in many of these cases the membranes, 
 stripped in the ordinary manner, were bathed in serum so that 
 the adhesion is not due to drying of the surfaces. 
 
 Cortex. — The gray matter, in aU those cases which I have 
 hitherto examined, has presented some alteration from the nor- 
 mal condition. In every one of which I have taken accurate 
 notes there has been some increase in the vascularity. In about 
 three-fourths I have noted that the capillaries in its texture 
 could be traced carrying red blood ; and in those cases in which 
 the vessels were not visible there has been a distinct blush of 
 hypersemia to be seen. The colour of the gray matter was also 
 often changed, and was of a dark or slaty colour in full a third 
 of the cases examined by me, and in one fifth it presented a yel- 
 lowish or fawn or a pale colour. There was a loss of its waxen 
 semi-transparency as well, and its texture appeared shorter, or 
 more friable, and more opaque. 
 
 The white substance presents to the unassisted vision no 
 changes which could be considered constant. In one-half the 
 cases it was injected, in the same proportion firm, but in one- 
 third it was soft. 
 
 The weight of the brain has been made the subject of exam- 
 ination by several physicians, the whole subject has been recon- 
 sidered by Mr. Crochley Clapham (in the West Biding Eejwrts, 
 vols, iii and vi) in a very thorough manner ; the papers ren- 
 der any reference to the results of other observers unnecessary. 
 Mr. Clapham's examination extends over a total of 1200 cases. 
 He concludes, that the average brain of females and males is 
 1303-83 grammes. The average weight of cerebellum, pons and 
 medulla = 169*7 grammes, the average age of his subjects be- 
 ing 47 years. 
 
298 
 
 LECTURES ON MENTAI DISEASE. 
 
 The ratio of cerebellum, pons and medulla to whole cranial 
 contents or encephalon, 1 to 7*68, these figures serve as a stan- 
 dard of comparison for special kinds of disease. 
 
 As regards his conclusions in respect to general paresis calcu- 
 lated from 243 cases ; the following table arranged with the re- 
 sults in all cases will show what diffeience exists ; the upper 
 line being the general results, the lower line, those of gene- 
 ral paresis.** 
 
 General results all ages 
 General Paresis 
 
 Male and Fe- 
 male Encepha- 
 lon. 
 
 1303-835 
 1270-271 
 
 Cerebellum, 
 
 Pons and 
 
 Medulla 
 
 C.P.M. 
 
 169-7 
 1740 
 
 Average 
 age. 
 
 4678 
 41-610 
 
 Ratio of 
 Encephalon 
 to C P.M. 
 
 lto7'68 
 1 to 7-80 
 
 Thus it appears that the cerebellum is not only above the aver- 
 age relatively to encephalon, but actually ; while the brain itself 
 is below the average ; a result which corroborates the conclusion 
 which Dr. Skae arrived at in the examination of thirty- five cases 
 which I have quoted in my previous pages. 
 
 As regards the alteration of the cerebral substance as shown 
 by its density, the specific gravity as been examined by otherst 
 as well as by myself, the general conclusions shown in general 
 paresis is that in certain cases (probably in the early stages) the 
 density of the gray matter is increased, while in the later stages 
 it is below the normal. In Dr. Bucknill's sixty-two cases of 
 which eight were of general paresis, there were five of increased 
 density and three of diminished, in my own fifteen cases the 
 general result was slightly above the average. 
 
 All these appearances point to the seat of the disease, as also do 
 the symptoms, being in the cerebral organ and prominently to the 
 cortex ; there is evidence of increased blood supply, correspond- 
 ing to the stage of mental excitabihty, then there is evidence of 
 
 * See also similar tables by M. Parchappe, De la FoUe Pwralytique, Paris, 1869. 
 
 t Dr. Bucknill, op. cit. Parchappe, loc. cit. Dr. Bastian, Jourtial of Mental 
 Science- Dr Skae, Mnrningsids Keport. See also Pathology of Ordinary Insnn- 
 ityi p. 281. 
 
GENERAL PARESIS. 299 
 
 interstitial changes in the substance, especially in the gray sub- 
 stance ; there is afterwards evidence of shrinking of the convolu- 
 tions or atrophy ; as in the widening of the intergyral spaces, 
 and diminished weight of brain and diminished specific gravity. 
 
 With respect to the condition of the other viscera, they may 
 be considered in the same order as before observed. Chest or 
 organs of respiration and circulation ; abdomen or organs of 
 nutrition and excretion. 
 
 As regards the lungs. Dr. Mickle says that he found evidence of 
 pleuritic affections in two thirds of his examinations and not un- 
 frequently acute lung affections, tubercle in one third, lobar and 
 lobular pneumonia and recent pleurisy in some. 
 
 The kidneys he found diseased in one third, and in one fourth 
 of his cases he found abnormality of renal arteries, consisting 
 of an unusual distribution of them. 
 
 The few reports of cases that I am able to give from personal 
 examinations, bear out the above, with the exception of the 
 frequency with which disease of the kidneys was found. I think 
 this may be due to the fact, that my patients were all females ; 
 and considering how many of Dr. Mickle's cases indulged in 
 drink, perhaps the disease of the kidneys was to some degree at 
 least attributable to that cause. "In my own cases," he says, 
 " though perhaps rarely acting alone, drink has appeared to be 
 by far the most frequent and efficacious cause of general 
 paralysis." His patients were largely drawn from the class of 
 common soldiers. 
 
 Besides the evidence to be gathered by an examination of the 
 organs after death, the condition of the blood during life and the 
 state of the urine have been investigated. 
 
 Microscopical or Histological Examination. — The second mode 
 of examination is that by the aid of the microscope. 
 
 Brain substance. — Sections made of brain tissue, exhibit under 
 the microscope the following constituents : — Nerve cells, neuroglia 
 and blood-vessels. 
 
 For the assistance in description of the morbid changes, the 
 normal appearance of these will be first described according to 
 what I myself view as normal, in the following order : — 1. Cells ; 
 2. Neuroglia ; 3. Blood vessels ; and we shall find that each of 
 these in different cases is involved in the alteration of structure 
 by disease. 
 
300 LECTURES ON MENTAL DISEASE. 
 
 1. The cells in the cerebrum are of three kinds; (a) small 
 apolar ; (b) middle polar ; nud (c) giant polar cells. 
 
 (a) The small cells (or corpuscles) vary shghtly in size from 
 being rather larger than red blood corpuscles to the size 
 of white corpuscles, they appear to be without nucleus or 
 processes, are of somewhat globular or ovoid shape, they are 
 afifected by stains, they exist in large numbers in the second 
 layer beneath the membranes, increasing in number in the 
 deeper part of this layer, where they are larger and more angu- 
 lar, they occur also solitarily or in small numbers between the 
 cells of the deeper layers, and in the cerebellum (Plate I). 
 
 (6) The middle sized or polar cells of the smaller kind (shown 
 in Plate I, fig. 1) occupy the deeper layers, the third and fourth of 
 the cortex, and the rest of the gray matter : they are larger and 
 longer than the preceding, they consist of body and processes ; 
 the body is angular and conical, the point, from which the chief 
 process proceeds, being directed towards the pia mater or out- 
 ward, tiie body contains a nucleus and nucleolus, M. Luys 
 describes the body to be marked with fibres like wicker work : 
 the processes proceed, fr'om both ends, and are sometimes single, 
 or occur in twos or threes, and appear to come fr-om points in 
 the body, the upper processes are extended in a somewhat waved 
 hne, and may in some instances be traced to nearly one- sixtieth 
 of an inch in length. 
 
 (o) Besides these, there are large cells called giant cells, shown 
 in Plate I, fig. 2. These occupy particular parts of the cortex 
 and are believed to be motor. The^ drawing is from the para- 
 central lobe of the left side in a man who died 'of pyaemia, and 
 of the age of 40, the preparation from which it is drawn was 
 made by my son, Dr. Herbert 0. Sankey. It is di-awn to 
 the scale of one-fourth to 1000 of an inch. The processes from 
 these cells, as in the smaller cells, proceed from both ends. From 
 one end the larger process is a continuation of the smaller end 
 of the cell and is single, but occasionally it is branched. The 
 smaller processes proceed from the bulbar end of the cell, and 
 from angular points of it, they proceed less dii'ectly and in a 
 lateral direction also. Such are the chief characters of the cells 
 of the cortex, they have a resemblance to the cells of the cord, 
 and to those of the cerebellum. 
 
GENERAL PARESIS. 301 
 
 The large cells have been described as altered in various 
 ways in general paresis, they have been found with the contents 
 as it were undergoing degeneration, or converted into a granu- 
 lar mass, but this appearance is also found in senile dementia 
 and in the aged. Dr. Major also says that the large cells appear 
 fewer in general paresis than in normal brain, a result which I 
 had noted in my own examinations and so frequently as to be 
 in my opinion quite a characteristic of the disease. Dr. Major 
 writes, " Instead of being arranged in rows or layers they are 
 much fewer and but sparsely arranged " and he concludes that 
 they must have disappeared by disease ; he also notices what I 
 have observed, that when found, they are much less sharply de- 
 fined, there is a want of definition between theii' lines and the 
 neuroglia in which they lie, they often appear more rounded, less 
 angular, and the connecting fibres are not to be traced. 
 
 The small cells in certain cases have been found more numer- 
 ous than in normal brains, by Dr. Major, (Vol. II. p. 5,) in both 
 the superficial and in the deeper layer. The increase of these 
 cells in the deeper layer causes the stratified appearance that 
 is seen by the naked eye, and which I noted in one third of 
 the cases reported in the table. 
 
 These general characters taken in the aggregate, show a mate- 
 rial change in the microscopical characters of the gray matter, 
 but if considered individually there is no change perhaps as far 
 as regards the nerve cells, but may not be met with in brains 
 of persons dying under different circumstances, and especially 
 in the brain of those with senile dementia. 
 
 The general conclusion then to be deduced from examination 
 of the brain cells is that they are certainly found in a diseased 
 condition in general paresis, and though experienced observers 
 speak cautiously and doubtfully on the question of any distinc- 
 tive character of such lesion, yet the two points, the increase of 
 the small cells, and almost entire absence in some cases of the 
 large cells, or with an altered condition of them, taken together 
 go far to establish evidence of disease. 
 
 2. Neuroglia. This is in fact the connecting tissue of the brain 
 substance, and forms a matrix for the cells, vessels, and nerve 
 fibres, which compose the white substance of the brain. When 
 normal, it is described to be a clear, formless, somewhat trans- 
 
302 LECTURES ON MENTAL DISEASE. 
 
 parent or wax-like medium. As seen under high powers it gives 
 an almost uniform, non-granular, semi-transparent, somewhat 
 yellowish appearance, it is but shghtly coloured by aniline or the 
 usual dies, but generally, owing to the sections not being abso- 
 lutely even, it may show a varying semi-transparency. "When it 
 appears at all granular, it might probably be owing to the 
 operation of the transmitted light ; if anything like texture is 
 discoverable, anOine blue appears to bring out a very fine fibrous 
 arrangement of irregular texture hke the fibres of wood, but it 
 requires higher powers to demonstrate this. When hardening 
 media have been used the granular appearance is often more 
 marked especially after spmt or cluromic acid. 
 
 Up to a very late date unequivocal evidence of changes in 
 the neuroglia had not been obtained. Analogy of the morbid 
 processes had been leading to the opinion that the symptoms, 
 and appearances were due to a cirrhosis of the cortex. There 
 was the phenomena of atrophy of the cortex, with adhesions 
 of the pia-mater and such would seem to favour this view. 
 So long ago as 1864 in an article on the pathology of gene- 
 ral paresis in the Journal of Mental Science, I alluded to the 
 opinions of Eokitansky with respect to the hypertrophy (or 
 Binclegewebe Wucherumj), of the connective tissue in these 
 words, " the presence of hyahue around the capillaries, the fi*e- 
 quent occurrence of fibres traversing the preparations of cortical 
 substance in general paresis, appear to be due to an excess of 
 connective tissue fibres. Whether this excess is from what 
 Eokitansky calls Wucherunj or overgrowth of the original connec- 
 tive medium, or is thrown out by the capillaries, or is formed con- 
 jointly by both, is and must probably remain hypothetical ; 
 but excess of connective tissue I think can be demonstrated." I 
 added " its relation to the phenomena of general paresis, 
 cannot yet in my opinion be clearly defined. The condition is 
 not confined to general paresis. Kolcitausky, as ah'eady described 
 met with it in other forms of disease. It can therefore only be 
 the essential morbid change in general paresis by occupying a 
 particular seat as the cortical surface of the brain or by a 
 special rate of progress, as by being chi'onic in one disease and 
 acute in another." 
 
 At the date of making my own microscopical examinations which 
 
GENERAL PARESIS. 3O3 
 
 formed the ground for the above remarks, the processes for 
 microscopic examination were not so perfect as they are now, and 
 the use of stains was scarcely known. Microscopical processes 
 have since been considerably improved and Dr. Wiglesworth has 
 succeeded in demonstrating this condition of the neuroglia in an 
 unequivocal manner by the process recommended by Dr. Bevan 
 Lewis. Having myself thoroughly examined his preparations 
 and compared the engravings with the drawings, I can vouch 
 for the faithful rendering of the appearance (Plate II, figs. 1 
 and2).«* 
 
 Dr. Wiglesworth corroborates the results which I had arrived 
 at, that the appearance or hyperplasia of the connective tissue is 
 to be met with in other forms of disease, but his means of exa- 
 mination enable him to say that in no case to such extent as in 
 general paresis. " In two brains which we examined from 
 cases of Bright's disease, one from a sane, the other from an in- 
 sane patient, some distinct fibrillation of the first layer of the 
 cortex was present, this fibrillation was, however, moderate in 
 degree and not sufficient to create any difficulty. Dr. Bevan 
 Lewis has, however, described and figured proliferation of the 
 connective tissue from a case of senile atrophy." 
 
 " The conclusion hitherto reached," writes Dr. Wiglesworth, 
 " is that the hyperplasia of connective tissue bears some definite 
 and constant relation to general paralysis either as cause or 
 effect," and further states his opinion " that the disease is a true 
 cirrhosis of the brain, altogether comparable to cirrhosis of 
 other organs, that the connective tissue hyperplasia is the pri- 
 mary element in the disease and the affection of the nerve cells 
 secondary." 
 
 By Dr. Wiglesworth' s generosity I have been enabled to give 
 plates showing this condition of hyperplasia (see Plate II) and 
 if these figures are compared with the sections in Plate I, the 
 difference wiU be abundantly apparent, the di-awings were made 
 by myself, and I have been careful not to overrate the appear- 
 ances. 
 
 3. Vessels. The cortex is supplied from the pia mater, there are 
 two kinds of vessels, one long and the other short, the longer 
 
 * On the Pathology of General Paralysis, by Joseph Wiglesworth, M.D-, Lond. 
 Journal of Mental Science, Jan., 18S3. 
 
304 LECTURES ON MENTAL DISEASE. 
 
 vessels penetrate to the fourth and fifth layer before they divide, 
 the shorter penetrate only to the second or third layer and divide 
 up into small branches. They are said to be contained in a 
 sheath which is probable, as most vessels entering a parenchyma 
 of any kind are so, that there is a distinct canal or open sheath, 
 however, in the normal cerebral substance is a mistake, and 
 such appears only in diseased brains, or brains shrunken by 
 atrophy, or by artificial means of hardening reagents. If peri- 
 vascular canals are found as distinct canals as in Plate III, fig. 
 2, the appearance is in my opinion due to disease or atrophy, 
 and is analogous to bronchiectasis of the lungs. 
 
 The blood supply of the brain generally is of much interest 
 and is given in the anatomical text-books, but what is of chief 
 importance in cerebral disease is that the supply is in distinct 
 areas. In injecting the brain by one vertebral artery, the injec- 
 tion is confined to its own area, and each arteriole appears to be 
 subjected to the same arrangement, there is an absence of 
 anastomosis, above that of the circle of Willis (see Localisation 
 of Cerebral Disease, by M. Charcot, translated by Dr. Hadden, 
 New Syd. Soc, page 58, et seq.). 
 
 The microscopical [examination of blood-vessels in connection 
 with general pathology, has been undertaken by numerous 
 observers, and especially by the Vienna pathologists, Rokitansky, 
 Wedl, and others. The vessels of the brain were particularly 
 selected, since the brain affords the most ready locality to obtain 
 examples isolated from their connections. 
 
 A theory was propounded by Dr. Salomon of S. Malmo, that 
 the phenomena of general paresis were exphcable upon a 
 general morbid condition of the blood-vessels alone. Studying 
 the changes that occur in blood-vessels in general, he suggested 
 that the vessels of the brain became constricted, and thus gave 
 rise to atrophy. The atrophy of the brain substance, he then 
 described from Rokitansky. Dr. Salomon's explanation was an 
 h^^Dothetical one, nevertheless it is so far true, according to my 
 observation, that the small arteries of the brain are in an abnor- 
 mal condition in every case, and other observers, have made 
 the same observation. But what has been found is not, as 
 described by Dr. Salomon, an ischsemia or closing up of the ves- 
 sel, leading to an atrophied condition of the cerebrum. 
 
GENERAL PARESIS. 305 
 
 Wliat I liave seen most frequently in general paresis, I believe 
 to be more the result of a paresis of the muscular coat ; the same 
 defects of nerve- action as observed in the iris aiid in the 
 optic disc, extend to the apparatus for regulating the blood 
 supply ; all the symptoms show an irregular cerebration, as 
 though the governing or regulating apparatus allowed at one 
 time an excessive, at another time a scanty blood-supply ; the 
 heart at one time, acting with greater force, the blood sent to the 
 cerebral vessels throws them into contortions and varicosities ; 
 and with such excess, there are simultaneously increased pro- 
 ducts as exudations of various kmds ; and this is the condition 
 which my autopsies have declared, and more recent observations 
 have shown. 
 
 To examine the condition of the capillaries and small arteries 
 the best mode appears to me to be that pursued by Herr Wedl, 
 to take a portion, as a cubic inch of the cerebral substance, and 
 in preference this should be from the frontal and parietal re- 
 gions, and to separate it with all its membranes and submit it 
 to a stream of water until the whole of the cerebral matter is 
 washed away. It is necessary that the water used should be 
 well filtered. After the membranes are freed from the cere- 
 bral matter, they may be stained with a colouring matter. 
 
 This is one mode, another way is to make sections of the 
 brain substance as in preparing it for examination of the cells 
 and nerve tissues. 
 
 By the former mode a vessel can be traced throughout its 
 length, by the latter a fortuitous section will here and there be in 
 the line of a vessel during a part of its course, and thus show 
 occasionally the condition of the vessel //( situ, it will also give its 
 surroundings. 
 
 By the two modes, in all the cases of general paresis I have 
 examined, I have seen that the small arteries are in numerous 
 places thrown into varicosities and some of extremeh' com- 
 plicated kind as shown in figs. 2 and 3. In several prepai-atious 
 there may be also a hyaline membrane surrounding or connected 
 with the vessel, and small amber or reddish uric acid coloured 
 particles adhering to the hyaline membrane, especially at the 
 angles of a division of a branch. 
 
 In several of my examinations I have seen a knot of a small 
 
 X 
 
3oG 
 
 LECTURES ON MENTAL DISEASE. 
 
 vessel so closely invested by false membrane as to give the ap- 
 pearance of an aneurism (Fig. 2 and Plate III, fig. 4) and it could 
 only be discovered to be a vessel, twisting on itself, by strong ligbt 
 thrown through it. I have never found in general paresis an 
 actual aneurism present, nor any appearance except the varix 
 described resembling one In chronic insanity appearances, 
 resembling aneurisms more closely, may be met with. 
 
 Fig. 2. 
 
 By the other mode or ordinary section of the brain. The 
 vessels are seen in situ which is a great advantage in some re- 
 spects. In order, however, to make the section it is usually the 
 custom to submit the brain substance to a hardening agent, 
 chromate of potash, chromic acid or spu-it. In studymg" the 
 appearances after this process, this fact must not be lost sight of. 
 
GENERAL PARESIS. 307 
 
 and especially as regards its effect on the channel in which the 
 vessel lies, (which has been called the peri-vascular canal). If a 
 section happens to lay open one of these canals along any dis- 
 tance, here and there will be found one of these twisted or 
 varicosed vessels in situ (Plate III, figs. 2, Sand 4). Out of 
 many sections one is fortunate enough occasionally to display a 
 sheath and its contents, but the chance can give no clue as to 
 the number of these varicosities, and which by the mode of 
 washing are seen to be very numerous in more or less degree. 
 When the hardening process or natural shrinking of the brain 
 substance has happened to open up the sheath, the artery ap- 
 pears in several of my preparations to be covered or surrounded 
 with a formless or hyaline membrane, (Plate III, figs. 1, 2, 
 3, and 4), this does not in my preparations always appear to ad- 
 here to the vessel or waU of the canal, but to reach from 
 one to the other at different points, or to stretch from one 
 curve of the vessel to another, as figured in Plate III, fig. 1 and 2. 
 Entangled in the hyaline membrane are small, uric acid coloured 
 granules soluble in acetic acid, this membrane looks like an 
 exudation so that its presence is evidence of a certain degree 
 probably of stasis, as the twisted condition of the vessel is of 
 its diminished tone or power of contractility, due to the paresis 
 of the inhibitory action of the vaso-motor nerves. 
 
 Though this varicose condition was discovered in all the 
 cases or nearly so of general paresis, I do not say that the 
 appearance is confined to this disease. I have not had sufficient 
 opportunity to examine other kinds of cerebral disease to enable 
 me to speak on the subject. The same appearance, however, 
 I found in one chronic lunatic with ataxy (as in Fig. 3, 
 Plate III). 
 
 Beside this hyaline and contortion of the vessel, Dr. AVigles- 
 worth has described a condition of artery show in Plate II, 
 Fig. 1 and 2, in which by his mode of examination the vessels 
 appear to be as it were entangled in a mesh of hypertrophied 
 connective tissue (hyperplasia) in conjunction with a general 
 increase of that element described above. 
 
 Spinal cord. — I have examined but few spinal cords in general 
 paresis, chiefly from want of time, having 1200 patients under 
 care at Han well, there was a difficulty in accomplishing so 
 
 x2 
 
308 LECTURES ON MENTAL DISEASE. 
 
 mncli. I, however, did examine a few, and I furnished the late 
 Dr. Lockhart Clarke with portions of cord for his examination, 
 and his results were given in the Lancet. The cases which I 
 examined were those having marked symptoms of ataxy and 
 showed distinct signs of disease, in places the cord has seemed 
 constricted, as though the membranous covering were irregularly 
 diseased, both softening and hardening have been found by 
 other observers (Mickle, op cit, j). 112) ; the subject deserves 
 further investigation. 
 
 But besides the above lesions, there is one which at one time 
 was supposed to be pathognomic, viz., a velvety appearance of 
 the floor of the fourth ventricle, this is frequently, but not in- 
 variably to be detected, it is obvious to the touch and eye, but 
 is better examined by lower magnifying power ; it appears to 
 be due to epithehum. 
 
 Dr. Mickle remarks " though as a rule in general paralysis 
 the cerebellum is not markedly diseased, it is often involved, its 
 meninges become hj-perfemic, thickened and opaque, and near 
 the median line, there is sHght adliesion and cortical degenera- 
 tion, this has been denied, nevertheless it is the case" Ojk cit., 
 p. 164. 
 
 III. Patholotju, or the explanation of the phenomena observed dur- 
 ing life and after death. 
 
 This part of oiu' investigation might be called the search for the 
 cause, qufB prfesens morbum facit, sublata tolht, mutata mutat. 
 
 It will be well perhaps to recapitulate some of the chief 
 symptoms, and the general results of the post mortem examma- 
 tions. This need be done only in a. very concise and abbreviated 
 form. 
 
 The observation of the symptoms is then as follows : the 
 disease is apt to attack persons of excitable or impressionable or 
 emotional land, and of gi-eat mental activit}', and during a period 
 of their gi-eatest mental activity, and is caiised often by some 
 great mental shock. 
 
 The fii'st symptoms show great emotional disturbance and ela- 
 tion of spirits, which condition usually subsides after a period 
 more or less long, and the jiatient appears in his normal state. 
 This condition may remain for a variable period, so long in rare 
 cases as one or two years, but after tliis, or when the remission, 
 
GENERAL PARESIS. 30g 
 
 as it is called, is very loug, there is a certain feebleness of intel- 
 lect observable ; later on there commences motor difficulties 
 which gradually increase to absolute annihilation of poAver. 
 
 So much for the life iDheuomena, the death phenomena arc of 
 course confined to the last condition of the morbid processes. 
 No observations have yet been authenticated of changes during 
 the course of the symptoms, we have therefore to draw conclu- 
 sions of the progress of the anatomical changes from the results, 
 to draw inferences from what we see of what has been the cause 
 of the morbid process. 
 
 What Ave see after death are firstly and chiefly the hyperplasia 
 of the connective tissue of certain parts of the cortical substance 
 of the brain, as demonstrated in Dr. Wiglesworth's preparations 
 shown in Plate II, there are evidences also of a grosser kind of the 
 same part, in the adliesions of the pia mater to the brain tissue, 
 and these are parts of an atrophic process is ^obvious from the 
 general shrinking of the brain substance, which morbid conditions 
 may extend to the cord also. 
 
 Viewing these phenomena as the results of the disease, we 
 have in pathological sense to enquire into the cause of these 
 changes, in other words to investigate the proximate cause, or 
 that cause quae prsesens morbum facit. 
 
 The pathology of a typical case of general paresis appears 
 to me after a due , consideration of aU the phenomena occur- 
 ing during life and remaining after death, to be as follows : 
 
 As ah-eady stated I am led to the conclusion that the cause is 
 primarily an effect produced upon, or lesion connected with the 
 nerve tissue directly and which is the exact reverse of what I 
 conceive to be the primary lesion in ordinary insanity. 
 
 At first this was not my impression, on the contrary, con- 
 sidering the close resemblance of the life phenomena to the toxic 
 effect of alcohol, the first inference to occur to any one's mind 
 would be that the disease is due to a similar or toxic influence 
 operating through the blood. Many of the phenomena of 
 drunkenness, as the bragging, the irreticence, the recklessness 
 of conduct, emotional disturbance as the alternation of hilarity, 
 and the drunken crying, as well as the motor disturbance exlii- 
 bited in the excitement, followed by a paresis of motor function, 
 as in the drunkard's speech, staggering gait, and general pros- 
 
310 LECTURES ON MENTAL DISEASE. 
 
 tration, the disturbance of equilibrium and double vibiou, run as 
 it were in close imrallelism to the symptoms of general paresis. 
 
 We cannot but admit a certain similarity of the effects, but as 
 we investigate the phenomena more critically there seems no- 
 thing to prove any identity so far as regards the primary causa- 
 tion, both sets of phenomena may meet on the road as it were, 
 but their starting points may be different. Both sets of symp- 
 toms at one part of their course may be, and probably are, due 
 to a similar operating cause. In other words, the action of 
 the alcohol may be to produce on the nerve tissues the same re- 
 sults as is produced by the disease, there is this wide difference, 
 however, between these agents, that the effect of one is tem- 
 porary and of the other permanent. 
 
 Supposing that in the disease, as seems to me to be the case, 
 the symptoms are produced through a severe shock or violent 
 stimulant or nervous discharge, which leaves the tissues ex- 
 hausted or actually injured, the toxic effect of the alcohol 
 may be to produce an effect of the same kind. We know 
 that the effect of the hydro-carbons is to paralyse the nerve 
 functions generally, sensory, mental and motor both voluntary 
 and involuntary for a time, and we sec the symptoms of 
 the disease have a close analogy. The phenomena of di-uuken- 
 uess may be used, therefore, as a key to the phenomena of the 
 tlisease so far as the similarity and the dissimilarity can be 
 traced. 
 
 AVe may learn something by studying these conditions, and 
 fii-stly, we may examine the phenomena as regards their resem- 
 blance. 
 
 The brain is an organ having the pecuhar and special pro- 
 perty of periodicity of action, of being, that is, thrown out of 
 gear at certain more or less regular periods. There is a special 
 contrivance to regulate this property, which depends much upon 
 the action of the vaso-motor nerves, which nerves are of course 
 closely connected with the entire nervous system. 
 
 What occurs in drunkenness is I conceive the following, and 
 we may divide it into stages. When first the toxic material has 
 entered into the circulation (where it is stated that it may be 
 detected), the inhibitory centres of the brain very soon as it were, 
 take the alarm, and cause the ai'terioles to contract, there is thus 
 
GENERAL PARESIS. 3II 
 
 produced a coudition of brain, more or less deficient in Llood, 
 which may be called one stage. 
 
 A diminished blood supply to the bram is attended by well 
 recognized iihenomena, which differ shghtly according to the 
 degree of deficiency ; but are as follows : — A slight deficiency or 
 a moderate amount of anaemia, is attended by elation of spirits ; 
 persons dying of exhaustive diseases, as phthisis, loss of blood 
 in htemorrhagic diseases, and by starvation it is known are 
 elated in mind. Marshall Hall relates the case of a gentleman, 
 who endeavoured to commit suicide by dividing the veins at 
 the bend of the elbow in his bath, and who as the blood flowed, 
 became changed in mind, and sent for a surgeon to bind up his 
 
 wounds, remarking to the surgeon " Had Sir A B 
 
 been bled, he never would have committed suicide." 
 
 I have personally witnessed a similar change myself, as a 
 student I was once called upon to bleed a gentleman, who was 
 greatly depressed in mind, and as the blood flowed, the patient 
 gradually changed, and before his arm was bound up, he began 
 to joke and relate sea-faring anecdotes of the usual comic kind. 
 
 The first stage therefore of the disease attended with hilarity, 
 may be due to the effect of the arterioles stopping a full supply 
 of blood, as in the action of alcohol ; but the early symptoms of 
 the disease are not universally those of elation. The vaso- 
 motor nerves are, it must be remembered, of two kinds, inhibi- 
 tory and motor or excitory ; a morbid action might affect either 
 and the effect would be variable. But in the action of the alco- 
 hol the vaso-motor action is not morbid, but remedial, the arrest 
 of the alcohol poisoned circulation is salutary and therefore 
 more uniform. 
 
 The action of alcohol on the bodily state generally, has also 
 been made the subject of inquiry by direct experiment, from 
 which we learn, that in small doses its first effect is to decrease 
 the body temperature, which effect passes off the quicker, the 
 smaller the quantity administered." The explanation of this 
 
 * " There is a fall in the bocly temperature, a greatly increased heat forma- 
 tion, varying directly with the strength of the dose," this continues for a certain 
 time, till a climax is reached, after which there is a return to the normal tem- 
 perature. Bevan Lewis, Journal of Mental Science, April, 1S80. 
 
312 LECTURES ON MENTAL DISEASE. 
 
 is, that at first, there is a certain amount of vaso-motor con- 
 traction, which checks the thermogenic processes, and that 
 after a certain space of time this passes off. 
 
 At this point, however, the two conditions, the alcoholic in- 
 toxication and the disease, diverge. The subsequent progi'ess 
 of the efl'ects of the alcohol, depends upon the quantity taken ; it 
 is well known, however, that various phenomena connected with 
 the nervous system follow, as double vision, vertigo, disturbance 
 of the equilibrium, sleep, coma, paralysis, death, all of which 
 are dependent upon the interference of the cerebral cumulation 
 and upon a deficiency of blood supply, (see AlcohoUsmus in the 
 Sequel). 
 
 The argument here, however, is not the effect of alcohol but 
 the effect of a deficient or defective supply of blood to the cere- 
 brum ; for since it is pretty clear that there is a state of defi- 
 ciency in intoxication and the symptoms of the disease resemble 
 the phenomena of alcoholic poisoning, it is a reasonable conclu- 
 sion that the anatomical base of each is the same. 
 
 "We have, however, to euquii-e how such a deficiency is caused. 
 The toxic agent accounts for the phenomena in alcohol poison- 
 ing ; the arrest of the circulation in those cases is a process of 
 protection and cure, aijd which is brought about through the 
 action of the vaso-motor nerves. 
 
 In the disease it is suggested that the action of the vaso- 
 motor nerves are equally at the foundation of the results, but 
 the difference is, that the vaso-motor system is involved pri- 
 marily, and this is borne out by certain differences which may 
 be observed. 
 
 The first difference to be noted, is in the rapidity of the 
 operation, in intoxication the effects arc produced in one 
 hour, which in the disease take many months, of course one 
 can easily admit that a slower introduction of a toxic agent, 
 would produce a slower result. I have already suggested that 
 such appears to be the true pathology of ordinary insanity, if 
 that be admitted, then we see that the slower infection is 
 accompanied by a totally different set of symptoms ; if it be 
 argued that the nature of the toxic agent may be different, and 
 so fix the prime cause in a peculiar agent in the circulation in 
 each case, avc should expect to see bodily symptoms, disturb- 
 
GENERAL PARESIS. 3I3 
 
 ances of digestive organs, &c. iu both diseases, but in general 
 paresis no such Rj'mptoms are observed, "while in ordinary 
 insanity they are the rule. 
 
 2. Dr. George Johnson has shown that in certain diseases, 
 cholera, kidney disease, &c. in which the blood is vitiated, certain 
 changes in the small arteries are found to counteract the effect 
 of a vicious blood supply, the small arteries become gradually 
 hjTpertrophied, we do not find hypertrophy of the small arteries 
 in general paresis, though it is common iu old cases of insanity. 
 
 3. Another difference between the action of a toxic agent on the 
 brain and the effects produced by the general paresis consists in 
 the fact that the toxic agent produces all the effects in propor- 
 tion to the quantity taken, the subject may be quickly killed but 
 he usually passes through the entu*e succession of stages, but 
 there is every reason to beheve that death may occur iu a 
 stage of the disease before any motor symptoms are exliibited. 
 
 4. The alcoholic poisoning has a natural tendency to cure ; 
 the disease has exactly the contrary tendency. The reason of 
 which appears to be that the phenomena of the toxic case are pro- 
 cesses of cure, and the shutting off' the circulation from the cere- 
 bral centres is to save them, as it were, from injury. The process 
 of contraction is due to certain vaso-motor centres connected 
 with the cerebral organs and the shuttmg oft' is sufficiently com- 
 plete to produce sleep, while those of the viscera, Iddneys, etc., 
 are free to act. 
 
 In the disease on the other hand the occlusion of the blood 
 supply is 7wt a curative operation, but is in fact due to paresis and 
 is an essential part of the disease. The function of shutting off 
 is seldom perfect or complete. Some physiologists hold that 
 both action and relaxation are regulated by special neural ap- 
 paratus, as by inhibitory as well as motor nerves, whether this 
 is so or not, the action is never complete for neither coma nor 
 insomnia is a constant phenomenon of the disease, nor does death 
 occur as a rule by coma, but rather by convulsion or arrest of 
 some bodily function, as of respiration or heart-action, or even 
 through paralysis of deglutition. 
 
 The defect in the cerebral circulation, especially iu the later 
 stages of the disease, is not so much probably an occlusion as a 
 torpid state of function due to the paresis of the arterioles and 
 
314 LECTURES ON MENTAL DISEASE. 
 
 which favours the hyperplasia which is found, and the formation 
 of hyahue which is thrown out around the vessels. 
 
 The general conclusion to he derived from the foregoing is 
 that the disease is due primarily to a fault of the innervation ; 
 that this is general in its extent, as the symptoms clearly show ; 
 that the lesion of nerve function is like that produced tem- 
 porarily by alcohol, but it is not due to toxic agency. This 
 affection of the nerve tissue, as shown also by the symp- 
 toms, is connected with the whole system, and probably the 
 sympathetic is as early affected as any portion. The compara- 
 tive restriction of the symptoms to functions of the nerve centres 
 and freedom of the nutrition organs, marks the disease as a pure 
 neurosis. If we examine the various nerve functions according 
 to the artificial arrangement, this will become very apparent, 
 from their universal imphcation. 
 
 The psychical phenomena are shown disturbed by the elation 
 of ideas, moywmanie des grandeurs, the moral functions in the al- 
 ternating hilarity and despondency, the general tone of good- 
 will towards everyone, the appetites by the sexual excitement, 
 the boulimia, the volitions in the violence and noise and then by 
 the paresis, the sympathetic system in the affection of the pupils 
 and the state of the circulation. 
 
 Then the changes found after death show distinct cerebral 
 disease which in many instances has extended to the spinal 
 cord, while there is also a freedom from visceral disease, or 
 those changes resulting from blood diseases. 
 
 In conclusion, we are now in a position to review the pheno- 
 mena of the two diseases. Ordinary Insanity and General 
 Paresis, and to draw a contrast between them. 
 
 The difference appears to be in this, in ordinary insanity the 
 injury produced by the circulation of an altered blood, is modi- 
 fied by the curative agency of the trophic system of nerves ; but 
 in general paresis the trophic nerve functions are involved with the 
 rest of the nerve functions, in the essential nature of the disease. 
 
 This view brings general paresis as regards its genesis, into 
 analogy with the affections of the spinal cord, with the diseases 
 of which it has many points in common. The reader is referred 
 to the section on spinal disease. 
 
GENERAL PARESIS. 315 
 
 ABSTEACT OF CASES OF GENERAL PARESIS. 
 
 Case XIX. — Ocncral Paresis following a great mental shock. Rapid improve- 
 tnent. Remission and relapse. Death in two years from commencement of the 
 attack. 
 
 A solicitor, 58 years of age, in large practice and good position and highly es- 
 teemed professionally, met with a severe family affliction and reverse of circum- 
 etances. Soon afterwards was observed to be altered in his manner, committed 
 many strange acts, showing an apparent indifference with regard to his troubles ; 
 ■with greater disposition to quarrel, and an unnatural peevishness of temper. 
 Undertook several large schemes, at variance with his cautious temperament, 
 and unlike his previous business habits. He would stop people in the street 
 with whom he had no previous intimacy, and would tell them matters with com- 
 plete disregard of ordinary reticence. He embarked in schemes on a large scale 
 with Utopian objects. His conduct at home became at last strange and excited. 
 He would not go to bed, talked of being attacked by fenians, (.an attempt had 
 just been made on the Queen which greatly excited and alarmed him). He ac- 
 cused a certain Mr. F. of being his enemy ; said Mr. F. was a fenian. Had all 
 his doors and windows barricaded. On my visit he put on a kind of forced cor- 
 dial manner, was very garrulous, but quickly quitted the room. He was ad- 
 mitted on the same evening. 
 
 On admission, his general appearance was good, he was well nourished and in 
 his usual health. Was said to have been four weeks ill. Mentally, he appeared 
 in elated spirits, talked much of the schemes that he was going to carry out. 
 He should cut a canal from the west of England to join the mouth of the Severn, 
 so that ships were to come right up to Cheltenham and Gloucester. He should 
 build several towns on the Cotswold Hills, and a cathedral. He should raise 
 large sums by loan to improve agriculture and would so realize a large fortune. 
 He talked much of Mr. F., said Mr. F. was a great debauchee. Spoke openly to 
 everyone of many private affairs, which are usually not mentioned 5 his conversa- 
 tion was interlarded with much prurient matter, and the manner of conversing 
 evinced much weakness of mind. He was easily diverted from one topic to an- 
 other, and was very open to slight flattery. He bragged a good deal of his own 
 cunning, but has evident fears on the subject of fenianism. He appeared re- 
 lieved on being admitted and to find a security against his foes ; fancies he is in 
 a cave in Lecklianipton Hill (was admitted after dark). He had decorated himself 
 with a blue scarf around his waist, on being talked to quietly, he appeared 
 ashamed and removed this ornament. 
 
 On the day after admission, became aware that he was at Sandywell; he pre- 
 tended that he was much pleased, and said that it was exactly what he wished, 
 he praised all the appointments, it was a splendid place and ho should purchase 
 it. He gradually lost his fear of fenians. Occupied himself in drawing out the 
 scheme for the cathedral, and churches on the hills around. Said he should 
 spend several millions ; the Queen would grant him and his wife each an annuity 
 of £10,000 a year, and each of his daughters £5,000. It was observed that his 
 fears and apprehension of enemies, etc., returned every evening. 
 
 ..4 fortnight after admission, alout the sixth wcekof disease, the report was : — Is 
 
3i6 
 
 LECTURES ON MENTAL DISEASE. 
 
 always elated in spirits, talks tuuch and jokes with everybody and associates 
 and addresses the most insane and imbecile of the patients, as though they 
 were quite rational, and able to understand and enter into his schemes. 
 
 One month after admission. Same symptoms continue, those of grand ideas, 
 of schemes, of money making, with libidinous conversation; fears about fenians, 
 and antipathy to tlie Mr. F. ; these were increased towards evening. 
 
 Five weeks after admission. Visited by wife and one daughter, at first refused 
 to see them, but eventually received them cordially. His aversion to his wife, 
 arose from a fancy that she sided with Mr. F. His fears concerning Mr. F. are 
 weaker and he occasionally alludes to then as morbid, says ho feels better, but 
 complains of a sense of weight in his limbs, eats largely. 
 
 Eighth week. Spent a day at home. Has lost all fears about fenians and be- 
 lieves his antipathy to Mr. F. was a mistake, is in good spirits, converses ration- 
 ally; expression much improved, says he feels well. 
 
 Ninth week. Left for six weeks on probation. His relations consider him 
 quite well. Has been quiet and rational since the last note, but examined 
 closely shows the following symptoms, slight feebleness of intellect, makes pue- 
 rile remarks, there is a certain tameness in his conversation, not to be expected 
 in one of his former position, the expression of the face is heavy ; speaks of his 
 health in rather too elated a manner, the disposition to eat largely (boulimia) 
 continues, says he has no weight in his limbs. 
 
 Fifteenth week. I called on him at the end of the period of his probation ; re- 
 ceived me cordially, appears to have further improved, speaks of his former delu- 
 sions, joking about " my friends the fenians," says he feels quite well and all he 
 required was to get up his strength, was discharged as " relieved." Had been 
 three months under my care. 
 
 I shortly after received a business note from him, in which he thanked me 
 for my " kind care and attention during his visit to Sandy well," he added, "I 
 do not get my strength so much as I would wish, and my legs fail me, but I 
 hope soon to recover my walking powers. I hope Mrs. Sankey and your family 
 circle arc well, and with very kind regards, I remain, my dear Dr. Sankey, 
 yours sincerely." 
 
 On his discharge he remained at home, was unable to return to business and 
 I learnt from his ordinary medical adviser that his mind showed gradually de- 
 clining power. He was in the habit of going into the clerk's room and talking in a 
 childish trivial way, and was found of prurient anecdotes. He gradually neg- 
 lected his personal appearance and was found one day sitting down in the street 
 on the curb-stone. 
 
 He was discharged in March, 1872, was admitted into Barnwood Asylum in 
 the following August, and died there in December, 1873. just two years from 
 the commencement of the attack. 
 
 Ca.se XX. — Qeneral Paresis, duration about two years. Death in the third 
 stage. History of Syphilis. 
 
 A. S., a female, married, 32 years of age, admitted into Hanwell, June 1861. 
 Married twelve years, previously was a domestic servant, and of excellent char- 
 acter. She lived with her grandfather the parish clerk, people very much 
 respected, was married at the age of twenty to a painter, who came from 
 
GENERAL PARESIS. 3I7 
 
 London to paint bor master's house. A.S. was of short stature and possessed 
 considerable personal attractions. There were several cliiklrcn by tlie marriage, 
 the patient's health failed in London, and she returned to live with her grand- 
 father, and accounts varied as to tlie family trials, but apparently the husband 
 was a worthless fellow, and infected the patient with syphilis. One or two of 
 the children were weakly and died. On the death of one the patient's attack 
 commenced, she was found insensible on 24th December, l&GO. 
 
 In June 1861, she was taken up by a policeman for pulling up the trees in a 
 nursery garden. She was also accused of having gone up to two gentlemen 
 in the high road, and throwing her arms round their necks, and kissing them. 
 Another account communicated by the relieving officer was that she had been 
 leading a very immoral life with soldiers ; and that her house was the scene of 
 the greatest immoralities, drinking and every other kind, that the children were 
 neglected and dirty. Her sister denied this, and says the first appearance of the 
 disease was shown by her going about and ordering a quantity of furniture. 
 
 On admission. She was in a very dirty and neglected state, temperate, 
 well-nourished, five feet one inch in height, pleasing features, dark hair 
 and irides, presenting slight paresis about lips and face. Expression somewhat 
 imbecile, is reported to have been insane since December, 1860. Had been 
 six months ill on admission. 
 
 On the second doAj after admission. Is excited and talkative, says God is very 
 gracious, she has a very nice husband, two children, that she is going to Margate, 
 hesitates and drawls in her speech. Tongue protruded by an effort, not tremu- 
 lous, coated. Says she has £17,(100 in the bank, that her husband has 40 and 
 then 70 millions. 
 
 Is feeble, and at times wet and dirty, is disposed to undress, requiring the 
 the dress to be fastened mechanically. 
 
 Six month after admissio7i, twelf til of disease. Is complaining of headache ; 
 eyelids swollen with crying, is destructive and violent, articulation indistinct 
 and mumbling, hand tremulous, says she has " such beautiful sentiments." 
 Tonics were ordered, first iron, subsequently 01. Morrhuco. 
 
 Tenth Month. Has not spoken for several weeks till to day; appears very 
 imbecile and childish in manner, voice is tremulous and stammering, much 
 twitching of the lips, superior and inferior, pupils nearly equal, walks with 
 peculiar gait ; has no grand ideas ; is stouter; tongue clean, protruded well; is 
 wet and dirty. 
 
 A seton was inserted in the nape, the operation did not appear to cause any 
 pain. 
 
 At the eleventh month. Is able to stand but is very tottering, expression 
 slightly improved, knew her mother who visited her and appeared pleased to 
 see her, has seldom spoken of late, keeps her bed, but lies quietly, conversed 
 with her mother, right pupil is larger than the left. Seton discharges well. 
 
 At twelfth month. Slight improvement, speaks out more cheerfully and says 
 she is better, can stand more firmly, walked to day without assistance to the 
 bath, takes her food well, and is well nourished. 
 
 Twelve and c half months. Answers questions more alertly and says she 
 feels very well, can walk with the assistance of one person, right pupil dilated. 
 
 Tliirteenth montli. When in bed begins to lie with knees drawn up, cannot 
 stand olone. 
 
 Fourteenth month. Knees constantly drawn up, is weaker and more restless. 
 
3i8 
 
 LECTURES ON MENTAL DISEASE. 
 
 Fifteenth month. Mind childish but not wandering, nor excited, knows 
 where she is, says in Hnnwell Asylum. Articulation very hesitating, syllables 
 slurred; tongue protruded well ; is wet and dirty; knees drawn up, says she 
 cannot put the right knee down. 
 
 Fifteen and a half months. Is getting thinner, both knees contracted, visited 
 by her mother, ask(>d after the children, soon after forgot that her mother had 
 been, when reminded, says the children are very happy, takes food well and 
 swallows without difficulty, says " I like food very much." 
 
 Eighteenth vaonth after admission- Continued confined to the bed, and 
 gradually getting weaker, but appetite remained good, and she called for food 
 at the proper hour ; her bowels acted regularly ; she continued to fail in power 
 and to emaciate, notwithstanding she took food ravenously. Both legs were 
 contracted, said she was going to die, voice was clear and stronger, but tremu- 
 lous or bleating, gradually sank and died without convulsions, or other marked 
 change on the same day, that she was said to have been found insensible, two 
 years previously. 
 
 Autopsy. Height 5 feet IJ inches. Body much emaciated, belly slightly green, 
 slight discolouration on posterior parts of trunk, rigor mortis in all the joints 
 least in elbows, the left knee is bent at a right angle, the right knee and thigh 
 much flexed, the heelin contact with the buttock, a mark of seton completely 
 cicatrized, pupils equal. 
 
 Head. Form, vertex low, circumference oval, forehead medium, measurement 
 G by 41, hair abundant, dark, integument, peritoneum and bone normal, diplOe 
 distinct. 
 
 Dura mater adherent to arachnoid, very opaque, much serum beneath arach- 
 noid. Pia mater strips readily, vascularity increased. Plexus choroides opaque . 
 
 Brain substance. General characters, weight of cerebrum 31 oz., cerebellum and 
 pons 5oz , sp. gr. of gray matter 1"033, of white matter.l 039, of cerebellum white 
 and gray matter in equal proportion 1"044, brain firm to the touch, of dark 
 colour, small, symmetrical. 
 
 Gray matter of dark colour^ injected layers very distinct and firm. 
 
 White matter pale, in points on section injected, of firm consistence, fornix 
 soft. 
 
 Microscopical examination of arterioles of cerebrum showed slight varicose 
 condition in several, from one of which Fig. 2. p. 30G was taken. 
 
 Lung nncoUapsed, of dark colour, strong tough adhesions on both sides. 
 Pleura covered with old adhesions. Both lungs of increased weight, texture 
 normal as regards cohesion, except upper part of right lung, where it is much 
 congested, several vomicae, varying from size of a bean to a small pea, exposed 
 on section, each lined with a thick membrane ; the lung ia more or less cre- 
 pitant throughout. 
 
 Liver normal. Kidneys the capsule is adherent to a slight degree, tubular 
 portion is congested and extends to the surface, one rough calculus impacted 
 in pelvis, weight of each 6 J oz. 
 
 Heart weighs 5 oz., healthy except slight opacity of aortic valve, right side 
 distended with large fibrinous clot, the left contains a small quantity of black 
 grumous blood. 
 
GENERAL PARESIS. 319 
 
 Case XXI.— General Paresis, death in the maniacal stage; duration about a 
 year. 
 
 F. C, set. 40. Surgeon in the Indian Army, June 1st, 1867. History of case 
 as gathered by fragments from various sources. He was in the massacre of 
 Cawnporc, 1357, and escaped with a few others, and underwent many risks and 
 hardships. Sometime afterwards his friends in India wrote that he was much 
 altered in behaviour, afterwards that he had a sunstroke, date of this was doubt- 
 ful, about a year ago his wife induced him to come to England, on the passage 
 his behaviour was observed to be peculiar, his wife died on the passage. He was 
 a good deal excited by this event and his behaviour called for the interposition 
 of the ships authorities, on arrival his children where attacked with measles and 
 the youngest died. On reaching Cheltenham his conduct was observed to be ex- 
 cited and strange. He was constantly going from place to place carrying a 
 younger child on his hip in the Indian fashion, calling on different acquaintances 
 and talking in an excited manner, behaving strangely to his mother's servants, 
 whom he alarmed; he walked about the streets at night, addressed women 
 whom he met and asked them into his mother's house. 
 
 Condition on admission. Is 5 feet 10 inches, square built, robust, well and 
 active, has defective vision, requiring highly convex glasses, and some obliquity 
 of the balls, amaurosis of the left eye, has dark brown complexion, general health 
 appears good, is troubled with haemorrhoids and subject to prolapsus, pulse of 
 good power, normal frequency, no difficulties of digestion or chest symptoms. 
 
 Talks almost'incessantly, conversation about himself, his plans, which he con- 
 tinually changes, talks to everyone he meets, to his servants of his own affairs, 
 which are of utopian character, marked elation of spirits and feebleness in intellect. 
 Talks much about marrying, thinks everybody he sees or meets would exactly 
 suit him, has made proposals to several, he will extol and abuse the same per- 
 son in the same breath. Expression of face somewhat sleek, facial muscles 
 appear relaxed and expressionless. On the signature of the certificates it was 
 left to me to fetch him from home, at first refused to come and was excited and 
 angry, after a while came voluntarily, and drove me in his own trap, was per- 
 suaded with little difficulty. After arrival made himself soon at home; soon 
 found occupation, groomed his own horse, was agreeable and sociable, but talked 
 continually of his skill and reputation, and wealth, but was very close in 
 spending his money, which seems to be his normal character. 
 
 After three months. Mental characteristics the same, less excitement, talks to 
 everyone with total absence of reticence. Occasionally trips in his articulation 
 running one syllable into another (slurs), eats largely, reads a good deal, novels 
 chiefly, in which he becomes much engrossed and repeats the incidents to every- 
 one he meets. 
 
 After six months. Health continues good, stammers rather more, mind 
 rather weaker ; is now full of a plan to make his escape, which plan he discusses 
 with everyone including myself and attendants, etc., has taken everyone into 
 his confidence in the matter, eats enormously, continues to ride and drive out 
 daily. 
 
 Eight months. Still occupied with the same plan, and was out riding to day, 
 while out went into a public house, leaving his horse with his attendant and 
 bolted across the fields, the man encumbered with two horses followed, found 
 him at his mother's and brought him back, mind now is more feeble, made two 
 
320 LECTURES ON MENTAL DISEASE. 
 
 offers of marriage of late to two ladies, first to one and then to the otlier, con. 
 tinually changing and in the presence of both, writes numerous letters which are 
 less connected in matter. 
 
 Tenth month. Is more restless and irritable, more feeble, talks more of his 
 great wealth and the great schemes lie is going to undert:ike (monomanie des 
 grandeurs). Has a propensity to purloin, was discovered concealing a pair of 
 boots in the bottom of his portmanteau, speech is more affected, increasing 
 difficulty in pronouncing the labials. 
 
 Ten and a half months. After a bad night was excited the first thing in the 
 morning, which passed off, dined at my own table as usual at two, then went 
 into the park and chased the sheep, and having cauglit one was endeavouring to 
 strangle it or as the attendant believed endeavoured to act indecently towards it. 
 He attacked the attendant, was very violent, raved and shouted, that he wanted 
 women, threw himself down violently, hurting his side, cmtinued to shout and 
 to dress and undress and call for women. When taken to his room, smashed 
 the window, tore down gas and paper, after a time became a little quiet gave 
 liimself three enemata and used a large candle as a bougie. Tr. Opii, 5j, 
 and he slept. 
 
 Excitement and raving returned iu the morning, opiate repeated, had about two 
 hours sleep, excitement increased on waking, Tr. Opii, 5j. Tr. Digit. 5ss, every 
 fourth hour, was calmer for a short time, when he again broke out, was very 
 violent, tore down the shutters in the night, wrenched out the fire-grate with 
 which began to demolish the door, threatened to murder the first person who 
 who came near him, allowed me after a little persuasion to open the door. Ho 
 was in a highl}' extatic condition, very libidinous, and elated, says he will be 
 Emperor, he will marry the Queeu, that he will marry 50 women. He will have 
 the Virgin Mary, etc. JUotor difficulties very marked, articulation mumbling, 
 next day he became rather calmer, in five days after or six from the outbreak, 
 the following note was made. 
 
 3an. 2oih, 18GS. Has continued to be excited and at times maniacal and raves, 
 at other times talks incoherently, imagines himself in communication with God, 
 addresses the deity in a familiar conversational manner, at times says he is in a 
 ship, takes his food well, sometimes pours his soup or wine or medicine on his 
 head. Has been out in the park, has sevei\il grazes on his fingers, does not talk 
 of women or exhibit the same sexual excitement, motor symptoms continue. 
 
 2St/i.. While in the garden to day became excited and rolled on the grass 
 and exhausted himself, was again placed in seclusion, no return of erotism but 
 is in high spirits. 
 
 Feb. 3rd. Restless and occasionally noisy, talks of women, has had a bath 
 daily, but not dressed since last report. 
 
 Feh- ith. On getting him out of bed, he was found to be more feeble, and to 
 be bleeding from the penis which was swollen, and was found to be tied with 
 a piece of thread, the ligature was removed. 
 
 Feb. 5th. The weakness was increased, he talked incoherently as heretofore 
 and about women, he gradually failed in strength, he complained in the evening 
 of a sorethroat and asked to have it examined. He spoke with a firm voice, 
 shortly after his powers rjuickly failed, he died apparently from exhaustion, that 
 is 11 days after the paroxysm of excitement. 
 
 Body examined on 3rtZ day, post-mortem, (Feb. 8th). No emaciation, slight 
 abrasion on the nose, 1 inch long from a graze during life, a small post-mortem 
 graze on the posterio-lateral region of the chest. 
 
GENERAL PARESIS. S^I 
 
 Head externally. Forehead in profile slightly receding, cranium on section 
 round, vertically low, hair natural, of a dark colour, integuments normal, 
 periosteum injected, bono very thin. 
 
 Internally. Dura mater adherent to bone and much injected. Arachnoid 
 adherent to dura-mater in places and opaque, especially in upper surface and 
 sides, serum efi'used beneath it, the pia-mater stripes readily. Its vascularity is 
 increased and serum in its meshes. 
 
 Brain substance. General characters. Brain firm, dark and congested, appears 
 small, symmetrical, the convolutions small and intra-gyral spaces appear 
 
 Special characters. Gray matter very dark, the layers are distinct, sp. gr. 
 1"044, white substance is dark and firm. 
 
 Chest and Abdomen, not examined except that an incision was made over the 
 distal end of the 7tli rib of the right side, when there appeared to be some cre- 
 pitation on manipulation, in examining this part the bone was found denuded of 
 periosteum and separated from its cartilage and some purulent discharge sur- 
 rounded the abraded ends, the pus was sero-purulent and unhealthy in character, 
 there was no injection of surrounding parts, no bruise or mark externally, the 
 integuments covering the part were pale and normal, no pleuritic adhesions. 
 
 Case XXII, General Paresis, commencing with depression from shock on 
 disappointment, state on entry at 5lh month Died in 33 months. 
 
 M. E. J. admitted June 1860, female, single, 35 years, servant. Had a child 
 when she was 19. 
 
 About 3 weeks after Christmas was disappointed in marriage, became altered 
 in behaviour, at first was depressed and would cry for hours together, soon after 
 began to talk nonsense, said she was going to Paris, talked in an elated manner, 
 spoke much of the man to whom she was to have been married, and who had 
 just married another, the mother kept her at home two months, when she be- 
 came destructive and threatened violence. Was taken to the workhouse. 
 
 Was an intelligent girl. 
 
 On admission. Mind appeared imbecile, was noisy and violent at times, in 
 fair condition as to nutrition, gait tottering, articulation confused, says she has 
 plenty of money, and can pay for anything that is given her, is industriously in- 
 clined and oS"ers to assist nurses. 
 
 November, IQth Month. Has gained flesh. Symptoms of general paresis well 
 marked especially as regards articulation, is at times excited, at times cries, when 
 she roars (blubbers) lustily. 
 
 March, lUh Month. Motor paresis much increased, appears unable to stand, 
 falls about, wet and dirty. 
 
 17th Month. Articulation worse, is scarcely intelligible, wholly confined to 
 bed, she is muttering, you must have a million million cows to suck, thousands 
 of dolls, beautiful cows, but is stronger, pupils equal. 
 
 \Sth Month. Is able to leave the bed, is more restless and would not remain 
 in bed, she takes nourishment well, and appears to gain strength. 
 
 I9th Month, Up and roaming about the ward, but gait unsteady. 
 
 2Qth Month. Is excited, attempting to strike, articulation very indistinct, has 
 dressed up a footstool and is carrying it about as a doll, 
 
 Y 
 
322 LECTURES ON MENTAL DISEASE. 
 
 21st Month. Mind very imbecile, pulls up clothes, apparently reffardless o 
 shame or decency, wants to show mo hor buttocks. 
 
 2ind Month. Paretic symptoms continue with restlesenoss, wanders about the 
 ward and shows a disposition to be violent. 
 
 26th Month. Is still able to be up, mind demented, gait unsteady, voice tre- 
 mulous, pupils equal, appears stron^jer than a month ago. 
 
 27th Month. Is stouter and is now well nourished, scarcely able to speak, is 
 still up and restless. 
 
 ZOth Month. General powers again failing, speech very drawling, langhs in an 
 imbecile manner, says she has a beautiful fortune left her, stuffs her month 
 with food in eating, has some difficulty in swallowing. 
 
 SZrd Month. Pupils equal, is unable to stand, lies in bed with knees up, swal- 
 lows with difficulty, constant grinding of the teeth, mind very demented, legs 
 gradually became more drawn up, died from exhaustion of the general powers 
 without convulsions in the 34th month of the disease. 
 
 Examination post-mortem, height 5 feet 4 inches, shoulders 12 inches, hips 
 10 inches, emaciation advanced, contraction of lower limbs, slight abrasion of 
 hips. 
 
 Head. Conformation, vertex low; form round, equal in fore and hinder part, 
 measured 6| by 5 inches, hair scanty, of dark colour, integuments and periosteum 
 normal, bone of increased thickness, and diploe distinct. 
 
 Membranes. Dura mater adherent to bone, arachnoid very opaque, much 
 serous effusion beneath it, raising membranes in the parietal region of left side 
 into bladders. Pia mater is adherent beneath and congested. 
 
 Substance. Cerebrum weighs 27oz., one side weighing half ounce more than 
 the other, cerebellum and pons five ounces. 
 
 Brain remarkably firm, small size, much bedewed with serum. 
 
 White matter, showing numerous blood points on slicing, very firm, floor of 
 fourth ventrical and both lateral ventricals and side of fornix covered with a pile 
 of velvet-like white matter, "gray matter of pale colour and layers indistinct 
 and broken down by removal of membranes. 
 
 Heart normal, lungs collapsed, obsolete tubercle in both apices. 
 
 Case XXIII. —General Paresis, duration aJiout two and a half years ? History 
 of epilepsy. Early history is imperfect. Death. Varicose condition of arte- 
 rioles. 
 
 K. W. a kept mistress, set. 28, fair education, daughter of a small tradesman 
 formerly a lady's maid, admitted into Han well August 1862, from a work- 
 house. 
 
 No friends of the patient were known, too imbecile to give any information. 
 After some days' residence in the asylum, she was hoard to mention the name of 
 a well known physician, this gave a clue, which resulted in discovery of a 
 brother, the footman of Dr. C. He stated that the patient was his sister, he 
 had not hoard of hor for seven years. The following history was eventually 
 gathered. She was subject to epilepsy from the age of 9 to 12, her father and 
 uncle were epileptic and died imbecile "on the fits leaving her she became 
 altered in disposition " probably at puberty. She entered the service of a lady as 
 
GENERAL PARESIS. 323 
 
 lady's maid. Slie was a person of good appearance, of which she still bore evi. 
 dence, she was always of haughty and ambitious character. She left service 
 and was kept in groat luxury by a gentleman for several years, being well sup- 
 plied with means; some time after she was left for six months, continued to 
 be well supplied with means, and still lived in great style, keeping a brougham, 
 etc- She is supposed to have soon become addicted to drink, she gradually be- 
 came invalided and for a time was ill, nature of illness uncertain, but she had 
 to part with all her goods by degrees and at last was maintained by her female 
 companions, who had known her in her wealth, she drank more and was at 
 times muddled fora whole week together. Atlast she had been gradually getting 
 affected in mind, became excited at times, talked to herself, when addressed would 
 not reply, was very restless and constantly on the move, would dress and undress 
 repeatedly during the day, became very slovenly in her person, at last she was 
 taken to the workhouse. On admission to workhouse the medical certificates 
 describe her condition as being "very indecent in behaviour, frequently ex- 
 posing herself before other persons, talking to imaginary individuals in the 
 ceiling or in the air, excessive restlessness, never keeping her limbs quiet for one 
 moment to another, has stated that she had large property." 
 
 On admission to Hanwell. Has not been noisy, walks about in a restless man- 
 ner, frequently changes her seat, answers questions in a whisper, and talks to 
 herself. Slept well last night, expression of vacancy and confusion, frowns and 
 knits her brows ; pupils are equal and act well, does not know how long she 
 has been in the asylum (came yesterday), cannot tell the day of the week, says it is 
 Tuesday (it is Saturday), says she has no headache, is very untidy in dress, 
 tongue is tremulous, uses her hand to assist in showing it, it is clean, bowels 
 not open since admission, no chest symptoms, nothing peculiar in gait, pulse 80, 
 is pale, but in pretty fair bodily condition. 
 
 One month after admission. Right pupil larger than left, occasionally vio- 
 lent, walks with a firm step, avoids me, her expression is lowering. 
 
 Two Months after admission. Is in good bodily condition, pupils unequa ap- 
 pears unable to understand what is said, right ear swollen, (insane ear). 
 
 Six Months after admission. Speaks in a very drawling tone, is violent at 
 times and very noisy, walks well, but frequently falls as though her knees gave 
 under her. 
 
 9th Month, This morning appeared to have lost the use of the left side, was 
 put to bed, in the afternoon walked as usual, or with very slight limp of left 
 leg. 
 
 15th Month. Has become more paralysed, mind is very imbecile, lies and 
 mutters unintelligibly, is wet and dirty, lies with her knees much drawn up, has 
 gradually failed from day to day, swallows with some difficulty, dejections 
 were passed unconsciously, sordes collected on the teeth. 
 
 16i/i. Month Both pupils dilated, unable to stand, but has rallied a little in 
 mind, swallows rather better, conjunctiva much injected, from this time to the 
 18th month failed slowly, both pupils became contracted. Death by exhaus- 
 tion. 
 
 Autopsy, assisted by Dr. Lockhart Clarke. Head externally, forehead reced- 
 ing, form long oval, vertex low, from front to back Gi inches, across parietal re- 
 gion 5 1, hair dark plentiful, integuments and periosteum normal, bone diploc 
 indistinct. Dura mater adherent to arachnoid, bony deposit in its texture 
 Arachnoid opaque, much serum effused beneath it. Pia mater strips readily, 
 
 y2 
 
324 LECTURES ON MENTAL DISEASE. 
 
 vasculikiity much increased, serum in its meshes. Plexus choroides turgid and 
 injected, and serum distends its textures. 
 
 Brain Substance, General characters, firm, of dark colour, congested, brain 
 small, regular and symmetrical, bedewed with serum, conrolutions are open, 
 and appear atrophied or shrunken. 
 
 Qray nuxtter. Dark, spotted with minute vessels, which appear congested, the 
 layers are indistinctly defined, and the gray matter seems diminished in thick- 
 ness. 
 
 White matter. Of dark colour, injected and marked with numerous blood 
 points on'section, the substance is firm or harder than normal, serum exudes from 
 its anterior surface. 
 
 Microscopic exa^nination. The vessels of the cortical substance were found in 
 numerous sections in varicosities similar to fig. 2, Plate III., and portions of 
 brain substance submitted to a stream of water till only vessels were left, the 
 appearance shown at fig. 2, page 306 was seen, and from which the drawing was 
 made. 
 
 Dr. Clarke reported to me that he found several of the large cells undergoing 
 degeneration, and having granular contents, specimens from this brain formed 
 the basis of some of my remarks on the state of the vessels in 1866. Some of the 
 arterioles, were situated in expanded sheaths or canals, some had no such 
 canals, as in Dr. Wiglesworth's preparations, Plate II, fig. 1 and 2. 
 
 Case XXIV. — Qeneral Paresis. History of injury. Delire des grandeurs. 
 Well marlced remission after motor symptoms were shown. 
 
 K. W. N., admitted Aug. 21st, 1875. 32 years of age, single, superior educa- 
 tion, intelligent. Natural disposition, quiet and studious, and industrious, fond 
 of athletic sports, especially, of horse exercise, hunting and racing, was good 
 rider and had ridden in more than one steeple-chase, habits temperate, short 
 stature, muscular and powerful, dark. 
 
 About a fortnight previous to admission was taken with symptoms which led 
 the friends to consider him insane. He went to the sea and stripped and tried to 
 swim to a vessel six miles at sea, was with difficulty rescued, he behaved in a 
 wild and irrational manner and was brought to Cheltenham, there he broke 
 out into a very wild delirium and was brought to Sandy well. 
 
 On admission, was wild and excited in manner, he insisted on driving the fly 
 himself and was shouting and holloaing all the way, was greatly elated in spirits, 
 began at once to converse with the attendants, telling them his whole history 
 and bragging of his wealth and intellectual ability, soon after began to dance 
 vehemently on the lawn till he perspired profusely, when spoken to replies in 
 great good humour, addresses me as "Dr." though he supposes I am Sir F. and 
 this is Sir F's house, he speaks rapidly and distinctly, with no hesitation or 
 stammering, has no difficulty of movement in limbs, talks somewhat loudly at 
 times, says he is going to "marry lots of women." 
 
 The pupils contract pretty equally but both are irregular in outline, muscular 
 power appears equal on the two sides. 
 
 Bodily health appears good, chest and abdominal organs normal, tongue clean^ 
 bowels act regularly, no thirst or heat of skin, pulse quick but regular, has 
 cicatrices on lower lip and broken teeth from injury from fall from horse. 
 
GENERAL PARESIS. 325 
 
 Previous history. Has had more than one serious horse accident, had a con- 
 cussion of the brain on two occasions, on one of which he was insensible 
 many hours, and on getting better had a tendency in walking to fall over on the 
 side opposite to the injury and had to be supported, considered himself that he 
 had quite recovered from this, he was ordered a draught of opium and digitalis 
 and slept part of the night, continued excited and in good humour all next day. 
 
 About one week after admission. Continues in high spirits, is noisy; singing 
 and shouting, has been writing voluminously, but what he writes is illegible, but 
 is in a firm hand, no hesitation in speech, is tolerably amenable to the discipline 
 of the house. (See Plate 4, Fig. 1, Specimen of writing). 
 
 2nd Week. Elated, good natured, easily led or persuaded, has amused him- 
 self by decorating his room and his dress with branches of trees torn from the 
 garden, occasionally dances, says his health is excellent, pupils unequal, slight 
 mumbling detected in speech. 
 
 5th Week. Has become more excited and more dirty in habits, sprinkling his 
 urine about the room, is frequently violent. 
 
 Visited by a friend at 8th week, whom he wished to go away with, became 
 very violent on being prevented and remained so for a quarter of an hour. The 
 delire des grandeurs well marked, speaks very volubly of his strength, his 
 wealth and his sexual powers, says he is going to cut out his intestines and then 
 he will not require to eat, that he will get a boa-constrictor to put in his inside 
 and that will make him grow twelve feet high, says that he can run ten miles an 
 hour, that he can fly, that he has 400 millions of money. 
 
 12th Week or Brd Month after admission. Is excited in manner and very 
 garrulous, but is less violent in conduct, and is at times quiet for long periods 
 together, talks of his immense wealth, enormous strength and height. He is 
 going to eviscerate himself to make himself lighter and then he shall fly, still 
 talks of the boa-constrictor to make him tall, the tallest man that ever lived (his 
 own statue is 5 feet 5 inches), is lewd in his conversation and occasionally vio- 
 lent, is also dirty in his habits, but can easily be led by a little persuasion. One 
 week later says he has brought up everything and that he shall fly off to heaven, 
 he will dig a hole in the trimk of a tree and go down through the world and 
 come out on the other side, writes cheques for millions of millions, says he is 
 going to marry two pretty women, talks of cutting his head off and having a new 
 one, slight thickness in the speech observable. 
 
 Nov. \4sth, or about lAth iveek. The same grand ideas continued, only slightly 
 modified, writing cheques for millions, going through the earth, etc., asked to go 
 to church said he intended to build a new church for himself, he could do it in 
 five minutes, is occasionally angry towards the attendants but on the whole 
 quieter and able to dine at my table. 
 
 Nov. 2Sth. The note says he amuses himself in a more imbecile manner, de 
 corating his head with pieces of coloured worsted or anything of tawdry colour, 
 bits of metal, glass, etc., continued to be libidinous. A distinct stammer in arti- 
 culation, pupils continue uneven, the gait slightly awkward, ataxic, has a little 
 difficulty in turning while walking backward and forward, is getting stouter, 
 eats largely, mixing all manner of things on his plate, meat; vegetables, tart, 
 fruit, is occasionally disposed to be violent. 
 
 6th Month after admission. Monomanie des grandeurs continued, speech was 
 more involved and articulation thick, complained of cramp in left leg while out walk- 
 ing, is now quiet and orderly in conduct, still writes cheques for different people. 
 
326 
 
 LECTURES ON MENTAL DISEASE. 
 
 writes constantly filling sheeU of paper which are wholly illegible, says he is going 
 to buy up the Agricultural College and teach everything himself, dresses himself 
 out fantastically with feathers, wire off soda water bottles, makes himself rings, 
 is very good natured over it, plays at billiards a good deal and plays well, makes 
 good straight strokes. 
 
 7th Month. Less excitement, more imbecility, mumbles in speech, has bought 
 the British Museum, says also he has a thousand then a ndllion horses, that he 
 has bought all the horses, that he can walk to London and back in a day, is 
 angry with me because I express a doubt about it, continues to write, nearly all 
 day, writing quite illegible, has had a cramp in his leg again. 
 
 8th Month. The alteration of speech more marked, tnonomanie des grandeurs, 
 libidinous feelings continue, mind more feeble. 
 
 From above date varied a little from time to time, but was more amenable to 
 order, more feeble in mind, seemed to doubt his great possessions. 
 
 9th Month. Had been depressed once or twice of late, took me aside, and said, 
 "is it not true that I am as rich as I thought," I told him of course those ideas 
 were mere symptoms of disease, he seemed to be saddened at my words, after 
 this I induced him to forego his puerile ornaments which he at once removed. 
 One month later, he continued quieter and orderly, there was still some thick- 
 ness of speech and feebleness of mind, he returned home to his parents, his 
 father who had watch the case very closely, considered him well. 
 
 I received reports from time to time giving excellent account of progress, the 
 parents (the father a very intelligent observer) considered that my prognosis ■was 
 not verified. I saw the patient at his o^vn home on several occasions, he re- 
 mained at home from (June 1876 to Nov. 30, 1877). The patient entirely lost 
 all his grand ideas gave a clear account of his health. He went into a lodging 
 with his mother in an open situation at the "West End of London, here I also 
 visited him, and watched the case closely, as the remission was of unusually 
 long duration. At no time, however, had I any doubt as to the case, to me there 
 was quite evident some feebleness of mind, the patient found himself unable to read 
 any book calling for close attention, he also from time to time complained of 
 stiffness and heaviness in his legs, the muscles of the face were inactive, the 
 countenance had the peculiarity of the disease, there was an occasional difficulty 
 in the articulation of a labial sound, he called from time to time on my son at 
 the hospital for paralysis, who detected the same s}-mptoms, and in November 
 1877, he suddenly became worse, more confusedinmindandextraordinary in con- 
 duct and had to be removed forthwith to Bethlehem, where he died in convulsions. 
 
Section IX. 
 STATES OF MENTAL WEAKNESS. 
 
 Various states of Mental Weakness. Imbecility— its connexion vs-itb criminality. 
 Idiocy — Anti-natal and post-natal causes of. Dr. Morel's classification o^ 
 causes. Dr. Shuttlesworth's — micro-cephalic idiot — Influence of synostosis 
 on idiocy. Cerebral malformation. Dr. Duncan's classification of the char- 
 acters of idiots — Acquired idiocy. Cachexia in relation to idiocy. Senile 
 decay — Grades of— Capacity for legal functions. 
 
 The next subdivision of our subject according to the classifi- 
 cation given at p. 104 is the subdivision (b) of Class A, in 
 which the mental symptoms are not due to morbid jprocesses but 
 depend upon developmental causes. 
 
 It will be seen that this subdivision is capable of being further 
 divided into two states, viz., Idiocy, and Senile Decay, which in 
 great measure may be considered to be allied as they consist of 
 states of mental weakness. 
 
 It will be convenient to speak of these states together. In 
 asylums it is often the practice that these patients are classed 
 by themselves ; and of late in the county of Middlesex aU the 
 patients of this character are treated in a distinct establishment. 
 In my opinion this system is bad, and had medical opinion been 
 consulted and taken, it probably never would have been 
 adopted. It is evident that the commercial spuit prevailed in 
 the councils in the promotion of this idea, and economy ruled the 
 decisions ; it was supposed that by collecting all the imbeciles 
 together, and thus concentrating dulness, apathy, and fatuity, 
 there might be a saving of rates. 
 
 The question of mental weakness or the actual capacity of 
 an individual may be brought before the medical man for his 
 opinion. It will be as well therefore to enumerate here the 
 different kinds of mental weakness collectively, though some of 
 the cases have already been under our consideration. 
 
 Mental weakness may be found chiefly under the following six 
 categories. In all asylums there are to be met with a very large 
 number of patients of weak mind from the following causes, 
 viz:— 
 
328 LECTURES ON MENTAL DISEASE. 
 
 1. Imbeciles, the result of previous mental disease, in whom the 
 active morbid processes have ceased, leaving the patient with a 
 permanent defect of intellect, a condition which is not unfre- 
 quently still progressive. 
 
 2. There are others classed as imbeciles, in whom the morbid 
 processes may be said to be subdued but still smouldering, 
 and though they are tranquil in mind, are subject to occasional 
 recurrence of active symptoms, such as violence or other kind 
 of maniacal exhibition. 
 
 3. Those in the last stage of general paresis in whom there 
 is also always a condition of weakness of mind bordering on 
 dementia ; the word dementia being a term to signify a profound 
 degree of imbecihty. 
 
 4. In nearly every asylum there are also cases of imbecility, 
 the result of epilepsy. 
 
 5. The subjects of idiocy proper. 
 
 6. The subjects of senility. 
 
 These patients appear at first sight a very uninteresting 
 group of individuals, but there is scarcely a class for which 
 more may be accomplished by way of amehoration than for 
 these. 
 
 The treatment of all kinds of mental weakness is very much 
 alike as regards the nursing and attention, the special requu'e- 
 ments of each variety will be found under each kind of case. 
 
 In a different page of the present book, each different kind of 
 mental weakness has its proper place excepting those under 
 5 and 6 which have now to be considered. These form the cases 
 of mental disease from developmental causes in contradistinc- 
 tion to insanity from pathological causes. 
 
 Idiocy, or the state of mental weakness from original develop- 
 ment is met with in aU degrees. 1. We have the simply 
 deficient person or person of feeble intelligence, who may be 
 simply a fool, but weU-developed in every other respect. 2. We 
 have one who is decidedly an idiot, but well formed in all his 
 bodily organs ; and 3. the idiot with general defective develop- 
 ment of body as well as mind, a stunted and dwarfed being, 
 called also a cretin. 
 
 1. It \vill be as well to say a few words respecting the simply 
 feeble-minded, or unintelligent person. It is fi"om this class or 
 
STATES OF MENTAL WEAKNESS. 329 
 
 description of individual, that a large proportion of the criminal 
 population is recruited, and the question of responsibility may 
 be a difficult one to decide respecting many of them. 
 
 Mr. Bruce Thompson writes, "the criminal as a class exhibits 
 a low state of intellect compared with the industrial class. A 
 large proportion of prisoners, as I shall show by figures are 
 weak-minded congenitally, and give a large proportion of insan- 
 ity compared with the civil population." Journal of Mental 
 Science, Oct., 1866. 
 
 " Their physique is coarse and re]3ulsive, the complexion dingy 
 almost atrabilious, their face, figure, mien, disagreeable ; the 
 women are painfully ugly." Ibid. 
 
 " Between crime and mental weakness," says Mr. Nicholson, 
 M.B., {Journal of Mental Science, vol. xix., p. 398) " there is but 
 an ill-defined hne of demarcation. Many imbeciles have distinctly 
 vicious propensities, all have deficient control, and are what is 
 called impulsive." 
 
 Sir W. K. Shuttleworth writes, " It is plain to all inteUigent 
 observers that the juvenile criminals at Parkhurst were defective 
 in physical organization from hereditary causes probably, and 
 early neglect and privation." 
 
 Such cases as the above border upon a condition of idiocy, 
 and the difference between them and the commonly intelligent 
 on one hand, and the decided idiot on the other, is only one of 
 degree. One can scarcely attribute their state to actual cerebral 
 malformation, but more probably it is due to deficient size of the 
 organ or quality of brain tissue, and absence of all culture. 
 Anyone who has not had much opportunity of gauging the buco- 
 lic mind, would be surprized to find, how low the intelhgence is 
 among many of them. In cases to be met with in certain agri- 
 cultural districts the intelligence is about on a par with the Bos- 
 jesmans. 
 
 There are other cases of defective mind shown early in life, 
 which appear to be due to an irregularity of development of the 
 intellect and which eventually improve. As soon as the child 
 is old enough to evince any will, this seems to be constantly 
 dominated by malicious propensities. Even before it speaks 
 plainly it shows its wilfulness in spite and mischief, and 
 petty cruelties towards anything which it can get at. At a 
 
330 LECTURES ON MENTAL DISEASE. 
 
 little more advanced period of life, the disobedience and vicious 
 acts increase. Cases of this kind have been set down as insan- 
 ity of early life. But as I employ the term Insanity for a dis- 
 tinct morbid process, it would only lead to confusion to apply 
 the term to such cases as these, which are as I conceive, merely 
 irregularities in the process of growth. 
 
 I have been consulted concerning several of these cases, and 
 have watched the development of the children for several years 
 afterwards, and have found, that as they gi'ow older they become 
 amenable to disciphne and education, and several of them I have 
 reason to beheve have turned out more than usually intelhgent. 
 
 One lad of about ten years old, when I first saw him, had at- 
 tempted to throw his younger sister out of the window. He had 
 done many acts of wanton cruelty. He was highly excitable, 
 and of quick temper, thin, pale, with twitchings and ii-regular 
 jerky motions of his Umbs, an open shameless masturbator, ex- 
 tremely quick in learning and could already express himself, to 
 a certain degree, in three languages. He was also quick at 
 arithmetic, his mental weakness consisted only in control. He 
 recovered completely as he grew i\^ after removal fi'om the scenes 
 of a town hfe to quite a country and rural district. 
 
 A boy, the only son of an aged couple, who was being edu- 
 cated in classics, at the age of eleven, by his father ; a pale, 
 anaemic, thin and dehcate child, inteUigent to speak to, from 
 time to time would break out into violent misconduct. He 
 once threw a knife at his father, and evinced several acts of 
 cruelty, etc. He was much improved by going to a tutor at the 
 sea- side, away from home, where his general health was much 
 strengthened. 
 
 The above cases are examples of irregular development of 
 function, there are others which are due to distinct deformity 
 and are true idiots. 
 
 2. Idiocy proper; with or without general bodily arrest of 
 development. 
 
 There are many degrees and varieties of idiocy. Dr. Shuttle- 
 worth classifies them thus : — 
 
 1. Congenital idiocy. 
 
 2. Acquired idiocy. 
 
 Of the former he makes eleven principal types : 1. Micro* 
 
STATES OF MENTAL WEAKNESS. 33 1 
 
 cephalic ; 2. Hydro- cephalic ; 3. Plagio-cephalic (or distorted 
 heads with features on an oblique plane) ; 4. Scapho-cephalic ; 
 5. Scrofulous idiocy ; 6. Mongolian type ; 7. Cretinoid ; 8. 
 Syphilitic; 9. Primary neurotic; 10. Sensorial, (two or more 
 senses deficient) ; 11. Mixed cases. 
 
 Of the Non-congenital cases, he enumerates 10 varieties : — 1. 
 Traumatic; 2. Post febrile; 3. Hydrocephalic; 4. Hypertrophic ; 
 5. Eclampsic; 6. Epileptic; 7. Paralytic; 8. Deprivative (of 
 two or more senses in infancy) ; 9. Emotional ; 10. Toxic. 
 
 These variations were classed by me in my former edition 
 into idiots from : — 
 
 1. Ante-natal, 
 
 2. Post-natal causes. 
 
 Which of course is much the same as congenital, and acquired 
 of Dr. Shuttle worth. 
 
 Of the first description, or ante-natal causes derived from the 
 parent, M. Morel thus epitomises the chief, dividing them 
 further into two kinds : 
 
 1 . Marriages of affinity. 
 
 2. Cachexia of parents, produced by 
 
 (aj Diseases ; as syphilis, scrofula, rickets, goitre, epi- 
 lepsy, insanity, alcohoHsm. 
 fbj Hygienic defects ; as marsh miasma, bad soil, climate, 
 unhealthy residence, bad ventilation of work- 
 shops, mines, &c. 
 (c) Errors of food ; as ergotized grain, maize, potato, 
 rice, opium, tobacco. 
 It will be seen by reference to Dr. Shuttle worth's table, that 
 a rough division of the varieties may be made by dividing them 
 into the diminished head or micro- cephalic idiot, and larger 
 heads or megalo- cephalic. 
 
 In the micro-cephalic idiot, the cranium may be and usually 
 is tolerably symmetrical in form. The diminutive head, may be 
 a part of a generally stvmted growth, and backwardness of de- 
 velopment ; this kind of idiot is also a dwarf, and is usually 
 deficient in vital stamina, quickly ages and dies by decrepitude 
 at an early date. To this form of idiot, the name of cretin is 
 applied. A cretin is thus always an idiot, but the idiot is not 
 always a cretin. 
 
332 LECTURES ON MENTAL DISEASE. 
 
 In other forms of micro- cephalic idiocy, the fault is cranial 
 only, and it is due according toliigh authorities to anomalies in the 
 order of the closure of the cranial sutures or to errors of eynos- 
 tosis. 
 
 The synostosial causes may be divided into two classes. 
 
 There were two sets of idiots exliibited in London about the 
 time when I first began to lecture on the subject, which were 
 typical of these two classes, one called the Aztecs, they had 
 bird-like features, conical head, etc. ; and Tom Thumb, with low, 
 broad features, short nose without bridge, breath between the 
 eyes, bloated thick and ungainly trunk. 
 
 But though these types are connected with irregularities of 
 synostosis of the cranial bones, there is abundant evidence of 
 malformation of the brain as well, in most of the examples. 
 The subject has been investigated by several authors, and among 
 others by Vii'chow." 
 
 With respect to the influence of synostosis it can be readily 
 conceived how the shape of the cranium would be modified by 
 one or other suture becoming ossified out of proper order. For 
 example, if there were premature ossification of the whole of the 
 sutures, the cranium would simply remain small, but symmetri- 
 cal ; if the sutures of the apex were ossified prematurely, the 
 head would remain small at the apex, and would increase only 
 at the base ; if the sutures at the base were first fixed, the cra- 
 nium would be contracted at the base, and expand only above. 
 Thus various forms of cranium would result. The chief varieties 
 found among idiots are shown in the plates illustrating M. 
 Morel's work, (Sur les Degenerescences de VEspece Humaine). 
 
 With the malformations of the cranial cavity, alterations not 
 only result in the general contour of the head, but of course 
 in the features also. Thus, if the base of the cranium ossified 
 slowly, the brain would find there an important means of com- 
 pensation, and an expansion of the base would result ; and this 
 would give the features, by displacement, the peculiar type of the 
 Aztec : while the closing of the sutures of the base prematurely 
 would produce the opposite form in the features, or the physiog- 
 nomy of the Tom Thumb type; the sphenoid bone, at the point of 
 
 * Ueber Unteraucliungen ucbcr die Entwickelung des SchadelgrundeSj etc. 
 
STATES OF MENTAL WEAKNESS. 333 
 
 junction with the basilar, forming a smaller angle than normal, 
 the hollow of the base would be shortened and the sphenoid tilted, 
 as it were, toward the occipital region ; the bridge of the nose 
 would be thus retracted and rendered broader, the orbits sepa- 
 rated, the eyes sunken, the cheek bones prominent. Idiots of 
 either kind may be also cretinous. 
 
 The cretin proper, most commonly has a round head, and it is 
 somewhat large in relation to the size of his body. His neck is 
 short ; in some cases there is goitre. The expression and the form 
 of the features are those of a child; the eyes are usually wide apart ; 
 the cheek bones high ; the nose without bridge, and small or 
 snubbed; the mouth large]; the teeth irregular, and the dentition 
 is usually delayed to a late period ; the belly is large ; the hmbs 
 large at the joints, and ill-formed ; if puberty be developed at 
 all, it is late ; but in the worst cases the cretin is sterile. 
 
 When the cretinism is not so far advanced and the puberty is 
 developed it is often accompanied by goitre. 
 
 Some writers appear to go too far in their estimate of the in- 
 fluence of synostosis as a cause of idiocy, this remark does not 
 include Virchow however. 
 
 There is no doubt that the contained organ or viscus has 
 great influence on the containing organ, but as a rule the higher 
 in function, or in order of importance that the part is, the 
 greater is its power of modifying the organs in relation with it, 
 thus aortic aneurism will cause absorption of the vertebra. So 
 that we should for general reasons be disposed to imagine, that 
 atrophy of the brain would be the cause of the smallness of the 
 calvaria, rather than the order of the synostosis; but on the other 
 hand the distinct varieties of the irregular closure of the sutures 
 in different cases rather point to the other conclusion. 
 
 There have been a great variety of malformations found in the 
 cerebrum itself. But as far as I can ascertain they occur in no 
 such uniformity or regularity, that they would seem to bear 
 any constant relation to the external form of head. 
 
 If malformations and deficiency of parts of the brain were the 
 real cause of the defective development of the bony case, it 
 would be probable that the symmetry of the cranium would 
 be more variously disturbed, though that the cranium is often 
 un- symmetrical, is a well established observation. 
 
334 LECTURES ON MENTAL DISEASE. 
 
 As regards the cerebral defects, among those most frequently 
 mentioned by different authorities, are certain anomaUes of 
 consistence, as excessive toughness or hardness ; partial absence 
 of convoluted arrangement of the hemispheres, or extreme sim- 
 plicity of the folds ; entire absence of cerebellum has been found, 
 absence of corpus callosum in several instances, with varying 
 condition of intellect ; absence of pineal gland, absence of a por- 
 tion of one hemisphere, rudimentary condition of oUvary bodies. 
 Atrophy of the peduncles, of corpora mamillaria, thalamus, 
 corpora striata, chiasma, are also given in Griesinger, who 
 mentions that Valentin and Niepce found each a case of a ciliary 
 ventricle, which exists as the normal formation in bu-ds. 
 
 Among the anatomical modifications found in the head, Grie- 
 singer draws particular attention to alterations in the arteries 
 traversing the skull. M. Niepce found the anterior cerebral and 
 the basilar artery to present a straitness of course very re- 
 markable. Griesinger found the foramina carotidis remarkably 
 straight in course, which was not due to any alteration of bony 
 tissue, and the same condition has been noticed by others. 
 
 The condition of the idiot may be looked upon as a retrogres- 
 sion in the scale of animal development — a degeneration of the 
 species, as enunciated by M. Morel in his work, " Sur les 
 Degenerescences de I'Espccc Humaine ; " and the cranial ano- 
 mahes are a part of the general retrogression. 
 
 I consider that the facts and the authorities lead to the follow- 
 ing general conclusion, viz., that among the small headed (or 
 inicrocephalous) idiots, there are two classes, one in wliich the 
 primary error appears to be in the brain itself; and the second, 
 in which the seat of the fault is said to be in the bones of the 
 cranium. 
 
 In the first category the primary arrest of growth is in the 
 brain tissue, and the cranium or containing organ is modified to 
 the requirements of the contained viscus. The cause of the 
 arrest of growth of the brain probably is some process of in- 
 flammation occurring during either intra-uterinc existence, at 
 birth, or immediately subsequent to birth, and also during the 
 early periods of infancy. Cases of idiocy from such causes are 
 sporadic, and the arrest of growth is frequently partial or 
 irregular, and the osseous tissue is moulded over an irregular 
 
STATES OF MENTAL WEAKNESS. 335 
 
 and un symmetrical organ. The form of head in these idiots is 
 therefore irregular in outline. 
 
 It is difficult entirely to separate all cases from each other by 
 the date of the origin of the cause. In many cases of idiocy 
 from birth, it is not easy to say that the operating causes were 
 just before or during birth, or during the early periods of lacta- 
 tion 
 
 Before proceeding to consider the idiocy from the post-natal 
 cause or acquired idiocy, it may be well to briefly speak of some 
 of the chief characteristics of the idiot. 
 
 The conduct may be summarized briefly by saying that the 
 idiot's actions have the general simple reflex characters, they are 
 without variation, often repeated in the same way, showing 
 various degrees of intelligence. 
 
 It is chiefly with the congenital idiots, whose general health 
 is often fairly good with the sole exception perhaps of epilepsy 
 to which some are liable, that the Idiot's asylum is peopled. 
 
 Their mental state varies both intellectually and morally. 
 
 Dr. P. M. Duncan gives an analysis of 50 cases in Journal 0/ 
 Mental Science, Jan. 1862. 
 
 As regards disposition, he found, 26 described as irritable, 24 
 inert. 
 
 Mental. — Profound idiocy in 8 
 
 Slight intelligence only, able to stand, walk a little, 
 
 and capable of shght instructions 21 
 
 Able to walk, run, or use their fingers, to attend, 
 do easy mechanical work, feed themselves, 
 memory and perception variable in power . 11 
 
 Simpletons superior to the above, but below nor- 
 mal intelligence 9 
 
 Imbeciles from Epilepsy 6 
 
 50 
 
 When born there is often nothing to be observed, except on 
 very close scrutiny, different in the congenital idiot from any 
 other infant ; but it may very soon be discovered that the child 
 is less animated, takes very little notice like ordinary infants, 
 and perhaps lies without moving its limbs so freely. As it grows 
 
33^ LECTURES ON MENTAL DISEASE. 
 
 it continues in the infantile condition, it makes no progress 
 in any way, to seize an object or to sit up, or to direct its 
 vision, later it makes no articulate noise, it may remain with- 
 out showing any bodily disorder. Later, and as the child grows 
 and begins to know his own strength, he may become mis- 
 chievous and even dangerous, this is particularly the case at 
 the period of puberty, a being of this low order of intellect, 
 scarcely level to the intelhgence of a dog, is often given to \'icious 
 habits of all kinds and especially is he influenced by his sexual 
 passion. He masturbates to a frightful extent and if he has in- 
 telligence enough to be influenced by the opposite sex, he will 
 commit violence or make disgusting exhibition of his passion. 
 This condition of things occurs only when, though the intelhgence 
 is low, the body is well developed and when no education or 
 training has been possible, or has not been attempted ; for such 
 the idiot asylum is capable of doing much. In idiots of lower 
 type the sexual desire often remains undeveloped. 
 
 Besides actually vicious propensities such as is shown often in 
 many children, as the tortming of insects, fighting and general 
 vindictive and turbulent behaviour, there are some pecuhar 
 tricks or propensities observed in idiots of this class such as 
 restless movements, rocking themselves backward and forward 
 or from side to side, gazing at the sun, playing with a stick 
 in waving it quickly in front of the eyes. M. Niepce as quoted 
 by Griesinger, {Comj^tes Rendus, 1853) relates a case in which an 
 idiot for years occupied his time in opening and shutting a 
 drawer, in which there where two keys which he rattled together 
 continually and returned to the same occupation every day. 
 
 As shown by Dr. Duncan's table about half of the number of 
 idiots show u-ritability of temper and half are of milder character ; 
 the intelhgence of many of the micro-cephahc kind is sufficient 
 to allow them not only to speak but to learn to do various 
 mechanical work ; they work, however, mostly in a simple mode 
 only, there are others who show a great alacrity in acquii-ing 
 particular works or to repeat lessons, to calculate, to di'aw, to 
 play musical instruments, yet in every other respect perfectly 
 unintelligent. 
 
 The cretin belongs to this class of idiocy or the micro-cephalic, 
 he is the subject of universal arrest of development. A lad at 
 
STATES OF MENTAL WEAKNESS. 337 
 
 Hauwoll, the offspring of cousins, twice repeated, was one of a 
 family of three, one other being also an idiot, this idiot who died 
 at the age of 15 of phthisis, had nearly the smallest head that 
 had ever been met with in a viable child ; his intelligence was 
 never developed beyond that of an infant 3 months old, he could 
 not direct his hands, nor stand, nor sit up, the calvaria is pre- 
 served in the museum of University College, (and was usually 
 exhibited at my lectures). 
 
 The description of idiots which we have been considering or 
 the cases of idiocy from anti-natal causes, corresponds of course 
 to the congenital idiot of Dr. Shuttleworth, though with some 
 differences. He distinguishes also several variations in the 
 shape which I have not specialized among large or small headed, 
 such as certain irregularities, as boat shaped, scaphio-cephalic, 
 plagio-cephalic or distorted heads with features in oblique p^ain. 
 No one's head probably is quite symmetrical any more than his 
 feet or hands are of the same size, and intelligence is compatible 
 with much irregularity of shape of the head, but far less so with 
 want of size. The microcephalic may include all variations of 
 shape. 
 
 Among idiots from anti-natal cause there are also megalo- 
 cephalic idiots corresponding to Dr. Shuttleworth' s acquired 
 idiocy. In these cases synostosis when in fault errs in the op- 
 posite direction, the cranium remains unclosed for very late 
 periods. So universal is this that early and late synostosis 
 might serve as a basis for the classification. The acquired idiocy 
 is due to cachexia produced by a combination of causes. 
 
 The idiocy, however, which is acquired and is associated 
 with the open sutures and enlarged heads is mostly due to 
 distinct post-natal influences. It is of course a variation 
 in time of very uncertain kind, between the causes acting 
 in utero, and those immediately afterwards. Those which 
 affect the infant in utero also affect ihe mother, as syphilis, 
 scrofula, debility, certain diets in impoverished districts, and 
 mountainous countries, bad drinking water and the like. All 
 these influences acting on the child directly through the mother 
 during gestation, continue their baneful influence on the child 
 after birth. They may therefore be considered with the post- 
 natal causes. 
 
33^ LECTURES ON MENTAL DISEASE. 
 
 The influence of sjTiostosis in these cnRes is by its late com- 
 pletion. 
 
 The date when the bones of the head are united varies natur- 
 ally within certain limits." 
 
 2. Meg alo- cephalic Idiocy. The idiots with lar(je heads are 
 those whose idiocy depends on post-natal diseases, and especi- 
 ally rickets. Idiots from this cause evince the origin of their 
 disease, by the absence of closing of the sutures, the peculiar 
 breadth and flatness of the head, as well as by evidence of the 
 affection of the bones, or malformation of the spine or sternum, 
 and bending of the tibia, enlargement of the joints, &c. In these 
 idiots, although the cranium is considerably enlarged, the cavity 
 contains usually such a proportion of serum, that the brain is 
 not more voluminous than normal. In some cases the sohd 
 contents of the skull have been found to be actually less than 
 normal. But in certain cases, the actual volume of the cerebrum 
 has been greater than it should be according to the age of the sub- 
 ject. Hypertrophy, according to Griesenger, is much more rare 
 than the opposite condition, but it is almost impossible to ascer- 
 tain the fact during life ; for, in both cases, the head is larger, and 
 the ossification of the skull is incomplete, " but what," he adds, 
 on the authority of Virchow "is of interest on many accounts 
 is, that the base of the cranium is but seldom extended by the 
 hydrocephalus, but rather remains contracted, or is developed 
 to the normal average." § 160, 
 
 Among the second description or post-natal causes. Dr. Morel 
 enumerates diseases of childhood ; as rickets, scrofula. Idiocy 
 is also due in some cases to cerebral diseases occurring in early 
 infancy, blows on the head, etc. 
 
 In many cases under cither of these categories, the fact of the 
 idiocy is not immediately apparent at the time of birth. It is 
 concealed by the normal condition of mental ieebleness, so tliat 
 the cause cannot be decided by the date of discovery. 
 
 * As regards the period of the normal closing of the suture, Professor 
 Welcker says the open frontal suture is by far less common in tlie nopro and in 
 inferior races. In Mongols it is found in 1 in 14, in Malays in 1 in 20, Ameri- 
 cans and Negroes 1 in 40 or 50. While in Europeans it is open in 1 in 10. 
 Quoted from Thurnam; On Synostosis, Nat. hist. Jieview, No. 18, 1SG5. 
 
STATES OF MENTAL WEAKNESS. 339 
 
 TIio low lying districts of large and unhealthy towns, is the 
 habitat of these cases, and in M. Morel's division of the subject 
 they were placed under idiocy — des Grande ViUea. They are 
 objects of most painful character to behold. Their bodies are 
 crooked and deformed. They have scrofulous enlargements and 
 diseases of bones ; are unable to sit up, but lie in doubled up 
 form, with painful expression of fatuity and suffering. The cases 
 are less common in England than formerly. 
 
 Of what there is to be said with respect to the treatment, both 
 sections may be discussed together hereafter. 
 
 Imbecility from senile decay. — ^Cases of this kind are to be 
 met with in every asylum. In some instances they are sent 
 there for proper care and management only ; but more fre- 
 quently on account of some troublesome propensities which are 
 present. 
 
 The condition is called senility, sometimes anility, when it 
 occurs in women. Senile insanity and senile mania, are terms 
 which are also used, the latter term to denote the most pro- 
 nounced cases. 
 
 This state of mental weakness, as well known, is usually very 
 gradual in its advent, commencing at ages differing in different 
 individuals, according to the state of the general health, and 
 state of nutrition of the subject. This tendency to decay is 
 evident in everyone soon after 40 years of age, when the hair 
 shows the earliest effect of age, in the commencement of bald- 
 ness or greyness. The skin, especially of the features, loses its 
 transparency, wrinkles appear. The complexion is more opaque 
 and sallow. The teeth become more yellow. The special sensa- 
 tions perhaps become less keen, glasses are required to assist 
 vision ; the hearing is not so acute. There is less aptitude for 
 exercise and muscular exertion probably. In most, such 
 changes are simply indications of the maturity of age ; but if 
 such alterations come on at too early a period, they may merely 
 indicate wear and tear, and the mental functions may remain 
 quite unimpaired. 
 
 But an exaggeration of such symptoms usually succeeds ; 
 when the mental functions also become involved. The individual 
 gradually loses flesh, shrivels as it were. The face becomes 
 more furrowed with wrinkles. The hair from grey becomes 
 
 z2 
 
340 LECTURES ON MENTAL DISEASE. 
 
 white, not only on the head but on the pubis also. The teeth 
 drop out. The man stoops ; his gait is feeble ; his step is short, 
 shambUng, and inelastic, his sexual capacity is extinguished. 
 
 In some, the decadence is in one du-ection, and in others in 
 a different direction. Impairment of sight and deafness is 
 marked in some ; in others, the motor debility is more obvious ; 
 as feebleness in walking, in rising from the sitting position, or 
 in tremors of the limbs; in others, there is watering of the eyes, 
 tendency to retention, and to diarrhoea, with all of which there 
 may be no greater mental change, than want of energy. 
 
 In others, mental imbecihty is a prominent symptom, this 
 comes on gradually, first of all by slight loss of memory, con- 
 fined at first to newly acquired impressions. 
 
 This condition of mind is one concerning which the physician 
 may be consulted by the patient himself, who may imagine he is 
 losing his faculties. Or the opinion may be sought as to the 
 patient's abilities for executing a will or other legal document. 
 
 Such a condition as above, of bodily decadence and mere de- 
 ficiency of memory should not, I think, invalidate a legal act. 
 Each case must of course depend upon its own details ; but 
 feebleness of memory of recent events, and difticulty in the 
 memory of names is often allied with considerable powers of 
 judgment and reasoning. It is at a more advanced degree of 
 failure of the powers, when a patient's case can be called one 
 of senile mania. The anatomical ground of the earlier stage is 
 probably due only to a feeble circulation — in itself due in some 
 cases to atheroma or disease of the vessels ; the result, in turn, 
 of a rheumatic or gouty state. 
 
 The defect in the vessels is a gi'owing one, the malnutrition of 
 the brain is therefore also progressive. 
 
 In the later stage of mental decay, the patients may be re- 
 duced to an extreme degree of childishness. The memory 
 especially indicates the change. They become restless and 
 unmanageable by their friends, and among the poor may wander 
 from home and get lost. 
 
 The following are notes of two cases sent to Hanwell : — 
 
 One old lady of sixty-nine years of age was sent to the asylum 
 because she could no longer be managed at home. It was re- 
 ported that she had been failuig in mind for three or four years ; 
 
STATES OF MENTAL WEAKNESS. 34I 
 
 slic liad latterly sliowu a propensity to wantler away, and she 
 was nearly lost on several occasions, She became an annoyance 
 to her neighbours by going from one to another to borrow some- 
 thing—such as a broom, a saucepan, but most commonly a 
 candle. She was very feeble and tottering. On her admission 
 an attempt was made to keep her in bed, but she constantly 
 wandered from her room and toddled about in her night-dress, 
 always apparently in search of something, enquiring eagerly of 
 every one she met, if they had seen her old man. Her old man 
 had, I understood, been dead very many years. At another 
 time she would be very busy — m a great fuss, and would say 
 she expected her old man home to dinner and she could not find 
 her saucepan. Her state reminded one of what happens to 
 ourselves in dreams, when, as soon as we have adjusted one 
 difficulty, some other immediately presents itself. 
 
 This old woman improved in health after a short residence in 
 the asylum, but no improvement in the state of her mind took 
 place. She was still tottering on her limbs, and one day she 
 fell down and fractured her olecranon, but she took no notice 
 of the injury. On being asked to show it, she would often for- 
 get which elbow was hurt, and would even use the injured arm 
 to bring the opposite elbow into view. She would give numerous 
 accounts of how the accident happened — sometimes she said the 
 cook did it with a broom, sometimes that the butler pushed her 
 down stau's ; clearly recurring to the scenes familiar to her fifty 
 years ago, when she Hved in service. 
 
 Another old woman, admitted in 1861, was a specimen of 
 failure of intellect and bodily strength, with remarkable elation 
 of spirits. She v.'as never serious — never answered without a 
 quibble or a joke. Her mind was, however, a sad jumble of 
 youthful and senile ideas. She was vain and coquettish. At 
 times she would give her age as eighty. She said her boys were 
 six and eight years old. She suffered much from lumbago, 
 and she would lie and groan and joke in the same breath. She 
 mistook the asylum for her own house, and used to call the 
 nurse her landlady. The following are some of the notes made 
 at her bedside during the last month of her life : " August 12. 
 — Is cheerful and joking ; says she is getting worse, and 
 has been getting- older ever since she was born. She is 
 
342 LECTURES ON MENTAL DISEASE. 
 
 eighty, but she wont ilio for 'ciu ; kill iicr who dare ; says 
 she has two chikli-en, the one six, and the other eight, good 
 boys." These children were drowned fifty years ago at the 
 ages she gave. " August 19. — Asks the hour, and remarks 
 that it is late ; that her old man is out, and ought to come 
 home ; is groaning and complaining of her back, but still 
 joking; is never serious, quibbles with questions put to her; 
 takes her food. Says ' she lives well and pays her rent;' gets 
 more feeble ; is unable to turn in bed ; is occasionally wet ; pulse 
 and heart- sounds very feeble. 
 
 " September 26th. — Continues in the same mood; greets me 
 with a quibble as usual ; is more feeble in body. 
 " October 8th. — Fails gi-adually, sleeps much. 
 " 22nd. — Sleeps much ; is dozing nearly all day, but rouses 
 herself when addressed ; and takes her food well ; says she is 
 pretty well ; intellect more obtuse ; is scarcely able to joke." 
 
 Another old lady, admitted at the age of 81 years was a good 
 example of what is called senile mania ; she was a Scotchwo- 
 man ; she also became unmanageable at home, or in the work- 
 house, from her propensity to wander about. Her case, however, 
 was remarkable on account of the degree of mental weakness 
 which it exhibited. On being asked her age, she said eighteen 
 instead of 81. Her face svas greatly wrinkled and her hau* 
 scanty and white. A looking glass being close at hand I gave it 
 her, she gazed stedfastly at it, and I thought it would have con- 
 vinced her of her error as to her real age ; but after looking at 
 the reflection of her own features for some time she said, " Tak 
 it awa its nae my mither," she did not recognize her own face. 
 
 These are examples of extreme cases, they illustrate the 
 degree to which the condition may extend without being incom- 
 patible Avith life, and death when it happens is usually through 
 failure of the other functions. 
 
 As regards treatment of these cases little can be achieved by 
 therapeutics unless there are symptoms of bodily disease as 
 diarrhoea, or interference of health from neglect by dirt, etc., or 
 improper food. Usually there are some indications of such, in 
 the pauper class it is common to find that these old people have 
 been fed on course food, cabbage, bacon and such like, not un- 
 frequently they have injuries from falling about, the general 
 
STATES 01' MENTAL WEAKNESS. 343 
 
 debility of the system is shown by the tcudciicy to larf^'c vibices 
 in the hmbs, by chilbhms, neglected sores from lying unat- 
 tended to, etc. 
 
 There woiild be no difiicutly in the cases quoted, in certifying 
 the unfitness of the individual to execute any legal instrument 
 whatever. Between these extreme cases and the mildest forms, 
 there are innumerable degrees, and where to draw the line be- 
 tween such as may, and those who may not, execute such an in- 
 strument is the difficulty, there is no crucial test to fix the line. 
 The loss of all ideas on the value of money has been given as 
 a means of determining the question, and it might assist with 
 other facts to yield a just estimate. But the acuteness of the 
 patient varies from day to day. At one time he may have a 
 correct idea of the consequence of his acts, and immediately 
 afterwards may be totally confused ; in such a case the reason- 
 ableness of the act itself might be a test of the patient's lucidity. 
 
 The opinion of the state of mind must be taken from the facts 
 of each case. 
 
PART III. 
 
 Section I. 
 EPILEPTIC INSANITY. 
 
 Epileptic Insanity not a special form. The phenomena of Epilepsy, Explanations 
 of— Dr. Hughlings Jackson on— Epileptic Mania — the symptoms of — Its 
 tendency to Imbecility— Hystero- Epilepsy— the diagnosis from true Epi- 
 lepsy—the relation of Epilepsy with Recurrent Insanity— to Crime— Treat- 
 ment. 
 
 We have now to enter the examination of those cases, which in 
 the classification at p. 104, I have placed under class B, and in 
 which the mental phenomena are only symptomatic, or acci- 
 dents during different morbid conditions. 
 These it was pointed out, were chiefly : — 
 
 I. Epileptic Insanity. 
 
 II. Alcohohsmus. 
 
 III. Certain Spinal Diseases. 
 
 TV. Organic Disease of the Brain. 
 
 These will be here spoken of in the above order. 
 
 Epileptic Insaniti/.— Thin is not a special form of disease, 
 neither as regards the epilepsy or the insanity, the cases which 
 find their fitting place in the asylum are cases of epilepsy, in 
 which the phenomena, besides the usual motor symptoms, affect 
 the mental faculties. 
 
 The mental faculties become implicated in an ordinary epi- 
 leptic case in two ways, and thus we have two kinds of cases to 
 treat in asylum practice. 1. Cases of imbecihty the result of 
 epilepsy. 2. Cases of mental disturbance, maniacal condition, 
 depending on epilepsy. 
 
 It is no part of my progi-amme to speak of ordinary epilepsy, 
 a few facts may be however useful in explanation of what is 
 called epileptic mania. 
 
 The relation of recurrent insanity to epilepsy, has already 
 been alluded to (p. 174 ct scij.). 
 
EPILEPTIC INSANITY. 345 
 
 Different explaiiutions liavc been given of the phenomena of 
 epilepsy. The explanation given by Dr. Hughlings Jackson is 
 that which is pre-eminently more satisfactory than all previous 
 views. In a paper in the West Fdclinrj Reports, he gives a 
 descriptive definition in these words. " Epilepsy is an occasional, 
 sudden, excessive and rapid discharge of gray matter of some 
 part of the brain." 
 
 Dr. H. Jackson would include every variety of discharge. 
 " The term epilepsy is not the name for any one grouping of 
 symptoms, but for any set of symptoms whatever presented 
 paroxysmally, from discharge of some part of the cerebral 
 cortex. Whether conciousness be lost or not, matters nothing 
 for this definition." 
 
 It is evident that in order to obtain a clear insight into the 
 cause of any phenomenon, we must study it from its genesis to 
 its perfectly elaborated state. 
 
 As akeady several times pointed out in the previous pages, 
 every neural act consists of afferent, centre and efferent, in other 
 words of impressions and movements. The latter term including 
 every part of the organism to which an efferent is distributed, 
 that is, to skin, muscle, gland or viscera, and it includes the mus- 
 cular coats of vessels, 
 
 Dr. Jackson proceeds to say in the following words : — " States 
 of consciousness, although always parallel with, are utterly 
 different from nervous states, which in the higher (cerebral) 
 centres are, as in tlie lower, concerned with impressions and 
 movements. It is not said that mind is made up of nervous 
 arrangements for impressions and movements, but that the 
 substrata of mind are thus constituted. Thus we do not say 
 that any kinds of mental state arise from nervous discharges, 
 but that they occur during nervous discharges." (See Con- 
 sciousness, p. 17 et seq.). 
 
 Again " according as the seat of the discharging lesion 
 varies, the symptoms of paroxysm vary, but since the cerebral 
 centres, even the highest of them, represent or re-represent 
 all parts of the body, we have all kinds of symptoms in the 
 paroxysms from differently seated discharging lesions." 
 
 We have the effect exhibited in every efferent direction, 
 " increased ffow of saliva, pallor of the face, sensation of cold 
 
34^ LECTURES ON MENTAL DISEASE. 
 
 arrest of respii'ation, sensation of suffocation, coloured vision, 
 noises in the ears, nausea, movements of the eyes, vertigo, sense 
 of aura, convulsion of the limbs." " In other words, every 
 epilepsy is a development, but a brutal development of thu 
 functions of some part of the cerebral cortex, the cells of which 
 have become highly unstable." 
 
 The above is quoted principally from M^est IVuliwj Jleports, 
 Vol. G. 
 
 In considering what is called epileptic mania, the whole series 
 of the phenomena will be easily understood upon the basis of the 
 above explanation. 
 
 The history in these cases is usually that the patient coming 
 from a neurotic parent, developes ordinary attacks of epilepsy 
 during childhood. The case is severe perhaps of its kind, and at 
 puberty instead of being ameliorated as sometimes happens, 
 becomes aggravated ; and the paroxysms are attended with 
 dehrium of more or less severe character. Some of these 
 patients show a tendency to a particular form of \aoleuce, and in 
 such cases, though the fits may come on only at distant in- 
 tervals, they may be of very dangerous character. "When they 
 occur ; they resemble closely those cases already alluded to as 
 Epilej}sie Larvee oi Morel (seep. 174). In these cases the act 
 of violence is not always attended by unconsciousness. In cases 
 of epileptic mania the violence is more frequently the precursor 
 of the convulsion or motor phenomena, as an aura or other 
 sensation may usher in the convulsive paroxysm in ordinary 
 epilepsy. 
 
 As Dr. Hughlings Jackson points out, the highest centres, 
 those which are the arena of the mental functions proper, are 
 most commonly sooner or later the seat of the discharge. In 
 common epileptic seizures, the cortex discharge follows by an 
 appreciable interval some lower discharge. The higher dis- 
 charge is then ushered in by an aura, or cutaneous impression, 
 a flash of light or optic centre discharge, a noise, etc., and then 
 as the effect arises there is a motor discharge, and loss of 
 consciousness, but as well known, the paroxysm may not reach 
 this condition, no motor, or no violent motor |)heuomena may 
 ensue, and the seizure is one of petit mal. 
 
 AVhat appears to take place in epileptic mania is that the pre- 
 
EPILEPTIC INSANITY. 347 
 
 limiuary phenomenon is a mental action, as a rule or as far as 
 my experience goes, there is less frequently the warning of an 
 aura, or other peripheral symptom ; the patient is rather more 
 generally excited, more talkative, more bragging or elated in 
 mind. He walks about in an excited manner, and in which 
 state is violent and dangerous. He may rush at the throat of 
 any one near, struggle with the greatest, fiercest, and blindest 
 fury, until exhaustion overtakes him, but in some cases the 
 condition will continue for several days, and terminate at last in 
 well marked epileptic convulsion with unconsciousness. Of all 
 patients in asylums these are the most dangerous, and what the 
 world would call the maddest. In other exacerbations of 
 maniacal kind the patient may be reasoned with, soothed by 
 management, and induced to forget his apparent anger, but no 
 impression of this kind can be made on the epileptic. 
 
 The seat of the discharging lesion is in these in those parts, 
 which are the substrata of the higher mental faculties. 
 
 Whether we call the explanation of a discharging lesion an 
 hypothesis or theory it appears to meet and explain all the well 
 observed results. 
 
 The theory of the tendency of the neural discharge to occur 
 in tracts previously traversed, falls in too with what is observed. 
 We know how quicldy the motor impulse follows on the im- 
 pression when it passes in a well established track. How 
 quickly for instance do we read aloud on seeing the symbols 
 representing the sounds, in this and all other so called automatic 
 movements, the track is quickly retravelled, there is evidently a 
 condition of the track itself which prevents as it were the dis- 
 persion, or spreading of the impulse to associated impressions in 
 connection with it. We are aware that no neAV train of thought 
 can pass without comparative difficulty; a new subject to be 
 learned, a new language to be acquired, is by a slow process, and 
 is accompanied by many mental digressions. In the words of Dr. 
 Hughhngs Jackson, " Every part of the system is represented 
 in the cerebrum, and even in the lower centres, the units of the 
 cerebral hemisphere (in the region of the corpus striatum at 
 least) represent potentially the whole processes of the body." 
 It is only a frequently repeated action that passes Avithout dis- 
 persion or hindrance. In epilepsy the discharging current finds 
 
34^ LECTURES ON MENTAL DISEASE. 
 
 u too c'iisy putli, and the epileptic's iniuil is one which has few 
 interferences by associated impressions, the character of the im- 
 beciles from epilepsy is that of the most uucomplex kind, in other 
 terms the simplest. It is not easy to impress such a mind with 
 any new fact, nor to turn it from any resolve by argument, the 
 tendency for the current to pass in the primitive track is too strong. 
 This character of the epileptic mind is cat-like. If a cat wants to 
 jump from a chair, no coaxing or inducement of food or indul- 
 gence will make it change its resolution, it may be delayed for a 
 time but ultimately the action will take place. It is so with all 
 the mental processes of the confirmed epileptic imbeciles, the 
 particular line of conduct is easy in one dii-ection and that 
 apparently in the most direct reflex route, no fresh impression 
 will outweigh or even modify its course. Is not this due to the 
 frequent down discharge through these direct routes, which 
 occurs in the epileptic seizure. 
 
 In a sound mind au impression is received, and its tendency 
 is to terminate in a particular motor impulse, but a previously 
 received impression is evoked by association, the impulse is 
 modified, but in an imbecile from epilepsy the stored impressions 
 are faint, have little powder, while the du-ect route is morbidly 
 patent. Hence the neural discharge readily finds an exit, and 
 the cortex itself is unstable, as it were like a badly insulated 
 Leydeu jar, and the result is an impulsive maniacal act. 
 
 In some cases which have come under my notice of this kind 
 and which we call epileptic mania, the patients have been man- 
 ageable at their own homes for a period, having been subject to 
 the usual form of epilepsy from an early age, but of such a 
 severity as to be quite unable to receive anything like a moral 
 training. They have shown impulsiveness in aU their doings, 
 being often irascible, and unmanageable even in their earliest 
 years ; so that they labour under a deficiency of control, and 
 on the approach of puberty they are wilful and unmanageable. 
 This has not however been universally the fact, for one of my 
 worst cases was in a woman at Hanwell, who up to the age of 
 about thirty had been able to maintain her mother by her in- 
 dustry ; yet this woman probably had to be managed. But it 
 would seem that the mind which has been allowed to go quite 
 uncultured is easily aficctcd by the malevolent impulses. The 
 
EPILEPTIC INSANITY. 349 
 
 maniacal outbreak takes place in some outrageous act of violence. 
 Several liomlciclal cases have thus been inaugurated and more 
 than one einleptic has been hung in consequence, for on the 
 cessation of the seizure, the patient returns to a condition of 
 composure more or less absolute. 
 
 These morbid neural discharges from the unstable cortex of 
 the parts underlying the mental faculties, like other discharges 
 do not always or necessarily terminate in unconsciousness. 
 
 The tendency of epileptic mania is to imbecility, the maniacal 
 dis]30sition of the seizures as a rule is but a transient phenom- 
 enon; most of the patients improve or become less dangerous in 
 their mode of seizure after a period in the asylum. Neverthe- 
 less it can scarcely be absolutely said when the tendency to 
 violence has ceased ; an epileptic who had been supposed to be 
 perfectly harmless for many years and was employed in out- 
 door work at Hanwell, or other very light work, such as con- 
 veying the washing from the laundry under the charge of an 
 attendant, one morning without showing the least Avarning, 
 raised the spade which he was using and presenting its edge 
 downwards, brought it down with all his force upon a fellow 
 patient working by his side, and severed the head from the ver- 
 tex down to the under jaw, and of course killed the man on the 
 spot. 
 
 The imbecility of epilepsy which may follow all kinds of cases, 
 whether maniacal or not, is of distinct character, the practised 
 eye can single out the epileptics in every imbecile ward of the 
 asylums, the term " simplicity " indicates the change and the 
 physiological condition at which the epileptics arrive in asylums. 
 The mental change has ah-eady commenced, or the patient 
 would not be consigned to such care. Dr. Eeyuolds computes 
 that some mental disturbance is to be detected in more than 50 
 per cent, of all cases of epilepsy, counting impairment of the 
 memory as such, and that epileptic mania occurs in as many as 
 one- sixteenth of all cases. The influences which lead to intel- 
 lectual weakness are, according to Dr. Eeynolds, very obscure, 
 " neither the age of the first attack, nor the kind or frequency, 
 nor duration in years seem to have any effect." " Such a high 
 rate of frequency as eleven hundred attacks in the year, may 
 exist for seventeen years without producing intellectual change, 
 
350 LECTURES ON MENTAL DISEASE. 
 
 wlicreas so low a rate as seventy-two in the year, may damage 
 the mental condition most seriously, and that in five years. 
 Besides the mental changes, epileptics show usually some 
 physical effects, as in then- gait, voice and expression. 
 
 Such are the cases most commonly found in asylums, the con- 
 dition called hystero-epilepsy by the French writers is much 
 rarer, though hysterical pscudo- convulsion may occur in female 
 lunatics, which has led to the term of hysterical mania, (see p. 
 191). The land of convulsive attack of these patients differs 
 from the true convulsion of epilepsy in the fact, that all the 
 exaggerated movements are co-ordinated movements, and not 
 the irregular contortions of true epilepsy. In hystero-epilepsy, 
 as it has been called, it is said that firm pressure on the ovaries 
 gives immediate relief. 
 
 Dr. Legi-and du Saulle whose work is the latest on this part of 
 our subject, mniutains, however, that there is no connection 
 l)otween hysteria and the womb or sexual organs, one proof which 
 he adduces is that hysterical symptoms occur in men. 
 
 The collection of cases brought together by Dr. Legrand du 
 Saulle are various, and are as it were, from the point of view of 
 the hysterical symptoms. On review of these cases some are 
 certainly true epilepsy, some I should consider chronic insanity 
 Avith hysterical symptoms and grave motor disturbances. Ac- 
 cording to Dr. Hughlings Jackson's views on epilepsy, it is pro- 
 bable that several of the severer forms, called hysteria by come 
 writers, are varieties of epilepsy in which the lesion is in the 
 higher or psychical centres. Such appears to be the nature of 
 those cases of pseudo -paralysis, of contraction of the hmbs, 
 aphasia, etc., which are occasionally observed. 
 
 There are similar cases in most asylums to those called hysteri- 
 cal epilepsy, as well as of what is called hysterical mania, and 
 which I have discussed in a previous page. 
 
 One cannot well draw a hard and fast line between all such 
 cases and others, some of the cases of hysterical epilepsj' are 
 severe, and are attended with loss of consciousness, and other 
 nervous disorders, as hemiplegia, or paraplegia. Hence anes- 
 thesia and other anomalies. Tlie patient too is compulsed, and as 
 strongly as in true epilepsy', but the difference betsveen the two 
 states is discernable as the kind of convulsion as described 
 
EPILEPTIC INSANITY. 351 
 
 above. Dr. Legrand clu Saulle, in his work, " Les Hysteriqiics,'' 
 has given a large collection of cases of hysterical disease with 
 mental symiDtoms in many of whom very grave disturbance of the 
 motor faculties were prominent. (Case 17 and 18, p. 214). 
 
 There is nothing, hoAvever, in Dr. du Sualle's work, which 
 would lead us to the conviction that such cases are exceptional, 
 and they are simply different stages in acute and chronic insanity, 
 attended with certain perverse symptoms, which in fault of a 
 better name, have been called hysterical. And certainly some of 
 these hysterical symptoms occur as part of the mental disorder 
 in ordinary insanity, in the acute or chronic stage without any 
 purely epileptic symptoms ; their true pathology may be as sug- 
 gested, viz., that they are cases of Jacksonian epilepsy in which 
 the paroxysm is wholly of the psychical kind. But the majority of 
 the cases called hysterical may have their cause in a naturally ill 
 balanced organization, or ill regulated mind. The outbreak 
 often resembles an act of ill temper and imgoverned passion. 
 Many of the cases would more justly perhaps come under the 
 catagory of Idiocy or weakmindedness. 
 
 Before dismissing the subject, there is the question of the 
 legal relations of epileptic seizures, to be alluded to ; especially 
 with regard to the question, whether the first epileptic seizure, 
 on the definition above stated of Dr. Hughlings Jackson, can be 
 an act of homicidal character. I do not think there exists an 
 example of such a chcumstance. 
 
 The cases already quoted (p. 181) under recurrent insanity, 
 especially that of the lawyer's clerk, who made a note in his 
 diary, " killed a child it was fine and hot," if not an attack of 
 recurrent insanity, could it have been an epileptic seizure ? I 
 think that no such an instance of epilepsy beginning in this 
 way ; if disease at all, the case would be rather recurrent insanity 
 of that kind called by M. Morel, Epilepsie Larvae. 
 
 The atrocity of the act of course makes no difference in the 
 pathology, the question is, can a dischargmg lesion of the cortex 
 be the cause of an act of such perversion of moral nature, and 
 occur as a first phenomena in epilepsy, there is no evidence to 
 render it at all probable. 
 
 There have been many instances of murder committed by 
 epileptics, in which the act was simply an epileptic seizure, 
 
352 LECTURES ON MENTAL DISEASE. 
 
 but in all that I have heard or read of, the epilepsy was of a well 
 developed character, notwithstanding Avhich not a few of these 
 unfortunates have been hung. 
 
 The special treatment of the epileptic mania may claim a 
 few words as regards the acute or active stage. The imbecile 
 from epilepsy may be considered as regards the imbecility, with 
 imbecility from other causes. 
 
 The treatment of epileptic insanity may be divided into the 
 management, and the therapeutics. 
 
 Epileptics require constant watching, in some cases it is true, 
 they give to one accustomed to them a warning of an approaching 
 outbreak, this should not however be trusted. The watch must 
 be by uiglit as well as day, during the paroxysm a patient may 
 throw himself down quite regardless of all danger, on to the 
 fire, into water, on to any dangerous object, or at night may 
 turn on his face, a common habit, and thus be smothered on the 
 pillow. Pillows have been invented to meet this danger, but 
 the proper prevention is the watching. In public asylums the 
 epileptics are placed in a Avard together and as their minds are, 
 in the majorit}', childish this is no hardship to the patient. "With 
 regard to dress, the epileptic should have no part tight, especially 
 around the neck. Some patients in their falls have a propensity 
 to strike their foreheads, and hats have been invented concealing 
 a soft pad, the propensity is only an exceptional one. The 
 epileptic should not be allowed to wear false teeth as in the 
 convulsion they might get impacted. 
 
 As regards ordinary hygienic treatment, the patients should be 
 lightly clothed day and night, their food should be good and 
 wholesome, and varying, with admixture of due proportions of 
 animal and vegetable kind, hut always strictli/ limitrd in quantitij. 
 It would be well to have each meal weighed out properly pro- 
 portioned to their age ; epileptics are enormous eaters and the 
 fits are induced by too great distension of the stomach. I have 
 met with more than one case, where the first attack was traced 
 to the patient's over eating. They are often alive to the neces- 
 sity of keeping the bowels regular. In bathing I have known 
 the fit to be induced several times, so that the patient in bathing 
 should be always carefully watched. 
 
 As regards the therapeutical treatment, I have lived long 
 
EPILEPTIC INSANITY. 353 
 
 enough to see very many changes, to see the reign of one drug 
 after another, and have used numerous kinds ; foremost even 
 now, stand the various bromides, though not so highly thought 
 of as formerly by some. I think the bromide of potassium 
 has been most used, I have myself witnessed a great deal of 
 good fi'om its use, as regards dimmishing the number of the 
 fits. One case that of an officer who had drunk hard and was 
 said to have had a sunstroke, while serving in a hot climate, was 
 brought to me having become violently maniacal and dangerous. 
 He was having seven or eight fits in the week. After taking 
 bromide of potassium for a fortnight, the fits were gradually 
 reduced at first to one in a week, then one in a month, and so 
 on, until he had only one in the year, but there was rather a 
 rapid induction of imbecility. On the apparent cessation of the 
 fits, by the wish of his parents, he was allowed to be at liberty 
 remaining as a boarder only ; in this way he was enabled 
 gradually to return to his former intemperate habits, but 
 without the fits recurring more frequently than one in three or 
 four months, and then of Hghter kind ; but his mind continued 
 to get more and more feeble and so continues. But the immunity 
 from such frequent attacks continued for nearly ten years. 
 I consider therefore that the bromide was distinctly beneficial, 
 he discontinued it after about eight years, he took at last as 
 much as forty grains at a dose, which was gradually diminished 
 as he left off taking it. 
 
 A young female, epileptic from early childhood, when I first 
 saw her, at the age of fourteen, had as many as thirty fits in one 
 night, when she began the use of bromide, and she is now two or 
 three and twenty, and free, or was free, when I last heard of 
 her seven years subsequently. 
 
 In another case, a male, subject to maniacal epilepsy, who had 
 gradually become very dangerous and violent, took bromide of 
 potassium for three months, which reduced the number of fits 
 considerably, but produced so much emaciation that his motlier 
 wished the drug to be discontinued ; she was epileptic herself. 
 
 It has been supposed that the bromide is an anaphrodisiac, 
 and its action in epilepsy has been attributed to such effect ; 
 there is little doubt that the sexual resthesishas induced epileptic 
 
 AA 
 
354 LECTURES ON MENTAL DISEASE. 
 
 seizures, but the action of bromide has not been satisfactorily 
 proved to have anaphrodisiac properties. 
 
 It has been said that the chloride of potassium or sodium has 
 an ti- epileptic properties. j\Ir. Littlcjohn of the West London 
 Schools, considered that the bromide induced thirst, and thus 
 induced the epileptic to drink largely, and by tliis means or as it 
 were by dilution, the benefit was produced ; and I hear that he 
 found decided improvement in his epileptics, by persuading them 
 to drink freely of water. 
 
 The bromides of ammonium and sodium I have used, but I 
 have not considered them to be so efficacious as the bromide of 
 potassium. I consider from what I gather from my own ex- 
 perience, that in the recent cases of epilepsy some benefit may 
 be efiected by their use, but in the old cases in which the patient 
 is imbecile, or demented, no good can be expected.* 
 
 Another remedy has been of late tried, the nitrite of amyl ; in 
 one case which was complicated with hysterical symptoms, it 
 was beneficial during the attack, the patient however ultimately 
 recovered under the use of bromide, and has remained well now 
 for eight years ; in the status epilepticus, the nitrite of amyl 
 seemed to arrest the violence of the convulsions for the time, but 
 seemed to have little effect in diminishing their recun-ence. 
 
 The numerous remedies as zinc, valerian, coimter-irritation, I 
 have tried without observing any benefit result. 
 
 * Dr. Hughes Bennett in an analysis of 141 cases, of the effects of the admin- 
 istration of the Bromides in Epilepsy, writes that there is every reason to be- 
 lieve that a prolonged use of Bromides has no bad effects on the physical or 
 mental powers, but that they may, by perseverance in their use, tend to eradi- 
 cate the disease- His cases were not what is called epileptic mania however. 
 Lcmcet, May 17 and 24, 1884. 
 
 See also, "On the Action of the Bromides," by Dr, Duckworth Williams. 
 Medical Times, 1864. 
 
Section II. 
 ALCOHOLISMUS. 
 
 The tendency to drink — From want of control — From disease — The toxic effect of 
 
 alcohol — Acute toxic effects— Chronic effects — Delirium Tremens — The 
 peculiar delirium — The subacute attacks — The chronic effects — Diagnosis 
 from General Paresis — Alcoholic Paralysis. 
 
 The next description of case wliich is occasionally to be found 
 in asylum practice is that of alcoholic poisoning, but the cases 
 are mostly in the chronic stage, which has been called Chronic 
 AlcohoHsmus. The degree of chronicity however in such cases 
 may vary, and the symptoms therefore are also various, and 
 usually are of the more pronounced character. 
 
 Intemperance as. regards alcohol is due to different causes ; 
 firstly hke vice, it may be allied to mental weakness and folly ; 
 secondly it may be due to actual disease. 
 
 • 1. The intemperate fool, ahas the common drunkard, has his 
 bouts, or periodical attacks ; in other words, the balance between 
 his good resolves and his lust for drink oscillates, and sometimes 
 one, and sometimes the other is uppermost ; most drunkards 
 have some desu'e to resist the temptation to drink. 
 
 2. The other cause of intemperance is the result of true 
 disease. The act of intemperance, or the resort to the stimulant, 
 is the form in which the recurrence of the attack of insanity shows 
 itself (vide p. 167 et seq. on Recurrent Insanity) . There have been 
 very painful examples of this kind of intemperance, occurring in 
 individuals of great intellectual culture, or exemplary character : 
 and who for periods, or during the intermission of the symptoms, 
 lead the most temperate and chastened lives, and who then per- 
 haps suddenly disappear, conceal themselves from their friends, 
 and resort to excessive drinking. 
 
 Such persons, however, do not necessarily sink into a state of 
 alcoholismus, their return to intemperance or the j^ropensitij to 
 drink is a part and a symptom of insanity, and it is not the 
 propensity that we are here concerned with. 
 
 Alcoholismus consists in the effects of the poison on the 
 
 AA 2 
 
35^ LECTURES ON MENTAL DISEASE. 
 
 system, these effects are our present subject and especially the 
 chronic effects. 
 
 We sliall have a clearer view of the phenomena, if we first 
 enumerate the action of alcohol upon the system, we may divide 
 the question into : — 
 
 1. The mental and nervous effects. 
 
 2. The physical or corporeal effects. 
 
 1. The mental or nervous effects of alcohol taken in full dose 
 constitute the phenomena of drunkenness, which may be divided 
 into those on the : — 
 
 1. Emotions. 
 
 2. Intellect. 
 
 3. Motor functions. 
 
 The effects on each of these divisions vary somewhat with the 
 dose, and as a rule the effects commence by the milder kind and 
 increase gradually as the poison becomes absorbed, so that we 
 may divide drunkenness into distinct stages. 
 
 1. The emotional effects of alcohol, as in insanity are the first 
 to appear, there is first a pleasurable excitement and a rapid 
 flow of spirits or cerebral action, there is a great hilai'ity, with 
 laughter and every other expression of joyful kind ; as the poison 
 becomes absorbed the emotions get beyond control, the man laughs 
 or cries immoderately, till a drowsiness by degrees comes over 
 the mind, and all emotion is annihilated and sleep is induced. 
 The physical condition that corresponds to this, is probably the 
 gradual shutting off of the circulation, by contraction of the 
 arterioles by degi-ees, until there is that state of anaemia pro- 
 duced on which sleep depends. 
 
 2. The intellectual phenomena at first, are a rapid flow of 
 ideas, then the ideas gradually become confused, the man 
 twaddles ; his emotions which are weakened to the same extent, 
 are uncontrolled by the intellect. The drunkard di-ivels in a 
 witless, fatuous manner. The senses participate in the effects, 
 there is vertigo, and double vision among the most common symp- 
 toms, and evidently dulness of the sense of common sensation, 
 as well as of the sense of taste, etc., these all increase until sleep 
 or coma completely intervene. 
 
 3. The motor effects take much the same course, and are at 
 first increased and eventually paralysed ; the di'unkard at first 
 
ALCOHOLISMUS. 357 
 
 raves, shouts, rushes about, dances, fights, then the vertigo 
 commences, the man reels, gradually loses his control over his 
 voluntary movements, his speech is affected, he fumbles with his 
 fingers, the co-ordination and equihbriation are affected more and 
 more, until the inebriate falls unable to move, and in a condition 
 of paralysis and unconsciousness. 
 
 The above are the effects of a full dose, which stops short of 
 producing death. When the dose is a fatal one, the physical ap- 
 pearances found after death, are thus given by Dr. Curnow in 
 Quain's Dictionary of Medicine, as observed by himself. The ef- 
 fects observable are chiefly in the viscera, as " intense injection of 
 the vessels of the pyloric end of the stomach and of the duodenum, 
 with a peculiar blanching of the mucous membrane between, 
 causing a vivid scarlet arborescent appearance on a white 
 ground." He found also, " about 2oz. of bloody serum in the 
 pericardium, and about 16oz. in the right pleural cavity (the 
 left pleura was adherent) , double pneumonia, extreme conges- 
 tion of the kidneys, and engorgement of the large veins covering 
 the posterior part of the brain." Most observers agree that a 
 general congestion of the brain is not found. 
 
 The above phenomena, observed on the administration of a 
 single and poisonous dose of alcohol, will afford a key to the 
 more chronic effects which we have to consider. 
 
 These chronic effects will be influenced by various circum- 
 stances, as : — 
 
 By the state of concentration or dilution of the toxic agent. 
 
 By the quantity of the agent itself. 
 
 By the condition as to habits or addiction to the use of alcohol 
 by the patient. 
 
 We consequently find different morbid states produced by 
 alcohol according to these conditions. The diseases may not all 
 come under the asylum physician, especially those which are due 
 to the more acute effects, nevertheless to obtain a continuous 
 view of the whole phenomena, it may be useful to examine the 
 whole series. 
 
 Firstly, the state of delirium tremens. 
 
 The description of delirium tremens is to be found in all 
 works on medicine. To review the symptoms, I avail myself 
 here largely of Dr. Bristowe'a Theory and Practice of Medicine ; at 
 
35^ LECTURES ON MENTAL DISEASE. 
 
 p. G04, ho observes, " it was long believed that it occurred only 
 in persons who, after drinking heavily, ■were suddenly deprived 
 of theii- accustomed stimulus. More recent enquiries, however, 
 show that it is the immediate consequence of excessive drinking, 
 and that it usually comes on in the course of long continued 
 intemperance, or of those occasional outbreaks of intemperance 
 (lasting it may be for a few weeks at a time), to which some 
 persons are Uable. It may no doubt supervene at the time 
 when such persons are commencing to abstain ; but not in con- 
 sequence of their abstinence." 
 
 The symptoms creep on gradually, there is perhaps, a gene- 
 ral in-itability and restlessness, notions or fancies or suspicions, 
 not at first amounting to true delusion, in fact more Hke the 
 morbid apprehensions of insanity ; the patient often imagines 
 that some mischief is threatening him. He absents himself from 
 home, or goes away to a distance. He imagines the poHce are 
 following him, or as expressed by old Burton, " Semper fere 
 vidisse militem nigrum presentem." 
 
 It will be remembered that for this state of things to be pro- 
 duced, it requires some persistence in the use of the toxic agent. 
 A single act of intoxication usually affects and disturbs the 
 digestive organs ; a continuance of the dose produces consider- 
 able and chronic dyspepsia. The appetite of the drunkard is 
 bad, his tongue is foul, he has acid eructations, perhaps shght 
 vomiting and diarrhoea ; when the condition of dehrium tremens 
 is produced, natural sleep leaves the patient. He is greatly 
 disturbed by dreams, startings of the hmbs, and a pccuUar 
 kind of delirium. 
 
 This dehrium is deserving of a remark. I have been in the 
 habit of calling it the dehrium of watchfulness,** the patient 
 
 • The delirium of watchfulness. It appears probable that this was the coma 
 vigil of the ancients, though it does not answer to the description now given of 
 that state. It seoms to be due to the irregular advent of sleep. When sleep 
 occurs there is a gradual, and eventually entire shutting off of the cerebral cir* 
 culation. In this form of delirium, tlie closure may be irregular in its order, 
 over the different areas of the circulation; thus the voluntary movements may be 
 sunk in an absolute slumber, while the intellectual or conscious psychical actions 
 as it were lag behind, the person dreams, and the psychical operation goes 
 on for a time : or the opposite may occur tlie mental functions may sink into 
 obUviousness, the motor remain active, the patient walks, somnambulisib. 
 
ALCOHOLISMUS. 359 
 
 only dozes by catches and wakes by starts and frights. His 
 mind appears awake, while his motor functions are asleep, he 
 mutters and talks of his ordinary occupation; a waggoner 
 speaks to liis horses, another gives orders to his servants, or a 
 tradesman to his customers, at the same time he appears to be 
 fearful of injury or of arrest, he endeavours to hide, perhaps he 
 has ocular illusions. He imagines that his bed is covered with 
 creeping insects, he sees muscse volitantes, and picks at his 
 bedclothes, while his hand is tremulous, if out of bed he falls 
 about or staggers. 
 
 While mentioning this kind of delirium and its cause and 
 signification in these cases, I am tempted to digress to point out 
 how the above explanation may probably apply to such condi- 
 tions as Braidism, mesmerism and the various conditions of 
 hysterical paralysis, with alternating hemi-ansesthesia, etc. 
 
 While such mental symptoms are present, certain bodily symp- 
 toms are prominent, the patient is often bathed in perspiration ; 
 he passes a quantity of Hmped urine, his tongue is loaded, his 
 bowels may be disturbed, or costive, his appetite aboHshed. 
 
 There is a natural tendency for the case to pass off, if the al- 
 cohol is kept away from the patient ; though some cases, especi- 
 ally in second or third attacks, occasionally prove fatal. 
 
 The above description applies to the acute case of alcoholic 
 poisoning, the symptoms do not as a rule continue over a week 
 
 These states occur from irritants acting in different portions of the organism. 
 The irritant need not be actually morbid. Medical men watching an anxious 
 case for many hours, day and night, experience this kind of mental wandering. 
 Country practitioners driving home after many hours watchfulness, may experi- 
 ence the same. Mentioning the occurrence once to my own brother, of having 
 on returning at night, been disturbed by fancying people were in the road in front 
 of my horse, he told me he was so used to it, that they ceased to disturb him, 
 and he always drove through them. Any constant irritant which prevents the 
 all round closure of the circulation appears to leave an area active and conscious. 
 Such a stimulus is the besion de respirer in pneumonia, this will give rise to this 
 form of delirium : another common case in which it may be observed is in scarlet 
 fever, when the patient cannot breath without the aid of the voluntary muscles. 
 This delirium should be distinguished from other forms, as it is intrinsically of 
 less moment. Its signification, however, is that there is a necessity for voluntary 
 action. To attempt therefore in chest disease to aUay by an opiate, where the 
 action of the muscles of the chest are needed, would be prejudicial and perhaps 
 fatal. <- 
 
360 LECTURES ON MENTAL DISEASE. 
 
 or ten days, so that it is rare that such a case is admitted into 
 an asylum. 
 
 The next description of case is that in which the toxic effect is 
 produced more slowly when the patient is an habitual sot. The 
 effects on the system are more persistent, are gradually aggravated 
 until the patient is no longer master of his own actions. This 
 state which may be called clironic alcoholismus, is met with also 
 in several degrees of severity and various degrees of chronicity. 
 
 The symptoms are never in these cases entirely wiped out by 
 a period of abstinence ; hence they all continue in some form. 
 The intellect is feeble, the patient is dull and Ustless. He 
 has perhaps several morbid fears haunting him, his spirits are 
 dull. His expression is more or less fatuous, his complexion 
 paUid or waxy, his gait shambling, he complains of various 
 symptoms, of want of appetite, sleeplessness, dreams, etc. His 
 dull expression and inactivity have led some to confound the 
 case with that of general paresis, from which disease however it 
 is easily diagnosed. 
 
 The diagnosis was the subject of a thesis by M. Thomeuf, an 
 analysis of which is given in Annales Medico- PsycJwlogiques, 
 October, 1859. He says that the form of mental symptoms usually 
 presented is a kind of melanchoHa with exaggerated fears, frights, 
 delusions of being followed or watched, of being accused of guilt. 
 He arranges the chief phenomena in two columns, to contrast 
 them, thus : — 
 
 In Alcoholismus. In General Fabbsis. 
 
 Headache, with sense of weight. Headache rare. 
 
 Hallucinations connected with the Hallucinations rare, 
 sight. 
 
 Delusion of persecution. Tendency to Grand ideas, 
 suicide. A consciousness of shame 
 or feeling of inferiority. 
 
 Embarrassment of conversation, chiefly Embarrassment of conversation, 
 
 due to fear. A trembling of the chiefly due to feeble conception and 
 
 muscles of the face, and especially to paralysis of the mnscles of the 
 
 of the tongue. face. 
 
 Feeble condition of motion, scarcely Feebleness, in the legs chiefly, 
 observable in legs; equal on the two 
 sides. 
 
 Trembling oftho hands and arms, more Nothing appreciable in the upper ex- 
 marked in the morning. Cramps trcmitiea, but occasionally a want 
 .ind subsultus of upper extremities. of co>ordiuation of the movements. 
 
ALCOHOLISMUS. 361 
 
 Pupils nearly always dilated. Pupils often unequal.often contracted. 
 
 Antesthesia (loss of sensibility) of the Sensibility normal or obtuse. 
 
 limbs to the elbows, and as far as the 
 
 knees. (Lancinating pains). 
 
 Sleep disturbed by dreams ; or often Sleep usually normal. (Not often 
 
 absent. absent). 
 
 Appetite deficient. Acid eructations, Appetite increased. 
 
 with slight morning sickness. 
 
 Rapid curability. Incurability. 
 
 Occurrence of delirium tremens. Epileptiform and convulsive attacks. 
 
 (Stomach derangements, diarrhoea.) (Constipation). 
 
 The case above described is quite amenable to treatment pro- 
 vided complete control of the nursing can be ensured. This 
 kind of case does not often however come under the asylum 
 treatment. In some cases indeed, there would be a difficulty in 
 satisfying the legal requirements for admission. The inebriate 
 establishments had they been entrusted with sufficient power, 
 might have rescued very many unfortunate individuals from this 
 state of things. 
 
 When the case, by delay, gets into a still worse condition, 
 when the patient's mind is completely fatuous, and he can be 
 certificated as no7i compos mentis, then only can he have the 
 discipline of an asylum. I have had in this way the care of 
 several chronic cases of alcoholismus, all of which have done 
 well. There is scarcely a condition m my opinion for which 
 amelioration can be more confidently foretold. 
 
 But the case may not be arrested even at this advanced stage, 
 the habit of drink may be carried on surreptitiously, till greater 
 effects are at last produced, and the motor functions become 
 still further involved and the symptoms then put on the form of 
 greater neural disturbance. 
 
 In the description of cases spoken of above, we have emotional, 
 intellectual, and motor symptoms, of different degrees of gravity, 
 and the symptoms are about equally afi*ected, when the case has 
 reached the chronic stage. 
 
 Occasionally however the toxic influence appears to produce a 
 greater influence on one faculty than another. We have patients 
 who arc more disturbed mentally, who have true hallucinations 
 and delusions. We have others whose memories seem to be 
 chiefly affected. One case which came under my care was a 
 ciu-ious example of a separation of mental faculty. This 
 
362 LECTURES ON MENTAL DISEASE. 
 
 gentleman who hail drunk very largely and was reduced to the 
 greatest degree of fatuity, recovered to a great degree, and has now 
 been well for twelve years and remains temperate, but for some 
 time his memory showed a pccuHar alteration. He was unable to 
 remember any event, but perfectly remembered persons. I met 
 him accidentally far from home, and came upon him at a water- 
 ing place unexpectedly in a shop, he addressed me at once by 
 name, but could not tell me where he was lodging, or when he 
 came to the seaside, but answered, " say a week," and appealed to 
 his companion for his address and time of arrival, and he had 
 been residing in the town three months, and his lodging was 
 close by. 
 
 In some rare cases the toxic influence is exercised upon the 
 motor faculties. 
 
 Dr. Broadhurst read a paper on a case which he called, alco- 
 Iwlic spinal paralysis, at the Medico -Chirurgical Society, in Feb. 
 1884. A gentleman aged 42, who had indulged in drink from 
 early life, was gradually failing in mental power for some months, 
 when there was noticed a gradual failure of power in the arms, 
 with wrist drop, this gradually extended and increased till the 
 legs were involved, it then affected the muscles concerned in 
 respiration and so proved fatal. Dr. Broadbent mentioned 
 other cases of similar character, and observed that the disease 
 resembled acute ascending spinal paralysis. In the discussion 
 which arose, Dr. Wilks remarked, " that it would seem that 
 those organs which were most affected by alcohol directly (toxic), 
 were most hkely to be affected chronically." Dr. Buzzard men- 
 tioned cases in illustration of the variations in the forms 
 assumed. In one case there was extreme muscular wasting, 
 and in another, he observed contraction, and he particularly 
 dwelt upon the occurrence of lancinating pains which were 
 often present, the symptoms pointed in his cases to spinal affec- 
 tions. But the great distinction between these alcoholic cases 
 and acute ascending spmal paralysis consisted in absence of 
 disease of the cord exhibited after death. But in some cases 
 mentioned, certain trunks of spinal nerves, however, (the 
 posterior tibial and radial), presented the characteristic appear- 
 ances of degenerative neuritis. 
 
 Diagnosis. — It would seem, in fine, that by a continuous action 
 
ALCOHOLISMUS. 363 
 
 of alcoholic poisoning nearly all the symptoms of the various 
 forms of spinal disease may be simulated ; but there will be cer- 
 tain characters to distinguish the cases. Firstly, the history of 
 excessive indulgence is itself pretty patent, then the alteration 
 in what may be called the trophic functions will be different ; 
 the face and features will show the bloated character of the 
 drunkard, the injected conjunctiva, the foulness of breath, the 
 tremors of the hands as pointed out in the table given above, 
 Avill distinguish the case from purely spinal disease, and from 
 general paresis, in which the digestive functions remain almost 
 normal. 
 
Section III. 
 SPINAL CASES. 
 
 Caaes of spinal disease with mental symptoms. Cerebro-spinal sclerosis. Loco- 
 motor ataxy — cerebral symptoms in — diagnosis in. Ataxy and general 
 paresis. 
 
 Among the patients admitted into our asylums there are very 
 commonly found some whose disease has a sort of resemblance 
 to general paresis but who really are suffering from disease of 
 the spinal cord. 
 
 It is well known that in certain forms of spinal disease there 
 may be cerebral symptoms of some kind ; the most frequent of 
 which is a degree of imbecility. It is not very long ago that such 
 a condition of mental weakness, coupled with any impairment of 
 the motor functions, would have constituted the diagnosis of 
 general paresis. 
 
 Since disease of the cord is less rapidly fatal than general 
 paresis, it is of importance for prognosis to distinguish between 
 these cases. And it is also important to differentiate them during 
 life that there may be no confusion in arriving at the true 
 pathology of either case after death. 
 
 In the majority of cases of disease of the spine, the mental 
 functions remain unimpaii'ed for long periods, but there are 
 others in which the mind is considerably disturbed at an early 
 date. M. Topinard found mental disturbance of some kind in 
 one tenth of the cases which he had collected for analysis. 
 
 It is now well known and admitted that in many examples of 
 general paresis, the ataxic symptoms are very marked, and in 
 the most typical cases of that disease, some ataxy exists at one 
 or other period of the disease. 
 
 The form of spinal disease in which the cerebral symptoms 
 are most common, is probably that affection of the cord called 
 multiple sclerosis, or cerebro-spinal sclerosis. 
 
 Dr. Boss in speaking of this affection says, (Diseases of 
 the Nervous Syston, Vol. II, p. 759), psychical disturbances 
 
SPINAL CASES. 365 
 
 are always observed in multiple cerebro- spinal sclerosis. 
 They consist of mental irritability, emotional excitability, 
 causing the patient to laugh or shed tears without apparent 
 motive, and impau-ment of memory and intelligence. At 
 other times the mental disorder assumes the form of distinct 
 unsoundness of mind. In such cases there may be melancholia, 
 monomania, with ideas of persecution or of grandeur, and the 
 patient may fall into a state of complete dementia. Dr. Bram- 
 well writes, "after the condition has become well established, the 
 facial expression becomes vacant, stoUd and stupid looking ; 
 and a pecuHar alteration in the voice is very generally observed, 
 the speech is slow and drawling, every syllable being pronounced 
 separately {scanning speech) ; the tone of voice too, is singularly 
 monotonous ; towards the end of the case it may be weak and 
 whispering. The cerebral symptoms become more prominent, the 
 headache and vertigo may continue); the mental faculties are 
 decidedly blunted ; in many cases the patient becomes irritable 
 and loses his self control ; actual mental derangement is occa- 
 sionally observed. {Diseases of the Spinal Cord, p. 256). 
 
 But in cases of locomotor ataxy, or sclerosis of the posterior 
 columns, it does happen occasionally also that the cerebral func- 
 tions become actively involved at the later period of the disease, 
 in the same way that in cases of general paresis ataxic symp- 
 toms become prominent. I met with an instance in a gentle- 
 man who had during the previous twelve years gone through all 
 the stages of locomotor ataxy, including lightning pains, ataxic 
 gait, girdle pain, pelvic difficulties, whose mind eventually be- 
 came impHcated ; and he was considered insane and to be the 
 subject of general paresis by some of the leading continental 
 physicians. 
 
 The cerebral symptoms were, however, totally different from 
 those of general paresis ; there was no garruhty, irreticence, or 
 mental excitement ; no bragging or reckless behaviour, no grand 
 ideas, kleptomania, sexual excitement, boulimia, etc. The 
 diagnosis was therefore clearly that of spinal disease and that 
 form called locomotor ataxy, and spreading gi-adually upwards 
 to the cerebrum proper. 
 
 The hand writing of this case before any mental symptoms 
 appeared, is given on Plate iv., and it is contrasted with that 
 
366 LECTURES ON MENTAL DISEASE. 
 
 of a patient with general paresis, during exaggerated mental 
 disturbance.** 
 
 Dr. Gairdner, (Glasgow), exliibited 3 patients at a meeting of 
 the Medico- Psychological Association in March, 187C, as ex- 
 amples of ataxy having certain points of resemblance to general 
 paresis. 
 
 First Case. A watch-maker with defects of articulation and 
 gait 2i- years, followed by imperfection in minute combined 
 movements, (for watch-maker's work). Mental integrity both 
 intellectual and emotional, he had no lightning pains, but start- 
 mgs of the limbs. The defect of articulation was the point in 
 which it resembled general paresis, the diflEiculty occurred with 
 the Unguals rather than labials, he had more difficulty in pro- 
 nouncing sixpence than perpendicular. 
 
 Second Case. Which Dr. Gairdner did not consider as locomo- 
 tor ataxy, the patient had slight epileptic or quasi-epileptic seizure 
 five years ago and again five months ago, progressive lesion of 
 motility chiefly manifested in gait and articulation, tremulous 
 hand writing, sKght tremor of tongue, no abnormal seusibihty, 
 sexual excess, habits otherwise temperate, no history of sypMUs, 
 the articulation was thick, defective memory. 
 
 Third Case. Gradual increasing fatuity, articulation like that 
 of general paresis, the labials first, then Unguals, perhaps palate 
 was involved, no affection of voice, no aphasia, shght tremors 
 of tongue fibres, no deviations or loss of power, uvula straight, 
 deafness -with great noise which afterwards ceased, occasional 
 vertigo, some thrills in the Hmbs, no pains, intellect quite 
 sound, no syphihtic taint, failed gradually mind and body, 
 bedsores, then complete paralysis of hmbs. 
 
 Dr Westphal mentioned tln*ec cases which he calls general 
 paresis in which the spinal symptoms preceded the mental, in 
 
 * Plate IV. The specimens of handwriting in this plato, are given to show 
 the difference between that of General Paresis and of Locomotor Ataxy with com- 
 mencing cerebral complication. The upper specimen is the handwriting of the 
 patient in Case xxiv, p. 325, with general paresis, shortly after admission. The 
 lower specimen is from the handwriting of a patient before nny very decided 
 mental disturbance occurred, but in whom the ataxic symptoms were of several 
 years duration ; the specimen is from the MS. of a long article of 70 pages, en- 
 titled Un Voyage au Brdsil, It shows the irregular pressure and command of 
 the pen in ataxy. 
 
}^i,ATE IV. 
 
 
 
 ^ /^ -y yr^"-*-^^ ^ 
 
 A"e*C.. .'■•i^->*«<»*or!i.i.'<i vJuJtJ Ite^. 
 
 I 
 
SPINAL CASES. 367 
 
 one case two years, in another nine, and in the third fifteen 
 years. Zeitschriftfiir Psychiatrie, Bd. xx, 1863. 
 
 Though a considerable differentiation of the spinal affections 
 have of late been made, so that each column of the cord has its 
 particular morbid phenomena, limited to a particular region 
 and to a particular area, yet we meet with many cases in which 
 the symptoms are less definitely marked, in which the lesion, 
 sclerosis or whatever it is, appears to spread to, and involve a 
 neighbouring part of the cord ; irrespective of its functions or ana- 
 tomy. It would appear in fact that the close investigation of the 
 different nervous symptoms has been one means of separating 
 the cord into special areas for particular functions ; and though 
 such study adds much interest, especially from the physiological 
 point of view, it is unfortunately true, that the coui-se of all spinal 
 disease is to one bad result. However, to know the extent of the 
 lesion and its particular site adds much to the power of estimating 
 the future progress of the case. So long as the purely spinal 
 functions alone are involved, the system can tolerate the changes. 
 Though the prognosis varies somewhat according to the seat as 
 well as to the extent of the structures involved. Thus a pure 
 case of locomotor ataxy, will last in cases from 10 to 15 years. 
 " In the majority of typical cases the average duration of life 
 appears to be from eight to twelve years," (Boss). The same 
 author describes seven varieties in the course of ataxy depending 
 doubtless on the extension of the disease to the neighbouring 
 portions of the cord. The disease of the posterior, as well as 
 that of the lateral columns has always a progressive tendency, 
 though the progress is slow in locomotor ataxy. The extension 
 of the sclerosis to the cerebral centres is a natural course, and 
 when this occurs and gives rise to cerebral symptoms of active 
 kind, the case may then be confounded with general paresis. 
 
 That the implication of the cerebral organs is not more 
 frequent, is probably due to the fact that previously to 
 the morbid changes reaching so far upwards, the centres 
 of respiration become involved, and the case terminates through 
 pneumonia or chest comphcatious, or by bulbar paralysis of 
 other kinds. 
 
 I have met with cases which showed the symptoms of lateral 
 sclerosis in old lunatics, and I have seen also patients whose 
 
368 LECTURES ON MENTAL DISEASE. 
 
 cases were considered general paresis with well marked Bymp- 
 toms and history of locomotor ataxy. 
 
 "While speaking of tliese spinal cases, wliich are sent occa- 
 sionally into asylums, it may be remarked that spinal symptoms 
 occasionall}' show themselves in old chronic lunatics. These 
 spinal affections may be of any of the various forms, they may 
 involve symptoms of ataxy, paresis, partial or general, or be 
 confined to lesion of trophic or vasomotory functions. Such 
 cases ought never to be confounded, however, with general 
 paresis, they are ordinary insanity with the epiphenomenon of 
 spinal affection, yet it is quite possible that they have been so 
 confounded. The difference and especially when the spinal 
 affection is ataxy may be thus contrasted : — 
 
 Paeesis. Ataxy. 
 
 Runs its course in a few years. Is much slower usually and may last 
 
 10 or even 20 years. 
 Commences with mental symptoms. Commences in a distal region as in the 
 
 legs, with darting or lightning 
 pains. 
 Motor symptoms are secondary in the Motor difficulties are the primary 
 
 order of time. phenomena. 
 
 Pain not experienced, but sensibility Pains of various kinds, girdle pains, 
 is duller. • pains of limbs, etc., peculiar and 
 
 like toothache. 
 Sexual excitement. Sexual feeling absent. 
 
 Pelvis difficulties very late, and not Pelvic symptoms are a prominent fea- 
 
 prominent. ture. 
 
 Mental symptoms very marked and Mental phenomena, imbecility and 
 peculiar, and especially delire des impaired memory only. 
 
 grandeurs, kleptomania. 
 
 These differentia? should be enough to distinguish these cases ; 
 but when there is a clear history, the diagnosis is rendered all 
 the easier ; and a history of the sharp and enduring pain in the 
 limbs, with a kind of anaisthcsia, existing over eight to ten years 
 one would think should settle the question. 
 
 A proper diagnosis is essential for several reasons : — 
 
 Firstly, as aiding the prognosis. Ataxy and spinal affections 
 
 have less grave signification when they are alone ; unfortunately 
 
 when symptoms connected with the spinal functions alone, even 
 
 though they have existed without much disorder of the health, 
 
SPINAL CASES. 369 
 
 become complicated "with cerebral symptoms, the prognosis is 
 much worse. Such a comphcation shows that the original 
 disease is extending upwards ; and when the symptoms have 
 been gradually extending from the legs to the pelvis, then to the 
 girdle, evidenced by hiccough, etc., and begin to affect the upper 
 extremities, as shown in the handwriting, any mental symptom 
 added becomes of grave import, showing of course a general ex- 
 tension of the sclerosis. It will be in such a case, only a ques- 
 tion of a brief time when the bulbar functions wiU be imphcated, 
 and the chest, and functions of deglutition will be involved. 
 
 But the diagnosis is important, secondly, in order to keep the 
 life phenomena and death phenomena of the two diseases 
 separate, without a clear diagnosis the history, symptoms, mor- 
 bid appearances and true pathology can never be studied. 
 
 It is doubtless due to the want of diagnosis that one reads of 
 cases of general paresis lasting eight to twelve years ; or that in 
 certain instances that general paresis occurs in old lunatics ; and 
 that certain patients with symptoms of i^aresis recover, for it is 
 well known that there are certain spinal affections which eventu- 
 ally get weU. 
 
 When the hfe phenomena are allowed such wide scope for 
 variation, how can any exact pathology be settled from the 
 appearances after death ; thus a knowledge of both diseases is 
 hindered. 
 
 BB 
 
Section FV. 
 ORGANIC CEREBEAL CASES. 
 
 Organic diseases of the biain — Ancomic Jelirium— Cerebral tumours — Apopletio 
 foci— Otitis and bone disease — Cancer — Sypliiiis. 
 
 The last tlivision under this portion of the subject ac- 
 cording to the classification at p. 104, is that of certain 
 organic cerebral diseases, which arc met -within patients sent into 
 asylums. 
 
 These cases are various, indeed it would be necessary to go 
 through the whole catalogue of cerebral disorders generally to 
 enumerate them. Several kinds of cases are described by dif- 
 ferent authors due to a distinct origin and which have never 
 fallen to my experience to witness; without including the nume- 
 rous varieties which the Scotch alienists believe they can recognize 
 (see Appendix of Classifications). Most of these so-called varieties 
 appear to me simply cases of ordinary insanity. I perceive 
 nothing exceptional in their character, progress or termination. 
 
 There are, however, states of mind which may be attended 
 with mental symptoms and which do not belong to insanity but 
 may be called accidental aberrations of mind. Everyone is aware 
 that delirium may arise from various bodily diseases, which if 
 we were to include under the term insanity, would extend the 
 catalogue of mental diseases indefinitely ; for example it is not a 
 very uufrequent thing for a patient recovering from fever, and 
 particularly typhoid fever, to be dehrious : a paper on this subject 
 was read by Dr. Hermann Weber, before the Medico- Chirurgical 
 Society, and while I was attached to the Fever Hospital I saw 
 several cases. A patient perhaps awakes as though from a 
 dream with an impression on the mind of unreal kind, but which 
 is to them real and a true delusion. This idea or belief remains 
 for a period more or less lengthened and it gradually fades as 
 convalescence is established. In two cases the delusion seemed 
 to be of more permanent kind, and the patient in one instance 
 was sent to an asylum ; such cases are rare. I have known 
 another case in Avhich the insanity is said to have commenced 
 after recovery from scarlatina; in this case there was renal dis- 
 
ORGANIC CEREBRAL CASES. 37I 
 
 ease, and the patient was subject to paroxysms of excitement 
 and violence, and became imbecile, these cases are only excep- 
 tional, rest on what may be an imperfect history, yet may 
 possibly be true. 
 
 A more common cause for a patient to be sent to an asylum 
 for treatment, is the mental disturbance which arises in hemi- 
 plegia after the first symptoms have subsided. It often happens 
 that at a subsequent stage there is set up some inflammatory 
 change around the focus of an apoplectic clot, which leads to 
 cerebral symptoms. The phenomena in such cases vary much 
 according to the seat of the clot and the parts involved, and to 
 the degree of irritation produced. 
 
 Cases also of cerebral tumours, irritations around bone disease, 
 cases of otitis as well as syphilomata, or cancer, will have symp- 
 toms resembling different forms of mental disease. 
 
 The symptoms from such accidents are widely different in 
 kind, in the order of appearance and in the progress, from 
 idiopathic mental disease, and may be distinguished readily from 
 insanity. 
 
 As an example of this kind may be cited the following. 
 
 A gentleman very actively engaged as a barrister, after con- 
 siderable application to business for a long stress, lost his father, 
 and was called upon in consequence as his executor to abandon 
 his annual holiday and devote himself very closely to work. His 
 health suffered considerably from this cause. Among the first 
 symptoms which were observed in him were fits of drowsiness, 
 he would fall to sleep in his chair, having previously been of very 
 active disposition. He was depressed and his reason was dis- 
 turbed, followed very quickly by excitement, and it became 
 necessary to place him under certificates. He was discharged 
 after three months, but his friends never considered him the 
 same. He went on to the continent, to Spain, and returned in 
 about three months. He was then observed to have facial para- 
 lysis of the left side, he consulted Sir W. Gull, and he was 
 recommended to refrain from work, and galvanism was used for 
 the facial palsy, the palsy was accompanied with ptosis of the eye 
 of the same side, and dilatation of the right pupil, and paralysis of 
 left arch of the palate. Shortly after he became violent, and the late 
 Dr. Forbes Winslow was consulted ; after being under his care a 
 
 BB 2 
 
372 LECTURES ON MENTAL DISEASE. 
 
 few mouths, improvement took place and ho went to the sea side. 
 While at the sea side he relapsed, was admitted under my care 
 in a state of maniacal excitement. I found the mental disturbance 
 very pronounced, with excitement and violence, there was deaf- 
 ness of left ear, ptosis of left eye, paralysis of left arch of the 
 palate, no discharge from ear. He recovered in six months suffi- 
 ciently to return home ; but there remained distinct cerebral 
 symptoms of a kind, as aversion to his relations, irritability of 
 temper, desire for litigation, etc., but he gradually improved for 
 several months, when mental u'ritabiHty and insane conduct 
 returned. He behaved outrageously in public, brawled in church 
 and was sent back, through magisterial interference to my care. 
 He again improved under sUght control, amused himself in 
 various ways, in di'awing, driving, and in writing a naiTative of 
 the life of a scripture patriarch. He had from time to time 
 twitching of the paralysed side of the face, and an occasional 
 discharge from the ear of offensive kind. He had two or three 
 shght attacks oij)etit mal. He fell once on getting off his horse, 
 at another time he dropped while walking, on the last occasion he 
 fell slightly convulsed and died, and a free discharge of bloody 
 purulent matter escaped from the ear. 
 
 Probably this case was due to internal cerebral disease, 
 evidently seated near the left temporal fossa. It did not follow 
 the usual course of ordinary insanity, though the first appearance 
 of symptoms were said to be depression, but more distinctly 
 drowsiness, and there was never illusion or actual delusion, the 
 progress of the case extended over an unusually long period. 
 
 Dr. Ferricr in the West Hiding Bcports, relates a case of cancer 
 of the cerebrum which was sent to the Yorkshire asylum, the 
 mental state was that of dementia. 
 
 The cases of organic brain disease to be met with in some 
 asylums, are more Hkely to be due to sj^^ihilia, and the case re- 
 quires more distinct description as it is said in certain cases to 
 put on the appearance of general paresis. Hence the diagnosis 
 of such cases becomes important, 
 
 A reference has already been made to syphilis as a supposed 
 cause of general paresis, and the reasons discussed for the con- 
 clusion that general paresis is not a form of syphilitic disease. 
 In this place it will be attempted to show how syphihs may 
 
ORGANIC CEREBRAL CASES. 373 
 
 affect the cerebral organ, and I shall avail myself of the review 
 of M. Fournicr's work in the Journal of Mental Science, hy Dr. 
 Mickle, April, 1880.<> 
 
 Syphilis affects the brain directly or indii-cctly ; the dii'ect 
 effects of syphilis are produced upon the meninges, the vessels, 
 or the brain substance, but as a rule it affects all tlu'ee simul- 
 taneously, the lesion is a hyperplasia, and ultimately a gumma 
 or sclerosis. 
 
 There are besides these essential lesions, secondary lesions as 
 extensions from disease of bone, membranes, etc., having a 
 syphilitic origin which may affect the brain. 
 
 The symptoms depend upon the position or combination of 
 the lesions. Dr. Fournier makes no less than six groups of 
 such phenomena, which he would limit to particular cases, 
 but which Dr. Mickle says occur in endless combination and 
 fusion. 
 
 Dr. Mickle would prefer a division of the cases according to 
 whether they arise from syphilitic neoplasms, or from syphihtic 
 inflammations, or fi-om toxaemia, or from the syphihtic cachexia. 
 
 For practical purposes however, the phenomena may be 
 viewed according to whether they are confined mainly : — 
 
 1. To the convexity of the brain and meninges ; or 
 
 2. To the basal arteries and base. 
 
 The syphilitic growth may attack the former and give rise to 
 symptoms more or less resembling general paresis. The mental 
 symptoms are more frequently of depression, or a form of 
 imbecility shown by gradual sinking of the inteUigence and 
 hebetude, in some cases with incoherance and loss of memory ; 
 occasionally there is distinct delusion, apprehensions, ideas of 
 persecution and suicidal propensity. 
 
 The diagnosis of the case is assisted by the history, by the 
 presence of other constitutional syphilitic symptoms, and also 
 by the nature of the symptoms themselves, and then- mode of 
 advent. There is usually headache (by no means a common 
 symptom of mental disease,) a cachectic appearance, often there 
 is local and partial paralysis or hemiplegia. 
 
 The diagnosis is also corroborated by the absence of the pccu- 
 
 * (Tlie review is signed by Dr. Micklc's initials.) 
 
374 LECTURES ON MENTAL DISEASE. 
 
 liar symptoms of general paresis, as mogolomania, etc, by the 
 order iu which any dysphasia occurs, and the general progi'ess. 
 
 The action of the usual anti-syphilitic remedies also will con- 
 firm the diagnosis of syphiUs, for unlike general paresis these 
 cases often prove amenable to treatment. 
 
PART IV. 
 
 TEEATMENT. 
 
 Division of the subject— Therapeutics —Dosps of Medicines ; special drugs found 
 useful — Aperients — Tonics — Baths ; Warm, Shower — Hydropathy — Moral 
 Treatment — Mental Rest — Removal from Home — Private House of a Medi- 
 cal Man — Special Establishment — Suicidal Patients — Attendants of Ex- 
 perience — Removal from Home ; the Question of Early Removal — Kinds of 
 Special Establishments — Amusements as means of Treatment — Association, 
 as a Remedy, with suitable sane companions — Effects of External Environ- 
 ments — Attendants, qualities of — Seclusion as a remedy for Excitement — 
 Association at meals — Principles of Non-restraint Treatment — The old 
 system of Restraint — American objections to Non-restraint — Visits and 
 Communication with friends — Exercise and Hygienic Treatment. 
 
 The treatment of meutal diseases is usually divided into — firstly 
 the Therapeutical, and secondly the Moral, in other words into 
 the physical and the mental. 
 
 Though in many ways these must go hand in hand, and can- 
 not be very precisely disjoined, we may speak of them separ- 
 ately. 
 
 In referring to the explanation of the mental functions, in the 
 former part of this work, it will be remembered, that the funda- 
 mental axiom connected with the mental functions, is that 
 mental acts are the result of an inter-action between the organism 
 and the envu-onments, bearing this in mind we may say that 
 the basis of the treatment should be directed to these two 
 factors. 
 
 The therapeutical treatment may be considered to be especi- 
 ally addressed to the organism or to the physical health ; and 
 the moral treatment to the regulation of the patient's environ- 
 ment. 
 
 Therapeutical Treatment. — Already in the previous pages, the 
 indications of treatment in the different stages of the disease have 
 been alluded to. In the acute stage of insanity proper, and also 
 in certain cases of general paresis, there may bo considerable 
 disturbance of the general health, and though a definition of 
 insanity has been given as " jD^'ZiVif/i?? sine pyrexia,'" it happens, 
 
'^^(j LECTURES ON MENTAL DISEASE. 
 
 in many cases that considerable febrile disturbance may exist. 
 But the cases vary in this respect ; the general principles of 
 medicine will dii-ect the course to be pursued against the bodily 
 symptoms. There is nothing special in mental disease by way 
 of treatment, except that in insanity and especially in the acute 
 cases, the doses of the drugs must be as a rule larger, e.(j. when 
 opium is employed the dose of the tincture for an adult should 
 be at least one di-achm ; of the salts of morphia, to produce its 
 full soporific effect, at least one quarter of a grain and so on. This 
 increase of dose is particularly necessary with this class of 
 medicine. The doses of aperient medicine need be httle different 
 from what is employed generaUy. 
 
 Among remedies mostly used are the following : — Opium, in 
 its various preparations ; chloral hydrate, when 20 grains will 
 usually be found sufficient ; hyoscyamine, in the dose of -j"^ to J^ 
 of a grain ; bromides. Among aperients, much depends on the 
 stage of the disease, in the chronic stages chronic medicines are 
 indicated, as the preparations of aloes, one of the most useful 
 forms that I have employed is a piU of equal parts of aloes and 
 mastich. Certain cases require enemata ; or if the remedy must 
 be concealed as not unfrequently is necessary, calomel is the most 
 easy of administration. A preparation of aloes caUed aloine, in 
 quarter grain to half graui doses may be concealed in beer. I 
 have used a preparation called elateriue, when much difficulty 
 existed in getting a patient to take any other land, J^ of a grain is 
 sufficient, and is easily concealed, it should be given at a meal, 
 or perhaps in its pure state it would be too di-astic. 
 
 Among tonics, iron in various combinations is often indicated 
 especially in females, I prefer the old fashion preparation caUed 
 Ferri Potassio-Tartras to any other ; when mediciues are ob- 
 jected to on account of the taste, and the patient is at all capri- 
 cious, the taste of iron in this form may be entirely covered by a 
 solution of hquorice ; cod-liver oil is frequently indicated. 
 
 Among stimulating tonics the chloric ether is useful, com- 
 bined with either non or a bitter, as quinine or gentian ; mor- 
 phia in small doses has been much recommended in gi-eat 
 depression ; I think it is useful occasionally in the melanchohc 
 stage of ordinary insanity. 
 
 Batlis come within the division of therapeutical remedies. 
 
TREATMENT. 377 
 
 Tlie ordinary warm bath is found useful in certain states of 
 excitement, and it has been recommended to be employed for 
 long periods together, as for 3 to 5 hours, keeping the water at a 
 constant temperature. In the paroxysm of excitement in the 
 early stage of general paresis it is more particularly suited. 
 French physicians combine the warm bath, or the hot bath, with 
 cold application to the head. 
 
 Of more frequeiit employment in England, is the shower bath. 
 
 The shower bath has been much extolled, and it is a fact that 
 the patients feel much rehef in its use, many have a propensity 
 to apply cold to the head without it being prescribed. 
 
 The shower bath has unfortunately been abused, it is a remedy 
 which may become punitive in its employment ; and if left to the 
 hands of an ordinary attendant as in such large establishments 
 as our pubHc asylums, it is necessary to take strict precautions 
 lest it be employed as a punishment. In well conducted asy- 
 lums this is usually prevented by not allowing the shower bath 
 to be used unless specially prescribed, and then only in the 
 presence of a superior officer. 
 
 Among baths must be included the wet packing of the hydro- 
 pathists, this also, unless precautions are taken, might become a 
 distinct instrument of mechanical restraint, but with the proper 
 precautions, it is a very useful remedy in cases of great excite- 
 ment. 
 
 Moral Treatment. — With respect to the moral treatment this 
 forms a more special portion of our subject. In general prac- 
 tice the hygiene and moral management of the case is usually 
 delegated to the patient himself, or to the nurse, and the direc- 
 tions are comparatively simple, and consist perhaps more fre- 
 quently in rules as to diet than to conduct. 
 
 The general principles, however, do not differ. The patient's 
 diet, when restricted to this or that course by the physician, is 
 chiefly to regulate the nutrition processes, and to obtain a rest 
 for an over -worked viscus. What is requned in mental cases 
 is rest for the affected orijait, that is the mind. This law is uni- 
 versal. In a broken leg the first care of the surgeon is to obtain 
 rest for the limb affected. 
 
 Mental rest is therefore emphaticalhj the object of all the moral 
 treatment. 
 
378 LECTURES ON MENTAL DISEASE. 
 
 This being the iiulicatiou, we have to consider the means by 
 which it is to be carried out, this may be described in equally 
 concisfe terms, and the remedy may be thus formulated : — 
 
 To change the patient's en\ironments. 
 
 It Avill be necessary in order to carry out this indication that 
 something of the nature of the case should be known and its 
 history. 
 
 Especially will it be important to know whether the case pre- 
 sents certain features, as firstly whether the patient is melan- 
 chohc or violent, suicidal or dangerous, epileptic, etc. These 
 particulars of course would have been obtained before the 
 question of treatment becomes to be determined upon. There 
 may be also certain matters or circumstances, in other words, 
 some of thejpatient's environments which excite him particularly. 
 A knowledge of the actual cause of attack, if it can be told, will 
 also be of service. 
 
 Probably the friends have abeady made up their minds con- 
 cerning the cause of the patient's state of mind, but probably 
 also they are wrong m their surmises. 
 
 In the first place the cause is seldom single, both physical and 
 moral causes are usually operating, a man may meet with a 
 calamity of any land, "as loss of wife or child, he may be so over- 
 whelmed as to commit suicide in consequence, but the calamity 
 should not produce such a result in a man in health. In most 
 cases physical and mental causes combine, (for the chief causes 
 sec p. 216 and 281). 
 
 Wc arc at present confining our attention to the moral causes 
 to give examples of such we may refer to the causes enumerated 
 in the reports, (see p. 217 and 289). 
 
 The moral causes given by the Commissioners in Lunacy, from 
 returns furnished to them, are the following : — 
 
 Domestic troubles, including loss of relatives and friends. 
 
 Adverse circumstances and cares of business. 
 
 Eeligious impressions and convictions. 
 
 Love affairs, seduction, etc. 
 
 Any of these causes may be operating in a patient's mind, but 
 the effect would not constitute disease, unless it was excessive. 
 There is not a cause among them which a physician could re- 
 move. The indication of his treatment is not to attempt this, 
 
TREATMENT. 379 
 
 but to modify its effect, the indication is to render the effect upon 
 the mind more bearable. 
 
 The problem thus becomes this, how is the mind to be made 
 able to bear its burden of grief ? 
 
 But though grief and depressing emotions do not constitute 
 the whole of the causes to which the treatment is called for, they 
 may form a large part of it. But as we have seen, the patient 
 in ordinary insanity may have passed this stage, and what we 
 have to do, is to check the opposite condition excitement and 
 violence, or some mischievous or dangerous propensity. 
 
 Widely apart as these manifestations are, they often start from 
 the same point and have the same basis. They are kept up per- 
 haps by the patient's surroundings. 
 
 Before entering upon the means for carrying out the moral 
 treatment, it should be well insisted upon, that both kinds of 
 treatment, therapeutical and moral, should be carried on together. 
 The bodily symptoms which have been described must be treated ; 
 for on the state of the general health and on the nutrition pro- 
 cesses must we depend the restoration of health. The moral 
 means are to prevent further mischief. 
 
 What constitute the most frequent acting sources of irritation 
 to the insane, in his own sphere, and for which a change is in- 
 dicated, are not in many instances what may be called either the 
 remote, or the proximate cause of the attack. Such a cause as 
 the death of a child, the loss of fortune, may have induced the 
 attack, against all such the physician is of course powerless. 
 Even if such a cause was imaginary, when the disease is estab- 
 lished, it is doubtful if refutation would prove so effectual as to 
 cure the patient, and more often than otherwise the settled grief 
 is purely imaginary, as the loss of salvation, etc. And what 
 the change of the patient's environments is able rather to do, is to 
 remove him from the local reminders of his supposed grievances ; 
 and a removal from the scene of his misery besides depriving him 
 of the many suggestions of his own changed condition, gives 
 him new objects for thought, and puts into his mind fresh ideas. 
 At home or in his accustomed place, every duty, every custom 
 or routine of life, has become probably irksome to him, and that 
 they arc so, is a source of misery. To be removed from these is 
 a relief. Even to be the object of observation or compassion, from 
 
380 LECTURES ON MENTAL DISEASE. 
 
 his former companions, or even servants, increases his uneasi- 
 ness of mind. He becomes sensitive to the anxieties which are 
 everywhere shown on his account, and it is a rehef to cease to 
 have such, even the sympathy shown to him and which he 
 would resent if not shown, would be a source of grief to 
 him. 
 
 The removal from such environments is particularly desirable 
 on the ground that all such displays act upon his emotions, and 
 on the very organs which requu'e rest. 
 
 But the earhest indications of insanity but very rarely come 
 under the notice of the speciaHst, many and perhaps the majority 
 of the cases are treated by the family adviser. And the patient 
 is often advised to take a rest from his business, to travel, to go 
 to the seaside, or take a shooting box in the north, etc., and in 
 many cases this is successful. The double action of a fresh at- 
 mosphere and mental rest restores the patient, and saves him 
 from the more serious illness of actual insanity. 
 
 These means, however, sometimes fail ; many things interfere 
 to mar the effect of the prescription, when it is determined to 
 try it. The business cares cannot be put off, the new position 
 does not agi-ee with the physical health, the discomforts of the 
 lodging arrangements, the fatigue of travelling, and the discom- 
 forts of long journeys, prevent the beneficial effects that were 
 anticipated. Instead of rehef, the patient's case becomes con- 
 firmed. It is in this stage that the specialist is first taken into 
 consultation, and it is my experience that most of the primary 
 cases of ordinary insanity have usually gone through a trial of 
 this kind, yet still remain as depressed as before. 
 
 "When this early stage has passed, and the means employed 
 have not proved successful, and when therefore the patient is 
 unequivocally insane, the removal to an asylum or special 
 establishment for the treatment of mental disease, becomes in my 
 opinion an absolute duty on the part of those acting for the 
 invahd ; and such alone affords the patient a fah chance 
 of recovery ; I look upon the removal from home to the private 
 house of a medical man, often resorted to in the prodromatory 
 stage, as simply a change like going to the sea, etc., and it is 
 often useful, and all that is necessary. 
 
 The above remarks are chiefly applicable to the earhest stage 
 of insanity when the patient is melanchoUc. 
 
TREATMENT. 381 
 
 But the patient may not bo dcprcssccl, on tlic contrary as in 
 the onset often of general paresis the patient is excited, elated, 
 perhaps violent and irascible. Such a patient needs to be taken 
 care of on account of his family and for his violence, but on 
 other grounds as well. If such a patient is master of a house, 
 he may make various demands on his servants, or his family ; 
 will command them to do this or that impossible or incongruous 
 act, and become highly incensed if not implicitly obeyed. Such 
 a man placed among strangers at once alters his tone, and is 
 rendered calmer. This is particularly so in general paresis, 
 there is a want of spontaneity in these patients, and they are 
 easily led by a little tact. 
 
 Again the patient may have suicidal propensity, that is, be 
 dangerous to himself ; when this is the case, there are stronger 
 reasons why he should change his environments. In his own 
 house the means of accomplishing his purpose are known to him, 
 and the facilities also for eluding the watch which may be put 
 upon him. He may refuse to be attended and forbid his servants 
 to watch him. In his own house, and in all private houses and 
 such localities, the means for committing suicide are in every 
 corner and at every step. 
 
 We are supposing the patient is in circumstances to have 
 servants, if he is not and can be only looked after by his own 
 friends, he is still worse placed whether he is dangerous to others 
 or himself. 
 
 In the case of the suicidal patient not only is it necessary that he 
 should be removed from his home to produce a beneficial change 
 in his thoughts, but he needs all the skill and care that only 
 special appointments of an asylum can give him. 
 
 My own conviction is, that it is impossible without the proper 
 appliances, such as a special establishment can afford, that 
 suicide can be wholly prevented ; nnskilled and inexperienced 
 nurses and attendants cannot be trusted. If they are ever so 
 watchful, the opportunities are so numerous in ordinary houses 
 that there can be no security. For a very suicidal patient, one 
 attendant is not sufficient, nor are two safe, there requu'es a 
 relay of nurses, for the propensity never sleeps ; and nurses, even 
 when they are relatives and most interested, must succumb to 
 fatigue. 
 
382 LECTURES ON MENTAL DISEASE. 
 
 The following was related to me by the late Mr. Wakley coroner 
 for Middlesex. A suicidal lady was boin"; nursed at home, and 
 every night had two nurses, always with her, one on either side 
 of her bed. On one occasion one of the nurses having a cold was 
 persuaded by the patient's daughter to go to bed, and the daughter 
 volunteered to take her place at her mother's bedside. The 
 daughter and the other nurse kept their post throughout the night, 
 as day light dawned the daughter remarked to the nurse, that the 
 patient had had an excellent night, and had never stirred. On ex- 
 amining more closely they found that she was dead. She had 
 drawn threads out of her sheet one by one, and had passed them 
 tightly around her neck and was dead. 
 
 I was consulted some time ago in the case of a gentleman with 
 suicidal propensity. In this case the fi-iends objected most 
 positively to his beiag removed from his home. It was asked 
 why his own house could not be converted into an asylum. The 
 objection to removal was chiefly that his wife, a great invalid, 
 would be injuriously affected by the patient's removal. The ex- 
 periment of home treatment was made, the result was death by 
 poison. The patient went out daily in his carriage attended by 
 his own servants, of course quite inexperienced men, but greatly 
 attached to their master. The gentleman called at different 
 chemists' shops and bought a small quantity of laudanum at each, 
 and took the whole at a dose and died. 
 
 A gentleman very depressed but of doubtful suicidal propensity, 
 was accompanied by his man servant in his daily walk. The 
 servant allowed his master to walk on the sea wall in a seaport 
 town during very rough weather, the servant walked on the land 
 side and suddenly saw his master thi'ow himself off' the path into 
 the sea where he was drowned. 
 
 I was called in consultation once, to advise concerning an old 
 lady who was very suicidal, and was under the care of her 
 daughter, the suicidal tendency was very active. I saw the lady 
 in the drawing room on the first floor, and noticed the windows, 
 which were large and opened down to the floor, were wide open, 
 and presented a most obvious opportunity for the patient to 
 throw herself out. On retiring to consult to a room below, 
 having left the daughter with the patient, I was impressing 
 upon my medical colleague the danger from these windows. 
 
TREATMENT. 383 
 
 when the daughter entered the room having left her mother, as 
 she said, for only a moment, to mention some other symptom. 
 In such a minute of course the suicide could have heen com- 
 mitted, but very fortunately it was not. But the circumstance 
 shows how difficult it is to impress ordinary people with the 
 danger of not attending to such small details. In a house 
 specially adopted for the care of patients of course no such win- 
 dow would be left unguarded. 
 
 My experience is that it is impossible to foresee all the means 
 by which a patient under the care of one attendant and with the 
 ordinary arrangements of a private house, may seek to accom- 
 plish his object. 
 
 A patient at Hanwell of melancholic disposition, managed to 
 elude the vigilence of his attendants on many occasions and 
 escape. Each time the attendant was to blame, and was severely 
 reprimanded, or discharged for neglect of duty; nevertheless this 
 very quiet and phlegmatic patient continually outwitted them all. 
 I once asked him how he managed it, his reply explained how 
 the suicidal patient may succeed in his object. He said, "you see 
 I am always thinking of escaping, I never think of anything else ; 
 these fellows (meaning the attendants) are thinking of a hundred 
 things, they can't be always thinking of me. So sometimes I stay 
 behind when we are out walking five or six together, and then 
 I sit down, if the fellow is up to his work, he calls to me to come 
 on ; and I come on. This happens hundreds of times, but some- 
 times it has not happened, and they don't miss me and I walk off." 
 This man once got as far as York, he was recognised. The 
 parish officers of the district where he was found were employed 
 to bring him back to Hanwell ; the parish officer was evidently 
 not an experienced attendant, for between York and Hanwell the 
 patient escaped three times. 
 
 The narration of the above is, however, to show how necessary 
 it is in all cases and especially in suicidal cases to have skilled 
 attendants, as well as special appliances. 
 
 This necessity is further shown by the fact that scarcely a day 
 passes, but one may read in the daily papers of a death by 
 suicide. A very large majority of these might have been pre- 
 vented. 
 
 And that they are prevented by proper means is proved by 
 
384 LECTURES ON MENTAL DISEASE. 
 
 the relative numbers of suicides that occur in asylums, and out. 
 In the 3'car 1880 there were admitted into all the asylums, 
 13,201 patients of whom 3,805 were reported to bo suicidal, and 
 the total number of suicides which occurred in the asylums was 
 5; and it must be borjie in mind that the 3,805 only represented 
 the number admitted in the year, there must have been a very 
 large number remaining, admitted in previous years, and in 
 whom the suicidal tendency was still active. 
 
 But it is not alone the superior caution, which experienced 
 attendants take in watching, there are in a properly ordered house 
 no facilities, and no opportunity for obtaining the means of com- 
 mitting the act ; there are too in every well managed house 
 numerous attendants, so that no one attendant can be become 
 less vigilant from fatigue. 
 
 The experienced attendant too, male or female, learns to be 
 patient under provocation of all kind, and perfectly calm under 
 language intended to irritate, and employed for that purpose. 
 This faculty of patience is acquired by experience and is to be 
 found in every establishment, where several patients are received. 
 The experienced attendant neither irritates the patient, nor 
 feeds his morbid craving for sympathy unduly. 
 
 The precautions taken in the arrangement of the house are chief- 
 ly against suicide, accidents, violence or escape. Where plenty 
 of attendants are employed, this need not deprive the patient of 
 a proper scope of freedom, so that he need not and does not as a 
 rule find himself deprived of hberty and constrained in any way. 
 
 The removal of the patient from the environments with which 
 he was familiar to fresh scenes, becomes in itself a kind of mental 
 treatment. 
 
 Isolation. — The question of the removal of the patient into a 
 house, hospital or asylum, (and which is called by the French 
 Isolation), must depend a great deal on the particular circum- 
 stances of each case. That early treatment is essential is the 
 opinion of everyone who has any experience in the matter. 
 In a committee of the House of Commons in 18G7 this question 
 was enquired into. Mr. Wilkes, Commissioner in Lunacy 
 and formerly Medical Superintcndant of a County Asylum, was 
 asked. " Do you not think there are cases of very excitable 
 temperament, in which being sent to those places, might increase 
 
TREATMENT. 385 
 
 tliG complaint, and tendency to mania?" He answered, "No 
 Sir ; I do not, I tliink the removal from home associations and 
 from exciting causes of the disease, tends very rapidly to the 
 recovery of the patient." Dr. Bucknill said, " I think the prin- 
 ciple should be to make the admission as early as possible in 
 order to provide for early treatment." Sir James Cox pointed 
 out that not only the highest per centage of cases, but the 
 shortest duration of treatment in Scotland is found in the Een- 
 frewshire asylum " into which the patients can be admitted 
 with the least preliminary formalities." He was asked, " You 
 think in all cases it is the great object to get early treatment ? " 
 A. "Yes; I think that is the greatest point to aim at." C^. 
 " If the facility of discharge would induce people to send the 
 patients earlier, the percentage of cures would be greater and 
 and the cures more rapid ? " A, "Yes, that is exactly what I 
 mean." Dr. Maudsley testified, that if insanity is to be cured 
 the patient must be put under treatment early, because re- 
 coveries are entirely in proportion to the early stage at which 
 treatment is adopted. If regulations were made more stringent, 
 the friends instead of sending them from home as is almost 
 essential in the case of insanity, would keep them at home under 
 improper conditions, and so very much injure the chance of 
 recovery. 
 
 Dr. Duckworth WilHams was asked, "Do you attach import- 
 ance to the pauper lunatics being sent early to asj'lums ?" A. 
 " Very great ; they should be sent at once." 
 
 Dr. Lockhart Eobertson, before the same committee, said, " In 
 an early case, early treatment is, of course, of great importance 
 to the patient." 
 
 Dr. Crichton Browne gave similar evidence, that early treat- 
 ment was of the greatest possible value. 
 
 Many of the above questions were distinctly in reference to 
 early admission into asylums, all the answers, however, apply 
 to necessity of early treatment, and it will be observed that 
 several of the answers are so worded, and this is the gist of those 
 questions, and all of them especially insisted upon the patient 
 being sent from home. 
 
 Dr. Mann gives the following particulars relative to the ad- 
 vantage of early treatment, calculated upon the admission into 
 
 cc 
 
386 LECTURES ON MENTAL DISEASE. 
 
 the asylum of 4,129 patients; the percentage of cures in those 
 who had been insane G months or less, 4G per cent. ; from 6 
 months to 12 months, 44 per cent ; 1 year and over, 12 per 
 cent; average 82^, per cent. (Manual 0/ Psychological Medicine, 
 p. 171). 
 
 If sent from home, the question where the patients are to be 
 sent, is the next point to be considered and it requkes some ex- 
 perience to decide this. 
 
 To place an insane person under the care of a medical man, 
 and away from home, legal authority is required. No person 
 can receive a patient into his house for care or medical treat- 
 ment, who is a lunatic or an alleged lunatic, {i.e., about 
 whose case there can be the least suspicion of its being mental), 
 without going through all the formahties of certificates as de- 
 scribed under the legal relations of the insane, in the last 
 chapter of this treatise, and to which the reader is referred. 
 
 Here the different kinds of establishment only will be enume- 
 rated. The insane are divided by the law into two classes, 
 called j)rivate patients and pauper patients. The establishments 
 provided for the latter class need no description, the state pro- 
 vides commodious and admirable accommodation for all paupers. 
 
 For the non-pauper class or private patients, there are hospitals 
 and private establishnients. 
 
 The hospitals are partly supported by charitj'', and partly by 
 payments from the patients. These payments vary from 
 very moderate charges up to any amount, according to the 
 means available from the patients' own resources, or from that of 
 then" friends. The higher charges of the wealthy patients go to 
 help the cost of those who pay less, thus, one man's affliction is 
 made to administer to another man's rehef. 
 
 This is the case in what are called the hospitals. 
 
 The private establishments vary more, probably, in the char- 
 acter of comforts which they afford according to the charge, and 
 to the class of society from which the patients are received : 
 some of the larger hospitals, which receive 200 to 800 patients, 
 are chiefly suited for small tradesmen, and the expense in them 
 is moderate, and varies a little above or below £1 a week. 
 
 From this amount up to £1 a day, there are all grades of es- 
 tablishments. 
 
TREATMENT. 3^7 
 
 Of course from a medical point of view the mention of the clilfcr- 
 eut charges may appear somewhat irrelevant, but the charges 
 affect considerably the association into which a patient would 
 be placed. And association is a powerful agent in the moral 
 treatment. It must be obvious to everyone, that the exclusive 
 association of the insane with insane cannot bo particularly 
 serviceable. Though it must be allowed that an occasional as- 
 sociation is less disadvantageous than anyone without actual 
 experience would suppose. (See Association, further on). 
 
 Many considerations necessarily enter the f[uestion of the 
 particular house, hospital or asylum to be selected ; and such 
 majters as convenience of access, or remoteness from other 
 localities, are perhaps as much consulted as the healthiness, 
 and hygienic and medical advantages, that are to be found in 
 the different institutions. 
 
 Speaking, however, as a medical man there can be no impro- 
 priety in my saying that I agree with the universal opinion of 
 all the specialty, from Eso[uu'ol to those of the present day, that 
 whatever establishment is selected it should be one in which the 
 head is a medical man ; for " une Asile des Ahenes est un instru- 
 ment de guerison." (Esquirol). 
 
 In England the public have at least this guarantee that every 
 patient placed in a house for care and treatment must be re- 
 ported to the Commissioners in Lunacy, who will personally 
 inspect the house, whether it be licensed or not. And that every 
 licensed house would not have been licensed until it was found 
 properly provided with all necessary appliances for the care and 
 treatment. Every medical man who is willing to receive an 
 insane person into his family circle must therefore be prepared 
 to satisfy the official visitors on this head. 
 
 The admission into a house, other than patient's own home, is 
 in itself a portion of the moral treatment and the slight restraint 
 of being with strangers often acts immediately and beneficially 
 upon the patient. 
 
 In houses devoted to the purposes of treatment, the moral 
 treatment is assisted by various means which may be thus 
 divided. 
 
 1. Amusements. 2. Occupations. 3. Association. — The object of all 
 
 cc2 
 
388 LECTURES ON MENTAL DISEASE. 
 
 of Avhicli is to direct the patient's mind and to keep it moderately 
 employed on Bubjccts calculated to interest and not to excite. 
 
 Amusements.— The most frequent and usual, in all cstablish- 
 raeuts consist briefly in the following ; — books, newspapers and 
 light nterature of all kinds, music, indoors and out, dancing, 
 drawing, painting, theatrical performances at home or in public, 
 and displays of similar character as conjuring, magic lantern, 
 etc., to w^hich maybe added a school; gardens, walks and di'ives, 
 visits to public entertainments or to scenes in the neighbour- 
 hood, excursions, picnics, games of various kinds. In-doors — 
 cards, chess, backgammon, solitau-e and such Uttle puzzles. 
 Out-doors — lawn tennis, croquet, archery. The keeping of 
 domestic animals. The above can be enjoyed by either sex. 
 
 For males only, cricket, bowls, billiards, fishing, the meet of 
 hounds, beagles, etc. 
 
 For females especially; needlework and embroider^', painting, 
 drawing. 
 
 Perhaps among amusements should be included, change to a 
 watering place, which will be spoken of under association to 
 which di\dsion it may equally belong. 
 
 Occupations. — In the j)ublic pauper asylums means of exer- 
 cising every mechanical trade. At Hanwell the following were 
 the chief. 
 
 For men. — Agricultural and garden labour, attending to farm 
 work, carpentry, blacksmith, printing, tailoring, bootmaking, 
 upholstery, mat-making, tin-work, brewing. 
 
 For u-omen. — Domestic work, in the wards, in the kitchen and 
 laundi-y. 
 
 In the institutions for the upper classes, occupation is equally 
 useful, but is not so easy to provide. For men, photography has 
 been an admirable resource with me on more than one occasion. 
 The rearing of fowls, rabbits, etc., the making of light articles in 
 wood as cages, boxes, and on several occasions, embroidery and 
 needlework have served as occupation for gentlemen. 
 
 Association. — This agent I consider the most important of all 
 in the moral treatment of the insane. Under this term I in- 
 clude various moral influences not easilj' classed under the other 
 divisions. , 
 
TREATMENT, 389 
 
 1. Attendance upon religious duties, the family prayers, and 
 the services of the chaplain. 
 
 2. The companionship with the sane of the patient's own 
 station ; in other words the association at meals, in the amuse- 
 ments, walks, etc., with the sane ; and the general association 
 of the patient with sane people, as far as possible under proper 
 supervision at home or at places of pubHc resort, as at concerts, 
 theatres, fancy fairs, etc. 
 
 In the pauper asylums, the nurses and attendants being of 
 quite equal or superior social status to the patient, this is always 
 easily provided. 
 
 In institutions or licensed houses for the u^jper class, com- 
 panions as proper associates from a higher class should be en- 
 gaged. Where the number of patients received is very large, 
 this is not very easy. 
 
 In smaller houses the family of the physician can assist in 
 this duty which is always highly appreciated by the patients. 
 
 There are of course always various kinds of cases to be 
 treated, but speaking in general terms they may be thus classed. 
 
 Fu'stly as regards station in Ufe, or educated and uneducated, 
 between these classes the asylum chosen itself may be sufficient 
 to make the necessary separation ; that is, the estabhshment 
 may be designed particularly for one or other kind. There are 
 a few establishments which only receive the upper class, and 
 from which practically the person of inferior status is excluded. 
 But it is quite true that those asylums which receive the lower 
 class, as the small tradesman, etc., do not pretend to shut the 
 doors to the higher, in which case the only separation they can 
 make is by arrangement of the building, and by supplying 
 separate apartments at higher expense. 
 
 I do not thnak that this is at aU advantageous, on the contrary 
 separate apartments are disadvantageous or more than that, in 
 many ways ; and principally because they isolate the patient 
 and nullify the power of judicious association. 
 
 The general opinion of those with the largest experience, 
 the superintendents of the large county asylums, is wholly 
 in favour of judicious association. The latest additions to 
 every large asylum are for the purpose of increasing asso- 
 ciation, as new dining halls, new recreation halls, new 
 
390 LECTURES ON MENTAL DISEASE. 
 
 chapels, and in these estabHshmcuts of course there can be no 
 evil from mal-associatiou as the patients are all of one status. 
 Still into these arc occasionally sent persons who have occu- 
 pied a better position, 
 
 It is an object in the moral treatment to discourage soU- 
 tary habits and not to foster exclusive propensities. If 
 the better class patient has his separate apartments, he 
 can have no society but his man servant, and even when a 
 companion of a higher education is engaged, the society for 
 both is monotonous and irksome to the sane at least, and 
 therefore not agreeable to the insane. And this is so with both 
 ladies and gentlemen, but particularly so for the latter; the only 
 change a gentleman can get under such circumstances is an 
 occasional visit from the medical or other officer, and this in a 
 large institution must necessarily be short and perfunctory, there 
 can be no real companionship in it. 
 
 Where the companion, nurse or not, is not unsuitable educa- 
 tionally for the patient, if the patient is to be much with, and 
 especially much alone with, the companion, some tact is neces- 
 sary in making the selection. "Without being at all in fault, 
 a companion may be injudicious or unsuitable from various 
 trivial causes. Minute directions may be given, but the mode 
 of carrying such out may not be in the person. 
 
 The companion should be chosen to suit the peculiarity of 
 each case, and not only the companion, but the nurse or attendant. 
 One person's manner is more or less agreeable even to the sane, 
 not only as an intimate or friend, but one servant's manners are 
 certainly more acceptable than another's. In a single family the 
 service of a particular servant is perhaps acceptable to one per- 
 son and inacceptable to another. It is so with the insane, the 
 ways of one servant may be considered quite disagi'ceable, ful- 
 some to one kind of person, and these very manners will be 
 actually of beneficial influence to another. AVlieu there are 
 many servants tliis can be readily arranged and the matter 
 usually adjusts itself. 
 
 In mentioning details such as the above it may be remarked 
 also that every small matter in the surroundings of a patient 
 should be considered. An Italian physician went so far as 
 to study what the prevailing colour of a room should be, 
 
TREATMENT. 391 
 
 and laid down laws in which ho recommended the use 
 of different colours to produce different effects. There is no 
 doubt that a study of this kind enters into every one's daily con- 
 sideration, especially among women, and the attention to 
 festhetical matters has of late been carried out to great extent, 
 the same attention to externals is well worthy of imitation in the 
 moral treatment of the insane. It does not require to be, as it 
 were, proclaimed from the house-tops, its influence would be 
 scattered to the winds by any such pretentious display ; there is 
 little doubt however that nicely furnished rooms, the attention to 
 the personal toilets of the patients' themselves, and that of their 
 associates, have influence, — the better and neater the patient 
 is dressed the quieter will he or she be. It is pretty well 
 knowQ to most people that considerable attention is now paid to 
 the furnishing and decoration of our public and pauper asylums. 
 In former times the walls were bare and whitewashed, they are 
 now all hung with pictures, dressed out with tables, brackets, 
 flowerfi, birds, etc., and it is rare to find any injured. With the 
 educated class the same style of decoration would not be appre- 
 ciated, but all are open to the influence of ornament in good 
 taste. 
 
 Tliej are also much influenced by the courtesies of society, and 
 impressed by a manner partaking of studied formality and kind- 
 ness. 
 
 Attenlants and Nurses. — The essentials for attendants on the 
 insane, whether nurse or companion, are the following : — 
 
 Perfect command over their own conduct and expression. 
 This is ',0 be acquired by practice. A patient from delusion, or 
 irritatioa, or for no apparent cause at all, may accuse, vilify, in- 
 vent thf most specious tales against the attendant, who must 
 learn tc hear such, without showing the slightest resentment ; 
 and nol only without showing it, but without feeling any : and 
 especialy without answering the patient. Or if forced to reply 
 to remember the rule, which should be at the base of all dealings 
 with tie insane, that 
 
 "A soft answer turnetb away wrath." 
 
 Patients vary infinitely in their conduct and disposition, but 
 classiig them roughly into the melancholic and the violent, the 
 
392 LECTURES ON MENTAL DISEASE. 
 
 nurse most suitable for one of the latter may be unsuitable for 
 the other kind. For the melancholic, of course a person with 
 good resources is necessary, for the violent, one of mild and 
 quiet temperament with well governed disposition, and with tact 
 is required. If the violence is in language only, the attendant 
 should listen quietly without replying ; unless to turn the sub- 
 ject into some other channel. When accustomed to a patient's 
 usual topics this may easily be done. Under any circumBtanceB 
 the attendant should avoid putting himself into opposition with 
 the patient either by word or gesture. Of course the attentlant 
 will have occasionally to interfere, as in case of violence or 
 destructiveucss, or for other reasons, as when the violence is 
 by acts, in which the patient may do damage of such kind as to 
 be of serious consequences. But no attendant should attempt 
 to oppose force to force until absolutely obliged. In such a 
 case the attendant should not attempt to use coercion singly 
 but should summon aid, so that the force used may be such as 
 the patient cannot resist. In certain conditions of maniacal 
 fury of sudden character, when the patient cannot be addressed 
 in words of any kind, the patient should be placed in seilusion, 
 that is separated from all possible surrounding excitants, 
 
 To place a patient in seclusion, two attendants at leas: should 
 bo employed ; if the patient attempt to bite, as may happen, 
 the best thing to do is to throw a blanket over his hea.1 whilst 
 the removal is taking place. No injury can be done to tli3 patient 
 by this means and he will be prevented from injuring otliers. 
 
 The term seclusion means being placed in a room entirely 
 secluded from everybody. 
 
 In an asylum or licensed house there is usually a rcom kept 
 for the pur^wso, with means to insure the patient's safety and 
 quiet. It should have shutters which will lock, but without 
 bars; it also should have no hooks, or projections, c.c, with 
 which the patient could injure himself. There shoiid be a 
 bed but it is well to have it fixed to the floor, sometiues such 
 rooms are padded around the walls. 
 
 The object to be sought is quiet. "When the patieit finds 
 himself thus isolated he very soon as a rule becomei calm. 
 "When he seems so, an attendant with tact may ent«r, and 
 8j)cak a few land words quietly, or take him food, a with 
 
TREATMENT. 393 
 
 any such cxcuso attcmx)t to imcify liim ; and under no cir- 
 cumstance should his violence be alluded to. 
 
 In every instance in which any patient is thus ' secluded ' 
 the fact must be entered in the case-book, and journals which 
 are laid before the official visitors at the next visit. 
 
 In rare instances the noise and violence, in conduct or act, will 
 continue for long periods, it is extremely rare, however, to find 
 it lasting throughout the entu'e day, and an opportunity should 
 be taken from time to time, to induce the patient to take exer- 
 cise ; if he or she shows a disposition to relapse into excite- 
 ment, and exercise be required, there should be always a 
 sufficient staff to execute the order. It is not often that 
 such hai^pens, and when this kind of paroxysm does occur and 
 continue for a long period, a sedative especially a dose of Hyos- 
 cyamine will be found useful to allay the condition. 
 
 Aywther mode of association is in taking the meals with others, 
 a solitary dinner in a single room is bad, both for its influence 
 mentally and physically. A person sitting down to dinner alone 
 can never take the meal with any pleasure, if possible therefore 
 the patients should dine with others ; the dinner table with the 
 superintendent and family as in a private family, at which there 
 are a sufficient number to constitute an agreeable society, is an 
 admu-able means of association. The presence of the heads of 
 the family gives an influence for good, and creates a proper feel- 
 ing between patient and physician. 
 
 On such occasions the influence of the opposite sex is always 
 useful, especially in the patients of good social position. The 
 presence of ladies at the dinner table wiU always induce the 
 male patients to restrain themselves, even though the lady is a 
 patient also ; the presence of childi-en, especially with the female 
 patients, is always soothing. 
 
 The meeting of both sexes at entertainments also induces 
 the patients to behave well, and strengthens the power of self- 
 control. 
 
 A dance or a concert in which the company is composed of 
 both sexes, and especially with due admixture of the sane, is now 
 an acknowledged means of moral treatment. 
 
 In most of the asylums of the present day, among the moral 
 means employed to a great extent, is change of scene, or 
 
394 LECTURES ON MENTAL DISEASE. 
 
 talcing the patients to the sea-side. This agent of course 
 may be consiclercil as a fresh association or as mere amuse- 
 ment, it depends upon whether the change is only temporary 
 or for a period. 
 
 It is to the latter case that the following remarks refer. A 
 mere trip to a fresh place is simply like any other kind of 
 amusement, but when a patient is taken to reside in a different 
 locahty there are several matters to be considered and which I 
 have learnt from experience. In the first place a change of 
 tliis kind is only suitable for chronic cases. An acute case or 
 a patient in the early stage does not require rousing, but rest, 
 they can scarcely be kept too quiet. To insure tranquihty in 
 chronic cases care is needed. I have found the trip to the sea- 
 side by no means so universally beneficial as I had anticipated. 
 For a time some chronic cases appear to be benefitted, but the 
 majority often relapse, and several among those for whom I 
 have tried this remedy were permanently disturbed. 
 
 There was one case particularly in which the effect was detri- 
 mental ; the patient was a lady, she had been insane several years 
 before she came under my care. She was what would be called 
 a chronic lunatic passing into dementia, with intervals of excite- 
 ment and violence. She was taken on two occasions to the sea, 
 once to Teignmouth in Devonshire, at another time to Llandudno. 
 At Teignmouth she became violent after having been tranquil 
 for some time, but since she was subject to attacks of the kind it 
 was not clear that the change had induced the paroxysm. On 
 the excitement passing off she seemed clearer in mind and spoke 
 more rationally than she had done for some time. The time for 
 returning home soon followed, and the patient was alternately 
 clearer and more excited for some time afterwards. By the 
 following summer she had become as she had been for several 
 years : but it was thought advisable, and her friends wished her, 
 to try another change. She was taken to Llandudno, and the 
 same occurred again. At first she seemed roused and clearer in 
 mind and spoke more rationally, mentioning things, which she 
 had not appeared to notice previously, and knowing all the 
 names of her companions of which she had previousl}' given no 
 evidence. One day while out walking on the Great Orme's 
 Head, she shi-ank back £i-om the edge of the water, and became 
 
TREATMENT. 395 
 
 SO excited that it was clecmed necessary to bring her horoe ; from 
 that time she remained in a very excited condition, and it was 
 some months before she became quieter, and her mind seemed 
 then more demented. This case was marked, but on closely 
 scrutinizing the others, and living with them as my custom is, I 
 could observe in most of them some change. In some two or 
 three the change was beneficial, but this was in cases already 
 convalescing. I considered it even trying in them. 
 
 I am therefore of opinion that considerable care is needed in 
 altering the i^atient's surroundings so widely and suddenly. 
 Patients in the acute stage are Hable to be much disturbed, 
 the chronic cases too, and the old chronic cases especially, are 
 unsettled and upset ; they miss their routine life, which the 
 chronic patients always affect, they cannot adjust then' mode of 
 life to their altered position, and not a few are disturbed in their 
 health. Every practitioner, who lives at the seaside or at a 
 watering place, knows that every one whether ill or not, who 
 pays a visit to the sea, has to go through a period of trial to sea- 
 son them, as it were, to the change ; until they get over this 
 period no benefit to health begins. It is clear that the atmos- 
 phere of the seaside is a remedial measure of great value, but it 
 is at the same time an active and powerful remedy. Young 
 people are not very sensitive to such changes; but in one respect 
 even they may experience the difference in the state of health ; 
 invariably there is some change in the alvine functions, either 
 an increased or sometimes decreased action of the bowels. 
 
 Old people and equally old insane, and the insane without being 
 old, are very sensitive to such changes. It is an established 
 fact that insane do not bear any removal well. In the County 
 of Middlesex, when a secoud asylum was opened at Colney 
 Hatch, a great many old chronic cases were removed from 
 Hanwell to that asylum ; these were the patients belonging to 
 parishes of the eastern part of the county. The patients had in 
 many instances been in Hanwell many years, and the mortality 
 among them was low, in the first year of the residence at Colney 
 Hatch so many died as to call for special mention. The same 
 always happens on receiving chronic patients into asylums, there 
 has scarcely ever been a new asylum opened, but that when the 
 first patients were received into it from other asylums, the mor- 
 
39^ LECTURES ON MENTAL DISEASE. 
 
 tality among such patients was increased. On the enlargement 
 of the Hanwell asyhim in 18G1 , there was a large number of patients 
 belonging to the west end of London removed from Colney Hatch 
 asylum to Hanwell, thus exactly reversing the former conditions 
 of the change above mentioned, the mortality among these old 
 cases increased to such an extent, that I was called upon to make 
 a special report upon the subject. 
 
 It must not however be concluded that the remedy of change 
 of environments is to be wholly condemned ; what it is necessary 
 to bear in mind, is that care and caution are needed in resorting 
 to this means of treatment. 
 
 No description of the moral treatment would be complete 
 without alluding to the general principles on which it should be 
 conducted. The general indication, that of procuring for the 
 patient enth'e mental rest, as by the means described in the 
 above pages, would scarcely be satisfactory without allusion to 
 some matters to be avoided. The system of treatment has been 
 divided into that by restraint, and by non-restraint. In Eng- 
 land the latter is adopted almost universally, but on the continent 
 restraint is considered necessary. By restraint is now meant, 
 that patients are restrained in their bodily movements by various 
 mechanical instruments, as by a kind of jacket in which a patient 
 cannot move his arms. Formerly restraint chairs were employed 
 in which a patient was locked in a sitting posture, or bed which 
 was a kind of box closing over the patient, etc., also there were 
 various straps to confine the limbs, or a weight or hobble tied 
 around the ankle. 
 
 Non-restraint is now the rule throughout England. ^Moderate 
 restraint, I am told, however lingers here and there in some 
 private estabhshments. I have no personal knowledge of the 
 fact. 
 
 The word non-restraint has been objected to, on the ground 
 that any confinement in an asylum is restraint, and bo far the 
 term is not an accurate one ; but every one knows that its 
 meaning is the non- employment of mechanical means to con- 
 fine the patient. But the system of treatment by non-restraint 
 includes a great deal more than that, it means the general abo- 
 lishment of all coercive measures whatever, such as punishments 
 of all kinds, the use of threats, stern conduct, or anything hke 
 
TREATMENT. 397 
 
 over-awiug tlio patient by language or demeanour. And it 
 means the opposite of all this, or gentleness, patience, and for- 
 bearance, and the more these are cultivated in an attendant, 
 the more influence will he possess for good with his patient. 
 
 It must not be supposed, however, that the treatment by 
 restraint where it is still employed, is so cruel as formerly, yet 
 the principle remains the same; namely: — of opposing and 
 coercing the invalid, instead of persuading and soothing him. 
 
 In this country, the present generation of the attendants on 
 the insane, scarcely are aware what the mode of treatment by 
 restraint, really means. The following is from Dr. ConoUy, 
 " Down to 1770, the inmates of Bethlehem were exhibited to the 
 public for money — the price of admission was at first twopence, 
 and afterwards one penny." 
 
 The medical treatment in 1800, according to Dr. Haslam, was 
 regulated according to the moon ; the lunatics were bound, 
 chained, and flogged, at particular periods of the moon's age, to 
 prevent accessions of violence. Besides absolute stripes, the 
 insane were treated in dungeons worse than the dens in which 
 we now think of placing our animals. This, however, may have 
 been from pure ignorance, or fear, but no refinement of cruelty 
 was added in these cases. In the old system, the ingenuity of 
 clever people was exercised in torturing the lunatic. Some of 
 the means by which intimidation was to be i^roduced in a 
 patient, are given to us in authors. There was a certain chair 
 invented by Dr. Cox. "We read," says Dr. Conolly, "with 
 almost as much amusement as wonder, the respectful acknow- 
 ledgment of Dr. Hallaran, that Dr. Cox had made known to the 
 profession the safe and effectual remedy of the circulating swing, 
 the invention of which Dr. Cox generously gives the credit of to 
 Dr. Davidson !" This chair was so contrived as to turn on a pivot, 
 and by means of a rack, could be made to revolve, with the 
 patient bound in it, at the rate of one-hundred revolutions per 
 minute : this was a most cruel torture. But Dr. Hallaran 
 thought no well regulated institution should be luiprovided Avitli 
 it — so apathetic, so hardened, docs custom make the mind to 
 any kind oi cruelty. For hopeless cases, Dr. Cox advised that 
 this machine should be used in the dark, and bo accompanied 
 with unusual noises and noisome smells. " By degrees," re- 
 
398 LECTURES ON MENTAL DISEASE. 
 
 cords the historian, " restraints became more and more severe, 
 and torture more and more inf,'euious. Among many cruel 
 devices, an unsuspecting patient was sometimes induced to walk 
 across a treacherous floor, it gave Avay, and the patient fell into 
 a 'bath of surprise,' and was there half drowned or half frightened 
 to death." (ConoUy, On the Treatment of the Insane icithvut Me- 
 chanical Restraint). 
 
 It is, however, the principle on which the treatment is based 
 that we should look at, not at its logical outcome. Those who 
 advocate the necessity of restraint claimed to do so on scientific 
 grounds. 
 
 The principle of restraint was thus enunciated by Guislain in 
 1852. M. Guislain, during his lectures, introduces the patient 
 and says : — 
 
 " The patient whom you saw address me just now is what is 
 called a sensible madman [maniaque raisonneur), who has been 
 in the asylum about five months." Tome iii., p. 94 et seq. 
 
 " You have heard him speak with much sense. He's tii*ed to 
 death, he says, and wants to return home. You perceive that 
 he is gradually getting better, and in the course of a short time 
 I am in hopes he will be considered convalescent." 
 
 " This state of improvement is solely the result of the restraint 
 exercised upon him."" 
 
 M. Guislain then added, "To control mania, privation of 
 liberty is the most efficacious remedy ; no medicinal agent can 
 equal it in power." 
 
 " It is entirely a moral means ; it has neither colour, taste, 
 weight, volume, etc." 
 
 " Its action arises out of recoil of the patient's mind on itself, 
 in the restraint which he is conscious of. Upon tho painful im- 
 pression which acts upon the captive, and which agitates him 
 profoundly. It reacts upon his will, which it seems to restrain. 
 Under its influence the man looses his activity, his petulance, 
 his expansive feelings ; this action operates on his reason, in- 
 ducing reflection, and develops his judgment. It is a therapeu- 
 tical means, which grows in proportion to the time that elapses. 
 It is nourished by the series of painful sensations." 
 
 In another place M. Guislain says, " I call certain agents 
 moral hypothenisators. I give this name to distinguish them 
 
TREATMENT. 399 
 
 from certain medicinal agents, which produce hypothenisation — 
 that is, sedative effects. That which moral hypothenisation 
 presents of special character is its mode of action. It is not a 
 question of medicine administered to the body, or introduced 
 into the system, it is simply a sensation perceived, a perception, 
 the sentiment of fear, fright, terror, considered in its debilitating 
 effects.'' Tome iii., p. 164. 
 
 " There is in this sensation prodigious power." M. Guislain 
 goes on to relate its several effects, and cases in which syncope, 
 various bodily diseases, and death, have been produced by 
 terror. " You see," he says, " one arrests the innervation — the 
 action of the heart, as by the action of hydrocyanic acid ; the 
 one is as prompt in action as the other, it can enervate the 
 organism, and can cause death." 
 
 "You will understand now why under certain circumstances 
 one can produce in maniacs a relief of their malady — a sudden 
 cure in some cases, by inducing in their minds the feeling of 
 peril more or less strong," (p. 1G8). 
 
 That mechanical restraint is necessary lias been abundantly 
 disproved in England in every County Asylum, if the practice 
 lingers in any establishment still, it is a proof I consider of in- 
 competence. 
 
 Non-restraint has gradually spread where the physicians are 
 the most enlightened, and for the reason that it has proved 
 the most successful mode of treatment. I consider the most elo- 
 quent testimony that has been given of its value, is from many 
 of those who still find fault with it, and who in not ado^jting it, 
 put forth the reason that the restraint they use, is reduced to 
 its safest minimum, '__thus apologising in a way for its use, by 
 admitting that it should be so reduced. 
 
 I have had about 4000 patients under my treatment. I never 
 used any mechanical restraint. I never possessed such a thmg 
 as a strait-jacket. 
 
 I think, however, the real question of the merits of either 
 mode has been often lost sight of in the discussions that have 
 taken place on the subject. The real base of the question is 
 not the mechanical but the moral influence, which I consider 
 objectionable in the system of restraint. One of the most 
 curious matters in connexion with the question is the view that 
 
400 LECTURES ON MENTAL DISEASE. 
 
 generally prevails in America. " Dr. Walker, President of the 
 
 Association of Superintendents, gravely told his fellow-members, 
 that he supposed, if anything had been settled to the satisfaction 
 of Members of the Association, it is, that in this country 
 (America) our patients, by original temperament, or by some 
 inherent quality of the universal Yankee, will not submit to the 
 control of any person, they consider their equal or inferior, so 
 readily." As to that of mechanical restraint another member. 
 Dr. Compton, said, " I think an asylum cannot be found in this 
 country, where the first thing a boy learns to read is the De- 
 claration of Independence, and where every youngster learns 
 that he is in ' the land of the free and the home of the brave,' 
 in which restraint will not be necessary." So that the love of 
 freedom in the individual is at the bottom of depriving him of 
 freedom ; and because they do not submit easily to control is the 
 reason they are made to undergo it. 
 
 In the above quoted passages it is clear, however, that re- 
 straint is looked upon, both by those who prescribe it, and by 
 those who have to endure it, as a i^unishment and that is the 
 very reason why it is objectionable. The non-restraint system does 
 not allow punishments to be used. It considers that punish- 
 ment is detrimental. The object, as stated above is to procure 
 mental rest, not irritation, or a feehng of disgrace, and not to 
 arouse feelings of viudictiveness or a sense of injustice, etc., 
 which inmishmcut usually begets. That restraint rouses the 
 malevolent feelings is the reason that makes it objectionable. 
 The principle of the uon -restraint system is to soothe by every 
 means that can be devised, by kind words, sympathy, by divert- 
 ing the thoughts from unpleasant subjects, etc., and not to 
 irritate the patient by inflicting punishment. The objection is 
 not against the machine, but the feeling excited by having it 
 imposed. 
 
 For this reason it is that true non-restraint avoids the use 
 of mechanical means altogether ; the public and open an- 
 nouncement that no feeling of revenge, no exhibition of anger, 
 nothing but kindness and forbearance will be shown, soon pro- 
 duces a good eflfect, and if not, a few cheery words to assure the 
 patient that he is among those who will treat him considerately 
 will produce a salutary effect. It is not necessary to display 
 
TREATMENT. 4OI 
 
 great authority, or to order this or that to produce a fcehng of 
 superiority. Tlie general respect of the establishment to the 
 physician will produce sufficient evidence of his power, thus the 
 patient soon learns that he is where he can be cared for, and 
 will be kindly treated at all times, and will have attentive con- 
 sideration to all his wants. 
 
 It is very rare indeed that a patient who has been treated 
 in an English asylum feels any dislike to revisit it; this 
 is the case, at all events, in those estabhshments where pro- 
 per care has been taken. Unfortunately there may be from 
 time to time an attendant who under great provocation may 
 resent an insult or injury, or one who cannot forget an accusa- 
 tion, though totally untrue. Such attendants are unsuited for 
 then' calling and should be weeded out at once. 
 
 Correspondence. — Patients are always allowed to communicate 
 with theu' friends by letter, and to receive letters, this is regulated 
 by the Act. If a patient is excited on the receipt of any letter 
 the writer may be exhorted to write less frequently, or to avoid 
 particular topics. If a patient write to any public character or 
 to one who is a stranger, the physician may intercept the letter 
 and lay it before the official visitors ; for without such precautions 
 a patient might order goods for which he could not pay, or his 
 letter might contain false accusations, etc., which he would not 
 send if he were sane. Letters to parents or wives, to a husband 
 or guardian are sent to the addresses with or without a hne of 
 explanation from the physician. 
 
 Visits. — In connexion with the subject of treatment by associ- 
 ation, as a remedial resource and a part of the moral treatment, 
 is the question of the " Visits of Friends " as the matter is 
 usually called. It means the communication of the patient with 
 his former acquaintances of any kind. I think most physicians 
 of experience agree upon the general question, viz., that such 
 visits are more or less trying, and obviously so for this reason, 
 that in placing a patient in an asylum, the object is to break the 
 connexion of the patient with his former environments. It must 
 at the same time be admitted that all such communication 
 cannot be wholly disallowed either for the patient's sake or for the 
 relatives'. The differences which exist in different physicians' 
 Tiews on the subject are wholly with regard to the mode andfre- 
 
 DD 
 
402 LECTURES ON MENTAL DISEASE. 
 
 qucncy of such visits. In the county asylums set days arc 
 approi^riatctl for visits, but this cannot so easily be done 
 with private patients. The bad effect of any visit results 
 from the excess of emotional disturbance, that it causes in 
 the patient. Such emotional disturbance is in proportion 
 to one of two circumstances. 1. The great affection or 
 emotional disturbance produced by the sight of particular 
 individuals. 2. The length of period that has elapsed since the 
 two have met. The injurious effect I think can be lessened by 
 judicious conduct on the part of the visitor. 
 
 It is chiefly in the early days of treatment, or early separation 
 from home, that the emotional effects cause the greatest dis- 
 turbance to the patient's mind. 
 
 The visitor should be warned that the visit in the first place 
 should be of very short duration, not exceeding ten minutes at 
 first, for any mental effort is very fatiguing to the patient. In 
 the conversation with the patient nothing should be mentioned 
 of an adverse or painful kind, and only a few topics should be 
 introduced. A visit of this kind with a promise to return at an 
 early date will satisfy the patient without causing disturbance ; 
 and I think frequent visits of such kind cause less disturbance 
 than a visit paid only after a longer interval ; a frequently repeated 
 visit of short duration like this becomes a matter of course, 
 and rouses less emotion in the patient's mind. 
 
 Precautions are most needed for the melanchohc ; the maniacal 
 will often receive a visitor without increasing their excitement. 
 The chronic patient, and the imbecile are not affected injuriously 
 by visits, and in cases I have found benefit to accrue from a 
 visit of a friend for a month at a time. I have seldom been 
 without a visitor of such kind or relative of a patient residing. 
 
 My rule is therefore to encourage intercourse of judicious 
 friends, and in the acute stage to favour frequent visits of very 
 short duration ; and I find the patients receive such without any 
 mental commotion. 
 
 The above circumstances are connected chiefly with the acute 
 stage and the treatment by association, there are some matters 
 whicli are connected with the management of particular pro- 
 pensities and with the general or hj'gicuic management of the 
 patient's surroundings, which have to be mentioned. 
 
TREATMENT. 403 
 
 These are briefly the rules as to : — Kismg and going to bed ; 
 Exercise ; Baths ; Meals and taking of food. 
 
 As to the time of rising and retiring to bed, the former habits 
 of the patient should be followed, say for example 8 a.m. for 
 rising and 10 p.m. for going to bed. The patients in nearly every 
 case require attendance at both times to see that the toilet is 
 properly performed and to give assistance ; the use of the morn- 
 ing bath or tub should be encouraged, the weakly patients who 
 are unable to rise so early will have the breakfast taken to them. 
 
 In the forenoon the patients should have walking exercise 
 regularly. 
 
 Warm baths at least once a week are needed for those patients 
 who do not have the morning bath. Imbecile patients on such 
 occasions should be not merely dipped but soaped and rubbed 
 down as in the Turkish baths. 
 
 As to meals ; 8.30 to 9 a.m. for breakfast, 2 p.m. for dinner, 
 6 p.m. light tea, 8 p.m. for supper, will be found convenient 
 as it allows the patient to have exercise both before and after 
 dinner ; a meal at 8 does not interfere with an evening enter- 
 tainment. 
 
 Some patients require their mode of eating to be superin- 
 tended, lest they eat too ravenously or without due mastication. 
 Some cannot feed themselves, when this is the case the meat 
 should be finely divided and given with a spoon. 
 
 Some patients refuse food altogether, this occurs usually in 
 the early stage, but in certain cases it extends into the chronic 
 period, in such a case various means may be successful according 
 to the nature of each case. Some patients refuse to eat, when 
 food is taken to them in the ordinary way, but if they can pilfer 
 a morsel will eat it greedily ; a morbid desire for sympathy seems 
 to be the root of this, such a patient can be nomished during 
 the existence of this feeling by placing food in different corners, 
 etc., as it were accidentally ; a little cunning of the sane will 
 beat the cunning of the insane. A patient at Hanwell who had 
 refused for several days to allow anjiihing to pass his lips was 
 treated in this way ; the gardener, an old attendant who had 
 been many years in the service seated himself beside the patient 
 as though quite casually and took some cake out of his basket 
 and began to eat it talking all the time. Seeing the patient eyeing 
 
 dd2 
 
404 LECTURES ON MENTAL DISEASE. 
 
 the cake, he passed a bit to him, still continuing to talk, which 
 the patient ate and continued henceforth to take his meals 
 regularly. A patient sometimes refuses food asserting that it is 
 poisoned. I have overcome this difficulty by giving the patient 
 an egg. Some will not eat from delusion of various kinds, as 
 that it is sinful, that they are deprivmg others of food, etc., in 
 such cases it may be necessary to use artificial means. One 
 patient will relent when he sees the preparation being made, and 
 especially on the exhibition of a stomach-pump. "When all these 
 schemes fail and the patient's health is suffering, food may be 
 given forcibly in varioiis ways, as by inserting a wooden spoon 
 between the teeth and pouring the nutrient into the bowl, the 
 head and arms being held by attendants. In females I have 
 seldom failed by this means. As an ultimate resource the 
 oesophageal tube must be used and the fluid poured through a 
 funnel affixed to it. When a patient has not taken nourishment 
 for several days it is often necessary, and is also nearly 
 always useful to give an aperient with the nourishment. 
 Strong ale, with egg and infusion of senna, or the Mist, 
 sennro will be found beneficial in most cases, unless the patient 
 is already too much reduced. In acute cases the propensity 
 does not often last, but in some chronic cases it persists. I 
 once knew a patient who was fed by his attendant regularly for 
 months through the tube and took the tube as a matter of course. 
 
 In all cases of refusal of food, when once food has been given or 
 taken, it should be offered again or repeated after a given time 
 that is to say at the period when the pre\ious meal has been 
 digested and when the natural feeling of appetite is returning. 
 
 In conclusion, it may be allowed here to add a word on the 
 subject of the principle of private asylums, against which much 
 of late has been urged in the medical journals. 
 
 Bearing in mind in the first place, that to conduct the moral 
 treatment and to carry out the directions which I have described 
 in the above paragraphs, the constant supervision of the medical 
 man is necessary, or even essential, and no one could so well 
 fulfil all the duties, show the same minute attention to details, 
 or give the same moral support to the patient's mind as the 
 master of the house in which the patient is placed ; where every 
 circumstance, and even every article of furniture becomes as it 
 
TREATMENT. 4^5 
 
 were a materia medica. The iuflueuce of all the patient's sur- 
 roundings, of his environments, is so constant that such cannot 
 be readily relegated to others. 
 
 This would appear to be undeniable, and so far as I know is 
 not denied, but the objections to private asylums, or against the 
 prmciplo of such estabhshments, is founded upon different 
 ground, viz., that the proprietor's interest is to retain the patient, 
 to retard his recovery, and thus deprive a person of his liberty 
 unjustly. 
 
 If such an accusation were made only by the general public, 
 it might be considered as a part of the pleasantry, commonly 
 aimed by humourists agamst doctors in general. 
 
 It is a different matter when we find such accusations brought 
 against members of the profession in the medical journals. It is 
 moreover curious that the logical inference of such an accusation 
 should pass unnoticed. If medical men were capable, or more, 
 were in the habit of retarding recovery for the sake of gain, every 
 medical man in practice, the whole profession, would become im- 
 plicated in the mercenary charge. It is supposed it is true, that 
 the bribe is greater in one case than the other, but many smaller 
 bribes are equal to one larger bribe ; and the smaller are easier 
 to conceal. But is it possible ? Can a medical man retard the 
 cure of any case, and would it be to his interest to do bo if he 
 could. The very pages of the journals referred to, filled as they 
 are by writers advocating improved methods of cure, the whole 
 medical literature, show that the ambition of every medical man 
 is to cure, and to cure rapidly. 
 
 But if after all, a pecuniary inducement lies at the base of all 
 medical ambition, which is not my assumption, and a reputation 
 for rapid cure is of value to the general practitioner, why is it 
 not of the same value to the specialist. Why should the specialist 
 differ in his notions from the rest of the profession. 
 
 But there are other precautions and provisions which have 
 yet to be described, which render improper detention of a patient 
 impossible. An enquiry into the working of these provisions 
 resulted in the establishment of the fact, that no instance of 
 any improper detention had been proved since they came into 
 operation. 
 
 The evil therefore has not been proved to exist, and the remedy 
 
406 LECTURES ON MENTAL DISEASE. 
 
 advocated or Buggested to prevent the possible occurrence of such 
 an evil, is I think as objectionable and quite as inadequate as the 
 present system. 
 
 It is advocated that all asylums should be pubhc, and be 
 administered by paid officers who should have no pecuniary in- 
 terest in the success of the cstabhshment. That is in fact that 
 while the pauper asylums should remain as they are at present, 
 that other asylums of a superior Icind should be provided for 
 patients of a different social position. 
 
 In reply to this it may be asked by what law or right are the 
 public to be deprived of the services of a physician of their own 
 choice. 
 
 Why, when a friend or relation becomes insane, is the fact to 
 be made pubhc by drafting him into a state asylum ? 
 
 "WTiy is the disease to be treated only and studied only by 
 medical men elected by lay governors and subscribers to such 
 establishments ? 
 
 If a medical man has given his attention to the investigation 
 of mental disease, in regard to its pathology and treatment, why 
 may he not put into practice the views that he has arrived at, and 
 without the interference of a lay committee, who often have 
 crude notions of their own ? 
 
 And it may be asked, why is it to be expected that a medical 
 officer should be more efficient when actuated by a sense of duty 
 alone, than one equally influenced by duty and dependent on his 
 good name for his own success ? 
 
 There are estabhshments of the kind alluded to, already es- 
 tabhshed wliich meet the wants of the public, and if not, there is 
 no reason why they should not be increased, if the demand call 
 for them. These institutions, supported and endowed by charit- 
 able people as the Warneford and the Holloway asylums, are a 
 great boon to a class whose income fails them when they become 
 insane ; but in such estabhshments of course the association of 
 patients with patients only, and the absence of association with 
 the sane must be the rule. 
 
LEGAL RELATIONS OF INSANITY. 407 
 
 PART V. 
 
 THE LEGAL EELATIONS OF INSANITY. 
 
 Legal Detinitions of Insanity— Medical duties various— To decide Existence of 
 Insanity — Modes of procedure — Points to be observed — States of Eemission 
 and lucid intcrTal— In Eecurrent Insanity— In persons of feeble mind- 
 Competency and Eesponsibility— Justice Stephen on Criminality— Legal 
 signification of Responsibility— Medical opinion— Will in regard to Respon- 
 sibility — Knowledge as a test of crime— Imposition of Restraint — Medical 
 duties in regard to Restraint— Modes of Procedure— Process de lunatico 
 inquirendo— For placing a patient under care — Precautions against im- 
 proper restraint— For taking charge of Lunatic— Selection and appointment 
 of Medical man. 
 
 This is obviously a medico-legal question, a question, that is, in 
 which the lawyer and the physician should meet on mutual 
 ground. There has been probably as much difference and con- 
 tention on this border territory as on any border land what- 
 ever. 
 
 There are however weU marked functions for the two pro- 
 fessions, and no need of contention if the parties can first 
 settle upon what belong to each. The lawyer imagines that the 
 medical man makes too large a claim, and the medical man 
 considers that the lawyer does the same, and as I am of the 
 latter opinion and profession, I will endeavour to make good my 
 reasons for saying so. 
 
 I consider that the functions of the medical man are confined 
 to making a diagnosis, this is surely a purely medical function, 
 and I do not see that any one should take exception to it. 
 
 I consider to the law belongs all the rest, that is to make the 
 laws and see that they are duly observed, to protect the lunatic 
 from the public, and the public from the lunatic. 
 
 In the remarks that I am about to make, I think I shall be 
 able to show that the chief difficulties which exist, are due to 
 the fault of the law and lawyers. I am quite aware that the 
 
408 LECTURES ON MENTAL DISEASE. 
 
 lawyers take exactly tlie opposite view on this point also. One 
 reason for this difference is that the lawyers affect the ancient 
 doctrines the physicians the new. 
 
 The first Bourco of dissension and difference is in the inter- 
 ference in the diagnosis, the lawyer claims the right of settling 
 the boundaries of sanity and insanity. The medical man of course 
 must obey the laws or statutes that are made by the lawyers 
 directly they become law ; when these however are contrary to 
 medical science, he can only give a perfunctory assent to them. 
 
 The statutes made by the lawyers settle many matters, about 
 which, though in doing so they approach very closely to the 
 functions of the medical man, there is no gi'ound for difference. 
 
 According to the legal authorities there are " three classes of 
 lunatics or persons of unsound mind, concerning whom the 
 legislature has made special provision, namely : — Private lunatics, 
 pauper lunatics, and criminal lunatics ; or in other words, for 
 those who are maintained out of their own property, those who 
 are provided for by the poor laws, and those being criminal who 
 are under special jurisdiction." (Fry's Lunacy Acts). 
 
 The relative number of persons known to the authorities at 
 the date of 1882 was as follows. Private 592G, pauper 48,325, 
 criminals 4G2. 
 
 According to the legal definition of the terms used, every 
 person whose mind from his bhth by a perpetual infirmity is bo 
 deficient as to be incapable of du-ecting him in any matter 
 which requh'es thought or judgment is in legal phrasiology, aji 
 idiot. 
 
 Every person, qtd gaudet hicidis intervallis, and who some- 
 times is of good and sound memory, and sometimes no/i compos 
 mentis, is in legal phrasiology, a lunatic. 
 
 Every person who by reason of a morbid condition of intellect, is 
 as incapable of managing himself and his afiau's as an idiot or a 
 lunatic, not being an idiot or a lunatic, or a person of merely 
 weak mind, is in legal phrasiology, a 2)<^''son of unsoimd mind. 
 (The Law concerning Lunatics etc. By Chas. P. Philhps.) 
 
 The above is from Mr. Commissioner Phillips work. He adds, 
 " further that if the mind is unsound on one subject it is not 
 sound on any subject the mind being indivisible." For this he 
 gives the authority of Lord Brougham in Waring v. Waring. 6 
 
LEGAL RELATIONS OF INSANITY. 409 
 
 Moo. P.O. 350 and Lord Lyndhiirst iu Drew v. Clarke, 5 Buss. 
 167. In my opinion tins is good psychology and I presume good 
 law. But the legal definition of the lucid interval does not pre- 
 cisely coincide with what the medical meaning of the term is, 
 but since " the rule has been laid down by Lord Thurlow that 
 persons iu the habit of watching a lunatic can best prove his 
 lucid intervals," it would seem that the question in a legal pro- 
 ceeding would have to be elicited in the evidence. 
 
 The object of the law is twofold viz., to protect the lunatic, and 
 to protect the community from the acts of the lunatic. 
 
 For either object the question of the sanity or insanity of the 
 individual must be preliminary, the services of the medical man 
 are resorted to, to pronounce an opinion on the question. 
 
 The most frequent occasions which call for this office are the 
 following. 
 
 1. To give an opinion on the capacity of a person to execute a 
 legal instrument. 
 
 2. To relieve the lunatic from the responsibility of his acts. 
 
 3. For what is called the imposition of restraint; the duties of 
 the medical man under this third category are of twofold kind. 1. 
 To commit the lunatic to the care of another. 2. To undertake 
 the care of the lunatic. 
 
 The primary question therefore is to determine whether the 
 person is of unsound mind. 
 
 1. To decide the question as to the existence of unsoundness 
 of mind is, as I view the matter, simply a medical question, and 
 in other terms it is to make a diagnosis of disease. 
 
 The previous pages should assist one in arriving at such a 
 diagnosis, but it will be as well to point out how the question 
 may be decided. I would suggest the following rules. 
 
 The question is simply whether there is or is not present 
 disease. To determine this a medical man should not only be 
 able to reply in the affirmative or negative, but he should be able 
 to say what was the form of disease if any existed. To deter- 
 mine this, an isolated symptom would not suffice, nor even two 
 or several. The case may be (see p. 101) a disease proper, that 
 is ordinary insanity or general paresis ; or secondly the mental 
 symptoms, if present may indicate idiocy or senility ; or thirdly if 
 not any of these, then the case will belong to those forms of dis- 
 
4IO LECTURES ON MENTAL DISEASE. 
 
 ease which I have classed under the symptomatic mental diseases. 
 The sj'mptoms of these diseases are never obscure in the pri- 
 mary attack, and if the phenomena are present they will be 
 followed and will follow in a given succession, it is not enough 
 that we should have symptom A, B or C ; but A, B and C must 
 follow in a certain succession. The symptoms of a case of ordin- 
 ary insanity and of general paresis are set forth in the previous 
 pages ; and the truth is, concerning the primary attack of either 
 of these cases there is not much likeliliood of any difficulty 
 occurring, unless it be the following ; in ordinary insanity the 
 patient in the melanchohc stage retains considerable intellectual 
 capacity, and the question is then whether a given amount of 
 depression of spu'its can amount to such a disease of the mind, 
 as to excuse or invaHdate an act. On the maxim of Lord 
 Brougham and Lord Lyndhurst holding good, viz., that if the 
 mind is unsound on one subject, it is not sound on any subject, 
 it should do so. Undoubtedly such a condition as depression of 
 spuits, leads a person often to commit suicide, and the law 
 sometimes then (perhaps charitably) admits the plea of insanity ; 
 but depression is only one symptom, to constitute actual insanity 
 there should be other symptoms as described. The symptoms of 
 general paresis are so marked and are not evanescent ; they give 
 less cause for hesitation about the diagnosis, and two acts, which 
 are very symptomatic of this disease, often lead to an investiga- 
 tion as to sanity, namely indecent exposure and kleptomania. 
 These symptoms occur in the early stage of the disease, and are 
 usually associated with other states of mental aberration, which 
 leave very httle doubt on the question of insanity. 
 
 A more difficult condition to adjudicate upon, is the case dur- 
 ing what I have described (p. 267) as the remission of the symp- 
 toms, which frequently takes place in this disease. In this 
 btate, in certain cases ordinary observers, and we may almost 
 add everyone who has not had special experience, would detect 
 no mental defect in the subject. Indeed, I bcheve the condition 
 of mind of the patient, is such as to enable him to form a correct 
 judgment on any ordinary matter ; such a person may be able to 
 give a sound opinion upon questions with which he has been fami- 
 har ; if the patient were a medical man, for example, he might be 
 able to treat a patient ; if he executed a will, it might be a judi- 
 
LEGAL RELATIONS OF INSANITY. 4II 
 
 cious one ; or ou the contrary, it might not. The difficulty of 
 saying, therefore, when the patient was competent or responsi- 
 ble is very great. There are certain signs akeady described 
 which would enable a medical man to say, that disease of the 
 mind existed ; but the question of responsibihty, under the cir- 
 cumstances, must be left to the law, and probably the nature of 
 the act done would assist the law to decide. An example of this 
 kind occurred to me : a gentleman was able to write out a will 
 and to get witnesses to it ; it was of such kind, that some dis- 
 pute might have arisen on its general tendency, but besides 
 such a source of doubt as its injustice, he willed that his pro- 
 perty should be divided into twelve equal portions, and be 
 divided among thirteen legatees. 
 
 The greatest difficulties in regard to the estabhshing the plea 
 of insanity, especially in criminal cases, is in connection with 
 cases of recurrent insanity {vide p. 163) and epileptic insanity. 
 
 With the former case there will be distinct evidence of a pre- 
 vious attack. As this has been dwelt upon at some length at 
 p. 179, et seq., the reader is referred to what is there said. This 
 equally applies to the cases of obscure epileptic seizure, which 
 will be found also discussed at p. 180. 
 
 This leads naturally to the consideration of the state of weak- 
 ness of mind, from any cause. It is on such a condition that 
 the greatest difficulty between the two professions exists, both 
 with regard to questions of competency and criminality. 
 
 Perhaps the medical man is inclined to a too lenient view of 
 the crime committed in such a state, to which his studies render 
 him prone ; the lawyer at all events is not under such influence, 
 but from the constant intercourse with deeds of crime, may be 
 more inclined to severity. Sir James Stephen for example 
 writes, " It should not be forgotten in connexion with the sub- 
 ject, that Httle or no loss is inflicted either on the madman him- 
 self or on the community by his execution. It is indeed more 
 difficult to say, why a dangerous and incurable madman should 
 not be painlessly put to death, as a measure of humanity ; than 
 to show why a man who, being both mad and wicked, commits 
 a cruel murder, should be executed as a murderer," p. 178. 
 This might be used in my view, as an argument against all 
 capital punishment rather, or that none should be hung lest the 
 innocent should suffer. 
 
412 LECTURES ON MENTAL DISEASE. 
 
 The difficulty at present, while the law is as it is, is to ad- 
 judge the responsibility or excusability in cases of the feeble 
 mind. The transition between the totally irresponsible idiot 
 and the responsible person of feeble mind, is one of very gradual 
 kind. It is not possible, to di-aw a hard and fast line between 
 these cases, and it is equally difficult to fix upon any test 
 which will decide the question. Moreover the question is influ- 
 enced by a variety of external circumstances. One feeble or 
 weak minded person may be competent to perform one kind of 
 act and not another ; another may be trusted with one kind of 
 duty and is obviously incapable of some other. 
 
 We may, therefore, consider the question in regard to the 
 duties or circumstances, under which the medical opinion is 
 sought, and this we may divide into : — 
 
 1. Competency. 
 
 2. Responsibility. 
 
 1. Competency. — As regards a person's competency, most of 
 the cases of any difficulty are connected with comparative com- 
 petenc3' under which an act was committed. This might be left to 
 the jury to settle, and under the present views of the legal pro- 
 fession it is as well that it should be so ; provided that the facts 
 can be well placed before them. 
 
 If a medical man is called iipou to give an opinion, there is 
 no reason why he should not do so, for at least his evidence 
 would be as good as any other person's. 
 
 There are some medical matters too, which can be much 
 better adjudged by the aid of medical kuowlodgc. 
 
 The following case occurred to me, which will illustrate this. 
 A barrister who became insane and who recovered sufficiently 
 to be discharged from the asylum ui which he was placed, de- 
 sired to make a fresh will. He appHed to a solicitor and stated 
 the facts coherently and clearly ; he especially dii'ccted the 
 solicitor to the fact that he had been insane, and that he was 
 now completely recovered. 
 
 The Avill was made. He relapsed after this and was again 
 placed under certificates, and after a time he died. 
 
 His will was produced, in which he had left his widow totally 
 unprovided for and had divided his property among his own 
 family, a sister and her children. The will was disputed and my 
 
LEGAL RELATIONS OF INSANITY. 4I3 
 
 opinion was asked ; the solicitor who made the will testified to the 
 perfect sanity of the testator, as did a friend whom he had in- 
 vited to breakfast with him on the day when it was made. I 
 beheve it is admitted, that an act done in a "lucid interval" 
 would hold good. My opinion, however, was entu-ely adverse to 
 the validity of the document, and on these grounds. " "When at 
 his worst period or during the acute symptoms of his malady, he 
 had an intense aversion to his wife, and accused her of acts and 
 conduct which were pure delusions. This altered affection or 
 delusion extended through his whole case and never completely 
 left him ; he had three acute attacks and two lucid intervals, 
 and it was in the last that the will was made. He was under 
 my care. He wrote to me at the time he made the will, to get 
 me to give him a certificate of his recovery. This I dechned, 
 and on his discharge, I reported the discharge as discharged im- 
 proved only. 
 
 I considered him fit to return home, and did not think there 
 was any occasion for him to be under care, but he was altered 
 in various ways, and though he returned to live with his wife and 
 behaved always courteously and kindly, he recurred frequently 
 to the accusation that she had placed him under my care, which 
 was not the case. He moreover did not object in the least to 
 me, and came on a visit to me voluntarily, after his discharge, 
 and invited me to his house. 
 
 My opinion, therefore, that he was not sane, rested upon the 
 fact, that this morbid feeling had never left him ; and that it 
 was morbid, was shown by the existence of amaurosis and evi- 
 dence of diseased temporal bone with facial palsy, thus proving 
 unequivocally the presence of organic disease, of which he 
 ultimately died. (The case is related at i?. 371). 
 
 Such physical facts are what the peculiar knowledge of a 
 medical man can justly estimate and which a non-medical man 
 could nolr, and especially would medical experience be available 
 in relation to any physical deformity of the head in persons of 
 feeble mind. 
 
 I do not think either that a common jur^', in the majority of 
 instances, could so well weigh the influences of an organic kind 
 on the character of the individual ; a little consideration will 
 make it evident, that passions of different kind arc developed in 
 
414 LECTURES ON MENTAL DISEASE. 
 
 diflferont dej^ec in dififerent individuals ; ■what is a temptation 
 to one man is none to another, and when the inducement to a 
 particular act is equally strong in two individuals, one may pos- 
 sess more control than another from his natural organisation. 
 But the law makes little allowance for such, and I do not know 
 how it can. 
 
 Yet such might afford considerations for a merciful punishment, 
 if they did not affect the question of criminahty ; and according to 
 the views of legal authority they do not affect the question of re- 
 sponsibility, because they are not of such degree as to deprive 
 the person of his judgment. 
 
 2. EcspoyisibiUtij. — As regards the question of responsibihty the 
 medical man's office is really the same as that when he is called 
 upon to pronounce an opinion as to competency, and that only ; 
 he is merely to state whether there is present disease or such a 
 condition of body by an original deformity or natural decay as to 
 incapacitate the individual. 
 
 It is essential, however, that he should, when questioned on 
 the subject of a person's resj)onsibiIity, be certam that he 
 rightly understands the meanmg of the word or perhaps he will 
 be disposed to encroach on the functions of the law. 
 
 This forms one of the points of difference and difficulty 
 between the two professions. 
 
 The word ' responsible,' Su* James Stephen says, is under- 
 stood differently by the two professions, at least he says that the 
 medical men have misunderstood the meaning of this term. 
 That the legal signification of the term, "is simply, is the per- 
 son liable to legal punishment," again "I understand by respon- 
 sibility nothing more than actual habihty to legal punishment." 
 (Ilistorij of the Criminal Law of Emjland. Vol. II, p. 9G.) 
 "All that a judge directing a jury ever does or can under- 
 stand by responsibility or nresponsibiHty is that the person 
 referred to is or is not liable, accorduig to the existing law 
 of England to be punished" (p, 127). In this sense the 
 question is not medical at all, beyond the duty of replying to 
 the question put to him, of saying whether the person was or was 
 not in a condition of disease. The question is not to a medical 
 man whether a lunatic should be hung or not, that is the legal 
 part of the subject, and really all that faUs within the scope of a 
 
LEGAL RELATIONS OF INSANITY. 415 
 
 medical witness then is to pronounce upon the presence of 
 mental disease. Having given the opinion that the accused is 
 insane the medical man may leave the question of punishment 
 to the law. 
 
 This would be a simple duty had not another question been 
 generally complicated with it. The question usually put to 
 medical witnesses is, did the accused at the time he com- 
 mitted the offence know that he was doing wrong, or in the 
 legal terms, " to establish a defence on the ground of insanity 
 it must be clearly proved, that at the time of committing the act, 
 the party accused was labouring under such a defect of reason 
 from disease of the mind as not to know the nature and quality 
 of the act, or if he did know it that he did not know that he was 
 doing what was wrong." 
 
 This is to say the least, a very difficult psychological problem ; 
 and one which a medical man, such as Baron Huddleston de- 
 scribes him to be, merely one in the possession of a diploma, 
 might well hesitate about answering. There is no doubt that the 
 question has proved a difficulty, it involves many points of ex- 
 treme nicety. It is easy to say a man is insane, for example, 
 but to say how far his disease has effected the nice adjustments 
 of reason is almost impossible. The question may be taken in 
 its most obvious meaning, we need not for example cavil with the 
 terms of right and wrong and cite the different estimates of 
 different people or different dispositions, or say according to 
 some people it is right to revenge ourselves, or to return evil for 
 evil. The most obvious objection to this test of insanity is, that 
 it is based on what may be called a mere abstract quality of 
 mind, viz., on Judgment. 
 
 We may analyse mind, but we cannot isolate the elements to 
 deal with them as separate and independent properties, Judg- 
 ment, Volition, Emotion, etc., or other faculties, which are mere 
 phases of one conglomerate mental process. 
 
 Knowledge of right and wrong is a judgment, and judgment 
 is never isolated by disease. A medical man might decide, it is 
 true, from the symptoms present, that the man was insane ; and 
 as insane assume in certain cases that he could not wholly, fully 
 or in a healthy manner, know the quality of a given act ; but 
 such assumption, I fear would only amount to a legal or medical 
 
4l6 LECTURES ON MENTAL DISEASE. 
 
 fiction or to rest upon a peculiar interpretation of terms. If we 
 are only to reply to the question whether a person had a know- 
 ledge of the quality of an act, there would he very few whom we 
 could absolve from responsibihty, or in other words plead that they 
 were insane. 
 
 Connected with every judgment in the common actions of hfe 
 there arc both emotion and volition intimately blended but in 
 different degi'ees ; the vohtion may be arrested before it results 
 in movement, the emotion equally checked by a counter impres- 
 sion, till a judgment, such as occurs in the solution of a mathe- 
 matical problem, may be almost disjoined from the other faculties ; 
 but a judgment of this particular kind seldom is found except in 
 the solution of very abstruse i)roblems ; and such judgment has 
 very little to do with insanity. A man seldom goes mad over a 
 problem of Euclid, for example ; and the act, concerning which 
 an ordinary opinion is sought, is never so free from emotion. 
 
 To form a just estimate of how far a man's knowledge is 
 biased by his disease, and to be able to say how far morbid feel- 
 ing took the j)lace of a healthy feeling in affecting a man's 
 judgment under particular circumstances, it is as well we 
 should know what according to law constitutes a criminal act. 
 
 According to Sir James Stephen the following conditions 
 must be fulfilled to prove criminaHty, that is responsibihty. 
 
 1. The act must bo done by a person of competent age. 2. 
 The act must be voluntary, and the person who does it must 
 also be free from certain forms of compulsion. 3. The act must 
 be intentional. 4. Knowledge in various degrees according to 
 the nature of different offences, must accompany it. 5. In many 
 cases either malice, fraud or negHgence enters into the definition 
 of oflcuces. G. Each of these general conditions (except the 
 condition as to age) may be affected by the insanity of the 
 offender. 
 
 It is with the second category, therefore, that insanity has to 
 be first considered, the act to be voluntary opens up the question 
 of will, and in connection with this, No. 3 also is concerned, "the 
 act must be also intentional." 
 
 So that an act to be criminal, besides the knowledge dependent 
 upon the understanding, there must be shown to have been the 
 exercise of will. 
 
LEGAL RELATIONS OF INSANITY. 417 
 
 Sir J. Stephen explains the meaning he attaches to the word 
 ' will ' which does not differ from the signification as deBcribod at 
 page 22. He jioints out however this, that in using the word in 
 relation to legal questions he considers that it should not be con- 
 fined to the single or a concrete act of volition, but be also taken 
 in a more general signification. ' 'When I speak of Will," he writes, 
 "I mean by the word, (1) either the particular act of volition 
 which I have already described and which is a stage in a 
 voluntary action, or (2) a permanent judgment of the reason, 
 that some particular course of conduct is desii'able, coupled 
 with an intention to pursue it, and which issues from time 
 to time in a greater or less number of particular vohtions. 
 For instance, a man's will is to write a book or to take a 
 journey. That is, he judges upon the whole that it will be 
 well for him to write a book or take the journey, and he 
 means to do it ; but in order to execute his will in this sense 
 of the word innumerable particular volitions are necessary." 
 
 Such an explanation of the term as I have signalized by the 
 figure 2, applies to a general view, while that marked 1 to a 
 concrete action, ■-•* and the general view is derived from the 
 observation of many acts as explained, and being general is less 
 precise. It would seem in fact to correspond to the term pro- 
 pensity or intention, in the more common way of speaking. 
 
 So that besides knowledge, there must be the exercise of will, 
 and will in both senses conjointly, if we take the same view of 
 will as Sir James Stephen. For the concrete act of will, as a 
 blow struck on a sudden impulse, is under some circumstances 
 not considered to amount to crime ; the continuous act or the 
 abstract will, (in other words the state of mind distinctly pre- 
 ceding the act), is that which gives the evidence of crime, shows 
 a malice prepense. This condition of mind is more allied to 
 emotion, the act at all events appears to be instigated by an 
 emotion of some kind, as hate, cupidity, revenge, etc. 
 
 Why, it may be asked, is not a defect of the faculty of emotion 
 evidence of insanity as well as of will or judgment. A man's 
 hatred and malice may be due to a morbid process and are pro- 
 bably more frequently so than his judgment. 
 
 » Compare remarks on the Ego, p. 10. - 
 
4l8 LECTURES ON MENTAL DISEASE. 
 
 But though wo as medical men may demur to the dicta we 
 find imposed on us and point out the difficulties that beset us 
 from what has been named "judge made law," our duty in 
 practice is clearly to take the law from the lawyers. 
 
 The authority for the Rules laid down for determining the 
 question of insanity is comparatively of recent date. 
 
 The authority on which this question rests, is the answers of 
 the judges to certain questions, put to them by the House of 
 Lords, subsequent to the acquittal of McNaghtcn on the ground 
 of insanity for the murder of Mr. Drummond in 1843. 
 
 These views have been always much objected to by medical 
 men of experience in insanity, and Sir James Stephen says, 
 *' I cannot help feeling, and I know that some of the most dis- 
 tinguished judges on the bench have been of the same opinion, 
 that the authority of the answers is questionable ; they leave 
 untouched the most difficult questions, and lay down proposi- 
 tions liable to be misunderstood." 
 
 I think no medical man could venture upon an opinion, upon 
 the integrity of one faculty as that of the knowledge of right 
 and wrong, without taldng into consideration the mental facul- 
 ties in their solidarit}^ and then there is the question whether 
 medical knowledge enables him to throw special Hght upon the 
 question of responsibility. 
 
 Does a medical man's special Imowledge give him a greater 
 facility in making a proper estimate of the quality of an act ? 
 I think it does. As an example, which I take from Sir James 
 Stephen's work, " the fact that a man stammers and that the 
 pupils of his eyes are of different sizes, are in themselves no 
 excuse for crime, but they may be the symptoms of general 
 paralysis of the insane, which is one of the most fatal forms of 
 the disease." I take the following argument, also from the 
 same work : Sir James Stephen in commenting upon the 
 answers to the Lords, says — " the answers if taken literally, cer- 
 tainly imply that the effect of insanity, if any, upon the emotions 
 and will, is not to be taken into account in deciding whether an 
 act done by an insane man, did or did not amount to an offence." 
 If this is meant, that the effect of disease upon the emotions and 
 will can never, under any circumstances, affect the criminality of 
 the acts of persons so afflicted, it would be so surprising and would 
 
LEGAL RELATIONS OF INSANITY. 4I9 
 
 have such monstrous consequences, that something more than an 
 hnphed assertion of it seems necessary ; and he puts the follow- 
 ing ease. Supposing a man's mind is so occupied with certain 
 insane thoughts, as to make it impossible for him to reason 
 calmly on matters connected with them. He might on account 
 of them be prevented, say, from following one of Euclid's pro- 
 positions. Might he not also, by a succession of similar 
 thoughts, be unable to justly weigh the nature of some other 
 act, say the wrongfulness of committing some particular criminal 
 act? 
 
 In such a case, (and though it is imaginary it is quite com- 
 monly to be met with in various lunatics,) or in lunatics so occu- 
 pied with their delusions, that they can give no attention to any 
 other subject, as to then* own health, well being, dfec, I think a 
 medical man with experience among the insane, could give a 
 better estimate of the quality of any act, than one who was not 
 conversant with insanity ; and such an experienced person could 
 form a juster opinion of the effects of the disease on the mind 
 generally. 
 
 Nevertheless, I think that the mode of forming an opinion, 
 on such a question, is that simply of making a diagnosis of dis- 
 ease, for which purpose one must follow the ordinary rules of 
 medical practice and cannot abide solely by the test as laid 
 down by the House of Lords. In a criminal trial, if the medical 
 man is of opinion that insanity exists and says so, his duty ter- 
 minates or should do so. 
 
 3. The next question on wliich medical opinion is required, is 
 the imposition of restraint. 
 
 This duty involves the consideration of many technicalities 
 which are difficult to describe ; their object, however, is clear 
 and beneficent, viz., to protect the lunatic — as it may be said — 
 from himself or his own acts, and his friends and public from 
 the lunatic. 
 
 The medical man's connexion with this duty, is as I have 
 said, two- fold : — 1. To commit the lunatic to care and custody ; 
 and, 2. To exercise the care and custody of the lunatic. These 
 are opposite functions, and the law has taken care that they 
 should be exercised only by distinctly different persons. 
 
 EE 2 
 
420 LECTURES ON MENTAL DISEASE. 
 
 1. The first duti/ is therefore to commit the lunatic to care and 
 custodi/. 
 
 There are two proceBses by which this is accompUshctl and 
 which arc perfectly distinct, and the fact of these two dillercnt 
 processes unfortunately compHcates the question in every pos- 
 sible way. There are two jurisdictions ; two sets of officials 
 with their powers and modes of procedure ; two sets of func- 
 tions and duties, &c. 
 
 1. The one process, the more ancient, takes a separate means ; 
 First, Of establishing the insanity. Second, It commits the 
 lunatic to the custody of a special guardian. Third, It takes 
 charge of his property, and appoints a person to administer his 
 estate under special supervision. 
 
 To establish the first question, an inquirj', in fact a trial, is 
 instituted, and the person adjudged to be insane is said to be a 
 person non compos mentis, found so by inquisition ; the process is 
 usually spoken of as de lunatlco inquireudo. 
 
 For the understanding of the case, the following brief descrip- 
 tion of the process, will render the medical man's part more 
 easy. 
 
 The reason why this process, which is inordinately expensive, 
 costing upon an average £100, is resorted to at all, is because, 
 firstly, it is that usually advised by the patient's legal adviser — 
 as it alone enables any pecuniary matters to be settled ; and 
 another reason seems to me to operate, viz., that few understand or 
 are cognizant of the other, or less expensive process, and no one 
 as it appears to me, knows its exact legal import. It authorizes 
 the placing an insane person under care, but gives no authority, 
 except under certain circumstances, (16 and 17 Vic. cap. 97, §. 
 91), for any one to manage his pecuniary matters. 
 
 I extract the following as to the mode of procedure, to obtain 
 an order of inquiry de lunatlco. 
 
 The inquiry is obtained by petition to the Lord Chancellor, even 
 a stranger may be the petitioner, and therefore a relative, a cred- 
 itor, tenant, a remainder man, &c. " The petition should state that 
 the person, on whose behalf the exercise of custody is invoked, 
 \snon cowpos mentis, and that the petitioner and he are related or 
 connected in a manner stated in the petition ; and the petition 
 should pray an inquiry into the truth of the statement, concern- 
 ing such person's state of mind." 
 
LEGAL RELATIONS OF INSANITY. 421 
 
 This duty usually devolves on the legal adviser ; the peti- 
 tion, however, has to be supported by affidavits, and to make 
 such affidavit it is, that the office of the medical man is invoked. 
 
 The affidavit of the medical man should set forth his opinion 
 nnd support such opinion or diagnosis by facts. In practice, 
 these facts, given in draft to the legal adviser of the petitioner, 
 arc put into proper form to be presented, and of course they 
 have to be sworn to. 
 
 The medical duties are therefore purely professional and un- 
 complicated by many formahties. 
 
 The notice of the presentation of the petition for inquiry has 
 to be given to the alleged lunatic, and to be by service upon him 
 of a copy of such petition, and in which he is informed that the 
 inquu-y will be before a master in lunacy, and that if ho de- 
 sires it he may demand the assistance of a jury. 
 
 When the alleged lunatic demands a jury, the Lord Chan- 
 cellor may order that the inquiry should be conducted by a 
 Lord Justice or before a master in lunacy. At the inquiry the 
 medical man making the affidavit is examined. 
 
 Further details, not necessary here to mention, as not coming 
 under the purely medical functions, will be found in Phillip's 
 Law of Lvnatics or Forbes Winslow's Manual of Lunacy, which 
 for the medical practitioner will be found the best. 
 
 The patient being found lunatic or of unsound mind, the 
 master in lunacy appoints two committees to manage the 
 lunatic's affairs. One, the committee of the person, and the 
 other, the committee of the estate ; the effect of which is that 
 responsible persons can exercise for the lunatic all the duties 
 that a sane person can perform for himself ; but they are re- 
 sponsible to the Lord Chancellor, for the proper performance of 
 their duties. The Lord Chancellor has his proper officers, viz., 
 the masters in lunacy and the visitors in lunacy, to superintend 
 this. 
 
 The lunatic is by this process thoroughly protected, the only 
 cbawbacks to the process are the following : — 
 
 It is costly. 
 
 The process is not suited to cases in the active stage of the 
 disease, it would be actually injurious to the largo majority of 
 patients to have such an inquiry impending over their heads. 
 
422 LECTURES ON MENTAL DISEASE. 
 
 The j)rocess is too todiouB. In a case in which an inquiry 
 took place on a patient of mine, though I do not think any un- 
 usual delay occurred, the patient was cured before the decision 
 was promulgated, and the commission was superseded as soon 
 as made. The patient had been insane five years before the 
 inquiry was sought, at which time it became necessary because 
 some railway shares had to be transferred; the particular 
 railways insisted on the authority to deal with them. 
 
 The committee of the person can give authority for the ad- 
 mission of a patient into any asylum, or place the lunatic under 
 any one's care, subject to the approval of the Lord Chancellor's 
 visitors. 
 
 2. The other mode for placing a lunatic in an asylum or under 
 care, rcquu-es the functions of the medical practitioners to sign 
 certificates of unsound mind. 
 
 I cannot help remarking that the numerous difficulties, mis- 
 apprehensions and popular prejudices connected with the care 
 of the insane, are connected with this mode of giving authority 
 for the custody of the lunatic. The general legal practitioner or 
 solicitor does not seem to be acquainted with the statutes by 
 which this mode of dealing with the patient is authorized, and 
 no one seems to understand the status of the patient detained 
 under certificate. 
 
 The duty of the medical man is to certify the existence of 
 the disease, and perhaps here his duties should end; but no 
 medical man ends them here. In most cases he is the adviser, 
 the counsellor of the family, and in their distress on the 
 occurrence of the calamity which has befallen them, he cannot 
 desert the family, nor is he likely so to do. I therefore add 
 some particulars to guide him in his self-imposed responsibihties. 
 
 In the first place he must follow the course prescribed by law. 
 This course is aimed whoUy to prevent collusion, and dishonest 
 actions in incarcerating a person under a false charge. Its aim 
 therefore is one which no medical man of the present day can do 
 otherwise than sympathizp with cnth-ely. 
 
 The law provides that to place a person under control as a 
 lunatic and who is not a pauper, that the lunacy or unsoundness 
 of mind shall be unequivocally proved by two independent 
 medical witnesses. 
 
LEGAL RELATIONS OF INSANITY. 423 
 
 The followiug arc tho precautions to accomplish this : — 
 
 1. The medical man must not be related to the patient, or in 
 any \Yay with the medical man who is to have the care of the 
 patient. 
 
 2. He must be registered, therefore duly qualified. 
 
 3. He must state the date of his examination of the patient 
 which must be within seven clear days of the patient's admission 
 under care. 
 
 4. He must state where he saw the patient, the parish, name 
 of house, street and number, and the county in which the house 
 is situated. 
 
 5. He must give the names of the patient in full or the name 
 which will identify the patient (in the case of wandering 
 lunatics, the actual name may not be known). 
 
 6. He must state if he can the occupation of the patient. 
 
 All the above facts, are for the purpose of identifying the 
 patient, and giving the present condition of the patient. Hav- 
 ing stated these facts, he must give the facts indicating in- 
 sanity, this therefore is the main spring of the whole proceeding, 
 and requires the most care and attention. There are no direc- 
 tions for the best mode of satisfying the requirements of this 
 part of the act. The certificate must satisfy the Commissioners 
 in Lunacy to whom it is submitted. I am not aware that they 
 have published distinct instructions of what they require. I have 
 however submitted some hundreds of certificates to their super- 
 vision, written by medical men of all grades of experience, and 
 therefore consider I may indicate what my experience has 
 taught me. 
 
 The certificate is divided into ' facts indicating insanity ob- 
 served by myself {i.e., the certifier) and 'facts (if any) indicating 
 insanity communicated by others.' 
 
 With regard to the first part it will be observed that what is 
 wanted are facts not opinions, and own observations not com- 
 munications. The hint given at p. 123 will assist the medical 
 certifier in tliis duty ; the patient may exhibit change in the 
 various ways indicated by the mnemonic ; such as in manner ; 
 but in the certificate it would not suffice to say only that the 
 patient is altered in manner, but the fact must be described ; as, the 
 patient is morose or greatly depressed in spirits, suUen, taciturn, 
 
424 LECTURES ON MENTAL DISEASE. 
 
 etc. Or again it would be less satisfactory to say the patient has 
 delusions than to say in what the delusion consisted; as, he says 
 he is dead, that his head is made of wood, etc. : and with regard 
 to the emotions it is better to say that the patient is con- 
 stantly moaning, and is constantly saying he is lost, that he is 
 going to hell, and that he has an anxious expression, than simply 
 to say that the patient is depressed. 
 
 "With regard to the facts which are communicated " (if any)." 
 It would seem that though these are desirable they are not 
 essential ; whatever they may be, it is essential that the authority 
 for them should be given hj name, as his uncle, John Smith, in- 
 forms me ; this evidence too should consist of facts not opinions, 
 such as he endeavoured to cut his throat, and he has made 
 several attempts to hang himself, that liis habits have become 
 slovenly, he has neglected his work or duty, has sat for hours in 
 a listless attitude, etc. 
 
 The certificates are usually made upon printed forms wliich 
 arc kept by the law stationers, or by the authorities, or pro- 
 prietors of the estabhshment to wliich the patient is to be taken ; 
 and the dii-ections printed on the margin, render all the details 
 easily understood. 
 
 Two medical certificates are required for the admission of a 
 private patient into a private house or asylum, the two medical 
 men must not be partners, nor must they have any relationship 
 with the person to whom the patient is to be sent. 
 
 These duties are full of precautions, but they apply more to 
 the person receiving the patient. It would appear strange how 
 any medical man can be liable to penalty of any kind for sign- 
 ing them, provided the facts he states are true and he obeys the 
 precautions mentioned, yet medical men have suflered severely 
 in a pecuniary sense in vindicating their innocence and bona 
 fides. 
 
 To sign the certificate and to place the date of the examination 
 and signature completes his medical duties ; the certificate it 
 must be remarked is no committal, is not an order for admission, 
 it is only a warranty jointly with another given to the person 
 who signs the actual order, which occupies a different page of 
 the forms supplied. 
 
 If the certificate is informal it is no certificate at all. If it is 
 
LEGAL RELATIONS OF INSANITY. 425 
 
 not acted upon witliin seven clays it ceases to bo valid ; there are 
 provisions made however in the act for minor verbal correc- 
 tions, which are allowed. 
 
 The provisions for the admission of a pauper are slightly 
 different, instead of two medical certificates one is sufficient ; the 
 order for admission is usually signed by a Justice of the Peace, 
 or it may be signed by a clergyman, together with the relieving 
 officer or an overseer of the parish from which such pauper 
 shall be sent. 
 
 The medical man's duties termmate with the completion of 
 the certificate. If he assist in the removal of the patient he does 
 it as a friendly act only, one need not therefore say more with 
 respect to the formahties of the admission of the patient as these 
 must be mentioned in the next part of the subject, where the 
 function of the medical man as a custodian are to be mentioned; 
 this resolves itself into a consideration of the precautions taken 
 by the legislature against improper detention in asylum or other 
 house. 
 
 2. The medical duties in relation to receiving a patient. 
 
 In the first place as regards private lunatics, Mr. Fry says, the 
 law does not require that every lunatic should be brought neces- 
 sarily under control ; in fact it takes no cognisance of private 
 lunatics until appUcation is made on their behalf, unless they are 
 dangerous to others, or not under proper care. {The Lunacy 
 Acts, By D. P. Fry). The act (16 and 17, Vic. cap. 97, §. 68), 
 appHes to all lunatics private or pauper, and it mentions four 
 categories under which the law should be set in action. 1. For 
 a dangerous lunatic. 2. One not under proper care and control. 
 8. One is wandering at large. 4. Is cruelly treated. 
 
 The medical man receiving the patient has no duty imposed 
 upon him to judge under what circumstances a patient is placed 
 under care, provided it is recommended, and he has the means 
 of properly accommodating the patient; and the legal require- 
 ments are complied with. 
 
 It is a common error to suppose that only dancjcrous lunatics 
 must be sent to an asylum, there is a case reported in the Jour- 
 nal of Mental Science, for April, 1869, of Gin v. Glcnnie and Ray, 
 and the Lord Chief Justice is reported to have chargedthc jury in 
 the following words. " If they were of opinion that the plaintiff 
 
426 LECTURES ON MENTAL DISEASE. 
 
 was not in a fit state to be at large, then however they might 
 sympathize with him, their verdict should be for the defendant. 
 If, however, under all the circumstances of the case, they came 
 to the conclusion that the plaintilf was not of unsound mind, 
 or being so was not so dangerous to himself or others, they should 
 
 find for him The question for them to consider was whether 
 
 the plaiutifT was at the time he was x>laccd in an asylum, a dan- 
 gerous lunatic.'' In a second trial Mr. Justice Smith is reported 
 to have said ; " It was plain that there could be no justification 
 for confining the plaintiff in a lunatic asylum unless he was, at 
 the time and when the order for his reception into the asylum 
 was signed, a person of unsound mind, and in such a state of 
 diseased mind, as to be deprived of the use of his reason, and to 
 be dangerous to himself or those with whom he might come in 
 contact." Twenty years previously a similar dictum was given 
 by Lord Chief Baron Pollock which called for a reply fi-om Dr. 
 ConoUy, and subsequently from the Commissioners in Lunacy to 
 the Lord Chancellor,''' and notwithstanding these, it seemed that 
 the same notion was entertained by legal authorities 20 years 
 afterwards, and now after 15 years more, it seems that the same 
 opinion still haunts the legal mind. 
 
 The following is a condensed quotation of the Act IG and 17, 
 Vic. cap. 97, §. 68. "Every officer of a parish who shall have 
 knowledge that any person is xcandering at large, whether a 
 a pauper or not, but is deemed to be a lunatic shall apprehend 
 and take such person before a justice, or if not wandering at 
 large, but not under projKr care and control, or is cruellg treated or 
 neglected by any relative or person having care of such person, 
 he shall give information on oath before a justice, and such jus- 
 tice shall either himself visit, or examine such person, and it 
 shall be lawful for the said justice by an order under liis hand to 
 du'ect such person to be received into an asylum." 
 
 And by §. 70. neglect of this duty would render the parish 
 ofYiccr liable to a fine of £10. 
 
 The subject was mentioned in the House of Lords by Lord 
 Monteagle, when Lord Brougham, as reported in the Times, July, 
 24, 1849, said : — " It was clear to him that if the learned judge 
 
 * See also Fry's Lunacy Acts, p. 319. 
 
LEGAL RELATIONS OF INSANITY. 427 
 
 had really stated upon tlic trial, (alludiug to Mr, Justice Smith) 
 what he was represented to have stated, there must be a motion 
 for a new trial." He recommended speculating attorneys to 
 bring no action upon the dictum for if they did, they certainly 
 would have their costs to pay. 
 
 The reasons why it would not be expedient to confine the 
 powers of having a lunatic placed under protection except there 
 were dangerous symptoms, were thus set forth by Dr. ConoUy in 
 the letter alluded to. 
 
 He pointed out, " that there were many other forms of un- 
 sound mind, which although for a length of time unattended with 
 any actual danger to the lunatic or others, lead to consequences 
 so intolerable, that an asylum must be resorted to for reHef from 
 them. Delusions as to rank and consequence, as to property^ 
 as to money withheld, as to attachments on the part of persons 
 of high station, or as to suggestions made by voices in the air, 
 or words written in the sky, often prompting actions so absurd, 
 so inconvenient, and entailing such persecution on particular 
 families, that interference is positively required before the indi- 
 vidual becomes dangerous ; the danger must not be waited for, or 
 incurred, it must be prevented. 
 
 There can be no doubt therefore that a medical man is quite 
 justified in giving a certificate for any purpose, whether it be for 
 the care and treatment, that is for the good of the patient, or for the 
 good of the public and the friends and family of the patient, and 
 not only is he justified, but in cases it becomes his duty so to do ; 
 however dangerous or hazardous to himself such duty may 
 be. That it is a risky duty is obvious to anyone who is aware of 
 the legal tortures to which medical men have been subject in con- 
 sequence. And if a man is justified in sending a patient into an 
 asylum, or committing him to the care of any individual, it is 
 obvious one is equally justified in receiving the patient. 
 
 But no one, medical man or not, may receive a lunatic or 
 alleged lunatic into his house for profit, without lu'oper authority ; 
 but anyone may board a lunatic, or alleged lunatic, as a friend 
 or relative, if he receives no profit and takes charge of one only. 
 But in the latter case if the lunatic is neglected or allowed to 
 wander at large, he is liable to be dealt Avith by the clause of the 
 act already quoted. 
 
428 LECTURES ON MENTAL DISEASE. 
 
 Dii-ectly auy payment or any equivalent is made for the board 
 or care of the lunatic or alleged lunatic, the proper orders, etc., 
 are necessary ; even though but one patient be received, and this 
 apphes equally to lunatics so found by inquisition ; only in the 
 latter case the order for reception is made by the committee of 
 the person only, without the necessity of fresh medical examina- 
 tion. It has been considered doubtful whether a person receiv- 
 ing only one patient, and that patient one found by inquisition, 
 is bound to report the same to the Commissioners in Lunacy. 
 The practice of late has certainly been not to report it. There 
 are therefore numerous cases boarded as single patients, not 
 known by the Commissioners, but which are Imown to the 
 Visitors of Chancery Lunatics who constitute a separate board. 
 This is an anomaly without any advantage arid might be 
 amended. 
 
 If a person only receive one patient of any kind no license is 
 required. 
 
 The formahties to be observed on receiving a single patient 
 are the same as when more than one is received, they will there- 
 fore be alluded to when we speak of the rules for the reception of 
 more than one. 
 
 Considerable doubt as regards its legality has existed in 
 the minds of medical men and others who arc wiUing tc 
 receive a patient into their family, in those cases in which 
 the nature of the disease is doubtful. It is quite true that 
 there is a margin even in actual insanity, when the patient 
 would be considered by all but a specialist to be quite 
 sane. A specialist is supposed to view all cases through a dis- 
 torted vision ; but he at least should perceive the early symptoms 
 with more readiness than the inexperienced. At Sandywell my 
 assistant Mr. Yorke Wood lived in a detached house of mine 
 about a mile from the park. He was requested by an acquaint- 
 ance of his own to receive a lady to board with him, to which 
 I offered no objection. When I saw the patient I at once per- 
 ceived that the case was one in the early stage of ordinary 
 insanity. Mr. Wood, who had had some experience, was sur- 
 prised and indeed alarmed ; he considered my diagnosis incorrect. 
 But as the house was mine, I desu-ed at all events that we should 
 not be doing an unlawful act, and I advised Mr. Wood, as I 
 
LEGAL RELATIONS OF INSANITY. 429 
 
 would advise everyouo who finds himself in similar cii'cumstances 
 to do, viz., to call in two independent medical men, and ask 
 them to see the patient with the view to certify to the insanity, 
 if tlioy were of opinion the patient was insane. Both the 
 practitioners called in had experience in insanity, and one of 
 them had a great experience, hut they declined to certify, there 
 was therefore no hesitation in retaining the patient. One 
 could not do more, nevertheless the patient really was insane, 
 and is now a chronic lunatic. This happened 20 years ago, and 
 she went through all the stages described in the previous pages. 
 So that the confines between sanity and insanity are not al^ways 
 well marked, there is no doubt that there are hundreds of 
 patients at the present time boarded in separate houses, of simi- 
 lar kind to the above, but quite unknown to the authorities. 
 
 When a person receives more than one insane jj'T'tient for 
 profit, the house becomes, what is called popularly, and to all in- 
 tents and purposes is, a private asylum. 
 
 The precautions instituted by the law in this case, become more 
 stringent, and are of such searching nature that it would seem 
 impossible for one to believe, when once they are aware of them, 
 that any such cases of unjust incarceration as related could odcur. 
 Or that any one either from crass ignorance or something worse, 
 could attempt to foist upon a credulous pubhc sensational accounts 
 of this character. But judges are among the credulous. 
 
 The precautions are as follows : — No one can receive two or 
 more insane patients without a licence ; in London and 10 miles 
 around the licence is obtained from the Commissioners in Lunacy. 
 
 As the Commissioners have had to be mentioned several times 
 it may be explained that they are the Board established to carry 
 out the laws, which were made upon the reform that follow^ed 
 upon a noted speech by Lord Ashley in the House of Commons 
 in 1838. An act was passed with the regulations for the pro- 
 tection of the lunatic and a board appointed to carry it 
 out, and Lord Ashley was appointed its first chamuau, the 
 date of this act was 1845, and it is called 8 and 9 Vic, cap. 
 100, this act was made in consequence of abuse found to exist 
 by a commission appointed in 1844 of which Lord Ashley was 
 the chairman. Most of the provisions of that reform still exist 
 and the commission contmues to superintend its working, and 
 
430 LECTURES ON MENTAL DISEASE. 
 
 uutil quite lately under the same chairman, now the Earl of 
 Shaftesbury, whose name and life ought to be a guarantee to all 
 that no abuses are allowed to pass unchecked. 
 
 We may now proceed to enumerate these checks and precau- 
 tions, they relate to the proper selection of a responsible person, 
 and to the fitness of the premises for the proper care and treat- 
 ment of the patient. 
 
 For the pauper asylums these matters are under the authority 
 of County Magistrates, who elect the Medical Superintendent 
 and provide the building ; which is inspected from time to time 
 by the Commissioners in Lunacy. As the Commissioners visit 
 every asylum, they arc often able to give profitable suggestions. 
 
 In the matter of the asylums under the management of Charit- 
 able Committees, similar to the general hospitals supported by 
 voluntary subscriptions, the general body of subscribers elect the 
 Medical Superintendent. 
 
 But with regard to private houses, or as they are commonly 
 called, i)rivate asylums, the permission to receive patients may 
 be said to be in the metropoHtan district wholly in the hands of 
 the Commissioners in Lunacy ; but in the provinces generally, 
 under the County Magistrates and the Commissioners. 
 
 To admit more than one lunatic into one's own house a license 
 is necessary. This license has to be procured either from the 
 Commissioners in Lunacy if the house is situated in Jliddlesex or 
 in an area of about seven miles of London, or from the quarter 
 sessions of the county in which it is situated. This licence is 
 by no means given as a matter of course. In their tlm-teenth re- 
 port the Commissioners say, " The legislature has given us a 
 discretion on the subject ; and the question to be considered by 
 us, on receiving fresh applications for a new licence appears to 
 be, whether or not an additional house is required for the accom- 
 modation of insane persons, and also whether the qualification 
 of the persons applying are such (under other circumstances) 
 as would induce us to grant a new licence." 
 
 " Should it seem advisable to grant a new licence. It is our 
 custom to propose the following questions." 
 
 These questions are eight in number. 1 and 2 relate to the 
 social position of the applicant, whether married or single, if in- 
 tending to reside, if any children and then- ages. 3. If a medical 
 
LEGAL RELATIONS OF INSANITY. 43 1 
 
 man, and if so, where he received his medical education, what ex- 
 aminations he has passed, what degree he has received, how long 
 in practice. 4. What special experience in lunacy. 5. Produce 
 testimonials as to skill and as to pecuniary means for main- 
 taining an " establishment in a comfortable state." 6. What 
 interest he possesses in the house and premises, have any other 
 persons interest jointly with the api^licant. 7. What class of 
 patients is it proposed to receive, paying what weekly or other 
 rate of board. Should these be answered satisfactorily, an in- 
 spection of the premises is undertaken. 
 
 It may be mentioned that the examination of the qualification 
 required by the 3rd and 4th question is not a mere perfunctory 
 affair. Having had to undergo this system of investigation 
 twice in my career, I speak on the subject from actual experi- 
 ence. 
 
 With regard to the question relating to the fitness of the pre- 
 mises for the reception of patients, it is ordered by the statute (8 
 and 9, Vic, cap. 100, §. 24). "That the application for a licence, 
 shall be accompanied by a plan of such house, to be drawn upon 
 a scale of not less than one -eighth of an inch to a foot, with a de- 
 scription of the situation thereof, and the length, breadth and 
 height of every room, a statement of the quantity of land annexed 
 appropriated to the exclusive use and recreation of the patients." 
 
 These plans are afterwards to be hung in a conspicuous place 
 in the house. 
 
 Such being the precautions for the proper care of the patient, 
 it is ordered that no patient can be received therein without the 
 order already alluded to. These papers which are commonly 
 spoken of as the certificates, consist of three distinct parts, viz., 
 the order for reception, the statement, and the medical certificate ; 
 the statement merely gives certain particulars of the patient, 
 which are of interest but only secondary importance, as the age, 
 sex, religious persuasions of the patient, the duration of attack, 
 if the first attack, if dangerous, suicidal or epileptic, and it has 
 to be signed by some relation or friend, to whom notice of death 
 may be sent and t\'1io can vouch for these particulars. It has no 
 authoritative importance and the facts may or may not be accu- 
 rate and if not correct would not invalidate the order. 
 
 The order for reception in private cases must be signed by a 
 
432 LECTURES ON MENTAL DISEASE. 
 
 responsible person, not necessarily a relative but preferably so, 
 as implied by the words in the schedule, " degree of relationship 
 if any, or other circumstances of connection with the patient." 
 
 I consider these words important, they allow a certain latitude 
 of choice provided the connection with the patient is explained ; 
 it happens on occasions that a friend must intervene. 
 
 Sometimes and not unfrequently perhaps a lunatic may resent 
 the act, so that a husband or wife, son or daughter has good 
 reason for avoiding the duty. This part of the statute which 
 appears to me to be wise, was violently condemned by Baron 
 Huddleston ; in a recent trial he is stated to have called it a 
 monstrous power. It is very clear if he did so, that he did not 
 understand the matter. He is reported to have said it was 
 monstrous that any pauper T\dth two medical men, " whose only 
 qualification was the possession of a diploma, could deprive a man 
 of his liberty," the whole case in fact of Weldon v. Winslow 
 seemed to be a muddle ; it is to be hoped the reporters were in 
 fault only. 
 
 There was no deprivation of Hberty in this case at all, there 
 were no certificates which were put into force, as explained by 
 the Earl of Shaftesbury in his speech on the Earl of Morley's 
 motion on the lunacy laws subsequently. 
 
 But firstly as regards the signature of a pauper, would Baron 
 Huddleston maintain that a pauper should never sign a certifi- 
 cate, say for his own daughter. I quote this case as it is one 
 that has recently occurred. However the law is exphcit and if 
 the law allows a pauper to sign an order, the medical man has 
 nothing to do but to accept it. The present remarks however 
 are intended to show that there is nothing in the usual mode of 
 procedure prescribed by the law, which the medical man need 
 feel any scruple in obeying. The person signing the order is 
 called upon to state his own occupation, thus probably showmg 
 his status, and we shall see that the act provides for any 
 culpability that might arise from this source, there are checks 
 at every stage. 
 
 This order (a) must only be given after the signee has seen 
 the patient, and it liolds good for the admission of the patient for 
 one month. The order may be signed before or after, one or both 
 (a) 16 and 17 Vic, cap. 96, § 4. 
 
LEGAL RELATIONS OF INSANITY. 433 
 
 medical certificates, the medical certificates do not therefore 
 necessarily give the warrant to the person who signs the order. 
 
 On receiving a patient it is the duty, as regards the order, for 
 the person accepting the care to see that it is in proper form, 
 that it gives the name of the patient and states whei-e (h) the 
 signee saw the patient, ivhen he saw him, and that his signature 
 is attached with the date, his place of abode and his occupation. 
 
 An order would not be valid unless these particulars were 
 given and the patient should not be received, nor unless the 
 date of the order was within one month of the admission (c). 
 
 It is important also that the statement (d) of particulars, 
 relative to the patient so far as known should also be appended. 
 
 In the next place, to render the whole order available, it must 
 be accompanied by the certificates, of two medical men. Baron 
 Huddleston is reported to have said that it is monstrous that 
 mere qualification should give a medical man this power, but if 
 qualification is not sufficient, what is ? And where are medical 
 men to be had who are more than qualified; " merely possessing 
 a diploma," were the words he is reported to have used. 
 All that a medical man can do to prove his qualification is by 
 passing an examination, and the proof of which is a diploma. 
 
 To receive a patient the two certificates must accompany the 
 order, the two certificates the law prescribes must be totally 
 independent of each other, and the examinations must be 
 separate. 
 
 The medical men who sign the certificates must be entirely un- 
 connected with one another, and with the person who is to have 
 charge of the patient ; nor can a certificate be signed by any one 
 who is a Commissioner, or by a person interested in any hcensed 
 bouse, or is medical attendant on any patient therein, (f) or by 
 any one receiving any percentage, or m any way interested in 
 the payments, (g) or by any medical man who shall in any 
 capacity attend any licensed house, or any asylum, hospital, or 
 other place where any lunatic shall be confined. 
 
 (b) 25 and 26 Vic, cap. Ill, § 23. 
 
 (c) 16 and 17 Vic, cap. 96, Schedule A No. 1. 
 
 (d) 16 and 17 Vic, cap. 96, § 4. 
 (/) 8 and 9 Vic, cap. 100, § 23. 
 (g) 25 and 26 Vic, cap. Ill, § 24. 
 
434 LECTURES ON MENTAL DISEASE. 
 
 This last proliibition appears to cxclutlc every man who lias the 
 least practical acquaintauce with the subject and can scarcely be 
 inteudecl. If it is the law, it is constantly broken, for many 
 thousand lunatics are at present in asylums, certified by medical 
 men who are the parish officers, and treat the lunatics in the 
 different worldiouses. 
 
 The provisions of the law however show how jealously the 
 wrongful admission into an asylum is guarded against. 
 
 On the admission into any house, the proprietor for his own 
 sake or the person taking charge of the patient, must see 
 whether these regulations are complied with ; that is that the 
 person signing, is firstly a registered practitioner, secondly that 
 he had seen and examined the patient within one week of the ad- 
 mission, thirdly that the certificate is properly signed and pro- 
 X)erly dated, and for the certificate to be correct it should not 
 omit to say at what place the examination took place. 
 
 Finding all these matters, that is the order, and the two cer- 
 tificates correct, the patient may be admitted ; then comes another 
 series of duties for the security of the patient. 
 
 In the case of a private patient a copy of the order and the 
 certificates must be sent to the Commissioners, and if the asylum 
 into which the patient is admitted is in the provinces, another 
 copy must be sent to the committee appointed by quarter sessions 
 to overlook the local licensed houses. 
 
 The medical man or other person taking charge of the 
 patient, will be careful to further satisfy himself that the other 
 documents are in proper order, for example : — 
 
 As regards the substance of the certificates, as " the facts in- 
 dicating insanity," the person recei\'ing the patient must exer- 
 cise his own judgment as to their sufliciency. A certificate 
 which is defective may be amended ; but if both certificates 
 were whoDy inadequate to show that the patient was insane, I 
 should imagine the i)atient should not be admitted ; unless the 
 symptoms were very obvious, and especially unless the patient 
 were dangerous or bodily ill ; the law of humanity would then 
 authorize the reception conditionally. I have received more than 
 1000 certificates ; I can only recall to mind one founded 
 upon a wrong diagnosis, and that was scarcely an error as the 
 case was acute alcohohsmus, and which had nearly passed off 
 
LEGAL RELATIONS OF INSANITY. 435 
 
 during the patient's preliminary residence in the workhouse. The 
 
 certificates gave the following facts as indicating insanity ; 
 " Says as she was travelling to London from Gloucester, the 
 devil flew in at the window which made her start and her bag 
 which she held in her hand was jerked out of the window, and 
 it contained a hundred pounds," this satisfied the magistrate 
 who signed the order for the patient's admission ; the main fact, 
 however, was real and I was enabled to recover the money for 
 her. After another day's abstinence in the asylum she was 
 discharged. I have also received a patient recovering from a 
 drunken bout who was much confused in mind, he was also an 
 epileptic. This patient appeared to me, not to requke an 
 asylum and I discharged him at the end of a week, in neither 
 of the cases was the admission into an asylum unjustifiable. 
 
 The patient having been duly admitted, the next duties en- 
 tailed on the Superintendent is to set in action those checks to 
 improper admission, which are prescribed by law, and which 
 belong to the functions of the Commissioners in Lunacy to see 
 that they are compHed with. As the checks are principally 
 directed to the admission of the private patients, the regulations 
 for such class will be here chiefly described. 
 
 Within the next twenty-four hours after admission a copy of 
 the certificates, order, and statement must be sent to the office of 
 the Commissioners of Lunacy, and in the case of a provincial 
 house, also to Visiting Justices appointed at quarter- sessions ; 
 the Commissioners institute a very searching examination into 
 all the technicahties connected with the form of certificate, and 
 if there is found any omission or error, they return the certificate 
 for correction, i.e., if the error is not one of fundamental im- 
 portance ; such as the omission of some essential part, as omis- 
 sion of order, etc. Fourteen days are allowed for corrections; if 
 the Commissioners consider the certificates or order absolutely 
 defective they order the patient to be discharged. This does not 
 often happen, as the medical officer of the asylum has fii-st ex- 
 amined the papers, but cases of the kind are given in the annual 
 report of the Commissioners. 
 
 In such examination the Commissioners would at once detect 
 any attempt at an improper admission, as for example, if the order 
 was signed by a ** mere pauper " or a person not a relative, and 
 
 FF 2 
 
43^ LECTURES ON MENTAL DISEASE. 
 
 not shown to have a satisfactory reason for undertaking the duty, 
 and they would at once make enquiry into the cause. Sup- 
 pose, for example, a footman signed for his master, or even an 
 attorney for one not connected by ties of family relationship, such 
 kind of connection would be patent on the order. I once ad- 
 mitted a patient of the same name as one of the medical men who 
 signed the certificate, and I was asked for explanation as regards 
 relationship. If, again, a patient was examined at a house of 
 different kind or position to that of the usual residence of the 
 patient, the matter would attract the attention of the examiner ; 
 and every one connected with lunacy knows how keen this 
 of&cer is with regard to any imperfections. 
 
 If the medical certificates do not give sufficient indication of 
 insanity, the certificates would be returned for further evidence, 
 and this happens tolerably often, owing to the want of sufficient 
 expUcitness in the document. 
 
 After having sent the document to the Commissioners, the 
 patient's case, consisting of his personal appearance, history, 
 etc., has to be entered in a prescribed form in the case-book, 
 and into the register of the estabUshment, the forms of which 
 are ordered by the statute. 
 
 The Commissioners on the supposition that the circumstaneeB 
 appear correct, next require, within seven days, a medical re- 
 port of the condition of the patient. Should this report not 
 prove insanity, a second or third is demanded, as in the cases, 
 iii and iv, pp. 170 and 172. 
 
 So that in the case of a private asylum, to incarcerate, as the 
 term goes, an individual, there must be a collusion between three 
 medical men ; two who signed the certificate, and the licensee 
 of the asylum ; and they must combine with a fourth party who 
 signed the order. This is what the sensational writers would 
 have their readers believe is of common occui'rence ! 
 
 The safeguards, however, do not end here, for the owner of 
 the asylum would be placing himself at the mercy of three per- 
 sons, two medical men and one other whose social position and 
 residence has to be given, and the discovery of a single act of 
 the kind would immediately deprive bim of his license to receive 
 another patient. 
 
 For the sake of the narrative, if we can imagine that these 
 
LEGAL RELATIONS OF INSANITY. 437 
 
 impedimeuts have been overcome, and suppose that no actual 
 proof of improper admission has entered into the mind of the 
 officer who examines certificates for the Commissioners, (an officer 
 too of the greatest experience in this particular duty) the next 
 hazard these people would have to incur would be a visit from 
 the Commissioners themselves. The Commissioners visit each 
 metropohtan licensed house four times a year, but the provincial 
 houses are visited six times a year; that is, twice by the Commis- 
 sioners, and four times by the Visiting Magistrate of the locality. 
 And most houses are also visited twice by the Lord Chancellor's 
 visitors. The Commissioners at their visit have their own list of 
 patients, they have also the plan of every house, and no alteration 
 in the internal arrangement of the house can be made without 
 their sanction ; they see and speak to every patient in the house ; 
 they visit and inspect every room ; so that the opportunity of 
 conceahug any inmate is impossible. The Commissioners also 
 examine aU the Case-books and the Eegisters which are ordered 
 to be kept by the statutes, they have the original certificates 
 laid before them, and the license of the proprietor, all of which 
 they countersign. 
 
 The chances, therefore, of unjust incarceration would appear 
 to most people amply provided against ; unless the monstrous idea 
 should be entertained that all the people engaged were in collu- 
 sion. This should, I think, convince any one that their fears 
 were unfounded on this matter. 
 
 This being the practice of the official visitors, and the mode in 
 which they carry out the letter and the spirit of the act, it is the 
 duty of the medical man having care of one patient, or several, 
 to be prepared to afford them every facility for conducting their 
 examination, and to be prepared with all the documents, books, 
 and general information they require. He must produce every 
 patient and allow each to speak to the Commissioners apart 
 from interruption. 
 
 At the visit of the Commissioners there are seven books which 
 have to be produced. 
 
 The visitor's books, in which to enter the result of their visit — 
 these are of two kinds : — One which mentions any matter on 
 which they wish to comment; which book is open to inspection of 
 any one who may wish to see it. So that the state of the house, 
 
438 LECTURES ON MENTAL DISEASE. 
 
 the condition of the patients generally, or any complaint that 
 they may make may be duly recorded, but in this book the name 
 of no patient is mentioned. The second book is a key to the 
 first, and gives the names of any patient on which they have 
 commented in the first report book. These books remain and 
 can be inspected by the magistrates -when they also inspect the 
 institution. But this second book cannot be shown to any one 
 else. 
 
 Copies of the entries in these report books have to be sent to 
 the Commissioners in London, and in provincial asylums to the 
 Visiting Justices. 
 
 These reports refer, by direction of the statutes, especially to 
 the following particulars : — (1) It is incumbent on the visitors 
 to inspect the whole of the premises ; 2. To see every patient ; 
 8. To ascertain whether any patient has been under restraint, 
 and if so, why ; 4. To inspect the orders of admission and medi- 
 cal certificates, and in certain cases the Hcence, as well as the 
 books required to be kept, and other documents ; they have also 
 to inquke as to the performance of di\ine service ; the occupa- 
 tion and amusements of the patients ; the system of treatment, 
 and the money paid by each patient {a and h). 
 
 Besides which, among other matters, there are laid before the 
 visitors, any letters written by patients, and which from their 
 nature, it has been deemed expedient not to send to theii' ad- 
 di'esses. 
 
 All letters addressed to the commissioners or visitors, are ex- 
 pressly ordered by the statute 25 and 2G Vic, cap. 3, § 40, to 
 be forwarded. " Every letter written by a private patient in 
 any asylum, hospital, or licensed house ; or by any single 
 patient ; and addressed to the commissioners in lunacy or com- 
 mittee, or in the case of houses within the jurisdiction of %'isi- 
 tors, to the visitors or any of them, shall, unless special 
 regulations to the contrary have been given by such commis- 
 sioners or visitors, be forwarded unopened." 
 
 The other books and documents which are to be laid before 
 the visitors, are the following (8 and 9 Vic. cap. 100). A Queen's 
 printer's copy of the act bound up with the visitors' report book ; 
 the 2nd or patients' book referred to, the medical visitation 
 
 (a) 8 and 9 Vic, cap. 100, § 04. (h) 25 and 26 Vic, cap. Ill, § 35. 
 
LEGAL RELATIONS OF INSANITY. 439 
 
 book, the register of admissions, register of death or discharge, 
 and the case book. 
 
 The visits are ordered to be without notice and to be kept 
 privy from the proprietor of the asylum. All the visitors' clerks 
 or assistant clerks, are obliged to take on oath of fidelity and 
 secrecy. 
 
 The visitors or commissioners practically have the power of 
 revoking the licence of any one contravening these regulations. 
 
 It will be seen, that there are numerous matters to be consi- 
 dered by any medical man undertaking the care of an insane 
 patient. Though complicated, they are not difficult to bear in 
 mind when the principle is considered, for which they were 
 enacted, viz., the protection of the lunatic from deprivation of 
 his liberty and unjust isolation. 
 
 The uses of isolation have already been described in the sec- 
 tion on treatment (p. 384). The lunatic, cannot in all cases 
 have perfect freedom to go here or there, to mix in this or 
 other public amusement. He needs protection, but there is no 
 need of incarceration ; on the contrary, bodily exercise and varied 
 scenes, short of causing excitement, are usually prescribed and 
 in most establishments freely encouraged ; all that is required 
 is to ensure mental rest. 
 
 Most institutions, private as weU as public, are freely open to 
 inspection of those who are not solely attracted by curiosity. 
 My own experience is that most patients are very ready to re- 
 turn to their old quarters, after they have been discharged. 
 
 There are two provisions in the statutes, which ought to 
 remove the apprehensions which sensational writers have formed 
 and fostered ; by special clauses in the various acts, any patient 
 who has been in any asylum at any period within five years, 
 may voluntarily return for treatment without the prehminary 
 forms described, this privilege is occasionally claimed. The 
 other is that by special permission of the commissioners, a 
 friend or relation, as a wife or sister, may take up their resi- 
 dence in the private asylum with the patient ; this privilege is 
 more frequently resorted to. In my own case, I have never 
 been without such an inmate, for twenty years past. 
 
APPENDIX. 
 
 The following are the chief systems of classification of mental 
 diseases, which have been proposed. I may refer the reader to 
 my remarks generally on classification, p. 102. 
 
 It would be impossible and quite useless, to give many of the 
 very numerous systems of these classifications. I shaU confine 
 my remarks to those which have received the greatest atten- 
 tion. 
 
 The various systems have been based on different foundations, 
 as Psychology, Anatomy, Symptomatology, and Etiology. 
 
 According to the account given in Bucknill and Tuke, one 
 of the earhest, which received much attention, was by Arnold, 
 (1782), into Ideal, Notional, and Pathetic; the first included 
 four, the second eight, and the third sixteen varieties. 
 
 Pinel suggested the system which perhaps has been mostly 
 used in aU countries ; into, 1. Mania. 2. Melanchoha. 3. De- 
 mentia and Idiocy. 
 
 Esquirol, whose writings were highly prized, divided Insanity, 
 into, 1. Lypemania. 2. Monomania. 8, Mania. 4. Demen- 
 tia, 5. Idiocy. 
 
 Dr. Conolly adopted Pinel's system into, Mania, Melanchoha, 
 and Dementia. 
 
 Dr. Noble's system has also been weU received. 1. Emotional. 
 2. Notional. 8. InteUigential. 
 
 AU these systems are classifications of the mental states in 
 insanity, not a classification of disease or of morbid species. 
 
 Dr. Griesinger, whose work is a standard authority in every 
 language, divides the subject thus:— 1. States of Mental Depres- 
 sion. 2. States of Mental Exaltation. 8. States of Mental 
 Weakness. This I think is more a classification of symptoms 
 than diseases. 
 
442 APPENDIX. 
 
 Dr. Skae proposed au elaborate list founded upon the as- 
 sumed causes. 
 
 1. Hysterical INFania. 
 
 2. AmeuorrhoGal Mania. 
 8. Post-connubial Mania. 
 
 4. Puerperal Mania. 
 
 5. Mania of Pregnancy. 
 
 6. Mania of Lactation. 
 
 7. Climacteric Mania. 
 
 8. Ovario-Mania (Utero-Mania). 
 
 9. Senile Mania. 
 
 10. Phtbisical Mania. 
 
 11. Metastatic Mania. 
 
 12. Traumatic Mania. 
 
 13. Syphilitic Mania. 
 
 14. Delirium Tremens. 
 
 15. Dipsomania. 
 
 16. Mania of AlcohoHsm. 
 
 17. Post-febrile Mania. 
 
 18. Mania of Oxaluria. 
 
 19. General Pai-alysis. 
 
 20. Epidemic Mania. 
 
 21. Idiopathic Sthenic. 
 
 22. Idiopathic Asthenic. 
 
 This is more a list than a classification, but it has been 
 thrown into classes by Dr. Batty Tuke, thus : — I. Idio-Ence- 
 phaHc, which he subdivides into, (a) Traumatic ; (i) Adven- 
 titious ; (c) Over-Escitation ; ((/) Defective Organization. 
 II. Evolutional, as : (a) Pubescence ; (b) Pregnancy ; (c) the 
 Puerperal state ; {(J) the Climacteric state ; {e) the Senile 
 state. III. ]\Iorbid conditions of the Body imphcating the 
 Brain ; (a) Diathetic ; (b) Toxic ; (c) Metastatic. 
 
 Dr. Daniel Hack Tuke's classification is : — 
 
 Class I. — The Intellect or the Ideas. 
 
 Order 1. Development Incomplete ] -r \ Vi. 
 
 ' Dementia. 
 Order 2. Invasion of Disease Delusional Insanity, 
 after Development. ' Monomania. 
 Mania. 
 
Order 2. Partial 
 
 APPENDIX. 443 
 
 Class II. — The Feelings and 'Moral Sentiments. 
 
 Order 1. Development lucomplete . . Moral Imbecility. 
 
 n J n T • r -rv- ( Moral Insanity. 
 
 Order 2. invasion oi Disease T\r i it 
 
 p, -r. 1 J. 1 Melanciiolia. 
 
 after Development. | Exaltation. 
 
 Class III. — The Projyensities, Instincts, or Desires. 
 
 Order 1. General Mania. 
 
 Homicidal Mania. 
 Suicidal Mania. 
 Erotomania. 
 Dipsomania, etc. 
 Dr. Bucknill has also elaborated a classification, but my space 
 does not aUow me to give it in full. It is to be found in his 
 book, Psychological Medicine, p. 804. It consists of 63 varieties. 
 It contains three classes, twelve sub-classes, and seven orders, 
 with species of Pathological conditions. Neurotic, Hsemic, and 
 Trophic, differentiating the Genera. 
 
 There are classifications, which are mere arrangements for 
 particular treatises, as Dr. Maudsley's — 
 
 Intellectual or Ideational. 
 Emotional or Affective. 
 Dr. Morel. Traite des Maladies Mentales. 
 
 1. Hereditary Insanity. 
 
 2. Toxic. 
 
 3. Insanity from transformation of other disease. 
 
 4. Idiopathic. 
 
 5. Sympathetic. 
 
 6. Dementia. 
 
 Dr. Guislain, the Belgian physician. 
 
 1. Melanchohe. 
 
 2. Extase. 
 
 3. Manie. 
 
 4. Fohe. 
 
 5. Dehre. 
 
 6. Demence. 
 
 I have abeady said that I do not agree with any of these pro- 
 posals. At least they seem to me to assist us but very shghtly 
 in grasping the various kinds of cases that we meet with iu 
 practice. The following, however, seems to me to be more com- 
 
444 APPENDIX. 
 
 preliensive and Batisfactory, it was drawn up at the International 
 Congress of Alienists held in Paris in 18G7. 
 
 I. Simple Insanity, embracing the different varieties of mania 
 melancholia, and monomania ; circular insanity, and mixed 
 insanity, delusion of persecution, moral insanity, and the 
 dementia following these different forms of insanity. 
 
 (All these are included under the head Ordinary Insanity, in 
 the previous pages). 
 
 n. EpiUptic Insanity. (Symptomatic in my arrangement). 
 
 in. Paralytic Insanity. (General Paresis). 
 
 IV. Senile Dementia. 
 
 V. Organic Dementia. 
 
 VI. Idiocy. 
 Vn. Cretinism. 
 
 It will be seen that all these correspond to my own arrange- 
 ment, with this exception, that Alcoholismus is not included nor 
 Spinal Diseases. 
 
 Hcematoma or Insane Ear. — This affection, which is met in the 
 different forms of mental disease, is not exclusively confined to 
 insanity, though it is much more common among the insane 
 than among the sane. 
 
 It consists in a pecuhar deformity of the external ear, by 
 which all the folds of tragus, and hehx are obhterated. At first 
 the disease is shown by a purpHsh swelling of the ear, which 
 gradually increases until the whole organ is puffed out into an 
 irregular and somewhat globular swelling. If punctured at this 
 stage, a small quantity of venous blood oozes from the punctures. 
 The swelling gradually subsides, and the processes of the ear are 
 variously drawn out of form, so that when the whole of the 
 tumefaction has subsided, the ear appears like a contracted or 
 shrivelled mass of very irregular shape. 
 
 The affection is much more common on the left side than on 
 the right, and is more frequent in males than females. 
 
 It has been variously accounted for, but I here give the results 
 of my own conclusions on the question. 
 
HiEMATOMA OR INSANE EAR. 445 
 
 There is no doubt that the swelling is due to an extravasation 
 of blood, and of venous blood. This at first distends the tissues 
 generally, separating the membranous from the cartilaginous 
 structures of the ear ; then coagulation takes place and adhesive 
 inflammation, this is followed by gradual contraction of the 
 coagulum and a general deformity is the result. When this has 
 terminated the ear retm'ns to its natural colour, and it is often 
 marked with white lines of new cicatrices. 
 
 The cause of the extravasation has been variously suggested. 
 It has been asserted that the state is the direct result of violence, 
 and the ground for this view has rested chiefly on the fact that 
 the affection occurs more frequently on the left side, and in men ; 
 it is maintained that a blow being struck, as for instance a box 
 on the ear, would be inflicted by the right hand, and so would 
 inflict the injury on the left side ; but when inflicting a blow on 
 a lunatic, it is not hkely that the aggressor would use so inno- 
 cent a means as a box on the ear. I have had numerous cases 
 of insane ear, but I never could trace the commencement to 
 such a cause ; though doubtless a blow on the ear might be in 
 some cases the exciting cause. But if a blow on the ear was the 
 real cause of the affection, why should the case be more common 
 among the insane ? 
 
 I believe the pathology of the affection in the insane to be as 
 follows. In certain cases of ordinary insanity and in general 
 paresis, there is found after death a condition of the bones of the 
 skull in which the whole of the diploe are obUterated, and the 
 bone is dense and ivory-like thi'oughout its entire thickness. 
 (Seepage, 226). 
 
 The external ear is suppHed with blood by the auricular 
 branch of the posterior auricular artery, and the posterior 
 auricular vein is the means by which the blood is returned to the 
 circulation, this vein accompanies the arteiy, but besides, there are 
 numerous smaller veins from the posterior surface of the ear, which 
 are in direct communication with the vein on the anterior sur- 
 face, by vessels which pierce the cartilage ; and in certain cases 
 it appears to me, that the chief of the venous cu-culation may 
 take place through these vessels. These are in free connection 
 with the veins outside the skull, which join the venous system 
 within the skull, "by means of small branches that pass 
 
44^ HyEMATOMA OR INSANE EAR. 
 
 tlirougli the sagittal suture, and through tlie parietal and 
 mastoid foramina." (Elhs). And when that condition of the 
 hones of the skull alluded to occurs, there must evidently he a 
 constriction or an actual ohlitcratiou of these venous trunks, and 
 thus a stagnation of the circulation of the veins of the ear is 
 produced. 
 
 The condition is not a thrombosis nor an embolus, but 
 probably a gradual obliteration of the vessel by the deposition 
 of bony tissue in the interior of the canal. 
 
 The appearance is thus always connected with a stage of the 
 disease in which the bony tissues become involved, and as this 
 is almost universally at a late period of the morbid changes, 
 the hfematome is a sign of a chronic condition of the patient, 
 and denotes structural changes of advanced kind, and it gives, 
 therefore, an unfavourable prognosis. 
 
INDEX. 
 
 ABSTRACT Ideas, 5 
 Fallacy of, 7 
 
 Examples of, 7 
 
 Acts Mental, acquired, 38 
 
 (See Statutes) 
 
 Action, Anomalies of, 154 
 Acute Insanity, 109 
 
 Case XV of, 212 
 
 Etiology. (See Etiology) 
 Affections, Alterations of, 115 
 Affidavits in Commissions de lunatico, 
 
 421 
 Aidomania, 190 
 
 Aitkin on Frequency of Tubercle, 238 
 Age, Influence of, in Ordinary Insanity, 
 
 221 
 
 " in General Paresis, 2S1 
 
 Allbutt, Dr., on Optic Disc, 263 
 
 Alcoholismus, 355 
 
 compared with General Paresis, 
 
 360 
 Alcoholic Paralysis, 362 
 Aldridge on Optic Disc, 263 
 Aloes in Treatment, 205 
 Alternation of Mania and Melancholia, 
 
 132 
 Amentia. (See Dementia) 
 Amsenomania, 190 
 American opinion on Restraint, 400 
 Amusements, 387 
 Anatomy, Morbid, of Ordinary Insanity, 
 
 224 
 
 of General Paresis, 293 
 
 ■ of Spinal Cord, 68 
 
 Appetite in Ordinary Insanity, 123, 137 
 
 in General Paresis, 274 
 
 Apprehension, Morbid, 111 
 Arachnoid, State of, 294 
 Arnold's Glassi£cation, 440 
 
 Association as a means of Treatment, 
 
 388 
 Asylum, 429 
 
 Ataxy and General Paresis, 367 
 Attitude in General Paresis, 266 
 Attendants and Nurses, 391 
 Auditory Illusions and Delusions, 148 
 Austin on Moral Causation of General 
 
 Paresis, 289 
 Automatism, Trousseau on, 20 
 Automatic Movements, 79 
 Marshall Hall on, 80 
 
 BAILLARGER, Dr., on FoHe Circu- 
 laire, 164 
 
 on General Paresis, 251, 276 
 
 Basis of Certitude, 27 
 
 Bastian, Dr., on Consciousness, 17 
 
 on Specific Gravity, 298 
 
 Baths, various, in Treatment, 142, 376 
 Belief as a Mental Product, 27 
 Blandford, Dr., on Moral Insanity, 185 
 Blodsinn, 188 
 Bloodvessels in Ordinary Insanity, 236 
 
 in General Paresis, 304 
 
 Boarders, 439 
 
 Bodily Symptoms, 1st stage. Ordinary 
 
 Insanity, 123 
 2nd stage, Ordinary Insanity, 
 
 134, 137 
 
 in General Paresis, 273 
 
 Bones Fractured, 259 
 
 Bordier, Case of, 181 
 
 Boulimia, 274 
 
 Brain, Histology of, in Ordinary In« 
 
 sanity, 234 
 
 in General Paresis, 299 
 
 in Idiocy, 333 
 
448 
 
 INDEX. 
 
 Bramwell, Dr., on Spinal Cord, 68 
 
 on Cerebro-Spinal Disease, 3fi5 
 
 Brierre de Boismont on General Paresis, 
 
 251 
 Bristowe, Dr., on Delirium Tremens, 
 
 136, 357 
 Broadbent, Dr., on Syphilis and Brain 
 Disease, 286 
 
 on Alcoholic Paralysis, 362 
 
 Broadhurst, Dr., on Alcoholic Paralysis, 
 
 362 
 Bromides in Epilepsy, 353 
 Browne, Dr. Crichton, on General Pare- 
 sis, 296 
 Bucknill, Dr., on Classification, 440 
 Burman, Dr., on General Paresis, 240, 
 290 
 
 CALMEIL on General Paresis, 240, 
 251 
 Cancer, Simulating Insanity, 3/2 
 Case I Kecurrent Insanity, 168 
 
 „ II Ditto, 160 
 
 ,, III Dr. Lockhart Robertson's, 
 170 
 
 „ IV of Dr. Pownall, by Dr. Davy, 
 
 172 
 
 „ V of E. T., Recurrent Insan- 
 
 ity, 176 
 
 ,, VI of E., Recurrent Insanity, 
 
 176 
 
 ,, VII Melancholia, 199 
 
 „ VIII Chronic Insanity, 201 
 
 ,, IX Acute Insanity and Phth- 
 
 isis, 202 
 
 „ X Acute Insanity, 204 
 
 „ XI Ditto, 205 
 
 „ XII Chronic Insanity, 206 
 
 „ XIII Acute Insanity, 208 
 
 „ XIV Melancholy with Stupor, 
 210 
 
 „ XV Acute Insanity, 212 
 
 „ XVI Melancholia Metamorpho- 
 sis, 213 
 
 „ XVII Hysterical Mania, 214 
 
 „ XVIII 214 
 
 „ XIX to XXIV General Paresis, 
 315 et seq. 
 
 Catalepsy, 208 
 Catamenia, 134 
 Cells, Nerve, 64 
 
 in General Paresis, 300 
 
 Cerebral Disease in Asylums, 370 
 Cerebellum in General Paresis, 308 
 Cerebro-spinal Conneiions, 71 
 
 shown Pathologically, 75 
 
 by Embryology, 73 
 
 Anatomically, 71 
 
 Differentiation of, 73 
 
 Certificates, 423 
 
 who may not sign, 423 
 
 Certitude, Kant's view, 27 
 Chancery Lunatics, 420 
 Change of Air and Scene, 393 
 Character, 56 
 
 Induence of, 284 
 
 Change of, 159 
 
 Charcot on Cerebral Disease, 73, 304 
 Chloral, 141 
 Chronic Insanity, 146 
 
 Modes of Termination of, 185 
 
 Symptoms in, 147 
 
 Chronic Lunatics, Proportion of, 162 
 Circular Insanity. (See Folic Circulaire) 
 Civilization, Influence of, 219 
 Correspondence of Patients, 401 
 
 D .^MONOMANIA, 191 
 Death in 1st Stage, 127 
 Definition of General Paresis, Dr. 
 
 Mickle's; 254 
 
 Author's, 254 
 
 of so-called Varieties, 190 
 
 Delire des Grandeurs, 261 
 Delirium Tremens, 357 
 
 of Watchfulness, 359 
 
 Delusion, Ocular, 150 
 
 Auditory, 148 
 
 in 3rd Stage, 148 
 
 Dementia, 327 
 Depression of Spirits, 109 
 
 in Chronic Stage, 147 
 
 Development of Mind, 32 
 
 Diagnosis of General Paresis, 247 
 
 of General Paresis and Spinal DiB- 
 
 ease, 86 
 
INDEX. 
 
 449 
 
 Digitalis, Dr. Dumesnil ou, 278 
 Dipsomania, 355 
 Dirty Habits, 161 
 Disease, Definition of, 100 
 Disposition, Change in, 156 
 
 ■ in Idiots, 335 
 
 Dr. Pownall's case, 172 
 
 Drunkenness and General Paresis, 360 
 
 Dumesnil, Dr., on Digitalis and Opium, 
 
 278 
 Duncan, Dr., on Idiocy, 337 
 Durliam, Mr., on Sleep, 77 
 Du SauUe on Hysteria, 191 
 Duties of Commissioners in Lunacy, 
 
 439 
 
 ■ on receiving a patient, 434 
 
 Dynamics of Mind, 59 
 
 EAR, tlie Insane Hcematomai 444 
 Early Treatment, on, by Dr. 
 
 Bucknill, "Dr. C. Browne, Dr. 
 
 Mann, Dr. Maudsley, 385 
 Ego, as an abstract termj 9 
 
 ■ as a concrete term, 10 
 
 Emotions as a mental product, 21, 41 
 
 Lewes on, 21 
 
 •— Spencer on, 21 
 
 Bain on, 22 
 
 — — in General Paresis, 260 
 
 in Ordinary Insanity, 109 
 
 Enquiry de lunatico, 420 
 Epilepsy and General Paresis, 288 
 Epileptic Insanity, 344 
 
 Treatment, 352 
 
 Epilepsie Larvee of Dr. Morel, 175, 346 
 
 Equilibriumi 98 
 
 Erotomania, 191 
 
 Esquirol's Classification, 441 
 
 Etiology of Ordinary Insanity, 216 
 
 of General Paresis, 280 
 
 Exciting Causes of Ordinary Insanity, 
 
 216 
 
 of General Paresis, 289 
 
 Excito-motory Function, 33 
 Examples of Ordinary Insanity, 199 
 
 FALEET, Dr.; on General Paresis, 
 251, 258 
 — — on Folic Ciroulaire, 164 
 
 Feelings, Change of, 155 
 Fci'rier, Dr., on Equilibriation, 98 
 
 on functions of cerebrum, 82 
 
 Folie k double Forme, 163, 191 
 
 Circulaire, 163, 191 
 
 Forcible Feeding, 403 
 
 Forms necessary for the Eeception of a 
 
 Patient, 428 
 Fournier on Syphilitic Brain Disease, 
 
 373 
 on Syphilis and General Paresis, 
 
 286 
 Foville on Syphilis and General Paresis, 
 
 286 
 
 GAIRDNER on Spinal Disease, simu- 
 lating General Paresis, 366 
 Gait in General Paresis, 266 
 Ganglion, 64 
 
 Gangrene of the Lung, 239 
 Gaskell on Homicidal Insanity, 183 
 General Paresis, 250 
 Genesis of Mind, 59 
 Goitre in Idiocy, 333 
 Gregory on Causes, 216 
 Griesinger's Classification, 441 
 
 Division of Cases, 187 
 
 on Idiocy, 336 
 
 on Pathology of Insanity, 227 
 
 on Recurrent Attacks, 167 
 
 on Tubercle in Insanity, 237 
 
 Guislain on Moral Treatment, 398 
 
 on Varieties of Mania, 105 
 
 on Classification, 443 
 
 HABITS, Change of, 156 
 Hsematoma Auris, 444 
 Hair, 124 
 
 Hall, Dr. Marshall, SO 
 Hallucination, 119 
 Hamlet, A Melancholic, 110 
 Handwriting, 366 
 
 Hearing, Illusion connected with, 119 
 Heart in Ordinary Insanity, 240, 246 
 
 • in General Paresis, 240 
 
 Heredity as a cause, 222 
 History of Philosophy, 2 
 
 G G 
 
450 
 
 INDEX. 
 
 Iliatology of Ordinary Insanity, 235 
 
 of General Paresis, 299 
 
 Hood, Sir Charles, Statistics, 219 
 
 on Ueart Disease, 240 
 
 Homicidal Mania, 192 
 Hospitals for the Insane, 386 
 Howden, Dr., on Kidney Disease, 241 
 Huxley, Mr., on Automatism, 20 
 Hygienic Treatment, 402 
 Hyperplasia, Eokitansky on, 802 
 
 Dr. Wigloswortb on, 303 
 
 Hyoscyamine, 143 
 Hypochondriacal Insanity, 193 
 Hystero-Epilepsy. Le Grande dn SauUe 
 
 on, 351 
 Hysterical Insanity, 127 
 
 Dr. Du SauUe on, 214 
 
 Mania, 191 
 
 IDEAS, 5 
 Kinds of, 6 
 
 Anomalies of, 152 
 
 Idiocy, Acquired, 337 
 
 Causes of, 330 
 
 Congenital, 329 
 
 and Synostosis, 338 
 
 Micro-Cephalic, 33 
 
 Classification of, 328 
 
 Dr. Shuttleworth on, 329 
 
 Dr. Duncan on, 335 
 
 Illusions various, 118 
 
 and Delusions, 118 
 
 Sexual, 114 
 
 Imagination as a Mental Product, 28 
 Imbecility, 187 
 Incoherence, 152 
 Indecent Exposure, 259 
 Insanity, Ordinary, 1st stage, 107 
 
 2nd stage, 130 
 
 3rd stage, 146 
 
 in Puerperal Women, 127—130 
 
 Instincts, Moral, in Ist stage, 113 
 Intellect, Change in, 137 
 
 in General Paresis, 261 
 
 Intoxication and General Paresis, 312 
 Intemperance, 285, 353 
 
 as a Cause, 285 
 
 International Classification, 44-1 
 Iron in Ordinary Insanity, 141, 376 
 Isolation, Treatment by, 384 
 
 JACKSON, Dr. Hughlings, on Morpho- 
 logy, 73 
 
 on Epilepsy, .^45 
 
 Johuson, Dr. George, Eflfocta of Impure 
 
 Blood, ^14 
 Joy as a Cause of Insanity, 291 
 Judgment as a Mental Process, 45 
 
 as a Mental Product, 30 
 
 Kant's division of, 48 
 
 h priori and h posteriori, 49 
 
 Jury, a patient may demand, 421 
 
 KANT'S View of Sensualism, 47 
 on Judgments, 48 
 
 Doctrine of Space, 51 
 
 Kidney Disease in Ordinary Insanity, 
 
 241 
 
 in General Paresis; 299 
 
 Changes in, 244 
 
 Dr. Johnson on, 244 
 
 Kleptomania, 261 
 
 Knowledge of Eight and Wrong, as a 
 
 legal test, 415 
 Krafi't-Ebing on Disease Simulating 
 
 General Paresis, 277 
 
 LACTATION, 130 
 Lanceraux on Syphilitic Disease, 287 
 
 Legal Relations of Insanity, 407 
 
 Classification of Lunatics, 408 
 
 Precautions against Improper In- 
 carceration, 429 
 
 Le Grande du Saullo on Hysterie, 214 
 
 Lewis, Mr. Bevan, Examination of Brain, 
 303 
 
 Lewes on Comte, 2 
 
 History of Philosophy, 3 
 
 Criticisms of Kant, 50 
 
 on Whewell, 50 
 
 Life, Definition of, by Lewes, 9 
 
 Littlejohn on Treatment of Epilepsy; 
 354 
 
 Lunacy, Commissioners of, 429 
 
 Lunatics, Dangerous, 434 
 
 Lunacy Laws, 331 
 
 Lungs in Ordinary Insanity, 237 
 
 in General Paresis, 354 
 
 Lycanthropy, 193 
 
 Lypemania, 193 
 
INDEX. 
 
 451 
 
 MACINTOSH, Dr., ou Morbid In- 
 stincts, 116 
 
 Mania Acute, 130 
 
 ■ ■ — ■ recovery, 134 
 
 • death, 135 
 
 'h potu,' 194 
 
 Phthisical, 196 
 
 Syphilitic, 196 
 
 Mann, Dr., on Early Treatment, 385 
 
 Manner, Change of, 155 
 
 Marc6, 136 
 
 Masturbation, 223 
 
 Maudsley on Early Treatment, 385 
 
 Definition of Mind, 8 
 
 Classification of Insanity, 442 
 
 Major, Dr., on Histology of Brain in 
 General Paresis, 301 
 
 Meason, Dr., on Urine in General Pare- 
 sis, 275 
 
 Mechanism of Mind, 59 
 
 Medical Certificates, 431 
 
 Duties on Imposition of Restraint, 
 
 419 
 
 in Certifying, 422 
 
 ■ on Receiving a Patient, 425 
 
 in Regard to Legal, 409 
 
 ■ Opinion, why Sought, 412 
 
 • on Responsibility, 414 
 
 on Competency, 412 
 
 Melancholia, Acute, 108 et seq. 
 
 Agitans, 193 
 
 Attonita or cum Stupore, case, 210, 
 
 161, 194, 235 
 
 Erotica, 122 
 
 Errabunda, 122, 193 
 
 Metamorphosis, 213, 193 
 
 Religiosa, 194 
 
 Membranes, 226, 296 
 
 Memory as Mental Product, 16 
 
 Absence of, 158 
 
 in Old Age, 340 
 
 in Insanity, 157 
 
 Meningitis, 127 
 
 Menstruation, 134 
 
 Mental Pliilosophy, 1 
 
 Processes, 32, 57 
 
 Products, 4 et seq. 
 
 Mickle, Dr Julius, on General Paresis, 
 251, 254 
 
 Mickle, Dr Julius, on Syphilitic Brain 
 Disease, 373 
 
 on the Reflexes in General 
 
 Paresis, 273 
 
 ■ on Intemperance in General 
 
 Paresis, 285 
 
 Microcephalic Idiocy, 332 
 
 Microscopic appearances in Ordinary In- 
 sanity, 234 
 
 in General Paresis, 300 
 
 Mind, Definition by Lewes, 8 
 
 by Dr. Maudsley, 8 
 
 Development of, 8 
 
 Mnemonic of Symptoms; 123 
 Misconception concerning Dangerous 
 
 Lunatics, 425 
 Monomania, 194 
 Moral Causes of Insanity, 217 
 
 of General Paresis, 289 
 
 Treatment, 377 
 
 Insanity, Dr. Blandford on, 185 
 
 Dr. Pritchard on, 165 
 
 Morbid Anatomy of Ordinary Insanity, 
 
 242 
 
 ■ of General Paresis, 293 
 
 Morel, Dr., Classification, 443 
 
 on Causes of Idiocy, 330 
 
 on Idiocy and Cretinism, 338 
 
 Epilepsie Larvee, 175 
 
 on Heredity, 222 
 
 Moreau de Tours on Exophthalmic, 265 
 
 Mortality, 127 
 
 Motor Faculty, 109 
 
 Motility in 1st stage, Ordinary Insanity, 
 
 120 
 
 in 2nd stage. Ordinary Insanity, 
 
 133 
 
 in 3rd stage, Ordinai-y Insanity, 159 
 
 Excess of, 120 
 
 Diminished, 121 
 
 Abnormal, 161 
 
 Torpid, 160 
 
 -VTERVE 
 
 ERVE Cells, Normal, 64 
 
 in Gonoral Paralysis, 301 
 - in Ordinary Insanity, 234 
 -■ Dr. Major on, 301 
 
 gg2 
 
452 
 
 INDEX. 
 
 Norvea, Development of, 60 
 
 Current, 07 
 
 Neumann, Heihing mit Defect 180 
 Neural Force, 01 
 
 Principles of, 03 
 
 Current, 07 
 
 Functions, 59 
 
 Neuroglia, 234 
 
 in General Paresis, 301 
 
 Niepce on Brain in Idiocy, 334 
 Nicholson on Criminals, 329 
 Noble, Dr., Classification, 441 
 Non-compos Mentis, 408 
 Noyes Opbthalmic Examination, 204 
 Number of the Insane, 408 
 Nymphomania, 194 
 
 OCULAR Delusions, 150 
 Occupation in Treatment, 388 
 
 Liable to Insanity, 218 
 
 Odour of the Insane, 142 
 
 Oinomania, 155, 194 
 
 Onanism, 223 
 
 Opium, its use and dose, 376 
 
 Optic Disc in General Paresis, 263 
 
 Ordinary Insanity, 1st stage, 109 
 
 • 2nd stage, 130 
 
 3rd stage, 146 
 
 Order for reception of a Patient, 424 
 Organic Brain Diseases, 370 
 
 PANPHOBIA 198 
 Paralysis, Alcoholic, Dr. Bnzzard, 
 
 Dr. Broadbent, and Dr. Broadhurst 
 
 on, 862 
 Parchappe, Dr., on Pathology, 227 
 
 on General Paresis, 251 
 
 Paresis, General, 250 
 
 Origin of Term, 250 
 
 French writers on, 251 
 
 Pathology of Ordinary Insanity, 243 
 
 of General Paresis, 308 
 
 Pauperism and Liability to Insanity, 
 
 219 
 Peacock on Weight of Brain, 229 
 Persistence of Sensations, 41 
 Persecution, Delusion of, 112 
 
 Philosophy, 1 
 
 Schools of, 1 
 
 History of, 2 
 
 Phthisis as a cause, 196 
 Phthisical Insanity, 127, 196 
 Phobia of various kinds, 198 
 Physical Causes, 221 
 Pinel's Classification, 441 
 Pneumonia in Insanity, 239 
 Pownall, Dr., Case of, 172 
 Postmortem Appearances, 225 
 
 Table of Ordinary Insanity, 226 
 
 of General Paresis, 293 
 
 Precautions, Legal against Incarcera- 
 tion, 423 
 
 against Improper Certificates, 
 
 432 
 Predisposing Causes, 217, 281 
 
 Pregnancy, 130, 195 
 
 Pritchard, Dr., on Moral Insanity, 185 
 
 Private Asylums, 380, 404 
 
 ■ how Licensed, 430 
 
 Private Patients, 430 
 
 Processes, Mental, 32 
 
 Products, Mental, 4 et seq. 
 
 Prognosis in Ordinary Insanity, 143 
 
 Psychology, 1 — 4 
 
 Puerperal Condition, 129 
 
 Insanity, 127 
 
 Varieties, 195 
 
 Dr. Tuke on, 196 
 
 Pulse in General Paresis, Dr. Mickle on, 
 273 
 
 Pupils in General Paresis, 2fi4 
 
 Pyromania, 196 
 
 RACE in Relation to General Paresis, 
 288 
 Reasons for Certificating a Person, 425 
 Reason, Development of, 39 
 Reasoning Insanity (FoUo Raisson- 
 
 ante), 193 
 Recurrent Insanity, 165 
 
 Proportion of Cases, 165 
 
 Cases of, 167 
 
 and Epilepsy, 175, 177 
 
 and Crime, 181 
 
INDEX. 
 
 453 
 
 Recovery in 1st stage of Ordinary In- 
 sani^y, 124 
 
 2nd ditto, 134 
 
 in General Paresis, 269 
 
 Reflex Action, Simple, 33 
 
 Complex, 37 
 
 ■ in General Paresis, 267, 273 
 
 Refusal of Food, Treatment of, 404 
 
 Religious Melancholy, 113 
 
 Remissions in General Paresis, 267 
 
 Report on Admission of Patient, 434 
 
 Responsibility, 65 
 
 Martineau, and Dr. Carpenter on, 65 
 
 Sir J. Stephen on, 416 
 
 Respiratory Organs in Ordinary In- 
 sanity, 237 
 
 Restraint and Nou-Restraint, 397 
 
 American Views on, 400 
 
 Reynolds, Dr. Russell, on Epilepsy, 349 
 
 Ribs, Fractures of, 259 
 
 Robertson, Dr. Lockhart, case of Recur- 
 rent Insanity, 170 
 
 Rokitansky on Brain, 302 
 
 ■ on Hyperplasia, 302 
 
 Ross on Cerebro-Spinal Disease, 364 
 
 Rousselin, Dr., on General Paresis, 253 
 
 SAFEGUARDS against Illegal Con- 
 finement, 436 
 Salomon on general paresis, 304 
 
 on Cerebral Vessels, 304 
 
 Sankey, Dr. Herbert, Histology of 
 
 Brain, 300 
 
 Preparations of Plate, 1 
 
 Satyriarisis, 196 
 
 Savage, Dr., on Recovery from General 
 
 Paresis, 270 
 Schools of Philosophy, 1 
 Seclusion, 392 
 Second Attacks, 105 
 Self-love, Abnormal, 116 
 Senility, 339 
 Sensation, as Process, 46 
 
 as Product, 11, 33 
 
 Sensations, Vivid and Faint, 13 
 
 Nature of, 14 
 
 Persistence of, 14 
 
 Positivist's view, 14 
 
 Sensations, Metaphysical view, 15 
 Sensualists, 47 
 
 Sex, liability to General Paresis, 281 
 Sexual Propensity and General Paresis, 
 
 284 
 Shaftesbury, Lord, 432 
 Shock Mental, as Cause in General Pa- 
 resis, 290 
 Shower-baths, 376 
 Shuttleworth, Dr., on Idiocy, 337 
 
 Sir Jas., on Criminals, 329 
 
 Single Patients, 430 
 
 Skae, on Weight of Brain, 298 
 
 on Specific Gravity, 231 
 
 on Relation of Weight of Brain, 229 
 
 ■ on Classificatioui 442 
 
 Skin, 142 
 
 Smell, illusions of sense of, 120 
 
 Space, Kant on, 52 
 
 ■ Spencer on, 52 
 
 Cousin on, 54 
 
 Speech, discursive, 152 
 
 Incoherent, 152 
 
 in General Paresis, 264 
 
 Specific Gravity, 231 
 
 Dr. BuckniU on, 231, 298 
 
 Dr. Skae on, 231, 298 
 
 — ■ in General Paresis, 298 
 
 Spinal Cord, Dr. Bramwell on, 68 
 
 Dr. Gowers on, 71 
 
 Anatomy of, 68 
 
 Motor Tracts, 69 
 
 Disease of, 365 
 
 Spontaniety in General Paresis, 261 
 
 Stages in Ordinary Insanity, 108 
 
 Comte's in Mental Science, 3 
 
 Statics of mind, 32 
 
 Statistics, Sir Chas. Hood on, 240 
 
 Stupor, 19G 
 
 Stephen, Sir Jas. F., on Medical Duties 
 in Legal Enquiries, 414 
 
 Suicidal propensity, 116 
 
 Statistics of, 116 
 
 Mania, 194 
 
 Treatment of, 380 
 
 Summary of Mental Process, 57 
 
 Sunstroke as Physical Cause, 287 
 
 Symptoms, classification of, 109 
 
 of General Paresis, 255 
 
 Bodily, in Ordinary Insanity, 134 
 
454 
 
 INDEX. 
 
 Synostosis, Tlinrnam, Dr., on, 838 
 
 Welker, Dr., on, 338 
 
 Virchow on, 333 
 
 Errors of, 332 
 
 Syphilitic affections, 197 
 
 • Mania, 196 
 
 Quain's Dictionary on, 196 
 
 Mania, Dr. Hughlings Jackson on, 
 
 196 
 Disease of Brain, and General 
 
 Paresis, 373 
 Dr. Mickle on, 373 
 
 TA.BLES of Morbid Appearances, Or- 
 dinary Insanity, 224. 
 
 General Paresis, 293 
 
 Taste, illusions of the sense of, 121 
 Tebaldi, Dr., on Optic Disc, 264 
 Temper, change of, 155 
 Temperament, most liable, 220 
 
 in General Paresis, 284 
 
 Terms, not much used, list of, 198 
 
 Therapeutics, 375 
 
 Thompson, Dr. J. Bruce, on Crime, 329 
 
 Thomeuf on Alcoholism, 360 
 
 Times, Cases of Suicide reported in the, 
 
 182 
 Tone, 99 
 
 Tonics, in treatment, 376 
 Torpor, 160 
 Treatment, by Best, 397 
 
 Moral, 389 
 
 in General Paresis, 279 
 
 in Acute Stage, Ordinary Insanity, 
 
 140 
 Thurnam, Dr., on Synostosis, 338 
 Trousseau on Automatism, 20 
 Tubercle in relation to Insanity, 237 
 Tuke, Dr. Hack, Classification, 442 
 Dr. Batty, Classification, 442 
 
 ttRINE in General Paresis, 275 
 
 VARIOUS Forms of Insanity, 190 
 Variation in General Paresis, 276 
 Vaso-Motor Nerves, 305 
 Virchow on Synostosis, 333 
 Vessela of Cortex in General Paresis, 303 
 „ „ Chronic Insanity, 
 
 245 
 Vision, Illnsions of, 119 
 Visits of Friends, 401 
 
 of Commissioners, 437 
 
 of Visitors, duties of, 437 
 
 WANDERING Lunatics, 425 
 Weakness, Mental, 327 
 
 Causes of, 327 
 
 Varieties of, 328 
 
 Wedl on Disease of the Vessels, 304 
 Weight, Relative, of Brain in General 
 
 Paresis, 298 
 Welcker on Synostosis, 333 
 Wet Packing, 142, 377 
 Westphal, Dr., Cases of, 366 
 Wiglesworth on Mental Dynamics, 97 
 on Hyperplasia in General Paresia, 
 
 303 
 on Pathology of General Paresis, 
 
 302 
 
 on Melancholia Attonita, 235 
 
 Microscopical Preparation of Cere- 
 
 br^l Cortex, in General Paresis, 
 
 Plate, 2 
 Will as a Product, 22 
 
 as a Process, 45 
 
 Carpenter, Dr., on, 25 
 
 Cardinal Manning on, 25 
 
 Martineau on, 25 
 
 in Relation to Responsibility, 418 
 
 Spencer on, 24 
 
 Williams, Dr. Duckworth, on Bromides, 
 354 
 
 on Early Treatment, 3S5 
 
 Willis, Early Recognition of General 
 
 Paresis, 251 
 Wood, Dr. W., probability of life in 
 
 Lunatics, 136 
 
RC601 
 Sankey 
 
 Sa5