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HANDBOOK 
 
 INSANITY 
 
 Practitioners and Students 
 
 DR. THEODORE KIRCHHOFF 
 
 PHYSICIAN TO THE SCHLESWIG INSANE ASYLUM AND PRIVATDOCENT AT THE 
 UNIVERSITY OF KIEL 
 
 ILLUSTRATED WITH ELEVEN PLATES 
 
 NEW YORK 
 
 WILLIAM WOOD & COMPANY 
 
 1893 
 
Copyrighted, 1892 
 WILLIAM WOOD & COMPANY 
 
CONTENTS. 
 
 GENERAL PART. 
 
 THE ANATOMICAL BASIS AND THE LOCATION OF MENTAL 
 
 DISTURBANCES. 
 
 I 
 
 Introduction, .......... 
 
 The Brain as the Site of Normal Mental Processes, . 
 
 Conclusions from the Developmental Histoiy and the Structure 
 of the Brain, 
 
 The Site of Mental Disturbances in the Brain Based on Patho- 
 logical Anatomy and Explained by Psychological Con- 
 siderations, . . ' 
 
 B. 
 
 II. 
 
 CLASSIFICATION, IMPORTANCE, AND MODE OF ACTION OF THE 
 CAUSES OF INSANITY. 
 
 Causes Acting upon the Community, . . . . .21 
 
 Civilization, ......... 21 
 
 Race and Nationality ; Geographical Position, Soil, Food ; 
 
 Seasons and Climate, 23 
 
 Sex and Social Position ; Age, ... . . . .24 
 
 Heredity, . .29 
 
 Crime and Genius ; Education, ...... 32 
 
 Occupation, 33 
 
 Causes which Act only upon the Individual, . . .33 
 Bodily Causes. — The Brain and its Membranes, . .33 
 Coincident Diseases of the Cord, Nerves, and Sympa- 
 thetic, 35 
 
 Anaemia and Exhausting Diseases of Internal Organs, . 36 
 Diseases of the Sexual Organs and Disturbances of their 
 Function, ......... 37 
 
 Febrile Disease and Poisoning, ...... 39 
 
 Psychical Causes, ........ 42 
 
IV 
 
 CONTENTS. 
 
 III. 
 
 THE SIGNS OF MENTAL DISORDERS. 
 
 PAGE 
 
 Introduction, 45 
 
 A. The Disturbances of Consciousness, 46 
 
 1. Disturbances of the Perceptive Process, . . .46 
 
 2. The Disturbances of Consciousness during Sleep and 
 
 Dreams ; Associated States of Impaired Conscious- 
 ness and Hypnotic Conditions, 62 
 
 3. Disorders of Self- Consciousness, . . . . .66 
 
 B. Disturbances in the Association and Course of Ideas, . . 68 
 
 1. Apperception and Association, . . . . .68 
 
 2. Accelerated and Retarded Course of Ideas, . . .70 
 
 3. Delusions, 72 
 
 4. Disorders of Memory and Fantasy, ... . . ' 78 
 
 C. Disorders of Emotional Life 84 
 
 1. Affects, Sensual and Higher Feelings, . . . .84 
 
 2. Terror and Allied Feelings, 89 
 
 D. Disorders of Volition and Action, 91 
 
 1. Impulsive Movements, 91 
 
 2. Expressive Movements, . . . . . ' . . 100 
 
 E. Concomitant Physical Symptoms, ...... 107 
 
 IV. 
 
 THE COURSE OF MENTAL DISORDERS. 
 
 A. Course, Duration, and Termination, 
 
 B. General Prognosis, 
 
 114 
 
 122 
 
 V. 
 
 THE DIAGNOSIS OF MENTAL DISORDERS AND THEIR BORDER LINES. 
 
 A. General Standpoint, 
 
 B. Psychiatric Examination, 
 
 1. Diagnosis of the Disease, 
 
 2. Diagnosis of Recovery, . 
 
 C. The Border Line of Insanity, 
 
 D. Post-Mortem Findings, . 
 
 129 
 131 
 131 
 145 
 
 147 
 150 
 
 VI. 
 
 THE TREATMENT OF INSANITY. 
 
 A. Psychical Treatment, 151 
 
 B. Prevention of Insanity, 154 
 
CONTENTS. 
 
 C. Bodily Treatment, 
 
 1. General Standpoint and Modes of Treatment, 
 
 2. Hypnotics, 
 
 3. Treatment of Important Symptoms, 
 
 D. Asylums and their Advantages, ... 
 
 E. Treatment of Convalescents, . . . 
 
 PAGE 
 
 , 155 
 
 . 155 
 
 . 158 
 
 . 161 
 
 . 166 
 
 . 166 
 
 VII 
 
 HISTORY OF PSYCHIATRY, .... 168 
 
 A. Antiquity, . . 168 
 
 B. Middle Ages and Modern Times, 170 
 
 C. Gradual Reform of Psychiatry in the Past Hundred Years, . 174 
 
 1. Erection of Insane Asylums, ..... 174 
 
 2. Opposition to Mechanical Restraint, .... 175 
 
 D. Present Treatment of the Insane, 178 
 
 SPECIAL PART. 
 
 CLASSIFICATION OF INSANITY, 
 
 . 183 
 
 II. 
 
 SIMPLE MENTAL DISORDERS. 
 
 A. Melancholia, . 
 
 
 
 
 
 
 . 186 
 
 B. Mania, .... 
 
 
 
 
 
 
 . 201 
 
 C. Periodical Forms, . 
 
 
 
 
 
 
 . 216 
 
 Periodical Melancholia, 
 
 
 
 
 
 
 . 218 
 
 Periodical Mania, 
 
 
 
 
 
 
 . 220 
 
 Circular Insanity, ~ . 
 
 
 
 
 
 
 . 223 
 
 D. Paranoia, 
 
 
 
 
 
 
 . 230 
 
 1. Walmsinn, 
 
 
 
 
 
 
 . 231 
 
 2. Verruecktheit, 
 
 
 
 
 
 
 . 236 
 
 3. Confusion, 
 
 
 
 
 
 
 . 254 
 
 III. 
 
 MENTAL DISORDERS ASSOCIATED WITH PERMANENT ANATOMICAL 
 CHANGES IN THE BRAIN OR WITH GENERAL DISEASES. 
 
 Introduction, 
 
 A. Dementia, 
 
 B. Senile Dementia, 
 
 258 
 259 
 262 
 
VI 
 
 CONTENTS. 
 
 C. Paralytic Dementia, .... 
 
 D. Other Forms of Dementia with Paralysis, 
 
 Cerebral Syphilis, .... 
 Focal Diseases of the Brain, 
 
 E. Mental Disease in Epilepsy, . 
 
 F. Insanity and Hysteria, .... 
 
 G. Mental Disorders with Neurasthenia, . 
 
 Chronic Forms, ..... 
 
 Acute Forms, 
 
 H. Mental Disorders Due to Poisons, . 
 
 J. Feeble-mindedness (Imbecility and Idiocy), 
 
 PAGE 
 
 266 
 296 
 296 
 300 
 301 
 311 
 320 
 320 
 330 
 332 
 346 
 
GENERAL PART. 
 
HANDBOOK OF INSANITY. 
 
 THE ANATOMICAL BASIS AND THE LOCATION OF MENTAL 
 DISTURBANCES. 
 
 Introduction. 
 
 Psychiatry is the science of mental disturbances and 
 their treatment. It is an empirical science, whose contents 
 are furnished by external and internal experience, i.e., by- 
 objective observations on the patient and by the subjective 
 observations which the patient makes upon himself. The 
 internal experience escapes the physician much more read- 
 ily than in other medical sciences. The mental processes 
 of other individuals are only in part accessible to obser- 
 vation, in so far as they can be communicated by speech, 
 gestures, and actions. The internal bodily activity which 
 takes place, for example, between a stimulus and a sensa- 
 tion, and is called psychophysical, occurs in an inter- 
 vening link, viz., the brain or organ of psychophysical 
 activity. Here is the boundary tract in which the links 
 in the chain of stimulus and sensation come in contact. 
 In the investigation of this tract, psychiatry requires the 
 aid of psychology. 
 
 In so far as the mental processes depend, outside of this 
 boundarj^ tract, upon the basis of the physical functions, 
 especially upon the brain, a field of investigation which 
 is positively comprehensible is open to observation, and 
 we are, in a measure, justified in looking for the symp- 
 toms of a mental disturbance in changes of the physical 
 basis. In order to understand the symptoms we must 
 
 3 
 
4 HANDBOOK OF INSANITY. 
 
 first endeavor to find the location and character of the 
 anatomical changes. But anatomy alone does not suffice 
 for a thorough understanding. We must not desist en- 
 tirely from the attempt to investigate the intermediate 
 processes which lead from external to internal experience. 
 Hence the relation of bodily and mental disturbances must 
 be made clear by the intimate association of cerebral 
 pathology and psychopathology. 
 
 The Brain as the Site of Normal Mental Processes. 
 
 Anatomically the brain is the rallying-point of almost all 
 the spinal systems of fibres ; in addition the most varied as- 
 sociation-systems are present in the cerebrum itself. Com- 
 parative anatomy teaches that relatively to the size of the 
 body the size of the cerebral lobes increases, in general, 
 with the intelligence of the animal. The same relation is 
 shown in the increasing development of the surface of the 
 brain by fissures and convolutions, and for this reason the 
 cortical gray matter is universally regarded as an espe- 
 cially important part of the cerebrum. As a rule, individ- 
 uals of great mental activity possess very large brains, 
 with a marked development of the surface. It is probable 
 that great importance also attaches to the thickness of the 
 cortex. 
 
 Developmental history shows that the development of the 
 surface and the mass of individual parts does not always 
 coincide in point of time with the appearance of higher 
 mental activities, but that it precedes the latter in a cer- 
 tain measure. The association-fibres in the cerebral cortex 
 develop within the first year of life, and it is not until the 
 age of seven to eight years that they attain the arrange- 
 ment which is permanent in adults. The development of 
 these fibres occurs latest in the frontal lobes. 
 
 A further argument in favor of the view that the mental 
 processes take place in the brain is furnished by self- 
 observation during mental processes, which are accom- 
 panied by very feeble sensations in the brain. 
 
DEVELOPMENT OF BRAIN. 5 
 
 The assumption that the brain is the site of mental 
 activity is rendered very probable by the above statements, 
 and this is confirmed by our experience concerning morbid 
 changes. Before proceeding to the consideration of path- 
 ological conditions, we must first recall some data con- 
 cerning the developmental history and structure of the 
 brain. 
 
 Conclusions from the Developmental History and the 
 Structure of the Brain. 
 
 The mode of development of certain brain fissures is 
 important. The Sylvian fissure is associated intimately 
 with the development of the basal ganglia, in whose vi- 
 cinity the cerebral wall grows more slowly and, therefore, 
 remains in a depression; this part is known as the Island 
 of Reil. The three so-called total fissures, viz., the hippo- 
 campal, calcarine, and occipito-parietal, are developed in 
 an entirely different manner. They appear in the third and 
 fourth months of fcetal life. The hollow medullary tube 
 of the embryo then possesses, at its anterior extremity, 
 several vesicular dilatations; especially important is the 
 most anterior or fore-brain vesicle, from which the two 
 cerebral hemispheres develop. The mass of the thin wall 
 of the fore-brain vesicle now grows more rapidly than the 
 inclosing skull, which has become cartilaginous. Hence 
 folds develop toward the side of least resistance, i.e., into 
 the cerebral ventricles; they extend through the entire 
 thickness of the cerebral wall, and are, therefore, called 
 total. As a permanent expression of this process the adult 
 brain contains in the inferior horn of the lateral ventricle, 
 and corresponding to the hippocampal fissure, the Am- 
 nion's horn or pes hippocampi major. In the posterior 
 horn the pes hippocampi minor is found beneath the cal- 
 carine fissure. A prominence which corresponds to the 
 parieto-occipital fissure, and is very distinct in the fcetal 
 brain, is obliterated in the adult. 
 
 All the other principal fissures do not correspond to pro- 
 
6 
 
 HANDBOOK OF INSANITY. 
 
 jections into the lateral ventricles, and are due to local ele- 
 vations of the adjacent cerebral cortex. The coarser vas- 
 cular arrangements are probably important, because the 
 fissures contain the larger veins, and it may be assumed 
 that the resistance of the latter gives rise to these cortical 
 fissures. 
 
 But even the total fissures do not develop entirely on 
 account of differences in the growth of the cortex. The 
 parieto-occipital fissure is supplied solely by the arteria pro- 
 funda cerebri, the hippocampal fissure by the arteria cor- 
 poris callosi, and the course of the middle cerebral in the 
 Sylvian fissure also indicates a connection between the 
 
 Fig. 1. 
 
 vascular development and the growth of the surface. 
 Furthermore, the most important so-called cortical centres 
 are situated around the fissures which appear earliest and 
 are best supplied with blood. 
 
 In view of these data the significance of the fissures is 
 easily understood. They may also be regarded, in part, 
 as nutritive grooves, inasmuch as the vessels often enter 
 the pre-formed fissures. The large size and extent of the 
 pia mater probably depend, however, on the nutritive needs 
 of the brain, which contains approximately one-fifth of the 
 entire mass of blood in the body. Although the vessels do 
 not cause the development of the fissures, the distribution 
 of the former by different arrangements of the fissures must 
 
DEVELOPMENT OF BRAIN. 
 
 exercise great influence on the activity of the correspond- 
 ing parts of the brain, and it is probable that for this rea- 
 son the activity of the same cortical regions will differ in 
 different individuals. Hence arises the necessity of accu- 
 rate topographical investigation of the cerebral cortex as 
 regards the local differences in the healthy and diseased 
 human brain. 
 
 In the third foetal month the layer of gray matter is 
 almost one-fourth the thickness of the hemispheres, but 
 in the fourth month it diminishes to one-seventh. Va- 
 rious layers are found even before this period ; a deeper 
 layer of cellular elements often exhibits a wave-shape, 
 
 Fig. 2. 
 
 while the outer boundary still runs in a straight line. In 
 the middle of the layer of cellular elements, and also in a 
 deeper layer, light bands appear, at the latest during the 
 fifth month. But some of the cellular layers unite and 
 disappear during the later fcetal months, so that their per- 
 manent arrangement can only be studied in the new-born. 
 In the fifth month a distinct nucleolus sometimes appears 
 in the round nuclei of certain cell-layers; a few nuclei 
 have short processes so that they appear angular. 
 
 Ganglion cells are only recognizable in the cortex of the 
 fully developed foetus ; indeed, distinct boundaries of pyra- 
 midal cells are found only in infants of one to two months, 
 and even here they are mingled with imperfectly developed 
 cells. 
 
8 HANDBOOK OF INSANITY. 
 
 The simplest classification recognizes an external, mid- 
 dle, and internal layer. At the beginning the cells are 
 arranged like a string of pearls from without, inward ; or 
 we may speak of a palisade-like or columnar arrangement 
 of the rows of cells. This is most distinct during the first 
 foetal months; later the cells are arranged more closely 
 together, and the longitudinal streaks are somewhat oblit- 
 erated by the transverse layers. Even after the formation 
 of the fissures, rows of granules may be followed close to 
 the border of the cortex ; if nerve-fibres have formed, they 
 can usually be followed only to the middle layer, where 
 they radiate like a brush, and thus remain parallel to the 
 surface only at the trough of the fissures, while at the 
 cap they break through the layers to the outer boun- 
 dary. This difference in the course of the medullary fibres 
 and cell-layers in the trough of the fissures and the apex 
 of the convolutions is important in regard to the physio- 
 logical connection between association-fibres and ganglion 
 cells ; it indicates that, in this relation, greater importance 
 is to be attached to the apex of the convolutions. 
 
 It is also important to know that the fibres of the coma 
 radiata radiate chiefly in the apices of the convolutions, 
 the association-fibres in the troughs of the convolutions, 
 and that the growth of these different systems together has 
 given rise to the convolution of the cortex. 
 
 A few regions of the cortex can be distinguished by a 
 special arrangement of the layers and cells. As a general 
 thing, these regions also possess special functions. The 
 centromotor region alone contains the so-called giant-cells ; 
 the speech region alone contains a large accumulation of 
 spindle-cells ; the visual region alone contains the peculiar 
 lamination of the Vicq d'Azyr's stripes, and the assumed 
 olfactory and tactile region possesses the peculiar structure 
 of the hippocampal convolution and its appendages. The 
 remainder of the cortex exhibits no striking differences. 
 
 I will not enter into a description of the important 
 commissural systems. Apart from the association-fibres 
 already mentioned, I will merely refer to the corpus cal- 
 
SITE OF MENTAL DISTURBANCES. 9 
 
 losum, which connects the hemispheres. These two sys- 
 tems prove that definite regions of the brain are physio- 
 logically associated. 
 
 The Site of Mental Disturbances in the Brain Based on 
 Pathological Anatomy and Explained by Psycho- 
 logical Considerations. 
 
 It must be our first object to ascertain to what extent 
 focal diseases have aided in our knowledge of the location 
 of mental disturbances. In so far as the lesions have 
 interrupted conduction systems, they have not taught as 
 much as disease of the centres, and it has been found that 
 the interruption of certain systems of fibres leading 
 from the cerebrum to the cerebellum gives rise to distinct 
 slowness and difficulty of the mental functions. Among 
 the large ganglia the optic thalamus seems to possess more 
 intimate relations to the higher mental functions than 
 does the corpus striatum, inasmuch as the former alone 
 undergoes atrophy in congenital absence of the cerebral 
 hemispheres. The disturbance in the intellectual develop- 
 ment of individuals in whom the corpus callosum is absent 
 or only very small, indicates that the higher mental pro- 
 cesses are not dependent upon the frontal brain alone; 
 indeed, in these cases, the occipital lobes are mainly atro- 
 phied. If the brain is imperfectly developed as a whole, 
 as in some idiots, there can be no question of localization. 
 Nor is any further conclusion warranted from irregular 
 development in the cortical layers, unless it is circum- 
 scribed. For example, in a few idiots the frontal lobes 
 contained only very narrow pyramidal cells, which were 
 distributed irregularty, so that it was almost impossible 
 to distinguish the layers. Here the imperfect mental de- 
 velopment may be attributed to the imperfect development 
 of the frontal cortex. 
 
 Description of Figs. 3, 4, and 5, which are made according to 
 Ecker's brain-scheme, with the aid of the literature of the locali- 
 zation question. 
 
10 
 
 HANDBOOK OF INSANITY. 
 
 The dotted line gives a schematic posterior boundary of the 
 apperception organ in the frontal brain, and the anterior boundary 
 of the perception organ in the occipital and parietal lobes. This 
 line incloses the centro-motor region. These three tracts coincide 
 
 AH^cerebrimedu 
 
 approximately with the areas of distribution of the anterior, pos- 
 terior, and middle cerebral arteries. The fact that the centres for 
 
 ci»J£C^- 
 
 Fig. 4. 
 
 speech and writing (which are developed in one hemisphere alone) 
 are not contained in our centro-motor region, proves the merely 
 schematic value of the division ; nevertheless these two important 
 
CORTICAL CENTRES. 
 
 11 
 
 centres are in close proximity to this region. For purposes of 
 teaching we require a sharp separation of the centres, which in 
 reality often pass into another. The speech-region, in particular, 
 must be regarded as a composite cortical region. Only the corners 
 of the speech-region are formed by its centres, while the corti- 
 cal fields of the optic and auditory nerves, as well as of various 
 
 Fig. 5. 
 
 motor nerves, anastomose at the edges with the speech -centre. 
 Hence the interruption of the afferent connections of adjacent 
 sensory regions at these edges will give rise to speech -disturbances, 
 as well as the destruction of more central parts. 
 
 1. Centre for motor aphasia (Broca's region). Speech images. 
 
 2. Centre for sensory aphasia (Wernicke's region.) Speech images. Auditory 
 centre. Word-deafness. 
 
 3. Hypoglossal field. 
 
 4. Facial field (inferior branches). 
 
 5. Motor trigeminus field (portio minor). 
 
 6. Centre for agraphia. Writing images. 
 
 7. Centre for coarse arm movements. 
 
 8. Centre for coarse leg movements. 
 
 9. Centre for coarse arm and leg movements. 
 
 10. Centre for complicated movements of hand, arm, and leg. 
 
 11. Supposed centre for levator palpebrae superioris. 
 
12 HANDBOOK OF INSANITY. 
 
 12. Centre for disturbances in all sensory tracts. 
 
 13. Centre for alexia. Writing images. Word-blindness. 
 
 14. Visual centre ; * indicates macula lutea. 
 
 15. Doubtful centre for smell and taste ; in this vicinity, perhaps, also a tactile 
 centre, including sexual feelings. 
 
 The reports of scattered cases in which, after complete 
 destruction of one cerebral hemisphere, mental disturb- 
 ances did not set in, have called attention to the possibility 
 of vicarious activity of the other half of the brain, pro- 
 vided that both halves possess originally the capacity for 
 exercising the same functions. The question of the co-or- 
 dinate value of the hemispheres is of the highest impor- 
 tance in the examination of the site of individual func- 
 tions. The relegation of speech-disturbances to the left 
 half appeared to prove their unequal value, at least in the 
 exercise of their functions, while it allows the possibility 
 of the development of this function in each hemisphere. 
 For a time the notion of the unequal value of the hemi- 
 spheres was supported by the observation that the left 
 frontal lobe develops more rapidly and abundantly than the 
 right. It was also shown that, in mental strains, the 
 left forehead exhibits, on the average, a somewhat higher 
 temperature than the right one. Not long ago the site of 
 aphasia was confined strictly to the left inferior frontal 
 convolution ; at the present time other cortical regions are 
 known to possess intimate relations to aphasia. These are 
 situated in the vicinity of the visual centre in the occipi- 
 tal lobe, and of the acoustic centre in the superior temporo- 
 sphenoidal convolution. It was also supposed that the 
 localization of aphasia in the left hemisphere was ren- 
 dered doubtful by the observation of cases of aphasia after 
 lesions of the right hemisphere, but this doubt was relieved 
 by the proof that the latter cases occurred in left-handed 
 individuals, who favor the right hemisphere by the move- 
 ments of the left hand. 
 
 The function of speech is complicated, and it is neces- 
 sary to distinguish several varieties of aphasia. The loss 
 of the power of hearing words causes word-deafness ; that 
 •of reading, word-blindness; the loss of articulate speech 
 
APHASIA. 13 
 
 causes motor aphasia, and of the power of writing agraphia. 
 The two latter groups contain the principal modes of ex- 
 pression of human speech. Gestures accompany speak- 
 ing, and both are usually lost at the same time, so that 
 pantomime need not he considered separately. The views 
 which generally obtain at the present time are shown in 
 Fig. 10, and comparison with Fig. 7 shows that the 
 
 Fig. 6 (After Ballet) . —a, The region of print images ; p, the region of lan- 
 guage images ; y, the region of the speech images ; S, the region of writing images. 
 
 speech-centres are situated between the centres for move- 
 ments and special sense-impressions. This arrangement 
 seems to show the close relation of speech to all the other 
 cortical functions. All four speech-centres are supplied 
 by the middle cerebral artery, which, however, also sup- 
 plies other centres. 
 
 The manifold character of the symptoms of aphasia is 
 partly explained in the manner just indicated, but some 
 cases cannot be explained by anatomical considerations 
 alone, and require psychological examination. Speech is 
 an internal and external process, composed of conceptions 
 and words. Aphasia shows that the word does not neces- 
 sarily accompany the conception. The word is a collective 
 notion, arising from the combination of several varieties 
 of images (auditory, visual, speech, and writing) . These 
 four principal components of the word are formulae which 
 every judgment utilizes, but, according to the tendencies 
 and abilities of the individual person, they appear either 
 in varying degrees or only in part in his deliberations. 
 The purely internal processes of seeing, hearing, speak- 
 
14 HANDBOOK OF INSANITY. 
 
 ing, and writing are entirely similar to those of external 
 speech, but, as they are phenomena "which occur within, 
 they must be distinguished as internal speech. Accord- 
 ing as the internal mental processes are associated exclu- 
 sively or chiefly with conceptions of language, print, 
 speech, or writing, human beings may be divided into 
 groups, viz.', into those who think in conceptions of lan- 
 guage, print, speech, or writing. 
 
 Most people think in language conceptions. Auditory 
 images of the words generally accompany our conceptions ; 
 we hear our thoughts. In only a few individuals are 
 thoughts clothed in written words ; these read the visual im- 
 ages of their conceptions. This is most marked in artists, 
 who remember things in general as memory-pictures. In 
 them speech-conceptions appear in the form of writing-im- 
 ages. Individuals in whom the memory of the movements 
 of speaking or writing accompany the conceptions, speak or 
 write their thoughts internally ; the corresponding feelings 
 of movement are closely associated with every thought. 
 Cases of association of thoughts with writing-movements 
 are probably rarer than those associated with speech-move- 
 ments. But we generally employ alternately this or that 
 form of internal speech, otherwise the loss of one form would 
 entail complete loss of speech. As language- images are first 
 acquired, the other forms are often of inferior importance. 
 It is important, from this standpoint, to know the physio- 
 logical brain formula of a patient, i.e., the physiological 
 variations in the course of his speech-conceptions which 
 are due to his personality. Such considerations throw 
 some light on the location of speech-conceptions and their 
 disturbances. The early development and better nutri- 
 tion of the left hemisphere, together with the better devel- 
 opment of the centres of movement of the right hand, 
 harmonize with the fact of the localization of the speech- 
 centre in the left hemisphere. The other forms of dis- 
 turbance, viz., word-blindness and word-deafness, are 
 situated more frequently on the right side, and thus the 
 entire cortex remains the site of language-conceptions. 
 
LANGUAGE. 15 
 
 Language possesses the most manifold relations with 
 the totality of mental life. Almost every mental disturb- 
 ance is composed of the most complicated phenomena, and 
 we find, accordingly, that the cerebral lesions of insanity 
 are diffused over the cortex ; the circumscribed lesions of 
 other clinical complexes only indicate individual places, 
 to which part-symptoms are due. Another inference may 
 be drawn from the psychological consideration of lan- 
 guage. There are hallucinations which belong to the 
 most important signs of insanity; they are to be regarded 
 as disturbances of conception, produced locally in the cor- 
 tex, and in which the individual can no longer distinguish 
 between the internal processes and their external causal 
 conditions. In this sense we may distinguish internal from 
 external vision, etc. If the ability to differentiate is want- 
 ing, an hallucination is present, dependent upon processes 
 in those parts of the brain which preserve memory-pictures 
 of the most varied kinds. Interpreted in this way every 
 mental disturbance is essentially a disturbance of memory, 
 the primary function of brain-matter. 
 
 Another observation which increases the importance of 
 diffuse anatomical changes in speech-disturbances is the 
 fact that diffuse diseases appear to be attended with much 
 more marked disturbances of mental activity than cases 
 in which there are focal lesions. A further peculiarity is 
 the increase in the intensity of mental disturbances with 
 the increase in the distance of the anatomical changes 
 from the inferior frontal convolution and their approxi- 
 mation to the occipital lobes. It is certain that the more 
 remote centres of sensory impressions in the occipito-tem- 
 poral lobes (perception organ) are more important in regard 
 to the higher mental activities than the adjacent motor- 
 centres. In psychoses we must regard aphasic conditions, 
 in so far as they develop in the cortex, as dependent, not 
 on circumscribed, but on diffuse lesions. 
 
 Two cortical regions possess comparatively simple rela- 
 tions to the higher psychical functions, viz., the centro-mo- 
 tor and visual centres. We must distinguish atactic and 
 
16 HANDBOOK OF INSANITY. 
 
 paralytic disturbances according as the anatomical changes 
 are situated in the parietal lobe, or in the central convolu- 
 tions and paracentral lobules. Although we cannot assume 
 that the higher processes of consciousness necessary to the 
 execution of movements develop in these centres, neverthe- 
 less they constitute indispensable transition places for such 
 processes. With every disturbance of function in any 
 part of the cortex, there is naturally restriction of the con- 
 tents of consciousness, inasmuch as the paths of mental 
 processes extend over the entire surface. 
 
 We will now consider the disturbances of visual percep- 
 tion. If the cuneus and the first occipital convolution 
 are injured, simple optical perception is destroyed ; in uni- 
 lateral lesions this disturbance is an hemianopsia, in bilat- 
 eral lesions, complete blindness. After injury of the re- 
 maining occipital convolutions retinal impressions are no 
 longer utilized psychically. This experience is confirmed 
 by the visual hallucinations observed in insanity, espec- 
 ially in general paresis, and which preceded diffuse changes 
 in these parts of the brain. We have to deal here with irri- 
 tative processes in those parts of the cortex in which other 
 lesions cause hemianopsia and blindness. This is con- 
 nected with a peculiar theory concerning different degrees 
 and forms of visual disturbances, and which has led to the 
 assumption of a color, space, and light sense. The patho- 
 logical changes are confined occasionally to certain ones 
 of the different layers of the cortex. The superficial lesions 
 of the cortex then cause loss of the color and space sense, 
 while loss of the light-sense arises from deeper destructions 
 of the cortex. This theory, however, has not been posi- 
 tively proven. There is no doubt, however, that the visual 
 disturbances of dementia paralytica are localized in the 
 region mentioned. This disease also presents other local- 
 izable phenomena, such as diminished intelligence and 
 will, which are found associated with diffuse disease of 
 the frontal lobes. They constitute the chief reason for 
 regarding the frontal lobes as the organ of apperception 
 for sensory impressions. 
 
PATHOLOGICAL ANATOMY. 17 
 
 If we adhere to the principle that, in the main, diffuse 
 lesions give rise to mental disturbances, it is evident that 
 the frequent absence of gross anatomical changes is ex- 
 plained by imperfect methods of examination, although I 
 believe that improved methods will disclose changes in 
 only a limited number of psychoses. Little importance 
 attaches to the view that certain psychoses are due to dis- 
 eases of the skull and dura mater. Changes in these parts 
 generally accompany pathological processes in the cortex. 
 It must be remembered that the blood supply of the dura 
 mater is not derived from the same vessels as that of the 
 hemispheres. Pathological conditions in the pia mater 
 are more constant concomitants of diseases of the cortex. 
 
 A more definite indication of the localization of mental 
 disturbances is afforded by the following findings: In 
 maniacal conditions red softening of the cortex is some- 
 times found in layers ; the middle layer of the three which 
 are visible to the naked eye being softened. On detaching 
 the pia mater, the outer layer usually follows. More 
 rarely the softening affects the outer layer itself, and then 
 the surface appears rough when the pia mater is removed. 
 In the rarest cases the softening occurs at the boundary 
 of the cortex and white matter ; an exactly similar condi- 
 tion is sometimes found in dementia paralytica. In the 
 latter event the softening is due to degeneration of the 
 medullary fibres. The softening in mania appears to be 
 connected with the mode of ramification of the vascular 
 trunks of the cortex in three superjacent series. In a 
 measure we are then justified in regarding the site of soft- 
 ening as the site of greatest irritation. The restriction of 
 anatomical changes to individual layers is also found in 
 so-called gliosis and miliary sclerosis of the cortex ; tumor- 
 like proliferations of the glia in the superficial layer of 
 the cortex, with formation of cavities and disappearance 
 of nervous elements, leads to symptoms similar to those of 
 dementia paralytica ; in other cases small reddish gray dots 
 are situated at the boundary of the gray and white matter. 
 However, none of these peculiar changes enable us to draw 
 2 
 
18 HANDBOOK OP INSANITY. 
 
 a conclusion with regard to the nature and mode of devel- 
 opment of the mental disturbance. 
 
 Certain chronic changes are also mere results of the 
 irritation, not its causes. 
 
 Somewhat more light is thrown upon the subject by re- 
 garding these changes as nutritive disturbances. One 
 difficulty in attempting localization from this standpoint 
 is owing to the fact that focal lesions very often produce 
 irritative conditions in their immediate vicinity, and 
 these lead to symptoms which are otherwise due only to 
 diffuse lesions. Such remote effects are particularly apt 
 to develop on a vasomotor basis. 
 
 The interpretation of certain psychoses as nutritive dis- 
 turbances is facilitated by the following considerations. 
 In the foetus and early infancy tissue-necroses are more 
 apt to occur in the cortex than in the basal ganglia, because 
 in the former the length of the arteries is much greater 
 and the vessels are much more delicate than the terminal 
 arteries; they are, therefore, compressed more readily. 
 These conditions are most unfavorable in the vessels of 
 the Sylvian fissure and the entire motor region. The 
 largest terminal branches of the pia mater pass to the 
 white matter beneath the cortex, so that the necroses occur 
 earlier and more extensively in the medullary layer than 
 in the cortex. This medullary layer contains the layer of 
 the association-tracts, and hence small lesions give rise to 
 great gaps in the psychical processes. These observa- 
 tions, however, cannot yet be utilized in the explanation 
 of different forms of disease. 
 
 A little attention must here be devoted to the considera- 
 tion of unilateral hallucinations, which develop in the 
 central sensory regions. Unilateral auditory hallucina- 
 tions are comparatively frequent, and in a few cases cor- 
 tical lesions of the opposite cortex were found on autopsy, 
 without any other changes, so that the connection was 
 undoubted. As a rule, however, the lesions cannot be 
 sharply localized when there are extensive affections of 
 the cortex or where several senses are implicated. 
 
 The question whether individual parts of mental opera- 
 
LOCALIZATION IN INSANITY. 19 
 
 tions are associated with definite parts of the cortex, has 
 lately been agitated in another way. Reference has been 
 made to mental focal symptoms ; attention has been called 
 to the fact that compound mental products, such as con- 
 cepts and the power of language, are acquired singly and 
 may also be lost singly. But the observations in this cat- 
 egory are confined to a few clinical cases in which chiefly 
 proper names and numbers were forgotten, or foreign 
 languages were forgotten while the mother tongue was 
 retained. Anatomical changes in layers were assumed, 
 but proofs are wanting. It must also be remembered that 
 we attribute no specific functions to the nervous elemen- 
 tary parts of the brain. Furthermore, all the higher mental 
 activities are so complicated that we cannot assume that 
 they are connected with simple elements. They are com- 
 posed of numerous concepts in different sensory tracts. 
 If a part is lost, it is not even necessary to remind our- 
 selves that other parts of the brain may act vicariously, 
 but there are so many concepts derived from other sensory 
 tracts which have entered consciousness in the contents of 
 the assumed complicated concept, that it is not permissible 
 to speak of the loss of an individual component of con- 
 sciousness. All internal processes constitute conscious- 
 ness ; there are no individual modes of consciousness. The 
 processes of consciousness are dependent on the entire 
 nervous system, not on the cerebral cortex alone. 
 
 Taken all in all, the attempts at localization of mental 
 disturbances possess only a general value. Even the fact 
 that memory is sometimes lost only in part, tells us noth- 
 ing concerning a definite site of the loss in question. 
 There is even some doubt as to whether, for example, the 
 memory of a certain language or of music alone may be 
 lost. Greater credibility attaches to the observation that 
 the memory of proper nouns is lost more easily than that 
 of common nouns and adjectives. But there are no cir- 
 cumscribed affections of the brain which teach us any- 
 thing concerning the loss of such local memories. Mental 
 diseases are not merely diseases of the brain but diseases 
 of the person. 
 
II. 
 
 CLASSIFICATION, IMPORTANCE, AND MODE OF ACTION 
 OF THE CAUSES OF INSANITY. 
 
 The causes of insanity are either direct and immediate, 
 or indirect and predisposing. The latter favor the devel- 
 opment of mental disturbances and produce a predisposi- 
 tion to them. In the individual case it is often difficult 
 to decide whether we have to deal with a sign of the dis- 
 ease, i.e., with an effect of these causes, or with one of 
 the causes themselves. Statistics furnish a great aid in 
 the study of the causes of insanity, but they must be in- 
 terpreted with caution. 
 
 Different causes are so often combined in the same case 
 that we are hardly ever justified in making a single one 
 responsible for this or that effect. Hitherto all attempts 
 at etiological classification of psychical diseases have failed 
 on account of the numerous possibilities in each case, and 
 also because an entire series of diseases would be left 
 without a known cause. 
 
 The term psychical trauma has been applied recently 
 to constantly repeated injurious influences which may 
 produce a permanent morbid condition in certain parts of 
 the nervous system. It is interesting in this respect that, 
 apart from distinct mental disorders, some of the lower 
 functions which are closely related to emotional and men- 
 tal activities during health may also be morbidly changed 
 in the same way. These are symptoms such as palpita- 
 tion, insomnia, nervous digestive disorders, laughing and 
 crying spells — conditions which are apt to develop after 
 continued injurious psychical influences. That these con- 
 ditions are not morbid per se is evident, because, like 
 redness of the face in anger, pallor in fright, they are 
 
 20 
 
CIVILIZATION. 21 
 
 perfectly natural results of their antecedents. But if they 
 occur in uninterrupted succession the injured nervous 
 system constantly reacts in this way, and its exhaustion is 
 an evidence of the morbid condition. (Here we may prop- 
 erly speak of a psychical injury, a trauma, and the recog- 
 nition of the casual connection shows the way of prevent- 
 ing further injury.) Among many illustrations of psy- 
 chical trauma, we will mention only the following : The 
 one-sided method of tormenting children with mechanical 
 learning by rote results in early psychical exhaustion ; the 
 constant repetition of the same injurious stimuli rapidly 
 leads to exhaustion of the cerebral activity, which either 
 causes disease directly or predisposes to subsequent dis- 
 ease. In this way the effect of constantly recurring inju- 
 rious influences assumes great power. We will now con- 
 sider the predisposing causes according as they affect the 
 community or the individual. 
 
 A. CAUSES ACTING UPON THE COMMUNITY. 
 
 Civilization. 
 
 The increasing frequency of insanity is an undoubted 
 fact, and has often been explained by the advance of civil- 
 ization. This is, however, only true in a measure. 
 
 It is calculated that, in civilized nations, there is, on 
 the average, one insane individual to two hundred inhabi- 
 tants, and this proportion is probably below the truth. 
 As statistics refer, in general, only to recent times, I will 
 make use of some older statistics which cover a small dis- 
 trict and enable us to make a comparison between former 
 and recent times. In Schleswig-Holstein, in the year 
 1803, there were 700 insane among 602,807 inhabitants, 
 i.e., 11 to 10,000. In 1840, there were 2,125 insane among 
 772,974 inhabitants, i.e., about 28 to 10,000. In 1880, 
 there were nearly 34 insane to 10,000 inhabitants. 
 
 The value of statistics, however, is impaired by several 
 considerations. In the first place, the advance of civiliza- 
 tion has prolonged the life of the insane, and thus caused 
 
22 HANDBOOK OF INSANITY. 
 
 an apparent increase in their numbers. Furthermore, the 
 increasing care with which statistics are obtained must 
 be taken into consideration. 
 
 The chief disadvantages of our present civilization are 
 clearly evident from the fact that the increase of mental 
 disorders is coincident with the enormous increase in the 
 population of large cities. We would need to describe 
 city life in order to touch upon all the injurious factors 
 which they exhibit. We need merely mention the bad 
 hygienic surroundings, poverty, factory life, immorality, 
 and the unmarried state. All these conditions are com- 
 bined with the unceasing struggle for existence. 
 
 If we look at some other aspects of civilization which 
 obtain not alone in the cities, it remains doubtful whether 
 they exercise injurious effects, or whether some of them 
 do not even prevent the development of insanity. Thus, 
 it is questionable whether the religious and political con- 
 vulsions of our times are etiological factors. Religious 
 questions absorb the public interest less than in former 
 periods. Political revolutions are attended by such com- 
 plicated factors, that it is hardly possible to determine sep- 
 arately the real effect of the political condition. It is in- 
 teresting in this regard that among the French, who exhibit 
 no excessive tendency to mental disorders, political and so- 
 cial changes appear almost with a certain regularity. The 
 influence of such events appears to be exerted mainly in the 
 character and complexion of the disturbances, rather than 
 in a notable increase. During the last Franco-Prussian 
 war it was even maintained that many individuals, who 
 were on the verge of insanity, were guarded against pro- 
 nounced insanity by the mental excitement and occupa- 
 tion afforded by the troublous times. This question, how- 
 ever, is very complicated in character. 
 
 There is no doubt that the improvement in food, cloth- 
 ing, and dwellings, which goes hand in hand with 
 advancing civilization, does not favor the development of 
 mental diseases. The general advance in moral ideas 
 also antagonizes the spread of insanity, so that it re- 
 
RACE AND NATIONALITY. 23 
 
 mains doubtful whether civilization in general may be 
 regarded as the cause of the increase in insanity. 
 
 Race and Nationality. 
 
 For a time it was believed that the Scotch Highlanders, 
 the Irish, and the negro, exhibited less tendency to in- 
 sanity, because certain forms, especially paralytic demen- 
 tia, were not observed among them. This exceptional 
 condition disappeared as soon as these people began to 
 live in the large cities. In the United States the negroes 
 are now attacked by general paresis, from which they re- 
 mained exempt during slavery. Perhaps the Jews exhibit 
 a comparatively greater predisposition to insanity, but 
 this may be explained by another peculiarity apart from 
 race, viz., the fact that the Jews intermarry very often in 
 close family circles ; the crossing is insufficient, and hered- 
 ity thus gives rise, by in-breeding, to a rapidly increasing 
 predisposition. In general, however, statistics show no 
 special tendency of any race to insanity, and this is also 
 true of the different nationalities. 
 
 Geographical Position, Soil, Food. 
 
 The geographical position of a people is sometimes asso- 
 ciated with mental diseases. A connection has always 
 been assumed between the endemic occurrence of cretinism 
 in some of the Alpine valleys and certain conditions of the 
 soil. The excessive use of maize as an article of food by 
 the peasants of Northern Italy gives rise to so-called pel- 
 lagrous insanity. 
 
 Seasons and Climate. 
 
 The effect of these cosmical conditions cannot be ascer- 
 tained with certainty. A few observations among agri- 
 cultural populations appear to show that there are more 
 admissions to lunatic asylums during the summer months, 
 but this also appears to be true of cities. As a general 
 thing, climate also exerts no influence. 
 
24 HANDBOOK OF INSANITY. 
 
 Sex and Social Position. 
 
 In men the more efficient and dangerous factors are the 
 struggle for existence, drunkenness, and excesses ; women 
 are more endangered by pregnancy and the puerperal con- 
 dition, lactation, or unsatisfied sexual life. According to 
 the law of crossed heredity, and, at the same time, the 
 predominating influence of the father, insanity will be 
 inherited somewhat more frequently by the female off- 
 spring. Inasmuch as periodical disorders, as a rule, are 
 hereditary, the repeated number of admissions to asylums 
 to which this very fact gives rise will in itself, appa- 
 rently, increase still more the already more frequent affec- 
 tions of this kind in females. It is a striking fact that 
 many very young girls are attacked by insanity. This 
 must be attributed to faulty education, rather than to 
 unsatisfied sexual desire, inasmuch as so many of the pa- 
 tients have hardly entered upon the period of puberty. 
 In later years, the evil effects of celibacy are more pro- 
 nounced in women than in men. 
 
 Age. 
 
 We cannot speak of insanity of the new-born, because 
 in them the manifestations of mental life consist, at the 
 most, of instinctive movements, but the germs of the dis- 
 ease are apt to develop at this early age. The brain of 
 the new-born is very susceptible to irritation, despite its 
 ability rapidly to overcome single injurious influences. 
 This is shown by the marked rise of temperature follow- 
 ing slight irritants, but which remain without permanent 
 injury, if they act only temporarily. Nervous disturbances 
 are, however, a frequent result of prolonged febrile con- 
 ditions. 
 
 The consideration of the causes of insanity in childhood 
 is very important. The division of the original instinc- 
 tive life into conscious sensations and concepts, begins to 
 develop during childhood. Volition and thought, apart 
 
AGE. 25 
 
 from sensory impressions, are not yet present. Hence, 
 we speak of desires which grow from the sensual basis of 
 feelings of pleasure and dislike. The personality, which 
 is not yet completely defined, is passionate and instinctive, 
 and unconscious egoism is a constant phenomenon. The 
 manifestations of this process of development are subject 
 to rapid changes and alternations. 
 
 Completely developed mental disorders are very rarely 
 found in childhood. Their form is often so indefinite that 
 they are regarded rather as evidences of naughtiness and 
 bad manners. Among the poorer classes there is a de- 
 cided predominance of idiocy, and this must be attributed 
 to insufficient nourishment. 
 
 Great importance attaches to the influence of heredity 
 in the mental disorders of childhood. Children, whose 
 ancestors suffered from insanity or other nervous dis- 
 eases, not alone become delirious from slight causes, such 
 as digestive disturbances, slight fever, teething, but they 
 are apt to be depressed for a long time after the ordinary 
 disagreeable events of daily life. Mental work at school 
 rapidly exhausts them ; fright and punishment excite them 
 in a dangerous degree. Many of these children also ex- 
 hibit evidences of bodily degeneration. 
 
 Apart from hereditary influences the morbid predispo- 
 sition not infrequently develops from injuries sustained 
 during or after birth, such as compression in a generally 
 contracted pelvis, violent forceps delivery, fall upon the 
 head, etc. In some of these cases the physical develop- 
 ment is delayed. Such children are especially apt to be 
 spoiled by the parents. 
 
 In the later years of childhood, severe injuries to the 
 head are often followed by imbecility. The heat of the 
 sun, and frequent overheating of the head by hot stoves, 
 act in the most injurious manner upon infants, and are 
 regarded as the causes of early mental weakness, occasion- 
 ally of temporary conditions of excitement. There is no 
 doubt of the connection of ear diseases with mental dis- 
 orders. Deaf -mutism is a sad illustration of this fact. 
 
26 HANDBOOK OF INSANITY. 
 
 All catarrhs of the ear in children require the most care- 
 ful treatment. 
 
 Unbiassed observers have failed to note cases in which 
 insanity was due to the presence of worms. 
 
 Among the immediate psychical causes I will mention 
 merely terror, fright, and worry, which lead occasionally 
 to suicide. The importance of imitation will be consid- 
 ered later. 
 
 The next period at which a distinct change develops in 
 the bodily and mental processes is the age of sexual de- 
 velopment or puberty. 
 
 The addition of the powerful sexual impulse considera- 
 bly enlarges the category of ideas at the age of puberty. It 
 is a further important fact that at this period the heredi- 
 tary predispositions become especially evident. Physio- 
 logical development gives a new impetus to the inherited 
 cells in the germ-layer, and thus the phenomena depend- 
 ent thereon appear almost suddenly in full intensity. 
 For this reason mental disorders are much more frequent 
 at the period of puberty than during childhood, and they 
 are more varied in character, in accordance with the larger 
 experience of the individual at puberty. This period re- 
 tains the instinctive manifestations of emotional life, 
 and in addition there are vague sexual feelings whose end 
 is indistinctly recognized, and lead to perverted interpre- 
 tations and manifestations. Fantastic moods characterize 
 the common basis from which mystical and sexual feel- 
 ings arise. Violent outbreaks, sudden actions, without a 
 real internal basis, arise in this stage of development of 
 the vital processes. Rapid change of mood is very char- 
 acteristic. Apathy of feeling, and the most superficial 
 judgment of the dangerous results of the instinctive actions 
 indicate the almost always rapidly developing mental weak- 
 ness in the cases in which hereditary predisposition coin- 
 cides with the development of puberty. We must hold 
 fast to the great frequency of hereditary taint in mental 
 diseases of puberty. For this reason they also exhibit the 
 other signs of hereditary affections, viz., rapid improve- 
 
PUBERTY. 27 
 
 ment, frequent relapses, and persistence throughout almost 
 the entire life. If hereditary taint is wanting, the purely 
 affective forms of insanity, which are more favorable as 
 regards permanent recovery, are more frequent than the 
 other forms. 
 
 At this age we find comparatively many incendiaries 
 who commit such actions either from uncomprehended 
 internal motives, or from impulsive, but clearly defined 
 feelings. Homesickness is another feeling which may 
 increase to a morbid height. Other conceptions also force 
 themselves upon the child, accompanied only occasionally 
 by hallucinations. Peculiar disturbances of motion, which 
 have an awkward and foolish character, must also be re- 
 garded as the results of the ill-defined feelings and impulses 
 to which we have referred. Temporary muscular rigidity 
 is sometimes present. 
 
 Certain of these conditions have been grouped under the 
 term hebephrenia, but it is unnecessary to increase still . 
 further the numerous forms of insanity by giving them 
 different names, according to the age at which they 
 develop. 
 
 At this period, girls are exposed to greater risk of men- 
 tal disorder than boys, but after sexual maturity is estab- 
 lished the danger is less for a number of years, until they 
 reach the age when the requirements of life bring new 
 duties and injurious influences. 
 
 The period of greatest bodily and mental development 
 shows the greatest frequency in the number of cases of 
 insanity. The mental equilibrium is disturbed by external 
 circumstances and influences, but the internal vital condi- 
 tions, as such, are more innocuous. In old age, on the 
 contrary, the internal processes do the most harm. The 
 exhausting influences of mature life are the bodily and 
 mental excesses, which are brought on by the stress of 
 life's battles. Although the power of resistance is great- 
 est, the harmful influences have grown to a disproportion- 
 ate extent. Among these, alcoholism and syphilis need 
 special mention. Dementia paralytica occurs chiefly at 
 
28 HANDBOOK OF INSANITY. 
 
 this age, apparently as the result of the causes referred to, 
 and independently of hereditary taint. 
 
 At the age of bodily and mental retrogression, more 
 harm results from internal processes. Like the beginning 
 of the sexual functions, so also its cessation produces pro- 
 found changes in the entire personality. In women the 
 beginning of this period (menopause) is more sharply de- 
 fined than in men. Even in otherwise healthy women, 
 striking mental changes are observed at this period, and 
 there is often a fuller mental development. 
 
 The close relationship of olfactory hallucinations and 
 sexual irritation is also manifested at this period. If 
 malignant tumors develop in the breasts or ovaries during 
 the menopause, coincident mental disturbances are very 
 often accompanied by hallucinations of touch and smell. 
 
 The constant mental changes appear to belong among 
 the first signs of the onset of the change of life ; generally 
 a depressed, but occasionally, a cheerful mood. Artificial 
 removal of the ovaries may act in the same way as the 
 menopause. Indeed, this is also observed after ovarioto- 
 mies, total extirpations, or laparotomies in general. 
 Perhaps such results are due to the action of the sympa- 
 thetic nervous system. Certain symptoms of the meno- 
 pause, such as hot flushes and other congestive phenomena, 
 speak decidedly in favor of this connection. 
 
 In men the period of retrogression is much more pro- 
 longed. Growing old is the sign of involution of all the 
 vital processes. The activity of the brain is impaired by 
 the internal processes ; the rigidity and calcification of the 
 vessels play a part in this condition. A characteristic of 
 the process of involution is the return of the instinctive 
 desires and impulses, and this indicates the recurrence to 
 the childish stage. The gradual decay of the nervous 
 system takes place in a direction opposite to that in which 
 it reached its highest development. Memory is the most 
 marked illustration of this fact. The influence of heredi- 
 tary predisposition is also noticeable during the period of 
 involution. But when, despite the gradually increasing 
 
HEREDITY. 29 
 
 weakness of the mental functions, the frequency of mental 
 diseases diminishes with increasing age, it must be re- 
 membered that the number of predisposed individuals is 
 diminished by the fact that many of them have been 
 attacked by insanity at an earlier period, and that, as a 
 rule, the cares and worries of life diminish in old age. 
 Apart from rapidly increasing mental weakness, the 
 symptoms of insanity in old age often are complicated by 
 paralytic phenomena, which are due mainly to disease of 
 the vessels. 
 
 Heredity. 
 
 In investigating the question of heredity, we must en- 
 deavor, if possible, to go back several generations. Apart 
 from many other accidental causes, it must be remembered 
 that a child is not alone the offspring of his parents, but 
 is also the last link in a long chain of ancestors. It is 
 impossible that all their peculiarities can be inherited by 
 one individual. Certain members of a family escape the 
 inheritance of various peculiarities, for definite diseases, 
 such as, for example, haemophilia, are propagated only 
 in the male line, or they skip a generation. The connect- 
 ing link in the chain of inheritance of insanity may also 
 be formed by other nervous diseases or by allied condi- 
 tions, such as striking peculiarities, criminal or suicidal 
 tendencies. As the interpretation of such conditions va- 
 ries with the personal view-point, it is clear that the 
 statistics concerning the importance of heredity will vary 
 greatly. According to cautious investigators thirty to 
 forty per cent of cases of insanity exhibit evidences of 
 heredita^ taint. 
 
 Numerous experiences in psychiatry favor the notion 
 that even acquired peculiarities may be communicated to 
 the offspring. The probability of inheritance is very 
 greatly increased, if both parents have an hereditary taint, 
 or suffer from insanity. The danger is much less when 
 the predisposition is transmitted only on one side. It 
 must also be remembered that acquired insanity in the. 
 
30 HANDBOOK OF INSANITY. 
 
 ancestors is only dangerous when children are born during 
 the course of the mental disorder. 
 
 It is now regarded as certain, that the influence of the 
 father in heredity is more important than that of the 
 mother. Inasmuch as inheritance is usually crossed, we 
 should expect that the female members of the family would 
 be more endangered. This is not entirely confirmed by 
 experience, because, according to several authorities, in- 
 sanity of the mother is especially apt to be inherited 
 by the daughters. Hereditary taint, when transmitted 
 through several generations, gradually leads to degenera- 
 tion. In the first generations we find, apart from nervous 
 symptoms, the disappearance of ethical feelings ; then fol- 
 lows a generation in which the tendency to excesses 
 appears, and the danger is then greatly increased by alco- 
 holism. In the third generation there is perhaps suicide 
 or an affective form of insanity, and finally there appear 
 more profound mental disorders, such as congenital idiocy. 
 The last stage is often associated with various malforma- 
 tions and inhibitions of development. 
 
 As regards the form of mental disturbance, heredity acts 
 in two ways, each of which is sharply defined, and only 
 rarely do we find transitional forms. The more extensive 
 group embraces symptom-complexes which are distin- 
 guished, not alone by variability as regards each one, but 
 also by the fact that they are apt to pass into one another. 
 This group has taught the multifarious relations of hered- 
 ity; all the neuroses already mentioned and allied condi- 
 tions, such as inebriety, criminal impulses, etc., lead to 
 the most manifold symptoms as the result of hereditj\ 
 
 In the second group there is inheritance of the same 
 form of mental disturbance as that presented by the an- 
 cestor, but this form is very much rarer than the preceding 
 variety. The disease may appear in the children at the 
 same age as it did in the parents, or under similar condi- 
 tions — for example, when mother and daughter are attacked 
 in childbed. The most striking phenomenon in this re- 
 spect is the inheritance of the tendency to suicide. Cases 
 
HEREDITY. 31 
 
 are reported in which one member of a family after another 
 committed suicide, although they lived in remote parts of 
 the world. Suicide on an hereditary basis is found even 
 in children at the age of five years. 
 
 As we have already hinted, the variability of the symp- 
 toms in the individual case is characteristic of hereditary 
 taint. Eapid changes of mood, frequent relapses, compar- 
 atively great mental ability, are found in addition to pro- 
 nounced evidences of disease. On the other hand, there 
 is sometimes a striking uniformity in the course of the 
 individual attack of insanity in certain cases. 
 
 It was formerly supposed that relationship of the parents 
 was sufficient to produce insanity in the offspring. This 
 is disproved by more recent statistics and by historical 
 illustrations — for example, the Ptolemy s. Among them 
 the king always married his sister, yet insanity was not 
 pronounced in this family during a period of three hun- 
 dred years. Nevertheless, it remains an interesting fact 
 that deaf -mutism often occurs as the result of intermarriage 
 of relations. 
 
 The condition of the parents at the moment of impreg- 
 nation is also important. Children procreated during the 
 drunkenness of otherwise healthy parents sometimes ex- 
 hibit congenital mental and nervous disturbances. The 
 significance of morbid cerebral activity at the moment of 
 procreation is also shown by the fact that insane individ- 
 uals produced healthy children during the intervals 
 between attacks of insanity. 
 
 The assumption that heredity depends upon a definite 
 condition of the germ-layers is favored by the observa- 
 tion that, in cases of hereditary taint, the outbreak of the 
 disease very often occurs at the period of puberty. The 
 general change in all the internal vital processes at this 
 period makes it easily understood that such germ-layers 
 should also be implicated. 
 
32 HANDBOOK OF INSANITY. 
 
 Crime and Genius. 
 
 There is no doubt that a considerable number of crimes 
 are committed by the insane, and it has been proven that 
 the greatest criminals belong, as a rule, to families in 
 which hereditary taint has been demonstrated. Further- 
 more, the offspring of such criminals are often attacked 
 by insanity. 
 
 The Italian school has made extensive investigations in 
 this direction. In addition to the proof that a number of 
 criminals resemble savages (among other resemblances, 
 tattooing is especially frequent among them) , it has been 
 shown that the born criminal resembles the insane or epi- 
 leptic. Changes in the skull and brain and imperfect 
 development of ethical feelings have been found. Other 
 characteristics common to both groups are the frequent 
 relapses, independent of good or bad treatment, good or 
 bad external surroundings. 
 
 Genius has also been said, by some writers, to be con- 
 nected with insanity. It is, indeed, an astonishing fact 
 that many men of great talents belong to families with an 
 hereditary taint, that many become insane, or have feeble- 
 minded brothers and sisters or children. Finally, it has 
 often been observed that a family unexpectedly dies out 
 in the person of a great genius. All these phenomena are 
 characteristic of hereditary conditions, but the question is 
 not yet thoroughly settled. 
 
 Education. 
 
 One of the purposes of an ideal education is the removal, 
 by means of the uniform development of all the functions 
 of body and mind, of those dangers which may leadr to 
 insanity. The present neglect of physical education in- 
 creases still further the efficiency of the errors in mental 
 education. Errors in education are most dangerous when 
 they coincide with hereditary predisposition. Excessive 
 strictness as well as latitude may work equal mischief. 
 The passions and desires of the children must be regulated 
 
OCCUPATION. 33 
 
 so that they do not forget the habit of self-control. A 
 strain upon the memory as the result of learning by rote 
 may produce precocious children, but they fail when sub- 
 jected to the strain of actual life. Children in general 
 attend school at too early a period, and are compelled to 
 study too long and often under unfavorable hygienic con- 
 ditions. 
 
 Occupation. 
 
 Brain-workers are more endangered than those who do 
 manual labor. Among the former artists occupy the front 
 rank as regards the danger of insanity. Even under or- 
 dinary circumstances, constant devotion to music is very 
 wearing. Nervous conditions of all kinds, especially in- 
 somnia, are rapidly produced; irritability in family life 
 is apt to davelop. Actors rank next to artists in this re- 
 spect. The excitement of speculation is also injurious, 
 and many merchants succumb to paralytic dementia. 
 During a war, soldiers are also exposed to many causes 
 of insanity — forced marches, exhausting diseases and 
 wounds, and excitement of all kinds. 
 
 The causes of the frequent affection of prostitutes, sail- 
 ors, and others in the lower walks of life, are complicated 
 in character. They include drink, poverty, syphilis, and 
 sexual excesses. Many prostitutes have an hereditary 
 taint. 
 
 The absence of an occupation is also an efficient factor, 
 as is illustrated by the frequency of insanity among 
 tramps. 
 
 Insanity also occurs frequently among prisoners; prom- 
 inent causes are remorse, and solitary confinement, which 
 favors the sudden development of terrifying hallucinations. 
 
 B. CAUSES WHICH ACT ONLY ON THE INDIVIDUAL. 
 
 BODILY CAUSES. 
 
 The Brain and Its Membranes. 
 Almost all diseases influence the mood to a certain ex- 
 tent. We need merely mention the depression of gastric 
 
34 HANDBOOK OF INSANITY. 
 
 and intestinal affections, the anxious conditions in circu- 
 latory disturbances, the peculiar cheerful and careless 
 mood of some phthisical patients. The more directly such 
 influences act upon the cerebral cortex, the more dangerous 
 do they become. 
 
 Among the influences which exert a material influence 
 on mental disorders is congestion of the cerebral cortex. 
 This acts either by increasing the cerebral pressure, or by 
 gradually changing the nutrition of the tissues. 
 
 Mental disturbance does not always follow congestion, 
 because relief is long possible on account of the extensive 
 vascular network of the cortex. If this does not occur, 
 insomnia is the most common result ; restlessness, irrita- 
 bility, and hallucinations are also frequent symptoms. 
 Insolation is a cause of such congestion, and the latter also 
 accompanies various cerebral and meningeal diseases. 
 This is easily explained by the anatomical association of 
 the blood-vessels of the meninges and cortex. The diffuse 
 changes thus produced in the cerebral tissues are impor- 
 tant, but similar symptom-complexes may also be produced 
 by focal lesions, if they develop in the cortex and are at- 
 tended with diffuse changes in their vicinity. A deficiency 
 of blood or venous stasis, even if it develops suddenly 
 from paralysis of the vasomotor nerves, diminishes the 
 irritability. One of the most striking symptoms of cor- 
 tical anaemia is drowsiness ; this may terminate in stupor 
 and unconsciousness, sometimes combined with convul- 
 sions, if the anaemia develops rapidly. Its slower develop- 
 ment leads to impairment of memory and, indeed, of the 
 mental functions in general. In most diseases of the brain 
 and meninges, the change of symptoms is frequent, on ac- 
 count of the numeraus changes in the degree of fulness of 
 the cerebral vessels. 
 
 Everjr form of meningitis may lead to mental disturb- 
 ance. Hemorrhage, softening, multiple and general scle- 
 rosis, gliosis and tumors, if they give rise to diffuse 
 changes in the vicinity, are generally followed by condi- 
 tions of mental enfeeblement. 
 
INJURIES TO THE HEAD. 35 
 
 Cerebral concussion and injuries to the head give rise 
 to inflammations of the skull and meninges, which may 
 extend to the brain. In the brain itself they may cause 
 disturbances of the cortical circulation, with secondarj^ 
 nutritive disturbances and psychical disease. The latter 
 either follows the injury at once, or appears after a long 
 interval. When cerebral concussion leads at once to dis- 
 ease, there are found, in addition to headache, vertigo and 
 terrifying hallucinations, sensory and motor disturbances, 
 such as narrowing of the pupils, gritting of the teeth, and 
 paralyses. These symptoms generally subside quite rap- 
 idly, but indecision and enfeebled mental activity, with 
 great irritability, persist for a longer time. In many 
 cases the further course is very unfavorable, and permanent 
 mental weakness sets in. The slowly developing cases 
 also exhibit irritability and weakness from the start; epi- 
 leptic convulsions, without any demonstrable local lesion, 
 have also been observed. Such persons are easily ex- 
 hausted, and this is also shown, for example, by the slight 
 power of resistance to small doses of alcohol. Although 
 it cannot be denied that the majority of mental disorders 
 after injury are characterized by great irritability, inde- 
 cision, and rapid mental enfeeblement, yet the term trau- 
 matic insanity is a generic term, which embraces the 
 most varied causes and symptoms. 
 
 Coincident Diseases of the Cord, Nerves and Sym- 
 pathetic. 
 
 There is sometimes a hardly noticeable transition in the 
 occurrence of the symptoms when the causes develop at 
 the same time in the brain and spinal cord. We need 
 merely call to mind the diffuse and systematic scleroses of 
 the cerebral nervous system, and especially tabes. The 
 clinical symptoms of the latter are sometimes united so 
 closely with those of paralytic dementia that they are 
 inseparable. On the other hand, tabes may occur inde- 
 pendent^ in connection with a mental disorder, so that 
 their relation is not certain. But there are certain signs, 
 
36 HANDBOOK OF INSANITY. 
 
 especially persecutory delirium with hallucinations, whose 
 constant associated occurrence forces us to the conclusion 
 that the tabes and psychosis have a common basis. Mental 
 weakness often develops, especially at the close of the 
 course of tabes. The recent interpretation of tabes as a 
 disease of the entire cerebral nervous system, assumes a 
 direct connection between the tissue changes in the brain 
 and cord. 
 
 The medium of the vasomotor system becomes necessary 
 in explanation of the mental disturbances in general neu- 
 roses, neuralgias, and injuries to the nerves. Mild dis- 
 turbances, especially depression, are sometimes found in 
 Basedow's disease. Insanity also accompanies chorea not 
 infrequently. The symptoms are terror, loss of memory, 
 and irritability. Epilepsy and hysteria are also often 
 associated with insanity, but these affections will require 
 special consideration. 
 
 The vasomotor element is still more distinct in certain 
 neuralgias ; the connection is especially distinct when the 
 attacks of pain periodically precede the mental disturb- 
 ance, or the latter follows pressure on painful points along 
 the nerves. Temporary conditions of excitement have also 
 occurred after operations of various kinds, during which 
 sensitive nerves have been injured. 
 
 Affections of the cutaneous nerves may induce morbid 
 mental symptoms. Even slight cutaneous eruptions give 
 rise to irritability and bad temper, and in predisposed 
 individuals they may cause an outbreak of insanity or 
 color its symptomatology. Disease of the terminal rami- 
 fications of the nerves of special sense may also provoke 
 hallucinations and mental disturbance, but as a rule hal- 
 lucinations are central in origin. 
 
 Anaemia and Exhausting Diseases of Internal Organs. 
 
 The following causes act as remote causes of insanity, 
 not alone by vasomotor or reflex influences, but also, as a 
 rule, through the agency of a general, prolonged anaemia. 
 These include pulmonary diseases of all kinds, but the 
 
VISCERAL DISEASES. 37 
 
 causal significance of tuberculosis is not very great. The 
 importance of heart disease as a cause of insanity, in so 
 far as the connection is explained by the general anaemia, 
 is also greatly overestimated. In some cardiac affections 
 there is passive congestion of the brain ; in these there are 
 apt to be conditions of anxious excitement, while depres- 
 sion predominates in general weakness of the circulation 
 and anaemia. The reflex effects of palpitation and cardiac 
 oppression also attend these diseases. All cardiac patients 
 are irritable ; in coincident insanity the peculiar restless- 
 ness is often manifested impulsively in violence. Aortic 
 lesions, however, are usually an exception to this rule. 
 
 The development of imbecility after operative removal 
 of the thyroid gland is a noticeable phenomenon; it is 
 supposed to result from changed circulatory conditions in 
 the brain. 
 
 Importance has always been attached to digestive dis- 
 turbances as a cause of insanity. The abundant nerve 
 plexuses of the abdomen are a source of reflex irritation. 
 The possibility of the absorption of toxic substances, for 
 example sulphuretted hydrogen, has also been kept in 
 mind. Irregular distribution of blood, stases in the portal 
 circulation, undoubtedly play a certain part. The chief 
 importance, however, attaches to the impairment of general 
 nutrition, but we must avoid mistaking cause and effect, 
 inasmuch as digestive disturbances often result from the 
 psychical disease. Psychoses due to intestinal worms are 
 found, perhaps, only in children. 
 
 Psychical disturbances in the course of renal disease 
 must be attributed to acute or chronic uraemia. In Eng- 
 land, however, it is maintained that both diseases are due 
 to vascular changes. 
 
 Diseases of the Sexual Organs and Disturbances of 
 Their Function. 
 
 Some observers regard this cause as very frequent in 
 females, others think it very unimportant, but all are 
 agreed that diseases of the male sexual organs play a very 
 
38 HANDBOOK OF INSANITY. 
 
 minor part. In women tissue changes and displacements 
 of the uterus, with inflammatory conditions, are impor- 
 tant. Although they do not often produce decided insan- 
 ity, nervous disturbances are usually not wanting. Vag- 
 inal catarrhs, ulceration of the cervix, neoplasms, etc., act 
 in this way. An erotic or hysterical character is often 
 absent. The sterility due to genital affections often acts 
 in a psychical manner. The disturbances of menstruation 
 must be regarded both as cause and effect. Although it 
 is doubtful whether they often produce insanity, they often 
 influence the course of the mental diseases. 
 
 Sexual excesses may undoubtedly produce psychoses, 
 but they are also often an indication of already existing 
 disease. The principal injurious factor is the exhausting 
 nervous action, and for this reason unnatural gratification 
 of sexual desire is the most dangerous. In some cases 
 masturbation results from peripheral irritation, such as 
 oxyuri and cutaneous eruptions near the genitalia, but 
 in the majority of cases the cause is cerebral. In these 
 patients are often found, due to the same cerebral basis, 
 olfactory hallucinations of a disagreeable character, such 
 as the stench of faeces and corpses ; these phenomena are 
 associated not infrequently with a tendency to religious 
 mysticism. 
 
 It is often maintained, particularly with regard to 
 women, that continence produces a predisposition to men- 
 tal disorders. This is not true of healthy individuals. A 
 large number of women never have sexual intercourse and 
 remain sane. Those in whom this cause is effective 
 probably suffer from an hereditary taint. 
 
 The connection between pregnancy and insanity is 
 brought about, in part, by circulatory disturbances. In ad- 
 dition, there are chemical changes in the constitution of the 
 blood. It has been held, in opposition to this view, that 
 the mental disturbance sometimes continues after delivery, 
 but experience teaches that this is not true in many cases. 
 In combination with other causes, for example, heredity, 
 the frequent occurrence of psychoses during pregnancy is 
 
PREGNANCY. 39 
 
 easily understood. During the first months of pregnancy, 
 in which the mechanical changes in the circulation can 
 exert no noticeable effect, temporary psychical disturbances 
 of a mild character may also occur. They are probably the 
 result of a reflex nervous process. The fact that women 
 who are illegitimately pregnant are attacked most fre- 
 quently, is due to the numerous other harmful factors to 
 which they are exposed. 
 
 The connection between childbed and insanity is more 
 difficult of explanation. This fact is the more striking 
 because certain symptoms are found quite constantly in 
 the puerperal psychoses. They generally develop unex- 
 pectedly between the fifth and tenth days of childbed. 
 In some cases an injurious influence may be exerted by 
 the prolonged absorption of toxic substances, particularly 
 when febrile movement has been present. Another very 
 probable cause is the general anaemia which attends the 
 loss of blood. In very rare cases conditions of violent 
 excitement, lasting only a few hours, develop during the 
 first few days after delivery, and these must be attributed 
 to the sudden changes in the circulation and to high fever. 
 Allied to these conditions is the quite rare occurrence of 
 insanity after miscarriages. 
 
 The cases of insanity during lactation usually do not 
 develop before the third month, and this indicates their 
 connection with the general exhaustion and anaemia. 
 Hereditary predisposition to mental disorders cannot al- 
 ways be excluded, and then the lactation is merely an 
 exciting cause of the outbreak of insanity. 
 
 Febrile Diseases and Poisoning. 
 
 Formerly it was generally believed that febrile delirium 
 appeared and disappeared with the febrile movement. It 
 must, therefore, be regarded as a step in advance, when it 
 was learned that the delirium and other mental disorders of 
 febrile diseases may occur during the prodromal stage, prior 
 to the rise of temperature. On the other hand, the mental 
 disturbance may not develop until the fever has run its 
 
40 HANDBOOK OF INSANITY. 
 
 course. Hence it follows that the fever is not the sole 
 cause of such symptoms. Certain attacks of mental dis- 
 turbance may develop during the course of intermittent 
 fever, and take the place of the chill, although they run 
 an apyrexial course. The majority of the diseases in 
 question are infectious, and their organized germs must 
 be considered in connection with the cause of the mental 
 disturbances. This group includes typhoid and intermit- 
 tent fever, cholera, the acute exanthemata, articular rheu- 
 matism, lyssa, and perhaps pneumonia. It may be assumed 
 that the germs of these diseases produce changes in the 
 blood, which impair the nutrition of the cerebral cortex. 
 As the virus is circulating in the blood before the onset of 
 fever, we are justified in assuming that this virus, not the 
 febrile movement, may give rise to the mental disturbance. 
 This also holds good with regard to the development of 
 symptoms after the cessation of the fever. The virus may 
 exert a chemical action, or it may give rise to local ana- 
 tomical changes in the brain. In acute articular rheuma- 
 tism localized inflammations and mechanical obstructions 
 of the vessels are found in the meninges and the vessels of 
 the cortex. In view of these facts, it is evident that fe- 
 brile movement may not be regarded as the main cause of 
 these psychoses, although it undoubtedly facilitates their 
 outbreak. The increase in the bodily temperature acts as 
 an irritant upon the nervous tissues, as is shown in cases 
 of insolation. If the fever t lasts a long time, anaemia of 
 the cortex results from weakening of the heart's action ; 
 when the fever is of short duration, we may assume con- 
 gestion of the brain. 
 
 We will now pass to the general consideration of the 
 symptoms which develop after poisoning by various well- 
 known drugs. There is an entire series of substances 
 which are taken for the purpose of producing conditions 
 like that of drunkenness, and whose continued ingestion 
 leads to mental degeneration and disease. The extensive 
 use of opium, hasheesh, and similar drugs for the produc- 
 tion of intoxication is well known. Alcohol may be 
 
ALCOHOLISM. 41 
 
 placed on a par with opium as regards its disastrous 
 effects. Its continued abuse gives rise to symptoms 
 among which mental weakness and moral deterioration 
 are especially prominent. Heredity also plays a great 
 part in this vice, and the psychical disorder is then apt to 
 be periodical. In such cases it is sometimes doubtful 
 whether the abuse of alcohol is the cause or effect of the 
 nervous predisposition. Some patients experience, from 
 time to time, an uncontrollable desire to drink. The 
 presence of the alcohol in the drink is not, however, ab- 
 solutely indispensable, Because these individuals, in asv- 
 lums, sometimes drink only large amounts of water. The 
 other causes which aid the poisonous action of alcohol 
 can only be hinted at ; the chief one is the mental struggle 
 against the vice. The necessary degradation of the exter- 
 nal surroundings finally leads to the overthrow of the 
 mental and physical forces. The poorer the quality of the 
 alcoholic drink, the more disastrous are its effects ; whis- 
 key which contains fusel oil and absinthe is much more 
 dangerous than beer and good wine. 
 
 Among physicians it is especially the abuse of morphine, 
 more rarely of cocaine, which may lead to the production 
 of mental disorders. The physician's ability to take the 
 poison unnoticed for a long time is a source of great 
 danger. 
 
 We will merely mention the names of an entire series 
 of substances which act in a similar manner. Among 
 these are salicylic acid, iodoform, and ergot. After the 
 ingestion of the latter epidemics of psychical disturbance 
 have been observed. Spoiled maize has given rise to wide- 
 spread, so-called pellagrous insanity. Psychoses have 
 also been observed after the excessive use of tobacco, also 
 after prolonged abuse of chloroform and chloral. More 
 common are the injurious results of poisoning by certain 
 metals, especially lead and mercury. They occur not very 
 rarely in painters and miners in lead works, either as 
 temporary conditions of violent excitement, or as pro- 
 longed affections, in which disturbances of speech and 
 
42 HANDBOOK OF INSANITY. 
 
 other paralyses indicate pronounced disease of the cerebral 
 cortex. Workers in mercury also exhibit symptoms 
 which indicate an action upon the cortex. The bromide 
 salts may give rise to serious motor symptoms, with men- 
 tal enfeeblement, but this usually disappears soon after 
 the discontinuance of the remedy. Gases may act in a 
 somewhat similar manner. Carbonic oxide produces con- 
 gestion of the brain, and sometimes even softening of the 
 cortex. Psychical disorders have also been reported, in a 
 few cases, after inhalation of carbon bisulphide and also 
 illuminating gas and sulphuretted hydrogen. 
 
 PSYCHICAL CAUSES. 
 
 The views concerning the extent of efficiency of the 
 psychical causes of insanity vary greatly, but I am in- 
 clined to believe that they are among its most frequent 
 and fruitful sources, both in preparing the soil and 
 particularly in acting as the immediate causes of the 
 disease. One cause, which acts as a constantly re- 
 peated injury, is the grief due to the loss of near rela- 
 tives. The effects of psychical pain are so much more 
 marked when it is kept hidden from view. The internal 
 wounds, which are concealed externally by smiles, act 
 slowly, but surely. Morbid general sensations increase the 
 emotional excitement; insomnia, in particular, prevents 
 the restoration of new force to carry on the struggle in the 
 soul. There is no doubt that, in numberless cases, re- 
 pressed or immoderate grief is the source from which all the 
 manifestations of insanity flow. A similar effect is pro- 
 duced by business worries. Their action is slowly pro- 
 gressive; slight cares and troubles usually mark the onset, 
 nor do they need to increase during the further course of 
 the affection, inasmuch as the power of resistance dimin- 
 ishes under the repeated blows. Constantly gnawing fears, 
 without actual material losses, may lead to the mental 
 breakdown. We always find two factors in these causes, 
 viz., the repeated and constant occurrence, and the pain- 
 ful element of feeling. Both together prevent the inhibi- 
 
WORRY AND OVERWORK. 43 
 
 tory counter-effects of other ideas. Hence, we must 
 look upon continued painful feelings as the most impor- 
 tant psychical causes of insanity. Joyful feelings never, 
 perhaps, give rise to insanity, especially because, as a 
 rule, they only act temporarily and the equilibrium is 
 rapidly restored. 
 
 The form of the disease sometimes agrees with the de- 
 termining cause, inasmuch as fear and despair etc., may 
 lead to similar notions during the psychosis. More 
 frequently, however, the mental disturbance pursues an 
 independent development, irrespective of the causal feeling. 
 
 The direct action of these causes is rarely immediate in 
 point of time, as a long-continued internal psychological 
 preparation is usually necessary. Irritative and paralytic 
 conditions of the vasomotor system are constantly noticed ; 
 but it does not explain very much to say that such condi- 
 tions give rise to the final symptoms. 
 
 Violent grief over the loss of a loved one is dissolved into 
 distress which lasts so much longer the greater the gap that 
 has been left in our lives. If no restorative comes to the 
 exhausted brain, torturing thoughts stream rapidly into 
 the field of consciousness, until associated ideas w T ell up ir- 
 regularly from the depths of unconscious cerebral life, and 
 make all order impossible. Hence the resemblance of im- 
 moderate emotions to maniacal excitement, and also the 
 tendency of many insane to unbridled emotions. The 
 emotional movement wells up irregularly from the flood 
 of cerebral activity, and volition can no longer keep it in 
 the proper connection of psycho-physical action. Voli- 
 tional thought yields to the power of external actions, 
 and the emotional excitement becomes a permanent mor- 
 bid disturbance. 
 
 Mental overwork, such as, for example, is due to ambi- 
 tion, also constitutes a psychical cause of insanity. Dis- 
 agreeable feelings here accompany failure, and disap- 
 pointed ambition is accompanied by inhibited self-esteem. 
 Repeated failures and unavailing efforts to maintain an 
 unduly exalted position increase these harmful influences. 
 
44 HANDBOOK OF INSANITY. 
 
 Unbounded ambition may lead to mental disorder, but it 
 may also be an evidence of its actual existence. 
 
 One-sided devotion to a few branches of knowledge also 
 acts injuriously. Exhaustion is here recognized by the 
 feeling of strain while thinking, and failure of the associ- 
 ation of ideas ; these intellectual feelings find a place in 
 consciousness, in which only loose connections bind them 
 to the bodily functions, and the connection with the latter is 
 only established by the introduction of bodily disturbances. 
 But we are so much the more forced to regard these causes 
 of psychical disorder as direct and immediate, because the 
 efficient factor is the internal process which runs its course 
 in consciousness. 
 
 I will briefly refer to two other undoubted direct causes 
 of insanity. Unrequited love causes disappointment, 
 grief, and a variety of violent feelings, which may exert 
 a profound influence on consciousness, but experience 
 teaches that this hardly ever produces permanent mental 
 disturbance, except upon an hereditary basis. We may 
 also refer to the effects of religious sentimentality upon 
 the production of insanity, merely to warn against an 
 exaggerated idea of its importance. 
 
 The occasional occurrence of psychical epidemics due to 
 religious causes requires a few words of comment. The 
 fact that morbid conceptions may be conveyed to others 
 has been observed in those who lead secluded lives, and 
 also among large masses of men. This has been compared 
 to the process of suggestion during hypnosis, and the phe- 
 nomena in question have been explained by a sort of wak- 
 ing suggestion. A restriction of consciousness to a few 
 categories of ideas prevents the will from rationally di- 
 recting the course of such ideas. With the increasing 
 weakness of volitional activity, the combinations of 
 thoughts which arise from internal and external impres- 
 sions assume the upper hand, and produce the mental 
 disturbance. 
 
III. 
 
 THE SIGNS OF MENTAL DISORDERS. 
 
 Introduction. 
 
 The general doctrine of the signs of mental diseases 
 concerns itself with the elementary phenomena, which 
 compose the most complex clinical pictures. It considers, 
 from a general standpoint, the individual elementary dis- 
 orders which are variously grouped in the special forms 
 of disease. In order to avoid all metaphysical specula- 
 tions, we will call the soul the logical subject, to which 
 all the individual data of internal experience and observa- 
 tion are applied as predicates. We will regard conscious- 
 ness as a fact of experience of the individual, which can- 
 not be made clearer by further definition. There is an 
 essential difference between internal and external experi- 
 ence, between the perception of conditions of the ego and of 
 changes in the external world. The psychical processes 
 in the individual belong entirely to his inner experience, 
 and can only be observed by others by means of definite 
 changes in speech, gestures, and actions. Hence, the phe- 
 nomena of healthy and morbid mental life must be recog- 
 nized by the aid of psychology and anatomy. 
 
 All internal experience possesses for us direct reality, 
 while the objects of external experience are only recog- 
 nized indirectly. If they are to become objects of con- 
 ception and thought, they must pass in some way into 
 internal experience. Concepts, feelings and volitions con- 
 stitute the contents of our internal experience, but they 
 are so complex that it becomes the object of psychology to 
 resolve them into their simplest elements. The real ele- 
 ment of all mental activities is the impulse, that activity 
 in which sensation and will become efficient ,in their pri- 
 
 45 
 
46 HANDBOOK OF INSANITY. 
 
 mary combination. The mental development of every 
 individual introduces herein the process of apperception, 
 i.e., the grasping of external and internal impressions by 
 means of attention. It is only with the independence of 
 this process that a higher mental development follows, 
 with which all higher feelings and volitions are asso- 
 ciated. As these concepts are only grasped singly, their 
 grouping under general notions would not aid us much 
 in their comprehension, but they are so complicated that, 
 for clinical purposes, they must be divided into certain 
 groups. 
 
 The first group of mental changes which we will con- 
 sider includes : 
 
 A. THE DISTURBANCES OF CONSCIOUSNESS. 
 
 1. Disturbances of the Perceptive Process. 
 
 The reception of sensory impressions may be disturbed 
 in their passage through the nerves of sense. This per- 
 ception is often falsified at the terminal distributions of 
 these nerves. Diseases of the eye, catarrhs of the middle 
 ear, irritative conditions of the nasal mucous membrane 
 and the buccal cavity, inflammations of the skin and mu- 
 cous membranes, and morbid changes in the viscera and 
 muscles, may play a part. 
 
 Special attention must be devoted to the eye. For the 
 present, we will examine only the phenomena which 
 take place in the terminal distribution of the optic nerve. 
 This category includes certain light phenomena which 
 develop in the retina — the so-called light dust of the inter- 
 nal field of vision, also obscurations and color phenomena. 
 Their development is aided by processes in the retinal 
 vessels, especially by the implication of the blood corpus- 
 cles. The pulsation of the central artery of the retina 
 also produces hallucinations. A material influence upon 
 these phenomena is exerted by the pupillary region, be- 
 cause this is the apparent view-point for the subjective 
 observer, but processes in the macula exert the chief in- 
 
VISUAL HALLUCINATIONS. 47 
 
 fluence in the production of many visual hallucinations. 
 The action of the ocular muscles and nerves possesses less 
 importance. 
 
 A common feature of all the shapes arising from the 
 retinal light proper is their enlargement, often to an 
 enormous extent. This is probably explained by the near- 
 ness of the object seen, especially when the latter is sit- 
 uated in the eye, and the refracting action of its parts is 
 wanting. These hallucinations appear mainly as lights 
 or obscurations in the shape of disks, corresponding to the 
 shape of the yellow patch. When these discs of light or 
 darkness burst forth, as it were, from the macula, they 
 form fruitful material for morbid manipulation in the 
 concepts of the brain. The healthy individual overlooks 
 such processes, especially as they do not develop so vio- 
 lently, or he recognizes the mode of development' and is 
 not alarmed thereby. It is only when there is impairment 
 and restriction of consciousness that the efficiency of ele- 
 mentary sensory deceptions is favored ; hence these so-called 
 peripheral hallucinations are found chiefly in such con- 
 ditions. In this relation flames and lightning are terri- 
 fying phenomena. Fiery points, stars, and rays, such as 
 appear after injury to the eye, also on coughing, sneezing, 
 or bending over, as a rule, are observed only temporarily. 
 But if they are prolonged, as in fever, they form the ma- 
 terial for morbid manipulation in the concepts. Local 
 congestions of the retinal vessels, and the toxic action of 
 morbid chemical constituents of the blood upon the retinal 
 termination of the optic nerves, produce peripheral hallu- 
 cinations in fever, and especially in alcoholic intoxication. 
 In the delirium of alcoholism, dark or shining appearances 
 develop in great number and rapidity. We must assume 
 conditions of irritation or paralysis in the macula lutea, 
 which is affected by variations in the fulness of the ves- 
 sels. The coincident impairment of consciousness does 
 not permit any explanation of these sensory impressions 
 which are conveyed to the brain, and they are interpreted 
 as crawling insects, rats, mice, pigs, cows, etc. The phe- 
 
48 HANDBOOK OF INSANITY. 
 
 nomenon sometimes has a special color because, after 
 looking for a long time at colored objects, the tired retina 
 sees the complementary colors. The sky often furnishes 
 the opportunity for the production of this phenomenon. 
 
 In addition to the blood-corpuscles moving in the ves- 
 sels in front of the retina, the angular pigment epithelium 
 and the roundish granule cells also furnish material for 
 different shapes. If the sensory deception develops in one 
 eye alone, the possibility of distinguishing it from a unilat- 
 eral hallucination, which has developed centrally, is to be 
 sought in the fact that the central development gives rise 
 to much more complicated phenomena. We then find 
 frequently that there are also hallucinations of other 
 senses, and these are combined more readily with other 
 concepts. Moreover, peripheral hallucinations are more 
 pronounced in the dark, and when the eyes are closed, 
 than in a bright light. 
 
 At all events, the entoptically visible masses of the retina 
 must be regarded as the source of numerous retinal phan- 
 tasms ; as the products of nerve substance they differ from 
 the effects of the external world, but are influenced by the 
 latter in certain respects. The movements of the ocular 
 muscles and the retinal pulsations are manifested by ap- 
 parent movements of the retinal phantasms. It has been 
 ascertained in some cases that visual hallucinations appear 
 to grow larger on nearer approach, and this must be ex- 
 plained by the influence of accommodation. The combina- 
 tion of light and dark objects in the entoptic field of vision, 
 with the movements which are superadded by the ocular 
 muscles or retinal pulsations, suffice, when consciousness 
 is morbidly restricted, to produce the notion of various 
 running animals or shapes. As this variety of hallucina- 
 tions depends upon the presence of entoptic masses, we can 
 understand the great variations in their frequency and 
 extent, in otherwise similar morbid conditions of the brain. 
 Under physiological conditions, the frequency of entoptic 
 shapes varies greatly, so that we may expect this form of 
 hallucinations only in those patients who have already 
 
VISUAL HALLUCINATIONS. 49 
 
 experienced these peripheral processes during periods of 
 health. 
 
 The condition of the optic nerve in its path to the brain 
 furnishes an important amplification of the mode of devel- 
 opment of hallucinations. Division of the nerve has been 
 known to abolish previously existing hallucinations, but, 
 on the other hand, there is a series of cases in which hal- 
 lucinations existed despite complete atrophy of the nerve. 
 Hence the site of development must have been situated cen- 
 trally. Pathological data force us to the conclusion that 
 such hallucinations develop in the cerebral cortex, probably 
 only in the occipital and parietal lobes. In dementia par- 
 alytica in which the anatomical changes are confined 
 commonly to the frontal lobes, hallucinations are very 
 rare ; these changes have also been found in the posterior 
 parts of the brain when the patients exhibited distinct hal- 
 lucinations during life. 
 
 Peculiar interest attaches to the unilateral appearance 
 of a half body, for example, half a face or a part of a 
 card, associated with a loss in the field of vision, at- 
 tributable to an interruption of conduction in the corre- 
 sponding optic nerve. This could only be understood on 
 the assumption that the material for the hallucination was 
 collected by the intact optic nerve fibres, and hence the 
 memory images were also halved. 
 
 Although it is very difficult, in individual cases, to 
 prove the peripheral or central origin of an hallucination, 
 this differentiation is very important. It must be remem- 
 bered, however, that both forms may occur together. The 
 theory that hallucinations only develop peripherally as- 
 sumes that the retina possesses a sort of memory, but very 
 little proof is offered in favor of this view. The manifold 
 character and the complicated combinations of visual hal- 
 lucinations, derived from the entire experience of the in- 
 dividual, cannot possibly be attributed to a peripheral 
 retinal memory. 
 
 That memories of our entire range of experience develop 
 in the cortex, is one of the most assured observations of 
 4 
 
50 HANDBOOK OF INSANITY. 
 
 each individual, and between these memories and halluci- 
 nations there is a difference only in degree. It is unjus- 
 tifiable, however, to attribute all hallucinations to central 
 causes. The vividness of some hallucinations appears to 
 be explained insufficiently by a condition of irritation 
 which is confined to the cortex, and hence it was inferred 
 that a centrifugal stimulus passed from the cortex to the 
 terminal distribution of the optic nerve. It was claimed, 
 in support of this mode of conduction, that the phenomena 
 sometimes change their location in space on moving the 
 eye; also that after-images may follow hallucinations 
 which have run their course, for example, when they had 
 developed on falling asleep. But if we adhere to the view 
 that some hallucinations develop peripherally, both of the 
 cases here mentioned can be easily explained. 
 
 Nor does the vividness of other central phenomena re- 
 quire the assumption of a centrifugal conduction of the 
 irritation. This will be understood on studying the pri- 
 mal property of nervous substance in general, and which 
 we call memory in the broadest sense of the word. All 
 visible objects may leave more or less permanent impres- 
 sions on the brain, and remain as memory-pictures in our 
 memory. They may regain their actual distinctness, 
 partly by directing the attention upon them or by repeti- 
 tion of the same impressions from without. This process 
 is known to every healthy individual. I think of a friend, 
 and at once his image stands before me. This faculty 
 varies greatly in different individuals. For example, 
 some painters can paint a portrait from memory. The 
 only material difference between the memory-picture and 
 the actual sensation consists, perhaps, in the fact that the 
 former is associated with the idea that the object is not 
 really present. Between such memory-pictures and cen- 
 tral hallucinations there is only a difference in degree, the 
 process is always the recalling of the memory-picture. 
 
 It is a striking fact, however, that, as a general thing, 
 only a few, constantly recurring memories form the con- 
 tents of hallucinations. A patient constantly sees a skull 
 
ILLUSIONS. 51 
 
 upon a chair, another sees a black object. This is not so 
 astonishing, however, if we bear in mind the property of 
 nervous tissues to recall readily past experiences. 
 
 The special causes of irritation of the cortex will be dis- 
 cussed in other places. Here it may be remarked that 
 the absence of judgment and of revision by other regulated 
 conceptions gives rise to fleeting and unconnected images 
 even in dreams. When the attention is disturbed, as in 
 insanity, the memory-pictures of the irritated cortex may 
 also appear in the waking condition. 
 
 Perhaps there is an alternate action between the per- 
 ception-brain and the place which we assume as that of 
 volitional interpretation of the internal mental processes, 
 viz., the apperception organ in the frontal lobes, in which 
 the predominant activity of one part produces morbid phe- 
 nomena. It is most disastrous for the psychical activity 
 when, with stimulation of the central sensory surfaces 
 and impaired consciousness, the connection of ideas and 
 memory-pictures takes place rapidly and independently of 
 the will. This is the case in the insane. In this condition 
 the power of the hallucinations is very great, and it is true, 
 in a certain sense, that the patient not alone thinks he has 
 visual hallucinations, but that he really sees the shapes. 
 They may be perceived alongside of unchanged, really per- 
 ceived external objects. The overpowering convincing 
 effect of the hallucinations often leads the patient to per- 
 form the most senseless acts. 
 
 All the forms of hallucination hitherto mentioned are 
 thus really produced by processes in the inner life of man, 
 or, strictly speaking, in his central nervous system. 
 These are grouped together under the term visual halluci- 
 nations, and are distinguished from phantasms whose dis- 
 tinguishing feature it is that they are produced by exter- 
 nal objects ; this includes all objects situated in front of 
 the retina and also the corresponding parts of the eye 
 itself. To these the term illusion is applied. A normal 
 consciousness easily recognizes all illusions as deceptions, 
 and corrects them by the aid of the other senses and quiet 
 
52 HANDBOOK OF INSANITY. 
 
 reflection. The excited or irrational patient often inter- 
 prets external objects falsely. Opacities of the vitreous 
 and cornea may cause illusions, and in fact all processes 
 which give rise to entoptic shadows on the retina. There 
 are cases of unilateral visual illusion which disappeared 
 after iridectomy or extraction of the lens, or even after 
 closing the lids. 
 
 The whole of visible nature may be the field of these illu- 
 sions; they develop only when the eye sees an object and 
 hence are always a product of the present. Previous im- 
 pressions are often necessary to the development of hallu- 
 cinations. In retinal blindness there may be hallucina- 
 tions but no visual illusions. In the darkness of night 
 and twilight, the excited fancy is most apt to adopt false 
 interpretations of ill-defined visual impressions. 
 
 Finally, in broad daylight the patient sees things in 
 shapes which are different from the reality, and then there 
 is a gradual transition between illusions based on a false 
 interpretation of objects, and purely imaginary concepts 
 or delusions. Thus, Don Quixote saw giants' arms in- 
 stead of the vanes of the windmills. Here the mode of 
 development of illusions may approach very closely to that 
 of hallucinations proper, because impressions acting from 
 without are often no longer present. Illusions depend 
 upon error of recognition, upon a false interpretation of 
 external. objects. Illusions do not exclude hallucinations. 
 They may occur at the same time in one individual, and it 
 is then not always easy to distinguish them. Such a com- 
 bination is probably of common occurrence, and the refer- 
 ence of hallucinations proper to the external world is so 
 much easier when they are favored by illusions within 
 and in front of the eye. 
 
 But that hallucinations, like ordinary memory-pictures, 
 are per se referred to the outside world, is evident from the 
 fact that such memory-pictures are always seen in front 
 of us, even when the eyes are closed ; on the other hand, 
 it is very difficult to transfer the memory-picture behind 
 one's back. 
 
AUDITORY HALLUCINATIONS. 53 
 
 We will now study the development and location of 
 auditory hallucinations. This is extremely important, be- 
 cause it touches upon the domain of speech, which distin- 
 guishes man from the animals and forms the ways and 
 means for all higher mental development. Internal hear- 
 ing is much more vivid than internal vision. It is the 
 habit of man to think in word-images. The majority 
 accompany their thoughts with the special form of lan- 
 guage-images or writing-images, others with speech- 
 images, i.e., there is in them a stimulation of the speech 
 muscles by the brain. Ideas are more rarely associ- 
 ated with writing movements. We may, therefore, con- 
 clude that internal hearing is associated with internal 
 speaking. Hence, when irritative conditions develop in 
 the cortical auditory centres, the greatly intensified sound- 
 images and word-images are not alone referred to the outer 
 world, but they also reach the highest degree of distinct- 
 ness, because a stimulus also passes to the muscles of 
 speech. Internal speech is a process which exhibits the 
 most different degrees of vividness and thus indicates the 
 transition between healthy and morbid mental activity. 
 As a matter of course, it does not accompany every cen- 
 tral irritative process, but when it does the auditory 
 hallucinations possess overpowering force. They are 
 much more extensive than visual hallucinations, and this 
 must be attributed to the frequent combination with 
 speech-images. This association of word and idea is so 
 firm that in the majority of people every thought produces 
 a sensation in those muscles of speech which would be 
 employed in actual articulation. These slight impres- 
 sions of movement are sufficiently strong to act recur- 
 rently as sensations of movement. This is proven by the 
 statement of many who suffer from auditory hallucina- 
 tions that it seems to them as if their thoughts are spoken 
 or repeated internally, as if communications are made to 
 them through the agency of their thoughts. Thinking 
 double is merely another term for the same process of 
 associated movements in the speech muscles. The state- 
 
54 HANDBOOK OP INSANITY. 
 
 ment is also made that the words are spoken in advance, 
 before they have been uttered by the patient, as if they 
 have been pressed into his brain. If the judgment is im- 
 paired, these words, which are first understood internally, 
 are referred to the outer world, and then the notion 
 follows that the words have a real external origin. 
 
 This does not exhaust the central origin of auditory 
 hallucinations. The memory-pictures of the voice of cer- 
 tain persons are easily aroused ; we can readily recall, in 
 memory, the timbre of the voices of members of our family. 
 Such concepts are also at the command of the insane and 
 are rapidly associated with other memory-pictures. The 
 patient hears the voices of those about him expressing his 
 own thoughts. In explanation of this process the patients 
 call these hallucinations internal voices, which are con- 
 veyed by the telephone or telegraph, recently by the phono- 
 graph. The more impaired the patient's consciousness, and 
 the more ignorant he is, the more readily does he adopt such 
 an explanation. The loudness of these voices varies from 
 the gentle internal speech of the healthy man to the most 
 vivid distinctness, in which the patient really hears as dis- 
 tinctly as if the words were spoken ; indeed, the deception 
 may be so pronounced that the words drown an actual 
 conversation. There are also cases in which the decep- 
 tion does not seem to extend beyond the patient's body and 
 is not referred to the outer world ; they speak of thought- 
 speech, and hear, not the voices of deceased individuals, 
 but their thoughts in their own soul. Or the voices cause 
 a gentle noise, which is referred to some part of their own 
 body ; in these cases it is probable that the reference of the 
 voices to any part of the body is due to a morbid sensation 
 in that part. 
 
 It is a peculiar expression of patients with auditory 
 hallucinations that others read their thoughts ; the pecu- 
 liar character of their own speech muscle movements seems 
 to be described in this way. In a few cases the patients 
 themselves have noted these movements of the organ of 
 speech. We are not justified in claiming that pure inter- 
 
AUDITOKY HALLUCINATIONS. 55 
 
 nal audition precedes internal speech, i.e., the associated 
 movements of the speech-muscles, but the association of 
 both processes varies according to the peculiarity of the 
 affected individual. Whoever is in the habit, as a healthy 
 individual, of thinking more in writing-concepts than in 
 speech- concepts, associates the auditory hallucination with 
 a writing-image, and this probably accounts for the rare 
 cases in which the hallucinated word is seen upon the 
 wall, the table, etc. 
 
 That the point of irritation in the brain possesses ma- 
 terial importance is shown by the fact that unilateral au- 
 ditory hallucinations have been observed after focal lesions 
 on the opposite side of the brain. 
 
 We must now determine to what extent true hallucina- 
 tions may develop in the course of the auditory nerve and 
 its terminal distribution. Anatomically it must be noted 
 that, unlike the retina, the terminal distribution of the 
 auditory nerve (Corti's organ) is not developed from apart 
 of the brain. Hence, there is no reason at all for assum- 
 ing a peripheral memory, and we can only conjecture that 
 perhaps diseases of Corti's organ may be direct causes of 
 auditory hallucinations. 
 
 Deaf people may experience auditory hallucinations, in 
 a manner analogous to the visual hallucinations in atrophy 
 of the optic nerve. We may here refer likewise to the 
 ability of great musicians to compose symphonies, despite 
 complete deafness, and this presupposes almost actual dis- 
 tinctness of sound-concepts. 
 
 There are numerous causes of auditory phantasms out- 
 side of the auditory nerve, and these must be included 
 among illusions. Our attention is first attracted by so- 
 called entotic noises ; the part which is here played by in- 
 dependent irritative conditions of the termination of the 
 auditory nerve cannot be estimated, and such conditions 
 must be examined in connection with those causes which 
 appear in the immediate vicinity. In the ear itself we 
 find inflammations of the drum membrane and cavity, and 
 all those conditions which increase the pressure of the fluid 
 
56 • HANDBOOK OF INSANITY. 
 
 in the labyrinth. Hence, chronic catarrh is the most fre- 
 quent cause of noises in the ear. Congestion and inflam- 
 mation of the semicircular canals act in the same way. 
 Loud and persistent noises arise from pulsating vessels, 
 such as the internal carotid ; or roaring noises develop, 
 especially in general ansemia, in the bulbus of the internal 
 jugular vein beneath the floor of the middle ear. All 
 these sounds may become the material of illusions when 
 consciousness is disturbed, but the healthy individual 
 usually secures the proper interpretation. The latter, how- 
 ever, often refers the whistling, etc., to the external 
 world until experience teaches him that the noise is 
 located in his own head. Other bodily sounds, such as 
 the movements of air and gases in the bowels, rales in the 
 lungs, and heart sounds may also constitute the material 
 for illusions. 
 
 All real sounds of the outer world may also be falsely 
 interpreted into illusions, and here the close relationship 
 is shown between auditory illusions and delusions. 
 
 As a matter of course, hallucinations and illusions of 
 hearing may exist together. Many of these patients stop 
 their ears. This is perhaps explained by the assumption 
 that illusions due to the ill-defined noises of every-day life 
 (rattling of wagons, etc.) are thus prevented, but the at- 
 tempt will be partly useless and only explicable in view of 
 the undoubted attempt to prevent hallucinations which are 
 referred to the outer world. 
 
 Hallucinations and illusions of smell cannot be distin- 
 guished separately except in those very different cases in 
 which they are produced in the central olfactory cortex or 
 in which they are due to the interpretation of causes situ- 
 ated outside of the body. The boundary between the ter- 
 minal distribution of the olfactory nerves and the adjacent 
 mucous membrane does not allow us to decide practically 
 between peripherally developed hallucinations and illusions 
 based on processes within the body. Although we may 
 regard peripheral olfactory hallucinations as possible, they 
 are the same, for our purposes, as illusions. Nasal 
 
OLFACTORY HALLUCINATIONS. 57 
 
 catarrhs, congestion and proliferations of the mucous 
 membrane, and all other pathological changes in the nose 
 are among the causes of illusions. Smells which actually 
 develop in any part of the body, such as the smell of de- 
 composing epithelium of the tongue, may give rise to the 
 notion of decomposition or poisoning. The possibility of 
 the misinterpretation of all smells in the external world 
 into illusions is also easily understood. 
 
 Disagreeable olfactory hallucinations have also been 
 observed in progressive destruction of the olfactory nerves 
 by tumors, so long as an irritative condition of the nerve 
 persisted. Very few cases of true hallucinations have been 
 observed after entire destruction of the nerves. A notice- 
 able phenomenon is the loss of smell, lasting hours or days, 
 in persons suffering from increased cerebral pressure. 
 This must be attributed to variations in pressure, and per- 
 haps this cause partly explains the periodical occurrence 
 of olfactory hallucinations. This may also be true of the 
 other nerves of special sense. 
 
 Concerning the olfactory hallucinations which develop 
 in the central olfactory area, not much can be said, be- 
 cause its location in the cortex is not positively known. 
 It is a very striking clinical fact that olfactory hallucina- 
 tions are often associated with morbid sexual phenomena. 
 
 The development and situation of gustatory hallucina- 
 tions are very similar to those of smell. They are also 
 very rare, but not devoid of importance, as they sometimes 
 lead to refusal to take food. The difference between hallu- 
 cinations and illusions becomes indistinct at the boundary 
 between central and peripheral parts. Very often the 
 possibility of direct effects of processes in the mucous 
 membranes cannot be excluded in the " contact " senses of 
 smell and taste. For example, the chemical action of de- 
 compositions in the buccal cavity undoubtedly plays a fre- 
 quent part. The possibility of a purely central develop- 
 ment is shown by the fact that gustatory hallucinations 
 are often combined with those of smell, hearing, and sight. 
 
 Great practical importance attaches to hallucinations of 
 
58 HANDBOOK OP INSANITY. 
 
 feeling. The main difficulty in examination is found at 
 the boundary line between hallucinations and illusions. 
 The wide distribution of the terminal nerves in the integu- 
 ment, mucous membranes, and internal organs leads to a 
 further difficulty. In almost all cases only small parts of 
 the entire sense of feeling are to be examined. We must 
 determine whether these belong to definite peripheral nerve 
 tracts or to tracts whose nerves unite only in the centres. 
 In the latter event the deception of feeling probably is pro- 
 duced in the brain, i.e., it is an hallucination, in the for- 
 mer event it may also be an illusion. In the skin the 
 proof of such connection is not often possible, it is easier 
 in the mucous membranes and internal organs. The 
 demonstration that hallucinations develop peripherally in 
 the skin is not practicable, because we are not accustomed 
 to refer cutaneous sensations to any other parts. On ac- 
 count of this peculiarity cutaneous sensibility, as a contact 
 sense, is closely related to smell and taste. In the main it 
 is mechanical impressions, and also differences in degrees 
 of heat, which give rise to illusions of the sense of feeling. 
 A proof of the view that deceptions of feeling are com- 
 monly illusions is found in the fact that, as a rule, the 
 patients merely compare their sensations with similar pro- 
 cesses. But after the illusion has lasted a long time, its 
 original cause disappears in the patient's mind and may 
 pass into his memory, whence it may appear later as an 
 independent hallucination. This is also true of the other 
 Senses. The well-known notion of the presence of an 
 amputated limb affords an illustration of an hallucination 
 which has become central, after the original irritative 
 phenomena in the cicatrix of the nerves have disappeared. 
 This process is a complicated one, however, on account of 
 the implication of the muscular sense. Indeed, this can 
 often not be separated from cutaneous sensibility in con- 
 sidering deceptions of feeling. When, for example, un- 
 usual positions of the limbs give rise to illusions in dis- 
 eases attended with cutaneous insensibility, this is due to 
 the peripheral terminations of the nerves in the muscles.. 
 
HALLUCINATIONS ORIGINATING IN VISCERA. 59 
 
 The central origin of muscular sense may also give rise to 
 hallucinations, as is shown by the remarkable feeling as if 
 the patient were flying. 
 
 The combination of correctly interpreted perceptions with 
 misinterpretation of other impressions is found most fre- 
 quently in ideas concerning the condition of the viscera. 
 This is particularly true of the hypochondriac. Deceptions 
 concerning the condition of the genitalia are very impor- 
 tant in this regard ; also the disturbance known as imper- 
 fect feeling of satiety which is often due to gastric affec- 
 tions. All other viscera whether healthy or diseased may 
 also cause changes of common sensibility and thus lead to 
 deceptions. This common sensibility undoubtedly has a 
 central origin, as is shown particularly by the occurrence 
 of numerous associated sensations which depend on irrita- 
 tive conditions of the most varied nerves. Pain is the most 
 important disturbance of common sensibility, and is very 
 significant in the development of hallucinations. But if 
 diseases of the nerve-fibres themselves are converted into 
 delusions, we see that falsely interpreted sensations are not 
 always true sense-deceptions, and that the difference be- 
 tween these two forms of disturbance of the perceptive pro- 
 cess must be maintained. 
 
 Hallucinations in general are connected with the 
 contents of consciousness at the time, and this is shown 
 most clearly when the thoughts are expressed aloud. 
 As auditory hallucinations occur chiefly in chronic dis- 
 orders they form the most frequent variety; and their 
 connection with thoughts entertained at the time is very 
 common and is expressed in speech. The patient calls 
 these processes "voices," although numerous other noises 
 are also heard. The auditory hallucinations are usually 
 of a disagreeable, distressing character. Reproaches, in- 
 sults, and ironical remarks, generally in short sentences, 
 excite the patient and lead him to commit violence 
 against his supposed revilers and persecutors. Their 
 threats impel him to flee; their commands lead to sense- 
 less and unnatural acts, especially when they are ascribed 
 
60 HANDBOOK OF INSANITY. 
 
 to higher powers. The pitch and timbre of the voices are 
 often distinguished, and are then ascribed to different per- 
 sons. They speak in a whispering or hissing tone, from 
 a distance, from above or from the floor ; at other times, 
 they are so loud that all other sounds are drowned. More 
 rarely the patients hear loud noises, music, or singing ; in 
 the rarest case's do they have an agreeable character. The 
 patients hear hammering, ringing of bells, or the driving 
 of nails into a coffin. They are usually associated with 
 visual hallucinations, in the shape of supernatural beings.' 
 God or Christ appears to the patient, promises him future 
 greatness, directs him as to the manner in which to obtain 
 his rights. As the auditory hallucinations return to the 
 circle of ideas from which they have usually developed, 
 they form a constant stimulus for the same delusions. 
 
 In a fewer number of cases the voices are entirely for- 
 eign to the patient's ideas and thus excite still greater 
 terror. 
 
 The contents of visual hallucinations are not always so 
 unpleasant. As they occur most frequently in acute affec- 
 tions, they are cheerful or depressed, according to the 
 character of the psychical disorder. The usually peri- 
 pheral hallucinations of the alcoholic consist of mice, rats, 
 birds, insects, whose rapid movements often provoke 
 the patient's mirth, but sometimes terrify him. Other 
 peripherally developing light-phenomena are masses of 
 fire or light; the patient imagines himself in heaven, 
 and sees the glory of God, or believes he is surrounded 
 by the flames of hell. The more impaired consciousness 
 is, the more terrible do the contents of such visual hallucina 
 tions become, and these conditions of terror are sometimes 
 of frightful violence — for example, in epileptics. 
 
 However, not all statements of the patient concerning 
 visual hallucinations may be accepted unreservedly. 
 They are often merely dreams which are regarded as real, 
 or the patient has a tendency, when leading questions in 
 this direction are asked, to boast of fleeting ideas as dis- 
 tinct sense-perceptions. 
 
COMBINED HALLUCINATIONS. 61 
 
 Olfactory hallucinations are usually disagreeable in 
 character. The smell of a cadaver or of sulphur is often 
 mentioned ; the delusion of poisoning and refusal to take 
 food often accompany such hallucinations. The majority 
 of gustatory hallucinations are also disagreeable and are 
 generally attributed to mixtures with food. In a few cases 
 the hallucinations are pleasant. 
 
 Hallucinations of feeling are very numerous and vary- 
 ing. They are more frequently pleasant than hallucina- 
 tions of other senses, yet the disagreeable ones predomi- 
 nate. This is especially true at the onset, when they are 
 generally foreign to the contents of the patient's ideas. 
 With increasing mental weakness their disagreeable na- 
 ture disappears. We must not regard as real all the 
 strange judgments which patients affirm concerning their 
 true, but falsely interpreted sensations. The patient em- 
 ploys peculiar expressions to express his sensations. 
 Pinching, pricking, burning, tearing, which indicate a 
 peripheral origin, are frequently employed. These are 
 often combined with statements that the patients are being 
 magnetized — evidently an attempt to explain the sensa- 
 tions. Their contents also depend greatly on the feelings 
 which arise from the condition of the viscera. 
 
 Hallucinations of several senses are very commonly 
 associated with one another. This is particularly true of 
 the contact senses, especially smell and taste. Auditory 
 hallucinations are often observed alone; visual hallucina- 
 tions are hardly ever independent of hallucinations of 
 hearing or feeling. 
 
 The strength of hallucinations varies during the disease, 
 being less at the beginning and end; they rarely cease 
 suddenly. When recovery begins, the visual hallucina- 
 tions usually become less vivid, the outlines become 
 vague, auditory hallucinations become remote and indis- 
 tinct. At this time the patient's attention may be drawn 
 to the morbid character of his condition in order to has- 
 ten recovery. But even then caution is necessary, be- 
 cause attention should not again be called to the disap- 
 
62 HANDBOOK OF INSANITY. 
 
 pearing conditions. It is entirely wrong, however, to 
 attempt, at the height of the disease, to reason the patient 
 out of his hallucinations. This is usually harmful because 
 the patient's mistrust is excited or increased. 
 
 Hallucinations occur not alone in mental disturbances, 
 so that they must be associated with a change in the 
 entire personality before they justify the diagnosis of 
 insanity. 
 
 2. The Disturbances of Consciousness during Sleep 
 and Dreams. Associated States of Impaired Con- 
 sciousness and Hypnotic Conditions. 
 
 Sleep is related so closely to mental activities and dis- 
 turbances that it becomes necessary to investigate its 
 cause. As a rule, two causes co-operate in its production, 
 viz., the exhaustion of the central nervous system and the 
 diminution of attention. Sleep is associated with the ac- 
 tivity of the apperception organ ; inhibitory effects upon 
 the movements of the heart, respiration, etc., are pro- 
 duced ; during their influence the psychophysical side of 
 mental life rests and recuperates. An increase or diminu- 
 tion of the regular periodical function of the brain, which 
 appears in the shape of sleep, may be one of the most strik- 
 ing signs of mental disturbance. 
 
 The most important is insomnia, because it is not alone 
 a sign but a cause of the development of the psychical dis- 
 order. Restless sleep may also occur constantly in a 
 healthy individual, but when it is a new sign it acquires 
 greater importance. 
 
 Somnambulism is a more important symptom. As a 
 rule during sleep, more rarely in the daytime after hys- 
 terical or epileptic seizures, the patients walk about, per- 
 form various acts, even commit crimes, and then lie down, 
 without having, on awaking, more than a confused mem- 
 ory of such events. During the attack the disturbance 
 of consciousness is usually not very profound, because the 
 individual is often awakened by noises or sudden contact. 
 The sureness of movement amid dangerous surroundings, 
 
SOMNOLENCE. 63 
 
 for example, in walking upon a roof, can only be explained 
 by the imperfect conception of the situation, where danger 
 is not recognized, so that dizziness and fear are wanting. 
 
 A more profound disturbance of consciousness is ex- 
 hibited in the various forms of somnolence. Conscious- 
 ness is impaired or entirely wanting for long periods; 
 these are only interrupted for short intervals during which 
 the ingestion of food and the wants of nature are attended 
 to. These conditions are distinguished from normal sleep 
 by their long duration and by their causation ; this may 
 consist of an organic disease of the brain or a purely ner- 
 vous cause, with or without previous exhaustion. 
 
 The so-called dream conditions, which appear in attacks 
 of longer or shorter duration, are a peculiar form of im- 
 pairment of consciousness. Special importance attaches 
 to those which develop during or after spasmodic seizures, 
 and in which violent acts are occasionally performed. Psy- 
 chologically we have to deal with a disorder in the interpre- 
 tation of all impressions by the attention, and everything 
 points to a disturbance of the apperception organ, explica- 
 ble by variation of the amount of blood in the cerebral cor- 
 tex. At the end of this series of different degrees of im- 
 paired consciousness stands unconsciousness in which 
 physiological stimuli are no longer converted into mental 
 processes. The unconsciousness may be temporary, as in 
 drunkenness, severe convulsions, febrile conditions, inflam- 
 mations of the brain ; or permanent, in the course of many 
 chronic forms of insanity, especially in imbecility. 
 
 The unconsciousness of sleep may suffer an interruption 
 which leads to a changed condition in the shape of dreams. 
 Products of decomposition arising from the processes of 
 disassimilation act during sleep as irritants and overcome 
 the existing inhibitions so that individual concepts appear 
 and may be united with feeble sensory impressions. The 
 latter are illusions, but may be associated with true hallu- 
 cinations arising from memory-concepts, and may enter 
 the impaired consciousness. The most abundant material 
 is offered by the movements and processes within the 
 
64 HANDBOOK OF INSANITY. 
 
 body, the muscse volitantes, and auditory impressions due 
 to tinnitus. 
 
 It is an important fact that dream-like conditions may 
 be produced by certain poisons and drugs. Atropine 
 arouses memory-pictures of ugly and terrifying things, 
 cannabis indica of beautiful things, ether produces the feel- 
 ing of flying in infinity. Hence, different mental activi- 
 ties are excited singly, or, as in chloroform narcosis, a 
 definite order in the implication of certain parts of the 
 brain can be recognized. Dreams are thus characterized 
 as morbid processes, but, like central hallucinations, they 
 grow insensibly out of normal, undisturbed sleep. 
 Whether this partial activity of the brain in artificial and 
 natural dreams is accompanied and caused by circulatory 
 conditions cannot be proven, but may be assumed from its 
 similarity to the condition of sleep. 
 
 Allied to sleep is the disturbance of consciousness 
 known as hypnosis. The latter is distinguished from sleep 
 by the fact that only some of the cerebral functions are 
 inhibited. Unlike somnambulism, hypnosis is an artifi- 
 cially produced condition. After the hypnotized indi- 
 vidual has passed into a condition of half-sleep, in which 
 catalepsy finally develops, the peculiar stage of hypnosis 
 proper develops. Voluntary movements are again possi- 
 ble, and sensory impressions may be received, but con- 
 sciousness is restricted in a peculiar manner, so that it is 
 only susceptible to certain external impressions. The indi- 
 vidual may be led by suggestion because the fully inde- 
 pendent faculty of active attention is wanting. Hence, 
 this disorder must be sought in the apperception-organ. 
 Experience shows that the frequent production of hypnosis 
 may lead to mental disturbance, especially as persons 
 suffering from an hereditary taint are best adapted to hyp- 
 nosis. Although favorable results from the employment 
 of hypnosis in the treatment of psychical affections have 
 been reported, the condition is still so obscure that we 
 cannot yet recommend it to the practical physician. Apart 
 from so-called hypnosis major, which is due in great. 
 
CATALEPSY. 65 
 
 measure to an hysterical basis, ordinary artificial hypnosis 
 may be regarded as a partial sleep. The assumption also 
 appears to be justified that the differences between sleep 
 and hypnosis are due to the varying rapidity with which 
 the different senses are put to sleep, hearing and muscular 
 sense being the last to become exhausted. The decisive 
 influence is exercised by attention, and in this connection 
 we may assume longer or shorter periods of contraction of 
 individual vascular tracts in the brain as the intermediate 
 accompanying phenomena. 
 
 Much more importance attaches to catalepsy, which is 
 either a part of other diseases, or appears independently. 
 It is a symptom-complex, composed of impaired conscious- 
 ness, with anaesthesia, muscular rigidity, and more or 
 less flexibility of the limbs. Retention of urine and depri- 
 vation of food are subordinate symptoms, which are ex- 
 plained by the motor and psychical condition. The term 
 catalepsy is also employed when one or the other of these 
 symptoms is absent. The basis is always a mental dis- 
 turbance of some kind, hysteria, melancholia, progressive 
 paresis with weakness, or a more independent disorder of 
 consciousness. Upon this basis develops the peculiar mus- 
 cular rigidity, associated with so-called waxen flexibility. 
 This combination is difficult to understand physiologically ; 
 the tetanic rigidity first develops, later the flexibility. 
 The explanation is not proven but plausible that the rigidity 
 is due to unequal innervation of antagonistic muscles, 
 while, in waxen flexibility, they are innervated, at any mo- 
 ment, with complete uniformity. The condition is gener- 
 ally involuntary, but sometimes semi- voluntary as the re- 
 sult of delusion or as a sort of play, and is then confined 
 to a few groups of muscles. Hysterical individuals and 
 some paretics have a tendency in this direction. As a 
 matter of course, a certain degree of clearness of con- 
 sciousness is then necessary. The more consciousness is 
 impaired, the more general is the extent of the motor 
 symptoms. The location of catalepsy must be referred to 
 the frontal lobes, the disturbance of consciousness point- 
 5 
 
66 HANDBOOK OF INSANITY. 
 
 ing to the apperception-organ, the motor symptoms to the 
 adjacent central convolutions. 
 
 Stupor and ecstasy may resemble catalepsy in their out- 
 ward manifestations, but have a different origin. These 
 disturbances of consciousness are associated with definite, 
 partly voluntary and conscious notions. According as 
 these concepts are sad or cheerful, stupor or ecstasy will 
 be produced. Self -consciousness is not entirely abolished, 
 but the ability to concentrate the attention actively is 
 merely impaired, slowed, or accelerated. Hence, stupor 
 and ecstasy may be influenced by delusions which are 
 generally absent in catalepsy. But as an organic basis is 
 not wanting in stupor, it is associated with other symp- 
 toms, such as slow, superficial respiration, circulatory dis- 
 turbances, slowness of digestion, etc. As the final effect 
 of a melancholic condition, stupor very often passes grad- 
 ually into dementia. The inability to distinguish these 
 conditions accurately is evident from the fact that the 
 term stupor is also applied to conditions of exhaustion 
 after epileptic convulsions, maniacal excitement, and fe- 
 brile diseases. Ecstasy is distinguished from catalepsy 
 only by its development from delusions, and its combination 
 with hallucinations. 
 
 3. Disorders of Self -Consciousness. 
 
 The above-mentioned signs of mental disturbances, es- 
 pecially of consciousness, necessitated a distinction between 
 consciousness in general and self-consciousness. We have 
 already applied the term consciousness to the occurrence of 
 impressions of internal and external experience, and their 
 conversion into mental processes. In the to-and-fro 
 movement of concepts in this consciousness, one group of 
 coherent individual concepts is distinguished apart from 
 the others ; it is the group whose source resides in our- 
 selves. The sensory concepts received from our own 
 body and the movement-concepts of our limbs are co- 
 herent and permanently present. At any time they are 
 readily associated with other concepts, according to habit 
 
CHANGE IN THE EGO. 67 
 
 or voluntary effort. This consciousness of our own per- 
 sonality is self-consciousness. In mental disorders a change 
 of self -consciousness may be one of the most prominent 
 signs of disease. The most important form of the disor- 
 ders of self-consciousness is the consciousness of disease. 
 Long before the beginning of the disease proper, there is 
 often a terrifying feeling of impending loss of reason, es- 
 pecially in individuals with an hereditary taint. This 
 feeling is sometimes so vivid that the patient seeks admis- 
 sion into an insane asylum. Even at the height of the 
 disease some patients feel that there is a disturbance in 
 the course of their moods which is not dependent on ex- 
 ternal influences. As a rule, morbid general sensations 
 constitute the direct basis of this diseased self-conscious- 
 ness. But while the patient is struggling against the con- 
 stantly recurring morbid impressions and feelings, the 
 well-defined concept of his own ego is becoming changed. 
 Here it loses, there it gains elements by detachment or 
 combination with other groups of concepts, and with the 
 feeling of resistance the normal self -consciousness disap- 
 pears or changes more and more. The association with 
 the past is lost, and the present personality appears foreign 
 to the former ; if fragments of the former have been re- 
 tained, delusions of double personality may develop. At 
 other times self -consciousness disappears so completely that 
 the patient regards himself only as an object, or even this 
 becomes so remote from the circle of inner self -observation 
 that a nihilistic delusion develops, the notion that nothing 
 exists or that the person of the patient no longer exists. 
 This absence of self-consciousness has been often found 
 associated with atrophy of the cortex, especially in demen- 
 tia paralytica — another proof that the frontal lobes are in- 
 timately related with these disorders. But apart from 
 these special forms of the feeling of being sick, it is one 
 of the most striking and widespread symptoms in almost 
 every psychical affection that this feeling is lost after 
 the affection has lasted a long time. Patients in an asy- 
 lum often exhibit a clear comprehension of the speech and 
 
68 HANDBOOK OF INSANITY. 
 
 acts of their fellow-patients, but have false judgments 
 concerning themselves. 
 
 The convalescent patient recovers his former self-con- 
 sciousness and gains a clear insight into his disease. This 
 is one of the most important signs of beginning or com- 
 pleted recovery after disturbances of self -consciousness and 
 mental diseases in general. 
 
 B. DISTURBANCES IN THE ASSOCIATION AND COURSE 
 
 OF IDEAS. 
 
 The disturbances of consciousness which we have con- 
 sidered in the previous section are observed, in not a few 
 cases, in those who are mentally healthy. The disorders 
 in the association and course of ideas, which we will 
 now discuss, may also occur occasionally in the sane, but 
 in general they are evidence of an already existing or 
 developing mental disorder. 
 
 1. Apperception and Association. 
 
 As the boundaries of inner experience are also the limits 
 of consciousness, the elements of the disorders now under 
 consideration belong within these limits, inasmuch as 
 they also occur within that broad field of cerebral life from 
 which individual concepts may reach apperception. We 
 must distinguish, however, whether the material of the 
 concepts is called forth actively by attention or is passively 
 noticed. In the flow of cerebral life concepts appear in 
 great numbers ; if a sort of struggle ensues between them 
 to reach apperception, we feel this internal activity as an 
 action to which we apply the term active attention. But if 
 one of the concepts in question is favored by its characteris- 
 tics to such an extent that the apperception of another con- 
 cept cannot come into question, it is received merely by 
 passive attention. With the ideas which are aroused by 
 external sensory impressions are constantly combined the 
 memory-pictures of former ideas ; the association of the 
 ideas furnishes the material from which the attention 
 
ASSOCIATION OF IDEAS. 69 
 
 collects individual elements. When the selection is made 
 from a number of such concepts, the attention is active and 
 only brings up one after another for interpretation ; the 
 attention is passive when an undoubted association of in- 
 dividual concepts has taken place. The lunatic is very 
 often in such a position that he is only passively and not 
 actively attentive to the internal processes of his experi- 
 ence, and constantly grows more and more impotent 
 against the successively appearing ideas and bheir com- 
 binations. Not alone the present concepts come into 
 play, but the entire prior development of consciousness is 
 superadded. There is, however, an imperfect interpreta- 
 tion of the concepts which have developed in the past and 
 the present, and their irregular combination leads to in- 
 coherency. When active attention has not yet disap- 
 peared entirely, the disorder appears as absent-minded- 
 ness. When active attention ceases entirely we find con- 
 ditions in which the combination of ideas may even be 
 made to depend upon the will of others, as in suggestion. 
 This is done experimentally in hypnotism, and the so-called 
 epidemic spread of mental disorders is also explained in a 
 similar way. The predominance of irregular combina- 
 tions of concepts over the regular arrangement into clear 
 notions is the first and most important sign of mental 
 weakness. In congenital and acquired feeble-mindedness 
 there is no regular and close combination of new and old 
 concepts. But in all conditions, which vary from mental 
 health to complete imbecility, the disturbance appears in 
 the greater or less difficulty of active selection among the 
 concepts and their combinations. Purely external influ- 
 ences make themselves felt, as, for example, the association 
 of ideas with words of similar sound, which are either 
 spoken by the patient himself or by others. Such persons 
 are apt to speak in verses which have no connection and 
 merely show a relation of sounds, especially of the terminal 
 words. Other patients grasp only a single word in a con- 
 versation and associate with this the series of ideas which 
 are then appearing in their consciousness. 
 
70 HANDBOOK OF INSANITY. 
 
 2. Accelerated and Retarded Course of Ideas. 
 
 If an accelerated flow of ideas takes place, as in 
 some conditions of excitement, the overfilling of con- 
 sciousness in itself leads to incoherency. This requires, 
 however, a high degree of acceleration of the flow of 
 thought ; in moderate degrees the combination of different 
 series of thoughts is facilitated. The individuals then 
 become more brilliant and witty ; the successful expression 
 of delicate irony and the ability to rhyme easily are some- 
 times found in such cases. But when the concepts follow 
 one another so rapidly that they cannot enter their suitable 
 combinations, a wild flight of ideas is developed. In the 
 highest degrees, even vigorous external impressions are 
 no longer able to restrain the hurrying flood of ideas for 
 a moment. 
 
 Incoherency may also arise from slowing of the concepts 
 and their combinations. The anxious patient becomes 
 confused because his thoughts appear slowly. Confusion 
 characterizes conditions of mental exhaustion with a slow 
 course of thought. Sometimes the incoherency is only ap- 
 parent, if aphasia, due to a definite anatomical lesion, is 
 present. Another result of the slow course of thought is 
 the monotony of the ideas. The violent psychical pain 
 completely fills the consciousness of the melancholic 
 patient, and allows nothing else to develop ; the march of 
 thought sometimes appears to stand still entirely, and only 
 single words and phrases are repeated for hours. 
 
 The insufficient change of concepts is not alwaj T s due 
 to their slowness of succession, but occasionally is depend- 
 ent on their long duration. This disorder is often ob- 
 served, in a mild form, in healthy individuals ; we cannot 
 escape certain notions, "we can't get rid of the idea." 
 This is especially true of rhythmically associated groups 
 of ideas, such as verses and melodies. As a rule these 
 phenomena disappear rapidly, at the most in a few days ; 
 if they last longer, they appear to us to be morbid, and are 
 associated wi-th disagreeable feelings. " Gruebelsucht" is 
 
IMPERATIVE IDEAS. 71 
 
 a remarkable clinical form of this disturbance. The 
 ideas which force themselves upon consciousness almost 
 always appear in the shape of questions, usually of a reli- 
 gious or metaphysical character. This disagreeable feeling 
 of compulsion is also common to imperative conceptions 
 which appear in various other affections. The feeling of 
 compulsion on the part of the patient must be emphasized 
 because this alone distinguishes it from delusions. Nu- 
 merous patients complain that they cannot get rid of cer- 
 tain annoying thoughts whose folly they recognize, and 
 which lead them to commit actions which they find laugh- 
 able or disgusting. In the individual cases, the contents 
 of the imperative conceptions are always confined to a 
 narrow circle. The psychological explanation of a large 
 number of these imperative conceptions seems to be 
 hinted at in the consideration of the circumstance that, 
 in our mental processes in general, we usually employ 
 comparison, and attempt to make a selection among an- 
 tagonistic concepts. 
 
 While, in this play of question and answer, the healthy 
 consciousness at first shows no preference among the nu- 
 merous ideas which lie ready for combination, but first 
 compares the single ones, in the morbid condition an 
 antagonistic idea enters consciousness with imperative 
 force. Such questions are : " Why is the moon round and 
 not square?" or, "Why are twice two four, and not six?" 
 or, " Why is not the stove in the middle of the room?" Or 
 the question refers to an action just completed, and runs : 
 " Why have I done this, and would not the opposite have 
 been preferable?" Or an individual doubts whether he 
 has closed the door properly or has properly addressed a 
 letter, and cannot rid himself of the thought even after 
 renewed examination. The antithesis of the present situ- 
 ation always forces itself into the course of the patient's 
 thoughts : on a tower, he thinks of jumping down ; near 
 a locomotive, of throwing himself in front of it ; in an 
 open square, of the dread of being unable to pass. In the 
 latter cases the imperative notion may be favored by the 
 
72 HANDBOOK OF INSANITY. 
 
 occurrence of vertigo. Others cannot remain in closed 
 rooms, from the dread that some accident, such as fire, 
 may render their escape impossible. 
 
 But the imperative conception does not always appear 
 in relation to an antithesis; it often originates imme- 
 diately and directly, and is not found in the shape of a 
 question. The patient occasionally can repress the de- 
 veloping thought before it pushes itself distinctly into con- 
 sciousness. But if this is no longer possible, and the 
 single independent concept becomes firmly rooted, a 
 transition is furnished to the stage in which the hitherto 
 strange notion appears natural to the patient. Previously 
 he had attempted to correct the idea, which was rec- 
 ognized as morbid, by all other ideas at his command, 
 but now this single one becomes the fixed point around 
 which all others are grouped, and thus a form of delusion 
 develops. 
 
 3. Delusions. 
 
 Delusions are false judgments, and hence closely allied 
 to errors in their development and contents. Superstition 
 shows a transition between delusions and error. Common 
 to all of them is a weakness of judgment, which is either 
 congenital or acquired. Acquired lack of judgment char- 
 acterizes delusions. Every healthy individual makes 
 mistakes, but he is able to correct them, according to the 
 degree of his congenital and acquired mental abilities. 
 Superstition, as a result of education, and an expression 
 of the general condition of culture of the community, is 
 influenced with much greater difficulty; but, unlike de- 
 lusions, it does not always persist against all opposition, 
 as a firm acquisition of the diseased brain. We must as- 
 sume a disease of the brain, because the development of a 
 delusion is either associated with an hallucination, or 
 can only be explained by a central irritative condition. 
 According as the connection occurs only among previous 
 remembered concepts or as these are associated with new 
 external sensory impressions, delusions exhibit a close re- 
 
DELUSIONS. 73 
 
 lationship to hallucinations or illusions. A false judg- 
 ment is due, however, only to the uncritical acceptance of 
 the combination of ideas which occupy the foreground, 
 and this depends on some morbid condition of the brain. 
 Hence a certain degree of mental weakness is necessary to 
 the development of delusions. The imperfect comprehen- 
 sion of the morbid element indicates in itself the weakness 
 of judgment, and this is not found in imperative concep- 
 tions. The more frequently and vividly hallucinations de- 
 velop in a brain, particularly when several sensory tracts 
 are affected at the same time, so much the more readily is 
 judgment disturbed. Even when the hallucinations sub- 
 side, the patient, as the result of the underlying weakness 
 of judgment, is no longer able to escape from the morbidly 
 facilitated concepts. Here his own personality takes part 
 in the process. The disappearance of more profound 
 sympathy for others, especially for members of his own 
 family, is one of the most certain signs of the beginning 
 mental weakness which accompanies delusions. When 
 several delusions exist, the lack of judgment is generally 
 so great that the patient makes the most contradictory 
 statements, and his previous personality appears to him to 
 be entirely changed. If the power of judgment is more 
 marked, the patient generally eludes questions concerning 
 his delusions, whose strange character still astonishes him 
 somewhat. Sometimes he makes an explanation by means 
 of comparison ; for example, he states that it is as if this 
 or that sensation is produced by the external influence of 
 other persons ; more frequently he simply states that things 
 are as he says. The hallucination, which is usually un- 
 derlying, is so vivid that the connection with other con- 
 cepts of former experience becomes easy to his impaired 
 judgment and requires no explanation. Delusions which 
 develop directly, without hallucinations, are more apt to 
 change and disappear. 
 
 The contents of delusions are as manifold as the ideas 
 of man. Like the latter they are associated chiefly with 
 expression by means of language. Hence the largest 
 
74 HANDBOOK OP INSANITY. 
 
 number are based upon a combination with such auditory 
 concepts as can be expressed in speech. There are 
 important clinical differences, however, so long as the 
 mental disturbance is in process of development, and the 
 chief difference in their contents depends upon whether 
 the patient is in a cheerful or depressed mood. Numerous 
 hypochondriacal delusions refer . to the body and result 
 from disturbances of common sensibility. The patient is 
 convinced that he is suffering from a severe disease (dis- 
 eases of the heart, lungs, spinal cord, genitals). Some- 
 times the dreaded disease changes or several diseases are 
 feared. Sometimes the hypochondriacal delusion has very 
 strange contents. Headache or painful sensations in gen- 
 eral are attributed to changes in the brain. The patient 
 then feels that his brain has dried up or disappeared, or 
 has undergone some other peculiar change. One patient 
 was convinced that the posterior parts of his brain were 
 removed, and that he possessed only a face and a small 
 part of the brain. Or the head is excavated, and the brain 
 replaced by a sponge or a bladder. Still more varied are 
 the delusions which are associated with conditions and sen- 
 sations in the digestive organs. The mouth and anus ap- 
 pear closed ; the oesophagus is so narrow that deglutition is 
 impossible. The stomach is filled with glass and pieces 
 of wood ; the food is retained in the body and is gradually 
 deposited beneath the skin. Other hypochondriacal de- 
 lusions develop from irritative conditions of the sexual 
 apparatus, especially in young people who practise mas- 
 turbation. The dread of being impotent prevents the 
 performance of coitus. Sensations in the skin cause re- 
 peated washings for fear of having been made unclean by 
 contact with some object. The dread of finding sharp 
 objects in the clothes extends to other objects, and a so- 
 called fear of contact develops. As various organic feel- 
 ings often combine to produce hypochondriacal delusions, 
 the notion of bodily transformation often develops, so that. 
 the patient thinks he is bewitched or is controlled by mag- 
 netic machines. In the highest grades, the entire body 
 
EXPANSIVE DELUSIONS. 75 
 
 appears changed, and the notion develops that the patient 
 is converted into an animal. 
 
 Delusions very often assume the shape of ideas of per- 
 secution, which vary according to the predominant affec- 
 tion of the different senses. The patients taste or smell 
 poison in the food ; gestures or remarks of others are in- 
 terpreted as inimical influences. The tendency to refer all 
 events to their own personality leads them to find, in 
 letters and newspapers, remarks which refer to themselves. 
 
 Associated with these conditions is the delusion of hav- 
 ing committed sin, which is one of the most constant 
 symptoms of melancholic forms of disease. Many believe 
 they have committed a great wrong which they cannot 
 describe more closely, others accuse themselves of the 
 most fearful crimes. The majority dread or even wish 
 the most terrible punishment as penalty for their crimes. 
 
 Unlike the depressive delusions just mentioned, there 
 are others of an expansive nature. In milder degrees they 
 appear merely in the form of an exaggerated idea of the 
 patient's bodily and mental abilities. He feels able to 
 perform great feats of strength, although his physical 
 powers may, in reality, be very slight. The more judg- 
 ment is lost, the greater is the difficulty experienced by 
 the patient in recognizing the morbid element of such 
 notions. While the maniacal individual still retains so 
 much judgment that he remains within possible bounds, 
 the feeble-minded one becomes, in periods of . excitement, 
 unbounded in the contents of his delusions. He has hun- 
 dreds and thousands of children, he is Christ or God, and 
 speaks all the languages of the world. He claims to be 
 physically able to lift the universe. And yet a good share 
 of these claims is merely boasting and fantasy. Indeed, 
 as the excitement of the feeble-minded subsides, questions 
 are almost always necessary in order to lead the active 
 play of the fancy into the production of expansive ideas. 
 
 Although many delusions are accompanied by corre- 
 sponding feelings and moods, antagonistic moods are also 
 observed at times, and, on the other hand, all emotional 
 
76 HANDBOOK OF INSANITY. 
 
 excitement is sometimes absent. This occurs both in con- 
 valescent stages and in the beginning of terminal dementia. 
 
 If a high degree of excitement or depression is no longer 
 present, and feeble-mindedness has not yet developed, de- 
 lusions may appear as attempts at explanation of the pa- 
 tient's own morbid condition. These are not so much the 
 results of hallucinations present at the time, but are 
 trains of thought which appear coincidently with the hal- 
 lucinations or independently. 
 
 The following fact is of prime importance as regards the 
 interpretation of the development and course of delusions. 
 In patients belonging to the most different classes, and in 
 all parts of the world, we always find certain definite 
 series of delusions in constant repetition. In many such 
 series of ideas persist throughout the entire course of the 
 disease ; they are called fundamental or primordial. Like 
 central hallucinations and imperative concepts, they either 
 develop directly in the diseased brain or are excited by 
 slight external impressions, or by processes within the 
 body. The latter factor requires some explanation. In 
 ordinary health, but much more frequently in morbid con- 
 ditions, irradiated sensations in the body are often associ- 
 ated with irritations in the same or other nerve tracts. For 
 example, auditory impressions often produce sensations of 
 light, or colors give rise to auditory impressions. In such 
 cases of irradiation it can often be proved that the origins 
 of both nerves lie adjacent to one another. In a similar 
 way the development of certain delusions is connected with 
 sensations located in adjacent parts of the brain. But as 
 the expression in speech of these associated sensations al- 
 ways revolves within very narrow circles, the contents of 
 the associated concepts are also limited by certain indi- 
 vidual ideas and words, and these recur constantly in all 
 individuals after the same internal stimulus. This sheds 
 light on the uniformity of so many delusions in different 
 individuals. They must develop in certain anatomical 
 tracts, and find expression only in generally known terms 
 of speech. 
 
SYSTEMATIZATION OF DELUSIONS. 77 
 
 It is only after long duration of the delusions that these 
 become associated with series of thoughts due to logical 
 inferences. These must be regarded as real attempts 
 at explanation, but soon become part of a regular system 
 of delusions. This form often exhibits a very uniform 
 character in the shape of so-called querulous insanity. A 
 patient with morbid self-esteem, who has suffered some 
 injury, usually well-merited, acquires the notion that 
 bitter injustice has been done to him, and that his honor 
 requires him to fight the matter. Accordingly he begins 
 one lawsuit after another, and sacrifices home and fortune 
 in obedience to his morbid desire. Of course, such results 
 only follow when the delusion is attended by a certain de- 
 gree of mental weakness. 
 
 Delusions of a depressive and expansive nature are not 
 infrequently associated with one another. The persecuted 
 individual attributes the persecutions to his own assumed 
 personal superiority, or the supposed possessor of great 
 wealth thinks this is kept from him by enemies. In these 
 cases one concept is often due to the other as the result of 
 an attempt at explanation ; in this way, also, fixed delu- 
 sions often develop after the morbid condition has lasted 
 a long time. The more often the delusion appears, the 
 more readily does it displace antagonistic concepts. The 
 interpretation of new impressions always occurs in respect 
 to the already morbidly changed concepts, and so com- 
 pletely displaces the relation of the patient's personality 
 to the outer world, that he thinks he has become a differ- 
 ent individual. The logical manner in which such patients 
 defend their delusions is often astonishing ; the concepts 
 have been accustomed to run their course in certain logical 
 forms so that it is difficult for the observer to detect the 
 flaw in the first links of the series. By practice in de- 
 fending their delusions the patients often attain such 
 dialectic skill that they conceal the weak points, and often 
 deceive even judges. The patient's relatives often believe 
 that he has such and such a fixed idea, but that he is other- 
 wise sound in mind. Careful examination, however, shows 
 
78 HANDBOOK OF INSANITY. 
 
 that extensive series of ideas are displaced by delusions, 
 but the predominance of certain ones creates the impres- 
 sion that these alone are present. Mental disorders are 
 always complicated and are never confined to single tracts. 
 The' very impossibility of correcting a so-called single 
 fixed idea shows a want of judgment, which is due to 
 mental weakness. 
 
 4. Disorders of Memory and Fantasy. 
 
 Among the combinations of concepts in general, great 
 importance attaches, in regard to the knowledge of insan- 
 ity, to those in which the mental faculties, known as 
 memory and fantasy, are involved. Memory is a primor- 
 dial property of nerve substance, and is the result of oft- 
 repeated impressions. Although we do not understand 
 the psychoplrysics of this process, the ability to recall 
 ideas is a fact of daily experience. All concepts are con- 
 veyed originally through the senses. Many impressions 
 may be retained without previous apperception, and 
 appear later in consciousness, from other causes, as some- 
 thing apparently foreign ; they adhere to the nerve-sub- 
 stance and form involuntary recollections. Many belong 
 to conscious experiences, and then can be renewed volun- 
 tarily. We must therefore distinguish a memory for the 
 recollection of concepts and for their renewal. After 
 periods of unconsciousness the ability to renew impres- 
 sions received during that state is impaired, but these 
 may subsequently enter consciousness and be remem- 
 bered. In the voluntary renewal of concepts there is, 
 at the same time, a reference to the contents of con- 
 sciousness, the renewed ideas are recognized, and re- 
 ferred directly to the past. This more restricted mem- 
 ory occupies a higher plane than the unintentional recur- 
 rence of concepts. The relation and combination of 
 remembered concepts, with the contents of former experi- 
 ence, are utilized particularly by the group of ideas 
 constituting the self -consciousness of the individual's own 
 personality. They are arranged in memory as a con tin- 
 
LOSS OF MEMORY. 79 
 
 lied, uninterrupted series. Only the most recent elements 
 of this series remain as complete parts of memory, further 
 back more and more details are obliterated, and still fur- 
 ther back only a few recollections remain. This renders 
 possible a process in memory which is called localization 
 in time. As this power varies greatly in healthy indi- 
 viduals, the physiological brain formula of each individual 
 must be considered in examining mental disorders. The 
 organic basis of memory, the cerebral tissue, does not 
 possess the faculty of retaining impressions iu a uniform 
 manner, so that the power of voluntary recollection — the 
 other side of memory — may fall into the background. 
 This is especially true of the insane. In the arrangement 
 of successive concepts so many links of the chain have 
 disappeared, that, on account of these lacunae in memory, 
 the patient has no unit for measuring time. 
 
 Patients often do not know how long they have been in 
 the asylum, when they had dinner ; weeks appear to them 
 like days, years like months. The memory of recent 
 events is first lost, and finally the memories of childhood. 
 The memory of feelings and the possibility of the vigorous 
 performance of actions first begins to diminish after the loss 
 of the memories of childhood. This is explained by the fact 
 that recent events adhere more loosely to the nerve substance 
 and cells, while those which have been repeated for years 
 and in a measure have become organic adhere more firmly. . 
 Feelings are more inborn and are more the expression of 
 organization than are the acquisitions of the intellect, and 
 hence they adhere longer than the latter. Finally, the 
 memory of the mechanical movements necessary for the 
 daily wants of life is the last to be extinguished. In 
 some cases of recovery after concussion of the brain, a 
 restoration of memor3 T in the inverse order has been 
 observed. 
 
 The strength of adhesion of certain concepts depends 
 not alone on the length of time which has elapsed since 
 their development, but also on the character of the special 
 nerve tissue of the brain. Memory also depends very 
 
80 HANDBOOK OF INSANITY. 
 
 materially on the strength of the impressions. Hence it 
 is evident that the affections of memory must be very 
 manifold. 
 
 One of the most common disorders in daily life is to 
 forget a word, which is "on the tip of the tongue." We 
 may even have a notion as if the approaching memory is 
 again receding. This is to be distinguished from weak- 
 ness of memory, in which the renewal of concepts is im- 
 perfect or entirely absent, because the organic nervous 
 substance no longer contains the former impressions. On 
 the other hand, absent-mindedness occurs when the relation 
 of the concepts to former events of our own consciousness is. 
 disturbed. The latter is a temporary, functional disorder, 
 so that at other times the renewal of the concepts in mem- 
 ory is easily effected. Forgetfulness, which forms a tran- 
 sition to the weak memory of old age, appears to depend 
 more upon an organic basis. In old age, there is only a 
 passive yielding to external impressions so that they dis- 
 appear rapidly from memory. Finally, the old man 
 remembers nothing of the present, while his vivid recol- 
 lection of times long past becomes so much more strik- 
 ing. A similar condition obtains in numerous forms of 
 insanity, particularly those associated with conditions of 
 weakness. 
 
 Every impairment of consciousness interferes with 
 memory. From a loss of memory concerning a certain 
 period of time, we infer unconsciousness during that pe- 
 riod. In the impairment of consciousness known as 
 " daemmerzustand " (dreamy state, literally a condition 
 of twilight), the capacity of remembering events which 
 occurred at the disappearance of consciousness is often re- 
 stored, but the impressions adhere feebly and the remem- 
 brance is then very brief. Immediately after the act an epi- 
 leptic may say distinctly that he remembers certain details, 
 but at the subsequent judicial examination these have disap- 
 peared from memory. In conditions of excitement, like- 
 wise, the interpretation of the surroundings is often inac- 
 curate so that the memory thereof is merely summary,, 
 
LOSS OF MEMORY. 81 
 
 and does not go into details. Conditions of exhaustion of 
 the nervous system, for example, after sexual excesses, 
 febrile diseases, etc., lead temporarily to mental enfeeble- 
 ment, during which the reception as well as adhesion of 
 new impressions are rendered difficult or impossible. Some 
 patients subsequently remember a few events during the 
 period of mental disturbance, others remember absolutely 
 nothing. Thus patients, after the lapse of a long series 
 of years, believe that they are still at the same age as 
 when they were first attacked. In these cases new im- 
 pressions during the period of sickness have not become 
 permanent constituents of memory. It is also an evidence 
 of the imperfect reception of concepts in the memory when 
 patients again perform the same acts which they had 
 hardly finished, or tell a story several times in succession 
 to the same person. This is generally due to severe affec- 
 tions of the cortex. At the same time the renewal of old 
 experiences is soon confined to tracts in which long prac- 
 tised habitual concepts are found. Even in imbecility 
 teachers retain the ability of repeating the rules of gram- 
 mar, physicians of writing prescriptions. It is an evidence 
 of great mental weakness when forgetfulness in these 
 little matters occurs in daily life, and is not noticed ; for 
 example, if an accountant makes the same mistake after 
 repeated calculations, if a man leaves his house several 
 times and forgets to close the door, or goes out without 
 his hat, etc. As a matter of course, such instances of 
 forgetfulness are morbid only when frequently repeated ; 
 they are probably due, in most cases, to extensive and 
 deeply spreading diseases of the brain. 
 
 At all events an organic basis attaches to certain defects 
 of memory, which are characterized by the loss of certain 
 definite groups of concepts ; as they are often associated 
 with focal diseases of the brain, they are so much less rec- 
 ognizable as complete psychoses. They include so-called 
 amnesic aphasia, disorders of writing-images, etc. In a 
 few remarkable cases temporary loss of a single foreign 
 language, of numbers and the former musical ability, has 
 
82 HANDBOOK OF INSANITY. 
 
 been observed, while all the other properties of memory 
 remained intact. Hence the term local memories has 
 been employed. If the forgotten powers return in a few 
 days, there can only have been a disorder of the cerebral 
 circulation or a slight mechanical interruption to conduc- 
 tion. After a concussion of the brain, a surgeon forgot 
 that he had a wife and children, while in other respects 
 his memory was intact. 
 
 Morbid change of memory may also be manifested by 
 increased reception and facilitated renewal of memories. 
 The common intensification of memory in children finds 
 its counterpart in the similar ability of some feeble-minded 
 individuals, although in the latter it is almost always one- 
 sided. 
 
 The increased reception of the material of memory de- 
 pends very materially on the mood. The melancholic 
 generally notices only sombre impressions and neglects 
 cheerful ones. On the other hand, the maniacal individual 
 manipulates chiefly the cheerful impressions, and associ- 
 ates only flattering remarks with his increased self-esteem. 
 
 The insane exhibit notable disturbances in the truth of 
 their memories ; as the mood of the moment exercises the 
 greatest influence on the manner in which memory-pictures 
 are conceived, a falsification of the previous impressions is 
 thus produced. Hence his entire previous life appears to 
 the melancholic patient as a chain of sad experiences and 
 evil deeds. At other times the chief factor is the associ- 
 ation of the contents of the morbid consciousness with 
 accidental external impressions. The deception of mem- 
 ory is then shown by the fact that the patient believes he 
 has already seen persons or objects in his vicinity. A 
 somewhat similar condition is that in which, while a cer- 
 tain situation is being noticed, the impression is created 
 as if the same situation had been lived through before. 
 Such notions are very fleeting and many follow one another 
 within a short time. At first the individual is surprised 
 by the impression, and seeks for the completion of the dis- 
 agreeable unclearness of his memory. This feeling of 
 
DECEPTIONS OF MEMORY. 83 
 
 •uncertainty inhibits the voluntary combination of the 
 concepts and renders nugatory the criticism of the unusual 
 contents of consciousness. 
 
 Epileptics exhibit very decided deceptions of memory 
 in connection with the attacks. The remembrance of 
 having already gone through the same experience extends 
 over a greater period. On admission to the asylum the 
 patient states not alone that he has already been there, 
 and that this or that has already been said to him, but all 
 the events of the present become to him memories of the 
 past. This deception may last months and years, and 
 gives rise, in the patient, to the notion that he is leading a 
 recurring double life. In this way poetical fancies con- 
 firm the belief in the transmigration of souls. When the 
 notion of double life appears prominently in paroxysms, it 
 is known as double consciousness. Here the renewal of 
 even the most common concepts is lost for days or months. 
 If the old condition returns, the old memories return, but 
 those belonging to the recent, almost childish condition, 
 remain wanting. One patient narrated during the next 
 attack the things that had occurred to her during the 
 previous one. Similar phenomena are also observed in 
 periodical insanity. 
 
 The disorders of memory depend mainly upon peculiar- 
 ities in the course and combination of series of concepts 
 which are in themselves independent, and stand loosely 
 associated. An allied activity, but in which, at first, a 
 voluntary selection completes the combination according 
 to a definite plan, is that faculty known as fancy. Its 
 essential characteristic is thinking in images, while the 
 articulate expression of more sharply defined notions is 
 wanting. Even as children we abandon ourselves to the 
 play of our ideas; the adult may likewise give free rein 
 to his fancy. It takes part in dreams, and it is prob- 
 able that vivid fancies and dreams are very often mistaken 
 for hallucinations. It is also probable that hallucinations 
 would occupy much less space if we could sharply dis- 
 tinguish them from the notions of fancy. The latter are 
 
84 HANDBOOK OF INSANITY. 
 
 often associated with bodily sensations ; the hungry indi- 
 vidual dreams of feasts, the thirsty one of delicious drinks. 
 In the hypochondriac the fancy is busy in depicting fu- 
 ture diseases. The melancholic patient associates anxious 
 feelings with notions of capital punishment, which the 
 fancy paints in all its details. The patients are engaged 
 in building a world of fancy, without, however, being en- 
 tirely convinced of its reality. Without paying any 
 attention to those around him, the patient makes speeches, 
 abandoning himself, like an actor, to the situation of the 
 moment. He walks up and down, and has a lively con- 
 versation, so that it would appear as if he saw or heard 
 imaginary persons. But when his attention is attracted 
 by the questions of the observer, he interrupts himself, 
 smiling, for a certain length of time, or again resumes his 
 harangue. This lively play of fancy entertains the pa- 
 tient. It occurs particularly during conditions of excite- 
 ment, and after recovery the patients explain that they 
 carried on conversations, not as the result of true halluci- 
 nations, but that the vividly excited fancy impelled them to 
 utterance in speech. Feeble-minded patients also delight 
 in boastful descriptions, but the latter result mainly from 
 the questions asked them and lack the creative element of 
 fancy. 
 
 C. DISORDERS OF EMOTIONAL LIFE. 
 
 1. Affects, Sensual and Higher Feelings. 
 
 Acute feelings always produce changes in the course of 
 our concepts, and the latter, on the other hand, strengthen 
 the feelings. Hence we call them affects. As a rule, 
 violent feelings suddenly inhibit the flow of ideas; 
 this may result from severe pain or from unexpected sur- 
 prises. It is only after the cessation of the affect, as a 
 rule, that the cause appears, and then fright, wonder, joy, 
 or anger may become apparent. Joyful affects subside 
 more rapidly than gloomy ones, which have a tendency to 
 pass into permanent moods. By means of numerous 
 
EMOTIONAL DISORDERS. 85 
 
 physical sequelse the affect reacts upon the emotional 
 excitement. Angry gestures increase anger, palpitation 
 increases the fear of the timid individual. Finally these 
 sequelae exhaust the affect ; anger wears itself out, tears 
 soothe pain. Otherwise the one who is subject to an 
 affect loses, when he is no longer master of his own 
 movements, the mastery over his own feelings and ideas. 
 Hence, there are affective conditions, with complete con- 
 fusion of ideas, which are distinguished only in name 
 from a maniacal seizure. Between the affects of healthy 
 ndividuals and these extreme conditions of excitement 
 there is an entire series of intermediate conditions which 
 are arbitrarily called healthy or morbid. Nevertheless 
 there is a certain average, from which the deviation may 
 not be too great, without indicating a disproportion be- 
 tween the degree of stimulus and the excitement. Sensa- 
 tions and feelings, which produce pleasure or pain, are 
 sensory subjective feelings. The sum of all feelings which 
 arise from the sensations of our own body constitute com- 
 mon sensation. The most important part in this respect 
 is played by conditions of the viscera, but sensations in 
 the eye and ear also form part of common sensibility. In 
 higher degrees the feelings of pleasure or pain produced by 
 these sensations lead to increase or diminution by bodily 
 movements and then pass into impulses. 
 
 But the disorders of impulse fall within the domain of 
 action, while for the present we confine our attention 
 strictly to disturbances of emotional life. We have to con- 
 sider not alone the disorders arising from sensual (in the 
 philosophical sense) feelings, but also, and to a greater 
 extent, those arising from the higher mental feelings, i. e. , 
 all emotional movements which accompany the association 
 of ideas and the mental processes attended with conscious 
 selection. 
 
 An increase of the feeling of pain is present in many 
 mental disorders. All stimuli of the outer world and of 
 the body itself then increase the emotional excitability ; 
 even the stimulation by customary impressions becomes a 
 
86 HANDBOOK OF INSANITY. 
 
 source of painful feelings. This is observed especially at 
 the beginning of many forms of insanity. It is mainly 
 a sign of depressed melancholic conditions, but may occur 
 temporarily in cheerful excitement. The term psychical 
 pain has been applied to the highest degree of these feelings. 
 Such conditions are distinguished from bodily pain only 
 by the site of development. Psychical pain is a result of 
 nutritive disturbances or grosser changes in the brain, 
 and does not disappear until these causes are removed. 
 So long as these exist it occupies the foreground of con- 
 sciousness, and represses all other feelings and ideas. 
 In slighter grades there is an ill-defined feeling which is 
 manifested as restlessness, anxiety, or sadness. Out of 
 this feeling, which forces every impression into the same 
 direction, develops the sad mood in which sympathy and 
 love excite only mistrust and hatred. The increased sen- 
 sibility brings everything into relation to itself, because 
 it is really affected unpleasantly by everything. Being 
 distrustful, the patient ascribes his condition to noxious 
 influences in the external world, considers himself perse- 
 cuted, or seeks the cause of his malady in former actions 
 which now appear sinful to him. The frequent associa- 
 tion with hallucinations increases the sensibility and con- 
 firms the resulting delusions. 
 
 The combination of the disturbance of bodily " sensual'* 
 feelings with the gloomy contents of consciousness de- 
 presses the self-esteem and produces, as a rule, a vivid 
 feeling of illness. Another result of the inhibition of 
 the flow of thought, which follows the predominance of 
 gloomy notions, is the restriction of thought to the pa- 
 tient's own personality. The feeling of sympathy for 
 others is extinguished. If the original gloomy affect is lost 
 during the course of the disease, the loss of sympathy be- 
 comes a sign of mental weakness and the absence of all 
 higher psychical feelings. The feeling of shame is also 
 lost. Hence, even a diminution of the painful feelings has 
 set in. In certain congenital conditions of feeble-minded- 
 ness the feeling of shame and of sympathy for others is 
 
LOSS OF ETHICAL FEELINGS. 87 
 
 not developed, but we here find a pronounced egoism. 
 The lack of heart and tenderness is also a striking symptom 
 of many acquired mental diseases. The disappearance of 
 disgust at immoral and unsesthetic actions and speech is also 
 one of the gravest signs in the development of the disease. 
 This symptom also has a very bad prognostic significance 
 in the transition into mental failure. It is associated with 
 diminution of self-esteem. In some conditions of excite- 
 ment this is not such a serious matter. But if a patient, 
 who is not emotionally excited, does not hesitate to do 
 indecent things in the presence of others, it constitutes an 
 evidence of great mental weakness or profound disturb- 
 ance of consciousness. The absence of the higher mental 
 feelings, especially religious, ethical, and aesthetic, their 
 disappearance or imperfect development are forms of the 
 diminution of the painful feelings, which are almost 
 always morbid. A special form in this category is a part 
 of congenital weak-mindedness, and is often called moral 
 insanity. 
 
 The last-mentioned symptoms may also be attributed to 
 a diminution of the pleasurable feelings. If the patient 
 loses the power of enjoyment of the good fortune of himself 
 or others, or if pleasure in higher things is restored, these 
 signs are important. The constant feeling of illness, de- 
 pendent on a nutritive disturbance of the brain, makes it 
 impossible for the depressed patient to feel his own pleasure 
 or that of others. A fellow-feeling may be impossible on 
 account of the overfilling of consciousness with sad or 
 cheerful concepts, so that even the excited patient appears 
 as an egoist. 
 
 In him the pleasurable feelings which result from bodily 
 sensations have undergone a marked increase. He praises 
 his own health, declares himself capable of great feats. 
 At the same time the course of other combinations of ideas- 
 is facilitated. Allied to this condition is that which we 
 have already described under the term ecstasy. 
 
 By the alternation and mixture of disturbed feelings 
 of pleasure and pain are produced groups of symptoms 
 
88 HANDBOOK OF INSANITY. 
 
 which form the most frequent signs of mental disease. 
 When there is increased excitability of both kinds of 
 feeling, the symptom of change of mood appears. 
 
 The change from one condition to its opposite takes 
 place with rapidity. The unstable equilibrium is deflected 
 to one side or the other by the most trifling cause. The 
 fact that a notion of the uncertain equilibrium of his own 
 mood enters the patient's consciousness, results in irritable 
 depression and uncertainty of action. On account of his 
 irritability *he is always at swords' points with those 
 around him. The impulse to ward off all external in- 
 fluences occupies the foreground. In epileptics and ine- 
 briates these conditions are dangerous to those around 
 the patient. 
 
 The change of mood is sometimes so rapid that it leads 
 apparently to a simultaneous admixture of opjDosing feel- 
 ings. The affect of pathos exhibits this mixture, and 
 is indicative of disease unless founded in the previous dis- 
 position of the individual. 
 
 The temperament of the individual must always be 
 taken into consideration; it influences the intensity of 
 emotional excitement and the rapidity of its changes. The 
 choleric and melancholic temperaments, which have a 
 tendency to strong affects, are inclined to depressed moods, 
 while the sanguine and phlegmatic temperaments, with 
 feebler affects, turn rather toward the enjoyments of life. 
 On the other hand; the temperaments are characterized 
 either by a rapid or slow change of mood. In the latter 
 event thoughts are apt to be directed toward the future. 
 The melancholic individual is immersed in the notion of a 
 joyless future ; the phlegmatic individual adheres firmly to 
 his notions. Easily moved by external impressions, the 
 rapid temperament of the sanguine and choleric is fasci- 
 nated by the present. 
 
 In another group of disturbances of feeling the stimulus 
 produces the antagonistic feeling. There is a reversal or, 
 at least, a complete turn in the connection between stim- 
 ulus and sensation. We may here mention the so-called 
 
TERROR. 89 
 
 idiosyncrasies of hysterical patients, in whom sensations, 
 such as odors of flowers, which are agreeable to the healthy, 
 are unpleasant, while nauseous smells produce agreeable 
 sensations. This is indicated not infrequently in preg- 
 nancy. A practically important group of these disorders 
 is found in the domain of sexual life. Here we find feel- 
 ings of dislike against the opposite sex, of love for the 
 same sex, with corresponding desires for sexual inter- 
 course, usually in individuals with an hereditary taint. 
 Such individuals are generally morbid in their entire 
 mental development. 
 
 The higher mental feelings may also suffer reversal, as 
 shown by the delight taken in the pain experienced by 
 human beings and animals, by the criminal tendencies of 
 the feeble-minded, etc. These qualities usually appear in 
 early childhood, and thus demonstrate their hereditary 
 basis. Similar reversals of feelings of pleasure and pain 
 may also appear in acquired, non-hereditary forms of 
 insanity. 
 
 2. Terror and Allied Feelings. 
 
 We will now consider a disorder of feeling which is 
 firmly connected with definite physical signs. The affect 
 of terror is associated intimately with disturbances in the 
 action of the heart and respiration, and also of the secre- 
 tory and vasomotor nerves. For this reason the condition 
 is known as prsecordial terror. The patient experiences 
 an oppression, a pressure in the region of the heart or its 
 immediate vicinity. He feels as if the heart were com- 
 pressed, as if a weight lay upon it, or as if the chest would 
 burst. Disturbances of respiration lead to the assertion 
 that the windpipe is being compressed. The sensations 
 in the throat and heart are attended with incomplete res- 
 piration, and with acceleration or retardation of the pulse. 
 These symptoms, together with the fact of the psychical 
 origin of terror, compel us to believe that disturbances in 
 the cortex radiate into the pneumogastric tract. It can 
 only be attributed to actual diseases of the heart or lungs, 
 
90 HANDBOOK OF INSANITY. 
 
 in those cases in which such diseases are actually demon- 
 strable, because, as a general thing, the origin of terror 
 must be sought in the central nervous system. In violent 
 terror there is almost always a temporary suppression, 
 followed shortly by increased excretion of urine, and 
 also of perspiration. All these physical signs also occur 
 constantly in normal terror, resulting from frightful and 
 gloomy impressions. In the terror of the insane, due to 
 hallucinations and delusions, these physical elements last 
 for a longer period. But after the prolonged duration of 
 conditions of terror, which result from profound, even 
 anatomical changes in the cortex, the psychical element 
 becomes more prominent. The most violent conditions 
 of terror, such as appear in epileptics and paralytics, and 
 in which there is often a profound impairment of con- 
 sciousness, are often attended with but slight implication 
 of respiration and the heart's action. Some insane patients 
 ascribe the feeling of oppression to the head, and their 
 terror is then lacking in distinct physical signs. In other 
 cases, perhaps, we have to deal with milder grades of 
 terror; the faint-heartedness of some patients probably 
 depends on a condition of mild terror. 
 
 As in all affects, so in that of terror, contractions and 
 dilatations of the vessels play a decided part. It may be 
 assumed that vasomotor phenomena run their course in 
 the cortex similar to those which are observed periphe- 
 rally. As very many forms of insanity are attended by 
 affects, it is evident that changes in the pulse will be found 
 in them. The feel and the sphygmograph sometimes dis- 
 close a peculiar pulse which may be utilized as a sign of 
 certain forms of insanity. Thus, incurable and chronic 
 
 Fig. 7. 
 
 forms exhibit the pulsus tardus (Fig. 7) , in whose sphyg- 
 mogram there is an absence of the rapidly rising top of 
 
IMPULSIVE MOVEMENTS. 91 
 
 the wave, while it falls without any secondary elevations. 
 This is an evidence of paralysis of the vessels. The dis- 
 appearance of the elastic tension of the vessels occurs in 
 those forms of insanity which have run their course, and 
 is also frequent in paralytic dementia. The use of the 
 sphygmograph, however, has not carried us very far in 
 the diagnosis of the individual clinical forms of disease. 
 
 D. DISORDERS OF VOLITION AND ACTION. 
 
 1. Impulsive Movements. 
 
 We have described impulse as the real element of all 
 psychical functions, as that activity in which sensation 
 and will are still acting in their original combination. In 
 the disturbances of emotional life we studied, in part, the 
 clinical significance of impulses; we will now consider 
 their relation to voluntary acts. It is important, however, 
 that the continued predominance of accompanying feel- 
 ings and sensations over clearly volitional acts first brings 
 impulsive life into appearance. This contrast and the 
 predominance of feelings over volitional acts causes the 
 deviations from healthy instinctive life. In a healthy 
 consciousness every sensation and concept is accompanied 
 by feelings which arouse a desire for the continuance or 
 for a change of the existing condition. It is only when 
 these feelings attain a more violent degree that we recog- 
 nize them as an impulse. Under certain circumstances 
 such impulses are irresistible, but generally we overcome 
 them. 
 
 Among the morbid impulses we first mention the violent 
 desire to use the muscles, to perform movements, i.e., bodily 
 restlessness. In maniacal conditions it is manifested by 
 walking about restlessly, striking, shouting, etc. Very 
 often the patient does not intend to destroy objects or mo- 
 lest those around him, but merely seeks relief of his over- 
 flowing feelings. Terror and frightful ideas may give 
 rise to acts of violence. Slighter grades are found in daily 
 life in timid and anxious people who perform all sorts of 
 
92 HANDBOOK OF INSANITY. 
 
 useless movements, pick at their clothes, change their 
 position, etc. In morbid increase of fear we find aimless 
 wandering about by day and by night, constant opening 
 and closing of the windows, dressing and undressing, etc. 
 There is also great restlessness in many conditions of 
 mental weakness, which leads to a collection of all con- 
 ceivable objects. In the development of recent conditions 
 of excitement, the gradual increase of this impulse may 
 be noted. At first the patient is merely busy, then he 
 walks about sometimes for hours, and exhibits other signs 
 of excitement. At the height of the disease we find him 
 shouting, singing, running and dancing, tearing his 
 clothes ; he adorns himself with rags and other attain- 
 able objects. He twists bundles of straw or grass, and is 
 continually striking about him; he smears the walls of 
 the room with faeces and washes it with his urine; or 
 he scratches the walls, and destroys the doors and win- 
 dows. In the highest grades of excitement the general 
 restlessness is increased to such a degree that it is diffi- 
 cult to understand how such muscular efforts can be per- 
 formed almost without interruption by an often feeble 
 body. The maniac has no feeling of exhaustion because 
 all the movements are performed impulsively, undisturbed 
 by voluntary action. Such a condition may develop 
 without coincident hallucinations or delusions. It is 
 plausible to assume that this is due to direct irritation in 
 those cortical regions which have accumulated memory- 
 pictures of movements. 
 
 This development of impulsive movements, apart from 
 every influence of the will, is shown most distinctly in 
 the so-called imperative movements of demented individ- 
 uals. These are monotonous movements, which recur 
 regularly, often in a definite, even rhythmical series. 
 Originally they may have been produced in great part by 
 hallucinations and delusions, but after the disease of the 
 brain has run its course they are left over as independent 
 remains, and are continued as a matter of habit after their 
 former purpose has been forgotten. These patients are 
 
IMPERATIVE ACTS. 93 
 
 almost always wanting in the ability of voluntary selec- 
 tion of conscious acts. Some of them rub the scalp con- 
 stantly, until large bald spots are produced ; others grasp 
 certain parts of the body, for example, the nose and ears, 
 at equal intervals in a certain order. When disturbed, 
 the tempo is accelerated and the movements become more 
 violent, without losing their regularity. Other patients 
 walk rapidly a few steps forward, then one backward or 
 to the side, and repeat these movements innumerable 
 times, or they suddenly rotate a few times, or they dance 
 for hours, until exhaustion sets in, often without saying 
 'a word or making any other manifestation. 
 
 The intervening link of imperative conceptions often 
 leads, in the non-demented, to imperative movements, 
 which often appear in the form of imperative acts. The 
 notion of an act, which has pushed itself with irresistible 
 force into the patient's consciousness, drives him, despite 
 his clear insight, to the most terrible deeds. The impul- 
 sive character is shown almost constantly by the accom- 
 panying affect of fear. These distressing conditions lead 
 to acts which the patient abhors, but which he commits 
 in the feeling that only in that way can he find safety and 
 rest. Suicide, murder, and arson are acts of this kind. 
 Destruction of objects may also take place, and exposure 
 of the person and similar actions are also observed. 
 The acts are usually performed rapidly and violently, and 
 are brought about by accidental external circumstances. 
 The sight of a knife or club rouses the conception of mur- 
 der, and the terrible deed is done with the rapidity of 
 lightning. An indefinable feeling of muscular restless- 
 ness sometimes warns the patient, and he then adopts pre- 
 cautions or begs those around him to do so. Well-defined 
 delusions or hallucinations are wanting. 
 
 The acts of violence of melancholia are related to the 
 former in their external appearance; the violent precor- 
 dial fear demands relief. An hallucination shortly before 
 the deed, especially an auditory hallucination in the shape 
 of brief commands, sometimes intensifies the impulse. 
 
94 HANDBOOK OF INSANITY. 
 
 After the act has been committed there is generally a feel- 
 ing of great relief, though this is often followed by a feel- 
 ing of bitter remorse. 
 
 Impulsive acts also occur in another series of mental 
 disorders, in which there is either congenital for acquired 
 feeble-mindedness, or an impairment of consciousness. 
 Hysterical and epileptic individuals with an hereditary 
 taint, individuals who are feeble-minded from youth, pa- 
 retics, or patients with simple forms of insanity which 
 have run their course, commit fearful self-mutilations, 
 arson, robbery, without any clear motive or distinctly 
 conscious concepts. Even after the deed the patient is ' 
 rarely clear concerning it, or it surprises the individual 
 himself. In this category belong some cases known as 
 impulsive insanity. A proof of the impulsive origin of 
 these conditions is the remarkable fact that they occur in 
 paroxysms with intervals of many years. 
 
 Suicide may occur in the insane as an impulse. This 
 form of suicide must be distinguished from several others. 
 If an excited patient, frightened by hallucinations, jumps 
 through a window, or into a river, this is not really a sui- 
 cide, inasmuch as the patient has attempted to avoid a 
 danger, not to destroy his life. Or if a patient takes his 
 life with the view of pleasing God, it cannot be regarded 
 as impulsive. But there are cases in which the patients 
 have an irresistible impulse to kill themselves, although 
 they struggle against it with a clear consciousness and 
 have no reasons for such an act. In certain families all 
 the members succumb to this fate, and usually at the 
 same period of life. 
 
 In the same way impulsive murder in the insane is to 
 be distinguished from that which follows delusions or 
 hallucinations, and in which the patient revenges himself 
 upon his supposed persecutors or obeys a commanding 
 "voice." A sudden blind impulse may seize an epileptic, 
 who cruelly kills his victim and then does not remember 
 the deed ; or a patient struggles in vain against the fear- 
 ful impulse and feels free only after the deed is done. 
 
BOULIMIA. 95 
 
 Arson is committed by some feeble-minded individuals, 
 especially at the period of puberty, for reasons which are 
 obscure to themselves. 
 
 In certain forms of imbecility the tendency to steal 
 stands on the same level as the already mentioned impulse 
 to accumulate articles. The morbid character of such 
 impulses, however, is only determined by the proof of 
 mental disturbance in general, which is also manifested 
 by other characteristics of the entire personality. The 
 single impulse is merely the most prominent sign and is 
 apt to force the others into the background. 
 
 Definite forms of the disease are shown in the disorders 
 of individual impulses. First, as regards the desire for 
 food. The feeling of hunger is conveyed through the ter- 
 minations of the pneumogastric. An increased desire for 
 food and drink may appear without previous hunger or 
 thirst, at the mere sight of food, or immediately after a 
 meal there is an unappeasable feeling of hunger which 
 imperatively requires gratification, but is often relieved 
 by small amounts of food; or large amounts, even of 
 indigestible articles, are swallowed ravenously. Often 
 the articles ingested are nauseating to healthy indi- 
 viduals, or incredible amounts of edible articles are swal- 
 lowed. In the latter event we assume a defective feeling 
 of satiety. Other forms of increased hunger are based on 
 hallucinations or delusions, but the disgusting phenomenon 
 of eating fseces presupposes a profound disturbance of 
 consciousnesss. 
 
 Diminution of the need of food, as part of a complete 
 mental disorder, is almost always due to delusions of poi- 
 soning or hallucinations, and often leads to complete refusal 
 to take food. In severe affects, there is often an inde- 
 pendent loss of appetite, with or without coincident gas- 
 tric catarrh. Continued refusal of food is usually favored 
 by a secondary gastric catarrh, or the general weakness 
 and disturbance of the nervous functions lead to imper- 
 fect digestion, and this in turn causes diminished appetite. 
 
 The longing for certain articles appears in the insane 
 
96 HANDBOOK OF INSANITY. 
 
 sometimes as a desire for spices or strong coffee or tea. 
 Allied to this is the desire for alcoholic drinks. One 
 who is depressed or suffering from mild melancholia 
 takes stimulants in order to cheer up; the excited in- 
 dividual endeavors to conceal his internal uncertainty 
 by alcoholic excitement. There are also cases in which 
 the morbid desire appears as true inebriety, especially 
 when it occurs in paroxysms with comparatively free 
 intervals. The impulse to drink arises from an acutely 
 painful feeling, and an exhilarating action of the al- 
 cohol is not attained as in healthy individuals. The 
 inebriate is not fastidious in his selection of stimulants. 
 In a few cases they drink only water in enormous 
 amounts if alcohol cannot be obtained. The drunken 
 fit lasts a few days, even weeks. The chronic symp- 
 toms of alcoholism give rise to variability of the im- 
 pulsive attacks, with a rise and fall of all the symptoms. 
 The patient attempts to relieve disagreeable sensations by 
 intoxication. For days and nights he lives in bar-rooms, 
 unmindful of his reputation and family. As a rule, the 
 condition is suddenly checked. The patient grows quiet, 
 exhausted, has no further desire for drink, and gradually 
 returns to his previous condition. Some experience a 
 decided antipathy to alcohol during the interparoxysmal 
 periods. A certain number of inebriates, however, are 
 also habitual drinkers. A tendency, however slow, to 
 mental weakness is unmistakable. 
 
 Disorders of the sexual impulse will now be considered. 
 Many of them are signs, not causes of mental disturbance. 
 In healthy individuals the sexual passion varies greatly 
 in intensity, so that it becomes difficult to decide at what 
 stage morbid excess begins. It is to be considered morbid 
 when the sight of the nude in art produces lascivious 
 ideas. In many insane individuals, especially females, 
 the primary psychosis often receives a special coloring 
 from the addition of a morbidly increased sexual desire. 
 This is shown by the expression of the face, the constant 
 talk concerning marriage or pregnancy, or the desire for a 
 
SEXUAL IRRITATION. 97 
 
 uterine examination. Some of these patients manifest un- 
 usual cleanliness, are constantly combing the hair or wash- 
 ing the body. The bounds of modesty are overstepped 
 by attending to the wants of nature in the presence of 
 the physician, or by carrying around the night vessel as 
 soon as he appears. Or the patients suddenly strip them- 
 selves on seeing a man and offer to perform coitus, or they 
 lie in bed and imitate sexual intercourse by the corre- 
 sponding movements of the body and face. Still more 
 disgusting is the tendency of these patients to smear fseces 
 and urine, and this connection of disordered sexual sense 
 and olfactory sense reminds us of the clinical, and perhaps 
 anatomical, association of these functions. Sexually ex- 
 cited patients often have distinct olfactory hallucinations. 
 Special odors sometimes give rise to sexual fancies. The 
 greatest increase of this disorder leads to violent assaults 
 upon men, vile and abusive language being employed in 
 order to conceal the true feeling. At other times similar 
 attacks occur as the result of annoying feelings, and 
 these conditions must be sharply differentiated. The term 
 nymphomania, applied to the most extreme cases, is a mis- 
 nomer, because the condition is not an independent disease 
 of the sexual sense. 
 
 The frequent combination of religious mysticism with 
 sexual irritative conditions is an important fact. De- 
 vout prayers in sexually excited individuals, uninterrupted 
 religious exercises, constant reading of lives of the saints, 
 which are full of the temptations of the flesh, the occa- 
 sional occurrence of the most terrible orgies in certain 
 revivals show the causal connection and clinical relation- 
 ship between religious fervor and sexual desire. The 
 transmutation of the sexually colored contents of con- 
 sciousness into firm delusions retains, in these cases, the 
 striking association of religious and sexual elements ; the 
 patient calls herself the bride of Christ, or the Virgin 
 Mary. This combination is more frequent in women, but 
 in men there is also found a constant association of relig- 
 ious delusions with sexual irritative conditions which, 
 7 
 
98 HANDBOOK OF INSANITY. 
 
 especially on an epileptic basis, often lead to severe con- 
 ditions of excitement attended with violence. 
 
 Sexual desire may also diminish in insanity. It may 
 be entirely absent in dementia, and is occasionally dimin- 
 ished in melancholia or conditions of exhaustion. Dimin- 
 ished sexual desire is sometimes a sign of progressive 
 disease of the spinal cord. 
 
 The character of the sexual sense may also be changed 
 and perverted. Even in healthy individuals there may 
 be temporary peculiar desires in this respect ; for example, 
 pregnant women attempt to bite human bodies, excited 
 men are tempted in this way by little girls. Allied to 
 this is the morbid phenomenon in which normal intercourse 
 is followed by the slaying of the female. The impulse to 
 unnatural sexual gratification, which is periodically wide- 
 spread among rude, and also among excessively cultured 
 nations, is also morbid. At the present time pederasty is 
 almost always practised either by those who are satiated 
 with normal intercourse or have a strong hereditary ten- 
 dency to nervous diseases. The latter group of cases is 
 decidedly the larger. Public and boarding schools are gen- 
 erally the breeding-places of this vice. It is remarkable 
 that there is sometimes a periodical tendency to pederasty ; 
 this is sometimes due to an epileptic basis, and forms 
 a sort of substitute for an epileptic attack. Finally, 
 pederasty is sometimes an early sign of paretic dementia. 
 
 There is another category described under the term con- 
 trary sexual sensations. In these there is a complete 
 reversal of sexual desire. With the very beginning of 
 sexual desire there is a distinct liking for persons of the 
 same sex, those of the opposite sex producing in the pa- 
 tient either complete apathy or even disgust. Ordinary 
 attempts at intercourse are not made or they prove fail- 
 ures; then follow romantic friendships for those persons 
 of the same sex who disclose similar tendencies, or, at 
 least, permit the manifestations of the perverse love. 
 Vigorous sensual feelings and pronounced jealousy are 
 often present. There is often a tendency to assume the 
 
SEXUAL PERVERSIONS. 99 
 
 walk and dress of the opposite sex. For example, the 
 male patients who feel themselves like women prink 
 themselves, sway the body at the hips, and assume femi- 
 nine habits and dress. They often possess all the defi- 
 ciencies of woman without any of the attractive qualities of 
 man. Others feel clearly that their impulses are opposed to 
 reason, but despite violent struggles they remain the slaves 
 of their passion, and sometimes end in suicide. Great 
 forensic importance attaches to some cases in which mur- 
 der, attended with mutilation and even with devouring of 
 the body, formed a complete substitute for sexual inter- 
 course. In some cases, sexual pleasure is produced by 
 wounding the skin or the genitalia with a knife. 
 
 One proof of the morbid character of such impulses is 
 their occasional periodical character. The patients usu- 
 ally feel the approach of the attacks, and generally make 
 all preparations so that it can be passed through as easily 
 as possible. In the intervals they are good husbands and 
 fathers, and gratify their unnatural impulses only a few 
 times in the course of a year. 
 
 Perversions of the sexual sense are also observed not 
 infrequently at the onset of senile dementia. Here the 
 patients find gratification in simple exposure of the per- 
 son. Almost all forms of increased sexual desire may 
 also occur in the excited stages of circular insanity and 
 in the beginning of paralytic dementia. 
 
 A general feeling of indifference leads to weakness or 
 even complete loss of volition. The loss of will power is 
 especially frequent in the severe forms of congenital and 
 acquired dementia. The desire for food excites only tem- 
 porary, simple movements, and even these are sometimes 
 entirely absent. Such patients must then be fed, and 
 deglutition only begins after the introduction of food into 
 the buccal cavity. But even when intelligence is rela- 
 tively intact and independent of any delusions, abulia 
 sometimes occurs in certain forms of mental disturbance, 
 especially in conditions of exhaustion. These patients are 
 very readily influenced, and not infrequently they are said 
 
100 HANDBOOK OF INSANITY. 
 
 to be devoid of character, although a morbid condition of 
 the brain is undeniable on careful examination. 
 
 2. Expressive Movements. 
 
 Impulsive and volitional movements serve as the ex- 
 pression of certain conditions of consciousness. Both 
 forms of movement are not separate as regards observa- 
 tion, and actions, which are generally called voluntary, 
 are, as a rule, composed of both kinds. On the other hand, 
 volitional actions, by becoming gradually imbedded in 
 memory, are converted into automatic movements, as is 
 shown in the practice of all complicated movements of the 
 body. In walking, talking, piano-playing, etc., the will 
 has first executed every individual movement, but later it 
 combines the most complicated movements and they be- 
 come more and more automatic, until all accompanying 
 feelings are absent and an almost mechanical process re- 
 sults. Hence, many acts of insane with impaired con- 
 sciousness appear to be voluntary ; the association of the 
 impulse with the voluntary movements, due to the function 
 of memory of the brain substance, is so intimate that the 
 boundary between the two is apt to be obliterated. In 
 addition, the accompanying feelings generally determine 
 the strength of the involuntary and voluntary impulse in 
 consciousness. In this struggle of impulse and conscious 
 will the latter is often overcome ; this is clearly shown in 
 the general forms of expressive movements. They are 
 one of the chief means of determining emotional excite- 
 ment and associated psychical disorders. They are con- 
 trolled in a measure by adults and healthy individuals, 
 but children and insane, especially the feeble-minded, 
 clearly show the condition of their consciousness. Their 
 expressive movements are not voluntary, but follow di- 
 rectly the underlying affects and impulses. The pressure 
 of the facial muscles leads to various physiognomic ex- 
 pressions. The character of the mental disorder is 
 shown in the general bearing and appearance of the pa- 
 tient. Finally, corresponding expressions are manifested 
 
EXPRESSION IN MANIA AND MELANCHOLIA. 101 
 
 by the timbre of the voice. In many cases these expressive 
 movements alone permit the experienced observer to form 
 an approximate judgment concerning the special form of 
 disease. 
 
 The excited patient has a bold, defiant bearing, his eyes 
 glisten, he speaks loud and rapidly, or chatters, laughs, 
 and sings. His movements are rapid and irregular, and 
 he has no rest. His clothing is disordered, dirty, torn. 
 He adorns himself with flowers, feathers, bits of paper, 
 and bright metal ; he is careless of his personal cleanliness. 
 
 The depressed patient sits with a sad expression, staring 
 in silence ; or not a syllable can be got out of him, and he 
 is obstinately mute to all questions. The anxious, excited 
 patient walks about restlessly, wringing his hands, and 
 moaning and crying aloud. There is great distortion of 
 the features, and the tearful expression sometimes ap- 
 proaches a laughing one. In children and women, espe- 
 cially in hysteria, one affect may pass immediately into the 
 other, but, as a rule, the original one is soon resumed. 
 This is also true of the insane. Thus, the violent laughter 
 of a cheerfully excited patient, which was attended by 
 violent contractions of the diaphragm, is suddenly con- 
 verted into spasmodic crying, and the facial expression at 
 the same time shows the anxious condition; 
 
 When the emotional conditions have subsided, the ex- 
 pressive movements often assume a more distinct char- 
 acter. Well known are the wrinkled, suffering features 
 of the hypochondriac ; the swimming eye of the hysteric ; 
 the dignity, proud air, and arrogant tone of the patient 
 suffering from delusions of grandeur. It must be re- 
 membered, however, that other considerations are often 
 necessary to enable us to arrive at a conclusion. Thus, 
 profound melancholy may lead to the same rigid and 
 indifferent expression as advanced imbecility. 
 
 Many cases present no change of expression to super- 
 ficial observation. Finally, there is no doubt that the 
 majority of asylum patients present a certain similarity 
 to one another in bearing, expression, and general appear- 
 
102 HANDBOOK OF INSANITY. 
 
 ance, after the affective condition has run its course. As 
 a matter of course, this is not marked in the demented, 
 who are unmindful of their surroundings, have become 
 callous to cold and heat, rain and wind. In them the 
 similarity of expression is mainly due to its absence. 
 
 A peculiar expression is furnished by patients with 
 hallucinations. One with auditory hallucinations often 
 listens bent over forward, or he closes his ears ; he often 
 scolds and attempts to defend himself against supposed 
 complaints. One with visual hallucinations looks fixedly 
 into empty space, in an ecstatic or anxious manner ; the 
 patients with olfactory hallucinations play their nostrils, 
 hawk and spit a good deal, especially as gustatory hallu- 
 cinations are likewise often present. In hallucinations of 
 feelings there are numerous gestures, the common feature 
 of which is probably the attempt to ward off an inimical 
 influence. 
 
 The acts of the insane, as the result of delusions, are 
 also very manifold ; mutilations and acts of violence are 
 especally frequent. 
 
 Finally, we must again consider the disorders of speech. 
 The language of gestures has been discussed in the pre- 
 ceding remarks on movements of expression, and we now 
 turn to speech in the ordinary sense of the word. Like 
 gestures, articulate speech has grown out of the impulse to 
 accompany feelings and affects with movements which 
 stand in direct relation to the feeling-producing impres- 
 sions. It is true that all senses are open to external 
 impressions, but the auditory sense in particular conveys 
 the expression of concepts, sensations, and feelings by the 
 production of tone gestures. But these are merely impulsive 
 movements of expression, and speech proper only develops 
 when the intention to communicate concepts and feelings 
 to others is present. Language is developed from roots 
 consisting of short syllables. An abbreviated repetition 
 of the process is indicated in the language of children, but 
 its form and contents are then produced by the adults 
 around them as much as by the children themselves. In 
 
FORMATION OF NEW WORDS. 103 
 
 certain forms of mental disturbance, in the retrogression 
 of the faculties to a childish stage, we find a tendency to 
 form new words out of simple roots. This process cannot 
 be analyzed into its original constituents, viz., impulsive 
 and voluntary expressive movements, because the adult 
 patient draws a great part of the new material from the 
 store of language already at his disposal. Nevertheless, 
 a large part of the words newly formed by the patient 
 must be regarded from the standpoint of the original ex- 
 pressive movements, although there are also other condi- 
 tions of development. A confirmation of the notion that the 
 formation of such words is allied to that from speech roots 
 is found in the circumstance that some patients employ 
 monosyllabic new words in different senses by displacing 
 or introducing single vowels or consonants. 
 
 Another method, and probably much more frequent, is 
 the development of new words through hallu cinations. The 
 intimate relations between speech and hearing naturally 
 point especially to auditory hallucinations. As an expres- 
 sion of the unity of thought and word, human speech, 
 in the form of internal speaking, is felt even by the insane. 
 He is not always able to distinguish between the morbid 
 internal voices and the normal speech heard internally ; 
 often, however, he recognizes the former as something 
 foreign, and as not belonging to him, although it comes 
 from within him. The development of morbid concepts 
 from peripheral auditory hallucinations and illusions often 
 finds direct expression in peculiar phrases and words. 
 If the vividness of the auditory hallucinations is not over- 
 powering, there is sometimes a chaotic mixture of words, 
 which, in cultured patients, may appear to form a well- 
 defined language by the addition of syllables taken from 
 foreign languages. Such speech is utterly devoid of 
 meaning, but the patient often defends it with great skill. 
 Letters and treatises may be composed in this fashion. 
 Such language is always an indication of profound dis- 
 turbance and advanced mental weakness. But it must 
 be remembered that vivid internal hearing accompanies 
 
104 HANDBOOK OF INSANITY. 
 
 the development of such fantastically formed speech. It 
 is unnecessary to assume that the entire process is always 
 preceded by auditory hallucinations, but in the majority 
 of cases, the insane speech notions and the auditory hallu- 
 cinations develop coincidently on the same diseased basis. 
 When the concepts are already of a fearful character, the 
 delusion of persecution may develop in connection with a 
 suspiciously sounding word or noise, and these processes 
 at once find articulate expression in phrases which some- 
 times exhibit a remarkable similarity in different patients. 
 This can only be explained by the similarity of the mor- 
 bid process. On the other hand, such great differences 
 are also noted that they can only be explained by bearing 
 in mind the individual differences in the predisposition, 
 development, and education of the brain and its psychical 
 functions. 
 
 The term pseudaphasic confusion has been applied to 
 the condition in which incomplete and falsely interpreted 
 auditory hallucinations are expressed by the patient in a 
 mutilated or falsely understood form. The new words or 
 incomprehensible word-structures are to be regarded as 
 the remains of well-known utterances. This condition is 
 also associated with other hallucinations, but at all events 
 it is a sign of severe implication of the brain. In a certain 
 measure it is the antithesis of the flight of ideas of excited 
 patients in whom the confusion is merely an expression of 
 the facilitated association of ideas, while a disturbance in 
 the formation of words is wanting. 
 
 Echo-speech, the simple repetition of words just heard, 
 is observed in dementia ; all comprehension or volition on 
 the part of the patient is wanting. 
 
 A peculiar disorder of speech, without hallucinations 
 or delusions, and generally distinguished from maniacal 
 flight of ideas by the absence of profound affects, is the 
 endless reiteration of the same meaningless, disconnected 
 words, in the form of a speech or sermon. This is known 
 as verbigeration ; the spasmodic element in the outbreak 
 of the words makes the term speech-spasm appear suitable. 
 
VERBIGEKATION. 105 
 
 It would seem as if motor inhibitions must be overcome by 
 a powerful stimulus, and on this account the expression 
 sometimes becomes pathetic. This distinguishes verbi- 
 geration, as a rule, from the repetitions of words due to 
 psychological causes. Verbigeration may also be observed 
 in letters. 
 
 Finally, speech may be changed voluntarily on account 
 of delusions. Some insane speak only in superlatives and 
 have a few pet expressions, or there is a tendency to use 
 only diminutives, so that the speech becomes somewhat 
 childish. Another peculiarity is the frequent repetition 
 of certain words, on account of the delusion that speech is 
 being lost. Sometimes words are compounded which do 
 not belong together. 
 
 Aphasia proper will be discussed in the section on de- 
 mentia paralytica. 
 
 Writing also furnishes important signs of mental dis- 
 ease. In general the peculiarities of the written style 
 correspond to those of speech, although some patients, 
 who exhibit undoubted signs of insanity in every speech, 
 write in a perfect, apparently normal style. It must be 
 remembered that writing is always learned after talking. 
 Many patients control themselves in conversation so that 
 nothing morbid appears, but express their real ideas on 
 paper. In writing they reveal their delusions and feelings 
 much more readily than by word of mouth. 
 
 The form of the writing is also an important aid, in 
 diagnosis. Childish construction, awkwardness, and ob- 
 scurity of expression are found in the feeble-minded ; the 
 dement writes hardly at all. The melancholic writes 
 little ; the monotony of his ideas is shown in the constant 
 repetition of the same complaints, fears, and self-accusa- 
 tions. The characters themselves are small, occasionally 
 tremulous; there is little difference between the up and 
 down strokes, because the pressure of the pen is feeble 
 and timid. Excited patients write a good deal, and in 
 firm characters. The writing is done rapidly, in accord- 
 ance with the accelerated flow of ideas. Finally, the hand 
 
106 HANDBOOK OF INSANITY. 
 
 can no longer keep pace with the ideas, words are omitted, 
 sentences are unfinished. A second letter is often written 
 transversely across the first, and all the corners of the 
 paper are utilized. The paranoiac makes special signs, 
 and all sorts of flourishes. He underscores a good deal, 
 makes exclamation and interrogation points without rea- 
 son. At times he draws and scrawls. Sometimes he 
 writes single words in Latin, German, and even Greek 
 letters. These intentional changes in the writing corre- 
 spond, in many cases, to its contents. Certain signs cor- 
 respond to certain delusions, especially by the addition of 
 certain terminations. Sometimes the patient attempts to 
 write the smallest possible, almost microscopic characters. 
 Such writings disclose their morbid origin at once, es- 
 pecially if they contain unintelligible drawings of ma- 
 chines, fabulous animals, or symbolic signs. 
 
 In dementia paralytica the writing constitutes one of 
 the most important signs. Even before the appearance of 
 other symptoms an uncertain, spasmodic, tremulous form 
 of the letters may arouse the suspicion of the development 
 of the disease. Some letters are very long, others small 
 and obscure. Characteristic of the advancing disease is 
 the omission of certain letters and words, or poor spelling, 
 or repetition of single words and lines. Many erasures 
 are made, and the second attempt is even worse than the 
 first. The date or signature may be forgotten, while en- 
 tire sentences may be copied from some book which is 
 lying accidentally near the writer. The paper is full of 
 blots, the letters often leave the ruled lines. The commu- 
 nication becomes more illegible and unintelligble as it 
 approaches the conclusion. 
 
 In children with a neuropathic taint who have become 
 blind or deaf-mute at an early period, and in idiots, the 
 letters are often written with the left hand in the direction 
 from right to left. This mirror writing is rarely done by 
 the adult insane, probably because their long employment 
 of the ordinary direction inhibits a tendency to the wrong 
 method. 
 
SENSORY DISORDERS. 107 
 
 E. CONCOMITANT PHYSICAL SYMPTOMS. 
 
 These symptoms are often elements of the psychoses 
 themselves, not alone because they may act as the basis 
 of delusions and hallucinations, and are part-causes of the 
 disease, but because they indicate the point of attack in 
 the treatment of the disease. 
 
 The investigation of the disorders of sensibility in the 
 insane is difficult, on account of the impairment of con- 
 sciousness and the distrust of the observer. Complete 
 absence of sensibility to pain and temperature is found, in 
 very demented individuals. This is due, as a rule, to the 
 absence of a reception of the impressions in consciousness. 
 The patients may be cut or burned or their limbs muti- 
 lated, without any manifestation of pain. Or the saliva 
 drools from the mouth, flies walk about the face, etc., 
 without an attempt on their part to prevent it. This indif- 
 ference can only be understood by the absence of all atten- 
 tion, and cannot be regarded as a peripheral disturbance 
 of the cutaneous nerves. This is also true of self -muti- 
 lations, such as castration, tearing out the eyeball or 
 tongue, self-crucifixion. Religious delusions in particular 
 enable the patient to bear incredible sufferings in silence. 
 Peripheral anaesthesias may also occur, but they are usu- 
 ally only accidental concomitants of the psychosis. They 
 may acquire great importance, however, by being converted 
 into delusions. There is very often, at first, a tendency to 
 describe the condition allegorically. Later, the explana- 
 tion of the anaesthetic condition assumes a more positive 
 shape, and the patient states that the affected limb is made 
 of glass or wood. If there is very extensive diminution 
 of sensibility, the patient's feeling of his own personality 
 may be extinguished and he believes himself dead. If 
 the anaesthesia is confined to certain viscera, for example, 
 if the ingestion of food takes place without feeling, the 
 patient believes that he has no stomach. If the anaes- 
 thesias are due to progressive organic affections of the 
 brain, feelings of disappearance and nothingness are es- 
 
108 HANDBOOK OF INSANITY. 
 
 pecially marked. Perhaps we must attribute to such 
 anaesthesias the complaints of emptiness, pressure, band- 
 like compression of the head, drying of the brain, air and 
 water in the brain, etc. When the disease extends to the 
 spinal cord, the parts supplied by the latter become in- 
 volved. Anaesthesias of the muscles produce numerous 
 symptoms. It must always be remembered, however, that 
 psychical insensibility due to diminished attention suffices 
 to explain such anaesthesia. Even the healthy individual 
 will forget pain as the result of anger or excitement. 
 
 Hypersesthesias or purely quantitative intensification of 
 normal sensibility are not frequent in psychoses. But if 
 the term is meant to include qualitative changes arising 
 from the combination with psychical elements and alter- 
 nation with anaesthesias, it is very frequent. The attempt 
 to distinguish a peripheral and central origin is not very 
 feasible, because cutaneous and muscular sensibility are 
 chiefly involved and, as in the case of hallucinations, these 
 are analyzed with difficulty. But experience shows that, 
 in not a few cases, circumscribed hyperaesthesia of the 
 skin or mucous membranes may be the cause of some 
 special symptom in insanity. The integument is then 
 rubbed to the raw by the patient. Similar symptoms also 
 depend upon diseases of the cord, especially those associ- 
 ated with the sexual apparatus. It is, however, impossi- 
 ble to determine to what extent peripheral and central 
 elements are mingled in the feelings of distressing mus- 
 cular restlessness, pains in the heart, and similar condi- 
 tions. In hypochondria, in particular, the s} 7 mptomatology 
 is composed of a mixture of peripheral and central hyperaes- 
 thesias. In this disease one form is often converted into 
 the other. An originally peripheral hyperaesthesia gives 
 rise to psychical hyperaesthesia, and this gradually becomes 
 independent. This is shown most distinctly in neuralgias 
 associated with menstruation, because the renewed peri- 
 pheral irritation increases the psj^chical irritability already 
 present, and sometimes produces a periodical recurrence 
 of secondary delusions. 
 
BODILY TEMPERATURE. 109 
 
 The temperature of the body undergoes numerous 
 changes. Every excitement is attended by a rise of tem- 
 perature, due in part to the production of heat attending 
 the increased muscular movements. This elevation of 
 temperature is marked in the most severe forms of mania, 
 and in epileptic attacks, but it is then due, in great part, 
 to the stimulation of certain heat centres. In motionless 
 melancholies and dements the temperature falls, also in the 
 exhaustion after conditions of excitement. This symptom 
 can best be combated by constant rest in bed. It is a 
 peculiar fact that, in the insane, a rise of temperature is 
 sometimes absent in conditions which usually give rise to 
 fever. For example, typhoid fever or pneumonia may 
 run an almost apyrexial course. Other patients have a 
 very great tendency to a rise of temperature. 
 
 Digestion shows the most notable changes among all 
 the organic functions. It is usually impaired at the be- 
 ginning of all psychoses. In melancholia gastric catarrh 
 is shown by anorexia and a thick yellow coating on the 
 tongue. The food is often imperfectly masticated, the 
 bolus remains in the mouth for a long time, and, if not 
 expectorafed, finally reaches the stomach after awkward 
 movements of deglutition. If, in addition to the psychi- 
 cal inattention, there is also paralysis of the muscles of 
 deglutition, the patient swallows the wrong way, and at- 
 tacks of coughing, pulmonary inflammations, or almost 
 instant suffocation may result. The insane suffer not 
 infrequently from spasms of deglutition which leads to 
 temporary abstinence from food. Excited patients swal- 
 low forcibly so that they run the risk of impacting firm 
 particles of food. If paralyses are present, even the in- 
 gestion of fluids may be dangerous. After the food has 
 entered the stomach, it may resist digestion on account of 
 its imperfect mastication. Diarrhoea frequently results 
 in such cases, but, as a general thing, the insane are more 
 apt to suffer from constipation. The excited or profoundly 
 melancholic patient often passes an evacuation from the 
 bowels without noticing it. 
 
110 HANDBOOK OF INSANITY. 
 
 The variations in the weight of the body justify, in a 
 measure, the assumption that, in the majority of cases, 
 the psychoses are the expression of a general nutritive dis- 
 turbance of the entire body. On the other hand, it is also 
 possible that the disease of the brain is the immediate cause 
 of the change in weight. As a rule progressive loss of 
 weight accompanies the course of the disease to its climax. 
 Remissions are attended with increased exacerbations with 
 renewed loss of weight. This sometimes alternates regu- 
 larly in the periodical and circular psychoses, but after a 
 while, in these as in other chronic psychoses, the body 
 adapts itself to the morbid condition, and the weight re- 
 mains uniform. The weight almost always increases in 
 rapid convalescence, and also in the transition to terminal 
 dementia. Hence, this sign is favorable only when there 
 are other indications of mental recovery. The greatest 
 differences in weight develop very rapidly after puerperal 
 psychoses, and also after protracted refusal of food. 
 
 Another series of nutritive disturbances are due to pri- 
 mary affections of the central nervous organs (congenital 
 or acquired) and may be grouped together as disorders 
 of the trophic functions. The so-called signs of degener- 
 ation are congenital and almost always hereditary. The 
 dwarfed growth of some idiots, with the childlike appear- 
 ance, and the absence of hair on the face and mons ven- 
 eris belong to this category. Disturbances in the growth 
 of the skull must often be explained by trophic influences, 
 at all events the mechanical influences attending parturi- 
 tion are an insufficient explanation. Among the malfor- 
 mations of the skull, visible during life, we must mention 
 a disproportion between the bones of the cranium and 
 face, and unequal development of the two halves of the 
 face. Further signs of degeneration (although their sig- 
 nificance is not unquestioned) are : imperfect position, and 
 inordinately large or small size of the ears, the absence of 
 the lobe of the ear, and imperfect development of the 
 concha. Greater importance attaches to irregularities in 
 the position and development of the teeth, also to double 
 
HANDBOOK OF INSANITY. 
 
 KIRCHHOFF. 
 
 Ear Plate. 
 
DESCRIPTION OF EAR PLATE. 
 
 The two adjacent ears represent a congenital and an acquired 
 malformation. Among the numerous congenital malformations 
 which are described as signs of degeneration, a very frequent one 
 is the enlargement and overlapping of the helix, known as the 
 "handle ear." 
 
 The second picture shows a very much enlarged ear, which is 
 drawn out smoothly in an upward direction. It was produced by 
 pulling an innumerable number of times upon the upper rim. 
 This movement was one of a series of imperative movements, and 
 also resulted in notable atrophy of the ear. 
 
 Hsematoma auris (othaematoma) is found usually, as upon our 
 picture, in the scaphoid fossa, between the helix and antihelix, 
 and passes through the concha proper more or less close to the 
 auditory foramen. It usually spares the tragus and antitragus. 
 In our case a slight perforation of the tumor had occurred, and is 
 recognizable by the somewhat semicircular line in the middle. 
 
 In the ear of the second picture marked shrivelling of the in- 
 ternal auricular cartilage gradually occurred after disappearance of 
 the tumor. This acted toward the middle and gave rise to short- 
 ening of the affected parts in a direction radiating toward the 
 auditory foramen. 
 
SIGNS OF DEGENERATION. Ill 
 
 tows of teeth, hare-lip and fissure of the palate, a narrow 
 vertical or excessively flat and broad palate or a unilater- 
 ally flattened palate may also be mentioned. Also deflec- 
 tion of the nose or the palpebral fissures. The latter 
 are occasionally too small and adherent close to the outer 
 rim of the cornea. Other signs of degeneration are : con- 
 genital blindness, disseminated retinitis, fissures in the 
 iris, albinism. Other parts of the body may also be 
 affected, but we will mention only two, viz., the genital 
 apparatus, in which the most numerous malformations 
 are observed, and secondly, the hair on the body (beard in 
 women, unilateral beard in men, grayness of a few locks 
 of hair in childhood, etc.). One or more of these signs 
 may be found in an individual, but, as a matter of course, 
 a single one possesses little significance. Their importance 
 depends upon the fact that they indicate hereditary pre- 
 disposition. 
 
 The second group of trophic disorders develops during 
 disease of the fully grown brain. The ear of the insane 
 sometimes presents a tumor (othematoma) which has 
 long been the subject of dispute. At first it is a circum- 
 scribed tumor of the concha, usually on the upper and 
 outer parts ; it fluctuates on palpation, and is bluish-red 
 in color. It develops in a few days, remains unchanged 
 for weeks and months, and disappears gradually, leaving 
 a deformed concha. It is due to an extravasation of blood 
 into the cartilage, which is partially ruptured. During 
 the absorption of the blood the ear shrivels, despite thick- 
 ening of the cartilage. It has been observed in rare cases 
 in healthy individuals, without any history of injury or 
 hereditary or acquired predisposition to insanity. But, as 
 a rule, it must be regarded as an indication of* past or 
 threatening insanity. It generally occurs in severe and 
 advanced stages, in which other vasomotor disorders are 
 noticed. If such a patient is subjected to external violence 
 on the ear (often of a trifling character) the othematoma 
 develops. But both factors are necessary, viz., trauma- 
 tism and the trophic disorder (brittleness of the vessels) . 
 
112 HANDBOOK OF INSANITY. 
 
 Corresponding processes are observed very rarely in the 
 nasal cartilages. 
 
 Another trophic disorder is brittleness of the bones, 
 attended with disappearance of the lime salts, chiefly in 
 the ribs and sternum. An increased amount of lime salts 
 in the urine has also been observed. The destruction often 
 extends to the cartilage, which is converted into a gelat- 
 inous mass. Trifling violence sometimes breaks several 
 ribs. In one case a slight blow with a hair-brush frac- 
 tured the radius in a paralytic dement. These conditions 
 often heal rapidly at the beginning of a psychosis, but 
 later they readily undergo suppuration. 
 
 The tendency to suppuration in vasomotor-trophic dis- 
 orders affects particularly the subcutaneous cellular tissue. 
 It happens, for example, that paralytic dements, who are 
 kept carefully clean, will exhibit an elevation of the epi- 
 dermis, due to the formation of a vesicle, upon the back, 
 and also upon parts which are not subject to pressure. 
 When this takes place on the back a bed-sore is apt to 
 form in a few hours. This suppurates, and after slow ex- 
 foliation of the skin and shreds of tissue, shows how deeply 
 the destruction has taken place. Under careful treatment 
 recovery is possible. In other cases a phlegmonous process 
 develops within a few days, gangrene of the cellular tis- 
 sue takes place, with infiltration of pus between the mus- 
 cles, febrile movement, and rapid death. A proof that 
 such acute decubitus depends essentially on paralysis and 
 fragility of the vessels, and that trauma is only an exciting 
 cause, is found in the fact that it occurs also in paralytic 
 dements who are not paralyzed, but are constantly run- 
 ning about and lie down only for a few moments. Like 
 othcematoma, acute decubitus is an evidence of an incura- 
 ble psychosis. 
 
 The secretion of tears, like other secretions, is often 
 very slight in cases of melancholia. It is only in begin- 
 ning recovery after profound melancholy that tears again 
 appear, and they then exercise a soothing effect. When. 
 
SALIVARY CHANGES. 113 
 
 there is a rapid change of mood in feeble-minded patients, 
 tears are apt to come and go. 
 
 In all depressed conditions the secretion of saliva appears 
 to be diminished. Whether an increase constantly ac- 
 companies conditions of excitement is not certain, but, at 
 all events, this happens occasionally. The secretion may 
 be the result of increased movements of the mouth, as in 
 constant speaking, or the . saliva may be secreted volun- 
 tarily, in order to be smeared on walls, anointed upon the 
 body, etc. Some perfectly quiet demented patients expec- 
 torate freely in a skilful manner, others employ it as a 
 convenient means of defence against annoying approach. 
 Sometimes the patients expectorate enormous quantities, 
 especially when gustatory and olfactory hallucinations 
 lead them to cast out, with the saliva, poisonous elements 
 from the body. When stuporous patients, with the body 
 bent over forward, allow saliva to run out of the angles 
 of the mouth, so that their clothes are constantly wet, this 
 ptyalism is not necessarily due to morbid increase of saliva. 
 The normal amount of saliva secreted is very large, and 
 in individual cases it is difficult to determine whether it 
 is really excessive. 
 
 Although examination of the urine is difficult in the 
 insane, certain changes appear to be found regularly in 
 psychical disturbances. In all conditions of depression 
 the amount of urine is very slight, and vice versa 
 in conditions of excitement. In some hysterical cases 
 there is almost complete suppression. As a general 
 thing the amount of phosphates is diminished, but cases 
 have also been reported in which they were present in ex- 
 cess. In periodical mania sugar has been found occasion- 
 ally in the urine, but in some of these cases slight diabetes 
 was also present between the attacks. Albumin, occa- 
 sionally even a few casts and blood-cells, have been found 
 in the various forms of spasmodic attacks observed in the 
 insane. 
 
IV. 
 
 THE COURSE OF MENTAL DISORDERS. 
 A. COURSE, DURATION, AND TERMINATIONS. 
 
 The boundary between disease and healtli is not sharply 
 defined, so that we are not always able to tell when the 
 physiological limits are exceeded. The observation of a 
 large number of individuals furnishes us with average 
 types, but even among these there are certain psychical 
 conditions of healthy life which are subject to great alter- 
 nations and yet do not constitute the forerunners of morbid 
 processes. 
 
 We may distinguish between morbid conditions and 
 processes. The former are not always terminal states of 
 diseases which have run their course, but may also be con- 
 genital. They are permanent, while morbid processes 
 exhibit a progressive tendency. This difference is some- 
 times obliterated by the fact that the mental disorder runs 
 a very slow course, and thus simulates a morbid condition. 
 Healthy psychical life also has a slow development ; hence, 
 the process of life itself may bring with it the morbid 
 process; this special process is known as degeneration. 
 
 The beginning of the disease, whether it develops out 
 of an already existing congenital condition or out of com- 
 plete health, is difficult to determine, especially on account 
 of the usually slow development of the disease. It is al- 
 most exclusively in cases with an hereditary taint that 
 the symptoms sometimes break out with sudden violence. 
 But, as a rule, the disease begins gradually and is attended 
 with prodromata. 
 
 The first changes occur mainly in the finer movements 
 of emotional life, in morals and character. The tastes, 
 
 114 
 
PRODROMATA. 115 
 
 habits, and desires of the patients change ; they are in an 
 excited or depressed, often in a changeable or irritable 
 mood. They suffer from an indefinable feeling of illness. 
 This gradually increases, the patient becomes timid and 
 has a presentiment of the impending loss of reason. There 
 may also be sudden attacks of desperation, and at times a 
 tendency to suicide. The facial expression and the ges- 
 tures undergo a change. There is an irresistible tendency 
 to movement, to wander restlessly to and fro, without 
 finding rest or comfort ; or they complain and exaggerate 
 their sufferings. They complain that their ideas have 
 disappeared, that they will never be well, and that death 
 is inevitable. Others complain of the loss of memory, their 
 ideas are concentrated more and more upon their own ail- 
 ment, and excessive egoism develops. For weeks, months, 
 and even years these prodromata, in the shape of absent- 
 mindedness, indifference, or striking activity, may pre- 
 cede the outbreak of the disease proper. At a later period 
 physical disorders are added to these mental phenomena. 
 Among the most important is disturbed sleep and fright- 
 ful dreams. Headache and dizziness are often distressing 
 symptoms. The appetite is lost, digestion becomes im- 
 paired, obstinate constipation develops, and often there is 
 a sudden rapid emaciation. The observation of these 
 prodromata is of the greatest importance, because their 
 treatment offers the possibility of preventing the psycho- 
 sis. As a rule, the observations of the patient's family 
 concerning the period at which these changes begin are 
 entirely unreliable. The most striking symptom to the 
 laity is the gradual change in the character. Later 
 prodromata may consist of a feeling of delayed and im- 
 peded thought and imperative notions. The special 
 character of the psychosis can rarely be predicted from 
 the prodromata, although the subsequent condition of 
 depression or exaltation often has its corresponding pre- 
 cursors. 
 
 When the severe organic forms of insanity, particularly 
 dementia paralytica, develop, the prodromata often have 
 
116 HANDBOOK OF INSANITY. 
 
 a different character. There are early signs of mental 
 weakness; mental exhaustion soon occurs, the lapses of 
 memory are very striking. The reception of new impres- 
 sions is slow; there is diminution or even complete loss of 
 the ethical feelings. On account of the transgression of 
 criminal laws, the eyes of the family are often opened 
 earlier in these cases, especially when the patient's cir- 
 cumstances do not explain his thefts, wastefulness, or sex- 
 ual offences. Finally, the suspicion becomes confirmed 
 when motor disorders develop, especially in speech and 
 the facial muscles. In some who are about to become 
 paralytic dements there is occasionally a great increase 
 in mental activity without other disturbance or weakness 
 of the mental functions. They are enterprising and man- 
 ifest abilities which they had not possessed before, and 
 act in an entirely different manner from their previous 
 habits. This change of character is more striking than 
 in the prodromal stage of other conditions of excitement. 
 
 The onset of the mental disorder proper is either gradual 
 or sudden. The majority of those forms which run a rapid 
 course, such as febrile and postfebrile psychoses, insanity 
 of parturient and puerperal women, and insanity after 
 violent emotions, injuries to the skull, attempts at hang- 
 ing, and carbonic-oxide poisoning, have a sudden onset. 
 They also run a rapid course, attended with violent symp- 
 toms. These psychoses are also characterized by the sud- 
 den cessation of the attack, with immediate restoration of 
 the former mental condition. Such conditions have been 
 described as transitory insanity. A characteristic feature 
 is the profound disturbance of consciousness during the 
 entire attack, with subsequent marked hiatus of memory. 
 This, like the other severe irritative symptoms (hallucina- 
 tions, fear, psychomotor irritative processes) , depend upon 
 circulatory changes. Some of these cases may even run 
 their course in a few hours, and then, as a rule, terminate 
 in recovery after a deep sleep, followed by a complete 
 hiatus of memory concerning the attack. They offer a 
 favorable prognosis, inasmuch as they usually recover 
 
REMISSIONS. 117 
 
 rapidly and completely. This is also true of pathological 
 affective conditions and alcoholic excesses. 
 
 The slowly developing psychoses often run a slow course, 
 attended by the development of delusions and hallucina- 
 tions. After they have reached their culminating point, 
 they may remain in that state for a long time. But, as a 
 rule, there is soon a diminution in the severity of the 
 symptoms, or even a remission or intermission. These 
 changes are especially marked so long as the disorder is 
 still attended by affects. It is a matter of practical im- 
 portance that such remissions usually follow a change of 
 surroundings or locality, but are soon followed by a fresh 
 exacerbation. When the symptoms disappear entirely 
 during the intervals, we speak of lucid intervals. 
 
 Many external influences may give rise to remissions 
 during chronic psychoses. The symptoms are sometimes 
 intensified in spring and improved in autumn. Excessive 
 heat and cold may act in a similar way. 
 
 The remissions are sometimes so complete that they 
 may deceive us concerning the duration of the disease. 
 At such times many chronic patients possess so much self- 
 control as to conceal their delusions entirely. Some 
 maniacs cease to talk irrationally so that we might look 
 for recovery, did not their indifference to outside interests, 
 the lack of sleep and of other favorable bodily conditions, 
 show that recovery was still remote. Certain melancholies 
 may conceal their insanity and their impulse to commit 
 suicide until the very day on which they reach their end. 
 
 These remissions may last from a few hours to several 
 years. The remissions are more prolonged the more 
 chronic the mental disorder, and the less the hopes of com- 
 plete recovery. Lucid intervals may last days, weeks, or 
 months. 
 
 There is also an important class of psychoses in which 
 a regular alternation of morbid and comparatively healthy 
 conditions is typical and characteristic (periodical psycho- 
 ses) . The different periods may last days, weeks, months, 
 or even a number of years, but even in the intervals the 
 
118 HANDBOOK OF INSANITY. 
 
 patients may not be regarded as mentally sound. This 
 class is subdivided into two groups, viz., periodical psy- 
 choses proper, and cyclical or circular psychoses. In the 
 latter a period of depression alternates, according to certain 
 rules, with one of exaltation. This alternation is usually 
 indicated even during childhood, and the patients almost 
 always suffer from hereditary taint or their mental condi- 
 tion is below the average on account of general impair- 
 ment of the entire constitution. The completely developed 
 symptoms are generally seen only in asylums, and it is 
 then found that the periodical course is due to causes de- 
 veloping within the body, not to external agencies. Here, 
 where the symptoms are not changed by external circum- 
 stances, the different periods are found to resemble one 
 another completely. This is particularly marked at the 
 beginning of periodical conditions of excitement. These 
 conditions offer an unfavorable prognosis, inasmuch as 
 they usually persist during life. A long, lucid interval, 
 or a prolonged, only slightly depressed period, not infre- 
 quently simulates recovery, and at such times the patient 
 may be perfectly responsible. As the return of these con- 
 ditions is due to internal processes, we should not speak 
 of relapses, but should reserve this term for those forms 
 of insanity in which the new disease is the result of fresh 
 external causes. The psychoses due to alcoholism are 
 illustrations of true relapses. 
 
 While the different periodical psychoses may vary 
 greatly in duration, yet in a still larger number of cases 
 their duration is similar. In very rare cases the exact 
 similarity leads to the suspicion of infectious causes, such 
 as malaria. Indeed, in some cases a previous intermittent 
 fever impresses its periodicity upon subsequent attacks, 
 and such alternating psychoses exhibit, for a time, a ter- 
 tian or quartan type. Their subsequent course, however, 
 does not exhibit the original type. 
 
 After the disease has developed it rarely remains at the 
 same height. This is true, for example, of the not frequent 
 forms of so-called constitutional affective insanity which oc- 
 
COURSE OF SYMPTOMS. 119 
 
 cur in females and someti mes in a periodical form . In peri- 
 odical psychoses, but especially in simple mental disorders 
 which do not recover, and in several organic psychoses, 
 there is much more often an increase, either uniform or 
 by fits and starts, of the symptoms, with a tendency to 
 mental weakness. In a certain measure it is true that 
 when, after a primary depressed mood, prolonged excite- 
 ment dominates the scene, mental weakness will finally 
 develop into dementia. 
 
 The course of the disease is rarely effaced by the fact 
 that it becomes complicated with other forms of insanity. 
 We do not refer to the varying forms of the periodical 
 psychoses, but to the coincident occurrence of several 
 forms of disease, such as, for example, melancholia with 
 a former congenital weak-mindedness, menstrual insanity 
 or dementia paralytica with paranoia, alcoholic insanity 
 with simple psychical disorders. 
 
 Changes for the better or worse are found most fre- 
 quently during the subsidence of curable psychoses. 
 Convalescence is sometimes accelerated by a. severe fever, 
 such as typhoid fever. Otherwise, as a rule, the signs of 
 emotional excitement are first lost; and evidences of 
 awakening interest in the outer world become manifest. 
 At first this improvement may last only a few hours or 
 days, and bad days alternate with good ones, until a final 
 advance is made to complete recovery. Even after the 
 intellectual disorder has entirely disappeared, the emo- 
 tional equilibrium remains unstable for a long time. The 
 former healthy personality becomes more distinct ; if de- 
 lusions or hallucinations make their appearance, they are 
 recognized as such. Facial expression, speech, and exter- 
 nal appearance remind us of the normal condition, sleep 
 and appetite are restored, and with the knowledge of the 
 morbid character of the former acts the transition to com- 
 plete recovery is indicated. 
 
 Certain transitory forms of insanity last only a few 
 hours or days. The majority of simple psychical disor- 
 ders which recover last at least a few weeks, and gener- 
 
120 HANDBOOK OF INSANITY. 
 
 ally several months. When the causes of the development 
 of the disease reside within the patient's own body, it is 
 more apt to last for life. A duration of several years is 
 not very rare and does not exclude the possibility of 
 recovery. 
 
 Recovery is sometimes attended by the restoration of 
 certain bodily functions, such as perspiration, salivation, 
 weeping, menstruation, which had been checked during 
 the disease. In rare cases a favorable influence is exerted 
 by local inflammations, such as abscesses, boils, parotitis, 
 pneumonia, infectious diseases. 
 
 Every psychosis which does not improve, passes into a 
 chronic stage. The impairment of the mental activities 
 and the diminution of the violent symptoms are attended 
 with the return of quiet sleep, good digestion, and increas- 
 ing weight of the body. The patient becomes more indif- 
 ferent to those around him. This condition may be tem- 
 porary and may tend to recovery if it is the result of 
 mental exhaustion. But if the return of the former psy- 
 chical personality does not go hand in hand with the bod- 
 ily improvement, then recovery is improbable. 
 
 The term incomplete recovery or improvement is em- 
 ployed when the remains of the disease, which has just run 
 its course, are more distinct than secondary or acquired fee- 
 ble-mindedness. Such patients may live quietly in an 
 asylum, and an attempt to discharge them often fails be- 
 cause the unusual requirements in the life of the outer 
 world rapidly overthrow their equilibrium. But much 
 depends upon circumstances. If his home is a happy one, 
 his pecuniary circumstances good, and his position in 
 life assured, the patient may, perhaps, return home and 
 fill his place in a tolerably satisfactory manner. But 
 even in the apparently mildest forms of acquired fee- 
 ble-mindedness we always notice a certain weakness of 
 memory and impaired mobility of the emotions. Un- 
 cleanliness in person and dress is apparent ; conduct which 
 is devoid of tact, irritability, and unbridled yielding to 
 violent affects are striking. 
 
MORTALITY. 121 
 
 There are gradual transitions from these conditions to 
 complete dementia. The patient long retains the memory 
 of past times, longest of the mechanical skill which he 
 has previously acquired. He can play music, work at his 
 trade, play cards or even chess; later everything disap- 
 pears. 
 
 Simple forms of insanity do not prevent long life. But, 
 in general, the mortality of the insane is considerably 
 higher than that of the mentally sound population. The 
 insane also possess a greater predisposition to certain 
 bodily diseases. This is due to the fact that the mental 
 disorder gives rise to irregularities in nutrition, general 
 anaemia, lack of sensitiveness to injurious external influ- 
 ences and to exposure to colds. Overcrowding of asylums 
 causes further injurious factors, especially as regards epi- 
 demics. The frequency of tuberculosis must be attributed 
 to living in crowded apartments, and to this cause the 
 mortality in great part is due. Another cause is the diffi- 
 culty of early recognition of intercurrent diseases, on 
 account of the disturbance of consciousness and the fre- 
 quent absence of manifestations of pain. 
 
 Among the individual causes of death, the mental dis- 
 ease itself must first be considered. The connection is 
 most distinct in dementia paralytica and its underlying 
 diffuse, chronic disease of the cerebral cortex. The pro- 
 gressive paralysis of the central nervous organs proves 
 fatal by the paralytic attacks, decubitus, severe injuries, 
 etc. Feeble heart's action and imperfect respiration per- 
 mit the development of pneumonia, as in paralytic dements 
 and other chronic insane, and this cause of death is about 
 as frequent as tuberculosis. Anaemic and marantic pa- 
 tients are most apt to succumb to pneumonia associated 
 with hypostasis. In such cases the central paralyses of 
 the vasomotor system usually lead to a rapid fatal termi- 
 nation. Demented patients suffer from chronic intestinal 
 catarrh, due to the ingestion of straw, wood, stones, etc. , 
 and this induces rapid loss of vital energy. Uncleanliness 
 aids the development of furunculosis after slight injuries, 
 
122 HANDBOOK OF INSANITY. 
 
 and this is followed not infrequently by erysipelas. Fi- 
 nally, numerous surgical affections result from self-muti- 
 lation or injury by others, and may be the cause of death 
 on account of the impossibility of proper treatment. The 
 brittleness of the bones is a predisposing factor in many 
 cases, especially in dementia paralytica. There is marked 
 disappearance of lime salts, especially in the ribs. Slight 
 blows cause fracture of the ribs, and not infrequently this 
 gives rise to pleurisy. The tendency to suicide has nu- 
 merous victims, especially outside of asylums. Obstinate 
 refusal to take food is generally associated with gastric 
 catarrh and may terminate in death after extreme exhaus- 
 tion. 
 
 B. GENERAL PROGNOSIS. 
 
 The prognosis as regards life often depends more upon 
 the existence of other bodily diseases than on the condition 
 of the brain affection. We have seen that, on the whole, 
 insanity diminishes the power of resistance to febrile dis- 
 eases. Further, primary nutritive disorders of the brain 
 have a tendency to produce permanent tissue changes in 
 the brain and meninges. Certain forms of insanity are 
 characterized by immediate inflammation of the cortex. 
 Of these the most dangerous is dementia paralytica, which 
 proves fatal in one to three years, often in a shorter period. 
 An unfavorable prognosis attaches to the conditions of 
 excitement which are due to severe congestion of the 
 brain. The cortex may soften rapidly in some layers or 
 a hemorrhage may prove rapidly fatal. Persistent motor 
 restlessness and insomnia increase the danger of sudden 
 collapse, and rapid oedema of the brain may also develop 
 under such circumstances. The more violent the cause 
 and the more recent the disease, the greater is the danger 
 to life ; as a matter of course, old and feeble persons suc- 
 cumb most readily. Persistent refusal to take food and 
 attempts at suicide are most frequent in recent melancholic 
 conditions. Hence, the danger of a fatal termination is 
 much greater at the beginning of the disease in a recent 
 
PROGNOSIS. 123 
 
 mania or melancholia. After the affect has subsided 
 and mental weakness sets in, the mortality falls consid- 
 erably. 
 
 The prognosis as regards recovery from insanity requires 
 much greater psychiatric knowledge. Milder degrees of 
 mental disorder often do not come under the physician's 
 notice, and run a favorable course in the family circle. 
 According to asylum statistics recent cases have a much 
 more favorable prognosis than older ones. The most fre- 
 quent recoveries (up to sixty per cent) are obtained in the 
 first month of the disease, about twenty per cent in the 
 second half of the first year, and at the most twenty-five 
 per cent in the second year. After the disease has lasted 
 many years, recovery occurs in very rare cases. 
 
 Periodical attacks with long free intervals are unfavora- 
 ble as regards complete recovery, but will probably improve 
 very materially. At first these patients enter the asylums 
 once every year, every three years, or even every seven 
 years, but in time the attacks become more prolonged and 
 the free intervals shorter. In the continued cases a slow, 
 gradual development usually indicates a prolonged course 
 and difficult curability ; a sudden outbreak is more favor- 
 able as regards recovery. Sudden recoveries after pro- 
 longed duration of the disease are suspicious, and slowly 
 advancing recoveries are usually more permanent. Ir- 
 regular changes in violent symptoms are more favorable 
 than long persistence in the same course. The distinct 
 advance of severe symptoms and the development of sys- 
 tematized delusions have a very unfavorable prognostic 
 significance. Especially grave in this respect are pro- 
 tracted conditions of sexual excitement, which end usually 
 in dementia. 
 
 It is a favorable sign in violent mania when there is 
 not alone a temporary diminution of the excitement, but 
 a change to a depressed mood. Such changes often lead 
 rapidly to the normal condition. The prognosis is favor- 
 able in all cases when, with beginning quiet and clearness, 
 the former likes and pleasures make their appearance, 
 
124 HANDBOOK OF INSANITY. 
 
 when the feeling for propriety of conduct returns, and the 
 love for the family is restored. 
 
 The most important sign of real recovery is the decided 
 recognition of the disease as such hy the patient. Caution 
 must be exercised, however, in two directions. In the 
 first place there is a possibility of intentional deception, 
 and in the second place there may be a recognition of the 
 morbid character of the mental disorder in a patient al- 
 though recovery is not to be looked for. Hence, the value 
 of this sign in prognosis resides in the fact that its absence 
 excludes complete recovery, while its occurrence after the 
 subsidence of violent symptoms usually has a very favor- 
 able significance, although it only justifies a prediction of 
 probable recovery. In ■ mental weakness this symptom 
 sometimes develops at a later period. As a rule, it is dif- 
 ficult for the convalescent to form a correct judgment con- 
 cerning hallucinations, especially the slight impulse to 
 movement which attends so many auditory hallucina- 
 tions. When the morbid character of the disease has 
 been recognized, the patient also tolerates mention of 
 the occurrences which have happened during his illness. 
 Whoever carefully avoids such memories is probably not 
 yet normal,- but has merely become sufficiently quiet to 
 conceal his delusions. It is only when the patient recog- 
 nizes the pathological changes in his mental life as some- 
 thing strange, that he is able to express thankfulness for 
 his recovery. 
 
 With advancing recovery, sometimes even before the 
 mental improvement, bodily improvement also takes place. 
 The weight increases, appetite and sleep improve. An- 
 other favorable sign is the return of former ailments which 
 had disappeared during the insanity, viz. , nervous head- 
 aches, digestive disturbances, etc. But if complete bodily 
 health develops during protracted insanity, the prognosis 
 is very unfavorable, and the transition into imbecility is 
 probable. Such patients may become extremely obese. 
 Slight increase of weight, however, is not an unfavorable 
 sign. 
 
PROGNOSIS. 125 
 
 There is a difference, as regards prognosis, between 
 hereditary psychoses, whose outbreak is due to late 
 accidental causes, and those in which heredity has pro- 
 duced a morbid development of character from early 
 childhood. If the patient with hereditary taint has been 
 mentally normal until his attack of insanity, the prognosis 
 of the single attack is more favorable than in non-heredi- 
 tary cases, but there is a greater predisposition to relapses. 
 
 An unfavorable prognosis usually attaches to those ac- 
 quired forms of insanity which develop after injuries to 
 the head, insolation, apoplexy, meningitis, and particu- 
 larly after epilepsy. 
 
 In syphilitic insanity due to specific changes in the 
 brain, great success is sometimes attained temporarily by 
 inunction treatment. But such cases are exceptional, 
 and the majority terminate, at the best, in feeble-minded- 
 ness. 
 
 When general anaemia, menstrual disorders, curable 
 diseases of the genitalia, and mild inflammations of the 
 intestinal canal are the cause of insanity, the prognosis is 
 favorable. This is also true of insanity after febrile dis- 
 eases so long as it is the expression of ansemia or exhaus- 
 tion of the brain, while complication with severe diseases 
 of the brain or with a serious infection or intoxication 
 makes the prognosis poorer. 
 
 The prognosis is unfavorable in old topers ; here the in- 
 sanity is usually attended with severe inflammations of 
 the meninges and even the cortex. In moderate alcoholism 
 many cases of insanity appear to have a favorable prog- 
 nosis, but they exhibit an unusual tendency to relapses. 
 
 Temporary or violently acting causes permit a more 
 favorable prognosis than slowly acting causes which last 
 for years. Thus, in continued sexual excitement recovery 
 is rare, while masturbators who abandon their vice may 
 be entirely restored. An extremely unfavorable progno- 
 sis obtains, however, in those cases in which the delu- 
 sion of a close union with the supernatural is associated 
 in an obscene manner with the tendency to masturbation. 
 
126 HANDBOOK OF INSANITY. 
 
 Temporary causes which act only once, such as pregnancy, 
 the puerperal condition, and nursing, allow a very favor- 
 able prognosis. 
 
 It is on account of this latter group of cases that the 
 prognosis as regards curability in general is better in fe- 
 males, while drunkenness and the injurious influences 
 attending the struggle for life still further aggravate the 
 prognosis in males. 
 
 The significance of age in prognosis is easily understood. 
 Childhood is greatly endangered by the so frequent hered- 
 itary taint ; in youth the prognosis of insanity is much 
 more favorable than in advanced age. Puberty and the 
 climacteric furnish a favorable prognosis only when there 
 is no hereditary taint. 
 
 We will now consider the prognosis of a few individual 
 symptoms. A profound disturbance of consciousness, de- 
 veloping gradually in the course of the disease, indicates 
 an unfavorable termination, while its sudden occurrence is 
 more favorable. The impulse to collect articles, loss of the 
 sense of modesty, and uncleanliness during violent mania, 
 are not so grave as in chronic conditions with extinguished 
 affects. Incoherency and firm delusions during excite- 
 ment may disappear ; without excitement they are usually 
 signs of mental weakness. Permanent impairment of 
 memory has an evil significance. If confusion is accom- 
 panied by new-formed words the prognosis is bad. 
 
 Insensibility to heat and cold, staring into the bright 
 sunlight, absence of the feeling of satiety, the ingestion 
 of nauseous articles, especially of excrement, are found 
 almost exclusively in severe, unfavorable cases. Condi- 
 tions of sexual excitement before and after the period of 
 potency are of grave omen, especially the rekindling of 
 sexual desire in old men. 
 
 Visual hallucinations usually occur only in recent cases, 
 auditory hallucinations in chronic ones, and the latter, 
 like olfactory hallucinations, are grave signs. Still more 
 unfavorable is the combination of hallucinations in several 
 sensory tracts. 
 
MOTOR SYMPTOMS IN PROGNOSIS. 127 
 
 Actions which are done apparently without motive and 
 which are subsequently defended with various reasons 
 have a very bad significance. Like crankiness, they point 
 to degeneration-insanity. Imperative concepts, move- 
 ments, and impulsive imperative acts are also symptoms 
 of the same morbid group; or they indicate profound 
 organic destruction of the tissues, as in the rhythmical 
 and stereotyped imperative movements of imbeciles. 
 
 Among the purely bodily disturbances the motor symp- 
 toms are most important as regards prognosis. Par- 
 alyses, spasms, and disorders of co-ordination as attend- 
 ants of psychoses are usually due to severe diseases of 
 the central nervous system, unless they are hysterical in 
 character. Catalepsy associated with disturbance of con- 
 sciousness also occurs in curable cases, and muscular tre- 
 mor is not always an unfavorable sign; for example, 
 in the beginning of alcoholism, anaemia, and nervous ex- 
 citement; but if associated with paralyses of the limbs 
 or ocular muscles it is more serious. Difference in the 
 size of the pupils and strabismus, if not habitual, can 
 only be utilized in association with other symptoms. 
 Rigidity and contraction of the pupils rouse the suspicion 
 of progressive paresis. Disturbances of speech, so-called 
 syllabic stuttering, and the corresponding disorders of 
 writing point to the same unfavorable form of disease, 
 but may also occur in general neurasthenia. Continued 
 gritting of the teeth is an indication of severe irritation 
 of the cerebral cortex. Continued flow of saliva hardly 
 ever occurs except in higher grades of mental weakness ; 
 at the same time there are usually pronounced changes of 
 mimic innervation. An unfavorable termination is often 
 revealed at an early period by the staring, expressionless 
 gaze, and the distortion of the features due to unequal 
 innervation. If the features and posture are relaxed, the 
 chin depressed, the saliva flowing from the angles of the 
 mouth, and the faeces and urine are passed involuntarily, 
 then the transition into imbecility has generally taken 
 place. On the other hand, recovery is early manifested 
 
128 HANDBOOK OF INSANITY. 
 
 when the features clear up, and the normal play of features 
 of the former personality again develops. 
 
 Neuralgias have no significance in prognosis, while 
 anaesthesia and analgesia are decidedly unfavorable. The 
 severe trophic disorders, such as othematoma and fragility 
 of the ribs, almost always indicate a termination in death 
 or dementia. 
 
 The absence of the menses in recent cases is not unusual, 
 but their return is always a desirable sign. If menstrua- 
 tion returns before improvement of the mental condition, 
 it indicates at least an improvement in the vegetative con- 
 ditions of the organism, and is occasionally the precursor 
 of recovery ; but if improvement does not occur soon, then 
 the return of menstruation, like that of other bodily func- 
 tions, without mental improvement, has an unfavorable 
 prognostic significance, 
 
THE DIAGNOSIS OF MENTAL DISORDERS AND THEIR 
 BORDER LINES. 
 
 A. GENERAL STANDPOINT. 
 
 A psychiatric diagnosis is in the main a psychological 
 one. But although the psychoses are diseases which run 
 their course particularly in the psychical domain, yet the 
 accompanying bodily symptoms may not be neglected. 
 Definite diagnoses are based less upon single, undeniable 
 manifestations of disease than upon definite groups of 
 phenomena. Everything depends upon the interpretation 
 of the mental acts by the observer. For example, in the 
 uneducated a belief in witches cannot at once be regarded 
 as an evidence of disease, while such a belief in a cultured 
 individual forces us to investigate the reasons which have 
 led him to this belief. 
 
 More or less difficulties in diagnosis are created by the 
 families of the patients, who, to a greater or less extent, 
 acquire the habit of accepting his delusions as real. They 
 attribute the disease to entirely immaterial causes ; they 
 weaken the significance of the patient's wrong acts or jus- 
 tify them. If the patient has attacked a passer-by, they 
 explain that the former must have been irritated. On the 
 other hand, the patient himself offers serious difficulties. 
 Usually there is distrust of the physician, because the pa- 
 tient's feeling of uncertainty concerning his own mental 
 functions makes him fear removal to an asylum. Hence, 
 he refuses to proclaim his delusions, and is either silent 
 or gives unsatisfactory answers. It is only in exceptional 
 cases that patients, with a certain consciousness of their 
 own illness, voluntarily lay bare their internal condition 
 to the physician. 
 
 9 129 
 
130 HANDBOOK OF INSANITY. 
 
 The existence of a psychosis may not be denied on ac- 
 count of the incomplete resemblance of the case to one 
 of the principal forms of insanity, because there are various 
 mixed forms or incompletely developed varieties of insan- 
 ity. As a rule, it is not difficult to discover at least the 
 general signs of excitement, depression, or mental weak- 
 ness, although even this is not always patent. In such 
 cases the patient's acts furnish better information. 
 
 The chief evidence of the existence of a psychosis is a 
 change in the character of the psychical life, in the pa- 
 tient's moods, feelings, tendencies, habits, volitions, and 
 judgments. Hence, his previous character must be known 
 to the physician or must be described to him by others. 
 In some cases, however, there is merely a higher develop- 
 ment or intensification of the prominent characteristics. 
 The change is also indistinct in congenital conditions. 
 
 The diagnosis of mental disturbance in children presents 
 special peculiarities. For example, it is not always easy 
 to determine, at an early period, slight degrees of feeble- 
 mindedness. A late acquisition of speech is usually 
 noticed even by the parents, also the rapidity with which 
 study tires the child. It is especially important to dis- 
 tinguish congenital or early deaf -mutism from imbecility. 
 In the latter condition the child is dull and apathetic, and 
 looks aimlessly about him; in the former, he looks with 
 an attentive expression upon the speaker. Tests of hear- 
 ing then give further information. 
 
 A complete diagnosis includes a knowledge of the cau- 
 sation of the disease. The patient's previous life must be 
 investigated in all directions in order to understand the 
 development and course of the disease. In this way we 
 will avoid the error of making a diagnosis of a definite 
 form of disease from a single symptom, inasmuch as there 
 are no so-called pathognomonic symptoms. 
 
EXPRESSION OF MOODS. 131 
 
 B. PSYCHIATRIC EXAMINATION. 
 
 1. Diagnosis of the Disease. 
 
 The examination is begun in a somewhat similar man- 
 ner to that employed in any other disease. The name, 
 age, and occupation are first obtained. This will deter- 
 mine, in a rough way, whether consciousness is impaired 
 or unclouded, whether memory is retained, or the course 
 of ideas is accelerated or retarded. The bodily posture, 
 gestures, and facial expression will then furnish sufficient 
 data to enable us to continue the examination in certain 
 directions. In excited patients the further course of the 
 examination will be guided by the manifestations of dis- 
 ease themselves, in self-contained individuals we reach 
 further facts and observations by questions concerning the 
 events of their former life, while completely irrational pa- 
 tients soon compel us to regard the present condition, which 
 is then made clearer by the statements of the family. As 
 a general thing, however, we should allow the impres- 
 sion made by the patient to act upon us in as unbiassed a 
 manner as possible, and to gain his confidence by dilating 
 quietly upon his present notions. Excessive questioning, 
 at the start, is apt to intimidate the patient or to produce 
 distrust. Gradually we may enlarge upon the symptoms 
 which are exhibited voluntarily. 
 
 Among these the expression of the mood is almost al- 
 ways the first. In recent cases, as a rule, affects appear 
 very clearly. The cheerful mood is disclosed freely, and 
 there is no objection in calling the patient's attention at 
 once to the fact that there is no reason for mirth in his 
 present position. He will either pay no attention to this 
 reprimand or he is not infrequently led to disclose, in rapid 
 speech, his inner feelings. In this event we attempt to 
 ascertain disorders in the course of his ideas, which are 
 rapidly shown in the higher grades of cheerful excitement, 
 but require careful observation in the slighter grades. A 
 certain degree of loquacity and jumping from one subject 
 of conversation to another are important signs in the diag- 
 
132 HANDBOOK OF INSANITY. 
 
 nosis of a condition of excitement. Great aid is furnished 
 by observing the movements of expression. While cheer- 
 ful excitement presents a frequent change of expression, 
 in depressed moods our attention can be directed for a 
 longer time to their external signs. The melancholic thus 
 furnishes an excuse for asking him concerning the reason 
 of his depression, but if his despair is known to be un- 
 founded we should avoid calling his attention thereto in 
 order that distrust may not be aroused. A friendly, sym- 
 pathetic manner is necessary if we wish to ascertain 
 whether the melancholic affect results from delusions and 
 hallucinations, or whether there is a simple affective con- 
 dition. To the existence of these two conditions, viz., 
 delusions and hallucinations, the examination must now 
 be directed unless the patient himself has already revealed 
 them. 
 
 Delusions are very characteristic of certain psychoses. 
 In the beginning of the disease the patient, in many cases, 
 instinctively attempts to conceal them, and eludes all at- 
 tempts to discover them until some point is touched which 
 throws him into an affect, or until, by means of all sorts 
 of questions, a point of contact is found through which 
 the entire chain of morbid ideas may be developed, appa- 
 rently without intention. The conduct of the patient some- 
 times puts us on the trail. A distrustful bearing rouses 
 the suspicion of the notion of secret enemies and persecu- 
 tions. Excessive self-satisfaction, which is often exhibited 
 in the dress, indicates ideas of grandeur, while frequent 
 prayers and tearful expression make it probable that we 
 have to deal with the delusion of having committed a 
 crime, with a religious color. Not every statement of a 
 peculiar character must be regarded as a delusion, because 
 the insane, like the sane, may be mistaken, or the idea 
 of jealousy, for example, may be based on fact. Thus, so 
 far as regards its contents, the delusion of jealousy of the 
 alcoholic cannot be distinguished from a possible mistake. 
 But more frequently the delusions are so peculiar that their 
 morbid character strikes us at once. 
 
CONTENTS OF DELUSIONS. 133 
 
 The contents of delusions may be built up from the en- 
 tire experience of man, yet the main elements of delusions 
 exhibit such a widespread agreement with one another 
 that the experienced observer, relying upon inferences 
 drawn from external appearances, is often able, with sur- 
 prising rapidity, to obtain from the astonished patient the 
 confession of his morbid ideas. It is a notable fact that 
 the same morbid ideas appear in so many patients. In 
 the individual cases the principal groups of delusions 
 (which have already been discussed) are easily recognized 
 as variations of the same theme, and the diagnosis will 
 quickly distinguish depressive notions of self-impairment 
 or expansive ideas of grandeur. There is no material dif- 
 ference, so far as regards the medical diagnosis, whether 
 a mother says that she or her children are poisoned. If 
 a patient revels in ideas of great wealth it is immaterial, 
 so far as regards our interpretation of his statements as 
 delusions, whether the treasures consist of mountains of 
 gold or more modest sums. These differences possess 
 value in diagnosis only in so far as they are evidences of 
 absence of judgment and thus become a measure of the 
 degree of mental weakness which in a greater or less 
 degree accompanies all delusions. 
 
 In a series of cases depressive and expansive delusions 
 are both present. They may appear in rapid alternation, 
 but even then one group is the more prominent. A mani- 
 acal patient may say, in the same breath: I have been 
 poisoned, I am the king; a paralytic dement, with the 
 most florid delusions of grandeur, may say that he will be 
 killed to-day; or a profoundly melancholic patient may 
 casually remark that he lives in a palace, surrounded 
 by princes. Such brief expressions of opposite moods are 
 not rare in recent affective conditions, and do not compel 
 the diagnosis of an unfavorable form of disease. But if 
 the two principal groups of delusions develop slowly 
 alongside of one another, so that, for example, the antag- 
 onistic notions of delusions of grandeur and of persecution 
 have had time, during a number of years, to form firm 
 
134 HANDBOOK OF INSANITY. 
 
 combinations and to grow "together into a firm system, 
 then we have to deal with a more serious ailment, with 
 " verruecktheit " in the proper sense of the word. 
 
 We must next ascertain whether the delusions are ac- 
 companied by hallucinations, and which have developed 
 first in point of time. As the latter do not develop on the 
 same basis, in so far as they are peripheral in origin, 
 this must first be examined, because certain peripheral 
 hallucinations are susceptible of direct treatment. If the 
 hallucinations have developed centrally in the cortex, it 
 will probably be impossible to determine the period of 
 their development. Their relationship and similarity of 
 development are then so great that in many cases halluci- 
 nations may only be regarded as delusions which are pro- 
 vided with a vivid sensory accompaniment. In this respect 
 we may refer to all those relations which may be recognized 
 between auditory hallucinations and their expression in 
 speech. The firm association between concept and lan- 
 guage makes it easy for us to understand the powerful con- 
 vincing power of auditory hallucinations which readily 
 overcomes the critical objections of reason. It must be 
 borne in mind that the basis is cerebral and not merely 
 logical. Hence delusions, like hallucinations, may also 
 appear in antagonism to the predominant moods and feel- 
 ings. 
 
 As a regular connection between certain sensations (as- 
 sociated sensations) takes place along definite nerve tracts, 
 in like manner we must assume the development of certain 
 delusions and hallucinations as connected with definite 
 tracts, so that they must always develop in the same 
 manner after certain peripheral or cerebral stimuli (asso- 
 ciated concepts) . In this way alone can we explain, in a 
 measure, the narrow range and repetition of the contents 
 of primordial delirium, which are found on the whole to 
 be independent of the mood and of the special form of dis- 
 ease. 
 
 The search for hallucinations is often facilitated by the 
 patient's manner. A listening attitude, staring at one 
 
HISTORY OF THE PATIENT. 135 
 
 point, sudden starting and speaking are occasionally very 
 characteristic. The diagnosis is easier when the patient 
 speaks of "voices" and "images." The simple mention 
 of electrical or magnetic influences, etc., if made casually, 
 sometimes induces the individual to express his secret 
 thoughts. 
 
 Peculiarities in the surroundings, for example, in the 
 furniture of the room, may also guide the diagnosis. 
 After a few questions to test the memory, we must en- 
 deavor to obtain from the patient (or those around him) a 
 history of his previous condition. It is of great practical 
 importance to question the patient and his family sepa- 
 rately. We must particularly avoid unreserved accept- 
 ance of the statements of the family, especially as they 
 are inclined to regard signs of the already existing disease 
 (for example, excesses of all kinds) as causes of the men- 
 tal disorder. 
 
 The hereditary conditions must first be ascertained — 
 the existence of insanity in the relatives, the special form 
 of the disease, the occurrence of nervous diseases of all 
 kinds, of drunkennesss, or a tendency to suicide. Under 
 certain circumstances we must inquire into the question 
 of hereditary syphilis or tuberculosis, or whether concep- 
 tion took place during drunkenness or the epileptic condi- 
 tion. 
 
 We proceed next to the history of the development and 
 growth of the patient — whether injurious influences were 
 at work during pregnancy or parturition, whether the de- 
 velopment of the brain was impaired by diseases of 
 infancy; whether convulsions appeared at a later period. 
 We then enter upon the peculiarities of the further bodily 
 development, especially sexual development and mastur- 
 bation, the timely or premature occurrence of puberty and 
 menstruation. The questions next extend to the time at 
 which the patient learned to speak, the progress in school, 
 social tendencies, and the peculiarities of character. With 
 regard to later life we must ascertain the occurrence of 
 exhausting diseases which lead to anaemia. 
 
136 HANDBOOK OF INSANITY. 
 
 The investigation then passes to the patient's occupa- 
 tion, his marital and social relations, etc. 
 
 Special importance attaches to the disappearance of 
 ethical feelings, of love for the family, defective sense of 
 propriety, the aesthetic feelings in general. 
 
 We must also ascertain whether the disease began sud- 
 denly or slowly, whether disturbances of consciousness 
 occurred at the onset or later, whether the disorder was 
 continuous or progressed by fits and starts. The previous 
 history often justifies renewed examination of the present 
 mental condition and this may facilitate the correct diag- 
 nosis. 
 
 Physical examination of the body must now be under- 
 taken. The most important point is the character of the 
 sleep, then the general nutrition, adipose development, 
 muscular strength, and weight of the body. 
 
 Examination of the bodily temperature often requires 
 special care, because the other diagnostic aids in the rec- 
 ognition of bodily diseases are often wanting in the insane. 
 
 The vasomotor system is almost always implicated. 
 This is shown most distinctly in paralyses of large vascu- 
 lar tracts or in more or less circumscribed tracts, the walls 
 of whose vessels offer a diminished resistance to the cur- 
 rent of blood. The experienced touch easily recognizes 
 the pulsus tardus of many insane. 
 
 Physical examination of the lungs must not be neglected, 
 because pulmonary diseases in the insane occasionally run 
 their course without a rise of temperature. 
 
 As a matter of course, the condition of the digestive 
 organs merits special consideration. In recent cases of 
 melancholia gastric catarrh is sometimes the exciting 
 cause of concepts from which the refusal to take food 
 develops. 
 
 As regards gynecological examinations, it is better to 
 do too little than too much, and they should be made only 
 when there is a definite indication. It is advisable to 
 make such examinations only in the presence of witnesses. 
 
 Examination of the urine is desirable, and, whenever 
 
EXAMINATION OF EYEWEAR, AND SKIN. 137 
 
 there is marked emaciation, the tests for sugar should be 
 applied. 
 
 Ophthalmoscopic examination is necessary, because con- 
 gestion of the brain and the fundus often go hand in 
 hand. Retinal diseases, especially retinitis pigmentosa, 
 and opacities of the refracting media may help to explain 
 visual hallucinations. 
 
 Examination of the ear is equally important. The re- 
 moval of hardened wax has often relieved auditory hallu- 
 cinations. Plugging the ear with cotton sometimes leads 
 to the suspicion of auditory hallucinations which were, 
 perhaps, not apparent from the manner and conversation 
 of the patient. Inflammations of the middle ear some- 
 times lead to the recognition of purulent meningitis and 
 thrombosis of the sinuses, whose occasional connection 
 with psychoses has been observed. 
 
 When olfactory hallucinations are present the nose 
 should be examined. 
 
 The tests for cutaneous sensibility must be accepted 
 with great reserve. The examination of motility is very 
 important because motor disorders, when associated with 
 insanity, are usually the expression of severe diseases of 
 the brain. The combination of psychoses with focal dis- 
 eases of the brain and external injuries may also give rise 
 to numerous motor symptoms. The significance of such 
 symptoms should not be overestimated in severe cases of 
 alcoholism. The further course and the previous history 
 will generally prevent a mistake with the usually more 
 persistent but similar disorders of paralytic dementia. On 
 the other hand, the changeableness of some paralyses does 
 not exclude severe cerebral disease. In dementia para- 
 lytica, for example, the paralyses sometimes change their 
 locality or disappear for a time in a few hours or days ; 
 differences in the size of the pupils may pass from one 
 side to the other. Phenomena of this kind are also ob- 
 served in some other forms of insanity. Mistakes are, 
 only avoided by taking into consideration all the other 
 symptoms of the case. It may here be mentioned that 
 
138 
 
 HANDBOOK OF INSANITY. 
 
 very wide pupils, with good reaction to light and accom- 
 modation, are found often in hysteria and mania, while 
 this symptom is wanting in epileptic attacks, meningitis, 
 and increased cerebral pressure in general. The mobility 
 of contracted pupils is ascertained with difficulty, but 
 pronounced narrowing is an important sign of profound 
 disease of the brain, and is very frequent in beginning 
 dementia paralytica. 
 
 Great scientific interest attaches to the examination of 
 the skull, although, in the diagnosis of psychoses, only 
 the most marked changes come into question. These 
 never occur when the mental condition is entirely normal, 
 while variations from the normal are also found in the skulls 
 of sane individuals. These include the sexual differences. 
 The female skull is smaller, on the whole ; its height is 
 
 Fig. 8.— (After Merkel.) 
 
 less, but its breadth is more developed. The base of the 
 female skull is narrower and shorter. The most strik- 
 ing peculiarity of the female skull, as seen in the living 
 subject in profile, is the line of the upper curvature ; the 
 
VARIATIONS IN THE SKULL. 139 
 
 flattening of the parietal region passes quite suddenly on 
 the one side into the vertical frontal line, on the other side 
 into the sloping line of the occiput, so that more or less an- 
 gular curves develop on both sides. In the male skull 
 
 Fig. 9.— (After Merkel.) 
 
 this line is arched ; seen from the front, it is also distin- 
 guished by the greater prominence of the parietal emi- 
 nences, so that it becomes angular compared with the 
 rounded female skull. 
 
 In the different races we find numerous variations in 
 the skull, which cannot be utilized in the diagnosis of 
 psychoses because they are often observed in the sane; 
 for example, large uniformly developed skulls, kephalones. 
 On the other hand small skulls, microcephalus, generally re- 
 veal an abnormal formation of the brain. Among other 
 forms I will call attention to the very frequent saddle head 
 (Fig. 10), in which a saddle-shaped depression occupies the 
 site of the large fontanelle. 
 
 The foetal brain does not fill the skull completely, a 
 
140 HANDBOOK OF INSANITY. 
 
 considerable space between the two being filled with 
 fluid. In its further growth the brain changes its posi- 
 tion in relation to the skull because the hemispheres 
 grow mainly from in front backward. The brain pro- 
 bably continues to grow until the age of twenty-five 
 years, but the growth of the skull ceases much earlier. 
 From birth until the seventh year the skull grows rapidly, 
 then there is almost complete standstill until puberty, and 
 during this, latter period it is supposed that the brain grows 
 
 Fig. 10. — (After Merkel). 
 
 more markedly. After puberty the skull grows in a more 
 uniform manner. 
 
 Three factors come into play in the growth of the skull — 
 the growth of the brain, constituting a force which presses 
 from within outward; the traction or pressure of the 
 muscles attached to the skull; and the structure of the 
 bones themselves. These influences are more important 
 than pelvic pressure during birth. The effects of the 
 latter may last for months and years, but the brain is 
 immature and there is conriderable room for accommoda- 
 tion within the skull. The three factors mentioned must 
 always be considered as coincident in point of time. That 
 the shape of the skull is influenced by the growth of the 
 brain is shown by the unilateral flattening in idiots with 
 atrophy of one hemisphere. Slight differences between the 
 
GROWTH OP THE SKULL. 141 
 
 two halves of the skull possess little value in psychiatric 
 diagnosis. 
 
 Among the muscular forces the chief part is played by 
 the traction of the muscles of the neck and the pressure of 
 the muscles of mastication. Strongly developed muscles 
 on the back of the neck flatten the occipital curve, while 
 feeble muscles increase its convexity; if the bones are 
 soft, as in rickets, a permanent deformity may result. 
 Vigorous temporal muscles narrow the skull. In an oc- 
 cupation which leads to permanent obliquity of the trunk 
 (and therefore of the head) the muscles of the neck act 
 unilaterally and the skull becomes oblique. As a matter 
 of course, such a scoliotic skull is not a sign of mental 
 disturbance. 
 
 The growth of the bones may be changed in general 
 rachitis, and constant lying on the occiput may be injuri- 
 ous in rachitic children. Another significance attaches 
 to ossification of the sutures. As a general thing, the de- 
 velopment of the skull is retarded in a direction perpen- 
 dicular to the ossifying suture. If the ossification occurs 
 prematurely, it leads to extremely pronounced changes, 
 especially at the base of the skull. 
 
 Meningitides in early life may change the intracranial 
 pressure and, in combination with other causes acting 
 from the outside, may lead to various deformities of the 
 skull. 
 
 In making measurements we follow the plan adopted 
 by the German Anthropological Society. 
 
 The horizontal plane (Fig. 11, h h) is determined, on the 
 macerated skull, by two straight lines which connect, on 
 both sides, the lowest point of the inferior rim of the orbit 
 with a point in the upper rim of the auditory canal lying 
 vertically above the middle of the auditory meatus. In 
 the living subject this plane can only be determined ap- 
 proximately, but with sufficient accuracy for practical 
 purposes. The plane can be rendered visible by applying 
 a rubber ring. The head to be examined must be placed 
 in such a position that this plane is parallel to the natural 
 
142 
 
 HANDBOOK OF INSANITY. 
 
 horizon. The horizontal planes should be marked out 
 before taking the longitudinal dimensions of the skull, 
 because, when the occiput is very prominent, the greatest 
 length, Lgr (to the external occipital protuberance) does 
 not coincide with the ordinary measure of length, the so- 
 called straight length L which passes from the middle of 
 the arch of the eyebrows above the nose to the most 
 prominent point on the occiput, parallel to the horizontal 
 plane. The auricular or ear height, OH, is the distance 
 between the upper rim of the auditory meatus to the point 
 
 Fig. 11. 
 
 of the vertex situated above it in a vertical line. The 
 greatest width is measured, wherever it may be found, to 
 the exclusion of the mastoid processes. The distances be- 
 tween the malar processes and between the auditory 
 foramina are measured with a pair of compasses, the 
 other distances are measured with the tape. 
 
 A certain proportion of breadth to length has given rise 
 to the terms long and short skull and the intermediate 
 mesocephalic skull. A so-called cranial index has been 
 
MEASUREMENTS OF THE SKULL. 143 
 
 introduced, the value of which is expressed in figures when 
 the transverse diameter is multiplied by 100, and the 
 product divided by the longitudinal diameter. Finally, 
 the inclination of the profile line, pf, to the horizontal 
 plane may be utilized in order to determine the profile 
 angle P. When this angle is much less than a right 
 angle, the individual is called prognathous, and orthogna- 
 thous when the angle approaches a right angle. Progna- 
 thism is almost always associated with premature cessa- 
 tion of the growth of the sphenoid and ethmoid bones, 
 and hence indicates a so-called sphenoidal kyphosis, with 
 which cretinic deformities are apt to be combined. 
 
 The following are the average measurements in the liv- 
 ing subject : 
 
 Man. Woman. 
 
 Straight longitudinal diameter 18 cm. 17.5 cm. 
 
 Greatest transverse diameter 15 14 
 
 Ear height 11 10. 5 
 
 Distance between the zygomatic processes.. 11 11 
 Distance between the auditory foramina. .. 12.5 11.5 
 Horizontal circumference (measured through 
 the eDds of the greatest longitudinal diam- 
 eter) 55 53 
 
 Sagittal circumference (from the root of the 
 nose to the external occipital protuber- 
 ance) 35 33 
 
 Profile angle : 
 
 Prognathous 82° 
 
 Orthognathous 83°-90° 
 
 100 X width 
 Length, width, index = leDgth — 
 
 Dolichocephaly (long skull) 
 
 up to 75 
 
 Mesocephaly 75-80 
 
 Brachycephaly (short skull) 80-85 
 
 In addition we may take the following measures, which 
 show particularly the differences between the anterior and 
 posterior halves of the skull, while the lateral differences 
 are found by comparing the lateral semi-circumferences 
 taken separately. 
 
144 HANDBOOK OF INSANITY. 
 
 Woman. 
 
 Auriculo-occipital line (from the anterior 
 
 border of one mastoid processto the other 
 
 over the external occipital protuberance) . 24 cm. 22 cm. 
 
 Auriculo-frontal line (from the anterior rim 
 
 of one auditory foramen to the other across 
 
 the glabella) 30 28 
 
 The various points to which we have referred as neces- 
 sary to a comprehensive psychiatric examination do not 
 complete the list. For example, the peculiarities of speech 
 and writing must be carefully noted. Writings may be 
 very important when it becomes necessary to arrive at a 
 conclusion without seeing the patient. It is a very com- 
 mon fact that patients who are able to conceal their con- 
 dition during conversation, freely reveal their morbid 
 ideas in letters. 
 
 A single personal examination may suffice to determine 
 whether the patient must be removed to an asylum or 
 whether he may be treated at home, but it is insufficient 
 for a complete psychiatric examination, and in difficult 
 cases prolonged observation is necessary. In doubtful 
 cases the asylum is the proper place for protracted obser- 
 vation, because the trained attendants supplement the 
 personal observations of the physician. 
 
 The second point in diagnosis, i.e., whether the psychical 
 disorder is independent or dependent upon another cere- 
 bral disease, can also be ascertained with certainty only 
 after careful continued clinical observation. Mistakes 
 have occurred in cases of drunkennesss, typhoid fever, 
 acute meningitis, and poisoning. As a rule, drunkenness 
 is easily recognized by the odor of the breath, the speech, 
 and the tottering gait, but in many cases there is great 
 similarity to mental disorder. In fact, drunkenness is 
 really an artificial insanity. In it we may find indica- 
 tions of all forms of insanity, from slight melancholia to 
 complete inhibition of the mental functions, such as is 
 observed in idiocy. There may also be conditions of ex- 
 citement in which the bodily and mental activities are in- 
 
RECOVERY FROM INSANITY. 145 
 
 creased. Increased self -consciousness and impulse to move- 
 ment remind us of mania, boastful speeches made with 
 a stammering tongue may make the differentiation from 
 similar phenomena in general paresis almost impossible. 
 The resemblance may be still greater when, on account of 
 a special predisposition, the intoxication develops as a 
 rapidly subsiding mania. Sometimes drunkenness acts 
 as the immediate exciting cause of permanent insanity. 
 As a matter of course, the differentiation is impossible 
 when an insane individual becomes drunk. Usually the 
 symptoms of drunkenness are then very violent or a very 
 small amount of alcohol suffices to produce intoxication, as 
 the majority of the insane are very susceptible to alcohol. 
 Typhoid fever sometimes begins with the symptoms of 
 a maniacal attack with great excitement, at other times 
 with symptoms of melancholia. When mental disturb- 
 ances begin unexpectedly, the suspicion of typhoid fever 
 should be kept in mind, especially in young people and 
 when the disease is epidemic. In a few days the fever 
 and other symptoms will clear up the diagnosis. 
 
 2. Diagnosis of Recovery. 
 
 This problem is especially difficult in individuals who 
 suffered from feeble-mindedness or hereditary taint before 
 the onset of the psychosis proper. 
 
 The difficulty resides chiefly in the fact that the symp- 
 toms which are proof of the disease have subsided, but not 
 disappeared entirely, and are apt to return under slight 
 provocation amid different surroundings. For this reason 
 the judgment of the relatives is often more decisive than 
 that of the asylum physician because the restoration of the 
 previous personality is better recognized by them. We 
 must here take into consideration the possibility that pa- 
 tients may conceal material symptoms of their disease. 
 Hallucinations and delusions which the patient knows are 
 regarded as morbid by the physician are sometimes con- 
 cealed by him, in order to secure his discharge from the 
 asylum or from treatment. This dissimulation may be 
 10 
 
146 HANDBOOK OF INSANITY. 
 
 skilfully practised by patients in whom the original affect 
 has disappeared. But we will either be able to detect an 
 antagonism between the patient's speech and actions, or 
 the careful observation of the former course of the disease 
 and the previous life of the patient will confirm any doubt 
 concerning the simulated recovery. In other cases only 
 the discharge from the asylum will show the dissimulation 
 by the irrational acts which soon make their appearance. 
 The dissimulation is very dangerous in suicidal melan- 
 cholies who sometimes conceal their morbid feelings and 
 ideas with great skill. This danger is to be kept in view, 
 particularly when the tendency to suicide has been mani- 
 fested several times in the family. It may be very impor- 
 tant in such cases to see the patient's letters, in which he 
 often discloses his most secret thoughts. At times, also, 
 the written characters may reveal the attempt at dissimu- 
 lation. 
 
 It is sometimes very important to determine whether 
 insanity is real or simulated. This may even come into 
 question in non- judicial cases. In imbecile and hysterical 
 insane, in particular, there is sometimes a tendency to 
 exaggerate. Although the intentional deception can usu- 
 ally be recognized, it is more difficult to exclude the really 
 coexisting mental disorder. The matter becomes still 
 more complicated from the fact that simulation is practised 
 chiefly in those forms of insanity which develop upon an 
 hereditary basis in the form of degeneration, and hence 
 per se exhibit numerous deviations from the ordinary clin- 
 ical histories. Simulation is practised in the main, how- 
 ever, by criminals who desire to avoid punishment. But 
 the malingerer grows tired of his role so much the more 
 readily as exaggeration of the individual symptoms is one 
 of his most common mistakes. Such deception is easily 
 discovered in an asylum, and, hence, doubtful cases should 
 be sent to an institution. Here the observation of undis- 
 turbed sleep is easily made, and therefore conditions of 
 excitement are more rarely simulated. Another mistake 
 is the combination of different forms of disease — for exam- 
 
SIMULATION. 147 
 
 pie, melancholia and epilepsy, which are not often associ- 
 ated in reality. The malingerer is apparently irrational and 
 gives entirely wrong answers, but it is apparent that he is 
 able to follow the conversation, because he soon manifests 
 a symptom which the physician had referred to as want- 
 ing. It is especially difficult for him to imitate the phys- 
 ical concomitants of a psychosis — for example, the loss of 
 weight. 
 
 The physican should always avoid answering the ques- 
 tion, so often put by the judiciary, as to the responsibility 
 of a patient, and should confine himself strictly to the 
 question of mental health or disease. The question of 
 responsibility must then be determined by the legal 
 authorities. 
 
 C. THE BORDER LINES OF INSANITY. 
 
 These innumerable disorders of the mind and of ethical 
 feelings must be considered from a common standpoint, 
 viz., that of degeneration, which in the majority of cases is 
 inherited or congenital, and is much more rarely acquired. 
 
 Among the many expressions of mental taint we have 
 already described a series of imperative conditions, and 
 among these we will again refer to agoraphobia, or fear of 
 places. It is almost always associated with other condi- 
 tions of fear, which develop after mental and bodily strain 
 upon the basis of a morbid predisposition of the nervous 
 system. The peculiar so-called "gruebelsucht," which is 
 very often associated with fear of contact, is also not an 
 independent disease, but is based on a morbid predis- 
 position that is shown by other mental and bodily symp- 
 toms. But it is rarely possible to demonstrate such con- 
 ditions as part of a pronounced psychosis (particularly 
 paranoia) ; we must be satisfied with the demonstration of 
 the morbid predisposition which stands on the border line 
 of insanity. 
 
 The desire for food, and especially for sexual gratifica- 
 tion, which also belong to healthy life, may occur impera- 
 tively in certain border conditions, the morbid basis of 
 
148 HANDBOOK OF INSANITY. 
 
 which is often difficult of demonstration by the physician. • 
 This is only possible when he finds an hereditary morbid 
 predisposition in the mental and physical development of 
 the individual. There is also another series of symptoms 
 known as the impulse to commit suicide, to steal, to drink, 
 and to commit arson, but these impulses do not exist inde- 
 pendently of other mental disturbances. All these impulses 
 can only be understood after the following psychological 
 considerations. In every healthy individual there is an 
 impulse to action as the result of the internal vital pro- 
 cesses. As a rule, quiet reflection and conscious selection 
 furnish the direction of his acts. But as a man who is 
 taking a walk, for example, strikes the weeds with his 
 cane, so there are hundreds of outlets to this unem- 
 ployed impulse to activity in acts of no moment, provided 
 there is no opposing stimulus. By means of antagonistic 
 notions of decency and propriety the mentally healthy 
 individual regulates any pronounced feelings which de- 
 velop out of healthy vital processes. The mentally feeble 
 individual yields to them without reflection. Hence in 
 many cases we have to deal, not with increased, but with 
 unrestrained impulses. If a patient in an asylum steals 
 his neighbor's bread, this will not be called an impulse to 
 steal, because it is merely a trivial satisfaction of his de- 
 sire ; if an insane passionate smoker takes cigars wherever 
 he finds them, he follows a well-grounded impulse. The 
 unconcealed exhibition of tendencies, passions, and vices is 
 then not a phenomenon of disease, but is merely manifested 
 on account of the disease. Such insane, in whom the 
 resistance arising from the sense of duty and rational re- 
 flection is wanting, can be led to commit crimes at the 
 slightest impulse. 
 
 It is difficult to distinguish normal from morbid impulses 
 in the insane, because the latter, still more than the healthy 
 individual, is seized by affects and his actions are thus deter- 
 mined. It is often difficult to decide to what extent revenge, 
 fear, homesickness, or thoughtlessness have led to an act of 
 violence. It is only when insanity can be excluded, that 
 
ECCENTRICITY. 149 
 
 their full significance may be attributed to these affects. as 
 normal motives of action. Otherwise the physician must 
 demonstrate that morbid condition of the mind, on the basis 
 of which the unbridled or morbidly intensified impulse has 
 found expression. It may be said that these impulsive 
 conditions are part of a psychosis and are not on the 
 border-line. The incendiary impulse, in particular, is 
 often regarded as an independent disease, but its morbid 
 character is only determinable when an organic taint of 
 some kind is present. This is often facilitated by the 
 fact that the incendiarism occurs so often at the period of 
 puberty. Here the obscene impulse of the sexual devel- 
 opment is added to the others which arise from the inter- 
 nal vital processes, and finds its relief in a manner which 
 is often surprising to the individual himself. The proof 
 is most difficult in the milder grades of feeble-mindedness, 
 whose signs occasionally consist only of morbid irrita- 
 bility, stubbornness, conceit, lying, etc. Hence, an opin- 
 ion concerning such young incendiaries not infrequently 
 requires prolonged observation. Girls are affected in this 
 way somewhat more frequently than boys. 
 
 Another group of morbid conditions which stand on the 
 border-line of insanity is exemplified by eccentric indi- 
 viduals. These include adventurers, who often change 
 their abode without reason, and take long journeys. A 
 periodical course of the vagrant tendency and its accom- 
 panying symptoms is often more or less marked. Some 
 of these restless wanderers finally end in an asylum. 
 Many remain free from restraint, but are in constant con- 
 flict with established public order. Certain spendthrifts 
 belong to this class, but their condition can only be re- 
 garded as morbid when degeneration can be traced 
 throughout their entire development. 
 
 In some degenerative conditions the elements of allied 
 forms of insanity can be recognized, although the boun- 
 daries of insanity are not overstepped. Some individuals, 
 apart from a few peculiarities, show no signs of mental 
 disorder to their family for many years. Then some 
 
150 HANDBOOK OF INSANITY. 
 
 trivial insult becomes the starting-point for constant com- 
 plaints. Their obstinacy on this point soon becomes 
 striking, and as they make themselves disagreeable on 
 this account, fresh food for further complaints is furnished. 
 Real delusions and hallucinations are wanting, and a sys- 
 tem of delusions does not always develop out of such con- 
 ditions. In very few cases a progressive course terminat- 
 ing in imbecility is observed. Litigious and quarrelsome 
 persons may become veritable thorns in the flesh, but 
 the morbid basis is rarely recognized. It is onty when 
 the impulsive thirst for lawsuits and quarrelling threatens 
 to destroy fortune and happiness, that the eyes of the rela- 
 tives are opened to the existence of a mental disorder. 
 
 Religious enthusiasm and fanaticism often stand on the 
 border-line of insanity. The great majority of such indi- 
 viduals suffer from hereditary taint. 
 
 D. POST-MORTEM FINDINGS. 
 
 These possess very little value as an aid in the confir- 
 mation of diagnoses in psychiatry. If the diagnosis can- 
 not be made during life, the autopsy will hardly ever aid 
 in arriving at a conclusion. Even the distinct findings 
 in certain forms of imbecility merely justify the assump- 
 tion that some psychosis has run its course. At the most, 
 extensive atrophy of the convolutions of the frontal lobes 
 point to dementia paralytica, and extensive defects in 
 the brain render a previous idiocy probable. Even a mi- 
 croscopical examination is not entirely demonstrative. If 
 the psychosis has been observed during life, then all the 
 findings in the brain become important, especially diffuse 
 changes in the cortex. Functional disturbances, includ- 
 ing those associated with congestion or anaemia, usually 
 leave no traces. 
 
VI. 
 
 THE TREATMENT OF INSANITY. 
 A. PSYCHICAL TREATMENT. 
 
 The physical basis, especially the brain and central ner- 
 vous system, is only involved to a certain degree in men- 
 tal disorders, even in the most pronounced cases. Only 
 in so far as there is a change in the psychophysical appa- 
 ratus may we expect to exert an influence on the course 
 of the disease by suitable treatment. All other bodily 
 changes, so far as they influence the mental condition, are 
 important points of attack in treatment. Bodily and men- 
 tal treatment, however, must always go hand in hand. In 
 determining the limits beyond which psychical treatment 
 loses its efficiency, it must be remembered that voluntary 
 thought in concepts is not dependent immediately upon 
 the psychophysical mechanism, while all emotions are 
 intimately connected with it. The latter may, therefore, 
 be influenced immediately, the former only through the 
 medium of the emotions. As all psychical processes are 
 associated more or less with emotions, a large field remains 
 for psychical treatment, especially in recent cases. 
 
 It is evident that every attempt to refute, by means of 
 reason, a patient's delusions must be useless, nor can we 
 exert an immediate influence upon his will. 
 
 But much can be effected by influencing his emotions 
 and moods, both as regards the latter, and also the higher 
 psychical processes dependent upon them. Experience 
 teaches, however, that even the immediate influence upon 
 the moods is limited, and that often we can merely keep 
 away new injurious influences. Many excitements and 
 exacerbations may be produced by rousing the feelings, 
 
 151 
 
152 HANDBOOK OP INSANITY. 
 
 and hence can be avoided by a friendly and equable 
 demeanor. 
 
 The personality of the physician plays the principal part, 
 and by his sympathy, freedom from bias, and quiet deci- 
 sion he must increase the ascendency which he has already 
 gained from the correct judgment of the case. The influ- 
 ence of the physician's personality upon the insane is es- 
 pecially evident outside of asylums, while the latter possess 
 powerful auxiliary aids in treatment. In an asylum the 
 visits of the physician exert a continued effect upon the 
 patient, because all the regulations of the institution prove 
 to him that the physician is at the helm. 
 
 For this reason an asylum is the proper place for those 
 patients who at first resist treatment. Sometimes a hos- 
 pital will suffice temporarily, because the influence of the 
 physician is much greater than when the patient is living 
 at home. For the present we will consider chiefly the 
 period during which the patient has not entered an asy- 
 lum. We desire to influence his mood ; for this purpose 
 the surroundings must be sympathetic, the patient's inter- 
 est must be aroused and diverted from the causes of the 
 disease. This is generally possible when we bear in mind 
 that violent affects require treatment in asylums, while 
 the milder cases, which are amenable to this form of treat- 
 ment, require the advice of the practitioner. The laity 
 are inclined to look for a cure in distractions. While it 
 cannot be denied that conversation, the theatre, and con- 
 certs occasionally cause relief, this is generally so fleeting 
 that the family soon recognize the self-deception. Even 
 the temporary improvement disappears as soon as the pa- 
 tient recognizes the object of the distraction. At all 
 events it is dangerous to subject a fresh psychosis to con- 
 stant bodily and mental restlessness engendered by frequent 
 amusements and journeys. We must urgently caution 
 against bringing such a patient in contact with new stim- 
 uli. If he cannot remain longer in tne family, he should 
 enter an asylum. Only older forms of disease, which are 
 lacking in affects, will be aided by such distractions. 
 
OCCUPATION. 153 
 
 The best distraction for all is moderate, regulated occu- 
 pation, and preferably in the patient's own calling, if this 
 has not been the cause of the disease. Tendencies and 
 habits are often inseparably united with the occupation. 
 Hence women suffer particularly from removal from home, 
 and we should avoid losing time in travel, etc., if it is 
 impossible for them to remain in the family. 
 
 When this is no longer possible the alienist must adopt 
 other principles in treatment in an asylum. In the be- 
 ginning, at least, our object must often be to remove the 
 patient from the action of those daily irritants which are 
 often exercised upon him in his business, in the cares of 
 self-support, in the irrational conduct of his relatives, and 
 often in violent reproaches. In recent cases it is then 
 always better for a time to break off all communication 
 with the family in order to avoid emotional excitement. 
 As a rule, visits from members of the family are only use- 
 ful during convalescence. As a matter of course, this is 
 not true of chronic conditions and of the free intervals of 
 a periodical affect. In such cases visits cheer the monoto- 
 nous life of the patient. These remarks also hold good of 
 communications in writing. 
 
 But here, as everywhere in psychiatry, we must indi- 
 vidualize, and the treatment must be changed according 
 to the special individuality of the patient. Hence the 
 great importance of a knowledge of the previous life of the 
 patient. 
 
 It is evident that psychical treatment must consist, in 
 great part, of the avoidance of injurious influences. The 
 view is still widespread that not alone should we avoid 
 opposing the patient, but that we should express assent to 
 his fears, tendencies, and particularly to his delusions. In 
 many cases this is injurious ; fears of an obscure nature 
 may be rapidly converted into firm delusions and the pa- 
 tient's own doubts may be removed. A contradictory 
 opinion should be expressed cautiously in order to avoid 
 dispute, and in general the morbid concepts should be dis- 
 cussed as little as possible. The patient should be told 
 
154 HANDBOOK OF INSANITY. 
 
 frankly that he is regarded as sick, and he should be 
 treated with uniform, friendly patience and quiet sympa- 
 thy. In other ways, also, frankness is the only proper 
 method ; deception is generally as bad as force. If a pa- 
 tient is to be taken to an asylum, deception and artifice 
 are harmful, because they give rise to distrust of the fam- 
 ily and the physician. A quiet, but firm declaration that 
 the disease necessitates such a measure will generally make 
 the employment of force unnecessary. As a matter of 
 course, it may be unavoidable in conditions of violent 
 excitement and great impairment of consciousness. 
 
 As a rule, religious communications should not be per- 
 mitted in recent cases ; in permanent cases it may often 
 be allowed and is occasionally even desirable. 
 
 B. PREVENTION OF INSANITY. 
 
 The prevention of insanity presupposes an accurate 
 knowledge of its causes, the most prominent of which is 
 heredity. Here we may refer to the question of the mar- 
 riage of the insane or of those suffering from an hereditary 
 taint. The fact that unmarried individuals are relatively 
 more liable to insanity than the married, has sometimes 
 led to an affirmative answer to this question. The rare 
 cases in which marriage has appeared to prevent the out- 
 break of insanity do not justify us in recommending 
 marriage generally under such circumstances. On the 
 other hand, the repression of long-standing love may cause 
 still greater injury to an individual in danger of becoming 
 insane. 
 
 The physician must also consider whether the marriage 
 in view entails danger of the propagation of mental and 
 allied nervous disorders to the offspring. If the other 
 partner is healthy and belongs to an undoubtedly healthy 
 family, then the affection and other circumstances should 
 decide, provided that no decided mental disorder has yet 
 developed. But if the other partner also suffers from 
 hereditary taint, the physician should decidedly oppose 
 the marriage. The danger appears to be greatest when 
 
EDUCATION. 155 
 
 inebriety is associated with other nervous disorders. The 
 question of marriage may also arise after recovery from 
 an attack of insanity, or after decided improvement of the 
 more violent symptoms. If recovery has lasted for several 
 years after a single attack and both parties have no hered- 
 itary taint, marriage may be allowed. If the recovery is 
 questionable and only one of the parties has an hereditary 
 taint, it should be opposed unqualifiedly. I would also 
 advise against marriage when the recovery is questiona- 
 ble, even if there is no hereditary taint on either side. 
 
 It is also the function of the physician to guard against 
 the development of germs of the disease during childhood 
 and youth, or to prevent its development when hereditary 
 taint is present. This is done by carrying out the gener- 
 ally recognized principles of hygiene and a careful course 
 of education. Special precautions are necessary at the 
 period of puberty, and aberrations of the sexual impulse 
 must be carefully watched. If the congenital or acquired 
 taint becomes more distinct, unusual attention must be 
 paid to the choice of a calling. We must warn against 
 any occupation which requires great strain or exciting 
 responsibility ; a uniform activity remote from the tumult 
 of a large city may maintain the tottering equilibrium of 
 the threatened individual. A special danger attaches to 
 the abuse of alcohol. 
 
 C. BODILY TREATMENT. 
 
 1. General Standpoint and Modes of Treatment. 
 
 The principle of rest and the prevention of new injuri- 
 ous influences holds good for the bodily as well as the 
 psychical treatment. We can merely remove the causes 
 or ameliorate the existing symptoms of the disease. Dis- 
 orders of the female sexual organs must be cautiously 
 examined and treated, because much injury may be done 
 in this direction. It must be remembered, however, that 
 the recognition of bodily diseases in the insane is often 
 extremely difficult, because many patients say very little 
 
156 HANDBOOK OF INSANITY. 
 
 or nothing concerning their sensations. Hence the most 
 careful objective examination of all organs must be a 
 preliminary to bodily treatment. 
 
 The former practice of venesection has now been aban- 
 doned in great part, but in violent cerebral congestion, in 
 recent as well as protracted conditions of excitement, 
 rapid improvement may follow venesection. In such con- 
 ditions, as a rule, an equal effect is produced by local 
 abstractions of blood (cupping and leeches), especially as 
 their repeated application causes a more permanent effect. 
 As a general thing, however, the insane should be deprived 
 of as little blood as possible. 
 
 In anaemia we can sometimes increase the supply of 
 blood to the brain by strengthening the heart's action, 
 especially by the moderate use of alcoholic drinks. 
 
 Rest in bed is also important for the proper supply of 
 blood to the brain, and possesses so many other advantages 
 that it should be employed in all recent cases. It protects 
 against loss of heat and strength, it keeps irritating sen- 
 sory impressions remote, and offers the patient bodily and 
 mental rest. Anaemic and feeble patients, who exhaust 
 their powers by constantly running about, usually show 
 considerable improvement soon after taking to bed. In 
 addition, the diet should be nourishing, but non-irritating. 
 
 Rest in bed can always be carried out in private prac- 
 tice (except in cases of violent excitement, which belong 
 in an asylum) , but external conditions often prevent the 
 employment of lukewarm baths, which are an almost 
 equally valuable remedy for the improvement of recent 
 cases. The uniform moderate stimulation of all the cu- 
 taneous nerves produces a refreshing effect. Cutaneous 
 respiration increases after the cleansing of the skin, the 
 temporary dilatation of the cutaneous vessels stimulates the 
 circulation, and the general effect is almost always quiet- 
 ing in anxious and excited patients. The bath is gener- 
 ally followed by increased appetite and a refreshing sense 
 of being tired. In insomnia sleep can sometimes be secured 
 by prolonged lukewarm baths which, if kept up for several 
 
HYDROPATHIC TREATMENT. 157 
 
 hours, should have a temperature of 28° R. ; otherwise 
 26-27° R. will suffice. But such prolonged baths are 
 rarely pleasant to the patient. If it is obtained by force, 
 the bad effects will appear in the greater irritability of 
 the excited patient. 
 
 Wet packs can only take the place of baths to a limited 
 extent. They should not be applied more than a few 
 hours because they are inconvenient and soften the skin. 
 They often produce quiet sleep. Experience shows, how- 
 ever, that cold water cures rarely produce a good effect in 
 psychoses. Shower-baths are not curative measures, but 
 merely the remains of measures of restraint. Cold river 
 and sea baths are too exhausting in recent, fully developed 
 psychoses, while they may be advantageous in the allied 
 conditions of neurasthenic individuals. Foot-baths some- 
 times act well by derivation ; the addition of mustard or 
 faradisation in a warm foot-bath increases the derivation, 
 and may act as a sedative and produce sleep. Cold com- 
 presses to the head cause temporary relief in rush of blood 
 to the head and headache; an ice-bag has the same 
 effect. 
 
 The use of the milder cutaneous derivatives is occasion- 
 ally desirable. Dry cups, blisters, feebly irritative plas- 
 ters, applied best to the back of the neck, may be employed. 
 All cutaneous irritants which lead to prolonged suppur- 
 ation must be avoided. But if a local pain in the skull 
 continues for a long time, we may try to produce a deep 
 inflammation by the application of tartar emetic ointment 
 to the shaved scalp, according to Autenrieth's method ; 
 this is apt to cause exfoliation of splinters of bone. 
 Good results have been observed in such cases, and the 
 absorption of adjacent exudations within the cranium is 
 possible in this way. 
 
 A similar resolvent action has been attributed to the 
 passage of the galvanic current through the head, but this 
 should only be done by an expert. The use of the faradic 
 current is simpler; its action is generally stimulating and 
 refreshing. This is especially true of general faradiza- 
 
158 HANDBOOK OF INSANITY. 
 
 tion, in which one electrode is placed beneath the feet in 
 a foot-bath, and the other is stroked over the body. 
 
 In cases of imperfect nutrition, massage is sometimes 
 used to advantage. Under certain circumstances excessive 
 feeding may also be useful. 
 
 2. Hypnotics. 
 
 Insomnia is characteristic of the development of many 
 psychoses, and its relief demands the urgent attention of 
 the physician. Apart from baths, this is effected mainly 
 by the administration of hypnotics. At the start it is 
 advisable to produce sleep, if possible, by other means, 
 for example, heavy beers and wine, which often do well in 
 anaemic and exhausted individuals. On account of the 
 long duration of most psychoses, there is danger that the 
 patient may become addicted to certain hypnotics, and 
 hence they should be changed from time to time. 
 
 The best hypnotic is chloral hydrate which, in doses of 
 from two to three grams, produces a quiet sleep of several 
 hours, without specially disagreeable after-effects. Large 
 doses and long-continued administration should be avoided. 
 In diseases of the heart and vessels it may lead to vascular 
 paralyses and their sequelae. It is, therefore, better to 
 give smaller doses (one to two grams) combined with 
 morphine. On account of its disagreeable taste, which is 
 best concealed by adding succus liquiritise, it is often re- 
 fused by the patient. It may then be given per enema. 
 
 When chloral hydrate can no longer be given, paralde- 
 hyde should be used. It may be given for a longer time 
 than chloral without producing injurious effects. At the 
 start it is given in doses of 5.0 gm., after a time it may be 
 increased to 10.0 gm. or more. The taste is still more nau- 
 seous than that of chloral. It is concealed somewhat by 
 adding one and one-half times the amount of tinctura 
 aurantii simplex, and then shaking. The after-taste and 
 odor are extremely disagreeable and sometimes last twenty- 
 four hours. Hence, it is given occasionally per enema 
 with an emulsion of oil. 
 
HYPODEMICS. 159 
 
 In many cases these two excellent hypnotics cannot be 
 ■employed, principally on account of their bad taste. 
 Among the tasteless hypnotics we may mention sulfonal. 
 This dissolves in water with great difficulty and is almost 
 entirely tasteless, so that it may even be given unnoticed 
 in solid food. 2.0 gm. sometimes give rise to dizziness 
 which may last quite a while ; it is very efficient in divided 
 does of 0.5 gm. from two to six times a day. Its action 
 varies greatly in different individuals. An eruption re- 
 sembling that of measles is observed occasionally after its 
 administration. In several old, marantic individuals the 
 urine for a long time had a Burgundy-red color and hae- 
 moglobinuria was present; in one case this disappeared 
 after the discontinuance of the drug. 
 
 Certain alkaloids are also employed as hypnotics, chiefly 
 by hypodermic injection. We must be guarded in their 
 employment, not alone on account of the risk of acquiring 
 the habit, but also on account of disagreeable after-effects. 
 Internal administration should first be tried, and hypo- 
 dermic injections used only after the former has proven 
 unsuccessful. Hyoscine, given internally as hyoscine 
 muriate in doses of 0.001-0.002, has no disagreeable after- 
 effects, but hypodermic injections of one-half to one mgm. 
 not alone produce profound sleep, but also a tottering gait, 
 dilatation of the pupils, dryness in the throat, and a feeling 
 of confusion in the head. The. sleep is not refreshing, but 
 the quiet produced for several hours is so complete (occa- 
 sionally after a brief preliminary period of violent excite- 
 ment) that it may be utilized, for example, in overcoming 
 the resistance of a maniacal patient to entering an asylum. 
 Injections of morphine furnish a more harmless method 
 of producing quiet in such cases. Morphine is also a 
 curative remedy in insanity. Its effect in relieving pain 
 is the most important, and it then acts indirectly as an 
 hypnotic. Hypodermic injections act more rapidly, but 
 there is less danger of the morphine habit when the drug 
 is administered internally. In general it may be said 
 that injections act as a temporary sedative in the most 
 
1G0 HANDBOOK OF INSANITY. 
 
 varied cases of insanity, but that we may rarely convert this 
 into a permanent action by methodically repeated applica- 
 tions. In circular insanity, however, experience seems to 
 show that it is possible, by means of repeated injections 
 of larger doses, to interrupt the doleful alternation of cheer- 
 ful and depressed moods. In conditions of great weakness 
 and in strong excitement, attended with dilatation of the 
 vessels of the brain, morphine is contra- indicated. Caution 
 is also necessary in valvular lesions of the heart. The 
 resulting nausea and vomiting, which are often annoying 
 at the start, soon disappear. More serious import attaches 
 to other after-effects, such as paralysis of the vessels, with 
 or without respiratory paralysis. The ordinary initial 
 dose is 0.015 ctgm. The increase in the dose depends upon 
 individual circumstances. Larger doses than four to five 
 centigrams should not be exceeded, and these are only 
 reached after the drug has been administered for several 
 weeks or months. Sometimes a sedative action may be 
 produced by gradually diluting the solution until finally 
 distilled water is given, of course without the knowledge 
 of the patient. 
 
 The action of opium is similar to that of morphine. It 
 is generally believed that it acts better than morphine in 
 the melancholic terror conditions of females. It is often 
 given in anaemia. The resulting constipation compels the 
 use of enemata and laxatives. Its taste is not pleasant, so 
 that it may be given by enema or in the form of supposi- 
 tories. Opium is best given in the shape of tincture, ten 
 to twenty drops, two to three times a day, or in powder, 
 beginning with 0.03 twice a day, and rapidly increasing 
 to several decigrams at a dose. It should be discontinued 
 gradually, and should not be given in hypnotic doses. 
 
 When the ordinary hypnotics fail us, we may resort to 
 belladonna, cannabis indica, stramonium, apomorphine, 
 and the innumerable other similar preparations. 
 
 The bromides are used extensively to diminish irritabil- 
 ity in various directions. Potassium bromide is chiefly 
 used, and the salts of sodium and ammonium are only 
 
BROMIDES. 161 
 
 useful in combination with the former. It is employed 
 to act directly on the cerebral cortex in epileptic and other 
 irritative conditions of the motor centres, and in periodical 
 conditions of excitement which are unattended with vas- 
 cular changes. Unlike opium, the bromides act by means 
 of chemical changes in the nervous tissues. The diminu- 
 tion of peripheral irritative conditions of a neuralgic char- 
 acter greatly enlarges the field of application of the bro- 
 mides. They are given in irritative conditions of the 
 sexual organs and also in non-peripheral sexual irritation ; 
 they are more efficient in females, particularly in menstrual 
 conditions of excitement. But the diminution of sexual 
 excitement requires very large doses, and, after protracted 
 administration, these give rise to the well-known disa- 
 greeable after-effects. 
 
 3. Treatment of Important Symptoms. 
 
 A purely causal treatment is possible in very few cases 
 of insanity — for example, in febrile diseases, S3 7 philis, dis- 
 eases of the kidneys, stomach, etc. But in the majority 
 we must be content with treating the most important 
 symptoms of insanity. 
 
 Among the conditions attending insanity great prac- 
 tical importance attaches to the refusal to take food. This 
 is observed most frequently in melancholia as a result of 
 hallucinations or delusions. The patients taste or smell 
 poison in the food, or they abstain in order to fulfil a vow 
 or because they are unworthy of eating. In some the 
 abstinence may be due to a desire to commit suicide or to 
 the notion that the digestive organs are impermeable. At 
 first we must not attach much importance, outwardly, to 
 the patient's refusal to take food, because repeated and 
 urgent requests to eat may even confirm his fear of poi- 
 soning. In many cases hunger is our best ally. After a 
 few days this occasionally becomes so great that the pa- 
 tient ravenously devours the food placed before him. In 
 many cases it is well to disregard apparently the refusal 
 to take food, to place the meals regularly before the patient, 
 11 
 
162 HANDBOOK OF INSANITY. 
 
 and to leave him alone with them for some time. Many- 
 eat when they think themselves unobserved. This is more 
 apt to occur in bed, and indeed rest in bed is the first re- 
 quisite, in refusal to take food, in order to maintain the 
 bodily strength and heat. Expectant treatment must 
 vary with the individual case. When consciousness is 
 impaired and will-power diminished, it is often sufficient 
 to place the spoon to the lips or to push the food into the 
 mouth, whereupon the movements of mastication and de- 
 glutition will occur in a reflex manner. Delusions or 
 hallucinations can sometimes be overcome temporarily by 
 the positive assurance that eating is permitted, or by a 
 quiet command. The fear of poisoning is sometimes re- 
 lieved by tasting the food. Some patients will eat eggs, 
 others take their neighbor's food, which appears to them 
 .innocuous. But, as a general thing, hunger proves the 
 strongest incentive. If the patients drink water — and 
 this is often the case even when otherwise there is obsti- 
 nate refusal to take food — we may add sugar to the water. 
 In fact, the drinking of water is a reason for delaying the 
 apparently necessary forced feeding. 
 
 We must also attempt to keep the mouth clean by rins- 
 ing with water. The treatment of an accompanying gas- 
 tric catarrh or constipation is sometimes facilitated hj 
 the fact that the patients do not resist the administration 
 of drugs whose preparation in the apothecary appears to 
 them to be free from suspicion. Enemata of water should 
 be tried, because a sufficient supply of water causes less 
 danger from prolonged abstinence from food. 
 
 With a good condition of nutrition and rest in bed a 
 week may be allowed to elapse before proceeding to forced 
 feeding. Under favorable circumstances we may even 
 wait two weeks or more. But if the complete refusal of 
 food has been preceded by a prolonged period of imperfect 
 nourishment, or if other exhausting causes were at work, 
 then artificial feeding becomes necessary within a few 
 days. 
 
 The best method is the introduction of a tube into the 
 
ARTIFICIAL FEEDING. 163 
 
 stomach, either through the mouth or nose. As the mouth 
 can be opened, in many cases, only by brute force, the 
 introduction of the tube through the nose is almost always 
 the milder method. The soft nasal sounds (Jacques' pat- 
 ent) may be highly recommended. They should have a 
 funnel-shaped enlargement, for the convenient reception 
 of the nutrient fluids. As a matter of course, the patient 
 must be held firmly by one or more persons, and this is 
 best done during dorsal decubitus in bed. The tip of the 
 tube is made flexible by dipping it for a short time in hot 
 water, and is slightly curved in a downward direction. 
 The tube is introduced slowly and generally meets with 
 resistance, which is easily overcome, at the posterior phar- 
 yngeal wall and at the level of the larynx. Although the 
 sound usually glides freely past the larynx, especially if 
 the tip is not bent too strongly, the danger of entering the 
 trachea is to be kept in mind in patients who are paralyzed 
 or in whom severe disorders of consciousness prevent vio- 
 lent reflex movements. A tolerably certain means of 
 ascertaining whether the tube has really entered the stom- 
 ach, consists of auscultation of the organ while a third 
 person is blowing air through the sound. In the adult, 
 when the head is bent backward, the distance from the 
 incisor teeth to the cardiac orifice of the stomach is forty to 
 forty-four centimetres (maximum, forty-six, minimum, 
 thirty centimetres) , so that a mark made upon the sound 
 will inform us concerning the position of the stomach ex- 
 tremity. A single feeding often suffices to make the pa- 
 tient eat voluntarily. Otherwise the feeding must be per- 
 formed once or twice a day, according to the patient's 
 strength. The entrance of the sound is facilitated by oil- 
 ing it, by gently pushing it forward and backward. A 
 movement of deglutition facilitates the introduction, and 
 may be produced by pouring a few drops of water into the 
 free nostril ; the patient then, in a measure, swallows the 
 sound. At first we pour in only a few drops of fluid, 
 which must be free from clots, etc. In order to be abso- 
 lutely sure we may begin with a few drops of water. At 
 
164 HANDBOOK OF INSANITY. 
 
 the first feeding we should give at the most one-half litre 
 of the nutrient fluid, in order that the retracted stomach 
 with its insufficient supply of gastric juice may not be 
 overburdened. Great difficulty sometimes arises on ac- 
 count of vomiting, which occurs involuntarily after the 
 introduction of the fluid. The addition of a few drops of 
 chloroform or brushing the pharynx with cocaine may re- 
 lieve this symptom. We are generally powerless when 
 the vomiting takes place voluntarily as the result of delu- 
 sions. Such patients also extrude nutrient enemata, and 
 we must then allow them to starve to death. Obstinate 
 involuntary emesis may lead to the same result because the 
 continued vomiting of the gastric contents alongside the 
 sound forces us to discontinue the artificial feeding on 
 account of the danger of suffocation or foreign-body pneu- 
 monias. Sometimes artificial feeding may be continued 
 for weeks, months, or even years. 
 
 Occasionally we can succeed in introducing fluid food 
 in the following simple manner : The patient is placed in 
 a horizontal position, the head bent slightly backward, 
 and held in this position, unless the resistance is too great, 
 and the fluid is then poured directly into one nostril. As 
 a precaution, we begin with a little water, in order to 
 begin the proper movement of deglutition. 
 
 As a general thing, forced feeding is impracticable in 
 private practice, and the patients requiring it should be 
 sent to a hospital or asylum. Indeed we are now ap- 
 proaching the treatment of those symptoms which can 
 only be carried out successfully in asylums. These in- 
 clude, above all, the tendency to commit suicide. 
 
 Such patients require special supervision and may not 
 be left alone for a moment. The possibility of watching 
 several patients of this kind is furnished by a ward in 
 which orderlies are on duty day and night. In such wards 
 every opportunity for carrying out the dangerous tendency 
 must be wanting. Nails, hooks, projections on the walls 
 and beds, sharp instruments (spoons should be used, rather 
 than knives and forks) must not be permitted. The pa- 
 
PREVENTION OF SUICIDE. 165 
 
 tients may not wear neckties or ribbons. Some individ- 
 uals are so inventive as regards methods of committing 
 suicide that they must be kept in a room which, apart 
 from the bare walls, merely has windows (provided with 
 fine wire grating or with very strong glass) and doors 
 without knobs or latches. The bed must be removed, and 
 even then the patient may attempt to choke himself with 
 strips of clothing, or he may run his head against the 
 wall. The latter plan rarely proves fatal, although frac- 
 tures of the skull and cervical spine have been known to 
 follow. Nothing then remains but to confine the use of 
 the hands by means of leathern gloves or a strait-jacket, 
 together with constant supervision in the "watching 
 ward." In very rare cases we are finally compelled to 
 tie the patient to the bed or to adopt chemical restraint, 
 i.e., to produce narcosis by injections. It is an important 
 rule, however, that every patient who is in mechanical 
 restraint must be constantly watched in order to prevent 
 serious accident, as, for example, hanging by the bands of 
 a loosened strait-jacket. 
 
 The tendency of the present time is the avoidance of 
 all mechanical restraint, and it may be dispensed with if 
 the attendants are sufficiently numerous and well trained, 
 and if strong drugs are resorted to. In rare cases, how- 
 ever, it would be fanatical to dispense with restraint ; for ex- 
 ample, in cases of severe injury, in restless patients, which 
 can only heal when rest is enforced. Or mechanical re- 
 straint may be necessary in conditions of exhaustion, be- 
 cause drugs would still further injure the exhausted nervous 
 system. In incurable cases we may use chemical restraint, 
 out of deference to the feelings of the family, but in recent 
 cases there is danger of chemical injury to the brain. Fi- 
 nally, there are cases of uncleanliness, of smearing the 
 faeces, in which at least the application of gloves becomes 
 necessary. 
 
 Filthiness and a tendency to destroy things often compel 
 us to give the patients unusually tough clothing, made 
 commonly of strong linen which is fastened at the back. 
 
166 HANDBOOK OF INSANITY. 
 
 Violent patients should use table utensils made of papier- 
 mache, with which no serious damage can be done. The 
 attendants must never be permitted to employ mechanical 
 restraint without the order of the physician. 
 
 D. ASYLUMS AND THEIR ADVANTAGES. 
 
 A good asylum offers to curable patients an advantage 
 which is not possessed even by hospitals, viz., the oppor- 
 tunity for regular occupation, especially in the open air. 
 Occupation is furnished in workshops and in all house 
 arrangements which require cleaning. Females find 
 sufficient to do in making clothes and in attending to the 
 linen and to the wash. The fact that the physician pos- 
 sesses the power of compelling obedience to his orders 
 greatly facilitates mild treatment. The force of example 
 and of the uncomplaining obedience of a large corps of 
 attendants and of numerous other patients usually prevents 
 the newly arrived patient from rebelling against the dis- 
 cipline. The time for waking and sleeping and eating, 
 of taking walks and of working, is determined by the 
 physician, so that a patient, who is no longer able to man- 
 age himself, is forced, like the wheel of a machine, to fol- 
 low its course. Even violent forms of excitement often 
 disappear rapidly in an asylum because the patient rapidly 
 learns that a strict, though sympathetic spirit of order, 
 not his morbidly excited will, is the ruler, supported by 
 external arrangements against which he is powerless. 
 But in the best asylums the discipline is less effective than 
 the medical treatment. 
 
 E. TREATMENT OF CONVALESCENTS. 
 
 There are very many cases in which the slow progress 
 of recovery and very profound, although still morbid, 
 homesickness have compelled a premature discharge from 
 the asylum in order to prevent the danger of an exacerba- 
 tion or even of suicide. Under favorable conditions at 
 home, recovery in such cases usually is undisturbed, but 
 
CONVALESCENCE. 167 
 
 if these conditions entail new cares and worries, a relapse 
 is soon unavoidable. In such cases it is the duty of the 
 family physician, who is better posted than the asylum 
 physician, to decide whether a return to the former condi- 
 tions of life will be attended with more serious results than 
 a longer stay in the asylum. Every excessive strain, such 
 as the premature resumption of the former occupation, is 
 dangerous. 
 
 The period of convalescence requires psychical treat- 
 ment which may aid materially in accelerating recovery. 
 Any delusions which may have been left over may now 
 be removed by friendly objections, and occasionally by 
 light jests. Some feel the necessity of receiving, from 
 the physician, the constantly renewed assurance of the 
 morbid nature of their ideas and feelings. Patience, 
 sympathetic insight into the patient's personality, yielding 
 without weakness on the one side, and' firmness without 
 obstinacy on the other side, must be the main features of 
 the physician's activity. The disease is explained as a 
 misfortune that may happen to any one, and the doubting 
 patient will again acquire self-confidence and trust in the 
 future. The convalescent follows the one who understands 
 him, like a child seeking protection. The physician must 
 listen patiently to his communications, and must for a 
 time continue to be his mental guide. As a matter of 
 course, the care of the body must not be neglected, 
 
VII. 
 
 HISTORY OF PSYCHIATRY. 
 
 A. ANTIQUITY. 
 
 It was the most important result of the works of the 
 Hippocratic school and its founder that, with the recog- 
 nition of the physical basis of mental disorders, the first 
 attempt was made to withdraw their treatment from the 
 hands of the priesthood. In Greece and Egypt patients 
 were received in the temples, where the supernatural influ- 
 ences of mysterious powers were combated by conjurations 
 and magic remedies. The insane thus received protection 
 against external injurious influences, but it is doubtful 
 whether the treatment was otherwise beneficial. Mental 
 disorders were regarded, as is shown by the use of the 
 term melancholia and the constant administration of helle- 
 bore, simply as the results of morbid bodily conditions, 
 especially of changes in the principal secretions, such as 
 bile, mucus, etc. For this reason no sharp distinction 
 was drawn between psychical diseases and diseases of the 
 brain. As a rule, febrile delirium was included among 
 the mental affections. The term phrenitis was applied to 
 all violent, especially febrile, diseases which were associ- 
 ated with mental disturbances, so that it was approxi- 
 mately identical with what was called " nervous fever" by 
 practitioners at the beginning of this century. For ex- 
 ample, phrenitis included many cases of typhoid fever and 
 also the irritative cerebral conditions of severe pneumonias. 
 
 On the whole, the treatment of the insane was non- 
 stimulant and sedative ; in the feeble-minded it was mainly 
 gymnastic. It is a striking fact that hereditary predisposi- 
 tion was not considered or mentioned. Nor were the 
 
 168 
 
THE HIPPOCRATIC SCHOOL. 169 
 
 changes in the skull which occur in the insane referred 
 to, while many complicated and obscure morbid condi- 
 tions were properly interpreted and explained. The brain 
 was regarded as the site and starting-point of most forms 
 of insanity, although their causes were sought in irrita- 
 tion by bile, mucus, and water. 
 
 The confusion of true cerebral diseases, febrile general 
 diseases and psychoses, also prevented an accurate differ- 
 entiation of the various forms of psychical disease. For 
 example, the terms melancholia and mania were applied 
 mainly to insanity in general. In accordance with this 
 the treatment was quite uniform. The most important 
 elements were cold and warm douches, rest, proper diet, 
 and gymnastic exercises in the feeble-minded. 
 
 The prevailing opinions among the laity also agreed 
 with such views. How correct and, in individual respects, 
 profound were the theories and investigations of the Hip- 
 pocratic school, is evident from the fact that much atten- 
 tion was devoted to the statement of Erasistratus that the 
 area of the surface of the brain furnishes a measure of the 
 mental ability ; in opposition to this view the importance 
 of the internal structure was maintained. 
 
 The Roman law early laid the foundation for the view 
 followed by all subsequent legal authorities that an " in- 
 sanus" may retain, under certain circumstances, control 
 of his affairs, but that a "furiosus" requires guardianship. 
 The decision concerning civil and criminal responsibility 
 lay entirely in the hands of the judge. 
 
 Asklepiades of Bithynia (124 B.C.) was opposed, in a 
 measure, to the doctrines of the Hippocratic school. In 
 addition to measures of restraint, he also employed psy- 
 chical treatment, especially music as a sedative. He at- 
 tached great importance to baths and cold frictions, and 
 was less in favor of venesection and confinement to dark 
 rooms, which were recommended by all his contemporaries. 
 
 Celsus made important statements. He required that 
 the treatment should be adapted to the peculiarities of 
 each individual case. Baseless fear is to be relieved by 
 
170 HANDBOOK OF INSANITY. 
 
 gentle speech, or by kind deceit; maniacs can occasionally 
 be controlled only by blows ; melancholia often yields to 
 strains of music. As a rule the patient should not be em- 
 bittered by contradiction. The most important object of 
 treatment is to secure sleep ; poppy and henbane are es- 
 pecially effective. 
 
 Soranus of Ephesus, who lived in Rome under the 
 Emperors Trajan and Hadrian, opposed measures of re- 
 straint. He was also unreservedly opposed to whipping 
 and to intentional intoxication of the patient, but favored 
 general and local abstraction of blood. He attached the 
 greatest importance to psychical treatment, to isolation 
 under supervision, to the action of light, and the avoidance 
 of irritation. 
 
 Aretseus of Cappadocia soon after advanced the scien- 
 tific side of psychiatry. He recognized the crossed action 
 of the nerve centres. He confined the term melancholia 
 to the conditions which are so called at the present time, 
 and regarded it as the primary form from which all others 
 develop. He furnished excellent descriptions and consid- 
 ered the causal conditions, such as social position, mental 
 work, and overwork. The chief importance in treatment 
 was attached to drugs. After-treatment consisted of 
 thermal, sea, and sand baths, sea voyages, and a sojourn 
 in beautiful countries. 
 
 Galen (131-201 a.d.) distinguished primary cerebral 
 diseases from those which are due to diseases of other 
 organs, and also differentiated phrenitis from chronic dis- 
 orders attended with depression or exaltation. 
 
 These constitute the most important steps in the devel- 
 opment of psychiatry in ancient times. 
 
 B. MIDDLE AGES AND MODERN TIMES. 
 
 The decay of medicine during the Middle Ages allowed 
 the achievements of antiquity in psychiatry to sink into 
 oblivion. The knowledge of the physical basis of insanity 
 disappeared more and more, the old idea of possession 
 gained sway, and attempts at healing again fell into the 
 
INFLUENCE OF SUPERSTITION. 171 
 
 hands of the priesthood. Practical medicine maintained a 
 precarious existence in convents. Superstition and relig- 
 ious bigotry struggled for the upper hand in the treatment 
 of the insane. The devil was suspected everywhere, and it 
 was regarded as an act of Christianity to oppose him by 
 means of prayers and exorcism. 
 
 When violent and maniacal patients became too annoy- 
 ing they were simply sent out of the country. In many 
 cities guardians of the insane were appointed, who were 
 responsible for their care, or the family were held respon- 
 sible. When this could not be done the authorities inter- 
 vened, the expense being borne by the family. 
 
 Permission to consign the patients to the towers of the 
 city walls was long regarded as an especial favor. Toward 
 the close of the Middle Ages the increasing number of 
 insane led to the erection of a special building in Nuern- 
 berg. In other places, at the most, a few rooms in a hos- 
 pital were fitted up wherein restless patients could be kept 
 in chains. Whenever circumstances permitted, the family 
 was compelled to keep its insane members imprisoned. 
 There were portable prisons, so-called stocks, which could 
 be placed in any room. 
 
 The notion of the possession of the insane by evil spirits 
 prevailed everywhere. In Basle and many other towns 
 maniacs were whipped by the hangman in order to drive 
 out the evil spirits. In non-excited conditions the symp- 
 toms of the disease were often regarded as sins, and were 
 treated accordingly by confession, fasting, pilgrimages, 
 and self-castigation. 
 
 The conditions were similar in other European countries 
 with the exception of Spain and Italy, in which regular 
 insane asylums are found in the last centuries of the Mid- 
 dle Ages. 
 
 The notion of demoniacal possession developed at this 
 time into that of possession by witches. The witch pro- 
 cesses were due mainly to the prevailing belief in devils 
 and demons, together with the working of the Inquisition. 
 
 The influence of demonological views was so great that 
 
172 HANDBOOK OF INSANITY. 
 
 even such distinguished men as Paracelsus and Plater op- 
 posed them very feebly with medical opinions ; although 
 the thorough anatomical knowledge of Plater brought him 
 nearer to a correct comprehension of insanity than Para- 
 celsus, who despised anatomy. The latter stated, however, 
 that exorcism of the devil was useless, and he attempted 
 to cure insanity by external cutaneous irritants, cathartics, 
 and venesection. He regarded sleep as an important 
 auxiliary and also made suggestions for a sort of psychical 
 treatment. 
 
 Plater made a rather obscure distinction between demo- 
 niacal possession and natural insanity. Emotional ex- 
 citement is to be treated at first by sympathy, advice, and 
 persuasion, then follow threats and blows. He recognized 
 the necessity of restraint in violent cases, but advises that 
 at times the chains should be cautiously loosened. 
 
 Even Weyer, the most celebrated opponent of the notion 
 of witches, did not deny the reality of the pranks of Satan 
 and did not dare to attribute them to mental disease. He 
 merely attempted to restrict the assumption of magical 
 influences to rar,e cases. 
 
 The influence of Luther, who was a firm believer in 
 the devil and the doctrine of possession, long prevented a 
 proper appreciation of the trouble in Protestant North 
 Europe ; and until a late period in modern times the in- 
 sane were persecuted as sorcerers and witches. 
 
 The hopeless condition of the insane who were seques- 
 tered in prisons is made clear by several descriptions 
 which have been made known. Sometimes they were kept 
 for years in cells which were destitute of doors and win- 
 dows, with only an opening in the ceiling. Through this 
 opening food and drink were lowered to the patient. His 
 feet and hands were often chained to the wall. Gloves 
 with iron rings were used to prevent suicide. 
 
 A certain degree of improvement became noticeable in 
 the seventeenth and eighteenth centuries when the insane 
 were admitted to houses of correction. Certain of the 
 prisoners were compelled to dress, clean, and feed the pa- 
 
MEDICAL TREATMENT. 173 
 
 tients. In exceptional cases greater freedom was granted 
 to the insane, and thus various measures of restraint be- 
 came unnecessary. As a rule, however, the poor sufferers 
 were neglected, the prisoners mocked and gibed them, or 
 they were confined as formerly to dismal quarters. Many 
 physicians regarded restraint-chairs, to which the patients 
 were bound, as a mild measure, because it protected them 
 against the blows and harsher measures of the brutal 
 turnkeys. 
 
 It was not until the beginning of this century that 
 Langerman advocated the medical treatment of the insane 
 in addition to mere detention. But the treatment long re- 
 mained a cruel one. In addition to emesis, repeated cath- 
 arsis, and cold douches with hundreds of pails of water, 
 rotary machines played an important part. By means 
 of a revolving chair the patient was rotated around 
 his vertical axis a hundred times a minute, and vomiting 
 often followed. The resulting exhaustion was regarded 
 as sedation, and such tortures were supposed to possess 
 indirect psychical curative powers. It was also thought 
 that patients could be cured by placing them in a closed 
 sack. The ingenuity of physicians in inventing new 
 measures of restraint as curative remedies is hardly cred- 
 ible. 
 
 But gradually the opposition to the view that restraint 
 is a curative measure in psychoses became stronger and 
 stronger. The remedy threatened to be more harmful than 
 its former application, which was only intended to render 
 the insane harmless, because the increasing number of pa- 
 tients, and the growing notion concerning their curability, 
 increased the zeal of the physicians. The apparent sci- 
 entific foundation for the employment of restraint long 
 preserved the system, although more humane views every- 
 where became more prominent. 
 
174 HANDBOOK OF INSANITY. 
 
 C. GRADUAL REFORM OF PSYCHIATRY IN THE PAST HUN- 
 DRED YEARS. 
 
 1. Erection of Insane Asylums. 
 
 It would be wrong, however, to overlook the fact that 
 along with these imperfections in the treatment and 
 knowledge of mental disorders, important works on psy- 
 chiatry appeared in many countries, together with notable 
 improvement in the treatment and care of the insane. We 
 cannot enter here into the scientific results. They were 
 closely associated with the prevalent philosophical doc- 
 trines, and can therefore only be comprehended from a 
 knowledge of the latter. Their external expression was 
 found in the external arrangements, particularly the insane 
 asylums, which appeared in Germany at a comparatively 
 late period. For example, in 1645 a special asylum was 
 founded in Florence, and at the beginning of this century 
 Chiarugi of Italy carried out the most humane principles 
 of treatment ; he also gave instruction in psychiatry. In 
 1681 the first independent asylum for the insane in France 
 was built at Avignon. In 1728 the first asylum was opened 
 at Warsaw; in 1741, in Springfield, England. A little 
 later the rudiments of an asylum were established in 
 Wuerzburg and Braunschweig. In 1751 the Philadelphia 
 asylum was inaugurated. In the same year the insane 
 patients of St. Luke's Hospital in London were divided 
 into curable and incurable cases. In German countries 
 very slow progress continued to be made. 
 
 An illustration of the extent to which some physicians 
 were in advance of their contemporaries is shown by the 
 fact that in 1804 Glawnigs proposed that an asylum be 
 erected in order that the insane might be enabled to do 
 farm work. At this time Langerman of Bayreuth re- 
 sorted extensively to occupation in the treatment of insan- 
 ity, and employed mechanical restraint only in exceptional 
 cases. 
 
ABUSES OF TREATMENT. 175 
 
 2. Opposition to Mechanical Restraint. 
 
 In France, Daquin was the first to oppose mechanical 
 restraint in his writings, and Pinel was the first who dis- 
 pensed with it in practice. He practised the treatment of 
 the insane in Paris in a humane manner, and his writings 
 were epochal in the progress of French psychiatry. But 
 despite his efforts the treatment of the insane remained 
 very poor, so that in 1818 Esquirol reported to the Min- 
 istry that the unfortunate insane were treated worse than 
 convicts and that their condition was worse than that of 
 beasts. 
 
 In the insane wards of thirty-three cities he found them 
 living in the most damp and unhealthy buildings. They 
 were clothed in rags and lay upon straw in order to pro- 
 tect themselves against the damp cold of the floor. With 
 poor food and harsh treatment, without air or light, they 
 were chained in places in which wild animals would not 
 be kept. Although the Ministry, in 1819, forbade the use 
 of underground cells and required rooms with windows, 
 the condition was not much improved until the law of 
 1838 was passed. 
 
 In Germany, in 1817, Hayner issued a pamphlet which 
 exercised great influence. His description of the abuses 
 then existing is pathetic. He especially opposed the use 
 of chains and of restraining-chairs, which impeded motion 
 and often led to crippling of the limbs. He also opposed 
 the view, which was supported by physicans, that corporal 
 chastisement is useful in the treatment of the insane. He 
 regarded the camisole as indispensable at times, but only 
 for a few hours, during which time a nurse must be in 
 constant attendance on the patient. This requirement 
 will also be accepted by the most fanatic opponent of re- 
 straint. 
 
 In 1796 Tuke erected in York, England, an asylum for 
 the abolition of unnecessary and cruel restraint, and this 
 served at the time as an example of humane treatment. 
 But no one dared to remove mechanical restraint entirely, 
 
176 HANDBOOK OF INSANITY. 
 
 and half a century elapsed before all abuses were corrected,, 
 especially in some private institutions. In 1815 patients 
 were found in a public asylum with an arm or leg or with 
 both limbs chained to the wall ; the chain merely allowed 
 the patients to stand or sit upon a bench fastened to the wall. 
 One unfortunate had an iron ring around his neck, fas- 
 tened by a chain, ending in another ring ; the latter could 
 slide along a vertical iron rod, six feet in length, which 
 was fastened to the wall. Around his body was placed a 
 strong iron band, about two inches wide, which had, at 
 each side, a round projection to enclose the arms and keep 
 them firmly applied to the body. In this torture the pa- 
 tient had lived twelve years. He was only excited peri- 
 odically, and during long intervals was comparatively 
 conscious. Finally he was rescued by an official investi- 
 gation. 
 
 Under such circumstances it is not surprising that the 
 demands for the entire abolition of restraint became louder 
 and louder. The no-restraint system required the in- 
 troduction of other and humane methods of treatment, 
 and redounded to the honor of its founder, Conolly. 
 Wherever the old system was supplanted the difference 
 in the results obtained became especially noticeable. 
 Imagine, for example, the effects of restraint in partially 
 paralyzed patients. They were tied down in large night- 
 chairs, because otherwise they would soil themselves. 
 Here they sat the whole day, and at night were placed, 
 bound, upon straw. If they complained or shouted, they 
 were quieted by blows. If we contrast this with the care 
 now devoted to a paralyzed general paretic the advantages 
 of the new system are seen to be considerable. Instead 
 of restraint we employ baths, and soft bedding with fre- 
 quent changes. 
 
 But the greatest advantages of the no-restraint treat- 
 ment were shown in conscious patients. A friendly man- 
 ner and quiet speech aroused confidence where formerly 
 only fear and distrust prevailed. The patients willingly 
 obeyed the orders of kind attendants. It has become 
 
INTRODUCTION OF NON-RESTRAINT. 177 
 
 more and more evident that well-trained and kind attend- 
 ants are absolutely necessary to the proper treatment of 
 the insane. 
 
 As a matter of course there were great difficulties con- 
 nected with the introduction of the no-restraint system, 
 but it was soon found that noise and disorder rapidly 
 diminished, and that periods of excitement ran a more rapid 
 course. The removal of measures of restraint was found 
 most useful in suicidal cases. The destruction of win- 
 dows, bedding, and clothing became less frequent, because 
 the attendants were more careful and attentive. Tempo- 
 rary isolation, however, was found necessary, usually 
 without any notable resistance on the part of the patients, 
 who felt that solitude was good for them. 
 
 The physicians themselves were compelled to have pa- 
 tience. But they found that scenes which, at first sight, 
 appeared full of confusion and excitement generally re- 
 solved themselves into simple conditions if quietly treated 
 for a few minutes. Violent conduct and threatening 
 speech soon ceased if not opposed by irritability and 
 displeasure. Patient, quiet admonition and evidence of 
 self-control rarely failed to produce their effects. The 
 same spirit of humanity extended to the attendants and 
 patients. Thus the new system rapidly gained adherents. 
 It was developed in detail and found new auxiliary meas- 
 ures in the different modes of occupation of patients. 
 Every year brought new proofs of the utility of such princi- 
 ples in curable and incurable cases, and, what was most ef- 
 fective, the number of recoveries increased. Even in the 
 first few years Conolly employed education as a means of 
 cheering and quieting the patients in his asylum. Not 
 alone did the uneducated enjoy the acquisition of new 
 knowledge, but the recalling of former knowledge was a 
 source of pleasure to the cultured and facilitated their 
 recovery. 
 
 The possibility of dispensing entirely with restraint has 
 been often demonstrated, but on the whole the carrying 
 out of the no-restraint system has become largely a ques- 
 12 
 
178 HANDBOOK OF INSANITY. 
 
 tion of expense. The few exceptions only prove the rule. 
 In order to prevent abuse, however, we must hold fast to 
 the rule that restraint is inadmissible in incurable cases, 
 especially when constant medical supervision is wanting. 
 It must be confessed, however, that while the changes 
 mentioned were adopted in English asylums, the treat- 
 ment of the insane without measures of restraint did not 
 at first meet with a favorable reception on the continent 
 of Europe. But finally the results of no-restraint became 
 so firmly established that the victory is now decided. 
 
 D. PRESENT TREATMENT OF THE INSANE. 
 
 The question whether curable insane should be separated 
 from incurable cases has long been debated. As a matter 
 of course, the mingling of recent cases with idiots, epilep- 
 tics and filthy patients must exercise an injurious influence 
 upon the former. The necessary differences in the ar- 
 rangements for treating both classes of patients also led 
 to the desire for separate asylums. In Germany institu- 
 tions were accordingly erected for curative purposes alone, 
 and in these the attempts at reform, which were neces- 
 sarily attended with considerable expense, could be carried 
 out more readily, while the old asylums were furnished 
 with suitable changes for incurable cases. The compara- 
 tively frequent recoveries in the former class rapidly 
 removed some of the former prejudices of the public. The 
 increased cost of such asylums located in different places 
 led to the erection of two independent asylums in the same 
 place. Any errors in prognosis as regards curability or in- 
 curability could then be corrected very easily, and the pa- 
 tients could be transferred from one division to the other. 
 In this way complete separation became impossible. It was 
 found, however, that the partial mingling of both classes 
 of cases was not so injurious as had been supposed, if care 
 were taken to separate the excited and filthy patients from 
 the quiet ones. The presence of some incurable patients 
 was even found to be beneficial, in a measure, because it 
 helped newly admitted patients in becoming accustomed 
 
MODERN INSANE ASYLUMS. 179 
 
 to the new order of things. Moreover, some of the old 
 patients received a fresh stimulus from the recent cases 
 which had just come from the bustle of the outside world, 
 the discharge of cured patients permitted them to gain 
 fresh hope, and thus became an incitement to renewed ac- 
 tivity, the best means of cure. The chief element, then, is 
 not so much the complete separation of curable and incur- 
 able cases, as it is the most humane treatment under the 
 different external conditions. 
 
 Every insane asylum now possesses a medical superin- 
 tendent and all the means for treating the sick. In addi- 
 tion the entire building should create an impression of 
 comfort. Whenever possible the asylum should be placed 
 not alone in a healthy district, but also in one which is 
 full of natural beauties. It should be surrounded by large 
 gardens, and when mechanical means of isolation are 
 necessary this should be done, not by heavy bars of iron 
 but by light railings or thick unbreakable glass. The 
 rooms should be enlivened by comfortable furniture and 
 pictures on the walls ; pianos, billiard tables, and reading 
 rooms serve for the entertainment of the patients. Occu- 
 pation is made possible in numerous work-rooms, and in 
 attending to garden work. 
 
 The more free the treatment became, the more evident 
 it became that very many patients were capable and desir- 
 ous of work. The former anxious seclusion from the outer 
 world was found to be unnecessary, and the constantly in- 
 creasing overcrowding led to the development of free meth- 
 ods of caring for the insane. The most extensive develop- 
 ment was found in the farming colonies for males, associ- 
 ated with large institutions. These colonies are small 
 farms, which are tended, in great part, by the patients 
 themselves. Not alone does this afford a useful activity 
 to the patients, but it also diminishes the cost of their 
 maintenance. 
 
 Less extensive is the so-called family care, in which one 
 or more patients are cared for in the family of a stranger. 
 This is also known as a scattered colonial system. More 
 
180 HANDBOOK OP INSANITY. 
 
 or less close connection with a neighboring asylum affords 
 the possibility of using baths, and permits a return to the 
 asylum whenever this becomes necessary. When such 
 an arrangement is possible, the patients feel themselves 
 very fortunate ; they consider themselves useful members 
 of human society, and notice that their morbid tendencies 
 and ideas are recognized and treated as such. As a mat- 
 ter of course, it is assumed that such families are subject 
 to regular supervision. The results are uniformly good, 
 and the system merits further extension in Germany. It 
 has been extensively carried out in Scotland and, for sev- 
 eral centuries, in Gheel, Belgium. 
 
SPECIAL PART. 
 
CLASSIFICATION OF INSANITY. 
 
 The classification of insanity is the most difficult prob- 
 lem in scientific psychiatry. None has hitherto proven 
 satisfactory, and my own classification undoubtedly pos- 
 sesses many defects. It merely attempts to furnish a 
 rapid survey of the essentially different clinical forms of 
 insanity. 
 
 Three plans of classification have been hitherto adopted, 
 viz., upon an anatomo-pathological basis, and upon the 
 basis of the causes or the symptoms of insanity. All 
 these systems have been artificial. Anatomical changes 
 are absent in the majority of cases ; so many causes act 
 at the same time that it would often be arbitrary to regard 
 one as decisive in the individual case; even the symptoms 
 of insanity are sometimes so manifold that accidental mat- 
 ters may long conceal the essential elements. 
 
 But so long as we are not even able to explain the men- 
 tal processes in the healthy nervous system, the attempt 
 to circumscribe its abnormalities within a natural system 
 will be unsuccessful. Nothing remains but a classifica- 
 tion with the aid of the different artificial systems. 
 
 The relationships between different groups of insanity 
 also appear in our classification and characterize their 
 clinical course. But the artificial character of the entire 
 system is shown, for example, by the fact that the curable 
 forms of insanity are not only found among the simple, 
 usually curable mental disorders, but that, like the forms 
 occurring after intoxications and some forms occurring 
 during fever, they must also be placed alongside the incu- 
 rable forms of dementia. On the other hand, paranoia, 
 despite its simple functional nature, is characterized, as a 
 
 183 
 
184 HANDBOOK OF INSANITY. 
 
 rule, by a more unfavorable course, and yet must be placed 
 alongside the other simple mental disorders. 
 
 Even the oldest observers made a fundamental distinc- 
 tion which is still maintained ; it depends upon the pre- 
 dominance of a depressed or an excited mood. These moods 
 may occur in all forms of mental disorders, either singly 
 or alternating with one another. Hence, the first classifi- 
 cation, which runs through all the individual forms of 
 insanity, is that into depressed and exalted conditions, 
 dependent mainly on disorders of emotional life, but al- 
 ways accompanied by disorders in the association of 
 ideas; disturbance of consciousness may also be present 
 in varying degrees. 
 
 Although we everywhere find conditions of depression 
 and exaltation, yet certain groups of symptoms are known 
 under the terms melancholia and mania. A disturbance 
 of the association of concepts is also demonstrable in almost 
 all cases; but in only a few clinically distinct groups do 
 we apply the term paranoia, which includes the terms 
 " verruecktheit " and "wahnsinn" and the secondary con- 
 fusion. A few subdivisions readily result from the com- 
 bination of disorders in the connection and course of the 
 concepts with disorders of consciousness, especially of the 
 perceptive processes. 
 
 The separation of so-called hallucinatory psychoses has 
 been attempted anatomically as well as clinically, but is not 
 yet practicable. For the present it seems better not to 
 regard hallucinations as independent diseases, but merely 
 to examine their relations to the clinical history of the 
 psychosis. 
 
 The symptom-groups of melancholia and mania and 
 their periodical alternation, and paranoia form one main 
 group of simple mental disorders, which is distinguished 
 from the group associated with permanent anatomical or 
 general diseases. The simple mental disorders are gen- 
 erally to be regarded as probably curable; the affections 
 belonging to the second group are, in great part, incurable. 
 The simple or functional disorders may also be attended 
 
CLASSIFICATION. 185 
 
 with more profound anatomical changes and pass into the 
 more unfavorable forms. Hence our classification can 
 only be regarded as a temporary makeshift. This is shown 
 most clearly in the position of dementia in our system, 
 which forces us to place the simple disorders that terminate 
 in imbecility and dementia in a special sub-group of the 
 second main division because its occurrence is attended 
 very often by distinct anatomical changes in the brain. 
 Primary dementia is also placed improperly in the same 
 group, in order that the similar clinical histories should 
 not be separated. Still more forced is the position of con- 
 genital feeble-mindedness, so-called imbecility, in the same 
 group, because, although anatomical changes in the struc- 
 ture of the brain are undoubtedly present, they are not yet 
 accessible to our gross methods of examination. The dis- 
 cussion of imbecility cannot be separated, however, from 
 that of idiocy and other forms of feeble-mindedness. 
 
 The second main group also contains the practically 
 important forms of dementia with paralyses, especially 
 dementia paralytica proper, then the psychoses associated 
 with epilepsy and other general neuroses, among which 
 the nervous exhausted conditions of recent times constantly 
 occupy more and more space. The addition of alcoholic 
 forms, although apparently at variance with an artificial 
 system, is permissible because they serve to indicate that 
 we have to consider, in mental disorders, not alone psy- 
 chological or anatomical causes in the central nervous 
 system, but also chemical changes in the entire body, as a 
 matter of course including the central nervous system. 
 
II. 
 
 SIMPLE MENTAL DISORDERS. 
 A. MELANCHOLIA. 
 
 The chief characteristic of melancholia is a sorrowful 
 mood of varying intensity, more or less associated with 
 disorders of consciousness, and of the association of ideas. 
 All of these together, but chiefly the disorders of emotional 
 life, give rise to the morbid manifestations of the volition 
 and acts of the patient. In the simplest form of inde- 
 pendent melancholia the depressive affects and feelings or 
 the anxious mood occupy the foreground. There is a grad- 
 ual transition between conditions of dissatisfaction and 
 bad temper without sufficient provocation, and this simple 
 melancholia. If such feelings permanently dominate the 
 mood, then further disorders of the mental processes fol- 
 low. The patient notices that his ideas run a slower 
 course, that alongside the painful contents of his con- 
 sciousness there is no room for other thoughts. At first 
 he feels with pain a growing indifference to those around 
 him, but gradually this is lost and the painful feelings 
 suppress all other concepts or give to them the same pain- 
 ful color. Not alone has the former enjoyment of society 
 and intellectual pleasures disappeared, but the satisfaction 
 in his own occupation disappears in a striking manner. 
 From these beginnings develop the different forms of 
 melancholia. 
 
 At first there is often a distinct feeling of being sick, 
 the patient sometimes endeavors to conceal the change in 
 his tendencies and feelings. The unnatural character of 
 his sensations and his distaste for things formerly held 
 in high esteem, often lead him to complain that he can no 
 
 186 
 
PRODROMES. 187 
 
 longer enjoy anything. He feels himself torn out of his 
 former community with men, he is filled with mistrust 
 and suspicion, and thus resists all external impressions. 
 A sensation of changed individuality constantly oppresses 
 him. Although he still acknowledges that some of his 
 anxious notions are false, yet it is impossible for him to 
 feel, think, or act differently. The loss of self-reliance 
 becomes more and more distinct, accompanied by true 
 spiritual pain. He seeks solitude, becomes silent or merely 
 states that everything around him has changed. Rela- 
 tives and friends appear to act differently, he does not 
 deserve their care, he is too wicked. The world has be- 
 come dead to him. The things occurring around him, 
 even his own experiences, are felt by the patient as by an 
 outsider. Every attempt to influence him leads to a pain- 
 ful disturbance of his concepts. Very irritable individ- 
 uals, especially women, soon acquire obscure notions that 
 injury is to be inflicted upon them, or every cheerful re- 
 mark increases the sorrowful depression into apathetic 
 brooding or impulsive acts, which are intended to relieve 
 the distressed ego of the patient. 
 
 The contents of consciousness are not always confined 
 to these anxious concepts; a well-preserved memory 
 furnishes new food for self-torturing thoughts. These 
 thoughts run a slower course and are associated solely 
 with the fundamental mood ; the external perceptive pro- 
 cesses are delayed. Voluntary attention is hardly possible 
 or is very fleeting. 
 
 With the further development of the disease certain 
 ideas appear unsought out of the general feeling of de- 
 pression and present themselves to the patient as an expla- 
 nation of his sufferings. No conscious logical selection 
 permits the development of these explanations, but the 
 entire previous contents of consciousness are again lived 
 through, and any part thereof may come in contact with 
 the present feeling. It is surely no accident that, in very 
 many cases, this connection is afforded by religious ideas, 
 because these adhere firmly to the mind in earliest youth.. 
 
188 HANDBOOK OF INSANITY. 
 
 In a feeling of despair the patient seeks refuge in religion, 
 but he can no longer pray, and doubts concerning the 
 firmness of his own belief increase his notion of wicked- 
 ness to a morbid height. The Bible is read, but no com- 
 fort is found ; only texts which he refers to himself. Great 
 influence is exerted by those writers who discuss the un- 
 pardonable sin against the Holy Ghost. Its very obscurity 
 is dangerous to the melancholic patient, because he is apt 
 to find, in his own life, some circumstance which may be 
 interpreted as such a sin. Sexual aberrations are espe- 
 cially apt to enter this circle of thought. Other self-accu- 
 sations concerning sins that have been committed are also 
 frequent, but they usually remain general in character. 
 The patient fears that he has forfeited salvation, and 
 that he is doomed to eternal damnation. 
 
 Others believe that they are victims of human justice, 
 they dread the prison and capital punishment. A patient 
 suffers terror of soul, like a criminal after a heinous crime. 
 These general reproaches are usually gradually, but some- 
 times immediately, converted into a special notion which 
 is the starting-point of new melancholic complaints. This 
 change is a serious one, and proves, at least, that recovery 
 will not occur rapidly. It may also arouse doubts con- 
 cerning the diagnosis, inasmuch as the delusion of perse- 
 cution, of " verruecktheit, " has much similarity with these 
 conditions. A knowledge of the course of the disease 
 alone will prevent a mistake. The chief feature is the 
 affect of melancholia. Moreover, ideas of self-aggrandize- 
 ment are hardly ever wanting in "verruecktheit," while 
 the melancholic usually has lessened notions of his own 
 worth. 
 
 The clinical history changes when hallucinations de- 
 velop. They usually bear the impress of the depressed 
 mood, and their sensory distinctness removes every doubt 
 which may have existed. Voices threaten death and 
 damnation. The sound of shooting or of bells is connected 
 with the idea of execution. Shapes and shadows frighten 
 and threaten. The patient sees himself surrounded by 
 
PRECORDIAL FEAR. 189 
 
 flames or hell, and abysses open before his feet. He smells 
 corpses and tastes poison in his food. The clouded con- 
 sciousness mistakes harmless words and sounds for dan- 
 gerous influences. A dull pain in the head becomes a 
 proof of profound disease of the brain and impending 
 death. The terror-filled fancy finds in all perceptions a 
 confirmation of its fears. The sympathy of relatives 
 seems like an attempt to conceal a new misfortune or 
 danger. 
 
 These different symptoms appear in varying degrees 
 and combinations, so that the manifestations of simple 
 melancholia may be very manifold. A materially differ- 
 ent picture is presented when the feeling of fear enters 
 the symptom-group. This feeling is referred to the 
 cardiac region (precordial fear), and is one of the 
 most important and frequent accompaniments of severe 
 melancholia. The external quiet of simple melancholia 
 becomes converted into anxious restlessness. From the 
 start sleep is almost always disturbed because the patient 
 is tormented by the pressure in the cardiac region ; other 
 disagreeable sensations soon follow, such as constriction 
 of the neck or a dull feeling in the head ; bad dreams and 
 anxious thoughts become more numerous. The daily work 
 may make the condition endurable during the day for a 
 time, but in the stillness of night it is rapidly intensified, 
 and if sleep does not refresh the excited brain, the days, 
 likewise are filled more and more with disheartening fears. 
 
 The implication of the organs of the body is much more 
 distinct in anxious than in simple melancholia. The ap- 
 petite is lost, the nutrition is rapidly impaired. Respiration 
 is superficial, the heart's action is accelerated and often 
 irregular, the pulse is small, the skin cool. When the 
 terror shows variations or occurs in paroxysms, its increase 
 is shown by suppression of the urine and perspiration, its 
 subsidence by increase in these secretions. The more 
 chronic the precordial fear the more indistinct do these 
 symptoms become. 
 
 General restlessness soon makes its appearance. The; 
 
190 HANDBOOK OF INSANITY. 
 
 patient can no longer remain in one place ; he runs about 
 the room, sits down, rises, goes out of doors, always with 
 the indefinite, but unfulfilled hope that the change may 
 relieve the terrible restlessness. 
 
 Although confined to a few anxious concepts, the flight 
 of ideas may be accelerated. Delusions may now develop, 
 intensified by hallucinations. Religious notions are often 
 awakened, and are then explained as the dread of being 
 possessed by evil spirits. With the increasing terror the 
 consciousness is gradually impaired. Perception of the 
 outer world takes place only with reference to the domi- 
 nant affect. 
 
 The affect is shown more and more distinctly in the 
 facial expression. The facial muscles become rigid and 
 unchangeable folds appear; the brow is furrowed, the 
 angles of the mouth drawn downward, the mouth often 
 appears wider, almost quadrangular, the lips are gently 
 moved to and fro. In the higher grades anxious moaning 
 and sighing accompany the unchanging complaints and 
 exclamations. One pleads for mercy, the begs other that he 
 may be spared or perhaps that he be burned to death, de- 
 spite his fear of this agonizing fate. The contradiction 
 is perhaps only apparent because the terror is so dreadful 
 that even burning to death appears the lesser evil. This 
 condition may last weeks and months. The patient clings 
 to every one around him and force is often required to 
 remove him. Then the unfortunate wrings his hands, 
 beats his head, tears the skin of his face and hands, tears 
 his hair, and is constantly inflicting slight wounds. The 
 restlessness may increase still further to inarticulate 
 shouting, unceasing running about ; the patient cannot be 
 dressed or undressed without force. It is only during a 
 temporary subsidence of the terror that we occasionally 
 hear expressions which permit us to recognize that the 
 despair is associated with the former psychical processes. 
 Soon the terror again conceals these processes, and only 
 the later reports after recovery prove their continuance. 
 
 Now come the impulsive manifestations of the tortured 
 
RAPTUS MELANCHOLICTJS. 191 
 
 ego and acts of violence, which must be regarded as dis- 
 charges of the terror-laden consciousness. Suddenly the 
 patient destroys everything within his reach. Not infre- 
 quently he mutilates his own body; tears out his eyes, 
 cuts off the genitalia, etc. Sometimes a leap into the river 
 or out of the window closes the dreadful scene. Such acts 
 are sometimes due merely to the endeavor to relieve the 
 condition of internal tension. We then find impulsive 
 actions, which are inexplicable even to the patient after 
 recovery has taken place. This one kills his parents or 
 children, another kills his wife. The sight of a knife 
 makes the thought and deed one. This so-called raptus 
 melancholicus is perhaps not so dangerous in anxiously 
 excited patients because, as a rule, they are sent early to 
 an asylum. But these sudden discharges may also occur 
 in patients who were apparently quiet. Especially dan- 
 gerous in this respect is melancholia in which, for a long 
 time prior to the act of violence, the patient may have re- 
 mained motionless or even rigid. 
 
 Attacks upon surrounding individuals, self -mutilations, 
 and attempts at suicide serve the involuntary purpose of 
 freeing the patient from his intolerable position. In fact, 
 after such acts they feel relieved, as a rule, and this may 
 even be followed by recovery. The profound disturbance 
 of consciousness at the time permits only an indistinct 
 remembrance of the deed, so that remorse is not increased 
 by memory. Moreover, he is often apt to regard himself 
 as the unresisting tool of a higher power. 
 
 The attacks of precordial fear usually develop suddenly ; 
 more rarely they are preceded by oppression, headache, 
 and vertigo. They may be repeated at short intervals or 
 after the lapse of years. In the intervals the depression 
 may be distinct or it may be so slight that the patient ap- 
 pears healthy amid the accustomed surroundings. As a 
 rule, the more violent the attack the more permanent is 
 the subsequent quiet, but there are also cases in which 
 the act of violence precedes the following sj-mptoms. 
 
 A disease which began as simple melancholia may lead 
 
192 HANDBOOK OF INSANITY. 
 
 to a materially different symptomatology. Slowly or rap- 
 idly there develops a rigid absorption in the internal men- 
 tal processes (stupor). The disorder of consciousness is 
 not so profound as it appears, as is shown by the fleeting 
 mimic movements, wrinkling of the forehead, twitching 
 of the lids, an anxious gaze. A sudden change of color 
 or a deep sigh shows that the motionless patient is filled 
 with anxious thoughts, and convalescent patients confirm 
 this opinion. In more severe cases the internal life of 
 such patients becomes a real dreamy condition, in which 
 external impressions are received in a confused, shadowy, 
 and inimical manner. A terrible, baseless, but paralyz- 
 ing fear takes possession of consciousness and makes every 
 movement impossible, while at the same time the fright- 
 ful consciousness of inability to act or to will increases the 
 terror tenfold. These patients sit as rigid as a statue, 
 with an anxiously astounded or rigid, mask-like expres- 
 sion. But they do not always neglect the care of their 
 immediate bodily necessities. It is only in the most severe 
 grades that they are unable to dress themselves, keep 
 themselves clean, and take food alone.. These acts are 
 continued for a long time, although slowly, and show that 
 the patient at least perceives the internal processes of his 
 own body. Sleep is usually disturbed very much and often 
 there is complete insomnia, although the patient lies qui- 
 etly in bed. 
 
 In these conditions the concomitant symptoms of mel- 
 ancholia appear more distinctly. The speech may exhibit 
 striking changes. In simple depression it is slow, infre- 
 quent, and monotonous: the voice sounds muffled, while 
 the timbre varies according to the degree of fear, from a 
 gentle tremulous voice to shrill outcries and violent moans 
 and complaints. In anxious excitement the speech be- 
 comes more rapid but retains a peculiar tremor. 
 
 The loss of sleep, which is common to all forms of mel- 
 ancholia, is often followed by painful, or at least annoying, 
 sensations in the head, such as pressure at the vertex, ten- 
 sion of the occiput, or a feeling of emptiness which is 
 
DIGESTIVE DISORDERS. 193 
 
 sometimes translated by the allegorical expression that the 
 brain has disappeared or that the soul is lost. 
 
 Neuralgic pains are rare ; the apparent analgesia in con- 
 ditions of great fear and impairment of consciousness must 
 be attributed to the lack of attention. 
 
 Digestion is constantly impaired in melancholia. It is 
 possible that a gastro-intestinal catarrh may give rise to a 
 refusal to take food through the agency of a secondary 
 delusion, but, as a rule, such refusal develops independently 
 out of psychical motives. Constipation is very frequent, 
 but this may be preceded, more often it is followed, by dis- 
 tinct evidences of gastro-intestinal catarrh, undoubtedly 
 due to the insufficient secretion of digestive fluids. The 
 clearest evidence of the imperfect digestion and absorption 
 of food is the rapid diminution in the weight of the body 
 at the beginning of melancholia. After the severe forms 
 of melancholia have lasted for some time, even if food is 
 not refused, general emaciation and exhaustion may pro- 
 ceed to a fatal termination. Even forced feeding is use- 
 less when the exhausted nervous energy is powerless to 
 stimulate digestion. 
 
 Refusal to take food in consequence of delusions is one 
 of the gravest symptoms of melancholia. It is rarely as- 
 sociated with the intention to put an end to life by starva- 
 tion, but the patients complain that they have lost their 
 fortunes, and refuse to take food because they cannot pay 
 for it or because they are depriving others of food. 
 
 The secretory activity of various organs is affected. 
 Tears do not flow, perspiration is usually suppressed, the 
 skin is dry, the hair and nails become dry and brittle. 
 Apart from the attacks of fear, the urine is small in quan- 
 tity ; thick, tough saliva sometimes flows from the corners 
 of the mouth. 
 
 Menstruation is disturbed, often absent. Sexual desire 
 is usually abolished, but obstinate masturbation is some- 
 times observed in profound impairment of consciousness. 
 
 Respiration, whether slow or accelerated, is always su- 
 perficial. There is often general anaemia from the start, 
 13 
 
194 HANDBOOK OF INSANITY. 
 
 and this increases with the further course of the disease. 
 The diminished activity of the heart is soon shown in 
 various ways. The face, hands, and feet are slightly 
 swollen, and these parts soon become bluish in color, like 
 certain of the mucous membranes. The hands and feet 
 are apt to be cold to the feel, while the internal excitement 
 is manifested in the face by heat and sweating of the fore- 
 head. The pulse is generally small and tense, but it 
 changes with the variations in the primary affect. 
 
 One striking symptom is observed in all forms of insan- 
 ity, but is especially frequent in melancholia, viz. , a sud- 
 den change of mood. In the midst of the depression a 
 temporary cheerfulness suddenly appears, more frequently 
 during the development and subsidence of the disease than 
 at its height. With the return of the depression the 
 cheerfulness is often converted into self-reproaches and 
 proofs of the patient's own perversity and wickedness. 
 
 Melancholia usually runs a very slow course, lasting at 
 least months, and occasionally years ; in very rare cases it 
 lasts only a few hours, but hallucinations or delusions are 
 then necessary for diagnosis. The development of the dis- 
 ease sometimes takes place by fits and starts, and frequent 
 changes in the severity of the symptoms are common in 
 all stages. These may be due to sudden changes of 
 temperature, the onset of the menstrual period, even the 
 growing darkness of twilight aggravates the symptoms in 
 some cases. 
 
 Moderate grades of melancholia with periods of notable 
 improvement may last many years. Such patients can 
 usually maintain their position in their accustomed sur- 
 roundings. After a time the family attaches little weight 
 to their complaints, and to the occasional threat of suicide. 
 Even in this apparently slight degree of development of 
 the disease there is great danger of suicide. A suddenly 
 developing precordial fear compels a discharge through 
 the medium of an act of violence, and the danger of sui- 
 cide should not be forgotten, at least by the physician. 
 
 Every melancholia may become chronic. The more 
 
CONVALESCENCE. 195 
 
 violent sypmtoms often subside ; the hallucinations become 
 less vivid, the delusions fall into the background, the ex- 
 ternal restlessness is lost ; the patient may even resume an 
 occupation in which no responsibility is incurred. This 
 condition may last for years, especially in an asylum, 
 without passing into recovery. 
 
 In other cases of chronic melancholia the symptoms lose 
 none of their violence, but the delusions and their mani- 
 festations assume a somewhat stereotyped character and 
 may be repeated like a machine ; the rigid or anxious ex- 
 pression becomes ingrained; the same complaints are 
 repeated in the same way. The stupor may last for years 
 until death, but more frequently the tension is somewhat; 
 lessened ; the consciousness becomes clearer, although the 
 patient does not gain a clear insight into his disease. He 
 remains apathetic and incapable of mental effort, and the 
 melancholia may continue in this stage until the end of 
 life. He has no sympathy for his family, and the sorrow- 
 ful mood is still dominant. 
 
 The transitions into recovery will now occupy our at- 
 tention. At the end of three to six months the symptoms, 
 as a general thing, gradually subside and give place to the 
 normal condition. Sleep first imj)roves, then the attacks 
 of fear become less frequent and violent, the facial expres- 
 sion gains life, and sympathy for the family begins to be 
 manifested. The patients begin to talk, gain appetite, 
 and show more and more of their former individuality. 
 Gradual improvement is more durable than sudden im- 
 provement, which is very rare. Certainty of recovery 
 can only be entertained when the mental improvement 
 goes hand in hand with physical improvement. As a 
 rule, this takes place very rapidly. On the other hand, a 
 return of physical improvement, without notable mental 
 recovery, leads us to fear the development of dementia. 
 Another important point is the self-knowledge of the mor- 
 bid character of the affection, which generally appears with 
 advancing recovery. 
 
 Although gradual improvement is the usual event, yet 
 
196 HANDBOOK OF INSANITY. 
 
 the changing symptoms of anxious melancholia and the 
 severe phenomena of stupor are exposed to many varia- 
 tions during the period of convalescence, although they 
 may terminate in complete recovery. These patients some- 
 times manifest a temporary increase of the feeling of well- 
 being before complete equilibrium is established. On the 
 other hand, the improvement may be concealed by a rigid 
 demeanor, until finally this exhaustion of the entire ner- 
 vous system gives place to complete recovery. 
 
 The degree of insight, after recovery, into the morbid 
 character of the disease depends materially upon the de- 
 gree of culture possessed by the patient. While the cul- 
 tured individual recognizes the melancholic condition as 
 a morbid mental state, the uncultured patient understands 
 with difficulty that he has suffered from a disease and 
 speaks of dreams and fancies that tortured him. 
 
 Death may result, with comparative rapidity, after vio- 
 lent conditions of anxious excitement, as a result of the 
 complete exhaustion and insufficient supply of food. A 
 series of dangerous diseases develop with comparative fre- 
 quency in these conditions, for example, pneumonia, and 
 surgical fever following wounds, which it is difficult to 
 treat on account of the patient's restlessness. In simple 
 melancholia and stupor pulmonary tuberculosis is a fre- 
 quent complication. 
 
 Finally, the termination in dementia must be mentioned, 
 although it is not frequent. It is true that there are nu- 
 merous protracted cases in which a certain grade of mental 
 weakness develops, particularly in the ethical domain, 
 but the intellectual functions are usually intact for a long 
 time and their entire loss is not frequent. The best meas- 
 ure is the patient's ability. Although independence of a 
 high grade does not persist, we find among chronic melan- 
 cholies many who, under proper guidance, are able to do 
 so much that they cannot be regarded as demented. 
 
 In general the prognosis of melancholy may be regarded 
 as favorable. Much more than half the patients recover, 
 and often regain a certain grade of mental ability. He- 
 
PROGNOSIS. 197 
 
 reditary taint or previous injury to the skull with cerebral 
 concussion are unfavorable factors. If the exciting causes, 
 such as grief, pecuniary trouble, nutritive disorders of all 
 kinds, can be removed, the prospects of recovery are in- 
 creased. The age of the patient is very important. 
 Childhood, puberty, and old age are more endangered than 
 vigorous youth and adult life. Melancholia is most fre- 
 quent at the period of sexual development and hence it is 
 especially frequent at this period in females, in whom the 
 sexual life affects the mental processes so deeply. The 
 disease is not much less frequent in old age, and some 
 observers even maintain that its frequency then exceeds 
 that during the developmental period. The period of in- 
 volution of the body brings melancholia to an especially 
 distinct expression. The women are again attacked more 
 frequently on account of the changes induced by the cli- 
 macteric. There are still other causes which increase the 
 number of cases in females, viz., pregnancy, childbed, and 
 nursing. The latter forms do not differ, as regards symp- 
 toms, from those already mentioned, so that it is super- 
 fluous to speak of puerperal melancholia as a special form 
 of disease. 
 
 It is a point of great practical importance that a melan- 
 cholia which develops in a brain that is less capable of 
 resistance on account of hereditary or acquired taint, differs 
 in some respects from melancholia developing in a pre- 
 viously healthy brain. In the former event there is often 
 a mixture of morbid and normal elements. This may de- 
 ceive the inexperienced observer, especially as the patients 
 have a tendency to justify their conduct by reasons, to 
 attribute their mood to sorrowful circumstances. The 
 below-par condition of the brain and entire nervous con- 
 stitution give rise to the course of this form of melancholia 
 which is also called constitutional. It would be better, 
 however, to lay stress on the attempts at justification and 
 to call the disease a folie raisonnante in a melancholic 
 form. These cases occur chiefly in women. Their dis- 
 satisfaction and irritability lay them open to the danger 
 
198 HANDBOOK OE' INSANITY. 
 
 of being misunderstood. They are not alone morose but 
 incapable of work ; they are especially annoyed by repeated 
 reproaches and are then regarded as quarrelsome and ma- 
 licious on account of the changes from a depressed to an 
 angry mood. When such excitement, which has been 
 added from the outside, has subsided, the patient feels so 
 much unhappier. This increase of the painful affect ter- 
 minates occasionally in suicide. 
 
 The chief element in the treatment of melancholia 
 is to obtain mental and physical rest for the patient. 
 The physician must make the family recognize at the 
 start that the patient's conduct is the unavoidable re- 
 sult of a morbid depression. Distraction by means 
 of travel, entertainments, etc., is to be avoided by all 
 means, and inactivity is the only proper treatment at 
 the outset. As the family can rarely be induced to follow 
 such advice, independent melancholias, as a rule, should 
 be transferred to an asylum as early as possible. This is 
 not so true of the melancholic conditions with which other 
 psychoses begin. If the patient cannot be transferred, 
 we should advise the family to be as unconcerned and 
 cheerful as possible, neither to oppose nor to accede too 
 much to the patient's complaints, but to attach the chief 
 importance to the performance of the numerous little acts 
 which fill out the family life. A quiet pressure of the hand 
 does more than an hour's conversation. The more simple 
 and natural the care, the less design does the patient 
 see therein, and the better for him. But unfortunately it 
 is usually impossible to be uniformly quiet and sympa- 
 thetic for months, when the individual's own heart is 
 bleeding for the patient, and then again the other injuri- 
 ous influences of the outer world cannot be entirely ex- 
 cluded in the family. The simplest method of obtaining 
 the desired rest for the patient is to keep him in bed. 
 This removes him from the injurious influences of his 
 work and of evidences of excessive tenderness, and at the 
 same time secures the necessary rest for the body. Mild 
 cases, however, generally refuse to go to bed, and in these 
 
SUICIDE. 199 
 
 special cases we may occasionally permit a change of 
 scene, under the care of a good nurse. 
 
 As a general thing, however, such measures are insuf- 
 ficient and asylum treatment is indicated. This becomes 
 absolutely imperative whenever we have reason to fear 
 suicide, acts of violence of other kinds, or a refusal to take 
 food. In truth every melancholic must be regarded as 
 capable of committing suicide, and although this suspicion 
 must not be carried too far — the rest of the family should 
 not act as spies upon the patient, because the home condi- 
 tions cannot prevent a well-planned suicide — yet the phy- 
 sician- must never lose sight of this danger and must 
 transfer the patient to an asylum in time. 
 
 If the patient must remain at home, it is to be remem- 
 bered that attempts at suicide are made chiefly in the 
 early morning hours. If constant supervision is imprac- 
 ticable, then the patient's hands must be restrained 
 mechanically. Nobody will deny the necessity of such 
 measures when a physician or asylum aid cannot be 
 quickly secured. But then it becomes the duty of the phy- 
 sician to insist upon immediate admission to an asylum. 
 
 Next in importance to mental and bodily rest in the 
 treatment of melancholia is the regulation of sleep. Usu- 
 ally the physician resorts at once to the administration of 
 drugs. But it must be remembered that the patient may 
 not take medicines on account of the fear of poisoning, 
 and on the other hand their continued admintstration 
 during a long illness may prove injurious. As a matter 
 of course, a sedative must be occasionally given if we 
 must quiet temporary excitement in order to render possi- 
 ble the transfer of the patient to an asylum. But this is 
 a form of restraint and is not a curative measure. We 
 may speak of medicinal treatment only when a drug is 
 given according to some definite plan, not when it is used 
 now and then to combat individual symptoms. Above 
 all, the physician should not make experiments with any 
 of the innumerable new drugs, whose action is still imper- 
 fectly understood. The number of tried remedies is small. 
 
200 HANDBOOK OF INSANITY. 
 
 The best sedative and hypnotic in melancholia is morphine 
 or opium. In solution morphine may be given unnoticed 
 in the food ; when the patient becomes suspicious, hypo- 
 dermic injections may be used. The regular daily dose 
 of one to two centigrams will suffice, and more than three 
 centigrams should hardly ever be given. Combined 
 with 2.0 grams chloral hydrate at night, morphine is an 
 effective hypnotic, while chloral alone is much less useful 
 and after a while produces disagreeable effects (headache 
 and dulness during the day) . In females, opium appears 
 to act better than morphine. Protracted anxious restless- 
 ness of moderate degree and general anaemia indicate the 
 use of opium. This is given in powder, at first two cen- 
 tigrams two or three times a day, and then increasing in 
 a few days to two or three times this amount, until nota- 
 ble sedation is effected. 
 
 In special cases other remedies may occasionally be re- 
 sorted to, and we refer to the article on general treatment. 
 We may here mention the use of mild alcoholic drinks, 
 such as beer, wine, or punch. Prolonged warm baths are 
 very serviceable, and may be replaced occasionally by wet 
 packs. In severe excitement and prsecordial fears the last 
 method has very little effect, and we must then resort to 
 more rapidly acting remedies, particularly to morphine. 
 
 The more severe the disease the less effect will be pro- 
 duced by direct treatment with drugs, and the chief atten- 
 tion must then be paid to the nutrition and hygienic 
 measures. The necessity of artificial feeding is always a 
 decisive reason for bringing the patient to an asylum. 
 When food is freely taken, it should be as nutritious as 
 possible. All the organs must be carefully examined, and 
 any diseases which may be present should receive appro- 
 priate treatment. The immobile melancholic must be led 
 around a good deal in the open air, the anxiously excited 
 patient should be kept in bed. Both must receive frequent 
 baths, both for purposes of cleanliness and also to stimulate 
 the activity of the skin and heart. During convalescence, 
 but only at that period, the patient may receive the com- 
 
DESCRIPTION OF PLATE I. 
 
 Comparison with the exposed facial muscles in an anatomical 
 atlas is advisable in examining these plates. 
 
 MELANCHOLIA. 
 
 Upon the brow of the young melancholic who dreads decapita- 
 tion is seen distinctly a horizontal fold of the frontal integument, 
 only in the middle above the root of the nose. This restriction of 
 the contraction of the frontal muscle to its middle bundles is very 
 common in the expression of grief, but the brow of the man to the 
 right and above exhibits complete transverse furrowing ; this was 
 also a true profound melancholia. 
 
 Other muscles also act to produce the expression of grief. The 
 two corrugators bring the eyebrows closer together, and hence ver- 
 tical folds form over the root of the nose. But as the frontal 
 muscle often acts more strongly upward, the inner extremity of 
 the eyebrow is occasionally raised ; this is shown very well in the 
 lower half figure, in which the forehead is wrinkled only on one 
 side (this was not taken from a melancholic patient) . Then the 
 upper lids, which usually hang down flabbily, also appear curved. 
 This is also effected by contraction of the orbicularis palpebrarum, 
 which at the same time causes wrinkling of the skin of the outer 
 angle of the eye (compare the picture of the woman on the right) . 
 The combination of the contraction of the three groups of muscles 
 mentioned produces the careworn expression of the upper half of 
 the face ; perhaps the pyramidal muscle of the nose also takes part 
 by its lessened activity, because the antagonistic middle bundles 
 of the frontal muscle may then act more vigorously in an upward 
 direction. At all events, the resultant right-angled furrowing of 
 the forehead is to be regarded as a sign of melancholia. 
 
 A less constant feature, but one which materially increases the 
 melancholic expression, is the marked character of the naso-labial 
 folds. This, almost alone, imparts a sorrowful appearance to the 
 lower half of the face in the picture of the woman, but that ex- 
 pression is due mainly to the drooping of the angles of the mouth 
 and the protrusion of the lower lip. This woman had torn the 
 hair from her head in her great fear ; the folded hands intensify the 
 general anxious expression. 
 
HANDBOOK OF INSANITY. 
 
 KIRCHHOFF. 
 
 Plate I. 
 
 -a-; 
 
REMOVAL FROM ASYLUM. 201 
 
 forts of religion. At this time positive psychical treat- 
 ment is again indicated. Terrifying delusions may now 
 be shaken by reasoning. Even if logic is not of much 
 avail, the convalescent is thankful for the well-meant 
 efforts, and he regains more rapidly the necessary self-sup- 
 port if he feels himself aided by others. 
 
 Should a convalescent melancholic be removed from the 
 asylum as early or as late as possible? Usually the family 
 physician needs to exert his influence against too early 
 removal, because the danger of suicide in unexpected at- 
 tacks of fear may again be encountered. Complete recovery 
 alone furnishes full security. In individual cases, how- 
 ever, an early removal may be advisable. If a family 
 thereby secures its support so much earlier, and if the pa- 
 tient derives satisfaction from providing for those depend- 
 ent on him, if a satisfactory activity awaits him at home, 
 then his dismissal from the asylum is indicated. It may 
 also be desirable to place a well-to-do patient under better 
 climatic surroundings than he will find at home. If he re- 
 covers entirely in some other locality, his return to his 
 former pursuits is facilitated in view of the prejudice 
 against patients who have been in an asylum. If the 
 patient has furnished proof of his recovery under other 
 conditions, he is received at home with greater confidence. 
 The family should receive him as unconcernedly as possi- 
 ble, and should act toward him as toward his former 
 self. Hence they may speak concerning his disease, be- 
 cause he does this willingly and manifests gratitude for 
 the care and kind treatment bestowed upon him. If a 
 melancholic returns home quiet, but not recovered, he 
 must be treated as a patient and treated in the manner 
 already indicated. 
 
 B. MANIA. 
 
 A morbidly elated mood constitutes the fundamental 
 basis of mania, varying from slight cheerfulness to violent 
 rage. It is accompanied constantly by an accelerated 
 flow of ideas, and by more or less accelerated conversion 
 
202 HANDBOOK OF INSANITY. 
 
 of conditions of mental excitement into acts, while disor- 
 ders of consciousness, including hallucinations, usually 
 appear only in the higher grades of the disease. Stress 
 should be laid on the fact that in mania, which occurs in- 
 dependently, the symptoms all develop upon the same 
 morbid basis, not alone in psychological dependence upon 
 one another. For example, the cheerful mood does not 
 depend upon the facilitated flow of ideas. It is probable 
 that congestion and disturbed chemical changes in the 
 cortex form the common anatomical basis. Mania has an 
 organic basis, although this cannot often be demonstrated 
 and it is therefore customary to call it a functional disease. 
 The greater the lack of inhibition of the mental processes. 
 and the resultant actions, the more the originally cheerful 
 mood is converted into a violent, indeed angry excitement, 
 in which there may finally be an impairment of conscious- 
 ness. 
 
 The prodromata of mild maniacal excitement are accom- 
 panied quite constantly by a sorrowful mood, which may 
 be regarded as an expression for the feeling of the newly 
 developing irritant, which appears foreign and incom- 
 prehensible to the patient. Sometimes this melancholy 
 phase cannot be distinguished from a mild, independent 
 melancholia. The patient is quiet, depressed, suffers from 
 general malaise, insomnia, attended with digestive dis- 
 turbances and emaciation. 
 
 In a few weeks these symptoms disappear, and the pa- 
 tient believes the threatened danger is past, especially as 
 the renewed enjoyment of work and the more cheerful 
 mood are attended with a better physical appearance. 
 But it soon becomes evident that this is merely the begin- 
 ning of a series of morbid phenomena. The first striking 
 feature is the increased talkativeness, and the greater in- 
 terest in surrounding affairs. The patient makes numer- 
 ous calls upon friends and strangers ; the conversation is 
 one-sided — an answer is not demanded or expected, but 
 given by the patient himself. The facilitated association 
 and accelerated flow of ideas permit witty and surpris- 
 
PRODROMES. 203 
 
 ing turns of conversation, which under other conditions 
 must be sought with difficulty. The formerly modest in- 
 dividual suddenly becomes eloquent in society ; after din- 
 ner he makes impromptu poetical remarks, and is 
 admired by the majority on account of his new talent. 
 If the thread of conversation is occasionally lost by him, 
 this is usually excused, in a merry company, by the influ- 
 ence of wine. Indeed, the cerebral irritability is early 
 shown by the fact that very small amounts of alcoholic 
 stimulants are sufficient to produce excitement. 
 
 In daily life, however, the eyes of those around the pa- 
 tient are rapidly opened. The restless activity and the 
 feeling of constantly increasing abilities lead the patient 
 to form plan after plan, although none is carried to com- 
 pletion. In addition, he writes numerous letters; their 
 form enables us to detect the rapidity of their production ;; 
 large letters run rapidly in bold curves across the paper, 
 underscorings are very numerous, and the contents corre- 
 spond to the flow of ideas, although the restraint of the 
 slower writing-concepts still curbs the contents to a cer- 
 tain extent. 
 
 Even at this time many are mistaken and admire the 
 patient's bold thoughts, despite various offences against 
 propriety which he commits. Nor can it be denied that 
 the fancy of mild maniacal excitement may be an attractive 
 phenomenon, although it furnishes little real power of 
 imagination. It must be remembered that the mental 
 activity of the patient does not run in the customary tracks ; 
 that, as a rule, he does not care whether he is regarded 
 as cranky or peculiar, and that he has lost the finer 
 considerations of social propriety. His imagination acts 
 without object or restraint. He sees his ideas arrange 
 themselves involuntarily, according as they are aroused 
 by impressions of this or that sense. At times, the pa- 
 tient's look indicates a condition of poetic inspiration, 
 and, after his recovery, he may relate wonderful dream- 
 like experiences. 
 
 In mania we can follow the paths along which ideas 
 
204 HANDBOOK OF INSANITY. 
 
 and words are mentally combined, because conscious se- 
 lection is absent, and the patient is left involuntarily to 
 the play of his thoughts. The careful consideration of 
 speech in mania throws some light upon this form of as- 
 sociation of ideas. There are two different methods of 
 association, one according to the sound of the words, the 
 other according to the relationship of ideas. Thus, a 
 patient who hears the ringing of a bell, begins to rhyme 
 with words like well, dell, sell, hell. In the other method 
 the name of a person which reminds the patient of the 
 idea of a fish, rapidly gives rise to ideas of shell-fish, 
 oysters, fisheries' exhibitions, etc. As a general thing, 
 both modes of association are employed. The patient says 
 this house is made of wood and stone ; wood is an article of 
 fuel ; the fire is hot, etc. On account of such jumps the 
 accelerated flow of ideas often, apparently, loses its inter- 
 nal connection, but the consideration of the mode of 
 speech shows us that this so-called flight of ideas does not 
 occur entirely without internal connection. But our 
 knowledge of the connection of the thoughts is entirely 
 unsatisfactory, and we can detect only small bits in the 
 structure of the thoughts within the patient's mind. As 
 in dreams the boldest flights of thought pass across our 
 mind without arousing the slight feeling of their disjointed 
 character, so the same thing may occur in mania. As a 
 rule, the mental processes are entirely clear to the patient. 
 In a flight of ideas of a moderate grade, the mood is 
 mainly a cheerful one. The fact that his thoughts come 
 voluntarily, without effort, increases the patient's satisfac- 
 tion, and makes him look hopefully into the future. But 
 this mood is not uniform, and even cautious opposition 
 will produce a violent manner and evidences of irritation. 
 Such impressions, however, are very brief, and the mirth 
 soon comes again to the front. This varying mood and 
 irritability now removes all doubt in the minds of the 
 family concerning the morbid character of the condition. 
 "When the patient will not tolerate the slightest opposition 
 without cursing and shouting, or destroying clothing and 
 
MANIACAL GESTURES. 205 
 
 furniture, the patience of the family becomes exhausted, 
 and the physician is summoned. The anger of the pa- 
 tient is not excited by external causes alone. An out- 
 break of angry excitement often appears in the midst of 
 unbridled mirth, but soon returns to the previous condi- 
 tion. In a similar way we often notice, at this period, a 
 temporary depressed mood, with violent crying and com- 
 plaining, and for which not the slightest external cause 
 can be found. This also subsides rapidly, and the domi- 
 nant mood remains cheerful. 
 
 The gestures soon excite the interest of the observer, 
 not alone the play of the features, but also the movements 
 which accompany impulses and acts. The play of fea- 
 tures is lively, the eye is bright, the skin often reddened. 
 At the height of the disease there is no doubt that the pa- 
 tient cannot control the facial expression. Distortions and 
 even spasmodic twitchings accompany the increase of ex- 
 citement, and it becomes evident that the facial movements, 
 like the impulses and acts, are not alone free from inhi- 
 bition, but take place as the direct result of irritative con- 
 ditions in the cerebral cortex. In mild mania all active 
 gestures result from the excitability, but their impulsive 
 character may still be regulated and checked. The ex- 
 ternal activity is also confined, in great part, to customary 
 channels. For example, the patient walks about to an 
 unusual degree, but he is apt to conceal his restlessness by 
 the statement that walking is very necessary and healthful. 
 Another makes long trips, foolhardy boating excursions, 
 or exhausts himself in mountain climbing. The motor 
 restlessness is manifested in a less serious manner by use- 
 less packing and unpacking of books, or constant fussing 
 among old papers, under the pretext of putting things in 
 order. Women busy themselves with their toilet, or make 
 daily changes in the arrangement of their hair. To this is 
 soon added increased coquetry. They dress themselves 
 fantastically, the manner becomes more self-complacent, 
 and they often have a tendency to display their superiority, 
 especially by singing and acting before large audiences. 
 
206 HANDBOOK OF INSANITY. 
 
 In the female sex the sexual impulse soon pushes into the 
 foreground. Acquired modesty ma} T veil its manifesta- 
 tions, so that it first appears under other forms — for ex- 
 ample, in the shape of accusations against other women 
 or the tendency, on every occasion, to speak with the phy- 
 sician about menstruation, etc. Such subjects of conver- 
 sation are apt to be associated with excessive devotion to 
 religious exercises. At a later period the excitement is re- 
 vealed more clearly by protestations of love, and finally by 
 shameless offers of sexual intercourse. In men sexual ex- 
 citement is less marked, probably because it can be grati- 
 fied by them, without difficulty, in houses of prostitution. 
 But the same tendency appears in their conversation, and 
 is shown particularly by double entendres and smutty 
 jokes. Masturbation is kept more concealed in both sexes. 
 In slighter grades of excitement we find only an excessive 
 dressiness, the reading of lascivious novels, attempts to 
 touch the bodies of persons of the opposite sex or merely 
 to come in contact with their clothes. 
 
 During this stage there is often observed, in men, an 
 excessive addiction to stimulants, but this is probably due to 
 their opportunities, inasmuch as the maniac likes society 
 and his mood is intensified by alcoholic drinks. As a rule, 
 very slight amounts produce intoxication. 
 
 Nor may we speak of an impulse for collecting articles 
 in describing an activity which results, independently of 
 the will, from direct psychomotor irritants. There are no 
 delusions as intervening links, but the removal, even theft, 
 of articles is an expression of restlessness which finds sat- 
 isfaction in the purposeless grasping of such objects. 
 
 In the milder grades of mania, delusions and hallucina- 
 tions are rare. The mistakes which the patients make in 
 the personality of others are due, as a rule, to insufficient 
 observation, so that a partial likeness suffices to produce 
 the deception. In the same way sounds are rapidly worked 
 up into definite ideas. Hence we have to deal with illu- 
 sions, not with peripheral or central hallucinations. 
 
 Although all these phenomena indicate an increased 
 
FRENZY. 207 
 
 activity of the nervous system, the income is- soon less than 
 the output. The excited patient often forgets hunger and 
 thirst, chooses improper food, and these factors, together 
 with the loss of sleep, soon result in loss of weight which 
 proves the impaired nutrition. Although the feeling of 
 exhaustion is absent even after great bodily efforts, yet the 
 very increase of excitability is an evidence of exhaustion of 
 the nerve power. The pulse is moderately accelerated. 
 The menses are often absent, but this has no particular 
 significance. 
 
 Thus far we have considered only the symptoms of the 
 milder grades of independent mania. The disease may 
 remain at the height indicated for several weeks or months 
 and then pass gradually into recovery, or it may lead to 
 the symptoms known as frenzy from the prominence of the 
 unbounded motor excitement. But as other insane, es- 
 pecially melancholies during attacks of fear, also grow 
 frenzied, we prefer to use the term mania, because, con- 
 sidering the different violence of the individual symptoms, 
 the severer conditions of manial excitement have the same 
 symptoms as the milder grades already described. But it 
 must be noted that, after the preliminary melancholic stage, 
 severe mania passes much more rapidly through the 
 milder degree of excitement, and the symptoms proper 
 rapidly attain their complete development. The more 
 prolonged and profound the depressed mood the greater 
 are the duration and violence of the following mania. 
 
 The direct manifestations of the irritative condition of 
 the cortex can be recognized much more distinctly in all 
 the symptoms of severe mania. Hence the psychomotor 
 movements occupy the foreground, and numerous hallu- 
 cinations and delusions appear directly, without any at- 
 tempt at explanation. Although only the very highest 
 grades of severe mania are accompanied by more lasting 
 anatomical changes in the brain, yet in some cases the ac- 
 companying physical symptoms show the marked irrita- 
 tion of the nervous system. Hence these few cases do not 
 justify the creation of a special group, distinguishable 
 
208 HANDBOOK OF INSANITY. 
 
 under the term acute delirium from simple functional 
 mania. Nor do I feel justified in accepting a group 
 known as hallucinatory confusion, on account of the very 
 great prominence of hallucinations, because these cases 
 also exhibit the other symptoms of mania. 
 
 At the height of its development, then, severe mania 
 exhibits enormous motor restlessness. The motor impulse 
 of the patient is discharged in entirely irregular move- 
 ments. There is no longer any question of actions with a 
 definite purpose. Perfect regardlessness in movements 
 and actions; ceaseless, uniform activity by night and 
 day, are the signs of this motor excitement, the patient 
 attacking every obstacle with violence, and regardless of 
 consequences. Convalescents or others who still possess 
 a certain amount of reason occasionally state during the 
 attack that they cannot do otherwise, that they must 
 dance and jump and tear things. The frenzy is increased 
 by the necessity of restraining the patient's liberty, and 
 doors and windows are frequent objects of attack. But 
 if the restraint is moderate and destructible objects are 
 not within reach, the motor excitement is often expended 
 in a less harmful manner. Laughing and crying, singing 
 and whistling, clapping his hands, the patient jumps and 
 dances around the room, cleans up along the floor, the walls 
 and windows; if supervision is insufficient, he washes 
 himself with his own urine ; then he drums upon the door, 
 beats the table, overturns a bench, and makes rapid turns 
 around the room, laughing and shouting. He overturns 
 other persons, and takes from them some utensil, merely 
 to throw it away in a moment. Or he dresses and un- 
 dresses with rapidity, cuts his clothing or bedding into 
 narrow strips which are placed fantastically upon his per- 
 son. A turban of rags or twisted bundles of straw 
 adorns his head, the articles of clothing are placed on the 
 wrong parts of the body, the shoes and stockings are 
 thrown away, again collected, and ball is merrily played 
 with them. Leaves are placed in every buttonhole. 
 All attainable objects are picked to pieces and then re- 
 
HALLUCINATIONS. 209 
 
 constructed into new ones. The patient collects all sorts 
 of useless objects — stones, pieces of wood and glass, nails, 
 shreds of paper, spoons, forks — fills his pockets with 
 them, and uses them for all sorts of foolish notions. The 
 walls, furniture, and windows are scratched or besmeared, 
 and drawings are made upon the floor or table. Plastic 
 works of art of a very doubtful value are made from chewed 
 pieces of bread or other soft material. The patient is con- 
 stantly entering into new plans, admiring in the highest 
 degree his own skill. At the same time he is usually 
 outside the hurlyburly, as it were, and perhaps remarks 
 ironically, when his follies are opposed, that he is allowed 
 to do anything because he is crazy. 
 
 This condition may last, without any feeling of ex- 
 haustion, for weeks, hardly interrupted for hours by rest- 
 less sleep or by a feebler frenzy for a few minutes when 
 exhaustion begins to be manifest. The flight of ideas is 
 often partly obliterated, but is still manifest by certain 
 phrases and words. The incoherence now increases to the 
 highest grades, because the already overfilled conscious- 
 ness very often receives constantly new impressions from 
 numerous hallucinations. These are very changeable, 
 chiefly of a pleasant character, but very often interspersed 
 with frightful ones. They are accompanied by a very 
 rapid change of mood. True central hallucinations, es- 
 pecially visual, develop. Series of shapes in gaudy attire 
 pass by ; they talk and sing in front of the window. The 
 vividness of these phenomena induces the patient to take 
 part in the play ; for some moments he speaks theatrically 
 in long periods, then listens, speaks again, then suddenly 
 laughs and jumps about, because the scene no longer in- 
 terests him. The vividness may be so great that an indi- 
 vidual who enters the room does not interrupt the dialogue, 
 but a role is assigned to him. Incoherence is, however, 
 generally manifested so that the spectator is unable to 
 follow the association of ideas. Hence the delusions, 
 which are chiefly nourished by the hallucinations, are 
 rather remarks en passant than firm opinions. The de- 
 14 
 
210 HANDBOOK OF INSANITY. 
 
 lusions are fleeting, and develop in great measure on the 
 basis of the increased self-esteem. Some patients declare 
 themselves princes or kings, but an internal systematiza- 
 tion of such fancies hardly ever takes place. Frightful 
 hallucinations and delusions also develop at times and 
 force angry affects into the foreground. Hallucinations of 
 taste, smell, and feeling are more often in a disagreeable 
 than in an agreeable association. They also return some- 
 what more constantly in the course of mania and then 
 lead to an increase of the refusal to take food, which is 
 already pronounced in the excited patient ; the fear of poi- 
 soning now makes its appearance. In women (and un- 
 doubtedly in connection with the approach of menstrua- 
 tion) hallucinations of the lower senses increase and cause 
 disagreeable sensations which lead to great excitement 
 and indeed to violent attacks. Other female patients 
 revel in maternal feelings, rock a pillow upon the arm, 
 lay it lovingly upon the breast, but soon remove it to 
 begin another occupation. 
 
 In severe mania the fleeting and confused character is 
 common to all hallucinations, illusions, and delusions, 
 whether of an agreeable or disagreeable nature. This be- 
 comes more marked the more violent the disease, and in 
 the highest grades they lose their distinctness to the ob- 
 server. The patient now rolls and twists upon the floor, 
 stamps his feet, claps his hands, beats time upon the floor, 
 blows violently. Indistinguishable syllables and sounds, 
 detached parts of sentences and outcries, are strung to- 
 gether in a disconnected series ; inarticulate cries and moans 
 are uttered with foaming mouth, and this is only stopped 
 by complete hoarseness. Irregular twitchings of the face 
 and limbs, gnashing of the teeth, stammering speech, and 
 detached irregular clonic convulsions show the implication 
 of the psychomotor centres, and such cases are usually at- 
 tended with high temperature and acceleration of the 
 pulse. 
 
 General sensibility seems to be diminished and but little 
 attention is paid to pain. The patient does not notice the 
 
DIMINISHED SENSIBILITY. 211 
 
 numerous slight injuries which result from his own vio- 
 lence ; even more serious wounds remain unnoticed, or the 
 patient tears off the bandages, and uses them in sport. 
 Another runs around naked in a cold room, or is exposed 
 for hours to the direct heat of the sun. This insensibility 
 is probably due to lack of attention. The patient must be 
 guarded, however, against all such injurious irritants, be- 
 cause they undoubtedly enter into the course of his ideas 
 and aggravate the disease. In temporary remissions of 
 mania we learn that he is able to distinguish heat and 
 cold and is susceptible to all changes in the condition of 
 his body ; occasionally he complains of headache and for 
 brief moments even has a distinct feeling that he is ill. 
 
 A peculiar phenomenon is the absence of the feeling of 
 satiety, although it is not very frequent at the height of 
 the disease. This is probably an expression of the very 
 extensive nutritive changes in the body, and the often in- 
 sufficient supply of food. Much more frequently no at- 
 tention is paid to the food offered, and occasionally there 
 is even a decided refusal of food, following hallucinations 
 of smell and taste. This is soon followed by catarrh of the 
 digestive tract, constituting a very grave symptom which 
 precedes an unfavorable course and death by exhaustion. 
 
 If fever appears — often in consequence of the numerous 
 wounds — the entire breakdown of the vital forces is usu- 
 ally very rapid. This condition is accompanied by a 
 rapid, irregular, or dicrotic pulse. 
 
 In general, however, the pulse is quite regular in severe 
 mania, and, like the temperature, is changed only by ac- 
 cidental complications. But in the severest cases, which 
 are attended by meningitic irritative symptoms, paralytic 
 symptoms occur at times, due probably to cerebral oedema. 
 
 As a general thing, there are fluctuations in the severity 
 of the symptoms. These fluctuations appear to be so 
 much less pronounced, the more violent and rapid the en- 
 tire course of the disease. 
 
 A fully developed case of mania, in which the symp- 
 toms are moderate in severity, usually remains at its 
 
212 HANDBOOK OF INSANITY. 
 
 height for several months, and at least six months elapse 
 before the disease has run its course. Cases have been 
 reported in which the attack ceased in a few days or even 
 hours ; but it must be remembered that an hysterical or epi- 
 leptic basis could often be demonstrated, or that they were 
 due to intoxications or febrile delirium. At all events we 
 must be very cautious in accepting an independent so-called 
 transitory mania. A duration longer than six mouths 
 does not exclude recovery, which may occur at the end of 
 a year, but involves great danger of passing into incura- 
 ble conditions of feeble-mindedness. 
 
 If the symptoms of mania still remain distinct the term 
 chronic mania is suitable in a measure, but its appropri- 
 ateness is lost more and more until finally we may only 
 speak of mental weakness in which violent excitement oc- 
 casionally develops, as the result of accidental external 
 causes. Finally, these are merged into quiet feeble-mind- 
 edness with a certain degree of irritability, into complete 
 dementia, or a loquacious, confused condition is still recog- 
 nizable as the remains of true mania. But the milder as 
 well as the severer forms offer the best chances of recovery 
 among all psychoses. In the severe forms, however, a 
 considerable proportion terminates in death from exhaus- 
 tion. 
 
 The termination in recovery passes through certain in- 
 tervening stages. In mania which has developed indepen- 
 dently, recovery is never sudden, but more quiet hours and 
 days alternate with periods of greater excitement. Sleep 
 improves and the impulse to movement subsides, while the 
 irregular association of ideas is still evident from incohe- 
 rent utterances or appears at least in the shape of great 
 loquacity. In milder cases a certain recognition of the 
 morbid nature of the disease is found in the attempt to ex- 
 cuse this or that irrational act, or tearful irritability 
 alternates with cheerful excitement. After severe mania 
 recovery occasionally begins with periods of exhaustion, 
 which may simulate rigid melancholia. If this condition is 
 prolonged, for example, for several months, prognostic 
 
TERMINATIONS. 213 
 
 importance attaches to the bodily weight. If this in- 
 creases only a little, it is probable that the disease will yet 
 terminate favorably, while a rapid increase rouses a fear 
 of termination in incurable dementia. In general, the 
 weight of the body should be carefully watched. In per- 
 manent and complete recovery there is almost always a 
 uniform advance of the mental and bodily functions, the 
 bodily weight follows the changes in the mental condition, 
 and hence, if the weight remains stationary for a long 
 time, it is to be feared that the morbid process has not yet 
 run its course. As a matter of course, accidental affec- 
 tions of internal organs must be taken into considera- 
 tion. If there is coincident tuberculosis we will not ex- 
 pect that the bodily nutrition will improve very greatly 
 with mental recovery. 
 
 It may here be noted that such febrile conditions, or 
 even febrile diseases like typhoid fever, may exercise a 
 favorable influence on the course of mania. 
 
 The subsidence of the condition of excitement occasion- 
 ally alternates with prolonged melancholic depression, and 
 this reminds us of the beginning of the disease. Cares 
 for the future and reproaches concerning the acts done 
 during the excited stage annoy the patient, and even mel- 
 ancholic delusions may appear. The mental activity is so 
 slight that such ideas form a justifiable basis for their 
 fears, but they are gradually lost with the increasing feel- 
 ing of strength. Now the bodily exhaustion is also felt 
 distinctly; former neuralgias, etc., sometimes return in 
 their accustomed manner. 
 
 Another transitional condition is a foolish, childish 
 loquacity with silly conduct which then passes slowly 
 into recovery. But all the transitions through dulness 
 or feeble-mindednees, which indicate the great exhaustion 
 of the nervous system, may be absent and, apart from 
 the frequent alternations, there may be a simple dimin- 
 ution and gradual subsidence of the symptoms. This is 
 favored most by a few good nights' sleep. 
 
 The permanent recognition of the morbid character of 
 
214 HANDBOOK OF INSANITY. 
 
 the disease is not always attended with a distinct remem- 
 brance of the events of the disease ; the greater the excite- 
 ment the greater is the loss of memory. A real hiatus 
 of memory is rare, but it is only in the mildest cases that 
 the memory of all details is accurate. 
 
 Mania appears to be a less frequent disease than mel- 
 ancholia. It is most common at the age of twenty to 
 twenty-five years. Younger individuals are also attacked, 
 but its frequency diminishes rapidly with advancing age, 
 so that old people rarely suffer. The only exception is the 
 puerperal condition. Many of these so-called puerperal 
 manias are attended by numerous hallucinations; they 
 are due to anaemia (from loss of blood) , and their course is 
 relatively favorable. In general, however, sex exerts 
 little influence on the frequency of mania. 
 
 Special mention should be made of the peculiar course 
 of mania in a constitutionally damaged brain, whose func- 
 tions were always below par or had become so in the 
 course of time. The disease is often not very severe, is 
 very prolonged, and a disputatious condition and attempts 
 at explanation of the excitement are very prominent. In 
 the milder grades the mixture of healthy and morbid ele- 
 ments is so pronounced that the laity and many physcians 
 deny the possibility of a morbid basis. But a rapid 
 though temporary increase to useless maniacal acts will 
 teach them differently, or careful observation reveals sud- 
 den brief periods of depression among the manifestations of 
 cheerful excitement. When such conditions are associated 
 with slight, often unrecognized feeble-mindedness, they 
 occasionally bring to mind the so-called moral insanity. 
 The tendency to interpret irrational acts in an apparently 
 rational manner must be regarded as an unfavorable sign 
 in an otherwise mild mania, because the psychoses which 
 develop in a feeble brain have a greater tendency to be 
 prolonged and to return. Nevertheless they do not, as a 
 general thing, pass into complete mental weakness, even 
 after prolonged duration, although the higher intellectual 
 faculties distinctly diminish. 
 
DESCRIPTION OF PLATE II. 
 
 MANIA. 
 
 The characteristic feature of the expression is the mobility and 
 variety, although cheerfulness predominates. Hence it is difficult 
 to retain details and our pictures show but few forms of expression. 
 The painful melancholic affect makes firm traces in the integument 
 of the face, while this is moved very fleetingly in maniacal excite- 
 ment, and it can only be comprehended when the play of physiog- 
 nomy is attributed to its causes in the brain itself. The disturb- 
 ances in the circulation and nutrition of the brain, especially of 
 its cortex, lead, through the excess of nervous activity, to unre- 
 strained forms of expression in which there is much that is super- 
 fluous. The two pictures of the young man therefore give only a 
 flint idea of his constant grimaces, which were continually inter- 
 rupted by laughing and chattering, by movements of the head and 
 body. The cheerful expression of the young girl permits a better 
 resolution into the movements of individual muscles. The palpe- 
 bral fissure becomes smaller from contraction of the orbicularis 
 palpebrarum, and at the same time the contraction of the levators 
 dravv s the upper lip upward ; the zygomatics open the mouth and 
 draw its angles upward and backward, so that the teeth are ex- 
 posed. The more movable skin of the old man permits the same 
 effects to be seen more distinctly in various folds ; hence we find 
 wrinkles of the lower lids and outer angles of the eyes and trans- 
 verse folds at the root of the nose, because the cheeks and upper 
 lip are raised. The transverse wrinkles on the forehead are acci- 
 dental ; in cheerful affects, as a rule, the forehead becomes smooth. 
 The brightness of the eye, which results from congestion and pres- 
 sure of the adjacent muscles, is very often an essential feature of 
 cheerful excitement. As is well known, the expression of greatest 
 joy approaches that of weeping and pain; the girl's folded hands 
 also show this relationship. 
 
 On account of the restlessness of the bodily movements I have 
 been unable to photograph anger and the more violent passions. 
 It must not be forgotten that the facial expression is materially 
 changed by the position and movement of the entire body. 
 
HANDBOOK OF INSANITY. 
 
 KIRCHHOFF. 
 
 Plate II. 
 
 % .^\N 
 
 ■■&*»■*' 
 
 ^ 
 
RESTRAINT AND HYPNOTICS. 215 
 
 Even the milder grades of mania should not be treated 
 in the family, because the necessary removal of external 
 irritants is there impossible, and the patient cannot be 
 kept constantly in bed. This is often attainable in a hos- 
 pital. When the motor excitement is pronounced, an asy- 
 lum is the only proper place for treatment. The possi- 
 bility of isolation is especially important, because when 
 employed in moderation, especially in combination with 
 frequent attempts to bring the patient again among others 
 and thus to give him opportunity for occupation, isola- 
 tion is the most important aid against maniacal excite- 
 ment. We can generally dispense with mechanical re- 
 straint, or at least get along with the milder measures, 
 such as the application of leather gloves. Permanent re- 
 straint is only justifiable in cases of severe surgical in- 
 juries and threatening exhaustion of the vital powers. A 
 well-fitted asylum is provided with gardens in which ex- 
 cited patients may walk undisturbed for a few hoars 
 every day. It is still better when the excitement can be 
 calmed by suitable occupation. In milder grades the 
 maniac often expends his excitement in garden and field 
 work, and such occupations, together with walks in the 
 open air, cannot be recommended too highly. 
 
 Prolonged baths are useful for sedation, and frequent 
 baths are also necessary for the care of the skin. The 
 room should be well warmed, the clothing should be 
 warm, SDugly fitting, and occasionally closed on the back 
 by special mechanical contrivances. Food must be fre- 
 quently offered if the patient forgets to eat and drink on 
 account of the excitement. 
 
 Among the hypnotics, choral hydrate with the addition 
 of morphine is very effective ; sulf onal may sometimes be 
 given unnoticed. The greater the excitement the more 
 important do hypodermic injections of morphine become. 
 They are especially useful in disquieting hallucinations, 
 particularly when repeated methodically. In the milder 
 grades of mania, when there is a sexual color to the symp- 
 toms, and in the protracted forms, sedation often follows 
 
216 HANDBOOK OF INSANITY. 
 
 the use of potassium bromide in large doses. Abstrac- 
 tion of blood is only permissible in symptoms of meningitic 
 or protracted cortical irritation. Even then, the results 
 are only temporary. Ansenria indicates the administra- 
 tion of suitable remedies, but the chief importance at- 
 taches to good nutrition. Strong cathartics should be 
 avoided and a movement from the bowels every second or 
 third day will suffice. 
 
 The methodical use of hypnotics often will secure per- 
 manent rest in bed, but we must avoid excessive doses in 
 recent cases, because termination in dementia is not infre- 
 quent. 
 
 The psychical treatment of mania cannot be laid down 
 in general rules, and requires an inborn talent more than 
 in other psychoses. Inappropriate commands and, to still a 
 greater extent, anger concerning foolish acts on the part 
 of the patient are injurious. A jest at the proper time 
 will sometimes prevent an outbreak of anger. As a 
 matter of course, such ruses are useless in violent mania. 
 
 As a general thing it it is advisable to delay removal 
 from the asylum until recovery is complete. At all events 
 travel and other distractions are injurious during conva- 
 lescence. If such convalescents come under the care of 
 the general practitioner, he must continue to keep awaj* 
 all external irritants and, when necessary, secure com- 
 plete quiet by the use of morphine. Under such circum- 
 stances it is an excellent remedy when given internally. 
 
 C. PERIODICAL FORMS. 
 
 Almost all psychoses exhibit periodical changes in their 
 course, especially during their development. These 
 changes are usually irregular and due to accidental exter- 
 nal causes. In discussing melancholia and mania, it was 
 found that the changes of reaction in the mood were much 
 more distinct when the mental constitution had been im- 
 paired, prior to the attack, by hereditary taint or acquired 
 disability. The influence of heredity is visible in a large 
 
PERIODICITY OF SYMPTOMS. 217 
 
 number of mental disorders. Certain groups are distin- 
 guished as periodical forms of insanity, because period- 
 icity is their most important clinical sign. In addition, 
 we find that the development and decline of the disease are 
 comparatively rapid. The morbid condition itself is very 
 variable and mingled with healthy elements. In the in- 
 tervals between the attacks the patients are not normal, 
 and a new attack may develop from the internal predis- 
 position, without external influences. As a matter of 
 course, all exciting causes may interfere with the regular 
 periodical course. When distinct attacks recur at long 
 irregular intervals, the difference between this invalid 
 basis and completely restored mental health after a psy- 
 chosis affecting a healthy brain is shown in various ways. 
 Such persons are easily exhausted, sensitive, and irritable. 
 On the other hand, there is a certain apathy to higher in- 
 terests or such interest is associated with stress upon the 
 personal relations. Great facility in the association of 
 ideas may permit bold series of thoughts, but they cannot 
 be worked out with patience. If no independence of reso- 
 lution is required, such an individual may long conceal his 
 morbid impulses under the influence of an habitual activity 
 which is regulated by others. In conversation, however, 
 we can detect peculiar turns of thought, and the entire 
 behavior is out of the common run. 
 
 In view of the fact that these individuals are not men- 
 tally healthy, we must regard complete psychoses, which 
 develop in them, as persisting during life, so that the 
 periodical changes in the symptoms develop during the 
 course of the disease. A main difference consists in the 
 fact that, in the one case, the changes occur close together 
 within the brief duration of the psychosis proper, while, 
 in the other case, they accompany the entire life. Certain 
 of these groups are characterized by an approximate regu- 
 larity as regards the duration and form of the symp- 
 toms. Irregular periodical changes are excluded from the 
 present discussion; the diseases which will now be de- 
 scribed belong almost exclusively within the boundaries 
 
218 HANDBOOK OF INSANITY. 
 
 of melancholia and of mania. They are composed of the 
 regular recurrence of melancholic or maniacal conditions, 
 or of the regular alternation of melancholia and mania. 
 The apparent caprice in their occurrence has only a clinical, 
 not an anatomical basis. The hereditary taint is common 
 to the other irregularly varying psychoses, and the in- 
 validism of the entire mental constitution is found in cer- 
 tain other periodical affections associated with invalidism 
 of the entire nervous constitution, such as neurasthenic, 
 epileptic, and hysterical conditions. The latter occupy a 
 special position on account of the distinct appearance of 
 many nervous symptoms which have an organic basis. 
 It is important to know that the first attack of periodical 
 insanity is often due to an external exciting cause. Then 
 in the following attacks the definitive clinical history is 
 gradally evolved out of the general mass of symptoms. 
 
 Periodical Melancholia. 
 
 It occurs more frequently in private practice than in 
 asylums, because it is usually mild, and consists mainly 
 of the distressing consciousness of inhibited thought and 
 volition, or of inhibited feelings. This restriction is con- 
 fined mainly to the course of ideas, and there is an absence 
 of hallucinations ; the anxious reaction of feeling and the 
 depressed mood are not attempts at explanation, but are the 
 original symptoms of a true melancholia. Consciousness 
 is little impaired, but its contents are often narrowed by 
 imperative conceptions. 
 
 Typical periodical melancholia begins rapidly after a 
 brief initial depression. The pronounced melancholia 
 then lasts either for a comparatively short time (a few 
 weeks) or for one or more years, the latter being the com- 
 mon form. Consciousness is then clear, and the memor} r 
 of events is subsequently complete. Hallucinations are 
 rare and usually present only at the start. During the 
 entire period, however, certain delusions often persist un- 
 changed and are accompanied by anxious feelings of vary- 
 
REPETITIONS OF SYMPTOMS. 219 
 
 ing intensity. The character of the ideas, the tendency 
 to suicide, and the other symptoms are the same as in ordi- 
 nary melancholia. Then, without any apparent previous 
 change, the terror and delusions are very often lost sud- 
 denly. The patient, who yesterday was very ill, meets us 
 to-day with cheerful mien, and declares himself perfectly 
 healthy. In fact, physical recovery now takes place very 
 rapidly, and the change in the bodily weight is especially 
 striking. 
 
 The first attack of a subsequent periodical series might 
 be suspected from the rapid onset and subsidence, if we 
 knew the patient's previous mental constitution. This 
 would be substantiated if the feeling of illness often was 
 accompanied by attempts at explanation, as, for example, 
 that the patient had committed a crime, and, in his. opin- 
 ion, was only disquieted by justifiable remorse. 
 
 When the attack is over, no mental weakness is notice- 
 able as regards the patient's occupation, but there is usu- 
 ally a slight ethical defect, perhaps shown only in the 
 prominence of egoistic feelings and the lack of sympathy 
 for others. In many cases, however, they are less inde- 
 pendent and more irritable when unusual demands are 
 made upon them than before the first attack. This gen- 
 erally occurs in the twenties, rarely at a later period. Ten 
 years or more, as a rule, elapse before the second attack. 
 Then a second attack occurs suddenly, similar in all details 
 to the previous one. Thus, one patient was dominated, 
 in three attacks, by the delusion that she had choked her 
 mother to death years before ; even the same movements, 
 refusal to take food, moaning, and crying were repeated in 
 exactly the same manner. 
 
 The rare brief periodical attacks exhibit a few devia- 
 tions. The symptoms of inhibition predominate, and 
 almost stuporous signs are found. Violent fear with 
 occasional outbreaks, auditory hallucinations, usually of a 
 religious character, sometimes vivid visual and olfactory 
 hallucinations torment the patient, who is apparently rigid. 
 Afterward he proves that he was cognizant of things going 
 
220 HANDBOOK OF INSANITY. 
 
 on about him. At the end of a few weeks the condition 
 ceases almost suddenly ; the patient states that he feels as 
 if a veil or pressure were removed, and that he feels well. 
 There is often refusal to take food, so that the weight of 
 the body may diminish very markedly in a few weeks. 
 Then follows the free period, usually lasting several 
 months, rarely more than a year, as in one patient under 
 my observation. At first his attacks were very much 
 alike, but then the intervals became shorter and to the 
 former symptoms of pure melancholia were added delu- 
 sions that had not been noticed before, associated with 
 auditory hallucinations and fear of poisoning. Finally 
 he committed suicide. During the free intervals he rec- 
 ognized the morbid nature of his illness. 
 
 The rare cases of periodical melancholia are increased 
 somewhat in number by a few cases in which the pre- 
 dominant affect is accompanied by impulsive centrally 
 produced movements ; in addition there are numerous hal- 
 lucinations. If the remembrance of the attack is very in- 
 distinct, we must always think of the possibility of an 
 epileptic dream condition. 
 
 As a rule, the treatment of a periodical attack requires 
 admission to an asylum, where the measures to be adopted 
 ^re the same as in every melancholia. 
 
 Periodical Mania. 
 
 Periodical mania is much more frequent than periodical 
 melancholia, particularly in females. It is sometimes 
 synchronous with menstruation, bat more frequently this 
 exerts little influence. Some observers believe that the 
 attacks, even in males, attend periodical increase of sexual 
 desire. Melancholic prodromata are not constant. They 
 are often very slight, but in severe and prolonged periodical 
 mania, prodromal severe melancholic symptoms are con- 
 stant. The milder cases are more frequent. In them the 
 maniacal excitement begins suddenly, remains at its height 
 for several weeks, and then subsides with equal abruptness. 
 
PERIODICAL MANIA. 221 
 
 At the height of the disease the mixture of healthy and 
 morbid elements is especially distinct, and the patients 
 are constantly attempting to justify their irrational speech 
 and acts in long harangues. If the necessary dialectic 
 skill is wanting, it is replaced by brief remarks, such as 
 " that it is natural to get violent and excited, if one is con- 
 stantly irritated," etc. Hence, these milder cases often 
 create the impression of moral depravity because the im- 
 pulse to movement and the inner restlessness constantly 
 give rise to deeds which are contrary to morals. The 
 perfectly proper behavior after the attack shows the mor- 
 bid basis of the former condition so much more distinctly. 
 In the quiet intervals the patients are usually silent con- 
 cerning the excited stage, and answer evasively, or attri- 
 bute it to supposed irritation in the surroundings. The- 
 intervals rarely last more than a few weeks or months. 
 These mild attacks often recur during the patient's entire 
 life, without any external provocation. The patients 
 always exhibit distinct evidences of mental invalidism; 
 in the intervals they are irritable and often apathetic to 
 outside interests. With advancing years the boundaries 
 of the attacks may be somewhat obliterated and the excite- 
 ment grows less ; there is distinct diminution of mental 
 ability, but dementia does not develop. 
 
 In another series of cases the flight of ideas is more 
 pronounced during the attack; insomnia, motor restless- 
 ness, and hallucinations occur in the same way as in a 
 single attack of violent mania. The combination with 
 angry passions is verj r common. But even in the highest 
 grades of excitement the patient very often remains ra- 
 tional, in a way, and the profound disturbances of con- 
 sciousness with subsequent amnesia, which occur in the 
 severest grades of mania, are very rare. The mixture of 
 healthy and morbid elements is likewise characteristic of 
 this form of disease. As a rule, the severe forms of peri- 
 odical mania also develop and subside more rapidly than 
 single attacks, but diagnostic doubt can only be removed 
 after the repetition of the attack. The similarity between 
 
222 HANDBOOK OF INSANITY. 
 
 the different attacks has even been spoken of as photo- 
 graphic. In some cases there is an exact repetition of va- 
 rious physical signs (vasomotor paralyses, unilateral head- 
 ache, increased secretion of urine or perspiration, etc.) 
 and even the tone of the voice, the facial expression, the 
 dancing and jumping are repeated in exactly the same 
 manner. 
 
 The same delusions and hallucinations with very simi- 
 lar contents also make their appearance. In an asylum, 
 in which the outbreak of the new attack is not obliterated 
 by external influences, slight changes in clothing or the 
 constantly repeated desire for their discharge, usually in- 
 dicate the beginning of an attack with such certainty that 
 the attendant is accustomed to report that " so and so is 
 about to have another attack because he again does this or 
 that." 
 
 The duration of each attack is approximately the same 
 in the same individual, but this is not true of the inter- 
 paroxysmal periods. In the severe cases a certain degree 
 of mental weakness develops, in the intervals, with ad- 
 vancing years. 
 
 The prognosis as regards complete recovery is unfa- 
 vorable, but the individual attack will very probably run 
 a favorable course without passing into a chronic form. 
 In the most favorable cases the attacks remain absent for 
 years. The termination in dementia is very rare. 
 
 The treatment must be confined to the individual at- 
 tacks. It sometimes appears as if attempts to abort an 
 attack result in severer outbreaks at a later period. Mor- 
 phine and potassium bromide are chiefly recommended, 
 and are undoubtedly useful in moderate cases. If potas- 
 sium bromide is given in large doses for a few days before 
 the threatening outbreak (beginning with 6.0 gm. daily 
 and increasing by 2.0 gm. daily until 12-14.0 are reached) 
 the prodromata alone may be developed, and at all events 
 the excited stage, if it does appear, is much milder, 
 although it is very often decidedly prolonged. In some 
 cases there was no doubt that the duration of the free in- 
 
EFFECT OF BROMIDES. 223 
 
 tervals was diminished so that the value of the drug was 
 problematical. One patient presented tottering gait and 
 thick speech after large doses of the bromide, but during the 
 free interval she begged that the drug be given to her 
 during an attack, because she felt that the excitement was 
 lessened thereby, and it was then unnecessary to isolate 
 her. 
 
 Even during the periods of excitement the bromide may 
 be continued, although in smaller doses. In one case 
 which formerly ran its course, without bromide, as an 
 angry mania without hallucinations, the attacks after the 
 administration of the drug became much shorter and 
 were attended with numerous terrifying hallucinations of 
 sight, hearing, and smell, which resembled so-called hallu- 
 cinatory confusion. This peculiar chemical reaction of the 
 brain had no effect -upon the subsequent free interval. 
 Then for a time bromide was discontinued, and severe out- 
 breaks were aborted by sulfonal. After the bromide was 
 again administered, there followed a brief attack, similar 
 to the one described above. Other observers have re- 
 ported more favorable results from the use of the bromides. 
 Periodical manias rarely are treated at home. In asylums 
 their violence is greatly ameliorated by isolation, and 
 sometimes this is effected in a simple manner by pro- 
 tracted rest in bed. Periodical manias are probably the 
 most suitable field for the application of methodical 
 chemical restraint, but even here narcotics are not cura- 
 tive remedies. Cannabis indica is particularly praised in 
 this condition. In other respects the treatment is the 
 same as that of ordinary mania. 
 
 Circular Insanity. 
 
 Those cases of periodical mania in which there is a pro- 
 longed and distinct melancholic prodromal stage, approxi- 
 mate circular insanity. The latter consists essentially of 
 an alternation of the maniacal and melancholic conditions, 
 which either follow one another immediately or are sepa- 
 rated by an interval. If a sharper distinction is to be 
 
224 HANDBOOK OF INSANITY. 
 
 made from the above-mentioned form of periodical mania, 
 then circular insanity must be regarded as dependent upon 
 the existence of a perfectly free interval and not merely 
 of the apparent quiet of a transition. In the sequence of 
 mania and melancholia the occurrence of a free interval 
 would be of less diagnostic importance because this 
 sequence occurs only in circular insanity. Conditions of 
 exhaustion with a tinge of melancholy are comparatively 
 rare after mania. As a matter of fact, every possible 
 form of combination between melancholia, mania, and 
 free intervals is observed. Cases in which a free interval 
 does not develop between the two antagonistic conditions 
 are called alternating insanity; but the generic term, 
 circular insanity, also applies to them. 
 
 Special attention must be paid to the distinction be- 
 tween a true and an apparent interval. We will suppose a 
 patient in the period of maniacal excitement ; after the ex- 
 citement has reached its height it begins to diminish. 
 He becomes less violent in his speech and acts, but his 
 former personality has not returned. He sees everything 
 in a bright light, makes all sorts of plans, interferes in 
 matters which do not concern him. It is evident to every 
 unbiassed observer that he is not yet well. Then the 
 excitement diminishes still further. A condition of rest 
 and external equilibrium follows, but is very brief. The 
 first signs of returning trouble appear, the patient seeks 
 solitude, and soon the melancholic condition is distinct. 
 
 Now let us consider a true interval. A patient is in 
 the period of melancholic depression but has begun to 
 resume his accustomed occupations. He begins to regard 
 himself as well, and judges correctly his previous morbid 
 and his present condition. His complete personality is 
 restored. The longer this condition lasts (and it may 
 last several months or more) the more distinctly is it a 
 true interval. This interpretation is not changed, even 
 if the former personality exhibited the signs of mental in- 
 validism, because this is generally the case in circular 
 insanity. 
 
APPARENT ECCENTRICITY. 225 
 
 We will now give the clinical history of true circular 
 insanity, with or without intervals, devoting our atten- 
 tion first to the milder forms because they are more fre- 
 quent and come under the notice of the general practitioner. 
 We often meet with individuals who are not regarded as 
 insane, but who pass their entire lives in a periodical alter- 
 nation of moderate excitement and depression. In the 
 excited period they appear to exhibit merely a slight 
 change of character and at times an unusual activity. 
 They pay numerous visits, write unnecessary letters to 
 mere acquaintances, sleep little, make trips, are exces- 
 sively cheerful on every occasion. Although their acts 
 are done in a disorderly way and their conversation ex- 
 hibits something of an incoherent character, their real 
 condition is not noticed by persons who have not known 
 them at an earlier period, although its morbid character 
 will not escape the careful observer and is sometimes even 
 diagnosed correctly by members of the family. 
 
 This morbid condition becomes more distinct when, 
 after the excitement has lasted a longer or shorter time, 
 it passes gradually or suddenly into the opposite condition, 
 so that we seem to be dealing with two different individ- 
 uals. The patient ceases to make visits, becomes reticent, 
 seeks solitude, complains of general malaise, precordial 
 fear, and loss of appetite ; he is sad and anxious without 
 reason. He has a distinct feeling of his condition and is 
 depressed on that account. This may lead to refusal to 
 take food, and, in extreme grades, he locks himself in his 
 room for several months, without attracting notable atten- 
 tion on the part of those around him. Other individuals 
 see him only from time to time and have no opportunity 
 of observing him while he is locked in his room. Hence 
 they have no suspicion with regard to his peculiar condi- 
 tion for a number of months, and when he again makes 
 his appearance — when the period of excitement again be- 
 gins — he appears to be the same person as before. He 
 may be regarded as an eccentric character, of feverish 
 activity, but his morbid condition can only be determined 
 15 
 
226 HANDBOOK OF INSANITY. 
 
 by accurate observation of the alternation between excite- 
 ment and depression. 
 
 This mild grade of circular insanity runs its course 
 almost unnoticed, and yet it alone serves to explain the 
 peculiarities of certain individuals. In many of these 
 cases the first indications are observed in childhood. For 
 long periods such children exhibit unfounded depression 
 and excessive riotousness, which is attributed generally to 
 moral defects or improper education. Years elapse before 
 the distinct development of the disease. Circular insanity 
 may be regarded as an intensification of the change of 
 mood which occurs with a sort of regularity and without ex- 
 ternal cause in individuals with an hereditary taint. This 
 interpretation is not shaken by the fact that outbreaks 
 of the disease occur chiefly in the developmental years 
 and at the extinction of sexual activity. For this reason 
 the larger proportion of patients belongs to the female 
 sex. 
 
 Although there are many transitions between this half 
 concealed form and the distinct circular forms, we will 
 now consider only one in which all the symptoms are fully 
 developed. It may begin suddenly or very slowly, but 
 the circle usually begins in the same way in the same pa- 
 tient. The circular course is rarely distinct from the start, 
 and its development is often preceded for years by fre- 
 quent attacks of single or periodical melancholia or mania. 
 The variability of the psychoses which are based on an 
 hereditary taint appears to require a certain length of time 
 before definitive conditions develop. 
 
 Let us assume a case in which a severe melancholic 
 condition has developed rapidly after an apparent or real 
 interval. In order to give all the different possibilities, 
 we would have to describe again the symptoms of melan- 
 cholia in general. It will be sufficient to emphasize a few 
 symptoms. A striking phenomenon is the distinct mimic 
 expression, and we are justified in attributing this to the 
 fact that, as a rule, the most profound disturbance of con- 
 sciousness does not occur in the melancholic stage of cir- 
 
STUPOR. 227 
 
 cular insanity. The feeling of illness is generally very 
 pronounced, and makes the patient extremely unhappy; 
 when he is still communicative, he often expresses great 
 fear of the oncoming attack of excitement which he fore- 
 sees. Definite delusions are rarely observed. In more 
 marked stupor the face assumes a mask-like expression, 
 and changes of expression are accomplished by slow con- 
 tractions of the muscles. Furrows and wrinkles are lit- 
 erally graven into the skin. More rarely the expression 
 of spiritual pain is associated with that of purely physical 
 headache; then we probably find rush of blood to the 
 head, ringing in the ears, a feeling of pressure in the 
 head. Sleep is poor, despite the apparent rest while in 
 bed; bad dreams. torment the patient. The weight of the 
 body falls considerably, but after a time the body becomes 
 accustomed, in a measure, to the morbid condition, and 
 there is a slow increase in weight. 
 
 Let us now assume the special case of a female patient 
 who lies in bed in rigid stupor. The condition lasts sev- 
 eral weeks ; the menstruation, which was due at this time, 
 may remain absent or it may have no effect upon the con- 
 dition; more rarely it produces a change. On careful 
 observation slight bodily changes are found to appear. 
 Sometimes the patient takes a deep breath, lies upon the 
 other side of the body, the lips move occasionally, and a 
 strange expression flashes across the face. At the end 
 of a few hours she raises herself in bed and sighs ; the 
 pulse is not accelerated, occasionally somewhat fuller 
 than before. As the patient soon lies down again, a care- 
 less observer may believe that the condition is the same 
 as before. But the experienced observer recognizes the 
 slight forerunners of the storm. It breaks forth suddenly 
 in a night, in a few hours, even a few minutes. Now the 
 pillows and bedding begin to fly, loud scolding opens the 
 scene, and a true maniacal frenzy begins. It is unneces- 
 sary to describe this further, but one important sign must 
 be mentioned. In the majority of cases consciousness is 
 comparatively well maintained. 
 
228 HANDBOOK OF INSANITY. 
 
 The peculiar lack of correspondence between a patient's 
 consciousness and his really maniacal actions often makes 
 him a veritable torment to those around him, especially 
 when the maniacal excitement has somewhat lessened. 
 The patient is able to carry out his desires with great 
 shrewdness, and to make thorough use of every opportu- 
 nity in this direction. Hence, he is very fertile in devis- 
 ing measures to deceive his attendants, to steal the property 
 of others (often entirely useless articles) , and to carry out 
 all possible useless follies. In the asylum he soon rules his 
 fellow-patients, fleeces them whenever possible. This is 
 made easier by his conversational talent. Such patients 
 become so much more troublesome because, on account of 
 their constant affirmation of their clear mind and fine cul- 
 ture, they are often transferred to better wards, where they 
 are a source of great annoyance to more rational patients. 
 They are filthy in the extreme and carry the dirtiest articles 
 in their pockets ; they flare up at every remonstrance, and 
 attempt, by means of loquacity, to conceal their faults from 
 others. 
 
 A very characteristic feature during the excitement is 
 the mimic facial expression and the general bearing, which 
 acquire a stereotyped appearance in the course of time. 
 As a matter of course, the expression is not constant but 
 changes frequently. But the repetition of the same range 
 of feelings is exhibited in every fresh attack by the same 
 gestures, speech, and expression. Occasionally there is a 
 temporary tearful affect, more rarely a true melancholic 
 depression of brief duration. 
 
 The attack almost always subsides slowly. Opinions 
 differ as to whether the circle begins with melancholia or 
 mania. The majority are agreed that melancholia opens 
 the scene, so that we are perhaps justified in assuming 
 that the melancholic stage has been overlooked in the other 
 mild cases. 
 
 It has often been maintained that circular insanity is 
 always unattended with hallucinations, but this is not 
 always true. Perhaps they appear only in the severest. 
 
HANDBOOK OF INSANITY. 
 
 KIRCHHOFF. 
 
 Plate III. 
 
 :_._J 
 
DESCRIPTION OF PLATE III. 
 
 PERIODICAL FORMS. 
 
 The rare form of periodical melancholia generally presents no 
 changes in expression from that found in simple melancholia. The 
 two upper pictures represent an impure form of periodical melan- 
 cholia, because it is irregularly interrupted by conditions of violent 
 excitement ; on the whole, however, the periodical change is con- 
 fined to the melancholic depression. The first picture illustrates, 
 in part, the remarks made concerning the plate on melancholia. 
 
 The second picture exhibits a peculiar expression which has 
 nothing to do with melancholia. It was due only in part to the 
 depressed mood of the patient, but chiefly to the bright sunlight. 
 The wrinkling of the forehead and eyebrows, the folds on the skin 
 of the nose, the drawing upward of the lower lids, cheeks, and 
 upper lip serve to diminish the palpebral opening and prevent the 
 entrance of light. The same play of features was repeated, how- 
 ever, in a darker place, and the patient's conversation showed that 
 she experienced feelings of disgust and repulsion, associated with 
 the melancholic mood. 
 
 Periodical mania may run through the entire gamut of cheerful 
 expressions, passing into rage and the most immoderate affects, 
 which, in part, cannot be photographed. There is even difficulty 
 in milder forms of excitement on account of the bodily move- 
 ments. For example, in the first of the two lower pictures the 
 woman seats herself in order to be photographed ; hence the bold 
 draping of the shawl and the comfortable position of the hands. 
 The firmly closed mouth, together with the lightly wrinkled eye- 
 brows, which are drawn downward, give an expression of decision 
 with a slight admixture of mocking spite resulting from the slight 
 elevation of the mouth on one side, where the naso-labial fold is 
 more distinct. 
 
 The second picture gives a cheerful and cunning expression, 
 owing to the smooth forehead, the elevation of one eyebrow, and the 
 raised angles of the mouth with pronounced naso-labial folds. 
 
HANDBOOK OF INSANITY. 
 
 KIRCHHOFF. 
 
 Plate IV. 
 
DESCRIPTION OF PLATE IV. 
 
 PERIODICAL FORMS. 
 
 In circular insanity we furnish pictures merely of the antago- 
 nistic maniacal and melancholic conditions, as the expression in 
 the latter is very similar to that in the free intervals. 
 
 The pictures show this antagonism very distinctly. As the 
 wrinkles of the melancholic period, which persist for a long time, 
 are permanently fixed, the expression of excitement is somewhat 
 obliterated. Upon the forehead of the melancholic woman are 
 two semicircular furrows above the outer parts of the eyebrows. 
 During the melancholic stage this patient suffered from violent 
 headache, and the frontal muscle exhibited frequent brief con- 
 tractions in its outer parts above these furrows. The spasmodic 
 muscular contraction was confined to the outer parts because the 
 median portion is held more firmly in position, and hence the 
 peculiar semicircular furrows were produced. 
 
 As a matter of course there was a very active play of features 
 during the period of excitement, and the pictures can therefore 
 only be regarded as accidental forms of expression. Both patients 
 spoke constantly and made grimaces. 
 
TERMINATIONS. 229 
 
 cases, especially when the change coincides with the 
 period of menstruation. 
 
 The duration of the different periods varies greatly in 
 different individuals, but they are more uniform in the 
 same patient. In very rare cases a period runs its course 
 in a few days, usually several weeks elapse, occasionally 
 even months and years. In general the melancholic stage 
 is longer than the maniacal stage, and the intervals are 
 shorter than either. The greatest variability is shown in 
 the duration of the intervals, which are so much more 
 marked the more pronounced the excitement has been. 
 
 The termination in true dementia is not observed. The 
 intelligence remains at the same level after the disease 
 has lasted twenty or thirty years or even longer. The 
 patients rarely exhibit premature mental or physical decay. 
 
 As a general thing the disease grows weaker in old age, 
 both as regards the duration and severity of the attacks. 
 If the intervals are also shortened and mixed a form of 
 disease may finally be produced, in which only the fre- 
 quent and rapid, but brief, changes of mood furnish indi- 
 cations of the former course. 
 
 The prognosis is unfavorable, and real recovery is never 
 observed. Even temporary amelioration of the symptoms 
 is not a favorable sign, because they maj T soon be replaced 
 by more severe ones. In very rare cases the climacteric 
 is a turning-point, from which a decided improvement 
 starts. 
 
 Although not a few of these patients suffer in old age 
 from apoplectic attacks, no anatomical basis of the disease 
 has been discovered. 
 
 We can merely attempt to ameliorate the attacks by 
 means of treatment and cannot expect to produce recovery. 
 The chief indication is the removal of external injurious 
 influences, and this can best be done in an asylum. It is 
 true that the asylum authorities are not inclined to retain 
 these patients, especially the milder cases, because they 
 are very troublesome, but the family suffers extremely 
 and the patients themselves pass through an attack more 
 
230 HANDBOOK OF INSANITY. 
 
 easily in an asylum. When the free intervals are pro- 
 longed, they may be utilized for temporary dismissal from 
 the institution. 
 
 Drugs are most effective in hastening the subsidence of 
 excitement, while they effect little in the beginning of the 
 melancholic and maniacal stages. Potassium bromide, 
 as well as opium and morphine, are useless. The treat- 
 ment must be conducted according to the general princi- 
 ples which have already been discussed in various places. 
 Good effects are sometimes obtained from keeping the 
 patient constantly in bed. 
 
 D. PARANOIA. 
 
 In the groups of mental disorders which are grouped 
 under the term paranoia, the most important sign — apart 
 from the symptoms of melancholia and mania which may 
 recur in it — is the systematization of delusions. In mel- 
 ancholia and mania the delusions have somewhat of a 
 fleeting character, and the association of the concepts is 
 not arranged according to a definite plan. This takes 
 place in paranoia. The manifold combination of the other 
 symptoms of mental disorder with the so-called fixed ideas 
 gives rise to numerous clinical pictures. There is still a 
 great lack of harmony concerning their classification, but 
 certain sub-groups are readily distinguished. These are 
 " wahnsinn" and " verruecktheit." * Then follows a third 
 group in which certain terminal states, on the one hand of 
 melancholia and mania, on the other hand of wahnsinn 
 and verruecktheit, coincide, but whose clinical pictures 
 contain no signs which point to the different origins. In 
 this latter group the term paranoia possesses only a sec- 
 ondary significance, and in it must also be included the 
 terminal forms of certain conditions which were recog- 
 nizable originally as verruecktheit, because they, with all 
 others, have the common feature of confusion, without 
 passing into complete mental imbecility or dementia. 
 
 * These terms have no exact equivalent in English. They corre- 
 spond, in the main, to what was formerly called monomania. 
 
WAHNSINN. 231 
 
 1. Wahnsinn. 
 
 " Wahnsinn " is a mental disorder in which delusions 
 and hallucinations are rapidly combined into a composite 
 whole, intimately associated with strong affects. In ver- 
 ruecktheit the affects are only accidental elements of the 
 clinical history and disappear rapidly. During completely 
 developed wahnsinn the affects are constantly present as 
 soon as the delusions make their appearance. Hence it ex- 
 hibits irregular changes in its appearance which are absent 
 to such a marked extent in verruecktheit. It is a more acute 
 form of paranoia which, on the whole, runs a more rapid 
 course and may offer more favorable prospects of recovery. 
 When paranoia occurs in persons with a healthy brain it, 
 appears more frequently as wahnsinn, while verruecktheit 
 rouses the suspicion of previous mental invalidism. 
 
 As a matter of course the description must distinguish 
 between the occurrence of depressed and excited affects, 
 although this separation is often wanting in the individual 
 case. The development of wahnsinn with depressed affect 
 has great similarity to melancholia, but the significance 
 of the delusions is greater, even at the beginning of the 
 disease. They refer in a definite manner to the patient's 
 person and often to conditions of his own body. The rela- 
 tions to society are then drawn very rapidly into the circle 
 of these delusions and are brought into relation to anxious 
 feelings and sensations. 
 
 We will describe the more violent symptoms of such 
 cases. After several weeks of insomnia and irritable 
 mood, in which the patients draw surprising and disqui- 
 eting conclusions from harmless perceptions, and concern- 
 ing whose falsity they do not allow themselves to be con- 
 vinced, a general restlessness makes its appearance, 
 attended with considerable disturbance of consciousness. 
 No connection between the anxious concepts can yet be 
 recognized in the confused remarks. But in a few days 
 greater outward calm is manifested, and we can obtain 
 correct information from the patient concerning certain 
 
232 HANDBOOK OF INSANITY. 
 
 things. Anxious notions link themselves to the still in- 
 definite hallucinations, such as tapping at the window, 
 distant noises, or there may be definite shapes and voices. 
 But the feeling of derogation, of persecution by enemies 
 forces itself rapidly into the foreground of his notions; 
 around this fixed idea many others shoot up, all taking 
 their material from the contents of consciousness, so that 
 a composite whole is again formed. The excited anxious 
 mood does not permit the formation of such a finely sys- 
 tematized plan as in verruecktheit, but all thoughts run 
 together to one point. A living personality remains the 
 central point of the morbid mental life ; fear captures all 
 delusions and does not permit their development into a 
 firm structure in such a quiet reasoning way as in ver- 
 ruecktheit, but it does not prevent the selection and com- 
 bination of individual notions according to a continuous 
 thread ; the melancholic patient, on the other hand, simply 
 abandons himself to his anxious notions as a guilty 
 sacrifice. 
 
 Although the presence of hallucinations cannot be dem- 
 onstrated in all cases, this is often possible, and hence, in 
 view of the similarity of the other manifestations, their 
 constant occurrence is very probable. All these part-phe- 
 nomena of the disease add to the peculiar contents of the 
 delusions; their intimate combination also entails the 
 falsification of the patient's perceptions. His relatives 
 appear strange; they only retain their apparent loving 
 conduct in order to conceal their hatred and evil designs. 
 Their conduct is outrageous because he, the patient, has 
 done nothing wrong. This undeserved misfortune is an 
 undeniable fact ; not alone his family persecutes him, but 
 on the street every one looks at him. In the asylum the 
 patients, attendants, and physicians unite in saying 
 vulgar things, in satirical remarks and curses (which are 
 based on hallucinations) . The element of feeling in the 
 struggle against such influences is especially distinct in 
 females. Not alone at the beginning of puberty, but also 
 at other periods of life, women exhibit a violent feeling 
 
DELUSIONS OF PEKSECUTION. 233 
 
 with regard to the noxious influences. Their fear is not 
 a passive one, which yields to fate, nor does it suddenly 
 lead to violence, but it is accompanied by feelings of pain- 
 ful, unjustified suffering and by the tendency to permanent 
 resistance and struggle. These patients are apt to become 
 violent because all influences revolve around their own 
 person. They are always right and do not listen to any 
 explanation of falsely interpreted remarks and noises, etc. 
 (as is done in verruecktheit) , but they speak and gesticu- 
 late constantly, and often compel us to restrain them. 
 This is naturally a new proof to their minds, and demon- 
 strates the brutality of their assumed persecutors. The 
 highest grades of fear and terrified resistance are mani- 
 fested, and such an anxious excited mood, accompanied 
 by definite, systematized delusions and hallucinations, 
 may last for weeks, months, or years, with brief interrup- 
 tions. The latter are not periods of exhaustion, as in an 
 anxious excited melancholia, but are periodical changes 
 whose nature cannot always be ascertained. It is a very 
 important fact in the consideration of wahnsinn that sleep 
 and appetite remain normal. The good sleep is an impor- 
 tant sign in several respects. It is unfavorable because, 
 in doubtful cases, it indicates that firm delusions are pres- 
 ent, and hence the mental disorder offers less chance of 
 recovery. The complete rest of the body during sleep 
 permits irritative conditions in the internal organs to 
 moderate, and the nutrition of the body remains good, 
 but the patient awakes in the morning with the same 
 painfully excited demeanor and is tortured by the same 
 ideas of persecution. Hence he talks a good deal during 
 the day, curses and threatens. In other respects his man- 
 ner is rational. His clothes are carefully handled, he is 
 cleanly and acts properly at the table ; indeed, the move- 
 ments are rarely involuntary, but are held in check. The 
 patient occasionally threatens suicide but rarely carries 
 out his threat; affects are present, but they can be re- 
 strained. On special occasions in an asylum, such as 
 social festivities, he may control himself sufficiently to 
 
234 HANDBOOK OF INSANITY. 
 
 take part, but soon afterward he again abandons himself 
 to his delusions, which receive a new impetus from corre- 
 sponding hallucinations. We may also find in the course 
 of the disease periods of external calm which remind us 
 occasionally of a periodical course, but the delusions re- 
 main distinct and thus distinguish the condition from 
 periodical insanity. 
 
 Permanent delusions, which are associated with violent 
 affect, and usually with an exalted feeling, are chiefly 
 religious, especially as they are almost always nourished 
 by hallucinations. Here we find the inspired prophets 
 who proclaim their divine mission in a loud voice. The 
 affect is so pronounced that, even when confined to his 
 room, the patient cannot restrain his flow of speech. These 
 patients are not so careful with regard to their personal 
 appearance, and they can rarely check themselves vol- 
 untarily. Indeed, the highest grades of ecstasy may 
 develop, with apparent rigid inhibition of all movements. 
 The patient sees heavenly visions, Christ, the Virgin 
 Mary, who call upon him to become the apostle, pope, or 
 bride of Christ. These are often mingled with sexual 
 sensations, feelings of the highest bliss and delight. 
 During this ecstasy, which does not, as a rule, last more 
 than a few days, the patient is almost completely insensible 
 to his surroundings. With widely opened eyes he lies mo- 
 tionless on the floor or upon his knees. After the gradual 
 awaking from this condition there is usually a tolerably 
 complete memory of the visionary perceptions, but at first 
 there is no recognition of the diseased element. Their 
 experiences are regarded as true revelations and are often 
 amplified by further similar hallucinations. For some 
 time the patient cannot find his bearings and occasionally 
 does all sorts of queer acts, gesticulates, cries out aloud, 
 or strips off his clothing. 
 
 In other cases the ecstasy is not so profound and pro- 
 tracted. The patient is impelled to preach the corruption 
 of the world, to assert himself to be the Saviour, every- 
 thing being uttered with great pathos. This condition 
 
TERMINATIONS. 235 
 
 acquires great dramatic power when the supposed message 
 from heaven is associated with the notion of a struggle 
 against the powers of evil. In the course of time these 
 patients learn to control themselves somewhat, and for a 
 number of days may even recognize that they have acted 
 under a delusion. 
 
 This is the way in which recovery slowly takes place. 
 But a subsidence of the symptoms must not rouse inordi- 
 nate hopes, inasmuch as wahnsinn is one of the less 
 favorable forms of insanity and terminates quite often in 
 confusion. As a general thing, wahnsinn with exalted 
 mood runs a more rapid course than that form which is 
 associated with depression. One year is the average 
 duration in cases which recover. In unfavorable cases the 
 affective basis does not then disappear, the delusions re- 
 tain their loosely connected systematization, and the tran- 
 sition into progressive confusion is gradual. Finally a 
 certain irritable, silly character occupies the foreground, 
 but not dementia. The terminal stage cannot be distin- 
 guished from other disorders which pass into the clinical 
 history of general paranoia. 
 
 The two forms of wahnsinn which have been mentioned 
 occur, as a rule, in middle life. The development is not; 
 rapid. Careful observation shows a prodromal irritable 
 stage which lasts at least several weeks. As a matter of 
 course the delusions are much more manifold than has 
 been described above, but the various similar manifesta- 
 tions of this kind will be considered under the heading of 
 verruecktheit. 
 
 The objects of treatment are sedation and protection. The 
 prominence of the affect requires special attention because 
 its treatment alone offers an effective weapon. Rest in 
 bed is to be recommended; isolation is advisable when 
 illusions are prominent, while true hallucinations become 
 more distinct when the patient is alone. Under such cir- 
 cumstances the patient may be left in the company of 
 others so long as he is not dangerous on account of sudden 
 acts. It is hardly ever possible to keep these patients at 
 
236 HANDBOOK OP INSANITY. 
 
 home. Powerful drugs are necessary to keep the affects 
 in subjection, and the delusions usually lead the patient to 
 refuse drugs. Potassium bromide is the most valuable, 
 but only when given in large doses. Its effect may be 
 aided by the use of morphine, especially in violent excite- 
 ment. We must avoid prolonged baths, packs, etc., be- 
 cause the more conscious patient sees in these baths only 
 inimical attacks ; when consciousness is more clouded, as 
 in the condition of ecstasy, all these measures are useless 
 or even give rise to violent excitement. 
 
 2. Verruecktheit. 
 
 " Verruecktheit " is a mental disorder in which delusions 
 usually associated with hallucinations are carefully com- 
 bined, sometimes rapidly, but as a rule slowly, into a pro- 
 gressive delusional system ; the combination with affects 
 is accidental and gradually disappears. It is one of the 
 forms of paranoia. Their relation is seen particularly in 
 those cases which, after a long course, terminate in con- 
 fusion, not in dementia, and exhibit the same symptoms 
 that are found in the wahnsinn, which terminates in sec- 
 ondary paranoia and in some terminations of melancholia 
 and mania. It occurs almost exclusively in individuals 
 with an hereditary taint and always runs an unfavorable 
 course. As its name implies, it is a displacement of the 
 mental personality from its former position, and leads to 
 a permanent and profound change in personality. In the 
 beginning, at least, consciousness is unaffected, and the 
 affects which are sometimes observed are only temporary. 
 As a rule the disease develops very slowly ; more rarely it 
 apparently begins suddenly after a short period of irritable 
 depression. 
 
 Although verruecktheit is not simply a morbid intensi- 
 fication of certain peculiarities of character such as occur 
 in persons of very different degrees of culture and stations 
 in life, still it is very common to find among the ancestors 
 suspicious characters who exhibited, for example, an unu- 
 
HALLUCINATORY DELUSION OF PERSECUTION. 237 
 
 sual tendency to envy or pride. Such peculiarities are 
 exhibited by the patient even during childhood. He ex- 
 hibited a liking for solitude, did not take part in the sports 
 of other children, and had no friends among them. At 
 the period of puberty these tendencies became more 
 marked; he lived secluded, devoured by mistrust and 
 suspicion. 
 
 The great abundance of forms in which the disease 
 appears necessitates a classification, but we must lay 
 stress upon the fact that the following groups only possess 
 systematic importance, inasmuch as verruecktheit rarely 
 remains within the bounds that will be set forth. 
 
 In the foreground of verruecktheit stands the delusion. 
 This may develop from so-called primordial delirium, but 
 is more often associated with hallucinations. Hence fol- 
 lows the division into simple or hallucinatory verrueckt- 
 heit. A further division refers to the contents of the 
 delusions, which imply either derogation or exaltation of 
 the personality, and hence the groups of delusions of per- 
 secution and delusions of grandeur. 
 
 On account of its frequency and the completeness of its 
 symptoms we will first consider the hallucinatory delusion 
 of persecution. 
 
 Its basis is the development of systematized ideas of 
 derogation as the result of permanent, on the whole mo- 
 notonous hallucinations. Strictly speaking, these are not 
 fixed ideas, but are, in a measure, variable because the 
 original delusion acts in a falsifying manner upon the 
 remaining contents of consciousness. Hence a progress 
 of the delusions forms part of the clinical history. As we 
 shall see later, a delusion of persecution, for example, may 
 develop into a delusion of grandeur. The delusion also 
 extends gradually to the entire mental life of the patient. 
 The concepts which, especially at the onset, were not yet 
 morbidly changed, and their associations, are therefore 
 only combined in a systematic manner in so far as they are 
 not opposed to the dominant delusions. 
 
 This apparent restriction to certain circles of thought is 
 
238 HANDBOOK OF INSANITY. 
 
 at first so pronounced that outsiders do not notice any- 
 morbid element. Not a small proportion of the patients 
 attend to their duties in the ordinary way, difficult scien- 
 tific labors may be carried out, and nothing peculiar is 
 noticed in conversation. An occasional smile without 
 apparent cause, a peculiar glance toward the ceiling, solil- 
 oquies, etc., are regarded as mere peculiarities, although 
 concealed hallucinations and delusions are already present. 
 Many years sometimes pass in this way. A slight change 
 of manner may have been noticed by the family, but they 
 have become accustomed to it. The delusions and hallu- 
 cinations often have not obtained convincing reality to the 
 patient, and their interpretation still rouses doubt. But 
 the correct perceptions of the external world are already 
 combined with personal sensations and ideas which falsify 
 the former; something that does not belong to them is 
 looked for and observed. Startled by this fact, the patient 
 endeavors to quiet himself by rational reasons, but only 
 with temporary success, because the vivid distinctness of 
 the hallucinations rapidly overcomes the criticism. This 
 loss of criticism is perhaps a sign of mental weakness ; but 
 the judgment of the patient in other matters, which do 
 not concern his person, is still too great to permit us to 
 regard this expression as appropriate. The patient is still 
 astonished concerning the awakening mistrust and asks 
 himself for the cause. But he constantly returns to the 
 idea that some plan has been formed against him, that 
 enemies are attempting to ruin him. He now finds that 
 everything about him is changed. Everything excites his 
 mistrust; people speak ill of him and slander him. Tri- 
 fling circumstances usually rouse such thoughts. Real 
 misfortunes affect him less and are not attributed to his 
 supposed enemies, while slight events which affect his 
 person are woven into the developing system of delusions 
 of derogation. He now has a special tendency to look 
 back into his past and to combine events which have long 
 passed with the fresh impressions of the present. 
 
 An auditory hallucination of an inimical character re- 
 
DELUSIONAL SYSTEM. 239 
 
 turns more frequently and grows louder. More rarely its 
 contents are immaterial, but even then it is combined with 
 the delusional system. A physical ailment may effect a 
 rapid change in these concealed processes. In the large 
 majority of cases a disagreeable auditory hallucination 
 now gives a definite direction to the undefined fears. At 
 one blow the concealed contents of long-experienced fears 
 are converted into a terrible certainty. Usually these 
 hallucinations consist of a single word (villain, murderer, 
 pig) , often they are a sexual accusation ; or they are short 
 sentences of similar import. Startling as this may be at 
 first, its frequent recurrence suppresses every doubt of its 
 reality, and it is often drawn very slowly into the con- 
 stantly growing web of delusions. The patient hears him- 
 self mocked everywhere, in the house and upon the street. 
 Now the links are formed in a progressive delusional 
 system, in part slowly and steadily in a psychological 
 manner, in part rapidly and by fits and starts on account 
 of the morbid irritative condition in the brain. Usually 
 he then infers from the ever-present danger that a con- 
 spiracy of his enemies has been formed. Wherever he 
 goes he finds himself surrounded by enemies and followed 
 by spies. He generally does not know his enemies person- 
 ally, and makes no further effort to see the persons whose 
 mocking voices he hears. This is a notable evidence of 
 the increasing lack of judgment, because formerly he 
 would open the window or go to the street in order to see 
 his supposed pursuers. He now requires merely an ex- 
 planation of the process and is apt to find it in physical 
 action at a distance. As one person cannot accompany 
 him everywhere, he must be pursued by a society — Free 
 Masons, Jesuits, secret societies of all kinds, the police. 
 The voices heard are explained by electrical apparatus or 
 the telephone. The telegraph communicates his fate to 
 the entire world. Hence he refuses to answer questions, 
 because the questioner only pretends to be ignorant but is 
 really cognizant of everything. Soon the threats are con- 
 veyed to him in all sorts of ways ; any newspaper report 
 
240 HANDBOOK OF INSANITY. 
 
 conveys a hint of his crimes and is worked up into the 
 growing system of delusions. He finds undeniable accu- 
 sations and threats everywhere ; out of the irrelevant con- 
 versation of those about him he picks words and refers 
 them to himself. The people point at him, the preacher 
 refers to him in his sermon, and the street-gamins whistle 
 songs about him. 
 
 A great feebleness of judgment has already developed 
 when such harmless matters are drawn without hesita- 
 tion into the system of delusions. The constant observa- 
 tion disquiets the patient and he attempts to escape. He 
 changes his dwelling or makes a trip. At first this re- 
 lieves him, because for the first few days the enemy 
 seems to have lost track of him. But soon the pursuit is 
 renewed and the auditory hallucinations again begin. 
 Again he changes his dwelling with the same result, and 
 finally he recognizes, in despair, that escape is impossible 
 from the terrible conspiracy against his honor or his life. 
 
 Now the patience of the persecuted patient may become 
 exhausted. For a time he drops his timid and reticent 
 manner and speaks to this or that person concerning 
 their inimical conduct. On the whole, he maintains a 
 passive demeanor. He avoids the outer world, closes 
 windows and doors, stops the keyholes, cooks his own 
 food. But even this seclusion is useless because his 
 thoughts are no longer concealed from his enemies. The 
 letters that he writes are immediately read aloud by an 
 invisible enemy ; hardly has a thought developed in his 
 mind before it is expressed aloud. Indeed, the current of 
 innervation to the speech muscles, which precedes the 
 auditory image in point of time, gives rise to words which 
 are spoken before the thought is conceived. He is now 
 entirely in the hands of his enemies, who force their 
 thoughts upon him. 
 
 The inner restlessness requires an outlet, and this is 
 effected more frequently by public accusations than by 
 acts of violence. As a general thing he seeks protection 
 from the authorities. Either he unfolds the entire delu- 
 
APPEALS TO LEGAL AUTHORITIES. 241 
 
 sional system, and his insanity is then evident at once, or 
 he attempts to make the true reason of his persecutions 
 probable by hinting at facts, and careful examination of 
 all accompanying circumstances may be necessary before 
 the patient's true condition becomes evident. On the 
 whole, however, the authorities pay no attention to the 
 complaints, and, as a matter of course, the patient now 
 assumes that the authorities are in league with his ene- 
 mies. Higher authorities are invoked ; finally, parliament 
 and king are annoyed. As a matter of course, many of 
 these patients have been transferred to an asylum before 
 matters have come to such a pass. 
 
 I will now pause a little in the description in order to 
 complete the history in a few details. We have hitherto 
 spoken intentionally only of the auditory hallucinations, 
 because they are so disproportionately frequent and also 
 because they furnish the most distinct idea concerning the 
 nature of verruecktheit. There is sometimes a real, but 
 usually only an apparent absence of auditory hallucina- 
 tions in verruecktheit. This is probably owing to the 
 fact that the strength of the innervation currents to the 
 speech muscles is not always so great that it appears to 
 the patient as distinct internal speech. These gradual 
 differences between undoubted original notions of his own 
 brain and those which appear to be forced upon him from 
 without, but are really only another expression of the same 
 process, make it so difficult for him to distinguish between 
 reality and deception. 
 
 But the disease is very often attended with a series of 
 other hallucinations. Hallucinations of common sensa- 
 tion, especially in the skin and internal organs, are apt to 
 develop into delusions. The knowledge of physical appa- 
 ratus is generally utilized in explanation. The terms 
 electricity and magnetism are usually employed to cover 
 the indefinite notions concerning the supposed underlying 
 physical processes. The disorders of common sensation 
 consist of vertigo, shocks of the entire body ; the bed is 
 drawn upward, the limbs are moved against the patient's 
 16 
 
242 HANDBOOK OF INSANITY. 
 
 will ; burning boring pains alternate with tearing, draw- 
 ing of the limbs. Even new words are formed in order 
 to express the annoying sensations. It is often difficult to 
 distinguish the real hallucination from its fantastic expla- 
 nation and amplification, because many patients do not lose 
 the tendency to exaggeration even during the disease. This 
 one complains that his brain is torn out, the other that 
 his spinal cord is removed; this one's skull is opened and 
 shut, the other has a wire drawn through his head ; or a 
 stone or one of the other organs has taken the place of the 
 brain. The thoracic and abdominal viscera are very often 
 implicated ; they are replaced by wheels, the heart is de- 
 prived of blood and pumps only air into the vessels, the 
 rectum is torn out or a mill-stone lies in front of it. All 
 this is done by the secret contrivances of his enemies. 
 They torment him day and night, exchange his limbs, 
 place microscopic animals under his skin, etc. If these 
 feelings, under the influence of superstitious notions, are 
 attributed to a supernatural devilish cause, and if alter- 
 nating auditory hallucinations confuse the patient's con- 
 duct, they result in the delusion of "possession." The 
 enemies, the devils, reside in the patient's ears and deafen 
 him with their terrible outcries, they rise from his belly 
 into his head, they utter blasphemous remarks which he 
 must communicate to the whole world. He preaches the 
 sinfulness of the world and foretells the day of judgment, 
 but at the same time feels himself compelled to cry out 
 against his will. He says that the devil is in him and 
 forces him to such acts. The most remarkable descrip- 
 tions and explanations are reported by the patient con- 
 cerning the sexual apparatus, and such notions are sup- 
 plemented by visual hallucinations. Men see themselves 
 surrounded by naked women. Women experience the 
 act of coitus; at the same time they are usually violent 
 and irritated, slam the doors and break objects; more 
 rarely they revel in voluptuous feelings or perhaps in the 
 thought that they have become pregnant with the Saviour 
 of the world. 
 
DELUSIONS OF GRANDEUR. 243 
 
 In close relation with the feeling of being possessed, 
 which often has a religious tinge, we find olfactory hallu- 
 cinations. In fact, a division of verruecktheit according 
 to the different forms of hallucinations is not possible, be- 
 cause the auditory hallucinations alone occupy a special 
 position; the other forms are combined in manifold ways. 
 Certain ones, however, are more often found in combina- 
 tion; we have already referred to the combination of 
 olfactory and genital hallucinations which often occur in 
 religious ideas. Sulphur and pitch, poisonous vapors, are 
 conveyed to the patient in the most remarkable ways. 
 The stench comes through the chimney, the cracks in the 
 floor, or specially constructed pipes. The patient plugs 
 his nostrils with cotton, cloth, etc. As gustatory and 
 olfactory hallucinations are often combined, the food 
 tastes like urine and faeces, arsenic, or chloroform. Many 
 of these patients are constantly spitting in order to get 
 rid of the distressing sensations. It is clear to him that 
 he is to be poisoned ; he takes the greatest precautions in 
 eating his meals, changes his restaurant at every meal, 
 has chemical examinations made, etc. 
 
 Visual hallucinations are the rarest, and generally con- 
 sist only of shadowy appearances or fantastic embellish- 
 ments of illusions. At all events the patient suffers much 
 less from visual hallucinations than does the one who is 
 filled with delusions of grandeur. 
 
 We will now consider the delusion of grandeur. Apart 
 from the fact that it may occur with or without halluci- 
 nations, we must distinguish whether it develops inde- 
 pendently at the beginning of the disease or whether it 
 develops out of the delusion of persecution. The latter 
 variety, although perhaps less frequent than the former, 
 will be first considered. In a few cases a logical deduc- 
 tion of the ideas of grandeur from the delusion of perse- 
 cution may be traced. On account of the constant per- 
 secutions to which he is subjected he reaches the suspicion 
 and finally the positive conclusion that he is persecuted 
 because of his resemblance to some prominent individual, 
 
244 HANDBOOK OF INSANITY. 
 
 or because he himself occupies some important position. 
 The general observation by others must have some special 
 reason. Now everybody looks at him respectfully, the 
 newspapers furnish hints which make it clear to him that 
 all his persecutions were due to his commanding person- 
 ality. Increased self-esteem and expansive ideas may thus 
 develop psychologically in connection with the ideas of per- 
 secution. But the special character of the exalted ideas 
 depends mainly upon the hallucinations. A feeling of 
 magnetic currents and the notion of awaking suddenly to 
 new life occur in this connection, and hence the change 
 often takes place suddenly. With hardly any preliminary 
 sign the patient suddenly announces that he is a prince, 
 king, the Son of God, the Messiah. This may result from 
 some trifling circumstance, but more often from a true hal- 
 lucination, especially of hearing. A voice from heaven 
 or the apparition of an angel announces to him his lofty 
 position. Hence verruecktheit so often has a religious 
 basis, furnishing prophets, apostles, the bride of Christ, 
 the Virgin Mary. Corresponding to the original develop- 
 ment out of ideas of persecution, a struggle is often main- 
 tained for some time between the powers of evil and 
 the divine influences, but finally results in the victory of 
 God's elect. From time to time the struggle is again re- 
 newed and temporarily the exalted mood is clouded, but 
 renewed visions, delightful odors, and feelings of pleasure 
 confirm the former opinion. The weakness of judgment 
 is often so great that the patient proclaims himself 
 Messiah and king in the same breath, and this terminates 
 occasionally in a wild mixture of confused ideas of grand- 
 eur, which are rarely interrupted by ideas of persecution. 
 But usually the exalted ideas remain constant for years 
 and the patients are accustomed to postpone the fulfilment 
 of their wishes to later times. These individuals do not 
 long remain out of an asylum. The patient, knowing 
 himself heir to a throne, writes letters to the real incum- 
 bent. The second Son of God sends around printed pam- 
 phlets in which he calls the pope Anti-Christ. Such 
 
CHARACTER OF ACTS OF VIOLENCE. 245 
 
 harmless acts are often accompanied by dangerous attacks 
 upon others. A supposed slanderous remark induces the 
 patient to beat a passer-by on the street; armed with 
 weapons against his enemies he shoots the one whom he 
 considers the arch-conspirator. Another hears a divine 
 voice, "kill him," and immediately stabs a by-stander; a 
 church or house is put to flames either from revenge or to 
 serve as a shining beacon to the glory of God. On the 
 other hand, he does violence to his own body ; self -muti- 
 lations, even suicides, are observed. 
 
 These patients also become nuisances by their constant 
 complaints to the authorities against their enemies or by 
 the incessant pleading of their cause in print. The one 
 who is suffering from a delusion of persecution is not con- 
 tent with lamentation and complaining, but the most 
 intense feelings of opposition and revenge do not let him 
 rest. He complains to the courts in endless reports, and 
 without even waiting for an answer he may mete justice 
 with his own hands. This constitutes an important dif- 
 ference between the murder committed in verruecktheit 
 and in melancholia. The former is the result of hatred or 
 assumed justifiable resistance ; the latter is often associated 
 with feelings of profound pity. 
 
 We have just considered the development of the delu- 
 sion of grandeur from the delusion of persecution, and 
 will now discuss its coincident and independent develop- 
 ment. 
 
 A patient suddenly receives from a higher power the mes- 
 sage, " You are perfect, you will not die, but keep quiet." 
 She does not remain quiet, but tells her experience on the 
 following day ; soon afterward she feels and hears that 
 she is damned. But the effect of the message again ex- 
 alts her, and for a time she looks forward with joy to the 
 day of judgment. At the end of some months a new 
 voice tells her that she may not eat or she will be damned 
 eternally ; nevertheless she eats and for years afterward 
 feels that eternal damnation is her lot ; instead of being 
 the most perfect creature on earth, she has become the evil 
 
246 HANDBOOK OF INSANITY. 
 
 woman, the serpent. This notion in turn disappears after 
 the lapse of years, and the exalted feeling that she is per- 
 fect and eternal dominates the further course of the dis- 
 ease. In a similar way we find, from the start, ideas of 
 exaltation and derogation alongside of one another in more 
 or less intimate association. The more violently the dis- 
 ease begins the more closely joined are these apparently 
 antagonistic ideas, and they appear directly out of con- 
 sciousness without any logical connection. 
 
 The same ideas recur in many different patients, and it 
 almost appears as if one had learned them from another. 
 This can only be explained by their original organic de- 
 velopment, as in the case of central hallucinations ; hence, 
 also, their convincing power, which is so much greater 
 the more vivid the sensory accompaniment in the shape 
 of hallucinations. After a while an arrangement of the 
 antagonistic delusions is effected, and in the course of 
 years they grow together into a system. ' The degree of 
 logical connection and psychological foundation of the 
 originally independent series of ideas depends upon the 
 grade of intelligence which still remains intact. 
 
 A patient states that she cannot rid herself of the idea 
 that she is a princess, and at the same time she hears that 
 she may not eat. She is astonished at the first fact and 
 distressed about the second ; she fasts, and only at a much 
 later period does she explain the connection by stating that 
 a period of probation must first be endured before attain- 
 ing her high destiny. This cerebral mode of development 
 of antagonistic concepts is not really surprising if we 
 remember the rapid alternation of cheerful and mournful 
 ideas in mania and other psychoses. 
 
 The new thoughts at first astonish the patient, and it is 
 only gradually that they unite with the fund of ideas 
 already present. It is important to note that profound 
 affects of long duration do not attend the origin of such 
 delusions. 
 
 We turn next to the consideration of verruecktheit 
 without hallucinations. 
 
SYMPTOMS IN CHILDHOOD. 247 
 
 This always presupposes a mental basis which is below 
 par. The acceptance of the delusions is only made possi- 
 ble here by a weakness of judgment which is always either 
 congenital or has developed in early childhood. On the 
 other hand, a so-called original verruecktheit may also be 
 associated with hallucinations, and then constitutes a va- 
 riety midway between the already described forms and 
 the simple verruecktheit which we are about to discuss. 
 There are numerous transitional forms, but a description 
 of pronounced differences should be attempted in order to 
 show more clearly the individual symptoms. But it must 
 not be forgotten that the hallucinatory delusion of perse- 
 cution and grandeur develops generally on the basis of 
 hereditary taint. If we here attach the chief importance 
 to this early developed basis and if the term original ver- 
 ruecktheit is not employed for this simple form of the 
 disease, it is due to the fact that this term has become 
 naturalized in psychiatry as applied to verruecktheit, 
 developing upon the hereditary basis and associated with 
 hallucinations. It would be more correct to apply this 
 term also to the simple forms without hallucinations. 
 
 We have to deal, accordingly, with individuals in whom 
 the origin of the disease dates back to earliest youth, pe- 
 culiarities being noticeable in the child in all the domains 
 of thought and feeling. There is, however, an early dis- 
 tinction in the main direction of thought, either toward 
 the side of derogation or of exaltation, or the combination 
 of these notions is an early one. 
 
 We begin with the first form in which self-depreciation 
 constitutes the essence of the disease. At an early period 
 the child feels himself neglected by his parents, brothers 
 and sisters, and finally becomes antagonistic, in a measure, 
 to his family. These thoughts gain more and more 
 strength, and finally they begin to influence his percep- 
 tions. He thinks himself neglected by other children 
 and sees hostile distrust in the shyness of boys of his age. 
 Such children are much alone and often have a tendency 
 to extensive promiscuous reading; they meditate and 
 
248 HANDBOOK OF INSANITY. 
 
 dream concerning all sorts of queer notions. Derided by 
 his companions the child becomes more sensitive, and from 
 the morbid predisposition the fully developed psychosis 
 slowly grows. Not alone the reproaches of others, called 
 forth by the patient's peculiar conduct, but even the most 
 harmless circumstance is manipulated into a coherent sys- 
 tem. A progressive psychological development is usually 
 more distinct in verruecktheit without hallucinations than 
 in the so-called hallucinatory form. Gradually all per- 
 ceptions become confirmations of the constantly crystalliz- 
 ing ideas of derogation ; in married life this appears often 
 in the shape of jealousy. 
 
 It is especially interesting to follow the comparatively 
 frequent transition into ideas of exaltation, while the 
 further course of the delusion of persecution in simple ver- 
 ruecktheit is the same as in the hallucinatory form. As 
 a rule these persons have an exaggerated idea of their 
 own abilities even in early childhood. They dream of 
 lofty ideals — the family life is not sufficiently aristocratic. 
 The sensitiveness and irritability in the bosom of the 
 family are the same as in the form of disease just de- 
 scribed. As a premature physical development often 
 accompanies the peculiar mental character, they are 
 brought prematurely among grown people. Friendly 
 words and harmless flattery make a deep impression upon 
 these children and give rise to the notion that they are 
 destined for something higher. In their dreams they see 
 themselves members of cultured circles of society, and in 
 waking moments these serve as the basis for building 
 castles in the air. The notion of aristocratic descent now 
 appears occasionally and is supported by the supposed un- 
 feeling treatment at home and the kind manner of outsiders. 
 The suspicion that they are the children of other parents 
 becomes stronger and stronger and requires its psycho- 
 logical realization; this is effected undeniably by the 
 weakness of judgment. In a perhaps real but very slight 
 resemblance to the picture of a ruling sovereign the pa- 
 tient recognizes the secret of his birth. Cautiously he 
 
EROTIC AND RELIGIOUS SYMPTOMS. 249 
 
 endeavors to gain information on this point from his 
 parents. They are naturally astonished, perhaps con- 
 fused, and thus his suspicions are confirmed. The reason 
 of former slights now becomes clearer, and out of the an- 
 tagonism of self -depreciation and exaltation is gradually 
 developed the coherent series of delusions. According as 
 either of these series predominates, the clinical history 
 may resemble that of delusions of persecution or of 
 grandeur. 
 
 The history often receives a special color from erotic or 
 religious elements. In many cases both develop in early 
 youth and increase in intensity at the period of puberty.. 
 Religious enthusiasm and masturbation are found associ- 
 ated, but Platonic feelings may also be marked without 
 sexual aberrations. Temptations by the devil alternate 
 with feelings of inspiration ; the interpretation of texts in 
 the Bible facilitates the development of a delusional sys- 
 tem. The enthusiasm or humility which accompany 
 their faith or doubts are rarely profound affects; they 
 make sport of the feelings of sinfulness and atonement. 
 This constitutes a difference from those cases of verrueckt- 
 heit in which hallucinations exert full power over action ; 
 here we are more apt to find refusal to take food, complete 
 mutism, self -mutilations, and even crucifixion and also 
 violence against others. Another form of the delusion 
 of grandeur develops in the domain of invention or the 
 improvement of existing conditions. Queer originals are 
 always numerous in society ; in riots and other forms of 
 social excitement they appear in greater numbers, and 
 not infrequently lead the masses. In quiet times they are 
 a torment to their fellows until some irrational act leads 
 them to the asylum. 
 
 As we have already remarked, the independent original 
 development of a delusion of grandeur is very rare, but 
 there are some cases, especially of an hereditary charac- 
 ter, in which the ideas of depreciation are rare and so over- 
 shadowed by the delusion of grandeur that the former is 
 unnoticed. Hallucinations, especially visions, are gener- 
 
250 HANDBOOK OF INSANITY. 
 
 ally present in such cases. These forms, which are always 
 more violent, terminate early in confusion, and the delu- 
 sion then has a disorderly and monstrous character. 
 Every question provokes fantastic answers. The patient 
 is poet, philosopher, general, discoverer, at the same time ; 
 astonishment at such remarks leads to further exaggera- 
 tions, such as " I am the world, or God." 
 
 We find, accordingly, that as soon as we leave the gen- 
 eral, somewhat schematic description and turn to a special 
 form of the disease, numerous transitions are found be- 
 tween the different forms of verruecktheit. 
 
 Before proceeding further with the general description 
 we will describe the so-called insanity of querulents, which 
 has occasional points of contact with all the varieties al- 
 ready discussed. 
 
 Atlhough the individuals who suffer from this form of 
 the disease usually have an hereditary taint, the outbreak 
 of the disease does not take place, as a rule, until a later 
 period of life, though a number of peculiarities had long 
 been evident. The special exciting cause is always some 
 defeat in a court of law. The irritable mood then permits 
 a false interpretation of the actual facts. A tinge of ex- 
 cessive self-appreciation without decided delusions of 
 grandeur causes from the start an irritated opposition to 
 the supposed injuries. Hence the querulent fights for 
 his rights everywhere and avenges every slight with 
 morbid persistence, especially by means of new lawsuits. 
 As hallucinations are rare, very sudden actions are not 
 observed, and at the start the delusions are cautiously 
 concealed. It is then often difficult to arrive at a conclu- 
 sion. But a certain degree of weakness of judgment soon 
 appears. The regardlessness of consequences in securing 
 his end makes the patient forget his real interests ; he sac- 
 rifices fortune, health, and the happiness of his family. 
 The more his complaints are dismissed by the courts, the 
 more he believes in the partiality and corruption of the 
 judges. In a morbid reliance upon himself he assumes to 
 possess a knowledge of the law and legal methods and 
 
INSANITY OP QUERULENTS. 251 
 
 pleads his own case before the authorities. If reprimanded 
 for his conduct, he demands a change in the laws or resists 
 their execution.. An unbounded egoism thus seeks to dis- 
 place the boundaries of the law; the inner excitement, 
 which is constantly growing more passionate, no longer 
 confines itself strictly to the truth. The disappearance of 
 the last remains of reason is shown by the more and 
 more impudent demands, and the passion, which is no 
 longer held under control, passes all bounds. A more or 
 less pronounced delusional system now develops. 
 
 The mental disorder in the shape of verruecktheit now 
 becomes more distinct. The patient becomes the pro- 
 tector of the oppressed. Plans for the improvement of 
 the law, even for the improvement of the general condi- 
 tion of mankind, may make their appearance, and thus 
 there is a transition to a complete form of verruecktheit. 
 But the milder, slowly progressing cases are often difficult 
 to recognize among the original symptoms growing out of 
 the irritable mood. The patients are usually removed to 
 an asylum at an early period. When the irritable mood 
 subsides, we are often surprised at the great degree of 
 weakness of judgment, shown by the unmeasured demands 
 in consequence of the supposed injustice. Sometimes the 
 patient even smiles at his own want of moderation. At 
 the same time we generally find that he has become in- 
 different to other interests and that his feelings and de- 
 sires are devoid of mental vigor. 
 
 It still remains for us to consider briefly a few phenom- 
 ena which may occur in all complete forms of verrueckt- 
 heit. The use of peculiar, self-formed words is frequent, 
 generally in association with auditory hallucinations, 
 sometimes with hallucinations of feeling. More rarely 
 the verbal monstrosities are perverse expressions of insane 
 ideas, and this is seen most frequently in the transition of 
 the disease into confusion. A few examples will show the 
 character of these words ; the physician is received daily 
 with the salutation, "Rokamohel, Rodababa." One pa- 
 tient calls himself " paraweitzika, " another speaks of 
 
252 HANDBOOK OF INSANITY. 
 
 " pulanus gekatekowbet, " etc. The writing of these pa- 
 tients exhibits the same characteristics. 
 
 It is very difficult to give a general description of the 
 outward bearing of the patients, but a common feature in 
 many cases is a certain perversity and crankiness of ex- 
 pression and conduct. But this cannot be attributed to 
 the mental condition, because congenital peculiarities of 
 the skull and face sometimes impart a certain direction 
 to every expression. The more the verruecktheit is based 
 upon the general development of the patient, the more 
 frequently do we also find other malformations, and with- 
 out exaggerating their importance they sometimes con- 
 firm an unfavorable prognosis. 
 
 Inequality of the pupils is frequent, but has no great 
 significance. Temporary relaxations of groups of mus- 
 cles, but not paralyses, are observed, and also occasional 
 twitchings. These may be defensive movements result- 
 ing from delusions. Motor inhibition and cataleptic 
 rigidity are rare or seen chiefly in the transition into con- 
 fusion ; the rigidity is often confined to certain groups of 
 muscles. In some cases tension is noticeable in the entire 
 mental condition. These conditions may disappear in a 
 few weeks or may become chronic; the delusions then 
 become less distinct, and a final termination in dementia 
 is to be expected. 
 
 Other motor disorders, such as tremor, permanent pa- 
 ralysis, general convulsions, do not belong to the clinical 
 history, but are accidental symptoms. If retention of 
 urine and fseces happens to be present and disease of the 
 spinal cord can be excluded, we should suspect voluntary 
 retention. For example, one patient did not wish to lose 
 the golden contents of his rectum. 
 
 Sleep is normal unless disturbed by violent delusions 
 and hallucinations, and the general nutrition is also 
 excellent. 
 
 Verruecktheit is one of the most frequent of mental dis- 
 orders. On account of the numerous cases which appear 
 at the climacteric, the female sex is attacked more f re- 
 
TERMINATIONS. 253 
 
 quently than the male. Apart from those cases in which 
 the patients have been morbid from earliest childhood and 
 the verruecktheit has developed imperceptibly out of the 
 constitutional predisposition, the disease appears, in the 
 majority of cases, at the development of puberty, i.e., the 
 end of the second and beginning of the third decennium. 
 It may begin, however, at any period of life, but most 
 rarely in old age. 
 
 The disease usually runs a very chronic course. It is. 
 often preceded by a period of depression, more rarely it 
 apparently begins suddenly with violent symptoms, but 
 then the previous development has merely been concealed. 
 As a rule, it progresses by fits and starts, and there is 
 hardly any psychosis which exhibits such protracted and 
 notable remissions. With the subsidence of hallucina- 
 tions and their accompanjdng affects, there is a certain 
 improvement in many cases. Although still convinced 
 of the truth of their delusions, the patients are able to re- 
 strain them and are not influenced by them in their actions. 
 Slight peculiarities of conduct and the retention of some 
 apparently subsidiary parts of the delusions, together 
 with a certain reluctance to discuss the morbid ideas, tes- 
 tify to the incompleteness of recovery. The patients often 
 dissimulate with great skill in order to obtain their dis- 
 charge from the asylum. 
 
 The terminations of the disease, therefore, are incom- 
 plete recovery, a chronic state, confusion, imbecility, or 
 death. Recovery is very rare, but improvement is often 
 so pronounced, especially in delusions of grandeur, that 
 a return to the former occupation becomes possible. The 
 previous weakness of judgment and general mental inva- 
 lidism persist. The progressive mental decay is more 
 pronounced when the clearly established disease continues 
 for years or even for life. The transitions into confusion 
 and imbecility are gradual. The highest grades of de- 
 mentia are not observed, as memory is never lost. Death 
 may occur from suicide or accidental complications. 
 
 In a psychosis which is, on the whole, incurable, the 
 
254 HANDBOOK OF INSANITY. 
 
 treatment can only be directed against individual groups 
 of systems, and even this is extremely difficult in ver- 
 ruecktheit. We already know that these patients, espe- 
 cially when suffering from hallucinations, are dangerous 
 members of society. Hence they should be sent to an 
 asylum, at least in the beginning. After the lapse of 
 time, when imbecility or confusion have destroyed the rare 
 affects, they may be transferred to colonies of insane, to 
 the care of a family, or perhaps to their own home. 
 
 3. Confusion. 
 
 The confusion here referred to is not separated sharply 
 from verruecktheit ; its relation to paranoia is indicated 
 by the combination, although not firmly, of former delu- 
 sions. The series of ideas are only held together by a 
 loose chain. Temporary affects threaten the remainder of 
 the connection while a certain degree of mental weakness 
 is recognizable in quiet thought, and an attempt is no 
 longer made to find a logical basis for the delusion which 
 appears only temporarily in the affect. It is evident, 
 therefore, that this form of confusion may develop from 
 wahnsinn, mania, and melancholia ; it is therefore a sec- 
 ondary form of paranoia. The absence of dementia is 
 shown by the fact that the patient can often reason cor- 
 rectly concerning things which do not refer to his morbid 
 personality. 
 
 Confusion affords an excellent illustration of the funda- 
 mental principle of all mental disorders that notions which 
 appear involuntarily always gain a predominance over 
 those which are selected consciously. Hence confusion 
 is often the termination of mental disease. Thus it is 
 found after melancholia when the violent constant affect 
 disappears, but the delusions remain and mental weakness 
 appears. We also meet with the conditions known occa- 
 sionally as acute hallucinatory confusion, and which were 
 discussed among the violent forms of mania. If these 
 pass into chronic excitement the confusion becomes more 
 
TERMINAL CONFUSION. 255 
 
 constant, although remissions recur continually and ena- 
 ble us to recognize that a combination of the delusions is 
 still attempted. Although these delusions form no defi- 
 nite system, they prove that the disease is a secondary 
 paranoia. 
 
 There are still other psychoses which either run their 
 course with or terminate in distinct confusion ; for exam- 
 ple, the mental disorder attending epilepsy and neuras- 
 thenic conditions of exhaustion. They hardly ever exhibit 
 a delusional system, because this is not permitted by the 
 obscuration of consciousness; hence this confusion does 
 not belong to paranoia. 
 
 Whatever the manner in which confusion has developed, 
 loosely connected series of delusions are more or less dis- 
 tinctly recognizable. But they are lacking in firm sys- 
 tematization, and this is only indicated by single words or 
 sentences ; from the frequent repetition of such words and 
 sentences we can sometimes distinguish the morbid psy- 
 chical condition which preceded the confusion. If hallu- 
 cinations are still present (and this is true of not a few 
 cases) they usually find a more distinct expression in sud- 
 den movements and individual acts than in the confused 
 speech. But both the delusions and hallucinations have 
 lost their compelling hold upon the feelings and actions of 
 the patient. They appear and disappear with equal ra- 
 pidity. The play of ideas has no internal connection and 
 varies with accidental circumstances. But conditions of 
 greater activity alternate with periods of quiet and in- 
 creased rationality, in which the patient may give some 
 information concerning the hallucinations and delusions 
 which he has had. 
 
 It is difficult to describe the endless varieties in the man- 
 ifestations of confusion. Even in higher grades memory 
 is not entirely lost, except for recent events. The dis- 
 placement of the standpoint of his own personality, which 
 formed the centre of the former systematized delusions of 
 the patient, remains unchanged longest. Hence we find, 
 for example, a senseless repetition of large figures, of fan- 
 
256 HANDBOOK OF INSANITY. 
 
 tastic images of the patient's own worth; but the talk of 
 millions, etc., has become merely a play of words. Ideas 
 of derogation disappear more readily in the confused 
 speech. Although profound emotions are lacking, tem- 
 porary excitement is very common and may be attended 
 with sudden acts of violence, so that the patient is often 
 very dangerous. The execution of definite plans is im- 
 possible because the will is too unstable. The habits 
 of previous days of activity lead only to the performance 
 of minor mechanical actions and make some of the patients 
 useful members of the household of an asylum. 
 
 As a matter of course, confusion develops gradually from 
 the previously mentioned conditions, and transitions may 
 be pictured in all stages ; depressed or elevated moods still 
 alternate frequently. A cheerful manner mingled with 
 conceit, anxiety in expression and gesture, malice, obsti- 
 nacy, are observed. Many patients can answer brief ques- 
 tions, especially those which concern the details of every- 
 day life, but as soon as we ask concerning the cause of their 
 illness or touch upon any of the relations of the mental 
 personality, they rapidly become confused and give sense- 
 less, incomprehensible answers. This is most distinct 
 when they are asked to write, as in the following frag- 
 ment of a letter : " My dear, truly married Emperor Will- 
 iam in Berlin ! As my truly beloved has been vouchsafed 
 to your loyal right hand and to what belongs to it through 
 the death of your dear Emilia, and as so many hours of 
 grief have been accorded to us, we will with our dear 
 brothers of pain, as you have communicated to my dear 
 Emilia from your couch, so that I can no longer retain 
 my beloved of your absence any longer in my heart," etc. 
 In speaking the flow of thought is naturally interrupted 
 by external circumstances and is drawn into other direc- 
 tions, but this cannot be followed except, perhaps, with 
 the aid of a phonograph. The following will serve as an 
 illustration of confused remarks : " My children poisoned 
 with wine — powder that stunk — your name is — actually 
 murder a woman — fat and oil — the water costs money — 
 
DESCRIPTION OF PLATE V. 
 
 PARANOIA. 
 
 Characteristic pictures of the variety of paranoia known as 
 wahnsinn could not be obtained. 
 
 The pictures of the old man illustrate verruecktheit with halluci- 
 nations in the form of delusions of persecution. He tasted, 
 smelled, and felt that he was poisoned. Intelligence is undisturbed, 
 and the vigorous expression in the first picture is due to the fact 
 that he wished to show his excellent qualities by means of the 
 photograph. The second picture was taken without his knowledge 
 while he was expatiating, in the midst of his delusions, on his 
 former strength compared with his present miserable condition. 
 This patient often communicates by telephone with his enemies. 
 He then sits with closed eyes, moves the lips gently, and makes slow 
 movements with the trunk. This is shown in the third picture, 
 which was taken without the knowledge of the patient. 
 
 The patient shown in the picture to the right and below also 
 suffers from verruecktheit with hallucinations, but confusion has 
 already occurred, so that a system can no longer be recognized in 
 his delusions. Delusions of persecution still predominate, especially 
 as the result of auditory hallucinations. The expression of the 
 face and the position of the hand show cautious distrust, probably 
 as the result of auditory hallucinations then present. The uni- 
 lateral wrinkling of the forehead is habitual in this patient, is 
 increased by every affect, and must be regarded as a spasmodic 
 condition, perhaps as a sign of degeneration. 
 
HANDBOOK OF INSANITY. 
 
 KIRCHHOFF. 
 
 Plate V. 
 
DESCRIPTION OF PLATE VI. 
 
 PARANOIA. 
 
 The two upper pictures show patients in whom the most marked 
 confusion has developed out of verruecktheit. The man formerly 
 suffered from melancholic delusions of derogation, and the per- 
 manent furrowing of the forehead corresponds to such a mood. 
 The furrowing corresponds very closely to the three sides of a tri- 
 angle. The lower half of the face no longer presents a melancholic 
 character ; the refractory look, the firmly closed mouth, and the 
 folded arms are the expression of dislike to sitting quietly while 
 the photograph is taken. The patient is usually boisterous, curses 
 in a confused way, and talks against " voices. " 
 
 The woman formerly thought herself persecuted, then regarded 
 herself as a princess, but for years has been entirely confused. She 
 is generally in motion, certain imperative movements being re- 
 peated hundreds of times a day. The play of features is spasmodic 
 and often changes, so that it corresponds to no definite expression. 
 
 The two lower pictures show verruecktheit with predominance of 
 ideas of grandeur ; intelligence is somewhat impaired, but confusion 
 has not yet developed. The patient was very willing to be photo- 
 graphed and explained each time what he meant to express by his 
 position and gestures. On the first picture he speaks "the imperial 
 word in a commanding tone ;" in the second one " the Divine word 
 in a singing tone." 
 
HANDBOOK OF INSANITY. 
 
 KIRCHHOFF. 
 
 Plate VI. 
 
 iifc* «fi 
 
TERMINAL CONFUSION. 257 
 
 miserable I have a large fortune." Here a certain loose 
 connection is still recognizable. It is important, however, 
 to know that the confusion may be entirely absent when 
 simple short questions are propounded. In doubtful cases 
 this is an important differential sign from conditions of 
 mobile dementia in which' regular series of thoughts are 
 no longer possible. The confusion under consideration 
 does not pass into dementia ; the ability to perform regular, 
 although only mechanical, acts remains intact. 
 
 After all affects have subsided, this condition may last 
 for years until death supervenes, and the physical condi- 
 tion, particularly sleep, generally remains excellent. 
 17 
 
III. 
 
 MENTAL DISORDERS ASSOCIATED WITH PERMANENT AN- 
 ATOMICAL CHANGES IN THE BRAIN OR WITH GEN- 
 ERAL DISEASES. 
 
 Introduction. 
 
 We have heretofore discussed functional disorders which 
 are probably due to chemical changes in the nervous sub- 
 stance. After long duration and great violence these may 
 lead to permanent anatomical tissue changes, and hence 
 we meet with some of the terminal forms of the functional 
 psychoses in the present section. This classification is an 
 artificial one, especially when we must here describe dis- 
 eases without anatomical change, merely because the 
 clinical history is identical with that of allied conditions in 
 which anatomical changes are very distinct. Such con- 
 ditions are primary dementia and imbecility. The posi- 
 tion of these two conditions in this section appears some- 
 what more justified if we assume that the anatomical 
 changes which their course warrants us in expecting are 
 not found simply on account of imperfect means of exam- 
 ination. 
 
 The functional psychoses, after a very violent course, 
 show that the chemical morbid processes lead to tissue 
 changes and in this way sometimes prove fatal. If this 
 fate is escaped, the permanently resulting anatomical 
 changes give rise to symptoms which distinguish them 
 clearly from functional disorders and, as we shall soon 
 see, secondary dementia then develops. 
 
 The connection of psychical disorders with general 
 affections of the nervous system and other organs and 
 with febrile diseases is also utilized for the separate de- 
 scription of certain psychoses. This division is also 
 
 258 
 
PKIMARY DEMENTIA. 259 
 
 artificial because simple mental disorders may appear at 
 the same time with such diseases or may even develop in 
 connection with them, without losing their own indepen- 
 dence. But in certain cases the psychoses develop from 
 these diseases in such an intimate connection that they 
 thereby receive a special impress. For example, a para- 
 noia upon a neurasthenic or alcoholic basis can only be 
 described in this connection. 
 
 Senile dementia and paralytic dementia are perhaps the 
 only psychoses which exhibit a definite relation between 
 the clinical symptoms and the anatomical changes. But 
 we often meet with exceptions, and this is still more true 
 of the other psychoses of this subdivision. Moreover, 
 there are sometimes combinations of the different forms. 
 
 It must also be remembered that there are not alone 
 many impure mixed forms, but also undeveloped and 
 therefore indistinct forms. 
 
 A. DEMENTIA. 
 
 Dementia is acquired as the result of disease, while 
 feeble-mindedness may be congenital or acquired. De- 
 mentia may begin the course of the disease and then either 
 disappear or remain permanent, or it is the termination 
 of other psychoses. 
 
 The former variety, viz., primary dementia, is a rare 
 disease. It occurs almost entirely among young individ- 
 uals, occasionally at the period of puberty, but chiefly in 
 men in the thirties, and develops almost suddenly, within 
 a few hours or days. The causes are mental or physical 
 exhaustion, fright or mechanical concussion of the brain, 
 hemorrhages, the puerperal state. The affects are very 
 slight; hallucinations and delusions are absent. Mem- 
 ory is rapidly lost. At the onset a certain restlessness 
 is occasionally observed, and a few purposeless, even 
 violent acts are performed, but soon there is complete abo- 
 lition of all mental activity. The senses are blunted and 
 respond slowly to stimuli. The ability to store impres- 
 sions is considerably diminished or entirely abolished, and 
 
260 HANDBOOK OF INSANITY. 
 
 there is no trace of voluntary activity. The patient does 
 not answer questions, must be fed, and only eats when 
 food is placed in his mouth. He remains standing for 
 hours in one spot or lies motionless in bed. The face is 
 devoid of expression, the pupils are dilated and react 
 slowly. Sensibility is generally lost, so that even strong 
 electrical currents cause no impression ; the cutaneous re- 
 flexes are diminished. The muscles are flabby, but in 
 rare cases there is temporary muscular rigidity. The 
 heart's action is feeble, the pulse slow and small; there is 
 often oedema of the feet and the cyanotic limbs are cool to 
 the feel. Sleep is quiet and profound. The temperature 
 of the body is lowered, and the weight often sinks consid- 
 erably, even if sufficient food is ingested. Respiration is 
 superficial. In the most severe cases the faeces, urine, 
 and saliva escape involuntarily. 
 
 As a rule this condition remains uniform, but temporary 
 excitement occasionally occurs, during which the patient 
 sings, whistles, talks incoherently but often in a rhythmi- 
 cal manner. The disease generally lasts several months, 
 but may also terminate in a few hours or days. When 
 the disease terminates favorably, as is true of the majority 
 of cases, the face gains expression, the patient begins to 
 speak a few words and to perform a few movements 
 slowly; he grows cleanly at an early period. The nutri- 
 tion improves and recovery gradually becomes complete. 
 The memory of the period of disease is generally extinct 
 or very imperfect. 
 
 Recovery may be aided by good food, wine, beer, iron, 
 etc. Careful attention to the skin, lukewarm baths, and 
 keeping the body warm in bed also act favorably. 
 
 A rarer termination is that of permanent dementia, and 
 this is similar to that observed after other psychoses. In 
 this event the grave turning-point will be recognized by 
 increase in the bodily weight while the other conditions 
 remain the same. It is not always easy, when the period 
 of observation is short, to distinguish it from severe mel- 
 ancholia. But the consideration of the causes and the 
 
HANDBOOK OF INSANITY. 
 
 KIRCHHCFF. 
 
 Plate VI 
 
DESCRIPTION OF PLATE VII. 
 
 MOBILE DEMENTIA. 
 
 At first sight we will not recognize the expression of dementia 
 in the adjacent pictures, although the individuals were completely- 
 demented. Hence the pictures show the important fact that the 
 facial expression of the insane very often does not correspond to 
 the mental condition. This shows that the actions, speech, and 
 demeanor, past and present, must all be compared. 
 
 The girl shown in the two upper pictures was formerly maniacal ; 
 her play of features is not volitional. She exhibits great bodily 
 restlessness, with a tendency to striking and biting ; she sings, 
 hisses, threatens, but the words employed present no coherence. 
 
 The expression of the woman in the lower picture is produced 
 voluntarily and is due to a theatrical tendency. The mouth and 
 eyes are wide open, hence the forehead is wrinkled and the eye- 
 brows arched ; the elevated and extended hands aid in producing 
 an expression of astonishment and fright. The much more violent 
 affects of profound mental distress and horror are expressed in a 
 similar way, but they also exhibit rectangular furrowing in the 
 middle frontal region and various vasomotor signs, such as dilata- 
 tion of the pupils, acceleration of respiration, etc. All these signs 
 are absent in our patient. 
 
 The picture of the man also shows a purposeless play of the facial 
 muscles. The upper half of the right side of the face exhibits mel- 
 ancholic elements ; the right half is grinning. 
 
DESCRIPTION OF PLATE VIII. 
 
 DULL DEMENTIA. 
 
 The adjacent pictures also contain elements" of melancholic forms 
 of expression, because they repi-esent terminal stages of melancholic 
 forms of disease, although the patients are completely demented. 
 The pictures of the woman were taken after an interval of several 
 weeks and show very well the rigid, stereotyped expression of a 
 melancholia which has passed into dementia. 
 
 The wrinkled brows of the young man on the left also indicate 
 previous melancholic depression ; he has been demented for years 
 and sits mute, but occasionally tears his hair and picks off the skin 
 of the face and scalp ; this is shown by the light spots and the bald 
 head. 
 
 The young man on the right is also mute ; his previous history 
 is obscure. His general bearing and gait seem to indicate increased 
 self-esteem, and this does not appear to be contradicted by the 
 facial expression. But as a matter of fact he is completely de- 
 mented and makes terrible grimaces. He has become a veritable 
 expert in movements of the mouth and displacement of the integu- 
 ment of the forehead. All the movements are made in a quiet, 
 dignified manner, while the hands are crossed on the back or the 
 arms folded on the chest. 
 
HANDBOOK OF INSANITY. 
 
 KIRCHHOFF. 
 
 Plate VII 
 
 ''-^I^V&v^fc ■■**&&* 
 
SECONDARY DEMENTIA. 261 
 
 distinct melancholic depression, the disordered sleep, and 
 the occasional manifestations of the vivid mental life will 
 soon enable us to arrive at a diagnosis. 
 
 The second form of dementia, so-called secondary de- 
 mentia, is a terminal condition of other mental diseases 
 and is very frequent. When the highest grades are 
 reached it usually remains permanent, but it may also 
 undergo notable improvement, although it never disap- 
 pears entirely. It is divided into agitated and apathetic 
 dementia. 
 
 In agitated dementia there is more or less excitement. 
 The patient exhibits a disconnected frivolous dotage and 
 mobile grimaces. We find a stupid play of expression, 
 without vivid affect : stupid smiles or tearful grimaces, a 
 childish, foolish, stupid demeanor. The patients run to 
 and fro, laugh, dance, and sing; some are constantly 
 cheerful, others are tearful, others exhibit alternations if 
 disturbed in any movement. Many perform monotonous 
 movements in endless repetition, sometimes of a very 
 complicated character, for example, grasping the right 
 ear with the left hand and at the same time touching the 
 nose with the right hand ; brushing and picking at the 
 clothes, etc. It is possible that these movements were 
 originally the result of delusions or hallucinations, but 
 now they are independent. They are the direct results, 
 without psychical intermediation, of the irritative condi- 
 tion of the cortex, which is supposed to result from pro- 
 gressive destruction of the cerebral tissue. 
 
 Mobile dementia is, clinically, often a transition to the 
 apathetic form, into which it generally passes after it has 
 lasted a sufficiently long time. Despite their outward 
 activity the patients have no comprehension of questions. 
 Uncleanliness is the rule. The restlessness occasionally 
 persists at night ; the nutrition then suffers and does not 
 improve until the transition into apathetic dementia takes 
 place. 
 
 Finally, the highest degree of dementia is found in the 
 apathetic form. This is mental death. It might be sup- 
 
262 ' HANDBOOK OF INSANITY. 
 
 posed that we had to deal with beings deprived of the 
 brain did not the continuance of the vegetative functions 
 testify to the activity of the lower centres. All indepen- 
 dent action is wanting. The patients must be fed, washed, 
 held when attending to the wants of nature. With ex- 
 pressionless features and relaxed muscles they sit immov- 
 able for days in the position in which they have been 
 placed. Saliva flows from the mouth, mucus from the 
 nose, the urine escapes into the clothes, and the fseces are 
 passed unnoticed. Speech ceases, and merely inarticulate 
 cries may now and then accompany a temporary excite- 
 ment ; sometimes the patients may bite and scratch when 
 they are stimulated. The movements performed are slow, 
 the muscles are flabby. Nutrition is often excellent, and 
 great obesity may develop. This condition may last for 
 years before death ensues. As a general thing, however, 
 death follows soon as the result of the poor circulation, 
 pneumonias, and exhausting diarrhoeas. 
 
 The sole treatment consists of careful nursing. As not 
 a few cases of secondary dementia show no anatomical 
 changes in the brain, and as these are the cases which, 
 as a rule, end in death with comparative rapidity, the 
 pathological changes found in another series of cases must 
 be regarded as results rather than as causes of this form of 
 dementia. The most frequent change is general atrophy 
 of the brain, with dilatation of the ventricles ; meningeal 
 opacities and thickenings are less frequent. The micro- 
 scopical changes consist of accumulation of fat and pig- 
 ment in the ganglion cells and dilatation of the capillaries, 
 with accumulation of granules in the sheaths. It is 
 probable that the number of negative cases would be 
 diminished if we excluded the milder cases of mental 
 weakness. Clinically, imbecility is also entirely different 
 from dementia, however numerous the transitions may be. 
 
 B. SENILE DEMENTIA. 
 
 Senile dementia is a mental disorder which is accom- 
 panied by diffuse atrophy of the brain, and is either the 
 
SENILE DEMENTIA. 263 
 
 termination of a melancholia or mania acquired during 
 old age, or it appears from the start as a condition of 
 mental weakness. The latter form will first be discussed. 
 It is associated with the physiological involution of the 
 brain, and hence there are numerous transitions between 
 the diminished mentality of old age and true dementia. 
 In some cases prodromata are almost entirely wanting, 
 but usually the dementia develops gradually. 
 
 Forgetfulness first becomes noticeable. Memory for re- 
 cent events first fails, while the memories of early childhood 
 may be even more vivid than usual. A certain loquacity 
 and tendency to diffuse repetition of the same stories may 
 increase this appearance, but these very repetitions show 
 that memory is impaired. If this forgetfulness is noticed 
 by the patient it leads him to make false statements as a 
 sort of excuse for his conduct. He becomes irritable and 
 mistrustful ; if he mislays anything, he maintains that it 
 has been stolen or mislaid by others. The same mistrust 
 induces him to conceal things, in order to guard against 
 robbery. He often does not know his own property and 
 appropriates that of others, without any special tendency 
 to theft. He exhibits a restless, busybody manner. By 
 day and night he rummages among old papers and other 
 objects. A brief tired feeling often overcomes him during 
 the day, in the midst of a conversation or during a meal. 
 He pockets useless objects, valuables, tools, stumps of 
 cigars, etc., and offers violent resistance when an attempt 
 is made to take them away. His restlessness drives him 
 into the street, where he makes senseless purchases, and 
 only returns home by accident or after going a round- 
 about way. 
 
 Soon the patient mistakes windows for doors or may 
 injure himself severely ; he handles dangerous articles re- 
 gardless of danger to himself or others. Many commit 
 gross offences against good manners and morals, make 
 sexual attacks, especially upon children. The sexual 
 sense, in general, is intensified and the impossibility of 
 normal gratification leads to many immoral acts. 
 
264 HANDBOOK OF INSANITY. 
 
 Obstinacy, vanity, and great selfishness are added to 
 these symptoms ; resistance to impracticable plans rouses 
 the temporary anger of the patient. The extinction of 
 emotional life is shown in the lack of sympathy toward 
 his family ; any affects which may be noticed are super- 
 ficial. The patient often fails to recognize his own rela- 
 tives and forgets their names. 
 
 At this time the anatomical basis of the morbid process 
 is often manifested distinctly by slight spasmodic seizures, 
 temporary paralyses of single nerves, vertigo, aphasic dis- 
 turbances. Remarkable improvement may also be noticed, 
 but in general the dementia increases progressively. The 
 patient dresses wrongly, puts his legs in his coat, draws 
 his stockings over his hands, attends to the wants of na- 
 ture wherever he may happen to be, and handles the 
 excrement. 
 
 As a rule, hallucinations and delusions are absent in 
 this pure form of dementia. As a matter of course, they 
 may be present when the condition has begun with melan- 
 cholia or mania. A feeling of loneliness is expressed; 
 statements are also made that nothing exists, that the 
 world has been destroyed. Definite delusions relating to 
 the patient's person are also found, such as that he is not 
 provided with food. Imbecile ideas of grandeur are most 
 frequent, such as revelling in gold, which is looked for in 
 the hands that are smeared with fseces. There are rarely 
 true hallucinations, usually only errors of observation. 
 
 This sad picture is sometimes relieved by the retention 
 of some pleasant traits of the former life. In fact, the 
 childlike, not the childish and foolish elements, may pre- 
 dominate. When the naughtiness of childish conduct, 
 uncleanliness, and violence predominate, the interruption 
 of the course of the disease by apoplectic attacks may 
 prove a real relief to the family. Now the bodily decay 
 becomes prominent ; the voracious appetite is replaced by 
 anorexia, often on account of digestive disturbances from 
 overloading of the stomach. Insufficient sleep accelerates 
 the decay of the vital energy, and the patient is compelled 
 
ANATOMICAL LESIONS. 265 
 
 to take to bed. Somnolence may next develop. On 
 awaking a slight excitement may begin, but finally the 
 word-images are lost as an expression of ideas. The de- 
 mentia is gradually shown more and more in the expres- 
 sion, and apathetic dementia is often the termination 
 unless death results from some bodily disease, such as 
 pneumonia or intestinal catarrh. Death often results 
 from simple loss of vitality. The extensive calcification of 
 the arteries which accompanies the disease is also shown 
 by the pulsus tardus. Irregularity and changes in the 
 size of the pupils are often observed. Other motor dis- 
 orders, such as asymmetry of the face, tremor of the 
 limbs, and especially of the muscles of speech, are not 
 uncommon. 
 
 The disease rarely develops before the age of sixty years ; 
 in the few cases which begin between the ages of fifty and 
 sixty years, premature senility is manifest. The disease 
 generally lasts several years, in rare cases only a few 
 weeks. 
 
 Treatment can effect little. The main elements are 
 good food, stimulation of the circulation, cleanliness, and 
 nursing. Restlessness at night is relieved by light beer 
 and wine and by narcotics, such as opium and morphine. 
 Chloral hydrate is a dangerous remedy on account of the 
 brittle condition of the vessels and the senile changes in 
 the heart. 
 
 The anatomo-pathological changes are important. The 
 parietal bones are often very thin, occasionally transparent 
 from disappearanc of the diploe. Marked thickening may 
 be observed in other places. Extensive pachymeningitic 
 deposits, adhesions of the dura to the skull, and hsema- 
 tomata are frequent. There is an excess of serum in the 
 dural cavity. The pia mater is often thickened and 
 opaque and contains calcareous plates and large Pacchio- 
 nian bodies. The size of the brain is diminished, its 
 weight lessened, the fissures gape, and the convolutions 
 are narrow, especially in the frontal lobes. The gray 
 matter of the cortex is atrophied and the lamination oc- 
 
266 HANDBOOK OF INSANITY. 
 
 casionally obliterated. The white substance is ansemie 
 and there is often distinct atrophy of the fibres, with in- 
 crease of the neuroglia. The ventricles are dilated, and 
 there are occasional spots of softening in the cortex and 
 white matter. The ganglion cells usually exhibit atrophy, 
 fatty degeneration, and accumulation of pigment. Athe- 
 romatous degeneration of the vessels is frequent, but does 
 not always extend to the capillaries. 
 
 C. PARALYTIC DEMENTIA. 
 
 Paralytic dementia is a mental disorder which is char- 
 acterized by mental weakness, progressing rapidly to 
 dementia, and is regularly associated with increasing 
 motor disturbances and vasomotor paralyses. The clin- 
 ical history varies greatly, according as profound affects 
 with delusions are present or not. Most frequently there 
 is a distinct expansive mood during a certain period of 
 the disease ; more rarely there is a depressed mood or a 
 simple demented condition without affect. We will first 
 describe the first and more typical variety. 
 
 Paralytic dementia is attended with a definite anatom- 
 ical change in the brain; it is mainly a disease of mature 
 life in the male and always terminates unfavorably. 
 
 The disease never begins suddenly, and indeed, as a rule, 
 certain morbid signs have appeared and disappeared for 
 several years. At first the disturbances are general in char- 
 acter: general malaise, irritability, frequent headaches. 
 The pain in the head is often annular or consists of a feel- 
 ing of pressure ; sometimes the sutures are especially sen- 
 sitive. The mood is irritated, often almost melancholic, 
 and is usually out of harmony with the existing circum- 
 stances and with the mood of healthy days. Hence the 
 disease has been called a progressive change of character, 
 accompanied at an early period by certain signs of mental 
 weakness. The latter feature is shown most distinctly by 
 the great forgetfulness and the readiness with which ex- 
 haustion occurs after mental work. At times the patients. 
 
PRODROMAL SYMPTOMS. 267 
 
 cannot bring themselves to do any work at all. The 
 weakness of memory affects chiefly the events of the 
 present and the immediate past. The ability to retain 
 new impressions is lost ; a visit, a meal, a matter of busi- 
 ness are forgotten at once. In comparison with what the 
 patient is still able to do, his exhaustion appears inexpli- 
 cable to his family, and they reproach him for his want 
 of energy. All mental work which is attended by inde- 
 pendent decisions becomes more and more impossible, 
 while mechanical routine work can be performed for some 
 time longer, although carelessness and omissions are early 
 noticeable. At the same time, or soon afterward, the pa- 
 tient is annoyed by more violent headache with scotomata 
 and pains in the eyes and tinnitus aurium ; his interpre- 
 tation of the present now becomes inaccurate, and con- 
 sciousness is clouded in a measure. A notable improve- 
 ment in these symptoms now takes place, as a general 
 thing, and they are replaced by other irritative conditions ;, 
 difficulty in breathing, fulness in the stomach, pains in 
 the limbs, and hence insufficient sleep. Finally, slight 
 disturbances of individual motor nerves are found very 
 often as prodromata of typical paralytic dementia. Oc- 
 casional awkward movements of the tongue, temporary 
 twitchings of the face, unilateral facial paresis, or tremor 
 of the limbs, are observed even at this time, so that all 
 the signs of the fully developed disease are indicated, viz. , 
 beginning mental weakness, vasomotor changes, and 
 motor disturbances. The combination of these signs is 
 important in distinguishing dementia paralytica from 
 neurasthenic conditions, in which mental weakness is 
 wanting. Moreover, the paralytic dement notices very 
 little or nothing of the change in his mental condition, 
 while the neurasthenic makes this change the central 
 point of his mental interest. 
 
 While the disease progresses in every direction, the 
 blunting of the feelings deserves special mention. The 
 indifference to sad and joyful events within the family 
 circle is especially striking if the patient has been a man 
 
268 HANDBOOK OF INSANITY. 
 
 of delicate feelings. Corresponding losses are also ob- 
 served in the aesthetic domain. The patient loses all 
 interest in art, science, and other higher intellectual pur- 
 suits, and exhibits a striking preference for coarse sensual 
 pleasures. True irritative phenomena, with excited or 
 depressed mood, are still absent, while distinct mental 
 weakness and helplessness are found in all psychical pro- 
 cesses, and the inability to concentrate the attention 
 becomes greater. The patient appears very absent-minded, 
 hardly notices what is going on about him, or his percep- 
 tions lack their former clearness. The uncertain inter- 
 pretation of external impressions increases the weakness 
 of memory and unites with it to form a condition of dull 
 brooding. If the mind is somewhat clearer, the deficiency 
 of judgment becomes so much more striking during con- 
 versation. Even at this time fantastic additions are made 
 to stories if their reality is disputed, or violent statements 
 are made as an expression of the irritable mood of the 
 patient who has been detected in exaggerations. 
 
 Perversities of action now become more prominent, par- 
 ticularly in aesthetic matters. Gross offences against cus- 
 toms, laws, and morals accumulate. The patients begin 
 to drink a good deal, frequent low resorts, address women 
 on the street in the most vulgar manner. In society, upon 
 the street, or in front of the open window they expose 
 their genitals without noticing the impropriety. Money 
 is wasted in the most extravagant manner and senseless 
 purchases are made. When their money is wasted debts 
 are contracted, but their payment is entirely forgotten. 
 All these acts are attended with an indescribable equa- 
 nimity, which is undisturbed by any remonstrance, simply 
 because the events do not reach the level of fully con-, 
 scious judgment. These symptoms may exist without 
 marked excitement or distinct delusions, so that the pa- 
 tients create the impression of drunkards. This is 
 understood so much more readily in view of the fact that 
 very small amounts of alcohol suffice to excite the patient. 
 -But the same conduct often continues long after the period 
 
CHANGES OF MOOD. 269 
 
 of action of the alcohol, and the internal excitement is 
 now manifested by the tendency to make numerous plans, 
 often merely by the repetition of visits to friends and 
 acquaintances, or even to strangers. 
 
 At this stage we find quite constantly a slight obstruc- 
 tion to the tongue, which becomes more distinct when the 
 excitement increases, together with slight associated 
 movements of the facial muscles in speaking and slight 
 tremor of the hands. This is sometimes associated with 
 vertigo or spasmodic attacks, after which the patients 
 very often recover somewhat of their mental tone. In an 
 equal number of cases, however, these mild attacks are 
 the boundary between the complete psychosis and its pro- 
 dromata. At the close of the prodromal period the mood 
 is extremely capricious, passing directly from cheerful 
 carelessness to morose tearfulness and reckless anger. 
 This irritability, on the one hand, and the ready exhaus- 
 tion, on the other hand, show most clearly the mental 
 weakness in the condition of the paralytic, although it is 
 unnoticed by the patient. 
 
 It is an astonishing feature, however, that the patient's 
 conduct is wrongly interpreted for a long time by those 
 around him. Thus, officers still continue in service de- 
 spite gross carelessness and irrational, often inhuman 
 treatment of their soldiers, and officials and merchants 
 are regarded as merely nervous despite the greatest dis- 
 order in their papers. It is only when distinct delusions 
 and other symptoms become marked or some single action 
 brings the patient in conflict with the criminal law that 
 the eyes of the family are opened. 
 
 Although the variability of the mood often leads to sad 
 notions, they are rarely prominent for a long time ; but the 
 delusions, which soon make their appearance in an expan- 
 sive form, are preceded for a longer or shorter period by 
 depressed delusions. The latter will be considered in de- 
 tail in the discussion of the depressive form of the disease. 
 Here we will at once discuss the ideas of grandeur which 
 develop, usually after a depressed interval. 
 
270 HANDBOOK OF INSANITY. 
 
 As a matter of course, the transition from the prodro- 
 mata to the complete disease is not abrupt, and at first 
 we find only indications of the ideas of grandeur. The 
 restless patient becomes enterprising and eager to improve 
 things. He determines to change his occupation and to 
 instruct the authorities in their duties. He telegraphs here 
 and there, and buys things in the most foolish and extrava- 
 gant manner, for example, a dozen coaches and twenty 
 parrots, etc. So long as he is not restrained the expan- 
 sive ideas are manifested by such acts, but when restraint 
 is exercised, as in an asylum, the mental weakness appears. 
 Instead of then attempting to gain his desires forcibly, he 
 is content to revel in the increased flight of his ideas. 
 There is a remarkable similarity in the contents of these 
 ideas, varying slightly with the social position, education, 
 race, sex. Men speak of size, riches, power, and glory; 
 women of dress, love, and children. The patients are 
 colonels, generals, princes, kings, and are called to lead 
 the nation, the world, the universe. They own castles 
 and palaces whose walls are made of gold. They possess 
 enormous treasures, beginning with hundreds of thousands 
 and soon reaching millions and billions. Their liberality 
 is unbounded and they dispense titles, offices, and treasures 
 to their relatives, friends, and others. The patient often 
 has no distinct notion of the monstrous character of his 
 statements, but much of it is mere boasting ; this is shown 
 especially by the facility with which the exaggerations are 
 increased when doubt is thrown upon them. The patient 
 is fond of bragging, and if he has just given away thou- 
 sands and more is asked, he is at once willing to give mill- 
 ions. But he rapidly forgets this, and may state that a 
 present of a few dollars is in itself a liberal one. It is 
 also surprising when we find that such a boaster himself 
 begs for a nickel or is happy at the gift of a cigar. Im- 
 mediately afterward he says that he is the emperor or 
 God, that he understands all the languages of the world. 
 When asked to speak in a foreign language, he declares 
 that he has forgotten it or makes some empty excuse. 
 
IDEAS OF GRANDEUR. 271 
 
 He does not attempt to combine his delusions into a 
 system, and the ideas of grandeur are loosely strung to- 
 gether; fanciful additions to his thoughts are usually 
 wanting, and frequent conversations almost always reveal 
 a great poverty of thought. The monotony of the con- 
 stantly recurring monstrosities shows the mental weak- 
 ness. The apparent productivity is often the result of the 
 questions put to the patient. The size of his assumed pos- 
 sessions often transcends his vocabulary, and he is com- 
 pelled to coin words in order to describe them. The boun- 
 daries of time and space disappear, the laws of nature and 
 probability are transgressed without hesitation. One pa- 
 tient possesses one hundred elephants with which he 
 ploughs the land, horses that play ou every instrument and 
 speak different languages ; he builds a railway of emer- 
 alds and rubies to the skies ; he lives in a diamond palace, 
 from which roads, made by himself, lead across the entire 
 earth, which he rules. Contradictions to former statements 
 are not uncommon. If the patient attempts to assume a 
 dignified appearance or majestic walk, this is often at vari- 
 ance with his miserable, uncleanly exterior. While he 
 invites mankind to great feasts at tables miles in length, 
 he walks about in torn clothes and with dirty hands. 
 
 The direct outcome of the idea of grandeur from the 
 morbid processes in the brain is sometimes shown when a 
 depressed mood appears temporarily. But exaggeration 
 remains the special sign ; the patient says he has squan- 
 dered billions, must remain in prison for thousands of 
 years. Such moods are often associated with slight at- 
 tacks of vertigo. 
 
 Another group of ideas of grandeur refers more closely 
 to the patient's own person and bodily sensations. These 
 notions often become more prominent when the height of 
 the excitement is passed. Everything appears rose-col- 
 ored, he is young and beautiful, is strong enough to over- 
 come hordes of the strongest men. He has an iron chest, 
 can fly or jump over church-steeples. When his pupils 
 are examined, he maintains that they are three yards 
 
272 HANDBOOK OF INSANITY. 
 
 wide. He boasts of his appetite, eats stuffed elephants,, 
 can drink a thousand bottles of champagne. His sexual 
 desires can only be gratified by an innumerable number of 
 women. Female patients give birth to the most beautiful 
 children, all twins or still greater number at a birth. 
 They have three or more husbands. In general, the ex- 
 pression of ideas of grandeur in women is confined within 
 more modest bounds than in men. 
 
 Similar ideas are entertained with regard to mental 
 ability. The patient is a poet and musician of the first 
 rank, writes all the law-books of the world, his thoughts 
 are all noble and great. With his waking thoughts he 
 mingles the fancies of his dreams. 
 
 Although there is a certain monotony in the repetition 
 of the same ideas of grandeur within definite boundaries, 
 there is within these limits a great variety of ideas which 
 change from minute to minute. Although they often re- 
 semble one another for long periods, even during the 
 entire duration of the disease, there are many in which, 
 for example, a patient who first called himself a wealthy 
 sovereign afterward proclaimed himself a great artist. 
 Fixed delusions are not present, but certain ones predom- 
 inate, around which other fleeting ones spring up and 
 disappear. The latter often lead the observer to suspect 
 poetic fancy and bright thoughts, but repeated observa- 
 tion enables him to recognize the dulness. 
 
 Although hallucinations may be entirely absent, they 
 are not very rare in the different periods and forms of the 
 disease. In the expansive form, especially in the period 
 of excitement under consideration, visual hallucinations, 
 chiefly oc<rur, such as angels and glistening shapes. Au- 
 ditory hallucinations are rare and the increasing dementia 
 makes them more indistinct. 
 
 The increasing failure of memory deserves further no- 
 tice. All measure of time is lost; the patient does not 
 know whether he has been in the asylum for days or 
 weeks and is ignorant of the day of the week. He for- 
 gets names, gives a wrong date to his birthday. 
 
DESCRIPTION OF PLATE IX. 
 
 PARALYTIC DEMENTIA. 
 
 In special cases this form of disease may present any of the forms 
 of expression shown in the previous plates, but the most important 
 signs are the paralytic phenomena, or rather the enfeebled use of 
 individual groups of muscles. Several pictures of the same indi- 
 vidual appeared to be best adapted to convey an idea of the twitch - 
 ings and irregular paresis. 
 
 In the first picture the man consciously sat for his photograph 
 and therefore assumed a comparatively intent expression. His at- 
 tention was then diverted and he was directed to say " photography. " 
 The attending difficulties led to irregular spasmodic contractions of 
 the muscles, and the difficult movement of the mouth is shown in 
 the picture. The distress resulting from the inability to articulate 
 the word is shown by the rectangular crossed furrows in the fore- 
 head. There is also a decided difference between the two sides of 
 the face. In the picture to the right the right eyebrow is more 
 wrinkled, the left eyebrow is more elevated, and there is a corre- 
 sponding increased furrowing of the forehead. The third picture 
 shows these phenomena to a less extent, but there is more marked 
 paralysis of the levator palpebrarum on the right side. 
 
 In the picture of the girl the slight ptosis of the lids is bilateral. 
 Otherwise the expression of her face is perfectly vacant. The ear 
 exhibits a shrunken hsematoma. 
 
HANDBOOK OF INSANITY. 
 
 KIRCHHOFF. 
 
 Plate IX. 
 
DISORDERS OF ARTICULATION. 273 
 
 Numerous bodily disturbances also occur, usually at the 
 same time as the psychical symptoms, sometimes earlier, 
 but also often later. They belong to the entire clinical 
 history, but for the sake of clearness must be described 
 separately. 
 
 Speech and voice are first affected. Articulation is in- 
 terfered with by tremor and irregular twitchings of the 
 muscles of the face, lips, and tongue. The tremor begins 
 generally near the naso-labial fold and in the upper lip. 
 The originally fibrillary twitchings are seen more dis- 
 tinctly when the patient is excited or begins to speak. 
 After a few words have been spoken, the twitching disap- 
 pears for a few minutes. In connection with other sus- 
 picious symptoms, it may permit a very early diagnosis, 
 as it is rare in other psychoses. It is seen occasionally in 
 melancholia, more often in neurasthenia, and may also be 
 a prodrome of bulbar paralysis. 
 
 Notable differences in the innervation of the facial 
 nerves may be found at an early period. The two halves 
 of the face become dissimilar, and we find imperfect 
 marking of the grooves in whose vicinity twitching of the 
 muscles takes place. One naso-labial fold is shallow or 
 obliterated, the angle of the mouth is lowered ; this side of 
 the face has less mimic expression and its contractions 
 are slow. True paralysis, however, does not exist, and 
 indeed complete paralysis is very rare at any period of 
 dementia paralytica. 
 
 The movements do not correspond exactly to their ob- 
 ject ; they are uncertain and irregular. Hence the motor 
 disturbances are most marked when fine, complicated 
 movements are to be performed. Thus, long before paraly- 
 sis of the lips, tongue, or palate is noticeable, we find a 
 disturbance of speech, due to insufficient quickness and 
 accuracy in the co-ordinated contractions of the groups of 
 muscles emploj^ed in articulation. The speech disturbance 
 of general paresis is an inability to combine letters into 
 syllables and syllables into words — it is essentially a dis- 
 order of articulation, but also of co-ordination. The letters 
 18 
 
274 HANDBOOK OF INSANITY. 
 
 forming a syllable are properly enunciated singly, but 
 they are combined with difficulty. This is also true of 
 the combination of syllables into words; some syllables 
 are omitted, others repeated, others placed in the wrong 
 position, so that the condition has been called syllabic 
 stuttering. During the development of these disorders 
 the exhaustion of the muscles becomes more distinct with 
 their repeated action. The tongue is protruded in short 
 jerks, because the requisite power is wanting and the 
 patient is uncertain with regard to the amount of force 
 required. Hence, when directed to protrude the tongue, 
 it is only advanced to the lower lip. The patient then 
 makes the queerest attempts to protrude it, even uses the 
 fingers for this purpose ; at the same time associated move- 
 ments occur, such as wrinkling of the forehead and open- 
 ing of the eyes. In speaking, the final syllables suffer 
 most. The indistinct enunciation of syllables may be 
 spasmodic, as in stuttering, or a slow dragging of a sylla- 
 ble, as in scanning. Certain labials and hissing sounds 
 suffer particularly, the mouth being opened as little as 
 possible ; when the lips are pressed together too forcibly, 
 speech may be entirely abolished for a time. At times 
 we hear a sudden improper accentuation of individual 
 syllables or words. 
 
 In the description given we find a combination of sev- 
 eral disorders of speech, which are described separately as 
 syllabic stuttering, stammering, scanning, bleating, lisp- 
 ing, hesitation, and tremor. It is difficult, however, to 
 make such sharply defined distinction, especially in para- 
 lytic dementia, because the anatomical changes may occur 
 in all those tracts to which the speech disorders may be 
 attributed. These domains are the beginning and end of 
 the cortico-bulbar speech tract; in the cortex, probably 
 near the motor centres of the central convolutions, we must 
 look for the co-ordination of speech expressions, in the 
 medulla oblongata for the formation of the elements of 
 speech (vowels and consonants). As the anatomical 
 changes do not occur uniformly or at the same time in all 
 
PHONETIC DISORDERS. 275 
 
 these tracts, the distinctions between the various speech 
 disorders are partly obliterated, and our description has 
 been confined, therefore, to the actual facts ordinarily 
 observed. But the more the disease is confined to the 
 cortex, the more distinct becomes the disordered co-ordi- 
 nation of the word as a unit composed of elements and 
 syllables, and these are jumbled up, either because the 
 sound memories are vague or because their coaptation 
 is carried out improperly. If the disease has developed 
 in the medulla oblongata, we find the interference chiefly 
 in the production of elements; at the same time the 
 movements of the tongue, cheeks, and lips are disturbed 
 in mastication, deglutition, whistling, etc. When the 
 disorder is mainly in articulation, the clinical history is 
 closely allied to that of numerous other diseases of the 
 medulla, such as multiple sclerosis and true bulbar paraly- 
 sis. Hence, only that disorder which has its origin in 
 the cortex can be regarded as characteristic ; in a few pure 
 cases this can be recognized separately. It is question- 
 able, however, whether the disturbance described as thick 
 speech should be referred to the cortex or the medulla ob- 
 longata. The phrases "truly rural," "national intelli- 
 gencer," and the words " electricity," " initiative," etc., are 
 especially adapted to bring out the speech disturbances in 
 question. 
 
 The matter becomes still more complicated when pho- 
 netic disorders appear. The degree of tension of the vocal 
 cords is sometimes permanently impaired, speech becomes 
 whispered, monotonous, lower in pitch. Occasionally the 
 patient becomes hoarse or makes improper use of his air 
 supply and the tension of the vocal cords. For example, 
 if the first sounds were too loud the voice soon sinks to a 
 whisper, and finally the breath fails completely. The 
 changed timbre is especially evident in singing. All these 
 disturbances depend mainly on the innervation of the lar- 
 yngeal muscles, but disturbed mobility of the velum palati 
 is also shown by a nasal voice. 
 
 An important proof of the speech disturbance of para- 
 
276 HANDBOOK OF INSANITY. 
 
 lytics is found in reading aloud. "Wrong words are read, 
 because the patient either mixes up the syllables of the 
 printed words or replaces the words by others which are 
 allied in meaning, sound, or appearance. At the same 
 time the letters composing these words may be pronounced 
 correctly, but difficult words are articulated by the intro- 
 duction of easier letters. There are also cases in which 
 the latter disturbance of articulation is absent and the 
 pure disorder of co-ordination appears. Syllables, espe- 
 cially terminals, are added to the words and sentences of 
 the text, some words are replaced by others of an entirely 
 different meaning, and in this way a new and incoherent 
 text is created. Repetition of the reading brings forth 
 constantly new combinations of syllables and words which 
 only possess a remote resemblance to the original. At 
 the same time the patient thinks he has read correctly, 
 although he fails to understand the text. This disorder 
 in reading sometimes precedes that in speaking. 
 
 We must now consider the disorders of speech which 
 depend upon disease of other parts of the cortex. Not in- 
 frequently we observe temporary attacks of true aphasia, 
 consciousness being either abolished or more or less im- 
 paired. These are due to circulatory changes, circum- 
 scribed cedemas in the cortex, or more pronounced changes 
 in the ganglion cells. Such conditions often follow so- 
 called paralytic attacks, which consist essentially of spas- 
 modic motor disturbances with impairment of conscious- 
 ness. For weeks the patient may be unable to find the 
 name of some object which he recognizes. Or there may 
 be entire loss of speech, with partial comprehension of sur- 
 rounding circumstances. The variability in these symp- 
 toms and their combination with the peculiar changes of 
 speech which we have already considered are character- 
 istic of paralytic dementia. Aphasia is permanent only 
 in focal destructions of the cortex — and this does not hap- 
 pen in typical paresis — or when complete dementia abol- 
 ishes speech. Increasing dementia is thus the last cause 
 of speech disturbance. When dementia has set in the 
 
PUPILLARY SYMPTOMS. 277 
 
 patient fails to understand language. It is characteristic 
 of the primordial importance of speech as the expression 
 of all psychical processes that even in the majority of 
 cases of focal aphasia intelligence gradually suffers, par- 
 ticularly because diffuse changes occur around the focal 
 lesion and the connections with other parts of the brain 
 are thus implicated. Inasmuch as paralytic dementia is 
 a diffuse affection of the cortex, it is evident that its co- 
 ordinatory and aphasic speech disturbances must be inti- 
 mately associated with increasing dementia. 
 
 A few words may be devoted to the disorders of the 
 contents of speech. The patients indulge in circumlocu- 
 tory expressions, use fanciful self-made words and terms 
 of expression, and return to the grammatical construction of 
 the days of childhood. Sometimes the patient talks as if 
 he were embarrassed, but as this develops during the 
 course of the disease, it may be assumed to be the result 
 of organic causes. Sudden interruption of a sentence, 
 however, may simply mean that the demented patient is 
 incapable of completing the line of thought. 
 
 We now turn to the disorders of other motor-cerebral 
 nerves which are not concerned in speech. Pupillary 
 symptoms are very important, but only when they have 
 developed during the disease, and other causes may be ex- 
 cluded. For this reason differences in the size of the 
 pupils often do not possess very great significance ; more- 
 over, this symptom is also observed in other psychoses. 
 More importance attaches to frequent changes in the size of 
 both pupils, especially during excitement, and to the trans- 
 fer of dilatation from one side to the other. In the latter 
 event the disorder is undoubtedly bilateral. Unilateral 
 dilatation indicates disturbed innervation on this side only 
 when the mydriasis is very marked. Otherwise it may 
 be due to contraction of the other pupil. In such a case 
 the disturbance is probably present in that eye whose iris 
 is less freely movable. There may also be irregularities 
 in the shape of the pupil. A much more frequent and 
 important sign is striking and permanent contraction of 
 
278 HANDBOOK OF INSANITY. 
 
 both pupils. This symptom is so significant that when any- 
 mental disturbance has been demonstrated it almost forces 
 us to the conclusion that it will develop into dementia 
 paralytica. Only the highest grades of myosis are signif- 
 icant, and the pupils are usually only as large as the head 
 of a pin. Vision remains unchanged. It is worthy of 
 notice that this marked myosis is also observed when dis- 
 ease of the spinal cord is absent. Shading or illumination 
 of one or both eyes is often unable to produce a change in 
 the size of one or both pupils, while they react to accom- 
 modation. Hence, there is reflex rigidity of the pupils 
 with retained accommodation mobility. This phenom- 
 enon is also tolerably frequent in dilated or moderately 
 dilated pupils. 
 
 Very pronounced and permanent mydriasis usually ap- 
 pears only toward the end of the disease. 
 
 Slight paralyses of individual ocular nerves, especially 
 the abducens or a branch of the motor-oculi, often pre- 
 cede the disease for years. The resulting diplopia dis- 
 appears, as a rule, after it has lasted for several months. 
 Temporary nystagmus and spasm, more frequently ptosis 
 of one or both lids, are also observed occasionally. Ac- 
 cording to recent investigations the latter symptom has a 
 cortical origin in the lower part of the parietal lobe. 
 
 The cortex also contains a centre for movements of 
 mastication, and it is therefore very probable, in the ab- 
 sence of changes in the medulla oblongata, that the symp- 
 tom of constant violent gritting of the teeth (very fre- 
 quently at the close of the disease) is due to disease of the 
 motor-cortical region. As this symptom is observed in 
 very few other psychoses, it becomes an important diag- 
 nostic sign. 
 
 Great importance attaches to disturbances of the nerves 
 regulating the movements of deglutition, because they 
 give rise to the risk of " swallowing the wrong way. " In 
 this way the danger of suffocation often arises toward the 
 close of the disease. The difficulty of deglutition is owing 
 rather to awkwardness than to true paralysis of the mus- 
 
GAIT. 279 
 
 cles. Such patients should be fed very slowly, because 
 they generally have a tendency to swallow food raven- 
 ously. 
 
 The movements of the a^ms and hands become awkward 
 at an early period, and the patients soon become unable to 
 thread a needle, button the clothes, etc. This awkward- 
 ness (often associated with rapid exhaustion) is sometimes 
 greater on one side of the body. A certain degree of 
 stiffness of the muscles soon adds a new obstacle to the 
 execution of intended movements ; tremor at such times 
 must also be regarded as a disturbance of innervation. 
 The incorrect gauging of the resistance and the degree 
 of muscular effort to be employed is the cause of irregular 
 jerky movements. 
 
 This is shown most distinctly in writing. Like speech, 
 the writing also discloses the mental condition of the pa- 
 tient. The letters themselves are uncertain, the strokes 
 extend beyond the normal limits and run in curved lines. 
 Blots are numerous, the paper is soiled, the ink is partially 
 rubbed out in places, the lines are written in different 
 directions, sentences are interrupted, punctuation is 
 senseless or entirely wanting. So long as writing is at 
 all possible the tremulous, uncertain character is distinct. 
 After the ability to write is entirely lost, the patient is 
 greatly embarrassed when requested to write, and usually 
 makes some excuse, such as "he cannot write without 
 glasses or does not feel inclined to write." In some cases, 
 however, writing is unaffected. If the disorder in writing 
 precedes speech disturbances — and this is quite often the 
 case — it forms a very important sign in the recognition of 
 the disease. 
 
 Apart from the complication with tabes the gait may 
 be affected to a notable degree. At first the walk may be 
 tolerably rapid, but there is a certain weakness of the in- 
 dividual movements, the steps are short, and the feet 
 are not lifted sufficiently, so that the patient stumbles 
 over inequalities in the ground or on walking upstairs. 
 The ataxic gait need not be described here. When lying 
 
280 HANDBOOK OF INSANITY. 
 
 in bed the legs can be moved freely for quite a long time, 
 but gradually the movements become tremulous and jerky, 
 slower and more rigid, until finally a certain rigidity and 
 tension of the muscles are the only evidence of the attempt 
 at motion. It is very often found that every attempt to 
 place the arms or legs in a new position meets with in- 
 creasing resistance. We must then ascertain whether 
 this resistance results psychically from notions of dread 
 and fear or is a result of direct irritation of the brain. 
 In the latter event the tension probably persists during 
 sleep. But the fear which is occasionally manifested is 
 less a psychical cause of the increasing rigidity of move- 
 ment than an involuntary expression of the dread that a 
 movement is required which will be attended with pain 
 on account of this tension of the muscles. In some cases, 
 however, the fear which depends upon the increased cere- 
 bral pressure may predominate over the rigidity which 
 also originates in the cerebral cortex. The patients then 
 resist every approach, do not allow themselves to be dressed 
 or undressed, press the jaws together with unyielding force 
 when food is offered; they often retain fecal discharges 
 for several days. Such rigidity, which may subside tem- 
 porarily, must be distinguished from spasms due to dis- 
 ease of the lateral columns of the cord. In fact, variations 
 in the degree of disturbance of the gait are, to a certain 
 extent, characteristic. 
 
 The lack of uniform innervation is also evident in the 
 position of -the trunk ; the body is held obliquely toward 
 one side, backward or forward. The position changes 
 frequently, but becomes somewhat more constant when it 
 is associated with the so-called paralytic attacks. 
 
 These paralytic attacks are very frequent, and may be 
 apoplectiform or epilectiform. They are found among 
 the prodromata of the disease; the "fainting spells" re- 
 ported by the family are probably of this character. At 
 a later period they become more distinct as apoplectic 
 attacks, the patients fall to the ground, and the ensuing 
 unconsciousness lasts longer. They rarely prove fatal 
 
EPILEPTIFORM ATTACKS. 281 
 
 directly, but their sequelae often terminate in death. 
 They differ from true cerebral hemorrhage in that perma- 
 nent severe paralysis is wanting, but there is a constant 
 impairment of motion in certain groups of muscles on 
 one side of the body. The rapid course of such attacks 
 and the absence of post-mortem findings force us to con- 
 clude that they are the result of sudden, circumscribed 
 circulatory changes in the brain, perhaps followed by 
 oedema. 
 
 The epileptiform paralytic attacks must be regarded as 
 the results of direct irritation of the cortex. The attacks 
 are generally preceded by greater irrationality and in- 
 creased difficulty of movement, occasionally by increased 
 psychical irritability and a feeling of vertigo. The patient 
 suddenly falls to the floor and convulsions set in, either 
 general or unilateral. In a few cases the convulsion at- 
 tacks the head, limbs, and trunk in a certain order. The 
 unilateral convulsions often extend, in a little while, to the 
 rest of the body, thus resembling true epileptic seizures. 
 
 The spasms are sometimes confined to one side of the 
 face, or this is associated with constant movements of the 
 tongue. After the attack, twitchings of certain muscles 
 of the face or arms sometimes continue for hours. After 
 complete cessation the patients are very confused for a 
 long time. A considerable increase of mental weakness is 
 noticed almost constantly, and the dementia often develops 
 suddenly after the attacks. They may also be followed 
 by disturbances of speech and hemiplegia, but these gener- 
 ally recover in great part. The attacks recur at irregular 
 intervals of days, weeks, and months, and very rarely are 
 they entirely absent. They sometimes occur in series; 
 hundreds of attacks have been observed within a few days, 
 and then death generally follows. This termination has 
 also been observed within a few hours after a few attacks. 
 They may also be followed by maniacal excitement or the 
 latter may take their place as a psychical equivalent. 
 During the attacks the temperature generally rises, and 
 sometimes exceeds 41° C. 
 
282 HANDBOOK OF INSANITY. 
 
 Disorders of the bladder and rectum, independent of 
 disease of the spinal cord, are due to insufficient atten- 
 tion on the part of the patient. Complete paralysis of the 
 sphincters only occurs in general paralysis attending 
 spinal diseases. 
 
 Numerous psychomotor disorders occur as irritative 
 phenomena during the course of the disease. For exam- 
 ple, slight catalepsy and peculiar postures of the limbs. 
 "We also find useless imperative movements, which occur, 
 however, in the shape of co-ordinated movements, such as 
 clapping the hands, picking, rubbing. These may also be 
 due in part to local irritation of the skin. 
 
 Finally, the motor disorders of dementia paralytica are 
 often associated with systemic diseases of the cord, es- 
 pecially tabes and .spastic spinal paralysis. The not 
 infrequent combination of tabes and paralytic dementia 
 compefs us to assume an intimate relation between them. 
 These cases are distinguished from simple dementia para- 
 lytica by the distinct sensory symptoms, the ataxic gait, 
 Romberg's symptom, and optic-nerve atrophy. It is not 
 improbable that these phenomena are associated with the 
 extension of the disease to the occipital cortex. Descend- 
 ing disease of the lateral columns occurs almost constantly 
 in slowly progressing dementia paralytica. In such cases 
 the spastic symptoms are much more permanent and pro- 
 nounced than in other cases. 
 
 The reflex excitability, which is occasionally increased 
 at the beginning, diminishes quite constantly toward the 
 close of the disease. If the reflexes are increased in com- 
 plete dementia, it may be explained by the abolition of 
 the inhibitory influence of the brain. But diminution of 
 the superficial and deep reflexes is almost always associated 
 with disease of the spinal cord, especially tabes. 
 
 Rare, and probably accidental, disorders are peripheral 
 paralyses due to a neuritis. The observation of cases of 
 paralytic dementia which followed peripheral paralyses 
 has led to the suspicion that the former may develop from 
 
.ANAESTHESIAS. 283 
 
 the latter, but this mode of development has not been 
 demonstrated. 
 
 Neuralgias are frequent not alone among the prodromata, 
 but also during the disease. They are perhaps dependent 
 on meningitic processes or upon circulatory disturbances 
 in the brain itself. 
 
 This is true of anaesthesias only to a certain extent. Cer- 
 tain anaesthesias are undoubtedly due to cortical lesions, 
 but these are confined to small portions of the body. This 
 occurs when the parietal cortex is involved, and the mus- 
 cular sense seems to be especially affected. But as anaes- 
 thesia commonly develops only in the later period of the 
 disease, the dementia is commonly too far advanced to per- 
 mit us to obtain accurate data concerning its situation. 
 Disorders of feeling are very important, however, because 
 they may be the cause of numerous severe injuries and 
 mutilations, such as burns from cigars, a stove, bites in 
 the tongue, etc. Delusions which are due to the disorder 
 of sensation increase the danger. Mere insensibility of a 
 limb may induce the patient to regard it as something 
 foreign, and therefore to inflict injury upon it. 
 
 Occasional losses in the domain of the special senses also 
 depend upon the extension of the disease to the posterior 
 brain. This has been observed more accurately in regard 
 to the sense of sight. Such symptoms must be distin- 
 guished, for example, from those which result from atro- 
 phy of the optic nerve in tabes, or from diseases of the 
 eye, especially inflammations of the retina. We refer to 
 disorders of vision which point to the cortex as their source 
 on account of their unilateral character. The color sense 
 may be impaired, likewise the distinction between light 
 and dark. The various forms of contraction of the field 
 of vision which are due to focal lesions may occur tem- 
 porarily in dementia paralytica. 
 
 It is also very probable that the subjective light phe- 
 nomena and visual hallucinations which are observed 
 occasionally in paralytics are the result of irritative con- 
 
284 HANDBOOK OF INSANITY. 
 
 ditions in the occipital cortex. Hallucinations of all kinds 
 may also occur in dementia, but they are rarer than in 
 other psychoses and have less influence, on account of the 
 dementia, upon the patient's conduct. 
 
 Vasomotor disorders are of great importance in this dis- 
 ease. The variable character of many of the mental and 
 bodily symptoms appeared to show that the vasomotor 
 system is the first to be implicated, and this is also evident 
 in the subsequent course of the disease. The pulse is fee- 
 ble and shows that the walls of the vessels are distended 
 very gradually. Progressive paralysis of the entire vaso- 
 motor system leads to temporary complete paralyses in 
 certain parts. These include vertigo, apoplectiform at- 
 tacks, unilateral sweating, rush of blood to the head and 
 face, local redness of the skin — all of which rapidly appear 
 and disappear. This alternates with spasm of the vesssels, 
 shown by pallor of the skin and a feeling of coolness. 
 Toward the end of the disease permanent vasomotor paraly- 
 sis is evinced almost constantly by the cedemas and cyano- 
 sis, especially of the hands and feet. Punctate hemorrhages 
 into the skin, also hemorrhages from the internal organs, 
 particularly the bowels, are observed. These symptoms 
 are attributed to implications of the sympathetic nervous 
 system and probably are due, in part, to a direct affection 
 of the cerebral cortex. 
 
 Closely related to the vasomotor changes are the trophic 
 disturbances, but we must be careful to exclude lesions 
 which result from external injury. The most important 
 trophic changes are the othematoma, fractures of the bones, 
 and gangrene from pressure. These cannot be attributed 
 solely to external mechanical influences, such as a blow or 
 pressure, because the often trivial injury could not pro- 
 duce such severe effects were it not for the vasomotor - 
 trophic basis. 
 
 Respiration is usually unchanged. It is probable that 
 the frequent pneumonias are not due to vasomotor paraly- 
 sis, but that they are " foreign-body" pneumonias. 
 
 Dementia paralytica usually runs an apyrexial course, 
 
DEPRESSION IN DEMENTIA. 285 
 
 and the bodily temperature may not be raised even during 
 inflammatory complications. On the other hand, disten- 
 tion of the bladder and rectum may occasion brief pro- 
 nounced rise of temperature. When the disease is far 
 advanced the temperature often falls below 37°. 
 
 We will now turn to the consideration of the rarer 
 depressive form of general paresis. It begins with the 
 same prodromata as the already-described expansive form, 
 so that it is only recognized by the constant predominance of 
 melancholic feelings and ideas. Fear and delusions, which 
 are perhaps always associated with conditions within the 
 body, always possesss a monstrous and unmeasured char- 
 acter. Loud outcries, with all the signs of inner restless- 
 ness, and sudden suicide are not uncommon, even when the 
 dementia is comparatively far advanced. If the affect has 
 subsided and the mental faculties can still develop ideas 
 with a certain connectedness, we find simple melancholic 
 self- accusations, mingled with depressed feelings con- 
 cerning the patient's own body. Such a condition of con- 
 sciousness may long be concealed beneath a rigid bearing 
 before complaints are uttered. Sometimes these are uttered 
 very early and can be distinguished from simple melan- 
 cholia by their peculiar monstrous character, apart from 
 the other symptoms of paralytic dementia. It is equally 
 common, however, to find ideas which might belong to 
 the history of simple melancholia. In other cases the 
 patient is tormented by the idea that he has contracted 
 debts of hundreds of thousands or millions of dollars, that 
 he has been converted into a glass house, or that his head 
 or brain is shrivelling and drying. Surrounding persons 
 and objects may also appear to shrivel until the very 
 existence of life is denied. Sometimes the mood of nega- 
 tion is shown in acts rather than in speech. The patients 
 offer resistance to everything that is done for them, spit 
 out the food that is placed in their mouths, tear their 
 clothes. 
 
 We have already seen that the depressed mood some- 
 times forces its way into the expansive mood. If this 
 
28G HANDBOOK OP INSANITY. 
 
 occurs with a certain regularity, the term circular form 
 of dementia paralytica is applied, but such a condition is 
 rarely observed in a pronounced form. 
 
 If delusions and material changes of mood are wanting, 
 then dementia, in addition to the other signs of paresis, 
 predominates in the course of the disease. Impairment 
 of memory and of psychical functions of all kinds develop 
 gradually until the dementia reaches the same degree as 
 in the other forms, accompanied by all the bodily disorders 
 of the disease. Hence all the different varieties resemble 
 one another completely at the close of the disease. The 
 latter, so-called demented form, is found with comparative 
 frequency in women. These patients are not transferred 
 so frequently to asylums, because the mental signs of the 
 disease are milder and lead more rarely to conflicts with 
 law and order. In many of these cases the condition is 
 mistaken for a long time for neurasthenia. It develops 
 at a comparatively early age, sometimes even before the 
 thirtieth year. 
 
 The course of paralytic dementia in general is subject 
 to many changes, and all the symptoms of the disease may 
 disappear so completely that we are tempted to believe 
 in true recovery. After a time, sometimes even after 
 the lapse of one or two years or more, more severe symp- 
 toms reappear, and thus confirm the progressive character 
 of the ailment. But as a rule there is a steady increase 
 of the dementia as well as of the motor symptoms. The 
 duration is extremely variable, but averages about three 
 years. In elderly people and in women the duration is 
 longer. If dementia predominates, without delusions or 
 affects, the course is also much prolonged and, according 
 to some, may extend over twenty years. Exceptional 
 cases run their course, with violent symptoms, in a few 
 months or even weeks. These galloping cases are of tenun- 
 recognized and are, perhaps, sometimes included under so- 
 called acute delirium, to which we have already referred. 
 
 It remains for us to consider the termination which is 
 common to all forms of the disease unless its course has 
 
TERMINATIONS. 287 
 
 been interrupted by severe paralytic seizures or diseases 
 of various organs. If this does not happen, the dementia 
 constantly increases and a mere vegetating body remains. 
 Finally, walking becomes impossible and the hands be- 
 come incapable of independent movement. The helpless 
 patient then lies in bed, passes urine and faeces involun- 
 tarily. Slow compression-gangrene often accelerates the 
 termination, or this is brought about by some complica- 
 tion, such as pneumonia, suffocation by food, nephritis, 
 etc. If the patient escapes these dangers he emaciates 
 and gradually succumbs. 
 
 At the beginning of quiet dementia and after the affects 
 have subsided, many patients acquire a temporary obesity 
 which persists so much longer, the slower the course of 
 the disease. Toward the end of the disease we sometimes 
 find brief periods of excitement, and certain irritative 
 symptoms, such as grinding of the teeth, may become 
 prominent. In fact, the latter symptom may persist until 
 death. 
 
 Paralytic dementia terminates, therefore, in death, in- 
 asmuch as complete recovery and the very slow forms are 
 so extremely rare that they need hardly be considered in 
 prognosis. Unless the fatal termination results from sui- 
 cide, suffocation, injuries, paralytic attacks, compression- 
 gangrene, or internal diseases, the patients die from gen- 
 eral exhaustion. But with careful treatment at the onset, 
 improvement or retardation of the course of the disease 
 may be effected to such an extent that the patients may 
 remain capable of mental work for a long time. Some 
 observations appear to show that remissions are only last- 
 ing in the expansive form of the disease and when speech 
 disturbances are very slight or almost absent, while the 
 depressed or demented forms hardly ever present such im- 
 provement. 
 
 The development of the disease is favored by the nox- 
 ious influences inherent in the agitated life of recent times, 
 especially when associated with want, worry, and bodily 
 excesses. Hence it occurs chiefly in men of mature years. 
 
288 HANDBOOK OF INSANITY. 
 
 The disease may develop between the ages of twenty 
 and sixty years, but it is by far most frequent between the 
 thirty-fifth and forty-fifth years. Outside of this period 
 the diagnosis may only be made when all other possibilities 
 are excluded. Cases have been reported, however, as 
 early as the age of twelve. In women the influence of the 
 menopause somewhat extends the age limit. Females are 
 attacked about one-sixth as often as males. Women of 
 the higher classes rarely suffer. Military officers, mer- 
 chants, firemen, railway and telegraph officials suffer in 
 strikingly large numbers; lawyers and physicans are also 
 attacked with comparative frequency. Heredity does not 
 play so important a part as in other psychoses, and the 
 disease is much more often acquired from mental over- 
 work. It is probable that syphilis is an important predis- 
 posing cause, but when severe symptoms of syphilis are 
 still present the signs of dementia paralytica are not typi- 
 cal, as we will see later. Alcoholic excesses alone give rise 
 to different symptoms, but drink combined with sexual 
 excesses very often result in typical paresis. Dementia 
 paralytica after injuries to the head also exhibits some 
 special symptoms. 
 
 The microscopic changes in the brain extend at the same 
 time to the blood-vessels and the interstitial tissue, and 
 later involve the entire brain substance. In the vascular 
 sheaths are found red and white blood globules, the vessels 
 are filled with blood and often bent. Thickening of the 
 wall makes the vessel narrower, in places the nuclear pro- 
 liferation in the sheaths produces a nodule, and sometimes 
 miliary aneurisms are found. In other places connective- 
 tissue prolongations sprout from the sheaths of the vessels. 
 In some cases the disease of the vessels is also found in 
 other organs. 
 
 The basement substance in a large part of the cortex 
 contains an increased number of nuclei. In addition, we 
 find numerous lymphoid wandering cells and connective- 
 tissue cells, among which spider cells are especially prom- 
 inent in the layers of the cortex and in the white matter. 
 
ANATOMICAL CHANGES. 289 
 
 Extensive adhesions of the meninges to the surface of the 
 brain are found only in those places in which there is in- 
 crease of the connective-tissue cells, and a condensation of 
 the basement substance (so-called sclerotic atrophy) . Such 
 adhesions are found frequently but not constantly ; they 
 may be absent in slowly progressing cases in which great 
 thickening of the meninges has occurred. It is probable, 
 indeed, that the adhesion is only temporary, that it de- 
 pends on swelling of the basement substance and may 
 disappear with it. This does not occur until shrinking of 
 the entire brain tissue has set in. Perhaps the absence of 
 adhesions may also be due to mechanical conditions, inas- 
 much as variations in intracranial pressure will affect 
 chiefly the cortex. This may explain the fact that the 
 adhesions are never so pronounced in the sulci as upon the 
 convexity of the convolutions. On the other hand, certain 
 mechanical processes of softening after death explain, in 
 part, the fact that detachment of the meninges generally 
 removes the cortex in definite layers. Previous disease of 
 the tissues, however, is the cause of the more rapid soften- 
 ing of certain layers in the dead body or the firmer adhe- 
 sion of other layers. The chronic interstitial inflamma- 
 tion sometimes gives rise to sclerosis of the tissues ; in 
 these rare cases the brain substance is hard and firm on 
 section. 
 
 The morbid processes in the nerve cells may be briefly 
 summarized. The pyramidal cells of the middle layers 
 are often affected most distinctly, and hence the cortex 
 often tears here when the membranes are detached. The 
 ganglion cells in general are at first swollen, contain large 
 nuclei which almost fill the cell, and also a very distinct 
 nucleolus. In time they shrivel, lose their sharp outlines, 
 and the cell processes disappear. Fatty degeneration and 
 pigmentation, calcification and the formation of vacuolse in 
 the cells need merely be mentioned here. 
 
 There is also a distinct atrophy of medullated nerve 
 fibres, and quite often only in certain parts of the cortex 
 and medullary tissue. This is found, in approximately 
 19 
 
290 HANDBOOK OF INSANITY. 
 
 the same way, only in closely allied forms of dementia, 
 such as senile and epileptic dementia, and in connection 
 with the other findings it is characteristic of general pa- 
 resis. 
 
 The changes visible to the naked eye appear in the 
 following manner. Distinct opacity and thickening of 
 the meninges extend from the top of the frontal lobe more 
 or less uniformly over the parietal portions to the occipital 
 lobe, where a sharply defined border is sometimes observed. 
 These cases seem to be unattended with disturbances of 
 vision. Even when the latter are present, the extension 
 of the disease over the occipital lobes is not always so 
 distinct that we may assume an unquestioned relation 
 between them. The thickening of the meninges is a proof 
 of disease of the underlying cortex. In dementia para- 
 lytica it is always connected with encephalitic processes, 
 while simple leptomeningitis may develop independently. 
 Corresponding to the distribution of the microscopic 
 changes, the thickening and adhesions of the meninges 
 are most pronounced at the base of the frontal lobes, the 
 median aspect of the hemispheres and the region of the 
 island of Reil, while the parietal lobes are less affected, 
 especially toward the base. "When the speech disturbances 
 were very pronounced an unusual degree of adhesion of 
 the pia to the speech convolutions on the left side has been 
 noted. In a number of cases the adhesions at the base of 
 the frontal lobes were associated with tabetic symptoms. 
 
 The atrophy of the convolutions affects mainly the fron- 
 tal lobes, the superior parietal convolutions, and sometimes 
 the adjacent part of the temporal lobe and insula, occasion- 
 ally the occipital lobe. In these regions the convolutions 
 are narrowed and sometimes exhibit sharp edges, the sulci 
 gape ; certain parts are sunken. A section of the convo- 
 lutions shows that the gray cortex is very narrow. The 
 entire weight of the brain, and especially of these parts, 
 is greatly lessened. The diminution, on the average, is 
 100-200 gr., but sometimes the weight of the brain falls 
 below 1,000 gr. (the average weight of the brain in adult 
 
ANATOMICAL CHANGES. 291 
 
 males is 1,350, in females 1,250). The changes men- 
 tioned are usually distributed uniformly over both hemi- 
 spheres, but no slight differences in this regard are some- 
 times found. 
 
 The ventricles of the brain may be greatly dilated so 
 that the atrophy of the brain tissue between them and the 
 surface is very pronounced ; atrophy of the basal ganglia 
 is exceptional. Recently, however, atrophy of the optic 
 thalamus has been observed in the posterior region, espe- 
 cially the pulvinar, and has been supposed to be related to 
 suddenly developing disorders of tactile sensation, speech, 
 and vision. More frequently the optic tract and its ap- 
 pendages are atrophied, more rarely the olfactory bulb 
 and other cerebral nerves. 
 
 Distinct atrophy of the fibres has been found occasion- 
 ally in the central tubular gray matter, and this is sig- 
 nificant because it contains numerous fibres which connect 
 it with the optic thalami. Certain observations seem to 
 show that it is the path for the production of expressive 
 movements, and that the association of the thalamus and 
 central tubular gray matter may perhaps be the central 
 point for mimic innervation. At all events, there appears 
 to be no doubt that in dementia paralytica the more com- 
 plicated disorders of movement may be considerably in- 
 creased by the atrophy of fibres in the central tubular 
 gray matter. 
 
 Greater clinical interest attaches to hsematoma of the 
 dura mater, although it is not very constant and is also 
 found in other psychoses, injuries to the skull, other dis- 
 eases of the brain, and occasionally in constitutional dis- 
 eases, such as tuberculosis. The hsematoma is a membrane 
 on the inner surface of the dura mater, usually in the 
 distribution of the middle meningeal artery (at the apex 
 of the parietal lobes), but sometimes extending to all the 
 cerebral fossae. It is generally a loose yellowish deposit, 
 infiltrated with hemorrhagic extravasations, and can be 
 separated from the dura. Renewed hemorrhages may 
 gradually result in a very extensive membrane, which 
 
292 HANDBOOK OF INSANITY. 
 
 may produce special symptoms as the result of com- 
 pression of the brain (especially series of epileptiform 
 attacks) . 
 
 Changes are sometimes found in the nuclei of the me- 
 dulla oblongata, for example, colloid degeneration of the 
 hypoglosssal and facial nuclei. 
 
 Apart from the disease of the posterior columns of the 
 spinal cord peculiar to tabes, we very often find a chronic 
 myelitis of the postero-lateral columns, especially when the 
 dementia runs a slow course. More rarely there are scat- 
 tered myelitic or sclerotic foci. In galloping dementia the 
 spinal cord is unchanged. 
 
 The diagnosis of progressive paresis with delusions of 
 grandeur is usually not very difficult when the disease 
 has reached its height. It is more difficult during the 
 prodromal period. Special consideration must be paid to 
 the change of character, the loss of former higher interests, 
 ethical ideas and aesthetic feelings, and the impairment of 
 memory and judgment; then the mild vertiginous attacks 
 and the numerous motor disturbances among which the 
 more prominent are myosis and the speech disorders ; at- 
 tention may again be called to the increase of the latter on 
 reading aloud as an aid in diagnosis. It is well to have 
 the patient read rapidly, when all defects often become 
 surprisingly distinct. 
 
 At this period neurasthenics present many of these 
 symptoms. But profound change of character and ethi- 
 cal and intellectual weakness are absent in neurasthenia. 
 The patient also observes the motor symptoms very care- 
 fully, while the paralytic usually does not notice them. 
 Tremor of the tongue and associated movements of the 
 facial muscles in speaking are seen very rarely in neuras- 
 thenia. The readiness with which such patients are ex- 
 hausted is shown by the increase of the speech disorders 
 after exertion, but after a night's rest they are least pro- 
 nounced. In dementia paralytica the speech disorder is 
 also distinct immediately after waking. The mental 
 weakness in the latter is also shown by the insufficient 
 
DIAGNOSIS. 293 
 
 arrangement of speech concepts, so that there is much 
 greater hesitation in speaking. 
 
 For a time the disease may sometimes be mistaken for 
 mania, when delusions of grandeur and a condition of ex- 
 citement are well developed. But mania develops with 
 comparative rapidity, while the prodromes of paresis often 
 date back for years. Attention should also be directed to 
 the monstrous, unbounded character of the delusions of 
 grandeur. Finally, the speech disorders and paralytic 
 seizures possess decisive importance. There are, however, 
 cases in which the symptoms of complete mania last for 
 several months before motor disturbances begin. 
 
 If a depressed mood predominates and the delusions 
 have negative contents, especially when they are associated 
 with feelings of derogation concerning the patient's own 
 body, the condition may be mistaken for melancholia. If 
 evidences of mental weakness are found, and especially if 
 the age is favorable to the development of dementia para- 
 lytica, the outbreak of this disease is to be feared. 
 
 At certain periods paranoia exhibits certain similarities 
 to dementia paralytica, but they disappear on closer obser- 
 vation. The delusions of the former are firmly systema- 
 tized, and it exhibits no motor disorders. There is also a 
 great difference in the two diseases with regard to the 
 mental ability and judgment .of matters which are not 
 related, to the contents of the delusions. For example, the 
 paranoiac almost always recognizes insanity in others : the 
 paralytic dement hardly ever does so. 
 
 The forms of dementia which are associated with paral- 
 yses (and which will be discussed in the following section) 
 are distinguished by the greater constancy of the accom- 
 panying hemiplegias or other paralyses. The development 
 and course of the disease and the age of the patient also 
 aid in diagnosis. Mistakes are often made, however, es- 
 pecially when diffuse and circumscribed changes in the 
 brain are associated with one another. 
 
 Without a knowledge of the previous history it is often 
 •difficult to distinguish general paresis from epileptic in- 
 
294 HANDBOOK OF INSANITY. 
 
 sanity, because the latter may also exhibit weakness of 
 memory, speech disorders, occasionally even delusions of 
 grandeur, and an epileptiform attack may occur in the 
 same manner in both affections. In epileptics, however, 
 all these symptoms usually diminish rapidly as the inter- 
 val after the attack increases. The religious character of 
 the delusions, the reckless violence of the acts of the epi- 
 leptic, who is usually in a dreamy state, are further means 
 of differentiation. Apart from the fits, an epileptic dement 
 may resemble a paralytic dement very closely, but this 
 form of dementia usually develops at an early age, and 
 remains in statu quo for many years. 
 
 The treatment of the disease in its incipiency is of chief 
 importance to the practitioner because the fully developed 
 malady offers no prospect of recovery. 
 
 Inasmuch as mental strain of every kind is the chief 
 etiological factor, the first requisite is the greatest possible 
 rest. This necessitates the removal of the patient from 
 his accustomed surroundings. He is thus separated from 
 his occupation and family, and at the same time from a 
 hundred slight influences which daily irritated him. The 
 new surroundings should contain no new irritants ; hence 
 a prolonged stay in the country with a stranger is advisa- 
 ble. Travel for purposes of recreation should be avoided. 
 Bodily and mental repose must be secured in all directions. 
 If morbid sexual excitement is manifested in a married 
 man, the removal of the possibility of excesssive inter- 
 course will exert a good influence. If he seeks to gratify 
 his desires with other women, this very fact may make it 
 necessary to transfer him to an asylum. This may also 
 be necessary at the start, on account of a tendency to sui- 
 cide, refusal to take food, extravagance or offences against 
 public morals. Otherwise the patient should not be re- 
 moved to an asylum at too early a period, especially if 
 violent affects are absent. When nursing and the care of 
 the patient become difficult, he may be removed to a hos- 
 pital. But when the disease exhibits notable remissions, 
 which may even render the resumption of work possible,, 
 
TREATMENT. 295 
 
 it is surely in the interests of the patient to keep him out 
 of an asylum as long as possible. If the conditions favor 
 treatment outside of an asylum and away from home, at 
 least six months to a year will be required to secure any 
 prospects of permanent success. 
 
 We must warn against excessive cold-water cures and 
 douches, and also against all exhausting methods of treat- 
 ment, such as anti-syphilitic treatment with mercurial 
 inunctions. In some cases this is followed by rapid loss 
 of power and the development of violent excitement. In 
 cerebral syphilis with paralytic symptoms inunction treat- 
 ment offers greater chances of success. But if the paral- 
 ysis has developed to such a degree that atrophy of the 
 brain tissue may be assumed, we must protest vigorously 
 against active treatment by inunctions. Hypodermic in- 
 jections of mercury seem to be especially dangerous on 
 account of the frequent formation of abscesses. Even 
 when inunctions are employed at an early stage, they 
 should only be continued for a short time; if improve- 
 ment does not take place rapidly, the treatment should be 
 discontinued. 
 
 Potassium iodide is a less dangerous remedy than mer- 
 cury, but no unquestioned successes have been obtained 
 through the action of this agent. Inunctions of tartar- 
 emetic ointment upon the shaven scalp have been recom- 
 mended, but the results are more than doubtful, and this 
 measure should not be employed in private practice. 
 
 Insomnia requires early treatment. The remedy which 
 succeeds most frequently is chloral hydrate, in combina- 
 tion with morphine. Chloral may not be given con- 
 tinuously because it increases the weakness of the vascu- 
 lar system, as shown by local cutaneous affections and 
 rapidly spreading compression-gangrene. In many cases 
 sulfonal is a good substitute, and if this is refused injec- 
 tions of hyoscine often give good results. 
 
 Anxious excitement, which may attain the highest 
 grades, is best combated by hypodermics of morphine. 
 Milder grades are relieved by prolonged baths. Violent 
 
296 HANDBOOK OF INSANITY. 
 
 restlessness generally subsides after isolation, which i 
 usually be of short duration. 
 
 In paralytic attacks of long duration the evacuation of 
 the bladder and rectum must be carefully attended to. 
 The increasing imbecility sometimes necessitates artificial 
 feeding, preferably through the nose. The danger of 
 " swallowing the wrong way" is best avoided by carefully 
 feeding the patient. 
 
 Careful attention to cleanliness by frequent lukewarm 
 baths seems to prevent bed-sores ; the position of the body 
 must also be changed regularly. The greatest difficulties 
 in nursing arise when rigid tension of the muscles, with 
 feelings of fear, has developed. Cleanliness and feeding 
 then demand forcible interference. 
 
 D. OTHER FORMS OF DEMENTIA WITH PARALYSIS. 
 
 Cerebral Syphilis. 
 
 The relations of syphilis to dementia paralytica have 
 already been considered. "When it appeared to act as a 
 casual factor, the period which elapsed between its ex- 
 istence and the onset of the dementia was usually so long 
 that it appeared to act rather by producing general weak- 
 ness of the organism than by specific disease. A differ- 
 ent condition results when definite anatomical changes 
 of a specific character are associated directly with clin- 
 ical symptoms. We will first consider diffuse syphilitic 
 affections. 
 
 Post-mortem examinations have shown that cerebral 
 hemorrhages, as the result of syphilitic disease of the ves- 
 sels, may occur as early as the fourth month after infec- 
 tion, and that a third of the cases of syphilitic disease of 
 the nervous system occurs within the first year. In a ma- 
 jority of cases, however, nervous syphilis does not begin 
 until years after infection. The localization in the brain 
 may be determined by cerebral concussion or mental over- 
 work. The disease is first manifested in the small arter- 
 
VESSEL CHANGES. 297 
 
 ies, which become narrowed and are finally converted into 
 impermeable bands. Gummous new formations on the 
 vessels are also found. 
 
 The changes in the vessels produce partial or complete 
 interference with circulation in the corresponding parts of 
 the brain, with or without softening. This explains the 
 fleeting character of circumscribed paralyses due to the nar- 
 rowing of small arteries, and the obstinacy of such symp- 
 toms as hemiplegia and aphasia, which are due to occlu- 
 sion of larger vessels. As the changes in the vessels are 
 almost always associated with inflammation of the dura 
 mater and adhesion of the meninges to the convexity of 
 the brain, we thus find anatomical conditions which serve 
 to explain the similarities as well as the differences be- 
 tween cerebral syphilis and typical dementia paralytica. 
 The accompanying symptoms often lead to the diagnosis of 
 cerebral syphilis. A characteristic sign is the extremely 
 violent headache which is very obstinate and is especially 
 severe at night. Another important symptom is circum- 
 scribed anaesthesia, particularly in the face, associated 
 with paralysis of the third nerve. Other cerebral nerves 
 may also be paralyzed, but the changeability of the symp- 
 toms is usually a striking feature so long as larger foci of 
 disease are wanting. In addition there is a combination 
 of symptoms in anatomically distinct tracts ; for example, 
 left hemiplegia and aphasia, paresis of the right leg and 
 left arm, etc. — symptoms which cannot be referred to a 
 single origin. These conditions develop and usually dis- 
 appear gradually. Complete loss of consciousness is not 
 common, but peculiar conditions, like intoxication, are ob- 
 served, from which the patients can only be roused incom- 
 pletely ; at times they give surprisingly rational questions 
 and then relapse quickly into deep sleep. 
 
 The mental disorders are also characterized by incom- 
 pleteness of the symptoms when small vessels are affected. 
 The location of the disease in the frontal lobes gives rise 
 to symptoms which closely resemble those of paralytic de- 
 mentia. Usually this is the pure demented form, with- 
 
298 HANDBOOK OF INSANITY. 
 
 out increased or diminished affects; pronounced delusions 
 are still less frequent, although delusions of grandeur are 
 occasionally distinct. A striking discrepancy is shown 
 when a patient who is apparently profoundly demented 
 unexpectedly manifests the delusions of grandeur, as the 
 result of some accidental external cause. Even in the 
 prodromal period there is a confusing variety and change- 
 ability of the symptoms, but the mental weakness appears 
 at a very early period. The memory and mental faculties 
 in general fail rapidly, the higher feelings become blunted, 
 and great irritability and capriciousness set in. The fa- 
 cial expression is stupid. Although progressive dementia 
 predominates the scene, violent conditions of excitement 
 occasionally occur and furnish a transition between the 
 vague prodromata and the more distinct dementia ; violent 
 conditions of fear, with terrifying hallucinations, are also 
 observed at times. The greatest resemblance to dementia 
 paralytica often follows the onset of paralytic seizures 
 and speech disturbances, but they may be distinguished 
 by their changeable and temporary character. 
 
 The duration is also extremely variable; sudden im- 
 provement and relapse occur, or even unexpected death 
 during a paralytic attack. 
 
 Syphilitic affections usually begin at an earlier age than 
 typical paresis, so that the suspicion of underlying syphilis 
 becomes less when a doubtful clinical history begins in 
 later life. As a matter of course, the diagnosis of syphilis 
 is greatly aided by the discovery of cicatrices, thickenings 
 of the bones, buboes, etc. In doubtful cases we may 
 adopt experimental treatment with potassium iodide and 
 inunctions. If this proves beneficial, the treatment may 
 be continued more boldly. But unless some distinct benefit 
 is obtained soon after the first inunctions, we must be very 
 careful in the protracted administration of anti-syphilitic 
 remedies. The anti-syphilitic, as well as other treatment, 
 depends upon general principles which cannot be dis- 
 cussed here. 
 
CEREBRAL SCLEROSES. 299 
 
 Diffuse Cerebral Sclerosis, Gliosis, etc. 
 
 Certain other diffuse diseases of the brain run a clinical 
 course which is attended by many of the symptoms of 
 progressive dementia with paralysis. They can rarely be 
 recognized during life, but may occasionally be suspected 
 from certain signs. In diffuse cerebral sclerosis there is 
 an extensive increase of connective tissue in one or both 
 hemispheres, sometimes confined to circumscribed parts, 
 but distinguishable from insular sclerosis by the fact that 
 the transition into non-affected parts is gradual. The 
 brain substance is firm and cut with difficulty. Atrophy 
 of the brain appears to proceed very slowly. Inflamma- 
 tions of the meninges are also found often in combination 
 with sclerosis. 
 
 As the encephalitis which gives rise to sclerosis is very 
 often unilateral, the motor and sensory disorders likewise 
 are chiefly unilateral. Rhythmical twitchings in certain 
 parts of the paralyzed side and tremor are regarded as 
 characteristic. This is an important fact because the. ac- 
 companying mental disturbances have great similarity to 
 simple progressive dementia ; the resemblance is increased 
 still more when speech troubles develop. The patients are 
 usually men between the ages of thirty and fifty years ; the 
 disease terminates fatally in a few years. 
 
 Another diffuse affection of the brain, known as gliosis,, 
 is confined to the superficial layers of the cortex in which 
 the glia undergoes pronounced proliferation. This process 
 is associated with the formation of cavities and atrophj^ 
 of the nervous elements. The disease begins generally in 
 early childhood with convulsions and mental irritability ; 
 later it may assume the form of paralytic dementia, often 
 associated with optic atrophy and symptoms of tabes. 
 
 The cortex may also be affected in other ways, for ex- 
 ample, after diseases of the meninges, so that numerous 
 clinical pictures may develop; among these progressive 
 dementia is noticeable. It is impossible to give a general 
 
300 HANDBOOK OF INSANITY. 
 
 description of all these forms, which vary according to the 
 predominant affection of this or that part of the cortex. 
 
 Focal Diseases of the Brain. 
 
 When violent purulent inflammations of the brain 
 which lead to the formation of abscesses give rise to psy- 
 chical disorders, the latter generally occupy the back- 
 ground. The action of the causal agent usually is fol- 
 lowed rapidly by a profound impairment of consciousness 
 which prevents the prominence of individual signs of 
 mental disturbance. As soon as the course of the disease 
 has become chronic, certain more definite signs of mental 
 derangement will attract attention, and if the previous 
 history is imperfectly known the condition may be as- 
 sumed to be purely psychiatric. This is also true of brain 
 tumors and of the sequelae of cerebral hemorrhage, em- 
 bolism, and thrombosis. As a rule the psychical phe- 
 nomena depend upon the extent to which the cortex is in- 
 volved, but decided impairment of intelligence may also 
 be produced when the lesion is situated below the cortex. 
 In such cases it is very probable that disease of the vessels 
 has given rise to the focal lesion as well as to the coinci- 
 dent mental disorder. 
 
 We cannot enter here into the description of the numer- 
 ous symptoms of focal lesions of the brain, especially as 
 they possess only minor importance as regards a knowledge 
 of the accompanying psychosis. But the distinction be- 
 tween tumors and simple softening spots may here be in- 
 dicated. In the former we usually find a depressed and 
 tearful mood, the patients are retiring and finally become 
 apathetic and imbecile. In addition there is changeable- 
 ness of mood; the intelligence and memory are usually 
 impaired. In the later course sombre, tearful affects be- 
 come more frequent. Complete psychoses are rarer and 
 almost always ' exhibit the signs of progressive dementia. 
 Otherwise the symptoms vary according to the location 
 of the tumor. Choked disc and optic neuritis are present 
 
FOCAL LESIONS. 301 
 
 in almost all cases, and contractions of the field of vision 
 are also common. The greater or less prominence of the 
 psychical symptoms depends in a measure on the rapidity 
 of growth of the neoplasm. In cerebral hemorrhages 
 aphasia is a very frequent symptom, and in consequence 
 thereof the patient often appears more demented than he 
 really is. After the aphasia has lasted a considerable 
 time, the general course of the mental processes also suf- 
 fers deterioration. The patients usually have a very irri- 
 table, tearful, but changeable mood. 
 
 In multiple sclerosis, progressive dementia and sj)eech 
 disorders may simulate paralytic dementia, but the voli- 
 tional tremor and nystagmus permit a correct diagnosis 
 at an early period. The signs of spinal disease also appear 
 more distinctly and earlier than in general paresis. Scle- 
 rosis does not begin after the age of forty years. 
 
 The symptoms of syphilitic lesions when due to the oc- 
 clusion of large vessels also fall under this head. 
 
 In general, focal diseases of the brain rarely come under 
 psychiatric treatment and belong rather to diseases of the 
 brain proper. It must be kept in mind that psychical dis- 
 eases are diffuse diseases of the cerebral cortex, and it is 
 only by assuming an influence upon the cortex in general 
 that we can explain the occurrence of mental disorders in 
 focal lesions. As a rule, the irritative phenomena in such 
 cases are temporary, and all the various focal diseases end 
 in dementia. 
 
 The treatment depends on the symptoms and follows the 
 general principles already laid down for the treatment of 
 psychical disorders. 
 
 E. MENTAL DISEASE IN EPILEPSY. 
 
 We now turn to the consideration of those mental dis- 
 orders which are associated with general diseases of the 
 nervous system. The general neuroses, of which the most 
 important to us are epilepsy, hysteria, and neurasthenia, 
 must be considered from two standpoints, according as 
 
302 HANDBOOK OF INSANITY. 
 
 they affect healthy nervous systems or develop in individ- 
 uals whose nervous system is below par on account of 
 hereditary taint. In the former event they may run their 
 course without affecting the mental processes ; in the latter 
 some mental disturbance, however slight, will result. 
 
 The mental disorders which occur in epilepsy present 
 great differences. While some individuals suffer from 
 distinct epileptic attacks and in the intervals exhibit not 
 the slightest mental abnormality, yet as a rule the neuro- 
 sis impairs the mental life to a greater or less extent. Al- 
 though milder conditions of irritability and mental weak- 
 ness are not very striking, they are apt to pass into severe 
 mental disorders. This is true of about a third of all epi- 
 leptics. A slight change of character is usually noticeable 
 at an early period ; subsequently low impulses become prom- 
 inent and are attended by general weakening of the in- 
 telligence. There is also an entire series of peculiar con- 
 ditions which are very characteristic of the epileptic basis. 
 
 The most important feature of an epileptic attack is the 
 disturbance or loss of consciousness, while convulsions 
 may be entirely absent. In addition to fully developed 
 attacks, there are mild vertiginous conditions in which 
 there is merely a brief (a few seconds to half a minute) 
 loss of consciousness, associated with interruption of any 
 occupation which has been begun and unattended with 
 spasms. The patient suddenly stops in the midst of any 
 occupation, stares vacantly for a few moments, sighs 
 deeply, and the attack is past. He then continues his in- 
 terrupted occupation. These conditions are recognized 
 most easily as true epilepsy when they alternate with con- 
 vulsive seizures. There are also numerous transitions from 
 these slight attacks to the more severe ones. 
 
 There are a number of psychical disorders which may 
 take the place of an epileptic attack, such as so-called epi- 
 leptic dreamy states, true psychical equivalents, and epi- 
 leptoid conditions. In psychical epileptic attacks there is 
 usually complete loss of memory of events during the at- 
 tack, and the mental disorder often appears almost sud- 
 
EPILEPTIC AURA. 303 
 
 denly. Often, however, we find an aura, as in simple epi- 
 lepsy, but the psychosis proper usually appears without a 
 prelude. Gradually a peculiar condition of mind develops 
 between the periodical attacks, and must be distinguished 
 from the aura which immediately precedes the attack. 
 Hence, we must first consider those mental disorders which 
 develop before, during, or after an epileptic attack, and 
 then those which develop during the intervals. Later we 
 will consider the true epileptic psychoses, which extend be- 
 yond the period of an attack. 
 
 The epileptic aura may consist of various mental 
 changes, lasting a few minutes or hours. For several 
 hours before an attack some epileptics become depressed 
 and irritable ; others exhibit great slowness of comprehen- 
 sion, weakness of memory, and apathy toward higher 
 ethical notions ; still others exhibit an unusual cheerful- 
 ness, great reliance upon their own powers, and this in- 
 creases perhaps into a condition of great restlessness and 
 loquacity. 
 
 Intellectual disorders which precede the attack by a few 
 minutes belong more directly to the attack itself; this be- 
 comes so much more distinct when the same notion or 
 hallucination constantly returns just before every attack. 
 Thus the patients see flames, often the colors red and 
 purple ; they hear bells ringing or a distinct voice ; some- 
 times they notice an odor or stench. These phenomena 
 are usually repeated in the same patient in exactly the 
 same manner with every fresh attack. 
 
 On account of the impairment of consciousness, special 
 mental disorders at this time are noticed very little. But 
 it is worthy of note that some patients, after the termina- 
 tion of a spasmodic seizure, retain a certain summary 
 memory of the notions which appeared during the attack 
 in their clouded consciousness. They then describe the 
 condition as a disagreeable dream, or there may be violent 
 qualms of conscience or thoughts of indescribable misfor- 
 tune, although they are unable to base these feelings on 
 reality. 
 
304 HANDBOOK OF INSANITY. 
 
 The mental disorders after the epileptic attack are more 
 important. The patients are then more or less imbecile 
 for a few minutes to a few hours. It is difficult for them 
 to collect their thoughts, to account for the persons and 
 things around them. Some remain in this condition for 
 hours, and are very sad and depressed, while others are 
 tormented by an indefinable fear. 
 
 Other mental disturbances may also appear immediately 
 after an epileptic attack. After a few moments of rigidity 
 there may rapidly develop a condition of great violence 
 and blind rage, probably accompanied in many cases by 
 frightful hallucinations, and manifested by the most reck- 
 less violence and tendency to destruction. The patients 
 do not retain the slightest memory of this condition. More 
 harmless are those cases in which the patients merely walk 
 about restlessly for a little while, but there are gradual 
 transitions between the temporary psychical disorders 
 which follow the epileptic attack immediately and the 
 long-continued psychical disorders in which the epileptic 
 seizure appears to be of minor importance, and the mental 
 disorder becomes an equivalent for it. 
 
 We must first devote a little attention to the ordinary 
 mental condition of epileptics in the intervals between the 
 different spasmodic seizures. As we have already stated, 
 there are some epileptics in whom not the slightest trace 
 of mental disorder can be detected in these intervals. 
 In the majority of cases, however, peculiar changes can 
 be more or less distinctly recognized. The predominant 
 characteristic of the epileptic is his irritability. The pa- 
 tients are usually distrustful, easily angered, and become 
 violent on very slight provocation or none at all. They 
 are obstinate and constantly moody. The irritable mood 
 becomes especially striking on account of the frequent 
 alternation with a mood of entirely different character, in 
 which the patient is timid and reticent, obeys all injunc- 
 tions implicitly, or even exhibits complete submissiveness, 
 sometimes tinged with tenderness and politeness. At 
 times there is an abnormal, causeless mirth. These 
 
THE EPILEPTIC CHARACTER. 305 
 
 symptoms may undergo numerous changes, which cannot 
 be attributed to external causes. Sometimes they per- 
 form their duties diligently and carefully, but there are 
 times in which this becomes impossible. A tendency to 
 lie is very often observed, and this may be associated with 
 envy and jealousy. Epileptics are often intriguers and 
 indescribably ingenious in lying, but at the same time 
 coarse and lacking in consideration when their faults are 
 brought home to them. These symptoms are always 
 periodical, so that we are surprised occasionally by evi- 
 dences of good-humor and amiability. 
 
 We may also find, in the interparoxysmal periods, a 
 pseudo-religious character, in which a great deal of time 
 is devoted to reading the Bible. This characteristic is so 
 much more disagreeable because it is almost always asso- 
 ciated with a disappearance of ethical feelings in actions 
 toward others. 
 
 We now turn to the consideration of epileptic insanity 
 proper. Its characteristics are the periodical paroxysmal 
 recurrence of very brief and violent symptoms, which are 
 either forgotten entirely or merely remembered summarily. 
 
 Their relationship to the milder psychical changes of 
 an epileptic vertiginous attack is shown most distinctly 
 in the brief dream conditions, whose description remind 
 us in many respects of the losses of consciousness already 
 described. The condition lasts several hours or days, 
 consists chiefly of great confusion, but often of great fear, 
 and is often accompanied by impulsive acts. The prodro- 
 mata are a morose manner or hopelessness, increased by a 
 vague consciousness of what is impending, if the pa- 
 tient has already had repeated attacks. He begins to 
 wander about and is the victim of an indefinable fear; 
 attempts at explanation sometimes crop out, and the pa- 
 tient regards himself as the victim of a conspiracy. Im-; 
 pulsively he resists and seeks revenge ; suicide and homi- 
 cide may then occur, and, particularly in young people, 
 incendiarism. The special characteristics of these acts 
 are their violence and suddenness. In this condition the 
 20 
 
30 G HANDBOOK OF INSANITY. 
 
 patients attack one person after another, and, not satisfied 
 with killing the supposed enemy, again inflict numerous 
 wounds upon him or destroy objects in a blind rage. 
 
 These attacks are often, although not always, accom- 
 panied by hallucinations. They possess a frightful char- 
 acter and thus intensify the affect. Shining objects, fire, 
 bloody phantoms, terrible dangers, ghosts, more rarely 
 distinct individuals, such as a black man or the devil, 
 throng upon them. Sometimes they surround the patient 
 on all sides. Auditory hallucinations are rarer, olfactory 
 hallucinations (stench) somewhat more common. 
 
 After an act of violence has been done, the external ex- 
 citement may rapidly subside, but the dreamy condition 
 generally continues for some time, even after the fear has 
 disappeared. The memory of what has occurred may be 
 tolerably clear during the attack, but then disappears rap- 
 idly, either completely or only partially, so that the patient 
 is able to remember certain events. This fact should lead 
 us to exercise great caution in judicial cases, because the 
 suspicion of intentional deceit naturally arises if a confes- 
 sion which was made soon after the act is afterward dis- 
 puted by the individual. As a general thing, however, 
 there is complete loss of memory during the entire dura- 
 tion of the attack. 
 
 A different history is presented by the " dream condi- 
 tions" without fear. Here the contents of consciousness 
 are usually of a religious nature. The patient sees the 
 heavens open, and is himself an angel, God or Saviour. 
 Or he plays the part of a contrite, finally pardoned sinner. 
 Calling the name of God is almost a special characteristic ; 
 commands received from God impel to sudden acts. An- 
 other notable feature is the frequency with which acts of 
 sexual violence are committed during this condition. The 
 condition generally develops very rapidly, but the disor- 
 der of consciousness is lost very gradually. The uni- 
 formity of the individual attacks is very characteristic. 
 This is also true of another series of epileptic "dream 
 conditions," in which the contents of consciousness revolve 
 
DREAM STATES. 307 
 
 around romantic events, which are usually invented, but 
 are taken seriously. In other cases the patient passes 
 through the strangest adventures during his " dream con- 
 dition." He makes long journeys and finally turns up in a 
 foreign land without knowing how he reached there. Such 
 a state is closely allied to somnambulism, and in some 
 cases the latter undoubtedly belongs to the group of 
 epileptic "dream states." This can only be inferred, 
 however, when the patient exhibits other signs, such as 
 nocturnal epileptic attacks with enuresis, biting of the 
 tongue, etc. 
 
 The epileptic mental disorders hitherto described either 
 accompanied epileptic spasmodic seizures or took their 
 place, and were of brief duration (a few hours or days). 
 Some cases, however, furnish a transition to chronic forms 
 of mental disease. Although the convulsions here play a 
 minor part in the clinical history and may even be entirely 
 absent, the course of the disease has the symptoms char- 
 acteristic of epileptic insanity, so that the attacks are called 
 prse-epileptic and post-epiletic, or are regarded as psychical 
 equivalents. In addition to their greater duration (weeks 
 and months) , these conditions exhibit less impairment of 
 consciousness, so that it is preferably termed dulness. As 
 these conditions do not differ essentially from the brief 
 mental disorders on an epileptic basis which have already 
 been described, we will merely call attention to a few 
 points that distinguish them from other simple psychoses. 
 Although consciousness is not abolished, its disturbance 
 is more profound than in ordinary psychoses ; its onset is 
 more rapid, almost sudden, and it subsides usually after 
 a " dream state. " The loss of memory of the attack and 
 of everything connected with it is often complete. The 
 senseless recklessness of the patient's acts and the reli- 
 gious tinge of the contents of consciousness are further 
 distinguishing marks. The periodical recurrence of sim- 
 ilar attacks is significant, and if they alternate with con- 
 vulsive seizures every doubt is removed. Nocturnal con- 
 vulsions may be recognized by their sequelae, such as 
 
308 HANDBOOK OF INSANITY. 
 
 headache and exhaustion, enuresis, bites in the tongue, 
 extravasations of blood into the conjunctiva and face, 
 and finally the peculiar change in the character of epilep- 
 tics during the interparoxysmal periods. Difficult, stutter- 
 ing speech may also persist, as a sequel, for some time. 
 It is also well to know that the psychical epileptic equiva- 
 lents are usually separated more widely in point of time 
 than ordinary spasmodic seizures. 
 
 Finally, one form of mental disorder develops after a 
 series of simple epileptic attacks or after the frequent rep- 
 etition of single attacks. This is usually known as epi- 
 leptic degeneration. It is manifested chiefly by the loss 
 of intelligence, which increases progressively. As in all 
 psychoses which progress to dementia, the loss of the 
 higher mental feelings appears earliest and most distinctly. 
 Hence, we here find cruel acts of violence which are un- 
 opposed by any ideas of morality, so that there is no 
 question of subsequent remorse. The intellectual decay 
 continues, and is always most pronounced immediately 
 after the attacks, so that perceptions then result only after 
 stronger stimuli. For a long time there is great irrita- 
 bility, so that the patient becomes violently angry on slight 
 provocation. In comparatively few cases, however, do 
 we find the highest grades of apathetic dementia in which 
 the patients are helpless and filthy. It must be regarded 
 as a peculiarity of demented epileptics that they long 
 (sometimes always) retain the sense for externals, such as 
 cleanliness of clothing. The earlier the primary epilepsy 
 began the more pronounced does the dementia become. 
 Bodily decay and paralyses then set in, together with dis- 
 orders of speech. 
 
 The term status epilepticus is applied to a condition 
 which develops when the patients, as the result of the 
 rapidly succeeding attacks, no longer return to conscious- 
 ness and lie as if in coma. Death may occur in this con- 
 dition. There is usually a rise of temperature to 41° or 
 42° C, which is not due to the increased muscular action 
 during the convulsions. The exhaustion is extreme and 
 
STATUS EPILEPTICUS. 309 
 
 is rapidly increased by the fact that the patients cannot 
 be nourished. The number of attacks may amount to 
 hundreds, and may last from a couple of weeks to a month, 
 with brief interruptions. 
 
 Concerning the anatomical basis of epilepsj^ and its 
 associated mental disorders we really know nothing posi- 
 tive. The most frequent cause is heredity, then follow 
 alcoholic excesses, drunkenness of the parents, and con- 
 ception while drunk. Next come the cerebral diseases of 
 early childhood. Another important cause is concussion 
 of the brain after injuries to the skull and the allied form 
 of psychical trauma, viz., fright. 
 
 The following data may be considered in regard to prog- 
 nosis. Intelligence is more apt to suffer in those forms of 
 epilepsy which are characterized by frequent brief loss 
 of consciousness and vertiginous attacks than after severe 
 convulsive seizures. This fact appears to show that the 
 mental disorder is not merely a sequel of the attacks, but 
 that both are different manifestations of the same primary 
 process. The chances that the mental powers will remain 
 intact are also so much greater, the rarer the attacks, 
 whatever their character. As a rule, the single attacks 
 recover, but in general the mental disorders of epilepsy 
 must be regarded as a very unfavorable form of disease. 
 
 The diagnosis is easy in pronounced cases, but it is 
 sometimes very difficult and can only be made after pro- 
 longed observation which discloses the periodical course. 
 Many cases of epileptic insanity have probably been de- 
 scribed as transitory mania, and this mistake is avoided 
 with difficulty. Such cases usually last only a few hours 
 to one day, and run their course as a violent attack of rage 
 with impulsive acts of violence. As a rule, they begin 
 suddenly, without real prodromata, and rapidly attain 
 their maximum ; they are accompanied by vivid halluci- 
 nations. After the excitement the patient falls into a deep 
 sleep, from which he awakes with a dull head and a feeling 
 of great exhaustion and without a clear memory of the 
 things that have happened. Here the signs of an epi- 
 
310 HANDBOOK OF INSANITY. 
 
 leptic basis are the sudden beginning, the profound dis- 
 turbance of consciousness with subsequent loss of memory, 
 the impulsive violence of the acts, and the tolerably sud- 
 den cessation of the symptoms. 
 
 It is important to remember that psychoses other than 
 those described may also be associated with epilepsy. If 
 the association is accidental, such psychoses cannot be 
 called epileptic. Id some cases secondary dements be- 
 come epileptic at a later period, so that it may be assumed 
 that the cortical disease has extended to motor regions. 
 The status epilepticus may be mistaken for eclampsia and 
 ursemia, but the previous history and the examination of the 
 urine will prevent mistakes. Certain difficulties may also 
 be produced by a condition of rigid mutism, which has 
 much resemblance to profound melancholia. It is only 
 after this has run its course that we find a distinguishing 
 feature in the defect of memory. Conditions of stupor, 
 alternating with verbigeration and mutism, which prob- 
 ably have an epileptic basis, have also been observed. 
 But these clinical conditions are interpreted by others in 
 a different way, for example, as katatonia, and their 
 position in our nosological system cannot be decided 
 here. 
 
 The treatment of the mental disorders of epilepsy is the 
 same as that of epilepsy itself. Potassium bromide en- 
 joys great repute not alone in preventing convulsions and 
 excitement, but also in maintaining the mental powers. 
 The effective dose varies greatly in different cases. We 
 generally begin with 2.0-6.0 daily and then increase, as 
 required, to 8.0-10.0; the remedy is continued for a few 
 weeks, and the dose is then diminished or discontinued. 
 But if good results are obtained, a dose of 4.0 daily may 
 be continued unchanged for years. In asylums we are 
 apt to be mistaken in this regard, because the change to 
 new and well-regulated surroundings and the improved 
 nutrition may have been more efficient .than the drug. 
 Hence it is preferable to delay the administration of the 
 drug unless it is indicated at once by imperative symp- 
 
HYSTERIA. 311 
 
 toms. After an attack it is also well to let the patient 
 sleep as long as he will or to secure sleep by drugs. 
 
 When potassium bromide is useless, atropine or curare 
 may be employed, although good results are rare. Injec- 
 tions of morphine may relieve the severe symptoms in the 
 status epilepticus; chloral enemata are also recommended. 
 It must be kept in mind that patients suffering from epi- 
 leptic insanity are dangerous to others, so that they can- 
 not be removed too quickly to an asylum. Even if the 
 progressive dementia is only slight, sudden acts of vio- 
 lence may make the patient dangerous to himself and 
 others. 
 
 F. INSANITY AND HYSTERIA. 
 
 The answer to the question whether hysteria is always 
 a mental disorder depends upon our conception of mental 
 disorder in general. There is no doubt that even the 
 mildest forms of hysteria are often attended with a pecu- 
 liar change of character, which we find again in all forms 
 and degrees, but true hysterical insanity is a different affec- 
 tion and runs its course under definite peculiar symptoms. 
 
 As a rule, hysteria is a congenital and inherited consti- 
 tutional neurosis, so that the mental functions exhibit 
 many evidences of being below par. Hysteria in the 
 male is so rare that we will refer only to the affection in 
 the female sex. The disease often begins in childhood, 
 but most frequently at the period of puberty. Although 
 sexual life has great influence on the disease, still, not 
 more than half the patients exhibit any irritative condi- 
 tions of the genitalia, and it is even doubtful whether 
 these are cause or effect. Furthermore, even the slightest 
 indications of sexual excitement are often absent in chronic 
 uterine disease of hysterical patients. 
 
 The mental symptoms may be divided into three groups : 
 those which show a special change of character; those 
 which accompany or are substituted for an hysterical 
 seizure ; finally, those which belong to hysterical insanity 
 proper. 
 
312 HANDBOOK OP INSANITY. 
 
 From early childhood the majority of future hysterical 
 patients exhibit an unstable mental equilibrium. They 
 are very impressionable, laugh or cry on the slightest 
 provocation. They are quick, have talent for study, and 
 a natural tendency to imitate, a certain talent for acting. 
 At the same time they are deceitful, fond of command, 
 excitable, sometimes very depressed. They get excited 
 over trifles and remain unaffected by events which should 
 touch them more deeply. They often suffer from numer- 
 ous nervous affections, such as headache, abdominal pains, 
 palpitation, nightmare, feeling of pressure in the throat, 
 occasionally distinct spasmodic seizures. To these real 
 complaints they often add imaginary ones in order to 
 make themselves interesting. Religious tendencies at a 
 very early age with conditions of ecstasy are signs of an 
 hysterical basis. 
 
 In adult hysterical patients these predispositions de- 
 velop with varying intensity. A changeableness of char- 
 acter is first observed. Without any internal reason they 
 pass from cheerfulness and amiable traits to moroseness, 
 sensitiveness, and violence, and become unjust and ma- 
 licious. They exaggerate everything, are capricious in 
 their feelings, in the noblest emotions as well as the low- 
 est impulses. They are found at the head of charitable 
 associations, and redouble their energies in solacing the 
 down-trodden and in uplifting those who have lost hope. 
 On the other hand, they are capable of the greatest moral 
 transgressions, and finally are not abashed by crime. They 
 are spirits of opposition and contradiction. To-day they 
 maintain the opposite of what they asserted yesterday. 
 
 But despite this capriciousness they exhibit remarkable 
 persistence under certain circumstances— complete mutism 
 on account of the fear that speaking is injurious ; fasting 
 for weeks in order to avoid gastric disease ; lying in bed 
 for years in the firm conviction that walking is impossible. 
 But such obstinate persistence is due not to strength but to 
 weakness of will. 
 
 The capriciousness of character is, however, the most 
 
HYSTEEICAL SEIZURES. 313 
 
 marked feature. An hysterical patient who has been 
 married only a few weeks complains that she is mis- 
 understood, that she has not found the one whom she 
 could make happy with the exuberance of her love. She 
 makes things as unpleasant for her husband as possible, 
 and later manifests this antipathy even to her children. 
 Lying is a constant feature, and, in a measure, is the sign 
 manual of the hysterical character. The slyness and per- 
 sistence with which useless lies are told are sometimes 
 astonishing. Sometimes they consist of false accusations 
 and slanders. Hysterical patients have wounded them- 
 selves with knives and torn their own clothes in order to 
 prove an accusation of rape. Or they slander others 
 through the medium of letters which they write to them- 
 selves. The chief cause of such acts is the desire to ap- 
 pear interesting. 
 
 Even the tendency to sexual excesses which is often 
 manifested is due to the desire to make themselves prom- 
 inent. In some cases, however, there is really increased 
 sexual excitement. The patients may then retain the 
 urine in order to secure daily catheterization, or feign 
 disease of the uterus in order to have a speculum intro- 
 duced. 
 
 Every hysterical patient may pass from the mildest to 
 the most severe of these mental disorders and finally pass 
 into a pronounced psychosis. The main elements remain 
 the increased excitability and diminished will power, which 
 is increased only for certain perverse purposes. The pa- 
 tients follow the impulse of the moment and are incapable 
 of controlling their antipathies against individuals and 
 certain impressions, such as smells and sounds. 
 
 The intelligence and memory are not much affected. 
 This very fact makes them able to carry out their designs, 
 and they may thus become veritable nuisances to those 
 around them and to the physician. 
 
 In order to understand the relations of hysteria to epi- 
 lepsy we must first describe hysterical convulsions. An 
 hysterical seizure includes numerous other physical symp- 
 
314 HANDBOOK OP INSANITY. 
 
 toms besides the convulsions, but they will only be consid- 
 ered with regard to their psychical basis. 
 
 The sensory and motor disorders of hysteria have no 
 anatomically conceivable basis, but are arranged in the 
 sense of physiological activity and at the same time show 
 the signs of psychical origin. 
 
 The prodromata of a spasmodic seizure are usually 
 so distressing to the patients that they yearn for the re- 
 lieving action of the spasms. Great restlessness and irri- 
 tability distress them, and the attacks are also preceded 
 by incessant yawning and sighing. The symptoms of an 
 aura are, however, so manifold that they are incapable of 
 coherent description. One feature is common to most of 
 them, viz., the anxious hoping for the spasmodic attack, 
 while the epileptic fears the seizure. When the convul- 
 sions begin the loss of consciousness is not as sudden as 
 in epilepsy, so that the patients do not injure themselves 
 in falling. At the onset all the movements are still ar- 
 rayed in a regular physiological manner and stand under 
 psychical guidance. In the severest cases complete loss 
 of consciousness then follows. In the milder cases the 
 patients can see and hear everything going on around 
 them. The spasmodic movements are very extensive and 
 irregular in their sequence. 
 
 The details of hysterical seizures cannot be entered into 
 here. It is characteristic of many cases that they can be 
 interrupted at any time by pressure on the ovarian region. 
 This effect usually lasts only during the continuance of 
 the pressure. The single attacks generally run their 
 course in about a quarter of an hour, but they may be re- 
 peated and even amount to hundreds (status hystericus) . 
 
 Contractures due to tonic spasms are subordinate to the 
 psychical processes of attention and volition ; while they 
 are frequent in hysteria, they do not occur in epilepsy. 
 The paralyses of hysteria associated with sensory disorders 
 also show the extreme facility with which psychical stim- 
 uli change the symptoms of the disease. Catalepsy, with 
 waxen flexibility, may also appear in hysteria under the 
 
DREAM STATES. 315 
 
 influence of the psychical excitability and coincident dim- 
 inution of will power. The psychical influence is usu- 
 ally recognizable even in the disorders of the circulation 
 and the secretory organs. Unlike epilepsy, the persistence 
 of hysterical seizures for years produces no notable dis- 
 order of intelligence. 
 
 Although we are not in the habit of speaking of hyster- 
 ical equivalents or post-hysterical conditions, it cannot be 
 denied that similar conditions are found in certain " dream 
 states" which follow or replace an hysterical attack. 
 These states are longer or shorter attacks of impairment 
 of consciousness. In the simplest form this disorder of con- 
 sciousness extends beyond the spasmodic stage for a longer 
 or shorter period. The patients lie with relaxed limbs, 
 quiet respiration and slow pulse, the eyes rolled upward 
 and to the side. In exceptional cases this condition may 
 last days, even weeks. 
 
 The dream states, which belong to the domain of som- 
 nambulism, must be regarded as equivalents or protracted 
 hysterical seizures. The patients are roused with com- 
 parative difficulty from this condition. 
 
 The dream states may acquire a different complexion 
 from the addition of vivid hallucinations ; they are com- 
 bined with conditions of ecstasy in which rigidity of the 
 muscles is also observed. Hallucinations of sight are espe- 
 cially important and are often of a terrifying nature. 
 The patients see dark shadows, flames, animals, such as 
 rats and snakes, also larger animals, which assume fantas- 
 tic shapes. Naked men, corpses, funerals, murders, are 
 also seen. The anxious restlessness may be increased still 
 further by threatening voices and sounds and disagree- 
 able odors. 
 
 Still more frequent are ecstatic conditions, with feelings 
 of delight and heavenly phantasms, and this is shown in 
 the patient's appearance. She is transferred to an imag- 
 inary world, and the contents of consciousness are often 
 chiefly religious. In the posture of prayer or ecstasy, 
 with the eyes turned toward heaven, the facial expression 
 
316 HANDBOOK OF INSANITY. 
 
 shows complete abandonment to bliss. The rigid posture 
 may then pass into that of crucifixion or it imitates other 
 scenes in the life of Christ or the martyrs. Praying, the 
 singing of psalms, and loud prophecies sometimes break 
 the silence for a time. Later the patients state that they 
 felt happy in paradise, in the presence of God and the 
 angels, etc. During the period of ecstasy there is often 
 insensibility to external stimuli, the pulse may be acceler- 
 ated, the respirations slow, the pupils wide. 
 
 Sometimes the contents of consciousness refer to some 
 actual previous experience; for example, an attempted 
 rape. This event is then experienced again with numerous 
 fanciful additions, and may lead to acts of desperate resist- 
 ance and violent outcries. The scene often terminates in 
 a convulsive seizure. Events of recent occurrence are 
 also repeated occasionally in a loquacious manner, but in a 
 very dreamy state of consciousness ; the memory of this 
 condition is then very imperfect. 
 
 Finally, we may mention a dream state which occurs in 
 young girls, characterized by foolish excitement and usually 
 preceding a convulsive seizure by a few hours. Singing, 
 laughing, and dancing alternate with the tendency to col- 
 lect various articles. The patients are usually in a cheer- 
 ful humor, talk impertinently, do all sorts of foolish and 
 mischievous acts, imitate animals. They do not recog- 
 nize those around them, and have only an imperfect mem- 
 ory of the condition. 
 
 As a rule, all these conditions last from a few hours to 
 a day, but the mild cases are sometimes protracted over 
 several weeks or months. They begin and end quickly, 
 their course is variable, and at times the impairment of 
 consciousness may disappear almost entirely, while the 
 other morbid symptoms remain the same, but are not rec- 
 ognized as such. These conditions often occur after 
 childbed, severe hemorrhages, or conditions of exhaustion 
 in general, and the prognosis is then comparatively good. 
 The numerous hallucinations are sometimes interpreted as 
 indicative of good or bad fortune, but on account of the 
 
HYSTERICAL INSANITY PROPER. 31? 
 
 impairment of consciousness systematization of delusions 
 is rare. At all events, the delusions rapidly disappear 
 with the dream states. 
 
 Before proceeding to the discussion of hysterical insanity 
 proper, it must be mentioned that simple forms of in- 
 sanity may also occur in hysteria. When the simple in- 
 sanity subsides, the hysterical symptoms may then persist. 
 A theatrical demeanor and erotic tinge partially obliterate 
 the clinical history of simple psychoses in an hysterical 
 individual. 
 
 The basis of hysterical insanity is a degeneration, and 
 can be regarded as a mental invalidism which imparts to 
 the symptoms of the psychosis their direction. On an 
 hereditary foundation its development is especially un- 
 favorable, and it then often progresses steadily, although 
 sometimes very slowly, to dementia. In the beginning 
 the fundamental trait of hysterical insanity is the extreme 
 sensitiveness of the patient, the feeling that she is un- 
 noticed, and this psychical excitability is combined in 
 various ways with the numerous symptoms of hysteria.. 
 When we hear constant complaints of neglect although 
 the most sympathetic love is exerted in order to gratify 
 the slightest wish, a suspicion of beginning weakness of 
 judgment is justified, and this is confirmed by the steady 
 advance to more or less severe degrees of dementia. The 
 numerous disorders of sensation and other hallucinations 
 interfere, from the start, with a quiet judgment by the 
 patient concerning her own condition, and thus they are 
 rapidly converted into delusions. At first the vividness of 
 the ideas gives rise to a system which is intended to ex- 
 plain the depressed feelings, but this soon passes into 
 confusion or dementia. 
 
 The condition does not progress steadily, but by fits and 
 starts. It is often accompanied by shameless sexual im- 
 pulses, together with olfactory hallucinations and religious 
 ideas. Hysterical insanity is chronic and progressive, 
 unlike the milder conditions of a similar nature in simple 
 hysteria, in which the individual attack runs a brief 
 
318 HANDBOOK OF INSANITY. 
 
 course without notable injury to the intelligence. It is 
 distinguished from simple paranoia by the striking com- 
 bination, at the onset, of psychical excitability and mor- 
 tified self-love, and by the fact that the wild current of sen- 
 sory disorders is interpreted without judgment ; the course 
 is usually more rapid, and the union of sexual, religious, 
 and olfactory disturbances is peculiar to hysterical in- 
 sanity. 
 
 Another form of hysterical insanity is unattended with 
 hallucinations or they play a very subordinate part. Here 
 the main feature is the patient's attempt to find in ex- 
 ternal influences an explanation for her own morbidly 
 exalted or depressed mood. Great facility of speech, 
 which often passes into a certain dialectic skill, is often 
 associated with this condition, in which the patient is ab- 
 sorbed utterly in her own interests and is incapable of fol- 
 lowing foreign interests. In addition, there are numer- 
 ous physical symptoms which can merely be referred to 
 (motor and sensory paralyses, narrowing of the field of 
 vision, disorders of secretion). 
 
 Even attempts at suicide may be made as the result of 
 desperation. Usually, however, they are not meant seri- 
 ously, although by accident they may terminate fatally. 
 Hence, necessary precautions must not be omitted even in 
 an asylum, although we ought to appear indifferent to the 
 suicidal attempt. This form rarely terminates in demen- 
 tia, while the higher feelings are lost in the growing self- 
 ishness. In these persons we not alone observe sexual 
 excesses carried out in an impulsive manner, but also the 
 theft of valuables from shops and friends. 
 
 The course of all the mental disorders which are as- 
 sociated with hysteria may be extremely variable. If the 
 mental disturbance occurs in paroxysms, the chances of 
 recovery of the individual attack are favorable, although 
 relapses and new attacks are probable. But the hysterical 
 change of character and protracted hysterical insanity may 
 lead to permanent progressive conditions. The danger 
 of terminal dementia is greatest in very young people, but 
 
TREATMENT. 319 
 
 is much rarer than in epileptic insanity. On the whole, 
 the prognosis of the mental disorders of hysteria is un- 
 favorable, despite the probability of the subsidence of the 
 individual attacks. When the sexual life plays an un- 
 deniable part, considerable improvement sometimes occurs 
 at the menopause or after removal of local irritation. 
 Otherwise the hysterical character, at least, remains until 
 the end of life, or, in severe cases, more or less pronounced 
 dementia gradually develops. 
 
 Treatment offers the best chances of success when we 
 can succeed in removing the causes. Treatment of the in- 
 dividual symptoms is less successful because the patients 
 must not be allowed to notice that we regard them as 
 mentally diseased. If conditions of mental or bodily ex- 
 haustion are present, these must be relieved and renewed 
 vigor restored to the exhausted nervous system. This 
 usually requires, above all else, the removal of the patient 
 from her accustomed environment and her transfer to 
 surroundings in which she is compelled to recognize the 
 mild authority of another. In many cases tbe personal 
 influence of the physician may be even more important, 
 as is evident from the well-known effects of suggestion in 
 hysteria. This factor is more important, however, in sim- 
 ple hysteria with slight change of character than in cases 
 in which the mental disorders are more marked. But 
 suggestion may only be employed by the mild means of 
 personal authority, not as hypnosis proper. The un- 
 shakable faith which the physician acquires through ear- 
 nest sympathy thus becomes one of his most effective 
 auxiliaries. 
 
 The bodily exhaustion is to be treated according to gen- 
 eral principles. Thus, the rest cure, electricity, cautious 
 cool douching after lukewarm baths, etc., may be valu- 
 able in combating prominent symptoms. Potassium bro- 
 mide is not as effective as in epilepsy. It may possibly 
 secure sleep by diminishing the nervous excitement, but 
 its administration is contra-indicated in conditions which 
 exhibit a tendency to hypnotic phenomena. Finally, we 
 
320 HANDBOOK OF INSANITY. 
 
 must warn against the protracted use of morphine because 
 the patients too often succumb to the morphine habit. 
 
 Proper psychical treatment under favorable external sur- 
 roundings and good nursing are therefore the best reme- 
 dies. This is especially evident in the occasionally almost 
 epidemic occurrence of hysterical affections in which men- 
 tal disturbances play a prominent part. In the similar 
 conditions which develop occasionally in schools at the 
 present time, recovery usually ensues very rapidly when 
 the patients are separated from one another. 
 
 The spasmodic phenomena which occur in such epidemics 
 are sometimes associated with others which resemble 
 chorea. Indeed, mental disorders may occur in chorea 
 and show that this neurosis is constitutional. But these 
 disorders are too varied to permit the establishment of a 
 special disease known as choreic insanity. 
 
 G. MENTAL DISORDERS WITH NEURASTHENIA. 
 
 Chronic Forms. 
 
 In this class extensive spasmodic symptoms are almost 
 always absent, but great irritability and weakness of the 
 entire nervous system occupy the attention of the patient 
 so that he becomes a constant observer of all his manifold 
 symptoms. The mental disorders associated with neuras- 
 thenia are very numerous, and include many conditions 
 which are on the border line of insanity, and also the 
 greater part of those morbid conditions which are known 
 as hypochondria. The latter term has lost its original 
 meaning and should now be applied only to designate in- 
 dividual symptoms. 
 
 Neurasthenia may be congenital or acquired. Many 
 of its symptoms are found in other psychoses if they have 
 developed on a neurasthenic basis. Here we will first 
 consider those symptoms which possess a certain inde- 
 pendence and at the same time a more intimate connection 
 with the course of mental processes. 
 
 The main features of congenital and acquired neuras- 
 
INCREASED EXCITABILITY. 321 
 
 thenia are the extreme readiness of response and the rapid 
 exhaustion of the nervous and mental functions. 
 
 The mental disorders associated with neurasthenia do 
 not occur in paroxysms. Their development and course are 
 slow and gradual and continue, with slight changes, for a 
 long time. A constantly recurring feature is the feeling of 
 prostration of the bodily and mental vigor. In moments 
 of excitement neurasthenics are inclined to attribute their 
 irritable mood to every possible external circumstance, but 
 with the return of the general nervous exhaustion the in- 
 sight into the connection between their mood and their own 
 conduct also returns. The feeling of being sick does not 
 follow reflection, but is imperative. The morbid element 
 in the mental condition of these patients often consists of 
 the very fact that this feeling of being sick is not suffi- 
 ciently explained by other conditions of the body. Al- 
 though we will meet numerous bodily symptoms which 
 now and then lie at the foundation of the general condi- 
 tion and give it its general direction, this connection is 
 not the rule. 
 
 The increased mental irritability is not alone too great, 
 but is also too protracted, and a combination of increase 
 and diminution of irritability over limited fields is un- 
 deniable. There is thus an absence of symmetry in the 
 conduct of these individuals which cannot be concealed by 
 the great self-control that is occasionally present. This 
 may be true of the higher feelings as shown, for example, 
 in excessive love and affection for others, or in the slight 
 power of endurance in mental work, while even difficult 
 mental processes are grasped at once with great ease. 
 These conditions are sometimes subject to irregular 
 changes. 
 
 In comparatively strong natures the increased excitabil- 
 ity occupies the foreground, in weaker natures the rapid 
 exhaustion becomes more prominent. When the exci- 
 tability becomes blunted with increasing exhaustion men- 
 tal decay usually sets in, while the excitability disappears 
 with increasing endurance when neurasthenic conditions 
 21 
 
322 HANDBOOK OF INSANITY. 
 
 recover. It is fortunate for such individuals when their 
 mental development is slow, because recovery of the fun- 
 damental neurasthenic condition is then most apt to 
 occur. 
 
 We have already said that one of the most important 
 signs of the mental disorder associated with neurasthenia 
 is the manner in which the feelings, thoughts, and actions 
 of the patient absorb his entire attention, and we will now 
 enter a little more closely into the details of this imperative 
 thought. By this term we mean the various ways in 
 which concepts, feelings, and impulses to action force 
 themselves irresistibly upon the patient and overpower 
 him. We may accordingly speak of imperative sensations, 
 notions, and acts. In a measure the patient has lost con- 
 trol over the contents of his consciousness. A thought 
 presents itself to him, to his surprise, without any connec- 
 tion with the ideas which may be present in consciousness 
 at the time, or it follows immediately upon the sight of en- 
 tirely irrelevant external objects. A constant feature is 
 the recognition of the disorder and an often extremely 
 distressing feeling of compulsion. 
 
 The imperative concept is rarely independent. If it 
 remains simple and independent, it corresponds usually 
 to a single idea. A single word constantly thrusts itself 
 into the contents of consciousness, or the notion of some 
 entirely foreign object, for example, a water-closet, or the 
 name of a person in whom the patient has no special in- 
 terest, continually intrudes in the most annoying manner. 
 The distressing perception of this compulsion may natu- 
 rally arouse fear and doubt in the ordinary psychological 
 way, so that these cannot be called imperative notions ; 
 but even apart from such correct inferences, an impera- 
 tive notion occasionally becomes associated with others 
 along the path entered upon. 
 
 A frequent illustration of these associated imperative 
 notions in neurasthenics is the notion that a letter has not 
 been sealed, and this impels them to see whether the letter, 
 lying on the desk, is still open. If the letter has already 
 
MORBID FEARS. 323 
 
 been mailed, the fear is excited that others might read its 
 contents, and then the restlessness impels to new thoughts. 
 Perhaps this or that expression in the letter looks suspi- 
 cious, a new letter is written in order to explain matters to 
 the recipient and to beg his pardon, and then the distress- 
 ing scene may begin over again despite the most careful 
 supervision of the correspondence. Well known, likewise, 
 is the notion that a door has not been closed, and this 
 leads to continued reclosing, although the individual is 
 fully conscious of the folly of his conduct and is even 
 ashamed of it. These imperative notions may develop 
 during the most varied occupations. The notion that a 
 light has not been extinguished compels the patient to rise 
 at night in order to see whether the light has really been 
 extinguished, or if this is not done, the fear of fire is 
 aroused in a distressing manner. Indeed, the performance 
 of such little acts after these notions usually offers some 
 relief, at least for the time. But if the patient, conscious 
 of the morbid nature of his doubt, does violence to his 
 feelings and, for example, fails to recount a sum of money 
 which, for fear of miscounting, he has already counted a 
 number of. times, then the accompanying distressing affect 
 increases and bodily feelings of an annoying character 
 appear, such as tremor, palpitation, acceleration of the 
 pulse, sweats, and diarrhoea. Quite a frequent phenomenon 
 is the dread of touching door-knobs and other objects to 
 which infectious matters might possibly have adhered. 
 Or the notion that a bit of glass or a sharp splinter of bone 
 may be concealed in the food leads to constantly renewed 
 examinations, despite the knowledge of their uselessness. 
 The patient cannot do otherwise — he cannot escape from 
 the notion. One individual suddenh^ thinks that he may 
 soil his clothes upon the street ; this is followed by the 
 notion that the dirt may come in contact with his body, 
 excite the disgust of others, or fall into their food ; he now 
 avoids all contact with the floor, the walls, or with other 
 people, walks only on tiptoe, constantly brushes his hands, 
 etc. 
 
324 HANDBOOK OF INSANITY. 
 
 Still more distressing are the conditions known as grue- 
 belsucht (vide page 70) . 
 
 "We thus approach the domain of hypochondriacal com- 
 plaints, which depend materially upon the culture and 
 medical views of the patient. The dread that a serious 
 ailment is developing finds sufficient grounds in bodily 
 disorders which may really be present or solely in the 
 nervous conditions which result from the neurasthenic 
 basis. The complaints refer mainly to the fashionable 
 diseases which are then attracting most attention. Cholera 
 and influenza, syphilis and phthisis are found again and 
 again in the reports of these neurasthenics; a chronic 
 pharyngitis becomes incipient phthisis, slight eczema is 
 converted into syphilis, etc. The demonstration of the 
 absence of all cause for alarm does not relieve the patient, 
 and the distressing feeling and imperative conception of 
 this or that disease again makes it appearance. This 
 imperative conception dominates the scene, while the nu- 
 merous other symptoms which result from the primary 
 taint usually become subsidiary. 
 
 The feelings called forth by the imperative concept do 
 not possess the vividness and duration which we might 
 be led to expect ; the recognition that they are not appro- 
 priate constantly becomes evident to the patient himself. 
 Hence the mood, although usually inclined to irritability 
 and dissatisfaction, is very variable and capricious, and 
 we are often surprised by redeeming traits, among which 
 an active sympathy is the most attractive. 
 
 Among the accompanying bodily symptoms neuralgic 
 pains are frequent. One of the most frequent complaints 
 is that of headache of the most varied kinds, over the en- 
 tire head, the forehead, or occiput. There is often a feel- 
 ing of heat in the head, and not infrequently the patient 
 feels rotary movements within the head. These feelings 
 are associated with a certain degree of interference with 
 thought, although this is not so distinct in reality as the 
 patient imagines. The rapid exhaustion after mental ef- 
 fort increases the morbid feelings in the head. Circum- 
 
SPINAL IRRITABILITY. 325 
 
 scribed hyperesthesias of the scalp are frequent, and even 
 the combing of the hair may be borne with difficulty. 
 
 There are usually irritative phenomena in other sen- 
 sory tracts, dependent on great sensitiveness to external 
 impressions. Flashes of light, tinnitus, and other subjec- 
 tive phenomena alternate with one another. The hyperes- 
 thesia to light sometimes causes great suffering, especially 
 if accompanied by attacks in which specks and flashes of 
 light fill the field of vision. We also find liking for or 
 antipathy to certain forms of smell and taste. The pa- 
 tients may suffer from loud noises, and even their own 
 voices may produce an intolerable sound. 
 
 This irritability of the senses is combined not infre- 
 quently with great subjective weakness and rapid exhaus- 
 tion, so that the field of vision soon becomes obscure or 
 hearing becomes indistinct. The same mixture of exces- 
 sive irritability and exhaustion is found in the muscles 
 and viscera. The patients often complain of heaviness 
 and a tired feeling in the limbs after slight exertion, and 
 of numbness, pricking, and formication. A common 
 symptom is the feeling of painful exhaustion in the neck 
 and back ; it may appear spontaneously, on pressure, or on 
 motion. When there is also hyperesthesia of the spinous 
 processes the entire condition is known as spinal irrita- 
 tion. Muscular restlessness may also become one of the 
 most distressing of all the symptoms. ISTow and then there 
 may be a spasm of this or that muscle, especially in the 
 legs, but general spasms are not observed. Fibrillary 
 twitchings occur, particularly in the facial muscles, and 
 this symptom may be important in the differential diag- 
 nosis between dementia paralytica and neurasthenia. 
 The paretic does not notice the twitchings; the neuras- 
 thenic devotes his entire attention to them. The latter also 
 notices, with dread, slight disturbances of speech, espe- 
 cially the use of wrong words during excitement. 
 
 A description of the hypochondriacal complaints con- 
 cerning digestion would lead us too far ; other organs also 
 give rise to numerous symptoms. Of much greater im- 
 
326 HANDBOOK OF INSANITY. 
 
 portance are the disorders of the blood-vessels and the 
 circulation. Palpitation of the heart may be so severe 
 that the patient feels and hears the cardiac impulses ; to 
 this is generally added a feeling of fright and restlessness, 
 which is apt to be followed by slight hypochondriacal de- 
 lusions. Such attacks may be associated with dilatation 
 of the left pupil, and it is probable that both symptoms are 
 due to irritation of the sympathetic nerve. Paralyses 
 of the sympathetic occur very often in neurasthenia. 
 Blushing when surprised or when spoken to is one of the 
 most annoying complaints of the neurasthenic, and is 
 aggravated when they concentrate their attention upon it. 
 
 Paroxysmal attacks of heat and throbbing of the vessels 
 may occur over the entire body. These sensations are 
 extremely annoying because they also extend to the inter- 
 nal organs and give rise to distressing restlessness. These 
 conditions, which occur especially after emotional excite- 
 ment, show that the entire central nervous system is 
 irritable and rapidly exhausted, and also enable us to 
 understand other peculiar neurasthenic conditions. We 
 know that the feeling of fear is accompanied, as a rule, 
 by irritation and paralysis of the vasomotor system, and 
 that feelings of vertigo develop in a similar connection 
 with the vasomotors. It is very probable, therefore, that 
 implication of the sympathetic explains the various forms 
 of morbid fears in neurasthenia. It must be admitted, 
 however, that visible symptoms on the part of the vascular 
 system are not always present. But that these conditions 
 do result from vascular changes is shown by the fact that 
 they are usually attended by more or less severe vertigo. 
 
 The morbid fears which will now be discussed are ob- 
 served, as a rule, after definite causes. The most com- 
 mon form is the fear of places which develops upon en- 
 tering a square, an empty street, or a lonesome region. 
 The patient is suddenly attacked by the fear that his 
 strength will leave him and that he will be unable to walk 
 farther. This is accompanied by a feeling of oppression, 
 palpitation, constriction of the throat, an outbreak of cold 
 
FEAR OF PLACES. 327 
 
 sweat, with tremor and weakness of the legs. If the pa- 
 tient turns about or succeeds in reaching a side row of 
 houses, the feeling of fear disappears. The condition is 
 accompanied by a mere indefinite fear of some impending 
 danger, and is often overcome by the company of any per- 
 son who happens to pass. Height vertigo may develop 
 with similar symptoms sometimes if the patient is seated 
 alone near a high window, while he is perhaps able, in 
 company, to climb a steep cliff. Repetition increases the 
 severity of the attacks as a rule, and hence the dread of 
 a similar position facilitates their occurrence. In other 
 words, mental irritability must be combined with weak- 
 ness of the vasomotor system in order to produce such 
 conditions. The same combination probably obtains in 
 other allied conditions, such as fear of crowds or of closed 
 rooms. After the attack has subsided the patients some- 
 times laugh at their own folly, but are unable to repress 
 the fear on the next occasion. The fear is a true impera- 
 tive feeling. 
 
 In this connection we may mention imperative acts so 
 far as they are independent and not related in thought to 
 fears or delusions. Some homicides, thefts, rapes, etc., 
 seem to be explicable in this manner, although in many 
 of these cases careful examination shows that the acts are 
 based on hallucinations or delusions. When the latter are 
 absent we usually find an honest attempt on the part of 
 the patient to struggle against the morbid impulse, which 
 appears incomprehensible to him. 
 
 But all the symptoms mentioned do not lead to a gen- 
 eral change of mental life which may be regarded as neu- 
 rasthenic insanity. It is merely to be noted that various 
 forms of insanity, such as mania, melancholia, paranoia, 
 dementia paralytica, present a peculiar appearance when 
 they develop upon a neurasthenic basis. Indeed, it would 
 be preferable to discuss the condition in the section on 
 general symptomatology, were it not for the fact that the 
 mental phenomena of neurasthenia possess such great 
 clinical importance. 
 
328 HANDBOOK OF INSANITY. 
 
 The causes of neurasthenia include all those which give 
 rise to mental and nervous diseases in general and which 
 are shown in exhaustion of the entire nervous system. 
 An important cause is mental strain associated with a 
 sense of responsibility in a position of influence. Hence 
 active talented men of prominence are especially prone 
 to this affection. Otherwise the female sex predominates 
 on account of its greater emotional excitability and dimin- 
 ished power of resistance. Youth entails some danger 
 form overwork in school. At the period of puberty, pre- 
 mature development of the sexual sense with excessive 
 masturbation gives rise to exhaustion. Cases of neuras- 
 thenia again grow more numerous at the menopause and 
 also at the period of senile involution. Middle life is most 
 endangered by the external conditions. Sedentary habits 
 (in officials, merchants, students) and continued dissipa- 
 tion are frequent factors. Insomnia is also a very prom- 
 inent cause. Exhausting diseases of all kinds, whether 
 acute or chronic, lead to the development of neurasthenic 
 conditions. 
 
 The course of the mental disorders of neurasthenia is 
 rarely uniform. As a general thing they develop slowly ; 
 more rarely they occur suddenly after exhausting diseases. 
 The variations in their course are usually not dependent 
 on external causes; improvement and exacerbation may 
 occur with equal surprising rapidity. A word or look 
 may suffice to make the patient feel worse. The influence 
 of the weather is manifold and varies in every case. The 
 subsidence of all symptoms is sometimes so marked that 
 the disease is not noticeable for months or even years. 
 In the majority of cases the disease lasts until the end of 
 life, though complete recovery has been observed in a few 
 cases. 
 
 The prognosis of the mental disorders of neurasthenia is 
 more favorable when the condition is due to demonstrable 
 external agencies. Cases in which imperative feelings 
 occur are more favorable than those in which there are 
 imperative ideas. Neurasthenia, per se, does not lead to 
 
DIAGNOSIS. 329 
 
 dementia, but this termination may occur in any other 
 psychosis which develops on a neurasthenic basis. 
 
 The diagnosis of neurasthenia as the basis of an existing 
 mental disorder may be extremely important to the prac- 
 titioner. He must differentiate the affection from some 
 other psychosis or severe disease of the nervous system 
 and from dementia paralytica. 
 
 The depression of a beginning psychosis is more pro- 
 nounced than that of neurasthenia and is not relieved so 
 easily by external stimulation. For a long time it may 
 be difficult to exclude organic nervous diseases, such as 
 focal lesions of the brain, diffuse sclerosis, tabes, and the 
 differential diagnosis can only be made after prolonged ob- 
 servation. 
 
 Most important, however, is the differentiation of neu- 
 rasthenia from beginning paralytic dementia. The main 
 feature of the latter is the impairment of judgment ad- 
 vancing to dementia, but the mental weakness of the 
 neurasthenic is merely a ready exhaustion, while the 
 judgment of external circumstances is not materially af- 
 fected so long as they do not refer to conditions within the 
 patient's own body. In the latter event the patient ob- 
 serves himself with morbid care, while the paralytic pays 
 no attention. This is very evident in the case of speech dis- 
 orders which, in neurasthenics, may give rise to the fear 
 of impending dementia paralytica. In the latter affection, 
 however, they are unnoticed or disregarded by the patient. 
 Other motor disorders, such as contraction or inequality 
 of the pupils, tremor of the hands and legs, may occur in 
 both affections, but are less frequent and persistent in neu- 
 rasthenia. Furthermore, imperative thoughts are not 
 met with in paresis. In advanced dementia a mistake is 
 no longer possible. 
 
 The discussion of the treatment of neurasthenia does not 
 come within the scope of a work on insanity, but many use- 
 ful hints will be found in the general section on treatment. 
 It may here be remarked, however, that the neurasthenic 
 often derives more benefit from travel than from a stay in 
 
330 HANDBOOK OF INSANITY. 
 
 an institution. When disease is associated with pro- 
 nounced chronic mental disorders, the treatment, in the 
 main, must be directed against the latter. . 
 
 Acute Forms. 
 
 Acute forms of neurasthenia are always acquired and 
 follow immediately upon certain definite causes. They are 
 conditions of exhaustion of the nervous system in which 
 the implication of the mental processes is the main factor. 
 They afford a transition to the succeeding group of toxse- 
 mias in which the morbific cause acts even at the moment 
 of the development of the disease. The relation between 
 the two groups is also shown by the fact that certain of 
 these exhaustive conditions, viz., febrile delirium, are at- 
 tributed to an organized virus. Indeed, it is doubtful 
 whether some of the mental disturbances of infectious dis- 
 eases are not due directly to such a virus, and that the in- 
 crease of temperature has no effect. On the other hand, 
 sudden febrile conditions, which depend on irritability of 
 the exhausted nervous system, are sometimes observed in 
 protracted and exhausting constitutional diseases. Per- 
 haps chemical poisons produced within the body play a 
 part in such cases. We refer here mainly to those con- 
 ditions which develop after the termination of an infec- 
 tion. They may appear at the close of an exhausting febrile 
 disease, or a little later when exhaustion becomes more 
 distinct during convalescence. We may also mention 
 those conditions in which the nervous exhaustion is due 
 to imperfect nutrition, as in shipwrecked individuals, etc. 
 The delirium of dying individuals is allied to these con- 
 ditions. 
 
 The lassitude after sleepless nights, accompanied by 
 grave cares and worry, and after excessive mental work, 
 may be the cause of acute neurasthenia in which a dreamy 
 impairment of consciousness may be the chief element of 
 the mental disorder. There is an inability on the part of 
 the patient to realize clearly his impressions from sur- 
 
ACUTE NEURASTHENIA. 331 
 
 rounding circumstances and also his own thoughts. He 
 finds himself in a state of complete helplessness and be- 
 comes restless and anxious, because all external impressions 
 have an uncanny character. His utterances are corre- 
 spondingly confused, and indeed the entire condition has 
 been described as asthenic confusion. The confused fear 
 leads occasionally to dreamy irrational acts which have 
 an undeniable resemblance to those committed on an epi- 
 leptic basis. This resemblance is so much more important 
 clinically, because after the act there is usually a greater 
 or less defect of memory and occasionally a temporary 
 complete loss of consciousness. That this condition is 
 due to exhaustion of the brain is evident from the fact 
 that rapid and complete restoration follows sleep and 
 improved nutrition. It need merely be mentioned that 
 the combination with hallucinations and delusions may 
 give rise to morbid conditions which correspond to other 
 psychoses, but these do not belong necessarily to the ex- 
 haustion of the brain now under discussion. Even in 
 these cases complete recovery usually occurs in a few 
 weeks if the patient is transferred to better surroundings 
 and secures sufficient sleep. The transition to dementia 
 is rare ; the termination in death from progressive bodily 
 exhaustion is more frequent. 
 
 The relation to bodily exhaustion is still more distinct 
 in those forms of acute neurasthenia which directly follow 
 profuse losses of blood, difficult childbed, and other ex- 
 hausting conditions. As a general thing, hallucinations 
 are then more prominent. Upon them depend, in the 
 main, the confusion and anxious mood which lead not in- 
 frequently to sudden acts of violence, especially suicide, 
 and to sudden running away. These conditions last a few 
 days and usually terminate as suddenly as they began; 
 but irritability and weakness of memory may continue for 
 some time. The danger consists in the sudden failure of 
 the vital energies, which must be combated by stimulants 
 (wine, whiske} r , camphor) , hypnotics, and proper feeding. 
 
 Finally, acute conditions of a similar nature may follow 
 
332 HANDBOOK OF INSANITY. 
 
 sexual excesses of all kinds. Here again the combina- 
 tion of religious delusions and nauseous olfactory halluci- 
 nations dominates the clinical history. The prognosis is 
 also favorable if the general condition can be improved 
 and the causes removed. 
 
 H. MENTAL DISORDERS DUE TO POISONS. 
 
 A certain class of mental disorders is due to the action 
 of poisons which enter the body from without. In a text- 
 book on insanity we cannot enter in detail into a descrip- 
 tion of the various forms of poisoning, but some of the 
 more important symptoms will be considered, inasmuch 
 as the practitioner may be placed in such a position that 
 he is compelled to infer the causal poisoning from the 
 mental symptoms alone. 
 
 These conditions develop either after a single severe at- 
 tack of poisoning or after the protracted and constant ad- 
 ministration of poisonous substances. The action of alco- 
 hol will chiefly concern us in both forms. Striking 
 mental changes may also occur after a few other rapidly 
 developing poisonings. After carbonic-oxide inhalations, 
 a preliminary period of unconsciousness is followed for 
 days by a condition of confusion which is distinguished 
 with difficulty from similar conditions, unless the previ- 
 ous history is known. A notable feature, however, is the 
 absence of hallucinations, and violent headache is also 
 very striking. During the period of complete unconscious- 
 ness the diagnosis depends upon the other toxic symp- 
 toms, as described in treatises on toxicology. 
 
 When delirium occurs in the conditions of unconscious- 
 ness produced by the so-called anaesthetics, it is generally 
 of a cheerful character, occasionally with a sexual coloring 
 as in nitrous-oxide anaesthesia. It resembles the acute in- 
 toxications after taking opium and hasheesh. Fantastic 
 hallucinations are very numerous in these forms. 
 
 The higher mental activities suffer so much more 
 markedly the more often the poisonous substance acts. 
 
MORPHINISM. 333" 
 
 Among the anaesthetics, sulphide of carbon is still to be 
 considered in this respect. After some prodromes of an 
 indefinite nature, such as pressure and pain in the head, a 
 feeling of dizziness and dulness, a more or less distinct 
 condition of excitement develops after the poison has been 
 acting for a few weeks. The individual becomes very 
 lively, talkative, and irritable, sexual desire is increased, 
 and occasionally the appetite becomes insatiable. At in- 
 tervals there is a temporary depressed mood ; then mem- 
 ory becomes distinctly impaired in many until they become 
 irrational, and at the same time speech is stuttering and 
 the tongue is moved with difficulty. Impairment of vision 
 and ringing in the ears are also observed. Spasms and 
 fibrillary twitchings in different muscles are rarely absent 
 entirely, and these, combined with great muscular weak- 
 ness, present a picture which somewhat resembles demen- 
 tia paralytica. This possibility must be kept in mind in 
 the vicinity of India-rubber factories, and the patients can 
 then be guarded against relapses by permanent removal, 
 from the injurious occupation. 
 
 Dementia paralytica may also be suspected in poisoning 
 with iodine and bromine, in lead encephalopathy, and in 
 mercury psychoses. We may also remind the reader of the 
 violent delirium of acute phosphorus-poisoning. A little 
 more attention must be devoted to the action of morphine. 
 
 Morphinism, or the morphine habit, results from the re- 
 peated abuse of the drug. As a rule, it is first taken 
 under medical supervision in order to relieve various 
 painful affections. When injected under the skin it pro- 
 duces such an excellent sedative and hypnotic action that 
 a desire arises for the repetition of this effect, especially 
 as it is often associated with dreams of an agreeable char- 
 acter. When given during periods of exhaustion mor- 
 phine produces greater activity and a general feeling of 
 well-being. Gradually it becomes indispensable, and at the 
 same time the dose must be increased to produce the 
 desired effect, until finally 2.0-3.0 may be taken daily. 
 
 The mental symptoms may be due directly to the use of. 
 
334 HANDBOOK OF INSANITY. 
 
 the drug, while other so-called abstinence symptoms follow 
 its withdrawal. The former include a striking change of 
 character; irritable, morose, misanthropic, the patient 
 grows more and more indifferent to outside interests and 
 becomes more and more selfish, until finally all his desires 
 turn around the satisfaction of his hunger for morphine, 
 which gradually loses its pleasant effects. As a rule, the 
 mental disorders are confined to the domain of ethical 
 ideas, while intelligence is affected only in so far as the 
 memory and power of endurance in mental work are con- 
 cerned. Chronic morphinism hardly ever leads to de- 
 mentia, and when this appears to be the case another 
 psychosis should be suspected. In every case, however, 
 there is a diminution of resolution and power of action. 
 At times, especially during the periods of abstinence, 
 hallucinations occur, often combined with feelings of fear. 
 
 The bodily symptoms of morphinism will not be de- 
 scribed here; they may be found in any text-book of 
 neurology. 
 
 It is important to remember, in regard to the diagnosis 
 of doubtful cases, that the morphine is excreted in the 
 urine, where it may be found by chemical tests. 
 
 The term alcoholism is applied to all the morbid condi- 
 tions which are due to the abuse of alcoholic drinks. It is 
 to be kept in mind, however, that the alcoholic basis of 
 some psychoses merely gives to them a special coloring, 
 but that they do not forfeit their own characteristics. 
 
 The simplest form of alcoholism, viz., an attack of 
 drunkenness, shows some of the most important elements 
 of the disease. The mental processes appear to be accel- 
 erated and facilitated in a fit of drunkenness. The increased 
 self-esteem leads to boldness and jollity. At first the 
 bodily powers are also increased. Increased necessity for 
 movement is shown by singing, screaming, laughing, 
 dancing, and increased sexual desire is not infrequent. 
 In a little while, however, the individual finds it difficult 
 to concentrate his attention upon internal as well as ex- 
 ternal processes ; the interpretation of external impressions 
 
DRUNKENNESS. 335 
 
 also becomes slower. The aesthetic feelings and ideas 
 are first extinguished in the drunken man, although he still 
 retains and expresses the feeling of increased power. This 
 offers a marked contrast to his foolish actions. A char- 
 acteristic feature is his denial of his excited condition and 
 its cause. Not infrequently there is an unfounded change 
 of mood from joviality to depression. With the constantly 
 increasing loss of the power of attention, the individual 
 enters the condition of complete drunkenness. During 
 the transition deceptions of the senses may be manifested ; 
 as a rule, these are illusions, not true hallucinations. 
 Consciousness is lost more and more, and while speech 
 becomes confused, motor disorders of various kinds end 
 the scene. 
 
 A termination in conditions which resemble dementia 
 after passing through excitement of all the mental func- 
 tions, accompanied by changes of mood and early disap- 
 pearance of ethical feelings, by a tendency to denial of 
 drunkenness, by sexual excitement, hallucinations, and 
 motor disorders — all these symptoms, either separately or 
 combined, form part of chronic alcoholism. As a matter 
 of course there are numerous transitions between the sin- 
 gle drunken fit and the symptoms of chronic alcoholism. 
 The fact that severe conditions of drunkenness develop 
 in some individuals after taking very small amounts of 
 alcohol shows that these persons, whether as the result of 
 heredity or of acquired diminution of mental vitality, are 
 less capable of resistance and have a predisposition to 
 mental disturbances, whatever may be the exciting cause. 
 
 In such individuals there is a tendency to the devel- 
 opment of numerous hallucinations, especially of sight. 
 These conditions last only a few hours ; the contents of the 
 hallucinations are frightful in character and consciousness 
 is in a dreamy state. Acts of violence may be committed 
 while only a summary memory remains. In old topers 
 such a condition may also be superadded to the permanent 
 alcoholism. But when an apparently healthy individual 
 falls into this pathological drunkenness, these severe results 
 
336 HANDBOOK OF INSANITY. 
 
 of a single poisoning with alcohol can only be explained on 
 the hypothesis that his central nervous system is below par. 
 Sometimes these conditions do not develop until some 
 time after the ingestion of alcohol, especially after the 
 passions have been aroused. From a medico-legal stand- 
 point it is imj)ortant to remember that this pathological 
 drunkenness is always associated with unconsciousness 
 and is usually followed by loss of memory of the events 
 which happened during it. 
 
 Chronic alcoholism embraces all those mental and 
 physical disturbances of function which are produced by 
 the habitual abuse of alcohol. Drunkenness is always as- 
 sociated, however, with other causes, and is indeed often 
 the result of such causes, viz., family cares, worry, etc.; 
 or the love of drink may be merely a part symptom of an 
 underlying general morbid predisposition. The abuse of 
 alcohol also acts by giving rise to purely physical disorders, 
 particularly to diseases of the digestive organs and to 
 changes in the vascular apparatus. 
 
 The main element in the psychical changes is the pro- 
 gressive loss of ethical and intellectual functions, the 
 former being usually first affected. The notions which 
 are based on customs and morals, and which, in connec- 
 tion with the personal elements of the temperament, im- 
 part to the latter its special coloring — in a word, the 
 character of the patient gradually changes and finally is 
 lost. He loses the capacity of acting according to prin- 
 ciple. His views concerning honor and propriety become 
 lax, and all the higher feelings yield to the impulses of 
 the moment. Egoism becomes the mainspring of all 
 actions, and finally everything is sacrificed to the desire 
 for drink, which alone is capable of relieving temporarily 
 the distressing results of the alcoholic poisoning. At the 
 beginning there may be a severe struggle between the 
 growing passion and the patient's self-control, but usually 
 the latter succumbs. The habitual drunkard finally be- 
 comes a confirmed liar, upon whose statements not the 
 slightest reliance may be placed. The moral degeneration 
 
CHRONIC ALCOHOLISM. 337 
 
 progresses until nothing will prevent the individual from 
 committing even deeds of violence in order to obtain drink. 
 
 This loss of character becomes evident long before the 
 apppearance of intellectual weakness. For this reason 
 the individual is handled with difficulty, inasmuch as the 
 intact intelligence makes [it appear improbable to the ma- 
 jority that his offences against law and morals are due to 
 a pathological mental disturbance. It cannot be denied 
 that at this stage the patients are not proper subjects for 
 asylum treatment, because the necessity of removing all 
 opportunities for obtaining drink compels us to place 
 them in wards in which their personal liberty is greatly 
 curtailed. In such wards they cannot be kept long be- 
 cause they are unavoidably brought in contact with many 
 sad experiences. The patients should be placed in inebri- 
 ate asylums, because experience has shown that abstinence 
 from alcohol for one to two years occasionally permits the 
 redevelopment of an intact, morally vigorous emotional 
 life, and often warrants a return to former pursuits. When 
 this does not take place the inebriate asylum will pre- 
 vent further degeneration. 
 
 The docility of patients who are deprived of alcohol is 
 sometimes surprising. The fact that this is most marked 
 at the beginning of such treatment proves that it is due 
 to a morbid condition of exhaustion. In general, the 
 nervous system becomes impaired under the prolonged 
 abuse of alcohol, and hence so many neurasthenics are 
 found among drunkards. Their irritability is often ex- 
 treme, and the slightest provocation may give rise to 
 violent passion and outbursts of rage, in which all con- 
 sideration for those about them is lost. Sometimes the 
 sudden anger is vented upon their own person. Profound 
 depression is apt to occur, especially in the morning, 
 sometimes with a tendency to suicide, but after renewed 
 ingestion of alcohol this mood disappears and may change 
 to the opposite. This frequent change corresponds to 
 their indecision in acting and to their weakness of will 
 power. 
 
 22 
 
338 HANDBOOK OF INSANITY. 
 
 Even at this stage the intelligence often remains intact. 
 Occasionally impairment of memory first develops, then 
 there is rapid loss of the power of attention, especially in 
 independent mental activity. The patient may take in- 
 telligent interest in a conversation, but can no longer read 
 a book attentively or do scientific work. But in every 
 case the impairment of intelligence is recognizable in the 
 one-sided and insufficient comprehension and interpreta- 
 tion of new impressions, so that thought is confined to the 
 patient's own immediate interests. In this way there is 
 a gradual decay of mental life which may progress, often 
 after the lapse of many years, to complete dementia. 
 This is hastened by the development of other psychoses or 
 severe symptoms in other parts of the nervous system. 
 
 Two factors characterize alcoholism when the symptoms 
 just described are complicated by temporary or permanent 
 psychical disorders, viz., the character and great number 
 of the hallucinations and the frequency of the delusion 
 of marital infidelity. 
 
 The hallucinations are extremely mobile and variable, 
 often of a very fantastic character. In great part they 
 may be mere illusions, due to the imperfect interpretation 
 of actual occurrences. Lights and movable objects play 
 a great part in this process. A feature common to all 
 these hallucinations is their elementary and fantastic 
 character. Lights, flames, and stars alternate with clouds ; 
 a spot forms before the eye, assumes regular outlines, 
 a head or claws appear, and gradually is converted into 
 an animal; this changes its position, disappears, then 
 returns to its former position. All possible and impossible 
 animals may appear, but small ones predominate. They 
 run around the room, jump upon the patient, grow, dis- 
 appear in the floor or wall. He sees fire, combats, battles 
 hordes advance upon him. These appearances are gener- 
 ally of a frightful, rarely of a pleasant character. In the 
 latter event birds, brilliant flowers, and beautful land- 
 scapes are seen. The auditory hallucinations are like- 
 wise of an elementary character, such as roaring, tinkling, 
 
ACUTE ALCOHOLIC INSANITY. 339 
 
 hissing, shooting. When they assume a definite shape 
 their contents are usually threatening, mocking, insulting. 
 The large number of sounds is also characteristic. The 
 same features are found in the rarer cases in which smell 
 and taste are affected, and hence we can understand the 
 peculiar symptoms presented by the alcoholic delusion of 
 persecution. To make the description complete, a few 
 farther details are requisite. Hallucinations of feeling 
 occur in a similar way ; the patients feel animals entering 
 the skin and gnawing their limbs; the fire burns their 
 hair and skin. Such changes of feeling sometimes de- 
 velop in the sexual apparatus, and are then apt to be asso- 
 ciated with the delusion of marital infidelity and un- 
 founded jealousy. In fact, sexual life is very commonly 
 drawn into the morbid symptoms, so that the delusion of 
 jealousy is sometimes regarded as peculiar to alcoholism. 
 In some cases it may be due to increased desire asso- 
 ciated with rapidly progressing impotence, as occurs es- 
 pecially in advanced cases of alcoholism. The delusion 
 of jealousy is not always founded on hallucinations, but 
 irrelevant words and gestures are interpreted in the sense 
 of the delusion. Sometimes the patients (male and female) 
 accuse those around them of making improper proposals. 
 
 So-called acute alcoholic insanity generally begins at 
 night, quite suddenly, and may disappear within a few 
 days. This condition is distinguished from the closely 
 allied delirium tremens by the predominance of sexual 
 ideas, which are combined into a confused system with 
 the other symptoms, consciousness remaining compara- 
 tively clear ; olfactory hallucinations are quite frequent ; 
 the motor disorders which are prominent in delirium 
 tremens are not pronounced. 
 
 A few words with regard to the motor and sensory dis- 
 orders of chronic alcoholism in its ordinary form. Tremor 
 of the tongue, facial muscles, and hands is commonly 
 present, and is more distinct in the sober condition than 
 during the immediate effect of alcohol. Localized cramps, 
 for example, in the calves, are rarer. Distinct paralyses 
 
340 HANDBOOK OF INSANITY. 
 
 are not very common ; pareses are more frequent. These 
 symptoms are often due to peripheral neuritis. Circum- 
 scribed ansesthesias or pains in the limbs may be very 
 annoying and may form the basis of delusions. Visual im- 
 pairment may result from retinitis and temporary changes 
 in sight to circulatory changes. Vaso-motor paralyses of 
 various kinds occur in alcoholism ; for example, enlarge- 
 ment of the vessels in the face, degeneration of the walls 
 of the vessels and the heart. Affections of the digestive 
 tract also influence the patient's mood. 
 
 Before discussing the course and termination of chronic 
 alcoholism, we must examine the peculiar condition known 
 as delirium tremens. It rarely follows a single excess 
 and never follows a single intoxication in an otherwise 
 temperate individual. It occurs usually after some excit- 
 ing cause, such as an injury or a pneumonia, but may also 
 develop independently during the course of alcoholism. 
 Hard drinkers of whiskey rarely escape it, although its" 
 frequency depends upon other external circumstances, 
 especially upon the general nutrition. It is rare when the 
 alcoholism is produced by good wines and beer. It is un- 
 necessary to enter again in detail into the symptoms 
 which are common to delirium tremens and to alcoholic 
 insanity. The contents of the hallucinations are approxi- 
 mately the same in both conditions. The visual hallucina- 
 tions generally have the characteristic of small size and 
 are also extremely numerous. It is very probable that 
 the appearance of animals in such large numbers is due 
 to disorders of accommodation and to changes in the fun- 
 dus oculi, i. e. , their development is in great part peripheral. 
 They are terrifying to the patient, especially as they are 
 associated with corresponding hallucinations of hearing 
 and the tactile sense. Among the latter the feeling of 
 crabs, snakes, spiders, and ants upon and in the skin is 
 especially characteristic, and upon them depends, in part, 
 the constant picking at the bedclothes which is almost 
 always observed at the height of the disease. 
 
 During these hallucinations consciousness is profoundly 
 
DELIRIUM TREMENS. 341 
 
 impaired, but not entirely lost, because the patients will 
 answer questions for a moment when addressed in a per- 
 emptory tone. Insomnia is prominent among the pro- 
 dromes, likewise a great susceptibility to fright, and 
 these symptoms are always present in the fully developed 
 disease. As consciousness is not entirely lost and atten- 
 tion can be aroused momentarily, the conduct of the 
 patient often appears awkward and foolish. This impres- 
 sion is strengthened by the mobile restlessness of the 
 patients and the manner in which they are constantly oc- 
 cupied with the objects of their hallucination. The grab- 
 bing for the rapidly-moving apparitions and the conversa- 
 tion with the innumerable beings that storm upon him 
 often converts the scene into a lively spectacle which 
 may exhibit even comic effects. In other cases great 
 anxiety predominates, but a delusion of persecution is 
 usually not expressed in set terms. The inimical con- 
 tents of the hallucinations may give rise, however, to acts 
 of violence against the patient's own life or against those 
 around him. Even apart from definite hallucinations, 
 the consciousness is filled by terrifying thoughts, as is 
 evident from the fact that patients suffering from delir- 
 ium tremens and chronic alcoholism very often assert 
 that they or others in their company have committed a 
 murder. 
 
 The hallucinations are usually most marked as soon as 
 the patient closes his eyes in order to fall asleep, probably 
 on account of the pressure on the eyeball. In the same 
 way a convalescent, by closing the eyes, may reproduce 
 visual hallucinations which had disappeared. 
 
 The motor disorders of delirium tremens are of great 
 importance. Apart from the constant motion due to the 
 hallucinations, there is also direct muscular restlessness. 
 This is shown by purposeless walking and by the push- 
 ing away of objects which happen to be in the way. 
 Bathed in perspiration and completely exhausted, the 
 patient may break down, or after a few moments of ex- 
 haustion and apparent quiet the scene begins anew. 
 
342 HANDBOOK OF INSANITY. 
 
 Motor disorders due to direct central irritation also ap- 
 pear in the form of rapid twitchings of the facial muscles, 
 especially around the mouth and eyes, and in the shape of 
 nystagmus; in the form of tremor they extend to the 
 trunk and limbs. Tremor is most distinct in the ex- 
 tended fingers and the protruded tongue. Speech is thick 
 and difficult, chiefly from loss of power. This is also 
 shown in the uncertain and tottering gait, but in mo- 
 ments of excitement and rage this is lost and the patient's 
 strength may be almost incredible. General epileptic 
 convulsions are not very infrequent. 
 
 As the reflex irritability is very much increased, the 
 limbs are tossed about in bed and slight injuries are often 
 produced in this way. Even severe injuries, such as frac- 
 tures, may be unnoticed on account of the impairment of 
 consciousness and perhaps diminished sensibility to pain. 
 Uncomplicated delirium tremens is usually apyrexial, 
 but in the severest forms there may be an extreme rise of 
 temperature. In such cases death is the usual termina- 
 tion. In others death may occur from general exhaustion, 
 without fever; the pulse becomes soft and small, an ir- 
 regularly flickering delirium ends in complete loss of con- 
 sciousness, feeble movements are still indicated, the 
 twitchings become subsultus, and the vital energies are 
 extinct. The average mortality is about twenty per cent, 
 death being due to exhaustion, pneumonia, severe in- 
 juries, suicide, and accidental complications. Cases that 
 recover usually run their course in three to eight days. 
 Sometimes a short sleep seems to indicate recovery, but this 
 may be delayed, sometimes for several weeks, by a fresh 
 exacerbation of the excitement. In mild cases a profound 
 and prolonged sleep checks the delirium so completely that 
 the patient awakes entirely well. 
 
 The relief of the insomnia constitutes the most important 
 element of treatment. At the onset hypnotics are gener- 
 ally useless, but they become very effective toward the close 
 of the attack. Chloral hydrate is the preferable remedy 
 unless contra-indicated by cardiac disease. Otherwise the 
 
CHRONIC ALCOHOLISM. 343 
 
 treatment is restricted to careful feeding and to measures 
 necessary to protect the patient and those about him from 
 injury. Everything with which the patient might injure 
 himself or others should be removed. Personal restraint 
 by straight- jackets, etc., should not be permitted because 
 pneumonia and oedema of the lung are apt to develop. In 
 addition to nourishing food, especially milk, moderate 
 amounts of alcoholics should be given. This should also 
 be done in all cases of alcoholism which come under 
 treatment for some other, especially febrile, disease or on 
 account of an injury. Under such circumstances the sud- 
 den abstinence from alcohol may give rise to an attack 
 of delirium tremens. 
 
 After an attack of delirium tremens the tremor of the 
 limbs, especially of the hands, may last for a long time. 
 
 We find the condition returns to its former status, and 
 we thus return to the point in the further course of 
 chronic alcoholism which we reached a little while ago. 
 If this course is not interrupted by the conditions of ex- 
 citement already described, it is tolerably uniform in its 
 progress. But there is one form of mental disorder which 
 may occur in a chronic drinker after a single excessive 
 intoxication or several rapidly following excesses. True 
 alcoholic poisoning is then combined with the already 
 existing general change. The clinical history then pro- 
 duced contains the majority of the other symptoms pressed 
 close together and developed to a high degree. Hence 
 there is a great similarity to galloping dementia para- 
 lytica. The mood is very exalted, immoderate ideas of 
 grandeur develop, associated with great loquacity and 
 muscular restlessness, and pupillary differences, facial 
 paralyses, general tremor, and great difficulty of speech 
 complete the deceptive impression of dementia paralytica. 
 But this alcoholic paresis does not usually advance to de- 
 mentia ; within a few weeks or months it disappears and 
 the patient recognizes his condition. Recovery is perma- 
 nent in so far as it is not affected by the other symptoms 
 of chronic alcoholism. This condition must be distin- 
 
344 HANDBOOK OF INSANITY. 
 
 guished from the dementia with paralyses which may- 
 develop in a remarkably slow manner during the course 
 of ordinary chronic alcoholism. In the former condition 
 epileptiform paralytic attacks are rare, while the combi- 
 nation of alcoholism with epilepsy is especially apt to 
 provoke the slow process into dementia. As a matter of 
 course, the alcoholic patient may also be attacked by true 
 paralytic dementia, but the latter differs in its clinical 
 course from dementia with paralyses. Apart from the 
 lesser intensity of all the symptoms, it lacks the progres- 
 sive course, and if gradual and complete abstinence from 
 drink is secured we can effect a standstill and consider- 
 able improvement. Indeed, chronic poisoning with alco- 
 hol rarely leads to the highest grades of dementia. 
 
 A few words must be devoted to so-called alcoholic 
 epilepsy. Intense alcoholic poisoning in a chronic hard 
 drinker, as well as in a moderate drinker, may give rise 
 to a condition of profound disturbance of consciousness, 
 which lasts long after the drunken fit, is associated with 
 epileptic convulsions, and, on account of the development 
 of hallucinations, may closely resemble certain epileptic 
 states and equivalents. The resemblance is increased still 
 farther by the very rapid course of the symptoms, their 
 rapid cessation, and the loss of memory for events occurring 
 during this state. Individuals are attacked who were not 
 previously epileptic, although epileptics who have become 
 addicted to alcohol may also exhibit similar conditions. 
 If this condition develops only once, it may be called a 
 pathological drunkenness in the sense already described. 
 These convulsive seizures are apt to return after every 
 severe intoxication, and to such cases the term alcoholic 
 epilepsy is best suited. 
 
 After the ingestion of enormous amounts of poor alcohol, 
 the highest degree of intoxication may be manifested 
 from the start in complete unconsciousness and paralysis, 
 and this often terminates fatally in a short period from 
 acute oedema of the brain. 
 
 As a general thing chronic alcoholics die, before they 
 
ANATOMICAL CHANGES. 345 
 
 have reached the hightest grades of mental and physical 
 decay, from some intercurrent organic affection. The 
 character of the alcoholic drink is of great importance as 
 regards the rapidity of the entire condition. 
 
 Alcoholic stimulants that contain fusel oil are much 
 more dangerous than others ; the brain then suffers from 
 the action of the adulterations. For this reason alcohol- 
 ism is so wide-spread among the lower classes. It is much 
 less frequent among drinkers of beer and wine. 
 
 The constant drinking of smaller amounts of alcoholic 
 stimulants is usually much more dangerous than periodi- 
 cal excesses. Dipsomania {vide page 96) is not one of the 
 causes of chronic alcoholism, but when this condition coex- 
 ists in a case of chronic alcoholism it constitutes an im- 
 portant factor, and such patients usually fail very rapidly. 
 
 When simple psychoses develop upon an alcoholic basis, 
 we must distinguish between the temporary effect of 
 alcoholism and an independent psychical affection in an 
 habitual drinker. In the former event, severe symptoms 
 are especially manifest at the start and the disease also 
 runs a severe course. Alcoholism may not be inferred, 
 however, from the slight power of resistance to small 
 amounts of alcohol, because such intolerance occurs in 
 many nervous systems which are below par. It is doubt- 
 ful whether the psychoses of habitual drunkards which 
 are due to some other exciting cause exhibit any specific 
 symptoms. 
 
 Apart from the numerous changes in other organs, an- 
 atomical changes develop in the brain and meninges after 
 alcoholism has continued for a long time. Inflammations 
 and thickening of the meninges, atrophy of the brain sub- 
 stance, especially of the cortex, and internal hydrocephalus 
 then become prominent. But the motor disorders, espe- 
 cially paralyses, often result from diseases of the spinal 
 cord and its membranes and from inflammations of the 
 peripheral nerves. 
 
 As the treatment of the psychoses which are associated 
 with alcoholism is based on general principles, it only re- 
 
346 HANDBOOK OF INSANITY. 
 
 mains for us to make a few remarks on the treatment of 
 alcoholism. Complete restoration cannot be expected, and 
 we must be satisfied with an amelioration of the symptoms. 
 We may repeat that most can be done by diminishing the 
 quantity and improving the quality of the noxious poison. 
 There are no positive remedies or curative methods. Per- 
 manent abstinence from alcohol prevents farther progress, 
 but very few will decide upon permanent seclusion from 
 the world if a tolerable equilibrium is obtained after the 
 disappearance of the most severe symptoms. 
 
 J. FEEBLE-MINDEDNESS (IMBECILITY AND IDIOCY). 
 
 The artificial character of our classification is again 
 shown very clearly in this section. The extreme grades of 
 idiocy under the form of cretinism apparently have nothing 
 in common with the milder forms of feeble-mindedness, 
 especially if they are not congenital but remain after a psy- 
 chosis. These different groups are arranged in one class 
 because they belong together clinically. The antitheses 
 at both ends of the series are joined to one another by 
 numerous transitions whose - essential clinical feature is 
 mental weakness. The milder conditions of mental weak- 
 ness which result from other psychoses must be considered 
 separately from profound dementia, and, in view of their 
 clinical relationship, in conjunction with congenital fee- 
 ble-mindedness or imbecility. Clinically, the latter ap- 
 proaches the mild grades of idiocy in which there are 
 only slight anatomical changes. Then a slight step leads 
 clinically and anatomically to the higher and highest 
 grades of idiocy and cretinism. These are distinguished 
 from the acquired forms of dementia by the congenital 
 anatomical changes. 
 
 Concerning the first group of acquired feeble-minded- 
 ness little need be said (although it is one of the most ex- 
 tensive classes), because it is a termination of many 
 functional simple psychoses. One of its most strik- 
 ing features is diminished endurance in mental work,, 
 
IMBECILITY. 34? 
 
 while the individual ability in the customary occupation 
 may still be sufficient. Indications of the antecedent 
 psychosis are wanting, while the mental decay which 
 passes into dementia still contains such elements and thus 
 shows that the morbid process is extending more deeply. 
 In the feeble-mindedness to which we refer this has 
 ceased and the condition has become a permanent sequel. 
 Unlike neurasthenia, the ready exhaustion is confined to 
 mental activities, while other nervous functions are not 
 enfeebled. But the higher psychical functions, especially 
 in the ethical field, are also impaired, and defects in moral 
 views are noticeable when actions are required which call 
 for independent decision. 
 
 In congenital feeble-mindedness or imbecility the con- 
 dition differs merely in its mode of development, not in 
 its clinical aspects. Here there has never been a thorough 
 comprehension of the depth of moral convictions, and the 
 discrepancy between morals and the acts of an imbecile 
 depends essentially upon his lack of judgment, which is 
 often manifested, particularly in this connection. Very 
 often imbeciles exhibit excellent mental attainments in 
 other circumscribed fields. In matters which depend 
 chiefly on memory they often develop great cunning. 
 Otherwise the observation and comprehension of the outer 
 world are confined to objects under their immediate 
 notice and to the conditions and interests of their own 
 person. If their wants are satisfied they may lead quiet, 
 harmless lives ; if not, we may be surprised by outbursts 
 of anger and violence which show that self-control is en- 
 tirely wanting. No sorrow or remorse is felt after the 
 period of excitement has passed. The directness with 
 which their resolutions spring from the internal conditions 
 of the body shows the close relationship to the impulsive 
 acts of idiots. 
 
 From a causal standpoint feeble-mindedness which re- 
 sults from brain disease, injury to the skull or concussion 
 in early childhood, stands midway between congenital 
 imbecility and the conditions of mental weakness following 
 
348 'HANDBOOK OP INSANITY. 
 
 a psychosis in mature years. Clinically these cases show- 
 no material difference. But if an imbecile is attacked by 
 a psychosis in later life, the course of the disease exhibits 
 distinct peculiarities. Awkward and childish conduct be- 
 comes prominent. The morbid manifestations of the 
 changed mood far exceed the usual mean. The expression 
 of exalted self-esteem or of timid self -depreciation can no 
 longer be measured by the possible. Delusions of grandeur 
 occur in degrees which are otherwise found only in para- 
 lytic dementia. The disease presents unforeseen and sur- 
 prising changes. Many incomprehensible features in a 
 psychical disorder which develops upon a basis of feeble- 
 mindedness can only be explained by this basis. These 
 patients furnish numerous instances of conflicts with the 
 law and public morals. 
 
 The backwardness as regards the higher psychical feel- 
 ings may be more distinct than the imperfect development 
 of the intellect. The term moral insanity is often used 
 wrongly for such conditions. The moral defect never ex- 
 ists without implication of the other mental faculties, and 
 the former merely predominates. 
 
 The impossibility of acquiring the higher moral ideas as 
 a living reality entails the inability of understanding their 
 worth in general. These individuals confine all their feel- 
 ings and endeavors upon themselves and their own advan- 
 tage. The mentally normal individual in modern society 
 must always be able to comprehend the reasons which 
 prevent him from recklessly satisfying his immediate 
 selfish desires. This ability is lacking in the feeble- 
 minded individual, although he grows up in the midst of 
 civilization, from whose blessings he constantly draws an 
 abundant supply. The laws of morals may be studied and 
 memorized, but they remain dead masses of ideas. 
 
 The absence of sympathy is shown at an early age by 
 the tendency to torture animals or to enjoy their sufferings. 
 Indifference is manifested toward the nearest relatives, 
 even toward the parents. In some cases such phenomena 
 appear with more or less distinctness at certain intervals, 
 
SYMPTOMS IN YOUTH. 349 1 
 
 and we may here remind the reader of our former remarks 
 on periodical psychoses. In childhood these individuals 
 are lazy and lying, the despair of their parents and teach- 
 ers; in youth they become vagabonds, commit theft; 
 among them we find congenital criminals, especially 
 thieves. They soon become the plague of the authorities, 
 are not amenable to punishment, and regard the laws 
 merely as police regulations whose results they must avoid. 
 Finally, they gratify their propensities impulsively, with- 
 out regard to consequences. There is an uncontrollable 
 desire to masturbate and to gratify their sexual impulses, 
 even in early youth. 
 
 Immorality and coarseness, cruelty and malice, may 
 appear so much more deserving of punishment because they 
 are associated not infrequently with a certain degree of dia- 
 lectic skill. Delusions and hallucinations are absent. It 
 is then difficult to demonstrate intellectual defects, although 
 one circumstance aids us in disclosing the inhibition of 
 the development of mental life. In school these individ- 
 uals may be the equals of their companions up to a certain 
 period, but a striking feature is their unequal power of 
 attention. Then, almost suddenly, they remain backward, 
 often at the period of puberty, and cannot keep pace with 
 their comrades when independent thought is required. 
 It seems as if the internal development of the brain sud- 
 denly ceases. This defect becomes more evident in the 
 choice of a life career. They are unpractical individuals. 
 If the other members of the family are normal, the nature 
 of the feeble-mindedness becomes more distinct from the 
 contrast. If the hereditary taint is pronounced, the mor- 
 bid condition becomes so much clearer to the physician ; 
 but the internal contradictions must be shown so much 
 more carefully to the legal authorities. Despite their ap- 
 parent cunning, the acts of imbeciles often disregard the 
 ordinary rules of prudence. The chief object is always 
 the satisfaction of the moment; whether this is propor- 
 tionate to the means employed is immaterial. A theft is 
 committed in order to spend the proceeds in ridiculously 
 
350 HANDBOOK OF INSANITY. 
 
 useless articles. They employ intrigue and swindling 
 methods to achieve ends which could be obtained much 
 more easily by honorable methods. There is no reflection 
 interposed between the desire and the deed, but its execu- 
 tion is effected by impulse. A criminal deed is some- 
 times due to the impulse of imitation. 
 
 The mental ability fails still farther when a simple con- 
 ception suffices to convert another associated concept into 
 an actual deed. But such an imperative act differs essen- 
 tially from that performed by a neurasthenic. The latter 
 straggles continually against the idea which is constantly 
 cropping out and demanding realization. The imbecile is 
 left to the play of his ideas, without reflection or internal 
 struggle. It is true that these processes are associated 
 with vague feelings, but the imbecile does not comprehend 
 their connection with his notions and acts. Many acts 
 appear to be explained in this way, but the psychological 
 explanation is often found rather in the mind of the ob- 
 server than of the patient. For example, arson committed 
 by imbeciles may only be explained as the gratification of 
 revenge. It is true that this reason actually holds good 
 in not a few cases, but we must not always rely upon this 
 when the young incendiaries declare that the deed was 
 done without reason. As a matter of fact, the thought of 
 fire and its production may have been almost simultaneous, 
 or the childish delight in flickering flames may have been 
 sufficient reason for starting the fire. In other cases home- 
 sickness is the cause of arson by imbeciles, because they im- 
 agine that they can then change their abode. Here, again, 
 the reckless choice of means for attaining personal ends 
 permits of no reflection on the other bearings of the deed. 
 The impossibility of forming higher ethical notions en- 
 ables us to recognize the intellectual in addition to the 
 moral weakness. In addition to the inability of recogniz- 
 ing vices as such, f eeble-mindedness is demonstrated either 
 by the slight power of judgment or the diminished mental 
 activity. The laziness of these individuals is want of ca- 
 pacity. In order to avoid work they become tramps, 
 
IMPERFECT CEREBRAL DEVELOPMENT. 351 
 
 punishment makes them still more obstinate, and the 
 number of so-called incorrigibles in prisons includes many- 
 feeble-minded individuals. In reformatories, where they 
 are properly treated, they may often become, in a measure, 
 useful individuals. But even here their vanity, which 
 often tells them that they accomplish a great deal, may be 
 a great obstacle to their education and to the attempt to 
 make them amenable to the regulations of the institution. 
 
 These forms of imbecility, whether manifested mainly 
 in the moral or the purely intellectual field, do not show a 
 steady advance when the period of bodily development 
 has passed. We have already seen, however, that a cer- 
 tain periodical course of the symptoms is recognized when 
 there is an hereditary neurasthenic basis. Moreover, ex- 
 ternal accidental factors, such as an injury to the head or 
 a severe bodily disease, may cause a long-continued in- 
 crease of all the s3 T mptoms, which may disappear after the 
 removal of the exciting cause. There is then apparent 
 recovery if the original feeble-mindedness has not been 
 marked or has been overlooked. A similar condition may 
 be observed at the period of puberty. Such exacerbations 
 of an originally slight imbecility may disappear entirely, 
 even after the lapse of a year. 
 
 In the higher grades of imbecility the accompanying 
 anatomical changes can no longer be disregarded. We 
 must then employ the term idiocy, and this cannot be 
 separated from those inhibitions of mental development 
 which are accompanied by distinct anatomical aberrations. 
 We have to deal now with disorders of mental and 
 bodily development which exist from birth or early child- 
 hood. The individuals in question remain backward and 
 cannot attain the culture and education corresponding to 
 their age and condition in life. Deaf -mutism will not be 
 considered, and, in fact, those developmental disorders 
 which depend on sensory deficiencies (especially blindness) 
 are not really the objects of psychiatric investigation. 
 
 The imperfect development of the brain, upon which 
 idiocy depends, may be indicated in the ovum and become 
 
352 HANDBOOK OF INSANITY. 
 
 manifest during foetal life, but the disease which leads to 
 idiocy usually begins after birth, during the first five 
 years of life. Hence, the term idiocy includes inhibitions 
 of development, together with conditions which are ac- 
 quired in early life as the result of morbid changes and 
 destructions of important parts of the brain, because posi- 
 tive signs for the differentiation of these modes of de- 
 velopment are wanting. The most varied anatomical 
 changes are found in idiocy. Thus, the brain may be re- 
 markably small or remarkably large, although the latter 
 condition is rare. The structure of the brain may then 
 appear to be well developed and the body may also appear 
 to be vigorous. An explanation of the association of this 
 condition with idiocy is impossible, because even the mi- 
 croscope usually shows no change. 
 
 Much more frequent and important is the small size of the 
 brain, combined with that of the skull. The latter is not 
 always the cause of the former, because premature ossi- 
 fication of the sutures is not found even in the majority 
 of all cases of microcephalus. In some cases certain, but 
 not all, children of the same mother, who belongs to a 
 family which is undoubtedly free of hereditary taint, are 
 microcephalic, and it is then assumed that the cause is an 
 inhibition of the growth of the skull and brain due to 
 mechanical conditions, for example, to some obstruction 
 due to the membranes, but not to the uterus itself, be- 
 cause in the latter event all the children would be micro- 
 cephalic. The special form of microcephaly in cretinism 
 alone appears to be due positively to premature ossification, 
 of the sutures at the base of the skull. 
 
 For the present we will consider only simple microceph- 
 alus, which gives rise to idiocy. As a rule, the face is 
 well developed, but the jaws are sometimes very promi- 
 nent ; the cranium and brain are extremely small, the fore- 
 head flat. Although the convolutions are usually simpli- 
 fied, the principal fissures generally are more or less well 
 developed ; the convolutions are very rarely entirely nor- 
 mal. Other changes are inequality of the two sides of the. 
 
CRETINISM. 353 
 
 brain, unusual prominence of certain fissures, internal 
 hydrocephalus, and porencephaly. In some microcephalics 
 the brain is even much smaller than we would expect from 
 the size of the skull, when the space within the skull is 
 farther restricted by hydrocephalus or pronounced thick- 
 ening of the bones. 
 
 Partial atrophy of the brain is frequent, but the clinical 
 course of such cases is not materially different from that 
 observed when the atrophy is general. As a general thing 
 the frontal lobes are more profoundly affected, but in other 
 cases the occipital lobes are chiefly involved. There may 
 also be small sclerotic foci in the most remote parts of 
 the brain of idiots. A difference in the clinical history 
 develops, however, according as the inhibition of develop- 
 ment affects the cortex at the convexit} r or those parts of 
 the brain which are situated at the base. In the former 
 event the idiocy is pronounced, but the possibility of the 
 free development of the brain at the base, where the motor 
 tracts are found, is shown by the fact that the patients are 
 very active and are capable of co-ordinated movements. 
 When the base of the skull is shortened and the develop- 
 ment of the basal parts is inhibited, the patients are slow 
 and incapable of performing delicate movements. This 
 group includes cretins proper. 
 
 Cretinism occupies a special position in idiocy because 
 certain bodily symptoms constantly accompany it and be- 
 cause it sometimes appears endemically. Cretins are usu- 
 ally dwarfs. Although the head is diminished in size, it 
 is relatively large, because the trunk is small, often child- 
 like in appearance. The features are old and ugly, at the 
 same time childish. Thick lips, heavy lids, deep eyes 
 and a broad nose, thickened integument of the face and 
 great enlargement of the thyroid gland complete the pecul- 
 iar picture. As an endemic, cretinism is always accom- 
 panied by goitre and occurs only in high mountain ranges 
 and their spurs. Thus, it is found in the deep valleys of 
 the Alps, Pyrenees, Cordilleras, Himalayas, and the high 
 ranges of China ; it is much rarer among lower mountain 
 23 
 
354 HANDBOOK OF INSANITY. 
 
 ranges. Although hereditary influences are not excluded, 
 a local, perhaps contagious, infection appears to be neces- 
 sary. This view is strengthened, for example, by the fact 
 that distinct signs of the morbid condition do not develop 
 until several months afterbirth or even later, and that the 
 children of healthy immigrants may also be attacked by 
 cretinism. The cranial deformity may vary greatly, but 
 the most prominent feature is the inhibited development 
 of the base of the skull ; the cretins are correspondingly in- 
 dolent. The proliferation of the cartilaginous elements, 
 which precedes ossification in the healthy, does not take 
 place in all the other bones in cretins. This premature 
 cessation of ossification checks longitudinal growth. Even 
 simple idiots attain full growth only at a comparatively 
 late period. Cretinism is rarely sporadic. 
 
 The general condition of cretins differs so little from 
 that of other idiots that the same clinical description will 
 serve for both. We will first touch upon a few other 
 factors which lead to the development of idiocy or accom- 
 pany it as permanent bodily disorders. Injuries to the 
 head, inflammations of the brain and meninges in infancy 
 may lead to a stand -still of mental development at its earli- 
 est stage, and may also be manifested by many bodily 
 errors of development. Such signs of degeneration may 
 be distinguished with difficulty from the signs of bodily 
 degeneration which begin early in foetal life and hence also 
 accompany a congenital idiocy. These conditions include 
 various deformities of the skull, squinting, malposition 
 and absence of teeth; keel-shaped, narrow, and high pal- 
 ate ; defects in the palate and iris, deformities of the gen- 
 italia, etc. 
 
 An essential feature in the clinical history of idiots of 
 all ages is the absence of attention. This is so much more 
 marked because accompanying feelings upon which at- 
 tention must be based are extremely feeble. Hence very 
 few concepts are formed from the sensory impressions, 
 and the former are so superficial that they rapidly disap- 
 pear. The semi-sensory concepts are not combined with 
 
idiocy. 355 
 
 others into a real mental possession. There is an absence 
 of firmly arranged notions which decide the impulses of 
 the will, and there is also a lack of comprehension of men- 
 tal values which lead outside of the obscure feelings and 
 impulses of the patient's own ego. The lack of compre- 
 hension becomes more distinct the more the development 
 of speech is inhibited, because the possibility of education 
 depends materially upon speech. Even when speech has 
 been acquired quite completely, its use is ordinarily con- 
 fined to a few phrases and sentences. This is due to the 
 lack of interest in surrounding circumstances. The more 
 strongly the attention can be aroused, at least for a time, 
 the more perfect does speech become and the more exten- 
 sive are the relations to the outer world. The greater the 
 number of senses brought into play in these relations, the 
 better are the chances of improvement. Hence, the main 
 principle in the education of idiots is the simultaneous 
 stimulation of several senses (sight, hearing, feeling). 
 This also explains the great difficulty in the education of 
 children with defective senses. 
 
 Even when an idiot has acquired, in a measure, the or- 
 dinary branches of study, the contents of his mental life 
 are usually confined to a few groups of ideas. In some of 
 these cases one-sided talents are developed in an unusual 
 degree, but often in an impulsive and semi-conscious 
 manner, in which a mechanical sort of memory constitutes 
 the chief element. All higher endeavors are wanting, and 
 the mental processes are associated only with personal 
 sensations. Joy and sorrow are based chiefly on bodily 
 conditions, or they appear to be due directly to unknown 
 changes in the condition of the brain. These emotional 
 manifestations are found in the lowest forms of idiocy and 
 consist of two kinds. On the one hand, a morose, often 
 brutal and terrifying appearance ; on the other hand, con- 
 stant cheerfulness, with an expression of mildness in the 
 laughing features and gentle eyes. The dull idiot is 
 usually roused with difficulty from his brooding, unless an 
 interrupted impulse becomes manifest in unexpected vio- 
 
356 HANDBOOK OF INSANITY. 
 
 lent outbreaks of rage, directed not infrequently against 
 his own person. In the mobile idiot, on the other hand, 
 the attention is directed hither and thither, and the external 
 restlessness is also shown by the clapping of the hands, 
 purposeless jumping about, laughing and shouting. Their 
 endeavors are stimulated mainly by impulses, chief among 
 which is the need of food ; in great part this forms the 
 central point of all their mental processes. In the highest 
 grades of idiocy all objects are put into the mouth ; help- 
 less, filthy, without any manifestations of mind, the activ- 
 ity of such an individual is confined to the gratification 
 of his few impulses. The sexual sense is sometimes man- 
 ifested periodically, as in rutting animals, but the fre- 
 quent inhibition in the development of the genital appara- 
 tus is usually accompanied by feeble sexual desire. 
 
 The motor impulse is often restricted by motor disturb- 
 ances of various kinds. These include spasms, which may 
 be confined to the toes, one arm or leg, may appear as 
 unilateral athetosis, or may exhibit the signs of chorea or 
 epilepsy. The latter variety is the most frequent and 
 greatly impairs the prognosis. As a general thing, idiocy 
 remains at its original degree of intensity, but progressive 
 advance is to be apprehended when it becomes associated 
 with epilepsy. 
 
 Some idiots suffer from paralytic conditions of the limbs. 
 Many can neither stand nor walk, in others there is diffi- 
 culty of maintaining equilibrium while walking. In ad- 
 dition, spasmodic movements of the legs are frequent. 
 There may also be disease of the spinal cord, shown by 
 atrophy of individual groups of muscles and contractures 
 of the limbs. In the more severe grades of idiocy, symp- 
 toms which indicate grave anatomical lesions are rarely 
 absent. Even in the milder cases we find not alone a 
 feeble posture, uncertain gait, and awkward use of the 
 hands, but there are also various indications of spastic 
 and paralytic affections, imperfect development, or atrophy 
 of certain muscles or of an entire half of the body. When 
 the body presents no physical deformity, as in the mobile, 
 
DIAGNOSIS. 357 
 
 excited variety, the constant rocking and swaying move- 
 ments remind us of chorea, and show by their useless 
 character that they are imperative movements of direct 
 cerebral origin ; or they are a sort of play, as, for example, 
 blowing with the mouth, accompanied often by monoto- 
 nous singing and murmuring tones which seem to have a 
 sort of rlrythm. 
 
 The motor disturbances also include difficulty in speak- 
 ing, but this does not always show the degree of idiocy, 
 because there may be relatively good comprehension of 
 things heard. But the excessive use of infinitives and 
 certain interjections shows that intellectual weakness of 
 central origin exists as often as interference with speaking. 
 
 Distinct as the mental, weakness or the entire absence 
 of mental activity may be, the differentiation between 
 idiocy and imbecility becomes more difficult when the 
 bodily errors of development are less distinct. Idiots of 
 milder grades may become, in a measure, useful members 
 of society, inasmuch as they may learn some occupation 
 to which they devote their entire attention ; an imbecile is 
 often lacking in the necessary endurance and desire to 
 work. The achievements of the idiot, however, are like 
 those of a machine : he has no power of utilizing what he 
 has learned in an independent manner, and the standstill at 
 a certain stage of development is complete. The boundary 
 is usually reached at the period of puberty, if not earlier. 
 
 It is evident from the clinical similarity in the signs of 
 feeble-mindedness after other psychoses and those of con- 
 genital or early acquired idiocy that both forms are dif- 
 ferentiated with difficulty. It is important, however, to 
 distinguish all these forms of feeble-mindedness, which 
 remain stationary at a certain point, from those conditions 
 of mental weakness which tend to progressive dementia 
 and which we have alreadj^ studied in discussing the vari- 
 ous groups of mental diseases. The prognosis of imbecil- 
 ity and idiocy is entirely unfavorable as regards recovery, 
 and improvement can only be effected by pedagogic meas- 
 ures. In the higher grades of idiocy the patients are sub- 
 
358 HANDBOOK OF INSANITY. 
 
 ject to various injurious influences which shorten life, such 
 as injuries, digestive disturbances, and especially pulmo- 
 nary tuberculosis. 
 
 Idiots should be sent as early as possible to an idiot 
 asylum. In older idiots and in the other forms of imbe- 
 cility described in this section the treatment is merely 
 directed against the individual symptoms. The inatten- 
 tive imbecile may be led by flatteries and rewards, and 
 his activities may be called forth by strict regulations. 
 In an idiot of higher grade such measures are useless. 
 On account of their timidity, imbeciles are usually con- 
 trolled easily by punishment, but this should be adminis- 
 tered when they are alone, inasmuch as the presence of 
 others, when they are scolded or when food or other means 
 of gratification are denied, induces them to play the part 
 of a martyr. Hence isolation for a few hours is often the 
 most simple method of bringing an imbecile to terms. 
 Otherwise they must be kept under constant supervision, 
 as they are apt to tear their clothes when angry or even 
 to befoul themselves in order to annoy the attendants. 
 
 The description of imbecility and idiocy has shown 
 widely divergent conditions at both ends of the entire 
 series, but it has not revealed undoubted differences in the 
 varieties found at the middle of the series. For this reason 
 we regard it as impracticable to ask for a decisive differ- 
 ence in treatment, such as has been practised in France. 
 It is there held that the imbecile, on account of his selfish, 
 malicious, dangerous, and incorrigible impulses and acts, 
 is directly antagonistic to the common interests of societj^, 
 while the imperfectly developed but good-humored idiot, 
 who is susceptible of education to a certain degree, is in- 
 nocuous. Hence, the anti-social imbecile should be sent 
 to a reformatory, the extra-social idiot to a hospital. It 
 appears to us, however, to be too difficult to decide each 
 case in accordance with this principle, especially as the 
 border conditions are very numerous. Such a distinction 
 would also possess the greatest judicial importance and 
 would necessitate changes in the criminal law. 
 
DESCRIPTION OF PLATE X. 
 
 FEEBLE-MINDEDNESS. 
 
 The first picture illustrates acquired feeble- mindedness after a 
 simple mental disorder on a normal cerebral basis. The picture of 
 the scornfully smiling old woman hardly requires an explanation ; 
 the wrinkling of the brows is probably due, in part, to the ex- 
 cessively bright illumination. 
 
 The woman to the right suffers from congenital feeble-minded- 
 ness or imbecility. She entered the asylum on account of anxious 
 excitement, but is now cheerful and content. 
 
 The picture of the young man on the left shows some signs which 
 have been regarded as characteristic of moral insanity. It exhibits 
 a congenital criminal. Of illegitimate birth, he early began to steal 
 under the guidance of his mother, constantly read tales of robbery, 
 and expatiated upon them in poetical prolix dissertations which 
 evinced feeble-mindedness in various directions. His impudent 
 conduct in prison finally led to a diagnosis of insanity and he was 
 admitted to the asylum. It will not be conceded that he has " a 
 murderer's eye," as he himself maintains; but the general impres- 
 sion of criminality is increased by the following characteristic 
 signs, viz., scanty beard with thick curly hair on the head, promi- 
 nent chin, short upper lip, short nose. 
 
 The young man on the right side is an idiot of moderate grade 
 since childhood. The relative predominance of the face over the 
 calvarium, the sunken nose, and the imbecile laugh enable us to 
 recognize the idiot even without gross deformities of the skull and 
 signs of degeneration. 
 
HANDBOOK OF INSANITY. 
 
 KIRCHHOFF. 
 
 Plate X. 
 
INDEX. 
 
 Acquired feeble - mindedness, 
 346 
 
 Activity, mental, the brain the 
 site of the, 5 
 
 Acute neurasthenia, 330 
 
 Affections, syphilitic, 298 
 
 Affective insanity, constitu- 
 tional, 118 
 
 Affects, sensual and higher feel- 
 ings, 84 
 
 Age, relation of, to insanity, 24 
 
 Agitated dementia, 261 
 
 Alcoholic epilepsy, 344 
 insanity, acute, 339 
 
 Alcoholism, 41 
 chronic, 336 
 
 Anaemia and exhausting dis- 
 eases of internal organs, 36 
 
 Anatomy, pathological, 17 
 
 Apathetic dementia, 261 
 
 Aphasia, 13 
 
 Apperception and association, 68 
 
 Articulation, disorders of, 273 
 
 Artificial feeding, 163 
 
 Asylums and their advantages, 
 166 
 insane, erection of, 174 
 
 Atrophy of the brain, partial, 353 
 
 Auditory hallucinations, 53 
 
 Aura, epileptic, 303 
 
 Bodily and mental retrogres- 
 sion, 28 
 treatment, 155 
 Border lines, the, of insanity, 
 
 147 
 Brain, developmental history of 
 the, 4 
 imperfectly developed, 9 
 fissures, mode of develop- 
 ment of certain, 5 
 partial atrophy of the, 353 
 the, and its membranes, 33 
 the, as the site of normal 
 mental processes, 4 
 
 Catalepsy, 65 
 
 Causes of insanity, classification 
 of the, 20 
 of neurasthenia, 328 
 psychical, 42 
 Centres, the centi'o-motor and 
 
 visual, 15 
 Cerebral development, imper- 
 fect, 351 
 sclerosis, diffuse, 299 
 syphilis, 296 
 Changes, vessel, 297 
 Character, the epileptic, 305 
 Childbed, connection between, 
 
 and insanity, 39 
 Childhood, causes of insanity 
 
 in, 24 
 Chronic alcoholism, 336 
 Circular insanity, 223 
 
 insanity, clinical history of, 
 225 
 Civilization a cause of insanity, 
 
 21 
 Classification of insanity, 183 
 
 simple, 8 
 Combined hallucinations, 61 
 Complaints, hypochondriacal, 
 
 324 
 Conceptions, language, 14 
 Confusion, 254 
 Congenital feeble-mindedness, 
 
 347 
 Contents of delusions, 133 
 Convalescents, treatment of, 166 
 Co-ordinate value of the hemi- 
 spheres, 12 
 Cord, nerves, and sympathetic, 
 coincident diseases of the, 35 
 Course of ideas, accelerated and 
 
 retarded, 70 
 Cretinism, 353 
 Crime and genius, 32 
 
 Degeneration, epileptic, 308 
 Delirium tremens, 341 
 
 359 
 
360 
 
 INDEX. 
 
 Delirium tremens, treatment of, 
 
 342 
 Delusional system, 239 
 Delusion of persecution, 237 
 Delusions, 72 
 
 of grandeur, 243 
 Dementia, agitated, 261 
 apathetic, 261 
 mobile, 261 
 paralytic, 266 
 primary, 259 
 secondary, 261 
 senile, 262 
 
 with paralysis, forms of, 296 
 Depression in dementia, 285 
 Development, imperfect cere- 
 bral, 351 
 Diagnosis of recovery, 145 
 
 the, of mental disorders, 129 
 Diffuse cerebral sclerosis, 299 
 Dipsomania, 96 
 
 Diseases, coincident, of the cord, 
 nerves, and sympathetic, 
 35 
 focal, in relation to mental 
 
 disturbances, 9 
 of the brain, focal, 300 
 of the sexual organs, 37 
 Disorders, mental, associated 
 with general diseases, 258 
 mental, simple, 186 
 mental, with neurasthenia, 
 
 320 
 of articulation, 273 
 of self-consciousness, 66 
 phonetic, 275 
 Disturbance, mental, meningitis 
 
 may lead to, 34 
 Disturbances, mental, explained 
 by psychological consid- 
 erations, 9 
 mental, the anatomical basis 
 and the location of, 3 
 Dream states, 307 
 
 Education and insanity, 32 
 Empirical science, psychiatry 
 
 an, 3 
 Epidemics, psychical, due to re- 
 ligious causes, 44 
 Epilepsy, alcoholic, 344 
 mental disease in, 301 
 treatment of mental disor- 
 ders of, 310 
 Epileptic aura, 303 
 character, the, 305 
 degeneration, 308 
 
 Epileptiform paralytic attacks, 
 
 281 
 Erection of insane asylums, 174 
 Erotic and religious symptoms, 
 
 249 
 Expressive movements, 100 
 
 Fantasy, disorders of memory 
 
 and, 78 
 Fear, precordial, 189 
 Fears, morbid, in neurasthenics, 
 
 323 
 Febrile diseases and poisoning, 
 
 39 
 Feeble-mindedness, acquired, 346 
 
 congenital, 347 
 Feeding, artificial, 163 
 Feeling, hallucinations of, 58 
 Fissures, brain, mode of devel- 
 opment of certain, 5 
 significance of the, 6 
 Focal diseases in relation to 
 mental disturbances, 9 
 diseases of the brain, 300 
 Forms, periodical, 216 
 Frenzy, 207 
 Function of speech, the, 12 
 
 Gait, 279 
 
 General diseases, mental disor- 
 ders associated with, 258 
 Genius, crime and, 32 
 Gliosis, 299 
 
 Grandeur, delusions of, 243 
 " Gruebelsucht, " 70 
 Gynecological examinations, 13ft 
 
 Hallucinations, auditory, 53 
 
 combined, 61 
 
 of feeling, 58 
 
 olfactory, 56 
 
 originating in viscera, 59 
 
 unilateral auditory, 18 
 
 visual, 47 
 Head, injuries to the, 35 
 Hebephrenia, 27 
 Hemispheres, co-ordinate value 
 
 of the, 12 
 Heredity, 29 
 
 History, clinical, of circular in- 
 sanity, 225 
 
 developmental, of the brain,. 
 4 
 
 of psychiatry, 168 
 Hypnosis, 64 
 Hypnotics, 158 
 
 restraint and, 215 
 
INDEX. 
 
 361 
 
 Hypochondriacal complaints, 324 
 Hysteria, insanity and, 311 
 Hysterical insanity, 317 
 seizures, 313 
 
 Idiocy, 354 
 
 Imbecility, 347 
 
 Imperfectly developed brain, 9 
 
 Impulsive movements, 91 
 
 Injuries to the head, 35 
 
 Insane, present treatment of the, 
 178 
 
 Insanity, acute alcoholic, 339 
 and hysteria, 311 
 circular, 223 
 
 civilization a cause of, 21 
 classification of, 183 
 classification of the causes 
 
 of, 20 
 connection between child- 
 bed and, 39 
 education and, 32 
 hysterical, 317 
 in childhood, causes of, 24 
 localization in, 19 
 of querulents, 250 
 pellagrous, 23 
 pregnancy and, 38 
 prevention of, 154 
 real or simulated, 146 
 relation of age to, 24 
 the border lines of, 147 
 the treatment of, 151 
 
 Internal organs, angemia and 
 exhausting diseases of, 36 
 
 Language conceptions, 14 
 
 relations of, with mental 
 • life, 15 
 Localization in insanity, 19 
 Loss of memory, 80 
 
 Mania, 201 
 
 periodical, 220 
 psychical treatment of, 216 
 Melancholia, 186 
 periodical, 218 
 treatment of, 198 
 Meningitis may lead to mental 
 
 disturbance, 34 
 Mental activity, the brain the 
 site of the, 5 
 disease in epilepsy, 301 
 disorders at the period of 
 
 puberty, 26 
 disorders due to poisons, 332 
 
 Mental disorders of epilepsy, 
 treatment of, 310 
 disorders, simple, 186 
 disorders, the course of, 114 
 disorders, the diagnosis of, 
 
 129 
 disorders, the signs of, 45 
 disturbances based on path- 
 ological anatomy, 9 
 disturbances, the anatomical 
 basis and the location 
 of, 3 
 life, relations of language 
 with, 15 
 Microcephalus, simple, 352 
 Mobile dementia, 261 
 Morphinism, 333 
 
 Neurasthenia, acute, 330 
 
 causes of, 328 
 mental disorders with, 320 
 Neurasthenics, morbid fears in, 
 
 323 
 Normal and morbid impulses, 148 
 mental processes, the brain 
 as the site of, 4 
 
 Occupation, 33 
 Olfactory hallucinations, 56 
 Opposition to mechanical re- 
 straint, 175 
 Overwork, worry and, 43 
 
 Paralysis, forms of dementia 
 
 with, 296 
 Paralytic attacks, epileptiform, 
 281 
 dementia, 266 
 Paranoia, 230 
 Pathological anatomy, 17 
 
 anatomy, mental disturb- 
 ances based on, 9 
 Pellagrous insanity, 23 
 Perception, visual, disturbances 
 
 of, 16 
 Perceptive process, disturbances 
 
 of the, 46 
 Periodical forms, 216 
 mania, 220 
 melancholia, 218 
 Persecution, delusion of, 237 
 Phonetic disorders, 275 
 Physical symptoms, concomi- 
 tant, 107 
 Physician, personality of the, 152 
 Poisoning, febrile diseases and, 
 39 
 
362 
 
 INDEX. 
 
 Poisons, mental disorders due 
 
 to, 332 
 Post-mortem findings, 150 
 Praecordial fear, 189 
 Pregnancy and insanity, 38 
 Prevention of insanity, 154 
 Primary dementia, 259 
 Prognosis, general, 122 
 Pseudaphasic confusion, 104 
 Psychiatric examination, 131 
 Psychiatry an empirical science, 
 3 
 history of, 168 
 Psychical causes, 42 
 
 epidemics due to religious 
 
 causes, 44 
 trauma, 20 
 
 treatment of mania, 216 
 Psychological considerations, 
 mental disturbances explained 
 by, 9 
 Psychoses, periodical, 117 
 Puberty, mental disorders at the 
 
 period of, 26 
 Pupillary symptoms, 277 
 
 Querulents, insanity of, 250 
 
 Raptus melancholicus, 191 
 Real or simulated insanity, 146 
 Recovery, diagnosis of, 145 
 Removal from asylum, 201 
 Restraint and hypnotics, 215 
 mechanical, opposition to, 
 175 
 Retrogression, bodily and men- 
 tal, 28 
 
 Secondary dementia, 261 
 
 Seizures, hysterical, 313 
 
 Self- consciousness, disorders of, 
 
 66 
 Senile dementia, 262 
 Sexual organs, diseases of the, 
 37 
 sensations, contrary, 98 
 Significance of the fissures, 6 
 Signs, the, of mental disorders, 
 
 45 
 
 Simple classification, 8 
 
 microcephalus, 352 
 Somnolence, 63 
 Speech, the function of, 12 
 States, dream, 307 
 Statistics, value of, 21 
 Status epilepticus, 308 
 Suicide as an impulse, 94 
 
 prevention of, 165 
 Superstition, influence of, 171 
 Symptoms, erotic and religious, 
 249 
 
 important, treatment of, 161 
 
 pupillary, 277 
 Syphilis, cerebral, 296 
 Syphilitic affections, 298 
 System, delusional, 239 
 
 Terror and allied feelings, 89 
 
 The brain and its membranes, 33 
 
 Trauma, psychical, 20 
 
 Treatment, bodily, 155 
 of convalescents, 166 
 of delirium tremens, 342 
 of important symptoms, 161 
 of insanity, the, 151 
 of melancholia, 198 
 of the insane, present, 178 
 
 Trophic functions, disorders of 
 the, 110 
 
 Typhoid fever, 145 
 
 Unilateral auditory hallucina- 
 tions, 18 
 
 Value of statistics, 21 
 Verruecktheit, 236 
 
 without hallucinations, 246 
 Vessel changes, 297 
 Viscera, hallucinations origi- 
 nating in, 59 
 Visual centres, the centro- motor 
 and, 15 
 hallucinations, 47 
 perception, disturbances of, 
 16 
 
 Wahnsinn, 231 
 
 Worry and overwork, 43 
 

I 
 
 
 
 
 
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