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 CLINICAL MANUALS 
 
 FOR 
 
 Pkactitioners and Students 
 OF Medicine. 
 
Insanity 
 
 AND 
 
 Allied Neuroses 
 
 PRACTICAL AND CLINICAL, 
 
 GEORGE H. SAVAGE, 
 
 M.D., M.E.C.P., 
 
 PHYSICIAN AND SUPERINTENDENT OF BETHLEM KOTAL HOSPITAL: 
 
 LECTURER ON MENTAL DISEASES AT GUT'S HOSPITAL ; JOINT 
 
 EDITOR OF "the JOURNAL OF MENTAL SCIENCE." 
 
 WITR 19 ILLUSTRATIONS. 
 
 FHILABELPHIA : 
 HENRY C. LEA'S SON k CO. 
 
 188i. 
 
SAMUEL WILKS, Esq., M.D., F.R.C.P., F.R.S., 
 
 Senior Physician to Guy's Hospital, 
 IN GllATEFUL ACKNOWLEDGMENT OF HIS TEACHING AND HIS 
 
 FKIENDSHIP, 
 
 THIS WORK IS DEDICATED BY 
 
 THE AUTHOR. 
 
 0.? 
 
 f 
 
PEEFACE. 
 
 To those who have been engaged for years in the 
 culture of any branch of science, and in the imparting 
 of its data to others, there naturally comes a time 
 when the facts observed, and the apparent relations 
 between them, seem to demand some permanent 
 registration. One has, as it were, to take stock of 
 one's facts and see what has been learnt. I have for 
 some time felt that my period of observation without 
 registration must terminate, and that I owe it to my 
 position as physician to a large hospital to give the 
 younger members of my profession the results of my 
 more than twelve years' experience in Bethlem. 
 
 In this book I shall describe insanity and trace its 
 life history. I shall explain the legal relationships of 
 the insane, and make plain the duties of the physician 
 who has to be responsible for their safety and welfare. 
 Although the greater portion of this work will bo 
 the record of my own personal experience, I shall have 
 also to draw upon the experience of others when treat- 
 ing of idiocy, epilepsy, and chronic mental disorders, 
 because in Bethlem such cases are not treated. 
 
vi Insanity and Allied Neuroses. 
 
 In conclusion, I must thank many who, in one 
 way or another, have helped me in my work ; specially, 
 W. Haigh, Esq., who has not only corrected my 
 proofs, but has by criticism aided me much in the 
 legal chapters ; and Dr. F. Beach, who has contributed 
 to the chapter on idiocy. 
 
 G. II. S. 
 
 Bcthlem Roijol ITospitaly 
 October, 1884. 
 
CONTENTS. 
 
 CHAPTER PAGE 
 
 I. -What is meant by Insanity— Insanity from 
 
 Legal and Medical Standpoints ... 1 
 
 II.— Classification ......... 10 
 
 III.— Causes of Insanity, Predisposing and Exciting 16 
 
 IV.— Hysteria and its Relationships .... 80 
 
 v.— Acute Mania 99 
 
 VI.— Hypochondriasis and Melancholia . . . 128 
 
 VII.— Melancholia 151 
 
 VIII.— Dementia— Acute Dementia 207 
 
 IX.— States of Mental Weakness 221 
 
 X.— Delusional Insanity— Hallucinations . . 237 
 
 XI.— Moral Insanity 269 
 
 XII.— General Paralysis of the Insane . . .276 
 
 XIII.— Paralytic Insanity 351 
 
 XIV.— Puerperal Insanity 360 
 
 XV.— Epilepsy and Insanity 382 
 
 XVI.— Brain Tumours— Multiple Sclerosis . . .389 
 
 XVII.— Syphilis and Insanity 392 
 
 XVIIL— Relationships between Insanity and Pxiiiri.-^i.i 
 
 PULMONALIS 396 
 
 XIX.— Heart Diseage and Insanity 40i 
 
VIU 
 
 Insanity and Allied Neuroses. 
 
 CHAPTER 
 
 XX.— Diabetes and Insanity . 
 XXI.— Alcoholism and Insanity . 
 XXIT. -Idiocy and Imbecility . 
 XXIII. —Responsibility of Lunatics 
 XXIV.— Legal Relationships of Insanity 
 
 Appendix " . 
 
 Index 
 
 PAGE 
 
 . 411 
 
 . 419 
 
 . 437 
 
 . 460 
 
 . 483 
 
 . 522 
 
 . 533 
 
iK^SAmTY A^^D Allied 
 
 Neuroses. 
 
 CHAPTER I. 
 
 WHAT IS MEANT BY INSANITY INSANITY FROM LEGAL 
 
 AND MEDICAL STANDPOINTS. 
 
 Introductory — Insanity may depend on disease of any part of the 
 body — Eccentricity — Genius — Crime — Borderland between 
 sanity and insanity. 
 
 I SHALL not discuss normal psychology in this manual, 
 because, to my mind, the time has not come for the 
 re-arrangement of our ideas on mind and its physical 
 basis. 
 
 I feel strongly that as long as mind is supposed 
 to be located in the skull we shall make little progress. 
 Though I have examined sections of brains of patients 
 dying from almost all forms of insanity, I am left 
 with the feeling that we must be more general in our 
 pathology if we are to understand our subject. 
 
 The first question naturally is, what is meant by in- 
 sanity 1 I shall try to show clearly throughout this 
 work that no standard of sanity as fixed by nature can 
 under any circumstances be considered definitely to 
 exist. " Sanity " and " insanity," as recognised by 
 the doctor, and, in fact, by the general public, must be 
 but terms of convenience. No person is perfectly 
 sane in all his mental faculties, any more than he is 
 perfectly healthy in body. 
 B— 14 
 
2 Insanity and Allied Neuroses. [Chap. i. 
 
 There are flaws on the physiological side, and 
 defects on the mental. Insanity has to be looked upon 
 from two different aspects. From the physician's side 
 it has to be considered as a disease of the brain, 
 or a disorder of the mind, quite apart from any 
 consideration of responsibility whatever. From the 
 other side, that is, as seen by ordinary members of 
 society, insanity is scarcely recognised until it inter- 
 feres, in one way or another, with the laws that bind 
 society together. Later on I shall trace the origin 
 of some of the most marked forms of insanity, and I 
 shall be able to point out that the earliest symptoms 
 of unsoundness of mind can often be traced far back 
 into a period in the lives of the patients when they 
 were apparently fulfilling every social and moral 
 duty. Even at this time, from the medical point of 
 view, these people were sufi'ering from unsoundness of 
 mind, which would in the end destroy both body and 
 mind. It will be my duty chiefly to consider in- 
 sanity from the physician's point of view, and in 
 doing so we shall see that a man's sanity is to be 
 gauged purely by what is his own normal standard. 
 
 A man, in fact, must be considered as sane or 
 insane in relation to himself. The old and oft- 
 repeated statement that insanity is a perversion of the 
 ego is absolutely true. Sanity and insanity, then, 
 are to be measured by differences or changes of habit, 
 taste, and disposition in the individual, as well as by 
 other symptoms of change in the nervous centres. 
 The difference will necessarily be seen to be one not 
 only of degree, but one of time, so that a man being 
 sane now may be insane within a longer or shorter 
 period. I shall take it for granted that insanity de- 
 pends upon change in the nervous structures of the 
 body ; but by no means shall I restrict the causa- 
 tion of insanity to changes in the brain alone. Many 
 cases will have to be considered in which the insanity 
 
Chap. I.] Eccentricity. 3 
 
 depends, in my opinion, upon irritation propagated 
 along nervous tracks at a distance from the nerve 
 centres. Some may think that, in extending my ideas 
 of insanity as far as 'I seem to do in the above para- 
 graph, I am going too far. But the more I see of 
 insanity, the more convinced I am that the considera- 
 tion of mental disorder can only be fairly approached 
 by the complete consideration of general physiology, 
 i.e. the development, growth, and decay of the body 
 in all its parts. No development or growth can go on 
 without the action of the nervous system. Insanity 
 may depend upon vices of development, vices of 
 growth, or premature degeneration, local or general ; 
 but it may depend also upon the bad ministration 
 of the servants of the brain. As an old writer has 
 said, "The brain, like a gentleman, has many servants, 
 but withal may be badly served." Insanity may 
 seem to depend upon physical changes which, at 
 first sight, seem to have little or nothing to do with 
 the brain. Thus it does not need a physician's expe- 
 rience to know how dependent one is for energy and 
 power of work on good digestion. The relation which 
 exists between feelings of dyspepsia and states of 
 melancholy must be fully recognised. For though 
 some geniuses have been dyspeptic, the world's work 
 is best done by people who eat well and breathe 
 freely. 
 
 Insanity, as I have said, is a relative term, and it 
 is necessary that I should point out the other nervous 
 conditions to which it is allied. Many people are 
 considered only eccentric; and from the abnormally 
 emotional life often led by men of genius, genius is 
 looked for as the necessary accompaniment of eccen- 
 tricity ; at least, to be eccentric suggests an idea of 
 genius. (1) Eccentric people may belong to two classes 
 at least : those who have some insane inheritance (those, 
 in fact, who are on the borderland of insanity), and 
 
4 Insanity and Allied Neuroses. [Chap. i. 
 
 those wlio are passing from sanity into some form of 
 mental disorder, and wlio may again pass through this 
 disturbed mental borderland on recovery. (2) Eccen- 
 tricity may be developed de novo just as, I believe, 
 certain forms of mental perversion may be developed. 
 I think injustice has been done to man's power of 
 development and of self-government by those who 
 would look to the parent for every quality, good or 
 bad, possessed by the offspring. The human being 
 comes into the world with powers of development of 
 a most extraordinary kind, and there is hardly any 
 limit to the power of accommodation to the environ- 
 ment but that of simple pliysical possibility. It is a 
 necessity that certain persons of unstable disposition, 
 being surrounded by unnatural circumstances and 
 conditions, should develop abnormal properties. Thus, 
 the person who, being somewhat niggardly, has begun 
 by collecting trifles, such as pins, sardine boxes, horse 
 shoes, and the like, may end in shutting himself up in 
 an attic, in refusing to wear clothes, and being un- 
 willing even to wash, for fear of the cost of soap and 
 water. Such cases are looked upon as eccentric, and 
 I might fill a book in simply narrating instances of 
 eccentricity as seen outside asylums. Most persons 
 have both tricks of body and tricks of mind ; have 
 their own idiosyncracies of temperament, as we should 
 say. If the one or the other is not duly restrained 
 and checked, a habit is in process of development 
 which may influence for evil the whole life of the 
 individual. Eccentricity may appear in any one of 
 the various departments of mental life ; so that one 
 person may be suspicious, another may be jealous, 
 another subtle and. untruthful, while a fourth may be 
 violent, passionate, and revengeful. All these are 
 properties of the sound mind, if in due subordination ; 
 but if left unrestrained, or stimulated in growth by 
 foolish encouragement, their tendency is to make men^ 
 
Chap. I.] Genius. 5 
 
 in the first place, eccentric, and afterwards possibly 
 to form the groundwork of an attack of insanity. 
 Eccentricity is rarely developed before the period of 
 advanced middle life : or, at least, is not recognised 
 as such. The peculiarities in younger persons, which 
 are allied to eccentricity, are considered to belong to 
 hysteria or moral insanity, and I am inclined to think 
 they are justly so classed. These latter may be, and 
 for the most part are, cases of an undeveloped dis- 
 order, which, later in life, is almost certain to assume 
 an acute form, and, as such, many of them undoubtedly 
 bear a blood relationship to the more marked forms of 
 mental unsoundness. In former days a greater num- 
 ber of eccentric people were at large than at present, 
 and many of these were, without doubt, like the weak- 
 minded persons who are now condemned to the 
 county asylums. To conclude this short notice of 
 eccentricity, I would remark that, once fairly 
 developed, it is probably incurable. 
 
 I have incidentally referred to genius in its con- 
 nection with eccentricity and insanity. I am hardly 
 prepared to give a definition of genius, though I 
 would call attention to the fact that it is usually 
 associated either with some special incomprehensible 
 faculty for the dramatic portraiture of self-existent 
 abnormal emotion ; or altogether dependent upon a 
 simple over-development of an individual faculty of 
 mind. The first, in a sense, we may call the genius 
 of art ; the latter, that of science. With regard to 
 genius, I must say that it is an exception to find 
 patients with unusual capacity of any kind amoug 
 the inmates of an asylum. There may be found 
 " specialists " of every character and degree, that is, 
 men with persistence in limited pursuits ; thus, I 
 have known a patient in Bethlem who devoted years 
 to the delicate polishing of pebbles ; and another 
 whose one object in life was to clean windows, while 
 
6 Insanity and Allied Neuroses. [Chap. i. 
 
 tlie speciality of a third was still more limited, for 
 his sole aim was to keep bright the brass knobs of the 
 water taps. Therefore, from the point of view of the 
 superintendent of an asylum for acute cases of mental 
 disorder, I can definitely say that it is rare to meet 
 with extraordinary ability among the insane. On the 
 other hand, I must, however, admit that in my ex- 
 perience of people out of asylums, who have been 
 credited with genius, I have met with many who 
 possessed marked mental peculiarities and eccen- 
 tricities. It appears as if there were for each ordi- 
 nary person an average quantity of nervous power 
 and energy to be expended, and if a larger amount 
 than usual is got rid of in one direction, there 
 naturally results a deficiency in some other quarter ; 
 in fact, there is loss of balance. " Want of balance " 
 fairly describes the mental condition of many a genius. 
 How often, for example, has one met with a man of 
 letters, the man of taste and of energy, who objected 
 strongly to be controlled in his lower or more 
 animal tastes ! Thus it happens that so many men of 
 genius have given themselves liberty, if not license. 
 
 Another way in which to look upon the relation- 
 ship between genius and insanity, is to consider 
 'precocity. The old proverb, "A man at five, a fool 
 at fifteen," very well illustrates what is frequently 
 seen. Precocious children are commonly the off- 
 spring of insane or nervous parents. I have, myself, 
 had in Bethlem one. female patient, whose two 
 children, both under six years of age, were playing 
 classical music in public. I have seen other children 
 who developed almost in infancy strong animal pas- 
 sions. When considering idiocy, I shall have to dis- 
 cuss more in detail the disorders incidental to infancy 
 and childhood, and therefore I now leave this part of 
 the question of precocity, merely stating that, in my 
 experience, the children of the insane may develop 
 
Chap I.] Borderland of Insanity, 7 
 
 certain aptitudes or passions at the expense of the 
 rest of their nervous development. 
 
 The special aptitudes are for music, sometimes 
 for art and mathematics, and a wondeiiully retentive 
 memory may be present. Tt is rare to see such a 
 child with all these talents developed at one time, 
 but it is common to see a child with one or more of 
 these who is totally wanting in moral sense. I shall, 
 nnder the head of " moral insanity," and when con- 
 sidering " hereditary neurosis," give details of such 
 cases. One naturally passes from these considera- 
 tions to the relationships of crime to mental un- 
 soundness. I shall have to devote a chapter more 
 especially and fully to this matter. But here I 
 speak only of the borderland of insanity, which 
 has been so carefully explored by Dr. Maudsley. 
 There can be no doubt in the minds of those 
 who see much of the criminal classes and of those 
 who see much of the insane classes, that there 
 is something in common between them. I must not 
 be misunderstood in saying this, for there is an 
 immense difference between some insane persons and 
 some criminals ; but as the savage and the statesman 
 have connecting links between them, so among cri- 
 minals and lunatics there are many grades which 
 approach one another very closely. To begin with, 
 the j^hysical aspect of a chronic lunatic resembles 
 very closely that of a confirmed criminal, and the 
 mental degeneration of man leaves his features so 
 changed and debased that he resembles the man who, 
 from vice of birth or faulty surroundings, has never 
 developed the higher social qualities. As Dr. Mauds- 
 ley has well pointed out, " Though there is a 
 borderland, there is no boundary stone ; and there 
 are cases in which exist some insanity and much 
 crime, and others with much insanity and little 
 crime." And at present this borderland is the one 
 
8 Insanity and Allied Neuroses. [Chap. i. 
 
 on which most forensic battles have to be fought. 
 Though from theoretical points of view it may appear 
 that any one with criminal tendencies must be looked 
 upon as insane (as one, in fact, who cannot be calcu- 
 lated upon, and whose actions are not governed and 
 controlled as are those of the ordinary social unit), 
 yet society, as represented by lawyer, judge, and jury, 
 will continue to hold the balance in its own hands, 
 and punish those who may, after all, be of unsound 
 mind, the expert's opinion notwithstanding. 
 
 The relationships of insanity to crime are further 
 evidenced by the fact that so many criminals develop 
 other nervous disorders while under punishment for 
 their offences. Epilepsy is much more common 
 among criminals than among the sane. Sense per- 
 versions are mujh more common among them also. 
 They appear wanting in the highest of all mental 
 power, the power of controlling, or organising and 
 applying, what faculties they possess. Their nervous 
 systems are unstable and easily break down. These 
 facts, important as they are to the student of mental 
 physiology, can at present hardly be applied in the 
 treatment of the criminal. Though the relationship 
 must be fully recognised, it would be no more fair 
 to say that crime and insanity are directly connected 
 (that is, generally connected), than it would have 
 been fair to say that genius and insanity were 
 similarly allied. 
 
 The test of family relationship must, after all, be 
 connection by paternity. If a large proportion of 
 criminals can be found having insane parents or 
 insane children, it must be admitted that there is 
 some closer connection between insanity and crime 
 than mere accident. And if we can trace the de- 
 velopment of criminal instincts to insane parentage, 
 if we can prove the direct transmission of criminal 
 instincts from father to son, we shall have done much 
 
Chap. I.] PosT-MoRTEM Examinations. 9 
 
 to show that there are true links between intellectual 
 and moral perversion. 
 
 In speaking of the inheritance of neurosis, I shall 
 have to give instances in which some members of a 
 family have been insane, while others have been 
 "ne'er-clo-weels," and perhaps one member has be- 
 come criminal. In the borderland now under con- 
 sideration there are other tracks to be explored, and I 
 shall have to point out that hysteria, hypochondriasis, 
 epilepsy, somnambulism, and other allied states, are 
 all at least more nearly related to mental unsound- 
 ness than to sanity. I am anxious not to be sup- 
 posed to be of the opinion that every perversion of 
 nervous action, every unusual display of intellectual 
 or moral force, is to be regarded as a case requiring 
 the interposition of the physician whose chief care 
 has been for the insane. But till insanity is looked 
 upon as a phase of bodily disorder, till it is seen to 
 be related to all the other disorders of the nervous 
 centres, it will not be justly appreciated and properly 
 treated. Insanity, although associated with nervous 
 disorders and change in the nervous tissues, cannot 
 yet be localised ; we cannot say that a patient suf- 
 fering from acute mauia has certain nutritional 
 changes in his brain. 
 
 One of the greatest difficulties which has ever pre- 
 sented itself to the student of insanity has been the 
 fact that post mortem so little has been found visible 
 to the naked eye. I may say that, with my expe- 
 rience of years, and after seeing many hundreds of 
 jjost-mortem examinations of the bodies of the insane, 
 I have met with few coarse changes within the skull, 
 and even with the higher powers of the microscope all 
 that can often be detected may be evidences of change 
 in the nutrition of the connective tissue of the brain. 
 This may seem unsatisfactory ; but the time will come 
 when the inter-relations between the millions of nerve 
 
lo Insanity and Allied Neuroses. [Chap. ii. 
 
 cells witli their manifold processes, and their depen- 
 dence for healthy action upon healthy blood and pure 
 air, will be better understood. The brain, like a 
 kaleidoscope, consists of innumerable parts, which 
 adapt themselves to varying patterns. A shake 
 occurs, the pattern changes, but each one of the pieces 
 still exists- as it did before ; no change in shape, no 
 change in colour, only change in relationship. So, I be- 
 lieve, it will be found to be with many forms of insanity, 
 change in one faculty changing the mental pattern. 
 
 CHAPTER II. 
 
 CLASSIFICATION. 
 
 Ideal classification — Classification of the London College of 
 Physicians — Author's classification. 
 
 We may classify by the causes, as in epileptic, 
 puerperal, or alcoholic insanity; or by the /brms which 
 the symptoms assume; thus, mania, melancholia, or 
 dementia. 
 
 We may divide cases according as to whether the 
 senses are at fault, or the reasoning faculty is per- 
 verted. We may arrange as to whether the disorder 
 arises in connection with development, growth, 
 maturity, or decay, or whether the disease arises 
 primarily in brain disease, or is secondary to other 
 bodily illness. Further, special faculties may suffer 
 chiefly or primarily, the senses being disordered may 
 lead to insanity ; the organic or the reproductive sides 
 of a man may be disordered ; his judgment and will 
 may suffer ; memory or the moral sense may be want- 
 ing. Insanities may be acute or chronic, recurrent or 
 circular ; they may be curable or incurable. I sub- 
 join an ideal classification, the classification which is 
 accepted by the London College of Physicians, and 
 
Chap. II.] Scheme OF Classification. 
 
 II 
 
 finally, the classification which for convenience I 
 follow. 
 
 shall 
 
 SCHEME OF CLASSIFICATION. 
 
 Insanity of early deve- 
 lopment ^ 
 
 Causes of insanity of ^ 
 I cMldliood 
 
 I Forms of insanity in 
 I cMldhood "^ 
 
 Insanity of adolescence \ 
 
 Insanity of maturity . < 
 
 Insanity of climacteric 
 
 ' Idiocy, from brain deficiency. 
 Idiocy, from sense deficiency. 
 Idiocy, from inability to develop. 
 . Imbecility, from inability to develop fully. 
 ' From congenital causes. 
 From epilepsy. 
 From injury or brain disease. 
 Mania. 
 Melancholia. 
 Moral perversion. 
 
 Due to : 
 Onset of sexuality, masturbation. 
 Stress of work. 
 Phthisis, etc. 
 
 (Nervous system only fit for low pres- 
 sure). 
 Symptoms : 
 Mania with conceit. 
 
 Emotional melancholia and hypochon- 
 driasis, with liability to recnr, and 
 tendency to mental weakness. 
 Mania. 
 Melancholia. 
 Dementia, 
 General paralysis due to strain or excess. 
 
 ( Delusions. 
 In women < "Persecutions." 
 
 ( Hallucinations. 
 In men : Often hypochondriacal, due to 
 visceral Oreak-down. 
 
 Insanity of age 
 
 r Mania. 
 A Melancholia. 
 ( Dementia. 
 
 All tend to dementia. 
 
 NOMENCLATURE OF ROYAL COLLEGE OF PHYSICIANS. 
 
 IMania. 
 
 Melancholia. 
 
 Dementia, including acqu.ired 
 
 imbecility. 
 Idiocy, congenital imbecility. 
 General jiaralysis of the insane. 
 Puerperal insanity. 
 Epileptic insanity. 
 Insanity of puberty. 
 Climacteric insanity. 
 
 Senile insanity. 
 
 Toxic insanity, alcohol, gout, 
 lead, etc. 
 
 Delirium tremens. 
 
 Traumatic insanity. 
 
 Insanity associated with obvious 
 morbid change or changes in 
 the brain. 
 
 Consecutive insanity, from fe- 
 vers, visceral inflammations. 
 
12 Insanity and Allied Neuroses. [Chap. ii. 
 
 So-called cases of monomania should be named according as 
 the prevailing symptoms are those of mania, melancholia, or 
 dementia ; and distinct hereditary tendency should be mentioned. 
 
 I purpose making use of the following groups in 
 
 my manual : 
 
 Hysteria — Mania. 
 
 Hy pochon driasis — Melancholia. 
 
 Dementia, general and partial, primary and secondary. 
 
 States of mental weakness — Chronic mania and melancholia. 
 
 Recurrent insanity. 
 
 Delusional insanity. 
 
 General paralysis of the insane. 
 
 Paralytic insanity — Epilei^tic insanity. 
 
 Puerperal insanity — Post-connubial, puerperal, lactation. 
 
 Toxic insanity — Alcohol, lead, opium, chloral, etc. — Gout. 
 
 Visceral insanity — Renal, cardiac, pulmonary. 
 
 Insanity with syphUis — Myxoedema — Grave's disease — Asthma 
 
 — Diabetes. 
 Idiocy in its various degrees. 
 
 Any classification of insanity must necessarily be 
 provisional. At all events, till our knowledge of mind 
 in health and disease is greatly extended, I shall divide 
 the cases we are to consider into what I have found to 
 be convenient groups ; if not classes or orders in the 
 kingdom of disease, they represent sufficiently defi- 
 nite collections of symptoms to bear general descrip- 
 tions. They are, in fact, definite enough to enable the 
 student of medicine to classify any cases which come 
 under his care according to them. The classification 
 will in many particulars be a cross classification, so 
 that certain cases will ajipear under different headings. 
 The time may come when a classification of mental 
 disorders may be according to the physiological changes 
 which take place in the nerve centres. In my pre- 
 sent classification, I shall feel bound to recognise 
 the fact that certain cases of insanity are due to 
 disease of the brain of a very definite and observable 
 character, and that certain other cases of insanity de- 
 ])end for their origin on the existence of some bodily 
 defect or degeneration, which, causing irritation at 
 
Ch.p. II.] Recovery FROM Insanity. 13 
 
 the periphery, in the end sets up brain disease by 
 a continuity of the nervous tissues, or by some other 
 reflecting process. Unlike most ordinary diseases, an 
 attack of insanity does not either pass away entirely, 
 or kill a patient, but in the majority of cases leaves 
 him more or less mentally crippled. The physician 
 has often recognised the fact that a man is not the 
 same after having a serious attack of illness. A man 
 differs in one or more particular after he has passed 
 through small-pox, fever, rheumatism, or even gout. 
 It has been said that a bee-master, before he had an 
 attack of small-pox was able to handle these stinging 
 insects with impunity^ but after his recovery he was 
 no longer able to follow his occupation, the bees dis- 
 continuing to like him, and even not tolerating his 
 presence. I myself have seen several patients whose 
 temper and dispositions have been markedly affected 
 by an acute illness such as rheumatic fever, so that 
 a patient who had been previously of quiet, indus- 
 trious and domesticated habits, and a good wife, became, 
 after recovery, a selfish, indolent, home-neglecting 
 person. These are accidents when considered in rela- 
 tionship to general bodily diseases, but they are pecu- 
 liarly common when associated with insanity. The large 
 residuum of insanity which fills our county asylums 
 consists to a great extent of the patients who, having 
 had one or more attacks of insanity, have neither died 
 nor recovered. There is, in fact, a very strong feeling 
 prevalent that a patient once having had an attack 
 of insanity is never cured under any circumstances. 
 This I shall oppose entirely ; but I acknowledge that 
 a very considerable proportion are maimed in one way 
 or another by an attack of insanity. It is only what 
 might be expected, for the more delicate an instru- 
 ment, the greater its liability to injury by rough 
 handling or rapidly changing conditions. The eye, 
 itself but a window of the mind, is recognised to be 
 
14 Insanity and Allied Neuroses. [Chap. ii. 
 
 an organ which suffers permanently from slight in- 
 flammatory or other disorders, which did not appear at 
 first to be of much importance. Is it therefore sur- 
 prising that the still more highly developed and 
 organised human brain should show signs of storms 
 that sweep over it % 
 
 I have been in the habit, in clinical teaching, of 
 dividing all my patients into the curable and incu- 
 rable, but I have always added that I intended in 
 this division to separate those patients suffering from 
 general paralysis of the insane, from those suffering 
 from every other form of nervous disorder. In my 
 clinical division of insanity I make the symptoms, or 
 outward signs, the points of division. Thus we have 
 mania, melancholia, dementia, delusional insanity, and 
 states of weak-mindedness. Each of these classes will 
 have to be more fully subdivided ; and a more natural 
 form of division, in my judgment, is that which I 
 have already referred to, and have placed at the head 
 of this chapter. 
 
 First in this table one has the insanity of develop- 
 ment, as seen in the arrests and perversion of children, 
 ending almost invariably in idiocy, or in imbecility. 
 Attacks of nervous disorder affecting the unstable de- 
 veloping nervous tissues of childhood, cause, as may be 
 expected, rapid and yjermanent degeneration. It is, 
 as it were, a destruction of a house of cards. 
 
 Next is the insanity of adolescence, and here we 
 meet with the same forms of mental disturbance, but 
 with a much more marked character than as seen 
 among children. The forces are greater, perhaps rather 
 more stable, but yet eminently mobile. The prognosis 
 in such cases will be better than among children, and 
 less satisfactory than among the mature. 
 
 The third division is formed by the period of 
 maturity, and here we meet with the greatest num- 
 ber of insane patients. Insanity seems peculiar from 
 
Chap. IT.] Explanation OF Classification. 15 
 
 this characteristic, that at the period of fullest vitality 
 mental disorder is most common. 
 
 It has to be recognised that in this we often see 
 the full blowing of the morbid flower of insane in- 
 heritance. We also see that the fine brain organism 
 breaks down when the greatest stress is thrown upon 
 it, and that the period of maturity is that of work, 
 ambition, disappointment, and of the uncurbed exer- 
 cise of the largest number of faculties of body and 
 mind. At the close of the period of full maturity 
 comes the period of change, the so-called climacteric 
 or, in woman, menopause. Some think no such period 
 occurs to men. But I am inclined, from my ex- 
 perience of the insane, to consider that (though, 
 perhaps, later) a similar period exists, and that, in 
 fact, a man does not pass from maturity into old 
 age without a period of mobility or instability, during 
 which he is assuming habits which, if duly developed, 
 are conservators of energy. The last division, accord- 
 ing to age, is the period of decay ; and I shall point 
 out that there are many varieties of nervous death, 
 some being rapidly destructive, and others leading 
 slowly to euthanasia. 
 
 I think it necessary to make some divisions, 
 according to the parts of the mind that seem to be 
 affected ; and I shall point out that whereas in one 
 case loss of energy is seen by the will-less condition 
 of one patient, in another perversion of moral nature 
 may be so great as to justify the use of the term 
 moral insanity. 
 
 My division of insanity being provisional, and in 
 no way pretending to be final, will be found more 
 useful than elaborate new plans which would entail 
 labour to the student to master, and which will in 
 the end have to be thrown aside. Moreover, my 
 classification, being on the old lines, will be understood 
 by all 
 
i6 
 
 CHAPTER TIL 
 
 CAUSES OF INSANITY, PREDISPOSING AND EXCITING. 
 
 General predisposing causes : Effect of race — Education — 
 Sex — Age — Neurotic predisposition — Occupation — Heredity — 
 Constitution and temperament. Moral causes : Domestic 
 trouble — Mental anxiety and overwork — ^Keligious excitement 
 — Love affairs (including seduction) — Fright and nervous shock. 
 Physical causes : Intemperance in drink — Intemperance 
 (sexual) — Venereal disease — Self-abuse (sexual) — Over-exer- 
 tion — Sunstroke — Accident or injury — Pregnancy — Parturition 
 and the puerperal state — Lactation — Uterine and ovarian dis- 
 orders — Puberty — Climacteric— Fevers — Privation and starva- 
 tion — Old age — Other bodily diseases or disorders — Previous 
 attacks — Hereditary influences ascertained (direct and col- 
 lateral) — Congenital defect ascertained — Other ascertained 
 causes — Unknown causes. 
 
 In this chapter I shall show the many contributing 
 conditions which may aid in the development of 
 insanity. Insanity rarely springs into existence; it 
 begins to grow long before it is seen. 
 
 When speaking of " cause," I use the term in the 
 widest sense for convenience, and not pretending to 
 exact expression. The sun, the rain, the dissolving 
 soil, the very earth-cast of the worm, contribute to 
 the growth of the grass, and in a sense may be said 
 to cause the grass to grow; so it is with insanity 
 and the many and complex relations of life. I 
 shall consider all the assisting conditions in the 
 environment as causes, when they can be shown 
 probably to have influenced the result. 
 
 Any division which one makes must be artificial, 
 and suited for the present time and our limited 
 knowledge, both moral and physical. Predisposing 
 and exciting are but convenient expressions of the 
 immediate conditions connected with the disorder; 
 
Chap. III.] Predisposing Causes. 17 
 
 the effect of a moral shock may be similar in kind and 
 in degree to that of a physical one, and the body may 
 suffer in the same way from each. A fright or a 
 blow may produce pallor, faintness, and sickness ; and 
 a graver shock or blow may produce insensibility, 
 or mental disorder of more active kinds. Thus, any 
 division depending on terms like moral and physical 
 must be understood to be used for convenience, and 
 not as representing any definite idea of physiology 
 or psychology. 
 
 Without considering the terms 'physical and 
 psychical as final, I shall make use of them, and 
 I have adopted the rather convenient table which is 
 approved by the Medico-Psychological Association; 
 this table contains the chief accepted causes which 
 are given of mental affections. 
 
 In any classification we must refer to the time- 
 honoured division into ^' predisposiTig " and "ex- 
 citing " causes. The " predisposing " and " exciting " 
 causes must again be divided into general and special. 
 Here we may often be able to place two distinct 
 events or conditions which have precipitated the cata- 
 strophe. Or one physical cause may act in several 
 directions ; thus : a drunken man loses his situation, 
 and is brought face to face with want ; drink has been 
 preparing the brain, and the shock of the loss of his 
 situation is just sufficient to upset the already un- 
 stable balance. Delirium tremens is often known to 
 follow a physical shock or injury, and in the same 
 way I have known a sudden mental shock to produce 
 insanity, resembling, in many particulars, delirium 
 tremens. Thus, I saw a lady suffering from acute 
 mania of a restless, noisy variety, the patient being 
 emotional, and at night seeing vermin about her, and 
 strange faces on the walls of her bedroom. She 
 had been a secret drinker, and having been left a 
 good deal alone of an evening by her husband, had 
 c— 14 
 
i8 Insanity and Allied Neuroses. [Chap, iil 
 
 had ample opportunities for indulging her evil habits. 
 She had been, by a kindly motive, induced to go out 
 one evening, but had failed to get home in conse- 
 quence of her drunken condition ; she had been cared 
 for in a police cell, and the next morning fined five 
 shillings. The loss of position incurred by this acci- 
 dent upset her balance, and for a time she was insane. 
 
 When considering the relations of drink to insanity 
 in detail, I shall have to speak more fully of its 
 double action, or I might go farther and say, its 
 multiple action, for it affects the mind, body, and 
 estate in a most complex way. But, whether we 
 consider causation from the side of predisposing and 
 exciting, or from the bodily or the mental side, when 
 we come to life studies we shall very rarely find one 
 single predisposing and one single exciting cause. 
 Generally, when persons become insane they do not 
 suddenly jump from sanity to insanity ; the whole 
 thing, as a rule, is a morbid development. The bodily 
 and the mental relations become changed step by step, 
 and the final outbreak of insanity, which causes the 
 friends to seclude the patient, is but the last step 
 in the downward course. So much is this the case, 
 that a very large number of patients are sent to 
 asylums with the earliest recognised symptoms of 
 their disease given as the cause of the affection. By 
 this means many so-called drink-produced cases are 
 wrongly accused of intemperance. Sleej)lessness may 
 lead to the use of stimulants, and these in their turn 
 upset Uhe digestive functions, and the patient, thus 
 weakened and exhausted, loses all self-control and 
 becomes mad. 
 
 As I have already said, predisposing causes are to 
 be divided into the general and special. Many 
 writers have considered almost every one of the 
 varying conditions of civilised life as possible predis- 
 posing causes to insanity. In fact, any one of the 
 
Chap. III.] Influence of Race. 19 
 
 many-sided parts of the character of man, when over- 
 developed, may predispose to a loss of mental balance ; 
 and doubtless it is of the utmost importance, in 
 studying the genesis of insanity, to consider with care 
 anything that may assist in the fuller understanding 
 of mental action. 
 
 GENERAL PREDISPOSING CAUSES. 
 
 Effect of race. — It has been supposed that 
 insanity occurs more among some races than among 
 others, or, at least, that some forms of insanity are 
 more likely to appear among, say, the more excitable 
 races than among the phlegmatic. But evidence is 
 wanting to show that peculiarities of race alone are 
 sufficient to cause marked differences in the insani- 
 ties. Por though excitement and excess may tell 
 disastrously upon the unexcitable, I am inclined 
 to think that direct nervous stimulation is like their 
 native sun to the more excitable southerners, a 
 natural and constant part of themselves. An amount 
 of excitement or excess which might disturb an 
 Englishman would little affect the Italian or Spaniard ; 
 and statistics clearly show that insanity may occur 
 at least as frequently among the slow-living (I had 
 almost said torpid) races of the north, as among the 
 excitable southerners. In Scandinavia, causes such 
 as solitude act as disastrously as indolence and 
 excitement among other races. 
 
 Dr. Ashe, of Ireland, contributed to the Medical 
 Congress of 1881 a collection of statistics showing 
 the infrequency of general paralysis of the insane 
 among the Irish, and in the same collection were 
 brought together statistics from other Celtic races. 
 And although we find that in the highlands of Scot- 
 land and in the rural parts of Ireland and Wales, 
 a general paralysis of the insane is almost unknown, 
 
20 Insanity and Allied Neuroses. [Chap. iii. 
 
 yet as soon as the same peojole migrated to cities 
 they seemed to enjoy no immunity from this disease, 
 so that there could not have been any question of 
 purity of race alone as giving immunity. 
 
 It used to be said in America that the same im- 
 munity was enjoyed by the negroes in slavery ; but 
 whatever the cause may have been in the days of 
 servitude, I have the best authority for stating that 
 general paralysis of the insane occurs now, not only 
 among negroes, but among negresses also. I know of 
 no special race-immunity, either from ordinary in- 
 sanity, or from general paralysis. Recently I had 
 an opportunity of studying the condition of the 
 Indians of north Canada in the Hudson's Bay Ter- 
 ritory, from the notes made during five years by Mr. 
 Walton Haydon, and I found that insanity, associated 
 both with excitement and depression, occurs among 
 the natives. Few opportunities, however, are given 
 for the study of such patients, for among imcivilised 
 races, to be mad is sufficient reason to be killed. It 
 might be supposed that some races, like the French 
 branch of the Latin race, were specially predisposed, by 
 reason of the constancy with which political agitations 
 disturb the whole country ; but it is noteworthy that 
 political and social convulsions do not greatly increase 
 the numbers of the insane, and that, in fact, the chief 
 part which such differences play is rather to colour 
 or give shape to the disorder than to cause any 
 marked increase. It was shown, during the Franco- 
 Prussian war, that large numbers of people on the 
 borderland of insanity seemed rather to be prevented 
 from passing into the land of madness by the mental 
 excitement and occupation afforded by those stirring 
 times. In fact, it did what one is constantly striving 
 in vain to do, it gave occupation to the thoughts of 
 the nervous, thus taking them away from the insane 
 contemplation of self. 
 
Chap. III.] Influence of Education. 21 
 
 Education has to be considered among llie 
 predisposing causes. And here it will be found that 
 insanity occurs amongst the most highly educated, as 
 well as among those without any learning at all. 
 Does education produce insanity % Is the present 
 age of school boards one in which insanity is manu- 
 factured by overwork % These are two of the most 
 important questions which present themselves for 
 solution at the present day. In my opinion, true 
 education, that is, the true development of mind and 
 body, are the best preventives of insanity. Over- 
 education, or bad education, consists really in the 
 development of one side of the human being at the 
 expense or to the neglect of the rest ; and the fault 
 which one constantly sees is in educating the child 
 along the lines to which its tastes lead it without 
 paying sufficient attention to correlated functions. 
 The precociously artistic child is encouraged to dabble 
 in colours, and the musician of five years old is placed 
 in the hands of a master. This is bad education, and 
 is likely to do harm. I should not, however, think it 
 well to follow the advice of a recent writer who 
 suggested that it would be advantageous if all men 
 were taught to be ambi-dexterous. For although it 
 is well to be able to use both hands, it is better that 
 one should be more facile and read}^, rather than that 
 both should be indifierently handy. I have rarely 
 seen insanity produced by anything that could be 
 fairly called over-education, if hygienic rules were 
 followed, and if patients were not already strongly 
 predisposed to insanity by inheritance. The weak- 
 mindedness produced by . over-special education falls 
 most markedly upon those who have insane inheri- 
 tance. As has already been stated, precocity is 
 not unusual in such persons, and the precocious child 
 is one often having intellectually w^eak parents, who 
 are likely to mismanage it in all directions. 
 
22 iNSAmTY AND ALLIED NEUROSES. [Chap. HI. 
 
 A forcing process goes on which ends in a premature 
 decay or an unnatural production. The education 
 which I have seen do most harm is that which may- 
 be called education out of harmony with the sur- 
 roundings of the individual. Thus, the promising 
 artisan who wins some prize, or who is taken up by 
 some well-meaning patron, and who is educated in the 
 book learning of the ancients, or in the science of the 
 moderns, runs danger of suffering. I have constant 
 examples in Bethlem of young men, who, having left 
 the plough for the desk, have found, after years of 
 struggle, that their path was barred by social or 
 other hindrances, and disappointment, worry, and 
 the solitude of a great city have produced insanity of 
 an incurable type. The question of the number of 
 hours of daily work that are to be considered sufficient, 
 beyond which over- work comes in, is a question which 
 must depend on the individual ; and in dealing with 
 the question of education as a cause of insanity, 
 I insist chiefly on the disturbance produced by 
 education bad in quality or amount. 
 
 A strong healthy girl of a nervous family is 
 encouraged to read for examination, and having dis- 
 tinguished herself, is, perhaps, sent to some fashionable 
 forcing house, where useless book learning is crammed 
 into her. She is exposed, like the Strasburg geese, to 
 stuffing of mental food in over-heated rooms, and 
 disorder of her functions results. Or if a similarly 
 promising girl is allowed to educate herself at home, 
 the danger of solitary work and want of social 
 friction may be seen in conceit developing into 
 insanity. It is in this manner that the results of 
 defective education become often apparent in the case 
 of the weaker sex now-a-days. 
 
 Finally, with regard to the question of education, 
 most writers, who begin by stating that there is a 
 great increase in insanity, end by saying that the 
 
Chap. III.] Influence of Sex. 23 
 
 increase is due to the increase of education, and that 
 insanity grows directly as the education of the people 
 increases. But this, again, to my mind, needs con- 
 siderable qualification. Now-a-days education has 
 spread far and wide ; and although it may be 
 theoretically for the benefit of mankind that the 
 larger proportion should read and write, and have 
 a sufficient knowledge of many tilings, yet it leads 
 men to over-estimate their mental acquirements as 
 compared with their bodily ability ; so that the fact 
 that a very large number of clerks become insane is 
 rather an evidence that there are many more clerks 
 living struggling existences, than that the study 
 required to qualify them for their occupation has 
 caused their mental disturbance. With the increase 
 of education are produced over-ambition, feverish 
 pursuit of gain and pleasure, aggregation in towns, 
 celibacy with vice of one kind and another, and the 
 development of religious indifference and general 
 unbelief, associated with neglect of general hygienic 
 conditions. 
 
 Sex. — Both sexes are liable to insanity, and suffer 
 from acute attacks of mania, melancholia, or dementia, 
 almost in equal proportions. But some forms of 
 insanity, such as general paralysis of the insane, are 
 at present much more common among men than 
 among women. Whatever the cause of this may be, 
 I have no doubt of the fact that insanity of this 
 particular type is greatly on the increase both among 
 men and women. Even in my recollection of the 
 insane, which extends over a period of a little under 
 twenty years, I have noticed U marked increase in the 
 number of female general-paralytics seen in the middle 
 classes. It is still a question as to the absolute pro- 
 portion between the number of insane among men 
 and women. The Commissioners' returns for 1883 
 show: in private asylums, 2,181 men, against 2,617 
 
24 Insanity and Allied N'euroses. [Chap. in. 
 
 women; and in pauper asylums, 29,741 men, against 
 35,521 women. 
 
 In most asylums there are more female than male 
 admissions, and certainly in Bethlem Hospital we 
 always have an excess of female patients, and this 
 excess is regular and constant. But there is also to 
 be considered the question that women seem to be 
 more readily cured, and are more liable to recurrences 
 of insanity, so that, taking the number of females 
 admitted, they would not exceed the males in such a 
 marked degree, though still they would be in excess. 
 The sex makes a difference, not only in number, but 
 also as to the causation of the insanity. As I shall 
 have to point out, one of the most dangerous periods 
 in the lives of nervous persons is the period of 
 puberty. This period is dangerous to men, but it is 
 much more so to women. Everyone is familiar with 
 the hysterical girl ; but few appreciate at first, 
 at its full value, the danger of the onset of desire 
 as it occurs in lads. The nervously predisposed 
 youth might well be represented by the artist as 
 a frail, bloodless body being struggled for by the 
 spirits of Eros and Psyche. Women are more 
 often upset by sexual troubles, and the periods of 
 pregnancy, parturition, and lactation add gravely to 
 the danger which they run of becoming insane. It 
 must be fully recognised that many of the sexual 
 perversions which occur among the insane are 
 attributable to their insanity, and are not to be 
 looked upon as the causes of the disordered con- 
 dition. 
 
 That there is an excess of female lunatics might be 
 expected from the greater nervous instability of 
 women, from the larger number, proportionately, of 
 women living at any one time in England, to the 
 greater tendency of insanity to recur in women, and 
 to the greater tendency of mothers to transmit 
 
Chap. III.] Influence of Age. 25 
 
 insanity to their female children, who again are the 
 more numerous. 
 
 In connection with sex one must consider mar- 
 riage. Among the insane we lind among men most 
 single men, but among women more married than 
 single women. And here we must remember women 
 marry earlier than men, and have extra causes of 
 disturbance, to which I have already referred. 
 Widows are much more liable to break down than 
 widowers ; and this is comparatively easily explained. 
 In modern society marriage is looked upon as the 
 proper social end of a girl's life : she is educated 
 for and led to expect that household duties will be 
 hers, and, as a rule, she is hardly prepared for any 
 independent struggle with the world ; and if for a 
 time she has gone out as governess or shop-assistant, 
 it has been only with the idea that this condition 
 would be temporary. When married this is all given 
 up, her accomf)lishments become neglected, and her 
 family is made the centre of her life. If accident or 
 disease deprive her of her husband, she has a hard 
 struggle for her bread; worries, anxieties, loss of 
 social position, and deprivation of sexual gratification, 
 all assist. These causes are sufficient to upset the 
 nervous balance of a large number of women ; so 
 many, in fact, that I often feel I shall have to de- 
 scribe a form of mental disorder under the name of 
 " widows' disease." 
 
 A§"e. — I believe that occasionally children come 
 into the world of unsound mind. It may, however, 
 seem an exaggeration to speak of the mind of a 
 newly born animal ; but I* have had opportunities of 
 seeing children whose mothers have been in Beth- 
 lem during the later months of pregnancy suffering 
 from insanity, and some such children have almost, 
 from the hour of birth, been restless, intractable, 
 sleepless, and unnatural little creatures. 
 
26 IlSiSANITY AND AlLIED NeUROSES. [Chap. III. 
 
 Various forms of brain defect or disease causing 
 idiocy may occur from birth, and will be considered 
 with idiocy later. As a rule, all nervous distur- 
 bance of a severe kind in early infancy leaves the 
 mind a wreck. I have seen acute mania and acute 
 melancholia in very young children ; dementia, apart 
 from idiocy, can scarcely be recognised in children. 
 
 I have known a girl of eleven years of age who 
 persistently refused food, and had done this so long 
 that her whole weight was only thirty-four and a half 
 pounds ; she had the marked skin changes seen with 
 starvation. Kind but firm treatment, with good 
 feeding, restored this child. Dr. Heron, under 
 whose care she was, says he has traced insanity in 
 one parent's family. 
 
 The next period of special interest is the age of 
 puberty, in which we meet with various forms of 
 insanity, all of which have a great tendency to 
 culminate in weak-mindedness, if they last for any 
 considerable period, or if they are severe in degree. 
 They are chiefly characterised by emotional distur- 
 bance, by exalted ideas of power and worth, or by 
 the converse feelings of unworthiness. They may be 
 associated with hypochondriacal conditions of one 
 kind or another, the patient frequently referring the 
 symptoms to the head or brain, and assuring you that 
 his or her brain is either dried up or swollen. At 
 this period moral perversions are very common, espe- 
 cially if there is strong inheritance of insanity ; lying, 
 thieving, lust, cruelty, and destructiveness being not 
 uncommon. 
 
 A lad of fifteen, whose mother was many years 
 ago in Bethlem, and whose uncle died of insanity, 
 went on well enough till he was set to work in an 
 ofiice ; he became restless, and though able, he never 
 stopped long in a place. He was plausible and cun- 
 ning, and thus easily got fresh situations. It was 
 
Chap. III.] Climacteric Insanity. 27 
 
 found, after a time, that he was not so good at his 
 work, and further investigation brought many of his 
 faults to light; he had lied persistently, he had 
 destroyed property, and valuables which had passed 
 through his hands were missing or injured, and yet 
 none of these things could be brought home to him. 
 Such a case will probably become a chronic lunatic or 
 a criminal. This is the age when insanity, associated 
 with phthisis pulmonalis, is not uncommon. 
 
 The period of full maturity and development, 
 during which the larger proportion of nervous dis- 
 orders occurs, next occupies our consideration. 
 
 Mania, melancholia, and, occasionally, primary 
 dementia are met with, chiefly at maturity, there 
 being endless varieties of each. This age is the 
 one in which which premature decay, as seen in 
 general paralysis, makes itself recognised. When 
 reviewing in detail the causation of general para- 
 lysis of the insane, I shall have to point out the 
 fact that the age of this disease is the age of 
 full vitality. It appears as if among the strongest, 
 most thoughtful, most energetic and useful of men, 
 this disease has its richest harvest. I shall point out 
 that there are many other diseases of the body which 
 have mental sides (if I may use the term) ; thus, with 
 gout and with degenerations of various organs, we may 
 have developed melancholia, hypochondriasis or symp- 
 toms of dementia. Later in life a period of several 
 years occurs in which melancholia, especially of the 
 hypochondriacal type, occurs. In women this is re- 
 cognised as " climacteric insanity," and I shall give the 
 same name to it whether occurring in men or women. 
 The chief characteristics of the disease are feelings 
 of bodily misery, sleeplessness, together with feelings 
 of spiritual unworthiness. This is the age of ''unpar- 
 donable sin." Such cases frequently recover if they are 
 judiciously treated for a snfiiciently long period. For, 
 
28 Insanity and Allied Neuroses, fchap. in. 
 
 like most other climacteric conditions, it is often 
 years before the fresh balance is re-established. The 
 period of the climacteric, already a period of degene- 
 ration, is succeeded by a still more fully .marked 
 decadence. Life is drawing to a close, and the 
 weight of years is telling, not only in feebleness of 
 body, in impaired digestion, but in loss of control of 
 the faculties, or marked pain in their action, so that 
 painful thought or brain-ache occurs, which is but 
 another way of describing melancholia. The most 
 common result of mental degeneration is a return to 
 childishness, and this childishness may be approached 
 somewhat suddenly or more gradually, so that the 
 old person may pass from a period of health and 
 strength through a time which is like the period 
 of adolescence, and is associated with a similar in- 
 stability and tendency to emotional disturbance. 
 Second youth may be passionate or hysterical. 
 The mental edifice, tottering to its fall, may be still 
 further damaged by some other physical accident. 
 Thus, apoplexy may comj)lete the intellectual ruin 
 begun by age, the whole depending on a further 
 extension of arterial disease, the brain acting feebly, 
 and being but poorly nourished. With the reduced 
 supply and assimilation there are fewer and fewer 
 exhibitions of mind, till, the supply being finally cut 
 ofi*, the end is reached. 
 
 Wetirotic iiilieritsaiice a^iid predispositioii. 
 — In general, I should say there is one chief predis- 
 posing cause, namely, neurotic predisposition. This 
 statement may be said to be like Moliere's explana- 
 tion of the effect of opium : " its effects were sopo- 
 rific." I only give a term and no explanation; but I 
 would insist in my belief that only a certain number 
 of persons are so constituted that they can become 
 insane. 
 
 Any one may have a brain tumour, or may die 
 
Chap. III.] Neurotic Inheritance. 29 
 
 from abscess of the brain j probably most may develop 
 general paralysis of the insane, but I believe few can 
 become " insane." Those who become insane may 
 inherit the predisposition directly ; and it is remark- 
 able to see how very precise the similarities of the 
 nervous derangements in parents and children may 
 be. I have known one member after another of a 
 family commit suicide, and I have even known the 
 members of one family to possess a predilection for 
 the mode of destroying themselves. I have, again, 
 known mother and daughter break down under the 
 same conditions, as, for example, after childbirth. It 
 may be said in both these cases there was a great 
 probability of the relations dwelling on the fate of 
 their friends, and begetting the evil thought by 
 brooding over it ; but this connotes a disposition of 
 subjectivity which is in itself abnormal. In con- 
 sidering, however, the predisposing causation of 
 insanity by inheritance, I would insist, most of all, 
 on direct inheritance of insanity. First, the danger 
 is great, the nearer the begetting of the child is to the 
 insanity. 
 
 Thus I have seen one girl of weak mind, who was 
 begotten on the very day her father had his first 
 convulsive fit, which was his first symptom of general 
 paralysis of the insane ; here there was no doubt about 
 the time of conception possible, from the wife's 
 history. Again, a patient was admitted into Bethlem 
 whose father was discharged from an asylum on 
 leave, partially recovered, nine months before her 
 birth ; and I was consulted in another case in which 
 the patient was begotten by a father who was on 
 leave from an asylum. That the direct inheritance is 
 of the utmost importance I have seen evidenced by 
 the fact that a patient in Bethlem Hospital, suftering 
 from insanity during pregnancy, bore a child who 
 was insane from birth. I shall have to refer to the 
 
30 Insanity and Allied Neuroses. [Chap. iii. 
 
 history of this child later, and need say no more 
 at present than that it is but one of several children 
 born of insane mothers, who have been perverse from 
 the very womb. The inheritance, then, is direct as 
 to time, the danger being greatest during the period 
 of insanity, and immediately before and after it^ so 
 that I have known many cases of insane patients 
 whose mothers had puerperal insanity, the first attack 
 of recognised insanity following the birth of the 
 patient, though, doubtless, the factors of the disease 
 existed earlier. The form of insanity may be direct, 
 that is, it may be similar in parent and child ; and 
 the insanity may affect the one sex more than the 
 other, but this does not always follow. I have known 
 one case where a man had two wives, and by each 
 wife one child, a boy by one and a girl by the other, 
 yet both these children were alike nervously un- 
 stable, tht father's mother having been a lunatic. 
 
 As in other diseases, so here, one generation may 
 escape, or, rather, may pass on the instability without 
 developing it. It is, hoAvever, still doubtful what 
 governs the inheritance; and it seems that in some 
 cases certainly the father passes his insanity more on 
 to his sons than to his daughters. But, in my 
 experience, I should say that whereas a mother 
 certainly passes her tendency to nervous disorder 
 most strongly to her daughters, a father very gene- 
 rally passes it to both sons and daughters in a rather 
 less degree. It has been thought by some that a 
 child inherits the mental characteristics of the parent 
 he most nearly resembles in appearance, but this is 
 doubtful. It is almost certain that direct inheri- 
 tance is the most dangerous, and that the danger 
 is greatest if the father is insane at or near the 
 time of the begetting, or if the mother is insane 
 during or soon after the pregnancy. I am not sure 
 as to the amount of danger to the offspring when the 
 
Chap. III.] Neurotic Inheritance. 31 
 
 mother has had very pronounced insanity, or even 
 insane longings, during the early months of pregnancy, 
 which has been recovered from before the end of the 
 pregnancy. If there be insanity in the families of 
 both parents the danger to the offspring is greatly 
 increased, and this may be easily accepted. The 
 common dread of marriages between cousins and 
 other blood relations is due to this fact, and the 
 union of family defects is seen not in an arithmetical 
 but geometrical increase of danger. I strongly 
 maintain that, with marked insanity direct on 
 the one side, a slight, even distant, taint on the 
 other side increases in a very marked degree the 
 risk of the children proving insane. The forms of 
 insanity transmitted or produced by such unions 
 will require further consideration ; but I may say 
 that moral defects, so-called criminality, and forms 
 of weak-mindedness, are very common as the result 
 of such marriages. Besides direct inheritance of in- 
 sanity, the offspring of [nervous, hysterical, unstable, 
 or degenerate parents are proved to inherit nervous 
 instability, and this is most clearly seen in cases 
 where two near relations of nervous, but not insane 
 stock, marry. I have seen such parents produce 
 whole families of idiots and weak-minded children. 
 
 If, again, we have insanity on one side, and age, 
 physical weakness, or some form of degenerative 
 disease, such as phthisis, on the other side, the risk of 
 insanity in the offspring is increased. 
 
 Besides the above, there are cases in which the 
 insanity is due to inheritance, though not of ordi- 
 nary nervous disease ; and we are not yet in a posi- 
 tion to explain its action. Certain temperaments 
 in the parents jDroduce insane children, and I have 
 known a whole family of lunatics, the offspring of 
 non-neurotic parents. This is merely a statement 
 of the fact that at present we do not know the first 
 
32 Insanity and Allied Neuroses. [Chap. iii. 
 
 cause of insanity. From some cases I have seen I 
 believe that injuries or degenerative changes in the 
 brain of a parent may lead to insanity in the 
 children. And here, again, the nearer the begetting 
 is to the injury the more the danger. It is in this 
 way, I believe, that the children of general paralytics 
 may inherit ordinary insanity if begotten after the 
 disease has fairly begun. 
 
 Besides the effects of msanity in the parents s^nd 
 their forefathers, and in brothers and sisters, we must 
 consider cousins and second cousins, as this at least 
 gives evidence of nervous stock. It is sometimes 
 important to discover in brothers and sisters other 
 neuroses ; one brother may be an idiot, another epi- 
 leptic, and a third suffering from ordinary insanity. 
 No general law, however, has been discovered ex- 
 plaining why one suffers from one form of neurosis, 
 and another from some other form ; the cliief inference 
 would be, that in a family where hysteria, idiocy, 
 epilepsy, and insanity occur, the parents, one or both, 
 are of highly unstable nervous systems. 
 
 Occupation. — Under the head of education I 
 spoke of occiq^ation and social positiooi in their relation- 
 ship to the causation of insanity. And I pointed out 
 that just as many educated as ignorant were found to 
 suffer mentally. Neither riches nor poverty prevent 
 persons becoming deranged. The millionaire and the 
 pauper may alike be mad. Though, as I shall show, 
 riches do not prevent the malady, yet the care and 
 treatment is naturally affected by the possession of 
 wealth. The consequence is that there is an appearance 
 of excess of insanity among the lower classes, simply 
 because the bread-wiiuier, being incapacitated from 
 work, must necessarily be removed from his home, 
 whereupon his absence not only deprives his family 
 of his earnings, but also compels one or more to look 
 after him instead of adding to the common store. The 
 
Chap. III.] Precarious Occupations. 33 
 
 liberty of the subject depends, after all, to a certain 
 extent, upon the length of the purse. The weak- 
 minded rich man can be kept among his friends by 
 the aid of servants and attendants, but the poor man 
 is sent to the workhouse infirmary or to the 
 asylum. Certain occupations seem more favourable 
 for the development of mental disorders than others, 
 and my own impression is that certain ijrecarious 
 occiqmtiojis, at all events recently, have played an 
 important part in the production of insanit}'. Thus I 
 refer to the question of agricultural depression, in 
 considering which question it will be well, however, 
 to guard against possible sources of error. But the 
 fact most certainly is, that a larger proportion of small 
 farmers have been admitted to Bethlem durinsf the 
 last few years than formeiiy. One source of fallacy 
 may be that owing to money losses they cannot be 
 paid for by their friends in private asylums, and there- 
 fore more of them have been sent as free patients. 
 But notwithstanding this possibility of error, the pre- 
 carious conditions of the farmer's life seem eminently 
 those likely to cause a mental break-down. Insanity 
 is comparatively rarely produced by a single shock 
 or emotion. Just as the stone is worn by the con- 
 stant dropping, so the mind is upset by the recurrences 
 of worry; and worry, not work, is the cause of the 
 break-down of farmers, ^o nmount^'of foresisfht or 
 industry will save them from the effects of disastrous 
 years. And it seems that the inability to stave off 
 misfortune has a particularly depressing effect. 
 
 There are many other occupations which are suffi- 
 ciently exhausting, or subject to recurring annoy- 
 ances. Speculative businesses belong to this class. 
 And in referring to general paralysis I shall have to 
 speak of the mode of life followed by speculators 
 as one tending, in my belief, to the development of 
 this form of mental disease, 
 r^l4 
 
34 Insanity and Allied Neuroses, [Chap. iii. 
 
 In Betlilem we have a very large number of 
 governesses. But here, again, the fact must be taken 
 into consideration that, just as the younger men, who 
 are struggling from the lower ranks of the 
 artisan into the higher social ranks, strive first to 
 become clerks, so girls of the same station endeavour 
 to become governesses. And if any special ability, 
 such particularly as that for music, is exhibited, they 
 are forced and cultivated along that special line at 
 the expense of their general health and mental 
 balance. To my mind, the governess's life is a very 
 good example of the j)redisposing causes of insanity, 
 as seen in action. Thus we see a girl of nervous 
 temperament, with high powers of receptivity, 
 anxious, self-sacrificing, and with emotional and 
 artistic feeling, thoroughly good and hard-working ; 
 showing more aptitude than her sisters for music, 
 she is encoui'aged to spend many hours of a day 
 in practising the piano (I have known such a one 
 practise eight or ten hours a day regularly besides 
 occupying her time with other matters) ; and after 
 years of home practice she is taught, at considerable 
 sacrifice to her pai"ents, by some leading master, and 
 she overstrains herself in her endeavour to make the 
 most of the advantages which she was constantly 
 told she enjoyed. In this way her young growing 
 life suffers ; dyspepsia, constipation, and sleeplessness 
 come early; uneasiness occurs at the top of the 
 head ; menstrual irregularity shows itself, at times 
 there being profuse exliaustmg menorrhagia, at others, 
 painful scanty flow. In tliis unstable condition she 
 obtains some engagement, or, more disastrously, I 
 would say, a situation. Here she is better fed, and 
 has regular hours ; but, on the other hand, there are 
 no means of drawing herself out of herself. The 
 child, or children, are more or less trying to her 
 temper, and she, the enthusiast, is hourly annoyed by 
 
Chap. III.] Effect of Occupations. 35 
 
 the utter lack of interest exhibited by her pupils. 
 She often has no companions of her own age and 
 station, the heads of the household look down upon 
 her as belonging to an inferior grade, and her own 
 education and position prevent her from associating 
 with the domestic servants. In this manner she 
 becomes only one degree better than the prisoner in 
 solitary confinement. She is thrown into a purely 
 subjective life, building castles in the air, dreaming 
 what would be, or might have been, if only intellect, 
 the crown of man, had its proper sway, till at last the 
 castles in the air become to her no longer fairy ideas, 
 but actual realities. She thinks herself wedded to some 
 wealthy nobleman ; or, on the other hand, she may de- 
 velop ideas of suspicion, and fancy that every person 
 about her is wishing to take from her her only posses- 
 sion, her virtue. It is also worthy of consideration 
 that many who lead the life of governesses have been 
 compelled to do so by some domestic misfortune which 
 has suddenly compelled them to turn their education 
 to account, as being the only sure source of livelihood 
 enabling them to preserve the vestiges of their former 
 social position. In such cases as these, in addition to 
 the perplexities and mortifications of their un- 
 accustomed life of dependence, there would be a 
 previously established predisposing cause. 
 
 From the above we can see how a governess's 
 occupation may act as an important factor in the 
 development of insanity. Beggars are said to be 
 remarkably free from insanity. That may be true in 
 England, but on the Continent it seems to me that 
 insanity creates many successful mendicants. Prosti- 
 tutes are said also to be specially predisposed to 
 insanity, and I am not surprised that it should be so. 
 In early life (for very commonly they commence 
 their vicious career as mere children, and have, like 
 the habitual drunkard, in many cases a directly 
 
36 Insanity and Allied Neuroses. [Chap. in. 
 
 vicious inheritance), tliey are driven not only to 
 gross sexual excess, but with it they take to drink, 
 irregularity of hours, and are exposed to all sorts of 
 risks of bodily disease, general and local. Thus a 
 young unstable woman, indulging in excess and 
 exposed to disease, breaks down. 
 
 Reference has been made to the influence of con- 
 finement on persons (more especially of solitary con- 
 finement) in the production of insanity. But at 
 present I need only repeat the statement that the 
 criminal classes contain a large number of people 
 with insane inheritance, who are from birth predis- 
 posed to insanity, persons who are already on the 
 confines of insanity, and who merely require some 
 slight alteration in their health and surroundings to 
 push them over the border-line. Solitary confinement, 
 the enforcement of a subjective life, may lead to 
 insanity. The captive, having nothing to occupy his 
 attention, is pretty sure to develop castles in the air 
 of one kind or another. 
 
 Among predisposing causes I would notice the 
 time of the year, the climate, and the like. In 
 Bethlem for years past we have always received the 
 largest numbers of applications for the admission 
 of acute cases in the summer ; and next in frequency, 
 early autumn seems the period most associated 
 with these disturbances. Although many superin- 
 tendents have been at considerable pains to trace 
 relationships between meteorological changes and the 
 occurrences of attacks of insanity, and of epileptic 
 fits, at present no distinct or direct connection 
 has been made clear. I should certainly not agree 
 with some writers, in saying that as a rule attacks 
 of mania occur in winter, but would rather say 
 they are more common in summer and autumn. A 
 question that is still repeated, is, Has the moon really 
 anything to do with insanity'? And sonje of our 
 
Chap. III.] Heredity. 37 
 
 asylum attendants still believe in the connection. 
 My opinion is, that many lunatics will remain quiet 
 in bed during darkness, but will be mischievous and 
 refractory if there is light enough. 
 
 Among special predisposing" causes, here- 
 dity stands first in importance. The child carries 
 on from his parents special qualities and disposi- 
 tions, and one recognises in all races of animals, 
 and even in the vegetable kingdom, special qualities 
 derivable from the male, and others from the female. 
 Hitherto, with all our observations and statistics, we 
 have been unable to foretell what would be either the 
 sex or the quality of the human offspring. We do 
 not even know whether, in fact, a child who resembles 
 in appearance his father is more or less likely to 
 resemble him in mind. But we do know that quali- 
 ties of mind and body are transmissible, for without 
 this there would be an end to all trainine* and de- 
 velopment. If the child did not inherit the result of 
 all that had gone before, with additional power of 
 development on his own part, all social growth would 
 be rendered impossible. The torch of civilisation is 
 handed from father to son, and as with the idiosyn- 
 crasies of mind, so the very body itself exhibits well- 
 defined marks of its parentage. 
 
 Dr. Bucknill has thrown doubts upon the impor- 
 tance of inheritance, and has said, with a certain 
 amount of appearance of reason, that if insanity be so 
 easily transmitted from parent to child, how is it that 
 so many in a family escape % For instance, in a 
 case in which the plea of insanity is made use of to 
 save a man from the gallows, the criminal being the 
 only one among six children whose sanity is called 
 in question. How is it that we so seldom find the 
 criminal to have insane brothers and sisters, and that 
 the expert is often driven to seek for insanity among 
 the uncles or cousins, and considers himself specially 
 
38 Insanity and Allied Neuroses. [Chap. iii. 
 
 fortunate if he finds an insane mother or father % 
 This is true enough, yet no one is surprised to hear 
 that in a family of six or eight, only one has some 
 physical peculiarity, or some mannerism or trick 
 which has been noted in the father's or mother's 
 family for generations. We have to remember that 
 the child is not only the offspring of his father and 
 his mother, but he is the last of a long procession, 
 and that he is the representative of their many 
 peculiarities and aptitudes, and it would be impossible 
 for him to have them all, as some would be contra- 
 dictories. 
 
 A good example may be seen by the presence of 
 an extra finger or thumb. This peculiarity may run 
 through several generations. But it only selects a 
 few individuals. Yet, surely, no one would doubt 
 the importance of its recurrence as evidence of family 
 peculiarity. Other peculiarities, bodily and mental, 
 are strikingly inherited, some of them clinging to the 
 male side, and others to the female side. Thus 
 hsemophilia will pass from male to male in a long 
 series, missing the females altogether. This is a good 
 example, also, of another peculiarity of inheritance, 
 which is seen among the insane, the transmission of 
 a tendency without its development in the person 
 transmitting. Thus, in hsemophilia, a father may 
 beget a daughter who has no tendency to bleeding, 
 but she has sons who are bleeders. The insane 
 parent may beget a child without any insanity, but 
 the next generation may develop it to its full extent. 
 
 Insanity, again, has the peculiarity of having 
 many other correspondencies and accompanying 
 attributes, so that, being taken as the supreme degree 
 of nervous disorder, it may be represented in other 
 terms by epilepsy, hysteria, hypochondriasis, vicious 
 or criminal tendencies, or even painful nervous dis- 
 orders such as neuralgia, 
 
Chap. 111.] Heredity. 39 
 
 Insanity may be transmitted direct as far as kind 
 goes, so that the hyjDochondriacal parent may have 
 a hypochondriacal son ; or the inheritance may be 
 altered in form, the maniacal parent having a melan- 
 cholic or epileptic child. 
 
 One of the phenomena of inheritance seems to 
 be a tendency that may be transmitted to break down 
 under similar conditions, such as age or child-birth. 
 Thus I have known several instances in which the 
 family inheritance was a tendency to pass into a state 
 of weak-mindedness with melancholy at a certain 
 period of life. The weak spot in the family was the 
 nervous system, and they began to die from above 
 downward. Perhaps the suicidal tendency is one 
 which appears to be most directly and distinctly 
 transmitted, and I shall have occasion elsewhere to 
 narrate cases in which one member after another of a 
 family has committed suicide, although under dis- 
 similar conditions of climate and social surroundings ; 
 though in fact separated by continents, the same family 
 tendency to self-destruction, the same inability to bear 
 reverses philosophically, the same unrestrained motor 
 impulse to end their troubles has manifested itself. 
 
 Another form of direct inheritance is seen in those 
 cases in which mother and daughter have suffered from 
 puerperal insanity. But in this, as in the last case, 
 there is added the direct tendency to dwell upon the 
 illness, or misfortune of the near relation. Nothing 
 seems to make a deeper impression upon a man than 
 the fact that a brother or father committed suicide ; 
 and no impression seems so readily made as in the 
 case of a woman affected by some disturbance during 
 the period of pregnancy or child-birth ; so that the 
 conditions capable of direct transmission are not un- 
 complicated examples of simple heredity. 
 
 It is rare to be able to trace direct inheritance of 
 insanity through many generations. 
 
40 Insanity and Allied N'eu roses. [Chap. ill. 
 
 The tendency of disease is to death or destruction. 
 There may be a vis medicatrix naturce in acute diseases, 
 but it seems to me that in insanity there is compara- 
 tively little tendency to direct correction of faults of 
 birth. 
 
 The person with weak nervous system is likely 
 to beget children with weak nervous systems also. 
 This tendency, then, if present on both sides of the 
 family is likely to produce examples of extreme mental 
 weakness, such as is seen in idiots. The tendency to 
 inheritance of insanity depends, to a very great extent, 
 upon the bodily as well as the mental condition of the 
 parent. In this manner one has frequently seen cases 
 in which an insane parent has begotten, or developed, 
 sane children in intervals between the attack of in- 
 sanity ; but if the father happens to beget a child 
 about the period of an attack, the chances of the 
 sanity of the child are small. The same holds good in 
 reference to the mother. 
 
 Another mode of starting neurotic inheritance by 
 heredity is from injuries to the head, or mental dis- 
 order in a parent, associated with physical illness. I 
 have notes of insanity occurring in the offspring after 
 injuries to the head of the father ; and in other cases 
 I have met with post-febrile insanity in the father 
 giving rise to weak - mindedness or liability to 
 insanity in the children begotten about the time of 
 the father's illness. Undoubtedly some forms of 
 insanity are much more readily transmitted than 
 others, and it is of the utmost importance that we 
 should be in a position dogmatically to say there is, 
 or there is not, danger to the children of such and 
 such parents. The advice of the consulting physician 
 is frequently sought as to the propriety of certain 
 couples marrying ; and although the advice given is 
 often disregarded, the question is sufficiently important 
 to be considered carefully. I am in the habit of 
 
Chap. III.] Constitution and Temperament. 41 
 
 saying that general paralysis of tlie insane is not to be 
 considered as an ordinary nervous disorder ; that it 
 does not occur directly as the inheritance of ordinary 
 insanity; at least, that it very frequently has no 
 connection whatever with ordinary forms of mental 
 derangement. On the other hand, the children of 
 general paralytics, especially those who may have 
 been begotten after the first well-marked symptoms 
 of general paralysis have developed themselves, are 
 likely to be idiotic, or, if they are sane as children, they 
 may later in life develop ordinary neuroses. I have 
 seen one patient in Bethlem suffering from melan- 
 cholia, whose father, to my knowledge, died of general 
 paralysis ; and I have been consulted about the child 
 of a medical man who has been weak-minded from 
 birth, she having been begotten after her father pre- 
 sented well-marked symptoms of general paralysis. 
 
 These facts of inheritance show that the damaged 
 brain, whether damaged by injury or decay, may 
 give rise to states and conditions leading to mental 
 degeneration or disorder in the offspring. 
 
 Constitution and temperament. — My ex- 
 perience leads me to believe there is a distinctly melan- 
 cholic temperament, but I am not equally prepared to 
 say that there is a special type constitutionally pre- 
 disposed to attacks of acute mania. The term melan- 
 cholia, derived from the old-world belief that black 
 bile had much to do with mental depression, is so far 
 borne out by experience that the dark-complexioned 
 and dark-haired melancholies are very largely in excess 
 of the fair persons suffering from mental depression j 
 this notwithstanding the fact that at least an equal 
 number of people belonging to the middle classes in 
 England are fair, and with light hair. It seems as 
 though there were truth in the old idea that per- 
 sons with dark complexions were likely to have slug- 
 gish function,-; and tendencies to look on the gloomy 
 
42 Insanity and Allied Neuroses. [Chap. iii, 
 
 side of things. I shall have to point out that insanity 
 is associated with various other forms of constitution, 
 and that no temperament is free : for though diseases 
 like phthisis give a special colouring to mental dis- 
 order ; though gout, with its loaded and impeded cir- 
 culation, may impress a s^Decial character on mental 
 trouble, yet, as " man is born to trouble, as the sparks 
 fly upward," so it would be unreasonable to expect all 
 insane people to possess specially insane temperaments, 
 or that all should break down from one cause. The 
 stress of life may fall most heavily along the weakest 
 lines and may cause break-down ; whereas troubles of 
 another order might, in the same case, fail to cause a 
 mental decline. Those unused to insane patients are 
 constantly on the look out in an asylum for peculi- 
 arities in aspect, or marked strangeness in the eyes of 
 the persons they meet. But as no one expects to meet 
 the poet in society with his " eyes in a fine frenzy rol- 
 ling," so no one should expect always to see the lunatic 
 with a mad aspect. It, however, often strikes an 
 observer, that among chronically insane patients there 
 does seem to be a development of a special type of 
 feature, and that this type is distinctly a low one. 
 That just as it is rare in an idiot asylum to see a 
 beautiful and well-formed child (although not an im- 
 possibility), so in a lunatic asylum I would say it 
 is seldom one meets with striking j)hysical beauty. 
 The transmission of insanity, as I said before, tends 
 gradually to the abasement and ultimate extinction 
 of the race. Degeneracy in nature is naturally in 
 opposition to beauty and well-being. If an insane 
 temperament be allowed to exist, it is that which 
 is represented by what is ordinarily called the ner- 
 vous temperament, and in certain families we meet 
 with all the varieties of neurosis in one member or 
 another. Such a family may be said to have the 
 nervous constitution, and may be looked upon as 
 
Chap. III.] The Nervous Constitution: 43 
 
 nearly related to the insane, yet tliere may be nothing 
 physical which can be pointed to as characteristic 
 or typical. 
 
 Besides direct inheritance, the crossing of mem- 
 bers of consumptive families with members of other 
 families suffering from some other forms of degenera- 
 tion seems, in my experience, to produce the nervous 
 constitution which shows itself in a tendency to 
 nervous break-down. It is often difficult to drav/ 
 any fine line between predisposing and exciting causes, 
 but in some the distinction is simple and straight- 
 forward. A person having an insane parentage 
 gets into feeble health, and is thereby predisposed 
 to break down, by inheritance primarily, by physical 
 weakness secondarily. He gets hold of some quack 
 publication, or falls under the influence of some 
 emotional teacher, and thus the spark is applied to 
 the explosive, and the result is the outbreak ; or a 
 lad, with some strongly insane inheritance through 
 his mother, receives a blow on the head, and he 
 becomes maniacal. A man acquires the habit of 
 gambling, drinks and smokes to excess, and leads 
 a life of recklessness, during which he receives an 
 injury to his head, and this is followed by a slight 
 attack of deliriuim tremens, resulting in an outburst 
 of insanity. In this case, drink was at work impair- 
 ing the nourishment of the nervous tissues, lowering 
 the vitality of the man, rendering him less stable, so 
 that a slight disturbance of his nervous system, pre- 
 viously undermined by alcohol, led easily enough to a 
 more chronic perversion of mind. In the last two 
 cases, the exciting causes Avere both blows on the 
 head, but the predisposing causes differed entirely. 
 And my chief objection to any tabulated returns of 
 the causation of insanity, as seen in asylum patients, 
 is that it is extremely uncommon to find a simple, 
 straightforward case in which there has been but one 
 
44 Insanity and Allied Neuroses. [Chap, in 
 
 predisposing and one exciting cause. As " the last 
 straw breaks the camel's loack," so the continuance of 
 one vicious habit, indulged in for a sufficient length 
 of time, may lead to mental derangement, the same 
 cause being both the predisposing and exciting agent. 
 
 Exciting causes may, like predisposing ones, 
 be either moral or physical. Mental disorder 
 may be equally produced by a mental shock or a 
 blow on the head. The exciting cause may be 
 uniform or multiform in nature. It may take the 
 form of undue excitement or of want of fellowship. 
 Solitude or joy, love or hate, may be at times suffi.- 
 cient to cause a mental upset. To sum up this part 
 of my subject, I would say that one cause may be 
 predisposing alone, or predisposing and exciting, or 
 exciting alone ; that there are causes which may be 
 considered as complex or mixed, and that some causes 
 act both physically and morally. 
 
 Moral and pliysical cauisatioii. — Moral. — 
 I shall briefly refer to each cause given under this 
 head. Domestic trouble is the first moral cause, and 
 includes the loss of relatives and friends. Yearly 
 many patients are admitted into asylums with a 
 history of domestic trouble as the alleged cause 
 of their insanity. This is one of the constant 
 causes ; that is, it is one of the causes that act 
 from day to day and from hour to hour. It is 
 not like the sudden shock or fright, but it is the 
 condition which is associated with a thousand and 
 one other slight ailments. Domestic trouble, so 
 called, is one of the most far-reaching of morbid 
 actions. The appetite is impaired, digestion fails, 
 sleep is disturbed, respiration is no longer regular 
 and quiet ; the pulse often becomes hard, the tension 
 being high. The more the development of such con- 
 ditions is watched, the more one is convinced that 
 grave general nutritional changes are going on. I am 
 
Chap. III.] Domestic Trouble. 45 
 
 convinced, with Dr. Sutton of the London Hospital, 
 that this condition may readily pass either into Bright's 
 disease or insanity, and I would look upon the degree 
 of tension in the whole body as the one dangerous 
 element to be considered. Grief, as a part of 
 domestic worry, is also of great impoi'tance. Good 
 examples of what is meant by the effect of grief in 
 producing insanity are frequently seen in the wards 
 of Bethlem, where a woman has watched and 
 nursed for months together, with very little rest by 
 day or night, some near relative whose nervous and 
 exacting temperament has tasked the nurse to the 
 utmost. Such a person, after the excitement of 
 nursing and the burial of the relative, sinks into a 
 condition of extreme weakness, and, as a result, 
 conjures up all sorts of imaginary crimes that she has 
 committed, often thinking she has neglected, or even 
 killed, the person for whom she was sacrificing so 
 much. Grief or shock at the loss of relatives, 
 though it may cause insanity, does not necessarily pro- 
 duce melancholic symptoms. At first sight, one would 
 think that the loss of a near relation would produce 
 mental depression, but such an example as the follow- 
 ing will show that mental disorder may be produced 
 by painful shock which shows itself as acute mania. 
 A young woman, who had been engaged to be married 
 to a man who had emigrated to one of the colonies with 
 a view of making his fortune, lost sight of her lover for 
 eight or nine years, and supposed herself deserted by 
 him. She unexpectedly received a letter from him, 
 asking if she were still free and willing to accept him, 
 as he was returning home. She readily accepted him, 
 and spent all her liard-earned money in providing a 
 trousseau suitable for the bride of a wealthy man. 
 He returned, and she was married to him, though she 
 was somewhat surprised to find he was physically a 
 wreck, and had not the appearance of wealth. On 
 
46 Insanity and Allied Neuroses. [Chap. iii. 
 
 the ninth day from her wedding she awoke to find 
 her husband dead by her side. The seeds of disease 
 sown in the colony had borne their fruit in his sudden 
 death. The result of this shock (for she found her- 
 self now penniless and a widow) was an attack of 
 acute mania which lasted several months. Other 
 similar cases of grief producing acute mania are 
 sufiiciently common. Grief may produce a depression 
 passing into melancholia, or the blow may be a stun- 
 ning one. Thus, a person nursing most devotedly for 
 months her paralysed husband, broke down, and, 
 after a slight fit of unconsciousness, lost her 
 memory of all recent events, and is now practically 
 incurably weak-minded. To sum up, domestic worry 
 may, and undoubtedly does, produce insanity, both in 
 those with an hereditary predisposition and in those 
 without. The domestic worry acts on the body and 
 on the mind ; in some the body sufiering chiefly, and 
 the patient dying of kidney disease or allied diseases ; 
 or, where the mental symptoms predominate, the 
 patient becomes melancholic, maniacal, or weak- 
 minded, the melancholy often gathering with a dream- 
 like vagueness of imagery about the relative who has 
 died. 
 
 Adverse circiiiiistaiices (including business 
 anxieties and ^^ecuniary difficulties).-— TYvis variety of 
 cause acts mostly on men, while domestic trouble, etc., 
 falls most heavily on women. This cause also rarely 
 acts suddenly, but is long preparing for the disaster 
 by petty worries, anxieties, loss in position and social 
 regard, which may be often followed later by penury, 
 starvation, or over-stimulation induced by anxiety and 
 sleeplessness. Later I shall refer to the frequency 
 with which this cause is given for general paralysis. 
 Every year patients are admitted who have sustained 
 severe money losses, and amongst them are cases in 
 which distress to themselves and faniilies has been 
 
Cbap. III.] Nervous Axxiety. 47 
 
 suddenly produced. It must, however, be borne in 
 mind that money losses are not uncommonly asso- 
 ciated with early mental disorder as being an effect 
 of the latter rather than its cause. Now-a-days, the 
 speculative man who, through loss of memory or 
 slight impairment of judgment begins to lose his 
 business, is often likely to end in ruin. It is a very 
 important symptom, if it can be clearly shown that a 
 business man is losing his aptitude for accounts. I 
 have known such a person exhibit a failure in his 
 rubber of whist, this being the earliest symptom of a 
 disorder which cost him many thousands of pounds. 
 In such a case the money loss is the result, not the 
 cause of the disorder. Special conditions, such as 
 those of the farming interest and the landed pro- 
 prietor in anxious times, undoubtedly cause dis- 
 order ending in insanity, and it is but natural that 
 this should be so. I must repeat that mental disorder 
 is in most cases a morbid growth, and that worry and 
 anxiety, if constantly straining the nervous energies, 
 are pretty sure to cause a break down in certain 
 people. Pecuniary anxieties, of course, may be asso- 
 ciated with success as well as with failure, and although, 
 as has been repeatedly noted, joyous passions and 
 pleasures are less destructive than painful ones, yet 
 the anxiety of becoming rich and enlarging the barns 
 and store-houses may produce a wear out. I have 
 seen several cases in which men of unbounded energy 
 have risen from the ranks by sheer force of will and 
 work, men who seemed argus-eyed, and able to go 
 through the labours of a Hercules. But they drew 
 upon their capital too heavily, and the end was phy- 
 sical and mental bankruptcy, though with boundless 
 wealth, 
 
 To conclude this section, adverse circumstances, 
 money losses, especially those associated with constant 
 anxiety, tend to act by depressing physically and 
 
4 8 Insanity and Allied Neuroses. [Chap. hi. 
 
 mentally, and by producing symptoms similar to those 
 described as the result of domestic trouble, lead to 
 insanity. 
 
 Two points to be noticed are that more men than 
 women suffer from insa.nity produced by causes of this 
 nature, and that general paralysis of the insane is 
 a common result. 
 
 Mental anxiety and wos'ry witli over- 
 work. — This group of causes acts both on men and 
 women, and for convenience other causes of worry 
 and anxiety, such as can scarcely be considered do- 
 mestic or economic, are placed under this head. 
 Foolish ambition, failure, especially if repeated, the 
 striving to hold a false position, the fact of being out 
 of relationship to surromidings (this is seen in the 
 intellectual or social parvenu), and over-work, are 
 the chief varieties that I shall here consider. 
 
 Ambition may be what is teimed laudable ambi- 
 tion, or it may be the striving for the unattainable ; 
 and all students of Faust must be impressed with the 
 danger there is in seeking either for satisfaction in 
 the sensuous or in the intellectual alone. Such un- 
 attainable ambition leads to mental disturbance. The 
 unfortunate person is always striving for the stars, 
 and his mental attitude is well pourtrayed in some of 
 the weird sketches of William Blake, himself very 
 near insanity. Ambition of this kind acts on body 
 and mind alike. It occurs as a cause of insanity 
 mostly in young men ; and I shall have to refer later 
 to a special class of youths, seen chiefly at the old 
 universities, who, straining to lead absolutely pure 
 and unemotional lives, ignore the fact that they have 
 animal parts and animal passions; they do not see, 
 that although control is the highest thing to be 
 attained, suppression is impossible, and either too 
 much must not be expected or failure must be allowed 
 fox\ Men with such ambition not unfrequently pass 
 
Chap. III.] Overwork. 49 
 
 into a condition of mental hypochondriasis, and unless 
 some rude social or physical disturbance recalls them 
 to their senses, they stand a great chance of becoming 
 first insane, and later weak-minded. 
 
 Omr-work needs some consideration, since few 
 questions are asked more frequently of the phy- 
 sician than such as relate to the influence of over- 
 work in the production of insanity. In educa- 
 tion we have seen that bad^ ill-directed teaching- 
 may act injuriously upon the growing mind ; but 1 
 give my opinion strongly, that with judicious 
 education, even when a large number of subjects is 
 studied, no danger is to be apprehended. The kind of 
 over- work which produces ill results is forced work in 
 direct opposition to the tastes and aptitudes of the 
 pupil, especially when this takes place under bad 
 hygienic conditions, and with the excitement and 
 pressure of impending examinations acting as a stimu- 
 lus. Good examples of over-work are, to my mind, 
 best found in the young governess and the self- 
 educated man. The severity with which young girls 
 are forced by injudicious and ambitious parents 
 deserves censure. A girl of fourteen or fifteen years 
 old is expected to spend twelve hours a day in learn- 
 ing languages, practising music, drawing, and deport- 
 ment ; and if I have to censure one part of the 
 education more than another^ it is the deportment. 
 Girls are not j)ermitted to exercise their limbs and 
 their chests with heart and lungs, but must, forsooth, 
 use implements of torture to keej) their shoulders 
 straight and their waists within the bounds which 
 nature intended. Just as the forced plant may flower 
 out of season, so the forced girl will become prema- 
 turely a woman. The sexual instincts are developed at 
 the cost of the already enfeebled body, and excessive 
 or irregular and painful menstruation occurs in girls 
 who are ill-fitted to bear any extra drain on their 
 E— 14 
 
50 Insanity and Allied N'el roses, [Chap. iii. 
 
 strength. Over- work may seem to be an odd term to 
 give to the combined causation of this state, but if 
 such a girl be not over-wrought I do not know 
 who is. 
 
 Another common example of over-Avork is that 
 seen in the self-educated man, who so frequently has 
 an unbounded desire for knowledge, but does not 
 know how to acquire it. He has a great idea that 
 knowledge of facts is education, and looks with con- 
 tempt upon the older universities and schools as m.ere 
 excuses for passing time for the jeunesse doree. He 
 cannot see that education literally and really means 
 the development of all sides of the character, and 
 that mere special culture will fail to make a learned 
 man. The effects of solitary self-culture are worse if 
 begun after the plastic youthful nervous system has 
 taken its form, as it is hard to change its figure after 
 it has once hardened into habit. 
 
 Work of a monotonous character is injurious, and 
 assists in producing mental disorder. But such work 
 is comparatively rare. To rny mind, the letter-sorter, 
 the proof-reader, and persons employed to check me- 
 chanical labour run the greatest risk of breaking down 
 from this cause. A clerk or an accountant may sufier 
 from the monotony of his work, but with all its dry- 
 ness it is not so absolutely uniform as that of the man 
 who sorts letters, signals trains, or corrects proofs 
 under the pressure of time. 
 
 Meligioiis exciteiiiefiit.— Probably few causes 
 of insanity are more frequently in the mouth of the 
 general public than religious excitement : and yet the 
 experience of the asylum physician is that religious 
 excitement does not produce any large proportion of 
 the cases which come under his observation. In 
 considering the effect of religious excitement in the 
 production of insanity, we have to remember that 
 there are several very important sides to the question. 
 
Chap. III.] Religious Mania. 51 
 
 Firstly, what is meant by religious excitement % 
 Secondly, is the effect direct or indirect % and thirdly, 
 what is the nature of the })erson so affected ? 
 
 There seems to be abroad a feeling that nearly all 
 insanity is the result of drunkenness, love, or religion. 
 All of these may, separately or together, assist in the 
 production of mad folk. But I think too great atten- 
 tion is j)aid to them as special factors of the disorder. 
 An increase of insanity is sometimes apparent after 
 religious revivals ; but it is a question whether a large 
 number of the people who thus exhibit insanity are 
 not already prepared for the manifestation of insane 
 symptoms, and whether religious excitement has only 
 acted in modifying or giving colour to the insanity. 
 In fact, religion has been only the exciting cause, and, 
 as has already been remarked, it does not follow that 
 the symptoms produced by religious excitement should 
 necessarily be of any particular religious type. When 
 people talk of religious mania, they often confound two 
 things ; first, the cases in which patients are constantly 
 speaking about religious matters, more especially those 
 who are for ever repeating texts, or with hand- 
 wringing and melancholy aspect, are complaining that 
 their souls are lost ; and next, the cases which appear 
 to have been produced by some religious movement. 
 There is a very great distinction to be made between 
 the many cases which exhibit some religious symptoms 
 and the few which are really caused by religion itself. 
 Just as good education, even though a great deal of 
 it is forced upon the growing animal, rarely produces 
 harm, so religion even in excess need not be the 
 simple cause of mental disturbance. 
 
 It may be well here to point out a reason for the 
 constant recurrence of religious ideas in the insane. 
 One of the most marked characteristics of religion is its 
 mysticism, its professed dealings with powers which 
 cannot be weighed and measured, and yet which have 
 
52 Insanity and Allied Neuroses. [Chap. iii. 
 
 an enormous influence on the well-being of the indi- 
 vidual. The person passing from a condition of 
 sanity into one of insanity goes through a series of 
 indescribable feelings, and he thinks his new ex- 
 periences may after all be explained by the powers of 
 the Omnipotent exercised over him. JReligions have 
 always dealt largely in explaining strange or unusual 
 occurrences, and the same tendency is constantly met 
 with in persons of unsound mind. In many cases 
 the patient, suffering from the earlier stages of melan- 
 choly, is looking about for some possible cause of his 
 misery, and having failed to find in his bodily or 
 mental surroundings any satisfactory explanation of 
 his feelings, he discovers one in some text of Scripture. 
 The religious side of civilised society is an important 
 one, and finds occupation for such a large class of 
 men, and more women, that it would be strange 
 indeed if it did not produce some special fruit when 
 the mind is unbalanced. A direct way in which 
 religious excitement acts is by causing restless un- 
 curbed emotional excitement, so that the person 
 affected may pass through a period of religious 
 devotion into one of hysterical disturbance, and this 
 may lead to maniacal fury. On the other hand, 
 religion may act indirectly, as we have recently had 
 experience with the Salvation. Army, to a certain ex- 
 tent causing, but to a much greater extent colouring, 
 the disease. Thus an old clergyman, whose arteries 
 are getting rigid and who is suffering from dyspepsia 
 and constipation, becomes sleejDless and worried, and 
 fancies that he is on the brink of ruin, or that his 
 children are in distress ; next he feels he has not been 
 a good father or a faithful pastor. From this state it 
 is but a slight step to the belief that he is utterly 
 unworthy, and that while he has been preaching to 
 others he himself will be a castaway. Similar cases 
 to this are common enough, and I believe the majority 
 
Chap. III.] Religious Mania. k,i 
 
 of them occur with those who are the most earnest 
 of all in their profession, especially if with earnest- 
 ness there is but little culture of the broader kind. 
 
 Among patients who are upset by religious excite- 
 ment I distinguish two classes, the one the young and 
 emotional, the other the old or degenerating, who 
 are frequently emotional too. In connection with the 
 first class we have to bear in mind the fact that 
 religion is very closely allied to love, and that the 
 love of woman and the worship of God are con- 
 stantly sources of trouble in unstable youth. And it 
 is interesting to note the frequency with which these 
 two deep feelings are associated. In the second class, 
 as we have said, the older cases occur, and these 
 are chiefly characterised by mental depression with 
 feelings of unworthiness, and with ideas of not 
 having done their duty, or having committed that 
 most wonderful of all faults, ^'the unpardonable sin." 
 In these cases, too, there may be sexual perversions 
 as well, so that one patient will consider she has com- 
 mitted the unpardonable sin in allowing marital 
 congress, while another thinks she has failed by 
 denying it, thus driving her husband to sin. The 
 religious and sexual sides of man's nature are both 
 closely connected with the emotional development and 
 are connected with his organic nature. I have often 
 been astonished to find that miserable patients in a 
 lunatic asylum were still indulging in some form of 
 sexual excess. 
 
 To sum up, religious excitement may produce some 
 insanity in unhinging those among the young, espe- 
 cially among the young nervous females of a society 
 over which an emotional religious wave passes. As 
 a rule, however, religious insanity, so called, is the 
 symptom, not the cause of the disorder. 
 
 liOve (including seduction). — I naturally pass 
 from the consideration of insanity that is produced 
 
54 Insanity and Allied Neuroses. [Chap. iii. 
 
 by religious disturbance to that caused by love. And 
 here I shall consider love in the more spiritual sense, 
 having in the next section, under physical causes, to 
 refer to sexual excesses of various kinds. 
 
 Love has a powerful exercise in stimulating to 
 bodily and mental action. Desire is one of the 
 strongest of animal passions. The wild animal, such 
 as a stag, who is docile or timid to a degree, will, 
 when that causa teterrima belli, love, enters in, become 
 a furious and dangerous antagonist. Education and 
 the restrictions of society have done much to suppress 
 the appearances of emotion, and have controlled most 
 markedly the exhibitions of sexual longing. But the 
 root of the evil lies deeper, and as soon as self-control 
 is lost, one sees the passions manifested in all their 
 naked truth. Love, under these circumstances, will 
 have to be looked upon as one of the causes, and also 
 of the symptoms, of mental disorder. Generally, dis- 
 appointment, unrequited affection, or extinguished 
 passion are the chief causes, so that it may be ac- 
 cepted as extremely rare for disturbance to arise from 
 the successful pursuit of love. As with the other 
 causes, there must be fretting or jarring of the wheels 
 of the machine to cause disaster. The mere healthy 
 fulfilment of functions is not likely to produce disease. 
 The persons most likely to break down from disap- 
 pointed affections are women ; and the danger in- 
 creases with age up to a certain limit, so that it 
 would be considered a much more serious thing for 
 a woman of thirty to be cast off by her lover than 
 for one of twenty. The consideration, however, of 
 nervous inheritance would have something to do with 
 the prospect, and any other cause of special bodily 
 deterioration will have also to be noted. Thus, as 
 may readily be expected, seduction, in addition to 
 cruel desertion, will greatly increase the probability of 
 a mental upset. 
 
Chap .III.] Ner I '0 US Siroci:. 5 5 
 
 Under the head of love I think it well to refer iu 
 another class of cases, which probably are uncommon. 
 I have seen several examples in which young men 
 and young women of highly sensitive, and sometimes 
 of strongly religious tendencies, have, like some of the 
 saints of old, suppressed their passions till they have 
 seen visions appearing to them, perhaps, as ghostly 
 temptations to sin. 
 
 FrigSit aiicl nervous sliocU.— From time to 
 time a good many diseases of the nervous system have 
 been attributed to shock or fright, but just as at the 
 present time fewer believe in fright producing chorea 
 than formerly, so I believe the influence of fright, in 
 the production of insanity, is looked upon as less 
 potent than it was. Yet I have seen several cases in 
 which there could be no doubt that fright was the im- 
 mediate cause of the insanity. Thus, a young man 
 returning home from a public-house on the fifth of 
 November, was greatly alarmed by a practical joke 
 played upon him by some of his companions, who 
 threw squ.ibs at him as he passed along a dark lane. 
 On the morrow he was found in his bed in a condition 
 which induced his brother to think he had been 
 drinking, but this proved to be an attack of acute de- 
 mentia, from which he suffered for some months, 
 but ultimately recovered, v>'ith absolute oblivion of 
 the period which had intervened. In another case, a 
 fire in the house set up an attack of acute mania, 
 which ended fatally within a week. In other cases I 
 have seen less sudden shocks act as disastrously. I 
 have known a man falsely accused of theft, and 
 another who was boycotted by his fellows without 
 cause, both of whom for some weeks led a life of great 
 anxiety, pass into conditions of insanity of longer or 
 shorter duration. I could give many other examples 
 in which frights, such as those occurring from acci- 
 dents or from felonious attacks, have been follov/ed by 
 
56 Lysax/tv and Allied N'euroses, [Chap. hi. 
 
 serious mental symptoms, so that a woman assaulted 
 with a criminal intent has become weak-minded, and 
 at least some of the cases of post-connubial insanity 
 are due to the shock of marriage. One important 
 point to be remembered is, that although shock or 
 fright may occasionally act immediately and dii'ectl}^ 
 yet at other times the result does not make its ap- 
 pearance for weeks or even months after the actual 
 occurrence. This is not only especially true in the 
 case of frights, but will be seen constantly to occur 
 with the more ordinary causes of insanity. If we 
 trace sufficiently far back, a single exciting cause may 
 seem to have given a bend or inclination in the whole 
 nervous life, which from that time goes on to degene- 
 ration, and not to evolution. 
 
 Physical causes : Intemperance in drink. 
 — Intemperance, as I have said before, is a Aery mul- 
 tiple agent in causing insanity. It acts upon the brain 
 directly as a poison ; it acts indirectly upon the brain 
 by impairing nutrition and interfering with the depu- 
 ration of the blood ; it acts morally by lowering the 
 social condition of the majority of those who indulge 
 to excess, and indirectly it leads to injuries, expo- 
 sure to cold, and similar damaging influences. I 
 shall have to consider insanity as specially connected 
 with drink, and therefore here I shall but briefly give 
 a general outline of its action. 
 
 Large single doses of stimulants may act almost 
 like a shock, and render the person taking them power- 
 less, or, in some cases, suddenly maniacal ; more com- 
 monly the excess in drink is a frequently-repeated 
 act, and the effects are the result of the constant repe- 
 tition, the whole nutrition of the body suffering. It 
 will be noted that in these cases there is a progres- 
 sive loss of mental power, which resembles, in many 
 particulars, the progressive loss of faculties which is 
 seen in general paralysis of the insane, the higher 
 
Chap. III.] Intemperance. 57 
 
 powers of self-control being earliest lost, the moral 
 sense and social and domestic feelings suffering in 
 turn, till, later on, memory and reasoning power, and 
 finally even the simpler organic nervous actions, are 
 suspended. 
 
 Intemperance may act in another way. Bouts or 
 recurrences of drinking are associated with repeated 
 attacks of delirium tremens, these attacks shaking the 
 nervous system so severely that in the end it totters 
 and falls, I have seen several cases belonging to 
 nervous families in which an attack of delirium 
 tremens has passed directly into an attack of acute 
 mania, persisting for weeks after the alcoholic poi- 
 soning had been got rid of. The influence of drink is 
 greatly increased if there be strong inheritance, so 
 that certain persons, who might have become insane 
 from some other cause, become insane in consequence 
 of drink, as it were, by accident. 
 
 Again, the effect of drink in producing nervous 
 disturbance must be considered in connection with in- 
 juries to the head. I have known several cases ad- 
 mitted into asylums with drink given as the cause of 
 insanity, whereas the true cause was injury to the 
 head, which rendered the nervous system so unstable 
 that a slight amount of drink "flew to the head," as 
 the friends of the patient graphically expressed it, and 
 seemed to stop there, for the balance having been lost 
 it required some weeks to set it right. 
 
 One special relationship of drink to nervous disease 
 is the direct transmission of drinking tendencies from 
 father to child. I have known a drunken father be- 
 get a child who became a drunkard, and also children 
 who have been idiotic or who have become insane. 
 
 Dipsomania is a symptom which I shall discuss 
 more fully later on. With this subject of intem- 
 perance in drink I must insist that it often requires 
 very careful discrimination of cases to be perfectly 
 
58 Insanity and Allied Neuroses. [Chap. hi. 
 
 sure tliat drink is the cause of the insanity, and 
 not one of the earliest symptoms. For, in my ex- 
 perience, one of the most common tendencies of early 
 lunacy is to seek for sleep, relief from pain, excite- 
 ment, or alleviation of trouble in drink. In such 
 cases the nervous disturbance was already fairly 
 started before the drink was taken to excess ; here, 
 then, drink can at most be looked upon as an excit- 
 ing, not predisposing, cause. 
 
 Intemperance in other forms of stimulation or 
 narcotism must be noted. Thus morphia, chloral 
 hydrate, sal -volatile, or tobacco, may act almost 
 exactly in the same way as stimulants. Before, 
 however, leaving this subject, I would say that if 
 there be a marked increase of insanity among the 
 educated classes, I have no evidence that there is any 
 direct connection between the increase of insanity and 
 any increased consumption of intoxicating drinks. 
 Amona: the lower orders it has been shown that when 
 wasfes are hio-h and work abundant sfreat excesses in 
 drink are common, and, at the same time, insanity 
 abounds ; but that with strikes and depression of trade 
 follow teetotal movements and decrease of admission 
 to asylums. 
 
 Teetotalism is no preventive to insanity, for we are 
 constantly in the habit now-a-days of seeing patients 
 who have been teetotallers for years, or even for their 
 whole lives, and yet have not staved off attacks of in- 
 sanity. Among total abstainers we have, of course, to 
 recoo-nise the fact that a certain number abstain as the 
 earliest symptom of their insanity, that is, of their per- 
 version. They are suffering from mental depression, and 
 feel contrite and desirous to make amends for the past ; 
 but, as the Scotch proverb has it, " when the devil was 
 ill, the devil a saint would be," so the drinker has be- 
 come teetotal as a symptom of his melancholy; and 
 the reaction may be as marked as the original fit of 
 
Chap. III.] Sexual Excess. 59 
 
 abstinence, the unfortunate drinker again returning 
 with fresh vigour to his cups, when the wave of 
 depression has passed. 
 
 In some cases, after the depression of the absti- 
 nence an ordinary attack of insanity may follow, or 
 the patient may become changed in mental character, 
 and remain perverted as long as he lives. 
 
 Sexital excess. — This is a somewhat delicate 
 and difficult point to discuss, not from any feelings of 
 modesty (for to the physiologist all things are pure), 
 but because the practical knowledge of the physician 
 is limited as to the intimate relationship of the sexes, 
 and his evidence is consequently likely to be im- 
 perfect. It is quite certain that the modern way of 
 associating the sexes as established by society is alto- 
 gether unnatural and arbitrary. The sexual instincts, 
 which were originally intended, and still exist in the 
 animals most nearly allied to man, purely for the con- 
 tinuation of the species, have been in the human 
 animal cultivated for ages as a special source of plea- 
 sure, out of relationship, I had almost said in direct 
 opposition, to the function of reproduction. Sexual 
 indulgence is, therefore, gratified under every kind of 
 stimulant, and without any definite periods of rest. 
 This most costly of functions is performed in the most 
 reckless manner by immature individuals, v/ho are 
 wasting not only their physical income in riotous 
 living, but are drawing by every means in their power 
 upon their physical capital. Sexual excess is a purely 
 relative term. What would be excess in one indi- 
 vidual would have no disastrous effect upon another, 
 and it will be ray duty to point out what I consider to 
 be the symptoms of nervous disorder produced di- 
 rectly by sexual excess. 
 
 In some cases bursts of excess, like outbreaks of 
 drinking, produce sudden disturbances, and I have seen 
 several cases of young newly-married people who 
 
6o Insanity and Allied Neuroses. [Ciiap. in. 
 
 were rendered emotional!)' insane in consequence of a 
 few days' sexual orgie. It is common with English 
 authorities to look to sexual excess as the chief cause 
 of general paralysis of the insane, and I must own 
 that I have noticed that the wives of certain general 
 paralytics are representatives of what I may call the 
 gross animal type of woman. This, however, is not 
 evidence that they or their husbands have indulged 
 unduly in sexual intercourse, for the voluptuous in 
 appearance are not always the amorous, and I believe 
 Ovid would have associated excess rather with thin 
 and slender women. In several cases I have received 
 histories of epilepsy occurring for the first time about 
 the period of sexual congress, and in one case there 
 seemed to be distinct relationship established between 
 imperfect sexual congress and epilepsy, followed by 
 insanity. 
 
 Venereal tlisease (more especially syphilis). — 
 Occasionally young patients are admitted suffering from 
 considerable mental depression with general hypochon- 
 driacal symptoms, associated with an attack of gonor- 
 rhoea. Such patients have been preparing gradually 
 an attack of insanity, which has been simply precipi- 
 tated by the moral and physical distress induced by 
 the gonorrhcea. 
 
 The many ways in which syphilis acts as a cause 
 of insanity will require a rather lengthy description, and, 
 like many of the preceding causes of insanity, may have 
 more than one aspect of connection with unsoundness 
 of mind. Many insane persons contract syphilis after 
 they have become insane, and the attack of insanity 
 may have nothing whatever to do with the syphilitic 
 disorder. On the other hand, cases are seen to occur 
 in which syphilis, contracted years and years before, 
 colours the hypochondriacal melancholy, and gives the 
 malady the form that, by some, is named syphilo- 
 phobia. I remember some years ago a Persian Avho 
 
Chap. III.] Syphilis. 6i 
 
 was in Bethlem suffering from a form of simple melan- 
 cholia, which for weeks seemed to be without any 
 definite delusion ; the patient was suffering from 
 simple melancholy, as evidenced by his whole aspect, 
 and by the slowness of his mental action. He .said he 
 could give no account of the origin of his misery ; but 
 after careful watching it was noticed that he Avas 
 constantly washing his underclothing, and on one 
 occasion became violent because another patient had 
 taken some bread which he had touched. It soon be- 
 came evident that he was suffering from syphilophobia, 
 and feared that anything which touched his body 
 might convey the disease to others. This is just 
 another example of the roundabout way which the 
 insane will take to explain the misery from which 
 they suffer. 
 
 Besides the mental influence of an attack of 
 syphilis, we may have patients suffering from epilepsy 
 produced by some syphilitic tumours of the brain or 
 its membranes, and the insanity may be in every 
 particular like that occurring with ordinary epilepsy. 
 In my experience it is more common to get progressive 
 weak-mindedness as the result of epileptic fits due to 
 syphilis than it is to meet with attacks of mania 
 directly associated with the fit. Thus, epilepsy pro- 
 duced by syphilitic tumours within the skull may 
 tend to weak-mindedness, and allied to this condition 
 must be considered some cases in which multiple 
 syphilitic tumours have affected special parts of the 
 brain, so that symptoms which were indistinguishable 
 from those of general paralysis of the insane have 
 been developed, and the diagnosis has only been 
 cleared up at the j'^ost-mortem examination. Besides 
 the symptoms associated with epilepsy, we may have 
 various kinds of insanity, such as mania, melancholia, 
 or dementia, connected either with syphilitic tumours 
 in the skull, or with syphilitic disease of the arteries. 
 
62 Insanity and Allied Neuroses. [Chap. in. 
 
 Cases will be described fully in which various per- 
 versions of intellect have been directly traceable to 
 coarse syphilitic lesions, cases, some of which, at least, 
 have been cured by having been placed under proper 
 treatment. 
 
 Two special varieties of cases are noteworthy. In 
 the first of these there has been some severe local 
 disease setting up sensory perversion ; thus, a patient 
 with double optic neuritis due to syphilis had impaired 
 vision, and as a result became suspicious and dan- 
 gerous, thinking people, whom he saw but vaguely, 
 were going to injure him in one way or another. In 
 the second, tumours of the brain due to syphilis may 
 produce epilepsy, which very often gives rise to 
 some symptoms of local paralysis, such as strabismus 
 and ptosis ; such symptoms, by the way, being rare in 
 ordinary cases of insanity and general paralysis, point 
 often directly to their specific origin. In some 
 syphilitic cases, without epilepsy, the mind may become 
 deranged ; in these we are obliged to suppose that the 
 symptoms are due to syphilitic arterial change, though 
 I must say at present I have no pathological grounds 
 for the belief. The relationship between the two 
 maladies is this : a man having had syphilis, followed 
 by constitutional symptoms, without either fits or 
 paralysis, becomes altered in character, and ultimately 
 weak in mind. The only explanation is, either that 
 the disease affects the general nutrition, or so injuri- 
 ously affects the arteries that the sujDply of nutrition 
 is limited. This possible limitation of nutrition leads 
 us to consider another way in which syphilis may 
 act. 
 
 I have seen several patients, who have been 
 admitted into asylums, suffering from insanity with 
 syphilis, which latter has been persistently and 
 energetically treated. These patients were extremely 
 weak and cachectic, but whether the cachexia was due 
 
Chap. III.] Self-Abuse. 63 
 
 to syphilis or sypliili :■ plus treatment I cannot say ; but 
 in any case I believe the symptoms were more due to 
 cachexia than to syphilis specifically. 
 
 To conclude, syphilis may produce moral- perver- 
 sion with hypochondriacal symptoms, or it may act 
 directly on the brain by means of tumour or impeded 
 circulation ; finally, it may act by reducing the whole 
 vitality of brain and body, or by interfering with 
 recovery. 
 
 §elf- abuse fsexual). — This, as a cause of 
 insanity, is certainly fully recognised by the pro- 
 fession and the world at large, but that it occurs in 
 both sexes is not so fully known. In handling this 
 subject I feel more than ordinary difficulty in ad- 
 justing the balance without u.ndue inclination, I 
 have already said that youth is a period of nervous 
 instability, and that it is a period when smaller shocks 
 will cause an upset, or derange the balance. The 
 whole of a new side to the life is being developed, and 
 the hitherto chiefly egoistic is now growing out of 
 itself, and becoming more altruistic. At this period 
 of instability, excess of any kind, especially excesses 
 that act, not only on the body, but on the moral 
 nature, are very serious in their consequences. 
 Masturbation is probably, in a large proportion of 
 cases, an educated vice. It is taught . by one to 
 another ; but I liave records of cases both of boys and 
 girls in which the individuals acknowledge that they 
 developed untaught their evil habit, and they have 
 given me graphic descriptions of the way in which 
 they first learnt secretly to gratify their lusts. 
 Masturbation does produce a certain amount of 
 insanity ; of this I have no doubt whatever ; but it 
 produces insanity chiefly, if not solely, in those who 
 are highly nervous. Such patients have highly 
 mobile nervous systems, and too frequently have 
 precocity both in mind and passion, so that they have 
 
64 Insanity and Allied Neuroses. [CLap. in. 
 
 been forced in education, and at the same time have 
 prematurely developed sexual desires. In such per- 
 sons, masturbation is indulged in to great excess 
 with very serious results. I have known precocious 
 sexual development associated with masturbation, 
 which was began without teaching before the indi- 
 vidual was five years of age. As a rule, the earlier 
 the masturbation commences, the stronger the ner- 
 vous inheritance, and the greater the tendency to 
 insanity as a result. 
 
 Although masturbation is a frequent cause of 
 insanity, it may also be looked upon as a symptom. 
 It is within my experience that many patients have 
 behaved with perfect self-control till becoming insane, 
 when they have given themselves up to the indul- 
 gence of this vice, so tliat it is not safe to say that 
 a person suffering from insanity, and at the same 
 time indulging in masturbation, has produced his 
 insanity by this vicious and destructive habit. Such 
 cases are seen among young women and boys, who 
 are suffering from acute mania. They are seen again 
 among general paralytics in the earlier stage of 
 the disease, and in many cases of puerperal insanity, 
 in which latter cases it is probably connected with 
 local irritation. Masturbation, as a symptom of 
 disease, also occurs at the climacteric, and seems to be 
 like a final blaze of passion before its complete ex- 
 tinction, or at least its altered condition. ,It may 
 again occur as a symptom in old age. I have even 
 known it habitually indulged in by a chronic lunatic 
 of over ninety years of age. Masturbation, then, may 
 occur as a cause of insanity in either sex, but it occurs 
 still more frequently as a symptom of mental dis- 
 order. 
 
 Over-exertion. — In considering this as a cause 
 of insanity, I follow the table A, although I have but 
 little experience of simple over-exertion producing 
 
Chap, iii.i Sunstroke. 65 
 
 insanity. That men of extreme energy and un- 
 bounded power of work do break down will be more 
 fully illustrated under the head of general paralysis. 
 Such men seem to burn the candle at both ends ; and 
 as an example, I Avill give the case of a lawyer, who, 
 having made a large business, married a young wife 
 who was fond of society, and who induced her 
 husband to go out a great deal, and encouraged him in 
 leading an active political and parochial life. The 
 work of this many-sided and continuous kind ended 
 in premature wear-out. I have seen a few cases of 
 young athletes who have become insane, but I have 
 never been able to satisfy myself that insanity in any 
 way depended upon the exercise. In one case a 
 famous runner, who afterwards became a clergyman, 
 passed through stages of excitement into Aveak- 
 mindedness, and as intellect disappeared it was 
 noticeable that the attitude and movements of the 
 runner persisted even longer than those of the 
 clergyman. In one other case, a man who had been 
 in the habit of using fifty-pound dumb-bells became 
 insane; but I should hardly like to say that the 
 excessive exertion had anything to do with it. 
 Continuous exertion, however, under bad hygienic 
 surroundings, is a cause of nervous exhaustion, and 
 is likely enough to disturb an unstable nervous 
 system. But we must always be prepared to find 
 that the over-exertion taken by a person of unsound 
 mind was rather the result of his insanity than a 
 cause of it. Many patients, in the earlier period of 
 general paralysis of the insane, will walk long- 
 distances, ftud accomplish what appear to be mar- 
 vellous feats, as parts of the disease ; but the friends 
 would be much more likely to attribute the symptoms to 
 the exercise rather than the exercise to the disease. 
 
 Ss,iai§tr©Iie. — Although sunstroke produces a 
 certain amount of insanity yearly, the evidence as to 
 F — 14 
 
66 Insanity and Allied A^euroses. [Chap iii. 
 
 its causing insanity, in England at all events, fre- 
 quently is small. Just as during the summer we 
 expect to hear of rabies and hydrophobia, so with a 
 temperature above the average we are sure to hear 
 of sunstroke. I divide the cases into those in which 
 the sun has had, first, a direct, and second, an indi- 
 rect action on the patient, sunstroke being really the 
 cause of the first cases, but exhaustion associated with 
 either want of food or excess of stimulants, together 
 producing the disorder in the latter. Frequently 
 cases of general paralysis are supposed to have been 
 caused by sunstroke, but in these cases the fit of 
 unconsciousness has been mistaken for sunstroke. 
 
 Accident, or iiijtu^^ — I shall consider trau- 
 matic insanity more in detail later on, but here I 
 only say that insanity may be j^roduced in some cases 
 by injuries to the head. Epilepsy, undoubtedly, with 
 its associated mental disorders, may be produced by 
 head injuries. A certain number of cases of general 
 paralysis of the insane have also been traced to injuries 
 of one part or another of the nervous system. Thus, 
 injuries to the brain, from concussions and similar inju- 
 ries to the spinal cord, have, in my experience, given 
 rise to the disease. As already noticed, when speaking 
 of the effects of drink, some persons who have been 
 injured in the head are more unstable nervously, 
 and are more liable to become affected by other ex- 
 citing causes of insanity than they were before the 
 injury. I believe, too, that injuries to the brain of a 
 parent may produce nervous instability in the off- 
 spring. That, in fact, just as Brown Sequard's rab- 
 bits exhibited epilepsy as a direct inheritance from 
 parents in whom epilepsy had been produced arti- 
 ficially, so human beings may become insane as a 
 result of injury to the heads of their parents. Injury 
 to the head may act indirectly by causing some bone 
 depression or disease, so tl^at inflammation of the^ 
 
Chap. I IT.] Pregnancy. 67 
 
 membranes may be a cause of the disorder. In at 
 least one case I have seen comparatively slight injury 
 to the head produce insanity in a lad, who was, 
 however, strongly predisposed to insanity by direct 
 inheritance. 
 
 To sum up, injury may produce insanity, 
 whether it affects the brain or spinal cord. It may 
 produce symptoms immediately as the result of the 
 injury, or the symptoms may develop secondarily to 
 some altered condition of nutrition. It is a ques- 
 tion whether effusions of blood within the skull may 
 give rise to nutritional changes at the cortex, which 
 may end in insanity. I have been unable to decide 
 from any cases I have seen, but certainly in one case 
 of general paralj^sis, where early and severe head 
 injury was given as the cause of the disease, there 
 was present a large organised membrane, which might 
 have had its origin in the injury. 
 
 Preg^nancy. — Under this cause I shall, for con- 
 venience, put together pregnancy and all the condi- 
 tions associated with parturition, and the period 
 succeeding. 
 
 The subject of puerperal insanity has, from time 
 immemorial, been considered as a special one, the 
 only speciality really being causation. In puerperal 
 insanity, the mental disorder has nothing special 
 or peculiar about it. The term puerperal " mania," 
 is misleading, for we may have mania, melancholia, 
 or dementia, directly associated with pregnancy and 
 childbirth. The action of pregnancy in the produc- 
 tion of nervous disturbance is simple and straight- 
 forward enough. Just as at puberty there is a 
 perversion of function associated with the early de- 
 velopment of sexual instinct, so with the perfection 
 of the function there may be a very serious alter- 
 ation in the various parts of the body. We are all 
 sufficiently used to the cravings of the hysterical 
 
6S Insanity and Allied Neuroses. [Cbap. in. 
 
 girl and of the pregnant woman, and though I would 
 not for a moment consider all fanciful desires of this 
 nature as being necessarily associated with insanity, 
 yet I am sure that in persons of nervous stock 
 the tendency to peculiar longings is more marked 
 than in those of greater stability. 
 
 Pregnancy seems to cause insanity in two distinctly 
 different ways ; or perhaps it would be better to say 
 that at two distinct periods of pregnancy insanity is 
 likely to appear. During the earlier months, at the 
 time when physical disturbance is most common, and 
 when the woman is suffering from sickness, neuralgia, 
 malaise, and restlessness generally, she may pass into 
 a condition of insanity which may disaj)pear about 
 the end of the fourth month. The pregnancy here has 
 acted as an irritant, if I may so say, causing irritation 
 similar in many respects to that produced by ovarian 
 tumours or uterine affections, first inducing ordinary 
 bodily symptoms, and later developing insanity in 
 persons predisposed to it. In the second place, we find 
 insanity developing during the later months of preg- 
 nancy ; and though the worry, physical and mental, 
 of the pregnant condition, has been the chief factor 
 in developing the disorder, the termination of the 
 pregnancy does not bring mental relief, and the 
 patient passes from a state of insanity of pregnancy 
 to one of puerperal mania. In most cases of insanity 
 connected with pregnancy, or the puerperal state, 
 there are other contributing causes. Inheritance 
 plays a very important part, and, in my experience 
 of many hundreds of cases, I should say that inheri- 
 tance is the chief factor, and the pregnant condition a 
 secondary one. 
 
 Besides the physical disturbance produced by 
 pregnancy, I shall have to consider the fact that, 
 under certain circumstances, the characters of the 
 various pregnancies are different, Thus, I have known 
 
Chap. III.] Pregnancy. 69 
 
 insiiiiifcy to occur only Avith male pregnancies, and 
 I believe other cases liave been described in which 
 they have taken place only with female children. 
 Pregnancy, again, is likely to act as a cause of in- 
 sanity in women who have had previous attacks 
 which may have originated from other causes ; and 
 what is most common in my experience is, for a 
 woman who has had several attacks of puerperal 
 insanity, to have later an attack of insanity with 
 pregnancy, the nervous system becoming more and 
 more unstable, and a very slight cause disturb- 
 ing the balance. Many women go through other 
 causes of depression without suffering nervously, and 
 yet become insane with each pregnancy or each 
 delivery. 
 
 Insanity may follow parturition, there having 
 been no marked insanity before ; it may be an exag- 
 geration of the emotional state produced by the pains 
 of labour. Just as we said insanity might be started 
 by a fit of delirium tremens, so an attack of mania 
 may be started by labour pains. Next, ephemeral 
 attacks of insanity, may follow the onset of milk, 
 Alarming symptoms, such as fever, high j)ulse, sleep- 
 lessness, and anxiety may occur a few days after 
 delivery, and may pass off' after the administration of 
 a purge. At this period we may have an attack of 
 insanity which may rapidly pass off also, and in my 
 opinion some cases of infanticide are committed 
 during these ephemeral attacks of mania. Puerperal 
 convulsions may also be followed by insanity, but it 
 is not specially common to find the insanity following 
 any unnatural delivery. A certain number of cases 
 follow delivery under chloroform, and we, of course, 
 meet with cases after the application of forceps ; but 
 by far the larger number of cases that have fallen 
 under my observation have succeeded labours which 
 were natural in every particular. 
 
7© Insanity and Allied N'euroses. [Chap. iii. 
 
 With the clanger of parturition we have to con- 
 sider blood-poisoning. I have seen several cases of 
 puerperal insanity in which ^;osi mortein there were 
 found evidences of distinct septic poisoning, but 
 that this was the cause of the insanity I am not 
 prepared to say. It is a generally accepted belief 
 that the insanity following delivery within a fort- 
 night is likely to assume a maniacal form ; but if 
 the insanity come on at a later period, the symptoms 
 will probably be melancholic. At almost any period 
 after delivery symptoms of insanity may arise ; and 
 the effect of lactation is difficult . to measure, for 
 though, some women may give nourishment to their 
 children for years without suffering, others will 
 suffer considerably from the drain of a few weeks 
 or months. It is thus evident that persons of the 
 nervous type, if reduced by any general or local 
 cause, are likely to have an attack of insanity, and 
 in such cases it is rare to find one cause alone pro- 
 ducing the effect. A woman having had several 
 children in rapid succession, and having suckled the 
 last with the idea that by doing this she would 
 avoid the risk of pregnancy, discovers that she is 
 advanced in pregnancy and gives up suckling ; 
 she gets through her confinement fairly well, but 
 again suckles her child, and thus reduces herself to 
 a very weak condition of physical health. She be- 
 comes sleepless and nervous, fancying that she is 
 going to be deserted, or that something is going to 
 happen to her children and herself, and finally makes 
 an attempt upon her own life, whereupon she is 
 declared to be insane, and is placed under proper 
 control. The weakness produced by prolonged 
 lactation and frequent pregnancy has caused the 
 disorder. 
 
 We have thus seen that the action of pregnancy, 
 parturition, and lactation may be simple or compound. 
 
Chap. III.] Uterine Disorders. 7 1 
 
 They may act immediately, or the result may be post- 
 poned for some time. Several of the more common 
 symptoms of the insanity of this period are gener- 
 all}'- placed among the causes, such as sleeplessness, 
 jealousy, dislike of husband, or family jars. 
 
 Uterine £iaid ovarian disorders. — I fear 
 that in asylums comparatively little is done in the 
 way of careful study of uterine conditions. For my 
 own part, I have been, and am still, afraid that by 
 interfering with the uterus by careful and repeated 
 examination, the ideas of the patient would be con- 
 centrated on herself, and would develop hypochon- 
 driasis, which is already too common. Flexed or 
 misplaced uteri, with simple ulceration of the os or 
 cervix, may produce a long string of symptoms ; but, 
 on the other hand, the concentration of thoughts on 
 the reproductive organs is, in my opinion, fraught 
 with even greater danger. I have seen a few cases in 
 which some marked mal-position has set up unmis- 
 takable symptoms, which have been relieved by its 
 removal. In one case, a patient suffering from 
 melancholia recovered on the replacement of a pro- 
 lapsed uterus ; and that the uterus has a direct 
 influence upon mental action may be seen in other 
 ways. I have seen a patient suddenly recover after 
 a retro-uterine hsematocele had developed ; in this 
 case, the cure rather followed the physical suffer- 
 ing than the uterine disease. In a few cases, cancer 
 of the uterus has been at least associated with 
 insanity, but the part played by the cancer is doubt- 
 ful. It may, like any other uterine disease, cause 
 worry, anxiety, sleeplessness, pain, and nervous 
 exhaustion; or it may give colour to the insanity 
 itself, so that the patient with cancer of the uterus 
 may declare that she has a menagerie in her inside. 
 In one recent case, cancer developed itself both in the 
 uterus and breast, the association being interesting as 
 
72 Insaaity and Allied Necroses. [Chap. iii. 
 
 occurriijg in the two distinct parts of tlie repro- 
 ductive system. 
 
 Next as to the effect of ovarian disease on insanity. 
 There is a class of hysterical patients whose symptoms 
 become sufficiently grave to require their removal to 
 an asylum, in whom one meets with ovarian tenderness, 
 swelling, and irregularity of menstruation, sometimes 
 with menorrliagia. And although the insane symp- 
 toms do not dejDend on ovaritis, the whole group 
 of symptoms is intimately connected. I have found 
 ovarian enlargement and tenderness associated with 
 melancholia with stupor, and a profuse flow of saliva. 
 In some of the cases, treatment directed to the 
 ovaries produced beneficial results, I have seen 
 about six cases of ovarian dropsy associated with 
 insanity, and I shall later give particulars of the 
 symptoms seen with the association of these two 
 diseases. They seemed to be of two descriptions ; 
 with the one were associated the earlier symptoms 
 of the ovarian disease, i.e. irritability passing into 
 mania ; with the others were associated hypochon- 
 driasis and melancholia. Unfortunately none of the 
 cases were in such a condition as to justify surgical 
 interference : the only one which, having improved 
 considerably in general health, Avas temporarily trans- 
 ferred to general hospital for operation, died suddenly 
 from rupture of the cj^st. 
 
 To sum up, insanity may be started either by 
 serious uterine or ovarian disease, and the symptoms 
 may have some direct relationship to the seat of the 
 disorder. 
 
 Paitoerty. — We have I'eferred to this in connec- 
 tion with the causation of insanity among the predis- 
 posing causes. We also referred to it when con- 
 sidering sexual causes and self-abuse. The period of 
 puberty is one of special danger in families with 
 the neurotic taint. At this period, too, phthisis and 
 
Chap. III.] TuiL Climacteric Period. 73 
 
 allied disorders are most common, and tlie body, 
 being hardly as yet firmly set, cannot withstand any 
 extra shock. The forms of insanity occurring at this 
 period are chiefly characterised by their tendency 
 eith(T to get well rapidly or else to pass directly into 
 a condition of weak-mindedness. As we saw that in 
 childhood the necessary result of nervous disease was 
 idiocy or imbecility, so now" we see that a common 
 end of acute insanity at or about the period of 
 puberty is dementia or chronic weak-mindedness, 
 
 Climactei'iCo — At the other end of life, answer- 
 ing in many respects to the period of puberty, we 
 meet with a time in which the whole system is 
 unstable and ready to develop unhealthy tendencies. 
 At this period, the reproductive organs_, specially in 
 w^omen, may develop morbid growths, so that cancer of 
 the breast or uterus is most commonly first met with 
 about this time of life. Elsewhere I have said that a 
 climacteric period occurs in men as well, though not 
 so well marked as among women. At the climacteric 
 there is a well-recognised intellectual change common 
 among women, so that they may become more fully 
 intellectually developed than at any earlier period : 
 they pass into a state of mind and body which is best 
 described as one of greater freedom. Many great 
 writers among women have done their best work 
 after the menojDause : but this increased activity is 
 evidence of considerable change in the nervous and 
 bodily relations, and it is not surprising that, in some 
 cases, instead of intellectual development there 
 should be signs of intellectual decay. The chief 
 characteristic of insanity at this period is a hypo- 
 chondriacal habit of mind, so that patients of one 
 group consider that they have mis-spent their lives, 
 and that they are morally ruined ; while those of 
 the other group, developing the same sort of ideas, 
 consider they have either injured their bodies, or 
 
74 Insanitv AXD Allied Neuroses. [Chap. hi. 
 
 have in some way become changed or unnatural. 
 Other symptoms exhibiting sense perversion are not 
 uncommon, and may possibly be ex^Dlained upon the 
 theory that they are the ordinary symptoms of the 
 climacteric insanely interpreted. Thus, it is common 
 for women t of about forty-five years of age to com- 
 plain of feelings of heat and oppression on the crown 
 of the head, and of feelings of heat and cold all 
 over the body. It, however, requires the insane 
 person to explain these feelings by saying she has 
 something hot and alive in her head, or that chloro- 
 form, chloride of lime, or ammonia are thrown over 
 her. The climacteric is associated with changes in 
 the reproductive functions, and, as a consequence, 
 there are frequently hallucinations of smell. I am 
 impressed with the fact, that where we have ovarian 
 troubles we may expect to find hallucinations of 
 smell and touch. 
 
 Fevers. — It is comparatively rare to receive 
 patients into Bethlem whose insanity depends di- 
 rectly upon fever, but there are two distinct con- 
 ditions under which mental disturbance is developed 
 from febrile diseases. 
 
 In the first the initial delirium of a fever, such as 
 scarlet fever, may start the morbid process, and the 
 patient pass from delirium into mania. During the 
 past eleven years there have been admitted some half- 
 a-dozen cases of fever, mistaken for acute mania. I 
 have thus had cases of small-pox and scarlet fever ; 
 and although I should have been prepared to find that 
 typhoid fever might also have given rise to the same 
 kind of error, yet so far I have not met with it. 
 
 Next, after fevers, patients may pass into various 
 states of mental unsoundness. This, however, does 
 not depend upon any special hyper-pyrexia, nor, as 
 far as I know, on any special complication in the fever 
 itself. It is due more to the predisposition to nervous 
 
Chap. III.] Fevers. 75 
 
 diseases generally, and to some accidental predisposi- 
 tion that may have been acquired or inherited which 
 conduced to the fever. Sir William Jenner, years 
 ago, at the Clinical Society, pointed out the existence 
 of special family inheritance of predisposition to acute 
 febrile diseases ; and any one who has had experience 
 of ordinary general practice, well knows how certain 
 families are attacked in all epidemics which visit the 
 districts in which they reside, while others are free. 
 
 One other important consideration is, whether 
 such persons belong to what may fairly be called a 
 nervous stock. For although I have but limited ex- 
 perience of such families, many of those who have 
 come under my notice have had insane and otherwise 
 neurotic relatives. Observations have been made at 
 the Fever Hospital in reference to two important 
 questions j first, whether patients suffering from 
 fevers, who have mis-shapen heads, are more subject 
 to delirium than others ; and again, whether patients 
 with nervous histories are more liable to delirious ex- 
 citement. But I believe that as yet no decision has 
 been arrived at on these points. It is generally ad- 
 mitted now that in fevers there must necessarily be 
 some primary or secondary nervous disturbance. 
 
 In some cases, as a result of fever there is tem- 
 porary or permanent weak-mindedness, chiefly evi- 
 denced by irritability and selfishness. This may pass 
 into a condition of dementia which may be but slowly 
 recovered from. We meet with such mental perver- 
 sions following the continued fevers, also with small- 
 pox, scarlet fever, cholera, and rheumatic fever. I 
 have seen various forms of mental weakness suc- 
 ceeding rheumatic fever, both with and without hyjDer- 
 pyrexia. Having no personal experience of tropical 
 fevers, malarial or other, I think it best to leave on 
 one side the consideration of reported cases of nervous 
 disturbance following them. 
 
76 Insanity AND Allied Neuroses. [Chap. hi. 
 
 To conclude this part of causation, I would say 
 that insanity may be started by the initial processes 
 of the fever, or may be sequelae of the febrile process. 
 These conditions may affect those predisposed by 
 inheritance, or others. 
 
 Fffivatioii and starvation.— Privation, as a 
 cause of general debility, may predispose to insanity, 
 and react very sei'iously on those who are beginning 
 to show signs of mental disorder. Starvation is more 
 commonly a symptom than a cause, and I shall have 
 to point out the various reasons which may induce 
 patients to refuse their food. The discussion of this 
 subject will be found under Melancholia. 
 
 Old age. — This acts in several ways, and as a 
 patient recently said to me, he felt that, like Swift, 
 he was "dying from the top." Many cases do die by 
 their nervous systems degenerating along the line of 
 highest development; and as a seed contains poten- 
 tially a tree, so a man may be born with tlie tendency 
 to break down at a certain period in a definite way. I 
 have seen such cases of families in which there ap- 
 peared to be a dangerous and almost fatal period of life. 
 I have seen patients suffering from emaciation and 
 active melancholia at sixty-five years old, and, on 
 inquiring, I have heard that a parent and a grandparent 
 had broken down in a similar way at a like age. I 
 have seen a man attacked with dementia at between 
 sixty and seventy years of age, his mother having 
 suffered similarly. There is nothmg very suriDrising 
 in this. One sees cases in which apoplexy, kidney 
 disease, heart disease, lung disease, or gouty troubles 
 develop in members of the same family and at about 
 the same period. Later I shall refer to the connection 
 between the diseases of age and insanity. 
 
 Naturally man passes from middle and mature 
 life slowly into "the lean and slippered pantaloon." 
 He should, according to the dramatist, pass from 
 
Chap. III.] Old Age. 77 
 
 sanity into a condition of folly, but fortunately only 
 a small proportion follow this precept to tlie letter. 
 Age, with accompanying brain -wasting, may be 
 chiefly marked by loss of self-control, as evidenced 
 by loquacity or irritability ; or by change of habits, 
 by niggardliness with dread of ruin ; or there may 
 be outbursts of passion and lust. It does not, 
 however, follow that wasting of brain should be 
 directly and immediately associated with wasting of 
 all intellectual capacity ; for we meet many an old 
 man whose memories of the past are rich and varied, 
 who may yet be the subject of progressive senile 
 weak-mindedness, as shown by some of the symptoms 
 above mentioned. In age, the check, self-control, is 
 removed in one man, and the result may be maniacal 
 excitement of a peculiar kind, rapidly tending to 
 exhaustion of body and destruction of mind. In 
 others the brain-changes are followed by melancholia, 
 and the man's mind, like his body, seems to go on 
 crutches. He thinks and moves painfully, the result 
 of the bad nutrition of his brain being, that he 
 feels the very working of his mind just as he feels 
 the digestion of his food. The perception of these 
 unusual sensations gives him pain and causes concen- 
 tration of his ideas upon himself, this being the 
 chief factor of the development of melancholy. 
 
 A third condition is that of simple childishness, in 
 which some peculiarity or habit of the man's life 
 becomes more accentuated, so that the antiquarian 
 and collector becomes a very magpie in collecting, 
 or the domestic man becomes uxorious, only happy 
 when surrounded and attended to by all his suffering 
 family. 
 
 Age, then, in some families shows itself in brain- 
 weakening in parent and child in direct line, or it 
 may, by simple degeneration, produce various forms 
 of mental weakness due to brain-ageing. 
 
78 Insanity and Allied Neuroses. [Chap. ni. 
 
 Other bodily diseases and disorders of function 
 will be considered later in their relationships to 
 mental symptoms. I have repeatedly expressed my 
 belief in the fact that every disease has a nervous or 
 mental aspect^ and that it is but a question of degree 
 whether a person is insane or not, whether, in fact, 
 the disturbance of the nervous system by bodily dis- 
 ease is so slight as to be merely represented by pain, 
 irritability, or general malaise, or whether it is more 
 pronounced, assuming some form of recognised in- 
 sanity. 
 
 Heredity. — In order to complete the table of 
 physical causes of insanity, I must again call at- 
 tention to hereditary infiuence, direct and indi- 
 rect, as causes of insanity ; the only point to be 
 added being that inheritance acts from a mental as 
 well as from a physical side. The fact that a father 
 or mother has died of insanity is, in many cases, a 
 perpetual worry, which is in itself a cause predisposing 
 to the disease. 
 
 Cong-enital defects of all kinds, but chiefly 
 those of the senses, have a very distinct influence on 
 the mental life of the individual. A person blind, 
 deaf, and dumb is almost necessarily an idiot, though 
 it is possible that with an enormous amount of 
 trouble and special training, such an individual can be 
 taught a considerable number of things through the 
 common sensibility of the skin ; but, as a rule, a being 
 whose intelligence is starved by the obliteration or 
 want of development of the senses will be but feeble- 
 minded. Tlie superintendents of deaf and dumb 
 asylums confirm one's impression, that children who 
 for years had been shut out to a very great extent 
 from communion with the outer world are much below 
 the average in intellect ; and in fact I know that one of 
 the greatest of difficulties which these superintendents 
 have to contend against is that a- large number who 
 
Chap, mo Bodily Deformities. 79 
 
 are sent to theui are practically without any real edu- 
 cation. Tliey are perhaps eleven or twelve years of 
 age, and have for that period been neglected, so that 
 the animal side of their nature has developed without 
 any controlling influence in proportion. I have had in 
 Bethlem cases of insanity in the deaf and dumb, and 
 have found such cases extremely difficult to influence. 
 I would say that congenital sense defects tend to in- 
 sanity and weak-mindedness, directly through a loss of 
 knowledge, and indirectly as making a patient more 
 keenly sensitive in other particulars. 
 
 This leads me to note, in passing, the influence 
 of bodily deformities in the production of insanity. 
 Anything which causes the thoughts and feelings 
 of a patient to be concentrated upon himself is un- 
 healthy, and any deformity has such a tendency. I 
 can readily recall several such cases from among 
 patients in Bethlem. One woman, who for years had 
 been called the pig-faced woman, and who wore very 
 thick veils to hide her facial peculiarities, at last be- 
 came violent, and attacked people without reason. 
 Another patient with peculiar formation of face (who 
 by the way attributes her peculiarity to a fright her 
 mother received from a bull), fancied people were 
 shunning her ; and it is comparatively common to 
 meet with cases of sensitive young men who, because 
 they have, or think they have, some facial peculiarity, 
 withdraw themselves from the society of their fellows 
 and endeavour to make up for the social life by a 
 studious subjective one. Such cases not unfrequently 
 develop some form of insanity with ideas of persecu- 
 tion or annoyance, and the patients so suffering fancy 
 they are specially selected by society as butts. 
 
 No table would be complete without a provision 
 for unknown and unascertained causes ; for the 
 outer world not being very critical as to symptoms, 
 often mistakes the symptoms for the cause, so that 
 
8o , Insanity and Allied Neuroses. [Chap. iv. 
 
 we must be prepared for fresh exciting causes of in- 
 sanity with every fresh scientific improvement, social 
 disturbance, or political excitement. The telephone, 
 the Salvation Army, or a change of government, 
 may each act as the last grain of sand which turns 
 the balance, and the only moral I would draw from 
 this is, that we must avoid being ourselves, like the 
 lunatiC; too ready to explain. 
 
 CHAPTER lY. 
 
 HYSTEEIA AND ITS RELATIONSHIPS. 
 
 Hysteria in insane families — Hysteria as an early symptom of 
 insanity — Hysteria alternating with insanity — Grave 
 hysteria seen in asylums — Hystero- epilepsy — Neurastlienia. — 
 Massage — Hysterical mania — Aciite delirious mania — Typho- 
 mania. 
 
 As a branch of the nervous tree, hysteria must be 
 here considered in some of its various relationships 
 with other neuroses, but space will fail me to fully 
 describe hysteria as it occurs ordinarily and in its 
 simplest form. T shall, in considering this subject, 
 refer to the graver forms of hysteria, to those forms 
 which are to be seen in general hospitals or in 
 asylums ; cases which have, from some cause or 
 another, been found to be intractable at home. The 
 common feeling is one of regret that such cases are 
 sent to asylums at all, and friends think that it is a 
 mistake for such simple cases of nervous disorder to be 
 sent to associate with the insane. Yet, as I shall 
 point out, some such cases will die unless sent away 
 from their old surroundings, and in my experience 
 asylum treatment has often cured when hospitals have 
 failed. Every shade of nervous disorder^ from the 
 
Chap. IV.] Hysteria as a Symptom of Insanity. 8i 
 
 simplest emotional storm of laugliter witli tears, up to 
 violent mania, may occur with what may be properly 
 called hysteria. I find it difficult to draw any line 
 between cases of simj^le mania, with mischievous ten- 
 dencies occurring in young nervous women, and cases 
 which are classed as hysterical mania. There are 
 many gradations between the simple and severe nerve- 
 storms. 
 
 Simple hysteria is comparatively rare among the 
 inmates of an asylum. It may seem somewhat para- 
 doxical to say that hysteria is a branch of the nervous 
 tree, and yet that in an asylum one rarely meets with 
 hysterical fits ; but frequently months pass over 
 without a single case of hysterical fits occurring 
 among the one hundred and fifty to two hundred 
 female patients in Bethlem. 
 
 The relationsliip of hysteria to insanity is manifold. 
 In the first place hy origin. The same parentage 
 will produce insanity in one member of a family and 
 hysteria in another, the hysterical person perhaps 
 spending a long life without ever having more than 
 severe attacks of hysteria, although exposed as nearly 
 as possible to the same surroundings and influences as 
 those which have produced insanity in a sister. 
 
 In the second place, hysteria may he the earlier 
 symptom of nervous disorder which leads on to in- 
 sanity, and I shall have to refer to cases in Bethlem 
 who have suffered in various ways with hysteria, which 
 has later developed into insanity. 
 
 In the third place, we may have ordinary cases 
 of hysteria becoming exceptionally troublesome, and 
 although these are still looked upon as cases of hysteria, 
 yet they may require to be secluded. 
 
 With this introduction, I pass to the consideration 
 of hysteria as it presents itself to those connected 
 with asylums. 
 
 I think it unnecessary to give a definition of what 
 G— 14 
 
82 Insanity and Allied Neuroses. [Chap, iv. 
 
 I mean by hysteria, as the examples given will serve 
 best to pour tray the disorder, and I shall feel less 
 hampered by having no definition to confine me. 
 
 Alternation of hysteria and insanity. — 
 
 One woman admitted twice into Bethlem, on each 
 occasion suffering from the most violent acute mania, 
 had a history of hysterical paraplegia, which had 
 lasted for a considerable time before admission ; 
 the para^Dlegia passed off, to be succeeded by the 
 acute mania. In another case there was an alterna- 
 tion in the symptoms, so that the girl, . when maniacal, 
 was able to do mischief, but when she became quiet, 
 hysterical paraplegia rendered her passive. Such 
 cases as these are not very uncommon, and the history 
 of their coming into an asylum is, that to the physical 
 weakness which sent them to the hospital, some 
 moral perversions are added. Thus, a young married 
 woman, a patient in a general hospital, was treated 
 for some vague and ill-defined form of paraplegia. It 
 was supposed to be hysterical by the physician under 
 whose care she was placed. After a few weeks' resi- 
 dence she became discontented and troublesome, 
 utterly regardless of truth, and with a loss of sense of 
 what was right in other particulars ; so that what with 
 disturbing patients at night by her screaming, and 
 stealing small articles, and causing additional confu- 
 sion by her untruthfulness, she was considered unfit 
 for the hospital, and was transferred to the asylum, 
 where, after months of treatment, by means of gal- 
 vanism and other stimulants, she was discharged re- 
 covered. 
 
 Other cases, in which hysteria is well marked, 
 lose self-control and give vent to passion, or become 
 mischievous and mendacious ; and with a still further 
 development of nervous weakness and instability, 
 begin to imagine that people are bent upon in- 
 juring their character and reputation ; or they may 
 
Chap. IV.] Loss OF SENSIBILITY. 83 
 
 develop emotionally religious ideas, and get delu- 
 sions as to the intentions of the curate or some 
 member of their church. Such morbid develop- 
 ments are common enough, and show that in these, as 
 in most other cases of mental disorders, insanity is a 
 consistent growth. The symptoms develop them- 
 selves out of an unrestrained or ill-regulated sexual 
 passion^ which disturbs first the emotional side of 
 the character, and affects later the associated social 
 relations, thereby destroying first the ideas of pro- 
 priety as regards the sexes, and next the require- 
 ments of organised society regarding truth and honesty. 
 Memory, sense-perception, and intellect may persist 
 normally, though the patient rarely admits she has 
 
 had knowledo-e of what she has said or done during 
 
 . ... ^ 
 
 the period of excitement ; and in this I think may be 
 
 found a useful means of distinguishing these cases 
 
 from ordinary cases of mania, for the maniacal patient 
 
 ordinarily has a memory of what has gone on around 
 
 him, and on recovery is willing, even anxious, to 
 
 recall or refer to what has taken place, while the 
 
 hysterical woman will deny having any recollection of 
 
 the past. 
 
 The senses may be perverted, and if they are, it is 
 
 generally in the way that is noteworthy among the 
 
 ordinarily hysterical. Patients may have loss of 
 
 common sensibility, and in this case the one half of 
 
 the body may become anaesthetic, and I have known 
 
 girls burn themselves unconsciously when in such a 
 
 condition. In the case of one girl in Bethlem, who 
 
 might be fairly placed in this group, a finger was 
 
 eaten by the rats without her withdrawing it from the 
 
 hole in which she had placed it, and at the time 
 
 she told me that she held it there for a man to kiss, 
 
 and that she was not going to withdraw it while he 
 
 was kissing it. In another case a girl introduced 
 
 broken pieces of needles and pins between her eyelids, 
 
84 Insanity and Allied Neuroses. [Chap. iv. 
 
 and when I was called to see her she at once accused 
 me of having done it myself. There is, more rarely, 
 loss of colour-sense, and in some cases there is altera- 
 tion in the auditory sense ; and from the filthy habits, 
 such as the eating of faeces, developed by some cases, 1 
 believe the sense of taste and smell must be impaired. 
 In one young girl, who had several attacks of insanity, 
 associated with precocious sexual development, a habit 
 of reading everything upside down was developed, and 
 if a book Avere placed in the ordinary position she 
 would pass into a convulsive state, which she said she 
 could not help, but that the fit depended upon the 
 book being placed, as she said, wrong. This patient 
 was, however, convinced of her delusion, if I may use 
 the term, by the stratagem of asking her to write her 
 naine in a birthday-book, which she did correctly, and 
 not inverted. All the manifold tales one hears of mi- 
 racles, all the tales of ghosts, many of the instances of 
 the thought-reader and spiritualist, are, in my opinion, 
 the result of cases of hysterical insanity. The old idea 
 that wherever any trouble was present there was sure 
 to be a woman, is confirmed, in my opinion, by the 
 fact that whenever strange manifestations take place 
 which are beyond the sphere of observation by our 
 senses, there will be found a girl with hysterical his- 
 tory, or otherwise distinctly neurotic. But to continue, 
 besides the comparatively harmless disturbances which 
 may be produced in a family by the presence of an hys- 
 terical member, the patient may develop, either from 
 religious motives or from some feeling of gastric 
 uneasiness, ideas that it is wrong to take food. One 
 girl will think she is commanded to take only bread 
 and water ; or another that bread is not intended, only 
 water ; another will think she is only to take food 
 under very special conditions, so, unless she has done 
 a certain act or has exercised a certain self-restraint, 
 she is not entitled to eat, some text of Scripture 
 
Chap. IV.] Treatment of Hysterical Patients. 85 
 
 influencing her conduct, and, from sheer inability to 
 keep her alive otherwise, it may be necessary to send 
 her to an asylum. As a rule such cases should be 
 tried in every way possible at home ; for although I 
 believe the discipline and treatment of an asylum are 
 extremely useful in such cases, yet the present feeling- 
 is that to have been in an asylum is a stain upon one's 
 character, and so for a young girl it is as well to do 
 one's best before trying this last resource. 
 
 Food, warmth, exercise, and absence of friends are 
 the first essentials, and next the ovarian or uterine 
 trouble must be attended to. And here I would say 
 that it is dangerous to have much done in the way of 
 physical examination. If it be found that there is 
 tenderness about the ovaries, a blister or leeches 
 may be applied, in the inguinal regions, and the 
 patient kept in bed for a short time, ■ Dry cupping- 
 may be of service sometimes. Bed, however, is 
 distinctly to bo avoided as soon as any acute trouble 
 has passed, for the characteristic of all hysterical 
 cases is the tendency to laziness, want of will, and 
 getting into bad habits. If it be necessary to feed 
 a patient, it is well that it should be done with as 
 little fuss and as much firmness as possible, the food 
 being administered either by nose, by stomach-pump, 
 or sometimes by rectum. In my experience I have 
 found it well to vary the modes of feeding, so that the 
 danger of getting into a habit is avoided. I have 
 known a girl who required feeding- in consequence of 
 her weak physical condition, who became stout, and 
 apparently in good physical health, yet, having been 
 fed three times daily with beef-tea, wine, and similar 
 foods, declined to assist herself in any way, and even 
 rudely said to the doctors, " I know you must feed me, 
 and I like giving you the bother." The proper treat- 
 ment of such a girl is to give a warning that now she 
 is strong she will not require feeding, and for the next 
 
86 Insanity and Allied Neuroses. [Chap. iv. 
 
 few clays she may take or leave her food as she likes, 
 and the chances are that after a severe hysterical storm 
 she will take her food, and the habit will have been 
 broken once for all. In some of these cases a liberal 
 addition of salt to the beef-tea will create a thirst, 
 which will cause the patient to take fluid food left in 
 her way, and thus again the habit may be broken. 
 
 Besides the refusal of food in these cases, neglect of 
 personal cleanliness is one of the most troublesome 
 symptoms. I remember the time when the distinction 
 between hysterical paralysis and ordinary paralysis 
 was considered to consist in the fact that the former did 
 not foul their beds or clothes, whereas the latter could 
 not help themselves j but now I look on any such 
 dogma as worthless. For one sees many hysterical 
 cases who are filthily dirty in their habits. So far, 
 then, I think I have established the fact that these are 
 cases which are distinctly hysterical, and yet which 
 require to be sent to an asylum ; in many such cases 
 hospital treatment has failed. I am, however, quite 
 unprepared to say what the direct brain causation may 
 be. It has to be looked upon as functional distur- 
 bance, for lack of better knowledge. 
 
 Constantly cases are seen in hospitals and in 
 private life in which grave hysterical symptoms have 
 been but the precursor of some general physical break- 
 down, ending in death. There are, on the other hand, 
 cases of comparatively coarse brain disease, in whicli 
 the only symptoms have been hysterical. I have seen 
 the fost-mortem examinations of several cases iii 
 which slight symptoms (all of which were referred to 
 hysteria) were the only clinical evidences of serious 
 disease in the anterior lobes of the brain. In one 
 there was adhesion between the two first frontal lobes, 
 and in the second there was a firm condition of the 
 whole of both frontal lobes, associated with a general 
 fibrous excess. It does not follow that because in 
 
Chap. IV.] HvSTERO-EpILEPSV. 87 
 
 these two cases the frontal lobes were alone affected 
 that hysteria is the natural outcome of disease of these 
 areas. Such disease may in some way upset the 
 balance or withdraw the control, and the result may- 
 be what we see, for hysteria, in many cases, may well 
 be looked upon as an unrestrained exercise of the lower 
 parts of the human organisation. Alterations in the 
 anterior lobes alone will not produce hysteria. I have 
 seen diseases in this region sometimes producing 
 absolutely no traceable clinical symptom, or setting 
 up epilepsy or some allied condition. 
 
 Hysteria usually occurs in women, but I have seen 
 grave hysteria in young men ; and though I have 
 never met with true hemi-ansesthesia and paraplegia 
 in hysterical young men, yet I have seen some cases 
 of globus hystericus, so that the man passed from the 
 condition of the hysterical girl into that of the hypo- 
 chondriacal man. 
 
 Hysteria may colour other mental affections ; that 
 is, an exaggeration of any one of the perversions seen 
 in hysteria may become a delusion. Thus, I am in the 
 habit of regarding many of the pains and feelings of 
 distress and anxiety, which are referred by the patients 
 to their throats, to an exaggeration of the ordinary 
 hysterical conditions, in the same way as I would 
 interpret the false statements made by those patients 
 that they had been raped, to an explanation of uneasy, 
 unsatisfied feelings originating from the reproductive 
 organs. 
 
 Hystero-epilepsy. — Besides the cases of simple, 
 but grave, hysteria which have already been con- 
 sidered, others are admitted into asylums, in which 
 the convulsive symptoms are those which call for most 
 attention ; cases, in. fact, of hystero-epilepsy. I have 
 had two such cases in Bethlem ; one in a man, who was 
 conscious throughout the whole epileptic seizure, the 
 other in a woman, who professed entire unconsciousness. 
 
88 Insanity and Allied Neuroses. [Chap. iv. 
 
 This latter was a single woman aged twenty-five, 
 a dressmaker, with no history of insanity. She had 
 suffered from hysteria, and had been for a time cata- 
 leptic, and was sent to a hospital for the treatment 
 of her nervous disorder. She was transferred to 
 Bethlem because she became destructive, was sleepless, 
 and, at times, dangerous ; she was always worse about 
 the time of her menstrual periods. After admission 
 she was quiet for nearly two months, then she had a 
 severe fit ; for a time she was cataleptic, then suddenly 
 '5prang on the attendant, knocked her down, and be- 
 laboured her severely. After this she became con- 
 vulsed, but there was an organisation in the convulsive 
 movements which was very striking, so that, at one 
 time, she would grasp at an object within her reach, 
 and at another time her convulsions would be in 
 harmony with a tune that happened to be played on 
 the piano at the time, her hands keeping time to the 
 music ; in her convulsions she bit anyone who came 
 near her, or pulled their hair. At the time of the 
 attack her pupils were contracted, and the conjunctiva 
 less sensitive than normal. She had a most marvel- 
 lous power of keeping her eyes open without winking, 
 so that with the ophthalmoscope I watched the 
 condition of her disc for over half an hour, during 
 which time she never winked. The day after the fit 
 she denied any recollection of what had happened, but 
 complained of exhaustion. When in a fit she was 
 placed either in a wet or dry pack, and later, with the 
 onset of each fit, she was put into seclusion. When 
 nearly well, domestic grief caused her to have a 
 relapse, from which she ultimately recovered, was dis- 
 charged well, and has for years maintained herself. 
 
 With both the hysterical and hystero- epileptic a 
 grave responsibility is incurred from their violence, 
 though this violence is more frequently that of the 
 tongue than of any other more dangerous member. Yet 
 
Chap. IV.] Insanity of Limbs. 89 
 
 friends will come in great alarm to know what is to 
 be done with a young woman who either impulsively 
 knocks her relatives about, or who threatens suicide. 
 
 A large proportion of these hysterical cases at the 
 period of the emotional storms will say they will go 
 and kill themselves, and occasionally they undoubtedly 
 do attempt suicide. It is rarely necessary to send a 
 girl to an asylum simply because she threatens to kill 
 herself \ I believe very few would do it under any cir- 
 cumstances, and such cases as these, by judicious 
 supervision, may be quite as well treated at home as 
 in an asylum. 
 
 In the first chapter I said that madness was not 
 confined to the intellect and understanding alone, but 
 that there might be insanity of a limb or of a stomach ; 
 that, in fact, there are cases in which disordered 
 nervous function is exhibited by some motor or 
 visceral disturbance. One hears periodically of cases 
 of insane arms, cases in which malleation, as it has 
 been called, is carried on, the patient moving his arm 
 up and down, as if using a hammer, hour after hour, 
 at the rate of forty or fifty strokes a minute, antl 
 continuing the exhausting process for hours. Some 
 such cases I have seen pass the borderland of hysteria, 
 and claimed as belonging to insanity. With the 
 insane stomach the same holds good. Patients may 
 emaciate, and be reduced most rapidly to mere skele- 
 tons through gastric disturbance associated with 
 hysteria. I have known cases of people who appeared 
 to vomit everything that was given them for weeks ; 
 the vomiting was hysterical, and the exhaustion pro- 
 duced thereby was sufficient to turn the scale, and 
 send the girl into an asylum. 
 
 With all the symptoms that have been described 
 associated with hysteria, hystero-epilepsy, and hys- 
 terical insanity, so called, there may be, and generally 
 is, perversion of the functions of the ovaries. There 
 
90 Insanity and Allied Neuroses. [Chap. iv. 
 
 may be amenorrhoea, dysmenorrhoea, or menorrhagia, 
 and with these physical disorders there may be 
 marked eroto-mania and tendency to masturbation. 
 
 Newrastlieiiia.— I cannot close this subject with- 
 out referiing to the Weir-Mitchell treatment of the 
 so-called neurasthenic cases which Dr. Playfair has 
 so fully introduced into England. Patients who 
 have slowly become chronic invalids have been by 
 this method brought back not only to life but to 
 active usefulness. The history and treatment of a 
 case is as follows. A woman, generally single, or in 
 some way not in a condition for performing her 
 reproductive function, having suffered from some real 
 or imagined trouble, or having passed through a phase 
 of hypochondriasis, chiefly affecting her uterus or 
 ovaries, and often being of a highly nervous stock, 
 becomes the interesting invalid. She is surrounded 
 by good and generally religious and sympathetic 
 friends. She is pamjDered in eveiy way. She may 
 have lost her voice, or the power of one limb. These 
 temporary paralyses often pass off suddenly with a 
 new doctor or a new drug ; but, as a rule, they are 
 replaced by some new neurosis. In the end the 
 patient becomes bed-ridden, often refuses her food, or 
 is capricious about it, taking strange things at odd 
 times, or pretending to starve. Masturbation is not 
 uncommon. The body wastes, and the face has the 
 thin anxious look, not unlike that represented by 
 Rosetti in many of his pictures of women. There is 
 a hungry look about them which is striking. With 
 the wasting, real loss of power follows. The patients 
 must not be accused of malingering when they say 
 they cannot walk or sit up. If not vigorously treated 
 they will die. In treating such a case the following 
 principles must be observed. Removal of the patient 
 absolutely from all friends, and the personal supervi- 
 sion, in all but solitary confinement, of the patient by 
 
Chap. IV.] Hysterical Mania. 91 
 
 the skilled nurse. The "massage" is performed in a 
 way resembling shampooing, twice daily, beginning 
 with half an hour at a time, and gradually ex- 
 tending to two or two and a half hours twice 
 daily. Milk in half-pint quantities must be given 
 every hour or two hours, and strong beef-tea in 
 similar quantities in the morning and afternoon. The 
 muscles of the trunk and extremities must be not 
 only individually rubbed, but also daily stimulated 
 by electricity. It will soon be found that, under this 
 treatment, patients will develop ravenous appetites, 
 and will take three full meat-meals daily, besides the 
 milk and beef-tea. Stimulants should be given with 
 the meals. 
 
 Dr. Sharkey, of St. Thomas's Hospital, has told 
 me of cases, who, after years of bed-ridden weak- 
 ness, have been able to take horse exercise within 
 three months ; and of others in whom the gain 
 in weight has been nearly one pound daily. In one 
 of his cases, a woman of twenty-nine years of age 
 weighed only four stone two pounds, and yet within 
 a few months became stout and strona;. If this 
 treatment is to be followed, no half measures must be 
 taken. Removal, seclusion, massage, and feeding, 
 are the means of cure, and they must be made use 
 of not separately, but all combined. 
 
 Mysterics&l maiila, acute delii'ious mania, 
 typlio- mania.— From the study of hysteria and 
 hysterical disturbances, one naturally passes to the 
 consideration of mania in which there is marked 
 emotional disturbance ; and first I shall refer to cases 
 of acute delirious mania, or what has generally been 
 called "brain fever." This disorder has many dis- 
 tinct points of difference from acute mania ; and 
 from the extreme danger to life which arises from it, 
 it requires a special and detailed study. 
 
 Before entering fully on its study and description, 
 
92 Insanity and Allied Neuroses. [Chap. iv. 
 
 I shall point out the chief characteristics of ordi- 
 nary mania, so that the differences between ordinary 
 mania and delirious mania may appear. 
 
 Mania, is most common in those with a neurotic 
 inheritance, but may occur in persons with no such 
 history. It is generally preceded by a period of 
 depression, which may either suddenly or gradually 
 pass away, to be succeeded by excitement, the chief 
 characteristics of which are restlessness with tendency 
 to violence ; the ideas seem to flow along certain lines 
 more rapidly than in health, and the associations, 
 verbal and otherwise, though somewhat hard to follow 
 from the rapidity of their formation, are yet traceable, 
 if the sense impressions are noticed. Memory may be 
 perfect, or, although not lost, altered, so that the past 
 is left with an irregular outline. Will is unstable, 
 and the emotional side of the individual is less re- 
 strained, so that there is a tendency to excesses of 
 one kind or another. Ordinarily all these changes 
 are connected with but little alteration in the physical 
 appearance at first. The body temperature is gene- 
 rally normal, the appetite is capricious, the tongue 
 furred or foul, and the bowels confined ; the symp- 
 toms frequently become worse towards night, there 
 being almost always marked sleeplessness. E-ecovery 
 is frequent. 
 
 In acute delirious mania there is frequently insane 
 inheritance ; the outbreak of insanity is often sudden, 
 or the transition from indolence or melancholy to 
 mania is sudden ; the maniacal outbreak generally has 
 some definite cause, and may suddenly follow on a 
 shock, a grief, or on some physical disease, such as a 
 pneumonia or a fever. The patient is more restless 
 than in ordinary mania, and the sleeplessness is 
 more constant ; the language is more incoherent, and 
 resembles the talk of a patient in the height of a 
 fever, for though attention may be recalled for a 
 
Chap. IV.] Acute Delirious Mania. 93 
 
 moment, no continuous trains of thought are started 
 by sense impressions from without. 
 
 Early in the disease the temperature is raised, 
 ranging from 100^ in the morning to 102*^ at night. 
 The face is often flushed, the pulse small and rapid, 
 respiration may be rapid or sighing. 
 
 The patient, if extremely ill, will lie on the back 
 muttering. The lips are covered with dry brown 
 sordes, and the tongue is dry, cracked, and leathery. 
 All food is refused, there appearing to be great 
 pain in swallowing ; bowels obstinate and confined. 
 There is no rash and no sweating. Masturbation 
 is common ; urine and faeces passed involuntarily. 
 
 Bed-sores rapidly form. The patient quickly 
 wastes, and may die in a few days, or may pass into 
 a condition of profound physical weakness associated 
 with mental torpor ; there may be some paraplegia 
 or contraction of the lower extremities. The memory 
 is either wanting, or greatly affected. Recovery may 
 take place, and in some cases years have passed 
 without any relapse. The rapid exhaustion, the 
 increased temperature, the delirious chatter, and hal- 
 lucinations of the senses, especially of sight of a 
 transient nature, and the frequently fatal issue, 
 distinguish this disease. 
 
 Acute delirious mania. Acute mania. 
 
 Cause often definite. Cause doubtful. 
 
 Onset often sudden, [creased. Onset gradual. 
 
 Temperatxire considerably in- Tem^Derature nearly normal. 
 
 Kefusal of food. Appetite capricious. 
 
 Rapid wasting with weakness. "Wasting much less. 
 
 Flushed face. Pale or sallow complexion. 
 
 Hallucinations, variable and Hallucinations more persistent 
 like those of fever. if present. 
 
 Greater incoherence of speech. Incoherence associated with 
 
 sense impressions. 
 
 ;JVIemory often wanting. Memory present, often in- 
 
 fluenced by the surround- 
 ings. 
 
 Result often fatal. Results mostly favourable. 
 
94 Insanity and Allied Neuroses. [Chap. iv. 
 
 A. case such as the following is a good example. 
 A woman thirty years of age, having no neurotic 
 inheritance, but with a delicate mother, fell out 
 of health and became sleepless and nervous ; no 
 history of love-disappointment or injury could be 
 obtained ; there had been loss of flesh with irre- 
 gularity in menstruation ; her appetite was capri- 
 cious, and she was considered by her friends to 
 be giving way to whims and fancies ; she was, in 
 fact, becoming troublesome and hard to manage. 
 Change of scene was tried, and followed by temporary 
 improvement, yet, on the whole, the patient w^as below 
 par. A fright, of no extreme severity, caused a sleep- 
 less and disturbed night, followed by further de- 
 velopment of restlessness. She became loquacious 
 and rather incoherent, or perhaps it would be better 
 to say, silly in her way of talking. She then became 
 less careful about her dress and appearance, got up at 
 night and removed her night-dress, and would have 
 walked about nude. After this there was a develop- 
 ment of sexual desire. She spoke of being married, 
 and her habits became dirty and offensive. Food was 
 refused, and she rapidly lost strength ; all endeavours 
 to support her general health failed, and night after 
 night she was restless, unless subdued by strong 
 narcotics. Nutrient enemata and feeding by nose and 
 by stomach pump were tried, but with little good 
 effect, and notwithstanding every endeavour, the 
 patient lost weight rapidly and sank, having become 
 partly conscious before death. During the whole 
 period the temperature had been high. 
 
 In another case a very similar history was given, 
 the chief point of interest being that this young 
 woman had high temperature for some weeks before 
 it was considered necessary to send her away from 
 home. The reasons for having removed her were 
 that she refused food, was wet and dirty, had also 
 
Chap. IV.] Acute Delirious Mania. €,5 
 
 habits of self-abuse which could not easily be con- 
 trolled, and which were getting fixed. She was sent 
 to a general hospital, but here she was so violent in 
 her language and in her opposition to certain of 
 the nurses, that it was found impossible to keep 
 her there. She was transferred to Bethlem in a 
 very weak condition. Her lower limbs were mere 
 skeletons, and there were bed-sores on both hips 
 and over the sacrum, the legs being contracted, while 
 any attempt to move them was followed by a 
 violent emotional outburst. Food was taken very 
 badly, and it was with difficulty that she could be 
 persuaded to take sufficient. A steady insistance, 
 however, in the taking of food with an abundance of 
 stimulants, was followed by good results, so that her 
 legs became stronger, she was able to walk, the loss 
 of power over bladder and rectum disappeared, bed- 
 sores healed, and the whole of the emotional disorder 
 passed away, and in the end the patient was cured 
 after eight months' treatment. 
 
 Acute hysterical mental disorder of a melan- 
 choly ty^e. — Edith S., single, 22, sister an idiot, 
 maternal uncle insane, maternal aunt insane. She 
 was a somnambulist as a child; had chorea when 11 
 years old ; has been subject to neuralgic headaches ; 
 she was admitted into a general hospital on February 
 4th, 1884, and was considered to be suffering from 
 grave hysteria. The attack was the result of loss 
 of relations by death, and change in her social posi- 
 tion. She refused food, passed her urine and faeces in 
 bed. Her temperature was raised, there was a dry 
 brown tongue, foul breath and great and rapid ema- 
 ciation. She was sleepless, at times excited, emotional, 
 and incoherent ; had hallucinations of sight ; some loss 
 of common sensibility of left arm, and tenderness over 
 left ovary. There was later noticed to be some con- 
 fusion about greens and pinks, her memory was fourd 
 
96 Insanity and Allied Neuroses. [Chap. iv. 
 
 to be defective. The patient was removed to Beth- 
 lem ; there she was constantly and persistently fed 
 with nourishing and stimulating food. She resisted 
 for a time. Within a month of her admission she 
 w^as mentally w^ell, though very weak. She will keep 
 well for a time at all events^ but with such a history 
 of nervous disease in the family we must expect 
 lelapses. 
 
 1 have seen other cases recover, in which the chief 
 symptoms were the delirious excitement and persistent 
 high temperature, the refusal to take food, dry brown 
 tongue, constipation, fulness or tenderness of the 
 abdomen, rapidly succeeded by emaciation, contraction 
 of the lower limbs, and development of huge bed- 
 sores. These cases have generally occurred in women, 
 and have almost always been associated with some 
 ovarian excitement. They fall under the head of 
 what has been called typho-mania, and are of extreme 
 interest to the general pathologist ; for though these 
 j)atients seem to have a disease of an inflammatory 
 nature, yet we have hitherto failed to find the sources 
 of the disorder. I have made post-mortems on such 
 cases, in which it was impossible to detect coarse 
 disease of any kind whatever; and on examining 
 the brain of one case, I have found the vessels 
 congested, and in that of another I have found them 
 empty. 
 
 In several cases there have been found changes 
 or diseases in some distant organ. Thus, in a pa- 
 tient who died in Bethlem, besides some fulness of 
 the intracranial vessels, an ovarian cyst, in a con- 
 dition of inflammation, was found; and in another 
 elderly woman, who died in a similar condition, there 
 was found a series of abscesses about the uterus. 
 The chief point of interest in these cases, from the 
 clinical side, is the high temperature. There is no 
 great variation in the range, but one usually finds the 
 
Chap. IV.] 
 
 Food. 
 
 97 
 
 niglit temperature the higher, and this is from 100° 
 to 102°. I have no explanation to give of this, for 
 we are totally ignorant of any brain centre which has 
 a special controlling influence over the heat-producing 
 function. In these cases the heart and lungs appear 
 to be healthy. From the side of treatment which in 
 these cases, to my mind, is of infinite importance, I 
 
 Temperature of a case of Acute Delirious Mania. 
 
 would recommend the early administration of abun- 
 dant easily assimilated food, and that no feeling of 
 sentiment should withhold the physician from feeding 
 artificially. I should feed such a patient every three 
 hours, night and day, with half-a-pint of fluid food, 
 letting her have milk with an %gg, milk thickened 
 with arrowroot, beef-tea, mutton-broth with one or 
 other of the meat extracts, and with each meal I 
 would give some stimulant equal to about one half- 
 ounce of brandy. The idea that in such cases brandy 
 or spirits of any kind will affect the brain inj uri ously 
 is a mistake, and many a sleepless patient would rest 
 H— 14 
 
98 Insanity and Allied N'ex/roses. [Chap. iv. 
 
 after a night-cap of port- wine negus or a bottle of 
 porter, who is otherwise restless. Food, then, is the 
 first consideration. 
 
 If the patient is to be treated at home, it will be 
 almost certainly necessary that she should have some 
 form of sedative. Bromide of potassium, in some 
 cases, seems to be specially indicated, its supposed 
 effect in suppressing sexual desire making it useful. 
 In some cases I have given half- drachm doses of 
 bromide of potassium as eneraata, by this means 
 succeeding in calming the irritability of the mucous 
 membrane of the vagina ; and, if seen sufficiently 
 early, before there is much weakness, these cases may 
 be benefited by baths of from 98° to 120°; the higher 
 the temperature the shorter the time the patient must 
 be retained in the water. I have frequently pre- 
 scribed a bath of 100° night and morning, each of one 
 hour's duration. Chloral may be given with the 
 bromide of potassium, or alone, in doses not exceeding 
 thirty grains to begin with. I, personally, do not 
 like chloral in these cases, for many reasons, one 
 being that it has a tendency to make patients, who 
 are still taking their food, suspicious and inclined to 
 refuse it. Occasionally I have given chloral and 
 brandy combined in some extremely weak cases, and 
 with considerable benefit. I have failed to see good 
 results from local or general counter-irritation, or by 
 the application of ice to the head. I should, however, 
 add, that some physicians of large experience believe 
 that in chloral they have a means to combat this 
 ilisease. 
 
 From what we have seen it will be clear that the 
 diagnosis of this disease may be difficult. The chief 
 diseases for which it may be mistaken are typhoid 
 fever, meningitis, the later stages of some febrile 
 disease, such as rheumatism with hyper- pyrexia ; but 
 in this disease there is rarely, or never, intolerance of 
 
Chap, v.] Acute Mania. 
 
 99 
 
 light, or complaints of pains in the head, or vomiting, 
 thus separating it from meningitis ; and that there 
 is no tendency to diarrhoea, no enlargement or 
 tenderness of the abdomen, would separate it from 
 typhoid fever. The disease may kill, and, as I have 
 said, is a much more fatal malady than ordinary 
 acute mania. Patients may get well, or they may 
 pass into a condition of weak-mindedness after tiie 
 acute attack. I have, however, never seen a case 
 suflfering twice from this condition ; for though, as I 
 have said, I have seen cases suffering from some form 
 of insanity with a history of brain fever before, yet 
 I have never come across a patient with a relapse of 
 delirious mania. There is a great tendency in patients 
 who suffer from this condition, if they do not recover, 
 to pass into a state of chronic weak-mindedness with 
 excitement ; they will suffer from general incoherence, 
 and may live for years. 
 
 CHAPTER Y. 
 
 ACUTE MANIA. 
 
 Maniacal conditions— ]\fania as a stage in ment.il disorder — Bodily 
 symptoms — Mental symptoms — Course and varieties — 
 Eesults. 
 
 This is a form of mental disorder of variable intensity 
 and duration, in whi(;h loss of control of the various 
 constituents of mind is the most marked character- 
 istic. No more precise definition will cover all the 
 cases I shall have to consider in this group. 
 
 Acute mania. — 1. May be the whole of the 
 disordered process. 
 
 2. Or part of a more complex form of insanity. 
 
100 Insanity AND Allied Neuroses. [Chap. v. 
 
 Thus it may be a stage in recurrent mania, or in 
 folie circulaire. 
 
 3. It may be a symptom of a more serious disease, 
 such as general paralysis of the insane. 
 
 4. It may be a concomitant of epilepsy following 
 or replacing a fit. 
 
 5. Or it may be the further development of a 
 delirium due to fever or alcohol. 
 
 6. It may replace some other neurosis, such as 
 asthma or hysteria. 
 
 General s^inptoius of mania. Bodily 
 symptoms. — In acute mania the patient generally 
 loses flesh, the circulation is weak, so that pulse trac- 
 ings are often very feeble, the complexion sallow, 
 tongiie slightly tremulous, flabby, and with a tendency 
 to white fur, breath often rather foul, aj^petite at first 
 impaired, becomes variable, capricious, and unnatural, 
 and may later, if the patient be passing into a more 
 chronic state, become almost insatiable. The bowels 
 are usually confined, the urine is normal as to con- 
 stituents^ but may be diminished in quantity, or 
 occasionally, in some of the slighter cases allied to 
 hysteria, it may be of low specific gravity and abun- 
 dant. 
 
 In women menstruation is generally absent. In 
 both sexes there is fi^equently eroticism. There may 
 be loss of common sensibility. The patient is rest- 
 less by day, and sleepless by night; frequently he 
 objects to wear any clothes, and I have often found 
 some change in common sensibility. Earely is there 
 hyperaesthesia ; more commonly, local or general loss 
 of feeling. 
 
 A good deal has been said of the aspect of the 
 maniac, so that he is supposed always to have wild 
 staring eyes, a harsh raucous voice, with a peculiar 
 mousy smell ; not one of these is characteristic. 
 The eyes have nothing special in their appearance, 
 
Chap, v.] AIental Symptoms. loi 
 
 the pupils being dilated and sluggish in the majority 
 of young active cases, pointing to the mania as a 
 condition of physical weakness, not one of any 
 inflammation of the brain or its membranes. The 
 voice may be raucous from over-exercise, and the 
 smell may be mousy from constant sweating, due to 
 severe continued exercise and dirty habits. The 
 hair, at times, assumes what has been called an 
 electrical condition. We have had patients in 
 Bethlem whose attacks of recurrent mania weie 
 always associated with the hair becoming stiff, dry, 
 and wiry j and, undoubtedly, nutritional changes may 
 occur in each fresh attack of mania. The maniac is 
 generally credited with a large amount of physical 
 power ; and although one is now and again astonished 
 at some feat of unusual strength, I have failed to 
 satisfy myself that there is ever any unnatural power 
 in the patients. They may have the appearance of 
 possessing extra force from the fact that they have 
 often singleness of purpose, which concentrates all 
 their energies on one object; for, although the acute 
 maniac is, by definition, a person weak of will, yet 
 we constantly meet with cases in which either a 
 repetition of certain hallucinations, or the persistence 
 of some delusion, acts as a fresh stimulant to exercise 
 in a fixed line. Though maniacs are not physically 
 stronger than the sane, one must admit in some cases 
 a power of endurance which is astonishing. A weak 
 woman, for example, will day after day, and night 
 after night, talk, scream, and gesticulate^ at the same 
 time taking little or no nourishment. 
 
 Mental symptoms. — Under bodily symptoms 
 we have noticed the fact that there may be changes 
 in sensibility, and this is seen in different ways. 
 Thus, a patient may appear not to feel, being so much 
 occupied by his delusions or by the fury of his ex- 
 citement ; but, in other cases, there is, undoubtedly^ 
 
I02 
 
 Insanity and Allied Neuroses. [Chap. v. 
 
 loss of feeling in parts of the skin^ and besides loss of 
 feeling, probably perverted feeling is most common, 
 so that the patient complains of itching or halluci- 
 nations, imagining that people tear or scrape his 
 
 A case of Simple Acute Mania. 
 
 body. In several cases I have seen hypersesthesia, 
 and in two the patients fancied that their bodies had 
 swollen inordinately. They gazed at their limbs 
 with horror, fancying that soon they would be too 
 big to remain in the house. In one of these the 
 result was great violence, because the patient fancied 
 
Chap, v.] Hallucinations. . 103 
 
 that lie would, by his great bodily increase, be crushed 
 to death, as the walls of his bedroom would not 
 expand to his necessities. In another case I have 
 seen general tenderness in all the bones of the body, 
 so that either steady or sudden pressure upon a bone 
 ]:)roduced shrieking and signs of pain, and this oc- 
 curred whether the patient's attention were occupied 
 or not. He shrieked suddenly if his shin were 
 pressed under the bed-clothes. 
 
 Halliicmations.— Although the appearance of 
 the eye-balls may be natural, every variety of hallu- 
 cination and illusion may affect the sense of sight. 
 The person suffering from delirious mania frequently 
 sees spectral images, insects, or vermin, very much 
 after the fashion of the fever patient ; the acute 
 maniac is likely to be troublesome at night, from 
 hallucinations of one kind or another. He may see 
 liis near relatives, sparks and flashes of light, or a 
 succession of figures like a panorama. The sights, as 
 a rule, are constantly changing, the condition of mania 
 being a mobile one. 
 
 Hallucinations of hearing are common, the pa- 
 tient hearing the voices of his old comrades, or 
 those of his relations. Many of the actions of the 
 acute maniac depend on the hallucinations of hearing. 
 Besides " voices," there may for some time have been 
 sounds, drummings, thumpings, or ringing of bells, or 
 the repetition of musical notes, which may have been 
 considered by the patient either as communications 
 from his friends, or else as things done to annoy and 
 disturb him \ so that, his sleep being light at the best, 
 he is convinced that these things are done maliciously, 
 and hence he is embittered against those whom he 
 supposes to be the instigators of the disturbance. 
 
 Hallucinations of taste and smell may occur, the 
 idea most commonly being that some filthy or poison- 
 ous gases are being used to injure, or that poison or 
 
I04 Insanity AND Allied Neuroses. [Chap. v. 
 
 filth is being mixed with the food. Hallucinations 
 of this kind may prevent the patient from taking 
 his food. 
 
 Next to sense perversions, I have to refer more 
 fully to the condition of the memory in acute mania. 
 
 A case of Acute Mania. 
 
 In the more severe cases of delirious mania, as in 
 cases of acute primary dementia and cases of melan- 
 choly with stupor, there may be complete loss of 
 memory, so that the patient, after days or weeks of 
 incoherent noisy restlessness, wakes up to find himself 
 in an asylum ', and often is angry at his situation, 
 and cannot be persuaded that he at any time has 
 
Chap, v.] 
 
 Memory in Acute Mania. 
 
 105 
 
 required such detention. There is in such cases a 
 period of mental soreness after the excitement ]ias 
 passed, in which everything seems to affect the patient 
 painfully, and he looks upon the actions of his friends 
 
 A case of Clii'oiiie Mania. 
 
 as injurious and unkind. The memory during the 
 attack, on the other hand, may be slightly altered or 
 masked, so that the patient's condition is very like 
 that which most persons have experienced in dreams, 
 a feeling of something having happened which, at 
 'first, was difficult to recall, but which, when once the 
 thread has been found, may be readily followed up. 
 
io6 Insanity and Allied Neuroses. [Chap. v. 
 
 It is well here to recognise the fact that the me- 
 mories of some of the emotionally insane are not trust- 
 worthy, and that patients who have passed through 
 an attack of insanity will often be ready to give full 
 details of their experiences, but these experiences are 
 not reliable. They develop romantic histories from 
 their inner consciousness. The memory of the at- 
 tack may be, however, clear and precise, and it is 
 well to remember this, for patients are keenly alive 
 to what is said of them while they are insane. I 
 have known them in Bethlem deeply wounded by the 
 ignorant commiseration of a visitor to the wards, who 
 with all kindness has said, " Poor things ! how very 
 wretched it makes me to see them ! " And I have 
 had lessons myself when convalescent patients have 
 told me that they remembered a somewhat harsh ex- 
 pression or thoughtless word used in reference to their 
 cases. 
 
 Another important point to be noted concerning 
 the memory of persons suffering from, mania is, that 
 sometimes there is a kind of double consciousness, the 
 patient's memory during each recurrence of mania 
 having chiefly to do with the acts and feelings of the 
 previous attack of insanity. Thus, a patient who was 
 treated by me with hyoscyamine during a first violent 
 attack of insanity, took a great dislike to me, in con- 
 sequence, I believe, of the powerfully unpleasant 
 feelings produced by that drug. She recovered, and 
 for some time was not only passively, but actively 
 grateful for all the kindness shown her ; but no 
 sooner was she again, affected with mania than she 
 returned to her hatred of me, and her first act on re- 
 admission was to crush my hat over my eyes and 
 call me " poisoner." In another case, a patient who 
 had been three times in Bethlem, on each occasion 
 reverted to the injustice of his incarceration, the 
 wickedness of asylums, and my specially sinful and 
 
Chap, v.] Imagination Among THE Insane. 107 
 
 godless habits ; the same man when well being my 
 very good friend. 
 
 Imagination., probably, is the most attractive side 
 of mania. The poet, the actor, and the artist, all 
 look upon the lunatic as an imaginative being. The 
 superintendent of an asylum regards the imagination 
 of the lunatic in quite another way : he meets with 
 comparatively little real brilliant imagination. The 
 chief points to be noticed are that maniacs do not 
 think along strictly conventional lines; that they 
 have often lost all fear of being thought odd or 
 singular, together with all finer appreciation of the 
 proprieties of society, and will say things painful or 
 vulgar without compunction. Thoughts seem to run 
 riot, and in the rapid flow of words strange associa- 
 tions are made. The imagination of the maniac is 
 undesiafned and uncontrolled. He lies idle, as it 
 were, and lets his ideas arrange themselves according 
 as they are started by impressions made from without 
 upon one sense or another. The aspect of the patient 
 points at times to a state allied to poetic ecstacy, 
 and after recovery strange dream -like experiences 
 may be obtained from some patients. 
 
 Connected with this subject is the one of rapid 
 verbal association, punning, and verse-making. In 
 mania one is able to trace the way in which ideas and 
 words are linked together in the mind ; in fact, the 
 study of speech, in acute mania, teaches much about 
 the mode of association of ideas. There are two 
 distinct methods of combination, the verbal and the 
 ideational, so that one patient, hearing a tinkle of a 
 bell, at once begins rhyming with words like bell, 
 tell, fell, knell, and hell. Another, seeing a ring 
 upon one's finger, rapidly passes from ring to fling 
 and sing, with many more verbal associations. 
 But another way of association is by similarity of 
 ideas, so that a person's name suggesting a fish, 
 
io8 Insanity and Allied Neuroses. [Chap. v. 
 
 the patient rapidly passes from whelks to oysters, 
 shell-fish, garden-snails, and fishery exhibitions. Pro- 
 bably the most common is to have a combination of 
 both methods, as when a woman, seeing a hat, in- 
 stantly said cat, mouse-trap, kittens, the association 
 being first hat and cat verbal, and next mouse-trap 
 and kittens, ideational. 
 
 It would be wrong to say we do not meet with 
 poetic imagination among the acutely maniacal. Eor 
 example, a patient who associated all her ideas of 
 moral qualities with colour was brilliantly imagi- 
 native. Everything that was good and jDure was 
 white and upright or straight, perfection to her mind 
 being a square of perfect whiteness. Unfortunately 
 slie looked upon me as a black round. She was 
 consistent in all her speech, and hardly ever made a 
 mistake when qualifying acts by means of the use 
 of colour. Occasionally patients are given to imagi- 
 native drawing, while others produce verses by the 
 hundred ; but, generally, both drawing and poetry 
 are very bad. 
 
 The consideration of imagination and of the 
 rapid but altered association of ideas naturally 
 leads me to what is called incoherence. It is not 
 every maniac who is really incoherent ; the apparent 
 incoherence is due to our want of knowledge of the 
 connecting links of thought, in fact of our ignor- 
 ance of the method of thought-building going on 
 in the patient's mind. As in dreams the most ex- 
 traordinary jumble of ideas may appear before us 
 without impressing us with the slightest sense of 
 incongruity, so with the person suffering from mania 
 there may be a similar condition. To the patient 
 himself there is generally a pretty definite inter- 
 pretation of what passes in his mind, and generally, 
 I think, the incoherence is to be looked upon as evi- 
 dence of rapid change of idea rather than a succession 
 
Chap, v.] Incoherence. 109 
 
 of perfectly isolated and disconnected thoughts. Just 
 as the traveller, resting above the clouds on a moun- 
 tain top, sees peak beyond peak reaching above the 
 impenetrable sea of cloud ; the peaks alone are 
 visible, yet he knows that deep down below the ob- 
 scuring cloud lie the foundations of the mountains 
 whose summits alone are visible, so we remember in 
 our dreams but a few of the things that have passed 
 through our minds, the connecting ideas having 
 vanished. A similar state exists in mania. 
 
 What connection would one see between Sir James 
 Simpson and a second Saviour, till gradually one finds 
 the idea was thus evolved ? As Christ came into the 
 world to pay the debt of sin, but did not abolish the 
 penalty of suffering, and as now Simpson and the dis- 
 covery of chloroform have practically annulled suffer- 
 ing, some one must bear the weight of the penalty. 
 
 One of the chief characteristics of incoherence and 
 of dream-thought is that both are stimulated by sense- 
 impressions without any intermediate thought-action. 
 They are thought-reflexes, if I may use the term. Just 
 as, when asleep, the slightest exposure of a limb to cold, 
 by a shifting of the bed-clothing, may start a whole 
 series of thoughts about skating, the Alps, or an 
 Arctic expedition, to be suddenly changed into the fall 
 from a precipice suggested by some slight change in 
 the position, so, in the insane, a sense-impression sud- 
 denly turns aside the flow of thought into another and 
 unexpected channel. 
 
 Incoherence of the tyj)e just described is a chief 
 feature in mania. Fixed delusive conceptions and 
 ideas that have been called monomanias do not belong 
 to this condition. It may be considered that the feel- 
 ing of contentment, of well-being, of power and wealth, 
 which the patient suffering from mania often possesses, 
 belongs to the imaginative side. It is, however, hard 
 to understand how the fever of thought should be 
 
no Insanity AND Allied Neuroses. [Chap. v. 
 
 associated with a feeling of satisfaction ; but it is a 
 constant experience to find acute cases perfectly satis- 
 fied with their mental condition. I have scarcely, if 
 ever, met a person suffering from mania who in the 
 least appreciated his state. This feeling of satisfaction 
 may give rise to the nearest approach to fixed delu- 
 sions. Thus, a young fellow who, without having 
 any opportunities for enjoying life, as it is called, 
 but who has long looked upon the stage as a haven of 
 license and a pleasure to be ardently desired, when 
 he becomes maniacal imagines he is the most gifted of 
 actors ; and it is not uncommon for us to receive such 
 cases into the hospital after they have caused annoy- 
 ance at one theatre or another by the persistence of 
 their endeavours to obtain engagements. This feeling 
 of personal worth may become the one most prominent 
 delusion, and may really be a serious drawback to 
 recovery. The feeling of power may be associated 
 with one of changed personality, the patients ima- 
 gining they are royal or heroic. And here the 
 strange association of ideas again works, so that a 
 Reginald thinks himself born to be a king, and a 
 John Charles considers himself to be a successor of 
 the Stuarts. 
 
 As far as judgment is concerned, it is difficult to 
 say that maniacal patients are without power of 
 i jndgina:; but one of the most characteristic symptoms 
 of such cases is the inability to weigh justly their sur- 
 roundings and their companions. It is, therefore, 
 common for us to have two patients at a time, who 
 agree in nothing but the belief that every patient in 
 the asylum is there unjustly; or that those who are 
 acting peculiarly are doing so with a purpose, desir- 
 ing, in fact, to remain in the asylum for their own 
 objects ; or else they see absolutely nothing singular 
 in the strangest and wildest excitement in others. 
 Their judgment upon other things may be correct ; 
 
Chap, v.] Judgment and Will. iit 
 
 they may be able to play chess, or discuss politics. 
 One patient in Bethlem, who was as dangerous as a 
 man could be, and full of insane ideas, was able to 
 play his rubber, fence, or chat reasonably. 
 
 The will, being the balance of motive, is uncertain, 
 and not to be calculated upon, the only thing marked 
 about it being its changeableness. The person with 
 acute mania, unless haunted by some more persistent 
 hallucinations than usual, is as changeable in his will 
 as he is incoherent in his speech. Mania is a condi- 
 tion of Aveakness, as I have said, bodily, and the man 
 is below par; so, mentally, his faculties are unstable and 
 not to be depended upon. There is no steady purpose, 
 but instability with emotional display : like the child 
 and the old man, he is ready for laughter or for tears. 
 Passion of all kinds is easily stimulated, but satisfac- 
 tion rarely follows. As one might expect, the weak 
 man is irritable, nervous, and cowardly ; and, with 
 all the threats which are heard in an asylum, it is rare 
 for the acute maniac to engage in an open attack upon 
 his fellows. 
 
 So far, then, we have passed in review the symp- 
 toms, bodily and mental, which are grouped together 
 in the class " mania." 
 
 Probably no one case exhibits all these symptoms, 
 but all are directly connected with a condition of 
 nervous instability. 
 
 I shall now describe the more common varieties 
 which occur in this group. 
 
 Pirst, simple acute mania may be divided according 
 to whether the symptoms most affect the intellectual 
 or the moral (I had almost said organic) side of the 
 patient. I shall consider cases of the latter variety 
 first, because they are so near in many respects to or- 
 dinary cases of eccentricity. The cases such as those 
 now under review are probably the cause of more 
 family worry and distress than any others ; and the 
 
T 1 2 Insanity and Allied Neuroses. [Chap. v. 
 
 reason is that the friends cannot recognise the slighter 
 symptoms of insanity. It is common for me to hear 
 the friends of such patients say, " 1 believe it is bad- 
 ness in my relation, and I have done everything in 
 my power to knock it out of him/' The one charac- 
 teristic of the disorder is complete moral perversion. 
 This, however, does not necessarily imply open acts of 
 licentioiis immorality ; but it connotes change in dis- 
 position, habits, and manner of thought quite out of 
 relationship to the education and surroundings of the 
 patient. In one case the patient always showed 
 evidence of an approaching attack of insanity by 
 changing his religious creed, and by seeking some new 
 spiritual guide. Later he threw off all religious ideas, 
 and gave himself up to sensual indulgence. In another 
 case, a man who for nearly half a century had held an 
 important position in a public office, who had been 
 a bright and shining light of English middle-class 
 society, and a representative of respectable dissent, 
 took to visiting public-house bars, making love to 
 barmaids, and indulging in cocktails and cigars in 
 way which scandalised his religious friends. One 
 was bound to admit that this man, whose memory re- 
 mained perfectly good, whose judgment upon his own 
 professional subjects was unimpaired, and who was 
 not unreasonable or unreasoning, was nevertheless 
 temporarily changed, and that the change was the 
 L-esult of brain disease of some sort, which, having 
 passed away, left him as well as ever, and regretful of 
 the short period of loss of self-control. He at no 
 time during the attack became what is ordinarily 
 called maniacal. 
 
 Such cases occur among women as well as men, 
 and it is common for us to have one or two examples 
 in Bethlem. Take, for instance, a woman a little past 
 middle life, who becomes fidgety, over-meddlesome, 
 ^nd generous ; she is anxious to make garments for 
 
Chap, v.] Intellectual Acute Mania. 113 
 
 all the poor children of the metropolis. Her lodgings 
 become a receptacle for a motley collection of what 
 would ordinarily be considered by hei' to be rubbish. 
 Now she prizes the heap of gaudy rags, and is full 
 of the schemes by which she is to make clothes for 
 some, and make money for others by means of a bazaar. 
 In the asylum she begins to collect everything, 
 rags, paper, bones, pins, bits of glass, soup-tins, in 
 fact anything that can be found. This period of col- 
 lecting is associated with a coquettish manner, 
 distinct ideas of her good looks, and the possibility 
 of her getting a husband. There is irritability, and 
 there are complaints almost daily against one atten- 
 dant or another. She does not sleep well, and has 
 more ailments than the hypochondriac. Her state of 
 disturbance having lasted for several months, she 
 vslowly becomes herself again, resumes her quiet 
 orderly life, and ceases to have any special mission 
 among the poor. The most troublesome of such cases, 
 undoubtedly, are those who periodically take to drink, 
 the danger being that the drink may tend further to 
 establish mental unsoundness ; for most cases of 
 insanity of this kind are recurrent, and I am inclined 
 to think that many of them have strong nervous inhe- 
 ritance, that, in fact, they might by some writers be 
 looked upon as cases of hereditary insanity exhibiting 
 the moral perversion common in this group. 
 
 I have to consider next the cases of acute mania 
 in which the intellectual faculties are chiefly affected. 
 This, in fact, is " acute mania " as ordinarily under- 
 stood. There is nothing special in the causation 
 of this disorder. Anything that has already been 
 considered as predisposing and exciting causes may 
 act in the production of this form of insanity. As 
 remarked in discussing the last subject, maniacal 
 conditions are those of physical restlessness, and 
 the symptoms have already been described in the 
 1—14 
 
114 Insanity and Allied Neuroses. [Chap. v. 
 
 general introduction to this chapter. Acute mania 
 occurs mostly at the periods of adult and mature life. 
 It may, however, take place at either extreme, so that 
 I have seen cases of children, one, in fact, only four 
 years old, who was suffering from an attack of acute 
 mania, as evidenced by restlessness, sleeplessness, ex- 
 citement, objectless destructiveness, great irritability, 
 and vicious propensities, associated also with perver- 
 sions of sense and de2)raved appetite. I have been 
 consulted about one case on the verge of ninety, who 
 was maniacal then for the first time in his life. So at 
 the other extreme of life one may meet with acute 
 mania, either primary, if I may so use the term, that 
 is, coming on without any previous well-marked signs 
 of mental degradation, or it may occur as the conse- 
 quence of brain-wasting, or alteration of some kind in 
 the nutrition of the nervous centres, Nearly always 
 acute mania is preceded by a period of mental depres- 
 sion and sleeplessness. These symptoms are associated 
 with epigastric uneasiness ; the patient for some days 
 or weeks feels unable to fulfil his ordinary duties, 
 he complains of lassitude, and his friends think he is 
 becoming hypochondriacal. He frequently takes to 
 drugging himself with narcotics, tonics, or purgatives. 
 This period, as I have said, may be of very variable 
 length, so that in one patient it is short and of slight 
 intensity, and in another the entire stage may be mis- 
 taken for one of profound melancholia, till a sudden 
 outburst of mania follows, and shows the melancholia 
 to have been but the initial process of a maniacal 
 attack. 
 
 It is not necessary here to point out all the 
 varieties of uneasy melancholic and hypochondriacal 
 feelings which may precede an attack of mania. The 
 patient often takes to drink at this period. The 
 excitement may develop itself slowly, or may burst 
 out quite suddenly, a very slight cause of excitement 
 
Chap, v.] Acute Mania. 115 
 
 determining the explosion. With this there is, as a 
 rule, no increase of tempera.ture, and^ except during 
 the acts of violence, there is no increase in the rate of 
 the pulse or respiration ; the face loses colour and 
 becomes sallow and anxious-looking. There is often 
 loss of appetite and constipation ; the tongue may be 
 moist and tremulous ; and here it may be noticed that 
 tongue-tremor is not characteristic of general paralysis, 
 for, in my experience, more tremulousness is met with 
 in early acute mania than even in early general 
 paralysis. The attack of mania may be a continuous 
 one, the symptoms varying slightly from day to day, 
 the thoughts following rapidly, apparently uncon- 
 nectedly, but connected, as we have already seen, with 
 impressions from without. Violence towards others 
 may be present, but generally the maniacal patient is 
 not the one who is to be dreaded, as he is more like a 
 passionate child than a dangerous being. He may be 
 stirred to violence with his tongue, and impulsively 
 destroy property ; but in my experience he is rather 
 cowardly than otherwise. The destructiveness is 
 most marked in reference to his clothes, bedding, and 
 things connected with his meals. Attacks on others 
 may be made by persons suffering from acute mania 
 in consequence of false ideas. He may believe 
 that, being of great importance in the world, his 
 detention in an asylum is withholding him from the 
 pleasures and duties of his position ; or he may be 
 affected by hallucinations, so that he may be convinced 
 that it is his duty to injure this person or the other 
 whom he believes to be a criminal or an evil spirit. 
 The safeguard, however, is that these patients are 
 us^^ally unable to combine in any way, and they give 
 sufficient warning as to what they propose doing. An 
 attack of acute insanity of this kind may continue for 
 weeks and months together, and no treatment will be 
 found to have any good effect in cutting short the 
 
ii6 Insanity and Allied Neuroses. [Chap. v. 
 
 attack. About five years ago a young Greek girl was 
 admitted into Bethlem, who, after having had an 
 attack of mental depression, was suffering from the 
 most violent acute mania it is possible to conceive. In 
 her case, which I may take as an example, every 
 variety of treatment was followed without any good 
 results, but in the end she again passed into a con- 
 dition of mental depression, and then recovered 
 mentally, to die some years afterwards of phthisis. 
 She was a girl of good general education, of strikingly 
 handsome appearance, who rapidly passed from plump- 
 ness into a condition of extreme meagreness. She 
 seemed to be able to do without rest by day or night ; 
 she chattered and sang ; she destroyed all her 
 clothes and everything breakable that came in her 
 way, and she had to be clad specially in a kind of 
 combined garment because she was constantly in 
 the habit of standing on her head in doing what is 
 called the " Catherine wheel " of the streets. She was 
 treated with narcotics of every description, morphia, 
 opium, belladonna, conium, chloral, camphor, bromide 
 of potassium ; counter-irritation was tried, the wet 
 pack and the dry pack, seclusion, abundance of stimu- 
 lants, chloroform for hours daily, and yet the dis- 
 ordered process seemed in no way to be hindered. 
 This serves as a good example of what has become the 
 creed of the older asylum attendants, that an acute 
 attack of mania is a process which has to be passed 
 through, and that the best thing to be done is to guide 
 and not interfere with it. In this case the change 
 was a steady one. I would say that the more pro- 
 longed the initial melancholic stage the longer is the 
 second stage of excitement likely to be, and the longer 
 these two the less hopeful the prognosis, and the? 
 greater the amount of excitement the greater is the 
 tendency for the patient to pass into a condition of 
 mental depression afterwards. This depression may 
 
Chap, v.] Recovery. 117 
 
 be of two kinds, simple exhaustion of the nervous 
 centres, as seen in partial weak-mindedness, or de- 
 pression of the melancholic type. 
 
 Other cases exhibit a peculiar rhythmic process 
 in recovery. Patients have attacks of violence, suc- 
 ceeded by periods of health or depression, succeeded 
 again by j)eriods of excitement, followed by others of 
 depression. This process may last for a considerable 
 time, and then the attacks of mental disorder may 
 become shoj^ter and shorter, till at last a condition of 
 health is regained. These cases I compare to the swing 
 of a pendulum, and I have shown how the swing of 
 the pendulum through an arc of excitement is fol- 
 lowed by a swing through an arc of depression ; and 
 as the stability increased, the movement was through 
 shorter arcs of disturbance, till at last stability was- 
 re-established. 
 
 Besides the above ways, cure may be sudden, 
 and this unexpected cure may be accidental or 
 natural. Thus, every year one has cases of insane 
 patients who have recovered their mental balance as 
 the result of a physical illness. One patient gets an 
 attack of erysipelas and his mind clears ; another gets 
 an attack of neuralgia, or has a gum-boil, causing 
 swollen face and much pain, and he recovers. Similar 
 bodily disorders may produce similar results in the 
 melancholic as well as in the maniacal. Certain 
 cases get well only to relapse, and one of the most 
 important questions is not merely the prognosis of the 
 immediate attack, but the prognosis as to recurrence. 
 Simple acute mania is a disorder which is very likely 
 to recur if it make its appearance in a family known 
 to be neurotic. The prognosis, too, is worse after 
 each recurrence, and it is also made more grave when 
 slight phyisical or moral disturbances, such as are 
 certain to recur, can be shown to be the causes. Thus, 
 a patient whose attacks were started by child-birth 
 
ii8 Insanity AND Allied N'euroses. [Chap.v. 
 
 or other physiological process, is likely to have recur- 
 rences ; and, as I have said, each recurrence makes 
 the prognosis worse. For although it does not follow 
 that a patient who has had six or eight attacks should 
 not recover from any more, yet the chances are that 
 she will to the end of her life be subject to recur- 
 rences upon the slightest provocation, and that her 
 children (if she have any) will be of the most unstable 
 nervous type. Thus, in the case of a woman who, 
 herself being of nervous family, had two children, 
 and with each child an attack of insanity, one be- 
 came a lunatic and was subject to recurrent attacks 
 of acute mania, till she became permanently altered 
 in her mental life, and will remain for the rest of 
 her days an eccentric emotional person, liable to 
 outbreaks of acute violence, while the other was a suf- 
 ferer from every variety of hysterical trouble. 
 
 It is noteworthy that persons with strong nervous 
 inheritance sometimes pass through a series of nerve 
 storms with comparatively little damage to their intel- 
 lects, while others, less nervous, suffer much more 
 severely from single attacks. Thus, one patient in 
 Bethlem, who was subject for years to recurrences 
 of most violent acute mania, maintained in the in- 
 tervals an extraordinary amount of mental vigour. 
 She belonged to a family in which nervous disease 
 was common. 
 
 A large number of cases of acute mania recover 
 from their first attacks, and I would further say 
 that cures may be perfect, so that the patient 
 becomes as sane and reasonable as ever he was in 
 his life. The result, however, of mania may be less 
 satisfactory. A patient, after having had an acute 
 attack of mania, may first be morally damaged, so that 
 he takes to evil ways j and I fear that the friends of 
 patients occasionally attribute such moral perversion 
 to the associations and companionships of an asylum. 
 
Chap, v.] Moral Ferj'ersion. 119 
 
 Young cases suffer specially in this way. I say that 
 I would prefer not admitting lads into Bethlem, 
 because however careful one may be, such patients 
 are specially apt to learn evil from their elders, and 
 the cases to which I am now referring are more parti- 
 cularly liable to this contamination. They have lost 
 a great deal of mental vigour ; the acute attack has 
 weakened their judgment and impaired their intellect, 
 allowing their lower animal side to have more power 
 than is good. Such cases, then, after an attack of 
 acute mania, especially when they have been treated 
 in a general asylum, may, though discharged re- 
 covered, be looked upon as going with a moral limp 
 After discharge they frequently decline to follow 
 their old vocation, and become a burden to their 
 friends. This is not all, for they often give way 
 to drink and to other excesses, and not uncommonly 
 pass into the criminal classes. 
 
 Besides this moral perversion which may follow 
 an attack of mania, some intellectual peculiarity may 
 bo the scar which is left, and the patient, quitting 
 the asylum recovered from his acute attack, has 
 now some habit which for the rest of his life stamps 
 him as an eccentric. He may be solitary, penurious, 
 given to odd ways of dressing and of living ; he may 
 be in the habit of talking to himself, or he may 
 have some one special delusion, which he keeps out 
 of sight of the ordinary friend, but which neverthe- 
 less influences the rest of his life. 
 
 When later writing about the so-called cases of 
 monomania, I shall point out that most of these 
 have passed through mental storms, and that the ex- 
 traordinary delusions are but the result of these acute 
 attacks. Acute mania may be succeeded by any one 
 of the many varieties of weak-mindedness, so that the 
 stage of dementia which is common after the acute 
 attack may persist and leave the patient in a state 
 
I20 Insanity AND Allied Neuroses. [Chap. v. 
 
 of second childhood \ or it may leave him fairly 
 well-behaved and fairly active, but his whole in- 
 tellectual being has been reduced to a lower level, so 
 that the man who was a leading barrister may now 
 be contented with a supply of drawing materials, 
 with which he passes his time in making hideous 
 copies from the illustrated papers. Another man, 
 who at one time was an officer in the army, is now 
 content to polish pebbles against the wall, in the 
 hope thereby of getting a cigar or a little tobacco 
 from a visitor in return for his gems, while others 
 become hewers of wood and drawers of water to an 
 asylum. At present we have in Bethlem an old bank 
 clerk who cleans the floors and fetches the meals, 
 having no longer any wish to return to his former oc- 
 cupation. 
 
 Another more troublesome result of acute mania 
 may be that the patient passes into a state of chronic 
 noisy incoherence, chattering the whole day long, 
 generally in an aggrieved way or with threatening and 
 abusive language. Every asylum has cases of this 
 kind, in which there is a special sort of logorrhoea, 
 the association of ideas being often utterly untraceable, 
 and . no condition of brain yet being known to 
 correspond with this condition of chronic mania. 
 
 Under the head of acute delirious mania we saw 
 that death was not an uncommon sequel to that dis- 
 order, but in simple acute mania it is not nearly so 
 common to meet with fatal results. We see acute 
 mania ending fatally when associated with some other 
 bodily disease or injury, and from time to time we 
 meet with cases who die from the excitement of 
 mania. Such cases have gone on talking, raving, and 
 destroying day and night ; they may have taken food 
 freely, but they have steadily lost ground and at length 
 have died. 
 
 The prognosis in all cases of acute mania, then, 
 
Chap, v.] Acute Mania. 121 
 
 must be guarded, and I would say tliat, with any 
 case of acute mania, in which excitement was great, 
 sleeplessness well marked, food either not taken at all, 
 or not assimilated, must be regarded with danger, 
 especially in young and old cases. I have seen several 
 cases of elderly women dying comparatively sud- 
 denly ; they have been excited for weeks after the 
 attack of mania ; then becoming unexpectedly quiet, 
 they have sunk and died. 
 
 Acute mania recovering hy degrees and with remis- 
 sions. — Reginald IST., single, 22, admitted October, 
 student, first attack of insanity, no nervous inheri- 
 tance ; the causes of this outbreak were over-study, 
 and disappointment with change in his prospects. 
 
 The first symptoms were restless irritability, a 
 ravenous appetite, and false ideas as to his father's 
 wealth and position. He was loquacious, believed 
 he would be a hero, and that he could write as well as 
 Shelley. He became extravagant and witty. There 
 was more brilliancy than one ordinarily sees in mania. 
 He asked me for a definition of acute mania, and 
 answered it himself by saying, " it is believing your- 
 self to be a boxing man, and proving it to demon- 
 stration ; " he also referred to the analysis of emotions 
 as a filthy process. Within a few days of his admis- 
 sion he became quiet, tidy, and well-behaved ; but this 
 lasted only a week, after which he became as noisy as 
 ever ; by November 3rd he was removed to a con- 
 valescent gallery, only to be sent in ten days to the 
 refractory ward again. For the next few weeks he 
 varied ; for a few days being quiet, and then again 
 breaking out with all his old violence. In one attack 
 his violence was extreme, and hyoscyamine was tried 
 in vain. After this he slowly recovered, and was dis- 
 charged. 
 
 Acute mania, rapid recovery. — Elizabeth W., mar- 
 ried, age 34, three children, youngest 19 months old. 
 
122 Insanity and Allied Neuroses. [Chap. v. 
 
 No insane inheritance. Has suffered from rheumatic 
 fever ; was said to have had incipient phthisis. The 
 cause of her present state was said to be pecuniary 
 trouble and domestic anxiety. Her husband was 
 intemperate, and frightened her while he was suf- 
 fering from delirium tremens. She was admitted 
 into Bethlem on January 23 ; her first symptoms were 
 violent emotional disturbance, which began four days 
 before admission. She became restless, and refused 
 food. She was incoherent in speech and in ideas, 
 and her movements were wild and uncontrolled. She 
 was sleepless ; she said she was Jesus Christ at one 
 moment, and that she was dead the next. 
 
 On admission she was extremely thin and anaemic ; 
 she talked in a rambling way, her eyes were bright, 
 pupils large, hair rough and semi-erect; she gesticulated 
 and moved her fingers and hands in a rhythmic way. 
 She made rhymes; she passed her urine and faeces 
 under her. Pulse 120, temperature 100*4°. 
 
 The temperature soon fell to 99°, though there 
 was very little change in any other symptom for 
 some days. She refused all food. 
 
 By January 30 she was reported as more quiet, and 
 as taking her food, but still very weak. 
 
 February 4th. — She said that yesterday she 
 suddenly awoke to herself, and wondered where she 
 was, and why ; she said she had lost recollection of 
 much of the past few weeks. 
 
 February 15. — Still weak, but progressing 
 favourably. After being tried with change of air 
 and leave of absence, she was discharged well on 
 March 26th. 
 
 Mania Diay he 'part of the insane process, and not 
 the whole. Thus, in folie circulaire, mania is succeeded 
 by melancholia, to be again succeeded either by a 
 period of health, or by a fresh attack of mania. 
 There is nothing special in the attack of mania, it 
 
Chap, v.] '^ FOLIE ClRCULAIRF.y 1 23 
 
 being characterised by the usual bodily and mental 
 disturbances which we have already described. The 
 j)eriods of excitement are not of absolutely equal 
 length, and the relationships between the periods of 
 depression and those of excitement vary. This form 
 of mental disorder is extremely rare, in my experience, 
 in England. I am used to cases of mania and melan- 
 cholia recurring at irregular intervals, in which the 
 end is mental destruction ; but the establishment of a 
 regular process of recurrent periods, such as described, 
 is practically unknown to me, the cases which I have 
 met with falling more properly into either cases of 
 recurrent mania, or cases of mania ending in per- 
 manent weak-mindedness. 
 
 Folie circulaire, as described, is a mental disorder 
 most frequently met with in women, coming on often 
 soon after puberty, rarely cured, in which a period of 
 excitement is followed by a period of rest and of 
 melancholy, the three stages following each other in 
 any order, there being probably the most with de- 
 pression first, which is followed by mania, which is suc- 
 ceeded by a period of health, or at least by a period of 
 comparative health. Patients suffering from this dis- 
 order are said rarely to be quite themselves even at 
 their best. I have seen many cases in which there 
 have been cycles of this kind, but the periods of 
 depression or of weak-mindedness became longer and 
 longer, while the stages of health were restricted till 
 in the end mental weakness resulted. 
 
 In some women the menstrual period always starts 
 a fresh outbreak of excitement ; but such cases are re- 
 current, and do not properly belong to the group 
 called Jblie circulaire. 
 
 Mania may be the first or one of the earlier symp- 
 toms of general paralysis of the insane. In some 
 cases the mania appears suddenly ; but I consider, 
 as a rule, that in such cases the way has been paved 
 
124 Insanity and Allied Neuroses. [Chap. v. 
 
 for the outbreak of excitement by antecedent de- 
 generation, and that in this respect they resemble 
 others to which I have referred as cases of acute ex- 
 citement following chronic brain change. The acnte 
 mania of general paralysis may be preceded by the 
 ordinary melancholic period often assuming a 
 markedly hypochondriacal type. The attack of 
 mania may be of short duration, and leave the 
 patient profoundly altered, as far as his mental 
 abilities are concerned, but yet with little appear- 
 ance of physical illness. Attacks of mania may 
 appear from time to time in the progress of general 
 paralysis, each attack tending rapidly to mental de- 
 struction. There are no special characteristics to 
 enable one at once to diagnose the mania of general 
 paralysis from that due to other causes. The dia- 
 gnosis must be made from the physical conditions and 
 symptoms. 
 
 Mania may be associated with epilepsy, it may 
 precede the epilepsy, or take the place of a fit ; 
 but more commonly the patient, after a fit of 
 convulsions with unconsciousness, becomes quite 
 suddenly violent. Such cases are among the most 
 dangerous possible, as the outbreaks of destructive 
 violence come on as suddenly as do the fits them- 
 selves. Thus, some years ago I saw the wife of 
 a publican who was said to have had an attack of 
 apoplexy some little time before. There was no 
 doubt she had been strange in habits and manner, 
 and that she had lost consciousness at times ; these 
 losses of consciousness were, however, looked upon as 
 simple fainting fits, but when she had a very severe 
 attack of convulsions, affecting one side, it was supposed 
 she was suffering from a fit of apoplexy, but to the 
 astonishment of her friends and the doctor, she 
 suddenly recovered consciousness after sleep, and 
 became violent and destructive. When first called I 
 
Chap, v.] Mania with Epilepsy. 125 
 
 found her unconscious and breathing stertorously, 
 with clonic convulsions of the left side, and with only 
 the history given me by friends that she had an 
 attack of paralysis. On the first occasion I had 
 been misled into the idea that this kind of attack 
 was an apopletic seizure, and prescribed accordingly. 
 Next day I was suddenly summoned to find lier 
 in the wildest state of excitement, rushing about 
 her house, breaking the ornaments, and abusing her 
 servants and relations. This period of excitement 
 lasted nearly two days, after which she was again 
 herself. On another occasion, somewhat later, she 
 had a similar fit ; but having learnt by experience the 
 nature of the seizure, I prescribed a full dose of 
 chloral hydrate whilst she was still unconscious, the 
 result being that she slept continuously for about 
 twenty-four hours, and when she awoke she was free 
 from mania. When succeeding attacks took place 
 she was sometimes tried with chloral, and sometimes 
 without, but always became maniacal if the drup; 
 were withheld. Cases of this kind are common 
 enough in the larger county asylums. There are cases 
 in which a large amount of purposive action may take 
 place, and serious injury may be done, and yet the 
 patient may be without the faintest recollection of 
 what has taken place during the period of violence. 
 That crime has been committed by patients during a 
 state of epileptic furor I have no doubt, crimes, too, 
 of a most brutal and devilish kind. The perpetrator of 
 some brutal murder may apparently have taken care 
 to secure his victim, and to hide his crime, but yet 
 there is a complete ignorance of all that has hap- 
 pened. He may impress the jury unfavourably 
 by this apparent indifference, and by his denial of 
 any knowledge of what took place, although it is 
 clearly proved that he appeared to see and avoid 
 witnesses. But one of the most striking things about 
 
126 Insanity and Allied Neuroses. [Chap. v. 
 
 epilepsy is the complete break of continuity of 
 thought, which so generally occurs both in the graver 
 and in the slighter attacks of epilepsy. 
 
 In a later chapter the relations of epilepsy to 
 insanity will be fully considered, but before leaving 
 the subject I will repeat that the mania following 
 epilepsy may be of the most violent, destructive, 
 impulsive character which can be conceived, and that, 
 unlike ordinary mania, it leaves not even a perverted 
 memory behind. 
 
 As one of the greatest difficulties lies in dis- 
 tinguishino; between acute mania and acute delirium, 
 I must call attention to the fact that delirium may 
 pass into mania ; this occurs most frequently in 
 persons with direct insane inheritance. 
 
 Thus I have seen attacks of acute mania follow 
 the delirium of fevers, acute alcoholism, and the 
 delirium resulting from belladonna, and from the 
 administration of chloroform. 
 
 Acute mania may take the place of hysteria or of 
 spasmodic asthma, and I shall not be surprised to 
 meet with other conditions, such as angina and hypo- 
 chondriasis, which may prove to be equivalents of a 
 maniacal pain storm. 
 
 The patSi©log>" of aiaaBiia.— Any condition of 
 physical illness may set up an attack of mania in 
 predisposed persons. Mania must be looked upon 
 as depending rather upon weakness than inflam- 
 mation. The excitement and restlessness are results 
 of want of conti-ol, not of excess of power. The 
 circulation is feeble, and the power of re-action small. 
 Power of assimilation is also generally impaired, the 
 secretions and excretions not being normal. The 
 pallor of the face points to the anaemia, and the wide 
 pupil to the nervous weakness. As far as the local 
 pathology is concerned, but little that is definite can 
 be said. 
 
Chap, v.] The Pathology of Mania. 127 
 
 Doubtless there are local or general changes in the 
 nervous system, but no clue has yet been obtained to 
 any special change which can be called the physical 
 cause of maniacal symptoms, nor have we sufficient 
 data to point to as evidence of the changes produced 
 by mania in the brain or other nervous organs. 
 
 Such being the case, all that can be done is either 
 to describe what one would expect to find (and this 
 in the human body is very misleading and untrust- 
 worthy), or else, by recording stray but scattered 
 facts, leave to later observers the arranging and com- 
 paring of results. 
 
 I shall, for my part, give a few of these detached 
 observations under this head. After death from 
 acute mania, I have several times found no changes in 
 the brain which were visible to the naked eye. I 
 have in some such cases found local disease elsewhere, 
 as in the lungs, ovaries, kidneys, heart, or liver. 
 
 In some cases I have found evidences of old- 
 standing wasting of the brain which seemed to have 
 prepared the way to the fatal attack of acute mania. 
 
 I have found the brain remarkably blanched on 
 the one hand, and on the other I have found either 
 venous congestion, or fine capillary injection, general 
 or local. 
 
 Frequently I have found excess of subarachnoid 
 fluid. Ko importance attaches to the milky patches 
 found in the arachnoid, and there is no special condition 
 of dura mater, or of any particular convolutions. 
 
 Histologically I have rarely failed to find, in fatal 
 cases of acute mania, changes in the nerve cells, more 
 especially in the pyramidal layer. The nerve pro- 
 cesses may be wanting, the cells may be swollen and 
 indefinite in outline, and in some cases they are much 
 Avasted or suffering from degeneration of one form or 
 another. In some cases there was certainly excess of 
 leucocytes in the vessel sheaths, or parallel to them. 
 
128 Insanity and Allied Neuroses, [Chap. vi. 
 
 There is, then, no special change to be seen in the 
 brain, and in the sympathetic, as far as I have 
 examined the cervical and some of the abdominal 
 ganglia, I have failed to discover a clue to the dis- 
 order. 
 
 Before concluding this section, I must give as my 
 experience, that persons may die of acute mania, and 
 yet their bodies may exhibit nothing which a skilled 
 pathologist would, at present, at least, be able to say 
 was sufficient to destroy life. 
 
 CHAPTER VI. 
 
 HYPOCHONDRIASIS AND MELANCHOLIA. 
 
 Hypochondriasis — Allied to hysteria and insanity — Simple hy- 
 pochondriasis — Insane hypochondi'iasis — General or local 
 hypochondriasis — Feeling of impending death or of a general 
 disease — Brain hypochondriasis— Gastro -intestina], throat, 
 epigastric, rectal hypochondriasis — Reproductive organ 
 hypochondriasis — Hypochondriasis mixed with melancholia. 
 
 Hypochonclriasis.— Just as, in considering mania, 
 I pointed out that hysteria in many respects might be 
 considered an undeveloped mania, and might be 
 looked upon as a very closely related condition, one 
 which had the same orign, and might have the same 
 termination, so in this chapter I shall Legin by con- 
 sidering the condition called hypochondriasis, and its 
 further development of melancholia. 
 
 We begin mental life by receiving impressions, and 
 slowly building up, with those impressions, a power 
 to receive higher ones, just as we commence motor 
 life by combming the simple muscular forces till they 
 become the wonderful machine that speaks and 
 writes. Step after step is gained both on the sensory 
 and motor sides. From the lower we rise to the 
 
Chap. VI.] Hypochondriasis. 129 
 
 higher ; and in healthy development, forgetting those 
 things which are behind, we stretch forward to the 
 new. The muscular adaptations are organised, so 
 that they become automatic, and a similar organisation 
 takes place with respect to our sensations. Doubtless, 
 the child feels much more real satisfaction in his 
 simple meals than does the gourmet. To the child, 
 the satisfaction is one that is felt by his whole body. 
 I am in the habit of saying that, in my belief, the 
 persistence of the ego does not lie so much in any 
 highly organised nervous centre, but has its origin 
 with the earliest processes of nutrition, and that the 
 ego springs into being rather along the gastro- 
 intestinal track than, Minerva-like, from the brain. 
 Self-feeling is altered in many cases by a change 
 in the digestive functions ; and just as we have the 
 most perfect movement, without a knowledge of the 
 muscles which are being brought into action, so we 
 can, and must, really have only perfect sensation 
 when the sense-organs are in perfect health, and 
 react automatically to the surroundings. A man 
 who is in health receives impressions without knowing 
 it ; when he has to strain his ears or eyes, he is not 
 acting in harmony ; when he is thinking he should 
 have no feeling of weight or pressure within his skull, 
 and when digesting, he should have no knowledge of 
 the existence of his stomach. 
 
 In the class of patients whom we are about to 
 consider, the functions are from one cause or another 
 thrown out of gear, so that the automatic action of 
 sensation no longer exists. The person feels every- 
 thing he does, and knows from his sensations that 
 he has viscera. The knowledge of this necessarily 
 distracts his attention from what might be called 
 the higher, and concentrates them upon the lower or 
 more organic sides of his being. Nearly every patient 
 suffering from melancholia complains of feelings of 
 j-14 
 
130 Insanity AND Allied Neuroses. [Chap. vi. 
 
 illness. In mania, we saw the feeling was one of 
 buoyancy and exuberance. With melancholia we 
 meet with a slowing of all vital processes. What the 
 pathological basis of melancholia may be one cannot 
 at present tell. It however seems, in most cases, 
 that it must be associated with impaired nutrition of 
 the nervous centres and the conducting system. In- 
 stead of conduction and reaction to impressions being 
 active, they are so slow that they can be felt in their 
 action. 
 
 Hypochondriasis and melancholia depend more 
 probably for their existence upon some general bodily 
 condition than do most other forms of insanity. The 
 person of unstable nervous system, who has a worry- 
 ing or constantly painful feeling, due to some bodily 
 disease, is likely to be absorbed by this constant irri- 
 tation, and have his life centred, as it were, around 
 the seat of painful impression. As we shall see, some 
 centres seem specially liable to start these morbid 
 feelings, making the man, in one case, hypochon- 
 driacal, and in another, melancholic. Before, how- 
 ever, proceeding farther, I would say that the dis- 
 tinction between hypochondriasis and melancholia is 
 rather arbitrary. It may be convenient, but it is 
 not philosophical to treat of the body apart from 
 the mind, and the physical symptoms separately fi-om 
 the mental. Purther consideration will show that 
 a man who believes himself forsaken by God, may, 
 after all, have got that idea in consequence of some 
 gastro-intestinal trouble, and that damnation has 
 been his method of interpreting dyspepsia. It has 
 been generally said that morbid sensations are the 
 essential of hypochondriasis, and morbid feelings 
 the essential of melancholia. But, as I have said, the 
 distinction is one that is scarcely satisfactory, and 
 when considering cases as they present themselves 
 in practice, we shall see that patients may belong 
 
Chap. VI. 1 Hypochondriasis. 131 
 
 to a hypochondriacal class on the one hand, and 
 yet have distinctly melancholic symptoms on the 
 other. 
 
 For convenience, I shall only consider at first the 
 cases of bodily hypochondriasis, for they will form a 
 useful group by which to connect the melancholia 
 and hypochondriasis classes. I shall have to describe 
 cases of mental sensitiveness without any defined 
 feeling of unworthiness, cases in which people, instead 
 of looking at their tongues and feeling their jDulses, 
 are constantly asking themselves if they are doing 
 their duty. 
 
 Of ordinary hypochondriasis there are three 
 classes seen in an asylam, besides the sufferers from 
 general hypochondriasis, who complain of some 
 general disease like syphilis or hydrophobia, or who 
 believe themselves to be on the point of death. And 
 just as the hysterical woman may remain hysterical 
 all her life and never become insane, so the hypo- 
 chondriacal patient may remain hypochondriacal 
 to the end. The classes consist first of those who 
 complain of brain-working or brain loss ; secondly, 
 of those who complain, as does the ordinary hy]->o- 
 chondriac, of some digestive trouble ; and, thirdly, 
 those who believe that there are some defects in their 
 reproductive organs. Emotional depression springs 
 from a feeling of real bodily illness, but the illness is 
 rarely of what may be called a coarse kind, but is 
 the result of impaired function, and not of structural 
 disease. In insane hypochondriasis it is common to 
 find a very clearly marked localisation of the com- 
 plaints, and though one does meet hypochondriasis of 
 the ordinary type in an asylum, this is less common ; 
 it is not of these that I now write. 
 
 Patients recovering from an attack of insanity 
 frequently feel nervously tender, and complain daily 
 of some fresh ailment, wanting a liniment to-day and 
 
132 Insanity and Allied Neuroses. [Chap. vi. 
 
 a ionic to-morrow. Though hypochondriasis is gene- 
 rally seen among men in an asylum, it is also seen 
 among women. It occurs in the middle-aged more 
 than in the J^oung ; but we frequently meet with sexual 
 hypochondriasis among the latter. Young people 
 also exhibit various phases of brain hypochondriasis, 
 the gastro-intestinal cases belonging chiefly, but not 
 solely, to those of more mature years. The causation 
 may be general or local ; there may be some physical 
 cause for the feeling, and the concentration of atten- 
 tion upon the weak spot may have exalted its sensitive- 
 ness to a diseased point. Intellectually, these people 
 rarely, if ever, show signs of weakness ; at all events 
 not for years, and I believe that the hypochondriacal 
 patient rarely ends in dementia. He often is con- 
 ceited j and it seems to me that hypochondriasis may 
 be looked ujDon as a kind of conceit. Patient after 
 patient will say that he suffers as no one ever suffered 
 before, that it is quite useless to compare him with 
 his neighbours, and that he is utterly unlike all others. 
 The association of ideas with him is natural. Will 
 seems generally enfeebled in consequence of inability 
 to divert his thoughts from painful sensations ; the 
 appetite is bad, constipation generally exists causing 
 him further anxiety, and he is often irritable and 
 emotional. His memory is good, and his judgment 
 of things, apart from himself, is good, so that he could 
 be trusted in a court of law as an ordinary witness. 
 He is not subject to hallucinations of his senses, his 
 perversions being illusions ; that is, he misinterprets 
 what is presented to his senses. Sleep is broken, and 
 often disturbed by dreams of an amorous type, which 
 still further distress him. A hypochondriac may kill 
 himself or another, but generally he appears to be 
 cowardly, and many have told me that, although 
 tired of life, they never for a moment dreamt of 
 killing themselves. 
 
Chap. VI.] Brain Hypochondriasis. 133 
 
 Tlie hypochondriacal condition is not a very 
 hopeful one. Prognosis depends upon the length of 
 time in which it has been developing, the age of the 
 patient, and the physical basis from which it springs. 
 The older the case, and the longer and the more 
 steadily it has been developing, the less hope is there 
 of recovery. In some it takes a long time before it 
 becomes really an insane condition. A case begins 
 with recurring periods of depression, in which the 
 patient feels out of sorts, and commences to over- 
 haul his various bodily functions and habits ; he 
 wonders whether it is smoking or drinking which is 
 causing his sleeplessness, whether tea disagrees with 
 him, or if milk should be his only drink ; he exhibits 
 irritability and inability to work. He tries all sorts 
 of nostrums recommended by his friends, follows the 
 teetotallers or the vegetarians, being in turn delighted 
 with the results of his experiment and disgusted 
 with their failure. Such patients stand a very great 
 chance of being mismanaged, for between the attacks 
 of depression they appear so well to their friends, 
 and express such a powerful conviction that they will 
 never be ill again, that they are not definitely put 
 under treatment till the morbid feelings have become 
 established. The insane hypochondriac does not live 
 to a great age, as a rule, the older man or woman 
 wearing out and dying of some secondary trouble, 
 such as inflammation of the lungs. The younger 
 cases ma}^ rarely pass into weak-mindedness, or mind 
 restriction ; or if sufficient lever-power to induce them 
 to work can be brought to bear upon them, they may 
 completely recover. 
 
 Oroup I.— JSraiti liypoclioiidriasis.— In an 
 asylum, although headache is not very commonly 
 complained of, yet Ave constantly hear complaints 
 about uneasy feelings in the brain. One class of 
 patients, both ■ male and female, complains much of 
 
T34 Insanity and Allied Neuroses. [Chap.vi. 
 
 changes in the brain. In these cases it is almost in- 
 variably found that there has been some sexual trouble. 
 I have met with many complaints about strange 
 sensations at the top of the head and in the brain in 
 patients who say that they have injured themselves 
 by masturbation. I have met with this also in cases 
 where sexual excess has been indulged in, and I am 
 inclined to think it may occur also in cases where 
 there has been an unnatural suppression of all sexual 
 instincts. The patient tells you that he is sure his 
 brain is dried up or changed in some way, and one 
 man described the feeling as that of being possessed 
 of a brain like a Spanish onion, in which the thin 
 scaly coverings had been removed without causing 
 pain, but now that the fleshy layers were being 
 removed the pain was dreadful. In this case, change 
 of surroundings, active and energetic companions, 
 and some unpleasant physical trouble acted satis- 
 factorily in starting him along a fresh line, which 
 has so far been followed with beneficial results. 
 Women suffer similarly, and in them the pain on the 
 top of the head is constantly associated with men- 
 strual irregularity. At the climacteric I have 
 frequently seen similar cases. Thus, in a patient 
 recently in Bethlem, the feeling complained of was 
 that of opening and shutting of the brain, so that she 
 would ask me to listen to the top of her head, or at 
 least to place my hand there to feel the snapping. 
 If such condition depend upon a cause like the 
 climacteric, the prognosis is better than when it 
 simply depends on the laborious action of degenerat- 
 ing organs. The following case, taken down from 
 the patient's own lips, conveys more graphically than 
 any other description could, the misery of the brain 
 hypochondriac. 
 
 " I am a medical man, and my age is forty-seven. 
 I always had a very good constitution, and possessed 
 
Chap. VI.] Statement of a Hypochondriac. 135 
 
 great muscular strength, active habits, and an ex- 
 citable temperament. One morning in March, 1879, 
 being at the time in perfect health, I was tempted to 
 commit self-abuse. 1 had done it before, but not 
 very frequently, having foolishly abstained from mar- 
 riage, I was immediately afterwards seized with 
 giddiness. Whilst dressing before the looking-glass 
 I noticed that my face was flushed in a manner I had 
 never before seen, being livid and congested, and of a 
 dark purple hue. My pupils were also exceedingly 
 dilated at the time. On that day I felt my gait 
 tottering and my temper disposed to be irritable. 
 That night 1 had very little sleep, and suffered severe 
 pain in my head. From that time sleep departed 
 more and more. I resorted successively to every 
 known narcotic drug, gradually increasing the doses, 
 until I gave them up as inert. I went away to moun- 
 tain scenes to try change and exercise, but no benefit 
 accrued. I returned and made a desperate struggle 
 to carry on my practice, but finding myself becoming 
 worse, I went to the Hydropathic Hospital in York- 
 shire, and underwent the treatment there without 
 any good result. I then transferred myself to the 
 Leeds Infirmary, and was under Dr. Cliftbrd Allbutt. 
 There drugs were given to me, but nothing produced 
 sleep. I prayed to be bled or leeched, but was 
 refused. I then bribed the nurse to put fifteen 
 leeches on my temples, after which I obtained, for 
 the first time for many months, three hours' sleep. I 
 was so pleased with the result that I dressed myself 
 and returned home to my practice ; but finding my- 
 self getting worse, I left in November, 1879, and 
 since then I have spent two years mostly in bed, 
 suffering intense pain all the time ; and for the 
 last two years I have been a patient in Bethlem. My 
 principal troubles now are almost entire sleeplessness, 
 intense pain in the back of the head, most severe in 
 
136 Insanity and Allied Neuroses. [Chap. vi. 
 
 the mornings and after food, especially liquid food. I 
 am troubled with dreadful libidinous desires, in spite 
 of all efforts to avoid them. This was, however, 
 relieved to some extent by bromide of potassium ^ in 
 large doses. I am now slowly but surely getting 
 weaker, losing flesh ; my circulation is becoming more 
 feeble, my appetite poor, a dragging pain at the 
 heart sometimes, but not often ; at night spasm of the 
 larynx nearly chokes me. About three years ago I 
 was struck by a remarkable appearance of the veins 
 in my hands, and they presented the appearance of 
 containing little or no blood, but on opening a vein 
 for nearly an inch in length, I could squeeze only 
 a slight drop of blood from it ; whereas, on the con- 
 trary, the deeper veins were unnaturally distended. 
 When the paroxysms of feverish excitement are on me 
 my whole body' feels as if the blood were nearly 
 boiling. I have often wished the medical men in 
 Bethlem to test the supposed delusion as to the state 
 of my veins, but they have not done so. I notice 
 but little diminution in my mental activity, and this 
 convinces me that no structural change of brain 
 structure has taken place, and that the true nature of 
 the lesion is paralysis of the vaso-motor system, more 
 or less of the whole body, but more especially of the 
 sinuses in the posterior part of the brain, as I dis- 
 tinctly feel intense pressure, and on moving my head 
 creaking noises are heard. I attribute these noises 
 to the stretching of bands of lymph thrown out 
 around the sinuses, so that they may be kept dilated. 
 I am perfectly convinced that recovery is impossible, 
 that all treatment is useless, and that this is, with- 
 out doubt, the true meaning of the passage in 1 John 
 V. 16 : " There is a sin unto death : not concerning this 
 do I say that he should make request " (Revised ver- 
 sion). And I believe this evidence is overwhelming, for 
 I was in magnificent health before doing this sin, and 
 
Chap. VI.] Gastric Hypochondriasis. 137 
 
 was struck down instantaneously, and have been in 
 misery and pain ever since. My bowels are con- 
 stipated occasionally^ but at rare intervals. I have 
 pseudo-tetanic spasms down the spinal cord, and at 
 times intense dragging, gnawing pain in the same 
 region. " 
 
 Another male patient recently in Bethlem was 
 fully convinced that all his back-brain had been 
 removed by a miraculous interposition of Providence, 
 and that he possessed nothing but his face and, as he 
 said, a little span of brain which enabled him to 
 recognise his friends. From time to time, from week 
 to week, the poor fellow would march about with his 
 hand on the top of his head, begging us to have com- 
 passion on him and communicate with his relations in 
 order to take him home and die. The misery of his 
 existence seemed to be complete, and the prognosis, 
 though wholly unfavourable as to cure, did not even 
 give the hope of annihilation of the suffering, which so 
 frequently occurs to the ordinary melancholic patient 
 when he becomes weak-minded. The misery in his 
 case would not become mechanical, but would slowly 
 wear him to the grave. 
 
 Oroup 2.— Gastric liypochondriasis.— In 
 this group we have three divisions. First, patients 
 who complain of obstruction or disease about the 
 throat; secondly, those who complain of similar feel- 
 ings and uneasiness at the pit of the stomach ; and 
 thirdly, those whose complaints are referred to the 
 lower bowel. There are other cases in which two or 
 more of these symptoms are united, and one meets 
 constantly with cases in which reference is made to 
 uneasy feelings, referred to one or other part of the 
 digestive track. A patient at present in Bethlem 
 thinks that his food passes directly into his left 
 arm, whereas another imagines that it passes into 
 his circulation. Of the cases with throat trouble. 
 
138 Insanity and Allied Neuroses. [Chap. vi. 
 
 examples occur both among the men and the women. 
 I have met with cases of simple exaggerations of 
 hysterical globus in young patients, and I have met 
 also with similar cases in men at the extreme of life. 
 One young man was constantly in the hands of 
 
 A case of Hypochondriasis, with, ideas of Bowel Obstr action. 
 
 quacks (who, by the way, probably live more on 
 hypochondriacs than on any other class), in con- 
 sequence of an idea that his throat was contracted, 
 and that it was impossible for him to swallow. 
 He came of a nervous and phthisical stock. He 
 had been nurtured among an emotionally religious 
 sect, and at the onset of manhood be became ner- 
 vously and hypochondriacally disordered. Change of 
 
ciiap. VI.] Gastric Hypochondriasis. 139 
 
 surroundings, absence of quacks, use of tonics, and 
 sea-air did him good. 
 
 In another case, where the father was an inmate 
 of Bethlem, the son Avas admitted suffering from 
 hypochondriacal insanity, with the persistent idea that 
 
 A case of Hyjpocliondriacal Melancholia. 
 
 there was some malignant growth at the back of his 
 throat. He took hours to swallow any food if left to 
 himself, and would become violent and excited if 
 contradicted. Everything was done to convince him 
 that no obstruction existed. Probangs were passed, 
 his throat examined by the laryngoscope, he was 
 allowed to examine his own throat by reflected 
 light, and, as a last resort, he was sent to a leading 
 
140 Insanity and Allied Neuroses. [Chap. vi. 
 
 laryngologist who certified that his throat was normal. 
 Keason, however, is wasted on the insane hypochon- 
 driac, and this patient, after more than a year of 
 treatment, was discharged uncured, but in robust 
 general health. I have frequently seen him since, 
 and his condition is unaltered, no sense of duty to 
 relations or friends being able to stimulate him to 
 work, and no reason can convince him but that he 
 is slowly dying of general wasting. And when it 
 is pointed out to him that he is getting fat, he says 
 it is but the infiltration of his tissues with diseased 
 matter. 
 
 There is one other case worthy of note under this 
 head. It is that of a patient who returns to Bethlem 
 every few years wdth exactly similar ideas. He is 
 admitted in a depressed and anxious state, refusing to 
 speak at first, but pointing to his throat, which he 
 wishes us to understand is closed up. In a day or 
 two he will say that he has no doubt about it, for 
 although in other attacks he felt in the same way and 
 thought there was throat obstruction, now he is 
 completely convinced that his end has come. He 
 invariably loses all these ideas in a few weeks, and 
 goes out well. 
 
 The above cases are good examples of throat 
 hypochondriasis, as seen in young hysterical or 
 nervous patients, in the adult with strong nervous 
 inheritance, and in the old associated with periodic 
 attacks of mental depression connected with physical 
 weakness. 
 
 In the next group the troubles are referred to the 
 epigastrium. This is the ordinary seat of painful 
 impressions in all nervous disorders. And the 
 Psalmist, in saying that his " bowels yearn," recog- 
 nised the fact that emotional feeling and disturbance 
 were ever associated with an uneasy sensation in the 
 abdomen. In early melancholia, in acute mania, even 
 
Chap. VI. i HVPOCHONDRIACAL Mf.LANCHOLY. I4T 
 
 ill simple fits of passion, uneasy epigastric sensation 
 is experienced. In acute mania this may lead to 
 excess of stimulants taken with a view of soothing 
 the uncomfortable feeling, Avhereas in the melancholic 
 patient the sensation may give rise to some fixed 
 delusion. Patients both old and young, male and 
 female, suffer in this way, and describe in different 
 ways their uneasy feelings. One will say that he 
 feels the food passing down the gullet and then 
 drop into a cloacal cavity, and another will allege 
 that it passes from the gullet into some tissue of his 
 body, or into the main circulatory system. In all 
 these cases the bodily symptoms differ in no way from 
 those of the ordinary hypochondriac. ' The insane 
 person is but an exaggeration of the ordinary 
 hypochondriac, and the prognosis depends entirely 
 on general conditions. In some of these cases the 
 chief difficulty in getting them to take sufficient food 
 is, that they are convinced that there is a limit to the 
 capacity of their abdomens, and they will refuse with 
 violence to take more food, and may have to be fed 
 artificially. 
 
 One practical point is noteworthy, and it is that 
 most of these patients have concave abdomens, and 
 although they may waste, and, in many respects, have 
 much the appearance of patients suffering from severe 
 chronic or malignant disease, yet, with all their com- 
 plaints, no local obstruction, nor any dilatation of 
 the gut will be found. Dr. Ord, of St. Thomas's 
 Hospital_, thinks that in some such cases there is 
 to be detected, even in life, contraction of the sigmoid 
 flexure, and that the stool passed in such cases will 
 be found to be extremely small and pipe-like, 
 
 Hyiiocliondriacal melancholy with ideas of bowel 
 obstruction and unv^orthiness, in a young woman. — 
 Kate M., single, twenty-nine. Maternal aunt in- 
 sane ; mother and two aunts died of phthisis. This 
 
142 Insanity and Allied Neuroses. [Chnp. vi. 
 
 patient spat blood twelve months ago and lost flesh. 
 Menstruation at times profuse. This is the first 
 attack of insanity, and it began with a sudden out- 
 break of destructive violence, which in a few hours 
 passed into melancholy. On admission she was 
 wasted and sorrowful -looking, silent and unoccu- 
 pied. She refused food, and said she was a great 
 sinner. She had to be fed with the stomach pump 
 for some v/eeks. She was sleepless, and would stand 
 about all night, and for this I had her placed in " dry 
 pack." 
 
 After two months' feeding by stomach tube, or by 
 nose-tube, some salt was added to the beef-tea, and a 
 thirst was created, which she herself satisfied. 
 
 Prom this time she took some food, and said she 
 was much better. She was sent to our convalescent 
 home, where she spent most of the year 1883. She 
 gained flesh, but still maintained that she had a 
 disease which prevented her eating. She said that all 
 her life she had been constipated, but that now^ her 
 bowels were completely closed, so that nothing ever 
 could pass again. 
 
 She was tried on leave of absence at home, but at 
 the end of three weeks was brought back much 
 wasted. Probably the patient will die of phthisis in 
 a year. 
 
 In some of these cases ulceration of the duodenum 
 has been proved to exist, by Dr. Claye Shaw, and I 
 have found similar pathological changes. Patients 
 belonging to this group, as a rule, slowly lose flesh 
 and strength, become bed-ridden, and die. It is well 
 that every method of feeding should be pursued, and 
 that the food should be varied in every way, in the 
 hope of finding some which will be retained and 
 assimilated. The many patent foods, such as the 
 peptones and extract of meat, with pepsine or other 
 digestives, may be administered. Nutrient enemata 
 
Chap. VI.] Gastric Hypochondriasis. 743 
 
 may be given, altliougli I have rarely seen good fol- 
 low their use, when the other methods have failed, 
 and I have once or twice seen symptoms of collapse 
 in such cases follow rectal feeding. 
 
 The last variety of this group contains cases in 
 which the complaint is that the bowels never act, 
 and that from some cause or another the lower 
 bowel is closed. There is no distinction in general 
 appearances between this class and the last, the 
 symptoms being similar in almost every particular. 
 Recently we had a patient in Bethlem, who for 
 over a year was possessed by the idea that all his 
 food was retained and gradually passed under his 
 skin, so that, as he said, he had tons of potatoes in 
 him ; and although when weighed from month to 
 month he was shown to be steadily losing weight, 
 this did not satisfy him, for he reiterated, as a fact, 
 the statement that he had tons of food about him. 
 He steadily lost strength, g.nd died, there being no 
 physical cause for the trouble in his abdomen to 
 account for his painful sensations. 
 
 A similar case is that of a woman, single, 
 fifty-two years of age, who had a previous attack 
 of insanity, from which she recovered. She was 
 admitted into Bethlem in the spring of 1883, pos- 
 sessed with the ideas that she was eternally lost, 
 that her blood was turned into water, and that her 
 bowels were filling up. She was constantly trying 
 to force a passage with her fingers (and this is 
 one of the most trying symptoms which occur in 
 these patients, the constant endeavour to relieve in 
 some way the uneasy sensations from which they are 
 suffering). For a time this patient lost flesh and 
 strength, but after seven months' treatment she began 
 to get stout. She was still, however, possessed with 
 ' the same miserable feelings and unhappy sensations. 
 I fear the case will pass into a chronic state from 
 
144 Lysanitv and Allied N'euroses. [Chap. vi. 
 
 wliicli she will never recover. This last case serves 
 as a good example of the whole class. 
 
 It is comparatively rare to meet in an asylum a 
 patient whose complaint about visceral sensations 
 is not joined to some idea of moral un worthiness ; 
 and it will be almost invariably found that the 
 patient who thinks he has lost his inside, or that 
 nothing passes through him, will sooner or later be 
 convinced that his soul is wrong in one way or 
 another. 
 
 Each case of hypochondriasis requires special 
 treatment. The young case requires exercise, liberal 
 diet, and if possible change of scene, change of com- 
 panions, and such conditions as are best obtained 
 by foreign travel with skilled attendant or medical 
 companion. A doctor's house in the country, Avhere 
 the patient is taken about pretty regularly by the 
 medical man, is also of use, but I believe many cases 
 are spoilt for want of early and decided cutting off 
 from old religious and social surroundings. Tonics, 
 in the form of iron, arsenic^ or zinc, are useful, but 
 no good will be done to such a patient unless he be 
 allowed to take some simple form of aperient pretty 
 regularly. I am in the habit of commencing with 
 some mineral water every morning before break- 
 fast, or giving tamar Indien, or encouraging the 
 habit of taking fruit stewed or fresh, or oatmeal 
 porridge. Too much attention must not be paid 
 to the state of the bowels, but yet there is consti- 
 pation in nearly all the cases, and it is just as well 
 to recognise the fact. If purgatives or aperients of 
 the kind described fail, it is well to try belladonna 
 alone or with nux vomica, and I have found good 
 i-esults in the administration of five grains of the 
 extract of aloes and one grain of quinine daily. To 
 place the patient under the best hygienic conditions 
 as to food, stimulants, and surroundings should be 
 
Chap. VI.] Sexual Hvpochondriasis, 145 
 
 the chief object ; then if the patient be young, and 
 has not suffered long from the disease, he may recover. 
 
 Oroiip 3.— Sexual. — Though ordinary hypo- 
 chondriasis occurs mostly in elderly men, there is a 
 variety of the same disorder commonly met with in 
 young and middle-aged men and women. Nothing in 
 this world so depresses a man as the belief that he 
 is impotent, and whether he has been in the habit of 
 using his reproductive organs or not, the idea that 
 he is unmanned reduces him to despair ; and although 
 I have said that as a rule the hypochondriac is not 
 actively suicidal, I have here to qualify that state- 
 ment in reference to the cases suffering from sexual' 
 hypochondriasis. 
 
 Besides the cases of middle-aged men who believe 
 themselves to be impotent, there are other cases of 
 youths who have given way to masturbation. Such 
 youths pass into a state of self analysis, and of study 
 and contemplation of their reproductive organs and 
 their functions in the same way that the ordinary 
 hypochondriac studies his digestion. 
 
 In some cases the idea is that there is something 
 or other wrong, and no reasoning or explanation is 
 able to persuade them to the contrary. Either the pa- 
 tient is haunted with an idea that he is physically and 
 morally ruined because he has erections of the penis, 
 or he is equally distracted because they are absent. 
 This class is the one which gradually develops ideas 
 about spermatorrhoea. Take, for example, a man, 
 twenty-eight years old, who was from early boyhood 
 given to self-abuse. He married with the idea that 
 he would thus, at all events, get rid of that vice, and 
 j)ass into a healthier and more physiological condition. 
 For a time he seemed better, but he indulged in the 
 most extreme way in sexual gratification. He con- 
 tinued at his work, but became nervous because 
 the sexual act became less pleasurable, and he 
 K— 14 
 
146 Insanity and Allied Neuroses. [Chap. vi. 
 
 was gradually convinced that lie was suiTering from 
 spermatorrhcEa. His whole ideas were concentrated 
 upon this matter. He consulted doctors, quacks, profes- 
 sional medical works, and followed every particular 
 advice which he could get, at one time exhausting 
 himself by abstinence from meat and stimulants, 
 and at another time overdrawing his physical ac- 
 count by long and weakening exercise. Notwith- 
 standing all his endeavours, the so-called sperma- 
 torrhoea became worse and worse, so that, as he ex- 
 pressed it, the mere going to the closet, or brushing by 
 a woman in the street, would produce an emission 
 without any sensation. Do what he would, the idea 
 followed him into the workshop, the church, and the 
 street that he was slowly being drained away. I 
 found that arsenic and avoidance of doctors did him 
 more good than anything else. I impressed on him, 
 at the same time, the importance of continuing at his 
 work, and trying to occupy his mind in one way or 
 another. 
 
 Case of sexual hypochondriasis ; recovery, 
 — A coachman, who had been a trusted servant of 
 one of our English noblemen, and who had led the 
 rather free life of a gentleman's gentleman during 
 the seasons in London, had not only contracted some- 
 what extravagant habits, but also had managed to get 
 venereal disease in its various forms. He became 
 engaged to be married, and then a reformation took 
 place in his conduct ; but he was surprised to find that 
 this purer form of affection was less associated with 
 erotic feeling than he expected, and he became pos- 
 sessed by the idea that he was impotent. His one 
 idea was that it was of no use his living, that he was 
 no longer fit to be reckoned among men ; and although, 
 if roused from these ideas, he would talk not only in- 
 telligently, but pleasantly, about his past experiences, 
 he soon relapsed when left to himself. After twelve 
 
Chap. vi.i Sexual Hypochondriasis, 147 
 
 months' treatment at another asylum he was brought 
 to Bethlem, and having been over a year there I 
 tried the effect of forcing him back into his old asso- 
 ciations, and daily a former job-master to his master 
 came to take him out for drives in the park and 
 elsewhere. For some weeks little progress was made, 
 yet, undoubtedly, his interest was returning to his old 
 pursuits, and before three months had passed he was 
 sufficiently well to be sent on leave of absence j at 
 the end of his leave he was discharged recovered, and 
 has not only lost his ideas about impotence, but has 
 been satisfactorily married to his former love, and is 
 in full work. 
 
 It is comparatively rare to meet with women 
 suffering from similar ideas ; and I am in doubt 
 whether to place the following case under this head, or 
 rather to look upon it as the outcome of ordinary me- 
 lancholia. A young woman, who, by the way, was 
 begotten by a father while he was himself on leave of 
 absence from an asylum, having become engaged to be 
 married to a young man suitable in every way, took a 
 vague fancy that it was wrong to marry. She treated 
 her lover with indifference, and caused him consider- 
 able worry and annoyance ; but he fancied these were 
 the ways of women, and were tests of his affection, and 
 submitted to all her freaks, the more especially as her 
 mother said, " it will be all right when once married." 
 After several contretemps the wedding-day arrived, and 
 the young couple were married ; it turned out after- 
 wards that the bride had to be freely stimulated with 
 brandy before she could be got to church. There was 
 some trouble about changing her dress, and getting 
 her into her travelling costume ; but this was accom- 
 plished, and bride and bridegroom started for their 
 future home, where they were to spend their honey- 
 moon. It was with difficulty that the bride was per- 
 suaded to go to bed, and on the bridegroom repairing 
 
148 Insanity and Allied Neuroses. [Chap. vi. 
 
 to the bridal chamber he found his bride still in her 
 clothes, lying outside the bed. No persuasion could 
 induce her to undress, and the matter-of-fact bride- 
 groom went to bed, and slept without his bride. The 
 bride spent the night in restlessly moaning and picking 
 her fingers, saying she was unnatural, and not like 
 other women. It was proved conclusively that there 
 was no physical incapacity on the part of the bride or 
 bridegroom, and the case having been tried in the 
 divorce court, nullity of marriage was decreed. 
 
 In this last case everything depended rather upon 
 the ordinary melancholic feelings that something was 
 wrong being referred to the reproductive organs, and 
 so, though not a perfectly pure case of hypochondriasis, 
 sufficiently resembles it to be cited here. And there 
 are many young women admitted into Bethlem with 
 vague feelings of being unnatural in consequence of 
 suppression of the menses ; these generally recover in 
 mind and body under tonic and general treatment, 
 with the re-establishment of the function. 
 
 A group of strange cases closely connected with 
 the above is represented by some instances in which 
 some act of immorality is committed, and although it 
 may not have been a very grievous fault morally or 
 socially, yet the person is never able to throw off the 
 impression. Thus, a middle-aged single man, who had 
 led an altogether continent life, on one occasion ex- 
 posed his person at his bedroom window, and although 
 no one seems to have been affected by the exposure, 
 and although for some weeks it made no impression 
 upon him beyond a slight feeling of having done an 
 immodest and unworthy act, yet, becoming dyspeptic 
 and out of health, he began to be impressed more and 
 more with the gravity of the act he had committed. 
 He sought relief by going to his religious adviser ; he 
 tried by confession, by charity, and by general good 
 deeds, to wipe out the evil ; but nothing he could do in 
 
Chap. VI.] Dysentery and Hypochondriasis. 149 
 
 any way removed the anguish, and day by day his 
 grief grew like a monster in a nightmare, threatening 
 to smother and destroy him. He had no loss of intel- 
 lect, no loss of reasoning power, had fair ability to 
 transact his ordinary business, but whenever alone the 
 same horror always returned. Such a case may seem 
 unusual ; but I have seen a dozen at least similar in 
 nearly every particular, except that the first cause has 
 been different in each, but has been, without excep- 
 tion, some dirty or low act in connection with the re- 
 productive organs, the symptoms rarely coming on at 
 first, but growing almost unperceived till the morbid 
 condition is fully established. Where practical, ad- 
 vising such patients to learn a musical instrument 
 is useful in distracting the attention and giving a 
 pleasant stimulus. Marriage is hardly to be recom- 
 mended, for they are already sufficiently prone to 
 dwell upon sexual matters, and being ignorant of the 
 physiology of reproduction, are likely to indulge with- 
 out restraint, or else, through nervousness, to feel 
 impotent. 
 
 General far aly sis of the insane^ with early syinptoms 
 of a hypochondriacal nature. — Thomas F., married, 42, 
 architect, admitted February, 1882. Paternal aunt in 
 an asylum. Phthisis also present on the father's 
 side. His illness began with suspicion and doubt 
 three months before admission. Over-study was given 
 as the cause. He was very suspicious, and fancied he 
 was going to be hanged. He thought the room was 
 filled with electricity. He had hallucinations of sight 
 and hearing. He complained of his thoughts and his 
 words running away from the top of his head. He re- 
 sisted being dressed. He refused food. He was full 
 of hypochondriacal delusions for a year, then he slowly 
 developed fully-marked general paralytic symptoms. 
 
 General hypochondriasis following dysentery. — 
 Eliza 0., single, 31. No history of neurosis in the 
 
150 Insanity and Allied Neuroses. [Chap. vi. 
 
 family. This patient had suffered from some "West 
 Indian fever, and had to return to England in 
 consequence of dysentery. She was extremely ema- 
 ciated and anaemic. 
 
 She believed God communicated with her, telling 
 her not to eat, and added that she must die. 
 
 She was obstinate, and at times inclined to be 
 violent if she were forced to take food. 
 
 IsTo dysenteric symptoms existed, and no treatment 
 made any impression on her symptoms. 
 
 She moaned all day long about her dying state 
 and about the brutality of the doctors in not sending 
 for her relations, as she had at most only a few days 
 to live. 
 
 She understood everything that was said to her, 
 and her speech and actions were coherent. 
 
 The one idea which dominated every other was 
 that of her coming death, and no reference to the fact 
 that she had had the same ideas for many months 
 past had any power with her. 
 
 Her condition being associated with weakness due 
 to a physical disorder may possibly be recovered 
 from. 
 
 In similar cases the patients have had ideas that 
 they had syphilis, small-pox, or some other contagious 
 disease, and it is common for such ideas to be associated 
 with the notion that there was moral impurity as 
 well, so that there is but one step between the fancy 
 that the person is suffering from syphilis and that he 
 is an unpardonable sinner. These cases have all the 
 other characteristics of the hypochondriac, intellec- 
 tually and morally. 
 
 To sum up, hypochondriasis may be so extreme as 
 to require the removal of a person from home sur- 
 roundings, and may even require detention in an 
 asylum ; the chief reasons for sending such persons 
 to asylums are the obstinate refusal of food, or the 
 
Chap, vii.] Melancholia. 151 
 
 suicidal tendencies. Hypochondriasis may be simple, 
 or more commonly it is connected with some delusions 
 of a melancholic type. 
 
 Hypochondriacal insanity may attack persons of 
 any age or condition. 
 
 It may be the initial stage of some other mental 
 disorder, such as mania, or it may be the first part of 
 the diseased process in general paralysis of the insane. 
 
 It may depend on some organic disease, such as 
 phthisis or renal disease ; or it may only be what is 
 called a functional disorder. 
 
 It is curable in direct proportion to the acuteness 
 of the attack, and to the general vital condition of the 
 patient. 
 
 Change of surroundings, exercise, and good hygienic 
 treatment, are better than many visits of the doctor. 
 
 CHAPTER YII. 
 
 MELANCHOLIA. 
 
 Melancholic conditions — Melancholia as a stage in mental disorder 
 — Varieties : active, passive, and stupid — Development, course, 
 and result — Relationship of melancholia to delusions. 
 
 Melancholia is a state of mental depression, in 
 which the misery is unreasonable either in relation 
 to its apparent cause, or in the peculiar form it 
 assumes, the mental pain depending on physical and 
 bodily changes, and not directly on the environment. 
 
 1, Melancholia may be one stage in the mental 
 disorder ; thus, it may usher in mania or general para- 
 lysis of the insane, it may be present after an attack 
 of mania, as a phase of reaction, or it may be one of 
 the stages vcLfolie circiolaire. 
 
152 Insanity AND Allied Neuroses. [Chap. vii. 
 
 2. Melancholia may be a complete process in 
 itself. 
 
 Melancholia varies greatly in its aspects, just as 
 grief causes an emotional storm in one person while 
 it stuns and stupefies another ; so the exaggerated 
 melancholy may be of an emotional or of a dull 
 lype. 
 
 I shall divide the class of cases which come under 
 the head melancholia as naturally as I can : 1. Into 
 those with simiole melancholy, i.e. those in whom the 
 misery and its expression are simply slight exaggera- 
 tions of natural states, those cases in whom there is 
 no real delusion, no fiction such as that they are 
 ruined or damned. 2. In contrast to these are 
 those suffering from active insanity, those who, instead 
 of suffering in silence, are constantly bemoaning their 
 lot, and, with hand-wringing and hair-tearing, are 
 heaping curses upon themselves. Such cases often 
 resemble patients suffering from mania in aspect. 
 
 The cases of most profound misery are classed as 
 suffering from Tnelancholia attonita, or passive melan- 
 choly. 
 
 Grief is a weight crushing these patients out of all 
 their social relationships. 
 
 They are the most miserable to look at of all 
 lunatics. So mindless may they appear that they may 
 be mistaken for patients suffering from dementia. 
 
 Melancholia may depend for its existence on some 
 delusion, but much more frequently the misery gives 
 rise to the delusion. A saturated solution of grief 
 causes, as it were, a delusion to crystallise and take 
 a definite form. 
 
 Melancholia has a bodily and a mental aspect. 
 
 Physical symptoms. — It is associated with an 
 anxious expression more or less pronounced, the skin 
 is generally sallow, the appetite bad, digestion imper- 
 fect, tongue moist, often tremulous and fiabby, bowels 
 
Chap. VII.] Physical Symptoms. 153 
 
 confined, and general nutrition impaired. Some di- 
 gesti\'e fault is, in many cases, the basis of the refusal 
 to take food, which is one of the most serious symptoms 
 in this disorder. The circulation is feeble, but as a 
 i-ule there is nothing special in the pulse which can 
 be associated with melancholia. Later I shall point 
 out that melancholic symptoms are not unfrequently 
 associated with visceral disease ; but the association is 
 not so frec[uent as to deserve extended notice here. I 
 have known the volume of the pulse materially dijSTer 
 in cases of recurrent melancholia, so that whereas the 
 upstroke was represented by a quarter of an inch in a 
 period of depression, it was represented on the sphyg- 
 mographic tracing by nearly half an inch in the 
 interval of health. Eespiration is generally slowed, 
 but without any noteworthy change in rhythm. As 
 a rule, the bodily movements are slow or monotonous, 
 and the temperature is occasionally sub-normal ; 
 frequently it is maintained at its ordinarj^ standard, 
 or may in active melancholia be above normal. 
 Although sexual feelings are in many cases in abey- 
 ance, yet this is not constantly the case. Menstruation 
 is frequently absent in women, but there may still be 
 sexual desire, and in both men and women I have 
 known cases of sexual excess and of masturbation 
 during periods of mental depression. Sleeplessness is 
 one of the most characteristic symptoms of this 
 condition. There are several varieties of sleepless- 
 ness, one in which the patient is restless, excited, and 
 unable to remain for a single minute in one position. 
 Such cases belong to the active melancholic class. 
 Other patients will lie placidly without moving, but 
 suffering torments (so they tell me) from sheer misery, 
 and some such placidly sleepless patients seem to be 
 able to do without complete loss of consciousness in 
 sleep for a very great length of time. They do not 
 wear themselves out as do the more active and restless 
 
154 Insanity and Allied Neuroses. [Chap. vii. 
 
 cases. They get rest, and probably there is some 
 sleep, although an unrefreshing or unrecognised sleep, 
 which enables them to endure for many months. I 
 remember a patient who recovered in the end, but 
 who for over three months was never found asleep 
 once by the night watch, who visited her hourly ; and 
 on recovery this patient asserted that she never lost 
 consciousness during the whole of the three months. 
 
 There are other conditions of sleep which we meet 
 with in melancholia. In some the patients own they 
 sleep, but at the same time say that the sleep is alto- 
 gether unrefreshing, so that when they wake up 
 they feel no better than when they went to bed. 
 Another form of insensibility occurs in these pa- 
 tients, so that they eat or drink in large quantities, 
 and yet without any feeling of satiety. Lastly, they 
 may sleep in a way which many have described as 
 " dead sleep," a condition which they compare rather 
 to syncope than to ordinary forgetfulness. They de- 
 scribe a sudden plunging into unconsciousness, and 
 an unexpected, unsatisfied return to wakefulness, and 
 in these cases also there is as complete a want of any 
 refreshing influence as in the former ones. 
 
 Sensory symptoms. — Sense perception in such 
 cases is often dull, and in some cases the melancholia 
 seems directly to be associated with impairment or 
 loss of one or more of the special senses. I am con- 
 stantly in the habit of referring particularly to cases 
 in which loss of sight or deafness is associated with 
 the development of melancholic symptoms ; but gener- 
 ally the chief change is one of dulled perception and 
 slow reaction. In a way this may be explained by 
 the abstraction of the patient's attention; his mind 
 being entirely occupied along one line it is difficult 
 to attract his attention in another. In this way an 
 apparent loss of common sensibility may occur, so 
 that a melancholic patient may pick his hands till 
 
Chap. VII.] Mental Symptoms. 155 
 
 they bleed, or make holes in his forehead with his 
 nails without seeming to feel it. The chief perver- 
 sions of sense, however, are the hallucinations and 
 illusions which are so common in these patients. 
 
 Probably, next to delusional insanity, it is more 
 common to meet with hallucinations in this group of 
 m.ental disorders than in any other. A very large 
 proportion of patients suffering from melancholia have 
 sense perversions, and half of the dreads, horrors, and 
 suspicions which fill the minds of the patients are due 
 to subjective impressions. " Yoices " are constantly 
 heard by night and by day threatening, warning, 
 accusing, and vilifying. Visions of horror, alarm, and 
 threatenings are conveyed by one or other of the 
 senses, which keep the patient ever on the rack. The 
 causation of these hallucinations will be considered in 
 detail, and examples will be given later. It may, 
 however, be well to state here that hallucinations, 
 although most common of hearing and next probably 
 of sight, are still extremely frequent with common 
 sensibility, producing the thousand and one strange 
 feelings of so-called magnetism, electricity, spiritual 
 communication or influence, and the like. 
 
 Mental symptoms. — In ordinary melancholia 
 the memory is good ; patients accurately recall what 
 has taken place before the attack ; they remember 
 what has occurred during the attack, and vividly 
 recollect the supposed cause of their break-down, 
 which generally to them appears some frightful enor- 
 mity or injury which has been magnified and coloured 
 by their morbidly sensitive condition. I have several 
 letters from patients telling me they remembered 
 being told by the doctors to rouse themselves, and 
 that such advice had had an influence upon them. 
 They feel acutely the tones in which they are ad- 
 dressed, and it is of the utmost importance that, 
 though they should be spoken to in a straightforward 
 
156 Insanity and Allied Neuroses. [Chap. vii. 
 
 way, yet this should be done without sneering or 
 bantering, for they will recall an unkindly word or act 
 as well as a kindly one. The association of ideas is 
 often natural, and although the ideas may seem to flow 
 but slowly compared with those in the acute mania, 
 yet they are normal in relation to one another. Patients 
 often will be found able to argue perfectly clearly and 
 connectedly about other patients, and upon subjects 
 not connected with their own insanity \ but as soon as 
 they are brought face to face with their own condition 
 they are unable to balance ideas. The patient who 
 feels herself a source of contagion, and who is desirous 
 to be buried alive to prevent others being affected with 
 the pestilence, is in no way convinced she is wrong 
 because from day to day the patients around her do 
 not acquire the disease ; yet she can see the absurdity 
 of one who daily complains that she was galvan- 
 ised the night before, or of another who says the 
 attendants are men in women's clothes. We had some 
 little time ago at Bethlem a woman possessed by the 
 idea that she had the itch, and this idea caused her to 
 object to shake hands with the doctors ; and although 
 she was at one time answered according to her folly, 
 and at another not according to her folly, her ideas 
 long remained unchanged, neither reason nor banter 
 appealing to her. As far as her powers of judgment 
 with respect to the best mode of managing a house 
 or controlling her children were concerned, she was 
 reasonable enough. She lost her delusion one night 
 suddenly. 
 
 One characteristic of the melancholic patient is 
 that his egotism should be so nearly allied to that of 
 the hypochondriac, and in Edgar Allan Poe's words, 
 "he is doubting, dreaming dreams no mortals ever 
 dared to dream before," so that a patient suffering 
 from melancholia will describe himself as being the only 
 one who has had such experiences. The very charm 
 
Chap. VII.] Letter of a Melancholic. 157 
 
 of texts in Scripture about the unpardonable sin is 
 that there was to be but one cast away. If there had 
 been hundreds of unpardonable sinners it would not 
 have appealed to the insane more than the general 
 statement that we are all sinners, or. as the Psalmist 
 
 A case of Melancholia with Ecstacy. 
 
 said in his haste, " all liars." The egotism of melan- 
 choly is very well shown in the graphic letter whiclt 
 I insert here : 
 
 " Yous etes trop bonne envers moi qui ne merite 
 pas la moindre consideration. Si vous pouvez cepen- 
 dant venir encore une fois me voir ici je vous serai 
 
158 Insanity and Allied Neuroses. [Chap. vii. 
 
 bien obligee. II ne faut pas attendre, ma chere amie, 
 que je retourne dans le monde. Je suis trop mechante 
 m^me pour cela, et si pour ce monde, alors certaine- 
 ment pour le ciel. J'ai quitte, d'une maniere la plus 
 impie, ma propre position dans la societe ; ce ne fut 
 jamais mon destin que d'etre ici. Je m'y suis con- 
 damnee pour ma seule faute, faute inouie, je crois, 
 dans toutes les annales de la race humaine. II reste 
 chez-vous quelques objets qui m'ont autrefois apparte- 
 nus, et je serais bien obligee si vous vouliez avoir la 
 bonte de les distribuer de quelque maniere qu'il vous 
 semblera bon. Tant de jolies choses que je ne reverrai 
 jamais, des cadeaux de mes parents et de plusieurs 
 amies-dehors cheres, tons inutiles a present. Oh ! 
 que ne puis-je aller vous voir comme dans les temps 
 passes, et entendre votre voix douce et gaie ! Vous 
 avez ete toujours si bonne et pleine d'amitie pour moi, 
 et j'ai regrette toute votre affection. Que n'ai-je 
 suivi votre bon exemple, alors j'aurais ete aussi utile 
 et heureuse ! Les benedictions du ciel restent sur 
 votre tete ; vous etes du nombre des saintes qui 
 demeurent dans les lieux qui seront pleins de la 
 gloire et de la presence de Dieu. Pensez-vous de 
 temps en temps a moi, miserable et seule dans les 
 tourments de I'eternite, et sans aucune amie pour 
 soulager mes mis^res ! Recevez I'assurance de mon 
 amitie, mais c'est une amitie pleine de regret, 
 
 Yotre mal-heureuse 
 
 Eleonore." 
 
 The correlative of egotism is .self-consciousness; 
 and, as some have described it, the melancholic seems 
 "wrapped "up in himself; and this idea of "self- 
 wrapping " is a good one, and describes the condition 
 admirably. It is impossible to define the boundary 
 between the melancholic patient, and the one who, 
 from exaggeration of self-feeling, has become the 
 
Chap. VII.] Religious Mania. 159 
 
 delusional lunatic ; for although the general bodily 
 and mental symptoms of the latter differ materially 
 from those of the former, yet they are but variable 
 developments from a similar stock. In the one, 
 the growth and development of ideas has gone on 
 under a morbid influence, so that the growth, like that 
 of a plant growing in a cellar, may be considerable 
 and varied, but yet with an unhealthy colour in 
 every fibre, whereas the other has ceased to develop, 
 but remains preserved in all its grim horror by its 
 dark surroundings. 
 
 Other points connected with the egotistical and 
 self-conscious side are the ideas of moral and physical 
 change and perversion. Patients describe themselves 
 as being unnatural, as having lost all power of human 
 love ; they believe themselves to be ruined, and to be 
 the causes of misery to those around them ; or they 
 may be crushed by the dread of an impending sorrow. 
 I often think that the priest of Apollo Laocoon 
 well represents the unpardonable sinner, and that the 
 sword over the head of Damocles marks but the 
 feeling of impending fate as felt by the patient 
 suffering from melancholy. 
 
 Two other prominent symptoms are associated in 
 the public mind with melancholia. The one, religious 
 mania so-called, and the other, suicidal tendencies. I 
 have referred (see page 50), under the head of causation 
 of insanity, to the relationship of religious move- 
 ments to inyanity, and I would repeat the statement 
 that religion rarely produces insanity, but constantly 
 colours it. It may be said that the very fact of its oc- 
 curring so frequently as a symptom, and having some 
 relationship as an exciting cause, are sufficient evi- 
 dences that it is an important element in the produc- 
 tion of the disorder. But I would reply that the gun- 
 cotton requires but a light, it matters not whether 
 it comes from an electric spark, a steam - engine_, 
 
i6o Insanity and Allied Neuroses. [Chap. vii. 
 
 or a silent match. The real explanation of the im- 
 mense number of cases with religious ideas, suffering 
 from melancholia, is that religion, being an unde- 
 fined environment of man, lends itself readily to the 
 explanation of the unknoAvn. Religion begins by 
 formulating a series of dogmata which can in no way 
 be dispi'oved, and its followers are taught that they 
 are to judge of their relationship to the great ques- 
 tions, not so much by their actions as by their feelings. 
 What wonder is it, then, that, having strange feelings 
 which they have never before experienced, they should 
 infer that these are only to be explained on religious 
 grounds % It does not matter much what the previous 
 education of the patient has been. I have known a 
 man who for twenty-five years led the life of a cul- 
 tured atheist ; a man whose whole energies were 
 developed for self -gratification in every way ; who 
 was refined by his knowledge of ancient and modern 
 literature, and by a constant intercourse with the 
 world, yet, on becoming melancholic, he subsided into 
 an emotionally religious man, appealing to all whom 
 he met to look after the welfare of their souls, be- 
 lieving himself to be cast away for ever. 
 
 It is needless now to enlarge further on the so- 
 called " religious mania," as it will be seen that in 
 the great majority of cases referred to this group, 
 there is only a strong tendency to explain their 
 misery by means of some text or religious dogma ; 
 for instance, one patient who was desperately suicidal 
 and also homicidal, believed that he was destined to 
 be the second Judas Iscariot, and would have to pass 
 through the same course as his prototype when mil- 
 lennium was at hand. This last patient was, as I say, 
 not only suicidal, but homicidal. As a rule there is 
 much greater danger from suicide in these cases than 
 from homicide ; but as it is impossible accurately 
 to gauge the motives of an insane person, it would be 
 
Chap. VII.] Suicidal Tendencies. i6i 
 
 daDgerous to say that simply because a man is strongly 
 suicidal he is not likely to be homicidal also. It 
 might be said that a man who believed himself to be 
 Judas Iscariot would have no reason to wish to kill any 
 one but Christ ; but this very man determined and 
 attempted, on two occasions, to kill me, without being 
 able to give any other reason than that he would be 
 no worse off in the future state whether he killed me 
 or not. This is a good example of the difficulty, if 
 not impossibility, of calculating on the actions of an 
 insane person, though in many respects he may appear 
 to be nothing beyond a monomaniac. 
 
 Suicidal tendencies may arise from very different 
 causes, just as the attempt may be made in very 
 different ways. It is strange, in reference to this last 
 point, that suicidal patients should have favourite 
 methods of putting an end to their lives, and that 
 they will even incur danger in order to accomplish 
 their end. In this way I have known a patient ex- 
 tremely well-behaved while at our convalescent home, 
 who appeared to have forgotten all about his desire to 
 kill himself until he was discharged, when, avoiding 
 river and railway, he blew his brains out with a 
 revolver, having first attempted to kill himself in this 
 manner before his admission into the hospital. It is 
 narrated also that a patient escaped from an asylum 
 and swam a river, and then threw himself under a 
 railway train. The monotony of their thoughts thus 
 persists and shows itself even in attempts at self- 
 destruction. Patients may commit suicide to get 
 rid of the bodily or mental misery from which they 
 suffer ; it is thus with certain hypochondriacs ; they 
 may commit suicide because they believe themselves 
 too bad to live, or because they think their influence 
 is spiritually or physically contaminating. They may 
 kill themselves because " voices " urge them to do so, or 
 tell them they are too cowardly to dare to die ; ideas 
 L— 14 
 
1 62 Insanity AND Allied Neuroses. [Chap.vn. 
 
 of being followed or persecuted often cause suicide ; 
 patients may achieve the same end because they 
 believe they have to bear the sins and sorrows of the 
 world ; or believing they are already dead, or so 
 utterly changed and unnatural, they consider that 
 throwing themselves into the river is but getting rid 
 of a dead and decaying body. The dread of vivisec- 
 tion and the horror of hearing the cries of their re- 
 lations, who they think are being tortured, make 
 patients desperately suicidal. 
 
 It is difficult to give every possible cause or idea 
 which may lead to suicide. The above, however, 
 point out sufficiently the chief causes which may give 
 rise to attempts at suicide in patients suffering from 
 melancholia ; for it must be remembered that patients 
 may kill themselves when suffering from other forms 
 of mental disease as well as melancholia. The maniac 
 may throw himself from a height, because he believes 
 that angels bear him up ; or the general paralytic, 
 with all his fulness of happiness, may cause his own 
 death in his attempt to show his immortality. 
 
 Melancholia having now been considered generally 
 in its bodily and mental aspects, and having been sub- 
 divided into convenient groups, it remains for me to 
 describe more fully its general pathology and aetiology, 
 its course and the results followins: it. 
 
 Melancholia may be the mental side of bodily 
 disease. In certain temperaments change in the 
 nutrition of the brain depending on some general or 
 local disease may set up mental pain. The mental 
 machine no longer acting smoothly, there is friction 
 and imperfect action. 
 
 Melaiicliolia is common in conditions of phy- 
 sical weakness apart from organic disease. 
 
 [Exhaustion, or drain on the nervous system, 
 may set up the disordered process. 
 
 Not only is direct drain a cause of melancholia, 
 
Chap. VII.] Exhaustion. 163 
 
 but any cause, bodily or mental, which worries the 
 body or the mind, any cause which by its constancy, 
 or by its frequent repetition, gives no chance of repair, 
 may also cause melancholia. 
 
 In some cases toxic materials in the blood will act 
 in the same way. 
 
 Just as mania was pointed out to be a condition 
 of weakness with loss of control, so melancholia is a 
 state of painful self-conscious weakness. 
 
 Melancholia may in its course be progressive, 
 passing from a vague feeling of inexplicable unhappi- 
 ness through a stage of more profound misery to one 
 of the deepest woe. 
 
 Melancholia may consist of a series of fits of de- 
 pression of greater or less intensity separated by 
 periods of mental health. 
 
 As I have already stated, melancholia may be 
 the initial stage of any form of mental disorder. 
 
 Melancholia may suddenly pass off, or it may 
 gradually clear up. 
 
 In most cases the recovery from melancholia is 
 associated with improvement in general health. 
 
 Slow, steady recovery is especially common in 
 young, otherwise healthy, people, and in those in 
 whom the melancholy has been but an exaggeration 
 of a natural physical or moral depression. Thus it 
 was with a man who slowly became possessed by the 
 idea that he had been the cause of his late wife's 
 death, and who, in consequence, was sleepless, suicidal, 
 and lachrymose for weeks ; but when he began to sleep 
 better and to assume a more healthy aspect bodily 
 and facially he began to lose these ideas, and men- 
 tally and physically became well. In other cases, the 
 attacks of depression go and come for a time, gradu- 
 ally becoming more pronounced, and in such cases con- 
 siderable risk is run and fatal accidents occur. Thus, 
 a woman I once saAv in the country was suffering 
 
t64 Insanity and Allied Neuroses. [Chap. vii. 
 
 from mental depression that had followed the death 
 of her husband, which left her in poor circum- 
 stances. She was living in a solitary, out-of-the-way 
 house. She was depressed ' for some days, and then 
 set about her household duties as before. Again de- 
 pression came on, and her friends grew alarmed. I 
 saw her, and warned them of the danger of leaving 
 her alone. The magistrate was informed of her con- 
 dition^ but when he visited her she was again quiet, 
 and he declined to act in the matter. Within a week 
 after she hanged herself in the barn. In such cases, 
 in women, it is particularly noteworthy that the chief 
 danger occurs about the menstrual periods. Cases 
 with recurrences of this kind, if treated sufficiently 
 early, may go through the inverse process, having 
 slighter recurrences at longer intervals till they com- 
 pletely recover. 
 
 Some cases recover suddenly, and these cases are 
 even more difficult to explain than similar ones met 
 with in acute mania and hysteria. I have known a 
 patient with melancholia with delusions, fall asleep, 
 and wake up to find the cloud gone. And I have 
 known a person convinced of the faithlessness of his 
 wife, who had constructed a whole romance of cir- 
 cumstantial evidence which completely misled me into 
 believing that it was possible that he was after all 
 rather sinned against than deluded, lose the whole of 
 this airy fabric when leave of absence was granted to 
 him and his home environments were re-established. 
 Not only may delusions pass off suddenly, but the 
 gloom of melancholy may also lift itself as a cloud 
 from a valley. One patient, who was in Bethlem for 
 fifteen months, although standing like a veritable statue 
 of woe, neither speaking nor eating, nor allowing 
 anything to be done for him during that time, yet 
 when being removed as " uncured " from the asylum, 
 suddenly woke up, conversed freely, and remained 
 
Chap. VII.] Delirious Melancholia. 165 
 
 well for twelve years, after the lapse of which time 
 he was brought back to Bethlem in a similar con- 
 dition. Having, however, become wiser by former 
 experience, we did not on this occasion allow him to 
 become mentally rigid ; but by means of sending him 
 for drives, and for a few hours at a time restoring his 
 home associations, we were enabled a second time to 
 discharge him, and this time as "cured." I shall 
 give other examples of the more or less sudden cures 
 which may occur in melancholia. 
 
 Others may pass from melancholy with stupor as 
 an active disorder^ into a state of stolid misery, in 
 which the miserable aspect is rather the indication of 
 the misery which has been felt than an index to the 
 feelings at the time. 
 
 Melancholia may end in secondary dementia, and 
 in all large asylums there are sure to be found many 
 patients, often useful helps in the wards, who have 
 passed through attacks of mental misery. Such 
 patients may, in their weak-minded state, show no 
 signs of their old disorder or of their old delusions ; 
 they may show few or many scars as the result of the 
 fights they have passed through ; and yet, from their 
 simple silly condition, it is impossible to say what 
 was the nature of the first attack, whether maniacal 
 or melancholic. 
 
 Melancholia often ends in death. A certain 
 number of young cases die of " broken heart ; " and 
 I suppose the best way of describing this mode of 
 death is to call it simple melancholia. In my ex- 
 perience, it is not uncommon to meet with cases similar 
 to those dying of acute delirious mania in this class. 
 
 Acute delirious melancholia has already been re- 
 ferred to in a case given at page 95. 
 
 In this condition the general symptoms closely 
 resemble those met with in acute delirious mania. 
 The patients are often highly unstable from nervous 
 
i66 Insanity and Allied Neuroses. [Chap. vii. 
 
 inheritance. Moral causes, such as grief or love 
 affairs, act as powerful causes. There are sensory- 
 perversions, such as partial anaesthesia and colour 
 blindness. Ovarian tenderness is commonly present 
 with menstrual irregularity. The bodily temperature is 
 above normal, the tongue dry and brown, and food is 
 refused. The condition approaches that of typhoid. 
 Neglect of personal appearance, and apparent forget- 
 fulness of friends and surroundings, all complete 
 the parallelism between the two states ; only in acute 
 delirious melancholia mental depression is present. 
 Rapid death or recovery follow. 
 
 Patients admitted into Bethlem every year in con- 
 siderable numbers, refusing food, obstinate, nervous, 
 and suspicious, often die, notwithstanding care and 
 constant feeding, of some bodily disease other than 
 that of the brain. 
 
 These are often young girls who refuse food 
 because they are unworthy^ or because they feel un- 
 natural. In these cases there is often lung disease, 
 which may be the cause of the whole of the mental 
 disorder, or I believe that the impaired nervous state 
 may lead to low forms of inflammation of the lungs 
 which end fatally. 
 
 I have met, too, with tubercular disease of the 
 kidneys and other visceral diseases in similar cases. 
 In an old man who was admitted with profound 
 melancholia, and with the idea that he was dying, 
 and therefore ought not to be cared for, we found 
 there was old peritonitis due to perforation of 
 appendix cseci, which_, without giving rise to any phy- 
 sical signs, had caused the production of half-a-gallon 
 of pus. Other cases of melancholia die, and their 
 symptoms really de^^end on the changes due to 
 general paralysis of the insane, which has not been re- 
 cognised owing to the silence and the obstinacy of the 
 patient. 
 
Chap. VII.] Simple Melancholia. 167 
 
 So that I end this part as I began it, by repeat- 
 ing that melancholia may be the mental symptom 
 of bodily disease. 
 
 Special forms of inelancliolia. — Simple 
 
 melancholia. — It is of the utmost importance that 
 mental disorders should be recognised as early as 
 possible, and in studying the condition which I have 
 called simple melancholia, I shall insist on the 
 necessity of recognising it as a stage of disorder 
 which, if neglected, may become chronic and 
 incurable. 
 
 I have described a group of cases under the head 
 of acute mania, in which the chief, if not the only 
 symptoms were slight alteration in the social relation- 
 ships of the individual; and under melancholia I must 
 place those with slight perversions of feeling and 
 intellect of a gloomy nature. In the former men 
 acted in an eccentric way, so that those who had 
 been steady and industrious became amorous and 
 given to drink and self-indulgence. With the 
 simply melancholic patients, we meet with every 
 shade of depression, which may be dependent either 
 upon some traceable bodily disease, such as phthisis, 
 or may arise from some bodily disorder. The 
 patients to whom I refer very commonly have 
 insane relations, and are, in fact, already unstable. 
 Such cases are very commonly met with in the 
 young of both sexes ; but they also occur in middle 
 and advancing life in patients who are doing their 
 life's work energetically and well. It is common 
 for physicians to be consulted for symptoms of 
 melancholia by active-minded busy men, who have 
 really exhausted themselves by over- strain rather 
 than by over-work ; and many such cases not only 
 recover, but live to rise nearly to the top in their re- 
 s])ective professions ; though as a rule their mental 
 tlaw prevents the very best being done by them. 
 
i68 Insanity and Allied Neuroses. [Chap. vii. 
 
 Melancholic depression of this kind aflfects each in- 
 dividual differently ; some are wretched, being occu- 
 pied with their own feelings of misery, but without 
 delusions. They resemble, in many points, the ordi- 
 nary hypochondriac, save that they are more content 
 to be left alone, and are not desirous of pouring their 
 woes into every ear ; and their woes are mental, not 
 bodily. 
 
 The younger cases begin much in the following 
 way : A young man of about twenty years of age, 
 having entered some business or calling without any 
 definite desire to follow that avocation, sticks to it 
 conscientiously for a time, but without the interest 
 and enthusiasm which is natural to youth. He often 
 takes to brooding and vdshing he was something else ; 
 but family requirements keep him where he is. He 
 is at the same time leading a quiet and unhealthily 
 reserved life. When away from work he has no 
 special hobby, and drifts into idle speculations. If 
 he happen to have indulged in masturbation he be- 
 comes worse ; he takes a long time in undressing and 
 getting into bed, and is equally long in rising and 
 washing in the morning. He displays a want of 
 crispness and energy in every act which is not auto- 
 matic. ' He frequently, at this time, takes to reading 
 theological and medical books, and some morning 
 astonishes his friends by an outburst of tears, or by 
 marked irritability and change in his temper. He 
 may make some attempt to throw off the bondage 
 which he feels holding him, but unless his condition 
 be recognised and his surroundings entirely changed, 
 he will probably pass into a more profound stage of 
 melancholy. He feels weak, disgusted with himself, 
 and thinks that he is unlike other youths, and that 
 there must be something radically wrong because 
 he has no feelings of sympathy or love for any one in 
 the world. He may express himself as feeling dead. 
 
ch:^p. VII.] Simple Melancholia. 169 
 
 Such patients will frequently make a confidant of the 
 doctor, and express every anxiety to recover, but at 
 the same time acknowledge themselves unable to 
 make an effort. There is but one method of treat- 
 ment for such cases. For a time let them be rooted 
 up and allowed to move from place to place, or if 
 means are wanting, let some change of occupation 
 be sought ; I would also recommend some mechanical 
 occupation, such as work at the bench, on the farm, 
 or such like. Yoyages are undoubtedly serviceable ; 
 but then there is always some risk that these patients 
 may become suicidal, and therefore it would be un- 
 wise to send them to sea, unless under careful charge. 
 Occupation, interest, and change, associated with 
 cold baths, sea-bathing, regular muscular exercise, 
 and a liberal diet with stimulants taken with the 
 meals, frequently produce beneficial results. It is, 
 however, of great importance to remember^ that 
 as this morbid condition has been slowly establish- 
 ing itself, so it cannot be expected to pass off very 
 rapidly, and a period of from four to twelve months 
 is necessary to effect a cure. If the case, instead 
 of improving, become worse, we have an example 
 of a form of simple insanity, which may require 
 asylum treatment ; for these cases should not at first 
 be sent to asylums, treatment in the homes of 
 medical men or of tutors being preferable. As soon 
 as a young patient threatens to commit suicide, it is 
 time to consider the question of removing him to an 
 asylum. The other symptom which often necessitates 
 the seclusion of such patients is that of refusing food. 
 Further examples of the class simple melancholia 
 are found in young girls who come into the asylum 
 with the very worst of characters as far as suicidal 
 tendencies are concerned. I must own that there is 
 much more cry than wolf, in my experience ; for 
 although I have seen at least a hundred such cases, 
 
170 Insanity and Allied Neuroses. [Chap. vii. 
 
 one half of wliom have been said to have attempted 
 suicide even while in the hospital, the attempts were 
 about as futile as those of the hysterical girl. We 
 admit patients of this kind, who at once set to work 
 to pick a hole in a vein with a pin, to choke them- 
 selves with a i^ocket-handkerchief, to drown them- 
 selves by holding their faces in a wash-basin, or even 
 attempt self-destruction by what they call swallowing 
 their tongue. I would not willingly throw the at- 
 tendants on such cases ofl' their guard, but I would 
 here register my experience that suicide in such cases 
 is very rarely effected. 
 
 In these young women there is either restlessness 
 and inability to work, or stolid indifference ; they are 
 sallow in complexion, the tongue is tremulous, often 
 flabby and coated, appetite bad, food often refused, 
 bowels confined, circulation feeble, and menstruation 
 absent. Tonics, change, and exercise cure the 
 majority of such cases. 
 
 Sex influences the aspect of these cases of simple 
 melancholia. They pass gradually into those suffering 
 from more severe types of melancholia, and those 
 in whom delusions exist, and I shall consider some 
 cases which may be looked upon as connecting links 
 in the chain of disorder. 
 
 Among men we meet with patients whose misery 
 has become excessive, though unassociated with de- 
 lusion ; they may be desperately suicidal from sheer 
 distress, or they may feel driven to do insane acts 
 through what they call "influence." They are weak 
 of will, and are driven like a leaf on a rapid stream. 
 
 Simple melancholia passing into m^elancholia with 
 delusions. Eemissions, recovery. — W. H., single, aged 
 nineteen. No insanity in his family, but phthisis 
 killed several on his father's side. He had a first 
 attack when seventeen, but recovered, and has been 
 well since. Masturbation, if not the cause, was an 
 
Chap. VII.] Suicidal Melancholia. 171 
 
 early symjDtom of the disease. Two months before 
 admission he became irritable and lazy, and woidd not 
 get up in time for his business. He complained of 
 pains at the top of his head. He became stolid, 
 but without delusions. He refused food, was rest- 
 less and sleepless. His expression was dull. Slowly 
 he developed the idea that he had committed the un- 
 pardonable sin. He had visions and hallucinations 
 of hearing and of taste. He believed he was going 
 to die. Pupils widely dilated ; extremities cold. On 
 admission he was obstinate, and neglected his bladder 
 and bowels ; his expression was dull and his general 
 health feeble. 
 
 He had to be fed with the stomach pump, and 
 was constantly wet and dirty. He began to take his 
 food within a week, and in two weeks had begun 
 to show signs of returning sanity ; in three weeks 
 he appeared well, but a month from admission he 
 once more passed into a state of melancholia, from 
 which he again recovered. These recurrences were of 
 slighter degree, till in the end he was discharged well 
 for the second time. 
 
 Such a case resembles those already described, in 
 which the patients oscillate between acute mania and 
 health for some time before they become stable. Ad- 
 vantage should always be taken of the periods of 
 health to try change in the surroundings, although 
 relapses may occur. 
 
 Example of destructive and suicidal excitement in 
 a youth. Recovery. — A lad of twenty years old, who 
 was brought up purely at home among female rela- 
 tions, developed habits of self-contemplation and of 
 masturbation, which rendered him weak, nervous, 
 emotioual, and unfit for his ordinary avocations. He 
 gave way to several emotional storms, in one of 
 which ho destroyed a good deal of furniture, and 
 seriously lacerated his hands. He was admitted into 
 
172 Insanity and Allied Neuroses. [Chap. vii. 
 
 Bethlem tied hand and foot, with the usual history 
 that he must not be left a minute. For a few days 
 he was very much excited, and gave way to mastur- 
 bation to an excess. Besides this, he was dirty in his 
 bedroom, and on one occasion he drank the contents 
 of his chamber. When spoken to he said he was 
 obliged to do this, but he declared that no voices or 
 other indications from without made him act as he 
 did, but that he "felt he must." It is common to 
 meet with weakly cases who say they are influenced; 
 they feel that when doing a thing they do not them- 
 selves exercise any volition. By means of employment 
 and getting him interested in his old occupations and 
 amusements, among which were music and chess, he 
 rapidly regained general tone, and passed into a state 
 of convalescence. 
 
 Among women we meet with very similar cases, 
 such as the following : An artist's daughter, whose 
 education had been somewhat irregularly carried on, 
 whose physical development was feeble, and whose 
 inheritance was neurotic, at the age of twenty became 
 disturbed in mind and body. Menstruation ceased 
 to be regular, her appetite failed, she slept badly, 
 and became indolent, irritable, and restless. The 
 symptoms slowly increased. She fancied herself un- 
 worthy to live, a disgrace to her family, and one who 
 was bound to cause harm to her relations. She was 
 convinced that she was unnatural in mind and body ; 
 that she was without natural affection for God or 
 man, and that it was but wasted kindness in her 
 friends to try and " cure her." A complete change 
 in the surroundings, a regular diet, and constant 
 exercise, with medical treatment of the amenorrhcea, 
 produced great improvement in her physical con- 
 dition, and the mental cloud thinned away, till it dis- 
 appeared altogether, leaving her once more a bright 
 and happy girl. 
 
Chap. VII.] Simple Mela ncholia . 173 
 
 It would be useless to enlarge much more upon 
 such cases, it being acknowledged that a certain 
 number may be treated at home ; that more may be 
 treated in a private house where complete separation 
 from relations is ensured, and others must be sent to 
 asylums and hospitals, either because the home circum- 
 stances are not suitable for their treatment, or the 
 patient's condition from suicidal tendencies or refusal 
 of food necessitates extra and skilled care. 
 
 Cases of simple melancholia may occur, as T have 
 said, in middle life. Thus a strong vigorous man, who 
 had engaged in some fresh speculations, involving the 
 greater part of his fortune, found that the venture 
 was not so successful as he expected. He was dis- 
 tressed at the thought that his newly-married wife 
 might have to face difficulties, if not poverty. These 
 causes started sleeplessness and a tendency to worry ; 
 his appetite failed, and he suffered from dyspepsia 
 and constipation. For a time he took to keeping 
 a bottle of sherry in his office, and supported him- 
 self by nips, till, having over-drawn his physical 
 account, he failed utterly, and his wife and friends 
 were alarmed to find him collapsed as it were, and 
 unable to rouse himself from his chair. No vital 
 interest and no affection seemed to exist in him, He 
 neglected important business, and irritably refused to 
 be fed or to be doctored. Certain threats of suicide 
 rendered it necessary that he should be watched, and 
 a very few weeks of removal from home, with careful 
 medical and general treatment, restored him to his 
 family, among whom he has since lived, and continues 
 to follow his occupation. 
 
 In another case a woman, who had had a large 
 family rather rapidly, passed into a weak physical 
 condition, having no appetite and sleeping badly. She 
 talked in such a veiy casual way about self-destruc- 
 tion, and her want of affection for her children, that 
 
174 Insanity and Allied Neuroses. [Chap. vii. 
 
 her friends became alarmed, and a doctor who saw 
 her recommended them to apply for admission into 
 Bethlem. The woman with her husband came to see 
 me, and I decided that before sending her into an 
 asylum it would be better to try general treatment ; 
 for I found that, associated with prolonged lactation, 
 there had followed menstrual irregularity, and finally 
 amenorrhcea, which had persisted for nine months. 
 Warning the friends of the danger, and showing 
 the necessity of constantly having a companion with the 
 patient, I commenced treatment by means of Griffiths' 
 mixture. Weeks passed, during which she returned 
 regularly, but although improved in health her mind 
 remained dull and oppressed. She told me that she 
 went about her work like a machine ; that she did 
 not care what happened to her children ; that she had 
 no aftection whatever for them ; that she understood 
 one was at that time dying of bronchitis, but she did 
 not care. On a subsequent visit she said the child 
 had died, and still she did not care, and surely I must 
 admit she was unnatural after that. Other medicines 
 were tried without avail, till I put her on arsenic, 
 which she continued in increasing doses for several 
 weeks ; one morning she came into my room, with 
 a completely altered aspect^ and at once exclaimed, 
 "Well, doctor, I am natural again." I asked her, 
 "Since when?" She replied, "As soon as I became 
 regular." These slighter conditions of melancholia as- 
 sociated with feelings of not being natural, occur very 
 constantly in cases of amenorrhcea. As we may meet 
 with amenorrhcea lasting some time after the re- 
 establishment of the general health in nervous cases, 
 so simple melancholia may be the last symptom to 
 leave before the complete mental recovery. 
 
 In older persons simple mental depression 
 occurs, associated with the earlier stages of senile de- 
 generation \ generally, apathy, indolence, and the 
 
Chap. Vn.] 
 
 Active Melancholia. 
 
 175 
 
 dread of some unknown calamity are the symptoms, 
 and the chief danger is suicide. The treatment must 
 be palliative ; as a rule there is little prospect of perfect 
 recovery in such cases, although a fresh intellectual 
 
 A case of Active Melancliolia. 
 
 balance may be established, it is one of a less de- 
 veloped or complex character. 
 
 Active melancliolia. — This name fairly de- 
 scribes the disorder, and I should say it occurs mostly 
 in women and men of middle age, and of advancing 
 years. It is characterised by restless misery, as seen 
 in the constant picking of fingers, pulling out of hair, 
 and a tendency to strike or damage anything that 
 
176 . Insanity and Allied Neuroses. [Chap. vii. 
 
 appears to be an obstacle to its free exhibition. Gene- 
 rally in these cases there is some marked delusion, and 
 most commonly this delusion is connected with the 
 idea that some one else is going to be injured on her 
 account. The delusion may shift according to the 
 surroundings ; thus, one woman now in Bethlem, 
 when at home, believed she would cause the ruin 
 and death of her relations, and that, in consequence, 
 she must be killed. When admitted, her idea was 
 that the doctor's child must be crucified through her, 
 because it was the babe of Bethlehem. 
 
 In another case the patient moves restlessly about 
 moaning, and worrying every one she comes in contact 
 with, because she thinks her friends are accused of 
 having done things which are disgraceful, and she is 
 constantly repeating that she is " mixed," and that it 
 is not their fault. In this way two years have, been 
 passed, and the only prospect of recovery lies in the 
 fact that she is still capable of being recalled to her 
 old ideas, and can be induced to play the piano, 
 speak French or German, and recognise visitors. 
 Thus there is a groundwork upon which an intellectual 
 fabric may be re-established. 
 
 One young woman recently admitted into Beth- 
 lem after her first confinement, which was a tedious 
 and instrumental one, became deeply melancholic 
 within two months of the birth of her child, having 
 been sleepless, and oppressed by the idea that she was 
 going to die, this feeling being most marked in the 
 early morning ; she became suicidal and violent, re- 
 fused food, said she was inhumanly wicked, that she 
 had ruined her husband, and ought to be got rid of. 
 After admission she would romp up and down the 
 wards, moaning, and pushing furniture or patients 
 about. She seemed so lost to sensibility, that she 
 picked the greater part of her finger-nails off with pins. 
 
 The treatment of this case was by repeated small 
 
Chap. VII.] Active Melancholia. 177 
 
 doses of morpliia, with occasional saline aperients, and 
 within six months she completely recovered, and 
 returned to her home. Many of these cases of active 
 melancholia do not recover, some wearing themselves 
 out rapidly by their constant sleepless activity ; such, 
 patients cannot be well treated out of an asylum, as 
 they are often violent and destructive, besides being 
 hard to manage. Some pass into a state of auto- 
 matic misery, and in most asylums such cases as the 
 following are to be seen. 
 
 A woman was admitted into Beth 1 em, two of whose 
 sisters had also suffered from melancholy ; she was 
 forty-five years old, and single, had had several 
 previous attacks of mental depression, and when ad- 
 mitted was suffering from the most marked active 
 melancholia I have ever seen. She would keep on 
 rocking backward and forward, moaning that she did 
 not know what to do. Day by day this went on, and 
 the tone of her voice kept constantly getting harsher 
 and louder. At first she wasted, and it appeared 
 likely she would wear herself out. She, however, 
 began to take food in abundance, gained flesh, and 
 slept better. The prognosis naturally became graver 
 as far as mental relief was concerned, bodily gain 
 without mental gain being generally of unfavourable 
 import. In her case the repetition of the formula, 
 " I don't know what to do," had become perfectly 
 automatic, and went on without distressing her. It 
 was noteworthy that on one occasion, on a cold frosty 
 morning, an attendant, more hasty than considerate, 
 said to her, " If you don't know what to do, I do ; and 
 if you make much more noise I shall send you out in 
 the grounds." The patient, without any change in her 
 expression, lowered the tone of her complaint, and for 
 the rest of her stay never returned to the trying 
 pitch of her first wail. After many years she is still 
 the same. 
 
 ivi-14 
 
i7vS Insanity and Allied Neuroses. [Chap. vii. 
 
 Some patients, suffering from active melancholia, 
 have hallucinations of hearing or of sight ; but I should 
 say in the majority of cases they have simple delusions 
 arising from the feelings of melancholy. Such cases 
 may be suicidal ; but I do not consider these nearly so 
 likely to injure themselves as the more stolid cases to 
 be referred to later. No general treatment can be re- 
 commended for all. In the younger cases, suitable 
 tonics, such as arsenic, zinc, and iron, with stimulants, 
 a liberal diet, and exercise, are most beneficial. I do 
 not often use morphia, bromide of potassium, or 
 chloral hydrate in these cases, but in older cases, and in 
 those connected with the climacteric, T find morphia by 
 mouth or subcutaneously, in repeated and increasing 
 doses, sometimes beneficial ; however, I would warn 
 those using this remedy not to be misled by the tem- 
 porary improvement, for frequently cases progress 
 favourably for a time, only to relapse when the 
 remedy is discontinued ; and I have known a habit of 
 taking morphia to be started in an asylum. 
 
 Passive melaiicliolia.— Patients in this class 
 differ greatly from the last, as far as appearances are 
 concerned. There is a direct series leading from 
 simple melancholy through passive melancholia into 
 melancholy with stupor. And it is open to doubt 
 whether most cases described as acute dementia are 
 not rather to be looked upon as cases belonging to 
 the last variety. 
 
 Passive melancholia may arise, as may the other 
 varieties, from acute or chronic causes. It may occur 
 in men or women, in young or old. But again I would 
 say, the majority of cases seen in Bethlem fall between 
 40 and 60. The incidence is generally slow, there 
 being a gradual failing in physical health, while fre- 
 quent complaints of dyspepsia and sleeplessness are 
 made. Listlessness and an aspect of anxiety, restless 
 worry, or jealousy, are often the first objective signs. 
 
Chap. VII.] Melancholia with Stupor. 179 
 
 These become more marked, and some trivial circum- 
 stance establishes the fact that the person is suffering 
 from delusions. She may suddenly accuse her hus- 
 band of wishing to poison her, or reprove him for not 
 interfering with those who are annoying or injuring 
 her. A dream of horror may seem to precipitate the 
 illness ; or, what is a common experience with me is, 
 that a middle-aged woman nursing a relation or 
 friend who has died, becomes haunted by the idea 
 that she has caused his death. Hallucinations, 
 especially of hearing, may appear ; she hears voices of 
 demons tempting to evil, jeers of spirits or of 
 men deriding or accusing her of unworthiness. The 
 bodily health suffers in an equal degree with the 
 mental ; suicidal tendencies develop themselves, and 
 not unfrequently desire arises to kill the children, if 
 there be any, to save them from further chance of 
 misery. A more pronounced variety of the same con- 
 dition is met with in 
 
 Melancholia with stupor. — In this the 
 patients are speechless and passive, but with an aspect 
 of misery. The chief point is the more or less com- 
 plete loss of reaction to external stimuli, as the result 
 of oppression from dread or from complete subordi- 
 nation of all intellectual life to a feeling of terror. 
 
 I believe there are two distinct mental conditions 
 occurring in melancholia with stupor ; in one there 
 is, as it were, prolonged panic. I know many 
 persons who, under suddenly terrifying circumstances, 
 became powerless to move even for self-preservation, 
 and one group of patients suffering from melancholy 
 with stupor seem in a condition very similar to this. 
 
 In the other class we meet with patients who form 
 a very definite idea of an impending evil. It may 
 vary from spiritual destruction to bodily annihilation ; 
 but on recovery they are generally able to tell 
 what was the mental state causing their physical 
 
i8o Insanity and Allied Neuroses. [Chap. vii. 
 
 condition. Patients suffering from melancholia with 
 stupor are not to be confounded with a few cases 
 suffering from primary dementia, or with others pos- 
 sessed by some delusion which renders them statues- 
 que. Some writers doubt whether such a condition as 
 acute dementia exists, and would classify all cases 
 of this kind with melancholy, believing that every 
 absolutely passive patient, with a stolid or melancholic 
 aspect, is suffering from some delusive horror. I can 
 hardly agree with this, as I have seen at least one 
 patient who, on recovering, said that the time of his 
 inactivity was really a blank to him, and was in no 
 way associated with painful recollections. I would 
 say that the few cases of acute primary dementia 
 which I have seen have followed some sudden 
 fright, injury, or poisoning of the higher nervous 
 centres, and that the touchstone is that of memory ; 
 that, in fact, a person recovering and having a recol- 
 lection of misery associated with his illness must be 
 looked upon as suffering from melancholy with stupor, 
 whereas the patient suffering from acute dementia 
 would have no such recollections. I admit that a few 
 cases of very acute melancholia deny any recollection 
 of their state. It may be possible that certain cases 
 beginning with melancholy and having painful impres- 
 sions may pass into a state in which no memory 
 exists ; that, in fact, just as we have cases of acute 
 mania in which a j)eriod is completely forgotten, so 
 there may be cases of melancholy in which a blank 
 likewise exists. I shall take it for granted that there 
 is a distinction between the conditions called dementia 
 and melancholia with stupor. In the latter there may 
 be occasionally ansesthesia, but I have not found this 
 to be as common as has been supposed. Reaction 
 may be slow, but patients have told me on recovery 
 that they felt the prick which I had given them, al- 
 though they did not flinch. The special sensations 
 
Chap. VII. J Melancholia with Stupor. i8[ 
 
 are confused and dull ; people about the patient 
 often appear to him as enemies, either as his execu- 
 tioners or as people sent to torture or remove him ; 
 or he may have a dream-like idea that he is in a 
 
 A case of Cataleptic Melancholia. 
 
 Strange world and that the people about him are not 
 inhabitants of the earth at all. One of the charac- 
 teristic symptoms of this condition is muscular 
 rigidity. Patients object actively to everything which 
 is done for them, so that it takes two or three persons 
 to dress and undress them, and as many to feed them. 
 
1 82 Insanity and Allied Neuroses. [Chap. vii. 
 
 Be3'^ond this it is common to meet with catalepsy 
 more or less complete. I. have rarely met with this 
 condition in a very fully developed form, but at the 
 same time it is rare to be without some case of partial 
 catalepsy in Bethlem. 
 
 These patients invariably have other accompanying 
 physical symptoms, such as cold livid extremities, ex- 
 cessive flow of nasal mucus, and general disregard of 
 their personal appearance ; the eyes are often directed 
 to the ground, the lids being half closed, with a honey- 
 like excretion exuding along the edges ; the skin is 
 often dewy or greasy and gives a feeling of coldness to 
 the touch, and although patients with stupor do not take 
 food freely or voluntarily, yet if they are kept warm 
 and carefully looked after they do not emaciate. Their 
 temperature is readily affected by their surroundings. 
 There is no evidence externally of intellectual action, 
 but they exhibit will in so far as they resist interference. 
 This condition probably is best represented by a pro- 
 found dream or nightmare. The result of such cases 
 is not favourable, but few recovering. This con- 
 dition occurs more frequently in the young than in 
 the old, and is certainly as common in young men 
 as in young women. Certain cases live for years 
 in much the same condition, having to be washed, 
 dressed, fed, and tended like young children, while 
 others die of some intercurrent trouble, most frequently 
 phthisis. This condition may follow from fright. 
 Thus I have known a young sailor whose melancholic 
 stupor followed shipwreck and fire, both occurring on 
 his first voyage. In another case a false accusation 
 and loss of situation was the cause. In another an 
 attempted rape was the direct origin of the attack, 
 and a fourth followed brutality or excess on the part 
 of a husband on the marriage night. 
 
 To conclude, following the example of Professor 
 Griesinger, I have arranged the symptoms which 
 
Chap. VII.] Melancholia with Stupor. 183 
 
 distinguish between raelancliolia with, stupor and. de- 
 mentia in the following tabular form : 
 
 MELANCHOLIA WITH STUPOR. DEMENTIA. 
 
 Development, often rapid. Slow. 
 
 Nutrition fails. Often good. 
 
 Complexion, yellow. Normal. 
 
 Excretions, deficient. NormaL 
 
 Sleep, bad. Good. 
 
 Opposition to ail movements Passive. 
 
 Appetite, refusal of food. Voracious. 
 
 Suicidal. Not suicidal. 
 
 Memory, present. Absent. 
 
 Having ah-eady considered simple melancholia, 
 active and passive melancholia, and melancholia with 
 stupor, I shall proceed to notice first the relationships 
 of melancholy to delusions, hallucinations, and other 
 sense-perversions ; secondly, cases specially suicidal ; 
 thirdly, those which have been called religious 
 melancholies ; fourthly, melancholia as connected with 
 certain periods of life, such as the climacteric and 
 senility ; fifthly, the same condition as related to 
 certain bodily disorders, such as gout, heart disease, 
 and kidney disease ; finishing with a consideration of 
 recurring and chronic cases in which recovery has 
 been long retarded. 
 
 The feeling of mental depression is like a cloud 
 'twixt sun and earth ; it slowly settles upon a mind, 
 gradually blotting out the light of hope and desire, 
 and leaves it ready to pass under any depressing in- 
 fluence. There has been seen to be a dulling of the 
 whole life, and this becomes more and more pro- 
 nounced till every part of the being reacts slowly and 
 painfully. This, in its earliest state, is that of simple 
 melancholia, which I have already described ; but a 
 further stage may be developed, so that a patient, 
 feeling wretched and utterly unlike himself, seeks 
 for some explanation of the state. It has been 
 said tliat wise men investigate while fools explain ; 
 
184 Insanity and Allied Neuroses, [chap. vii. 
 
 and I am sure that none are so ready to explain as tlie 
 insane. 
 
 The explanation of his miseries given by the 
 patient suffering from melancholia depends to a great 
 extent upon his inheritance, his education, and his 
 surroundings at the time of his illness. The expla- 
 nation may be a direct development, as seen in the 
 emotional girl who has been brought up in the midst 
 of enthusiastic dissenters, who thinks her state is pro- 
 duced by the neglect of religious ordinances of which 
 she has heard so much ; or the explanation may be 
 in direct antagonism to the past life ; thus, the 
 man who has lived a worldly, careless life^ when he 
 is melancholic, turns to religion for an explanation. 
 The anxious mother may explain her misery by 
 imagining that her children are suffering or are in 
 danger, while the merchant dreads insolvency, and the 
 old man fears loss of reputation and the workhouse. 
 
 The following is a good example of the way in 
 which delusions of this kind arise : A farmer in 
 England finds the times a2:ainst him. He has a 
 large and increasing family with yearly reduction of 
 capital. Hather than lose everything, he determines 
 to realise the property still remaining to him, and 
 try his fortune in another land. He sells his stock, 
 and leaving his wife (who is six months pregnant) 
 with her family in England, he proceeds to New 
 Zealand. The money he left for his wife was suffi- 
 cient to last a year or so, but the anxious pregnant 
 woman, fearing something might happen to him or his 
 funds, saves and pinches, not supplying herself with 
 food necessary for her condition. She works constantly 
 for her children, even up to the time of her delivery, 
 and refusing extra diet, she leaves her bed to resume 
 her domestic duties far too soon. Here, then, we 
 have physical causes of weakness associated with con- 
 stant mental anxiety, and as a result, depression and 
 
chnp. VII, A UTOBioGRAriiv OF A Melancholic. 185 
 
 sleeplessness, the two becoming more pronounced, 
 till at last she refuses food, ha\dng the conviction that 
 there is no more food in the vv^hole world, and that 
 everything she eats is reducing the small stock that 
 is to maintain humanity. Similar growths of delu- 
 sions may constantly be witnessed. 
 
 As another example I would refer to a man 
 who, being entitled to a sum of money, which he 
 accepts instead of a pension, started a business for 
 his only son. He had no sooner done this than he 
 was impressed with the risk he now ran of dying 
 in poverty, there being no longer a certainty of 
 an income when he was beyond work. Slowly but 
 surely the misery wrought upon him, till, passing 
 through the vague period of unexplained wretched- 
 ness, he became possessed with the idea that he was 
 ruined, friendless, and a beggar, and must be thrust 
 out into the streets. 
 
 Autolbiograpbical sketch of melancliolia, 
 and recovery. — " I am thirty-two years of age, and 
 have been married ten years. I was fore-woman in a 
 silk warehouse in the city. While there I suffered 
 from pleurisy in the side, which was thought to be 
 caused by carrying heavy things. I also suffered 
 from headache during the whole ten years I was so 
 employed. My employers failed in business, and 
 soon after I got married. I was of very active habits 
 and excitable temperament. After marriage I missed 
 the active life I was accustomed to in the city, and 
 became somewhat melancholy, and suffered slightly 
 from headache. I had four children within four and 
 a half years, and then six years elapsed without any 
 addition to my family. I then had another child, whom 
 I lost when he was six years old. Shortly before his 
 death, my neighbour induced my landlord to give my 
 husband notice to quit, but this notice was not carried 
 out. I was always at home all day alone, my husband 
 
1 86 Insanity and Allied Neuroses. [Chap. vii. 
 
 following his occupation. This notice to quit gave 
 me a shock, and the death of my child, soon 
 afterwards following, intensified it. During my 
 previous confinements, I had had upsets, particularly 
 in the second one. I then saw the antimacassar 
 around the looking-glass in my bedroom on fire. I 
 screamed, and was queer from that time, but re- 
 covered, and had another child. This, the last 
 confinement, was a very bad one, the baby being very 
 large. I now became exceedingly nervous, and 
 dreaded some one was coming to arrest me for a 
 murder I had committed. This delusion continued 
 about three months, and my child had to be fed by 
 bottle, my milk having stopped. I did not believe 
 my child was dead. I always had the sensation of 
 falling into a deep black place. This lasted night and 
 day for three weeks, the death of my child having so 
 much afl[ected me. I underwent medical treatment 
 at my home, but derived no benefit therefrom. I was 
 then brought to Bethlem in May, 1883, having the 
 idea that I was being taken to a museum. As soon 
 as I entered Bethlem (not knowing it was an asylum), 
 I screamed, thinking that steam was coming from a 
 boiler. I was taken to a padded room, and soon 
 after the paroxysm left me I felt relieved. I laboured 
 under the idea that all who were in the asylum were 
 transformed into dogs, and the feeling I experieiiced 
 was like sulphur rising in me. My food tasted as 
 bitter as wormwood. Those particular delusions 
 lasted about two months. I used to watch the 
 patients all night, thinking they were goiug to fly 
 on me and devour me. In tliis way I was without 
 sleep for nearly two months, restless, got out of bed, 
 and walked about. The delusion then took another 
 turn in the shape of my imagining that the woman 
 who induced my landlord to give me notice to quit 
 was in collusion with God, and that I was God ; and 
 
Chap. VII.] Autobiographical Sketch. 187 
 
 every time I went to see her she hid behind the 
 garden. I thought all the people in the asylum were 
 there for twelve months playing their part until the 
 judgment day, when they would be saved from their 
 sins. I also thought that all the world was a delusion. 
 The night I was put into the padded room I kept 
 running about, thinking that the padding was going 
 to give way. I also imagmed that all the food was 
 poison, so refused to take it. The day I looked at 
 my tongue and eyes, I said that they were to be taken 
 out ; I thought God had ordained it. I was always 
 groaning and crying, alleging it was my fate to go 
 through these dreadful things, and that the day would 
 arrive when I should be crucified, and that when I 
 went to bed I should be summoned during the night 
 to go through it. I also had a delusion that my 
 husband and my family were in Bethlem, and that I 
 was Christ. I never told my delusions to any one, 
 until after being in Bethlem two months, when I 
 mentioned them to a patient who slept in the same 
 room with me. On that occasion I asked her if I was 
 Christ, and the patient replied, ' No ! Do you think 
 a poor woman like you is Christ % ' I have lost my 
 delusions, and was sent to Witley about six weeks 
 ago, and have returned recovered. I now sleep well 
 throughout the night, sometimes dreaming of my 
 child. I enjoy my dinner and supper, but cannot eat 
 in the morning. I am not the same person since I 
 had the cholera when I was fifteen years old. 
 At first, when friends came to see me in Bethlem I 
 used to cry and did not care to see them, as I 
 imagined they were not my own friends ; but now I 
 receive their visits with extreme pleasure, and feel 
 sorry when they are going away, and their departure 
 does not affect me afterwards. My mother's brother 
 died at Hanwell ; my sister died at the White House, 
 Bethnal Green (this sister having had a fright when 
 
1 88 Insanity and Allied Neuroses. [Chap. vii. 
 
 a child), and another sister was also there soon after 
 lier confinement. I have a cousin (mj father's 
 brother's son) now in Colney Hatch. All my sisters 
 and my mother suffered from headache. I was not 
 afraid of any of them, and would do anything to help 
 them. I was discharged recovered." 
 
 These examples show what I mean when I say 
 that (as chemists might put it), there being a saturated 
 solution of misery, a crystal forms with a definite out- 
 line. In a few cases undoubtedly the melancholy 
 follows some delusion, but as a rule the delusion has 
 been started by some slowly developed morbid process. 
 It is natural that a man should be melancholic who 
 believes that he has lost his inside, or that there are 
 wild beasts within him ; and the woman who believes 
 that she is nightly injured, threatened, or assaulted, 
 becomes miserable and depressed. Thus, a woman in 
 Bethlem, who believed that evil spirits came to her 
 room and abused her sexually, became desperately 
 suicidal. The delusions were marked before the other 
 melancholic symptoms exhibited themselves ; but in 
 tracing back we find the delusions had their origin in 
 some hallucination of the senses. 
 
 Suicide has been referred to when considering 
 the general symptoms of melancholia : and although 
 1 object to classify cases purely from the existence of 
 one symptom, yet, when we remember the great social 
 and general importance attached to suicide, I think it 
 deserves consideration rather more in detail than 
 many other special symptoms. We have seen that 
 ideas of self-destruction may arise from various feel- 
 ings bodily and mental, and I know no special class 
 characteristics which would enable me to say there is 
 a special suicidal insanity. Suicide is met with more 
 frequently at an earlier age among members of the 
 more emotional races than with us in England, 
 and it is not uncommon in France and Italy for 
 
Chap. VII.] Suicidal Tendencies. 189 
 
 sentimental children to drown themselves because 
 of a rebuke or the loss of a pet, or in consequence of 
 some trivial neglect or supposed insult. Occasionally 
 in England schoolboys will kill themselves from some 
 slight disturbing cause. As age increases the tendency 
 to commit suicide increases also, and it will be seen 
 from statistics that there is scarcely any limit to the 
 age at which men may get tired of life. Men and 
 women both commit suicide, but there are certain 
 favourite methods which each sex prefers. A man 
 will cut his throat or blow his brains out, while a 
 woman will hang or drown herself. It has even been 
 shown that seasons of the year affect the mode and 
 number of suicides. I may say that; for my part, I 
 find it hard to agree with the verdict of English 
 society, that every person who takes his life is neces- 
 sarily a lunatic. That a man in killing himself is 
 generally doing an unreasonable act I admit, but that 
 this act connotes a general intellectual disturbance, 
 which can be fairly grouped under any pathological 
 heading, I doubt. To act on impulse is unreasonable, 
 but many of our best, as well as some of our worst, 
 actions follow impulse^ and suicide too may result from 
 impulse. Suicide may be carefully thought out ; thus 
 I have seen one patient at least, who, having most 
 carefully considered whether his children would be 
 pecuniarily benefited if he died, finding that they would 
 certainly be better off by his death than by his life, took 
 the most cool and deliberate means to effect his end. 
 As it turned out, although he ought to have died from 
 his wounds, he did not, and although carefully made, 
 he had miscalculated his pecuniary relationships. 
 
 There are cases in every asylum for which special 
 provision is required, and it will be well to give 
 examples. Such cases are generally of insane inheri- 
 tance. Frequently suicidal tendencies have been trans- 
 mitted from father to son ; and, as in the causation 
 
190 Insanity and Allied Neuroses. [Chap. vii. 
 
 of insanity I referred to direct inheritance, and gave 
 as an example the suicidal tendency, I would repeat 
 that nothing has struck me more than the histories 
 I have received of direct suicidal inheritance. 
 
 The most suicidal patients, in my experience, are 
 those who believe that they are to be injured. 
 Suicidal tendencies are most marked in the early 
 morning. There seems to be a feeling of horror which 
 drives them to distraction, and makes them prefer 
 suicide to persecution. In one young woman in 
 Bethlem the tendency to suicide was extreme, and 
 being prevented in every ordinary way from injuring 
 herself, she tried to destroy her life by swallowing 
 broken china, buttons, corks, horse-hair, and every 
 available irritating substance she could get her mouth 
 to. These insane acts proved the means of her 
 recovery, for the collection of foreign bodies in her 
 stomach set up such violent pain and colic that they 
 were only relieved by a large dose of calomel, which 
 brought away the irritating matters and left her free 
 from pain and delusions. 
 
 Another good example of an extremely suicidal 
 patient is that of a man admitted into Bethlem in the 
 early part of 1883. His insanity was strongly marked 
 on the mother's side. He had received two or three 
 severe injuries in railway accidents during his life, and 
 was lame. He was employed as signalman in a very 
 quiet place, where the number of hours he was on 
 duty debarred him from having much companionship, 
 most of his time being spent in waiting and watching 
 Naturally a man of nervous disposition by inheritance, 
 and rendered more unstable by physical weakness and 
 maiming, he dwelt upon his misfortunes, which in- 
 creased in magnitude as he contemplated them. The 
 morbid mental growth developed, and he became im- 
 pressed with the idea that his wife and children were 
 l3eing injured. He had hallucinations of hearing, and 
 
Chap. VII.] Suicidal Tendencies. iqi 
 
 was constantly horrified by the voice of his wife and 
 children, who were being, as he thought, tortured. 
 In this condition he was brought to Bethlem, 
 and for some two or three weeks he caused great 
 anxiety. His general health was attended to, and he 
 was encouraged to do little jobs about the ward. His 
 interest was aroused, his wife and children were allowed 
 to see him and write to him frequently, and with the 
 bodily improvement confidence became re-established, 
 and after a few weeks' residence at the convalescent 
 home he was discharged well, having been under treat- 
 ment only some seven weeks. 
 
 In another case, a single man thirty years old, a 
 decorator and grainer, without any known insane 
 inheritance, began to fail in general health some two 
 or three years before he was admitted into Bethlem. 
 He had haemoptysis with cough and loss of flesh, but 
 there were no evident signs of phthisis. He became 
 despondent about his condition, was restless, and 
 made several attempts at self-destruction. He grew 
 weaker and more nervous, was haunted by voices 
 talking at him, and annoyed by unpleasant smells, in 
 consequence of which he refused animal food. He 
 took a great dislike to all his relatives, thinking 
 they were in league against him. On admission 
 he was a thin, anxious, worried-looking man, suffering 
 still from an injury produced by his having thrown 
 himself under a railway train. While in the hospital 
 he varied considerably, at one time rapidly losing 
 flesh, and bringing up considerable quantities of blood, 
 at which times he generally was more amenable to 
 treatment and discipline. When these attacks passed 
 off, and he again recovered his general health, his 
 mind became distressed, and he was once more 
 troubled by hallucinations, in consequence of which 
 he refused his food. He had to be fed constantly by 
 the stomach-pump, but after several remissions he 
 
192 Insanity and Allied Neuroses. [Chap. vii. 
 
 steadily began to improve both in body and in mind, 
 and at length became sane and in fair bodily condition. 
 His case is an example of suicidal tendencies de- 
 pending upon physical weakness and bodily disease, 
 which being removed, allow the disappearance of 
 suicidal tendency. 
 
 In the next case the suicidal tendency, which was 
 the most troublesome symptom, has not disappeared, 
 although the patient has suffered for over three 
 years. He was a banker's clerk, married, and of 
 steady habits. His mother and sister have both been 
 insane, but have recovered, and two of his maternal 
 uncles committed suicide. He was a German who 
 had come to England to push his way, and by despe- 
 rate energy and hard work had risen to a position of 
 considerable trust and importance in a foreign bank- 
 ing-house. He had always been an exacting, self- 
 conscious man, and in consequence of financial troubles 
 in the city he became sleepless and irritable. He 
 believed that the head of the firm was anxious to dis- 
 place him, and that there w^as a conspiracy in the 
 ofiice to accuse him of theft. He had also hallucina- 
 tions of smell, was suspicious about his wife, and 
 being a fond father, he thought the interests of his 
 children were being neglected. Before admission he 
 cut his throat seriously, nearly killing himself. 
 With difficulty his life was saved, but he was in 
 no way to be trusted, being a source of constant 
 anxiety and trouble. At the same time he was over- 
 sensitive, and full of the belief that other patients 
 wished to annoy him. Thus in a letter to me he 
 says : " When in the lavatory, one of those present, 
 placing himself in an unmistakable, loathsome atti- 
 tude, asked me if I had had a good night, a hint 
 being conveyed to him by one of the persons sleep- 
 ing in the same room in which I sleep. I mentioned 
 it to you a long time ago, and the tricks and foul 
 
Chap. VII.] Suicidal Tendencies. 193 
 
 insinuations have been of constant occurrence." This 
 patient did not recover, and the prospect is highly- 
 unfavourable. In connection with this case it is 
 well to mention the fact that patients who are an- 
 noyed by hallucinations also suffer from what they 
 call " these hints," and are both dangerous to them- 
 selves and to others. 
 
 I shall, under the head of delusional insanity, 
 give the case of one who has threatened violence 
 to others, and who says that although he considers 
 suicide a sign of weakness, yet he fully recognises 
 the fact that annoyances may be carried to such an 
 extent that it would be better for him to die than to 
 endure, and I fear that if he deliberately made up 
 his mind on this matter, it would be impossible to 
 j)revent him accomplishing his end. 
 
 Intensely suicidal ideas arise, not only, then, 
 from pure misery and from dread of persecution, or 
 in consequence of annoyances arising from bodily and 
 mental nervous disturbance, but danger also occurs in 
 the stage of depression following excitement. In this 
 way I have seen one woman destroy herself just 
 as she was beginning to improve. She had, as it 
 were, opened her eyes to the fact that she was in an 
 asylum, and it seemed such a terrible thing to con- 
 template that she strangled herself. Although it 
 is generally somewhat easy to recognise suicidal ten- 
 dencies in patients, he would be rash who would say 
 that a person of unsound mind, of whatever the 
 variety, would not attempt self-destruction. Young 
 emotional patients frequently threaten and appear 
 determined on suicide, but they rarely carry their 
 threats into execution. General paralytics very 
 rarely, if ever, intentionally kill themselves ; though 
 their exaggerated ideas, and their loss of common sen- 
 sibility may lead them into accidents which may end 
 fatally. The acutely maniacal patient injures himself 
 N — 14 
 
194 Insanity and Allied Neuroses, [chap. vii. 
 
 under similar circumstances, and the weak-minded 
 patient may, by accident, get into mischief; but 
 suicide must ever be looked upon as one of the dan- 
 gerous symptoms connected chiefly with melancholia. 
 
 The so-called religious insanity has been referred 
 to when considering the influence of religious teaching 
 upon the production of insanity; and also when 
 tracing the origin of delusions and their explana- 
 tion. It is only just to own that although there 
 can never be a clinical group of cases with reli- 
 gious ideas as the distinguishing characteristic, yet 
 in asylums we ever meet with cases aptly called 
 "the unpardonable sinners." These patients, for the 
 most part, have been brought up in narrow religious 
 sects, and many of them have been agents in one way 
 or another for the dissemination of religious know- 
 ledge. Among men with these ideas we constantly 
 meet with the Sunday-school teacher, the Scripture 
 reader, and city missionary, and among women 
 those similarly engaged. We may meet with these 
 cases in very young girls and boys, who by the 
 type of their symptoms prove the close connection 
 existing between the erotic and religious. This 
 class is not so well represented in full manhood and 
 womanhood, unless some special causes of exhaustion 
 have arisen. At the climacteric they are specially 
 common, and in Bethlem we are rarely without 
 many women whose whole ideas of life are cramped 
 by the belief that they are unpardonable sinners. 
 
 I am frequently asked what is the unpardonable 
 sin, and what does the patient mean by this sin. In 
 many cases it refers to some sexual abuse. In the 
 younger patients the idea has often arisen from indul- 
 gence in masturbation during the time they were 
 professing Christians. In many patients, at the 
 climacteric, some sexual disorder again has tinged 
 or started the delusion. In a few cases, before the 
 
Chap. VII.] The Unpardonable Sin. 195 
 
 mental depression there was a stage of excitement, 
 connected with the increased erotic tendencies, at 
 which time the patient indulged in sexual excess or 
 masturbation, and when the period of depression fol- 
 lowed he came to consider this unnatural offence 
 in a person of mature years to be the unpardonable 
 sin. The most common idea and the scriptural one 
 is that the unpardonable sin is blasphemy against the 
 Holy Ghost (St. Matthew xii. 31) ; but here arises 
 the difficulty as to what blasphemy against the Holy 
 Ghost is. I have known a lad suffering from melan- 
 cholia, who believed that he committed that sin when 
 he thrust his penknife into the ground and combined 
 the name of the Holy Ghost with an ordinary curse. 
 
 Perhaps in no published work is the sad tale of 
 the fall of a high-sou led, pure-hearted man, reared in 
 the bosom of religion, into this terrible state, told more 
 graphically or with more intensity than in George 
 Borrow's strange but pleasant book, " Lavengro." 
 Peter, the hero of the work, thus describes his temp- 
 tation, his fall, his emotions, his remorse, his despair, 
 and finally his resurrection from the depths into which 
 he had fallen. 
 
 " One autumn afternoon, on a week-day, my father 
 sat with one of his neighbours taking a cup of ale by 
 the oak table in our stone kitchen. I sat near them 
 and listened to their discourse. They were talking of 
 religious matters. 'It is a hard matter to get to 
 heaven,' said my father. ' Exceedingly so,' said the 
 other. ' However, I don't despond ; none need de- 
 spair of getting to heaven save those who have com- 
 mitted the sin against the Holy Ghost.^ 'Ah,' said 
 my father, ' thank God I have never committed that ! 
 how awful must be the state of the person who has 
 committed the sin against the Holy Ghost I I can 
 scarcely think of it without my hair standing on end.' 
 
 "And then my father and his friend began talking 
 
196 Insanity and Allied Neuroses. [Chap. vii. 
 
 of the nature of the sin against the Holy Ghost, and 
 I heard them say what it was. as I sat with greedy 
 ears listening to their discourse." The evil seed had 
 been sown. Truly, " ignorance is bliss," where it is 
 not merely folly, but criminal, to be wise. Peter con- 
 tinues his pathetic tale. After describing his tempta- 
 tions, his broodings, and his surmises as to what must 
 be the condition of the person who had committed the 
 sin against the Holy Ghost, his strong inclinations to 
 commit it himself, were it not that a strange kind of 
 fear "prevented me"; his decisive declaration that 
 from his experience "it is not a good thing for chil- 
 dren to sleep alone " ; his inattention at school ; he 
 thus finally describes his fall after fearful struggles : 
 
 " Arising from my bed, I went upon the wooden 
 gallery, and having stood for a few minutes looking at 
 the stars with which the heavens were thickly strewn, 
 I laid myself down, and, supporting my face with my 
 hands, I murmured out words of horror, words not to 
 be repeated, and in this manner I committed the sin 
 against the Holy Ghost." Angels might have wept 
 over the fall of poor Peter Williams, for he knew not 
 what he did. 
 
 His description of his after-state of remorse and 
 despair is a most strikingly graphic piece of descrip- 
 tive writing. How it must come home to the soul- 
 rending experience of hundreds of thousands of 
 young people to-day, who have been moved by emo- 
 tional teachers ! He felt stupefied ; he had a dim 
 idea that something strange and monstrous had oc- 
 curred j at school he could not learn ; cheerfulness 
 abandoned him ; he became reserved and gloomy. 
 "I seemed," he says, "in my own eyes a lone mon- 
 strous being ;" and he could not pray. "What is the 
 use of praying"?" he said; "I have committed the sin 
 against the Holy Gliost." 
 
 He describes the death-bed scene of his father, and 
 
Chap. VII.] Story of Peter Williams. 197 
 
 how his beloved parent's parting words, " trusting they 
 would meet in heaven," filled him with horror. He 
 progressed in years, and worked hard for his intellec- 
 tual improvement, yet physically and mentally he was 
 still deeply affected. He would sit brooding alone, 
 and " count the months and the days which yet inter- 
 vened between me and my doom," for he felt his days 
 were being shortened. At last, after terrific struggles, 
 lie abandoned home and family, and, " a prey to 
 horror and despair," ran wild through the hills of his 
 native Wales. He fell into the hands of robbers and 
 gipsies j he was burnt by the sun, and drenched by 
 the rain, and " had frequently at night no other 
 covering than the sky or the roof of some cave." 
 At last his desperation culminated in the awful 
 temptation to self-destruction, from which crime he 
 was saved by what he considered to be a merciful 
 interposition of Providence. 
 
 " I felt myself quite unable to bear the horrors of 
 my situation ; looking around, I found myself near 
 the sea ; instantly the idea caine into my head that I 
 would cast myself into it, and thus anticipate my final 
 doom. I hesitated a moment, but a voice within me 
 seemed to tell me I could do no better ; the sea was 
 near and I could not swim, so I determined to fling 
 myself into the sea," 
 
 Then he gives the following account of his won- 
 derful escape. 
 
 " As I was running along with great speed in the 
 direction of a lofty rock which butted over the waters, 
 I suddenly felt myself seized by the coat ; I strove to 
 tear myself away ; looking around, I beheld a vener- 
 able, hale old man, who had hold of me. ' Let me go,' 
 said I fiercely. ' I shall not let thee go,' said the old 
 man ! ' In whose name dost thou detain me % ' said I, 
 scarcely knowing what I said. ' In the name of my 
 Master, who made thee and yonder sea, and has said 
 
198 IXSANITV AND AlLIED NeUROSES. [Chap. VII. 
 
 to the sea, So far shall thou come, and no farther ; and 
 to thee, Thou shalt do no murder I ' " The old man, 
 knowing Peter's mother, from whom he had received 
 much kindness when on a journey, conducted him to 
 his house, and although Peter did not unbosom him- 
 self, he confessed he was sorely afflicted in mind. The 
 old man knelt down and prayed long and fervently, 
 Peter kneeling likewise. When they had risen from 
 their knees the old man left him for a short time, and 
 on liis return led him into another room, where there 
 were two females ; one was an elderly person, the old 
 man's wife, the other was a young woman, who was 
 a distant relation to the old man. He remained 
 several davs in the old man's house, and after receiving 
 repeated words of consolation and encouragement, de- 
 parted for his home. Peter arrived safely, to find that 
 his cousin had died and left him his heir, and that the 
 goodly farm on which his cousin had lived was now his 
 property, and in a few days he took possession of 
 it. Here he felt his solitude, and frequently wished 
 for a companion with whom he could exchange ideas, 
 and who could take an interest in his pursuits. 
 He remembered that the Scripture says that it is not 
 good for man to be alone, and then it was that the 
 image of the young person (Winifred) whom he had 
 seen in the house of the old man frequently rose up 
 distinctly before his mind's eye. He resolved to make 
 suit, was successful, and soon won her heart. He 
 married her. His affairs prospered, so that he was 
 almost happy, taking pleasure in everything around 
 him, in his wife, his farm, his books and composition, 
 and the Welsh language, till one night, as he was read- 
 ing the Bible, and feeling particularly comfortable, a 
 thought having just come into his head that he would 
 print some of his compositions, he came to the fatal 
 passage, " All manner of sin and blasphemy shall be 
 forgiven unto men : but the blasphemy against the 
 
Chap. VII.] The Unpardonable Sin. 199 
 
 Holy Ghost shall not be forgiven unto men." Peter 
 rushed out, his wife imploring him to tell her what 
 was the matter. He could only answer with groans, 
 and for three days and three nights he did little else 
 than groan. He became at last calm. His wife per- 
 sisted in asking him the cause of his late paroxysms. 
 It is hard to keep a secret from a wife, so Peter told 
 her the sad tale as they sat one night over the dying 
 brands of their hearth. He thought she would have 
 shrunk from him with horror, but she did not. She 
 raised her eyes, and looking up in his face said, "Let 
 us go to rest ; your fears are groundless. " 
 
 Peter was cured, and became one of the most cele- 
 brated, devoted, zealous, and successful of Welsh 
 missionaries. 
 
 It will be seen in this case that a man, who ap- 
 peared otherwise sane, had become fully impressed, by 
 means of his early religious education and surroundings, 
 with the idea that there was an unpardonable sin 
 against the Holy Ghost, and that in boyhood he had 
 committed it. Whatever the delusion, the same 
 egotism exists; the patient invariably says he is the 
 only person who ever acted thus, and that there can 
 be no possible hope for him. The feeling seems to 
 arise in at least two different ways; in one a very 
 stormy voice of conscience appears for ever to be 
 trumpeting in the ears of the unfortunate patient that 
 he is lost ; and in the other case (and this is most 
 common among younger patients) there is a feeling 
 of deadness, a feeling that nothing arouses them to a 
 sense of their sin. They will write long letters, 
 saying they feel they must be cast away, because they 
 know they have committed grave crimes, but yet they 
 do not feel any real sorrow for their act. and this 
 proves they are the unpardonable sinners ; they 
 had neglected their opportunities, and the time 
 for turning has passed. Such cases are looked upon 
 
200 Insanity and Allied Neuroses, [Chap. vn. 
 
 generally as very vinfavourable ; but, in my experience, 
 a fair proportion get well, although it may take years 
 before they recover, the prognosis depending to a 
 great, extent on the age and general health. The 
 majority of young cases, if there be no chest disease, 
 recover. A large proportion of the middle-aged 
 cases, especially those following lactation, also recover. 
 Many suffering from melancholia occurring at the 
 climacteric recover, but require some time for the re- 
 establishment of perfect health. In senile cases the 
 prognosis is still worse. Many cases after middle 
 age slowly sink and die, while others will remain 
 wretched and unoccupied, and end in weak-minded- 
 ness. Again, others will improve in physical 
 health, while their mental actions grow restricted, 
 and they become automatic " miserable sinners," 
 such as are represented by one patient now in 
 Bethlem, who says nothing but " dead and damned." 
 The only treatment available in such cases must 
 be of a general character, and must be regulated 
 according to the age and physical state of the patient. 
 In the younger cases, iron, quinine, and mineral acids, 
 with saline purgatives, such as mineral waters, taken 
 the first thing in the morning, are sometimes useful. 
 In the climacteric cases, tonics, stimulants, morphia, 
 and purgatives are of service. I rarely give bromide 
 of potassium or chloral hydrate. In a few cases where 
 exhaustion was extreme ten grains of chloral hydrate, 
 with half-an-ounce of brandy every two hours, proved 
 of service. In senile cases, rest in bed with good food 
 and small repeated doses of morphia are beneficial. 
 Some physicians consider that the treatment of severe 
 cases of melancholia, such as are seen among the un- 
 pardonable sinners, is best followed if the patient be 
 kept in bed. 
 
 ■ At the climacteric period considerable mental 
 disturbance arises \ it is generally melancholic or 
 
Chap. VII.] 
 
 Senile Mela nchol la . 
 
 2QJ 
 
 delusional in type, both in men and women. I must 
 confess that the evidence in favour of a distinct 
 climacteric period in men is not quite convincing. 
 
 Senile iiielaiicliolia. — With old age come 
 many troubles, and the so-called " weight of years " 
 may be but another name for sadness of heart. "The 
 
 A case of Senile Melancliolia. 
 
 almond-tree shall flourish, and the grasshopper shall 
 be a burden, and desire shall fail : because man goeth 
 to his long home, and the mourners go about the 
 streets : or ever the silver cord be loosed, or the 
 golden bo\\d be broken, or the pitcher be broken at the 
 fountain, or the wheel broken at the cistern." The 
 machine is wearing out, and vdth the wear there is 
 conscious painful sensation connected with almost 
 
2 02 Insanity and Allied Neuroses. [Chap. vii. 
 
 every act. All sprightliness and spontaneity of life 
 have passed. Even tlie conservative period of order 
 and method is now over, and the few things that can 
 be done are limited in every direction by pain oi 
 feebleness. Although wear-out will have to be con- 
 sidered also in connection with dementia, there is 
 also a condition of painful action and sensation, 
 such as may be described by the term senile melan- 
 cholia. It appears sometimes rather suddenly, as 
 the result of some family distress or domestic loss. 
 Thus a man of eighty-four years of age, who had 
 shown no signs of insanity, lost his wife within a few 
 months of their keeping their golden wedding, after 
 which the poor old man, brooding over his loss, and 
 feeling his solitude, developed the idea that he had 
 killed his wife, and must now destroy himself. Rest 
 and change of surroundings, with suitable companions, 
 restored his peace of mind, and he spent the rest of 
 his life in mental health. 
 
 In another case a merchant sustained a very 
 serious loss in a speculation, and brooding alone over 
 his misfortune, developed melancholia, and contem- 
 plated suicide. Change of scene for a time relieved 
 him ; but a return to his office was associated with a 
 re-development of the melancholic symptoms, which 
 finally carried him off. In senile cases the age must 
 be considered relatively to the character of the indi- 
 vidual physique ; for we meet with men who are worn 
 out at forty, and, on the other hand, there are active 
 men possessing the energies of middle age at seventy. 
 I should say the reality of age depends as much, or 
 more, on the arteries as on the years. I have been often 
 struck with the arterial changes which are visible in 
 one form or another of mental disease. The rigid 
 artery may be associated with other diseased vascular 
 conditions ; among other things, with bad nutrition 
 of the brain. Or we may meet with g rosser cerebral 
 
Chap VII.] Chronic Melancholia. 203 
 
 changes in connection with apoplexy, and which we 
 shall consider later under a special heading. I must, 
 however, here say that I have seen several cases in 
 which there was marked mental depression preceding 
 attacks of apoplexy in patients with diseased arteries. 
 I saw one doctor, who suffered from constant sub- 
 jective annoyance through his ears, his nose, and his 
 skin for months before his fatal attack of apoplexy. 
 In some other cases of senile melancholia, mental or 
 bodily hypochondriasis, with great emotional disturb- 
 ance, is met with ; and it is not unknown for patients 
 of advanced years to destroy themselves, being con- 
 vinced they have outlived their time. 
 
 The prognosis of senile melancholia must depend 
 upon the inheritance, and the general physical con- 
 dition of the patient. If the arterial tension be 
 high, and if there be alb^imen in the urine, the 
 prognosis must necessarily be bad. If the patient 
 have already had other attacks of insanity or apo- 
 plectic seizures, the prospect is likewise dark. If, 
 however, the general health be good, the appetite 
 maintained, and the patient easily induced to try 
 change in surroundings and companionship, he may, 
 with general care as to hygienic treatment, get well, 
 even though he has passed fourscore years. 
 
 The consideration of melancholia would be in- 
 complete if I did not refer, at least incidentally, to 
 cases of chronic melancholia, to cases of recurring 
 melancholia, and to cases in which, after many years 
 of depression, patients have recovered. Properly, the 
 first two groups will fall under the class of weak- 
 mindedness or chronic insanity, but yet there are 
 grounds for taking them out of this class and con- 
 sidering them specially. Chronic melancholia may be 
 of any one of the above varieties ; and, as I have 
 pointed out, w« . may meet with cases of active 
 melancholia, in which the patients will go on wringing 
 
204 Insanity and Allied Neuroses. [Chap. vii. 
 
 their hands and pulling their hair, year after year, 
 only speaking monotonously about the misery 
 they are suffering, till I suppose (for I have not 
 had the opportunity of watching such a case be- 
 yond ten years) they become ultimately mere auto- 
 mata and weak-minded in every respect. The other 
 cases in which melancholia recurs differ only in 
 degree from those which have several distinct at- 
 tacks of melancholy and completely recover, being 
 discharged after each recovery from the asylum. In 
 Bethlem we have on the incurable list about six or 
 seven cases of this variety, patients who, perhaps 
 fifteen or sixteen years ago, were admitted suffering 
 from profound melancholia with suicidal tendencies, 
 refusal to take food, and delusions as to unworthiness. 
 They recovered, and were discharged from the hospital 
 only to relapse almost as soon as they were restored 
 to their old surroundings. Again they recovered, 
 but on each restoration to home and duties they 
 broke down, and in consequence of this inability 
 to fit themselves into their old relationships, 
 they necessarily became permanent inhabitants of 
 an asylum. Here they pass a fairly contented and 
 useful life, every few years developing their old 
 melancholia, and for varying periods consider them- 
 selves to be miserable sinners or persecuted victims. 
 What the brain pathology of such conditions can be 
 remains a perpetual puzzle to me. That a lady 
 should for two years be amiable, agreeable, trust- 
 worthy, without any special peculiarity of any kind, 
 and should be allowed to go in and out of the asylum 
 with perfect freedom during this time ; and that she 
 then should slowly become a wretched suicidal melan- 
 choliac for twelve months, and once again recover, 
 only in a few years more again to pass under the 
 wave of depression, still remains a puzzle. The end 
 of such cases, I believe, is generally mental weakness ; 
 
Chap. VII.] Chronic Melancholia. 205 
 
 and if this be so, I suppose each attack reduces the 
 intellectual powers a little. Cases such as these lead 
 me to the consideration of the last group, the cases 
 of retarded recovery. 
 
 In one case symptoms of melancholia occurred in 
 a woman 35 years old, without children, whose mother 
 was in an asylum, and whose husband, then nervous, 
 afterwards died of general paralysis. This woman 
 was admitted believing herself to be utterly wicked, 
 and that she had acted inhumanly in allowing her 
 insane mother to be sent to an asylum. She was al- 
 ways contemplating suicide. There was a combina- 
 tion by this patient and another to secure sufficient 
 rope to hang them both ; but fortunately, when one 
 managed to get a piece of rope with which to effect 
 their purpose, the other, the patient now under con- 
 sideration, not only declined to hang herself, but gave 
 information which prevented her fellow-conspirator 
 from carrying out her purjDOse. Year after year 
 passed without any amelioration in the symptoms of 
 this patient. She was always insisting that she must 
 go out and be hanged; only varying this with the 
 statement that, as society would not recognise her 
 right to be hanged, she must go out and murder a 
 man, and then it would be all right. After several 
 changes in her relationship to the other patients and 
 attendants, she was moved into an entirely new 
 gallery, where the change had a wonderfully beneficial 
 effect. I was able to send her on leave of absence, 
 and she ultimately recovered and has remained well 
 and grateful for some years. 
 
 A still more remarkable case was that of a man 
 who was admitted in Bethlem on the 27th September, 
 1834, and who was a patient in Bethlem for thirty- 
 lour years, and for fifteen years sat with his head 
 bent upon his chest, apparently regardless of every- 
 •-hing about him, yet one felt sure, from incidental 
 
2o6 Insanity and Allied Neuroses. [Chap. vii. 
 
 circumstances, that he really did perceive what was 
 transpiring, and that, therefore, his condition was 
 one of melancholy and not one of weak-mindedness. 
 One evening, when sitting in the billiard-room with- 
 out taking any interest, he began to look about him ; 
 a few days after he was cheerful, in fact almost 
 exuberant, and onlthe 14th of May, 1879, was dis- 
 charged recovered, and has remained well since. 
 
 I shall consider later the mental symptoms 
 associated with suppressed gout and visceral diseases. 
 Melancholia may occur with renal disease and with 
 heart disease. Melancholic symptoms are not un- 
 common with displacements of the uterus and with 
 uterine fibroids. Losses of the special senses may 
 lead to nervous irritability, suspicion, and depression ; 
 in several cases, facial deformities, and the shyness 
 connected therewith, have been traceable as causes of 
 melancholy, frequently with suicidal and homicidal 
 tendencies. 
 
 As far as the diagnosis is concerned, there are few 
 points to which I need specially refer. I have said 
 that melancholia is mental pain, out of relationship 
 to the surroundings; but from time to time cases are 
 seen in which men of good position and of undoubted 
 reputation say they are too wicked to live, that they 
 are hypocrites and the like, and in some such casfs 
 the penitent defaulting trustee, not the melancholic 
 patient, is to be seen. 
 
207 
 
 CHAPTER VIII. 
 
 DEMENTIA ACUTE DEMENTIA. 
 
 General or partial — Primary, from injury or shock— Secondary, 
 (a) to physical conditions ; (6) mental disorder— Typical general 
 dementia — Partial dementia, loss of appetite, loss of will- 
 power —Loss of memory — Dementia, secondary to fever, pneu- 
 monia, child-birth, injuries, alcoholism, epilepsy, age. 
 
 In considering dementia I shall make two clear divi- 
 sions. In one there is destruction more or less com- 
 plete of the mind, which can never be recovered from, 
 and in the other there is functional arrest, which may 
 pass off. 
 
 Both conditions appear the same to the ordinary 
 observer, just as is the case with conditions of real or 
 apparent paralysis seen in hysteria. 
 
 I shall describe dementia in its several forms, in- 
 cluding both these types ; and also refer to its various 
 causes, and later I shall consider the partial insanities 
 which have been usually placed under the head of 
 weak-mindedness. 
 
 As mental life begins with but little evidence of 
 intellect, and with imperfectly organised sense im- 
 pressions and motor impulses, so it may end with a 
 return to its simplicity in age. At the one end of 
 life there may be inability to develop intellectually ; 
 this is called amentia; and at the other end destruc- 
 tion of mind may leave the whole intellectual fabric a 
 ruin ; this is called deme^itia. 
 
 Ko two houses fall into ruins in exactly the same 
 way, though in the end the four walls alone may 
 remain as evidence of the once inhabited dwelling ; 
 and so with mental destruction, it will be found that 
 
2o8 Insanity and Allied Neuroses. [Chap.viii. 
 
 though in the end similar foundations and simple 
 boundaries of mind may remain, all the finer parts 
 are removed ; whether age, war, or fire has destroyed 
 the houses, the results are alike ', similarly, either 
 age, disease, or injury may wreck the mind. It will 
 be seen that the mind may show the effects of destruc- 
 tion in various ways, and the destruction may progress 
 at very different rates. 
 
 There is no such thing as complete dementia, for 
 life could not exist with total suppression of mind 
 and sense reaction ; but there are varieties of dementia 
 in which most of the parts of mind exhibit signs of 
 weakness, and this I shall call general dementia^ in 
 contrast with the partial dementia which will be 
 shown to affect special parts or factors of mind. 
 
 Cases of dementia sbould be to the mental philo- 
 sopher like analysis to the chemist, or like weathering 
 of rocks to the geologist. Dementia, by separating 
 and isolating certain faculties, and by interfering with 
 the action of mind enables one to get a clearer view of 
 mind than is to be gleaned from the study of the 
 normal mind in healthy action. 
 
 By studying aberrant development and partial 
 dementia, much will be learnt which can only be 
 hinted at in a book intended for students. 
 
 Dementia is to be divided into prmiary or 
 secondary. Comparatively few cases can be looked 
 upon as purely direct and primarv, but some are 
 seen, especially such as are due to physical disorders, 
 as fevers, poisoning, or direct injury. Many more are 
 secondary to other states of bodily or mental disorder. 
 
 I shall begin, as I did in considering mania and 
 melancholia, with a description of dementia as a 
 whole. Not that it is at all common in diseased 
 any more than in normal states to find perfectly 
 typical examples. 
 
 In a case of complete general dementia, there 
 
Chap. VIII.] General Dementia^ 209 
 
 would be a general weakness of the senses, the 
 memory and the higher organising and controlling 
 powers. The senses would react slowly to their re- 
 spective stimuli, reflex actions would be performed, 
 and in some cases (in my experience) the loss of the 
 higher control would cause reflex action to be 
 rendered more rapid and more active than in health. 
 
 Many acts of the more common kind would be 
 done automatically. The power of storing impres- 
 sions would be greatly impaired or even annihilated, 
 so that the memory for recent impressions would be 
 wanting, and memorj" of the past would be some- 
 what affected. There would be no evidence of 
 volition, and emotional display would be rare. 
 
 The loss of self-control and of general control 
 would be marked, but the evidences of loss of self- 
 control would not as a rule be seen in display of 
 energy along unwonted lines, but would be marked 
 by suppression of the energy. 
 
 That different amounts of loss of power produce 
 these different results, I have often seen in progres- 
 sive degeneration. 
 
 Thus a woman who had been badly marked by 
 small-pox, when sane, got over the consciousness of her 
 disfigurement ; but with dementia came a constant 
 desire to hide her face, but as the dementia became 
 more profound she again disregarded her appearance. 
 
 So much, then, for the effects of loss of control. 
 
 There might be tears, or a ripple of a smile might 
 pass across the features, but these displays of emotion 
 would have no relation to the surrounding circum- 
 stances. In such a condition there could be no power 
 of abstraction, no ability to judge by comparing one 
 thing with another, nor could there be any origination 
 of ideas. There generally would be more or less plastic 
 muscular condition directly opposed to tJie rigid cata- 
 leptic state which we have observed in melancholia. 
 o— 14 
 
210 Insanity and Allied Neuroses. [Chap. viii. 
 
 There would be good digestion and good appetite, with 
 the habits frequently dirty, the patients neglecting 
 themselves, both as regard urine and faeces. In such 
 cases there would be absence of sexual desire; sleep 
 good, so that patients would sleep as soon as put to 
 bed, and would remain in the position in which they 
 were left till morning. Such is a description of com- 
 plete or general dementia, a very good example of 
 which is to be seen in the following case : 
 
 Case of acute primary general dementia. — Patient 
 was single, twenty-two, and a farmer. Two sisters 
 insane. Admitted March, 1873. On November 5, on 
 his return from a public-house, he was frightened by 
 some fireworks which were thrown at him as he went 
 along a dark lane. He got home, but remembered 
 nothing about the journey, nor his actions after he 
 was there. He was not drunk. 
 
 The next morning he did not get up, and when 
 his brother tried to get him to go to his usual work 
 he took no notice. When taken out of bed he stayed 
 where he was placed. His brother thought it all 
 resulted from drink, and fancied he would sleep it off. 
 For the next few days he was dull ; then for a short 
 tiuie and at intervals he was violent, and seemed to 
 see objects of dread. 
 
 On admission he was described as a fat lubberly 
 fellow, who neither moved nor spoke ; and who had to 
 be fed, washed, and tended like an infant. 
 
 He ate and slept well, and was in no way violent. 
 The general idea was that this patient had been weak- 
 minded from birth. He occasionally whistled to him- 
 self, but did nothing to pass the time. He scratched 
 his face into sores. The continuous electric current 
 was applied to his head daily. He roused after 
 some weeks, and said his first returning recollection 
 was of the galvanism. His mind was a total blank 
 from November till June 1. He became not only 
 
Chap. VI 1 1 .] Par tia l Dementia . 2 n. 
 
 active, but pleasant and cheerful, and rather over- 
 demonstrative for a time. He went back to his 
 work; for some years I heard that he was well, and 
 I have little doubt that if he had broken down 
 again we should have ha 1 an ap;)licatiun for his re- 
 admission. 
 
 Partial dementia, occurring as an acute dis- 
 order, is supposed to be uncommon. I am, however, 
 inclined to think there is a special group of cases 
 which should be looked upon as belonging to this class. 
 Young adults, who have given wav to excesses, 
 especially when several varieties of excess have been 
 indulged in at the same time, become unable to per- 
 form the duties for which they have been educated 
 and fully prepared, A young man of twenty who 
 had had a liberal education, with a special training in 
 art, and who was put to an artistic calling, overworked 
 himself and indulged in masturbation ; he became 
 unable to do the finer parts of his artistic work. 
 He began by being inattentive ; next he spoilt the 
 materials ; and later, his work showed no signs of 
 any of his former artistic knowledge or ability. 
 He, in fact, was distinctly losing the highest and 
 latest of his acquirements. Rest for a short time 
 enabled him to return to his work ; but he had not 
 sufficiently regained strength, and rapidly relapsed 
 into his condition of partial weak-mindedness, and 
 unless prolonged rest with exercise, good food, together 
 with somewhat stimulating companionship and sur- 
 roundings are provided, the prospect of the case is un- 
 favourable. 
 
 One of the most common varieties of partial weak- 
 mindedness is seen in the loss of confidence, so that 
 persons who have hitherto been fully able to jDer- 
 form the duties of their profession, become doubtful, 
 uncertain, and incapable. I remember one case 
 especially in which this was remarkably well seen. A 
 
212 Insanity and Allied Neuroses. [Chap. viii. 
 
 lawyer, thirty-two years of age, whose mother had 
 been insane, and in whose family phthisis was also 
 present, became uncertain and doubtf\il about his 
 ability to fulfil his duty. He had had a slight 
 attack of insanity eleven years before, from which 
 he completely recovered. He had also one attack of 
 rheumatic fever. The supposed cause of his insanity 
 was loss of situation, but the truth really was that 
 he gave up his situation because he felt doubtful 
 about being able to continue his duties. There was a 
 feeling of. unworthiness at one time in his case which 
 caused me to look upon it as one of melancholia ; and 
 undoubtedly the symptoms were of a mixed kind. 
 But the most characteristic symptoms were shown by 
 his utter inability to decide upon any course of action. 
 If, for instance, he was asked to lunch, he would take 
 twenty minutes to decide whether he, as a patient, had 
 a right to accept any invitation at all, and if at last 
 he went, half compelled and half persuaded to leave 
 his ward, he would further hesitate before taking a 
 seat, lest that seat might be required by some one 
 else; and then the meal would be prolonged to a 
 most inordinate leng-th in consequence of his inability 
 to decide upon what he should and what he should 
 not do. 
 
 After two years of treatment he left to be under 
 private care for a time, but again drifted into an asylum, 
 whence he was once more set at liberty, and since 
 then I have met him in one place or another still 
 vaguely passing from one thing to another, but utterly 
 unable to decide on any definite course of action. In 
 this condition I believe he will pass the rest of his 
 life ; for ever weighing motives and endeavouring to 
 decide upon what he should do, but quite incapable 
 of acting freely and at once. We see in this last 
 case that partial dementia may present itself as loss 
 of will. 
 
Chap. VIII.] Memory and Mental Faculties. 213 
 
 Partial and progressive dementia are found as- 
 sociated with the loss of common sensibility ; and 
 I shall point out that in many cases of myxoedema 
 there is a progressive deterioration of intellectual 
 power associated with slow conduction of impression, 
 loss of common sensibility, and general loss of tem- 
 perature ] but I am not prepared to admit with Dr. 
 Ord that this mental deterioration results alone 
 from the loss of peripheral stimulus. I am, however, 
 inclined rather to consider it as part of a diseased 
 process, in which not only the central but also the 
 peripheral nervous centres are affected. Besides 
 weak-mindedness connected with loss of common 
 sensibility, there arises mental degradation connected 
 with loss of the special senses ; just as idiocy may 
 arise from the want of hearing, so loss of hearing, espe- 
 cially if combined with any other sense-loss, will tend 
 to produce intellectual weakening along certain lines. 
 
 Memory is often taken as the test of mental 
 strength or weakness ; but it has to be looked upon in 
 very different ways. It is possible for an imbecile to 
 have a wonderful power of memory. In fact, the 
 most marvellous memories are often the most useless, 
 and are seen among the chronic imbeciles. Memory 
 begins to fail naturally in certain particulars at about 
 middle age ; and memory of names, of persons and 
 places, and the like, fails in most busy men soon after 
 forty years of age. This is physiological, and may be 
 considered as due to two causes. In the first place 
 the middle-aged man has found the futility of collect- 
 ing matter not likely to be required later. He has 
 not the same special interest, and does not pay the 
 same attention to new names and faces as he did when 
 a younger man ; and, next, there is doubtless a limit 
 to the storing capacity of the human brain for 
 disjointed disconnected facts. Many old men are 
 characterised by a further degradation of memory, 
 
2 14 I^^SJ^VTV and Allied Neuroses. [Chap. viii. 
 
 while repetition and wearisome recalling of long past 
 details are supposed to be characteristics of senility. 
 This may pass beyond simple functional loss, and be- 
 come so marked that the patient may require to be 
 looked after and controlled. I know some physicians 
 would strongly oppose the sending to an asylum of 
 patients suffering chiefly, if not solely, from loss of 
 memory, especially if this occur in old people ; but 
 examples are occasionally seen in Bethlem, where it 
 appears to me that the kindest and best treatment for 
 senile weak-mindedness is seclusion in an asylum. 
 Thus, an old man, seventy-eight years old, when his 
 memory and other faculties were becoming weaker, 
 married a young wife, and indulged in sympathetic 
 weakness which brought him pecuniarily to ruin. The 
 next stage in his mental degradation was an increase of 
 irritability and a tendency to self-neglect, so that be- 
 coming poor, dirty, irritable, and impressionable, he was 
 always in trouble. Seclusion for a time in Bethlem 
 restored him to physical comfort ; and although seclu- 
 sion cannot reduce the weight of increasing years, it 
 nevertheless allowed him to live in comfort without 
 further injuring his prospects, or causing annoyance or 
 trouble to his friends or neio-hbours. 
 
 Loss of memory may follow other conditions besides 
 age, and may be the chief symptom of mental disorder ; 
 and I feel it difficult to decide whether it is more 
 correct to place these cases among those of primary or 
 of secondary degeneration. In the following case, 
 a woman forty years old, with some insanity on 
 the father's side, who had been exhausted by the con- 
 stant w^atching and nursing of a paralysed husband, 
 doAeloj^ed quite suddenly loss of memory of recent 
 events ; this followed a fit, apparently hysterical, 
 which occurred three weeks before her admission into 
 the hospital. Nothing could be more complete than 
 her loss of memory, so that although told at one 
 
Chap. VIII.] Loss OF MeMORY. 21 5 
 
 moment a person's name, condition, and relationship 
 to her, she had the next moment forgotten en- 
 tirely both name and relationship. It was most 
 interesting to observe how purely the loss of memory 
 was a Ijss of power to store recent impressions. !She 
 was tested in every way as to her memory of the past. 
 She conld give the German for any article which was 
 shown to her, she having lived some years ago in 
 Germany. She could strike a note on a piano when 
 told to do so, and she could also recognise the name 
 of a note when struck. She had unimpaired power 
 of comparing past impressions, so that she could 
 argue in a way ; and her ideas as to the time of year 
 and time of day were evidently formed, not from 
 memory but from reason. Thus, if I asked her at 
 five o'clock in the afternoon of a day in November, 
 what was the month of the year, she would at once 
 look at the clock, look out of doors, then at the fire- 
 place, and finding it was dark, the leaves withered, 
 with still a few hanging on the branches, and a fire 
 burning on the hearth, she decided it must be some- 
 where about October, If asked the same question 
 five minutes afterwards she would go tlirough the 
 same argument with a similar result. I tried the 
 effect of deep impressions, but they were as little 
 persistent as the fainter ones, and I could not find 
 that it was of any importance whether memory was 
 appealed to through one sense or through another. 
 A visual impression was forgotten as soon as an 
 auditory one. A striking illustration of her state 
 was afforded when she was told by her friends 
 that her husband had died. She burst into a storm 
 of tears, but immediately stopped and asked what 
 she was crying about. This patient, after some 
 time, had another attack of loss of consciousness, 
 associated with some loss of power with change 
 in the common sensibility of the left side. She 
 
2i6 Insanity and Allied Neuroses. [Chap. viii. 
 
 recovered from this, and in no way appeared better 
 or worse, and at the present moment she is in 
 Bethlem enjoying good health ; but, if I may use the 
 expression, with complete loss of memory for all pre- 
 sent impressions, whether they appeal to her through 
 the special senses, common sensibility, or even through 
 the organic side. This last is evidenced by the fact 
 that she has no feeling of satiety, and will continue 
 to eat as long as any food is in her way. It has been 
 suggested that this is a case of general paralysis j but 
 I can only say at present that it is impossible for 
 me to satisfy myself that this is so. It was sug- 
 gested by a,t least one eminent physician that the 
 detention of such a person in an asylum was un- 
 justifiable ; but my own feeling distinctly is, that a 
 person who has no recollection and has desires and 
 appetites, is a person pretty sure, especially if a 
 woman, to get seriously compromised, and, if she 
 have money, to be injuriously influenced, if allowed 
 to be at large. 
 
 Dementia may be due either to physical 
 or mental disease. — Physical. — I often meet 
 with cases following fevers in which the most 
 marked evidence of weakness of intellect is loss of 
 memory, and it may be said generally that loss of 
 memory has to be considered as the most important 
 symptom. After typhoid fever I have frequently 
 seen patients whose memory, for a longer or shorter 
 period, was seriously damaged, and now and then 
 such cases do not recover, but steadily pass from one 
 stage to another till they become absolutely and per- 
 manently weak-minded. The same result may follow 
 rheumatic fever, and I am inclined to believe that 
 such weak-mindedness following the latter disease 
 occurs more commonly in cases where there has been 
 excessively high temperature j but of this I am not 
 in a position to speak authoritatively, because the 
 
Chap. VII L] Syphilis. 217 
 
 cases are only seen by me after the acute symptoms 
 have passed off. 
 
 Another condition very frequently giving rise to 
 weak-mindedness, is alcoholic 'poisoning. The general 
 effect of alcohol will be pointed out to be gradual 
 deterioration of mind, beginning with loss of self- 
 control, passing on to loss of the moral sense, so that 
 every desire is gratified without regard to truth, 
 honour, or any higher social feeling. After this it is 
 common to meet with dulness of perception and loss 
 of memory, the patient becoming more or less indo- 
 lent, self-satisfied, and dull to reaction from without. 
 This condition of weak-mindedness may well be looked 
 upon as but the result of premature hardening of the 
 nervous tissues, so that conduction of impressions is 
 retarded, and the impressions themselves are imper- 
 fectly received and slowly organised. When mental 
 weakness, due to alcoholic poisoning, has got as far as 
 this the prospect of cure is very small. 
 
 The next condition of weak-mindedness I have to 
 consider is that due to syi^hilis. I do not suppose 
 there is anything absolutely specific in the condition 
 I am about to describe, but having met with it more 
 frequently in cases suffering from syphilis than in 
 any others, I deem it at least noteworthy. A patient 
 having had constitutional syphilis some years before, 
 becomes apathetic, indolent, and at times emotional 
 and entirely unable to perform his business or his 
 social duties. Such an one shows no special delusions, 
 and for a time is kept at home. If the friends 
 be sufficiently well off they may be able to treat 
 him there, but if he be the bread-winner, and his 
 retention at home prevents others from earning the 
 means of sustenance, it will be absolutely necessary 
 to put him away. A patient in this condition has 
 generally marked loss of expression, a look of apathy, 
 not of misery, which may be increased if he have 
 
2i8 /.vsAX/ry axd Allied Neuroses, rch.p. viii. 
 
 any paralysis of a cranial nerve. He will answer 
 slowly but reasonably, and very probably will say 
 there is notliing the matter with him. On inquiry, 
 however, it will be found that he is wet and dirty, 
 although there is no evidence of paraplegia. Such 
 cases may remain in this condition for years, and in 
 some, treatment utterly fails to do any good whatever. 
 Iodide of potassium or mercury may be exhibited 
 in extreme doses without results. In some cases, 
 undoubtedly ])enefit results, and that quickly. I 
 have seen such a patient completely cured and remain 
 well for years after ; but then the disease was almost 
 certainly connected with a gumma. What the change 
 is in the above cases I do not know. It may be that 
 there is some change in the arterial walls, some 
 thickening of the membranes, or even interstitial 
 change in the brain itself. The importance of re- 
 cognising the syphilitic origin of these cases is 
 great, since many similar ones have been mistaken 
 and set down as simple ordinary dementia of general 
 paralysis of the insane. 
 
 Weak - mindedness of every form may follow 
 epilepsy, and will be considered under that head. A 
 blow on the head will produce w^eak-mindedness, and 
 I suppose some of the old cases of sudden suspension 
 of all but organic life, resulting from depressed frac- 
 tures of skull, may be looked on as cases of acute trau- 
 matic dementia. When, later, discussing the varieties 
 of mental weakness, I shall point out the relationship 
 of dementia to other forms of mental disorder. 
 Almost all acute attacks of mental disease leave the 
 patient mentally enfeebled for a time at least. 
 
 When speaking of mania and melancholia, I 
 pointed out that there is often action and reaction, so 
 that a patient may be depressed after he has had an 
 attack of acute mania ; there will be found weak- 
 mindedness more or less directly associated with an 
 
Chap. VIII.] Dementia a nd Bodil y II l ness. 2 1 9 
 
 acute mental illness. After a severe bodily illness 
 patients feel weak in body ; and after a similar dis- 
 order of the mind there is intellectual weakness. 
 This condition is, in my experience, most common 
 when the mental disorder has been specially connected 
 with some bodily illness. If the patient has become 
 insane after pneu7nonia or a fever, or if she be insane 
 in consequence of child-birth, the chances are that 
 she will have to pass through a stage of mental 
 weakness exhibited by apathy, indolence, tendency 
 to the neglect of person and proprieties ; there is often 
 a large appetite, with a disposition to sleep and grow 
 fat. Such condition requires every means of external 
 stimulation, and in women the ovarian functions 
 must be looked to, as they are almost always irregular 
 or in abeyance. Such patients should not be kept 
 longer in an asylum than is necessary. I have fre- 
 quently found it my duty to force such weak-minded 
 people back into their families, where they slowly 
 re-establish their family relationships, and then com- 
 pletely recover. 
 
 So much, then, for dementia. I feel it difficult 
 to make a quite satisfactory treatise on this subject, 
 because weak-mindedness has to be considered from so 
 many points of view. The mere reduction of mental 
 power, the decreasing scope of the mind's activities 
 and sympathies, the impaired transmission and 
 velocity of thought, and the diminished reaction of 
 the nervous centres, must all be looked upon as 
 evidences of mental weakness. Disease itself is 
 the evidence of weakness, and the body and mind 
 are only strong when well. It would, therefore, 
 have been quite allowable for me to have considered 
 every variety of mental disorder as evidence of 
 mental weakness ; but instead of this I have in this 
 chapter brought together the chief conditions which 
 led to marked and direct loss of power in one or 
 
220 Insanity and Allied Neuroses. [Chap. viii. 
 
 more of the most prominent faculties, whether arising 
 from the bodily or mental side. 
 
 The diagnosis between melancholia, stupor, and 
 dementia has already been made, and the chief 
 sources of error lie in the diagnosis between perma- 
 nent and temporary weak-mindedness. The cause of 
 the illness and the age of the patient must decide ; 
 if young there is fair hope of recovery, if neither 
 associated with epilepsy nor due to prolonged ex- 
 haustion from masturbation. If alcohol is the cause, 
 the prospect is fair, if there have not been several 
 previous attacks. If following fevers, pneumonia, or 
 child-birth, the prognosis is also fair. If associated 
 with epilepsy, apoplexy, or degeneration of arteries, 
 the chances of recovery are small. 
 
 Treatment. — In all cases change of surround- 
 ings and cheerful stimulating companionship are neces- 
 sary. If any good is to result in the cases which are 
 curable, it must follow liberal diet and exercise. As 
 soon as I can trust a patient who is suffering from 
 partial dementia, or from dementia due to some phy- 
 sical cause, I send him home on trial, or, at least, 
 get the friends to visit and encourage him. 
 
 In cases of young men suffering from the effects 
 of masturbation, every means must be used to give 
 occupation to the mind, and to strengthen the body. 
 Cold bathing and gymnastics are good. Drugs, such 
 as bromide of potassium, are not good. Iron, arsenic, 
 and occasional purges, are more likely to be of 
 service. 
 
 In older cases the chief care is to prevent the 
 patients from injuring themselves in body or estate. 
 Such cases are often best looked after in private 
 houses. 
 
221 
 
 CHAPTER IX. 
 
 STATES OP MENTAL WEAKNESS. 
 
 Examples of chronic insanity — Chronic incoherence — Chronic 
 mania — Weak-mindedness with easily roused fury — Weak- 
 mindedness, with special limited caiDacities — Weak-minded- 
 ness, with temporary sanity before a fresh attack of mania — 
 Weak-mindedness, with a second attack of melancholia due 
 to age — Chronic active melanchoha — Chi'onic passive melan- 
 cholia — Recurrent melancholia, with tendency to weak- 
 mindedness — Eecurrent melancholia, with distinct alteration 
 in character — Recurrent mania, with but little intellectual 
 loss — Profound secondary dementia, of fifty years' duration 
 — Weak-mindedness, with persistent delusion — Weak-minded- 
 ness, with hypochondriasis. 
 
 In all asylums, and especially in the large county 
 asylums, there are many patients who are incurable, 
 and yet who are fairly useful in doing the simpler 
 and more mechanical work of an asylum ; without 
 them the larger asylums would prove much more 
 costly, as they are the hewers of wood and drawers 
 of water, whose services, if wanting, would have to 
 be replaced by paid labour. Notwithstanding their 
 ability to perform these duties, they are hopelessly 
 insane and unfit to be at large. Whether they have 
 as much liberty as is possible is another question not 
 to be settled here. Many such patients gradually 
 develop a special aspect, and are recognisable wher- 
 ever they are met ; but this is not true of all persons 
 suffering from chronic insanity. There are several 
 degrees in which this chronic mental affection shows 
 itself. 
 
 First, after an attack of insanity which may have 
 been maniacal or 'melancholic, the mental balance is 
 never set right ; there is some peculiarity left, some 
 loss of capacity or some loss of control, which more or 
 
222 Insanity and Allied Neuroses. [Chap. ix. 
 
 less influences the life's history to the end. In 
 its slightest degree this is called eccentricity or per- 
 verseness, and many patients are discharged from 
 asylums as recovered, who are really affected to some 
 slight extent but not enough to justify detention, 
 though the aiSection is too great to permit of a return 
 to former occupations. I have known active men of 
 business, who, after an attack of insanity, have ap- 
 peared well and rational, but all power of application 
 to work had gone. In others, evidence of loss of 
 control was seen in intemperance or moral instability. 
 
 Doubtless a whole series of such cases could be 
 arranged, exhibiting every degree of loss of mental 
 power. One interesting fact is, that from the result 
 you cannot judge of the nature of the mental storm 
 which has raged. A man may be eccentric or intem- 
 perate as a result of mania or melancholia. 
 
 Attacks of insanity, especially if they are repeated, 
 tend to alter the whole mental life. 
 
 The alteration may be slight, affecting the finer 
 social adjustments, or may be grave, destroying all 
 social qualities. The alterations may leave a nervous 
 instability, which is shown in greater readiness to 
 break down under slight causes of disturbance, and I 
 shall give examples of this as seen in weak-minded 
 persons, subject either to recurrent attacks of violence 
 or who are liable at irregular intervals to passionate 
 uncontrolled outbreaks. 
 
 Such patients, though in the intervals apparently 
 sane, are ever ready to do some dangerous or violent 
 act. These dangerously insane persons may be able to 
 read, write, and talk as well as ever, they may retain 
 certain accomplishments, and yet are not safe to 
 be at large. No single examination by a doctor could 
 satisfy him that ma,ny of these persons require special 
 care, and that they are not fit for liberty. 
 
 Attacks of insanity may leave the patient a 
 
Chap. IX. 1 Chronic Incurable Lunatics. 223 
 
 complete wreck, or they may leave as a result minds 
 with altered adjustments, so that in one case the 
 lower or more organic part of man has an inordinate 
 power, while in another this same organic life may 
 be so deficient as to endanger the life of the man. In 
 other cases attacks of insanity leave a few promi- 
 nent delusions, which may be morbid outgrowths of 
 the disturbed nervous system ; I might say natural 
 growths, from the delusions of the acute disorder; 
 or they may be growths developing from the lower 
 parts of the man's nature, unrestrained by his higher 
 powers, growing from absence of control. Thus cases 
 of monomania may arise. 
 
 Besides the above cases, due to disease, natural 
 progressive decay in neurotic subjects may give rise to 
 all sorts of chronic perversions, and to states of mental 
 weakness of various kinds. 
 
 There are many other groups of cases which might 
 be referred to. In some with strong inheritance a 
 strong bias sets in at certain ages, which may lead to 
 the special overgrowth of one side of a man's charac- 
 ter, and may thus overbalance his mind. In some 
 cases sense-perversion seems at the root of the dis- 
 turbance. The two chief points in which cases be- 
 longing to the above groups agree are their inability 
 to fulfil their old functions, and their perversion of 
 social feelino^s. 
 
 I shall begin with a description of some of the 
 cases of chronic incurable lunatics ; those who have 
 survived the storm, but are mental wrecks. 
 
 For convenience I shall briefly trace the develop- 
 ment of examples of such cases from the beginning. A 
 full clinical description of any one case would be im- 
 possible ; for as soon as the mental storm has ceased, 
 and the patient has passed into a condition of chronic 
 mental unsoundness, the life passes monotonously, and 
 with comparatively few changes, lasting often to an 
 
2 24 Insanity and Allied Neuroses. [Chap. ix. 
 
 extreme length, so that on the incurable fund of 
 Bethlem, as on a pensioners' list, there are always 
 aged survivors. 
 
 Characteristic case of chronic maiiia. — A woman, 
 was forty-one years of age at the time of her 
 admission into Bethlem in 1847. She was the wife of 
 one of Her Majesty's household. She had an attack 
 of insanity when twenty- three years old. As a 
 girl she had been a circus rider of considerable 
 personal attractions, and of distinction in the ring. 
 She married, but had no children. She became 
 affected by melancholia, and had ideas that through 
 some fault of hers her husband was ruined. She 
 attempted to strangle herself. Before admission 
 for a time she was intemperate. The condition of 
 melancholy continued for years, so that she would 
 sit about the wards unoccupied, taking no interest 
 in what was passing around her, eatiug but little 
 food, quiet, and sleepless at night. After a pro- 
 longed period of mental depression she had a corre- 
 spondingly prolonged period of mental excitement ; 
 she became dangerous and violent, and her language 
 was abusive and obscene. She is described as 
 being a very demon when roused. She was full 
 of delusions, said she had been killed in various ways, 
 and was also possessed by the idea that she was 
 very wealthy. When first I knew her, in 1865, she 
 was the terror of the ward, and I have frequently 
 seen her attack attendants and medical officers in an 
 extremely brutal way. She at that time traced, and 
 still traces, some connection between the Boyal Family 
 and herself, and would take a visitor up to a picture of 
 the Queen, and say, " That is me when I was a child." 
 Incoherence, violence, and coarse language were the 
 order of the day for years ; but I determined to re- 
 move her from the companionship of the noisy and 
 acute cases with whom she had associated for over 
 
ch ap . 1 X. ] Dementia \vi th Ma iyia . 225 
 
 thirty years, and place her in a small infirmary in 
 which were only five quiet cases. The result has been 
 satisfactory in so far that, although her tongue has not 
 ceased from abuse, her language is less coarse, and 
 her dress and mode of life much more satisfactory 
 than when she was acting in harmony with her more 
 boisterous surroundings. General incoherence with 
 hallucinations are the present symptoms of her mental 
 condition. When spoken to she will talk in a rather 
 strident voice volubly about '' soldiers," " keep," 
 ''scrape," and other things which to us seem discon- 
 nected. Her dress is quaint. She will constantly 
 appeal to the " invisibles," who appear in her case to 
 address her generally from the chimney. She has 
 apparently lost any real notion of age and general 
 conditions of society, so that she, at Christmas, on 
 receipt of a card with a cherub, will think that it re- 
 presents a baby which she is going to have ; her erotic 
 tendencies are not extinct, and she is still dreaming 
 of marriage. Little disturbs her beyond some defect 
 in the quantity or quality of her food. When ex- 
 cited she is easily roused to anger. She has no real 
 affection for those about her, nor does she dwell w^ith 
 any fondness of memory upon the husband of her 
 youth. Her general health is good, and in this con- 
 dition of babbling, unstable weak-mindedness, ex- 
 hibited by incoherent chatter, she will live till some 
 unexpected bodily ailment carries her off. The case, 
 then, is one in which a second attack of insanity was 
 marked by prolonged melancholia, which passed into 
 chronic weak-mindedness, associated with maniacal 
 outbursts. 
 
 Dementia with outbursts of mania. — Half of the 
 work of county asylums is done by patients who 
 belong to the above class. I am in the habit of 
 pointing out, as I go round the wards, those whom 
 I call my advanced specialists, patients who will only 
 p— 14 
 
2 26 Insanity AND Allied Neuroses. [Chap. ix. 
 
 perform certain limited actions. Thus, one woman for 
 many years polishes or scrubs the floors, while another 
 is only happy fitting stones or pebbles into gaps in the 
 paths. Such represent the patients I am now re- 
 ferring to. If left alone they will behave quietly, but 
 any interference with them, esj)ecially if it involve 
 change in their habits or occupations, will be violently 
 resisted. I sometimes compare the mental state of 
 such cases to that of a mountain lake, on which a very 
 small storm will produce a large amount of distur- 
 bance. The following is a striking example : 
 
 William E , a musician, aged thirty-two on 
 
 admission ; was placed to the incurable list in 1847, 
 and from the first he was reported as dangerous until 
 thoroughly kno^vn, and even then hard to manage. He 
 declined to recognise his surname, and always when 
 spoken to replied in an affected way. If his surname 
 happened to be mentioned, and if he were in a good 
 temper, he would say, " That man Bill E., of whom you 
 speak, was removed from here long ago ; I have only 
 just come ; I am Wilberforce or Guelph, the redeemer 
 of the tribe of Judah." He used to stand on iron if 
 he could find any about the wards, and would rub the 
 back of his head to carry off the electricity with which 
 he said he was charged, and would stuff the left side 
 of his nostril to prevent the electricity from flowing 
 into his penis. A thunderstorm had a most violently 
 disturbing influence upon him, so that it was always 
 necessary at such times carefully to avoid him. In 
 this condition of delusions, with loss of identity^ ex- 
 treme irritability, and tendencies to violent outbuists, 
 he lived till 1879, when he died from an attack of 
 bronchitis. 
 
 These cases serve as good examples of the danger 
 which would arise from following too generally the 
 advice so freely given, to keep cases of chronic 
 insanity out of asylums. Certain patients, no doubt^ 
 
Chap. IX.] Chronic Mania. 227 
 
 can be as well treated at home or in villages as ia 
 asylums, but it would be an extremely dangerous 
 experiment to try to keep at large patients who are 
 liable to outbursts of fury occurring without warning; 
 or those who are disturbed by the slightest emotional 
 storm, and who would inflict serious injury when 
 enraged, and yet can in no way be influenced by 
 dread of punishment or by ideas of responsibility. 
 
 Cases of chronic mania may remain as useful 
 drudges for years, and then a fresh attack of acute 
 insanity may occur, leaving the patient more weak- 
 minded, more liable to recurrences of excitement ; or 
 in the second onset of acute insanity the whole aspect 
 may be changed. 
 
 Case of weak-mindedness, with temporary return 
 to sanity on the outbreak of a fresh attack of mania. — 
 Thomas H., aged 53, a clerk, having no insane 
 relations, was first attacked by insanity in 1866, and 
 was taken to the Exeter asylum. The attack began 
 with exalted ideas. He insisted in carving and 
 presiding at every dinner-table ; told his friends that 
 he owned Buckingham Palace, and that the world and 
 the sun obeyed his all-powerful control. From this 
 acute state he passed into one of happy, contented 
 weak-mindedness, which lasted for several years, and 
 it is reported that the superintendent saw no prospect 
 of any change. One day he began to talk quietly 
 about his past life, and toDk an interest in his family 
 and business relationships. He wrote several sensible 
 letters, and made enquiries as to the welfare of those 
 connected with him. This period lasted under two 
 weeks, when he became violently maniacal with exal- 
 tation of ideas, sleepless, restless excitement in which 
 he was constantly occupied in converting his pillow 
 into the Prince Consort ; the excitement showing no 
 signs of abatement, he was transferred to another 
 asylum in a state of chronic mania. 
 
2 28 Insanity and Allied Neuroses. LChap. ix. 
 
 Case in which a fresh attack of melancholia 
 followed years of quiet contented weak-minded7iess. — 
 John C, a farm bailiff, aged 39, was admitted into 
 Bethlem in 1861, suffering from a first attack of 
 insanity, said to have been associated with an 
 ulcerated leg. It began with melancholic symptoms, 
 alternating with excitement, and with ideas that he 
 was being poisoned. For the next ten years his 
 symptoms became those of the ordinary weak-minded 
 drudge. From morning to night he was tidying, 
 scrubbing, and putting his room in order. He was 
 allowed great liberty, so that he wandered about the 
 grounds collecting trifles, and latterly took to repair- 
 ing the paths in the gardens. This occupation seems 
 to have given him endless satisfaction and pleasure, 
 and the elaborate way in which he arranged every 
 particular stone in the place he wished it to occupy, 
 formed a good instance of a power for application 
 to detail connected with absolute weak-mindedness. 
 Without any warning, on the 10th of February, 1883, 
 he became torpid and was anxious to stop in bed. 
 When spoken to he said the devil had got hold of 
 him, and no amount of coaxing or persuasion would 
 induce him to resume his old occupations. On investi- 
 gation I found he was markedly more feeble, his 
 arteries more rigid, and his respiration less free than 
 formerly. There appeared to be a general reduction 
 of physical power, associated with melancholia. 
 
 It is well also to remember, that although many of 
 these cases of chronic mania seem to be quiet and 
 harmless, yet many of them have acquired habits 
 quite incompatible with their being at large. Thus, 
 one patient in Bethlem, who was of gentle birth and 
 of superior education, although now a useful aid and 
 thoroughly trustworthy in many respects, is given 
 not only to irritating and pinching other patients, 
 but has habits of collecting rubbish, filth, and the like 
 
Chap. IX.] Chronic Melancholia. 229 
 
 in his pockets. Some lose all delicate sensibility, so 
 that one will swallow leaves, filth, or other refuse, 
 while another will expose his penis on every occasion. 
 
 Conditions of weak-mindedness associated ivith 
 TYielancholic symptoms. Chronic melancholia. — Just 
 as we saw in acute melancholia that there may be 
 active, passive, or stupid melancholy, and that there 
 may be melancholia with or Avithout delusions, so m 
 considering the chronic incurable cases it is note- 
 worthy that some are actively melancholic from the 
 beginning to the end, while others are chronically 
 passive. This was marked in a case of a woman, 
 forty-five years old, admitted into Bethlem in con- 
 sequence of an attempt to strangle herself. On 
 admission this patient moaned aloud and wrung her 
 hands, saying she had destroyed the world. She was 
 restless, miserable, solitary, and meagre. She con- 
 tinued in this state of agitation and melancholy not 
 only for the one year during which she was in Bethlem, 
 but in another asylum she continues up to the present 
 time (eight or nine years having elapsed) still to 
 lament in the same strain the evils she is causing. 
 Such a case is all but hopeless, and although the 
 general health is fair and the appetite improved and 
 sleep better, yet the prospect of mental recovery is 
 extremely small. 
 
 Another case was that of a widow, admitted suf- 
 fering with melancholy of the passive type, overbur- 
 dened with the idea that her un worthiness had caused 
 the death of her husband and the ruin of her children, 
 and that she, an unpardonable sinner, must live on for 
 ages in her inhuman and unnatural condition ; that 
 nothing could save her from the living hell wliich she 
 was now experiencing. Nothing rouses her to action, 
 and, unless moved by the attendants, she will sit from 
 m^orning to night alone in a dark corner of the room- 
 This condition of passive melancholia may last for years, 
 
230 Insanity and Allied Neuroses. [Chap. ix. 
 
 generally ending in a somewhat more placid condition 
 or state of weak-mindedness, but often with no 
 visibly different symptoms occurring for many years. 
 Other cases (and these, perhaps, the more commonly 
 met with in Bethlem) are those suffering from recur- 
 rent melancholia. Thus, a widow was admitted 
 to the incurable list of Bethlem in 1867, having had 
 five previous attacks of melancholia from which she 
 had recovered : she had had a hard struggle for her 
 existence, in consequence of the state of her mental 
 health. After admission she was desperately de- 
 pressed and sleepless, refusing food, and insisting on 
 remaining unoccupied j when spoken to, she replied in 
 a whisper that she must be left to her fate, and that it 
 was perfectly useless trying to do anything for her ; that 
 she was altogether a wicked person, and that no decent 
 person ought to speak to her 3 that she was an outcast 
 and can never be well or good again. This condition 
 lasted for some months, then slowly passed off, leaving 
 her in robust health, cheerful, contented, and obliging. 
 The period of mental soundness continued for eighteen 
 months, and then a cloud, similar to previous ones, 
 settled upon her with the same symptoms. During the 
 last few intervals of health I granted her a free pass 
 to go in and out of the hospital at will. This she 
 always used properly, and when she felt herself 
 becoming melancholic she declined to make use of her 
 freedom. It is hard to believe that this patient 
 will ever remain permanently well ; but during the 
 past few years the attacks of mental depression have 
 been fewer and at greater intervals, and the periods 
 of contentment and health have been of longer 
 duration. The more common result in such a case is, 
 when old age comes on, for the patient to be more un- 
 stable, and ultimately to become more weak in mind. 
 In Bethlem we have on the incurable list a fair 
 number of such cases, who from their education and 
 
Chap. IX.] Permanent Weak-mindedness. 231 
 
 accomplishments, while they ar© iii health are useful 
 aids towards the employment and amusement of the 
 more acute cases. 
 
 Recurrent nielancliolia. — The next case illustrates 
 the position which melancholia may take in a case of 
 permanent weak-mindedness, Samuel B., aged thirty- 
 five, single, a stationer, was admitted in 1853. He had 
 suffered from one previous attack of insanity ten years 
 before, and recovered. After a period of depression he 
 became excitable, self-satisfied, and although incapable 
 of being trusted, yet he was easily managed, and if 
 not interfered with, aided in work about the hospital. 
 He was subject, at irregular intervals, to recur- 
 rences of depression, in which he refused food, and 
 declined to speak. This stage was succeeded by 
 extreme weakness. He had to be fed with the 
 stomach pump, and notwithstanding this became 
 much emaciated. He slowly recovered from the 
 period of depression. Attacks of this kind recurred, 
 each seeming to leave him weaker in mind, so that he 
 became a standing joke to the other patients on 
 account of his dandified actions and gallant airs. 
 He spent his time, and any spare money he be- 
 came possessed of, in additions to his dress. This 
 condition of things was maintained till he was 
 sixty-three years of age, when again he felt sure 
 he was unworthy. He was fully persuaded that 
 something serious was going to happen, and that he 
 ought not to eat. He declared that he was filled 
 up, and that there was no more room for food. 
 Inflammation of the right lung supervened, and he 
 died. Fost morteyn his brain was found to be of fair 
 weight, dura mater normal, excess of subarachnoid 
 fluid, membranes free, marked depression at the right 
 apex of the junction of the first frontal with first 
 ascending parietal convolution. There were some signs 
 of softening in pons varolii ; the rest of the viscera, 
 
232 Insanity and Allied Neuroses. [Chap. ix. 
 
 except the lungs, were fairly healthy. This case is 
 given as an example of the ordinary end of a case of 
 recurrent melancholia. 
 
 Recurrent mania. — A governess, w^ho, on ad- 
 mission into Bethlem, in 1866, was fifty-one years old, 
 had strongly marked insane relationships in her family, 
 one member or another exhibiting every variety of 
 neurosis. This was the first attack of insanity re- 
 quiring removal to an asylum. She believed that 
 people conspired against her, and periodically she had 
 outbursts of extreme excitement. Each attack was, 
 as a rule, preceded by a slight period of hypochon- 
 driacal depression, and at the same time there was 
 change in her facial aspect, the attendants describing 
 it as " grinny ; " and I think " sardonic grin " very 
 well describes the expression. For many years this 
 patient's attacks were preceded by periods of mental 
 health, lasting from six to eight weeks at a time, to 
 be followed by a period of most violent and destruc- 
 tive mania. Eor instance, in one particular year she 
 became excited on the 5th of January, and quiet again 
 on the 13th of February ; then excited on the 28th of 
 May, and quiet once more on the 16th of July. In 
 August a fresh attack of excitement was followed in 
 September by quiet \ in October again excitement, 
 followed by quiet in November, and in the middle of 
 November a fresh attack of violence occurred. This, 
 I may say, was a year of exceptional frequency of re- 
 currence ; but some years would pass with only three 
 attacks. The characteristic of the attacks was, as I 
 have said, a very short period of depression, as a rule, 
 but sometimes there was no warning whatever; and 
 I have known this patient dine quietly, and within 
 five minutes of the conclusion of the meal be as de- 
 structive and violent as a patient could be. For days 
 she would scream, threaten, and curse in the most 
 terrible way, almost always using similar expressions 
 
Chap. IX.] Recurrent Mania. 233 
 
 in each attack, rhyming time after time on hell and 
 devil ; mistaking her relations if she happened to see 
 them, and imagining that those who were dead were 
 still about her. Night brought her no rest, and 
 for weeks together this excitement would rage. Her 
 appetite was large and food was taken voraciously ; 
 her dress was disordered and torn, and her grey 
 hair dishevelled and cast to the winds. No special 
 warning heralded the cessation of the storm, but as it 
 came so it left, sometimes absolutely suddenly, the 
 patient being weakened and exhausted in mind and 
 body for some time afterwards. The chief peculiarity of 
 this case is, that, having had very many of such terrific 
 nerve storms there has practically been no intellectual 
 degradation, so that in the intervals of calm this lady's 
 memory, afi'ections, and habits are just what they 
 might have been without this recurrent mania. In 
 my opinion this depends, to a great extent, upon her 
 strong insane inheritance. As for treatment, it seems 
 reasonable to try the effect of powerful remedies, such 
 as hyoscyamine before or after the commencement of 
 each outb.-eak of mania ; but I can only say that in 
 this case I gave most powerful depressants a.nd nar- 
 cotics without any satisfactory result. For a time 
 she was treated with hyoscyamine \ but the effect was 
 that the excitement was ouly temporarily allayed, 
 while the appetite for food was destroyed, so that she 
 became alarmingly weak. For two years I kept her 
 almost constantly under the influence of conium juice, 
 giving her this medicine in increasing doses up to four 
 ounces, and I was inclined to believe that its use 
 seemed to be, at all events, associated with fewer at- 
 tacks, which were also less severe ; nor was any damage 
 done to her general health or appetite. Whether this 
 was the result of years, or the effect of the medical 
 treatment, I know not, but this patient has now had 
 more than twelve months of quietness and sanity. 
 
2 34 Insanity AND Allied Neuroses. [Chap. ix. 
 
 Secondary dementia^ lasting unchanged for fifty 
 years, with jjrogressive wasthig of muscles. — Priscilla 
 K., aged 77, admitted into Bethlem 1832. At first 
 she was mischievous, with jDeriods of depression with 
 refusal of food. For a few years regular attacks of 
 excitement and depression occurred, and these ended 
 in a state of dementia. The patient does nothing ; 
 she sits alone, but with a pleased smile always on 
 her face ; she neither speaks to nor associates with 
 the other patients ; she eats, drinks, and sleeps. She 
 can walk, but unless forced to do so will remain where 
 she is placed. Every now and then she makes a 
 chattering noise, and seems childishly excited, but one 
 cannot trace any external cause for this excitement. 
 
 Her muscles have steadily and uniformly wasted, 
 till her hands and arms look like a skin-covered 
 skeleton. 
 
 This patient may live on for years, unless the 
 chest muscles waste too much to continue the respira- 
 tory function, or unless she meets with some accident 
 owing to her feebleness. 
 
 This is a marked example of progressive removal of 
 higher intellectual centres, which being so gradual has 
 allowed accommodation. A more rapid process must 
 have killed the patient long ago. 
 
 Weak-mindedness with persistence of one or more 
 morbid ideas is also common, and this group of cases 
 leads very naturally to that in which we find patients 
 with fixed delusions as of persecution, and others with 
 monomaniacal ideas. 
 
 One lady, who has been over twenty years in 
 Bethlem, is always quiet and well behaved ; she shuns 
 notice, and often students spend six months in the 
 hospital without seeing her. She is possessed by the 
 idea that Methuselah is coming for her, and so, 
 regardless of other men, she guards her fading charms 
 for this father of mankind. 
 
Chap. IX.] Chronic Insanity. 235 
 
 Chronic insanity with hyjjochoiidriacal delusions. 
 — Jane J., single, 67, governess; first attack of in- 
 sanity was in 1852. Several other attacks followed, 
 and at length, in 1857, she was placed on the in- 
 curable establishment of Bethlem. 
 
 She had melancholic ideas at one time, and was 
 excited and maniacal at others; she believed the 
 doctors and others were injuring her, and she com- 
 plained of a feeling of confusion, her chief cry being to 
 be "let alone and not bothered." She fancied things 
 were done to annoy her, and that even the birds 
 sang only to tease her. 
 
 At irregular intervals attacks of the above kind 
 came on and passed away, leaving the lady again busy 
 and pleasant. She was very handy with pen, pencil, 
 and needle, and spent her time in writing a novel, 
 drawing flowers, or doing fancy work ; but during the 
 periods of quiet she is fully possessed by the idea that 
 she is making new lungs, and attendants object to 
 go out into the streets with her because of a blow- 
 ing noise she makes every few minutes, regardless of 
 her surroundings. 
 
 At times she spends whole days and nights making 
 distressing noises. It is interesting to note that 
 this patient suffers from emphysema of the lungs. She 
 is full of hope still of marrying. She will remain as 
 she is probably to extreme old age. 
 
 Another lady who suffered from melancholia of 
 the most profound kind for years passed into a state 
 of partial weak-mindedness, which has long been little 
 more than hypochondriasis. Her one object in life 
 is to think of her ailments and of her misfortunes. 
 Her letters are full of references to the buried past, 
 and are of a childish character. Acute melancholia 
 has changed the once active but emotionally religious 
 woman into a confirmed hypochondriac, fit only for 
 an asylum. 
 
236 Insanity and Allied Neuroses. [Chap. ix. 
 
 A similar case was that of a man already referred 
 to, whose one idea was his coming meal, and his one 
 expression was the character of that meal. He would 
 thus in the morning from breakfast to dinner time 
 say once a minute, " I will have my dinner at one 
 o'clock." He died at the age of 78. 
 
 Among cases of chronic insanity are placed those 
 having more or less complete loss of mental power ; 
 this may be exhibited by loss of control, by sensory 
 defect, by want of will-power or of memory, with 
 survival of some human attributes. It may be 
 characterised by insane habit, as when mania or 
 melancholia become chronic. It may be marked by 
 instability, so that there are periodical outbreaks or 
 tendencies to be easily upset. It may be shown by 
 the growth or persistence of delusions of any kind. 
 
 As far as treatment is concerned, nothing can be 
 added beyond what I said about cases of dementia. 
 
 Prognosis. — Though it is generally accepted 
 that insanity which has lasted for a few years, and 
 insanity which has not changed during that time, is 
 not likely to be recovered from, yet cures occur from 
 time to time among the most chronic cases. In some 
 cases, especially among women between forty and fifty 
 years of age, a fresh vital balance is established, and 
 with this there may, after years of alienation, be a 
 return to sanity. In others, patients grow into cer- 
 tain habits, and unless removed they will remain 
 till the end of their days placidly weak-minded. 
 
 I believe that removal from one asylum to another 
 would be of great service in some cases ; just as the 
 bone-setter from time to time performs some extra- 
 ordinary cure by breaking down adhesions round a 
 joint, so the change to less agreeable surroundings may 
 set free the latent powers of the mind. 
 
237 
 
 CHAPTER X. 
 
 DELUSIONAL INSANITY — HALLUCINATIONS. 
 
 Examples of insanity depending on hallucinations — Delusional 
 insanity in man, persecution, etc. — Delusional insanity in 
 woman, persecution, etc. — Delusional insanity in woman, 
 exaltation — Delusional insanity with jealousy — Delusional 
 insanity with ideas of constant change in the surroundings— 
 " Symbolisms." 
 
 Chronic insamty associated with halluci- 
 nations and delusions. Delusional insanity. 
 
 — In this group of cases I shall have to describe a 
 class of patients who have generally been placed with 
 those suffering from mental weakness ; but there seem 
 to be several objections to this, the chief one being 
 that, except from an expert's point of view, these 
 patients are often extremely shrewd, and exhibit none 
 of the ordinary symptoms of weak-mindedness, their 
 memories being good, their volition strong, and their 
 emotions well under control. They differ from those 
 whom we call sane in having sense impressions, which 
 differ entirely from the sense impressions of the 
 ordinary person, or in having some fixed idea, which 
 owes its origin to some sensation and feeling which 
 we do not understand ; and this delusion, like the 
 hypochondriac's sensation, is not to be removed by 
 argument. Such persons have a faculty of faith ; 
 "they cannot reason, they can only feel." Any one 
 of the senses may mislead the mind, and any false 
 idea may become fixed ; but the interest in these cases 
 lies in the fact that though so many possible com- 
 binations of symptoms might occur, practically the 
 groupings are few and definite in character. 
 
238 
 
 Insanity and Allied Neuroses. [Chap. x. 
 
 In most cases these ideas have a direct relationship 
 to the preservation of the individual or to the exis- 
 tence of society. They belong to his social side. 
 Suspicion, jealousy, and the like, represent the 
 character of the delusion. 
 
 I am quite unable here to fully enter into the 
 
 A case of Dalasional Insanity with Hallucinations of Hearing. 
 
 development of hallucinations ; but I sliall take this 
 opportunity of briefly referring to some of the chief 
 varieties, and I shall take occasion to illustrate them 
 by typical exampl3s. 
 
 Hallucinations may be described as sense-im- 
 pressions resulting without any external stimulus, so 
 that hallucinations of sight may occur in darkness or 
 to blind eyes ; and hallucinations of hearing are to be 
 
Chap. X.] Delusional Insanity. 239 
 
 met with not uncommonly among deaf j)atients as well 
 as in the stillness of night. Hallucinations may occur 
 in any one of the senses ; they may occur in one of 
 "OnQ bi-lateral senses, so that one ear alone may be 
 subject to hallucinations. Hallucinations may occur 
 in various forms of mental disorder ; hallucinations 
 of sight being very common in some of the more 
 acute cases of mania as well as in delirium. In fact, 
 hallucinations of all the senses may occur in mania 
 similar to those met with in delirium. Hallucinations 
 of hearing are the most common, " voices " being 
 most frequently met with ; the voices may speak in a 
 whisper at a distance, may speak directly into the 
 ear, or may shout loudly, or even scream. They may 
 be heard from above or from below, in the chimney 
 or under the floor. The " voice " may apjDear as that 
 of a man or woman ; it may be recognised as friendly 
 or inimical ; it may appear to be in a monotone, or it 
 may appear as a chant. Besides " voices," the patients 
 may hear buzzings or thum pings as of a hammer, 
 or of a drag on a carriage, or there may be whistlings, 
 growlings, or, what is comparatively common, ringing 
 of bells, or the knocking of nails in a supposed coffin. 
 A medical friend of mine suffered for some time with 
 hallucinations of hearing, which at one period caused 
 him to discharge his coachman because he believed he 
 was always using the drag on the wheel, and later he 
 was constantly annoyed by what he believed to be 
 run-away rings at his night-bell. I would say that, 
 as a rule, hallucinations with recovery become fainter 
 and fainter as if a distance were being placed between 
 them and the hearer. It does not follow that persons 
 having hallucinations should necessarily be of unsound 
 mind, but there are two conditions in which their pre- 
 sence is of great consequence. In a patient predisposed 
 to insanity by inheritance, or one who has had previous 
 attacks, any recurrence of hallucinations should render 
 
2 40 Insanity AND Allied Neuroses, [Cimp. x. 
 
 the Mends on tlieir guard and cause extra caution. 
 And again, if a patient has suiFered from insanity, in 
 which hallucinations have been prominent symptoms, 
 it is well not to discharge him finally as recovered till 
 all hallucinations have passed away. I have known 
 one patient in Bethlem, who told me that for months 
 before it was necessary for her to be sent from home, 
 she heard voices up the chimney, and that she treated 
 them exactly as she would wandering thoughts when 
 reading a book, by an involuntary shake of the head, 
 and a fresh application to the work in hand ; but, as 
 she lost physical strength, she found this impossible, 
 and in the end the voices controlled her, and not she 
 the voices. 
 
 In another case, the patient, who had suffered from 
 profound melancholia with ideas that she was ruined 
 and must go to the workhouse, having lost these 
 melancholic ideas, yet told me that when reading to 
 herself, or thinking, everything she either read and 
 comprehended or that she thought carefully about 
 was repeated in a peculiar musical way two feet 
 above her head. Hallucinations of hearing, then, may 
 be associated with various forms of insanity. As a 
 rule, they are painful impressions ; but I had for- 
 merly in Bethlem a patient who enjoyed, as he 
 said, his conversations with a French lady who went 
 for walks with him. In this case hallucinations of 
 hearing were associated with other hallucinations, 
 and when he enjoyed those pleasant hallucinations of 
 hearing he also perceived a pleasant odour ; but 
 when, later in his disorder, he suffered from two 
 voices wrangling with him, the querulous and oppos- 
 ing voice was associated with a disagreeable smell. 
 In this case the patient finally developed the idea 
 that he had a spiritual wife within him who com- 
 muned constantly with him, and who had prophetic, 
 spiritualistic, and mesmeric powers. 
 
Chap. X.] Thought-Re ADiNG. 241 
 
 The next point for consideration in respect to 
 hallucinations of hearing is the power which patients 
 suppose to be possessed by others of reading their 
 thoughts. There are always patients whose chief com- 
 plaint is that persons know their thoughts, or know 
 more about them than they ought ; they seem to 
 be unduly sensitive, as it were, to their neighbours. 
 Such patients may say they have " loud thoughts," 
 and they will avoid every contact with others for 
 fear that their inner life may be known. Re- 
 cently there was a man in Bethlem who would 
 not allow any one to sit within earshot of him, 
 if he could help it. Another patient was admitted 
 because he had committed assaults upon people 
 for no other reason than that they knew too much 
 about him. This patient used to go early in the 
 morning on the top of a hillock on Hampstead 
 Heath, to keep a look out that no one was observing 
 him or taking his thoughts away from him. Another 
 patient found that his thoughts were heard by some 
 means, and were also answered ; questions were con- 
 stantly put to him by day and night, in the gallery, 
 the airing-court, at the closet, and even at chapel ; 
 various taunts and insinuations w^ere conveyed to 
 him in this manner. He insisted that these voices 
 came through a telephone ; he thought that with the 
 microphone and telephone the slightest sound could be 
 made audible. He was told by a voice one night 
 that it was due to the pulsation of the brain, but he 
 thought it might also be from the imperceptible action 
 of his own organs of speech, for he finds that when he 
 thinks vehemently the tongue moves slightly. The 
 way these feelings are interpreted is endless ; one 
 patient was very angry with me because he be- 
 lieved that I kept by me a most marvellous set of 
 microphones and telephones which enabled me to 
 follow the thoughts of each patient at will. With 
 Q— 14 
 
242 Insanity and Allied Neuroses. [Chap. x. 
 
 the development of any new instrument which be- 
 comes popularly known, there is always a free use 
 of the discovery made by the insane ; and in Bethlem 
 we hear of every variety of telephonic communica- 
 tion. 
 
 Hallucinations of sight are not so common as 
 hallucinations of hearing ; they are met with in con- 
 ditions allied to delirium, and in acute delirious mania 
 patients see all sorts of moving bodies. In a few 
 cases of mania there are visions of horror ; and, asso- 
 ciated with religious melancholia, visions of hell, of 
 angels, of threatening spirits, and the like, are seen. 
 In many cases, especially when ideas of persecution 
 exist, dead friends are seen, and some chronic lunatics 
 thus appear to be spiritualists. Occasionally associated 
 with hallucinations of sight ideas of filthiness or con- 
 tagiousness are met with, and especially those patients 
 who believe they have the itch will, at the same time, 
 often declare themselves to be filthy. In one or two 
 cases I have met with hallucinations of sight, which 
 seemed to be but the misinterpretation of imtscm voli- 
 tantes. One lady was constantly shaking her handker- 
 chief in front of her face, rubbing her hands on parts 
 of her dress, and then, unless prevented, would throw 
 the handkerchief into the fire, believing it was covered 
 with vermin. Her description of the upward and 
 downward movements of the vermin corresponded to 
 the ordinary movements of muscce volitantes, A num- 
 ber of patients suffering from chronic insanity, who be- 
 lieve themselves to be watched, persecuted, or otherwise 
 influenced from without, think that certain " phan- 
 tasmagoria," as they call them, are played before them 
 at night to alarm or injure them. Occasionally, but 
 rarely, the patient may be induced to draw his ideas 
 of what he sees ; but I have never been able to get a 
 satisfactory, or, in fact, comprehensible vision repre- 
 sented by an insane person. 
 
Chap. X.] Hallucinations of Smell. 243 
 
 Tlie other senses are less highly developed, and 
 the exhibition of disorder in their action is less 
 marked and varied 
 
 With taste we get hallucinations, or, more com- 
 monly still, illusions associated with ideas of poison, 
 In many cases, young women with ovarian distur- 
 bances, and, perhaps, sickness, refuse food, complaining 
 of bad smells and tastes of poison. I have seen the 
 same refusal of food due to the same hallucinations 
 in a woman who had had children, and was therefore 
 used to the vomiting of pregnancy; yet when insane 
 she explained her sickness as due to metallic poisoning. 
 In phthisis, again, patients frequently refuse their 
 food, believing they are being poisoned. Insane 
 patients may complain of poisoning, or of acid tastes 
 allied to that produced by electricity, but very com- 
 monly the complaint is either that drugs are put into 
 the food, with the intention of producing insanity 
 or insensibility, or that filth of some kind, most 
 commonly faecal, is administered with drink or meat. 
 Others fancy human flesh or blood are given them. 
 Some patients say that all power of discrimination 
 has been lost, and that their taste, in fact, has been 
 taken away. Hallucinations of taste may occur with 
 ordinary mania, but are more common in melancholia 
 and in conditions of weak-mindedness. 
 
 The hallucinations of smell are very similar to 
 those of taste. Occasionally, in the excitement of 
 mania and of general paralysis, there are pleasant 
 hallucinations of smell ; but in many cases of mental 
 depression^ especially those associated with ovarian 
 and uterine trouble, the smells are of an unpleasant 
 kind : one woman complaining of dead bodies near 
 her, while another thinks a smell of dung pervades the 
 room, or emanates from her own body, A few com- 
 plain of a pungent odour like that of ammonia, and 
 certain " miserable sinners " complain of a foretaste- 
 
244 Insanity and Allied Neuroses. [Chap. x. 
 
 of hell in the shape of smells of brimstone. It 
 has been said that in general paralysis the patient 
 early loses the power of discriminating the smell of 
 pepper, but in my experience this is not at all a 
 common defect in such cases. 
 
 The last point to consider here is common sen- 
 sibility, and its endless perversions. Patients, espe- 
 cially at the climacteric, are in the habit of com- 
 plaining that they are badly treated ; that, in fact, 
 persons take liberties with them, and they will 
 describe hideous tortures to which they are subjected. 
 Some will accuse nurses and doctors of chloroforming 
 them, of burning them during the night with acid, 
 chloride of lime, or ammonia. The most common 
 complaint, however, is that electricity, magnetism, 
 galvanism, mesmerism, or some other subtle force is 
 brought to bear upon them, and applied to torment 
 them by their enemies. 
 
 A patient^ s descri2)tion of his hallucinations, taken 
 down by the head attendant. Mesmeric influence. 
 " (I must see the Telephone Company with a view 
 of learning the most recent investigations). My de- 
 ductions since being here, from experiences in general, 
 are as follows : 
 
 " I have heard the same set of three voices, in- 
 cluding a female, with occasionally a third or fourth 
 at intervals ; these voices are those of my neighbour, 
 J. B., of New Cross, and his wife ; the voices have 
 travelled with me for some eight miles from home ; 
 I have heard them make remarkably intelligent 
 observations, always at the time of speaking accom- 
 panied by electrical vibrations or slight shocks, the 
 farther away from the first starting-point the less 
 disagreeable ; they have used strong words as to 
 business affairs which were being carried on at the 
 time. They anticipate my words before they are 
 spoken (this occurrence has only been noticed during 
 
chap.x.] Voice Hallucinations. 245 
 
 the last three weeks). If I begin by uttering a 
 sentence^ and by effort abruptly check the thought, 
 which is an exceedingly difficult matter, they make an 
 observation ; they can see me wherever I may be, or 
 wherever the current is carried, by, I presume, the aid 
 of two glasses ; and have also from remarks made a 
 figure of the human body, with its anatomical arrange- 
 ment, so as to enable them to pass the current to any 
 part of my body and receive the reflex ; they can see 
 by the figure's parts how such and such directed 
 shocks emanating from the operator take effect, 
 showing with what success the shot has succeeded. 
 For example : many times when I have taken a seat 
 a remark has been made such as this : ' We'll give his 
 heart a touch ! ' Another voice asks, ' Which side is 
 his heart % ' The shock or shocks have been given on 
 receiving the answer like the pricking of a pin, three or 
 four generally. This is not particularly disagreeable, 
 until it is repeated ; then a remark is again made as 
 to the pulsation. This generally is accompanied with 
 a slight vibration under my feet, and through the 
 chair to my body. At other times it catches my 
 thighs particularly, drawing me, as it were, downwards, 
 always accompanied by some exceedingly disagreeable 
 observations, in the gallery and elsewhere : ' There, 
 now look at the him ; he can't stand. Look at him ! ' 
 It takes all my effort to stand upright, by straining 
 my muscles and withdrawing the strain again. This 
 applies to particular parts of the carpet, and is not con- 
 fined to the same parts, but varies as the operator 
 says, ' Now give it him hot ! ' when I hear the bat- 
 tery working, and thirty seconds or so after comes the 
 tingling sensation on the spot, which is continued for 
 about thirty paces (I hear the wife saying, ' Try to get 
 over them ! ') and if I stand produces the tension 
 of my body, which would, without great effort on my 
 part, compel me to fall. This applies to wherever I 
 
246 Insanity and Allied Neuroses. [Chap. x. 
 
 may be walking. I find these influences show them- 
 selves more decidedly when I wear boots with 
 nails in the soles and heels, and particularly when 
 walking between two iron gratings or other iron sub- 
 stances, or between two looking-glasses. I have dis- 
 covered that walking at right angles saves me from 
 getting a disagreeable jerking of my muscles, in com- 
 parison with turning a curve. The peculiar electrical 
 influences when walking seem to be regulated at the 
 operator's will. As regards the alteration of the spot, 
 I always find (when I am sitting) about my head and 
 neck a drawing sensation towards the window, espe- 
 cially between the shoulders ; this I put down to the 
 window frames being made of iron, which I have only 
 lately discovered, as also the walking between the iron 
 gratings. When at my meals the voices make remarks 
 about my eating, and the way I use my knife and 
 fork, etc. Sometimes I see in the room, like a flash 
 across my face or by the side of my head, what appears 
 like a fused length of silk about eighteen inches long, 
 which for the moment gives me a shock very sud- 
 denly, accompanied by terrible threats from the same 
 voices at intervals. While I have been out in the 
 
 gallery during Mr. D 's (the attendant) absence, 
 
 the carpet has been exceedingly strongly charged, 
 quite disabling me from standing still \ the only means 
 of saving myself from falling being to alternate my 
 steps, and step from right to left. The carpet retains 
 the electricity for a very short space of time, this being 
 accompanied with such venomous remarks as the 
 
 following : "Oh, you ■ ■ W., my bowels are waiting 
 
 patiently for you to-night ! ' The female voice bears 
 all possible resemblance to that of Mrs. F., whom I 
 know but very little of, but sufiicient to recognise her 
 voice. All throughout in her manner she has shown 
 decided symptoms of hysteria, frequently crying out, 
 ' Oh, Mr. W. ! Mr. W. ! what will become of your dear 
 
Chap. X.] Voice Hallucinations. 247 
 
 wife and cliildren % ' and then shortly afterwards re- 
 marks diametrically opposite. At other times she 
 speaks in the ordinary rational way. The remarks 
 from all four voices, or, possibly, five, are heard 
 throughout, as though it were through an aperture or 
 speaking-tube. 
 
 "In the atmosphere the prominent striking features 
 that occur throughout the day are (1) as though 
 a pellet something like a quid of tobacco was sent 
 across the room with force against the wall or other 
 object, apparently connected with the thread, as I 
 have seen it occasionally partly in fusion (the 
 voices are now saying, ' D — - — him ; we will have 
 him off to-night ! '), with a thud-like sound, have seen 
 it strike a piece of newspaper on the couch, and move 
 it (I possibly fancy this motion). As soon as the con- 
 cussion is produced, there emanate from it a large 
 number of these gossamer threads, known by their 
 creeping sensation upon different parts of the body, 
 each charged with electricity, from the tingling sensa- 
 tion they produce, settling upon the clothes, and 
 finding their way to the body by way of the neck- 
 collar, wrist-bands, etc. ; (2) I have found, without 
 exception, across all prominent doorways leading from 
 the house one of these threads, which catch the neck 
 or face, and produce the same tingling sensation, which 
 does not leave me throughout the day. 
 
 "I suppose that these threads are in connection 
 with the battery, which, being of so delicate a sub- 
 stance, seems not to break but rather give ; or it may 
 be, if it breaks, there is so strong an affinity to the two 
 broken parts that they readily join again; such being 
 the case would account for the medium being carried 
 to an almost infinite distance. 
 
 " Second kind of discharge is like a sudden prick 
 through the coat, aimed at a certain spot as spoken 
 of by the operator, who appears taken off his guard, 
 
248 Insanity and Allied Neuroses. [Chap. x. 
 
 talking too loudly ; the pricking or smarting comes 
 direct to the spot (the pricking more frequent). 
 
 " Third kind, only heard in the bedroom at night. 
 This is preceded by an extra violent exercising of the 
 battery, result being a loud noise, always the same, 
 resembling an iron plate being struck with a hammer, 
 or a ball from Shoeburyness striking the butt or 
 target ; result, vibration in different parts of the bed, 
 producing internal convulsive feelings, rising from the 
 abdomen in spasms (not particularly painful, like 
 wind), w^hich rise to the region of the heart. Pre- 
 vious to the operator's performance, the question 
 has been asked: 'Which side does W. lie?' An- 
 swer : ' On his right ' ; sometimes, ' Oh ! I don't 
 know ' (the voices are again speaking, saying : ' Now, 
 
 you , you will not get out ; we have got you !) ; 
 
 when the object which sounds like a broken plate 
 (but of course is not one) at the time of concussion, 
 there seems to radiate from it several of the before- 
 mentioned pellets, as they appear to drop on the bed, 
 the pillow more frequently, only smaller than the 
 pellets on the wall, making but a slight sound, and 
 they seem singly to be inhaled, accompanied by a 
 dryness of the thorax, as of thirst. Sensation : a 
 strong feeling of faintness and desire to go to sleep, 
 with the constant lulling sound, ' Go to sleep ! go to 
 sleep ! ' which was accompanied with the repeated 
 
 remarks : ' I wish the ,' or some other 
 
 epithet, ' would go to sleep. Lor' bless you ! his 
 heart is almost stopped now.' I keep as quiet as 
 possible. Another remark comes in a whisper : ' It's 
 all up with him, I think.' This has occurred on 
 about five occasions, in such a way as to produce a 
 feeling of extreme exhaustion ; and on rising in the 
 morning, after hearing throughout the night plainly- 
 spoken remarks, with oaths, ' He shan't leave the 
 bedroom to-night alive/ the feeling has worn off to a 
 
Chap. X.] " Sexual Vampires^ 249 
 
 great extent towards morning, when I have been able 
 to get out of bed much to their expressed surprise. 
 
 "I believe (this I say with all solemnity) I should 
 have succumbed on three occasions had it not been for 
 feigning sleep, or from the operator (of which there 
 are two or three engaged) giving in towards the 
 last, with the remark, when told to set it on more 
 strongly : ' I can't, and I won't, do the murderous 
 job ; let it stand till five o'clock in the morning.' 
 
 " Felt the tingling sensation about seven months 
 ago, but at first did not pay much attention. 
 
 " The voices were here prominently about four 
 months ago, when I began to get alarmed, as they 
 were accompanied by exceedingly offensive epithets, 
 and from ten weeks back by threats. 
 
 " During this morning, in the grounds^ a curious 
 remark was made : 'It shall be his children next.' " 
 
 When referring to hallucinations of sight, I said 
 that other hallucinations were frequently associated 
 with them, and that a feeling of being dirty or filthy 
 was not a rare accompaniment of visual hallucination. 
 Some years ago we had at one time several cases of 
 elderly spinsters in Bethlem, who had probably spent 
 a great part of their lives in tidying and dusting 
 the relics which they kept in their prim little houses ; 
 dust and dirt were their abominations, and when they 
 became insane they naturally developed from their 
 uneasy feelings an idea that everything about them 
 was filthy. In this case the quiet and discipline of 
 an asylum enabled them to return once more to their 
 old-maidish habits. 
 
 Galvanism is made use of very frequently to 
 explain almost every morbid sensation which a 
 patient experiences. Another class of feelings re- 
 lating to these must be alluded to here. A certain 
 number of men, generally of young middle age, 
 become possessed by the idea that they are being 
 
250 Insanity AND Allied Neuroses. [Chap. x. 
 
 weakened by some process by which their virility 
 is drawn off; and, just as I previously said that 
 no class of patients is more suicidally inclined 
 than those who believe themselves to be impotent, 
 so none are more dangerous than those who believe 
 themselves to be " tapped," " drawn," or " emascu- 
 lated " by others. A patient recently in Bethlem, 
 who had lost the sight of one eye, and who had been 
 under the surgical care of a leading London oculist, 
 became possessed by the idea that this oculist was 
 able to weaken him by the removal of his semen ; the 
 consequence was that he was most murderously in- 
 clined, not only towards the oculist, but to all in any 
 way connected or acquainted with him. 
 
 In another somewhat similar case, an older man, 
 of very insane family, was impressed by the idea that 
 there was a kind of society, the function of which was 
 to "draw" men, as he called it. He seemed to look 
 upon them as sexual vampires. He thought that the 
 owner of a large private asylum had a staff of 
 " runners," who pursued, debauched, and emasculated 
 those who had been placed at any time under his 
 medical care. This patient being influenced by this 
 idea was found, when at large, with a dangerous- 
 looking knife in search of " runners ; " and I have no 
 doubt would have made an end of any one he took to 
 be such. In the end he was declared to be a lunatic, 
 and was placed under the charge of the Lord Chan- 
 cellor. I may say his delusion affected not only his 
 ideas about himself, but also about others, and when 
 addressing the special jury he told them that they, as 
 honest men, knew that half of them were eunuchs. 
 
 So far, then, for the special relationship of 
 hallucinations. After thus describing them, it will 
 be only necessary to give examples of the more 
 common ways in which they are combined. For con- 
 venience, I have separately grouped cases depending 
 
Chap. X.] Hallucinations of Hearing. 251 
 
 to a great extent upon hallucinations. As the sane 
 mincl is built up of sane impressions, so there are 
 certain insane states which are the natural outcome 
 of perverted sense-impressions. Whether the fault 
 of the perversion arises from brain primarily, or from 
 sense primarily, I cannot say ; but the groups are 
 natural. 
 
 Unduly sensitive persons are best understood if 
 we compare their mental state with that of a man 
 with a whitlow. The latter never seems able to move 
 or act in any way without injuring his finger. It seems 
 to him as if everything conspired to strike him on the 
 tender spot. In healthy unconsciousness he was 
 ignorant of the constant unrecorded impressions this 
 finger received, but now he is made particularly self- 
 conscious. Certain insane patients are like the man 
 with the whitlow \ every action which takes place near 
 them causes distress and pain, and all things distinctly 
 and painfully affect them. 
 
 Simple suspicion with hallucinations. — A lady, 
 about whom I was consulted, was in the habit of 
 taking lodgings for herself and her maid at various 
 watering-places in England. At the end of an uncer- 
 tain period, she would quietly give notice to the land- 
 lady that she must leave at once, but that she would 
 pay a month's rent in advance. This recurred so 
 frequently that her friends, whom by the way she 
 shunned, fancied some strange delusion must be the 
 cause of her frequent flittings. It became evident 
 that her movements were due to "voices." Each 
 change was followed for a time by comparative free- 
 dom from mental trouble ; but later, when, in fact, 
 the stimulus of moving had worn off, she again heard 
 people making remarks about her. Her education 
 and bringing-up had so fully impressed upon her her 
 duties as a lady, that when annoyed she simply took 
 the most straightforward way of leaving the annoyance 
 
252 Insanity AND Allied Neuroses. [Chap. x. 
 
 behind. In a person of the lower orders the chances 
 are that another line of action would have been 
 followed, and some one or other would have been 
 knocked down. 
 
 The following cases are characterised by what I 
 should call over-sensitiveness : 
 
 Acute hallucinationalinsanity, curable. — A young, 
 over- wrought, nervous girl (A. W.), who has spent 
 far too much time in book-learning and solitary study, 
 having neglected the healthy outdoor exercises of her 
 brothers and sisters, and having shunned meetings 
 with the other sex, fails in appetite and digestion, 
 and suffers considerably from constipation, associated 
 with " fulness of the head." Irregular menstruation, 
 sometimes excessive and at other times painful or 
 wanting, still further alters her bodily tone. Prom 
 being amiable she becomes irritable, sleepless, and 
 weak ; she gets more and more self-conscious ; thinks 
 she has not done the best thing with her life, or 
 that she has made some great mistake ; becomes in- 
 tolerant of correction by relations or governesses, 
 and bursts into rages for which she does not appear 
 contrite afterwards. Next, she avoids going out of 
 doors, at first giving as an explanation that she does 
 not care to go out ; later, she owns that people make 
 remarks about her, point at her, refer to her in 
 one way or another. Unless energetic measures are 
 taken early in these cases, such as removal from 
 friends and surroundings, and forcing into a more 
 objective mode of life, they will become either incur- 
 able cases of delusional insanity or weak-minded. 
 
 Another similar case (A. S.) developed the same 
 symptoms under like conditions, but circumstances 
 rendered it impossible for her to have any other 
 treatment than that of an asylum ; the consequence 
 has been that the ideas of inspection, interference, 
 and the like have become fixed, or at all events now 
 
Chap. X.] Hallucinations of Persecution. 253 
 
 recur so consta,ntly tliat I fear she will never more 
 be able to live at large. It is striking to notice the 
 way in which delusions of this kind will grow and 
 become mature, and remain in their fully-developed 
 state for many years. Thus, from time to time, 
 paragraphs will be noticed under the heading of 
 " police news," in which a lady appeals to the magis- 
 trate for protection, or will ask his advice as to 
 what she ought to do to prevent herself from being 
 poisoned. Many years ago, a lady of nervous inheri- 
 tance was left a widow in poor cirumstances, and had 
 a severe struggle to make both ends meet. With a 
 solitary struggling life slowly developed ideas that 
 people were treating her badly, morbid sensations ex- 
 hibited themselves, these she interpreted as the effect 
 of poison ; she appealed to the magistrates and took 
 various articles of food to be analysed; the negative 
 result of the analysis only confirmed her ideas that 
 a conspiracy was formed against her ; she became 
 actively troublesome and annoying, and had to be sent 
 to an asylum. Her hallucinations grew more and 
 more fixed ; with her, as with so many similar 
 cases, the acuteness of their exhibitions varied con- 
 siderably ; and it was noteworthy that any special 
 cause of physical depression was associated with an 
 exacerbation of the hallucinations. She would behave 
 quietly and appear fairly contented for weeks together, 
 when she would, as the result of a cold or a fit of 
 indigestion, complain bitterly that she could not live 
 in the way she was at present living ; for that on 
 the night before she was certain that something was 
 put on her pillow which produced profound uncon- 
 sciousness, not natural sleep, and that during her 
 unconsciousness all sorts of terrible things had been 
 done to her. She was fully possessed by the idea that 
 her all-powerful enemies were able to bribe or cozen 
 the attendants, doctors, and every one, from the 
 
2 54 Insanity AND Allied Neuroses. [Chap. x. 
 
 highest to the lowest, to injure her. In confirmation 
 of this, she would say her hair was rapidly coming 
 out, and that this was due to one of the attend- 
 ants puttiug something in the pomatum or oil which 
 was sent up from the dispensary specially for her; 
 and so suspicious was she, that unless the medicine 
 was made up for her specially and given directly to 
 the head attendant, she would decline to take it. This 
 condition has lasted for years, and will continue as 
 long as she lives. 
 
 The condition of her case naturally leads me to 
 refer to those suffering from what has been called 
 the delirium of persecution. It is easy to under- 
 stand how a patient, who first of all believes himself to 
 be watched, soon becomes persuaded that this watch- 
 ing is initiated by some one and for some object. 
 As I pointed out in melancholia, the mysterious ex- 
 planation is the one which appeals most readily to 
 persons of unsound mind ; and the man who is 
 persecuted at once refers his troubles to the Jesuits 
 or the Freemasons. More recently, secret societies 
 and Fenians have taken the parts of the Freemasons 
 and Jesuits. There are some insane people who attri- 
 bute their troubles to their neighbours because the 
 " voices " appear to come from the wall. Detectives 
 also play their part in the suspicions of this class of 
 lunatics, but the typical cases of persecution seem 
 pretty sure to pitch upon one of these secret associa- 
 tions as a source of explanation of their sufferings. 
 
 The following case is an example : William 
 T. W., single, 26, writer in government employ, 
 one sister an epileptic and insane, phthisis on 
 mother's side; supposed cause was impairment of his 
 sight. The symptoms came on steadily a month 
 before his admission to the hospital. He had hal- 
 lucinations of hearing "voices," and galvanic batteries 
 disturbed him. He believed two persons conspired 
 
Chap. X.] Delirium of Persecution. 255 
 
 together to injure and annoy him. He complained of 
 his head being affected. His general health was fair, 
 he slept well when not disturbed, and ate well. The 
 accompanying letter best explains his ideas : 
 
 " Bethlem Hospital, 
 
 " St. George's Ed., Southwark, S.E., 
 "Oct. 6th, 1879. 
 
 "Revd. Sir, — I beg to lay before you the facts of 
 my most distressing case, and I know that you will, 
 with your usual kindness, render me every assistance 
 you can. 
 
 " I was brought here on March 5th, and have been 
 subjected to galvanism ever since ; that is, an herma- 
 phrodite tries to drive me out of my mind by attempt- 
 ing to take my semen. It is a well-known fact in. 
 the medical profession that it can be done. The name 
 of the lady is Miss B., daughter of Mr. B., of Guy's 
 Hospital. The students at Guy's Hospital know some 
 of the facts of the case, and I may mention that Dr. 
 Savage, the head doctor of this hospital, a Guy's man, 
 is my greatest enemy, because, if he would let me have 
 a Turkish bath I could get rid of the electricity in my 
 body. I was galvanised so as to become a living 
 magnet when I was at home ill. I was dragged home 
 by three policemen, and then lodged in the workhouse 
 before I came here, and was neither taken before a 
 magistrate nor certified by two doctors. My sister 
 Susan knows something of the case, but is afraid to 
 tell my mother, whom I cannot convince, as she does 
 not understand what galvanism will do, and will not 
 consult a medical man. 
 
 "I have written to Sir J. B., my cousin, but T 
 suppose the letters are stopped. My mother, I may 
 say, admits that I am not insane, but I think my 
 sister Susan works upon her mind with some tale that 
 it will be eventually for my benefit. I may mention 
 
256 Insanity AND Allied Neuroses. [Chap. x- 
 
 that there are two gentlemen in this hospital who 
 have been driven out of their minds before they came 
 here by galvanism. I am sorry to trouble you in the 
 matter, but as you will see it is a matter of life and 
 death to me, I hope you will pardon the liberty I take. 
 If you let me have a solicitor to see me, I think he 
 could obtain my release; or if you would write to my 
 mother and convince her that galvanism can do what 
 I say, I should be extremely grateful. I may say 
 every day is of the greatest importance, as the galva- 
 nism annoys me more when I attempt by clandestine 
 means to obtain my release from this horrible place. 
 
 '' I am, revd. sir, 
 
 " Your most obedient servant, 
 " To the Rev. J—." " Thos. W. W. 
 
 "P.S. — The doctor is a friend of Mr. B.'s, and 
 has admitted before the students that I am being 
 annoyed by galvanism." 
 
 There is a general feeling that cases of insanity 
 with ideas of persecution are highly unfavourable ; but 
 I would rather put it in this way : that when a 
 patient has gradually passed through the various 
 stages referred to, when he has suffered from simple 
 unexplained misery, then has been annoyed by 
 hallucinations of one kind and another, and slowly 
 developed an explanation for the whole of these 
 morbid feelings, that the disordered process has been 
 going on so long that the prospect of cure is small. 
 
 Another variety of delusional insanity is seen in 
 what might be called the inquisitive or meddlesome 
 cases. I have met with one patient, not in an asylum, 
 who was constantly getting into trouble as a result of 
 his inquisitiveness. He had a feeling that everything 
 had some connection with him, and would ask to see 
 private letters, or would thrust his nose into conver- 
 sations in no way intended for him, the consequence 
 
Chap. X.] Delirium of Persecution. 257 
 
 being that he, on more than one occasion, got severely 
 chastised. This feeling of extension of personal 
 interest is a phase of mental over-sensitiveness, 
 another side of which is seen in the following case : 
 
 Walter A., single, 27, no neurotic inheritance ; 
 supposed cause of his insanity was loss of fortune 
 and blighted prospects in life. He received a severe 
 injury to his head two or three years before the 
 appearance of his nervous symptoms. He attempted 
 suicide in August, 1882, at the time believing there 
 was a system of persecution against him. Every- 
 thing depends now on his supposing that people are 
 either whispering the word hougre, or are suggesting 
 that he is a very objectionable man. Every act or 
 word is misconstrued, yet this patient retains his 
 ordinary mental capacity. I annex an account of the 
 case compiled from particulars given by himself. 
 
 " When I set foot upon French soil, two years ago, 
 I discovered a system of en arriere persecution of 
 people constantly taking notice of me, and supposing 
 me to have the appearance of excessive venery. This 
 671 arriere persecution was introduced into every 
 action of my life. I was in perfect health. When in 
 France I went to various places, and spent some time 
 at Dijon, where I was introduced into good society. 
 I was kindly treated in every way, but I still thought 
 that this en a7'riere persecution followed me every- 
 where I went. My father was very well off, and I 
 would have been so had my father not lost almost 
 everything he possessed, having had his mill destroyed 
 by fire. This circumstance did not affect my mind in 
 any way. I had a disappointment in love, but told 
 nobody of it. This also did not affect my mental 
 balance. The character of society, at the present 
 time, is corruption, and I believe that to be the cause 
 of my illness, my mind being sensitive. My will had 
 been so affected by this en ar7'iere persecution, that I 
 K — 14 
 
258 Insanity and Allied Neuroses. [Chap. x. 
 
 got into a despairing condition, and threw myself over 
 Westminster Bridge, when I was rescued by some 
 bargemen, but I felt no regret at doing this rash act. 
 I considered that there was no possibility for me to 
 accomplish any work in this world, therefore I 
 attempted suicide. Even now I do not see my way 
 to accomplish any work, but if I had absolute 
 seclusion I should be able to do so ; at present, 
 however, I see no chance of it. I hear persons 
 talking and discussing, in obscene terms, my condition, 
 which offends me, and this occurs more when I am 
 subjected to this en arriere persecution. I think the 
 appearance of my eyes is that of excessive venery, and 
 other people think so likewise. Since I have been in 
 Bethlem this belief is not more fixed, and it remains 
 as it was. I think that disappointment influenced 
 my thought very much and undermined my life, and 
 that my nervous constitution is also being slowly 
 undermined, and that my lungs are a little affected. 
 My ai)petite is good, but my rest is bad, having had 
 hallucinations. " 
 
 Another variety of delusional insanity is com- 
 mon among women j thus, among younger women 
 we occasionally meet with those who imagine that 
 they have been injuriously affected by some man ; 
 and such cases will write compromising letters, or 
 make accusations against gentlemen, demanding satis- 
 faction, or that their characters shall be cleared 
 before the public. I would say. as a practical point, 
 that such cases are not, in my experience, those 
 who demand money. It is not a purely mercenary 
 consideration which they require ; the ways in which 
 they believe themselves to be affected are almost 
 endless. Thus, one girl said that a man at a distance 
 caused her to feel all sorts of strong sexual desires, and 
 that she was sure by some means or other he intended 
 to get the better of her. 
 
Chap. X.] . Sexual Delusion. 259 
 
 The ignorance of all physiology in which English 
 girls are brought up, associated with narrow religious 
 teaching, is answerable for a certain number of cases 
 of this descriiDtion, A young girl at puberty feels 
 strange and hitherto inexperienced sensations and 
 desires j she becomes alarmed and anxious, and in 
 some this gives place to a nervous exaggeration of the 
 feeling of depression which is so common after or with 
 menstruation. The morbid sensibility further dwelt 
 upon and explained, starts a delusion, which if not got 
 rid of develops into a chronic incurable condition of 
 the kind I am now considering. Other cases in which 
 this type of delusion is common are those of single 
 women about forty-five years old. 
 
 The following (McM.) is a good example : This 
 patient was forty-three, single, with insanity on the 
 father's side. She had been a governess, and had 
 suffered from one previous attack of insanity. The 
 first symptom noticed was her refusal to take food. 
 She believed people were wishing to injure her ; she 
 feared she would be lynched by the mob, and insisted 
 upon going straight to the Queen. She heard dis- 
 turbances in the street which really did not exist. 
 During the night she was convinced there were men 
 in the hotel who were influencing her muscular and 
 nervous systems, which she believed they were able 
 to do without in any way approaching her. She 
 screamed violently at night, and endeavoured to escape 
 by means of the window. She said that disagree- 
 able vapours were forced into her room, this symptom 
 being not uncommon in similar cases. She imagined 
 that all the men with whom she was brought into 
 direct contact were wicked and unworthy, and that 
 they fell under the influence of a certain major who 
 was plotting to ruin her. This lady was constantly 
 leaving good situations without cause given, for the 
 reason that she fancied this major was following 
 
2 6o Insanity AND Allied Neuroses, [Chap. x. 
 
 her, or was in the house trying to get at her. With 
 her, as with many others suffering in a like manner, 
 there were ideas that the wicked major had a power 
 of transforming himself and appearing in different 
 ways and in various forms. Such a case as this is 
 absolutely incurable. 
 
 Another marked case is that of a woman (L.) who 
 was admitted into Bethlem in May, 1882, under the 
 delusion that she was followed by two men and a 
 woman who were constantly prying into her affairs, 
 and she said she would be glad if I could secure the 
 services of a detective to arrest them. I asked her 
 how she felt here. She answered, " They are con- 
 stantly annoying me vdth telephones ; and those wh o 
 annoy me are a man and woman who constantly watch 
 me ; they look into my windows ; they read everything 
 I write ;. they know my thoughts before I speak ; 
 they prick me with a needle fixed in a wire, and they 
 even get under my bed. They have constantly car- 
 ried on this system of troubling me since I was at 
 Marazion many weeks ago, and I believe that every 
 workman in the neighbourhood is a conspirator with 
 the telephone people to annoy me." In this case, 
 again, I fear there is no prospect of cure. The only 
 savinoj element is that it is associated with the 
 climacteric, and certain cases recover then which other- 
 wise would have to be considered incurable. From a 
 practical point of view, it is noteworthy that patients 
 may be extremely dangerous, by making accusations 
 on the one hand, or by attempting to protect them- 
 selves on the other. 
 
 Delusional insanity with a strongly sexual char- 
 acter is common also in widows. We have, then, this 
 very distinct group of cases in which there are per- 
 versions of feeling connected with the reproductive 
 organ, associated with other perversions of the special 
 senses, such as hallucinations of hearing and of smell. 
 
Chap. X.] Delusions. 261 
 
 These cases are most common in single women of 
 mature age and in widows. 
 
 They are dangerous from their false accusations, 
 and they are rarely curable. 
 
 Another case, somewhat different, is that of a 
 music teacher (M. E. B.), single_, aged 31. Her 
 father committed suicide, and her maternal aunt is 
 now in an asylum. During the past two years she 
 had exhibited symptoms of mental unsoundness, 
 marked by nervous instability and fancifulness. Men- 
 struation had been regular, and her general health 
 good. She attempted to strangle herself because of 
 her feelings of being pursued. She heard voices ac- 
 cusing her, but the idea that most especially an- 
 noyed her was that everything she came in contact 
 with was stuffed with matches and pins. Her look of 
 worried anxiety, when she moved from one place to 
 another, was very striking, so that on meeting her you 
 at first imagined that she had lost something and was 
 seeking for it. She would at once tell you that the 
 annoyance from these pins was extreme. When she 
 got up in the mornings, and, having washed herself, put 
 on her first garment, she at once became uneasy, and 
 reversed it again to see that there were really no pins 
 there. This process of dressing and undressing occu- 
 pied so much time, as a rule, that she was three hours 
 every morning before she could go to breakfast. She 
 would talk about her case in a fairly matter-of-fact 
 way ; and would ask whether it were better rapidly to 
 get into her clothes, to submit to or struggle against 
 the ideal misery, or whether it were better for her to 
 examine and re-examine till she had, at all events, 
 partly or temporarily satisfied herself. Such cases 
 occur, as I have said, chiefly in women. They are as- 
 sociated with fear, dread, doubt, and suspicion. They 
 occur, I believe, chiefly in those with insane inheri- 
 tance; in fact, in my experience these cases are but 
 
262 Insanity AND Allied Neuroses. [Chap.x. 
 
 slow, natural developments of a temperament which 
 may be called the insane one ; and just as there 
 are certain patients with moral deficiencies who have 
 strong insane inheritance, so there are others who 
 come of insane stock and are predisposed to develop 
 delusional insanity. The causation of this form of in- 
 sanity is very obscure. There are undoubtedly pre- 
 disposing influences, as in the case of an occupation 
 which tends to a subjective life, so that the middle- 
 aged governess and the struggling widow seem specially 
 liable to be aflected. 
 
 I must next refer to a group of delusional cases 
 with exalted ideas. The "Queens" of an asylum are 
 many, and as a rule must be looked upon as incurable. 
 The cases I have hitherto been considering have been 
 found to sufier from hallucinations of their senses ; 
 but, in this last group, frequently no hallucinations 
 exist, but there are delusions of a pronounced type. 
 
 Examiile of delusional insanity with exaltation. — 
 A lady, who had been brought up in luxury and sur- 
 rounded by wealth, was suddenly thrown into a state 
 of want through the insolvency of her father. She 
 became more and more exacting, and more impressed 
 with the position to which she believed herself still 
 entitled. Slowly she became more reserved, and in 
 the end was impressed with the idea that she was a 
 queen, and that everything in the asylum belonged to 
 her. From the time that this idea became fully esta- 
 blished she has in no way changed, but behaves as a 
 lady, occupying herself in art of a rather wild descrip- 
 tion, and with literature in the shape of a French dic- 
 tionary, which she is committing to memory, and she 
 takes a fixed and supreme position as Queen Anne. 
 In this happy belief she will remain as long as she 
 lives. The development of ideas of grandeur among 
 women of this class is interesting ; it is a slow, steady 
 growth, and contrasts with the exaltation which is 
 
Chap. X.] Delusional Jealousy. 263 
 
 met with in youths without experience of the world, 
 which is the simple unrestrained expression of buoy- 
 ancy ; and on the other hand it contrasts with the 
 exaltation of the general paralytic, where I believe loss 
 of self-control and increased vital action explain the 
 temporary exaltation, which is like the flare of the 
 rapidly-consuming wick. The mode of the growth of 
 the exaltation of such cases is, to my mind, a,s follows : 
 
 Patients, hoping for a success which they are 
 never likely to attain, build castles in the air which 
 often become realities to them. It does not follow 
 that all the castles should be of the same type. One 
 girl dwelt upon the image of her doctor till she be- 
 lieved he was to be her husband. It mattered not that 
 he was already a married man with a family. She was 
 convinced that obstacles of that kind could be easily 
 overcome, and that the person who represented himself 
 to be a married man really was not married at all. 
 In her case no amount of change of scene or occupa- 
 tion made any appreciable difference in her condition. 
 
 Another dangerous and troublesome variety of 
 delusional insanity is associated with jealousy. A 
 married person will sometimes get a fixed idea that 
 the husband, or wife, as the case may be, is incon- 
 stant, and the very slightest occurrences may be a 
 convincing proof of the truth of such accusations. 
 A good example of the danger and of the ditii- 
 culty of such cases is that of a man, married, aged 
 forty, who had a large family. He was of a ner- 
 vous, emotional disposition, given greatly to self- 
 exaltation, and spent most of his time in what he 
 thought was doing good to others, but allowing his 
 wife to be the bread-winner. She led an active, busi- 
 ness-like life, and was successful in her endeavours. The 
 husband began to wonder how she got on so well, and 
 put it down as due to immorality ; although one would 
 have supposed that his experience of life would have 
 
264 Insanity AND Allied Neuroses. [Chap. x. 
 
 taught him that a middle-aged married woman, with a 
 family and small pretensions to good looks, would not 
 have much opportunity of making a fortune immorally. 
 Still, haunted by the idea that she was receiving visits 
 from men, he tried every conceivable trick to surprise 
 and detect her, and exposed her to all sorts of physical 
 and moral indignities to trace her evil ways. He be- 
 came dangerous, threatening her and vowing vengeance 
 upon those whom he considered as her paramours. 
 He was sent to Bethlem, where he behaved him- 
 self perfectly well as far as appearances went, 
 and it was with considerable difficulty that I was 
 able to detect his delusions, till one day my name 
 was linked with that of his wife as co-respondent. 
 This condition of delusion remained unaltered for 
 some months ; but I found him one day working 
 and making himself useful in the wards, and shortly 
 after he made a statement that he had lost all his 
 suspicions, and owned himself to have been deluded. 
 A change to the country was followed by a period of 
 apparent health ; but after a few months at home the 
 whole of his suspicions returned, and he had to be 
 secluded for the safety of his wife and friends. Since 
 then he has been for some years at a county asylum, 
 where, I believe, he will have to spend the rest of his 
 life, as any return to his friends will be associated 
 with a recurrence of his delusions, which will prove a 
 source of annoyance and danger beyond the limits of 
 endurance. 
 
 I have frequently been struck by the connected 
 and reasonable way in which a patient would talk 
 about his delusion. In fact, unless one was absolutely 
 in a position to contradict his premisses, he must 
 admit the conclusion. Delusions of jealousy may how- 
 ever be lost, and recovery be complete and permanent. 
 One man told me, in the most circumstantial way, the 
 whole history of his detection of his wife's wickedness, 
 
Chap. X.] Delusional Jealousy. 265 
 
 describing graphically the man, the place, and the occa- 
 sion; winding up with an admission that when received 
 into Bethlem he was suffering from mental depression, 
 the result of this sad discovery ; and thanking me 
 for my kindness, he said he was anxious to leave the 
 hospital, but not to return to his wife, who must now 
 be separated from him for ever. I was astonished, 
 but allowed him to leave the hospital for a month to 
 live with a married son. At the end of the month he 
 returned, and with tears told me that the accusation 
 he had made against his wife was utterly unfounded, 
 and that a more considerate, conscientious, and 
 honourable woman never lived ; that the only explana- 
 tion he could give was, that it was the mental perver- 
 sion which disease is said to cause, for his married life 
 had been an unbroken calm. 
 
 In the next case a most extraordinary series 
 of delusions, associated with hallucinations, had 
 slowly developed. The patient's (M. R.) own version 
 was, that on a certain evening, he and his wife being- 
 engaged playing a game at cards, the latter left the 
 room, and from that time there was a complete con- 
 fusion ; in fact, although he remained just as he had 
 been before this wife of his was spirited away, another 
 woman, resembling her in every outward particular, 
 took her place, assuming her seat at the card table, 
 and accompanying him to bed. He admitted that 
 she was the mother of some of his children ; he be- 
 lieved that a strange but hideous play was being 
 enacted, and that the very names of his children were 
 made to react upon them in what he called a "name- 
 play ; " that their whole lives were to be sacrificed for 
 the supposed amusement of Jesuits or some other 
 secret society. The following report siifficiently indi- 
 cates the condition in which he was admitted into 
 Bethlem : He was received on the 10th of February, 
 1883; has delusions that certain people whom he 
 
266 Insanity AND Allied Neuroses. [Chap. x. 
 
 believes to be Roman Catholics are practising ghastly 
 cruelties on him, by watching his wife and children, 
 and substituting duplicates for them ; thinks he is a 
 duplicate, and says they are always signalling at him. 
 He speaks of the cruelties as something dreadful, and 
 says there is a ghastly Roman Catholic plot over the 
 whole country, which causes substitutes to be made 
 for all his relatives ; that the originals are carried olf 
 to asylums and elsewhere, where they are cruelly 
 treated ; that words have special meanings apart from 
 their ordinary signification, and that these meanings 
 are only known to a few of the initiated ; complains of 
 loss of power in the extensor muscles of the right leg 
 (no pain or tenderness) ; the right foot drags slightly. 
 The prospect of any alteration in this case is of the 
 smallest kind : first, from the length of time during 
 which the symptoms have been developing, and 
 secondly, from the completely organised form which 
 they have assumed. 
 
 Another variety of delusional insanity is what has 
 been called " symbolising insanity." Patients, generally 
 of the educated class, of middle age or advancing years, 
 have a sensitiveness to their surroundings, very like 
 that I have already described, but with them the 
 limits or suggestions refer indirectly, and not always 
 unpleasantly, to them. 
 
 One, a most trustworthy business man, developed 
 the idea that honours were in store for him if he only 
 knew the way to get them ; he believed there was a 
 secret code which he had to find out and act upon. 
 He would take his dinner, and then deeply lament 
 that he had done it, fearing he might have neglected 
 his opportunity. At night he would watch and pray, 
 like a knight of old before his armour, fearing his 
 chance might come unawares. Any movement of the 
 slightest kind affected him, and he would not rest till 
 he had assured himself that nothing had been meant. 
 
Chap. X.] Symbolising Insanity. 267 
 
 Year after year has passed, and still he is longing 
 for honours which never come, and seeing fresh 
 symbols in the simplest of actions. 
 
 The subjoined is a very good example of the 
 class. In this case, conscientious, hard, intellectual 
 work which was not properly appreciated, created 
 discontent and a feeling of injustice which caused 
 him to seclude himself, and brood over his misfor- 
 tunes, till he became possessed by the idea that there 
 was a symbolism in everything which he saw or ex- 
 perienced ; and the end is that this brilliant mind is 
 now entirely self-contained, its circle of interest nar- 
 rowing from day to day. 
 
 Symbolising. — H. L., single, aged 45, school- 
 master, no insane inheritance ; the cause is supposed 
 to have been sunstroke, but there was a question 
 of acute alcoholism preceding it. Money losses, and 
 failure of his school in consequence of fever breaking 
 out among the pupils, were the chief factors in finally 
 developing symptoms of insanity. These seemed causes 
 enough in themselves, but he also formed a very good 
 example of the natural development of insane symp- 
 toms from eccentric habits and solitude. He became 
 melancholy, restless, and possessed by ideas that 
 everything had some reference to him, and so im- 
 pressed was he by this that he threatened to commit 
 suicide to get rid of it. He had in earlier life been 
 brought up with a young lady as foster-brother, and 
 when she married it seemed to have caused him a good 
 deal of worry ; not that he had made any advances 
 towards her, but when it happened that she was re- 
 moved from him he seemed deeply aJflfected. This, 
 however, passed ofi", and only reappeared when 
 symptoms of insanity were developed. Then he be- 
 came possessed by the idea that this lady was really 
 his spiritual wife, and not only did he claim her, 
 but he claimed her children too. His diary, which 
 
268 Insanity AND Allied Neuroses. [Chap. x. 
 
 lie kept partly in shorthand and partly in ordinary 
 writing, gives a very good idea of the morbidly sensi- 
 tive condition in which he was ; for one day he would 
 imagine the flower-pots of his opposite neighbours 
 were placed in twos, thereby meaning he ought to be 
 paired. On another morning he would fancy the 
 flower-pots were arranged in threes or singly, and 
 this again had an allusion to his anomalous condition, 
 being spiritually married and yet single. He refused 
 food, but declined to enter into any argument as to 
 whether he were justified or not in trying to starve 
 himself. During the whole time that he has been 
 under observation he has refrained from having any 
 communication with or associating in the amusements 
 or occupations of other patients. He looks earnestly 
 on the floor, and is doubtless occupied with hallucina- 
 tions, this hypothesis being borne out by his diary, in 
 which he constantly refers by name to his spiritual 
 friend. I append a few of his notes taken from his 
 diary : 
 
 " Ghosty, dear, why are you like a comet % Be- 
 cause you are so impalpable % No. Because you 
 make us all think of our latter end? Good, but not 
 it; try again. Because it will be 100,000 years 
 before we see you again % Better ; this would be the 
 height of conjugal felicity ; what you aim at, Ghosty, 
 is it not % No. This is it, Ghosty, dear : because, 
 as the comet approaches the centre of light, the size 
 of the tail represents the waste of the head. Conser- 
 vation of force, Ghosty! You can't get over that; 
 that is too big for you even. Good night, Ghosty." 
 On another page he writes to the Ghost as follows : 
 " Mon cher ombre, je viens de voir ' La Dame aux 
 Camelias ; ' I'entree du pere k la fin du troisieme 
 acte est bien arrangee, n'est-ce pas % J'ai pense ^ toi, 
 et, en criant, 'Mon ombrelle, mon ombrelle !' je me 
 suis jete dans tes bras, en imagination, mon cheri, tu 
 
Chap. XL] Moral Insanity. 269 
 
 sais. Vis a vis il y avait le Comte D y et sa 
 
 bonne. J'ai remarque a moi-memej ' Yoila un 
 
 mariage comme il faut.' Ah ! mon ombre, mon ange 
 gardien, tu sais tout ; et tout ce que tu fais est pour 
 
 le mieux. *' Ton devoue, 
 
 (« » 
 
 In all the cases which I have already described 
 under the head of delusional insanity, it will have 
 been noticed that some perversion of sense, halluci- 
 nations of one kind or another, have slowly led up to 
 the development of fixed delusions, and I fear that 
 no amount of medical or general treatment is in any 
 way likely to cure such cases. They are necessarily 
 dangerous both to themselves and others during a 
 considerable part of their course ; but, in certain of 
 the cases, with time comes on pronounced weak- 
 mindedness, or the delusions seem to become confined 
 within definite limits, and in that manner are more 
 easily reckoned upon ; and, consequently, in some of 
 these latter cases patients may be treated away from 
 an asylum. 
 
 CHAPTER XI. 
 
 MORAL INSANITY. 
 
 Loss or perversion of the liiglier social acquirements as : a symptom 
 of disease — a result of disease — a result of inheritance — 
 Represented by lying and thieving — Representing loss of con- 
 trol over the appetites — Precocity — Special ability for music, 
 mathematics, or remembrance of details. 
 
 All modern writers admit that there may be mental 
 disorder in which the intellect is either fairly deve- 
 loped or unaffected by disease, and yet in which great 
 moral disorder or defect is present. It has been 
 maintained that where moral perversion exists, there 
 
270 Insanity AND Allied Neuroses. [Chap. xi. 
 
 will also be found some intellectual want ; and a 
 similar remark has become a truism as to the sane 
 mind in the sane body. It is not convenient or pos- 
 sible to classify all forms of mental disorder according 
 to bodily symptoms, nor is it possible to deny that 
 moral disorders may exist with little or no intellectual 
 change. Although moral perversion in such cases is 
 generally associated with intellectual weakness of one 
 kind or another, yet there are cases in which the 
 chief mark of disorder is seen in breaches of the 
 moral laws which society has found it necessary to 
 establish. There is a borderland in which persons 
 must be placed who are partly bad and partly mad ; 
 there are people who have not the power of control- 
 ling their lower instincts ; in whom the animal pro- 
 pensities may override the intellectual. It is very 
 easy to pass from the consideration of these borderland 
 cases to those of the criminal classes pure and simple ; 
 the criminal classes must be looked upon from the 
 nervous stand-point as unstable and prone to develop 
 symptoms of nervous disease more readily than the 
 non-criminal classes. But besides the class of persons 
 who may be said never to have developed into a 
 higher moral and intellectual state, there are some 
 who, having been once sane and self-restrained, be- 
 come vicious as a result of nervous disorder ; and 
 there is also a special class of young patients who 
 from the first exhibit no distinctive intellectual loss, 
 but miay, in fact, be brilliant in some particulars, and 
 yet without any moral sense. 
 
 Pirst, then, after attacks of insanity patients may 
 become vicious. I have known a man come into an 
 asylum with a history of good conduct and strictly 
 moral behaviour. He has had a short, sharp attack 
 of mania, followed by a slight period of depression ; 
 but from that time, although sent from the asylum. as 
 having recovered, he has been an entirely changed man, 
 
Chap, XL] Kleptomania. ' 271 
 
 and, instead of being sober and moral, lias now become 
 intemperate and vicious. - It is true that one some- 
 times sees the reverse take place, so that I have known 
 a husband come, years after his wife has been dis- 
 charged recovered from an attack of insanity, and say 
 that not only has his wife remained well since her 
 attack, but has been a changed woman, being more 
 amiable and self-sacrificing than she was before. This 
 is no single instance, but represents the change I am 
 here referring to, a moral change, a change in temper 
 and disposition succeeding an attack of insanity. 
 
 Not only does one see a moral perversion, as gene- 
 rally understood, but I have seen at least a dozen cases 
 in which the patients have become what is called klep- 
 tomaniacs after an attack of insanity^ and they will 
 act with the utmost deliberation and with apparent 
 power of calculation and combination to effect their 
 purposes. Thus, a French governess (Marie S.), age 
 26, single, with no inheritance of insanity, was ad- 
 mitted into Bechlem in March, 1871. She was suffer- 
 ing from active melancholia (said to be caused by 
 sunstroke), associated with constant restlessness, pick- 
 ing her dress and fingers. Complaints were made that 
 she was fiilthy in her habits. She wanted some one to 
 kill her, or to be allowed, as she said, to sleep for a 
 fortnight. I may say there was some ground for be- 
 lieving that the French war of 1870 had caused her a 
 good deal of anxiety. She improved considerably in 
 general health, but persisted in saying she was a 
 devil ; but, notwithstanding this, she continued to be 
 active, pleasant, and rational in conversation. Later 
 it was found that she had been in the habit of purloin- 
 ing articles of clothing belonging to other patients, 
 securing in the most adroit way the best articles, espe- 
 cially those which were less recognisable, and effacing 
 the various marks in ways which one could never dis- 
 cover. She was as able a liar as she was a thief, and 
 
272 Insanity and Allied Neuroses. [Chap. xi. 
 
 protests of amendment and contrition were always 
 followed in a short time by fresh depredations. 
 This conduct, we found, was in direct opposition to 
 all her old habits. She herself owned to the inability 
 she felt to control this desire for appropriating 
 goods, and said that, after all, she must be a devil to 
 do such things. 
 
 At the present time v.^e have in Bethlem another 
 case in which a woman who has suffered from insanity 
 following child-birth has become stout and weak- 
 minded ; and who, although a useful drudge, is un- 
 trustworthy where portable property is concerned. I 
 sometimes make a distinction between those of our 
 patients who, being weak-minded, are like magpies and 
 collect anything that is bright and movable, and the 
 other class, such as those above described, who are 
 adept and cunning thieves, and will own and recognise 
 their faults, though they are unable to amend them. 
 Whilst speaking of kleptomania and moral insanity, I 
 would remark that, almost yearly, cases are admitted 
 into Bethlem who have been taken before the magis- 
 trates accused of theft, many such cases proving to be 
 in the early stage of general paralysis of the insane. 
 In my experience it has been more common to find 
 the moral perversion represented by kleptomania fol- 
 lovmig an attack of insanity, among women than among 
 men. But when it occurs as the result of direct in- 
 sane inheritance, it may take place in either sex at any 
 age. It is unnecessary to describe in detail the other 
 moral perversions which may follow acute insanity ; 
 suihce it to say that intemperance in eating and 
 drinking, in lust, in desire for property or for any low 
 taste, may occur in such cases. 
 
 The next group of cases of moral insanity is by far 
 the most difficult to deal with. They have been 
 treated by the physician whose special study is idiocy, 
 as well as bv the family physician and the jurist, and 
 
Chap. XL] Sexual Precocity. 273 
 
 each has found it difficult to know in what light to 
 look upon these rtiauvais siijets. The history is gene- 
 rally of the following kind : One parent almost cer- 
 tainly belongs to a markedly insane family, or both 
 parents belong to the same stock, which is a degene- 
 rating or nervous one. The child has been an only 
 child, the child of old age; or has had brothers and 
 sisters, some of whom have been deaf and dumb ; 
 or idiocy or epilepsy has occurred in the family ; he 
 was bright, but restless and fretful in infancy, 
 difficult to amuse or occupy ; and as time went on he 
 was characterised by being peculiar ; either being 
 bright or having brilliant special endowments, so that 
 he was perhaps attracted by music at a very early 
 age, and as soon as he could speak would hum cor- 
 rectly airs he had heard ; or, there being nothing- 
 special in his early infancy, it was first noticed at 
 school either that he had depraved tastes, or it was 
 found necessary to send him from school in con- 
 sequence of immoral practices, or because of thieving 
 or lying, and this although his master may have ex- 
 pressed regret, because he had shown a special power 
 for mathematics or a wonderfully retentive memory. 
 It is not uncommon for children of this kind to get 
 on moderately well up to the age of puberty, and 
 then become utterly unmanageable in consequence of 
 the development of sexual desires and giving way most 
 openly to masturbation ; or, if boys, making attempts 
 of every description to gratify their lusts upon children 
 or women of any age. Such boys expose themselves 
 indecently and misbehave openly. As a rule, they 
 express contrition at the time they are caught and 
 threatened, but the memory of the punishment never 
 seems to be sufficient to restrain them when the next 
 temptation comes. These patients are almost invari- 
 ably immoral sexually, and are the most cunning of 
 liars, so that on cross-examination they will answer so 
 s— 14 
 
2 74 Insanity and Allied Neuroses. [Chap. xt. 
 
 rapidly and apparently so consistently that an ordinary 
 investigator may doubt whether there has not been 
 some mistake in the accusation. 
 
 Some of these cases are horribly cruel, and others 
 demoniacally vindictive. I have known them tor- 
 ture lower animals which were unable to defend 
 themseh^es (for such patients are cowards) with red- 
 hot irons, pins, needles, and the like, or by setting fire 
 to them by means of turpentine or spirit. As to the 
 vindictiveness exhibited by such patients, I was con- 
 sulted once about a youth, the son of a clergyman, 
 who was constantly setting fire to the houses of those 
 with whom he was placed. He was, to all appearances, 
 an ordinary-looking lad, with a fair amount of ability, 
 but with the restless, uncontrolled nervous instability 
 common in these cases. Each change of residence was 
 associated with temporary amelioration, only to be fol- 
 lowed by some coarse or gross act, which, in turn 
 having been punished, was followed by some attempt 
 to burn the house. In one case it was quite clear that 
 a nervous lad of the same class, connected on the one 
 hand with a family of high mathematical ability and 
 on the other with nervous instability, was morally in- 
 sane ; for a time being possessed by the idea that he 
 was injured, he would make accusations against people 
 of robbing and ill-using him. These latter symptoms 
 are those which require a few words of special refe- 
 rence. Certain persons, probably more frequently 
 women than men, make lying accusations against per- 
 sons of the other sex ; and although it may be shown 
 that such patients come of nervous stock, it will be 
 hard to persuade the public to let them off" on that 
 plea. Constantly accusations, without the slightest 
 truth in them, are made by morally insane patients ; 
 and those of us who have lived in an asylum can fully 
 recognise the danger which the outside world runs 
 from insane accusations ; especially those made by 
 
Chap. XL] Sexual Precocity. 275 
 
 patients wlip are intellectually bright but morally 
 perverse. 
 
 The intellectual abilities of many of these morally 
 insane people are striking, but they are further evi- 
 dences of want of balance. One power, or one faculty, 
 seems to have developed at the expense of all the rest, 
 and it is common to see precocity in the morally in- 
 sane. It may be sexual precocity, it may be calcu- 
 lating or mathematical ability of a certain kind, 
 or a taste for and power of reproducing music ; 
 and, alone or combined with either or all of 
 the above powers, there may be a memory of the 
 most marvellous definiteness and clearness, so that 
 dates especially are recollected with wonderful pre- 
 cision. 
 
 The picture here given and the examples, show one 
 of th© most difficult and dangerous groups of insane 
 patients. The patients, from their intellectual ability, 
 completely upset the conventional ideas of insanity, 
 and the presence of superior powers of mind with 
 good memory seems to assure the ordinary observer 
 that the acts, vicious or criminal, which have been 
 perpetrated, must have been performed by a respon- 
 sible person. In some cases the physiognomy of the 
 patient is in his favour. 
 
 What is to be done with such cases % To begin 
 with, doubtless, the offspring of insane parents, or 
 children with certain peculiarities of mind and body, 
 require special education. Some of these patients are 
 sent with benefit to asylums for idiots, but I am 
 inclined to believe that they require careful individual 
 training ; and that with this continued from the age 
 of four or five up to twenty, a certain number may be 
 saved from perpetrating criminal acts. It is not well, 
 either, to over-stimulate any intellectual powers they 
 possess, nor is it well to attempt to suppress them. 
 Let the musical faculty be developed in a methodical 
 
276 Insanity and Allied Neuroses. [Chap. xn. 
 
 way; but let a fair, yet not an exhausting, amount 
 of care be devoted to memory and matliematics, 
 and let outdoor exercise and gymnastics be culti- 
 vated. Every tendency to excitement should be 
 avoided, and for the sake of other children the most 
 careful isolation and supervision at night is necessary ; 
 but, with al] this care, the result in most cases will be 
 unsatisfactory. 
 
 CHAPTER XII. 
 
 GENERAL PARALYSIS OF THE INSANE. 
 
 General i^aralysis of the insane — General paralysis without 
 insanity — Nature of general paralysis — Other forms of 
 paralysis met with in asylums — Causation : Stages, varie- 
 ties, with examples — Sym]ptoms in detail — Diagnosis — Pro- 
 gnosis — Treatment. 
 
 By far the most interesting group of cases, from a 
 scientific point of view, which one has to consider in 
 an asylum is that of general paralysis. This disease, 
 unlike many of the so-called neuroses, has undoubtedly 
 a physical basis, and, in my belief, the keystone of 
 the nervous pathological arch is general paralysis. 
 The disease, chiefly aflecting the robust middle-aged 
 active -minded man, rapidly destroys everything 
 human in him, leaving him to exist, often for months 
 together, an unconscious automaton. I believe that 
 the disease can only fruitfully be studied and finally 
 understood by subdividing the cases as much as 
 possible into groups according to the symptoms ; 
 not with the idea that each subdivision represents 
 a definite, form of disease, but that there will thus be 
 found certain natural groupings of bodily and mental 
 symptoms. The study of the connection which will 
 be seen to exist between these latter will sooner or 
 
Chap. XII.] General Paralysis of the Insane. 277 
 
 later clear up many points in the pathology of the 
 nervous system, and will also add not a little to the 
 comprehension of mental function. 
 
 The first question to be considered is, whether the 
 disease called general paralysis of the insane deserves 
 its name, and whether it must be considered as neces- 
 sarily connected with insanity. One of the questions 
 which general physicians ask is, whether this same 
 disease, which is called general paralysis, can exist 
 without mental disorder. I always reply that I have 
 seen several cases who for years have exhibited 
 bodily symptoms in every particular coinciding with 
 those found in the patients in our asylums suffering 
 from general paralysis of the insane, and yet without 
 the slightest evidence of insanity, even without 
 any loss of memory or of self-control ; so that, in fact, 
 the patient was sound in mind although a general 
 paralytic in body. The reason, I believe, that the 
 condition has hitherto been misunderstood is, that 
 asylum physicians rarely see cases in general hospitals ; 
 and general physicians only occasionally have the 
 chance of watching true general paralysis. In 
 my opinion, general paralysis may develop in any 
 of its forms without mental symptoms for a con- 
 siderable length of time ; but unless cut short 
 by some inter-current or accidental cause, mental 
 deterioration shows itself before the end. The symp- 
 toms may be only those of weak-mindedness, and 
 may be so slight that comparatively little importance 
 is attached to them. 
 
 Having thus given my opinion that general 
 paralysis may occur with few or no mental symp- 
 toms, I would next say that the term does include 
 various forms of nervous degeneration, and that, in 
 fact, the term as at present used includes several 
 classes which will have to be subdivided as our know- 
 ledge increases. Of these subdivisions I shall have 
 
278 Insanity and Allied Neuroses. [Chap.xii. 
 
 to speak more fully later; for I do not consider 
 that the divisions which have been made, either from 
 the clinical or pathological side, are sufficiently pre- 
 cise. To say that one group of cases suffers from 
 spinal general paralysis, and that another suffers from 
 cerebral general paralysis, is not sufficient ; nor is it 
 satisfactory to speak of general paralysis in men, 
 general paralysis in women, and general paralysis in 
 old people. It will be found impossible satisfactorily 
 to divide the cases according to the condition of the 
 brain as found after death. The disease is general 
 in its cause and its effect, and in the brain we only 
 take into consideration one of the factors of the 
 disease. The best divisions, to my mind (because they 
 are both clinical and pathological), are those made by 
 Dr. Julius Mickle, and I shall have to refer to his 
 excellent monograph in detail again. 
 
 I believe, then, that several distinct varieties 
 of general paralysis exist, or rather that several 
 distinct series of changes occur in the nervous 
 centres, giving rise to a progressive and fatal 
 nervous disease, which has been called general para- 
 lysis. I can hardly be expected, therefore, to say 
 that I believe general paralysis to be a definite and 
 specific disease. I am in the habit of saying that, in 
 my experience, any conditions which may start a 
 progressive decay of the higher nervous tissues will 
 give rise to symptoms resembling those which have 
 been classified as general paralysis ; that we have in 
 such a diseased condition a gradual destruction of 
 nerve centres. Moreover, it may be purely a 
 matter of accident whether this be due in the first 
 place to premature disease of arteries, or to mal-nutri- 
 tion associated with constant strain ; imperfect rest, 
 and regeneration of the nerve tissues ; or whether, 
 again, it be due to changes in the relations between 
 brain and vessels following injury or inflammation. 
 
Chap. XII.] Progressive Degeneration. 279 
 
 That the disease is progressive is without contradic- 
 tion ; that it rarely affects a large part of the brain 
 or nervous systems suddenly is also a fact ; that its 
 action, whether upon the brain or cord, is very small 
 and hard to be detected at first, I also believe ; that 
 it affects first the highest intellectual and motor 
 acquirements is undoubted. Both Dr. Maudsley and 
 I have independently taught that in this progressive 
 degeneration the last and highest acquirements fail 
 first, so that the musician loses his power over his 
 fingers, the seamstress can no longer sew, the dan^ 
 sense fails in her ikis, and the actress blurs her phrases 
 and forgets her part. This effacement of the highest 
 acquirements will be seen to be associated with the 
 loss of self-control, and, in fact, the patient passes 
 from his normal condition into a state as nearly as 
 possible identical with that produced by mild alcohol- 
 ism ; and at least in one case I have been able to 
 ascertain that the early symptoms of general paralysis 
 resembled exactly those produced in the same patient 
 when partly intoxicated. From the above I infer 
 that the degeneration is one generally beginning in 
 the highest and last organised parts of the nervous 
 tissues, and that as it spreads it produces more and 
 more marked signs of degeneration. The rapidity 
 of degeneration, the amount of mental loss in a given 
 time, differs in each case. Why this disease should 
 specially affect men ; why it should affect to^vnsmen 
 and men leading active industrious lives, men, as a 
 rule, of good physique and active temperament, I 
 cannot explain. The disease is special, in so far 
 that it ends fatally in nearly all cases, and in almost 
 always the same way ; and that, whatever the earlier 
 symptoms may have been, the later ones are similar 
 to a remarkable degree. 
 
 It must be remembered that in an asylum 
 other forms of paralysis occur. In Bethlem I have 
 
28o Insanity AND Allied Neuroses. [Chap. xii. 
 
 seen examples of almost every known variety of para- 
 lysis occurring quite independently of any symj)toms 
 which would incline one to suspect general paralysis. 
 We have ordinary hemiplegia, paraplegia, dissemi- 
 nated sclerosis, locomotor ataxy, and bulbar paralysis, 
 but these are not to be mistaken for the cases of 
 general paralysis of the insane. 
 
 I have said that general paralysis may occur in 
 the sane, and I would here refer to several cases about 
 which I have been consulted. The first is that of a 
 married man, aged thirty-eight (no insanity in his 
 family), who had led an active, industrious life. He 
 came to see me in consequence of change in his hand- 
 writing and hesitation of speech. When I examined 
 him I found that his pupils were unequal, his 
 tongue tremulous, his hand-writing shaky, with a 
 tendency to drop terminal letters of words. There 
 was a greatly increased patella reflex ; yet with 
 all these bodily symptoms I could detect no change in 
 his mental capacity whatever. His memory was 
 good ; he was not emotional ; nor had he lost any 
 power of self-control. This patient has for years been 
 under my observation, and has shown no intellectual 
 disturbance whatever, and at the present time I 
 believe he is earning his living. The end will pro- 
 bably be weak-mindedness, but at present there are 
 no points to guide one as to when it is going to 
 develop. Constantly I am called upon to see cases 
 in general hospitals, in which the bodily symptoms 
 are marked, while the mental ones are absent, or very 
 slight. In some cases the bodily symptoms are only 
 prematurely developed, or out of relation to the 
 mental ones, either occurring much more markedly than 
 is usual in the earlier stages, while the mental symp- 
 toms are slight ; or the bodily symptoms may appear 
 to be followed in a short time by the mental ones. 
 
 In the following case the mental symptoms were 
 
Chap. XII.] Causation OF General Paralysis. 28 i 
 
 extremely slight, altlioiigh the bodily signs were 
 distinct enough : A married man, set. forty, had been 
 for many years in the Custom House, and had a 
 very keen delight in self-culture. He was one of 
 the typical Englishmen of the middle classes, who 
 devote every spare moment to improving their minds. 
 He told me that since boyhood he had been accus- 
 tomed to carry about with him manuals of one science 
 or another, foreign grammars, or other means of general 
 education. He took little exercise, refrained from all 
 stimulants, and led what might be called an exemplary 
 life. Six or seven months before he came to see me, 
 he tottered in his walk, and noticed that his hand- 
 writing was changing in its character, and that he 
 was no longer able to do the clerical work which was 
 expected of him. When he first visited me he at 
 once pointed to his head, and said that, like Swift, he 
 was " going first at the top," and for a moment he 
 appeared emotional, but by carefully avoiding refe- 
 rence to his physical weakness, he was induced to 
 speak of his powers and abilities with considerable 
 personal satisfaction. Since then I have seen him 
 several times, and find that his muscular power is 
 lessening, that he is ataxic in walk, with absence of 
 patella reflex, and that there is a general feeling of hien 
 etre quite out of accord with his physical condition. 
 In this case the bodily symptoms are much more pro- 
 nounced than are the mental ones, but I have no 
 doubt of the nature of the case, and the certainty of 
 its unfavourable termination. Many other such cases 
 are seen by me every year, but the examples I have 
 given must suffice. 
 
 Causation of general paralysis. — It will 
 be convenient to consider causation under one general 
 heading, making no distinction between the groups of 
 cases to which I have already referred, although I am 
 sure it will be found that certain cases^ depending on 
 
2«2 
 
 Insanity and Allied Neuroses. [Chap. xii. 
 
 special causes for their origin, have special modes of 
 development, and manifest corresponding peculiarities 
 in the symptoms. For example, traumatic general 
 paralysis may differ essentially from that produced by 
 alcoholism, and this again from that due to syphilis ; 
 however^ it will be advisable for the present to avoid 
 any particular differentiation of the causation, leaving 
 this to a later stage, w^hen we shall have before us 
 all the symptoms. I will first consider the causation 
 generally, as if the disease were a specific one. 
 
 The favourite idea in England at present is that 
 general paralysis depends upon sexual excess^ and Dr. 
 Maudsley has done much to establish this belief. 
 Undoubtedly sexual excess may be a cause of general 
 paralysis ; it is certainly a very exhausting cause, but 
 such excess is difficult to determine, for I suppose it is 
 rare to find two individuals who are similarly liable to 
 exhaustion from this or any one cause. Just as a 
 slight alcoholic indulgence will produce intoxication 
 with one, whilst another may require an enormous 
 amount of alcohol to affect him ; so with sexual in- 
 dulgence, what is excess in one is moderation in 
 another. There are patients admitted yearly into 
 Bethlem whose disease I believe to be chiefly pro- 
 duced by sexual excess ; but such men are generally 
 not only living lives of general excitement, but are 
 wedded to women of a specially amatory nature j and 
 although it would be unscientific to connote excess as 
 necessarily associated with certain types of women, I 
 have been struck by the frequency of the occurrence 
 of general paralysis in the husbands of some women of 
 voluptuous physique. Again, as with other disorders 
 of the mind, it is often difficult to distinguish between 
 early symptoms and causes. Undoubtedly sexual 
 excess may have something to do with the production 
 of general paralysis, but there is no doubt that sexual 
 excess is a common early symptom of the disease.^ I 
 
Chap. XII. 1 Anxiety and General Paralysis. 283 
 
 am quite sure I have been able to eliminate sexual 
 excess from a considerable number of cases wliich 
 have come under my notice, especially among women. 
 
 Masturbation, in my experience, very rarely gives 
 rise to any symptoms like those of general paralysis of 
 the insane, 
 
 A lcoholis7n is also a recognised cause of mental de- 
 generation, and alone or combined with other excesses 
 and injuries is, to my mind, an undoubted cause of the 
 disease. 
 
 Syphilis, which is supposed to play such an im- 
 portant role in most nervous disorders, especially those 
 of an intricate kind, has also been credited with the 
 production of a large amount of general paralysis. 
 And here, again, I must say that I have had cases 
 under observation in which the progressive mental 
 and bodily degenerations had to be classified as be- 
 longing distinctly to general paralysis, on the one 
 hand, and on the other were as distinctly due to syphilis. 
 When considering the pathology of the disease, I shall 
 refer to cases in which there have been found after death 
 local syphilitic changes that have given rise to S3nnp- 
 toms indistinguishable from those of general paralysis. 
 
 Injiiry also must be credited with the causation of 
 a certain number of cases, and probably most of those 
 which are seen in general hospitals, and which have 
 but little mental derangement, are those which follow 
 injury. 
 
 The above are the chief physical causes, and on 
 the moral side I would place, first of all, anxiety. I do 
 not look upon general paralysis as the disease of over- 
 work, and although it seems steadily to increase with 
 the increase of civilisation and with higher education, 
 and although it appears now among women who 
 are struggling to take the places of men, yet my ex- 
 perience is that the relationship is not with work, 
 but with worry. General paralysis occurs mostly in 
 
284 Insanity and Allied Neuroses. [Chap. xii. 
 
 the anxious-minded, conscientious man, and as far as 
 my experience among the middle-classes is con- 
 cerned it is rather due to over-strain than over- 
 work. Many examples occur in which the struggling 
 man manifests symptoms of general paralysis just 
 when success appears to have been achieved, and 
 I have seen several cases in which the insanity 
 and break-down were attributed to retirement from 
 active business, whereas the truth was that the 
 over-strain which had secured a fortune had left 
 the man a wreck. Anxiety about business matters 
 seems to be most disastrous. Occasionally one 
 meets with cases in which the disease has been 
 started by domestic unhappiness, but these, as 
 I say, are less common. Some little time ago a 
 patient was admitted into Bethlem suffering from this 
 disease, and I have no doubt it was produced in the 
 following way : The man, an energetic manager of a 
 successful business, prosecuted some workmen under 
 him for want of performance of their duties j he 
 failed to get a conviction through a conspiracy of 
 the workmen, and the result was that his life was 
 rendered miserable by a system of threatening and 
 intimidation. Sleeplessness, worry, and loss of appe- 
 tite were followed by the ordinary signs of general 
 paralysis of the insane. To sum up, general paralysis 
 usually arises from a combination of causes ; the 
 most common direct causes being excesses of all 
 kinds, whether sexual or alcoholic, which act more 
 powerfully when associated wdth strain, worry, and 
 anxiety ; and, finally, we see that physical injuries 
 may also produce the disease, as may also such phy- 
 sical diseases as syphilis, etc. 
 
 Varieties of general paralysis of the 
 insane. — Under this heading I shall consider, first, 
 the various forms of mental andbodily disorder, which 
 are classed as general paralysis. Undoubtedly there 
 
Chap. XII. I Varieties of General Paralysis. 285 
 
 are some natural and some artificial divisions, and tlio 
 wliole arrangement must be considered as a provisional 
 one, I shall divide tlie cases, first into acute and 
 chronic; then into those in which the symptoms are 
 'primarily maniacal^ with exaltation of ideas : next 
 the melancholic and hypochondriacal cases ; and, lastly, 
 those in which dementia is more or less pronounced 
 from the onset. It will be seen in tracing the history 
 of cases that they nearly all end in dementia sooner 
 or later. In the next division I shall consider whether 
 the hrain or cord symptoms are most marked, or come 
 on earliest; and when considering the latter I shall 
 divide the cases into those in which the j)osterior 
 coho7nns of the cord are most affected, and those in 
 which the lateral columns are chiefly involved. In 
 considering cases I shall discuss the various symptoms 
 which may occur, and later exemplify the symptoms 
 by means of typical cases. 
 
 Dr. Mickle has described five groups of general 
 paralysis, pathologically and clinically. 
 
 Undoubtedly there is a series of pathological 
 changes connected with each definite group of clinical 
 symptoms, but a great deal remains to be done to 
 associate these. 
 
 Besides ordinary cases of general paralysis, one 
 meets with numerous cases in which there is some 
 slight peculiarity, either as to the causation or course 
 of the disease ; or one or more of the syaiptoms may 
 be unduly prominent ; or symptoms which rarely 
 occur may from time to time present themselves. 
 Thus, although it is rare to meet with strabismus or 
 ptosis in general paralysis, they do at times occur ; 
 and although fits are usual, yet the disease may run 
 its course without their presence. General paralysis 
 may follow upon some local disease ; and just as I have 
 seen symptoms of general paralysis develop on old 
 locomotor ataxy, so I have seen it occur in cases which 
 
286 Insanity AND Allied Neuroses. [Chap. xii. 
 
 have suffered from some other nervous lesion, such as 
 the paralysis of childhood. The special points of 
 pathology and diagnosis will be considered towards 
 the end of this chapter. 
 
 Stag^es ill tlie course of general paralysis 
 of the insane. — The greatest medical importance 
 still attaches to the very earliest stages of this disease, 
 for if any good is to be done, it must be done early, 
 before any well-marked symptoms, evidences of real 
 degeneration, have shown themselves. 
 
 It is still very difficult to give any distinct 
 answer to the question as to the length of time the 
 warning symptoms may precede the evident signs of 
 the disease. Generally after the disease has made 
 itself evident, or after the death of the patient, the 
 friends will give further details which may enable one 
 to trace the first steps in the morbid process. 
 
 I shall briefly refer to the warning or prodronfial 
 symptoms first, and next consider the initial symptoms. 
 The 'prodromal symptoms may be either bodily or 
 mental, or both. 
 
 The bodily symiotoms are generally some degree of 
 paralysis. Thus the wife of one patient now in Beth- 
 lem noticed temporary loss of speech, followed by 
 hesitation and tremor, nearly eight years before she 
 suspected that any serious disease was imminent. 
 The attacks of aphasia recurred at intervals, and 
 when it was necessary to send the patient to an 
 asylum, the difficulty of speech and tremor of tongue 
 and lips were very much marked. 
 
 In other cases, giddiness or attacks of vomiting- 
 may precede the disease. Loss of power in the lower 
 extremities, too, is not uncommon, so that the history 
 will be given of a fall as the cause of illness, whereas 
 the fall was the earliest result of nervous change. 
 
 Locomotor ataxy, or some other form of paralysis, 
 may exist long before general paralysis is detected. 
 
Chap. XII.] Mental Symptoms. 287 
 
 Headache, or pains in the head of a variable kind, 
 may be noticed. Slight convulsions may have occurred, 
 and may have been recovered from and forgotten, 
 till the general paralysis shows itself many years 
 afterwards. 
 
 On the mental side there may have been noticed 
 some moral or intellectual change, slowly or quickly 
 changing the whole nature of the man. 
 
 In one case the patient had, for two years before 
 he was suspected of illness, been guilty of mean acts 
 and fraudulent appropriation of property. 
 
 These acts were done with great caution, and with 
 evident knowledge of the nature of the act and the 
 liability attached, yet he ought not to be considered 
 fully responsible. 
 
 Intemperance in drink, or in any other respect, 
 may be the warning, and I have known a return to 
 uxoriousness, or a development of jealousy or strong 
 family affection, precede the outbreak of general 
 paralysis. 
 
 Irritability, restlessness, broken sleep, or drowsi- 
 ness, especially after meals, may also be noteworthy. 
 
 Loss of memory for recent matters, for facts not for 
 dates, names, or other abstract details, may occur. 
 Complaints of loss of power and a kind of mental 
 hypochondriasis may also serve as a warning. I have 
 known more than one man who has told me that he 
 was sure he was going mad ; and in one case a doctor 
 told me he was suffering from this disease, though 
 after telling me this he neglected his own diagnosis 
 and began to talk freely of his patients. He died 
 eight years later of general paralysis. 
 
 I am always guarded in my prognosis when a 
 strong, middle-aged man, not of a neurotic family, 
 consults me for vague and variable nervous symptoms. 
 
 In such cases, I insist on the danger there may 
 be, and advise abstention from business, from domestic 
 
288 Insanity and Allied Neuroses. [Chap. xii. 
 
 and social engagements. I often say that if men in 
 this stao'e or condition could be made to treat their life 
 like a piece of music, and keep fixed intervals of rest 
 between the notes of action, they might stop the 
 disease. 
 
 In a steadily progressive disease it is impossible to 
 make clear distinctions between the stages ; and it 
 must be admitted that the initial stage is one about 
 which each author differs. For my part, I look upon 
 the " initial stage " as equivalent to the first noticed 
 symptom, there being no break between its appear- 
 ance and the recognition of a disordered or diseased 
 state. The initial stage, or first symptom, may be 
 one act or one symjotom, or it may be a group of 
 symptoms or series of acts ; it may be motor ^ 
 sensory, or mental. 
 
 Probably tremor of tongue, clipping of words, or 
 some slight change in gait, are the most common 
 initial symptoms. A convulsion may start the process. 
 Change in feeling, possibly loss of power of smell, or 
 local ansesthesia, or slight perversion of sight, such as 
 colour blindness, may occur. 
 
 Hypochondriasis may also be a first symptom. 
 
 On the mental side, emotional disturbances, passion, 
 restlessness, lust, extravagance, and loss of memory are 
 the most common heralds of disease. 
 
 There is nothing special either in the prodromal or 
 in the initial symptoms of the disease, and there is no 
 possibility of saying what will be the duration and 
 course of the disease from the earlier symptoms. Some 
 patients who begin with excitement become melan- 
 choly, and more who are first depressed become excited. 
 In one case, quiet dementia, which had lasted for 
 eighteen months, was followed without warning by a 
 most violent outbreak of maniacal excitement. As a 
 rule, from the early symptoms one may judge whether 
 the case will be one of so-called spinal or cerebral 
 
Chap. XII.] General Paralysis. 289 
 
 general paralysis, and again wlietlier the disease will be 
 of tlie tabetic or tlie lateral sclerotic type. 
 
 Again, the prognosis is worse if convulsions were 
 the starting-point. 
 
 General Paralysis of the Insane. 
 
 First stage. — Mania, melancholia, dementia, con- 
 vulsions, commonly lead to the 
 
 Second stage, which in all varieties tends to 
 dementia. Loss of control of rectum and bladder 
 marks the 
 
 Third stage of marked dementia. 
 
 The first stage. Oti general paralysis of the uisane is 
 very variable, and I believe at present we have no 
 means of judging of its probable duration. It may 
 conveniently be taken to begin with the period when 
 the disorder is such that the question of special treat- 
 ment is considered. This stage, having begun in any 
 of the ways I have already described, may, in its turn, 
 be a steady, progressive development of the initial 
 symptoms, or a reaction from them ; the case which 
 begins in a worn-out man with weak-mindedness will 
 probably continue to exhibit weakness of mind as 
 the chief symptom ; speaking generally, in the iirst 
 stage the most common of all conditions is that of 
 mobility and changeableness. 
 
 If the patient after a short period of mental de- 
 pression passes slowly or rapidly into a state of exalta- 
 tion, the steps are probably the following : Re- 
 covering from his depression, he becomes restless and 
 energetic, and passes into what I call the changing 
 or reforming stage. He is not contented with his 
 house or his business ; he is irritable, and if op- 
 posed loses all self-control for a time ; his constant 
 restless and only half -completed plans distress and 
 annoy those near him. He is often sleepless, or, 
 at any rate, he gets up very early, and says he has 
 T — 14 
 
290 Insanity and Allied Neuroses. [Chap. xii. 
 
 found that hitherto he has slept too much. He is at 
 times destructive, or, as he thinks, constructive, tearing 
 up books to rearrange them. He may determine to 
 change his profession, or he may seek out royalty or 
 politicians to instruct them in their duties. 
 
 Telegraphing, sending endless post-cards, and hiring 
 cabs are common symptoms. 
 
 The purchase of useless articles in large numbers 
 is also characteristic. A man who buys a dozen 
 broughams and twenty parrots is probably a general 
 paralytic. A patient in the early stage may deter- 
 mine to do some benevolent act, or may ruin himself 
 as a champion of some craze. Any symptom which is 
 met with in early stages of intoxication may be pre- 
 sent : one man boasting of his ancestors, a second of his 
 strength, a third swearing friendship to a lacquey, a 
 fourth boasting of his amours and maundering senti- 
 mental ballads, while another is bathed in tears of 
 sympathy, and others again being reduced to simple 
 drunken folly. 
 
 The effect produced by drink may foreshadow what 
 the same man would do when he is in the early stage 
 of general paralysis. Restlessness, to my mind, is the 
 most general symptom : one man never ceasing to walk 
 as if for a perpetual walking match ; another filling 
 every piece of paper he can steal or borrow with 
 badly-written letters ; another violently playing any 
 game he can get at ; and others painting, singing, 
 and talking without ceasing. 
 
 The memory may fail a little in this stage, and the 
 will is not firm, so that the patient is easily led ; the 
 association of ideas is good, as a rule. Hallucinations 
 may occur ; but I find it difficult to be sure of the 
 number and variety of these as seen in general para- 
 lysis. Such a patient is glad to own that God talks 
 to him, or that beautiful female angels appear to him; 
 but I find that such patients rarely spontaneously talk 
 
Chap. XII.] Organic Functions. 291 
 
 of voices or of visions. Smell of pepper may oe lost, 
 as Yoisin has said ; but this is very rare in my ex- 
 perience, and is associated with other losses of sen- 
 sibility. 
 
 There is rarely hypersesthesia, while local anaesthesia 
 is more common. 
 
 There may be alteration in the reflexes. The skin 
 assumes one of several aspects : it may be like that of 
 the beer-drinker, in one case swollen, expressionless, 
 and flabby, with a greasiness, especially on forehead, 
 and about aloe, nasi ; or it may resemble that of the 
 spirit-drinker, being sallow, thin, dry, and with vascu- 
 larity over the malar bones. In some cases a specially 
 anaemic look is present, the patient having a 
 tallowy aspect of a very special nature ; yet I have 
 failed to find any particular blood changes in such 
 cases. The hair, which is generally abundant, may 
 become grey. 
 
 Changes in the eyebrows and eyelashes have been 
 described ; a kind of weeping of the latter has been 
 pointed out ; but I do not think it is of much value. 
 
 The pupils are frequently unequal, and may be 
 eccentric or irregular. Sight is rarely aflected ; and, 
 in my experience, it is rare to find any changes in 
 the optic discs ; ptosis or strabismus is rare. 
 
 Next, as to the organic functions. 
 
 After the first, when the appetite may be small, 
 and the tongue furred, the appetite is very good, and 
 the patient accepts all he has given him as the very 
 best. 
 
 His bowels are fairly regular; but there is, in 
 some, constipation. 
 
 Sexual passion is strong ; but power is often defi- 
 cient. Sexual excess and masturbation are common. 
 
 The breathing and heart's action are normal, as a 
 rule, though I have febrile pulse-tracings in some early 
 cases with excitement. Sleep, which was not profound, 
 
292 Insanity AND Allied Neuroses. [Chap. xii. 
 
 becomes more and more deep and satisfactory. Dreams 
 of a pleasant type are common. 
 
 The bodily weight is rapidly increased. 
 
 The muscles are well nourished, and, save in spinal 
 cases, the gait is good. 
 
 The muscles react normally to the electrical stimuli ; 
 in a few cases they are unduly excitable, or certain 
 groups of muscles show some slight changes 
 
 The tongue is tremulous, being put out un- 
 certainly. 
 
 The handwriting is becoming shaky, and letters 
 are being dropped. 
 
 The patient has lost his highest muscular powers, 
 so that the musician fails with his fingers, and the 
 danseuse with her feet. The actor plays false, and the 
 clerk mis-spells. 
 
 The temperature may be normal, or, in certain 
 cases, vary from 100*^ in the morning to 102*^ at 
 night. 
 
 The urine is very variable in quantity and quality. 
 
 The first stage may impercejotihly pass into the 
 second, or a fit may be the dividing mark. This fit 
 may be of a very variable nature. In one patient a 
 slight twitch is seen to pass over the face, pallor occurs, 
 and in a minute the patient recovers, wondering what 
 is the matter, and why others look at him. A simple 
 attack of bilious vomiting may represent the fit, or 
 there may be a series of fits of the most violent kind, 
 keeping the patient unconscious and in a status epilep- 
 ticus for days. The fits may be general, or may affect 
 but one side j they may resemble ordinary epilepsy or 
 apoplexy. 
 
 After recovery of consciousness there is a period of 
 confusion, which may last a few days ; but any hemi- 
 plegia is soon recovered from, thus distinguishing the 
 fits from those of apoplexy. 
 
 After the fit a marked mental deterioration is 
 
Chap. XII.] Second Stage of Paralysis. 293 
 
 noticed ; often the patients become careless in their 
 dress and gross in their appetites. The fits may kill 
 at once, or may recur at irregular intervals, generally 
 following a similar course in each attack. 
 
 The fits may leave aphasia. 
 
 The memory fails, and though some cases appear to 
 regain even their old ideas of grandeur, they are 
 found to be much more manageable. In the second 
 stage of confirmed general paralysis all the muscular 
 and mental symptoms exhibit marked increase of 
 weakness ; and, as the first stage might be called one 
 of loss of control, this may be said to be one of loss 
 of power. 
 
 The most marked symptoms now are loss of facial 
 expression; generally, but not always, increase of 
 tremor of lips and tongue. The speech is more hesi- 
 tating ; words like ''artillery" are badly pronounced, 
 and the voice may become changed and monotonous. 
 The gait becomes more or less affected, and the 
 restlessness is less. The appetite is good, but 
 the food is often badly masticated, and may be swal- 
 lowed with difiiculty. At this stage there may appear 
 some peculiar habits, such as that of constantly swal- 
 lowing, or of movements of the lower jaw ; and 
 grinding of the teeth may also show itself. This last 
 symptom is a very common one, and may go on for 
 months, in some cases the teeth being worn down or 
 even broken ofi! Common sensibility is often lost, 
 the changes in the reflexes more marked, the pupils 
 are more constantly unequal, and some changes may 
 be visible in the discs; these are simple hypersemia 
 or tendency to atrophy. The patient may have a 
 complete remission for a time, or may improve to a 
 great extent. 
 
 In some cases the whole character of the disease 
 changes: one patient, who had before been obstinate 
 and hypochondriacal, becoming, after a fit, fat and 
 
294 Insanity and Allied Neuroses. LChap. xti. 
 
 jolly, and another becoming deeply emotional or 
 melancholic. 
 
 Skin changes may also occur, so that a patient 
 may have livid extremities, or may develop haema- 
 tomata of the ears. 
 
 Hallucinations are rare, and the delusion of gran- 
 deur is less insisted upon ; the emotional side is less 
 stable, and the memory failing. This description is 
 only a typical one, for each case has some peculiarity 
 of its own. I have known patients appear for a day 
 or two to recover their mental and physical powers to 
 a surprising extent. 
 
 In this stage there may be a tendency to subcuta- 
 neous bruising, and to the formation of large ab- 
 scesses or whitlows, which are found to contain 
 broken-down blood and not healthy pus ; and the 
 inflammation associated with the condition is of a low 
 type, and causes little pain. Nevertheless, blood- 
 poisoning and sudden death may occur. 
 
 The patient may remain in this stage for any time 
 from a month to several years. He may become fat 
 and flabby, or he may waste rapidly : in the former 
 case fits will probably return ; and in the latter some 
 secondary lung affection may hasten the end. 
 
 Loss of control of the rectum and bladder mark tlie 
 third stage ; at first, only as a rare accident, or only 
 while in bed j but later all control is lost ; all the 
 bodily and mental symptoms become accentuated. 
 The patient also now loses strength, sits about unoc- 
 cupied and demented ; being either iinable to walk or 
 unsteady in his gait. 
 
 He may get wasting and contraction of the legs, 
 bed-sores rapidly forming. These latter, however, 
 often show a strange power of repair. Swallowing 
 becomes difficult and dangerous, the tremulous tongue 
 can hardly be protruded, and speech is thick and in- 
 distinct. 
 
Chap. XII.] Third Stage of Paralysis. 295 
 
 Grinding of the teeth is very common. 
 
 Loss of sensibility, blindness, and deafness may 
 be present ; the bones may become brittle, so that a 
 very slight injury may break a rib or a limb. 
 
 The fits probably become more frequent, and are 
 associated with increase of temperature and profuse 
 sweating, which may be local or general. The tem- 
 perature may, in some cases, be subnormal apart from 
 the fits. 
 
 The end may be due to a series of fits, to lung 
 complications, such as pneumonia, to simple exhaus- 
 tion due to bed-sores, or want of power to assimilate 
 food ; accidents, such as choking or blood-poisoning, 
 may also occur. 
 
 Besides the above there are cases starting with 
 hypocliondriasis passing into melancholia with re- 
 fusal of food and general obstinacy, diagnosis being 
 doubtful for some time, as the patient will neither 
 walk, speak, nor write ; the pupils may be unequal, 
 and the skin greasy. In many cases a fit may clear 
 up the case, and when it has passed into the second 
 stage it runs the usual course. I have known several 
 pass from a rather prolonged first melancholic stage 
 into a long stage of happy, fat weak-mindedness, to 
 be followed by fits, loss of power, and death. 
 
 In cases starting from simple weakness of mind, 
 the symptoms vary a great deal : one sufiering chiefly 
 from loss of memory, while another becomes querulous 
 or nervous. The bodily symptoms resemble those 
 already described, and the cases pass through similar 
 stages. 
 
 I have seen good examples oi general paralysis of 
 the '''' double form^^ the point that has struck me in all 
 being the extreme differences seen in the two stages. 
 So much has this been the case that in each I 
 have doubted whether my diagnosis had been formed 
 correctly. Thus, a patient admitted with typical 
 
296 Insanity and Allied Neuroses. [Chap. xti. 
 
 symptoms of general paralysis passes into a state of 
 simple melancholia, most of his Other bodily and 
 mental symptoms having remitted j this having lasted 
 for some time, a fresh outbreak of violence and exal- 
 tation again confirms one's first opinion, and this may 
 again be succeeded by melancholia ; each attack, 
 however^ leaves some mental scars to prove its real 
 nature. 
 
 Some cases terminate early from complications, 
 others pass rapidly through the ordinary stages, and 
 others are specially severe. 
 
 Rapidly fatal general paralysis. — E. G., married, 
 set. 33, grandfather melancholy, parents healthy ; the 
 supposed cause of this attack was anxiety about 
 money matters. There is a history of a previous 
 attack of insanity, seven years before, from which the 
 patient completely recovered. This attack lasted four- 
 teen days, and began with hesitation in speech with 
 great incoherence, sleeplessness, and refusal to take 
 food. He fancied that his shop assistants were being 
 starved, and that people were removing his goods 
 without payment. On examination when admitted 
 he was found to be weak, nervous, and restlessly ex- 
 citable. Within three months he was noticed to be 
 very feeble on his legs, and it was difficult to under- 
 stand him, as his speech was so thick ; later, he had a 
 convulsive fit, from which he recovered, but remained 
 in a half-dazed condition. There was no special para- 
 lysis ; but great exaggeration in the reflexes. Four 
 months after admission he was found one morning 
 in an unconscious state, head turned to the right, 
 with conjugate deviation of eye-balls also to the right, 
 and pulse 170, respirations 55, temperature 105°, 
 right pupil slightly larger than left, loss' of power 
 of rectum and bladder ; the breathing assumed the 
 Cheyne-Stokes character ; he became more profoundly 
 unconscious, and died. Post-mortem : the convolutions 
 
Chap. XII.] Acute General .Paralysis. 297 
 
 of right side of hemisphere gave the idea of being 
 wasted from compression due to a large false mem- 
 brane, the result of pachymeningitis, in which a soft 
 clot had formed ; the pia mater peeled off readily, the 
 brain weighed 43^ oz., and beyond pleuritic adhe- 
 sions on both sides of the chest, there was nothing- 
 noteworthy found in the body. On microscopic 
 examination there was found great excess of connec- 
 tive tissue in both brain and cord, this being widely 
 diffused, and having a semi-transparent gelatinous 
 aspect unlike that found in more chronic cases. In 
 the above case the peculiarities were insane inheri- 
 tance and a previous attack of insanity ; but the 
 point to which I desire to draw attention in quoting 
 this case is the rapidity with which, when once the 
 disease became fairly started, it ran its course. The 
 symptoms were rather melancholic than maniacal ; 
 but I have seen many cases in which all the ordi- 
 nary symptoms of general paralysis have been present, 
 and in which the patient has died within three 
 months. This, in my experience, is more common 
 with maniacal cases than either with those suffering 
 from melancholic symptoms, or those of simple weak- 
 mindedness. 
 
 Acute general 'paralysis of the insane. Fatal re- 
 sult. — Louis F. Gr., married, set. 50, artist ; no history 
 of insanity in the family, no previous attack of in- 
 sanity, although he had suffered from pleurisy with 
 delirium two years before ; said to have been steady 
 in his habits, cheerful, and intelligent. Two months 
 before admission he was noticed to be irritable, 
 nervous, and depressed. He lost power to do really 
 good artistic work, and forgot to complete orders he 
 had on hand. He went from London to Paris, and 
 was unconscious of the difference of the cities. On 
 his return to England his bodily health was seen to 
 be failing ; he was sleeping badly and his appetite 
 
298 Insanity and Allied Neuroses. [Chap. xri. 
 
 decreasing. There seemed to be difficulty in swallow- 
 ing ; he was clean in his habits, and had no extrava- 
 gance in his ideas. He mistook himself, and when 
 he saw his image in the glass wished to smash it. 
 He was suspicious, violent, and obstinate about his 
 food. The diagnosis was general paralysis in an 
 early stage. Within a fortnight of admission he was 
 so weak as to be obliged to be kept in bed. Bed-sores 
 rapidly developed, and he died within six weeks. The 
 above example is a fair one of what is met with 
 every year, some running even a more rapid course, 
 and being complicated by convulsive fits. In this 
 case no post-mortem was allowed to confirm the 
 diagnosis. 
 
 Example of chronic case of general paralysis with 
 severe convulsions recurring during the greater part of 
 the disease, and death at the end of nine years. — 
 George E. S., married, set. 43, butler, admitted for the 
 first time into Bethlem in 1866; no insane inheri- 
 tance. This was the second attack of acute mental 
 disorder, there having been a distinct remission 
 between the first and second. On admission he was 
 talking incoherently, was dangerous to others, filthy 
 in his habits, and childish in his general behaviour. 
 
 Althou2:h on the first admission there was some 
 doubt as to the nature of the disease from which he 
 was suff'ering, on his second admission the loss of 
 muscular co-ordination was very distinct, lips tremu- 
 lous, and gait unsteady. Incidentally, he had an 
 attack of erysipelas, which in no way affected the 
 course of the disease. Steadily the symptoms of 
 general paralysis progressed, and two years after his 
 second admission he is described as thin, much 
 paralysed generally, speech not to be understood, 
 some contraction of right arm and leg, and reflex 
 action exaggerated. He suffered at irregular intervals 
 from fits. During the next three years fits became 
 
Chap. XII.] Case of General Paralysis. 299 
 
 rather fewer in number, but were extremely severe, 
 lasting sometimes two or three days. He became 
 helpless and bed-ridden, gradually lost sensibility, 
 and, his breathing becoming implicated, he died, after 
 nine years of disease. Post-mortem : brain found 
 much wasted, dura mater adherent throughout, arach- 
 noid with many milky spots, great excess of sub- 
 arachnoid fluid, pia mater separable from cortex, 
 several convolutions markedly wasted, especially the 
 left ascending parietal and frontal, considerable 
 wasting in the right side posterior to the fissure of 
 Rolando, vessels at base atheromatous, cord wasted, 
 other viscera natural. In this case there were 
 symptoms of general paralysis occurring nine years 
 before the death of the patient ; there was a distinct 
 interval of partial health, during which he was able 
 to live at home. With the readmission, there ceased 
 to be any doubt as to the nature of the disease, 
 which was marked by progressive dementia, numerous 
 epileptiform fits, and ultimately death. Post-mortem : 
 a wasted brain, with special wasting along the motor 
 area, corresponding with the right-sided palsy. 
 
 ExaTnple of ordinary case of general paralysis in 
 a man. — Clarence E., married, set. 37, wine mer- 
 chant, admitted November, 1872; no insane relations, 
 not very sober habits. This was his first attack of 
 insanity, and anxiety was supposed to have been 
 the cause ; but it seems that he had been unstable 
 and restless all his adult life, having been first a 
 medical student, then a surveyor, later connected 
 with some irregular troops in New Zealand, and, 
 last of all, wine merchant. There was said to have 
 been an injury to the head, but intemperance, at ail 
 events for a time, was undoubted. He had a fit of 
 some kind in New Zealand, and this, probably, was 
 the starting-point of the disease. On admission he 
 was a typical example of mania with exaltation. He 
 
300 Insanity and Allied Neuroses. [Chap. xir. 
 
 said he was the eldest son of God, that he was 
 formerly a great duke, had unbounded wealth, and he 
 was liberal and benevolent in the extreme. He told 
 me, with regret, that the patients denied that he 
 was either king or archbishop, and even denied his 
 divinity ; that he slept from twenty to sixty hours a 
 night. Occasionally he would say that he had lost 
 all his delusions, but it only required a minute's 
 conversation to get evidence of their persistence. In 
 his case was well shown the inability to appreciate 
 facts, so common in these cases; for although he 
 would boast of being able to make enormous breaks 
 at billiards, he was not in the slightest degree dis- 
 concerted by being beaten by a tyro. He lost strength 
 and flesh rather rapidly during the first few months 
 after his admission, there being great increase of 
 tremulousness of his facial and lingual muscles. He 
 walked restlessly and quickly about the grounds for 
 hours together, and when not walking was writing 
 endless letters and dispatches to great people. His 
 memory next became markedly affected, and his sense 
 of colour seemed changed, so that when he took to 
 painting he produced the most astonishing efiects. 
 Six months after admission his speech, for a few 
 days, became greatly affected, and at the same time 
 there was loss of power in his extremities, but there 
 were no distinct convulsions. He recovered from this, 
 and ate and slept well, becoming contented and less 
 boastful. He complained of spermatorrhoea. 
 
 In the autumn of 1873 he had a slight attack of 
 pneumonia, from which he recovered. During the 
 year 1874 he was in much better health, and even 
 worked in the gardens. His hand-writing, however, 
 became characteristically shaky, and early in 1875 
 his aspect became dull and expressionless. He was 
 unsteady in his gait, and on several occasions fell, 
 bruising himself. His muscles were fairly well 
 
Chap. XII.] Case of General Paralysis. 301 
 
 developed, his memory was progressively failing, he 
 was easily moved to tears ; the average bodily 
 temperature was 98*4° in the morning and 100° at 
 night ; loss of control over bladder and rectum 
 appeared, with great loss of sensibility. In May, 
 1875, there was evidence of a convulsive fit during 
 the night; but he recovered from this, and for 
 another month gained flesh. In 1876 the patient 
 was fat, flabby, and demented. He was unable to 
 stand, and the reflexes were so exaggerated that on 
 several occasions he was nearly jerked from his chair 
 by them. His appetite was good, his lower limbs 
 somewhat contracted, the right pupil larger ; he 
 laughed senselessly if spoken to, and resisted any 
 interference. He was threatened with bed-sores, 
 which were prevented by keeping him sitting in 
 suitable chairs, and not allowing him to lie in bed by 
 day. In November, 1876, he had a severe convulsive 
 seizure, affecting the right side, and was unconscious, 
 but restless. He recovered from this fit, but was, in 
 every way, weaker, his lower limbs becoming more 
 contracted ; he ground his teeth constantly, making a 
 most terrible noise. During the year 1877, as long 
 as he lived, he never regained consciousness ; he 
 swallowed automatically when food was put into his 
 mouth, but never articulated. On examination, optic 
 discs were found pale and atrophied, but he was able 
 to see to a certain extent, and also to hear. For 
 months he remained in bed, his limbs becoming drawn 
 up. In August of the same year he had another fit, 
 the fit having been preceded by a condition of ex- 
 treme irritability as far as reflexes were concerned. 
 The head was drawn to the right side, the right 
 pupil larger; there were clonic spasms of lower jaw 
 and occipital and frontalis muscles. He recovered 
 from this fit, and lived on till March, 1878, when he 
 died, worn out. Post-mortem : the body was greatly 
 
302 Insanity and Allied Neuroses. [Chap. xii. 
 
 emaciated, with rigid flection of both hips and knees ; 
 dura inater adherent, arachnoid thick and very 
 opaque ; great excess of fluid, so that the brain was 
 softened and watery ; cord and brain both much 
 wasted ; brain weighed 38 oz. ; much atheroma of 
 the vessels at the base of the skull ; signs of old 
 inflammation of both lungs ; wasting of kidneys, and 
 liver nutmeggy. This case will be seen to exhibit all 
 the chief characteristics of the disease we are con- 
 sidering, but was unusually long in its course. 
 
 Example of ordinary case of general paralysis in 
 a woman. — Mary A., married, set. 36, formerly an 
 actress, no insane relations ; present attack, the first, 
 supposed cause, great anxiety and money troubles 
 of her husband. The first symptoms showed them- 
 selves nine months before admission in March, 
 1882. She became excited and incoherent for twenty- 
 four hours, and from that time there was marked evi- 
 dence of mental weakness. This progressed till it was 
 found necessary to send her to Bethlem. On admis- 
 sion she is described as having a vacant expression, 
 but that she was always wanting to be dressed elabo- 
 rately, thinking herself to be a great personage. When 
 spoken to she invariably replied by saying "jolly." 
 She walked awkwardly, her speech was hesitating, and 
 her comprehension dull ; her expression was vacant ; 
 her appetite was good j there was loss of power over 
 bladder and rectum ; within one month of admission 
 she became noisy, violent, destructive, refused to take 
 food, and had to be fed with the stomach pump. An 
 erythematous rash, followed by large bullae, appeared 
 on the legs ; the temperature was subnormal. She 
 steadily lost strength and died. Post-mortem showed 
 some adhesions of dura mater of the skull, arachnoid 
 slightly milky, excess of subarachnoid fluid ; brain 
 weighed 33 oz.; marked flattening of first and second 
 frontal convolutions, and over the whole of the left 
 
Chap. XII.] Paralysis with Exaltation. 303 
 
 vertex ; membranes, when separated, left roughened 
 surface ; arteries not atheromatous, excess of fluid in 
 both lateral ventricles ; cord wasted, but firm ; lungs 
 both congested, with adhesions of both pleurae ; kidneys 
 small, somewhat granular; small fibroid tumour on wall 
 of the uterus. 
 
 General paTalysis in a woman ; exaltation. — This 
 is interesting, from the fact that it occurred in a 
 childless woman who had indulged in sexual ex- 
 cess, and had also suffered from a previous attack of 
 insanity ; and to the fact that there was great ex- 
 aggeration of ideas. Charlotte H., married, set. 42, no 
 insane relations; had a first attack of insanity in 1872, 
 when she accused her servant of drunkenness and 
 theft, refused to pay tolls or cab fares, and squan- 
 dered her money in useless ways, pawning her jewel- 
 lery to obtain money. She believed herself to be 
 pregnant ; she always impressed upon us the fact that 
 she was going to be delivered of triplets. After nine 
 months' treatment she was discharged to go home to 
 her husband, it being noted that she had settled down 
 into chronic weak-mindedness of general paralysis, but 
 that she was able to do her household work. She re- 
 mained at home till January, 1875, when she was 
 readmitted with the history that, three months before 
 there had been a marked exaggeration of her symp- 
 toms, her memory becoming worse, and her extrava- 
 gance reappearing. Her memory was extremely 
 defective, both for recent and past events, so that she 
 would get up in the night, with the idea that it was 
 morning, to prepare her husband's breakfast. She was 
 destructive, tearing up her clothes ; was markedly 
 tremulous in her speech ; her walk was unstable ; she 
 was unable to thread a needle or to direct any precise 
 movement. The right pupil was the smaller ; eccen- 
 tric, and reacting but slightly. Up to a period of 
 three months before her readmission she had been 
 
304 Insanity and Allied Neuroses. [Chap. xii. 
 
 excessively amorous, but of late all desire ceased. Tlie 
 appetite was good, and she slept well. From the time 
 of her admission to the time of her death, in February, 
 1876, she steadily lost ground, bodily and mentally, 
 dying in the end with bed-sores and pneumonia, the 
 bodily temperature being 105^. Post-mortem : dura 
 mater adherent, arachnoid free, with large excess of 
 fluid ; convolutions much wasted, especially on left side 
 posteriorly, and about fissure of Rolando a few adhe- 
 sions were scattered \ brain was tough on section ; no 
 excess of fluid in ventricles ; cord wasted; lungs small, 
 fibroid ; kidneys wasted, with adherent capsules. 
 
 General 'paralysis with a 2^eriocl of complete re- 
 'mission ; death frora hcemorrhage into spine. — In the 
 next case, an attack of maniacal excitement caused 
 the admission of the patient into Bethlem two 
 years before he was finally admitted, sufiering from 
 rather advanced general paralysis, from which he died. 
 Henry J. C, single, age 29, has one sister insane. 
 Supposed cause of present attack unknown ; has been 
 a commercial traveller, has drank a good deal, and 
 worked very hard. His first symptoms appeared in 
 August, 1873, when he began to mope, and felt un- 
 able to do his work. He ate well, but slept badly. 
 After the period of depression he became emotional 
 and excitable, irritable and threatening. He also be- 
 came extravagant and generous ; his sleep became 
 profound ; he is said to have indulged sexually to a 
 great extent ; he believed himself to be Christ. On 
 admission he was very maniacal, dirty, destructive, and 
 dangerous. Bromide of potassium and cannabis in- 
 dica were given with little eff'ect. Morphia also 
 failed to keep him quiet. An abscess formed in one 
 leg, from which grumons unhealthy-looking pus was 
 discharged, and it was with difliculty this was healed. 
 Various narcotics and sedatives were tried, but seemed 
 to have little or no effect till the period of excitement 
 
Chap. XII.] Paralysis with Remission. 305 
 
 passed off of its own accord, after a severe attack of 
 purging and vomiting. In July, 1874, he was reported 
 as convalescing. In September, 1874, he was sent on 
 leave; the leave was extended till November, when 
 he was discharged ; but I had my doubts about his 
 recovery being complete, as he could not recognise 
 the fact that he had been excessively violent and 
 dangerous. He was readmitted in September, 1876, 
 with a history that he had been energetically at 
 work for a year, but that suddenly he had become ex- 
 travagant, restless, and possessed by ideas of grandeur. 
 On admission it was noticed that his speech was greatly 
 affected, and there was no longer any doubt as to the 
 nature of his disorder. He talked freely of his mil- 
 lions, was grand, benevolent, and demonstrative, and 
 with strongly marked erotic tendencies. A t the begin 
 ning of the year 1877 he lost strength and flesh, but no 
 physical disease could be detected. Early in February 
 of the same year he wet his bed, and had an epileptic 
 fit, marked by half-opened eyelids, twitchiug of the 
 eyelids and lip muscles, inversion of right thumb, 
 clonic convulsion of hands and feet, pupils minute, 
 right the larger, temperature 98^. In the evening of 
 the same day the fits returned, affecting both extre- 
 mities, breathing rapid, skin sweating, temperature 
 108'5°. The patient then died. Post-mortem : brain 
 was found to be of full size, 49-| oz., with no special 
 changes beyond excess of subarachnoid fluid ; vessels 
 at the base atheromatous ; other viscera fairly healthy 
 with exception of the cord. On opening the spinal 
 column blood of a dark colour escaped from the 
 meninges. On tracing this upward it was found con- 
 nected with a large clot surrounding the cervical 
 region, so that the high temperature and the sudden 
 termination of the case depended upon a rupture of 
 an atheromatous artery into the dura mater of cord. 
 Case of a young siiiyle yirL — The following is a 
 TJ— 14 
 
300 Insanity and Allied Neuroses. [Chap. xii. 
 
 young case, in some respects similar to the last, being 
 single, and belonging to a nervous family, and being 
 much below the average age. E. W., single, set. 24, an 
 actress, mother given to drink, and other relations 
 exhibited in minor ways neurotic tendencies. This 
 Avas the first attack, supposed to be due to love dis- 
 appointment, the truth being she had been seduced 
 and abandoned. The first symptoms commenced seven 
 months before admission ; change of temper was noticed, 
 she became tremulous and jerky in movement, and 
 fancied that her sister treated her badly ; she was 
 sleepless. On admission she was restless and excited ; 
 she said she had seen Christ appear to her, and that 
 he had given her a new skin. She spent her money 
 recklessly, and she claimed high connections. The 
 pupils were unequal, the left being the larger of the 
 two, tongue tremulous, speech hesitating, very emo- 
 tional, and with varying forms of exaltation, so that 
 at one time she would claim twenty husbands, and at 
 another would say she possessed boundless wealth, 
 especially in jewels and dress. Her bodily health 
 improved, and for a time she was amiable and quiet, 
 but the bodily weakness and tremor were marked. 
 The temperature during this time varied from 98"6° to 
 99*6°, and I may say that the night temperature was 
 generally maintained during January, 1881, at 100'2°. 
 It was seen that her highest acquirements became 
 most affected, so that, though she believed she could 
 still dance and recite, her attempts were feeble in the 
 extreme. 
 
 During February, 1881, she is reported to have 
 been at times depressed, and complained of head- 
 ache. She pulled out her hair and rubbed holes in 
 her forehead ; the tremor of hands was more marked, 
 patella reflex much increased ; the urine neither con- 
 tained albumen nor sugar. During the autumn of the 
 same year she had improved sufficiently to be allowed 
 
Chap. XII.] Paralysis with Remission. 307 
 
 to go to the theatre with a sister ; she recognised 
 several people whom she met there, and spoke 
 connectedly about the past. In November her eyes 
 were carefully examined and reported to be normal, 
 with the exception of haziness of the lenses. During 
 the first few months of 1882 she remained in much 
 the same condition, although her mind seemed to be 
 slowly getting w^eaker. In May, 1882, the catamenia 
 reappeared for the first time for two years without the 
 slightest mental change. During the rest of the year 
 she lost in weight and became quite unable to stand, 
 attempts made by herself resulting in falls and bruises. 
 In the summer of 1883 she began to grind her teeth 
 constantly, and gradually loosened nearly the whole 
 set. Further physical weakness developed, and by 
 August she was bed-ridden, unable to swallow solid 
 food, legs contracted, with slight twitchings of muscles. 
 There were no marked convulsive fits, but during the 
 course of the disease there had been several attacks of 
 loss of consciousness representing the same condition. 
 She sank slowly and died. Post-mortem : the brain 
 weighed 36| oz. ; great excess of subarachnoid fluid 
 and of fluid in the ventricles ; much wasting generally 
 of the convolutions ; brain substance soft, and almost 
 universal adhesions of membranes to cortex; both 
 kidneys in a condition of extreme cystic degeneration, 
 with very little secreting structure left ; the rest of the 
 viscera were sufficiently healthy. 
 
 In this case a single woman of twenty-four years 
 of age developed general paralysis, which was some- 
 what long in its course, but presented the various 
 mental and bodily symptoms met with in the disease ; 
 and although sexual excess may at some time have 
 been indulged in, it certainly had not been for some 
 time before admission, and the lapse from virtue had 
 been of short duration. One other point was the 
 recurrence of menstruation after an absence of two 
 
3o8 Insanity and Allied Neuroses. [Chap. xii. 
 
 years. I have met with two or three female cases 
 of general paralysis in which the menstruation has 
 been maintained throughout ; but in this case I was 
 surprised to find a re-establishment without any 
 special physical change or mental improvement. 
 
 Case of general 'paralysis in a young single woman., 
 with acute course. — This case is that of a single woman, 
 set. 27, machinist, maternal uncle insane, sister died 
 of phthisis; first attack of insanity, supposed cause 
 being the removal of a tumour under chloroform 
 seven or eight weeks before admission. Several 
 slight epileptiform fits came on, and were followed by 
 great hesitation in speech, loss of memory, senseless 
 laughter, and loss of power of lower extremities. On 
 admission, in 1883, she was reported to be suffering from 
 an ichthyotic condition of skin, her tongue and lips 
 were tremulous, marked hesitation in speech, the re- 
 flexes were normal. She had hallucinations of hearing, 
 and was emotional. Although there was no marked 
 exaltation, yet she would always say, however feeble 
 she might be in gait, that she was " all right." Later, 
 she was constantly yawning, the reflexes became 
 exaggerated, the right pupil the larger ; she became 
 restless, dirty, and destructive, so that she had to be 
 sent into another ward. By the end of January, 1884, 
 she was bed-ridden, and rapidly sank, after diarrhoea 
 came on. Thus her case was acute and typical, 
 although occurring in a single young woman. 
 
 General paralysis in a woman, following worry. 
 — M. M., single, set. 53, schoolmistress, admitted 
 July, 1879, no insane relations; first attack of insanity, 
 said to be due to over- work and anxiety ; and it is 
 certain that she had had a very great deal of worry 
 and pecuniary trouble for a year or more before she 
 broke down. She was said to have had convulsions 
 before the change in her disjiosition took place, there 
 being doubt as to whether they were epileptic. On 
 
Chap. XII.] Paralysis following Worry. 309 
 
 admission she had many delusions ; she thought she 
 was being poisoned, and that she and those about her 
 were dead ; she was obstinate about her food, and was 
 negligent of personal cleanliness ; she had halluci- 
 nations of sight and hearing by day and night ; she 
 feared debt, and said she would sooner die than owe. 
 Within one week of her admission she was served 
 with a writ, and this caused a great deal of mental 
 disturbance ; she remained excited for some days, and 
 had to be put in a padded room. In August she is 
 reported to have been feeble in memory, the halluci- 
 nations of hearing being very marked, the patient 
 alleging that she had heard conversations between the 
 doctors and her enemies. At the end of August she 
 had a fit, in which both sides were convulsed, but there 
 was no coma nor paralysis ; she remained for a time 
 dazed, but on the fourth day became maniacal and 
 violent, and continued so nearly a week. After the 
 excitement there were signs of physical weakness, and 
 her mind and memory were very feeble, so that she 
 had to remain in bed. In the middle of October she 
 had another fit, being excited after it, the excitement 
 being followed by right hemiplegia, speech and memory 
 being very defective. In December and January she 
 had other fits at irregular intervals, the peculiarity of 
 these fits being, that after a short, sharp set of con- 
 vulsions the patient was quiet for an hour or two, 
 then became maniacal ; during this period she showed 
 few signs of paralysis of the right side, although her 
 speech was still thick. After a few days of excite- 
 ment she became quiet and remained in her bed, 
 suffering from right hemiplegia. There was no 
 material change till the 28th of March, when she was 
 more sensible than usual, recognised the doctor, and 
 said it was " blessed Easter- tide." After dinner she was 
 seized with convulsions of the left arm and leg, head 
 drawn to left shoulder ; the fits were clonic, lasting 
 
3 TO Insanity and Allied Neuroses. [Cimp. xii. 
 
 from a few seconds to several minutes. The eye-balJs 
 turned first to the right and then to the left ; no 
 increase of temperature at first, although the next 
 day the left half of the body was two degrees in 
 excess of the right. Post-mortem : adhesions of mem- 
 branes, especially in first and second frontals, ascend- 
 ing frontal, and parietal, left side ; in right, adhesion 
 first frontal and ascending frontal ; brain 46 oz. ; heart 
 \?>\ oz. ; kidneys small, wasted. 
 
 General imrahjsis in a woman. Pacliymenin- 
 gitis. — A. B., married, set. fifty ; one sister died of 
 puerperal insanity, another of delirium tremens. This 
 patient had had no previous attack of insanity, 
 and the present cause is supposed to have been 
 anxiety about her husband's business matters, two 
 years previously. This illness began with sleepless- 
 ness and depression six months before admission ; 
 she then became weak-minded and forgetful, at times 
 talked incessantly, at other times was restless and 
 irritable, talking in the wildest way of her being 
 connected with the Koyal Family. On admission, 
 July 31, 1883, she refused food and had to be fed 
 with a stomach pump ; she constantly pulled ofi" her 
 clothes ; her speech was thick, tongue and lips tremu- 
 lous, right pupil the larger, patella reflex well marked, 
 considerable exaltation of ideas, especially about 
 money ; she became very feeble on her legs, her arti- 
 culation became worse, and memory for present things 
 defective. On the 24th of October of the same year 
 she had a series of convulsive fits, from which she 
 rallied a little ; but her breathing becoming implicated, 
 she sank and died on the 3rd of November. In this 
 case, post mortem, was found great wasting of some 
 convolutions, especially about the junction of parietal 
 with occipital regions on both sides ; there was also 
 pachymeningitis on the left side, with general wasting 
 of both frontal regions. The rest of the body was 
 
Chap. XII.] Pachymeningitis. 311 
 
 not examined. In this case, thongli tlie woman's -age 
 was onlj'" fifty, her appearance was that of at least 
 sixty ; the symptoms were very characteristic, there 
 being progressive weak-mindedness, exaltation of ideas, 
 restless destructiveness, associated with lingual and 
 labial tremor, loss of power, convulsions, and death. 
 
 General paralysis in an old man. Pacliynienin- 
 gitis. — S. B., set. sixty-one, but with an aspect of a 
 man of seventy, married, an artist, no insane rela- 
 tions ; no previous attack of insanity, the present 
 one dating back six months, supposed to be due 
 to pecuniary losses, showing itself with forgetfulness 
 of small things ; he became incoherent and childish, 
 losing himself in his own house, mistaking his rela- 
 tions, and neglecting the decencies of society, rest- 
 less, fidgety, rubbing his head with his hands. On 
 admission, November 22nd, 1883, there was great 
 tremulousness of lips and tongue, with hesitation of 
 speech. After admission he became more restless and 
 interfering, and at the same time he lost mental 
 power. A month after admission he had a series of 
 convulsive seizures, from which he again recovered, 
 but he was left distinctly weaker in mind after the 
 convulsions. At the end of January he had a further 
 series of fits, from which again he recovered. Mental 
 and physical weakness increased, and he died, pachy- 
 meningitis being found post mortem. 
 
 The above case is a good example of the difficulty 
 which may arise in distinguishing between senile 
 weak-mindedness and genera,l paralysis of the insane, 
 and the diagnosis can scarcely be considered complete 
 till the post-mortem examination. My opinion that 
 it was general paralysis was founded upon the pro- 
 gressive weak-mindedness, restlessness, tremulousness 
 of tongue with hesitation of speech, together with 
 the recurring convulsive seizures which left no per- 
 manent paralysis. 
 
312 Insanity and Allied Neuroses. [Chap. xii. 
 
 Oeneral paralysis with simple prog^res- 
 sive dementia. — As I have said, the natural mental 
 termination of general paralysis is weak-mindedness, 
 but in some cases this is developed without any inter- 
 mediate stages of excitement or depression. This 
 may follow in cases beginning with convulsions, or it 
 may occur in cases such as that about to be described, 
 without any definite explanation. The weak-minded- 
 ness may show itself as simple loss of memory, as 
 loss of power to accommodate one's self to one's 
 surroundings, or as a childish emotionaj condition, 
 or as one of boyish frolicksomeness, or as cowardice. 
 
 The following case of general paralysis with 
 simple progressive dementia is a fair example. E. 
 M., married, set. 46, merchant; no insane relations, 
 mother died paralysed, one brother died of apoplexy. 
 This was the first attack, the cause being great 
 money losses and anxiety about his family. He 
 had always been temperate and hard-working. He 
 had, as his first sign of mental degeneration, a 
 convulsive seizure two and half years before he 
 was considered insane. His present illness began 
 with incoherence and confusion of thought and speech ; 
 he was unable to enter into any rational conversation, 
 and had a vacant expression of face. On admission, 
 September, 1880, he was stout and expressionless, 
 with feeble power of reaction and negligent of his 
 personal appearance. His optic discs were found to 
 be in a state of grey atrophy. The reflexes were 
 exaggerated, and nearly all the muscles, both of face 
 and limbs, were found to be unduly irritable to the 
 electric current. Bodily this patient improved, so 
 that he became more than one stone heavier in seven 
 months, but mentally he grew weaker; the right pupil 
 was larger than the left, and reacted to accommoda- 
 tion, but not to light. There was great tremor of 
 facial muscles and hesitation in speech. This patient 
 
Chap. XII.] Paralysis with Melancholia. 313 
 
 exhibited a mental peculiarity which is not uncom- 
 monly seen in general paralytics, so that there was 
 a temporary and limited re-establishment of the 
 intellect; and although he got progressively weaker 
 in mind, he occasionally brightened np and re- 
 cognised his friends and relations, and could even 
 understand his position as a patient in an asylum. 
 Such periods of remission are not uncommonly fol- 
 lowed by convulsions or exaggeration of mental weak- 
 ness. By February, 1883, the patient became greatly 
 emaciated, and there was contraction of his neck and 
 lower extremities. He spent most of his time in an 
 unconscious state. At the end of February he had a 
 severe series of epileptiform fits, and died. Post-mor- 
 tem : the brain weighed 44 oz. ; great excess of fluid 
 in membranes and in ventricles ; adhesions of mem- 
 branes to cortex ; on both frontal convolutions and on 
 the right frontal lobe there was considerable wasting ; 
 the arteries at base atheromatous ; the aorta extremely 
 atheromatous ; both kidneys peeled badly, the rest of 
 the viscera were normal, except that the lungs were 
 oedematous. 
 
 Oeneral paralysis witti melaiicliolic 
 syifiiptoms. — A great deal has recently been written, 
 more especially by Yoisin, on the subject of general 
 paralysis with hypochondriacal and melancholic symp- 
 toms, and I think he deserves credit for pointing out 
 the number of patients who die from this variety of 
 the disease, and who have never shown any of the more 
 usual symptoms accompanying it. I find that the gene- 
 ral practitioner looks upon exaltation of ideas and the 
 inequality of pupils as the two pathognomonic signs 
 of general paralysis ; but asylum physicians must all 
 have been struck with the cases which are admitted 
 into an asylum obstinately refusing food, losing flesh, 
 and causing anxiety from their feebleness, and in 
 the end dying. Some such cases, with care and by 
 
314 Insanity and Allied Neuroses. [Chap. xii. 
 
 means of artificial feeding, rapidly improve, and the 
 physician looks for recovery ; but, instead of that, the 
 patient, becoming fat, also becomes weak-minded. It 
 is then, perhaps, noticed that there is inequality of 
 pupils, tottering gait, and marked loss of expression. 
 There has been difficulty from the very onset to 
 get the patient to put his tongue out or to speak, 
 hence the condition of tremor has not been noticed. 
 In such an instance, if fits occur, the case is cleared up ; 
 but if not, it must be looked upon as one of dementia 
 consecutive to melancholia. In all these cases deatli 
 results, and both doctor and friends are astonished at 
 the fatal result. Some cases do not recover at all, 
 but pass from melancholy to extreme physical weak- 
 ness, or death, the whole period of the process being 
 but a few months. 
 
 In looking over the records of the deaths of 
 patients in Bethlem, I meet with many that, I am 
 now sure, belonged to the class of melancholia with 
 general paralysis which were not then recognised as 
 such, although I used to point out that a certain 
 number of melancholic patients always died, and 
 without w^hat appeared to be sufficient pathological 
 cause. The subjoined case is a typical one of the 
 kind. John C, admitted January, 1874, married, 
 set. 47, merchant, no insane relations ; first attack of 
 insanity, which had lasted six weeks, caused by loss 
 of money and anxiety, and began with the loss of 
 identity. He refused to take food because he believed 
 he could not afford it, and also because he thought 
 people were trying to poison him. After admission 
 he was reported as silent and obstinate, refusing his 
 food, negligent of his person, and sleepless. He had 
 to be fed artificially. There was a history of a con- 
 vulsive seizure during the early part of his illness. 
 He slowly lost strength, but remained perverse and 
 melancholv. I was unable to discover anv cause for 
 
Chap. XTI.] jP^^yiZF^/5 WITH TONGUE TrEMOR. 315 
 
 his physical deterioration, and for the difficulty in 
 breathing which came on. He sank and died in 
 March the same year. Post-mortem : brain fifty 
 ounces ; dura mater adherent ; somewhat thickened 
 arachnoid with many opaque patches ; subarachnoid 
 fluid in great excess ; considerable wasting of con- 
 volutions, the right frontal lobes being most reduced ; 
 vessels at base atheromatous ; brain matter fairly 
 firm ; and only other changes found in the lungs were 
 due to pneumonia. Other similar cases have occurred 
 in which convulsions reappeared, or in which other 
 bodily symptoms had made themselves manifest. 
 
 General paralysis \^itli little toitgue 
 tremor. — In the opinion of one or two of the oldest 
 physicians in our specialite, tremulousness of tongue 
 with hesitation in speech are the invariable symptoms 
 of the general paralysis ; but I would at once give as 
 my opinion that, although this is generally true, it is 
 but an example of the more general principle that the 
 most highly developed faculties suffer soonest. Speech, 
 with all the delicate control of the tongue, is one of the 
 last human acquirements, and in any condition of pro- 
 gressive mental degeneration will suffer as a rule ; 
 but there will be exceptions, which at present are not 
 to be explained ; and I am quite used to meet jDatients 
 suffering undoubtedly from general paralysis, yet with 
 little or no tremor or hesitation. The following is a 
 very good example. 
 
 Thomas A., married, set. 43, ironmonger, paternal 
 grandfather and maternal cousin insane, phthisis pre- 
 sent on the paternal side. His first attack of insanity, 
 which had lasted three months, could not be attributed 
 to any definite cause. It began by great irritability 
 and extravagance, with sleeplessness, and ideas that 
 he was possessed of immense wealth and power ; 
 that he had received revelations from God, and that 
 he was married to most of the duchesses in England. 
 
3t6 Insanity and Allied Neuroses. [Chap. xii. 
 
 Both pupils were contracted, but reacted to light and 
 accommodation ; tongue clean, moist, and very slightly, 
 if at all, tremulous; his walk was ataxic; the reflexes 
 normal ; his hand-writing shaky and. abbreviated ; but 
 his speech as clear as possible ; and his facial muscles 
 without loss of expression. This case has now been 
 five months under observation ; I am convinced that 
 the patient is suffering from general paralysis, and 
 yet there is no marked change in expression of face, 
 nor is there hesitation in speech. 
 
 ISpiual g'eueral paralysis.— There is a group 
 of cases in which either the paralytic symptoms 
 precede the mental symptoms, or in which they are 
 very much more pronounced. In cases already re- 
 ported it will have been remarked that most of 
 those which terminated fatally exhibited paralysis 
 of the lower extremities more or less ; and I be- 
 lieve the process of degeneration is one affecting 
 the whole nervous tissues, and, therefore, sure 
 to implicate the spinal cord, if the disease lasts 
 long enough. A question, which at present I am not 
 in a position to discuss, has been referred to recently 
 by Dr. Mickle, for since Terrier has elaborated his 
 ideas on the localisation of function in the cortex of 
 the brain, observers of general paralysis of the insane 
 have sought to localise degenerations, representing the 
 special lines of weakness met with in these cases. It 
 would be of some importance to be able to say of the 
 patient with general paralysis associated with tabes, 
 that degeneration would be found in such and such a 
 part of the motor area ; or that, if the case be one with 
 changes in the lateral columns, another part of the 
 cortex would be affected. That this will be demon- 
 strated sooner or later I feel sure. The following 
 cases are examples, jirst of general paralysis asso- 
 ciated with ataxic symptoms ; the second, of those in 
 whom the symptoms pointed to a change in the lateral 
 
Chap. XII.] Ataxy PRECEDING Paralysis. 317 
 
 columns, which post-mortem examination confirmed. 
 The first group may again be divided into those in 
 which ataxy preceded, and those in which it developed 
 with or after the general paralysis. 
 
 The following case is an example of ataxy 'pre- 
 ceding general paralysis^ which exemplifies very well 
 the progressive nature of the degeneration \ the 
 patient not only had typical ataxy, but became both 
 blind and deaf, and showed symptoms of bulbar 
 paralysis. R. M., married, aet. 47, merchant, no 
 insane relations, mother died asthmatic, no known 
 cause for the illness. The first symptoms showed 
 themselves at the end of 1877, when he refused to see 
 people, and threatened to drown himself. He had 
 increasing difificulty in expressing his ideas, became 
 altered in manner, his memory failed, and even then 
 had a habit of letting his saliva run from his mouth. 
 Before admission he became reckless in business, and 
 emotional, especially at night, when he would bellow 
 for hours together. On admission he thought every 
 one was against him, he refused food, had exaltation 
 of ideas, thickness of speech, and. ataxic walk, 
 which had been present some year or more; there 
 was some nystagmus. Two months after admission 
 he was reported to be more shaky on his legs, and 
 optic discs to be partly atrophied; later he had a slight 
 attack of faintness followed by slight loss of power in 
 left thigh; patella reflex was absent. At the end of 
 1878 both discs were described as markedly atrophic, 
 and deafness was also noted. Although feeble, he 
 was restless, constantly trying to move rapidly about. 
 In •November he had a fit, and from that time lost 
 power rapidly. After the fit he was reported to be 
 unconscious, the tongue dry and brown, pulse 74, 
 axillary temperature 98°, surface temperature of fore- 
 head, right side, 93-8°, left, 94-6°; there was twitching 
 of the right side, inability to swallow, left pupil larger 
 
3i8 Insanity and Allied Neuroses. [Chap, xii. 
 
 both pupils being insensible to light. The patient 
 died, the brain exhibiting wasting with some adhesions, 
 the cord showing evidences of changes in the posterior 
 columns. 
 
 In the next case symptoms of rapid general para- 
 lysis and ataxy have developed together. Thomas 
 J. B., married, set. 51, clerk, no insane relations ; 
 first attack of insanity, supposed to depend on intem- 
 perance, although he has been temperate for the last 
 two years. A slight attack of depression, lasting one 
 week, occurred two years ago, at the time when he 
 became teetotal. He has had two severe falls, but 
 there are no signs of local head injury. The first 
 symptoms of this attack occurred three weeks before 
 his admission, on September 21st, 1883, when he 
 became strange in manner, unable to attend to his 
 business, sleepless, with exaltation of ideas, believing 
 himself to be a very great man, able to compose 
 poetry, and paint pictures at least fit for the Academy. 
 He said his father was the son of a nobleman. 
 He was restless, boastful, and encroaching, con- 
 stantly moving rapidly about, and willing to race or 
 fight with any of the patients; pupils small, but 
 equal ; memory for recent events bad ; walk unsteady, 
 legs being thrown away from the body and falling on 
 the heels ; patella reflexes absent ; says he does not 
 feel the ground ; on closing his eyes he reeled and fell 
 at once. There was but little tremor about the lips, 
 and slight irregularity or hesitation in speech. He 
 continued happy and contented with his powers, 
 making many pictures and filling reams of paper. On 
 September 28th it was reported that there was diver- 
 gence of eyes and consequent diplopia, on account of 
 which he kept right eyelid down. There was marked 
 cerebral giddiness when left eye was closed, no evi- 
 dent changes visible in his discs. Since September 
 both bodily and mental weakness steadily progressed, 
 
Chap. XI 1.1 Lateral Sclerosis of Cord. 319 
 
 and the case is now a marked one of general paralysis 
 in an advancing stage, witli ataxic symptoms. So far 
 I have never met with a female case of general para- 
 lysis in which ataxy was marked ; the same rule 
 seeming to hold with this as with ordinary ataxy, 
 that women rarely if ever suffer. 
 
 L<atera1 sclerosis of cord livltb g^eneral 
 paralysis. — The next class of cases is one in which 
 I have taken very special interest, the symptoms in 
 many particulars grouping themselves regularly, so 
 that I am hopeful at all events that this variety of 
 general paralysis will prove to be not a mere formal 
 division, but a natural class. The first important 
 peculiarities which I have encountered are that it 
 frequently occurs in women as well as in men ; that 
 it occurs in the single as well as in the married ; and 
 in patients much younger than the average age for 
 general paralysis. In a certain number of the cases I 
 have met there has been an undoubted history of 
 syphilis. On the bodily side the walk is peculiar and 
 spasmodic, giving one the idea that no sooner has the 
 foot touched the ground than a reflex is immediately 
 started, causing the foot to jump suddenly up ; the re- 
 flexes are exaggerated, clonus being at times present ; 
 optic disc changes may also occur. A'^ery frequently 
 capillary stigmata are present over the malar bones, 
 and develop for a time as the disease jDrogresses. 
 
 Male case of general 'paralysis., with lateral scle- 
 rosis, and fatal termination. — Francis R., single, 
 pet. 30, medical student, no history of insanity ; first 
 attack of six months' duration, said to have followed 
 excesses, and a former attack of syphilis. The 
 first symptoms were change in disposition, oddness 
 in behaviour, and absence of mind. He had always 
 been vain about his appearance and his powers, 
 and this had developed into extreme exaltation, so 
 that he looked upon himself as a perfect paragon, 
 
320 Insanity and Allied Neuroses. [Chap. xii. 
 
 notwithstanding the fact that he had failed to pass 
 even his preliminary examination. On admission, 
 September, 1881, he was a man of medium height, 
 squarely built, fair complexion, with bright malar 
 capillary congestion. His walk, although constant, 
 was of the jerky kind I have described, the patella 
 reflexes exaggerated, the pupils unequal, the right 
 being the larger, both reacting to accommodation, but 
 slightly only to light. For twelve months he slowly 
 developed weak-mindedness, great hesitation in 
 speech, the facial and lingual tremors being extreme, 
 and his whole appearance being one of great 
 nervous irritability, the very approach of any one 
 causing him to give a general start. He lost control 
 over his bladder and rectum, and slowly became 
 indifferent to his surroundings, neither reading nor 
 associating. By October, 1882, he was quite unable 
 to walk alone, and could not articulate a single word, 
 was very wet and dirty, and the lower extremities 
 were becoming contracted. From this time he lost 
 ground steadily, and died in March, 1883. Post- 
 inortem : excess of subarachnoid fluid, with opacities 
 of that membrane ; the membranes peeled readily, but 
 left both frontals rough, especially the left ; ventricles 
 large, containing excess of fluid ; brain weighed forty- 
 four ounces ; cord wasted, with very well-marked de- 
 generation in the lateral columns. 
 
 Female case^ vjith lateral sclerosis of general para- 
 lysis, and fatal terjnination. — Edith C, married, 
 set. 35, printer's wife, no history of insanity in the 
 family ; first attack of six weeks' duration. This 
 patient, although married, had no children, and in 
 this particular resembles several other cases I have 
 met with, in whom the symptoms of general para- 
 lysis have been associated with childless marriage. 
 She was admitted in March, 1883, the first symp- 
 toms having been false accusations against her 
 
Chap. XII.] Lateral Sclerosis. 321 
 
 husband. She then became incoherent and restless, 
 wandering about in her night-dress, saying her 
 husband wanted to poison her. She was excitable, 
 and had exalted ideas about riches ; thought there 
 was some chloroform in her husband's brain, that he 
 was mad, and that she was a duchess. On admis- 
 sion she had hallucinations of taste ; the pupils were 
 extremely small but equal, and this is noteworthy. In 
 these cases the pupils are frequently pin-points, and 
 equal, reacting but very slightly. She slept badly, her 
 walk was shaky and unsteady, and reflexes were greatly 
 exaggerated. The ophthalmoscopic examination did 
 not show any changes. After admission she steadily 
 got more feeble in gait, more tremulous in speech, 
 with difficulty of swallowing, and loss of power over 
 bladder and rectum. In May of the same year she 
 had an epileptiform attack with general convulsions, 
 but the symptoms were most marked on the right 
 side. From this time she lost power and sank. 
 Post-mortem : great general wasting of convolutions, 
 especially of the ascending frontal, right side ; adhesions 
 of membranes of first right frontal ; great dilatation 
 of lateral ventricles ; brain weighed forty -four ounces \ 
 cord wasted, with marked changes in the lateral 
 columns ; other viscera healthy, except atheromatous 
 condition of arch of aorta. This last case is one of 
 about ten that I have now met with, in which the 
 ordinary mental symptoms of general paralysis, with 
 exaggeration of reflexes and exaltation of ideas, have 
 occurred in married women of middle age ; and I hope 
 to collect my observations on these cases in a future 
 number of the Guy's Hospital Heports. 
 
 Cases ipith remissions. — In many cases of general 
 paralysis, which have begun with the wildest maniacal 
 excitement, this passes ofl", to be replaced by a period 
 of arrest or even remission of the symptoms ; and it is 
 important to remember that the remission may appear 
 v— 14 
 
322 Insanity and Allied Neuroses. [Chap. xii. 
 
 to be so complete that patients are discharged recovered, 
 only to be readmitted in a much more advanced stage of 
 the disease. The remissions may be of variable length, 
 rarely lasting more than twelve months. They occur 
 more frequently in those cases in which the symptoms 
 have been acutely maniacal ; they very rarely occur 
 more than once in any single case. I can only re- 
 member one patient in whom there was more than one 
 distinct remission. These remissions are rarely com- 
 plete, one or other of the bodily or mental symptoms per- 
 sisting ; and I should say from my experience, that 
 the tremor of lips and tongue, if once established, rarely, 
 if ever, passes ofif ; pupil irregularity may pass off, as 
 well as changes in the reflexes or exaltation of ideas. 
 The only case in which cure of general paralysis seemed 
 to me to have occurred was that of McC; but I regret 
 to say that recently I have evidence that he is again 
 suffering from some obscure nervous disease, there- 
 fore I can scarcely claim him as an undoubted cure. 
 
 The following is his case : D. McC, married, 
 set. 50, railway agent, no insane inheritance ; the 
 first attack of insanity requiring seclusion, although 
 he had been peculiar four years before ; cause said to 
 have been over-work ; was sober and industrious, all 
 ideas of syphilis being repudiated. The first symp- 
 toms were those of excitement, with incoherent 
 rambling conversation, exaltation of ideas both as to 
 wealth and station; was benevolent with his exaltation, 
 offering to benefit all his friends with thousands of 
 pounds. He believed that he had a secret which was 
 for the benefit of the human race. On admission, 
 October, 1879, he talked incessantly, with the wildest 
 exaltation ; was sleepless, haggard, worn,, and rest- 
 less, being unable to stand still for a minute. He 
 was treated with hyoscyamine for a time without any 
 benefit. He was incoherent, and his left pupil was 
 very much larger than his right. He informed me that 
 
Chap. XII.] Paralysis with Remission. 323 
 
 a London oculist had told him it was due to syphilis : 
 but he indignantly denied ever having that disease. 
 His speech was hesitating, and he got worse, although 
 his general health improved ; he took several hours to 
 finish a short letter. In December of the same year an 
 inquisition was held, at which well-known physicians 
 gave evidence to the effect that he was suffering from 
 general paralysis, and not likely to recover. He was 
 wet and dirty at times, and his memory became 
 progressively weaker. On January 20, 1880, a car- 
 buncle on the back of his neck began to form, and. 
 rapidly spreading, caused an enormous swelling, fol- 
 lowed by sloughing, which extended from the nape of 
 the neck to both shoulder-blades. No sugar in the 
 urine was discovered. From the time of tlie appearance 
 of this carbuncle his mental symptoms improved, and 
 by the 20th of March he was much improved men- 
 tally and bodily. He was sent to Witley, and after 
 that he was on leave till the end of May, when he was 
 discharged well. Some months later, after repeated 
 applications, a supersedeas was granted by the Court 
 of Chancery, and once more he was allowed to manage 
 his affairs, and till recently was considered by his 
 friends of sound mind and body. Since then I have 
 heard that he is under treatment with anomalous 
 paralytic symptoms, but without mental disorder, 
 the opinion of his physician being that he is suffering 
 from some syphilitic nerve lesion. As the above 
 case has for four years been at large, and has been 
 able to establish his sanity, after at least five experts 
 of distinction had considered him as a general para- 
 lytic, it is suflQciently noteworthy. 
 
 General jyaralysis with remission. — Henry W., 
 married, set. 37, silver chaser, admitted February 
 9th, 1881, no insane relations; the first attack due to 
 business anxieties, and the first symptoms showed 
 themselves two months before admission, when he 
 
324 Insanity and Allied Neuroses. [Chap. xii. 
 
 bought a plot of land without being able to pay for it. 
 He talked about travelling, and taking a hundred of 
 his friends with him ; he was going to build a large 
 house, become a member of Parliament, and was full 
 of extravagance and joyousness. On admission he 
 was a tall, spare man, sleeping, eating, and digesting 
 well, pupils contracted. These conditions were asso- 
 ciated with tremor and hesitation of speech, and change 
 in hand-writing, while restlessness was one of the most 
 marked symptoms. This attack passed away, and in 
 April of the same year he was sent down to our con- 
 valescent home, and then for a month's leave of absence 
 to his own home. At the end of his leave he was so 
 much recovered that he was discharged, his friends 
 being warned that it was only a remission, and that 
 the symptoms would probably soon start afresh, and 
 then would be fatal. 
 
 On the 18th of October, the same year, he was 
 brought back to Bethlem, his friends saying he had 
 slept well till ten days before admission, when once 
 more he became extravagant, and possessed of false 
 ideas of the value of money. He collected rubbish, 
 thinking it was gold, talked with much hesitation 
 of speech about millions, and of the hippopotami 
 he was going to stock his farm with. It was now 
 noticed that his expression was dull, that there was 
 great tremor of lips and tongue, the pupils small and 
 equal, skin greasy, speech clipped and hesitating, 
 memory bad ; he was very restless and mischievous, 
 tearing up books or clothes. At this time there was 
 no change in his optic discs. In bodily health he 
 improved, getting quite fat and healthy-looking, in 
 which condition, with progressive loss of memory, he 
 remained till August, 1882, when he had a fit, the 
 temperature not being raised, and there being but slight 
 convulsions associated with the unconsciousness. 
 From time to time he had other nts^ which were always 
 
Chap. XII.] Double Form of Paralysis. 325 
 
 of the following nature : without warning of any 
 kind he fell forward on to the floor, and with slight 
 twitching of all his limbs lay there unconscious for 
 from ten minutes to an hour, passing his urine and 
 faeces under him. His recovery was like that of 
 one waking from sleep; and although each fit left him 
 mentally weaker, the change was only small. In 
 February, 1883, his vision was noticed to be weak, the 
 pupils still contracted, but not circular ; left optic 
 disc pale, sharply defined ; right optic disc very 
 white, edges very sharply defined ; knee-jerk well 
 marked. He always replied that he was "very well," 
 if spoken too. The fits recurred ; but it was strange 
 that even during the last month of his life, on several 
 occasions he so far collected himself as to be able to 
 speak not only consistently, but accurately, about 
 things which had happened in the hospital two years 
 before ; this is only another example of the extraor- 
 dinary way in which general paralytics will temporarily 
 recover from almost any symptoms. Towards the end 
 of December of the same year he became unable to 
 swallow, lost flesh rapidly, and died. Post-mortem : 
 brain weighed 49 oz., there being excess of subarach- 
 noid fluid ; but a remarkable absence of adhesions 
 between brain and membranes ; the brain itself was 
 remarkably firm, the cord firm, with a considerable 
 amount of fluid within the membranes ; both lungs 
 congested posteriorly ; there was atheroma also in 
 large amount in the aorta. This case illustrates what 
 has been said about remissions ; and although yearly I 
 am obliged to discharge patients whom their friends 
 consider perfectly recovered from attacks of insanity 
 which I attribute to general paralysis, yet these cures 
 prove invariably but remissions. 
 
 General paralysis of the double form. 
 — Cases of this variety were described at the In- 
 ternational Medical Congress of 1881, by Dr. de 
 
326 Insanity and Allied Neuroses, [Chap. xii. 
 
 Lemaestre. Hitherto tliej have not been sufficiently 
 recognised in England. It is, of course, open to 
 objectors to say that they are only varieties of general 
 paralysis with remissions, the period of remission being 
 marked by typical reaction from the state of exaltation. 
 
 Herbert F., single, set. 42, accountant, no in- 
 sane relations ; first attack of insanity, no cause 
 known. Admitted, April, 1883, the symptoms having 
 existed about six weeks ; they began with nervousness 
 and twitching, followed by depression and threats of 
 suicide. This soon was replaced by great exaltation of 
 ideas, and extravagance. He believed himself rich 
 and powerful, and offered marriage to several ladies. 
 Tongue tremulous ; pupils equal ; hallucinations of 
 hearing ; memory weak ; sleeps well ; excessive patella- 
 reflexes ; writing shaky. Five weeks after admission 
 he had swelling of both legs, and some unhealthy- 
 looking pustules formed. In June he was variable, 
 weaker in mind, and emotional. In September he 
 became melancholic and said he had offended God; 
 but again he became emotional, violent, and passionate. 
 In February, 1884, he was quiet, and had not any 
 of the old exaltation, his appearance being that of one 
 suffering from melancholy with stupor. His circula- 
 tion was very feeble, his hands being livid and con- 
 gested. There was little loss of expression; the 
 tremor of tongue and hesitation of speech were less, 
 yet he was wet and dirty. If he had been seen 
 for the first time in February, he would hardly have 
 been recognised as a general paralytic ; and this is one 
 of the chief characteristics of this variety, that it may 
 impress the observer first as unmistakable general 
 paralysis, the change in the character of the disease 
 throws doubts upon the diagnosis, and another change 
 may confirm the first opinion. 
 
 Such cases may begin with melancholia and pass 
 into exaltation ; or may begin with mania and pass 
 
Chap. XII.] The Optic Discs. 327 
 
 into melancholy. Each change, however, shows in- 
 crease of mental weakness. 
 
 I wish I could give as distinct groujis of patho- 
 logical changes as I have given of clinical symptoms, 
 but at present I am not quite prepared to accept all 
 Dr. Mickle's divisions as final. 
 
 Special consideration of symptoms.— 
 It will now be necessary rapidly to run over the 
 symptoms which occur in general paralysis, and in 
 doing this I shall first discuss the bodily and then 
 the mental symptoms. The pupils are said to be 
 generally unequal, I shall give as my experience that 
 in one group, those associated with change in the 
 lateral columns of the chord, the pupils are frequently 
 reduced to pin-points, and in an asylum, if I meet with 
 a case with such smallness of pupils, I at once expect 
 a further development of the symptoms of general 
 paralysis. Inequality of pupils is common but not 
 constant, varying not only in the different stages of 
 the disease itself, but from day to day ; the pupils are 
 at one time eccentric and at another irregular in out- 
 line. In the later stages of the disease they are often 
 dilated. In tabetic cases the reaction to light is de- 
 fective, but to accommodation it may exist. I have no 
 knowledge of any relation between dilatation of the 
 pupil of one side being associated with any special 
 symptoms, and I should at once deny the proposition 
 that with dilatation of either pupil there is constantly 
 exaltation of ideas. Fallacies must be guarded against, 
 patients without general paralysis must be recognised 
 as sometimes having inequality of vision in their eyes 
 and inequality of pupils. I have been misled for a 
 time in patients who had syphilitic iritis, and once 
 by a patient with a false eye. 
 
 Strabismus and ptosis are rare in general para- 
 lysis, and permanent mydriasis is also rare unless 
 associated with syphilis. The condition of the optic 
 
»3 
 
 28 Insanity and Allied Neuroses. [Chap. xii. 
 
 discs has been discussed for years past, and my expe- 
 rience at Bethlem is that in the early stages of 
 general paralysis, whatever the variety, there is 
 certainly no constant change in the discs. There is no 
 hypersemia, no grey degeneration, nor any alteration 
 either in vessels or nervous tissues. Later, and more 
 generally, changes begin to show themselves in a 
 certain number of cases towards the end of the 
 second stcge, and although it is uncommon to find 
 any really distinct optic neuritis, changes associated 
 with dimness of outline of the disc and with fulness 
 of vessels become manifest. Vision may or may not 
 be affected ; as a rule it is either very slightly changed, 
 or the patient is so weak in mind that it is not ap- 
 preciated. In about equal numbers those patients 
 suffering with tabetic symptoms and those with lateral 
 sclerotic symptoms are affected by changes in the optic 
 disc, and in several cases sight was completely lost. A 
 full account of those changes which may occur in 
 the optic discs will be found in the Ophthalmological 
 Heports of 1883, vol. iii., the reports being by Dr. 
 Edmunds, of St. Thomas's, and Dr. Lawford, clinical 
 assistant at Bethlem. 
 
 In my experience, hearing is not so commonly 
 affected, and I have only met with two or three cases 
 in which in the last stage of general paralysis of the 
 insane hearing was lost almost entirely. 
 
 As to taste and smelly though I have perseveringly 
 tried Yoisin's experiment as to the loss of ability to 
 detect the smell of pepper in early general paralysis, so 
 far I have met with very few cases in whom this defect 
 was present ; I have met recently with a case of rapid 
 general paralysis with general anaesthesia and progres- 
 sive dementia in which pepper was not recognised; but 
 all the other symptoms were sufficiently well marked, 
 and this symptom was of no practical use at all. Taste 
 and smell, then, are in my experience rarely affected. 
 
Chap. XII.] Tremor of Lips and Tongue. 329 
 
 Next in importance to the pupils, and according to 
 some even of the first importance, is the condition of 
 tremulousness of Hjjs and tongue. Ah^eady I have 
 said, that of all muscular co-ordinations in the body 
 those of the lingual muscles are most highly organised, 
 and in degeneration suffer most and earliest. The 
 nature of the tremor has been variously described by 
 one as fibrillar, and by another as general. I should 
 say that in the earliest stages in which it is present it 
 is marked by a slight irregular want of control, the 
 patient projecting it by little jerks at a time, as if un- 
 certain how much force was being used, and to what 
 extent the tongue was protruded. The tongue itself 
 often has lost its expression, and is irregular in out- 
 line ; as disease advances it becomes still larger and 
 more flabby, and if protruded at all, will be found to 
 rest on the lower lip ; the tremor is less in the morn- 
 ing than during the latter part of the day ; it may be 
 all but absent after periods of complete rest, but after 
 talking, and more especially after eating, it is well 
 marked. I think it is more manifest, as is also the 
 tremulousness in the lips in general paralysis, with 
 changes in the lateral columns. With the tremor of 
 tongue and of lips has to be connected the clipping of 
 words ; this varies considerably, some patients scan- 
 ning almost like those with disseminated sclerosis, 
 others halting in speech or dropping the terminations 
 of the words. It is interesting to remember that the 
 change is very similar both in writing and in speech, 
 so that just as there is a dropping of letters there is a 
 clipping of words. 
 
 Besides speech alteration there are other changes 
 in which the tongue is affected. In the most 
 advanced cases great difficulty of swallowing arises, 
 and this is one of the causes of fatal accidents to 
 these patients. I have seen several cases who have 
 introduced into their mouths large masses of food or 
 
33° Insanity and Allied Neuroses. [Chap. xii. 
 
 even big pieces of bone, which they have managed to 
 get lodged at the back of the throat, with imminent 
 risk of suffocation. In the early part of the second 
 stage it is not uncommon to get peculiar movements of 
 the jaws, as if the patient were swallowing his saliva. 
 There may be a noisy movement of the lips, or, what is 
 most common, grinding of the teeth, which when once 
 established rarely is lost ; so that patients becoming 
 rapidly demented will grind their teeth for hours 
 together, making the most objectionable noise, and 
 by this means eventually teeth may be broken or 
 forced from their sockets. The food is swallowed by 
 these patients unmasticated, and the appetite, which in 
 the earliest stage of general paralysis may be capricious, 
 becomes insatiable; the bowels, at first constipated, 
 become regular during the greater part of the disorder, 
 but in the later stages diarrhoea is not uncommon, masses 
 of undigested food being passed. I have been unable to 
 discover any special elements in the food, Miich seemed 
 to pass altogether unaffected by the digestive processes. 
 The skin in general paralysis is noteworthy. In 
 acute cases the face is pallid, often waxy ; later, 
 when expression is being destroyed, the skin becomes 
 thicker and greasy, the greasiness appearing most 
 about the forehead and the nose. This is often so 
 marked that on passing a fore-finger over the side 
 of the nose and closing the thumb on it the sensation 
 as of powdered French chalk is given. I know of 
 no special skin disease associated with general para- 
 lysis, but in later stages I have met with irregular 
 bullae appearing at different parts of the body. In the 
 lateral sclerotic variety I have commonly met with a 
 great deal of capillary congestion over the malar pro- 
 minences. The import of this is doubtful; it may merely 
 be a coincidence, or it may be that general paralysis 
 and this condition both occur in certain temperaments ; 
 or it may be that certain vaso-motor paralyses lead 
 
Chap. XII.] The Muscles in Paralysis. 331 
 
 botli to general paralysis and capillary congestion ; but 
 still, in this case I do not understand why the conges- 
 tion should be so localised. There may be some con- 
 nection between these congestions and oth-hsematomata 
 and pachymeningitis. I have rarely met with hyper- 
 sesthesia in general paralysis, but anaesthesia is com- 
 mon. It may occur in localised patches in the earlier 
 stages of the disease, and may vary from day to day in 
 the area over which it extends. It may pass off alto- 
 gether for months, again to reappear in the later 
 stages of the disease. In some cases it is extreme, so 
 that I have known a patient fall asleep with his hand 
 in front of the fire till it was completely roasted ; and 
 in another case a patient who, having a contraction 
 due to a burn affecting his left arm, got a piece of 
 pumice-stone and during one night rubbed an inch or 
 more of the web into a hole. This anaesthesia, I believe, 
 may alter the reaction of the reflexes ; thus, on one 
 occasion, a patient who for a long period had been my 
 best example of exaggerated patella reflex, when tried 
 was found to have lost this symptom, and on further 
 investigation I found he was completely ansesthetic 
 in his lower extremities. Danger arises to such cases, 
 as they are liable to bruise themselves unconsciously, 
 and cases have been scalded to death by getting into 
 a bath of hot water. 
 
 The muscles in general paralysis may remain well 
 nourished and active for a long period. It has been 
 said that there is no alteration in the electrical relation- 
 ship of these muscles, and I must own that the expe- 
 rience gained in Bethlem by the use of the currents, 
 the examination being made by skilled electricians, 
 has led to no results. Stray muscles here and there 
 were found to be losing power without any definite 
 reason ; my own feeling is that in most cases there is 
 undue excitability in nearly all muscles during the first 
 stage ; and that this excitability is much more marked 
 
332 Insanity^ and Allied Neuroses. [Chap. xii. 
 
 in those cases which afterwards exhibit fully developed 
 symptoms of lateral sclerosis, in whom, towards the 
 end of the disease, extreme contraction of the lower 
 extremities takes place. For a very considerable time, 
 even up to death, the other cases maintained rounded 
 limbs, the muscles being of the ordinary size ; although 
 with them, as with the tongue, I should say there is a 
 want of expression. 
 
 In the same relationship we must look upon the 
 hand-writing^ to which symptom so much importance 
 has been attached. As general paralysis advances, 
 the patient becomes less able to write, but there is 
 nothing absolutely characteristic in the hand- writing 
 itself. Tremor may occur with age, with alcoholism, 
 with paralysis agitans, with melancholia, and mania ; 
 and I have specimens of hand-writing from all the 
 above which are indistinguishable. It is interesting 
 to compare the hand- writing of the general paralytic in 
 health and in disease, there being the same general 
 character in the writing, although there is the tremor 
 visible in both upstroke and downstroke as the dis- 
 ease progresses; but the shakiness alone is of no im- 
 portance, unless the terminal letters are noted to be 
 occasionally omitted. In a few cases I have seen a 
 marked improvement in legibility in hand-writing in 
 early general paralysis, the fact being that patients 
 finding themselves unable to write quickly have, on 
 this account, taken more pains with what they did. 
 As the disease advances the patient can no longer 
 write with a pen, but may be able to control a pencil; 
 and with this the words become more and more abbre- 
 viated, so that when he is bed-ridden his speech is 
 becoming indistinguishable, and he is no longer able 
 to write at all. 
 
 The hones of the general paralytic sometimes be- 
 come remarkably brittle ; and when I hear of many 
 fractures in a single patient in an asylum, I am 
 
Chap. XII.] HmMATOMATA IN THE EaRS. 333 
 
 inclined rather to blame the ribs than the attendants. 
 I have known a general paralytic get a fractured 
 radius from a light blow with a hair-brush. Such 
 fractures not unfrequently unite naturally, and this 
 is one of the peculiarities of many general paralytics, 
 that, although they may receive fractures, develop 
 bed-sores or abscesses, these rapidly heal. 
 
 Besides the above changes there is a tendency to 
 low forms of inflammation in the subcutaneous areolar 
 tissue, so that in the first place we may meet with 
 sluggish forms of whitlow or " mad-fingers j" or else 
 light bruises may produce enormous abscesses, which 
 contain pus mixed with broken-down blood. In one 
 case a patient, simply by slipping out of his bed, 
 bruised the outer side of his thigh, producing no 
 abrasion of skin, but within two days there was an 
 enormous bruise with oedema and tense swellinfif, re- 
 sembling a bad case of phlegmonous erysipelas, which 
 led to a large abscess j he recovered, however, 
 without any bad symptoms, and without sloughing 
 of skin. On the other hand, a patient died in 
 Bethlem, and the friends were ill-satisfied in conse- 
 quence of the bruised condition of his body ; a slight 
 blow on the face having caused an enormous sub- 
 cutaneous haemorrhage, and a fall on his back from a 
 bed having produced a symmetrical haemorrhage into 
 both loins of an extraordinary amount. ISTo signs of 
 the injury were visible for two days, when it was 
 noticed that both buttocks were becoming black ; the 
 patient sank suddenly of acute septicaemia, and post 
 mortem a felt-like clot of disorganised blood, with 
 unhealthy looking pus, was found . between the sub- 
 cutaneous areolar tissue and the muscles. I believe 
 that the hcematomata which occur from time to time 
 in the ears of general paralytics have a similar origin. 
 These hsematomata are, in my opinion, more common 
 in general paralytics than in other cases. I have seen 
 
334 Insanity and Allied Neuroses. [Chap. xii. 
 
 tliem more than once in cases of chronic insanity ; 
 once in insanity with phthisis and refusal of food ; in 
 chronic mania with restless destructiveness ; and in 
 secondary dementia, with obstinacy about food. The 
 left ear is more commonly affected than the right, 
 and this certainly lends weight to the idea that trau- 
 matism, in the shape of the right hand of the at- 
 tendant, has something to do with the causation. I 
 have only seen one case in which a patient was dis- 
 charged well, having had marked hsematomata. My 
 own feeling is that the causation of these swellings 
 is altered condition of blood, and altered condition 
 of smaller vessels, associated with violence of some 
 kind. Similar hsemorrhages certainly occur in other 
 parts of the body when violence has been exercised. 
 
 Convulsions have been treated in two ways by 
 those who have written on general paralysis of the 
 insane, some treating them as essential symptoms of 
 the disease, others considering them to be complica- 
 tions. Without pretending to explain their causation 
 fully, I look upon them as a common, although not 
 essential symptom, and yet not as a mere complica- 
 tion. The convulsions may be the very first noticed 
 symptoms ; the first convulsion may be extremely 
 severe, or it may be of a very slight nature. In one 
 or two cases I have the history that patients have 
 had slight attacks of what looked like the petit Trial 
 of epilepsy for some time before general paralysis 
 became fully recognised. In one case slight faintness 
 followed by aphasia occurred some years before the 
 patient had to be removed from home. The convul- 
 sions may be at one time extremely severe, and at 
 another but very slight in character, sometimes being 
 mistaken for a mere faint ; or they not uncom- 
 monly resemble a bilious attack. It is more 
 common to meet with fits in patients who have 
 become fat, and who have become quieter, than in 
 
Chap. XII.] Convulsions. 335 
 
 those who have passed through the first stage 
 altogether; and in such cases the fits will mark 
 a passage from the first to the second stage. 
 The fi-ts may be general, the patient falling down, 
 with or without a cry, completely unconscious, and con- 
 vulsed all over his body ; the convulsions may be more 
 marked on one side than on the other, and they may 
 be noticed to start always from one spot ; they may 
 pass off in the course of a few seconds, or they may 
 recur on the slighest external irritation for days toge- 
 ther. Some fits have been called apoplectic from 
 their extreme severity, and from their more frequently 
 affecting one side of the body only. Many patients 
 have convulsions on the one side followed by temporary 
 hemiplegia, but I have not been able to trace any 
 relationship between the part convulsed and the in- 
 equality of the pupils : although in some cases I have 
 found that the side which was convulsed, and which 
 afterwards became paralysed, at the onset of the dis- 
 ease, was in a more excitable condition electrically 
 than the opposite. The results of convulsions in 
 general paralysis are remarkable. They pass off more 
 rapidly than if organic lesion were present, as in 
 apoplexy ; and less readily than in ordinary epilepsy: 
 pointing, it seems to me, in many cases to an inter- 
 mediate pathological condition, to a condition in 
 which the discharge arises in consequence of not 
 merely functional instability, but to alteration in the 
 structure of the cortex. Besides the physical changes 
 which follow convulsions, the mental deterioration 
 which succeeds them is remarkable, many patients 
 becoming rapidly weaker and more childish after each 
 fit. In one case I have seen a remission ushered in 
 by a fit. At the time of the convulsions various 
 treatments have been suggested : nitrate of amyl has 
 been given, but I have failed to find any good result 
 from its administration. 
 
336 Insanity and Allied Neuroses. [Chap. xii. 
 
 From convulsions one naturally passes to a con- 
 sideration of the temperature in general paralysis. 
 The fits are almost invariably associated with altera- 
 tions in temperature, some cases having a marked 
 increase shortly before convulsions. I have myself 
 been fortunate enough, on one or two occasions, to have 
 taken the temperature of a patient who within the 
 hour had convulsions ; and in such cases it was 
 usually two or three degrees above normal. My 
 experience is, that in general paralysis in the earlier 
 stages there is very little, if any, increase in tempera- 
 ture, except in the acute cases. About the period of 
 the onset of fits there is a tendency to irregular 
 increases ; before, during, and after fits, the tempera- 
 ture may be high. Between the fits the temperature 
 may be normal, but not uncommonly there is a 
 tendency to increased temperature at night, and all 
 excitement, whether bodily or mental at this time, is 
 associated with increase of temperature. The tempera- 
 ture varies irregularly, and I believe in many cases 
 the irregularity depends on some intercurrent trouble. 
 It is certain that with bed-sores and with local lung 
 inflammations there occurs increase of temperature. 
 In the later part of the disease, if uncomplicated, the 
 temperature of the morning is about 100°, and of the 
 evening 101° to 102°, and if any further increase occur 
 it is well to be on the look-out for some physical 
 trouble likely to terminate the case. In a few 
 extreme cases I have met with sub-normal tempera- 
 tures, so that the thermometer has registered only 96° 
 or 97°. Accidental circumstances may cause sudden 
 and marked increase of temperature, as was seen in 
 the case I have described, in which, with haemorrhage 
 into the cervical region of the cord, great increase of 
 temperature took place. Most of the fits in general 
 paralysis are associated with sweating, which may 
 be partial, or unilateral, or general ; the extreme 
 
Chap. XII.] Mental Symptoms. 337 
 
 amount of sweating whicli may occur is only to be 
 appreciated when once seen. I have frequently seen 
 the development of sudamina within a few hours of a 
 fit. With the sweating, the temperature of the body 
 rapidly falls. Having taken sphygmographic tracings 
 of hundreds of cases of general paralysis, I have come 
 to the conclusion that there is no special fulse which 
 can be said to be in any way associated with this 
 disease. In a few the left ventricle acts with undue 
 vigour, as if to overcome some general resistance 
 to the circulation, and in a few distinctly febrile 
 symptoms are present ; but the pulse trace pointed to 
 nothing which can be in any way looked upon as 
 characteristic in most cases of general paralytics. 
 
 The urine again, which was carefully examined 
 by Dr. Crichton Browne, varies extremely from 
 a specific gravity of I'OIO to one of 1*035. In 
 the majority of cases I found there was excess ot 
 phosphates, and that chlorides might be reduced in 
 quantity, and that urea was abundant, but uric acid 
 not in excess. It is extremely difiiciilt to speak of 
 the quantity which may be passed, especially in the 
 later stages of the disease, for the patients becoming 
 wet and dirty their excretions cannot be collected. 
 Albumin is very rarely present. 
 
 Mental symptoms.— The signs of general paraly- 
 sis are simply evidences of progressive mental weaken- 
 ing ; and in acute alcoholism one sees produced tem- 
 porarily every shade of mental symptom which may be 
 seen more permanently in general paralysis. Earliest, 
 we meet with loss of self-control, and latest, we come 
 to loss of all bodily fower ; emotional disturbance is 
 common, patients becoming lachrymose and lustful; 
 the will is feeble and uncertain, driving the patient 
 headlong in one direction, only the next moment to 
 carry him in the opposite. His senses may be per- 
 verted, but hallucinations are not so common among 
 w — 14 
 
33S Insanity and Allied Neuroses. [Chap. xii. 
 
 general paralytics as among most of the other types of 
 insanity. The symptom by which general paralysis 
 has been best recognised is that of exaltation or of 
 grandeur ; and although ideas of power and influence 
 are met with, as we have seen under other conditions, 
 yet there is something almost characteristic in the 
 great ideas of the general paralytic. The patient is 
 altogether exuberant ; he is prepared for any emer- 
 gency : at one moment saying he is a king, and at 
 the next an inventor ; in one breath claiming the 
 queen for his wife, and in the next prepared to add 
 all the duchesses to his harem. There is a strange 
 benevolence in most of these cases ; they are only too 
 anxious to share their wealth and blessings. The 
 exaltation may assume many forms, one of the 
 simplest being represented by the patients who tell 
 you they are " all right," and such patients will 
 tell you they are as well as ever they were, 
 though unable to stand. Another class is chiefly con- 
 cerned about meals, and although a patient is having 
 the most ordinary diet he will tell you his meal 
 consists of whale cutlet and stufled elephant. Such 
 patients may appreciate the folly of a neighbour, but 
 fail to see anything peculiar in their own ideas. 
 Thus, I have heard the following conversation between 
 two general paralytics : "I am king of England," 
 said one ; the other, turning with a scornful laugh to 
 me, said, "That man says he is king of England ; I am 
 God Almighty, and I don't know him." In the same 
 way I have known a medical paralytic recognise the 
 disease in others by th-e very symptoms from which 
 he was suffering himself. 
 
 Grandeur of ideas loith benevolence is the chief 
 characteristic of the exaltation of general paralysis. 
 The patients think happily, they talk happily, they 
 write happily, and are altogether inconsistent till 
 the weak-mindedness which comes on, leaves them 
 
Chap. XII.] DiA GNOSIS. 339 
 
 demented, although possibly still automatically mut- 
 tering of their past glories. Yoisin says that the 
 melancholia which may be present with general 
 paralysis has generally a hypochondriacal form, there 
 being three marked varieties, namely, the ideas of 
 obstruction of the organs, the denial of existence, and 
 the idea of reduction in size, what in fact has been 
 called micromania. The hypochondriacal insanity is 
 thus described by Dr. Yoisin : The paralytic hypochon- 
 driac has some ideas which are rarely met with 
 outside general paralysis ; which are, in fact, supremely 
 absurd and appear suddenly ; he is unstable, and that 
 is what brings about a delirium nearly resembling 
 general paralysis. If the mental symptoms are those 
 of dementia, the symptoms are in no way special, one 
 part of the mind seeming to suffer more in one case 
 than in another, till the disease so far advances as to 
 reduce the patient to a condition of complete dementia 
 similar to that met with in the last stages of the other 
 mental disorder. 
 
 Diagpnosis. — The fatal nature of this disease 
 makes it of the utmost importance that a definite 
 diagnosis should be made, and I shall point out 
 several sources of error, premising by saying that, 
 after twelve years' experience in Bethlem, I find the 
 utmost difiiculby in tracing the probable result not 
 only in cases of hypochondriasis with melancholic 
 symptoms, but in cases of maniacal excitement in 
 middle-aged men. There is not one single patho- 
 gnomonic symptom of this disease, and in deciding, 
 one must form one's judgment by taking the history 
 and the symptoms together. 
 
 Alcoholism^ acute or chronic, is probably the most 
 common cause of error. General paralysis may result 
 from alcohol, or alcoholism may accompany general 
 paralysis. The diagnosis must depend upon the other 
 physical symptoms and on the history. The man who 
 
340 Insanity and Allied Neuroses. [Chap. xii. 
 
 is an habitual drunkard, and who has been led into an 
 acute debauch, suffers from gastric disturbance or 
 sleeplessness, and has no inequality of pupils, no change 
 in his reflexes, no greasiness of skin, is probably suffer- 
 ing from alcoholism and not from general paralysis ; 
 time alone will clear up to a certainty his condition. 
 The same difficulty has arisen from lead poisoning, only 
 there the history and the blue line, with possibly some 
 affection of the extensor muscles of the fore-arm, will 
 enable you to form a diagnosis ; although I believe lead 
 poisoning, like alcohol, may produce general paralysis. 
 
 In my experience, the most difficult cases, after 
 these with alcoholism, are those suffering from cJironic 
 maniacal excitement, and I have frequently to retain 
 such patients for months, without being able to 
 satisfy myself as to the diagnosis. They are restless, 
 excited, loquacious, joyous, and boastful, and with 
 exaltations they may even be benevolent, but more 
 frequently they are aggressive. Their appetites after 
 the earliest stage of sleeplessness become enormous ; 
 there may be tremor of tongue and lips ; the pupils 
 are generally equal ; the complexion is sallow and 
 leathery ; but the face keeps thin, and there is little 
 or no loss of expression ; there is no tendency to fits ; 
 the patients are destructive to their clothes, fre- 
 quently pull out their hair, and are noisy and de- 
 structive at night. There is not the same tendency 
 to remission or to get fat which is common in general 
 paralysis with a maniacal onset. In such cases 
 blistering of the scalp has resulted in cure in many 
 cases, and in others the symptoms have become fixed, 
 constant chatter of an incoherent kind persisting. 
 
 Syphilis may produce mental and bodily dis- 
 orders hardly to be distinguished from general para- 
 lysis, and probably it also causes one form of the 
 disease. In the first place there may be thick- 
 enings of the arteries due to the syphilis leading to 
 
Chap. XII. 1 PoST-APOPLECTlC DEMENTIA. 34T 
 
 dementia, and but for the history I do not know any 
 means of distinguishing the one class from the other, 
 for anti-syphilitic treatment often fails to have any 
 effect whatever. Gummata, if they happen to cor- 
 respond with the motor areas of the brain, similarly 
 produce symptoms resembling general paralysis, and 
 the only points beyond the history of importance are 
 the greater frequency of headache with syphilis, and 
 the much greater tendency to strabismus and ptosis, 
 followed, if the case be progressive, by hemiplegia ; there 
 may, in addition, be facial paralysis, or some marked 
 paralysis of a cranial nerve, or loss of one or more 
 special sense. Treatment will in some cases clear up, 
 as in the following : John Charles P., married, set. 
 34, clerk, admitted October 2nd, 1883, no insane 
 relations ; first attack lasted three months. He had 
 been somewhat intemperate ; suffered from syphilis ; 
 was suspicious, and thought people were going to murder 
 him ; was unable to look after his business ; thought he 
 had swallowed a button, which caused him great bodily 
 suffering; he tried to choke his wife and to cut his 
 own throat. After admission he was noticed to have 
 marked ptosis, external strabismus, and dilatation 
 of right pupil ; was dull and obstinate, wet and dirty. 
 Ophthalmoscopically the right eye showed choroido- 
 iritis, with patches of atrophy and masses of pigment. 
 The treatment by perchloride of mercury was followed 
 by satisfactory results, and he was. discharged re- 
 covered. 
 
 In old patients it is often difficult to decide, 
 for progressive weak-mindedness is common as a 
 result of senile changes ; and, on the other hand, 
 excesses in old patients may produce general paralysis, 
 which runs a similar course to that seen in younger 
 patients. 
 
 Post- apoplectic dementia may be mistaken for 
 dementia following the fits of general paralysis, and 
 
34^ Insanity and Allied Neuroses. [Chap. xii. 
 
 this is sometimes hardly to be distinguished, except 
 from the fact that with apoplexy the paralysis is 
 more permanent, leaving the patient for weeks hemi- 
 plegic, so that there may be pronounced weakness of 
 one limb or another long after recovery from other 
 symptoms, while fits of general paralysis occurring in 
 an old man will leave him very little the worse in 
 body, although vastly deteriorated in mind. 
 
 Some forms of tuinour affecting the brain may 
 lead to suspicions of general paralysis, and I am 
 inclined to think that implication of the frontal lobes 
 by any growth may cause grave doubts, and unless 
 headache, or some local nerve palsy occur, the case 
 may be diflS.cult to diagnose. I have seen hydatids 
 affecting the frontal regions, produce anomalous mental 
 symptoms not cleared up till after death. 
 
 Epilejosy may end in weak-mindedness, but the 
 frequency of the fits, with the comparatively slight 
 loss of mental power following epileptic fits, dis- 
 tinguish them from those of general paralysis. I can 
 understand that disseminated sclerosis may produce 
 symptoms of weak-mindedness, tremulousness, hesi- 
 tation of speech, fits, and the like ; but I have only 
 seen one case in Bethlem, and in this, the age, 
 the irregularity of the symptoms, the nystagmus, 
 and the tremor of hands and head cleared up the 
 diagnosis. 
 
 Other possible fallacies have been suggested, and 
 Dr. Mickle, in addition to the above, gives dementia 
 with other forms of paralysis, senile dementia, senile 
 dementia with paralysis, locomotor ataxy, paralysis 
 agitans, chronic generalised palsy (such cases prob- 
 ably may be general paralysis without mental symp- 
 toms), other forms of acute or chronic paralysis, acute 
 ascending paralysis, tremors of age, and simple speech 
 defect. 
 
 What has already been said will suffice to 
 
Chap. XII.] Prognosis. 343 
 
 distinguish general paralysis of the insane from condi- 
 tions nearly allied to it. 
 
 Prognosis. — As soon as it is definitely settled 
 that a patient is suffering from general paralysis of 
 the insane, the prognosis is really made. 
 
 No such case, as I have said, when fully established, 
 ever recovers ; remissions occur, but not cures ; in some 
 cases, however, the disease runs a much slower course 
 than in others. My own experience agrees in the 
 main with writers who say that the average duration 
 of a case of established general paralysis is three years. 
 By this one means that as soon as the speech, the 
 pupils, and. the gait, together with signs of mental 
 decay, show themselves, three years would, almost cer- 
 tainly see the fatal conclusion of the case. In my ex- 
 perience cases of simple general paralysis without 
 marked mental symptoms live much longer than those 
 in which there is both bodily and mental degeneration. 
 The disease, as far as prognosis is concerned, must 
 be considered from the maniacal, melancholic, and 
 demented sides. With acute mania a prospect of re- 
 mission exists ; so that in most cases the general para- 
 lytic, with ambitious mania and restlessness after 
 a few months' treatment, becomes rapidly quiet, 
 and remains so for joeriods varying from a month 
 to over a year before a return of excitement or of 
 convulsive seizures, which may rapidly produce a fatal 
 ending. With melancholic general paralysis the 
 progress is pretty uniform, and I think rarely lasts 
 two years. With simple progressive dementia the 
 symptoms may last for several years. In nearly all 
 cases the prognosis is influenced by the body tempera- 
 ture and by the occurrence of fits, so that a patient who 
 has a temperature constantly over 100'^ will probably 
 rapidly sink, and a patient with constant recurrence 
 of fits will likewise probably die early. In women 
 the disease is not, as a rule, so rapid as with 
 
344 Insanity and Allied Neuroses. [Chap. xii. 
 
 men. The early occurrence of bed-sores, abscesses, or 
 lung com]Dlications tends greatly to the increase of 
 danger. Patients, who after the acute stage rapidly 
 become fat, run a great risk of early and severe fits. 
 There is danger, as I have said, from local injuries, the 
 blood appearing to be in a very unhealthy condition, 
 and septicaemia may result from comparatively slight 
 injuries. 
 
 Treatment. — To attempt to treat a disease which 
 one recognises to be incurable is, to say the least of it, 
 unsatisfactory ; but something must be done, and one 
 hopes, from time to time, that something may be dis- 
 covered which may possibly arrest this disease in its 
 earliest stages. I have tried every variety of medi- 
 cine, new and old, which has been recommended for 
 nervous diseases. Years ago the virtues of physo- 
 stigma were sung, and still, for want of anything 
 better, I am in the habit of ordering that drug in 
 small doses, and I can only say that I have never seen 
 it do any harm, and a few patients seem to have im- 
 proved while being treated with it. The old treatment 
 was by means of counter-irritation applied to the 
 scalp and to the spinal column, blisters or cauteries 
 being the favourites. I have used setons and blisters 
 with but little satisfaction. In a few doubtful cases 
 improvement has taken place, and the case which I 
 have already referred to as relieved by the occurrence 
 of a huge carbuncle, impelled me once more to try the 
 effect of setons and treatment of this description, 
 but with little effect. 
 
 In my opinion, the general paralytic requires, 
 above all things, to be removed from his home and 
 surroundings, and to be fed with light, rather unstimu- 
 lating food, and to have sufficient, but not exhausting 
 out-door exercise. Return to home is one of the most 
 certain things to produce a relapse, and in the case 
 of many of the general paralytics who have passed 
 
Chap. XII.] Pathology. 345 
 
 through my hands, and about whom I have had some 
 doubts, the diagnosis has been cleared up at once 
 when their friends have insisted upon trying them at 
 home. Any excess acts disastrously, and I believe 
 that this statement may even be extended by saying 
 that general paralytics are extremely susceptible to the 
 influence of powerful drugs. In cases where extreme 
 violence with destructiveness was present, I tried 
 hyoscyamine, but found it necessary to give that drug 
 with extreme caution, as one-twentieth part of a grain 
 would produce alarming symptoms of collapse. I 
 have refrained for some time from giving any powerful 
 drugs of that kind, for fear of doing harm by shaking 
 further the tottering physical edifice. 
 
 Pathology. — To treat satisfactorily the pathology 
 of general paralysis of the insane, one requires a 
 large amount of space, and very elaborate diagrams 
 with descriptions ; even then, as the points of most 
 importance are not definitely fixed, the result would 
 be but tentative; I shall, therefore, content myself 
 with giving a general outline of my experiences. 
 
 The scalp is generally thick and hairy, the calva- 
 rium often deeply marked by pacchyonian bodies, which 
 often occur in great excess, the dura mater being com- 
 monly adherent in patches at the vertex ; the dura 
 mater itself is rarely much thickened ; there may be 
 in its inner surface ferruginous stainings, and I have 
 seen one case in which three convulsive fits were re- 
 presented by three thin films resting on the dura 
 mater of different shades of red-brown; these stainings 
 may occupy either the whole of the inner surface, or 
 they may occupy one complete half, or half of the base. 
 
 Occasionally one meets with false membranes, 
 occupying the whole or half of the vertex imme-. 
 diately under the dura mater, as seen in the annexed 
 illustration (page 346). This false membrane is 
 due to pachymeningitis, and may vaiy in thickness 
 
34^ Insanity and Allied Neuroses. [Chap. xii. 
 
 and consistency. In one case I have seen the greater 
 part of it converted into a hard cartilaginous cap, 
 resembling a second calvarium. In other cases I 
 have found it a felt-like mass, with or without local 
 haemorrhages into its substance. These membranes 
 may occur in very old or in ordinary cases, and 
 
 Pachymeningitis . 
 
 there is no relationship between them and the dura- 
 tion of the disease. On removal of the dura mater, 
 and a false membrane if it be present, the arach- 
 noid will be found to exhibit a certain number of 
 milky spots, and there will be almost always a con- 
 siderable amount of subarachnoid fluid. This may be 
 most visible over particular areas, so that there are 
 lakelets of fluid taking the place of wasted convolu- 
 tions, the convolutions most commonly affected being 
 the ascending parietal, paracentral, and base of the 
 
Chap. XII.] Pathology. 347 
 
 first frontal. On attempting to remove the membranes, 
 adhesions may occur. At one time it was invariably 
 accepted that adhesions were sure to be present, but a 
 change has come over the general opinion, and now-a- 
 days it is admitted that general paralysis in an 
 advanced condition may occur, and yet no adhesions 
 be found. 
 
 Adhesions, if present, vary considerably in their 
 extent and site ; they may occur chiefly on one side ; 
 they may occur at the base of the first frontal ; they 
 may be present along the centre of the convolutions, or 
 attached to their margins. Adhesions occur most 
 commonly over the frontal, parietal, and temporo- 
 sphenoidal lobes, with occasional patches scattered 
 over the rest of the brain ; they are most common on 
 the superior surface, but they may also be present on 
 the inferior. They may occur in acute cases, and 
 may be readily separable, or they may be so universal 
 that an attempt to remove the membranes causes 
 a peeling off of the grey matter with them. There 
 is generally a considerable amount of fluid in the 
 lateral ventricles; but this varies to a great extent, 
 so that in some cases, with a small amount of fluid 
 in the membranes, much is found in the ventricles 
 giving rise to an appearance of hydrocephalus. In 
 such cases, post imoi^te^n, a great deal of softening of the 
 brain tissue about the ventricles is found ; on section 
 the brain is generally firm, unless this excess of fluid be 
 present ; so that the brain examined two or three days 
 after death will be found to cut like a cheese ; the 
 grey matter may be thin, but not uncommonly there 
 is nothing specially noteworthy in it. In some cases, 
 however, two or three zones, varying in tints, are very 
 distinct in the grey matter. I have never found any 
 miliary aneurisms in such cases ; the vessels at the 
 base may be extremely atheromatous; the capillaries 
 may, on examination, be found to be much twisted or 
 
348 Insanity and Allied Neuroses. [Chap. xii. 
 
 kinked, with quantities of leucocytes in their sheaths ; 
 and blood crystals may also be present. 
 
 In the spinal cord there may be considerable 
 wasting with excess of subarachnoid fluid, adhesion 
 of membranes to surface, and local or general pachy- 
 meningitis. There may be spicules of bone in the 
 arachnoid scattered all over the surface ; effusion of 
 blood may occur within the dura mater, associated 
 with epileptiform fits. 
 
 The minute changes which may occur in the 
 nervous tissues are considerable, and affect three 
 tissues specially, the connective tissue, the capillaries, 
 and the nerve cells. In early general paralysis there 
 is commonly excessive growth of connective tissue, 
 there being a large number of Deiter's cells scattered 
 throughout the tissue; these are most marked in the 
 superficial layers of brain and cord. 
 
 The capillaries have unduly prominently marked 
 nuclei, with other changes pointing to inflammatory 
 action; from the perivascular sheath processes of con- 
 nected tissue may ramify; the perivascular sheath 
 itself may be crammed with leucocytes, and I have 
 seen parallel rows of escaped leucocytes near the vessel 
 walls. The connective tissue, which in the earlier 
 stages is partly loose and transparent, in the latter 
 stages becomes firm and contracted. The nerve cells 
 are afiected in various degrees, the pyramidal cells of 
 third layer suffering most ; these lose their processes 
 first, and swell, the nucleolus often being very marked 
 and appearing as a bright spot ; the nucleus becomes 
 large, granular, and at times pigmented. The cell wall 
 may burst, or in some cases may contract round the 
 nucleus, leaving a pericellular space of irregular out- 
 line. I have seen this space filled with coloured 
 debris from the degenerated nucleus. The other cells 
 may become swollen or granular, and scattered among 
 these cells various foreign bodies may be present, some 
 
Chap. XII.] The Sympathetic System. 349 
 
 being of irregular size and rounded outline, faintly- 
 staining with logwood, homogeneous in structure, 
 having the general aspect of stained serum. Some 
 other bodies seem to be the result of broken-down 
 nerve tissue, and a very large number of bodies, called 
 miliary, are the result of methods of hardening. 
 
 In the spinal cord the changes are of three dif- 
 ferent kinds : general wasting, in which all the tissues 
 seem equally affected ; secondly, cases in which the 
 posterior columns are mainly implicated ; and thirdly, 
 the cases in which the lateral columns, or the lateral 
 and anterior, suffer. 
 
 Of the second, it is only necessary to say that the 
 changes resemble those which occur in locomotor 
 ataxy, and may consist of changes in the radicular 
 fasciculi ; or the lateral posterior column may be the 
 one which is chiefly affected. 
 
 In the third group the changes are of a kind 
 which has been described as secondary lateral sclerosis, 
 or Turck's paralysis. 
 
 As with the brain, so with the cord, the three 
 tissues may become affected, the connective tissue, 
 vessels, and nerve tissue, each being affected in a 
 similar way to that of the brain. The central canal, 
 which is always referred to when speaking of changes 
 in the spinal cord, may present almost any variety of 
 change ; at one time the canal being filled with debris, 
 and at another there being excessive proliferation of 
 the epithelium, in another the whole region may be 
 represented by an aggregation of cells and granules, 
 which deeply stain with logwood. In some cases the 
 canal is of great size, and in others it is all but 
 obliterated. 
 
 Sympathetic system. — In the changes in general 
 paralysis of the insane, one part of the nervous 
 system after another has been looked upon as the 
 starting-point of the disease \ and it is not to be 
 
350 Insanity and Allied Neuroses. [Chap. xii. 
 
 wondered at that the sympathetic system should have 
 been blamed. Two French writers, Bonnet and 
 Poincare, think they have found the source of general 
 paralysis in degenerative changes occurring in the 
 sympathetic ganglia of the neck. I have carefully 
 examined sections from these regions in many cases of 
 general paralysis, and I can only say that I have 
 found absolutely nothing characteristically patho- 
 logical. That many cells are granular and contain 
 pigment is nothing unusual ; and I must repeat that T 
 have hitherto failed to detect evidences of disease in 
 the cervical ganglia. 
 
 Changes have been found in the nerve trunks 
 generally, and this is but confirmation of the state- 
 ment that general paralysis is a degeneration which 
 may afiect all parts of the nervous system. 
 
 To sum up, the pathological changes which I have 
 found are either the results of premature decay and 
 local wasting, or are due to a process which must 
 be considered as allied to inflammation, although the 
 term inflammation can hardly be used for a process 
 which may extend over years. The changes may 
 occur primarily in brain, cord, or peripheral nervous 
 system, for although I can give no cases of paralysis 
 by propagation to make one believe in the propagation 
 of a diseased process from the periphery to the centre, 
 yet evidence is not wanting. In general paralysis, as 
 I have said, other organs may sufier ; the blood may 
 become unstable and prone to rapid change ; the 
 arteries may be affected in several ways ; and the 
 kidneys may likewise suffer, primarily, or through the 
 arteries. 
 
351 
 
 CHAPTER XIIT. 
 
 PARALYTIC INSANITY. 
 
 Insanity associated with paralysis, other than general paralysis of 
 the insane — Apoplexy — Paralysis agitans — Locomotor ataxy. 
 
 Insanity following" apoplexy. — This division is 
 one in which I shall place several varieties of mental 
 disorder associated with conditions of physical weak- 
 ness due to changes iji the nervous system. 
 
 It is one of the most striking evidences of 
 the close relationship which exists between mind 
 and brain, that serious damage to a brain, such 
 as that following from apoj^lexy, rarely allows of 
 perfect intellectual recovery ; and that just as a scar 
 remains as the evidence of an old wound, so change in 
 disposition, or loss of memory, may be the intellectual 
 scars left by apoplexy. The lesions take place at the 
 base, not the surface of the brain. 
 
 Every variety of weak-mindedness may be the result 
 of apoplexy ; for instance, I have known a man, who 
 formerly was a fluent speaker, recover with an ability 
 to write and to understand as well as ever, but with 
 inability to express himself with freedom of speech. 
 Probably, emotional instability is the most cominon 
 result of apoplexy, the person becoming loquacious, 
 irritable, and tearful. These slight perversions may 
 have no direct interest to the asylum physician unless 
 they develop beyond moderate bounds ; but still, in 
 them must be recognised the earlier stages of a dis- 
 eased process. The loss of memory, irritability, and 
 loss of self-control may render it necessary to seclude 
 patients ; and I have seen several important trials 
 
352 Insanity and Allied Neuroses. [Chap. xiii. 
 
 as to the validity of wills turn upon the degree of 
 mental weakness exhibited by a patient after apoplexy. 
 The loss of memory may be so extreme that a patient 
 is not responsible one moment for what he did the 
 moment before ; or a man may be so emotional that 
 slight influence from without must be acknowledged to 
 be undue influence and sufiicient to invalidate a will. 
 
 Of all symptoms following apoplexy^ aphasia,, asso- 
 ciated usually with right-side paralysis, appeals most 
 strongly to the minds of laymen ; and I have known 
 at least one patient considered to be insane by a jury 
 because he was unable to express himself in words, 
 the jury being fully convinced that a man who made 
 unintelligible noises, when asked a plain question, must 
 be a fool. About the same time as the above inquisi- 
 tion was held, a jury accepted the fact that a man, 
 who had recently died, might have been of sound mind 
 although aphasic, and his will was held good, the two 
 cases showing how diflS.cult it is to impress a jury 
 with the essentials of a condition like aphasia ; when 
 the aphasic patient is before the jury, their common 
 sense, so-called, overrides an expert's opinion. I would 
 say, in reference to this subject, that aphasia may 
 exist to almost any degree, yet there may be sufficient 
 mental power to transact all the business of life sanely 
 and satisfactorily. 
 
 The cases of insanity following apoplexy divide 
 themselves into those with excitement, those with 
 depression, and those with simple weak-mindedness, the 
 majority of the cases being weak-minded from the first, 
 but the dementia becoming more and more profound. 
 The apoplexy may be the result of senile softening, or 
 of true hsemorrhagic effusion. In the former state we 
 rarely have patients admitted into Bethlem, though 
 such cases, I believe, are not uncommon in county 
 asylums, where patients live for many years, and die 
 of old age with its degenerations. 
 
Chap. XIII.] Dementia following Apoplexy. 353 
 
 Apoplexy in the following case was dependent on 
 brain softening ; it occurred in a case of chronic in- 
 sanity, and was associated with considerable amount 
 of excitement : Jane W., married, set. 83, admitted 
 into Bethlem in September, 1857, when 60 years 
 old, with the idea that people were conspiring against 
 her ; her mental derangement was attributed to a 
 law affair. She was a quiet, industrious old patient 
 till the apoplexy preceding her death. In November, 
 1876, she fell down insensible, but soon regained 
 mental power, still, however, suffering from left 
 hemiplegia. For the next few months she remained 
 in bed, at times being quiet and sensible, in fact 
 more sensible than she had been for years ; but during 
 the night, and at other irregular intervals, she was 
 violent and noisy, sometimes screaming for hours 
 together. She said she felt herself falling through 
 the bed and floor, and gave this as the reason 
 for her excitement. She sank and died in the middle 
 of January of the same year. Post-mortem : the 
 brain, which weighed 38 oz., exhibited consider- 
 able wasting of the convolutions, dura mater thick 
 and adherent to calvarium, arachnoid opaque, pia 
 mater easily separable from brain, much atheroma 
 of vessels at base, a spot of softening the size of a 
 hazel-nut at posterior edge of right thalamus opticus ; 
 there was nothing abnormal in the rest of the viscera. 
 The above case was of interest from the fact that dis- 
 turbance within the skull was associated with chanere 
 in the mental symptoms in a person who, for twenty 
 years, had been under observation in Bethlem, there 
 being a transition from comparative sanity to maniacal 
 excitement. 
 
 The next case is a good example of dementia 
 following apoplexy. Here the patient suffered 
 from more than one attack of apoplexy, but did 
 not regain sanity after the first attack. Alfred D. 
 X— 14 
 
354 Insanity and Allied Iveuroses. [Chap. xiii. 
 
 married, set. 59, doctor; both father and mother 
 died of apoplexy ; he was sober, and had no history of 
 other bodily illnesses. He was admitted in 1872. 
 Six months before admission he had a fit, and from 
 that time he became childish, saying " yes " to every- 
 thing. His memory was so imperfect that he did not 
 recognise his own name, and any words he uttered 
 were incoherent; at times he would give way to great 
 passion, and at other times he would appear melancholy, 
 and burst into tears. Although feeble, he attempted to 
 get about, and he would wander in an objectless way 
 from place to place. In July of the same year he had 
 another fit, which is described as affecting his whole 
 body. In September following he was found by the 
 night-watch on his left side, and vomiting, with his 
 right arm over his chest moving in a waving manner ; 
 he resisted if the right side were pinched ; there was 
 no reflex when a similar stimulus was applied to 
 the left ; pupils were small and equal, breathing 
 became more difficult, and he died on the following 
 day. Post-mortem : there were several indejjendent 
 apoplexies, one affecting the left frontal lobe, which it 
 had excavated ; both occipital regions bore scars and 
 old pigment ; in the right ventricle was a large quan- 
 tity of loose black clot ; brain weighed 50 oz., heart 
 17 oz. ; kidneys with small cysts and with adherent 
 capsules ; convolutions of both sides were flattened 
 by pressure. In this case an unusual number of apo- 
 plexies occurred in one patient, and the result was 
 simple progressive dementia without excitement, the 
 course of the disease being rather rapid. In such 
 cases as this one would recommend that the patient 
 should be kept at home if possible, as the prospect of 
 life is short, and the difficulty of managing a paralysed 
 patient, especially if only weak-minded, is not extreme ; 
 but, as in this case, it may happen that the only place 
 open for the patient is the workhouse or an asylum ; 
 
Chap. XIII.] Apoplexy. 355 
 
 I therefore felt justified in giving him the benefit 
 of Bethlem. 
 
 Mental change immediately following an attack of 
 apoplexy, which vjas followed hy a second fit termi- 
 nating fatally. — Joseph L., married, set. 35 ; no in- 
 sane relations, a jewel-case maker ; first attack of in- 
 sanity attributed to over-work, although there is no 
 evidence as to the nature of this over- work. The 
 patient was admitted into St. Thomas's Home early 
 in November, 1883, suffering from the result of fits, 
 supposed to have been epileptic. He had been ex- 
 cited, and fancied people were against him ; said that 
 hands were continually being placed on his bed with a 
 view of injuring him ; he repeatedly got out of bed to 
 catch these people. He saw rats about his bed, and 
 said that he was walking a great many miles a day on 
 business. His character was said to have been changed 
 ever since an attack of fits. Formerly he was quiet 
 and reserved, but now talkative and communicative. 
 He had attacked his friends ; he thought they were 
 mesmerists and conjurers, who prevented him from 
 sleeping, and that his workshops were in the hospital. 
 Four days after admission I found him apparently in 
 a sane condition, with no sign of paralysis except 
 slight facial palsy. His memory appeared perfect, 
 and he recognised the delusions from which he had 
 suffered. He made complaints of feeling cold, but 
 w^ent to bed at the usual time, and was found dead at 
 4 a.m. Post-mortem : the membranes on right side 
 were gorged with blood, causing considerable flattening 
 of the convolutions ; there were evidently two periods 
 of haemorrhage, one marked simply by blood staining 
 of a brownish colour, which merely stained the frontal 
 lobes and the first occipital lobe, the mass of blood 
 having been absorbed ; the second was a large fresh 
 clot, separating cortex from membranes, which had 
 escaped from right lateral ventricle, the latter being 
 
356 Insanity and Allied Neuroses. [Chap. xni. 
 
 filled with a very large, fresh, soft clot which had 
 burst through the outer part of the corpus striatum. 
 Other parts of the brain were healthy, great thickening 
 and calcification of the mitral valves, and some athe- 
 roma of the aorta. Here we have a case of arterial 
 degeneration and apoplexy in a young man, there 
 being two sets of fits, each represented by a separate 
 haemorrhage ; the first haemorrhage seems to have been 
 slight, and to have spread chiefly over the right frontal 
 region, a small quantity also affecting the occipital 
 region of the same side. Together these haemorrhages 
 were sufficient to set up all the mental disturbances 
 from which the patient suffered. 
 
 Besides the cases in which haemorrhage or softening 
 set up mental disorder, there are other cases, rarely 
 seen except in asylums, in which effusions of blood 
 occur beneath the dura mater. I have seen several 
 such cases in which the appearances were misleading. 
 
 These blood effusions are the result of changes which 
 have given rise to symptoms of general paralysis of 
 the insane, and are stages of pachymeningitis. 
 
 Paralysis agitaiis and its relationsliip 
 to insanity have been described by Professor Bail, 
 of Paris, and at the International Medical Congress, 
 1881, he described moral derangement and insanity 
 as seen in cases of paralysis agitans, and he came to 
 the following conclusions : That mental derangement 
 is more frequent in paralysis agitans than has been 
 generally supposed ; that in slighter forms the psycho- 
 logical change is limited to irritability and restlessness, 
 but that in more severe cases it amounts to positive 
 insanity ; that three forms at least of mental distur- 
 bance may be observed in such cases, the first corre- 
 sponding to what is called lypemania or melancholia, 
 the second closely bordering on dementia, and the 
 third exhibiting an intermittent or periodical charac- 
 ter ; lastly, that there is in cases of shaking palsy no 
 
Chap. XIII.] Locomotor Ataxy. 357 
 
 distinct connection between the loss of intellectual 
 l)OAver and the severity of the pliysical symptoms. I 
 have never had a case in Bethlem of insanity with 
 shaking palsy, but I have seen repeatedly cases in 
 which tlie paralysis was distinctly correlated to mental 
 weakening, and in the main I would accept Professor 
 Ball's observations. I have met with insanity in the 
 children of parents with paralysis agitans. 
 
 Insanity connected t^ itii locomotor ataxy, 
 independently of general paralysis. — Authors 
 have already recognised the fact that locomotor ataxy 
 may be altered in its course by the onset of brain 
 symptoms, and an interesting pamphlet was recently 
 written by Dr. A. Pierret, who traced the relationship 
 between the symptoms of locomotor ataxy and the 
 intellectual disturbance which affected the patients. 
 During the past year I have had several opportunities 
 of verifying these observations, and at Guy's and St. 
 Thomas's I have seen cases which I am kindly allowed 
 to quote for the purposes of this work, and which are 
 good examples: W. H. J., set. 38, compositor; no 
 history of neurosis in the family, no excesses, nor 
 over- work ; married, with several children. Three 
 years before admission (June 23rd, 1881) he noticed 
 difficulty in walking, some pain in the feet, which in- 
 creased. Two years before admission he lost all sexual 
 desire and power; his memory was noticed to be 
 failing, and a year after he lost himself, as he de- 
 scribed it, for an hour or so. At another time he 
 thought his wife was against him, and on awakening 
 in the morning he could not remember the number 
 of his children, nor how old he was ; he became dull 
 and moping, solitary in his habits, with alternate fits 
 of excitement and depression ; he was also disturbed 
 emotionally, and had to give up his work in conse- 
 quence of his mental weakness. For a time he 
 recovered, and was able to work again, but two 
 
358 Insanity and Allied Neuroses. [Chap. xiii 
 
 months before admission into St. Thomas's he had 
 a fit lasting from five to ten minutes, entirely losing 
 consciousness ; the arms, but not the legs, were con- 
 vulsed. From this time the difiicultj in walking 
 became much worse, patella and plantar reflexes ab- 
 sent, gait markedly ataxic, the left leg being the more 
 affected; viscera and urine normal. On July 1st the 
 patient thought he was dead; was depressed and con- 
 fused in his mind for several days ; two small ulcers 
 appeared on the sole of the foot ; left pupil slightly 
 the larger, neither acted to light, but both to accommo- 
 dation ; nothing abnormal in fundus occuli ; some loss 
 of sensation over arms, trunk, and legs, impressions 
 being delayed. Towards the end of July the patient 
 had a rigor, with a temperature of 103-8° ; but this 
 did not seem to affect his general condition in any 
 way. In August he was reported as being better 
 mentally, and soon after he was discharged from the 
 hospital. Dr. Bristowe looking upon the case as one of 
 locomotor ataxy with mental disturbance, and not as 
 a case of general paralysis ; and I must say that, from 
 what I heard, this was borne out, although the history, 
 is suspiciously like many cases of general paralysis. 
 
 In the next case the symptoms were somewhat 
 different, the patient being younger, and the mental 
 excitement more acute. William R,, set. 28, an en- 
 gine-fitter ; admitted into Guy's under Dr. Mahomed, 
 June 7th, 1883 ; enjoyed good health up to the time 
 the present symptoms appeared. For several years 
 he had had trouble with his water, first incontinence 
 and then retention. Five years ago loss of sensibility 
 in lower extremities, with inco-ordination ; three years 
 ago severe abdominal pain, with vomiting ; the last 
 two years has lost sensibility in hands and arms. His 
 symptoms on admission were those of typical ataxy, 
 no symptoms being absent; lightning pains in the 
 extremities, and gastric crises being well marked. He 
 
Chap. XIII.] Locomotor Ataxy. 359 
 
 was described as an intelligent man, with no dulling 
 of intellect in any way. On July 1st he suddenly 
 became unconscious ; his pulse remained good, but his 
 respirations became infrequent ; after half an hour 
 he recovered. During the next fortnight he had 
 several similar attacks, in one of which unconscious- 
 ness lasted for twelve hours, and temperature rose to 
 107°, and he was thought to be dying. On the 6th 
 of July he became noisy and threatening ; for two 
 nights he was constantly struggling and shouting in- 
 coherently ; he fancied he was going to be murdered, 
 and that people were sticking red-hot wires into his 
 legs. He became more quiet, but was suspicious, 
 thinking he was going to be poisoned, and refused 
 food ; he thought a policeman was walking outside 
 his room, and he appealed to him for protection ; he 
 thought that during the night he had been ripped up. 
 By July 19th he had recovered so far as to admit that 
 he had had delusions and hallucinations. From this 
 time he improved to such an extent that he was dis- 
 charged mentally well, although ataxic. 
 
 In a third case, W., set. 45, admitted into Bethlem 
 in 1879, having suffered from well-marked loco- 
 motor ataxy for some years, but without any signs 
 of general paralysis of the insane. This patient was 
 again seen by me early in 1884, when there was still 
 no evidence of general paralysis. He was quite unable 
 to stand, and full of fear of persecution. He said his 
 legs were made to be lightning conductors, and his 
 enemies twisted his guts, removed his semen for their 
 own purposes, and introduced cats up his rectum, thus 
 causing his loss of control over the rectum. 
 
 The chief symptoms that have been described as 
 occurring with locomotor ataxy are those of suspicion, 
 and it is interesting to be able to trace a direct connec- 
 tion between the morbid sensations of a patient suffer- 
 ing from ataxy with delusions. In the earlier stages 
 
360 Insanity and Allied Neuroses. [Chap xiv. 
 
 of this patient's case there had been gastric crises and 
 lightning pains, and it is not a very extraordinary 
 development for a patient to misconstrue these feelings 
 into torture by poison or by red-hot Avires introduced 
 into the limbs. The whole feeling of persecution has 
 to be studied together, and it will be found, when 
 cases are completely investigated, that an idea of per- 
 secution, or a feeling of nervous dread connected 
 with nervous weakness, may be interpreted by ideas 
 of following, haunting, persecution, detectives, or the 
 like by insane persons. 
 
 CHAPTER XIY. 
 
 PUERPERAL INSANITY. 
 
 Insanity associated with marriage — Insanity associated with preg- 
 nancy — Insanity associated with delivery — Insanity associated 
 with the puerperal state — Insanity associated with lactation 
 and weaning. 
 
 Before considering the subject which more especially 
 belongs to this chapter, I shall refer to a group of cases 
 which are not only of grave medical, but also of legal 
 importance. There are cases in which insanity is first 
 recognised soon after marriage. These must be consi- 
 dered from two or three different points of view. First, 
 there are those in whom insanity existed but was not 
 recognised till after the marriage ; secondly, those in 
 Avhom strong predisposition to insanity existed, and 
 the attack was only related to marriage as being its 
 exciting cause (other subdivisions might here be made 
 as to whether the excitement was moral or physical) ; 
 and in the third group, physical exhaustion, due to 
 great excess, caused a mental break-down. I have 
 seen both men and women suffer thus, but women 
 suffer more often than men from shock, distress, and 
 the like, while men suffer more from exhaustion. 
 
Chap. XIV.] Insanity and Marriage. 361 
 
 In the first group, cases occur which are of the 
 utmost medico-legal interest, and it is now established 
 that nullity of marriage can be declared if it be found 
 that one of the contracting parties was insane at the 
 time of the marriage and unable to understand the 
 nature of the contract. I have elsewhere incidentally 
 referred to the case of Hunter v. Hunter, in which 
 this was decided ; but quite recently I was called in 
 to see another case with the following history : A girl, 
 whose father was and is insane, became engaged to 
 be married to a very suitable man. Everything ap- 
 peared to go on satisfactorily till the wedding day 
 was fixed, when the girl began to doubt her affection 
 for her sweetheart. She ceased to superintend her 
 trousseau, and gave up many of her favourite 
 pursuits. Her friends and relations thought that 
 as soon as she got married all would be right ; but 
 when married she seemed still more desponding and 
 unlike herself, and refused altogether to allow her hus- 
 band to have connection with her. I have little doubt 
 but that with time she may become herself again, but 
 I should strongly advise her husband to have nothing 
 more to do with her. 
 
 A Scotch doctor for some years, after a very suc- 
 cessful academical career, went into general practice 
 and bid fair to succeed in his profession. He be- 
 came engaged to be married, and nothing in any 
 way peculiar was noticed in his manner till shortly 
 before his marriage, when he was noticed by his 
 friends to be eccentric ; but this was at the time 
 looked upon as the result of excitement, and likely to 
 prove of a transient nature. On the day of the 
 wedding his behaviour was still more strange, and his 
 bride was alarmed at his conduct. This state of 
 excitement and mental instability persisted, so at the 
 end of a few weeks a separation had to take place, 
 and soon after the husband was sent to an asylum, 
 
362 Insanity and Allied Neuroses, [chap. xiv. 
 
 where his symptoms became those of acute mania, 
 which passed into a condition of chronic delusional 
 insanity, from which he suffered for years ; however, 
 at the end of seven years a change took place in his 
 mental state, and it seems now doubtful whether he 
 may not in the end become well enough once more to 
 be at large. I am, however, convinced that his wife 
 would be perfectly justified in sueing for a divorce, on 
 the plea of insanity at the time of the marriage. 
 
 In the next case there was no insanity till after 
 marriage, and excess is said to have started the break- 
 down. T. L., married, set. 23, actor by profession ; 
 strong nervous tendency in the family, but no re- 
 cognised insanity ; no previous attack of insanity. 
 He had been married three days before the attack 
 broke out. It began with great taciturnity, varied by 
 excitement coming on without assignable cause. He 
 had some exaltation of ideas, and at the same time 
 fancied he had committed the unpardonable sin. For 
 eight months he was under treatment and was finally 
 discharged well, and has remained so since. I have 
 met with no good example of insanity purely started 
 by marriage, both as a predisposing and exciting cause. 
 In most of the cases I have seen, the marriage has 
 been the exciting cause of the outbreak, or has simply 
 made manifest the insanity which has existed before. 
 
 Insanity following marriage shock. — Emma A., 
 married, set. 24 ; epilepsy in family, sober, industrious, 
 had a fit of some kind three days before admission. Her 
 lover attempted her seduction, and this was a great 
 grief to her, and caused a temporary mental distur- 
 bance, but she went on with the engagement, and 
 was married. The morning after marriage she was 
 incoherent and wild. She wandered from home, and 
 was taken up by the police. She threatened suicide, 
 and she took a violent hatred to her husband. She 
 had hallucinations of hearing, hearing her husband's 
 
Chap. XIV.] Insanity of Pregnancy. 363 
 
 voice chiefly iii the right ear. She was nervous and 
 weak, obstinate at times, and at others impulsive. 
 She remained in this state of partial weak-mindedness 
 for the three months she was in Bethlem. I heard 
 she slowly recovered after some months at home. 
 
 Insanity of pregnancy and cMld-hirth. — A very 
 large proportion of acute cases of insanity depend 
 for their cause on the above conditions. The non- 
 medical world is perfectly familiar with these cases. 
 There are very many and important considerations to 
 be referred to in this connection, as the disorder has 
 more social aspects than have many other forms of 
 insanity. I shall have to consider the relationship 
 of the woman to her home, her husband, and her 
 child. 
 
 There is also the important question of the taint 
 and its transmission to the offspring, and the liability 
 to recurrence of similar attacks. 
 
 The question of recurrence is one which is also of 
 great importance ; and I am inclined to believe that 
 the discredit which attaches to "cures" of insanity, 
 to a great extent, is due to the fact that so many 
 patients, who have suffered from puerperal insanity, 
 have other attacks under similar circumstances. 
 
 The subject divides itself naturally into one of 
 three periods, namely, the insanity of pregnancy, the 
 insanity of delivery (which again must be considered 
 as insanity commencing with delivery, that imme- 
 diately following delivery, and insanity coming on 
 a few weeks later), and the insanity of lactation, or, I 
 would prefer to say, the insanity occurring during 
 lactation or at the period of weaning. 
 
 I would premise by saying that, as far as the 
 symptoms are concerned, there is absolutely nothing 
 characteristic in the form which the insanity assumes ; 
 and that with puerperal conditions you may have 
 mania, melancholia, or dementia j and the very term 
 
364 Insanity and Allied N'euroses. [Chap. xiv. 
 
 puerperal mania is misleading. I am of oj)inion that 
 inheritance plays a very important part in puerperal 
 insanity. 
 
 First, the insanity of pregnancy. These cases are 
 not nearly so common as those following childbirth. 
 They are divisible into two classes : those in which 
 insanity comes on in the earlier months of pregnancy, 
 and those in which the derano-ement occurs durins^ the 
 later months. It must be remembered that it is 
 quite common to get exaggeration of the ordinary 
 reflex nervous symptoms of pregnancy in neurotic 
 patients ; that, in fact, longings of pregnancy may 
 pass beyond the limits ordinarily met with and become 
 insanity. I have seen cases in which extraordinary 
 appetites have been connected with pregnancy in 
 neurotic subjects ; and what is more, I have seen the 
 offspring of mothers who have suffered from these 
 unusual conditions themselves later develop insanity. 
 Insanity of pregnancy may occur with a first preg- 
 nancy, or, what is more common, it may occur with 
 a later one ; and I am inclined to believe that the 
 following is the more common mode of production 
 of such cases : A woman of insane family becomes 
 pregnant, and with the pregnancy has some marked 
 nervous peculiarities, which pass off and are forgotten 
 till after delivery, when they reappear ; or when 
 sleeplessness, irritability, and change of character 
 usher in an attack of ordinary puerperal insanity. A 
 second and third pregnancy, occurring within short 
 intervals, are each followed by attacks of insanity. 
 But with the fourth and fifth pregnancy the eccen- 
 tricity of pregnancy becomes undoubtedly an insanity, 
 and the patient, during the earlier months of preg-- 
 nancy, suffers either from maniacal or melancholic 
 symptoms, which may pass off to reappear after 
 pregnancy, or they may continue steadily through 
 the pregnancy up to delivery, and beyond it; the 
 
Cbap. XIV.] Insanity of Pregnancy. 365 
 
 patient seeming to become more and more unstable in 
 consequence of preceding attacks of insanity, till at 
 last a very much less force is required to upset tlie 
 balance. One such case I have known to become 
 ultimately so little able to resist causes of depression, 
 that insanity, at first following delivery, next occurred 
 with pregnancy, and then followed a simple inflam- 
 mation of the tonsils. It is noteworthy that more 
 disturbance, both of body and mind, may occur with 
 male than with female pregnancies ; and cases are 
 recorded in which chorea or epilepsy has followed 
 only when the children have proved to be males ; 
 and although no general law can be deduced, yet it 
 is interesting to find that popular feeling in this case 
 coincides with medical experience. 
 
 Cases are also recorded in which insanity has 
 passed ofi" when conception has taken place ; and I 
 have met with such cases as the following : A 
 woman, having suffered from puerperal insanity, and 
 having been secluded for some months, has lost all her 
 excitement, but has become apathetic, and might be 
 described as suffering from partial dementia. Nothing 
 that we could do in the asylum roused her or made 
 her anxious to return to her home and family ; but 
 by sending her home and re-establishing home rela- 
 lationship, she has become rapidly better, although 
 sometimes the improvement has been associated with 
 a fresh pregnancy. I do not think the pregnancy 
 alone was the cause of the recovery. 
 
 The insanity of pregnancy may be maniacal or 
 melancholic, but in my comparatively small expe- 
 rience of such cases, I should say it was generally 
 melancholic with hypochondriacal symptoms, or with 
 misinterpretation of the ordinary signs of pregnancy. 
 Thus, a woman suffering from insanity of pregnancy 
 believed that the vomiting from which she was suffer- 
 ing was due to poison ; acting on this belief she 
 
366 Insanity and Allied Neuroses. [Chap. xiv. 
 
 persistently refused food, and accused her husband of 
 wishing to get rid of her. If I see a case in which 
 the symptoms of insanity have slowly developed 
 during the first two or three months of pregnancy, 
 and have been directly connected with excessive 
 vomiting, neuralgia, and sleeplessness, I generally give 
 a favourable prognosis, considering that the patient 
 will probably re-establish her nervous balance by 
 the end of the fourth month ; and in many such 
 cases I have seen the patients make a perfect 
 recovery, and pass through the puerperal state un- 
 disturbed. Patients of this class may break down 
 again after delivery, or they may have similar 
 attacks with succeeding pregnancies. But, on the 
 other hand, I have known cases who have had 
 no second attack at all. As to treatment, I would 
 advise the ordinary measures recommended for vomit- 
 ing and neuralgia in pregnancy ; although I have 
 failed myself to do good with such drugs as cerium, 
 hydrocyanic acid, or morphia, I have found attention 
 to the bowels and to the general hygienic measures of 
 much greater service. 
 
 The question of induction of premature labour has 
 been referred to me by several obstetric physicians, 
 and I have uniformly said that I have never yet seen 
 a case which justified its practice, for in the first 
 place the operation will probably have no efiect in the 
 way of cutting short an attack of insanity, and adds 
 somewhat to the dangers to life incurred by the 
 patient. I have seen miscarriages occur in the insane 
 without any mental gain following them, and, there- 
 fore, the only justification to my mind wmild be the 
 destruction of a child who ran a very great risk of 
 being an idiot. 
 
 Insanity coming on during the later months of 
 pregnancy is more common than that last described, 
 and is generally associated with melancholia. Again, 
 
Chap. XIV.] Insanity WITH Early Pregnancy. 367 
 
 there are commonly ideas of poison in the food, dis^ 
 like to husband, suspicions and general dreads, apathy 
 and negligence of personal appearance and of home 
 duties. Whether only a coincidence or not, I cannot 
 say, but I have recently seen general paralysis of the 
 insane occurring in pregnant women, and I shall have 
 to record in brief one or two such cases. 
 
 During the past year three patients have been 
 admitted into Bethlem suffering from the insanity of 
 the later months of pregnancy, and these cases have 
 had to be discharged temporarily to be delivered at 
 home, as no provision for such cases exists in Bethlem. 
 
 Example of insanity with j^Tegnancy.—Elizsiheth 
 K., married, set. 32, has had three children, the young- 
 est being sixteen months old. She was admitted into 
 Bethlem in August, 1883, she then being five months 
 pregnant, with symptoms of insanity which had lasted 
 less than one month. They came on suddenly during 
 one night, when she woke up and said that she had cruci- 
 fied Jesus Christ. She attempted to destroy her life by 
 throwing herself from the window. She thought her 
 children had already been killed ; had hallucinations 
 of sight and hearing; believed there were faces at the 
 window, and that voices were audible outside her 
 room ; she was in constant dread of some terrible 
 catastrophe which was about to happen. After ad- 
 mission she was noticed to be dazed and confused, 
 with loss of memory. This condition of suspicion and 
 dread passing into weak-mindedness persisted till she 
 was sent away to be delivered. Before delivery she 
 appeared to regain her mental soundness, but six 
 weeks later, having become physically weak, she 
 again became melancholic, and had to be re-admitted 
 into Bethlem, where she rapidly recovered. 
 
 Insanity with early 'preg7iancy. Recovery about 
 five months. Delivery and maintenance of health. — 
 Louisa C, set. 24 ; no insane relations ; second attack 
 
368 Insanity and Allied Neuroses. [Chap. xiv. 
 
 of insanity. First followed child-birth. Present 
 attack began in June, 1883. (She was delivered in 
 March, 1884.) She became restless and wanted to 
 leave her home. She was emotional and quarrelsome; 
 she destroyed her clothes, and believed her husband 
 was very rich. On admission into Bethlem she was 
 noisy, silly, and given to causing mischief; she had 
 ideas that her child had been poisoned. She became 
 more quiet for the first time in September, but again 
 became silly. In October a marked improvement 
 took place, which continued without relapse. She was 
 sent out on leave, was delivered naturally of a healthy 
 female child, and was discharged recovered. 
 
 In the following case we have a very good example 
 of the various conditions connected with puerperal 
 insanity and the insanity of pregnancy : F. M,, mar- 
 ried, set. 21 ; paternal uncle epileptic, great aunt 
 insane, one brother epileptic, another suffered from 
 insanity produced by drink, and the father was 
 an extremely excitable man. The patient had suf- 
 fered from hysterical attacks, and had also had an 
 attack of chorea during pregnancy. She had a pre- 
 mature confinement with her first child, but did not 
 develop insanity then. When admitted into Bethlem 
 she was pregnant two or three months. She was 
 then restless, violent, and at times accused herself of 
 unfaithfulness. There were peculiar choreic move- 
 ments of her limbs. She resisted food and medicine, 
 and said her food was poisoned. At this time she 
 had the morning sickness of pregnancy. For some 
 weeks she was emotional, violent, and destructive, 
 refusing her food. Later, about the fourth month of 
 her pregnancy, there was much general improvement. 
 Her aflfection for her husband returned, and she began 
 to occupy herself in her ordinary ways, and by the 
 fifth month of pregnancy was well enough to go home 
 on leave, and later was delivered of a female child 
 
Chap. XIV.] Pregnancy with Paralysis. 369 
 
 after an easy labour. Witliin four days of delivery 
 she became noisy and violent again ; she was brought 
 back to Bethlem, where she went through another 
 sharp attack of acute mania, aud had to be fed wdth the 
 stomach-pump for some days. Within two months of 
 her delivery she was again convalescent, and was 
 discharged recovered, and she has had several children 
 since without any recurrence of insanity. Fortunately 
 domestic and other conditions were favourable for 
 her. 
 
 In the next case insanity was connected with 
 the early months of pregnancy. Emma N., set. 33, 
 sister likewise insane; first attack, following domestic 
 trouble. It came on two months after she had 
 ceased to menstruate from pregnancy. She be- 
 came strange in manner, and took no notice of her 
 children j she refused food, and would not speak ; 
 tried to strangle herself with a towel. I may say 
 that this pregnancy followed immediately on her 
 recovery from her last delivery, she suckling at the 
 time. She thought men were waiting for her in the 
 passage to take her away ; she was subject to halluci- 
 nations of hearing, and her physical condition was one 
 of extreme weakness. During her stay in Bethlem, 
 I'est, regular diet, and quiet caused her to lose her 
 delusions, and she has been discharged sufiiciently 
 recovered to pass through her confinement at home. 
 
 General 'paralysis associated with 'pregnancy. — 
 That with general paralysis the bodily functions may 
 be healthily performed in many respects is note- 
 worthy. The general paralytic may appear for some 
 time strong, stout, and lusty ; I have known more than 
 one general paralytic father beget children. I have 
 now to note cases in which general paralysis occurred 
 in pregnancy. In one case the patient was admitted 
 into Bethlem pregnant, with fully established general 
 paralysis. She was delivered of a living child, and 
 Y— 14 
 
370 Insanity and Allied NEUROSES.VZ\^z.^.y.\N. 
 
 once more, while at home, became pregnant. In the 
 other case the symptoms of general paralysis occurred 
 about the same time. Procreative power may remain 
 in general paralysis till quite a late period of the 
 disease, and so may pregnancy, with its fearful risk 
 to the children. 
 
 A. B., married, set. 33, housewife, mother said 
 to have died of "brain-softening;" the cause of the 
 insanity said to be anxiety and over- work. She had 
 had two children, and it was a question whether her 
 mental condition had been quite the same during the 
 past two or three years. When admitted into Beth- 
 lem menstruation had been absent for two months, 
 and it proved that she was pregnant. She was rest- 
 less, constantly muttering to herself, irritable, talka- 
 tive, and incoherent; muscularly weak, with great 
 tremor of facial and lingual muscles; speech drawling 
 and indistinct, with general hesitation ; loss of 
 power in lower extremities and bladder. This con- 
 dition of mental and physical weakness progressed 
 till she was discharged to be delivered elsewhere, since 
 which time the mental symptoms have been less 
 marked, but sufficiently clear to verify the diagnosis. 
 
 Temporary relief of insanity may occur during 
 the act of delivery. Two distinct points deserve 
 consideration. First, the insane mother may be 
 delivered unconsciously, there being anaesthesia, so 
 that a weak-minded woman may give birth to a child, 
 and it may found smothered in her bed, and yet 
 she may truthfully say she did not know of its 
 birth ; secondly, a patient who has suffered from in- 
 sanity of the later periods of pregnancy may, during 
 labour, appear to wake up and to appreciate every- 
 thing about her, only to relapse after delivery is 
 fully accomplished. 
 
 Insanity of delivery. — "With delivery one has 
 frequently seen considerable mental disturbance as a 
 
Chap. XIV.] Puerperal Insanity. 371 
 
 purely natural and physiological circumstance ; but 
 beyond this a condition may arise more or less of 
 temporary derangement, the pain of labour starting a 
 condition of mental instability which may become 
 fully developed insanity ; and just as, on the one hand, 
 I referred to a case in which the pain of labour was asso- 
 ciated with temporary return of reason, so the nervous 
 shock may, on the other hand, upset the balance. 
 Such cases are rare, and have notliing special in them 
 beyond the causation. 
 
 Puerperal insanity. — True puerperal insanity 
 may be maniacal, melancholic, or demen-^ed in form. 
 As I have said, the maniacal attacks are those which, as 
 a rule, come on soonest after a delivery. It has been 
 said that there are critical periods, and that there is 
 special danger with the onset of milk, with the recur- 
 rence of the time representing the menstrual period, 
 and later, that weaning is a source of special danger ; 
 but I have failed to find any specially critical 
 periods. 
 
 Before considering the causation of puerperal in- 
 sanity more fully, I would call attention to the period 
 of delirious excitement which may come on during the 
 second or third day after delivery. A mania transi- 
 toria may arise suddenly and pass off as quickly ; the 
 patient will have a flushed appearance, with a full 
 pulse, and active, talkative delirium, with hallucina- 
 tions, in which she may cause damage to herself and to 
 her child. This state of excitement may be frequently 
 subdued by the administration of a purge and a nar- 
 cotic at night. Medico-legally this condition is of 
 great importance, because during this period of ex- 
 citement the mother may commit infanticide, and not 
 only be guiltless as far as responsibility is concerned, 
 but may have not the smallest recollection of what has 
 taken place. 
 
 It is generally accepted that physical causes plaj 
 
372 Insanity and Allied Neuroses. [Chap. xiv. 
 
 a greater part in the production of this variety of in- 
 sanity than do moral causes. Inheritance is of great 
 importance as a predisposition, and in my experience 
 it is common to find the inheritance directly trans- 
 mitted, that is, along the female side. I have known 
 both mother and daughter suffer from puerperal in- 
 sanity. When child-bearing begins late in age 
 there is an increased danger. Any specially 
 depressing causes, such as prolonged suckling, 
 followed by another pregnancy, or rapidly recurring 
 pregnancies, delivery of twins, and the like, are 
 noteworthy in the causation. I do not find, in my 
 experience, that instrumental labours are specially 
 dangerous. The causes in most cases are multiple, 
 and have often been acting some time before delivery 
 takes place. Thus, during pregnancy, there may have 
 been a drink-craving which has been yielded to, and 
 this has predisposed to an attack of insanity. Other 
 physical causes, such as ulceration or abscess of the 
 breast, may have had a share. Insanity, too, may 
 follow eclampsia, although this is rare also. I believe, 
 however, that it is not very uncommon to meet 
 with violent- acute mania, associated with pyeemic 
 conditions, and a few patients die every year 
 in Bethlem in whose cases I believe pysemia has had a 
 share in the causation of the disorder. It is note- 
 worthy that labours in which chloroform has been ad- 
 ministered have, in my experience, several times been 
 followed by attacks of insanity in patients who have 
 had other children before and after, born without 
 anaesthetics, without attacks of insanity. 
 
 As to the moral causes, grief, worry, anxiety, and 
 the like, are the most effective. Fewer women seem 
 to become insane after the birth of illegitimate chil- 
 dren than might have been expected. Dr. Clouston 
 shows that in Scotland illegitimate births give 
 rise to an excessive number of cases of insanity, 
 
Chap. XIV.] Puerperal Mania. 373 
 
 in some cases seduction and the birth of natural 
 children act distinctly as a cause. Desertion or death 
 of husband, and loss of the child, may act as severe 
 causes of depression, which may pass beyond a natural 
 limit. The above are the more common causes, vs^hich 
 may act separately or combined. The ordinary course 
 of an attack of puerperal mania is as follows : A 
 patient having had no bodily trouble to excite the at- 
 tention of her friends, becomes sleepless, but without 
 depression at first ; she seems ill at ease, and then 
 may complain of some uneasiness in her head ; next 
 she complains that she is afraid she is going to lose 
 her reason. The sleeplessness, however, is the most 
 marked early symptom, the milk and lochia often 
 being both natural, she takes a dislike to her husband 
 and perhaps to her child, making trifling complaints 
 against one or the other. She often complains of un- 
 pleasant smells, and becomes irritable with all around 
 her. Next she complains of her food, and may alto- 
 gether refuse to take it. This period of sleeplessness, 
 with irritability and some depression, is followed 
 sooner or later by excitement, chattering, incoherent, 
 blasphemous or amorous talk, and then the attack of 
 mania is fully developed. There is nothing special 
 in its form, but there are a few symptoms which are 
 more commonly present than perhaps in other cases 
 of mania, such as sleeplessness, anxiety, aversion to 
 relations, erotic tendencies, mistakes of identity, with 
 hallucinations of smell and taste, and refusal of food. 
 M. B., married, set. 28, four children, no insane 
 inheritance, the last confinement three weeks before 
 admission, symptoms coming on one week after 
 delivery. The first marked symptoms beyond sleep- 
 lessness were peculiar ideas about her food, antipathy 
 to those dear to her, violence in language, destructive- 
 ness of clothing, dirtiness in habits, and blasphemous 
 and filthy language. She had hallucinations of sight 
 
374 Insanity AND Allied Neuroses.iqm^v-^^^- 
 
 and hearing ; said she saw her babies in heaven, and 
 that she was bewitched at night ; complained of nasty- 
 smells ; thought she was the Virgin Mary ; and was 
 generally obstinate and incoherent. For some time 
 she remained in much the same condition, but at the 
 end of five months she was sent to our convalescent 
 home, and at the termination of another month was 
 discharged well. 
 
 The next case was in many respects similar. 
 Isabella M., married, set. 26, no insane relations. 
 This was her second child. The first symptoms followed 
 between the second and third week after delivery, 
 when she became sleepless and talkative ; talka- 
 tiveness is a very common adjunct to the sleepless- 
 ness. She rapidly became worse, her language grow- 
 ing violent and obscene. She had delusions, and 
 thought she was the mother of God and Mary of 
 Bethany ; she mistook people at times j she refused 
 food ; she called her husband by various names, at one 
 time thinking he was Christ ; she had a great dislike 
 to her child ; and she was fed with the stomach- 
 pump. On admission she was suff'ering from a 
 typical attack of acute mania, and this condition of 
 excitement continued without any alleviation for five 
 months, when, after menstruation had been re-estab- 
 lished, she recovered completely and was discharged 
 well, having been under observation six months. 
 
 There are some special points in these cases 
 requiring consideration. First, as to the milk. Milk 
 may be suppressed at the time of the outbreak ; 
 it may continue after the development of mental 
 symptoms, and in such cases there is great danger lest 
 the breasts should be neglected and abscesses form in 
 consequence of the whole of the attention being paid 
 to mental symptoms. In Bethlem friction of the 
 breasts with salt or with castor oil is more frequently 
 adopted than the use of belladonna, and with 
 
Chap. XIV.] Puerperal Mania. 375 
 
 satisfactory results. The lochial discharge may be 
 suddenly arrested in some cases, especially in those 
 in which there is suspicion of pyaemia \ but in an 
 ordinary case of puerperal insanity the lochial dis- 
 charge continues normally. I have known both milk 
 and lochia suppressed, both present, or one present 
 and the other absent, during attacks of insanity. 
 Puerperal insanity is supposed to be a specially curable 
 disease, but, in my experience, a considerable proportion 
 of the cases of acute mania die, bearing out what I 
 have elsewhere said, that mania associated with 
 surgical or other troubles is a serious bodily disease. 
 A very large proportion undoubtedly do recover^ and 
 of these a considerable number have recurrences of the 
 disorder ; nor does it follow that means taken to pre- 
 vent having children will hinder attacks of insanity. 
 Besides death and recovery, I have to record that a 
 large number of cases remain either permanently insane 
 or permanently weak-minded after a single attack of 
 puerperal insanity, and therefore, even in a first attack, 
 great caution must be used in giving a prognosis. A case 
 of acute puerperal mania, having lasted from two or 
 three to eight or nine months, will often become 
 healthy in appearance but weak in mind. Nourishing 
 diet, stimulants, and the like, have produced general 
 health, but dementia remains, the patient taking little 
 or no interest in her surroundings, exj^ressing no 
 desire to return home, and seeming indifferent to 
 husband and children. Such cases, as a rule, will be 
 found to be suffering from amenorrhoea, or if not the 
 prognosis is grave in the extreme. I always look 
 upon the consecutive weak-mindedness of puerperal 
 mania as being curable while menstruation is absent, 
 but when physical health is re-established without 
 mental gain the prognosis is bad. 
 
 It is of tJie utmost importance that such cases 
 should be sent home on trial before all chance of 
 
37<3 Insanity and Allied Neuroses. [Ch^v-y^^"^- 
 
 recovery is at an end. I believe tliat the re- establish- 
 ment of home relationships is about the best means of 
 cure for many of these cases. As far as the treatment 
 of a case o£ acute puerperal mania is concerned, I 
 would take the symptoms somewhat in detail. The 
 general and guiding principle must be to give rest and 
 support. Rest must be procured by general measures 
 and not by means of narcotics. Chloral and bromide of 
 potassium, morphia, and henbane have been tried and 
 failed ; they rarely secure sleep, and, if continued, 
 leave the patient more unstable and farther from 
 health. If cases like these are treated at home, it will 
 be necessary to make use of one. or other narcotic, 
 and I generally advise a frequent change in the 
 remedies, so that a patient is treated with bromide 
 of potassium one night and chloral the next. With 
 sleeplessness, beef-tea, a glass of spirits and water, or 
 a bottle of porter may give rest when narcotics fail ; 
 and there is no reason for any dread of stimulants in 
 mania. The friends and certainly the children should 
 be kept out of sight of the mother. The room should 
 be kept cool, bright, and well ventilated. The bowels 
 should be kept acting regularly, all sources of local 
 irritation about the vagina should be removed, and, 
 as soon as the patient is strong enough, bathing 
 should be made use of. When strong enough to get 
 about, the patient should have fresh air, out-of-door 
 exercise, and a change to the seaside is often bene- 
 ficial. 
 
 One other question of treatment remains as to 
 which class of patients should be sent to asylums, and 
 when. There is a very strong feeling against sending a 
 young married woman to an asylum when the attack 
 follows a first child, the feeling being natural that the 
 child or children will sufier socially, and that the 
 mother herself will look forward with dread to any 
 future confinement. If the friends have ample means, 
 
Chap. XIV.] Melancholia. 377 
 
 if their home is in a healthy district, and if the doctor 
 can see the patient twice daily at least for the first few 
 weeks, it is possible to treat almost the most serious 
 case at home, but any of the above conditions being 
 wanting, it will be found well to remove the patient 
 from her former surroundings. The chief dangers 
 arise from refusal to take food, exhaustion from un- 
 trained attempts to keep the patient quiet, and from 
 wild ungoverned actions depending upon delusions in 
 reference to husband or child ; so that, to sum up 
 on these cases of puerperal mania, they are mainly 
 curable, but some die and others remain from the 
 first weak-minded. The treatment is supporting and 
 calming, the smallest quantity of narcotics and the most 
 food possible ; although some must be sent to asylums, 
 they must not be kept under control too long, but 
 should be sent home as soon as symptoms of danger 
 have passed ; and it may be remembered, that although 
 it is well to advise caution in regard to other pregnan- 
 cies, it does not follow that a patient will keep well 
 in consequence of having no more children, nor does it 
 follow that because she has had one attack of insanity 
 she will have attacks following the birth of every child. 
 
 Besides the attacks of mania there may be attacks 
 of melancholia, the onset of the disease being in every 
 respect similar to the attacks of mania ; sleeplessness, 
 anxiety, and dread, being followed by delusions in 
 reference to husband or children, and associated with 
 hypochondriacal or other similar symptoms. As I 
 said before, melancholic symptoms generally, but not 
 always, come on later after delivery than attacks of 
 mania, and in the cases under consideration melan- 
 cholia is the rule, mania the exception. 
 
 Harriet K. B., married, aet. 26, had three children, 
 the last born three months before her admission into 
 Bethlem. Her mother suffered from insanity, associated 
 with cancer. The first symptom, after sleeplessness, 
 
378 Insanity and Allied Neuroses. [Chap. xiv. 
 
 was refusal to take food. She said she had eaten too 
 much food, and was therefore lost j that God would 
 never forgive her, and that there was no passage 
 through her bowels. Her habits were said to have 
 completely altered. She no longer took interest in 
 her children, nor would she go out of the house. 
 These symptoms came on insidiously without any 
 special exciting cause within a fortnight of de- 
 livery. She was suicidal, and represented very well 
 the type which may become dangerous ; for patients of 
 this class will not only desire death for themselves, 
 but also for their children. Within a fortnight of 
 admission this patient began to take her food freely ; 
 but her mental symptoms varied so that she would eat 
 well for a time, and then refuse food ; at the one time 
 being less influenced by her false ideas than at the other. 
 She became more actively troublesome about five 
 months after admission, and caused anxiety from her 
 rapid emaciation. It was found she was in the habit 
 of eating her meals, and then making herself sick. 
 Being carefully watched, this was prevented, and the 
 patient steadily improved, and was well mentally at the 
 end of six months. After her recovery she gave an 
 account of her feelings, of which the following are 
 the most important details : 
 
 May 3rd, 1884. 
 Mrs. K. B. — Has been ill since birth of child 
 (third), 18th of July last. From that period until 
 the present time entire cessation of courses. About 
 fourteen days after confinement felt that " God 
 would not forgive her," "that she was lost." Ex- 
 tremely depressed. Thought she had " committed 
 suicide and every crime under the sun." Did not 
 hear voices, but " felt that something told her to go 
 and hang herself." She procured a rope for that 
 purpose, but was prevented from carrying out her 
 design by her friends. Was extremely sleeplesfi 
 
Chap. XIV.] Insanity OF Lactation. 379 
 
 all this time. Kefused food, thinking she would 
 starve herseJf^ but yielded when pressure was used. 
 She had great repulsion to husband and children, 
 which she says was a great change in her sentiments, 
 as she always was much attached to both. She had 
 no desire to injure the child last born. Gives a 
 perfectly clear and lucid account of her condition, 
 and appears to have an active remembrance of her 
 delusions. 
 
 In some cases after delivery the patient slowly 
 becomes apathetic ; she takes little or no notice of her 
 child, and may be slightly emotional ; her indifference 
 becomes more and more marked, till it is recognised as 
 a mental disorder. She neglects her personal cleanli- 
 ness, and has to be tended like a child ; this condition 
 may slowly pass off, or it may be but the early 
 symptoms of an incurable state of dementia. 
 
 InsRiiity of laictatioii. — Insanity of lactation 
 is a variety of insanity in which exhaustion seems to 
 play the chief part. Some women suffer severely 
 from weakness, whenever they attempt to nurse 
 their children ; but the cases which one sees in an 
 asylum very frequently are those in which lactation 
 has been prolonged to an unhealthy extent, with the 
 idea that thereby pregnancy would be avoided. 
 In several cases I have seen the prolonged lacta- 
 tion produce all the evils of weakness, yet succeeded 
 by a pregnancy, and thus not only has there been 
 physical depression, but moral worry in addition. 
 The term over-lactation must be looked upon as 
 purely relative, and some writers would look upon all 
 cases of insanity coming on two or three months after 
 delivery as cases of insanity of lactation, by reason of 
 the similarity of the symptoms. The number of cases in 
 which the insanity was distinctly traceable to lactation 
 has not been numerous in my experience, and I have 
 seen quite as many cases associated with pregnancy as 
 
380 Insanity and Allied Neuroses. [Chap. xiv. 
 
 with lactation. The symptoms naturally divide them- 
 selves into the bodily and mental. There is commonly 
 pallor, with a peculiar chlorotic appearance, giddiness, 
 indigestion, with uneasy feelings at the top of the 
 head, shortness of breath, and complaints of palpita- 
 tion, generally associated with sleeplessness. Mentally 
 most of the patients are depressed, dreading some harm 
 for themselves or their children, irritable at times, with 
 delusions of unworthiness, and with hallucinations of 
 sight, smell, and hearing. These cases frequently get 
 well. I expect an ordinary case of this kind to take 
 from three to six months in an asylum to recover, and 
 I believe the sooner you are able to send such cases to 
 the seaside, or away from towns, the better. Various 
 forms of stimulant and tonic should be given. Iron is 
 very useful, and partly digested foods or cod-liver oil 
 in some of its simpler forms, or hydroleine, will be 
 found useful, the sleeplessness being treated by food 
 rather than narcotics. Such attacks may recur, and 
 it is of special importance to get the general health 
 re-established before any fresh pregnancy occurs. The 
 following case is a fair example of the ordinary symp- 
 toms met with in this disorder : 
 
 E. M., married, set. 29, mother and two bro- 
 thers insane, sister died of phthisis. The patient 
 has had rheumatic fever ; this is the second attack 
 of insanity ; the first being four years ago j she 
 has had three children, the youngest being four- 
 teen months old. Since the birth of this child 
 she has not menstruated ; but suckled up to the 
 time of her insanity, which came on one month before 
 admission, when she became very excitable, and for a 
 time was maniacal, having a tendency to be erotic ; 
 she had hallucinations, and said she had seen the devi], 
 and heard cats when none were about. She mistook 
 people, and was coarse and violent in her language. 
 Within two months of admission she had a slight 
 
Chap. XIV.] Insanity of Lactation. 381 
 
 attack of rheumatism, followed by mental improve- 
 ment, and from this time her general health became 
 better, and she recovered, being discharged three 
 months after admission. 
 
 In the next case the symjDtoms were those of 
 melancholia, with active expression, followed by re- 
 covery. Florence B., married, set. 20 ; maternal ancle 
 insane. This attack followed her first confinement, 
 and came on with dulness and depression four months 
 after delivery. She became steadily more dejected, not 
 speaking nor taking any interest in things about her. 
 When pressed she said she had lost her soul, and that 
 she saw strange figures in her room \ that she had 
 given her child away, and that her husband had de- 
 serted her. She feared ruin, and was concerned about 
 the costliness of everything, dreading she would be 
 unable to pay. She refused her food, and was on 
 several occasions noisy, as well as sleepless at night. 
 She tried to force her way out of the window, and had 
 to be placed on the ground floor. For some time no 
 change took place, her aspect being one of extreme 
 misery, and her face covered with indolent acne, 
 which she pricked, causing her face to be sore and un- 
 healthy-looking. Three months after admission her 
 appetite began to improve, and she slept better. From 
 this time her interest in her surroundings re-developed, 
 and after one month's leave she was discharged, re- 
 covered, seven months after admission, and eight 
 months after the beginning of the attack. 
 
 The above cases, occurring in young women, are 
 examples of the curable form ; but if there had been 
 several previous attacks of insanity, and if the jDatient 
 had been older, the prospect of cure would have been 
 much less, such patients passing into states of chronic 
 melancholia or of weak-mindedness. 
 
382 
 
 CHAPTER XV. 
 
 EPILEPSY AND INSANITY. 
 
 Epilepsy a symptom of insanity — A neurosis allied to insanity 
 by origin — Similar conditions causing both insanity and 
 epilepsy — Epilepsy producing insanity — The frequency not 
 the severity of the fits of most importance ; the younger 
 the patient the greater the danger ; idiocy resulting— Bru- 
 tality of epileptics — Mania — Melancholia or dementia as- 
 sociated with epilepsy — Ej)ileptic furor. 
 
 Epilepsy and insanity.— The days wlien epilepsy 
 was considered to be a disease apart from insanity have 
 passed away. Epilepsy is only to be considered as a 
 symptom which may arise from an almost endless 
 variety of changes in the brain. Vascular or structural 
 changes may cause a condition of motor instability which 
 is represented by the return of these epileptic discharges. 
 We, at present, do not know what starts the discharge ; 
 but whatever the condition is, there seems to be a uni- 
 formity as to its origin, for in the great majority of 
 cases the symptoms repeat themselves exactly ; and 
 in referring to what may be called mental epilepsy, 
 the chief characteristic will be found to be the abso- 
 lute uniformity of the symptoms ; however, we are not 
 at present concerned with the production of epilepsy, 
 only finding space here for the record of mental symp- 
 toms which may be distinctly traced to the epileptic 
 conditions. By that, I mean not that the epileptic 
 discharges produce all the mental disturbance, but 
 that the conditions which give rise to epilepsy may 
 also give rise to mental as well as motor disturbance. 
 In some cases the change of balance or change of 
 nutrition which is represented by an epileptic fit acts 
 directly in producing mental disturbance. First, then, 
 nearly all epilepsy tends naturally to weak-mindedness. 
 
Chap. XV.] Epilepsy. 383 
 
 this def)eiiding rather upon the frequency of the fits 
 than upon their severity. Epilepsy is extremely 
 closely allied to ordinary insanity, and is but one 
 branch of the nervous tree. I have met not only with 
 members of the same family suffering from epilepsy 
 and insanity, but I have seen one twin sister 
 insane and the other epileptic. The effect of the fits 
 depends also upon the age at which they commence ; 
 many cases of imbecility and idiocy result from the 
 onset of fits in childhood. The chances of mental im- 
 plication also depend upon the nervous history of the 
 family and also upon the cause of the disease, cases of 
 so-called idiopathic epilepsy being more hopeless than 
 those cases in which some ascertainable and treatable 
 cause can be found. It is only necessary to say 
 farther of these cases, that suRple petit mal, frequently 
 recurring, may be found to so affect a young man or 
 boy that he is no longer capable of being educated with 
 persons of his own age ; he becomes solitary, and may 
 damage his prospects still more by acquiring habits of 
 self-abuse, the fits continuing and probably becoming 
 more frequent, the mind also suffering; the patient 
 may become weak and silly, living an organic life, 
 but without power of further development or cure. 
 The above is one of the simplest cases. 
 
 Not uncommonly epileptics, with general intel- 
 lectual degeneration, either develop or discover low 
 brutal habits and tastes, becoming brutalised in aspect 
 and beastly in habits. In large asylums such patients 
 not uncommonly have to be carefully watched, be- 
 cause their evil tendencies lead them to commit 
 u:nnatural offences or brutal bloodthirsty acts. The 
 recurrence of fits with these cases may, as we shall 
 presently see, be the starting point for fresh excite- 
 ment, or they may tend to further destruction of 
 mental power till the patient is left a helpless 
 paralysed dement. In some cases melancholia and 
 
3^4 Insanity and Allied Neuroses. [Chap. xv. 
 
 hypochondriasis are connected with the development of 
 epilepsy, and such cases may be suicidal and require 
 the utmost supervision. Patients, whether suffering 
 from ordinary dementia, maniacal excitement or me- 
 lancholia, may live for considerable j^eriods. The causes 
 of death are not uncommonly accidental, and many 
 ingenious contrivances have been designed to prevent 
 suffocation in the fit, but now-a-days the Commissioners 
 insist upon special epileptic wards, with low beds, and 
 an attendant constantly in the dormitory, so as to be 
 able to attend any patient in fits. Pillows of stretched 
 perforated material have also been suggested as 
 enabling patients, although turned on the face, to be 
 able to breathe. 
 
 The next consideration is the relation of epilepsy 
 to certain acutely maniacal outbursts. It is common 
 to meet with cases in which, immediately before or 
 immediately after a fit, an outburst of uncontrollable 
 fury of the most destructive kind takes place. Such 
 attacks are among the most distressing accidents of a 
 large county asylum, patients suffering in this manner 
 being completely untrustworthy and excessively dan- 
 gerous. In one class the patients become querulous 
 and discontented, asking the doctor repeatedly when 
 they are to be discharged, perhaps also attacking 
 doctor or attendant, and then stating that they have 
 done it to get out. This querulousness may be but 
 the initial symptom of an outburst of epileptic fits. In 
 these cases the change of temperament gives some 
 little warning, but in others there may be no such 
 indication. In the more common cases a patient falls 
 down in an epileptic fit, and remains unconscious for 
 a longer or shorter time, the unconsciousness being 
 often followed by a sudden return to consciousness, 
 marked by excessive destructive violence, utter 
 regardlessness of personal danger, and an extreme 
 outburst of fury which can only be recognised when 
 
Chap. XV.] Masked Epilepsy, 385 
 
 it lias been seen. These cases are, without exception, 
 the most dangerous of all lunatics, and the complete 
 oblivion which surrounds their acts of violence 
 renders them striking examples of the way in which, 
 automatically, acts of extreme complexity may be 
 performed without the actor having the faintest recol- 
 lection of the past. 
 
 Masked epilepsy (I'epilepsie larvee).— This 
 condition is one which till recent years was not recog- 
 nised in England, and even now it is not uncommon 
 to meet with those who have doubts about the reality 
 of the condition. The essentials are loss of recollec- 
 tion of whole continuous periods in life, there being 
 what may be called a double consciousness, and it is 
 interesting that a romantic description of such a case 
 should form the basis of George Sand's " Consaelo," the 
 hero of this story being, during one part of his life, com- 
 pletely unconscious of what he has done in the other. 
 The condition is closely allied to the sleep-walking state. 
 That this condition is allied to epilepsy has been shown 
 by French authors on the following grounds : First, it 
 occurs in neurotic subjects ; next, it may be associated 
 with epilepsy in one way or another ; thirdly, it may al- 
 ternate with epilepsy and take its place; fourthly, it 
 may end in ordinary epilepsy ; and lastly, it may be 
 relieved by bromide of potassium. The details of these 
 cases are only to be fully seen in Les Annates Medico- 
 Psychologiques, and the cases there recorded are 
 so extraordinary that it needs a very considerable 
 personal knowledge of the authors to allow one to 
 accept their statements. Patients are represented as 
 being unconscious for days together, and acting in 
 peculiar but highly organised waj^s. Some of the 
 simpler cases are less difficult of comprehension. Thus, 
 a lady of culture and refinement suddenly and with- 
 out warning turns pale, becomes fixed in her gaze 
 and begins to make use of a string of obscene and 
 z-U 
 
386 Insanity and Allied Neuroses. [Chap. xv. 
 
 blasphemous phrases ; at the end of a few minutes she 
 ceases, flushes, appears confused, and in no way remem- 
 bers what she has said and done. Attacks of the same 
 description recur at irregular intervals, always asso- 
 ciated with pallor and the use of similar obscene and 
 blasphemous language. 
 
 In other cases unconsciousness, with a tendency 
 to run, to strike, or to perform some simple mechani- 
 cal act, occurs. In my experience I have only met 
 with three similar cases ; in one a man would, from 
 time to time, lose himself and wander from home and 
 find himself long distances from where he started 
 without knowing how he got there ; and in another, 
 a man with strongly insane inheritance caused great 
 distress to all his friends from time to time just as 
 his fortunes appeared to be mending. Three sepa- 
 rate times had he been started in life with good pros- 
 pects, but each time he disappeared without rhyme or 
 reason, to be discovered in some part of the continent 
 in a state of poverty. He professed unconsciousness 
 of what had taken place, and I believe with truth. In 
 his case he also suffered later from an attack of in- 
 sanity. It is important that, if this condition exist, it 
 should be fully recognised, but it would be a very 
 dangerous thing generally to allow a person accused of 
 crime to plead epileptic unconsciousness. The question 
 has been repeatedly suggested as to how much or how 
 complicated the acts of such a person may be. For 
 instance, would it be possible for a person suffering in 
 this way to steal only valuable things, or would he, if 
 affected by a desire to pilfer, take everything that 
 came in his way % 
 
 One case recorded in French literature showed 
 how general this pilfering might be. A man of 
 education and position, when under the epileptic influ- 
 ence, would collect everything that came in his way, 
 and the result showed that he would steal things 
 
Ch ap . X V. ] Ma sked Epil EPS V. 387 
 
 altogether undesignedly, such as a baby's feeder and a 
 cigarette case, things useful and things useless. I 
 should therefore hesitate before admitting that a 
 patient accused of stealing valuable things did this as 
 an epileptic. 
 
 Case of masked e'pilepsy. — W., single, aged 28, 
 family history good, intemperate ) as a result of 
 drink and injury to his head had a series of epileptic 
 fits, followed by melancholia, in consequence of 
 which he had to be sent to the county asylum. While 
 there he was depressed and tried to kill himself. At 
 times he appeared lost, and did odd things ; thus, he 
 would whiten the fire-grate and blacklead the hearth. 
 
 He varied a great deal, but towards the end of the 
 fourth year he recovered, and was discharged sane, 
 but still subject to fits. He remained well over a year, 
 but after his discharge he was subject from time to 
 time to fits, which were preceded by an aura, which 
 was of sufficient duration to allow him to undo his 
 necktie and collar. These fits recurred at irregular 
 intervals. He was teetotal, steady, and industrious. 
 On one occasion, while he was walking along a lonely 
 road, he felt a fit coming on, and undid his necktie and 
 collar ; he then lost consciousness. On recovery, he 
 found himself lying by the roadside, but a distance of 
 two miles from where he remembered undoing his neck- 
 tie. Other evidence was at hand to show that he had 
 first had his fit, and then had, in a state allied to som- 
 nambulism, got up and walked along the road till the 
 post-epileptic sleep came on, when he lay down or 
 fell by the roadside, and slept till he was again well. 
 
 His walk was said to have been staggering, so 
 that those who met him passed him, believing he was 
 drunk. He was perfectly unconscious during the 
 walk and after it. Eits have recently returned; and 
 he has had once more to be sent to an asylum. 
 
 The medico-legal relationship of insanity will be 
 
388 Insanity and Allied Neuroses. [Chap. xv. 
 
 considered later, but here I would say there is no 
 doubt that a very close connection exists between the 
 neuroses, epilepsy, and criminality. Epilepsy is not 
 only a disease commonly feigned in jails, but is also 
 really common among criminals. 
 
 Treatment.— -\t would be wrong not to speak of 
 the treatment of the insane suffering from epilepsy, 
 though their cure is hopeless at present. I have 
 pointed out that in county asylums they are specially 
 placed so that there shall be the minimum of risk of 
 their becoming asphyxiated when in fits ; but besides 
 this, many other precautions must be taken. They 
 must be prevented from falling into fire or water, and 
 it is well to provide them with head-gear, resembling 
 in many points a thick turban, so that if they fall on 
 their heads little or no harm results. The medical 
 treatment is still a matter for grave consideration, one 
 class of medical men looking to bromide of potassium 
 as a sheet anchor, whereas another class believes that 
 more harm is done by bromide than if the patient be 
 left untreated. Some think that iron is distinctly in- 
 jurious, and others look upon the effect of mineral 
 tonics as certainly beneficial. Many of the superin- 
 tendents of county asylums think that purgatives are 
 the desideratum. My opinion, founded, I must own, 
 on but small experience of these cases, is that general 
 hygienic treatment is the most useful, and that in some 
 cases bromide of potassium prevents the frequent re- 
 currence of fits, and thereby does great service j that 
 purges are useful, especially in those cases in which 
 food is taken in large quantities, and that general 
 treatment is to be looked to rather than special, for at 
 present it appears to me we are no nearer having any 
 one specific cure for all the many conditions which 
 give rise to epilepsy than we were in the days when 
 everything from a snail's shell to a pumpkin-seed was 
 recommended. 
 
Chap. XVI.] Insanity with Brain Tumour. 389 
 
 In one case, a boy with early epilepsy and tendency 
 to weak-mindedness was sent away from the city in 
 which he lived, and was prevented from following his 
 precocious tastes for reading and music. He led the 
 life of a little savage for a few years, and at thirteen 
 or fourteen was a healthy animal, without fits, and 
 without education ; at sixteen he was quite up to the 
 average schoolboy, and has kept well. 
 
 Education, if not pressed unduly, may be pursued 
 with many epileptic children without injury. 
 
 CHAPTER XYI. 
 
 BRAIN TUMOURS. MULTIPLE SCLEROSIS. 
 
 Insanity with brain tumour — Insanity with multiple sclerosis. 
 
 Insanity with brain tumour* — Any intracranial 
 growth may cause mental disorder, and the chief in- 
 terest at present of these local changes is in the 
 observance of the clinical symptoms which are gradu- 
 ally enabling the physiologist to localise function, 
 and thus aid the philosopher in his divisions of 
 mind. It is rare to meet with insanity directly de- 
 pending upon a growth within the skull. Tumours 
 may arise in connection with the blood-vessels, with 
 the membranes, with the bones, or with the brain 
 itself. These growths may chiefly affect the cerebrum 
 or cerebellum ; the growths may be malignant or 
 simple, the most common being sarcomatous, tuber- 
 cular, and syphilitic. The chief and most general 
 mental symptom connected with all these growths 
 is increasing stupidity ; convulsions may be present, 
 with some local paralysis. Among several thousand 
 patients in Bethlem, I have only met, jjost mortem^ 
 
390 Insanity and Allied Neuroses. [Chap.xvi. 
 
 with one abscess and one exostosis apart from un- 
 doubted syphilitic tumours. The abscess occurred in 
 a woman, who, having had previous attacks of melan- 
 cholia, and who had a sister also melancholy, was 
 admitted to Bethlem acutely maniacal ; the patient 
 passed into a condition of restless excitement, with 
 refusal to take food, and in the end died. On post- 
 mortem examination a considerable abscess with thick 
 walls was found spreading from the membranes into 
 the brain. 
 
 The changes connected with syphilitic tumours are 
 considered elsewhere, and the other tumours producing 
 epileptic convulsions naturally fall under the head of 
 epileptic insanity. 
 
 Insanity \iritli multiple sclerosis. — It has 
 surprised me that so few cases have been recorded of 
 insanity with the above disease, the only other case I 
 know of, besides the one I am about to record, being 
 that recorded in the April number of the " Journal of 
 Mental Science," 1884, published by Dr. Gasquet, in 
 which considerable excitement, and symptoms like 
 those of general paralysis of the insane, were present, 
 but with a feeling of physical weakness. The case I 
 record was transferred from St. Thomas's Hospital, a,s 
 being altogether unmanageable among ordinary hospital 
 patients. 
 
 Ernest D., single, set. 21, sculptor, paternal 
 grandmother insane, uncle dipsomaniac, phthisis 
 on maternal side ; first attack of insanity^ no cause 
 known ; the patient was admitted in October, 1878, 
 having been excitable and irritable for five weeks. It 
 was said that he had choreic movements gradually 
 coming on for two years, during which time he was 
 a patient at the Queen Square Hospital. When 
 admitted into St. Thomas's Hospital the case was con- 
 sidered to be that of typical sclerosis, having all the 
 peculiarity of head and limb movement which is 
 
Chap XVI.] Insanity with Multiple Sclerosis. 391 
 
 common to that disease. Soon after admission the 
 excitement and irritability became more marked, 
 and frequently he was either childish or luicontrol- 
 able ; he screamed and shouted, and was violent to 
 himself and others. On admission into Bethlem he 
 is described as fairly nourished, of middle height, un- 
 able to stand; any attempt at movement was followed 
 by irregular spasmodic movement of all his limbs; 
 he generally lies with his head drawn forward from his 
 chest with a peculiar jerking backward and forward ; 
 no nystagmus ; speech scanning and all but unintel- 
 ligible ; evacuations and urine passed under him. He 
 was detained in Bethlem till the end of January, when 
 he was discharged weak-minded and paralysed, but 
 with no further tendency to mental excitement. In 
 the end he died in Wandsworth asylum from the 
 extension of the sclerosis. 
 
 I have no doubt that a few years ago this case 
 would have been looked upon as one of chorea with 
 mental symptoms ; and it was in many particulars 
 like that disease, but there was sufficient evidence to 
 make the diagnosis sure. 
 
 There are other convulsive conditions which de- 
 serve a passing notice in relationship to mental changes. 
 With chorea, I should say, it is common to meet with 
 some intellectual weakness ; and if the cases are ex- 
 tremely severe this may pass into absolute dementia, 
 while in fatal cases delirium and great excitement may 
 be present. Dr. Gowers has collected evidences of 
 the relationship between chorea and other forms of 
 nervous disease ; and in Bethlem it is common to find 
 that patients, who have suffered from chorea in early 
 youth, have in later years become subject to hysteria 
 or other true neuroses. 
 
 Of 846 patients admitted into Bethlem only six 
 had had chorea, and of these four were maniacal, one 
 melancholic, and one demented. 
 
392 
 
 CHAPTER XYII. 
 
 SYPHILIS AND INSANITY. 
 
 Moral effects — Syphilopliobia — Softening gummata — Epileptic 
 fits — Arterial disease — Weak-mindedness — General jiaralysis — 
 Cachectic states. 
 
 "When treating of the causation of insanity generally, 
 I referred to some of the relationships which syphilis 
 holds to mental unsoundness, and shall here in more 
 detail give the results of my experience. 
 
 Syphilis may act morally or physically. It may 
 colour the melancholia from which a patient is suffer- 
 ing, and thus cause him to believe that he is a source 
 of physical as well as of moral contagion. 
 
 It may be the starting-point of syphilophobia, 
 which I look upon as a form of hypochondriasis. I 
 have never met with insanity depending on the febrile 
 disturbance of early syphilis. 
 
 Constitutional syphilis acts by causing (1) gum- 
 mata ; (2) by producing disease of the arteries ; (3) by 
 producing local degenerations ; (4) by causing a 
 cachectic condition. 
 
 The gummata may lead to epilepsy, which in its 
 turn causes weak-mindedness ; or they may produce 
 some local brain change, associated with special dis- 
 orders and consequent insanity ; or they may produce 
 brain changes from affection of the motor areas of the 
 brain, which are not to be distinguished from general 
 paralysis of the insane. 
 
 The syphilitic disease of the arteries may give rise 
 to apoplectic seizures or to simple dementia. 
 
 The local changes are, in my belief, associated 
 
Chap. XVII.] 
 
 Optic Neurosis. 
 
 393 
 
 either with locomotor ataxy, or more frequently with 
 progressive paralysis, associated with changes in the 
 lateral columns of the cord. 
 
 The cachexia of constitutional syphilis may give 
 rise to various shades of melancholia, ending in some 
 lung disease if not cured. 
 
 A case of Syphilitic Dementia. 
 
 The next point of interest in the relationship of 
 syphilis to insanity is that optic neuritis may give rise 
 to delusions. Thus, a trainer to a large racing stable, 
 who had within four years contracted syphilis, became 
 anxious on account of his impaired vision, and was ad- 
 mitted into one of the London hospitals, where his sight 
 became more obscure, and he became querulous and hard 
 to manage. He believed persons were tampering with 
 
394 Insanity and Allied Neuroses. [Chap. xvii. 
 
 his goods, and were going to do him some harm. He 
 took the law into his own hands, and struck those near 
 him ; his violence and delusions, caused him to be sent 
 to Bethlem. He was put under energetic mercurial 
 treatment, and rapidly regained his sight and lost his 
 delusions, and he has remained well for the last six 
 years. Here we have a good example of the develop- 
 ment of insanity out of natural causes. The patient 
 by training and occupation was very suspicious, and 
 loss of sioht made him more so. 
 
 The last special point I wish to consider briefly is 
 the relationship of syphilis to general paralysis of the 
 insane. 
 
 A fair number of cases of this disease have sis^ns 
 of syphilis upon them, and more have histories of the 
 malady. I am not prepared to say that there is a 
 special form of general parah' sis always due to syphilis, 
 but I have met now with about a dozen cases in whom 
 the two diseases occurred and seemed to be related. 
 
 Some of the cases had peculiarities which are, at 
 least, noteworthy. 
 
 Syphilitic gumma-insanitij. Recovery. — It is not 
 necessary to give in detail all the facts which have 
 led me to the above conclusions, and I would only 
 refer to a few instances as examples. One man, 
 who had had syphilis five years before, was ad- 
 mitted sufiering from partial dementia with ptosis, 
 external strabismus, and dilated pupil. No treatment 
 did any good, and for months he steadily lost ground ; 
 so weak did he become that it was decided to allow 
 him to remain till his death, and all medicine was dis- 
 continued. He began to take his food better and gain 
 flesh, and in about another three months was fit for a 
 change, and in the end was discharged well. During 
 the next four years he had fresh outbreaks of syphilis, 
 as shown by shin nodes, ulcer on prepuce, and ulcer 
 on septum nasi, but prolonged mercurial treatment 
 
Chap. XVII.] Syphilis and General Paralysis. 395 
 
 and Turkish baths have finally fully re-established his 
 health, nothing remaining but the dilated pupil. 
 
 I have seen several similar cases, and in two fatal 
 results have followed. In one no coarse brain lesion 
 of any kind was found ; and in a second, thickening of 
 the membranes in the course of the sixth explained 
 the internal strabismus which was present, and a small 
 gumma, resting on the optic commissure, explained the 
 optic neuritis and loss of ^dsion. 
 
 Syphilis and general paralysis. — A single man, of 
 thirty, who had syphilis five years before, began to do 
 odd things, and to cause his friends anxiety, in con- 
 sequence of his mental weakness, and foolish and 
 wasteful actions. He was restless, emotional, irritable, 
 and with failmg memory. He would not be ruled by 
 his friends, and had to be sent to an asylum. Here 
 he was silly and restless. He decorated himself with 
 leaves and flowers. He was in fair general health, 
 but the tremor of tongue and lips was very marked ; 
 his speech was hard to understand. All his reflexes 
 were much exaggerated ; there was no paralysis of 
 any cranial nerve. 
 
 He remained in tliis state for two years, then 
 became bed-ridden, with contraction of the lower 
 extremities ; and with the onset of fits and the develop- 
 ment of bed-sores he died. 
 
 There was wasting of ascending frontal with 
 parietal convolutions, and of the first frontals ; excess 
 of fluid ; no local tumours ; marked grey degeneration 
 of the lateral columns of the cord. 
 
 Such cases are young, often single j they always 
 liave exaggerated reflexes, generally with capillary 
 congestion, similar to that seen in cirrhosis over malar 
 prominences. 
 
 In all such cases anti-syphilitic treatment should 
 be tried, but will fail if distiixct symptoms of general 
 paralysis are present. 
 
396 
 
 CHAPTER XYIII. 
 
 RELATIONSHIPS BETWEEN INSANITY AND PHTHISIS 
 PULMONALIS. 
 
 Degenerative lung changes are common terminations of nervous 
 diseases. — Ptithisis in one parent, with, neurosis in the other 
 makes the prospect of neurotic inheritance greater. — Phthisis 
 in the insane is frequently without general symptoms. — In 
 the insane there is suspicion and refusal of food. — Degene- 
 rative lung changes causing death occur in melancholia and in 
 general paralysis. — Phthisis may kill patients who are con- 
 valescing from an acute attack of mania or melancholiq, — 
 Spasmodic asthma, with insanity. 
 
 Phthisis and insanity. — Whatever in the 
 future may be shown to be the relationship between 
 bacilli and phthisis, I am sure that there will be 
 proved to be a very distinct connection between 
 some low forms of lung inflammation with destruc- 
 tion of tissue and death and disorder of the nervous 
 system. It has been sufficiently long recognised that 
 the ordinary termination of progressive paralysis is by 
 some inflammation of the lungs, and, in my opinion, 
 this is not altogether due to mechanical congestion. 
 Later, I shall point out various relationships which I 
 have found to exist between phthisis and insanity ; 
 and I repeat here my belief that phthisis occurring in 
 one parent, and neurosis in the other, will make the 
 tendency to nervous disorders much greater than 
 without phthisical parentage. There is a special set 
 of symptoms associated with phthisis occurring in 
 insane patients. 
 
 One of the peculiarities of phthisis in the sane has 
 long been recognised to be a general hopefulness, so 
 that patients who are rapidly emaciating, who are 
 coughing and spitting, sweating and suffering from 
 
Chap, xvrii.] Phthisis and Insanity. 397 
 
 colliquative diarrhoea, will tell the doctor that, if they 
 could only get rid of their cough, they would be well 
 again. On the other hand, in an asylum phthisis is 
 found associated with melancholic symptoms, with few 
 or no physical symptoms ; but, as a rule, with con- 
 firmed suspicion and obstinacy. The general course of 
 the disease and the symptoms are as follows : A 
 patient, with insane inheritance, becomes out of health, 
 dyspeptic, and generally ailing. His friends suspect 
 that the family complaint, phthisis, is developing ; but 
 the signs of the disease are so few that it is thought a 
 change of scene will remove the trouble. He is sent 
 on a voyage, and for a time his general health im- 
 proves ; but with this there has been noticed an 
 irritability of temper and a suspiciousness which were 
 quite unnatural to him. In some cases the symptoms 
 require the patient to be placed in an asylum abroad ; 
 and it is not till he has been under observation for 
 some time that the true state of matters is discovered. 
 A fresh attack of irritability, and a further develop- 
 ment of emaciation, lead to careful exploration of the 
 chest, when it is discovered there is dulness at one or 
 both apices. At the same time refusal to take food is 
 marked, and I would say, in the main, I agree with 
 what Dr. Rayner has said, that the refusal to take 
 food is most marked with the earliest symptoms ; that, 
 in fact, with consolidation refusal to take food is pretty 
 constant, and that breaking down of lung tissue is 
 frequently associated with a return to eating. I am 
 in the habit of saying that, in the cases of phthisis, 
 the pneumogastric itself conveys wrong impressions, 
 and that the irritation at the lung end is treated as if 
 it were derived from the stomach. At any rate, with 
 phthisis obstinate refusal of food is so common that 
 when I am investigating a young case of insanity, and 
 hear that there is obstinate refusal of food and pro- 
 gressive wasting, I at once suspect phthisis, and seek 
 
398 Insanity and Allied Neuroses. [Chap, xviir. 
 
 for it. There may be, at this period, nothing in the 
 waj of cough or expectoration to excite attention ; but 
 there is occasionally early haemoptysis j and in my 
 experience this is common late in the disease, and 
 then is one of the causes of death. 
 
 Besides refusal of food, which refusal is due, in 
 most cases, to ideas that there is poison or filth of 
 some description put into the food, there is often 
 obstinacy of an extreme kind to any interference from 
 without ; so that patients will resist being dressed in 
 the morning, and will equally object to being un- 
 dressed at night. They will resist being moved, and 
 they will be in direct opposition to all about them. 
 Some of these cases have a considerable flow of saliva, 
 and others ai'e constantly ejecting saliva and mucus 
 from their mouths, probably because they believe their 
 secretions to be poisoned. Diarrhoea comes on, and 
 the utter neglect of personal comfort necessarily 
 causes great trouble to friends and attendants. Bed- 
 sores rapidly form. Cases of this kind may last for 
 many months without any apparent change in their 
 mental state ; but it is common to meet with phases 
 of mental improvement associated with exacerbations 
 of the lung trouble. I have seen one case always 
 better after a severe hsemorrhage, and in another, 
 when the patient had gone abroad for phthisis, he 
 became sane ; but by the time his bodily symptoms 
 were better, it was necessary to bring him back to 
 England, in consequence of the return of his suspicions. 
 A second advance of the lung disease was associated 
 with mental improvement, only to be followed by 
 mental relapse, with arrest of the pulmonary disease. 
 In the end phthisis and the insanity became fully 
 established, and he died obstinate, deluded, and ex- 
 hausted. It is not uncommon to be able to discharge 
 such cases from asylums in the last few weeks of 
 their existence ; and every year I am in the habit of 
 
Chap. XVIII.] Phthisis and Insanity. 399 
 
 recommending friends to take sueli patients home 
 to die. 
 
 To sum up. This class consists generally of 
 ' young patients, in whom phthisis develops slowly 
 but steadily ; on the physical side emaciation, haemop- 
 tysis, and diarrhoea are the chief and only symptoms, 
 whereas, mentally, there is obstinate or stolid melan- 
 cholia, with refusal to take food, depending upon hallu- 
 cinations of taste and smell, or delusions about poison, 
 Other hallucinations may be present, more especially 
 those of hearing ; the end of such cases is almost cer- 
 tainly death. Post-mortem : no special tubercular con- 
 ditions have been found by me in the brain ; lung 
 changes as well as fatty changes in the liver have 
 been met with. 
 
 Phthisis and insanity. — William C, single, 
 25 ; mother insane ; first attack of insanity coming 
 on without any known cause. The symptoms were 
 first noticed ten weeks before admission, and were 
 described as mental and physical collapse. He wished 
 he was dead, and thought his whole body was polluted, 
 so that he must destroy it to get a new one ; he wanted 
 his head blown open. He believed his friends were 
 against him. On admission ho wa:? extremely thin, 
 and very obstinate ; he would take no food, and was 
 wet and dirty. He had no cough or expectoration, 
 slight sweating, temperature higher at night. Much 
 rachitic deformity of chest. No dulness, or other signs 
 of phthisis. Later, dulness was noticed at right apex, 
 and some large rales. These symptoms slowly in- 
 creased, but for a time he took his food voluntarily. 
 He sank and died. 
 
 A second group includes cases which, perhaps, 
 
 scarcely deserve the term phthisis. I can only say that 
 
 several which have been under my care have not pro- 
 
 • vided me with bacilli, therefore that they were phthisical 
 
 at all remains doubtful. Cases of melancholia, occurring 
 
400 Insanity and Allied Neuroses. [Chap, xviii. 
 
 later in life, say from forty to sixty, are often found 
 after death to have large cavities in the lung, and 
 I am sure that there is a very distinct connection 
 between the lung degeneration and the weak physical 
 health connected with the melancholia. I have seen 
 one or two cases in which cataleptic symptoms have 
 Leen present in patients who have died with lung 
 disease ; and I would only insist upon the fact that 
 it is of the utmost importance to examine every case 
 of melancholia, whether young or old, whether with or 
 without general symptoms, for lung disease. It may be 
 well here to allude to the fact that gangrene of the lungs 
 was supposed to be especially common among the in- 
 sane. In my experience it is rare, and I am still doubt- 
 ful how much is due to mechanical causes, such as the 
 introduction of foreign bodies into the lungs themselves. 
 
 To conclude, phthisis kills a large number of 
 insane patients. 
 
 Phthisis, especially if associated with neurotic 
 taint, produces highly unstable nervous systems. 
 
 Phthisis in the insane is associated with certain 
 groups of symptoms characterised by suspicion and 
 refusal of food on the one hand, and with masking 
 of the physical symptoms on the other. 
 
 Degenerative lung disease is common in melan- 
 cholia and in general paralysis. 
 
 Sanity not uncommonly returns before death in 
 phthisical lunatics, and some recover sanity to die in 
 a year or two of phthisis. 
 
 Spasmodic asttimsi, witli insanity. — Spas- 
 modic asthma must be looked upon as a nervous 
 disorder, and it is of great interest and importance 
 to be able to trace distinct relationship between 
 it and other nervous disturbances. I have met 
 with several cases in which insanity has alternated 
 with spasmodic asthma in patients who have for 
 years been subject to recurrent attacks of asthma, 
 
Chap, xviii.j Insanity WITH Asthma. 401 
 
 and wlio have become almost suddenly well, as far 
 as the asthma was concerned, but who at the same 
 time developed insanity, and as long as the in- 
 sanity was present the asthma was absent. This 
 alternation of symptoms in many respects resembles 
 what I have already referred to as occurring with 
 some cases of hysteria. Cases which I shall refer to 
 more particularly are subjoined, two having been 
 discharged, and two others still being under treat- 
 ment. 
 
 Elizabeth G., single, set. 34, with no insane 
 inheritance. This is the second attack of insanity, 
 the first having occurred five years ago. There was a 
 history of phthisis in the family. This patient had 
 been admitted to the Incurable Hospital at Putney 
 in consequence of the chronic asthma. When ad- 
 mitted into Bethlem she was as melancholic and 
 suicidal a case as one could well see. She refused her 
 food ; she thought people were making remarks, and 
 that there were voices and accusations of every 
 description to annoy and distress her. She attempted 
 suicide, and while in the hospital she drank off all 
 her medicine, hoping thus to effect her object. This 
 condition of active suicidal melancholia continued till 
 she developed an attack of asthma, after which she 
 was perfectly sane, and for a time had few re- 
 currences of asthma. This, however, returned with 
 obstinate violence, and at present she is subject to 
 recurrent attacks of spasmodic asthma, but retains 
 her sanity. 
 
 Kate M., single, set. 28, insanity on mother's 
 side, and phthisis on the father's side. Patient has 
 been subject to neuralgia. She has had three pre- 
 vious attacks of insanity. Soon after she menstruated 
 she developed symptoms of spasmodic asthma, which 
 continued till 1874, when she had her first attack of 
 insanity ; during this attack she was free from asthma ; 
 
 A A — 14 
 
40 2 Insanity and Allied Neuroses. [Chap, xviii. 
 
 with mental health asthma returned. "With each 
 fresh attack of insanity there was a repetition of the 
 bodily and mental symptoms met with in the first 
 attack. The present attack began six weeks before 
 admission (October, 1883). She was maniacal; she 
 pricked her skin to allow the sand to escape from 
 under it, as she said. She saw black things above 
 her and in her food. She was very destructive and 
 abusive. 
 
 She was obstinate and refused her food, having to 
 be forcibly fed. She was extremely thin and weak. 
 By January, 1884, she was well enough to go to the 
 Convalescent Home, and for a short time had peace of 
 mind and body ; as she got stronger the asthma re- 
 turned, and she was discharged well mentally, but 
 suffering from spasmodic asthma, and I suppose she 
 will continue to break down every few years. 
 
 Matilda K., single, ?et. 32, admitted Feb., 1884, 
 no insanity in the family, sister died of tubercle ; 
 first attack of insanity, which has lasted three 
 months. She has been subject to spasmodic asthma 
 ever since puberty, but for some months back there 
 has been a change, so that she has been free from 
 asthma, and also free from her "delicacy of chest." 
 The immediate cause of the mental disorder was said 
 to have been the breaking off an engagement. 
 Amenorrhoea has lasted since August. She first 
 became slee^pless, then moody and taciturn ; she was 
 emotional, ajid threatened suicide ; she thought she 
 was going to hell, and saw the tortures which were 
 being prepared for her ; she saw the spirits of her 
 dead friends ', she said the asthma had gone to her 
 head, and had destroyed her brain ; that her skull 
 was empty ; she refused food, w^as obstinate and 
 silent \ she was a good example of melancholia, with 
 ideas of unworthiness ; she had hallucinations, and was 
 bothered by hearing voices shouting obscenities at her. 
 
Chap. XVIII.] Insanity with Asthma. 403 
 
 Very slowly this patient gained strength, and in the 
 end recovered. 
 
 In one other case chronic bronchitis was replaced 
 by insanity. 
 
 Ann W., widow, set. 64; no insane relations ; had 
 suffered from asthma and chronic bronchitis for twenty 
 years; about Christmas, 1883, she became free 
 from bronchitis, but excited mentally. She fancied 
 people were talking about her ; she believed people 
 were going to injure her and her son ; she was 
 emotional and obstinate ; she said her food did not 
 pass through her, and that she was lost; she was 
 suicidal, threatening to injure herself with knives, or 
 to set herself on fire ; she refused food, and had to be 
 artificially fed. 
 
 In this case the age is against the recovery of the 
 patient. 
 
 Obstinacy, refusal of food, and suicidal tendencies, 
 with hallucinations of the senses, and delusions as to 
 being eternally lost, are the chief symptoms of these 
 cases. 
 
 Dr. Clifford AUbutt has pointed out the relation- 
 ship between spasmodic asthma and some abdominal 
 neuroses, and I expect we shall find similar relation- 
 ships between some of the abdominal neuroses and 
 insanity, so that a hypochondriac will be found to be 
 free from his hypochondriasis when acutely insane. 
 
 I have also met with cases in which nerve-storm 
 headaches have been entirely absent during attacks of 
 insanity, and in one case no recurrence of these nerve- 
 storm headaches took place after recovery from a 
 severe attack of melancholia. 
 
404 
 
 CHAPTER XIX. 
 
 HEART DISEASE AND INSANITY. 
 
 Heart disease and insanity — ^Acute mania, with repeated attacks of 
 rheumatism — Symptoms resembliag general paralysis asso- 
 ciated with advanced aortic disease — Kidney disease and 
 insanity. 
 
 It is fully recognised that there is a great want of 
 careful statistics as to the exact j^troportion in which 
 heart disease is found to be present in cases of in- 
 sanity, though it is well known as a common cause of 
 nervous diseases; and without such statistics all 
 that I can do is to record my experience of cases in 
 which melancholia or mania has been, at all events in 
 some way, associated with heart disease. I have met 
 with a large number of cases of insanity in which 
 there has been some heart affection, most frequently 
 following rheumatic fever; and I have already re- 
 ferred to my belief that there is occasionally associated 
 with rheumatic fever a nervous disorder which may 
 develop into insanity ; this being quite independent 
 either of the hyperpyrexia which may occur with, or 
 of heart disease which may follow, the rheumatism. 
 I have been impressed by observing many cases 
 suffering from mitral disease also being subject to 
 melancholy. In fact, melancholia is always looked 
 for by me in patients who, having had several attacks 
 of rheumatism, with heart affection, become insane. 
 With aortic, or with both aortic and mitral disease, the 
 symptoms may be either melancholic or maniacal ; but 
 I am inclined to think that with simple aortic disease 
 and with hypertrophy of the left ventricle, it is at 
 least not uncommon to meet with acute mania and 
 exaltation of ideas. This is interesting to me in 
 
Chap. XIX.] Heart Disease and Insanity. 405 
 
 connection with other observations which I have made 
 upon the same subject. In patients who have suflfered 
 with mental disorder resembling in many particulars 
 general paralysis of the insane I have found very 
 marked atheroma of the aorta. So that in doubtful 
 cases of men with exaltation of ideas I expect to find 
 •post mortem hypertrophy of the left ventricle and 
 atheroma of the aorta, with more or less brain change. 
 
 In the following case there was acute mania, 
 with repeated attacks of rheumatism : Sidney C, 
 single, set. 22, medical student \ had had four at- 
 tacks of rheumatic fever already, and his heart was 
 most seriously damaged. This was the first attack of 
 insanity, and had lasted three weeks, and followed 
 directly his last attack of rheumatic fever. It began 
 with incoherence, excitement, and sleeplessness. He 
 stated he was going to Lord Hartington ; that he was 
 to have a peerage and £150,000 a year ; that he was 
 going to found a university of his own ; and, in fact, 
 he was as full of grand ideas and benevolence as any 
 general paralytic I have ever met with. He was con- 
 stantly writing letters, and restlessly moving about. 
 The pulse was of the water-hammer type, and double 
 murmur was heard at the base of the heart. With iron 
 and general tonic treatment he became better, sleeping 
 and eating well ; he was finally discharged recovered. 
 
 In the next case, symptoms resembling general 
 paralysis were associated with advanced aortic disease. 
 Osborne O., single, fifty-nine years old; no insane 
 inheritance, although some of his relatives were said to 
 have suffered from spinal disease. The first symptom 
 arose, without any special exciting cause, six months 
 before his admission. He wrote insulting letters to 
 his relations, became excited, constantly talking about 
 himself, the many speculations he was going into, 
 and the fortune he intended to make j he said he was 
 governor of the Australian colonies. He also became 
 
4o6 Insanity and Allied Neuroses. [Chap. xix. 
 
 dirty in some of his habits, and had an entirely false 
 appreciation of the value of things. While in Beth- 
 lem he was constantly excited, talking vehemently, 
 with all the inconstancy and benevolence of the 
 general paralytic. It was discovered that his heart 
 was much hypertrophied, that there was double mur- 
 mur at the base ) and there was a question as to 
 the existence of a mitral systolic murmur as well. He 
 became weaker in mind, and more emotional. One 
 day after breakfast, a year from his admission, while 
 sleeping he suddenly died ; and 'post mortem we found 
 a firm, somewhat wasted brain, with excess of fluid, 
 but without any marked adhesions between arachnoid 
 and cortex, but with very marked atheroma of the 
 arteries. There was degeneration of the kidneys ; 
 heart weighed eighteen ounces, with strong adhesions 
 between the left ventricle and the pericardium ; the 
 left ventricle much enlarged and thickened, with the 
 aortic valves involved. The pulse-tracing in this case 
 was most characteristic of forcible action of the left 
 ventricle, the upstroke of the tracing being one and a 
 half inches long. The pathology of the condition was 
 somewhat involved, and I was unable distinctly to 
 say that his physical condition depended entirely or 
 chiefly on valvular conditions ; for it seemed to me 
 that the adherent pericardium, interfering with the 
 action of the left ventricle, had been the chief factor 
 in the production of the hypertrophy of the left side 
 of the heart. 
 
 It is interesting to notice that, in this case again, 
 there were symptoms of exaltation, with suspicion of 
 general paralysis of the insane, although no adhesions 
 were found on the surface of the brain post m^ortem,. 
 
 To conclude. The brain must be very seriously 
 afiected in the performance of its functions by the cha- 
 racter of the supply of nourishment which is provided 
 for it by the heart. One knows that the general 
 
Chap. XIX.] Kidney Disease AND Insanity. 407 
 
 aspect of anxiety which is depicted on the faces of 
 many patients suffering from heart disease is recognis- 
 able enough ; and that this anxiety should be further 
 developed into melancholia is easily to be believed. 
 For the healthy performance of function there must be 
 not only a sufficient, but a regular supply ; anything 
 interfering with the quantity, quality, or regularity of 
 supply may upset the nervous balance, and cause, 
 on the one hand, anxiety, with sleeplessness and 
 vague dread ; on the other, exaltation of ideas, with 
 emotional instability. 
 
 It is not to be forgotten that cases of heart disease, 
 with hypertrophy of the left ventricle, may be difficult 
 to diagnose from ordinary cases of general paralysis of 
 the insane. 
 
 Kidney disease and insanity. — There are at 
 present several very important questions to be con- 
 sidered in relation to kidney degeneration. It re- 
 quires to be determined whether the theory of Gull 
 and Sutton is true, that there is a general fibroid de- 
 generation occurring in the cases in which ultimately 
 the renal symptoms are most marked ; and whether, 
 besides a fibrosis which affects the arteries and ab- 
 dominal viscera, there is also a fibrosis of the brain. 
 At one time I was induced to examine the kidneys of 
 very many general paralytics who had died in Beth- 
 lem, but with only negative results ; for after com- 
 ])aring the structure of forty kidneys from such cases, 
 I was unable to find any really characteristic change of 
 the fibroid nature in them. But although I have not 
 been able to establish any definite connection between 
 fibroid degeneration in the kidneys with any group of 
 cases of general paralysis, yet I have found a number 
 of cases of insa;nity in which there has been marked 
 degeneration of the kidneys. And although I cannot 
 pretend to have discovered a renal insanity, I think it 
 is worth while to record cases in which kidney disease 
 
4o8 Insanity AND Allied Neuroses. [Chap.xix. 
 
 has been at least associated with insanity, guarding 
 myself by saying that I fully recognise the fact that 
 insane persons must die of some disease sooner or 
 later, and that, therefore, it is only natural to expect we 
 should meet with kidney disease in the insane as well 
 as in the sane. It is not common to meet with albumi- 
 nuria in acute cases of insanity, and I may say this 
 after examining several hundred specimens of urine of 
 the insane. 
 
 In the following cases, which I shall give in brief, 
 the patients were suffering from melancholia ; they 
 had "mania of suspicion"; they all died, one by his 
 own hand while on leave of absence. 
 
 Kidney disease^ melancholia, urcemic convulsions, 
 death. — Clara L., single, set. 35, governess ; anxiety 
 was the supposed cause of this her first attack. It 
 had lasted six months. She had no insane relations. 
 She became depressed, declining to answer questions ; 
 she thought her friends were unkind to her ; she wan- 
 dered about the house without an object ; at times she 
 was violent, attempting to bite her relations ; she was 
 dirty and untidy. She had hallucinations of sight 
 and hearing ; she thought she was very wicked, and 
 that Grod was angry with her. She was also suffering 
 from amenorrhoea of some months' duration. On ad- 
 mission, what struck one most was the prominence of 
 her eye-balls, the right being extremely protruded. On 
 examination with the ophthalmoscope, neuritis in both 
 eyes was detected, both optic nerves being swollen, 
 veins dilated and tortuous, numerous small hsemor- 
 rhages and white patches, the right eye having these 
 most marked. Albumen was found to be present in 
 the urine in large quantities. Her general health im- 
 proved during the next few months, when she was 
 found one morning unconscious, having lost a con- 
 sidei-able amount of power on the left side. Her 
 speech was thick and indistinct, and she was unable to 
 
Chap. XIX.] Insanity with Kidney Disease. 409 
 
 swallow solids. Two months later slie had another 
 series of convulsions, in which her head was turned to 
 the right side ; breathing became stertorous, and nine 
 hours after the convulsions she died. Post-mortem : 
 besides wasting of the cortex of both kidneys, with 
 adherence of the capsules, the condition of the brain 
 was noteworthy. The lateral ventricles were enor- 
 mously dilated ; in fact the large amount of fluid in 
 these ventricles had pressed the convolutions to such a 
 degree that they were almost smoothed out, and the 
 ventricular walls had the appearance of those of a 
 case of hydrocephalus. I have no doubt that this 
 case would have been looked upon in former days 
 as one of serous apoplexy j and it is interesting to 
 note that there was so much fluid eflusion into the 
 ventricles, and no dropsy elsewhere. 
 
 The second case was that of Robert S. T., surgeon, 
 married, set. 60, with no insane relations. He had 
 suffered from albuminuria for eight years ; but mental 
 symptoms had only lasted four months, and they 
 began with religious despair. He refused to eat, as- 
 serting that his relations were placing drugs and dele- 
 terious substances in his food. He was excitable, and 
 aimlessly wandered from room to room. He thought 
 he was lost, and that he was a hypocrite. He had 
 ceased to take any interest in his profession. On ad- 
 mission he had hallucinations of taste j he believed he 
 had some infectious disease, and that his soul was 
 everlastingly lost ; refused food, and slept badly. 
 During the time he was in the hospital he remained 
 in much the same state, so that he declined to enter 
 into any friendly communications with any one. He 
 became more feeble, and died. In his case there was 
 nothing found post mortem beyond the ordinary con- 
 tracted kidneys ; and the question is if old-standing 
 Bright's disease alone led to dread, anxiety, and re- 
 fusal to take food, and thus developed the melancholia. 
 
4IO Insanity and Allied N'euroses, [Chap. xix. 
 
 The last case is that of John V., draper, married, 
 set. 46, who had one sister suffering from an attack 
 of mania. This was his first attack of insanity, and 
 the symptoms followed anxiety and worry during 
 the previous year, the worry being due to money difii- 
 culties. His first complaints were of pains in the head. 
 He was sleepless; complained of voices and loss of 
 memory, and wandered about the house at night ; at 
 times he was violent, suspicious, and fancied people 
 had taken property belonging to him. On admission 
 he was melancholic, taking little notice of his surround- 
 ings, and unable to give a connected account of himself. 
 Within a few months of admission it was noticed that 
 he was suffering from albuminuria ; his feet became 
 swollen, and his face puffy ; with the swelling of his 
 legs and the physical distress, he improved, and was 
 so much better that he was sent to our convalescent 
 home, and later was allowed to go on leave. One day, 
 without any special alteration in his symptoms, he 
 avoided his friends, and managed to commit suicide by 
 hanging. In his case the complaints he made of ex- 
 treme sleeplessness before he was admitted into Beth- 
 lem inclined me to think that while on leave the sleep- 
 lessness recurring caused him to lose power of self- 
 control ; and hence his suicide. That the first and the 
 last cases were due to anxiety I have little or no 
 doubt. The evidence given by the patients and 
 their friends was sufficiently clear, and it is becoming 
 more plainly demonstrated that anxiety, or, if I may 
 use the term, perpetual strain and high tension, may 
 give rise to kidney disease, so that the causation of 
 the mental symptoms was probably of a two-fold 
 nature, strain, anxiety, and sleeplessness producing 
 arterial change, and this tending to unstable nervous 
 conditions ending in insanity. 
 
411 
 
 CHAPTER XX. 
 
 DIABETES AND INSANITY. 
 
 Diabetes with insanity — Exophthalmic goitre — Myxcedema. 
 
 The question as to the causation of diabetes remains 
 as far from solution as ever. Notwithstanding the 
 discussion at the Pathological Society during the ses- 
 sions 1882-83, the relation of sugar in the urine, 
 either to nutritional disorder or to change of any 
 kind in the nervous centres, remains unsettled. In 
 my opinion there appear to be several strong reasons 
 against considering diabetes to be merely a nervous dis- 
 ease. In the first place there are certainly no common 
 changes found in the brain and higher centres in 
 diabetes ; and next, it is uncommon to find this dis- 
 ease well marked among insane patients. IsTotwith- 
 standing the observations made by Dr. Dickinson at 
 Bethlem Hospital some years ago, in which he dis- 
 covered traces of sugar in a considerable number 
 of cases, 1 am convinced that some error crept into 
 those experiments ; and I am inclined to think that 
 the reduction of the copper which took place was 
 rather due to the presence of uric acid than of sugar. 
 At all events, on careful repetition of the investiga- 
 tion in the spring of 1883 with Dr. Hale White, I 
 was confirmed in my belief by finding sugar in only 
 three cases in the hospital. There is, however, accord- 
 ing to Dr. Maudsley and others, a relationship of 
 another kind between neuroses and diabetes ; diabetes, 
 according to these observers, occurs in the same families 
 in which insanity is also present. I have not as yet 
 made sufficiently numerous or careful inquiries as to 
 the truth of this observation, but I must admit I have 
 already met with several cases confirming it. 
 
412 Insanity and Allied Neuroses. [Chap. xx. 
 
 In the three following cases sugar was found in 
 considerable amount in the urine. One patient (J.) 
 with brain hypochondriasis, who believed that he had 
 lost his " back brain" and with it the power of thought. 
 The second case (H.) was peculiar from many points 
 of view. This man was of advanced years, and his in- 
 sanity depended upon post-apoplectic conditions. After 
 the attack of apoplexy it was discovered that he was 
 passing a moderate amount (thirty to forty ounces) 
 of urine daily, of specific gravity luider 1*020, with 
 a considerable amount of sugar. The sugar may have 
 been altogether independent of the apoplexy and the 
 insanity ; for the patient has sufficiently recovered to 
 be discharged, but sugar is still present in the urine. 
 In the third case, the sugar occurred after an attack 
 of puerperal insanity, and I believe that it will be 
 found not to be uncommon for sugar to appear in cases 
 of puerperal insanity in which the milk secretion has 
 been arrested. To sum up, I know of no direct re- 
 lationship between diabetes and insanity. 
 
 Exophthalmic goitre TFith iiiisanity. — In 
 referring to myxoedema I point out the interesting 
 connection existing between degeneration and altera- 
 tion in the peripheral and central nervous systems, and 
 the relationship of these changes to the development 
 of symptoms of insanity ; here too a similar interest 
 exists, for with exophthalmic goitre we have a strange 
 perversion which must be considered as more or less 
 intimately connected with the sympathetic system, or 
 at all events I may safely say the vaso-motor systems ; 
 and as in myxoedema we had disease of the ordinary 
 nerve tissues, so here the nerve tissues of organic life 
 seem to be implicated. It is unnecessary to describe 
 in full the symptoms of this disease, suffice it to say 
 that, as with myxoedema, the disorder is most com- 
 mon in women. Its chief symptoms are palpitation 
 of the heart, a rapid pulse, prominent eye-balls, and 
 
Chap. XX.] Exophthalmic Goitre. 413 
 
 enlargement of tlie thyroid gland. Its relationship to 
 myxcedema has latterly been further established by the 
 remarkable observations made in Switzerland, to the 
 effect that removal of the thyroid gland may be asso- 
 ciated with development of myxoedematous symptoms. 
 In the Guy's Hospital Heports, vol. xxvi., I have de- 
 scribed the relationship between exophthalmic goitre 
 and insanity, and I will here briefly recall the chief 
 facts observed. 
 
 It is not necessary for all the symptoms to be 
 present in each individual case ; the palpitation, the 
 prominent eyes, or the enlarged thyroid, may be the 
 first or only symptom for a considerable period, but 
 as a rule all the symptoms are present sooner or later. 
 In Bethlem I have seen three fully developed cases of 
 this disease connected with insanity. The following is 
 a good example : 
 
 C. S., single, set. 28, admitted in 1877, an artist, 
 having two insane relations. This was the first attack 
 of unsoundness of mind, the cause being unknown. 
 Two months before admission into Bethlem she be- 
 came incoherent, was noisy and excitable, had delu- 
 sions^ thought that she was an actress, and had false 
 ideas of her powers and influence. The chief charac- 
 teristics of her insanity were excitement, incoherent 
 talking, violence, destructiveness, and sleeplessness. 
 She had suffered a good deal from palpitation of the 
 heart ; according to her friends, exophthalmic goitre 
 had been developing for about a year, and she 
 had worried herself considerably about the change in 
 her personal appearance. On admission she was 
 found to be a pale, anaemic girl, with marked and 
 pretty uniform protrusion of both eye-balls, and slight 
 enlargement of the thyroid gland. The number of the 
 pulse was not then recorded, but later it was 140 to 
 the minute. She continued to be acutely maniacal 
 during the next month, became filthily dirty in her 
 
414 Insanity and Allied Neuroses. [Chap. xx. 
 
 habits, constantly filling her mouth with dirt, stones, 
 and sticks. She was treated medically with liquor 
 ergotse and tinctura belladonnas, but without any 
 benefit. Within ten weeks of her admission she be- 
 came much weaker, and was confined to her bed. She 
 suffered much from vomiting and purging ; the pulse 
 was 135, respirations 40, temperature 98^. The eyes 
 were more prominent than ever, especially the left ; 
 the pupils, which at first were large, became somewhat 
 larger ; she was still dirty in her habits, but less 
 noisy ; palpitation of the heart was marked, and a 
 systolic bruit was heard at the base of the heart. This 
 was very rough in character, but was not audible at 
 the apex. A bruit also occurred at the base of the 
 neck on both sides. The patient now became dull and 
 sleepy, skin hot and dry to the touch, although the 
 temperature was really normal. She became more 
 dull and sleepy, and could hardly be roused. Pulse 
 140, respirations 50, temperature 100°. ISTo lung 
 complications could be detected ; heart palpitating ; 
 conjunctivse suffused, optic discs pale, vessels appeared 
 large and dilated ; the vomiting became less, purging 
 continued. On the next day she was reported to 
 be gradually sinking. Post-mortem : the brain was 
 found to weigh 44|^ oz., the dura mater was thick, but 
 free, the arachnoid thin and quite normal. There was 
 an appearance of congestion about the finer vessels, 
 giving a bright red dendroidal appearance to the sur- 
 face of the brain. There were no local wastings of 
 the convolutions ; there was slight excess of subarach- 
 noidal fluid ; grey matter, normal but thin ; white 
 matter, soft ; ventricles with excess of fluid, walls and 
 floors of ventricles granular, vessels at base normal ; 
 cervical sympathetic ganglia normal in appearance ; 
 lungs congested at base, and having several patches on 
 the surface like apoplexies. Heart \Z\ oz., firmly 
 contracted ; early atheroma visible in the aorta ; clot 
 
Chap. XX.] Exophthalmic Goitre. ^\^ 
 
 in the right auricle. Both kidneys congested, capsule 
 thick and adherent ; liver very fatty ; suprarenal 
 capsules small and breaking down. There was some 
 fulness in Peyer's patches, and the s^^leen was normal. 
 On careful microscopical investigation of the cervical 
 ganglia of the sympathetic, perfectly healthy appear- 
 ances were found. I have never examined a more 
 typically-healthy sympathetic in my life. The case, 
 then, so far as the post-mortem is concerned, exhibits 
 no special disease except in the suprarenal bodies. 
 The congestion in Peyer's patches were remarked in 
 connection with the fact that similar conditions have 
 been described by Mr. Howse, in the " Pathological 
 Transactions" for 1877, as having been found in 
 another case of this disease. 
 
 In all the three cases recorded in the Guy's Hos- 
 pital Peports there was present a restless condition of 
 mental irritability and violence, with dirty habits, re- 
 fusal of food, emaciation and diarrhoea, and in two of 
 them death. I was unable to convince myself of any 
 change in the cervical ganglia of the sympathetic. 
 Other cases have been described more recently by Dr. 
 Carlyle Johnstone, and I have no doubt that now the 
 relationship has been pointed out it will be seen to 
 be more common than might have been imagined. 
 Besides ordinary insanity associated with this con- 
 dition, I have met with several cases of general para- 
 lysis of the insane, with one or all of the symptoms of 
 this disease ; and other writers have described proptosis 
 as an accompaniment of general paralysis. I am per- 
 suaded that in cases where this proptosis was present 
 other symptoms would have been found if sought for. 
 
 The third condition of interest is that in which 
 there are recurrences of mental and bodily symp- 
 toms together. One patient, at present in Bethlem, 
 subject to recurrences of mental excitement, always 
 exhibits a prominence of eyes with a rapid pulse and 
 
41 6 Insanity AND Allied Neuroses. [Chap. xx. 
 
 a somewhat enlarged neck among the earliest symp- 
 toms of the recurrence ; and that this is not a singular 
 example I am convinced, not only from my own 
 observations, but from the inspection of photographs 
 of cases of recurrent mania during the periods of 
 excitement and of rest, which I have met with from 
 time to time. 
 
 To sum up. With insanity there may occur all of 
 the symptoms of Graves's disease, and this condition 
 may be a permanent progressive one ; so that the 
 patients die of Graves's disease with insanity, or they 
 may die of general paralysis in which exophthalmos 
 with rapidity of pulse has been present constantly, or 
 recurrently, or periodically \ symptoms of sjanpathetic 
 disturbance may also be associated with recurrent 
 mental disorder. The treatment of such cases must de- 
 pend rather upon general than upon special symptoms, 
 and I may say I have met with several cases of acute 
 mental disorder with symptoms of exophthalmic goitre, 
 which have completely recovered, and have lost both 
 the symptoms of mental disorder and those of bodily 
 disease. 
 
 Myxoedenia and insamty. — I have special 
 interest in considering this condition and its relation- ' 
 ship to insanity, because I believe I was the first in 
 England to describe this relationship, and since my 
 description many other writers have recognised its 
 force. I annex a likeness of a case in which myxoe- 
 dema was well marked. I am convinced that there 
 is some very special connection between the alteration 
 in the type of face and conditions allied to myx- 
 csdema. A certain number of weak-minded patients 
 assume aspects strikingly similar, and one special 
 group had long been recognised by me before I knew 
 anything of myxoedema. These are not fully deve- 
 loped cases af this disease, but I believe they will be 
 found to have much in common with it. With 
 
Chap. XX.] 
 
 Myxcedema. 
 
 417 
 
 myxcedema, as has been pointed out by Gull and 
 Ord, a certain cretinoid appearance becomes developed 
 in patients formerly healthy, and with this condition 
 a slowness of nervous reaction is also present. 
 Patients have, in fact, alteration not only in the 
 
 A case of Myxcedema with Weakness of Mind. 
 
 peripheral nerve endings, but also in the higher 
 centres, so that perception is dull and conduction 
 slow, the reaction having been likewise impaired. 
 Which of these plays the most important part in the 
 production of the mental weakness I am not pre- 
 pared to say ; but I have sufficiently referred to the 
 B B — 14^ 
 
41 8 Insanity and Allied Neuroses. vOi-x-^.^y.. 
 
 importance of normal sense perception in producing 
 healthy nervous action, and need say no more on the 
 subject, but proceed to give an example of insanity 
 with myxoedema. 
 
 Sarah B., widow, set. 60 ; had had one previous 
 attack of insanity, the supposed cause being the death 
 of her husband. A maternal aunt had suffered from 
 insanity also. The symptoms of this attack occurred 
 three months after the death of her husband, and 
 about three months before admission into Bethlera. 
 The first symptoms were incoherent letter-writing and 
 hallucinations of sight. She became threatening and 
 violent ; fancied people were insulting her. She was 
 feeble in memory and complained of people watching 
 her, speaking about her, and wishing to starve and 
 annoy her. Tliese symptoms exhibit nothing specially 
 characteristic, being similar to those commonly met 
 with in elderly widows of a nervous type ; but on 
 careful investigation it was found that her perception 
 was very dull, temperature sub-normal, her aspect fully 
 myxoedematous, her speech slow and muffled. She 
 has a sense of suspicion and of injury such as I have 
 described as common in these cases. The prognosis 
 in all such cases appears to me to be unfavourable. 
 It depends rather upon the bodily condition and upon 
 the secondary degenerations which may occur during 
 the development of the disease. In the above case no 
 albumen is present in the urine, therefore one may 
 expect this patient to continue slowly to develop the 
 symptoms already described for years to come, and 
 then she will die of some secondary disease at an 
 advanced age. 
 
 The following is an example of myxoedema in an 
 early stage in a man. George E., hairdresser, married, 
 set. 37 ; no insane relations. This, his first attack of 
 insanity, had lasted three weeks before his admission, 
 oil September 24, 1883. It began with suspicion that 
 
Chap. XXL] Alcoholism and Insanity. 419 
 
 a young man was going to kill liis wife ; lie thought 
 his food was poisoned ; he was restless, sleepless, and 
 much depressed ; had hallucinations of hearing ; he 
 could not control his thoughts ; constantly " bad lan- 
 guage appealed to him." 
 
 Slowly this patient gained confidence in himself up 
 to a certain point, but there he again failed. He was tried 
 at home but could not manage to stay there, voices and 
 followers annoyed him. He occupied himself in pho- 
 tography, but preferred to remain in the hospital. 
 
 Physically this patient exhibits the symj^toms of 
 myxoedema only to a moderate degree, but they are 
 all increasing. His face is becoming cretinoid ; his 
 temperature is sub-normal ; his skin is hard and does 
 not sweat ; his sight is impaired and his hearing is 
 failing. Slowly but steadily he will pass into dementia. 
 No treatment will be of any use. 
 
 CHAPTER XXL 
 
 ALCOHOLISM AND INSANITY. 
 
 Alcohol as a cause of insanity— a. Directly as in alcoholism — 
 h. Indirectly as producing gout, renal disease, arterial de- 
 generation. — a. (1) Acute alcoholism — (Delirium tremens) — 
 Acute alcoholism in neurotic persons — Acute alcoholism in 
 persons suffering from head injury — Acute alcoholism in 
 persons suffering from physical weakness. — (2) Chronic al- 
 coholism, producing sense perversions, with hallucinations, 
 giving rise to ideas of persecution or of jealousy— Chronic 
 alcoholism with moral perversion, convulsive and jDaralytic 
 seizures, general jparalysis, dementia — Dipsomania — Opium 
 and morphia-taking — Chloral-taking — Tobacco and insanity — 
 Chloroform-taking — Insanity due to lead poisoning — Gout 
 with insanity — Post-febrile insanity — Insanity following deli- 
 rium — Weakness of mind following feverish state — Moral 
 perversion following feverish state. 
 
 The role which alcohol plays in the causation of 
 insanity has already been briefly referred to. 
 
420 Insanity and Allied Neuroses. [Chap. xxi. 
 
 I have now to consider the forms of insanity 
 which owe their origin specially to this agent. 
 
 To one great class of reformers alcohol is the general 
 cause of insanity, and is directly to be blamed for the 
 supposed increase of the disorder among the people. 
 I have no doubt but that among some classes it is 
 quite true that drink is the chief cause of mental dis- 
 order, just as it undoubtedly is of social disturbance. It 
 has been shown that insanity increased directly with 
 the power of the working classes to get drink, and 
 decreased in times of distress in which money could 
 not be got to provide stimulants. 
 
 Drink may cause insanity, and it is chiefly harm- 
 ful under certain conditions to which I shall refer. 
 
 Drink often gets blamed for producing insanity, 
 whereas the intemperance was the first symptom of 
 the disease. 
 
 Intemperance in the use of stimulants may act 
 as a direct poison, at once affecting the whole nervous 
 system, or it may affect the man by throwing him 
 out of his social circle into a lower one, and thus, by 
 producing poverty and loss of caste, act and react on 
 the unstable mind. Alcoholic excess may act directly 
 on the nervous tissues, or primarily on the general 
 organs of secretion and excretion, interfering with 
 the depuration of the blood, and thus act by prevent- 
 ing the brain from being properly nourished. 
 
 Alcoholic excess, then, may be the predisposing 
 cause of insanity ; may be the exciting cause ; or may 
 only be a symptom of the disorder. 
 
 There seems to be a great deal of misunderstand- 
 ing about the legal relationship of insanity to drink, 
 and I shall, when describing the legal relationship of 
 insanity, have occasion to point out the various de- 
 grees of responsibility which exist with intemperance 
 in drink. 
 
 That insanity of a definite kind, and having special 
 
Chap. XXI.] Alcoholism. 421 
 
 symptoms originated in intemperance, does not in any 
 way affect tlie fact that insanity is present. 
 
 Almost every variety of insanity may be started 
 by drink ; but there are also special symptoms con- 
 nected with poisoning of the nervous tissues. I shall 
 point out that poisoning by opium or other drugs 
 may give rise to similar symptoms. 
 
 The most practical question is whether persons 
 suffering from alcoholic insanity should be sent to 
 asylums. If suffering from simple acute alcoholism, 
 or if suffering from delirium tremens, it is best not to 
 send them to lunatic asylums ; though a superinten- 
 dent is justified in receiving a dangerous alcoholic 
 case, and will be held free by the law if certificates 
 have been duly filled, and the order and statement are 
 in proper form. In some cases the sending such a 
 patient to an asylum has a beneficial efiect, at least 
 for a time. I have known several hard drinkers be- 
 come sober for considerable periods when they dis- 
 covered their nearness to ordinary insanity. 
 
 The great danger of admitting such cases is that 
 they rarely appreciate the intention of their friends, 
 and are commonly vindictive. Such cases, too, are 
 frequently morally perverse and sly; trumped-up 
 accusations and vexatious law-suits are constant 
 sources of worry as a result of their admission. 
 
 Drinking may be an early symptom of insanity. 
 It may occur in cases where restlessness and sleepless- 
 ness are the early symptoms of disorder. It may occur 
 in cases of hypochondriasis with anorexia. It may be 
 part of the loss of control of the appetites seen in 
 general paralysis of the insane. It may be the result 
 of insane habit, which, from taking " nips," has 
 developed into taking to excess. It may grow out of 
 the craving of pregnancy, or it may be a symptom of 
 climacteric uneasiness. It may be a direct inheritance, 
 or it may be a result of neurotic inheritance. 
 
42 2 Insanity and Allied Neuroses. [Chap. xxi. 
 
 1 shall not describe delirium tremens in full. 
 It is sufficiently recognised and described by the 
 general physician. It may be the result of one de- 
 bauch \ it may follow prolonged drinking ; it may 
 follow an injury or a mental shock in persons who 
 have been intemperate. I believe, in such cases, joyous 
 news may also upset the balance. There may be one 
 or many attacks of delirium tremens. If many 
 attacks, there is almost certain to be some other sign 
 of mental weakness. 
 
 I have made a distinction between delirium 
 tremens and acute alcoholism, for the following 
 reason. I have seen several cases in whom a single 
 short bout of drinking has started acute delirious mania 
 in highly neurotic subjects. The causes of the attack 
 and the general symptoms have resembled mania 
 more than delirium tremens. 
 
 In one case a young married man, whose father 
 was distinctly neurotic, and whose sister had been 
 seen by me sufiering from mania and refusal of food, 
 took steadily to drinking. He was a restless, active- 
 minded man, who was trying to make a fortune 
 rapidly by speculation. He felt his own danger, and 
 the day before I saw him he consulted a physician, 
 and got a narcotic drau&'ht. The same nio^ht he 
 became wildly excited and violent, and had to be 
 restrained. When T saw him early the next morning 
 his face was flushed, his tongue furred and tremulous. 
 He was at one moment shouting at the top of his voice, 
 and the next he was quiet and fairly self-possessed. 
 He had but few, if any, hallucinations of sight, and 
 had no true horrors. He was erotic, and took food 
 fairly. I told his friends that I believed it would turn 
 out to be a case of iu sanity started by delirium 
 tremens, and this proved to be the case. All the 
 tremulousness passed off; his tongue became clean, 
 and incoherence, sleeplessness, and chattering were 
 
Chap. XXL] Acute Alcoholism. 423 
 
 the symptoms of an attack of mania, from which he 
 recovered. 
 
 In the next case more violent delirium tremens 
 was followed by more prolonged mania. 
 
 Charles A., married, aet. 34, cousin insane. 
 First attack of insanity, following at once on a 
 very sharp attack of delirium tremens, produced by 
 frequent bouts of spirit drinking. Besides drink, 
 there had been failure in business, and nine months 
 before an injury to the head. He first became 
 suspicious, believing the police were after him ; he was 
 sleepless, and had bad dreams. He attempted to get 
 out of the window ; he threatened to kill himself. He 
 had hallucinations of sight, hearing, and taste. He 
 refused all food, and was violent in his attempts to get 
 away from those who wished to injure him. He 
 accused his wife of wishing to poison him, and he 
 threatened to injure her. On admission, he was 
 suffering from acute mania of a very delirious type. 
 His face was flushed, his tongue and lips dry brown ; 
 there was yellowness about his conjunctiva; his bowels 
 were constipated, and his urine had to be drawn off". He 
 was incoherent, and violent in his resistance. He had 
 to be fed with the stomach pump. His bowels were 
 relieved by enemata, and he seemed for a day more 
 quiet, but he again became violent and obstinate. 
 For a month he remained in this condition, his state 
 being one of extreme danger. Constant artificial 
 feeding, however, gained the day, and his general 
 health and strength improved. His tongue became 
 clean, and his bowels more i-egular. He had halluci- 
 nations and delusions for some weeks longer, but in 
 the end recovered. 
 
 In the next case, one attack of mania following 
 drink was followed by a period of six years' health, 
 to be succeeded by a second similar outbreak due to 
 drink. 
 
424 Insanity and Allied Neuroses. [Chap. xxi. 
 
 A. W., married, literary man, sister insane, 
 father excitable. Had one short, sharp attack of 
 mania, following intemperance, six years ago. He 
 recovered, and for some years was teetotal. The 
 present attack followed a fortniglit's heavy drinking 
 and excitement due to successful speculation. He had 
 the most extravagant ideas, and wrote and telegraphed 
 to the social and legal heads of society ; hired and 
 • bought whatever he fancied, and behaved in a very wild 
 way. He became more violent and had to be sent to an 
 asylum, where for a week he was restless, noisy, 
 violent, and destructive. It is hardly possible to 
 imagine any one more filthy than he was during this 
 period. In the end he slowly passed through a time 
 of depression to health. 
 
 In most similar cases discontent lasts for some 
 weeks after the mental improvement has commenced. 
 In the above cases we have examples of mania of a 
 simple form started by delirium tremens ; mania of a 
 severe delirious type having the same origin ; and, 
 lastly, drink causing a short attack of mania in place 
 of delirium tremens. 
 
 Just as drink acts often with special efibct on 
 persons with insane inheritance, so it acts specially 
 on many who have received injuries to the head. I 
 have met with patients in whom a very little stimu- 
 lant would produce drunkenness, and in others I 
 have seen acute mania started by stimulants under 
 similar conditions. In a man who had served 
 through the China war, and who had received a 
 severe head injury from a bursting shell, very little 
 drink, even beer, produced drunkenness, and this was 
 followed on two occasions by violent maniacal attacks 
 which lasted a week or two. 
 
 Under certain other conditions of physical weak- 
 ness, alcohol acts with increased power ; and I believe 
 that I have seen cases recovering from insanity who 
 
Chap. XXL] Chronic Alcoholism. 425 
 
 had less tolerance for stimulants than they had before 
 their attack of nervous disorder. 
 
 Chronic alcoholism, like acute alcoholism, may pro- 
 duce insanity, or it may be a symptom of nervous 
 disorder. In the former case we shall find some inte- 
 resting perversions of the senses, and also tendencies 
 to nervous deo^eneration of one kind and another. 
 
 In the latter we have what has been called dipso 
 mania. With chronic alcoholism, then, we may have 
 simple dementia of any degree, ranging from loss of 
 recent memory to the obliteration of all but the most 
 automatic parts of mind. 
 
 Some forms of intoxication are supposed to act 
 differently from others ; the easy-going beer-drinker 
 differs from the sentimental champagne bibber, and 
 these again from the desperate, often melancholic, 
 spirit taker. Absinthe has different effects to brandy, 
 or else the individuals who seek the various stimulants 
 differ greatly among themselves. 
 
 It is said that with absinthe there is a greater 
 tendency to convulsive seizures, 
 
 I have no distinct proof that general paralysis is 
 due to alcoholic excess alone, but I believe that there 
 is a cirrhosis of brain as well as of liver, and that a 
 similar cause may start both. 
 
 Patients who have long been in the habit of 
 drinking to excess may become melancholic, may take 
 the pledge, and may give rise to hopes that they are 
 reformed. Chronic alcoholism may be replaced by 
 chronic insanity of one kind or another. 
 
 Chronic alcoholism may be slowly replaced by some 
 moral perversion, so that an apparently good wife 
 who has been a secret drinker may take to hate her 
 children, and maltreat her husband and the servants. 
 In such cases there may be relapses into drunken- 
 ness, and cure is very rare. 
 
 With all these alcoholic cases there may be power 
 
426 Insanity and Allied Neuroses. [Chap. xxi. 
 
 to transact business, and there is generally cunning, 
 untruthfulness, and malice. 
 
 In persons of neurotic family, with comparatively 
 little alcoholic excess, and in cases of chronic alcoholism, 
 there are, as I have said, special symptoms often pre- 
 sent. Suspicion is one of the most common forms 
 of disorder. A man is physically and mentally tremu- 
 lous from drink. He suspects persons, he is on the 
 look-out for plots of all kinds. This insane suspicion 
 grows, often slowly, to an extraordinary extent, so 
 that at last it is hard to get out the evidence of 
 insanity because the patient is so suspicious of every- 
 one that he will deny his firmest belief to mislead 
 those who are questioning him. 
 
 No men are more dangerous than those suffering 
 from insanity with suspicion. They constantly carry 
 weapons, and will not hesitate to use them. 
 
 Delusions as to plots, police, government malice, 
 revenge by noble or distinguished persons to screen 
 themselves, are all common in this malady. As an 
 extension of these we have delusions as to " follow- 
 ing," persecution, watching, and the like. 
 
 Ideas of poisoning are very common, and may 
 have a physical basis in the chronic gastritis of the 
 drinker. Voices are commonly heard accusing the 
 patient or abusing and annoying him. If the voices 
 direct and control the actions they render the patient 
 highly dan]-erous. Visions may be present; but peculiar 
 sensations in the skin are most noteworthy; they are 
 described as being like galvanism. One patient said 
 he felt like one placed on an insulated stool having 
 shocks taken from him. Sometimes the feelings 
 resemble fine lines being applied to the skin, a 
 "gossamer feeling," as one patient said to me. In 
 some cases strange feelings affect the reproductive 
 organs, and this may give rise to false accusations and 
 to jealousy. Jealousy and violent accusations against 
 
Chap. XXI,] Dipsomania. 427 
 
 liusband or wife are common in chronic alcoholism, 
 and may be dangerous to life or to reputation, the 
 consistency of the tales very easily misleading those 
 who cannot understand partial insanity. Erotic 
 passion may show itself as a symptom of alcoholic 
 insanity. Kleptomania may also be present. 
 
 Insanity with violent jealousy due to drinh. — 
 Thomas S., married, set 25, maternal uncle and 
 aunt insane. The patient had rheumatic fever. 
 He slowly developed habits of intemperance, and 
 squandered a large fortune. He had two attacks 
 of insanity of exactly similar character. He was 
 suspicious ; he heard voices directing him. He 
 threw himself into the river. He thought his rela- 
 tions were plotting against him. He refused food, 
 and fancied things were dirty. He accused people of 
 injuring him at night. He told the Commissioners 
 that I had microphones applied to the brains of the 
 patients, and so read their thoughts. He threatened 
 to kill me. He accused his wife of misconduct, and 
 said her last child was not his. He was removed to 
 another asylum and for a time improved. In the end, 
 with such habits, a bad inheritance, and a damaged 
 life, he will be sure to have recurrences, and die in a 
 lunatic asylum, if he does not kill himself before. 
 
 Dipsomania must be considered an irresistible 
 desire for stimulants. It may grow out of habit, it 
 may be an inheritance, it may be an insane symptom, 
 or it may be the vestige of an attack of insanity. It 
 occurs in men and in women. It is more common after 
 thirty than before ; but in patients of insane inheri- 
 tance it may be met with at a very early age. It may 
 be a concealed vice, or it may be a raging passion. 
 Its chief characteristic is the moral perversion which 
 it causes. The patients, who may be everything that 
 is good and refined when in health, become the most 
 unmitigated liars and the most contemptible cowards 
 
428 Insanity and Allied Neuroses, ichap. xxi. 
 
 and sneaks. No meanness is too low for the dipso- 
 maniac, if it enable him to get his stimulant. Moral 
 perversion, weakness of will, and emotional instability- 
 mark the disease. The prognosis is looked upon as 
 very unfavourable, but I believe the careful study of 
 these cases shows that some are curable. If the 
 disease is a symptom of other nervous or bodily 
 disease it may be relieved ; but if it has slowly 
 grown to be a definite habit, nothing will cure it. If 
 neurotic taint is strong, its cure is not probable. 
 
 The efforts of the legislature and the founders of 
 the Dalrymple Hetreat have done good work. 
 
 Chloral habit — With every addition to the Phar- 
 macopoeia some good may be gained, but my experience 
 leads me to fear that every new hypnotic does at least 
 as much harm as good. In cliloral at first we were 
 led to believe that we had a drug which neither 
 upset the digestion nor in any way acted in- 
 juriously, giving a peaceful sleep to the weary, and 
 leaving a brighter and a better man. As was to 
 be expected, this drug was largely used in asylums, 
 but that it is not all that it was said to be is proved 
 by the steady way in which its use has dropped out of 
 the regular practice of asylums ; and in some I should 
 almost as soon ask the superintendent if he used re- 
 straint as if he used chloral. 
 
 Chloral has its uses, to which I shall refer later ; 
 but now I have to consider certain mental afiections 
 produced by its abuse. It may set up a craving for 
 its use, much like that for drink or for opium^ and 
 may give rise to similar moral perversion. I do not 
 look upon the moral perversion solely from the material- 
 istic point of view, but I also consider that if there be 
 established a very strong, or, as I have put it, an irre- 
 sistible craving for a thing, this will over-ride what we 
 call moral laws, which are less powerful agents. The 
 diseased state is the craving, and this varies in degree, 
 
Chap. XXI.] Opium-taking. 429 
 
 being greatest with the most potent drugs or stimuli. 
 I believe opium-crave is the greatest, and that for 
 chloral among the least, and as a result the moral per- 
 version is not quite so great in the latter as in the 
 former. 
 
 Chloral will produce a crave, and with this certain 
 moral defects. Chloral will establish a sleepless habit, 
 and it will cause a feeling of deep depression, asso- 
 ciated with anxiety and a hypochondriacal feeling at 
 the epigastrium. It may produce very great emotional 
 disturbance and irritability, passing into deep melan- 
 cholia, with suicidal tendencies. 
 
 In my experience it produces loss of control and 
 tendency to impulses, so that suicide or homicide may 
 result in a moment of loss of control. The terrible 
 feeling of depression described by several patients who 
 have been regular chloral takers was most marked on 
 awaking in the morning, when the person felt as if he 
 must precipitate himself out of the window. The loss 
 of self-control ends in death from over-doses in the fol- 
 lowing way : A patient who used to take a certain 
 dose, now takes it without relief ; he gets up and 
 takes a little more, still not losing consciousness, 
 though in a state of partial insensibility ; he then 
 takes an excessive dose, and sleeps to death. 
 
 I have seen stupor produced in one case by 
 a single very large dose of chloral, taken with 
 suicidal intentions, in a woman who had been leading 
 an irregular life. She in the end got well, after being 
 insane for nearly three years. 
 
 Opium has a most baneful eflfect on the minds 
 of those who are in the habit of constantly taking it, 
 and more recently the vice of morphia-taking, or 
 rather of morphia-injection, has become so common 
 that the Germans speak of morphismus as well as 
 alcoholismus. The chief effect of both is to produce 
 the lust or crave for the drug which upsets all the 
 
430 Insanity and Allied Neuroses. [Chap. xxi. 
 
 moral character in the way I have already described, 
 the impulse being stronger than with any other, and 
 the temporary exaltation or ecstacy being still more 
 marked. The same set of syniiDtoms, resembling deli- 
 rium tremens, may arise from either, and it is said 
 that if an injection of morphia be given it will quiet 
 in morphismus, but that alcohol will cause excite- 
 ment. 
 
 In this state there is the same tremor, the same 
 want of appetite, the same refusal of food, the same 
 ideas of poison, the same hallucinations, and I believe 
 the same tendency to erotic ideas. This state may be 
 produced either by opium administered by the mouth, 
 or by morphia injections. 
 
 It may be cured, or at least the attack may be 
 got over, by the total removal of the drug, and this 
 may be done suddenly, though I must add that the 
 shock produced by the sudden withdrawal is so alarm- 
 ing that some medical attendant should be handy 
 to supply stimulants, and be ready for the collapse 
 which will follow. Sickness and diarrhoea will fol- 
 low, and may cause alarm, but usually they pass in 
 the course of a few days. The diet should consist 
 of the plainest, most easily digested fluid food, and 
 some of the meat extracts or peptonised foods will be 
 of service. 
 
 Beside a chronic craving for the drug, which over- 
 rides all moral or social laws, there may be chronic 
 morphismus, with hallucinations of the same kind as 
 those which are seen to occur with alcohol. I have 
 had lately in Bethlem two cases with exactly the same 
 ideas. Both were suspicious, both were pestered by 
 voices of friends and of enemies, and were told to do 
 all sorts of things ; both were much distressed on 
 account of the supposed ill-conduct of their friends; 
 and both had feelings of shocks, being, as they said, 
 galvanised. These two cases spent some time in 
 
Chap. XXI.] Lead Poisoning. 431 
 
 comparing their various symptoms, and eacli told me 
 they were in every respect similar. The patient with 
 the morphia habit got quite well, but is subject to 
 relapses. 
 
 Tobacco has many enemies, and after many battles 
 have been fought, it has been shown that it may pro- 
 duce blindness, associated with distinct changes in the 
 optic nerves. I never yet saw a case of insanity due 
 simply to tobacco. I have seen aggravation of other 
 nervous symptoms follow its use. I have met with 
 nervousness, indecision, sleeplessness, and jealousy 
 depending on the excessive use of tobacco. It is more 
 common to find excessive smoking first upsetting the 
 digestive functions, and then causing secondarily ner- 
 vous weakness. Smoking in very young subjects 
 tends to indolence and self-indulgence, and may thus 
 be a just cause in. producing disordered action or loss 
 of control. 
 
 Chronic chloroform habit, with similar demorali- 
 sation has been described, but I have not seen any 
 such cases ; I have seen all the symptoms of alcohol- 
 ism produced by the excessive use of sal-volatile in 
 one old man. The habit was so long established, that 
 half-a-pint of this drug was taken at a time. One 
 peculiarity, too, of this case was that the patient con- 
 sidered himself a model of temperance. 
 
 Im^anity clue to lead poiisoniiig'. — It is in- 
 teresting to notice that a certain series of symptoms 
 follows poisoning by various different substances ; and 
 that the symptoms so produced resemble approxi- 
 mately those which occur in two very opposite dis- 
 orders of the nervous system, hysteria and general 
 paralysis of the insane. In hysteria we have what 
 has been called the mocking-bird of nerve disease ; so 
 that every symptom which may be the result of disease 
 or destruction of the nervous system may be repre- 
 sented by hysteria. In general paralysis of the 
 
432 Insanity AND Allied Neuroses. [Chap xxi. 
 
 insane I pointed out that an endless variety of 
 symptoms occurs similar to those found in such 
 different diseases as epilepsy and locomotor ataxy ; 
 and with alcohol and lead similar symptoms may 
 arise. It is doubtful whether some other mineral 
 poisons do not produce similar effects upon the 
 nervous system ; but here I have only to deal with 
 lead. I have seen acute mania following lead poison- 
 ing, and passing off with removal of the cause. In 
 one case in Guy's Hospital, under Dr. Moxon, a 
 woman had used a lead lotion freely, before admission, 
 to a large open wound. This was followed by acute 
 mania associated with a blue line on the gums. Other 
 cases of acute mania have more recently been observed 
 distinctly connected with lead poisoning. I have seen 
 acute mania rapidly followed by symptoms closely re- 
 sembling those of general paralysis, due to the same 
 cause. 
 
 A man, aged thirty-two, was admitted into Beth- 
 lem, who had worked as a clerk for some years in a 
 lead manufacturer's office ; great hesitation of speech, 
 tremor of tongue, exaltation of ideas, emotional dis- 
 turbance, and restlessness were present. On investi- 
 gation, the patient's friends said (although I had found 
 a blue line on his gums) that it was impossible for 
 lead to be the cause of his troubles ; because, as clerk, 
 he had really nothing to do with the metal ; but 
 believing the blue line rather than the friends, I 
 treated him accordingly, and he recovered, and ex- 
 plained the lead poisoning by the fact that depression 
 in trade had caused reduction of hands, and an 
 increase in his duties ; so that not only had he to do 
 the correspondence, but he examined and sorted the 
 white lead. Symptoms such as the above are now 
 recognised as being associated with lead poisoning. 
 But Dr. Bayner is convinced that the symptoms may 
 not only resemble those of general paralysis, but the lead 
 
Chap. XXI.] Gout with Insanity. 433 
 
 may, in fact, start the disease itself ; so that general 
 paralysis may arise definitely from lead poisoning. 
 At all events, I would say, from my own experience, 
 that certain cases^ with symptoms of progressive 
 mental weakness and some loss of bodily power fol- 
 lowing lead poisoning, die, and in some cases have fits. 
 
 A third condition of mental disorder associated 
 with lead is that following epilepsy, which has its 
 starting point in lead poisoning. There is nothing 
 special in these cases, except that there may be more 
 or less pronounced symptoms of paralysis, such as are 
 seen ordinarily arising from lead. 
 
 Oout with insanity. — Recently books and 
 papers without number have been written on this 
 strange disease, and I feel that fashion in medicine 
 and the evidence of waves of thought are nowhere 
 better seen than in relationship to this subject of gout 
 Twenty -five years ago one heard of gout as a disease 
 acquired by our forefathers and transmitted by them, 
 in a more or less degenerate form, to us ; but now-a- 
 days one hears everywhere of gout and gouty troubles. 
 I have no doubt that civilised people, especially those 
 belonging to the educated classes living in cities, eat 
 too much stimulating food j that, in fact, they do 
 not keep their sewers well flushed, the consequence 
 being that there are obstructions and overflows 
 connected with unpleasant results. Whether there be 
 a special blood poisoning by uric acid or not, or 
 whether gouty conditions are dependent on defective 
 blood purification generally, is not for me to consider. 
 Some would look to gout as a nervous disease prima- 
 rily, but I do not agree with these. I have no doubt 
 that there are cases of insanity connected directly 
 with gout, and I subjoin a case which is as nearly 
 typical as could be desired, the disorder being co- 
 existent with and also co-extensive with gout. 
 
 John E., naval officer, married, set. 53, had no 
 c c — 14 
 
434 Insanity and Allied Neuroses. [Chap. xxi. 
 
 insane blood relations, had been distressed by the in- 
 sanity of his wife. The symptoms had begun eight or nine 
 months before admission, and were thought at first to 
 have been the result of his domestic worry and pecuniary 
 difficulties ; but it was shown that before the onset of 
 his symptoms he had not had his usual attack of gout. 
 He was a man who lived well, but was not intemperate. 
 He became depressed and sleepless ; he refused food ; 
 and was constantly endeavouring to escape because he 
 believed he was to be vivisected. He believed detec- 
 tives watched him, and that he was a centre of con- 
 spiracy. He made five or six determined attempts at 
 suicide, and I remember few patients who caused 
 more anxiety than did this one. Nothing seemed to 
 influence him for good, and his whole thoughts were 
 concentrated on escaping from the world and his perse- 
 cutions. This state continued till three months after 
 his admission, it being now a year since the appear- 
 ance of the first symptoms of his insanity. One 
 morning, going round the wards, I was surprised to be 
 greeted by him in a cheerful way, he pointing to his 
 foot, and with a smile saying, "Doctor, I have got the 
 gout again, and I am all right." This was true ; he 
 had a sharp attack of gout, was as cheerful, bright, and 
 happy, as a man could be, and with the relief of gout 
 there was no return of insanity ; from that time to 
 this, now some six years, he has periodically visited 
 us, and always says, " Well, doctor, I have got the 
 gout, and hope to keep it as long as I live, because my 
 mind is perfectly well and clear as long as I have it." 
 The prognosis in a case of that kind must certainly 
 be doubtful, for we cannot tell how soon he may 
 again sufier from the so-called suppressed gout. 
 
 Other writers have recognised the feeling of 
 terrible depression which is often connected with 
 undeveloped gout ; and the experience of most men 
 has enabled them to witness the immense increase of 
 
Chap. XXI.] Post-Febrile Insanity. 435 
 
 irritability wliicli may occur with an acute attack of 
 gout. 
 
 Attacks of acute mania have been described as 
 depending on undeveloped gout, and as passing off 
 with the development of acute gout. I have not seen 
 such a case myself, though I have met one or two 
 gouty persons who have told me that they were most 
 buoyant just before an attack of the gout. Gouty 
 degenerations of various kinds may tend to ideas of 
 dread, persecution, and to senile weak-mindedness, or 
 in the end apoplexy. 
 
 The treatment of insanity depending on gout must 
 be in all respects similar to the treatment of gout ; 
 and I am afraid that when asked how to prevent a 
 patient getting suppression of gout I am unable to give 
 explicit advice, for the drinking of stimulating full- 
 bodied wines is not always sufficient to produce it, 
 even in predisposed cases. As a rule, I think exercise, 
 so far as you can consistently recommend it, Turkish 
 baths, saline purgatives, and change of suiTOundings, 
 will be found the most likely to prevent the insanity, 
 or to assist in the removal of depression connected 
 with gout. 
 
 Post-febrile insanity. — There are several dis- 
 tinct conditions under which symptoms of mental 
 disorder arise in connection with febrile states. 
 
 1. The delirium may be replaced or immediately 
 followed by mania ; this may or may not be associated 
 with extraordinarily high temperature. 
 
 I have seen mania succeed the delirium of drink, 
 the delirium of belladonna, the delirium of pneumonia, 
 and of specific fevers. 
 
 In these cases there is generally well-marked 
 neurotic inheritance ; the patient passes through the 
 first few days of febrile disturbance naturally, then 
 becomes sleepless, chattering, and often amorous ; 
 refusal of food is very common, and rapid exhaustion 
 
436 Insanity and Allied Neuroses. \.ich2i^.y.y.\. 
 
 follows. The mania may have most of the charac- 
 teristics of ordinary delirium, but may persist for days 
 or weeks. If sufficient food be given, the patient 
 generally recovers, but with refusal of food rapid 
 exhaustion and death may follow. After the mania 
 has lasted for a variable nurhber of weeks, depression 
 or partial dementia is well marked, there being some 
 vague dread or other in the former case, and in the 
 latter listlessness, with loss of memory, disregard of 
 friends and relations, and neglect of the decencies of 
 life. As soon as possible such cases should be sent from 
 asylums, and change in their surroundings tried in 
 every way. Tonics, stimulants, and abundant fluid 
 foods are necessary. 
 
 I do not think it matters whether the disturbance 
 be due to local inflammatory disease, such as pneu- 
 monia or pleurisy, or to rheumatic, scarlet, or typhoid 
 fevers 
 
 Besides the above forms of mental disorder, I have 
 seen insanity associated with the outbreak or incuba- 
 tion of scarlet fever and small-pox, and in such cases 
 the early onset of delirium of a marked kind has been 
 followed by mania, which again has been followed by 
 the specific rash. In several such cases the acute 
 mania passed off with the development of the specific 
 symptoms of the fever, but in others the two diseases 
 were both present. 
 
 Fevers and feverish states may be followed by 
 temporary or permanent weakness of mind. It is not 
 unusual to meet with cases of loss of memory after 
 typhoid fever, even when the febrile process has not 
 been specially severe ; after rheumatic fever there 
 may be a similar loss of mental power. 
 
 Besides loss of memory, I have met with cases of 
 moral and intellectual perversion which followed 
 feverish diseases. 
 
 In my opinion there is no specific disease of the 
 
Chap. XXII.] Idiocy and Imbecility. 437 
 
 brain due to fevers, but I believe that either brain 
 wasting may result from the rapid body wasting of 
 fever, or, in nervous persons, the balance may be dis- 
 turbed by the all-pervading febrile process. 
 
 CHAPTER XXIL 
 
 IDIOCY AND IMBECILITY. 
 
 Causation of idiocy — Varieties of idiocy : genetoiis, microce- 
 phalic, eclampsic, epileptic, hydrocephalic, paralytic, trau- 
 matic, inflammatory — Idiocy of deprivation — Cretinism. 
 
 Though from a developmental point of view this class 
 of mental disorders is of very great interest, yet the 
 little real good which can be done renders the care 
 and treatment of idiots an employment which is 
 trying and unsatisfactory. In considering idiocy, I 
 shall refer to several classifications which have been 
 made, and constantly refer to the most satisfactory 
 book in English on the subject, that of Dr. Ireland. 
 
 Idiots and imbeciles may be classified according to 
 their facial types; and Dr. Langdon Down has pointed 
 out that among idiots there are to be found those 
 having a special negroid type, while others approach 
 the Mongolian in aspect. Such a classification must 
 merely be looked upon as provisional. Other authors 
 have divided the cases according to the degree of their 
 mental acquirements, and this division is convenient 
 and natural in many respects. Thus there are certain 
 idiots who are but automatic beings, without any evi- 
 dences of the action of the higher centres whatever ; 
 and there are others who, with higher powers, are 
 still only able to move about, and to make use of a few 
 words or sounds. A third and still higher class may 
 be able to walk and talk a little, and may be suscep- 
 tible to the influences of education to some extent. 
 
438 Insanity and Allied Neuroses. [Chap. xxii. 
 
 Higher still, we may have imbeciles who are able to 
 walk and talk, and acquire to a greater extent than this, 
 but who are nevertheless generally defective, and cannot 
 be looked upon as ordinary children. In this last 
 class there may be weak-minded individuals who have 
 special aptitudes (the so-called idiot savant) ; and here 
 we may also meet with moral imbeciles, having mathe- 
 matical, musical, or mechanical abilities, on the one 
 hand, or children without moral sense on the other. 
 In both these divisions there sometimes occur cases with 
 wonderfully retentive memories. Besides the above 
 groups, there are cases in which the power of develop- 
 ment is not altogether arrested, but is greatly de- 
 layed ; so that a lad of sixteen may have the mental 
 capacity of a child of six, and may be capable of 
 indefinite development ; intellectually such an one is 
 always in arrears. In connection with the above cases 
 have to be considered cretins, who, with special phy- 
 sical peculiarities, have mental deficiencies which may 
 be of any of the above types, and in any degree. 
 
 Idiocy has also been divided according to its cause ; 
 for instance, the state may have been due, in the first 
 place^ either to congenital deficiencies, or to some ac- 
 quired fault ; to deficiency of brain, or to a deficiency 
 of sense ; it may have followed inflammation of the 
 brain, or resulted from convulsions started in teething. 
 I prefer myself to look at the idiot from the more 
 widely-considered pathological point of view ; and I 
 would say that idiots may be the result of morpho- 
 logical or histological deficiencies. Thus a child having 
 only basal ganglia can necessarily only be an automa- 
 ton ; a child with porencephalus, having a deficiency 
 between the ganglia at the base and the cortical layers, 
 is also necessarily weak-minded, there being a want of 
 connection between the receptive and the constructive 
 parts of the brain. In others, too, there maybe defi- 
 ciencies in the commissural or combining fibres, the 
 
Chap. XXII.] Classification of Idiocy. 439 
 
 halves of the brain existing, but there being no power 
 of getting the various parts into harmonious working. 
 In other cases there seems to be arrest in the brain 
 cell development, the layers of cells in cortex remaining 
 in an undeveloped state, or only partially entering into 
 the many relationships for which they are intended. 
 These latter changes may be the result of arterial alter- 
 ation, of inflammatory process such as those following 
 injuries; in one special group there is a great overgrowth 
 of connective tissue at the expense of all higher tissue. 
 Dr Ireland's classification is : 
 
 1. Genetous idiocy. 
 
 2. Microcephalic idiocy. 
 
 3. Eclampsic idiocy. 
 
 4. Epileptic idiocy. 
 
 6. Hydrocephalic idiocy. 
 
 6. Paralytic idiocy. 
 
 7. Cretinism. 
 
 8. Traumatic idiocy. 
 
 9. Inflammatory idiocy. 
 10. Idiocy of deprivation. 
 
 There are some general questions which must be 
 referred to before any special details are entered upon, 
 and one of the most important of these is the causation. 
 
 I have no doubt that inheritance takes the first 
 place in the production of idiocy ; but it is an un- 
 doubted fact that insane parents may beget sane chil- 
 dren, and that there are sane parents who produce 
 only idiotic imbeciles or epileptic children. The 
 relationships of inheritance are •difiS.cult to understand. 
 I have seen several idiots whose mothers were insane 
 at the time they were pregnant with them ; and al- 
 though I have heard of cases in which a fright during 
 pregnancy has been said to have produced idiocy, I 
 have myself no facts to confirm the statement. 
 
 Insanity in father or mother may produce idiocy in 
 son or daughter. 
 
 The insanity in the parent may have been tempo- 
 rary, or it may have been chronic or incurable, such 
 as general paralysis of the insane. On several occa- 
 sions I have met with insane parents, whose insanity 
 has not shown itself for years after the birth of 
 
440 Insanity and Allied Neuroses. [Chap. xxii. 
 
 chiidren who have proved to be idiotic. In the 
 same families in which one meets with insanity one 
 also meets with idiocy. Dr. Ireland says, " idiocy is, 
 of all mental derangements, the most frequently propa- 
 gated by descent." Mr. Lndvig Dahl showed that 
 fifty per cent, of idiots had insane relations. Dr. 
 Langdon Down believes that if the neurosis be present 
 on the mother's side^ the first children are most likely 
 to be affected ; and if on the father's side, it is the 
 later-born children who will show the weakness. 
 
 One of the most common beliefs in reference to 
 idiocy is that consanguineous marriages are among the 
 most common causes of the production of this condi- 
 tion. In the popular mind, the marriage of cousins 
 is sure to produce idiocy ; but I am quite of the 
 opinion of Mr. Huth, who most carefully studied the 
 whole question, that consanguinity alone has little to 
 do with the production of idiots. If the stock be 
 healthy in mind and body, there is no extra risk in 
 the marriage of cousins ; the real thing is, that when 
 near relations marry, any tendency to physical or 
 mental weakness is immensely increased ; and, there- 
 fore, if two members of a neurotic family marry, the 
 prospect for the offspring must be bad. Mr. Huth 
 went so far as to believe that, under favourable cir- 
 cumstances, consanguineous marriage was rather bene- 
 ficial than otherwise. This I can believe may appear 
 to be the fact; but the chances are that the greatly ac- 
 centuated diseases of the related parents would cause 
 much mortality in the weaker members, only the very 
 strong surviving. 
 
 Much time has been spent, and whole aruiies of 
 statistics collected, to trace the origin of this imperfect 
 mental development, and, as a result, it seems to me 
 that evidence has been collected in sufficient amount 
 to prove that tendencies to degeneration in one or both 
 parents, especially tendencies affecting the general or 
 
Chap. XXII.] Causation OF Idiocy. 441 
 
 nervous systems, are specially likely to produce idiocy. 
 That scrofula seems in some way to be related to weak- 
 mindedness is shown by the number of parents of such 
 patients who die of consumption, and also by the 
 number of idiots who suffer from some form of scro- 
 fulous disease. What their relationship to bacilli is 
 I fail to recognise. As Dr. Ireland says, most in- 
 fluences which lower the general health in the parents 
 have been assigned as causes of idiocy ; but, contrary 
 to what might be expected, it does not seem to be a 
 frequent consequence of hereditary syphilis. There is 
 considerable difference of opinion as to the effects of 
 drunkenness in parents upon the production of idiocy. 
 Some, including Dr. Down, lay stress upon intoxica- 
 tion in the father at the time of the conception ; but I 
 must confess that it seems to me very hard to prove 
 that the father was in such a state at the time of con- 
 ception. Drunkenness, with its accompaniments of 
 bad hygiene and enfeebled physique in one or both 
 parents, is certain to produce a weakly offspring, and 
 some such will be sure to suffer from idiocy. If idiocy 
 be the result of degeneracy in the stock, it would 
 be likely that children born from aged parents would 
 tend to be less healthy than others, but no special rela- 
 tionship of aged parents to idiocy has been proved. 
 
 Other conditions, at present unknown, tend to the 
 production of idiocy, and in cretinism one sees the 
 special result of some general condition; and in the 
 same way idiots are met with among the most healthy 
 and sober families. It is a common experience to find 
 a weak-minded youth or adult in any of the out-of-the- 
 way villages in England, France, or in Scandinavia. 
 The very capacity which man exhibits for development 
 connotes a possibility for reversion to lower organic 
 and intellectual types. Other circumstances have 
 been referred to besides primary brain deficiency ; 
 thus, children born deficient in one or more of their 
 
442 Insanity and Allied Neuroses. [Chap. xxii. 
 
 senses run a great risk of being weak-minded ; and a 
 superintendent of a large deaf and dumb institution 
 told me that his chief difficulty arose, not from the 
 deafness and dumbness, but from mental weakness, 
 which was always seen in children of this class. 
 
 Oemetoiis idiocy. — This term is used to com- 
 prehend all those cases, which, starting in foetal life, 
 cannot be traced to any specific disease. The term is 
 convenient, as including a series of cases not otherwise 
 to be collected, although, as the majority of idiots are 
 idiotic from birth, the term is hardly a happy one. In 
 these cases morbid inheritance plays an important part, 
 age or decay in the parents often existing ; in others 
 physical diseases are common, such as rickets and stru- 
 mous disorders ; the whole body is feebly built, there 
 being torpor, with feeble circulation ; the palate is gene- 
 rally keel-shaped, the molar teeth being closely approxi- 
 mated ; teeth are late in appearing, and deficient in 
 number. This point of the narrowness and height of 
 the vaulted palate may be of considerable importance ; 
 for although this kind of palate may be present in 
 healthy individuals or in persons suffering from 
 ordinary insanity, if it be associated with weak- 
 mindedness or moral peculiarities in youth, I be- 
 lieve one is justified in saying that the tendency 
 to moral or intellectual deficiency is congenital. The 
 teeth in idiots of this kind may be worm-eaten and 
 irregular in outline, but syphilitic teeth are certainly 
 not common. Such idiots are generally short, with 
 frequent occurrence of deformities j the ears are flat 
 or irregular in shape, of large size ; hernias are also 
 present not uncommonly ; testicles may be present or 
 absent. These cases may vary in degree very con- 
 siderably, the worst cases being speechless automata, 
 often given to restless moving of head and hands. Of 
 this group several varieties have been pointed out. 
 Dr. Langdon Down and others have marked a variety 
 
Chap. XXII.] Cretinoid Idiots. 443 
 
 closely resembling the Mongolian type of head and 
 face. Other racial types are named from their 
 resemblance to the Grecian, Ethiopian, Malayan, and 
 American Indian. 
 
 An interesting group of what might be called 
 sporadic idiots was described by Dr. Fletcher Beach 
 and Dr. Hilton Fagge as cretinoid idiots ; they are 
 children of low stature and broad features, nose thick, 
 mouth large and wide, hands and feet spade-like; they 
 are late in walking, and almost invariably imbecile or 
 idiotic to a degree. The distinguishing characteristics 
 of these children are soft symmetrical protuberances 
 on each side of the neck above the clavicles ; these are 
 merely fat masses. Some of these cases are described 
 by Dr. Beach in the third volume of the " Transactions 
 of the International CongTess," 1881 (p. 626). It 
 suffices to say, that these cases of apparent sporadic 
 cretinism are rare, but appear from time to time in 
 districts where neither goitre nor cretinism occur. 
 
 Genetous idiots may be educated to a certain point, 
 and both Dr. Down and Dr. Ireland say that a child 
 born with defective intellect is more susceptible of 
 improvement by physical and intellectual training, 
 than a child who has become idiotic by deprivation. 
 When the idiot's physical strength and circulation are 
 fair, the prospect is, of course, better than when they 
 are feeble. There is no special pathological condition 
 associated with the above varieties. Differences in 
 shape of skull and alterations in relationship of the 
 sphenoid have been described, besides want in mass 
 of brain and imperfect or defective commissural re- 
 lationship. General measures are the only ones likely 
 to be of any service beyond special systems of practical 
 education. And here one would say that the funda- 
 mental principles of the education of idiots will depend 
 on a simultaneous appeal to several senses at the same 
 time; so that when an action is desired, the suggestion 
 
444 Insanity and Allied Neuroses, [chap. xxii. 
 
 for it should be made to sight, to hearing, and touch : 
 music and drilling must always be looked upon as 
 two of the most important aids which exist for the 
 development of the weak-minded of this and other 
 descriptions. 
 
 Microceplialic idiocy. — The chief character- 
 istic pathologically in this group of idiocy is the fact 
 of cerebral deficiency. In some cases grotesque expe- 
 riments seem to have been made by nature to show 
 with how small an amount of brain the human being 
 may exist. As a rule, the average size of heads of 
 idiots is smaller than those of healthy individuals ; in 
 the class under consideration the difference is great. 
 Whatever may be the general feeling as to the re- 
 lationship of size and shape of head to mental ability ; 
 whatever view be taken of the value of phre- 
 nology, it must be admitted that there is a size below 
 which any real mental capacity cannot be found to 
 exist. Dr. Ireland says that below seventeen inches 
 in circumference the manifestation of intellectual 
 power wi]l be feeble, and he gives the term micro- 
 cephalic the limit of seventeen inches. Some 
 parents have produced a series of microcephalic idiots, 
 including one case of twins. The smallness of the 
 head may depend upon the partial or general defi- 
 ciency j the cerebellum is relatively larger than the 
 brain. The aspect of a typical microcephale is extra- 
 ordinary, and well seen in any idiot asylum. 
 
 Microcephalic idiots of an extreme degree are, 
 from time to time, exhibited by showmen as belonging 
 to some lost race, or to a people living on trees or 
 underground. Most of these patients are short in 
 stature and frequently active in movement ; they are 
 restless, often quick of perception ; the prognosis will 
 depend, to a great extent, on the size of the skull at 
 birth, extremely small-brained children developing little 
 either in body or mind. These patients sometimes 
 
Chap. XXII.] Microcephalic Idiocy, 
 
 445 
 
 are supposed to resemble animals, and have been 
 described as birds, sheep, apes, and the like. In the 
 most advanced cases they have no power of feeding 
 
 A case of Sporadic Cretinism. 
 
 or protecting themselves. If of a slightly higher type 
 they may be amused by trifling things, may have 
 strong tendencies to imitation, and may be able to get 
 about and help themselves up to a certain point : 
 
446 Insanity and Allied Neuroses. [Chap. xxii. 
 
 fortunately sexual power is absent, or at all events 
 defective. It is still an unsettled point as to whether 
 the brain or the skull ceases to develop ; whether the 
 brain is restricted in its development by the premature 
 ossification of the skull, or whether the skull ossifies 
 over a brain which has ceased to develop. Dr. Ireland 
 thinks that the brain ceases to develop, and not that 
 it is arrested by the skull. Yery little can be done in 
 the development of the above cases. Healthy sur- 
 roundings and supervision, with care as to feeding 
 and warm clothing, are about the best means of pro- 
 longing life and developing some little intelligence. 
 
 eclamptic idiocy. — Any serious disturbance of 
 the nervous system in early childhood has, as I have 
 said, a tendency to arrest development or even to de- 
 stroy what has already grown. Any cause which gives 
 rise to convulsions in childhood may be the cause 
 of idiocy or imbecility. Fortunately but few of the 
 children who have fits become idiotic. Dr. Shuttle- 
 worth found that at Earlswood fourteen per cent, of 
 the cases of idiocy were ascribed to teething con- 
 vulsions. Cases arising from convulsions have little 
 chance of improvement. It seems as if the con- 
 vulsions had destroyed the power of further develop- 
 ment, at all events of higher intellectual development. 
 Some of these cases can be trained to mechanical work. 
 The eclampsic idiot differs from the next class, that of 
 
 Epileptic idiocy, from the fact that in the 
 former the fits were but the starting point of the 
 diseased process, and having wrought their evil, ceased, 
 whereas in the epileptic patient the fits depend not 
 so much upon a reflex irritation, as upon some organic 
 brain change, which, continuing in force, causes the 
 fits to be constant. Epilepsy, whether in the form of 
 severe fits, or only of slight losses of consciousness, 
 may occur in patients who are already idiotic, and 
 may in no way be connected with the production of 
 
Chap. XXII.] Epileptic Idiocy. 447 
 
 the weak-mindedness ; both the fits and the idiocy 
 depending upon the same pathological condition of 
 
 An Epileptic Idiot. 
 
 the brain. But the symptoms in the class I am now 
 speaking of depend for their causation upon the 
 recurrence of epileptic fits. In speaking of epilepsy, 
 
448 Insanity and Allied Neuroses. [Chap. xxii. 
 
 I have already shown that in adults the tendency is 
 to produce weak-mindedness, and it may easily be 
 understood how disastrous must be the result of re- 
 curring fits occurring in the undeveloped child. It 
 matters little, if at all, what the cause of the epilepsy 
 may be, although it is certain that the tendency to 
 weak-mindedness is increased if there be a strong 
 neurotic inheritance, as the patient in that case has 
 a strong predisposing cause, and an equally strong 
 exciting one. As I have said, the frequency of the 
 fits and their early development are the two most 
 important facts in this relationship. 
 
 Epilepsy occurring before seven years of age is 
 certain to leave the patient weak-minded. The epi- 
 leptic idiot is said to be the drollest inhabitant of the 
 idiot asylum. He is often wild, untractable, and irrit- 
 able, many of his symptoms resembling the symptoms 
 of ordinary insanity. Some of these cases, when the 
 fits are absent, appear as if they were making great 
 improvement, but this appearance is deceptive. I 
 was consulted some little time ago about a child who, 
 up to seven or eight years of age, had been perfectly 
 healthy ; epileptic fits of a slight character appeared 
 at rather long intervals; from that time there had 
 been an arrest in her mental development, but there 
 was no marked intellectual degeneration. As there 
 was some bowel irritation, I treated her for worms, 
 and later with tonics. She recovered for a time, and 
 seemed to regain some of her mental ability ; so much 
 so, that I was tempted to give a favourable prognosis, 
 but the fits again came on, her mind rapidly deterio- 
 rated, and she had to be sent to an asylum. 
 
 This is a very good example of the course which 
 such cases are likely to take, giving some ground for 
 hope at the time when the fits are in abeyance, which 
 hope speedily proves illusory when the fits recur. It is 
 extremely rare to cure epilepsy, and idiocy dej)endent 
 
Chap. XXII.] Hydrocephalic Idiocy. 449 
 
 upon epilej)sy is scarcely more curable, althongh it 
 may well be remembered that tLie epileptic condition is 
 one depending upon so many minor conditions, that it 
 is not to be wondered at that epilepsy, from time to 
 time, is cured or outgrown, and intellectual life started 
 afresh ; hence, most writers on idiocy say that idiocy 
 depending upon epilepsy is more curable than any 
 other form, except that of idiocy due to deprivation. 
 In treating such cases, the invariable amount of 
 bromide of potassium will be given ; but I prefer to 
 follow the advice of Dr. West : " The diet should be 
 mild, nutritious, but usually stimulating, and, as a 
 general rule, should include meat comparatively seldom, 
 and in small quantities. I have certainly seen epileptic 
 fits increased in frequency and severity by an abun- 
 dant meat diet, and diminished in both respects when 
 a diet chiefly of milk and vegetable was adopted." 
 
 Hydrocephalic idiocy. — Hydrocephalus may 
 end in death, may end in mental recovery, or may 
 leave the child more or less weak-minded. The hydrO' 
 cephalus may come on before or after birth ; the 
 special cause of its development is still doubtful, 
 although there seems to be a distinct relationship 
 between hydrocephalus in the children and the 
 physical degeneracy in the parents, hydrocephalus 
 being thus associated distinctly with tubercle. Hydro- 
 cephalic persons may be of every shade of intellectual 
 capacity, some growing up to adult life and keeping 
 their reason ; others passing into dementia as the 
 result of some acute mental disturbance ; the cases of 
 which I am now speaking particularly never develop 
 the average mental capacity. It has been remarked 
 that hydrocephalic idiots may be weak primarily from 
 brain change, or they may suffer chiefly in consequence 
 of deprivation of one or more of their special senses. 
 Blindness and deafness may occur in consequence of 
 hydrocephalus. The chief noticeable symptom is the 
 D D — 14 
 
45° INSANI7V AND ALLIED NeU ROSES. [Chap. XXII. 
 
 change in the shape of the head, there being a marked 
 enlargement in the frontal region, which extends right 
 round the skull. This group of idiots provides most 
 of those with really big heads. The hydrocephalic 
 head resembles a ball in shape^ the widest circum- 
 ference being often at the temj)les ; there may be 
 
 Hydrocephalic Idiot. 
 
 flattening posteriorally, and the palate is said not to 
 be vaulted, but the teeth are frequently good. It is 
 said that in hydroceplialns the fontanelle is raised ; in 
 rickets it is depressed, 
 
 I shall later refer to cases in which the brain is 
 hypertrophied, and in which the skull also becomes 
 much enlarged. A third form of cranial enlargement 
 which may exist with idiocy, is that connected with 
 
Chap. XXI T.] Hydrocephalic Idiocy. 
 
 45 1 
 
 congenital syphilis, and in this case the presence of 
 rashes and the peculiarity of the teeth may serve to 
 differentiate, when taken with the fact that the 
 syphilitic skull is irregularly bossed, not uniformly 
 enlarged. The size of the skull does not imply a rela- 
 tion between its malformation and the amount of 
 
 ' ' *''''*^"'C^'^'''^ "— '^ 
 
 A Paralytic Idiot. 
 
 intellectual deficiency, some hydrocephalics with huge 
 heads growing to maturity, and being fairly intellec- 
 tual ; and even among idiots the larger-headed hydro- 
 cephalic idiot is not necessarily more idiotic than one 
 less affected. Hydrocephalus may produce idiocy 
 first, and then a rapidly fatal termination ; but in 
 some cases there may be an arrest of the hydroce- 
 phalus, wdth considerable power of intellectual culture 
 
452 Insanity and Allied Neuroses. [Chap. xxii. 
 
 possible. Probably the chief danger in these cases is 
 associated with their tubercular diathesis. Dr. Ire- 
 land says they are, as a rule, soft, gentle, and trusting 
 in disposition, although awkward in movement. With 
 the hydrocephalus there may be fits, or local paralyses, 
 and then the prognosis becomes worse. These cases 
 require the treatment which would be given to un- 
 healthy children with a tubercular history. Cod- 
 liver oil had better be given in one of the many partly 
 digested forms, stimulants with abundance of milk, 
 and for preference a seaside home should be resorted 
 to. I believe strongly that good results are pro- 
 duced upon some of these cases by the frequent ad- 
 ministration, in small doses, of alcohol in one form oi 
 another. 
 
 Paralytic idiocy. — Iij every asylum there are 
 hemiplegic or monoplegic children, with limbs drawn 
 up; withered, and contracted. The origin of the 
 paralysis may be from some vascular lesion (although 
 intracranial haemorrhages are rare in children), to 
 some tubercular deposit, or some other growth, or as 
 the result of want of development, or inflammation of 
 one side of the brain. Injuries occurring before, 
 during, or after birth, may undoubtedly prevent 
 further development ; although one half of the brain 
 may be damaged, it does not follow that there is 
 intellectual deficiency. Paralysis may exist from 
 birth without any marked arrest in mental growth ; 
 but, on the other hand, certain cases, with half of the 
 brain injured, neither develop in mind or muscle. 
 
 These cases have been called paralytic idiots. One 
 of the limbs may entirely cease to grow. A special 
 type has been described in which the temporal bone 
 on one side has become absolutely flattened to such 
 an extent that the one hemisphere is considerably 
 less than half the size of the other. Such a patient 
 would have a tottering gait, a stupid appearance,- 
 
Chap. XXII.] Traumatic Idiocy. 453 
 
 and a dulness of perception, although some possibility 
 of intellectual development might exist. I would say 
 in reference to these cases, that with marked partilysis 
 from bii-th there may be equally marked mental defi- 
 ciency, but this is not essential. The pseudo-hyper- 
 trophic paralysis, Duchenne says, may be rarely asso- 
 ciated with weak-mindedness. In the treatment of 
 paralytic idiocy, the general and hygienic measures 
 must, of course, be tried, and it is also necessary that 
 electricity, galvanism, friction, and passive movements 
 should be used for the weakened limbs. 
 
 Traumatic idiocy. — Dr. Ireland places in this 
 group idiots who have received some injury to their 
 brains which may not have left any permanent injury 
 apparent, and he would compare them to those cases 
 of ordinary mental weakness which follow from so- 
 called concussion. It certainly strikes one that it is 
 not uncommon to meet with cases in whom a shock, 
 physical or moral, seems sufficient to change the whole 
 vital relationships of the individual, so that from that 
 time he is either a changed being, or one with definite 
 tendencies to degeneration. Injuries, it is said, with- 
 out producing signs of inflammation, may cause weak- 
 mindedness, or inability for development in children. 
 It seems to me that it is the sudden injury which does 
 the harm, and that comparatively little injury appears 
 to have been produced by the mutilations which 
 fashion in the shape of heads has so frequently caused 
 among savage races. It seems strange that, if sudden 
 shocks to the brain should produce idiocy, more chil- 
 dren are not born fools. According to some, the 
 right of primogeniture rests upon the danger which 
 a first-born son has to run at his birth. 
 
 Statistics still leave it uncertain as to the relative 
 number of first-born children that become idiotic ; 
 but the evidence seems to me to point slightly in 
 favour of the belief that there is greater danger to 
 
454 Insanity and Allied Neuroses. [Chap. xxri. 
 
 first-born children, especially if tliey are males. Idiocy 
 does not seem to follow unduly on instrumental 
 labours. It seems certain that injuries before or 
 after birth may cause idiocy ; but that injuries occur- 
 ring later, in the first few years of childhood, are still 
 more dangerous than intra-uterine injuries. The 
 prognosis depends very much upon the general physical 
 development. Most of these cases are said to belong 
 rather to the imbecile than the idiotic ty]oe. 
 
 Inflamma-tory idiocy. — Inflammation and 
 arrest of development may follow on injury ; but this 
 special class is intended to include those in whom 
 inflammations of the nose and ears, which are asso- 
 ciated at times with contagious fevers, may spread to 
 the brain membranes. Such lesions, as a rule, prove 
 fatal ; and although parents are apt to consider idiocy 
 as a consequence of fever, it is probably more often 
 the fact that the weakness which had existed all 
 along was not noticed till at the age when these fevers 
 commonly occur. 
 
 Inflammation of the brain or its membranes un- 
 doubtedly may occur before birth, in which cases the 
 causation of the disease is not cleared up till after 
 death. As might be expected, the grades of idiocy 
 from this cause vary considerably. 
 
 Under the head of inflammatory idiocy is considered 
 that of hypertrophic idiocy. In this branch, of which 
 I have seen several cases under the care of Dr. Beach, 
 the skull is usually much enlarged, the enlargement is 
 more general than in hydrocephalus. No known cause 
 has been discovered for this aflfection. There may be 
 great increase in size of brain without any marked 
 idiocy on the one hand, or without intellectual in- 
 crease on the other. Some of the children have been 
 described in whom precocity existed. Most of the 
 cases die early, some with paralytic symptoms, with 
 or without fits. The distinctive diagnosis rests upon 
 
Chap. XXII.] Idiocy of Deprivation. 
 
 455 
 
 the observation that in hydrocephalus the increase is 
 most prominent at the temples, and in hypeii:rophy it 
 is most prominent above the superciliary ridges. In 
 hydrocephalus the width between the eyes is increased. 
 In Dr. Beach's second case the prominences above the 
 superciliary ridges were well marked ; the brain 
 was very heavy, it weighed 62 ounces. Connective 
 tissue increase seems to be the chief histological 
 
 A Hypertroph.ic Imbecile. 
 
 change in these cases, and the mental symptoms ap- 
 pear to be due to the gradual suppression of intellec- 
 tual function caused by pressure. When the calvarium 
 has been removed the brain behaves post mortem as 
 if it had been subjected to immense pressure, and it 
 is impossible to replace the skull-cap. Such a con- 
 dition is practically hopeless. 
 
 Idiocy of deprivati«ftn. — I have already re- 
 ferred to the effect of sense deprivation, and this 
 class includes those in whom mental development was 
 
456 Insanity and Allied Neuroses. [Chap. xxir. 
 
 defective in consequence of the gateways to know- 
 ledge being closed. Dr. Ireland properly says, idiocy 
 by deprivation is like a seed which does not s^^rout 
 because it is kept away from sunlight and moonshine j 
 while incurable idiocy is like a seed in which the ger- 
 minal faculty has been destroyed. In connection with 
 this group, the ever-memorable case of Laura Bridg- 
 man, in whom all the senses but that of touch were de- 
 stroyed, is to be remembered."^ This case shows clearly 
 how, with sufficient time and pains, the deficiencies 
 due to degeneration of one sense can be made up by 
 the training of others ; and the important considera- 
 tion is this, that idiots who are idiotic or imbecile 
 from want of one or more senses may be developed to 
 a very considerable extent if treated sufficiently early. 
 If such children have been allowed to run wild till 
 they are twelve or thirteen years old, it is extremely 
 difficult to do much for them. Early methodical 
 training is the only thing to look to. 
 
 Cretmism. — Associated with all the natural 
 beauties of mountain scenery one meets with the most 
 deplorable class of idiots called cretins. The causa- 
 tion of their condition is still doubtful, although it has 
 been observed and studied by many able observers. 
 A definite relationship exists between cretinism and 
 goitre, and there seems to be some relationship be- 
 tween limestone districts and the presence of goitre. 
 Wherever goitre exists limestone seems to be present, 
 and where goitre has had its home for generations 
 cretinism is common. In England, in several districts, 
 goitre is conunon enough ; but my personal experience 
 of some parts of Cumberland, where I saw hundreds 
 of goitrous people with families, led me to believe that 
 something was wanting in England for the full de- 
 velopment of cretinism. Although one or two cretins 
 existed in the district I refer to, such cases were very 
 * See "Journal of Mental Science," vol. xxi., p. 893. 
 
Chap. XXII.] Cretinism. 457 
 
 rare. The aspect of the cretin, especially with the 
 large goitre, is characteristic ; a iiat broad face, thick 
 lips, and a large mouth, a flat nose, with depressed 
 root, and slanting eyes, big expanding ears, the w^hole 
 carried by a squat dwarfish creature with a sallow un- 
 healthy complexion. In these cases the facial aspect 
 has been traced to the sphenoids, and the premature 
 ossifications of the base of the skull have been looked 
 to as the cause of the condition. And it is interesting 
 to remark, that in one case of cretinoid degeneration 
 in a woman (myxoedema) which I had in Bethlem, 
 there was great overgrowth of bone, with exostoses all 
 over the alse of the sphenoids. So much for the causal 
 relations of cretinism. It is found in Sardinia, 
 France, Austria, Switzerland, and the Pyrenees. It is 
 met with also among the Andes, and the Himalayas. 
 It occurs in China, Sumatra, the Rocky Mountains of 
 America, and in Madagascar. The condition is not 
 necessarily hereditary ; but it is noteworthy that 
 cretinous or goitrous parents may produce cretins 
 among their native mountains, but the same parents 
 may produce healthy children in other districts. 
 
 Every variety of weak-mindedness may occur with 
 cretinism. In some, only the slightest moral or intel- 
 lectual defects owe their origin to this condition, 
 whereas in others complete absence of mind or power of 
 mental development is due to this cause. Some children 
 are met with who from birth have irregularly-shaped 
 heads. They have the conformation of features I have 
 described, and although generally the child develops 
 slowly, cases may occur in which physical development 
 is fair. The appetite is often ravenous ; they eat 
 much and sleep much ; they are placid and expression- 
 less. The abdomen is round and tub-like, limbs 
 small and feeble, teeth are generally irregular and 
 scattered, speech may be, and often is, slow in develop- 
 ment, and stammering when it does come. Symptoms 
 
458 Insanity and Allied Neuroses. [Chap. xxii. 
 
 generally appear before the fourth year, and rarely 
 come on after the seventh. There are more mc^e than 
 female cretins. Hearing seems to be more defective 
 than seeing ; taste and smell are often deficient, and 
 feeling, if not dull, is often confused and with false 
 impressions. Intellectually there is eveiy degree of 
 obtuseness, so that in the lowest or full cretins the 
 life led is a purely negative one ; as we get higher, 
 speech and desire may be present in rudimentary states, 
 and in the highest cretins we meet with little beyond 
 imbecility, with more or less moral deficiency. With 
 all the above conditions may be associated complica- 
 tions such as epileptic fits, tubercular tendencies. The 
 prognosis of the case will be rendered more difficult, 
 and the hope of relief will be reduced, if any such com- 
 plications exist. The one treatment is the early 
 removal from the dangerous neighbourhood. The 
 mother of a cretin should be removed from the neigh- 
 bourhood. When a mother of one cretin is pregnant 
 she should be removed, and no second child should be 
 allowed to be born where the danger exists. In any 
 case, great good may be done by change of drinking- 
 water, change of surroundings, associated with healthy 
 nutritious food. Iodine alone has been tried and 
 has failed, iron in one shape or another being much 
 more useful. 
 
 In these cases, as in most others of mental weak- 
 ness, regulated gymnastics and drilling are useful 
 additions to the treatment. 
 
 There are a few more special points to which one 
 may refer before leaving the subject of idiocy. For 
 any special study of idiots one must not only take in 
 detail the deficiencies which may possibly exist asso- 
 ciated with weak-mindedness, but consider also the 
 shades and degrees of these complications, and also 
 notice the secondary results following in the course of 
 the development of children of weak mind. As I have 
 
Chap. XXII.] Idiocy and Imbecility. 459 
 
 said before, in cases of nervous disorder or deficiency 
 the whole bodj sulGfers. In the great majority of cases 
 the aspect of the idiot is repulsive ; the stature is 
 short ; the habits inhuman ; there being in one case 
 a neglect of personal cleanliness, and in another un- 
 controlled appetites. Idiots unfortunately frequently 
 beget or bear children, such children being all but cer- 
 tainly idiotic. Besides, v^hat has been described as 
 acute mental disturbance may occur in children whose 
 nervous systems are not sufficiently stable to recover 
 from these attacks. Mania I have referred to as oc- 
 curring in early childhood, and resulting in weak- 
 mindedness. Melancholia, too, with suicidal tendencies, 
 has been referred to under similar circumstances; it 
 must be remembered that among idiots there may be 
 corresponding nervous disturbances, so that maniacal 
 outbreaks or melancholic attacks may occur in these 
 patients. The child who has attacks of mania, being 
 idiotic, may again become quiet and tractable, only per- 
 haps to have recurrent outbreaks of mental disorder. In 
 every idiot asylum there are some specially bad children 
 who seem to correspond to the cases of chronic mania 
 in ordinary asylums; such patients are not only very 
 troublesome, but are not likely to improve. To sum 
 up : idiocy and imbecility are but degrees of weak- 
 mindedness, in which one or more of the factors of 
 mind are partly or wholly undeveloped ; the condition 
 may depend upon changes occurring before or after 
 birth, and are largely dependent upon nervous inhe- 
 ritance. These cases are only partly curable ; the 
 most that can be done with a great majority being to 
 try to render them less repulsive than they have been, 
 and to teach them some mechanical arts. For such 
 treatment special training is required. 
 
460 
 CHAPTER XXIII. 
 
 RESPONSIBILITY OF LUNATICS. 
 
 Responsibility — Testamentary capacity, and other practical and 
 social matters connected with insanity. 
 
 I CANNOT, within the scope of this work, pretend to 
 enter upon any discussion as to the actual and definite 
 legal responsibility of persons of unsound mind, as 
 such a discussion would necessitate a full exposition 
 of the foundations of the criminal law in England, and 
 the application of its principles to the technique of 
 insanity, together with a copious reference to cases 
 which have arisen in respect of such application. 
 
 The medical and legal professions have always been 
 somewhat at variance upon this head ; the difference of 
 opinion has doubtless arisen from the difference of 
 motive on either side. The physician, looking upon his 
 patient as an individual to be cured, is tempted to 
 extend the boundaries of disease, and waives the ques- 
 tion of responsibility altogether ; the lawyer, whose 
 business it is to define that which has to be condemned, 
 is impelled to narrow them, and search for points of re- 
 semblance between the terra incognita of mental per- 
 version and the lines he has already laid down. A too 
 free extension of either view is equally undesirable, and 
 the physician must on his part be willing to admit 
 that a system of laisser-faire, and indiscriminate 
 exoneration from all blame, is out of harmony with 
 both the experience and expressed motives and wishes 
 of the human race, and is to be avoided in practice. 
 Experience teaches us to look upon evil as a necessity, 
 and when we have done this we seek for the best 
 possible arrangement of that which we cannot avoid. 
 Thus we have the foundation of the criminal law in 
 its relationship to morals ; and as it is endorsed by the 
 conseTisus of public opinion, it behoves the physician, 
 
Chap. XXIII.] Responsibility. 461 
 
 as a unit of the social mass, to conform to it, and to 
 furnish such facts and experiences as he may deem 
 likely to facilitate and clarify its procedure. The 
 question of responsibility is in truth not a medical 
 question at all. It may be a question either of philo- 
 sophy, of law, or of common sense. But neither the 
 philosopher, the lawyer, nor the ordinary individual, 
 when they have to deal with cases of unsound mind, 
 can move a step without a knowledge of the necessary 
 facts. These are the province of the physician, and if 
 he himself does not undertake to discuss the question 
 of legal or philosophical responsibility from the wider 
 point of view, it is nevertheless desirable that he 
 should supply such materials toward the ultimate 
 building of the edifice as are the result of his own 
 experience ; and in cases of responsibility having to 
 do with the ordinary social relationships of persons of 
 unsound mind, he is from the nature of his position 
 singularly capable of pronouncing a just opinion and 
 proffering advice to others. 
 
 As to the law (which is chiefly "judge-made," or 
 depends upon the replies given by the judges to the 
 questions proposed by the House of Lords in the case 
 of McNaughten, occurring in 1843), it is now, I 
 think, a matter of general opinion that it requires 
 considerable modification. I cannot but think that 
 the time may shortly arrive when physicians will take 
 upon themselves to furnish a consensus of opinion as 
 to the lines upon which it should be re-modified, so as 
 to benefit by the important results of recent scientific 
 and medical research. The broad and sweeping pro- 
 visions of the law cannot with justice be applied to 
 insanity as a whole, but there must be given such 
 data as will serve to classify the variable will-afiec- 
 tions to which persons of unsound mind are liable ; 
 and the manner in which such, as far as they are 
 owing to disease, may assist in producing crime. 
 
462 Insanity amj allied Neuroses. [Chap, xxiii. 
 
 One of the difficulties which has arisen has been 
 that lawyers have definitely demanded precise lines 
 of demarcation to be drawn between sanity and in- 
 sanity; and also between conditions in which pun- 
 ishment should be administered, and conditions in 
 which the person must be looked upon as irrespon- 
 sible. Specialists know from experience that there 
 are persons dwelling, as Dr. Maudsley would say, 
 on the borderland of crime and insanity, who may 
 at one time be more insane and less criminal, and 
 at another more criminal and less insane. That, in 
 fact, sometimes they merit punishment, and at others 
 may require treatment. Just as we have seen that 
 there is no clear distinction between sanity and in- 
 sanity, so we must admit that there is no possibility of 
 drawing by definition any clear distinction between 
 liability for acts done, and irresponsibility. There- 
 fore it is necessary that the provisions of the criminal 
 law should be clearly defined and categorically stated 
 with respect to all the main circumstances of the case. 
 
 One of the main standpoints of the law hitherto 
 has been to administer justice upon the supposition 
 that delusions are essential in lunacy. Another has 
 been to enquire whether the lunatic was capable of dis- 
 tinguishing between right and wrong at the time of 
 the act. Both these principles, although they might 
 be made use of as useful aids to any enquiry, are 
 radically defective, inasmuch as they exclude from 
 consideration the most important medical evidence ; 
 that is, the most important facts of the case. A 
 delusion, as the physician well knows, is never the 
 expression of the whole of the disordered motives 
 which directly or indirectly aflfect the causation of the 
 act. And those who are most of all conscious of 
 the difference between right and wrong are often 
 those who suffer from the strongest infiuences of dis- 
 ease which overrule their knowledge. Again, it is 
 
Chap. XXIII.] Crime and Loss of Control. 463 
 
 highly unjust to say that because a person does 
 not appear to have a delusion as the foundation for 
 his act that he must be held responsible. It is 
 not necessary to have a delusion to annul responsi- 
 bility. A person may in acute mania kill another in 
 the mere buoyant exercise of his feelings of strength ; 
 and although he may have delusions, the loss of self- 
 control and not the delusions was the cause of the 
 accident. This loss of self-control is one of the most 
 difficult points to be established as a symptom of 
 mental disease. It is admitted that the epileptic may 
 commit a crime, being unable to control himself, his 
 mind being in much the same condition in which 
 his body is when seized by epileptic convul- 
 sions, and quite beyond his control. Other con- 
 ditions may give rise to acts which are uncontrolled, 
 and which no ordinary amount of pressure or change 
 of surroundings would enable the person to control ; 
 and here arises the difficult and complicated question, 
 Under what conditions is this loss of self-control a 
 symptom of mental disease, and under what conditions 
 is it to be looked upon as the result of conditions 
 which might and ought to have been checked by the 
 patient % In some circumstances, the temporary loss 
 of control is due to self-indulgence in the individual ; 
 and then rightly the person is considered to be re- 
 sponsible for having knowingly allowed himself to get 
 into a position in which he would become unable to 
 restrain himself. But even this is a dangerous prin- 
 ciple to admit, for it is easy to see that a very slight 
 dereliction on the part of the individual might lead to 
 an extremely difficult position. 
 
 And, again, there can be no doubt that a vast 
 number of cases may arise in which the insanity of 
 the patient and the impulses from which he has 
 suffered in consequence of nervous disease, if not suffi- 
 cient to exculpate him from blame altogether, ought 
 
464 Insanity and Allied Neuroses. [Chap, xxiii. 
 
 nevertheless to be alleged as strong condonation of his 
 offence. The physician claims as a general principle, 
 that an insane person, whatever his delusions or other 
 mental symptoms may be, must be considered alto- 
 gether irresponsible for any criminal act he may 
 commit ; and I think the tendency of legal reform 
 should be to make full allowance for the influences of 
 disease upon conduct. 
 
 Criminal acts may arise from delusions of one kind 
 and another, from hallucinations of the various senses, 
 from loss of control, which may act in various 
 different ways; the most difficult point of all to de- 
 cide upon is the so-called impulsive insanity, in 
 which a patient loses self-control, and commits an 
 act, the details of which he remembers, but which 
 he truthfully says he was unable to prevent. Such 
 insane impulses undoubtedly do occur, and I have 
 been consulted by patients who have told me that 
 loss of control of this kind would come upon them 
 like a storm, and that they would seek shelter any- 
 where to avoid the danger which might arise to them- 
 selves or others. It is simple enough when these 
 impulses occur in persons who have suffered from 
 mental unsoundness, but it is much more difficult 
 when the only evidence of insanity is the existence of 
 these impulses ; for it may be said that they are but 
 the result of uncontrolled pleasure of power, which is 
 common to all. I should hesitate before accepting 
 impulse, unless I had evidences of insanity in other 
 members of the family, or neuroses such as neuralgia 
 or epilepsy in the patient himself. 
 
 Having offered these general remarks upon the 
 subject, I will now confine myself to some specific 
 details, all of which will, I think, furnish evidence of 
 the extreme difficulty that exists in making any broad 
 distinction between responsibility and irresponsibility 
 in individual cases. 
 
Chnp. XXIII.] Alcoholic Intoxication. 465 
 
 I may first, however, remark tliat it must be ad- 
 mitted that in the great majority of cases of insanity, 
 ordinary motives appeal to the person of unsound mind 
 in a way precisely similar to that in which they affect 
 the sane. There are patients in asylums who can be 
 guided by anticipated pleasure, or by threatened de- 
 privation of enjoyments, and therefore who must be 
 looked upon as so far controllable if not responsible. 
 A patient is frequently told that if he will control 
 himself for so many days he shall see his relations ; 
 or, on the other hand, he may be told that with self- 
 control will come liberty of spending a day away 
 from the asylum. In fact, in this way alone hospitals 
 and asylums can be managed for the benefit of the 
 patient. But, although managed in this way, it does 
 not necessarily follow that the extension of the belief 
 in power of self-control is justifiable when a crime 
 has been committed ; there are certain classes of 
 patients who at once must be recognised as likely to 
 commit crimes against society if at large, without 
 there being any idea whatever that they can be con- 
 sidered as responsible. Some of the specific details to 
 which I shall now refer will afford an illustration of 
 this. 
 
 The subject of alcoholic intoxication is one 
 which presents many difiiculties. A person, say, 
 is given powerful stimulants, masked or concealed in 
 some way ; or being weak, or suffering from an old 
 injury to the head, an amount which formerly would 
 not have affected him now produces a great effect ; 
 in a state of acute alcoholism he commits a crime, 
 and doubtless would be considered not guilty ; but 
 if he has experienced several times the danger 
 which he incurs by taking stimulants even in 
 small quantities, and yet continues to indulge, and 
 then perpetrates a crime, he may justly be considered 
 responsible, even although it may be proved that by 
 
 E E — 14 
 
466 Insanity and Allied Neuroses. [Chap, xxiii. 
 
 inheritance, or in consequence of injury to the head, he 
 is especially liable to be afiected by stimulants. Next, 
 if, in consequence of intemperance, he becomes slowly 
 affected by mental disorder, and in a state of delirium 
 tremens he commits a crime, he will probably not be 
 considered fuPly responsible. If, instead of delirium 
 tremens, alcohol produces chronic insanity or general 
 paralysis of the insane, and in this condition of 
 genuine insanity he does harm, he will not be con- 
 sidered responsible for his acts. Thus it will be seen, 
 from the above example, how complicated are the rela- 
 tionships between responsibility and irresponsibility. 
 
 Theft may be a sign of mental disorder. The general 
 paralytic who believes himself immensely wealthy, 
 and who thinks that the whole world is his, can hardly 
 be blamed for helping himself to what he believes to 
 be his. Again, there are certain weak-minded persons, 
 especially those with insane inheritance, who may be 
 incapable of education as far as the rights of property 
 are concerned. In many states of weak-mindedness 
 following acute attacks of insanity there is a tendency 
 to collect rubbish of all kinds, and to pilfer generally, 
 and the pilfering may be done with all the apparent 
 design and consideration of a skilled thief. It has 
 been said, too, that epileptics are dangerous in a similar 
 way. Theft is common in general paralytics, in 
 imbeciles, and in patients suffering from the effect 
 of fccute insanity. There are other crimes against 
 property which may well be considered under the 
 same head, certain of them having been classified by 
 former writers as independent diseases. Thus we 
 have heard oi pyromania in the same classification as 
 kleptomania. As a rule, monomania of this kind are 
 either the result of imperfect intellectual and moral 
 development due to strong nervous inheritance, or else 
 they are the vestiges of a nervous storm which has 
 now passed. I have met with one or two cases in which 
 
Chap. XXIII.] Homicidal Mania. 467 
 
 lads of from ten to fifteen have been pyromaniacs, 
 and liave been the cause of endless trouble, in conse- 
 quence of their tendency to burn or destroy everything 
 which interfered with their immediate comfort. 
 
 Suicidal and homicidal maniacs have been specially 
 classed in consequence of their grave relationship to 
 the community at large. As far as suicide is con- 
 cerned, I have already devoted attention to this point ; 
 but here I shall refer to conditions leading to homicidal 
 impulses as seen in asylums, and from these will be 
 seen some of the chief dangers to society arising from 
 insanity. 
 
 Homicide may be the result of simple uncontrolled 
 passion, the loss of control following physical or 
 mental weakness ; it may follow, as we have seen, 
 a delusion as to persecution, patients being more 
 especially dangerous when they believe that their 
 strength, moral character, or situation, are being 
 affected by conspiracy or plot ; or when they hear 
 voices telling them that an organised body like the 
 Jesuits or Freemasons is going to injure wife or 
 children. Probably the most dangerous of all patients 
 are those who distinctly believe themselves to be 
 persecuted, or hinted at ; such patients, as the one 
 I have described under delusional insanity (page 241), 
 are marked examples of the danger which arises 
 from these cases. 
 
 Homicide or suicide may occur as a natural out- 
 come of nervous sensitiveness. One patient knocked 
 another down because he coughed ; and he attacked 
 another weak-minded patient because he pushed his 
 bedroom door twice; he said, after attacking him 
 violently, that if he did it again he should murder 
 him, and I believe he would have done his best to 
 that end, if not prevented. To show the extreme 
 danger there is with such cases, I may say that, after 
 careful consideration and a prolonged interview with 
 
468 Insanity and Allied Neuroses. [Chap, xxiii. 
 
 this patient, he told me that although he abhorred 
 violence, he felt that he must protect himself on the 
 one hand ; and that as soon as he found annoyances 
 beyond his endurance or control, he should destroy 
 himself ; and that he would leave it for me to judge 
 whether he could be deterred from his end if once he 
 determined on it. Violence may arise from a natural 
 outgrowth of insane vanity ; some patients are sources 
 of danger from the way they assert their power and 
 importance. One patient in Bethlem attempted to 
 murder two others, because one placed his hands 
 upon him, and because the other did not sufficiently 
 comprehend his exalted position ; the history of the 
 man shows that for years he has been slowly passing 
 into a condition of pride and unrestrained passion 
 only compatible with insanity. 
 
 Homicide or suicide may be the direct result of 
 what is called by patients "influence." In some there 
 is a feeling of weakness and inability to decide 
 upon what is best to be done, but, on the other 
 hand, they are conscious of their actions, though 
 they cannot prevent themselves from following cer- 
 tain courses. This weakness, associated with the ten- 
 dency to action which they cannot control, they call 
 "influence." On the other hand, there are similar 
 cases under "influence," which, without in any way 
 describing themselves as weak-minded or feeble of pur- 
 pose, say that there is something within them driving 
 them to action ; some such cases call the motive power 
 the devil, but others leave the influence unnamed. In 
 some patients, neither simple loss of control, delusions, 
 hallucinations, persecutions, or influences, have any 
 effect in the production of homicidal tendencies, but 
 simple weak-mindedness seems to be connected with a 
 childish tendency to destructiveness, and therefore the 
 crime is a perfectly wanton, causeless act. After 
 all, the difliculties which arise in cases of homicide are 
 
Chap. XXIII.] Homicidal Mania. 469 
 
 not such as can be so readily cleared up even when 
 the patient has been under observation in an asylum. 
 I would say that, in considering a murder, the first 
 question to be asked is, What was the assigned cause 
 for the crime % was it the natural development of 
 the man's surroundings and habits % To my mind 
 certain crimes themselves are sufficient evidence of 
 mental unsoundness. If a person with or without 
 some sudden shock become completely changed in his 
 domestic relations, if the man who was a good hus- 
 band and kind father kills wife or child, without there 
 being any established delusion, I think the crime 
 itself is sufficient to cause a iwiiina facie belief in the 
 existence of mental unsoundness. The chief points, 
 then, are the apparent causelessness of the crime, 
 the utter want of relationship between' the crime 
 and the supposed end to be attained, the relation- 
 ship between the crime and any delusions, the es- 
 tablishment of any insane or nervous inheritance, 
 or the proof that the patient himself at one time 
 or another has been of unsound mind or epileptic. 
 Next after the consideration of the causation of the 
 crime itself and its surroundings, it is important to 
 obtain evidence as to acts immediately preceding and 
 immediately following the deed, as well as to find 
 out the details. Insane patients possessed by delu- 
 sions, or driven by influence, may nevertheless nerve 
 themselves to act by taking stimulants, and yet this 
 must not be attributed to sanity, nor must the crime 
 itself be laid to the charge of drink. 
 
 A crime may be committed, and when the perpe- 
 trator is discovered, or when he gives himself up, he 
 may appear to be quite reasonable. This is especially 
 the case in epileptic and impulsive cases. After the 
 outbreak of passion there may be are-establishment of 
 the intellectual balance, and it may appear as if with 
 the act of violence temporary sanity at all events has 
 
470 Insanity and Allied N'euroses. [Chap. xxiii. 
 
 returned. It is difficult to get the lay mind to under- 
 stand that acts of this kind can really be due to tem- 
 porary insanity. But the same holds good both with 
 suicidal attempts and with homicidal attacks. There 
 may be almost immediate improvement following the 
 outbreak. 
 
 One special subdivision of this subject may be 
 referred to here, namely, infanticide. To begin with, 
 concealment of birth, which is the first degree of this 
 crime, may follow in a person of unsound mind who 
 is delivered of a child. In one case I myself saw a 
 woman with a fully developed child in the bed, the 
 mother having been delivered without any evidences 
 of pain, so that, although there were neighbours in 
 the same house, the delivery took place without their 
 knowing it ; yet the mother herself said, and I believe 
 truthfully, when I first saw her, that she did not 
 know anything had happened. A woman, then, may 
 be delivered without knowing that a child has been 
 born; but in such a case the child and the placenta 
 will probably be where they were delivered, in an 
 unaltered condition, no means having been taken to 
 separate the cord. Next, as we have seen when 
 considering puerperal insanity, there may be a frenzy 
 associated with the birth of a child, which may 
 disturb the mental balance for a longer or a shorter 
 period. Next there may be an ephemeral mania 
 associated with the oncoming of the milk. In all 
 these cases the murderous act may be done without 
 premeditation, and with little or no recollection of 
 what has happened. With puerperal insanity there is 
 commonly a dislike to both husband and child ; there 
 being in one case a nervous irritability which prompts 
 the mother to get rid of the crying child which dis- 
 turbs her rest ; or, on the other hand, she may not 
 believe that the child is hers at all, or she may 
 think its birth has alienated her husband's afifection. 
 
Chap. XXIII.] Self-accusation. 471 
 
 With puerperal melancholia the mother may have 
 some delusion, fancying that the child will be 
 starved, or that it is already suffering from serious 
 ailment ; or she may kill it simply to send it direct out 
 of this world into a happier state. With the weak- 
 ness following lactation, or in cases in which rapid 
 child-bearing has produced exhaustion, great weakness 
 and melancholia may occur, in which the mother 
 butchers her whole family, generally possessed by the 
 idea that she is benefiting them and saving them 
 from further misery. The law rightly in this particular 
 looks upon the crime itself as sufficient evidence of 
 the insanity ; that a loving mother should destroy her 
 offspring is unnatural and unreasonable, and ought 
 not to be considered as an act for which she can be 
 held responsible; and it would be well if the law 
 would look more frequently at crimes as symptoms 
 of insanity in other cases, rather than compel experts 
 to discover other collateral evidences of insanity, and 
 then decline to accept them because they have no 
 definite connection with the act itself. Infanticide, 
 although generally a crime committed by the mother, 
 may be perpetrated by the father also \ and the case 
 of Goulclstone, occurring in the year 1883, was an 
 example of a man who, being temperate, well-behaved, 
 and industrious, but belonging to a slightly nervous 
 stock, killed all his children in a fit of despondency, 
 which was out of relationship to all surrounding 
 circumstances, the crime depending on his neurotic 
 constitution. In his case^ in the end it was decided 
 that he was of unsound mind, and that he should be 
 reprieved and sent to Broadmoor. 
 
 One other point deserves notice and consideration 
 here, and that is the question of self-accusation. When 
 any serious crime is committed some person is sure to 
 give himself up to justice, saying that he is the per- 
 petrator of the crime. In many such cases the 
 
472 Insanity AND Allied Neuroses. [Chap, xxiii. 
 
 behaviour of the person is quiet and self-possessed, 
 and the police are sufficiently convinced to take him 
 in charge, and thus delay is caused, which may en- 
 able the real criminal to effect his escape. One of 
 the most common conditions under which these self- 
 accusations occur is drunkenness, and this, as a 
 rule, is cleared up within twenty-four hours by the 
 recantation of the person, or by the development 
 of other alcoholic symptoms. In the other cases 
 it will generally be found that the person has been 
 suffering from mental depression and sleeplessness, 
 with extraordinary restlessness and tendency to 
 wander for some little time before the self-accusa- 
 tion ; in fact, that he has been like so many other 
 persons suffering from early insanity, looking for some 
 interpretation of his misery, and on hearing of this 
 crime he feels that he must in some way or other have 
 been the cause of it. We see this condition in 
 patients in asylums ; thus, on the death of George 
 Sand one patient was deeply concerned, as he main- 
 tained that it was by his action that she died ; and 
 when the Emperor of E-ussia was assassinated, seve- 
 ral people were willing to accept the responsibility 
 of the crime. It is possible even to meet with two 
 persons supporting each other in one delusion; and 
 in one police district in London I was told by the 
 divisional surgeon that a whole family supported the 
 insane statement of the father, being themselves weak- 
 minded and influenced by his delusion. Hence 
 extraordinary complications maj?- arise from the occur- 
 rence not only of self-accusation, but of combination 
 or agreement of persons of unsound mind upon the 
 same delusion. 
 
 Besides the crimes to which I have referred, rape, 
 unnatural offences, and the like, may occur in con- 
 nection with insanity. The imbecile or idiot may 
 have some sexual desire, which he may forcibly 
 
Chap. XXIII.] Testamentary Capacity. 473 
 
 gratify. The offspring of nervous patients, of the moral 
 imbecile, or the senile dement, may be guilty of 
 exposing their persons in public, or criminally assault- 
 ing young children or old women without being re- 
 sponsible for the act. Similar crimes are committed 
 by the general paralytic in the earlier stage of excite- 
 ment and in weak-mindedness, and by epileptics. Loss 
 of control may be very well marked, and may result 
 in some brutal assault. Similar acts may occur in 
 old persons, in whom lust reappears as an evidence of 
 senile weakening. Attacks of the kind described may 
 result from delusions. To sum up : unnatural or 
 brutal offences of a sexual nature may result from 
 undeveloped higher control ; from loss of the same 
 control ; or from degeneration or disease, in which 
 case they may follow simply from delusions. I have 
 met with one case of a young single man given to 
 masturbation who had complete sensual perversion, 
 so that he lusted after men, not women. 
 
 Testamentary capacity. — It will be impos- 
 sible for me under this heading to consider all the 
 bearings of insanity upon the validity of wills, but 
 there are certain points which I may be able to make 
 clear in reference to mental conditions which distinctly 
 prevent persons from performing legal acts. The law 
 of England, in considering a will, is much more 
 influenced by the will itself than by any statement 
 or evidence as to the mental condition of the person 
 making a will. If a will is distinctly the representa- 
 tion of the desires expressed by the individual during 
 his life, it would be upheld, although the person 
 could be proved to have been insane. Again, a will 
 made by a lunatic during a period of sanity, if con- 
 sistent, would probably be upheld ; and it has been 
 suggested that persons of unsound mind, even though 
 suffering from general paralysis, should be allowed to 
 make a will during periods of sanity, even though 
 
474 Insanity AND Allied Neuroses. [Chap, xxiir. 
 
 still under certificates. The will, then, will be con- 
 sidered good or bad rather from its nature than from 
 the conditions under which it was signed. 
 
 But certain wills are opposed, and the chief grounds 
 for opposition are incapacity or undue influence. The 
 incapacity may depend upon simple weak-mindedness, 
 or upon any conditions in which there is such unsound- 
 ness of mind as is likely to affect the will itself. No per- 
 son with delirious ideas, such as one sufferingfrom mania 
 or from active melancholia., could make a will which 
 might not be upset. But the more common condition 
 of inability to will results from weak-mindedness. This 
 is most commonly met with in cases where the patients 
 are suffering from mental changes due to senility. 
 Weak-mindedness may be congenital, or may be the 
 result of an acute attack of insanity, or age ; so that 
 simple weak-mindedness, in which a person may be 
 readily influenced to do wicked or unjust foolish 
 things, may occur from congenital weakness, or may 
 follow acute mental disorder, or may result from age 
 alone, or from mental depression occurring with age, 
 or from apoplexy or similar brain disease. 
 
 Imbeciles need scarcely be considered farther, but 
 patients suffering from weak-mindedness due to other 
 attacks of insanity merit a little further consideration. 
 After an acute attack of insanity some patients are never 
 themselves again ; some never forgive their relatives 
 for having sent them to an asylum ; and I maintain 
 emphatically that, in my experience, patients who are 
 discontented after severe attacks of insanity are still 
 to be considered of unsound mind, and likely to make 
 wrong dispositions of their property in consequence 
 of false ideas about their relations. Again, after 
 some attacks of insanity, mental weak-mindedness 
 may result, as shown by emotional instability ; such 
 patients often take to emotional forms of worship, and 
 are easily moved to leave their property to some 
 
Chap. XXIII.] Testamentary Capacity. 475 
 
 cliurch or institution for whicli in their lives, while 
 sane, they had little sympathy. 
 
 The weak-mindedness of age may be marked by 
 similar emotional or intellectual feebleness ; it is not 
 uncommonly marked by querulous and exacting con- 
 duct on the part of the patients towards those 
 who have devoted years to their service, a for- 
 getful ness of all past sacrifices, and an apparent 
 loss of memory of old relationships and present 
 duties. In senile weak-mindedness persons are easily 
 influenced, and in such states wills or codicils may 
 have been executed. If the memory can be proved 
 to be very defective, so that it can be established 
 that the executor did not remember the existence 
 of his heirs- at- law, it is probable that a will leaving 
 property away from them would be successfully con- 
 tested. In senile weak-mindedness, too, it is not 
 uncommon to meet with persons influenced by lower 
 animal motives. Some old men sufier from sexual 
 passion as a form of weakness, and they may be induced 
 by it to do many weak or wicked things. 
 
 Probably weak-mindedness, associated with apo- 
 plexy, is the most common cause of contests about 
 wills. I would begin by saying that although apo- 
 plexy is frequently associated with weak-mindedness, 
 yet it is very common to meet with persons Avho 
 have suffered from apoplexy, and yet who are perfectly 
 able to make a will. I have had on one or two occa- 
 sions to examine persons who, having suffered from 
 apoplexy, were going to make their will, and being 
 anxious that they should not give rise to litigation, 
 took the trouble to have expert opinions as to their 
 mental condition before signing their wills. After 
 apoplexy aphasia is common, and I have seen several 
 wills contested because the testator could not be under- 
 stood by speech. Perfect testamentary capacity may 
 exist with aphasia; but in some cases in which aphasia 
 
476 Insanity AND Allied Neuroses. [Chap, xxiii. 
 
 and amnsesia co-exist, the patient may be unable to 
 understand the life relationships sufficiently to make 
 a just will ; or, he may not himself make the will, but 
 may be too readily influenced by anyone suggesting to 
 him what the contents of the will should be. If, after 
 apoplexy, memory is retained, if there is no special 
 change in the emotional nature, and if there are no 
 signs of change of character and disposition which 
 would directly influence the opinion which the testator 
 holds of his near relations, it is clear that the patient 
 should be allowed to make a will. 
 
 Besides the above conditions, we must remember 
 that epilepsy, by producing mental weakness, may 
 incapacitate a person from making a will. Before an 
 outbreak of insanity, although the patient may appear 
 reasonable at the time, there may be a moral perver- 
 sion causing him to dislike and suspect his relations, 
 which may induce him to revoke his old will and make 
 a new one; this is more common with those who 
 have suffered from previous attacks of insanity, fol- 
 lowed by former seclusions. 
 
 The most dangerous symptom, as far as will- 
 making is concerned, is the general suspicion that 
 people are in league against the testator. This symp- 
 tom of suspicion may either cause the person to destroy 
 all wills, or to make a will in favour of some stranger 
 or of some charitable institution. The onset of melan- 
 cholia may also be associated with the revocation or 
 alteration of the will, so that a pei^son who thinks that 
 he has not made a good use of his life and property 
 may leave his whole fortune away from his relations 
 to some religious body. To conclude, nearly every- 
 thing depends upon the nature of the will itself; 
 but wills may be shown to be unreasonable from 
 the mental weakness of the testator, or because he 
 was unduly influenced, and I have pointed out 
 some of the various conditions in which mental 
 
Chap. XXIII.] The Medical Certificate. 477 
 
 weakness may occur, or in whicli influence may be 
 exerted. 
 
 Practical and social questions connected 
 with insanity. — Under this head I shall consider, 
 first, in what circumstances it is necessary that 
 patients should be placed under certificates, then the 
 circumstances which influence the selection of a place 
 of treatment for the insane, whether the patient should 
 be sent to an asylum, should be treated at home, or 
 in the family of a stranger in what is called " single 
 care." There are many other important questions, 
 such as the use of travelling and the continuing to 
 follow the same trade or profession, and the more 
 important social question of marriage. 
 
 When called to see a patient of unsound mind, one 
 of the first and important questions to decide is, 
 whether a patient can be safely and satisfactorily 
 treated without being under certificates. Generally 
 relations will sacrifice a good deal rather than have 
 their friends " made lunatics," as they express it. 
 There is but one point to decide, and that is, whether 
 it is necessary, in any way, forcibly to control the 
 actions of the patient. If this is done he should be 
 under certificates. If treated in his house, and if he 
 is childish and not obstinate or wilful, he may be 
 easily treated without certificates, but if of unsound 
 mind and treated either in a stranger's house (whether 
 with a relation, servant, friend, or doctor), he should 
 in every case be under the legal restrictions of cer- 
 tificates. It will sometimes happen that doctors will 
 decline to sign certificates of insanity, especially 
 in the case of first attacks in young patients, such 
 as attacks of hysterical and puerperal insanity. 
 In such cases, the person who receives the patient 
 into his house should obtain a certificate from the 
 doctor or doctors who consider that the patient is not 
 insane, to the eff'ect that he is not insane, but 
 
478 Insanity AND Allied i\^Z7i?c5^5". [Chap, xxiii. 
 
 requires control. The next point is as to where 
 the patient should be treated. First of all I would 
 say that the question of the liberty of the subject is, 
 after all, one of means. A man with unlimited wealth 
 need scarcely ever be sent to an asylum ; but I think 
 that, although he may be treated at home, it does not 
 follow that that form of treatment is the best; and 
 though wealth may secure many things, it can neither 
 buy health, nor necessarily alone obtain the best sur- 
 roundings for a person of unsound mind. Persons 
 of moderate means are those for whom one has 
 generally to advise, and the advice may be arranged 
 under the following heads : Travelling with a com- 
 panion or doctor ; treatment in a private home ; 
 treatment in an asylum or hospital of some kind. 
 
 Travelling is undoubtedly of great service in some 
 cases; but I for one must protest emphatically against 
 the fashion of sending patients, suffering from all 
 kinds of nervous disorder, away from their homes on 
 the chance of some of them deriving benefit. Travel- 
 ling is useful in many young cases suffering from 
 weakness, bodily or mental, especially in those 
 suffering from morbid self -consciousness, and for those 
 with hypochondriacal tendencies. The self-conscious 
 girl, who, having spent five or six of her developing 
 years in hard monotonous book-learning, is benefited 
 by a course of fresh sense impressions, which travel 
 and change supply. Going from England to the 
 Continent, visiting Paris and the German cities, where 
 art and music can be studied in comfort and without 
 dissipation, to be succeeded by a sojourn in Switzer- 
 land or in the Mediterranean, will frequently establish 
 for life a young nervous system which was tottering 
 from over-strain. The over-worked student who, after 
 an easy life at school and college, has freshly awakened 
 to the importance of real continuous hard work if he 
 wishes for success in his profession ; who, without the 
 
Chap. XXIII.] Travelling as a Remedy. 479 
 
 discipline foi' work, and regardless of the warnings 
 given by indigestion and sleeplessness, often continues to 
 work, stimulated by coffee and cold water, and neglect- 
 ing his old physical exercises, breaks down under some 
 trifling moral or physical shock. Such an one, unless 
 removed from his old surroundings and occupations, 
 will run a great risk of becoming insane. Change 
 and vigorous exercise, gradually increased in quantity 
 and continued for several months^ will often have the 
 most beneficial results. In adolescent insanity, with 
 or wdthout sexual vice, companionship, and the active 
 exercise of travelling are very beneficial. Many a 
 young fellow who is developing unhealthy religious 
 ideas, loses his fear of the unpardonable sin after six 
 months' knapsack work in England or on the Con- 
 tinent. I oppose the sending abroad of any cases in 
 which there is a ground for suspecting general paralysis, 
 or in which apoplexy was a cause of break down. A 
 sea voyage is useful when the physical health of the 
 patient precludes active exercise, and when there is no 
 distinctly suicidal tendency, or any tendency to sudden 
 impulses to violence. Sea voyages are, therefore, 
 useful in the milder forms of hypochondriasis, and in 
 cases in which some lung trouble is threatening, and 
 in others in which there has been dyspepsia, sleepless- 
 ness, and general loss of tone. The time of year will 
 determine the kind of travelling which must be 
 advised, the sunshine of the south of Europe being 
 useful during the wdnter and early spring, and the 
 bracing mountain scenery being most useful in summer 
 and autumn. For a long voyage, that to Australia 
 probably provides the best change for such patients, 
 but the Cape is more handy, and often affords suffi- 
 cient change. Travelling, then, is useful in milder 
 cases of insanity ; in cases threatening with nervous 
 break-down, and it may be of the utmost value after 
 recovery from an attack of insanity, or in cases where 
 
480 Insanity and Allied Neuroses. [Chap. xxiii. 
 
 the attacks are in the habit of coming on periodically 
 at a certain time each year, or each second or third 
 year. 
 
 Next as to home treatment. The first considera- 
 tion is, that the person of unsound mind has probably 
 others about him who are nervously unstable, there- 
 fore he will not be treated in the most considerate 
 way by them, and again his influence may be disas- 
 trous to those about him. It is often my experience 
 to find it perfectly impossible to treat an insane 
 person in his own home, because of the thwarting 
 action of his relations. And, on the other hand, I 
 have seen cases in which an insane brother has started 
 insanity, hitherto unknown in the family, which 
 passed from member to member till three or four had 
 become insane. 
 
 Home cure is only suitable for cases in which there 
 is hope of speedy recovery, and where there are judi- 
 cious friends and sufficient space. Insanity following 
 fevers, insanity due to childbirth, may often be success- 
 fully treated at home. Care should be taken that 
 the patient is, if possible, on the ground floor, so as to 
 avoid accidents from precipitation ; and, although the 
 patient is at home, he must not be too much visited by 
 near relations. In fact, the success of home treatment 
 depends upon the quiet of home, with the absence of 
 relations. 
 
 Next, as to the cases suited to single care. Under 
 " legal considerations " I shall point out the neces- 
 sity of having certificates even for a single case 
 where insanity is pronounced, and where there is 
 any real restriction to liberty. It is often of the 
 utmost importance to have young developing children 
 belonging to highly nervous families removed from their 
 homes, but yet placed under home-like treatment and 
 discipline. Neurotic boys are specially likely to suflfer 
 from the surroundings of a mixed school ; and I advise 
 
Chap. XXIII.] Single Care. 481 
 
 that such patients be kept in the house of a medical 
 man who has had some experience of nervous disorders, 
 at the same time that he attends school, or, at all events, 
 is taught with other children. Epileptic children, too, 
 are better educated in private houses. They often re- 
 quire special education, and also their epileptic fits 
 are distressing, and may be injurious to other children. 
 In the same way the unstable girl at puberty, and the 
 hypochondriacal young man, may require skilled super- 
 vision for a year or two from seventeen or eighteen 
 years of age, and this is best effected by private care. 
 With large means any case can be treated at home, the 
 necessity being sufficient skilled attendance both by 
 night and by day j cases of insanity due to drink or 
 to acute physical disorder may be also satisfactorily 
 treated. 
 
 My own opinion is that it is neither for the wel- 
 fare nor for the comfort of chronic lunatics to be 
 treated alone ; and I believe that the present reaction 
 in favour of sending patients to private houses rather 
 than to private asylums will be the cause of scandals 
 such as arose in former times from the keeping of 
 lunatics in private houses. First, the chronic lunatic, 
 if placed in a house by himself with two, three, or four 
 private keepers, is in the position of a man controlled 
 by his servants, and having no companionship or occu- 
 pation ; for it is absurd to suppose that a cultured man 
 is happy when he is watched momentarily by inferiors, 
 is forced to take his meals by or with them, and for 
 amusement expected to play games with his servants. 
 Although it is somewhat an improvement when a young 
 medical man is put in charge, yet the want of experi- 
 ence, and the natural desire for some freedom on the 
 part of the doctor, does not insure the perfect comfort 
 of the lunatic. 
 
 Many forms and degrees of weak-mindedness natu- 
 rally may be treated at home or in the home of a doctor ; 
 F F — 14 
 
482 Insanity and Allied Neuroses. [Chap, xxiii. 
 
 patients suffering from the more advanced state of 
 general paralysis may also be managed in single care ; 
 but in the case of a patient suffering from hallucina- 
 tions and delusions it seems to me that he is happier 
 and better off in a small private asylum or hospital 
 than under private care. Whatever the statistics 
 of cures may appear to show, 1 am quite sure that, 
 other things being equal, more patients get well 
 when associated than when in single charge ; and 
 although it may be said that private asylums are 
 hot-beds of farming in lunacy, yet self-interest is, at 
 least, as great in single care as when a dozen paying 
 patients contribute to the income of the proprietor. 
 Patients who, from their smallness of means, or from 
 the nature of their symptoms, cannot be treated at 
 home, may either be sent to one of the hospitals for the 
 insane, or else to private asylums {see Appendix) ; or, 
 if means be entirely wanting, they may be sent to their 
 county asylum. 
 
 About the most important social question that 
 the practitioner will be asked is, whether a patient, 
 if he recover, should be allowed to return to his former 
 occupation. The advice given must depend upon the 
 nature of the employment, the temperament of the 
 man, and the nsiture of his insanity. If the man is 
 an emotional unstable person, and his business tends 
 to throw him in the way of drink, gambling, or heavy 
 speculation, he should be induced to follow rather the 
 mechanical or clerical part of his business, and leave 
 the active side to others. The morbidly self-conscious 
 man had better give up sedentary occupations, and try 
 his hand at farming or mechanical pursuits. It may 
 happen that a change of occupation for a year or two 
 at about eighteen years of age may enable the nervous 
 student to return to the work necessary for him to 
 enable him to follow the profession of his choice. The 
 most important indications should be drawn from the 
 
Chap. XXIV.] Legal Rela tionships of Insanity. 483 
 
 effect of the return to old surroundings, and if it is 
 found that with each return to study or the office 
 mental disorder reappears, it is evident that some 
 change in life must be made. Business relationships are 
 difficult to decide upon ; but there are social ones of 
 even greater difficulty, and when a question of marriage 
 arises it is hard to satisfy either one's conscience or 
 one's clients. On the one hand, I have known men 
 and women, who had suffered from attacks of insanity, 
 marry, and live for years without any return of the 
 disorder ; but the risk is great. On the other hand, 
 I have known two insane people marry, and have seen 
 their insane children, and I have seen an insane man 
 marry while still nominally under control, and the re- 
 sults in this case also have been disastrous. 
 
 CHAPTER XXIY. 
 
 LEGAL RELATIONSHIPS OF INSANITY. 
 
 Commissioners in lunacy — Private lunatics — Chancery lunatics — 
 Unlicensed and licensed asylums — Registered hospitals — 
 Medical certificates — Delirium tremens — Visitation system — 
 Pauper lunatics — County and borough asylums — Ill-treatment, 
 escape, recovery, temporary absence, transfer, and death of 
 lunatics — ^Wandering and criminal lunatics. 
 
 In this section, abandoning the pathological distinc- 
 tions of disease, I shall have to consider briefly the 
 various kinds of lunatics that may arise, in connection 
 with their social, circumstantial, and legal relation- 
 ships existing before or at the time of their insanity ; 
 the nature of the various public or private institutions 
 provided for their benefit, and the manner in which 
 such are regulated and controlled by the state ; the 
 manner, also, in which such regulations affect and 
 determine the welfare of the patient, the obliga- 
 tions of the physician, and the procedure of those in 
 
484 Insanity and Allied Neuroses. [Chap. xxiv. 
 
 charge of the lunatic. Though it will be my object to 
 confine myself to the medico-legal aspect of the ques- 
 tion, I shall not be precluded from briefly referring to 
 the mode of procedure to be adopted by officials of 
 different grades, and the public at large, in reference 
 to circumstances in which they may be placed with 
 regard to lunatics. 
 
 In order to avoid subsequent confusion, it will be 
 desirable that I should in the first place briefly ex- 
 plain the nature of the official hierarchy instituted by 
 the government for the regulation of general matters 
 of lunacy, as it exists at present. At the head of 
 this branch of the executive is the Lord Chancellor, 
 subject to whose control all those having jurisdiction 
 in lunacy perform their functions. Appeal from any 
 decision or order in lunacy made by him is transferred 
 to the Court of Appeal established by the Supreme 
 Court of Judicature Act of 1873. Under his control 
 there are two Masters in Lunacy and one Regis- 
 trar in Lunacy, also visitors of lunatics appointed to 
 pay visits at stated intervals to such patients as are 
 immediately under the jurisdiction of the Lord Chan- 
 cellor. The Masters in Lunacy, the visitors, and all sub- 
 ordinates, are either appointed by the Lord Chancellor 
 himself, or are subject to his approval ; the masters 
 being Serjeants or barristers of ten years' standing \ 
 the visitors, of whom there are three, being two 
 of them physicians, who at the time of election must 
 be in actual practice, and the third, a barrister of not 
 less than five years' standing. The masters are bound 
 upon oath faithfully to discharge the duties of their 
 office. The visitors are required to give up the prac- 
 tice of their professions, and are prohibited from 
 having an interest in any house licensed for the re- 
 ception of lunatics. 
 
 The chief functions fulfilled by the preceding 
 officers are practically, I may say, the determination, 
 
Chap. XXIV.] Commissioners in Lunacy. 485 
 
 by what is called a commission in lunacy, as tc 
 whether certain private individuals are sane and 
 capable of managing their own affairs, or other- 
 wise. The mode of procedure adopted in such cases 
 I shall have occasion briefly to describe when speak- 
 ing of private lunatics. Such persons as are found 
 to be insane by inquisition become then Chancery 
 lunatics, and their affairs subject immediately to the 
 jurisdiction of the Lord Chancellor and the Masters in 
 Lunacy, who make the requisite orders to provide for 
 their restraint, and the just administration of their 
 property during the time of their illness ; the visitors 
 being appointed to investigate and report as to 
 whether such orders are duly observed. 
 
 In former days an administration similar to and 
 partially identical with the above was the sole existent 
 branch of the executive to which was entrusted any 
 control over general matters of lunacy : the deter- 
 mination of the insanity of private patients, and the 
 administration of their affairs, being the chief, in fact, 
 almost the only matter taken cognisance of. Now, 
 however, as a result of the growing influences of 
 public opinion and the general interest taken in 
 matters of lunacy, as also of the development of the 
 middle classes in England, and the ameliorated scien- 
 tific treatment of the insane, there has gradually been 
 created by successive legislation an important body of 
 functionaries, to whom, in the main, with the excep- 
 tion of such matters as I have referred to above, 
 is entrusted the practical superintendence of all 
 general matters of lunacy in the country. 
 
 This body consists of the Commissioners in Lunacy, 
 eleven in number, three of whom are physicians and 
 three l barristers, who are remunerated ; while the 
 remainder, including the permanent chairman, are 
 unpaid. Here let me guard against a possible source of 
 confusion. That to which I have previously referred 
 
486 Insanity and Allied Neuroses. [Chap. xxiv. 
 
 as a commission in lunacy is not a meeting of the 
 Commissioners in Lunacy, but, as I have said, an 
 inquiry into the circumstances of any private case 
 instituted by the Masters in Lunacy under the Lord 
 Chancellor. The ambiguity has arisen out of the fact 
 that the predecessors of the Masters in Lunacy, two 
 in number, were called commissioners, and thus an 
 inquiry instituted under their auspices came to be 
 called a commission in lunacy. The growth of the 
 present body of Commissioners has arisen out of a local 
 and entirely different source, although they also are 
 nominally under the Lord Chancellor's jurisdiction. 
 
 Formerly the College of Physicians was required 
 to elect five fellows to act as commissioners for 
 licensing and inspecting mad-houses in the imme- 
 diate vicinity of the metropolis, a similar function in 
 the provinces falling to justices of the peace. Sub- 
 sequently their number was increased to fifteen, and 
 then, by legislation in 1832, the body was changed to 
 a body styled the Metropolitan Commissioners in 
 Lunacy, to whom, ten years later, was accorded the 
 duty of visiting the public and private asylums 
 throughout England and Wales. This in its turn 
 was superseded in 1845 by the present board of 
 eleven, the sphere of whose influence (as may be seen 
 from the annual reports issued by them in the March 
 of each year) has gradually been extended until there 
 are few circumstances in connection with persons of 
 unsound mind which do not fall under their imme- 
 diate control. They have the superintendence of the 
 management of all public and private establishments 
 throughout the country for the reception of the in- 
 sane; they retain the powers of granting licenses to 
 houses within their immediate jurisdiction, i.e. for the 
 metropolis and within a radius of seven miles ; they 
 may make rules for their own duties and those of their 
 officers ; two of their numbej' in turn visit all county 
 
Chap. XXIV.] Commissioners in Lunacy. " 487 
 
 and borough asylums and licensed houses at least once 
 in every year, or oftener if the occasion requires it ; 
 they issue regulations concerning the admission of 
 patients, the keejmig of case books with the necessary 
 particulars concerning their illness by the medical 
 officers, the general treatment of the insane, the 
 visitation of patients by properly qualified medical 
 men where there is no resident physician, the admis- 
 sion of friends of patients to visit them, the reception 
 of special boarders in licensed houses, and the arrange- 
 ment of chronic lunatics in workhouses. Copies of the 
 medical certificates of insanity have to be forwarded 
 for their inspection, as also certificates of death, of 
 cure, particulars concerning the escape and recapture 
 of patients, their removal from one asylum to another, 
 even the change of residence of any person having 
 charge of a single patient, and the notices of dismissal 
 of nurses or attendants for misconduct ; also the ab- 
 stracts of the accounts of the county asylums, and the 
 lists of pauper lunatics, together with a vast number of 
 other particulars. They have the power of ordering 
 prosecution for non-observance of the regulations 
 laid down by them, of administering oaths and ex- 
 amining witnesses on oath and directing expenses to 
 be paid to them, of employing persons to make 
 inquiries and report on special cases. 
 
 Thus it will be seen that the control of nearly all 
 systematic procedure in reference to lunatics through- 
 out the country falls within the province of their juris- 
 diction. And, indeed, in reference to those matters 
 falling more immediately under the jurisdiction of the 
 Lord Chancellor, the Lunacy Commissioners have the 
 power of reporting to this functionary if they have 
 reason to believe that the property of an alleged lunatic, 
 in whose case no commission in lunacy has been held, 
 is not properly protected or applied for his benefit, 
 which report "is to be taken as a petition for enquiry." 
 
488 Insanity and Allied Neuroses. [Chap. xxiv. 
 
 These are the main facts in reference to the 
 government of the insane as at present adopted by the 
 higher branches of the executive. To the duties of 
 magistrates and officers of minor importance I shall 
 have occasion to refer later, when treating of the 
 different classes of lunatics, and the methods of pro- 
 cedure adopted in reference to them. 
 
 Private lunatics. — By private lunatics I refer to 
 those supported out of their own property, who may 
 or may not be dealt with in Chancery according to the 
 determinations of a lunacy commission, or otherwise 
 under the Lord Chancellor ; or who may be supported 
 by their friends. Such may be dealt with as described 
 above ; they may be kept as single patients in private 
 unlicensed houses, or they may be confined in private 
 or public asylums or registered hospitals under orders 
 or medical certificates, where they are practically sub- 
 ject to the same regulations as the lunatics of other 
 classes, and to the jurisdiction of the Lunacy Commis- 
 sioners. Before entering into any particulars concern- 
 ing the places in which they may be confined, and the 
 regulations in connection with them when they have 
 been found insane, I will briefly describe the mode of pro- 
 cedure adopted by commission or inquisition in lunacy in 
 the case of C^'ancery lunatics, who, though forming a 
 small section of the above group of private lunatics, so 
 far as numbers are concerned, may be considered as, 
 for the most part, belonging to a higher social class. 
 
 When any person possessed of property is deemed 
 to be of unsound mind, and incapable of managing his 
 or her affairs, a petition may be presented, by any per- 
 son interested in the issue and willing to incur costs, 
 to the Lord Chancellor, praying for an enquiry into 
 his or her state of mind. The petition must be sup- 
 ported by the affidavits of two medical men, setting 
 fo"th on oath their opinions as to the state of mind of 
 the alleged lunatic, and their reasons for holding such 
 
Chap. XXIV.] Commission in Lunacy. 489 
 
 opinions. These affidavits must be clearly drawn up, 
 •with duly numbered paragraphs ; they must include a 
 full statement of the qualifications of the medical man 
 himself, and must contain sufficient proof of his special 
 knowledge of insanity. He must set forth his opinions 
 with considerably greater detail than in an ordinary 
 medical certificate, giving the history of the develop- 
 ment of the symptoms, his opinion as to the issue, sup- 
 plementing his information by facts which have come 
 under his own immediate cognisance ; in fine, every 
 collateral information must be given which would 
 assist the Lord Chancellor in forming his decision. 
 Should a primA facie case be made out, the Lord 
 Chancellor directs the Masters in Lunacy to hold an 
 enquiry. A notice is then sent to the alleged lunatic, 
 if within the jurisdiction, upon the receipt of which he 
 is entitled to demand a jury, and take measures for 
 his defence, except, indeed, the Lord Chancellor 
 should find upon personal examination, or by his 
 representative, that he is mentally incompetent to 
 express a wish on this head, in which case the Lord 
 Chancellor directs the Masters in Lunacy to person- 
 ally examine the lunatic, and investigate the facts, 
 and when they have certified their finding thereon 
 their certificates have the same efiect as an inquisi- 
 tion taken upon oath of a jury. This mode of pro- 
 ceeding is also to be adopted where the alleged lunatic 
 does not demand a jury. Whether with or without a 
 jury, the investigation must be confined to the state of 
 mind of the supposed lunatic at the time of the en- 
 quiry, and no evidence is allowed as to anything done 
 or said by him anterior to a period of two years before 
 the enquiry. When the enquiry is held before a jury 
 the verdict must be either " that the alleged lunatic is 
 of sound mind, and capable of managing his affairs, or 
 that he is of unsound mind, and incapable." The 
 Masters in Lunacy are not entitled to accept a divided 
 
49° Insanity and Allied Neuroses, [Chap. xxiv. 
 
 verdict. I may say here, however, that even if he 
 were found sane by inquisition, I cannot see that there 
 is anything to prevent him being still confined under 
 the certificates of two independent medical men just as 
 if the inquisition had not been held. Such a case would, 
 in the issue, be likely to cause further litigation. 
 
 The Lord Chancellor has the power of directing 
 the costs of an inquisition to be paid either by those 
 presenting the petition, by those opposing it, out of 
 the estate of the alleged lunatic, or partly in one way 
 and partly in another. There are many important 
 provisions with reference to the management of the 
 estate of Chancery lunatics for which reference must 
 be made to the Acts, or legal opinion must be taken. 
 A petition for inquisition should not, in my opinion, 
 be presented unless serious monetary interests are at 
 stake, as, in spite of every judicious and graduated 
 regulation of costs, the expense is still very great ; in 
 fact, if such were not proved to be the case, as if also 
 there were not prinid facie evidence of the improba- 
 bility of the lunatic's cure, the Lord Chancellor would 
 probably refuse to allow the enquiry to take place. 
 Any person desiring to traverse the inquisition must 
 petition within three months from the date of the re- 
 turn. Where liberty to traverse has been applied for, 
 whether granted or not, the Lord Chancellor may order 
 the inquisition to be superseded, with the consent of 
 the lunatic and interested parties, on such terms and 
 conditions as he may think proper. He possesses this 
 power even where a traverse has not been applied for. 
 
 Should a lunatic be found so by inquisition, two per- 
 sons, technically called "committees," are appointed by 
 the Lord Chancellor, to one of whom is entrusted the 
 care of the person of the lunatic, and to the other the 
 care and management of his property, both being sub- 
 ject to the control of the Chancery visitors. These 
 latter are bound to visit the patient four times in each 
 
Chap. XXIV.] Commission in Lunacy. 491 
 
 year, the period between any two visits not being 
 alloM'^ed to exceed four montlis, unless he be conjSned 
 in a licensed house, registered hospital, or asylum, in 
 which case he must be visited once in each year. The 
 visitors must report to the Lord Chancellor upon 
 various matters in connection with the patient's wel- 
 fare ; their reports are kept secret, and filed, and are 
 destroyed upon the death or recovery of the patient. 
 
 This, then, is the mode of procedure in case of a 
 commission in lunacy being held. In reference to 
 persons not found lunatic by inquisition, who never- 
 theless come under the immediate jurisdiction of the 
 Lord Chancellor, the most important class consists of 
 those where the interference of the Lord Chancellor is 
 desirable as regards the management of the estate, 
 though it is not required as to the custody of the per- 
 son, and where the estate is too small to render a 
 commission in lunacy expedient, " In any case of 
 this kind, if it be established to the satisfaction of the 
 Lord Chancellor, by report of one of the Masters in 
 Lunacy, or by the report of the Commissioners in 
 Lunacy, or by affidavit or otherwise, that the person 
 in question is of unsound mind and incapable of 
 managing his affairs, and that his property does not 
 exceed .£2,000 in value or £100 in yearly income, the 
 Lord Chancellor may, without directing any enquiry 
 under a commission in lunacy, but after giving due 
 notice to the alleged lunatic, make an order for ren- 
 dering the property, or the income, available for 
 maintenance or benefit, or for carrying on his trade or 
 business." The Lord Chancellor also, with the help of 
 the Masters in Lunacy, may take what specific mea- 
 sures he deems expedient for the furthering of these 
 purposes. Similar powers are given to the Lord 
 Chancellor with regard to persons acquitted from any 
 criminal accusation on the ground of lunacy. 
 
 Before leaving this subject, it is desirable that I 
 
492 Insanity and Allied Neuroses. [Chap. xxiv. 
 
 should specify the considerations by which medical 
 men should be guided in recommending patients to be 
 made wards of the Court of Chancery. The most im- 
 portant case is when serious money interests are at 
 stake, as I have described above. It must be fully 
 understood that a person of unsound mind can transact 
 business imless he has been placed under certificates ; 
 so that a person, although acknowledged by his friends 
 to be a lunatic, can sign cheques and make a will, and 
 squander his property without let or hindrance, unless 
 he is made a lunatic by inquisition, or unless he is 
 under certificates. An injunction is the best method 
 of preventing money being obtained while steps are 
 being taken to certify that the patient is of unsound 
 mind. An injunction can readily be obtained by the 
 solicitor, supported by the medical affidavits, in the 
 manner I have described above ; and if the property 
 be certified under the amount named, and the two 
 medical affidavits be found satisfactory, application 
 will be followed by an order of the court appointing 
 the " committee " of the person and of the estate. 
 
 It must be observed that no person under certifi- 
 cates can legally transact any business, and whoever 
 has charge of lunatics in private or public must re- 
 member that it is his duty to prevent any business 
 being done. 
 
 Having now noticed the chief points in connection 
 with inquisition in lunacy, I shall pass on to consider 
 circumstances in connection with private lunatics. I 
 may first just remark, that though a certain number of 
 persons become lunatic in the eye of the law in this 
 manner, by far the greater number come under the cog- 
 nisance of the law by being confined in public or private 
 asylums, on the strength of the certificates of medical 
 men, where they are then provided for by the law 
 under the regulations of the Lunacy Commissioners. 
 
 Private lunatics, whether found so by inquisition 
 
Chap. XXIV.] FrIVATE CONFINEMENT. 493 
 
 or otherwise, may be taken care of by their friends ; 
 they may be confined as single patients in unlicensed 
 houses, or in registered hospitals or licensed houses, or 
 in county and borough asylums. 
 
 In the first place, in reference to any lunatic who 
 may be confined 'privately in the house of some rela- 
 tive or friend, or other person deriving no profit from 
 the charge, the only cognisance taken by the law is 
 that " it is lawful for the Lord Chancellor or the Home 
 Secretary at any time by an order in writing under his 
 hand directed to the Commissioners in Lunacy, or any 
 of them, or to any other person, to require the person 
 or persons to whom the order is directed, or any of 
 them, to visit and examine the lunatic, and report 
 upon the subject." 
 
 With regard to the subject of the ill-treatment of 
 private lunatics in the charge of their friends, for 
 which some provision is now made by the law, it ap- 
 pears that during the early part of this century the 
 law was very imperfectly laid down on this head, 
 that decisions were unintelligibly conflicting, and that 
 many perpetrators of ill-treatment escaped in conse- 
 quence of there being no technical possibility of re- 
 warding them with the punishment they deserved. In 
 their eighth annual report, however (1854), the Com- 
 missioners in Lunacy mention the case of one Evan 
 Roberts, who was confined, first by his father, and after 
 his father's death by his brother, in a small room, 
 chained to the bedstead, and otherwise neglected and 
 ill-treated. In this case Lord Campbell, who charged 
 the jury, distinctly laid it down, " that the use of re- 
 straint, greater in degree, more severe in character, or 
 longer in duration than is necessary for the security 
 and care of a lunatic, is an offence at common law 
 punishable by indictment." There was also about this 
 time the case of Charles Luxmore, a lunatic, the son 
 of a small farmer in Devonshire, who suffered similar 
 
494 Insanity and Allied Neuroses. [Chap. xxiv. 
 
 ill-treatment at the hands of a brother-in-law, the 
 latter being found guilty and sentenced to six months' 
 imprisonment. 
 
 Some difficulties have arisen in respect of such re- 
 lationships as a wife under the care of her husband, 
 or a child of its parents, it having been held that 
 " the section only applies to such persons as have the 
 charge and care of lunatics otherwise than in conse- 
 quence of natural obligation arising from the relation 
 of husband and wife or parent and child." For in- 
 stance, in 1872, a son (alleged to be illegitimate) was 
 indicted for neglect and ill-treatment of his lunatic 
 mother; but the Court held that " having regard to his 
 relationship with the lunatic the Act did not apply." 
 In connection with this case the Commissioners re- 
 marked in their next report " that they thought it 
 unfortunate that the court did not reserve the point of 
 law," and there can be no doubt that this is one of the 
 points on which, even at the present time, a modifica- 
 tion of the law is much to be desired. Looking, how- 
 ever, at the circumspection exercised by the Lunacy 
 Commissioners, I strongly recommend all persons, 
 whether in the medical profession or otherwise, to be 
 extremely careful how they act in connection with per- 
 sons of unsound mind, even with the best intentions. 
 
 If the lunatic be received to board and lodge in the 
 house of any one compensated by pecuniary remunera- 
 tion, although this house come under the designation of 
 unlicensed houses, it is under the superintendence of 
 the Commissioners in Lunacy, and their regulations 
 are most stringent. No person can be received into 
 such a house without an order and two medical certifi- 
 cates (except by an order of the " committee " in the 
 case of persons found lunatic by inquisition). In this 
 case, as also in the case of other kinds of establish- 
 ments, the order must be signed by some person who 
 has seen the patient within one month of the time of 
 
Chap. XXIV.] Private Asylums, 495 
 
 his reception into the asylum. Though the Commis- 
 sioners request that, as a general rule, some near 
 relation should sign the order, this is not absolutely 
 necessary. A stranger may sign it, and in some cases 
 it is desirable that the nearest relation should not do 
 so. Thus in some acute curable cases, especially those 
 in which drink has had a share in the production of 
 the symptoms, if the wife sign the order, the husband, 
 on recovery, may be enraged at the part she took, and 
 further trouble may arise. Copies of the order and 
 certificates must be immediately forwarded to the 
 Commissioners ; also a statement of the patient's 
 health, more than two and less than seven days after 
 his reception ; the patient must be visited by a phy- 
 sician unconnected with him or with those having charge 
 of him ; a "medical visitation book " is to be kept, with 
 accurate records of the patient's health, accessible to 
 the Commissioners when they visit the establishment ; 
 notice must be forwarded in case of death, discharge, 
 removal, escape and recapture, or change of residence. 
 For all these matters stereotyped forms are prepared, 
 and must be strictly filled in and adhered to ; any 
 lapse, especially in the way of neglect or ill-treatment, 
 being followed by indictment for misdemeanour or the 
 penalty of a fine. 
 
 We come now to licensed houses or private asy- 
 lums, which often present many advantages. They are 
 under the personal control and management of a pro- 
 prietor or superintendent, and are not hampered by 
 the general regulations pertaining to the larger establish- 
 ments. Naturally more liberty can be allowed to the 
 patient, and greater facility for the visits of friends. 
 The arrangements are often similar to those of a 
 private family, and aflTord a greater degree of privacy, 
 together with the necessarj'- safeguards of the larger 
 establishments. The license for these establishments is 
 granted by the Lord Chancellor within the immediate 
 
496 Insanity and Allied Neuroses. [Chap. xxiv. 
 
 jurisdiction, viz. for the metropolis and within a radius 
 of seven miles \ in the provinces by the county or 
 borough justices at quarter sessions. The holder of 
 the licence must reside on the premises licensed, and 
 the resident physician or medical attendant must be 
 approved by the Commissioners. Licences are fre- 
 quently held by members of the medical profession j; 
 but they may be held by ordinary persons, or by ladies 
 for the reception of female lunatics. The most stringent 
 inquiry is instituted as to the personal fitness of the 
 applicant for such a post, his or her social condition, 
 and by vs^hom pecuniary emolument will be derived ; 
 particulars must be given as to payments, etc.; in- 
 quiry is also made as to the structural adaptation of the 
 establishment to be licensed. In the case of a medical 
 applicant, he must state full particulars concerning his 
 general and professional education, his degree, where 
 and in what manner he has acquired his experience in 
 lunacy ; he must produce satisfactory testimonials as 
 to his medical skill and his personal fitness to be 
 entrusted with the care of the insane ; he must be pos- 
 sessed of adequate pecuniary means, besides other 
 matters. The licence is usually granted "for such 
 period not exceeding thirteen calendar months as to 
 the Commissioners may seem fit ; " but I may say 
 that the Commissioners have determined not to in- 
 crease the number of licensed houses within the metro- 
 politan area except under exceptional circumstances. 
 
 In boroughs, the consent of the recorder, in writing, 
 is also required ; and the applicant forwards his appli- 
 cation to the clerk of the peace, as also to the Com- 
 missioners, who must first inspect the premises, and 
 report to the. justices before the latter can entertain 
 the proposal, which is almost invariably decided in 
 accordance with their recommendation. A copy of 
 the licence, when granted, must be forwarded to the 
 Commissioners. Licensed houses having a hundred or 
 
Chap. XXIV.] Registered Hospitals. 497 
 
 more patients, are compelled to have a resident 
 medical superintendent; those with under a hundred 
 and over fifty must be visited daily by a medical atten- 
 dant ; where there are less than fifty, twice a week. 
 
 We now come to registered hospitals. In 1815 
 there were nine such institutions in existence, now * 
 (1884) there are sixteen. Registered hospitals for 
 the reception of lunatic patients differ little in their 
 constitution and management from ordinary hospitals. 
 They are generally under the control of a committee, 
 consisting of elected and ex-officio members, and are 
 supported by endowment or by annual contribution. 
 Copies of the regulations concerning their management 
 must be approved by the Secretary of State and sent 
 to the Lunacy Commissioners. For the most part 
 they have the same relation to the lunacy laws as 
 licensed houses. Every hospital must be registered, 
 and is required to have a resident physician, surgeon, 
 or apothecary, as the superintendent and medical 
 supervisor. So far as the social class of the patients 
 is concerned, speaking generally, these institutions 
 occupy a position midway between the ordinary pri- 
 vate asylums and the county asylums for paupers (to 
 which we shall come presently). The Commissioners 
 in Lunacy strongly recommend the extension of hos- 
 pital accommodation for the insane poor, who, although 
 not paupers, are unable, nevertheless, to afford the 
 expense incurred in. a private asylum. Their recom- 
 mendation is also to be supported from the fact that 
 there are a large number of mild and curable cases 
 occurring nowadays among a class such as governesses 
 and clerks, either without resources or whose resources 
 are too slight to bear the cost of a serious illness. To 
 such it would be a social indignity to ])e relegated 
 to a pauper asylum, but they are able and willing 
 to avail themselves of the benefit afibrded by the 
 * See Appendix. 
 G G 14 
 
498 Insanity and Allied Neuroses. [Chap. xxiv. 
 
 treatmenfc in a hospital. Formerly there were too 
 few of these refuges of a charitable nature for the 
 insane. 
 
 In connection with these institutions an interesting 
 question arose a few years ago, as to whether persons 
 not being actually insane, but conscious of a loss of self- 
 control (owing to alcohol or other causes), or liable to 
 fits of recurrent insanity, could be received into them 
 as voluntary boarders. The Commissioners laid the 
 case before counsel, and the opinion given was " that 
 there appears to be nothing in the statutes to prevent 
 the admission of the persons referred to as voluntary 
 boarders into registered hospitals, and that there would 
 apparently be no difficulty in enforcing legally the 
 stipulations and conditions of any agreement by bond 
 or otherwise for their residence therein." A provision 
 somewhat analogous to the foregoing is made (and 
 applies both to hospitals and licensed and unlicensed 
 houses) by the sixth section of the Act 16 & 17 
 Vict., c. 96, as follows : " That it shall be lawful for 
 the proprietor or superintendent of any licensed house, 
 with the previous assent in writing of two of the Com- 
 missioners, to entertain and keep in such house, as a 
 boarder, any person who may have been discharged as 
 a patient from such house, for such time after such 
 discharge as he may desire to remain, not exceeding 
 the time specified in such assent." No fresh orders or 
 certificates are required in these cases, A personal 
 examination by the Commissioners is necessary, how- 
 ever, in order that they may be assured that it is by 
 the desire of the patient that he so remains. A friend 
 or relation of the patient may also be allowed to re- 
 main as his companion during the time specified by 
 the Commissioners, which they have the power to 
 terminate when it shall seem fit to them. 
 
 Legal opinion has been taken to the effect that 
 such persons are themselves capable of contracting to 
 
CTiap. XXIV.] Medical Certificates. 499 
 
 observe the regulations of the house or hospital in 
 which they desire to remain. 
 
 I have spoken of the signing of medical certificates 
 in connection with the reception of private lunatics 
 into hospitals and licensed houses, and I shall have 
 occasion to refer to them again when treating of 
 pauper lunatics : although certificates of this class are 
 not of the voluminous nature required by the Lord 
 Chancellor in case of inquisition in lunacy, certain 
 forms are laid down with regard to them which are of 
 the last importance both to medical men and to all 
 concerned. In the case of private lunatics we have 
 seen that two certificates were required. These must 
 be signed by properly qualified medical men (one being 
 a registered physician, surgeon, or apothecary) " duly 
 authorised or licensed to practise as such, by or as a 
 member of some college, university, company, or insti- 
 tution legally established and qualified to grant such 
 authority or license in some part of the United King- 
 dom." They must have no connection with the person 
 to whose care the lunatic is to be transmitted ; they 
 must not be in partnership one with another, nor 
 may they be related to the person who signs the 
 order. I must strongly insist upon the gravity of 
 this important subject, and warn my fellow-prac- 
 titioners that the law is most stringent in res[)ect 
 to the regulations it has laid down. The Christian 
 and surnames of the patient must be written in full, 
 together with the proper address and occupation, if any. 
 The certificate must state the facts observed by the 
 doctor, and those communicated by others, from which 
 the conclusion of insanity has been deduced. The cer- 
 tificate is valid for seven clear days only, and if the 
 patient be not removed to the asylum before the 
 expiry of that date, fresh certificates (unless the old 
 ones can be re-dated with propriety) are required. No 
 patient can be received into an asylum upon the 
 
500 Insanity and Allied Neuroses. [Chap. xxiv. 
 
 strength only of facts communicated by others to the 
 medical man who signed the certificate. A separate 
 examination is necessary. In exceptional cases, how- 
 ever, where a statement accompanying the order for 
 admission is sent, describing circumstances which 
 render it impossible for two certificates to be procured 
 (as, for instance, in the case of a dangerous lunatic), 
 the patient may be sometimes admitted on one certi- 
 ficate, but within three clear days two other such 
 certificates must be duly furnished fulfilling the pre- 
 ceding conditions, or those conniving at the detention 
 of the patient are "guilty of misdemeanour." 
 
 So particular are the Commissioners, to whom these 
 certificates are sent, that they ordered the liberation 
 of one patient on the ground that the certificate was 
 invalid, because it did not contain the number of 
 the house in which he had lived ; again, in another 
 case, because the medical men signed certificates, not 
 from what they observed on any particular day, but 
 from what was known to them in consequence of 
 having attended the patient during a considerable 
 period of time ; and yet in another, when it was found 
 that the medical man had signed a certificate six weeks 
 prior to the admission of the patient, the Commis- 
 sioners wrote to the proprietor that they considered 
 his negligence " a most grave ofience." 
 
 Medical men may be fined £20 for signing cer- 
 tificates without due observance of the regulations, or 
 if falsity be suspected, they may be indicted for mis- 
 demeanour. They are also liable to action on the part 
 of the patient himself, and in a case of which I have 
 the particulars before me, .£150 damages were 
 recovered, the charge being that Dr. " had neg- 
 ligently and culpably failed duly to enquire into the 
 truth of the facts." 
 
 In connection with these facts it should not be 
 forgotten that a power is given to the medical man 
 
Chap. XXIV.] Medical Certificates. 501 
 
 which no other functionary in the land possesses, 
 namely, the deprivation of a subject, not merely 
 of his liberty, but of his civil, social, financial, po- 
 litical, and even of his domestic rights. 
 
 Copies of the certificates have to be sent to the 
 Commissioners in Lunacy, and must be inspected by 
 the visiting commissioners when they go their rounds ; 
 theoretically they have no legal value until they have 
 been thus vised by the authorities. The following, 
 however, is important : "If, after the reception of any 
 lunatic, it appears that the order or medical certificate, 
 or (if more than one) both or either of the medical 
 certificates upon which he was received is or are in 
 any respect incorrect or defective, such order and 
 medical certificate, or certificates, may be amended by 
 the person signing the same, at any time within 
 fourteen days next after the reception of such lunatic; 
 provided, nevertheless, that no such amendment shall 
 have any force or efiect unless the same shall receive 
 the sanction of one or more of the commissioners.^' I 
 strongly recommend medical men, in all important 
 cases, to keep a copy of the certificates they issue, as 
 circumstances may arise rendering it desirable for 
 them to have at hand some particulars concerning the 
 facts and reasons which guided them at the time in 
 certifying the insanity. 
 
 The Commissioners point out that " few of our 
 duties require more vigilance than that of satisfying 
 ourselves, in all doubtful cases, as to the validity of 
 the orders and certificates on which patients are 
 admitted into asylums, or become subject to detention 
 in any place." Complaints of the negligence of 
 medical men, and their disregard of the marginal 
 directions, are frequent, "The object of all these 
 precautions," say the Commissioners, "is to provide 
 that no one shall be deprived of his liberty as a person 
 of unsound mind, except upon specific grounds existing 
 
502 Insanity and Allied Neuroses. [Cbap. xxiv. 
 
 at the exact time when it is proposed to place him 
 "imder restraint." 
 
 Apart from the purely legal restrictions in con- 
 nection with medical certificates, there are one or two 
 general matters to which I may as well refer. 
 
 It is incumbent upon a medical man, in signing a 
 certificate, to consider not only the question of the 
 insanity, but whether the patient is, or is not, a fit 
 subject to be detained under restraint, and what 
 benefit he is likely to derive from the peculiar form of 
 treatment it is proposed to subject him to. It is 
 practically impossible to lay down any general rules 
 for guidance in this diflQcult matter, as almost every 
 case presents some individual peculiarity ; the medical 
 practitioner must be guided by his own experience 
 and tact. Perhaps the form of insanity offering the 
 most obstacles to due certification is that of delu- 
 sional insanity. "Madmen," says Dr. Blandford, 
 "have an unpleasant way of revealing family secrets, 
 and it is convenient to call all such revelations 
 delusions. Here you must, if possible^ derive informa- 
 tion from others who are not primarily concerned, old 
 servants, medical men, acquaintances, and the like. 
 But for them I should certainly have been disposed to 
 accept as delusions some of the facts that have been 
 told me by patients, and even now I am in doubt 
 about some, never having been able to arrive at the 
 truth." Undoubtedly this is good advice, but the 
 medical man must be sure to give his own reasons also 
 for coming to his conclusion. What is wanted is 
 logical and consistent prima facie proof of the patient's 
 fitness to be placed under restraint. Hearsay evidence 
 should not be entered without its being stated to be 
 sucli, nor should any statement be made which cannot 
 be verified upon oath in a court of justice. The 
 doctor who signs the certificate should always bear 
 in mind the responsibility he incurs. 
 
Chap. XXIV.] Restraint in Delirium. 503 
 
 Perhaps one of the most difficult matters in con- 
 nection with the signing of certificates, has proved 
 to be the placing under restraint of persons suffer- 
 ing from the delirious loss of control resulting from 
 the misuse of alcohol. The late Baron Bramwell, 
 in a case brought before him at the Surrey summer 
 assizes in 1862, in which an action for trespass 
 was brought against a medical man for placing the 
 plaintiff, who was suffering from deliritmi tremenSj 
 under restraint, held that " at common law and 
 apart from the lunacy statutes, a medical man may 
 justify measures necessary to restrain a dangerous 
 lunatic, and that if he be called in to attend a person 
 suffering under delirium tremens, he may justify such 
 measures as are reasonably necessary, either to cure 
 the person so suffering, or to restrain him from doing 
 mischief so long as the fit lasts, or is likely to 
 return." In the case of a widow in 1863, with whom 
 restraint had been used for what the medical men held 
 to be delirium tremens, but which she denied, the 
 Lord Chief Justice remarked in his summing up, 
 "that there had, no doubt, been some restraint upon 
 natural personal liberty, but was it not necessary 1 
 Let the jury put themselves in the position of these 
 gentlemen, or of the friends and relatives of this 
 person (the plaintiff), and let them ask whether, even 
 supposing that the defendants were responsible for all 
 that had been done to prevent her from getting out 
 into the streets or throwing herself out of the window, 
 the jury would not consider that these gentlemen, so 
 far from being proper subjects of condemnation and of 
 censure, were not rather fit objects of gratitude and 
 regard." The Lord Chief Justice further deprecated 
 "exposing medical men unjustly to vexatious and 
 harassing actions." 
 
 In another case, however, the family of a certain 
 individual, not a pauper, made complaint to the 
 
504 Insanity AND Allied Neuroses. [Chap.xxiv. 
 
 relieving oflEicer of his violent conduct ; this officer 
 caused him to be conveyed to the lunatic ward of the 
 Lambeth workhouse upon a single medical certificate, 
 to the effect that he was of unsound mind aggravated 
 by drink, and wholly unfit to be at large ; that his 
 conduct, both at home as well as abroad, was out- 
 rageous, and that he was continually threatening his 
 own life and that of his children." In a few days this 
 person recovered from the effects of his intemperance, 
 and subsequently brought an action against the reliev- 
 ing oflS.cer. Mr. Justice Byles, in summing up the 
 case, credited this functionary with having " acted as 
 he believed it to be his duty to do, but as he had not 
 obtained the certificates required by the statute, he 
 was legally wrong, and a verdict must go against him." 
 The jury thereupon found for £20 damages, and their 
 verdict was subsequently confirmed upon appeal being 
 made. In this case we have an illustration of both 
 sides of the question. 
 
 Dr. Clouston, also, in his recent work, urges " that 
 in cases where the attack is likely to last for any 
 length of time, patients suffering from delirium tremens 
 should, in the ordinary course, be sent to an asylum, 
 or registered hospital, as these institutions possess the 
 requisite facility for their treatment, such, as could not 
 be commanded at the patient's own home or at an 
 ordinary hospital." In this I entirely concur, and I 
 cannot but think that if the treatment, which is 
 available, and which is by no means a heavy expense 
 in these temporary cases, were sought oftener than it 
 is at present, much brutality and crime might be pre- 
 vented. There is no sight more salutary to those who 
 are the slaves of some noxious habit, than to be thrown 
 for a short time among the surroundings of disease 
 and loathsomeness which are its worst results, where 
 they have ample time both for observation and reflec- 
 tion. Though a permanent re-establishment of the 
 
Chap. XXIV.] Regulations of Commissioners. 505 
 
 perverted will should be impossible, an influence may- 
 be awakened whicb will go far to counteract the 
 baneful tendency for the future, and will, at any rate, 
 avert evil consequences at the time of the attack. 
 
 A great deal has doubtless been done for the 
 treatment of those who develop the mania of alcohol, 
 by the establishment of the licensed " retreats " for 
 habitual drunkards; and the state having recognised 
 the divergence of this subject from the subject of 
 insanity^ has provided, by the ninth section of the 
 habitual drunkards Act of 1879, that "no licence 
 shall be given to any person (for one of these 
 'retreats') who is licensed to keep a house for the 
 reception of lunatics." 
 
 The above remarks will also suggest the course 
 often to be pursued in the case of lunatics who may 
 be dangerous to themselves or others, from other 
 causes than alcohol. 
 
 Finally, in reference to the subject of certificates, 
 I would recommend those who have to certify, to avoid 
 the use of all vague terms such as " excitement," 
 "bad temper," "emotional," and the like; and, if 
 possible, in obtaining these particulars to abstain 
 from all strategy and underhand procedure, as the 
 discovery of such may have a most injurious effect 
 upon the course of the patient's illness. It is better 
 to be straightforward and open, as it will then 
 be found much easier to obtain the patient's con- 
 fidence, and this having been obtained, there will be 
 little further difficulty in discovering the suspected 
 hallucination or delusion. This is but the illustration 
 of a general principle to be adopted in the treatment 
 of the insane. 
 
 There are a vast number of regulations of the Com- 
 missioners in reference to circumstances which may 
 arise in connection with the restraint of lunatics, to 
 the most important of which it will be better that I 
 
5o6 Insanity and Allied Neuroses. [Chap. xxiv. 
 
 should refer, after having treated of pauper lunatics 
 and county asylums, as many of their provisions 
 apply equally to these as to the other classes I have 
 already described. I may here, however, refer to the 
 system of visitation adopted with regard to registered 
 hospitals and licensed houses. 
 
 All registered liospitals, wherever situated, and all 
 licensed houses " within the immediate jurisdiction," 
 ai'e placed under the supervision of the Commissioners 
 in Lunacy ; while licensed houses beyond the immediate 
 jurisdiction are under the supervision of visiting 
 justices, though also of the Commissioners in Lunacy. 
 
 Every hospital must be visited by two of the Com- 
 missioners, one being a barrister and the other a doctor, 
 twice a year, without notice being given ; if the licensed 
 house be within the immediate jurisdiction, four times 
 a year, except a special representation be made to the 
 Lord Chancellor by the Commissioners, when the Lord 
 Chancellor may direct that " any house licensed by 
 them, and not receiving pauper patients, shall be 
 visited twice only in the year." The duties of the 
 Commissioners with regard to such visits are strictly 
 laid down. It is incumbent upon them " to inspect 
 the whole of the premises, to see every patient, to as- 
 certain whether any patient is under restraint, and if 
 so, why ; to inspect the orders of admission and medi- 
 cal certificates, and in certain cases the license as well 
 as the books required to be kept and other documents. 
 They are also to enquire as to Divine service, the 
 occupations or amusements of the patients ; the system 
 of treatment and other matters ; and to enter the 
 result of their inspection and enquiries in the visitors' 
 book, and any remark they may think fit to make in 
 the patients' book." Copies of such entries by the 
 visiting commissioners must be forwarded to the Com- 
 missioners within three days of the visit by the medi- 
 cal superintendent, upon whom falls the obligation 
 
Chap. XXIV.] Visitation System. 507 
 
 of affording the commissioners every facility in the 
 pursuit of their enquiry. The visiting commissioners 
 also themselves report to the Commissioners on the 
 subject of their visits, and such reports are pre- 
 served by the secretary. They have the option of 
 paying such visits not only according to the prescribed 
 intervals of time, but at such hour of the day or night 
 as they think fit, in fact, at any time. 
 
 With regard to licensed houses beyond the metro- 
 politan jurisdiction, it is provided "that visitors shall 
 be appointed in any county or borough at the Michael- 
 mas quarter sessions in every year (but in boroughs 
 with the consent of the recorder), consisting of three 
 or more justices, VT'ho are to act gratuitously, and one 
 (or more) physician, surgeon, or apothecary, who is to 
 be remunerated . . . but no person interested 
 in a licensed house can act as visitor, clerk, or as- 
 sistant clerk." The provisions laid down vdth regard 
 to their visits are similar to those in respect of the 
 visiting commissioners. Two at least of the visitors 
 (one being a physician, surgeon, or apothecary), are to 
 visit each licensed house within their jurisdiction four 
 times a year at least, and at such other times as the 
 justices may direct ; and, in addition, each house may 
 be visited at any time. The visits are paid without 
 previous notice, and care is taken that no proprietor 
 has fore-knowledge of the visit intended to be paid to 
 him. 
 
 In addition to the visitation by the visiting 
 justices, " every licensed house not within the imme- 
 diate jurisdiction of the Commissioners in Lunacy, is 
 to be visited without previous notice by two at least 
 of the Commissioners (one being a physician or sur- 
 geon, the other a barrister), twice at least in every 
 year." 
 
 The objects of all such visits are thus stated in a 
 report issued by the Commissioners in 1847, "to 
 
5b8 Insanity and Allied Neuroses. [Chap. xxiv. 
 
 ascertain that the patient is duly confined, that he has 
 medical aid, fit attendance, and proper comforts during 
 his confinement, that he is provided with employment 
 and amusement ; that his food is good, and his 
 place of residence healthy, clean, well ventilated, and 
 in good order ; that he himself is not ill-treated, neg- 
 lected, or improperly restrained ; and finally, that he 
 is liberated when fit for liberation." And thus with 
 regard to the results ; " without adverting to the many 
 cases where persons have been restored to the world 
 by means of such intervention, important benefits and 
 comforts of various sorts have been obtained for insane 
 patients by the present system of inspection and 
 supervision. The dwellings for the insane are no 
 longer the gloomy prisons in which they were formerly 
 confined j cleanliness, warmth, and ventilation are in- 
 sisted upon; better diet, clothing, and bedding have 
 been provided ; personal restraint is diminished, and 
 even when still employed, its severity is greatly miti- 
 gated, and its application strictly watched ; the health 
 and mental condition of the lunatic are more carefully 
 considered ; occupation and amusement are more gene- 
 rally afforded to him, and in all respects better treatment 
 is secured, whilst an opportunity is periodically given 
 to him of representing any hardship to which he may 
 have been subjected, an advantage which, as is found 
 by experience, many patients fully appreciate." All 
 this is undoubtedly true, and I look upon many of 
 these advantages as the gratifying result of an in- 
 creased knowledge of mental disease, by means of 
 which the mind of the lunatic has been carefully ex- 
 plored, and everything turned to account which is not 
 drawn within the noxious influence of local perver- 
 sion. I use the word local advisedly, being of opinion 
 that there are comparatively few cases of lunacy in 
 which, during a considerable period of the attack, the 
 mind does not retain, with judicious treatment, many 
 
Chap. XXIV.] Pauper Lunatics. .509 
 
 influences applicable to the ordinary phenomena of 
 normal life. 
 
 Provision is also made that letters addressed by 
 lunatics to the Commissioners should be forwarded 
 unopened, and that facility should be allowed them 
 for being visited by their friends ; friends are also 
 enabled to obtain particulars concerning those con- 
 fined, or supposed to have been confined as lunatics, 
 upon application to the Commissioners. Letters, if 
 not sent as addressed, must be kept, after being 
 initialed, for the authorities to see. 
 
 Of the books directed to be kept in asylums, the 
 most important is the medical case book. In this a 
 statement is to be entered, immediately upon entrance, 
 of the name, age, sex, and previous occupation of the 
 patient, whether married or single, his or her external 
 appearance, habit of body, temperament, appearance 
 of eyes, expression of countenance, previous habits^ 
 any peculiarity in the fornj of the head, and a large 
 number of medical particulars with regard to physical 
 condition, a description of the phenomena of the 
 mental disorder, changes in temperament or disposi- 
 tion, etc. etc. During the first month after admission, 
 entries in this book must be made at least once in 
 every week, oftener where the nature of the case re- 
 quires it ; after this, once a month, and in chronic 
 cases, once in three months. A record of the treat- 
 ment adopted is also to be subjoined. 
 
 I now come to the subject of pauper lunatics, 
 who form by far the most numerous class ; though 
 the regulations concerning them and the institu- 
 tions in which they are confined can be embodied 
 in more succinct form than the foregoing. I cannot 
 do better than quote the following passage, which 
 will give a clear idea as to their position in the 
 country. Pauper lunatics, whether they are paupers 
 in respect of destitution existing independent of their 
 
5IO Insanity and Allied Neuroses. [Chap. xxiv. 
 
 lunacy, or in consequence of it, " must be relieved 
 by the guardians, or other local authorities who 
 are charged with the administration of relief to the 
 poor ; but the relief, on the other hand, must be 
 afforded in the particular manner which is pointed out 
 or prescribed by the law as adapted to the peculiar 
 circumstances of their unfortunate condition. When- 
 ever it is requisite or proper to do so for the purpose 
 of care or treatment, they ought to be sent to the 
 county or borough asylum, or, in default of such ac- 
 commodation, to some registered hospital or licensed 
 house j but where it is not necessary to adopt that 
 course, they may either be kept in the workhouse or 
 be lodged with relatives or friends, or be boarded out, 
 or otherwise maintained as may be deemed most suit- 
 able .... thus, in respect of their lunacy, 
 pauper lunatics come under the jurisdiction of the 
 Commissioners in Lunacy, whilst in respect of their 
 pauperism they come under the jurisdiction of the 
 Local Government Board." 
 
 The county and borough asylums in which the 
 numerous class of pauper lunatics are for the most 
 part confined, are comparatively a recent creation. 
 Anterior to 1808, the only enactments affecting 
 pauper lunatics were the provisions of vagrant acts, 
 " authorising the detention of dangerous maniacs in 
 chains if necessary, rather with a view to the pro- 
 tection of the public than for their own benefit." 
 Then successive legislation left it to the option 
 of the justices as to whether they should provide 
 asylums or not, and it was not till 1845 that stipu- 
 lation was made, " rendering it incumbent upon the 
 justices of every county or borough, not already 
 provided with an asylum, to obtain one either sepa- 
 rately or jointly with other counties or boroughs." 
 From the seventh annual report of the Commissioners 
 in Lunacy issued in 1853, it appeared "that in 1852 
 
Chap. XXIV.] County and Borough Asylums. 511 
 
 there were still several counties unprovided with 
 asylums, and that there were only four boroughs 
 which separately possessed one." At the present 
 time, however, the expenditure of these institutions is 
 defrayed out of the county rates to be raised for the 
 purpose in the case of counties ; and in the case of 
 boroughs, either out of the borough rates or out of the 
 borough funds, as the council of each borough may 
 determine. Two or more asylums may be provided 
 for any county or borough where necessary, and a 
 separate committee of visitors appointed for each 
 asylum. The asylums are ostensibly provided by 
 each county or borough " for the pauper lunatics 
 thereof," the word lunatic bearing the old interpreta- 
 tion of " every person of unsound mind, and every 
 person being an idiot." The justices have the power 
 to appoint committees of visitors to manage the 
 asylums thus provided. " Such visitors may enter 
 into temporary contracts for sending pauper lunatics 
 into the asylums of other counties or boroughs, or into 
 registered hospitals or licensed houses, as well as for 
 receiving pauper and other lunatics of other counties 
 or boroughs into their own asylums, when there is 
 accommodation to spare." I may say here, however, 
 that the flux generally lies the other way : large 
 numbers of patients who have passed a considerable 
 time in licensed houses and hospitals, having to be 
 discharged when their slender resources are ex- 
 hausted, or in accordance with the regulations of 
 such institutions, to make way for those cases in 
 which there is greater prospect of cure. These and 
 similar cases find their way at last into county 
 asylums. Yet in many other cases, especially 
 those in which any undue social exaltation or 
 pride, or vanity, bear a part in the symptoms (and 
 such cases are by no means few in number), there are 
 doubtless many who reap a benefit from the change of 
 
512 Insanity and Allied Neuroses. [Chap. xxiv. 
 
 surroundings, and recover, tlieir recovery being, no 
 doubt, partly due to the wholesome change. 
 
 With regard to the management of such institu- 
 tions, " the committee of visitors are to make general 
 rules for the government of the asylum, with the 
 approval of the Secretary of State \ and subject to 
 such general rules they may from time to time make 
 orders and regulations for the management and con- 
 duct of the asylum, setting forth the number and 
 description of officers and servants to be kept, their 
 duties and salaries ; the diet of the patients ; the re- 
 servation of beds for certain cases ; and the exclusion 
 of persons afflicted with any contagious or infectious 
 disease, or coming from a district where any such 
 disease prevails." There must be a chaplain in priest's 
 orders licensed by the bishop of the diocese, a resident 
 medical officer who is in the majority of cases the 
 superintendent of the asylum, together with a clerk 
 and treasurer, and many other officers. Provision is 
 made for patients belonging to a religious persuasion 
 differing from that of the Established Church, who 
 may be visited by ministers of their own denomina- 
 tion. Strict regulations are made about the accounts, 
 which have to be submitted to the committee of 
 visitors, the Secretary of State, and the Lunacy Com- 
 missioners. Annual lists of all pauper lunatics through- 
 out the country have to be made out at the beginning 
 of each year, which lists, prepared by the clerks to the 
 guardians or overseers of parishes, must be forwarded 
 to the committee of visitors, to the justices of coun- 
 ties and boroughs, to the Commissioners in Lunacy, and 
 the Local Government Board. These asylums are 
 visited by the Commissioners in Lunacy once in every 
 year, thus it will be seen that the most elaborate scrutiny 
 is exercised over the details of their management. 
 
 With regard to the imode of adTnission to such 
 institutions, we have already Feen that the object of 
 
Chap. XXIV.] County AND Borough Asylums. 513 
 
 the statutes is to secure the reception into such 
 asylums of all those, and those only, who are fit sub- 
 jects for its treatment. " On becoming aware that 
 any pauper resident in his district is, or is deemed to 
 be, a lunatic, and a proper person to be sent to an 
 asylum, the medical officer is to give written notice 
 thereof within three days to the relieving officer ; or 
 if there be no relieving officer, to the overseers." 
 Again, '' on becoming aware that any pauper resident 
 in his parish is, or is deemed to be, a lunatic, the re- 
 lieving officer (irrespective of the question of his 
 insanity) is required to give notice to some justice of 
 the county or borough, who is thereupon to deal with 
 the case, unless the pauper cannot be conveniently 
 taken before a justice, in which case he may be 
 examinedj and the requisite order made by an offi- 
 ciating clergyman of the parish, in conjunction with 
 the relieving officer." Where there are no relieving 
 officers, these duties are discharged by the overseers. 
 The justice, upon examination of the alleged pauper 
 lunatic, or the certificate concerning him, or being 
 satisfied that he is " a proper person to be taken charge 
 of and detained under care and treatment," may 
 make an order for his reception ; and if certificates 
 are given jointly, by both the medical officer 
 called in by the justice, and the medical officer 
 of the parish or union, he is bound by the statute 
 without alternative to make such an order, accom- 
 panied with certain particulars, and "directing" the 
 superintendent of the asylum to receive the pauper as 
 a patient. The regulations in all matters concerning 
 the certificates are as stringent and almost identical 
 with those to which I have referred in the case of 
 private lunatics. 
 
 There are some other important regulations of the 
 Commissioners, applying for the most part equally to 
 licensed houses, to registered hospitals, and to county 
 H H — 14 
 
514 Insanity AND Allied Neuroses. [Chap. xxiv. 
 
 asylums, which I have reserved to consider in this 
 place. In the matter of a patient suffering ill-treatment 
 at the hands of any superintendent, officer, nurse, 
 attendant, servant, or other person, whether this be 
 owing to violence or neglect, such person is liable to 
 be fined ,£20, or be indicted for misdemeanour. Into 
 this subject we have already entered to a certain 
 extent when speaking of lunatics under the imme- 
 diate charge of their friends. Suffice it to say here, 
 that the regulations of the Commissioners are espe- 
 cially directed towards a prevention of the above. 
 One of their regulations is to the effect that the dis- 
 missal of any nurse or attendant for misconduct is 
 to be reported, together with the cause of it, within 
 one week. The object of this, they say, "is by 
 means of a central register available for general refer- 
 ence, to prevent improper persons from being em- 
 ployed in the care of the insane." 
 
 If any lunatic escape from the asylum or hospital in 
 which he is confined, notice is to be given to the Com- 
 missioners within three days, and if the house be 
 licensed by justices, to the visitors also. If retaken 
 within fourteen days he may be retained under the 
 original order and certificates, but not otherwise. If 
 the escape occur through the connivance of any officer 
 or servant, he will be liable to a penalty of £20. 
 Notice must also be given of the recapture. 
 
 On the recovery of any lunatic, if he be confined 
 in a licensed house or registered hospital, " notice 
 must be given to the person who signed the order of 
 admission, or by whom the last payment was made ; 
 and if the patient be not removed within fourteen days, 
 notice must then be given to the Commissioners, and 
 hi the case of a house licensed by justices, to the visi- 
 tors also. Any person may be discharged or removed, 
 whether recovered or not, by the order in writing of 
 the person who signed the order of admission ; . . . . 
 
Chap. XXIV.] County AND Borough Asylums. 515 
 
 but if the lunatic be dangerous, the consent of the 
 Commissioners or visitors must be obtained for his 
 discharge or removal, though he may be transferred to 
 some other establishment, under the control of an 
 attendant." In the case of a pauper lunatic having 
 recovered in a county asylum, the power to discharge 
 him rests with the visitors of the asylum, any three of 
 whom, or any two with the advice of the medical 
 officer, may direct such discharge. The visitors may 
 notify their intention to the overseers of the parish in 
 which the pauper is settled, or from which he was 
 sent, or to the relieving officer, in which case they 
 must see to his removal forthwith. Provision is also 
 made for delivering any pauper lunatic to his rela- 
 tives or friends, on their giving an undertaking to the 
 satisfaction of the visitors, "that he shall be no 
 longer chargeable to any union, parish, or county, and 
 shall be prevented from doing injury to himself and 
 others." There is also a charitable fund established to 
 meet the wants of such persons after they have been 
 discharged, and until they are able to resume their 
 ordinary labour. {See Thirteenth Report of the Com- 
 missioners, 1859.) 
 
 If it be thought that tem-porary absence from an 
 asylum would be desirable in reference to any patient, 
 this is provided for by the statutes in the case of 
 private patients by allowing them to " go to a speci- 
 fied place for a definite length of time, or to be out on 
 trial for a specified period." In the case of pauper 
 lunatics, " any two of the visitors, with the advice in 
 writing of the medical officer of the asylum, may per- 
 mit any patient to be absent from the asylum on trial, 
 for such period as he may think fit, making an allow- 
 ance to him, the amount whereof is to be charged and 
 paid as if he were in the asylum." But it must be 
 remembered, that " if any superintendent, officer, or 
 servant permit any patient to be at large, save in the 
 
5i6 Insanity and Allied Neuroses. [Chap. xxiv. 
 
 case of temporary absence cliilj authorised," lie will 
 liable to a penalty. 
 
 Provision is also made for the transfer of patients 
 from one asylum or hospital to another ; the proposal 
 must originate with those having authority to order 
 the discharge of the patient, and the consent of two of 
 the Commissioners must be obtained ; " fresh medical 
 certijficates need not be obtained, but copies of the 
 original order and certificates, together with the order 
 of removal and consent, must be given to the pro- 
 prietor or superintendent of the house or hospital to 
 which the patient is transferred." Where people have 
 to undertake the transfer of private patients, if de- 
 sired, persons may be generally found who are willing 
 to contract for the expense incurred, and undertake 
 the responsibility. In the case of pauper lunatics, the 
 visitors, being justices, " subject in certain cases to the 
 consent in writing of two of the Commissioners, may 
 address an order to any overseer, relieving officer, or 
 other person to effect the transfer." 
 
 Whenever the death of a patient occurs, in whatever 
 class of asylum, a certificate must be drawn up by the 
 medical officer, stating the cause of death, and men- 
 tioning the name of any attendant or relative present. 
 A copy of this must be sent to the Commissioners, to 
 the person who signed the order for admission, to the 
 registrar of deaths, and to the coroner ; and where 
 the house is licensed by justices, to the clerk of the 
 visitors. Suitable entries must also be made in the 
 books of the establishment, and particulars sent to the 
 coroner so that he may hold an inquest if necessary. 
 The expenses of the burial of pauper patients are 
 borne by the union, parish, or county to which the de- 
 ceased was chargeable. 
 
 With regard to the subject of pauper lunatics in 
 workhouses^ we have already seen that it is intended 
 that all such cases as are in any way suitable should 
 
Chap. XXIV.] County and Borough Asylums. 517 
 
 be sent to the county asylum ; and it is prohibited to 
 restrain any " dangerous lunatic, dangerous insane 
 person, or dangerous idiot," in a workhouse for more 
 than fourteen days, nor may he be retained when he 
 has been reported as such by the medical officer, or 
 when he requires "frequent or habitual restraint." 
 The preceding prohibition applies more especially 
 to the case of dangerous lunatics, but it does not 
 of course follow that all lunatics who are not 
 dangerous may be so retained. Nevertheless, it 
 certainly appears that where certain individuals are 
 not deemed suitable to be sent to an asylum, as, for 
 example, in the case of harmless idiots and others, 
 these persons may be legally detained in a workhouse 
 even against their will ; and in some workhouses, as is 
 known, there are even separate wards set apart for the 
 insane paupers. " The existence of such wards is not 
 unlawful, but it will be a question in every case how 
 far the lunatics maintained in them may be proper 
 persons to be sent to an asylum." Special legislation 
 upon this subject, I may say, exists in the metropolis, 
 into which, however, we cannot enter here. Pauper 
 lunatics who are not fit subjects to be sent to an 
 asylum, may also receive out-door relief, when in 
 charge of relatives or otherwise : they must be visited 
 quarterly by the medical officer. 
 
 In the case of private lunatics in county or 
 borough asylums, it is provided that where the 
 accommodation admits of it, the committee of visitors 
 may take means to admit upon payment a certain 
 number of lunatics, not paupers, who may be 
 " proper subjects to be admitted into a public 
 asylum." They may require " that no lunatic 
 shall be admitted without an undertaking by the 
 person signing the order for admission for the 
 due payment of the weekly charge for the lodging, 
 maintenance, medicine, clothing, and care of such 
 
5i8 Insanity AND Allied Neuroses. [Chap. xxiv. 
 
 lunatic during his continuance in the asylum, and of 
 the expenses of his burial in case he die therein, as 
 well as for his removal from the asylum within six 
 days after due notice given in writing by the super- 
 intendent of the asylum." Such lunatics " are to 
 have the same accommodation in all respects as the 
 paupers." There are provisions, however, in the 
 statutes relating to lunatics so circumstanced, which 
 tend to include them under similar regulations, and 
 to afford them similar privileges, when possible, to 
 those of private lunatics in registered hospitals and 
 licensed houses. 
 
 Wandering lunatics or lunatics found improperly 
 provided for, are not included in any of the foregoing 
 classes, yet there are certain provisions in respect to 
 them which must be duly observed. If such a lunatic 
 be found by any person he should give notice to a 
 constable, overseer, or relieving officer, and such 
 officer is bound to cause him to be taken before a 
 justice, who^ when it is made known to him (the 
 justice) "upon oath of any person whomsoever," that 
 any such person exists within the limits of his juris- 
 diction, must order him to be brought before him. 
 After calling to his aid a medical man, they may 
 make an order for his reception into any registered 
 hospital, asylum, or licensed house. The justice may 
 act upon his own knowledge in such a matter, he may 
 suspend the execution of his order for fourteen days 
 if necessary ; the medical man may also require the 
 order to be suspended. The lunatic, when he has 
 been sent to the asylum, becomes a pauper " as re- 
 gards his maintenance therein," and is dealt with as 
 such, until he is taken under the charge of his friends 
 and relations. The lunatic, however, may be given 
 up to his friends if they satisfy the justice (or the 
 visitors of the asylum., if he has been incarcerated 
 therein), that proper care will be taken of him. 
 
Chap. XXIV.] Criminal Lunatics. 519 
 
 Criminal lunatics. — Having previously referred 
 to the question of the legal responsibility of the insane, 
 I will now endeavour briefly to summarise the provi- 
 sions of the law with respect to criminal lunatics, 
 which consists of («) individuals certified to be insane 
 whilst awaiting trial for an offence ; (3) those acquitted 
 or reprieved on the ground of insanity ; (7) those felons 
 certified to have become insane whilst undergoing sen- 
 tences of penal servitude. There is another class, 
 consisting of those who were about to commit a crime, 
 but who were prevented from doing so, concerning 
 whom it is provided " that any person so apprehended 
 may be sent by two justices, acting with the advice of 
 a medical man, to the county asylum, if there be one; 
 and if not, to some hospital or licensed house, to be 
 there maintained at the charge of the parish of his 
 settlement, and if such parish cannot be ascertained, 
 at the charge of the coanty or borough where he was 
 apprehended." It being allowed, however, that the 
 property of criminal lunatics should be applied towards 
 their maintenance, I should presume from these pro- 
 visions that most lunatics of this description are likely 
 to come under the the class of '' wandering lunatics " 
 referred to in the preceding section, who may be pro- 
 vided for by their friends, or for whom the conditions 
 of their restraint may be arranged by these latter. 
 Substantially the provisions are the same, and if found 
 to be borne out by experience, I cannot see that the 
 above need be included in the class of criminal lunatics 
 as recognised by the law, although I notice that they 
 have been referred to under this head before. 
 
 In regard to this subject, Blackstone points out 
 " that if a man, who in his sound mind has com- 
 mitted an offence, becomes mad before arraignment, 
 he ought not to be arraigned ; if after he has pleaded, 
 and before trial, he ought not to be tried ; if after 
 trial and a verdict of guilty, but before judgment, 
 
520 Insanity and Allied Neuroses, ichap. xxiv. 
 
 judgment ouglit not to be pronounced ; and if after 
 judgment, execution ought to be stayed." This con- 
 cise statement of the obligations imposed upon the 
 law was, towards the beginning of the present century, 
 met with the following provision, which in the main, 
 T believe, holds at the present day ; " that if a person 
 charged with treason, murder, or felony (or any mis- 
 demeanour), be acquitted on the ground that he was 
 insane at the time of committing the offence, the jury 
 shall find specially to that effect ; and in any case, 
 and also where a person indicted for any offence, or 
 brought up to be discharged for want of prosecution, 
 is found to be insane either by the jury charged with 
 the indictment, or by a jury impanelled for the pur- 
 pose, the court is empowered to direct his confinement 
 until the Queen shall give order for his safe custody 
 during- her pleasure, in such place and in such manner 
 as to her Majesty may seem fit." 
 
 In this, however, there is no mention of any 
 special provision having been made for the accommo- 
 dation of insane criminals, and many persons of this 
 description, without doubt, were still kept in the 
 county gaols and houses of correction, instead of being- 
 placed in more suitable establishments. But in 1807 
 a select committee of the House of Commons was ap- 
 pointed to enquire into the condition of the criminal 
 and pauper lunatics throughout England and Wales, 
 and in their report they strongly recommended the 
 establishment of a central asylum. It was not till 
 1816 that arrangements were made, at the charge 
 of the government, for the provision of accommoda- 
 tion for sixty criminal lunatics in connection with 
 Bethlem Hospital, who, though dependent upon the 
 government for their maintenance, were under the 
 care of the governors of the hospital as to all other 
 matters. We gather from the reports of the Com- 
 missioners that, in time, the number of patients 
 
Chap. XXIV.] CrIMINA L L UNA TICS. 5 2 1 
 
 nearly doubled, and ultimately, in 1849, "an 
 agreement was entered into with the proprietor of 
 Fisherton House, near Salisbury, for the erection of a 
 detached ward for the same class." It was evident 
 that matters were now tending towards the establish- 
 ment of a separate asylum for criminal lunatics. At 
 length, in 1863, such an asylum was formally opened 
 at Broadmoor, near Wokingham, Berks, an establish- 
 ment which has been found, I believe, to answer the 
 purpose for which it was designed. This state asylum, 
 which includes also those who have been found insane 
 whilst undergoing sentences of penal servitude, or of 
 imprisonment, are visited by the Commissioners in 
 Lunacy, who report thereon to the Secretary of State, 
 with whom, I may say, rests the power of directing 
 the removal, temporary absence, or discharge of any 
 criminal lunatic confined therein. 
 
APPENDIX. 
 
 Forms of Ordek, Statement and Certificate, — Errors in 
 Certificates. — Form of Affidavit. — Hospitals for 
 THE Insane and Idiot Asylums. — Private Asylums. 
 
 Lunatics 1. 
 (16 & 17 Vict. 
 
 C. 9 !.) 
 
 private 
 patient. 
 
 N.B. — Tinder all circumstances, if possible, the " Order ^^ and 
 *^ Statement ^^ below to be filled up by the patienVs relatives. If 
 no relatives, by the nearest friend. 
 
 "OEDEE" FOE THE EECEPTIOI^ OF A PEIYATE 
 
 PATIENT. 
 
 (A) Within 
 one month 
 previiius to 
 the date of 
 the order. 
 
 (B) " Luna- 
 tip," or " an 
 idiot," or " a 
 person of un- 
 sound mind." 
 (CJ" Order" 
 must be 
 signi d,if pns- 
 sible.hy near- 
 est relative. 
 
 Sched. (A) No. 1, Sects. 4, 8. 
 
 jt^ the -imdersigned, hereby request you to receive [name of 
 
 patient in full) 
 
 ■whom I last saw at 
 
 on the (A) day of 188 
 
 a (B) as a patient in your Hospital. 
 
 Subjoined is a statement respecting the said {name of 
 patient in full) 
 
 Name, (C) 
 
 Occupation (if any) 
 
 Place of abode 
 
 Degree of relationship (if any) "^ 
 
 or other circumstances of con- > 
 
 nection with the patient .) 
 
 B.itttf this day of one thousand 
 
 eight hundred and 
 
 To the 
 
 Superintendent of 
 
Statement of Lunacy. 
 
 523 
 
 STATEMENT. 
 
 If ant Pakticvlars ix this Statemext be not Known, the 
 
 Fact to be so Stated. 
 
 iN'ame of patient, with Chj-istian name | 
 at length ..... 
 
 Sex and age ..... 
 
 Married, single, or widowed . 
 
 Condition of life, and previous occu 
 pation (if any) .... 
 
 Eeligious persuasion, as far as known 
 
 Previous place of abode. 
 
 Whether first attack 
 
 Age (if known) on first attack 
 
 WHEN and WHERE previously under | 
 care and treatment . . . . / 
 
 Duration of existing attack . 
 
 Supposed cause .... 
 
 Whether subject to epilepsy . 
 
 Whether suicidal .... 
 
 Whether dangerous to others 
 
 Whether found lunatic by inquisition, ") 
 and date of commission or order for > 
 inquisition . . . . . j 
 
 Special circumstances (if any) prevent- 
 ing the patient being examined, be- 
 fore admission, separately by two 
 medical practitioners .... 
 
 Name and addi'ess of relative to whom 
 notice of death to be sent . 
 
 Name, (E) 
 
 Occupation (if any) 
 
 Place of abode 
 
 Degree of relationship (if any), 
 or other circumstances of con- 
 nection with the patient . 
 
 8 & 9 YICT., Cap. 100, Sec. XLV. 
 
 Dates must 
 te inserted. 
 
 N.B. — Medical certificates of patient's examination, and the 
 signatures, are required by the above statute to be dated 
 within seven clear days of the patient's reception. In 
 stating the residence the number of the house must be 
 specified, when there is any, and if not, the name of the 
 occupier. 
 
 (E) The 
 "Statement" 
 must be 
 signed, but 
 " whei-e the 
 PC'sun sign- 
 ing the state- 
 ment is not 
 the person 
 who signs r he 
 order, the fol- 
 lowing parti- 
 culars con- 
 cerning the 
 person sign- 
 ing the state- 
 ment are to 
 be added." 
 
524 Insanity AND Allied Neuroses. 
 
 The medical men signing the certificates must not he in 
 partnership, nor one an assistant of the other ; and they 
 must use the terms specified in the statute, for which see 
 the notes of reference helow. 
 
 By Order of the Commissioners in Lunacy. 
 
 1. — It is ahsolutely necessary that the medical men should 
 write their certificates legihly, so as to afford the oppor- 
 tunity of an exact copy heing made. 
 
 2. — " All alterations in the original certificates, unless hy the 
 certifying medical men, invalidate them ; and the initials of 
 the latter must he placed to every change or addition 
 made." 
 
 3. — " If a registered medical man descrihes himself as * a duly 
 qualified registered practitioner,' it is not necessary that 
 he should specify his medical qualifications in full, in 
 addition." 
 
 The following exhibits the relative frequency of mistakes in 
 certificates per cent. : 
 
 The most common mistake is the omission of the name of 
 the person who has communicated the facts ; the next most 
 common is the omission of the occupation of the patient, and 
 next the omission of the address in full. Notwithstanding the 
 directions given in the margin, many certificates are written 
 with *' general practitioner" in place of physician, surgeon, or 
 apothecary. 
 
 In nine per cent, alterations had to he made in the facta 
 observed hy the medical man, things heing placed under this 
 head which could not have been observed, or else unimpor- 
 
 (A) Here set tant facts recorded which might have depended on passion or 
 
 Sfl^adon ^i^kj and not on insanity. 
 
 entitling .he 
 
 person certi- 
 
 tfielsa^phy-' MEDICAL CEETIFICATE.— Sched. (A) No. 2 
 
 sician, sur- 
 
 geon orapo- Sects. 4, 5, 8, 10, 11, 12, 13. 
 
 thecary, ex. j j » > 7 j 
 
 quaii'fled re- ^^ the undersigned 
 
 practitioner" being a (A) duly qualified registei-ed practitioner [1]. 
 
 sufficient. ^"^^ being in actual practice as a (B) [15]- 
 
 (B)"Physi- hereby certify that I, on the day of 18 
 
 SGon*'ot^^' at (C) Here insert the street and NUMBER of house {if any). 
 
Medical Certificate. 525 
 
 OR NAME IN FULL OF OCCUPANT "apothe- 
 
 (C) [21] in the county of "^l/^i.'^l 
 
 separately from any other medical practitioner personally " General 
 
 examined. of (D) State full address and^fy^^^x^^ 
 
 OCCUPATION {if amj), (D) [22] and that (^C). Here in- 
 
 the said is a (E) [6] street, and 
 
 and a proper person to be taken charge of and detained under "heh'ouse^if 
 care and treatment, and that I have formed this opinion upon any), or other 
 the following grounds, viz. : lars.^N.B.-if 
 
 DO street nor 
 
 1. Facts indicating insanity observed hy myself. (F) Some hous-, state 
 <fe/mfe FACT or FACTS must he specified ofocrapint 
 
 (D)A'.B.of 
 
 TQ-i insert full 
 
 L*'J address and 
 
 occupation 
 
 2. Other facts (if any) indicating insanity communicated (if any). 
 
 to me by others (G) (State the NAME IN FULL of the tf,'''o^T" 
 
 person giving the information) •■ ^*^^°*'" S^of 
 
 unsound 
 rrt/?n mind." 
 L*aOj CF) Here in- 
 sert the facts. 
 a;<vn.>vv Some definite 
 Slgncn, fact or facts 
 -vr„™» mustbespe 
 
 •^^^™6 cifled 
 
 Place of abode pieaseto 
 
 write the 
 facts legibly, 
 
 BatCtf this day of one thousand ^'^^g"ff*p^o® si. 
 
 eight hundred and ^le 
 
 ° C4) Here state 
 
 the inforraa- 
 
 tionandiaame 
 
 — in full from 
 
 whom re- 
 ceived. 
 
 FORM OF AFFIDAVIT IN CASES OF INQUISITION. 
 
 This should he a concise statement of all you know of the case 
 indicating insanity, put in distinct paragraphs. 
 
 1. I, A. B. (here state (1) medical qualification ; (2) special 
 qualifications for understanding insanity) 
 
 2. Having had the following opportunities for observing 
 X. Y., am of opinion that he is of unsound mind. 
 
 3. For months his conduct has been 
 
 4. His memory has been defective. 
 
 5. He has the following delusions 
 
 6. In my opinion he is unfit to manage himself and his 
 affairs. 
 
 7. An d is not likely to recover for a considerable time, if 
 at all. 
 
526 Insanity AND Allied Neuroses. 
 
 Ordtnary Form for Case Taking. 
 
 Date of admission 
 
 Name Age 
 
 Condition Occupation 
 
 Heredity. (1) Nervous (2) General... 
 
 Supposed causes 
 
 Habits of life 
 
 No. of attack Duration 
 
 Earliest symptoms and mode of development 
 
 State of digestive functions 
 
 Appetite 
 
 Bowels 
 
 Eelated delusions , 
 
 State of reproductive organs 
 
 Sense organs. Eyes Ears 
 
 Senses, sigM 
 
 „ hearing 
 
 ,, taste and smell 
 
 „ common seuvsibility 
 
 Delusions 
 
 „ melancholic 
 
 „ of exaltation 
 
 Suicidal tendency Homicidal tendency . 
 
 Memory of (1) recent ..(2) distant events. 
 
 Reaction to questions 
 
 Sleep Dreams 
 
 Muscular condition 
 
 „ walk •.... 
 
 „ reflexes 
 
 Body weiglit 
 
 Condition of other viscera 
 
 Hand- writing 
 
Hospitals FOR the Insane, etc. 527 
 
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INDEX. 
 
 Absinthe, Effects of, 425 
 
 Accident^s a cause of general para- 
 lysis, 283 
 
 of insanity, 66 
 
 Accusations, False, 261 
 
 , Self-, 471 
 
 Adhesion of membranes in general 
 paralysis, 347 
 
 Affidavit, Form of. (See Appendix). 
 
 Age, Influence of, in causing in- 
 sanity, 25 
 
 -, Old, as cause of insanity, 76 
 
 Alcobolism and general paralysis, 
 279, 339, 420, 425 
 
 as cause of dementia, 217 
 
 of general paralysis, 283 
 
 of insanity, 56, 420 
 
 , Chronic, 425 
 
 iu connection with, the ad- 
 mission of patients into work- 
 houses, 504 
 
 in connection with the signing 
 
 of certificates, 502 
 , Restraint in connection with, 
 
 603, 504 
 , Self-restraint in connection 
 
 with, 465, 466 
 Allbutt, Dr. Ciitford : alternation 
 
 of neuroses, 403 
 Alleged lunatics, Proceedings in 
 
 respect to, 513 
 Allied states to insanity, 38 
 Alternation between asthma and 
 
 insanity, 400 
 between gout and insanity, 433 
 
 between headache aud in- 
 sanity, 403 
 
 between phthisis and insanity, 
 
 399 
 
 Ambition, Foolish, as cause of in- 
 sanity, 48 
 
 Amnsesia, Testamentary capacity 
 with, 476 
 
 Anaasthesia in general paralysis, 
 231, 291 
 
 Annoyance, Complaints of, 259 
 Anxieties, Business, 46 
 
 cause of general paralysis, 283 
 
 , Domestic, 44 
 
 , mental over-worl^ 48 
 
 Aortic disease and insanity, 405 
 Aphasia, Testamentary capacity 
 
 with, 475 
 Apoplexy and testamentary capa- 
 city. 475 
 
 , Hallucinations preceding, 239 
 
 , Insanity following, 351 
 
 , Senile, with mania, 352 
 
 , varieties, 351 
 
 Aptitudes in moral imbeciles, 275 
 
 , Special, 7 
 
 Arterial disease, 392 
 
 , Syphilitic, and insanity, 
 
 392 
 Aspect of insane, 42 
 Assault, Criminal, 473 
 Asthma and insanity, 126, 400 
 
 , cases, 401 
 
 Asylums, when necessary, 477 
 
 Atavism, 30 
 
 Ataxic gait in general paralysis, 
 
 285, 318 
 Atrtxy and insanity, 359 
 
 , Cases of, 859 
 
 : Dr. Bristowe, 357 
 
 : Dr. Mnhomed, 358 
 
 Autobiographical sketch by a sub- 
 ject of hallucinations, 244 
 
 of melancholia, 185 
 
 of prrsecution, 257 
 
 of puerperal insanity, 378 
 
 Ball, Professor : paralysis agitans 
 
 and insanity, 353 
 Beach, Fletcher : hypertrophic 
 
 idiocy, 454 
 
 : sporadic cretinism, 443 
 
 Bes-gars, Insanity rare in, 35 
 Belladonna, Delirium of, followed 
 
 by insanity, 345 
 
534 
 
 Insanity and Allied Neuroses. 
 
 Benevolence in general paralysis, 
 
 338 
 Betlilem hospital. Criminal lu- 
 natics confined in, 520 
 Blackstone : exposition of law con- 
 cerning criminal lunatics, 519 
 Blandford, Dr. : the signing of 
 
 certificates, 501 
 Boarders in hospitals, 498 
 Borrow, George : the unpardon- 
 able sin (" Lavengro"), 195 
 Brain concussion and idiocy, 453 
 
 fever, 91 
 
 hypochondriasis, 133 
 
 tumour with iu sanity, 389 
 
 Bright's disease. Insanity with, 408 
 
 , Suicide from, 210 
 
 , "Worry as cause of, 45 
 
 Broadmoor asylum for criminal 
 
 lunatics, 521 
 Bruising in general paralysis, 294, 
 
 333 
 Bucknill, Dr., on heredity, 37 
 Burial of pauper lunatics, 517 
 
 Cachexia, Syphilitic, and insanity, 
 392 
 
 , , , Description of ,392 
 
 Campbell, Lord : chai-ge to jury 
 concerning restraint, 493 
 
 Case-book, Medical entries to be 
 made in, and provisions re- 
 specting, 509 
 
 Catalepsy, 181 
 
 Causation, Definition of, 16 
 
 of general paralysis, 281 
 
 of mania, 113 
 
 Causes, Complex, 17 
 
 Exciting (moral) : 
 
 domestic, 44 
 
 fright, 55 
 
 grief, 45 
 
 mental anxiety, 48 
 
 money troubles, 46 
 
 over-work, 49 
 
 religion, 60 
 
 (physical) : 
 
 accident, 68 
 
 climacteric, 73 
 
 congenital defects. 
 
 78 
 
 fevers, 74 
 
 intemperance, 56 
 
 mastiirbation, 63 
 
 old age, IQ 
 
 over-exertion, 64 
 
 pregnancy, 67 
 
 privation, 76 
 
 puberty, 72 
 
 Causes, Exciting (physical) : 
 
 , sexual excess, 59 
 
 , sunstroke, 65 
 
 , unknown, 79 
 
 , uterine and ovarian, 
 
 71 
 
 , venereal disease, 50 
 
 , Physical, psychical (moral), 
 
 17 
 
 , Fredisposinsr, general, 18 
 
 ■ , , , age, 25 
 
 , , , education, 21 
 
 , , , race, 19 
 
 , , , sex, 23 
 
 , , hereditary constitution, 
 
 41 
 
 , , neurotic tendency, 28 
 
 , , occupation, 32 
 
 , , Special, 37 
 
 , , , constitution, 41 
 
 ■ , , , neurotic tendency, 
 
 28 
 
 Celts, Earity of general paralysis 
 in, 19 
 
 Certificates, medical. Alcoholism 
 in connection with, 503 
 
 , , by whom to be signed, 
 
 499 
 
 , , for how long valid, 499 
 
 , , Hints to medical men as 
 
 to drawing up, £02 
 
 , , if defective how to be 
 
 remedied, 501 
 
 , , in Chancery cases, 488 
 
 , , in connection with hos- 
 pitals and licensed houses, 499 
 
 , , objecting of commis- 
 sioners, 501 
 
 , , Penalties respecting, 
 
 600 
 
 , , Proceedings of commis- 
 sioners in reference to, 501 
 
 , , provisions relating to 
 
 such persons, 499 
 
 , , rules to be observed, 502 
 
 , , separate examination 
 
 necessary, 500 
 
 . , , Strategy undesirable in 
 
 respect to, 502 
 
 • , , Strict provisions con- 
 cerning, 601 
 
 , , to be forwarded to Com- 
 missioners, 500, 501 
 
 , , Treatment without, 477 
 
 , , two required, 499 
 
 of death to be forwarded to 
 
 Commissioners, 616 
 
 Chancery lunatics, Provisions con- 
 cerning, 488, et seq. 
 
Index. 
 
 535 
 
 Chart, Temperature, in man' a, 98 
 Childless women, General para- 
 lysis in, 303 
 Chloral crave, 429 
 
 habit, 428 
 
 , Suicidal tendencies due to,429 
 
 Chorea and insanity, 391 
 Chronic insanity. 225 
 Classificatiou of insanity, 10 
 
 of lunatics. (See Lunatics.) 
 
 , Provisional, 12 
 
 , Scheme of, 11 
 
 Climacteric, 73, 200 
 Clouston,Dr.,on delirium tremens, 
 
 604 
 Collateral inheritance, 82 
 Commission in lunacv, 488 
 
 , Costs of, 490 
 
 , Description of, 489 
 
 , Medical certificates in 
 
 connection with, 489 
 
 , nature of verdict, 489 
 
 , Notice of to be sent to 
 
 alleged lunatics, 490 
 , proceedings after cus- 
 tody of person, 490 
 
 . , where desirable to be 
 
 held, 492 
 Commissioners in Lunacy, 485 
 , documents to be for- 
 warded for their inspection, 509 
 
 , Duties of, 487, et seq^. 
 
 , history of appointment 
 
 of, 486 
 
 , Jurisdiction of, ^ 
 
 , objects of their visita- 
 tion, etc., etc., 507, 508. (See 
 chapter xxiv., page 483.) 
 
 , proceedings in reference 
 
 to certificates, 501 
 
 , their power of granting 
 
 licenses, 496 
 
 . , their power of prose- 
 
 cutiog for non-observance of 
 regulations, 500 
 
 , their regulations con- 
 
 cerniag the management of 
 asylums, 501 
 
 , their visitation of 
 
 county asylums, 512 
 , their visitation of regis- 
 tered hospitals and licensed 
 houses, 503 
 
 , Metropolitan, 486 
 
 " Committees," persons appointed 
 to take charge of Chancery 
 patients, 4£0 
 Confidence, Loss of, in dementia, 
 211 
 
 Conium in recurrent mania, 233 
 
 Continence, Effects of, 55 
 
 Convulsions cause of idiocy, 446 
 
 in general paralysis, 289, 334 
 
 Costs of commission in lunacy, 490 
 
 County asylums, 510 
 
 , Administration of, 511, 
 
 et seq, 
 
 (-Foi- /wrtfier particulars see Places 
 of confinement for the insane. ) 
 
 Court of Appeal, 484 
 
 Cravings for drink, 427 
 
 for opium and morphia, 430 
 
 • of pregnancy, 67 
 
 Cretinism, 456 
 
 , Sporadic, 443 
 
 Crime and insanity, 8 
 
 in connection with al- 
 coholism, 465 
 
 in connection with forms 
 
 of disease, 43, et seq. 
 
 in connection with re- 
 straint of lunatics, 520 
 
 in connection with self- 
 indulgence, 465, 466 
 
 in connection with self- 
 restraint, 465. 469 
 
 , proceedings in regard to 
 
 those prevented from commit- 
 ting-, 519 
 Criminal lunatics, Places of con- 
 finement for, 519 
 
 , Provisions concerning, 
 
 520 
 
 , their various classes, 519 
 
 Cure in mania, 119 
 
 Dahl, Ludwig, on idiot descent,440 
 Death of patients, Provisions of 
 
 Commissioners on, 516 
 Defects, congenital. Effect of, 78 
 
 , Some bodily, 79 
 
 Degeneration, Neurosis from, 31 
 Delirium of belladonna followed 
 
 by insanity, 435 
 
 tremens and insanity, 422 
 
 , Nece-sity of restraint 
 
 for persons suffering tinder, 503 
 Delivery, Insanity of, 370 
 Delusional insanity, 237 
 Delusions, medico-legal relations, 
 
 464 
 Denientia,Acute, and melancholia; 
 
 , primary, 210 
 
 , Alcoholic, 217 
 
 and amentia, 207 
 
 , Degrees of, 207 
 
 , Diagnosis of, 220 
 
536 Insanity and Allied Neuroses. 
 
 Dementia, Epilepsy and, 218 
 
 from physical or mental 
 
 disease, 216 
 
 , Hypochondriacal, 235 
 
 , Nature . f , 207 
 
 of general paralysis, 289, 295, 
 
 312 
 
 , Partial, 211 
 
 , Post apoplectic, 351 
 
 , , Diagnosis of, from 
 
 general paralysis, 841 
 
 —^, Primary and secondary, 208 
 
 , seC' 'ndary and cliroxiic, Varie- 
 ties and cases of, 225 
 
 , SypMlitic, 217, 393 
 
 -^, Treatment of, 220 
 
 , Typical, 209 
 
 , with outburst of mania, 225 
 
 Depression before mania, 114 
 
 Deprivation, Idiocy by, 455 
 
 Diai'etes and insanity, 411 
 
 Dickinson, Dr., on diabetes, 411 
 
 Dipsomania, 37, 427 
 
 Dirt, Feeling of, 249 
 
 Disseminated sclea osis and general 
 paralysis, 3i2 
 
 and insanity, 390 
 
 Double consciousness in epilepsy, 
 385 
 
 form of insanity in general 
 
 paralysis, 325 
 
 Down, Dr. Langdon : intemper- 
 ance in parents, 441 
 
 , : types i f idiocy, 487 
 
 Dysentery, Hypochondriasis fol- 
 lowing, 149 
 
 Eccentricity, 3 
 
 , Varieties of, 4 
 
 Eclampsic idiocy, 446 
 
 Edmunds, Dr. : optic nerves in 
 general paralysis, 328 
 
 Education as cause of insanity, 21 
 
 , Bad, 22 
 
 in epilepsy, 389, 481 
 
 iu neurotic children, 480 
 
 Ego, Feeling of, 129 
 
 in melancholia, 156 
 
 Emoti'nal disturbance in general 
 paralysis, 337 
 
 jSpi'epsie larvee, 385 
 
 , cases, 387 
 
 Epilepsy, 124 
 
 and dementia, 218, 383 
 
 and epileptic mania, 384 
 
 , Diagnosis from general para- 
 lysis, 342 
 
 , Effect of fits of, 383 
 
 , Idiocy from, 4i6 
 
 Epilerisy related to insanity, 382 
 
 , Syphilitic, 392 
 
 , Treatment of, 388 
 
 Epileptic idiots, 446 
 Epileptics, Bnitality of, 383 
 
 , Intractability of, 448 
 
 , Prognosis of, bad, 448 
 
 Escape of lunatics, 514 
 
 , Provisions concerning, 
 
 514 
 Exaltation of ideas. Growth, of, 
 
 263 
 
 in delusional insanity, 262 
 
 in general paralysis, 338 
 
 Excess, Sexual, 59 
 
 Excitement, religious, Effect of, 50 
 
 Exophthalmic goitre and insanity, 
 
 412 
 with general paralysis, 
 
 415 
 with recurrent mania, 415 
 
 je. Dr. Hilton : sporadic cre- 
 tinism, 443 
 
 Farmers, Insanity in, .33 
 
 Feeding in melancholia, 142 
 
 Fevers as cause of insanity, 74 
 
 , Delirium of, 75 
 
 , Dementia of, 216 
 
 , Post-febrile, 435 
 
 Fisherton House, near Salisbiiry, 
 for criminal lunatics, 521 
 
 Fits in general paralysis, 292 
 
 , Varieties of, 293, 334 
 
 Folie a deux, 472 
 
 circulaire, 122 
 
 Food, Eefusal of, 141, 153, 171 
 
 Fright as cause ot insanity, 55 
 
 , Case of, 55 
 
 Galvanism, Ideas of, 244 
 Gasquet, Dr. : case of dissemi- 
 nated multiple sclerosis and in- 
 saaiity, 390 
 Gen ral paralysis, Acute, 297 
 
 , Ataxic, 317 
 
 , Causation of, 281 
 
 , Chronic, 298 
 
 , Convulsions in, 334 
 
 , Den rented, 295, 312 
 
 , J i gnosis of, 339 
 
 , Double form of, 325 
 
 ' , Dr. Maudsley on pro- 
 gressive degeneration in, 279 
 
 , Dr. JVlicMe on, 278 
 
 , effects on oiispring, 41 
 
 , First stage of, 290 
 
 — '■ from over-strain, 65 
 
 , Hypochondriacal, 295 
 
Index, 
 
 537 
 
 General paralysis. Ideas of grand- 
 eur in, 338 
 
 , Initial symptoms of, 288 
 
 in a single girl, 306, 308 
 
 in w( iman, 302 
 
 , lateral sclerosis, exam- 
 ples of, 318, 320 
 
 ,Loss of self-controlin, 337 
 
 , Maniacal stage of, 123 
 
 not an ordinary netirosis, 
 
 41 
 
 , Ordinary case of, 299 
 
 , Pathology of, 345 
 
 , Physical basis of, 376 
 
 , Prodromata of, 386 
 
 , Prognosis of, 3J3 
 
 , Eemission of, 304, 321 
 
 , Second stage of, 292 
 
 , Senile, 311 
 
 ■ , Speech in, 329 
 
 , Spinal, 316 
 
 • •, Stages of, 289, 388 
 
 , Symptoms in detail of, 
 
 007 
 
 , Syphilitic, 395 
 
 , Temperature in, 336 
 
 , Third st;ige of, 294 
 
 , Treatment of, 34i 
 
 - — , Tremor in, 329 
 
 , Urine in, 337 
 
 , Varieties of, 278, 284 
 
 , with exophthalmos, 415 
 
 , with little tremor, 315 
 
 , with pregnancy, 369 
 
 , without mental symiD- 
 
 toms, 277, 280 
 
 , Writing in, 330 
 
 Genetous idiocy, 442 
 
 , altered race-type of, Dr. 
 
 Down on, 443 
 Genius and insanity, 5, 275 
 
 , Varieties of, 5 
 
 Girl, General paralysis in young, 
 
 306, 308 
 Glycosuria in insanity, 411 
 
 , Cases of, 412 
 
 Goitre, 412, 415, 4*6, 457 
 Goulds tone. Case of, 471 
 Gout and insanity, 433 
 
 and melancholia, 206 
 
 Governesses, Insanity in, 34, 49 
 Gowers, Dr., on chorea, 391 
 Grandeur, Ideas of, in general 
 
 paralysis, 338 
 Graves's disease and insanity, 412 
 Grief as cause of insanity, 45 
 
 , Action of, 45 
 
 Gummata producing insanity, 392, 
 
 394 
 
 Hsematomata in general paralysis, 
 
 333 
 Hsemoi-rhage into spine in genera] 
 
 paralysis, 304 
 Hallucinations, Case of acute, 242 
 
 in delusional insanity, 238 
 
 in general paralysis, 290 
 
 in mania, 102 
 
 of feeling, 24i 
 
 of hearinar, Varieties of^ 240 
 
 of sight, 212 
 
 of suiell and taste, 243 
 
 Hand-writing in general paralysis, 
 
 332 
 Hearing in general paralysis, 328 
 Heart disease and insanity, 404 
 
 and melancholia, 206 
 
 , Aortic, exaltation or 
 
 melanchoha. 406 
 , Mitral, and melancholia, 
 
 405 
 Heredity as cause of insanity, 37 
 Heron, Dr. : case of youthful 
 
 melancliolia, 28 
 " Hints," Danger of, 193 
 Histological changes, Unsatisfac- 
 
 to y, 9 
 Holy Ghost, Sin against the, 195 
 Home treatment, 480 
 , Directions concerning, 
 
 481 
 
 , where desirable, 480 
 
 Homicide, 487 
 
 , impulses in delusional cases, 
 
 468 
 
 owing to " influence," 468 
 
 owing to weak-minded- 
 ness, 468 
 Hospitals, Eegistered, 497 
 
 . (Spb Appendix,) 
 
 House of Commons : inquiry into 
 
 condition of pauper and criminal 
 
 lunatics, 520 
 Hunter v. Hunter : nullity of 
 
 marriage, 360 
 Huth, Mr., on consanguineous 
 
 marriages, 440 
 Hydrocephalic idiocy, 249 
 Hydrocephalus with insanity, 449 
 Hypergesthesia and general para- 
 lysis, 291 
 Hypertrophic idiocv, 454 
 Hypochondria' -al dementia, 235 
 Hypochondr asis, 128 
 
 , Brain, 133 
 
 , , Case of, 134 
 
 , form of general paralysis, 295 
 
 , ga-^tric. Varieties of, 137 
 
 , Prognosis of, 133 
 
538 
 
 Insanity and Allied Neuroses. 
 
 Hypochondriasis rare in women, 
 
 149 
 
 , Eesults of. 133 
 
 • , Sexual, 145 
 
 • , , Case of, 146 
 
 stage of general paralysis, 
 
 285, 288 
 
 . Symptoms of, 132 
 
 , Treatment of. 144 
 
 , Varieties of, 131 
 
 , SypMlitic, 392 
 
 Hysteria, 80 
 
 , alternation with, insanity, 82 
 
 , insane families, 81 
 
 , massage, treatment by, 90 
 
 rare in asylums, 81 
 
 , Treatment of, 85 
 
 with sense perversion, 83 
 
 Hysterical mania and melan- 
 
 cbolia, 95 
 Hystero-epilepsy, 86 
 , Cases of, 88 
 
 Idiocy, 437 
 
 ■ by deprivation, 455 
 
 , Classification of, 438 
 
 ■ , cretinism, 456 
 
 , Eclampsic, 4i6 
 
 ■ , Epileptic, 446 
 
 , Genetous, 442 
 
 , Hydrocephalic, 449 
 
 , Inflammatory, 454 
 
 , Microcephalic, 444 
 
 , neurotic inheritance, 439 
 
 - — -, Paralytic, 452 
 
 — — , sporadic cretinism, 443 
 
 , Traumatic, 453 
 
 Idiot savant, 438 
 
 , Acute insanity in, 459 
 
 Imagination in mania, 106 
 
 Imbeciles, 437 
 
 Imbecility, 454, 459 
 
 Impotence, Ideas of, 145 
 
 Impulse in epilepsy, 383 
 
 , medico-legal aspect of, 463, 
 
 464 
 Incoherence in mania, 109 
 
 , Case of chronic, 226 
 
 , Chronic, 120 
 
 Indians, Insanity in, 20 
 
 Infanticide, 470 
 
 owing to ignorance of birth, 
 
 470 
 owing to puerperal insanity, 
 
 470, 471 
 Inflammatory idiocy, 453 
 Influence, Undue, in wills, 474 
 Inheritance, Direct, 29 
 - — , Neurotic, 28 
 
 Inheritance, Drink-craving, 424 
 
 Injunction of Lord Chancellor, 
 492 
 
 Injuries cause of general paralysis, 
 282 
 
 , mode of action, 67 
 
 to head as causes of insanity 
 
 in parent or child, 40, QQ 
 
 Inquisition, Description of, 484 
 
 , traverse of within three 
 
 months, 490 
 
 Inquisitiveness as symptom of in- 
 sanity, 256 
 
 Insanity, alternating with hys- 
 teria, 82 
 
 , Definition of, 1 
 
 of development, adolescence, 
 
 maturity, decay, 14 
 
 , Relativity of,- 2 
 
 Intemperance, alcohol as cause of 
 insanity, 56 
 
 in parent as cause of idiocy 
 
 in children, 441 
 
 , modes of action as cause, 57 
 
 Ireland, Dr., on idiocy, 437 
 
 , on treatment, 444, 446, 419, 
 
 452, 456, 458, 459 
 
 Jealousy, Case of, 264 
 
 due to drink, 427 
 
 in delus.onal icrsanity, 263 
 
 Jury, verdict in commission in 
 lunacy, 489 
 
 Kidney, Disease of, and insanity, 
 407 
 
 , no special form of in- 
 sanity depending on, 408 
 
 , suicide, 410 
 
 Kleptomania, 271, 466 
 
 from drink, 427 
 
 Lactation, Insanity of, 379 
 
 , cause, symptoms, examples, 
 
 prognosis, 380 
 
 Lateral sclerosis in general para- 
 lysis, 319 
 
 , case, man, 319 
 
 , , woman, 320 
 
 "Lavenaro," 195 
 
 Lawford, optic nerves in general 
 paralysis, 328 
 
 Lead poisoning and general para- 
 lysis, 340 
 
 , Insanity due to, 431 
 
 , mania, epilepsy, general 
 
 paralysis, 432 
 
 Legal responsibility, 460 
 
Index. 
 
 539 
 
 Legal responsibility in connection 
 
 vvitli delusion, 463 
 ■ , main provisions of law 
 
 witli respect to, 462 
 ■ , Reference to question of, 
 
 460 ei seq. 
 , relationship with prin- 
 ciples of criminal law, 460 
 , suggestions concerning 
 
 medical side of question, 462, 
 
 463 
 , where defective know- 
 ledge of right and wrong, 462 
 Letter describiug hallucinations, 
 
 255 
 
 of melancholiac, 157 
 
 Letters of lunatics to be retained 
 
 for inspection if not forwarded, 
 
 509 
 Lips, Tremor of, in general 
 
 paralysis, 329 
 Lochia in inierperal insanity, 355 
 Locomotor ataxy and general 
 
 paralysis, 285, 318 
 Lord Chancellor, Functions of, 484 
 ■ .management of Chancery 
 
 patients, 488 
 Love as cause of insanity, 54 
 Lunatics, burial of, 516 
 
 , Cijaucery, 488 
 
 , Crimes committed by, 467 et 
 
 seq., 519, 520 
 
 ■ , Criminal, 537 
 
 , Dangerous, 517 
 
 , Death of, 516 
 
 , Escape of, 514 
 
 , Home treatment of, 477 
 
 , ni-treatment of, 493 
 
 , , cases in point, 493, 
 
 494 
 
 ■ in worthouses, 516 
 
 , Marriage of, 483 
 
 , Pauper, 509 
 
 , Piivate, 488 
 
 , Recovery of, 514 
 
 ■ , Eettirn to occupation of, 
 
 482 
 
 , Self-restraint of, 465 
 
 , Superintendence of, by state, 
 
 484 
 
 • , Temporary abseaace of, 515 
 
 , Testamentary capacity of, 473 
 
 , Transfer of, 516 
 
 ■ , treatment without certifi- 
 cates, 480 
 
 , Visitation of, 506 
 
 , Wandering, 518 
 
 , what persons desirable to 
 
 make Chancery lunatics, 491 
 
 Lunatics with relations or friends, 
 
 493 
 {For further particulars see Places 
 
 of confinem.ent for the insane) 
 Lust in early general paralysis, 288 
 Luxmore, Charles, case of, 493 
 
 Magnetism, Ideas of, 244 
 
 Malleation, 89 
 
 Mania, Acute, 91 
 
 , , Conditions of, 99 
 
 , , Varieties of. 111 
 
 , bodily symptoms, 100 
 
 , causation, 113 
 
 , Chronic, 224 
 
 , , and general paralysis, 
 
 340 
 
 , Delirious, 93 
 
 , Descrii3tion of, 92 
 
 , diagnosis, 98 
 
 , duration, 115 
 
 , Epilepsy and, 124 
 
 following apoplexy, 352 
 
 , Case of, 355 
 
 , Hysterical, 91 
 
 , lead poisoning, 432 
 
 , mental symptoms, 101 
 
 , pathology, 126 
 
 , prognosis, 117 
 
 , Puerperal, 360 
 
 — — stage of folie circulaire, 122 
 
 , stages, 114 
 
 , Transitopia-puerperal, 371 
 
 , Treatment of, 97 
 
 Marriage among insane, 483 
 
 and insanity, 25 
 
 , Consanguineous, 440 
 
 , Insanity due to, 361 
 
 , following, 360 
 
 , Nullity of, 361 
 
 Massage, 90 
 
 Masters in Liinacy, 484 
 
 IMastnrbation, 63, 145 
 
 Maturity, Insanity of, 27 
 
 Maudsley : borderland of in- 
 sanity, 7 
 
 : diabetes and insanity, 411 
 
 : epilepsy, 385 
 
 on general paralysis, 279 
 
 Melancholia, Active, 175 
 
 , , Chronic, 176 
 
 , autobiography of patieat, 
 
 185 
 
 , catalejjsy, 181 
 
 , Chronic, 203 
 
 , Conditions of, 151 
 
 , Course of simple, 168 
 
 , Delinitioii of, 151 
 
 , Divisions of, 152 
 
54<^ 
 
 Insanity and Allied Neuroses. 
 
 Melancliolia, explanations of 
 
 symptoms, 184 
 
 , Hypochondriacal, 128 
 
 , Hysterical, 75 
 
 , letter of patient, 157 
 
 , Mental, 155 
 
 , Passive, 178 
 
 , Physical, 152 
 
 , Puerperal, 377 
 
 , recovery, 163 
 
 , Eecnrreut, 203 
 
 , remissions, 171 
 
 ; resulrs, 165 
 
 , Senile, 201 
 
 , Sensory, 154 
 
 , Simple, 172 
 
 , Special forms of, 1 ' 7 
 
 , Stages of, 163 
 
 , sudden cure, 164 
 
 , symptoms, 152 
 
 , treatment, 200 
 
 , with, bodily disease, 162 
 
 , with general paralysis, 3:3 
 
 , with stupor, 179, 182 
 
 Membranes, Adhesions of, 347 
 Memory, Acute loss of, 214 
 
 , Loss of, affecting wills, 475 
 
 , , in dementia, 213 
 
 Mental weakness. States of, 221' 
 , Testamentary capacity 
 
 in, 475 
 , Varieties of causes of, 
 
 221 
 
 , with chronic mania, 224 
 
 Metropolitan Commissioners, in 
 
 what manner differing from 
 
 Lunacy Commissioners, 486 
 Mickle, Dr. : diagnosis of general 
 
 paralysis, 342 
 , , on general paralysis, 
 
 279, 285 
 Microcephalic idiocy, 444 
 , resemblance of patients 
 
 to animals, 445 
 Milk in puerperal insanity, 374 
 Mitral disease and melancholia, 
 
 404 
 Money losses, cause and symp- 
 toms of insanity, 47 
 Monomania, 119 
 Monotonous work, Effect of, £0 
 Moon, Einfeet of, 36 
 Mural insanity, 7, 269 
 
 , Cases of, 275 
 
 , Classes of, 271 
 
 due to insane inheri- 
 tance, 273 
 
 from drink, 421 
 
 , Nature of, 270 
 
 Moral insanity, precocity or abil- 
 ity, 275 
 
 , training, 9 
 
 , with cruelty, 274 
 
 Morbus cordis. (See Heart dis- 
 ease.) 
 
 Morphia, symptoms and treat- 
 ment, 430 
 
 Multiple sclerosis and insanity, 
 390 
 
 Murder, Causation of, 467, 468 
 
 , Relationship of, to mental 
 
 perversion, 468 
 
 Muscles in general paralysis, 331 
 
 , wasting in dementia, 234 
 
 Musical aptitude in moral imbe- 
 ciles, 275 
 
 Myxoedema (Ord), 213 
 
 • , Case of, 418 
 
 , Symptoms of, 9 
 
 with dementia, 417 
 
 with insanity, 416 
 
 Narcotics, Effects of, 58 
 
 in mania, 116 
 
 " Ne'er-do-weels," 9 
 
 Negroes, General paralysis in, 20 
 
 Neurosis, Alternation of, 400 
 
 : Dr. Chfford All butt on, 403 
 
 from degeneration, 31 
 
 of degeneration, 39 
 
 started by injury, 40 
 
 Neurotic inheritance of idiots, 
 439 
 
 Nomenclature, College of Physi- 
 cians, 11 
 
 Notices of admission to asylums, 
 495 
 
 of death or recovery to be 
 
 forwarded to Commissioners, 
 51-t, 516 
 
 Nullity of marriage from in- 
 sanity, 361 
 
 Occupation as cause of insanity, 
 32 
 
 ■ , Precarious, 33 
 
 , Return to, when desirable, 
 
 482 
 
 Opium crave, 429 
 
 Optic disc in general paralysis, 
 327 
 
 in syphilis, 393 
 
 Ord, Dr. : Dementia in myx- 
 oedema, 213 
 
 , on contraction of sigmoid 
 
 flexure, 141 
 
 Orders of admission into county 
 asylums, 513 
 
Index, 
 
 541 
 
 Orders of admission into un- 
 licensed bouses, 494 
 
 to be forwarded to Com- 
 missioners, 495 
 
 Ovarian disease as cause of in- 
 sanity, 71 
 
 Over-exertion, 49 
 
 pressure in education, 22 
 
 work, Cause of, 49 
 
 , Nature of, 49 
 
 , rare as cause of insan- 
 ity, 49 
 
 Pacbymeningitis, Cases of in 
 
 general paralysis, 310, 311, 346 
 Palate in genetous idiots, 442 
 Paralysis agitans and insanitj', 356 
 Paralytic idiocy, 452 
 
 insanity, 351 
 
 Parturition, Insanity of, 69 
 Pauper lunatics, 609 
 
 in workbouses, 516 
 
 , Places of confinement 
 
 for, 510 
 , Regulations concerning, 
 
 510 et seq. 
 "Persecution," Ca=!e of, 257 
 
 from drink, 421 
 
 , Ideas of, 286 
 
 Pbtbisis, absence of symptoms in 
 
 insanity, 396 
 
 and insanity, 396 
 
 , sanity before deatb, 40O 
 
 , suspicion, irritability, refusal 
 
 of food, 398 
 Pierret : locomotor ataxy, 357 
 Places of confinement for criminal 
 
 lunatics, 519 
 
 ■ for tbe insane : 
 
 County and borougb asylums, 
 
 510 
 , Gradual growth 
 
 of, 510 
 512 
 
 -, Management of, 
 
 , manner of ad- 
 mission, 513 
 
 ^ proceedings of 
 
 justices and relieving offi- 
 cers, 513 
 
 , tbe admission 
 
 of patients, not paupers, 
 517 
 
 • , wbat persons to 
 
 be admitted, 513 
 
 Licensed bouses, or private 
 asylums, 495 
 
 • , , Advan- 
 tages of, 495 
 
 Places of confinement for the 
 insane : 
 Licensed bouses, or private 
 asylums, Management of, 
 496 
 
 , . Eegula- 
 
 tioQS concerning, 493 
 Registered hospitals, 497 
 
 , class of individuals 
 
 for whom deigned, 497 
 
 , Management of, 497 
 
 , Regulations con- 
 cerning, 497 
 
 • , relation to lunacy 
 
 laws, 497 
 
 , Voluntary boarders 
 
 in, 498 
 Under single care, 493 
 (For full particulars concern- 
 ing procedure in respect to 
 management of such places 
 see chapter xxiv.) 
 Pneumonia, followed by insanity, 
 
 435 
 PoisoninsT from alcoholism, 426 
 
 ■ ', Ideas of, 243 
 
 Practical and social questions, 477 
 
 et seq. 
 Precocity, 5, 275 
 
 and genius, 6 
 
 Pregnancy as cause of insanity, 67 
 
 , cases, 357 
 
 , General paralysis with, 369 
 
 , Insanity of, 363 
 
 , mode of action, 68 
 
 , symptoms, 335 
 
 , varieties, 3S4 
 
 Premature labour. Induction of, 
 
 not justified, 366 
 Primogenitare, Risks of, 453 
 Prisooers, Insanity in, 36 
 Private lunatics, 488 
 
 , Ill-treatment of, 493, 514 
 
 , Regulations concei-ning, 
 
 488 
 Privation as cause of insanity, 76 
 Prostitutes, Insanity common in, 
 
 35 
 Pseudo - hypertrophic paralysis 
 
 and imbecility, 453 
 Puberty as cause of insanity, 26, 72 
 Puerperal insanity, 69, 360, 371 
 
 , causation, 371 
 
 , form, 371 
 
 , lochia, 374 
 
 , milk, 374 
 
 , prognosis, 375 
 
 , pyaemia, 372 
 
 — — , treatment, 376 
 
542 
 
 Insanity and Allied Neuroses. 
 
 £*uerperal melanciiolia, 377 
 
 Punning in mania, 107 
 
 PtipUs in general paralysis, 291, 
 
 327 
 Pursued, Ideas of being, 261, 421 
 Pyaemia in puerperal insanity, 372 
 Pyromania, ^Q 
 
 Queens of asylums, 262 
 
 Race, Effect of, 19 
 Eape by tbe insane, 472 
 Kayner : lead and insanity, 340 
 
 : pbtbisis and insanity, 397 
 
 Recovery, Late, in melancbolia, 
 
 205 
 • of patients. Charitable fund in 
 
 respect to, 515 
 
 in county asylums, 515 
 
 in licensed house or regis- 
 tered hospital, 514 
 Reflexes in general paralysis, 291 
 Ri gistrar in lunacy, 484 
 Relapses in mania, 117 
 Religious excitement as cause of 
 
 insanity, 60 
 
 ideas in melancholia, 159, 194 
 
 , Origin of, 52 
 
 Remissions in general paralysis. 
 
 Case of, 304, 321, 323 
 
 in melancholia, 171 
 
 not cure, 322 
 
 Renal disease and melancholia, 
 
 206 
 Responsibilitj^ of patients in 
 asylums in connection with 
 alcohohsm, 465, 503 
 • in connection with vari- 
 ous forms of disease, 466 
 (For furtTiav %'iarticulars see Legal 
 
 responsibility.) 
 Restlessness in general paralysis, 
 
 290 
 Retreats for habitual drunkards. 
 
 Provisions respecting, 605 
 Rheumatic fever and dementia, 
 . 216 
 
 and insanity, 404 
 
 Roberts, Evan, Case of, 493 
 
 Sclerosis, Disseminated, and 
 general paralysis, 342 
 
 , Insanity witb, 390 
 
 Scrofula and idiocy, 441 
 
 Secretary of State, liis govern- 
 ment of criminal lunatics, 521 
 
 Seduction, 55 
 
 as cause of insanity in puer- 
 peral cases, 373 
 
 Self-accusation, owing to intem- 
 perance, 472 
 
 , owing to mental depres- 
 sion and restlessness, 472 
 
 control. Extension of prin- 
 ciple of to criminal matters un- 
 desirable, 465 
 
 , Loss of, as a symptom of 
 
 disease, 464 
 
 , , in asylums and 
 
 hospitals, 465 
 
 , , in general para- 
 lysis, 279, 337 
 
 , Self-indulgence m con- 
 nection with, 463 
 
 education, Some evUs from, 
 
 49 
 
 feeling, 128 
 
 Senile melancholia, 174, 2'">1 
 
 Sense, Loss of, cause of idiocy, 455 
 
 , Perversion of, in hysteria, 83 
 
 Sex, Influence of, 23 
 
 , , in me aucholia, 170 
 
 , , ta puberty, marriage, 
 
 widowhood, 24 
 
 Sexual desire in general paralysis, 
 291 
 
 excess as cause of insanity, 
 
 59, 282 
 
 self-abuse as cause of insanity, 
 
 63, 283 
 
 Shaw, Dr. Claye: ulcer of duo- 
 denum, 142 
 
 Shock, moral, Effect of, 55, 362 
 
 Shuttleworth, Dr. : eclamiDsic 
 idiocy, 446 
 
 Sin, The unpardonable, 194 
 
 , , George Borrow on, 195 
 
 Single care, Cases of ill-treatment 
 with respect to, 493 
 
 , Confinement of lunatics 
 
 under, 493 
 
 , Treatment under, 480 
 
 Skin in general paralysis, 291, 339 
 
 Smell, Hallucinations of, in gene- 
 ral paralysis, 328 
 
 Social position in relation to in- 
 sanity, 32 
 
 Solitude cause of insanity, 32 
 
 Speculators, Insanity in, 33 
 
 Speech, Change of, in general 
 paralysis, 329 
 
 , , , cases, 318 
 
 , , , varieties, 317 
 
 Spermatorrhoea, 145 
 
 Spinal cord in general paralysis, 
 348 
 
 — — general paralysis, 316 
 
 Starvation as cause of insanity, 7G 
 
Index. 
 
 543 
 
 strabismus in general paralysis, 
 
 327 
 Stupor, Melancholia with, 179 
 
 and dementia, 180, 183 
 
 Suicide in melancholia, 159, 161, 
 
 169, 188 
 
 and responsibility, 468 
 
 Sunstroke as cause of insanity, 
 
 65 
 Suspicion, Simple, 251, 476 
 
 , with phthisis, 399 
 
 Sutton, Dr. : worry as cause of 
 
 Bright's disease, 45 
 Swallowing, Difficulty of, in 
 
 general paralysis, 294 
 , Habit of, in general paralysis, 
 
 349 
 Symbolism, 265 
 in delusional insanity, Cases 
 
 of, 267 
 Sympathetic system in general 
 
 paralysis, 349 
 Syphilis as cause of dementia, 
 
 217 
 
 , case of general paralysis, 285 
 
 , of iiisaiiity, 60 
 
 , Diagnosis of, from general 
 
 paralysis, 3l0 
 
 , Effect on arteries of, 392 
 
 , on vision, causing gene- 
 ral paralysis, 393 
 
 , Modes of action of, 61 
 
 , Moral action of, 392 
 
 Syphilophobia, 392 
 
 Taste, Hallucinations of. (S?e 
 Hallucinations. ) 
 
 in gpneral paralysis, 328 
 
 Teeth, Grinding of, in general 
 paralysis, 293 
 
 Teething convulsions cause of 
 idiocy, 446 
 
 Teetotalism, Influence of, on in- 
 sanity, 58 
 
 Telephones, Delusions about, 241 
 
 Temperament as cause of insanity, 
 41 
 
 Temperature chart in general para- 
 lysis, 292, 336 
 
 in mania, 98 
 
 Testamentary capacity, 473 
 
 defective, in consequence 
 
 of aphasia, 476 
 
 . , in consequence of 
 
 apoplexy, 475 
 
 ■ , in consequence of 
 
 defective memory, 475 
 
 • , in consequence of 
 
 delusion of suspicion, 473 
 
 Testamentary capacity defective 
 in consequence of emotions and 
 passions, 476 
 
 , in consequence of 
 
 "influence," 476 
 
 , in consequence of 
 
 results of maniacal attacks, 476 
 
 , in consequence of 
 
 weak-mindedness, 474, 475 
 
 Theft as symptom of mental dis- 
 order, 466 
 
 Thoughts heard by others, 241 
 
 Throat hypochondriasis, 138 
 
 Tongue in general paralysis, 291 
 
 Transfer of patients from one 
 place of confinement to another, 
 516 
 
 , Persons willing to con- 
 tract for, 516 
 
 of pauper lunatics, 516 
 
 Traumatic cause of general para- 
 lysis, 283 
 
 idiocy, 453 
 
 Travelling, for what class of 
 patients desirable, 478 
 
 Treatment at home, 480 
 
 by sea voyages and travelling, 
 
 479 
 
 in asylum, 477 
 
 in single care, 477, 480 
 
 of adolescent insanity, 479 
 
 of dementia, 220 
 
 of epilepsy, 38S 
 
 of general paralysis, 344 
 
 of hypochondriasis, 144 
 
 of idiocy, 438, 455 
 
 of mania, 97 
 
 of melancholia, 169 
 
 Tremor of tongue in general 
 paralysis, 291, 329 
 
 Tumour. (See iirain-tumour. ) 
 
 , Diagnosis of, from genera] 
 
 paralysis, 342 
 
 , Symptoms from, 389 
 
 Typhoid fever and dementia, 216 
 
 Typhomania, 91 
 
 Unknown causes. (See Causation.) 
 Unnatural offences, 472 
 Unpardonable sin. The, 194 
 Unworthiness, 53 
 Urine in general paralysis, 292 
 , Dr. Crichton 
 
 Browne on, 357 
 Uterine disorders as cause of 
 
 insanity, 71 
 
 Venereal disease. (See Syphilis.) 
 Virility, Fear of loas of, 250 
 
544 
 
 Insanity and Allied Neuroses. 
 
 Visions, 242 
 
 Visitation, Objects of commis- 
 sioners', 508 
 
 of county and borough 
 
 asylums, 512 
 
 of houses beyond metropo- 
 litan jurisdiction, 507 
 
 of medical attendants, 497 
 
 of private lunatics, 490 
 
 of registered hospitals and 
 
 licensed houses, 506 
 
 Visitors of Chancery lunatics, 490 
 
 Voisin : loss of smell in general 
 paralysis, 328 
 
 : melancholic general para- 
 lysis, 313 
 
 Voluntary boarders in hospitals, 
 498 
 
 Wandering lunatics, 518 
 
 — '■ , Provisions with regard 
 
 to, 518 
 
 "Weakness. (See Mental weak- 
 ness, and Dementia.) 
 
 Wealth, Influence of, on treatment 
 of insanity, 479, 481 
 
 Weaning, Insanity of, 379 
 
 White, Dr. Hale : changes in dia- 
 
 Widowhood, Effect of, 25 
 Will, Loss of, in dementia, 213 
 Words, Clipping of, in. general 
 
 paralysis, 288 
 Workhouses, Class of patients not 
 
 to be admitted to, 517 
 , Dangerous lunatics not to be 
 
 confined in, 517 
 
 , Pauper lunatics in, 517 
 
 , Separate wards in, 517 
 
 Worry as cause of Bright's 
 
 disease, 45 
 of general paralysis, 
 
 283 
 of insanity, 44 
 
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