COLUMBIA LIBRARIES OFFSITE 
 
 HEAI TH SCIENCES STANDARD 
 
 RECAP 
 
 HX641 28911 
 RC601 .B9421898 Aprimerofpsycholo -^ 
 
 m^K OF PSYCHOLOG 
 
 AND 
 
 M€NTALD!SeASe 
 C.B.BURR.M.D. 
 
 Second Revised Edition 
 
 Q,'^ 
 
 ^ 
 
MEDICAL LIBRARY, 
 
 Walter M Brickner, M. D. 
 No 
 
 5^^ ay 
 
 'S^[^ 
 
 :vC/ 
 
 
 i? 
 
 
 p^ 
 
 
 C^z 
 
 iy'o 
 
 '^5 
 
 ^^^ 
 
 
 Columbia ?aniber)E^it|>\^S 'g 
 in tlje Citp of i^eto gorfe 
 
 College of ^fjpgicianis anb ^urgeong 
 
 3^eferente Hihvm^ 
 
 
 t'-'tb « 
 
 c^ 
 
 
 ^J.^ 
 
 '^DT^^, 
 
 
 \:^^^fyfe^aS ^f^ 
 
.4^ 
 
 mc^i 
 
 
 ,o^ 
 
 
 •r: 
 
 
 £> 
 
 (^^^/:^ 
 
 CvS'. 
 
 («J> 
 
 y- _ y.v 
 
 1^ 
 
A PRIMF^; 
 
 OF 
 
 Psychology ^ufl Mer..al 
 
 FOR USE IN TRAIN. .■ OLS rUR A- GND- 
 
 ANTS AND NURSHS / iN MEDir 
 
 CLAS^' 
 
 C. B. BURR M.D 
 
 MEurcAi, Director or Oak Grove Hospital foi: Vkrv .jk.vtal Diseases, 
 
 Flint, Mich. ; Formerly Medical SuPEiaNTP^- the East- 
 
 ern Michigan Asyllm: Member or .. kican 
 
 Medico-Psychological Associvh ,. n:. 
 
 Second edition Cborongbly Revised 
 
 Philadelphia, New Yoek, Chicago 
 THE F. A. DAVIS COMPANY, PUBLISHEES 
 
 1898 
 
COPYRIGHT, 1898, 
 
 BY 
 
 THE F. A. DAVIS COMPANY. 
 
 [Registered at Stationers' Hall, London, Eng.] 
 
 Ku^^.: 
 
 Philadelphia, Pa., U. S. A. : 
 
 The Medical Bulletin Printing- House, 
 
 1916 Cherry Street. 
 
PREFACE TO FIEST EDITION. 
 
 The association of the concept embarrassment and 
 the concept commiseration has produced the judg- 
 ment to write tliis unambitious little book. 
 
 The embarrassment has been incident to simplify- 
 ing in teaching what is at best an abstruse subject. 
 The commiseration I have felt for the members of 
 the Training-school Class, who have been compelled 
 to stand "quiz" on the subject of a lecture without 
 aid to memory other than an imperfect syllabus. 
 
 To the classes of 1892 and 1894, who have bravely 
 struggled on without such assistance, this work is 
 affectionately inscribed. 
 
 G. B. B. 
 
 Eastern MicHroAN Asylum, 
 PONTIAC, Mich., December 12, 1893. 
 
 (iii) 
 
PEEFACE TO SECOND EDITION. 
 
 At the suggestion of a medical friend there is 
 published in connection with the second edition of 
 this hook^ as a general guide in the management of 
 cases of insanity^ a valedictory address delivered to 
 the class of 1895 of the Training-school for Attend- 
 ants of the Eastern Michigan Asylum. 
 
 It is a source of much satisfaction that a field of 
 usefulness has been found for the Primer of Psy- 
 chology as a text-hook for medical students. 
 
 C. B. B. 
 
 Oak Grove Hospital,, 
 Flint, Mich., November 17, 1897. 
 
 (T) 
 
GLOSSARY. 
 
 Albuminoid: Eesembling albumin. 
 
 Aeticulate: An invertebrate animal, having the 
 body and members jointed. Example: spider 
 or worm. 
 
 Assimilate: To convert into a like substance. (Lat. 
 ad, to, and similis, like.) 
 
 Auditory: Pertaining to hearing. (Lat. audire, 
 to hear.) 
 
 Cerebral: Relating to the brain. (Lat. cerebrum, 
 the brain.) 
 
 Congenital: Dating from birth. (Lat. con, with, 
 and genitus, born.) 
 
 Convolution: (Lat. convolutus, rolled together.) 
 
 Convolutions, Cerebral: The round, undulating, 
 tortuous projections observed on the surface of 
 the brain. 
 
 Co-ordination: The act of bringing different parts 
 or objects into similarity of condition, or har- 
 mony of action. 
 
 Ego: The personality. (Lat. ego, I.) 
 
 Emunctory: An organ of the body which serves to 
 carry off excrementitious matter. 
 
 Environment: That which encompasses, or encir- 
 cles, or surrounds. 
 
 (Yii) 
 
viii GLOSSAEY. 
 
 Evolution: An unfolding; development. (Lat. 
 evolvere, to roll ont^ to nnroll.) 
 
 ExcREMENTiTious: Consisting of matter evacuated, 
 or proper to be evacuated, from tlie animal body. 
 (Lat. ex, out, and ceniere, to separate.) 
 
 Function: Action of an organ or set of organs; a 
 special office or use. (Lat. fungere, functus, to 
 perform.) 
 
 Inaeticulate: Not jointed. (Lat. in, not, and 
 articulus, a small joint.) 
 
 Inheeent: Existing in something so as to be in- 
 separable from it. 
 
 Inoeganic: Devoid of organized structure; unor- 
 ganized; as rocks, minerals. 
 
 Inveetebeate: Destitute of a backbone. (Lat. in, 
 not, and vertebra, a joint.) 
 
 Mammal: One that suckles its young. (Lat. mamma, 
 the breast.) 
 
 Mollusk: An invertebrate animal, having a soft, 
 fleshy body which is inarticulate, and not radiate 
 internally. Example: an oyster. 
 
 Mucous Membeane: Membrane lining all cavities 
 of the body which open externally and are con- 
 tinuous with the skin. It secretes mucus. 
 
 Nasal: Pertaining to the nose. (Lat. nasus, the 
 nose.) 
 
 Objective: Outward; external; exterior to the 
 mind. 
 
 Pathological: Pertaining to disease. (Or. pathos, 
 disease, and logos, discourse.) 
 
GLOSSARY. IX 
 
 Percept: That which is perceived. (Lat. percipere, 
 to take or receive.) 
 
 Eadiate: Animal in which all parts are arranged 
 uniformly around the longitudinal axis of the 
 body. Example: the star-fish. 
 
 Eetina: An expansion of the optic nerve, forming 
 one of the coats of the eye. 
 
 Segmentation: The process of dividing into seg- 
 ments; a self-division as a result of growth. 
 
 Sensory: Of, or pertaining to, sensation. 
 
 Subjective: Of, or pertaining to, a subject; per- 
 taining to, or derived from, one's own con- 
 sciousness. 
 
 Syllabus: A compendium containing heads of a 
 discourse; an abstract. 
 
PART L 
 
 PSYCHOLOGY. 
 
 Psychology: tlie Science of ike Mind. 
 
 The word Psychology is derived from two Greek 
 words: Fsyclie, Soul, Mind; and Logos, Discourse. 
 
 The problems of the mind involve those of Biol- 
 ogy: ilie Science of Life {Bios, Life; Logos, Dis- 
 course); and Physiology: tlie Science of properties 
 and functions of Living Beings {Physis, Nature; and 
 Logos, Discourse). 
 
 Life is defined as "a relation or combination of 
 matter and force in which peculiar phenomena (ap- 
 pearances) take place;, which are: (1) motion from 
 inherent power, (2) a capacity for appropriating 
 nourishing material, and (3) the capability of multi- 
 plication or reproduction for the preservation of 
 species. In the higher forms differentiation^ of 
 structure and development occurs; and, in the high- 
 est, sensibility (feeling), intellection (thought), and 
 will (volition)."^ 
 
 ^ A production of diversity of parts by a process of evolu- 
 tion or development. 
 
 '^ The late Dr. A. B. Palmer. 
 
 (1) 
 
2 PSYCHOLOGY. 
 
 That which distinguishes the living from the not 
 living is the j)OSsession of the three qualities or at- 
 tributes: Motion, Nutrition, and Reproduction, — as 
 above mentioned. 
 
 The locomotive moves from the force exerted by 
 exj)ansion of water. Inorganic substances change 
 their positions from force exerted upon them (as the 
 rolling of a stone from an earthquake upheaval). 
 Heat and electricity are so-called modes of motion. 
 The acid and the alkali^ coming together in solution, 
 make disturbance in the glass (motion from chemical 
 action). All these are illustrations of motion, but 
 not motion from inlierent power. 
 
 Stones enlarge by additions to their surfaces (ac- 
 cretion), but cannot appropriate substances with 
 which to grow. 
 
 Two or more stones may be produced from one 
 by a i^rocess of breaking or disintegration. They 
 have no ability, however, to reproduce their kind. 
 
 Certain plants, on the contrary, demonstrably 
 have motion from inlierent power: as witness the 
 sensitive plant, which closes when its leaves are 
 touched; the morning-glory, which opens and closes 
 its petals; the ivy, which climbs the conductor-pipe 
 or the tree; the insect-eating plant, which closes 
 about and absorbs the prey which alights upon it. 
 Plants have also ability to appropriate nourishing 
 material. This is absorbed from the soil, or from the 
 atmosphere, or, as in the case of the insect-eating 
 plant, as above shown. 
 
PSYCHOLOGY. 3 
 
 Plants reproduce their kind Ijy contact of the 
 male and female elements. Conclusion (Judgment): 
 Plants possess life. 
 
 The lowest form of animal life is that of the 
 amcelja. Tin's consists of a simple mass of albumi- 
 noid matter, possessing irritability (rudimentary sen- 
 sation), contractility (enabling motion from inherent 
 power), the i)ower of segmentation or division, 
 through which it re})i'oduces itself. From this low 
 form of life np to man, showing the highest organ- 
 ization, differentiation of structure occurs. 
 
 The lowest form of animal life in which a nerv- 
 ous apparatus (and this very rudimentary) appears 
 is the jelly-fish. This animal possesses a muscular, 
 digestive, and circulatory system sufficient for its 
 needs. The oyster has an imperfect nervous, mus- 
 cular, circulatory, respiratory, and reproductive 
 apparatus. The oyster has a bony system, its skele- 
 ton being upon the outside and constituting its shell. 
 In the reptile and fish there is a higher development 
 of the bony, muscular, digestive, circulatory, re- 
 spiratory, nervous, and reproductive S5"stems, with 
 special adaptation of structure for the conditions in 
 which the animal exists. 
 
 Special senses are not developed in the lowest 
 animal organisms. In the very lowest form, as the 
 amoeba, there is irritability; in higher, common 
 sensation (impressions of pain). As the scale is 
 ascended, the tactile sense, and from this on, other 
 senses, as vision, hearing, etc., develop. 
 
4 PSYCHOLOGY. 
 
 In the higher animals^ accompanymg certain 
 nervous manifestations, there appears what is called 
 consciousness (mind). Fishes can be taught to come 
 at the ringing of a bell; Canary birds to perform 
 various acts; domestic animals to do useful service 
 to man; wild animals to perform tricks and to subor- 
 dinate savage instincts to man's will. Dogs some- 
 times develop remarkable intelligence. In the high- 
 est form of life (mankind) the development of the 
 brain and nervous system reaches its greatest per- 
 fection, and manifestations of mind are of the most 
 complex character. 
 
 The Brain is the organ of the mind. 
 
 Simplicity in the structure of the brain indicates 
 low mental development, as shown in idiots and im- 
 beciles. As complexity in structure increases, con- 
 volutions grow deeper, and gray matter becomes 
 more abundant, mental operations are correspond- 
 ingly higher. The size of the head, unless it ex- 
 ceeds or falls far below certain limits, is not indic- 
 ative of the degree of mental development. 
 
 The Brain is the organ of the mind, and in the 
 Ceeebeum (the large brain) reside the higher mental 
 faculties. This is shown: — 
 
 1. By experiments on the lower animals. The 
 pigeon deprived of the cerebrum remains apathetic 
 and drooping. If thrown into the air, contact with 
 this element produces, through what is known as 
 reflex action, the muscular movements of flying, but 
 these gradually become feebler until the bird sinks 
 
PSYCHOLOGY. 5 
 
 to the ground. If food is placed within its reach it 
 is not voluntarily ajjpropriated. If inserted far back 
 in the mouth, food is swallowed through reflex action. 
 The frog deprived of its cerebrum rights itself if an 
 attempt is made to turn it over. If pricked or 
 prodded, it jumps, Init is quiet and motionless unless 
 disturbed by contact with something. It initiates 
 nothing. The behavior of animals thus deprived of 
 the cerebrum is akin to that of human beings suffer- 
 ing from profound dementia. 
 
 2. By disease of the brain, which is so often 
 associated with disturbance of the mental operations. 
 
 3. By the mental deficiencies which exist in con- 
 nection with lack of cerebral development, as in 
 idiots and imbeciles. 
 
 What is meant by the mind? This is impossible 
 to define. Mind is known only through its opera- 
 tions. I am conscious of my mind from evidence 
 within (subjective). I am conscious of mind in 
 others because they act in obedience to outward, or 
 apparent, circumstances as I do myself under similar 
 conditions (objective evidence). Their so-called 
 "reaction to their environment" is similar to my 
 own. 
 
 The faculties of the mind are three: — 
 
 1. Thinking (intellection, thought). 
 
 2. Feeling (sensibility, emotion). 
 
 3. Acting (will, volition). 
 
b PSYCHOLOGY. 
 
 Thinking. 
 
 Development of the Mind. — There is necessary to 
 this the Senses. Knowledge is derived throngh 
 the medium of the Senses, of which there are six: — 
 
 1. Hearing: mental impressions through the audi- 
 tory apparatus. 
 
 3. Seeing: mental impressions through the visual 
 apparatus. 
 
 3. Smelling: mental impressions through nerves 
 supplied to the nasal mucous membrane. 
 
 4. Tasting: mental impressions through nerves 
 supplied to the tongue. 
 
 5. Touch: mental impressions through sensory 
 nerves supplied to external parts of the body, skin, 
 and -mucous membranes. 
 
 6. Muscular: that sense through which we are' 
 made aware of the force exerted by contracting 
 muscles.^ 
 
 There are necessary to the mental upbuilding: — 
 
 1. Sensation. 
 3. Perception. 
 
 3. Memory. 
 
 4. Ideation. 
 
 ^ Information as to weight and resistance is received 
 through the muscular sense. Compare the impression re- 
 ceived from compressing a rubber ball with tnat from a sim- 
 ilar attempt upon a piece of steel. The essential difference 
 between the touch and the muscular sense is plainly ap- 
 parent. 
 
PSYCliOLOGY. 7 
 
 5. Keasoning. 
 G. Judgment. 
 
 A Sensation is an impression made upon an 
 organ of sense, which organ must Ije composed of 
 three parts: — 
 
 1. A nervous mechanism to receive the impres- 
 sion. 
 
 2. A sensory nerve, or nerve of special sense, to 
 convey the impression to the brain. 
 
 Illustration of simple sensation of touch. Arrow 
 represents impression conveyed by sensory nerve 
 to nerve-centre in brain. 
 
 3. A nerve-cell, or group of cells, to receive the 
 impression. 
 
 Take the eye for illustration. A ray of light from 
 some object falls upon the retina. An impression 
 is conveyed through the optic nerve to the centre 
 of sight in the brain and there received. This is a 
 
8 PSYCHOLOGY. 
 
 simple sensation. Sight, or Seeing, is a different 
 thing, however, and involves, jnst as hearing, smell- 
 ing, touch, taste, and the muscular senses do, some- 
 thing else, which is called 
 
 Peeception". This is the conscious recognition of 
 the external causes of a given sensation. 
 
 To illustrate: For the first few days or weeks of 
 a child^s life its existence is vegetative purely. It 
 pays no attention to objects about it. Later on, it is 
 said to "notice,''^that is to say, it takes cognizance 
 of what comes before it. It will follow with its eyes 
 a candle or a ball of bright yarn. It will watch for 
 them. It will associate a pleasant sensation with the 
 candle or the ball of yarn. It perceives that the can- 
 dle or the ball of yarn is the cause of this sensation, 
 — it has the conscious recognitiofi of the cause, or 
 Perception. When first a nursing-bottle is placed 
 to its lips, the lips close down about it and the 
 operation of sucking begins, — this through refiex 
 action. There is an impression conveyed by the 
 touch- and taste- organs of the mouth, through cor- 
 responding nerves, to the sensory, or special sense, 
 centres in the brain; from these centres refieeted 
 upon motor nerve-centres in the brain, and through 
 motor nerves going from the brain to the muscles. 
 Eesult: the operation of sucking. This is a purely 
 refiex act at first. Later, the child watches for the 
 bottle of milk, sucks upon it by a voluntary effort 
 when it is offered, or perhaps helps itself, if the bottle 
 is placed in the cradle. There is here Perception: 
 
PSYCHOLOGY. 9 
 
 tliii recognition of the external causes of the sensa- 
 tions which tlie bottle and its contents furnish. 
 There are consequently necessary to Perception: — 
 
 1. A nervous mechanism to receive impressions. 
 
 2. Sensory nerves, or nerves of special sense, to 
 convey impressions. 
 
 3. Nerve-centres in tJie brain to receive impres- 
 sions. 
 
 4. Consciousness. 
 
 Perception is made up from a number of distinct 
 
 Illustration of visual perception. 
 
 percepts: as, for example, form, size, color, vibra- 
 tion, density, taste. These individual impressions 
 united, and with the aid of consciousness, form a 
 percept of the object. 
 
 In order that percepts once acquired may be 
 stored up for future use, there is necessary another 
 mental faculty, which is 
 
 Memory: the retention in mind of impressions 
 received. 
 
 There are two kinds of Memory: — 
 
10 PSYCHOLOGY. 
 
 1. Memory of percepts. 
 
 2. Memory of self (Organic Memory). 
 
 The memory of self (organic memory) permits 
 the registration and storing up of impressions from 
 all parts of onr bodies: from our bones^ muscles^ and 
 internal organs. Upon this storing up, the Ego — 
 the Personality — depends. Sensations such ^s are 
 here mentioned do not, as a rule, come into con- 
 sciousness independently; but, taken together in 
 health, they constitute our feeling of well-being: 
 our sense of self. In disease we may become, at 
 times, acutely conscious of some or all of them. 
 The development of the personality is extremely 
 interesting. 
 
 The child at first is unconscious of its own exist- 
 ence, of its own individuality. It refers to itself 
 in the third person: "Johnnie wants it," "Mamie 
 wants it.'' The Ego — I^s not present. The child 
 inspects its fingers and toes, as it does that which 
 is held before it, as something foreign to itself. 
 Later, organic sensations proceeding from the fingers 
 and toes and impressing themselves upon the con- 
 sciousness give to the child the recognition of pro- 
 prietorship. The organs become part of the child's 
 body. The existence of the child at first seems to 
 be of a dual character. Later, the Ego is formed — 
 the personality — through sensations proceeding from 
 all the organs and tissues of the body and registered 
 in the organic memory. 
 
 The Peksonality is of great interest to those 
 
rSYCIlOLOGY. 11 
 
 studying insanity, for in disease of the mind it is 
 frequently fouiid that alteration in organic sensa- 
 tions has given to the individual an impression of 
 bodily loss or of change in constitution. Change 
 in sensation, proceeding from the foot, may lead to 
 the belief that this member is lost or dead. Change 
 in nervous action and checking or hindrance of men- 
 tal operations may lead to the delusion that the mind 
 is under the control of another. Disturbance in the 
 internal organs may occasion the belief that poison 
 is administered; change in the action of the nerves 
 of the skin, that electricity or some harmful agency 
 is at work upon tlie body. All sensations, indeed, 
 may be so altered in insanity as to lead to the belief 
 in a double personality. 
 
 This is not difficult to understand when we call 
 to mind the clod-like, heavy, foreign feeling of a 
 frozen foot. Here the sensory nerves are blunted, 
 and sensations proceed from the unaffected tissues 
 above the frozen point. The organic memory may 
 be so vivid in its reproductions as to convey to the 
 soldier the consciousness of the presence of an am- 
 putated extremity. 
 
 Impression's taken cognizance of, or perceived by, 
 the mind are hoarded by Memory. 
 
 The process of grouping percepts together (Re-pres- 
 entation — Fe-coUection) ly the aid of Memory to form 
 concepts, or ideas, is called Ideation. 
 
 Illustration: Take an object in the hand; receive 
 all the impressions possible from it through the 
 
12 PSYCHOLOGY. 
 
 medium of common sensation and the special senses. 
 You have here a group of impressions coming into 
 consciousness^ constituting a percept of the object 
 (Presentation). Remove the object^ and associate 
 the different individual percepts together through 
 the aid of memory. You still see it^ hear it, or feel 
 it. This constitutes a concept, or idea, which is a 
 group of percepts reproduced in memory (Re-pres- 
 entation — Re-collection). 
 
 Illustration of concept, or idea. Each grape repre- 
 sents the memory of a percept. These united by 
 the stem, Ideation, form the concept. 
 
 Reasoning. — This faculty is also necessary to the 
 development of the mental life. Reasoning is tlu 
 association of concepts, or ideas, to form a judgment, 
 and the association of judgments to form new judg- 
 ments. In reasoning, we weigh and compare con- 
 cepts, or ideas, by their likeness, or similarity, and 
 by their unlikeness, or dissimilarity. 
 
PSYCHOLOGY. 13 
 
 Take, for example, the naturalist's classification 
 of the animal kingdom. A similarity in structure, 
 in that all possess a spinal column, causes large num- 
 bers of animals of widely different appearance to be 
 grouped under the designation veriehrates. So of 
 other orders: essential differences in structure sepa- 
 rate the mollusks from the articulates and the ar- 
 ticulates from the radiates. To go further, closer 
 anatomical or physiological resemblances cause the 
 division of the vertebrate kingdom into families, or 
 subclasses: mammals, birds, reptiles, and fishes. 
 This process of weighing, comparing, and measur- 
 ing is called Reasoning, and the result of the process, 
 Judgment. 
 
 Apply heat to iron. The iron expands. Asso- 
 ciate the concepts iron, lieat, and increase in size, or 
 expansion. Judgment: Heat expands iron. 
 
 Take the judgment, lieat expands iron, and asso- 
 ciate with it the concept water. Judgment: If heat 
 expands a dense body,- it will a body less dense, — 
 heat will expand water. 
 
 Take concepts of iron heated and iron cool. The 
 one required more room to contain it than the other. 
 Associate with judgment, lieat expands water, another 
 judgment: Water expanded will require more room 
 to contain it. 
 
 Take for concepts: expansion and containi^ig. 
 Associate them by reasoning, and the judgment is 
 formed: Anything expanded requires more room to 
 contain it, and, if compressed, great force is created. 
 
14 PSYCHOLOGY. 
 
 Associate concepts of compression and steam (ex- 
 panded water). There is called up the concept of 
 force, of expansion^, and something to resist the ex- 
 pansion (steel). Judgment: Expanded water con- 
 fined in a receptacle of steel — a boiler — exerts great 
 force, and may be nsed in moving powerful bodies 
 (the locomotive). 
 
 Again: Compare the idea, or concept, man — which 
 involves many percepts of his different attributes — 
 with the concept reptile. Judgment: Man is the 
 superior being. 
 
 Again: We look out-of-doors upon a cloudy sky. 
 We perceive the absence of sunlight; we perceive 
 the direction of the wind; we are conscious of, or 
 perceive, a chilliness. We group these percepts to- 
 gether, and by the aid of memory reduce them to 
 concepts. There is a re-collection of past experi- 
 ences. We associate the concepts together by rea- 
 soning. Eesult: Judgment, that the day will be 
 anpropitious for a picnic. 
 
 Judgment: The result of a comparison or associa- 
 tion of concepts, or of the comparison or association 
 of judgments. 
 
 Let two telegraph-poles be taken as representing 
 each a concept, or idea. Reasoning is the wire that 
 unites the two; Judgment is the result of the union. 
 
 Or let each pole represent a judgment. The wire, 
 Seasoning, unites the two, the whole forming a new 
 judgment. 
 
PSYCUOLOGY. 15 
 
 To recapitulate: — 
 
 Sensation + Consciousness = Percept. 
 Percept + Percept + Memory = Concept. 
 
 Concept + Concept = Judgment, 
 
 or 
 Judgment + Judgment = New Judgment. 
 
 The plus sign wliicli stands between the words 
 Percept and Memory is the equivalent of Ideation. 
 
 The plus sign which stands between the words 
 Concept and the words Judgvient is the equivalent 
 of Bcasoning. 
 
 As before stated, Sensation, Perception, 3Iemory, 
 Ideation, Reasoning, Judgment, enter into the think- 
 ing process. If any avenue to the brain is closed, as 
 by congenital deafness or blindness, mental devel- 
 opment and mental ability are correspondingly 
 lessened, although scientific methods applied in the 
 education of the remaining senses go far to remedy 
 the deficiency. 
 
 Thought in man is usually, perhaps invariably, 
 conducted in words or their visible signs. Let any- 
 one try to think and he will find that he is men- 
 tally grouping words together into sentences and that 
 his unspoken idea is framed as if it were to be ex- 
 pressed. The deaf-mute, who has not a vocabulary 
 of words, thinks in visible signs; that is, in gestures 
 which stand for the representatives of ideas. ^ 
 
 ^ See foot-note on page 24. 
 
16 PSYCHOLOGY. 
 
 Feeling : Emotion. 
 
 We come now to the consideration of the second 
 function or manifestation of the mind: Feeling^ or 
 Emotioist. If taken np in logical order, it should 
 have been considered previous to thinking, inasmuch 
 as feeling (sensibility) must inevitably precede think- 
 ing. The term "feeling^' must not be confounded 
 with the sensation springing from the special sense 
 of touch. What is understood by "feeling/' as the 
 word is here used, is a bundle of mental experiences 
 of pain and pleasure that everybody can appreciate, 
 but is difficult to describe. The majority of con- 
 cepts are, to some extent, of a pleasurable or painful 
 character; that is, there are few which may be 
 classed as entirely neutral: from which some satis- 
 faction, or the opposite, is not derived. To the ex- 
 tent to which ideas are accompanied by pleasurable 
 or painful feelings they may be considered emo- 
 tional. An emotion, therefore, may be defined as 
 an idea accompanied ly a feeling of pleasure or pain. 
 As the feeling preponderates the idea grows less and 
 less distinct until almost overshadowed. The word 
 "Emotion" comes from two Latin words: e, from, 
 and motio, motion. In the emotions lie that which 
 moves to action. Motive, desire, and affection here 
 have their abiding-place. The feelings have their 
 own means of expression, their own language: the 
 language of the emotions. Witness the blanched 
 face, the contracted muscles, the dilated pupils, and 
 
PSYCHOLOGY, 17 
 
 protruding eyes of Fear; the flushed face, swelling 
 throat of Kage; the anxious or relaxed and down- 
 cast physiognomy of Mental Depression; the bright 
 eye, the clapping hands, and laughing expression -jf 
 Pleasure; the cooing sound of Satisfaction. 
 
 The emotions lie close to the organic (bodily) 
 functions. They find their quick reflex in the mus- 
 cular expressions of friglit, pleasure, despair, and 
 comfort, already referred to, as the idea of unemo- 
 tional character finds its slower expression by the 
 organs of speech or voluntary action. Displaying 
 in themselves the earliest states of consciousness, the 
 emotions are among the first to sufi^er in mental dis- 
 ease, as will be hereafter shown. The individual 
 breaking down with mental disease reacts to painful 
 or pleasurable impressions with an unaccustomed in- 
 tensity. 
 
 Feelings prompt desire. Desire forms the con- 
 necting link between feeling and that which we come 
 next to consider, viz.: — 
 
 Volition. 
 
 Volition is defined as action prompted hj feeling. 
 Thus, it is to be distinguished from all other forms 
 of action not so prompted: from simple reflex 
 action, already spoken of, and from higher reflex 
 (automatic) action. 
 
 In speaking of perception in the child, reference 
 was made to the operation of taking food. At first 
 
18 PSYCHOLOGY. ' 
 
 this was an uiiconscioiis and purely reflex act. There 
 was transmitted to the child a nervous mechanism 
 that, excited by the presence of the bottle to the 
 lips, occasioned the mnscnlar act of sncking. 
 Through inherited transmission the child was en- 
 dowed with this simple instinctive power. Through 
 ages the nervous mechanism in use in the appro- 
 priation of food has acted in definite ways, and 
 nervous channels, so to speak, have resulted. Sen- 
 sory impulses have traveled from lips and tongue to 
 the cerebral sensory centres; they have been reflected 
 upon motor centres, and traveled back along the mo- 
 tor nerves to groups of muscles about the tongue and 
 throat. A path, a rut, a definite route, so to speak, 
 has thus been traversed; and impressions registered 
 in the organic memory, and action prompted thereby, 
 have enabled the appropriation of food to go on until 
 such time as desire impels and voluntary action per- 
 mits the gratification of appetite. This constitutes 
 one of the few inheritances of the human infant. 
 
 The organic memory of pain and the reflex act 
 of crying (the expression of pain in the absence of 
 conscious suffering) is another inherited quality. It 
 is the organic sensation of hunger, which expresses 
 the demand on the part of the system for food, that 
 impels to the taking of food before there is con- 
 scious recognition on the part of the child of its own 
 wants or the ability to gratify them. Later on, 
 voluntary action — action prompted by feeling, by de- 
 sire — appears. Compare the child with the chick. 
 
tSYOHOLOGY. 19 
 
 which, immediately after emerging from the shell, 
 walks around in search of food and picks it up, takes 
 refuge under its mother's wings when called, or flees 
 from the cat, and displays, from the first, adaptabili- 
 ties and powers which, in the child, are the result of 
 education. Mental development, except under rare 
 circumstances, however, goes little further in the 
 chick. It is, in all essential respects, the mature 
 animal. It is through prolonging the period of in- 
 fancy that evolution lias Ijrought about in mankind 
 the capacity for high mental development. 
 
 Again, certain acts which the child laboriously 
 and tediously acquires become, by the assistance of 
 the organic memory, automatic in their character. 
 Take the illustration of walking: It is in the child 
 the result of slow education of the nervous centres. 
 Behind it there is at first a feeling of desire to walk; 
 then comes the education of the voluntary muscles 
 of locom.otion. Eventually, by means of the nervous 
 channels established in the brain, walking is carried 
 on automatically, the initiation of the movement 
 only being voluntary. The child walks, runs, and 
 turns about, all without the conscious exercise of 
 volition. Contact with the ground, the sensory im- 
 pulse proceeding by the way of the spinal cord to 
 the brain, its reception by the sensory centres, its re- 
 flection upon the motor centres, and, through the 
 motor nerves, to the muscles concerned in the act 
 are the steps in the process. So of self-defensive acts. 
 At first the child requires to be protected from all 
 
20 PSYCHOLOGY. 
 
 manner of harm. Later, throiigli education, it ac- 
 quires self-defensive ability and involuntarily shields 
 itself from that which threatens. One is conscious of 
 fleeing from danger, or of taking self-defensive meas- 
 ures, oftentimes after the act is completed. All sorts 
 of habits of life are thus formed. Winding the watch 
 before retiring frequently takes place without con- 
 sciousness. The act of locking or unlocking a door 
 is done automatically. Piano-playing, an accomplish- 
 ment tediously acquired, is finally carried on through 
 the organic memory without appreciable voluntary ef- 
 fort except in the act at its beginning. These are 
 liigher cerebral reflex, acts. 
 
 The Higher Volition, like the other faculties of 
 mind, is a plant of slow growth, and involves dis- 
 crimination, comj)arison, weighing of ideas, and 
 judgment as to the best course for the person to 
 pursue. It is difficult to say when the child first 
 exercises volition. The choosino- between that which 
 is sweet and that which is without marked flavor, but 
 better for his needs is, to be sure, an action prompted 
 by feeling; but the higher volition implies discrimi- 
 nation between that which is desirable and profitable 
 and that which is undesirable and unprofitable. 
 Cultivation of the reasoning and judgment are neces- 
 sary to this. 
 
 The education of the will is most important to 
 the future of the child. The matured judgment 
 places an inhibition — a restraining influence — ^upon 
 the actions, that decision between that which is ulti- 
 
PSYCHOLOGY. 21 
 
 niately good and that wliicli is immediately gratify- 
 ing may result. It may be a source of present satis- 
 faction to Hinitc in the face one who has injured me_, 
 but the higher volition restrains the act. 
 
 The law rightly makes distinction between im- 
 pulsive acts and those prompted by deliberation and 
 clioice. One in the heat of passion kills by a blow 
 another who has seriously wronged him. Here the 
 judgment was obscured by the emotional feeling, 
 and a muscular act resulting in death occurred. On 
 the contrary, brooding over a wrong, one deliberately 
 decides to kill, and carries his plan into execution. 
 In the one case the act was semi-instinctive, self- 
 defensive in a way. It was prompted by feeling, to 
 be sure, but the emotion obscured the judgment. 
 Eesult: manslaughter. In the other case there was 
 a deliberate choosing, a careful adaptation of means 
 to ends, a judgment to kill. This was murder. 
 
 It is important to distinguish between 
 
 Simple Eeflex Acts, 
 Higher Eeflex Acts, 
 Volitional Acts, and 
 Inhibitory Acts (a variety of the volitional). 
 
 The first — Simple Eeflex Acts — are instinctive: 
 as the involuntary withdrawal from contact with that 
 which is painful; winking; breathing. 
 
 The second — Pligher Eeflex Acts — were originally 
 voluntarily acquired, — learned, — but, once learned, 
 go on, in a measure, automatically, the volition, if 
 
23 PSYCHOLOGY. 
 
 exercised at all, merely initiating the movement: as 
 the act of walking. 
 
 Volitional Acts are those which spring from feel- 
 ing and represent choice, desire: as the putting on of 
 rubbers in wet weather, to protect health. 
 
 Inhibitory Acts — a variety of volitional acts — are 
 those which check the immediate response to desire 
 and feeling, and introduce a restraining influence — 
 a "will not to do,^^ so to speak. Both the higher 
 
 Illustration of volition. 
 
 volitional and inhibitory acts imply the exercise of 
 judgment. 
 
 LIMITATIONS OF THE AVILL. 
 
 1. The will has no prolonged power over invol- 
 untary muscles. Let one try to stop breathing, and 
 demonstrate this for himself. 
 
 2. The will does not control movements which 
 have not been acquired by practice. One may satisfy 
 himself of the truth of this in his first bicycle ride. 
 
 3. Painful thoughts cannot be dismissed from the 
 
PSYCHOLOGY. 33 
 
 mind by an ellort of the will. They must be sup- 
 planted and crowded out by introducing others. 
 
 General Considerations. 
 
 All of the foregoing has its bearing upon the study 
 of mental disease. In insanity any or all of the func- 
 tions of the mind may be disturbed. 
 
 Sensation may be impaired or lost. The special 
 senses of taste and smell may be so much at fault that 
 the vilest substances placed in the mouth do not ex- 
 cite disgust. In such a case Perception also fails. 
 Faulty perception may further manifest itself in 
 Hallucinations and Illusions. 
 
 An Hallucination is a false perception without an 
 adjective reality. Example: One, looking upon the 
 bare floor, fancies he sees a snake. There is nothing 
 whatever upon the floor which could lead to that per- 
 ception. He is suffering from a visual Hallucination. 
 
 One looks upon a carpet with bright figures and 
 irregular tracings, and sees in the bright figures birds 
 of brilliant plumage, and in the tracings of duller 
 colors snakes or rats. He is suffering from an Illu- 
 sion, that is, a false perception luith an oljective 
 reality. 
 
 He hears the sound of escaping steam from the 
 radiator, and, in this sound, the voice of some one 
 threatening to kill him; in the ticking of his watch 
 he hears commands; in the locomotive whistle he 
 perceives calls and shrieks. He is suffering from 
 
34 PSYCHOLOGY. 
 
 illusions of hearing. He hears a cry when all is still; 
 he has an auditory hallucination. Thus, in smell, 
 taste, touch, and the muscular sense hallucinations 
 and illusions may develop. The weight of the bed- 
 clothes may give the impression, through the mus- 
 cular sense, of a heavy load; or one may fancy him- 
 self exerting great muscular strength, may even per- 
 spire and become manifestly exhausted through 
 efforts to sustain bodies which in fancy are burden- 
 ing him, while, in fact, he is entirely free from any 
 weight or pressure. 
 
 Hallucinations of hearing exist in insane patients 
 who have deafness, acquired; of vision in those who 
 have become blind: there could be no better illus- 
 tration of the fact that we hear and see with the brain 
 — the mind — not with the eye and ear. The inference 
 follows that hallucinations of hearing or vision in one 
 congenitally deaf or blind would be impossible, — the 
 cerebral centres which preside over these senses in 
 health never having been in action. ISTo true con- 
 ception of sound can exist in one congenitally deaf, 
 or of color in one totally blind from birth. Conse- 
 quently no hallucination can be present.^ 
 
 ^ In the Journal of Mental Science for July, 1895, an in- 
 teresting account is given of the hallucinations of a deaf 
 paranoiac. The case reported by Dr. Cramer to the Psychiat- 
 ric Association at Berlin is, in brief, as follows: He was 37 
 years old and had been born deaf; but had been educated 
 and learned to be a portrait-painter. When admitted to the 
 asylum at Eberswalde he was much excited and violent. 
 
PSYCHOLOGY. 25 
 
 Hallucinations and illusions give rise t(j Delusions. 
 Hallucinations may be present in the juind of one 
 not insane. As long as they are corrected by the 
 reasoning and Judgment they do not amount to delu- 
 sions. Believed in, however, and present because of 
 a diseased condition, they become delusions. 
 
 A Delusion, therefore, is a false belief due to disease. 
 The cjualification "due to disease" is introduced 
 because there are multitudes of false beliefs in the 
 world not due to disease, but to faulty education, as 
 the belief in witchcraft, satanic possession, the evil 
 eye, the visitation of ghosts. Christian Science,^ etc. 
 
 "He was very suspicious, not at all communicative, and very 
 difficult to handle. In about ten months he began to im- 
 prove and engaged in out-door work. A year afterward he 
 again resumed his painting and was willing to converse. 
 Dr. Cramer framed a number of questions which the deaf 
 man answered in writing. Instead of hallucinations of 
 hearing, for he could not hear, he imagined that communi- 
 cations were made to him by the ordinary signs used by the 
 dumb, and through the words which he had been taught to 
 utter by muscular exercises of the mouth and throat, and 
 also by studying the motions of the lips in others. In these 
 ways he thought that obscure ideas were introduced to his 
 mind. Cramer took occasion to observe that it was an error 
 to believe that in all our thinking heard words are used. In 
 this he is convinced that there are great differences, some 
 even transacting thought through the acoustic form of 
 words, others through the revival of images formed from 
 the movements of the organs of speech or the sensation of 
 accomplished muscular efforts." 
 
 ^ , 111., February 23. — Mrs. — — died 
 
26 . PSYCHOLOGY. 
 
 In estimating tlie importance of a false belief as bear- 
 ing npon the mental state of the subject^ it is neces- 
 sary to take into consideration his natural habits of 
 thought, his previous education and mode of life. A 
 philosopher suddenly expressing a belief in witches 
 might be justly regarded as having an insane delu- 
 sion. It would not be safe to conclude, however, in 
 the case of an illiterate Southern negro, that an ex- 
 pression of a belief in witchcraft implied insanity. 
 
 The Ideation, Reasoning, and Judgment may 
 be at fault in mental disease: Ideation, in the imper- 
 fect grouping of percepts into concepts (incoherence); 
 Reasoning, in the irregular association of ideas (inco- 
 herence); Judgment, in erroneous conclusions (delu- 
 sions). 
 
 Two classes of delusions are spoken of: Fixed 
 Delusions and CJianging Delusions. 
 
 The Memoey may be at fault, both in the recol- 
 lection of percepts and in the registration of organic 
 sensations, as heretofore mentioned in connection 
 with the personality. 
 
 here a few clays ago after a brief illness of inflammation 
 of the bowels. She and her husband and other members 
 of the family were Christian Scientists. An attempt v^as 
 
 made to cure Mrs. — by prayer and other practices 
 
 usually resorted to by members of that faith before summon- 
 ing a regular physician. The physician was called too late 
 to be able to render any assistance. It is thought by the 
 neighbors and friends of the deceased that the woman could 
 have been saved if medical aid had been summoned sooner. — - 
 Press Report. 
 
PSYCHOLOGY. 27 
 
 The Emotions — feelings — may be at fault. As 
 previously mentioned, disturbance of the emotions is 
 an early manifestation of mental disease in many of 
 its forms. 
 
 In the graver forms of insanity, associated with 
 nervous degeneration, the Higiieh IIeflexes (the 
 co-ordination) are disturbed. 
 
 Volition, which in conditions of sanity is checked 
 and governed by the judgment, may be abolished or 
 very much impaired. Examples: The irregular mus- 
 cular movements, shifting glance, and inattentiveness 
 of mania; the unwillingness to put forth muscular 
 effort in melancholia. 
 
PART II. 
 
 INSANITY. 
 
 Insanity is defined as "^a prolonged departure from 
 the individual's normal standard of thinling, feel- 
 ing, and acting f' 
 
 It is a prolonged departure^ because there are many 
 conditions in which tliere are temporary departures 
 from the normal standard of tliinking^ feeling, and 
 acting which are not called insanity. Thus, in intoxi- 
 cation one neither thinks, feels, nor acts as when 
 sober, but this condition is not accounted insanity, 
 and the subject is fully responsible in the eyes of the 
 law for his conduct. In the delirium of fever — due 
 to overheating of the blood, its too rapid circulation, 
 and its conveying deleterious or poisonous substances 
 to the brain — the subject is temporarily deprived of 
 his g,bility to think, feel, and act normally. It is true 
 of shock, a blow on the head, fright, an epileptic 
 convulsion, fainting (from loss of blood or heart- 
 failure), and apoplexy, that there may be temporary 
 loss of consciousness and the mind does not act 
 naturally; but the person thus suffering is not re- 
 (28) 
 
INSANITY. 29 
 
 garded insane. Insanity may develop in consequence 
 of injury, in consequence of the delirium of fever, in 
 consequence of the loss of blood, and in consequence 
 of apoplexy or epilepsy; but the condition itself is not 
 an insane condition.^ 
 
 The definition speaks of the individuaV s normal 
 standard. This means tliat every case is a law unto 
 itself: that there is no fixed standard of thinking, 
 feeling, and acting. It cannot be said, for example, 
 because one does not act under certain conditions as 
 his neighljor acts, because he does not show the same 
 amount of feeling that his neighbor manifests, or 
 because lie does not think in the same lines that his 
 neiglibor thinks, that he is insane and the other sane. 
 In giving an opinion as to whether insanity exists, it 
 is necessary to compare the person's present with his 
 former habits of thinking, feeling, and acting. 
 
 Tlie '^'departure'" may display itself in complete 
 change of characteristics, tastes, and tendencies; in 
 simple perversions of the feelings and judgments; or 
 in an exaggeration of natural traits of character. 
 
 Causes of Insanity. 
 
 These are as numerous as the causes of disease in 
 general. They may be classified, for convenience, as 
 follows : — 
 
 Direct physical causes, 36 per cent. 
 
 Indirect physical and emotional causes, 8 per cent. 
 
 ^ The word "insanity" means literally "unsoundness," but 
 ii is the medical, not the literal, meaning which is here given. 
 
30 INSANITY. 
 
 Vicious habits, 25 per cent. 
 
 Constitutional and evolutional causes, 28 per cent. 
 
 1. Direct Physical Causes. — These are such as 
 affect mental operations through direct action upon 
 the brain: as a blow on the head; injury; haemor- 
 rhage; disease of any kind, as cancer, consumption, 
 Bright^s disease; child-bearing and its attendant 
 j)erils; prolonged nursing, etc. In each of these 
 there is a direct action upon the brain, either from 
 violence, through increase or diminution of its blood- 
 supply, through deleterious substances carried in the 
 blood, or through altered nervous sensations going 
 from the part affected to the brain. 
 
 2. Indirect Physical and Emotional Causes. — 
 Under this head are grouped: fright; shock (not 
 shock from injury, but mental shock); grief; care 
 and anxiety; business failure; trouble of all kinds; 
 domestic infelicity; disappointed affections; the 
 feigning of insanity, etc. Causes such as these affect 
 the brain indirectly through the physical system. 
 The man who has failed in business, for example, 
 loses sleep over it; he does not take the proper 
 amount of exercise, perhaps through fear of meeting 
 acquaintances and having his troubles brought 
 vividly before his mind; his appetite is impaired — 
 he takes food indifferently or refuses it altogether. 
 He has actual distaste for food, — this because his 
 changed habits of life have brought about disorder 
 with the emunctories of the system: the bowels, kid- 
 neys, skin, and lungs. What food he takes is imper- 
 
INSANITY. 31 
 
 fectly digested and badly assimilated. The blood- 
 supply to the brain is insufficient and impoverished 
 in quality. Sleep is troubled by painful dreams, it 
 does not rest him, and the process of repair which 
 constantly goes on in the brain during sleep in the 
 normal state is not carried on naturally during the 
 period of emotional strain. lOventually, through all 
 these causes, he loses his ability to think, to feel, to 
 act naturally; and there conies to be a prolonged 
 departure from his normal standard in these respects, 
 constituting insanity. 
 
 3. Vicious TTahiis. — Tender this head are classed: 
 intemperance; opium, chloral, and cocaine habits; 
 sexual excess; self-abuse; and all habits of life which 
 directly undermine the physical constitution and thus 
 affect the brain. ^ 
 
 4. Constitutional and Evolutional Causes. — Under 
 this head come all causes of insanity which operate 
 because of some innate defect in constitution or de- 
 velopment of the individual. Here hereditary tend- 
 ency figures to a great extent. One inherits a sus- 
 ceptibility, so-called, to mental disease from intem- 
 perate, vicious, insane, or delicate ancestors. His 
 nervous constitution is unequal to the task of carrying 
 him through certain inevitable crises in development. 
 There is known hereditary tendency to mental dis- 
 
 ^ It will be observed that vicious habits are, after all, but 
 direct causes; but for convenience and clearaess they are 
 separately considered. 
 
32 IKSAKITY. 
 
 ease^ either remote or immediate, in about 50 per 
 cent, of all cases under treatment in large insti- 
 tutions. Probably if tlie facts were invariably dis- 
 coverable, the percentage wonld be fonnd vlastly 
 greater. 
 
 Aniong the constitntional and evolntional causes 
 are : — 
 
 Pubescence. — The pubescent period is that during 
 which the boy or girl passes to manhood or woman- 
 hood. At this period the organs of reproduction 
 ,take on development, and a change in the character- 
 istics of the person occurs. Certain desires, aspira- 
 tions, and tendencies not before felt are then first ex- 
 perienced. It is a critical time in the life of the 
 person, and, unless he or she is well organized, 
 mental overthrow is apt to occur. A form of disease 
 known as recurrent mania frequently develops at this 
 stage of life. The age at which pubescence is estab- 
 lished varies in different climates. For this climate it 
 is approximately from 13 to 16 years. 
 
 Adolescence. — Possibly the individual may have 
 passed safely the pubescent period, having inherited 
 sufficient nervous strength to carry him beyond this 
 first physiological crisis, but at the next develop- 
 mental period (that of adolescence) he breaks down, 
 without direct assignable cause, or from some cause 
 which would be insufficient to produce insanity in 
 one well constituted. The adolescent period comes 
 at the age of 30 to 35. 
 
 Again: The mile-stones Pubescence and Adoles- 
 
INSANITY. 33 
 
 cence may ]je left behind in the march of develop- 
 ment, and tJie person go on mentally well until the 
 change of life, — the so-known Climacteric Period. 
 This change in the woman takes place at the age of 
 about 45; in the man, between 50 and GO. It marks 
 in both a stationary plane. The period of develop- 
 ment is past, and those organs which took on activity 
 at the time of the pul)escent epoch begin to cease 
 active functionating. 
 
 About fifteen years later — in the woman of 60, and 
 the man of 70 — Senile changes (those due to old age) 
 make their appearance, and mental and bodily feeble- 
 ness ensues. Frequently mental feebleness reaches 
 such an extreme that insanity is said to exist. 
 
 We have thus the four periods: Piibescence, mark- 
 ing the advance from youth to manhood; Adolescence, 
 that from manhood to maturity (these two periods 
 are developmental or evolutional); Climacteric, the 
 stationary period; and Senile, the dissolutional 
 period, or period of decay. 
 
 Causes of insanity may be conveniently grouped 
 under one of the four heads above mentioned. In 
 c^ery case the natural constitution of the subject 
 figures to a greater or less extent. It is true of the 
 direct and indirect physical causes, as well as of 
 vicious habits, that a cause feeble in its intensity may 
 produce a disturbance of balance in one not well or- 
 ganized, whereas one having a good nervous inherit- 
 ance and strong mental equipment may be able to 
 resist the cause and retain his integrity of mind. 
 
34 INSANITY. 
 
 Forms of Insanity. 
 
 There is no such, thing, strictly speaking, as a dis- 
 ease of the mind; but the expression is commonly 
 employed, and is a convenient one for describing dis- 
 turbances of those operations of the brain which in- 
 volve consciousness. Mental disease is always associ- 
 ated with disturbance of function or structure of the 
 brain. Among the pathological conditions are con- 
 gestions, effusions, anaemia (lack of blood-supply), 
 opacities of the membranes, thinning of the gray 
 matter, adhesions of the membranes to the cortex^ of 
 the brain, and degeneration of brain-matter. 
 
 The names commonly employed in the classifica- 
 tion of mental disease chiefly stand for groups of 
 symptoms'. Mania being a Greek word, meaning 
 furor; Dementia being derived from two Latin 
 words: de, without, and mens, the mind; Paranoia, 
 from Greek words para, defective, and nous, under- 
 standing. One notable exception is in the name 
 Melancholia, which comes from two Greek words 
 meaning "black bile,^^ it being supposed by the 
 ancients that this affection was incident to disorder 
 of the liver. 
 
 Insane conditions may be conveniently grouped 
 under four general heads: — 
 
 1. States of mental elation. 
 
 2. States of mental depression. . 
 
 3. States of mental weahiess. 
 
 ^ The covering of gray matter. 
 
INSANITY. 35 
 
 4. Structural Irain disease, ivith yroviinent mental 
 manifestations. 
 
 Under States of Mental Elation are found Mania 
 Acute, Mania Chronic, Mania Eecurrent, and Hys- 
 tero-mania. 
 
 Under States of Mental Depression: Melancholia 
 Simple, Melancholia with Stupor, Melancholia with 
 Frenzy^ Hypochondriacal Melancholia, and Hystero- 
 melancholia. 
 
 Under States of Mental Weakness'. Dementia 
 Chronic, Dementia Monomania, Dementia after Mel- 
 ancholia, Dementia after Mania, Paranoia, Imbecil- 
 ity, and Idiocy. 
 
 In the last group — Structural Brain Disease — 
 may be included Paretic Dementia, Dementia with 
 Paralysis, and Epileptic Dementia. 
 
 MANIA ACUTE. 
 
 Mania Acute is an insanity of recent onset, the lead- 
 ing characteristics of which are elation, changing delu- 
 sions, and active excitement. 
 
 The development of Mania is usually somewhat 
 sudden, although it will be found, as a general thing, 
 that the patient has suffered, for some time before 
 excitement occurs, from depression, emotional dis- 
 turbance, sleeplessness, loss of appetite, and bodily 
 derangements. When excitement appears, the pa- 
 tient becomes noisy, restless, incoherent in his con- 
 versation, and lacking in self-control. All of the 
 fr.culties of the mind are affected. 
 
36 IKSANITY. 
 
 The Thii^king is much disordered, manifesting it- 
 self along the following lines: — 
 
 Sensation is lively; impressions travel qniekly, 
 and are chiefly objective and pleasurable. 
 
 Perception false. Hallucinations of sight and hear- 
 ing are frequent;, are of a changing character, and are 
 usually pleasurable. Illusions are rare. 
 
 Memory temporarily impaired; percepts registered 
 inaccurately or in a distorted way. 
 
 Organic Memory changed. Personality changed, 
 leading to delusions such as those of great strength 
 and power, — that of a superior being. 
 
 Ideation much interrupted; percepts come into 
 consciousness one after another irregularly, are not 
 grouped into concepts accurately (incoherence), and 
 are fleeting and disorderly. 
 
 Reasoning and Judgment impaired. Incoherence 
 in grouping of concepts. Delusions of a changing 
 character, usually pleasurable. Delusions of divine 
 patronage, a call to preach, and inspiration are not 
 uncommon. 
 
 Feeling: — 
 
 Emotions exalted and pleasurable. 
 
 Acting: — 
 
 Will impaired. Mental reflexes prompt: Inhib- 
 itory control lost or greatly impaired. Assaults are 
 made impulsively, or blows and kicks are dealt to 
 others because of the irregular and excited muscular 
 action constantly present. Destructiveness. Atten- 
 tion is fixed with difficulty — one thing after another 
 
INSANITY. 37 
 
 engaging- it temporarily. Impressions, largely object- 
 ive and being derived from different objects in rapid 
 succession, are fleeting and inaccurate. 
 
 Physical Symptoms. — The circulation is rapid; the 
 skin hot; the tongue dry and coated; the eyes suf- 
 fused and congested; the temperature elevated; the 
 urine scanty; bowels at times loose, at other times 
 costive; sleep fitful; headache and other evidences of 
 pain rare. There is no actual distaste for food, but 
 occasionally refusal of food, — this from inattention, 
 and not from delusions. 
 
 In Mania there is no tendency to suicide. The 
 habits are frequently^ untidy by reason of inattentive- 
 ness to bodily wants. 
 
 Terminatio7i. — The tendency of simple Acute 
 Mania is toward recovery, provided the physical 
 health can be maintained. 
 
 In this connection it is desirable to speak of a 
 form of acute mania partaking more of the nature of 
 inflammatory action of the brain. In this disease, 
 called Acute Exhaustive Mania, all the above symp- 
 toms are extremely intensified; the excitement is 
 more of the nature of delirium; there are low mut- 
 tering, picking at the bed-clothes, accumulation of 
 sordes upon the teeth, higher fever, increasing debil- 
 ity. Death is very apt to occur from rapid exhaustion. 
 
 MANIA CHKONIC. 
 
 Mania Chronic is an insanity of long duration the 
 leading characteristics of which are elation^ greater 
 
3S INSANITY. 
 
 fixity of delusions than in acute mania, restless- 
 ness, ir7^it ability, and mental impairment. 
 
 The termination of mania acute^ when recovery 
 does not ensue^ is nsnally in dementia chroniC;, or in 
 Mania Chronic — the form of disease under considera- 
 tion. This is^ therefore^ a secondary condition. 
 
 In Chronic Mania: — 
 
 Sensation is less lively; impressions are less rapid. 
 They are^ as in acute mania^ largely objective, but, 
 as a rule, less pleasurable. 
 
 Perception false. Hallucinations of any or all of 
 the special senses may be present, are of fixed charac- 
 ter, and are not invariably pleasurable. Illusions are 
 occasionally present. 
 
 Memory permanently impaired. 
 
 Organic Memory impaired. Personality changed. 
 
 Ideation interrupted. Percepts less rapid, and 
 more regular, than in acute mania; incoherence less 
 marked. 
 
 Reasoning and Judgment impaired. Incoherence 
 in grouping concepts frequent, but not invariable. 
 Fixed delusions. 
 
 Emotions superficial; easily stirfed. Irritability. 
 
 Will impaired. Attention is more easily fixed. 
 Mental reflexes prompt. Inhibitory control impaired, 
 but hot lost; assaults are made from this cause, from 
 delusions, or from excessive irritability. 
 
 Physical Symptoms. — These are of no especial sig- 
 nificance. As a rule, vegetative functions are carried 
 
iNSANixr. 39 
 
 on normally; appetite and appropriation oi' food 
 good. 
 
 Tendency to suicide, none. Habits are very fre- 
 quently untidy because of failure to correct degraded 
 tendencies in the aeute stage of the disease. 
 
 Termination. — Recovery from Chronic Mania is 
 not apt to occur. 
 
 RECURRENT MANIA. 
 
 Recurrent Mania is a disease characterized hij 
 periods of excitement, periods of depression, and, at 
 times, periods of composure and complete lucidity. All 
 powers of the mind are more or less affected in Re- 
 current Mania, the symptoms presented varying with 
 the stage of the malady. In excitement the demeanor 
 of the patient is similar to that of acute mania, but 
 excitement is rarely so high. Well-marlced delusions, 
 illusions, and hallucinations are frequently absent, 
 and there may he perfect coherency. The conduct of 
 the patient during excitement is mischievous, and 
 apparently attributable to moral perversion. He 
 seems to be prompted by malicious feelings. If de- 
 structive, he appears to be so deliberately. In the 
 period of excitement he misconstrues motives, makes 
 unfounded accusations, sets patients up against each 
 other or patients against attendants. There is im- 
 pairment of the inhihitory control. 
 
 The increased capacity for cerebral effort and the 
 heightened emotional tone shown early in the period 
 
40 INSANITY. 
 
 of excitement are well illustrated by the following 
 letter from a patient: — 
 
 Eastern Michigan Asylum. 
 
 PoNTiAC, Mich., July 29, 1894. 
 
 Dear Dr. Burr: Please allow me to take a minute to tell 
 you that I am fully aware that my present condition is one 
 of "elation." But I believe and hope I shall go safely 
 through without a "bust-up." Your kindness and the con- 
 sideration extended me by all your staff are highly appre- 
 ciated. I am sleeping fairly well now, have good appetite, 
 and, of course, life has a good deal of sunshine for me just 
 at present. As you know, about the only time that I can 
 write, or compose, anything worth anybody's reading is 
 during a period of elation; so I feel as though I should 
 "make hay while the sun shines"; but I do not intend to 
 inflict much or many (?) of my lucubrations upon yourself. 
 
 Very respectfully yours, 
 
 During the period of depression the patient is 
 dull and listless. He lacks energy and application. 
 His conduct is similar to that of one suffering from 
 melancholia^ but there is usually an absence of fixed 
 delusions. As the excitement is less than that of 
 acute mania^ so the depression is less pronounced 
 than in melancholia. The patient is frequently re- 
 morseful for unpleasant acts which he has done dur- 
 ing excitement. Depression may shade off into com- 
 plete composure and lucidity of weeks^, months^^ or 
 years' duration^ or on its subsidence excitement may 
 again slowly make its appearance, 
 
INSANITY. 41 
 
 Physical Symplonis. — Jii the period of excitement 
 all ol the bodily J'liiiclions are carried on normally. 
 In the period of depression there is apt to be con- 
 stipation, sleeplessness, headache, distaste for food, 
 painful sensations coming from the internal organs, 
 and dyspepsia. 
 
 IIYSTEKO-MANIA. 
 
 This is a form of insanity consequent upon the 
 uncJiecJied inipuhes arising from an hysterical mental 
 organization. These unchecked impulses of the 
 hysterical patient may become to such an extent 
 habitual that a true insanity develops. The acts 
 of disorder, the noisiness, the destructiveness, so 
 prominent in these cases, are due to impairment of 
 the will and the inhibitory control. There is an 
 absence of delusions, although the patient may feign 
 their existence. Patients of this description are very 
 imitative and are apt to do what they see other pa- 
 tients about them doing. Along with the excitement 
 there are the usual Physical Signs of Hysteria: the 
 pallid countenance, flushed only during active mental 
 disturbance; the cold, clammy hand; the relaxed and 
 perspiring skin; the dilated pupils; the sensation of 
 a ball in the throat. 
 
 MELANCHOLIA SIMPLE. 
 
 Melancholia Simple is a form of insanity present- 
 ing depression and fixed delusions. It is, in almost 
 every particular, the complete reverse of acute mania. 
 
4:2 INSANITY. 
 
 Its development is slow. Disturbances of tlie emo- 
 tions are the earliest manifestations. As in mania, 
 there are sleeplessness, loss of appetite, and bodily 
 derangements, but from different causes than those 
 which obtain in excitement. 
 
 Sensation is dull; impressions travel slowly, and 
 are chiefly subjective and painful. 
 
 Perception false. Hallucinations of hearing are 
 frequent, of sight rare. Hallucinations are of a fixed 
 character and usually painful. Illusions may be 
 present. 
 
 Memory not much impaired. Percepts registered 
 accurately, but slowly. 
 
 Organic Memory impaired. Personality may be 
 changed, and in consequence the delusion of demo- 
 niacal possession, or others equally unpleasant, ap- 
 pear. 
 
 Ideation slow. Percepts are grouped coherently, 
 but with difficulty, leading to the delusion that the 
 mind is hopelessly lost, that the mental operations 
 are checked by some external power. 
 
 Reasoning and Judgment. — Coherency unimpaired. 
 Delusions are almost invariably present; they are 
 of a more or less uniform character; a belief in un- 
 worthiness; that the unpardonable sin has been com- 
 mitted^ that the conduct of the patient has brought 
 harm upon others; that he is responsible for the sins 
 of the world; that his family is coming to want. 
 Delusions are always of a painful nature. 
 
INSANr."Y. 43 
 
 Emotions depressed, painful. Emotions arc de- 
 pressed to such a degree, at times, tliat the patient 
 believes himself incapable of mental feeling. 
 
 Will slow to act, because every act involves dis- 
 tinct effort. Inhi1)itory control unimpaired. Atten- 
 tion can be fixed, ]jut the effort is wearying. Mental 
 reflexes slow. Assaults upon strangers or people not 
 related to the person are rare. Homicidal assaults 
 are sometimes made upon children, or near and dear 
 relatives, because of the delusion that want or sorrow 
 stares them in the face, and that they would be better 
 off dead than living. There is no tendency to de- 
 structiveness. 
 
 Physical Symptoms. — The circulation is slow; the 
 skin pale and cold; the tongue moist and coated, 
 and shows indentations from the teeth because of 
 deficient tonicity; the pupils are large, and respond 
 slowly; the sclerotics are pearly white; temperature 
 is normal or subnormal; urination som^etimes pro- 
 fuse, because of intense emotion; bowels invariably 
 costive; sleep poor and troubled by painful dreams; 
 headache at the vertex or occiput (anaemic headache) 
 almost constant, — as a rule, worse in the early morn- 
 ing; appetite lost; food is refused from delusions of 
 unworthiness to eat or of bringing want upon others. 
 
 In Melancholia there is strong tendency to suicide. 
 The habits are usually tidy. 
 
 Termination. — Eecovery, or chronic dementia. 
 The relatively frequent termination of Melancholia 
 
44 INSANITY. 
 
 in dementia is due largely to the marked disturb- 
 ances of reasoning and judgment, shown by the fixed 
 character of the delusions. 
 
 MELANCHOLIA WITH STUPOR. 
 
 This form of Melancholia gives to the physiog- 
 nomy of the patient the appearance of one suffering 
 from mental impairment. There is a dull, sodden 
 expression. There are great torpor and apathy. 
 Delusions exist, and are of a painful character, but 
 are much less active than in simple melancholia. 
 The circulation is feeble, the hands are blue and cold, 
 and temperature is frequently subnormal. All the 
 mental faculties are blunted. Volitional acts are per- 
 formed feebly and after much urging. The mental 
 reflexes are very slow. The appearance, in brief, 
 is that of extreme mental and bodily depression, 
 feeling (emotion) being also depressed to the extent 
 that acute mental suffering does not exist. Food is 
 refused because of torpor and dejection; if placed 
 in the mouth, it is permitted to remain unswallowed 
 — if fluid, it may run out upon the face. Untidiness 
 of habits is frequently present. There is not, as a 
 rule, tendency to suicide. 
 
 Termination. — In this disease there is a strong 
 tendency to dementia, with fixed habits, as that of 
 holding the hands in unnatural positions or assuming 
 constrained attitudes. 
 
INSANITY. 45 
 
 MELANCHOLIA WITH FRENZY. 
 
 This is a form of disease having characteristics of 
 hath mania and melancholia. There are noisy excite- 
 ment, restlessness, destnictiveness, tendency to self- 
 mutilation and self-injury. Because of having cer- 
 tain features in common with mania, it can best be 
 studied by comparison of the two forms of insanity. 
 Thus, we have, both in Mania and in Melancholia 
 witli Frenzy, excitement and sleeplessness. In tlie 
 latter case, however, the excitement and sleepless- 
 ness occur in consequence of delusions of persecu- 
 tion; in Mania, in consequence of exalted emotions. 
 In Ijoth, sensation is lively, attention is fixed with dif- 
 ficulty, and perception is false; but, while in Mania 
 impressions are chiefly objective and pleasurable, in 
 Melancholia with Frenzy they are both subjective 
 and objective and painful. The attention, in ^lania, 
 is fixed with great difficulty, because of the rapidity 
 with which impressions come from without; in 
 Melancholia, because of the concentration of atten- 
 tion largely upon that which is within. Hallucina- 
 tions, in .Mania, are frequent and changing, and 
 usually pleasurable; illusions are rare. In Melan- 
 cholia with Frenzy, hallucinations are almost con- 
 stant, are of fixed character, and painful; illusions 
 are common. The memory and organic memory are 
 in both cases altered. Organic sensations are changed. 
 There are disturbances of sensation in the skin in 
 Melancholia with Frenzy, leading to picking of the 
 
4:S IKSAKITY. 
 
 face and scaljo to remove fancied insects or vermin. 
 The ideation^ and reasoning and judgment;, are in 
 both, cases impaired; but, while in Mania there are in- 
 coherence and delusions of a pleasurable character, 
 in Melancholia with Frenzy there are partial coher- 
 ence and distressing delusions. The emotions, in 
 Mania, are exalted and pleasurable; in Melancholia 
 with Frenzy, lively, but painful. The one suffering 
 from Melancholia with Frenzy shows prompt mental 
 reflexes, makes assaults, is destructive and disor- 
 derly; but for a different reason than the one suf- 
 fering from Mania. In the latter case it is because 
 of the rapidity with which the confused mental 
 operations are carried on, inattention, and changing 
 mental impressions; in the former case, because of 
 the existence of delusions. If the man suffering with 
 Mania makes an assault, it is from lack of inhibitory 
 control, or because of the irregular and excited mus- 
 cular action which is constantly present. If one 
 suffering from Melancholia with Frenzy makes an 
 assault, it is to ward off fancied injury. 
 
 The Pliysical Symptoms in both instances are very 
 much the same. If food is refused in Mania,, it is 
 because of inattention; if in Melancholia with 
 Frenzy, because of delusions of poison. 
 
 In Mania there is no tendency to suicide, while 
 the tendency to suicide in Melancliolia ivith Frenzy 
 is extreme. One cannot be too watchful of these 
 cases. In Melancholia with Frenzy self-mutilation 
 frequently occurs, sometimes in an abortive attempt 
 
IKSAKITY. i^ 
 
 to commit suicide; again, from the belief in an of- 
 fending member, — that the eye "offends" and should 
 be "plucked out/' or that the presence of the sexual 
 organs has contributed to the distress of the patient, 
 and that they should be removed. 
 
 Termination. — The tendency of Melancholia with 
 Frenzy is toward recovery, provided sufficient food 
 can be introduced into the system, either by natural 
 or artificial means, to keep up the strength, upon 
 which there is a constant and tremendous drain be- 
 cause of excitement. 
 
 HYPOCHONDRIACAL MELAXCHOLIA. 
 
 In this form of disease, frequently occurring at the 
 climacteric period, the thoughts of the patient seem 
 to be entirely self-centred. The idea of unworthi- 
 ness, which is so common in simple melancholia, and 
 that of persecution, which pertains to melancholia 
 with frenzy, are, as a rule, absent. Impressions are 
 wholly subjective and arise from disturbances of 
 Organic Sensation and Organic Memory. These lead 
 to the belief that the bowels are removed; that they 
 are closed up; that the brain is sodden and can no 
 longer act; that the blood does not circulate; that 
 food does no good, is not digested, and not absorbed; 
 that the kidneys are gone; that the sexual organs 
 are without activity, and the like. Patients having 
 Hypochondriacal Melancholia suffer mnch distress 
 of mind, and are a source of great drafts upon the 
 sympathy and resources of those having the respon- 
 
48 INSANITY. 
 
 sibility of their care. Appearing, as the disease does, 
 so frequently at the change of life, just before nerv- 
 ous decay sets in, the organic sensations which give 
 rise to the delusions may often be attributed to fail- 
 ure in nervous supply to the internal organs, with 
 consequent impediment to their functionating. 
 
 HYSTERO-MELANCHOLIA. 
 
 While hystero-mania at its inception is largely 
 the result of unchecked impulses determining mus- 
 cular movements, Hystero-melancholia is the result 
 of the habitual lacJv of restraint upon the emotions. 
 Patients with Hystero-melancholia present the ordi- 
 nary signs of hysteria. In addition, they are ex- 
 tremely emotional, but rarely give way to active 
 excitement, as in hystero-mania. They weep easily; 
 they suffer, in fancy or actually, much mental dis- 
 tress; they are incapable of exertion. They per- 
 mit their limbs to become contractured from disuse. 
 They present paralysis of motion and anaesthesia 
 (lack of sensation).^ Such patients are without 
 delusions, aside from those which strictly pertain to 
 bodily sensations and movements. Cases of Hystero- 
 melancholia are not, as a rule, suicidal, — delusions 
 
 ^ One patient with whose case I was familiar, who sub- 
 sequently recovered, remained for eighteen years in bed, 
 exacting the most constant care from her relatives. She 
 believed herself paralyzed, and when she first came under 
 my observation her knees were flexed at a right angle and 
 the muscles of the lower extremities withered almost to 
 nothingness from disuse. 
 
INSANITY. 49 
 
 as to unworthiness, the unpardonable sin, poison, or 
 persecution, which impel to suicide in melancholia 
 and melancholia with frenzy, not being in existence 
 in these cases. They ofteii threaten suicide, and one 
 may, U7ider strong impulsion, seize a favorable op- 
 portunity to destroy himself. I have known the 
 approach of a train of cars to furnish this opportu- 
 nity to one whom I have every reason to believe was 
 not seriously contemplating self-destruction. It 
 should be remembered, furtlier, that acts committed 
 for the purpose of exciting alarm or sympathy, and 
 not intentionally suicidal, may result fatally. 
 
 DEMENTIA CHRONIC. 
 
 This is a terminal stage of mania acute and other 
 uncured forms of insanity. It is defined as mental 
 impairment acquired, to distinguish it from imbecility 
 and other congejiital mental impairments. There are 
 all degrees of Dementia, and the extent to which 
 Dementia is apparent upon slight acquaintance with 
 the person depends a gTeat deal upon his original 
 mental capacity. To take a concrete illustration: 
 One possessing originally a hundred concepts, or 
 ideas, and losing one-half of them through De- 
 mentia, would show mental weakness less than he 
 originally in possession of fifty who had lost one-half. 
 The capital remaining in the first "case would be 
 much larger than in the second, and leave a better 
 basis to do mental business on. Dementia, there- 
 fore, is a relative expression. All of the faculties 
 
50 INSANITY. 
 
 of tlie mind are impaired in Dementia. This is par- 
 ticularly true of the Memory, the Eeasoning and 
 Judgment, and the Volition. 
 
 Sensation is slow. 
 
 Perception of ordinary objects may not be inac- 
 curate. There frequently remains, however, a resid- 
 uum of the hallucinations and illusions of the earlier 
 period of the mental disorder — the grounds in the 
 tea-cup, so to speak. These, however, are less active, 
 less pleasurable, or less distressing, as the case may 
 be. 
 
 Reasoning and Judgment are impaired. 
 
 Memory is impaired. 
 
 Attention is feeble. 
 
 Habits formed in the acute stage of disease — for 
 instance, the habit of grasping the hands tightly, or 
 of passing the hand over the face, or of moving the 
 arms, at one time expressive of painful emotions — 
 may be, and frequently are, continued in Dementia, 
 without any emotional basis. Likewise the habit of 
 picking the skin, plucking out the hair, or mutilating 
 the finger-nails may be continued. 
 
 Physical Symptoms immaterial. Sleep, appetite, 
 digestion, and assimilation usually good. 
 
 Demented patients act slowly. They initiate 
 (begin) very little, and frequently require close 
 supervision and painstaking effort on the part of 
 others to direct their energies successfully into useful 
 channels. Habits of employment, however, which 
 have become so definite as to be, in a measure, auto- 
 
iisrsANiTY. 51 
 
 matic, may be well carried on, even where there ex- 
 ists incapacity for mental application and fixing of 
 the attention. 
 
 Patients in Dementia are frequently childish. 
 They react to little pleasures, trifling pains, and dis- 
 appointments much as children do. The Inhibitory 
 Control is always impaired. 
 
 Irritability is more or less constantly present, and 
 assaults are made from this cause. Usually for as- 
 saults there is some real or fancied provocation, 
 though it may be nothing more than the inadvertent 
 jostling of one hy another in passing. 
 
 Carelessness in habits is invariable; neglect of 
 personal appearance so constant as to require to be 
 corrected by others. Degradation in habits is some- 
 times present— this largely becanse of lack of effort 
 on the part of somebody else to correct improper 
 tendencies during the acute stage of the patient's 
 disease. 
 
 Termination. — Dementia Chronic is hopeless as 
 regards recovery; but much can be done by well- 
 directed endeavor to form the patient's habits, cor- 
 rect vicious and degraded tendencies, and establish 
 systematic employment, rendering life fairly com- 
 fortable. 
 
 IDIOCY AND IMBECILITY. 
 
 These are mental defects from congenital causes or 
 arrest of development in infancy. In Idiocy there 
 is a complete absence of mental action, the operations 
 of life being purely vegetative. 
 
52 IKSAKITY. 
 
 Imbecility is of all grades; from that which is 
 extreme up through the so-called defective types to 
 paranoia., the highest form of congenital mental in- 
 firmity. Imbeciles are lacking in self-control, are 
 irritable, impulsive, mischievous, and imitative of 
 improprieties. The higher faculties of the mind are 
 feebly developed. Powers of thinking are circum- 
 scribed. The emotions of imbeciles are easily 
 aroused, and inhibitory control is feeble; conse- 
 quently they often do acts of violence. They are 
 not, as Imbeciles, proper subjects for treatment in 
 institutions for the care of the insane, — measures 
 adapted to them being more of an educational than 
 medical nature. Imbeciles, like sane people, how- 
 ever, may become insane. 
 
 PAEANOIA. 
 
 Paranoia is a form of disease occurring in one of 
 congenitally defective nervous organization, and marhed 
 ly certain ivell-defined symptoms which seem to he 
 due to defects of development, and frequently appear 
 as an exaggeration of the natural characteristics. 
 
 One suffering from Paranoia is from childhood 
 somewhat peculiar. He may be bright and receptive 
 in certain ways, may learn readily in school, but 
 shows eccentricities of conduct; is self -conceited, 
 introspective, and develops asymmetrically. With- 
 out obvious exciting cause, or with some slight cause, 
 as a fever, a trifling injury, or a disappointment, he 
 becomes suspicious. This feeling is usually at first 
 
INSANITY. 53 
 
 vague and indefinite. Mental depression may pro- 
 ceed to a considerable degree. There are associated 
 with it, however, no fixed delusions of unworthiness, 
 or of poison, as in melancholia, but vague ideas of 
 conspiracy and disposition on the part of others to 
 deprive him of his property or business rights. A 
 business failure, perhaps, which has been the natural 
 outcome of poor methods and indifferent applica- 
 tion, is charged up to the machinations of those in- 
 imical to liini.^ 
 
 This is the so-called "persecutory stage." Follow- 
 ing this is what is known as the "transition stage." 
 Some event may occur in the patient's life — a visual 
 hallucination, a vivid emotional experience, a dream, 
 a fortuitous circumstance, a casual remark by another, 
 or the encounter of a passage in reading — which may 
 furnish to the patient a key or clue to the mysteries 
 surrounding his past career. He begins then to see 
 that things have thus been planned out for him from 
 the beginning; that he was to be brought up by 
 those claiming his parentage, to conceal his noble 
 birth; that he is a prophet, or even Christ. He 
 diligently cons the Scriptures for references to him- 
 
 ^ I once knew a patient who, in this condition, enlisted in 
 the army. He felt himself watched and checked in his laud- 
 able undertakings, on every hand; he believed that the 
 generals of the army — Sherman and Grant— were conspiring 
 to keep him in the position, of private, and prevent his meet- 
 ing that reward in promotion to which his abilities and meri- 
 torious conduct entitled him. 
 
54 INSANITY. 
 
 self^ and finds in this passage and that the predic- 
 tion of his coming; of the persecution to which he 
 will be subjected; of his ultimate triumph. He sees 
 now the reason why he has been persecuted in the 
 past. It has been because of the envy of others^ or 
 because those who knew of his mental gifts or his 
 true social position desired to keep him from coming 
 into his inheritance. 
 
 It is not difficult to see in the foregoing a de- 
 scription of the cranks of the world — the "harmless 
 insane/^ the physician's ofiice-bore and the neighbor- 
 hood nuisance. The usual quiet conduct, the con- 
 tinued application to business, the ability to con- 
 verse rationally on current topics, the bright memory, 
 the logical method of presenting beliefs, the perfect 
 volitional control, frequently deceive as to the true 
 nature of the patient. 
 
 As a matter of fact, the so-called cranks, of this 
 description, constitute a dangerous element in so- 
 ciety. They are apt to make sudden homicidal as- 
 saults in consequence of delusions.^ Many of the 
 
 ^ They believe that in committing acts of homicide they 
 are benefactors of society. Thus: — 
 
 Chicago, December 8. — Prendergast, the assassin, made a 
 formal protest against the plea of insanity being introduced 
 in his case to-day. When he was led into Judge Brentano's 
 court-room, he handed his attorney, Mr. Essejx, a letter in 
 which he asked that the insanity plea be withdraAvn, declar- 
 ing that he believed people will get an idea that he did not 
 kill Carter Harrison for the benefit of the people at large, 
 
INSANITY. 00 
 
 assassins of distinguished persons have belonged to 
 the Paranoiac class. Jn asylums, such patients are 
 frequently very comfortable and able to control un- 
 pleasant characteristics. They accept their confine- 
 ment as part of the scheme in their lives, believing 
 that some good will eventually accrue to them or 
 the world in consequence. They often show a sort 
 of proprietary interest in the institution, and are 
 useful in various lines of work. 
 
 Dementia is not rapid in these cases. Some re- 
 tain until late in the disease a tolerably full pos- 
 session of their original i)ower to think correctly, 
 except in the line of their delusions; to reason upoji 
 subjects foreign to themselves; to recollect perfectly; 
 to acquire new facts; and even to display ability in 
 the line of construction or invention. 
 
 To recapitulate. In Paranoia w^e have: — 
 
 Sensation unaffected. 
 
 Perception unaffected, as a rule. Occasionally 
 hallucinations occur. 
 
 Memory unimpaired. 
 
 Organic Memory and Personality changed. 
 
 Ideation unimpaired. 
 
 Reasoning and Judgment. — l^o incoherence in 
 grouping of concepts; but, reasoning from false 
 premises, a logical delusion results. 
 
 but rather from a personal or selfish motive. Attorney Essex 
 declined to state whether he would give the letter any con- 
 sideration. — Press Report. 
 
56 INSANITY. 
 
 Emotions, in persecutory stage, painful; after 
 transition period, as a rule pleasurable. 
 
 Attention unaffected. 
 
 Will unimpaired. Eefiexes unimpaired. Assaults, 
 if made, are because of delusions of conspiracy or 
 fraud. 
 
 Physical Symptoms, immaterial. There is fre- 
 quently a distinct lack of symmetry of the head. 
 
 There is rarely any tendency to suicide. Excep- 
 tional cases, lioivever, are extremely suicidal. The 
 habits are tidy. 
 
 Termination: chronicity. Tendency to Demen- 
 tia is not as pronounced as in the acute forms of 
 disease, such as mania and melancholia. 
 
 DEMENTIA AFTEK MANIA AND DEMENTIA AFTER 
 MELANCHOLIA. 
 
 In these disorders there is a condition of temporary 
 impairment consequent upon the prolonged disorder of 
 the mental operations. The patient thinks, feels, and 
 acts slowly, but in other respects in a manner ap- 
 proaching the natural. The time is a critical one, 
 and great caution is necessary that the patient be 
 not mentally overstimulated. Overstimulation oc- 
 curring, — too much introduced at once into the 
 mental life, — confusion is apt to result and recovery 
 to be hindered or prevented. The patient must not 
 overstrain his mind at first, but by degrees come into 
 its full exercise. The blacksmith convalescing from 
 
INSANITY. 57 
 
 typhoid fever should not at first wield the heavy 
 sledge all day. 
 
 DEMENTIA MONOMANIA. 
 
 The symptoms of Dementia Monomania are those 
 of mental impairment, with a single delusion, or 
 several delusions of the same general type. Three 
 classes of patients show this disease in its purity: 
 those suffering from insanity due to prolonged, 
 steady alcoholic indulgence; traumatic cases; and 
 those having mental trouble due to constitutional 
 disease, as consumption and cancer. Hallucinations 
 of sight and hearing of a persecutory type com- 
 monly accompany the alcoholic cases; and visceral 
 illusions, delusions of poison, unseen agency, and 
 suspicion attend constitutional disease. Visceral 
 illusions are due to perverted organic sensations. 
 Clouston, a distinguished Scotch alienist, once made 
 the extreme assertion that a pure and uncomplicated 
 monomania of suspicion points to the existence of 
 consumption. Certain it is that this particular symp- 
 tom is almost universally found in insanity from con- 
 stitutional disease. 
 
 SENILE DEMENTIA. 
 
 This is a variety of Chronic Dementia occurring in 
 consequence of old age and general nervous and mental 
 hrealcing-down. There are impairment of all the 
 mental processes; irritability; perversions of feeling, 
 
58 INSANITY. 
 
 especially toward near relatives; and oftentimes ex- 
 treme mental confusion and incoherence. At times a 
 recollection of remote events is present^, but recent 
 events are not recorded in memory. Such patients 
 frequently require^ toward the last^ the same atten- 
 tion it would be necessary to bestow upon little chil- 
 dren. 
 
 EPILEPTIC DEMENTIA. 
 
 This is mental impawment associated with Epilepsy. 
 There is slowly increasing feebleness of thinkings 
 feelings and acting. Just before^, during^ or imme- 
 diately following epileptic convulsions there are apt 
 to be great mental confusion, irritability, and im- 
 pulsiveness. Assaults are made and outrageous con- 
 duct is indulged in, without subsequent recollection 
 (Disorder of Higher Reflexes). 
 
 Epileptic patients are apt to be untidy, especially 
 during convulsions, when involuntary expulsion of 
 the contents of the bowels, bladder, or seminal vesicles 
 may occur. These patients are extremely dangerous 
 to others. I have known suicidal attempts among 
 epileptics, and accidents which require surgical in- 
 tervention are common. 
 
 There is great danger to epileptic ■ patients in 
 going to high places, from the use of cutting instru- 
 ments, or from being near machinery. I have known 
 one to fall from a boat while in a seizure, and drown 
 immediately, despite the well-directed efforts of his 
 companions to save him. 
 
INSANITY. 59 
 
 PARETIC DEMENTIA (SYN.: PARESIS, GENERAL 
 PARALYSIS OF THE INSANE). 
 
 This is a disease displaying slowly increasiufj men- 
 ial impairment, disorders of muscular movement, dis- 
 turbances of Jiigher reflexes (inco-ordination), mental 
 and physical decay. It is a disease of adult life, and 
 observed chiefly in those wlio.se habits have been 
 irregular; who have been addicted to excesses of 
 various kinds; have had syphilis; have been steady 
 drinkers; or who, from one cause or another, have 
 rapidly exhausted their nerve-force. 
 
 It is a structural brain disease. There exists de- 
 generation of the cortex (gray covering) of the Ijrain, 
 and a low grade of inflammation of the cortex and 
 membranes. A patient breaking down with paretic 
 dementia is at first visionary and erratic. He is full 
 of pleasurable emotions; has large ideas of busi- 
 ness; entertains impracticable schemes; perhaps loses 
 much money because of poor investments and im- 
 proper ventures. His handwriting becomes some- 
 what irregular, and he drops words. In executing 
 the finer movements of the fingers and of the face, 
 he shows lack of precision. Hesitation and thick- 
 ness in speech early occur, giving to those knowing 
 the person, but unaware of his nervous breaking- 
 down, the impression that he is drinking to excess. 
 Later there is frequently showm a lack of respect for 
 the rights of property, and appropriation of what 
 comes within reach, under the impression that it 
 
60 INSANITY. 
 
 belongs to the patient. The feelings are easily 
 stirred, and the patient is extremely irritable if op- 
 posed in his impracticable notions. Delusions grow 
 more and more extravagant as mnscnlar inco-ordi- 
 nation and debility increase. The patient believes 
 himself possessed of thousands of millions; that he 
 is the strongest man in the world; that he can set 
 out worlds in the heavens; that he is God; that 
 train-load after train-load of diamonds is coming to 
 him direct from the mines; that he owns all the 
 banks and the fleetest horses; that, in order to fly, 
 all that is necessary is to make the first attempt. 
 The fine lines of expression of the face become 
 slowly obliterated. The pupils are unequal or 
 strongly contracted. There is often a glassy appear- 
 ance of the cornea. From bad to worse the patient's 
 condition goes on, with occasional periods of remis- 
 sion. Seizures of an epileptiform or apoplectiform 
 character occur. Sometimes death comes suddenly; 
 of tener as a result of slow exhaustion, and after a 
 tedious period of confinement to bed, during which 
 bed-sores, dependent upon a lack of nutrition of the 
 skin, develop. Toward the close of life the patient 
 requires the same degree of attention as a little child, 
 but as long as consciousness remains there is a feel- 
 ing of strength, of power. Chohing from paralysis of 
 the throat, angesthesia, and paralysis of the Madder, 
 which may result in overdistension and rupture, are 
 symptoms encountered from time to time and should 
 be especially guarded against. There is often ex- 
 
INSANITY. 61 
 
 treme fragility of bones, and fractures occur from 
 muscular action or trifling accidents. The expression 
 "first rate/' which has been termed the "verbal 
 formula of a hopeless malady/' is used in reply to 
 inquiries as to the health. Periods of furious, un- 
 reasoning excitement are apt to occur. In these, 
 fortunately of l)rief duration, as a rule, the patient 
 loses all self-control, tlirows himself about, grates his 
 teeth, and is noisy and extremely destructive. 
 
 The above are the usual manifestations of this 
 form of disease. Occasionally the mental symptoms 
 are those of extreme depression, and then there is an 
 intensity, an exaggeration, so to speak, of depression 
 which, taken in connection with the physical signs, 
 enables the observer to distinguish the condition from 
 melancholia. There is absence of grandiose delusions. 
 Deep-seated disturbances of Organic Sensation and 
 Organic Memory occur, leading to the belief that a 
 portion of the organism is dead or that the body is 
 "all gone." Such cases as this — lacking the one 
 element which is present in those of the other class, 
 — viz., that of good feeling — are pitiable in the ex- 
 treme. 
 
 Sensatiofi — at first lively, later slow — may be abol- 
 ished. 
 
 Perception false. Hallucinations or Illusions at 
 times present. 
 
 Memory hopelessly impaired. 
 
 Organic Memory impaired. Personality totally 
 changed. 
 
62 INSANITY. 
 
 Ideation feeble; irregular. 
 
 Reasoning and Judgment progressively impaired. 
 Grandiose delusions. 
 
 Emotions, as a rule, exalted and pleasurable; some- 
 times extremely depressed. 
 
 Will impaired; inhibitory control impaired and 
 lost; higher cerebral reflexes impaired and lost. The 
 Attention is fixed with difficulty. 
 
 Physical Symptoms. — Progressive lack of power 
 in the voluntary muscles, and inco-ordination of 
 movement; change in pupils; constipation or diar- 
 rhoea; enormous appetite; lack of control over the 
 bowels and bladder; retention of urine; cystitis; 
 bed-sores; fragility of bones; convulsions or apo- 
 plectiform attacks. 
 
 In Paretic Dementia there is, as a rule, no tend- 
 ency to suicide, but self-mutilation may occur, in the 
 belief that a dead or offending member should be 
 removed. 
 
 The homicidal tendency is met with in occasional 
 cases. One patient planned to crush another's head 
 in a door. 
 
 Habits careless from the first, and toward the 
 close of the disease untidy and degraded. 
 
 Termination: death. 
 
 DEMENTIA V7ITH PARALYSIS. 
 
 This is a form of dementia produced hy, and de- 
 pendent upon, previous damage to the hrain by an 
 apoplectic attack, the occlusion of some blood-vessel 
 
 y 
 
INSANITY. G3 
 
 cutting off the nutrition of certain parts of the brain, 
 or cerel)ral degeneration in some of its forms. Here 
 well-defined delusions are rare, but there are great 
 irritability, emotional disturbance, perversions of 
 feeling, and a tendency to misconstrue the motives of 
 others. 
 
 The outlook in this disease is unfavorable. Im- 
 pairment of the bodily and mental health is apt to 
 go slowly on. Death may occur from apoplexy or 
 an epileptiform or apoplectiform seizure. 
 
PART HI. 
 
 MANAGEMENT OF CASES OF INSANITY. 
 
 The successful management of cases of insanity 
 necessitates recognition of the physical basis of men- 
 tal disease, and the directing of treatment to the 
 brain the organ of the mind. 
 
 It is the duty of those having the grave responsi- 
 bility of caring for the insane intrusted to them to 
 have in mind these two great aims: — 
 
 1. To promote the recovery of patients. 
 
 2. To limit the amount of dementia in unrecov- 
 ered cases, and thereby promote their well-being and 
 happiness. 
 
 As every case of mental disease is a law unto it- 
 self, so must each be individualized and treated upon 
 its own merits. There can be no wholesale plan of 
 management. 
 
 Quickness of perception, kindness, tact, and good 
 judgment are qualities indispensable to the success 
 of an attendant upon the insane. Kindness implies 
 though tfulness, attentiveness, conscientious devotion: 
 sentiments which find their reflex in judicious, well- 
 directed effort. Coddling, demonstrativeness, and 
 display of warmth of affection are always unnec- 
 sary and frequently detrimental to the interests of 
 patients. Kindness should find its chief expression in 
 good deeds, not in words. 
 (64) 
 
MANAGEMENT OF CASES. G5 
 
 The recovery of patients is promoted by 
 
 1. Building up the general liealtk; 
 
 2. Correcting pernicious habits', and 
 
 3. Checking morhid impulses. 
 
 To build up the general health, there are neces- 
 sary good food, exercise, abundance of sleep, and 
 possibly medication. 
 
 The Administeatiox of Food is the most im- 
 portant duty of an attendant, and upon its successful 
 accomplishment everything depends. Food should 
 be delicately prepared, temptingly served, and pre- 
 sented to the patient in an inviting manner. Dishes 
 and utensils should be scrupulously clean and bright; 
 the tray covered with a clean spread; a napkin pro- 
 vided for the patient's use, which, in case he is fed 
 by the hand of another, should be placed about his 
 neck to protect the clothing. Before giving food, 
 the person of the patient should be cleansed, the face 
 sponged, and hands thoroughly cleaned by the use of 
 the nail-brush; the nails trimmed. The patient 
 should have an opportunity to rinse his mouth with 
 cold water, and a tooth-brush or a cloth should be 
 used upon the teeth to remove unhealthy accumula- 
 tions. 
 
 Where food is refused from inattentiveness, as in 
 Mania, it is often impossible to give more than a 
 few spoonfuls of -liquid at a time. In such cases the 
 administration of nourishment should be repeated 
 every hour or every half-hour, as may be, those times 
 being selected during which the patient's attention 
 
66 MANAGEMENT OF CASEB. 
 
 can be gained — when it is the least occnpied with 
 other matters. Inattentive joatients sometimes take 
 food better at night, when all is still, than in the 
 day-time. 
 
 Where food is persistently refused because of delu- 
 sions, — as in Melancholia or Dementia Monomania, 
 — a careful study of the patient's characteristics and 
 peculiarities will commonly point a way to the end, 
 and resort to rectal alimentation or mechanical feed- 
 ing will Ijecome more and more rare as experience 
 increases. Milk is an ideal food for the insane, and 
 in debilitated cases it is often well to give it in con- 
 nection with egg and liquor, as in an eggnog. In 
 meeting capricious and delicate appetites, gruels, 
 custards, broths, wine-whey, beef-tea, koumiss, 
 jellies, and fruits will all be found of service. In 
 states of acute exhaustion or threatening exhaustion 
 attended by unhealthy conditions of the mouth and 
 digestive tract, lemon-juice or lemonade in small 
 quantities is often of the greatest value. Certain 
 patients will take liquid food in small quantities 
 where solid food is altogether refused. A patient 
 having delusions of poison may accept eggs boiled 
 in the shell, or potatoes baked in the skins, particu- 
 larly if the cooking goes on in his presence, nat- 
 urally believing that no poison can be introduced 
 into these articles. One who ignores the request of 
 his attendant or physician may eat in obedience to 
 that of some fellow-patient. Another will take food 
 from the dinino'-room after the others have left. 
 
MANAGEMENT OF CASES. 67 
 
 picking up something here and there, who is un- 
 willing to eat in the presence of others, or who be- 
 lieves that he is unworthy to be served until they 
 have finished. One will eat if left alone and appar- 
 ently unnoticed. Another will take food if he can 
 acquire it surreptitiously; and opportunity should 
 be afforded suspicious patients to thus appropriate it. 
 One will eat crackers or bread, or fruit, if placed in 
 his pocket. Another will exchange plates with a 
 neighbor, and take the food prepared for him, be- 
 lieving that no poison has been introduced into that 
 particular plateful. One suffering from active delu- 
 sions of poison may accept part of a glass of milk if 
 his attendant shows sufficient confidence in it to drink 
 a portion in the patient's presence. One l)elieving 
 it wicked for her to eat, will often take food if it is 
 forcibly placed in tlie mouth — the least show of force 
 being all that is necessary to effect the entrance of 
 the spoon. Under this coercion she feels that she 
 escapes responsibility for the doing of that which her 
 conscience disapproves. In giving food, as well as 
 bestowing other attentions upon suspicious patients, 
 an affectation of indifference is often very efficacious. 
 Under these circumstances a patient believes that the 
 attendant has no personal interest, has no ends to 
 serve. 
 
 Whatever delusions or morbid impressions in- 
 fluence the patient, whether of repugnance to food 
 or delusions of suspicion or poison or extravagance 
 (which latter cause the patient to believe that he is 
 
68 MANAGEMENT OF CASES. 
 
 of finer fibre than those abont him and not depend- 
 ent as they npon nutritive substances) the careful 
 attendant or nurse will^ as a rule, be equal to the 
 occasion, and the necessity for forced feeding will be 
 avoided. There is a wide variety of liquid food of 
 unquestioned value from which to make selection; 
 among these milk, malted milk, Mellin's food, broths 
 of various kinds, and Phillip's digestible cocoa are 
 convenient for administration and adapted to weak 
 digestions. 
 
 Mechanical feeding should be the last resort, and 
 the operation invariably be performed by the physi- 
 cian. It should be borne in mind in this connection 
 that there is oftentimes danger of overfeeding; that 
 where a condition of much debility exists, harm may 
 be done by the introduction into the stomach at one 
 time of what would be, under ordinary conditions, a 
 proper amount of food; the assimilative powers are 
 arrested, the secretions deranged, and the organs of 
 digestion in no condition to care for it. For the pur- 
 poses of nutrition in these cases a teaspoonful to a 
 tablespoonful of milk given in the natural way after 
 intervals of an hour is better than the administration 
 of a larger amount artifically. Milk, preparations of 
 beef, milk-toast, and other albuminous foods may be 
 pancreatinized — artificially digested — ^before admin- 
 istering, and in certain instances a purely liquid food 
 may be advantageously administered by the rectum.^ 
 
 ^ In certain cases this is helpful for its moral effect. I 
 have known patients to take food with avidity to escape the 
 humiliation of rectal feeding. 
 
MANAGEMENT OF CASES. 69 
 
 In the Administration of Medicine only the 
 smallest amount of force in opening the mouth is 
 justifiable. It is far better, under ordinary circum- 
 stances, to give medicine by enema than to force it 
 into the mouth and compel its being swallowed by 
 holding the mouth and nose — an expedient which is, 
 I fear, too frequently resorted to, and of which I 
 personally very much disapprove. In giving food or 
 medicine Ijy enema, however, the anatomical rela- 
 tions of the parts should be borne in mind and plenty 
 of help provided, so that no danger will be encoun- 
 tered of doing the patient injury. I have known a 
 fatal accident to occur from the administration of 
 an enema. In the introduction of the syringe-nozzle 
 the assistance of vision will be, in the case of an ex- 
 cited or frenzied patient, indispensable. 
 
 Personal Attention and ^N'ursing. — The pa- 
 tient sJiould 1)6 'kept tidy and neat at all times. Every- 
 thing about him — clothing, bedding, furniture — 
 should be changed and laundered or aired at fre- 
 quent intervals. Clothing and bedding must be 
 changed immediately if soiled, and the person of the 
 patient at each changing must be carefully bathed. 
 Eiforts should be made to inculcate fixed habits of 
 tidiness, by getting the patient to sit upon the cham- 
 ber or taking him to the closet at stated times if 
 he is strong enough to be gotten up from bed. The 
 condition of the bowels should be carefully looked 
 after, that constipation or other derangements may 
 not ensue. Heed should be given that the patient 
 
70 MANAGEMENT OE CASES. 
 
 urinates at regular intervals. Patients laboring un- 
 der excitement fail to empty the bladder, from in- 
 attention; patients suffering from melancholia, from 
 apatjiy and indifference. Paretic patients often have 
 distension of the bladder because of lack of power 
 to expel its contents, or because of the absence of the 
 impulse to urinate, arising from sensory paralysis. 
 It is important to call to the attention of the physi- 
 cian any suspicions of failure of the patient to empty 
 the bladder, that the dismal accident of rupture may 
 not occur. The details of catheterization, giving of 
 enemata, attention to bed-sores, and care of the feeble 
 pertain to ordinary sick-nursing. 
 
 In nursing the insane it should be constantly borne 
 in mind that symptoms of any disease, as, for in- 
 stance, pneumonia, may be masked by the mental 
 condition, and that complaint may not be made of 
 pain, discomfort, or even severe distress. 
 
 ExEECiSE. — It is of the utmost importance that 
 one suffering from mental disease, whose strength 
 will permit, should be taken out-of-doors for exercise 
 every day in pleasant weather. Great caution should 
 be observed to assure one's self that the patient's 
 physical condition will admit of his going. He 
 should not be taken for exercise to-day because of a 
 general direction to this effect yesterday, but the 
 advisability of the act should be invariably deter- 
 mined before a step is taken. There should be care 
 that the walk is not too long; that the patient is 
 not fatigued by it; that he is not taken into places 
 
MANAGEMENT OF CASES. 71 
 
 of danger; that he is not exposed to the cold, or to 
 tlie heat of the sun, unduly; that he is suitaljly 
 clothed; that he is not permitted to sit upon the 
 damp ground or loiter in places where he may he 
 seen hy others and his condition made the subject 
 of remark. In maniacal excitement, unless the 
 strength is too much reduced (and in a decision of 
 this kind the o})inion of the physician should be 
 taken), walks are well ])orne and are profitable. The 
 restlessness of mania must have vent. To repress it 
 too much is to intensify excitement and do the pa- 
 tient harm. In the occupation of walking out-of- 
 doors there is a diversion of the nervous energy into 
 healthy channels. The sleep and the appetite are 
 better, and all the bodily functions are more satis- 
 factorily performed in consequence of it. Fresh air 
 in abundance is introduced into the lungs; the 
 blood is more rapidly and perfectly oxygenated, — 
 it is of a more favorable quality to nourish the brain. 
 The bodily secretions are quickened. That form of 
 exercise is the best in which the largest number of 
 muscular groups can be utilized, and, as a rule, that 
 the most satisfactory which introduces a variety of 
 healthy percepts into consciousness. This is true for 
 obvious reasons, it having been shown under "Lim- 
 itations of the Wiir^ that a thought cannot be dis- 
 missed l)y mental effort, but must be supplanted by 
 another in order that it may be removed. Patients 
 suffering from mental depression are frequently 
 averse to going out-of-doors, or even to the society 
 
72 MANAGEMENT OF CASES. 
 
 of their fellow-patients. In overcoming this disposi- 
 tion, the attendant is promoting his patient's well- 
 being and lessening the intensity of his morbid men- 
 tal operations by presenting healthy subjects for con- 
 templation. Pleasurable emotions stimulate vital 
 activity. All are aware of the depressing effects of 
 trouble, bad news, mental shock — how they take 
 away the appetite and derange the bodily functions. 
 The contrary is true of pleasurable emotions. All of 
 the vital functions are stimulated by these to greater 
 activity; hence their importance as aids to the re- 
 covery of the insane. 
 
 In Hypochondriacal Melancholia there is, gener- 
 ally speaking, a disinclination to take exercise, and it 
 is important that this disposition should be met and 
 the determination of the patient to remain in-doors, 
 in his room, or in bed be thwarted. Much caution 
 should be observed, however, that undue exercise is 
 not taken, and the patient's complaints and protests 
 should be duly weighed.^ 
 
 Employment and Diveksion are desirable for 
 the same reasons that exercise is desirable. Through 
 them healthy topics of thought are introduced to dis- 
 
 ^ I once knew an hypochondriacal patient to be sent out- 
 of-doors for a walk by her physician, it being believed by 
 him and by all who had dealings with her that her objections 
 to going out were purely mental, and that there was no 
 physical condition which would be a barrier to the exertion. 
 On the morning in question she had gone but a few steps 
 when she fell dead from heart-failure. 
 
MANAGEMENT OF CASES. 73 
 
 place those of a morbid character; muscular action is 
 diverted from unhealthy into healthy channels; vol- 
 untary control is stimulated; the ability to fix the 
 attention is increased; restlessness, disorder, and 
 destructiveness are diminished; sleep, appetite, and 
 the bodily functions are improved. The furnishing 
 of a congenial diversion, such as taking a patient to 
 a concert or a church-service, often supplies an ef- 
 fective motive for self-control and is a stepping-stone 
 to his recovery. 
 
 In recent mental diseases, employment is of serv- 
 ice for the immediate well-being of the patient, sub- 
 stituting new topics of thought and directing the 
 energy along useful lines. 
 
 In arresting the tendency to dementia, employment 
 is of the utmost value. In settled dementia we not 
 only find employment an outlet for nervous energy, 
 which is apt to expend itself in moving restlessly to 
 and fro, in picking at the clothing, and in degraded 
 habits, but we possess in it a means of re-education of 
 the brain, of opening new routes of nervous travel, 
 and bringing into action groups of nerve-cells not 
 formerly in commission. As my experience increases, 
 I am more and more convinced of the practicability 
 of employing almost all patients, no matter what 
 their mental condition may be — save those, of course, 
 enfeebled in body from paralysis or other cause — in 
 some line of work. The employment may be simple, 
 but will be found sufficient to contribute materially 
 to the welfare of the patient and that of others. 
 
"i i MANAGEMENT OF CASES. 
 
 In the progress of mental disease brain-waste is 
 rapid. Eestoration and repair are brought abont 
 during Sleep. It is consequently important that 
 nothing should interfere with the patient's obtain- 
 ing a suitable amount of rest. Exercise and employ- 
 ment in the day-time and the establishment of fixed 
 habits of living go far to bring this desirable state of 
 things about. Inability to sleep depends frequently 
 upon actual starvation of the nerve-centres. Under 
 such conditions the taking of a little food just be- 
 fore retiring — as a glass of hot milk or a cup of cocoa 
 or chocolate — may be all that is necessary to induce 
 repose. A warm bath or cool sponging to the spine 
 will also be found of value in some cases. Where 
 medicine is precribed for the purpose of producing 
 sleep it should be administered under the careful 
 direction of the physician; should^ as a rule^ not be 
 given where circumstances warrant its temporary 
 withdrawal; and should be discontinued as soon as 
 habits of sleep are measurably re-established. In 
 this matter, as well as in others connected with the 
 management of such cases, the patient's individuality 
 should be carefully studied. The reason why he does 
 not sleep should be discovered, if possible, and means 
 taken to meet the indication. One persistently wake- 
 ful and noisy at night — this from sheer timidity when 
 sleeping alone — may be quiet and calm and rest well 
 in a dormitory with others. A patient whom I once 
 had under observation, who for years was thought to 
 require an hypnotic at night because of noisy demon- 
 
MANAGEMENT OF CASES. 75 
 
 stratioiis, slept like a cliild after lieijig plaeed in a 
 covered bed, beeause lie believed that while there his 
 enemies eould not steal his sheep. Another patient, 
 suifering from chronic mania, was noisy the night 
 througli until afforded one day the opportunity to lie 
 down for an hour. That night she slept, and on suc- 
 ceeding nights, if she had najiped in the day-time, 
 she rested well. 
 
 Prolonged rest in led is frequently necessary. 
 Certain case« of Eecurrent Mania are, in disturbed 
 periods, quieter and more comfortable if permitted 
 to remain alone in bed than if up and about. Here 
 exhaustion of the brain is less, the horizontal posi- 
 tion affording a means for more perfect nutrition of 
 that organ. Fewer percepts are introduced into con- 
 sciousness, and mental confusion is less. In ordinary 
 cases of Eecurrent Mania this plan would be inadvis- 
 able, but in those exceptional cases attended by much 
 confusion and a high grade of excitement it is fre- 
 quently of great service. In xlcute Exhaustive Mania 
 the patient should be kept in bed to prevent further 
 physical decline, and should be nursed as one in the 
 delirium of fever. In Melancholia attended by great 
 physical depression, the mental operations are often 
 surprisingly improved by a few days in bed in a 
 horizontal posture — this for the reason already given. 
 
 The objections to rest in led are: the dangers of 
 suicide, of the formation of habits of inactivity, and 
 of the development of untidiness. These objections 
 may be met by w^atchfulness and attention. 
 
76 MANAGEMENT OF CASES. 
 
 COEKECTING PERNICIOUS HABITS AND CHECE:ING 
 MOEBID IMPULSES. 
 
 As the tendency of the insane person^s mind is 
 toward neglect in personal appearance, disorder, lack 
 of self-control, contemplation of morbid subjects, and 
 impulsive acting, so should the energies of those hav- 
 ing the responsibility of his care be directed to the 
 establishment of neatness, the correcting of habits of 
 neglect, the repression of evil or pernicious ten- 
 dencies, the substitution of natural for unnatural 
 thinking, and the restoration of habits of self-con- 
 trol. This is symptomatic treatment. 
 
 The custodial care of an insane person in an 
 asylum or hospital may be necessary or expedient^ 
 It may be necessary: (1) to protect the patient from 
 himself; (2) to protect others from the patient. It 
 may be expedient when not necessary. 
 
 Treatment away from home, or in an institution, 
 often accomplishes much for the patient; this for a 
 number of reasons. In the first place, one is apt to 
 exercise greater self-restraint among strangers or ac- 
 quaintances than among relatives. Latent powers 
 in this direction often become active after the trans- 
 fer of the patient from home. He falls readily into 
 the discipline and regime of an institution, and spon- 
 taneously displays powers of self-control not before 
 apparent. The withdrawal from scenes with which 
 former delusions have been associated contributes to 
 this. Eegular modes of life prescribed by others 
 
MANAGEMENT OF CASES. 77 
 
 take the place of self-appointed rules of conduct. 
 The routine itself is favorable — there is less to stimu- 
 late, less to annoy. In an asylum, the patient labor- 
 ing under excitement is not, as too often happens to 
 one in the care of relatives, threatened or punished 
 for disorderly conduct. If depressed he is not ad- 
 jured by everyone he meets to "brace u})." In an 
 asylum he becomes less introspective. He u thrown 
 into the society of those similarly afflicted, and finds 
 that his trouble is not more deep and abiding than 
 that of his neighbor. He perhaps recognizes in his 
 neighbor a deluded condition and can criticise in him 
 the conduct which springs from morbid ideas. Each 
 may be suffering from the same general class of de- 
 lusions, and each, recognize the error of judgment in 
 the other. 
 
 Eemoval from home is often an advantage through 
 substituting a real trouble for a fancied one. At 
 home the mind is occupied by morbid ideas to the 
 exclusion of everything else. Apart from familiar 
 scenes homesickness perhaps develops. As two sub- 
 jects cannot occupy consciousness perfectly at the 
 same time, there is here substituted a healthy for an 
 unnatural feeling, and a motive to recovery is sup- 
 plied. 
 
 It is often expedient to withdraw the patient from 
 his family; this in consequence of the influence of 
 his conduct upon the minds of his growing children. 
 The example of an insane member of a household, 
 and the anxiety and worry attendant upon his care. 
 
78 MANAGEMENT OF CASES. 
 
 are often to the last degree harmful^ and tend to 
 the mental deterioration of others. 
 
 It may be expedient to withdraw one from the 
 marital relation. There is, in some forms of insanity, 
 marked sexnal excitement, and indulgences growing 
 ont of this, condition may prove a serious obstacle to 
 the patient's recovery. 
 
 An insane person's removal from home may be 
 expedient for the benefit of society. While not ac- 
 tively dangerous, he may become so under provoca- 
 tion or through the development of new delusions. 
 Though apparently harmless, if he is disposed to 
 wander about and indulge in eccentricities of con- 
 duct and conversation he becomes a nuisance, an 
 annoyance, and his presence is demoralizing to the 
 community. 
 
 In the care of the insane punisliment should never 
 he employed. 
 
 Punishment is the infliction of pain for a crime 
 or fault. The insane person, having lost by disease 
 his ability to feel, to think, and to act in a natural 
 manner, is not responsible and should never be pun- 
 ished. It is appropriate, in my judgment, to supply 
 certain motives to self-control: as, for instance, with- 
 drawal of tobacco from those untidy in its use; or 
 denying those who have been guilty of improprieties 
 the privilege of attendance upon assemblies. These 
 disciplinary measures, though possibly regarded by 
 the patient himself as punishment, cannot justly be 
 thus considered. They are steps taken with the end 
 
MANAGEMENT OF CASES. 'J'O 
 
 in view of promoting tlie patient's self-respect and 
 establishing lialnts of neatness and self-control. The 
 ivithdraival of food or any of ihe necessaries of life, 
 as a correction for a fault, could never he, under any 
 circumstances, excusable, though, on the contrary, on 
 rare occasions the furnishing of a reward — as fruit, 
 candy, or a delicacy — because of some ])articularly 
 praiseworthy and commendal)le conduct, might be 
 justifial)lc. Scolding or harsh and ungentlemanly or 
 unladylil-e language should never he indulged in. It 
 does no good and is the source of no end of disagree- 
 ment and trouble. 0?ie is never excusahle for inci- 
 vility; and any tendency in this direction which the 
 attendant is conscious of in himself or which he sees 
 in others — patients or attendants — should be cor- 
 rected where practicable. 
 
 Employ the prefix "^Mr." or "Mrs.'^ invariably in 
 addressing your patient. Make requests; do not 
 command. A request pleases; a command antag- 
 onizes. An attitude of imperiousness toward the pa- 
 tient diminishes his regard for the attendant and if 
 the "order" is obeyed it is at the cost of his self-re- 
 spect. The attendant should be equally careful not 
 to be patronizing. To the majority of patients a 
 patronizing air is highly offensive. 
 
 In the government of patients, a firm, judicious 
 position should be taken and maintained. Be sure of 
 the right and propriety of the course, then consistently 
 pursue it. Let the judgment be made up calmly. 
 Waste no time in arguing or in reiterating again and 
 
80 MANAGEMENT OF CASES. 
 
 again what will be done in case compliance with a re- 
 quest is not forthcoming. The repeated You sJialVs, 
 which only call forth the I shall nofs, anger both 
 parties and are nnseemly. After calmly and dispas- 
 sionately telling yonr patient what course will be 
 taken in case of an indulgence in some particular 
 line of conduct^ carry out the plan without further 
 talk if the offense is repeated. 
 
 "How do you get on with this patient so well now- 
 adays ?^^ I once asked an attendant. "I guess it is 
 because IVe quit having the last word/^ she replied. 
 
 Avoid too much talking; heed reasonahle requests; 
 talie a firm and judicious position and maintain it. 
 
 Manual Eesteaint^ when necessary, should be 
 applied with the least possible show of force, and 
 never with violence. Forcible control may be neces- 
 sary to protect the patient from himself and to pro- 
 tect others from him. It is also expedient to prevent 
 bad habits and improprieties, to correct tendencies 
 to restlessness and excitement, and to promote self- 
 control. In my experience, force judiciously applied 
 and used as a last resort is rarely, if ever, complained 
 of, and does not give rise in the mind of the patient 
 to a permanent grudge or grievance. If, however, 
 the exhibition of force is the last link in a chain of 
 unpleasant circurnstances, for which the attendant is 
 to blame, its employment is not apt to be forgiven. 
 To illustrate: A command to do some particular 
 act is made, and is opposed because of the gruff or 
 authoritive manner behind it; a dispute arises; at- 
 
MANAGEMENT OF CASES. 81 
 
 tempts to coerce are made and resisted; both attend- 
 ant and patient become angry, and in the end tlie 
 patient suffers forcible control for that which was not 
 his, but the attendant's, fault. He is irritated and 
 affronted, and justly so. He has been treated badly. 
 
 The surroundings and person of the patient should 
 be spotlessly clean. An effort should be made, by 
 the introduction of pictures, books, pretty furnish- 
 ings, musical instruments, and games, to substitute 
 healthy for morljid topics of thought. Seek to get 
 the patient employed. r)ne is always more self-re- 
 specting when useful. 
 
 In the correction of certain vicious haljiis, more or 
 less frequent among those whose self-control is weak, 
 hard manual employment in the day-time and watch- 
 ful attention at night are the only agencies upon 
 which safe dependence can be placed. 
 
 The suspiciousness of patients is best met by frank- 
 ness and consistency, or, as mentioned under "Ad- 
 ministration of Food," by apparent indifference. 
 
 It is important that the attendant should be in the 
 confidence of the patient; hence the necessity that 
 the latter^s early impressions of his surroundings 
 should be favorable. In order to counteract morbid 
 impulses, the attendant must know about his patient's 
 mental operations. Unless in his confidence, these 
 may not be revealed. 
 
 Patients are suspicious of what they do not see. 
 It is unquestionably true that numberless accusations 
 of abuse are based upon sounds which patients hear 
 
82 MANAGEMENT OF CASifeg. 
 
 issuing from rooms with closed doors. Hence, so 
 far as is consistent witli modesty and propriety, per- 
 mit patients to see how others are cared for. 
 
 In the matter of delusions, he franh, tut do not 
 antagonize. If a patient states that he is God, it is 
 entirely nnnecessary to retort: "No, yon are not.^' 
 If, however, he asks: "Am I God?^^ it is the dnty of 
 the attendant to say: "We are tanght that the Lord 
 has never appeared npon earth bnt once, and then 
 in the person of Christ, many years ago." In this or 
 in some other way the question may be evaded, or 
 the attendant may quietly and pleasantly say, "No, 
 sir; that is an erroneous belief." Further discussion 
 of the matter is unnecessary and inadvisable. This 
 applies to recent cases, on the one hand, and, on the 
 other, to cases having confirmed delusions of long 
 standing. In the case of a convalescent patient, how- 
 ever, just as the mental cloud is lifting, timely, judi- 
 cious conversation may contribute much toward as- 
 sisting him to correct morbid judgments and control 
 diseased impulses. "He" (pointing to the nurse) "is 
 the first man that ever told me those ideas of mine 
 were not right," said a patient. "At home, when I 
 said ^I have the light here^ (opening his coat), they 
 told me it shone all over the room. He told me that 
 wasn't so and that such ideas would not be believed 
 here." 
 
 Homicidal assaults may arise in consequence of 
 delusions, or impulsive acts not intentionally homi- 
 cidal may result in death. The delusions which lead 
 
Management of cases. 83 
 
 to homicide are: first, those of persecution or of con- 
 spiracy; second, those of impending want and mis- 
 fortune. The only effective precaution against homi- 
 cide is vigilance. It is the duty of the attendant, in 
 cases of quarrels between patients, to interfere. This 
 may often be cleverly done by requesting of one his 
 assistance in some form of work at another part of 
 the room. Knives, scissors, and sharp instruments 
 should always be kept under lock and key. Brooms, 
 mops, dusters, and articles of this kind which may 
 be used as weapons, should never be left about, but 
 locked up immediately after using. Chamber uten- 
 sils should be dealt out only under the watchful su- 
 pervision of an attendant. Bath-tub keys, which 
 may be used like a l)rass knuckle, or with which hot 
 water may be drawn, should never be permitted to 
 come into a patient's possession. The searching of 
 clothing, bedding, and rooms should be systematic- 
 ally done, — in many cases daily, in the majority of 
 cases twice a w^ek. A threatening blow may some- 
 times be arrested by seizing the roll of the coat with 
 both hands, and qnickly drawing the coat down upon 
 the arms. 
 
 Homicidal impulses may exist for years under con- 
 trol and then suddenly develop; hence the impor- 
 tance of being fully informed of the character of the 
 patient's mental operations, and being ever on the 
 alert for the "unexpected,'' which is said always to 
 happen. 
 
 Suicide and self -mutilation may also be prevented 
 
S4 MANAGEMENT OE CASES. 
 
 by close watching and attention to the care of knives, 
 sharp instruments^, broken glassware and crockery, 
 and other articles with which injury may be inflicted. 
 Snicide by precipitation is relatively frequent; hence 
 the necessity for watchfulness when patients are^ out 
 walking, that they do not go into dangerous locali- 
 ties; that they have no opportunity to throw them- 
 selves before locomotives or street-cars, from high 
 places (as ladders or fire-escapes), under loaded 
 wagons, or into water. Care should also be exer- 
 cised that they pick up nothing with which they 
 may injure themselves subsequently. In-doors, at- 
 tention should be given to suicidal patients when 
 going up- and down- stairs, and the door to any shaft 
 should be kept closed and locked every moment when 
 the attendant is not standing in it. Be watchful lest 
 such patients throw themselves into open fire-places, 
 scald themselves, drown themselves in the bath-tub, 
 hang themselves in roller-towels, in sheets tied at 
 the window-guards, or in skeins of yarn suspended 
 from gas-fixtures. A patient whom I once knew 
 jumped up from the rocking-chair in which she had 
 been quietly sitting, faced the chair, and sprang into 
 it, only to throw herself backward upon her head. 
 She died almost at once. Unavoidable accidents of 
 this "nature will sometimes arise, notwithstanding the 
 most careful watching; but let no patient be afforded 
 the means of committing suicide, homicide, or self- 
 mutilation through the carelessness of an attendant. 
 Do not mahe the mistalce of Relieving that because a 
 
MANAGEMENT OF CASES. 85 
 
 patient continually talks of suicide he will not carry 
 threats into execution. Several fatal suicidal attempts 
 have occurred in my knowledge among patients of 
 this class. 
 
 Irrilahility. — This is frequently an expression of 
 physical pain of which the patient does not complain. 
 Its source should be looked for in sleeplessness, head- 
 ache, aching teeth, ahdominal pain, constipation, dis- 
 tended bladder, etc. 
 
 Mechanical Eestraint. — In tlie early days of 
 my asylum experience it was thouglit necessary to 
 use mechanical restraint often. Employment, night- 
 nursing, and personal attention have done away with 
 this necessity, until now in a well-ordered institution 
 resort to it is a conspicuous rarity. It may be neces- 
 sary in exceptional cases, but should never, except in 
 a grave emergency, be applied without the previously 
 expressed sanction of a physician. 
 
 Seclusion. — The isolation of a patient may be 
 expedient for his own benefit, or for the good of 
 others. When done, this should be with as little 
 demonstration and display of force as possible, and 
 only after due warning has been given. The course 
 may be necessary: first, because of noise and dis- 
 orderly conduct; second, in hysterical patients as a 
 measure of good (lack of self-restraint in these cases 
 being always greater when the patient is among other 
 people); third, because of obscenity or indecency; 
 fourth, to withdraw the nervous subject from per- 
 turbing influences and thus diminish mental con- 
 
86 MANAGEMENT OF CASES. 
 
 fusion.^ After secluding the patient, the door should 
 be locked quietly and without ostentation, or may be 
 left unlocked if it is believed that the patient will re- 
 spect the injunction to remain within the room. 
 
 Patients in seclusion should he visited frequently. 
 After quietly unlocking the door (doors should al- 
 ways be unlocked quietly) the key should be with- 
 drawn and placed in the pocket before the door is 
 opened. Both hands of the attendant are then free. 
 The practice of unlocking a door and pushing it for- 
 ward, hand on key, is extremely reprehensible and 
 dangerous. In entering the room of one who has 
 broken some piece of furniture and is making threat- 
 ening demonstration with a weapon thus secured, an 
 effective protection is a mattress held before the fore- 
 most attendant. By means of this the patient may 
 be crowded back and disarmed. 
 
 The objections to seclusion are: the danger of 
 suicide; the danger of increasing irritability; the 
 danger of untidiness. Suicidal patients should never 
 he secluded except with the previously expressed con- 
 sent of the physician, and, if apart from others, 
 should be carefully looked after. Seclusion some- 
 times increases irritability, ill-feeling, and wayward- 
 ness. When this occurs, harm results and the meas- 
 ure is inexpedient. 
 
 ^ Epileptic patients during confusional states are fre- 
 quently benefited by confinement to bed. Noise and dis- 
 order are lessened, and, fewer percepts coming into con- 
 sciousness, reaction, as manifested in impulsive assaults, is 
 diminished. 
 
MANAGEMENT OF CASES. 87 
 
 The disposition to hum and the tendency to steal are 
 observed in dift'erent forms of insanity. The fact 
 that these symptoms are conspicuously manifested in 
 some cases has led to their being improperly dignified 
 by special names for disease: as pyromania and 
 kleptomania. The tendency to burn is most fre- 
 quently observed in connection with chronic mania; 
 the tendency to steal, in the early stages of paretic 
 dementia, property being appropriated l^y the patient 
 under the delusion that it is his own. Patients who 
 are demented are apt to secrete articles of no value, 
 or little value, and unless carefully observed get 
 together accumulations of ruljbish and useless 
 trumpery. 
 
 Searching the clothing, the bedding, and possessions 
 of patients for matches and other articles collected, 
 and extreme watchfulness on the part of the attend- 
 ant to prevent things of this nature falling into the 
 patient's hands, are safeguards against accidents from 
 these sources. 
 
 Escapes. — In these days of open-door halls, em- 
 ployment out-of-doors, and the giving of larger and 
 larger liberties to patients, escapes will unfortunately 
 occur. They should never be chargeable to a lack of 
 vigilance or to disobedience of rules or regulations by 
 the attendant. Escapes, as other accidents, ^only too 
 frequently occur as the result of neglect of printed 
 rules. Eemember that the escape of a patient may 
 mean a homicide, an act of arson, or a suicide, and 
 
88 MANAGEMENT OF CASES. 
 
 let the attendant beware lest tlie accountability for 
 tbis be his. 
 
 Never, under any circumstances, talk of the condi- 
 tion of any patient to any person not entitled to re- 
 ceive information at)Out him. 
 
 The attendant is the agent of the people and rep- 
 resents them. He should be manly, high-minded, 
 and never frivolons. His position is an exalted and 
 responsible one. His work is appreciated by those 
 most familiar with his frequent acts of self-sacrifice, 
 heroism, and devotion. He should ever possess ex- 
 alted ideals, and in his rest from labor be able to 
 enjoy the satisfaction which springs from these and 
 from the consciousness of duty well-performed. 
 
PART IV. 
 
 SUGGESTIONS AS TO WHAT TO DO AND WHAT 
 TO AVOID IN CARING FOR THE INSANE. 
 
 Being an Address to the Training-school Class of 
 1895, Eastern Michigan Asylum. 
 
 My Dear Friends: 
 
 You have reached an important mile-stone in 
 your lives, and are to-night reaping the first public 
 reward of hard study and devotion to the highest 
 duties of the calling in which you are engaged. I 
 congTatulate you upon the successful accomplish- 
 ment of the work in which we set out together two 
 years ago. I stepped aside, and the benefits of the 
 last year which you have received have been lost to 
 me. The invitation to address you to-night gives me 
 a much-prized opportunity to say how deeply I have 
 felt our separation and how difficult a task has been 
 the severing of the bonds which attached me to this 
 school. Aware, as you are, of my affection for it, 
 you will not doubt that withdrawing my connection 
 with this dear institution, in which I have spent 
 many of my best years, was made doubly hard by the 
 thought that it involved separation from this class 
 
 (89) 
 
90 GENEKAL SUGGESTION'S. 
 
 and its agreeable associations. My heart is with yon, 
 and will always remain trne to the school, from 
 which I expect great results for good. Indeed, its 
 fruits and its influence have already justified its 
 establishment. Though it were to cease operations 
 with the graduation of this present class, the good it 
 has wrought would endure through all time. It is 
 impossible to estimate what its usefulness has been 
 and will be. No one can measure the importance of 
 a worthy aim earnestly followed. It is true of our 
 school that, were its house to fall to-day, its mission 
 would be found to have been to a great extent ful- 
 filled, and the results would be commensurate with 
 the outlay of time and study on the part of both 
 pupils and instructors. Fortunately, the good re- 
 ports I hear of your examinations, and the enthusi- 
 asm for the school on the part of those who have not 
 yet enjoyed its advantages, convince me that it stands 
 in no danger, that its work will go on uninterrupt- 
 edly, and that its corner-stone was not laid in vain. 
 It was a proud moment in my life when the mem- 
 bers of the first class in the training-school received 
 their diplomas; a prouder when the second class 
 graduated. It is the proudest now, when I stand 
 before you as valedictorian of this class which I 
 feebly assisted to instruct. Albeit, now one of the 
 "has-beens," and identified with the school only as 
 a, so to speak, quasi- emeritus instructor, I share your 
 pride in your work. I am with you heart and soul, 
 and would, if I could, assist you to assume the new 
 
GENEllAL SUGGESTIONS. 91 
 
 responsibilities which the reception of your diplomas 
 carries with it. 
 
 There is a pump at the Baldwin Building which 
 performs an important function. Steam, as you are 
 aware, is supplied to the different direct and indirect 
 radiators in the building for the purposes of heat- 
 ing. On cooling, the steam condenses and forms 
 water, which is returned to the boilers both for 
 purposes of economy in pumping, and because, be- 
 ing once deprived of its mineral ingredients by 
 conversion into steam, it becomes distilled, and no 
 longer forms deposits in the pipes and on the boiler- 
 shells. In this, the old building, the radiators being 
 higher than the boilers, water returns by gravity. 
 At the Baldwin Building, on the contrary, the water 
 is lower in the lower portion of the heating apparatus 
 than in the boilers and must be forced back. The 
 little pump has the work of forcing back this water, 
 and operates as will be more intelligible to you by 
 explanation of this black-board sketch. 
 
 Water falls from the radiators into this receiver, 
 "A"; reaching a certain level, a float is acted upon, 
 which in turn pushes up a lever, "5," which acts 
 upon a valve, "C/' in a high-pressure steam-pipe, 
 opens it, and releases steam. The steam flies to the 
 steam-chest of the pump, ''D''; the pump-piston 
 thereupon begins to travel, the suction, ''F/' to act, 
 and the water in the receiver is lowered to this line. 
 When this is accomplished, the valve "C"' closes, and 
 the pump ceases; but stands ready to resume opera- 
 
92 GENEEAL SUGGESTIONS. 
 
 tions the moment the normal water-level in the re- 
 ceiver is raised by pressure of the condensation from 
 below. Over and over this proceeding takes place. 
 I have watched this little pump again and again. I 
 never go to the Baldwin Building without looking in 
 upon the busy, contented, energetic, and determined 
 little fellow. He looks almost human, his expression 
 varying with the work he has in hand. If idle, he 
 is alert, and always stands ready to catch up the 
 broken thread. He has taught me some lessons, 
 which it is my good pleasure to communicate to you. 
 
 First. — He never changes his position or swerves 
 from a straight line. There he remains where 
 j)laced: calm, unassuming, serene, and self -poised; 
 but as determined as if the fate of the world de- 
 pended upon the faithful performance of his work. 
 With unerring stroke the piston travels back and 
 forth, back and forth, never making a false motion. 
 
 How much time is lost by false motions and what 
 a vast amount of work requires to be done over be- 
 cause not well done originally! 
 
 Do we remain where placed? Not always, I fear. 
 Do we deviate from a straight line in our daily 
 t^sks? Sometimes we do, I am sure; but I am 
 equally certain that much suffering, humiliation, 
 and self-censure would be spared if our walk and 
 conversation were always above reproach. Perhaps 
 it is too much to expect of erring mortals that this 
 shall be, but we can make a strong effort to emulate 
 the example of the pump, align our conduct by 
 
GENERAL SUGGESTIONS. 93 
 
 principles of rectitude, liold fast to that which is 
 good, and abate naught of the written law which 
 governs our relations with men, or of the Higher, 
 which forms the mainspring of right-doing. 
 
 Lesson 2. — The pump does whatever called upon 
 to do, and does it well When there is water in the 
 receiver above the proper level he does not rest until 
 it is drawn out. Tlie lives of men are fountains of 
 good and evil. In certain states, when the mental 
 balance is destroyed and the brake, which in health 
 the will places upon vicious tendencies, refuses to 
 operate, we may be the humble instruments of draw- 
 ing from our patients the good, and developing it. 
 A kind word, a generous act, a polite attention, the 
 "soft answer" which ''turneth away wrath," are daily 
 and hourly employed by the conscientious attendant 
 to draw out and nourish the latent spark of good 
 which disease has caused to remain dormant. 
 
 Using the words in another sense, we may draw 
 out the evil A\-hicli is within by directing the atten- 
 tion of the patient to things that are pure, and divert- 
 ing misdirected energy into healthy channels. 
 
 We can do whatever called upon to do, which our 
 physical and mental strength permits, even as the 
 pump performs his mission. 
 
 Lesson 3. — The pump does not overdo. He does 
 just enough, and no more. It is the judicious and 
 far-seeing attendant, who, in his relations with his 
 patient, knows just how far to go without antagoniz- 
 ing or arousing irritability and resistance. 
 
94 GENIlRAL SUGGESTIONS. 
 
 Some of tlie best-meant efforts fail from, over- 
 doing. Tliis is notably true of those which are 
 attended by too mnch talking. Talk often tires. In 
 conversation with one whose mental powers are weak- 
 ened by disease^ one shonld always remember the 
 danger of overstimulation producing mental fatigue 
 and confusion. 
 
 Lesson 4. — The pump never complains unless there 
 is lack of oil, or unless some part of his machinery 
 is out of condition. When there is lack of oil, or 
 when any mechanical obstruction to his operation 
 exists, he groans until his physician, the engineer, by 
 some attention starts him right. Trifles do not 
 annoy. It is only when quite seriously hampered 
 that he fails to do his work properly. I doubt if he 
 gives a thought to the Fenton Fair or Sunday-even- 
 ing permissions, and if called upon to do extra work 
 forges right ahead until all is accomplished that is 
 blocked out. Let the engineer raise or depress the 
 lever at this point, his speed decreases or increases in 
 proportion to the amount of steam released by the 
 valve. If hurried, he rises to the situation, and is 
 never cross when called upon to accelerate his move- 
 ments. 
 
 Lesson 5. — He does his whole duty. So long as 
 there -is a particle of water above the level in the 
 receiver, he keeps at work. The self-satisfied man 
 may flatter himself that he is doing his duty when 
 attending to the great things of life. The pump 
 does not ignore the little things. He works all the 
 
GENERAL SUGGESTIONS. 95 
 
 time that is necessary, attending to the trilling de- 
 tails which pertain to his small sphere of action. 
 
 Life is made up of little things. Simple duties 
 neglected, greater ones arise. Let the pump neglect 
 his work for a time, there is clogging of the entire 
 heating system of the building in which he presides. 
 The experiences of life teach that it is better to take 
 a few strokes with regularity — "to keep on sawing 
 wood/' as the expression goes — than to let work 
 accumulate. The disadvantage under which one 
 labors in the latter instance enhances the weight of 
 the burden. 
 
 Lesson G. — When the pump has nothing to do he 
 rests perfectly. He is like the normal heart in this 
 respect, which, between diastole and systole, is per- 
 fectly quiet, and receives in its walls the blood-supply 
 necessary for its nourishment. Some people do not 
 know how, and never can learn how, to rest. They 
 carry their business with them constantly. At their 
 reading, in their games, during their sleep, the spec- 
 tre of some duty unperformed haunts and disturbs. 
 This should not be the case. When off duty, let 
 your aim be to rest as completely as possible; let 
 there be perfect mental relaxation and physical 
 change. Eest does not necessarily imply sleep or 
 idleness, but change and diversion. This is physi- 
 ological rest. 
 
 Lesson 7. — In normal conditions the pump does 
 not make any noise. When there is a screw loose, 
 or oil is lacking, or something is wrong with the 
 
96 GENERAL SUGGESTIONS. 
 
 machinery, there is some commotion, bnt not other- 
 wise. He performs his duties noiselessly, spends no 
 time in getting ready to do, wastes no words abont 
 what he is planning, bnt qnietly and determinedly 
 carries out that purpose for which he was created. 
 There is no assumption of arrogance in his demeanor, 
 no blow and bluster, no fuss and feathers. He merely 
 displays a quiet assertiveness and a fixed resolve, the 
 effect of which latter is intensified by the unostenta- 
 tious, unobtrusive manner behind it. 
 
 I think I have told you about "Charles,^^ a special 
 attendant who was here many years ago, and cared 
 for a disturbed patient. Charles was not his name, 
 but he had been thus affectionately dubbed by the 
 gentleman for whose wants he was providing. "How 
 do you get on with Charles,^^ I asked the patient one 
 evening after having during the day, myself unob- 
 served, witnessed the relations of the two while out 
 walking, noticed the self-contained manner of the 
 attendant, and his judicious meeting of what might 
 have proven a serious episode. "^Very well,^' was the 
 gentleman's reply, "very well, indeed. He has his own 
 way usually. Charles is a very determined man, a 
 man of very few words; but when he says come, you 
 might as well come." 
 • Be determined, but humble and always polite. In- 
 sistence against the will of another upon a course 
 of action is robbed of its off ensiveness if it is politely 
 made. Do not say "come" unnecessarily. Be very 
 careful never to take a position with a patient which 
 
GENERAL SUGGESTIONS. 97 
 
 you cannot defend. Never threaten something which 
 you could not do with proper regard for the welfare 
 of the patient, and the institution whose reputation 
 you have in your keeping. 
 
 When necessary to say ''come'' say it kindly. "1 
 would if I were you/^ is an expression infinitely less 
 repellant than ''you must"; but even these unpleas- 
 ant words may be deprived of offensiveness by a gentle 
 apologetic manner in the speaker. Kever say "you 
 must" unless you are compelled to. If what you ask 
 is not complied with, do not repeat the request, but 
 gently and firmly enforce compliance with it. 
 
 Lesson 8. — The pump is small, but efficient. The 
 matter of size, except it be size of brain-cells, is of 
 less importance in your work than might be sup- 
 posed. It is the tactful, the discreet, the judicious 
 man, not necessarily the one of great physical strength, 
 who best succeeds in the management of cases of 
 mental disease. Great physical strength is desirable 
 only if there is present with it that gentleness in its 
 exercise which one of well-disciplined mind displays. 
 There is danger if its possessor is led into the error 
 of relying upon it to the neglect of those means of 
 management which are the result of thought, good 
 judgment, and careful study. 
 
 What to avoid do the lessons of the pump teach us. 
 
 First. — We have seen that he cannot remove ob- 
 stacles to his operations and is helpless under 
 mechanical difficulties. We, fortunately, in the exer- 
 cise of our reason and judgment and volition, can 
 
98 GENERAL SUGGESTIONS. 
 
 straighten the crooked path for ourselves, and cause 
 obstructions to melt away like snow before the sun, 
 if we but set about the task earnestly and hopefully. 
 We cannot afford to be cast down by difficulties, or 
 fold our hands and lament our misfortunes. We 
 must rise superior to all these, ever remembering 
 that the greater the difficulty, the greater the reward 
 whn overcome. 
 
 Second. — The pump cannot move if it would. 
 We may change our positions. Let us be assured 
 beyond a reasonable doubt, however, before making 
 decisions, that benefit, socially and financially, will 
 follow the change. Let not mere restlessness prompt 
 it. Let well enough alone, as a rule, and, in every 
 act of life, let good sense and reason act as a cheek 
 upon feeling and impulsiveness. 
 
 Third. — The pump is a machine. In our relations 
 with our patients we should aim to escape from being 
 machine-like. While there are certain acts in our 
 daily life which are better done in a routine fashion, 
 in doing the little things for patients, which together 
 constitute our general management, we must closely 
 individualize cases. By introducing variety (not too 
 much variety, but a little diversion and change) into 
 the daily lives of patients, we are helping mental ac- 
 tion,- substituting new topics of thought, and widen- 
 ing the mental horizon. Aim to induce patients to 
 do different things or the same thing in different 
 ways. If a morbid tendency induces one to remain 
 in the same position for hours at a time, interrupt 
 
GENiSllAL SUGGESTIONS. 99 
 
 the current in some way. Present something new in 
 exchange for the old. If a particular seat is selected 
 in obedience to some habit of dementia, change the 
 location of the chair, or furnish another surrepti- 
 tiously. If your patient insists upon sitting in his 
 room unoccupied, and absorbed in morbid thoughts, 
 induce him to work, break up in some way the dry 
 routine, and force, little by little, little by little (not 
 too rapidly, lest he tire) some healthy concepts into 
 ]iis consciousness. The use of games should be gen- 
 eral and frequent, and in patients who have no nat- 
 ural desire for amusements a taste should be culti- 
 vated. Be it ever so simple and childlike, occupation 
 or amusement of some kind introduced into the pa- 
 tient's life will be of service to him. 
 
 In one way, however, we may become machine- 
 like, to our own 1)enefit and the good of the patient. 
 The machinery of self-re])ression may Ije, by con- 
 stant exercise, so delicately adjusted as to operate 
 automatically, and inhibit (restrain) impulsive acts. 
 Anger and loss of self-control may be thus held in 
 check by the reflex exercise of nerve-centres well dis- 
 ciplined. We may follow the example of the pump 
 even to becoming machine-like in this particular. 
 
 In conclusion, I enjoin upon you, members of this 
 graduating class, a due appreciation of the respon- 
 sibilities you take upon yourselves with the reception 
 of these diplomas. Your relations Avith the asylum 
 will be infinitely closer from this time forward than 
 they have been in the past, your example, whether 
 
100 GENERAL SUGGESTIONS. 
 
 for good or ill^ incalculably stronger. Yon have in 
 yonr keeping the good name of the institution as well 
 as your own. May your works show that the new 
 responsibility is well placed and well assumed. For 
 good attendants my many years of experience has 
 taught me to entertain the highest respect. They are 
 a self-sacrificing^ earnest^ enthusiastic, and devoted 
 body of men and women. Too often, I regret to say, 
 their merits fail of due appreciation by the many who 
 must necessarily be unfamiliar with -their achieve- 
 ments, their self-denial, their discouragements. As 
 one's best reward, however, comes from a conscious- 
 ness of rectitude and honest effort, the attendant has, 
 with his boundless opportunities for doing good, a 
 source of satisfaction fully commensurate with his 
 self-sacrifice. 
 
 May the class of '95 never fail in its duty! My 
 sincerest wish is for the happiness, health, and pros- 
 perity of its members. 
 
INDEX. 
 
 I'AGE 
 
 Acute exhaustive mania ^7 
 
 rest in l)ed in ' '3 
 
 Acute mania '^^ 
 
 Administration of food G5 
 
 in exhaustion ^8 
 
 Administration of medicine 69 
 
 Adolescence (Lat. udolcsccre, to grow up) 32 
 
 Aids to recovery 65 
 
 Aims in management ■ 64 
 
 Alcoholic indulgence and dementia monomania 57 
 
 Ama?ba, the lowest form of animal life 3 
 
 Anesthesia, in hystero-melancholia 48 
 
 in paretic dementia 60 
 
 Apoplectiform seizures, in dementia with paralysis 63 
 
 in paretic dementia 60, 62 
 
 Apoplexy, as a cause of insanity 28, 62 
 
 in dementia with paralysis 62 
 
 Arguing with patient improper • • 79 
 
 Arresting tendency to dementia 64, 73 
 
 Arrest of development 51 
 
 Artificially-digested food 68 
 
 Assaults, homicidal, how prevented 82 
 
 in dementia chronic 51 
 
 in epileptic dementia 58 
 
 in paranoia 54 
 
 in paretic dementia 62 
 
 in mania acute 36 
 
 in mania chronic 38 
 
 in melancholia simple 43 
 
 in melancholia with frenzy 46 
 
 Asylum treatment '6 
 
 Attendant, importance of Ms w^ork -88, 100 
 
 Attendant, should be in patient's confidence 81 
 
 the agent of the people 88 
 
 Attendants - 64 e* seq. 
 
 (101) 
 
102 INDEX. 
 
 Attention, in dementia chronic 50 
 
 in mania acute 36 
 
 in mania chronic 38 
 
 in melancholia simple 43 
 
 in melancholia with frenzy 45 
 
 in paranoia 56 
 
 in paretic dementia 62 
 
 personal 69 
 
 to bladder .-70 
 
 to bowels . 70 
 
 to clothing, bedding, etc 69 
 
 to person 69 
 
 Bedding, attention to 69 
 
 Bed-sores in paretic dementia 60, 62 
 
 Biology 1 
 
 Bladder, attention to '. 70 
 
 distension of 60, 62, 70 
 
 rupture of 60, 62, 70 
 
 Blind, mental development in the. 15, 24 
 
 Bowels, attention to 70 
 
 Brain, degeneration in dementia with paralysis 62 
 
 disease, structural 35, 59, 62 
 
 the organ of the mind . 4 
 
 waste and repair ,. 74 
 
 Bright's disease as a cause of insanity 30 
 
 Burning 87 
 
 Business failure as a cause of insanity 30 
 
 Cancer as a cause of insanity 30 
 
 Care and anxiety as causes of insanity 30 
 
 Causes of insanity 29 
 
 constitutional 31 
 
 direct physical 30 
 
 emotional 30 
 
 evolutional 31 
 
 indirect physical and emotional 30 
 
 vicious habits 31 
 
 Causes of irritability 85 
 
 Caution, as to dangerous tendencies. ..58, 82, 83, 84, 86, 87 
 
 as to homicide 82, 83, 87 
 
 as to suicide 83, 84, 85, 86, 87 
 
 in entering patient's room 86 
 
 in exercise 70, 72 
 
 Cerebral reflexes, higher 21 
 
INDEX. 103 
 
 Cerebrum, the seat of higher mental faculties 4 
 
 Checking morbid impulses 70 
 
 Child-bearing as a cause of insanity 30 
 
 Chloral habit as a cause of insanity 31 
 
 Climacteric period (Greek Jdimax, a ladder) 33 
 
 Clothing, attention to 6U 
 
 to be searched 83, 87 
 
 Cocaine habit as a cause of insanity 31 
 
 Concept 12 
 
 or idea, illustration of 12 
 
 Confidence of the patient 81 
 
 Consciousness in animals 4 
 
 Constitutional and evolutional causes of insanity 31 
 
 Consumption, as a cause of insanity 30 
 
 in relation to dementia monomania 57 
 
 Contractures in hystero-melancholia 48 
 
 Correcting pernicious habits 76 
 
 Cranks 54 
 
 Dangers confronting epileptics 58 
 
 Deaf, mental development in the 15, 24 
 
 Delirium of fever as a cause of insanity 29 
 
 Delusion 25 
 
 Delusions, dependent upon hallucinations and illusions ... 25 
 
 how met 82 
 
 in dementia monomania 57 
 
 in hypochondriacal melancholia 47 
 
 in hystero-mania, absence of 41 
 
 in hystero-melancliolia 48 
 
 in mania acute 36 
 
 in mania chronic 38 
 
 in melancholia simple 42 
 
 in melancholia with frenzy 46 
 
 in melancholia with stupor 44 
 
 in paranoia 53 
 
 in paretic dementia 59, 62 
 
 of poison, how met 66 
 
 two kinds of 26 
 
 visceral, in dementia monomania 57 
 
 in hypochondriacal melancholia 47 
 
 in paretic dementia 61 
 
 Dementia, after mania 56 
 
 after melancholia 56 
 
 arresting tendency to 73 
 
 chronic 49 
 
104 INDEX. 
 
 Dementia, derivation of word 34 
 
 monomania 57 
 
 paretic 59 
 
 senile 57 
 
 with paralysis 62 
 
 Depression, in dementia after mania 56 
 
 in dementia after melancholia 56 
 
 in dementia monomania 57 
 
 in early stage of mania 35 
 
 in hypochondriacal melancholia 47 
 
 in hystero-melancholia 48 
 
 in melancholia simple 42 
 
 in melancholia with stupor 44 
 
 in paranoia 53 
 
 in paretic dementia 61 
 
 in recurrent mania 40 
 
 Desire, the connecting link between feeling and volition. . 17 
 
 Destructiveness, how prevented 71, 73 
 
 in hystero-mania 41 
 
 in mania acute 35 
 
 in recurrent mania 39 
 
 Development, arrest of 51 
 
 in deaf or blind 15 
 
 of mind 6 
 
 of the personality 10 
 
 Direct physical causes of insanity 30 
 
 Disappointed affections as a cause of insanity 30 
 
 Disposition to burn 87 
 
 Distension of bladder 60, 62, 70 
 
 Disturbances of sensation in dementia 49 
 
 in melancholia with frenzy 45 
 
 in paretic dementia 60 
 
 Diversion 72 
 
 Domestic infelicity as a cause of insanity 30 
 
 Door, how to unlock 86 
 
 Drowning 58, 84 
 
 Ego 10 
 
 Emotion 16, 27 
 
 Emotional causes of insanity 30 
 
 Emotions, in dementia monomania 57 
 
 in hypochondriacal melancholia 47 
 
 in hystero-melancholia . 48 
 
 in acute mania 36 
 
 in mania chronic 38 
 
INDEX. 105 
 
 Emotions, in melancholia simple 43 
 
 in nielancliolia with frenzy 4G 
 
 in nielancliolia with stupor 44 
 
 in mental disease 27, 30 
 
 in paranoia 53, 50 
 
 in paretic dementia 02 
 
 language of the 17 
 
 pleasurable, fi'om exercise 72 
 
 Employment 72 
 
 Enema, food by 01) 
 
 medicine by 09 
 
 Entering patient's room, caution in 80 
 
 p]pilepsy as a cause of insanity 29 
 
 Epileptic dementia 58 
 
 Epileptics benefited by rest in bed 80 
 
 Epileptiform seizures, in dementia with paralysis 03 
 
 in paretic dementia 00 
 
 Escapes 87 
 
 Evidences that brain is organ of mind 4 
 
 Evolutional causes of insanity 31 
 
 Examples of reasoning and judgment 13, 14 
 
 Excesses as a cause of paretic dementia 59 
 
 Excitement, in acute exhaustive mania 37, 75 
 
 in hystero-mania 41 
 
 in mania acute 38 
 
 in melancholia with frenzy 45 
 
 in recurrent mania 39 
 
 in paretic dementia 01 
 
 sexual 31, 78, 81 
 
 Exercise 70 
 
 a relief to restlessness 70 
 
 cautions in 70, 72 
 
 in hypochondriacal melancholia 72 
 
 in mania 71 
 
 in melancholia 71 
 
 Exercise, pleasurable emotions from 72 
 
 w^hat is accomplished by 72 
 
 Exhaustion, food in ; 00 
 
 Faculties of mind 5 
 
 Feeding, mechanical 08 
 
 Feeling (emotion) 10 
 
 Feigning of insanity as a cause of insanity 30 
 
 Firmness 79 
 
 Food .,.....,,.... ,.,,.r 65 
 
106 INDEX. 
 
 Food, administration of 65 
 
 artificially digested 68 
 
 by enema 69 
 
 in exhaustion 68 
 
 kinds of 66 
 
 refusal of, how met 66 
 
 refusal of, in dementia monomania 66 
 
 in mania acute 37, 65 
 
 in melancholia, simple 43, 66 
 
 with frenzy 46 
 
 with stupor 44 
 
 Food, withdrawal of, inexcusable 79 
 
 Forming habits of tidiness 69, 75 
 
 Forms of insanity 34 
 
 Fragility of bones 61 
 
 Fright and insanity 28 
 
 General considerations '. 23 
 
 General paralysis of the insane 59 
 
 General paresis 59 
 
 General suggestions what to do and avoid 89 
 
 Giving food by enema 69 
 
 Giving medicine by enema 69 
 
 Glossary vii 
 
 Grief as a cause of insanity 30 
 
 Habits, in dementia chronic 50, 51 
 
 in epileptic dementia 58 
 
 in mania acute 37 
 
 in mania chronic 39 
 
 in melancholia with stupor 44 
 
 in paranoia 56 
 
 in paretic dementia 62 
 
 in senile dementia 57 
 
 of tidiness, forming of 69, 75 
 
 pernicious, correcting 76 
 
 vicious 31, 76, 81 
 
 as causes of insanity 31 
 
 correcting 81 
 
 Hallucination 23 
 
 Hallucinations, in dementia chronic 50 
 
 in dementia monomania 57 
 
 in mania acute 36 
 
 in mania chronic 38 
 
 in melancholia simple ...,,,.,... 43 
 
INDEX. 107 
 
 Hallucinations, in melancholia with frenzy 45 
 
 in paranoia 5^5 «^^ 
 
 in paretic dementia 61 
 
 in recurrent mania 39 
 
 \\'ith sanity 25 
 
 liandwriting in paretic dementia 50 
 
 Hearing • ^ 
 
 Hemorrliage as a cause of insanity 29 
 
 Hereditary tendency (Lat. hereditare, to- inherit) 31 
 
 Higher cerebral reflexes 2 1 , 27 
 
 Higher reflex acts 21, 27 
 
 Higher reflexes, in epileptic dementia 58 
 
 in mental disease • 27 
 
 in paretic dementia ^^ 
 
 Higher volition 20 
 
 Home, removal from 76 
 
 Home-sickness a remedial agency 77 
 
 Homicidal assaults, how prevented 83 
 
 in epileptic dementia 58 
 
 in melancholia simple 43 
 
 in paranoia 54 
 
 in paretic dementia 62 
 
 Homicidal impulses 83 
 
 Hypochondriacal melancholia 47 
 
 exercise in 72 
 
 Hystero-mania 41 
 
 Hystero-melancholia 48 
 
 Idea 12 
 
 or concept, illustration of 12 
 
 Ideation 11 
 
 in mania acute 36 
 
 in mania chronic 38 
 
 in melancholia simple 42 
 
 in melancholia with fi-enzy • • • 46 
 
 in paranoia ^-^ 
 
 in paretic dementia 62 
 
 Idiocy 51 
 
 Illusion '^'^ 
 
 Illusions, in dementia chronic 50 
 
 in dementia monomania 57 
 
 in hypochondriacal melancholia 47 
 
 in mania acute 36 
 
 in mania chronic 38 
 
 in melancholia simple 42 
 
108 INDEX. 
 
 Illusions, in melancholia with frenzy 45 
 
 in paretic dementia 61 
 
 in recurrent mania ■. 39 
 
 Illustrations of concept, or idea 12 
 
 of sensation 7 
 
 of visual perception 9 
 
 of volition 22 
 
 Imbecility 51 
 
 Importance of work of attendant 88, 100 
 
 Impulses, homicidal 83 
 
 morbid, checking of 76 
 
 Incivility, inexcusable 79 
 
 Incoherence, absence of, in melancholia 42 
 
 in recurrent mania 39 
 
 in mania acute 30 
 
 in mania chronic 38 
 
 in paranoia 55 
 
 in paretic dementia 62 
 
 in senile dementia 58 
 
 Indirect physical causes of insanity 30 
 
 Infliction of punishment 78 
 
 Inhibitory control, in dementia chronic 51 
 
 in epileptic dementia 58 
 
 in hystero-mania 41 
 
 in hystero-melancholia 48 
 
 in idiocy 52 
 
 in imbecility 52 
 
 in mania acute 36 
 
 in mania chronic 38 
 
 in melancholia simple 43 
 
 in melancholia with frenzy , 46 
 
 in paretic dementia 62 
 
 in recurrent mania 39 
 
 Inhibitory (restraining) acts 22 
 
 Injury to the head as a cause of insanity 30 
 
 Insane conditions, grouping of 34 
 
 Insanity 28 
 
 causes of 29 
 
 every case a law unto itself 29 
 
 forms of 34 
 
 management of cases of 64, 89 
 
 Institution treatment 76 
 
 Intemperance as a cause of dementia monomania 57 
 
 of insanity 31 
 
 of paretic dementia 59 
 
INDEX. 109 
 
 Irritability, causes of 85 
 
 in dementia ^1 
 
 Jelly-fisli ^ 
 
 Judgment / , ao 
 
 and reasoning, examijles of 13 
 
 in dementia chronic 5^ 
 
 in mania acute 3G 
 
 in mania chronic 38 
 
 in mehmcholia simple 42 
 
 in mental disease 25 
 
 in paranoia 55 
 
 in paretic dementia 62 
 
 in recurrent mania 39 
 
 "Kleptomania" ^' 
 
 Language of the emotions 17 
 
 Life 1 
 
 Limitations of the will 22 
 
 Management, aims in 64 
 
 of cases of insanity 64, 89 
 
 Mania acute 35 
 
 development of _■ 35 
 
 Mania, acute exhaustive 37, 75 
 
 chronic '3/ 
 
 derivation of word 34 
 
 exercise in '1 
 
 giving food in 37, 65 
 
 Mania, recurrent 39 
 
 rest in bed in '^ 
 
 Manual restraint 80 
 
 Masturbation 31, 81 
 
 how to correct • ■ ■ • 81 
 
 Mechanical, feeding 68 
 
 restraint 85 
 
 Medicine, administration of 69 
 
 by enema 69 
 
 to produce sleep 74 
 
 Melancholia, cautions against suicide in. 43, 83, 84, 85, 86, 87 
 
 derivation of word 34 
 
 exercise in 71 
 
 giving food in 67 
 
 rest in bed in • 75 
 
110 li^DEIi. 
 
 Melancholia, simple, development of 42 
 
 with frenzy 45 
 
 cautions against suicide in 46 
 
 refusal of food in 46 
 
 with stupor 44 
 
 Memory ,. 9 
 
 in dementia chronic 50 
 
 in mania acute 36 
 
 in mania chronic ." . 38 
 
 in melancholia simple 42 
 
 in paranoia 55 
 
 in paretic dementia 61 
 
 in senile dementia 58 
 
 organic 10 
 
 organic, disturbed in paretic dementia 61 
 
 two kinds of 10 
 
 Mental action, in idiocy 51 
 
 in imbecility ; 52 
 
 Mental depression, states of 35 
 
 development, arrest of 51 
 
 in deaf or blind 15 
 
 Mental disease, forms of 34 
 
 elations, states of '. 35 
 
 faculties 5 
 
 overstimulation in dementia after mania 56 
 
 after melancholia 56 
 
 Mental weakness, states of 35 
 
 Mind 4, 5 
 
 development of 6 
 
 arrested in idiots and imbeciles 51 
 
 in deaf and blind 15 
 
 Mind, faculties of 5 
 
 impairment of, in dementia 49 
 
 progressive loss of, in paretic dementia 59 
 
 Morbid impulses, checking of 76 
 
 Muscular sense 6 
 
 Necessaries of life, withdrawal of, inexcusable 79 
 
 Nursing 69 
 
 prolonged, as a cause of insanity 30 
 
 Objections to rest in bed. .'. 75 
 
 to seclusion 86 
 
 Opium habit as a cause of insanity 31 
 
 Organic memory 10 
 
INDEX. Ill 
 
 Oiganic memory, in mania acute 30 
 
 in mania chronic 38 
 
 in melancholia simple 42 
 
 in melancholia with frenzy 45 
 
 in paranoia 55 
 
 Organic memory in paretic dementia Gl 
 
 Organ of sense composed of three parts 7 
 
 Paralysis, general, of the insane 59 
 
 in dementia with paralysis G3 
 
 in hystero-melancholia 48 
 
 in paretic dementia 59 
 
 Paranoia 52 
 
 a congenital mental infirmity 52 
 
 derivation of word 34 
 
 Paresis 59 
 
 Paretic dementia 59 
 
 a structural brain disease 59 
 
 Pathological conditions of brain in insanity 34 
 
 Patients in seclusion 86 
 
 Perception 8 
 
 essentials of 9 
 
 illustration of 9 
 
 in dementia chronic 50 
 
 in mania acute 36 
 
 in mania chronic 38 
 
 in melancholia simple 42 
 
 in melancholia with frenzy 45 
 
 in melancholia with stupor 44 
 
 in mental disease 23 
 
 in paranoia 55 
 
 in paretic dementia 61 
 
 in recurrent mania 39 
 
 Persecutory stage in paranoia 53 
 
 Personal attention and nursing 69 
 
 Personality 10 
 
 alteration of, in insanity 11 
 
 Physical symptoms, in dementia chronic 50 
 
 in dementia monomania 57 
 
 in dementia with paralysis 59 
 
 in epileptic dementia 58 
 
 in hypochondriacal melancholia 47 
 
 in hystero-mania 41 
 
 in hystero-melancholia 48 
 
 in mania acute 37 
 
 in mania chronic 38 
 
112 INDEX. 
 
 Physical symptoms, in mania recurrent 41 
 
 in melancholia simple 43 
 
 in melancholia with frenzy 46 
 
 in melancholia with stupor 44 
 
 in paranoia 56 
 
 in paretic dementia 62 
 
 in recurrent mania 41 
 
 in senile dementia 58 
 
 Pleasurable emotions from exercise 72 
 
 Poison, delusions of, how met 66 
 
 Precautions against dangerous tendencies . 58, 82, 83, 84, 86, 87 
 
 against homicide 82, 83, 87 
 
 against self-mutilation 83 
 
 against suicide 83, 84, 85, 86, 87 
 
 when entering patient's room 86 
 
 Prevention of homicidal assaults 83 
 
 Prolonged nursing as a cause of insanity 30 
 
 Prolonged rest in bed 75 
 
 Psychology 1 
 
 Pubescence (Lat. pu'bes, hair) 32 
 
 Punishment 78 
 
 Pupils in paretic dementia 60 
 
 "Pyromania" ; 87 
 
 Qualities of an attendant 64 
 
 Reasoning 12 
 
 Reasoning and judgment, examples of 13 
 
 in dementia monomania 57 
 
 in mania acute 36 
 
 in mania chronic 38 
 
 in melancholia simple 42 
 
 in mental disease 25 
 
 in paranoia 55 
 
 in paretic dementia 62 
 
 in recurrent mania 39 
 
 Reasons for custodial care 76 
 
 Recovery 64 
 
 aids to 64 
 
 Rectal feeding 69 
 
 Recurrent mania 39 
 
 rest in bed in 75 
 
 Reflex acts 21, 27 
 
 higher 21, 27 
 
 Reflexes, higher cerebral 21, 27 
 
INDEX. 113 
 
 Reflexes, in epileptic dementia 58 
 
 in mania acute 30 
 
 in mania chronic 38 
 
 in melancholia simple 43 
 
 in melancholia with frenzy 4G 
 
 in paretic dementia 02 
 
 Refusal of food, how met GO 
 
 in mania acute 37, 05 
 
 in melancliolia simple 43, GO 
 
 A\'ith frenzy 40, OG 
 
 with stupor 44 
 
 Regulations, disobedience of 88 
 
 Removal from home 76 
 
 Repair of brain-waste 74 
 
 Rest in bed 75 
 
 in acute exhaustive mania 75 
 
 in epilepsy 80 
 
 in melancholia 75 
 
 in recurrent mania 75 
 
 objections to 75 
 
 Restlessness relieved by exercise 70 
 
 Restraint, manual 80 
 
 mechanical 85 
 
 Retention of urine, in mania 70 
 
 in melancholia 70 
 
 in paretic dementia 60, 70 
 
 Room, caution in entering 86 
 
 Rules, disobedience of 88 
 
 Rupture of bladder 60, 70 
 
 Scolding inexcusable 79 
 
 Searching clothing, etc 83, 87 
 
 Seclusion 85 
 
 objections to 86 
 
 reasons for 85 
 
 in dementia with paralysis 63 
 
 Seizures, epileptiform and apoplectiform, in paretic de- 
 mentia 60 
 
 Self-abuse as a cause of insanity 31 
 
 how to correct 81 
 
 Self-mutilation in dementia chronic 50 
 
 in melancholia with frenzy 46 
 
 in paretic dementia 62 
 
 precautions against 83 
 
 Senile dementia 57 
 
114 INDEX. 
 
 Senile period (Lat. senex, old) 33 
 
 Sensation 7 
 
 in hypochondriacal melancholia 47 
 
 Sensation, in dementia chronic 50 
 
 in hystero-melancholia 48 
 
 in mania acute 36 
 
 in mania chronic 38 
 
 in melancholia simple 42 
 
 in melancholia with frenzy ■ . 45 
 
 in melancholia with stupor 44 
 
 in mental ' disease 23 
 
 in paranoia 55 
 
 in paretic dementia 61 
 
 of touch, illustration of 7 
 
 Sense organ, composed of three parts 7 
 
 Senses 6 
 
 Sexual excess as a cause of insanity 31 
 
 Sexual excitement 31, 78 
 
 Shock as a cause of insanity 30 
 
 Simple reflex acts 21 
 
 Sleep 74 
 
 how induced 74 
 
 medicine to produce 74 
 
 Smelling 6 
 
 Special senses 6 
 
 Speech in paretic dementia . 59 
 
 States, of mental depression 35 
 
 of mental elation 35 
 
 of mental weakness 35 
 
 Stealing 87 
 
 Structural brain disease 35 
 
 Suicide 42, 43, 46, 49, 56, 58, 62, 83, 86, 87 
 
 in epileptic dementia 58 
 
 in hystero-melancholia 49 
 
 in melancholia simple 43 
 
 in melancholia with frenzy '. 46 
 
 in paranoia 56 
 
 in paretic dementia 62 
 
 precautions against 83, 86, 87 
 
 Surgical accidents among epileptics 58 
 
 Surroundings of patients 81 
 
 Suspiciousness, how met 81 ' 
 
 Syphilis as a cause of paretic dementia 59 
 
 Tasting 6, 8 
 
INDEX. 115 
 
 Tendency to steal 87 
 
 Termination, dementia chronic 51 
 
 dementia with paralysis. '. 63 
 
 mania acute 37 
 
 mania chronic 39 
 
 melancholia simple 43 
 
 melancholia with frenzy 47 
 
 melancholia with stupor 44 
 
 jjaranoia 56 
 
 paretic dementia 62 
 
 The ego 10 
 
 Thinking- process, essentials of 15 
 
 Thouglit usually conducted in words or their visible 
 
 signs 15 
 
 Tidiness, habits of 69, 75 
 
 Touch 6 
 
 illustration of sensation of 7 
 
 Transition stage in paranoia 53 
 
 Treatment in an asylum 76 
 
 Ungentlemanliness inexcusable 79 
 
 Unladylike conduct inexcusable 79 
 
 Unlocking door 86 
 
 Valedictory address 89 
 
 Vertebrate (having a spinal column) 13 
 
 Vicious habits 31, 76, 81 
 
 Visceral delusions, in dementia monomania. 57 
 
 in hypochondriacal melancholia , 47 
 
 in melancholia with frenzy 46 
 
 in paretic dementia 61 
 
 Visiting patients in seclusion 86 
 
 Visual perception, illustration of 9 
 
 Volition 17 
 
 higher 20 
 
 illustration of 22 
 
 in dementia chronic 50 
 
 in hypochondriacal melancholia 47 
 
 in hystero-mania 41 
 
 in hystero-melancholia 48 
 
 in idiocy and imbecility 52 
 
 in mania acute 36 
 
 in mania chronic 38 
 
 in mania recurrent 39 
 
116 INDEX. 
 
 Yolition, in melancholia simple 43 
 
 in melancholia with frenzy . 46 
 
 in melancholia with stupor 44 
 
 in mental disease 27 
 
 in paranoia 56 
 
 in paretic dementia 62 
 
 Wliat to do and what to avoid in caring for insane 89 
 
 Will, limitations of 22, 71 
 
 Will (see Volition, above). 
 
 Withdrawal of food, or necessaries of life, inexcusable. . 79 
 
:fK 
 
 ^^ 
 
 '^ 
 
 r^ 
 
 <^' 
 
 'J: 
 
 COLUMBIA UNIVERSITY 
 
 This book is due on the date indicated below, or at the 
 expiration of a definite period after the date of borrowing, 
 as provided by the rules of the Library or by special ar- 
 rangement with the Librarian in charge. i 
 
 DATE BORROWED 
 
 DATE DUE 
 
 DATE BORROWED 
 
 DATE DUE 
 
 
 ' - ''< 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 ! 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 C28(638)M50 
 
 
 
 1 
 1 
 

 
 MAR 3 '39 ^i^UU^V^*-'^^^^^^"-^! 
 
 u