Plate r^1^%s \^^0m ^..Jf? ^ u>»" ' f/?(;m /'HoronRAfH'-. taken in the dbvon county lunatic Asriur F.'i- Jle^rriplx^n .>ec C/;,- /Jr.-./ .,^i/^„ ; <.-.,».s- ui I'm Apfftulu A MANUAL PSYCHOLOGICAL MEDICINE CONTAINIlfG THE LUMCY LAWS, THE NOSOLOGY, iETIOLOGY, STATISTICS, DESCRIPTION, DIAGNOSIS, PATHOLOGY, AND TREATMENT INSANITY lit^ m gipenM^ d ^m$ JOHN CHAELES BUCKNILL, M.D. Lond., F.E.S., F.E.C.P. FOBMERtT LOaD CHANCKLLOB's VI8IT0B OF LDNATIC9 AJST) BY DANIEL HACK TUKE, M.D., E.E.C.P. JOINT EDITOR OF ' THE JOUBNil OF MKKTAI, SCIENCE j' FORMBKIY LECTtJRKR ON P3 YCttOLOGICAl HBDICimS AT THK TURK SCHOOL OP MEDICINE AND VISITING FHISICIAN TO THE YORK RETREAT FOURTH EDITION LONDON J. & A. CHIJECHILL, NEW BDELINGTON STEEET 1879 Digitized by tine Internet Archive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/manualofpsycholoOObuck PEEEACE FIEST AND SECOND EDITIONS ■:> The Authors of the following pages have long felt the want of a systematic treatise on Insanity, adapted to the use of students ^ and practitioners in Medicine. Numerous monographs and works ^pn limited portions of Psychological Medicine have appeared of late years. They are of great value to the specialist physician, but they do not meet the oft-repeated inquiry of the student and practitioner, — '^ To what systematic treatise on Insanity can I refer ?^^ Dr Prichard^s excellent ^Treatise on Insanity^ has un- doubtedly been the one which hitherto has most nearly afforded ^ the desired information ; but it was written a quarter of a century ago, at a time when the Treatment of Insanity bore an 3 aspect entirely different from its present one ; and, moreover, it ■*^ is now out of print. A knowledge of the nature and treatment of Insanity is now 1 expected of every well-educated man. The India Board require ^- it of all persons to whom medical appointments are given under ^ their new system of competitive examination. It is reasonable ^ to expect that the good example thus set will be followed in ^ other quarters,- and a desire to obtain a competent knowledge Ej of this important branch of medical practice has become far 30 more general in the profession than it ever before has been. > ^ ^ . .. ,- ^ VI riiEFACE The Authors are aware that no amount of reading can render it safe to dispense with a clinical knowledge of mental disease. Their aim has been, to supply a text-book which may serve as a guide in the acquisition of such knowledge^ sufficiently elemen- tary to be adapted to the wants of the students, and sufficiently modern in its views and explicit in its teaching to suffice the demands of the practitioner. How far the Authors have succeeded in their purpose, it remains for their readers to determine ; of their shortcomings none can be more sensible than they are themselves. 1858 a>id 1862. PEETACE THIRD EDITION The Authors of this Manual have to explain that the active development of Psychological Medicine during recent years has compelled them to amplify their work. The great principle that Mental Disease depends solely upon cerebral conditions, which was systematically taught in these pages fifteen years ago, has now become so thoroughly established that it is no longer questioned. Its full recognition^ however, has been followed by such activity of observation and research that the field of inquiry has been extended in every direction, and at the present time it may truly be said that new opinions, new forms of Insanity, and new remedies have been and are being multiplied at a rate which far outstrips the steady march of consolidated knowledge. As the field of inquiry extends, the crop of good results is more diflScult to garner. The history of a text-book must follow that of its science. While this is expanding, it must enlarge j when this is consolidating, it may contract. At the present time Psychological Science is undergoing a most notable process of expansion, and there is no sign that it will ever again be " cribbed, cabined, and confined ^^ by dogmas, either legal or theological, nor any indication that its bounds will be cir- cumscribed by any limits more narrow than man's powers to Vni PREFACE investigate the secrets of organisation. Practically, however. Psychological Medicine has to teach what is known of Mental Disease and how to deal with it, and to this the Authors have endeavoured to restrict themselves ; and while they have felt bound to mention many opinions which are yet under discus- sion, and many observations which still need verification, they have striven so to present these to the reader that he may be able to distinguish the yet unstable from the solid ground of knowledge. The Authors have only to add that they have gladly availed themselves of the practical knowledge of Cerebral Histology possessed by one of its most successful investigators, Dr J. Batty Tuke, of Edinburgh, who is the writer of the histological portion of the chapter on Pathology, and that the authorship of the volume is divided, as before, between Dr Bucknill and Dr Daniel Hack Tuke — the chapters on the Lunacy Laws, Classifi- cation, -Etiology, Statistics, and Description of the Various Forms of Insanity, being written by Dr D. H. Tuke, and the chapters on Diagnosis, Pathology and Treatment, with the Appendix of Cases, by Dr Bucknill. November, 1873. PEEEACE FOURTH EDITION In this their fourth edition the Authors have carefully revised the work for the purpose of bringing it up to the knowledge of the day. From the great mass of matter which has been published on the subject of Insanity they have endeavoured to embody what appears most important and trustworthy, and they have striven to give to their fellow labourers in this field of research their full credit, whether it be for probable hypo- thesis or for proved fact. Their own opinions have been worn here and strengthened there by the friction and growth of five years of additional experience, but substantially they remain the same, and the details of change are scarcely worthy of comment. The same division of labour has taken place as in former editions, and the Authors have again received the valuable assistance of Dr Batty Tuke, who has contributed that portion of the sixth chapter which relates to the Histology of Insanity, and which has been illustrated by new plates. London June, 1879. CONTENTS CHAPTER I LEGAL ENACTMENTS IN EBFERENCE TO THE INSANE, INCLUDING THOSE SPECIALLY AFFECTING MEDICAL MEN Private and pauper lunatics Definition of terms employed Medical certificates . Actions against medical men Penalties Single patients Chancery single patients Payments for visiting lunatics in special cases Order for tlie reception of pauper and private patients Statement ..... Form of medical certificate Boarders Pauper lunatics not in asylums Select Committee, House of Commons, 1877 PAGE 1 5 6 8 10 11 13 14 14, 15 15, 16 . 10 17 17 17 CHAPTER II OP INSANITY IN GENEEAL Section I. — Synonyms and Definition . . . ,18 1. Synonyms— English, Hebrew, Greek, Latin, Italian, French, German . . . . , .18 2. Definition. Difficulties of attempting it. Illustrations — Locke, CuUen, Combe, Spurzheim, Lelut, Conolly, Guislain, Morel. Essentials of a definition — Copland, Bucknill . . 19 Legal definitions — Non compos mentis. Lunatic. Unsound mind. Partial Insanity. Unthrifts and prodigals, Lucid interval . . . . . .25 Xll CONTENTS PAGE Section II. — Classification . . . . .27 1. Various methods of classification proposed, and why. The Symptomatological, Psychological, Physiological, Etiolo- gical, Pathological . . . . .27 2. Ancient classifications — Hippocrates, Celsus, Roman Law, Cicero, Aretaeus, Cselius Aurelianus, Galen . . 29 3. Modern classifications — Sauvages, Vogel, Linnaeus, Cullen, Arnold, Crichton, Pinel, Esquirol, Conolly, Laycock . 31 Proposed Physiological classification . . .34 Parchappe, Aug. Voisin, Falret . . .35 Heinroth, Ideler, Hoflfbauer, Prichavd, Bucknill, Griesinger, Maudsley . . . . .36 Jacobi, Nasse, Friedreich, Flemming, Bell, Belhomme, Van der Kolk, Morel, Skae, Batty Tuke, Clouston, International Congress of Alienists, Committee of Medico-Psychological Association . . 37 Proposed Psychological classification . . .46 Proposed Symptomatological classification . . 48 John Stuart Mill, Professor Whewell . . .51 Proposed Somato-setiological or Pathogenetic classification (see also p. 310). Section III. — -Etiology . . . . .54 Predisposing and exciting causes of Insanity — 1. Predisposing — Hereditary predisposition. Constitution or Diathesis. Consanguineovis marriages. Relative liability of the sexes to Insanity. Age. The seasons, climate, moon, occupation, town and country life, &c. Civilisation. Pauperism. Tables. Marriage . 57 2. Exciting causes — Intemperance. Epilepsy. Afi'ections of the head and spine. Sexual vice. Fever. Ill health. Domestic troubles and grief. Religious anxiety and excitement. Disappointed afi'ections. Fear and fi-ight. Intense study. Political excitement and war. Franco- Prussian war. Joy and grief. Wounded feelings . 90 Relative influence of moral and physical, causes. Their classification. On cause-tables . . . 103 Section IV. — Proportion of the Insane to the population . . 108 England, Ireland, Scotland, France, America . 114 „ V. — Relative frequency of the Various Forms of Mental Disorder . . . . .116 ,, VI. — Proportion of Recoveries. Prognosis . . 118 „ VII.— Relapses ..... 129 „ VIIL— Mortality . . . . .131 Summary as regards Prognosis . . . 135 CONTENTS Xlll CHAPTER III ON THE VARIOUS FORMS OF INSANITY Preliminary observations Necessity of studying — a. The Physiology of the Nervous System h. Psychology c. The Disorders of the Nervous System generally Form for case-taking . Memoranda for case-book Section I. — Idiocy, Imbecility, and Cretinism II. — Dementia III. — Delusional Insanity IV.— Melancholia V. — Partial Exaltation or Amenomania VI. — Moral or Emotional Insanity (proper) VII. — Homicidal Mania . Legal tests of responsibility Hints in giving evidence „ VIII. — Suicidal Mania or Insanity „ IX. — Kleptomania ,, X. — Erotomania „ XI. — Pyromania „ XII. — Dipsomania „ XIII.— Mania . Supplementary Note — Handwriting and Composition of the Insane . PAGE . 142 . 142 . 142 . 145 . 147 . 148 , 149 . 176 . 194 . 215 . 234 ,. 239 , 254 . 269 . 271 . 272 , 278 . 282 . 284 . •287 . 292 . 305 CHAPTER IV BRIEF SKETCH OF THE VARIOUS FORMS OF INSANITY FROM A SOMATO-^TIOLOGIOAL POINT OF VIEW Somato-setiological or Pathogenetic Classification of Mental Disorders according as they arise from — I. Primary disease or defect of the encephalon. II. Disease or developmental changes in other organs. III. Poisons. Congenital or Infantile Deficiency .... 311 Traumatic Insanity ...... 311 General Paralysis or Paresis ..... 312 Insanity following Apoplexy ..... 333 Epileptic Insanity ...... 336 siv CONTENTS Senile Insanity .... Pubescent Insanity .... Masturbatic Insanity Uterine and Ovarian Insanity . Hysterical Insanity .... Insanity of Gestation or Pregnancy Puerperal Insanity (proper) Insanity of Lactation Climacteric Insanity .... Insanity from abdominal disorders Post-febi'ile Insanity .... Insanity with rheumatism and with cardiac disease Insanity and gout .... Insanity associated with phthisis Insanity after syphilis Alcoholic Insanity .... Pellagrous Insanity .... Cretinism ..... Epidemic Insanity .... PAGE . 345 . 345 . 346 . 349 . 349 . 352 . 355 . 363 . 366 . 368 , 371 373 380 , 382 387 391 397 400 400 CHAPTER V DIAGNOSIS OF INSANITY General remarks ...... 402 Difficulties of inquiry ..... 404 Diagnostic value of hereditary tendency . . . 405 Of previous attacks ...... 406 Of change of habits and disposition .... 406 Manner of examination . . . ... 410 Peculiarities of residence and dress, bodily condition, and gesture The physiognomy of Insanity . Demeanour towards the patient Diagnosis of Dementia „ Mania . „ Mania from Sanity * „ Eccentricity „ Melancholia „ Hypochondidasis . „ Monomania „ Moral Insanity, Homicidal Insanity, „ General Paralysis Detection of Feigned Insanity . „ Concealed Insanity Diagnosis of recovery &c. 412—116 . 418 . 424 . 425 . 431 . 438 . 443 . 445 . 451 . 454 . 458 , 462 . 468 . 476 . 479 CONTENTS XV CHAPTER VI PATHOLOGY OF INSANITY PAGE Physiological basis ...... 489 Natm-e of pathological conditions . . . . 494 Analogy between Dreaming and Insanity . . . 603 „ between Intoxication and Insanity . . . 504 State of brain in Insanity formulated . . . 506-7 Hypersemia ....... 507 Anaemia . . . . '. . . . 515 Relation of vascular and cellular changes . . . 518 Cerebral Atrophy — Table ..... 521 Insanity by sympathy . . . . . 533 Monomania ...... 537 Special changes — Webster, Morgagni, Bonetus, Boerhaave, Haller, Greding, Meckel, Soemmering, Arnold, Portal, Pinel, Esquirol, Foville, Bayle, Calmeil, Lelut, Leuret, Guislain, Parchappe, Griesinger — Microscopic research .... 541 Our own pathological observations — The Scalp and Cranium ..... 566 The Dura Mater, Arachnoid, and Pia Mater . . .569 The Cerebral substance ..... 577 Cerebral atrophy, induration, and hypertrophy . . 577 Inflammation, congestion, and anaemia of the cerebral substance 583 (Edema of the Brain . . . . .587 Specific gravity of the Brain . . ... 587 Disease of the Heart, Lungs, Stomach and Intestines, Liver, Spleen, Kidneys, and the Reproductive Organs. Bed-sores, or asthenic gangrene ..... 589 The Humoral Pathology of Insanity — the Blood, the Urine . 597 The Chemical Pathology of the Brain .... 600 The Pathology of General Paralysis . . . . 600 CHAPTER YI [continued). MORBID HISTOLOGY Normal Brain structure Yascular supply Nerve- cells . Neuroglia . 610 611 612 612 XVI CONTENTS Lesions in Brains of the Insane — 1. The membranes 2. The epithelium 3. The blood-vessels 4. The neuroglia 6. The cells 6. The nerve-fibres 7. Special morbid conditions of the gi'ey matter 8. Appearances in General Pai-alysis and Senile Dementia PAGE 613 616 616 623 627 629 629 631 CHAPTER VII TREATMENT OF INSANITY General observations .... - 634 Pinel's principles .... . 637 Esqiiirol's improvements , 640 Prophylaxis .... . 643 Insane diathesis .... .. 643 Marriage . . . . ■ . , 647 Treatment at the outbreak — in private or in asylum - 648 Choice of asylum .... . 650 Attendants for the Insane .. 654 The moral treatment of the Insane , 660 Mechanical restraint and seclusion . 674 Treatment of violence , 678 „ in asylums , 679 Classification in asylums . 680 Food and work .... . 684 Balls, concerts, and theatrical entertainments . 690 Removal from an asylum . 691 The domestic treatment of the rich . 693 The cottage treatment of the poor , 696 The medicinal treatment . 698 Bleeding ..... . 699 Tartrate of antimony , 701 Mercury ..... . 703 Opium ..... . 704 Hypodermic injection . 717 Hyoscyamus .... , 718 Conium ..... - 719 Chloral ..... , 721 Bromides of potassium, sodium, ammonium, and iron , 727 Digitalis ..... . 734 Ergot of rye • • . . . . 734 CONTENTS xvu Calabar bean Stimulants . Purgatives and aperients Counter-irritation and derivation Tonics Electricity . Baths The Turkish or hot-air bath The wet sheet or pack Forced alimentation . Ti'eatment of Epileptic Insanity Hysterical Insanity Masturbatic Insanity Syphilitic Insanity Puerperal Insanity General Paralysis Hypochondi'iacal Insanity Resume . . . PAGE . 735 . 735 . 736 . 737 . 738 . 738 . 739 . 743 . 744 . 745 . 748 . 749 . 750 . 751 . 753 . 754 . 757 . 757 Appendix — No. 1.— A. Cases illustrated by the portraits in the frontispiece 765 B. „ illustrating treatment . . . 769 c. „ ,, causation and pathology . 782 No. 2. — Note on classification .... 790 No. 3. — Recent returns of numbers of insane, etc. . . 795 Index . . . . . . .799 EEEATA ?e 114, line 37, after registered add and at large. 129, „ 16, /or IV read Section "VII. 131, „ 25,/or V read Section VIII. 156, „ 2,0, for reason read reasons. DESCEIPTION OF PLATES PLATE I For desciiption of this Plate see Appendix, p. 765. PLATE II (P. 161) For this lithograph, we are indebted to Dr W. A. F. Browne, Dumfries. PLATE III (P. 171) Two cretins with goitre (sisters) at Bagneres-de-Bigorre, Hautes Pyi-e- nees. Seen by Dr D. H. Tuke, March, 1878, and photographed for this work through the assistance of Dr Dejeaune, of Bigorre. PLATES lY, V, YI, Yll, YIII (Pp. 305-309) Fac-siniiles of the handwriting and specimens of the composition of the Insane. PLATE IX A tinted copy of Arndt's plate of a section through the gi'ey matter of the third frontal convolution, taken fi-om Schultz's ' Archives of Micro- scopical Anatomy,' 1867, vol. iii, p. 476. This plate does not show the full length of the section, as it would be impossible to give it on one page. It is accordingly shortened in its length, all the layers being somewhat thinner than they should be. PLATE X Fig. 1. Dravm fi'om the injected brain of a rabbit. This specimen was prepared by Dr Carter, of Leamington, x 120. As this drawing is taken from the bottom of a sulcus the white matter is external. Fig. 2. Transverse section of a vessel with thickened coats, x 300. Fig. 3. A fresh specimen of a cerebral vessel treated with water only, showing the hyaline sheath, moleculai- deposit, and crystals of haematoidin. X 300. XX DESCEIPTION OP PLATES Fig. 4. A fusiform aneurism from an uncoloured section of corpus striatum. X 120. Fig. 5. Transverse section of a lisemorrhagic focus in the cerebral convolutions. After Mierzejewski. Hartnack, oc. 4, obj. 4. PLATE XI Fig. 1. Deposit of pigment in the distended lymphatic sheath of a vessel of the grey matter of the convolutions. After Mierzejewski. X 210. Fig. 2. A vessel with its wall thickened from vitreous degeneration. Ibid. Hartnack, oc. 3, obj. 7. Fig. 3. Tortuous course of a vessel within its lymphatic sheath. Ibid. X 210. Fig. 4. Giant cell fi-om the paracentral lobe of a general paralytic, with pigmentary degeneration of its protoplasm and disintegration of its nucleus. Ibid. Hartnack, oc. 3, obj. 10. Fig. 5. Cell from the occipital lobe. Ibid. Hartnack, oc. 3, obj. 10. Fig. 6. Cell from paracentral lobe of a general paralytic ; the nucleus in process of disintegration. Ibid. Hartnack, oc. 3, obj. 10. Fig. 7. One of the bodies found in the white substance of the convolu- tions, and taken for a hypertrophied axis cylinder. Ibid. Hartnack, oc. 3, obj. 10. Fig. 8. The same, in the shape of a ribbon. Ibid. Hartnack, oc. 3, obj. 10. Fig. 9. Pigmentary atrophy of cells from a case of senile dementia. After Major, x 300. Fig. 10. Section of a paracentral lobe from a general paralytic, showing a cell undergoing pigmentary degeneration, and surrounded by nuclei and vacuoles. After Miei'zejewski. Hartnack, oc. 3, obj. 10. PLATE XII Fig. 1. Amyloid bodies on the free surface and in the substance of the corpus striatum from a genei'al paralytic, x 300. Fig. 2. Second stage of miliary sclerosis, from the white matter of the cerebellum, x 120. Fig. 3. Section of the white matter fi-om a general paralytic, showing the vacuolated and ramifying elements. After Mierzejewski. Hartnack, oc. 3, obj. 10. Fig. 4. A similar section to the preceding, but at a more advanced stage of the malady. Ibid. Fig. 5. Section of ascending parietal convolution of a chronic maniac, showing proliferation of nuclei around a vessel and in the neuroglia. X 300. Fig. 6. Extreme condition of colloid degeneration of neuroglia, from a section of the ascending parietal convolution from a case of Idiopathic Dementia, x 300. A MANUAL PSYCHOLOGICAL MEDICINE CHAPTER I LEGAL ENACTMENTS IN REFERENCE TO THE INSANE, INCLUDING THOSE SPECIALLY AFFECTING MEDICAL MEN. Before we treat of Insanity itself^ we think it well to give a brief resume of tlie principal enactments which have passed the legislature for the proper care and protection of the insane.* These are the indications of the interest excited in the public mind on their behalf ^ and have proved to be themselves the means of deepening and extending that interest. Had they effected no more than the erection of our present County Asylums^ the super- intendence of which devolves upon a number of able and humane medical psychologists^, to whom the insane and the public are signally indebted, they would have achieved an enormous amount of good. In the reign of Edward II it was enacted that '' the King shall have the custody of the lands of natural fools, taking the profits of them without waste or destruction, and shall find them their necessaries, of whose fee soever the lands beholden; and after the death of such idiots he shall render the same to the right heirs, so that such idiots shall not aliene, nor their heirs be disinherited.^^ It was also enacted that a portion should be "distributed for his soul by the advice of the Ordinary. ^^f * We have derived much assistance from the lutroduction to Lumley's 'New Lunacy Acts,' Collinson on ' Lunacy,' and Fry's ' Lunacy Acts.' t ' Lunacy Acts,' by D. P. Fry, Esq., who thinks that the person, go.ods, and chattek, as well as the lands of the lunatic, are referred to. See p. 147. <^ 1 4 LEGAL ENACTMENTS IN REFEEENCE TO THE INSANE Various amendments were made in this Act in the years 1811, 1815, 1819, and 1825.* In the Act passed in the first of these years, overseers were obliged to produce a medical certificate, testifying to the insanity of the patient ; and returns were to be made every year by the medical superintendent of the asylum, of the patients under his care, to the quarter sessions. In the Act of 1815, provision was made for the admission into an asylum of other than pauper lunatics, should accommodation exist ; and the over- seers of every parish were obliged, when required by the justices, to make a return of the lunatics within their district. The condition of pauper lunatics was again brought before the House of Commons in 1827; and in 1828t all previous sta- tutes were repealed, and increased provision made " to facilitate the erection of county lunatic asylums and improve the treatment of lunatics." In the year 1845 J it was found to be absolutely necessary to enact more stringent regulations for the building of county asylums. By this Act their erection was made no longer optional; boroughs and counties were compelled to provide, within a certain period, the requisite accommodation for pauper lunatics. The operation of this Act, although not practicable to its fullest extent, has, on the whole, been highly beneficial. Among subsequent Acts was the important enactment of 1853,§ *'An Act to consolidate and amend the Laws for the Provision and Regulation of Lunatic Asylums for Counties and Boroughs, and for the Maintenance and Care of Pauper Lunatics in England " (s. QQ orders quarterly returns of luna- tics not in asylums). The enactments since 1853, in regard to private patients, are those relating to — (1.) Chancery lunatics, 18, 19 Vic. c. 13, 1855 ; 23, 24 Vic. c. 127, s. 29, 1860 ; 25, 26 Vic. c. 86, 1862 ; 30, 31 Vic. c. 87, s. 13, 1867; 32, 83 Vic. c. 91, s. 13, 1869; 36, 37 Vic. c. m, ss. 17, 18, 1873 ; 38, 39 Vic. c. 77, s. 7, c. 87, ss. 76, 77, 88; c. 92, s. 38, 1875. (2.) Chancery lunatics not so fouvd hy inquisition, 25, 26 Vic. c. 84, ss. 12, 13, 14, 15, 1862. (3.) Single patients in tiulicensed houses, 17, 18 Vic. c. 114, 1854; 25, 26 Vic. c. Ill, 1862. (4.) Licensed houses and registered hospitals, 17, 18 Vic. c. 114, 1854; 18, 19 * 51 Geo. Ill, c. 79; 55 Geo. Ill, c. 46 ; 59 Geo. Ill, c. 127 ; 5 Geo. IV, c. 71. t 9 Geo. IV, 0. JO. + 8, 9 Vic. c. 126. § 16, 17 Vic. c. 97. PRIVATE AND PAUPER LUNATICS 5 Yic. c. 105, 1855; 25, 26 Vic. c. Ill, 1862. (5.) Gounty and borough asylums, 17, 18 Vic. c. 114, 1854; 18, 19 Vic. c. 105, 1855 ; 19, 20 Vic. c. 87, 1856 ; 25, 26 Vic. c. Ill, 1862 ; 26, 27 Vic. c. 110, 1863. In regard to jpauper lunatics, tlie statutes relating to — (1.) Gounty and borough asylums are 17, 18 Vic. c. 114, 1854; 18, 19 Vic. c. 105, 1855; 19, 20 Vic. c. 87, 1856; 25, 26 Vic. c. Ill, 1862; 26, 27 Vic. c. 110, 1863 ; 28, 29 Vic. c. 80, 1865 ; 31, 32 Vic. c. 122, ss. 13, 43, 1868 ; 34, 35 Vic. c. 14, s. 2, 1871 ; (2.) Licensed houses and registered hospitals, 17, 18 Vic. c. 114, 1854; 18, 19 Vic. c. 105, 1855; 25, 26 Vic. c. IIJ, 1862; 31, 32 Vic. c. 122, s. 13, 1868. (3.) Worlliouses, 25, 26 Vic. c. Ill, 1862 ; 30, 31 Vic. c. 106, s. 22, 1867; 31,32 Vic. c. 122, ss. 13, 43, 1868. (4.) Lunatics receiving out-door relief, 25, 26 Vic. c. Ill, 1862 ; 31, 32 Vic. c. 122, 1868. (5.) Incidence of the charge, 19, 20 Vic. c. 15, s. 9, 1856 ; 22, 23 Vic. c. 49, ss. 1, 4, 7, 1859; 24, 25 Vic. c. 55, ss. 6, 7, 1861 (maintenance of all lunatics in asylums thrown upon the common fund of the Union) ; 28, 29 Vic. c. 79, s. 1, 1865 (Union Chargeability Act, by which the cost of all relief was made chai'geable to the common fund of Union) ; 30, 31 Vic. c. 106, s. 23, 1867 ; 31, 32 Vic. c. 122, s. 14, 1868; 39, 40 Vic. c. 61, ss. 20, 23, 26, 1876. (6.) The Metroxjolis, 30, 31 Vic. c. 6, s. 30 (Act for the Establishment in the Metropolis of Asylums for the Sick, the Insane, and other classes of the Poor).* In regard to criminal lunatics, see 23, 24 Vic. c. 75, 1860; 25, 26 Vic. cc. 86, 104, 111, 1862; 27, 28 Vic. cc. 29, 119, s. 95, 1864; 29, 30 Vic. c. 109, ss. 68, 80, 1866; 30, 31 Vic. c. 12, 1867 ; 32, 33 Vic. c. 78, 1869. Lastly, in regard to Commissioners in Lunacy there have been, since 1853, the following enactments : — 17, 18 Vic. c. 94, 1854; 18, 19 Vic. c. 105, 1855; 22 Vic. c. 26, 1859; 23, 24 Vic. c. 75, I860; 25, 26 Vic. cc. 86, 111, 1862; 26, 27 Vic. c. 110, 1863. t N.B. — The chief statutes comprising the existing law of lunacy are the 8, 9 Vic. c. 100, 1845, relating to licensed houses and hospitals, amended by 16, 17 Vic. c. 96, 1853; 16, 17 Vice. 97, regulating county and borough asylums, amended. * In 1874 a grant of 43. a week was made by Parliament in aid of the mainten- ance of pauper lunatics in asylums. It is voted annually. The payment passes through the Local Government Board. t ' Lunacy Acts,' by Danby P. Fry, Esq. 6 LEGAL ENACTMENTS IN REFERENCE TO THE INSANE by 18, 19 Vic. c. 105, 1855; 25, 26 Vic. c. Ill, 1862. ' The most important Acts referring to commissions of lunacy and chancery patients are 16, 17 Vic. c. 70, 1853; 25, 26 Vic. c. 86, 1862. The meaning attached to the principal terms employed in these Acts is subjoined : Medical attendant means every physician, surgeon, and apothe- cary, who shall keep any licensed house, or shall in his medical capacity attend any licensed house, or any asylum, hospital, or other place where any lunatic shall be confined (8, 9 Vic. c. 100, s. 104). Asylum means any lunatic asylum erected under the provisions of any Act for the erection or regulation of county or borough lunatic asylums (loc. cit.). Hospital means any hospital or part of an hospital, or other house or institution (not being an asylum), wherein lunatics are received and supported wholly or partially by voluntary contribu- tions, or by any charitable bequest or gift, or by applying the excess of payment of some patients for or towards the support, provision, or benefit of other patients (loc. cit.). Licensed house means a house licensed under the provisions of some Act for the reception of lunatics (loc. cit.). Registered hospital means any hospital registered for the reception of lunatics (loc. cit.). In connection with the foregoing statement of Lunacy Statutes, it may be useful to the general practitioner to have the main regulations stated in regard to the signing of certificates and the care of single patients — the points on which he is most liable to fall into difiiculty. In regard to the giving of evidence in courts of law in criminal cases, see the close of the section on Homicidal Mania. 1. Laws regulating the admission of the insane into asylnms, in regard to Medical Certificates. — 1. No person (not a pauper) shall be received as a lunatic into any asylum, licensed house, or hospital without medical certificates (in addition to Order and Statement of particulars) of two persons, each of whom shall be a physician, surgeon, or apothecary (16, 17 Vic. c. 96, s. 4; c. 97, s. 74 ; 25, 26 Vic. c. Ill, s. 23. See Schedule F, No. 2 and No. 3). 2. The term physician, surgeon, or apothecary shall mean a person i-egistered under the Medical Act (25, 26 Vic. c. Ill, s. 47). He must be in actual practice. MEDICAL CEETIMCATES 7 3. Neitlier sliall be in partnersliip with or an assistant to tlie other (16, 17 Yic. c. 96, s. 4 ; c. 97 s. 74). 4. Neither shall be wholly or partly the proprietor of, or a regulai* medical attendant in, the house or hospital to which the patient is to be sent. Nor shall the father, brother, son, partner, or assistant of the medical man signing the certificate, be so connected with it (16, 17 Yic. c. 96, s. 12). 5. Nor shall the certifying medical man receive any percentage on or be otherwise interested in the payments to be made by or on account of any patient received into the said house (25, 26 Yic. c. Ill, 8. 24). 6. Nor shall he be a Commissioner or Yisitor. 7. Each shall separately from the other examine the lunatic not more than seven clear days before the reception of such person into an asylum, house, or hospital (16, 17 Yic. c. 96, s. 4; c. 97, s. 74). 8. If the medical certificate be defective, it may be amended by the person signing it within fourteen days after the reception of the lunatic, provided that no such amendment shall have any force until it has received the sanction of one or more of the Commis- sioners (16, 17 Yic. c. 96, s. 11; 25, 26 Yic. c. Ill, s. 27). 9. Under special circumstances preventing the examination by two medical practitioners, any person, although not a pauper, may be received as a lunatic into any asylum, licensed house, or hospital upon the order and with the certificate of one physician, surgeon, or apothecary, alone, provided that the statement ac- companying such order set forth the above-mentioned special circumstances. In every such case, however, two other such certificates shall, within three clear days after his reception into such house, be signed by medical men, each of whom not only fulfils Law 3, but is not in partnership with or an assistant to the one who signed the temporary certificate (16, 17 Yic. c. 96, s. 5 ; c. 97, s. 74). Pauper lunatics. — 10. No pauper shall be received into any asylum, house, or hospital, without an order (Schedule F, No. 1), under the hand of a justice, or the hands of an officiating clergy- man, and the relieving officer or one of the overseers of the union or parish from which such pauper shall be sent, together with such statement of particulars as is contained in such schedule, nor without the medical certificate according to the form in Schedule F, No. 3, see pp. 16, 17 (16, 17 Yic. c. 97, s. 73), of a medical man (see Law 2), the medical examination having been 8 LEGAL ENACTMENTS IN REFERENCE TO THE INSANE made within seven days previous to the reception of the patient (16, 17 Vic. c. 96, s. 1, and c. 97, s. 73). 11. Medical officers of unions or parishes are no longer prohibited from signing certificates in the cases of pauper lunatics belonging thereto (^Circular Letter from Commissioners,' 1853). 8pecialinstructions regarding 'medical certificates {see alsop. 17). 12. After the words "being a,'' the medical man must insert, not the word "Physician,'-' '^Surgeon," or "Apothecary,'' but the legal qualification, diploma, or license, entitling him to practise as such within the United Kingdom. 13. He must insert — 1. The date of examination. 2. The place, with the street and number of the house {if any) or other like particulars, where the patient was examined. 3. The patient's ordinary place of residence, and profession or occupation (if any). (Omission of name of street and number of the house where examined will invalidate certificate. Fry, p. 341.) 14. When more than one medical certificate is required he must insert before the words " personally examined " the words '' separately from any other medical practitioner." 15- The certificate need not be drawn up or dated on the day of examination. All that is required is that the examination be made within seven clear days before admission. 16. The medical man signing the certificate must specify therein the facts upon which he has formed his opinion, and must distinguish the facts observed by himself from those com- municated to him by others — the latter alone being insufficient.* N.B. — No medical man who signs the Order may sign the medical certificate, nor can he do so if his father, son, brother, partner, or assistant signs it (16, 17 Vic. c. 96, s. 12). II.— Actions against medical men in regard to illegal restraint or confinement. — " By the common law of England it is only a person of unsound mind, and dangerous to himself or others, that may be restrained of his liberty by another ; such is taken to be the law from the case in Br. Abr. down to the last case on the sub- ject." Lord Cambell in Fletcher y. Fletcher (28 L. J. R. (N. S.), Q. B. 134), cited in Mr. D. P. Fry's 'Lunacy Acts,' p. 91. In the case of Nottidge v. Bipley and Nottidge C^ Times,' June, 1849) the Lord Chief Baron said that, "if the plaintiff was not in such a state as to be dangerous to herself or others, then the plea to that effect not having been made out, the verdict ought to be for the plaintiff," on that issue also. The Commissioners * See 'Circular Letter of Commissioners,' 1853. ACTIONS AGAINST MEDICAL MEN 9 in Lunacy addressed a Letter to tlie Lord Chancellor on the 4tli of July, in which they said — " The object of the Lunacy Acts is not, as your Lordship is aware, so much to confine lunatics as to restore to a healthy state of mind such of them as are curable, and to afford comfort and protection to the rest. . . . Moreover the difficulty of ascertaining whether one who is insane be dangerous or not, is exceedingly great, and in some cases can only be determined after minute observation for a considerable time. . . . It is of vital importance that no mistake or misconception should exist, and that every medical man who may be applied to for advice on the subject of lunacy, and every relative and friend of any lunatic, as well as every magistrate and parish officer (each of whom may be called upon to act in cases of this sort), should know and be well assured that, according to law, any person of unsound mind, whether he be pronounced dangerous or not, may legally and properly be placed in a county asylum, lunatic hospital, or licensed house, on the authority of the preliminary order and certificates prescribed by the Acts." Fry, after citing the foregoing and producing evidence to show that the Court will not order the discharge of a lunatic upon a writ of habeas corpus, if dangerous to himself or others, even when the order and certificates are invalid, says, " Upon the whole, it appears that the power to restrain and confine a liinatic is limited at common law to cases in which it would be dangerous, either as regards others or himself, for the lunatic to be at large ; but that the power to place and detain a lunatic in a registered hospital or licensed or other house, under an order and medical certificates duly made and obtained in accordance with the provisions of the Lunacy Acts, is not so limited. It is important, however, that those provisions should be strictly observed" (p* 319). In 1862, at the Surrey Summer Assizes, an action was brought by 8goU against a medical practitioner, Wahem, " for placing the plaintiff (who, it appeared, was suffering from deli- rium tremens) under restraint as a dangerous lunatic. It was held by Bramwell, B., that at common law, and apart from the lunacy statutes, a medical man may justify measures necessary to restrain a dangerous lunatic ; and that if he be called in to attend a person suffering under deliriuin tremens, he may justify such measures as are reasonably necessary, either to cure the person so suffering or to restrain him from doing mischief, so long as the fit lasts or is likely to return''^ (op. cit., p. 92). A similar case, in which the Lord Chief Justice laid down the same judgment, occurred in 1863 {8ymm v. Fraser and Andrews). In connection with actions against medical men in lunacy cases, it is important to know the law in regard to the — Evidence of lunatics. — Notwithstanding the dictum that neither an idiot nor a lunatic shall be allowed to give evidence except during a lucid interval (Co. Litt., b. 6), the testimony of the insane has been repeatedly admitted in courts of law, so that, as stated by Taylor, " it may now be considered as settled that a lunatic who labours under delusions, but who, in the judgment 10 LEGAL ENACTMENTS IN REFERENCE TO THE INSANE of a medical practitioner, is capable of giving an account of any transaction tliat happened before his eyes, and who appears to understand the obligation of an oath, may be called as a wit- ness/' He cites Reg. v. HiJI, ' Jour, of Psych. Med.,' 1851. III. Penalties to which medical men are liable.— 1. The penalty for infringing the Lunacy Acts in regard to signing a medical certificate is £20, and every person falsely stating or certifying anything, or signing a certificate as a medical man when he is not one, is guilty of a misdemeanor (16, 17, Yic. c. 96). 2. The patient himself may institute proceedings against the medical man who has signed the certificate, either on the ground that he has never examined him or not done so within seven days of his admission, or negligently. For the first cause see the ' Sixth Report of the Commissioners in Lunacy ;' for the second their ' Seventeenth Report,' and for the third the last- mentioned Report also, and Hall v. Semple, 3 F. and F. 337 ; also Fry's 'Lunacy Acts,' p. 71. " The charge was, that Dr Semple had negligently and culpably failed duly to inquire into the truth of the facts, from which mainly he drew his conclusion that Mr Hall was insane, and in the course of the trial, which lasted five days, the law applicable to the case was fully discussed, and ably and elaborately laid down by the presiding judge. Upon being questioned by Mr Justice Crompton, the jury stated their opinion that Dr Semple hona fide believed that in what he did he was authorised by the Act, although he did it negligently ; upon which Mr Justice Crompton observed : — ' That is a verdict for the plaintiff on the ground of culpable negligence and want of reasonable care ;' to which the jury assented." 3. If any physician or surgeon, being a Commissioner, or any physician, surgeon, or apothecary, being a Visitor, shall sign any certificate for the admission of any patient into any licensed house or hospital, or shall professionally attend any patient in any licensed house or hospital (except in acccordance with the Acts), such physician, surgeon, or apothecary shall, for each offence against this provision, forfeit the sum of £10 (8, 9 Vic. c. 100, s. 23). 4. A medical man concerned in the unlawful taking or con- finement of a patient may be prosecuted by the Crown (8, 9 Vic. c. 100, s. 56). 5. Any person taking charge of a single patient for profit without order and medical certificates, as in a licensed house, shall be guilty of a misdemeanor (8, 9 Vic. c. 100, s. 90). SINGLE PATIENTS 11 6. Every medical officer of a parish or union, who shall have knowledge that any pauper resident in his parish is, or is deemed to be, insane, and a proper person to be sent to an asylum, shall within three days give notice thereof in writing to a relieving officer of such parish, or, if there is none, to one of the overseers. Penalty for omitting to do this, £10 (16, 17 Vic. c. 97, s. 70). 7. If a justice knows of such a case he shall either visit him himself or direct a medical man to do so, and report in writing his opinion, and if the medical man sign a certificate (Schedule F, p. 15) it shall be lawful for the justice or justices to make an order upon the guardians of the union or overseers of the parish for the payment of such reasonable remuneration for the exami- nation of the patient and all other reasonable expenses in or about the examination of such person as to such justice or justices may seem- proper (16, 17 Yic. c. 97, s. 69). It may be added that there are three kinds of cases contem- plated in the foregoing sections, of which constables, relieving officers, and justices are bound to take cognizance, viz. : — 1. Any person wandering at large and deemed a lunatic. 2. A pauper deemed a lunatic resident in the parish, 3. Any person deemed to be a lunatic, though not a ])au]per, and not wandering at large, hut who is not under fvoper care and control, or is cruelly treated or neglected by any person having the care or charge of him. This includes the charge of idiots. The lunatic must be a proper person to be sent to an asylum. See in connection with the ill- treatment of lunatics by their friends, &c., H. v. Smith (2 C. and P. 449) ; Peg. v. Pelham (8 Q. B. 959) ; Peg. v. Marriott (8 C. and P. 425); Reg. v. Porter, 10 L. T. (n.s.), 306. ^Eighth Annual Peport of the Commissioners in Lunacy,^ pp. 36, 38, and pp. 38, 39; also 8, 9 Vic. c. 100, ss. 112, 113, and 16, 17 Vic. c. 96, s. 9, and c. 97, s. 68; but the bearing of this latter Act upon the charge of lunatics by relatives was successfully disputed in Reg. v. Rundle (see 25 L. 7, 118, and Fry's ' Lunacy Acts,' p. 90). Porter was convicted under c. 96, s. 9, in 1864 {Times, March 21). IV.— Single patients. — 1. No one deriving a profit from the charge of a patient (except a Committee appointed by the Lord Chancellor) may board or lodge him, or take the care or charge of him without the same order and medical certificates* as are required on the reception of a private patient into a licensed * Of which a duplicate copy must be retained by the party having charge of the patient, and the original forwarded to the Commissioners. 12 LEGAL ENACTMENTS IN REFERENCE TO THE INSANE house (8, 9 Vic. c. 100, s. 90, and 16, 17 Vic. c. 96, ss. 8, 12). 2. Any person who thus receives the patient to board or lodge or takes the care or charge of him, must, within one clear day, transmit to the Secretary of the Commissioners, 19, Whitehall Place, S.W., a copy of the above order and certificates, and a statement of the date of such reception, and of the situation of the house into which such patient has been received, and of the name and occupation of the occupier thereof and of the person by whom the care and charge of such patient have been taken (25, 26 Vic. c. Ill, s. 28). 3. The person having the charge of the patient must also transmit to the Commissioners, after two clear days, and before the expiration of seven clear days, a statement of the condition of the patient according to the prescribed form signed by the medical man visiting the patient (25, 26 Vic. c. Ill, ss. 28, 41). 4. The said patient must be visited at least every fortnight* by a physician, surgeon, or apothecary who did not sign either medical certificate, and does not derive, and has not a partner, father, son, or brother who derives any profit from the care or charge of such patient, and he shall also enter in a book to be kept at the house for that purpose, to be called ' The Medical Visitation Book,' the date of his visits, and a statement of the condition of the patient's mental and bodily health, and of the condition of the house in which such patient is, and such book shall be produced to the Visiting Commissioner on every visit (8, 9 Vic. c. 100, s. 90, a,nd 16, 17 Vic. c. 96. s. 12). 5. In the event of the death, removal, discharge, or escape and recapture of such patient, the person by whom the care or charge has been undertaken, or into whose house he has been received, must transmit to the Secretary of the Commissioners the same notices as are required for a private patient in a licensed house. When transferred to other care fresh certifi- cates and orders are not required if the consent of the Com- missioners be first obtained (16, 17 Vic. c. 96, s. 20). 6. A person having the care or charge of a single patient may change his residence and remove him to a new residence in * The Commissioners allow this visitation to be much less frequent when they see fit to do so. If this is done, and the patient is in the charge of a medical man, the latter shall, once at least in every two weeks, make an entry in ' The Medical Journal ' of the condition of the patient's health, in the same way and subject to the same conditions as in the case of the visiting medical attendant (16, 17 Vic. c. 96, s. 14). CHANCEEY SINGLE PATIENTS 13 England, provided lie give notice thereof and of tlie place of such, new residence seven days before to the Commissioners, and to the person who signed the order for the reception of such patient, or by whom the last payment on account of such patient was made. 7. The patient^s caretaker may also, after obtaining the con- sent of two of the Commissioners, take or send such patient under proper control to any specified place or places, for any definite time, for the benefit of his health, provided that before any such consent is given, the approval in writing of the person who signed the order for the reception of such patient, or by whom the last payment on account of such patient was made, be produced to such Commissioners, unless they shall, on cause being shown, dispense with the same. 8. Any person receiving or undertaking the care of such lunatic and infringing any of these enactments is guilty of a misdemeanour. 9. Every letter written by a single patient and addressed to any person other than the Commissioners must be forwarded to the person to whom it is addressed, unless the person having charge over him prohibit the forwarding of it by endorsement to that effect under his hand on the letter, in which case he shall lay all letters so endorsed before the Visiting Commissioners on their next visit. Penalty for infringement £20 (25, 26 Vic. c. Ill, s. 40). 10. An y medical man visiting or having the charge of a single patient must report annually (Jan. 10, or within seven days) to the Commissioners (and oftener if they require it) the bodily and mental state of the patient (16, 17 Vic. c. 96, s. 14). 1 1 . The costs of periodical visits by the medical attendant will fall, with all other expenses, upon the person signing the order. V. Chancery single patients. — 1. When a person has been found lunatic by inquisition, an order, signed by the Committee ap- pointed by the Lord Chancellor, and having annexed thereto an office copy of the order appointing such Committee, shall be a sufficient authority for the reception of such person into any asylum, hospital, licensed house, or other house, without any further order or the usual medical certificates. Nor is the fort- nightly medical visitation, which is ordered for single patients in unlicensed houses, required in these cases (25, 26 Vic. c. Ill, s. 22). 2. If, therefore, the Committee places the lunatic so found by inquisition under the care of a medical or other person who receives profit from the charge, instead of placing him in a resi- 14 LEGAL ENACTMENTS IN REFERENCE TO THE INSANE dence rented by him for the patient, his order, as above, is suffi- cient for the lunatic's reception (see Fry's ' Lunacy Acts,' p. 28). 3. As regards visitation of the patient under the care of a Committee, the Lord Chancellor can at any time direct a Com- missioner or other person to visit him and report (8, 9 Vic. c. 100, s. 112). But the ordinary visitation consists of the visit of one of the Chancery Visitors four times a year — the interval between each visit not exceeding four months (25, 26- Vic. c. 86, s. 19, 20). VI. Payments for visiting lunatics in special cases. — 1. If the Lord Chancellor or the Home Secretary employ a person not a Commissioner in Lunacy to inspect or inquire into the state of any asylum, hospital, gaol, house, or place wherein any lunatic is confined, and to report to him the result of such inspection, he may be paid such sum of money as shall seem reasonable to the Lord Chancellor or the Home Secretary, as well as travel- ling and other expenses incurred while so employed (8, 9 Vic. c. 100, s. 113). 2. If a person has the charge of a lunatic for whom he receives no profit, the Lunacy Acts do not require medical certificates or any legal supervision, but the Lord Chancellor or Home Secre- tary may at any time, by an order in writing directed to the Commissioners or to any other person, require the person so addressed, to examine such lunatic and to report (8, 9 Vic. c. 100, s. 92) ; and payment for the trouble is to be reasonable in addition to travelling and other expenses (16, 17 Vic. c. 96, s. 33). 3. Examination of a pauper. See p. 11, No. 7 and p. 17. Schedule (F) No. 1. ORDER FOR THE RECEPTION OF A PAUPER PATIENT. I, C. 1). (in the case of a single Justice of the Peace, or in the case of tivo Justices, or of a Clergyman and Melieving Officer, We, C. D. and E. F.), the undersigned, having called to my {or our) assistance a Physician {or Surgeon, or Apothecary, as the case may he), and having personally examined A. B., a Pauper (omit the words "a Pauper "when the lunatic is not a Pauper), and being satisfied that the said A. B. is a lunatic {or an Idiot, or a person of unsound Mind), {add, where the lunatic is so sent,* " wandering at large ;" and in the case of a lunatic being sent iy virtue of the authority given to two Justices, add, " not under proper care and con- trol," or " and is cruelly treated {or neglected) hy the person having the * If sent as being wandering at large, and the name cannot be ascertained, the entry " name unknown " is sufficient. OEDEE 15 care or charge of him," as may appear to the Justices to he the case), and a proper person to be taken charge of and detained under Care and Treat- ment, hereby direct you to receive the said A. B. as a Patient into your Asylum {or Hospital, or House), Subjoined is a Statement respecting the said A. B. : Signed, C. D., a Justice of the Peace for the County, City, or Borough of (or an, or the Officiating Clergyman of the Parish of ). ^. F. the Believing Officer of the Union or Parish of {or an Overseer of the Parish of ). Dated the day of One Thousand Eight Hundred and Seventy To Superintendent of the Asylum for the County of , or the Lunatic Hospital of , or Proprietor of the Licensed House of (describing the Asylum, Hospital, or House). Statement. Same as for Private Patient, with the additions " Parish or Union to which the Lunatic is chargeable," and "Name and Christian Name and Place of Abode of the nearest known Relative of the Patient, and degree of Relationship (if known)." (To be signed by the Relieving Officer or Overseer.) Medical Cektificate. Same as for Private Patient, with the omission of " separately from any other Medical Practitioner." Schedule (F) No. 2. ORDER FOR THE RECEPTION OP A PRIVATE PATIENT. I, the undersigned, hereby request you to receive A. B., a Lunatic {or an Idiot, or a person of unsound mind), as a Patient into your Asylum {or House, &c.). Subjoined is a Statement respecting the said A. B. Signed, Name Occupation (if any) Place of Abode Degree of Relationship (if any), or other circumstances of connection with the Patient. Dated this day of One Thousand Eight Hundred and Seventy To Superintendent of the Asylum or of licensed House or Hospital for the County {or Borough) of Statement. If any Particulars in this Statement he not Jcnown, the Fact to he so stated. Name of Patient, with Christian Name at length Sex and Age ..... Married, Single, or Widowed Condition of Life, and previous Occupation (if any) IG LEGAL ENACTMENTS IN REFERENCE TO THE INSANE Religious Persuasion, as far as known Previous Place of Abode . Whether First Attack Age (if known) on First Attack . When and where previously under Care and Treat- ment ..... Duration of existing Attack Supposed Cause .... Whether subject to Epilepsy Whether Suicidal .... Whether Daugerous to others Whether found Lunatic by Inquisition, and Date of Commission or Order for Inquisition Special circumstances (if any) preventing the Patient beingexamined, before Admission, separ- ately by Two Medical Practitioners Signed, Name (where the patient signing the statement is not the person who signs the Order, the following particulars concerning the person signing the Statement are to be added) : Occupation (if any) Place of Abode Degree of Relationship (if any), or other circumstances of connection with the Patient Schedule (F) No. 3. medical certificate. I, the undersigned (here set forth the qualification entitling the person certi- fying to practise as a physician, surgeon, or apothecary, ex gra., being a Fellow of the Royal College of Physicians in London, Licentiate of the Apothecaries' Company, or as ike casemay he), and being in actual practice as a (physician, surgeon, or apothecary, as the case may he), hereby certify that I, on the day of , at (here insert the street and number of the house, if any, or other like particulars), in the County of separately from any other Medical Practitioner, personally examined A. B., of (insert residence and profession, or occupation, if any, of the patient), and that the said A. B. is a lunatic (or an idiot, or a person of unsound mind), and a proper Person to be taken charge of and detained under Care and Treatment, and that I have formed this opinion upon the following grounds, viz. : 1. Facts indicating Insanity observed by myself (here state the facts). 2. Other facts (if any) indicating Insanity, communicated to me by others (here state the information, and from whom). Signed, Name Place of Abode Bated this day of One Thousand Eight Hundred and Seventy. BOAEDEES, ETC, SELECT COMMITTEE 17 Addenda. Boarders. — The exceptional privileges enjoyed by boarders are provided for by 16, 17 Vic. c. 96, s. 6^ and 25, 26 Yic. c. Ill, s. 18; tlie latter extending tbe power to take boarders so as to include any person who may have been within the pre- vious five years a patient in any asylum, hospital, or licensed house, or under care as a single patient. Pauper Lunatics not in Asylums. — These, whether in work- houses, living with their relatives, or boarded out, are provided for by 16, 17 Vic. c. 97, s. 66, and 25, 26 Vic. c. Ill, s. 21, which enact that they are to be visited by the medical ofiicer every quarter, and to be included in his quarterly return. Eemunera- tion half a crown ; visits to patients in workhouses being excepted, " as the medical officer would constantly visit the workhouse in the course of his ordinary duty " (see ' Lunacy Acts,' p. 107, 130). Select Oommittee of House of Oommons, 1877. — This Com- mittee, appointed at the instance of Mr Dillwyn "to enquire into the operation of the Lunacy Law, so far as it regards the security afforded by it against violation of personal liberty,^' has issued a Blue Book containing a large mass of evidence, followed by a brief separate Report (1878), but as yet (May) no legislation has been based upon it. For the writer's views on the legislation called for, and an analysis of the evidence, the reader is referred to an article in the ' Contemporary Review,' Oct., 1877, entitled " Legislation for the Insane." CHAPTER II OF INSANITY IN GENERAL SECTION I— Synonyms and Definition SYNONYMS. Lunacy. Unsoundness of Mind. Mental Alien- ation or Derangement. Madness. Frenzy. Craziness. Wood- ness, used by Spencer, from a Saxon word Woed, mad ; another Saxon word is gemaad, or gamed, derived by some from fxa'ivofxai ; but by others with some reason from the Hebrew word mad. Those afflicted with madness were often called " Toms o'Bedlam," or " Bedlams " (see D^Israeli^s ' Curiosities of Literature '). It is stated that the old terms " innocent " and " natural " were used with discrimination ; the former referring to the quite idiotic class; the latter to the half-witted, impulsive class. "A bee in his bonnet/^ a Scotch phrase for a slight touch of insanity ; as the English say — " A kink in the head.^^ Scotchmen also say " he's ivud." Shiggaon* (Heb). The Hebrew word for strength is mad, from which some Hebrew scholars derive our word on account of the increased strength possessed by the maniacal. Mai'ta. TrapaTr\i]KTog. Traoa(ppo^iviTiQ (Gr.). Insanitas. Insania. Vesania (from ve, priv., and sanus). Vecordia {ve and cor.). Delirium (from deliro, to go out of the furrow in ploughing). (Lat.j Insania. Insanita. Delirio. Non e sano in mente. Pazzia. (Ital.) Delire. Folic. Insanite, Alienation Mentale. Maladie Men- tale. (Fr.) Irresein, Irrsinn. Narrheit. Wahnsinu. Psychische Krank- heiten. Krankhafte Seelenzustande. Geisteskrankheiten. (Ger.) Under " Insanity in General " we include Idiocy ; although * See Dent, xxviii, 28; 2 Kings ix, 20; Zech. xii, 4; Jer. xxix, 26; Hos. ix, 7- DEFINITION 19 it is more usual to distiuguisli between Insanity and Idiocy _, the former being a morbid condition induced in a person of sound mind, and the latter an original or infantile defect. When making this distinction, we may comprise them under Mental Alienation or Disease. DEFINITION. — What Dr Johnson said of any one who should attempt to define poetry, may very properly be applied to him who attempts the definition of Insanity — namely, that such attempts at definition will only show the narrowness of the definer. We believe it to be impracticable to propose any definition entirely free from objection, which shall comprise every form of mental disorder. In regard to Insanity in general, it may be asked, as Burton asks when speaking of melancholy — "Who can sufficiently speak of these symptoms, or prescribe rules to comprehend them ? As Echo replied to the painter in Ausonius, ' If you must needs paint me, paint a voice/ if you will describe it, describe a fantastical conceit, a corrupt imagination, vain thoughts and different, — which who can do ? The four- and- twenty letters make no more variety of words in diverse languages, than it produces diversity of symptoms in several persons. ^^ Who can supply an unexceptional definition of anger, or of imagination ? How much more difficult, then, must the task be when we are required, in the compass of a paragraph^ to define a disease which in turn assumes as many forms, not only as there are fundamental faculties liable to disease, but as many forms as these combined in endless variety can assume, and still further varied according as one or more of them may be exalted or depressed ? Such are the multiform morbid mental pheno- mena around which the psychologist has attempted to throw his all-embracing definitions. These definitions it is our purpose now to consider, for from them, while confessing the impossibility of supplying any definition not more or less open to criticism, we may possibly draw something which will serve us at least to describe, with tolerable clearness, though it should fail to define, the essential characters of Mental Alienation. Lockers celebrated dictum, that " madmen do not appear to have lost the faculty of reasoning, but having joined together some ideas very strongly, they mistake them for truths, and err as men do who argue from wrong principles,^'' and which has often been referred to as an acute and satisfactory definition of insanity, has only a very partial application, — comprising merely 20 OP INSANITY IN GENERAL those cases, in fact, in wliicli the patient is the subject of a delusion, illusion, or hallucination, and acts as he would pro- perly act were the delusion a reality. Nor was the definition adopted by Cullen sufficiently comprehens'ive — " a lesion of the intellectual faculties, without pyrexia and without coma/^ If, in this reference to pyrexia, it be meant that Insanity must not be confounded with the derangement of the mind occurring in fever on the one hand, or phrenitis on the other, Cullen no doubt correctly enforces a distinction which conventional use, at least, sanctions ; but if it be meant (as the student would be apt to understand it) that the absence of feverish symptoms is a con- dition necessary to the presence of Insanity, the statement is incorrect, and as the term is liable to misconstruction, we think it best to avoid it. Dr Combe's definition possesses considerable merit. " It is a prolonged departure, and without an adequate external cause, from the state of feeling and modes of thinking usual to the individual who is in health, that is the true feature of disorder of mind." Congenital defects of mind are obviously excluded from this definition, in accordance with the very general custom — not sanctioned, however, by etymology — of regarding idiotic and imbecile conditions of mind as not insane states. Nor does his definition comprise sudden attacks of Insanity. It has the merit, however, of making the mind of the individual himself, and not that of the physician, the standard of comparison by which to determine his insanity. The same writer is happier, we think, in his definition, when he speaks of Insanity being a "morbid action in one, in several, or in the whole, of the cerebral organs; and, as its necessary consequence, functional derangement in one, in several, or in the whole of the mental faculties which these organs subserve.'^ Dr Spurzheim and M. Lelut both err in their definitions of Insanity, in assuming that the patient must be unconscious of his disease; the former requiring "the incapacity of distinguishing the diseased functions,'' and the latter that there shall be " a disorder of the passions and will, without the patient's conscious- ness of such disorder." M. Lelut also requires a "lesion in the association of ideas" — a symptom which, however frequently present, ought not to be allowed to constitute an essential condition. Dr Conolly, while admitting the difficulties which attach to any attempt to define Insanity, has, however, offered a definition DEFINITION 21 whieli will be found to include a large number of cases^ and is as follows : — " An impairment of one or more of the faculties of the mind, accompanied with, or inducing, a defect in the com- paring faculty." It does not, however, comprise many of those instinctive and purely emotional acts in which the patient^s comparing faculty appears to remain intact. Dr Guislain has given the following definition of Insanity : — " It is a derangement of the mental faculties, morbid, apyrexial, and chronic, which deprives man of the power of thinking and acting freely, as regards his happiness, preservation and respon- sibility." Chronicity, however, is not essential to a definition of Insanity. Transitory madness — mania hrevis — seems to be quite forgotten for the moment in such definitions, although those who give them, fully admit the occurrence of such attacks. We should also prefer the expression thinking or acting, instead of thinking and acting. The latter objection applies, also, to the last clause of the definition adopted by M. Morel, who asserts that Insanity is " a cerebral affection, idiopathic or sympa- thetic, destroying the individuaFs moral liberty, and consti- tuting a derangement of his acts, tendencies, and sentiments, as well as a general or partial disorder in his ideas." Whatever definition of Insanity is adopted by the student, it is all-important that he should regard bodily disease, including defect, as an essential condition ; in other words. Insanity is a condition in which the intellectual faculties, or the moral senti- ments, or the animal propensities — any one or all of them — have their free action destroyed by disease, whether congenital or acquired. He will not go far wrong if he regard insanity as a disease of the hrain {idiopathic or sympathetic) affecting the inte- grity of the vrdnd, whether marlied hy intellectual or emotional dis- order J such affection not being the mere symptom or immediate result of fever or poison. That there are affections of the brain causing mental disturbance which are not comprised under In- sanity does not vitiate this definition. Medical science ought not, in fact, to recognise this distinction. But for reasons not diffi- cult to discover, custom has distinguished between the delirium of fever and the madness of alcohol on the one hand, and the frenzy of the maniac on the other. In the former instance the cause is so obviously physical, the mental condition supervening and passing away with the patient^s bodily disorder, that it is regarded as a mere accident of such disease. When, however, mental derangement does not arise in the course of a bodily 22 OF INSANITY IN GENERAL disorder, or, having so arisen, remains after the cause has passed away, then, naturally enough, men look out for another term to designate morbid mental symptoms, sometimes identical with those springing directly from acute attacks of bodily disease, but which make their appearance under very different conditions. It is to meet this want that a definition has to be framed which is justly open to criticism from a scientific point of view. If it does not allow, however strictly scientific, for these exceptional cases, it fails to serve any purpose as a practical definition. If it embrace states of fever and intoxication, it comprises what a uni- versal instinct has sought to exclude. Hence we can clearly see why chronicity and the absence of fever have been imported into the definition, and if there were no danger of understanding these phrases in some other sense than that Insanity does not include those affections which arise in the course of fever and from in- toxicants, there would be no objection to their use, but from their fi-equently conveying quite a different idea we think them unde- sirable. One reason why it is more difficult now to distinguish in a definition between those insane states which spring from bodily illness and those which do not, is, that we tend more and more to connect all forms of Insanity with a previous or present affection of some organ of the body. It seems to us, however, that arbitrary as is that definition which excludes the fleeting disorders of the mind arising as complications of other diseases, the distinction is essential for practical purposes. In Puerperal Insanity we meet with a striking example of a sort of border case, actually arising in the course of another dis- order, and yet so different from the ordinary delirium of fever, so apt to continue beyond the physical state which has given rise to it, that it has passed into the category of so-called mental dis- orders. It may be remarked, in passing, that the horror men have of Insanity is connected with the idea that it is not the outcome or sign of any ordinary illness. It is this which has stamped — we may say branded — it, as something distinct from bodily dis- orders, and it will always be observed with what avidity men seize some physical cause as an excuse for the insanity of their relations, such as a fever, or a blow, or age, or, as in the instance just referred to, the puerperal state. Now, if we turn to Copland's definition of Insanity, it will be found that he makes no allowance for what may be called the popular definition of the disease; and not only the popular, but generally understood definition among medical men. He DEFINITION 23 defines it as *''' a deviation from or perversion of the natural and liealtliy state of tlie mind^ as manifested either by the moral emotions and conduotj or by a partial or general disorder of the intellectual powers and understanding/'^ Such a definition must notj however, be blamed as being incorrect, for it is a true enough description, but it seems to fail in embracing mental conditions, deviating from those of health, which no one really includes under the term defined ; an opposite error to that of Guislain^s definition, which, unless the expressions employed be themselves carefully defined, conveys a signification that excludes cases which must be regarded as genuine examples of Insanity. Allowing for the exceptional conditions to which we have made reference, Dr Bucknill's definition is in accordance with the foregoing. He regards Insanity as " a condition of the mind in which a false action of conception or judgment, a defective power of the will, or an uncontrollable violence of the emotions and instincts, have, separately or conjointly, been pro- duced by disease.^'' {' Unsoundness of Mind in relation to Criminal Acts.'') We would repeat, then, that no definition ought to require chronicity, absence of febrile action, recognisable lesion of the intellect, or unconsciousness of the disease. A paroxysm of Insanity may occur suddenly, and be of brief duration. An attack of Insanity, however strictly idiopathic, may be accom- panied by feverish symptoms. It may be impossible to recog- nise disordered intelligence in a genuine case of Insanity. A patient may be miserably conscious of his malady ; well aware that his impulses are diseased but uncontrollable. On the other hand, the positive requirements of a definition demand the recognition of an abnormal condition of the intel- lectual or moral nature, or both, caused by cerebral defect or disease (either idiopathic or sympathetic). Moreover, to meet an arbitrary, if not a sentimental demand, this abnormal state must not be the passing symptom of fever, nor temporarily induced by intoxicants. We say sentimental, for, however anxious men ordinarily are to ignore Insanity in such cases as we refer to on account of the supposed stigma attaching to the disease, they are anxious to admit it in the same class of cases, when an act has been committed by their friends to escape from the consequences of which, irresistibility and consequent irresponsibility must be proved. Shall the element of impaired will and irresponsibility form 21 OF INSANITY IN GENERAL an essential part of a definition of Insanity ? It will be found that upon tlie answer to this question, the character of the various definitions proposed chiefly depends ; in other words, its character varies in great measure according as the definer does or does not include such an amount of disease as renders the individual irresponsible. Two objects of a definition of Insanity are thus constantly confounded together, which ought to be kept distinct — the medical and the forensic. For medical treatment it is sufficient for the physician that cerebro-mental disease exists, however incipient it may be ; but in the con- sideration of the punitive treatment merited by one who has committed a criminal act, the judge, assisted by a medical expert, ought to determine the extent of impairment of the will and the consequent irresponsibility of the prisoner. Now, it is simply impossible to include both these ideas in one definition, without narrowing it too much for medical use, or making it too comprehensive for the just demands of the law. If therefore a forensic definition be required, we must add to the foregoing definition that the cerebro-mental disorder is such as to suspend or imjjair the action of the healthy tvill. It is not in any definition, however, of mental derangement that the student will learn what Insanity is ; and in a court of law the practitioner ought never to be so unwise as to be tempted to offer one, for as Burrows says, it is " an ignis fatuus which eludes and bewilders pursuit." It is in the description of the disorder that the student will be able, as far as books can help him, to comprehend its true characteristics ; and, most of all, in his actual observation of the insane. For, notwithstanding the difficulties which beset the construction of a definition, there are in practice compara- tively few cases in which a difference of opinion exists as to the fact of Insanity being present in particular instances — a circumstance precisely analogous to what occurs in the exhibi- tion of almost any of the passions or emotions of our mental constitution. Thus, while definitions of anger would differ with every definer, all would agree that anger is anger when exhi- bited before them. A writer of eminence has defined love to be " desire kept temperate by reverence."* But who is the wiser for such a definition ? How different, and how infinitely superior, is the well-known description given by Shakespeare ! Cases of Insanity certainly exist in which doubt as to their * Quoted by Walker (with iipproval) in his ' Elements of Elocution.' DEFINITION 25 real nature will be experienced by the student ; but tbe exist- ence of tbese (sucb as graduate between reason and mental disease) is, as Sir Henry Holland observes, but a part of that law of continuity wbich pervades so generally every part of the creation. The following legal definitions will prove useful to the reader : Non comjp OS mentis. — General term to include persons labouring under mental disabilities, and is the most legal according to Coke. As compos mentis meant '' one in his senses " in Latin, the law of England adopted the phrase, non compos Tnentis, to indicate one out of his senses. Four classes were comprised under this term by Coke : 1. — Idiot, or fool natural, who from his nativity by a perpetual infirmity is non compos mentis. 2. A person who was of good and sound memory, and by sickness, grief, or other accident, wholly loses his memory and under- standing. 3. A lunatic, lunaticus, who has sometimes his understanding and sometimes not, qui gaudet lucidis intervallis, and therefore he is called non compos mentis so long as he has not understanding. 4. A person who, by his own vicious act, for a time deprives himself of his memory and understanding, as he that is drunken ; but such a person has no privilege by this voluntary contracted madness. (Shelford's 'Law of Luna- tics.') Lunatic. — By 8, 9 Vic. c. 100, s. 94, a lunatic ^"^ shall mean every insane person, and every person being an idiot, or lunatic, or of unsound mind.'' By 16, 17 Vic. c. 39, a lunatic '^ shall mean and include every person of unsound mind and every person being an idiot." Fry refers to the following authorities for definitions of lunacy, idiocy and insanity : — 4 Eep., 124 h, 128 a; Co. Lit., 246 h, 247 a, b ; Fitz N. B., 233 hj 1 Hale P. C, 29, 31 ; 1 Ridg. P. C, 513, 533; Blackstone, Comm. ; Bacon's Abr., Brooke's Abr., Viner's Abr. ; 1 Russel ' On Crimes,' 6 — 17, &c. Blackstone's definition : — " A lunatic, or non compos mentis, is one who hath had understanding, but by disease, grief, or other accident, hath lost the use of his reason. A lunatic is indeed properly one that hath had lucid intervals ; sometimes enjoying his senses and sometimes not, and that frequently depending upon the changes of the moon. But under the general name of non compos mentis, which Sir Edward Coke 26 OF INSANITY IN GENERAL s.ays is the most legal uame^ ai'e comprised not only lunatics, but persons under frenzies, or who lose their intellects by disease ; those that grow deaf, dumb, and blind, not being born so, or such, in short, as are judged by the Court of Chancery incap- able of conducting their own affairs " (Cited in Fry's ' Lunacy Acts,^ p. 4). Shelford adopts the above, and observes, " It is singular that the term hmaticus, which, though derived from a vulgar error, gives the title to the modern proceeding by commission, and is the only specific description of afflicted persons contained in it, is not to be found in any form of old writ/^ TJnsound mind. — This term, according to Shelford, seems to have been used in some statutes, and by Lord Hardwicke, in the same sense as insane ; but a greater latitude appears to have been given to the meaning of these words by Lord Eldon, who said that " they imported that the party was in some such state as was contra-distinguished from idiocy and from lunacy, and yet such as made him a proper subject of a commission to inquire of idiocy and lunacy ; and accordingly if a jury find a party to be of unsound mind and incapable of managing his affairs, it is held a sufficient finding to support a commission of lunacy." It would probably be difficult for the Commissioners in Lunacy to discriminate between " Lunatics " and " Persons of Unsound Mind " in their Annual Report containing the number and dis- tribution of these classes, in which the legal terms are retained, and appear somewhat tautological. Partial Insanity in law signifies that a person is insane on one or more particular subjects only, and sane in other respects. Lord Hale admitted a partial Insanity of mind as well as a total Insanity. The former is either in respect to things, quoad hoc vel illud insanire, — some persons that have a competent use of reason in respect of some subjects are yet under a particular dementia in respect of some particular discourses, subjects, or applications ; or else it is partial in respect of degrees, and does not excuse persons who commit capital acts in this state (I Hale's P. C. 30. Shelford, op. cit., p. 6). Unthrifts and Prodigals. — Under this head, Blackstone may be quoted : "The Roman law goes much beyond the English. For, if a man by notorious prodigality was in danger of wasting his estate, he was looked upon as non compos, and committed to the CLASSiriCATION 27 care of curators. But with us wlien a man on an inquest of idiocy hath, been returned an unthrift and not an idiot^ no fur- ther proceedings have been had. Sic utere tuo, ut alienum non ladas is the only restriction our laws have given with regard to economical prudence.^'' The summing-up of the master in lunacy in Windham^s case was as follows : — " Mere weakness of character, mere liability to impulse or susceptibility of in- fluence, good or bad, mere imprudence, extravagance, reckless- ness, eccentricity, or immorality, — no, not all these put together would suffice, unless they believed themselves justified, on a view of the whole evidence, in referring them to a morbid condi- tion of intellect '' ('Times,' 30th Jan., 1862, cited by D. P. Fry). Lucid interval " consists not in a mere cessation of the vio- lent symptoms of a disorder, but an interval in which the mind, having thrown off the disease, has recovered its general habit. The party must be capable of forming a sound judgment of what he is doing, and his state of mind such that any indifferent person would think him able to manage his own affairs. Col- linson ' On Lunacy,' p. 39, who refers to the following authori- ties in support : — Att., Gen. v. Paruther, 3, Bro. C. C, 444 ; Hall V. Warren, 9, Ves. Jun. 611. Fry also refers to — Groom V. Thomas, 2 Hagg. E. P. 433 ; Wheeler v. Alderson, 3 Hagg. E. R. 575; Wheeler v. Batsford, 3 Hagg. E. P. 599; Broyden V. Brown, 2 Add., 445, &c. Also ' Peport of Met. Com. in Lunacy/ 1844, pp. 104, 105. SECTION II.— Classification. I. Various methods proposed, and why. — Yery different arrange- ments have been made by different writers on Insanity, and they have grouped its varieties or forms upon opposite princi- ples, guided in some instances by the most prominent distin- guishing symptoms, in others by the mental functions whose disturbance is supposed to induce these symptoms, in others by the pathological changes occurring in the organs with which these functions are associated ; and lastly, in others by the somatic causes of the various forms of Insanity. The symp- tom atological almost necessarily involves more or less of a psychological classification, as the pathological does a physiolo- gical one ; so that the student will frequently be able to reduce 28 OF INSANITY IN GENEIIAL the classifications he meets with to a psycho-symptomatological, a physio-pathological, and an setiological classification. One great reason why there is so much apparent confusion and contradiction in the various classifications put forward is simply this, — that the subject is approached from different standpoints, all natural enough, and deserving the consideration bestowed upon them, so long as they are not regarded as sepa- rately complete, and exclusive of the others. They are not, it is true, to be jumbled together into one heterogeneous mass ; and yet they are perfectly consistent one with another when their right relative position and bearing are clearly stated, and they are called by their right names. We would insist strongly on this truth. Let us regard the subject from all sides, and not shut up every avenue of approach hut one. It is only thus that the psychology, physiology, pathology, and aetiology of Insanity can be placed (in their relation to classification) in their just proportions, and the result be a consistent whole. Now, that which makes Insanity a subject of study at all is manifestly the symptoms which indicate its presence — nay, which constitute its existence so far as popular observation ex- tends. These symptoms or phenomena, moreover, while to a medical man they are both mental and physical, are almost wholly mental to the ordinary observer. Remove all the physical signs of disorder, and to him the patient would still be insane. Remove the mental and retain the physical signs, and the patient would be esteemed sane, alike by the ordinary observer and the medical man. The psychical symptoms must then inevitably arrest our atten- tion first in the study of Insanity, and for this purpose some order in the treatment or description of these symptoms must be adopted. Without preconceived theory the observer must describe that which he sees before him. When he has done so, he can do no other than group his observations in the manner which appears the most simple, and we may say the most natural, if that can be called natural which concerns a departure from the ordinary course of nature. In doing so we are pursuing the symptom afological method of classification ; and inasmuch as the symptoms are psychical, the method is at the same time more or less psychological. The latter method may, however, be pursued so much more elabo- rately as to constitute an independent psychological classifica- tion side by side with the customary psychical grouping of the CLASSIFICATION 29 varieties of mental disorder. For instance^ when we speak of Emotional Insanity we adopt botli a symptomatological and a psychological classification. Our knowledge of what organs of the body, psychical states are the functions, leads naturally to a parallel classification — the physiological. So far as physiologists can tell us the physiology of the several centres or ganglia of which the encephalon is composed, so far we can approach the subject physiologically and adopt a corresponding classification. A closer examination of the symptoms of the insane than that which the ordinary observer makes when he only recognises a mental disorder reveals signs of physical disease. Syphilitic symptoms, e. g. either are or have been present, and these being clearly not caused by the mental condition of the patient, but having preceded it, and being moreover an indication of a morbid state of the body which has conditioned the disorder of the mind, they direct our attention to another of the several legitimate modes of approaching the study of Insanity. Thence arises another method of classifying the disease ; but let it not be supposed that it is an exclusive one. Such a classification is somatic, pathogenetic ; and if the morbid physical condition is, in truth, the cause of the mental state, it is (etiological. Further, if it reveals to us the pathology of the various forms of mental disease with which distinct bodily disorders are associated, it is also a pathological classification, although this term usually describes one which professes to be founded upon certain definite morbid appearances of the brain as the organ of the mind. The strictly ]pat}iological is a necessary result of the physio- logical classification ; for if we are acquainted with the structures or organs which in health subserve the normal action and manifestations of the mind, we must aim at discovering the morbid condition which proximately occasions the alteration in the mental functions, or, in other words, insane manifestations. We now proceed to glance at the various classifications which have been proposed. II. Ancient Classifications. — From the earliest periods more or less distinction has been made when mental diseases have been treated of. If the Father of Medicine did not venture on any classification, a learned French editor of Hippocrates considers that in his employment of terms he recognised three distinct conditions of the mind. Thus, he represents his use of fxavia as synonymous with our Mania ; his ^tAay^^oAia as synonymous 30 OF INSANITY IN GENEEAL with our Melancholy ; his TrajOtii'ota as synonymous with our Dementia. But it must be admitted that the employment of these terms in the same sense is by no means constant^ and it has been disputed whether Hippocrates did attach the idea of gloom or sadness to jusXay^oXta. He appears to have used the word (ppeviriQ in the sense of a febrile affection involving the brain, but not an idiopathic inflammation of that organ. Celsus treats of three kinds of Insanity : first, that which he calls after the Greeks phrenitis, and which is accompanied by febrile symptoms ; secondly,, that which begins almost without fever, is marked with sadness, and is caused by black bile; and thirdly, a form which he divides into two genera — a dis- tinction which is especially interesting. " For some err,^' he observes, " in having false images, and not in their whole mind, as Ajax and Orestes are represented in poetic fables ; in others the whole mind, or judgment, is affected." The Roman law made two classes of the dementes, or mad : furiosi, those who were excited and violent; mente capfi, those who were deficient in intellect. Cicero criticised the Greeks for their want of precision in the use of terms. Areteeus clearly distinguishes between Melancholia and Mania; the former, he says, " does not affect all the faculties of the mind ; the patients are sad and dismayed ; they are without fever." He, however, held that Melancholy is only the initial stage of Mania. Areteeus likewise clearly refers to Dementia. He evidently regarded all forms of Insanity as simply modifica- tions of the same essential disease. Caelius Aurelianus treats of Insanity under the two heads — ■ Mania and Melancholia ; the latter he regarded as not strictly a form of Insanity ; " from which disease it differs," he observes, '^ in that the stomach chiefly suffers, while in Madness it is the head." Under Mania he comprised delusions, of which he gives some interesting examples. With Galen the forms of Insanity appear to have been referred either to Dementia, or, more correctly speaking. Amentia {avoia), Imbecility (jua>pw(7 Mania, or Melancholia. From this brief reference to ancient classifications it will be seen how little of detail in this respect was attempted ; at the same time there was a tolerably clear recognition of three dif- ferent morbid mental conditions, — that of excitement, — that of depression, — that of fatuity. With the exception of the term Melancholia, which is based on principles alike of aetiology and CLASSIFICATION 31 humoral pathology^ the terms employed to designate the forms of mental disorder are strictly symptomatological. III. Modern Classifications. — We now pass to the consideration of modern systems of classification. Those of Sauvages and Vogel were symjitomatological. Sauvages, in his *■ Nosologia Methodica^ (1763), terms his eighth class of diseases Vesani83, under which he comprised Hallucinationes, Morositates, and Deliria. Yogel (1764), in his ninth class — Paranoise, included, among other states, those of Mania, Melancholia, and Amentia. Linnseus (1763) called his fifth class of diseases Mentales, which he divided into three orders, — Ideales, Imaginarii, and Pathetici ; a system essentially psychological. Upon main divisions like these, complex and fanciful sub- divisions were founded, in which very opposite affections were brought together. A reference to the classifications is not, howevei", without its use in showing the relation in which recent arrangements stand to them, and in indicating what, if any, progress has been made in our psychological nosology. Such a history of opinion reflects the leading theories upon the nature of Insanity, and marks new discoveries as they take place ; for example, Prichard^s classification would have been impossible before the time of Esquirol and Calmeil. Cullen's classification (1772), which is symptomatological, was, in his day, regarded as clear and natural ; and, doubtless, it possessed advantages over the systems of Sauvages, Vogel, and Linnaeus. For his larger classes he chose external and sensible signs ; rejecting conjectures respecting internal states of the body, he endeavoured to fix on the symptoms essential to the disease. But when he subdivided these classes he left this principle, and in attempting to indicate the origin of some of the varieties of the disorder, he did not elucidate the subject by his distinc- tions. Hence, Pinel has severely reprimanded him for dividing Mania into three divisions : — " The vain explanations and gratuitous theories which he gives respecting observed facts, by way of unravelling their mechanism, are they not opposed to the dignified and cautious course which a faithful historian of mental disorders ought to impose upon himself V He placed mental disorders in the class Neuroses, and under the order Yesanias ; in which it was intended to include those disorders in which the judgment is impaired without coma or pyrexia. These -he referred to four great divisions, viz. : — Amentia, 32 OF INSAN[TY IN GENERAL Melancholia, Mania, and Oneirodinia. Amentia miglit be either congenital, senile, or acquired. Melancholia, by which he implied partial insanity, comprised eight principal varieties ; some involving hallucinations of a painful, others of a pleasur- able nature, and including Daemonomania, Nostalgia, and Ero- tomania. Mania, by which he understood a general insanity (Insania Universalis), had a threefold division, according as the cause appeared to be mental, corporeal, or obscure. Oneiro- dinia, the last of Cullen's divisions, included somnambulism and nightmare. It is noteworthy how these early nosologists thoroughly re- cognised Insanity as a disease constituting but one division of the Neuroses — one order of that great class. Had this been kept more prominently and steadily in view by medical psycho- logists, that isolation of mental from other affections of the nervous system which has been so injurious in cutting them off from other bodily diseases would not have occurred, and we should not have found Burrows, in his excellent 'Commentaries,' appearing to doubt whether it is not rather to be classed among disorders of the vascular than the nervous system. Dr Arnold, in his 'Observations on Insanity' (1782), gave a classification of mental disorders which was eminently psycho- symptomatological. It was ingenious, but too elaborate. His main divisions were into Ideal, Notional, and (a sub-class) Pathetic Insanity. The first included four, the second eight, and the third sixteen forms of Insanity. Mania was comprised under Ideal, Delusive Insanity under Notional, and the varieties of Melancholia under Pathetic Insanity. He based his terms Ideal and Notional on the theory that the objects of sensation are represented in the mind by ideas, or images, while the mental states which arise from the exercise of the faculties in reflecting upon sensible objects or the operations of the mind may be called notions. The former included false perceptions ; the latter false concepttions. Pinel classified mental diseases symptomatologically under four great divisions — Mania, Melancholia, Dementia, and Idiotism. It is necessary to state the sense in which he employed these terms. That of Mania corresponded essentially to our use of the word. The most important observation which he made in re- ference to the forms of mental disease was the recognition of a form of mania without delirium, i. e. disorder of the understand- ing. Melancholia he described as a delirium which is exclusively OLASSIPICATIOISr 33 dii'ected upon one object^ or series of objects^ accompanied by sadness. Dementia implied weakness of the Understanding and Will ; while Idiotism did not answer to our Idiocy, but was rather an advanced stage of Dementia. Pinel refers to the facts which he and other psychologists had collected, as " the only basis upon which can be established any system of nosology founded in nature.^^ He thought we ought to follow the course pursued by Naturalists — first consider the particular symptoms with the greatest attention, then bring together a large number of ob- servations, and group them together according to their points of agreement. Esquirol extended, and, in some particulars, undoubtedly improved the classification of his master. He thus describes the one he adopted : 1st. Lypemania (melancholy of the ancients); disorder of the faculties with respect to one or a small number of objects, with predominance of a sorrowful and depressing passion. 2nd. Monomania ; in which the disorder of the faculties is limited to one or a small number of objects, with excitement and predominance of a gay and expansive passion. 3rd. Mania; in which the insanity extends to all kinds of objects, and is accompanied by excitement. 4th. Dementia; in which the insensate utter folly, because the organs of thought have lost their energy and the strength requisite for their functions. 5th. Imbecility or Idiocy ; in which the conformation of the organs has never been such that those who are thus afilicted caii reason justly. It will be seen that this author recognised a just distinction between Dementia and Imbecility or Idiocy, which Pinel did not. He introduced the terms Lypemania and Monomania. Dr Conolly, in his Lectures, has treated of Insanity under the generally recognised symptomatological forms of Mania, Melan- cholia, Dementia, &c. He observes, that ^'all forms of mental disorder are dependent on one of three states of the nervous system ; a state of increased, or diminished, or a state of unequal excitement of that system ;^^ and that "all other forms of Insanity appear to be mere varieties, or complications, or results.^'' Professor Laycock has attempted to base one classification upon a strictly ijhysiological basis. It consists of Disorders of (1) the encephalic centres subservient to the instincts and animal propensities, i. e. the medulla oblongata, cerebellam, and poste- 3 34 OF INSANITY IN GENERAL rior lobes of hemispheres ; (2) those centres subservient to the emotions and sentiments^ i. e. the ideagenic or sensorial substance of the cerebellum and hemispheres ; and (3) those subservient to the knowing and representative faculties (intellect), i. e. the nerves of the senses, their ganglia, and the ideational centres in the cerebral (and cerebellar ?) hemispheres. The student may have, however, for some time to be content with simply regarding Affections of the Mind — seeing that those changes which cause paralysis of motion or sensation do not necessarily cause mental disorder, and changes which do not lead to any obvious disturbance of motility or sensibility may cause the most profound mental disorder — as divisible, from this point of view, according as they arise from such defect or disease of (1) the cerebral hemispheres, as induces Idiocy, Dementia, &c. ; or from such defect or disease combined with disorder of (2) the sensory tract, ganglia or nerves, as exhibited in hallucinations and illusions ; or combined with disturbance of (3) the motor tract or ganglia, as exhibited in General Paralysis and Insanity with ordinary Paralysis. Where- ever the mental functions reside, there is the immediate seat of their derangement, i. e. Insanity; and any physiological system of classification must be dependent upon the knowledge afforded us on this subject by physiologists. If the views which, according to Ferrier, flow from his researches into the functions of the brain be established, the mode of expressing this classi- fication would be different, inasmuch as he does not regard one part of the brain as the organ of the mind, and another part as an organ of motion, &c., but the same parts as having both a subjective and objective function; physiological and psycho- logical functions of the brain being, on this hypothesis, only different aspects of the same anatomical substrata. It is in harmony with the endeavour to reduce mental phenomena, in the last analysis, to their motor and sensory physiological equivalents, as leading the way to a localisation of mental function, and therefore the correlation of morbid cerebral and morbid mental conditions, out of which a classification may be possible. Thus, Mental Disorders might be classified under two instead of three great divisions. Sensory Psychoses and Motor Psychoses. In the former would be included all forms of Insanity in which feeling and emotion and the power of sensory perception and ideation are more particularly involved (hallucinations, and conduct determined thereby), the posterior CLASSIFICATION 35 parts of the braiiij as experiments seem to show, being the centres ; while the latter would comprise those forms in which the higher intellectual faculties are affected as also motor power, the anterior lobes, here, being, in all probability, the centres. An example of classification founded strictly on pathological anatomy is afforded by that of M. Parchappe, who adopted the following division : Monomania. Insanity with Paralysis. Acute Mania and Melancholia. „ „ Epilepsy. Chronic Insanity. It must, however, be admitted that we are not yet in a position, as regards our knowledge of the morbid appearances of the brain, to base our nosology upon the revelations of the deadhouse, whether with or without the microscope; we can only await an advance of knowledge, which will render a strictly speaking anatomico-pathological classification possible, although an approach to it in the form of a pathogenetic or somato- setiological one may be adopted. Recently, M. Aug. Voisin has made a bold attempt in the same direction as Parchappe, but his classification is, to some extent, pathological in the broad pathogenetic sense, as well as the narrow anatomical one. Referring to systems based on etiology, and ridiculing their pathological pretensions, he instances '^Alcoholic Insanity," in which, with a common cause, we may have to deal with cerebral hsemorrhage, fatty degenera- tion of the capillaries, or chronic meningitis. In regard to his own classification it may be stated that, as respects idiopathic cases of Insanity, he recognises four different states, namely. Congestive Insanity marked by congestion and its products ; Anaemic Insanity marked by diminution of red corpuscles and other changes in the quality of the blood. The two remaining forms are due either to atheroma of the cerebral vessels, or to tumours and the various lesions accompanying them. De- mentia, General Paralysis, Idiocy, constitute other classes. He finds it necessary also to include in his entire classification a class of secondary cases which are consecutive to epilepsy, hysteria, &c., and lesions of the organs of sense. The late M. Falret, it may be observed, said that in the first instance he was a firm believer in pathology as a basis of classi- fication, that subsequently discarding this he adopted a psycho- logical system, and ended by adopting the symptomatological. 36 OP INSANITY IN GENERAL or what he called the clinical method of arrangement, as really the most practical. From the division of the German Psychologists into two great rival camps consisting of the psychical and the somatic schools, corresponding classifications of Vesaniae naturally followed. Of the representatives of the former, Heinroth, Ideler, and Hoff- bauer (the legitimate descendants of Stahl), the first named pro- posed one which is founded upon a verj similar mental analysis to that which is given at pp. 47-8, namely, the Intellectual Facul- ties, the Moral Disposition (gemiith), and the Will, in which he includes the Propensities. It is remarkable that he who has taken most untenable ground in carrying the doctrines of the psychical school to their extreme limits in regard to the nature and seat of Insanity, and whose leading dogma"^ is falsified by every day's experience, should have adopted a classification which, if we have regard to mental analysis at all, possesses decided merit, and presents in Prichard's opinion " the most complete system that can be formed.' ' Linneeus, as we have seen, regarded the vesanige from a mainly psychological point of view. Dr Prichard's classification was thoroughly psychological in principle ; grouping mental diseases under two great classes ; the first comprising Moral Insanity or Pathomania ; the second Intellectual Insanity, which comprised Monomania, Mania, Incoherence, or Dementia. Dr Bucknill observes that Insanity may be either Intellectual, Emotional or Volitional ; and adds that '' though in the concrete it is not easy to find pure and unmixed cases under either of these heads, such cases do occasionally subject themselves to observation, and the experienced psychopathist will find little difiiculty in appor- tioning a vast number of the other cases according to their prominent character, under one or other of these headings.'" * " Insanity is tlie loss of moral liberty. It never depends upon a physical cause ; it is not a disease of the body but of the mind — a sin. It is not and cannot be hereditary, because the thinking ec/o, the soul, is not hereditary. . . . The man who has during his whole life before his eyes and in his lieart the image of God, has no reason to fear that he will ever lose his reason. . . . Man possesses a certain moral power which cannot be conquered by any physical power, and which only falls under the weight of his own faults." It would seem impossible to compress within a single paragraph a larger amount of false and mischievous psychological teaching. It should only he retailed after being duly labelled " Poison." It is only fair to Heinroth, however, to say that his supporters insist upon his having been misunder- stood. MM. Lesegue and Aug. Morel characterise him as " penseur profound ; chercheur erudit;"and speak of his system as one "au sujet duquel tant d'idees fausses ont eu cours." CLASSIFICATION 37 C Unsoundness of Mind in relation to Criminal Acts/) More recently he has proposed a scheme which combines the psy- chical phenomena with pathogenetic relations and pathological conditions, the first forming the Classes, the second the Orders and Genera, and the third the Species. It will be found in the Appendix. Griesinger, commencing upon a psychological basis, admitted the two great groups of Emotional and Intellectual Disorders, associating with the latter, the Will. These he divided into states of (1) Mental Depression or Melancholia, states of (2) Mental Exaltation, and states of (3) Mental Weakness. Under Class 1 were comprised Hypochondriasis, Melancholia in a more limited sense. Melancholia with stupor. Melancholia with de- structive tendencies. Melancholia with persistent excitement of the Will ; under Class 2, Mania and Monomania ; lastly. Class 3 embraced Chronic Mania, Dementia, Idiocy, and Cretinism. To these he added Disorders of Sensation and of Motion. Dr Maudsley's mode of classifying mental diseases agrees with Prichard^s and Griesinger's in distinguishing two great divisions, the Intellectual or Ideational, and the Emotional or Affective. Under the former he ranges Mania, Melancholia (general and partial). Monomania, Dementia, General Paralysis, Idiocy, and Imbecility. Under the latter he includes Maniacal Perversion of the affective life or Mania sine delirio. Melancholic Depression with- out delusion (Simple Melancholia), and, lastly. Moral Alienation proper, approaching which, is the Insane Temperament. In his book on ' Body and Mind,^ however, he employs and seems to adopt the classification of Dr Skae. Diametrically opposed to the psychological was the somatic school of German Psychology represented by Max. Jacobi, Nasse, and Friedreich.* They directed the attention of medical psychologists in the strongest manner to the bodily causes of Insanity. Jacobi insists upon the ordinary forms of Mental Alienation being nothing more than signs indicating the exist- ence of lesion of some organ of the body. Hence, in his view the condition of the os sacrum was almost as important as that of the OS frontis. In his ' Observations on the Pathology and Treatment of Diseases connected with Insanity,^ published in 1830, he enunciates the true somato-setiological theory that * ' Historiscb-kritisehe Darstellung der Theorieen liber den Wahnsinn,' 1836 ; and ' Handbuch der Allgemeinen Pathologie der Psycbischen Krankbeiten,' 1839. 38 OF INSANITY IN GENERAL ^' there is no disease of the mind existing as such, but that Insanity exists solely as the consequence of disease, either functional or organic, in some part of the bodily system." This position was first enunciated by him in the second volume of his ' Sammlungen ' entitled " Psychical Phenomena and their relation to the System in a Healthy and Diseased State/'* Jacobi does not, however, discard the ordinary nomenclature, which, when clearly understood to be only sym- ptomatological, is useful, and in fact necessary, and, while never losing sight of the somatic cause of psychical manifestations, as the real morbid condition with which the alienist has to deal, he presents three great groups of symptoms : — Those of Insanity without delusion, the disturbance of the intellectual powers being slight ; those of Insanity with delirium or incoherence without delusion ; and thirdly, those of Insanity with delusion. Flemming, a disciple of the same school, felt strongly f the practical disadvantages of having only a psychological classifi- cation, and constructed a nosological table in which the somatic element is recognised. For example, he divides Imbecility into classes, according as it is congenital or is caused by injury to the brain, or by inflammation of the brain, or by nervous fever, or by epilepsy. Here is at least the germ of a somato-aetio- logical or pathogenetic classification, a shadow, along with Jacobi's " somatisch-psychische " doctrines, of coming events. It may here be observed that Arnold, in the early part of the century, asked himself the question, whether the classifica- tion of Insanity could not be arranged according to causes, and he arrived at the conclusion that the knowledge of his day would not admit of it ; but that it was a thing to be desired, and at some future day, feasible. " Of causes," he says, " we know too little to make them a foundation of the arrangement of diseases, and particularly of proximate causes, which alone can make us perfectly acquainted with their internal nature. * See also ' Zeitschrift f iir die Beurtheilung u. Heiluug der Krankhaften Seelen- zustande,' 1838, p. 43. t See ' Allgemeine Zeitsclirift fiir Psycliiatrie,' 1844, p. 104. Still more strongly wrote Petit a year before. In view of the endless subdivisions of some noso- logists in his day, founded upon every passing symptom, well might he, in his ' Memoire sur le Traitement de I'Alienation Mentale,' exclaim against such learned trifling, and characterise them as "bagage" and "fatras scientifique," and sweep tliem all away by asserting that " quelle que soit la nature du delire, il y a toujours uu point quelconque plus ou moins etendue du cerveau, qui est a I'etat maladif, et cet etat est le ii;eme, au degre pies, quel que aoit le point affecte." CLASSIFICATION 39 When the science of causes shall be complete, we may then w,ake iheTYi the basis of our classification ; but till then we ought to content ourselves with an arrangement according to symptoms. And as there is always a fixed arrangement between causes and effects, an exact arrangement according to sym- ptoms which we see, may tend to throw light upon their causes which we do not see ; and the analogy of the symptoms, point- ing out an analogy between the causes, may lead to similar and successful methods of cure in similar cases^ how imperfect soever may be our knowledge of the real and immediate causes them- selves " {' Obs. on the Nature of Insanity,^ preface to 2nd edition, 1806). In one of his Annual Eeports of the Maclean Asylum, Massa- chusetts, Dr Luther Bell, more than thirty years ago, objected to the usual classification according to prominent symptoms as '^ un- sound as respects the palpable characteristics or manifestations of Insanity : it also will not bear the test of accuracy as regards the cause of the disease or the pathological condition of the sufferer, since there is every reason to believe that the peculiar affection of the cerebro- spinal system, or merely the reflex action of more distant irritations upon that system is a unit, and these forms are merely the changing external symptoms, often having scarcely a diurnal continuance before passing from one to another. It is a division useless as regards moral or medical treatment, for neither the moral nor the medical reg-i- men would be determined by the name or class to which a case approaches the nearest, irrespective of the indications i^Tesented in each individiial constitution." While, however, rejecting the old nosology, Dr Bell did not substitute for it an setiological but a psychological classification, viz. a form of Insanity affecting the Intellect ; a second, touching the Moral Sense mainly or exclu- sively — Insanity of conduct, but not of conversation ; and a third, consisting in deranged or perverted Sensibilities, the intellect and moral sense being alike undisturbed. Such dis- tinctions as these he considered would be of essential value in the medical jurisprudence of Insanity and the training of the intellectual and moral faculties. Belhomme, in 1834, in his ' Considerations sur 1^ appreciation de la Folic, sa localisation,^ &c., proposed the twofold division of Idiopathic and Sympathetic Insanity ; and Schr. v. d. Kolk, in an article published in 1852,* adopted from a like somato- * ' Tydschrift der Ned. Maatscliappy tot bevordering der Genuskunde.' 40 OF INSANIIT IN GENEEAL aetiological or pathogenetic standpoint, the same classification of mental diseases, with important additions. " We are accus- tomed,'^ he says, " to compare the different kinds of mental disorder according to the differences of the phenomena which they call forth, and to note them down as Mania, Monomania, Melancholia, Dementia, and Idiocy. This classification certainly serves to distinguish the different forms and diseases to be retained ; however, it has not always appeared to me to be quite practical, because it proceeds more from the morbid symptoms than from the nature and origin of the disease. For some years I have, therefore, reduced the different forms of the disease to two principal groups, which may be designated as Idiopathic and Sympathetic Insanity, which are distinguished from one another by special characteristics, and which meet all our wants in treatment.'' Under Idiopathic Insanity* he included all cases originating in a primary affection of the brain, whether from liereditary predisposition, injury to the head, or mental influences; while under Sympathetic Insanity he comprised cases arising from disorders of the other organs of the body, especially the abdominal and generative. The great practical utility of this classification consists, he says, in the fact that recovery cannot take place unless the remote cause is removed. Under the primary class of mental disorders he treats of acute and chronic Idiopathic Mania, Hallucinations, Dementia, and Idiocy, while under the secondary, he describes Sympathetic Mania or Melancholia proceeding from the colon. Melancholia proceeding from the sexual apparatus. Mania from the kidneys and bladder. Mania from disorders of the heart and lungs, and so forth. The somatic causes of Insanity were much more elaborately studied and brought forward by Dr Morel as a basis of classi- fication, in his ^Traite des Maladies Mentales,' 1860. Pathology, in the broad sense of the word, was not disregarded. The pathogenetic relations of the varieties of Insanity were recog- nised. We subjoin an abstract of his classification. Group I. — Hereditary Insanity. 1st Class. Those who are of congenitally nervous tempera- ment. 2nd. Those whose Insanity is indicated by insane acts rather than insane conversation. Includes Prichard's Moral * The reader must not confound this with the sense in which Skae uses the same word. " Protopathic Insanity " may with advantage be used for Schr. v. d. Kolk's " Idiopathic Insanity," to avoid the confusion which has been caused. CLASSII'IOATION 41 Insanity. 3 re?. Constitutes the transition state between class 2, and Idiots and Imbeciles. The members of this class are marked by morbid impulses to incendiary acts, theft, &c. 4th. Idiots and Imbeciles. Gboup II. — Toxic Insanity. 1st Glass. Caused by intoxicating substances, as alcohol, opium, &c. Also poisonous ingredients, as lead, mercury, &c. 2nd. Caused by insufficient or diseased food, as ergot of rye. drd. Caused by marsh miasma, or the geological constitution of the soil (e. g. Cretinism). Group III. — Insanity 'produced hy the transformation of other diseases. 1st Glass. Hysterical Insanity. 2nd. Epileptic ditto, ^rd. Hypochondriacal ditto, consisting of three varieties. Group IY. — Idiopathic Insanity. 1st Glass. Progressive weakening or abolition of the intel- lectual faculties, resulting from chronic disease of the brain or its membranes. 2nd. General Paralysis. Group Y. — Sympathetic Insanity. Group YI. — Dementia, " a terminative state." Since we gave the foregoing classification of Morel, Dr Skae has proposed a more elaborate one, founded mainly upon causes.* His first group or natural order is common to all classifications — Moral and Intellectual Idiocy and Imbecility; the second is Epileptic Insanity ; the third, Insanity of Masturbation ; the fourth, of Pubescence. Then follow : — Hysterical Mania. Senile Mania. Amenorrhoeal Mania. Phthisical „ Post-connubial „ Metastatic „ Puerperal „ Traumatic Mania. Mania of Pregnancy. Syphilitic „ „ Lactation. Delirium Tremens. Climacteric Mania. Dipsomania. Ovario-Mania (Utero-Mania) . Mania of Alcoholism. * " The basis of my classification is essentially, although not entirely, an setiolo- gical one." ' Morisonian Lectures on Insanity,' ' Journal of Mental Science,' October, 1873. At an earlier period (1871), when speaking on a paper read at a psychological meeting, he is reported to have said, " It is based upon an attempt to group the various forms of Insanity into natural families." Op. cit., January, 1872. 42 OF INSANITY IN GENERAL Post-febrile Mania. General Paralysis with In- Mania of Oxaluria and Phos- sanity. phaturia. Epidemic Mania. Idiopathic ( Sthenic. Insanity (^ Asthenic. Now, each of these groups, according to Skae, presents psychological lineaments or symptoms which are peculiar to, and characteristic of it. Here are nearly thirty natural orders or families, each of which, it is held, has its natural history, its special cause and morbid condition, its average duration, and probable termination. Each is a separate disease, the symptoms of which when they vary, do so only within certain limits. The true test of this position must obviously be one of experience. It clearly admits of verification — analytically as well as synthe- tically. Is it or is it not a fact that those who adopt Dr Skae^s classification can, without being told the history of the patient, distinguish by the mental symptoms alone a case of Traumatic Mania from one of Phthisical Mania ? A case of Syphilitic from a case of Metastatic Mania ? It is no doubt true that the patient who is insane from epilepsy presents for the most part tolerably distinct characteristics, though even some of these "which would induce us to describe the case as one of Epileptic Insanity, without knowing anything of the past history of the patient, are really physical, in fact, physiognomonical, and not '^psychological lineaments." Still, in this instance, there are doubtless some striking psychological features ; but that a case of Traumatic Insanity presents ''its own special psychological character," the writer is disposed to question. His own experi- ence would induce him to think that very different mental symptoms frequently result from wounds or blows on the head ; and as regards another form, Puerperal Insanity, we constantly witness the most opposite mental states arise in conection with it — in one case Melancholia, in another Mania. Then, again, we have seen a student puzzled to know why the terms sthenic and asthenic should be restricted to Idiopathic Insanity, as it seemed to him to imply that Phthisical Insanity, for instance, cannot be asthenic. When, indeed, in accordance with this system of classification, a case is spoken of as simply one of " asthenic Insanity," it may well be doubted whether the term conveys so definite an idea as those which are in ordinary use. For instance, if employed to describe the mental condition CLASSIFICATION 43 of a patient in filling up the Form of Admission required by tlie Lunacy Board, it would be impossible from tbis alone to form any opinion as to the psychical condition of the patient. So also for the purposes of classification in an asylum, those terms which denote the present state of the patient^s mind would seem to be more practically useful than those which indicate the somatic cause of the mental derangement. It is surely of the first importance for this purpose to distinguish between acute Mania and Suicidal Melancholia. Obviously there are occasions when it would be more important to be informed that a patient is homicidal, than that his case is one of Sthenic Insanity or Traumatic Mania. On the other hand, it is manifest that for treatment, this aspect of the disorder is most important, and that the forcible way in which a somato-eetiological system of studying and classifying mental aifections directs the student or physician to the bodily origin of the disorder, with a view to the removal of the cause or morbid condition upon which it depends, is a power- ful argument in its favour. It should not be forgotten, how- ever, that it does not necessarily indicate the existing bodily affection ; the mental or cerebral condition being in many cases simply a remanet due to disorder of another organ which has passed away. Again, it might be objected that it throws into the shade, or even ignores, psychical causes of insanity, and that it would be quite possible to trace the causes of the attacks of the patients in any large asylum, and construct from those of a " moral " nature a psycho-^tiological as well as a somato- setiological nosology. In fact, " Post-connubial Mania " prob- ably as frequently owns an emotional as a physical cause. We might speak of a " Post-fright " and a '^ Post-grief " Mania, or of '' Post-study " Insanity, and so on through the several emo- tions and the intellectual faculties. This objection, however, has been met by Dr Skae's division of Idiopathic Insanity. The weakness of this classification, it has been frequently said, lies in its having any such division at all, m the sense in luhich he uses '[ Idiojpathic." If, indeed, it can enable us to distin- guish the natural history of those cases of Insanity which arise from a directly mental cause, the objection ceases to have practical force ; but it is to be feared that such will never be the case. Such and other criticisms naturally present themselves, although they are not valid reasons for neglecting this path of 44 OF I>;SANITY IN GENERAL inquiry, and so failing to connect, whenever it is possible, the mental disturbance with the fons et origo mali, of which it is but a symptom. As in skin diseases, so in affections of the brain involving Insanity, it is highly desirable to regard and to describe them in relation both to the characteristics they present and the causes which have induced them. In each, for instance, it is obviously of great moment to recognise a case originating in syphilis, and in each it is needful to convey a clear idea of the symptoms by the use of generally understood terms. No better proof of the practical utility of the old system of typical forms can be given than their retention on the part of Dr Skae him- self, in addition to his own classification. Besides which, com- mon to both, are symptomatological terms ; for what are Im- becility and Idiocy but expressions or signs of mental deficiency or disease, without telling us anything as to causes or patho- logy ? Nay, what is General Paralysis itself, in respect to nomenclature, but a symptom, and so of Epilepsy, which may arise from as many different pathological conditions as Mania or Melancholia ? We would further observe, in regard to the proposed classifi- cation, that we must distinguish between its somato-astiological truth, and the uniformity of the symptoms alleged to result from similar bodily causes. It may unfortunately be found that Skae was too sanguine in regard to the uniform mental groups arising from a common causation, and yet it may be true that he has helped us to distinguish separate pathological entities, the study of which will advance our knowledge of the origin, nature, and course of the mental disorders which they occasion — only, as we have said before, let us approach the subject from all sides, and not adopt any one classification exclusively. The classifications of Morel and Skae, along with that of Schr. V. d. Kolk, have been modified and amplified by Dr Batty Tuke, who groups them under seven great classes, — Arrested or impaired development of the brain, Idiophrenic, Sympathetic, Anaemic, Diathetic, Toxic, and Metastatic Insanity — nearly all the various forms contained in Skae's system, with the addition of, in the 2nd class, Phrenitic Insanity (inflammatory), and Paralysis with Insanity ; in the 3rd class. Enteric Insanity ; in the 4th class, Limopsoitos (from starvation) ; in the 6th class. Cretinism, and Insanity from opium-eating; and lastly, in the 7th class. Rheumatic and Pellagrous Insanity. On the other CLy^SSinOATION 45 tandj lie rejects Dipsomania, and Mania of oxaluria and plios- phaturia, and places Epidemic Mania tinder Hysterical Insanity. It should be stated that the author of this system distinctly calls it '^A Pathological Classification of Mental Disease/'' and he regrets Dr Skae^s not having adopted Pathology as the basis of classification.* It must, however, be pointed out that by a pathological classification it is not intended to convey the idea that the morbid anatomy of the brain, either as seen by the naked eye or as revealed by the microscope, forms the basis of this arrangement, but that by pathological is meant the morbid influence which in each case induces the symptoms. This is a very different use of the term from that in which it is employed by Parchappe and others. As to cerebral pathology, the author distinctly says, not only that it is now impossible '^to found a nosology on the abnormalities of the brain-tissue,^^ but that " we can never hope to indicate the seat of any special form of Insanity as situated in any particular portion of the encephalon." Doubtless this classification admits of improvement, and the method pursued must not be exclusively followed, but we do not agree with the ' American Journal of Insanity,^ that " It is no more satisfactory than those hitherto made.^'' Dr Olouston adopts in the main, and states he finds practi- cally useful, the classification of Skae. The reader is referred to his " Morisonian Lectures/^ on these varieties of Insanity, in the ^Journal of Mental Science,^ 1873-5, and to the same Journal for Januai-y, 1876. The following method of classification was proposed by the International Congress of Alienists, at their Meeting in Paris in 1867 :t 1st. Simple Insanity comprehends the different varieties of Mania, Melancholia, and Monomania, Circular Insanity, and Mixed Insanity, Delusion of Persecution, Moral Insanity, and the Dementia following these different forms of insanity. 2nd. Epileptic Insanity means Insanity with epilepsy, whether the convulsive affection has preceded the Insanity and has seemed to have been the cause, or which it has appeared, during the course of the mental disease, only as a symptoms or com- plication. * See ' Journal of Mental Science,' July, 1870, and his " Morisonian Lectures on Insanity." t The reader will find the entire Report in the ' Journal of Mental Science ' for 1870. 4G OF INSANITY IN GENERAL 3rd. Paralytic Insanity or Dementia, should be considered as a distinct morbid entity, and not at all as a complication, a termination of -certain forms of Insanity. There should be comprehended, then, under the name of paralytic insane, all the insane who show, in any degree whatever, the characteristic symptoms of this disease. 4th. Senile Dementia is the slow and progressive enfeeble- ment of the intellectual and moral faculties consequent upon old age. 5th. Organic Dementia embraces all the varieties of Dementia other than the preceding, and which are caused by organic lesions of the brain, nearly always local, and presenting, as almost constant symptoms, hemiplegic occurrences more or less prolonged. 6th. Idiocy is characterised by the absence or arrest of the development of the intellectual and moral faculties. Imbecility and Weakness of Mind constituting two degree or varieties, 7th. Cretinism is characterised by a lesion of the intellectual faculties, more or less analogous to that observed in Idiocy, but with which is uniformly associated a characteristic vicious con- formation of the body, an arrest of the development of the entirety of the organism. Under the titles " ill- defined forms,^^ '^ other forms," are to be set down all the varieties of mental alienation which it shall seem impossible to associate with any of the preceding typical forms. The general adoption of this classification, as also that pro- posed by Dr Skae, was recommended for adoption by a Com- mittee of the Medico- Psychological Association in 1869. The writer thinks there is something to be said in favour of the attempt to classify the various forms of Insanity according to the mental functions affected, as well as according to the other methods. Griesinger, and others who would be the last to regard the question with metaphysical eyes, recognise this. To decide what is mental disease we must first decide what mental health is ; and to do this it is inevitable that we should compare, not healthy and diseased mind as a whole, but in relation to the particular faculties and emotions which are dis- ordered. In fact, to follow out this line of inquiry systemati- cally, to parallel the normal activity of the various instincts and mental powers with abnormal action of the same, is one of the CLASSIFICATION 47 most important^ as it is one of tlie most interesting pursuits opened out to tlie medical psycliologist ; and is in some danger of being lost sight of in tlie present tendency to decry the psychological method of classification on account of the mis- takes which have been committed in the name of metaphysics. Could we determine, with certainty, distinctly separated facul- ties of the mind^ we might then, and only then, hope to possess a detailed and symptomatic nomenclature, according as one or more of them are involved. Did we possess a perfect knowledge of the physiology of the organ of the mind, we should naturally, as in other diseases, endeavour to adapt our terms to the struc- ture affected — assuming that there are different parts of this organ correlated with different psychical powers ; but, in the absence of this knowledge, it would seem reasonable to adapt them to the affected function j indeed, we do this to some extent in strictly physical diseases, for we speak of disorders of diges- tion, &c., as well as of the organs by which such processes are carried on. In the same way, we might speak of disorders of the intellect, sentiments, &c., instead of basing our classification exclusively on prominent symptoms, as is the case when Mania, Dementia, and similar terms, are alone employed. Accustomed as psychologists are to these expressions, it would be idle, if it were desirable, to attempt to discard them ; and they are con- venient in conveying, in most cases, a tolerably correct idea of the condition of the patient, and the two systems may be com- bined. In our present imperfect knowledge of the mind in health and disease, we can scarcely hope to attain more by either psychological or symptomatological classifications than that which, indeed, is absolutely essential in a systematic treatise, a certain orderly arrangement of the varieties of Mental Aliena- tion; in regard to which order we may say, as Dr. Lindley observes of a science admitting of far more exact observation : — " Our genera, orders, and the like, are mere contrivances to facilitate the arrangement,^^ &c. Were we to attempt, in this volume, to arrange the forms of Insanity on a purely metaphysical basis, we should treat of them under three heads, either Intellectual, Emotional, and Volitional, or adopt the division of the Intellect, the Moral Sentiments, and the Propensities or Instincts. We might thus construct a threefold classification of the mental faculties, coupled with the usually recognised Forms of mental defect and disease, which would relegate Idiocy and 48 OF INSANITY IN GENERAL Imbecility to the incomplete development of the Intellect ; De- mentia, Delusional Insanity, and ordinary Mania to its disorder after development : congenital or infantile moral weakness, or so-called Moral Imbecility, to incomplete development of the higher Emotions or Moral Sentiments ; Moral Insanity, simple Melancholia, or Exaltation to their disease after development ; Mania, with homicidal or other distinct morbid impulses to disorder of the Instincts or Propensities, or a loss of Volitional power ; uncontrollable propensities and a paralysed Will leading to the same result. In bringing the phenomena of diseased mind into relation with such classification, we should endeavour to refer every form of disease to that class or group of the mental faculties which the disease necessarily, though not exclusively, involves in its course. Thus, Delusional Insanity necessarily involves the intellectual faculties. The same is true of Dementia, Idiocy and Imbecility. The animal propensities are, however, so far from sympathising with the condition of the intellect, that they may be in a state of vigorous action. In presenting these metaphysical divisions, however, as one mode of approaching the subject, we are well aware that even tliese, simple as they are, assume a degree of distinctiveness for mental derangement, which is not in accordance with common, but only exceptional, experience. Idiocy, for instance, is not a defect of the intellectual faculties alone. Mania is no isolated affection, but usually involves all the mental faculties. What from this point of view we wish to insist upon, is the double truth that it is, in a large number of instances, practically useless to employ a metaphysical system of classification, but that there are cases which demand and forcibly illustrate such a system. Usually the intellect, the emotions, and volition are all in disorder ; on the other hand, the insane sometimes present remarkable exam- ples, when tested in regard to different psychical faculties, of healthy and diseased mental manifestations in combination. In the present, as in former editions of this work, we shall group mental defects and disorders under five great divisions which are primarily symptomatological, although, to a certain extent, they fall also under the psychological heads already indi- cated : I. The first, comprising Idiocy, Imbecility, and Cretinism — states of undeveloped intellectual power. CLASSIFICATION 49 II. The second, Dementia, a state in whicli intellectual power, once present, has been weakened or destroyed. III. The third, Delusional Insanity, or those states in which marked delusion is present, whether assuming a melancholy or depressed character {Melancholia with delusion), an exalted character {Monomania with delusion ; the Intellectual Mono- mania of Esquirol), or a destructive character {Homicidal and Suicidal Insanity, &c., with delusion). IV. The fourth, Emotional Insanity, or morbid states of the Emotions without Delusion, whether of a melancholy character {Melancholia Simplex), of an exalted character (Partial Exalta- tion; the Affective Monomania of Esquirol), or whether marked by a perverted moral sense or by impulses chiefly of a destruc- tive character {Homicidal Insanity, &c., without delusion or mental weakness. Instinctive Monomania of Esquirol) constitut- ing Moral or Emotional Insanity proper.'^ Y. The fifth. Mania, a state of general mental excitement or exaltation. All these forms or varieties of Insanity are liable to com- plication with Epilepsy, or, if acquired, with General Para- lysis. We do not know that this classification can be materially improved, having regard on the one hand to the desirability of retaining as far as possible the terms already in use, and on the other to the practical convenience of distinguishing between delusional and emotional morbid mental states, and, as distinct from these, states of actual fatuity, whether congenital or acquired. As regards General Paralysis, and Insanity complicated with Epilepsy, the mental symptoms present in these disorders will fall, from a symptomatological standpoint, under one or other of the foregoing divisions. It would obviously be altogether out of character with the above classification of Mental symp- toms or states, to enumerate in the same category, forms of Insanity the descriptive terms of which do not indicate more than a physical symptom or state. If separately distinguished, they must find their place in a classification constructed upon physical principles, that is, upon morbid bodily states. Not that a psycho-symptomatological nosology excludes these im- portant disorders, but simply that here they are associated with, * In fact, the term Moral Insanity is now universally restricted to that morbid condition which results in immoral acts without apparent intellectual disorder. 4 50 OF INSANITY IN GENERAL and form illustrations of, any one of the psychological groups of Insanity. In a somato-setiological, which should be regarded as the obverse of a symptomatological classification, they of course come first in order ; and the various mental symptoms or states which arise in their course occupy a secondary place. In describing the typical forms of mental disease as presented to us through a study of symptoms, we shall not reject the universally employed terms, Idiocy, Imbecility, Dementia, Mono- mania, Melancholia, Mania. We heartily wish " Monomania " had never been introduced into Psychological Nosologies, for if understood in a literal sense its very existence is disputed, and if not, the various morbid mental conditions it is made to include by different writers, leads to hopeless confusion. With one author it means only a fixed morbid idea ; with another only partial exaltation ; while a third restricts it to a single morbid impulse. As we proceed we shall consider its signification, but we shall not fi'e- quently employ the term. Examples of so-called Monomania may occur under either Delusional or Emotional Insanity. The same with Melancholia. When Emotional Insanity takes an exalted form it may be characterised by Religious Exaltation, Monomania of Vanity, &c. It then assumes the form of Partial Exaltation, ever tending to pass on into Delusional Insanity. When exaltation or excite- ment is general, the term Mania is employed. When Emotional Insanity is of a destructive character, the disease assumes a variety of forms. Homicidal Mania, &c. Dipsomania and Eroto- mania cannot be referred to the destructive class, but rather belong, especially the latter, to an exalted state. They are examples of natural instincts rendered uncontrollable by disease, and in any psychological classification will either be referred to disordered Volition or Emotion, according as the classifier chooses to regard the excessive manifestation as the result of paralysis of the Will, or any overpowering emotional impulse. Emotional Insanity, like the Moral Insanity of Prichard, is fre- quently employed in a comprehensive and a limited sense. Either may be made to include all the forms of Emotional Insanity in which no disorder of the Intellect is apparent, e. g. Melancholia without delusion ; or Exaltation (religious or otherwise) without incoherence. On the other hand, either may be restricted to those forms in which the moral nature is perverted by disease, without, as yet, intellectual disturbance ; CLASSIFICATION 51 and without being necessarily associated witli sudden irresistible impulses. In fact^ in tliese cases the will does not struggle against an impulse foreign as it were to the ego, and find itself overthrown and subverted, but the ego itself is perverted through an abnormal condition of the cerebral organization, constitu- tional or acquired ; we might, therefore, conveniently speak of Emotional Insanity fro'per when we wish to convey the restricted signification of the term. Moral Insanity jproijer would corre- spond to the same condition. Indeed, it is in this limited sense that, contrary to the original intention of Prichard, the term is popularly, and, indeed, among medical men, almost exclusively employed. Nearly all the forms of Insanity are so mixed, and blend so intimately the one with the other, that when describing them we shall shackle ourselves as little as possible with arbitrary divisions — nosological limitations which are better fitted for the study than medical practice. It has been said of this classification that most of the morbid mental states thus specified do not represent typical forms, and this is very true if by the term " Forms " we understand dis- tinct mental diseases originating in different bodily causes, pursuing a definite course, and having a distinctive morbid anatomy. But if they be regarded as conveying a correct idea of certain morbid mental states, separated from one another by their most prominent characters, they will serve a useful purpose to the student, and we cannot dispense with them. As Griesinger says,* all classifications must in the end return to the principal forms of Insanity, Mania, whether acute or chronic, Melancholia, and Dementia, '' because they are really founded on Nature.''^ (Auf welche als wirklich in der Natur begriindet am Ende doch alle Eintheilungen weider zuriick- kommen miissen.) Such a classification as the foregoing meets the requirements of " Natural Groups " as laid down by Mill, so far as it selects for division, characters which possess " the greatest number and the most important of their properties in common, — the names conveying "by their mode of construction as much information as possible,^' and having '^''the greatest amount of independent significance which the case admits of." It is not necessary to discuss the relative merits of MilFs and Whewell^s theories of Natural Groups, the former being based on Definition and the latter on Type, because Mill admits that " Natural Grouping * ' Die Pathologie u. Therapie,' &c., p. 121. 52 OF INSANITY IN GENERAL may be said to be suggested by Type {i. e. by mere general resemblance), but determined by Definition {i. e. by possessing specific characters or properties)/' wliich is sufficient for our present purpose. Influenced as any classification must be by our steadily advancing knowledge of the causes and pathology of Insanity, it is best we believe to adopt in a Manual, as our basis, an orderly arrangement of Morbid Psychological Pheno- mena, and to place side by side with these, a classification which recognises their aetiological and pathogenetic relations, and by so doing embraces such forms of mental disease as General Paralysis. The writer does not believe it is yet possible to proceed very far, with a sure step, in this attempt to construct a somato- Eetiological classification. At the same time he recognises the scientific importance of endeavouring to look at and group cases of insanity, not only by their mental symptoms, but by the physical state with which these symptoms are associated. Thus, as in the last edition, we suggest some divisions as helpful from this point of view, without maintaining that the varieties enu- merated have been established as Forms of Insanity or distinct pathological entities, whose natural history can be distinguished with scientific precision, and still impressed with the force of the criticisms which we have ourselves offered to this system. I. Insanity, or mental Deficiency, caused by primary disease or defective development of the encephalic centres (Proto- pathic Insanity). Examples. — Idiocy. Insanity with ordinary Paralysis* (" Or- ganic dementia"). General Paralysis. Epileptic Insanity (when of central origin) . Senile Insanity. Under this division fall cases of Idio-functional Insanity, those, namely, which, arising from excessive action or otherwise of the functions of the brain (see p. 317 last edit.), do not assume these and like forms. II. Insanity caused by disorder of, or developmental changes occurring in other organs than the encephalic centres (Deutero- pathic Insanity). Examples. — Pubescent Insanity. Uterine Insanity. Climac- teric Insanity. Puerperal Insanity. Also Rheumatic, Syphi- litic Insanity, &c. These vesaniae may be subdivided into * "Paralytic Insanity" applied to this condition is so apt to be confounded with General Paralysis as to be undesirable. CLASSIFICATION 53 those wliicli do and those wMcli do not originate in the repro- ductive system. III. Insanity caused by alcohol and other poisons (Toxic Insanity) . Examples. — Alcoholic Insanity^ Pellagrous Insanity. Inasmuch as a poison like alcohol directly injures the brain tissue^ it seems an arbitrary although a recognised distinction to separate Toxic Insanity from the first group. If allowed to form a subdivision thereof ^ we should then have only two great groups — Protopathic and Deuteropathic Insanity. The difficulty of drawing a clear line of demarcation between Toxic Insanity and Protopathic Insanity is illustrated by General Paralysis, which sometimes is and sometimes is not caused by excess of alcohol. Again, the attempt to approach Insanity from its purely physical side_, and to construct a classification based on somatic causes alone, encounters a difficulty in Idio -functional Insanity which the corresponding class of Skae — Idiopathic Insanity — equally encounters, namely, that mental shock, over- study, &c., are here the causes of the attack. From a broad pathogenetic point of view, however, this objection does not possess sufficient force to destroy the practical utility of such a class, should we desire to make the attempt to study the various morbid phenomena presented to us in Insanity, from the stand- point now under consideration. As the functions of the brain cannot be overstrained without cerebral strain also, the patho- logy (in its wider sense) of this group of cases is to a certain extent indicated by the nomenclature. We are not concerned, however, to defend any one system of classification, convinced that none is free from objection and more or less obvious incon- sistency. Lastly, it should be noted that a very large number of cases of Insanity are, from an setiological point of view, essentially constitutional, a very trivial exciting cause serving in many instances to induce an attack. Practically, it is of importance to recognise this, and when a neurotic constitution is the only apparent cause of mental disorder, it would form an example of Constitutional Insanity, falling under the division of Protopathic Insanity. This is not necessarily the same as Hereditary Insanity, a term to be restricted to mental disorder with a family history of insanity. Inasmuch as in both consti- tutional and hereditary insanity the cause is a predisposing one, and as an setiological or pathogenetic nosology deals mainly 54 OP INSANITY IN GENERAL with exciting or determining causes, these forms do not appear. Being in the background, they are eclipsed by the factor in the foreground ; and such predisposing causes precede so many cases of Insanity, that they would, if recognised in the terminology, swallow up the major part. Morel recognised this class not- withstanding. If it is adopted, however, it must be clearly uuderstood that a great many of the cases in other classes, as Puerperal Insanity, are constitutional or hereditary. SECTION III.-iEtiolo^. The Causes of Insanity may be either predisposing or exciting. For example, a man may be in an exceedingly feeble condition of health, in which the death of a friend, or other domestic trial, may induce an attack of Insanity, from which he would not have suffered had he been in the enjoyment of sound health at the time of the event. In such a case the predisposing cause of the patient's Insanity was ill health, the exciting cause, domestic grief. Among the most important predisposing influences are ■ — hereditary predisposition, a delicate mental organization, and an "unbalanced mind.'' Among the exciting are, — injury to the brain, intemperance, disappointed affections, &c. In different persons ' the same circumstance (intemperance, for instance) may have acted, in the one as a predisposing, in the other as an exciting cause. Predisposing causes may be either physical or moral, but they are, as a matter of fact, almost exclusively the former. The causes of Insanity may come into operation at the period of conception. We should expect this a priori, and experience appears to prove it. We allude more especially to the case of a parent begetting children when drunk. It is obvious that, on the one hand, the mental and physical condition of either parent at the moment of conception must exercise an important influence upon the future being, quoad his insanity ; while, on the other hand, it is equally obvious that there are but few instances in which the connexion between the transient mental states of the parents and the character and diseases of offspring can be satisfactorily traced in the way of cause and effect. At the moment of conception may also be transmitted, so far as the father's influence is concerned, any hereditary predisposi- tion which may exist. That other diseases of the parent besides OBSTETRICAL CAUSES 55 Insanity may predispose the child to mental disease can scarcely be doubted ; and among such diseases may be included^ not those alone which belong to the nervous system, as epilepsy^ but probably others, such as phthisis. When the ovum is impregnated, it is subjected to the influence of the mother's diseases or predisposition to disease. It is also liable to receive unfavorable impressions from transient con- ditions of the mother from mental shocks of any kind. The embryo may have also idiopathic disease of the brain. We may speak of a child's mental disease being cognate or innate, as distinguished from hereditary, when it is derived from influences operating during intra-uterine existence. There can be no question as to the origin of a considerable number of cases of Insanity, from causes referable to this division. Attempts to procure abortion should not be overlooked here. Dr Down, in a paper on " The Obstetrical Aspects of Idiocy,"* observes, that in 20 per cent, of the cases of idiocy collected by him, there was a history of marked disturbance of physical health of the mother during pregnaqcy ; in 4 per cent, a history of serious falls, followed by alarming uterine haemorrhage ; in 6 per cent, prolonged ill health ; in 10 per cent, persistent sick- ness, which had occasioned anxiety. He regards vomiting during gestation as an important producer of idiocy, deserving the serious attention of obstetricians. Again, in as many as 32 per cent, of the cases, there was as regards the mother a history of fright, intense anxiety, or great emotional excitement. Then follow the risks of birth, injurious compression of the cranial bones and brain, from a contracted passage or a protracted labour. Many crania are misshapen from this circumstance, without Idiocy or Insanity resulting ; but a distorted or asymme- trical skull must be regarded as a predisposing cause. Dr Crichton Browne has drawn attention to this cause in two interesting articles in vols. 1 and 2 of the 'West Eiding Lunatic Asylum Eeports.' He says Duges traced Idiocy, and Dr W. J. Little weakness and eccentricity of mind and other disorders of the nervous system to injuries received in abnormal partu- rition. Independently of an exceptionally narrow pelvis from disease, and with or without the injury not unfrequently done by the forceps, Dr Browne insists upon the fact of the greater size of the head in civilised races unaccompanied hy a j)ropor- tionate increase in the pelvic diameters, as an influence operating * ' Trans, of the Obstetrical Society of London/ vol. xviii, Dec. 6tli, 1876. 56 OP INSANITY IN GENERAL to a very considerable extent in the production of Idiocy, Imbe- cility, and Insanity. It is notorious that labour among savage women is much more easily performed than among civilised ladies, and it is difl&cult to doubt the risk of cerebral injury which must attend the latter. To the forceps Dr Browne attributes the occasional origin not only of Idiocy, Imbecility, and Moral Insanity, but "a peculiar constitutional tendency to mental or nervous disease.^' The following case will serve as an illustration : — " M. R — , one of a large family of intelligent and healthy children, was born after a tedious labour with a huge caput succedan§um, testifying to the pressure to which he had been exposed. He was not expected to live, did not cry for some hours after birth, could not suck for several days, had twitchings of the limbs for a fortnight, and then spasm for about three months. Did not walk until he was three years old, and then with a tottering unsteady gait, and only acquired a few monosyllables a year afterwards. He grew up a typical example of that kind of Idiocy which generally results from tedious and abnormal but non-instrumental labours, and which is not altogether of the baser sort. Although exceedingly feeble in his mental powers, ineducable and un;ible to articulate distinctly, he could still pick up and play upon the piano any tune which he might hear, and manifested some vigour of memory in certain directions. He had a small conical head, badly shaped features, and a convergent strabismus, and was at times distressingly dirty and mischievous in his habits." (Op. cit., vol. i, p. 12.) Dr Down, in the paper already cited, states as the result of his researches upon 2000 children, more or less idiotic, that 20 per cent, were born with well-marked symptoms of suspended animation, which required strenuous efforts to effect resuscitation. This suspended animation he regards as highly injurious to the integrity of the brain. No less than 24 per cent, were the children of primiparae ; the greater difficultyof parturition, and the exalted emotional life of the mother, being regarded as the main causes of the danger to mental power in the eldest child. Forty per cent, of resuscitated idiots belonged to primiparous offspring. *As to the employment of instruments at birth, Dr Down traced this in only 3 per cent, of the cases in regard to which certain information could be obtained ; and in most of these cases there were other causes present to account for the idiocy, leaving only a small fractional percentage in which the forceps was the principal cause. Labour was pro- longed in a very large number of instances, and the conclusion is arrived at that more mischief is done by prolonged pressure than by artificial help. The child who is free from predisposition to mental disease. HEREDITARY PREDISPOSITION 57 who lias safely escaped the perils of conception^ foetal life^ and birth, is still exposed to a variety of agents, some external, others internal. Among the former is the milk of a nurse strongly predisposed to Insanity ; or (as with cretins) unwhole- some water, food, &c. Among the latter is the first dentition, convulsions caused by which (however frequently they may seem not to be followed by any ill result) do exert no inconsiderable influence in arresting the development of previously healthy children. If, safely escaped from the risks attendant upon the first and second dentition, the child grows up, he is exposed to others at the period of puberty. At this stage of development the danger is no doubt greatest in the female. After puberty both sexes, but especially the male, are exposed to unfavorable influences, which may be comprised under the terms intellectual and emo- tional excitement. Man^s capacities for enjoyment and misery are alike increased; if wiser, he is also sadder. Then follow, with women, the dangers connected with pregnancy, parturition, lactation, and lastly, the critical period of life. These are the trial-epochs of life which test the mental strength and integrity of individuals. The influence of puberty and the climacteric period, and the prognosis to be given in Insanity resulting therefrom, will be referred to subsequently. Old age, finally, plays an important part among the causes of Insanity. From this rapid sketch of the circumstances capable of gene- rating mental disease to which man is exposed from the moment of conception to the time of his death, we proceed to consider the causes of Insanity in detail. Predisposing Cattses. Hereditary Predisposition is a term often made to comprise a taint traceable to relatives of very different degrees of con- sanguinity. It is sometimes used to signify one occurring in direct ancestors only. Evidence of Insanity in a direct line is clearly of far the greatest value. It may also mean the existence of Insanity in the uncles and aunts of any prior generation, a circumstance affording a strong presumption of hereditary pre- disposition. Again, it is an important evidence of family pre- disposition if the brother of the patient has been insane, for he 58 OF INSANITY IN GENERAL has precisely the same blood in his veins. At the same time it is clear that it would be a misnomer to speak of a patient's insanity being derived by hereditary transmission from a brother, or, indeed, from an uncle. It is, however, presumptive evidence of the existence of family predisposition when the brother or sister and the own uncle or aunt of the patient have been insane ; indeed, this combination is almost as strong as when a lineal ancestor has been deranged. Lastly, it is obvious that the fact of hereditary predisposition cannot be with certainty inferred from the insanity of cousins, owing to the presence of fresh blood from which the taint may have been derived. When we employ the term ''direct'' we mean lineal ancestors only ; and by '' collateral," that the existence of Insanity has been traced to an own uncle, or own aunt, or to a brother or sister; cousins not being included. It should be added, that the occurrence of Insanity in a parent after the birth of the person affected, cannot be regarded as certain proof of hereditary predisposition ; at the same time such predisposition remains highly probable ; its value must be judged of by the history and character of the attack under which the parent laboured ; whether, in short, it appears to have been accidental rather than constitutional. Esquirol observes that, of all diseases. Insanity is the most hereditary. "Although observed 337 times among 1375 lunatics, I am persuaded that this predisposing cause is still more fre- quent." This is nearly one fourth of the cases in which the cause was ascertained, and 21 per cent, of the admissions. He appears to use the term in an extended sense, but does not define it. However, we observe that recent French statistics show a proportion of 25 per cent, when only direct influence is included. Burrows says that six sevenths of his patients were the subjects of hereditary predisposition. Guislain estimates hereditary predisposition at one fourth of the admissions (56 out of 224 patients). He thinks it probable that it was actually 30 per cent. M. Michea believes that at least one half, if not three fourths, of the insane have had, or still have, some members insane in their family. Dr Damerow traced in 773 patients admitted at Halle, hereditary predisposition in 187, or about one fourth. The experience of the Retreat, during thirty-four years, was as follows : HEREDITARY PREDISPOSITION 69 Hereditary on the paternal side Do. maternal side Do. on both paternal and maternal sides Do. whether on paternal or maternal side uot known Known to be hereditary Not known or stated to be hereditary ... Male. i'emale. Total 19 20 39 17 23 40 3 3 6 32 36 68 71 82 153 ... 152 164 316 223 246 469* From this it appears tliat in 153^ or nearly one third of the total number admitted, hereditary predisposition was traced. Dr Thurnam observes, that those cases have not been considered of an hereditary character, the history of which was only charac- terised by the existence of Insanity in collateral blood relatives ; it being obvious that cases of this description do not necessarily establish any direct hereditary transmission. He adds that, had these been included, the proportion would have been raised to about one half or fifty-one per cent. At the York Asylum in 334 cases out of 1029 admissions during twenty-seven years (1846-72) hereditary predisposition was traced, or 31 per cent. (Dr Needham^s Tables in Eeport of 1873). Dr Stewart in a valuable article in the ' Journal of Mental Science,' April, 1864, on *^' Hereditary Insanity," based on the study of 901 cases admitted into the Crichton Eoyal Institution, Dumfries, gives the following statistics under four classes : — 1st class. Hereditary Insanity or eccentricity, i.e. when a first cousin or any nearer relation has suffered from such affection, 447 cases, or 49"61 per cent. ; 2nd class. Hereditary Diseases not Insanity, or in whose parents there was found some disease or condition which had apparently produced the Insanity in their offspring, 49 cases or 5"43 per cent. ; 3rd class, no Hereditary Disease, cases 245, or 2 7' 19 per cent.; 4th class. Hereditary condition unknown, cases 160, or 17'75 per cent. In 181 of the cases only one relative of the patient was known to be insane, whilst in 226 cases more than one relation had been affected; results, as Dr Stewart points out, approaching very nearly those observed at the York Eetreat. He gives the following table, showing the number of the hereditarily predisposed, whose parents, or col- lateral relatives, were affected, out of 901 admissions. * Dr Thurnam's * Statistics of Insanity.' 60 OF INSANITY IN GENERAL Parents or ancestors insane Brothers or sisters insane Uncles or aunts insane Cousins insane Relatives, relationship unknown, insane Total Male. 127 79 18 10 19 253 Female. 64 16 18 194 Total. 215 143 34 18 37 447 At Bethlem Hospital, Dr Savage* has traced disposition in 375 out of 1072 admissions from to November, 1876, being 34-9 per cent. The shows the insane relationship of the patients, appear under several heads. Having insane fathers „ mothers grandparents brothers sisters uncles aunts cousins other blood relations several relations hereditary pre- January, 1872, following table Some of them Males. Females. . 31 34 21 17 25 28 22 26 14 1 46 63 30 41 55 31 41 20 3 77 In connection with this subject, there are three very interest- ing inquiries : — first, whether the Insanity of the mother is more frequently hereditary than that of the father ; secondly, in cases of hereditary transmission, is the disease of the mother trans- mitted to a greater number of the offspring than that of the father ? and, lastly, is Insanity most frequently transmitted from the mother to the daughters, and from the father to the sons ? To the determination of these questions M. Baillarger has directed his attention, and his statistics afford an affirmative reply in each instance. ('Annales Medico-Psychol.,' 1844, p. 833. See also an article in the ^Allgemeine Zeitschrift fiir Psychiatrie,' 1848, p. 540.) The number of cases of Hereditary Insanity from which these conclusions are deduced amounted to 600, of which 440 were hereditary in the direct line by the father or mother, 13 had at the same time both collateral relations and brothers or sisters insane, 147 had only collateral relations insane. The fact of hereditary predisposition is assumed in the second as well as the * ' Guy's Hosp. Reports,' 1877. HEREDITARY PREDISPOSITION 61 first class (making a total of 453) ; but cases of tlie third class are rejected as being uncertain. Baillarger appears to include cousins in the term '' collateral/^ We find from statistics given by the late Dr Brigham (America) that out of 79 insane men, 42 had insane fathers and 35 insane mothers, and in two instances, both parents were deranged; while of 96 insane women, 37 had insane fathers and 56 insane mothers, and 3 inherited a predisposition to Insanity from both parents. The following tables from Thurnam, Brigham, and Stewart show the paternal and maternal influence on the number of males and females. Thtjenam, Beigham. Paternal influence. Maternal influence. Paternal influence. Maternal influence. Male. Female. 19 20 8-5 p. c. 8*1 p. c. Male. female. 17 23 7-6 p. c. 9-3 p. c. Male. Female. 42 37 7-07 p. c. 6-3 p. c. Male. Female. 35 56 5-9 p. c. 9*5 p.c. Stewaet. Paternal influence. Maternal influence. Male. Female. 49 33 9*4 per cent. 8'7 per cent. Male. Female. 37 31 7*1 per cent. 8'1 per cent. In the next table is exhibited the proportion of hereditary cases in the different forms of Insanity observed in the Crichton Institution, as reported by Dr Stewart. Mania. 51-0 per cent. Melancholia. 57*7 per cent. Monomania. 49*0 per cent. Moral Insanity. 50'0 per cent. Idiocy and Imbecility. 36-0 per cent. Dipsomania. 63-4 per cent. General Paralysis. 47'6 per cent. Dementia and Fatuity. 39' 5 per cent. It must not, however, be overlooked that a certain number of insane persons will necessarily have insane ancestors, without there being a necessary connection in the way of transmission 62 OF INSANITY IN GENERAL between the ancestor and the insane descendant. This source of fallacy does not appear to be of much practical moment. Buckle, indeed, called in question the evidences upon which the hereditary transmission of disease rests, but it is not possible in view of the constantly increasing stock of facts accumulated on this subject to deny this influence in regard to Insanity, apart from mere coincidence. Prosper Lucas, the highest authority in regard to hereditary influence, replies to the question whether this principle applies to disordered as well as healthy mental characteristics : — " II n^y a point d^etat pathologique de Fetre ou Tintervention de Fheredite morbide soit, et plus remarquable, et plus remarquee. Elle est une source possible de toutes ses lesions.^^ {' De L'Heredite.^) He quotes from Michaelis an instance in which all the male descendants of a noble family of Hamburg, remarkable from the time of the great grandfather for their great military talents, were attacked with Insanity at the age of forty ; only one re- mained, an ofiicer, who was actually forbidden to marry. The critical age arrived, when he too went insane. At Hartford, Connecticut, a maniac was admitted who was the eleventh insane member of his family. Moreau mentions the ninth member of a family having been so attacked, the others being his father, two brothers, two sisters, two cousins, and an aunt. We have ourselves known many instances of several members in a family being insane at the same time ; as at the present moment we know a melancholy illustration of heredity in the case of an insane mother and two insane daughters. "We might have supposed that bodily features would be trans- mitted along with mental peculiarity ; and Burrows says such is the case ; but Moreau's conclusions are quite opposed to this idea. He asserts that while personal resemblance and cerebral disorder may be transmitted by either parent, they never are so by the same (' L'Union Medicale,' No. 48). Thus, " when the children resembled the parent of the oppo- site sex the following results were obtained : — of 22 female suffering from Insanity, 17 had inherited it from the mother, and 5 from the father; while of 142 insane males, 95 had acquired the disease fi'om the father, and 47 from the mother; when, on the contrary, the analogy of resemblance was inverted, 47 sons who resembled their father, derived their Insanity from the mother, and 8 girls who resembled the mother, derived theirs from the father.^' ('Med.-Chir. Rev.,' April, 1863.) HEEEDITART PEEDISPOSITION 63 Wlien mental disease is transmitted^ does tlie form of Insanity- descend ? Very frequently this appears to be the case. Moreau confirms the opinion of Esquirol that such is even the general rule. He says it is rare that the form the malady assumes does not present the most striking resemblance^ sometimes even a true identity. Lucas accumulates evidence in support of this opinion, as regards Hallucinations, Monomania, Dipsomania, Suicidal Insanity, Melancholia, Mania, and even occasionally in Idiocy. Examples of hereditary Suicidal Insanity abound. Falret gives the case of a family in which the grandmother, mother, and grandchild were the subjects of Suicidal Melancholia ; and another example, namely that of a family in which the father who was of a taciturn disposition had six children, five boys and a girl ; the eldest, aged 40, precipitated himself from the third storey without any motive ; the second in age strangled himself at 35 ; the third threw himself from a window in attempting to fly ; the fourth shot himself with a pistol ; and, lastly, a cousin jumped into a river from a trifling cause. General Paralysis is stated to be highly hereditary, but we have not been able to meet with any facts which support the opinion that it has a tendency to reappear in the same form in the next generation. Insanity was hereditary in 8 out of 49 cases of general paralysis (or 16 per cent.) reported by Dr Barman in the ' West Riding Reports,^ but no information is supplied as to the form it assumed in the forbears. As regards Idiocy, Lucas cites the case of a child born of an idiot mother, who was idiotic and who from its infancy, left among the cows in the stable, acquired the habit of ruminating like them. Again, the eldest of three sisters, all imbecile, had two children, of whom one, a boy, was imbecile. Seguin says, " I have never had the charge, so far as I know, of an idiot, the son ©f an idiot, nor even of an imbecile ; whilst I have frequently known or seen in the family of one of my pupils an aunt, an uncle, and oftener a grandfather, idiotic, insane, or imbecile. ^^ It has been pointed out by Dr Leubuscher of Berlin, and others, that the outbreak of an hereditary disposition to Insanity is especially connected with the processes of development, as the occurrence of puberty, the climacteric period, and childbirth. But while the same form or type of mental disorder may descend from one generation to another, it is also certain that not only may one form be succeeded by one of a very different 64 OF INSANITY IN GENERAL character but by other neuroses, as Epilepsy or Chorea. Bur- rows enumerates Hypochondriasis, Apoplexy, Paralysis, Epilepsy, Convulsions, Chorea and Hysteria, as hereditary "relations of Insanity/^ Portal pointed out the fact that in the same family one nervous affection is replaced by another, instancing Mania and Epilepsy. Greding also observed Mania in the mother become Epilepsy in the children. Gintrac perceived that great nervous sensibility in one generation was metamorphosed into Monomania, Hysteria, Epilepsy, Neuralgia, in the next. Lucas, who cites these authors, devotes a chapter to the subject of here- ditary metamorphosis of diseases of the nervous system, and points out that the general law of the transmission of similar types is compatible with mutability of type — the transmission of allied but different forms of neuroses. In fact, Gaussail held that nothing is transmitted but the aptitude for some form or other of nervous disorder, and that this is wholly determined by causes subsequent to birth. Lucas shows that as in an indi- vidual any nervous affection may be transformed into another, and thus prove the consanguinity of these disorders, so may the like transformation take place in parents and children. Morel, Moreau, Maudsley, and Anstie have latterly pursued the subject in still more detail. Dr Anstie in an able paper " On the Hereditary Connections between certain Nervous Diseases " in the 'Journal of Mental Science,^ January, 1872, has pointed out two varieties of inherited neurosis, the Active Hereditary and the Dormant, while Lucas divides heredity into three divisions, according as it is manifested — (1) in mere predisposition or simple aptitude for a certain disease, (2) in the latent state or germ of the malady, or (3) in the patent state or actually deve- loped disease. We cannot conclude the consideration of hereditary predis- position without referring to the question so often asked. Is it right when there is, as people say, " Insanity in the family ^^ for a member of that family to marry ? The physician is certainly not called upon in all cases to advise against marriage, even if his advice were very likely to be followed. The result arrived at by Baillarger may assist in forming an opinion in the parti- cular case under consideration ; for instance, there would be less danger in a man marrying, whose mother, and not whose father, had been insane ; but still more important would be the cha- racter of the mental and physical constitution of the person himself, whether in short an insane diathesis is indicated. Pre- MAEEIAGE OF THE PREDISPOSED 65 disposition to Insanity might exist in a female^ and it be thouglit that marriage would exercise a favorable influence over the system and lessen the probability of an attack. We confess that in such a case we should greatly hesitate to encourage marriage. Certainly^ if in ever so small a degree there is to be a stamping out of Insanity^ we must act on the principle^ better let the individual suffer^ than run the risk of bequeathing a legacy of Insanity to the next generation. Eespecting those who have been actually insane^ we hold that the strongest dis- suasion ought to be employed to prevent the marriage of females who have not passed the child-bearing period of life. With regard to males^ marriage would no doubt be highly beneficial in many instances^ and if the risk of progeny is not run, may well be encouraged, provided the consenting party is fully informed of the individuaFs prior history and of the degree of liability of a relapse which exists. Every psychological phy- sician has known instances in which the comfort of a quondam patient has been vastly increased, and the probability of a relapse proportionately lessened ; the union proving in all respects a happy one. He may also be able to recall cases in which, not the individual who had been once insane, but the person who had risked having an insane partner for life, was the one to become the subject of mental disease. We have known a gentleman not only marry and have no relapse, but become himseM the head of an establishment for the insane. Clearly, then, all the circumstances of each case, the apparent amount of predisposition, and the signs of an insane diathesis, must be taken into consideration rather than the adoption of an inflexible rule, but both in these cases and where there has been actual Insanity, primary regard should be had to the risk of a family. Undoubtedly, however, it is much easier to say theoretically what ought to be advised than to give this advice consistently and resolutely in individual instances. Besides, in many cases the physician^s counsel, however excellent, will have too powerful an antagonist to contend with to allow of its being followed. Some difference in the opinion formed of the undesirable cha- racter of such connections may reasonably be made between those cases in which the ancestor has become insane after, and those in which he (or she) has become so before, the birth (con- ception) of the child. For while in the former it is possible that the germ of Insanity may have been latent in the constitu- tion of the parent, and as such be transmissible, the danger of 5 C6 OF INSANITY IN GENERAL transmission becomes a certainty, if the nervous system has been the seat of mental disorder prior to the generation of the oifspring. The exciting cause of the malady when the attack occurs in an individual after giving origin to a new life, may greatly affect the judgment formed by the physician ; for in- stance, Insanity from an accidental cause, as a blow, or simply from old age, should be differently regarded as a proof of con- stitutional tendency to Insanity, than spontaneous mental dis- orders occurring in the prime of life. Burrows, among the first to treat this question as one of grave practical import, expresses himself in favour of " greater precaution in matrimonial connections," and quotes from Boethius that in old times when a Scot was affected with any hereditary disease " their sons were emasculated and their daughters banished, and if any female affected by such disease were pregnant, she was to be buried alive." It is very remark- able that after all that has been said and done in our day in stamping out disease, and after a much fuller appreciation of the subtle influences of ancestral tendencies, there should be something like an opposite current of feeling which would look almost with favour, certainly not with horror, upon even fruitful marriages among those belonging to " an insane family." Thus, Dr Maudsley inclines to think that '' to forbid the marriage of a person sprung fi'om an insanely disposed family, might be to deprive the world of singular talent or genius, and so be an irreparable injury to the race of man." With our present ignorance of the laws of human production, he cannot think that " Science has yet the right to forbid marriage to those in whom some tendency to Insanity exists." In regard to men and women who have had actual attacks of Insanity, he admits that one may justly use the strongest words of dissuasion, " but how much further than that one is justified in going, does not seem at all clear." In cases of Puerperal Insanity he would not necessarily endeavour to. prevent a woman having children afterwards, but would be guided in each instance by special circumstances. In this conclusion all probably would unite. We should, however, as already intimated, be more inclined than Dr Maudsley to discourage marriage among those predis- posed to mental disease. It is certainly a happy law of nature, as some set-off against the melancholy results of propagation among the insane, that, sooner or later, beings labouring under the lower forms of CONSTITUTION OR DIATHESIS 67 mental disease die out. The mental faculties and bodily powers are at last reduced so loWj that ex nihilo nihil fit. Prosper Lucas clearly laid down the law that " there exists an inferior degree of mind in which the anomalous state of the mental force sinks so low beneath the natural order^ that repro- duction of it is almost impossible ^^ (op. cit.^ vol. i^ p. 579). The student wishing to work out this subject thoroughly must study MoreFs able work, ' Traite des Degenerescences Humaines/ in which the influence of insanity is traced through several generations with great care, and with the result above stated. Constitution or diathesis. — This is a circumstance constitut- ing a predisposing cause of Insanity, which is separated by very delicate lines from the disease itself on the one hand, and from hereditary predisposition on the other. Thus, for instance, in close connection with hereditary descent, but not necessarily derived from it, there is a certain constitutional weakness of mind which, falling far short of Imbecility, may be regarded as predisposing an individual to mental derangement — that is to say, he might escape without injury many of the trials of life but for this limited mental calibre. Then, again, many are constitutionally melancholy, and end in becoming melancholiacs. Esquirol recognised this, and expressed a general rule, in a more unqualified way than we should be disposed to do, when he said that melancholiacs are born with a peculiar temperament, which disposes them to Melancholia. The events happening during foetal life, or at birth, already mentioned, and, indeed, many circumstances apart from the insanity of ancestors may clearly induce a mental constitution which forms a predisposition to Insanity. An insane diathesis may, then, be hereditary or not. It is rare for writers to recognise this distinction, but, we hold it to be very important, for it frequently happens that when we fail to obtain evidence of insane relatives, and, indeed, when there is positive evidence to the contrary, we find unmistakable indica- tions of an original make of mind, so to speak, which constitutes a predisposing cause of the attack, and fully explains its occurrence. Whether this diathesis be hereditary or not, it is important to be alive to the indications of its presence. -These are various. Thus the excitable, nervous, and melancholic tem- 68 ■ OF INSANITY IN GENERAL peraments are well marked. A character in which overweening pride is a natural characteristic may be said to predispose to monomania of a certain kind. Again^ in the individuals history there are after occurrences indicating this neurosis. Such are those pointed out by Anstie — {!). Premature occurrence of puberty; sexual pre- cocity. (2.) Unexpected development of intense artistic feeling in children born of a naturally commonplace family. (3.) Convulsions during teething, without adequate cause. (4.) The development of a habit of lying or stealing in well-trained children. It may be said that no cause or combination of causes is so powerful as the natural constitution of mind. If a man has a weak point somewhere in his head, it is like a weak link in his watch-chain, which, on the occasion of a very slight strain, gives way, and the watch is lost. It is the defect in the chain which is the really important factor in its breakage, not the little accident which corresponds to the exciting cause. Consanguineous Marriages. — We may refer here briefly to the important question of the influence of rnarriugcs of consanguinity upon the generation of Insanity. It is a very complex one, and in our judgment it is far from being thoroughly worked out. On the one hand, those who deny the ill effects of these unions point to such facts as the following : Among animals, certain valued varieties are propagated within narrow limits, without their deterioration ; certain breeds of cattle and Arabian horses are noted for beauty and health while crossing has been studiously avoided. When deteriora- tion occurs in animals among the offspring of parent and child, it is explained by the age of the former. Among men there are certain people, as the Indians of North America, among whom very little Insanity or Idiocy exists, and yet marriages within very near degrees of relationship are common; some chiefs, also, in the South Sea Islands are remarkable for their strength and vigour, but are descended from a stock carefully limited in its alliances. The custom of the patriachs is further adduced — the marriage of Abraham to his half sister, of Isaac to his first cousin once removed, and of Jacob to his first cousin, without any known injurious results. An important contribution towards the solution of this ques- . tion has recently appeared, ' The Marriage of Near Kin,' by Alfred Henry Huth, 1875, and to it the reader is referred, as CONSANGUINEOUS MAEEIAGES 69 containing the most able and exhaustive defence of consanguin- eous marriages "which, has yet appeared. . Mr Huth while admitting that deterioration through the accumulation of an idiosyncrasy is more likely to occur in families in which the marriages of blood relations are habitual^ endeavours to show that practically this does not occur oftener than in other marriages. These are the main circumstances brought forward in support of the innocuousness of the marriage of near relations, and they have a certain amount of weight_, but they are not sufficient, the writer thinks, to justify us in encouraging the marriage of near cousins, for this reason, that if any taint of insanity does exist in the blood, it will be intensified. If the stock is quite healthy, it is probable that no ill effects will follow. Dr Morel believes that experience shows the injurious in- fluence of such unions, sooner or later, *'in a peremptory manner,^' and refers to the aristocracies of France. Dr Bemiss has published some striking facts bearing upon this question, which we extract from the ' Medico- Chirurgical Review ' for July, 1860 : Of 31 children born of brother and sister, or parent and child, 29 were defective in one way or another; 19 were idiotic, 1 epileptic, 5 scrofulous, and 11 deformed. Of 53 children born of uncle and niece, or aunt and nephew, 40 were defective ; 1 deaf and dumb, 3 blind, 3 idiotic, 1 insane, 1 epileptic, 12 scrofulous, and 14 deformed. Of 234 children born of cousins, themselves the offspring of kindred parents, 126 were defective; 10 deaf and dumb, 12 blind, 30 idiotic, 3 insane, 4 epileptic, 44 scrofulous, and 9 deformed. Of 154 children born of double cousins, 42 were defective ; 2 deaf and dumb, 2 blind, 4 idiotic, 6 insane, 2 epileptic, 10 scrofulous, and 2 deformed. Of 2778 children born of first cousins, 793 were defective; 117 deaf and dumb, 63 blind, 231 idiotic, 24 insane, 44 epileptic, 189 scrofulous, and 53 deformed. Of 513 children born of second cousins, 67 were defective; 9 deaf and dumb, 5 blind, 17 idiotic, 1 insane, 6 epileptic, 15 scrofulous, and 9 deformed. Of 59 children born of third cousins, 16 were defective ; 3 deaf and dumb, 1 idiotic, 1 insane, 2 epileptic, and 10 scrofulous. These facts, however interesting, must not be taken as neces- sarily proving that intermarriage caused all these diseases. In many of these cases it cannot be doubted that the intemperance 70 OF INSANITY IN GENERAL and immorality of the parents had a large share in producing insane and idiotic offspring. Out of 711 idiots, 98 or 13-7 per cent, were found by Dr Arthur Mitchell* to be the offspring of blood relations, viz. first cousins in 42 instances ; second cousins in 35 ; third cousins in 21. As in 84 instances no information could be obtained, the per-centage would be 15-6, if calculated on the number in which the facts were known. In contrast with this, he places the percentage of consanguineous marriages in Scotland at rS percent., or ten times less than with idiots. In regard to those mentally affected in another district, Dr Mitchell found in 260 persons 16 per cent, were the children of first, second, or third cousins ; or, if reckoned upon the cases in which particu- lars could be procured, 23 per cent. Much lower percentages have been arrived at by Dr Down. Of 852 cases of idiocy he obtained definite information in regard to parentage, with the following result : — 46 were the progeny of first cousins, 6 of second cousins, and 8 of third cousins, being 7 per cent, in which, blood relationship existed in the parents. On the other hand, the parental relationship of 200 sane and healthy persons in the community were examined into, and it was found that only one was the offspring of cousins. One cannot, therefore, as Dr Down observes, resist the conviction that the union of blood relations has some influence in the deterioration of the species. Finding, however, as he did on inquiry into the causes of idiocy in the above cases, that there was, as regards a con- siderable number, hereditary predisposition and other factors of mental disease, he arrived at the conclusion that " con- sanguinity is only one of the factors, and not the most important one, in the production of deterioration." {'' Marriages of Consan- guinity in relation to Degeneration of Race,'^ ' London Hospital Clinical Lectures and Reports,' 1866.) It is probable that, if Dr MitchelFs cases were further traced, rnauy other causes than consanguinity would be discovered to have been in operation. Illegitimacy is one to which he has himself referred. Again^ Mr Geo. H. Darwin considers, from the inquiry he has made into the amount of consanguineous marriages in the community at large, that Dr Mitchell's estimate ought to be raised consi- derably higher. In a paper in the ' Statistical Society's Journal,' June, 1875, he arrives at the conclusion that about 4 per cent, of all marriages are between first cousins ; in the country and * ' Edin. Med. Journ.,' vol. x, 1865. CONSANGUINEOUS MAEEIAGES 71 smaller towns between 2 and 3 per cent. ; in London, perliaps as few as 1^ per cent. He obtained returns from lunatic and idiot asylumSj but those wlio drew them up regarded them as extremely imperfect, and therefore they are so far misleading. From these it appeared that 3 or 4 per cent, of the patients were the children of first cousins, and therefore not greater than in the general population. He confesses that his labours are far from giving anything like a satisfactory solution of the ques- tion. At its Annual Session, in 1869, the New York State Medical Society received the report of a Committee appointed to in- vestigate the influence of consanguineous marriages, and the following important statistics, for which we are indebted to the ' American Journal of Insanity,^ 1870, were obtained : — The offspring resulting from 32 marriages of consanguinity are tabulated — 127 in number. There were 8, 11, 12, and in one family 14 children ; making an average of 4 children to each marriage, and some of the couples were still productive (comparing favourably with the average of three children). Fourteen of the above 127 children died under 2 years, or 11 per cent., the average mortality at that age in New York being 38 per cent. Of 12 who deviated from health, 5 were scrofulous, 2 were deaf mutes, 1 epileptic, 1 " simple,^' 1 had amaurosis, and 2 a peculiar deformity. Of the scrofulous children, one or both parents were either scrofulous or tuber- culous in 6 cases. In. the next group there are 3 cases in which there was a predisposition to Insanity. In the first an uncle, aunt, anci sister of the wife died insane, the husband was always in poor health ; they have 5 children all in tolerable health. In the second case the husband and the wife^s mother died insane ; the children are all healthy ; 1, a daughter of the above, married a near relative and her children are free from any disease ; they are now respectively 34_, 32, 30, and 26 years old. Of the 14 remaining cases in which the parents had good constitutions, the children are, without exception, healthy, some of them possessing decided genius as writers. Dr Jarvis (Mass.), so well known for his devotion to all questions re- lating to Insanity and the insane, in a letter addressed to Dr Newman, who reported on behalf of this Committee, observes that when the parents (being nearly related) have both perfect constitutions, the offspring have a double security against imperfection ; the converse being also true. Hence, the 72 OF INSANITY IN GENERAL objection does not rise from " the hare fact of their reJationshij), but in the fear of tlieir having similar vitiations of constitu- tion." The practical inference is that first cousins should not marry unless both they and their ancestors have been free from Insanity, However healthy themselves, if a near ancestor has been insane, the physician when consulted must say '' I forbid the banns." Although, therefore, it may be quite true that consanguinity in itself does not create mental disease, it is so difficult to ensure the sound constitutions of the parties marry- ing and of their ancestors that the marriage of those near of kin is very often undesirable.* Relative Liability of the 8exes to Insanity. — The conclusion at which Caelius Aurelianus arrived, that women are less subject to Insanity than men, has been disputed by Esquirol, Copland, Burrows, and others. Dr Has! am likewise stated, that " in our own climate women are more frequently afflicted with Insanity than men." Sufficient, care, however, does not appear to have been taken to ascertain the relative number of males and females in the general population, a point obviously necessary to deter- mine, before any just conclusion can be drawn as to the relative liability of the sexes to Insanity. Most writers having found the existing number of female lunatics greater than that of the males, have arrived at the conclusion that the female sex is more subject to Insanity than the male. Moreover, the pre- ponderance of women over men at those periods of life during which Insanity most frequently occurs was not recognised by Esquirol. Dr Thurnam, however, has clearly pointed out this source of fallacy, as well as that which arises from the fact that the mortality of insane men exceeds (in English asylums, at least) that of insane women by 50 per cent. Hence it is obvious that writers have erred in comparing the existing instead of the * The reader wishing to pursue the subject should refer to two able papers by Dr Sedgwick, " On the Influence of Sex in Hereditary Disease," in the ' Medico-Chirur- gical Review,' April and June, 1863. See also an article by Dr Child in the same Journal for April, 1862 ; Boudin, " Danger des unions consanguines et necessite des croisements dans I'espece humaine et parmie les animaux," ' Annales jd'Hygiene,' 1862; Devay's ' Hygiene de Famille,' 2nd edit. ; Burton's 'Anat. of Mel.;' White- head's ' Hereditary Disease ;' Maudsley " On Hereditary Tendency," ' Journal of Mental Science,' Jan., 1863, and Jan., 1864 ; Marce, ' Des Maladies Mentales,' 1862 ; Moreau (de Tours), 'Psychologic Morbide;' Etude sur les manages consanguins. Par Chipault. Paris, 1863. Studj sui Matrimonj Consanguinei. Sg. Paolo Man- tegazz, Milan, 1868. Dr Arthur Mitchell, " Consanguineous Marriages," ' Edin. Med. Jouru.,' 186.=i, and the articles of Dr Down (1866), and Mr Darwin (1875), referred to in the text. EELATIVE LIABILITY OF SEXES TO INSANITY 73 occurring cases of Insanity, in tlie male and female sexes. If, in our asylums, women live longer than men, they will, of course, proportionately accumulate. The preponderance of females over males in England and Wales at the last Census (1871) was 594,398. This excess at all ages does not, howevei', prevent the proportion of existing insane being greater among women than men, viz. 1 to 379 of the former, and 1 to 425 of the latter. The number of females living above the age of fifteen exceeded that of the males at the same period of life by 8*8 per cent. This, of course, is the period of life which, owing to the comparative infrequency of Insanity before the age of fifteen, is very important in the present inquiry. There is a large excess of females between twenty and fifty (except in a few mining districts). Between twenty and thirty, the importance of which period will be seen when we speak of " B.ge/' we find the excess of females to be at a maximum. Between thirty and forty the excess is still considerable. "In order that the comparison of the occurring cases be a, strictly accurate one,^^ observes Dr Thurman, the proportions of the two sexes at the several ages attached with Insanity, for the first time, should be compared with the proportions in which the two sexes at the same ages exist in the community in which such cases occur. The nearest approximation to this method which we have the means of employing is, by assuming that the proportions of men and women admitted into public institutions during extensive periods, represent — as, on the whole^ they probably do represent — the cases which occur for the first time " (op. cit., p. 149). From an examination of a table prepared by this writer, we ascertain that, in twenty-four of the thirty-two asylums which it comprises, there has been a decided excess of men in the numbers admitted. In many British asylums, the excess amounts to 25, 30, and even 40 per cent. ; and, in the whole number of thirty-two asylums, there is an average excess on the side of the male sex of 13"7 per cent. In the nine English county asylums contained in the table, the excess amounts to 12 per cent. From the same table, it appears that, in the asylums of the metropolis, the proportion of females admitted is much greater than in the provinces. This, as regards the admissions from London itself, is accounted for by there being a considerable 74 OF INSANITY IN GENERAL excess (13-7 per cent, at all ages, and 21-3 per cent, at all ages above 20) of women over men in the metropolis. In the " Rapport sur le service des Alienes du Departement de la Seine/' 1877, it is stated that up to 1860 the admissions of female lunatics were greater than those of men, while since that period, the proportion is reversed. (From 1860 to 1870, 52-96 per cent, men, against 47-04 per cent, women; and from 1871 to 1876 54-65 per cent, men, against 45-31 per cent, women.) Dr Jarvis, in a treatise on this subject, after examining the statistics of asylums in Great Britain, Ireland, France, Belgium, and America, has arrived at the conclusion that "males are somewhat more liable to Insanity than females.^' He justly observes that the liability of the sexes, " must vary with different nations, different periods of the world, and different habits of the people " {' On the Comparative Liability of Males and Females to Insanity, 1850'). On the whole, it is clearly proved that, in general, fewer women, as was taught by Cselius Aurelianus, become insane than men, although it is difficult to establish that the female sex is intrinsically less susceptible to the causes of Insanity than the male, since the former is less exposed to those causes than the latter. This difficulty does not alter the fact that Esquirol's conclu- sion is reversed, when we take into account the great excess of females in the population between the ages of twenty and fifty (the age specially subject to attacks of Insanity), and the fallacy of drawing conclusions from existing instead of occurring cases, on account of the accumulation of females in asylums by reason of their low mortality. Age. — Without reference to cases of Idiocy and Imbecility, it may be observed that no age is exempt from attacks of Insanity. Such attacks, it is true, are comparatively infrequent under four- teen or fifteen years of age. Scattered throughout this work, however, will be found a considerable number of references to cases of Insanity under puberty, and they might have been con- siderably increased. They are met with in private practice much more frequently than in asylums, the statistics of which, there- fore, give too favorable an impression as to the frequency of attacks of Insanity in the young. Between fifteen and twenty attacks increase ; while between twenty and fifty they are the most frequent. Whether they preponderate between twenty and thirty, or thirty and forty, may admit of question. AGE 75 During the forty-four years between ]796 and 1840, of those admitted at the Eetreat^ the greater number^ one third of the whole, were attached between twenty and thirty years of age. Each subsequent decennial period is marked by a gradually decreasing proportion. Thus : — Of every hundred cases, at the origin of the disorder, there were, at successive decennial periods of life, as follows {' Statistics of Insanity,^ p. 71) : — )-10 10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 96- 12-77 32-53 20- 15.9 10-6 603 •97 -24 = 100 Now, it is obvious that, to render these statistics of any value, they must be compared with the numbers living in the same community at the same periods of life. This means of com- parison we afford in the following table : Of every hundred individuals there' were living in 1841, at successive decennial periods of life, as follows : 0-10 10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 25-0 20-8 18-0 13-0 9-6 6-4 4-4 2-2 0-6 = 100 From which it is evident that the large proportion of persons who became insane (of those admitted at the Retreat) between twenty and thirty years of age, cannot be explained by the greater proportion of the number living at that period. When the whole of this series is worked out the order of frequency of attack in the decennial periods, was as follows : — 20—30 (maximum) ; 30—40, 40—50, 50—60, 60—70, 10—20, 70—80, 80—90, 0—10 (minimum). It will be seen from this that, not reckoning attacks prior to man's majority, the decades follow in their natural order. With regard to the decade 20 — 30, the experience of the American asylums* and some others, including that of Turin (Bertolini's tables), accords with the above result. If the experience of these institutions can be taken as fairly representing asylums generally, we should infer the increased liability of man to Insanity between the ages of 20 and 30, or that during this period he is brought into contact with an increased number of the causes of Insanity; probably both. The admissions into many other asylums do not, how- * Dr Pliny Earle's valuable compendium of the medical statistics of the North- ampton Lunatic Hospital (Mass.) relative to the admission of 1074 patients (1873), As already stated in regard to American asylums generally, the liability to attack is shown to he greatest between 20 and 30 years of age. Then follow :-^30 — 40; 40—50; 50—60; 60—70; 10—20; 70—80. These calculations take into account the numbers living at these periods of life in the general population. 76 OF INSANITY IN GENERAL ever, exhibit a similar preponderance between 20 and 30, but between 30 and 40. And althougli it must be remembered that admissions do not necessarily agree with the periods of attack, and that, therefore, such preponderance in the latter decade might be true of admissions, and not of attacks, it would seem, from a table prepared by Dr Thurnam, exhibiting from various asylums in Britain the period of attack, that the larger number of cases of Insanity admitted into these institutions occurred between 30 and 40, not, as at the Retreat, Turin, and the asylums of America, between 20 and 30. Also, in these asylums more become insane between 40 and 50 than between 20 and 30. But it is probable that, while this may be true of pauper lunatics, there would, among the upper classes, be a larger proportion of attacks between 20 and 30 than 40 and 50. Be this, however, as it may. Insanity is more frequent in manhood and in middle life than subsequently from 50 and upwards. The order of fre- quency in decennial periods is, according to the above statistics, as follows :— 30— 40 (maximum), 40—50, 20—30, 50—60, 60—70, 10—20, 70—80, 80—90 (minimum). In the Report of the Poor Law Board for 1859-60 an attempt is made to determine the age at the time of attack of 13,672 lunatics chargeable to the Poor Rates, January, 1st, 1859, We have compared these returns with the numbers living at the same ages in the general population, and, with this correction, find the succession of decades to be as follows : — 30 — 40 (maximum) ; 40—50, 50—60, 20—30, 60—70, 70—80, 80—90, 10 — 20. We should suppose that in a large proportion of cases the age when the disorder first manifested itself was not accu- rately ascertained. Although, however, an imperfect return of this kind must have the eifect of post dating the age specially liable to attacks of Insanity, there is considerable agreement between it and the last given decennial series, and when males only are taken, the agreement is almost complete. The Roman ages of man, according to the division of Varro, were five in number, ending with 15, 30, 45, 60, 75 and upwards. The first may be made to comprise the risks to which the embryo, the suckling, the tooth-cutting child, and the youth arrived at puberty, are exposed ; it is the age of Idiocy and Imbecility, but none of the foregoing statistics exhibit congenital disease ; we have no account of the number of idiots annually born to com- pare with the total number of births. This fact must be borne in mind in regard to attacks of Insanity "under 15.'' The THE SEASONS AND CLIMATE 77 second age develops tlie passions of manhood, and adds marriage, external excitement, and the struggles of early manhood; the liability to Insanity is greatly increased, and, according to the statistics of some institutions, attains its maximum. The third epoch, ending with 45, witnesses the termination of the repro- ductive age of woman ; with man it is the period of hopes and disappointments, of greater strain and anxiety, but also of greatly augmented capacity and knowledge. Shall we say it is mane's age of civilisation ? It is, at any rate, that which statis- tics at present point to as the one during which, in Britain, a majority of persons appear to become insane. The fourth epoch, if in some respects one of still greater consolidation and matured wisdom, does not close without some indications of declining power; the tendency to Insanity is less. The fifth age succeeds man^s grand climacteric ; the liabilty to acute attacks of mental disease is still smaller ; but ere it termi- nates, man becomes subject to mental decay or second child- hood ; the " pitcher is broken at the fountain, and the wheel at the cistern.^^ The Seasons ; Climate. — M. Parchappe has supplied us with some carefully prepared statistics on this subject. Thus, he found that out of 2669 admissions, the period of the year was as follows : During the Six Summer Months. (March — August.) During the Six Winter Months. (September— rebruary.) Ko. Prop, in 100. No. Prop, in 100. Men . . . Women . . 779 668 56-0 52-3 612 610 44-0 47-7 Both Sexes . 1447 54-2 1222 45-8 This result — the greater frequency of attacks of Insanity, or at least admissions into asylums in the summer months — accords with the experience of Esquirol. It must again be borne in mind that admissions and attacks are not necessarily identical. Guislain observes that there is a relation between the warmth of the atmosphere and mental disturbance. A fall of tempe- rature, on the other hand, often calms the insane. MM. Aubanel and There observe, as the result of their investigations, that the 78 OF INSANITY IN GENERAL month of June appears (in France, at least) to have the most influence in producing Insanity, then July and August, next May and April, January having the least influence. Periodical In- sanity is especially manifested in the spi'ing. The question of the influence of climate would seem intimately connected with that of the seasons ; but, as Guislain observes, " we do not, as might have been expected, find more Insanity in hot climates than in cold/^ The statistics of Insanity in different countries are so unre- liable for purposes of comparison that it is idle to compare them. Again, even if a hot climate were a predisposing cause, the larger amount of alcohol taken in northern countries would probably neutralise it. [For information respecting the influence of seasons on suicide, see the section on Suicidal Insanity in this woi'k.] Moon. — Of the alleged influence of the luminary to which '' lunacy" and " moonstruck" owe their etymology, it is neces- sary to speak briefly. The operation of the stars, if not the moon, on disease, was recognised by Hippocrates, and that of the latter was certainly admitted by Galen. From ancient to modern times the idea gained rather than lost strength, and Milton expressed a real belief, not a mere poetical figure, in the lines — " Demoniac phrenzy, moping melancholy, And moonstruck madness." Rush believed that there was an equal amount of truth on the side of those who admit and those who deny the influence of the moon, and reconciled the two by supposing there to be a kind of sixth sense — a perception of the state of the air and of light and darkness, to which we are insensible in health, and that the full moon rarefies the air and increases the amount of light, and so acts upon the insane. He thought that probably few in asylums had the requisite predisposition or sensibility ; and hence observers overlooked the fact. Dr Rush notices, in connection with the observation that light in itself tends to excite, and darkness to calm many of the insane, that during the eclipse of the sun in 1806 "there was a sudden and total silence in all the cells of the hospital." His conclusion on the whole ques- tion was that the cases are few in which the insane feel the in- fluence of the moon, and that mere increase of light is sufficient to explain excitement in such cases {' Med. Enquiries,^ &c., p. 170). INFLUENCE OF THE MOON 79 Esquirolj who derived fiav'ia from ixrivri (moon)^ and connects it with the superstitious belief of the ancient idolaters in astro- logy^ observes, after quoting Daguin^s ' Philosophic de la Folie ' in favour of the influence of the moon, " Certain isolated facts and phenomena observed in many nervous diseases would seem to justify this opinion/^ but adds, " I have been unable to verifiy this influence, though I have been at some pains to assure myself of it. It is true that the insane are more agitated at the full moon as they are also at the early dawn of day ; but is it not the bright light of the moon that excites them, as that of day every morning ? Does not this brightness produce in their rooms an eifect of light which frightens one, rejoices another, and agitates all ? I am convinced of this last effect from causing the windows of certain insane persons who had been committed to my charge as " lunatics " to be carefully covered/-' He says nothing at the Salpetriere or the Becetre confirmed the idea. " Nevertheless,^^ he adds, " an opinion which has existed for ages — which has spread over all lands, and which is conse- crated by popular language — demands the most careful attention of observers" (^Maladies Mentales,^ tom. i, p. 29). Such attention may be said to have been given, and with negative results like those obtained by Leuret and Mitivie, who, in their work ' De la frequence du pouls chez les alienes,^ re- presented by engravings the phases of the moon and the daily pulsations of the insane, during a month in summer and one in winter. Rushes fellow-countryman, Dr S. B. Woodward, after a care- ful comparison of ninety cases of death with the phases of the moon, failed to find any relation between them, and says, " These facts and coincidences we leave for the present with the single remark that no theory seems to be supported by them, which has existed either among the ignorant, or the wise men who have been believers in the influence of the moon upon the insane.''^ From a Report of this asylum (1848) we find that the superin- tendent, Dr Hopkins, agrees with this opinion, and says, ^''Many patients are certainly more excitable and restless on pleasant moonlight nights than in dark and gloomy weather; but this would seem to be occasioned by the real or imaginary sight of objects in or without the building, such as men, trees, animals, &c., or the motion, perhaps, of the passing clouds.''' Observations were made at the York Lunatic Asylum by Dr Allen, the superintendent, about half a century ago, from which 80 OV INS.VNITY IN GENERAL he came to the conclusion that the influence of the moon on the 2')eriod of death was very decided, and he connected this with the increase of excitement occurring at the new and full moons. At the York Retreat Dr Thurnam, struck by these results, con- structed a table showing the age of the moon at the time of the occurrence of 139 deaths (1796 — 1840), a much larger number than those on which Dr Allen^s conclusions were based, and the result was that his observations received no confirmation what- ever; thus, while the York Asylum table shows 15 deaths at the new moon, 11 deaths at the full moon,* only 1 death at the first, and 3 deaths at the last quarter ; the Retreat shows for the corresponding periods 40, 33, 34, and 32 deaths. Taking Dr Woodward^s ninety cases already referred to, their relation to the same quarters was found to be 20, 21, 22, 27 respectively. So that neither at the Retreat nor at the Worcester Asylum (U.S.) was there any special morbid influence exerted at the new and full moon, compared with the first and last quarters, as appeared to be the case at the York Asylum from insufficient data.f (See Allen^s 'Cases of Insanity,^ pp. 76 — 104; 'Annual Report of the Worcester Asylum, 1841,^ and ' The Statistics of the Retreat,' pp. 113 — 117. Mead, ' De imperio solis et lunre in corpore humana et morbis ;' Orton, ' On Cholera.' Laycock, 'Lancet,' 1842-3, 'On Lunar Influence;' Arago, 'Meteorological Essays.' Dr Lardner, ' On Lunar Influence;' Winslow, 'Psych. Journal,' 1856). Occupation, Town and Country Life, 8fc. — Dr Prichard states that " a most remarkable difference is found in the proportional number of lunatics in agricultural and in manufacturing districts. Previous to inquiry, we should conjecture that the causes of In- sanity would have more influence, and the disease be more pre- valent, in a manufacturing than in an agricultural population ; but the contrary is the fact" ('Treatise,' &c., p. 334). Dr Parchappe arrived at the conclusion that, so far as regards the population of the Lower Seine, the country people are less affected with Insanity than the town people. " We may legiti- mately conclude," he says, " from the facts collected at the asylum at Rouen, that the circumstances which surround the * Mr. Liike Howard found that the barometer is afEected by the changes of the moon, being lower with the new and full moon and higher at the first and last quarters. This receives general confirmation from the Falmouth Observatory. f It will be observed that whatever evidence has been adduced of fluctuations iu the excitement of the insane in connection with the moon, none whatever is alleged to exist as a cause of lunacy. TOWN AiSCD COUNTRY LIFE 81 inhabitants of tlie gi'eat centres of population in the Lower Seine^ constitute for them a predisposing cause of mental alie- nation/^ (' Notice Statistique sur les Alienes de la Seine Inferieure/ p. 30.) The large experience of Dr Gruislain led him to the same result. Further, the excellent French ' Lunacy Reports ' of M. Behic show that, as regards the whole of France, the amount of Insanity among the ^^professions agricoles" is very low, while it is high in the '' professions liberales." It seems that the French peasant is much more favorably situated than the English agricultural labourer. It is fully admitted that if in England and Wales we take the proportion of pauper lunatics to the population (not to paupers) in each county, there are more in the agricultural than in the manufacturing counties (see Table II, p. 86) ; for example, Lan- caster and the West Riding of Yorkshire are below the average of England and Wales, and Dorset and Wilts above the average ; Hereford being highest of all. There are exceptions as regards a county here and there, but the statement is true of groups. The figures supporting this statement are of interest, and we do not ignore them, although they are, to some extent, open to objection as evidence of the fact in favour of which they are adduced. On the other hand, in the Reports of the Scotch Commissioners, and especially in that for 1875, it is shown that while three Highland counties (Argyll, Perth, and Inver- ness) have, in propoi^tion to the population, a decidedly heavier persistent burden, as regards pauper lunacy, than two manu- facturing counties (Renfrew and Lanark) have, the number of lunatics receiving relief — actually coming under treatment — is proportionally larger in the latter than the former, i.e. a higher proportion of fresh cases of pauper lunacy appears on the poor-roll in urban than in rural districts, the alleged reasons being (1) the greater number of transitory forms of Insanity in towns ; (2) the more easily obtained admission and accommodation. In the country, the persistent lunacy is ascribed to (1) the migration of the robust to the towns ; (2) the emigration* of many of the mentally and physically * Dr Thurnam also, in his Annual Report, 1870, says, speaking of Wilts, that during 1851-61 there was a very considerable exodus of the labouring population. As it would, as a rule, be the more healthy and energetic men who would leave their homes, there would result an increase in the relative proportion of the bodily and mentally weak, and the effect could hardly be other than that of filling the union 6 82 OF INSANITY IN GENERAL healthy^ so leaving a disproportionate number of weak-minded behind. In the Report, a table prepared by Dr Sibbald shows that, while at the end of the year 1872 there were 177 lunatics per 100,000 in the principal towns, this ratio being less than in the small towns and rural districts, the occurring Insanity was in the principal towns 80 per cent, more than in the rural districts and small towns. This is a remarkable illustration of the fallacy of drawing conclusions from existing instead of occur- ring lunacy, and shows how the foregoing statistics in England and Wales, in regard to urban and rural Insanity, may be found to admit of a different interpretation from that which they appear to bear, when the English Commissioners work out the subject in the same way as has been done in Scotland. The opinion of Dr Sibbald may then, it is not unlikely, be confirmed — that ''a, much larger number of persons become pauper lunatics in the principal towns than has generally been supposed,^^ and also that " cases of general paralysis and other rapidly fatal diseases of the nervous system are more frequent in town than country, and it is probable that attacks of Insanity, swift in their onset and swift in their retreat, are also more common.^' With regard to ijarticular occupations, it is much to be regretted that any inferences should be drawn from the abso- iute number of patients following them, instead of from the proportion to the numbers in the population at large. Thus, if we take the number of clergymen and lawyers admitted at Bethlem Hospital during a certain period, we find them equal ; and the inference might be drawn that they are equally liable to mental disease. But a calculation of the proportion to the numbers in the general population enables us to show the fallacy of such a conclusion. From this, it appears that lawyers are about doubly liable (as might have been anticipated) to this disorder. In the first edition of this work we gave a table showing the relative proportion of the insane to the sane in the various callings and occupations ; the number of insane labourers, professional men, &c., in every 1000 sane. While this is clearly the only satisfactory way of arriving at sound con- clusions as to the influence of occupations on the mind, we con- clude to omit these statistics, on account of the imperfection of the returns of the occupations of insane persons in the Census. We must be content to wait until we have more correct statis- bouses and indirectly augmenting the proportion, perhaps even the numbers, of the PARTICULAR OCCUPATIONS 83 tics within our reachj showing the relation between occupation and Insanity. So we wrote in the last edition of this work. The Commissioners in Lunacy have since inserted, for the first time, in their Eeport (1877), tables of the occupation of the patients admitted into asylums in England and Wales during the year. The largest proportion occurs among ^^ persons engaged in the defence of the country;" the next in order, among *' persons who buy or sell, keep or lend money, houses," &c. (merchants, bankers, travellers, costermongers, and so forth) ; the third, among "persons of rank or property not engaged in any office or occupation ;" the fourth, among " the learned pro- fessions, or in literature, art and science ;" fifth, among '^persons engaged in entertaining and performing personal offices for man" (innkeepers, domestic servants, &c.) ; the sixth, " persons engaged in the conveyance of men, animals, goods, and mes- sages ;" the seventh, among " farmers, agricultural labourers, horse proprietors, fishermen," &c. ; the eighth, among "persons engaged in art and mechanical productions j" the ninth, " among persons working and dealing in food and drinks, and in animal and vegetable substances" (not beersellers) . Omitting some other classes, " scholars, children, and others of no occupation " are found at the bottom of the scale. It is to be regretted that some of the classes are so comprehensive as to include occu- pations having nothing in common, as farmers and fishermen, clergymen and actors ; bankei's and costermongers ; wives of publicans and wives of shoemakers ; so that it is impossible to determine the influence of some particular trade which it would be particularly interesting to ascertain. The statistics pre- pared by Dr Pliny Earle, referred to at page 75, bear on this subject. He says, in reference to the large number of farmers who appear from his tables to be insane, " Let us not hastily infer that, of all classes, farmers are the most subject to mental disorders. Nothing could be more erroneous. In the four counties from which the hospital chiefly derives its inmates, agriculturists are overwhelmingly more numerous than any other section of the population. So far as mere employment is concerned, as a generative cause of Insanity, the farmer is unquestionably less liable to that disorder than perhaps any other person. He is in a sphere more nearly natural than the artisans, the mechanics, and the professional men — persons of a civilisation abounding with artificial conditions and influences." Givllisatioii. — Instead of entering fully as in early editions 84 OF INSANITY IN GENERAL into tlie consideration of the influence of civilisation as a cause of Insanity, we shall give the conclusions at which we arrived and to which we adhere : 1. That, while the greater facilities which exist in civilised countries for obtaining a knowledge of the number of the insane, and the greater degree in which the disease is recognised, render any just comparison very difficult, and tend to show a much larger proportion than is actually the case, there can be little doubt, nevertheless, after making due allowance for this source of error, that Insanity attains its maximum development among civilised nations, remaining at a minimum among barbarous nations. 2. That, having regard to the main causes of Insanity, there can be no reasonable doubt that, in modern civilised society, these outweigh the circumstances which might be supposed to favour mental health ; these unfavorable causes being princi- pally, the increased susceptibility of the emotions to slight impressions — the abuse of stimulants — the overwork to which the brain is subjected, especially in early life, by an over- wrought system of education — and that condition of the lower classes which is a constant attendant upon civilisation — the higher emotions or moral sentiments, the lower propensities, and the intellectual faculties, being thus all subjected, sepa- rately or combined, to an amount of excitement unknown to savage tribes. 3. That, inasmuch as all civilisation is, up to the present time, to be regarded as imperfect and transitionary, it does not neces- sarily follow from the foregoing, that civilisation carried out to its perfect development — a civilisation which should exactly temper the force of the emotions, moderate intellectual exertion, and banish intemperance — would generate mental disease.* If these conclusions be correct, and if, as statistics indicate, there is more insanity among the poor than the rich, we may say that — Two great facts come out of this inquiry which appear at first sight to be contradictory, but which on examination are not in the least so, and are entirely consistent with the principles which * Dr Earle, in tl.e Report already made use of, speaking of those results of modern civilisation which are injurious, says, " Where these effects will end no prophet now can tell. But unless the race adapts itself more consistently and wisely to the change of circumstances, the prospect is anything but cheering to him who would wish to see a diminution, rather than an augmentation, of mental disorders." CIVILISATIOX 85 medical psYcliologv teaches. The one is that the liability to Insanity is infinitely less among savages than among civilised nations ; lesSj for example among the Xorth American Indians than the French or English ; and less^ it may be added, among a people presenting a peculiar and stationary form of civilisation like the Chinese than among Europeans. The other fact is this : that the liability to Insanity among the lowest — the most ignorant and degraded — class of a civilised people is greater than among the higher and educated classes. The mistake has been made of regarding as identical the condition of the savage and the English pauper, simply because both are ignorant. But here the similarity ceases ; when, therefore, we are told that Insanity is a disease, not of civilisation, but of ignorance, the truth of the statement cannot be admitted, if the speaker is comparing civilisation and barbarism — the intellectual and civilised man with the ig-norant savage. It is onlv true when by the terms employed it is intended to convey the idea that in a nation presenting the complex conditions of modern civilisation, the ignorant and degraded will supply a larger proportion of cases of Insanity than the more sober and better educated, not because they are ignorant, but because they are degraded. The confusion of terms now referred to is well illustrated by the common expression we employ in speaking of our '' City Arabs, ^^ who differ from their prototypes in all important particulars in reference to the characteristics of barbarism and civilisation. The increased liability to Insanity of a civilised over an uncivil- ised nation arises, then, from two very opposite causes. Both, however, have undoubtedly hitherto been (and probably always will be) the concomitants of what every one understands as civilisation. On the one hand, then, we have that severe — we might say desperate — intellectual and emotional strain which we afiirm develops more Insanity than the opposite condition pre- sented by the wild barbarian ; and on the other hand, at the opposite end of the social scale, we have to contend with that accompaniment, if not product (however debased), of modern civilisation, an impoverished class with brains ill-nourished and yet frenzied by drink — exposed, in consequence, to the risk of madness — and if fortunate enough to escape themselves, certain in a large number of instances to sow the seeds of Imbecility or Insanity in their children. In short, if they, having no predis- position to Insanity, do not go mad, they generate an insane diathesis in the offspring. In such a conclusion there is nothing 86 OF INSANITY IN GENERAL to damp the energies of tlie educator. The practical deduction from these propositions is that, while we should advise a nation of savages to remain as they are (having regard simply to the liability to mental disorder), even if by changing their condition they should attain to the state of the higher classes of a civilised nation, we should as strongly and quite consistently advise the savages in a civilised community to change their condition and join the ranks of the well-nourished, well-educated, well-trained, and sober classes. Pauperism. — The relation between poverty and Insanity may be further illustrated by the following tables. Table I, showing proportion oj paupers to tJw population in the counties of England and Wales, on July 1st, 1871, calculated on the Census of 1871, and the Poor Law Returns of 1871. County. Gloucester Hunts County. Proportion Lancaster . . . . 1 to 38 Derby . . . • „ 36 York, West Riding . „ 35 Chester . . . . „ 34 York, East Riding „ 34 Westmoreland . „ 34 Warwick . „ 32 Durham „ 30 York, North Riding . » 29 Salop „ 29 Cumberland „ 27 Stafford » 27 Worcester . „ 26 Nottingham „ 26 Middlesex . „ 25 Northumberland ,, 24 Leicester . „ 24 Surrey . „ 24 Kent .... » 22 Lincoln . „ 21 Cornwall . • „ 20 Monmouth . » 20 Rutland Sussex Berks South Wales Devon Hereford Hants Northampton Oxford Herts Somerset Suffolk Beds . Cambridge Bucks Essex North Wales Norfolk Wilts Dorset Proportion 1 tol9 » 19 » 10 „ 19 „ 19 „ 18 „ 18 „ 18 » 18 » 17 ,. 17 » 16 „ 16 „ 16 „ 16 ., 16 „ 16 „ 16 „ 15 „ 15 „ 14 » 14 Table II, showing the proportion of pauper lunatics to the popu- lation of the counties of England and Wales, calculated on the Census of 1871, and the Ltmacy Report of 1872. County. Proportion. +Durham . . . . 1 to 775 JYork, West Riding . . „ 663 JStafibrd . . . . „ 649 County. Proportion. Cornwall. . . . „ 633 tChester . . . . „ 538 JDerby . . . . „ 529 PAUPERISM AND INSANITY 87 County. Proportion. County. Proportion fWestmoreland . 1 to 517 ^^Northampton . . 1 to 398 •f York, North Riding „ 514 fSomerset . . „ 395 t „ East Riding . „ 495 fSussex . „ 394 fLincoln .... „ 495 tSuffolk . . „ 394 JLancashire „ 493 Monmouth . „ 392 fNorthumberland „ 493 fHauts . „ 389 fCumberland „ 484 Salop . „ 382 South Wales . „ 466 fDorset . „ 381 ^Nottingham „ 463 tNorfolk . . „ 375 fKent .... „ 444 fHerts . „ 361 tCambridge „ 442 fBucks . „ 354 fHunts .... „ 433 fBerks . „ 332 North Wales . „ 429 Middlesex . „ 328 fEssex .... „ 424 ^Leicester . . „ 323 Devon .... » 417 JGloucester . „ 323 JWarwick „ 407 fWilts . „ 319 tBeds .... „ 404 Oxford . . „ 318 tRutland .... » 403 fWorcester , „ 304 fSurrey .... „ 399 fHereford . „ 295 t These counties ar e mainly agricultural. J Mainly manufacturing. Table III, showing ti he proportio n of pauper lunatics to paupers in the counties of England and Wales, calculated 071 the Poor Law Returns of '. 871. County. Proportion. County. Proportion Cornwall . . 1 to 31 Kent . 1 to 20 Cambridge . » 28 Northumberland . „ 20 North Wales • „ 28 Monmouth . „ 20 Essex . „ 27 Oxford . „ 19 Dorset . „ 27 York, WestRiding. . » 19 Durham . . „ 26 „ North Riding . „ 18 Beds . . „ 26 Berks . » 18 South Wales . » 26 Cumberland . » 18 Norfolk . „ 25 Notts • „ 18 Suffolk . . „ 25 Gloucester . „ 17 Somerset . . „ 25 Surrey . >, 17 Northampton . „ 24 Hereford . . „ 16 Stafford . . „ 24 Chester . „ 16 Lincoln . „ 24 York, East Riding • „ 15 Wilts . „ 23 Westmoreland . . „ 15 Devon . „ 23 Derby . » 15 Hunts . „ 23 Leicester . • » 14 Bucks . „ 22 Salop . „ 13 Herts . „ 22 Warwick . • . „ 13 Rutland . • „ 21 Middlesex . . „ 13 Hants . „ 21 Lancaster . . » 13 Sussex . „ 21 Worcester . . „ 12* * The reader will find much valuable information in an article by Dr Clouston in 88 OF INSANITY IN GENERAL Marriage. — M. Parchappe analysed the condition, with regard to marriage, of 17,932 patients, in various asylums, and calcu- lated that 49 per cent, were single, while 40 per cent, were mar- ried. Eleven per cent, were widowed. Very similar relative results (taking both sexes) are obtained when the admitted civil condition of the patients during a certain number of years at the Bicetre and Salpetriere is compared with the corresponding civil condition of the population in Paris. The experience of the Retreat has shown that, of the patients therein admitted, a large majority had never been married, namely, two thirds. It appears from Dr Xeedham^s Report for 1872, which contains some carefully prepared statistics, that at the York Asylum, during the last twenty-seven years, of 1029 ad- missions, 476 were single, 443 married. Male admissions num- bered 603, of whom 278 were single, 257 married, and 68 widowed. Female admissions 426, of whom 198 were single, 186 married, and 42 widowed. We find that out of 1426 patients admitted into Colney Hatch Asylum during four years, their condition, with regard to marriage, was as follows : Unmarried. Married. Widowed. 645, or 45-23 per cent. . 6iZ, or 45 09 per cent. . 13S, or 9-68 per cent. Now it appears, from the Census of 1871, that the condition of the population of England and Wales, aged twenty and upwards, was, in respect of marriage, as follows : Uumarried. Married Widowed. Males 27"12 per cent. . . . 66*09 per cent. . . . 6'79 per cent. Females 25-85 „ ... 60-55 „ ... 13-60 „ Total 26-45 „ ... 63-19 „ ... 10-36 If, then, the preceding tables be compared, and the number of admissions under the three divisions in regard to marriage be compared with the numbers living in the population at large under the same divisions, it will be found that, although there are more than twice as many married as unmarried persons in England and Wales, there is a slight excess of the latter over the former in Colney Hatch Asylum. By a similar calculation we find the proportion stiU larger in the Wilts County Asylum. So that not only was there a greater absolute number of patients admitted into Colney Hatch Asylum (even after exclud- the ' Journal of Medical Science,' April, 1873, entitled " On the Local Distribution of Insanifv, and its varieties in Eucrlaud and Wales." MARRIAGE 89 ing the idiotic) who have never been married^ but also a greater number relatively to the persons unmarried in England and Wales. Of course, in this calculation it is assumed that the conjugal condition of the locality from which patients are sent to Colney Hatch is not very different from that furnished by the . Census of the general population. It is proper to state that the inference drawn from the last and similar tables is somewhat qualified by the fact that the proportion of married persons between 25 and 40 (so important a period in regard to admissions) is less than in the adult popu- lation, i.e. from 20 and upwards. The reader will see this from the following statement of the proportions of the married and unmarried in England and Wales in 1871, between the ages of 25 and 40. Unmarried. Married. Widowed. Males 26'85 per cent. ... 71'15 per cent. ... 2'00 per cent. Females 25-86 „ 70-14 „ 400 Total 26-33 „ 70-62 „ 3-05 MM. Aubanal and Thore ascertained the condition of 8603 patients in various asylums on the Continent and in America as follows : — Unmarried, 4395 ; married, 2908 ; widowed, 401 ; unknown, 899.* They support M. Parchappe, and say "it is evident that celibacy predisposes to Insanity.''^ It must not, however, be overloked, that one reason why Celibacy and Insanity are so often connected is, that the mental peculiarities of patients, when exhibited in years previous to their admission, have prevented marriage. It should also be remembered that in some instances, unmarried persons becoming insane would be removed to an asylum and increase the official returns of lunacy, whereas, if married, they might have been cared for in their own homes. We should certainly make a con- siderable deduction for these circumstances, but we should still have no doubt that, given a certain number of celibates and of married men, with the same mental proclivities, there would be more likelihood of Insanity occurring in the former class ; in other words celibacy constitutes a predisposing cause. In concluding the consideration of the predisposing causes of * Dr Earle's tables show a closer approximation between the married and sino-le in both sexes. With regard to the influence of widowhood, he concludes that " the grief, the anxiety, the care, and the labour consequent upon the loss of a spouse, operate much more effectively among women than among men as producers of Insanity." 90 or INSANITY IN GENEEAL Insanity, we may add, for the information of the reader, that under this head, the International Congress in 1867 decided to include hereditary influence, pure consanguinity, great difference of age between parents, influence of soil, of surroundings ; con- vulsions or emotions of the mother during gestation ; epilepsy ; other nervous affections; pregnancy; lactation; menstrual period; critical age ; puberty ; intemperance (habitual excess, dating far back) ; venereal excess and onanism. It will be seen that we have not ourselves adopted the same arrangement. Exciting Causes. The exciting or determining causes of Insanity may be divided into moral and physical. Arbitrary as this division often proves, we shall not reject it. The predisposing are mainly physical ; but the exciting are to a large extent, moral. Lucas emphatically denies the propriety of regarding one pre- disposing cause, hereditary predisposition, as altogether physical. It is with him "only a transmission and reflection in the descen- dants, of tivo orders of causes, and in each order, of all the species of the causes producing Insanity with the progenitors. It is the expression, the organic incarnation, of all the originating causes of the malady in the descendants, independently of the forms which it assumes, and of the nature of the affections or commotions which have determined it in the ancestors. ^^ It is with him neutral ; " being the representative of all causes, it is the exclusive privilege of none." It is both moral and physical. With the object of gaining information on the causes of Insanity in general, we have analysed the returns of a large number of asylums, English, American, and Continental. The total number of cases in which the cause was ascertained, after excluding hereditary predisposition, congenital condition, and old age, amounted to 30,087. On the whole, we have found a very marked agreement between the results of the various asylums, the statistics of which we have consulted. In this analysis we have been obliged to follow the causes tabulated by the Superintendent of Asylum Reports, but there are obvious objections to several of them, such as " Affections of head and spine," " Epilepsy." Our calculations have been made upon the total number admitted. OEDER OF FEEQUBNCY OF CAUSES 91 Firsts we find that among pliysical causes the following was their order of frequency : Intemperance. Epilepsy. Affections of Head and Spine. / Menstruation, \ Pregnancy, Uterine Disorders, viz. those of i „ . ... ' J Partnrition, V^ Lactation. Sexual Vice. Fever and Febrile Diseases. Secondly, as regards moral causes, their order was as follows : Domestic Troubles and Grief. Religious Anxiety and Excitement. Disappointed Affections. Fear and Fright. Intense Study. Political and other Excitement (Joy, &c.). Wounded Feelings. Or, without reference to the division into physical and moral: ■ — Domestic Troubles and Domestic Grief ; Intemperance ; Epi- lepsy ; Aifections of Head and Spine ; Uterine Disorders ; Religious Anxiety and Excitement ; Disappointed Affections ; Sexual Yice ; Fever and Febrile Diseases ; Fear and Fright ; Intense Study ; Political and other Excitement ; Wounded Feelings. Recently the Commissioners in Lunacy Iiave been able, by constructing a schedule of their own and obtaining returns from the superintendents of asylums, to present results in a better arranged form. They comprise 14,152 admissions. We observe that in their schedule, given in the Report of 1877, they enu- merate '' Epilepsy" and '' other forms of brain disease ;" but that, in a more recent list of causes which has been issued, these are omitted. Percentages are calculated upon the total number of admissions, not on cases in which the cause was known. From the classification of causes being different in the above table, and that prepared by the Commissioners, we are unable to compare them in all particulars, but it is satisfactory to find that they are in accord in regard to the most prevalent physical and the most prevalent moral cause of Insanity. In both, " Intemperance" (14*9 per cent.) is at the head in the former, and " Domestic Troubles and Grief" (6"3) in the latter. That 92 OF INSANITY IN GENERAL independent inquiries should lead to the same result shows that, amid much that is uncertain in the Statistics of Insanity, there is a certain amount of reliability and uniformity. Next in order, in the list of moral causes, are Mental Anxiety : Worry ^5*3) ; Adverse Circumstances (4-8) ; Religious Excite- ment (3-0); Love Affairs (1"7); Fright and Nervous Shock (r3). On the physical side are. Hereditary, with other ascer- tained cause in combination (9 '9) ; other bodily disorders, including old age (7-8) ; Epilepsy (6-5) ; Hereditary only (5-7) ; Congenital (3*7) ; Puerperal (3-3); other forms of brain disease, not General Paralysis (3'2) ; Accident or Injury (2'8) ; Puberty and Change of Life (2-4) ; Overwork (2-0) ; Congenital, with other causes, (1-7) ; Self-Abuse (1-5) ; Uterine Disorders (1-4) ; Sunstroke (M) ; Fevers (I'O). The heads of the new Schedule are as follows : MoEAL Causes. Domestic Trouble (including loss of relatives and friends). Adverse Circumstances (iucluding business anxieties and pecuniary difficulties). Mental Anxiety and " Worry " and Overwork. Religious Excitement. Love affairs (including Seduction). Frigbt and Nervous Shock. Physical Causes. Intemperance, in drink. „ sexual. Venereal Disease. Self-abuse (Sexual). Over-exertion. Sunstroke. Accident or Injury. Pregnancy. Parturition and the Puerperal State. Lactation. Uterine and Ovarian Disorders. Puberty. Change of Life. Fevers. Privation and Starvation. Old Age. Other Bodily Diseases or Disorders. Previous Attacks. Hereditary Influence ascertained. Congenital Defect ascertained. Other ascertained causes. The last ' Rapport sur le Service des Alienes du Departe- ment de la Seine' (issued 1877) gives the principal causes in the total admissions (2068), viz. — Physical. — Intemperance 577 (27*4 per cent.); Age 203; Affections of the Nervous System 115; Congenital 95; Other Diseases 71 ; Female Diseases 64 ; Epilepsy 59 ; Privation and Want 26. ifora/.— Domestic Grief 72 (3*4) ; Fright and INTEMPEEANOS 93 Nervous Stiock 36 ; Eeligious Excitement 20 ; Adverse Circum- stances 13; Loss of Eelatives or Friends 12; Jealousy 10; Political Events 8 ; Love Affairs 7. In 132 instances the father or mother of the patient was ascertained to have been insane. Of the main exciting causes of Insanity, we must speak more in detail. With regard to Intemperance, Lord Shaftesbury, in his evidence before the Select Committee on Lunatics, in 1859, expresses his opinion that 50 per cent, of the cases admitted into English asylums are due to drink, and cites Esquirol in support of this statement. It is more than doubtful, however, whether Esquirol possessed any statistics which would have borne him out in this assertion ; for although intemperance stands first in the above list, we do not find that, when calcu- lated upon the admissions, it exceeds, in most asylums, 12 per cent. Calculated upon the cases in which the cause was ascer- tained, the percentage is, of course, higher. Thus, from the Report of the Commissioners in Lunacy in 1844, it appears that of 9867 cases in which the cause was ascertained, 1792, or upwards of 18 per cent., were due to this cause. During 30 years the ratio per cent., according to Skae, was 11^ (males 16) at Morningside ; while the figure reaches 19 per cent, in the Report of the Scotch Commissioners, 1871. It will readily be admitted, however, that these figures fall far short of presenting a true picture of the complex influence of intemperance in induc- ing insanity, directly or indirectly. Those superintendents of asylums who estimate intemperance at 25 per cent, or higher, no doubt include those cases in which drink has not only been the proximate, but also the remote cause of the disorder. This estimate is greatly increased when we take into account the large number of cases in which the intemperance of parents causes the Insanity or Idiocy of their offspring. Again, calcu- lated on males only, the proportion of admissions from drink would be much higher. Thus, at the York Lunatic Asylum Dr Needham^s statistics show a proportion of 16 per cent, for both sexes on the total number admitted (1029), and for men 22 per cent. Dr Clouston gives for the cases admitted from Cumberland and Westmoreland, 16"15 for both sexes, 22*50 for men. Again, Dr Kirkbride, in his Report for 1871, says that, of 3599 patients admitted into the establishment in 31 years, about whom he was able to obtain information, 13 '42 per cent. (22"52 males, 2*39 females) had become insane through drink. Lee (1868) states that of 14,941 patients treated in 16 American 94 OF INSANETY IN GENERAL asylums, 11 '97 pei' cent, were due to this cause. Earle's sta- tistics for tlie Northampton Asylum show a proportion of 12 per cent, on the total number admitted of both sexes^ and for men 20 per cent. Tobacco* and opium must be added to alcohol as causing Insanity, though to a much less extent ; also lead. See case in ^Journal of Mental Science/ July, 1872. Insanity is not very unfrequently referred, in our Asylum Reports, to the use of mercury. We may refer a little more in detail to the effects of different kinds of intoxicating liquors. It is well known that absinthe and the substitution of strong for light wines have been most injurious in France. M. Morel assured the writer, a few years ago, that in those districts where the ordinary wine of the country is the only form of intoxicating drink in use, few persons become insane from intem- perance, but that directly you come to the towns, you witness the large amount of Insanity caused by spirits, and in Paris, Rouen, &c., by absinthe. Further, in many country districts strong liquors are being increasingly consumed, and with a proportionate amount of Alcoholic Insanity. Dr Decaisne has written an article in the ' Gazette des Hopitaux' (1869) on the effects of absinthe upon the nervous system, in which he repeats what he had fifteen years before maintained, that absinthe in the same dose and strength as alcohol, or eau de vie, has the most disastrous influence on the economy, and produces intoxi- cation much more rapidly. Dr Magnan has also written a memoir on the ' Experimental and Clinical Investigation of Alco- holism,' of which an abstract will be found in the 'Journal of Mental Science,' July, 1872, in which he enters in detail upon the peculiarly baneful influence of absinthe. The question of the influence of various forms of intoxicating drinks has been most carefully investigated by M. Lunier, and the results of his inquiries are published in the * Annales Medico-psychologiques' for 1872. His main conclusions may be thus stated : 1. Spirituous liquors, and especially those manufactured with spirit derived from beetroot and grain, tend in all parts of France to take the place of the natural drinks, wine and cider. 2. While the consumption of alcohol has nearly doubled * See " L' Absinthe et Tabac," par M. Jully (' bulletins de TAcademie de Medeciiie de Paris,' 1871). INTEMPERANCE 95 between 1849 and 1869^ the cases of Insanity from intemperance have risen 69 per cent, with men, and 52 per cent, with women. The progressive increase in the consumption per head of alcohol (strength 90° to 92°) was as follows: 1831 1-09 lit.* 1861 2-23 lit. 1841 1-49 „ 1866 2-53 „ 1851 1-74 „ 1869 2-54 „ The proportion of cases of Insanity caused by drink, rose in like manner : 1838 Men. Women. Both sexes. 7-64 1841 7-83 1856-8 14-30 3-09 8-89 1864 14-78 3-37 10-22 1867-9 22-82 4-71 14-78 3. In those departments which do not cultivate either wine or cider, but produce alcohol, and where the annual consumption has increased, in twenty years, from 3'46 lit. to 5'88 lit. per head. Insanity from this cause has risen from 9*72 to 22'3l per cent, with men, and from 2*77 to 4*14 with women. 4. In those which produce neither wine nor alcohol, but culti- vate cider, and where the consumption of alcohol, which was only 2 "43 lit. in 1847, is now 4*08 lit., the proportion of cases of Alcoholic Insanity attains 28*53 per cent, for men, and 9' 18 for women. M. Lunier says that the alcohol from cider is more per- nicious than that from beetroot or grain, and that in the Department of Calvados, where the largest proportion of cases of Alcoholic Insanity exists (56 per cent, men, 10 per cent, women), a great deal of alcohol from cider is produced and consumed. The relative frequency of Alcoholic Insanity among women, who previously were almost exempt from it, has in- creased fearfully. In Brittany and Normandy, he says, excess in drinking alcohol has become nearly as common with women as men. 5. In the departments which cultivate neither wine nor cider nor alcohol, and where the consumption has increased from 1"49 lit. to 2"69 lit.. Insanity from alcohol has risen from 7"37 to 10"25 per cent. 6. In those departments which both cultivate wine and manu- facture spirits of wine, but where the consumption, which was * A litie equals 341 fluid ounces (Eng.). 96 or INSANITY IN GENERAL 0-53 lit. in 18 i9 is now not more than 1 lit. per head, Alcoholic Insanity has only increased from 7'63 to ir40_, and is compara- tively rare among women. In the Somme, where but little alcohol is drunk, and scarcely so much in 1869 as in 1849, the number of cases of Insanity from drink has remained almost stationary among the men and quite so among the women. 7. In some departments, where the people drink relatively much white wine very slightly alcoholised and little spirit, as in the Vendee, Loire-Inferieure, Cote d'Or, Alcoholic Insanity appears to be as common as in those in which they mainly consume alcohol ; but in the former, conti'ary to what happens in the others, the cases of Insanity from drink are relatively very rare among females. M. Lunier attributes the fact that these white wines are almost as pernicious as spirit manufactured from beetroot or grain, to their containing but little tannin. He says that every- thing induces him to conclude that other natural wines, particu- larly the red wines which have not been sur-alcooUses, rarely determine chronic alcoholism. 8. The increase in the number of suicides has everywhere in France followed the increased consumption of alcohol. 9. As regards the relative effects of heer and spirit, it is noteworthy that in the north, where the consumption per head of alcohol has nearly doubled in twenty years (1849 to 1869), the cases of Insanity from alcohol have quadrupled among the men, while among the women, who drink a great deal of beer and little alcohol, the cases of Insanity from drink remain the same. It appears from the foregoing that the pernicious influence of intoxicating drinks as regards Insanity is in the following order : — alcohol from cider, alcohol from beetroot and grain, cider, wine, beer, the white wines referred to being much more in- jurious than red. We have already spoken of the influence exerted by drunken parents upon their offspring. M. Lunier estimates at 50 per cent, at least, in the great cities, the idiots and imbeciles whose parents were notoi-iously drunkards. In the majority of cases " children born of parents when drunk or who were constitutionally drunkards" are, he considers, weak in some way or other. Of the remarkable influence of alcohol in Paris in ijiducing Insanity during the late war, M. Lunier gives abundant proof in UTERINE DISOEDER, ETC. 97 the article referred to. During May^ ]87lj 55 per cent, of the admissions were due to this cause. We calculate that Ejiilepsy is the cause* in about 6 per cent. of the patients admitted into asylums. It is scarcely necessary to observe that it must never be regarded as a cause of In- sanity^ except when it manifestly precedes the mental affection. True epilepsy, however, is very rarely secondary. In the York Asylum tables, of 1029 admissions (causes ascertained in 864 cases) 23 were referred to epilepsy. In the Northampton (U.S.) tables, of 1074 admissions (causes ascertained in 687 cases) 62 were ascribed to this cause. Affections of the Head and Spine include their injury from external causes, apoplexy and paralysis, sunstroke and disease of the brain. In any large asylum the number admitted in the course of a single year, in consequence of apoplectic and para- lytic attacks, is considerable. Thus in 1852, of 1353 admissions into the Bicetre and Salpetriere we observe that 27 were attri- buted to apoplexy and 31 to paralysis, being a proportion for both together of about 4 per cent. In the same year 11 were admitted insane from external injuries, such as blows on the head, &c. Our total calculation under " Affections of the Head and Spine^^ gives a proportion of 6 per cent. Earless recent tables show that of 1074 admissions at the Northampton Lunatic Hospital, 10 were due to injury to the head, 4 to sunstroke and 14 to apoplexy and paralysis. In the York Asylum tables, of 1029 admissions (causes ascertained in 864 cases) 7 are referred to " head-stroke,^^ 25 to ^'injury to head.^^ The relation of Uterine Disorder to Insanity is frequently very difficult to determine. Although, however, often only an early symptom of the disease when set down as a cause, there remain a large number of cases in which suppressed or irregular menstruation is the true cause of the attack. The effect of the natural cessation of the catamenia at the critical age, proves the great importance of the suspension of the menstrual discharge, as a cause, as well as a symptom of Insanity. Pregnancy, child- bearing, and lactation, in their relation to attacks of mental * It must be understood that we speak in this section of causes in accordance with the usual custom of regarding epilepsy, &c., merely as such, and not as parts of the disease or disorder of the nervous system, of which insane manifestations are addi- tional symptoms in the progress of the malady. We shall regard them in the latter light when we approach the forms of mental disorder from this, the somato-ffitiological point of view. The two are, however, so closely connected, that this section should be read in connection with the subsequent chapter referred to. 7 98 OF INSANITY IN GENERAL disorder, will be considered in a future chapter. TLe propor- tion of admissions from uterine disorders appears to be about 5, or taking female admissions only, 10 per cent. Among asylums for tbe opulent classes exclusively, the ascertained proportion would be higher ; the real proportion higher still, among both poor and rich. To estimate with anything like accuracy the relation which Sexual Vice bears to Insanity, requires considerable discri- mination. In Dr Earle's recent tables of the Northampton State Lunatic Hospital, it appears that out of the male admissions (572) 19 were attributed to masturbation. In those of the York Asylum prepared by Dr Needham, out of 603 male admissions this cause is set down at 15. Eeliable facts are of course most difficult to obtain, and such figures reveal little of the real truth — the extensive mental mischief done — of which there can be no doubt whatever. In regard to other diseases than those already mentioned, one of the most important is Fever and febrile disorders, which appear to cause 2 or 3 per cent, of admissions. We believe it would be found, that Insanity more frequently follows con- tinued fever, accompanied by the mulberry- than the rose- coloured rash ; and also that it is less curable when it succeeds the former — the " typhus'' of Dr Jenner. The constitutionally irritable sometimes become unbearably so. In children it is not uncommon to witness illusions and extreme nervousness last for some time after the attack of fever, but they commonly pass away when the system is recruited. Sydenham observed Mania of a peculiar form " occasionally follow long agues, espe- cially if they be quartan. From the exhibition of strong eva- cuants, it degenerates into fatuity." ('Works,' vol. i, p. 93.) Although of secondary importance to fever, there are various diseases which in this place deserve enumeration. Such are cutaneous affections, including erysipelas, when repelled, otitis, intestinal worms, gout, rheumatism, disease of the heart, asthma, syphilis. " 111 health" is a general term frequently assigned as the cause of Insanity in statistical tables, but is so vague as to be worthless, and cannot be distinguished from the signs of the oncoming mental affection itself. Of moral causes. Domestic Troubles and Grief are unques- tionably the most important. Drunkenness, either of the patient or of some member of the family, is, in a large number of instances, the real cause of domestic trouble and therefore RELIGIOUS ANXIETY, STUDY, ETC. 99 remotely of the attack of Insanity. Domestic Troubles are of various kinds — ill-treatment and desertion^ also reverses of for- tune and poverty. Domestic Grief implies that arising from illness or death of a relative. Of the former, the admissions average 9 per cent., 3 of which appear to be more especially connected with pecuniary difl&culties ; about 5 per cent, are assigned to domestic grief — making their combined influence rank at 14 per cent. Among women only, the rate is much higher. At the York Asylum, out of 1029 admissions, 24 were due to business anxiety, 103 to domestic affliction, 104 to pecu- niary reverses. Religious Anxiety and Excitement. — In the analysis of our collected cases, we find it assigned in 3 per cent, of the total admissions. Doubtless, in many instances it was in reality the initial symptom of the disorder. Still we cannot for a moment doubt that the form in which religion is but too frequently presented is a serious cause of Insanity. Dr. Earle gives 17 cases out of the total numbers already mentioned, as due to '' religious excitement,^^ and 6 to " Spi- ritualism ; Dr Needham, 26 out of 1029 admissions, as due to the former. Disajopointed Affections were the assigned cause in about the above proportion, being nearly 3 per cent. In some asylums, the tables of causes exhibit " disappointed affections" much higher in the scale than religious excitement. Of the effects of Fear and Fright, several striking examples will be given in the description of the various forms of mental disorder. Of admissions, 2 to 3 per cent, are referred to this cause. At the York Asylum " sudden fright" is enumerated in 13 cases out of 1029 admissions. The influence of Intense Study is with difficulty separated from the habits or the feelings with which it is often associated. In asylums for the higher classes, the number of male admissions from this cause is by no means inconsiderable. la some of the American asylums it figures high. On this subject, see an important pamphlet by Dr Jarvis entitled ' Relation of Edu- cation to Insanity,^ "Washington, 1872. Out of 1741 cases the causes of which are given, admitted into sixteen American asylums, 205 were attributed to excess of study. As an indirect agent he considers it very potent. Unquestionably, in England, at the present day, brain forcing and the crowding of an immense number of subjects into one examination are doing 100 OF INSANITY IN GENERAL most serious miscliief ; and the strange thing is that those who foster this evil are frequently medical men, and ought, there- fore, to know better. Political Excitement and War might be expected to exert a great influence on the admission of the insane into asylums. M. Belhomme received into his private asylum ten patients labour- ing under Mania in consequence of the Revolution of February, 1848.* M. Legrand du Saulle admits the influence of the Revo- lution, but says any other cause acting on the predisposed would have produced the same result. That political commotions mainly affect those who are predisposed to Insanity is true, but this would apply to all other exciting causes, the importance of which we do not, on that account, ignore. In ordinary times, in England at least, the number of cases admitted from political excitement constitutes a mere trifle. An opportunity for testing this influence occurred during the Franco-Prussian war. M. Morel insists on the great frequency of Panophobia from the fear of the Prussian invasion and the agonies of the war. M. Bourdin considers he has failed to prove it. Would the children yet unborn suffer ? Both these physi- cians conclude with Pinel that under such circumstances they certainly do — that they are more irritable, more disposed to become melancholy, imbecile or epileptic. This remark of course applies as well to civil war. The large number of suicides which occurred during the reign of the Commune seems easily accounted for, without the increased intemperance to which Morel attributes it. M. Baillarger thinks that probably more will suffer after than during the Franco-Prussian war, in accordance with EsquiroPs experience as regards the Reign of Terror. M. Legrand du Saulle states that he does not know that after the horrible events which recently occurred in Paris there was a serious number of cases of Acute Insanity certainly referable to them. Morel relates the following : — Two brothers, one of whom witnessed the burning of his shop, fell suddenly into a state of stupor, to which a violent maniacal attack suc- ceeded. The other was witness in a trial during which the people madly invaded the sanctuary of justice, and was struck * Taking four years, 1847, 1848, 1849, 1850, there were the fewest admissions into the French asylums in 1848; but as explained by the experience of the Franco- Prussian war, it does not follow that there were fewer occurring eases of Insanity, still less that political evehts did not cause Insanity, although in some instances they mijilit avert it. WAR 101 in his turn witli such alarm, that the melancholy oppression which seized him finally terminated in the most deplorable manner. An artillery man, exposed during the days of June to the most terrible fire, and remaining alone on the spot which he guarded, fell immediately into a profound stupor and was long confined in an asylum in consequence of furious mania which succeeded. Morel also mentions that the burning of villages caused, in many instances, " crises of despair to which succeeded a state of Melancholia with tendency to suicide/'' Now what appears at first sight a remarkable thing is this : — That during the summer of 1871, the total number of insane in Paris was considerably less than usual. Allowing for the great mortality arising out of the cold winter and the war as well as the executions, M. Legrand du Saulle arrives at the conclusion in an article in the ' Annales Medico-psychologiques,^ "^ De Tetat mental des habitants de Paris pendant les evenements de 1870-71,^^ that the late war is another proof that ^^the gravest political events, although they may give, at the moment, a colour to the particular form of Insanity, do not produce, as is commonly supposed, an increase in the number of lunatics." It was observed that the excitement of the war, the rousing influence it exerted on many minds, was to some extent a set-off against its baneful effects on the mind. Lunier noticed that many neuropaths forgot their sufferings in the fearful suspense of the siege, and patients under treatment, the subjects of delusions and halluci- nations, got rid of them, for a time at least. In his own ex- perience, those who became mad were not, as Baillarger holds, the subjects of hereditary taint; on the contrary, with such, he thinks the war acted as a powerful diversion to avert the out- breaks of Insanity. As a fact fewer insane persons were ad- mitted into the French asylums during the war. The number of admissions, which from July 1st, 1869, to July 1st, 1870, was 11,655, was in the succeeding year [i.e. during the war of the Commune) only 10,2 i3, a falling off of 1412. It is, however, no less true that, during the same year, between fourteen and fifteen hundred persons became insane from the war. Statistics were obtained from various departments divided according to the occupation of the country by the enemy, and it was found that in the district only occupied for a very short time and where the struggle had been the most intense, the events of the war proved most disastrous in this respect. In Paris, the number ascertained to have become insane during 102 OF INSANITY IN GENERAL the siege and the Commune in the year 1870-71, exclusive of those not sent to asylums, amounted to 290 men and 121 women. In almost all cases, the form of Insanity assumed an acute type, and in the gi'eat majority of cases terminated rapidly, either in death or much more frequently in recovery. Hence on January 1st, 1872, there remained comparatively few in the asylums, whose Insanity had been caused by the war.* Among the causes of apparent diminution of attacks of Insanity, as shown by the admissions, it may be stated that many went to hospitals instead of asylums, and many remained with their friends ; and of course a large number of persons were killed who would in the ordinary course of events have become insane. Observations were made by Dr Nasse on the influence of the war between Austria and Germany in 1866, and he con- cluded that no injurious results occurred as regards Insanity. He agrees with Jarvis as opposed to M. Brierre de Boismont, that " neither war nor political commotion sensibly augments the cases of Insanity.''^ (' Zeitschrift fiir Psychiatrie,^ 1870, and 'Annales,' 1870.) Dr Curwen, the superintendent of the Harrisburg Asylum (Penn,), states that '^'^the breaking out of the war of 1861 was attended by a great and sudden increase for a few months of cases of mental disorder. It may also be noted as a remarkable fact, that while a great increase was noticeable at the commence- ment of the war, yet after the attention of the country was fully engrossed in its prosecution, and in all the cares and duties consequent upon its continuance, mental disorders were less frequent than for several years previous, arising unquestionably from the fact, that the public mind, as well as the minds of individuals, was fully occupied with the duties and obligations which the successful prosecution required and entailed. Excitement from various other causes acts prejudicially upon the mind. Out of the 1741 cases referred to at p. 99, 61 ai-e attributed to excitement. Sudden joy, contrary to an opinion sometimes expressed, does not produce nearly so much Insanity as grief ; its influence, however, in deranging the mental powers is occasionally, observed, and was illustrated by Gregory, in his lectures, by the history of a family, three members of which * See ' Les Honimes et les Actes de I'Insurrection de Paris,' 1872, J. V. Laborde. ' Les Commotious Politiques dans leurs Rapports avec I'Alieuation,' Dr. Collineau, Paris, 1873. 'Les Hommes de la Commune,' M. Jules Clerc, 1871. 'The Mcdico- Chirurgical Rev.,' July, 1874, Art. "The Psychology of Comniuuism." MORAL AND PHYSICAL CAUSES 103 became insane in consequence of an unexpected accession of fortune, "We believe these cases have been published^ but foi' the following particulars the writer is indebted to the notes of a gentleman who was present at the Professor's lecture. An elderly woman and two daughters lived together as companions in poverty for several years. The mother was rigidly penurious ; the eldest daughter was of a gay disposition, and thwarted her mother's wishes by spending money whenever she could obtain it; her sister, on the contrary, was grave, and had good abilities. A distant relative died, and they became rich beyond their utmost desire. On being informed, the mother became deranged, as also the eldest daughter. The younger daughter wrote to Dr. Gregory describing their condition, but in a short time she also became insane, probably from grief no less than from joy. In a few days the mother and the youngest daughter died. The eldest, upon whom the whole of the property now devolved, continued insane for some time, then recovered, and subse- quently married. Her husband lost all her money, and left her reduced as low as, if not lower than, she was before the accession of riches which caused the overthrow of her reason. Might not a recurrence of the attack have been expected ? On the contrary^ however^ she bore her losses patiently^ and she remained quite healthy in mind. An interesting example of the effect of excitement in causing Insanity is given by Dr Walker^ in his 'Report of the Boston Asylum (U. S.)' for 1851 : — An Irish boy, thirteen years of age, after arriving at that city in an emigrant vessel, became raving mad in two days, apparently from no other cause than the strangeness and novelty of what he saw. Delasiauve mentions the case of a lady who was very actively engaged in obtaining judicial separation from her hus- band and manifested no signs of Insanity, but directly she gained her cause she became deranged. At the York asylum, out of 1029 admissions, while 24 were ascribed to '' business anxiety,^' only one was referred to '^'business success. ■'' Wounded Feelings comprise " wounded self-love or " re- spect," ''being reproved,'^ "injured reputation," and similar circumstances mentioned in Asylum Reports as inducing the attack for which the patient was admitted. On the Continent, the returns under this head are much more frequent than in England, where they appear to cause but a fraction per cent, of the admissions. Relative influence of moral and physical causes {whether predisposing or exciting.) — Pinel and Esquirol arrived at the conclusion that moral causes are much more productive of In- sanity than are physical. M. Brierre de Boismont is a warm supporter of the same view, and advocates it with his usual 104 OF INSANITY IN GENERAL ability. Marce holds the same opinion. Guislain estimates, that of 100 admissions, 66 arise from the former, approaching very nearly the result arrived at by Dr Parchappe, viz. 67-1 per cent. Dr Hood, in his ' Statistics of Bethelem Hospital,' states that the moral causes of the attacks of those admitted, greatly exceed those of a physical nature. At the Retreat, the proportions have been reversed, the physical being in excess of the moral when the predisposing and exciting causes, exclusive of hereditary predisposition, are added together. For 100 moral there were 165 physical causes. As these predisposing causes of Insanity are physical, the results we arrive at, as to the relative influence of moral and physical causes, will obviously be affected by their addition, or otherwise, to our figures. Taking our own collected cases, we find that, having regard exclusively to the exciting causes, arranged in accordance with the distinction already adopted, of 30,087 cases in which the exciting cause was ascertained, 16,986 were due to physical and 13,101 to moral causes, being at the rate of 129 physical for 100 moral causes. Dr Barle arrived at the same relative conclusion: — "Thus it appears that of 1074 persons, there were 687 for whose mental disorder causes were assigned. Of these, 539 are agents whose action is primarily upon the body, and 148 are such as first act upon the mind. The number of physical causes, therefore, is about three and a half times as large as that of the mental or moral causes." (He includes in physical causes, heredity, epilepsy, paralysis, ill-health, &c., old age ; and congenital states) . The statistics of the York Asylum teach, says Dr Needham, "that in the causation of the mental disease, moral influences have operated in one third, and physical causes in two thirds of the cases admitted" (includes in physical causes, the same as Dr Earle). How are we to account for results so different from those arrived at by Pinel, Esquirol, and others ? The circumstance arises in part from the inherent difficulty of this subject, and partly — as in everything else about which men differ — from the different definition of the terms adopted. No two writers are agreed in what they include under moral and physical respectively. In illustration of tho former, it is only necessary to mention the extremely doubtful nature of vicious indulgence in this point of view. It is of mixed character in most instances, and yet we generally refer it solely to the division of physical causes. In a less degree, a patient who has become insane after leading an intemperate MOEAL AND PHYSICAL CAUSES 105 life, may Lave become so partly in consequence of domestic troubles. Dr Parchappe might enter the case under the latter head, by which it would increase his division of moral causes ; another might enter it under " intemperance,^^ and so add to the list of physical causes. It is, we suspect, mainly in this way, that although we have arranged Dr Parchappe^s table in accordance with our own classification of exciting causes in order to compare them, the moral still preponderate over the physical causes. It is quite possible (although, without knowing each case, impossible to decide) that his mode of tracing and appropriating the cause has been the correct one. It is impos- sible to avoid altogether this element of uncertainty. We also believe that among, the French, moral agents do exert a greater influence than with either the English or Americans. " Amour- propre blesse," and other items under " Wounded Feelings,^' figure to a much greater extent in their reports of causes than in ours. That the proportion between the two classes may vary in different parts of Great Britain, is proved by one of the Heports of the Royal Edinburgh Asylum, in which Dr Clouston states, "In the miaing and manufacturing counties, Durham, Glamorgan, and Stafford, the physical causes are four times as numerous as with us. In the agricultural counties, Wilts, Somerset, &c., the physical causes stand to the mental as three to one ; in the town popalation of Newcastle, Liverpool, Bir- mingham, and Bristol, as two to one.^^ In all the asylums in the above-mentioned places . only paupers are received ; the Edinburgh asylum is mixed. As an example of the second source of discrepancy, we may refer to the different ways in which epilepsy is regarded. Some, like Earle, add it, as in our list, to the column of physical causes ; others omit it altogether, in consequence of regarding it as simply one stage of the disease. If we deduct from our own cases those in which epilepsy was the alleged cause, the physical causes would be materially reduced, and still further by the exclusion of apoplexy and ordinary paralysis, all of which are omitted by Dr Parchappe. Again, it is certain that one ex- planation of the apparent discrepancy between statistical writers on Insanity, is to be found in some adding constitutional feeble- ness of mind to the list of (predisposing) causes ; while others, regarding it as a part of the disease, take no account of it. This will partly explain the different balance of figures given by Dr Parchappe and Dr Thurnam. When in regard to the Retreat 106 OP INSANITY IN GENERAL we only take the exciting causes (in which this element of dis- crepancy does not appear), we find the moral exceeding the physical causes, although not to the same extent as with the former writer. On the whole then, while the statistics we have collected together, indicate a preponderance of physical over moral causes, we are not prepared to say that they are sufficient, without further evidence, to negative the conclusion to which we think a priori considerations would conduct us, namely, the superior force, in civilised countries, of moral agencies in the generation of mental disease. A larger number of cases, and especially the means of tracing each to its real cause, would probably materially modify these figures. "We now refer solely to the exciting causes of Insanity, for we have no doubt that if here- ditary predisposition (when the only cause), congenital feeble- ness of mind, old age, and some other predisposing circum- stances, are added, the catalogue of physical agents will actually as well as apparently exceed those of a moral character. One thing is very clear, that before men discuss this question, they must agree upon what are physical and what are moral causes. Dr Major, of the West Riding Asylum, has proposed to pre- pare the cause-tables in Asylum Reports on a different principle from that which has hitherto been adopted. Instead of attempt- ing to determine, out of the several causes to which an attack of Insanity is usually assigned, which is the most important and rejecting the others, he simply states the number of cases in which certain causes contributed to 2^'''odiice the attack.* In a large county asylum, this course is probably the best mode of escape from the difficulty arising out of the impossibility of obtaining accurate information. In small asylums, however, where the past history of the patients can be more easily traced, the old plan is more likely to lead to definite results. In Dr Thurnam^s hands it elicited valuable information. The writer is disposed to believe that, as in most cases of insanity, the attack has been induced by a combination of causes, it would be best to construct a table recognising and representing this combination. Thus, of 50 cases, 10 might be due to heredity and intemperance ; 12 to temperament and pecuniary losses ; 8 to previous attacks and domestic trouble, and so forth. The combined action of several causes would thus not be lost sight * See 'Journal of Psychological Medicine,' 1877, and the Wakefield Asylum Reports, 1877. CONSTEUCTION OF CAUSE-TABLES 107 of_, while tlie number of cases in which certain causes contributed to produce attacks of insanity could be ascertained by addino* up the causes in the table^ singly. Of course in this, as in all other plans, the value of the result depends upon the correct- ness of the facts. To a certain extent Dr Major has himself adopted this principle. Thus, he gives the following interesting analysis of cases admitted during the year 1877, due to intemperance solely or in combination with other causes : Males. Females. Total. Percentage on admissions. Alcoholic excess (singly) 30 5 35 7-5 Alcoholic excess with hereditary ten- dency to insanity .... 14 5 19 4-0 Alcoholic * excess with other physical exciting causes ..... 9 4 13 2-7 Alcoholic excess comhined with moral exciting causes ..... 13 1 14 30 66 15 81 17-2 In concluding the observations on the exciting causes of Insanity we may state that under this head the International Congress of 1867 include — I. Physical causes. — Artificial deformities of cranium ; con- vulsions of infancy and dentition ; cerebral congestion (primary, not that which arises in the course of certain forms of In- sanity) ; organic affections of the brain ; senility ; pellagra ; anaemia ; constitutional syphilis ; intermittent fever ; typhoid fever ; eruptive fevers j acute rheumatism ; gout and chronic rheumatism ; organic affections of the heart ; pulmonary phthisis ; intestinal worms ; other acute diseases ; other chronic diseases ; suppression of h8emon:'hoidal flux ; menstrual disorders; metastasis ; alcoholic drinks ; abuse of tobacco ; other vegetable poisons j mineral poisons (lead, mercury, copper, &c.) ; in- solation ; intense heat ; intense cold ; blows and falls upon the head ; other traumatic causes. II. Moral causes. — Appertain to religion ; education ; love, (love thwarted, jealousy) ; family affections ; fluctuations of fortune ; domestic troubles ; pride ; disappointed ambition ; fright ; irritation ; anger ; wounded modesty ; political events ; nostalgia; ennui; misanthropy; sudden joy ; simple imprison- ment ; solitary confinement. The Congress only attached a secondary importance to the distinction between predisposing and exciting ; but thought some 108 OF INSANITY IN GENERAL division, however imperfect, is better than none at all. (See ' Journal of Mental Science/ Jan., 1870, p. 638.) III. Mixed causes. — Excess of intellectual work ; prolonged vigils ; evil habits of libertinism ; onanism (sometimes simply- predisposing) ; disorders of the reproductive system ; destitution and want ; bad treatment ; sudden change from a life of activity to idleness, and vice versa ; loss of one or more of the senses. SECTION IV.— Proportion of the Insane to the Population. On no subject has therebeen more absurd and illogical reason- ing, or more hasty generalization, than on the proportion of the insane to the population, whether in regard to various countries or in regard to the same country at different periods of its history. The most obvious essentials for making correct comparisons are constantly disregarded, notwithstanding which, highly important inferences are drawn with the utmost complacency, and appa- rently in entire ignorance of the fallacy which underlies such loose and worthless calculations. Even up to the present time, when the subject is discussed, we are often presented with merely a list of the numbers of lunatics in various countries, the conclusion being drawn that such numbers represent cor- rectly the liability to Insanity in these countries, — the difference sometimes ranging between one in a thousand and one in 30,000 ! Generally, the only basis for such calculations is the number of patients in lunatic asylums ; yet it must be obvious that, in consequence of the very different provision made for the insane in different countries, such a basis as this is utterly fallacious. But there are other circumstances which vary most materially among different peoples, and which must be taken into account before we can arrive at anything like a satisfactory result ; yet these have again and again been entirely overlooked. For example — the mortality of lunatics varies in the same country at different periods, and is greater in some countries than in others. Now, let the reader suppose that there were a law in Scotland that every lunatic should be put to death when all means of cure had been resorted to for the space of five years, and suppose that no such law existed in England ; it must be evident that a return of the number of lunatics in the two countries would exhibit a far larger proportion in England than in Scotland ; while, at the same time, it is not less evident that PROPORTION OP INSANE TO POPULATION 109 precisely the same, or even a greater nuraber, miglit become insane in the latter country than in the former. Although an extreme case by way of illustration is here supposed, the same error is in degree committed whenever the relative liability to Insanity of two nations is endeavoured to be ascertained, with- out an attempt being also made to ascertain the relative mor- tality of their lunatics. In other words, unless we can ensure an entire similarity in the various circumstances of two nations, or of the same nation at two different periods, we must obtain statistical returns — not of the number of lunatics existing at any given period, but — of the number of cases occurring in a nation, as compared with the population. " The tendency to Insanity in a class is expressed (as Dr Farr observes) by the proportion that become insane.^^ In our own country there are two. reasons why the proportion of the insane to the population appears to be greater than was formerly the case. The first is, that the disease is recognised as such to a far greater extent than formerly ; and the second is, that we know and make provision for, to a much greater extent than heretofore, the number of the insane throughout the country. In the short period of nineteen years, the estimated proportion of the insane in England rose from 1 in 7300 to 1 in 769 ; a difference which led to the belief in a frightful increase of In- sanity, but which by no means warranted such a conclusion. The knowledge of an evil, and the existence of that evil, are two widely different things. Insanity may or may not have in- creased j but our increased knowledge of its extent is no proof that it has. Again, it is obvious that, should there be a larger number relieved by treatment and discharged from asylums for the insane, there will be a larger number of recurring cases. It follows, therefore, that if in the estimate of those who become insane, these recurring cases are included, the simple circumstance of curing a greater number of patients will be the very means of making it appear that a greater number of persons are attacked by Insanity, — a greater number than would appear to be the case under more unfavorable circumstances. When the first edition of this work was published, the number of insane and idiotic in England and Wales was stated to be 33,641 (January 1st, 1857) or 1 in 577 of the total population (males 1 in 616, females 1 in 543). The total number registered, according to the last Report of the Commissioners in Lunacy, on the 1st of January, 1877, 110 OF INSANITY IN GENERAL amounted to 66,888, or 1 in 365 (males 1 in 392, females 1 in 342), being an increase of 33,247. In these figures, however, it must be remembered that no account whatever is taken of the number of insane persons not officially reported to the Lunacy Commissioners. This number cannot, of course, easily be guessed at. In former editions we said that, were it fully known, it would, when added to the number already ascertained, exhibit a proportion of at least one insane or idiotic person to every 300 of the population. Subsequent statistics, without including this unknown element, having raised the ascertained proportion from 1 in 569 to 1 in 365, we are confirmed in the opinion then expressed.* They were distributed as follows :t * The Census of 1871 reported more insane and idiotic than those known to the Commissioners at that period by upwards of 12,000, thus increasing the ratio to tlie population to 1 in 329. t The Report of 1878 not having appeared when these sheets passed through the press, the total numbers for Jan. 1, 1878, will be given in the Appendix. NUMBER OF INSANE IN ENGLAND AND WALES 111 00 iH (N 00 tP 00 00 IN cc (N 00 (M CO IN lO 05 m CO rH CO in 00 « in J> 1> CO -* ^ o^ CO CO IN 00 B vft IN ^ CO* CO CD CO CO I— 1 CO CD r-< T-l tP lO ^ CO IN i-H T-i CD i> >j -3 CO rH ■^ T-l o 00 o in I> I-H 00 ^ OS j> CO CO CD CO o ^ IN ^, IN CO CO r-t 00 ^ T-i rH CO eS s CO i-^ IN CD N CO ^ »ffl -# i« 1 in 1 00 IN 05 1 OS J 00 OS CO 1 '^ 1 CO i-H CO CO of o IN IN o CO o o 1 »o rH co' CD OS <:5 tf M 1-1 in in Oi -* "* 1 1— 1 1 IN r-< '-* 1 r-i H .^ 1— 1 -# 05 in 1 o in CO CD b i o i> (M 00 OS °l OS OS CO l>f N s iH 00 CO CO o rH 1 ^ 1 CO I-H 00 1 00 • CO iQ 1> 1 OS 1 CO CD J> t- '^ o ^ rH 00 ^ o o s CO I— 1 CO IN CD IN CO (N ac £>. J> 00 05 00 1 1 t^ IN OS _^ ec cc lO in T? in 1 1 OS in ■* o -* cc ■* CO IN ^ in IN 00 H H &H IN CO i> J> "3 IN x> o in CC cc 1 1 O CO CO ^ ^ cc in tH 10 oc 1 1 <-< rH !N >• M (N ff CO CO CD m 1 1 X> CO CO I— 1 o- i> o •<#l o: J> 1 1 00 C<3 IN 1 H cc 00 CO r-T iH iH O rH IN CS a a ^ "~* "~* 1— 1 ^S , .5 J ci 13 -" o- &> rt •S a, ^ -« ^|w fl fi ^-73 « 15! ,iS 0- tr ^ ^ S £ ffl S aj a o a> c O ■&. •-W _g •' H T 2 'w -^ s s n -< 1 c p: 1 ' 1 C o w • 1-4 »■ g < c p. IT f- a 'a '3 "^ o-S c . 1 t: t: tr -« ■? ^ a C > S , 1 *5 a p: c a - a a fc a c c 5 c C o „ ill ■s ? s C fl r 'i = o 1— 1- >— 1— 1 h- P- C Eh s "> o » != :« .s ^ It, 3 s i= a •^ CS ^5 ^ E > S ^ -o ai 1^ " Is. 3 O hH aj 5 a 112 OF INSANITY FN GENERAL The increase in the population since Jan., 1857, being 5,246,196, there would now be 42,859 lunatics in England and Wales, had the proportion of Lunacy and Idiocy to the popula- tion remained stationary, but instead of this baing the case, we find an excess of 23,777. The question is. Is this apparent or real ? Is there more occurring as well as existing Lunacy than there was some years ago, before so much attention was paid to the subject ? That a part of this increase is readily accounted for by the annually increasing facility of obtaining really accurate returns, and by the decreased mortality consequent on the care taken of the insane in our asylums, is, no doubt, true. Can it be shown that the whole is due to these or any causes other than the actual extension of the disease ? We are not prepared to reply in the affirmative, although a careful exami- nation of the subject shows how much that seems real is only apparent ; due, in short, to mere accumulation. That there is reason to fear some real increase of occurring Insanity is, how- ever, the opinion of the writer. We cannot absolutely solve this problem by figures because, notwithstanding the published statistics, the difficulty of ascertaining correctly the occurring cases of Insanity at once meets us. In the Annual Report of the Commissioners, the number of admissions into asylums is given, but not into work- houses, or into the dwellings of the poor, where there are single pauper patients. Again, as idiots and imbeciles are not dis- tinguished from the insane, or when they are so, are constantly confounded with cases of Dementia, we are unable to arrive at any just conclusion as to the number of those who become insane in a given year. We subjoin, however, such a statement of the admissions as is given in the Lunacy Report (1877) for eighteen years. It must also be remembered that, whenever a certain amount of lunacy has for long existed, for which proper accommodation has not been made, the moment a new asylum is completed, the '' Admissions " in that year's Report are aug- mented without there being more occurring lunacy. The limit of accommodation must obviously determine the number ad- mitted, and hence vitiate these returns as tests of the increase of Insanity. NUMBER OF INSANE IN ENGLAND AND WALES 113 Table. — Shoiving the ratio {per 1000) of the total number of Lunatics and Idiots to the population in each year from 1859 to 1877, and the ratio per 10,000 of the admissions into asylums during the same period. [England and Wales.) Population Total numljer Ratio to Number of Ratio to Year. (middle of of Lunatics and the population admissions into the population year). Idiots, Jan. 1. (1000). asylums.* (10,000). 1859 ... 19,686,701 36,762 1-87 9,310 4-73 1860 ... 19,902,713 38,058 1-91 9,512 4-78 1861 ... 20,119,314 39,647 1-97 9.329 4-64 1862 ... 20,371,013 41,129 2-02 9,078 4-46 1863 ... 20,625,855 43,118 2-09 8,914 4-32 1864 ... 20,883,889 44,795 2-14 2,473 4-54 1865 ... 21,145,151 45,950 2-17 10,424 4-93 1866 ... 21,409,684 47,648 2-23 10,051 4-69 1867 ... 21,677,525 49,086 2-26 10,631 4-90 1868 ... 21,948,713 51,000 2 32 11,213 511 1869 ... 22,223,299 53,177 2-39 11,194 5-04 1870 ... 22,501,316 54,713 2-43 11,620 5-16 1871 ... 22,782,812 56,755 2-49 12,573 5-52 1872 ... 23,067,835 58,640 2-54 12,176 5-28 1873 ... 23,356,414 60,296 2-58 12,773 5-47 1874 ... 23,648,609 62,027 2-62 13,229 5-59 1875 ... 23,944,459 63,793 2-66 14,317 5'98 1876 ... 24,244,010 64,916 2-68 14,386 5-93 1877 ... 24,547,309 66,636 2-71 ~ The main causes of this increase in number may be thus enumerated, viz. (1). The act of 1845 (see p, 4 of this work), which obliged counties to erect asylums for the insane; (2). The Act of 1853 (same page), ordering quarterly returns of lunatics not in asylums; (3). The Act of 1861 (p. 5), throwing the maintenance of lunatics in asylums upon the common fund of the Union, instead of the particular parish ; (4) . The grant by Parliament in 1874 of four shillings per head towards the maintenance of paupers in asylums out of the Consolidated Fund (see p. 5). Again, great as the increase of lunatics officially reported as under care has been, there has been a decline in the rate of this increase, as is shown by the following fact. During the five years ending 1864, the average annual increase of lunatics in England and Wales (the rise of popu- lation being allowed for) was at the rate of 2'97 per cent. ; during the next five years it was 2*31 ; in the succeeding one 1*92; and subsequently 1*17. Again, if we take two periods, * Couuty and borough asylums, hospitals, licensed houses, and houses for single private patients (includes re-admissions and transfers). lU OF INSANITY IN GENERAL 1859~G8 and 1868 — 77, the increase in the total number of the insane, allowing for population, was in the former period 24-43 per cent., and in the latter period 16-83 per cent., marking a decline in the rate of increase of 31 per cent. Taking certified lunatics only {i. e. those in asylums and not in workhouses or boarded out), the increase amounted to 30-58 per cent, during the earlier period, and 18-25 during the later one, showing a decline in the rate of increase equivalent to 40 per cent.* Taking the number of admissions (5th column) there were 59 persons admitted into asylums in 1876 to 100,000 living, ao-ainst 47 in the year 1859. Re-admissions and transfers were not distinguished from first admissions until 1869. This renders the attempt to consider the returns prior to this date as cor- responding to the numbers hecorning annually insane not alto- gether satisfactory. Again, as most of the reasons assigned for the apparent increase of the insane in England and Wales apply only to pauper lunatics, we ought to know the increase or other- wise of the admissions of private patients; but unfortunately these have only been distinguished during 1875 and 1876 — a period too short to be of use. In these two years there was an increase cf 6'2 per cent. ; in other words, for every 100 of the population who became insane in 1875, 106 became insane in 1876. It will be interesting to see whether future retm-ns show a like rise. Recurring to the table of admissions we may state, that taking three years, 1859 — 61, the proportion to the population in this group of years was 4*715; during the five years 1862 — G6 it was 4-590; during the five years 1867 — 71 it was 5-150; while duinng the last quinquennium of which we have any returns it was 5-655, showing an increase in the admissions, although the rate of that increase, when we compare the second and third group of years with the third and fourth, shows a decided fall, namely, from 12-200 per cent, to 9-806 per cent., or a percentage of decline in the rate of increase of 19-623. As regards Ireland, it appears that there were 18,730 insane and idiotic registered on January 1st, 1877, the proportion being 1 to 283 of the population. The Report of the Scotch Lunacy Commissioners of 1877 * Stiitistical tables, showing tlie increase in admissions and in the number of Lunatics under care, will be found in the writer's ' Insanity in Ancient and Modern Life, wilh chapters on its Prevention,' 1S78. NUMBER OP INSANE IN ENGLAND AND WALES 115 enables us to form some (though, doubtless an imperfect) idea of the proportion of insane in Scotland. The number of ascer- tained lunatics on January Istj 1877^ was 8862^ the proportion to the population being 1 to 411. Taking the United King- dom, it appears that there are about 96,480 persons ascertained to be under care as either Insane or Idiotic. In regard to France, where there has occurred the same appa- rent increase of Insanity as in England^ and where the proportion of insane or idiotic to the population has been estimated at 1 to (about) 400, M. Lunier, Inspector- General of the " Service des AlieneSj^^ presented a memoir to the Imperial Academy of Medicine, which appeared in the ' Annales Medico-psycholo- giques,^ January, 1870, in which he concludes — 1. The number of the insane in French asylums has increased since 1835 from 10,539 to 38,545 (nearly quadrupled). 2. The relative number, or the proportion of insane in asylums to the population, has risen from 3-16 to 10-03 in the 10,000 (tripled). 3. There is a continued yearly increase in the asylum population. This has gradually risen from the rate of between 400 and 500 a year, which it was previous to the law of 1838, to a yearly increase of from 600 to 1300, but since 1862 there has been a manifest yearly decrease, and the yearly increase has fallen to between 800 and 900. (This yearly increase in the asylum population is shown to have fallen from 5"94 per cent, in the five years 1841 — 46 to 2*57 in 1868.) In the Department of the Seine the admissions increased from 1800 to 1876 more than sixfold, while during that period the population of Paris scarcely aug- mented threefold (^ Rapport,^ 1877, p. 6). M. Lunier accounts for the apparently greater number of cases of Insanity by the increased confidence felt by the people in asylums, and the decreased tendency to conceal the occur- rence of madness in their families. He, however, excludes from this satisfactory conclusion " the Insanity resulting from alcoholic abuse, and still more that form termed General Paralysis of the insane, which I am tempted, to call the disease of this century, and which appears to increase not only in the large towns but also for many years past in the smaller centres of population with most alarming rapidity .^^ He adds, " For- tunately, the extension of mental disease is to some extent counterbalanced by its diminution in France in the cases of Ci'etinism and Idiocy."* * ' Aiuiales Medico-psychologiques,' Janvier, 1870, p. 33. 116 OF INSANITY IN GENERAL For the United States of America we have no later return than that of the Census of 1870, which gave 36,786 lunatics and 2 1,395 idiots, or 1 in 622 of the population. This ratio is well known to be much under the mark. SECTION v.— Relative frequency of the Various Forms of Mental Disorder. A difficulty arises from the various senses in which the same terms are employed. We have ascertained the form on admis- sion from a considerable number of Asylum Reports, and believe that the difference which exists between them is chiefly occa- sioned by the different views entertained in regard to " Mono- mania.'^ When it constitutes a separate and important division, under which are included Monomania of Pride and Vanity, &c., and the several forms of Moral Insanity, the proportions per cent, (exclusive of Idiocy) appear to be usually as follows : — Mania (acute and chronic), 50; Melancholia, 30; Dementia, 11 ; Monomania, 8 or 9. When, however, few or no cases are referred by the reporter to " Monomania,^^ the admissions unde>* the head of " Mania " are proportionately increased. Probably most who employ the term Monomania mean Delusion on one class of subjects. In Dr Boyd's statistics, about to be referred to, the term is not employed " unless the power of reasoning correctly on subjects unconnected with the illusion is retained. '' If Melancholia should connect itself with the subject of Delu- sion, the case would be classed as Melancholia. A very different proportion would appear, if we calculated the relative frequency of the various forms when the patients die, the largest number at the time of death being examples of Dementia (frequently coin plicated with General Paralysis). The next form of Insanity in order of frequency, at the time of death, is Mania (usually chronic) ; then Melancholia ; and lastly Monomania. From Dr Boyd's article on ''Vital Statistics," based on 2000 male and female admissions into the Somerset County Asylum, we have calculated the proportions relative to the forms of In- sanity admitted. (See ' Journal of Mental Science,' Jan., 1865.) Excluding the re-admissions, the Forms of Mental Disorder on admission were as follows : — Mania 42-9 per cent., Mclan- cliclia 18-4 per cent.. Dementia 10-6 per cent.. Monomania 5-3, RELATIVE FREQUENCY OF FORMS OF INSANITY 117 General Paralysis 5"1 per cent.. Idiocy 4*3 per cent.. Moral Insanity 1"1 per cent., Delirium Tremens 1'4 per cent., Epilepsy 10' 9 per cent. Of the male admissions the proportions per cent, were as follows : — Mania 39-4, Melancholia 15-2, Dementia 9-2, Mono- mania 6*2, General Paralysis 8'3, Delirium Tremens 1'4_, Moral Insanity 1*4, Epilepsy 12-2. Of the female admissions the proportions per cent, were as follows : — Mania (including Puerpei-al Mania 6"0) 46"3, Melan- cholia 21'6, Dementia ]2'1, Monomania 4'5, Idiocy 3'1, General Paralysis 2*0, Moral Insanity 0"8, Delirium Tremens O'l, Epilepsy 9'5. The subjoined summary by Dr Boyd will be of use to the reader : "In early life, Idiocy (not complicated with Epilepsy) and Epilepsy prevailed amongst the males, nearly two thirds of the cases heing of these classes, as might be expected, the one being congenital, and the other usually a disease originating in early life ; whilst among the females at the earlier periods. Mania was the most prevalent form, and the cases of Idiocy and Epilepsy were not half so numerous as in the males," the reverse of what is stated by Copland. " The annual reports of this institution have shown a preponderance of male Epileptics. The greater size of the head of the male foetus, and consequently the greater difficulty and liability to injury in parturition, renders the males more liable to convulsive diseases in early life. On December 31st, 1862, of 71 Epileptics, 38 were males. From 25 ' to 55, Mania was the most prevalent form of Insanity in both males and females. Melan- cholia was most common in males from 60 to 65, in female patients from 20 to 35 and from 40 to 45 j on the whole, it was most freqiient in females. Monomania was more common in males than females from 25 to 60. Dementia occurred from 30 to 60, after which, cases of (senile) fatuity were included; it prevailed most among females. Cases of General Paralysis occurred from 30 to 60, and were four times greater among males than females. Delirium Tremens occurred from 35 to 45, and was almost exclusively confined to males, and the readmissions of these patients once affected with delirium tremens were in a large proportion to their numbers. The other cases of admissions were chiefly cases of recurrent Mania and of Melancholia. The cases of Mania and recurrent Mania were the most mmierous in both sexes, but most so in the females," contrary to the statement of Copland. Dr Boyd observes that his statistics cenfirm the remark of Esquirol that " Insanity may be divided into Imbecility for childhood. Mania and Monomania for youth. Melancholy for mature age, and Dementia for advanced life." With regard to partial Insanity, under which Dr Boyd comprises Monomania, Melancholia, and Moral Insanity, there were not many cases under 20 ; " but at the next period, from 20 to 30, when the feelings and affections are fully developed, the cases were numerous amongst females. In the next period, from 30 to 40, the numbers were more nearly equal between the sexes, but still greatest amongst females ; and again from 40 to 50 the proportion of females was much greater than of males, the cases of Melancholia being more than double. After 50, these cases rapidly diminished in number, especially amongst 118 OF INSANITY IN GENERAL females, the number amongst the males frradually exceeding those of the females at the later jjeriods of life; on the whole, the females were more numerous than males. . . . Moral Insanity occurred before the middle period of life; the cases are few (18). Melancholia is the most common form of partial Insanity. . . . Some of this class have no disorder of the understanding, and manifest no delusion." " Of the 189 cases of Dementia none occurred before the age of 20, and only six from 20 to 25; as age advances, the numbers gradually increase to the latest period of life, and in this respect it differs from every other form of Lisanity." " Tlie earliest period at which General Paralysis occurred was from 25 to 30. From 30 to 40 there were 27 males and 7 females. From 40 to 50 there were 31 males and 7 females. From 50 to 60 and upwards there were 11 males and 3 females. The total numbers were 72 males and 17 females. " There were 75 cases of Idiocy, exclusive of those cases complicated with Epilepsy which have been included with the 189 cases of Epilepsy." (Op. cit., pp. 496 — 502.) SECTION VI.— Proportion of Recoveries. Prognosis. The metliod of calculating the proportion of recoveries has been the subject of some difference of opinion, and has involved a corresponding diversity of practice. Very generally, however, and, in our opinion, correctly, the recoveries have been calcu- lated on the admissions. Dr Farr, on the contrary, has, in some instances, calculated the recoveries upon the discharges. The superiority of the former method has, we think, been conclusively shown by Dr Thurnam. From the elaborate statistical tables of the latter it would appear that, during a term of years, the recoveries in a large number of British, American, and Continental Asylums varied, at the period at which he wrote, from about 25 to 50 per cent. An examination of the later reports of asylums for the insane will show that the difference between the maximum and minimum continues to be very similar ; of course in asylums where only curable patients are admitted, the percentage of cures will be much higher — 60 per cent., for example, as has happened at St. Luke's during a term of ten years. It is quite as true as when the ' Statistics of Insanity' was published that, "as regards the recoveries in asylums which have been established during any considerable period, — say twenty years, — a proportion of much less than 40 per cent, of the admissions (including readmissions) is, under ordinary circumstances, to be regarded as a low pro- portion, and one much exceeding 45 per cent, as a high propor- tion " (p. 136). In the last Report of the Lunacy Commissioners (1877) the RECOVERIES 119 recoveries in the Lunatic Asylums^ Hospitals^ Licensed Houses^ &c., in England and Wales, during eigliteen years (1859 — 'IS??) are given. It appears that of the patients admitted during this period 34"1 per cent, were discharged cured. The percentage for each year was about the same. The proportion of recoveries was highest in Registered Hospitals (38"3) ; then follow County and Borough Asylums (35' 7) ; Provincial Licensed Houses (31"4; Metropolitan ditto (27'0) j Naval and Military Hospitals (26-7); Criminal Asylums (17-6). In considering the probabilities of recovery in any case of Insanity the following points must be regarded. 1. It is of great importance to remember that the chances of cure are much greater when cases are subjected to treatment in the really early stage of the disorder. This is clearly shown by the experience of the Yoi'k Retreat in the table given below. This remains true, although there are several fallacies closely connected with it which cause disappointment in endeavouring to act upon it. One of these is that a vast number of so-called recent cases are not recent, and that among pauper lunatics they are often not in their nature curable, however early they are admitted into an asylum. Hence the attempts made to have a separate ward for " recent '' cases in one of the Middlesex asylums, and to afford every facility for admission, have led to much disappointment. Table. — Shoiving the Average Proportion of the Recoveries, in Cases of Recent and Longer Duration when admitted, 1796 to 1872. Duration of Disorder when admitted. Proportion of Recoveries per cent, of AdmissiouB. Male. Temale. Total. First Class — First attack, and within 3 months Second Class — First attack, above 3, and within 12 months Third Class — Not first attack, and within 12 months ........ Fourth Class — First or not first attack, and more than 12 months ...... Percentage of cases recovered . 69-79 43-03 57-84 12-21 74-10 42-81 65-16 20-10 72-13 43-01 61-96 16-44 40-90 48-17 44-90 120 OF INSANITY IN GENERAL From the above it will be seen that when first attacks were treated within three months of their occurrence, above 70 per cent, of such patients admitted into the Retreat up to the year 1872 have been cured. By some physicians the proportion is stated to have been higher, but this will often happen within a short and not a longer term of years. Thus, at the Retreat, the proportion of recoveries in the same recent class of cases was, up to 1 840, about 80 per cent. Further, if any unpromising cases (those, for instance, which are compli- cated with epilepsy or paralysis) are excluded by those who make the report, the fact of still more favorable returns is easily explained. In a table of the English Lunacy Report it appears that of 2209 patients admitted in 1857, the duration of whose disorder was under one month, 1125, or 50*9 per cent., and of those insane under three months 48 per cent., were discharged cured in the three years 1857 — 1859. Of those admitted who had been insane six years and upwards, only 5 per cent, recovered. The experience of the York Asylum from 1846 to 1872 was to the same effect. The statement would not be justified by these figures that if all cases of Insanity were placed under good asylum treatment within three months of the attack, 70 per cent, would recover, even of persons in the same social position. This would be a much too sanguine conclusion to arrive at, because a larger pro- portion of curable cases, e.g. acute mania, are sent to an asylum than others, in an early stage of the attack. On this and many other points mere figures are grievously misleading. In connection with the figures in the last line of the above table, it must be clearly understood that they refer to cases, and not to individuals. The same individual may appear more than once, and therefore increase the number of cases, whether in the admissions or the discharges. Hence, in regard to the pro- portion of recoveries of patients, it might happen that a patient recovered and relapsed a great many times, and so, by increas- ing the apparent recovery of patients, give a false idea of the number cured. We might from this source of fallacy report that 50 per cent, of patients were discharged cured from an asylum, whereas the proportion was actually much lower, in regard to individuals. It is true that the skill of the physician was equally called into play in relieving the mental disease in 50 per cent, of the cases ; but if we desire to ascertain the number of persons who are really restored to society cured, we EEOOVERIES 121 must take the numbei- of individuals, and not the same indivi- dual over and over again. Otherwise, we may fancy we have rescued from the useless condition of Insanity several members of society, whereas only one individual has for short periods returned to his friends, to die ultimately in the wards of an asylum. There is no doubt that from this cause too hopeful views have been entertained as to the permanent curability of Insanity, which is the practical question, and that which presents itself when we have to show that by the prompt and skilful treatment of the disease we shall economise in the long run, and shall not only save in the expense of building and enlarging asylums, but in the restoration of able-minded men to the various occupations from which they have been taken by attacks of mental disorder. It is of course something to patch up the mental fabric for a few years or even months, but this is not what people understand when they talk of cures. Cures with them are identical with the cures of different patients, whereas in the percentages ordinarily given in asylum reports, the cures do not represent the number of individuals cured, but simply the number of cures after attacks of Insanity, whether in the same person or not. And, again, by cures they generally understand lasting recoveries, in the same sense as in bodily diseases with which the comparison is made. It is said, again and again, that Insanity is at least as curable as pneumonia, rheumatism, &c., if taken in time, but it is forgotten that after recovery, relapses — and these very possibly not recovered from — are frequent in Insanity and rare in pneumonia. To compare the cures in the two diseases is therefore not fair, unless the relative frequency of relapses is allowed for. The total figures in the above table refer, as we have said, to cases, not necessarily to different persons. As this remark does not apply to the cases of " first attack,^^ since in these there is no source of fallacy from reporting the same person as cured more than once, the main drawback to the favorable inference drawn lies here in the possible relapses. If now — taking the experience of the Retreat from 1796 to 1878 — for the gross amount of cases of all classes, we substitute patients, we find that while 577 cases were discharged recovered, only 415 persons recovered; the percentage of recoveries on ad- missions being 43*22 in the former, and 40"37 in the latter.* * The fallacy of the usual mode of calculating recoveries is, it is true, modified, though not neutralised by the cases being included in the admissions as well as iu 122 OP INSANITY IN GENERAL Of the above 415 persons, 820 were admitted for the first time, Q(} were admitted twice, 17 three times, 6 four times, 3 five times, 1 seven times, 1 nine times, and 1 nineteen times, thus making 577 cases. First admissions must not be confounded with the number of patients who were only admitted once. This distinction is sometimes lost sight of. At the Retreat there were, from 1796 to 1878, 1028 first admissions, while there were no more than 823 who were only admitted a single time. The former (first admissions) correspond to persons, the latter to only that por- tion of these persons who did not return to the institution. If the recoveries in asylums were calculated on the persons who were only once admitted, the proportion would be found to be low, because persons subject to attacks of recurrent insanity are eliminated. This is well shown in the following table, for the preparation of which to illustrate this observation the writer is indebted to Dr Baker, the Superintendent of the York Retreat : Table sliowing the recoveries per cent, of tlie admissions of persons at the YorJc Retreat from 1796 to 1878, according as they have been admitted once, twice, or three times. Number of times admitted. Percentages of recoveries upon admissions oi persons. M. F. M. F. M. F. 1 . . . . 2 . . . . 3 . . . . Both sexes 35-6 41-0 J 50-0 43-4 J 40-0 64-1 38-5 41-5 530 If we desire to form an opinion as to the number of persons who are restored to society permanently, or at least for a long the recoveries. Thus, at the Ketreat during the period above mentioned (1796 — 1878) twenty cures of one patient have swollen the admissions as well as the recoveries. If we calculate the cases which recovered and the persons who recovered alike on the total admissions (instead of the persons who recovered on the persons admitted) the former would show, as above, 43-22, and the latter 31-08; the true mode of calculation (on persons admitted) showing 40-37, as in the text. EECOVERIES 123 period of time, we arrive at a much fairer conclusion by re- stricting our inquiry to the recoveries. of persons only admitted once into an asylum. As shown in the above table, of this class only 38*5 recovered, while of those persons who suffered from three attacks of insanity — and were therefore more curable patients (for a time) — as many as 63 per cent, were discharged recovered. In this calculation of course only one of the three recoveries is enumerated, or they would constitute cases. It has in many institutions been observed that the reported recoveries during the earlier periods of an asylum are greater than in the later periods, although it is to be supposed that latterly medical skill must have been at least as great as for- merly.* When this at first startling result of statistical comparisons does occur, various reasons have been assigned, among which may be enumerated (a), the larger proportion of chronic incur- able cases, which, instead of being uncared for or cared for in workhouses, have been brought to asylums in proportion as public attention has been directed to their neglected condition, and the large provision made for their care; (&), the probable increase of General Paralysis ; (c), the calculation in some instances of the recoveries on the discharges in the earlier period, and on the admissions in the later period ; {d), the more conscientious and scientific care probably exercised now than formerly in returning as recovered, discharged patients who are only improved, in connection with which must be mentioned the plan of sending patients out on trial before actually discharging them ; (e), the very small number of cases upon which earlier calculations were made; and lastly (/), the tendency to retain in asylums a good many patients who might be allowed to leave, from the humane motive of preserving them from almost certain relapse. If there has been in any instance a real falling off in curing the patients in an asylum, we should attribute it to the philanthropic zeal and humanity which, in the early years of a charity, may have influenced the individual treatment and cure of the inmates. The apparently unfavorable statistics of some * Dr Earle has in regard to 20 American asylums shown a very remarkable fall in the reported cures in the last five years of their history as compared with the second quinquennium ; namely, for every 100 that recovered in the former period, only about 74 recovered in the latter. The fallacy of taking the recoveries of cases instead of persons has been ably insisted upon and illustrated by Dr Earle in a pamphlet on ' The Curability of Insanity ' (1877), which is deserving of serious study by the Superintendents of asylums in Britain as well as in the States. 124 OF INSANITY IN GENBEAL modern institutions in the matter of recovery, as compared with old ones, where there can be no question that the treatment, moral and medical, was infinitely inferior to the present, arises, we can have no doubt, from the returns in one case being honest, and in the other " cooked/^ Dr Earle inclines to think that insanity has become more inveterate and actually incurable. It is to be hoped that the plan will be adopted in asylum Reports of specifying the number of persons who have been cured as well as the number of cases. The number of relapses out of these up to the date of the Report should also be given. There is, we think, an advantage in the duration of time of the attack being given as well, provided first attacks are distin- guished. If no time-table is given, it is impossible to test the truth of the statement that the hope of recovery is greater, the earlier the patient is placed under medical treatment. Cases of recovery after the disorder has lasted many years, although exceptional, are not wanting. Dr Buttolph, of the Trenton Hospital for the Insane, in one of his Annual Reports, records the case of a female who recovered after being insane eighteen years, and a male after six years. In the Report of the Devon Asylum (1850) is mentioned the recovery of a female patient who had been maniacal for twenty years. Rush relates the case of a farmer who recovered after being insane eighteen years. Recently we have seen a patient in Bethlem Hospital recover after fifteen years of profound melancholia. When Dr Williams used to ask him to play at billiards he refused. One day, the marker being away, Dr Williams pressed him to help as a kindness. He consented, and this seemed to be the turning point in his recovery. Of sudden recoveries a good example occurred in a puerperal case we saw not long since at Bethlem. The woman said one day after her dinner that she felt that she had recovered her reason, and so it proved ; nor had she any relapse. Her expression was, " I feel changed and am now quite well.^' Lastly, it may be observed that in the experience of the Retreat more than one third have been discharged within six months after admission. The average duration of residence has been about a year and four months. There are various other circumstances, besides the duration of the disorder, which affect the prospect of recovery. Among these may be enumerated the form of the disorder, physical complications, and the occurrence of acute disease, the cause of EECOVEEIES 125 the attack, age, sex, civil or social condition, hereditary predis- position, and the season of the year. 2. In illustration of the influence of the form of the mental disorder upon recovery, we may adduce the experience of Dr Kirkbride, of the Pennsylvania Hospital for the Insane, from its opening in 1841 to 1873, during which period 2994 patients were discharged cured. The proportion of the cures on the admis- sions were for Mania 57 per cent. ; for Melancholia they amounted to 48 per cent. ; for Monomania 46 per cent. ; and, lastly, for Dementia, 9 per cent. — most of which, it is scarcely necessary to observe, were of the acute form. Dr Earle in his tables, already referred to, gives the following percentages : Admitted. Discharged. Mania, Of 548 both sexes, 214 recovered = 39"05 per cent. Melancholia, Of 147 „ 35 „ = 23-81 „ Monomania, Of 19 „ 9 „ = 47-36 „ Dementia, Of 297 „ 25 „ = 8-41 Dr Earle adds that these results do not differ greatly from his opinions as derived from observation, with the exception of those relating to Monomania ; it being, in his experience, the most incurable of all. They were, with two exceptions, admitted before Dr Earless superintendence, and he has reason to believe they were cases of Dipsomania, and incorrectly entered under Monomania. Of 29 cases of Dipsomania, 24 " recovered ^' in the sense only of being restored to sobriety. At the York Asylum, during twenty-seven years, of 457 cases of Acute Mania admitted, 292, or 63'89 per cent., recovered. Of 110 cases of chronic ditto 7, or 6"36 per cent., recovered. Of 250 cases of Melancholia 118, or 47'2 per cent., recovered. Of 157 cases of Dementia 1 recovered. Dr Boyd^s statistics of admissions (1741 in number, exclusive of re-admissions) and recoveries, at the Somerset County Asylum, show that the latter were greatest in Mania. Then followed Melancholia, Monomania, Dementia. 3. Among physical complications, the presence of epilepsy, while _it does not necessarily prevent partial recovery, renders a permanent cure highly improbable. Dr Boyd, however, gives a proportion of 6"6 per cent, for men, and 7"1 for women. Apoplexy or paralysis is so grave a complication that some writers speak of the accompanying mental disease as hopelessly incurable ; but while this is the general rule, we have known 126 OP INSANITY IN GENERAL some striking- exceptions. Paralysis may remain and the mind recover. We do not include in these remarks the general paralysis of the insane, lasting recovery from which the writer has not witnessed. The blood tumour of the ear, first described by M. Ferrus {' Gazette des Hopitaux/ 1838), adds, when present, if not due to violence, to the serious nature of the case. It indicates that nutrition is much below par. Although occasionally, perhaps frequently, the result of a blow or fall, there can be no reason- able doubt that luematoma auris may occur independently of either. In the July number of the ^ American Journal of Insanity,' 1870, Dr Hun gives the details of twenty-four cases. It is noteworthy that only one was a female ; eight patients laboured under General Paralysis, six under Melancholia, four under Acute Mania, four under Chronic Mania, two under Dementia.* Dr Stedman, in a Report of the Boston Lunatic Hospital, observes, that " a man who has been insane above twenty years and was very unmanageable, was attacked with dysentery and remained dangerously ill for some weeks. He recovered from dysentery, and now no patient in the house is more quiet and controllable, indeed, to many he would appear mentally sound.''' Cases of temporary recovery of the intellectual powers from the accession of an acute disorder may here be referred to, such as the rare case of the female related by S. Tuke in his ' Description of the Retreat,' who, after being demented for many years, was attacked by typhus fever. During the stage of excitement, when others are usually delirious, she was entirely rational. " She recognised in the face of her medical attendant the son of her old master whom she had known so many years before ; and she related many circumstances respecting the family and others which had happened to herself in her earlier days. But, alas ! it was only the gleam of reason ; as the fever abated, clouds again enveloped the mind, she sank into her former deplorable state, and remained in it until her death, which happened a few years afterwards." Recently we have seen a female patient at * In nine instances both ears were affected; the right alone in nine, and the left in five cases; in one not stated. See Magnan's views on this tumour in the ' Annales Medico-psyehologiques,' May, 1871 ; also the ' Journal of Mental Science,' 1854, for " Fischer's Researches," translated by Dr Arlidge, and the same Journal for July, 1862. In nine of the above twenty-four cases the patients died in the asylum, in the same number they were discharged unimproved, while the six remaining were cases of dementia. EEOOVBEIES 127 Bethlem relieved by asthma — ^the physical alternating with the mental affliction. The following circumstances happening during an attack of Insanity may act favorably upon the disease : — Discharges of any kind after being suppressed, parturition, cutaneous erup- tions, sudden moral shocks, accidents. We know of a case in which a very severe fall upon the head had the happy effect of causing recovery. 4. With regard to the relation of the cause of the attack to recovery, it may be observed, that so far as the experience of the Retreat goes, physical causes have appeared most to interfere with the prospects of recovery among the female patients ; while among the males, those cases which were due to moral causes have recovered least favorably. Those marked by intem- perance often rapidly recover, and remain well while xmder asylum supervision, to relapse again when exposed to the original occasion of the attack. The generally favorable termi- nation of puerperal cases will be seen in the section on this form of Insanity. Insanity occurring after fever is sometimes per- manent, but is also not unfrequently recovered from in the most satisfactory manner. Too much importance must not, therefore, be attached to continued fever as a cause, unless its form has been such as to involve primarily, and seriously impair, the cerebral functions. The result of those cases of Insanity which follow traumatic affections of the head is unfavorable, though we have known remarkable exceptions to this general rule. Those due to sexual vice are very unpromising, ever tending to dementia. 5. In referring to age, it may be stated that at Bethlem, of those admitted under twenty-five, about three fifths have re- covered ; between thirty and sixty-five, about one half were cured; and of admissions after the last-mentioned age, about one seventh recovered. At the Somerset Asylum the most ' favorable age for recovery has been from twenty-five to thirty- five, amounting to nearly 42 per cent, of the whole, the admis- sions being more frequent at this decade, and the prevailing form of Insanity being Mania (Boyd). Insanity in the young cannot be regarded hopefully. First attacks of Insanity after fifty are unfavorable. In Dr Boyd^s Tables, out of 2000 admissions (including re-admissions) 746 were discharged cured, and of these 153 recovered after fifty, 74 after sixty, and 15 above seventy. It is needless to add that, when loss of mental 128 OF INSANITY IN GENERAL power is caused by advanced age, recovery is hopeless, althougli there may be transient gleams of intelligence. The writer knows a case, that of an elderly lady, who, after being the sub- ject of senile dementia for years, spoke rationally for a short time within twenty -four hours of her death. It is a popular belief that this brightening before death is frequent with the insane generally. In our experience, however, it is extremely rare. At the York Retreat this alleviation of the symptoms, so far as it has been observed and recorded, took place most frequently in Mania. Dr Thurnam^s statistics record 8 cases out of 33 of Mania, as many out of 45 cases of Melancholia, and 2 cases out of 14 of Monomania, in which a most decided im- provement before death occurred. Of these, however, there were three cases in which the patient was considered convales- cent and was taken off suddenly by such disorders as apoplexy and epilepsy. The less frequent fact of the aggravation of the disorder was observed in two cases of Melancholia. A patient at the Wakefield Asylum, under Dr Major, seen by the writer when in a profoundly melancholy and unpromising state, brightened up before death in a remarkable manner, and thanked those who had attended to him for their kindness. He had been insane nearly three years, and died of phthisis. 6. As regards sex, in relation to recovery, it has been found at Bethlem that there is not so much difference between the sexes as some other statistics indicate. During ten years, 54*4 per cent, recovered among the females, and 53*8 among the males. (Hood, p. 27.) At the Retreat (from 1796 to 1861) the difference in favour of the women was, however, as great as 5*5 per cent. Up to 1872 this difference was about 7 per cent. At St. Yon (Rouen) the excess was about 6 per cent. (Par- chappe). At the Somerset Asylum (Dr Boyd^s tables) it was 3, and at the York Asylum (Dr Needham^s tables) about 2 per cent. The comparative infrequency of General Paralysis among women must always make a difference in favour of this sex. 7. There has been only a slight difference observable at Bethlem in the recoveries of the married and unmarried, namely, married 54*9, unmarried 53"8, and widoioed 50 per cent. ■ 8. Hereditary predisposition is unfavorable to permanent re- covery ; that is to say, although it does not always injuriously affect the probability of cure in the first instance, it renders relapses much more probable. RELAPSES 129 9. The season of the year which has a beneficial influence upon recovery is one neither of extreme heat nor cold. At St. Yon the autumn quarter has proved the most favorable^ the winter quarter the reverse. Thus, 618 cures were distributed as follows : — Winter quarter (December, January, February), 92 ; spring (March, April, May), 123 ; summer (June, July, August), 142 ; autumn (September, October, November), 158. We see, however, that at the Pennsylvania Hospital Dr Kirkbrides' statistics as to the period of recovery from 1841 to 1873 show the following result : — Total number of cures 2994. Winter quarter, 659; spring, 710; summer, 817; autumn, 808; giving the highest number for the summer quarter. The largest number recovered in July. In comparing this with the fore- going, the reader must allow for some difference between the American and French seasons. IV. Relapses. — But the preceding estimate of recoveries would be obviously imperfect without a consideration of the question. What proportion of those who recover subsequently relapse ? In 1851, Dr. Max Jacobi traced the after history of 661 patients who had been admitted into the Siegburg Asylum during twenty years (1825 — 1845). Of these, H22 had not relapsed; 127 had relapsed once and recovered again; 64 had relapsed and appeared incurable ; 1 1 remained under care ; 137 had died, of whom 68 had not relapsed; 57 died insane, while there were 12, respecting whom no information could be procured. Thus about 50 per cent, relapsed, a proportion Conolly reckoned for Hanwell. In the course of years no doubt more would relapse. Dr Mitchell has traced the history of 1297 patients admitted into Scotch Asylums for the first time in 1858 (and in no asylums before), and ascertained their condition twelve years afterwards (1870). The result was: Recovered .. 851 Not recovered .. 261 Dead .. 412 Re-admitted ... .. 499 Remaining .. 273 Of the 851 recoveries only 538 persons recovered, or 41*5 per cent, of the admissions ; of these, 316 (or 59 per cent, of 538) relapsed for a time, leaving 109, who either remained or died insane. The remaining 429 permanently disappeared as recovered, being 33 per cent, of the original number admitted. 9 130 OP INSANITY IN GENERAL It will be seen that as 412 died and 273 remained, 685 or 53 per cent, were accounted for, while 612 or 47 per cent, had dis- appeared at the end of the twelve years. These were tx'aced as far as possible, and it was found that : 42 bad died insaue. 78 „ sane. 94 were living insane. 197 „ sane. Thus 411 out of the 612 were accounted for, the remaining 201 not being traced. Dr Mitchell felt justified, however, in assuming that these cases would terminate in the same propor- tion, and therefore constructed the following table : Percentage. 1. As dead in asylum ... ... ... ... ... 31"7 „ after leaving asylum but insane at death ... 4'9 36-6 2. As still alive and in asylum ... ... ... 21"0 „ but out of asylum and insane ... ... 10"7 31-7 Yielding a total for all those who had either died insane or were still living insane of ... ... ... 68"3 3. As having died out of the asylum, being sane at death . . . 9*0 As still alive and sane ... ... ... ... 22*7 31-7 1000 Thus in 12 years, of 1297 persons : 366 per cent, died insane. 31-7 „ are still alive and insane. 31'7 „ are either still alive and sane or died sane.* 100-0 It will be seen from the above that after twelve years there were 68'3 per cent, of those admitted either still living insane, or who had died insane. As of the former, but few would recover, and of those who were living in a state of sanity some v>'ould relapse ; this result is more favourable than it will eventually prove to be. Probably at least 73 per cent, would at death be insane ; leaving only about 27 per cent, of the total number of persons admitted who would die in a state of sanity. Dr Thurnam succeeded in tracing out the subsequent history of every patient who had been under care at the Retreat, * "Contributions to the Statistics of Insanity," by Arthur Mitchell, M.D., LL.D., • Journal of Mental Science,' Jan., 1877. EELAPSES. MORTALITY 131 during forty-four years, in ivlwm death had occurred. As tlie history of eacli case was therefore completed, the table which follows is of greater value than those prepared by Jacobi and Mitchell. That of the latter, however, will, when completed, surpass both, from the larger number of cases. Patients followed tkrougli life. Died insane during the first attack. Recovered from first attack. Total. Eecovery permanent. Died sane. Had subsequent attack. Died sane. Died insane. Total. Males . . 113 Females . 131 55 58 58 73 21 24 6 14 31 35 37 49 Total . 244 113 131 45 20 66 86 From this it appears that, of 131 patients discharged cured (after the first attack), only 45, or 35 per cent-, had no return of the disorder. But of the 86 who had a return of the disease, 20 died sane. Hence, only 65 or 26'8 per cent, of the whole number (244) died in a state of sanity. Of those who recovered, about 50 per cent, permanently relapsed. We gave Dr Thurnam^s summary in the last edition, but it would be more strictly correct to say, of 11 persons attacked by Insanity, 6 recover, and 5 die sooner or later during the attack. Of the 6 who recover, not more than 2 remain well during the rest of their lives ; the other 4 sustain subsequent attacks, during which at least 3 of them die. " But, although the picture is thus an unfavorable one, it is very far from justifying the popular prejudice that Insanity is virtually an incurable disease ; and the view which it presents is much modified by the long intervals which frequently occur between the attacks ; during which intervals of mental health (in many cases of from ten to twenty years^ duration) the individual has lived in all the enjoyments of social life ■'^ (op. cit., p. 123). V. Mortality. — Much diversity of practice has obtainad in regard to the mode of calculating the deaths in asylums for the insane — some having calculated them on the admissions or on the discharges ; while the correct method is that of taking for the basis of calculation the mean number of patients resident in an asylum — in other words, its average population. From the Lunacy Eeport of 1877 we learn the annual rate 132 OF INSANITY IN GENERAL of mortality during eighteen years ending December 31st, 1876. The deaths (calculated on the mean numbers resident, viz. 33,442) amounted to 10-3 per cent. The sexes are not dis- tinguished ; we may, however, repeat those given in former editions for the five years ending 1858, viz. for males 13-25, and for females only 8*96 — corroborating the remarks made in a former Section, on the greater mortality of male lunatics. The mortality (for both sexes) during the above eighteen years was only 7*5 in the Registered Hospitals. In Provincial Licensed Houses it was 8"6 ; County and Borough Asylums, 10*8; in the Metropolitan Licensed Houses, 10*8 percent. ; and in the Naval and Military Hospitals and Royal India Asylum, 9*8 per cent. From the last Report of the Scotch Commissioners, 1877, it appears that, separating the private patients in asylums from the paupers, the average mortality calculated on the numbers resident in the nineteen years 1858 — 1876 was for the former class, males 8*2, females 6"7; and for the latter class, males 9*7, females 8'2. At the Retreat, from its opening to the year 1877, the annual mortality has been 4*41, being 5"20 among the male, and 3'85 among the female patients. At the York Asylum for the twenty-seven years ending December, 1877, the corresponding figures are, 6"81 ; 8*33 ; 5'06. The above statistics range (for both sexes) between 5 and about 11 per cent., a mortality beyond which, for a mixed class of patients, must be regarded as excessive, while one of 6 or 7 cent, is vexy satisfactory. The period of the year exerts the same influence on the mortality of the insane as the sane. In the French asylums, spring and winter are the most fatal periods of the year ; then autumn, and lastly summer. Of every 100 deaths which took place in asylums in Scotland in the seven years 1865 — 71, 53*70 occurred in winter, and 46-29 in summer (Report, 1872). At Bethlem Hospital, the deaths during the winter months appear to have only very slightly exceeded those which occurred during the summer months. (Hood's ' Statistics.' p. 81.) A most important question remains to be answered. Is the mortality greater among the insane than the sane ? Un- doubtedly it is. The average annual mortality at all ages in England and Wales for the seventeen years ending 1854, was 2-33 per cent, for males, and 2-17 for females; the mortality for the ages above twenty was 2-53 per cent, for MORTALITY 133 malesj and 2*48 for females. It will be seen that although this is a more correct period to take for comparison, the difference in mortality between the longer and shorter period is so slight as not materially to affect the result. Now, in every asylum for the insane, whether at home or abroad, statistics of which are published, the rate of mortality is very much higher. We have already given the mortality in the asylums of our own country ; the lowest mortality being more than double the above, namely, 5 '2 9. At St Yon (Rouen) during seventeen years, it was 7" 6 per cent. The average age, at the origin of the disorder, of the patients who died at the Retreat, from 1796 — 1840, was about 39 years, at which period the expectation of life is at least 28 years. Instead, however, of the average age, at death, of these patients being 67 (39+28), it was only 66. At the York Asylum the average age at death was 49 1 and should have been QQ (^ Statistics of Insanity,'' p. 101.) The high mortality of the insane at various ages will be seen from the following table. No more recent return has been made by the Commissioners in Lunacy than this, which is obtained from their Report for 1861, Appendix I, We have derived the mortality of the general population from the Registrar-General^s Reports for the corresponding years. Table. — Showing the Mean Annual Mortality per cent, at different ages in the County and Borough Asylums, Hospitals, and Licensed Houses of England and Wales during the five years ending Dec. 31, 1858; compared with the Mortality at the same ages during the same years in the general population of England and Wales. Insane in asylums. General population. Males. ■ Females. Males. Females. ' 15—25 ... 8-26 7-87 -77 -81 25-35 ... 10-36 7-17 •95 -99 35—45 ... 14-35 7-66 1-26 1-20 45—55 ... 14-44 7-36 1-77 1-50 55—65 ... 13-70 10-35 3-06 2-75 65—70 ... 70—75 ... 22-41 17-22 } ^'^^ 5-68 70 and upwards . 31-16 25-76 11-83 11-09 75—85 ... ... 14-67 13-39 85—95 ... 30-72 28-12 134 OF INSANITY IN GENEI^AL As the above is a high mortality, and extends over a short period, it may give a j aster impression to add the lower death- rate of the York Lunatic Asylum (1814 — 1840), and the Retreat (179G — 1840), which we have thrown together fi-om table 26 and table E of the ' Statistics of Insanity.' We are unable to give the same decennial periods as in the previous table. Age. Both sexes. Insane. Sane. 20—30 4-18 •98 30—40 4-80 1-16 40—50 6-35 1-43 50—60 5-43 2-14 60—70 6-61 4-05 70—80 10-33 8-74 80—90 All ages 26-49 19-08 6-02 2-24 Dr Parr has strongly insisted on the greater rate of mor- tality among the insane than the sane. {' Stat. Journ.,' April, 1841, p. 24.) We have his authority for stating that he holds the same views now that he did then. It does not, however, necessarily follow, from the foregoing, that Insanity itself accounts for the whole of this shortening of life, inasmuch as the circumstances which have induced the disease (as intem- perance, vice, and bodily disorders) may be the real cause of injuring the constitution, and curtailing the life of the patient, independently of mental disease. But there can be no question that a part of the high mortality of the insane is directly due to acute attacks of the disease itself proving fatal, and above all to General Paralysis. It is clear that whatever influence Insanity has upon the dura- tion of life when the disease is in its acute stage, and in General Paralysis, there is not anything like the same tendency in this direction when it has assumed a chronic form. A London Actuary, Mr John Le Cappelain, taking Dr Thurnam's statistics as his guide, drew up the following table for the Massachussetts Commission on Lunacy in 1855. The average length of insane life of persons incurably deranged is — PEOGNOSIS 1 Males. Females. If attacked at 20 years of age 21-31 years. 28-66 years. 30 20-64 „ 26-33 „ 40 17-65 „ 21-53 „ 50 13-53 „ 17-67 „ 60 11-91 „ 12-51 „ 70 9-15 „ 8-87 „ 13^ Dr Farr states that at Betlilem and St Luke's the annual mortality among the " curables '^ was 11 per cent., and only 6 per cent, among the '^ incurables " (chronic cases) ; and at Hanwellj among those in a state of Mania, Monomania, or Melancholia, it was about 12 per cent., while in cases of Dementia the mortality was 8 per cent. It was found by Dr Thurnam that in asylums generally, there is rarely a larger proportion than 20 per cent, of deaths in persons above 60, and that at the York Asylum it was, during a certain number of years, 26 per cent., and at the Retreat 45 per cent., and of these 11 per cent, were from 80 to 97 years old. It may be added that the average duration of the disorder at death was above 17 years. Simimary as regards Prognosis. The foregoing examination, by the numerical method, of the experience of Institutions for the Insane, may be thus sum- marised and extended — mainly in regard to recovery of mental health. Hereditary predisposition is unfavorable to permanent re- covery, but not at all necessarily so to the restoration of mental health in the first instance, some statistics showing particularly favorable results. If the constitution is saturated with Insanity, signs of which have from time to time cropped up, it stands to reason that the ultimate prognosis must be much more un- favorable than in a healthily constituted person. The primary importance of that congenital condition of the brain, which causes the greater liability, under precisely similar external conditions, of A than B (in the first instance, deter- mining the occurrence of an attack of Insanity) must be con- stantly kept in view. This, whether hereditary or not, must be regarded as the/o??s et origio mali ; and is no more mysterious than the tendency in 136 OF INSANITY IN GENERAL one person to consumption, and in another to gout. As it cannot be expected that this predisposing susceptibility shall be ex- tinguished by an attack of Insanity, a well-marked insane dia- thesis must be taken into account in estimating the probability of a relapse. The prognosis must be greatly influenced by the future surroundings of the patient after he recovers. Idiocy and Imbecility, although modern science and humanity have done much to educate idiots and imbeciles, must remain at the bottom of the scale, because they involve congenital defect in, or arrested development of, the centre of the nervous system essential to the operations of mind. Dementia is, with rare exceptions, incurable. In Senile Dementia there may be returning gleams of intelligence, but no recovery. Acute Dementia is not unfrequently recovered from. General Paralysis, while admitting of remissions which pro- mise recovery, is the most unfavorable form of Insanity as regards mental recovery, and the most fatal. Hence, hesitation in speech, tremor of the tongue, an altered gait, are the worst signs that can manifest themselves in the invasion of mental disease. Epileptic Insanity offers little hope of really permanent re- covery. The exceptions are so few that it may be regarded as almost incurable. Apoplexy and Paralysis are very unfavorable complications. Perversion of the moral sense from disease must always be regarded unfavorably, except when arising in puerperal states, and in those temporary conditions which arise from sympathy with disorder of a distant organ, as in the development of the reproductive organs at puberty, or from so simple a cause as ascarides. It is important to ascertain the constitutional mental tendencies or character, for while a change of disposition is a proof of disease, the intensifying of naturally vicious traits of character may also be the result of increased diseased activity, and such a substratum as exists in these cases, renders a radical cure hopeless. Delusional Insanity is not a hopeful form of Insanity. Monomania, in the sense of a deeply rooted delusion or false PEOGNOsrs 137 conviction, in respect to one class of subjects, generally resists treatment obstinately. Still more unfavorable are the delusions of grandeur and riches. Hallucinations and Illusions of one, and especially of all the senses are unfavorable, except when due to an acute or febrile condition of the system. Insanity induced by intemperance is unfavorable, and, when it does not assume an incurable form, manifests a strong tendency to relapse after recovery. Acute Mania is in a large proportion of cases recovered from. Acute Melancholia, if cases which never reach an asylum are included, is, at least, as frequently cured, but certainly in asylum experience it comes next in order. Simple depression of Mind is not unfavorable, except in the decline of life. Climacteric Insanity is not a hopeful form of mental derange- ment. Drink-craving frequently manifests itself at this period of life. Change of life, however, occasionally exercises a beneficial influence on those already insane. Statistics clearly show that first attacks of Insanity occurring at or after 50, are much more rarely followed by recovery, than, attacks of earlier life. Hysterical Insanity is usually a favorable form of mental disease. Relapses are, however, frequent. The condition of maniacal exhaustion is one of peril, and calls for a guarded prognosis. Protopathic Insanity, as e. g. when due to sun-stroke or a blow, is much less curable than Deuteropathic Insanity. Puerperal Insanity is, as a rule, very curable, unless it assumes a phrenitic character. Alternations of excitement and depression, whether amount- ing to well-marked Circular Insanity or not, constitute a bad sign= Regular remissions cannot be regarded as favorable signs, although .they do occasionally occur, in a more or less marked manner, in cases which recover. Experience certainly does not confirm the unqualified observation of Rush, that '' remissions and intermissions of violent mental excitement 138 OP INSANITY IN GENEEAL are always favorable/' If by remissions, however, Rush simply means a change in the morbid symptoms, as opposed to a constant uniformity, he is no doubt correct in his opinion. A fear of poverty, refusal to take food, a disposition to com- mit suicide, suspicions of persecution, or of poison being put in the patient's food, are unfavorable signs. The Insanity of women is, generally speaking, more curable than that of men. Recovery is more probable if eai"ly treatment is adopted. In proportion to the continuance of the disease is the improbability of a cure. Better that the disease should appear suddenly than come on gradually. When recovery takes place it is nearly always gradual. In the exceptional instances of sudden recovery, however, relapse does not appear to be more frequent. The longer the period during which the causes exciting the attack have been in operation, the less probability is there of cure. Insanity caused by a prolonged moral cause appears to be less curable than when induced by one acting suddenly upon the mind, provided, however, that the shock is not so great as to induce Dementia. When a moral and physical cause combine to bring on an attack of Insanity, as in the case of vicious habits, the prospect of recovery is not favorable, and such attack is still more unfavorable when fixed ideas are present or the conversation is unconnected. Insanity due to moral causes alone is considered by Guislain to be much more curable than when arising from physical causes. With each attack of Insanity the probability of permanent cure diminishes ; at the same time many of the patients who relapse repeatedly recover. In obscure cases dirty habits often indicate organic disease, but in ordinary Mania they need not be regarded unfavorably. Cleanliness is always a favorable sign of returning health. The recovery of physical health unaccompanied by the return of mental sanity, is unpromising as regards the ultimate recovery of the patient. Stoutness under such circumstances is fre- quently the harbinger of Dementia. The relation between the weight- curve and mental states has recently received much PEOGNOSIS 139 attention. A case is reported in which " six times within three years, periods of excitement occurred which always gave place to symptoms of Melancholy. On the development of the former the bodily weight always began to rise, and reached its maximum when the exaltation was at its highest point. On the decrease- of excitement, the weight of the body began to fall till it reached, its minimum at the time of the most signal depression " (See 'Journal of Mental Science/ January, 1873, p. 614). On the other hand, maniacal excitement is frequently seen to be accompanied by the losing of flesh, and the prognosis is. assuredly bad. Restored affections are, perhaps, the strongest proof of return- ing mental health — are, in fact, to that extent, the restoration o£ sanity itself. The same observation may be made in regard to the return of proper delicacy of feeling in women. Return to accustomed tastes or habits is always to be hailed as a favorable indication even if in so trivial a matter as a relish for gingerbread, which has been known to be the first sign o£ returning sanity. Return to the mode of speaking, natural to the person affected with Insanity, is sometimes the first indication of recovery. It is said that Willis, observing George III speak in the rapid manner that was customary with him when well, declared he would recover. The case of a young man is related by Rush, who stammered before he became insane, ceased to do so when he was in the Pennsylvania Hospital, but began to stammer again when he showed signs of amendment. The return of suspended secretions is a favorable indication. This applies especially to menstruation. It is not the less true that patients who are regular, are more instead of less excited on the return of the period. Nor, again, can it be denied that menstruation often returns without being accompanied by the restoration of mental health ; sometimes even when a case is about to pass into hopeless Dementia. Certainly there is nothing like a uniform rule in this matter. Profuse secretions are not unfrequently critical, but (unlike Esquirol, who devotes a long chapter to the subject) we rarely speak of the crises of Insanity. Thus, extraordinary perspira- tion sometimes marks restoration of mental health : at another 140 OF INSANITY IN GENERAL time cutaneous eruptions. But the term is vague, and in no instance are we in more danger of putting the cart before the horse. It implies as ordinarily used, that the evacuation cures the disease — allows it to escape, in short ; whereas, in the majority of cases, the restoration of the natural secretion, in abundant quantity, is merely one sign of returning physical and mental health. A copious flow of tears is often a very good sign, but must not be confounded with bhe emotional sensibility which indi- cates deep-seated disease of the nerve-centres. These are as distinct as the rush of the mountain torrent after the removal of some obstruction, and the stream caused by the bursting of a water pipe. Contrary to an old popular idea,* Pregnancy appears to exert an unfavorable influence upon mental disorder. A case of periodic Mania (monthly) is, however, recoi'ded, in which the symptoms were suspended during gestation and returned after- wards. The cases, however, at our command are too few to admit of a decided conclusion. Parturition occurring in those who have become insane during pregnancy, does not appear to excite any influence whatever in some cases, while in others the influence is bad. In the early stage of Insanity, restoration of sleep is a very favorable, and prolonged insomnia an unfavorable symptom. The occurrence of another disorder in the course of the dis- ease, is sometimes accompanied by an amelioration or cure of the mental disorder. Mania with homicidal impulses is generally an unfavorable form. Dr Ray observes that " there are unquestionably some circumstances in these cases well fitted to reduce the propor- tion of recoveries somewhat below the average. In most, the homicidal act is the offspring of strong delusions, indicating, probably, the severest grade of cerebral disorder short of obvious organic lesion, and in those cases where the act was prompted by some sudden impulse, or that confusion and per- version of ideas common in Acute Mania, it is not improbable that every restorative movement may be repressed by the per- petual consciousness of the terrible deed. Still, there are * See a letter written in 1813, contributed by the writer to the ' Journal of Mental Science' in 1870 (p. 250). PROGNOSIS 141 recoveries in this form of Insanity — enough to deter us froni giving an unfavorable prognosis in every case/''* Contrary to the experience of Dr Stewart at the Crichton Institution, Dr Ray considers that, other things being equal, " patients with good intellectual endowments, recover in larger proportion than those less happily constituted^^ — the greater the mental energy, the greater the recuperative power of the Mind. * " On the Prognosis of Insanity " (' Amer. Journ. of the Medical Sciences,' Oct., 1870). CHAPTER III. OF THE VARIOUS FORMS OF INSANITY. Preliminary Observations. Before entering upon the study of the various forms of Mental Disorder and Defect, the student is strongly recom- mended — I. To have clearly before him the Physiology of the Nervous System in general, and of the Encephalon in particular, as comprising the centres of Sensation, Motion, and the Intel- lectual, Emotional and Volitional powers ; combining with this the important truth that the brain, as well as the spinal cord, is susceptible to reflex action. The physiology of the nervous centres must, along with other sources of knowledge bearing upon the seat and causes of Insanity, be constantly kept in view in the study of acquired or consecutive mental disorder. II. To adopt as a guide some system of classification of the mental powers in health ; for as the mental faculties are functions of the Cerebral Hemispheres, they must be studied as manifested in health, and hence Psychology, in its general out- lines, must be mastered. In opposing, as we have always done, the pursuit of Meta- physics in connection with Insanity apart from the study of cerebral physiology, as barren and unprofitable, we do not undervalue the importance of clearly recognising the manifesta- tions of a healthy mind and distinguishing them, as far as practicable, according to their characteristic features. Other- wise, how is it possible for us to compare healthy and un- healthy states ? How can we speak of a morbid condition of the emotions, if we do not form some previous idea of what a healthy emotion is ? Of defective intellect if we attach uo definite notion to what the Intellect is in its ordinary manifes- tations ? Or, ugain, how can we comprehend the departure PRELIMINARY OBSERVATIONS 143 from the healthy working of the laws of mental action unless we understand what these laws are ? Metaphysicians have very generally recognised the two-fold division of the mental powers into the Intellectual and the Affective. Plato tells us that he distinguishes two principal faculties — that of Feeling and that of Thinking. Among modern metaphysical writers this distinction has no less been admitted and enforced. Thus, Reid^s analysis of the mental faculties comprised two great divisions, the Understanding and the Will, in which latter he included the appetites, passions, and affections. And Stewart, although he added a third class of faculties (those which belong to man as a member of a political body), did not the less admit the foregoing distinction. Dr Thomas Brown, again, divided the internal affections of the mind into two orders — " intellectual states of the mind, and the emotions,'''' And his editor, Dr Welsh, truly observes, that " Intellectual states and emotions are felt by us as generically different, and must always thus be felt by us.''^ The further subdivision of the emotions into the higher sen- timents, and the propensities, is to some extent insisted upon by the Scotch metaphysicians. Mr Morell, in his ' Speculative Philosophy of Europe,' more distinctly recognises a threefold division of the powers of the human mind. Thus, in combating the phrenologists, whose triple division is well known, he observes, "We did not require any phrenological aid to convince us that the animal loassions, the moral feelings, and the intellect, present three different classes of phenomena, which cannot be perfectly resolved into each other." Lewes, in his ' Biographi- cal History of Philosophy,' observes that '' the subdivision of the affective faculties into propensities and sentiments ■" has passed into general acceptance. By Fichte, the Intelligence, the Feelings, and the Will, were regarded as essentially distinct. And Bain, in his excellent work on the ' Senses and Intellect,' concludes that the most convenient, as well as the most truthful division, is into '' the Intellect, Emotion, and Yolition." Dr Copland adopted, as the most practically useful classification of the mind — the Intellectual Powers ; the Moral Affections ; and the Instinctive Desires and Feelings, or " those strong and immediate incentives to action in the lower animals, which are controlled by reason in man." Whether the student adopts a division of the mental functions into the Intellect, the Emotions, and the Will, or into the 144 OF THE VARIOUS FORMS OF INSANITY Intellect^ the Feelings (including tlie Moral Sentiments), and the Propensities, otherwise called Appetites, Desires, or Instincts, he will possess something like a classification of mental sym- toms, which will prove useful to him as a groundwork for the study of Insanity. If he enter upon this study entirely ignorant of mental science, he may be an anatomist, but he cannot be a cerebral physiologist. These functions, disordered, constitute the symptoms comprised under Insanity — the presence or occurrence of which is the occasion of the whole inquiry — the indications during life of the disorder of the functions, and, therefore, of the organ upon which they depend for healthy action. When the latter of the above-mentioned classifications of mind is adopted, the position the Will occupies will be this : — A certain state of the mind, whether as a primary feel- ing or a recollected feeling exciting a desire, determines voluntary action — actuation — conduct. " Volition,''^ says Bain, " involves Feeling and something more ; that something being action or the putting forth of power to some end." While dis- tinguishing the Will from the Intellect and Emotions, Bain refers " the most simple and primitive volitions to the same class as the Appetites and Instincts." He regards the ends of voluntary action as " identical with our various emotions. ^^ With him, volition expresses all human action, so far as it is governed by motives. " Desire," he observes, " is a form or aspect of the Will." When action takes place without any antecedent desire, it is usually of an involuntary, reflex character, although Bain contends that such an action as (for example) withdrawing the hand fi'om a painful scald, is an example of pure volition. Under Intellect are included Memory, Imagination, Reason, Judgment. Ideas are formed from Perception — the perception of the objects of the external world. Object-consciousness and Subject-consciousness are so closely united that it is difficult to separate them — as diflS.cult as to separate Sensation and Ideation. Sensorial Perception passes imperceptibly into Intellectual Perception.* The importance of testing the condition of these faculties in a case of alleged Insanity is obvious. The following grouping of the Emotions will prove an aid to the medical psychologist in comparing healthy and morbid emotional states. * On this subject the writer may be allowed to refer the reader to his work ou the ' Influence of the Aliiul upon the Body/ pp. 27, 49. PEELIMINAEY OBSERVATIONS 145 Joy and its various forms and synonyms — Contentment, Cheerfulness, Mirtlifulness, and the intenser states of Rapture and Ecstasy. It is opposed to Grief or Sorrow, and their synonyms — Sadness, Affliction, Distress, Discontent, Melancholy. Hope, the antithesis of Despair. Self-esteem, culminating in Pride. The reverse of Humility, Modesty, Self-abasement, and Remorse. Love of Approbation, or Vanity, though a form of self- esteem, has very different characters, and may even degenerate into the opposite of self-esteem — Cringing. Courage, sense of Self-possession or Confidence. The opposite of Fear, Fright, Horror, with the minor form of Anxiety. When epidemic. Fear assumes the Panic form. Allied to Suspicion. Calmness : the reverse of Anger and its aggravated phases of Rage, Fury, Wrath, or what is commonly understood as Passion, leading to Scorn and Contempt. Love, leading to Veneration, Adoration, and Reverence. Opposed to Hate, and Revenge, Benevolence, Compassion, Pity. The antithesis of Malevol- ence and Misanthropy. For the laws of mental association, suggestion and repro- duction, usually comprised under the four heads of Contiguity, Similarity, Compound Association, and Constructive Association, the reader is referred to Bain's work ' The Senses and the In- tellect.' III. To take a general view of Disorders of the Nervous System, both from a symptomatological and pathological stand- point, in order that the student may see them as parts, which they really are, of a great whole. Thus, he may commence with Disorders of Sensation, not involving Insanity, and examine them in their various forms. Anaesthesia, Pseud^sthesia, and Hyperesthesia, including morbid action of the special senses. Then he may take disorders of Motion, as manifested in ordinary Paralysis, Loco-motor Ataxy, Convulsions, &c. Further, he must not overlook those disorders which result from the morbid action of the nervous system upon Nutrition and Secretion, in addition to those marked by sensory and motor phenomena. IV. Lastly, the student and alienist physician will find it essential to employ, in taking notes of cases, some definite 10 146 OF THE VARIOUS FORMS OF INSANITY form. In general, our practical knowledge of the characters of mental disorder must, like those of other diseases, be derived from two grand sources — the subjective and the objective. The former is exhibited in what insane persons tell us of them- selves in their conversation and autobiographies, and is highly instructive ; the latter includes the phenomena observed by ourselves as spectators of the disease. Much information may be obtained by subjecting the patient to processes of inquiry, by way of investigation and experiment calculated to test his actual mental condition, not only in regard to what he does manifest, but also in regard to what he can manifest. This latter mode of determining the patient's condition we are con- stantly resorting to, almost unconsciously ; but it is one which M. Falret has laid especial stress upon, and is, doubtless, one which admits of, and deserves much more systematic cultivation than it has hitherto received. From all these various sources, therefore, we must derive our information of the different forms which mental disorders assume ; by a careful observation of bodily symptoms ; by eliciting the actual condition of the mental powers of the patient ; by systematic tests (percussing the patient, as Guislain would say) ; and by ascertaining his sensations. In examining a patient's bodily and mental state, help may be obtained from the ophthalmoscope, sphygmograph, assthesio- meter. Galvanism, Faradisation, &c. The following Form was drawn up by the Committee of the Medico-Psychological Association in 1869, as adapted for a Case Book : — FOEM FOE CASE-TAKING 147 CASE BOOK. Name Admitted Age and Sex State as to Maebiagb Edttcation Wheee feom Occtjpation Religion r Previous attacks Causation << ^^'Tf ^''''^'y I rredisposing [_ Exciting Duration of Disease FiEST r Mental Symptoms \ Bodily Recent |^*^^.f SYMPTOMS I g°.^\y^^ Other facts Sistory. Where treated. Disposition and "I habits in health j Dangerous Mind Body ("Exaltation State on Admission. Depression Excitement Enfeeblemenfc - Memory Coherence Can answer questions ? Delusions ^Other abnormalities ^Appearance Colour of hair Colour of eyes Muscularity Fatness Nervous System Reflex action Pupils Special Senses Retina ered after much forcing. Her hands were cold and blue ; her fingers firmly flexed j exceedingly thin. She has remained in this condition about twelve months. The following sphygmogram was taken for the writer by Mr Sheldon, Clinical Assistant at St. Luke's. The pressure was 3 oz. Fig. 1. A state of delusional insanity passing into a condition which may be regarded as one of Acute Dementia, although it is impossible to say when the former passed into the latter, is illustrated by the two following cases which we have frequently examined at Bethlem Hospital, and for permission to use which we are indebted to Dr Rhys Williams. One of them was often spoken of as the shadow of the other. A young letter-carrier (C. B — ) in London was in usual health when one day a fellow-postman was arrested for stealing letters. C. B — believed him to be innocent, and therefore argued that there was nothing to prevent him sharing the same fate, and under this impression fell rapidly into a state of profound dejection. After being under treatment for some months at home and at Westminster Hospital and becoming * For permission to examine whom, and see the notes in the cas^-book, we are indebted to the Medical Superintendent, Dr. Mickley. ACUTE DEMNENTTA 189 worse he was remoYed to Bethlem. He had heen, it was stated, apathetic and cata- leptic ever since the moral shock referred to — one, it may be observed, which would hardly have upset a healthy mind. There was no hereditary predisposition to in- sanity, but a constitutional defect as regards robust mental power. When seen first by the writer he was standing like a statue with his arms by his side ; when extended they remained in the same position for a long time. They were not rigid, and were easily brought again to the side. He was perfectly mute, stolid, and did not assist himself in any way. His expression did not indicate mental suffering, and was, perhaps, more apathetic than absolutely vacant. His mouth was open, and the saliva trickled down continually. His circulation was feeble, his respiration slow ; his hands cold but not livid; he had no chilblains. He sometimes fed himself, at others it was necessary to feed him. He did not flinch when pinched or pricked. At times when ordered to walk he would do so, and stop at command. His general condition at this time is best described as that of an automaton. In about three months this patient was discharged " but little altered." When we saw him subsequently at home he appeared to be more lively, dressed himself, and spoke in whispering monosyllables, but he relapsed in some months and was removed to Hanwell, where we have recently (June, 1878), examined him. Dr Eayner states that he has improved since admission, but that he is in a mischievous state. The parallel case (F — ) was, as regards the expression of the countenance, more decidedly vacant. The fixed attitude and the cataleptic condition of the muscles when placed in certain positions were, in this case, striking symptoms. His eyelids were nearly closed, and on raising them, the eyes were seen strongly directed upwards ; the pupils dilated. The respiration was slow ; the breath very offensive ; the skin cool, but not so livid as in some patients labouring under this form of insanity. He was extremely anaemic. He required dressing, and did not attend to the calls of nature. The cause of the attack was stated to be family reverses and trouble. About eight months before admission he showed a want of interest in everything, and complained of painful feelings in the head after food. He had, on admission, hallucinations, saw faces in the table-cloth, heard voices which told him to do various things, which he said he must obey ; and sometimes said, laughing, that he heard the voices making a succession of puns. Subsequently he did not speak, or at most a few words in a whisper when urged to it. A year after admission this patient died.* Some time previously the note was made in the case-book, " He is weaker in every way, and vnU probably die by his lungs. His colour now is most cadaverous ; his skin cold and clammy. Mucus hangs about his nose and mouth." As the phthisis advanced the patient became much more sen- sible, not dirty at night as before, and answered questions. To his relatives he talked freely. We have no doubt that, after making the deduction required by M. Baillarger^s just observations, unquestionable cases remain in which there is a temporary suspension of the mental powers without any absorbing delusion, although comparatively uncommon. Lastly, there are cases not comprised by Esquirol and other * For a report of the operation by M. Roussel of transfusion of blood in this case see a communication by Dr Rhys Williams in the ' Brit. Med. Journal,' January 20th, 1877. 190 OP THE VARIOUS FORMS OP INSANITY writers, under the specific term Acute Dementia, which, how- ever, present symptoms of Dementia of a transient character. We refer to those which are not necessarily marked by any loss of sensibility, or by that mentally prostrate, motionless, and speechless condition which we note as present in genuine in- stances of Acute Dementia. There is, however, for a certain period — it may be only a few weeks — a state which scarcely differs in anything from the ordinary form of Dementia, except in the fact of its terminating in recovery, and this in a compar- atively short period of time. We have recently seen a lady pass from a condition marked by emotional disturbance, to one of complete incoherence, loss of memory, inability to recognise those around her, accompanied by a completely demented phys- iognomy. The characters of genuine Dementia were present, and a return of coherence appeared higdly improbable ; yet, within four or five weeks, her conversation became rational, and her expression of countenance the same as previously. When Dementia becomes chronic, the general description which has already been given of the disease more especially applies. .ffitiology. — The causes of Dementia are various. We have spoken of it as a sequence of General Paralysis and of Mania. It may succeed apoplexy, especially those transient attacks which injure the mind more than the body ; epilepsy ; intempe- rance, and the physical and moral causes of other forms of In- sanity. Fright is a well-ascertained cause. At the Eetreat a patient was admitted in a state of Dementia produced by fright. He was naturally of a timid disposition, and during his appren- ticeship his master frequently amused himself with exciting his fears. One evening the servant girl dressed herself up in men^s clothes, and opening the shop door, snapped an unloaded pistol at him. This so terrified him that his faculties were immediately injured. He became shortly afterwards almost frantic, and after being out of his mind for about two years, he was brought to the Retreat incurably demented. In speaking of Primary Dementia, we have recorded a case produced by sudden emotion. Senile Dementia may be regarded as another variety, although when established, it differs little in its symptoms from the chronic form. Among celebrated men at an advanced period of life who have succumbed to this form of mental disease, one of England's most distinguished writers and poets may sewe as an illustration of the various incipient symptoms and ultimate SENILE DEMENTIA 191 steady progress of senile decay of cerebral power. When sixty- five years of age there was, we are told, in the ^Life of Southey' (vol. vi, p. 386), evidence of defective memory on some points, less acuteness of the perfective faculties, an unaccustomed •irritability, confusion of time, and of place, as indicated by his losing his way in well-known places. The vigour of his faculties in general was observed by his friends to be weakened — a gleam or two now and then of his former genius, but at other times a painful absence of his usual animation, perspicuity, and elasticity of mind. His appearance is characteristically de- scribed as one of placid languor, sometime torpor, but generally cheerful — all fire and strength gone from his face. We have spoken of the painful consciousness which sometimes marks the first stage of Primary Dementia. So with the poet. He would lose himself for an instant, and, being fully conscious of it, " an expression passed over his countenance which was exceedingly touching, an expression of pain and also of resignation.^^ Then there was the altered step, and the eye fixed, now on space, now wandering anywhere ; now turned to his books as he walked round his library, " taking them down mechanically.^^ Eecent events, as is usual, were the first to be forgotten, the memory thrown clearly on the far past, and going back further and further, as the mind approached nearer and nearer to its second childhood. When he could not recall a name, he would some- times (his son states) " press his hand upon his brow and sadly exclaim — ' Memory ! memory ! where art thou gone V " The final stage was marked by a dream-like state of existence, which extended over the last — the sixty-eighth — year of the poet^s life. As Prichard remarks. Senile Dementia '^^has been observed frequently to make its appearance in men long engaged in active pursuits, soon after they have relinquished their business or professions, and have laid themselves by to enjoy ease and leisure for the remainder of their days. The disease often appears in a more marked and sudden manner in elderly persons, who have sustained a slight attack of apoplexy or paralysis, which has, perhaps, been speedily recovered from, and might be expected to have left but slight traces of disease. This expectation is verified, so far as the sensitive and motive powers are concerned, but the seat of intellect is found to have been shaken to its very centre.^^ In the instance of Southey, a severe domestic calamity, with forty years'" uninterrupted brain- work, combined to induce the condition of mind just described. 192 OP THE VARIOUS POEMS OF INSANITY Prognosis. — The prognosis must as a rule be most unfavorable. (See p. 135.) Fever, and acute maniacal paroxysms have, however, occa- sionally been the means of restoring to reason patients appa- rently sunk in hopeless Dementia. Of the effects of the former, several instances are on record. (See p. 126.) Such cases prove the fundamental difference which exists between Dementia and Idiocy, in which no feverish excitement of the brain could dispel the cloud and allow of sunshine. The transient gleam of intelligence occasionally occurring before death is referred by Dr Despiue to the principle enun- ciated by Claude Bernard, that when a histological element dies or tends to die, its irritability auguments before it is diminished. That this does not always occur in Dementia is explained by this writer by the circumstance that the brain-cells are, in the great majority of cases, too much degenerated to exhibit any vitality, and that, therefore, it is only when there is "^ a sort of paralysis of the histological elements of the brain ^' that such lightening up before death takes place. To the influence of maniacal paroxysms, Pinel bears witness. '' Many, especially young persons, after having remained several months or years in a state of absolute Dementia, are attacked by a paroxysm of Acute Mania, of twenty, twenty- five, or thirty days' continuance. Such paroxysms, apparently from a reaction of the system, are, in many instances succeeded by perfect rationality." He relates the case of a man in whom Dementia had been induced by over- depletion, and ^' all the functions of the understanding obliterated." Prior to recovery, " his coun- tenance was flushed, his eyes wild and prominent, attended by febrile excitement, extreme agitation, and at length complete delirium. Thus raised to maniacal consequence, our hero sallied forth, and provoked and insulted every person he met with as he went along. He continued for twenty days in a state of delirious excitement, when a calm succeeded, and the dawn of reason faintly glimmered above the tempest. Moderate employment and regular exercise, co-operating with the ener- gies of Nature herself, restored him, in a short time, to the full enjoyment of his intellectual faculties." We know of a case of Dementia, however, occurring in a young man, in which an attack of Acute Mania that promised much, passed away with- out any good result. We add a few sphygmograms taken from patients in a state SPHYGMOGEAMS IN DEMENTIA 193 of Dementia.* It is necessary to put the student on his guard, however, against supposing that uniformity of character attaches to the radial pulsations observed in different mental conditions. The condition of the heart, the vessels, and the character of the food recently taken must be taken into account. Another source of error is the varying amount of pressure used. At the same time such tracings as the following are not without their value, having all been carefully taken by the same physician. Fm. 2. {a) In a patient get. 18. Fig. 3. {b) In a patient set. 45. Fig. 4. (c) In a patient set. 37. Fig. 5. (d) In a patient set. 34. * From Dr Hun's article " On the Pulse of the Insane," in the ' American Journal of Insanity,' January, 1870. 13 194 OF THE VAEIOUS FORMS OF INSANITY Fig. fi. (e) In a patient set 40. The " Pulsus tardus " regarded by Wolff as associated with incurable insanity nearly resembles Fig. 6. For the purpose of comparison, we append tracings of the pulse in health, fever, &c. Fig. 7. (/) The pulse in health (tricrotic), after Marey and Wolff.* (Pulse 64.) Fig. 8. \ i\ h \ K W \\ ' h Qf) A dicrotic pulse (110 beats) in a case of fever. Fig. 9. (A) A monocrotic pulse accompanying increased temperature and frequency of the pulse (140 beats). SECTION III.— Delusional Insanity. From Dementia, which, with Idiocy, Imbecility, and Creti- nism, belongs to feeble conditions of our intellectual constitu- tion, we pass to delusional insanity, which, for the most part, * This and the two following tracings are taken from Dr Wolffs "Beobach- tnngen iiber den Puis bei Geisteukranken," ' AUgemeine Zeitschrift fur Psycliiatrie,' 1867—9. DELUSIONAL INSANITY. SYNONYMS 195 exemplifies undue intensity of the conceptive and perceptive faculties. Synonyms and Definition. — The term " Monomania ^^ was em- ployed by Pri chard in the foregoing sense. '' Monomania, or partial Insanity, is characterised by some particular illusion or erroneous conviction impressed upon the understanding, and giving rise to a partial aberration of judgment ; the individual affected is rendered incapable of thinking correctly on subjects connected with the particular illusion ; while in other respects he betrays no palpable disorder of the mind.^^ When there is no morbid perception, but only a false con- ception, the French employ the expressions conception fausse, conviction deJirante and idee fixe. Prichard^s definition sufl&ciently describes intellectual Mono- mania, with which, alone, we are now concerned. There is, however, an affective monomania ; and a Mania without delirium {i. e. without disorder of the intellect), or instinctive Mono- mania; these will demand our attention subsequently. M. Falret pere has been represented as denying the existence of Monomania ; but, although he objects to the term, and inclines to the idea of the mutual dependence or solidarite of all the mental faculties, he appears virtually to admit the con- dition of mind indicated by it, under the head of " partial expansive Insanity.''^ Moreau ignores Monomania altogether; and observes, that we are mad or we are not mad ; we cannot be half deranged, or three quarters ; full face or profile. Bail- larger says, " I believe that the differences among us are chiefly verbal, and that essentially, and in matters of fact, we are very nearly agreed." The term Monomania was first employed by Esquirol. Pre- viously, the word Melancholia was made use of ; the employ- ment of which was objected to by that writer, on the ground that partial Insanity, is not necessarily Melancholia. Dr Prichard makes an objection, to the effect, that had the classic sense of the word " Melancholia " not been lost, its adoption to signify pleasurable as well as gloomy, partial Insanity, would not have appeared paradoxical, for ancient writers attached no idea of despondency, but only madness, to the term. This, however, is scarcely correct ; for although, no doubt, the Greeks employed the word somewhat loosely, they did certainly attach the idea of gloom to it, when strictly defining it. Hippocrates, in one of his aphorisms, says, " If fear or distress continue for 196 OF THE VARIOUS FORMS OF INSANITY a long time, this is a symptom of melancholy."* And, in other places, he distinguishes Melancholy from Mania, by the absence of violence. Sometimes, however, he applies the word to madness in general. Modern writers, before Esquirol, used the word Melancholy to convey the idea of derangement on some particular point, whether accompanied by gloom or mirth. Thus Cullen included, under Melancholy, " hallucinations about the ])rosperous/' as well as " the dangerous condition of the body. Dr Good speaks of "a self-com'placent Melancholy," and defines Melan- cholia as an alienation confined to a few objects or trains of ideas, quite irrespective of their depressed or exalted character. It was for melancholy, used in this sense — that is to say, any ])artial Insanity, whether gay or sad — that Esquirol introduced the word Monomania, restricting the term lypemania to the state popularly understood as Melancholia. But, even Esqui- rol's use of his own term becomes rather vague, for he employs it in two senses ; the comprehensive one just stated, and that of gay partial Insanity' — the amenomania of Rush. " In lype- mania," he observes, " the sensibility is painfully excited or disturbed ; the sorrowful and depressing passions modify the intelligence and the will. The lypemaniac fastens upon him- self all his thoughts — all his affections ; is egotistical, and lives within himself. In Monomania [in the second of the above senses], on the contrary, the sensibility is agreeably excited ; the gay and expansive passions react upon the understanding, and the will. The monomaniac lives witJwtd himself, and dif- fuses among others the excess of his emotions." In illustra- tion of the former, this writer refers to the case of the woman who did not dare to bend her thumb lest the world should come to an end ; and to that of the man who imagined the earth covered with a shell of glass, under which were serpents, and did not dare to walk for fear of breaking the glass and being devoured by them. Under Monomania proper, he introduces those cases in which patients believe themselves to be illus- trious personages, as sovereigns, &c. Almost every asylum contains within its walls emperors, kings, or queens. Mono- manias, therefore, by Esquirol and the French writers who have followed him, are divided, when they write with scientific pre- cision, into those of a pleasurable kind (monomania proper, or amenomania) and those of a gloomy character {hjpemania or * Hi/ ^6j3og t} SvaOvniT] ttoXi'J' ^povov StanXir], fiiXayxoXiKov to toiovtov. DELUSIONAL INSANITY. DEFINITIONS 197 melancJiolia) . To them, in tlieir relation to the emotions, we shall have to recur when we come to treat of these forms of mental disease. "'In our opinion/^ observes M. Baillarger, '' the word Monomania best designates all the cases of partial delirium with a dominant series of ideas, whatever may be the accessory phenomena, the number or variety of false secondary ideas." A fixed idea in fact, like the delirium of Mania, like hallucinations, the result of the involuntary exercise of the faculties, overcomes the will, in consequence of a diseased con- dition of the brain." " Monomania is specially indicated by delusion." To the consideration of Delusions in general, we must now direct our attention. There are several terms made use of by psychologists, of which it is necessary to have a clear understanding, but, regard- ing which, unfortunately, great confusion exists among writers on Insanity. We refer to the terms hallucination, illusion, and delusion. The words themselves do not convey to the mind the sense in which they are employed. If we consult John- son's ' Dictionary ' we find under hallucination, the following definition, " error, blunder, mistake, folly ;" while illusion is defined to be, "mockery, false show, counterfeit appearance, error ;" and delusion, " a false representation, illusion, error, a chimerical thought." From these definitions, which are cer- tainly not remarkable for their discrimination, we may, how- ever, infer that the lexicographer recognised the distinction between the first and the other words, to consist in the former being simply a state of passive error, while the latter imply the causing others to err. This is consistent with the sense attached by Latin writers to the verbs from which they are derived. Cicero says — " Quae Epicurus oscitans alucinatus est." And Yirgil — " Circumfusa ruit, certantque illudere capto." In another place he says — " Aut qu£e sopitos deludunt somnia sensus." Hallucinor, or allucinor (more correctly al), is derived, by Dr. William Smith, from a\vw, aXvo-/c(i>, and is thus rendered in his dictionary, " to wander in mind, to mistake," &c. ; while 198 OF THE VARIOUS FORMS OF INSANITY illudo is " to play upon, to ridicule /' and deludo, " to play false with, to mock, to delude." Hence, illudo and deludo are, classically, synonymous, and differ from hallucmor in signifying to deceive, or to illude. When there is deceiving, an agent that deceives is implied ; and it has probably been in this way that the meaning attached to the words illusion and hallucination, about to be mentioned, has originated. A man, may be labouring under an error in three prin- cipal ways : An object may appear to be present before his eyes (to take, in illustration, the sense of sight) which has no existence what- ever there : he experiences sensations, although no material objects act upon the senses at the time. (Hallucination.) If unable to recognise their true character, when an appeal is made to reason, he is also insane. Secondly, an object may appear to his eyes in an entirely different form from that which it actually has. Here the sensations are produced by the false perception of objects. (Illu- sion.) If unable to recognise their true character, when an appeal is made to reason, he is also insane. Lastly, a person may (independently oi false inductions) have certain false notions and ideas, which have no immediate reference to the senses as in the two preceding instances; as, for example, when he believes himself or some other person to be a king or a prophet ; or that there is a conspiracy against his life ; or that he has lost his soul. Or, as another example, he may believe himself to be a tea-pot, without seeing or otherwise perceiving any change in his form. In all examples under this last head, a man is necessarily in- sane. He cannot have a false belief (not simply a false induction, but) the result of disease, and unconnected with the senses, with- out the mind being unsound. " Delusion" is generally used by English writers to include all these various errors so long as they are not corrected by the understanding. This, however, need not prevent our clearly recognising the scientific distinctions which have been pointed out, and which in psychological literature, may with great advantage be admitted. But while the word delusion may be employed in a general sense to comprise all these divisions, the phrase delusion 2^'roper would naturally imply any error which is neither an illusion nor a hallucination, and those false ideas or DELUSIONAL INSANITY. DEFINITIONS 199 notions wMcli do not, strictly speaking, involve sensation. In this sense Delusional Insanity includes hallucinations and illusions, whenever they involve the reason. Instances, however, will occur, as has been already intimated^ in which a difference of opinion will exist as to the class to which they ought to be referred. In the example referred to of a man believing himself or any one else to be a tea-pot, Brierre de Boismont would say that he was labouring under an illusion ; but such a case would appear to us more properly referable to the third class, that of false notions or conceptions.* There is no false sensation ; unless, indeed, we follow Condillac, who regarded imagination itself as only a mode of sensation, and held that " sensation embraces in itself all the faculties of the soul.^' The only practical course is to consider in each case, whether there is a false sensational perception, be it visual, auditory, olfactory, gustatory, or tactile. Again, Brierre de Boismont gives, as an example of illusion, an individual believing that an entire stranger is his wife, or Napoleon Buonaparte. In the majority of such cases, however, there need be no illusion of any of the senses. Thus, a lady, who, when she was insane, believed a particular person to be the Enemy of mankind, informs us, that his appearance was then in no respect different from what it is now ; but the patient added, " Ideally, he seemed nothing but Satan.^' On our asking whether she was not surprised at the individual not having the external form vulgarly attributed to Satan, she gave a reply, which was, doubtless, the correct scientific explanation of the fact, " I do not think I had enough reasoning power to be aware of any inconsistency in my belief." It may here, also, be remarked, that while in genuine illusion and hallucination, no appeal to the reason, even if that appeal succeed in producing conviction, alters the apjoearance of the object ; in delusion proper, once convince the patient of the absurdity of his belief, and the disorder itself entirely vanishes. The following case is a good example of Delusional Insanity, and his recovery illustrates the truth of the above remark. * Esquirol, in reference to such cases, speaks of persons losing their personal identity. But this sense is, in reality, no more lost than when the delusion has regard to some extraneous object. In fact. Brown draws one of his strongest arguments in favour of the universality of the consciousness of personal identity from the fact, that " even the very maniac, who conceives that he was yesterday emperor of the moon, believes that he is to-day the very person who had yesterday that empire."— PhilO' sophy of the Human Mind, p. 83. 200 OF THE VARIOUS FORMS OF INSANITY A man thought that his legs were made of glass. His servant, we are informed, " bringing one day some logs of wood to mend the fire, threw them carelessly down ; for which her master, who was terrified for his legs of glass, severely reprimanded her. Tlie surly maid, who was heartily tired of her master's insanity, gave him a smart blow on the leg with one of the logs, which hurt him a good deal, and so provoked him that he rose from his seat (from which he never walked for fear of breaking his legs) in a violent hurry, to revenge the insult. Soon after, when his anger was abated, he was happy to find that his legs were able to support him j and his mind was from that time perfectly freed from this absurd imagination." (Van Swieten ; and Arnold, vol. i, p. 127.) Patients have believed themselves transformed into wolves (lycanthropia), dogs (cynanthropia), lions, cats, cows, sparrows, cuckoos, earthen vessels, pipkins, jars, tea-pots, &c. Some have supposed themselves to be grains of wheat, and have been for ever in apprehension lest they should be so unfortunate as to be eaten up ; and a lady is recorded to have believed herself to be a goose-pie. It is related of a man, that he believed him- self to be Atlas, supporting the world on his back, and was in great dread lest it should fall and crush, not only himself, but all mankind to atoms. (Op. cit., pp. 124, 129, 133.) At St Luke's Hospital Dr Mickley recently pointed out to us a patient who believed himself to be a steam engine, and mimicked one in motion. Others believe they are gods, sovereigns, or prime ministers, and afford examples of " Delusional Insanity, of an exalted character " (see p. 49), although we cannot too often repeat that the delusion may be merely the indication of the condition of the affective faculties. To these we shall return when we speak of Monomania involving the Emotions. We may here refer to a case coming under our own cognisance in which the delusion was of this character : A foreigner believed himself to be Jupiter, and made a great disturbance in the church at Falmouth, in December, 1860. In the midst of the evening service he rose from his seat, and rushed, stick in hand, through the church, shouting in a very excited manner, " St. Pierre ! St. Pierre ! St. Pierre !" In broken English he exclaimed that he had come there to sleep, and that Jupiter might as well sleep there as in a barn. When removed from the church by the mayor and other gentlemen, his hat, stick, and a roll of papers were left behmd. The following was written upon one of his papers : Geniology. Albert and Victoria. JUPITER. We learn from Benvenuto Cellini's autobiography, that — The governor of the castle, in which he was confined, " had annually a certain periodical disorder, which totally deprived him of his senses, and when the fit came MONOMANIA OF PERSECUTION 201 upon him he was talkative to excess. Every year he had some different whim ; one time he conceived himself metamorphosed into a pitcher of oil; another time he thought himself a frog, and hegan to leap as such ; another time he imagined he was dead, and it was found necessary to humour his conceit by making a show of burying him. Thus had he every year some new frenzy. This year he fancied himself a bat, and when he went to take a walk, he sometimes made just such a noise as bats do ; he likewise used gestures with his hands and his body, as if he were going to fly." (Vol. i, p. 339.) In all these examples, ttere appears scarcely to be implied a morbid sensation ; at the same time, in some of them, the false idea may have originated in a morbid sensation. This may, per- haps, be suspected when a man believes himself to be made of butter, wax, &c. The case of the man who believed his legs were made of glass, would by many be called an example of illusion ; but we do not think rightly so. He might not, in the proper sense of the word, feel that his legs were vitreous ; he would probably conceive them to be so, but he would not, we imagine, contend that they looked like glass. In any one instance, however, in which the patient does so feel or see, the term would, doubtless, be correctly applied. When a man, after amputation of the leg, feels it still to be there, he unques- tionably does so from false sensations, which, however, he cor- rects by the testimony of his other senses. We know of a case in which the patient, who was always suspecting plots against his life {Monomania of Suspicion or Persecution), used to thrash the hedges and beat the walls with his stick, under the impression that they were his enemies. It is possible the walls and the hedges really assumed in his excited imagination the forms of his supposed foes ; but it is much more probable that there was no actual illusion of the visual organs. Another remarkable case of Monomania of Persecution will be referred to under Hallucination. The following is a case which will at once serve forcibly to illustrate the strange delusions to which patients are subject, and also the ill- defined boundary line which often separates a false conception, or intellectual belief, from an illusion. It affords an example of " Delusional Insanity of a melancholy character ^^ (see p. 49). Probably, by some, it would be regarded as an " illusion of hypochondriasis ;" but we think it is, at least in some of its features, illustrative of Delusion proper. A patient at the York Retreat gave this description of himself : " I have no soul 202 OF THE VARIOUS FORMS OF INSANITY I have neither heart, liver, nor lungs ; nor anything at all in my body, nor a drop of blood in my veins. My bones are all burnt to a cinder ; I have no brain ; and my head is sometimes as hard as iron, and sometimes as soft as a pudding." Another patient, equally deranged, thus described him in verse : — " A miracle, my friends, come view, A man, admit his own words true, Who lives without a soul ; Nor liver, lungs, nor heart has he. Yet, sometimes, can as cheerful be As if he had the whole ! " His head (take his own words along) Now hard as iron, yet, ere long. Is soft as any jelly ; All burnt his sinews, and his lungs ; Of his complaints, not fifty tongues Could find enough to teU ye. " Yet, he who paints his likeness here. Has just as much as him to fear j He's wrong from top to toe : Ah ! friends, pray help us, if you can. And make us each again a man. That we from hence may go." The expressions " hard " and " soft " would appear to imply- that the patient experienced such sensations, and therefore this latter error we should refer to the head of illusion ; but the error the patient had fallen into, in regard to the loss of his soul, &c., belongs surely to a different class — to that, namely, of false conceptions, independent of any sensation properly so called. Many examples of lycanthropia (to which reference has been made) are on record, although an extremely rare disease at the present day. It was recognised by ancient writers. " Those labouring under lycanthropia,^' says Paulus ^gineta, " go out during the night, imitating wolves in all things, and lingering about sepulchres until morning. You may recognise such persons by these marks : they are pale, their vision feeble, their eyes dry, tongue very dry, and the flow of the saliva stopped ; but they are thirsty, and they have incurable ulcerations from frequent falls.'' Halj Abbas described a disease, which he called melanclioJia canina, observing, that the patient delights to wander among the tombs, imitating the cries of dogs. This remarkable disorder spread throughout Europe in the fourteenth and fifteenth century. " Those suffering under wolf- LTOANTHROPIA 203 madness and dog-madness, abandoned their homes to resort to the forests, allowing their nails, hair, and beard to grow, and carrying their ferocity so far as to mutilate and sometimes to kill and devour children. In the year 1591, Peter Burgot, Michael Verdun, and another, were tried for this strange affec- tion and pleaded guilty. Peter Burgot avowed that he had killed a youth with his woK-paws and teeth, and would have eaten him, if the peasants had not given him the chase. Michael Yerdun admitted that he had killed a little girl gather- ing peas in a garden and that he and Burgot had killed and eaten four other girls. These three unfortunate persons were all burned alive.^^ {' Des Hallucinations,^ p. 327.) When visiting the asylum of Mareville, Morel told us of a patient, the youngest of five brothers, who had all been insane, whose condition was as follows :— " He was a prey to the most fearful apprehensions of futiire punishment for imaginary crimes ; all his limbs trembled while he implored the assistance of Heaven and of his friends. Soon after, he rejected every attempt made to console him, and all his thoughts became concentrated upon one idea. He thought he was a wolf." " See this mouth," he exclaimed, separating his lips with his fingers; "this is the mouth of a wolf, these are the teeth of a wolf ; I have cloven feet. See the long hairs which cover my body ; let me run into the woods, and you shall fire at me with a gun." Some time after this, when in an improved condition, he enjoyed nursing some children ; but scarcely had they left him when he exclaimed : " The unfortunates ! they have embraced a wolf." At another time he refused to eat his meals, but said : " Give me raw meat, for I am a wolf !" His wish was complied with, and his mode of eating was altogether like an animal. He shortly died, however, much emaciated, the victim, to the last, of this strange and terrible conception." Esquirol states, on the authority of Calmet, that in a convent in Germany, the monks believed themselves changed into cats, and that, at a certain hour of the day, these monks capered about the convent, mewing as fast as they could. One of the Convulsionnaires, Pinault by name, barked like a dog, and was, as might be expected, soon followed by others. Recently, in a Paris asylum, a patient believed himself to be a horse, and neighed like one. The writer examined a patient recently (1878) in the Essex Asylum who believes himself to be a horse. His occupation was not connected with the care of horses, being that of a gardener. He was admitted labouring under melancholia. Some time after, this delusion suddenly developed. When seen by the writer, he neighed like a horse, pawed with his foot upon the ground, and pranced about when Dr Amsden made the clicking sound which drivers are accustomed to use to their horses. A young woman, now at Bethlem Hospital, believes she is turned into a dog. She 204 OF THE VARIOUS FORMS OF INSANITY says slie smells like one, and that her eyes do not look as they used to do. Eefuses to take food, saying that dogs do not require to eat. This delusion was elicited some time ago ; at present she is silent when interrogated. Mr T. Bond, of London, informs us that when medical officer to St George's Union he had under his charge a patient who believed himself to be a dog, and under this delusion not only barked, but would even micturate in a characteristically canine manner. A delusion is very frequently the last symptom in the suc- cession of morbid mental phenomena; in truth, it may be but the reflex of an emotion ; and though, strictly speaking, an intellectual disorder, it may be the result, and merely the sym- ptom, of a disorder of the feelings. Emotional Insanity, indeed, not uncommonly terminates in well-marked delusional disorder. The delusion of being a royal personage may be an intellectual conception and yet the offspring and the index of uncontrollable pride ; and in the foregoing case, the belief in the transmutation into a wolf was intimately associated with a depressed state of the feelings — with Melancholia. So with a lady at Bethlem Hospital, who described to the writer how, after family troubles, she became depressed, and then by insensible degrees began to believe that she was to be thrown into boiling water under the ground, and then " thrashed alive." Whenever the night-watch entered her room, she thought that her hour had come, and was in great trepidation. At last she grew resigned to her hopeless fate, and she considers this was the begining of the recovery which followed, aided by removal to another ward. The same observation applies, with even greater force, to another so-called Monomania ; the disorder in which the patient conceives himself to be demoniacally possessed. Dsemonomania, in the vast majority of cases, has been but a symptom of dis- ease of the affective faculties ; so complex are the phenomena of diseased mind, and so completely do they set at defiance any rigid system of psychological classification. Paulus ^gineta, after speaking of madmen who fancy them- selves to be brute animals and imitate their cries, and of others who conceive themselves to be earthen vessels and are frightened lest they be broken, adds : — " Some believe themselves impelled by higher powers, and foretell what is to come as if under divine influence ; and these are, therefore, properly called de- moniacs, or possessed persons." This description, however, although it may have included, does not exactly describe more D^MONOMANIA 205 modern cases of Daemonomania — in whicli the patient is much depressed, pretends to no supernatural knowledge, and is firmly- convinced either of being possessed by, or actually transformed into the devil. A patient under Esquirol's care thus described herself : — " The devil has taken from me my body, and I have no longer a human shape. There is nothing so dreadful as to appear to live, and yet not be of this world. I burn — sulphur exhales with niy breath. I neither eat nor drink, because the devil has no need of food or drink. I feel nothing ; and, should I be placed in a terrestrial fire, I should not burn. I shall live millions of years ; that which is upon the earth cannot die. Were it not so, despair would have caused me long since to terminate my existence." "Nothing," says Esquirol, "undeceives her, and she is abusive in her language to those who seem to doubt the truth of what she affirms ; those who contradict her she calls sorcerers and demons. If they insist upon the correctness of their opinion respecting her, she becomes irritated, her eyes project, and are red and haggard, ' Look, then/ she says, ' at this beautiful figure ; is it that of a woman or a devil ?' She strikes herself violently with her fist upon her chest. She pretends, also, to be insensible ; and, to prove it, pinches her skin with all her might, and strikes her chest with a wooden shoe. Still, she manifests pain when not forewarned. This woman is tranquil, is not mischievous, and speaks rationally upon every other subject, when we can divert her thoughts." The writer we have just quoted from states that, out of twenty thousand insane persons who had passed under his observation, he had "scarcely seen one in a thousand stricken with this fatal disease.^^ He suggested, that the term Cacodamonomania should be employed; as the ancients did not use the word demon, necessarily, in a bad sense ; while he would apply that of Theomanm to those cases in which the patient believes him- self to be the Deity, or Jupiter as in the case just given as occurring at Falmouth. Examples of Daemonomania, and of other delusions, might be multiplied; those we have mentioned are, as it appears to us, mainly referable to the third division — that of delusion proper, although it is impossible to deny that in some instances a morbid sensation may have formed the basis of the delusion. Several of the examples already cited, are usually regarded as hypochondriacal illusions. To this division the following case would, by some writers, be referred ; but, however hypo- chondriacal the patient was, his particular delusion was rather a false notion than perverted sensation. The melancholy under which he laboured was father to the thought. If " electro- biologists^^ can make a man disbelieve his own personality, in certain susceptible states, and fancy himself metamorphosed into some other person, by the law of suggestion, as explained by 206 OF THE VARIOUS FORMS OF INSANITY Dr Carpenter, cannot melancholy feelings suggest such ideas or beliefs as these ? " A young hypochondriac," relates Arnold, " had a strong imagination that he was dead, and did not only abstain from meat and drink, hut importuned his parents that he might be carried to his grave and buried, before his flesh was quite putrefied. By the counsel of physicians he was wrapped in a winding-sheet, laid upon a bier, and so carried on men's shoulders towards the church; but, on the way, two or three pleasant fellows (hired for that purpose), meeting the hearse, demanded aloud of them that followed it, whose body it was that was then coffined and carried to burial ? They said it was a young man's, and told his name. Surely, replied one of them, the world is well rid of him, for he was a man of very bad and vicious life, and his friends have cause to rejoice that he hath ended his days thus, rather than at the gallows. The young man hearing this, and not being able to bear such injury, roused himself up on the bier, and told them they were wicked men to do him that wrong he had never deserved ; that, if he were alive again, he would teach them to speak better of the dead ! But they proceeding to defame him, and to give him much more disgraceful and contemptuous language, he, not able to suffer it, leaped from the bier and fell about their ears with such rage and fury, that he ceased not buffeting them till quite wearied." The result of this excitement was perfect recovery within a few days. There is at Bethlem Hospital a young man who avers that he is dead. When a recent note was made of him, he muttered something about a coffin. When pricked, he admitted he felt it, but that it would not cause blood ; when shown a drop, would not admit his vitality. Said the writer was warm, he cold. He believes he has been the means of making everyone diseased since he has been at Bethlem, through their inhaling the breath of a corpse. He has laboured now under this delusion for a year. He states that he knows the particular day he died, namely, after a slightly relaxed operation of the bowels. In the succeeding observations on False Sensations we shall speak of them as they arise in various forms of mental disease as well as Monomania or Delusional Insanity. False Sensations. — We will first take hallucinations. What a student has primarily to bear in mind is that the same sensations may result from the internal as the external world ; that in short the same nervous track may be traversed by subjective as by objective sensations, in the reverse order. This is the fundamental truth lying at the bottom of all hallucinations. Hallucinations were not regarded by Esquirol as caused in any instance by morbid conditions of the organs of sense, but as strictly cerebral, that is, mental in their origin. " The senses " he says, " are not concerned in their production ; they occur although HALLUCINATIONS . 207 the senses do not perform their functions, and even though they no longer exist/' This, of course, is quite true. It may be well doubted, however, whether there is sufficient reason for thus restricting the term, inasmuch as one individual may per- ceive an object which has no present existence (his mind becoming secondarily affected) in consequence of a diseased con- dition of the optic nerve in the first instance ; and another may perceive an object which has no present existence in consequence of primarily mental — that is, cerebral — disease. Dr Foville, indeed, states that he discovered lesions of the nerves in patients who had been the subjects of hallucinations, — a circumstance Esquirol was inclined to attribute to coincidence. Baillarger, moreover, has distinctly recognised this possible duplex origin of hallucinations, which he has divided into psycho- sensorial, or those which originate in the combined action of the imagination and the organs of sense ; and psychical, or those which are the consequence of a disordered mental condition, without disease of the senses. Brierre de Boismont considers that these distinc- tions depend upon the degree of intensity of the phenomena. Referring to hallucinations of the sense of hearing he says : " If the perception be feeble, the hallucination is without noise ; if it be more intense a sound is heard.'' And he thinks " the sound is heard, not from extension of the disease to the senses, but because certain conventional signs, always associated with certain ideas, are recalled when those ideas are produced with great vividness." Thus he defines a hallucination " the percep- tion of the sensible signs of an idea." " With the reflective man, it is the highest degree of tension at which his mind can arrive — a true ecstacy. In societies with profound convictions, where the imagination is not rectified by science, it is the reflec- tion of a general belief ; but, in these two cases, it does not offer any obstacle to the free exercise of reason." In such instances, Brierre de Boismont would call them physiological hallucinations, as distinguished from those which are accompanied with unsound- ness of mind, the pathological. This view of the subject, as he observes, '^leaves on their pedestal the statues of illustrious men, whom some would wish to throw down into the abyss of Insanity." It is important not to forget, as has been already intimated, that hallucinations may exist without Insanity. Thus, Andral, on entering his room, distinctly saw, for a quarter of an hour, the corpse of a child which he had dissected a short time 208 OF THE VARIOUS FORMS OF INSANITY before. Johnson, one day at Oxford, when he was turning the key of his chamber, heard his mother distinctly call " Sam," although she was then at Lichfield. We approach in the fol- lowing instances the border-land of Insanity, but in such cases the opinions of an individual, apart from disease, must be taken into consideration. For a Spiritualist, for instance, to believe that he sees his guardian angel is no proof of Insanity. Jerome Cardan the physician, and Erhard, both believed that they were attended by a supernatural personage. Erhard^s guardian was always attired in a black cape. Napoleon was said to have interviews with a familiar spirit in the form of a little red man ; and, on better authority, we are informed that he saw his star. " I see it," said he, " in every occurrence ; it urges me onward, and is an unfailing omen of success." Now that we are engaged in considering the disorders of the mind, we discard the use of the term in the physiological sense, and restrict it to the perception, along with evidence of cerebro- mental disease, of objects which, at the time, have no existence ; this false perception being either the consequence of the combined disordered condition of the mind and one or more of the senses (psycho-sensorial), or of the mind only (psychical). In regard to their frequency among lunatics, Esquirol says that of 100 insane patients, 80 have hallucinations. Brierre de Boismont states, that out of 62 patients in his asylum, hallucina- tions were present in 38 instances. With 18 monomaniacal patients, sight and hearing were involved in 8, taste and hearing in 1, hearing alone in 2, and sight alone in 1. Of QQ cases of Monomania, admitted during one year into the Bicetre, 35 — or one half — had hallucinations; namely, 19 of hearing, 11 of sight, 3 of taste, 1 of touch, and 1 of the internal organs. Melancholia aifected 21 out of the QQ monomaniacs, and of these 11 had hallucinations ; 6 being of hearing, 3 of sight, and 2 of taste. In Mania, hallucinations are frequently present. The writer last quoted, states that of 181 maniacs, 23 had hallucinations of hearing, 21 of sight, 5 of taste, 2 of touch, 1 of smell, and 2 of internal sensations. Hallucinations are also frequently observed in Puerperal Mania. In the ealier stages of Dementia, we meet with these phe- nomena ; also, occasionally, in General Paralysis. An instance is on record, in which the patient had almost lost the power of speech ; at times, however, he was able to make those around him understand, that he could see a shark beside him ready to HALLUCINATIONS 209 devour "his body. A patient now in tlie York Eetreat, labouring under Dementia, is the subject of tlie same ballucination. On retiring- to rest, lie is frequently alarmed by the appearance of a shark by his bedside. In regard to the relative liability of the senses to hallucina- tions, although among the sane, those of sight are frequent; among the insane, those of hearing appear to be decidedly the most common. They are estimated to form two thirds of the whole number. They appear to be most generally experienced when the patient is falling asleep ; partly, no doubt, in con- sequence of the less degree in which, at such times, the atten- tion is fixed, or the comparing faculty exercised. Of 144 cases of hallucinations, 62 are stated to have been in the night, 50 in the day, and 32 during both. A patient at the York Dispen- sary used to complain bitterly of a voice repeating in his ear everything that he was reading ; and, on one occasion, he dis- tinctly heard the same voice commanding him to throw himself into a pond in his garden. He obeyed the voice ; and, when removed from the water and asked why he had done so rash an act, he replied, that he much regretted it, but added, " He told me that I must do it, and I could not help it.'^ We know a case in which the patient believes he can at any time com- municate with or consult an absent relative. Often when asked a question, he appeals to this individual before replying, and receives, as he imagines, a distinct answer by which he is entirely guided. A patient at the Retreat used to believe she heard some one ordering her to seize the property of other persons. She accordingly did so, and would not restore the stolen goods, unless, as she imagined, the voice permitted her. In another case, a lady heard voices which told her that if she committed certain acts, or omitted to do others, she would have her right breast and her head cut off. As these punishments were often to be inflicted by those around her, she became much incensed at the attendants when they refused to comply with her wishes. Signs of amendment appeared in about three months after admission, and she ultimately recovered. The poet Cowper was distracted by hallucinations of the sense of hearing. ''The words,^' says his biographer, ''which occurred to him on waking, though but his own imaginations, were organically heard ; and Mr Johnson, perceiving how fully he was impressed with a belief in their reality, ventured upon a questionable experiment. He introduced a tube into his chamber, near the bed's head, 14 210 OF THE VARIOUS FORMS OF INSANITY and employed one, with whose voice Cowper was not acquainted, to speak words of comfort through this conveyance/' It is a remarkable proof how real such hallucinations appear, that this hazardous artifice was never discovered. It does not, however, seem to have been productive of any benefit. His medical attendant one day found him with a penknife sticking in his side, with which he had attempted self-destruction, believing he had been ordered to do so by a voice from heaven. In a patient in the York Asylum, an old monomaniac and an inveterate scribbler, some of whose composition is now before us, the medical superintendent, Dr Needham, could never dis- cover the slightest craze except on the point described by him in the letter quoted further on. His brother had the same delusion, and cut his throat under its influence. In this letter, which extends over twenty-three large and closely written pages, he accuses sundry persons of conspiring against him to prevent him sleeping at night, and he gives numerous conversations, which he says he heard, proving that his sus- picions were well founded. He drew correct inferences from false premises. He says that the men Walker and White originated a system by which they prevent him sleeping in the night. " From the mental connection and bodily sympathy between White and me, there is no need for him but to hreathe loio a succession of formed words, as long and as often as he pleases, which words consist of remarks directly and indirectly on my thoughts, of which he is perfectly conscious. Owing to this system I am obliged perforce to hear whatever he says, almost at any distance. Thus, while he is lying in bed in his own bedroom he carries on this system a gi-eat part of each night, and keeps me awake till by some chance or other I fall asleep. Both Walker and "Wliite have intended by this system to make me actually insane, by depriving me of sleep as much as they possibly could, or to present such an appearance as if I had naturally sleepless nights, without either of them being supposed to have had anything to do with it. White himself gets as much sleep as he can during the day, in order that he may carry on this system during the night, and carry on his work in the kitchen during the day as usual, sedulously keeping up all external appearances so as to evade suspicion from any quarter. This was just the way Walker acted. If I myself attempt to get any sleep during the day to repair the deficiency of the night, White, from knowing my thoughts, knowing also what I do or intend to do, resumes this system and effectually prevents me Henry and Edward Harcourt, who have been in mental connection and bodily sympathy with me before and since I have been in this asylum, and have at the distance of a mile or so round this asylum and York, for about twenty-one years, carried on the same system as Walker and White have carried on, and have been occupied every day, fi'om morning till late at night, with making remarks directly and indirectly on my thoughts, of which they have a perfect cognizance, while retaining their own individual consciousness, and which, owing to my rapport with them, I am obliged perforce to hear, are necessarily placed in the same position with regard to White as I am. Henry and Edward HALLUCINATIONS 211 HarcOTirt are in rapport with me, and White is in rapport with me. Whatever remarks on my thoughts H. and E. H. make to me, at whatever distance, White hears Whatever remarks on my thoughts White makes to me, at whatever distance, H. and E. H. hear. Henry and Edward Harcourt are conscious of and hear every word White says to me, and besides carrying on tliis system on their own account, they repeat after White, when he operates on me, separately and simultaneously, every word he says. At the distance of a mile or two they make their remarks, in their own distinct voices, which I, owing to my mental connection and rapport with them, am compelled perforce clearly to recognise and hear. I put down with careful selection some remarks made by White on various occasions in the course of his carrying on this peculiar system. " ' There's something about this way of going on, that I didn't think but what you'd be thought out of your senses if you said anything about it. I haven't been thought of, as if I'd anything to do with it ; I thought you'd want to get away from this asylum without saying anything about Walker and me going on in this wag.' " ' You shall not sleep to-night if I can help it ; you haven't a leg to stand upon, when you say anything to the doctor, about this way of going on. Nobody knows anything about it.' " " I could, of course, multiply this krad of internal evidence to any extent, but I have given sufficient examples of it now and aforetime in the case of Walker to prove that he and White have been engaged in a conspiracy against me, which has done me great injury." Next in frequency to hallucination of hearing are those of sigiit. All visionaries afford examples. The remarkable nar- rative of Cellini contained in his autobiography^ illustrates this form of hallucination^ as well as that of hearing. A lady at the Retreat had visions, in which she believed she held inter- course with supernatural personages. Ideas of great family consequence succeeded, and she imagined she was the heiress of very large property. Of this she would give the particulars on paper, and that in so rational a manner, that to any one unacquainted with her actual circumstances, her account ap- peared perfectly sensible. These delusions led into many acts of impropriety. Her general habits, however, were orderly, and she was capable of conversing or writing rationally, except when she touched upon the subject of her visions or her pro- perty. She assumed a great deal of consequence, but did not display it in her attire, which was remarkable for its neatness. Another lady (under our care) informed us, after her recovery, that she had repeatedly seen her (absent) husband playing at chess in the room in which she was sitting. The chessmen, &c., were exquisitely distinct. Hallucinations affecting the sense of touch are not very common. Patients sometimes complain of experiencing elec- tric shocks ; at other times, they fancy they are struck by 212 OP THE VARIOUS FOEMS OP INSANITY imaginary beings. Hallucinations of tliis sense require care- fully distinguishing from neuralgic affections. We have known a case in which a gentleman supposed that " electric fire " passed out from his eyes and ears^ and that his bedroom was filled with it at night. He charged his friends with being the cause of it. Hallucinations of smell are rarely met with uncomplicated with disorder of one or more of the other senses. Patients do, however, sometimes complain of very bad odours, and at others of very pleasant ones, without other hallucinations. We had a very good example of the former in an insane patient, some time since, who complained exceedingly of the injury done to her health by the sulphurous fumes with which some one, as she believed, continually filled her room. Lastly, the sense of taste is but rarely affected alone. Patients who believe they are taking poison in their food are not usually examples of this class. Hallucination of one sense is less commonly found than hal- lucination of several. Sometimes, but rarely, all the senses are involved. The fol- lowing is a remarkable illustration of this, occurring in a poor woman in York, under the writer's care. (' Monomania of Persecution.') She is firmly convinced of the existence of a persecuting fellow in a room above her own, who vents all his malignity upon her by means of certain machinery and wires. By the former, he manufactures a quantity of tow, which she sees " whirling round from the ceiling ;" and by the latter he torments her in the most cruel manner. He " brays" her in the night with three of these wires, so that she is stiff in the morning, and covered with marks " as if she had been switched," and the difficulty of rising is often increased by " skewing her down in bed." At another time he will thrust three wires into her mouth, which leave " a very bitter verdigris taste" therein. She protests that she can see a " hole like the cut of a knife" in one comer of the ceiling, through which he introduces the wires, and she says, " When I try to get hold of them, he soon has them away." He also delights to send her to sleep " ^vith that chloroform," which she feels di'opping from the ceiling upon her cap ; in addition to which she has, in consequence, enveloped her head in a couple of handkerchiefs. As regards the sense of sight, she has only once or twice seen her persecutor ; but when she wanted to speak to him, he turned away. He is a middle-sized and middle- aged man. She says, however, very naturally, " I feel him over much to want to see him." She hears him more frequently than sees him ; hears him " nestling about the room ;" she also hears the wires pushed through the ceiling ; and she has stopped her clock, and covered it up, because he used to employ his wires to make it strike some twenty times in the night, in order to disturb her. Her sense of smell is at present free; formerly she was much annoyed in this respect also. ILLUSIONS 213 Hallucinations may be continuous or intermittent ; they may, although rarely, be at the will of the individual, so that he can recall them at pleasure ; they may have one character to-day, and another to-morrow; in some cases, in which the sense of sight is hallucinated, closing the eyes will dispel the affection. Sometimes a patient hears sounds only through one ear, or sees imaginary objects only through one eye, the other eye and ear being unaffected. Again, the number of voices heard will vary ; in some instances an animated dialogue is sustained with all the force of reality ; in others two or more distinct voices are recognised by the patient ; and a linguist will occasionally hear voices in different languages. It is of the utmost importance to ascertain the character of the hallucinations ; for on this will often depend the danger which attaches to them and the necessity for the deprivation of the patient^s liberty. It is obvious that '^ Delusional Insanity, of a destructive character " (p. 49) must demand the very greatest care ; that a man who hears a voice commanding him to commit an act of violence towards others, or to destroy himself, requires strict watching or con- finement ; whilst a man who hears a voice proclaiming only his rank and wealth may be harmless, and require no restraint whatever. Regarding the subject from a medico-legal point of view, an inquiry into the existence of hallucinations will often afford a key, as Brierre de Boismont has well pointed out, to numberless determinations, singularities, and actions, totally unexplained by, and at variance with, the character, the manners, and the habits of the individual. Illusions. — These have already been distinguished from hal- lucinations, by the existence, in the former, of something internal or external to the body, which is the basis of the illusion. In the most perfect state of mental health, we are subject to certain illusions; but here, as Esquirol observes, "Reason dissipates them. A square tower, seen from a dis- tance, appears round ; but if we approach it, the error is rec- tified. When we travel among mountains, we often mistake them for clouds. Attention immediately corrects this error. To one in a boat, the shore appears to move. Reflection imme- diately corrects this illusion. Hypochondriacs have illusions which spring from internal sensations. These persons deceive themselves, and have an illusion respecting the intensity of their sufferings, and the danger of losing their life. But they never attribute these misfortunes to causes that are repugnant to 214 OP THE VARIOUS FORMS OF INSANITY reason. They always exercise sound reason, unless Melancholia is complicated with Hypochondriasis." Illusions, like hallucinations, may affect any one of the senses separately, or all of them. Those of sight are the most frequent ; those of hearing are the next in order; but some observers state that they are as common as the former. A gentleman, to whom we may here refer, afforded an interesting example of visual illusion. Every person lie saw at L (in Yorkshire), where he lived, presented a different appearance from the reality. His friends, who resided in another town in the same county, removed "him to their own home. As they travelled, they endeavoured to con%'ince liim of the absurdity of his illusions. He was not the least shaken in his belief, but at last said, " Well, if the people at S look like the people of L , I will believe I am under a delusion." As he entered the to-rtai of S , he anxiously watched for the first face, on seeing which he acknowledged that it presented the same strange appearance that he had seen at L . He therefore candidly admitted that he was deceived. The fact of his being open to conviction shows that the disease was not far advanced. After this he remained well for several years, when he had an attack of Acute Mania. The sense of toiich often suffers. With hypochondriacal patients, we observe endless varieties of false sensations, or visceral illusions, as they are sometimes called. It is often very diffcult, and sometimes quite impos- sible, as we observed before, to draw the line between some of these illusions and false conceptions. Frequently, they are united in the same case. If, however, the nerves of sensation convey to the mind exaggerated impressions regarding any part of the body, it constitutes an illusion ; and, if it is manifestly absurd, and the patient's reason cannot perceive that it is an illusion, he is also of unsound mind. These observations upon hallucinations and illusions may be concluded by succinctly stating the points of real practical im- portance in regard to them. Either may exist (the former rarely) in persons of sound mind ; but in that case they are dis- credited, in consequence of the exercise of reason and observa- tion, or, if credited, they do not influence the actions. They are sometimes with diflficulty distinguished the one from the other, and indeed often merge into or replace each other ; but, still they ought to be distinguished by the points of difference already laid down. Either may be the cause of violent acts, and terminate in murder, or suicide ; their discovery in criminal insanity is, therefore, most important. Hallucinations are most frequently met with in Monomania and Melancholia, but are MELANCHOLIA 215 not uncommon in Mania. We have several times observed them present with great vividness in incipient senile Dementia. In children we sometimes see remarkable examples of halluci- nations ; especially, so far as our experience goes, of sight. Illu- sions are not so common in Monomania and Melancholia as are hallucinations, being more frequent in Mania. The senses of sight and hearing are more liable to hallucinations, than those of touch, taste, and smell. Prognosis (see p. 136). — The existence of delusions or halluci- nations adds to the danger and unfavorable character of Mania and Melancholia. On referring to the classification of Insanity at p. 49 the reader will observe that next in order to Delusional Insanity, we give Emotional Insanity, whether manifested as Melancholia simplex. Partial Exaltation, or Moral Insanity proper (synony- mous with Emotional ditto). To be consistent with this arrangement, we ought rigidly to exclude from the description of these states all forms of Insanity complicated with marked disorder of the intellect. For the convenience of the reader, however, we shall include, while carefully distinguishing, these cases under the same section. Thus, we shall treat Melan- cholia as a whole instead of restricting ourselves to the purely emotional form of the disorder. So of Homicidal and Suicidal Insanity, &c. The reader will, however, perceive that while the following sections up to Mania include many morbid states in which the intellect is disordered, they differ from the preceding ones in including Emotional Insanity. SECTION IV.-Melaneholia. Synonyms. — MtXa-y^oXia (Gr., from /usAac^ black, and y!;o\r], bile) ; Melancholia (Lat.); Schwermuth, trilhsinn, tiefsinn (Ger.) ; MelancoUe (Fr.) ; Phrenalgia (Guislain) ; Tristimania (Rush) ; Sadness and Melancholy of English writers. Esquirol suggested the word lypeonania (XuTrr?, sadness, and juavia) in the place of melancholia, but added that he should employ the two words indifferently. Definition. — The signification attached to this term by the ancients, and by modern writers prior to Esquirol, has been 216 OF THE VAEIOUS FORMS OF INSANITY pointed out when speaking of intellectual Monomania. (See p. 195-6.) Psychical Symptoms. — The invasion of Melancholy, as of other forms of mental disorder, is variously characterised in different cases. It may be sudden, as when the immediate consequence of grief ; or gradual and long threatened by premonitory symp- toms, and, perhaps, the mere exaggeration of the patient's natural character ; or, lastly, it may be altogether secondary to other forms of Insanity, especially Mania. The first mode of invasion is, compared with the two latter, rare. The incubation of Melancholy is generally prolonged, and sufficiently obvious. The subject of it loses his relish for existence, he feels depressed and unequal to the ordinary duties which call him into public life, and in the domestic circle he is more silent than in health, and seeks entire solitude. In the words of Dryden — " He makes his heart a prey to black despair. He eats not, drinks not, sleeps not, has no use Of anything but thought ; or, if he talks, 'Tis to himself." Thus, while cheerless, moody, and taciturn, he is not idle in mind, for he unceasingly revolves his own desperate condition, which he regards as worse than that of any other person ; although with characteristic inconsistency, he may regard it as good enough for a wretch like him ; he magnifies every circum- stance which can be regarded: as of unfavorable omen, and is unable to realise those which are favorable ; he misconstrues every observation addressed to him, and if he read, every sentence of a gloomy nature appears intended specially for him. As the disorder advances, the melancholiac, ever fearful, is constantly anticipating some dire catastrophe. He casts a con- tinual gloom around him by his groans or sighs, and will fre- quently sit from morning ,to night deploring his unhappy lot; and when night comes, sleep, instead of being to him " balmy,'' or " tired Nature's sweet restorer," is probably clothed in sad- ness, and only the signal of an aggravation of his disorder. A patient now under care, but not requiring the restraint of an asylum, wakes again and again in the night, oppressed with the most terrible feelings of distress, to which she looks forward in the day with the greatest apprehension. These nocturnal attacks generally last about half an hour, when they subside, and are succeeded by comparative calm. But the early morning is SYMPTOMS 217 generally tlie occasion for increased mental suffering. One reason why melanclioliacs are almost invariably worse on waking, is probably to be found in tbe unwonted activity and force wbicli attend all operations of the mind at tbis period. Every one must have observed the vividness with which suggestions occur to the mind, and ideas irresistibly succeed each other, when conscious, although involuntary cerebration is then first put in action. Authors have owed some of their choicest thoughts and most felicitous expressions to this period of the day. With the melancholiac, his most vivid imaginations happen to be of the sombre class, and, becoming intense after the rest which the brain has had during the night, tyrannise over the feebly opposing power of the will and judgment. The increased susceptibility of the emotions in Melancholia renders its subjects, in the ea7'ly stage, easily moved to tears by trivial circumstances. The consolations offered by friends are refused as the storm blackens ; or, at least, are disregarded. It is generally futile to attempt to argue a melancholy patient out of his gloomy forebodings. A patient of the writer's, while admitting that a thousand things she had fancied from time to time had never come to pass, and that in these she had been mistaken, would always add in regard to some fresh foreboding, "1 am sure this is true." Refering to a person who had had similar notions, she would say, "His were fanciful^ mine are real." All the symptoms now described, with occasional remissions, which generally deceive the patient's friends, become in time so aggravated, and he is, to the most inexperienced, so decidedly insane, that he is at last placed under care. Occasionally, he is a volunteer, and seeks the tranquillity of an asylum himself. "When he is aware of the absurdity of his fears, though unable to escape them, the disorder is termed by Esquirol reasoning Melancholia (lypemanie raisonnante) . The association in the same character of a tendency to gloom, and an acute perception of, and love for, the ridiculous, is often remarkably exhibited in melancholy lunatics. The author of John Gilpin is a familiar example. Again, the actor, Carlini, consulted a physician to whom he was unknown, on account of the attacks of profound melancholy to which he was subject. The doctor, among other things, recommended the diversion of the Italian comedy ; " for," said he, '' your distemper must be rooted indeed, if the acting of the lively Garlini does not remove 218 OF THE VARIOUS FORMS OF INSANITY it/' "Alas!'^ ejaculated the miserable patient, "1 am the loery Carlini whom you recommend me to see ; and while I am ■capable of filling Paris with mirth and laughter, I am myself the dejected victim of melancholy and chagrin !" (Perfect's ' Annals of Insanity/ p. 404.) Such are the most prominent symptoms of Melancholia. An Athenian painter of celebrity, upon whose moral nature the fine s,rts do not, however, appear to have exercised a very humanising influence, purchased an old man, a captive brought home from the wars, and put him to torture, in order that he might be the better able to delineate the pains and passions of his Prometheus, which he was then engaged in painting. Upon this, quaint old Burton remarks, in his ' Anatomy of Melancholy,' " I need not be so barbarous, inhuman, curious, or cruel for this purpose, :as to torture any poor melancholy man; their symptoms are so plain, obvious, and familiar, there needs no such accurate ob- servations or far-fetched object ; they delineate themselves ; they voluntarily betray themselves; they are too frequent in all places ; I meet them still as I go ; they cannot conceal it, their grievances are too well known, I need not seek far to describe them." In short, the psychical symptoms of Melancholia are so well pronounced when present, and hence so readily recognised, that they do not require to be very minutely described. Patients labouring under Melancholia may, however, indicate their distress of mind by very different external signs. Some pour forth their grief in excited tones, and manifest a large amount of activity and restlessness. Others are altogether depressed and silent. The latter may be subdivided into those melancholiacs whose condition is marked by simple depression, and those in whom it is associated with decided inaction of the intellectual faculties — the Melancholia attonita of Bellini, Sauvages, and others, and MelancoUe avec stupeur of Baillarger. The French term Stupidite includes this condition and that known as acute dementia. See antea, ^'' Acute Dementia." A. B — , a young lady, sustained a disappointment of the afPections. Dyspepsia and obstinate costiveness followed. Symptoms of mental depression then appeared, succeeded by refusal to take food, and an attempt at self-destruction. The case then assumed the character of MelancoUe avec stupeur, profound melancholy accompanied with a state of semi-stupor. Tlie jirolonged warm bath, employed for several months, restored this patient to health. The unfavourable symptoms were always disposed to return on omitting the bath. After her recoveiy, which was complete, she distinctly remembered the condition in which she had been. MELANCHOLIA ATTONTTA 219 M. Dagonet^ in the Marcli and subsequent numbers of tlie 'Annales,^ 1872^ contributes several papers on 8tu^idite (or Stupemanie) , and regards it as most frequently the result of the acutest forms of Melancholia. He gives the two forms just mentioned, one in which there are sensorial illusions and painful delusions, the facial muscles being contracted and the features concentrated, the condition being allied to Ecstasy andjCatalepsy; the other marked by a total want of expression in the features. He records one intermittent case of stupor which extended over several years, the attacks lasting five or six weeks and the inter- vals of lucidity three. In his own experience cases of Stujndite ordinarily recover. M. Dagonet gives several interesting cases caused by the events of the Franco-Prussian war. A case of Melancholia with an absorbing religious delusion fell under the writer^s notice several years ago, accompanied by marked catalepsy. It may fairly be classed under " Melancolie avec stu'peur or " Melancholia attonita." It must be remem- bered that stupor does not, in the sense here employed, prevent there being a distinctly conscious delusion. A female servant, under twenty, had only been in service two days ; had not been considered out of health; catamenia regrdar. She herself, however, observed that her tongue was very much furred, and pointed it out to some one in the house. Li the evening, her master rang the bell several times without being attended to. On going into the kitchen La consequence, he found the servant standing motionless with her eyes and hands raised in the attitude of prayer, " as if in a trance." She did not reply to his questions, or cry, or laugh. For three days she remained in this statue- like condition, totally unconcerned about what was passing around her, but occasion- ally saying "yes," when asked a question; without, however, any regard to the sense. When seen by the writer on the fourth day, she was in the above condition ; frequently, but not always, placing himself in the attitude o£ prayer, and apparently absorbed in devotional exercises. When the arms were raised, a heavy weight was attached to one of them by a cord. "When this was suddenly cut, the arm rebounded very slightly, showing that it was not retained in that position by the mere exercise of -wiU. On being addressed, she stared with a vacant expression, and would some- times whisper " yes." The tongue was covered with a thick brown fur ; the pulse about 88, soft ; the bowels constipated. (It appears that her paternal grandmother was confined in an asylum.) A pm'gative was administered; motions and urine passed in bed. She was with great diiSculty uiduced to take food. On the sixth day she relapsed, was quite silent, and passed her evacuations in bed. Tongue much cleaner. A shower bath was given, which was violently opposed. In a day or two she improved again; wine and ammonia were given, but she again fell into her former state. From this she suddenly emerged, without any apparent cause, foiu* weeks after her first attack. She appeared then quite well in mind, and told the writer that she had all the time believed that she was about to be burnt upon a fixe or in oil, and that the reason she would not eat was because she believed she should be burnt the moment she did so. She had experienced frightful di-eams, which added 220 OF THE VARIOUS FOEMS OF INSANITY to her apprehension of some impending calamity. She also fancied that it was " the last day of the world." She stated she was now perfectly con\'inced that these impressions were delusions, hut that even now, especially at night, they presented themselves very strongly to her. With regard to her state at the time she became iU, she said she had felt sick and out of order for several days before going to her situation. The following case illustrates this condition : — A young man (E. W — ), a short-hand writer's clerk, who had been rather dull from birth, and was of a nervous temperament, was admitted into Camberwell House under Drs. Paul and Schofiekl, in December, 1876, in a state of melancholia with delusions. He could not be induced to say a word, and stood with his head bent on his chest, " Uke an automaton," and would not do the slightest thing for himself. A suicidal tendency was suspected. He had to be forcibly fed. His delusions, as ascertained from his friends, were that he fancied people designed to kill him by poison ; and declared that people were robbing him of large landed property. The dread of poison was the cause of his refusal to eat. His skin was cold and clammy ; his pupils widely dilated ; his pulse very weak. When seen within a month of admission by the writer, E. W — stood in a fixed attitude vnth open eyes, the pupils moderately dilated. On extending his arms, they remained in that position for a considerable time, the cataleptic tendency being considerable. He answered some of the questions put to him, but slowly and lethargically. He put out his tongue after some hesitation, and very slowly. He had improved since he was admitted. When seen again after an interval of ten months, the writer made the following note :— " Patient stands with his eyes shut, the pupils rather dilated, equal. His head is a little bent on his chest ; his face is pale, the expression does not indicate any acute feeling. The skin moder- ately warm ; tongue very red, slowly protruded, and as slowly retracted. Rather thin. Pulse 88, very feeble. Walks slowly ; but it is stated that he sometimes goes at a rapid rate in the airing court. Answered questions in monosyllables. Would not say why he does not eat. Is coaxed to take food. Same tendency to cataleptic condition of limbs as before." In this case it will be observed there was a foundation of constitutional dulnessj and upon this were grafted distinct delusions of a melancholy character^ followed by a state of mental stupidity, justifying the classification of the case under " Melancholia cum stupore/^ The native temperament cannot but colour the symptoms and affect the prognosis. Physical Symptoms. — Among the earliest (partly psychical) are insomnia and disturbed dreams. We know cases in which the dread of falling asleep is intensely agonising, from the anticipa- tion of dreaming, and awaking with horrible sensations. The digestive organs are frequently deranged; the tongue being unnaturally red or loaded, and the substratum firm, while there is a marked fulness or tenderness at the epigastrium, and the alvine evacuations are deficient in bile. As Conolly observes, melancholiacs will refer a sense of terror to the epigastrium, accompanying a feeling of having done wrong without knowing MELANCHOLIA SIMPLEX 221 what. The tongue is in other cases flabby^ very pale^ and in- dented at the edges ; a fixed dull pain^ or an ill-defined sense of oppression in the head, is also often complained of. The pulse is not usually acceleratedj but slow and compressible. The urine is often pale, sometimes high-coloured, and depositing lithates. The skin varies ; usually harsh, but not unfrequently moist and clammy or greasy. In women the uterine functions are more or less disordered, and are suspended in a large number of cases. In men the reproductive instinct is usually in abeyance. "The physiognomy is fixed and changeless ; but the muscles of the face are in a state of convulsive tension, and express sad- ness, fear, and terror; the eyes are motionless, and directed either towards the earth or some distant point ; and the look is askance, uneasy, and suspicious " (Esquirol). Sometimes Melancholia induces a passive attitude ; the arms hang loose at the side, the hands are open, and the muscular system is relaxed altogether; at other times, grief intensifies the action of the muscles ; the patient^s arms are rigidly flexed ; the hands clasped and pressed against his chest, or he wrings them in all the bitterness of despair. Melancholia may be simple ; complicated ; acute ; chronic ; remittent ; or intermittent. I. Simple form. There is here no disorder of the intellect, strictly speaking ; no delusion or hallucination. It is the melancolie sans delire of EtmuUer and Guislain ; the lypemanie raisonnante of Esquirol; and the melancholia simiplex of Heinroth. Dr. Prichard observes, "A considerable proportion among the most striking instances of Moral Insanity are those in which a tendency to gloom or sorrow is the 'predominant feature. When this habitude of mind is natural to the individual, and compara- tively slight, it does not constitute madness. But there is a degree of this affection which certainly constitutes disease of the mind, and that disease exists without any illusion impressed upon the understanding. The faculty of reason is not manifestly im- paired, but a constant feeling of gloom and sadness clouds all the prospects of life." {' Treatise on Insanity,^ p. 18.) " I meet every day,^^ observes Guislain, " with Melancholiacs who do not exhibit any disorder in their ideas, or lesion of the judgment.^^ " Melancholia is exclusively an exaggeration of the affective sentiments ; it is, in all the force of its signification, a gemiithshranJcheitj in the sense in which the word is employed by 222 OF THE VARIOUS FORMS OF INSANITY German psychologists. It is a pathological emotion^ a sadness, a chagrin, a fear or dread, and nothing more. It is not a con- dition which sensibly weakens the conceptive faculties.'^ {' Le90us Orales/ vol. i, p. 112.) There is occasionally a very marked physical disturbance im- mediately preceding attacks of mental depression. We have a patient under treatment who describes the sequence of her sen- sations with singular minuteness : the first in the series being a sense of intense oppression at the heart, which appears to her to extend gradually upwards, and is followed by extreme dejection of mind. It is to such cases that the Professor of Ghent refers when he says, " There is a melancholy which I call anxious or jmeunw-melancolic, on account of the disturbance of the thoracic organs. The distress which the patient suffers sometimes resem- bles attacks of suffocation. Occasionally this condition is asso- ciated with hysterical symptoms, but this is not generally the case. It is sometimes preceded by a painful feeling, which the patient refers to the region of the heart. This state may last two or three months before decided mental disorder is manifest. The patient loses his sleep, he is harassed with gloomy ideas ; his features become altered; anguish, accompanied by vague forebodings, announces the debut of the malady. ^^ He adds, " This variety of Melancholy scarcely passes, in some cases, beyond the character of Moral Insanity. It is then free from all disturbance of the intellectual powers ; so that the patient un- ceasingly complains to those who enjoy his confidence, that he is afraid that he will lose his mind. I have known patients who have lived two or three years in this condition, without having ever suffered the least derangement of the understanding, still less of the ideas. It may be the percursor of an attack of epilepsy ; it constitutes the prodromic stage of Suicidal In- sanity. It is not uncommon in females at the climacteric period.'^ It is the precordialangst of Dr. Flemming. Nostalgia. — (vocttoc, return ; aXyog, sadness). Home-sickness may sometimes be a variety of simple Melancholia, but it often, extends further. In six years, 1820-6, no fewer than ninety-seven soldiers in the French army fell a sacrifice to this disease. Young men and those from the country are more liable to be thus attacked than older men and those accustomed to city life. The inhabitants of mountain districts — the Highlander and the Swiss — are observed readily to droop and become nostalgic when abroad. Gavin, however, quotes from Dunlop the fact, that the NOSTALGIA 223 only two examples of Nostalgia wliicli occurred to him were a recruitj a country lad from tlie fens of Lincolnshire^ who died; of the disease ; and a London pickpocket, whom he saw in the hulks at Sheerness. In a case we recently met with in the Sailors Home, Falmouth,, the patient was a Spaniard, and died very unexpectedly with cerebral symptoms. His previous mental condition was charac- terised by apathy and a desire to return home, without any very definite indications of physical disease. Probably, no one had greater opportunities of observing this disease than the celebrated Larrey. He was decidely of opinion, from the observation of a large number of cases, that the mental faculties in nostalgic patients are the first to undergo a change. Unquestionable aberration of mind was present in the cases which he has recorded. This was evidenced by the great exaltation of the imaginative faculty. The prospect of their native home presented itself to their minces eye, like the fata morgana to travellers in the desert, depicted in the extravagant and delusive hues which 'a morbid fancy alone could suggest. All this is often in violent contrast to the rude, uncivilised, and poverty- stricken home which their better reason would represent as the sober reality. This state of cerebral excitement is accompanied at the commencement of the disorder, by corresponding physi- cal symptoms. The heat of the head is increased — the pulse ac- celerated ; there is redness of the conjunctiva : and unusual movements of the patient may frequently be observed — perhaps occasioned by the uncertain pains in various parts of the body, of which he usually complains. The bowels are constipated; there is a general feeling of oppression and weariness, indicated by the patient frequently stretching himself and sighing. There is an inability to fix the attention, and the conversation is, in consequence, somewhat unconnected. The symptoms which succeed are a sense of weight, and pain in all the viscera. The deficiency of nervous power produces a torpid and partially paralysed condition of the stomach and dia- phragm. The symptoms of gastritis, or gastro-enteritis, which immediately supervene, M. Larrey considers as but sequelee. The phenomena next presented, as the febrile symptoms increase, are those which we ordinarily observe when there is great de- rangement of the digestive functions, accompanied by fever. The prostration of strength which marks what may be called the third period of the disease is very great. The mental depres- 224 OF THE VA.EIOUS FORMS OF INSANITY sion keeps pace with tlie decline of bodily strength, and is often manifested by weeping, sighing, oi' groaning, A symptom re- sembling that of hydrophobia is sometimes present, — namely, great aversion to the sight of clear liquids, as water, together with the usual disgust of food. A propensity to suicide is not unfrequently manifested when the debility becomes extreme; paralysis is also common ; but, generally, death is the result of a gradual exhaustion of the vital powers. M. Larrey witnessed, during the retreat from Moscow, a large number of his comrades perish in a similar condition of mind and body, from the effects of intense cold. It has been frequently remarked, that the inhabitants of cold and moist as well as of mountainous countries, are liable to the moral impressions which are the origin of Nostalgia. The Dutch are a notable example. Larrey found, that the troops enlisted from the Dutch and the Swiss were precisely those which, during the disastrous campaign of Moscow and the cruel vicissitudes experienced, afforded the greatest number of victims to a morbid cerebral condition similar in its symptoms to Nos- talgia. It was observed on the other hand, that the army of Napoleon, which served in Egypt, did not produce a single case exhibiting the least symptom of this disorder. On the contrary, the soldiers became exceedingly attached to the climate, so as almost to consider it a second home, and, like the Israelites of old, there was not one among them who did not in his heart regret leaving the land of Egypt. The military hospital received many patients from among the Swiss Eoyal Guard, who were sent thither for undefined com- plaints which speedily merged into decided Nostalgia ; and this disorder seemed most prevalent during the extreme height of the barometer. Larrey gives the case of a soldier in tlie first Swiss Regiment. His state did not appear alarming to Dr. Comae, liis physician, when he first entered the fever wards- One day, however, when Larrey visited him, he was informed that the unfortunate man had committed suicide, and, hastening to his assistance, found him weltering in his blood, and at the point of death, from a large woimd in the region of the heart, inflicted with a knife. At the post-mortem examination, on sawing open the skull, M. Larrey was surprised to find a layer of lymph and purulent matter between the dura mater and the pia mater, which covered the entire circumference of the brain, and involved also the arachnoid membrane. On tlie cortical substance of the brain especially towards the anterior lobes, and at the superior edges of the hemispheres, many points of suppuration were observed. The sinuses of the dura mater, as well as all the vessels of the head, were gorged with black blood ; the ventricles contained HTPOOHONDRIAOAL MELANCHOLIA 225 a ratber large quantity of serum ; tlie base of tbe cerebrum and cerebellum alone remained sound. From tbe facts of tbis case, we may, witb Lan-ey, draw tbe conclusion tbat a deep moral sentiment, tbe desire to revisit bis native country, was tbe cause wbicb gradu- ally developed tbe cerebral disorder preceding tbe act of suicide in tbis Swiss — an act wbicb may be regarded as independent of tbe patient's volition. In two similar cases tbe post-mortem appearances were almost identieal. Tliere are misantliropical and love-sick forms of Melancholy, wliicli may be here enumerated, but do not require any special description. The latter rarely attains to a sufficient degree of intensity to render the restraint of an asylum necessary. Guislain estimates its frequency at one in four hundred admissions in the institution at Ghent. Misanthropical Melancholy rarely presents itself to our notice in an uncomplicated form, so severe as to constitute mental disease ; but, as has been justly observed, an aversion to human society, a desire for solitude, and a repugnance to the pleasures of life, constitute the very essence of all Melan- choly. {' Le9ons Orales,^ vol. i, p. 125.) Hypochondriacal Melancholy is by Guislain classed under the head of Melancholy without disorder of the intellect,that is, simple Melancholia. Griesinger regards it in the same light, as essen- tially a folie raisonnante melancolique. It is, however, so very generally accompanied by decided delusions, that it will be more convenient to consider it under the complex form. II. Complicated Melancholia,^ or Melancholy with decided disturbance of the intellectual faculties. [MelancoUe avec clelire, la melancoUe delirante of French writers.) — This we do not doubt is more common than the simple form. Guislain, however, states that in his experience they are of equal frequency. About 13 per cent, of the admissions into his asylum at Ghent were examples of each form. Eyijocliondriacal MelancJwIy . — Much confusion exists in regard to the boundary line between what is popularly called Hypochon- driasis and genuine mental disease ; and in truth, this confusion arises, in some measure, from the inexact limit which separates the one from the other in nature. In a particular case, it is often impossible to determine the precise period of the supervention of cerebro- mental disease. Guislain (op. cit., vol. i, p. 119) goes further than most writers, in including hypochondriacal symp- toms under Insanity. '' Hypochondriasis,-'-' he observes, " is a disorder of the affective faculties — most certainly an alienation. 1 Altbougb properly falling under " Delusional Insanity of a melancboly cbarac- ter," it is more convenient to describe it in tbis place (see p. 49). 15 226 OF THE VARIOUS FORMS OF INSANITY This is proved by tlie affection being transformed into other mental diseases/^ He divides it into two classes — bodily and mental. Patients afflicted with the former " believe themselves invalids and in suffering : they believe they have every infirmity and every complaint. They experience all the diseases which they hear mentioned. They apply to doctors, to charlatans, to druggists, to quacks, in order to have the disease explained to them, and to obtain remedies, which they generally take with avidity.^' He estimates that two patients out of every hundred are admitted at Ghent, in consequence of this condition — of course, in an advanced stage. In an ordinary case of Hypochondriasis under the ^Titer's care, the patient, a married woman, was constantly wishing him to prescribe for some fresh symptoms of an alarming character. Among his notes of this case he finds the following : — " Subject for seven years to attacks of pain in different parts of the body, especially the abdomen; palpitation, vertigo, &c. Is now fifty-eight. No family. Has the most absurd apprehensions. Is always worst in the morning; not when she awakes, but at about seven. Improves as the day advances. On one occasion she seemed like a person under the influence of strychnia; was relieved by calomel and opium. Is constantly dwelling on her state. Great dread of death. Is frequently in bed for a day or two, apparently at death's door, but without a single morbid physical symptom of real importance ; not materially relieved by valerianate of zinc." Such cases, more or less marked, abound in the experience of every physician. When occurring in the female, they generally assume a more decidedly hysterical form. In another case, that of a gentleman, the patient was firmly convinced that the testicles had wasted away, and brooded over the supposed loss of reproductive power. This is a very common notion with hypochondriacal men. In the case of a gentleman at Bethlem Hospital, in whom Hypochondriacal Melancholy exists in an aggravated form, the writer wi'ote down the following complaints as he heard them, the whining voice, the knitting of the brows, and the pathetic appeal for something to be done, being most characteristic : — " Oh dear ! oh dear ! Can't you do anything for me ? I was A 1 in the City, and making so many thousands a year ; now I am wasting away. Look at my clothes, and see how my stomach has gone. I've no stomach left. I've lost my height. I know my bones are the same, but my flesh has all gone. I am getting smaller altogether, don't you see ? The skin, or at least the flesh, on my head is gone. How can I live like this ? My teeth are smaller than they were. My nose is less ; it has gone, or nearly so. My hands are smaller. My private parts are wasting away. Feel my pulse ; it is so weak." The patient tears his clothes, and is very untidy. He is sometimes violent, breaks a window, or gives a patient a black eye, which he denies afterwards. A distinction must be drawn, Guislain notwithstanding, between Hypochondriasis as employed in its loose, popular HYPOCHONDEIAOAL MELANCHOLIA 227 signification, and those indisputable, although closely allied forms of mental disease, of which the last case is an example. It is important, however, that the student should remember, that Hypochondriasis may be associated with actual and fatal diseases, greatly as the sensations may be exggerated by the patient. On clearly distinguishing between these stages of the disorder — that in which there is, and that in which there is not, organic disease — his success in prognosis will depend. It will be found from medical descriptions of ordinary Hypo- chondriasis that the symptoms essential to the disease closely bor- der on Insanity ; and that some of those enumerated by authors, as of frequent occurrence, are inseparable from unsoundness of mind. Thus, we have '* often special delusions and illusions re- garding the patients physical condition,^^ " an incurable despair,^^ &c. Hence it is evident that authors have described, under the same name, a disease which, according as it assumes a mild or a severe form, may present very different aspects when viewed from a medico-legal standpoint ; and which, in its former phase, may be regarded as simple Hypochondriasis ; but in the latter, may very properly be termed Hypochondriacal Melancholy, or Melancholy the prominent symptoms of which are a hypochon- driacal nature. To ascertain, in particular cases, when the one begins and the other ends is doubtless a problem the solution of which will tax all the acuteness of the psychologist ; but the diffi- culty is not perhaps, greater than that of deciding, in some cases^ where what is popularly understood as Melancholy ends, and the genuine Melancholy of the psychologists begins. Hypochondriasis may certainly exist with the latter, and of course Melancholia may be present without Hypochondriasis ; but the two are frequently combined ; and for this combined morbid condition we do not know that there is any better phrase than Hypochondriacal Melancholy. In simple Hypochondriasis, the patient fears, without any sufficient reason, that he will soon die in consequence of his supposed complaints ; but when In- sanity more decidedly supervenes, he may fear that he will be poisoned, and to avoid this, may even terminate his own life ! Again, in simple Hypochondriasis, the patient exaggerates the importance of a trifling, but probably an actual ailment. When, however, there is well-marked cerebro -mental disease, he will invent the most absurd and impossible maladies that can be con- ceived, and become possessed with delusions which will leave no doubt as to his insanity. (See " Diagnosis.^^) 228 OF THE VARIOUS FORMS OF INSANITY Thus, a patient to whose case we shall shortly refer, gravely- attributed the eructations from which he suffered, to the three froars mentioned in the Revelation of St John. While, however, as in this instance, the character and gross- ness of the patient^s conviction will lead us to decide upon his Insanity ; in others, this opinion may be formed from collateral circumstances. Thus, it may happen that, in two cases, the error under which the patient labours will be precisely the same, and yet we may be justified in arriving at the conclusion that, in the one, the false conviction is, and in the other it is not, the result of cerebral disease ; this opinion being formed indepen- dently of the character of the delusion, from a consideration of various facts, proving the existence of cerebro-mental disorder. The case of Buranelli, who was executed for murder in 1855, was a remarkable illustration of the ill-defined boundary line which often separates these affections, and of the difficulty which exists when this occurs, and when the case involves the question of criminal responsibility, of deciding upon the existence of cerebro-mental disease. A commentary upon this important trial may be advantageously read in the 'Asylum Journal of Mental Science,' July, 1855. M. Michea, who has written a treatise on Hypochondriasis, concludes that this affection must be regarded as without the pale of Insanity, so long as the depression of mind is not the consequence of a delusion {idee fixe), so long as it has not for its exclusive object an extreme fear of death, and so long as it yields promptly to consolations offered, and to reason. Many of the observations now made in regard to the relation which Hypochondriasis, in a simple form, bears to Hypochondri- asis complicated with decided cerebro-mental disease, apply to Hysteria when regarded from the same point of view. Hysteria is not in ordinary cases to be regarded as Insanity, but there is a state of mind which may properly be designated Hysterical In- sanity, in which aggravated Hysteria constitutes a prominent symptom ; and which must be distinguished from simple Hysteria either by intensity, or by its complication with actual sexual delusions or excitement. It may here be observed, that Hypochondriasis and Hysteria have been regarded as identical diseases by Sydenham, Boer- haave, and other medical writers. They have been distinguished, however, by Cullen, Pinel, and others ; and there are, undoubt- edly, many distinguishing signs. Thus, while Hypochondriasis HTPOOHONDEIACAL MELANCHOLIA 229 affects both sexes^ but principally the male^* Hysteria affects the female sex almost exclusively ; while the mode of invasion of the one is slow and gradual^ that of the other is characterised by sudden attacks ; while the former is marked by the symptoms already described^ there are usually present in the latter, the globus hystericus, a facial expression better known than des- cribed, and if in an aggravated form, attacks of partial or com- plete unconsciousness, convulsions, spasms, and perhaps lock-jaw. Some remarkable instances are on record, in which intense mental emotion has been followed by changes in particular struc- tures, in relation to which the emotion was excited ; and which would seem to suggest the probable course which some cases, at least, of Hysteria and Hypochondriasis may have taken. As some of these may seen too remarkable to be easily credited, we will refer to a case well known to ourselves, — that of a highly respectable and most intelligent lady, in whom this phenomenon was exhibited. This lady was one day walking past a public institution, and observed a child, in whom she was particularly interested, coming out through an iron gate. She saw that he let go the gate after opening it, and that it seemed likely to close upon him, and concluded that it would do so with such force as to crush his ankle ; however, this did not happen. " It was impossible," she says, " by word or act to be quick enough to meet the supposed emergency ; and, in fact, I found I could not move, for such intense pain came on in the ankle corresponding to the one which I thought the boy would have injured, that I could only put my hand on it to lessen its extreme painf ulness. I am sm-e I did not move so as to strain or sprain it. The walk home — a distance of about a quarter of a mile — was very laborious, and, on taking off my stocking, I found a circle romid the ankle, as if it had been painted with red-currant juice, with a large spot of the same on the outer part. By morning, the whole foot was inflamed, and I was a prisoner to my bed for many days." Now, if, as in this instance, a powerful emotion, directed into a certain channel, can result in such marked physical changes without the agency of any local cause, it is highly probable that, in some instances, the firm conviction of an individual (it may, or may not be, the consequence of cerebral disease ), that he has, or is about to have, some particular disorder, and the constantly dwelling upon and dreading it, does produce, through trophic nerves, the very disorder upon which his apprehensions are con- centrated. * " I do not know whether Hysterical Insanity has ever been observed in men '' (^Griesinger). He distinguishes two forms — acute attacks of delu-ium and excitement even to developed Mania, manifested by singing, vociferation, cursing, &c. ; and a chronic form, appearing either in the form of Melancholia or Mania. He adds that Hysterical Insanity passes more frequently into Dementia than one might expect. 230 OF THE VARIOUS FOEMS OF INSANITY Melancholy may be complicated with many other delusions, besides those we have considered in connexion with Hypochon- driasis. Some of these have unavoidably attracted our attention when speaking of Delusional Insanity, because many insane per- sons have hallucinations and definite delusions of a gloomy character, in regard to what is going to happen to them. Doubt- less, in the large majority of cases, the delusion derives its tone entirely from the disorder of the affective faculties. Be this, however, as it may, the patient no longer suffers from simple Melancholia ; the disease is compound ; the integrity of the understanding is markedly impaired. Religious Melancholia {Melancolie religicuse, Monomanie reli- gieuse of French writers) may, or may not, be associated with obvious disturbance of the intellectual faculties. As it very generally is so, it may properly be considered in this place. But it may be well to observe, that Dr Prichard draws from thence some of his illustrations of " Moral Insanity .^^ Many patients become victims to the most gloomy fancies, and the conscience becomes so morbidly acute, that — " Night-riding incubi Troubling the fantasy. All dire illusions Causing confusions ; Figments heretical. Scruples fantastical. Doubts diabolical," — are incessantly presented to the mind, and life is rendered in- tolerable by perpetual misgivings as to the propriety of the most trifling circumstance ; or, the patient may be unceasingly engaged in devotional exercises. An Irish priest in the Bicetre kneeled so constantly, that his knees were almost completely anchylosed, the skin also becoming as tough as leather. Plutarch has given a graphic sketch of the condition of those labouring under Religious Melancholia in his day, or the super- stitious {SeKTi^ainoviai) , as he terms them. It would be difficult to employ more appropriate language for the present purpose. " To such a man, every little evil is magnified by the scaring spectres of his anxiety. He looks on himself as a man whom the gods hate and pursue with their anger. A far worse lot is before him ; he dares not employ any means of averting or of remedying the evil, lest he be found fighting against the gods. The physician, the consoling friend, are driven away. ' Leave RELIGIOUS MELANCHOLIA 231 me/ says the wretclied man^ — ' me the impious^ the accursed, hated of the gods, to suffer my punishment.'' He sits out of doors, wrapped in sackcloth or in filthy rags. Ever and anon he rolls himself, naked, in the dirt, confessing aloud this and that sin. He has eaten or drunk something wrong ; he has gone some way or other which the Divine Being did not approve of. The festivals in honour of the gods give no pleasure to him, but fill him rather with fear and affright. He proves in his own case, the saying of Pythagoras to be false, that we are happiest when we approach the gods, for it is just then that he is most wretched. Temples and altars are. places of refuge for the perse- cuted ; but where all others find deliverance from their fears, there this wretched man most fears and trembles. Asleep or awake, he is haunted alike by the spectres of his anxiety. Awake, he makes no use of his reason ; and asleep, he enjoys no respite from his alarms. His reason always slumbers ; his fears are always awake. Nowhere can he find an escape from his imaginary terrors. ^^ "We may illustrate this form of Insanity by an interesting case, in which the religious depression, and the delusions springing out of it, were intimately blended together. The patient, a gentleman of highly cultivated mind (with hereditary predisposition^ and the father of three sons more or less deranged), believed himself doomed, by an irrevocable decree, to eternal flames. He imagined that an entire change had taken place in the state of mankind; that all, except himself, had entered upon a state of bliss, but that he was reserved for everlastiag torments, as an atonement for the sins of the whole world. He stated that he had heretofore entertained the same views as others in regard to the character of Jesus Christ — namely, that His sufferings had obtained a general atonement ; but that he had now found that Christ was a triumphant, he a suffering Saviour. He now perceived that the Scriptures, and many other books, were full of predictions representing himself ; that the accoimts of Caia, Esau, &c., although historically true, had a relation to him ; that he was the son of perdition, the scape-goat, the man of sin, spoken of in the Bible ; that, in fact, both the Old and New Testament were full of predictions respecting him. When dissent from such views was expressed, the patient would respond, " Oh, I know you will deny it ; you are bound to deceive me. I do not mean voluntarily, but from the fictitious state of your own existence. You are only the corpse, the remains of yourself. It is, to be sure, idle to talk of my state to you ; but the heart that is full seeks, though in vain, to vent itself." When the individual thus addressed assured liim that he had as firm a conviction of his existence in the same state of body that he had always been in, as he could possibly have respecting the mysterious change which he supposed we had all undergone; and that as he (the patient) was quite singular in his opinion, he must allow that there was the strongest possible evidence against the correctness of his views : " I would admit it," he replied, " if there were another human being in the world but myself ; but, alas ! all the appearances of existence in persons and things around me are fictitious ; all are enjoying felicity but 232 OF THE VAEIOUS FORMS OP IM SANITY myself. I only am reserved to endless torment. Everything has changed its aspect. Objects around me are no longer seen in perspective, but appear ilat, and raised one above another, like a Chinese drawing. Spring will no more return." When a con- fident belief was expressed that spring would return, and a hope that it would remove his apprehensions, " They are not apprehensions," he replied, with earnestness ; " they are convictions ; but if spring does return, and resume its usual appearance (I don't mean a few crocuses and snowdrops), I will acknowledge myself in error." At the close of an interview with this patient, who was then in an asylum, " It may seem strange," he said, " to ask you to visit me again, but I shall be glad to see you ; for even the shadows, the resemblances, of those we know, are pleasant amongst strangers." The power of self-control was singularly illustrated by a cir- cumstance which occurred in the course of the above case. At the very time when he could not restrain the expression of his gloomy feelings before his wife, and could not attend in the least to his family affairs, he paid a visit to the poet Southey. Sub- sequently, the poet, who was cognizant of his guest's mental infirmities, expressed to the patient's wife the satisfaction he experienced in seeing him so well ; and added, he never knew him reason more clearly. On the wife repeating this to her husband, he exclaimed. " Why you know, I could not think of showing my weakness before Mm." The unintentional confession of his weakness is also an interesting feature in this reply. C. D — was another case of a very painful character, in which Melancholia alter- nated with Mania. The patient, also a gentleman, imagined (although he had led a regular religious life) that he had entirely neglected liis duties, and that he would therefore be burnt alive as a sacrifice to an offended Deity. Three months after he was placed in confinement he became maniacal, vociferating and swearing constantly. These symptoms passed away, and the former state of despondency returned, accom- panied by a suicidal tendency. During four months these opposite conditions fre- quently alternated — a phase of Insanity popularly kno\ra as "high and low." At last, while in his low mood, he suddenly became cheerful, and spoke rationally. Undisturbed sleep, to which for long he had been a stranger, followed, and he recoverod perfectly. He subsequently married. Melancholia, as has been previously stated, may be acute or chronic ; and this, of course, may be the case whether it be sim- ple or complex. The term acute, as applied to Dementia, has reference, in general, rather to its duration than to its character, just as we often speak of acute rheumatism (the symptoms of which may be mild) to distinguish it from the chronic form. When applied to Melancholia, however, the term conveys, in most instances, a correct impression of its character : and, when exhibited in this active phase, it is truly distressing to witness. Agony, anguish, and despair are terms which best describe this lamentable state. ACUTE AND CHEONIO MELANCHOLIA 233 The following case under tlie writer^s care is very illustrative of this condition and will form a good type of the class. The patient, possessed of good general ability, and a skilful artist, would sit crouched for hours, covering his face with his hands, bitterly bemoaning his lot ; at other times silent, with the exception of groans and sighs. His suffering appeared to be most acute. His expression was intensely sad ; the facial muscles fixed, as if by spasm, and altogether expressive of concentrated grief. But, while exquisitely sensitive to his condition, he never wept ,■ a reference to the causes of his dejection never caused a tear, but only an obstinate rejection of all proffered consolation. This complete absoi-ption in grief tyrannised over, rather than extinguished, his purely intellectual faculties. His power of recollection was as acute as ever, but he recalled the sorrows, and not the pleasures, of memory. The comparing faculty was in action, but only engaged itself upon contrasting his former happy with his present miserable condition. His judgment was still good, except when he judged himself to have more cause for grief than any one else in the world j and as to his reasoning powers in general, it was a case in which, to a very great extent, the patient reasoned correctly enough, only from false premises. His perceptive faculties were sufficiently quick, but he perceived only the dark side of his case. His imagination was but too active in painting aU the sufferings which awaited him. In short, he was full of fears, devoid of hope, and seemed as if he " would not if he could be gay." This patient died of phthisis, and, till within a few moments of his death, manifested the same acute symptoms of Melancholia. Chronic Melancholia is but too frequently the sequence of the acute condition. Melancholia also, as we have seen, may alter- nate with Mania — the folie circulaire of Falret, and the folie a double forme of Baillargerj who regards these alternations as phases of the same affection. All the varieties of Melancholy are disposed to be remittent ; and it is generally observed that the remission takes place in the latter part of the day_, the patient suffering the most acutely early in the morning, and for some hours subsequently. This circumstance affords a useful practical hint in those cases in which a suicidal tendency exists. Etiology. — To the causes of Insanity in general (p. 54) we may add that the exciting cause of Religious Melancholia is sometimes to be traced to the fiery denunciations of a well- meaning but injudicious preacher. It is remarkable that, even in pagan times, Marcus Aurelius made a law condemning to ban- ishment those ''who do anything by which men's excitable minds are alarmed by a sujperstitious fear of the Deity. '^ If the modern authors of such fearful results are not themselves to suffer banish- ment, it is heartily to be wished that the jpractice were entirely banished from the pulpit. In the following case the mental disorder was closely con- 234 OP THE VARIOUS FOEMS OF INSANITY nected with, if not caused by, unwisely prolonged religious ex- ercise. E. F — , set. 16, was apprenticed to a whitesmith, and bore an excellent character. One Sunday evening he went to a Methodist chapel, and thence, with some of his acquaintance, to a private house, where a party met for tlie purjiose of prayer and exhortation (or, as it proved, excitation). The boy returned home at half -past ten o'clock. Tlie Bible, which his father had been reading, lay on the table, so he read several chapters in it, and then prayed himself in a somewhat excited manner. They slept in the same room, and his father observed that he lay awake some hours frequently sighing, but was not " irrational." On returning home from his work next evening he found his son had been unable to work during the day, had eaten nothing, and was in a state of gi'eat depression, accompanied by a tendency to stupor. On the next day, when a gentleman called at the house, he clasped his hand in his, burst into tears, and talked incoherently. He evidently could not collect his thoughts, and was labouring under a sense of undefinable alarm. He was reluctant to walk or to sit down when desired to do so, but did not exhibit any aversion to his friends. For several days he continued in much the same state, and was mostly silent. The warm bath and purgatives were followed by complete recovery, and at the end of a fortnight he returned to his work. We may add that he subsequently married, settled respectably in life, and made an efficient workman. He had no relapse. " Eevivals'^ are not unfrequently the exciting cause of religious depression. (See p. 99.) Prognosis. — (See page 135.) The course of Melancholia varies mainly according to the constitution of the patient, his age, the degree in which the disorder is simple or complicated, and the presence of hereditary predisposition to mental disease. It has some tendency to pass into that ''tomb of human reason — Dementia.''^ Conolly observes that " a great number of the patients now surviving, aud who were marked in the register, on admission, as affected with Melancholy, are now in the state of Dementia." The statistics of the Retreat show that this tendency is much less marked than in Mania. Thus, out of forty -nine patients who died there, and who had been admitted in a state of Mania, sixteen were examples ol Dementia ; while of forty- eight who died, and who were admitted labouring under Melan- cholia, only /owr died in a state of Dementia. SECTION V. Partial Exaltation, or Amenomania. From Melancholia we may turn to the consideration of an opposite or exalted emotional condition — that, namely, to which the terms Amenomania [amoenus, agreeable) and Charomania (^y^aipo}, to reioice)have been applied ; the former by Rush, the PARTIAL EXALTATION 235 latter by Frencli writers. It is the gay Partial Insanity or Monomania proper of Esquirol. There is, very generally, so intimate a connexion between those examples of Delusional Insanity, in which the delusion is of a gay and elevated character, and those exalted states of the feeling which we proceed to consider, that the two are rarely separated. They may be so, however ; and it therefore happens, of necessity, that in the description of the various forms of mental disorder, we shall come upon the same phenomena when engaged on very different forms of Insanity. Thus, when our attention was specially directed to delusions, it was impossible to avoid a refer- ence to those cases in which the patient believes himself a king or the Deity. — " Delusional Insanity of an exalted character -j" and, in the consideration of the present division, we necessarily meet with cases in which the exalted state of the emotions led to these delusions. When Esquirol restricted the term Melancholia to its present popular signification, he applied that of Monomania,* at least the affective class of monomanias, to examples of exaltation of the sentiments. It is customary to speak of Monomania of pride, of vanity, &c. ; and French authors have la monomanie vaniteuse, or Nar- cisse ; and la monomanie anibitieuse, or orgueilleuse, ov-des riches, or des grandeurs. The former is described by Guislain in the following terms : — " It ordinarily manifests itself under the form of a tranquil Mania which exhibits the patient infatuated with his beauty, his grace, his mind, his dress, his talents, titles, and birth. These lunatics love to see themselves in the glass, and to deck them- selves out ; sometimes they display an astonishing art in varying their attire, although their wardrobe may be very scanty ; they invent new fashions ; they arrange their hair tastefully ; and they study to set themselves off to advantage, by attention to their toilet, person, and figure.'^ We are acquainted with such a case at present ; a patient who has no very de- cided delusion, but who is influenced by the most exalted notions respecting himself : his every gesture, and expression, and conversation, display his diseased self-love, his monomanie vaniteuse, associated, however, with great intelligence, and an extent of knowledge of which many who are sane might be justly proud. He constantly boasts of his "descent from one of the best families in the United Kingdom," " a family of note," and that his family have iu their possession " three different coats of arms, finely emblazoned on parchment." His " maternal blood is equally * For the various senses in which Esquirol employed this term, see p. 197. 236 OF THE VAllIOUS FORMS OP INSANITY good." He is intensely sensitive to everytliing which can, by any possibility, be construed into a slight of himself ; and the omission of any of the most trivial accustomed marks of respect, is tortm-ed into intentional incivility. The studiously arranged dress, the self-satisfied attitude, and the buoyant step of this patient, are aU in keeping with the sentiments which are present in such morbid excess. The following case is an illustration of morbid vanity in a lady, although not developed to an extent which raises the question of confinement. G. H — , a maiden lady, set. seventy, her face bearing the furrows of many years, walks erect notwithstanding, and is decked out in the most antiquated foppery. All the colours of the rainbow may be seen upon her person, and while the eye is dazzled with gilt and tinsel, it is difficult to suppress a smile at the expense of this caricature of human vanity and weakness. As she walks along the streets, children flock around her, bowing and curtseying, and soliciting sweetmeats and halfpence, with which she is always provided, and which she gives with an air of most gracious condescension, quite characteristic of her class. This conduct does not arise from benevolence, but is the fruit of vanity in another form — the attempt to obtain homage from the only class willing to give it. Her eccentricities do not interfere with the peace and good order of society, and she converses with entire rationality. She has one brother equally eccentric, and another is confined in an asylum for the insane. Not unfrequently these several forms are confounded with general Mania, when from their partial character, and from the small degree in which the sequence of ideas is confused, they may properly be distinguished from it. Esquirol indeed com- plained of this confusion. '' Writers," he says," have not ob- served the diiference between Monomania and Mania, because of the excitement, susceptibility, and fury of some monomaniacs." " Amongst monomaniacs the passions are gay and expansive ; enjoying a sense of perfect health, of augmented muscular power, and of a general sense of well-being, this class of patients seize upon the cheerful side of everything ; satisfied with themselves, they are content with others. They are happy, joyous, and com- municative. They sing, laugh, and dance ; controlled by vanity and self-love, they delight in their own vain-glorius convictions — in their thoughts of grandeur, power, and wealth. They are active, petulant, inexhaustible in their loquacity, and speaking constantly of their felicity. They are susceptible and irritable ; their impressions are vivid, their affections energetic, their deter- minations violent ; disliking opposition and restraint, they easily become angry, and even furious." Guislain estimates the frequency of the Monomania of Pride at one in 300 admissions, exclusive of cases of General Paralysis, EELIGIOUS EXALTATION 237 with which extravagant ideas respecting wealth are so frequently associated. Religious Exaltation or Excitement is less common than the opposite condition — that of religious melancholy or depression which not unfrequently succeeds it. It has been estimated that only one per cent, of cases of excitement assumes this form. It includes the theomania of Bsquirol. In the boy whose case we mentioned when speaking of reli- gious melancholy, religious excitement formed the first phase of the attack, depression the second. In asylums, patients are not so commonly admitted in the early stage of excitement as afterwards, when signs of depression are present. Dr Prichard gives an excellent description of religious excite- ment, as illustrative in his opinion of disorder of the moral faculties without lesion of the intelligence ; in cases in which it has followed a state of supposed religious destitution. The strain of excitement, however, is too much, and the expressions of happiness too ecstatic to be long mistaken. Pride and haughtiness succeed, accompanied by a violent deportment "quite unlike the effects of a religious influence, and soon unfold the real nature of the case ; or it is clearly displayed by the selfish- ness, the want of natural affection, the variableness of spirits, the irregular mental habits of the individual. In the cases to which I have now referred, there has been no erroneous fact impressed upon the understanding — no illusion or belief of a particular message or sentence of condemnation or acceptance specificially revealed.-'^ (^Treatise,'' p. 20). Many authors, and especially Heinroth, have referred to this form of mental disorder those personages of antiquity who professed to foretel future events, as the Pythia at Delphi, Cassandra, &c. Some of the founders of religious sects may, with more pro- bability, be regarded as the subjects of Eeligious Insanity; having, in some instances, been themselves the dupes, when censured for having duped their credulous followers. Irving, in modern times, is a familiar illustration of the class. To what extent Mahomet was also an example offers an inquiry gf great interest, but cannot, in this place, be discussed. We may, therefore, refer to a work entitled, ' Mahomet considere comme aliene, par le docteur Beaux ; rapport a TAcademie Royale de Medecine par M. Eenaudin.^ A patient at the Retreat believed it was his religious duty to have " two wives and a concubine.-'^ 238 OF THE VAEIOUS FORMS OF INSANITY It is easy to see that under favorable circumstances, and among the ignorant, such a delusion might lay the foundation of a new- sect — Mormonism, for instance. The founder of the sect might be deluded, but sincere. " Religious revivals,^^ whatever opinion may be entertained in regard to their general or ultimate influence for good or evil, are doubtless the occasion for the outburst of some well-marked examples of intense religious excitement, in which excessive devotional feeling ovei'rides the reason. In some cases a fearful state of prostration, either of mind or body, or mainly the former occurs ; but in others the condition is one of religious ecstasy, or exaltation, complicated in many instances with hysteria. Some fall into a trance, others see visions. " Some of the con- victed see in their visions,^' we are told, " a black horse, others see a black man ; others see Jesus Christ on the one side and the devil on the other, and they cry, ^ 0, Jesus Christ, save me from the devil.^ " An eye-witness of the Irish revivals speaks of ' theomania.' " Insanity " says the Eev. W. Mcllwaine, of Belfast, " generally in one of its worst forms, theomania ( and not unfrequently in other forms of Insanity equally to be dreaded, such as acute mania), has been developed to a fearful extent. Speaking guardedly, I may assert that, from unquestionable sources, I have come to the knowledge of at least fifty such cases within the last six months in this immediate neighbourhood." Some of the disciples of Irving appear to have been in a very remarkable state of religious exaltation. And, in passing, it may be observed as a curious circumstance, that some of his congregation uttered a peculiar cry or sound, which Archdeacon Stopford, who heard it, instantly recognised thirty years after- wards, as identical with what he heard in Belfast. " That moment it flashed upon my memory ; it was with some slight modification, but in its character essentially the same, the un- mistakable cry of Irving' s prophetess — a sound that while I live I never again can mistake or misinterpret.'' Religious exaltation assumes a variety of epidemic forms. Assisted by the infectious influence of sympathy, it was exhibited in some phases of the " danciiig mania j" among the " Convulsionnaires ;" and among the American Shakers, who profess to have originated in the Camisards or French prophets. MOEAL OE EMOTIONAL INSANITY PROPER 239 SECTION VI.— Moral or Emotional Insanity (proper) * A class of cases demanding mucli consideration and discrimi- nation must now occupy our attention. They are mainly of a destructive character, and may be distinguished from emotional disorder of a melancholy and exalted character, by the term " Emotional Insanity proper, " or what is ordinarily understood as Moral Insanity. Synonyms. — Oemuths-wahnsinn- or Jcrankheit (Ger.) ; Manie raisonnante (Pinel) ; Monomanie affective, and when an irresis- tible impulse, instinctive or sans delire (Esquirol) ; Folie d' action (Brierre de Boismont) ; Moral Insanity [proper] (Prichard) . In a systematic treatise like the present, it is necessary to place the reader in possession of information in regard to alleged forms of mental disorder, although in this instance it is proper to warn him that much difference of opinion prevails in respect to what has been called Moral Insanity, and that some eminent alienists deny its existence altogether. So long, however, as the question is suh judice, it forms an interesting object of in- vestigation and research for the student of insanity. That intellectual power and the perception of moral truth do not necessarily exist in the same degree with the same person, that they do not always develop themselves pari passu are propositions which, as the result of common observation, obtain general acceptance. But that there should be anything like congenital defect of the moral sense {anotnia of Dr Bush), in conjunction with intellectual powers not strikingly deficient, is a proposition not generally recognised, or so easily established. It is obviously one which must be carefully considered in the description of mental diseases. (We shall define as we proceed.) Many analogies subsist between the moral and intellectual faculties, and, in many respects, they may be observed to be under the influence of the same laws. The sentiments, no less than the intellect, are indicated by, or associated with, certain temperaments and physical signs ; thus, good nature usually coexists with a sleek and fat habit of body. Virtuous and vicious tendencies are unquestionably hereditary ; or, as congenital, are displayed from the earliest infancy in children subjected to just the same educational influences. The moral facul- * See p. 50 of this work. 240 OP THE VARIOUS FORMS OF INSANITY ties may be either excited or depressed by disease. " Who has not seen," asks Dr Rush, " instances of patients in acute dis- eases, discovering degrees of benevolence and integrity that were not natural to them in the ordinary course of their lives V and we may add vice versa. Dreams affect the moral faculties as well as the intellect ; under their influence we are benevolent, devotional, passionate, and affectionate, as well as imaginative and talkative. Dr Lockhart Robertson has expressed himself more strongly on this subject than many would be prepared to do, when he says, " We find that either concomitant with intellectual disease, or even singly (the Moral Insanity of systematic writers), the moral powers of the mind may be perverted or entirely obliterated, exhibiting itself in entire moral perversion, in an inability to control conduct, and in total suspension of the natural affections. ('Essay on the Moral Management of Insanity,^ &c., p. 103). Ray, in his ' Jurisprudence of Insanity' (p. 103), after treating of Mania as it affects the intellectual powers, proceeds to observe, that a more serious error can scarcely be committed than that of limiting its influence to them. " It will not be denied," he adds, " that the propensities and sentiments are also integral portions of our mental constitution ; and no enlightened phy- siologist can doubt that their manfestations are dependent on the cerebral organism. Here, then, we have the only essential condition of Insanity — a material structure connected with mental manifestations ; and, until it is satisfactorily proved that this structure enjoys a perfect immunity from moi-bid action, we are bound to believe that it is liable to disease, and conse- quently, that the affective as well as the intellectual faculties are subject to derangement." Sauvages and others attempted to distinguish in their classi- fications between hallucinations and morbi loatlcetici, but Pinel drew from his practical experience much more decided conclu- sions, and recognised a form of mental disorder to which he gave the name of manie sans delire, or '' madness without delirium," that is to say, without lesion of the intellect. To the question placed at the head of his chapter, " Can mania exist without lesion of the understanding ?" {' Traite Medico- philosophique sur F Alienation Mentale,' 2nd edit., p. 155), he replies, " We may entertain a just regard for the writings of Locke, and yet think that his notions about Mania are very MORAL OR EMOTIONAL INSANITY PROPER 241 incomplete^ when lie regards it as inseparable from disordered intellect. Like this author^ I thought so myself, when I resumed at the Bicetre my researches on this disease, and I was not a little surprised to see many madmen, who at no time had manifested any lesion of the understanding, and who were under the dominion of a sort of instinctive fury, as if the affective faculties alone had been diseased." This description, however, only includes one class of cases, those, namely, in which there is simple instinctive fury or excitement — an ungovernable passion, excited upon the least provocation [emportement maniaque). PineFs first example of Mania without delirium {i. e. disorder of the intellect) is of this order (op. cit., p. 156), We know of a case in which a man was an example of strict integrity and honour, but exhibited such extreme violence of passion and irritability of mind, that it was almost impossible to associate with him. He was extremely suspicious, and looked on the dark side of every circumstance and character, and when once he had formed an opinion, it became a preju- dice which nothing could surmount. He was not in an asylum, and had he committed a homicidal act, it is very doubtful whether the law would have held him irresponsible. His father and mother lived in a cottage on the edge of a moor, and were both subject to attacks of unmistakable Insanity. At these times they would leave their home and wander among the furze, where they were frequently found laid on the ground by hunting parties. The right understanding of the conditions to which Pinel applied the terms ^^ reasoning madness,^^ and ^'^ mania without delirium," and also the Moral Insanity of Prichard, is much assisted by the adoption of EsquiroFs division into affective and instinctive Monomania. We have, in a former section, referred to this writer's " Affective Monomania," as applied to cases of exaltation. Here, however, we think the use of the term is much more legitimate, and is indeed very convenient. In the first division, " monomaniacs are not deprived of the use of their reason; but their affections and dispositions are perverted. By plausible motives, by very reasonable explana- tions, they gratify the actual condition of their sentiments, and excuse the strangeness and inconsistency of their conduct." This condition we spoke of in the first edition of this work as " Mania with general extravagance of conduct." It might 16 242 OF THE VARIOUS FOUMS OF INSANITY perliaps be described as one of general moral obliquity — depen- dent, of course, upon cerebro -mental disease. The ego itself is perverted (see p. 51). In the second, " the patient is drawn away from his accus- tomed course, to the commission of acts which neither reason nor sentiment determines, which conscience rebukes, and which the will has no longer power to restrain. The actions are involuntary, instinctive, irresistible.'^ The ego is overborne by an impulse. Dr Prichard's observations on Moral Insanity apply more especially, but by no means exclusively, to the first division {Manie raisonnante of Pinel ; Folie cVaction of Brierre de Bois- mont). Esquirol observed that Dr Prichard had confounded the instinctive madness of Pinel, with his Moral Insanity ; and Dr Prichard, in a subsequent publication, admitted that the terms have reference to two distinct classes of cases. We have already taken occasion to point out the wide area of morbid mental phenomena which this writer's term embraces ; and a reference to his own definition may tend to a clearer apprehen- sion of a disorder, which, more than any other, has puzzled the psychologist, perplexed the advocate, and disconcerted the divine. He defined it to be " Sb morbid perversion of the natural feelings, affections, inclinations, tempers, habits, moral dispositions, and natural impulses, without any remarkable dis- order or defect of the intellect, or knowing or reasoning facul- ties, and particularly without any insane illusion or halluci- nation." " The signs of reasoning Monomania," observes Esquirol, '' consist in the change and perversion of the habits, disposi- tions, and affections. . . The understanding is not essen- tially disturbed, since it assists in the acts of the insane person, and the patient is always ready to justify his sentiments and conduct. Reasoning Monomania has an acute and chronic course. We distinguish three periods in it. In the first, the disposition and habits are changed. In the second, the affec- tions are perverted ; and, at length, in the third, a maniacal excitement appears ; or else a weakening of the faculties, more or less rapid, leads the monomaniac to Dementia. '' It is necessary to admit," observes Marc, " since facts demand it, that there are two sorts of Monomania, one of which is instinctive, the other reasoning. The first bears the monomaniac on to instinctive and automatic acts, which are MOEAL OR EMOTIONAL INSANITY PEOPEE 243 not preceded by reasoning ; the other determines acts^ which are the consequence of a certain intellectual operation/^ (Vol. i, p. 244.) Thus^ then^ it is important to remember^ that writers who maintain the existence of Moral Insanity clearly hold that it is not necessarily instinctive, impulsive, irresistible. For although (in a loose use of the word) the man morally mad may be said to be irresistibly so — that is, his condition of mind is not voluntary — the examples of so-called irresistible impulse belong to quite a different class. Ignorance of this distinction has often led to deplorable confusion. A case of sudden and irre- sistible impulse might afford an illustration of Moral Insanity ; but many cases of what would be held to be Moral Insanity do not fall under the division of instinctive madness. Symptoms. — The most striking feature of Insanity, in general, and the strongest proof of the presence of any of its forms, is the change which takes place for the worse, in the individual's character and habits. To cases of congenital deficiency of the intellect, however, whether altogether idiotic or only partially imbecile, it is at once manifest that this test does not and cannot apply. In such instances the natural character is itself in an abnormal condition, and ceases to be the standard of health. This observation is equally true as regards one form of the disorder now under consideration. If there ever be, con- genitally, a condition of the moral sense analogous to intel- lectual deficiency, it is impossible to apply, in such instances, the test referred to — a test which is alone applicable to mental disease when acquired. We have seen many well-marked examples of lunatics, who, on arriving at manhood, were placed under restraint because age brought with it a certain legal responsibility, the absence of which, in early life, rendered the patients' friends willing to content themselves with their own surveillance. In such cases, parents assert that the child, the boy, and the young man, alike presented the symptoms of an inert moral nature, and of an activity of the animal propensities, over which threats, rewards, or punishments exercised a very trifling control. There was formerly a patient at the Richmond Lmiatic Asylum, Dublin, whose case illustrates this class. We are informed that "he exhibited a total want of moral feeling and princijjle, yet possessed considerable intelligence, ingenuity, and plausibility." " He has never," says Dr. Crawford, " been different from what he 244 OF THE VARIOUS FORMS OF INSANITY now is ; he has never evinced the slightest mental incoherence on any one point, nor any kind of hallucination. He appears, however, so totally callous with regard to every moral principle and feeUug, so thoroughly unconscious of ever having done anything wi-ong, so completely destitute of all sense of shame or remorse when reproved for his vices or crimes, and has proved himself so utterly incorrigible throughout life, that it is almost certain that any jury before whom he might be brought would satisfy their doubts by returning him insane." For obvious reasons, we are prevented publishing the details of many cases of this description falling under our own ob- servation. We may mention, however, the case of a patient admitted into an asylum at the age of seventeen, labouring under " Moral Insanity and Epilepsy.'^ He possessed decided intellectual vigour, united with an exceedingly obtuse perception of moral responsibility. His father stated that his character had been the same " from the cradle.'^ At nine years of age he endangered the life of a little boy — his playfellow ; subse- quently, at school, he was characterised by similar mental qualities, learning more quickly than other boys, yet com- mitting many acts of violence. He was, consequently, obliged to leave several schools. Later on he had epileptic fits. We know of another well-marked case of peculiarity in the temper and moral disposition, manifested from the earliest infancy, in which the intellectual faculties are not only equal to, but above, the average. The disease, or defect, was hereditary. The patient has been in an asylum for years. The most lucid description of Moral Insanity which we have met with is that given by Crichton Browne. For this reason we quote it, quite apart from the authority which attaches to his opinion, because it is proper to state that it was written a considerable number of years ago. The value of the facts, how- ever, to which he refers, and upon which that opinion was based, is not affected by the course of time. " Moral Insanity is of frequent occurrence in early life. The intellectual faculties of the person affected by it remain entire and unimpaired. He is perfectly capable of perceiving, and knowing and judging. He cherishes no delusion. He cannot in the ordinary and legal acceptation of the term be pronounced insane. And yet he is to all intents and purposes of unsound mind, and as much requiring guidance, restraint and treatment as the furious maniac. He suffers from entire perversion of the moral prin- ciple, from the want of every good and honest sentiment. He is actuated by impulse, or by the most selfish, depraved, and cruel motives ; he presents, in short, a perfect picture of a MOEAL OR EMOTIONAL INSANITY PEOPEE 245 desperado and a ruffian. The existence of Moral Insanity_, like tlie existence of everytMng else, has been called in question, and at the present day there are not lacking those who will reck-' lessly commit the moral monomaniac to the scaffold or the penitentiary, little thinking that in so doing they punish disease and not crime. We are forced to acknowledge Moral Insanity as an actual disease by the most cursory glance at the previous history of some of those by whom it is manifested. Many of them from being refined and virtuous, and upright and prudent, have become coarse and licentious, and dishonest and reckless. We believe that many of our jails and penitentiaries are peopled by such/^ C Journal of Mental Science,' 1860, p. 314). Dr Prichard in his smaller volume, ' On the Different Forms of Insanity^ (2nd edit., p. 157), speaks of a youth, ^^an incor- rigible thief, and addicted to falsehood and deception in every way and apparently devoid of all perception of right or wrong." The mother of this boy was subject to attacks of acute Mania. Although he mainly had in view cases in which the moral cha- racter underwent a change, Dr Prichard thus expresses himself in regard to the class now referred to : — " It seems not im- probable that many persons, wrong-headed and perverse through life, and singularly capricious and depraved, would afford in reality, if the matter could be ascertained, examples of Moral Insanity, native or congenital.'' Other examples of moral madness in early life will be found in Eay's ' Medical Juris- prudence of Insanity,^ p. 99, and in EsquiroPs ' Maladies Men- tales,'' tome ii, p. 1 15. Dr West says that, in his experience, children are more subject to moral than intellectual aberration. It must, of course, be admitted that ordinary idiots are usually to a large extent idiotic morally as well as intellectually; but we have not yet seen sufficient evidence to prove that a con- dition deserving the name of moral idiocy exists, in connection with an average development of the intellectual faculties, not- withstanding the statements of some observers, whose oppor- tunities of observation, both in regard to the insane and idiots, have been very large. Dr Woodward, formerly physician to the State Lunatic Asylum in Massachusetts, held that, '''besides a disease of the moral powers, there seems to be, in some cases, something like moral idiocy, or such an imbecile state of the moral faculties from hirth, as to make the individual irre- sponsible for his moral actions." He adds, however, that "the persons to whom I refer have rarely much vigour of mind. 246 OF THE VAEIOL'S FORMS OF INSANITY although they are by no means idiots in understanding." More strongly speaks Dr Maudsley, after observing that " there are certain beings who are truly moral imbeciles." " It is remarkable^ indeed," he adds, " what an acute intellect may sometimes coexist with an entire absence of the moral sense." (Reynolds^ ' System of Medicine/ art. Insanity.) Although we do not admit what can properly be called moral idiocy apart from more or less lesion of the intellect, we fully grant that there may occasionally be good intellectual abilities, in association with congenitally feeble moral powers and voli- tion (a moral insensibility), and therefore a proportionate irre- sponsibility. During foetal life, diminished nutrition of the body or dimin- ished nutrition of one part and increased nutrition of another, may have occurred ; and thus resulted in the production of an undue proportion or predominance of a mental function. There is, indeed, during foetal life (and we may practically widen this period, and say, during that which elapses before the character is or can be observed), abundant opportunity for the influence of perverted nutrition ; whether it be in the formation of protoplasm and new cells, or the subsequent processes connected with the growth and organisation of the tissues ; or again, whether the elements of the circulating blood be in an abnormal propor- tion ; or lastly, whether it be the mysterious but well-recognised principle, in virtue of which there is an hereditary predisposi- tion to disease, which rules over and perverts the nutritive processes. Thus, in a case of what would by some be regarded as congenital moral imbecility, the mother of the patient was the subject of malignant disease of the uterus during gestation. Now, it is possible that this condition of the mother interfered with the proper nutrition of the cerebral tissue of the foetus, and was one among other causes which contributed to the final result. Persons born with talipes, or strabismus, owe their defect to some disease of embryo life. In like manner, during the same period of existence, the brain may undergo pathological changes which induce defective moral power. A cliild bom perfectly healthy may, through some illness or accident during early life, become completely changed in moral character. We know a case in which a child had pertussis at three years of age, followed by symptoms of hydrocephalus, from which she recovered ; but ever after, there was a marked perversion of the moral feelings, without any failing in the perceptive faculties ; and, although her judgment is far from good, there is no decided lesion of the understanding. She is quick, has MOEAL OE EMOTIONAL INSANITY PEOPEE 247 an excellent memory, and can acquire knowledge easily. Her parents state tliat, although, in the abstract, she knows the difference between right and wrong, she has appeared incapable of following the former like other children. Education failed to counteract the most determined propensities to falsehood and theft, and at the age of puberty the sexual instinct was strongly developed, and has ever since formed a prominent feature of her malady ; in consequence of which she was placed in an asylum when only seventeen years of age. We know also a case of Moral Insanity wMch dates from an attack of scarlet fever occurring when a boy was under five years of age. Erom that time there was a certain change of character, a want of seK-reliance or ability to help himself in any difficulties, so that he constantly wanted help in his employments. Great excitability was also manifested. As he grew up he practically reversed the motto esse quam videri, for if he had the videri in anything, the esse was a secondary consideration. He excelled in spelling at school, but not in other depart- ments of knowledge. He was a good reader of ordinary tale books and of popular scientific works ; his memory was very tenacious, not only of the facts, but of the very words. The change in his moral natirre was strikingly shown by his appearing to lose the distinction between truth and falsehood, he having been truth- ful and conscientious before, and while making a high profession of religion he was deceiving his friends and himself also. He chose low society in preference to the refined associations by which he was surrounded at home. For some time after his regard for truth had disappeared, he distinguished between meum and tuum, but this distinction was after a while removed also ; and he possessed himself of some articles of little value, which he evidently appropriated from a morbid desire to steal, and not from any use he could make of the articles. To immorality, in the popular sense of the term, he has not manifested any tendency. Some time after he attained his majority, his fi'iends had reason to fear that he would commit some act of violence which would bring him into the hands of justice, and, after having endured an amount of anxiety and suffering which those only who know these painful cases from practical experience can fully estimate, they obtained the opinion of two medical men familiar with mental disease, who had no hesitation in certifying to his insanity, and he was placed imder proper care and restraint. We may add that there is no known hereditary taint of Insanity in this gentleman's case, and that everything in his training and surroundings was calculated to foster, vnfh- out morbidly exciting, religious feeling and conduct. Perversion of tlie moral sense may also occasionally be traced to accidents^ followed by injury to the bodily structures ; as a fall from a borse^ or a blow by which, the head has sustained injury. Thus, among the cases falling under our own notice — A lad of good abilities was thro^vn from a horse, when twelve years of age, and his head sustained much injury in consequence j the skull bearing evidence in after-life of the accident. Eor several months afterwards the mind was weakened, but then gradually recovered its tone; at twenty years of age, however, he suffered from Melancholia, followed by alternate attacks of excitement and depression, but was not placed in confinement. Ultimately it was necessary to place him in an asylum, when he afforded a marked example of Moral Insanity. 248 OF THE VARIOUS FOEMS OF INSANITY A case recorded in Dr Wigau^s work ' On the Duality of the Mind ' is generally known, and well illustrates the influence of injury to the cerebral substance upon the moral character. A blow upon the head, given by a teacher with a ruler, was followed by an entire alteration in the moral feelings. Mr Cline tre- phined, there being a very slight depression of the bone, and a bony spiculum was found pressing upon the brain. Perfect recovery of mind followed. Dismissing the consideration of congenital cases of defect or disease of the moral faculties, and those arising from various causes in infancy and youth, we may pass on to those in which Emotional disorder comes on or is first exhibited in adult life ; and here the test already spoken of may be most properly applied. The standard of mental health may then justly be sought for in the natural and habitual character of the patient. This it is which is now altered, and the symptoms by which it is rendered manifest may next be considered. Usually the change in the feelings and conduct of the patient is gradual. Frequently lie is more absorbed and reserved, and on any provocation, however slight, is unreasonably irritated. He becomes suspicious, liable to attribute false motives to his friends and others, and to cast ungenerous reflections upon his nearest relatives. The husband suspects the fidelity of the wife, the wife that of the husband, without the slightest foundation. The patient is observed by strangers to be morose ; and, as the clouds gather, his acquaint- ance become conscious, without knowing exactly why, and very probably without once supposing the man to have become, in plain English, mad, that he is, somehow or other, an altered being. At last the storm bursts ; and some act is committed of an outrageous character. He is then regarded as either insane or criminal ; the former, probably, if the act does not make him decidedly amenable to the laws of his country, and his destination is the asylum : the latter, most probably, if the act has been homicidal, and he is consigned to the executioner. In other cases an individual has been subjected to over-exertion of mind, his powers overtasked, or his feelings put upon the stretch, in consequence of anxiety or unaccustomed responsibility. He then finds himself susceptible to the slightest mental emotion, loses his sleep and rest, is conscious of more or less uneasiness about the head, a sense of tension and dull aching pain, is probably MOEAL OE EMOTIONAL INSANITY PEOPER 249 troubled with palpitation of the heart, and finds himself unequal to the discharge of his usual duties. His digestive organs are also often disordered, his appetite uncertain, the secretions de- praved. In addition to all this, he may be distressed by certain impulses and tendencies which are alike repugnant to his reason and to the dictates of his moral nature. Often the impulse is to do violence to himself and others, or simply to break glass or articles of furniture. We know a case in which the patient was, in the first instance, strongly impressed with the desire to obtain pistols ; he was astonished and perplexed with so strange and purposeless a desire. Under these circumstances, it is no unusual thing for the patient to deliver himself up to the care of some judicious friend, or an asylum ; and a happy thing it is for himself and society when such is the case. A patient, the subject of Emotional Insanity, thus expressed herself to the writer: — " I have my reason, but I have not the command of my feelings. Circumstances in life create feelings and prejudices which prevent my passing through life smoothly. My intellect is not insane ; it is my feelings I cannot control.^' It would have been impossible to have described her state more correctly. Since we first recorded this case the patient has committed suicide. In the following case there was no delusion in the first instance, but eventually, when seen by the writer, there was a distinct delusion of persecution by the police, and indeed of conspiracy on the part of the asylum authorities and others. Another element in this case (whether to be regarded as a symptom or a cause of moral perversion is doubtful) was intem- perance, after being respected as a sober clergyman. It is remarkable that when in the asylum where he was first confined, it was noted that '* he has no craving for drink, and avoids it.^^ A mixed case like this is highly instructive, and shows how at different stages of the disorder, a different opinion might fairly be held in regard to the form of his insanity, how difficult it would be to prove distinct intellectual aberration in the early stage, and how the salient symptoms of the case are referable to a perversion of the higher emotions — the affections, the temper, the disposition. A. B.— set. 56, a clergyman in good position and respected, became altered in character. Among other things he gave way to drink. He was separated from his wife in consequence. One day when he was partially intoxicated he assaulted a ^250 OF THE VAEIOUS FORMS OF INSANITY policeman when interfered witli, and was committed to gaol. Afterwards he was transferred to an asylum, in the case-hook of which it is stated, " On admission, he is an intelligent-looking man, with a very well-developed head, and he is of good address, but his manner is a little excitable and nervous, and far too deferential for a man in his position. He ascribes his assault on the police to an irresistible impulse to retaliate what he considered a wrong done him by their seizing him. He considers it was justifiable anger, but that it was on the whole unbecoming his position as a clergyman. Li fact he reasons most intelligently from false premises. No delusion noted. " Mav 30. WTiile able to converse on ordinary topics very intelligently, and support his arguments faii-ly, as a rule showing great ingenuity in accounting for the eccen- tricities of his conduct, yet the most trivial circumstances are apt strongly to excite his feelino-s, and then his reasoning powers are overbalanced and crowded by passion. Inordinate variety, and craving for sexual intercourse, are very marked characteristics of his state, but he has no craving for, and avoids stimulants. He is extremely plausible, affected with extreme moral obliquity, so that he is constantly making false state- ments without betraying any sense of shame or detection, and yet he appears at times conscious of his failings, and makes endeavours to conceal them. Shows no affection for his wife and family. " December 20. A wish to command others is strongly asserting itself, nevertheless he endeavours with great plausibility and cunning to become all things to all men in order to propitiate them if he thinks anything can be gained by it. Moral sense very perverted. No evidence of delusion. " Februarv, 1876. Has much improved, but is still apt to domineer and assert his opinions dogmatically on subjects of which he has no knowledge, and is not confused on the proofs of his ignorance being demonstrated. " March 31. Much less obtrusive, and has not given way to temper lately, endea- vouring to exercise great self-control. Has little reverence for his profession. " April 10. Has been quiet, orderly, and gentlemanly, sleeps and eats well, but his manners are eccentric and extreme. Egotism is a marked feature in his case. The moral sense is much blunted, and his conversation betrays an unbecoming zest for immoral stories, while he jests at his own immorality. " May 26. Is able to conduct himself properly, and being as free from delusion as from the first he is, by order of the Secretary of State, discharged." Subsequently he committed an indecent assault, and was committed to another asylum. \\'Tien seen there, we found him a man of extreme plausibility, utterly untruthful, and with decided delusions in regard to conspiracies against him, especially on the part of the police. The superintendent of the asylum made the striking observa- tion that he began by telling what he knew was a lie, and ended by really believing it. Thus the delusion owed its origin to moral perversion in a once respected clergyman. In those cases in which delusion cannot be detected along with moral perversion, there is very frequently a certain feeble- ness of mind, or even childishness, which, although not so great as to meet legal definitions of imbecility, is from our present point of view sufficient to take the case out of the category of moral insanity, assuming such to exist, pure and simple. It is obvious that there is in such a case as the following, for exam- ple, a condition of the intellect which a Judge would be very likely to decline to admit to be so deficient as to lessen re- MOEAL OE EMOTIONAL INSANITY PEOPEE 251 sponsibility, yet tte man is in an asylum ; not^ indeed, because of his intellectual weakness, but because he is dangerous to society. W. W. was, when recently seen at Brentwood, under Dr Campbell's charge, a man of twenty -nine years of age, who displayed no delusion, and was not in a mental con- dition, which in a single interview suggested imbecility. His physique was good. On asking Dr Amsden why he was in the asylum, the reply was given that he was affected morally ; that this showed itself in bestial acts, and in violence of temper. On further inquiry we found that, although never strong minded, and apt to cry like a child at trifles, and make foolish remarks, " he can converse on ordinary topics like most members of the class from which he is derived." Here then is a case which a medical psychologist might regard as one of congenital imbecility, if the term be employed m a mild sense, but which it would astound a jury to be told was such, if they had an opportunity of seeing and conversing with him. " For legal purposes," Dr Amsden remarks, " the absence of marked intellectual defect is a bar to proof of incapacity for the management of himself and his affairs. The moral sense is chiefly implicated as shown by violent passions, cruel disposition, and want of control over emotion. He was removed from a workhouse to the asylum by the Commissioners in Lunacy, for throwing stones at the old men. He is active and industrious, but not trustworthy." He learned to read and write in the workhouse school. He is stated to be " very quick at learning anything, is a good dancer, and one of the singers at chapel." W. W. was illegitimate, through, it is believed, an incestuous union ; the mother, whom we have examined, is a weak-minded woman. Another son was very dull, married, and had a daughter, also of weak mind. The question naturally arises. Are the physical symptoms of the morally insane such as might be looked for if they are the sub- jects of a physical disease ? The answer has already, to some extent, been anticipated by the enumeration which has been made of several well-marked premonitory symptoms. It should also be remembered that in many of the insane, in whom there is indisputable lesion of the understanding, the most careful scrutiny will fail to discover any disorder of the circulation, as indicated by the pulse and the respiration, or of the fnnctions, of secretion and excretion, as indicated by the tongue, the alvine evacuation or the renal secretion. And, with the exception of the congenital class of cases already referred to, it may, we believe be safely afl&rmed that, among those patients whose moral nature appears to be specially invaded by disease, derangement of the physical health is, in the early stage, as frequent as among those whose intellect is manifestly disordered. And the ter- mination of cases of Moral Insanity in some unmistakable dis- ease of the nervous system, as General Paralysis, will not unfre- quently solve any doubt which may have been felt previously in regard to the disease of one or more of the bodily organs. 252 OF THE VARIOUS FORMS OF INSANITY Furtlier, Moral Insanity most frequently assumes a chronic form, and therefore it is not surprising if physical symptoms are some- times not well marked. In acute forms, that is to say, when the patient is restless and excited, and perhaps commits a breach of the law, the physical symptoms are generally obvious enough. The exceptional class above spoken of includes those cases of perverted moral feeling, the history of which extends back to the earliest infancy, and probably to congenital malformation of the brain, and in which the proof of an abnormal physical condition is to be found in various facts which a careful inquiry into the family and particular history of the patient will elicit. But even in these cases, there is one physical disease to which the patient, in a large number of instances, is or has been subject, and that is epilepsy. Nor can we forbear the expression of the belief that convulsions in infancy are, in relation to their ultimate effects on the mind, not sufficiently recognised. Often do these pass away, and are forgotten, when the dentition is accomplished which induced them ; but some portion of the cerebral tissue has received injury, which in any other tissue of the body, were its severity two-fold, would be easily recovered from, but which in so delicate a tissue as the nervous — in which the very process of repair is so hazardous to the integrity of the associated function — permanently injures the moral or intel- lectual powers of the child, and is painfully perceptible as he grows up to manhood. .ffitiology. — In the cases which we have given we have already specified various causes. See also the chapter on causes of Insanity generally (p. 57). Prognosis. — Unfavorable. See p. 136. The period which has elapsed since the first edition of this work was published has been marked by two opposite currents of medical opinion. On the one hand, the tendency has been to ignore not only the name but the doctrine of Moral Insanity.* On the other, some of those most conversant with crime are inclined to regard it as closely allied to, if not identical with Insanity. Thus, Mr J. B. Thompson, the resident surgeon of * See an extraordinary proof of this in an article in the 'American Journal of Insanity,' Jan., 1S73, by Dr Ordronaux. WMle a protest may be entered against the abuse of the doctrine, the position taken by the author of this article in regard to Moral Insanity seems to us, we confess, like " an attempt to set back the clock of the century, and to revert to superstition and supernaturalism in medicine." MORAL OR EMOTIONAL INSANITY PROPER 253 the General Prison for Scotland^ at Pertli, in an article on " The Hereditary Nature of Crime/^ in the ' Journal of Mental Science/ Jan., 1870, says, " From large experience among criminals I have come to the conclusion that the principal business of prison surgeons must always be with mental disease; that the number of physical diseases are less than the psychical ; that the diseases and causes of death among prisoners are chiefly of the nervous system ; and, in fine, that the treatment of crime is a branch of psychology." Although it does not follow from this allegation that those criminals whom Mr Thompson would regard as labouring under diseases of the nervous system are bright intellectually (the contrary being in many instances the case), the inference is inevitable that, if the position taken in this essay be established, a large number of persons possessing so much intelligence as to be regarded by judge and jury as compos mentis, are insane and irresponsible. The conclusion is practically much the same whether we regard a criminal as the subject of Moral Insanity, or of an intellectual defect which a court of law refuses to recognise. The writer believes that a fair consideration of such cases as those which he has given from his own experience, will lead to the conclusion that congenital and acquired mental conditions are to be met with, of which the broad salient features consist in emotional irregularities rather than delusion, hallucination, or imbecility, although some feebleness of mind will usually be detected. It is the part of the observer of disease to endeavour to seize such distinctions, instead of attempting to reduce them to one uniform symptomatological level, and so losing the prac- tical lesson which significant physiognomical lines of morbid phenomena are calculated to teach. The distinction in question has been forced upon the minds of such alienist physicians as Pinel, Esquirol, and Guislain, while Griesinger, against his prepossessions, was driven to admit it in one form, namely, " transitory mania," not from speculative considerations or metaphysical refinements, but from the occurrence of cases of moral defect and disease which would not fit in with their pre- vious theories, and which were indeed altogether foreign to their notions. At the same time, we hold that the cases are rare in which disorder of the intellectual faculties cannot sooner or later be discovered by careful observation, and to this end the atten- tion of the observer ought to be carefully directed in each case. 254 OF THE VARIOUS FORMS OF INSANITY We say " sooner or later," because seeing that insanity usually springs in the first instance, from the depths of the moral nature, no delusion may have developed itself at the time when irregularities of conduct or dangerous acts occur, and when the practical question presents itself, whether an individual is labouring under cerebral disease. Judging from past expe- rience, we may be satisfied that strictly intellectual disorder will before long declare itself, but this by no means destroys the importance of recognising the disease as such at the earlier period, just as when in scarlatina the rash has not yet come out, or in rare instances never does, we do not deny the presence of the disease, but recognise it in spite of the absence of the erup- tion. Whatever, then, may be thought of extreme theories which have been advanced in regard to Moral Insanity, we agree with Griesinger that " it should constantly be borne in mind, that an individual may talk quite rationally, and at the same time show by his acts and by his conduct (and even by what he does not do) that he is mentally deranged." {' Die Pathologie und Therapie der Psychischen Krankheiten,^ 1871.) SECTION VII.-Homicidal Mania. We proceed to consider that most important form of mental disorder which passes under the name of the homicidal. Synonyms. — Homicidal Insanity ; Monomanie meurtrierey Mono- manie homicide (Fr.) ; Mordtrieh (Ger.). Definition. — Although usually defined as simply an irresistible impulse to kill, we must for practical purposes treat under Homicidal Insanity or Mania, cases which, while characterised by homicidal deeds and irresistibility, arise from morbid motives, and even delusions. It is generally classed under the Mono- manias ; at the same time it may, and often does, coexist with general defect or disorder of the mind. In treating of hallu- cinations, it was stated that a homicidal act may be the result of hearing imaginary voices commanding the patient to kill. Motives, therefore, very dissimilar in their nature, and equally the result of disease, may lead to the same act ; it may be fairly presumed, however, that such hallucination, so far from being the first in the series of morbid mental changes, is, in some instances, itself the offspring of a diseased propensity. Attention is especially directed to this observation, because it is not uncom- HOMICIDAL MANIA 255 mon for authors to charge the intellect with being the instigator of an act, of which it appears to be the proximate cause ; over- looking the possible antecedent genesis of the act in perverted propensities, which might suggest and give their own peculiar tinge to any hallucination or delusion. This, however, need not prevent the admission, that the primary cause of homicidal acts may, in other cases, be traced to the understanding ; the propensities playing but a secondary role in their development. Thus, a gentleman attempts to kill his wife, because he labours under the delusion that she administers poison to him in his food. Again, should an individual, anxious to commit suicide, shrink from the execution of the act, he may murder another person, in order that he may himself be put to death. But here the origin of the malady is not to be found simply in an intellectual process of thought j the motive lies deep among the feelings, and is even here closely associated with the homicidal propensity. Further, a man may terminate the earthly existence of his children in order that they may be spared the trials of this life and be safely landed in heaven. But apart from all these de- lusional motives, there remains, it is alleged, the unreasoning, blind, and forcibly impelling impulse to kill. We cannot more clearly convey the view which is taken by the upholders of Homicidal Mania than by quoting from the article by Crichton Browne, already laid under contribution; '' That insane and irresistible impulse prompting to murder and destruction which has been designated Homicidal Monomania is a malady fi^om the incursions of which childhood is not exempt. The powerful, sometimes unconquerable impulse felt by those suffering from this disease originates in various circumstances, and various reasons may be given for a homicidal act by the monomaniac committing it. He may believe [when intellectual disorder is present] that he is conferring a real benefit upon the person he kills, or that, by destroying life, he is obeying the behest of Heaven Or he may do it [when intel- lectual disorder is not present] from a pure love of destruction and cruelty, or from the force of imitation. Frequently a mere blind, motiveless impulse to destroy is felt, against which the monomaniac himself earnestly strives. Examples of this disease as occurring in early life are by no means uncommon.''^ (After supporting this opinion by cases, it is added, " Like propen- sities we have seen manifested by the eldest son of a gentleman occupying an elevated position in society ; one who, from his 256 OF THE VARIOUS FORMS OF INSANITY very cradle, had mingled with the gentle and refined. At his own earnest request this boy was permitted to act as butcher to all the farmers on his father^s estate. His favorite amuse- ment was putting fowls and rabbits to the most cruel and ago- nising deaths, and he gloried in gratuitously shooting the roes whilst with young. "Whilst repairs were going on at his father^s house, he sawed through the scaffolding in such a manner that when the workmen mounted it, they might be precipitated to the ground. Such is destructive or Homicidal Insanity.^^ {Op. cit., p. 310.) Classification and Symptoms. — In former editions of this work we gave a carefully prepared analysis of the most remarkable cases of Homicidal Mania, classified under two heads — 1st, those cases in which there is no marked disorder of the intellect, examples of Emotional Insanity ; 2nd, those in which such disorder is more or less apparent. The former class was subdivided accord- ing as there is, or is not, evidence of premeditation and design. In the latter class were included cases marked by deficiency of intellect, as Idiocy, Imbecility, or a certain feebleness of mind not amounting to these pronounced states (a most important class) ; while others are rather indicated by a state of exaltation, shown by delusions, hallucinations, &c., these usually consti- tuting the motive, but not necessarily so, as it may be quite impossible to connect them with the commission of the homicidal act. In the present edition we omit the particulars of these cases, with a few striking exceptions, and shall content our- selves with giving the results of the former analysis and adding several fresh examples which illustrate this form of mental disease. Analysis of cases. 1. Without marked disorder of the intellect : (a) Without premeditation or design ... ... ... ... 31 (6) With „ „ 4 — 35 II. Cases in which there was more or less disorder of the intellect : (a) With deficiency of intellect 5 (b) With delusions, &c. ... ... ... ... ... ... 10 — 15 Total 50 As an illustration of the first division of the first class, occurs the case of a woman reported by Dr Skae, in his ' Report of the Royal Edinburgh Asylum for 1850.' It is an excellent HOMICIDAL MANIA. OASES 257 example of this class. There was no disorder of the intellect, no motive^ and no design evinced ; only an impulse. " She deplored in piteous terms the horrible propensity under which she laboured. ^^ Dr Wilks informs the writer of a case under his care in which a well-marked homicidal impulse was developed. The patientj a lady, consulted him on account of an impulse which she at times experienced to kill her boy, whom, so far from feeling any antipathy to, she fondly loved. She bitterly deplored and earnestly desired to be delivered from it. She was wholly at a loss to account for this feeling, and she stated that when it was present to her mind she left the room, in order to prevent herself carrying it into execution. There was not in this case the slightest suspicion of epilepsy. We have recently examined a young man, formerly a coach- driver, who along with various serious physical symptoms has been the subject of a mental one of great interest in this connection. While driving four-in-hand, the horses ran away, and before he succeeded in stopping them he was greatly ex- hausted and frightened. From that time (two years) he has had diminished power over his arms, he has now slight ptosis, diplopia and amblyopia, with other symptoms not important to our present purpose. The interesting point is this : that a short time since, on a day when his motor power had been worse than usual, he was standing with a boot-jack in his hand near one of his children, and experienced a sudden impulse to give the child a severe blow with it. He instantly threw it aside, horrified at the impulse. The man would be regarded as quite sane. It is clear, however, that the disease has only to advance a little further to render the commission of a sudden and homicidal act possible, without the patient being insane in other respects. In the Essex County Asylum there is at the present time (1878) a man whose case constitutes an important contribution to the subject now under consideration. No doubt the history suggests masked epilepsy, but proof of it fails, and if proved, the importance of the case would not be destroyed. On ex- amining him with Dr Amsden we elicited the following par- ticulars : D. P., aged 52, married, a labourer. A year ago he was for a short time melan- choly. He was treated at home, and recovered. A fortnight ago, when talking kindly to his wife, he cut her throat. There was no provocation whatever. He 17 258 OF TUE VARIOUS FORMS OF INSANITY cannot account for it. He greatly regrets it. He had not, he says, the slightest motive for doing it, for he was on the best terms with his wife. It appeared that a short time before, a daughter had fallen into disgrace, and this preyed upon his mind. He was not unconscious when he committed the act, and there is no proof that he ever had petit mal. He has never had fits. His father is stated to have died of epilepsy. He is a dark bilious-looking man. He looks depressed, as is natural, and complained on admission of sleeplessness. In the case-book it is stated, " While confessing his homicidal attempt, he deeply deplores it, says he is fond of his wife, that they never had any disagreement, and that it was a sudden and uncontrollable impulse whioli overcame him. No delusion is detected, and he converses intelligently. General health fair. Slight cephalalgia." Sucli cases prove beyond all doubt that tliere may arise a morbid impulse^ sometimes ovei-powering, to destroy life. It is idle to attempt to evade the force of the evidence again and again brought forward to establish this fact, or to endeavour to tone it down in order to meet the requirements of our law courts. Psychological science has suffered grievously already from the attempt to make a sort of compromise between the simple teaching of mental pathology in these cases, and the learned but false dicta of the judges. Thus fettered, some alienists have united with the lawyers in denying the doctrine of irre- sistible impulses and, indeed, of Emotional Insanity, pure and simple, altogether. Disease, however, will not alter her cha- racter in accordance with the preconceived theories and require- ments of the law ; and the only really scientific and dignified course for medical psychologists to pursue, is to state psycho- logical truths fearlessly, and leave the law to take care of itself. This would be much better than to exercise an immense amount of ingenuity in attempting to discover delusions and other proofs of intellectual disorder — an attempt which no one woiild dream of making in regard to the same case if honestly dis- cussed from a purely medical point of view, or reported in the case-book of an asylum. To those who, in opposing purely Emotional Insanity, assert that this condition is only an early stage of what will eventually prove to be also a disorder of the intellect, it is enough to reply that, whether a temporary or a permanent state, the fact remains that a criminal act may be committed in consequence of cerebro-mental disease, without as yet any apparent lesion of the perceptive and rea- soning powers. The greatest difficulty, no doubt, arises in those cases of uncomplicated Emotional Insanity in which the mental disorder is of a sudden and transitory character, not preceded by any symptoms calculated to excite suspicion of Insanity. Pi'oof of MANIA TEANSITOEIA 259 hereditary predisposition may alone be forthcoming, and not even that. It is probable that in nearly all, if not all instances, there has been j^etit mat. This form of disease has received considerable attention under the name of Mania Transitoria.* ( Vesania anomala, Sanger and Eetzen) . A thorough knowledge of the preceding mental condition would so generally reveal more or less morbid emotional disturbance, th.at we believe it to be exceedingly rare, if the definition of this disorder requires that there shall be a sudden paroxysm without such antecedent manifestation, that the duration of the morbid state shall be short, and its cessation sudden. In this emotional disturbance we should include the morbid feelings of the patient, both mental and pbysical ; and if the truth could be ascertained, we have no doubt such would in the vast majority of cases be dis- covered, but as they rarely can be got at, and are, under the circumstances, open to suspicion, it happens that, practically, in some cases involving criminality, there is no reliable proof forthcoming of any prior history of mental disorder. Oases are therefore not unfrequently met with, paroxysmal in cha- racter, of brief duration, and which suddenly cease, so far as the patient's history allows us to judge. f It must also be remembered that, still more frequently, outbursts of maniacal fury, including destructive and homicidal impulse, occur with- out the other condition being fulfilled — previous sanity. M. Legrand du Saulle, in a discussion at the Paris Medico- psychological Society, Jan. 29th, 1872, reported the case of — * See Krafft-Ebing's 'Die Lehre von der Mania Transitoria fiir Aerzte mid Juristen dargestelt.' Erlangen, 1865. t On this form of mental disorder the reader will find a useful article by Dr S. T. Clarke, in the 'American Journal of Insanity/ Jan., 1872, in connection with the case of Pierce, found " not guilty, on the plea of Insanity," and one by Dr Jarvis, July, 1869, on " Mania Transitoria." Castelnau (' Annales d' Hygiene publique et de Medicine legale,' xiv. 217, 1851) on " La Folic instantanee," concludes that " there exist instantaneous changes in the mental faculties, i. e. instantaneous Insanity," and gives many instances. Dr Devergie, in 1858 (vol. xi) concurs with Castelnau, though he points out that there is generally some mental irregularity previously, as well as heredity. He reports a case which was decided to be one of Transitory Mania, by Calmeil, Tardieu, and himself, the Court acquitting the prisoner (who killed his mother-in-law) on this ground. Devergie observes that " in the short period of seventy years we have passed from incredulity, or rather the most profound io-norance of the distinctions of Insanity, with such immense advantage, that now our judges and juries accept as founded on evidence not only delusions on a single point (Monomania), but even those transitory aberrations which in the world's judgment transform a man of previously honorable character into a criminal." 260 OF THE VARIOUS FORMS OF INSANITY Theodore, ajt. 26, intelligent rather above the average, of good conduct and great sweetness of character, who one day assassinated two men without premedita- tion, without motive, and without apparent excuse. He asks, Had he been drinking ? Had he epileptic vertigo? and replies that the perpetrator of this inexplicable crime seemed to have acted under the influence of a transitory attack of Insanity. He was sent to an asylvim, whei'e on admission he was very calm and reasonable, and was soon occupied in the office. After a certain time, his mental health being always good, the doctor desired he should be discharged. The prefect refused. For live years the doctor and the prefect respectively proposed and forbad his discharge. At length the patient appealed to the Minister of the Interior, who directed an alienist physician to examine him. His report was favorable, and his release was ordered, subject to a monthly examination by a medical man. M. Legrand du Saulle was appointed, but at the end of eighteen months this oversight was dispensed with. Soon after came the war, and the doctor does not know what became of him. He says one thing always struck him in his interviews — the absence of all remorse for his act or any consideration of the families of his victims. He could never work upon his feelings in respect to them. One day he told the doctor he had had his salary increased, but that unhappily he had no family to benefit from it. " You forget," replied the doctor ; " the honest man who has involuntarily injured another, is he not bound to repair the injury ? Half your earnings belong to the widows and children of the two men you have killed." The speaker only succeeded in provoking a slight smile. M. Legraud du Saulle ends the account of this case by observ- ing that in the face of this wounded egotism, this " Secheresse affective/^ and absolute want of every mark of compassionate sentiment, he said to himself that Theodore could only be an epileptic. At the same time he could not undertake to prove it. (See ^Annales/ May, 1872, p. 413.) That the mere act itself, however strongly suggestive of Insanity, must in the absence of collateral proof be taken as evidence with extreme caution, is most true. Usually, we believe there will be some decided evidence procurable of hered- itary disease or of a change in the feelings prior to the com- mittal of the act — generally of both — and yet Ginesinger was compelled against preconceived ideas to admit that the act, and the act alone, might constitute sufficient evidence of the Insanity of the homicide. " Are there not cases," he asks, " in which in criminal deeds a morbid mental state exists and has an influence, and yet presents no external manifestation V And he replies, "^ I believe it possible Who would dare to deny the possibility of active organic influences of a morbid nature, which although not externally noticeable, might, when disturbed and disordered at the moment of action, turn the scale towards crime ?" And he says he was constrained in a case of murder to admit that ^''neither before, nor at, nor after the EPILEPSY IN RELATIOJST TO HOMICIDAL ACTS 261 deedj did we find certain signs of mental disease." (" Weder vor, noch bei^ noch nacli der That finden wir bestimmte Merk- male geistiger Storung.") Griesinger considered the act must have been due to petit mal, and that this disease had weakened volition, without, however, any external mental symptom. ('Die Pathologie und Therapie der psychischen Krankheiten/ p. 123. Stuttgard, 1861. See also ' Syd. Soc. Trans.,^ by Drs Eobertson and Eutherford, p. 119.) The presence of epilepsy is unquestionably a point of extreme importance. In doubtful instances careful inquiry should be made whether epileptic seizures, however slight and transient, have been observed. Some of the most dangerous homicidal lunatics, without delusion, are subject to attacks of epilepsy ; they may be under the influence of destructive impulses only when a fit is threatened. See " Epileptic Insanity." At the York assizes a man charged with the murder of a policeman was with difficulty saved from the gallows on the plea of Insanity, the result of epilepsy. The defence, as expressed hy the prisoner's counsel, rested " upon the plea that at the time of the commission of the homicide at Huddersfield, he was under the influence of a well-known species of Insanity, viz. Mania connected with epilepsy, indicated by a blind uncontrollable fury, exhibited on the slightest provocation or injury, upon the use of a full diet, or the use of small quantities of intoxicating liquors." The prisoner, after the murder was committed, amused himself with singing songs, apparently unconscious of the gravity of the crime, and exhibiting no symptoms of regret for the injury he had done or fear of the consequences to himself. The successful issue of this case contrasts with that of Bowler, tried some years previously for shooting at Burrows. The defence was epilepsy, the prisoner having been on one occasion brought home apparently lifeless after a fit, from which time a great change took place in his character and habits, he eating his meals almost raw, and lying on the ground in the rain. Although among other i^roof s of Insanity present he was suicidal, he was found guilty and executed, on the ground that he could distinguish right from wrong ! '^ The existence of instinctive monomania has," observes Marce, " been denied, and it is said that these impulses are mostly associated with epileptic vertigo. These objections are not without value, but they appear to me insufficient to abolish this class of instinctive monomanias. If an impulse has often been accompanied by a delusion or hallucination, the fact of an irresistable impulse remains so predominant among all the other symptoms, that it stamps the patient in a way which strikes one at the first glance .... In spite of all that may be said, there are unquestionably instinctive monomanias free from all complication." (Des Maladies Mentales, p. 381.) Some cases of alleged Homicidal Mania fall under the desig- 262 OF THE VARIOUS TOEMS OF INSANITY nation of Uterine or vSkae's Amenorrlia3al Insanity, and consti- tute when established, illustrations of this form of mental disease. A young cook, in good health, with the exception of disordered menstruation, had a gentle disposition, hut at each menstrual period she became maniacal and wt)nld pui-sue with a knife any one who displeased her. After menstruation she was well, and regarded her acts in their true light. (Marc, vol. i, p. 317.) See ako in the same work (vol. ii, p. 112), the case of A.B. — , a female, aged twenty-six, who experienced at each menstrual period a strong homicidal impulse. A striking example of a powerful impulse to destroy life occurred in a schoolmaster, not long ago, in Paris.* It is especially interesting, as showing the power of seK-control up to a certain point. A young man, set. 25, and of gentlemanly appearance, after giving his address, and declaring himself to be a schoolmaster in a certain well-known college, begged that the Commissary of the Police would take hun in charge with a view to his confine- ment in the Asylum of St. Anne. He then explained that he was not mad in every respect; on the contrary, he possessed the full use of his mind; only while sleeping among the pupils confided to his charge he was seized \vith the most destructive inclinations. Night after night in an agony of fear he had struggled with himself, and it was with the greatest difiiculty that so far he had succeeded in restraining his intense desire to strangle one or two of the little boys. Now all his energies were exhausted ; he felt that this unknown power would ultimately triumph over him, and rather than commit the crime, he placed himself in the hands of the police. At this moment a boy accused of theft was brought into the room. The eyes of the school- master were immediately lit with a strange light, and had it not been for the timely assistance of a brawny policeman, the boy would have been thi'ottled before the very eyes of justice. There are some cases of Homicidal Insanity in which, while the symptoms unquestionably establish unsoundness of mind and irresponsibility, there arises the suspicion that revenge has to some extent prompted the act. This and other motives are not unfrequently mixed up, in Insanity, with such symptoms. In May, 1872, a soldier named Jordan, set. 39, under the influence of a homicidal impulse, destroyed the life of a child by cutting its throat with a razor. He was a gunner in the Royal Artillery at Climping, near Littlchampton, Sussex. Now, in this case there was a certain amount of evidence to indicate revenge as a motive for the act, for in consequence of being out all night he was put under arrest by Bombardier Semple and confined for two days, and it was Semple's pet child that the prisoner killed. Yet the judge. Baron Martin, dismissed this idea as quite un- proved, and, more remarkable still, he felt so forcibly the evidence of Insanity that he said, in concluding his address to the jury, " When such impulses come upon men, according to the medical evidence, they were unable to resist them. It would be safe in such a case to acquit the accused on the ground of Insanity ; " and the jury * We have mislaid our authority for this case. MURDEEOUS IMPULSE WITH DELUSION 263 broiTght iu a verdict accordingly of " Guilty of mui'der in an unsound state of mind," which, to meet legal technicalities, was altered to " Not Guilty of murder, on the ground that at the time he committed the act he was in an unsound state of mind." This was not a case of simple irresistible impulse, belonging to the class of Transi- tory Mania, for the prisoner had been in a despondmg state of mind for a considerable time, and had at one period been treated in hospital for a disease at first regarded as delirium tremens, but subsequently this diagnosis was set aside. What his disorder really was at that time does not appear to have been ascertained, but it may have been acute Mania. His conduct was stated to have been good, having been twenty years in the service, and his marks indicating about eighteen years' good service. A fellow-soldier proved that after dinner Jordan read a novel for half an hour, and then went to the box containing the razor, took it out, put on his tunic, and went out on to the battery, from which he could see right roimd the Fort. A few moments after «ame the alarm — the children's cries — the father and mother running out, and their acclamations of horror. The witness stated that the prisoner had always seemed quite right, and that he was a very sensible man. In this case it must be noticed tiat the prisoner ran away. The feiTyman to whom he went to be ferried over the river Arum said he trembled very much. He knew the prisoner well, and he always seemed to be like other persons. When apprehended he said, " It's of no use to deny it," and that he had no animosity against the bombardier or his family, and that it must have been the devil. Before the magistrates he said, " I have had a great deal preying on my mind ; I hardly knew what I was doing. Two years ago my wife went away, and I have had a great deal on my mind ever since. The bombardier, his wife or family, never did me any harm that I am aware of. It was the Fort that preyed on my mind; there was not sufficient company nor enough work. If it had been a livelier place and with more company, it would have worn ofE." * The really remarkable feature of this case is that the judge disregarded the legal tests of responsibility and was guided by medical sciencOj for there have been many examples of uncontrol- lable homicidal impulse more striking than this^ in which^ how- ever, the judge strongly contended for the responsibility of the prisoner and discarded the plea of Insanity. We cannot better illustrate the second (the delusional) division of the second class of cases of Homicidal Insanity than by a highly interesting case of Homicidal Mania in the Morning- side Asylum, reported by Dr Yellowlees in the ' Edinburgh Medical Journal/ 1862. Some, however, would demur to the assumption that his suspicions of persecution amounted to actual delusions. Smith, a joiner, became a printer and an author. For seven years he was a * A full report of this case will be found in the ' Journal of Mental Science,' Oct., 1872. From an inquiry made of Dr Orange, the Superintendent of the Broadmoor Asylum, the writer finds that Jordan, who has since been an inmate of that institu- tion, remains insane. Dr Orange writes (March, 1873), " His mind is stUl in an unstable condition, and I should not be surprised at the access of a maniacal paroxysm at any time." Subsequently (1877) the wi-iter conversed with him at Broadmoor. He deplored the act he had committed. There was no delusion detected. No Epilepsy. 264 OF THE VARIOUS FORMS OF INSA>:iTY laborious and successful teacher, and officiated as precentor in Grcyfriars Church. His first indications of insanity bore the character of touchiness or needless sensi- tiveness, which rapidly intensified mto a monomania of suspicion or belief in his being tlie subject of persecution. He summoned before the court a person who called him " ^Tiisker Willie," but the summons was dismissed, which induced Smith to assail the magistrate soon after in church for his unjust judgment. For this he was con- fined in prison, but, his insanity being recognised, he was sent to an asylum, whore he secreted a sharp dagger with the intention of revenging himself. After a short residence in another asylum he was discharged well, and opened a shop as a publisher in Edinburgh in 1831. He issued numerous periodicals, but he soon became as much annoyed as ever with being called nicknames in the street. " His former ideas as to malevolence and persecution returned in full force ; indeed, they seem never to have been entirely absent, but only in abeyance for a time, and he was constantly sum- moning persons to the police court for trivial injuries or imaginary wrongs." In 1826 he removed to another street and worked as a joiner. In consequence of his continued annoyance and his failure to obtain justice, he entertained the idea of personally exacting the vengeance denied him by law, and he collected swords, firearms, &c. He said to some one that " if he could just get bloodshed he would be satisfied, but that he must kill somebody." He fortified his house, alleging that he feared his enemies, and especially the police. In one of his publications he says that if the attempt is made to apprehend him, " before they make me prisoner, I will make my entry swim with blood." It was now judged necessary to secure him, and, this being accomplished with considerable difficulty, he was committed to prison as a dangerous lunatic in 1840, and subsequently to a workhouse, where he murderously assaulted the medical attendant, and he was thrust into a cell in an outbuilding, where his food was handed to him through the partially opened door. He was now removed to the Morningside Asylum. In order to secure him, the roof of the cell had to be removed and the arms of the lunatic entangled with ropes before he could be secured. " He was then put in irons and brought to the asylum (1841), but the man who brought him was so terrified at his prisoner and at the thought of his vengeance, that I am told he secured his own safety as soon as Smith was within the house by making ofiE as fast as he could, with the key of the wrist-locks in his pocket ! " There he was under the care of Dr Mackinnon and Dr Skae for twenty years, and was con- stantly endeavouring to wreak his vengeance upon the medical officers or the attendants, his attempts displaying much premeditation and cunning design. He one day stabbed Dr Mackinnon and his assistant with a pointed iron rod, but happily the wounds did not prove dangerous. " He often afterwards said, that many a time when Dr Mackinnon was conducting morning prayers and he was sitting near him as precentor, he could scarcely keep from rising and braining him ^\-ith the chair he was sitting on. He always gloried in this murderous attack, and only lamented that he had not been more successfnL" In reference to subsequent attempt?; Dr Yellowlees observes, " The man^s whole life was a study how to murder, and he was constantly gloating over the thought and a cruel and bloody- revenge." Herein consists the present interest of the case. MUEDEEOUS "IMPULSE WITH DELUSION 265 For months he fabricated a weapon consisting of cuttings of lead kneaded into a heavy ball and attached loosely to the end of a stick, so as to form a life-preserver ; with this, when the attendant put his head into the doorway, Smith, who lay in wait, bestowed a fearful blow. He now spent a good deal of time in writing an accoimt of some new inventions, including the discovery of perpetual motion and other extravagant schemes. " They constitute the first very obvious manifestation of Intellectual Insanity, supervening on the moral perversions he had laboured under so long." It must, however, be admitted, that SmitVs early notions about being persecuted, although to some extent warranted by being actually teazed, amounted to delusions. In 1846 he was for the first time personally restrained by a belt fastened round the waist, to which wristlets were loosely attached, a course which was pursued in consequence of his threa-t to commit murder on a certain day. In 1849 restraint was discontinued except when out walking, but his mental state was the same, and it is recorded in the note-book in 1852 that, " if possible, he is more than ever full of murderous threats." A little later it is stated that — " He used to entice mice into his room by leaving some of his food near a hole in the corner ; he prevented their escape by closing the hole, killed them by tearing them into quarters with his fingers, and had the pieces arranged in a row in the morning to show his attendants how he would treat his enemies if he could." Subse- quently he made another desperate attempt to murder an attendant, with the same careful preparation as on former occasions, and Dr Yellowlees does not appear to use too forcible language for the subject of it when he says, " It is scarcely possible to find language strong enough to describe the bloodthirsty passion which possessed the man, the devilish ingenuity, deliberateness, and determination with which all his attacks were made, or the fiendish delight with which he gloried in relating them, and revelled in the thought of a merciless and bloody success." In 1855 his physical health gave way. Restraint was finally discontinued. Homi- cidal vows and threatenings continued to mark his mental state. " Years passed away thus; and they may be described in a single sentence: — Gradual mental deteriora- tion with persistent and unquenchable desire for revenge and blood." The patient is thus described by Dr Yellowlees when he first saw him in 1858 : " He was always to be found sitting up in bed with his ink-bottle beside him and his manuscripts on his knee. He was now a bent old man, with coarse wiry brown hair, fast turning to grey. He had greyish whiskers, and long, grey, shaggy eyebrows overhanging deep yet little fiery eyes that gleamed with cunning and cruelty. He had a very decided nose and a good brow, while his mouth and chin told you he had once been a man who could both dare and do. His manner was rude and defiant, as if his visitor had done him some personal wrong. . . . His answers were short and blunt. He at once gave you the impression that he had found a savage satisfaction in turning his hand and hatred against every one, seeing that every one had turned his hand against him. . . . Ere you left he was almost certain to tell you, if he thought you worth speaking civilly to at all, that he was going to remain in the asylum no longer; that he had already shown what he could do, and was determined ere the week was over to murder the doctor or some of the attendants." 2G6 OF THE VARIOUS FORMS OF INSANITY He had a sliijht apoplectic attack at the end of 1858, but his mental condition was not altered. His health failed much in 1860, and he laboured under bronchitis and asthma. In the following winter he was worse, but " throughout it all his mental condition remained unchanged, and he might have been seen gasping his vows of murder or his loyal anthems during a paroxysm of dyspnoea. It was not in his nature to yield. But nature herself yielded at last, and he died about the age of seventy, Dec. 3rd, 1861." * Under tlie influence of dreams, homicidal acts have, there can be no doubt, been committed. They may occur at the moment of awaking from sleep, before consciousness has fully returned, or in a state of actual somnambulism. The case of Bernard Schirnadzig, who killed his wife while in a state intermediate between sleeping and waking, in the belief that he saw a stranger before him, is full of interest. (See Marc, vol. i, p. 56.) The Germans call this condition scliJaftrunlcenheit (sleep-drunken- ness). In the newspaper reports of the police courts in January, 1859, occurs a very interesting and important case. A poor woman, Esther Griggs, was brought before the Marylebone Police Court, charged with throwing her child in the night out of the window into the street. There can be no doubt that it was due to the influence of a dream. Sergeant Simmonds, 20 D, said — "At half past one o'clock this morning, while on duty in East Street, Manchester Square, I heard a female voice — ' Oh my children ! save my children ! ' I went to the house. No. 71, whence the cries proceeded, and the landlord opened the door. I went up stairs, accompanied by two other constables, and while making our way to the first front room I heard the smasliing of glass. I knocked at the door, which I found was fastened, and said 'Open it; the police are here.' The prisoner, who was in her night-dress, kept on exclaiming, ' Save my children ! ' and at length, after stumbling over sometliing, let me and my brother officers in. When we entered we found the room in total darkness, and it was only by the aid of our lanterns that we could distinguish anything in the room. On the bed there was a child five years old, and another three years of age by her side. Every- thing in the place was in great confusion. She kept on crying out * Where's my baby ? Have they caught it ? I must have thrown it out of the window ! ' The baby must have been thrown out as I was going up stairs, for before getting into the room I heard something fall. I left a constable in charge of the prisoner, and I ascer- tained that the child, which had been thrown from the window, had been taken to * The pathological appearances found after death do not belong to this chapter, but it may be mentioned that the cerebrum weighed only 35^ oz. ; the cerebellum 5i oz. ; the arachnoid was opaque and slightly thickened ; there were distinct softenings iu the right corpus striatum, left thalamus, and floor of posterior cornu of right ventricle, all of old standing. All the arteries of the brain were more or less atheromatous. A cast of the head having been taken seventeen years before he died, it was found, when compared with one taken after death, that its capacity was less by at least twelve cubic inches. THE PUEEPEEAL STATE A CAUSE OE HOMICIDE 267 the infirmary. She told me that she had been dreaming that her little boy had said that the house was on fire, and that ivhat she had done tvas with the view of preserving her children from being burnt to death. I have no doubt that if I and the other constable had not gone to the room, all three of the children would have been flung out into the street. . . . From the excited state in which the prisoner was, I did not at the time take her into custody. I had understood that the surgeon had said it was a species of nightmare which the prisoner was labouring under when the act was committed. The window had not been thrown up. The child was thrust through a pane of glass, the fragments of which fell uito the street." The form taken by insanity in the puerperal state is not un- frequently that of Homicidal Mania. Here it is readily ad- mitted on account of the accompanying physical disease_, but the fact of there being a homicidal impulse is not the less patent. Dr Orange^ in his ' Broadmoor Eeport^^ 1877, records the case of a woman, get, 31, who was tried at the Hants assizes in March, 1876, for the wilful murder of her newly born child, and was acquitted on the ground of Insanity. " She was improperly nursed and cared for after her confine- ment, and being left by herself against her repeatedly expressed wish to the contrary, she was unable to overcome or control an impulse to take her child's life. This she did by strangling it with a pocket-handkerchief when it was a few days old. She was a delicate affectionately-disposed woman, sensitive, nervous, and liable to depression.''^ To the foregoing description and illustrative cases, a brief summary of the chief characteristics of Homicidal Mania may be added. It manifests itself under very different mental condi- tions. Understood in its broadest sense, it may or may not be ■associated with decided lesion of the intellect. It may or may not be impulsive in character. It may or may not be preceded by premonitory symptoms so appreciable as to have been recognised. It may or may not be manifested from early life. However, careful investigation will reveal, in the majority of cases, a dis- turbance more or less of the intellectual as well as the moral faculties ; leaving still a considerable number of cases in which there is a sudden, blind, motiveless, unreasoning impulse to kill. An inquiry into the patient^ s history will very generally detect a change in the character and hereditary predisposition to Insanity ; the former, however, obviously cannot be looked for in cases where mental disorder can be traced back to infancy, or where intellectual or moral defects are congenital. Further, the homicidal act, when the result of disease, is usually accom- panied by no motive, or a very trivial one, except so far as delu- 2G8 OF THE VARIOUS FORMS OF INSANITY sion, or the gratification of a diseased propensity, can be re- garded in this light. This rule must not, however, be made too absolute, inasmuch as among acknowledged criminal lunatics there are some in whom a motive can be traced. The subject of Homicidal Mania very frequently exhibits the utmost sang froid, and will even appear amused by his performance ; on tlie other hand, in the purely impulsive form, the patient may bewail his deed in the strongest manner. The homicidal act is often done tuithout premediation or design, but we have already seen that there may be premeditation, and there may doubtless be a resort to ingenious deception. A woman, thirteen days after her confinement, cut off the head of her child with a razor, while labouring under Puerperal Mania. She obtained a razor on the pretext that she wanted to cut her nails. She was acquitted by the jury on the ground of Insanity. (Chelmsford Assizes, March, 1848.) A convalescent patient once induced his attendant to lend him a razor for the purpose of shaving. He sat down before a glass, and having shaved one side of his face, called to him to see with what dexterity he had performed that part of the operation. The attendant came forward, but the patient started up and nearly severed the man's head from his body with the razor. This case is related by Perfect. Frequently it is observable that the homicidal maniac sets no bounds to the destruction of his victims, a contrast to the ordinary criminal, who does not kill more than his object renders necessary. In many cases it transpires that the sight of a weapon pro- duced, in an abnormal state of the brain, a strong desire to use it. Again, the homicidal act is often excited by some notorious murder, which either arouses a morbid desire to imitate or to gain notoriety and newspaper fame, or perhaps directly arouses a latent homicidal tendency. The homicidal act, like the other actions of lunatics, is effected without accomplices ; the members of the patient^s own family are very frequently his victims 3* after the commission of the * In the 1877 Report of the Broadmoor Asylum we find that of 493 patients remaining on Dee. 31st, 1876, 223 (151 males, 72 females) had been charged with the commission of various forms of homicide. Of the former, 76 had caused the deaths of near relatives, 1 a Commissioner in Lunacy; 14 those of fellow-patients in other asylums or workhouses ; 6 those of persons in charge of them ; and 55 those LEGAL TESTS OP EESPONSIBILITY 269 act, he rarely escapes, or takes precautions to prevent discovery, but delivers himself up to justice, and, by bis own band, be frequently terminates, at once, bis life and bis insane career. Prognosis (see p. 135). — Altbougb in many cases it is pro- bable that tbe patient will not again attempt bomicidal violence, it is in all cases (tbose from Puerperal Insanity excepted) sufficiently possible to justify a course of action with regard to sequestration wbicb assumes tbat tbe disorder will return. Delasiauve gives tbe case of a man wbicb sbows bow guarded^ not to say unfavorable, tbe prognosis must always be. In 1824 this patient, pursued by ideas of Persecution (like " Wliisker Willie," reported by Dr Yellowlees), attacked a woman and would have kUled her but for prompt succour. Confined in the prison of Evreux, he soon became sufficiently well to be allowed a certain amount of liberty. Li 1830 he made his escape and remained very calm during several years. Fourteen years after the first attack, he committed another act of violence under nearly identical conditions, and was placed in an asylum for the rest of his life. (See 'Annales,' 1872.) Legal Tests of Responsibility. Altbougb in practice tbe plea of Insanity in criminal cases is in a large number of instances not determined according to tbe law laid down by judges, but according to tbe bigber law of bumanity, it is desirable tbat tbe reader sbould know wbat un- fortunately continues to be tbe main legal test of responsibility in criminal cases — ^tbe consciousness or knowledge of rigbt and wrong ; instead of being, as it sbould be, wbetber in consequence of congenital defect or acquired disease, tbe power of self control is absent altogetber, or is so far wanting as to render tbe indi- vidual irresponsible. As bas again and again been sbown, tbe unconsciousness of rigbt and wrong is one tbing, and tbe powerlessness tbrougb cerebral defect or disease to do rigbt is anotber tbing. To confound tbem in an asylum would simply of persons not included in these classes. Of the women patients, 60 had destroyed their own children, a striking contrast to the homicides among the men, 24 of whom killed their children. On the other hand 23 terminated the lives of their wives, and only 1 woman the life of her husband (along with her child). It may be added that of the above 493 inmates, 111 were charged with attempts to murder, maim, &c., 23 with burglary, 30 with larceny and petty thefts, 30 with arson, 20 with insubordina- tion, 16 with felony, and 7 with assaults ; 44 were certified insane while awaiting trial, 97 were found insane on arraignment, 250 were acquitted on the ground of insanity, 7 were reprieved on this ground, and 95 were certified to be insane while undergoing sentence of penal servitude. 270 OF THE VARIOUS FORMS OF INSANITY liave the effect of transferring a considerable number of the in- mates thence to the treadmill or the gallows. The writer heard the late Mr Justice Willes lay down the law in a very lucid manner, and apply it to a case of murder, in which the jury, in direct opposition to his lordship's ruling, brought in a verdict of " Not Guilty on the ground of Insanity.'^ " The great question," he said, " which the jury would have to decide was whether the prisoner had satisfied them, hy the evidence he had called, that at the time he committed the act he was in such a state of mind from Insanity as not to be responsible for what he did. With reference to that he was bound to tell the jury that every person is assumed, unless the contrary is proved, to be responsible for his acts. To acquit on the ground of Insanity, it must be clearly proved that at the time the offence was committed, the accused was labouring under such a defect of reason as not to know the nature and character of the act he was doing, and that he did not know he was doing what was wrong. That was the law by which they were bound — law made equally for the protection of society as for the protection of the prisoner, and according to that must they pronounce their verdict. The defence for the prisoner rested not so much upon the general derangement of his mind as upon a partial disease, consisting in an impulse alleged to have been uncontrollable at the time he committed the act. He would endeavour to illustrate this by one or two cases. First, as to the case where a man did not know the nature or quality of the act committed. Such a case would be the mistaking a man whom he might see for a wild beast or the Enemy of mankind, and striking a fearful blow under that delusion. In that case the man would be so deprived of his reason from the disease that he would not be responsible. But that was not the sort of Insanity suggested by the present case. As illustrating the second part of the proposition, he would name the case of a man meeting another on the road, and, under the delusion that this person intended to take his life, aiming a blow which resulted in death. In that case the accused would not be responsible. But if a man, instead of having a delusion that the party he was meeting intended to take his life, had the delusion that he had done him a serious injury by defaming his character, and he under that delusion caused the death of the party, he would be responsible for his acts. The delusion must be such that the man does not know the nature of the act he is doing, and that he does not know he is doing wrong. He had put this to them in the language in which the subject had been authoritatively treated by the Judges, and which was the law of the land." * * The answers given in 1843 by fifteen Judges to certain questions propounded to them (occasioned by the trial of McNaughton for the murder of Mr Drummond), and upon which the foregoing ruling rested, will be found in Hansard's ' Parliamen- tary Debates,' and Shelford's ' Law of Lunatics,' 1847, p. 586. For cases in which the prisoner was acquitted on the ground of Insanity, although knowing the nature and quality of the act, and quite conscious of the difference between right and wi'ong, see Taylor's 'Medical Jurisprudence,' 4th edit., p. 768. For cases in which the plea of irresistible impulse was admitted, see p. 760, also p. 262-3 of this work. The reader is also referred to " The case of Henry Gabbites," by Dr Kitching (' Journal of Mental Science,' July, 1867) ; the same writer's " Lecture on Moral Insanity " (' British Medical Journal,' 1857) ; "The Legal Doctrine of Responsi- bility in relation to Insanity," by S. W. North, M.R.C.S. ('Transactions of the HINTS IN GIVING EVIDENCE 271 Social Science Association,' 1864) ; " Insanity and Crime," by the Editors of the ' Journal of Mental Science,' 1864 (Townley's case) j ' Etude Medico-legale snr la Polie,' par M. Tardieu, 1872; the works of Esquirol and Marc; Brierre de Boismont, 'De la Folie raisonnante, &c.,' 1867; "De la Monomanie de Persecu- tion au point de vue de la Medecine legale" ('Ann. d'Hyg.,' pub. 1852); and Lasegue, "Memoire sur la Delire des Persecutions" ('Arch. Gen de Med.,' torn. 27). A case of delusion of Persecution, ending in homicide and acquittal, in which the Judge's common sense and humanity got the better of his law, wiU be found in the ' Journal of Mental Science,' July, 1872. For cases pro\dng the presence of the homicidal impulse without other symptoms of Insanity, see article by Dr Needham in the same number ; and for the important cases of Edmunds and Watson, see April, 1872. For case of insane infanticide and the Judge's summing up, see July, 1871. In addition to Mr J. B. Thompson's article in the Journal, Jan., 1870, already cited (p. 253), we would especially refer to the succeeding onem the October number, which should be read along with Despine's work, " Psychologic Naturelle," 1868. " When," he says, " I read Despine's conclusion, that the moral sense is utterly and invariably absent in all criminals who commit violent crimes in cold blood, I confess it startled me as a most extravagant proposition," but he adds that the result of his investiga- tion has much astonished him, and not a little shaken his incredulity. He states that of 430 murderers he has had in (medical) charge, only three discovered the slightest remorse for their crime, corroborating, he considers, the opinion that the moral sense is wanting in great criminals. Mr Thompson states that between 1865 and 1868, out of 500 admissions of female convicts into the General Prison for Scotland, 14, or 1 to every 36, became actually insane. Hints in giving Evidence. 1. A roedical man is obliged to make known, if asked in court, the statements or confessions made hj a patient to him. (Peake on Evidence, p. 88. Starkie on Evidence, p. 105. Shelford, p. 81.) 2. If a medical witness believes a criminal to be insane and is called upon to give evidence to that effect, he must not be content with stating his opinion, but must be prepared to state the reasons upon which that conclusion is based. For aid in arriving at a judgment, the reader is referred to the chapter on the Diagnosis of Insanity. 8. The medical witness should confine himself to a simple statement of facts, and not allow himself to be drawn into a metaphysical discussion, or an attempt to define Insanity. 4. A medical witness sometimes wishes to fortify his view of the case by inducing the counsel to read from medical works, and the question arises whether this can be legally done. Justice Willes on the occasion already referred to, when the counsel for the prisoner pursued this course, and was interrupted by the counsel for the prosecution, said, " Counsel was at liberty to 272 or THE VARIOUS FORMS OF INSANITY read, as part of his speech^ the opinions of a medical work^ but the jury would not have to decide the case upon medical criti- cism, but upon the case and the facts." The learned counsel then read from Taylor's ' Medical Jurisprudence/ in order to show that certain cases recorded there were similar to the one before the court. It would appear, from R. v. Crouch, 1 Cox, C. C. 94, that the opinions of a medical writer cannot be stated in an address to the jury, but Judge Willes did not distinguish between these and cases. 5. In regard to any notes the medical witness may have taken of the prisoner's state, he may only make use of those in court which he has committed to paper at the time he examined the prisoner. 6. It must not be forgotten that the prisoner may be sane when examined by the physician, and yet may have been insane when he committed the deed, and vice versa. SECTION VIII.— Suicidal Mania or Insanity. Synonyms. — Melancholia Anglica ; Autojphonia (med. authors) ; Selbstmordtrieb (Ger.); Manie du Suicide, Monomanie suicide (Fr.). '' Siiicid.e" is stated to have been introduced by the Abbe Desfontaines, in the last century, to signify both the act and the person who commits it. Definition. — Properly, a perversion or reversal of the natural instinct of love of life, leading to its destruction. We have had occasion, however, previously, to remark that the act of self-destruction may originate in different, and even opposite, conditions of the mind. There are melancholic as well as maniacal suicides. It may be said that in all cases the conservative principle, so deeply implanted in the inner recesses of our constitution, is overborne, if not itself primarily at fault, by the diseased action of other mental faculties or instincts. There is, in profound melancholy, a condition of misery, from which it is natural and reasonable, so to speak, to attempt to escape. Viewed apart from the moral bearings of the question, the patient may simply be regarded as choosing death as the least of two evils. He prefers severing the thread of life, to the endurance of its misery. But of two patients, equally a prey to Melancholia, the one will attempt to terminate his existence, while the other, so far SUICIDAL MANIA 273 from contemplating^ will recoil with horror from^ the act. By the latter, the natural desire to retain life may be possessed in much greater force than by the former ; or there may survive, in one^ religious convictions antagonistic to the execution of the act of suicide, which may either never have been present in the other, or may have been paralysed by disease. Other motives than those now referred to may prompt self-destruction. Thus, the act may be intimately associated with delusional forms of Insanity. From the foregoing remarks it will .be seen that Suicidal Mania admits of classification. First, there are cases in which the instinct of self-preservation is more especially diseased, being, as it were, reversed in its operation. There is here a blind, unreasoning, irresistible impulse to commit suicide — a true Suicidal Monomania. Several well-marked examples have come under our observation, and we liave recently been informed of a case in which the patient was attacked by a strong impulse to commit suicide, and, at his own urgent request, was confined in a lunatic asylum, where he has not manifested the slightest aberration of intellect. Two or three years previously, he was injured by lightning ; shortly after which he was decidedly insane, but recovered. M. Debreyne has recorded the following : — The patient, who was opulent, stated that he was perfectly happy, and free from any cause of suffering, with the exception of one circumstance which tormented him. This was the desire, thought, or violent temptation, to cut his throat whenever he shaved himself. He felt as if he should derive from the commission of the act " an indescribable pleasure'' He was often obliged to throw the razor away. ('Du Suicide,' p. 82. See also • Traite du Suicide,' 1857, par M. Bertrand, p. 265.) This form of Suicidal Mania may present, as has been well observed by M. Bertrand (op. cit., p. 259), the spectacle of an individual perfectly reasonable, influenced by an enlightened religion, physically and morally happy, well aware of the crim- inality of suicide, and yet impelled to commit it, in spite of himself, by a force acting automatically and superior to his reason and his will. Secondly, suicide may be the result, — not of an instinctive Monomania, but — of Melancholia. When treating of this form of mental disease, we referred to the frequency with which the ruling propensity is that of self-destruction. The degree in which the patient is depressed, is not the measure of his ten- dency to self-injury ; at the same time, intense depression is, in a large number of instances, the immediate antecedent of the suicidal act. " I was in such a despondent state for two years that I could not trust myself with a razor,^'' states a medical man, ^^but I found it went away as causelessly as it came.''' 18 274 OP THE VARIOUS FORMS OF INSANITY The tliird division comprises those cases of suicide which spring from delusions, hallucinations, &c. A man believes that he can only gain admittance into heaven by self-immolation ; another distinctly hears a voice commanding him to destroy himself; while a third sees a form which leads him on to the brink of a precipice or a river. M. de Boismont observed, of 171 suicidal patients: — Eighty-three in whom there were hallu- cinations of hearing ; thirty of sight ; six in whom there were illusions of hearing ; thirteen of sight ; thirty-three of smell and taste ; six of touch. And here it may be observed, in regard to suicide in general, that the question so often asked, Is suicide the result of cerehro- mental disease ? must be answered both affirmatively and nega- tively. That the act may be committed in a perfectly healthy state of mind cannot, for a moment, be disputed. On the other hand, that the act is, in a large number of instances, the conse- quence of disease, is equally indisputable. We will now briefly consider, seriatim, several points of interest and importance in relation to suicide. 1. Modes of Death. — Marvellously ingenious are the con- trivances resorted to, in order to destroy prematurely that which the great mass of mankind cling to so tenaciously, and are equally ingenious in devising means to preserve and pro- long. An almost universal passion is here extinguished, and its normal action reversed. The law, almost coextensive with the gift of life, that '^no man hateth his own flesh,^' is here dis- regarded and broken. The following is a statement of the modes of death adopted by 3598 persons, who committed suicide in France (but not necessarily insane) during one year. (Bertrand, op. cit., p. 160:— Strangulation Drowning f Pistol Gun... Not specifiLxl Asphyxia by charcoal Precipitation Cutting instruments Poison Other modes ... 1247 ... 1174 112 -N 112 C 487 263 J ... 305 162 ... 126 63 34 3598* * In England the resort to poison is much more frequent than in France; SUICIDxiL MANIA. AGE 275 It is observable how tbe attempt at suicide is often defeated by the conservative powers of nature^ and probably a diminished sensibility of the viscera. We have known a person swallow a large stone and other large dangerous articles without a bad symptom — the stone, &c., passing through the alimentary canal unassisted by purgatives, which, in fact, are often prejudicial in such cases. A case has been recorded in which a pewter fork was swallowed by a patient who believed poison was mixed with his food, and lived for five years afterwards, when he hung himself. The fork (six inches long) was found in the stomach, the prongs, which appeared to have been designedly bent towards each other, directed to the cardiac orifice. ('Annales,' 1843, p. 483.) It is singular how trivial a circumstance and insignificant a motive may divert a suicide from his purpose. One day, at the Retreat, the matron happened to enter a room where she found a male patient on the point of cutting his throat with a razor. The patient was remarkable for his love of order and cleanliness. The matron, unwilling to engage in a personal struggle, with great tact and presence of mind, remonstrated with him on the ground that he would make the room dirty, and begged him to cut his throat ■ — if cut his throat he would — over a basin f To this he at once assented, but when the basin was brought before him he no longer had the power to do it. Under such circumstances, much greater nerve and sustained determination were required than when he was alone and acting impulsively. 2, Age. — Many remarkable instances are on record, of children committing suicide. A writer in the '^Psychological Journal' (April, 1856) states, that — Of twenty-six cases of suicide in children, which he has collected, "one was five years old, two were nine, two were ten, five were eleven, seven were twelve, seven were thirteen, and two were fourteen. Seventeen were boys, seven girls, two not mentioned. Amongst twenty-two of them, ten were dro^vned, teii hung themselves, and two broke the neck. All the girls were di'owned. Five of the twenty-six failed in the attempt. Of the last, a woman, mentioned by Esquirol, who had thrown herself into the water at nine years of age, did the same at forty. M. Falret relates the history of a woman affected with Suicidal Mania from the age of twelve years ; and of another who, from the age of ten, made frequent attempts at self-destruction, which succeeded at forty-five. The inadequacy of the motive is often very surprising. One boy of nine years killed himself, after having lost a bird ; another of twelve because he was only the twelfth in his class at school. On the 7th of March, 1886, Henri Fournier, ast. 12, was sent by his mother for a watch, which he broke. He was sent to bed at ■six p.m., with a piece of dry bread. At ten o'clock his little sister was sent to see if he was asleep ; she returned with the answer that he was. A six o'clock the next morning, a woman entered his chamber and found him hung. He had made a rope of two cravats, and hung himself to a nail in the wall, climbing uj) by a wardrobe. Every one bore testimony to his mildness and intelligence ; he never complained of ill-treatment, except once observing that he got punished whilst his sister was always pardoned." " asphyxia," from the common use of charcoal m the latter country, appears to take its place. 276 OF THE VARIOUS FORMS OF INSANITY Of 3020 suicides in France, in one year, the majority were committed by persons between 40 and 50 years of age; 162 by minors ; and 20 by octogenarians. 3. /Sea;.-i-Women more rarely commit suicide than men. Some statistics indicate the liability to be threefold greater among the latter. At Bethlem, according to Dr Webster, 29 per cent, of the female, and 32 per cent, of the male admissions, are suicidal. In our own experience, the number of women who have attempted or committed suicide is certainly equal to the men. Two of the most determined cases we have known were females — one termi- nating her life by suspension, the other by poison. In the latter instance, the patient baffled every precautionary measure adopted to prevent the fatal catastrophe. In a third case, suicide was attempted but unsuccessfully, and the lady was restored to health by the use of the prolonged warm bath. In a fourth, self- destruction was contemplated, but the same treatment was fol- lowed by recovery. M. Brierre de Boismont has reported twenty-seven females who committed suicide when they were pregnant. 4. Marriage. — M. de Boismont's figures tend to show that, both among men and women celibacy favours suicide in the community at large ; but that, among cases of genuine Suicidal Insanity, the reverse occurs, there being a larger proportion married than unmarried. This he regards as one among other points of difference, between self-destruction committed by insane and sane persons. 5. Hereditary Transmission. — Many remarkable instances are on record of the suicidal tendency descending from one genera- tion to another. (See cases at p. 63.) Hereditary taint would go far to distinguish insane from sane suicides. 6. Seasons. — In regard to the influence of the seasons, it is unquestionable that there is the largest number of suicides in spring and summer — a fact which might scarcely have been expected a priori^ for the gloom of autumn would seem much more calculated to induce mental depression, and consequent self- destruction, than the joyousness of approaching summer. The suicidal epidemic recorded by Sydenham (1697) occurred in June. In 1806 a like epidemic raged at Rouen, during the months of June and July. From Dr Benedict's Report of the New York State Asylum for 1850 we learn that — ■ " There were admitted, during the month of July, the large number of forty-four patients from different portions of the state, nineteen of whom were suicidal. SUICIDAL MANIA. MOTIVES 277 Several of them had attempted suicide immediately previous to admission. From the 14th of July, fourteen attempts were made by eight different persons ; and twelve others, in whom the propensity was strong, required constant observation. The suicidal epidemic prevailed from the 12th to the end of July ; after which it gradually subsided, and left the minds of most of the patients." Lastly^ it may be stated as a factj not witliout its practical use^ that Brierre de Boismont found of 3518 cases of suicide committed in France, in which the exact period of the com- mission of the act was discovered, that 2092 were in the day ; 658 in the night ; 766 in the evening. 7. Assigned Motives. — We have abeady, when speaking of some cases of suicide in children, referred to their frequently trivial causes or motives. In the ' Express ' of June 20, 1861, we observe mention made of suicide ui a boy aged eleven, of Kusel (Germany), who hung himself because his parents did not allow him to buy a squirrel which he had taken a fancy to possess ! We may refer also to the case of a woman, aged twenty -three ('Express,' June 12, 1861), who attempted to commit suicide, and was vnth difficulty rescued from the Regent's Canal, the reason assigned by herself when brought before the police court being, " I wanted to see Blondin at the Crystal Palace, and my husband would not take Of the 3598 suicides tabulated in a former page, 977 were referred to Insanity as a cause (doubtless greatly underrated), 454 were the result of family troubles of various kinds, 203 of embarrassed circumstances, 313 of the desire to escape physical suffering, 208 of habitual drunkenness, 179 of want and the fear of want, 166 of the disgust of life, and 142 of bad conduct and debauchery. The desire to be talked about — the love of notoriety — is a very frequent motive among suicides of the uneducated, though newspaper-reading, classes. It is also well known that many cases of suicide have been prompted by imitation. Epidemics of Suicidal Mania, and of self-mutilation short of suicide, are among the many strange examples of Epidemic Insanity. Sui- cide so often succeeds the homicidal act as to indicate a very close relationship between them, due allowance being made for the mere desire to escape punishment or disgrace. It has been calculated that in 60 per cent, of cases of murder, suicide is attempted. It must not be forgotten that in the preceding observations we have been speaking of suicides in general, not those cases only in which mental disease was certainly present. From an ' examination of three recent Eeports of the Royal Edinburgh 278 OF THE VAEIOUS FOEMS OF INSANITY Asylum we observe that during three years 166 patients have been admitted with suicidal tendencies.* of whom 55 had attempted and 111 meditated the act before admission. The means adopted by the former were : — Cutting throat, with or without other means, 18; precipitation by itself, 7; hanging or strangulation, 7 ; poison, 6 ; starvation, 5 ; drowning, 4 ; burn- ing, 2 ; suffocation, 1 ; dashing head against wall, 1 ; drinking scalding water, 1 ; wounds, 3. Prognosis. — As a general rule, unfavorable. SECTION IX.— Kleptomania i>c\i7rrw i steal). Synonyms. — SteJdsucht (Ger.) ; Monomanie Meptomaniaque or du Vol ; Clejptomanie (Fr.). Definition. — Strictly speaking, an irresistible impulse to steal, the natural instinct to acquire having assumed a diseased activity ; but thieving from mental disease may also be the result of delusions. Under circumstances of real temptation, a man may steal and his congenital or acquired weakness of mind may justly acquit him of legal responsibility, but the use of the term in these cases is not a scientific one. It should, however, be remembered that the fact of external motive does not remove the possibility of Insanity, although, doubtless, those cases which are motiveless, as when the rich steal a worthless article, are much more easily credited. Marc observes, " This condition" — the impulsive form — " is, doubtless, very singular and inexplicable (?), as are so many other of the intellectual and physical phenomena of life ; but it is not the less real on that account, as is proved by numer- ous examples." Crichton Browne, after observing that " An instinctive impulse prompting to theft or Kleptomania is frequently felt in the young, and we say without hesitation that many of those young criminals who are yearly brought before our Courts of Justice and tried and punished for theft and like crimes, are * In his Report for 1862, Dr. Robertson states that the annual proportion of suicides in Sussex is 8-9 per 100,000, while in England and Wales it is 67. In the 42 county asylums there were, taking the three previous years, 7 suicides in 1859 ; 11 m 1860; and 12 in 1861. We observe that in the following year, juries on Coroner's Liquests in England and Wales found 1324 verdicts of suicide ; 961 being men, and 363 being women. The ' Times ' gives the proportion of suicides to the population as 1 in 14,286. KLEPTOMANIA 279 the victims of this disease," and " our cases ot Kleptomania in early life are only too numerous," gives the following in- teresting case : — "A girl between nine and ten years of age, whose parents were in most affluent cir- cumstances, and who had not the slightest inducement to the crimes which she committed, has repeatedly stolen silver and copper o£ various amounts, the property of her parents or of visitors in the house, and cast it away in the shrubbery, or concealed it so that it could not be discovered. She has stolen money and other articles from servants, concealing them likewise. Has stolen articles, and concealed them in servants' boxes. Has stolen biscuits and bread from a shop ; and also a pair of red stockings belonging to her sister, which were afterwards found in the water closet. She has stolen articles of jewellery, and concealed them. When a theft has been committed, and while it was regarded as criminal, a whole night has been con- sumed in entreaties, prayers, and caresses, in order to induce confession of the act, and surrender of the articles abstracted, in vain. Punishment was likewise without effect. She has volunteered confession and penitence, with an assurance of tota inability to resist the inclination, and a declaration that she is " different " when she steals. This child also lies, scratches the backs of looking glasses, and disorders furniture. It is worthy of observation that this girl generally steals bright or brilliantly coloured objects, and that she never makes any use of what she steals. The physician who saw her, believed her condition to be connected with the premature approach of puberty." (' Journal of Mental Science,' 1860, p. 311.) Of a patient at Bethlem Hospital Dr> Savage writes : — '' Many cases of purposeless stealing become inmates of our gaols before the real cause of the malady is known. The steal- ing of trifles is common and causes much trouble. We have one patient now who first showed his insanity by constant attempts at getting things from the "Exchange and Mart,"*^ and now he purloins tobacco and cigars if he have the chance. His case is all but hopeless ; he was formerly a well-educated high-minded, youth." (^ Considerations on the Cures in Insanity/' p. 29-30). Dr Hugh Miller, of Glasgow, has recorded a case of "Temporary Kleptomania" in the ^Lancet' (June 15, 1878), in which the patient, a young lady, experienced this symptom while he was attending her for necrosis of the lower jaw. This affection is sometimes strikingly hereditary. The fol- lowing is a highly interesting example, in which the propensity descended, both to son and grandson. We give it on the authority of Dr Julius Steinau, the author of an excellent little book on hereditary diseases : — " When I was a boy, there lived in my native town an old man, named P — , who was such an inveterate thief, that he went in the whole place by that name. People speaking of him, used no other appellation but that of ' tlie tliief' and everybody knew then who was meant. Children and common people were accustomed to call him by that name, even in his presence, as if they knew no other name belonging to 280 OP THE VARIOUS FORMS OF INSANITY liira J and he bore it, to a certain degree, with a sort of good-naturedness. It was even customary for the tradesmen and dealers, who frequented the annual fairs in this place (which are there of a more mercantile character than in other countries), to enter into a formal treaty with him — that is, they gave him a trifling sum of money, for which he engaged not only not to touch their property himself, but even to guard it against other thieves. [Not in this case an irresistible impulse.'] "A son of this P — , named Charles, afterwards lived in B — during my residence there. He was respectably married, and carried on a profitable trade, which sup- ported him handsomely. Still, he could not help committing many robberies, quite without any necessity, and merely from an irresistible inclination. He was several times arrested and punished. The consequence was, that he lost his credit and reputation, by which he was at last actually ruined. He died, while still a young man, in the House of Correction in Sp — , where he had been confined as a punishment fur his last jobbery. "A son of this Charles, and grandson of the above-mentioned notorious P — , in my native town, lived in the same house where I resided. In his early youth, before he was able to distinguish between good and evil, the disposition to stealing, and the ingenuity of an expert thief, began already to develop themselves in him. When about three years old, he stole all kinds of eatables within his reach ; although he always had plenty to eat, and only needed to ask for whatever he wished. He therefore, was unable to eat all he had taken; nevertheless, he took it, and distributed it among his playfellows. When playing with them, some of their playthings often disappeared in a moment, and he contrived to conceal them for days, and often for weeks, with a slyness and sagacity remarkable for his age. When about five years old, he began to steal copper coins ; at the age of six years, when he began to know something of the value of money, he looked out for silver pieces, and, in his eighth year, he only contented himself with larger coins, and proved himself to be, on public pro- menades, an expert pickpocket. He was early apprenticed to learn a trade ; but his master being constantly robbed by him, soon dismissed him. Tliis was the case with several other tradesmen, till at last, in his fourteenth year, he was committed to the House of Correction. Whether that institution was fortunate enough to correct this ill-fated youth, the writer of this essay is unable to state." In tlie last edition we gave an analysis of cases reported by Marc and others, as illustrative of Kleptomania, under two divisions ; the first, in which disorder of the intellect was alleged not to be present (cases of Emotional Insanity), — the second, in v/hich such disorder was manifest. We shall now simply give the following cases as typical of these classes : — A lady was subject to periodical attacks of Insanity, generally in the spring. They were followed, in one instance, by an irresistible desire to steal, for gratifying which she was brought to trial, but was acquitted on the plea of Insanity. This plea was urged with great ability by Esquirol and Marc. WTien asked what passed through her mind when she committed these thefts, she replied " I cannot tell ; but I have such a mad longing to possess myself of everything I see, that, were I at church, I should steal from the altar, without being able to resist it." (Marc, vol. i, pp, 275, 303.) In this and in other cases, it should be borne in mind that the character of the mental disorder was testified to by the highest KLEPTOMANIA 281 authorities, and that their evidence was considered conclusive by a court of law — proverbially suspicious of medical testimony. This remark implies to many of the cases adduced in this work as illustrations of Emotional Insanity. For cases illustrative of the influence of utero-gestation in ex- citing this Monomania, see Marc, vol. ii, pp. 262, 264, &c. ; and Dr Tilt's 'Diseases of Women.-' Under the second division we may refer to those cases of Greneral Paralysis, not uncommon, in which the patient steals in consequence of the delusion that everything belongs to him. "We recently saw in the Hull Borough Asylum, under Mr. Cas- son's care, a man labouring under General Paralysis, who in a somewhat early stage (the memory, however, failing) took various articles out of shops and from stalls, and had (his wife said) a particular propensity for stealing all kinds of hrazen articles. How ridiculous such a statement, which, we have no doubt, was quite correct, could be made to appear by a prosecuting counsel ! In another case of General Paralysis in the same asylum the patient took forty sheep out of a field and drove them up the passage where he lived. In the ' Journal of Mental Science ' January, 1873, Dr Burman {" On Larceny as committed by Patients in the earlier stages of General Paralysis ") records six interesting cases. One committed a robbery in a silversmith's shop and was sentenced to three months' imprisonment; a second, in comfortable circumstances, stole coals in open daylight and was sentenced to six months ; a third, a sober man, stole oil and was sent to gaol ; a fourth stole wineglasses ; a fifth stole some cloth, both being sent to the House of Correction ; the sixth was imprisoned for stealing nuts. In all these cases. General Paralysis was soon developed. Then there are cases of considerable mental weakness which the law is with difficulty brought to recognise, and in which there is a propensity to steal. Case of Renaud, aged forty-four. His Ideas appear to have been very limited, indicating a degree of imbecility. The medical commission, Denis and Marc, arrived at the conclusion that the mental condition of this individual did not appear to allow of the supposition that he had that degree of discernment and moral liberty which forms a necessary condition of criminality. (Marc, vol. i, p. 170.) A description of the disease would be incomplete without a brief reference, in conclusion, to the accompaniments which may assist us in recognising it. Hereditary predisposition to in- sanity ; evidence of mental derangement prior to the develop- 282 OF THE VARIOUS FOEMS OF INSANITY ment of the propensity; the earliest symptoms of General Paralysis ; the occurrence of any physical disorder, as brain fever, the suppression of any discharge, or an injury to the head ; puberty ; pregnancy ; the absence (in most cases) of any inducement to steal ; the general conduct of the individual, during and after the act, and especially (although cunning and concealment are consistent with this form of mental disorder) voluntary restoration of stolen goods — all these are circumstances of great importance in attempting to decide upon the existence of Kleptomania,* SECTION X— Erotomania (f>wc, love). Synonyms. — Love Melancholy (Eng.) ; Monomanie erotiqve, Hijsteromanie, Nymphomanie, (Fr.) ; Liehesivuth and Erotomanie (Ger.) ; Satyriasis^ Furor uterinus, Aidoiomania, &c. Definition. — According to Esquirol, Marc, and others, this term should be restricted to those cases which are characterised by excessive love for an object, whether real or imaginary. " In this disorder," the former observes, ''the imagination alone is affected ; it is an error of the understanding ; it is a mental affection in which amatory delusions rule, just as religious delu- sions rule in Theomania or in Religious Melancholy. It differs essentially from Nymphomania {vv/mtpT}, nymi:)ha>) and Satyriasis (crdQj/, penis) . In the latter, the evil originates in the organs of reproduction, the irritation of which reacts upon the brain. In Erotomania, the sentiment which characterises it is in the head. The nymphomaniac, as well as the victim of Satyriasis, are the subjects of a physical disorder. The erotomaniac is, on the contrary, the sport of the imagination. Erotomania is to Nymphomania and Satyriasis, what the ardent affections of the heart, when chaste and honorable, are in comparison with fright- ful libertinism ; while proposals the most obscene, and actions the most shameful and humiliating, betray both Nymphomania and Satyriasis." " The subjects of Erotomania," the same writer observes, " never pass the limits of propriety ; they remain chaste." And Marc also observes, that " in Erotomania, the disease has the cerebral functions for Hb point de' depart ; while * See article by Dr Bucknill in the ' Journal of Mental Science,' July, 18G3 ; also, for cases reported by M. Eeuaudin, tlie 'Auuales,' April, 1855. EEOTOMANIA. 283 in Njmpliomania aad Satyriasis^ the source of tlie disease lies in the reproductive organs/^ (Vol. ii^ p. 183.) It is by no means easy^, however^ to draw these distinctions in practice. The two may exist together. Patients may completely exceed the limits of propriety, without our having any evidence that the primary disease is in the generative organs. It is difficult, in not a few instances, to determine whether the .origin of the malady is there or in the head. In this as in other mental affections, the irritation may proceed from the centre or the peri- phery ; the disorder may be idiopathic or sympathetic. Nor do EsquiroPs examples of Erotomania sufficiently sustain the defini- tion with which he sets out. It may, perhaps, therefore be better to employ the term in a more comprehensive sense, so far as to consider EsquiroFs description of Erotomania as but one of its forms — the sentimental — or Erotomania proper ; and Nympho- mania or Uteromania (having reference to females), and Satyriasis (having reference to males), as additional forms. These latter are comprised under the term Aidoiomania [cudoia, p)-udenda, and jxavia) introduced by Marc; and the fureur genitale of Buisson. Symptoms. — In Erotomania there is sometimes great depression of the vital forces ; and in these cases, if the remedies employed do not soon take effect, the patient becomes more and more depressed in mind and body, emaciated, and rapidly sinks ; an example of the erotic fever {fevre erotique) of Lorry. In some cases there is, doubtless, an erotic condition which interferes but very slightly with the accustomed exercise of the intellectual faculties, but which entirely overmasters the patient^s controlling power (Emotional Insanity). To these Pri chard has referred, in connexion with Moral Insanity, and gives the follow- ing in illustration : "A young man, previously of most respectable character, became subject to severe epileptic fits,* wbich were the prelude to attacks of violent Mania, lasting, as it generally happens in this form of the disease, but a few days, and recurring at uncertain intervals. These complaints, after a time, disappeared in a great measure ; but they left the individual excessively irritable in temper, irascible, and impetuous, liable to sudden bursts of anger and rage, during which he became dangerous to persons who were near to him. Of symptoms of this description, a state approximating to the Satyriasis of medical writers is no unusual accompaniment ; but, in the present instance, the diseased propensities of the individual were displayed in such a manner as to render confinement in a lunatic asylum the only preservative against criminal accusations." ('Treatise on Insanity,' p. 25.) * Dr. Prichard did not consider that the presence of Epilepsy removed cases in which there is neither delusion nor imbecility, out of the category of Moral Insanity. 284 OF THE VARIOUS FORMS OF INSANITY Examples of the various forms of Erotomania will be found in Esquirol (' Malad. Ment.,' vol. ii, pp, 32, 49). A remarkable example of Erotic Monomania, in which there was no marked disorder of the intellect, is reported by Ferrus, Esquirol, and Marc. ('Annales d'Hygiene publique et de Medecine legale,' tom. iii, p. 198; Marc, vol. i, p. 30.) An interesting case is reported by Marc (vol. i, pp. 148-9). Erotic conduct appeared to be the result of the delusion that a lady was not married to her husband. The patient had, in consequence, to be placed under restraint. The same writer (vol. i, p. 209) cites from Gall the case of an idiot, seven years of age, who afforded a remarkable example of Satyriasis. Numerous examples of Erotomania (proper) are given by the same writer in his great work on the Brain, vol. ii, pp. 182, 193 ; and of Aidoiomania, pp. 193, 291. Of the latter see an example in the ' Journal of Mental Science,' Oct., 1872. See also ' Diet, des Sc. Med.,' Art. " Nymphomanie," by Villermay ; and Art "Satyriasis," by M. Rony; and M. Bayard's 'Treatise on Uteromania,' Paris 1836. Erotomania, in its extended signification, not unfrequently follows upon Religious Melancholy ; a case lately in the Retreat was an illustration of it. Schr. v. der Kolk says he believes we should rarely err if in a case of Religious Melancholy we assumed the sexual apparatus to be implicated, either from self-abuse or other causes. It is not uncommon in the old, and, it may be, in persons who have been patterns of chastity during life. We have seen it among the first indications of senile Dementia. It is more frequent among women than men; and, as Guislain observes, among the unmarried and widows than the married. It may often, in females, be traced to disordered menstruation ; also, as in a patient now in the Retreat, to ovarian disease. Nymphomania and Satyriasis may be excited also by irritiating substances in the bowels, by ascarides, by hgemorrhoids, by cutaneous eruptions, pruritus, &c. It may attack any age ; but the sentimental form — Erotomania proper — more especially alf ects the young, and those of an ardent, susceptible temperament. Idiots are frequently examples of the physical form (Aidoiomania). Erotomania is often complicated with Hysteria^ and sometimes with Hypochondriasis. SECTION XI.— Pyromania(Ti;(0,yJre). Synonyms. — MonomanieincencUaire, Pyromanie (Fr.); Feuerlust Brandstiftimgs-monomanie or hist, or trieh (Ger.). Definition. — A morbid impulse to burn. In a systematic work it is necessary to make some allusion to the condition of mind to which this term has been attache d PYHOMANIA 285 and to which reference is so frequently made in psychological literature. At the same time, we think that it would have been better, had psychologists included Pyromania under destructive Mania in general, instead of constituting it a distinct form of mental disorder. As such we do not recognise it. We are well acquaiated with the particulars of a case in which the act of burning was clearly connected with an impulse to destroy everything that came within reach. Mr had had a paralytic attack about eight years previously, but had very much recovered from its effects, with the exception of uncomfortable sensations in the head, accompanied by slight confusion of mind. He was married, and was very kind both to his mfe and children. Soon after retiring to bed, not having been worse than usual the previous day, and equally affectionate to his family (kissing his children before they went to bed, &c.), he shot his wife, attempted to shoot a servant, set fire to his house in at least six different places, and then committed suicide ! The house was burnt to the ground. An examination of the recorded cases of Pyromania will result in the rejection of a large number if not all of them from the category of instinctive or impulsive forms of Insanity, pure and simple.* In a considerable number, there appears to have been a feeling of revenge, which, associated with a low moral nature, sometimes independent of, but, in other cases, the result of disease, led to the commission of incendiary acts. Of twenty cases recorded by Klein and Platner, sixteen appeared to originate in a motive, although, in many cases, of a trivial character. It is to be observed, however, that, even in such cases, as well as in those alleged to be of an impulsive character, the age of the parties was under or about the period of puberty, and that a larger number of girls than boys have been the subject of this disorder. In short, as Marc concludes, incendiary acts are chiefly mani- fested in young persons, in consequence of the abnormal devel- opment of the sexual functions, corresponding with the period of life between twelve and twenty ; if then there exist any general symptoms indicative of irregular development, or of critical changes in the evolution of the reproductive system, attention should be drawn to the question whether an incendiary * By far the best monograph on this affection is Jessen's ' Die Brandstiftungen in Affecten u. Geistesstorungen ' (Kiel, 1860). In this work (extending to 335 pages) he gives a large number of cases of Pyromania, and he is careful to point out the distinction between those cases in which there was a more or less decided motive and those in which the act arose out of a purely diseased mental condition. He arranges his cases according as they are associated with Imbecility, Melancholia, Mania, Monomania, Dipsomania, and Epilepsy. While fully admitting its existence as a reasoning Monomania, he demurs to its occurrence in an instinctive form. 286 OP THE VARIOUS FOUMS OP INSANITY act has been the result of disease. Hence, attention should be also paid to such signs as a too rapid growth, or one that is retarded, as well as an arrest in the development of the sexual organs ; also, unusual lassitude, glandular swellings, cutaneous eruptions, &c. Further, it is not only important to ascertain whether signs were present, before the incendiary act, of approaching menstru- ation, its derangement or suppression ; but there is an obvious necessity of ascertaining whether there are any symptoms of disorder of the circulation, as an irregular pulse, determination of blood to the head, vertigo, headache, &c. ; or the nervous system, as involuntary muscular movements, trembling, spasms, and convulsions of any kind, epilepsy and catalepsy. In con- nexion with all these symptoms, there will generally be found some change in the character, such as a tendency to sadness, irascibility, and other symptoms of disordered cerebi-al functions. In many cases on record, there existed, from infancy, a condition of mind bordering on imbecility. We have recently seen a boy of feeble mental power in the Broadmoor Asylum who had been guilty of arson. On Jan. 1st, 1876, thirty-three patients were there who had been found guilty of the same crime. Dr Morel, in his recent treatise (1860), lays great stress upon Pyro- mania, as an instinctive form of Insanity, in some children with strong hereditary predisposition. In analysing some of the most remarkable cases illustrative of the disorder which are on record, we have classified them under the following heads : — I. Cases in which there was no marked disorder of the intellect. (Emotional Insanity) II. Those in which such disorder existed. Under the former head, it is convenient to distinguish those (a) in which there was no premeditation or design, from those {b) in which they were present. Again, under the second head, it may aid the investi- gation of the subject, to separate those cases (a) in which there was a deficiency of the intellect — imbecility, idiocy, &c. ; from those {b) in which there were delusions, hallucinations, &c. ; these generally constituting the motive. I. Without marked disorder of the intellect. {a) Without premeditation or design. The following is a case in point : A boy, sixteen years of age, set fire to the house of the father of a person to whom he was much attached. He struggled against the impulse for a year. (Marc, vol. ii, p. 291.) DIPSOMANIA 287 (6) Witli premeditation and design. Case of Jane Wells, aged thirteen, servant in Mr Stone's family, near London. Dr Southwood Smith certified, that she had been suffering from brain fever some time before ; that her convalescence had been protracted, and that her mind might have been mjured. The chief motive in this case appears to have been the pleasure of seeing a blaze. (Marc, vol. ii, p. 369.) II. Witli disorder of the intellect. {a) Depressed condition of the intellect^ imbecility^ &c. Case of a boy, K — , aged eleven years and six months. The conclusion arrived at by the expert who examined him was, that, owing to a defective education, he was still infantile, and that the first incendiary act of which he was guilty, was a childish trick— the second, the result of secret ill-Mall ; but that, independently of this, there was disease — congenital or acquired — which exercised a certain influence upon his conduct. (Dr Meyer, of Pinneberg, ' Annales de Henke ; ' Marc, vol. ii p. 330.) Case of slight imbecility, and of Pyromania, in a lad aged seventeen. No motive appeared beyond the love of mischief. It is, however, a highly interesting and instructive case. (Marc, vol. i, p. 406.) (h) Exalted condition of the intellect, hallucinations, &c. Case of a girl aged seventeen years, in which an inward voice was heard com- manding her to burn. This was the only sign of aberration of the intellect. ('Questiones Medicinse Forensis/ 1821; Ray, 'Medical Jurisprudence of Insanity,' p. 193.) Case of a girl aged fifteen, named Graborkwa. Here the disorder of the intellect was an hallucination that an apparition was constantly before her, impelling her to acts of incendiarism. (Klein, ' Annalen,' xii, p. 136 ; Ray, loo. cit.) Case of a young man, M. B — , a patient in an asylum in Paris, whose propensity it was to set fire to everything. It is to be inferred that it was associated with ordinary Mania. (Marc, vol. ii, p. 309.) The Austrian Government in 1851 repealed the law made about a quarter of a century before, that all youthful incendiaries should be handed over to the doctors for examination. The doctors themselves petitioned for the change and said the doc- trine that it arose from irresistible impulse and a peculiar organisation was exploded C^ London Med. Gaz.,^ Dec. 19, 1851), SECTION XII.— Dipsomania i^i^oc, thirst). Synonyms. — Polydipsia ehriosa insana, Mania craptilosa, Oino- onania ; Dipsomanie, Monomanie d'ivresse, Manie ebrieuse and crapuleuse (Fr.) Trunhsucht (Ger) ; Sapoi (E-uss.). Definition. — An uncontrollable and intermittent impulse to take alcoholic stimulants, or any other agent (e. g. opium and 288 OF THE VAEIOUS FORMS OF INSANITY hashisli) wliich causes intoxication — in short, a MetJiomania [fiiBr], ehrietas). Dr J. C. Browne* defines it as '^ an irresistible craving for alcoholic stimulants, occurring very frequently periodically, paroxysmally, and with a constant liability to periodical exacer- bations, when the craving becomes altogether uncontrollable." (Ans. 450.) Again, " Habitual drunkenness is a vice, and dipsomania is a disease. The essential distinction to me appears to be that in habitual drunkenness the indulgence of the propensity is voluntary and may be foregone, and in dipsomania it is not so The dipsomaniac is driven into the debauch by an impulse. The drunkard seeks the intoxicating effects. . . I have known several dipsomaniacs who, in the intervals between their attacks would not take stimulants when placed before them, but a drunkard, on the other hand, will take a stimulant when he can get it ; that is not so with a dipso- maniac.'" (Ans. 458.) This is a form of mental disorder which, in an especial manner, requires to be discriminated fi-om what may be termed a merely physiological condition, in which the human animal chooses to indulge in alcoholic beverages to excess. On the one hand, the admission of this disease into the department of mental pathology must not make us conclude that there is no such thing as in- temperance without disease — the absurd and mischievous doctrine that " intemperance is a disease " — and, on the other, the fact that the abuse of alcoholic drinks has, oftentimes, no disease to plead in its excuse, must not lead us to the opposite extreme of denying that a truly diseased cerebral condition may exist, the result of which is inebriety. Symptoms. — How, then, shall we distinguish the two conditions, when the result — intemperance — is the same in both ? First (as in all cases of alleged Insanity), by observing whether there are any symptoms present which can be referred to primary disorder of the nervous system, that is to say, other symptoms than those which, as in ordinary drunkenness, can readily be accounted for by the prolonged indulgence in alcohol. The family psycho- logical history, again, is of great importance. Cases in which an insane parent has a drunken son point strongly, of course, * In evidence before the Select Committee of the House of Commons (1872) on " Habitual Drunkards." From the same source are taken the citations from Drs Mitchell and Austie. iDIPSOMANIA. SYMPTOMS 289 to disease. The development of the appetite for stimulants, in early life^ is another indication in the same direction. But_, to come more closely to the circumstances attending the habit itself^ the prominent feature of this propensity is its irresistibility ; the thirst for drink is the tyrant which overbears all the higher emotions, and blindly leads the oinomaniac to a course, against which his reason and his conscience may alike rebel. "Its characteristic/^ says Dr Arthur Mitchell, "is an ungovern- able and remitting craving for drink, without any reference to externals j an ungovernable appetite for drink with no reference to social intercourse, or to joviality. ... It may appear without previous habits of drinking as the result of cerebral injury, of fever, haemorrhage, of mental shocks, of the com- motion in the system which attends the establishment of puberty, or of the arrival of the climacteric period.^^ (Ans. 1177.) As Dr Skae has so clearly pointed out in his Eeport for 1872, the dipsomaniac's paroxysms are preceded by a general perturba- tion of the system. He perspires ; the pulse is soft, but quiet. He is sleepless, uneasy, prostrate, and so craves a stimulant. Between his attacks he differs fi'om the mere sot in often posi- tively disliking beer or spirits, and may be a useful member of society. It is true, however, that the drunkard may become a dipsomaniac; and a dipsomaniac so injured by drink, that he sinks at last into a condition nearly resembling in appearance that of the ordinary drunkard, and then the broken-down aspect, the feeble tremulous limbs, the pale or leaden-coloured visage, watery and lustreless eye,* the deadened affections of the heart, the loss of truthfulness, the weakened intelligence, the dangerous irri- tability, are common to both. The difficulty, in many cases, is to determine whether the uncontrollable condition present is acquired or original. Moreover, in the former case, although * See the description given by Dr Peddie, of Edinburgh, in his pamphlet^ ' The Necessity for some Legalised Arrangements for the Treatment of Dipsomania, or the Drinking Lisanity.' See also Skae, in ' Edinburgh Medical Joui-nal,' 1858 ; Christison, ' On some of the Medico-legal Relations of Intemperance,' 1861 ; A. FoviUe, 'Archiv. gen de Med.,' Oct., 1867; Dr Mitchell, 'Journal of Mental Science,' Oct., 1872; "On " Inebriate Asylums," see idem, July, 1867. The writings of Salviitori, of Moscow' should not be forgotten, " Commentatio Pathologica de Ebriositate Continua, Eemit- tente, et Intermittente," in ' Comment. Soc. Phys.-Med. apud Univ. Mosquens Instit.' (1817), vol. ii, part i, pp. 260, 290; and the work of Briihl-Cramer, 'Ueber die Ti-unksucht' (Berlin, 1819). See also an able article in the ' British and Foreign Medical Review,' Oct., 1858; Magnan, 'Etude s\ir rAlcoolisme,' Paris, 1871. ' Drink in Relation to Insanity,' by Dr BuckniU, ' Journal of Mental Science,' July^ 1876. 19 290 or THE VARIOUS FORMS OP INSANITY truly an Insanity from drink, it must not be confounded with Alcoholic Insanity or with delirium tremens. The loose sense in which these terms (and mania a potu, &c.) are constantly employed by writers and even in medical dictionaries, is very embarrassing to the student. Dr Anstie, admitting the paroxysmal form of drink craving is rare, gives an instance of it " in a man who was in an exceed- ingly good position, and of exceedingly active business habits, and who was one of the cleverest business men that I ever knew ; he always lived a sober and chaste life, except when the fit was upon him ; he did not go far off to avoid scandal, but went to the nearest public house and consorted with loose women, and shut himself up in a back parlour and drank brandy with them for six weeks, close to the village where he was an important man. He was a manufacturer." (Ans. 573.) With women the drink-craving when present, sometimes only occurs at the menstrual period. Of this we have known most striking instances. The craving for drink may be the first symptom of an attack of Insanity. Thus Dr Major has re- corded " a pure case of recurrent mania which has been here (Wakefield) five times, in which one of the first symptoms of the onset of an attack, has invariably been a craving for drink which lasted during the attack, and quite left her when the attack of mania was over." (^ Journal of Mental Science,' July, 1876). That disease of the brain can excite this craving as the first of other symptoms of Insanity, is a suggestive fact in the consideration of the allegation that what was here the first, may in some instances, be the only symptom in addition to hereditary predisposition to insanity or drink. Dr C. Browne observes that he has known " dipsomania pro- duced by injuries to the head in perfectly sober and sedate men. I have seen it produced by sunstroke and by other causes. I recollect a case of a gentleman, perfectly sober, who had dipsomania, which was attributed to taking a draught of water on a hot summer's day, which caused fainting, and was succeeded by an entire change of character." (Ans. 450.) Dr. Hutcheson, who was among the first to draw especial attention to this disease, described it under three forms — the acute, the periodic, and the chronic. " The acute is the rarest of the three. We have seen it occur from hsemorrhage in the puerperal state, in recovery from fevers, from excessive venereal indulgence, and in some forms of dyspepsia. DIPSOMANIA. PROGNOSIS 291 "The peHodtc, or paroxysmal form, is much more frequent than the acute. This is often observed in individuals who have suffered from injuries of the head; females during pregnancy, at the catamenial period, and afterwards; and in men whose brains are over-worked. Like the form about to be mentioned, it is frequently hereditary, being derived from a parent predisposed to Insanity, or addicted to intem- perance. In such cases the probability of cure is very small. The individual thus afflicted abstains for weeks or months from all stimulants, and frequently loathes them for the same period. But by degrees he becomes uneasy, listless, and depressed, feels incapable of application, and restless, and at last begins to drink till he is intoxicated. He awakes from a restless sleep, seeks again a repetition of the intoxi- cating dose, and continues the same course for a week or two longer. Then, a stage of apathy and depression follows, during which he feels a loathing for stimulants, is the prey of remorse, and regrets bitterly his yielding to his malady. This is followed by fresh vigour, dilligent application to business, and a determined resolution never again to give way. But, alas ! sooner or later the paroxysm recurs, and the same scene is re-enacted; till ultimately, unless the disease be checked, he falls a victim to the physical effect of intemperance, becomes maniacal or imbecile, or affected with the form of the disease next to be mentioned. " Of all the forms of Oinomania the most common is the cJironic. The causes of this are injuries of the head, diseases of the heart, hereditary predisposition, and intemperance. This is by far the most incurable form of the malady. The patient is incessantly under the most overwhelming desire for stimulants. He will disregard every impediment, sacrifice comfort and reputation, withstand the claims of affection, consign his family to misery and disgrace, and deny himself the common necessaries of life, to gratify his insane propensity. In the morning, morose and fretful, disgusted with himself and dissatisfied with all around him, weak and tremulous, incapable of any exertion either of mind or body,~his first feeling is a desire for stimulants, with every fresh dose of which he recovers a certain degree of vigour both of body and mind, till he feels comparatively comfortable. A few hours pass without the craving being so strong ; but it soon returns, and the patient di'inks till intoxication is produced. Then succeed the restless sleep, the suffering, the comparative tranquility, the excitement, and the state of insensibility ; and, unless absolutely secluded from all means of gratifying the propensity, the patient continues the same course till he dies or becomes imbecile." The grand characteristic, then, of the disease under which the oinomaniac is alleged to labour is, the irresistible impulse by which he is impelled to gratify his propensity; being, during the paroxysm, " regardless of his health, his life, and all that can make life dear to him,^^ but the proof that it is really a dis- ease, and not mere vice concealing itself under the cloak of dis- ease, must be based on the symptoms already enumerated including the proof that mental control is really lost, in the same sense, at least, as it is said to be in other cases of Insanity. Absolute loss of volition or entire freedom from vice is not claimed for every lunatic justly admitted into an asylum. Prognosis. — Unfavorable . The chronic form is very intractable. Hutcheson states that S92 OP THE VARIOUS FOEMS OF INSANITY he has only seen one case completely cured ; and seclusion for two years was in this instance required. He most justly observes,, that such unfortunate individuals are sane only when confined in an asylum. Though not now on the subject of treatment, we may remark, that In a case under our care we have succeeded in inducing abstinence by substituting, for a considerable period. Chloric Jilther and Nux Vomica for brandy, and at the same time prescribing general remedies, especially Bismuth and antacids, to correct the condition of the digestive organs, upon which the craving for intoxicating drinks in part depended. The result of this case, which for long proved intractable, is the more interesting from being hereditary. Morel, in his work ' Des Degenerescences ' (p. 118), says, " I have never known those patients cured whose alcoholic tendencies originated in hereditary predisposition transmitted by their parents. Their discharge from the asylmm was immediately signalised by the repetition of the same acts." It has been urged as a reason against the condition now de- scribed being truly insane, that when the patient is sober he does not really and heartily determine to withstand the temptation; and that if he did so, he could master the propensity. Of course, this is true of many drunkards. We are certain it is not true in many cases of genuine Dipsomania ; although we admit that, occasionally, the power even to resolve may be partially para- lysed. Passing from the consideration of the several so-called Monomanias, or diseased manifestations of somewhat isolated propensities, we proceed to consider a more general affection, viz. Mania. SECTION XIII.-Mania. Synonyms. — Mavia (Gr.) ; Mania (Lat.) ; Manie (Fr.) ; Pazzia (Ital.) ; Tohsucht, Wuth, Tollheit (Ger.) ; Having Madness. This, perhaps the most interesting and best recognised form of mental disease, has been usually treated of by writers as essentially a disorder of the reasoning faculties. Dr Pricliard classed it under Intellectual Insanity. We are disposed, howerer, to regard it as belonging primarily to the affective group, although eventually involving the intellect, and therefore con- stituting an affection of the whole mind. Definition. — Mania is a term understood in various senses, and it doubtless includes many cases presenting very different sym- ptoms ; but in its primary sense, that of Raving Madness, it may be properly regarded as passion arising from disease, and more MANIA, SYMPTOMS 293 prolonged in its operation. Even anger itself was characterised by Horace as a short madness — ira furor hrevis est • and several writerSj including Finely have endorsed the sentiment of the poet. " He whoj^^ observes this writer " has identified anger with fury or transient Mania^ has expressed a view, the profound truth of which one feels disposed to admit, the more one observes and compares a large number of cases of Acute Mania. Such paroxysms are rather composed of irascible emotions than any derangement of the understanding, or any whimsical singularities of the judgment" No one will deny that the man who is in a passion, has his feelings rather than his reason disturbed in the first instance ; yet, when thus aroused, how confused is his language, how distorted is his judgment ! He hurries from one unfinished sentence to begin another ; his ideas flow too quickly to allow of their sufficiently rapid expression by language. But although Mania, in many instances, is a prolonged anger, it may, likewise, be altogether pleasurable in its manifestations, presenting a condition of exhilaration and uncontrollable excitement, in which the patient is rather mad with joy than anger. It is, however, not the less emotional in character, and is so far a state of irritability, that a very slight amount of opposition would be followed by a display of angry passion. Some of the cases given by writers as illustrative of instinctive Mania, or of a destructive impulse, may, perhaps, be considered as typical examples of Mania in its pure, uncomplicated form j — a form sufficiently well marked to allow of Dr. Prichard^s observation, that " the term Eaving Madness may be used with propriety as an English synonym for Mania. All maniacs display this symptom occasionally, if not constantly, and in greater or less degrees.^^ Whije, therefore, we regard Mania as usually having its origin in disordered emotions, we fully admit that the whole mind generally suffers in consequence, and that confusion then becomes universal throughout the " countless chambers of the brain." Symptoms. — Mania has, in almost all instances, its stage of incubation ; although, as compared with Melancholia and De- mentia, the transition is usually less gradual from slight to unmistakable mental disorder. There may be excitement as the first obvious symptom of deranged mental health. In a large class of cases^ the premonitory symptoms are char- 294 OF THE VArJOUS FORMS OF INSANTTY acterised by gloom and despondency [Stadium AManchoUcum) — the reverse of the supervening maniacal excitement. Occasionally^ there are cases, as Esquirol has observed, in which persons " sink into a deep stupor, appearing to be de- prived of every thought and idea. They do not move, but remain where they are placed, and require dressing and feeding. The features of the face are contracted, and the eyes red and glistening. Suddenly, Mania bursts forth in all the strength of its delirium and agitation. ^^ The physical symptoms by which a state of Mania is ushered in also vary. In the majority of cases, there is a more or less marked departure from the individual's former state of health. Insomnia is one of the most important symptoms. The condi- tion of the tongue, skin, and liver, is usually more or less de- ranged. There may be no pyrexia ; all the symptoms pointing to debility. Sometimes, however, the invasion of Mania is characterised by acutely febrile symptoms. There are also, in some instances, decided indications of active cerebral congestion. In not a few instances, the symptoms are referred by the patient to the abdominal organs ; in some, a remarkable sensation is experienced at the epigastrium, extending thence upwards to the head. We may here refer to a case in -wliich an attack of Mania was threatened, but was warded off by timely treatment. There was in this instance, at this early stage, a slight loss of memory. AATiat the patient chiefly complained of, however, was a strong, and to him unaccountable, tendency to be excited. He could not sleep. He was alarmed at his tendency to become exhilarated. His head was hot, and he would, of his own accord, get up in the night to bathe it. He complained of pain and a sense of weight at the pit of the stomach, which was full and resisting. The conjunctivae of this patient were not injected, but bright; the pupils rather contracted ; the tongue pale and rather dry ; lips congested ; pulse about 80, of moderate volume, and soft ; appetite very bad ; bowels constipated. It may be remarked, in passing, that the symptoms were relieved by prescribing alteratives to remove the obviously deranged condition of the digestive organs, followed by opium at bed-time, and the application of cold to the head. The symptoms displayed when the disorder is fully developed are by no means uniform, being determined, in part, by the patient's natural constitution of mind, and partly by the degree in which the several faculties and emotions are relatively disor- dered. The perceptions of the patient, whether primarily or secondarily affected, may, by their morbid action, convey to him a hallucination or illusion which shall be sufficient to determine MANIA. MENTAL SYMPTOMS 295 tlie particular character of his conduct. We have witnessed^ in a patient^ the most violent actions and the most abusive language' result from the fear that those who approached her would tread on certain celebrated personages whom she saw in miniature form before hereon the floor of her apartment; and it is of very frequent occurrence for a maniac to perceive, in his medical attendant, the lineaments of some other person towards whom he entertains vindictive feelings, and, in consequence of this illusion, to vent his rage upon him in every possible way. Innumerable are the delusions which may affect the course of thought and conduct pursued by the patient. Should he believe that he is about to reform the state of society (the prominent symptom of Dr Arnold\s " Scheming Insanity ''), he overflows with benevolent plans, projects, and intentions, all devised for the certain amelioration of mankind. In all this there seems little to correspond with the description of Mania with which we set out, but if we cannot listen to his plans until his discourse is concluded, or i£ he should be thwarted in his endeavour to carry into execution these impracticable schemes, a violent explosion of passion accompanied by imprecations and perhaps a display of his pugilistic powers, will probably be the termination, for the moment, of his expansive philanthropy ; and the seclusion- room becomes the receptacle of the reformer of the world. He is bent on destroying whatever lies within his reach ; his clothes, if not sufficiently strong are sacrificed to his rage ; and the scraps of paper on which he has so ingeniously designed the means by which his ideas may be realised, the letters to the Queen and Prime Minister in which he has so conclusively set forth the remedies for the relief of every human ill, are now, it is not unlikely, torn into a thousand pieces. If to this condition be added dirty habits, or the dirt-eating propensity, a truly deplorable picture is presented of what the '' lord of creation " may become when afflicted with mental disease. Dangerous violence, destructiveness in regard to senseless objects, a total disregard of cleanliness and decency, vociferous denunciations, loud and threatening language, rapid and impetuous utterance, harsh voice, imprecations and stamping- with the feet, now mark the climax of the paroxysm the madman labours under, in this marvellous disturbance of the emotions, involving, as it does, the overthrow of the moral, and the perversion of the intellectual portions of our mental constitution. The face, and the whole external man would tell, were the 296 OP THE VAEIOUS FOEMS OP INSANITY patient silent, of tlie commotion which is raging within. The tension of the muscles, the contracted brow, the flushed features, the brilliance and congestion of the eyes, the head thrown back in audacious contempt, or fixed in a menacing attitude, the disordered or even bristled hair, the puffing of the neck, and congested veins, — all indicate the mental tempest by which he is agitated. But it must not be inferred from these descriptions, that every case of Acute Mania presents either such well-pronounced symptoms, or even precisely the same passions of the soul in diseased activity. Fortunately, Eaving Madness is to be found at the present day much better described in books than observed in our asylums for the insane, thanks to the altered system of treatment, and perhaps also to an altered — that is to say — more asthenic phase of disease in general. The statement made by Arnold in regard to a patient labouring under " Phrenitic Insan- ity," that " he raves incessantly, or with short and those rarely lucid intervals, either about one or various objects ; and laughs, sings, whistles, weeps, laments, prays, shouts, threatens, attempts to commit violence either to himself or others, or does what- ever else the natui'e of his delirium prompts him to," is not applicable to nearly so large a proportion of cases of Maniacal Insanity as it was when Arnold wrote. Perhaps the most remarkable fact, in regard to the connection between the mental symptoms developed in Mania, and the phys- ical health, is the slight degree in which the latter is endangered, or even (it may be) materially disturbed. Careful notes taken of the state of the tongue, pulse, the renal secretion, and the alvine evacuations in a condition of great excitement, and compared with notes taken of the same patients when convalescent, will sometimes fail to show that change which would appear to be commensurate with the altered condition of the patient's system. This statement must, of course be so far qualified, that the muscular exertion and rapid locomotion connected with the period of actual violence, necessarily induce some temporary changes in the physical state, such as heat of the skin and acceleration of the pulse, which, however, cannot be regarded as other than the natural effect of certain movements, which effect would take place in individuals performing them, although in perfect health. And it is further sometimes observed, when physical disorder has been marked, that, in the change from excitement to tran- quillity, there is a persistence of morbid physical phenomena ; MANIA. PHYSICAL SYMPTOMS 297 tliat is to say^ some morbid physical symptoms were not wanting in tlie maniacal stage^ but they do not pass away immediately on the subsidence of the excitement ; — a fact which, to some extent, is explained by supposing that the physical symptoms induced by the cerebral irritation, have not had time to subside, although their immediate cause has disappeared. The above-mentioned absence of symptoms in regard to the pulse, temperature, &c., is, however, exceptional ; and we believe that, in a very early stage (often prior to admission into an asylum), well-marked physical symptoms are rarely wanting ; afterwards, the system begins, as it were, to tolerate the excite- ment to which it is subjected. A case lately seen at the house of the patient, illustrates the foregoing, weUj and it illustrates another fact, which is, that ia the onset of the attack, the symptoms may he those chiefly of irritation, while, in the course of a few days, they become much more decidedly febrile in character. The patient — a young man — complained, in the first instance, of feeling generally ill, and was unusually nei'vous, f eaiing to sleep alone, &c. His pupils were dilated, the conjunctivEe pale, the water copious and light in colour, and the jjulse about eighty. In a day or two, the mind became more affected, and the symptoms of Acute Mania set in. With these psychical symptoms, the conjunctivas became intensely injected, the urine scanty and high coloured, the pulse more frequent, and the head very hot. The tongue, which was foul beforcj became increasingly so, and red. For several days, the patient was acutely maniacal ; after which, the excitement abated, and, coincidently with this abatement, the tongue became cleaner, the pulse slower, the conjunctivae paler, and the urine more copious. What, then, are usually the evidences afforded by the physical symptoms of the patient, of his maniacal condition ? Drs Leuret and Mitivie made some very careful observations on the 2ndse in Mania, and arrived at the conclusion, that the mean number of pulsations in a minute is 90, being about 15 above the average of the healthy adult.* According to Dr Conolly, the pulse is frequently quick and feeble, seldom below 96, though it may be only 80, often as high as 120, variable, and readily increased in rapidity. It is difficult, however, to know, as has before been intimated, how much of this increased frequency is due to muscular exercise and other accidental circumstances, and how much to the disease itself. Jacobi thinks, that the condition of the pulse in Mania does not so much indicate the state of the patient^s mind, as the physical disorder existing * Dr Guy made observations on the pulse in fifty persons free from mental or bodily disease ; and when compared with the results of Leui'et and Mitivie, it would appear, that '•' it is only between 80 and 90 pulsations that there is any great excess on the side of the insane." — ' Forensic Medicuie,' p. 270, 298 OF THE VARIOUS FORMS OF INSANITY with, and probably the cause of it. He regards the observations of Leui-et and Mitivie as defective^ and appears himself to have arrived at negative, rather than positive results. Dr Foville has made observations on the frequency of the pulse in the in- sane generally. He took sixty-two patients (male and female) promiscuously, chronic and acute cases, and found the average pulsations to be 84 in a minute. Guislain thinks, that the cere- bral excitement of the insane is generally proportioned to the quickness of the pulse. " Occasionally,'^ he adds, " it is slow, as in some cases of Melancholy and Ecstasy, but then there is a peculiar rhythm ; each pulsation, even when the contraction of the heart does not indicate disease, presents a certain energy, in some degree convulsive. Occasionally, the pulse is slow, from a diminution of cerebral excitement.* Scarcely ever is there either hardness or fulness of the pulse.'' The writer is indebted to Dr Savage for the tracings of the pulse in two cases of Acute Mania in Bethlem Hospital given below. He informs us that he has frequently obtained similar sphygmo- grams in Acute Mania, and that these cases have recovered. '^ They bear a strong resemblance to those found in fever and acute diseases, but in the maniacal tracings the rate is less and * Although the appearances presented on ophthalmoscopic examination must, like other symptoms, be subject to much variation, and although the vascularity of the optic nerve is not always an index of that of the hemispheres, we may state that Dr T. C. AUbutt, in his work ' On the Ophthalmoscope in Diseases of the Xervous System ' (1871), gives the result of his own examination of 51 cases of Mania in the West Riding Asylum as follows : — In 25 the state of the optic nerves was symptomatic of intra-cranial disease, in 13 it was of doubtful meaning, and in 13 there were either no changes at all, or only local changes, such as glaucoma, &c. In the majority of these cases organic disease was suspected. Dr Allbutt found that in Mania, whether dependent upon organic lesion or only functional in character, the back of the eye, if observed within a feio days after a severe paroxysm, presented a vascular suffusion and pinlcness, so great as to obscure the disk. No exudation was observed in these cases unless some permanent mischief existed. Further, during the paroxysm itself the disk was anamic (spasm of the vessels ?). He refers the permanent changes in the disk "either to stasis from obstruction to the intra-cranial circulation, with consecutive atrophy, or to ramollissement, ending in simple white atrophy ; or they may present changes of a mixed character." See also the observations made by Dr Nowes ('American Journal of Insanity,' Oct., 1871) and by Dr Monti ('De I'Ophthalmoscoine dans les Maladies mentales'). We may add that Dr Allbutt fomid in 17 cases of Melancholia and Monomania that the optic nerve and retina were healthy in 10, doubtful in 4, and diseased in 3. Dr Allbutt very frequently noted anaemia of the retina in Melancholia. Dr Monti says that in Melancholia and Mania in an early stage, and particularly in the former, the results are negative, but if there is decided excitement, retinal congestion is often met with, MANIA. SPHYGMOGRAMS 299 the heart-beat more forcible. I have seen the same patient present a similar pulse-tracing in other attacks at the interval of one year or more. I have never seen a similar tracing in Melancholia. The pressure was one ounce in both tracings. Fig. 10. Fig. 11. The next tracing of the pulse in Mania is from Dr Wolff.* Fig. 12. The shin is sometimes moist, and offensive to the sense of smell, sometimes dry and harsh. The former condition is, occasionally, the cause of as diagnostic an odour as the never-to- be-forgotten effluvium of a variolous patient ; and is then immediately observed on entering a room where the maniac has been for some hours, especially daring the night. The bowels are sometimes relaxed for a considerable period in Mania, but constipation is more usual ; whether loose or confined, there is very frequently decided evidence of gastric and hepatic derangement. The dirty habits of maniacs are due to careless * " Beobachtungen iiber den Puis bei Geisteskranken," 'AUgemeine Zeitschrift fill- Psycliiatri?/ 1867-9, 300 OP THE VAEIOUS FORMS OP INSANITY indifference or design, not, as in General Paralysis, to loss of control over the sphincter ani. Dr Jacobi found, out of fifty cases, the bowels inactive in twenty instances, regular and of normal form in seventeen ; while, in thirteen, the stools were decidedly unhealthy, and, in nine of these, irregularly relaxed and confined. The urine is frequently sufficient in quantity, without being high coloured ; at the same time, during an accession of violence, it is often more scanty, and deeper in colour. Some years ago Drs Sutherland and Rigby examined the urine of a large number of patients at St Luke^s, and found that in 100 cases of Mania, it was of "dark colour ^^ in 52, and deposited a sediment in 87 instances.* Contrary to the conclusion at which Erlenmayer arrived, namely, that the urine is generally alkaline in recent cases of Mania, Dr Sutherland concludes that it is generally acid. Incontinence of urine is common, and is due to the causes referred to above in reference to the f^cal evacuations. The tongue may be redder than it should be, its muscular tissue firmer, and its papillae unduly prominent. Of 50 cases of Acute Mania examined in this respect by Jacobi, the tongue was in 1 7 instances veiy foul, white or tawny, grey or yellowish grey, but in no case actually dry, although it was frequently but little moist; in 16 cases the tongue was slightly furred, and in the remaining 17 it was quite clean. In the same number of cases, the breath was in 20 sweet, in 15 somewhat offensive, and in the same number decidely so, in some of these being '^ exceedingly sour.^^ In regard to the saliva, the same observer found out of 50 cases, that it was excessive in quantity in 21 instances (in 2 of which it was only so during the paroxysm), and slightly increased in 4. As a rule, the appetite of maniacal patients is large, often excessive ; sometimes more so at the onset, and during a paroxysm, than when the patient is calmer. A maniac may refuse food altogether but he rarely persists so long as to occa- sion any danger. Eeferring to Dr Jacobins 50 cases, we find that in 23 the appetite was normal, in 13 it was voracious ; in 7 it was at first poor, but subsequently excessive ; in 3 it varied, in 2 the appetite was increased during the exacerbations, and in the remaining two it was very bad. Thirst was a prominent symptom in 7 cases ; in 9 there was less than usual; and the remaining 34 did not vary fi-om a state of health in this respect. * For the cliemistry of the urine and blood, see the chapter on Pathology. STHENIC AND ASTHENIC MANIA 301 In the majority of cases of Acute Mania occurring in women, there was suppression of the catamenia. As regards nutrition, the patient generally gets thinner ; the remark applies here that was made in regard to the pulse, that it may result from circumstances associated with, but not essen- tial to, the disease. In some cases, there is marked emaciation. In 21 of Jacobins fifty cases, there was very decided evidence of defective nutrition, and in 15 this was in some degree the case ; in 15 cases there was more or less evidence of dyscrasia, and in 14 the complexion was sallow or earthy with a dark areola under the eyes. The diversity of symptoms in Mania may, to a great extent, be explained by the well-known fact, that an equal amount of excitement may result from two distinct and opposite conditions of the system ; excessive nervous action often co-existing with deficient nervous power. This is most important to bear in mind. One patient may be mad from an excess, another from a deficiency, of blood. The former may require depressants, the latter stimulants. There may be excitement and surplus nervous energy, and there may be a state of nervous debility and consequent irritative excitement, precisely opposite in its nature. We may very properly speak, therefore, of Sthenic and Asthenic Mania, even when both are acute. To the former, the description already given of the physical indications, more espe- cially applies. In the latter, the pulse is often very feeble, although frequent ; the tongue is decidedly pale, thin, flat, flabby, and indented at the edges ; the lips pale ; the conjunctivse watery, or if vascular, not presenting the same bright red injec- tion which is generally present in acute Sthenic Mania ; the pupil is not so much contracted, and it may be dilated. In books a dilated pupil is sometimes mentioned as characteristic of Mania, but this is by no means the case ; and, when it is present, we have usually found it in Mania of the asthenic variety.* The scalp may, or may not, be hotter than usual -, and in regard to this, and other symptoms, it may be observed, * Dr Pliny Earle, however, in an excellent paper in tlie ' American Journal of Insanity ' (April 1854), oljserves : — In many cases of the most furious Mania and that too, not unfrequently, in robust or plethoric persons, the pupil remains of its natural size. Sometimes, it is even dilated. The cases ia -vrhich it is generally most contracted are those of slender, nervous, perhaps debilitated persons, in whom there are various evidences of high excitability, and who not only tolerate but require a tonic, sometimes a stimulant treatment." 302 OF THE VARIOUS FORMS OF INSANITY that no just inference can be drawn from any one of them alone ; they must be judged of in their entirety. Extreme^ and sometimes sudden^ exhaustion, is a symptom always to be feared,, and carefully to be watched, in the early stage of Acute Mania — while the loss of flesh, so often observed, is not, even when very considerable, a circumstance which need occasion alarm, either as to the recovery of mind or body. The late Dr Bell of America in 1844 specially called the attention of the profession to a form of Mania in which the disease runs a rapid course and is attended by extreme exhaus- tion after excitement. In " Bellas disease '' (as it has been called), the attack is sudden, and loss of sleep, delirium and loathing of food are prominent symptoms. Others have called it typhomania.* Dr Bell makes no reference to the delire aigit of French writers, the acute delirious condition corresponding to the phrenitis of the ancients, which is distinguished from ordinary acute mania by more fever, more incoherence and ina- bility to recognise those around, by its rapid course, extreme prostration, and frequently fatal termination, but we have no doubt BelFs cases belonged to this category. "We should place under the same division seven cases reported by Conolly in the Lancet (1845), all of which proved rapidly fatal, one of which is thus described : "A male patient, aged thirty-six, a coachman, lost his situation, and became maniacal in consequence, threatening the life of his wife, trying to get out of the w-indow, and saying that the de\'il was in his room. When admitted, about a fortnight after his attack, he was thin, pale, restless ; always talking incoherently, or singing J his tongue was white, but it soon became dry and coated, and then in a few days moist. At first he refused food, then took it freely ; the bowels were costive, his voice was hoarse, the pulse at first 96, soon afterwards 120, and always very feeble ; he could give no distinct answers. Here was a case of recent Mania from a moral cause. Leeches were applied to the head, he had warm batlis ; croton oil was given when food was refused ; the tincture of henbane at night, and after a trial of this medicine, porter ; but he sank rapidly, became quiet and sleepy, and died ten days after admission." Conolly's diagnosis bears out Bell's supposition that in some asylums, deaths from Acute Delirious Mania are ranked under ordinary Acute Mania. See several cases of delire aigu in Dr Blaudford's work, '^ Insanity and its Treatment,-* 1871, p. 220. To return to ordinary Acute Mania it must be observed in * Dr Ray distinguishes between them. See the ' American Jom-uul of Insanity,* July and Oct., 1853. EECUERENT MANIA. 303 regard to its subsequent course that it may either yield rapidly to treatment^ may end as in the cases we have mentioned^ in death by exhaustion, may recur in paroxysms in an intermittent form ; may become chronic, or may terminate in Melancholia or Dementia. It is g'enerally said that one third of maniacal cases are inter- mittent. The paroxysm may return at various periods, being occasionally marked by very regular intervals of a month, a week, or two or three days. Schr. v. d. Kolk mentions the case of a patient who every other day about dinner-time became greatly excited and at last furious, but towards evening became calm, remaining quiet during the next day also and his speech be- traying but slight mental confusion. In another case the attacks came on every third day during four years. Such short inter- missions must be distinguished from those longer periods of complete recovery which are designated ^'lucid intervals ^^ (p. 27). It should here be observed that in Mania the remissions are rarely the same as regards the period of the day as in Melan- cholia, in which the exacerbations so frequently take place in the morning. With the maniac the night is often marked by great excitement, the patient who went to bed tolerably calm awaking from sleep wild and incoherent, while the day again may begin with comparative tranquillity. The term " recurrent '' is more conveniently restricted to those cases in which the patient recovers, probably leaves the asylum, and relapses again into Mania. In the case of a lady known to us, a maniacal paroxysm comes on every year. They form a disappointing class of cases, in which exposure to slight exciting causes, acting upon an unstable brain, upsets the balance of the mind, and it is often to be observed that one of the first symp- toms of a return of the disorder is a recurrence to exactly the same subject of excitement and delusion which marked the first attack. This recurrent form constitutes, from its importance and distinctive character, an important variety of Mania. When Mania becomes chronic, we witness an almost hopeless form of Insanity which is only too common in our asylums. The morbid phenomena of sensation are now often strikingly exhibited. Many of the cases we have already given under Delusional Insanity and Monomania are usually classed under the chronic stage of Mania. It is unnecessary to describe further the delu- sions and hallucinations arising in this state. For years the 304 OF THE VARIOUS FORMS OP INSANITY physical health of such patients as well as their mental condition may remain almost stationary^ and yet in a large number of cases the maniac has an ill look, a haggard expression, makes little red blood, is cachectic, and although he may not attract any special attention as being out of health, and, indeed, has not any prominent morbid symptom, he would, were he placed by the side of a man enjoying robust health, present a sufficiently striking contrast. He would look etiolated. Mania may pass, as we have said, into Melancholia ; and if these two conditions alternate, it assumes the unfavorable form of circular Insanity referred to at pp. 232, 233. A lady at the Eetreat had for five years attacks of excitement and depres- sion on alternate days. Or again, the patient may lapse into Dementia, into which it may be said that Mania manifests a constant tendency to degenerate. Indeed, Chronic Mania when advanced is so little distinguishable from Dementia, that the mental condition which one physician would call the former, another would designate as the latter. Of 49 cases of Mania ad- mitted into the York Retreat which ultimately proved fatal, the following was the mental state of the patients at death. In 30 the form of disorder was unchanged, 8 having, however, decidedly improved, while 22 were no better. In 19 the form had changed, 16 into Dementia and only 3 into Melan- cholia. It fares, indeed, with the patient after an attack of Mania, as with a city or garrison after the horrors of an assault. The milder but more permanent supremacy of the enemy may suc- ceed : or the whole may present but a heap of smouldering ruins ; or the re- action of native strength having repelled the foe, there may be more or less of obvious dilapidation to mark the fierce- ness of the conflict. .ffitiology. — See the causes of Insanity in general, p. 54. Mania occasionally arises from erysipelas. We have recently seen a case in which this cause operated. See a case in ' Guy^s Hospital Repoi'ts ' for 1873, of a female aet. 47, attacked with facial erysipelas eight days before admis- sion, which subsided in four days. An outbreak of Acute Mania occurred two days before entering Guy^s ; she had to be sent to an asylum. A peculiar case of Transient Mania following an attack of erysipelas of the face, is reported in the ' Journal of Mental Science,' Oct., 1875. Of Mania arising in connection with epilepsy, General Para- PLATE 17. "^fo i. ^^ ^^^^ ^^^ /^^^ ( 186e ) ( j£u>U 44-. /,g77 j C^,./t^a-l ^^.oC. ^//^^v ^A^ />!-«.- PLATE V. '■^4 V^'o^ 4 lidd !* HANDWEITINa AND COMPOSITION OP INSANE 305 lysiSj and the Puerperal state, we shall have to speak in a subsequent chapter. Prognosis. — Unfavorable in acute maniacal delirium [deli/re aigu) . Favorable in ordinary Acute Mania. A noisy boisterous mania is usually recovered from. The mortality at the York Eetreat of those admitted in a state of Mania, in forty-four years, was about 4 per cent., while in Melancholia it was more, viz. nearly 7. SUPPLEMENTARY NOTE. Handwriting and Composition of the Insane. We proceed to explain the accompanying facsimiles of the handwriting of the insane. With some exceptions they were tamates of the York Retreat or the Bootham Asylum, York, under Dr Needham's charge. Plate IV. — Fig. 1 represents the very neat (sane) handwriting of a young man under our notice who hecame a general paralytic. His writing when he was considerably advanced in general paralysis is represented in Fig. 2. A striking contrast. Fig. 3. — This was \\Titteu before any symptoms of insanity were manifested by a gentleman subsequently under our care for general paralysis. Fig. 4. — Written by this patient a short time before his death. Fig. 5. — A case of delusional insanity. The morbid indications of this writing are conspicuous by their absence. It is given for the purpose of contrastiug the handwriting of a patient labouring under exalted delusions as to wealth (a bUl con. taining ridiculously large sums being made out to himself), with what the writing would have been had these delusions been associated with general paralysis. The importance as a test of inducing a patient to write is thus shown by the contrast with Figs. 2 and 4 on the same plate. Plaie V. — Fig. 1 represents the handwriting of an incurable case ia the York Eetreat, the patient labouring under the delusion that she is a royal personage, a fact brought out in the signature, which may be said to be written as well as conceived insanely. The style of writing is thoroughly insane. Figs. 2 and 3. — Handwriting of the patient whose pulse-tracing is given at page 323. The contrast between his writing in health (2) and when labouring under general paralysis (3) proved valuable in diagnosing this case; exalted ideas not being a prominent symptom, and the gait at the same period not being distinctive. Fig. 4. — Partial Dementia. The specimen here given, commencing — " The melons ripen and the citrons blow — " forms only a minute portion of a large sheet ; this sheet being one page of a book, 20 306 OP THE VAEIOUS FOEMS OF INSANITY consisting of 200 pages of equally closely written matter penned at different times. It will be observed that the first and third, and the second and fourth lines, are usually continuous. It consists of extracts from poetical works, as Shakespeare, coupled ^vith cabalistic marks of his ovfn p, pfo;. ;etiological forms of insanity General Paralysis whose pulse-form resembled Fig. 15, but who at the time the subjoined marking was procured, was the subject of inflammatory fever due to bronchitis. Pulse 112. Compare with the figure given representing pyrexia at p. 194. It may be added that Dr Thompson refers the pulse- changes which take place in General Paralysis to arterial contractions, the result of certain pathological changes ; and with these he compares the tracing taken from the wrist of a healthy person immersed in cold water for some time, and therefore chilled (see Fig. 18). It is taken from 'Carpenter's Physiology,' 7th edition, p. 285. The resemblance is certainly remarkable. Fig. is. That the tracings taken of the pulse in the same patient will materially vary under different circumstances is well shown in General Paralysis, in which there appears to be a peculiar sen- sitiveness of the vessels. The three following sphygmograms were taken by Dr Thompson, from a man the subject of Gen- eral Paralysis in the Bristol Lunatic Asylum. Fig. 19 was taken Fig-. 19. in a low condition of the system. Fig. 20 in a similar state (on Fig. 20. SPHYGMOGEAMS IN GENERAL PARALYSIS 323 the same day) but slightly stimulated by dinner taken between tlie two tracings. Fig. 21 exhibits a still greater change. It was Fig. 21. taken after dinner^ when there was " some pyresic condition of the vaso-motors evidently local as to the system in general." He was admitted^ set. o'3, Sept. 30^ 1873, with General Paralysis. The tracings were taken in Nov. 1874. He is still an inmate of the Asylum. The pressure in these syphgmograms was 150 grammes. In Fig. 19 the temperature was 96° ; in Fig. 20, 98°, and in Fig. 21, 97. The subjoined sphygmogram of a general paralytic was taken from a patient examined by the writer in the National Hospital for the Paralysed and Epileptic, Queen Square, London, by Dr H. R. 0. Sankey, at that time Resident Medical Officer (pressure 5 oz.) Fig. 22. The first symptoms were irritability and "■ stopping in the middle of a sentence. ^^ The assigned cause was overwork as manager of a packing department of hosiers. Beyond squandering his money and saying there was nothing the matter with him ex- cept weakness in his knees, there were no indications of gran- diose delusions. Loss of memory, childishness, suspicions, tremulous articulation, and slurring of his words, and complete change in his handwriting (see Plate V, figs. 2 — 3) marked the subsequent course of this case. The deterioration in the handwriting of general paralytics is also shown in figs. 1 and 2 of the same Plate, in Plate VII, figs. 1 and 3, and Plate YIII, figs. 1, 2 and 3. As regards the age of those attacked with General Paresis^ 324 .ETIOLOGICAL FOKMS OF INSANITY we find from Dr Macleod that o,ut of 75 patients admitted into the Royal Naval Hospital at Yarmouth there were — wceu the ages of 20—30 . . 14* 30—40 . . 32 40—50 . . 20 50-60 . . 7 60—70 . . 2 Total . . 75 In a table prepared by Br Burmau, showing the age on admission into the Devon County Asylum, of 266 male patients the subjects of General Paralysis, the highest number (109) occur between 40 and 50; and the next (91) between 30 and 40. Thirty-eight were admitted between 50 and 60 ; seventeen between 20 and 30 j and eleven between 60 and 70. In regard to the female cases, the highest proportion was found to be between 30 and 40. (' West Riding Asylum Medical Reports,' vol. i.) In respect to sea-, the comparative immunity of women is a striking feature. On reference to the section on the Relative Frequency of the Various Forms of Mental Disorder^ the reader will observe that at the Somerset Asylum^ 8*3 represented the percentage of cases of General Paralysis among the male admis- sions, whilst among the females the proportion was only 2 per cent. Of 1963 male admissions at the Devon Asylum, 276 were cases of General Paralysis, while of 2099 females only 65 were so affected (Burman). This ratio closely corresponds with the foregoing. Other statistics give a proportion of eight males to one female. Mr Denne, on the other hand, informs us that, contrary to his former experience at Hanwell, he sees at the '^ Three Counties Asylum/^ Herts, a large number of cases among women. A patient whom we recently examined and made notes of shortly after his admission into the Royal Edinburgh Asylum, and for particulars of whose history, &c., we are indebted to Drs Sheaf and Haigh, affords us a good illustration of exceed- ingly well-marked General Paresis in a somewhat early stage. His articulation was affected, there was a slight tremor of the lips and tongue, and there was a very decided manifestation of the delire des grandeurs. He begged to be allowed to go by an early train to Paris to be cro^\aied Emperor of the French. He dwelt with fervour on the beauty of the princesses he should see there. His lips were pale, his voice husky, his aspect worn, his volubility extreme. His pupils appeared to be equal and rather contracted, but it was not easy to examine them on account of his excitement. He was rather tall and good-looking, and decidedly thin. Since his admission his wife and brother had visited him, and he had become * The youngest being 21. Dr Clouston has recorded the case of a youth aged only 16. ('Brit. Med. Jour.,' Sept., 1877.) LETTERS OP A GENERAL PARALYTIC 325 inore excited iii consequence, and tore his clothes. On the 5th October, 1872, the note was made, " He is now quieter, but believes he has bought the whole world ; that he has millions of money ; that he can walk ten miles an hour ; will walk to York to-night ; that everybody is a jolly good fellow, except some few of his friends, whom he means to shoot." We find that he became at the age of thirty, without any apparent cause or known hereditary taint, quite altered in his character, very easily excited and vain. Before long he betrayed incoherence in his conversation, had delusions, and appeared to have quite lost all sense of time or knowledge of dates. At last he became so noisy and violent that it was necessary to place him in an asylum. He also threatened to commit suicide. At this time he -wa-ote a letter to his wife, in which he says " Surely you don't tJiinlc me insane. You will I hope have the only pleasure I have on earth of seeing me once again at your sight" (sic). He signs himself, " Your sane loving husland Love and hisses to my darling children Yr. devoted husland." In a letter to his mother he says, "Sere I have been trapped'in the most abomin' able way. . . . If I am not let out at once I shall cut my throat at dinner, so farewell for ever i" and again, shortly after, he writes to her, " I am still imprisoned here and tlio' I legged you, to come and release you have not done I am mad raving, and have a great mind to execute a rash act which leaves me lut a feto ere death seals my doom." To a Professor he writes, referring to his confinement, "No step fraught with more danger and injury to me. I am determined to proceed at the earliest point to raise an action in the Court of Session for several £1000 and will spare no mercy in having them punished." Lastly, a few days after, he thus addresses his mother : — "1 am getting very tired of my confinement and if my deeply revered parents and Irother and sisters are still lurning with the same unextinguishalle love for ivhich they have so long leen conspicuous I cannot live here over this weeJc. I am sure and convinced thai that old fiend and ruffian my father-in-law has leen puzzled his old scattered Irainsfor years as to the lest devise for rendering this fair and leauteous earth a hell instead of an extactic paradise. I am often in tears especially at night when I reflect on my darling amiable image-god only leloved Irother — . Se ivas a Christian and he now ivears that crown of glory tvhich fadeth not away." Of the asylum he says, "It is getting intolerable, I cannot, and unless I am instantly set free and restored to the bosom of my leloved darling family. Ah ! Mama those who were instrumental in the hellish loay they did in putting me here, could not tho' they searched earth and land, sea and shy, or heaven or hell could have adopted a surer or more decided mode of Hasting the happiness of life ever set. {Fond love to — affect, son {Signed) ) iipon the great reioard. Oh if you could only see me here at nights, and also tvhen all alone your bowels of mercy zvould be moved. I never thought I had a legion of cruel enemies. By let my end be ly my own hands or ly the icill of the Great Creator. I hope my case will be peace." These letters are very cliaracteristic. The reader will observe the incoherence — a word now and then left out — a wrong word occasionally used, as " sight " for " side '' — the order of words reversed, and a line sometimes interposed in a curiously abrupt and dislocated fashion. Then, in regard to the matter, the union of pious ref eren,ces (more of which occur in the letter) along with violent expressions in regard to those whom he denounces as his 326 ETIOLOGICAL FOEMS OF INSANITY enemies, is worthy of note. No one familiar with the insane would hesitate to admit the genuineness of such a letter as this. (See Observations on the Handwriting of the Insane, p. 305.) The following case affords another good example of General Paresis in an early stage, but with rather different symptoms. E. F — , man-ied, set. 33, with an hereditary taint of Insanity. He was a very sober man, occupied as a bleacher, and of regular habits, with a %vif e and family ; no exciting cause of his mental disorder is known. About four years before the present attack he had delusions about poison in his food, but after eighteen months' treatment he was able to return to his work. He does not appear, however, to have remained free from symptoms of Insanity for more than about half a year, although nothing transpired sufficiently definite to render it necessary to place him in an asylum until September, 1872. The writer saw him on the day of his admission into the Cupar Asylimi, when his thick articulation and characteristic hesitation in pronouncing his words were well marked. His tongue was also tremulous, and his walk slow and somewhat straddling. He looked absent and stupid. We are indebted to Dr J. Batty Tuke for a copy of the notes made by himself and Dr Fi'azer at the time of his admission, from which we extract the most salient additional features. Body well nourished. The patient allows his words to drawl out of their own accord, -with very little effort. Stiffness or immobility of the lips, especially the upper, which is markedly so, and hangs like a curtain, while the diity of articii- lation devolves on the lower lip and tongue, more especially on the latter. He seems to have a difficulty in enunciating the letters " r " and " s," placing a long slur on the former, and substituting " th " for the latter, as in the words " form," " arm," " Leslie," " blessed," &c. Drawl most marked on second syllables. The tongue exhibited a general fibrillar tremor, the tip directed slightly to left side ; after being protruded for a short time it is retracted with a jerk, even when he is requested to keep it out. The pupils are unequal ; left largest, and of normal size, but somewhat sluggish ; right appears permanently contracted. The finer movements of manipulation seems to be affected, as there is some fumbling in buttoning up his clothes. His handwriting is fair, but very tremulous and irregular. Each stroke of the pen seems a work of some effort, and every letter has to be made by itself, and then joined on subsequently to the preceding one. Sensibility to temperature was tested by the hot and cold sponge, and found normal. As regards the tactile sensibiUty, the ajsthesiometer proved that he coidd distinguish the two points as such, at a distance of two thirds of an inch, over the greater part of the body, except on dorsum of right foot, up as far as the ankle, Vhere the limit of confusion was at one inch. By the electro-motor test, sensibility appears pretty normal in the upper extremities. When one handle of the battery was earned do^ni the spine, the other being held over the seat of the inferior cervical ganglion of sympathetic, as soon as it reached the lower dorsal and lumbar regions, the patient began to shrink and complam of the severe pain caused him, especially in the lower lumbar region. He is apathetic ; sits by himself in a corner, moody and unsociable. Xo exalted notions ; rather depressed than the opposite, yet there is the hieu eire of General Paresis, and when questioned as to his bodily health, looks contented and happy for the moment, and expresses his condition as being " fine," " first-rate," &t. Is long in replying to a question, and then frequently only in monosyllables. Memory, as CASES OP GENERAL PAEALYSIS 327 regards. time and dates, very defective; thought he had been here a month on the fourth day of admission, but as regards events connected with himself, it is good. He is tractable. Habits cleanly; sometimes useful about the house. Seldom, however, on his feet, except when asked to walk across the room or when sent on a message. As an illustration of the advanced stage of this disease^ the writer may give the following case, which came under his notice at the Hull Borough Asylum : The patient, a tailor, was admitted in a state of Mania in November, 1867, the entry being made by the Superintendent, 'Mr Casson, at the time, "Wild staring eyes; pupils much contracted ; maniacal expression of countenance." The symptoms were of only about fourteen days' duration, during which time he had done all sorts of foolish things^ ordered carriages, dinners at hotels, and numberless expensive articles. He had also been very restless, and did not sleep much at night. In the morning he would get up very early, go out, and call people up to have breakfast with them. Two days after- wards he was very wild and excited, and talked incessantly. In about a fortnight he became quieter, though his language was maladictory and blasphemous. Shortly after it was found he had decided hallucinations, such as seeing Christ, the devil. &c. For some months he remained in a doubtful condition, occasionally maniacal, but, on the whole, more composed, and in the summer of 1870 appeared to be in a very hopeful state, both in mind and body, and commenced work in the tailor's shop. He then became decidedly stout and very indolent, but after a while he improved in all respects. This, however, was but the lull which preceded the appearance of a symptom only too significant of the suceeding mental disorder. When at work his hands became tremulous. This was quickly followed by slowness of speech and a disinclination to enter into conversation. Moreover, there was now some loss of power over the sphincters. Notwithstanding the increasing gravity of these symptoms, half a year afterwards signs of amendment were manifest, and his habits, which had been dirty, became cleanly, and he was able to do a little tailoring again. To a superficial obsei-ver he might have seemed well. However, in three or four months he became talkative, and as to his physical condition he is desciibed as " in the bloated state of General Paralysis." Four months later he was quite in- coherent — in a perfectly hopeless state. About two years and three quarters after the first decided signs of General Paralysis, he was confined to his bed, never speaking unless when addressed, and then only in monosyllables. Bed-sores succeeded ; a water bed was made use of ; he was perfectly helpless, and could not speak, yet after some months had elapsed, his bodily power so far improved that he was able to leave his bed and sit up di'essed in the ward. When the writer saw him he could answer questions, chiefly in monosyllables, in a very slow unintelligent manner. His pupils were sluggish; equal. The tongue deviated a little to the right, and was rather tremulous. Fingers of right hand flexed on palm. Could walk pretty quickly across the room. JEtiology. — Differences of opinion still exist as to the most frequent cause of this malady. It is certainly suggestive that^ if we take two institutions, the York Eetreat, and the Eoyal Naval Hospital, Yarmouth, which offer a complete contrast as to the habits of life of the patients admitted into them respect 328 ETIOLOGICAL FOEMS OP INSANITY tively, we find that in the latter^ General Paralysis is of exceed- ingly frequent occurrence, and in the former^ it is very un- common. Now, if we ask ourselves in what respect these habits differ, there can be no hesitation in replying that it is in regard to a regular and temperate life. In the community from which the Retreat derives its inmates, a large number pursue the even tenor of their way without much excitement, and are very temperate in their habits. The difference in the annual consumption of intoxicating liquors in the two classes would be something enormous. The contrast would also be as great in regard to other forms of excess manifested by dissipated habits. The conclusion which this comparison suggests is con- firmed by a statement made to the writer by Dr Macleod, that a large number of cases coming under his care at Yarmouth are due to irregular habits of life — in not a few to debauchery on landing after a voyage. Then, again, if we contrast the class for whom the Retreat is established with the inmates of county and borough asylums, we shall find that whilst in the former, intemperance and poverty are of infrequent occurrence — indeed, as regards poverty scarcely known — they are prominent features in the antecedent histories of the latter class. At the time when there was no, or only a doubtful case of General Paralysis at the Retreat, the writer found at least eight in the Hull Borough Asylum, containing at that time almost exactly the same number of patients. These the Superintendent, the late Mr Casson, allowed him to examine, and of seven he took careful notes and ascertained, as far as possible, their past histories. As regards causes, he found that of these seven, three might be fairly traced to intemperance. Of one, a man of about forty, his wife said he had been ''a hard drinker.^^ This, of course, led to quarrelling and to trouble in his situation, and he had to go to the workhouse. Of another, a tailor, aged forty-three, the statement was made by a woman who lived with him since the death of his wife two years before, that he had been "a very heavy drinker, more particularly during the lifetime of his wife, who was a hard drinker also.^^ She said she had discouraged his taking so much, but that a short time before this attack he had " a heavy drinking bout." In the third case, a young man of twenty-eight, and formerly steady, was sent on recruiting service to Shefiield, where he married a worthless woman, who subsequently deserted him. This so preyed on his mind that he took to drink, and during CAUSES OF GENERAL PAKALYSIS 32& the twelve montlis previous to his admission " drank very heavily indeed." In a fourth patient^, a labourer^ there was no evidence given of drink^ but only of want. The causes assigned were " a bad wife^ who had left him; want of work^ and consequently insufficient food,-'^ The records of the county asylums of England would supply but too many parallel instances to the foregoing. Drink causing poverty _, and poverty leading to drink (the former in by far the largest proportion of cases) ^ are the familiar antecedents of an attack of General Paralysis. And the absence^ for the most part^ of these antecedents in regard to the patients admitted into the Retreat,, coupled with the comparative freedom from this particular form of Insanity^ can hardly be an accidental circumstance^ but one which justifies our accounting for the prevalence of G-eneral Paralysis by the influence of alcoholic and sexual excesses combined in many instances with insufficient nourishment. In the other cases the alleged causes were, in one instance, a fall on the back of the head, in another, loss of property, and in the third " a stroke.''^ In the statistics collected by Dr Burman respecting the cases of General Paralysis admitted into the Devon Asylum, of 103 cases in which the cause was ascertained, although intemperance forms the largest single cause, the moral causes slightly exceed the physical^ and Dr Burman thinks these statistics confirm Austin^s opinion that " an acutely painful impression on the moral sensibility is the usual cause of General Paralysis. '"' In 12 out of the 103 cases, the cause was referable to falls and injuries to the head, and in 7 to coup de soleil. As a circumstance of interest taken in connection with the class of persons who go to the Royal Naval Hospital at Yarmouth, it may be stated that, according to Dr Burman, " the occupations which next in frequency to that of labourers, recruited the ranks of general paralytics in the Devon County Asylum, were those of soldiers and marines or mariners, one seventh of the whole number of males being of one or other of these occupations," thus confirming CalmeiPs statement that " de toutes les professions, celle des armes exerce Tinfluence la moins douteuse et la plus funeste." Prognosis. — (See p. 135.) Recoveries, or rather remissions for months and even years, are not very unusual, but a relapse may be predicted as almost certain. Although, however usually incurable, cases do occur which raise a strong hope 330 ETIOLOGICAL FORMS OF INSANITY that the recovery will be permanent. Dr Macleod has, in his large experience of General Paralysis, discharged several apparently recovered. The first case was admitted ou 14th September, 1869, aud was marked, not only by the usual delusions, but also by twitches of facial muscles, tremor of upper lip, thick speech, and weakness of the knees. He was also violent and destructive. Under good diet, rest, and Sjt. Quin. et Ferri Phos. and Strychnia he gradually calmed down, became quite rational, and lost all abnormal symptoms, except the tremor of lip, and a slight thickness of speech. He was ill for three months, and was kept under observation for six months before he was discharged. August, 1878. He is still alive and in good health, drawing his pension regularly. In the second case, the patient, set. 32, was admitted in March, 1870, and had a history of being very restless and talkative on board his ship, boasting of his vast riches and wonderful adventures. His account of his age aud pre\'io\is mode of life was incoherent and conti'adictory. In the hospital to which he was sent, the report states that he was, by night, singmg and shouting and very destructive, and ou the 5th October he had a paroxysm of maniacal violence. On admission he laboured under numerous exalted delusions, such as that he was king of the world, that his brothers were kings, and that he possessed untold riches, millions in every bank, and that he had power to do whatever he chose to undertake. His speech was thick and articulation at times difficult, his gait very unsteady, his habits dirty ; the tempera- ture 98° in the morning, and 99° in the evening. Given such symptoms as the above, every medical psychologist's prognosis would be to the last degree unfavorable; yet, after being under treatment until March, 1871, he began to improve, the exalted delusions entirely passing away. The thickness of speech and difficulty of articulation, however, remained, although in a less degi'ee, and it was also observed that if he tried to lift anything hea-v'y his legs failed him, and this want of power he acknowledged. He remained under observa- tion until March, 1872, when he was discharged, and at the time Dr Macleod gave us the foregoing particulars (October, 1872), was well and pro-\dding for himself and family. June, 1873. Condition satisfactoi-y. August, 1878. Drew his pension mitil some time in 1875, when he was lost sight of, having either died or left the coimtry. Another of Dr Macleod^s patients was admitted June 27th, 1876, labouring under restlessness, debility, tremor of lips aud facial muscles, speech thick and hesitating, various exalted delusions. On July ord he had a severe epileptiform fit, fol- lowed by twitching which continued at intervals for three days. On recovery from the fit he was found to have lost the use of his right side, but had become quieter and more rational. From this time he steadily improved in body aud mind. By May, 1877, he had improved both in gait and speech, and was free from delusion. This continued, and he was discharged November 29th, 1877, the only symptom of disease being slight tremor of speech. He remains seemingly well (September 1st, DUEATION OF GENEEAL PAEALYSIS 331 1878). Time alone can show whether this patient really re- covers. The remissions in General Paralysis are certainly among the remarkable features of this remarkable disease. Of the 341 cases of patients admitted at the Devon Asylum tabulated by Dr Burman^ 12 were entered as discharged^ '' re- covered.^-" Two returned and died. Of the after history of 9 nothing seems to be known. One stilL remaining out is the case referred to by Dr Bucknill in his ' Annual Report/ 1862, where he states that " this was the only case he had observed in which there was no affection of the mental functions^ and the only case he had known recover.^' Of 924 deaths at the Somerset Asylum, Dr Boyd found 18 per cent, to be cases of General Paralysis. Dr Burman found the ratio to be 18i per cent, for thirty-sis asylums in Great Britain in 1869, and of the cases dying at the Devon Asylum, 19"45 per cent. (Op. cit.) The average duration of the disease is generally estimated at about thirteen months, but we think this is quite too low. Patients rarely live more than three years after the develop- ment of well-marked symptoms. That they do live much longer the following cases show : The writer saw a case at the Eoyal Naval Hospital at Yarmouth in 1872 tinder Dr Macleod's care, the symptoms having first manifested themselves upwards of eight ^ears before. The patient lay on a water bed, perfectly helpless, extremely ema- ciated, and unable to articulate a word. Age 37. He could move his arms fi-eely, but not his legs, and could drag them up towards him when the soles of his feet were tickled. Appetite voracious. There seemed no evidence of any mind being left, but Dr Macleod said he believed he knew his attendant, who had waited upon him three years, and that there were more signs of intelligence than six months ago. A glance at the past history of this case furnished by Dr Macleod well illustrates the most important features of this form of mental disease. When serving as engineer on the Mediterranean Station in 1864 he had decided delusions with occasional convulsive attacks, probably epileptic ; he was, after a short time, sent to England, and was soon able to attend to light duties at Portsmouth. In the following year he proceeded to China in a man-of-war, but completely broke down before he reached the Cape of Good Hope, giving expression to delusions of an exalted character about his riches and the amount of money in the bank. In December, 1865, he was invalided at the Royal Naval Hospital, Cape of Good Hope, for " Dementia and General Paralysis," and arrived in England, May, 1866. In the course of a month he was sent to the Royal Naval Hospital, Yarmouth, when his symptoms were as follows : — Too demented to give any account of himself. Memory completely gone. Much tremor of upper lip on attempting to speak ; speech thick ; articulation difficult. Tremor of tongue, which he protinaded with great difficulty. Very unsteady on his legs. Pupils acted regularly. Appetite very good; considerable emaciation. Rests well at night. Habits cleanly. By the end of the year he had become stout, weighuig 16 st. As he increased in size, he evidently became even S32 ETIOLOGICAL FORMS OP INSANITY more demented; his appetite diminished. Very difficult sometimes to understand what he uitended to say. Motor power m lower extremities less. In January, 1867, he suffered from epileptiform convulsions, after which it was observed that the motor power had considerably diminished, and he could no longer stand to wash himself, without assistance. He went on till the end of the year quiet and inoffensive, by day, sittin"- in the mess-room in an easy chair, or when the weather was warm, he was removed to the airing ground. He became wet and dirty in his habits. Weighed 14 st. A note in 1868 says, " He is now confined to bed, as when sitting up he was constantly attempting to walk and was in danger of injury from falls." In May he was f omid to weigh only 11 st. Refused food, and required stomach-pimip. Excited and noisy, saying as well as he could, that " he was King of England, and how dare they retain him in bed,'' and attempted to talk about dollars, money, and the bank. By the end of the year he was helpless and extremely emaciated. In 1869 he stiU talked about his riches. In 1870 the note occurs that, although unable to speak or walk, he nevertheless shouts and howls, and in 1871 that he requires constant atten- tion to keep him clean and dry. Thighs bent upon abdomen, and legs bent under the thighs. Epileptiform convulsions occasionally occur. June 14th, 1873. — After an attack of epileptiform convulsions his swallowing became very defective ; on the 18th he was free from twitches, and his swallowing had improved. Jmie 27th. — Very destructive, tearing his bedding j this passed off after a dose of castor oil. Aug. 3rd, 4th, 5th, and 6th. — Twitches in different parts j swallowing so much affected that he can only take liquids. Aug. 7th. — No twitches, is again able to swallow solid food ; throughout the rest of the year he was occasion- ally attacked with twitches, during which attacks, and for a short time afterwards he swallowed with great difficulty ; mind a perfect blank. 1874. — No apparent change, except that the swallowing gradually became more difficult, and he could only swallow fluid food. ;[875_ — From Jan. 1st the twitches became very troublesome, and he rapidly lost his remaining strength, dying Jan. 16th. This patient toas ten years under the disease, and seven years confined to bed; during most of that period he passed all his excretions in bed. By constant attention to cleanliness, it was found possible to keep him quite free from bed-sores. In the same dormitory, the writer saw a patient, (G. H.), a boatswain, set. 40, who was admitted six years before, with decided symptoms of General Paralysis and Dementia. In 1874 he was permanently confined to bed, as he had become so weak on his legs and dirty in his habits. Epileptiform convulsions come on frequently, and during 1875 and up to the July, 21st, 1876, the day of his death, he was supported by fluid nourishment, given very slowly on accomit of the increased difficulty of swallowing. We may add to the foregoing that, out of 271 cases admitted into the Devon Asylum, only 7 lived more than four years after admission. In 38 cases the total duraticii of the disease was ascertained, and the average proved to be one year and nuie months. With the female patients the dm'ation was one year longer than with the male patients (' West Riding Asylum Reports.' vol. i, p. 139).* * See also the Chapters on Diagnosis and Pathology. Of the large mass of literature bearing on this malady we may refer the reader to the following, in addi- tion to the works of Haslam, Delaye, Bayle, Calmeil, Perchappe, &c., mentioned in the Chapter on Pathology : — ' Ti'aite pratique des Maladies ner%-euses,' par Sandi*as, 1851. "Paralysie progressive," art. in the 'Diet, des diet, de Med.,' par Brierre de Boismont, 1851. ' Recherches sur la Folie paralytique,' par Jules Falret, 1853. INSANITY AND OEDINABY PAKALTSIS 333 Insanity following apoplexy, and usually accompanied with ordinary paralysis. This section comprises the division made by the International Congress of Alienists in 1867 (see p. 45) to include mental disease induced " by organic lesions of the brain^ presenting as almost constant symptoms hemiplegic occurrences more or less prolonged/^ and to exclude general paralysis and senile de- mentia. The mental condition was called '' organic dementia/^ in the classification above referred to. As interesting from an historical point of view^ it may be stated that Burrows in his Commentaries (1828) made the obser- vation that no malady is so intimately connected with mental derangement as apoplexy and ''Hhe extension of the apoplectic attack/^ paralysis^ but he added, " its afiinity is recognised in the twofold light of cause and effect." He says that comparatively few cases originate in apoplexy, and points out that this form of apoplexy is essentially different from that which terminates the life of the insane. " Sanguineous apoplexy is the species commonly originating Insanity ; and those in whom the san- guineous apoplectic diathesis prevails may be considered as almost equally possessing the maniacal diathesis ; it is difficult to pronounce which attack is most threatened If the attacks of apoplexy are slight and often renewed, the mind is very prone to extreme irritation and aberration ; when stronger and a partial recovery takes place, Insanity is sometimes tem- porarily, sometimes permanently, developed.'^ With sangui- neous apoplexy as a cause, he contrasts serous apoplexy as an effect and termination of Insanity. Burrows speaks of " the peculiar species of paralysis which Bayle describes " (General Paralysis) as quite distinct from the cases of Insanity originating in apoplexy to which he refers. The usual form for mental disease to assume when it follows apoplexy involving injury to the motor centres as indicated by Dr Wilks in ' Guj-'s Hospital Eeijorts,' 1866, and in ' Joui-nal of Mental Science/ where articles by Sankey, Clarke, Westphal, Meschede, &c., will be found. ' Recbercbes sur la Paralysie generale progressive,' par M. Doutrebente, 1870. " De la Paralysie generale par Propagation," par Dr. Ach. FoviUe, 'Annal. Med. Psych.,' Janvier, 1873. The late Dr Bell, of America, writing in 1844, said, it was only within three years that patients had been admitted into the McLean Asylum labouring under General Paralysis. On looking over the register of past years he could not find a case, the description of which resembled the "manifestations so graphically described by many English and Continental authors." 334 ETIOLOGICAL FORMS OF INSANITY hemiplegia, &c., is dementia. A man, 'past middle age, has an apopletic attack followed by paralysis. His mental health does not immediately suffer, beyond an impairment of memory ; there may also be aphasia. Before long, however, some weakening of the mental powers is observed ; unusual irritability is evinced ; odd fancies or even delusions manifest themselves for a time, but are after a while merged into the demented condition which sooner or later supervenes. More cases having this common history are to be found in hospitals, workhouses, and among the better classes in private homes, than in asylums. In tlie appendix to Dr Skae's ' Annual Report ' for 1871 is recorded the death of a female patient who some years pre\-iously had a paralytic seizure. After a period of good health, Dr "Wright states that Insanity came on gradually. The symptoms were general failure of the mental powers, manifested by a blunting of the perceptions, impairment of memory, general nervous restlessness, and mental irritability, and, finally, another attack of paralysis with aphasia. A post-mortem i-evealed softenhig of the anterior part of the right frontal lobe, which Professor Turner regarded as of long standing. We have seen a hemiplegic patient at Bethlem Hospital, under Dr Williams, the report of whose case by Dr Savage, in the ' Journal of Mental Science,' January 1878, we avail ourselves of in the following summary. A. A — , jet. 59, sober. Father and mother died of apoplexy. Patient was seized in January, 1875, with apoplexy, right hemiplegia, and complete aphasia. Recovered in six weeks sufficiently to resume professional work. Had a slight attack, chiefly con\'ulsive, in the following June, and a very severe fit in February 1876, in which he vomited and was again comnilsed. Was in bed several weeks, and then began slowly to regain strength. He was markedly weaker in mind, got about again, but was no longer equal to his duties. In October, had another extremely severe fit, and was speechless. During the next six months he improved greatly in general health, and was generally in a placid, weak-minded condition. He was, however, irascible, and at times noisy, and as he regained power was more difficult to manage, and became restless. Admitted, May 1877, the certificates stating him to be weak- minded, at times violent, at others tearful and emotional. He would shake hands with perfect strangers as if he knew them. Habits clean. Always a smile on his face. He only said " yes," or " yes dear," if questioned, and did not seem to under- stand much that was said to him. He would listen as if he understood, but he could never he got to do things by way of command. Forgot an. object he was asked to fetch before he got to it. Ophthalmoscope revealed pallor of both discs, the small vessels being in strong relief. In left eye, the large vessels were surrounded with lymph or connective tissue here and there. Sphygmogram showed high tension, but rather of a rigid than ^fv.ll vessel. For six weeks he improved greatly in general appearance, and seemed cheerful. He learnt no new words, and was weak-minded as before. Was friendly with anyone. In July he had a fit which affected his limbs generally, and he could not ai-ticulate at all for an hour after, but was soon himself INSANITY AND ORDINARY PARALYSIS 335 again. In September he was found on his left side, vomiting and unconscious, with left hemiplegia, his right fore-arm waving to and fro. Sensibility of right, but not of left conjunctiva. Reflex action of right foot, but not of left. Pupils small and equal. Pulse 120. Temp. 97°. Next day he was unconscious and quite hemiplegic. Died in 48 hours. Post-mortem. Dura mater adherent throughout ; excess of sub- arachnoid fluid ; convolutions flattened on both sides. Blood effused on surface of right side of cerebellum. Pia mater and arachnoid easily separable fi'om brain, left half of brain most wasted. Dr Savage considers the first attack of aphasia which was transient, to have been due to pressure, while in the attack which caused permanent aphasia, a large clot destroyed an important part of the frontal convolu- tions, rather cutting off the coimection with the " island of ReU," than injuring it ; the dementia being the result rather of general degeneration than of a spreading of inflammatory processes fi'om local centres of degeneration. There are cases again with, a distinct cerebral attack^ accom- panied by loss of consciousness,, which are very different both in their physical and mental symptoms. Such a case as the following is suggestive of syphilis^ but as no syphilitic history could be made out, it is given here. We examined the patient in the Bootham Asylum, York, and are indebted to Dr Needham for allowing us to consult the case-book and make use of the particulars entered there regarding his history and symptoms. The patient, a clergyman, when ofliciating in the pulpit, had " a fit ;" he lost his consciousness, and from that time the pupU of the left eye became widely dUated, and ptosis of the left eyelid has remained. He was hereditarily predisposed to mental disease. Decided symptoms of Insanity (irritability, and loss of sleep) did not declare themselves until more than five years afterwards. His fiiends, however, distinctly connected the seizure and the mental disorder. He manifested some tendency to suicide, and on admission to the asylum in 1862 (st. 40) he was in a state of partial dementia with delusions. He would sometimes refuse to answer questions ; at other times he would be cheerful and loquacious, and reply coherently although childishly. The sensory phenomena were striking. He constantly aflirmed that he was dead, that he had no legs, arms, or body, that he only weighed six pounds, and was but two years of age, that he had no sleep for two years, and that he could not either speak or move. Yet, if questioned respecting his former life he would give a correct account of the various changes which had befallen him. His memory of former events seemed to be unimpaired, but for recent incidents none whatever, not being able to recollect how or when or by whom he had been brought to York. Volition was almost nil. He could be led and persuaded like a feeble child. In early life he was of strong mind and body, and at Cambridge he graduated with high honours. His general appearance is described as one indicating serious organic disease of the brain. There was no hemiplegia, but there was a general loss of muscular power. He was wet and dirty in his habits. He improved remarkably under good care and treatment, and had considerable liberty granted him in his walks outside the asylum — a privilege which he, however, abused by coming home drunk. He was always a free liver. When seen by the writer (ten years after admission) the prominent symptom was paralysis of the third nerve, as indicated by ptosis of the left eyelid and extreme 336 ETIOLOGICAL FOEMS OF INSANITY dilatation of left pupil. He could see with both eyes, but imperfectly with the left. Tongue not tremulous (appeared on admission to be so) or devious. He spoke well and walked fairly. Beyond a narrow range of ideas there was nothing very striking elicited in conversation. September, 1878. — In the same condition, physically and mentally. Epileptic Insanity. Wc hare had repeated occasion to refer in the course oE this work to states of Insanity complicated with epilepsy, especially in the sections on Moral Insanity and Homicidal Mania. See pp. 252, 259 — 61. The subtle influence of epilepsy or rather of that condition of the nervous system which gives rise alike to epileptic seizures and certain mental symptoms, if strikingly shown in the loss of memory, is perhaps still more remarkably manifested in the change which takes place in the moral character, either permanently or during a brief period of mental epilepsy with or without convulsive seizure. In a large number of cases, the actual or comparative sanity of the patient for considerable intervals of time, the freedom from irascibility, passion, or violence, when removed from circumstances calculated to irritate, render it difficult to place such persons under restraint until an act has been committed which necessitates sequestration. It is to be observed that very frequently the presence of Epileptic Insanity is indicated, not by epileptic fits, but by the character of the mental disturbance, the paroxysmal gust of passion, the blind fury, without an adequate cause. Although, however, there are not ordinary epileptic fits, there are certain physical signs subsequently referred to. As experience shows that the mere epileptic vertigo or _2Jef/i mal is quite as dangerous to the integrity of the brain as the grand mal (and even more so), the very cases in which the most serious consequences follow, are often those in which it is the most difficult to prove that disease sufficiently accounted for the act. It is customary to speak of a Masked Epilepsy, the " Epilepsie larvee^^ of M. Jules Falret,* and (subsequently to him) Morel,t * " L'invasion de ces etats subite, la perte de la memoire les suit toujours ; les actes sont instantanes, d'une violence exceptionelle ; les hallucinations sont terrifi- antes, et k tons les acces, c'est toujours la meme succession de phenomunes." ('Annales,' Jan\aer, 1873). t " Les etats d'epilepsie larvee sont accompagnes de symptomes pai'ticuliers, parmi MENTAL AUTOMATISM SS/' marked by eccentric acts or a sudden paroxysm of violence without a distinct epileptic seizure. In the following case^ unmistakable epileptic j&ts occurred at one period of the patient^s life^ while at another maniacal symptoms took their place. In the ' St Bartholomew's Hospital Eeports ' (1870), Dr Thorne reports a case of epilepsy marked by ordinary convulsive attacks, but interesting from there being also from time to time attacks of mental excitement, which appeared to take their place. Though a temperate and well-conducted man, he would in these states seize a knife and declai'e that he would kill his children. After the paroxysm terminated, he would be quite oblivious of what had occurred. At another time he would steal. " On one occasion he was observed to be suffering from considerable mental dulness, and on his person were foimd parcels of violet and other scented powders, which he could have had no object in purchasing, and of which he declared most emphatically that he knew absolutely nothing." Dr Hughlings Jackson thinks it probable that when mental symptoms appear to take the place of a fit, there is a transitory epileptic paroxysm, although admitting that occasionally no signs of a prior fit are discoverable. " All kinds of doings after epileptic fits, from slight vagaries to homicidal actions, have one common character — they are automatic ; they are done unconsciously and the patient is irresponsible. Hence I use the term mental automatism ... I believe there is in such cases, during the paroxysm, an internal discharge, too slight to cause obvious external effects, but strong enough to put out of use, for a time, more or less of the highest nervous centres . . . The automatism in these cases is not, I think, ever epileptic, but always post-epileptic." {' West Riding Medical Reports,' 1875.) Many cases are given showing that elaborate and highly compound actions may be performed when a patient is unconscious, and their bearing on criminal acts is clearly pointed out. It must not be supposed, however, that the patient may not afterwards be aware that he has been under a delusion or impulse, and deeply regret what he has said or done. There are, no doubt, in different cases, different degrees of recol- lection. Thus an epileptic, at the Wakefield Asylum, knowing well how he had acted after a fit, told us that he was very sorry for having abused Dr Major. When admitted, he mani- lesquels se trouvent au debut, I'instabilite excessive du caract^re, la mobilite ; plus tard les transformations du delire, les actes instantanes, se reproduisant avec une veritable periodicite. J'ai signale aussi les bruits eclatants que les malades entendent et qui ne ressemblent en rien aux bruits dont se plaignent les delirants persecutes ; il y a la quelque chose de tout special " (Morel, idem), 22 338 ETIOLOGICAL FORMS OF INSANITY fested absolutely no mental symptoms^ but tlie conclusion was formed^ based on his history and his own admissions, that at the time of his fits he would probably manifest violence. One day he had a mild fit while conversing with a fellow patient and friend, a rational and truthful patient, who stated that he threw up his eyes and was slightly convulsed, but very soon regained consciousness and did not fall. Immediately on re- gaining consciousness he swore frightfully at his friend, accusing him of assaulting him, &c. The next day he had two fits, and then violently assaulted an attendant without the slightest cause, and soon afterwards, when seen by Dr Major, heaped every sort of abuse upon him, accusing him of blowing dust into his eye, &c. A day or two afterwards he came to himself, was conscious of his hallucinations and apologised for his violence and rudeness. There may, as in other forms of Insanity, be a motive mixed up with an insane condition. " The premeditation, the calculations, and the motives of revenge which in some rare cases control the accomplishment of the misdeeds of Epileptics, might lead magistrates to erroneous views ^^ (Falret). The absurdity of supposing that motive and calculation imply necessarily free will or soundness of mind has been insisted upon by Echeverria as well. The exalted religious sentiments in epileptics pointed out by Morel (' Traite des Maladies Mentales,' 1860, p. 701) have been recently studied by Dr Howden, the Superintendent of the Montrose Asylum {' Journal of Mental Science,^ Jan., 1873) in a number of interesting cases displaying strong devotional feelings, in striking contrast with the homicidal propensities we have mainly referred to. We give the following (curtailed) : .J. A — , set. 13, a good-looking intelligent boy, who, though an epileptic from infancy, has none of the physiognomic characters of the disease. During his lucid intervals he is active and intelligent. After the fits he becomes excited, subject to delusions, and given to wander, and exhibits strong amorous propensities. On admis- sion he told me he was Adam bom again into the world. When questioned as to his previous life in the Garden of Eden, he replied that he had been so long dead that he could not be expected to recall particulars, but added that it was perfectly true that he had eaten the forbidden fruit, and when asked why he had done so he replied, " Its all very well to blame me, but you would have done just the same thing if you had been in my place." He pointed to a picture of a woman on the wall which he said was a portrait of Eve. He says he has been in Heaven, and describes what he saw there. He has been in the Asylum now for two years, has fits every two or three weeks, and on recovering from them he is dull and stupid ; then he becomes possessed of some extravagant delusions, always of a religious nature. 'When ques- RESPONSIBILITY OF EPILEPTICS 339 tioned as to the ground of his belief, he generally says that it has been revealed to him, and that he feels it is true, pointing with his finger to his epigastrium. Dr Orange has recorded in Ms ' Eeport ' of Broadmoor, 1877, the case of a woman subject to epileptic seizures, more especially at and about the catamenial periods. She had violent and slight fits, but during the latter she scarcely lost consciousness. The circumstances of her act of wounding were referable to one of the more violent attacks. She rose up from her chair one morning with her baby in her arms and went to cut some bread for the elder child. Having got the knife in her hand for this purpose she had an epileptic seizure, and during the uncon- sciousness she cut her infantas hand clean off, and was found insensible by the neighbours. She had no recollection of the circumstances after getting possession of the knife. On two occasions when in these attacks, she had fallen into the fire, and once she had cut her own thumb. A large number of cases in our Asylums have passed beyond the transient and delusional forms of Epileptic Insanity, and having gradually succumbed to mental deterioration, are examples of hopeless Dementia, subject to " fits " and attacks of maniacal excitement, Dr Adam Addison, (" Clinical Notes regarding Epileptic Insanity," ^Journal of Mental Science,^ April, 1866), states, that of 41 epileptic patients in the Montrose Asylum, 21 were, and 20 were not, paralysed. The mean internal heat of the body was 98'9 ; the highest being in those who had suffered from fits in the day. Of 32 cases examined, the pulse was of normal fulness and firmness in 23, and feeble in 9. In 50 cases, loss of consciousness was the first symptom in 39; 27 bit the tongue during fit ; 30 uttered cry before fit -, 48 fell during fit ; 15 had fits during the night only, 35 both day and night; 3 did not have comatose symptoms. Of these, 13 were always irritable and vicious ; 13 hefore the fit, 26 after the fit ; and in 4 there was no mental change. Dr Addison found the urine greatly diminished when fits were severe and attended by mental excitement. The sp. gr. was high, with abundant lithates and diminution of chloride of sodium, urea, phosphoric and sulphuric acids. Is an ordinary epileptic to be always regarded as irrespon- sible ? No. If, however, it cannot be said that he is irre- sponsible, yet the fact of being subject to fits must form a. very strong presumption in his favour. 340 ETIOLOGICAL FORMS OF INSANITY Tardieu reports the case of a man who had smuggled goods to a large extent and was pursued by the custom house officers. He killed two of them. He was proved to be subject to epileptic fits. It must be admitted that in such a case the amount of a man's responsibility ought not to be rated so low as that of the man who is impelled during an epileptic seizure (however transient) to commit an unprovoked act of violence. " The lawyer '' as Echeverria forcibly says, " may persist in falling back in cases of Epileptic Insanity, upon the operations of a sane intelligence in order to judge the motives of a criminal act when committed by an epileptic ; but for an alienist it is certain that the victim of a disease which takes away from him all control over himself, even when he remains capable of distinguishing between good and evil, cannot be held responsible for acts which he accomplishes without will, and in an auto- matic and therefore unconscious manner." The following are sphygmographic tracings which Dr Thompson has published in the ' West Riding Asylum Reports,' vol. ii. They resemble those taken by Echeverria in the stage of coma and shortly after (^ On Epilepsy,' 1870). Pig.23 exhibits what " may be accepted as the type while the epileptic 'status' exists. . . attributable to a lax condition of the vessels." Fig. 23. Fig. 24 represents the tracing of the pulse of a man during a day on which the patient was seized with several fits. Fig. 24. EPILEPTIC INSANITY CLASSIFIED 341 Fig, 25. With these may be contrasted the tracings obtained by Dr Thompson from a colleague in good health (op. cit., vol. i). Fig. 25. In a paper* read at the Paris International Congress, 1878, Dr Echeverria gave the results of observations on 267 cases of unquestionable Epileptic Insanity, forming part of 532 carefully observed cases of Epilepsy. He lays great stress upon nocturnal attacks and vertigo, the latter proving more injurious than any other symptom, violent convulsions being always less frequently accompanied by Insanity. He found that Insanity arising sud- denly after the first attack in adults whose disorder could be traced to injuries to the head, intemperance, or syphilis, returned regularly at the end of other attacks. The association of paralysis with epilepsy was generally accompanied by marked intellectual change, with a progressive course, ending in Dementia. The most convenient classification was found to be into intermittent, remittent, and continuous, the first variety being characterised by fits exploding after intervals of more or less regular periods of sanity, the second by imperfect restora-" tion of mental health between the paroxysms, the third by persistent mental disorder, not changed by the attacks. The mental condition following attacks was often marked by a state in which the patients spoke or acted in an apparently rational manner, but found themselves in a condition of unconsciousness, that is to say, without the slightest knowledge of what passed around them, in short, a paroxysm of Mental Epilepsy, after day or night fits, or again without any prelude of physical attacks. The case of a young man is given, subject to petit mal, in consequence of a fall. One evening after an attack lie left home, and went in a cabriolet which he found stopping before a house, to the grave of his father, a mile and a half from Washington, where he gathered flowers to convey to his mother, whom he invited to go for a drive. When she asked how he had obtained the carriage, he answered that he had found it * For permission to use the manuscript after hearing it read at the Congress, of Mental Medicine, the writer has to express his obligations to Dr Echeverria, 342 JITIOLOGICAL FORMS OF INSANITY lost in the street. She ordered him to place the horse and carriage instantly in a coach-house, and seek their master. Instead of obeying, he appropriated them, and when the proprietor discovered them he pursued him as a thief. When before the magistrate next day he could give no account or explanation of his conduct ; in fact it was obliterated from his memory. Some months after, when at New York, he left home after one of his seizures, and roving about as a vagabond on the quays, he met an agent who engaged him as a sailor on a vessel about to sail to London. The agreement was duly executed, and after having left with this agent nearly all his money, &c., he embarked. The captain was not long in discovering he was no marine, and finding him very odd, forbade him to movmt the masts, and assigned him some light work. Three or four days after, the patient awoke out of this state of uncon- sciousness, and expressed the greatest astonishment on finding himself on board a vessel, and was unable to give any account of what had occurred. The mother discovered through the police the departure of her son, and took the measures necessary to place him in an asylum. There he had many similar attacks, preceded by nocturnal attacks and petit mal, until then unrecognised. In the intervals he was very gentle and reasonable, but during the attacks he was vicious, always in motion, and disposed to be violent. Dr Echeverria has yet to find a true case of Epilepsy with- out unconsciousness. It is more than patent in the stupor which Delasiauve regards as the characteristic of the disease. The intermittent form occurs ordinarily^ but not necessarily, with suddenness of the convulsions or is the avant courier. Sometimes the convulsions arise in the midst of the attack of Insanity as an intercurrent phenomenon, just as they do in Alcoholic Insanity. The intermittent mental attack may be developed spontaneously, without connection with the somatic attacks. The maniacal attack which accompanies the fit breaks out without an intermediate state of sleep or coma, is rarely dissipated in less than two or three hours, and may again appear one, two, or three days after the fit ; nor is it rare for intermittent Mental Epilepsy to reach its last stage without the least symptom of spasm. What Echeverria calls intermittent Mental Epilepsy is of course the same as the Masked Epilepsy of Morel and Falret already described, but his cases do not bear out the statement of the former, that in a shorter or longer time it ends in unmistakable epileptic fits as ordinarily under- stood, for many never had obvious convulsions at all to the end, when they often died of cerebral congestion with profound coma. The instantaneous acts of violence which usually mark such non- convulsive cases are thus, notwithstanding the absence of convulsion, transferred from an isolated form of mental dis- order to the category of epileptic affections, the proof of this lying in the patient's antecedents and certain physical signs, always remembering that the greater the epileptic excitement SYMPTOMS OF MENTAL EPILEPSY 343 and incolierenee, the less likely is it that there will be dangerous impulses or violence springing from hallucinations and morbid sensations which so often accompany mild and apparently inoffensive forms of Epilepsy. The important role played by hallucinations in Epileptic Insanity is shown by the fact that they were detected in 86 per cent, of the 267 cases ; namely, auditory 62 per cent. ; sight and hearing 42 per cent. ; smell 6 per cent. Lastly, 70 per cent, showed some troubles of general sensibility ; anaesthesia, hyperassthesia, &c., the false sensations taking usually the most terrible form. Athough hallucinations of hearing and sight are so frequent, it does not appear that patients suffer most from them, for they suffer an implacable torture from the state of their general sensibility, "in all the skin,^' as one patient de- scribed it, who struck the walls with his fists, and broke the panels of the door. It is most important to insist with Brierre de Boismont upon the influence of hallucinations in Epileptic Insanity, because they often lead to violent deeds. The symptoms on which most stress is laid are, irascibility, identity of character of the mental attacks in question, un- consciousness of acts performed, disordered cerebral circulation, vertigo with perspiration of the head, epistaxis during or after the paroxysms ; the morbid activity of the cervical sympathetic (to which Echeverria attaches much importance) being shown by lividity, injection of the conjunctiva, dilatation of the pupils, and a mass of whitish secretion in the palpebral angles, these symptoms being associated with a look of astonishment and hebetude. There is alternate dilatation and contraction of the pupils, the eyes widely opened when the patient becomes tumultuous, just as happens after attacks of petit or grand mal, lasting for about a minute. This epileptic pupil is regarded as betraying the doubtful or masked forms of Epilepsy, and cannot be feigned. Another symptom of value when associated with the others is slowness of respiration, the more marked the shorter the interval between the attacks. The temperature of epileptics, especially insane epileptics, was, in the cases on which these observations were based, generally below the normal one, in the interval of the fits, increasing always at their approach, along with acceleration and dicrotism of the pulse. Again, there was the period of profoundly heavy sleep of several hours, establishing the transition from insanity to sanity after Mental Epilepsy, as well as after the attacks of ren^ittent 344 iETIOLOGIOAL FORMS OF INSANITY and continuous Epilepsy, a sleep often mistaken for the sleep of drunkenness ; the more so from the epileptic usually recovering his consciousness quickly after waking. The result of many cases showed that Legrand du Saulle is too absolute in his state- ment that this sleep occurs only in those cases in which the patient had been previously intoxicated. In some cases the repetition of words and phrases, called by Echeverria " the Epileptic Echo," was a marked phenomenon, and is often strikingly shown in composition. In three criminals, Echeverria diagnosed Epilepsy, unsuspected at the time, but afterwards confirmed by subsequent observations at Auburn. The remittent and continuous forms of Epilepsy are usually marked by Dementia or symptoms resembling General Paralysis, and do not therefore give rise to difference of opinion. In the last-mentioned variety there are many exalted delusions, the main feature being confusion of thought and incapacity of action, rather than incoherence and entire inability to manage affairs. In the ^Journal of Mental Science,' October 1878, Dr Yellowlees has recorded the particulars of a case of " Homicide by a Somnambulist " (see very similar cases p. 266) which is closely allied if not identical with nocturnal Epilepsy. His mother died in an epileptic fit. Her father also died in *' a fit." The patient's maternal aunt and her son were both insane and a brother died in convulsions in infancy. On Epileptic Insanity, see "D'une Forme mal decrite de Delire consecutif i I'Epilepsie (stupidite epileptique) par Delasiauve," in the 'Annales,' 1852, p. 491; ' Du Delire iSpileptique,' by Hanshalter, 1853 ; Flemming's ' Psychosen,' p. 118 j Delasiauve's ' Traite de 1' Epilepsie,' 1854; Trousseau, 'Bull, de I'Acad. de Med./ t. xxvi, 1860-61 ; Palret, ' De I'etat mental des fipileptiques, Arcli. gen. de Med.,' December, 1860, &c. ; Morel, ' D'une forme de delire, suite d'une surexcitation nerveuse se rettachant a une variete non encore decrite de I'lEpilepsie larvee,' 1860 ; and especially Arthaud, " De I'etat mentale des epileptiques au point de vue medico- legal" (' Gaz. Med. de Lyons,' 1867) ; " Discussion sur I'epilepsie larvee," 'Annales,' Janvier and Mars, 1873 ; Echeverria " On Epileptic Insanity, and Violence and Unconscious States of Epileptics, in their relation to Medical Jurisprudence," 'Amer. Jour, of Insanity,' 1873 ; Baillarger, ' The responsibility of Epileptics ; ' the ' Med. Critic and Psych. Journ.,' vol. i ; Legrand du Saulle, ' La Folic devant les Tribunaux ; ' Castelnau on the ' Relations of Epilepsy to Mental Alienation ; ' Tardieu, ' Etude Medico-legale sur la Folic ; ' Dagonet, ' Des Impulsions dans la Folic ; ' Dr W. A. F. Browne, ' Epileptics, their mental condition,' ' Journal of Mental Science,' Oct., 1865 ; Dr HughHngs Jackson on ' Temporary Mental Disorders after Epileptic Paroxysms,' and ' Epilepsy, and the after effects of Epileptic Discharges,' ' West Riding Asylum Reports,' 1875 — 76; Dr Weiss on 'Psychic Epilepsy,' 'Allgemeine Zeitschrift fur Psycbiatrie,' 1878. SENILE INSANITY 345 Insanity from Old Age. Senile Insanity may assume in the first instance the form of Mania or Melancholia, but ultimately ends in Dementia, for description of which see " Senile Dementia,^^ p. 190. We may also refer the reader to an article by Dr Anstie in the ' Journal of Mental Science ' " On certain Nervous Affections of Old Persons '^ as having an important bearing on the Insanity of old age. In this article he observes that frequently allied with, but occasionally independent of insomnia and muscular restlessness is a peculiar state of mental irritability of the aged. " I am not now speaking of patients in whom there is mental alienation amounting to Senile Dementia. Far short of this, there is a phase of mental change in the aged, which is some- times inexpressibly trying to the patient himself, and still more to all those who are brought into contact with him. It may be said to consist in a peculiar perversity, a tendency to offer vexatious and frivolous delay and opposition to everything which is suggested by others, however important the occasion. This is the typical character of the mental state ; but in truth it shades off by imperceptible degrees into the form of Senile Dementia, with occasional or permanent delusions. They are just that sort of folk who insist on making pervet-se and un- reasonable alterations in their wills, when these had been settled long before in a just and convenient manner, or who quarrel in their last days upon some frivolous pretext with the friend of a lifetime.'' (April, 1870.) SECOND DIVISION.— DEUTBRO-PATHIC INSANITY. Insanity from Puberty. Pubescent Insanity. It is not surprising that so great a revolution of the system as that which occurs at puberty should exert a great influence upon the nervous centres, and should be attended by serious risk to their integrity. As a matter of fact, however, we know that our Asylums do not admit any considerable number of cases (we refer now to the male ^Qi) at the age of puberty* The 346 .ETIOLOGICAL FORMS OF INSANITY explanation is, that the abnormal mental condition which origi- nates in the evolution of the reproductive system at pubescence, is not usually manifested in a way which brings a youth to an asylum. He may be expelled from school for strange conduct, for stealing, or for dangerous impulses, but he is probably not regarded in any other light than a wicked boy. In the course of the next few years he gives infinite trouble to his parents, but they do not recognise his case as one of Insanity. To save repetition we may here refer to the remarks already made in the section on Moral Insanity. There are also cases in which, without moral perversion, there is great depression of spirits ; others in which there is a decided maniacal paroxysm, but such an occurrence must be regarded as rare. Those cases in which the moral character is mainly affected often prove to be epileptic; while those in which depression and disgust of life are prominent symptoms turn out to be illustrations of Insanity caused by masturbation, and will be spoken of in the next section. Insanity caused by Masturbation. Many years ago (1844) Dr Luther Bell, of the McLean Asylum, Massachusetts, and Dr Ray, pointed out in graphic terms this state of mental disorder as " a form of Moral Insanity." Sooner or later, however, decided delusions appear. The for^ mer described it as characterised by strong suspicions of threat- ened 'personal injury, of calumny experienced, of secret enemies, and analogous hallucinations, the patient at the same time evincing but little aberration in ordinary outward manner and conversation. " This type of disease," he says, " is so peculiar that it and its persumed cause are most generally correctly recognised on the application to the Asylum for admission, and before the patient is seen. The patient is committed with the strong anticipation that so slight a degree of Insanity can be readily and quickly removed. Vain hope ! Experience shows just enough of recoveries in such cases to prevent absolute despair, and no more. Nay, more, the progress of the mind is commonly downward ; more than in any other form of disease it is difficult to sustain the sufferer's self-respect, and to make him tolerably comfortable. Ordinary motives fall powerless upon him. If the delusions are few, the disposition is sulky, mis- chievous, and dangerous ; if many, they are always irritation INSANITY FROM MASTURBATION 347 and distressing. The hallucinations of these sufferers almost always run in a peculiar channel ; spirits or evil-disposed persons whisper through flues and wallsj or at the distance of miles, suggesting everything which is outrageous and insulting ; gases, and influences more etherial, are scattered around them to ren- der their existence wretched; nauseous matters are placed in their food ; their sleep is wantonly disturbed by gross personal outrages, and the like. They are subject to be driven to fury, and commit acts of violence, if some particular person is fixed upon as connected with their wrongs. They are also subject to impulsive acts of violence where no delusion can be presumed to have prompted them, and where, indeed, the patient, after the paroxysm had passed, is unconscious of any delusion ; he has committed the act of violence with no other explanation than that it crossed his mind to do it, and that simultaneously it was done. " Motives act scarcely at all upon these sufferers, except fear; higher appeals are powerless." {' Annual Eeport,^ 1844.) Dr Bell concludes this melancholy picture by expressing the opinion that (although the intellect is sometimes wonderfully little affected) the happiest thing that can happen for this class is to sink into Dementia. " Their own sufferings and those of their friends rarely have any earlier quiet." Schroeder van der Kolk has also well described this form of mental disorder. " If," he says, " one perceives in a young man a certain shyness, and an evasive and cast-down look, a dull irresolute character, which are soon accompanied by stupidity and confusion of head, and weakness of memory, then one must be mindful of this sad vice. In addition to this, there is an inconstancy of character and inconsistency of demeanour, ac- cording as the unhappy tendency is indulged without restraint, or as in some degree a check is put to it. The fear of man often arises ; they think that every one on the way looks at them, complain of it, allow themselves to be misled by all kinds of suspicion and perverted imaginations. If there occur, more- over, fanatical notions and self-accusations, then we can have scarcely a doubt as to the cause. "We find also, in general, an irregular circulation, the hands cool, yet bedewed with sweat, the head hot, especially the neck and back of the head and vertex. Biting of the nails, scratching of the fingers, from which numerous hang-nails arise, may occur in other forms of melancholy, but most frequently in this. The bowels are also sluggish, , . . The dull look isj for the most part, quite 348 ETIOLOGICAL FORMS OF INSANITY characteristic. The diminution of the intellectual power passes at last into Dementia. As a rule, it comes on more rapidly in young persons ; it also occurs more quickly and intensely in the male sex." C The Pathology and Therapeutics of Mental Diseases/ 1861-2, Eng. trans., 1870.) Lastly, Dr. Skae describes this vesania in words which all familiar with it will admit to be eminently truthful. " I think/' he says, " that this vice produces a group of symptoms which are quite characteristic and easily recognised, and give to the cases a special natural history ; the peculiar imbecility and shy habits of the very youthful victim ; the suspicion, and fear, and dread, and suicidal impulses, and palpitations, and scared look, and feeble body of the older offenders, passing gradually into Dementia or Fatuity." (' On the Classification of the Various Forms of Insanity,' 1863.)* Insanity from Uterine or Ovarian Disorder (in early or later life). In Dr Skae's classification, Utero- or ovario-Insanity is a term employed to designate the Insanity of old maids. Then, in addition, we have the mental disorders arising out of defective or irregular menstruation in early life. Dr Skae's " Amenorrhoeal Insanity " would, in this way, form a sub-class. Thus, at p. 261—2, we have described a case in which a homi- cidal impulse was due to disordered menstruation, as an ex- ample of " Uterine (Skae's Amenorrhoeal) Insanity." Many other cases of this kind will be found scattered throughout this work. Skae originally made Nymphomania a separate form of Insanity, but subsequently relinquished it. So far as such cases arise from affections of the reproductive organs, they may be referred to Uterine or Ovarian Insanity. Hysterical Insanity may be also merged into this aetiological division. Uterine or Ovarian Insanity 'proper might be retained for the form especially intended by Skae, in the cases mentioned above. " One of the most common symptoms is a sexual hallucin- ation — the belief that certain persons visit them and cohabit with them during the night, and other similar delusions." For description of Nymphomania, see p. 282, and the Ap- * See also Maudsley's " Illustrations of a Variety of Insanity," ' Journal of Mental Science,' July, 1868, INSANITY FEOM UTEEINE OE OVAEIAN DISOEDEE 349 pendix for a case (J. M.) ; also case of Acute Dementia from suppressio mensium (H. M.) In this connection we may observe that Dr Hergt^ of Illenauj regards deviations from a healthy state of the uterus which he has observed in a large number of female patients on post- mortem examination; as the first link in the causation of the attack of insanity. See the chapter on Pathology for some observations on disease of the reproductive organs^ including ovarian tumours. Under this section falls : Hysterical Insanity. The form of mental disorder in which uncontrollable excite- ment is accompanied by the symptoms recognised as hystericalj and which is known as Hysterical Maniaj is so distinctive in its features,, that the word is now of a symptomatological rather than, as originally intended, an eetiological character. Most vague, however, as is the term hysteria, its relationship to the reproductive system seems sufiiciently well marked to justify Hysterical Insanity being referred to its derangement. Professor Laycock, while, of course, insisting upon hysteria having its seat in the nervous system, lays it down as a principle that the " women in whom the generative organs are developed or in action are those most liable to hysterical diseases. Indeed, the general fact is so universally acknowledged, and so constantly corroborated by daily experience, that anything in the nature of proof is unnecessary.''^ (' Nervous Diseases of Women,^ p. 9.) The insane cunning which often forms a striking symptom of hysterical disorder of the nervous system is well described. " Of all animals,^^ he says, " woman has the most acute faculties ; and when we consider how these may be exalted by the iiifluence of the reproductive organs, there is not much ground for surprise at the grotesque forms which canning assumes in the hysterical female, although they have caused much speculation and aston- ishment. Insane cunning is usually exhibited in attempts at deception, but occasionally in a propensity to steal, or rather to steal slyly. It may be remarked that when it occurs, it is as much a symptom of hysteria as any corporeal affection whatever. It is a true Monomania, and is most likely to occur in the female who is hysterical from excess of sexual development, — one possessing the utmostmodesty of deportment, and grace of figure, and movement,^^ — a modesty springing out of that feminine 350 JETIOLOGICAL FORMS OP INSANITY timidity which is itself " a marked trait of the hysterical. The slightest noise^ or any fancied appearance of danger, is sufficient to excite alarm. Sometimes it accompanies paroxysmal affec- tions, or is a Monomania when it is exhibited in terror ; the patient fears she knows not what, will run somewhere or any- where, and utters the most wailful cries '' (p. 352-3). Those labouring under hysteria are described in a few words by Skae as presenting all shades of mental disorder, " from singular moral perversion, living without food, giving birth to mice and toads, passing all sorts of curious things with the urine, up to the long and singular forms it presents with varied sexual and erotic symptoms, until we find it presenting a truly maniacal aspect." On Hysteria in connection with Melancholia, see p. 229, and for a case presenting features of Hysterical Catalepsy, the next section. A case of catalepsy will be found at p. 239. " There is no border line," observes Dr Savage, " between insanity and hysteria." He refers to cases " that have for a time loss of control, who know that shouting and rushing about are unlady-like and improper, and yet give way to such conduct ; oases that if you can get a proper command over them can behave, and if judiciously treated, rapidly get well. We have (at Bethlem) many such cases associated with irregular men- struation or with the early onset of the catamenia. These cases exhibit every variety of mental symptoms. One will refuse to move without crutches ; another will insist on being fed ; one will remain always like a well-dressed doll, expecting to be noticed, but occupying herself in nothing but self-complacent introspection ; one case will eat rubbish, and another will read with the book upside down. Many such cases find their way into asylums, by a sad misfortune, I think ; for they are often so plastic and will-less, that they gradually get fitted into notches, from which it is impossible to move them. They suit themselves to their surroundings, and any attempt to force them back to the outer world is followed by an explosion that frightens friends and causes the patient^s return. It is difficult to fully explain the nature of these cases, for it will not do to say that they know they are doing wrong or foolish things and yet do them, for not only do many acute maniacs know what they are doing, but the great majority of sane people act as injudiciously in the most important actions of their lives. Yet the persist- ence of acting in a childish way is very characteristic of these INSANITY FEOM UTERINE OE OVAEIAN DISORDER 351 cases ; their general health, too, is good, or rapidly improves under regular care, and yet often, with this bodily improvement, there is no real mental gain. One variety of this hysterical mania is rather of an explosive nature — a girl rushes about, is rather fanciful than untidy in her dress and hair-dressing, is given to writing love-letters. Such cases may be often controlled by neglecting them as much and as judiciously as possible." An illustrative case is given which was interesting from the extreme degree of irregularity in her capillary circulation ; one hour she would be quite pallid and the next hour as crimson as possible. Referring to the opinion of the absence of mental weakening in hysteria, Dr Savage's experience confirms it in simple hysteria, but " there is always the danger that the hysteria is but the first stage, and that the patient may have an attack of Insanity following a longer or shorter interval ; some cases of Hysterical Insanity ending in death or dementia. Thus we had one girl who at 18 was admitted suffering from a noisy, boisterous mania; she knew all she was domg, and would at times control herself. She was soon cured, but next year returned profoundly melancholic, and died of phthisis. As to cure in hysterical cases, the explosive cases generally get well, but are very subject to relapses, and these relapses are very dependent on menstrual irregularity. The frequency of an inherited taint makes the case less hopeful, and marriage is a very dangerous remedy to recommend. A well-marked example is C. M — , who at 17 was admitted into Bethlem. At first she was rather depressed, but soon became noisy and amorous, always wanting to flirt in an affected way. She had a great idea of her powers of fascination. Her mother was insane. She rapidly got well, but soon made Bethlem quite a home. Tor some time she held to a delusion that she was married. She was discharged well after fifteen months residence. She kept well for four years when she was again admitted after the birth of her first child. Her symptoms were similar to those in the first attack, and again she is weU ,- but I fear if she continues to have children she will be subject to constant relapses, and that if she separated from her husband we should have no better result. C. F — , set. 19 when admitted. Was in Charing Cross Hospital for hysterical paralysis ; refuses food, and imagmes she has committed great crimes. Had distinct hysterical fits, and used to grow rigid when touched. Each attack of insanity was associated with amenorrhoea. Her first attack was so slight that she was not sent to an asylum. In her second she was six months in Bethlem, first desponding, then noisy and troublesome, and then rapidly recovering. Her third attack occurred after a love affair, in which she discarded her lover. Up to this time for three years she had been quite well. This attack was similar to the other, and she was discharged cured in six weeks, and followed the employment of a needlewoman till thirteen months later, when she again broke down and was in Bethlem, suffering as before, only more excited and violent, and the symptoms lasted for six months before she was well. J. D — , set. 20 when admitted, menstruation irregular. For two years had been subject to cataleptic fits ; she had delusions about marriage, was very erotic, and was at times most obscene in action and language. Medicines were of little use. She gradually improved, and although of an amorous disposition she got fair self-control, and was discharged well. Has had no relapse, though she has left nine years ago. Has married and had a family. 352 ETIOLOGICAL FORMS OF INSANITY G. s— , set. 19. She exhibited the restlessness, the tendency to dwell on love and marriage, and also the habit of lying, so common in these cases. It was also remark, able to see the variations in her capillary circulation. She slowly improved and got well, and has followed her occupation as a governess ever since. These cases that are considered as hysterical from the age of the patients and variability of the symptoms are common. Thus, each year six or seven per cent, of our female admissions are of this class. The percentage of cures is high in these cases, but it must not be supposed that all get well " (' Considerations on the Cures of Insanity,' p. 34-9). Insanity of Gestation or Pregnancy. Synonyms. — Insania gravidarum (Med. authors.) FoUe des Femmes Enceintes (Ft.) This disorder is not of frequent occurrence. Out of 2043 female patients whose form of insanity was ascertained by Rippingj of Siegburg, 64 or 3 per cent, arose during gesta- tion.* (Die Geistesstorungen der Schwangeren, Wochnerinnen u. Saugenden, 1877.) Of 383 female admissions, during ten years, at the Asylums of Eberbach and Eichberg, only four were attributed to pregnancy. It appears from some statistics, that cases of Insanity of Gestation occur chiefly about the end of the third or the beginning of the fourth month, the form of the mental disorder being Melancholia rather than Mania. (See article by Arnold von Franque, ' Wurzburgher Medizinisch Zeitschrift,' 1863.) In Ripping's cases, however, the fewest occurred in the third month, with the exception of the sixth. The numbers were much larger (and were equal) in the seventh, eighth, and ninth months. Griesinger attaches considerable importance to the influence of the emotions in the flrst preg- nancy, in those predisposed to Insanity. It is indeed a matter of surprise that more women do not become insane, under such altered circumstances, than is the case. We must, however, regard as abnormal mental states the morbid longings, pica, &c., of pregnancy. " Sly stealing,^' as Laycock points out, is a very characteristic feature of mental derangement from pregnancy. It should be added to the statement of the frequency of this form of disorder, in relation to female admissions, that its frequency in relation to puerperal and lactational forms was in 765 cases collected by Ripping, as follows : — 16'4 ; puerperal 50*6 j lactation 33 = 100. Out of 675 cases collected by * This includes the period of labour. INSANITY OF GESTATION OE PEilGNANCY 353 Gundry {' American Journal of Insanity/ 1860) 88 began during pregnancy^ 370 during tlie sixty days following delivery, and 207 during tlie period called lactational. Delivery may^ but often does not, exert a beneficial influence upon the mental malady. We do not refer to such, mild forms of mental disturbance as the above-mentioned " longings " of pregnancy, but to actual Insanity. Eecovery at the time of par- turition when it does occur often proves only temporary. Symptoms of mental disorder may arise during pregnancy and recur after labour. This occurred in the following case under the writer's care, in which the disorder assumed an hysterical form. When in service, a young woman, only 18 years of age, became enceinte, and abont a month after conception had " a fit," which appeared to have been hysterical in character. At nearly the full time of her pregnancy she was frightened by a thunderstorm, which caused her to be ill for several days mth pain in the head and vertigo. Eight days afterwards she suddenly fell down unconscious, burnt her hand in the fire, bit her tongue, and foamed at the mouth ; she was bled by the surgeon who attended her, and on the followed day a dead child was born. There were frequent attacks of convulsions during labour. From this time till a fortnight afterwards, when we first saw her, she was excited and incoherent ; the milk had soon been dispersed, and the lochia had ceased the sixth day. She was very pale ; pupUs dilated ; pulse 100, and weak ; tongue flat, furred posteriorly j bowels confined ; urine light coloured. She got very little sleep, and was always worse during the evening and night. Dui'ing the following week she made decided progress, though frequently " roaming and outrageous ; " then she had an hysterical attack which lasted about eight hours, apparently unconscious, but no convulsions. These attacks recurred several tunes, but she steadily recovered from her maniacal condition. At times she assumed a cataleptic attitude. The catamenia appeared two months after her con- finement. It should be added to the foregoing that an aunt of her father was the subject of suicidal melancholy, and that she had an uncle who was a desperate drunkard. Her mother attributed her daughter's insanity to having herself " fretted very much on account of her husband's illness and death " when pregnant. Of six cases of Insanity of Gestation reported by Leidesdorf (' Journal of Mental Science,' Jan., 1873), " four had already been mentally deranged before marriage. Pregnancy and the puerperal period heightened the mental disorder, and the patients passed into chronic incurable Insanity. In the course of a year one died in a condition of well-developed Dementia. In two cases the attack came in the form of Melancholia in the fourth month of pregnancy ; the one case underwent another excitement in the puerperal period, but terminated in recovery. The second case was a woman who in each pregnancy (this was the third) fell into a condition of considerable depression, with 23 S54 ETIOLOGICAL FOEMS OP INSANITY horrible hallucinations, and after delivery found herself re- covered/^ Dr Batty Tuke has reported the particulars of 28 cases of Insanity of Gestation, and observes regarding the period at which the attack occurred, that '' the fact is not without interest that the great majority of the attacks occurred at those periods of utero-gestation which are generally considered critical.'^ Three became insane during the third month, five during the fifth, one during the sixth, nine during the seventh, and one during the eighth ; a different result from Ripping^ s. The form of mental disorder was chiefly Melancholia. Out of the total number of 28, 15 were of this type, and 5 were in a state of Dementia with Melancholia. Nearly half either attempted or meditated suicide. In two unpromising cases there was Mania with exaltation. Moral Insanity was observed to be " by no means unfrequent, dipsomania being the most common symptom. This generally occurs during the earlier months of gestation, and is probably only an aggravated form of the well-known morbid craving or longing for particular articles of food which characterises the earlier months of pregnancy. As it advances it increases in intensity and gives rise to actual delusion and attempts at suicide. In two cases the moral per* version was evidenced by a homicidal impulse. ^^ In a case characterised by craving for drink, the woman became suicidal and so dangerous as to render the restraint of an asylum necessary. After three months^ during which her state was marked by moral perversion, sudden improvement took place ; she began to work, gave over lying and stealing, and her general demeanour was agreeable. She recovered at the commencement of the fifth month of pregnancy and was discharged. After her confinement the symptoms of melancholia reappeared, and she made a determined attempt at suicide. On readmission she was deeply melancholy, but under tonic treatment recovered, and left the asylum well. Three months after, having unfortunately become again pregnant, she manifested the same moral insanity as before, only with greater intensity. She also had delu- sions about her husband and neighbours ; so she continued until the birth of her child — a fine boy. Three months after her recovery from labotir the following note was made : — " No improvement in her mental condition. A more complete moral perversion could not exist in any one. She lies, steals, tells the nastiest stories without a blush, has not a grain of gratitude in her compositien, invents the most dangerous stories against those who have been kindest to her, and seems, in fact, to be an incarnation of evil. She became quite unbearable in the sick-room, so her baby was weaned, and she was removed to another part of the house." Again, four months after, " she broke a number of panes of glass to-day. Judgment, powers of reflection, and self-control, much impaired. Neat and tidy." Subsequently she again improved, and was removed by her husband ; but it has since been ascertained that, being again pregnant, her old malady has reappeared. She is now a patient in an asylum. (' Edin. Med. Journ.,' June, 1867.) tUERPSRAL INSANIW 355 Hereditary predisposition was ascertained in 12 out of the 28 cases. In 18 cases it was the first attack^ in 5 it was the second^ and in 2 the third. In 4 cases the patients were not married. As bearing on prognosis^ it may be stated that 21 of these eases recovered, 5 became dementedj 1 died, and 1 remained under treatment. Out of the cases reported by Ripping 34*4 per cent, recovered, 26*2 improved, o7'5 wereuncured, 12*5 died, and 9*4 remained under care — a much less favorable result than the foregoing. Puerperal Insanity (proper) Synonyms. — Insanity of Parturition. Insania post-far turn. Vesania fuerperalis (Med. authors). FoUe jpuer'perale, Manie puej-perale (Fr.) Fuerjperalwahnsinn (Ger.). Definition. — The term Puerperal Insanity, Mania, or Madness, is by different writers employed in a restricted or a comprehen- sive sense. If the latter, it is made to comprise — (1) cases occurring during gestation (see last section) ; (2) those arising within a period of about two months after parturition ; and (3) those due to lactation or weaning, especially the strain upon the system caused by the former when prolonged. It is here intended to imply by this expression the class of cases referred to in the second division, but it must be confessed that the line between the two latter divisions is often difficult to determine, and hence an observer will refer the same case to lactation which another refers to the puerperal state. Again, we, in any case, include under Puerperal Insanity proper, and exclude from the In- sanity of Lactation, the large proportion of cases which arise not only from labour itself, but from the excitement of the lac- teal system. If insanity arise in a woman who has been suck- ling about three months, we call it a case of Insanity of Lacta- tion, while if only two, we may perhaps call it a case of simple Puerperal Insanity. The distinction as regards time is therefore somewhat vague, and each case on the border line must be mdged on its own merits, as to whether it arises chiefly out of the puerperal state or the latter period of established lactation. We assume about sixty days for the former. General Remarks. — Puerperal Insanity is a disorder which from its importance merits special attentios. It invades the siek 356 ETIOLOGICAL FORMS OF INSANITY chamber at a time when it is most acutely felt ; nor is it, if we include mild cases, of very rare occurrence. The statistics of simple Puerperal Insanity are, however, on a small scale, those cases which arise fi'om lactation being usually included. Of 2181 female patients treated in the Eoyal Edin- burgh Asylum, in which the cases were distinguished by Dr Batty Tuke, 73 were examples of Puerperal Insanity proper, or 3*3 per cent. But this very imperfectly represents the number of occurring cases, because in many instances the patient recovers without being sent to an asylum. Out of 3246 admissions of insanity among women collected by Ripping, 211 or 6*8 per cent, belonged to this division — the proportion of cases of Puerperal Insanity in this its limited sense being 50*6 in 100 cases of general puerperal insanity. It is, certainly, a remarkable fact, as has been pointed out by Dr Reid, that, in lying-in hospitals, the number of patients who are so attacked, is very small. He states, that at the General Lying-in Hospital, Westminster, in which patients remain for three weeks after labour, out of 3500 who were delivered there, only nine were affected with Insanity. The experience of several other large institutions is to the same effect. We do not observe that Dr Reid offers an explanation. It might, perhaps, be accounted for by the very favorable circumstanes (quiet, good nursing, and sufficient nourishment) which surround the hospital patient, as compared with those of a patient of the same destitute class at her own home. Nor must it be overlooked that the absolute number of cases of Puerperal Insanity may be large, while, as compared with the enormous number of cases of labour, it may appear small. It may seem extraordinary that, in Esquirol's experience, patients of the higher class, among whom quiet, good nursing and sufficient food would not be wanting, suffered most from this malady. Here, however, these favorable circumstances may have been counterbalanced by others of an unfavorable description more or less connected with luxurious living. French statistics appear to show a larger proportion of cases of Puerperal Insanity than those of our own country, but they include cases occurring from lactation, so that it is not certain that, if a fair comparison were made, the results would differ. This must be borne in mind when Esquirol states that at the Salpetriere a twelfth and, during some years, a tenth of the female admissions were due to Puerperal Insanity. PUERPERAL INSANITY 357 With regard to the time at whicli the mental symptoms appear^ in the above 73 cases at the Eoyal Edinbnrgh Asylum, 20 certainly, and probably 27, showed signs of Insanity from the first up to the fifth day after labour, 36 from the fifth to the end of the fourteenth, and 10 or 11 from the fifteenth to the sixtieth day. Of 52 cases collected by Esquirol, the corre- sponding numbers were as follows : first period 16, second period 21, third period 17. Esquirol fixes on 60 days as the extreme limit of the lochial discharge. In 82 cases reported by Eipping, 6 occurred on the first day after delivery, or 7*2 per cent. ; 1 on the seventh day ; 6 on the third day; 35 or 42*6 per cent., during the first week; 22 or 26*8 per cent, during the second week ; 7 during the third week ; and 6 during each week following, namely, the fourth, fifth and sixth. From the above it will be seen that by far the largest propor- tion of cases occurred during the first fortnight after labour. Dr Burrows found the third and fourth day the most obnoxious to the disease. Of 66 cases reported by Dr Macdonald, formerly physician to the Bloomingdale Asylum, 29 became deranged within the first week, and 15 during the succeeding three weeks, that is, 44 cases during the first month. In the course of the second month 5 cases occurred, thus confirming the general rule that the danger diminishes as the distance from the period of parturition increases. Puerperal Insanity more frequently attacks females in their first than in their subsequent labours. Of the Edinburgh Asylum cases, the attack came on in 34 instances on the occasion of the first confinement, and in 16 instances on the occasion of the second. It is shown that " an increase of liability to Insanity exists between the ages of 30 and 40 in child-bearing women, and that first confinements occurring at that period are peculiarly frequently followed by true Puerperal Insanity.''^ In one case the patient had had Puerperal Mania three times before ; in four cases, twice ; in ten, once. In Ripping's cases (82) 24 were first confinements, 11 were second; 11 were third; 10 fourth; 6 fifth ; 5 sixth ; 5 seventh ; 4 eighth ; 2 ninth ; tenth ; 2 eleventh ; 1 twelfth ; and 1 thirteenth. The attack in 12 in- stances immediately followed the death of the child. Symptoms. — Although it must not be supposed from the usual expression '' Puerperal Mania ^' that Mania is the only form of 358 ETIOLOGICAL FORMS OF INSANITY Insanity which occurs in this condition, Melancholia, Delusionla Insanity and Dementia being possible results, yet Mania is undoubtedly the most frequently developed. In the 73 cases reported by Dr Batty Tuke, 57 presented the symptoms of acute Mania, 15 those of Melancholia, and one was a case of Epileptic Insanity. When cases of Puerperal Insanity (proper) assume the form of Melancholia, it appears that they are likely to prove recurrent cases of Insanity of Gestation; Mania, as we have said, being the usual form of Insanity arising after parturition. In Eipping's cases the majority assumed the form of Melancholia in a much greater degree than Mania during the first three days, namely 77 per cent, of the former, and 23 per cent, of the latter ; they exhibited the characters of Mania in the second half of the first week, and in the second week; whilst in the fifth and sixth week Melancholia again predominated. Some deny that there is any difference whatever between the character of the Mania manifested in the puerperal state and that of Mania arising from other causes. Dr Gooch makes the remark, that were any one conversant with mental maladies to be introduced to a patient suffering from Puerperal Insanity, he would not be able to tell, without inquiry, that the case was of puerperal origin. "As to the pretended special value of erotic symptoms," observes Foville, " M. Marce has demonstrated that there is nothing real in them, and we are entirely of his opinion." A strong suspicion as to the nature of the attack would, however, often be excited, putting aside the physical accompani- ments which would suggest the true state of the case. As Dr Macdonald says, " In the acute form of the Mania which succeeds parturition, we observe an intensity of mental excitement, an excessive incoherence, a degree of fever, and, above all, a dis- position to mingle obscene words with broken sentences — things which are rarely noted under other circumstances. It is true that, in Mania, modest women use words which in health are never permitted to issue from their lips : but in Puerperal Insan- ity this is so common an occurrence, and is done in so gross a manner, that it early struck me as being characteristic." In his evidence in the Mordaunt divorce case Sir James Simpson said : — " Self-accusations of impropriety were a common symptom of Puerperal Insanity. The organ diseased gave a type to the Insanity, so that with women suffering from it the delusions would be more likely to be connected with sexual matters." PCJEEPEEAL INSANITY 359 Among the cases at Bethlem Hospital, Dr Savage states that he has several times judged a case of insanity to be puer- peral, from the mincing gait and lascivious looks of the patient. Before the mental symptoms are fully developed, the patient becomes uncomfortable, peevish and restless, and cannot sleep ; the head aches, and there is an altered expression of countenance. Whether as cause or effect, the milk and lochia are often either diminished or suppressed ; the lochia more frequently than the milk ; the tongue is white, the bowels loaded, the urine generally scanty, and. Professor Simpson has pointed out, frequently con- taining albumen ;* the abdomen, in most cases, tolerant of pres- sure ; the pulse accelerated, and usually irritable in character, rather than febrile. There is, however, a class of cases in which the pulse and other symptoms indicate an inflammatory condi- tion of the system, and such cases are of a much more serious character. Dr Burrows noticed them chiefly in connexion with the first secretion of milk (on the fourth or fifth day) Some of these are examples of Phrenitis, and not properly of Mania, but of 16,444 cases delivered at the Dublin Lying-in Hospital, three only are reported by Dr Collins to have died of Phrenitis ; others are examples of inflammatory action going on in the peri- toneum, or other regions of the abdomen. Frequency of pulse is a symptom of primary importance. Dr B. Tuke in observing that when an inflammatory pulse is present, the prognosis must be most unfavorable, adds, '^ I am sorry to admit that in my experience, which extends to four cases complicated with internal inflammation, two of bronchitis, one each of peritonitis and pelvic cellulitis, the result was invariably fatal." As the patient attacked by puerperal madness becomes more decidedly insane, " the talking is almost incessant, and generally on one particular subject, such as imaginary wrongs done to her by her dearest friends j a total negligence of, and often very strong aversion to, her child and husband are evinced ; explo- sions of anger occur, with vociferations and violent gesticula- tions ; and, although the patient may have been remarkable previously for her correct, modest demeanour, and attention to her religious duties, most awful oaths and imprecations are now uttered, and language used which astonishes her friends ; the * In cases admitted at Bethlem Hospital, Dr Savage has rarely found albumen. In a woman who had a very acute attack after a miscarriage, albumen in slight quantity was detected, and wag present only during the period of excitement, 360 J^,TIOLOGI0AL FORMS OP INSANITY eye is wandering and unsteady, and the hearing most acute. The suicidal tendency is not uuconimon, especially in cases of Melancholia ; and it is important to recollect the fact in the treatment of such patients. In 111 cases of Puerperal Insanity at Bethlem Hospital, 32 were affected by it." (Dr Reid, in Psychological Journal/ No. 1, p. 135). A brief note or two of cases under the writer's care except No. 5, will serve to illustrate some forms of Puerperal Insanity. (1.) Mrs. C — was confined with her seventh child (a girl); labour perfectly natural. She had miscarried eighteen months pre%'iously, and had never menstruated afterwards. After the labour, the pulse was 80 and soft, the tongue clean, and the urine was passed the same evening. On the following day there was a fair lochial discharge, the pulse was only 80, and the skin was warm and moist, but she considered the supply of milk less than usual. On the third day the secretion of milk increased ; the bowels had been opened in the morning by me'dicine. The pulse rose to 100. Fourth day : had a restless night and was feverish during the day. Pulse 120, soft and compressible. The tongue, however, was clean. Fifth day : less fever, and thought herself going on well. Pulse less frequent, 108, very compressible ; tongue quite clean and moist. There was a good supply of milk, and the lochia were not unnatural in their character or quantity. No pain or tenderness in abdomen. The only thing she complained of was vertigo ; evidently requu'ed support. Sixth day : same. Seventh day : the writer was called to see her at 6 a.m. The change of expression was very marked. She was in a sluggish state, and replied very inco- herently to questions. It appeared that during the night she had been excited, talking nonsense, &c. The pulse was 120, full, but not hard. Tongue covered with a white fur, inclining to be dry; skin hot, but moist. The secretion of milk was now decidedly checked. The head was hot and had been very painful in the night; but the conjunctiviB were not injected, and the pupils were dilated. Towards evening the tongue became dryer, with a brown fur down the dorsum ; total inability to sleep ; increased confusion of mind, &c. The case was cleai'ly one of exhaustion, and was treated accordingly. Li two or three days the unfavorable mental symptoms passed away, and the patient made a good recovery. (2.) In the case of a poor woman who gave birth to an illegitimate child, tliis cir- cumstance and poverty conspired to upset her mind. The attack did not come on vuitil two months after her confinement. It was characterised by crying, laughing, and a total indifference to the baby. She was insane for about six weeks, recovering under morphia and iron. The child was weaned ; but the catamenia did not appear until five and a half months after recovery. The child had hereditary syphilis. The mother subsequently married. (3.) We had at one time a very troublesome case under care, one of Melancholia succeeding abortion, in which there had been alarming loss of blood. She was very anaemic, and for long the symptoms appeared to be little influenced by the pharma- ceutic remedies employed ; but she gradually improved. (4.) In another case, a woman, aged 37, had a child, and recovered well from her confinement. In about five months she became melancholic, absent, and was troubled with strange notions for which she was unable to accomit — scruples, suggestions, &c. She could not sleep ; she was pale ; tongue flabby and indented at the edges ; pulse frequent and feeble; skin relaxed; bowels confined; urine sometimes thick, some- times clear ; no appetite ; head cool ; conjunetivae pale. In about four months she PUERPERAL INSANITY 361 recovered under obviously indicated remedies, but was subject to hysterical attacks for some time after. (5.) J. A. L., set. 29, became suddenly insane a few days after her confinement. The symptoms were loud rambling talk, singing, hallucinations of sight, great excite- ment, insomnia, delusions, as that she had given birth to a young elephant. She was kept with ditficulty from injuring herself by jumping out of bed. On admission into St. Luke's Hospital, where Dr Mickley allowed the writer to examine her and obtain notes of the case, she was very noisy and reckless, tearing her hair off, and doing all she could to injure herself. She was pale, but well nourished. Had to be placed in a padded room. Abtmdant nourishment, and subsequently stimulants were adminis" tered. Sedatives also were given, but without procuring rest till the following day. The hands and wrists then became swollen and tense, along ■\\ath slight oedema of the ankles. Became quieter and more rational. Temperature very high; pulse rapid. Slight cloudiness of urine, tongue dry, papillae prominent. This patient became rapidly worse, the erysipelatous swelling increasing, the breathing becoming rapid, sordes appearing on the teeth, and the patient sinking on the seventh day after admission. No post-mortem. In the seven following cases the urine was tested for albu- men. A. B — had convulsions about six hours after delivery. The urine, which was smoky, was examined and found to be loaded with albumen and a thick sediment of lithates, sp. gr. 1040. The next day the fits were less violent, but she was quite maniacal, tearing up her clothes and otherwise misconducting herself ; evacuations were passed in bed. Was purged with calomel and croton oil. On the following day she was less excited and the fits ceased. At the end of the week she was convales- cent, and in ten days all trace of albuminuria had disappeared. There was in this case some oedema of the legs for a week before confinement. C. D — was attacked with convulsions during labour. The maniacal symptoms were more severe than in the previous cases, lasting ten days. The urine was albuminous, and remained so three weeks. She recovered well. In five mild cases of puerperal convulsions, a,ttended with a rapid pulse, a good deal of excitement, but no decidedly maniacal symptoms, there was no albumen in the urine, which was pale and of low specific gravity. These patients {primvparcB) recovered in about twenty-four hours. Sometimes a state of mental stupor succeeds — acute dementia, or what may turn out to be rather melancoUe avec stu^eur. There is apathy^ little apparent perception of what is passing around^ dirty habits^ a lost expression^ a tendency to catalepsy, and the patient may require feeding. .Etiology. — Hereditary predisposition is a striking feature of cases of Puerperal Insanity. Among exciting causes are mental shocks of any kind, distress of mind, especially in unmarried women, a tedious exhausting labour, flooding, and the use of the lancet for puerperal convulsions.* * A medical friend writes, " Two cases of convulsions occurred in my practice in one week whilst I was from home. Both were bled very freely at the time. On my return they were both maniacal (with no albumen in the urine). They were both 362 ^TIOLOaiOAL FORMS OF INSANITY Prognosis. — Very favorable, unless it assumes an inflammatory or typhoid type (see p. 137). The mortality in Puerperal Insanity is not large. At Queen Charlotte's Lying-in-Hospital, during 36 years (1828-63), the whole mortality from all causes (number delivered 7736) was 198. Of these, 16 were cases of Puerperal Mania. The mortality at Bethlem is stated to be 4^ per cent. Of the 73 cases at the Royal Edinburgh Asylum, 8 died, 7 became demented, 2 were discharged relieved, and 56, or 76 per cent., recovered. Ripping's experience at Siegburg was less favourable. Of 82 cases only 38 recovered (46'3 per cent.), 9 improved, 25 did not recover, 4 died, and 6 remained under treatment. If we throw these cases and the Edinburgh ones together, along with those at Wakefield mentioned below (a total of 193), we have a percentage of recoveries of 64. Of 38 attacks of Puerperal Mania occurring during the first month after labour, admitted into the West Riding Asylum (1869—72), 2 died (from a complication — Bright's disease), 31 recovered ; 5 of these being discharged in less than three months, 14 in less than six months, 6 in less than nine months, 3 in less than twelve months, and 3 in more than twelve months. Five remained under care, in an improved condition ('Medical Reports,' 1872, vol. ii, article by Dr Pedler). Dr Webster states, as the result of his statistics, that " three in every five cases of Puerperal Insanity may be confidently expected to recover within the year." Two thirds of Esquirol's cases were cured within the first six months after the com- mencement of th-e attack. Eighty per cent, of Dr Macdonald's cases recovered ; and out of 53 recoveries, 34 took place within the first six months of the attack. Brierre de Boismont asserts that cases of Puerperal Insanity (exclusive of Melancholia) have recovered under his care, on an average, in about a week. He has always found refusal to take food a bad sign. The number of months occupied in recovery at Bethlem Hospital in 58 cases of cures of first attacks of Puerperal Mania and 54 cases of Puerperal Melancholia has been ascertained by Dr Savage as follows : delicate and highly nervous subjects ; one was six months before she recovered her reason, the other twelve months." PUERPEEAL INSANITY. LACTATION 363 First Attacks of Puerperal Mania. Number of mouths before cure . . 1 2 3 4 5 6 7 8 9 10 11 12 15 18 Number of cases . 2 12 7943623 2 9 3 2 Cases uncured in from 12 to 18 months 13 Cases that died 7 (Three died of pyaemia j three of pulmonary tubercle j and one of Bright's disease). First Attacks of Piierperal Melancholia. Months before cui'e . 1 2 3 4 5 6 7 8 9 10 11 12 15 24 Number of cases .. 24779363225 13 Hencej the third month showed the majority of cases in Mania ; the sixth in Melancholia. To the above statistics it should be added, that they do not, as Dr Grooch and Dr Prichard have observed, lead to a prognosis even suflSciently favorable, inasmuch as cases are not usually admitted into asylums in a recent, and therefore the most curable stage of the disease. " Of the patients about whom," says Gooch, '' I have been consulted, I know only two who are now, after many years, disordered in mind, and of them, one had already been so before her marriage." See, in addition to Esquirol, Burrows, Gooch, Eeed, &c., the evidence in the Mor- daunt divorce case, ' Journal of Mental Science,' April, 1870 ; " Observations on Puer- peral Insanity," by Dr Boyd, idem, July, 1870 ; " A Contribution to the Study of the so-called Puerperal Insanity," by Dr J. T. Dickson, idem, Oct., 1870 j "On the Statistics of Puerperal Insanity," by Dr J. B. Tuke, 'Edinb. Med. Journ.,' May, 1865, and June, 1867 j ' Monographic der Puerperal-krankheiten,' Helm, 1840 ; ' Traite de la FoUe des Femmes enceintes, Marce, 1858 ; " Puerperal Mania," by G. H. Pedler, L.R.C.P,, in 'West Riding Asylum Medical Reports,' 1872, vol, ii; '• Observations on the Insanity of Pregnancy and Childbirth," by Dr Savage, iu ' Guy's Hospital Reports,' 1875. Insanity of Lactation, Synonym. — Insania Lactantium. Definition. — Insanity caused by lactation ; the period after labour being arbitrary, some fixing the minimum time at one^ others, like ourselves, at two months. As to its frequency, it may be stated that of 2181 female patients treated at the Eoyal Edinburgh Asylum mentioned at p. 351, 54 or about 2| per cent, were cases of Insanity of 364 ETIOLOGICAL FORMS OF INSANITY Lactation, using tlie term in the restricted sense already indi- cated. Ont of 2962 corresponding admissions collected by Ripping, 146 or 4-9 per cent, were referred to lactation. The proportion borne to puerperal cases in the wide signification of the term was 33 per cent. From Esquirol's total number of cases of Puerperal Insanity (in its widest signification) we rejected, when speaking of Puerperal Insanity proper, those which occurred after the six- tieth day, considering that these more properly belonged to the division of Insanity of Lactation. These cases amounted to 38, of whom half became insane a few days after a forced or volun- tary weaning, Esquirol observing that in his experience " nursing women, at least among the poor, are much more liable to become insane after weaning than during lactation." Sjrmptoms. — The physical symptoms are usually those indica- tive of bloodlessness — pallor, palpitation, headache, inability to sleep, sense of weakness and sinking, &c. Of 46 cases at Siegburg, 32 were affected with Melancholia and 14 with Mania. Of Dr Batty Tuke's 54 cases already referred to, the symptoms were those of Acute Mania, "severe, but evanescent,'^ in 10, Melancholia of various degrees of intensity in 39, and Dementia in 5. The maniacal symptoms rarely lasted more than ten days or a fortnight, and were generally attended with hallucinations of the different senses, and delusions. The Melancholia (which it will be seen was much the most frequent) was marked " by delusions either of a suspicious character, or as to personal identity, hatred of children, husband, or friends, and a strong suicidal tendency." The latter was present in 17 of the total number of cases. Instead of giving an ordinary case of Insanity from prolonged lactation, manifested by the usual characters of Melancholia followed by recovery, we subjoin an exceptional case, marked by acute maniacal delirium, and terminating fatally : "A farmer's wife, set. 27, was admitted into the Somerset County Lunatic Asylum. She was in a state of delirium ; attempted to injure her children and also herself ; skin hot ; feverish ; pulse 120. The attack came on a week before admission to the asylum, and four months after childbirth ; she had a carbuncle on her back ; general health bad ; she was incoherent and wandering ; had lost her memory, and was destructive. She was an irritable person, but of a kind disposition. For the first week she had to be fed by the stomach tube ; pulse 80. She continued restless. " She died four weeks after admission. The body was examined twenty-nine INSANITY OF LACTATION 369 hours after death, and the dura mater was found to be preternaturally adherent to the skull ; the cerebral vessels congested with blood ; slight opacity of the arachnoid ; spinal cord natural ; redness of lining membrane of the bronchial tubes j abdominal organs large and congested; uterus two ounces and a half; mucous membrane vascular; dark, congested patches ia the intestines. Cause of death meningitis, bronchitis, &c." (See this and other cases in ' Journal of Mental Science,' by Dr Boyd, July, 1870.) etiology. — Lactation prolonged beyond the endurance of tiie motlier and consequent anaemia and exhaustion. The ill effects of long nursing are shown by the number who become insane in the latter months of lactation. Of 54 cases at the Royal Edinburgh Asylum reported by Dr Batty Tukoj 2 had become insane during the third months 6 during the sixth month, 4 during the seventh month, 2 during the eighth month, 6 during the ninth, the same during the tenth, 5 during the eleventh, 6 during the twelfth, 2 during the thirteenth, and the same during the sixteenth. Hence 33 out of 54 occurred after the sixth month. In 13 cases the month was not recorded. In 8 cases the attack of Insanity appeared during the first nursing, in 4 during the second, in 9 during the third, in 5 during the fourth, in 6 during the fifth, in 2 during the sixth, in one during the seventh and the eighth, in 2 during the ninth, and in one during the tenth and the eleventh month. In the remaining 14 cases the women were multiparas, but the exact confinement was not ascertained. Ripping^s cases began mostly in the second half of the second month, or in the third month after delivery, less often in the fourth and fifth month, and seldomer still at a later period. Prognosis. — When resulting simply from the anaemia induced by prolonged suckling, the prognosis is very favorable. Of the 54 cases already referred to at Morningside, 39 recovered, and only 1 died; 12, however, lapsed into Dementia, 2 remained under treatment and were not promising cases. Of the 39 who recovered, 7 were under treatment more than nine months, 4 eight months, the same number seven months, 5 six months, 4 five months, 6 three months, 4 two months, 3 one month and 2 only three weeks. Of 29 cases at the West Riding Asylum, 1 died, 27 recovered (6 in three months, 12 in six months, 5 in nine months, 1 in more than twelve months, 3 were convalescent), and 1 remained incurable (op. cit.). In these cases the symptoms of Insanity 366 iETIOLOGICAL FORMS OP INSANITY appeared from six weeks to twenty-one months after the com- mencement of lactation. Of Eipping's cases (46) 42*5 per cent, recovered ; and 10'6 improved. One patient died. > Climacteric Insanity. It is stated by Dr Tilt that between 3 and 4 per cent, of women suffering from nervous disorders at this period become insane. Probably this is an under estimate. From statistics collected at the West Riding Asylum by Dr Merson ('West Riding Medical Reports/ vol. vi, 1876) showing the age at the time of the attack of Insanity, and the condition of menstruation in 333 cases, it appears that the age specially liable to an attack in connection with the climacteric period, is that from 44 to 48 ; the average age of cases between 40 and 54, being 46"5. In any single year, the highest number was at 50. Of 1054 admissions in four years, 159 were those of women at the change of life ; this not necessarily forming the only or even the main cause of the attack. It was found that single women were more liable to attacks at this age than married, but as this was observed to be the case, whether insanity was traceable to the cessation of the catamenia or not, the result did not appear referable to meno- pausal influence. As the morbid mental phenomena which occur at the change of life depend in women upon the altered condition of the utero- ovarian apparatus^ the mental diseases of the critical period of life are also examples of a Uterine or Ovarian Insanity. The term " Climacteric Insanity '^ was chosen by Dr Skae to include the mental affections of the male as well as the female sex at this period of life. An intense craving for drink may be the prominent, and perhaps the only symptom which characterises the morbid condition of the system. Skae gives as pathogno- monic of this form of Insanity, both in men and women, a class of symptoms which are certainly very common at this trial epoch of life, namely " a Monomania of fear, despondency, remorse, hopelessness, passing occasionally into Dementia.^"" The symptoms of the cases admitted into the West Riding- Asylum above referred to, were grouped by Dr Merson as fol- lows ; — 1. Cases ch^^racterised by simple depression without CLIMACTBRIG INSANITY 367 hallucinations of tlie senses, or intellectual derangement. In some, extreme nervous irritability and hyperassthesia of sensa- tion, almost amounting to hallucination. 2. Depression, also, tlie prevailing condition, but along with this, great emotional and intellectual disturbance. Hallucinations of the senses not un- common, and some vague delusions of a depressing kind nearly always present. 3. Delusions of suspicion and persecution the most prominent symptoms. In most cases, hallucinations of the senses and outbursts of excitement not unusual. The above cases were uncomplicated with organic disease of the brain, others suffered from Epilepsy, General Paralysis, atrophy, &c. During eight years the admissions under this head at the Hanwell Asylum (as regards women only) were reported as only eight in number. Of 361 female cases due to physical causes admitted into the Salpetriere, 27 were attributed to this cause. As showing the imperfection of these returns it may be added that in Dr Skae's Annual Eeports for 1869-70-71-72, we find, out of 558 female admissions during these years, 62 cases of Climacteric Insanity. Among the males, out of 515 admissions we find 44 cases reported. A woman, set. 45, was sentenced to death for wilful murder at Ips^\^ch iii 1876- The victim was a neighbour, and no cause could be discovered. Her insanity was connected with the cessation of the catamenia; and she suffered from maniacal paroxysms and convulsions at the periods when the catamenia would, ordinarily, have been present. This case is given by Dr Orange in the ' Broadmoor Eeport,' 1877. In the case of a woman, reported by Dr Merson, au impulse arose which " took the form of a desire to kill some one near and dear to her, and she confessed that, before anyone noticed her mental condition, she experienced this feeling, and had to leave the house of a daughter, with whom she was living, on account of an uncontrollable impulse to murder her grandchildren." Prognosis. — As observed by Griesinger, " the various condi- tions arising from sexual super-excitation in men of advanced years, are very grave in a prognostic point of view ; they gene-i rally proceed to Dementia. Schr. v. d. Kolk says, " if religious melancholy begins in the climacteric years, then the prognosis is very unfavorable.^^* In view of cases at Bethlem Hospital, Dr Savage observes that the characteristic period, " instead of being as one might * See Tilt on ' Diseases of Women,' and ' On the Changes of Life.' " Menstrual Irregularities," by Dr H. Sutherland, in the ' West Riding Lunatic Asylum Medical Reports,' vol. ii, 1872. 'The Climacteric Period in Relation to Insanity,' by Dr Merson, idem, vol. vi, 1876. ^ , ^ 368 JiTIOLOGICAL FORMS OP INSANITY have imagined, a bar to the progress of Insanity, really is the sluice at the opening of which all the mental power is wasted away" ('Guy's Hosp. Eeports'). "Those cases that have their first attack of Insanity at the climacteric, whatever the form of disease, are unfavorable, but cases that recover from this their first attack seem to be tolerably free from remis- sions." "The climacteric is dangerous to persons who have had previous attacks of insanity, especially, I believe, if these have been of puerperal origin " (' Considerations on the Cures of Insanity^). The cases reported by Dr Merson show a more favorable result, if the period of life extending from 40 to 54 years be taken ; inasmuch as of 147 in whom the attack was referable to the change of life, 69 or nearly 47 per cent, recovered. Exclud- ing cases complicated with epilepsy. General Paralysis, and other organic brain diseases, the proportion was as high as 59*5. It would have been interesting to know the recoveries from the 44th to the 48th year. Insanity from Abdominal Disorders. The influence of abdominal affections upon the mind has.been universally admitted, especially those of the colon and liver. So far as we know, however, Schr. v. d. Kolk was the first who attempted anything like a definite delineation of a special form of Insanity in connection therewith, under the designation " Sympathetic Mania proceeding from the Colon." According to him " it is characterised by a peculiar depression of spirits, by anguish of mind, and by the patients self-accusation of wickedness and baseness, either in the present or in some pre- vious time. The disease has a very slow course, and generally the anguish of mind and the self-accusings have already existed some time before the physician is consulted. At first the patient strives against his gloomy thoughts, and in presence of strangers he behaves quite like a sane person, so that one does not perceive or suspect anything unusual about him. This does not happen in Idiopathic Insanity. Moreover, the patient has generally suffered previously from sluggish bowels, sometimes even for years ; often the bowels are only open once in several days, without this having caused him any particular annoyance. In addition, not rarely do hsemorrhoidal complaints appear, namely, tumours and bleeding at the anus, or, perhaps, also a INSANITY FBOM ABDOMINAL DISORDERS 369 violent itching in this part. These heemorrhoidal sufferings^ however, especially the loss of blood, have usually diminished or even quite ceased before the outbreak of Melancholy. ^' The melancholy usually increases slowly if the mournful frame of mind is not more strongly developed by special circum- stances. The patient seeks to be alone and likes to conceal himself in a dark corner. He has also an extremely unpleasant feeling in the preecordia, which not unfrequently extends towards the left side, especially in women, and in them hysterical symp- toms are sometimes added, especially the so-called globus hys- tericus. Further, there is present an indescribable feeling of distress which does not, in the least, lose ground, and which is generally interpreted as qualms of conscience. ^^ After referring to inability to read or pursue any work re- quiring attention or memory ; sleeplessness ; self-tormenting accusations early in the morning; spinal irritation, marked by increased pain in the head on the upper part of the neck being- pressed ; urine dark and depositing a sediment, he adds — " All these symptoms are explained by the affection of the colon, and its reflex influence on the upper part of the spinal cord, on the brain, and even on the kidneys. In great praecordial distress the transverse colon is often enlarged and loaded with faecal matter. The bowels are then generally sluggish, and the feeling of uneasiness increases with retention of the fseces. Less frequently the patients complain of an uncomfortable feeling in the right side, and in the region of the liver." ('The Pathology and Therapeutics of Mental Diseases,' p. 128-34.) ■ Under the head of " Mania proceeding from the Urinary Apparatus," Schr. v. d. Kolk describes the following case. " A merchant from Liverpool, who had been for some days very much irritated, and had drunk whisky, got a catarrh of the bladder with painful and difiicult mic- turition j the urine was quite thick, and was only evacuated drop by drop. The treatment was directed against enlargement of the prostate. The catheter caused violent pain, and increased the difficulty in passing urine, so that off and on, complete anuria occurred. The mental symptoms which succeeded are stated to have been as follows : — Violent nervous symptoms, hallucuiations of hearing, and subsequently of seeing also. The urine was quite thick, and contained much mucus, and on account of the affection of the bladder, the patient had lime water with extract of cicuta, as well as intermediately a decoction of linseed. Under this treatment the symptoms of catarrh of the bladder rapidly diminished, the urine was clearer, and more easily passed. Therewith the patient awoke as out of a dream ; he was conscious that his former ideas had been en-oneous, and he appeared to be quite well. After a short drive he had an attack of orchitis, and he again became somewhat confused. In the further course of this case, a slight aggravation of the vesical catarrh occurred, and immediately his hallucinations retu/rned. But all the symptoms quickly disappeared 24 370 ^ETIOLOGICAL FORMS OF INSANITY through the continued use of Aqua Calais, and keeping the bowels regular ; in two months the man left the institution quite cured, that is to say, free from all urinary complaints, and free from all intellectual confusion. A year after his discharge I heard that he remained quite well." (' The Pathology and Therapeutics of Mental Diseases,' p. 148.) In tlie ' Report of the Royal Edinburgh Asylum ' for 1871 two cases are recorded associated with renal disease. The remarkable similarity of the symptoms in these patients^ one of whom was a female and the other a male^ and in whom *' Insanity was coexistent with the waxy form of Bright' s disease of the kidney/'* is particularly mentioned by Dr Wright : " In the case of the male patient Insanity had existed for years, and he indicated a predisposition to its occurrence. At the commencement of the disorder the symptoms were of the sthenic type, and consisted of maniacal excitement and delusions ; homicidal impulses were also displayed by him ; bodily health was then reported as good. After being resident in the Asylum for some years, the symptoms of this man's insanity gradually changed; they assumed the asthenic type. He became very querulous and extremely selfish ; his powers of self-control were much weakened, and he would cry like a child when recomiting his troubles, real or imaginary. This change of disposition commenced, and advanced pari passu, with the advent and progress of the symptoms of the kidney disease. His micturition became very frequent, urine was passed in large quantities, and of low specific gravity, and his complexion became colourless, and of the tallowy hue frequently noticed as co- existent with the waxy forms of Bright's disease. "In the case of the female. Insanity came on with the invasion of the kidney disease, or rather vAih. the general constitutional depression which preceded the appearance of more general symptoms. In this case, and in that portion of the former which corresponds (i.e. after the appearance of Bright's disease), the mental symptoms and general appearance of the two patients were almost identical; querulous, discontented, constantly moaning and weeping over their vuiliappiness ; no kindness consoled, no attention soothed them." In connection with the alleged relation between disease of the liver and the production of any particular mental symptoms^ there can be no doubt that Melancholia is the form of mental disorder which we most frequently witness in combination with hepatic derangement of a chronic character. In the ^Annales Medico-Psychologiques ' for Sept. 1872^ p. 201, is a paper by M. Lunier, on the relation between Icterus and Insanity, with cases showing a certain degree of relation- ship. Its chief object, however, is to illustrate, not the in- fluence of hepatic affections in causing, but in curing mental disease, with which we are not now concerned. Griesinger observes that Icterus " appears to have a great influence on the disposition (Stimmung), and we sometimes see acute icterus * Dr Wilks has recorded a case in the ' Jouru. of Ment. Sci.,' 1869, p. 243. POST-PEBEILE INSANITY 371 gravis accompanied by violent delirium without any cerebral change. As regards the influence of icteric states on the pro- duction of Chronic Insanity no definite observations are recorded/^ (Die Pathologie u. Therapie &c., p. 199.) In four of Dr Skae^s ' Annual Eeports ' within our reach, 1869-70-71-72^ no such case is entered as being admitted. Post-Febrile Insanity. Nasse, who has paid much attention to mental affections originating in fever, classifies them according as they are (1) the immediate result of the fever itself, or (2) constitute a a prolongation of the delirium when the fever has subsided, or (3) arise during convalescence. The last class is more especially intended by the term "Post-Febrile Insanity.-'^ The time during which it is gradually gaining force may be long or short ; irritability, as in the incubation of Insanity generally, is a frequent sign of the oncoming malady, and a change of manner in various ways which excites the surprise of the friends, and perhaps some degree of childishness. Out of 2000 patients admitted during six years at Siegburg, 43 cases, the certain result of typhoid fever, were admitted. Many of these cases are examples of Melancholia and Mania due to aneemia, and rapidly recovered. Then there are cases presenting the ordin- ary features of delusion about persecution, with hallucinations of hearing and (not so frequently) of sight, some cases passing into Dementia, but not complicated with paralysis. Sydenham recognised Insanity as among the sequelas of mtermittent fevers. He says, " one sort of symptom, and that an important one, it may be proper to mention in this place ; it yields neither to purges nor evacuants of any kind, least of all to bloodletting. In defiance of these, it even takes strength from their administration. It is a form of Mania peculiar, and sui generis. It occasionally follows long agues, especially if they be quartan ; it stands beyond the reach of all the usual remedies. From the exhibition of strong evacuants, it degen-' erates into Fatuity and ends only with the life of the patient. I have often wondered that no notice has been taken by authors of this symptom, as I have observed it not unfrequently. The other forms of madness are mostly cured by means of copious evacuation, bloodletting and catharsis. This can bear none of them (Sydenham's works, Syd. Soc. Trans., vol ii, p. 93). 372 iETIOLOGICAL FORMS OF INSANITY Pinel says, '' A man of letters, accustomed to excess at table, and lately recovered from an attack of tertian fever had towards autumn all tlie horrible symptoms of a suicidal tendency.'^ Insanity as the consequence of intermittent fever has been treated by Baillarger, and in publishing an article upon the subject thirty years ago, he stated that his only object was to provoke observations and researches into the study of Insanity from an aetiological standpoint. He gives two cases which, as he states, are in accordance with the observations of Sydenham. To such cases it was objected that if they stood in any definite relationship to the succeeding mental disease, a great many more instances of Insanity should occur in ague districts than is actually the case. Further, these two patients had had previous attacks of Insanity. He admitted that further enquiry was necessary, but the fact remained that two physicians, Sydenham and also Sebastian, had met with many instances and were aston- ished at the silence of other medical men. M. Baillarger added a third case, a cure who at twenty- eight years of age had a quartan fever, which was followed by an attack of Insanity. Intermittent fevers, he observes, predispose to Insanity in two ways, first by acting like all nervous affections (ague being more allied to these than anything else), and secondly by produc- ing anaemia. We have seen a patient at Bethlem Hospital, under Dr Williams, in whom the mental disease appeared to be closely related to ague. The case is thus recorded by Dr Savage. Alfred D — , set. 18, sailor. In the West Indies had an attack of " fever." He recovered, but was in feeble health, though he followed his employment and came home m his ship. As soon as he got to England he became excited and violent, threatening his father; he was sleepless and rambling in his talk, often swearing and using bad language. On admission he was a wTetchedly thin, sallow boy, of a most morose temper, insolent and overbearing. He refused to be examined by the doctors, as he said " they were quacks." After being in the hospital for two weeks he had an attack of ague, and also of facial neuralgia. He was then examined and found to have an " ague cake " of large size. Quinine was given in two-grain doses every four hours, and he rapidly improved in mind and body, so that he became a most handy, useful patient, cheerful and agreeable in the extreme. He no longer had grand ideas, but began to look about for some engagement in his old profession. In their statistics of the Bicetre, MM. Aubanel and Thore also report a case ; other cases are cited by Baillarger from Payen, Falret, and Villermay, Trusen, Nepple, and Moreau de Tours. (See '^Annales,' 1843, vol. ii, p. 372.) Hoffman has published a fatal case in the Giinsburg Zeitschrift IV. On Insanity consequent upon fever, see " Remarques sur le delire consecutif aux fievTes typhoides," par M. Sauvet, ' Aunales,' 1845, torn, ii ; ' Monomani ' INSANITY WITH RHEUMATISM AND CARDIAC DISEASE 373 ambitieuse survenue dans la period de declin d'une fievre typhoide, symptomes peu graves," par M. Leudet, ibid., 1850, torn, ii ; " Recherches sur la Revre typboide," par M. Louis, torn, ii; "Die Pathologic und Therapie,' &c., von Griesinger," 1861. Case reported by Dr Handfield Jones in the 'British Medical Journal,' January 12th, 1867. Insanity with Eheumatism and with Cardiac Disease. Griesinger directed attention to the Insanity which occasion- ally (he says " very rarely ") arises out of acute rheumatism. After disposing of cases of Acute Delirium and Maniacal Excitement, he observes '^ Sometimes, under the influence of accessory causes, we see prolonged Melancholia with stupor. Mania, mental weakness, &c., occur; in short, the development of actual mental disease in various protracted forms, sometimes associated with chorea-like attacks. In these as in the acute cerebral forms of rheumatism, we frequently see the articular affection diminish, or even disappear, with the appearance of the mental disturbance, and occasionally there is an alternate improvement of the one, and aggravation of the other — some- times even a decided retrogression of the latter on the appear- ance of the former^' (Op. cit. Syd. Soc. Trans., p. 189). Dr Clouston has illustrated the character and course of Eheumatic Insanity, by some interesting cases in the ' Journal of Mental Science,^ July, 1870. In these, chorea* was a marked symptom, but Dr Clouston regards them as examples of Rheumatic Insanity, because they appear to have been caused by the rheumatic poison. He holds that the chorea and the mental disorder were alike effects of a common cause. Of two cases reported by Dr Clouston we give one (abbrevi- ated) as an illustration : — C. M — , female, married, set. 24, admitted January l7th, 1870. First attack. — No relation is insane or rheumatic. Reserved and quiet in health, but nervous. Predisposing cause of attack; ill usage by her husband, poverty, cold, hard work, nursing her child for fifteen months up to the attack. Exciting * It is unfortunate that this term is applied to such very different conditions as that here referred to and the Dancing Mania. As the Greek work {xopua) signifies a dance, it would be more legitimate to restrict it to the latter ; but it is hopeless to attempt this distinction now. The mental weakness and hysterical sensibility which frequently result from chorea, mark an affection of the mind which would now be understood by employing the term Choreic Insanity. Of Choreomania — the irresistible impulse to dance or jump — we shall speak at the close of this Chapter, under Epidemic Insanity. 374 ^ETIOLOGICAL FORMS OP INSANITY cause; an attack of rheumatism, not very acute, which lasted two months before she became insane. She had pains in the back of her neck, fingers, feet, &c., which were swelled, and some feverishness, but was not confined to bed. A week before admission she quite suddenly ceased to complain of the rheumatic pains, and simulta- neously with this relief she shoioed signs of mental derangemen , and violent chorea of head, arms, and legs commenced. Her first mental symptom i were a sort of absence of mind and inattention to what was passing around her, taking no notice of questions put to her, or of her children ; also great excitement, tearing her clothes, &c. Quite sleepless, and the choreic movements had increased greatly in intensity. On admission was much excited; memory almost gone; talks incoherently in monosyllables. The only question she can be got to answer is her name. Pupils contracted, equal ; most violent choreic movements of face, head, arms, and legs ; reflex action diminished; cannot walk; respiration 20 per minute; heart beating quickly but regularly; no cardiac murmur; pulse 108, strong; tongue clean and moist; won't take food; urine clear, acid, sp. gr. 1015; no albumen or deposits; temperature 100'4°. Next day, choreic movements ceased in legs, which became now quite paralysed and nearly devoid of common sensibility ; the reflex action in them was gone ; bladder paralyseoio-*u=-*^ in^^.o^^^^ 5SS^; ■(,S3Ut!33qi0dB) 833TTno pmy ni nrejq ^q is^Bjt jo )a3ui33R]dsi(x o •* CO '^ CO ■* eo r4e* >4e< r^cvp^^He* -i* CO**-^ -^ -(J"-^ ■* CO-* t-* t^ r-H p-4 e* ■* ec CO f co-*e<5 eo ■*•* T)i TT tota-^-^ (siodnp •itoab) BjESnojqo B|jtip -am puB uiBjq jo jqSiaj^Y OCOCO' •£ CO (M COC^Ol ieoei««o»e^ «o»«eieicic •mnjisqajas JO .(ii.\ej3 oypsdg g-T'—'io ^ c C5 — — . ■*'-?'-*'CO -*« ^ ec-*-^' o p9=o o p Sip g gs 3 3 ssg s ^s i i ilsl ■amman JBI113IS3A :ranjq -3I3D JO XjlABxS 3gp3d>5 o ^ r-* -^ xj ? 9 99 9 9 opo p CO p o pops H I- H H I- I- I- I- H fc^ I- I- I- H I" H n- I- - I- ■asBSSip [B;nain jo nuoj ■a3v •xas Jaquron e.inaijBj; 5 g 5 : c — 5 >. II .g 2 a 'i =- >. =■ £ =! S =• 2 ^ i .S1.-3 io ^S .2^ = = £==■* « C S-.S • - >» — s ^ 2 E"5 §■ ^ § rS.S 0» CO.— . 1— I t^iec -^ -^ U3 XO''}* -^ CQ- U3 (S ^ CO o 00 CO •* 13 o oo U5Tf(iD US ^ ^ c^«o 00 o !0 CS U5 05 05 ^ 00 00 rH TJi ■* crocoos la Irt in la U3 OO O [^w^o""^ Ph "^ i- ESS -==10 >i >> 5 5^ S — r- - = >> i 5 5 = "= ^'3- 'S 3 >^ ;s ~ ct*^ s G « • s ? i o S — 3i— I CO Oi— i^am:^ CO OC^t^rH 1^ MCI S • ■? a S H 5 o ;2 . i s rS c S'i- g § 2 2 _ - P, a g g =-3. :s ^ i- a _ '^ "_ s >>_ S 1 = 1 I |:|g T^CCO -* ^H C* '*1>-«J r-H o c* 00 CO-— Oic* 00 c?occ5co o oei t- o ^ o t^ tr^ ' cc -# -^ t^ f»^ '^ f^ s ^ S o m CO t- ct c» 1-1 ^ S -;6:;;^ S s s sss s s s ss i=; f=;s;=-:s ^ f^i=:i^^ s &;§ ?0 us ^ OS r-l CI O 00 O iO ,-1 CC O O O 0» Oa 1 CC CO T? <0 'e O »ft 00 d lO o Tji rr" t^ c='^c*io CO -rn la 50C0 C-- OD CI rHrH C* COf— t 526 PATHOLOGY OF INSANITY The general results were an average amount of atrophy to the extent of five ounces and a quarter, varying from nothing to fifteen ounces, or one third of the whole cerebral mass. In thirteen patients whose ages exceeded sixty-five years, the average amount of atrophy was eight ounces and one sixth, or more than fifty per cent, above that of the old number. The amount in epileptic cases was greatly below the average of the whole. The general result arrived at was that — " In cases of Chronic Mania, of Dementia following Mania, and of primary Dementia, the amount of cerebral atrophy may generally be calculated upon by the enfeeblement of mental power. In all these forms of disease we have found some amount of atrophy, and have, for the most part, found this amount to correspond with the degree of mental decadence estimated with its duration. The first of these conditions, that is, the degree, it is impossible to tabulate : the second, that is, duration, it is not easy to show accurately in a tabular form. The sixth column of the table above referred to represents the duration of disease from the period of the first appearance of symptoms, as nearly as it could be ascertained. These sym- ptoms may have been slight for years, and grave for a short time only before death." " It must not be thought that extensive atrophy is only found where the mental symptoms are solely those of impair- ment or loss of function. It is not inconsistent with much mental excitement, or with numerous delusions ; but such excitement is powerless, and the delusions are transitory and puerile. Whether measurable atrophy exists in the early stages of Acute Mania and Melancholia, the data we possess do not prove ; although they are amply sufficient to demonstrate that the cerebral conditions upon which these forms of Insanity depend tend to pass into an appreciable and measui-able shrink- ing of the brain substance, unless the healthy cerebral action be speedily restored." " Opinions on the ultimate nature of the nutritive defect which results in cerebral atrophy and Insanity must neces- sarily be speculative, since the ultimate nature of nutrition itself is unknown to us. " Its apparent and exciting causes may be classified as follows : "1. In predisposed persons it may depend upon poverty of blood, since it is producible by deficient food and by diseases CEBEBRAL ATEOPHY 527 interfering with, tlie aliraentative processes ; and since an ana- logous train of symptoms occurs during starvation. '^2. It is probable that in other cases it ma j depend upon some derangement of ' the intimate connexion between the nervous and vascular systems, through, which their most impor- tant functions are performed/ since it is sometimes found to be accompanied by extensive disease of the minute cerebral vessels, the coats of which can be shown to be subject to fatty or earthy decay. '' 3. A third class of cases would appear to be producible by the molecular change effected by blows or violent concussions, and followed by atrophy, owing to some process as yet unknown to us. Atrophy of a testicle from a blow, without inflammation, presents an analogous instance. " 4. Another class of cases are th.ose following inflammation, and perhaps also following frequent and long-continued con- gestion. The basis of inflammatory action is an abnormal state in the mutual relationship between the blood and the tissues. That this state effects changes in the tissues, which, if not speedily repaired, must be followed by conditions of degraded nutrition, is proved by the pathology of every organ in the body. The brain certainly offers no exception. The capillaries become blocked up, or their coats become spoiled for the purposes of nutritive regeneration of the tissues. " It also appears probable that, during inflammatory or con- gestive conditions, albuminous matter or serous fluid may be effused by the capillary network into the intimate structure of the brain; thus separating its vesicles and tubules from the capillaries, and preventing the due nutrition of the elements of nerve-structure. For this form of atrophy, we have formerly suggested the prefix of relative, as it may exist where there is no shrinking of the brain ; atrophy with, shrinking being termed 'positive. The two, however, may, and fi-equently do, coexist. " 5. The most numerous class, however, is that which depends upon want of rest, during the especial period of nutrition of the brain — namely, sleep. "Want of refreshing sleep we believe to be the frequent origin of Insanity, dependent upon moral causes. Very often, when strong emotion tends to the production of Insanity, it causes, in the first instance, complete loss of sleep. In many cases, however, the power of sleeping is not lost, but the quality, so to say, of the function is perverted, the sleep being 528 PATHOLOGY OP INSANITY SO distracted by agonising dreams, that the patient awakens jaded rather than refreshed. We have known several instances in which patients becoming convalescent from attacks of Acute Mania have distinctly and positively referred to frightful dreams as the cause of their malady ; and it is probable that a certain quality of sleep, in which dreams excite terror and other de- pressing emotions more forcibly than waking events are likely to do, is scarcely less adverse than complete insomnia to the nutri- tive regeneration of that portion of the brain on whose action those emotions depend. In such a condition it is highly pro- bable that the very portions of the brain which most need a state of rest are, even during the sleeping quiescence of other por- tions, more wastefully engaged in the activity of their functions than they could be in the waking state. The main-spring of Insanity is emotion of all kinds. This, stimulated by phantasy, and emancipated from the control of judgment, during harassed sleep, may be more profoundly moved than at any other time. Bichat considered sleep to be a very complex state, in which it was possible for the cerebral functions to be in very different conditions of quiescence or activity : ' Le sommeil general est Pensemble des sommeils particuliers ;' and he considered that dreams represent the active or waking condition of certain of these functions during the repose of the others. In this manner a patient, some one or other of whose emotions has been pro- foundly affected, may continue to be sleepless, as far as the activity of the particular emotion is concerned, although he may by no means be the subject of general insomnolence ; and this consideration will afford what seems to be a fair explanation of the exceptional cases to this rule, that the moral causes of Insanity act by preventing the due nutrition of the brain, as it occurs during sleep." On these five classes of the causes of atrophy we shall here make some further observations. In tracing the course of cere- bral atrophy, it will be convenient to select that variety whose causation and phenomena are of the most simple and intelligible kind. This would appear to be presented by the atrophy accom- panying old age. The balance between the functions of repair and decay, which in health maintains every organ in a state of size and power uniform with certain limits, is lost as age ad- vances, and the tissues of the body lose their perfect organi- zation and pristine vigour. The duration of the life of an animal depends upon the period of its existence when this loss CEREBRAL ATROPHY 529 of balance occurs ; but it is not easy to understand why these slow but fatal changes take place at certain specified periods ; why the tissues of a sheep become worn out at the end of ten years^ and those of a stag endure seven or eight times as long. It is impossible even to point out any necessity for this de- gradation of tissue at all. We must accept^ as an ultimate fact, or as a law of nature, that such degradation of tissue in the organs of all living beings takes place at a certain fixed period of their existence. It appears to us not improbable that the age of senile decay in different animals may depend upon an hereditary habit of life fixed in the first instance by the more or less perfect manner in which some portion of the organism not in itself vital has been fitted to the circumstances of living. For instance, a sheep begins to lose its incisor teeth at four years old ; when they are lost it can no longer graze the mead, the vital tissues then degenerate from want of nutrition, and if the sheep be not converted into mutton it will die worn out at an early age, leaving behind a progeny with the hereditary tendency to decay at the same age, even if artificial food were supplied. A stages teeth do not decay early, and it can browse even after it has lost the incisors. It, therefore, not only lives to a far greater age, but begets offspring whose tissues have an heredi- tary tendency to postpone the decay of age. The long lives of birds of prey and the short ones of those which are habitually preyed upon and which if not eaten die early of old age, have probably become so through hereditary influences. The first eagle would outlive its victims and transmit to its offspring tissues with an hereditary tendency to resist decay longer than those of the grouse or the pigeon. May we not reasonably expect that in man the longer life conferred by a sanitary civilisation will gradually develop the hereditary tendency to yet longer life, and that the prevention of zymotic disease may, in the lapse of generations, defer the advent of senile decay to a period of life of which we have hitherto had no examples ? The prevention of typhoid fever may thus postpone the period of atheromatous deposit. At present, in man, retrograde changes commence at the age of about sixty years. About that time the nutritive repair of the organs begins slowly to fall short of the amount of their decay. The muscles gradually become smaller, weaker, and paler, and the brain undergoes the same process of change. In 34 530 PATHOLOGY OF INSANITY tlie brain, one cause of this process is, perhaps, more easily traceable than in other organs — namely, to a change in those minute vessels by means of which the processes of nutrition are carried on. Their coats are found to be thickened and opaque, and occupied by that which is called atheromatous deposit — namely, by a material composed of fatty substances and earthy salts. In the larger arteries, whose different coats are distin- guishable, this deposit, or rather this degeneration, is found to have its seat external to the elastic coat, and internal to the outside cellular envelope. If this degenerative change can be traced in the smallest arteries, whose construction is capable of being submitted to observation, it is probable that the change is not limited to them,' but that it extends to the capillaries, whose minuteness forbids its demonstration. The plasma of the blood would then permeate the capillary walls from within, outwards, and the exhausted cell contents would permeate from without inwards, with slowness ever increasing as the capillary walls were deteriorated. From this slowness would arise lentor of the cerebral functions, displaying itself at the earliest period in those functions whose activity is not kept alive by habitual use ; and to a still greater degree in those functions whose activity is dependent upon the stimulation of the senses, the organs of which have also undergone contemporaneous decay. But debi- lity of function, arising from the slow interchange of material between the capillaries and the cells, would not account for atrophy if the balance of the interchange was still exactly ad- justed. Slowness of mental function is often seen in persons of phlegmatic habit from this cause, without the condition of atrophy being present. But in the degenerative changes of old age, the balance of exchange between the capillary and the cell contents is not maintained. The probable explanation of this is afforded by the supposition, that the greatest activity of exosmosis from the capillaries takes place in that part of the capillary system which is adjacent to the arteries ; while the most active endosmosis of exhausted cell-fluid takes place into that portion of the capillary system which is adjacent to the minute veins. Now, the pathological changes under considera- tion affect the arterial system, if not exclusively, yet to a much greater extent than they affect the venous system. The arterial capillaries may have coats more thickened and degenerated than the venous ones ; and thus a greater impediment be placed against the outflowing of the materials for nutrition and repair, CEEEBEAL ATEOPHT 531 than against the inflowing of the exhausted cell-fluid^ and the foundation of atrophy be established. Whether any pathological changes corresponding in their nature to the fatty degeneration of the arterial coats take place in the cells themselves, we are unable to ascertain, or even to gain better grounds for reasonable conjecture, than the probable participation of all the tissues in the degenerative changes. The law which limits the duration of organic completeness, which weakens the force of that un- known something which we call vital power, and which permits the ordinary chemical affinities of the constituents of the body to exert themselves with increasing force, this law, doubtless, operates upon all parts of the organism, although with different degrees of intensity and at different periods of time. The glands which secrete the hair on the vertex vacate their office before those which secrete the hair on the brows, and the latter do so long before the glands which secrete nails. But the law of decay is universal, and doubtless touches the cerebral cells independently of their connection with the minute vascular net- work. Next to the atrophy of old age, that proceeding from patho- logical changes of the vascular system, approximating to the state called inflammation, is the most intelligible. We have above given reasons for the opinion that the chronic class of diseases known under the generic term of Insanity are not referable to inflammation of the great nerve organ. In- flammation, however, may, and sometimes does, cause changes in this organ, which are the conditions of Insanity. In the brain the state of inflammation itself either very quickly ceases, or very soon causes death ; but when it does cease, it leaves behind it consequences which are frequently the conditions of Insanity, and the causes of cerebral atrophy. Inflammation of all soft organs is apt to result in atrophy, after the organizable products which at first increase the bulk of the organ have contracted upon the blood-vessels, and cut off, to a greater or less extent, the nutrient supply. The heart, indeed, affords an apparent exception ; but its structure is seldom inflamed, and its hypertrophy is consequent upon increased exertion necessary to overcome mechanical difficulties which have arisen from inflammatory injury of its valves or serous covering. That inflammation of the brain is sometimes fol- lowed by atrophy, is as certain as that inflammation of Glisson^s capsule is followed by atrophy of the liver. Whether it arises 532 PATHOLOGY OF INSANITY from the same cause is yet unknown. It is now very generally admitted that the organic elements of the brain are bound to- gether by connective tissue ; the neuroglia or nerve-cement of Virchow corresponding more or less in its character with the connective tissue of the liver, which, when altered by inflam- matory processes, squeezes that organ into a hobnailed callosity. We have as yet no facts upon which to ground the opinion that changes in the neuroglia are frequent causes of cerebral atrophy. On this point, as on others, we must await the revelations of microscopic observers, who may perhaps be able hereafter to demonstrate a kind of cirrhosis in the brain. Thus we wrote in the second edition of this work, and we retain the passage now that our anticipations have been fulfilled by the accurate histological observations of Dr Lockhart Clarke, Dr Batty Tuke, and others. The term scleroma or scleriasis has indeed very properly been substituted for that of cirrhosis, which refers to the colour of the diseased liver, and is obviously inappropriate to designate an analogous change in the brain or spinal chord. In the meanwhile, the newest pathological science is tending to discredit the agency of the blood-vessels, and to locate all force of change in the cells. The truth in this matter will, perhaps, be found to be between Virchow and what he calls the Vienna school; so that the condition of the cells, and that of the nutrient vessels, may both be found of importance in the causa- tion either of disease or of natural decay. Of this, however, there can be little doubt, that the nutrition of the brain depends upon its exercise, and its exercise depends upon the perfection of its organisation. The organisation once permanently injured, its uniform and harmonious exercise becomes henceforth impossible; its nutrition is impeded and atrophy results. It will appear from the above that we attribute a large share of mental disease to pathological conditions of the brain, whose most prominent characteristic is defective nutrition of the organ. In a very large proportion of cases this deficient nutrition is manifested after death by an actual shrinking of the brain — a shrinking which is coextensive with the duration and the degree of loss of mental power. This loss of power marks all instances of cerebral decay, and is consequently a condition of most chronic cases of insanity. Partial mental excitement is, it is true, an incident constantly recurring, even in forms of mental INSANITY BY SYMPATHY 533 disease where tlie general loss of power is most conspicuous, and wliere organic atrophy is found to be most considerable. This partial and irregular excitability is common to organs whose nutrition is defective^ and the general vigour of whose functions is greatly weakened. Thus^ a diseased stomach, quite unable to supply the amount of solvent secretion needful to digest a due supply of food, frequently torments its wearer by excessive and irritating secretions of gastric juice, at times when it can serve no good purpose, and only tends to heart- burn and acid vomiting. So, also, the atrophied brain is exceedingly prone to sudden erethism, more or less partial, which manifests itself in strange and irregular excitement of the mental functions. Such excitement is usually followed by increased debility of function ; and it is by no means uncommon to observe a regular alternation of mental excitement and debility. The excitement is more or less partial, and affects principally the emotional functions. The intellectual functions are also liable to be so affected ; but, inasmuch as the operation of the whole of these functions is necessary to the performance of common intelligential acts, and, as in spoilt brains, the whole of them are not usually excited at the same time, the fact of this condition in any one of them often attracts no attention. The emotional and instinctive functions present the most frequent and easily appreciable instances of cerebral excitement. Pathologically they present counterparts of excessive gastric secretion which takes place in the ill-nourished stomachs of phthisical patients ; and there can be little doubt that, if we knew the locality of the different functions of the brain, and were capable of inspecting its organs during life, we should find this temporary and partial excitement characterised by local erethism of the pia mater. It is one indication of the small share which inflammatory processes have in the production of mental disease, that the partial hyperemia to which the atrophied brain is peculiarly liable never results in true inflam- mation. Insanity by Sympathy. — That the organ of the mind is thrown into diseased action by sympathy with, that is, by suffering with, other diseased or injured parts, is scarcely less certain than that the stomach, the heart, or the spinal marrow, are so affected. The modus oioerandi of this cause of disease is by no means clearly intelligible, either in relation to the brain or to the other organs, the explanations usually offered being little 534 PATHOLOGY OP INSANITY more than diversified verbal formularies of the fact. Thus, when -we say that the irritation of the cervix uteri is reflected upon the stomach, occasioning vomiting and distress in that organ, we come no nearer to an explanation of the mode of action than when we say that the stomach sympathises with, or suffers in conjunction with, or in consequence of, irritation of the organ first affected. And, in like manner, when we say that the brain suffers sympathetically with the uterus or stomach, we use a mere verbal formula for the colligation of two facts, with the intimate nature of whose connection we are wholly unacquainted. The knowledge which we actually possess on this subject may, in general terms, be thus stated : the most important organs of the body are liable to be thrown into states of functional disturbance by irritation or injury of other and frequently of distant, parts. The liability to this dis- turbance depends, in the first place, upon what is called con- stitutional irritability, or a state of the system in which slight causes of nervous action produce great effects ; and, in the second place, upon the intimate connection of the organ secon- darily affected with the nervous system, and its liability to be thrown into disorder by any alteration or disturbance in the state of that system. Any premature attempts to explain this important pathological fact, by hypotheses respecting nervous currents, or the exhaustion of nervous power, seem at present rather likely to obscure than elucidate the matter. We may, however, come one step nearer to a reasonable view of the fact, by considering all sympathetic disturbance as taking place in the nervous system itself ; and by considering the functional disturbance of secreting and other organs as merely the expres- sion of abnormal states of the nerves in those organs. Strictly speaking, therefore, sympathetic vomiting or palpitation is as purely a nervous phenomenon as loss of consciousness or convulsions ; and the latter as mental excitement or delusion. In early life the cerebro-mental functions are more intimately connected with those of the spinal system than at subsequent periods, and distant irritations are more frequent and efficient causes of mental disturbance in the infant than in the adult. Delirium and coma are, in children, frequently produced by intestinal irritation. In the adult, delirium, in comparison with convulsions, is so rarely a consequence of simple irritation, as to furnish strong evidence that the brain proper may exercise its functions ^^ith great independence of the excito-motory or spinal INSANITY BY SYMPATHY 535 system. The most frequent and unquestionable instances of cerebral disturbance from the distant irritation or sympathy are afforded in epilepsy and hysteria. In both of these diseases the paroxysm is compounded of disturbance both of the cerebral and spinal functions ; but during the interval, cerebral disturb- ance alone is frequently present, and in the paroxysm itself it is never wanting. In epilepsy, especially, is this the case ; for loss of consciousness, which is the primary and leading feature of the paroxysm, is the most serious and profound indication of cerebral disturbance, no less, in fact, than the temporary abnegation of all cerebral function. In hysteria, loss of con- sciousness is of less certain occurrence, although sometimes it is doubtless complete. In the interval of hysteria, however, cerebral disturbance is often not less marked than in epilepsy. The emotions are perverted, and even delirium is by no means uncommon. Now, both of these diseases are frequently but the expression of sympathy with irritation of distant parts of the nervous system in predisposed subjects. Therefore these diseases present unquestionable instances of mental disturbance, occasioned by sympathy of the brain with irritation of the distant nerves ; of the central organ of the system, suffering in its noblest functions, in sympathy with some fibres of its peri- pheral extension. The most probable explanation of the sympathetic disorders is, that injury to one part of the nervous system interferes with the process of secondary nutrition taking place in other parts. The rapidity with which they occur may, at first sight, seem adverse to this view ; for instance, in the case related by Dr Gooch, " Dr Denman passed a ligature round a polypus of the fundus of the uterus ; as soon as he tightened it, he produced pain and vomiting. As soon as the ligature was slackened, the pain ceased ; but whenever he attempted to tighten it, the pain and vomiting returned. The ligature was left on, but loose. The patient died about six weeks afterwards, and on opening the body, it was found that the uterus was inverted, and that the ligature had included the inverted portion.^^ Sympathetic disturbance of the functions of the brain are, in some instances, scarcely less rapidly occasioned, or less capable of receiving im- mediate relief. Thus, the irritation of a cutting tooth will sometimes produce in a child delirium and coma; and the removal of the irritation, by incision of the inflamed gum, will remove the syraptoms almost as speedily as in the example 536 PATHOLOGY OF INSANITY above quoted. But wlien it is considered that the processes of secondary nutrition are those upon which the functions of all organs immediately depend, and that any interference with these processes must necessarily and immediately disturb the normal course of the functions^ the short interval which is fre- quently observed to exist between the production of irritation and its sympathetic consequences, will present no difl&culty to the adoption of the theory which explains the latter in the manner here suggested. In our present state of ignorance of the manner in which influences are communicated from one part to other parts of the nervous system, it is impossible to explain how the processes of secondary nutrition in the nervous structure are interfered with in distant parts thereof. But this difficulty scarcely diminishes the probability that the explanation offered is the true one ; and, indeed, only presents one of those imper- fect links in reasoning, which the immaturity of physiological science renders of such constant occurrence in all departments of medical science. The operation of remedies is consistent with this view of sympathetic disturbance, since those narcotic substances which retard the processes of waste and repair in the nervous system, afford the most efficient means of prevent- ing the nervous functions from suffering in consequence of peri- pheral nervous injury. Moreover, this view of pathological sympathy is consistent with the only rational view of physio- logical sympathy. Secretions are the result of secondary nutri- tion. Many secretions are normally excited by the irritation of nerves more or less distant ; that of the mamma, for instance, of the testis, and to some extent, of the gastric glands. Here then, at least, are processes of secondary nutrition energetically influenced by the irritation of distant nerves. The organs of the brain are less under the influence of the peripheral nerves than are the periodic glands. A man may be as hungry as a famished wolf without thinking of food. Loud sounds may strike upon the waking ear, or vivid and remark- able objects upon the retina, without exciting attention, if the attention is deeply absorbed in other matters. Nevertheless, the brain may and constantly does act in sympathy with the state of the peripheral nerves ; and the normal waste and repair of the brain is constantly, although not solely, influenced by the impressions made upon the nerves of general, special, and functional sense. This independence of the brain upon those nervous irritations and impressions, which doubtless impart to MONOMANIA 537 it the first stimulus to functional activity, but wMch subse- quently exercise a permissive, rather tban an imperatorial in- fluence — tbis independence was needful for tbe preservation of mental health. The brain has its own laws, and is no abject dependent upon the sensations. Had it been otherwise, sanity would scarcely have been possible, and man would have been the puppet of every mean circumstance, the reasoning automa- ton of wind and weather. The moral law could for him have had no existence ; and his thoughts, feelings, and actions must have followed as the necessary consequence of the latest sen- sory impressions. Sensations are, in the first instance, needful to excite the mental functions into activity. "Without the stimulus of sense, the infant cerebrum would remain devoid of ideas and emotions, an inert mass like a lung, perfect in struc- ture, but into which air has never been admitted. But once excited to action and supplied with ideas, the brain is no longer dependent upon the organs of sense. It can act without them or against them, employing its energies upon the provision of ideas stored in the memory, and by its own emotional and instinctive habits. In connection with this subject are the interesting cases which have been observed by Dr Batty Tuke, in which the jportio 'mollis was found after death to be diseased in a patient who had su:ffered from hallucinations of hearing, and in another patient in whom disease localised in the neighbourhood of the olfactory bulbs was seen by the same careful observer where hallucinations of smell existed. Pathology of Monomania. — Every one conversant with the phe- nomena of Insanity is aware that there are patients in whom the aberrations from mental soundness are limited in the range of objects to which they apply, and the nature of subjective faculties which they implicate. In many instances of this kind, an enduring perversion of the modes of thought, the foundations of belief, and the workings of emotion on one, or at least on a few objects, are the well-recognised symptoms of that form of disease which systematic writers treat of under the head of Monomania. It would be incorrect to say that in the purest cases of Monomania none of the faculties are weakened ; since the simplest hallucination or delusion proves a want of healthy energy in the perception or the judgment. But as a whole, and outside the morbid subject of opinion and feeling, the mind is not manifestly weakened. Moreover, the general health of 538 PATHOLOGY OP INSANITY such patients is excellent ; and if they die of any acute inter- current disease^ no pathological appearances are observed in the brain. To account for the perverted opinions and emotion of such patients upon the principles advocated in these pages, is a more difficult task than in the more numerous cases in which existent pathological change can be demonstrated in the cerebral organ itself, or reasonably inferred from the accom- panying symptoms. Considering the healthy activity of the mental functions most implicated in Monomania, on subjects outside the circle of delusive opinion; considering the unim- paired state of the bodily health, so frequent in these cases ; and lastly, considering the frequent absence of pathological appearances in the brain after death ; it is impossible to attri- bute the mental phenomena to active processes of disease exist- ing in the cerebral organs. But, inasmuch as all perverted function must be dependent upon abnormal states of the mate- rial organ ; inasmuch as many instances of the kind under con- sideration originate in the ordinary causes of morbid change, and are accompanied during the early part of their course by the ordinary symptoms of cerebral disease, and as they some- times, though rarely, give way under the influence of time and moral treatment ; it is certain that these mental perversions are dependent upon abnormal states of the brain ; an explanation of which these conditions of functional perversion with apparent health of the organism appear capable, being that afforded by the establishment of a habit of cell-growth and nutrition in the mould or type impressed by a previous state of diseased action. A morbid process of some kind or other establishes a certain irregularity in the cell development, and impresses upon the intimate structure of the organ an abnormal habit of nutrition, which endures after the pathological factors have been removed. The physiological habit or constitution of the whole body is frequently altered by an attack of acute zymotic disease, which has, nevertheless, left behind it no legacy of determinate patho- logical change. That which takes place in the body at large is by no means uncommon in its most important organs ; and an irregular habit of functional activity is a frequent legacy of disease in the stomach, kidneys, and uterus. This habit depends upon a peculiar arrangement of cells, or mode of cell-growth, impressed by diseased processes, and continuing in the same mould or type aftgr these processes have ceased, MONOMANIA 539 This explanation of diseased, function arising from physio- logical growth_, taking place in a pathological mould or type, has been admirably elucidated in Sir James Paget's second lecture on ' Surgical Pathology/ He says : '^ The last condition which I mention as essential to healthy nutrition is a healthy state of the part to be nourished. " This is indeed involved in the very idea of assimilation which is accomplished in the formative process, wherein the materials are supposed to be made like to the structures among which they are deposited ; for unless the type be good the anti- type cannot be. " When any part or constituent of the body has been injured or diseased, its unhealthy state will interfere with its nutrition, long after the immediate effects of the injury or disease have passed away. Just as in healthy parts, the formative process exactly assimilates the new materials to the old, so does it in diseased parts ; the new formed blood and tissues take the likeness of the old ones in all their peculiarities, whether normal or abnormal; and hence the healthy state of the part to be nourished may be said to be essential to the healthy process of nutrition. '' After any injury or disease by which the structure of a part is impaired, we find the altered structure, whether an induration, a cicatrix, or any other, as it were, perpetuated by assimilation. It is not that an unhealthy process continues ; the result is due to the process of exact assimilation, operating in a part of which the structure has been changed ; the same process which once preserved the healthy state maintains now the diseased one. " Yet, though this increase and persistence of the morbid structure be the general and larger rule, another within it is to be remembered ; namely, that, in these structures, there is usually (especially in youth) a tendency towards the healthy state. Hence, cicatrices, after long endurance, and even much increase may, as it is said, wear out ; and thickenings and indurations of parts may give vray, and all again become pliant and elastic. '' I can hardly doubt that herein is the solution of what has been made a hindrance to the reception of the whole truth con- cerning the connection of an immaterial mind with the brain. When the brain is said to be essential, as the organ or instru- ment of the mind in its relation with the external world, not only to the perception of sensations, but to the subsequent iri^ 540 PATHOLOGY OP INSANITY tellectual acts, and especially to the memory of things which have been the objects of sense, it is asked. How can the brain be the organ of memory, when you suppose its substance to be ever changing ? Or, how is it that your assumed nutritive change of all the particles of the brain is not as destructive of all memory and knowledge of sensuous things, as the sudden destruction by some great injury is ? The answer is, because of the exactness of assimilation accomplished in the formative process. The effect once produced by an impression on the brain, whether in perception or intellectual act, is fixed and there retained ; be- cause the part, be it what it may, which has been thereby changed, is exactly represented in the part which, in the course of nutrition, succeeds to it. Thus in the collection of sensuous things, the mind refers to a brain, in which are retained the effects, or rather the likenesses, of changes that past impressions and intellectual acts had made. As, in some way passing far our knowledge, the mind perceived, and took cognisance of, the change made by the first impression of an object acting through the sense organs on the brain ; so afterwards it perceives and recognises the likeness of that change in the parts inserted in the process of nutrition.'^ All that Sir James Paget says respecting the physiological growth of brain upon the pathological type of disordered sensa- tion, will fully apply to the same growth on the type of disor- dered emotion ; and his views afford an admirable basis for a rational explanation of partial Insanity occurring in persons in whom, during life, there are no physical phenomena of diseased brain, and in whom, after death, there are no pathological appearances in the organ of mind. To resume — the theory we propound of partial Insanity, with- out appreciable change of the brain, is as follows : — When the disease first exists, it is attended by pathological states of the cerebral cells and vessels. A morbid condition of the cerebral organisation is occasioned, attended by the phenomena of In- sanity. After a short time the vessels recover their tone, the brain is nourished, and its size maintained as a whole. But the original balance of its organs is not regained ; their nutri- tion having been impressed in the type or mould of their diseased state. Perhaps some of the cerebral organs encroach on others by their actual bulk ; undoubtedly some of them overbear others by their greater activity. The result is chronic mental disease, of a nature which leaves behind no pathological appearance. SPECIAL CHANGES— MOEGAGNl, ETC. 54l Account of Special Pathological Changeii. — It lias been unfortu- nate for tlie advancement of cerebral pathology^ tbat those early writers who have devoted much care to the observation of cere- bral changes presented in loost-mortem examinations^ have either lacked the desire or the opportunity to make themselves ac- quainted with the mental phenomena which had preceded death. The careful and minute detail of appearances observed in the brains of persons supposed to have died insane, disconnected from any account of the symptoms which existed during life, are of comparatively little value, in the present imperfect state of pathological science. A few fossil teeth and bones enable Professor Owen to reconstruct the probable similitude of an ex- tinct animal; but the science of pathological anatomy has attained far less certitude than that of comparative anatomy ; and there- fore such descriptions as those of the post-mortem examinations made in Bethlem by Dr Webster, have their practical value diminished from the want of some account of the symptoms which in each case preceded death. The descriptions of the older anatomists, Morgagni, Bonetus, and others, have the same defect ; a defect, indeed, of which Morgagni was fully sensible, and of which he offers an explanation, or rather an excuse, in the fact that the medical men who had observed the cases, during life, frequently did not know whether to call the patient melancholiacs or maniacs. He says, " Melancholia is so nearly allied to Mania, that the diseases frequently alternate, and pass into one another ; so that you frequently see physicians in doubt whether they should call a patient a melancholiac or a maniac, taciturnity and fear alternating with audacity in the same patient; on which account, when I have asked under what kind of deli- rium the insane persons have laboured whose heads I was about to dissect, I have had the more patience in receiving answers which were frequently ambiguous, and sometimes antagonistic to each other, yet which were, perhaps, true in the long course of the Insanity.''^ — (De Sedihus et Ccmsis Morhorum, Epist. viii.) Of the thirteen examinations recorded^ Morgagni himself made eleven ; his pupils made one ; and the other one was made by Valsalva. The appearances noted by these great anatomists in this small number of dissections^ include a large part of the morbid appearances which extended observation, and the advan-j tages derived by latter anatomists from the instructions of those preceding them, have been able to distinguish. In one 542 PATHOLOGY OF INSANITY or other of the cases^ the dura mater was found thickened and adherent to the cranium ; the vessels of the meninges distended with dark blood : serum was found between the meshes of the pia mater, sometimes in large quantity ; there were also air- bubbles in the vessels of the pia mater ; the consistence of the brain altered — sometimes soft, sometimes more or less hard ; discoloration of the medullary substance, from distension of its blood-vessels ; serum in the ventricles, sometimes clear, some- times turbid ; the choroid plexus in some cases injected, in others containing cysts; the vessels of the brain sometimes distended with black and fluid blood ; in one instance the coats of the arteries were unusually firm {qiupve atheromatous). In one instance a fibrinous clot occupied the whole of the longitu- dinal sinus. This occurred in a young woman who died with general prostration of the vital powers. It is probably the earliest instance recorded of this appearance, and it is in- teresting in connection with Dr C. B. Williams* views on the formation of fibrinous clots in the cerebral sinuses of asthenic subjects. Of the thirteen insane persons of whom the autopsies are recorded by Morgagni, it is remarkable that no less than four came to an untimely end. One threw himself out of a window in the night, and was killed. One was tied by the throat by his keeper, so that he was strangled. One was starved to death during severe weather ; and ©ne, after recovery from Insanity, died from inflammation of the intestines, occasioned by a finish- ing dose of black hellebore. It would appear from this that the liability of the insane to violent death was very great in those times. Morgagni concluded that the cause of Insanity existed, in many cases, in the morbid changes of the pineal gland, and in many others in an induration of the brain. We are informed that, in his examination, he was in the habit of removing the head from the trunk, for the sake of convenience, before he examined the brain. This indicates forcibly the difference between the accuracy and delicacy of the examinations made by the greatest of the old pathologists and those of the present day. An examination conducted after this fashion would be little likely to offer evidence of moderate serous effusions, or the less obvious conditions of hypersemia. The pathological records of Insanity made by other anatomists of the last century are still less marked by exact observation than those of Mor- SPECIAL CHANGES — GEEDINa, ETC. 543 gsbgni, and are, perhaps, more interesting to the medical antiquary than to the modern pathologist. A brief reference to them may, however, be instructive, as showing that many of the changes which still most readily catch the attention of observers were then noted. Bonetus observed hypertrophy of the brain ; obliteration of the sutures; the dura mater adherent to the cranium and turgid with blood; the pia mater turgid with blood, and not insinu- ated between the convolutions ; water in the ventricles and other parts of the brain in large quantity ; the substance of the brain marked with a black spot, and sometimes with an inj&nite number of bloody spots, especially on pressing it ; in one case it was dry, hard, and friable. Boerhaave mentions that the brain of maniacs has been found dry, hard, and friable, and of a yellow colour. Haller classified the observations made by others upon the brains of insane and phrenitic persons, and concludes thus : — " From these few observations, for which we are chiefly indebted to Morgagni, but little certainty can be derived; since it not only frequently happens that we can discover no disorder in the bodies of maniacs, or even of such as have been totally insen- sible ; but where we do, we are as far fi*om being able to per- ceive an uniform connection between any one disorder of the mind and some corresponding preternatural state of the con- tents of the skull, that the very same appearances are exhibited after those most opposite disorders, idiotism and frenzy; which last seeming inconsistency may possibly appear less extra- ordinary if we consider the symptoms of drunkenness and frenzy^ in which we may observe that the very same cause pro- duces^ at first delirium, and afterwards, as the disorder ad- vances^ drowsiness and insensible stupor. This, however^ seems evident, that in the disorders of the mind the brain and its connections are usually affected ; and ivhen, in some rare in- stanceS) we can discover no disease of these jparts, ive may con- clude^ either that it is seated in their very elementary 'particleSj or has not heen sought for with sufficient patience and attention." — ^ {' Elements of Physiology.'') Greding, in 216 cases, found the skull unusually thick in 167 cases; the dura mater adherent to the cranium in 107 cases; the pia mater thickened and opaque in 86 out of 100 cases of Mania; and beset with small spongy bodies in 92 out of 100 cases. He observed effusions of serum between the dura and 544 PATHOLOGY OF INSANITY pia mater in 120 out of 216 cases of Insanity, and in 58 out of 100 maniacal cases ; the lateral ventricles were distended in 52 cases. The choroid plexus was found healthy in only 16 out of 216 cases of Insanity ; and it was thickened and full of hydatids in 96 out of 100 maniacs. These records will convey strongly the impression, that how- ever exact the observations of this pathologist might have been, he did not interpret the morbid appearances as we are accus- tomed to do at the present day. Effusions of serum between the dura mater and the pia mater, and diseased conditions of the choroid plexus, are conditions which need some description to be intelligible. Meckel remarked the increased density of the cerebral sub- stance in the bodies of the insane. Soemmering and Arnold confirmed this observation ; and the latter expressed his conviction that Insanity was occasioned by the increased density of the cerebral substance, and of those parts of the brain by means of which the soul is connected with the body ! Portal declared that all mental diseases were the effects of morbid alterations in the brain or spinal cord. He enumerated a great variety of alterations, but with so much inaccuracy that little reliance can be placed upon his descriptions. He enun- ciated, however, on this subject, the following sound and philo- sophical doctrine, which, to the present day, may well serve as a text for labourers in this difficult and obscure department of pathology: — Morbid alteration in the brain or spinal marroiv has been so constantly obse^-ved, that I should greatly prefer to doubt the sufficiency of my senses, if I should not at any time discover any morbid change in the brain, than to believe that mental disease could exist without any physical disorder in this viscus, or in one or other of its appurtenances." Pinel had no confidence in the revelations of pathological anatomy. In the preface to his excellent work on 'Mental Alienation,^ referring to the labours of Greding he remarks : — " But although one must eulogise his efforts to throw new light upon the organic affections of the insane, is it possible to esta^ blish any relation between the physical appearances manifested after death, and the lesions of intellectual function which have been observed during life ? What analogous varieties does not one find in the skull and brain of persons who have never shown any sign of aberration of mind ! And, therefore, how can we SPBCIAL CHANGES — PORTAL, PINEL, GALL 545 succeed in fixing the limits which separate that which is norma from that which must be held to be the result of disease V (Preface, p. xx.) In the body of his work (p. 142) he refers the primitive seat of Mania "to the region of the stomach and intestines, from whence, as from a centre, the disorder of the understanding is propagated by a species of irradiation, A feeling of constriction, &c., manifests itself in these parts, soon followed by a disorder and trouble of ideas." Well might Gall exclaim, in reference to these opinions of the great reformer of the treatment of Insanity, and to the opinions, scarcely more philosophical, on the same point, of PineFs eminent pupil and successor, Esquirol : — " It is a sad business that, in writing for men who ought to have the clearest ideas upon mental disease, it should be necessary to commence by estab- lishing the true seat of Mania ;" and he adds that Fodere actually undertakes to prove that the brain is neither the seat of inclina- tion, instinct or mental power, much less of Mania or delirium. {' Sur les Fonctions du Cerveau,' tome ii, p. 223.) In justice to Pinel it should be remarked, that, however mis- taken his views upon the pathology of Insanity may have been, they had at least the merit of referring a bodily disease to a bodily origin. In the preface to the second edition of his work, he thus wisely expresses an emphatic condemnation of metaphysical theories on this point : — " The most difficult part of natural his- tory is, without doubt, the art of well observing internal diseases, and of distinguishing them by their proper characters. But mental alienation presents new and diverse difficulties and obsta- cles to surmount, either in the unusual gestures and tumultuous agitations which it occasions, or in a kind of disordered and incoherent chatter, or in a repulsive or savage exterior. If one desires to account for the phenomena observed, one has to fear another rock — that of intermingling metaphysical discussions and the divagations of ideology with a science of facts." Esquirol, the pupil of Pinel, adhered with affectionate perti- nacity to the opinions of his great master. He states, in the *■ Dictionnaire des Sciences Medicales,^ that the principal changes observed in the brains of insane persons are — " The cranium frequently thick, sometimes eburnated, sometimes with thick-, ness of the diploe, very frequently injected, more rarely thin, its thickness variable in different regions ; the dura mater adherent either to the vault or to the base of the cranium, sometimes 35 546 PATHOLOGY OF INSANITY thickened, frequently its vessels developed and injected ; tlie iiiternal face of the dura mater clothed with a membraniform layer, as if the fibrine of effused blood had extended itself in the form of a membrane. Almost always between the arachnoid and the pia mater serous or albuminous effusions are found, which cover and almost efface the convolutions. Effusions at the base of the brain are common ; they exist almost always in the ventricles.'' In M. EsquiroFs great work, ' Des Maladies Mentales,^ pub- lished so recently as 1838, his opinions on pathology are con- siderably modified. Eeferring to the case of a recent maniac, who was killed by one of her companions, and in whose body he and his pupils were surprised to find no lesions of the brain or its meninges, he declares, that " pathological anatomy, in spite of the very important labours of MM. Foville, Calmeil, Bayle, Guislain, &c., has not been able to make us acquainted with the organic cause of Mania. Thirty years ago, I would willingly have written upon the pathological cause of madness. At the present day I would not attempt a labour so difficult — so much of incertitude and contradiction is there in the results of the necroscopy of the insane made up to this time. But I may add, that modern researches permit us to hope for ideas more positive, more clear, and more satisfactory.'' M. Foville describes in acute cases injection of the pia mater existing to a greater or less extent, according to the degree of inflammatory action in the cortical substance. In chronic cases, he describes opacity and thickness of the membranes, adhesion of the membranes to each other, granulations of the pia mater, and false membranes. The grey substance, he asserts, is, in acute cases, intensely red on its surface and in its substance. This redness is most vivid in the frontal and vertical region. The redness is not uniform, but mottled and diversified with spots of a violet hue, and with minute extravasations of blood. He de- scribes the consistence of the cortical layer underneath its surface as diminished, the surface itself being somewhat indurated. In acute cases, the pia mater, he says, is not adherent to the cortical substance, while in chronic cases it is frequently so ; and in this fact he sees an important distinction, capable of explaining the incurability of chronic mental disease. In chronic cases, the superficial or outer layer of the cortical substance becomes indurated and capable of being separated from the inner layer, which is softened and mammillated ; the outer layer is harder. SI'EOIAL CHANGES — FOVlLLE 647 the inner layer is softer ; tlie outer layer browner^ and frequently paler_, tHe inner layer redder than natural. Atrophy of the convolutions he also describes as frequent ; and this may be confined to the cortical substance, the surface of which is marked with irregular depressions filled with serum. The grey substance is sometimes softened throughout its thickness, and changed to a brownish colour ; the softening of the grey matter is sometimes so great that it may be washed off the white matter (which is sometimes harder than usual) by pouring water upon it. The medullary substance is frequently injected, showing numerous bloody points when divided ; sometimes it is more uniformly discoloured, and has a purplish hue ; sometimes it becomes exceedingly white and indurated ; sometimes, however, when indurated, it has a yellowish or grey tinge. Induration of the medullary substance is attributed by M. Foville to the adhesion with each other of the several planes of the fibres, of which he believes the mass of the white substance to be composed, and which are united to each other by fine cellular tissue. These observations of M. Foville, made partly at the Salpe- triere and partly at St Yon, are highly important and instructive. They agree, in many respects, as we shall hereafter see, with the researches of M. Parchappe ; and although in some respects it may be difficult to verify their correctness in the ijost-mortem rooms of institutions where but a few cases are examined, it is certain that the leading features of the pathological changes in the substance of the brain, which were first indicated by M. Foville, are to a greater or less extent recognisable in a great number of bodies, and amply deserve full and patient investi- gation, in order to establish their nature and their connection with the various forms of Insanity. The researches of Bayle and of Calmeil have reference rather to a particular form of Insanity, namely. General Paralysis, than to the pathology of mental disease at large. M. Bayle attri- butes Insanity to inflammatory irritation of the membranes of the brain, and paralysis accompanied by loss of mental power (dementia), to pressure exerted upon the brain by effusions resulting from this inflammatory state. M. Calmeil attributes Insanity in general to a chronic inflam- mation of the brain, and General Paralysis in particular to a " periencephalite chronique diffuse.''^ M. Lelut, who published in 1836 his work upon ' The Value of Cerebral Alterations in Acute Delirium and Insanity,' came to 548 PATHOLOGY OF INSANITY conclusions opposed to those of the authors last mentioned. He sums up the result of his researches as follows : '' Istly. Numerous alterations of the brain and its envelopes are met with in delirium and Insanity, especially in extreme forms of the latter ; but these alterations are neither constant nor exclusive. ''2ndly. Hence it must be allowed that the more or less local and coarse alterations in the skull, the brain, and its mem- branes, cannot be held to be the proximate causes of Insanity. They are, doubtless, capable of existence with a delirious or insane condition, but they do not constitute this condition ; and frequently they are only the exaggeration, the effect, or the transformation of it. " 3rdly. That which may be given as the nearest approach to the. proximate cause of delirium, and to the most acute form of Insanity, is inflammatory lesion of the brain and its tunics. But this alteration neither does nor can constitute the state which is anterior to it, and may even destroy life without pro- ducing it. "4thly. The conditions of the brain which approach most closely to the proximate cause of the chronic forms of mental alienation, with or without impairment of motion, are without doubt chronic inflammation of the substance and of the mem- branes of the brain, its atrophy and induration, which may be accompanied by variations in its specific gravity. But yet these alterations are not the proximate cause of these forms of Insanity, because they are neither constant nor exclusive, and they do not make themselves apparent except in an advanced period of the disease.^^ The arguments by which M. Lelut arrives at these conclusions appear almost as shifting as the organic lesions which are, and are not, according to him, the cause or the condition of Insanity. Inflammatory lesions of the brain are, according to him, very near being the cause of acute Insanity; but they are not the cause, because they may destroy life without producing Insanity. Chronic inflammations also approach closely to the cause of chronic Insanity (les conditions du cerveau qui se rapprochent le plus de leur cause prochaine) ; but yet they are not the proximate cause, because they only make themselves obvious after a while. Some years subsequently to the publication of M. Lelut' s book, another eminent French physician, M. Leuret published a SPECIAL CHAXf>ES — LELITT, LEUEET 549 work on the same subject. The title of this work^ ' The Moral Treatment of Insanity/ would lead us to expect views adverse to the somatic origin of mental disease ; and such, in fact, is the case. Physicians who treat Insanity with penal remedies are not likely to regard its cause as a pathological condition of the organism ; and, on the other hand^ physicians who refuse to regard Insanity as a bodily disease^ and who interpret its phenomena as manifestations of a fermentation in the spiritual essencOj easily and logically persuade themselves that sharp penal remedies are useful and justifiable in its treatment. M. Leuret certainly combats the somatic theory, and the pathological facts upon which it rests, with a logical acumen contrasting very strongly with the manner of the author last mentioned, and even of M. Esquirol. TVliile we entirely dissent from his conclusions, we are glad to avail ourselves of his assistance to ascertain the weak points of that doctrine which attributes Insanity to cerebral change alone ; a doctrine of the truth of which we are convinced, but the evidence of which needs to be multiplied, confirmed, and arranged, with a care and precision which it has not yet received. M, Leuret believes that he has established the following propositions. Ist. That the authors who believe it possible to establish an anatomical change as the cause of Insanity differ greatly among themselves ; thus, Greding asserted that thickness of the bones of the cranium occurs in 77 out of 100 patients,, while Haslam found this condition in 10 only out of 100 patients. Hyper- semia of the brain is recorded by Parchappe in 43 cases out of 100; and by Bertolini only in 14 out of 100. 2ndly. That some of the cerebral alterations (to which Insanity is attributed) are by no means well established. Thus, in the cases which are cited of hypertrophy in the brain, it ought to have been established that this was not owing to fulness of its vessels, or to the presence of a serosity in its tissue. These observations have not been made. Again, that which is called a dense brain, or a soft brain, expresses nothing distinctly, except in extreme cases. 3rdly. That the value attributed to certain alterations is deduced from a number of observations by far too small, so that one result frequently invalidates another; thus, M. Parchappe has deduced the average normal weight of the healthy brain from thirteen observations on men, and nine upon women, and upon this average he establishes the rule 550 PATHOLOGY OF INSANITY for atrophy of the brain. This average is evidently too small, and indeed M. Parchappe gives different averages elsewhere. 4thly. That the pathological alterations referred to Insanity are met with in patients who have never been insane. 5thly. That all authors confess that there are insane persons in whose brains no pathological changes are found. 6thly. That the lesions which are frequently met with among the insane, to which any value can be attached, are only nj.et with in cases in which Insanity has been complicated with para- lysis ; and that in order to decide if any lesion is the cause of Insanity, it is at least necessary to find it in a case of simple mental aberration, in which there has been no affection of motion or sensibility. That so able an opponent of the somatic theory, as M. Leuret undoubtedly is, should have been compelled to rest his argu- ments upon no better foundations than those above named, appears to afford strong presumptive evidence of the truth of that theory. We shall make some brief comments upon each of his objections. 1st. That authors should differ so greatly in their estimate of pathological changes, as M. Leuret has shown them to have done, can prove no more than that they have been inexact in their observations, or careless in recording them. The objection may to some extent be valid against the value of statistics in pathological science. It may show that one observer counted slight appearances of change, while another only recorded extreme instances ; but it can in no way detract from the value of the fact, that all the authors cited did observe the patholo- gical changes they have recorded, in a number of cases. 2ndly. That pathological changes of the brain need to be observed with greater exactness than heretofore is undoubtedly true. They have, however, been observed with greater exacti- tude than M. Leuret admits ; for instance, in the case he cites, hypertrophy, it is well established that in this rare condition the brain is paler and drier than usual, and that the increase in its volume cannot be attributed either to fulness of the vessels or to serous infiltration. 3rdly. This objection again applies to the statistical method of proof, as it is too frequently used. It applies, however, to the abuse of this method in all departments of pathological science. Doubtless, those who count observations without estimating them as recommended by Morgagni, misuse the SPECIAL CHANGES— LEUEET 551 numerical method in their deductions upon all diseases. Insanity included. 4thly. If M. Leuret could show that serious pathological change in the cortical substance of the convolutions has existed in persons whose mental functions have never been affected, he would go far to upset the somatic theory of the nature of Insanity; but this he has not done, nor, in our opinion, is he likely to do. That some pathological changes which are observed in insane persons, but which are non-essential to Insanity, should occur also in persons who have always been sane, is a fact of no value in the present discussion. 5thly. That in the brains of some insane persons no patho- logical changes are observable by existing means is not to be denied ; but it would not, in these cases, be more philosophical to doubt, with M, Portal, the sufficiency of our powers of observation than to use them as an argument against the existence of all pathological change of an organ whose functions are perverted, but whose structure is not obviously injured. Is M. Leuret able to point out the pathological changes which cause neuralgia, tetanus, chorea, or hysteria, or those by which life is destroyed by a blow on the epigastrium, or by concussion of the brain ? Deficient information should lead us to seek for more light, and should by no means induce us to veil that which we possess. 6thly. M. Leuret certainly mistakes the fact, when he affirms that cerebral lesions are only found in those insane persons who are paralysed, for whatever doubt may hang over the primary pathological changes which attend the earlier stages of simple mental aberration, there can be no doubt whatever that the secondary conditions which attend the chronic stages of simple Insanity, uncomplicated with paralysis, are undeniably obvious in degraded nutrition and atrophy of the cerebral organ. M. Guislain, who for many years was the able leader of psychology in Belgium, classed the lesions of the brain found in Insanity under nine heads : 1st, a state of sanguineous con- gestion of the meninges, of the brain, or of the two together; 2ndly, a state of serous congestion of the same; 3rdly, cerebral softening ; 4thly, opacity and thickness of the arachnoid ; 5thly, adhesions of the membranes to each other, or to the brain ; 6thly, cerebral induration ; 7thly, cerebral hypertrophy ; 8thly, cerebral atrophy ; 9thly, vices of conformation of the brain and of the skull. 552 PATHOLOGY OF INSANITY These conditions are, lie thinks, in a practical point of view, capable of being reduced to four fundamental alterations — sanguineous congestion, serous congestion, softening and indu- ration. It is open to doubt, however, whether the three latter of these alterations can be considered fundamental ; and it is certain that the four do not include all the conditions which may be considered fundamental. He does not include those aberrations of nutrition known under the names of inflammatory, atrophic, and antemic. That M. Guislain admits the existence of such conditions, is abundantly evident from the pages that follow. At page 367, ' Le9ons Orales,' tome i, he attributes to the state of congestion, not only ecchymoses of the arachnoid and pia mater, but false membranes, and a red appearance of the arachnoid, " having the aspect of an inflamed conjunctiva." Such an appearance, and especially the existence of false mem- branes, cannot be attributed to a state of congestion, and if they occur, should have induced this able physician to have admitted the inflammatory, as one of the fundamental states of the brain in Insanity. He estimates that, in one fourth of the bodies of persons dying insane, there is a congestionary state of the encephalic mass ; but he declares his opinion, that this proportion is far from that which obtains among the living insane, and that the majority of those who are cured have never had congestion of the brain in a notable degree. M. Guislain says, " The brain and its membranes may have been congested without the existence of a state which can be called inflammatory. If inflammation were always a condition of congestion, would one see the numerous cures which take place among sanguine and robust maniacs, who offer in the course of their disease those symptoms which one often con- siders to be inflammatory, and which are really only a vascular orgasm, and not a state of phlegmasia ? Broussais himself felt this in giving to this condition the name of subinflammatory. It is an influx of blood, which may in a manner be compared to that injection of the cheeks which accompanies shame and modesty ; that injection which makes itself evident in the eyes, over the whole face, the neck, and even over the breast of a man agitated by violent anger." It is evident, however, that a much more profound and serious change exists in the blood-vessels of the insane brain, than in SPECIAL CHANGES — PAECHAPPE 563 the transitory blnsli of modesty or the suffusion of passion. These states are physiological, and leave behind them no tendency to destructive change. The state of the congested brain in Insanity is pathological, tending to pass into a state of structural change, and respecting the wide deviation of which from a state of health there can be no doubt. If the congestion of Insanity were of the character which M. Guislain attempts to attribute to it. Insanity would be as transient as passion, or passion would be as dangerous as Insanity. M. Parchappe. — The most careful investigations into the patho- logical anatomy of Insanity, made in France, are, without doubt, those of M. Parchappe, the Inspector General of Asylums in that country. His first work on the different alterations of the brain in Insanity was published in 1838. M. Parchappe com- mences by admitting fully, '' That there is no single pathological alteration which can be proved to exist in all cases of Insanity ; but there are three which have been found in the majority of cases. This is a result which might have been expected. The pathologists who have searched for one essential characteristic pathological change, might have saved themselves a deception. The point which one may reasonably hope to attain to is, to be able to distinguish among cases of mental diseases those kinds which are characterised both by the constancy of the symptoms, and by that of pathological change." In M. Parchappe^s opinion, the uncertain recognition of patho- logical alterations in Insanity, and the occasional absence of all appearance of change, disprove, indeed, the theories of those who attribute Insanity to some exclusive pathological condition of the brain — for instance, to chronic meningitis, or to indura- tion of the brain — but they do not prove that these alterations are, as asserted by Bsquirol, Leuret, and others, mere compli- cations or consequences of the malady. The alterations which exist in simple inflammation of the brain and its membranes, are not those which are found in Insanity. Those which are found in Insanity may be distinguished into — 1st, those which may be considered accidental; 2nd, those which, existing in other maladies, yet appear to play a part in the production of Insanity; and 3rd, those which are believed to be essential to mental alienation. Among the first may be enume- rated cerebral haemorrhages, partial softening of the white substance, disease of the cerebral arteries ; and, among the second, thickening and opacity of the arachnoid, hypereemia of 554 PATHOLOGY OF INSANITY the pia mater and of the brain, serous infiltration of the pia mater, and dropsy of the arachnoid cavity. In the important last division, this author includes the following changes : sub- arachnoid ecchymosis, and a partial punctiform injection of the cortical surface, with or without softening, extended softening of the middle portion of the cortical substance, adherence of the pia mater to the surface of the brain ; rose, lilac, and violet coloured discoloration of the cortical substance, loss of colour of the cortical substance, atrophy of the convolutions, induration of the brain. M. Parchappe believes that he is able to establish the following classification of mental disease upon the patho- logical changes which he has observed. 1st. Monomania ; in this form of Insanity, no pathological change is found to exist in the brain, and the probable cause is to be sought in the organic predominance of some portion of the brain, in con- sequence of its size or activity. 2nd, Acute Mania and acute Melancholia ; in these forms of Insanity, the alteration found in the brain to a certain extent resembles those of inflamma- tory affections of the organ. They are hyperaemia of the pia mater and of the cortical substance, partial injections of the subarachnoid tissue, punctiform injection, and occasional soften- ing of the cortical substance ; it is rare that the meninges are found extensively thick and opaque. The above alterations are usually more decided in acute Melancholia than in acute Mania. In sympathetic Mania, that is, in Mania occasioned by the irritation of some part of the distal nervous system, no anatomi- cal changes may be discovered if the examination is made during the early period of the disease ; but after a while, the brain passes from the state of physiological excitement into that of pathological change, and then the above alterations may be expected to be found on examination. 3rd. Simple chronic Mania; in this form of Insanity, the aspects of the brain are altogether different from those which prevail in the acute paralytic forms of Insanity ; they are — atrophy of the convolu- tions with loss of colour and induration of the cortical substance, or of the medullary substance, or of both ; serous infiltration of the pia mater, and dropsy of the ventricles, connected with, and consequent upon, general atrophy of the braiu. 4th. Paralytic Insanity (general paralysis). In this the essential alteration consists in softening of the middle layer of the cortical sub- stance ; very frequently, also, the pia mater is thickened, adherent, and infiltrated ; in the acute form, the cortical sub- SPECIAL CHANGES — PAECHAPPE 555 stance is hypereemic and deepened in colour, and tlie pathological appearances of acute Mania are present. In the chronic form, the cortical substance has lost colour and become thin ; atrophy o£ the convolutions, and the appearances of chronic Mania are present. bth. Epileptic Insanity. In this the alterations resemble those of simple chronic Mania. In 1841, M. Parchappe published his ' Theoretical and Prac- tical Treatise upon Insanity/ a work more fully devoted to necroscopic record than AndraPs ' Clinique/ or Lallemand^s ' Letters.^ M. Parchappe attempts to establish his deductions by the numerical method ; and in this we think he has fallen into an error ; first, because the number of cases upon which he founds his averages are, under some heads, insufficient to establish a trustworthy, average ; secondly, because he has, in several instances, adopted methods of comparison which are open to much objection. The manner in which he arrives at an estimate of cerebral atrophy is objectionable, on account of both of the reasons above given. He founds his estimate upon a comparison between the weight of the brain examined and the average weight of healthy brains. Now it is evident that, if the diseased brain has originally been heavier than the average, a considerable atrophy might fail to be shown by a comparison of this kind. An atrophied brain, of large size, may still be heavier than the average of healthy brains. M. Parchappe^ s average weight of the sane brain may have been deduced from average individuals ; but he could make no selection of this kind for the other side of the comparison. The insane person whose brain has to be examined and compared, may have been a well-developed man, with all the organs above the average size, or with a brain originally large or small in comparison with the rest of his body. So true is the addition which Morgagni made to the dogma of Hoffmann, '' Ars medica tota in ohservationihus." Morgagni wrote, " sed jperpendenda sunt non oiumeranda ohservationes." In the resume upon thirty-eight autopsies of persons dying in the acnte stage of Mania and Melancholia, M. Parchappe (p. 45) affirms the same principles which he has enunciated in his former work, especially the absence of any essential and exclusive encephalic alteration. He affirms, moreover, that these dissections prove the existence of an analogy as strong as possible, if not perfect, between the cerebral alterations found after acute Mania and those of acute Melancholia ; and therefore 556 PATHOLOGY OF INSANITY he concludes^ that the distinction between these two states is not justified upon pathological grounds. The thirty-eight examinations afford the following resume : — In thirty-six the brain was the seat of hypergemia^ either in its periphery^ its membranes, or its substance ; in seven instances the hyperasmia was simple ; in twenty -nine it assumed the form of subarachnoid ecchymoses ; in twenty-three instances there were subarachnoid ecchymoses, with punctiform injection of the cerebral surface ; and in seventeen of the latter there was also softening of this surface. Sixteen times the cortical substance was reddened in colour. In one case there was no apparent encephalic alteration whatever ; and in several the alterations were inconsiderable. It is needful, therefore, to admit that the pathological condition of acute Insanity is of such a nature that it is possible for it to leave no naked-eye appearance of change. Taken singly, none of the alterations described can be held to express a pathological state of the brain which corresponds to the abnormal psychical manifestations ; but examined collect- ively, these alterations afford an idea of the pathological character which must be attributed to that state — namely, that of hyperaemia. This condition was only absent in two cases out of the whole thirty-eight ; and it is very probable that hyperaemia also existed during life, even in the two cases in which there was no trace of it after death. The thickening of the meninges, and the superficial softening of the cortical substance, which are so frequently found, would also indicate that this hypereemia is not that of simple but that of active congestion. " A legitimate induction may, therefore, be derived from the fact," says this author, " to the effect that there is usually, during life, an active sanguineous congestion of the brain coexisting with the symptomatic phenomena of acute Insanity." " One may even recognise, up to a certain point, a relation between the intensity of the symptoms during life, and the extent of the alterations after death." Of chronic Insanity, M. Parchappe details the appearances of 122 cases, which may be summed up as follows : — In seven instances there were no alterations, or almost none ; in eleven instances the alterations were simply hypertemic ; in five the two substances were softened ; twice there was induration of the true cortical substance alone ; eight times there was induration of the white substance alone ; twenty times there was induration SPECIAL CHANGES — PARCHAPPE 557 of the two substances ; sixty-one times there was atrophy of the cerebral convolutions ; sixty-four times there was hypereemia^ which was simple in forty- six cases, and in eighteen combined with ecchymoses, and in two cases with injection and softening of the cortical substance. This substance was coloured red five times. It was deprived of its [normal ?] colour fifty-nine times. It is evident, says M. Parchappe, from these facts, that there is no essential and characteristic pathological appearance in chronic Insanity. There may be no trace of pathological change after death, or only the unimportant one of simple hypersemia. But the alterations are remarkably dilferent from those which belong to acute Insanity. In the latter, the pre- dominant alterations are hyperjemic conditions, with arachnoid ecchymoses, injection and softening of the cortical substance. In chronic Insanity, the predominant alterations are atrophy of the convolutions, and induration of the two substances. '' The symptomatic differences in the two forms of Insanity corre- spond generally with the pathological differences in the organ of intelligence.^^ In chronic Insanity, the predominant state is pathologically opposed to the hypersemic condition of acute Insanity; and the atrophy of the convolutions, especially, expresses a movement of the plastic force opposed to that which represents active hypergemia. ^*^ The predominant alterations in chronic Insanity express, in general, a state of diminution of the plastic activity ; a state diametrically opposed to that expressed by the predominant alteration in acute Insanity, which has been shown to be active sanguineous congestion, representing the physiological principle at the highest point of plastic activity. And these conditions of the organism coincide with the psychical symptoms peculiar to the two forms of disease which present two opposed dynamical states — the one in which psychical activity is in a plus and the other in which it is in a minus condition.''^ M. Parchappe concludes his valuable treatise with a chapter upon the appearances of the healthy brain. From an early period of his investigations, he had instituted comparative examinations of sane and insane brains, having both before his eyes at the same moment. On this point he says : " I have thus been able to assure myself how inexact is the assertion frequently made, that between two brains of this kind, it is absolutely impossible to distinguish that which belongs to Insanity. The contrary assertion would be much nearer to the 558 PATHOLOGY OF INSANITY truth, especially if one did not make it without some restriction. In regard to paralytic Insanity, at least, it may be said, that the difference strikes the eye, and can only be mistaken by prejudice or inattention." He sums up the characteristic appearances of the sane brain as follows : — " Extreme tenuity and perfect transparence of the arachnoid, and of the pia mater. Absence of subarachnoid serous infiltration. The membranes may be detached from the convolutions without producing decortication. When the corti- cal substance is soft, and the membranes begin to become dry, it may happen that, in circumscribed points, they detach with themselves flocculi,and even small plates of the cortical substance. The cortical substance is of a grey colour, of which the shade varies a little in different individuals, and in the same individual in different parts of the thickness of the substance. To the naked eye the shade of the surface does not appear paler than that of the deeper parts. The internal portion is, perhaps, a little deeper in colour, and between the two we can sometimes distinguish an intermediate shading, paler than either. The medullary substance is of a pure and striking whiteness. The consistence of both substances is considerable when the death has been recent and the temperature moderate. The white substance is rather more firm than the grey. The surface of the ventricular membrane is smooth and brilliant, sometimes offering very fine granulations. The cut surface of the white substance is sometimes dotted with a small number of red points. Under the influence of the air, the blood in the vessels becomes more brilliantly red, and the cortical substance takes on a rosy tint, which gradually becomes deeper, but which never attains the intensity which characterises pathological alteration of colour of this substance. The influence of time and a hisrh temperature, produces softening and commencing putrefaction, and causes the detachment of flocculi with the membranes, like that produced by the drying of the membranes fi'om contact with air. The convolutions are pressed together, only offering space for imbedding the pia mater; and when the membranes are removed they still touch, and if separated, they return to their apposition on account of their elasticity, and the anfrac- tuosities efface themselves. The thickness of the cortical sub- stance varies in the anterior lobes from two or three millimeters, and on the convesity, and at the base, from two and a half millimeters to five." Si>ECtAL CHANGES — PAEOHAPPE 559 The eminent author we have here freely quoted^ has done excellent service to the cause of a rational pathology of mental disease. He has excluded all speculative hypothesis upon the nature of mind and its aberrations, and has set a worthy example to his successors in the careful and laborious manner in which he has observed and recorded the facts upon which alone any trustworthy knowledge in this as in all other departments of science can be founded. We are far from agreeing in all par- ticulars with M. Parchappe, but to the spirit of his inquiries, and to his general results, we give our hearty adherence. These results, however, require to be accepted with some limitations and exceptions ; and, as we hope hereafter to show, many addi- tions to them must also be made, to present a correct general idea of mental pathology. It is, however, no small praise to an author to affirm, as may with truth be done of M. Parchappe, that no candid investigation, even into his errors and deficiencies, can be made, without advancing the science of which he treats. The principal error in which M. Parchappe appears to have fallen is that of having made too abrupt a classification of Insanity into acute and chronic. The phenomena of the disease by no means justify a distinction of this kind so sharp and sudden as to lead to M. Parchappe^ s assertion, that the two forms of the disease present pathological conditions essentially opposed to each other. Doubtless the pathological appearances presented in a typical case of each form will sometimes contrast with each other as remarkably as he insists ; but a large proportion of cases of Mania and Melancholia have never been acute ; and a large pro- portion of cases which are unquestionably chronic in point of duration, present at intervals, all the symptoms of acute disease, and after death present an intermixture of those pathological conditions which M. Parchappe has described as opposed to each other from their very nature. Nothing is more common than for an atrophied brain to suffer from temporary hypertemia. It is a pathological law, that injured and ill-nourished organisms are liable to sudden congestions, almost in proportion to the amount of deficiency in their nutrition. Hypersemia is moreover peculiarly liable to take place in the atrophied brain in conse- quence of the loss of external support which the organ has sustained by shrinking away from the cranium. The lengthened, tortuous, and dilated vessels of the pia mater, in atrophied brains, indicate the frequency with which they have been in a hypersemic state. 560 PATHOLOGY OF INSANITY The form of mental disease which destroys life in the early period of its course is comparatively rare, and has been thought by many modern writers to be a distinct form. The French alienists of the present day call it Delire aigu, and distinguish it from recent Mania and recent Melancholia. In the brains of persons who have died while suffering from this form of Insanity, the strongly marked characteristics of hypereemia of the sub- stance and the membranes, even to the subarachnoid ecchymoses described by M. Parchappe, undoubtedly exist. But in the recent cases of Mania and Melancholia of most frequent occur- rence, if death were to occur from some accidental cause or intercurrent disease, which did not interfere- with the state of the cerebral circulation, it is by no means so certain that strongly marked signs of hyperaemia would be found to exist. In many cases of recent Mania, indeed, a condition of the brain the very opposite of hyperemia, is known to be the condition of disease, both from the nature of the cause, the effects of the remedies, and the ijost-morteni appearances, when chance has afforded an opportunity for observation. The fact, that all the symptoms of acute Mania fi^equently arise, and continue throughout the course of an exhausting bodily disease, which leaves every individual organ, the brain included, in an ill- nourished and anaemic state, affords irresistible evidence that the phenomena of acute Insanity must in many cases coexist with a state of the cerebral organ, the very reverse of hyper- semic. The rapid formation of ideas is so remarkable a sym- ptom in acute Insanity, that M. Parchappe, in common with M. Falret and others, considers it as a proof that the psychical activity is in a state of exaltation ; and he, logically enough, infers that the plastic activity of the organ of which psychical activity is the function, must also be in a state of exaltation, or, as he expresses it, in a 'plus state. This however, is not unconditionally true. Doubtless, in some cases, and for a short time, active hyperemia of the brain, attended by a rapid nutrition and decomposition of its substance, and accompanied by quick-flowing ideas and fancies, may be the condition of Acute Mania, as it is the condition of cerebral excitement in the early stage of intoxication. But it is an error to suppose that a rapid flow of ideas is always a sign of that psychical activity which depends upon an exalted state of cerebral nutri- tion. There is an idea-forming activity which resembles palpi- tation of the heart from weakness ; and ideas frequently flow SPECIAL CHANGES. — GBIESINGER 561 througli a debilitated brain in rapid succession^ because tbe mental irapression made by each of tbem is feeble and transitory. , Doubtless they follow a certain train^ but this is of the most desultory kind, because the organ answers to the faintest touch. The Germans have a curious term for this impressive and remarkable condition of the mind. They call it Ideenjagd (idea- hunt) . It is a hunt in which there is nothing hunted ; or, like the chase of the ocean billows, where the old are ever vanishing and the new arising, without evident purpose or end. Griesinger. — "We may fitly conclude this account of the opinions entertained on this subject by eminent French psycho- logists by giving the summary with which the great professor of Berlin concluded his instructive chapter on the Pathology of Insanity. " Keeping in view the great and well-constituted results, negative as well as positive, and altogether excluding rare and more isolated observations, we shall attempt in the following paragraph to compare the various states of psychical diseases with the anatomical conditions which most frequently correspond to them/^ " Acute Insanity. — ^As in a considerable number of cases of Acute Insanity the brain, on anatomical examination, appears perfectly healthy ; it must, in the present state of science, be assumed that the symptoms very often depend upon simple nervous irritation of the brain, or upon disorders of nutrition which are as yet unknown. ^'When palpable disorders exist, they consist chiefly in ansemia with more or less serous infiltration, or (more frequently) in hypersemia of the entire brain, and particularly in simple and ecchymotic hypersemia of the delicate membranes and cortical grey substance. These hyperemias appear sometimes to produce, and at other times merely to accompany, other morbid processes of nutrition which lead to further conse- quences. " This hyperaemia is frequently accompanied by thickening and opacity of the membranes, the result of chronic stasis. This may, in certain cases, proceed from the same causes as the hyperfemia itself; in others, however, it may be the result. " There is no constant distinct anatomical distinction between Melancholia and Mania ; the disorders in both forms are, never- theless, not entirely identical. ''In Melancholia the braiu appears perfectly healthy, more 36 562 PATHOLOGY OF INSANITY" frequently than in Mania ; when an anatomical lesion exists, it does not consist in hyperasmia so frequently as in Mania, but rather in anasmia with greater consistence of the cerebral sub- stance or with more or less serous infiltration. " Mania presents more rarely than Melancholia no lesion or simple hyperemia. The hypergemia is more profound and more intense (sometimes attaining to an erysipelatous hue of the entire cortex), and it more frequently proceeds to inflammation and softening, which affect the cortical substance in only certain layers, sometimes the middle, sometimes the external layer. The rapid occurrence of extended softening of this kind frequently corresponds to a state of profound Dementia which precedes death. The intense hyperaemias which accompany or produce the softening appear partly to determine the violent maniacal excitement. Frequently, also, when the Mania is of long standing, there is found pigmentation of the cortical grey substance. " Chronic Insanity. — Cases in which no anatomical lesion is found are here rarely observed ; the same may be said of simple hyperaemias. Opacity and thickening of the membranes are common (much more so than in acute Insanity). " Many cases present lesions which are never observed in the former class ; viz. atrophy of the brain, particularly of the convolutions, chronic hydrocephalus, effusions into the sub- arachnoid space, pigmentation of the cortical substance, extended and profound sclerosis of the brain. Here, softening is not so frequently met with in the superficial cortical layer as pigmen- tation, superficial induration, and adhesion of the pia mater ; all in very various degrees. " In these states, but, perhaps, also in the acute stages, slight superficial inflammations of the ventricular walls must necessarily be of frequent occurrence. The granular condition of the ependyma and the frequent adhesions of the ventricular surfaces demonstrate this. ''When the disease reaches the chronic stage, hypereemia ceases; when it does exist, it is of the nature of hyperasmia ex vacuo ; sometimes the more or less atrophied brain is anaemic and cedematous. All the changes in the brain are less indicative of active processes than of consecutive states and residues of former processes, and of marasmus corresponding to the character of the symptoms observed during life. "Between partial Dementia and Dementia there is as little MICEOSOOPIO EESEAECH 563 difference^ anatomically^ as between Melancholia and Mania; still, generally speaking, considerable atrophy of the brain corresponds to a condition of profound mental weakness. The reverse, however, does not hold good. " We arrive at the following general conclusions : (ft) Insanity, whether acute or chronic, may be the result of simple abnormal excitation or nutrition of the brain, without the existence of any palpable change. (6) In the majority of cases this is not the case ; it depends upon palpable diseases which are generally distinct in propor- tion to the duration of the Insanity. These consist partly in hypereemia and inflammatory processes, which, as a rule, are first observed in the pia mater and cortical substance, penetrate to various depths of the cerebral substance, and, if not arrested, terminate in incurable destruction and atrophy of the cerebral substance, a lesion to which the group of symptoms of Dementia corresponds. (c) Frequently, however, it is non-inflammatory changes in nutrition, recognised only in their final results — viz. marasmus of the brain, which corresponds to the serious secondary forms. The initiatory periods and stages of development of these nutrient changes, which correspond to the primary forms as yet are uninvestigated. To these processes we may give the name of atro'pidc irritation of the hrain. [cl) Our knowledge of symptoms is not yet so far advanced as to enable us to state with certainty whether in a given case of Insanity, anatomical changes exist, and where they are situated ; but the facts which we observe enable us to speak with as much confidence as we can in any other disease of the nervous system. (e) The most important circumstance in regard to anatomical diagnoses and prognosis is the existence or non-existence of severe motory disorders, in particular of general progressive paralysis.^' (Griesinger on ^Mental Diseases,^ Robertson and Rutherford^s translation, pp. 432, 434.) Since the second edition of this Manual was published, a great advance has been made in the investigation of the normal and morbid histology of the brain. This work is difficult and special; and requires great industry, skill, and devotion to its pursuit. It is not every one that has the organic capacity to use a microscope thoroughly well. If every one could do so 564 PATHOLOGY OF INSANITY as easily as he can look through an opera glass, pathological anatomy would make rapid strides ; but it is not so, and, perhaps, the astronomer's great instrument requires less skill and use than that of the modern pathologist. And when the armed vision has been educated, the great qualities of judgment to criticise and determine what is seen, and of faithfulness to record it, are imperatively demanded. These conditions being given and opportunites found, we may confidently trust the microscopist in observations where we can follow him with the reason though not always with the sense. That different microscopists differ so much from each other and even from themselves is but a proof that they pursue a most difficult art. Thus, His who first discovered the lymphatic canal surrounding the cerebral vessel is, now that others are beginning to see and describe it, the first himself to give it up. This space, as Dr Batty Tuke observes, is visible in animals who have died with ansBmic brain, and invisible in those whose brain is con- gested. The changing conditions of these fine observations are but beginning to be known and appreciated. The author of these pages has not had the good fortune to become a skilful microscopist. Perhaps he may be permitted to say that he pursued the microscopic investigation of morbid brain until irritation of the retina imperatively forbade its continuance, and that he ever regards this physical incapacity as no slight misfortune. In the meanwhile others have been working in this new field of research, Lockhart Clarke, Bastian, Moxon, Allbutt, Kesteven, Eutherford, and others ; but of all these we venture to say that no one has more skilfully and devotedly used great opportunities than Dr Batty Tuke, of Edinburgh, who was the first histologist in this country who systematically examined prepared specimens of the brains of persons dying insane, and it is with complete confidence that we have confided to him the difficult and responsible task of laying before our readers the present state of knowledge as to the histology of the insane brain. We trust that this original contribution from Dr Batty Tuke will bring the pathology of our subject up to the present date of correct knowledge, but, because histological investigation has advanced, we shall not omit the due consideration of naked-eye appearances. These, of late, it has been the fashion to depre- ciate with as much philosophy as a child shows when he breaks his old toy because he has a new one ; and we entirely disagree with Dr. Blaudford when he states that all the records of former PATHOLOGICAL OBSEEVATIONS 565 autopsies made with the naked eye are so much waste paper. In our opinion naked-eye appearances must ever be the common foundations of pathological knowledge^ and the triumph of cerebral histology will occur when it has taught us to recognise with the naked eye what condition of the tissues we should find with the microscope. As well might the naked-eye appearances of the lungs, the stomach, or the kidney be discredited because the microscope has taught us to understand them. Moreover, there are naked-eye appearances which stand by themselves as most important facts to which it is possible that histological research will hereafter add greater value. It may or it may not do so, but in the meanwhile they have an intrinsic value, which it would be mere pedantry to ignore. Take, for instance, the naked-eye appearance of abscess of the central white matter without aifection of the mind, and contrast it with the naked-eye appearances of the meninges and cerebral cortex which are never seen without mental disturbance. Are the records of such facts mere waste paper ? Histology has taught us and will teach us much, but we venture to think that even in the brain, and certainly in the body at large, naked-eye appear- ances have taught us more. Let us worship the rising sun with rational devotion and not act like " the idiot who takes his bauble for a God." Our own Pathological Observations. — We shall, therefore, now describe the naked-eye appearances which we have ourselves observed in the dissection of the bodies of the insane. On making the examination, it is oui* custom to note the size of the bony frame, measured by the length of the body and its breadth across the shoulders and hips. This affords a much better standard with which to compare the size of the head and weight of the brain, than that afforded by the weight of the body, which has been adopted for this purpose by some pathologists. The weight of the body varies so greatly be- tween the obesity of Dementia and the emaciation of Mania and Melancholia, that the standard it affords is most untrust- worthy. Careful observation, however, should be made of the state of emaciation or obesity ; also of any bruises, or bruise-like marks ; any bed-sores or deformities. The features, after death, generally lose all expression characteristic of mental disease. The examiner is frequently surprised at the regularity of feature and placidity of expression in countenances which, to the last 566 PATHOLOGY OF INSANITY hours of life, had been disfigured by the peculiarities of insane physiognomy. Even the heavy and the relaxed features of General Paralysis are braced up after death, and return to their normal expression. Often have we felt that we have never seen the sane expression of a patient^s face until after his death. The Scalp and Cranium — The dimensions and form of the cranium should be noted. Although we believe that in the insane the average dimensions of the head are below those of the sane, when the comparison is obtained by the examination of large numbers ; still, in a great number of instances, they will be found to be good ; and, indeed, the head is frequently not only large but phrenologically well shaped. We are not aware in what proportion of the sane the shape of the head is peculiar, since it is rare that opportunities occur for making exact observations upon them ; but among the insane a considerable proportion present decided peculiarities in the shape of the cranium. The most frequent one is a want of symmetry between the two sides. One side is rather flatter or smaller than the other ; or the whole cranium is pushed over a little to one side ; or one side is a little more forward than the other j or the two anomalies coexist, giving the cranium a sort of twisted appearance. These things will not be seen unless they are looked for, with accurate and careful eyes, upon the shaven scalp. Sometimes the skull is high and dome-like ; more frequently it is as if it had been compressed laterally, and elongated from before backwards — keel-shaped, in fact, like the skulls figured by Dr Minchin, in the ' Dublin Medical Journal,-' in which the centres of ossification of the parietal bones are increased iu number. Sometimes the forehead is preternaturally flat, narrow or receding, or very large and bulging ; or the occipital region is deficient, and the back of the head rises in a straight line with the nape of the neck. Sometimes the skull has a remark- ably square configuration. The square and the carinated form of skull we have most frequently seen in connection with Mania ; the dome-like and high vertical skull, and also the unsymmet- rical skull, most frequently in Melancholia. In Mania, the anterior cranium is more frequently of good shape and size than in Melancholia. In the latter the forehead is often small and mean, but sometimes it is disproportionately large and globose. The shape of the head as it ought to be according to the rules THE CEANIUM 567 of phrenologists, can only fairly be expected to coincide witli the mental symptoms, in those somewhat rare instances in which Insanity is the mere development in excess of natural character; and in some such instances we have found the shape of the head tally, in its general outline, with the indica- tions of phrenology. Occasionally, depressions are found in the outer skull, which sometimes do, and sometimes do not, correspond with the bulging in of the inner table of the cranium. When they do not so correspond, we have found that they indicate a local absorption of the diploe. It is an interesting question how far the shape of the skull alters in Insanity. If the forehead expands, even in mature age, under the influence of intellectual development, it is likely that it will contract under the influence of intellectual decay. Some writers have asserted that the shrinking of the brain in atrophy is commonly, and to a considerable extent, followed, and the cranium filled, by a flattening and shrinking of the cranial bones. (See Paget^s ' Lectures on Pathology.-') Rokitansky also affirms that atrophy of the brain frequently gives rise to deposit of bone on the inner table of the skull, especially about the anterior convolutions. We have not satisfied ourselves that the increased thickness of the cranium which is frequently met with in the insane, is in any way connected with atrophy of the brain. Some of the thickest and heaviest craniums which we have met with, have occurred in instances in which there was little or no cerebral atrophy ; and the condition of the cranium where there is undoubted atrophy of the brain, is not unfrequently one of abnormal tenuity. In pursuing the examination, the state of the ears and of the scalp should not be overlooked. The sanguineous tumour of the ear peculiar to the insane, and the shrinking of this appendage consequent upon such tumour, are noteworthy objects of atten- tion. These tumours, for the most part, occur in the worst and most hopeless cases ; but it is an error to suppose, as some authors have done, that they occur in such cases only. We have not only seen patients recover after the ear has been shrivelled up by the contraction subsequent to sanguineous tumour, but we have seen several patients labouring under quite recent Insanity, in whom a shrivelled ear led to the information that a curable attack had been undergone many years pre- 568 PATHOLOGY OF INSANITY viously, an attack which had been followed by perfect mental sanity of considerable duration. The scalp is sometimes full of bloody sometimes marked with scars and contusions, telling of blows and falls. In old cases of Mania it is sometimes remarkably loose upon the cranium. The cranium itself is frequently altered from its normal con- dition. When thicker and heavier than usual, it is also soft and full of blood. The eburnated cranium, which is at the same time thick, dense, and devoid of blood, has not been found by us in the bodies of those dying insane. In recent cases, the only abnormal condition to be expected in the cranium is its discoloration from excess of blood. This is often evident, not only at the margin where it has been separated by the saw; but also over the whole extent of its inner surface, after the dura mater has been separated, it often presents a mottled, but decided discoloration, from sanguineous congestion. In chronic cases, the skull-cap is sometimes thicker than usual, congested with blood, and soft in its texture ; sometimes thinner than usual throughout, or partially. In the latter case the thin portion usually occurs in the parietal region, in which the diploe frequently disappears to such an extent that the skull becomes diaphanous. The thin diaphanous skull is met with in all stages, but most frequently in cases of very chronic Mania and of Dementia, in which the patient has not been sub- jected to temporary attacks of cerebral hypereemia. On the other hand, a thick and heavy cranium is mostly met with in cases of chronic Insanity, which have been subject to attacks of congestion, or hypercemia e vacuo. The cranium is often strongly marked by indentations produced by the Pacchionian bodies. Not unfrequently, also, the crista galli is elongated and enlarged; and in epilepsy the protuberances of the sella turcica are enlarged, and the marks of the convolutions are sometimes more strongly impressed, especially in the middle fossae. Exostoses, or spiculse of bone, growing either from the vault or the base of the cranium, have been exceedingly rare in our autopsies. In 400 examinations of persons dying insane, including a large proportion of epileptics, we have only found a cranial exostosis in three instances. The dura mater is frequently found adherent to the cranium. In old cases, indeed, it is rare to find that this membrane separates from the cranium with its usual facility in adults. The degree of adhe- THE DUEA MATER 569 sion which exists in chronic Insanity varies, from that which can scarcely be called abnormal, to such a close and intimate union, that on the application of force the membrane splits into layers, rather than part from the bone, from which its fibres cannot be separated except by hard scraping. In acute cases, the dura mata is sometimes discoloured by sanguineous conges- tion. The Dura Mater. — Eecent anatomists discard the old view, that the inner polished surface of the dura mater is a reflection of the arachnoid. It certainly cannot be demonstrated by the scalpel, that any serous membrane lines the dura mater ; and the idea of a parietal arachnoid appears to have been due to the exigiencies of systematic anatomy, rather than to the evidence of demonstration. We adopt the view that there is no parietal arachnoid, and that the polished surface is actually part of the dura mater. This polished sui-face is not unfrequently the seat of exudative processes in the insane, although it is rare to find in this locality exudations of a true fibrinous character, the results of undoubted inflammation; notwithstanding the assertion of Eokitansky that the surface of the brain and the skull being bound together by a series of successive normal and false membranes, is a " termination of meningitis frequently found in mental disease, especially in cases of secondary imbecility." Notwithstanding this high authority to the con- trary, we must assert, that adhesions between the cerebral arachnoid and the dura mater are extremely rare in the bodies of persons dying insane. On the upper part of the brain we have never met with the state of things referred to by this author. The nearest approach to it that we have met with in this region has been the connection of the dura mater with the thickened arachnoid and pia mater, by means of several ligamen- tous bands, the condensed and organised remains of very moderate fibrinous exudation. In two instances, we have met with adhesion of the substance of the brain and its intervening members to the dura mater, along the petrous portion of the temporal bone ; and in one instance, along the ridges formed by the alse of the sphenoid. It is an occurrence of much greater frequency for the polished surface of the dura mater to be the source of an exudation not fibrinous, and not tending to contract adhesions. These exudations are very remarkable, and by different authors have hitherto been generally regarded — either, when much coloured with blood'pigment, as instances of 570 PATHOLOGY OF INSANITY sanguineous effusion into what was considered the sac of the arach- noid, or as false membranes arising from arachnoidal inflammation. That instances of these latter conditions are not very unfrequent, renders it the more needful to distinguish the peculiar exudation to which we refer. It resembles a layer of red-currant jelly spread over the dura mater. On examination there appears to be an extremely fine cellular network, containing in its meshes an albuminous fluid substance, coloured with blood-pigment. Sometimes the exudation extends to the temporo-sphenoidal fossse. Sometimes it is confined to this locality. Virchow has, quite recently, announced its nature to be that of a colloid tumour, flattened into the resemblance of a false membrane by its position. We adhere to the belief that it is an albuminous exudation, containing a small proportion of fibrine, and coloured with blood-pigment. Sometimes true haemorrhage is found on the inner surface of the dura mater. On the appearance of this as a layer, Rokitansky observes, " Those extravasations which have been supposed to be collections of blood between the serous and fibrinous layers of the membrane, with the exception of a few cases in which a small effusion has raised its innermost layer, must have been extravasations into the sac of the arach- noid, which, after acquiring an adhesion to the dura mater, have become encysted." (Vol. iii, p. 323, Sydenham Society's Translation,) In many instances of chronic Insanity, and of recent Insanity in which there had been a previous attack, we have found the dura mater in the temporo-sphenoidal fossas changed to an orange-yellow colour — not uniformly, but as if freckled. Doubt- less this discoloration was due to the blood-pigment of reab- sorbed haemorrhages or exudations ; and it points, like the other changes so common in this membrane, to the frequent existence in Insanity of one period during which the appendages of the brain are in a hyperaemic state prone to hgemorrhages, and to albuminous or albumino-serous exudations, coloured with dissolved blood-pigment. The coloured exudations above referred to seem to us to bear a close resemblance to the exudations of blood-coloured serum which take place between the cartilages of the ear, and to be owing to the same crasis. Sometimes the structure of the dura mater is found to have undergone osseous metamorphosis. We have never observed this occurring in the tentorium, where comparative anatomy would lead one most to expect it. We have, however, found it THE AEACHNOID 571 in tlie falx cerebri. Exostoses of the inner table of the skull probably have their origin in the dura mater. We have only once found a true tumour of the dura mater. This was as large as a filbert, pressed upon the pons, and was accompanied by epilepsy. Its structure was fibro-cellular, and it contained an abundant quantity of cholesterine in large plates. The Arachnoid. — "We have never found a state of undoubted inflammation presenting the appearance of the inflamed con- junctivaj as described by Guislain. In a few cases of acute Mania and Melancholia, we have observed the appearances of ramiform congestion ; but it may be doubted whether this was not due to the underlying vessels of the pia mater. Doubtless, in some cases, the hypersemia in the capillaries of the arachnoid amounts to actual stasis, otherwise the fibrinous false membranes, and the adhesions which are sometimes observed in it, would scarcely exist. A frequent change of this membrane, found in persons dying insane, is thickening with opacity. " The arachnoid tissue,^'' says Rokitansky, " is opaque, dull like whey or milk_, tumid and white, and it has the appearance and density of tendon." Often this change is limited to the arachnoid covering the convolutions of the vertex ; sometimes it is restricted to that part of it which corresponds to the sulci, leaving the part which covers the convolutions thin and transparent. Patches, however, of very decided thickening with opacity are occasionally found on the anterior convolutions of one or other hemisphere. The changes observed in the vertical region are rarely one sided, or even greater on one side than on the other. What does thickening with opacity of the arachnoid indicate ? According to the above author, the " changes frequently discoverable in this membrane can be attri- buted only to congestion, or to slight and passing attacks of inflammation.''^ " Opacity and thickening of the arachnoid are very common loosUmortem appearances. After middle life a moderate degree of them is almost constantly found, and their absence is the exception; for, at that period, every one must have been exposed to repeated congestions of the brain and its inner membranes. •'•' (Op. cit. p. 329.) The change here referred to as being so common is, although the same in nature, greatly less in degree than that commonly found in the bodies of persons dying insane. It is merely an opalescence as compared with decided thickening and opacity like a thin slice of the boiled white of egg. The frequently repeated congestions to 572 PATHOLOGY OP INSANITY which Rokitansky refers this change in the sane, exist in much greater force and frequency in the insane, and give rise to a corresponding intensity of this pathological change. It appears not to be so much the result of inflammation even of " slight and passing attacks/' as of congestion. In nature it closely resembles those opaque patches so frequently found upon the visceral pericardium. Its character is that of albumino-fibrous deposit, forming one link in the chain of degenerative change, which passes according to its locality, into atheroma or into fat. In connection with the arachnoid are the Pacchionian bodies, absurdly called glands. These Rokitansky regards as granula- tions of the arachnoid, rarely indeed altogether absent, but depending for their development upon the same repeated con- gestions which render the arachnoid itself thick and opaque. Luschka, however, has recently shown that these bodies are normal as to their existence, and pathological only as to their hypertrophy. He calls them arachnoidal villi, and refers the genetic cause of their growth to " the disturbances of the circu- lation which attend the natural involution of the organism in old age. In consequence of the impeded motion of the blood, a modified transuuation must take place, which (in our ignorance, it must be confessed of its precise nature) we regard as the principal cause of the increased amount of nutritive material with which the arachnoid is supplied.'' {' Wedl, Sydenham Soc. Trans.,' p. 352.) Now, in the insane of all ages, the Pacchionian bodies are frequently found to be greatly enlarged, so as not only deeply to indent the dura mater, but even to perforate it and to form for themselves reception-cavities in the parietal bones alongside the sagittal suture. Before the circulation has become impeded by the advance of age, they are prematurely produced in the insane by the impeded circulation of cerebral congestion, the frequent condition of mental disease. The e^pendyma of the lateral ventricles and the arachnoid membrane in this locality we have frequently observed to be the seat of those puzzling bodies, the amylaceous corpuscles. This ependyma is described by Virchow as the uppermost layer of the fine connective tissue, the neuroglia or nerve cement, which binds together the foundation masses of the brain. Be this and the arachnoid of the ventricles identical or not, it is certain that the walls of the lateral ventricles present, in chronic THE PIA MATER 573 Insanity, and especially in General Paralysis, a peculiar and frequent change. They appear to be covered with fine sand, or rather to be converted into the resemblance of fine sha- green ; a change due to a nodulated deposit of fibro-albumen. The arachnoid of the ventricles also becomes more thick, dense, and tough ; a change which is obvious in the septum lucidum, which in the early stages of General Paralysis, and in the later ones of chronic Mania, becomes a toughish and resistant membrane, instead of retaining the exquisite delicacy which renders its demonstration so difficult in health. Griesinger remarks the frequent occurrence of dilatation of the lateral ventricles in the insane, occurring in the great majority of cases with diminution of the cerebral mass, and more or less disease of the ventricular surface, and he considers that most frequently it is merely the necessary result of atrophy of the brain. In very few cases can it be considered the primary process and fundamental cause of the symptoms by paralysing the mental faculties through the pressure it exerts. Every small dilatation of the ventricles, however, must not be considered abnormal. The Pia Mater — tender mother of the brain and its wondrous offspring of thought and passion — is far more closely and inti- mately related, both in health and disease, with the organ to whose more noble parts it supplies nutriment, than either of the other meningeal wrappings. The pia mater is more than a mere investing membrane ; it is more than a subserous connective tissue of vascularit}'- greater than is common to such parts. It is a vascular plexus, so loose and large in its ramifications as obviously to suggest the idea that its construction is subservient to rapid and great changes in the blood supply of the convolu- tions. What the submucous vascular layer of the stomach is to the function of digestion, the pia mater appears to be to the higher functions of the brain ; and it is more than probable that active thought or intense emotion causes in it hyperaemia as sudden, frequent, and transitory, as the function of digestion gives rise to in the vascular layer of the stomach. One part of this plexus, or rather an appendage to it, the choroid fold within the lateral ventricles, has a structure analogous to, if not identical with, erectile tissue. Upon this resemblance an ingenious writer in the ' Dublin Quarterly Journal of Medicine ' has based his theory, that sleep in the normal state, and epilepsy in the 574 PATHOLOGY OF INSANITY abnormal state, are dependent upon a turgid or erectile condition of this apparatus, by means of which a gentle but general pressure is exercised from within upon the whole substance of the brain. With regard to epilepsy, there are insurmountable objections to this theory ; but the very existence of such a structure, in connection with the pia mater, increases the probability that frequent turgescence of this membrane is a physiological state. " There is no question," says Rokitansky, " that congestion of the pia mater is a very frequent occurrence." " Yet, if we except the post-mortem congestion of the pia mater covering the posterior lobes of the cerebrum, any considerable degi-ee of congestion is far less commonly met with in the dead subject than is supposed; and there is, perhaps, no respect in which moderation in estimating appearances needs so much to be impressed upon the unpractised observer, as in regard to the quantity of blood contained in the vessels of the pia mater. As a general rule, a very moderate injection of these vessels is erroneously looked upon as congestion." The terminations and consequences of these congestions vary, according to the frequency and duration of their cause. They consist of thick- ening and condensations (increase of volume) of the pia mater and arachnoid, of permanent infiltration of the former, and a varicose condition of its vessels. Such a state of the inner membrane is well marked after the congestions which are pro- duced by continued and forced exertion of the mind, or by repeated intoxication, especially by alcoholic drinks." (Op. cit. pp. 339 and 340.) Thus, we learn from this great pathologist the frequency of congestions of the pia mater ; their causation by two of the common causes of Insanity, mental overstrain and drunkenness ; and lastly, the difficulty which exists in recognising, after death, the existence of a pathological degree of this frequent occur- rence. The same difficulty exists in the tissue to which we have compared its functions, namely, the submucous vascular layer of the stomach. In both these instances, this difficulty of post- mortem recognition arises from the same cause. A moderate degree of congestion is in neither instance pathological. Con- gestion only becomes so when its degree or frequency tends to produce structural change. The last moments of life are commonly passed in a state adverse to the continuance of congestion, unless they are attended by such difficulty in the respiratory movements as to impede the return of the venous fail PlA MATEE 575 blood to the heartj and lience a state of congestion which may- have existed in the pia mater^ even up to a short time before deathj may have left no traces discernible after that event. The exudations of the pia mater in mental disease^ are not of the organisable, fibro-albuminous kind. It is rare even to find them opaque^ either from partially coagulated albumen or from fat. Even when the arachnoid is thickened and opaque from exudations of this kind, those of the pia mater are remarkably limpid and serous. Adherent false membranes are not found once in a hundred cases of persons dying insane ; and even in these rare instances, their occurrence usually is traceable to a pre-existent inflammation, and is not to be considered as a con- dition proper to Insanity. According to Vogel, fibrinous exu- dations result mainly from the minute capillaries, whilst serous or hydropic effusions derive their source from the small veins. The plexus of vessels which forms the pia mater is venous in its anatomical character, and the serous nature of its ordinary exudates may fairly be thus accounted for. Although fibro-albuminous exudates in the pia mater, and the false membranes and adhesions resulting therefrom, are so uncommon in Insanity, there is one form of adhesion of frequent occurrence in this membrane, namely, the slight but important adhesion between it and the grey substance of the convolutions. The plexus of vessels more or less infiltrated with serous effusion, is sometimes very readily separable from the grey substance which it invests. But in many instances it is not so. What are called adhesions, more or less intimate and extended, are found to have formed, so that sometimes over the whole extent of the convolutions, sometimes only in isolated parts, the convolutions cannot be divested of their vascular envelope, without small portions of the grey substance remaining adherent to it. In these instances there is no appearance of fibro- albuminous exudation into the pia mater; but it is probable that the cells of the grey substance, and their connective tissue, may have received an addition of fibro-albumen from the minute arteries and arterial capillaries in connection with the pia mater ; an addition which may prevent the small vessels from being withdrawn from the soft substance of the grey matter with the same facility as in the normal state. Something, also, may be attributed to an increased toughness in the coats of the minute blood-vessels preventing facile rupture. Congestion of the pia mater, and consequent serous effusion 576 PATHOLOGY OF INSANITY into its meslies, is the constant result of atrophy of the brain. '' When an empty space is formed within the skull by a reduc- tion of the volume of the brain^ it is filled up by an increase of the volume of the inner membranes of the brain, and especially by an extraordinary exhalation of serum into the tissue of the pia mater, the sac of the arachnoid, and the internal cavities of the brain, more particularly the lateral ventricles. These changes result from the congestion of the vessels which the vacuum produces. ^^ (Rokitansky, op. cit., p. 364.) Thus arises the Hyperemia e vacuo, the pathological condition of the very frequent cases of spurious apoplexy which occur among old and chronic lunatics — every attack of which renders the vessels of the pia mater more dilated and tortuous, and more disposed to the recurrence of the congestion. This may, and frequently does, concur with an anaemic as well as with an atrophic condition of the substance of the brain. In the healthy organ, congestion of the pia mater cannot occur without accom- panying congestion of, at least, the grey matter of the convolu- tions; but, under the pathological conditions which attend atrophy of the organ, a sudden congestion of the loose and water-logged membrane frequently occurs, without affecting the anaemic and atrophic brain otherwise than by adding a temporary impedi- ment to its functions by the sudden pressure. To recapitulate : — The pia mater, in rare instances, is found to be the seat of fibro-albuminous exudation, and consequent adhesion. It is the very frequent seat of congestion, which may or may not be obvious after death. Frequent congestions enlarge and render its vessels more tortuous. They also result in a thin hydropic effusion — more rarely in a turbid albuminous one. Not unfrequently the membrane contracts adhesions to the grey matter of the convolutions, but without visible exuda- tion of albumino-fibrine or false membrane. In cases of acute Mania and Melancholia, thin extravasations of blood, not larger than a finger-nail, occur in its tissue. Diffuse inflammation of the pia mater, and tuberculous infiltration and deposit, are extremely rare among the insane. The pathological conditions of the choroid plexus are as obscure as its physiological purpose. It is not found hyper- trophied in epilepsy, which it would be were the theory true which attributes the production of that disease to its turges- cence. It often contains cysts analogous to those observed in the Malpighian bodies in Bright' s disease ; but whether the CEEEBEAL ATEOPHY 577 frequency of these cysts is greater among the insane than the sane, there are no data to determine. It is very remarkable to how great an extent the changes we have here described are confined to the vertical, parietal, and frontal regions, and how largely the base of the brain is exempt. Perhaps the gravitation of the organ has somewhat to do with this phenomenon, as it may also have to do with the deeper sulci of the bones at the base of the skull. The Cerebral Substance. — The condition of the cerebral mem- branes, and, indeed, of all other parts, is, of course, in the pathology of Insanity, of secondary importance to the state of the substance of the brain itself. The condition of the cerebral substance is the prime question in the pathology of mental disease. Frequently this condition can only be judged of by the state of its blood-vessels, or can only be guessed at by that of its membranes, or some still more remote indication. Not unfrequently, in partial and sympathetic Insanity, it appears to be perfectly sound in structure, although the deductions of science assure us that this soundness is in appearance only, and is solely attributable to the imperfection of our means of observing and investigating. The bulk of the brain varies from a state of atrophy, in which it has been known to lose nearly a third of its volume, to one of hypertrophy, in which, but for the restraining pressure of the unyielding cerebral walls, there is but little doubt that it would be not less augmented. Cerebral atrophy, as the most frequent, is the most important of all changes in chronic conditions of mental disease. We have already written so fully on this subject, that our limits only permit a few further remarks. It is almost always accompanied by oedema of the pia mater, more or less general, by contraction of the convolutions, and widened sulci, and diminished thickness of the grey cortex, by altered colour, and by change of consist- ence in the grey and white matter, frequently by dilatation of the lateral ventricles, and in rare instances by a cribriform con- dition of the whole substance. A considerable degree of cerebral atrophy is rarely unattended by changes in the colour and consistence of the brain substance, sufficiently obvious to the eye of the experienced observer. It is frequently both antemic and discoloured; the grey substance contains less red and more brown ; and its coloration, also, in depth of tint, varies greatly ; sometimes its tint is deeper than 37 578 PATHOLOGY OF INSANITY is usual in healtli, but far more frequently it is paler^ and occa- sionally it is little more than a darkish buff colour. On this point Mr Solly remarks, that having many opportu- nities of examining the brains of the insane at Hanwell, he made coloured drawings of the cortical substance of all patients indiscriminately ; and he adds, " The general result of my ob- servations was, that a pale condition of this ganglion was almost invariably found in patients who had sunk into a state of imbe- cility, and was generally associated with some serous effusion, and thickening of the ai'achnoid and pia mater/' (Solly ' On the Brain,^ p. 398.) The uniformity of colour of the grey matter, also, is lost. The grey layer of the convolutions con- sists of six planes, in which the white and grey substances alternately preponderate. M. Baillarger, in his memoir on this subject {' Mem. de PAcad. de Med., tome viii), states that it consists of six of these alternate layers. There can be no doubt that such layers exist ; but the exact number of them is a question which has been much debated. In the normal state, a triple division is very obvious to the naked eye in the poste- rior convolutions of the cerebrum ; and in a state of atrophy it becomes still more obvious throughout all the convolutions where it was previously not observable. This appearance arises from diminution in the quantity of the pigment-coloured cells in the whole of the cineritious layer. This diminution in the bands where the white matter exists in largest quantity, renders the colour of the latter very apparent. According to the statement of M. Baillarger, the external layer of the convolutions is white, and not grey. It would, we think, be more correct to say that the external layer contains a less proportion of vesicular neurine to the tubular substance with which it is intermixed, than the layer next but one to the surface, and again, than the layer next but one to that. The consistence of the grey matter of the convolutions is very generally lessened when the organ is atro- phied. Sometimes the superficial layer is obviously softened, but more frequently the grey layer immediately under it is the seat of the greatest amount of softening. We may hope that GerlacVs observations on what has been called the bacillar layer of the cortex of the cerebrum will lead to an important increase of our knowledge of its pathological conditions. The colour and consistence of the tubular neurine are often notably altered. Unlike the grey matter, its depth of colour is generally increased. From the clear white of health, almost CEREBRAL INDURATION 579 imperceptibly tinged with pink, it assumes a dirty brownish hue — very faint^ indeed, but quite unmistakable. The consistency and density of the white substance vary greatly. In the Atrophia cerebri senium, the consistence of the white matter is generally a little increased. In the Atrophia cerebri prcecox, the consistence is increased whenever the primary condition of disease has been hyperaemia verging on phlogosis, and tending to the addition of albumino-fibrine to the substance of the brain. This is particularly the case in the atrophy which attends the later stages of epilepsy — an atrophy which is pre- ceded by a period of congestive hypertrophy, and meriting the name which has been applied to it, of concentric hypertrophy of the brain, if such a term applied to any organ is not somewhat absurd. In atrophy not consecutive upon a congestive condi- tion of long standing, but either primary or secondary to a state of general debility or dyscrasia, the consistence of the tubular neurine is diminished — sometimes to the extent of making it appear that the whole brain is infiltrated with serum. Hokitansky asserts that atrophy is accompanied by increased consistence and tenacity, or sclerosis, as it has been called. " The surface of a section of the hemisphere shrinks and becomes concave ; and here and there certain portions offer more resistance than others, and wrinkle and lie in folds." The whole substance also, in rare cases, becomes porous, like Grruyere cheese, or rather like the substantia perforata of the normal brain in appearance, the Stat crible of French authors. When induration exists, it is in greatest degree in the neigh- bourhood of the lateral ventricles. The latter are generally enlarged and distended, with a very limpid effusion ; and thus the bulk of cerebral substance is diminished, both from within and without. Sometimes the lateral ventricles are greatly contracted ; sometimes they are of normal size. Andral states, that unless each lateral ventricle contains more than an ounce of fluid, it cannot be reckoned abnormally large. It is unnecessary to refer, in this place, to the shrunken and pinched appearance of the convolutions, and the widely opened sulci. In not very unfrequent instances, the remarkable appearance of circumscribed atrophy affecting three or four convolutions, generally about the vertex, is presented. In such instances, the loss of bulk is replaced by a partial oedema of the pia mater, presenting the appearance under the arachnoid of a gelatinous bag. This partial atrophy of the brain has not 580 PATHOLOGY OF INSANITY hitherto been connected with any peculiar loss of mental func- tion calculated to add additional evidence to the arguments of phrenologists. Atrophy of the brain rarely exists in any considerable degree without a notable dimimdion of the breadth of the cortical grey substance of the convohitions. The normal breadth of this substance we have ascertained^ by numerous measurements, to be eight hundredths of an inch. In atrophied brains it is reduced to seven, and frequently to six hundredths. The reader will find in the table at p. 520 careful measurements of the cortical grey substance in the various forms of mental disease. These measurements were made with that form of compass which is called a hair- divider, and the hundredths of an inch marked off on a scale, the eye being assisted by a simple lens. Dr Major has used a graduated tube for this purpose, which he calls a tephrylometer, but we are informed that this instrument cannot be used without pressure on enter- ing, and tractive suction on removal from the brain substance, and we think our own simple mode of measurement the most convenient and accurate. The usual condition of atrophic brains, with reference to the state of the blood-vessels, is a degree of anaemia ; but some- times, owing to the circumstances of death, this condition is replaced by one of congestion, and the dirty white of the tubu- lar neurine becomes mottled with a faint violet discoloration. This is especially the case when death occurs soon after severe convulsive attacks, or during the course of congestive apoplexy. Cerebellum. — It is a remarkable fact, first noticed by Canzau- vieilh, that atrophy of the brain is confined to the cerebrum. Even in extreme age, when the cerebrum is much wasted, the cerebellum retains its full size. Dr B. Tuke, however, has met with three cases of atrophy of the cerebellum, and in all three there were no symptoms at all. {' Journal of Anatomy and Physiology,^ vol. vii.) Hypertrophy of the brain is an interesting but rare form of pathological change. But for the pressure exercised by the un- yielding walls of the cranium, the brain would doubtless undergo enlargement with every considerable degree of conges- tion which it suffers. It would enlarge like a congested liver, until like the liver it took on its secondary change and con- tracted in the state of scleroma or the allied state of cirrhosis. As it is, congestion of the brain constitutes one form of hyper- CEREBRAL HYPERTROPHY 581 tropTiy^ of common occurrence contrasted with the true hyper- trophy of the cerebral substance^ in which the brain is aneemic^ the vessels being emptied by the ever-increasing' pressure. In the bodies of persons who have died during the early period of epileptic disease, and of some who have died in the first stages of Mania, the brain appears too large for its case ; the convolutions are flattened; the sulci cease to exist as indenta- tions between the convolutions ; lines only can be perceived in which processes of the pia mater dip. The vessels of the pia mater itself are distended with blood; the grey matter is deep- ened in colour; the white matter pinkish, or mottled with pale violet ; and the cut ends of the vessel in it effuse an abundant quantity of puncta sanguined. This is false or congestive hypertrophy. We cannot concur with Griesinger in the opinion that general hypertrophy of the brain has no connection what- ever with mental affections, but, perhaps, he only meant to indicate that form in which it is an epiphenomenon on tumours, softening, and disease of the brain other than Insanity in any of its forms (op, cit., p. 425). In true hypertrophy, the brain swells up when the cranium is removed, so that the latter cannot be replaced ; the convolutions are flattened, the sulci obliterated ; the arachnoid is transparent, thin, and dry ; the pia mater is exsanguine ; the grey substance very pale ; the white substance pure white, with few traces of blood-vessels, dense and tenacious. As the change progresses, the mental functions, and especially the memory, become more and more feeble ; but Dementia, to the extent which follows atrophy of the brain, rarely, if ever, supervenes. Epileptiform convulsions appear towards the close of the case, and usually supply the form of death. In a marked case which came under our own notice, epileptiform convulsions existed at intervals for more than six months before decease. The post-mortem exam- ination displayed all the above appearances, with the addition of the remains of a sanguineous effusion, thin, old, and yellow, surrounding the crista galli of the ethmoid. There have been many differences of opinion respecting the nature of this pathological change. Dr Handheld Jones, in an excellent paper on " Fibroid and Allied Degenerations,^^ in ISTo. 27 of the ' Medico-Chirurgical Review,^ maintains that it is not a true hypertrophy. '' It can hardly be thought," he says, " that a true hypertrophy existed, otherwise surely there would have been some apparent superiority of intellect. The truth 582 PATHOLOGY OF INSANITY probably was, tliat there was just the ordinary amount of nervous matter, plus a certain quantity of interstitial exudation/' Doubtless it is not a true hypertrophy in this strict sense of the term, i.e. the abnormal increase of normal structure ; and although Kokitansky declares it to be '' a genuine hypertrophy/' he explains the meaning he attaches to this term ; so that, according to its acceptance in this country, it would be excluded from the category. He says, " it consists as such {i.e. as a genuine hypertrophy), not in an increase in the number of the nerve tubes in the brain, from new ones being formed, nor in an increase in the dimensions of those which already exist, either as thickening of their sheaths, or as augmentation of their contents, by either of which the nerve-tubes would become more bulky. It is an excessive accumulation of the intervening and connecting nucleated substance.'' He attributes its occurrence to an excessive development of the lymphatic system, although he admits that its immediate cause may be congestion. Dr Handheld Jones's test of a genuine hypertrophy appears, in this instance, fallacious, inasmuch as an increase of normal tissue may fail to confer increased power of function, if the new tissue is in a condition unfavorable to its activity — if, for example, it be subjected to pressure. Moreover, we have no knowledge leading to the belief that hypertrophy of the organic cells is inconsistent with a pathological condition, tending to interference with their function. An hypertrophied cell may be as much disabled as an atrophied cell. This particular kind of hypertrophy is seated in the parenchyma, being either hyper- trophy of the neuroglia, or due to a slowly formed exudate of an albuminous or fibro-albuminous character, gradually pervad- ing the whole of the cerebral substance. Either of these changes from the normal state, originating in some obscure vice of nutrition, may go on increasing until death from convulsions takes place, and the peculiar characteristics of cerebral hyper- trophy are found. More frequently, however, the process undergoes an arrest and an inversion. The hypertrophied tissue, or the exudate pressing upon the normal tissue, and upon the blood-vessels, impedes the nutrition ; this arrests the further progress of the hypertrophy, and a reverse movement takes place, tending to cerebral atrophy with induration. Such, we believe, to be the true pathology of a large class of epileptic cases — namely, of those in which the nutritive powers are at hrst in excess, the muscular system highly developed, the INFLAMMATION, CONGESTION, AND ANEMIA 583 functions vigorous, and the health, robust, and in which there is an early tendency to maniacal excitement, gradually passing into the opposite one of Dementia. The cure of these cases is hopeless, but the relief afforded by early antiphlogistic treat- ment, moderate and prolonged, supports our view of their patho- logical character. Inflammation, Congestion, and Anaemia of the Cerebral Substance. — Inflammation of the grey substance of the convolutions is, undoubtedly, an occasional cause of Insanity, although it cannot be admitted to be one of its conditions. According to the limitations of that most artificial of sciences, nosology, phrenitis is not Insanity, and does not belong to the speciality of the psychologists. The same may be said of cerebral hsemorrhage. The appearances and symptoms which primarily attend these forms of pathological change are, therefore, excluded from the present notice. But a brief reference fcannot be avoided to the changes which they frequently undergo, attended by symptoms of undoubted mental disorder. One of the reliquise of inflam- mation of the grey substance of the convolutions is a chronic induration of the superficial layer ; another is, that adhesion of this layer to the pia mater, which has been found by M. Parchappe so frequent in the insane ; others are a softened condition of the middle layer of the grey substance ; induration or atrophy of the whole of this substance ; in some rare instances, entire loss of it by ulceration and absorption. When the functions of the grey substance have been deteriorated by these changes, the white substance of the brain wastes from disuse of function, as the optic nerve wastes in cerebral amaurosis, and thus atrophy of the whole cerebrum finally results. Inflammation of the white substance of the brain is usually far more limited in extent than that of the grey substance. It is also a more chronic affection — destroying life, when fatal, by convulsions, low fever, pulmonary congestions, and gangrenous sores. Although, during its progress, the mind is always more or less disturbed, and actual delirium is frequent, yet it is a less frequent cause of Insanity in any of the acknowledged forms of the latter than inflammation of the grey substance. Parts of the brain which do not participate in the inflammatory action become oedematous, and others anemic from the pressure of those parts whose bulk is augmented. This disturbance of pressure and of the blood- supply consequent thereupon, is 584 PATHOLOGY OF INSANITY necessarily accompanied by disturbance of the functions of the organ, often to a greater extent than the j)ost-mortem appear- ances explain, since the pressure of the different parts equalises itself after the process of inflammation has been arrested by death. Cerebral Haemorrhage — The relation -which this accident bears to Insanity is of the same nature, but less intimate than that which inflammation holds. NumeroiTS instances of cerebral haemorrhage occur without giving rise to any mental disorder ; but, on the other hand, the processes of irritation and exudation, set up by a clot in the brain, not unfrequently do give rise to Mania, rapidly running into Dementia. In such cases the brain is found to be atrophied, and to contain clots or cysts, or cicatrices in the various stages of reparative or degenerative change. When cerebral haemorrhage is subsequent to atrophy, a re- markable modification of the usual symptoms of apoplexy may result. An enormous amount of blood may be slowly effused around the cerebral hemispheres, not only without the immedi- ately fatal result which would occur if the haemorrhage took place on a brain not atrophied, but without giving rise to urgent symptoms of cerebral pressure. Instead of exerting a fatal pressure upon the substance of the brain, the effused blood only displaces an equivalent quantity of serous fluid which finds its way from the cavity of the arachnoid and the meshes of the pia mater into the spinal bag. In the 29th vol. of the ' Medico- Chirurgical Review,^ we have given the details of a case remark- ably illustrating this statement. In this case a demented patient had an attack of apoplexy on the 29th of September, 1853, and he lived until the 7th of July, 1854. The 2iost-7nortem examination showed the remains of a sanguineous effusion, fibrinous and tough, which completely enveloped the cerebrum. It was situated in the cavity of the arachnoid, and over the vertex and sides of the brain was half an inch thick, and was the colour of venous blood. In the petrous fossa it was also thick, but had become yellow. It did not extend over the cerebellum, but the effusion from which it was formed. Lad found its way into the lateral ventricles, as those contained masses of dark -red fibrine ; a thin layer, also, extended two inches down the spinal canal. Between the visceral arachnoid and the brain there was a large amount of serous effusion. The cranial cavity required 52 ^ ounces of water to fill it. The brain displaced only 37| oz., so that the atrophy of the organ CEREBRAL CONGESTION AND ANEMIA 585 was equivalent to 15 oz., or nearly one third of its normal bulk. Subsequent to the occurrence of the apoplexy^ the patient lived a kind of vegetative existence^ with the smallest amount of mental and animal function we ever saw in a living human being during so long a time. Probably a sanguineous clot of ISoz. is impossible between a healthy brain and its case^ but if it were possible it would be utterly incompatible with the sur- vival of life beyond a very brief period. The small extravasations of blood often found on the surface of the convolutions in many cases of acute Mania and Melan- cholia, result from congestion of the pia mater. In some instances a dyscrasial condition of the blood may aid in the pro- duction of these effusions, as it does in the extravasations, which in the insane take place under the conjunctiva and between the cartilages of the ear. Congestion is one of the most important conditions of the brain-substance, but of its appearance little can be written. Congestion of the grey matter is indicated by various shades of red, brown, and grey, of which the practised eye becomes cognisant. In recent and acute Mania a deeper red tinge pre- vails. In cases of longer standing, and where atrophy of the organ also exists, the deeper tinge is of a brown or grey cast. The same distinction is true in congested states of the whole substance. In acute Mania and Melancholia the whole surface of the centrum ovale, in some instances, presents a uniform pinkish hue ; in others this hue is mottled with the normal white. In other instances, not in any way distinguishable from the last by the previous symptoms, the cut surface of the centrum ovale is mottled with a light violet hue. This hue is never uniform, except after death from long-continued epileptic con- vulsions. In acute Mania and Melancholia it is mottled either with white or with pinkish white. The above appearances of cerebral congestion are commonly accompanied by a great abun- dance of bloody points due to blood issuing from the cut orifices of the small vessels. This appearance is not constant, even in brains obviously discoloured by congestion. Its absence may be due to the loss of contractility in the small vessels, or to the blood they contain not being fluid. Anaemia of the brain -substance, made evident by paleness, both of the grey and white matter, and by the small number of blood-vessels which are visible, is observed in a few cases of acute Mania ; sometimes, also, but more rarely, in Melancholia. 586 PATHOLOGY OF INSANITY In many chronic cases, with cerebral atrophy, anremia is the ordinary condition of the brain-substance, although it frequently alternates with transient states of severe congestion. The state of the pulse, and the aspect of the skin of the face, the con- junctiva, and the lips, may indicate whether congestion or anaemia is present in the brain ; but these conditions cannot always be diagnosed from the mental symptoms. Andral has well pointed out this common nature of functional disturbance arising fi-om diverse causes : — " It is a law in pathology, that in every organ, the diminution of the quantity of blood which normally it should contain, produces functional disturbances, as well as the presence of an excessive quantity of blood. We have found, more than once, the brain and its membranes com- pletely bloodless in children who died in the midst of con- vulsions. We have also seen the state of coma, in which many of their diseases terminate, coincide with remarkable paleness of the nervous centres. Sometimes, also, in adults, we have been struck with the complete absence of colour in the brain, perceptible principally in the gi'ey substance, in cases wherein during life cerebral phenomena had taken place — such as deli- rium, convulsive movements, coma. Do not animals, also, who are bled to death, exhibit symptoms of this description ?" "But when we have referred the symptoms to hypergemia in one case, and to anaemia in another, are we come to the bottom of the subject ? By no means ; for this hypei'semia and this anasmia are themselves mere effects which — a thing very remarkable — the same influence can very often produce. Thus, by an emotion of the mind, the skin of the face becomes red in one person, and pale in another.''^ — {' Clinique Medicale.^) This enlightened view must be applied to explain the uniformity of symptoms which attend many other deviations from the normal condition of the brain-substance. Thus, indu- ration and softening are both found in atrophic brains, both in chronic Mania and Dementia. Either of them may be attended by a congested or an anasmic condition, auasmia being the usual condition, and hypergemia a frequent but transient state. With regard to induration of the brain-substance in the bodies of persons dying insane, we have never met with that "leather-like and fibro-cartilaginous hardness and resistance'' to which sclerosis of the brain is said to attain. The slighter degrees of induration dependent upon diminution of water in the brain, and perhaps also upon some amount of hypertrophy CEREBRAL (EDEMA AND SPECIFIC GRAVITY 587 o£ the neuroglia, or of albuminous exudation, are common in cerebral atrophy. The slighter degrees of induration may be general, but the higher degrees must be partial, since the organ could not perform its functions were it universally changed into a 'tough substance, like leather or caoutchouc. Callous cicatrices, marking the locality of old apoplectic rents, have offered the only examples of leather-like induration which we have met with among the insane. (Edema of the brain, a state in which the tissue of the organ is permeated by water or serosity, is a not unfrequent condition in persons who, with atrophy of the brain, have had great general debility or cachexia of the body. The brain appears unusually moist, and its cut surface is of a brilliant white. In extreme instances, this condition is exaggerated until parts of the organ are almost broken down into a pulp, and the appearance of ramollissement is produced. It is not, however, to be con- sidered one form of the latter affection. The two forms of ramollissement are not found frequently in the brains of persons dying insane. The same may be said of the cellular infiltration described by M. Durand Fardel. In four hundred autopsies of the insane, we have only met with it in two instances. In both instances it occurred in aged persons suffering from chronic Mania, in whom it gave rise to a series of convulsive attacks, which terminated in death. The brains of the insane appear to be certainly not more liable than those of others to various incidental affections. Thus, in four hundred autopsies of the insane, we have only once met with a hydatid, only once with tubercular deposit in the substance and meninges, only once with a fibro-cellular tumour, and not once with malignant disease. The arteries at the base do not appear to be more frequently or extensively affected with atheromatous change, than those of sane persons of the same age. And in the bodies of the insane we have never yet met with that cretaceous deposit in the coats of the small arteries, which makes them feel like pieces of fine wire embedded in the brain- substance. The Specific Gravity of Cerebral Substance in Insanity we were the first to investigate in this country. Other physicians have subsequently pursued the inquiry, especially Dr Sankey and Dr Skae. Dr Sankey in his lectures, published in 1866, has fallen into the unaccountable inaccuracy of stating that " Dr Bucknill did not examine the grey and white matter separately 588 PATHOLOGY OF INSANITY in his cases, which both Dr Skae and I have always done/^ A reference to the table at page 520, which we first published in the ' Medico-Chirurgical Eeview ' in 1855, will show that we did examine the grey and the white matter separately, and also the cerebellum. We may state briefly, that in the thirty cases first tabulated and published by us in the ^ Lancet,^ Dec. 25th, 1852, the average specific gravity of the cerebrum was 1040, the range being from. 1026 to 1046; while the average specific gravity of the cerebellum was 1043, the range being from 1039 to 1046. It was also observed that the specific gravity was higher "when life had terminated in coma or asphyxia, than when it had ended in syncope or asthenia. '^ In our annual Report of the Devon Asylum, for 1851, we published some investigations on the same subject, from which it resulted that the average specific gravity of the cerebrum was 1039|, and that of the cerebellum, 1042. In the sixty three cases published and tabulated in the ' Medico- Chirurgical Review," Jan., 1855, and which we now republish, the average of the white substance of the cerebrum was 1039, and that of the grey substance, 1037 ; that of the cerebellum, grey and white substance conjoined, 1040. The lowest specific gravity of white cerebral substance was 1033, the highest was 1046 ; of the gvej substance the highest was 1048, the lowest 1030; of the cerebellum the highest was 1040, the lowest 1030. The lowest specific gravities were generally connected with a watery or oedematous condition of the brain, which led us to adopt the term "relative atrophy," in conti'adistinction to that of " positive atrophy,'^ where the organ has actually shrunk. The two conditions, however, may coexist, as we remarked in the ' Lancet :' — " The additional fluid which makes the brain light, goes to make up for interstitial atrophy, but it does not wholly make up for it, and the brain shrinks from its bone case." "A low specific gravity does not necessarily indicate a diminution of cohesion, or the commencement of ramollissement, although it points in that direction. A brain may acquire a low specific gravity from an increased quantity of fat globules in its tissue, while retain- ing its normal consistence. We believe, however, that fat tends to accumulate only in softened brain, so that possibly this source of error may not exist ; but it is, nevertheless, a point of the utmost importance to determine how much of diminished specific gravity in brain-tissue is to be attributed to HEART DISEASE 589 tlie effusion of serum^ and how much to the accumulation of fatty matter. This question may be resolved by treating the substance with ether^ and by evaporation. We are convinced that in circumscribed softening of the brain (true ramollisse- ment) the low specific gravity is, to a great extent, owing to the amount of fatty matter deposited. In the last case of the table given, the specific gravity of the cerebrum, generally, was 1041 ; while that of the softened part was 1035 ; and, on examination, this pultaceous substance was found pervaded with an immense quantity of fatty matter. ^^ The conditions which favour high specific gravity are congestion and induration — those which favour a low one are oedema and fatty degeneration. A watery or oedematous condition of the brain is frequently met with in Dementia and chronic Insanity generally, and in such cases the specific gravity is low. It is low in the softened condition of circumscribed portions, which the microscope shows to be one form of fatty degeneration ; and in other cases in which it is low, it is probable that there is much diffused but unrecognisable fat ; finely granular amorphous fat diffused in the stroma, or contained in the cells and tubes, it being highly probable that morbid degeneration of brain-substance, like that of muscular tissue, takes place by the running together of the organic elements into forms of hydro-carbon.* The pectoral and abdominal viscera present, in the insane, some pathological peculiarities which require notice. Disease of the Heart is common among the insane, although Griesinger afiirms that " the newest and most reliable statistics show only a very average frequency. ^^ Obstructive valvular disease is often seen in connection with simple and with hypo- chondriacal Melancholia. Dilatation of the heart, with great irritability of the organ, and attacks of palpitation, are frequent in chronic Mania ; and we have observed, that this condition of the heart appears to impress its character of excessive excita- bility upon the mental disease, and that those who thus suffer are susceptible, irritable, impulsive, and subject to gusts of passionate excitement, but that they are neither malevolent nor refractory. In Dementia, the heart is liable to undergo fatty degeneration ; and in three instances of chronic Mania with Dementia we have satisfied ourselves by microscopic examina- tion that the death was occasioned by this change. * On this subject see Dr Bastian's article in the ' Journal of Mental Science,' No. 56, Jan., 1866. 690 PATHOLOGY OF INSANITY Disease of the Lungs occurs in the insane in all its varieties. It is frequently latent from the absence of cough, and from the patient's absorption of mind preventing complaint. The absence of cough in serious pulmonary disease is very peculiar. In Dementia it arises partly from torpor of the excito-motory system, partly from loss of attention — from the same cause, in fact, as that which gives rise to the frequent dirty habits of the insane. In Mania it arises from the attention being intensely preoccupied by the vivid ideas and delusions which absorb the mind. We have seen many patients in advanced stages of phthisis, who were never heard to cough so long as they were under the influence of maniacal excitement. When this under- went a temporary diminution, they were greatly troubled with cough, which was again arrested by the recurrence of excite- ment. The continuance of colliquative diarrhoea and perspira- tion, and of emaciation, proved that there was no halt in the progress of the disease, as the absence of cough has led authors erroneously to suppose. The torpor of the nervous system in Dementia leads to another peculiarity in pulmonary and in some other bodily diseases of the insane, namely, the absence of irritative or symptomatic fever ; and hence it happens, that in a demented person whose strength is but little impaired, and whose constitution is tolerably good, diseases will obtain a high degree of development, with symptoms so few or obscure as to be incredible to the general physician. It is on this account that the numerous sloughing sores to which general paralytics are liable, produce so little suffering, or constitutional irritation. We have known the stomach disorganised by cancer, without the patient complaining of any pain, until a few days before death, when perforation took place. The only case of true carditis we ever saw, occurred in an insane person who complained of no pain, and in whose heart, disease was only suspected twenty- four hours before death, in consequence of the failure of the pulse. This peculiarity in the intercurrent diseases of the insane should teach the physician to observe with watchful anxiety every physical indication from which he can derive knowledge of the attack of disease, before it is so advanced as to be beyond control. Pulmonary Gangrene is more common among the insane than the sane ; but not to the same extent here as at Vienna, where it appears to contribute largely to asylum mortality. The frequencji of Phthisis and of tubercular disease generally TUBEROULAE DISEASE 591 in Insanity has attracted the attention of many observers. Grie- singer having given the proportion of deaths from phthisis in various asylums^ observes that in certain asylums^ in the Bicetre, for example^ it rarely is remarked, and that the general sta- tistics made by Hagen, show that in asylums generally a little more than one fourth of the deaths are due to phthisis, and that this proportion is almost the same as for the general population above fourteen years of age. Griesinger observes that this may be true of the general population of large towns, but not for the rural population, and that we must therefore assume that phthisis is more frequent amongst those who inhabit large institutions (not asylums merely) than amongst the general population. We had ourselves arrived at and had published similar con- clusions thirteen years ago. We had been impressed by the increasing number of phthisical patients in the Devon County Asylum, and in our annual Report on that institution for the year 1860, we observed — '' One form of disease, from which several patients have died, suggests the anxious inquiry whether by any sanitary precau- tions it might have been averted, namely, that of pulmonary consumption. Four patients who have died were admitted with this disease in an advanced state, but in nine others the disease was undoubtedly developed during the residence of the patients in the Asylum, and the apprehension has been impressed upon me, that the disease may have been developed by the over- crowded state of the dormitories. Phthisis is exactly the dis- ease which would be developed by the bad influence of deterio- rated air, breathed habitually at night.'" In our Heport for the following year we further observed — " The number of patients who die of phthisis is always a source of peculiar anxiety, inasmuch as the development of this disease may be regarded as a test of the sanitary conditions of an insti- tution. Some of the patients who are carried off by it are indeed admitted with the disease already developed, and some- times far advanced ; others are admitted with the seeds of the disease in the constitution, which the progress of time would under any circumstances bring to maturity. But, in a certain number of cases, patients long resident in an asylum pass from a state of good bodily health into one of tubercular degenera- tion from influences which they experience, but from which they ought to be guarded during the time that they are empha- tically placed under medical care and treatment. Of these 592 PATHOLOGY OF INSANITY influences the bad air of overcrowded dormitories is unques- tionably the most potent, and although it is one from which, the poor do not escape in their own close and narrow sleeping rooms, it is yet an anti-hygienic condition to which the patients in an hospital ought never to be exposed. An overcrowded condition of an asylum, which is an hospital for the insane, is the worst possible condition in which it can be placed both for the physical and moral welfare of its inmates. But, in addition to this cause of consumption acting directly upon the body, there is one which may act upon it through the mind, namely — the influence of a monotonous and cheerless existence, which a long continued residence within the walls of an asylum is apt to become to patients of a certain mental constitution; not only therefore are efforts made to relieve the monotony of a forced detention for the sake of those patients whose malady admits the reception of curative influences, but also for the sake of the hopelessly insane, ought proper efforts to be made to stimulate the flagging interest, and to give colour to a dx-eary life.^^ Since the date at which the above remarks were made and published, we have enjoyed large opportunities for observing lunatics who have for lengthened periods been under treatment in private residences, living in their own homes, or as single patients in the private houses of others, and the result of our observations has been fully to confirm our opinion that under such circumstances the insane are not more liable to phthisis and other tubercular affections than other people, and that phthisis which forms so large a proportion of the mortality of asylums for the insane, is the produce of the institutions and not of the cerebro-mental disease. Gangrene is another disease of the lungs which is a far more frequent cause of death in lunatics residing in asylums than in the general population. Guislain first called attention to the liability of the insane to gangrene of the lungs in his Memoir published in 1836. He thought it generally due to the poverty of blood in patients who refused food, but although this is a frequent cause it is certainly not the only one. Sometimes it arises, as Griesinger has pointed out, from general septic infec- tion, originating, for example, from a bed-sore. In the six years' averages of the Prague Asylum, 7'4 per cent, of the deaths arose from pulmonary gangrene, while in the autopsies, in the Pathological Institute, of persons not insane the average was only 1"6 per cent. Without having any decided patho- STOMACH AND INTESTINES 59^ genetic value in connection with mental disease^ it would appear probable that gangrene of the lung is far more dependent upon inevitable circumstances of nutrition in which the insane are frequently placed than phthisis. Bronchitis and pneumonia are also frequent and fatal intercurrent disorders ; and all of these lung diseases are exceedingly apt to be developed to an intract- able degree in the insane before their existence is discovered. Mental excitement or mental debility disinclines or disqualifies the patient from complaining of pain or distress^ and the nervous system has often been so exhausted of irritability that there is no cough^ and but little dyspnoea, long after a period of the disease when very pronounced symptoms would have been developed in an ordinary patient. Diseases of the Stomach and Intestines bear to Insanity a relation of the highest importance. In acute Melancholia, attended by refusal of food, the mucous membrane of the stomach is frequently found to be inflamed and softened, or ulcerated, and it often requires all the skill of the most experienced physician to determine whether an inflammatory condition of the stomach is the cause or the result of the abstinence. Softening of the coats of the stomach is sometimes an effect or a concomitant of advanced cerebral degeneration. Whether the different forms of stomach-disease classed under the term dyspepsia, are efficient causes in the production of Insanity, by impeding the due nutri- tion of the body in general, and of the brain in particular, there are as yet no reliable data to determine. The probability is in the affirmative. This, however, is certain, that dyspepsia is common among the insane, and its removal by therapeutic and dietetic agencies is an important and efficient means of promoting the cure of mental disease. There is nothing remark- able among the insane in the pathology of the small intestines ; but the large gut suffers in chronic Insanity frequent and extraordinary displacements, which we are quite at a loss to explain. The most common of these displacements is that of the transverse arch of the colon to the lower part of the abdo- men, from whence again it ascends to take its proper position as the descending portion. But the most extraordinary anomaly we ever met with, was the formation of a cul de sac rising from the middle part of the rectum, and ascending in front of the other intestines until it reached the ensiform cartilage, the cul de sac being nearly two feet in length. Its walls were thicker than those of the colon, and it contained all the intes- 38 594 PATHOLOGY OF INSANITY tinal coats. The patient in whom it occurred had fiscites, and preparations were made for tapping ; but percussion and palpa- tion revealed the existence of something strange^ and the opera- tion was not performed. Had it been performed in the usual manner, the trocar would have passed into the rectum. Our friend Dr Parsey, of the Warwickshire County Asylum, assisted us in this case, and made the post-mortem examination. Many instances are on record of foreign substances found in the stomach and intestines. Once we found the stomach of an idiot crammed full of cocoa nut fibre, which had evidently been there some time. Ulceration and perforation of the coats of the stomach were rapidly fatal, but it was remarkable that the patient had no symptoms to call attention to his state until the last fatal complication occurred. Dysentery is apt to occur in asylums for the insane where the food is too liquid or insufficient, or where cleanliness is not thoroughly attended to ; and a con- siderable number of chronic lunatics, and especially of para- lytics, die of common but obstinate diarrhoea. The Liver is not more frequently congested, or otherwise dis- eased, in the bodies of the insane than in others. The old Greek theory, that madness depends upon black bile, has no foun- dation in pathological fact. The only noteworthy peculiarity in the liver which we have observed, has been an apparent loss of structure, occurring in Melancholia and Dementia of very long standing, and in which great emaciation and prostration of vital power have long preceded death. In seven instances of this kind we have found the liver shrunk and flabby, and its structure con- verted into an appearance closely resembling that of the healthy spleen. Dr Budd describes an analogous change occurring in persons not insane, but with acute and recognisable symptoms. The Spleen is usually small in chronic Insanity. The Kidneys are remarkably free from disease in all the forms of Insanity, and the changes which give rise to albuminous urine are especially rare in them. We have only met with three instances of decided Bright's disease among the insane ; and upon inquiry in other asylums, we have found that the experience of others has been of a similar nature. Prior to observation, we should have expected Bright^s disease and Insanity to have been frequently concomitant, on account of the common influence of intemperance in the production of the two disorders ; or even that the former might be the occasion of Insanity, through the influence of its accompanying aneemia, EEPEODUCTIVE OEGAXS 595 and tlie toxic action of unsecreted urea upon tlie brain. Grie- singer remarks tliat ^^Bright^s disease is exceedingly rare amongst the insane as a primary affection, but tlie slighter forms whicli accompany tlie various marasmatic states are naturally common." Dr Howden in his careful analysis of the Montrose Asylum autopsies, which generally agree with our own observations, has met with a much larger proportion of kidney disease. In 235 post-mortem examinations he found fatty degeneration of the kidneys in 55 cases, and cysts of the kidney in 31, and during three years twelve patients were admitted into his asylum with albuminuria. In connection with this peculiarity it would be interesting to know the habits of the sane population of Montrose, the prevalence of Bright^s disease among them and the causes of insanity. Eenal and vesical calculi are equally rare in the insane. We have not once met with either, and only once with prostatic calculi- In this case the bladder and kidneys had become diseased from irritation communicated from the diseased prostate. The Reproductive Organs are frequently the seat of disease, or abnormal function. Among male idiots and imbeciles, instances of deficient or excessive development of these organs are common; and the female population of every large asylum contains several instances of that masculine development of frame and constitution which indicates an abnormal formation of the sexual organs. There can be little doubt from the number of such instances, that the androgynous character is often accompanied by mental imbecility. Is it not always so to some extent, and is not this a cogent reason why the women who have invaded the sphere of man^s work and duty have, as a rule, proved such miserable failures ? The women of highest mental capacity have generally been remarkable for the strong development of the characteristics of their own sex. Amenorrhoea is a frequent cause or consequence of, or con- current phenomenon with, mental disease ; and its removal often leads to recovery of sanity. Extreme congestion of the ovaries and uterus, with false corpora luteco in the former, we have found in two instances of young women who died during the excitement of acute ISTymphomania. Ovarian tumours are not uncommon ; and at the time we write two insane patients are under our care, suffering from ovarian dropsy. One has been tapped several times, to ward off the imminent danger of death 696 PATHOLOGY OF INSANITY from tlie upward pressure of the fluid ou the stomacli and lungs. The other, an epileptic, with the assistance of Dr Parsey, we tapped for the same reason, nine years ago, draw- ing off five gallons of porter-coloured fluid ; and, strange to say, the cyst has only refilled to a slight extent. Bed-sores or Asthenic Gangrene is a most serious intercurrent complication, happily, far less frequent now than it formerly was, before the management of the advanced stages of General Paralysis was so well understood as it has now become. An article on this subject by us, will be found in the fourth number of the ' Journal of Mental Science,^ then called the ' Asylum Journal,^ in which this complication of Paralysis is referred to defect of nervous influence : — " It depends on the cessation of nutrition, and the consequent death of the tissues and the blood contained in them from the abstraction of nervous force, and resembles the destruction of the tissues of the eye and the ulceration of the cornea arising from destruction of the trunk of the trigeminal nerve, and gangrene after fractured spine and in continued fever.^' In the worst cases, the gangrene of Paralysis does not confine itself to the coverings of the sacrum, the trochanters, and other bony prominences. It sometimes attacks those parts where the fleshy cushion is the thickest, as the gluteal and lumbar regions. These early and severe cases bear a strong resemblance in the appearance of the parts to traumatic gangrene, and mortifications of the moist kind. The skin becomes dusky red, then brownish and mottled, and eventually black. Bullae sometimes form on the fingers and feet and the parts not subjected to pressure. In cases of rapid nervous degradation the decomposition of the body commences before death. The slightest pressure produces sloughing, the weight of one leg crossed over the other in bed, or the weight of the hand and forearm lying upon the abdomen. In two instances we have seen the cuticle peel from the whole body in the moist state observed in a rapidly decomposing corpse. Final eremacausis had become active while the vital functions were still languidly performed. In more frequent cases where the nervous power has deteriorated more gradually, paralytic sloughing is of the dry type and rather resembles senile than traumatic gangrene. A portion of skin from two or three to six or eight superficial inches becomes reddish, mottled brown, and then black. After a time a narrow line of demarcation is formed, and a thin dry slough is separated. Very often this HUMORAL PATHOLOGY 597 form of gangrene does not penetrate through the true skin ; after separations of the slough healthy granulations form^ and the sore frequently heals in a short time. The healing process in such cases of General Paralysis is not uncommonly observed to be remarkably rapid. Scarifications for erysipelas and other incisions will heal in such patients by adhesion^ and even while new sloughs are forming, old sores will granulate and heal with surprising rapidity. We cannot doubt that these affections are analogous to the mortifications which take place in the lower extremities of persons who have suffered mechanical injuries of the spine. They are pathogenetic, forcibly pointing to the implication of the spinal cord in the disease in which they so frequently occur. In his lecture on mortification. Sir James Paget observes that a '^ defective nervous force may be counted among the many conditions favorable to senile gangrene, and so, yet more evidently, the sloughing of compressed parts is peculiarly rapid and severe, when those parts are deprived of nervous force, by injury of the spinal cord or otherwise " . (p. 463). Sir B. Brodie also refers to these phenomena : — "I have known mortification in the ankles begin within twenty- four hours after injury of the spine, and a remarkable circum- stance it seems that injury of the spinal cord should thus lessen the vital powers so as to make the patient liable to mortifica- tion, when we consider how many circumstances there are, which would lead us to doubt whether the nerves have any influence over the capillary circulation." (' Lectures on Sur- gery and Pathology,^ p. 308.) The Humoral Pathology of Insanity. — The qualitative analysis of the blood of the insane has been made the subject of investi- gation by some German and French physicians. Although the somewhat difficult manipulations needful to obtain accurate and trustworthy results in an investigation of this kind, may be a severe test of the chemical abilities of alienists, we must admit that the uniformity of the gross result obtained by several independent inquirers, is sufficient to justify the important con- clusion, that the condition of the blood of the insane is opposed in character to that which is found to obtain in inflammatory diseases, and that it approximates to that found in non-inflam- matory neuroses, and in febrile affections. Hittorf, of the Siegburg Asylum, analysed the blood of seven patients suffering from acute Mania ; the results he obtained were, that in six out of the seven cases^ the fibrine was below 2-5^ the percentage of 598 PATHOLOGY OF INSANITY fibrine given by Becquerel and Eodier as the amount of this substance in liealtliy blood ; tliat, in the same number of cases, there was a diminution of the globules ; and, in five out of the seven cases, there was an increase of water. In Hittorf's analysis of healthy blood, however, the amount of fibrine is marked as low as 1'4. This disagreement with the result obtained by physiological chemists of reputation, is sufficient to detract fi'om the value of his conclusions. Erlenmayer has analysed the blood of patients suffering from various forms of mental disease. The conclusions he arrives at are, that the venous crasis, i.e. the increase of globules, is very rare among the insane, and principally occurs in idiocy and delirium tremens ; and that the fibrinous crasis, i.e. increase of fibrine, is equally rare in cases of Insanity free from compli- cations which would tend to modify the proportions of this constituent. M. Michea, who has investigated the condition of the blood in General Paralysis, found that, in the majority of cases, there was an increase in the number of globules ; in the majority, also, the quantity of fibrine was normal, in some it was diminished. The inorganic matter of the serum representing the albuminous constituent was diminished in little less than one third of the cases ; from which he infers, that " the spontaneous diminution and the insufl&cient formation of the albumen of the blood, are the immediate causes of a certain number of the cerebral effusions which occur in the paralytic insane. ^^ The analysis which Becquerel and Rodier obtained of blood in acute inflammations {' Path. Chem.,^ p. 105) shows a propor- tion of fibrine of 5'8 per cent., the normal standard being 2'5; a decrease of globules from the normal standard of 135 to 123'3; a decrease in the albumen of the serum, and also the alkaline salts ; and an increase of fatty matters. In encephalitis, Poggeolli and Marchal found the fibrine increased to 6'08, and the globules decreased to 106*05, affording a remarkable contrast to the proportion of these constituents found by Hittorf in acute Mania ; the highest amount of fibrine found by the latter being 2-03, and the lowest amount of globules being 109*191. The Urine in Insanity has been carefully investigated by Dr Sutherland, to whose papers on this subject in the ' Medico- Chirurgical Transactions ' of 1844 and 1855 we must refer our readers. A comparison of the results obtained by him, with those of Dr Bence Jones, in his inquiry respecting the proper- HUMOEAL PATHOLOGY 599 tion of phosphates in the urine of phrenitis^ delirium tremens^ and general paralysis, is highly instructive. In four out of five cases of acute Mania, Dr Sutherland found the proportion of phosphates above the mean quantity present in health ; in the fifth case it was nearly of the healthy standard. In one case it was as high as 9 '3 7, being nearly equal to that found by Dr Bence Jones in delirium from fracture of the skull. Dr Sutherland believed, however, that this excessive elimina- tion of the phosphates is rather a measure of the consumption of nerve-force than of inflammatory action. The results of treatment, of blood analysis, and of post-mortem investigations, proved to him that the condition of the brain in Mania is not inflammatory. In acute Dementia the amount of the phosphates was remark- ably deficient. It was lowest when the mental faculties were most feeble. In one case the proportion was 2*49, when the powers of the mind were in abeyance ; when they again began to be exercised, the proportion increased to 5*1. In another case, when first examined, the proportion was 5*23 ; but as the disease advanced, and when the patient was unable to compre- hend what was said to her, the phosphates fell to 2"37. In General Paralysis there was great deficiency of the phos- phates, these falling, as the disease advanced, from 4*42 to 1*57. In chronic Mania and chronic Dementia the amount of phos- phates was below the average in every case but one, a patient in whom the powers of the mind were little impaired. Dr Suthei'land thought that these results correspond in a very interesting manner with the analyses of the brain and of the blood in mental diseases. The tissue from which the phos- phates are eliminated is the albuminous ; and according to L^Heritier, the brains of infancy and old age, compared with that of the adult presents a minus quantity of albumen, fat, and phos- phorus ; while according to Couerbe, there is a plus quantity of phosphorus in the brain of acute Mania. In the reaction of the urine, the observations of Dr Suther- land are opposed to those of Erlenmayer, who in his thesis ' De Urina Maniacorum,^ states that the urine is generally alkaline in recent cases of Mania. Dr Sutherland found that in 125 cases of recent Mania, admitted during two years at St Luke^s, the urine was acid 111 times, alkaline 13 times, neutral 1 ; and that, in 100 cases of chronic Mania and Dementia, it was acid 61 times, neutral 6, and alkaline 33 times; in 2^ cases of 600 PATHOLOGY OF 11^ SANITY paralysis of the insane it was acid in 12, neutral in 1, alkaline in 12. The Chemical Pathology of the Brain has received little attention in this country. A careful paper on the subject by Dr Adam Addison will be found in No. 58 of the ' Journal of Mental Science.^ Dr Addison condenses the observations of Lassaigne, Von Bibra, Schlossberger, and others, and after detailing his own experiments on twelve insane persons he deduces the following results : " 1. A confirmation of the assertion that the different anatomical parts of one and the same brain present great differences in their quantities of water and fat, with the addition that these differences appear to be greater when complicated by Insanity. "2. A confirmation of the fact that the grey substance is far poorer in fat than the white. " 3. A confirmation of the law that the quantity of matters soluble in ether stands in an inverse relation to the quantity of water. " 4. That in the gi-eater number of the foregoing cases, the results as to the quantities of water were slightly higher than those of other experimenters on sane brains. "5. That the quantities of fat were generally smaller, and that in two cases of Idiocy — one of Dementia, and one of chronic Melancholia — they were below the quan- tity found in the new-born child, and in two cases not greater than the amount found in embryonal conditions of an early stage. " 6. That the quantities of phosphorus did not have a parallel connection with the degree of intelligence. " 7. That in three cases of hemiplegia the average quantity of fat in the corpus striatum, optic thalamus, and grey substance of the hemisphere opposite the paralysis, was less than the average quantity in the same parts on the other side. " 8. That in a case of cancer cerebri the,cancerous mass contained less fat and more albuminates than the unaltered cerebral substance." The Pathology of General Paralysis. — This interesting, but hope- less form of disease, may be said to have been unknown until it was fully described in the admirable ' Memoire ' published by Calmeil in 1826. Haslam, it is true, in his ' Observations on Madness ' (2nd edit., 1809, p. 259), refers to its symptoms in a manner which can leave no doubt that their peculiarity had engaged his attention ; but no further notice was taken of it until Bayle's thesis, in 1822, and CalmeiFs work in 1826, called to its remarkable phenomena the attention of all medical men practising in lunacy. It would appear that Haslam first described the disease but did not name it. Calmeil, who followed the English psycho- logist, gave it a name and got the honour of the discovery. GENERAL PAEALYSIS 601 This is acknowledged by Brierre de Boismontj who, in M. Tardieu's ' Supplement au Dictionnaire des Dictionnaires/ p. 601, after showing that he had described the Paralysis of the Insanity of Pellagra before M. Baillarger^ remarks : — '^ Je n^ai pas donne le nom a cette complication de la pellagre, cela est incontestable ; mais pour tout lecteur impartial, j'en ai fait con- naitre les principaux symptomes. Ma position a,, dans ce cas, quelque analogie avec celle de John Haslam, relativement aux medecins francais/^ Calmeil in his early monograph says, " The conclusion there- fore is permitted, that it is a chronic inflammation which gives rise to General Paralysis by determining to the brain a peculiar modification which we have not known how to appreciate ; and which, independently of the changes recorded, may have existed in all the individuals whom we have dissected.-'^ In his later work, ^ Traite des Maladies inflammatoires du Cerveau,^ 1859, he designates the disease as '^Periencephalitis chronica diffusa." Other French alienists attribute the pathological cause of this disease to changes still more special and limited than those first alleged by M, Calmeil. Thus, Bayle, with whom Esquirol concurs, attributes it to a chronic form of meningitis ; M. Delaye, to induration of the medullary substance. M. Bottex affirms that the meninges are always adherent to the cortical substance, and that any alteration in the medullary substance is rarely observed. M. Parchappe attributes it to the softening of the middle layer of the cortical substance, which permits the ready separation of the external layer. M. Belhomme confirms the alterations reported by others in the superficial parts of the cerebrum, but adds, that the changes originating them extend gradually to the very centre of the organ. These discordant opinions lead necessai'ily to the inference, that the pathology of this disease was yet purely a matter of surmise. That degraded conditions of nutrition are commonly found in the brains of persons dying of General Paralysis, was about all that could be stated as actual and reliable fact. The arachnoid is found opaque, but not so notably changed as to indicate the previous existence of inflammation in the common acceptation of that term. There is atrophy, and subarachnoid dropsy. The grey cortical substance is obviously thinner than in health. The medullary substance is often discoloured with pink mottling, or presents a slight shade pf brown pr grey. Its specific gravity 602 PATHOLOGY OP INSANITY is always diminished, a fact pointed out by the author in the Report for the Devon Asylum, for the year 1851, and more fully proved in his paper on the " Pathology of Insanity/' in No. 29 of the ' Medico- Chirurgical Review.' In the above- mentioned Report, the author expresses his opinion on the pathology of this disease as follows : — " I believe that General Paralysis is essentially a disease of nutrition affecting the ivhole oiervous system — that nerve-matter, both in the vesicular and tubular portions thereof, is imperfectly produced — and that the cerebral or generative, and the conducting functions are conse- quently interrupted. If chemical research should inform us hereafter of what pure neurine consists, it may perhaps be enabled to show that, as in rickets, the utility of the osseous system is injured for want of certain earth salts, so, in this disease, the atrophy observable in the gross mass of the nerve tissues, and the general decay of function depend upon want or change in the quantity or quality of the neurine.^' "We adhere to this opinion, which we believe justified by the fact first ascertained by us, and published in the above mentioned Report, that, " in the paralysis of the insane, the irritability of the muscles and the excito-motory function of the nerves is nearly lost ; in ordinary paralysis, whether dependent upon lesion of the spinal cord, or of the brain, these functions are retained. I think this point important, as it tends to prove that the cause of this disease is not localised in any one portion of the cerebro-spinal axis, but consists in some morbid change, pervading the whole nervous system, and probably implicating the distal fibrils. '^ That this disease consists in some vice of nutrition, whose nature is yet unknown, but whose extent embraces the whole of the nervous system, and is by no means limited to the encephalic centres, is a view which also appears to us to derive support from the atrophied and changed condition of the spinal cord. In the above-mentioned Report the author states, " I have made numerous examinations of the spinal cord, and always have thought that it presented a less diameter than ordinary. As, however, I could not verify the rough estimates of the un- assisted senses by any satisfactory appliances of measure or of weight, I am unable to advance my knowledge of this fact as satis- factory or conclusive. Satisfactory proof that the spinal cord is atrophied would be of great importance ; for, whilst most of the changes observed in the brain itself are common to other morbid GENERAL PAEALYSIS 603 conditions^ it would probably be found that atrophy of the cord, in addition to these changes, is peculiar to this disease. During many years after this was wi'itten, we paid much attention to the condition of the spinal cord in General Paralysis. We have weighed the medulla oblongata, and the upper portion of the cord, in many instances ; but, although our conviction is that its absolute weight is greatly diminished, the want of a trustworthy normal standard of comparison incapacitates the proof. The white fibrous matter of the medulla and of the cord has appeared to us indurated, as well as diminished in volume, while the columns of grey substance in the cord and the grey matter of the olivary bodies, have presented a deeper colour, often tinged with brown, and a softened consistence. The membranes of the cord, also, have, in many instances, been rougher than usual, and often accompanied with a dark grey discoloration. Since the above observations were published in our earlier editions, diligent investigations have been pursued into the pathology of this disease which seems to possess a peculiar attraction for pathologists, probably excited by the expectation that it does really depend upon some one peculiar modification of the nervous system, the discovery of which may give a new and valuable key to further research. It is remarkable, however, how little attention has been given until recently to the condition of the spinal cord, although all the symptoms would seem to indicate that this, if not the primary, is, at least, the constant seat of the disorder. Dr Boyd, who first called attention to morbid changes in the spinal cord, has published in the ' Journal of Mental Science,'' for 1871, the valuable records of his ipost-inortem examinations in the Somer- set Asylum. At page 366 he gives a table of the conditions which he observed in the cord in 161 cases. In only 5 males and 1 female was the spinal cord found to be apparently in a normal condition. In the remaining 155 cases, the cord was softer than natural in 36 ; it was indurated, firm, tough, and wasted in 20 ; fluid was found in the spinal canal in unusual quantity in 16, and blood in 14 ; and in all the other cases there were obvious morbid changes in the cord itself, in the canal, or the membranes. At page 19 of the same volume Dr Boyd records the morbid changes which he observed in the brain, but these were far from being so constant as those he met with in the cord ; and there is nothing to distinguish them from the 604 PATHOLOGY OF INSANITY changes generally observed in chronic cases of Insanity without paralysis. A valuable contribution was made^ in 1869, by that eminent pathologist Dr Lockhart Clarke, which will be found in No. 72 of the 'Journal of Mental Science.' In a case of General Para- lysis he found on slicing the cerebral white substance of the brain — " Numerous cavities of a round, oval, fusiform, or crescentic or somewhat cylindrical sliajie, and varying from the size of, a pea or a barleycorn to that of a grain of sand, so that the surfaces in some sections strikingly resembled the cut surface of Gruyere cheese, while those of others had more resemblance to a slice of the crum of bread." " They were for the most part empty, had perfectly smooth walls without any lining membrane, and seemed as if they had been sharply cut out of the tissue. A few, however, were found to contain what appeared to be the remains or the debris of blood-vessels mixed with a few granulations of hsematoidin." " It is almost certaiia that at least the greater number of these cavities were peri- vascular spaces or canals which originally contained blood-vessels suiTomided by their peculiar sheaths, and which subsequently became empty by the destruction and absorption of those vessels." " These remarkable vacuoles or canals were also found in the optic thalamus, in the pons A'^arolii, in the anterior pyramid and the upper part of the medulla oblongata. Neither the lower part of the medulla nor the spinal cord presented any appreciable deviation from the normal state. In the grey substance, in some places, nerves and cells were unusually loaded with pigment granules ; in other places they had under- gone, to a greater or less extent, the process of disintegration ; while here and there were scattered over areas of variable extent, irregular masses of fat particles of different shapes and sizes.* Decidedly the most important contribution to the pathology of General Paralysis which has been made of late years is that of Dr C. Westphal, published in the first number of Griesinger's ' Archiv. fiir Psychiatric/ and of which an excellent translation by Dr James Rutherford has been published in Nos. QQ and 68 of the ' Journal of Mental Science.' WestphaFs paper is both original and critical, and a great part of the value of his work consists in his power of collecting and estimating the observa- tions and opinions of other observers. No one, from learning and knowledge of the subject, could be more competent to per- form this difficult and important task. The naked-eye appearances of the brain Westphal summarises as follows : " Pachymeniagitic, in part haemorrhagic, collections upon the internal surface of * See also Dr Lockhart Clarke's communication to the ' Lancet,' September 1st, 1866. GENEEAL PARALYSIS 605 the dura mater and hsematoma of the latter ; opacity and thickening of the pia mater in various degrees ; in the slighter degrees especially along the course of the great vessels and the longitudinal cleft, frequently associated mth the formation of small granulations upon the surface of the convexity ; frequently the pia mater adheres to the cortical grey substance of the brain, so that in drawing it off, greater or smaller pieces of the latter remain attached to it, and the cerebral surface thus denuded of the pia mater acquires a torn and gnawed appearance. The adhesions occur essentially upon the summit of the gyri, and principally upon the convexity of the brain by the side of the longitudinal cleft, and on the anterior lobes. At other times the pia mater and its meshes are saturated and filled svith serum ; the membrane can then be easily removed without involving the sm'face of the brain. The ventricles, too, are very often much dilated with serous fluid, the ependyma is thickened, sometimes in the form of granidations. It has been further shown that in certain cases there is atrophy of the brain substance ; this may in some degree involve the grey cortex, but chiefly the medullary substance. The consistence of the cerebral substance sometimes appears changed, the white sometimes firmer and tougher ; the grey substance espe- cially in its more superficial layers, somewhat softer than normal. In the latter there is at the same time observed either a great fulness of the blood-vessels, giving it a violet red colour, resembling wine grounds, or it appears pale and faded. The nerves at the base of the brain do not generally present any alteration ; still, cases occasion- ally occur of atrophy of the optic nerves, and the nerves proceeding to the muscles of the eye." " I have reason to believe that the olfactory nerve is more frequently affected than has been generally acknowledged." In. tlie interpretation of these appearances, preceded as tliey frequently are by maniacal and febrile symptoms, the author argues against the inflammatory theory, concluding as the result of comprehensive special observations '^ that the maniacal excitement of General Paralysis does not in itself stand in re- lation to pathological increase of temperature/^ He objects to M. Parchappe^s method of examination and the conclusion he founded upon it, that the seat of the morbid process is in the cortical cerebral substance. Changes in this substance were investigated subsequently by Eokitansky who believed that an increased growth of connective tissue took place in it whereby a viscid glutinous fluid, rich in nuclei and the fibrous elements, was formed, with colloid and amyloid corpuscles resulting from the destruction of the nerve elements. Westphal points out the great dijB&culty of the examination, especially in the fresh pre- parations which were used by Eokitansky, and. concludes, " I dare aflB.rm that no one has yet demonstrated such processes in a manner at all convincing either in the grey or in the white substance.^^ The conditions of the cerebral vessels which have in this country been described by Dr Sankey as pathological in this disease, Westphal considers to be normal. 606 PATHOLOGY OF INSANITY " Whether we agree with the view taken by Eobiu of these sheaths (perivascular lymph spaces of His) or not, it is at all events clear that if we compare with this the descriptions and drawings of Wedl, Sankey, and others, set downi as pathological, we shall find that many of the drawings of the former and all those of the latter, are merely representations of a normal condition of the vessels. The serpentine form, too, upon which great stress has been laid (produced by the contraction of the alleged newly formed connective tissue around the vessels) is frequently seen in a well-marked deo-ree in healthy brains. I have never considered this condition to be pathological, and have often given expression to my views." He concludes that nothing has as yet been discovered of the finer changes of the cerebral substance in this disease, and that what we do know consists in the cognizance of certain grosser changes in the consistence and the amount of blood it contains, which do not appear to be of inflammatory origin, for there are no granulated corpuscles in the cortex or white substance, and the other traces of an inflammatory process are wanting. Of the meninges, indeed, opacity and thickening are extremely frequent, and have an analogy with chronic inflammations of other membranes. But chronic meningitis does not explain the nature of the disease, for these appearances are often absent in General Paralysis and often present when there has been no paralysis. " We may, therefore, at most infer that the cerebral changes lying at the foundation of the paralysis very frequently go along with chronic inflammatory conditions of the meninges, are accompanied by them, and stand in a certain relation to them ; but not that the fundamental morbid process is identical with a chronic meningitis or under all circumstances depends upon it." Although no peculiar characteristic and essential change has yet been observed in the brain, observations on the spinal cord have given more definite and practical results. Westphal remarks that the spinal cord was formerly very seldom exam- ined, and, thus, it came to pass that its condition was either entirely ignored, or the purely cerebral character of the disease was expressly inculcated, as distinguishing it fi'om other spinal affections. As both Dr Boyd and we ourselves had, more than twenty years ago, emphatically inculculated our opinions that General Pai-alysis was a disease of the spinal cord, we think that Dr Westphal, from want of information doubtless, scarcely here manifests the accurate appreciation of others which is so charac- teristic of his remarks. " Diseased conditions of the spinal cord are now, however, as I think I have shown, quite common in General Paralysis of the insane, and may be considered as amongst the best constituted facts. Virchow and more recently Magnan have also GENEEAL PAEALTSIS 607 recognised affections of the spinal cord. In so far as they have as yet been observed, these affections present various forms and degrees ; sometimes the membranes are involved, sometimes they are not. - On the dmra mater, inflammatory processes are occasionally observed (pachymen- ingitis, also of a haemorrhagic character). Affection of the pia mater is recognised by general opacity and thickening of its tissue : thickened bands and retiform lines are also frequently seen projecting from its surface, and moreover, filiform or more membranous adhesions pass between it and the dura mater. In regard to the disease of the spinal cord itself, there may be distingiushed, anatomically, the following forms : — 1st, Affection of the posterior columns thi'oughout their whole length from the cervical to the lumbar regions. 2nd. Affection of the posterior section of the lateral columns likewise throughout their whole extent. 3rd. Mixed affection of the posterior columns, and of the posterior portion of the lateral columns. The isolated affection of the posterior columns assumes a form somev,'hat different anatomically from the other varieties. It consists in a considerable loss of nerve elements (atrophy), in the place of which there has entered a connective tissue-like substance, which is sometimes plainly seen, when longitudinal sections are made, in the form of completely developed fibrous connective tissue. When transverse sections are made, it is seen that this connective tissue lies imbedded here and there in irregular plates, of larger or smaller size, between the transverse sections of the nerve tubes. Where the process is further advanced these plates unite with each other, so that when stUl further advanced, merely a connective tissue-like substance is apparent, in which here and there the transverse section of an isolated nerve tube may still be seen. The nerve tubes themselves appear partly very small, partly of ordinary diameter, and occasionally very broad. Atrophy and hypertrophy of the nerve tubes have therefore been spoken of ; but this point demands fm'ther investigation, as, even in the normal spinal cord, considerable differences occur in the diameter of the nerve tubes. The mode of pre- paration (for example, unequal hardening) also plays a part. I consider, therefore, that this question is not yet fully elucidated." In the posterior columns, constant distinctions can be made out in comparing tlie superior and iuferior portions of the cord in regard to the intensity and extent of the disease, but in the cervical region GolFs tracts are very frequently only affected. The more anterior portions of the posterior columns situated next to the posterior commissure always remain most intact. Fat cells, pale cellular elements containing nuclei and corpora amylacea, are often observed. In affections of the lateral and postero-lateral columns, granulated corpuscles and diffused lines of connective tissue, much broader than in normal conditions, are seen. If the lateral columns only are affected, the disease is always confined to their posterior section. A connection has not yet been demonstrated between these pathological conditions of the cord and those of the brain. The granulated corpuscles are not found beyond the foot of the peduncles of the cerebrum, and no abnormal changes have been as yet observed in the ganglia of the nerves. The idea of the 608 PATHOLOGY OP INSANITY extension of brain disease downwards to the cord^ must for the present be abandoned. The extension of disease of the cord upwards to the brain is more consistent with the fact of the degeneration of the posterior columns diminishing towards the cervical region. Still no such extension can be demonsti'ated^ and there is nothing as yet to justify the assumption of a direct continuation of the pathological process into the brain. We must for the present regard the cerebral and spinal diseases as simultaneously existing in General Paralysis in certain respects independently of each other. There is a certain disposition of the nervous system in which^ and according to unknown causes, sometimes the spinal, at other times the cerebral, and at others the peripheral cerebral nerves are attacked by the morbid pro- cess either in succession or simultaneously. As the morbid processes in the brain are not encephalitic, the connecting link seems to be the frequent occurrence of chronic meningitis in the brain and the cord. Westphal distinguishes two forms of the disease which may be recognised during life by distinctive difference of gait. In the Tabic form which he attributes to grey degeneration of the posterior columns of the cord, the gait is like that in tabes dorsalis. The patients lift their legs high and throw them outwards, stand firmly while their eyes are open, but stagger or fall when they shut their eyes. The motor dis- turbance in this form very frequently precedes the mental disease for a long time. In the Paralytic form the patient lifts his feet very little from the ground, taking short steps with legs apart, and does not stagger when he shuts his eyes. In this form the mental disease is generally far advanced before the motor affection is observed. Its pathology is believed to be chronic myelitis. Whether the tabic form of General Paralysis is the same affection as the Paralysie Generale Progressive of Regnier, or the mental disease which occasionally supervenes upon ordinary tabes dorsalis, we have not as yet data on which to form an opinion. It is probable future observers will distinguish more than two varieties of the disease. The pigmentary changes in the ganglia of the sympathetic which were first described by Poincare and Bonnet, have also been seen by Dr Batty Tuke and Dr Howden, but unfortunately for the sanguine hopes which were rested upon the discovery, they are found not to be pecu- liar to General Paralysis, but to be common in all forms of chronic mental disease. GENERAL PARALYSIS 609 The morbid conditions of tlie spinal cord wMch were first indicated by Dr Boyd and by ourselves, and the existence of which was pointed out with certainty by our own experiments on the gradual failure of reflex nervous action, have now been thoroughly recognised in the observations of Westphal, and they for the present constitute the special pathology of this disease. No change in the brain or its membranes has yet been demon- strated which is special to General Paralysis ; but the peculiar psychical symptoms of the more common form of this disease, the optimism, and the fertile imagination which creates such won- derful delusions in the midst of progressing Dementia, leads us to anticipate that future investigation will discover some special and characteristic cerebral change. We are but on the first steps of the ladder of observation and discovery into the physiology and pathology of the brain and its appendages, or to speak with more accuracy of the nervous system and its centres. It is only since the first edition of this Manual was published fifteen years ago, that the old belief in the spiritual nature of Insanity has utterly died out. It is only within this recent period that trustworthy observations have been made on the morbid histology of the brain, and even now next to nothing is known of its chemical pathology. But physical inquiry is alert and incessant, and if the authors should live to issue another edition, they confidently hope to record that the veil of ignorance has been rent in many directions, and that the genesis of mind and its diseases is no longer perceived merely as a general fact, but in its detail as a great and growing science. 39 CHAPTER VI {continued). MORBID HISTOLOGY The difficulties arising out of the peculiarly delicate structure of the brain, which for so long stood in the way of the anatomist, preventing him from arriving at a definite knowledge of the histology of the organ, were of necessity even greater stumbling- blocks in the path of the pathologist. The double-bladed knife of Valentin, which had aided in the elucidation of the healthy and the unhealthy conditions of other organs of the body, failed in producing sections of the brain sufficiently thin for submission to the microscope, and it was not until chemical agency was employed that any accuracy was obtained in our knowledge of the relations of its complex elements. As soon, however, as it was discovered that chemical solutions could be employed, which, whilst hardening the nervous tissue did not interfere with its relative structure, a host of observers broke ground in this yet untrodden field of anatomical research. In Germany the researches of Arndt, Jacubowitsch, Meynert, Bischoff, Stilling, Schroeder van der Kolk, Kolliker, and others, have served to place the anatomy of the brain on almost as definite a footing as that of any other organ of the body, whilst in England the splendid demonstrations of Lockhart Clarke stand pre-eminent. The pathologist soon followed in the track of the anatomist, a.nd although it cannot be said that his results have been so immediately brilliant, he has done most important work, which must, when further prosecuted, react on physiology and anatomy. In the last edition of this work an attempt was made to describe in a general manner the structural alterations revealed by the microscope in the various tissues of insane brains. Up to that time (1874) it could hardly be said that these changes had been in any instance definitely and finally correlated with clinical phenomena; little had been done to establish definite Pla^e Ia k^^^ Z Beriea'i. litn. 'Watsrs'.or Sor.s i S^ev/arl.LHK" E3" NOEMAL BRAIN STEUOTUEB 611 pathological entities based on morbid anatomy^ and we have to express our regret that although five years have elapsed we can point to only two instances in which this step has been success- fully accomplished. We propose^ therefore^ to repeat the substance of our general descriptions with such additions as recent observations have furnished us, and to append a detailed description of the minute histology of Greneral Paralysis and Senile Dementia after the careful descriptions of Mierzejewski and Herbert Major.* It may be broadly stated that morbid changes can be found in every insane brain if the investigation be thoroughly carried out, and although we are not prepared to go so far as Van der Kolk, who says that he has never failed in obtaining satisfactory explanations of the symptoms which had occurred during life by post-mortem examinations, minute and persevering mici'O- scopic observation will invariably prove the somatic nature of all those diseases in which mental obscuration is the predomi- nant symptom. In order to afford the student a criterion of health we have reproduced in colours Arndt^s plate of the normal brain struc- tures (PI. IX). It gives a good idea of the arrangement of the elements of the brain cortex as viewed by a magnifying power of 250 diameters and stained with carmine. It will be seen on reference to this illustration that the brain substance consists of vessels, fibres, cells, and an interstitial material, the neuroglia. The vascular supply of the brain, its distribution and amount, is of the highest importance to the cerebral pathologist. It is not here necessary to allude to the greater trunks or their branches, until these branches commence to ramify in the substance of the brain. Fig. 1, Plate X, shows the distribution of the smaller arterial branches from a larger one situated at the bottom of a sulcus, and indicates very fairly the appearances met with in injected specimens. Had it been drawn more diagrammatically it would have shown better the arrangement by which the brain is supplied at different depths by different systems of arteries. What is apparent at a glance in this picture is the enormous difference between the blood- supply of the grey and white matter. It may be fairly stated that the grey matter receives five times as much blood through- * 1. "Etudes sur les Lesions Cerebrales dans le Paralysie Geuerale." Par M. Mierzejewski, ' Archives de Physiologie,' 1875. 2. " Histology of the Morbid Brain." By Herbert C. Major, ' West Riding Asylum Reports,' 1874. 612 MORBID HISTOLOGY out its tissues as the wliite, indicating that the functions of the former are of a more active nature than those of the latter. It will be seen that the larger arteries go direct to the white matter, rarely throwing off branches on their way ; that when these have passed through the grey matter they branch off almost at right angles from the original track and follow the direction of the inner layer of grey matter, the various branches communicating freely with each other by short connecting capillaries. The grey matter is supplied by two sets of vessels ; the innermost layers by branches of somewhat less calibre than those going to the white matter, which branch off freely in every direction, anastomosing in the most intricate manner by means of loops and convoluted arterioles. These vessels supply all the grey matter, but the five outer layers are specially pro- vided with a system of straight arterioles, smaller in calibre than those ali'eady spoken of, which do not seem to give off many branches at any part of their course. The general direction of the main vessels is straight, with few undulations or twists. The normal condition of the nerve-cells, as they appear in prepared sections coloured by carmine, is well shown in Plate IX, which represents a vertical section through the third frontal convolution magnified 250 diameters. It must be remembered that the largest cells are best marked in the frontal lobes, that they are slightly less numerous in the parietal, and sparsely scattered throughout the deep layers of the occi- pital ; in the latter situation the cells are of a much more uni- form size than in any other part of the brain. A well-coloured section of healthy brain cut in the exact transverse direction will show the fountain-like arrangement of the cells, their bases to the white substance and their apices uniformly pointing out- wards. The majority of the cerebral cells are pyramidal in shape, and prolong their poles according to Cleland, into the outer or horizontal layer of grey matter. In the deepest layer multipolar cells occur at wide intervals. The nature and function of the neuroglia (nerve-glue) of Virchow, who was the first to describe it, was, and perhaps still is, the subject of considerable difference of opinion, although anatomical research, and physiological as well as pathological considerations support the views of Virchow and Kcilliker that it is a form of connective tissue consisting of a very finely granular reticulum. This is stated to be pierced by THE MEMBEANES. 613 the interlacement of ramified connective tissue corpuscles^ or of a network of fine fibres derived from such corpuscles. Besides these Deiters has described flattened and fibrillated cells like those of developing connective tissue. Other observers, Henle, Arndt, &c., hold that the neuroglia is a nervous element. There are other points in cerebral anatomy which need con- sideration, and which will be taken up as they suggest them- selves in connection with the morbid appearances of the various elements. It is hardly to be expected that a perfect examination by means of prepared sections can be carried out in all cases ; but it is strongly urged that the microscopic examination of fresh specimens should never be neglected, for by ifc demonstrations of the most important lesions of the blood-vessels and cells can be obtained, and the results of the application of chemical reagents to affected parts noted. Nothing is more simple than the mode of making such examination of fresh specimens; a speck of cerebral tissue taken on the point of a scalpel, or a minute vessel carefully dissected out with needles, should be laid on a slide, and a drop of glycerine and some colouring agent (aniline red) added, and the covering put on, and in the case of the cerebral tissue, firmly pressed down so as to squeeze it out to a thin film ; but for all details of histological tech- nology we cannot do better than refer our readers to Professor E-utherford's admirable little book. The introduction of freez- ing has considerably simplified the details, and shortened the time required for making prepared sections, and by the facili- ties it affords should encourage more observers to enter the field of microscopical cerebral pathology. The lesions which have been observed in the brains of the insane, will be considered according as they affect — 1. The membranes. 2. The epithelium. 3. The blood vessels. 4. The neuroglia. 5. The cells. 6. The nerve fibres. 7. The histological appearance of special lesions noticeable by the naked eye will be referred to. 8. The sympathetic ganglia in the neck. The various changes in the calvarium, bony formations on the falx and other similar morbid conditions will not here be spoken of, as they do not come strictly into the category of histological lesions. 1. The Membranes. — (a) Dura mater. — A thickened condition of the dura mater is comparatively rare. Its microscopic 614 MORBID HISTOLOGY characters are irregular dilatation and tortuosity of the vessels, the coats of which, especially the outer fibrous one, are much hypertrophied. {B) Arachnoid. — The "milky arachnoid" of the insane has not been thoroughly described as it presents itself under the microscope in transverse sections. L. Meyer has pointed out the existence of fine granulations on its external surface, and Griesinger, under the title of " Hyperaemia of the Arachnoid," alludes specially to the '^frequent and spontaneous ha)morrhages into its sac," particularly in " Paralytic Dementia." The pia mater. — It has been recommended that the pia mater should be removed from brain specimens previous to submit- ting them to hardening agents, in order to allow the solution to penetrate rapidly and equally. This should never be done, for stripping off this membrane takes away the possibility of observing some most important lesions. The pia mater should, however, be carefully peeled off from such portions of the con- volutions as are not to be reserved for hardening, placed on glass slides and cleaned with camel hair pencils, tvater alone being used. It should be noted whether the pia mater adheres to the brain substance in stripping it off. Specimens worthy of retention should be stained with picro-carmine and set up in glycerine jelly. This should never be neglected, as the condi- tion of the pia mater is very fi'equently an index to that of the subjacent nerve-tissues. A thicl:ened condition of the pia mater is of frequent occurrence amongst insane subjects. In vertical sections the spaces between the arachnoid and pia mater are seen to be widened, and each membrane presents the appearance of distinct lamination. In the spaces distended vessels are to be seen, and not unfrequently the dehris of extravasations more or less old ; in recent specimens the mus- cular coat of the vessels is to be seen thickened, more especially the circular fibres, which are in some instances immensely hypertrophied. In order to differentiate between the thick- ening of the coats, it may be well to tint the specimen with picrocarmine, as occasionally both the adventitia and intima have been found thickened. It is of the utmost importance to note the supporting processes of pia mater, which accompany the vessels entering the convolutions. These wdl be found deeply tinted with carmine for a considerable distance, but the colour gradually fades as the vessel approaches the white matter, where the membrane assumes more and more a hyaline THE MEMBRANES 615 cliaractei^ witli loss of its fibrillar structure and power of taking up tlie colouring agent. In recent specimens taken from subjects who Lave died in the delirium of fever^ and in many other conditions, the vessels of the pia mater have been found surrounded by deposits of haematoidin. Large aggre- gations of phosphate of lime have been observed in one case of idiopathic melancholia.* Thickening of the pia mater is always concurrent with thickening of the arachnoid. It is almost always found on the superior surface of the hemispheres^ unless associated with acute general meningitis of the tubercular form. This disease is not more common amongst the insane than the sane. It must be boime in mind that some degree of these changes in the pia mater is by no means uncommonly found in the brains of sane people, more especially in those of advanced age, and probably is to some extent associated with chronic alcoholism in many of these cases. In all cases of thickened pia mater a finely hyaline appearance is to be seen around the vessels, which by treatment with glycerine and acetic acid, is brought more prominently into view. Sir William Gull and Dr Sutton regard this as a peculiarly characteristic material, a product of a specific morbid process, arterio- capillary fibrosis, of which the contracting form of Bright^s disease is merely a local manifestation. They term it the hyaline fibroid membrane. Amongst the insane this appear- ance is very frequently to be found unassociated with disease of the heart or kidneys. Dr. George Johnson believes it to be merely an artificial product of the action of glycerine and acetic acid on the adventitia, and there is no doubt that these reagents do display this membrane in a remarkable way even in health, yet apart from any such mode of manipulation it may be very distinctly seen. As will be shown further on, a somewhat similar condition is to be found in the internal arteries of the brain, and there is reason for believing that in the pia mater the appearance is due to subinflammatory thickening of the adventitia of the vessels, which condition is brought more pro- minently into view by the clearing action of acetic acid, and the endosmose of glycerine between the vessel and the enve- loping membrane. These agents are not necessary for its demonstration, they only assist. The presence of a hyaline membrane is certainly not confined to cases in which the heart * ' Brit, and For. Med.-Chir. Rev.,' April. 1873, p. 458. 616 MORBID HISTOLOGY or kidneys liave been affected ; on the contrary, it may be found in all cases in which chronic hypersemia of the pia mater has existed. 2. Epithelium. — The " ground glass '' appearance which so frequently presents itself to the naked eye on the floors of the lateral and fourth ventricles in cases of General Paresis, and in those where chronic Mania has been a leading symptom, is the result of three different morbid conditions, which, taken in the order of their frequency, are changed epithelium, lymph exuda- tions and crystalline deposits. The two former conditions are always associated with evidences of hyperaemia or inflammation. The neighbouring vessels are twisted and contorted, and show well-marked hyaline sheaths, the brain substance is indurated and the fibres are thickened. They not unfrequently occur together, and in some instances are accompanied by large numbers of amyloid bodies which extend for some considerable distance inwards. "When change of the epithelium is the cause of the granulations a vertical section shows simply a thickening of the ependyma, resulting from proliferation of the epithelial cells, which protrude into the cavity of the ventricle, somewhat resembling villi. When lymph exudations have pushed the ependyma upwards it presents the appearance of rough, irregular, bullae-like nodules, consisting of the layer of proliferated epithe- lial cells and a greenish homogeneous stroma, which together overlie the brain matter ; frequently deposits of the same material can be seen infiltrating the subjacent cerebral tissues. Deposits of phosphate of lime beneath the ependyma of the lateral ventricles have been recorded as occurring in a case of General Paresis. Bergmann discoved a formation of pretty large crystals of " double phosphate '' in both plexus choroidei in a case of "^ Mania with mental weakness. ''* Where granulations occur on the surface of the convolutions they usually depend on changes in the granular layer, or on lymph exudations. A proliferation of the columnar epithelium of the central canal of the medulla oblongata is of not unfrequent occur- rence, occluding it at points where in health it is patent. 3. Blood-vessels. — We believe that the examination of the vessels of the brain in cases of insanity is of primary importance; and, further, we are of opinion that in every case careful search will show that morbid changes take place in one or other of * ' New Sydenham Society's translation of Griesinger,' p. 429. Plate X. CBerjea-^a, li-Qi. Watersion, Sons &, otevfart. Lith" E3ir/ THE BLOOD-VESSELS. 617 their component parts, and in the severer and more lasting forms of Insanity we find, as we might expect, very well marked deviations from health in every one of their coats. When we glancea gain at the picture (Plate X, fig. 1) which represents the normal condition of the finer circulatory apparatus in the cerebral lobes, we cannot fail to realise what a very vast and important influence the blood supply must have over the functions of the organ, and when we recollect that the blood- vessels by the intermediation of their adventitial coats are in direct connection with the connective tissue of the parts, we see how they must inevitably take part in all the changes which that connective tissue undergoes. But changes in function precede changes of structure recognisable by our present means, and it is in their functional perversion that we must trace the first link in the chain of events which leads to functional derangement in the nerve elements themselves, and secondarily to structural changes, the result of altered or impaired nutrition. If these abnormalities of blood supply are of long continuance we may justly anticipate permanent lesions of cells, fibres, and nuclei, and, phenomenally, chronic Insanity in one or other of its forms. In all autopsies of insane persons special attention should be paid to the naked-eye appearances of the vessels of the centrum ovale ; the degree of engorgement or anaemia must be noted> and most particularly whether they are dragged out by the passage of the knife. Vessels of moderate size should be dis- sected out (not dragged out), washed carefully with water and a camel-hair brush so as to clean them from brain matter, and submitted to the microscope. By this mode of procedure certain o£ the following morbid changes will be discovered. a. Thickening of one or other of the coats. j3. A thickened condition of the sheath and hyaline mem- brane. y. Deposits between the adventitia and the sheath. 5. Proliferation of nuclei. 6. Yitreous degeneration of the coats. a. Thickening of the coats. — The inner fibrous coat has been found in some rare instances considerably thickened, and more distinctly fibrous than in health. Hypertrophy of the muscular coat has been frequently observed. In extreme cases the circular fibres can be seen increased to fully three times their normal thickness. Treatment 6]3 MOEBTD HISTOLOGY of the specimen with a carmine solution brings out their peculiarities with great distinctness. Plate X, fig. 2, represents these appearances in a transverse section. It may be generally stated that this hypertrophy is best marked in those who have been the subjects of diseases implying hyperaemia, e.g. General Paresis and Epilepsy. It is found in senile cases although to a less degree. Hypertrophy of the heart does not appear to bo a necessary cause or accompaniment. The adveutitia and intima are occasionally found thickened. In some cases the arteries have been found more or less thickened as to their muscular coats, and more especially as to their outer fibrous coats, the effect of which is completely to occlude the vessels in many instances, and in all very materially to modify their calibre. As these vessels were found in sub- jects whose clinical history gave a distinct account of long- standing syphilis, they were regarded as probably syphilitic, but in the present position of the question of syphilitic arteritis, and in tbe absence of anything absolutely histologically charac- teristic of syphilis in their appearances, we express ourselves with some reserve as to their actual nature. j3. The hyaline membrane not being enumerated amongst the normal coats of the arteries in systematic works on anatomy is the reason why it is here considered separately. In many cases of chronic Insanity, if the vessels are treated in the manner described above, there will be seen a loosely enveloping mem- brane, apart from the adventitia, clear, homogeneous in structure, uncolorable by carmine, fibroid in consequence of longitudinal puckerings, forming triangular sacs at the bifurcations, and retaining between it and the adventitia various morbid deposits (Plate X, fig. 2, a). In prepared sections the pia mater can occasionally be traced entering with a vessel, deeply coloured by carmine, till it has passed through the grey matter and then becoming hyaline and unamenable to colouring agents. In sections of morbid brain in which the artei'ies have been cut longitudinally a similar membrane can be seen, non-fibrillated and non-fenestrated, occupying vascular spaces, and in which fibrous and muscular coats do not exist on account of the thin- ness of the preparations. It is difficult of demonstration in healthy subjects, although this has been effected by Lockhart Clarke, Robin, His, and others, but when thickened by disease this difficulty is to a great extent overcome. Rindfleisch says that, although the arteries of the brain are usually said to enter THE BLOOD-VESSELS 619 nakedj it is inexcusable for any one familiar with the morbid anatomy of that organ to overlook the " sheath of connective tissue/^ which, however slender, surrounds its artei'ies. Ober- steiner supports this view. In a beautiful series of preparations in our possession taken from the same subject, its various conditions can be traced. A very acute and accurate observer, Dr Herbert Major, has noticed its occurrence in cases of "Chronic Brain Wasting. ^^ The only objection to the term " hyaline membrane " is that it is suggestive of its being a pathological addition ; the whole of the evidence available seems to indicate that it is only the normal prolongation of the sheath which the artery derives from the pia mater, but which in health is difficult of demonstration on account of its gossamer texture, but which when altered by disease, or the physiological changes of old age, is readily brought into view. -y. Deposits between the aclventitia and the sheath. — As a rule morbid deposits should be searched for at the bifurcations of vessels, as they are apt to collect in that situation in consequence of the triangular sacculation of the sheath. Plate X, fig. 2, represents the two forms in which they are met with. Neither of these appearances is confined to cases of Insanity ; they have been found in the vessels of subjects who had died in the delirium of fevers and the coma of Bright^s disease, and we have seen masses of heematoidin in immense quantities around the cerebral vessels of a lad who died of haemophilia. As observed, the deposits are of two sorts — the first a very purely molecular material (a) ; the second irregular crystals of hsema- toidin (&). The purely molecular material is to be found in the smallest capillaries, in which position it strongly resembles the spores of the favus fungus ; viewed by the highest powers it is homogeneous in structure, of a pale yellow or brownish tint, more commonly colourless ; its individual particles possess highly refracting powers, are round, varying in size from ^^'^^ to ^y'oQ of an inch in diameter, and occasionally even smaller ; their appearance strongly suggests that they are of a fatty nature, but the application of tests for oil has failed to produce any change. From observations on the cerebral vessels of young animals in which this appearance was absent, it is not likely that it is the result of decomposition ; from its gradation in intensity according to the health or morbidity of the subject, "the strong probability is that this deposit is the result of transudation, which in a small degree takes place during the process of death 620 MORBID HTSTOLOGT in all cases, and to a greater extent during life in subjects who have suffered from frequent congestions, or whose blood-vessels have been otherwise weakened."* Crystals of hasmatoidin, the second form of deposit, are almost invariably found on the cerebral vessels of insane sub- jects ; they are irregular in shape, their angles rounded as if smoothed by attrition, and they are distributed pretty equally over the vessel except at the bifurcations, where they are aggregated. It cannot be said that either of these deposits is peculiar to any one form of Insanity. S. Proliferation of the nuclei of the walls of vessels is a frequent and well-marked appearance. It seldom exists apart from pro- liferation of the nuclei of the neuroglia, and is often associated with grey degeneration. Plate XI, fig. 1, a, shows the degree to which this condition can attain. The nuclei do not seem to increase in size to the same extent as those of the neuroglia, but they have a greater tendency to become oval or irregular in shape. Dr Meyer believes that there are actually cells, not nuclei, in the walls of the vessels. Some authors have described a spiny condition of the capillaries produced by numerous filiform appendages, or by the prolongations of the cells of the connec- tive tissue touching their walls and giving rise to this appear- ance. E. Vitreous degeneration of the coats of the small blood- vessels has been described by M. Mierzejewski in General Paresis, and is figured in Plate XII, fig. 2. Prepared sections ai-e necessary for the demonstration of the following abnormalities of vessels : Z,. Microscopic aneurisms and apoplexies. >/. Abnormalities of direction. B. Pigmentation of arterioles. t. A dilated condition of the brain surrounding the vessels. Z,. Microscopic aneurisms have been observed in the pia mater, the corpora striata, and the substance of the hemispheres, in the latter position in the neighbourhood of apoplectic cysts. In the corpora striata they can exist in considerable numbers, fusiform in shape (Plate X, fig. 4), and containing blood-clots. In rarer instances they are sacculated. In size they vary from j^ to ^g of an inch in length, and their breadth is about one fourth of their * ' Med.-Chir. Rev.,' April, 1873, p. 455. Plate XI. G- BeTTeau, liin. Waierston Sons fc Stewart, lift" I3iTi. THE BLOOD-YESSELS. 621 lengtli. All the coats of the distended vessels are thickened to a great degree (Plate X^ fig. 4). MM. Bouchard and Charcot^*^ have studied these aneurisms very carefully in their relation to cere- bral hjemorrhage. They believe them to be due to what they term a " sclerous arteritis/^ which seems to be identical with the periarteritis of Rokitansky. Under this condition they describe a thickening of the fibrous coats attended with proli- feration of the nuclei^ and atrophy of the transverse muscular striee. They figure the commencement of the aneurism as an ampullation of the diseased vessel, which eventually assumes the form of a pedunculated sac. In rarer instances they speak of the aneurisms being simply fusiform. We must refer the reader, however, for the full particulars to their interesting and import- ant treatise. Microscopic apoplexies are common in General Paresis, and one is figured in Plate X, fig. 5. Dr Charlton Bastian and Dr Blandford have described plug- ging of the vessels by minute embolic masses composed of aggregrations of white corpuscles in cases of acute Mania and Delirium. Ecker has measured the small cerebral vessels of the grey matter in various forms of Insanity, the result being, that " in cases of Mania " they are generally found dilated, and Hamaer noted the same condition in the vessels of the pia mater. Dr Major describes a dilatation of the arteries in " brain wasting/^ If}. Abnormalities in direction. — Deviations from the normal course of the vessels may take the form of extreme tortuosity or actual kinking, and are evidences of frequent congestions : this condition has been observed in cases of General Paresis, and has been regarded as a compensatory arrangement for the absence of hypertrophy, a lesion rarely met with in this disease. This theory is doubtful. All elastic tubes, when pressure is put upon their walls, greater in intensity than they were intended to bear, have, on its relaxation, a tendency to kink and convo- lute. This is more especially true of tubes composed of any jihrous elastic tissue, so that it seems more than probable that the overstrained straight vessel of the cerebrum when relieved from congestion becomes tortuous or even twisted upon itself.f Contorted vessels are often seen lying in distended vascular * See translation by Dr Maclagan, ' Study of some Points in the Patholoo-y of Cerebral Hajmorrhage.' Maclacblan and Stewart, Edinburgh. 1872. t Tortuous vessels have been observed in chronic Bright's disease. 622 MORBID HISTOLOGY spaces containing the hferaatoidin deposits already spoken of. A drawing of sucli a twisted vessel surrounded by nuclei is seen in Plate XII^ fig. 3. 6. The arteries as they enter the cerebrum from the pia mater ai'e occasionally seen covered with ingment up to the actual point of entry. As this condition is always associated with the debris of old apoplexies between the membrane and the outer layer^ the pigmentation is in all probability due to their disintegration. It bears a very marked resemblance to the pigment deposited on cells. t. The consideration of the dilated condition of the brain sub- stance surrounding the vessels opens up important physiologico- auatomical questions in addition to those purely pathological. The '^perivascular canals ^^ were described by His as the lym- phatics of the brain. Professor Laycock taught that the pia mater is a great lymphatic gland, and it is held by some that, if only by a logical process of exclusion, the spaces between the vessels and the brain substance must be regarded as the over- flow conduits. If we accept the observations of Dr Goodfellow, a similar relation exists in the cornea, and more recently E. B. Kiber and Tomsa have expressed an opinion that there is a system of lymphatics surrounding the vessels of the spleen. Obersteiner supports His and Eobin in the theory of cerebral perivascular lymphatics, and even goes so far as to assert that he has observed lymph corpuscles in the canals. He goes even further and asserts the existence of a direct lymphatic connec- tion between the cells and the perivascular canals by means of " spur-like " processes. This Obersteiner believes he has proved by direct injection, the results of which he has figured.* There cannot be a doubt that were this point in anatomy defi- nitely settled, it would afford grounds for many tangible theories as to the causation of pei'verted brain action. In a canal which comprehends the main and the overflow, the patency of the latter must be occasionally interfered with in consequence of the liability of the elastic main (the artery) to congestive dilatation. From the post-mortem appearances afforded by the examinations of subjects who have died in a state of acute Mania, we gather that hypersemia and congestion have been present during life. Experiments on animals have shown that when death has been caused by strangulation, which, of course, implies cerebral con- gestion, the coats of the vessels are in direct apposition with the * ' Wieu Stzb. d. k. Akad. Wisseucr/ bd. Ixi, 1 abth., Jan., 1871. THE NEUKOGLIA 623 surrounding cerebral substance. If we correlate these facts, at tbe same time admitting, for tbe sake of argument, tbe existence of perivascular lymph spaces in the brain, it is evident that during congestion the overflow pipe must be occluded, and the waste matter, which when unremoved has in all organs a mor- bific power, must in the brain exercise a toxic influence, which might account for many of the mental phenomena of Insanity. It must be admitted that the various deposits which have been observed lying between the sheath and the adventitia are strongly suggestive of a passage for the removal of waste pro- ducts. It is doubtful, however, to what extent observations founded on forcible injection can be depended upon. In the brains of recently killed animals no space can be seen unless death has been caused by hsemorrhage, in which case a distinct canal is observable around the emphj vessel. In subjects who have been liable to cerebral congestion spaces can also be seen ; in fact the vascular canal is distinctly dilated to an extent several times the calibre of the vessel ; the cerebral wall is indurated and has attached to it the sheath, on the inner surface of which lymph exudations exist in considerable quantities, and the adventitia is often attached to the sheath by fine trabeculae, (the spur-like processes of Obersteiner ?). Taking everything into consideration we are compelled to the conclusion that the evidence of the existence of perivascular lymph spaces is still imperfect ; in the consideration of this subject we must place great stress on the probable artificial or morbid causes for the production of such canals. According to Eberle, His has abandoned his theory. For recent contributions to this subject see ^ Pathologische Yeranderungen in den Lymphraiimen des Gehirns,^ by H. Josionck.* No difference has been detected between atheromatous deposits in the sane and insane. 4. The Neuroglia. — This substance is liable to various forms of disease, for the demonstration of which prepared sections are requisite. The neuroglia has been observed generally and locally increased, generally decreased in quantity, and its nuclei have been found undergoing morbid changes. These conditions have been named — a. General sclerosis. j3. Disseminated sclerosis. -y. Atrophy. * ' Archiv der Hellkunde,' Bd. six, Heft 3, p. 223, 1878. 624 MORBID HISTOLOGY B. Miliary sclerosis. £. Colloid degeneration. a. Up to the present moment the belief in the existence of a general sclerosis of the neuroglia depends on the report of one case which is f ally detailed in the ' Journal of Anatomy and Physiology/ May, 1873. In a hydrocephalic epileptic idiot (whose brain weighed sixty ounces), the hemispheres were found varying in weight ; the left being 23i ounces, the right 30| ounces. In the heavier or hypertrophied side the nerve-fibres were found lying in fasciculi consisting of from foui.* to six strands.* These fasciculi were separated from one another by a clear, finely fibrillar plasm in which nuclei existed in numbers somewhat larger than normal. The general theory of the paper is that the hypertrophy of the right hemisphere was due to an increase of the neuroglia, and it is suggested that the bulging brain which is occasionally met with in epileptics is caused bv the same species of sclerosis ; also that the large skulls of hydrocephalic dwarfs may be filled with brains similarly affected. 3. Disseminated sclerosis or grey degeneration is a lesion frequently met with in the brains of the chronic insane. Its most frequent seat is the white matter of the motor tract, less fre- quently it is met with in the hemispheres. In the pons Varolii, medulla oblongata, and spinal cord of epileptics, patches of this disease are of common occurrence, and in an extreme degree. When a fine section of nerve-tissue affected by this disease is examined by the naked eye, circumscribed opaque tracts can be seen, evidently of a nature different from the general structure. In coloured sections these tracts remain untinted. As a rule they will be found contiguous to a vessel or vessels whose nuclei ai'e much proliferated, and around which considerable prolifera- tion of the nuclei of the neuroglia exists. " In brains in which considerable proliferation of the nuclei is found, careful search will, in the majority of cases, enable the observer to discover opaque tracts, which refuse to become amenable to any clearing agent ; these being submitted to the microscope, after immer- sion in glycerine, will be found not to present the normal histological appearances ; the nerve-fibres are atrophied partially or completely, according to the stage of the disease ; in transverse sections the axis cylinders, and sheaths are destroyed, and the field is occupied by a finely molecular and fibrillated material * See woodcut, loc. cit. THE iNEUROGLIA 625 imbedded in a cloudy homogeneous plasm. In tliis matrix the proliferated nuclei exist, somewhat enlarged, sometimes slightly granular in appearance ; but around the implicated spot they are to be seen in much greater quantity and not actively diseased. The atrophied nerve-fibres occasionally project rag- gedly into the grey tract where they are lost.^'* Plate XI, figs. 1, 2, 3, and 4. There exists considerable difference of opinion as to the origin and nature of the change. Rokitansky believes that it is essentially an increase in the amount of the " connective tissue'^ (neuroglia) with proliferation of its nuclei, and that the homogeneous matrix which surrounds them is increased in quantity and becomes fibrillated, this condition causing pressure on the nerve-fibres and their con- sequent atrophy. Leyden refers the earliest change to an atrophy of the nerve-fibres, and the increase of the neuroglia in compensation for their loss. Rindfleisch and others are of opinion that the first stage is marked by proliferation of the nuclei of the vessels, which is followed by increase of the nuclei of neuroglia and the development of a morbid plasm which is, in all probability, modified neuroglia. So far our views coincide with his, but in numerous cases examined, nothing like nucleated cells, such as he has described, has been detected in the diseased tracts. y. Atrojihy of neuroglia is found in extreme cases of Senile Insanity ; its naked-eye appearances are well known. Under the microscope sections of such brains show a general disinte- gration of the various elements. The cells are deficient in number and deformed, the fibres are thickened and coarse, and the neuroglia does not exist in such quantities as to maintain the normal relation of parts ; it is, in fact atrophied, and the general texture of the section suffers from the absence of the interstitial substance. S. Miliary sclerosis. — For the full details of this remarkable lesion the reader is referred to the 'Edinburgh MedicalJournaF for September, 1868, and to the ' Brit, and For. Med.-Chir. Eev.,^ Jnlj, 1873. From these two sources the following resume is taken. Miliary sclerosis differs from all other forms of sclerosis in that it is not necessarily preceded, attended or followed by any proliferation of the nuclei ; that it is a circum- scribed lesion not involving surrounding tissues, except so far as it displaces nerve-fibres, that no morbid plasm is diffused * ' Brit, and For. Med.-Chir.,' July, 1873, p. 203. 40 626 MOliBII) HISTOLOGY beyond its own area, and that it is in no way connected with the blood-vessels. It is essentially a disease of the nuclei of the neuroglia of the white matter, and its progress is marked by three stages. In the first, a nucleus becomes enlarged and throws out a homogeneous plasm of a milky colour and appar- ently of a highly viscid consistence, for the long axis of the spot is almost always in the direction of the fibres, which are displaced by its presence instead of being involved by it ; thus indicating that its density is considerably greater than that of the cerebral matrix. In the centre of these semi- opaque spots a cell-like body is generally discernible, possessing a nucleus — the original dilated nucleus of the neuroglia. During the second stage of development the morbid plasm becomes distinctly molecular in character and permeated by very fine fibrils. Plate XI, fig. 5, indicates the appearance of miliary sclerosis in the second stage when viewed by a power of 120 diameters. It is probable that at this period a further displacement of the contiguous tissue takes place, as a degree of induration of the compressed fibres and vessels which curve round the diseased tract is indicated by the increased amount of colouring material which they absoi-b. Under a low power, and by direct light, these patches have a somewhat luminous pearly lustre ; when magnified 300 diameters they are seen to consist of a molecular material with a stroma of exceedingly delicate colourless fibrils ; they vary in size from ^ to xmo of an inch in length, and have a distinct outline. They are genei-ally oval and unilocular, occasionally bilocular, and more rarely multilocular. In the advanced con- dition of the second stage the plasm is more dense at the circumference than at the centre of the spot, and a degree of absorption of the nerve-fibres around it takes place. When a section is removed from spii'it and dried, the nervous elements shrink, and the diseased nodules either drop out or can be picked out easily with a needle. These nodules are not gritty, they are not acted upon by hydrochloric acid, boiling alcohol, or ether. When pure nitric acid is added, in addition to a series of remarkable changes which are fully detailed in the originab paper, the spots of disease and the sur- rounding tissues become clearer. It is still doubtful whether this lesion can be made out in recent specimens ; with prepared sections, however, it is readily seen. In the third stage the molecular matter contracts on itself. THE CELLS 627 becomes more opaque^ and often falls out of the section^ leaving ragged holes. This disease is of common occurrence in one or other of its stages ; it has been observed in various parts of the brain^ and it is not confined to any one class of mental disease^ although it has been found best marked in Insanities accompanied by Paralysis or Epilepsy. £. Colloid degeneration may be either a primary or secondary product^ that is to say, there is reason for believing that in certain forms of Insanity it is the primary pathological change, and that it is also to be met with in the brains of chronic cases as a result of long-continued perverted vascular action. This degeneration should be searched for in recent specimens. When found in the fresh brain it is seen to consist of round or oval bodies from :~ to ^^ of an inch in diameter, bounded by a distinct wall, containing a clear homogeneous plasm, which is transparent and colourless. The contents are sometimes some- what granular. In prepared sections, colloid bodies are occa- sionally found filling the whole field of the microscope (Plate XI, fig. 6), and the general appearance of the section may be best compared to a slice of cold sago pudding. Colloid bodies cannot be coloured by carmine, and sections in which they exist to any large extent do not take on more than a very pale pink tint. This lesion may be regarded as a degeneration of the nuclei of the neuroglia, and is found in both white and grey matter. It has been traced through various stages from simple enlargement to the extreme condition figured. It is not necessarily connected with proliferation of nuclei and is believed to be one of the most important of cerebral lesions. 5. The Cells are liable to the following morbid changes : a. Pigmentary, granular, or fuscous degeneration. j3. Calcification. -y. Hypertrophy. It is of the utmost importance to seek for these lesions in recent specimens; prepared sections have doubtless great interest in confirming fresh brain observations, but they should not be solely depended on. The grey matter of the convolutions should be examined as soon as possible after death, not more than twenty-four hours being allowed to elapse ; thin slices should be taken and successive portions from without inwards 628 MORBID HISTOLOGY submitted to tlic microscope after being geutly pressed out under a covering-glass. a. Piqinonfary, graniilnr, or fuscous degrvpratrou was first described by Mescliede (Virchow's 'Archiv/ ]8G5), and Lock- hart Clarke ('Lancet/ Sep. 1st, 1866). Poincare and Bonnet ('Annales Medico-psychologique?/ Sept. and Nov., 1868) poiut out the frequency of this lesion in General Paresis. In a short paper by Dr Howden, of Montrose, is contained the best account of granular degeneration of cells as observed in this country. Dr Howden does not regard it as specially confined to General Paresis. To quote his own words — '^ In all cases of long standing Insanity, the cells of the grey matter of the cerebrum present a granular appearance,* this appearance is most intense when the mental excitement has been most severe and long continued, as in General Paralysis, epileptic Mania, and remit- tent Mania ; it is always accompanied by a deposition of granules of haematoidin outside the walls of the capillaries and smaller vessels, and usually by deposits of free granules scattered through the grey substance. A careful examination with a variety of magnifying powers inclines me to think that, in mauy instances, the granules are deposited, not inside the cells, but around them, as the hsematoidin is around the blood-vessels ; and I have sometimes noticed them scattered along the fibres coming from the multipolar cells. The granules are unaffected alike by sulphuric ether and strong alkalies. In extreme cases the cell becomes converted into an opaque yellow, horn-like body, in which no trace of a nucleus can be detected. ^^ We believe that this granulation deposit occasionally, although rarely, commences around the nucleus and gradually extends to the periphery. Under any circumstances the nucleus is the last part to suffer. We agree with Dr Howden in thinking that these granulations are not of a fatty nature. In Plate XII, figs. 4, 5, 6, 9, and 10, show the various stages of this change. The cells of Purkinje have not as yet been observed to be similarly affected. |3. Calcification of the cells has not come under our notice. It is alluded to by Blandford as having been observed by certain pathologists. y. Hypertrophy of cells. — Drs J. Batty Tuke and Rutherford in a paper read before the British Association in 1870, pointed out that in cases of Senile Insanity where the cells of the outer * It must be remembered that in tbe most healthy subjects a degree of granular deposit exists in the cells of the cerebrum. THE ^s^EEVE-FIBEES 629 layers liad undergone atropliy, the cells of tlie two internal layers appeared to be much increased in size. Dr Major {' West Eiding Lunatic Asylum Reports/ vol. iii^ pp. 109-10) speaks of an inflated condition of the cells which closely resembles that described by the above-named observers. Examination of a long series of specimens will show a considerable difference in the size of the cells of the inner layers. It is possible that the term hypertrophy may not be strictly applicable^ it is intended to indicate a more than normal fulness and distinctness of the cellj the cause of which_, however^ is as yet undetermined. We ha,ve in our possession sections of spinal cord taken from a case of violent epileptic Mania^ in which the multipolar cells are to be seeUj with their poles as distinctly defined as in the diagram- matic drawing in Yirchow^s '' Cellular Pathology/ p. 260. The least practised observer must recognise that such a condition is beyond normality. 6. In Nerve-Fibres differences will be found as to their power of resisting pressure ; in some cases they retain their normal condition under the covering- glass^ in others they become readily ampuUated ; this does not depend on decomposition, as the observation has been made on various brains at a period not more than twenty-four hours after death, but would seem to indicate differences in the consistence of the fibres in the various cases. The degree of ampullation of nerve-fibre is noteworthy. A peculiar morbid product, the nature of which has not as yet been definitely ascertained, is often found scattered throughout the substance of the hemispheres and corpora striata (Plate XI, fig. 7), and on the surface of the medulla oblongata and the hemispheres bound down by the pia mater. These have been termed amyloid bodies. They bear no sjoecial resemblance to starch corpuscles, and opinion is divided as to whether they have any reaction with iodine. A'^irchow holds that these bodies are normal or at least the result of natural decay, but their pre- sence in such great numbers in brains which have suffered from very acute diseases, suggests that they are actual morbid products, probably due to the formation of moniliform swellings on the axial cylinder prolongations of the nerve cells, or on nerve fibres, as shown in Plate XII, fig. 7, which in their more decided . and isolated shape are seen in Plate XII, fig. 8. Special Morbid Conditions of the Grey Matter. — In many sub- jects where the pia mater is found thickened, hyperasmic and 630 MORBID HISTOLOGY closely adherent to the cineritious substance^ whatever may have been the nature of their symptoms or disease, the five outer layers of grey matter will be found to have undergone a change more or less implicating their structure. In extreme cases these layers will be found presenting none of their normal cha- racteristics, the cells are absent, the continuity of the fibres is destroyed, and their place is taken by a plasm closely resem- bling that of grey degeneration in the white matter. The absence of proliferated nuclei indicates a difference of genesis, and the general appearance is suggestive of infiltration of lymph, which has gradually caused atrophy and absorption of the normal structures. In cii'cumscribed spots or ulcers of yellow softening, vertical sections show ragged fibres, colloid bodies, and granular cor- puscles in the base of the diseased tract. As no species of tumour of the brain peculiar to Insanity has been observed, it is unne- cessary here to enter upon the general subject. The cells of the sympathetic ganglia of the neck are liable to pigmentary granulation. Poincare and Bonnet attach con- siderable importance to this condition in relation to General Paresis. It has been found well marked in other forms of cere- bral disease. The fatty degeneration of the various brain elements so frequently spoken of by certain histologists must be taken cum grano. Doubtless, there are many appearances noticeable in the cells and vessels which are very strongly suggestive of their being of a fatty nature, but it will be found that the application of the various tests for oil fails to produce any evidence of its presence. The " free oil globules " in the substance of the convolutions are, we think, scattered debris of granular cells. No attempt can be made, in the present state of our know- ledge of cerebral histological pathology, to localise lesions. All that can be safely said on this subject is that the convolutions of the vertex and those immediately bounding the great longi- tudinal fissure are the chief seats of disease. As we examine the more dependent convolutions we find fewer and fewer in- dications of morbid action. In searching for cerebral lesions, we may be guided to a very great extent by the naked-eye appearances presented by the arachnoid and pia mater; where these membranes are seen thickened or clouded, the subjacent cerebral substance is invariably diseased. The experience of every pathologist must confirm the statement that these condi- APPEAEANCES IN GENERAL PARESIS 631 tions (except under such special circumstances as tubercular meningitis) are in ninety-nine cases out of a hundred confined to the superior convolutions. The vertex^ that is to say, the upper fourth of the ascending parietal and ascending frontal convolutions, will be found to be the locale of the most definite manifestations of disease. We shall conclude this chapter by giving a short account of the microscopical appearances in General Paresis and Senile Dementia. General paresis. — The lesions observed may be conveniently divided under three heads. 1. Those of the vessels. 2. Those of the neuroglia. 3. Those of the nervous elements. Vessels. — These are the most constantly and earliest affected in this disease, not indeed eveiy where to an equal degree, but the process is general throughout the brain. The earliest change is an increase of nuclei in the capillary walls, and under the adventitia of the small vessels (Plate XII, figs. 1 and 2), later miliary aneurisms (Plate X, fig. 4), small haemor- rhages and rupture of the walls of the vessels are frequent (Plate X, fig. 6) ; the capillaries become thickened, and undergo a vitreous transformation (Plate XII, fig. 2) ; finally, they are destroyed by fatty degeneration. New vessels are believed to be formed, as the capillaries present appearances like those seen in the tail of the tadpole. Nuclear proliferation is most marked in the adventitia, but the transverse and longitudinal nuclei of the middle and inner coat participate ; sometimes red corpuscles are also seen, and there are chronic inflammatory processes and deposits of pigment granules in the adventitia. The vessels become twisted. A spiny or furred condition of the capillaries is often seen. Interstitial tissue. — The changed in this may be observed in three stages. In the first there is increase of the neuroglia nuclei, these nuclei varying in shape and in their conduct towards colouring agents, some staining deeply, others very feebly (Plate XI, fig. 4). In the second stage, the white matter is invaded by patches of amorphous, homogeneous, opaque matter of irregular form, unequal surface, and vacuolated ; they have badly defined margins and take up carmine readily. They contain many nuclei, and from the margins filaments ramify to form a network ; sometimes these areas correspond to the course of a blood vessel. Later on they contract, their centres become 632 MORBID HISTOLOGY well defined, the radiating filaments become transformed into ramiform prolongations (Plate XI, figs. 1, 2, and 3). These areas are no doubt what have been described as giant cells, small inflammatory foci consisting of numerous nuclei resolved together by coagulated fibrine. In the third stage, the nuclei of the neuroglia atrophy, diminish in size and become angular in outline. Nerve cells and fibres. — The nerve cells are often surrounded by numerous nuclei, and often by fibrine, they are frequently vacuolated and increased in size ; at other times they are more slender than normal. Their protoplasm becomes dim, less transparent, and the whole cell colours strongly with carmine (Plate XII, fig. 9). Later on the cells become filled with brown or yellow molecules ; the nuclei become disintegrated. Othe^ cells increase in volume, become filled with a pale granular matter insoluble in ethei-, and lose their power of taking up carmine (Plate XII, fig. 4). Their processes undergo similar destructive changes, the axis cylinder prolongation being the most resistant (Plate XII, figs. 7 and 8). In some cases they present oval enlargements and are often ribbon shaped (Plate XII, figs. 5 and 6). These oval bodies may be found separated from their connection with the cells. These appearances warrant one in regarding General Paresis as a chronic diffuse inflammatory process, affecting primarily the interstitial tissue, but followed by secondary degenerative processes in the essential nervous elements. Senile Dementia. — The lesions may be similarly divided to those in General Paresis — The vessels. — These are frequently atheromatous ; the arteries and capillaries are dilated ; their sheaths are loaded with pig- ment but their coats are not thickened ; the perivascular spaces are dilated and the surrounding brain tissue atrophied. Miliary aneurisms may be present. The Interstitial tissues. — The most marked changes are those of atrophy ; the neuroglia loses its finely reticular appearance, and appears broken down in patches within which only mole- cules and nuclei can be detected. The nuclei are somewhat increased and collected in groups ; in some cases they are shri- velled and deformed. The cells and fibres. — The cells are found changed throughout the depth of the grey matter, but the large pjiramidal cells show the lesions most mai-ked ; the processes are best observed in Pl3.te XII. 5 W m* '• •; ^ V A H % i .« « J.-}^'^- • ^ / N ^i^:^ WB. mk ^^#•^^1^ ^^^!^ •//- '^m^:3>^. '^^m^ w, ^#^ w p -'•m. WmM^ mm ^#tM C.Berjeau, Htr.- Waierston Sons i Stewart, Life" JSn APPEARANCES IN SENILE DEMENTIA 633 tte frontal and parietal lobes. The essential change is granu- lar degenei'ation going on to complete molecular disintegration of the nerve cells. In the first stage, they lose their sharply defined outline and become swollen ; the processes become broken off, all except the peripheral prolongations, which gives the cell a rounded appearance ; the nucleus becomes swollen, and the nucleoli appear with greater distinctness ; the cell loses its natural pigment and ceases to take up colouring matter. In the second stage the protoplasm of the cell becomes invaded by granules which render it opaque ; these are sometimes collected on one side pushing the nucleus from its position and deforming the cell contour (Plate XII, fig. 10). Lastly, the cell becomes completely filled with yellow granules, shrinks, breaks down, and leaves its nucleus surrounded by a heap of granules. In the third stage these granules are replaced by darker ones, insoluble in ether. The nerve fibres throughout are coarse, twisted, irregular, and sometimes broken up. These appear- ances warrant Dr Major^s view that Senile Dementia consists essentially in primary atrophy of the nerve cells. The changes everywhere are those of atrophy, without any trace of inflam- matory processes having preceded them. This concludes the account we can give of the present state of the morbid histology of Insanity. The subject is still in its infancy. It is only by the accumulation of a vast mass of care- ful observations, that advances can be made. Past experience has shown that this can only be done by microscopical investi- gation. The history of the morbid anatomy of spinal diseases is one to which we may point as an instance. Without the micro- scope, bulbar paralysis, infantile paralysis, and progressive muscular atrophy, would be still regarded as essential diseases. By the microscope only can the problems of the morbid anatomy of Insanity, be properly elucidated, and we would urge upon all engaged in the care and treatment of the insane to contribute their individual efforts to further our knowledge of these important questions. CHAPTER VII TREATMENT OF INSANITY General Observations. — The treatment of Insanity may be con- sidered under three heads or intentions — the Hygienic, the Moral, and the Medicinal. These domains of medicine, indeed, are by no means so distinct that it is always possible to say of means resorted to with a curative intention, whether their influ- ence belongs to one or the other. Thus, the removal of a patient from home may be hygienic, inasmuch as it removes him from the causes of disease — and moral, inasmuch as it produces novel mental impressions, which are often of much service in the treatment. A blister to the nape may be thought purely medicinal ; but there can be no doubt that sometimes its moral effect is not insignificant by attracting the attention of the patient from a morbid idea to a new sensation. The three intentions are, however, sufficiently distinct to render their separate indication useful in classifying the various means employed in the treatment of mental diseases. The sufficiency of the moral treatment of Insanity is main- tained by some authors, in support of the spiritual hypothesis of the nature of Insanity. It emanates from, and is consistent with, this hypothesis — whose most able exponent was no less eminent a person than the late Dr Mayo, President of the Royal College of Physicians. But it is Dr Leuret, a French Physician, who with that hardihood of logic which so frequently distin- guishes his countrymen, has carried this opinion into practice, in a treatment of his patients respecting the moral character of which there can be no doubt. He combats delusions with stern rebuke and severe punishment ; in fact he applies to his patients, at the present day, the same pi'inciples of treatment as those which are recorded in the pages of ' Don Quixote,' in the case of the madman of Cordova who ceased to persecute street dogs after he had been well beaten for his cruelty. Whipping luua- MORAL TREATMENT 635 tics in tlie good old times was not confined to Spain. Shake- spere makes Rosalind say — " Love is merely a madness ; and I tell you deserves as well a dark house and a whip as madmen do : and the reason why they are not so punished and cured is, that the lunacy is so ordinary, that the whippers are in love too." In ' Notes and Queries/ vol. xvii, p. 327^ we find the following notes on tkis subject. " The law of whipping vagrants was enforced in other counties much in the same manner as in Buckinghamshire. " The following curious items are from the constable's account at Great Staughton, Huntingdonshire : " Paid in charges, taking up a distracted woman, watching her and whipping her next day . . . . .086 " Spent on nurse London, for searching the woman to see if she was with child before she was whipped, 3 of them . .020" It is not to be supposed, however, that any physician of the present day understands by the moral treatment which he advocates, the use of means of cure like Rosalindas or the cap- maker^s baton at Cordova ; or the rotatory chair once in common use, but which fell into sudden disuse on the occasion of a death having taken place during its administration ; or the douche, the plunge-bath, or the prolonged shower-baths, which have been so greatly abused in this country. Doubtless what is meant to be designated by the term, is all that portion of the improved cure and treatment of the insane which is not phar- maceutical — for instance, the removal of a patient from the cares of business, or from family anxieties — surrounding him, in a cheerful country residence, with new scenes, new faces, new objects of attention and subjects for thought — affording occasion for the exercise of those organs of mind which are not diseased, and of repose for those which are — doubtless all this is con- sidered to be moral treatment. Whether it is entirely so, an obvious analogy may help to determine. Professor Laycock maintains analogy to be the essence of medical logic. It is, at all events, an important aid in medical reasoning, and may help, in this instance, to determine the right signification of a term whose wrong use has led, and is likely to lead, to serious errors. A merchant with a hardy cerebral organisation, but with a feeble stomach, suffers great anxiety from the fluctuations and losses of commerce ; he loses appetite and digestive power, becomes emaciated and generally out of health. A physician. 636 TREATMENT OF INSANITY who recognises the form of disease as nervous dyspepsia, recommends his patient to realise and retire, or to become a sleeping partner only, in business ; and to occupy his time iu travelling, or yachting, or sporting, or farming. He lays down some dietetic rules, and insists upon repose of mind and muscular exercise, the pure air of the country and cheerful occupation. Under this regimen, and without the use of one dose of medi- cine, the patient shakes off a chronic disorder which has for years rendered life miserable, becomes robust in appearance and in fact, and able to dine like a ploughman. Is this to be called the moral treatment of dyspepsia ? It is the very ana- logue of the treatm.ent under which another mercantile man — who, inheriting a stronger gastric organisation, but a more feeble cerebral one, and who has become insane from the same sources of nervous excitement and exhaustion, recovers under our care, without any aid fi'om the pharmacopoeia. Is that sensible part of the hydropathic system, which consists in cheerful society and regulated habits, to be called moral treat- ment ? If so, the whole of the treatment of the insane which is not medicinal is rightly called moral ; but not otherwise. Some cases of Insanity may , undoubtedly, be treated success- fully without the aid of pharmacy ; but it is of the utmost importance to recognise the agencies which are employed, in their just character and by their right names ; otherwise a very mistaken idea of the nature of Insanity, and of the treatment which is generally proper for it, is likely to arise — has in truth arisen, and needs to be refuted. Thus, we find in the number for July last of the ' American Journal of Insanity,^ an experi- enced physician declaring that '^ he always acted upon the presumption that the patients needed no active treatment. The insane hospital is to the insane what the splint and bandage are to the fractured limb — merely to ensure quiet.''' But Insanity is not quite like a broken limb, and the processes by which recovery takes place are more complicated than the mere growth of new bone. Eest in one position is all that is needed to set a broken bone, because it is known that with immobility, the pathological processes are certain to be reparative ; but it is not always so in brain diseases. The emotional repose and intellectual diversion, which are now sought to be obtained in well-conducted establishments for the treatment of the insane, are not, strictly speaking, moral agencies ; they constitute physiological measures taken to procure fuuctiunai repose for pixel's petncit'les 637 an iiritated and diseased organ. In some proportion of cases where the malady is not profound^ they may result in recovery. Pinel himself says that^ before resolving upon any principle of treatment^ he was in the habit of first limiting himself to the most simple means, and, in many cases_, of allowing the malady to run what appeared to be its natural course, in order that he might thus be able to make available all the curative resources which Nature can develop when she is not impeded by factitious obstacles. Such a rational method of proceeding is not moral, but physiological ; it is not opposed to medicinal treatment, but perfectly consistent with it ; it resembles the expectant delay which every wise physician will adopt in the treatment of diseases whose nature is not acute, and whose symptoms are not urgent, after he has surrounded his patient with favorable sanitary conditions, and before he commences active interference. The doctrine which the author has maintained in the ' British and Foreign Review ' (Xos. 24 and 25), respecting the emo- tional origin of Insanity, is by no means adverse to the opinion that moral agencies, properly so called, possess but a limited efficacy in its treatment. The emotional theory, which we believe to be the true explanation of the psychical nature of Insanity, goes to prove this — that emotional disturbance is the frequent source and the constant accompaniment of mental disease. It is opposed to the theory upon which the dogmas of the English Courts of Law have been founded — that Insanity is a perversion solely of the thinking faculties ; but it is quite con- sistent with, and indeed subservient to, the opinion — that the proximate cause of all mental disease is to be referred solely to an abnormal state of the brain. Some brief references to the principles of treatment laid down by a few authors whose authority stands highest in psychological medicine, deserve notice before we enter into detail. In more than the abolition of chains and the rescue of the asylum from the worst kind of the old prison discipline in order to establish that of a hospital for the cure of disease, Pinel was the father of the modern treatment of Insanity. The interest which attaches to authors before his day is of an antiquarian, rather than of a scientific kind, and his writings and practice very thoroughly effected that necessary part of all great reforms — the attack and loosening of the hold of abuses, which must be abolished before the work of reconstruction can commence. PinePs first chapter on treatment is, "' On the practice 638 TREATMKXT OF IXSANITY of Beating the Insane^ as a means to Promote their Cure." Well may he commence with the exclamation, " One must deplore the fate of mankind, when one reflects upon the frequency and the multiplied causes of Insanity, and the numberless cir- cumstances which may prove disastrous to those who suffer from it, even in the best organised constitutions/^ He refers to the dogma of Celsus, that when the madman "has done or said anything outrageous, he is to be coerced with hunger, chains, and stripes," — to the account which Dr Gregory gives, of the Scotch farmer of Herculean stature, who was famous for the cure of Insanity, by a method of hard labour, and who reduced his patients to obedience by a shower of blows, on the least show of resistance ; and he says that Dr Willis permitted his attendants to return blows for blows, in a manner " which gave to their brutality an independent and dangerous latitude." Let not these imputations on the treatment of the insane of this country surprise us, when we find the following principles of treatment laid down in Cullen's ' Practice of Physic :' " Fear, being a passion which diminishes excitement, may therefore be opposed to an excess of it ; and particularly to the angry and irascible excitement of maniacs. These being more susceptible of fear than might be expected, it appears to have been commonly useful. In most cases, it has appeared to be necessary to employ a very constant impression of fear ; and therefore to inspire them with the awe and dread of some parti- cular persons, especially of those who are to be constantly near them. This awe and dread is, therefore, by one means or other, to be acquired ; in the first place by these being the authors of all the restraints that may be occasionally proper ; but sometimes it may be necessary to acquire it even hy blows and stripes. The former, although bearing the appearance of more severity, are much safer than strokes and blows about the head." This, without doubt, was moral treatment after the fashion of the day, and Pinel even does not quite shake himself clear of the idea that it was desirable to frighten a poor lunatic. He says : " I have shown the nature and happy effects of the ways of kindness, in some cases of the use of fear — of a firm opposition to the dominant ideas and obstinancy of some insane persons, or a courageous and imposing determination, devoid, however, of all outrage, exempt from anger and animosity, and consistent with the sacred rights of humanity. This conduct differs widely from the coarse harshness, the blows, the wounds, yea, even the PINEL S PRINCIPLES 6^9 atrocious and sometimes murderous treatment^ which occur in asylums for the insane, where the keepers are not restrained by the most active and severe supervision/^ This bold physician, however, knew how to call brutality by its unsophisticated name. In his chapter on " Sudden Immersion in Cold Water as a Means of Cure," he describes Yan Helmont^s plan of keeping a patient under water until he was nearly drowned, in order that his ex- travagant ideas might be destroyed, even to their primitive traces — an object which according to this physician, could not be gained except by obliterating these ideas by a state border- ing upon death (idcirco inveniendum erat remedium quod posset occidere, necare, tollere, aut obliterare preefatam illam amentise imaginem). ^' One must blush," says Pinel, "at this medical delirium, worse, perhaps, than that of the madman whose reason it was to restore." Pinel was in a position to criticise such enormities with un- flinching severity, since he could affirm that his own attendants never raised a hand against a patient, even in reprisal ; that the strait-waistcoat and seclusion were used as little as possible ; that the repression he used was devoid of rigor, and in degree not exceeding the occasion, as was often proved by the patient^s yielding to it, on frank and friendly explanation ; and that even the fear which he thought so useful in the moral treatment of his patients, was a sentiment to which esteem could ally itself immediately that reason resumed its sway. Fear, conjoined with love, are the elements of veneration. It is no wonder that PineFs patients were capable of entertaining this high sentiment towards him, for it is the one which, at this distance of time, we feel that his whole character was calculated to inspire. Pinel's chapters on treatment, however, full as they are of vigoi^ous denunciation of the absurdities and cruelties which passed for treatment in his time, yet leave the impression that he had only been able to advance so far in the right path as to distinguish that which was decidedly wrong, without being able to found a system to replace the one which he demolished. He replaced, indeed, the brutal and cruel usages which were formerly employed in the custody of the insane, by a method which although far from being so gentle and indulgent as that which prevails at the present day, was nevertheless animated by a true spirit of benevolence and of that sound common sense which is its best ally; he not only did this (and, in doing so, he denounced baths of surprise, douches, and other painful modes of treats 610 TREATMENT OF INSANITY meut), but lie also ridiculed the " j^iolypharmacie ononsf reuse'' of his immediate predecessors in the treatment of Insanity. " Books of tnedicnl men, says Montesquieu, are monuments of the frailty of human nature and the power of art, which make us tremble when they treat even of the most trifling maladies, so much do they hold death up to us ; but when they speak of the virtue of remedies, they place us in entire security, as if we were immortal ! — This subtle criticism, so applicable to the mass of medical writings which adorn or burden our libraries, cannot but recall itself to one's memory when one constantly meets, in works upon Mania, with such empty terms as intemperature of the brain, the preparations of the humours before their evacua- tion, the seat of the peccant matter, and its so-called evulsion, or repulsion, &c. Are these very philosophic reflections not justified by a long catalogue of powders, of extracts, of juleps, of electuaries, of draughts, of cataplasms, &c., destined to triumph over mental disease ? And what ought one to think of the laws so religiously kept, even down to our day, of bleed- ings without distinction either of the exciting causes, or of differences of sex, or of individual constitution, or of the diverse kinds of Insanity, or of the stages of the disease ?" Pinel pro- posed to himself the task of assigning the proper limits to medicinal treatment, " since frequently our expectant method, seconded by a moral and physical regimen suffices to cure, and in other cases the evil is beyond all resource/' Doubtless, the discontinuance of glaring abuses, and the substitution of a rational expectancy for a " ]}ohjpharmacie monstreuse," "for the errors of a doctrinism full of prejudice and hypothesis, for the reign of pedantism and ignorance," was a change entirely bene- ficial ; but it indicates a task half completed. Rarely do the fates permit that the same hands shall destroy and reconstruct ; and Pinel was compelled to leave it to his successors to bring the treatment of Insanity within the domain of scientific medi- cine. The man upon whom this robe especially fell, was his eminent pupil Esquirol. To him we owe a considerable advance- ment towards a good analysis of mental diseases. An accurate observer and an elegant writer, he recorded the symptomatology of these affections, in a manner which has never been surpassed. Faithful to the humane traditions of his great master, he adhered to his general method of care, while upon that of his treatment he made important advances. Esquirol had the advantage not only of the clear field for the exertion of the medical art which esquirol's impeovements 641 had been provided by Piners reforms^ but he also had that of being aided in his labours by the observation and experience of other devoted workers. Thus, Bayle and Calmeil made him acquainted with General Paralysis, and gave him a power of prognosis, of the utmost importance in treatment, which his predecessor did not possess. A systematic exposure of the ignorance of others is not an amiable mode of making known our knowledge ; but the nature of the errors combated by an author is sometimes the best criterion which his works afford of the existing state of general opinion on the subject of which he treats. Thus, we do not find Esquirol debating the propriety of treating Insanity with the violent means recommended by Oelsus and Cullen, Far in advance of this, he combats the ignorant notion which views Insanity as one disease : — " In order to establish the basis of sound therapeutics in the treatment of mental alienation, it will be necessary to recognise all the general and individual causes of the malady ; to distinguish by certain indi- cations the source from whence the disorder has its rise ; to determine whether the physical reacts upon the moral nature ; to decide what varieties undergo spontaneous cure, those which demand moral remedies, those which require medicinal ones, and those which only yield to a mixed treatment." "What misfortunes and obstacles must those practitioners have encountered who have been only able to see one individual disease in all the insanities which they have had to treat ! They were not ignorant that, delirium being symptomatic of almost all diseases when approaching a fatal termination. Insanity might be also entirely symptomatic ; they were not ignorant that there are instances of Insanity evidently sympathetic ; they knew that a thousand exciting and predisposing causes give rise to Insanity; but paying no attention, except to the most obvious symptoms, they have permitted themselves to be imposed upon by the im- petuosity, the violence, the mobility of these patients ; they have neglected the study of the causes of Insanity, and that of the relation of the causes to the symptoms. Under the domination of theories, some have only been able to see the existence of inflammation, have accused the blood, and abused the lancet; others, believing in irritating bile, have checked the secreting organs and injured their functions. They have been prodigal of emetics and drastics. Some, having only taken into account the nervous influence, have given anti-spasmodics in excess. All have forgotten that the practitioner ought to have present 41 642 TEEATMENT OF INSANITY to his mind grand general views — the systematic ideas which dominate, which constitute medical science, the art which ought especially to devote itself to a thorough knowledge of the cir- cumstances and of the symptoms which are capable of disclosing the causes, the seat, and the nature of the malady which it has to combat." " Often one must vary, combine, modify the means of treatment, for there is no specific treatment of insanity. As this malady is not identical in all persons, so it has in every individual its different causes and characters ; so new combina- tions are required, and a new problem is to be solved, for each insane person under treatment.'^ — {' Maladies Mentales.') To have been the first to lay down the above sound principles of treatment was a great merit, and one scarcely to have been expected from a physician whose belief in the pathological foundations of psychological science was at least feeble. The above broad and just views of the treatment of Insanity are as needful to be urged at the present day as at the time they were written ; for although specific drugs are less in vogue, narrow and stereotyped modes of treatment are scarcely less in favor than they were, or less dangerous. And in no class of disease does the treatment need to be more infinitely varied than in Insanity. In other wide classes some broad rules may be laid down for the treatment ; and although physicians may differ respecting these rules, they will be found to adhere to one or other set of opinions respecting them. Thus, one feeds in fevers, another depletes ; but in Insanity, cases which present symptoms, at first sight, of close resemblance, demand most opposite modes of treatment ; and cases, which at first present symptoms most unlike, sometimes require to be treated in the same manner. An educated and exact observation is required to distinguish between the acute delirium which arises from cerebral hyperasmia, and that which arises from cerebral excite- ment in sympathy with intense irritation of some part of the periphery of the nervous system : or from the cerebral excite- ment which is but an expression of the defective nutrition of the organ from poverty of blood ; or cerebral excitement pro- pagated to all parts of the organ from some focus of irritation, some /oyer of disease in itself — as a small portion of inflamed substance or membrane, or the structural mischiefs surrounding an apoplectic clot. In all these instances the symptoms may bear a strong resemblance to each other ; and yet how different is the mode of treatment demanded in each of them ! : PEOPHYLAXIS 643 Prophylaxis, — The prevention of disease is daily becoming the first and most earnest intention of medical science in all its branches and departments, and the prevention of mental disease is clearly within the scope of the physician^s highest aims. If, as Mr Gladstone has recently told the British Medical Associa- tion, the family medical man has taken the place which the priest formerly arrogated to himself, as the confessor, adviser, and director of our modern social life, he is well placed to dam back the sources of Insanity at the very fountain head, to oppose with all his influence the generation of hereditary lunatics, to conserve by his care the bodily and mental health of pregnant and parturient women, and thus to provide that infants may be born with brains capable of sane life — to watch during the tender years when mind is forming with marvellous speed, and to indicate the natural laws which must not be broken without peril to the mental health — and then to advise against pursuits, occupations, and professions which may seem dangerous to doubtful mental stability. All this the confidential medical adviser can do, and is from time to time called upon to do, and in this way the prophylaxis of mental disease is widely promoted by the wise men of our profession in their general practice. It is not, however, in this broad and catholic view that we wish .to consider this question, but rather from the narrower point of view, how the physician may prevent the outbreak of Insanity in a person who not being yet insane is in more or less obvious danger of becoming so. No medical forethought can prevent the occurrence of Insanity from accidental causes, from fevers, sunstroke, and other physical injuries ; but a vast pro- portion of the insane become so in consequence of psychical conditions of life and modes of living which lead to the result as certainly and evidently as unsanitary conditions of physical life lead to typhoid fever or tuberculosis, and it is in such cases that a prophylaxis can sometimes be established. In order to do so the first step is the recognition of the Insane Diathesis. Insane Diathesis. — This peculiarity of constitution which was first insisted upon by Morel of Eouen, and Moreau of Tours, is, there can be no doubt, an element in the production of Insanity which can be greatly controlled by prudent advice and skilful treatment. Dr Maudsley has described this mental condition, under the designation of the insane temperament or neurosis spasmodica, as being rather intelligential than emotional. His description, however, does not correspond with that which 644 TREATMENT OF INSANITY we understand by the insane diathesis. The being he describes as odd, queer, strange, and not quite right, who does things in a different way from all the rest of the world, who thinks about thino-s under strange and novel relations, who is impressionable to subtle and usually unrecognised influences, and " who now and then does whimsical and quite purposeless acts,^' this being whom we, too, have often met with in life, seems to us really of unsound mind. The crack may be narrow, and very frequently it does not widen, so that such a feckless, odd, queer, strange, and not quite right being remains in much the same condition to the end of his days. His condition is complete in its incom- pleteness and unchanging. But by the insane diathesis we mean the condition of a person who is of really sound mind, yet who from constitutional fault is more liable than others to mental disease. As a person with the gouty diathesis may have no symptoms of gout but only be liable to them on slight occa- sion, so the insane diathesis is not Insanity but is a standing and ever imminent threat of it. It is as real a fact as diathesis of gout, or of tubercle, and as hereditary, not unfrequently indeed generated de novo by un- sanitary conditions in the parentage or in the foetal or infantine life, but most frequently the outcome of hereditary predisposi- tion. One form presents itself as constitutional timidity and self- depreciation ; the elastic spirits of youth are absent, and the world from the first paints itself in sombre colours. A more frequent form, at least in the male sex, is a reckless spirit of audacity and defiance of and resistance to all rule, often accompanied in children by lying and cruelty, and passing with advancing years into outrageous irregularities of life and debauchery. Another form is that of overweening self-conceit and preposterous vanity ; and yet another manifests itself in simply detestable temper, moroseness varied with outrageous passion. In all these forms the intelligence is not unfrequently precocious, and is always intact, for it is assumed, and is the fact, that these people are not actually insane but have only the tendency to become so. In these conditions moral treatment is the true prophylaxis. If left to run their course they inevitably mature into mental disease, and if the tendency be strong, too often nothing can prevent this termination. But if the more favorable instances of these ailing minds are brought under the influence of strong INSANE DIATHESIS 645 and wholesome minds, if wise culture be applied to the erring emotions, and discipline to the conduct in the early years of life, while they are yet applicable, the fearful heritage may often- times be avoided. In childhood and youth moral discipline is not impossible, although in this era of wanton independence, the rights even of children to do exactly that which is sweet to their own wills are exercised to a degree which our forefathers would have thought wrong and ruinous. Still during legal infancy the parents or those who are in loco j)arentum possess a legal power, which may be exercised in cultivating the emotions which are the springs of conduct, and the sources of sane or insane life. The choice between home treatment and school treatment, and if the latter the choice of school public or private, is often most important. Some boys with the insane diathesis will do well at a public school, others would inevitably go wrong there. Few, if any will do well at home, where it is almost impossible to be strict without being stern, or to carry out the most necessary discipline without harshly setting aside the claims and bonds of natural affection. The conduct of Howard, the philan- thropist, to his son, is a notable example of the unwisdom of a father to affect the role of a pedagogue. But the right choice of a tutor or a schoolmaster may in these cases of which we are writing be the most important act towards the preservation of mental health which any one can be called upon to perform, and there are schoolmasters now who really study mental pecu- liarities and who devote themselves to the task of training such minds as are tending towards abnormal development. Need we indicate these qualities which such a task demands ? Method, patience, persistent command of temper, self-denying industry and much knowledge of child nature. When we see what these qualities can do with the young idiot, we need not fear that they will always be powerless with the child whose mental functions are not absent but aberrant. Mental health depends so greatly upon physical health that the physician will constantly be able to promote the prophylaxis "by giving good advice as to the growth of a sound body. Air and exercise, and food and raiment have a powerful influence upon the mental growth of these frail children. Their studies also, that they should not be too severe, and that they should not be too complicated or stimulating to the imagination or the passions, that they should be wholesome in degree and kind. 646 TREATMENT OF INSANITY this also is an element of precaution which should by no means be overlooked. When the child has become a man or at least when he has become his own master is the time of greatest trial. The phy- sical and moral storm of puberty has had to be encountered, and greater temptations have to be met with less guidance. At college, youths who have even passed through public schools without disaster often break down into all the exaggerations and aberrations of emotion we have mentioned, and, much more, do boys who have been brought up in the relaxing indulgence of private homes. When mental instability is manifested at this age, the ques- tion may be put to the physician whether the youth shall go on with his studies or be idle, or in what manner shall he hit the safe medium of wholesome work, or shall he travel or remain at home, or what calling shall be chosen ; questions which can scarcely be answered aright without much knowledge of his art and of the world. In adult life the prophylaxis will include the consideration of an infinite variety of circumstances. Should the threatened man give up his work or his business if he can do so ? In many cases, undoubtedly yes ; in many others, certainly not. We have known instances in which the anxieties and chagrins attending such a step, taken with precautionary intention, have resulted in the outbreak of lunacy which it was meant to avert. Yet if the calling is attended with anxieties which weigh upon the ailing mind, it should be given up for a time or its burthen should be lightened. Should the threatened man travel ? We think not often. Change of scene may do much good, but not constant change of scene with its labours, irritations and trials, especially if undertaken in foreign countries. This constant change of scene which we call travel easily suggests itself to friends and physicians. It is so obvious a method of getting a man away from places and people and circumstances which are irritating and obnoxious, and of removing him out of sight for a while, that it is an expedient adopted with far more frequency than wisdom. We have ourselves known most disastrous results from it. Men threatened with lunacy who have been sent on their travels we have known to commit suicide in foreign hotels and in mountain solitudes, to have outbursts of raving Mania in railway stations, and in city streets, and to get into the hands of the police for outrageous conduct. The friends of such a MARRTAGE 647 man who send tim on his travels without efficient watch and wardj commit a flagrant breach of private responsibility and of public decorum. As far as cure is concerned they might as well throw their friend from the top of a house because a lunatic is said to have been so cured by pitching accidently on the right cranial spot. What they do, and know that they do, is to hide their friend for a while from the eyes of their own immediate public and to postpone the responsibility of taking proper steps for his care and treatment. A threatened lunatic, or one whom we may call a developing lunatiCj ought not to be sent to travel in foreign parts without guarantees that proper care and efficient watch and ward should be provided for him. If he be attended by a medical man instructed in his case, by a trustworthy body-servant and a good courier, and has " put money in his purse/^ there is no reason why the efficacy of foreign travel should not be tried under proper advice; but to allow sensitive relatives to seclude from the public eye a man on or over the threshold of Insanity, by sending him on the grand tour, without these safeguards, is to invalidate the whole spirit of the lunacy laws which are framed to protect Englishmen who on account of mental infirmity cannot take care of themselves. Travel within the four seas is quite a different measure, and with due provision for care and protection, for the right admix- ture of rest and fatigue, of change and repose, is a very fair and proper thing to try, not only in threatened yet undeveloped Insanity but also in many chronic conditions of mental disease, and especially also in the state of convalescence. Of Marriage it may be said that the celibacy of the insane is the prophylaxis of Insanity in the race, and although a well- chosen mate and a happy marriage may sometimes postpone or even prevent the development of Insanity in the individual, still no medical man having regard to the health of the community or even to that of the family can possibly feel himself justified in recommending the marriage of any person of either sex in whom the insane diathesis is well marked. The lottery of marriage is so great and the chances of happiness in it so uncertain, that for any one so threatened with Insanity to embark in it must ever be a most perilous enterprise, even for the individual, but to the children and grandchildren and the race the results are not uncertain. They are sure to be calami- tous. It is thus that the seeds of mental disease and of moral 648 TEEATMENT OF INSANITY evil are sown broadcast through the land ; and other nerve defects and diseases are multiplied and varied with imbecilities and idiocies and suicidal and other propensities and dispositions leading to all manner of vice and crime. The marriage of hereditary lunatics is a veritable Pandora's box of physical and moral evil. Treatment at the outbreak. — In our former editions we have written of treatment perhaps too exclusively from the stand-point which we occupied as the physician of a public asylum. We wish now to fill up our sketch of treatment as it is applicable to patients of the upper classes who are usually treated in private homes, or in private asylums. In the labourer and artificer class the lunatic is so far fortunate that, living from hand to mouth under the sweat of his brow, the outbreak of Insanity generally pauperises him at once and throws the responsibility of his care and treatment upon the public authori- ties. The law of the land is admirably designed for his pro- tection and welfare, and, if it be really carried out, the care and proper treatment of the pauper lunatic will be all that humanity and science can desire. He will be placed forthwith in one of the county asylums, a class of institutions of which our own profession and the community at large have every reason to be abundantly proud, and he will there receive care and treatment which his superiors in rank and wealth may well regard with jealous envy. His only danger will be in the chance of being shunted into the dismal and dreary neglect of the union house, where the guardians of the poor rates will regard him with an eye of calculating parsimony. If he be somewhat violent and dangerous, then so much the better for him ; if he be tranquil and melancholic so much the worse, for he will be the further removed from the chances of curative treatment. Even his cure might not be regarded as an unmitigated advantage if it should cost too much. Not long ago we were examining a union house, no worse than others, in company with the Guardians, and observing a recent and as we thought curable lunatic in detention there, we expostulated and advised that he should be sent forthwith to the asylum for treatment, but the Deputy Chairman of the Guardians remarked to us that the man was old and infirm and that even if he were cured he would have to be maintained out of the rates. Being a used-up labourer he was not worth the expense of being cured. As a rule, pauper lunatics are sent to the asylum through the instru- AT THE OUTBEEAK 649 raetitality of tlie relieving officer^ wlio interposes any amount of delay which he may think fit ; the statute indeed fixes a penalty for his delay beyond a certain limit, but we never yet heard of an instance in which it was inflicted. It would be well if some speedy and practical appeal could be made to an inde- pendent authority. However, once in a county asylum, the treatment of the lunatic is, as a rule, admirable. Asylums do indeed differ greatly from each other in the energy and liberality of their management, and more especially in the circumstance whether or not their wards are overcrowded with inmates. But as a great and general rule, the labourer or artisan whose means of support are suddenly interrupted by the intervention of Insanity, and who cannot be detained, much less treated in his own narrow domicile, is provided in the county asylam with a liberal, skilful, and disinterested treatment which gives him the very best chance of recovery, and which, if that event does not happen, provides him with a mode of living as free from the miseries of his condition as his circumstances will permit. On this latter point, however, we shall have something further to add in our observations on cottage treatment. But how, on the outbreak of Insanity, should a patient be treated who is not a pauper either actually or constructively ? This also will depend very much not only upon the condition but upon the means of the lunatic. Really efficient and satis- factory treatment in a private house is costly. Removal from the patient^s own home is in most cases not only advisable but imperative in acute outbreaks ; and with persons of small or moderate means, removal either to a private asylum or to one of those excellent institutions, the Hospitals for the Insane of the middle classes, is undoubtedly the wisest and most prudent step to be taken at once. All the means and appliances of skilful care and treatment may certainly be procured in the latter at a reasonable cost. To provide a separate private residence with an establishment of servants, a skilled attendant and proper medical care, will often cost six or seven hundred pounds a year, while the most efficient care and treatment in a Hospital for the Insane can be procured for one tenth part of that sum. The question of expense therefore limits efficient treatment of the majority of recent cases to institutions. If the patient is possessed of good means, there is no sufficient reason why the trial of 650 TREATMENT OF INSANITY private treatment should not be made. A retired and suitable residence may be procured, a suite of rooms made safe, one or more skilled attendants engaged, even a resident medical man be provided and any required amount of consulting professional attention. In acute cases of Mania and Melancholia, in which the patient is so much occupied by delusions and insane emotions, that he does not know whether he is at home or elsewhere, such a method of treatment is frequently adopted with successful results, and the social advantage of not having been treated in an asylum, frequently imaginary, but sometimes very real, is attained. With the exception of an acute outbreak of Mania or Melan- cholia in a person with some pecuniary resources, a recent and hopeful case of Insanity should be placed for curative treatment in an asylum, especially if there be reason to suppose that the patient is dangerous to himself or others ; and then comes to the medical adviser and to the friends the portentous question of what asylum, for these institutions differ from each other more than we shall venture to describe or depict. We shall, however, lay down a few general rules which may guide in the choice of an asylum, and at the same time indicate some of the means and methods by which, as we think, curative treatment ought to be pursued in an asylum. Choice of Asylum. — The asylum* should contain a considerable number of inmates. Some small private asylums with few inmates are well adapted for the continued residence of chronic lunatics needing more care at less cost than can be provided in private dwellings. Such asylums are excellent for the care and detention of chronic lunatics who are not fit for the enjoyment of domestic life, but they do not and cannot offer the means and appliances for the curative treatment of recent cases. For these an asylum containing at least thirty or forty patients should be chosen, and one containing four or five times that number should be preferred. A certain minimum number of fellow-patients is needful to establish that system of method and discipline which forms a great part of the curative influence of asylum treatment. The great importance of this influence upon the insane mind we have always insisted upon. Orderly conduct and obedience * We use the word asylum in these pages in its ordinary colloquial sense, intending it to include asylums for the middle classes or hospitals for the insane, and private asylums or licensed houses. CHOICE OF ASYLUM 651 to conventional rule, tliougli it be but that of an asylum, is the first step towards reasonable processes of thought and healthy states of emotion, and the lunatic placed in an asylum very constantly falls into the order and rule of the house as a boy, rude and unmanageable at home, falls into the order and rule of a great school. An additional and most important advantage obtained in an asylum of some magnitude is that it renders classification possible. The only classification, however, which is carried out in many private asylums is that of wealth. The patients who pay the most money get the best rooms, and those of small means get the worst. The tranquil, the timid, and the depressed are too often associated in the same small sitting rooms with the talkative, the noisy, the excited and the restless, if their payments are insufiicient to purchase more ample accommodation ; and yet it is known that a careful classification of the patients is one of the fundamental elements of successful asylum treatment. Another most important point in the selection of an asylum is that the person who rules the house should be resident in it. We do not say the proprietor, for in licensed houses this person frequently is not the ruler of the house, neither ought he to be if he is not a medical man. In all asylums fit for treatment, the ruler of the house must be a medical man, and, undoubtedly, he ought to be resident. The moral treatment of the insane so immediately depends upon personal authority, that it is absurd to suppose it can be adequately carried out under the faint reflection of power which an absent physician thinks fit to cast upon some unimportant deputy, whose subordinate position is always thoroughly well known both to patients and attendants, a knowledge which acts perniciously in various directions upon the success of treatment. In all public asylums and hospitals for the insane, the ruler of the house is always at the present day a resident medical man, and in all private asylums the same arrangement ought to be insisted upon. The power of holding in confinement in his house a number of insane persons surely ought only to be entrusted to a medical man who will reside in that house, or to some person, be he in the medical profession or not, who will confide the whole power of ruling that house to a competent medical resident. Another essential point in the choice of an asylum is that the 652 TREATMENT OF INSANITY attendants should not only be skilful and trustworthy and under the constant direction and control of the physician^ but that tbey should be in continuous charge of the insane inmates. We cannot imagine a system more immediately tending to the disadvantage of patients under treatment for mental disease, than that which prevails in some private asylums of maintaining a public traffic in attendants. Under this system a patient has 110 sooner become accustomed to an attendant and has learned somewhat to trust in him, and an attendant has no sooner learnt somewhat of his patient and has acquired a salutary influence over him, than the bond between them is likely to be broken by the attendant being " sent out on call " to some distant private patient under the treatment of some other medical man, the proprietor of the asylum sharing the attendant's wages. We have known a private asylum of good repute in which this traffic in attendants was so great, that at times there would be nearly as many attendants in the institution as there were patients, and at other times when calls had been numerous, the attendants would be so few as to be quite inadequate to the proper care and control of the patients. The care and treat- ment of the patients cannot be equable and satisfactory when this trade in attendants is carried on by the proprietor, by which his agents and instruments of care and control are liable to constant change, being sent away on a roster of call like postboys from the stable-yard of an hotel. We object to the system in this place, because we believe it to be pernicious to treatment, without referring to the question as to whether it is honorable for the proprietors of asylums to derive a profit by taking from servants who are no longer under their supervision a large proportion, amounting to from 30 to 40 per cent., of their wages. We know attendants upon lunatics living in domestic privacy who have thus paid hundreds of pounds out of their wages to asylum proprietors who have never seen the patients at all, and have not seen the attendants for years, nor heard from them except to receive the annual tribute. It should not be lost sight of that an asylum is and must be to a great extent a prison, and that if its inmates are not sus- ceptible of cure, they ought to be provided with the means of living in it as happily as possible in confinement ; and therefore it should be wholesome, spacious, and cheerful. The locality should be good, the house well adapted in its arrangements to its special pui-pose, and the surrounding grounds ample and CHOICE OF ASYLUM 653 attractive. The locality should not be within the crowded and dingy suburbs of a large town^ whose depressing influences of outlook, atmosphere, and associations cannot fail to have a bad effect on the feeble health and susceptible nerves of many insane persons, neither should it be in so remote a part of the country as to be inconveniently distant from the amusements, interests, and conveniences of towns, or so ill-placed that friends cannot obtain ready access, or that convalescing or intei-mitting cases should feel residence in it needlessly dreary and monotonous. It should be on a porous and well-drained soil and be well supplied with good water. The situation, in other words, should be cheerful, healthy, and convenient. Without entering upon details or descriptions as to archi- tectural form and arrangements, the house itself should be spacious, airy, well lighted, well furnished, not over-crowded, and well provided with baths, lavatories and water-closets, and with various means of recreation. We have too often seen the inmates of private asylums for the wealthy classes so crowded together in sitting rooms that there was not a chair or a seat on a sofa available for any new comer. How can curative treat- ment be expected, or the comfort and welfai-e of the incurable be provided for, under such conditions ? The limit of capacity in pauper asylums may fairly be estimated by the minimum of superficial and cubical space which is thoroughly consistent with health, but the asylum arrangements for the wealthy ought to be conducted on different principles, and a gentleman or lady ought to have some approximation to the house space in which he or she has been accustomed to move ; he ought not to be liable to have the possession of a chair constantly disputed, or to be unable to move about his sitting-room without jostling his fellow-patients. Many of the private asylums, and especially the metropolitan ones, appear to us to be licensed for the reception of a far greater number of inmates than they are capable of containing under conditions of comfort and wellbeing, the defect being most apparent in the sitting-rooms, which are often quite inadequate to the bedroom accommodation, which is generally taken as the standard of the house capacity. And this defect is thus rendered more grave by the absence of the wide corridors in private asylums which afford so much foot space in almost all public institutions, and which admit the possibility of walking about with some freedom within doors. It is a defect which might be remedied to some extent by the 654 TREATMENT OF INSANITY provision of spacious recreation rooms, or even of covered spaces in which patients might freely walk about during inclement weather. As a rule not half enough is done in our private asylums to provide the mere bodily exercise for their inmates which is needful for their health and comfort. But supposing the asylum, with its means and appliances, to be considered satisfactory, the most important question remains of how it is worked. An asylum has justly been described as an instrument in the hands of the psychological physician. The tool may be and often is very imperfect, but is the workman good ? According to our observation and belief, the workman frequently makes up to a great extent for the inadequacy of his means. The asylum physician ought to know his business practically and scientifically ; he ought to have firmness and gentleness, the hand of iron in the velvet glove ; he ought to be both loved and respected, to be cheerful and friendly, and at the same time a master in his own house, and capable of maintaining the domestic law. If so, he will insist upon punctuality, order, and method ; he will promote good-will and amiable relations between the inmates ; he will watch for and repress petty tyranny and injustice ; he will engage good atten- dants and servants, remunerate them fairly, treat them justly, and instruct and supervise them patiently in the discharge of their trying duties ; he will ever set before his mind, and endeavour to attain to, the prime object to which he has devoted his life, namely, to effect the recovery of the insane persons committed to his care, and if that be impossible, then to effect their improvement so far as that is possible, and to provide for their comfort and their greatest attainable happiness. It is nowhere difficult in these times to find a physician of really scientific ability who has devoted himself to the above duties and who carries them out carefully and conscientiously, and it ought not to be difficult to discriminate between such a man and one who is a shepherd whose only thought is how close he can shear, one to whom the misery of those confided to his care is very secondary to his own profit, one who regrets the recovery of the patient because his discharge is a diminution of income. Either the curative treatment or the comfortable detention of the insane would be very unsafe in the hands of such a man. Attendants for the Insane are more than nurses of the sick. They keep watch and guard, are the instruments of order and ATTENDANTS 655 discipline, and to a great extent the active agents of moral treatment. To their proper selection, training, and guidance, the success of treatment, whether curative or palliative, security from harm and accident, and the general comfort and wellbeing of the lunatic, are in great measure due. The requirements we make upon their patience, endurance, temper, and health, are so great, that their services when thoroughly good are wellnigh invaluable. In public institutions, they are generally trained from an early period of adult life to their difficult duties. To begin with, they ought to possess robust health, good intelligence, courage, fair education, conscientiousness, and what we will venture to call an open temper in contradis- tinction to mere insipid amiability, or moroseness, or phlegmatic apathy. Get a man from the tail of the plough, or a housemaid, with these qualities, and it needs but careful training and right example to make a good attendant. As a rule men who have been educated in a different school make bad attendants. They have to unlearn so much, and so it happens that old soldiers, old policemen, butlers, game-keepers, &c., are very poor material for this work. Men of better social rank and of higher educa- tion are generally failures, from the simple reason that they have generally failed already in a line of life more consonant with the proper ambition of their station in consequence of some defect in temper or character. Persons of better social position and education than these we have here indicated are often extremely useful as companions to the insane, but they rarely make good attendants. It cannot be expected that you will often get much good out of a gentleman who will demean himself by consenting to occupy a quasi menial position, and to associate with other attendants taken from what are called the labouring classes. An old hunter rarely makes a good plough horse. A system which we think might be tried with every prospect of success in large private asylums is the establishment of two classes of attendants, namely, a class of gentlemen or lady attendants and a sub-class of menial attendants. This plan if properly carried out would probably work with the same very satisfactory results as the nursing in some of our hospitals, especially in the University and King^s College Hospitals, where the higher and what we may call the aesthetic duties are per- formed by a sisterhood of ladies, and the menial duties by ordinary nurses. The attendance in some foreign asylums by 656 TREATMENT OF INSANITY Sisters of Charity has indeed not been what physicians to asylums would willingly see imitated in this country, but the great difficulty met with abroad would be less likely to be met with here, namely, that this most useful sisterhood has so much power that it frequently clashes with the medical authorities. The routine duties of an attendant in an asylum need scarcely be commented upon. Industry, punctuality, sobriety, cleanli- ness, we must assume, are taught by the example and precept of those whom he joins as a fellow-worker. But how is the man or woman to be taught to influence the minds of patients bene- ficially, to control the rude, to soothe the restless, comfort the desponding, lead the perverse, and generally become in the hands of his superior a valuable instrument of moral manage- ment ? That all this influence can be exerted over educated and cultivated persons by those who are comparatively unedu- cated is a common fact which, could scarcely have been antici- pated by forethought. When we have observed it, we come to reflect upon the great force of character which is often pos- sessed by the common people and upon their extreme shrewd- ness in estimating the characters of others. Education may not always improve this power. The man whose thoughts are bent upon the facts of science, or the theories of politics or theology, often has little thought to spare upon the manifesta- tions of mind in his fellow-men who surround him. The historian who can analyse the character of Alcibiades may be quite unable to form a just estimate of that of his doctor, his lawyer, or his cook ; but common people who walk in constant contact and struggle with the common everyday world learn to appreciate character as a useful means of existence. The boy who learns his declensions under a domestic tutor is innocent of human nature and of life- craft compared with the city Ai-ab, and even the young curate, full of Greek, mathematics, and theories of vice and virtue, is often practically ignorant of these matters compared with the rude louts whom he admonishes and instructs. The common people then, in this counti'y at least, form not so bad a material as might have been expected for the human instruments which the mental physician is bound to employ in the delicate duties of gaining moral influence over the insane. The two great mental qualities to cultivate in attendants are observation and kindness. A good attendant ought to be an observer to begin with, to have the natural power of remarking ATTENDANTS 657 differences between one patient and another^ and in tlie same patient at different times ; keen to notice circumstances which distress and those which soothej words which irritate and those which tranquillise, apt to remark all signs of disturbance and danger and all means of influence. By constant practice a very high and most useful development of this essential quality is very frequently gained. An attendant who cannot observe is about as useful in an asylum as a blind keeper would be in a game preserve. Stiil more important is active kindliness of disposition, productive of patience in the endurance of trouble and annoyance, and an ever- present inclination to soothe irritation and relieve distress. Mere apathetic good humour is a negative quality, if not a disadvan- tage, an appearance of virtue under the cloak of which active and beneficial work may be neglected. On the other hand an attendant- should be taught not to be fussy towards his charge, but to gain and maintain influence by steady and continuous care and kindness. He should be cheerful without being pert, and with gentlemen patients should be respectful without being obsequious. His demeanour will necessarily vary greatly according to the social position of his charge. An old and trusted attendant in a county asylum will very properly be far more authoritative towards the pauper lunatics under his charge than could possibly be permitted to any attendant on gentle- men. Still even to gentlemen orders must be given and obeyed^ though the manner of communicating them as requests, or as the directions emanating from the superior authority, will make all the difference between a right and a wrong method. The cruelties of attendants, which are sometimes discovered, are as nothing to the constant degradation which insane gen- tlemen feel in being directly subjected to the authority of coarse, low-born, and ill-nurtured men. The attendant has frequently to protect one patient from another, or to guard against mischievous and dangerous conduct ; and, in a variety of circumstances, he is liable to be called upon not only to insist in the most positive manner, but even to intervene, with physical force. When this latter alternative is inevitable, the golden rule of asylum management is that the attendant should never be held to be justified in engaging in a single-handed struggle with a lunatic, unless the circumstances are so sudden that assistance could not have been called. He may be suddenly attacked by a lunatic or have to defend another 42 658 TREATMENT OF INSANITY patient single-handed, or suddenly to interrupt conduct dangerous to the lunatic himself; but where persuasion has been possible, force should never be employed except by two or more attendants in such a manner as to make resistance on the part of the lunatic hopelessly futile. Attendants should be taught not to refer to delusions, and, what is more difficult, not to defer to them. The hitter is not always possible, though, owing to the singular inconsistence of the insane, it is far less difficult to do so than might have been expected. The Emperor of the World will allow himself to be addressed as Mr Brown, and the Deity will attend family prayers. The art of firmly and skilfully ignoring delusions is an im- portant part of treatment which needs to be very carefully inculcated upon attendants, since it would constantly save them much trouble to act in just the opposite manner, by which they would very frequently barter the permanent welfare and, perhaps, the recovery of the patient against transitoiy acquiescence and tranquillity. Not that the rule is without exceptions, but these ought to be deliberately determined by the physician who may think the present state of the patient's health too precarious to justify any resistance to a predominant delusion, or, when a delusion is hopelessly fixed and the patient obviously incurable, may think it harmless and not worth any passing discomfort, and who may, therefore, in these cases direct his attendants to gratify the indulgence of the insane idea. But, as a rule, attendants must be most carefully instructed neither to elicit the expression of delusions nor to dispute them when expressed, and also not by word or deed to acknowledge to the patients that they believe in them. One of the best tests of the value of an attendant is the tact with which he will carry out this principle of treatment. Another most important line of an attendant's duty is that of cheering the depressed, and a heavy and depressing duty it often is, and in the discharge of it the attendant should be well furnished with natural cheerfulness of disposition. Nothing is so contagious as emotion ; and the natural unforced cheerfulness of a constant companion is often the best medicine we can administer to the fearful, the depressed, and the desponding. Cheerfulness, however, is a quality in which we cannot give attendants much instruction. We must take and use it as a natural product, and if we are wise we shall value and preserve it. What we mean by cheerfulness in an attendant is not mirth ATTENDANTS 659 and '^laughter holding botli his sides/^ but a bright happy temper^ capable of sympathising with the unhappy^ and of longing to impart and of really communicating to a greater or less extent its own frame of mind, call it sense^ or thought^ or emotion^ for it is all three. The sun is down and the trees are black to the eyes of the melancholiaCj but a ray of imparted cheerfulness will make them green again, if but for a moment. Let the impression be repeated, and the daylight colour of healthy perception will gradually return. As a potent means of leaving delusions on one side so that they may die out, of relieving depression and of soothing irrita- bility, attendants have in their hands, to be well or ill used, the two great resources of occupation and recreation. These may be directed by the physician, but they can only be carried out by the attendants, and the manner in which they acquit themselves in this matter is a test of their own worth, and of the curative powers of the establishment to which they belong. In old parlance a lunatic was often called a '' distracted '^ person, drawn apart from healthy thought, and the main thing wanted in his treatment is distraction, in contrary sense, to turn him from his morbid emotions and ideas into the old mental courses, and for this purpose no other means are so powerful as mental and bodily occupation, employments or subjects of interest diverse to or aside from the courses of delusion or morbid feeling. To engage and interest the patient^s attention, to induce him to work or to lead him to amuse himself, is the difficult but most important task of the attendant, requiring all his tact, and temper, and cheerfulness, and industry. And the obvious condition of an asylum, in which these duties are well discharged, is as different from the dismal atmosphere of apathy, indolence, and neglect, which pervades other institutions, that it would hardly occur even to an uninstructed observer that they were ostensibly devoted to the same purpose. Neither are they in fact, for there are asylums in which detention and profit are the main objects, and there are others in which the cure, the care, and the comfort of the inmates are persistently and conscientiously pursued. To promote and preserve tranquillity, peace and goodwill among the patients towards each other and towards the atten- dants themselves is another great object which the latter have constantly to keep in view — to separate the tranquil from the boisterous, the timid from the rude and violent, to keep apart GGO TREATMENT OF INSANITY those who have personal antipathies^ to foresee and forestall the beginnings of rancour and strife, to be guardians of domestic peace and promoters of goodwill — such are not the least of the duties of these valuable assistants in the treatment of the insane. Another duty somewhat separate is that of Sick Nursing. The insane are liable to all ordinary kinds of accident and illnesses and to some which are more or less special to them. The management of General Paralysis during its latter stages, when the power of deglutition is almost lost, when the sphincters are relaxed and attention to natural wants abolished, when slight pressure produces bed-sores, — all this needs the most tender and careful and cleanly nursing. The mental and physical pecu- liarities of sick lunatics call for special endowments on the part of those who can nurse them in a satisfactory manner, and a man or woman who would make a good general attendant is not always a good attendant upon the insane in the infirmary or the sick room, where the duties are different, difficult, and peculiar. If a good nurse is a treasure to the sick who are sane, how much more so when physical disease is complicated by the restlessness and waywardness, the loss of attention to natural wants, and of the sense of propriety and of danger, which so often exist among the patients in the infirmary of an asylum. It will be seen from the whole of the above remarks the high importance which we attach to assistance we receive from the immediate attendants upon the insane in conducting that which is called — The Moral Treatment of the Insane. — No term has of late years been more profusely and empirically employed, and none has been less understood, than " the moral treatment of Insanity. ^^ To remove the causes of cerebral excitement is not moral treatment ; and even to be kind and gentle in word and deed to the insane cannot rightly be called moral, but physiological treatment. Thus, Dr Conolly says, " We seek a mild air for the consumptive, and place the asthmatic in an air which does not irritate him, and keep a patient with heart disease on level ground ; and on the same prophylactic and curative principles we must study to remove from an insane person every influence that can further excite his brain, and to surround him with such as, acting soothingly on both body and mind, may favour the brain's rest, and promote the recovery of its normal action " {' The Treatment of the Insane without MORAL TREATMENT 661 Mechanical Restraints/ p. 55). The removal, therefore, of sources of cerebral irritation and passionate excitement is not moral but physiological treatment. It may be easy to say what is not moral treatment, but it is by no means so easy for the physician of an English asylum to say in what this treatment really does consist. If he seeks for authorities in the writings of eminent Continental alienists, he finds that with them it consists in punishment. The system, described by Pinel, of the monks* who drilled the insane, as the sergeants of the great Frederick drilled the heroes who conquered Germany, is essentially the same as that of Leuret and Ideler ; the continuous but more painful blow of a torrent of water bemg substituted for a shower of blows from the stick. If the English physician looks to the writings of his countrymen, for some description of that moral treatment with which they boast to have replaced the barbarisms of mechanical restraint, he finds little more than vague generalities. The most inflexible firmness must be com- bined with never-failing kindness and gentleness and sympathy ; the patient is to be taught habitual self-control, by habitual indulgence ; in fact, the alienist physician is to be a veritable lion, but, like the notable Bottom in that character, he is to *' roar you as gentle as a sucking dove.'^ In Dr ConoUy^s history of the abolition of mechanical restraints, a paragraph occurs which indicates the importance he attaches to the influence of mind upon mind, in the treat- ment of the insane : " Among the improvements yet to be made in the practical department of public asylums, arrangements for what may be called an individualised treatment are par- tictdarly required. None but those daily familiar with the events of asylums can duly appreciate the great effects of such treatment in special cases. After the first improvement in patients received into the best asylums, some will remain stationary for a length of time, without the special attention of an intelligent and watchful attendant, whose duties are almost exclusively confined to such cases. For want of such especial care, the signs of improvement may fade away, and the chance of recovery be lost. Patients who have remained listless and unimproving for months, and who have seemed falling into a state of apathy or imbecility, or even verging on the hopeless state of dementia — iu a word, in which they received little personal notice or attention — are seen, in some encouraging instances, when happily transferred to attendants who have more disposition to attend to them, or better opportunities of so doing, or greater aptitude for the task, to awaken from their torpor, to become * " II le prevenoit que son obstination dans ses ecarts seroit punie le lendemain de dix coups de nerf de boeuf. L' execution de I'arret etait toujours ponctuelle, et s'il etoit necessaire, on la renouveloit meme a plusieurs reprises." — L' Alienation Mentale, p. 312. 6G2 TREATMENT OF INSANITY animated, active, and even iudustrious. The countenance reassumcs intelligent and cheerful expression ; a disposition to converse returns ; all tlie mental faculties appear gradually to reacquire capability of exercise ; and in some cases, entire amendment follows." — (p. 64.) Now what is tins individualised treatment but the influence of a sane mind peculiarly apt to address itself beneficially to the insane mind^ that is, moral treatment, or more strictly speaking intellectual and emotional treatment ? The existence, therefore, of such a thing is recognised as of infinite importance in certain stages of Insanity ; and as something in addition, and supplemental to, the ordinary kindness and physiological abstraction of excitement which too frequently constitute the whole of the modern English system of treatment. Any officer, or attendant, who is successful in the manage- ment of the insane, who daily impresses upon them the influences of his own character to their improvement, undoubtedly practises moral treatment ; often, indeed, as M. Jourdan spoke prose — without knowing it, or at least without knowing the nature of the good he does, or the rationale of its action. That a physical disease caused by an emotion is susceptible of cure by an opposing emotion is an unquestionable fact in other regions of nosology than that devoted to the neuroses. Dyspepsia caused by anxiety is cured by prosperity and content ; the dysentery of armies waits upon the depression of defeat, and is cured by the breath of victory. The opposite of that which influences any part of an organ to its detriment is likely to act upon the abnormal state so produced with beneficial effect. Therefore, emotions opposed to those which cause Insanity are likely to promote its cure. The proposition may be still wider. The causation of Insanity proves the vast influence of moral agencies upon the cerebral organism. This influence, if it can be brought to bear, must possess commen- surate power as a curative resource, even when the exciting causes are unknown, or known to be physical. Pinel classifies the passions, as causes of Insanity, into the spasmodic, the depressing, and the expansive or gay ; but nothing is more certain than that an expansive passion may produce Melancholia ; or that a spasmodic one — jealousy, for instance — may produce the meri'iest variety of Mania. Melancholia from depressing moral causes often changes into gay Mania, and the reverse. It is evident, therefore, that a knowledge of the moral cause of any particular instance of MOEAL TEEATMENT 663 Insanity will not always afford a clue to the emotions it is desirable to act upon, with a view to treatment. The actual condition of the patient^s mind must be made the object of study with this view^ and not the cause of that condition, which is so important a consideration in physical treatment. To appreciate that condition is the first step to success in acting upon it ; and a faculty of clear insight into character is the primary requisite of character in him who would take a useful personal share in the moral treatment of the insane. A physi cian may be very scientific, and skilful in the use of the ordinary weapons of physic,and yet be helpless as a child in the power of influencing the feelings of others in any determinate direc- tion ; as a clergyman may be a learned theologian, but powerless as a pastor -, as a schoolmaster may be full of pedantic lore, and yet practically as imbecile as Dominie Sampson. A faculty of seeing that which is passing in the minds of men is the first requisite of moral power and discipline, whether in asylums, schools, parishes, or elsewhere. Add to this a firm will, the faculty of self-control^ a sympathising distress at moral pain, a strong desire to .remove it, and that fascinating, biologising power is elicited which enables men to domineer for good pur- poses over the minds of others. . Without these qualities, no one can be personally successful in the moral treatment of the iusane. A mere amiable and feeble, or a coarse and uncontrollable mind, alike fail in this delicate duty ; and if the possessor of such a mental constitution has the wisdom to estimate this duty at its full value, he must perform it vicariously. That so much of it may be so well done vicariously by ordinary attendants is a most happy circumstance for mental sufferers, and proves that the possession, at least in a moderate degree, of the qualities indicated, are consistent with a defective education and a lowly social rank. In the first stages of acute Insanity all attempts at moral treatment are futile. That which, at this period, is called moral, is purely physiological — namely, removal of causes of cerebral excitement, and the arrangement of circumstances so as to secure, as far as possible, a state of cerebral repose. To this must be attributed the good influence of kindness and of the expression of sympathy, which is not always unfelt, even amidst the most acute delirium ; as it is certain, on the other hand, that the remembrance of harsh behaviour and needless restraint, of whatever kind, is often the cause of deep resent- 664 TREATMENT OF INSANITY ment, and even the source of new phases of delusion, at a period when the patient appeal's to be wholly occupied with trains of delusive thought and perverted emotion, having no apparent reference to the persons or things which surround him. Some authors affirm that patients retain a faithful impression of all the treatment they have received during the most acute attack ; others maintain the contrary. For instance : — M. Brierre de Boismont says, " Les alienes et les delirantes sont tres credules et les amuse comme les enfants ; leur memoire est excessivement ■ oublieuse." In truth, both these opinions appear to be correct, in different cases. In questioning convalescents, we have found that, in many instances, the acute stages of disorder have left a perfect blank in the memoiy ; in others, the most painful and minute recollection of the past period of suffering has been retained. When patients emerge from the first outburst of the storm of Mania into the comparatively tranquil condition, in which they can appreciate, to some degree, the nature of persons and things — or when the primary attack has been such as to permit such appreciation from the first, the influence of moral and intellectual agencies be.comes felt. The discipline of an asylum, and the moral treatment of its inmates, consist of means which, to the inexperienced observer, are likely to appear feeble and ineffectual, because the patients are, or ought to be, under constant surveillance, and wilful breaches of discipline cannot or ought not ever to be unobserved. Jeremy Bentham used to maintain, that if a thief about to pick a pocket were perfectly certain that he would be detected and compelled to restore the whole of the property stolen, with no other punishment, he would certainly not take the trouble to commit the theft. Now, although the many varieties of mis- conduct to which the insane are prone are not guided by the calculating selfishness of the sane thief, although to a great extent they are manifestations of perverted emotion or morbid instinct, the principle of the preventive power of watchfulness applies to them ; and hence it is that, under good and careful discipline, the need of repressive measui-es is comparatively very slight. Watchfulness replaces severity. The old maxim ohsta principiis prevents to a great extent those violent and dangerous outbursts of conduct which occur under negligent treatment, and which, for the protection of the sufferer and those around him, necessitate strenuous measures of repression or restraint. Hence it occurs that, under watchful and skilful MOEAL TREATMENT^ 665 management^ all that part of the wrong conduct of the insane which is under their control becomes controllable by slight means. This is especially the case in asylums of some magni- tude^ on account of the influence of rule and habit upon the old inmates, and that of example upon the new comers. The influence of example in enforcing obedience to the law has a wonderful potency. The lawless youth who has been the terror of his native village becomes obedient and docile when he enlists, often without suffering any punishment, and solely because he finds himself in the midst of an orderly system. The same influence tells forcibly upon the new inmate of an asylum ; he may resist at first, and his mouth may be as hard as that of an unbroken colt ; but after a while, and without any harshness, he will often answer to the slightest indications of the rein of discipline. In the moral treatment of the insane it is of the utmost importance to discriminate correctly between that part of wrong conduct which patients are able and that which they are unable to control. As a rule, that which they are able to control is controllable by means very far from being severe, either in appearance or in character. On the other hand, that part of their conduct which they are unable to control, and which is neither more nor less than the expression of pathological states of the brain, includes by far the greater part of the most violent and dangerous manifestations of Insanity. This conduct must be resisted solely by physiological and pharmaceutical means ; and direct moral treatment is as much out of place in opposing it as in inflammation of the heart, or of any other viscus. Clinical experience alone gives the power of distinguishing between the controllable wrong conduct, which is amenable to moral influences, and that violence utterly beyond the command of the will, which yields only to physio- logical remedies. As a rule, however, the alienist physician should make it a point to regard, under the latter light, all those aberrations of conduct which occur in the first access of the disorder, and which are accompanied by any appreciable signs of physical disturbance ; and if he sees fit to combine any moral influences with his physical treatment, he should take especial care that they are not of a nature to cause pain or annoyance, and so to give birth to antipathies and resentments which may stand greatly in the way of efficient moral treat- ment when the proper time for its use arrives. 666 TREATMENT OF INSANITY In the cTironic forms of Insanity the accompanying sym- ptoms of physical disorder, and the obstinacy and excess of moral perturbation, will after some experience enable the phy- sician to make the above diagnosis of the character of insane aberrations of conduct, without which the application of any measures of moral treatment is empirical and dangerous. Thus he will learn, that the violence of epileptic Mania is beyond the reach of any kind of moral control, and justifies only measures of precaution and protection ; while that of Mania impressed with the hysterical type of disease, is greatly under the influ- ence of judicious control. To weaken the hold of perverted, and effect the establish- ment of healthy emotion, is an indication of moral ti-eatment to a great extent fulfilled by the repression of wrong conduct. Action is the outward expression of feeling ; and the laws of mind are such, that many feelings derive increased vigour from their outward manifestation, and suffer diminution of their force by its suppression. This, at least, i§ true of habitual states of emotion, although it is not correct when applied to accidental ones ; a sudden grief may be deeper, that finds not vent in tears; and pent-up anger caused by an injury that cannot openly be resented, is notoriously unrelenting. But nothing is more certain in practical ethics than that any habitual state of feeling is fostered and strengthened by per- mitting its free expression in outward act. The blustering bully becomes more and more passionate by every act of vio- lence ; and the sentimental woman, who indulges herself in the outpouring of small sorrows, loses all epidermis of character, and becomes one of the most wretched of suft'erers. Hence the repression of the manifestation of habitual feeling succeeds in preventing the growth of such feeling and gradually weakens its force. The tendency to sudden excitement or anger, to pride, and the various forms of selfishness which constitute no inconsiderable part of the perverted emotions of the insane, is repressed by means taken to check the irregularities of conduct of which these feelings are the source. But the indication of moral treatment now under consideration is of wider import than the mere repression of wrong conduct. Many forms of perverted emotion do not lead to conduct which can be repre- hended as mischievous or dangerous; thus simple Melancholia, religious depression, some varieties of deep-seated but quiet antipathy, exaggerated pride and selfishness, constitute forms MOEAL TREATMENT 667 of perverted emotion which often do not express themselves in conduct adverse to the safety and welfare of the patient. In some instances of this kind, conversation and expostulation may be of use, but as a rule, any direct interference with perverted feeling not expressing itself in conduct, and therefore not to be affected by any antagonistic conduct, tends only to excite resist- ance, and creates mischief. The rule of moral treatment in these cases is, to remove as far as possible the cause of per- verted feeling ; to place the patient in a perfectly new surround- ing of circumstances, and to trust, first, to the operation of time in wearing out morbid feeling, and, secondly, to the genera- tion of feeling of an opposite and wholesome nature. Thus, nothing is more common than for an insane person to acquire antipathies to his dearest relatives and friends, accompanied or not by suspicions and delusions. So long as interviews with such relatives, or even intercourse by letter, or conversations about them with third persons, revive at intervals the full force of these feelings, no improvement takes place; but if the patient be removed from all contact with persons and things which suggest unhealthy reminisceuces, if conversation respecting his morbid feelings is interdicted, and especially if all intercourse with the objects of these feelings is absolutely denied for a sufl&cient time, antipathy often gradually gives way to the yearnings of restored affection. General depression, without delusion, is one of the purest forms of emotional Insanity. To resist or reprove depression is to increase it. The appropriate moral treatment is, to gain the patient^'s confidence, to fix his attention, and to furnish interest- ing and wholesome objects of thought, which will divert the mind from introspection, which will diffuse, break the train of thought, and so loosen the hold of concentrated emotion. For this purpose, useful occupation is far superior to any form of amusement. The higher the purpose, and the more appellant the nature of the occupation to the best abilities of the patient, the more likely is it to draw him from the contemplation of self-wretchedness, and effect the triumph of moral influences. We have observed some delightful cases of this kind, in which melancholiac patients undertook the charge of the sick ; and in Tennyson^s psychological epic, ' Maud,^ he makes the restoration of his brain-sick hero take place on the soundest principles of treatment, through the intervention of patriotism and martial ardour. It is sound wisdom, in the case of depression, not to 6G8 TEEATMENT OF INSANITY attempt too mucli at a time, but to work patiently and slowly. Deep and undemonstrative feelings, although of a morbid cha- racter, cannot be forced. A varied though orderly mode of life, in which useful occupation is pleasantly chequered by amuse- ment, an earnest and sympathising but not too interfering behaviour on the part of the physician and his assistants, the absence of the outward and personal causes of morbid feeling, and the aid of physical remedies in obviating morbid sympathies and susceptibilities, will effect a cure in most cases where there is no irremediable change in the organism, unless the morbid states of feeling have by long neglect become second nature. Resistance to delusive opinion, and the restoration of healthy modes of thought, is an indication of moral treatment, which is partly fulfilled by the measures proper to the two indications already discussed. Opinion, feeling, and conduct are so closely correlated that, to act upon one, necessarily influences all. Still, questions of moral treatment arise, which separately relate to each. With regard to delusive opinion, the main question is, whether it should be openly resisted — and if so, in what manner ? Very diverse judgments have been expressed on the point, from that of Leuret and others, who boldly attack delusions with the douche, to that of some English psychologists, who appear to think that any kind of interference with the course of nature, in this respect, is beyond the province of the philan- thropic physician. We are convinced that the best rule is to give (genei'ally without assigning reasons) a firm, steady con- tradiction to the truth of the patient's delusion, whenever it is obtruded upon notice ; but never to elicit the expression of a delusion, except for purposes of absolute need, as for certifica- tion, &c. A morbid thought not expressed, like a feeling not expressed, often dies out by the kindly influence of time. We have often known cases of fixed delusion, apparently hopeless, wear away by imperceptible degrees under this influence. For some reason or other, perhaps from some annoyance or other, the patient ceases to express his thoughts ; after a long interval, that obvious but indescribable change takes place in his ap- pearance which indicates returning sanity ; and, when put to the test, the delusion is found to have vanished. On the other hand, we have known sad havoc made among insane minds by an indiscreet and meddlesome person eliciting the expression of their various delusions. When the patient persists in expressing his delusions, the physician must use his judgment as to the MOEAL TREATMENT 669 propriety of contradicting tliem in words, or of maintaining a dissentient silence, and remaining as neutral as possible. A knowledge of the patient''s temper will be tlie best guide ; wlien contradiction can be borne without causing anger, it may be ventured upon ; but when this is not likely to be the case, an unassenting silence, or dissent suggested by demeanour, is the safer and better course. In the earlier stages of Insanity, when moral treatment is of little avail in comparison with physical treatment, the patient may be permitted to express his delusions without interference ; but in the second period when physical agencies have done their work, when delusive opinion appears to be in some respect the result of a morbid habit of thought, resistance to expressed delusions must not be neglected by any psychologist who aims at the actual employment of moral treatment. Simple dissent, sometimes, with an added exhortation to resist the influence of absurd ideas, is the full amount of positive resistance which can usually be offered. Argument is almost always to be avoided, but the subject of the delusion may be obliquely talked at ; and a little happy ridicule, in the hands of persons able to use it with skill and without offence, is not unfrequently useful. We cannot believe that any indications of concurrence in a patients delusions can be other than mischievous in any cases presenting the possi- bility of a cure ; in some incurable cases, however, such concur- rence may be excused on the ground of the happiness it confers. Every asylum contains some unquestionably incurable patients, whose happiness is greatly promoted by an acquiescence in their delusive opinions. We have a patient who has for years taken solicitous and trustworthy care of our horses and dogs, under the belief that they are his property. Another patient takes charge of cows and pigs, although he insists upon being addressed by the title of a certain lord. He is as trustworthy as he is arrogant, and while repudiating the slightest inter- ference on the part of attendants, does much useful work for us, because, he says, one gentleman ought to oblige another. No one with kindly sympathy towards lunatics would think of diminishing the amount of enjoyment which a hopeless lunatic can derive in this life, by opposing or contradicting harmless delusions, from which he derives, perhaps, more happiness than some sane people do from their false estimates of wealth, and rank, and fame. The most efficient method of loosening the hold of delusive 670 TEEATMENT OF INSANITY opinion is, by stimulating the exercise of healthy thought. When Van Swieten recommended that patients should be sub- merged until they were nigh unto dissolution, in order that old morbid trains of ideas might be destroyed and new ones sub- stituted, he overlooked the fact that loss of consciotisness does not get rid of any previous mode of thought, either normal or abnormal. Some curious facts are on record of change in the function of memory from pressure on the brain (see Sir Astley Cooper^s ' Lectures on Surgery,' and Sir B. Brodie's ' Psycho- logical Enquiries ') ; but they do not extend to any change in opinion. This, whether normal or abnormal, when it has become a mental habit, requires to be changed by slow physio- logical process. If even the healthy mind lays aside, for a time, a certain set or train of ideas for another set or train upon a widely different subject, it is found impossible, on resuming the former set, to think on them in exactly the same light. Feelings change, and proofs alter in value ; time mellows if it does not weaken memory ; and if old opinions are resumed, their angles and asperities are removed. With the delusive opinions of the insane the change is far more complete. If new objects of thought are not only presented to, but impressed upon the mind, if the patient is placed in the midst of circumstances entirely new to him — he is made to experience his pleasures and pains, his sympathies and sufferings, in a phase of existence apparently distinct from that from which he has derived all the suggestions of delusive thought — if employment is made to replace inertia, cheerful society and recreation to replace moping dulness, new trains of ideas become the habit of the mind, and the subjects of delusion gradually fade in the perspective of memory ; until at last it requires an effort of recollection to bring any traces of them to the surface of thought. It may be doubted whether any idea, sane or insane, which has ever strongly held posses- sion of the mind, is so thoroughly forgotten as to leave no traces of its passage. There are few men who do not vividly remember the impressions made upon them by some striking dream. Past delusions, also, are remembered, but new trains of thought divert attention from them ; and when, after a time, they are purposely summoned by recollection to the chancery of judgment, it is found that a wholesome change has deprived them of all their force, and a healthier mode of thought contemns the validity of their proofs. Argument is notoriously useless in the treatment of insane MOEAL TREATMENT 671 delusion. Never yet was a madman argued out of any absurd opinion, resulting from mental disease ; and facts to tlie con- trary are but examples of the form of Insanity changing or yielding to the influences of time or of treatment, or of the last correction of erroneous judgment being effected in a mind verging upon sanity, by the ordinary means which influence sane thought. Arago and Baron Humboldt once kindly undertook to convince a patient that perpetual motion, of which he believed himself the discoverer, was impossible. The patient, a man of science, yielded to their arguments ; but, on leaving them, be- fore he got round the corner of the street, he said, " For all they say, I must be right. ■'^ Systematic works on Insanity generally contain examples of the cure of delusion by artifice. Prichard, who has quoted several of them from Esquirol and Guislain, avows that he has had " no opportunity of making similar experiments, which, however, I shall certainly attempt whenever it may be in my power, though without sanguine hopes of success.^'' We have less hope than Prichard, for we should not think it worth while even to try the effect of legerdemain upon mental disease. We have seen so many painful instances of objective reality failing to influence delusion in the smallest degree, that we have not the slightest faith in the effect of the trick. At best it can only influence the semi-delusive ideas of hypochondriacs, as in the instance of a man whose supposed glass legs were well belaboured with a billet of wood by his angry servant-maid. But the delusions of Melancholia or Monomania hold on to the mind with quite a different tenacity. We have sent to a dis- tance for the children of a patient who believed they were all dead : when they came before her living and well, her alarm at their supposed apparitions aggravated her condition greatly. When was a man who believed himself ruined ever convinced to the contrary by every show and use of wealth ? We are sorry to be able to yield but very imperfect belief to the recorded accounts of the cure of delusions by legerdemain. The modern examples are so uncommonly like the old ones, that it is impos- sible to resist the suspicion that they have been copied from them.* * The following reference to ancient authorities on the suhject is from the charming pages of old Burton. "Sometimes, again, by some fained lye, strange newes, witty device, artificial invention, it is not amiss to deceive them. As they hate those, saith Alexander, that neglect or deride, so they will give ear to such as 672 TREATMENT OF INSANITY The occupation of the mind by educational processes of a pedagogic kind^ has a high value as a means of a moral treat- ment in some particular instances. Leuret relates a striking instance {' Des Indications a suivre dans le Traitement Moral/ p. 61) of compelling the patient to learn daily, by rote, a certain number of verses, by which he overcame a peculiar form of insanity, manifesting itself in the constant repetition of fixed ideas, expressed in the same formulae of words. Among educated patients, we have found literary pursuits of the utmost value as a means of moral treatment ; and in asylum manage- ment we find school classes, periodical publications, and a lending library, of great importance in affording relief to the monotony of confinement, and in giving topics of conversation and thought. With more individualised attention than is afforded in our large asylums, the moral treatment might be developed into something like the powerful means of resistance to insane pre- occupation which M. Leuret has made of it. In the Devon Asylum, during eight months of the year, evening-school classes are formed under an experienced schoolmaster, on three evenings in each week. They are carried on by the attendants as class- leaders, in several wards at the same time, and consist of will sooth them up. If they say they have swallowed froggs, or a snake, hy all means grant it, and tell them you can easily cure it ; 'tis an ordinary thing. Philodotus, the physician, cured a melancholy king, that thought his head was off, by putting a leaden cap thereon ; the weight made him perceive it, and freed him of his fond imagination. A woman, in the said Alexander, swallowed a serpent, as she thought ; he gave her a vomit, and conveyed a serpent such as she conceived into the bason ; upon the sight of it she was amended. The pleasantest dotage that ever I read, saith Laurcntius, was of a gentleman at Senes, in Italy, who was afraid to urinate lest all the town should be dro\nied ; the physicians caused the bells to be rung backward, and told him the town was on fire ; whereupon he made water, and was immediately cured. Another supposed his nose so big that he should dash it against the wall if lie stirred ; his physician took a great piece of flesh, and holding it in his hand, jjinched him by the nose, making him beleeve that flesh was cut from it. Forestus had a melancholy patient, who thought he was dead : he put a fellow in a chest like a dead man, by his bed's side, and made him reare himself a little and eat : the melancholy man asked the counterfeit, whether dead men use to eat meat ? he told him yea ; whereupon he did eat likewise, and was cured. Lemnius hath many such instances, and Go^-ianus Potanus, of the like." — Anatomy of Melancholy, vol. i, part ii, sec. ii. In another place he says : " Hercules de Saxonia. had such a prophet committed to his charge in Venice, that thought he was Elias, and would fast as he did ; he dressed a fellow in angel's attire, that said he came from Heaven to bring him divine food, and by that means staid his fast, and administered his physicke : so by the mediation of this forged angel he was cured." — Vol. ii, part iii, sec. iv. MOEAL TEEATMENT 673 reading, writing, and aritlimetic classes. Their influence as a source of wholesome mental occupation has been decidedly beneficial. During the summer months the evenings are spent in open air recreation. In works which treat upon the moral treatment of insanity it has been customary to prescribe rules for the guidance of the demeanour and behaviour towards the insane. From the excess of firmness which is demanded by some, one would think it needful that an alienist physician should have " an eye like Mars, to threaten and command/'' as if his functions were not unlike those of the worthy Mr Van Amburgh. Tbe universal gentleness and indulgence which others advocate would lead to an opposite extreme, scarcely less adverse to the true interests of the patients. The truth, as usual, lies between; and the physician who aims at success in the moral treatment of the insane, must be ready " to be all things to all men, if by any means he might save some.^^ He must nevertheless have a good back -bone to his character, a strong will of his own, and with all his inflections be able to adhere, with singleness of purpose and tenacious veracity, to the opinions he has on sound and sufficient reasons formed of his patient, and the treatment needed to be pursued towards him. "With self-reliance for a foundation to his character, it requires widely different mani- festations, to repress excitement, to stimulate inertia, to check the vicious, to comfort the depressed, to direct the erring, to support the weak, to supplant every variety of erroneous opinion, to resist every kind of perverted feeling, and to check every form of pernicious conduct. The physician may often, with the best success, take one part and the attendant another, — a good understanding exist- ing between them as to the end in view. ^' I have often heard my master, the estimable Esquirol, affirm,^-" says Leuret, " that an insane patient ought often to have the services of two medi- cal men who are thoroughly agreed to act in the same direction, but by different means ; the one taking the part of a consoling and officious friend, having only a restricted authority, and sub- mitting himself, or at least appearing to submit himself, to a superior authority ; the other exercising the supreme power, knowing everything, judging everything, and on occasions scolding even his colleague. I have found this officious friend in M. Marcel ; and one sees with how much tact he has availed himself of the confidence of the patient. My severity rendered 43 674 TREATMENT OF INSANITY the intervention of a protector needful ; and this protector, in exchange for the support he gave to the patient^ acquired the right to his gratitude/^ The system thus practised by the senior physician and his junior is available, and often successful by the aid of attend- ants. The exercise of authority should be assumed by the physician himself, or by the attendant, according to the temper and position of the patient, guided also, in some degree, perhaps, by the qualifications of the physician himself, accord- ing to which he may best be able to command, or to comfort and soothe. It is essential, however, that every measure should be taken under the immediate direction of the phys- ician, and that there should be a perfect understanding between him and his assistants. In the moral treatment of the insane a divided authority, or a diversity of intention, is fatal to all hope of success. The subject of moral treatment is as wide as that of moral education ; nay, wider ; for it is education applied to a field of mental phenomena extended beyond the normal size by the breaking down of all the usual limits. Every case has its peculiarities, requiring that its moral treatment should be adapted to them. Moreover, in identical cases, if such can be supposed to exist, the same treatment will not equally succeed in the hands of different medical meu. M. Leuret says {' Indications a Suivre ') — " To combat the same disease two physicians take each a different part ; since, finding in themselves dissimilar faculties and aptitudes, they choose the means with the use of which they are best acquainted. The moral pharmacopceia of the physician, if I may be permitted the expression, is in his head and in his heart ; he has in himself that which he gives to his patient. If ingenious, he will give much ; if clumsy, although learned, he will do no good. As for precepts and guides, if they exist for you, they are in you ; seek them not elsewhere. The moral treatment is not a science, it is an art, — like eloquence, painting, music, poetry. However great a master of the art you may be, if you give rules, he alone will submit himself to them who is your inferior. In matters of physical science there are precise rules; in mathematical ones, there are rigorous calculations ; but, in morals, there must be inspiration." Mechanical Restraint and Seclusion. — A work on Insanity would certainly be defective if all mention of the topic which. MECHANICAL EESTEAINT AND SECLUSION 675 of late^ has so much engrossed the attention of alienist physicians were omitted. But although we have taken an active part in the warm discussion on the question of the total abolition of all mechanical restraints, we do not feel called upon to revive it in these pages. We have for eighteen years conducted a large county asylum, without having had occasion to resort to the employment of mechanical restraint in the treatment of insanity. We entertain precisely the same opinions on the employment of restraint and seclusion as those which, twenty, years ago, we expressed to the Commissioners in Lunacy and which, with many others, they have published in their eighth Eeport for the year 1854. We shall, therefore, be content to quote some passages from that Report, in which we have set forth our opinion and practice in these important questions of treatment. " In the Devon County Asylum, restraint is never employed, except in surgical cases; in these, of course, the same principles must be adopted for the insane as are necessary for the sane, to ensure that absolute quietude of parts which is essential for the advantageous conduct of the healing process. It is not denied that cases have occasionally arisen in which it was diificult in the extreme to avoid the imposition of restraint; for instance, those of suicidal patients who have endeavoured to efEect their purpose by thrusting articles of clothing and other substances down the throat, by beating the head against the wall, and other means which are scarcely capable of being obviated by any watchfulness on the part of the attendants, " The occurrence of such cases, however unfrequent they may be, renders it im- possible to deny that the imposition of mechanical restraint may, in rare instances, be rendered necessary for the safety of the patient. " Mechanical restraint in the treatment of the insane is like the actual cautery in the treatment of wounds, a barbarous remedy, which has become obsolete from the introduction of more skilful and humane methods, but which may still be called for in exceptional and desperate cases. It may be said, that as these cases are so rare — that as large asylums are conducted, for many years, without one of them being met with — that as they do not appear, it may be considered as if they did not exist. " The abolition of restraint was an indispensable starting-point for efficient reform, since its employment was combined with a multitude of evils which its removal rendered intolerable. Under restraint, the management of the insane could be conducted by a small number of attendants, without calling upon them to exercise either self-control, intelligence, or humanity ; there was little need of medical skill, or employment, or recreation ; it was found that the easiest plan of controlling the lunatic was by an appeal to his lowest motives, especially to the most debasmg of all motives — to fear. " Without restraint, these conditions were reversed ; and, above all, it became necessary to influence and control the insane by higher and better motives. In my opinion, the essential point of difference between the old and the new systems consists in this, that under the old system the insane were controlled by appeals to the lowest and basest of the motives of human action, and under the new system 676 TREATMENT OF INSANITY they are controlled by the highest motives which, in each individual case, it is possible to evoke. "The lunatic is unable, without assistance, to control his actions, so that they may tend to his own well-being and to that of society. He is therefore placed under care and treatment, that he may be restored to the power of self-control ; under care that while this power remains impaired, he may be assisted in its exercise. This assistance may come in the shape of a strait-waistcoat, or in the fear of one ; or it may come in the sense of duty imposed in the operation of a gentle but effective discipline, of honest pride, desire of approbation, or personal regard, or the still nobler sentiments of religion. The first motive, that of fear, belongs to man and the animals, and its exercise is degrading and brutalising ; the latter motives are human, and humanising in their influence, and their development is the true touch- stone of progress in the moral treatment of mental disease. It was the brutalising influence of fear and the degrading sense of shame which constituted the true virus of mechanical restraints. " In repudiating the use of mechanical restraints in the Devon Asylum, the above principle has been kept in view with a jealous anxiety, lest the moral effects of restraint should present themselves in some other form. It would seem that it is more easy, or at least more consistent with our nature, to rule by fear than by love. And the annoyances caused by the insane, on their immediate attendants, are hard to be endured without exciting a spirit of retaliation. For this reason the plan of manutension, or holding violent patients for a long time by the hands of attendants, scarcely deserved the name of a reform; and seclusion, injudiciously and harshly employed, is liable to the same objection. If a patient is to be ignominiously thrust into a dark and comfortless cell, and detained there for an indefinite period, on the occasion of any outburst of temper or irritability, it may well be doubted whether mechanical restraint does not possess some advantages over such a system ; and the French physicians may be perfectly justified in preferring the gilet to their own cellules deforce. But, in my opinion, seclusion differs widely from restraint in its capacity for beneficial employment. Restraint, except in cases so rare that they may be left out of consideration, is always an unmitigated evil. Seclusion, wisely employed, is frequently an important and valuable remedy. The character of seclu- sion, as a remedy, has never recovered from the attacks made upon it by the advocates of mechanical restraint. They represented, truly enough, that a patient walking about pleasure-grounds, with his arms tied to his sides, was capable of more enjoy- ment than he would be if shut up in a dark and narrow cell, with all his limbs at liberty. In this objection, the fundamental principle of the new system was overlooked — that neither by restraint, seclusion, nor any other means, was it permissible to uiflict upon the insane any unnecessary or avoidable suffering, or any indignity or degrading coercion, whether of a physical or a moral kind. But the possible abuse of a thing is no valid argument against its use ; otherwise there is no important remedy, medical or moral, which might not be equally objected to. " Seclusion should not be resorted to merely as a punishment for improper con- duct, or as a means of getting rid of a troublesome patient ; but the extreme irritability of some patients, the uncontrollable fearf ulness of others, and the reckless violence of a few during periods of epileptic excitement are such that a removal from the society of their fellow-patients cannot be witliheld from them without sacrificing their interests and safety. In the employment of seclusion, everything depends upon its method. In the Devon Asylum the padded room is rarely used, except as a sleeping room for feeble patients, who are liable to get out of bed, and MECHANICAL RESTRAINT AND SECLUSION 677 fall against the walls at night. Its principal use, therefore, is not for seclusion. The attendants should have the power to impose seclusion only under the most pressing emergencies for brief periods, and until the medical officer can arrive. Seclusion being a remedy, should be directed solely by the medical man, whose care it should be to abstract from it every punitive characteristic. The easiest mode of doing this is to invest it with a medical character ; to speak of it as necessary for health, and even to add some other remedy, more purely medical. In numerous instances I have observed the most beneficial efEects result to the mental condition of patients, from the confinement to bed which had become necessary from some not very serious bodily disorders, — a sore leg, for instance, — and have derived therefrom, on this subject, hints which I have found not without value. "It is not, however, often feasible to confine a patient to bed for the sake of mental quietude. The relaxation so produced might increase the nervous irritability, which it was desirable to obviate. On this account it is found an excellent plan to seclude irritable patients in the open air ; to place them alone in an airing court, where they can be kept under observation, and where, by solitary exercise, they can walk off their excitability. On this account, also, seclusion rooms should be light and cheerful sitting-rooms, furnished with means of occupation and amusement ; the very reverse of cellules de force. Where such rooms are not attainable, a vacant corridor, gallery, or day -room, should always be preferred to the cramped space of a single sleeping-room. Seclusion, used as a remedy, should be made as agreeable as possible. It is thought of some importance that patients should, in many cases, have the power of ingress and egress to. and from their rooms. At the opening of this asylum, the bed-room doors of one whole ward were supplied with ordinary door- handles on the outside, so that the patients might enter their rooms without the aid of the attendant's key. In each ward where seclusions are most prevalent, single room doors have been prepared with ordinary door-handles and latches within and without, in order that the seclusion may as frequently as possible be robbed of its coercive character: used in this manner, as a remedial agent, seclusion as little deserves the opprobrium of being coupled with restraint as the warm bath or any other means of allaying nervous irritability. When possible, the patient is persuaded to submit to separation, before excitement has developed into violence, and the employment of force has become requisite. If seclusion is always looked upon as an evil, it becomes an evil by being postponed until it is needful to enforce it by superior physical strength. " There is, however, another aspect under which seclusion must be considered, wherein it is not remedial ; wherein it is acknowledged to be an evil, by its use being justified, as the least of two evils of which the annoyance and danger of the patients in general is the greater. It cannot be denied that Insanity frequently displays itself by excitement of the malignant passions ; and that some of the most depraved of mankind terminate their career in asylums. Towards these, seclusion must be occasionally employed in its harsher form, as a coercive means to prevent the welfare of the many from being sacrificed to the passions of the few. But, under a well- developed system of industrial employments, aided by medical remedies, this repres- sive kind of seclusion is rarely necessary, and in this asylum certainly forms by far the least frequent reason of its employment. Habits of industry, propriety, and order, are inculcated, and with strict surveillance leave to the ill-disposed but little opportunity for the indulgence of vicious propensities. By these means, habits of self-control are gradually established ; and frequently, in the end, self-respect is so far awakened that it becomes both prudent and just to withdraw surveillance." 678 TREATMENT OF INSANITY In conclusion, it may be useful if we briefly indicate some of the most common forms of violent conduct met with in the insane, and the treatment they demand. First. — The violence of an insane patient may result from an irritated state of the nervous system, and a general sense of discomfort resulting therefrom. Such a patient should be soothed and tranquillised by the kind and sympathising behaviour of those around ; the effects of his violence should be perceived and obviated, but not resented ; and the diseased hyperaesthesia of nerve should be calmed by appropriate medicinal and regi- menal treatment, narcotics, warm baths, &c. — local depletion for cerebral hyperaemia, or stimulants and full diet for the reverse condition of the brain. Secondly. — It may result from increased energy, or at least from increased rapidity of exhaustion of the nervous force, wasting itself in the rude conduct of boisterous good or bad temper. The treatment is medicinal and regimenal. These are the cases in which active and prolonged muscular exercise is sometimes of use. The patient may need to be walked rapidly between two attendants ; seclusion is occasionally need- ful. This condition rarely lasts long. Thirdly. — Violence may arise from delusion. The patient may think that those around him have injured him, or intend to do so ; he may consequently be violent from anger or fear. Or he may believe himself called upon to kill himself, or some one else, and hence become the subject of suicidal or homicidal violence. Such a patient must be soothed by gentle words and kind treatment, and medical remedies must be directed against the pathological condition of the brain upon which the delusion appears to depend. Fourthly. — Violence and destructiveness are sometimes in- dulged by a patient as the mere result of habit. Under unskil- ful management, the manifestations of excitement continue after its pathological conditions have ceased. Habit is the fruitful source of all that is good or bad in the actions of man, and its influence upon insane conduct requires to be carefully dis- criminated. When the habit is of long standing it can only be eradicated by a process of re-education. Change of circum- stances will do much to remove it ; but a careful and patient system of mental training — the application of moral treatment in its fullest sense — is the sole remedy not only of violent, but of all other insane conduct which is the result of habit. TEBATMENT IN ASYLUMS 679 Fifthly . — The violent conduct of an insane patient is some- times the expression of his normal state of mind and disposition. Violent and turbulent men supply their full share to the popu- lation of asylums. Sometimes the red hand is palsied by the touch of insanity. Sometimes the original disposition, and the power to express itself in dangerous act, remain unchanged. Violence of this kind, resulting from a fierce and wicked disposi- tion, might, on first thoughts, appear to justify the most direct and energetic measures of repression; bat when we reflect how little the malevolent disposition of a sane man has been proved, by the failure of all reformatory methods, to be modifiable by any forms of repression or punishment, when we reflect that punishment of any kind, even when most deserved, is entirely foreign to the beneficent calling of the medical man, we shall do right to conclude that it is enough to distinguish this form of violence from others which are the symptoms of disease, and to meet the dangers resulting from it by measures of pre- caution, while we strive to weaken the force of passionate and evil temper by that long-suffering charity which overcometh evil with good. Treatment in Asylums. — In the county asylums for paupers and in the hospitals for the insane of this country, the routine of treatment of the insane at the present day is so generally excellent that it admits of little criticism, so well understood by those whose duty it is to practise it that its details stand in no need of elucidation in this place, and so incapable of being taught excepting by personal and practical study and work that it will be needless to dilate in these pages upon points of asylum management upon which there exists a general consensus of opinion. "With a general conformity and resemblance in all main and essential points, the management of various asylums and the treatment of their inmates do present such an amount of diversity as might be expected from the freedom of opinion and of action which is permitted to scientific men in their discharge of complicated and difficult duties, in which precise rules cannot be laid down without injurious restraint upon individual action. It is not altogether disadvantageous that even wrong methods should sometimes be tried and tested, if this be done openly, honestly, and with a right purpose ; for this is one condition of advancement in practical science. We shall^ however, indicate some important points of treatment in 680 TREATMENT OF INSANITY asylums on which so much diversity of opinion appears yet to exist as to justify the expression of our own experience and opinions. Classification in Asylums. — By this we of course do not mean that nosological classification of the insane according to various systems which has already been fully discussed, but that practical division of the inmates of an asylum into various groups which is an important means of treatment, needing all the good sense and experience which the physician can employ. Classification must to a great extent be ruled by the facilities or disabilities offered by the buildings which the physician has to use as his instrument, by the number of wards, their size and position, and by the peculiarities of the patients which he has to classify. Is it possible, and if possible, is it right to abolish that opprobrium of asylums, the refractory ward ? If this can be done without too great interference with the general comfort and tranquillity, there can be little doubt of the advantage which is gained ; for to assemble together the more excitable patients in one place is clearly a direct method of increasing excitement. In the Devon Asylum we tried the experiment of distributing this class of patients throughout the wards, and of thus diluting the excitable element. Among the men it succeeded, in the women^s side it failed ; and this result might have been antici- pated, by reflecting upon the greater amount of latent excita- bility in the female sex. The tranquillity of the female asylum was on the whole deteriorated, and the greatest good of the greatest number was not promoted. Among the men the distributed excitability was not contagious, and the only reason why a special ward for the excitable and the dangerous should be maintained on this side of the house appeared to be the very unsatisfactory one that during working hours most of the tranquil wards are emptied of their inmates, who go to the field, the garden, and the workshops, leaving many of the wards practically tenantless, so that it becomes convenient to associate in one place and under one supervision those who were too excitable or too dangerous to accompany those who were capable of occupation. A large refractory ward is a great evil, and the best remedy, we think, is to have small wards for these cases and to make persistent efforts to dilute this element of disturbance and discomfort. These small wards should be abundantly provided with single rooms. The courts also should be of limited extent. For the patients CLASSIFICATIOX IN ASYLUMS 681 generally the grounds can scarcely be too spacious, open, and undivided, but experience has shown that fatal accidents may readily occur in a refractory airing court which is too large for the attendants to be always near at hand to their dangerous charge. Melancholy and depressed patients should certainly never be collected together, but divided and distributed as widely as possible. The timid and fearful should be separated from the talkative and the unquiet ; though this does not apply to the depressed who are not timid, and to whom strong moral impressions are sometimes of much benefit. We have occasionally seen an excellent effect produced in the female wards by the presence of infants or young children either admitted with their insane mothers or born in the asylum. Pet animals are often useful by cheering the monotony of asylum life ; but what pet animal can compare in its influence upon any true woman, or man even, with the young human animal, with the gentle tyranny of its appeal to the strongest and best emotions and instincts of our nature ? We have had several of these little mental physicians in our wards, and never knew the slightest harm happen to them, nor their failure to elicit the most tender interest and affection from a great number of the patients. A woman who in a state of manifest insanity had thrown herself and her two infant children into the river from which she alone was rescued, made the first step to recovery in the following manner. She had remained for many months in a state of the deepest depression, and had never spoken a word nor partaken of food except when quite alone. We caused an infant child of our own who could just walk to toddle past her. She evidently noticed it with interest, and on the next trial she could not resist the same womanly impulse, but called the little one to her, fondled it, and talked to it, with the first words she had spoken since the catastrophe. From that time she spoke to others, improved and recovered. When she was arraigned for murder, the Judge, Coleridge, directed the jury to return a verdict of '' Not Guilty,^-" and ordered her to be discharged into the custody of her friends, and she remained well. Morel, of Eouen, gives an interesting case in his ' Traite des Malades Mentales,^ p. 613, in which he recounts the history of a lunatic lady who was under his care as her travelling physician, which we may thus summarise : She suffered from deep Melancholia with delusions of persecution. She was an accomplished musician and artist, but although Morel took her through the glorious 682 TREATMENT OF INSANITY museums and galleries and spectacles of Italy, the result was only to deteriorate her condition. She never spoke, but groaned continually, and lost all habit of the natural instincts. At Venice, Morel took her to a magnificent theatrical display, at which she groaned, forced pins into her flesh, and at length exploded with the reproach that he had brought to the theatre a woman whom he knew was then condemned to be burnt for her crimes. Morel then thought he would try the effect of exciting painful emotions on the principle of ' moral homceopathy,' that pain might possibly be cured by pain. He had failed to make her manifest any regret or longing for her absent children, but he took her to many of the orphanages which are so common in Italy. He was astonished to see his patient, who would march groaning through museums and galleries with her head down, pass through these orphanages with looks of intelligent tenderness for the poor children, and sometimes caress them when she thought herself unperceived. At length at the hospital at Venice she was thoroughly moved by the sight of a poor dying woman who held to her breast her two young infants, and she spontaneously demanded that the two orphans should be received by her at her hotel, where she lavished upon them her care and solicitude. From that moment she began to recover, and although the subsequent treatment, which consisted of a course of German baths, was prolonged to fifteen months, the ultimate cure was complete. We have permitted ourselves to pursue this digression because it forcibly illustrates the importance in treatment of endeavour- ing to act upon the emotions. Idiots if numerous should most certainly be collected and treated as a class. Their repulsive appearance and objection- able habits render them unfit to associate with other patients without causing disagreeable and even injurious depressions. Moreover, they ought to be subjected to a system of diligent training and education, which can only be adequately applied to them in a class of some size. The best arrangement, no doubt, is a separate idiot asylum attached to the general asylum, in the manner which has been carried out at the Warwickshire County Asylum. The classification of the sick, the infirm, and the acute cases in asylums is important. Sometimes the sanitary condition of asylums of considerable size is so good that there is no sick, and therefore no need of a special place for the treatment of intercurrent body diseases ; but there ought always to be the means of readily providing such a place whenever the necessity shall arise, although a small number of sick cases may very adequately be treated in single rooms, in a tranquil ward con- taining some of the more healthy and intelligent of the patients. This arrangement is especially good on the female side, where patients who have little the matter with them form excellent assistants to the nurses. There is often no better or more CLASSIFICATION IN ASYLUMS 683 sanatory employment for a woman whose own malady is ceasing or intermitting than to aid in the nurse-tending of her sick sisters. The best feelings of womanly nature may thus be evoked to the advantage of both agent and patient. For the treatment of contagious diseases there ought to be the means of providing an infirmary unconnected with the wards^ when the need shall arise. Cases of acute delirium^ and of acute Mania, complicated with bodily disease, cannot be treated in an infir- mary containing the ordinary sick. Such cases ought to be treated in single rooms of good size, placed where the noise of raving delirium will not disturb and distract the other inmates. For convalescent patients the best place for care and treat- ment is not in the regular wards of the asylum, but in some detached or semi-detached residence, like the cottage-wards which we first established in the Devon Asylum, or, better, in small buildings, quite apart and away from the great institution, but under the easy inspection and control of the superintendent. It was partly for this purpose that we were the first to recom- mend and to construct detached blocks, complete in themselves, and at some distance from the asylum — a plan which has now been imitated in many other asylums with satisfactory results. The mischief is that these detached blocks present such tempt- ing facilities for providing increased accommodation that they are generally enlarged until they are spoiled as cottage- wards. A still greater removal from the asylum is even desirable, and where there is a neighbouring village, or the scattered residences of asylum servants, convalescing patients may be most advan- tageously placed therein as a halfway house to the freedom which follows discharge. Well-to-do convalescents should be removed from a private asylum into private lodgings or into residence in a private family, and in many places there would be little difficulty in providing the poor with the undoubted advantage of this gradual liberation. When a patient has not quite recovered, but is in a convalescing state, he or she is frequently found to be in an impressionable state, which renders the surroundings met with in an asylum increasingly painful and opposed to the thorough re-establishment of mental stability, and at this time removal from the wards without discontinuance of the medical care is prudent, wise, and humane. The happi- ness of the patient is greatly promoted, and the test of partial freedom may often be applied at a far earlier period than the physician would think it advisable to give an unconditional 684 TREATMENT OF INSANITY discharge. The statutory form of discharge on trial to the patient^s own home is quite a different measure, very proper and useful in certain cases of doubtful recovery, but it does not provide for that gradual restoration to health which is the common course of mental as of most other forms of recovery from disease. It is like pushing a man couvalescing from pneumonia directly from the warm atmosphere of the hospital iuto the cold air of the streets, with a promise that if he should suffer from relapse he may return with the same ticket. Food and Work. — We conjoin these elements of treatment because they are twin influences in that supply of good blood to the brain which forms the broadest and soundest foundation of the treatment of the insane. With too much food and too little work, or with too little food and too much work, the vivi- fying stream from which healthy mind is generated in the con- volutions of the brain, will either be impure or impoverished. Work, no doubt, has also a moral influence, and in that regard we may call it Occupation, and consider it together with Recreation ; but here we wish to call attention to its physical relation with the health of the nervous centres. Let the reader turn to Arndt's plate, of the circulation in the healthy brain, and reflect upon the enormous supply of arterial blood to the convolutions wherein the mental work of the organ is elaborated, and he cannot fail to be impressed with the primary necessity of abundant good blood for the development of mind. Ferrier's experiments with Faradization of the brain have proved this necessity in a singularly clear manner. As this able physiologist and experimenter informed the British Association at Bradford, " the results of experiments which he had himself made had shown the utmost importance of a proper arterial blood supply to the brain. He had found from experiments on numerous animals that when, owing to the operations necessary to expose the brain, the blood supply was lowered to a very great extent, the brain immediately ceased to give any action. When a brain was acting properly, with a circulation flowing through it freely, it reacted to a slight stimulus of electricity; but when the heart was very weak and the animal had lost a great deal of blood, he might apply any stimulus, however powerful, to the brain, and it would not react. Moreover, he had seen animals which had lost a large quantity of blood in that way fall asleep, and any stimulation would entirely fail to awaken them. Wherever there was a FOOD AND WORK 685 deficient arterial blood-supply to the brain there was always a diminution of tbe intellectual powers, and a tendency towards tbe elevation of tbe emotional states, leading generally to wbat was commonly characterised as depression." In the most acute forms of mental disease, especially in acute delirium, the life even of the patient depends upon the supply of good blood being sufficient to counterbalance the degenera- tive change taking place in the grey matter of the convolutions. In these cases the question of food is often that of existence, and the recumbent position must be retained to husband the muscular strength, and to enable the heart more easily to send an adequate supply of blood through the cerebral arteries. In the more chronic forms of Insanity, moreover, and in dealing with the large numbers of insane collected in asylums, some of whom will recover, and most of whom will improve under proper treatment, the due supply of healthy blood to the brain depends on the ingestion of good and sufficient food, on its digestion and conversion into blood, on the aeration of the latter in the lungs, and its impulsion by a strong heart through the cerebral vessels; and to gain these ends good food and work in the open air are the obvious means. In our own country, at the present time, the supply of good food to the inmates of asylums, whether public or private, is rarely defi- cient. Its necessity may sometimes have to be explained to lay authorities who have no physiological knowledge ; but it is so essential a means of curative treatment, and even of satis- factory care taking, that we can never expect that it should be neglected by any well-instructed medical men. Even in institutions filled with chronic and incurable cases, the effect of good and sufficient food in the diminution of excitement and on the mental improvement of the inmates, is one of the most remarkable phenomena of human physiology on a large scale with which we are acquainted. The general tranquillity and well being of the thousands of lunatics collected in our huge English asylums, as compared with the frightful excitement, turmoil, and uproar which were common in former times in this country, and with which, even in recent years, we have been apalled in some foreign asylums, this difference we do not hesitate to attribute in the main to an abundant supply of food. KJinder and better management may indeed have much to do with it, but the non-restraint system will never tran- quillise a number of ill-fed lunatics j and we have no doubt that 686 TREATMENT OF INSANITY the thin, poor dietaries which prevail in the asylaras of many foreign countries are the principal cause of the difficulty which many foreign alienist physicians have experienced in carrying out our improved treatment of the insane. If patients were well fed in foreign asylums, the proportion of those who would be excited and turbulent would be so much lessened that the question of mechanical restraint would be greatly diminished in its dimensions. As it is, we have seen within recent years such numbers of raving lunatics in several foreign asylums as to be out of all proportion to the population. In the asylum for the city of Florence, we counted in 1870 thirty-six women, each one of whom was tied tightly up in a strait-waistcoat, and almost all of them in addition strapped into restraint chairs, all of them in a high state of excitement, and producing an inconceivable Babel of discord ; and in 1 868 we saw in the public asylum at Bergen eight patients out of a total of fifty-six in strait-waistcoats, and almost all of them highly excited. If a good dietary had existed in these asylums, which we give as extreme examples of what we have observed to be the general rule, we do not believe it would have been possible to have found in them so many lunatics in such a pre- posterous state of excitement. But good food cannot produce its full tranquillising and curative effect upon the brain unless it is properly digested and circulated. The stomach and the heart must perform their functions well before the cerebral cells can absorb their nutri- ment, and to effect this purpose bodily exercise in the open air is in a great number of cases almost essential. This helps the digestion, expands the lungs, and strengthens the heart, and thus the brain gets what it wants to provide improving capacity for mental processes during the day and mental repose during the night tending towards health and sanity. Work on the land is the best undoubtedly. Antaeus-like, man recovers strength as he touches mother earth. No doubt the work of lunatics may be carried to excess, so as to weaken the heart and depress the general powers, and looking at the reports of some of our public asylums, in which labour seems to be regarded as the means to financial rather than to therapeutical success, one might well fear that it is sometimes abused. We must, however, freely confess that in a large acquaintance with public asylums and knowledge of their proceedings in this respect, we have never actually seen the lunatic inmates employed in labour be- FOOD AND WORK 687 yond the limit which was wholesome and beneficial. A medical superintendent may indeed readily fall into error in this respect in the case of individual patients unless he exercises due prudence and caution. Recent cases may be permitted to engage in labour at too early a date or to too great an extent, and their im- provement be retarded thereby ; and it certainly ought to be laid down, as a rule, that no lunatic patient should be permitted to engage in work except under medical sanction. Asylum stewards and bailiffs ought to be kept under strict medical control in this matter. We never, however, have yet visited an asylum where the whole of the lunatics have appeared to us to have been required to do more work than was directly good for their health both of body and mind. It appears to us that the women in our public asylums ought to share with the men the advantage of out-of-door work more than they do. Some of them are kept too stringently to monotonous and not very wholesome labour — that of the wash- tub, for example. Others lead to too great extent the unwhole- some life of the seamstress. If it should be inexpedient to employ them in the fields, surely they might be more employed than they are in the garden, and even on the farm. The dairy, the piggery, and the poultry yard, come fairly within the con- ventional sphere of woman^s duties, and would supply to the females in our asylums varied work and interest which could not fail to be beneficial and restorative. In considering this question in relation to private asylums we must change the terms and write exercise or occupation instead of labour. They are not indeed the same thing, and lack half the interest, the regularity, and the benefit. Gentlemen, we are told, will not work — an excuse too readily admitted for the apathy, indolence, and wearisome monotony of life which are observable in many private asylums. That gentlemen should not be expected to dig and delve like those who are to the manner born to such pursuits might be expected. But surely there are methods of providing sufficient bodily exercise with mental occupation to a far greater extent even among the indo- lent classes of society than is often done in private asylums. There may be some difficulty with a few literary or professional men who have almost forgotten the use of other muscular members than the tongue and the fingers, but the English gentleman when in sound health of body and mind delights in muscular exercise. Whether in town or country, he walks. 688 TREATMENT OP INSANITY rides, shoots, rows, plays cricket, or he has his workshop and lathe, and in a hundred ways makes his muscles the strong servants of his pleasure in a manner which astonishes the luxurious monsieur or the indolent signer of the south ; and yet when his mind fails he is found in a private asylum dawdling round the ground or lounging in the billiard room, or at most he is sent a dreary walk along the country roads without purpose and without interest. Compared with the pauper lunatic he eats more and works less or not at all, and the result is that he is far more miserable, more unhealthy, and less likely to recover. In the earlier stages of his disease and of his captivity he emaciates for want of duly assimilated food ; in the later stages he often become bloated and obese. There must be want of activity and enterprise, or ignorance of mental therapeutics, or apathy to the welfare of the patients, in any management which can permit such a state of things to exist ; for although it may be difficult to provide strong, varied, and interesting exercise for gentlemen in asylums, it certainly is not impossible. At present we may fairly ask where is the effort diligently and persistently made ? Where are the asylums for the rich whose proprietors have provided a supply of saddle- horses for their patients ? Where have they a boat on the river — where even have they a well used cricket ground — where have they taken a manor for sport, keeping greyhounds and beagles and ferrets and fishing apparatus — where even do you see gentlemen in a private asylum amusing themselves with garden work, carpentry, or at the lathe ? And yet all these things are not only feasible and practicable, but most of them are actually practised in public asylums. The patients in the asylum at Haslar are on the sea in their boats whenever weather permits, and those in the Yarmouth Asylum sweep the coast with their fishing nets. We ourselves kept boats on the estuary of the Exe and frequently indulged in sailing, rowing, and fishing, with none but lunatics for our crew. We have recently known a chronic and most unpromising case which is now con- valescent ; he was sent from a metropolitan asylum to the sea- side, where he had two months of daily boating and fishing, and to this he himself attributed, and with perfect justice, as we think, his remarkable recovery. Horse exercise is too costly for the poor insane, but we have known it used most beneficially by those who were able to afford it. We once knew a ride across country cure a man, or at least, it was the decisive FOOD AND WORK 689 turtn'ng- point of cure. He was the son of a country squire^ and his father by our advice sent him his hunters. On his first ride, after ten miles along the highway^ he turned to his attend- ant and said, " I have come along the road for your pleasure, and I shall go back across the fields for my own/^ So he rode straight home, taking everything in his way, and he rapidly recovered from that time. We have even had a lunatic living in an asylum who kept his pair of hunters and regularly used them in riding to hounds by the order of the Lord Chancellor. Riding across country may be thought an extreme and danger- ous occupation for a rich lunatic, but ordinary horse exercise along the roads is scarcely so. Riding is to thousands of the English country gentry second nature, and yet when they become residents, perhaps for life, and may be having but little or nothing the matter with them so far as capacity to take care of their own personal safety is concerned, they never are per- mitted the enjoyment of this most pleasant and healthy exercise. Then again sport, which is so healthful and delightful to the English gentleman, why should it not be provided for him because he has drifted into an asylum as a more or less per- manent resident ? We have known single lunatics out of asylums who kept packs of beagles, with the approval of the Lord Chancellor, and who thoroughly enjoyed the healthy exercise which they afforded. In one solitary instance the safe and exciting sport of running after these merry little hounds is provided for the inmates of a private asylum. Many of the superintendents of public asylums are coursers, to the delight and benefit of their patients. Why is this sport never provided for the insane who are rich ? Not even the quiet and apparently unobjectionable sport of angling is permitted to the inmates of private asylums, yet we know single patients who are constant and enthusiastic fishermen, and derive untold pleasure and benefit in the pursuit of their sport. Yet we can scarcely wonder that occupations and amusements which are in any way capable of being thought risky, or costly, or troublesome, should be omitted in private asylums when we so seldom see even the safe occupation of gardening resorted to. Even a skittle alley or a bowling green is rarely provided, although they are universal in public asylums, skittles in the south, bowls in the northern counties. Our skittle alleys in the Devon Asylum were the most popular amusements we had, the patients needing no other inducement to frequent play beyond 44 690 TREATMENT OF INSANITY the fun and enjoyment they had from it. A set of skittles did not last long, and even the lignum vltce bowls were soon worn out of shape. Perhaps they are vulgar, but the Shah played at them at Trentham. Moreover when lunatics above the social rank of the labouring classes find their way, as from various causes they sometimes do, into the wards of the county asylums, it is not observed that there is any insuperable difficulty in prevailing upon them to engage in work, occupation, and amusement. The difference of habit between the gentleman and the working man is not so great as to make a valid excuse for the frequent diiference between a public and a private asylum in this respect, the one appearing even to cursory view as a hive of industry, the other as a castle of indolence. We will not say that accidents never happen in these pursuits which we recommend, though we have never known one. A constant benefit may well be purchased cheaply by a rare acci- dent ; but, in fact, accidents to the insane do not come by the way or in the manner by which most people would expect them, and well watched liberty with enjoyment is certainly far less perilous than the weariness, though apparent safety, of restric- tion and monotony. A lunatic is far more liable to commit some violent act on himself or on others on account of the misery of a wearisome existence, than in breach of the confi- dence which is reposed in him for the purpose, well known to himself, of increasing his limited enjoyment of life. Balls, Concerts, and Theatrical Entertainments. — Of these we entertain considerable distrust, especially if they are large, ostentatious, or in any way public. A dancing and music party not on too large a scale, so frequently repeated that the edge of novelty is blunted, and strictly confined to the inmates of the institution — this certainly promotes the cheerfulness of asylum life without much danger of causing undue excitement. Music is a great resource to ladies, but the brass bands formed of asylum servants are a questionable hobby. In some asylums no attendant is engaged who cannot play upon some musical instrument, thus limiting the choice of fit and proper applicants for infinitely more important duties. An asylum superintendent has a very good right to a hobby-horse, but it is well that he should have one with a long back upon which he may take a goodly number of his , patients up behind, maybe to journey with them over the borders of madmau's-land. Music and EEMOVAL FEOM AN ASYLUM 691 theatrical entertainments may be a hobby of this kind^ but it needs to be ridden with direct purpose to this end. Removal from an Asylum is frequently a question scarcely secondary in importance to that of placing a patient in one. As a rule patients are only removed from pauper asylums by recovery or by death ; but a large proportion of the discharges from private asylums are of uncured patients who for good or bad reasons are taken to other asylums^ or who are removed to be placed under domestic care and treatment — a change which is likely to be beneficial or the contrary according as it is or is not adopted with prudence and knowledge. In the treatment of many cases, whether in public or private asylums, a time comes when removal to other influences is followed by marked improvement and often by rapid recovery. Unfortunately the poor man removed from a county asylum is, as a rule, immediately plunged into the hard work and trying circumstances which the struggle for existence of those who live literally by the sweat of the brow must ever entail. For him there is no intermediate halting place, and, therefore, his deten- tion in the asylum until he can be pronounced to be throughly of sound mind is a measure of precautionary hygiene, which might most profitably be replaced by residence in an asylum sanatorium, or an agricultural colony apart from the great insti- tution, if these could be provided. The provision made by the statute for sending such patients out upon trial with an allow- ance for maintenance does not fully meet the requirements of the situation, although it may assuage the struggles and moderate the steep gradient of sudden change. With regard to the Rich there can be no doubt that asylum treatment ought in all cases, where there is a probability of cure, to be supplemented by change of place, scene, and surroundings, whenever that critical period arises in which excitement with delusion, or depression with delusion, is obviously tending towards quietude with weakness of mind. In this stage, which occurs in very many cases, there is often so much nervous and mental irritability that the associations met with in asylums are no longer curative, but painful and injurious. If patients are retained in an asylum during this period they are liable to a return of the original mental state, or still worse to decadence into one of the many forms of mental decay. Change from the asylum to the patient's own home may be at this time most unadvisable, but change to domestic treatment in the residence 692 TREATMENT OF INSANITY of strangers who have the requisite qualities of good sense and good nature will often effect a cure rapidly, which would other- wise be lingering and long deferred or perhaps altogether lost. Change to lodgings or to a house taken for the use of the patient with attendants and servants provided by the asylum proprietor, is for obvious reasons more frequently recommended by the latter, and is certainly a valuable expedient, which indeed may often be tried where the greater change to domestic treat- ment is thought to be unadvisable. It may be tried when the patient is too excitable and uncertain in his conduct to be ad- mitted into any family circle or the inner life of any private home. It does not withdraw the patient from the observation of the medical man under whom his improvement has so far progressed, and who is able to provide the favorite or the most competent attendants and all needful requisites for care and treatment. Some of the larger ^Drivate asylums have small home-like establishments of this kind beyond their bounds, but included within their licence, and it is always easy to obtain house con- venience for this most useful change, under the statutory powers of the Commissioners to grant leave of absence upon trial. And we think that this trial of treatment out of asylums, but con- ducted by the asylum physician, ought to be made use of far more frequently than it is. The annual change to the sea side, which is now so generally given to the quieter inmates of pri- vate asylums, although excellent in itself, does not by any means meet the requirements of treatment which we are now discus- sing. We were ourselves the first to establish a sanatorium for lunatics at the sea side when in 1856 we placed between forty and fifty patients in a house at Exmouth. We had every reason to be satisfied with that experiment, and we are gratified in no slight degree in finding how universally and beneficially that experiment has been imitated by the medical officers of private asylums ; for the exodus of lunatics from asylums to the sea side every summer or autumn seems to us one of the greatest practical improvements that has been introduced of late years into the management of private institutions. The amount of health and happiness gained by this annual break into the monotony of asylum life is not easily calculable, and we have known patients who participated in this annual excursion at a critical time in the history of their malady recover entirely from the effects of it. Still, this is not the kind of change from DOMESTIC TREATMENT OF THE RICH 693 asylum treatment which we here wish to discuss on its curative merits. The sea side change only takes place at one time of the year ; it is generally made by a considerable number of patients for the needful purpose of avoiding expense ; and these patients are often removed for a time from the constant obser- vation and care of the asylum physician. As a result^ its bene- ficial effects are more seen in the improved physical health and in the temporary enjoyment of chronic lunatics than in the mental improvement of those who are curable. The curative treatment in the latter stages of insanity admits of much moral and intellectual influence, and in doubtful cases which hang on hand, needs to be tentative and varied, and always under the advice and guidance of a mental physician. The Domestic Treatment of the Rich. — By the rich we mean those who have fifty pounds a year and upwards. This may be thought an extraordinary limit, notwithstanding that the vicar of sweet Auburn was declared to be " passing rich upon forty pounds a year.^^ Still fifty pounds a year of income, or one thousand pounds of capital, has been fixed by act of Parliament as the limit which separates those who have a right to the pro- tection of their property by the Lord Chancellor in forma ^auperum from those who cannot obtain it excepting by the costly process of an Inquisition, and as a fact we see and are in the habit of seeing numbers of lunatics who enjoy unexception- able domestic treatment whose income very little exceeds the modest limit above mentioned. The wants of a chronic lunatic are not great; a healthy cottage, adequate food and raiment and a kind attendant comprise the most urgent of them, and these even in these times of enhanced prices can be and are procured for the small sum we have named. The really poor man in this old country is quite differently circumstanced, and his care and sustenance have to be wholly provided or in some way eked out either by charity or public obligation. But although fifty pounds a year is the legal limit in one direction, there is no limit in the other, and chronic lunatics include many who possess and have a right to enjoy, so far as they are capable of enjoyment, very large amounts of accumulated wealth. The question then fairly and practically arises, what kinds of chronic lunatics having means for their support, care, and treatment should be detained in asylums, and what kinds of them should enjoy the freedom and happiness of domestic treatment ? So long as a patient is excitable,' quarrelsome, and ncisy, or 694 lEEATME^'T OF INSANITY dangerous to himself or others, while he is suicidal or subject to attacks of impulsive or delusional violence, while he enter- tains delusions which are likely to cause grave domestic trouble or breach of the public peace if he be at large, or if he be rest- less and impatient of all restraint, control and guidance, an asylum is still the best place for him, however chronic and hopeless of recovery his case may be. On the other hand, if he become tranquil, docile, and only weak of mind or possessed by harmless delusions, even if he be subject from time to time to slight fugitive excitement, or to simple depression without suicidal tendency, there is no valid reason why he should not be placed either in a home of his owa or in the home of strangers, where he can enjoy his crippled life with as much freedom as his means and condition will admit. Dr Maudsley in his Pre- sidential Address to the Medico-Psychological Association in 1871, argued the question as to the comparative advantages of the treatment of Insanity in asylums and in private houses, and he elicited an exceedingly interesting and full discussion on the subject. Dr Maudsley laid down the following propositions : — " First, that not many persons recover in asylums who might not recover equally well out of them ; and secondly, that the removal of an insane patient from the asylum sometimes directly conduces to his recovery. ^^ The remarks we have already made on the curative influence of asylums during certain states and stages of mental disease will show that we cannot fully admit the soundness of the fii'st of these propositions ; and we expressed this disagreement in the discussion above referred to ; but to the second proposition we give our entire assent. Dr Maudsley maintained that the " discipline of an asylum, counting for a great deal in some cases, has this great disadvantage, that the patient's individuality is little considei'ed ; he becomes one of a crowd the majority of whom are not expected ever to get well, and his moral treat- ment is little more than the routine of the establishment and the dictatorship of an attendant.'^ This disadvantage it is which tells so injuriously upon the irritable state of nervous weakness which so often succeeds an acute attack of Insanity, during which the moral influence of one sound wholesome mind brought into constant relation with the recovering intelligence and subsiding storm of emotion is so invaluable, and this influ- ence can certainly be brought into play more advantageously in a private residence than in an asylum. As a rule patients are DOMESTIC TREATMENT OF THE EIOH 695 sent to an asylum too late^ and are kept there too long. Dr Blandford accurately expresses these views in his lectures. " During the time that an asylum might rfEect a cure, the friends would not hear of sending him thither ; but when all hope of cure is over, he is placed there because it is cheap and saves trouble." " How are you to know if a patient is capable of li^ang beyond the walls of an asylum ? The answer is simple; give him a trial: many unpromising cases I have known to benefit so much by the change that they would scarcely have been recognised. Few chronic lunatics are dangerous to others : these are easily known, and we should be slow to place in a private family anyone who has ever committed an homicidal act, unless he is fully and perfectly recovered ; suicidal patients require the protection of an asylum so long as Insanity remains, but there are scores of eccentric monomaniacs who are perfectly harmless, who only require surveillance and a limit to their supply of money, and can enjoy life thoroughly amidst the amuse- ments of town or sports of the country, their eccentricities being greatly smoothed away by the constant society of educated ladies and gentlemen. As the last genera- tion did away with the fetters and mechanical restraint used in asylums, so let the present release from the restraint of any asylum all those capable of enjoying a larger amount of liberty and freer atmosphere than that in which they now fret and chafe " (op. cit., pp. 361 and 372). With these sensible and humane opinions we entirely coincide, from the knowledge gained by the observation of many hundreds of insane persons who do reside in their own homes or in the private residences of other persons, and who are placed in ail the freedom and the enjoyment of life which their malady and their means will permit. But there is another side to the question. If many insane persons are kept in asylums who ought not to be there, certainly some others are kept out of asylums who ought to be placed therein ; and it is often at least as difficult to persuade the friends of a perverse and intractable dangerous lunatic, to place him in an asylum, as it is to prevail upon the friends of other lunatics who are harmless and docile to give them the indulgence, freedom, and happiness of domestic life. We are inclined to think that this difficulty is one of such magnitude and importance as to demand the interference of the Legislature, for if it exists with regard to chancery lunatics, who are under the immediate protection of the state, how much greater must be the evil with regard to those lunatics whose proper care and treatment are entirely dependent upon the good intentions and right judgment of their friends. And the relatives of lunatics have, as a class, peculiarities which often render it a most difficult, and sometimes an impossible task to persuade and influence them to a right and rational discharge of their duties. A large proportion of them are more or less 696 TREATMENT OF INSANITY eccentric in their viewSj and strange or irregular in their feelings, and on account of consanguineous similarity to the lunatic him- self, the very worst persons to form a sound judgment of the best mode of treatment to which he can be subjected. Even if they should be as correct in sentiment and judgment as other people, the mental physician constantly meets with this great difficulty in obtaining their concurrence with his views, that in the early and curable stages of Insanity they are affrighted at the responsibility of placing their insane relatives in an asylum with a view to curative treatment, and in the chronic and in- curable states, when a patient ought to be placed under domestic care, they have had time to become apathetic and too ready to leave their relatives in asylums because there they cost less, give least trouble, and are out of sight and mind. The Cottage Treatment of the Poor. — This is a question closely allied to that of the domestic treatment of the rich, but with certain differences. It has been argued to a great extent on the eagerly disputed merits of the remarkable institution of Gheel,and on the advisability of attempting to imitate that curious old-world establishment in our own country. The litei-ature on the Gheel question has become quite voluminous. Baron Mundy having collected 300 papers upon it. We must excuse ourselves from entering upon the discussion, with the remark that Gheel, like the British Constitution, has been the gradual growth of centuries, and that any exact imitation attempted in our age and country would be likely to be as futile as any one of the brand new constitutions planned by the Abbe Sieyes. Still it has been imitated on a considerable scale in Scotland under the wise auspices of Sir James Coxe, and the relief of our overgrown pauper asylums appears possible in this direction. At the discussion on Baron Mundy^s paper, which took place at the annual meeting of the Medico-Psychological Association in 1862, we expressed our doubts as to the extensive application of the system in this country. We had placed tranquil patients in the cottages of a village near to the Devon asylum for five or six years before that date, and were still endeavouring to extend the system. The results so far as our experience extended were most satisfactory, but we thought that the attempt to carry out the system to any large extent would be frustrated by the difficulty of finding many patients who were suitable objects for it, and by the additional difficulty of finding many people who were fitted to take care of COTTAGE TREATMENT OF THE POOR 697 them. We must freely confess, however, that our doubts on this point have since been removed by the knowledge of what has been done at Kennaway, and still more by the observation of the comfort and happiness of poor chancery lunatics living in the rude homes of their friends in Welsh farmhouses and other country districts, the actual cost of whose care and maintenance is often not greater than that of the inmates of county asylums, while their clothes, cleanliness, and diet, and the general care and comfort provided for them, are certainly not superior to those which could be secured in the best cottages of the English agricultural labourer. Indeed^ we have seen many chancery lunatics maintained in great comfort and happi- ness in English cottages, Siud caeteris jJctribus we believe their lot preferable to the poor insane who reside in more genteel resi- dences where the means of support are small. Gentility costs so much, and is of so little real service, at least, to an insane person. We left our Devonshire trial of this cottage system in full progress in 1862, but, although it was not revoked so far as we had carried it, its extension was not attempted, and this must have been the origin of the report which we heard on the Continent, and which appears to have been communicated to Griesinger, that we had changed our opinion of its utility. Nothing could be further from the truth, seeing that if our opinions have undergone change it has been in the opposite direction of increasing confidence in the system and a higher appreciation of its merits; and we venture to affirm that not- withstanding the various theoretic objections which have been urged, no one who has ever tested by practical experiment the system of relieving our crowded asylums by placing carefully- chosen lunatics in cottages under the easy supervision of asylum officers, has ever had cause to regret the trouble he has taken, or to doubt the comfort and happiness of his emancipated patients. After we left Devon in 1862 Griesinger paid a visit to the asylum, and wrote of our tentative beginnings of the cottage system in the following terms : " Is this system of treatment practicable ? It has been long in operation in Gheel ■with over a thousand patients, and in Scotland with several hundreds, and in the most satisfactory manner. In the Devonshire County Asylum an experiment on a small scale, by BuckniU, has been completely successful. What has been done there can also be done elsewhere. But the treatment of the patients ? Can that be as good as in the close establishment, with its airy dormitories, its gardens, its water-works, its three meals a day, with butcher's meat cooked in the newest and 698 TREATMENT OF INSANITY most approved style ? To this there is only one reply. Ask a patient under family treatment, who has formerly been an inmate of a good close asylum whether he would like to go back to it. The well-being of the individual, his real happiness, depends only to a small extent upon such things, but greatly upon emotional impressions. He who is not suitable for a close establishment, and for whom it is not necessary, regards it as a bondage, for the flesh-pots of which he never longs ; and — he is right." " It was there [in the Devonshire County Asylum] that I first saw it. I shall rejoice all my life over that evening, when my theoretical notions, in presence of these small beginnings, first gave way to the force of facts. ' Yes, it is not only possible but actual !' I could have exclaimed. The errors of years were destroyed in a single hour. And even if the thing were again given up in that place, and renounced by those who had instituted it, it has been workmg, and it will work for all time." (' Journal of Mental Science,' No. 65, p. 29.) The Medicinal Treatment must be founded, not upon the general resemblance of symptoms in different cases, but upon their points of dissemblance, and upon the discrimination of ultimate diagnosis; not upon the primary diagnosis which recognises a case of Insanity, but upon the idtimate diagnosis v:hich, as nearly as possible, refers the symptoms of each indivi- dual case to the exact pathological condition from which they arise. The medicinal treatment of Insanity may conveniently be classified into that of the acute and of the chronic forms of the disease, — into that whose aim is curative, and that in which it is only palliative ; and again, in the former, into that which is directed to the urgent symptoms of the outbreak in which the disturbance of the organisation is a prominent feature, and that of the more tranquil period which often succeeds between the outbreak and the convalescence, in which, after the apparent subsidence of the physical disturbance, the various forms and derangements of the mental functions are often the only obvious symptoms of cerebral disease. In the medicinal treatment of all cases of Insanity, the following objects have to be kept in view : 1st. To obviate any general derangement or diseased condition of the system. 2nd. To remove the pathological condition of the brain whether consequent upon, or independent of, general physical disturbance. 3rd. To treat urgent and dangerous symptoms. Sometimes the measures adopted to fulfil the first of these intentions embrace the second also ; for instance, where the measures adopted to relieve a state of general plethora or anaemia BLEEDING 699 relieve the same state in tlie cerebral organ. Sometimes the measures required to fulfil the first and second intentions are to some extent antagonistic ; for instance, where, with general debility of the system, there is a local hypergemia of the brain, and leeches with cold lotions to the head are found to be practically consistent with the use of nutritious food and stimu- lants. Sometimes there are no indications to guide the treat- ment towards the first intention, and the second becomes the prominent one. This is especially the case in the second period of recent Insanity, and in the chronic forms of Insanity, where, in the absence of any general disturbance of the system, the symptoms fairly point to a pathological condition of the brain. Sometimes, in the absence of symptoms either local or general the fulfilment of the third indication is the only one which can be attempted. Doubtless in every single case of Insanity there exists some pathological condition in the organ of mind ; but in the absence of symptoms pointing to the nature of this condition, the physician must avoid interference which may be mischievous, and be content to temporise; must be satisfied with removing the causes of irritation and excitement, and retaining his patient in an atmosphere of physical and moral hygiene. Bleeding. — In passing from these general principles to parti- cular remedies, the question meets us, whether bleeding is ever permissible in the treatment of Insanity ? Not without cause it was emphatically condemned by Pinel and Esquirol, and it would be easy to cite a number of authorities who have followed in their track. Dr Pliny Earle has done good service to psychological medicine by the publication of his useful essay on this subject. Before the time of Pinel, the insane were bled frequently and promiscuously, and it was said the most beneficial results were derived from the practice. PineFs condemnation did not put a stop to it, and we learn from Dr Earle that his book was greatly needed in America, in order that some check might be put to the mischievous results of T)r. B,ush^s teaching on this subject. The French authors cited state that they have frequently observed cases which appeared to be curable, pass into incurable Dementia in consequence of venesection. It is no wonder that abuse of treatment so flagrant should result in an universal condemnation of it ; and, in this country at least, the treatment of Insanity by general bleeding has passed into 700 TKEATMENT OP INSANITY universal clisfavoui' and disuse among' all who can be considered authorities on the subject. The treatment of Insanity described by medical officers of asylums, in the " Further Report of the Commissioners in Lunacy/' 184^7, contains no instance in which general bleeding is recommended. We have never used the lancet in the treatment of Insanity, but we must admit that cases do present themselves in which we have felt it our imperative duty to use leeches to the temples and cupping to the nape of the neck, to such an extent that the effect on the general system would not be much less than that of a moderate bleeding. One ought always to be suspicious of an universal rule, and more espfecially so when it has been adopted in opposition to a previous rule of the same character to the con- trary. It is very easy to save ourselves the trouble of thinking, by giving in our adhesion to a dogma, and the man who, at the present time, is most ready to affirm, with inflexible pertinacity, that in no possible case of Insanity is it right to bleed, would, had he lived seventy years ago, have been the very man most likely to affirm that no case of Insanity can be rightly treated without such bleeding. This, however, is not the spirit of philosophy, or even the courage of good sense which has the will and hardihood to think for itself. Men love to run into extremes ; but when most in extremes, let us remember that they are never altogether right, and never altogether wrong. If, therefore, our forefathers were undoubtedly wrong in their abuse of the lancet, it is just possible that we are not altogether right in looking upon it as tahoo. Acute Mania is not divided from inflammatory action of the brain and its membranes by any sharply drawn recognisable line of demarcation. On the contrary, some few cases of men- ingitis approach very closely in their nature and symptoms to the character of acute Mania; and some cases of acute Mania are accompanied by symptoms which indicate that cerebral Hyperaemia is so great in degree, and active in character, that a considerable abstraction of blood, by leeches or cupping- glasses, is the least that can be done with judgment to relieve it. Between the employment of local bleeding of this kind, and moderate general bleeding, no great question of principle can possibly exist. Let it not be thought that the author recommends bleeding in the treatment of Insanity. The fact that, in the treatment of more than two thousand cases, we have never yet used the TARTRATE ON ANTIMONY 701 lancet, is perhaps a proof that we have been, to some degree, under the influence of the general prejudice. The principle advocated is this, that no manageable remedy ought to be excluded from the treatment of a large and diverse class of diseases. The infinitely varied conditions of disease demand the occasional employment of every influence which can be guided in its action upon the organisation and its functions. No physician will act wisely in definitely rejecting the use of any manageable force of which he has knowledge, and therefore he will be disinclined wholly to expunge bleeding from the list of remedies which may be successfully employed in combating acute cases of Mania. General bleeding we cannot advise, but local bleeding by leeches to the temples or cupping to the nape is to be justified when, in addition to the symptoms of acute cerebral Hypersemia which are not uncommon in acute Mania, to heat of head, suffusion of eyes and face, throbbing of carotid and temporal arteries, &c., there are superadded the symptoms of inflammatory action within the cranium, together with accompanying febrile reaction. Such symptoms are pre- sented by irregular contraction of the pupils, by squinting, by convulsive twitching of the muscles of the face and arms ; by a hard, full, and bounding pulse ; with hot and dry skin, and the general characteristics of synocha. That such cases occur very rarely is the greater reason why the practitioner should be forewarned that they do occur ; since their prompt, active, and judicious treatment is a matter of life and death. Tartrate of Antimony. — There has been almost as much difference of opinion, of late, respecting the mode of using, and the benefits to be expected from, tartrate of antimony, as on the subject of bleeding. Dr MacFarland, at the last meet- ing of the American Association of Alienist Physicians, said, he had trusted that tartrate of antimony was " lying in the same grave where venesection had been buried long ago." The late Dr Burrows speaks of the benefits to be derived from its use, and mentions the large dose of thirty grains to have been given without producing vomiting. In the "Further Commissioners' Report,^' above referred to, a large proportion of the reporters mention this drug with approbation. Many writers state, that the benefits to be derived from it are pro- cured by keeping the patient in a state of nausea, and thus overcoming his tendency to acts of violence. It is to be feared that this drug is not alwajs used in asylums 702 TREATMENT OF INSANITY for definite medical purposes, but that it is frequently employed to aid in preserving quiet, by overcoming the demonstrative vehemence of choleric and turbulent patients ; that it is, in fact, used as the wretched wives of labouring men in the manufac- turing districts use it on their drunken husbands, under the name of " quietness," to produce physical depression, and thus avert outbreaks of anger and violence. In a trial of a woman for murder who had, with this intention, given her husband an over-dose which had proved fatal, the extraordinary fact was elicited from druggists and others, that the administration of tartrate of antimony in the domestic broth or tea has become quite a habit among the artisan class in the North of England ; and that many women buy their weekly quantity of "quietness," at the druggists' shops, as regularly as they lay in their weekly store of other every-day articles of consumption. It is to be feared that this pernicious habit prevails to a great extent in many asylums, and that " quietness " is given to lunatic patients when there is no real medical indication for the use of tartrate of antimony. It may not always be easy to draw a line of strict demarcation between the medical treatment of the insane, and measures adopted for their discipline and control, but it should be always attempted; and, as a rule, the physician should steadfastly refuse to prostitute the resources of his art to any meaner purpose than a struggle with the well-recognised sym- ptoms of disease. One source of mischief which a different line of proceeding entails is, that it throws suspicion and oppro- brium upon important remedies, even when they are used for purely medical purposes. In this manner, the shower-bath and tartarised antimony have suffered in character as remedial agents in the treatment of Insanity ; and it requires no inspiration to be enabled to prophesy that opium which, rightly used, is the right hand of the physician in the pharmacy of Insanity, will, ere long, be in danger of falling into disrepute, with the timid, for the same reason.* We have used tartrate of antimony, in some cases of Mania, with the happiest results. Our aim was not to produce nausea and depression ; and when these results have followed its use, our expei'ience is that little benefit is to be expected from the use of the drug. The benefit to be derived from it appears * Siuce the above was written this apprehension has been fully justified by the attack upon the use of opium in the treatment of Insanity which was made in Dr Maudsley's Presidential Address of 1871. MERCURY 703 indeed to bear a close relation to the tolerance wliich the patient has for it. If a maniacal patient can bear a grain dose of tar- trate of antimonyj three times a day, not only without suffering from nausea or purging, but with the enjoyment of a good appetite for food, the drug will, in all probability, be beneficial. The cases in which this tolerance exists, and this benefit may be expected, are not those in which there is much heat of head, accompanied by sleeplessness and a feverish condition of the system. In these, the treatment by leeches and warm bathing is far preferable to the use of antimony, which, indeed, they rarely bear well, or are improved by. The best cases for the tartrate of antimony are those in which the symptoms of acute Mania are accompanied in men of robust constitution, with little general disturbance of the physical health ; patients whose head is not hot or cool, who look well in the face, have a strong, good pulse, have a good appetite, and sleep well, — the mental symptoms being those of excessive turbulence, pride, anger, &c. ; patients who are always in contention, or desiring or endeavouring to perform some feat of strength ; patients who appear to enjoy superabundant vital energy. This condition, which is not a common one, but which occurs sufl&ciently often to make its recognition of great importance, is one of recent disease, although it is open to doubt whether it ever is the primary form of Mania. Probably it is always preceded by a period, more or less brief, in which the symptoms of cerebral Hyperaemia exist. These subside, and the symptoms above described take their place. The pathological condition of the cerebral organisation in these cases can only be matter of surmise. It seems probable that it is one of molecular change of great but irregular activity ; one in which the processes of cerebral exhaustion and regeneration, of decay and repair, are energetic, but in which they have escaped from the rules imposed upon them by the habits of health. That such cases recover under the administration of tartrate of antimony, which neither produces in them nausea nor depression, is a fact of which we have had the most convincing and satisfactory experience. Mercury. — The use of calomel, in the treatment of Mania, is yet more limited than that of tartrate of antimony. As a rule, it is a medicine to be avoided, on account of the irritability of the nervous system which it tends to produce. Five grains of calomel, however, in combination with ten of compound extract 704 TREATMENT OF INSANITY of colocyntli, or fifteen of jalap, may be given as a purge when the skin and conjunctiva are dusky and bilious ; and the milder preparations of mercury may be given in alterative doses, when the state of the tongue and the evacuations indicate the need of a stimulating action upon the liver. Mercury has by many physicians been freely given to produce ptyalism in Mania. In our opinion, however, this treatment only ought to be followed in the most exceptional cases ; the great nervous irritability caused by mercurialization being the very opposite condition to that we should desire to induce in the treatment of mental disease. A few cases, however, do occur in extensive practice, in which the full powers of mercury may fairly be tried. When a patient has passed from a state of acute into that of chronic Mania, which, in spite of treatment, threatens to become perma- nent ; when this state of affairs is accompanied by local heat of the head, sometimes also with a hard pulse, we have given the patient the chance which appeared to be afforded by mercuriali- zation, and, in some very unpromising instances, with the best results. We have known such patients improve greatly under the influence of a grain of calomel, given two or three times a day, so as to produce ptyalism. In several instances the ptyalism did not come on until considerable improvement in the physical and mental symptoms had taken place. In the use of this drug it does not occur as in that of the last mentioned, that tolerance is an indication of its utility. We have known very large quan- tities of mercury administered without touching the gums, and without producing any improvement. In the conditions above described, the probability of success will sometimes be augmented by small losses of blood from the temples, leeching, or by a seton in the nape. In the cases, however, above referred to, the calomel was not thus assisted, and the apparent benefits which resulted from its use were the less open to question. Instead of calomel, in these cases, we have occasionally used the bichloride of mercury, but not with the same success. We have also used this preparation in the earliest stages of General Paralysis, as recommended by Dr Sutherland ; but, in this form of disorder, we have never seen any obvious improvement result from it. Opium. — The right employment of opium in the treatment of insanity is a question whose importance is inferior to none in the whole range of psychological medicine. Many of the early writers on insanity, however, condemned the use of opiates and OPIUM 705 narcotics generally. They had observed that the mental sym- ptoms were generally exaggerated after natural sleep, — an observation which it is easy to verify in any case of hypersemic mania, in which short and fitful sleep takes place. They had also probably given opium in cases which were not fitted, or were not prepared for it, and they had observed that increased excitement followed such use of the drug. They had not learned to discriminate the conditions of mental disease in which opium becomes a true balm to the wounded spirit, — a sedative in mania, a restorative in melancholia, sometimes even a tonic augmenting appetite ; sometimes even an aperient, regulating the sensibility, and restoring eflEicient peristaltic action to the intestines. Van Swieten mentions a case in which a scruple of opium dissolved in vinegar was taken accidentally by a maniacal patient, on whom this single dose effected a cure ; and he afterwards employed this drug freely, but never went beyond fifteen grains. The use of opium in mania is said by Esquirol to have been due to an accident : A lunatic got possession of and swallowed an ointment which contained 24 grains of opium, and having been cured by the narcotic thus unadvisedly taken, the attention of medical men was particularly directed to the use of this drug in insanity. Valsalva and Morgagni prescribed it, and Pery cured maniacal patients in whom there was much insomnia with large doses ; he carried his doses as high as sixty-four grains in the twenty-four hours {' Esquirol,^ torn, ii, p. 214). The use of opium in the different forms of insanity has long been known to English practitioners. Ferriar gave grain doses of the aqueous extract in Melancholy, twice a day, with success, and was thus the precursor of the morphine treatment of this form of mental disorder, which at present enjoys so much favour; he generally combined it with bark. Halloran recommended its use in the first onset of the disease, which he believed was capable of being occasionally cut short by a full dose. After insomnia for two days, he had given 240 drops of the tincture of opium, the result of which was heavy sleep, lasting for nearly twenty-four hours, and terminating in complete recovery. Willis objected to opium, because it causes constipation, and some- times increases watchfulness. A case is mentioned in Darwin^s ' Zoonomia,^ in which an insane patient was cured by Dr Binns, 45 706 TREATMENT OF INSANITY by two doses of opium — the first containing two scruples, and the second, administered after an interval of four hours, con- taining one scruple. Dr Brandreth also records a case of acute mania, cured by 400 drops of tine. opii. Macintosh, in his ' Practice of Physic,^ states that injurious effects have followed the administration of opium in Insanity, from want of discrimi- nation in the selection of cases for its use, and fi^om the insuffi- ciency of the doses used. In cases where there was great irritability and insomnia, and there was no evidence of permanent organic lesion of the brain, he has seen the best effects result from 80 to 100 drops of laudanum, given every third hour. Dr Pliny Earle, an eminent American alienist, writes : — '' I employ narcotics to a considerable extent, and believe them to be the most effective, or among the most effective, agents in the treatment of insanity. Laudanum, and the sulphate of morphine in solution are more employed than any other; even in cases of acute Mania they may often be administered with utility in a much earlier stage of the disease than has been supposed. Of the first, I generally begin with twenty minims, three times a day; and carry up the dose, so rapidly as the patient will bear it, to one, two, or three drachms, three times a day, according to the necessity of the case. I rarely exceed one drachm and a half or two drachms.'^ CuUen gave opium in large doses. Of the Continental physi- cians, Guislain appears to have used opium in Mania most freely ; the dose should be large, he says, although it is best to commence with two grains, which he augments to ten, fifteen, or twenty according to the symptoms induced. Esquirol remarks, that the ancients made great use of nar- cotics, in the treatment of Melancholia; and he recommends these remedies, and especially opium, in that form of Melancholy which is vulgarly called nervous, — Melancolie sans Matter e of Lorry. He remarks that Odier used opium for this purpose, and that, in 1816, he published a case of Melancholy, which he had cured with opium, the dose being gradually carried as high as thirty grains, combined with an equal quantity of musk. The person who appears to have most contributed to the re- introduction of opium in the treatment of Insanity was Dr Shute, of Gloucester, and we learn from Prichard^s Treatise, that tinc- ture of opium, combined with sulphuric asther, or Hoffman's •anodyne, was extensively employed in the treatment of the patients in the Gloucester Asylum. Subsequently, Dr Phillips OPIUM 707 used opium frequently and successfully, in the treatment of Melancholia, at the Bethnal Green Asylum. Dr Seymour, the eminent physician to St George's Hospital, having visited the Bethnal Green Asylum, and seen the beneficial results of the opiate treatment, used it himself in private practice, and made known the excellent results he had obtained from it in the ' Medical Gazette/ From that time the opiate treatment, both in Melancholia and Mania, has gradually undergone develop- ment, until, at the present time, the skilful and discriminating use of this drug may truly be called the sheet-anchor of the alienist physician. The beneficial use of opium commences even before mental disease has become actually developed ; and Dr George Johnson has done excellent service in pointing out the great use of this drug in the prophylaxis of Insanity, in his Lectures published in the ' Medical Times,' in the year 1853. The chief objects of these Lectures was to give a description of those slighter derangements of the nervous system out of which, in a certain proportion of cases, the more formidable diseases of the mind are gradually developed. The field of ob- servation was extensive hospital and dispensary practice amongst the London poor, affording abundant opportunities for observing their habits and habitations, and for obtaining a knowledge and a record of many of their family histories. The results at which the author arrives are : — 1st. That in a large proportion of cases, the more formidable derangements of the nervous system have their origin in some form of mental shock and anxiety. 2nd. When the nature and origin of these nervous disorders are detected sufficiently early, the more serious forms of disease may often be prevented, and the slighter derangements entirely recovered from. 3rd. The method of treatment best adapted for the prevention and cure of the disease in question admits of some variation in different cases, according to the nature and the cause of the symptoms j but there is one remedy, which, when given in the mode and with the precautions indicated, is more efficacious than all others combined. That remedy is opium. The form in which it was prescribed is : — PiL Saponis co., gr. v, h. s., which moderate amount of the narcotic combined with exercise in the open air and tonics, appears to have been sufficient in Dr Johnson's hands to procure refreshing sleep removing the 708 TREATMENT OF INSANITY wearing effects of months of anxiety and restlessness, and to operate as an efficient prophylactic against mental disease. Delirium tremens, which, without being nosologically included among the pJwenesice, is undoubtedly a transitory form of Insanity, is cured by opium. In those instances of the disorder which occur in habitual drunkards when their customary stimulant is withdrawn, the drug requires to be aided in its operation by alcoholic stimulants ; but in those instances which follow long-continued watching, combined with mental exertion, or moral anxiety, opium alone, in such quantity as will ensure sleep, is the sole and almost infallible remedy. The transition is easy from delirium tremens to an important class of maniacal cases — Mania with pale face and weak pulse, with restless activity, and utter want of sleep, — and in these cases the preparations of opium or morphia are most beneficial. Their operation in effecting a cure is, however, greatly aided by that of other remedies, especially by warm bathing, by aperients when needed, by stimulants and nutritious food. The following will briefly illustrate the nature and treatment of this common case. J. B — , a tradesman in good circumstances, for some years past given to a dissipated course of life, the frequenter of taverns and theatres. Owing to a reverse iu business, he suddenly gave up his dissipated habits and remained at home, his business being conducted principally, as before, by his wife ; he became low-spirited, moping, and lost sleep at nights. Suddenly this state changed to one of wild, maniacal excitement, requiring his immediate seclusion in an asylum. His face was pale, and covered with a clammy sweat, the expression that of wild terror, the fore- head cool, the pulse feeble and quick. Ordered — Trae. Opii, luxl ; .^theris Sulph., "ixx, 4tis horis. Li a week from admission this patient was convalescent ; he had obtained some sleep from the first night, and the duration of sleep gradually increased. After recovery he told us, that during his illness the idea that he was about to be hanged was constantly present in his mind. J. C— , a single man, in easy circumstances, of steady and temperate habits and cheerful disposition ; his brother has had Melancholia. Without any known cause, a change was observed in his manner and mode of life ; he neglected his usual pursuits, and moped about, silent and abstracted ; then he became restless, walked about his bedroom all night long, and refused food. This state of things was allowed to continue so long that, when called to see him, we found him very nearly at death's door; his teeth and tongue were covered with sordes, his breath had the foetid odour of a starved person, his face was of ashy paleness, his forehead cold and clammy to the touch, his pulse thready, and his body emaciated ; he was reported to have had no sleep for a fortnight (this was probably an exaggeration), to have taken very little food for the same time, and none for the last three days. Wine and beef tea were given every hour ; and after these had produced a slight evidence of re- action, half a grain of morphia was administered. This treatment had the effect of OPIUM 709 somewhat improving the appearance of the patient, and cahning his restlessness ; a repetition of the opiate produced a few hours' sleep. The morphia was continued twice a day, and the improvement of the patient was evident from day to day. The bowels M'ere first acted upon by aloetic injections ; and when returning strength rendered anything like purgation less dangerous, rhubarb and grey powder were given twice a. day. In five days the patient was able to walk in the open air, leaning upon the arm of an attendant. Wlien first seen he was unable to articulate ; but, when returning strength enabled him to do so, he gave expression to his delusions, which were — that he had no existence; that the person called .J. C. was quite destroyed ; and that he was nobody, and nothing. These delusions subsided, as the patient gained good nights of sound sleep ; and the long convalescence which followed was principally marked by mental and physical debility. In tliis case the use of opium would, we tliink^ have been dangerous_, unless combined with the free use of wine and nutritious food. It would probably have rendered the respira- tion^ — already feeble from inanition^ — still more feeble, and thus have extinguished the flickering lamp of life by impeding the calorific process, already at a low ebb for want of fuel. Food and stimulants were the first essentials ; and these were administered, in opposition to the little force which the patient could employ, by feeding him with a spoon like a reluctant child. It may be doubted whether the food and stimulant alone would not have effected the restoration of the patient ; but the great improvement which followed the first few hours of sleep, and which continued to follow every period of sleep, seems to point to the opiate as a remedy of at least equal importance. Accord- ing to our experience, these cases with symptoms resembling typhus recover if they can be kept alive. The febrile condition appears to be the result of want of sleep, and total want of food. In cases of Melancholia, or Monomania, where absence of food has not been complete, but has been continued during a much longer period of time, and in which the patient has not entirely been deprived of rest, the appearances, though less threatening, are far more dangerous; there is an absence of the typhous appearance, the sordes of the mouth, the stupid look, the pale clammy skin, and restless motion : on the other hand, the body is far emaciated, the skin, instead of being pale and clammy, is harsh and dry ; the expression of eye and feature is not stupid, but anxious. Opiates are not found to agree with such cases. The question with them is one of feeding ; some- times, however, after a long abstinence, food is taken well, and even ravenously, but it appears to do no good. Many such cases, however, in spite of every effort made to save them^ ^raduallj- sinl? m^ tlie of inanition, 710 TREATMENT OF INSANITY There may be some doubt as to the correct nosological posi- tion of the above cases ; some would incline to place them in the class of Melancholia, or more strictly perhaps, in the sub- class lypemania (Melancolie avec delire). But, notwithstanding the nature of the delusion and the predominance of the depres- sing emotions, they appear to us to have a closer alliance to Mania. The leading delusion is indeed, generally melancholic, but there is that general derangement of all the intellectual functions — of attention, perception, comparison, imagination, &c. — which can only be recognised in Mania, the essence of which is a disturbance of all the mental functions, and a complete confusion of all the ideas. They appear, indeed, to furnish the connecting link between delirium tremens and Mania ; and it is on this account that we have given them precedence, in discussing the treatment of mental disease principally by means of opium. The opiate treatment of the more ordinary forms of Mania, namely, those distinguished by the excitement of pride and the combative propensity, requires a nice discrimination of the pathological condition. Opium may be most useful to one patient, who is arrogant, turbulent, violent, and most prejudicial to another with the same mental symptoms ; it may be most useful to the same patient, during the prodromic and first period of an attack, injurious during the second period, and again most useful when the symptoms of cerebral congestion have been allayed by other remedies. As a rule opiates are inadmissible in Mania so long as cerebral hyperaemia exists — either alone, or in conjunction with general plethora. When circumstances permit, these should be reduced before opiates are administered ; but frequently this rule cannot be strictly followed. The commonest maniacal condition is that in which the pulse is by no means full or strong ; but the head is hot, the eyes are injected, and the existence of active cerebral congestion cannot be doubted ; the patient is rest- less and violent, and without sleep for many nights. In such a case the physician is called upon to determine between two evils. Morphia or opium, prematurely given, will increase the cerebral congestion, and do mischief. Too long delayed, equal, or greater mischief, will result from the want of repose. The violence, restless agitation, and sleeplessness of the patient, will per- petuate a degree of hyperemia which a judiciously administered dose of morphia will often allay. There is great risk in laying OPIUM 711 down rules, but, as a general rule, after a patient has been without sleep for three nights, a full hypnotic ought not to be withheld, notwithstanding heat of head, and other symptoms of cerebral congestion. Practically, the physician finds himself in many cases compelled to give morphia, and to use remedies to reduce cerebral congestion concurrently by applying six, ten, or twelve leeches, to the temples, followed by cold lotions to the shaven scalp during the day, with or without an aloetic purgative, according to the state of the tongue, and the strength of the patient. This may be followed the same evening by a warm bath, with the cold still continued to the head, a full dose of black drop or morphia being given the last thing. Such treatment frequently has the most satisfactory results ; the patient gets several hours of sound and refreshing sleep, and a modified repetition of the treatment, continuing the antiphlogistic or the narcotic reme- dies, according to the progress of the symptoms, results in a rapid cure. The reader will find, in the Appendix, the brief records of several cases, illustrating the treatment both of the common forms of mania and of those whose management is beset with diffi- culty and peril. These cases it was at first intended to insert here and elsewhere in the body of this work; but it has been thought best to throw them together in a short collection of cases, apart from the principles of treatment which they tend to illustrate ; since it must be remembered that doctrine never quite tallies with practice, either in medicine or in any other of the arts of life. When a patient succumbs after the employment of energetic and complicated treatment, it is generally impossible to estimate, with any degree of accuracy, the relative share which the disease and the remedies had in the fatal result ; and one can only guess at the part which any particular medicine has played. Doubtless every patient who dies under the hands of a physician (that is, of one really such, and neither a homoeopathic sham nor an expectant pedant), dies partly of the remedies employed. Had the disease not been resisted, the chances of avoiding death would have been greatly diminished, and the event itself might have been much earlier ; but it would not have taken place in exactly the same manner — it would not, therefore, h^ve been the same death. Hence the assertion that the death of a patiezit^ to prevent which active remedies have been adopted, is 712 TREATMENT OF INSANITY the combined result of the disease and the remedies ; as the oblique fall of a tree, which has been propped on its heavy side, is the combined result of wind and the direct pressure of the ineffectual prop. Now there is, in certain cases of mania, a tendency to death from asthenia, — a tendency which Esquirol pointed out, attributing it to exhaustion of the sensibility. Opium is powerfully influential in lessening this danger if it takes good effect on the system, and procures restorative sleep ; but if the pathological condition is too profound for the remedy, and large doses of opium are administered without procuring the desired effect, the depressing influence of the ineffectual drug, which, in voiding its desired function, becomes a power- ful sedative, is added to that of the disease, and the tendency to death from exhaustion is greatly increased. In most cases of this kind, death would have taken place from asthenia fol- lowing long- continued sleeplessness, without any aid from the narcotic. Still the danger to be apprehended from this opera- tion of opium, and especially from the salts of morphine, is one whose recognition is of much importance. The knowledge of it has often withheld our hand from giving full doses of these narcotics, when the urgent need of procuring sleep even at considerable risk would otherwise have indicated their use. The operation of opium on the diseased nervous system is very remarkable. The enormous tolerance of it in many states — for instance, in hydrophobia and tetanus — and to a less extent in severe neuralgia and other affections accompanied by intense pain, is well known. There is also a most singular intolerance of il in some other diseased states of the nervous system, which we have never yet seen adverted to. Our attention was first called to it, twenty-seven years since, by the following circumstances : a badly-situated and damp asylum ward was occupied by idiots and demented patients ; the result was a dysenteric outbreak, which, in several cases, proved fatal. An eminent physician, whose advice we took respecting the treatment of the dysentery, recommended the rather free use of opium, in the form of mixture and suppository. The effect of the drug on three demented patients was most remarkable. The opium took no effect upon the cerebrum proper, but exerted the most depressing influence upon the excito-motory apparatus. The respiratory movements became more and more slow ; the temperature of the body decreased, the pulse failed, and the patiients sanls with the general symptoms of abolition of nervous OPIUM 713 power without narcosis upon the mental functions. There was no coma nor stupidity, the patients being fully awake to the last. Several other patients presented slighter degrees of this curious state, from which they were recovered by stimulants : but, in the three cases mentioned, the powers of life were already so much reduced by the dysentery, that the asthenia without coma proceeded, in from eight to twelve hours, to a fatal termination. In many instances, since this occurrence, we have seen the tendency to depression of the nervous power without coma, when opium has been administered to patients, the condition of whose mental faculties showed the existence of considerable cerebral atrophy ; and it has taught us to be extremely cautious in the administration of opium in advanced Dementia and General Paralysis. The state of the brain which leads to death from opiates without coma, and which seems to be a mixture of asphyxia and asthenia, occurs in other conditions besides that of cerebral atrophy. Something like it is occasionally to be seen in the treatment of delirium tremens. The patient struggles to free himself from the enemies who surround him, the imps or mur- derers who threaten him, the snakes which fill his bed. Dose upon dose of opium has been given, in the constant hope that each dose will succeed in procuring the curative sleep. All at once the patient falls back. His breathing becomes embarrassed, his pulse fails, and in a very short time he is dead. The asthenia in this case is sudden, taking the form of syncope ; but there can, we think, be little doubt that the fatal result is due to the same cause — the depressing effect of the drug upon the spinal nervous system, assisted by the nervous exhaustion due to the disease. Had the narcotic effect of the drug taken effect upon the brain, its sedative effect upon the excito-motory system would have been obviated. These considerations apply probably to the cases above cited. The pathological condition of the cerebrum, which occasioned excitement and forbade sleep, was too profound to be overcome by the narcotic. The drug, therefore, operated as a sedative upon the spinal system and accelerated that exhaustion of ner- vous power under which the patients sank. It is extremely difficult to recognise the cases in which the danger of such a termination of treatment exists. It is to be hoped that they are cases which, under any treatment, could not b^ve l?een saved^ as they probably are cases in which the patho-? 714 TREATMENT OF INSANITY logical changes in the cerebrum are profound. If it is permis- sible to estimate the severity, or even the nature of a pathological condition, by the degree to which it withdraws the system from the ordinary operation of remedies, the pathological condition of the cerebrum which tolerates otherwise poisonous doses of opium without coma or sleep, is one from which an unfavorable prog- nosis may with good reason be derived. This method of esti- mating pathological states has the sanction of Marshall Hall, who proposed the tolerance of loss of blood as the foundation of a practical system of diagnosis. The tolerance of opium may, on this ground, be one means of prognosis in mania. If large doses produce no effect upon the cerebral functions, death from exhaustion may be feared. In some cases this event cannot be obviated; but in others, the free administration of diffusible stimulants and of wine, the outward application of dry heat, and other similar remedies, may ward off imminent asthenia. In some cases the danger will not be seen before it is too late to make any attempts to turn it aside. In acute Mania, as in some cases of delirium tremens, the patient continues agitated, restless, and sleepless ; dose after dose of some opiate is admin- istered, in the sanguine hope that each dose will be successful in causing sleep, and therefore the last required. Sometimes the most watchful attention can detect no symptoms of failing power until it suddenly fails, and all efforts at restoration are vain. In a valuable paper contributed to the 23rd Number of the ' Journal of Mental Science,^ Dr Noble, of Manchester, has pointed out the danger which exists of producing fatal coma in the treatment of insanity by full doses of opium ; and he has well pointed out the indications by which this danger may be avoided. In our own practice we have not hitherto met with such cases ; an immunity which we are inclined to attribute to the selection we have made of the cases for full opiate treatment having been somewhat different ; so that the danger has pre- sented itself to us under a different aspect — no doubt because there was a stronger original tendency in the diseased condition to pass into that of nervous exhaustion than into that of fatal coma. That full opiates were occasionally followed by comatose sleep of a dangerous character was not unknown to our prede- cessors. Thus, in Halloran^s case, above cited, the patient passed twenty-four hours in an apoplectic kind of sleep which could not have been unattended with danger, OPIUM 715 Oj)iate Treatment of Melancholy. — In tlie form of disease called acute Melancholy, tlie pathological conditions appear to be identical with those of acute Mania, in which there is want of power and tone in the system. The difference in the mental symptoms which gives rise to the difference of name is depend- ent upon the preponderating activity of the depressing emotions, accompanied and stimulated by delusions which cause extreme terror. This difference of mental symptoms, which arises from no fundamental difference in the nature of the disease, calls for no alteration in the medicinal treatment. The moral treatment, indeed, has to be carefully adapted to these emotional peculiari- ties, when moral treatment becomes possible; but, in the first outbreak of acute Melancholia, when the patient sees in the physician a stern judge, in the attendants his executioners, in the chaplain a diabolical personage ; or when he believes that he has himself destroyed the world, and all that it contains, and is now himself to be destroyed ; when he has not slept for many nights, and has not taken food for many days; moral treatment of any kind is impossible ; the patient must often be placed in bed, and attended with soothing and gentle words, the natural expressions of sympathy which his wretched con- dition would elicit, but of which he almost invariably appears as little conscious as a patient in the terrors of delirium tremens is conscious of explanations that his fears are unfounded. Such cases must be treated in exactly the same way as cases of Mania. Usually, but not always, they are unattended by general plethora ; usually the head is more cool than hot ; there is sometimes great insomnolence ; the opiate treatment, therefore, is as often essentially needful in acute Melancholia as in acute Mania ; it is attended by the same risks, and must be guided by the same rules. In the treatment of Melancholia with delusion, — the lype- mania of Esquirol, — opiates are not always admissable. They are needful in proportion to the existence of irritability and a depressed condition of the cynaesthesis, in which, if there is not actual insomnia, there is very little sleep. In these cases the best form of opiate we have found to be the combination of the tincture with sulphuric gether, from 20 to 30 minims of each being taken two or three times a day. A frequent curious effect of the opiate in these cases is, that it not only does not tend to constipate the bowels, but that it regulates and promotes their ey^-cuation. Jn a number of instances we have observecl 716 TEEATMENT OF INSANITY this, and we have tested its reality by omitting the opiate, and finding that the regularity of the alvine evacuations was dis- continued. The only explanation which we can offer is, that, by promoting a more healthy tone of the whole nervous' system, the opium, in such cases, promotes the peristaltic action of the intestines. In Melancholia without delirium. Emotional Insanity in its depressed form, opium, and expecially morphia, are invaluable. Combined whith hygienic regulations addressed to mind and body, morphia exercises over these forms of diseases the most powerful and satisfactory influence. A gentleman of high endowments and culture, single, of studious habits, having lived in a secluded part of the country, became gradually melancholic from ennui and want of mental excitement. When placed under our care he had refused food for some time, under the double delusion that he could not afford it, and that there was no room for it in his stomach ; he was emaciated and weak, and slept very little, not more than one hour in the twenty-four ,• the bowels were habitually constipated, the tongue foul, and the breath fcetid. A teacupful of a mixture of beef tea and good port ^\■ine was given him with a feeding-spoon every three hours during the day, a grain of muriate of morphia was given every night, and five grains of aqueous extract of aloes every morning. Improvement rapidly followed; in a month the patient was able to walk seven or eight miles a day, and the delusion had disappeared. A feelmg of shyness, and want of volition, remained for many months, but yielded to gradually extended intercourse with society. Sometimes a perverted emotion, which has become appa- rently fixed and incurable, is held at bay by the beneficial influence of morphia. The following is a remarkable instance : M. L — , set. 56, was the wife of a carpenter, who, in repairing a nobleman's mansion, fell to the ground and was killed. From this and other causes of mental distress she became afflicted with suicidal Melancholia. "When in the asylum she made several attempts at suicide, and the desire appeared to be always preying upon her mind. Morphia was administered — at first in one, and then in two-grain doses, at night, with the result of overcoming every manifestation of the propensity. Under the larger dose she became actually cheerful. Wlien it was diminished she again became depressed, but not suicidal. At the request of Lord F — she was discharged from the asylum, to be placed with her daughter, a schoolmistress. Lord F — pro^dding liberally for her maintenance. Here she has become a regular morphine- eater, the smallest dose she can subsist upon being eight grains a day. Many attempts have been made to diminish this expensive, and, to a poor person, extravagant medicine, but with the constant effect of producing melancholic symptoms. While taking eight grains a day of muriate of morphia she enjoys good health, the tongue being clean, the pulse good, and the spirits equable, though always tending to depression. This poor woman cannot, therefore, be placed in the category of mere opium drunkards, in whom the drug produces baneful effects, not only on the mind, but also on the physical functions. In one respect the above cage js exceptional, it being rarely OPIUM 111 needful^ in cases of depressed Emotional Insanity^ to administer more than one grain of morphia at bedtime. The beneficial effects of this mode of treatment have been amply illustrated by Dr Seymour, to whose papers in the ^ Medical Gazette ' and the ' Medico-Chirurgical Transactions ' we must refer our readers for additional examples. When morphia produces sickness, pills of solid opium may be substituted ; but, as a rule, in these forms of Insanity, the muriate or acetate of morphia is preferable to any other pre- paration. Hy2:>odermic injection of the muriate of morphia we have em- ployed with good results, and our favorable experience has been since confirmed by other observers. Thus used, it appears to act more powerfully on the system than when taken into the stomach, since we have found half a grain injected into the subcutaneous cellular tissue of the inner arm produce sleep, after double the quantity had failed when taken by the mouth. A paper upon this mode of administering morphia in Insanity by Dr. Mcintosh, of the Perth Asylum, will be found in the ' Journal of Mental Science ' for October, 1861. Dr Mcintosh uses acetic acid to dissolve the needful quantity of acetate of morphia, subsequently neutralizing the acid with liq. potassae. We have found it better to dissolve the muriate of morphia in boiling water, which will readily take up four grains to the fluid drachm, of which solution from fifteen to twenty minims may be injected. This is certainly a very convenient method of administering morphia in Insanity : the puncture is so trifling that it does not appear in the slightest degree to alarm the patients, and in agitated cases the little operation can be performed much more readily than a dose of medicine can be given by the mouth. It has also the great advantage of disturbing the stomach and parching or furring the tongue much less than when morphia is taken by the mouth. Dr Mcintosh met with one case of dangerous coma from its use in a patient who had cardiac disease. We have not ourselves as yet observed the production of any unpleasant symptoms by it.* In some cases, all preparations of opium are found to dis- agree ; sometimes they produce constant sickness, with anorexia ; sometimes they fail to produce the effect desired — They increase irritability, but do not induce sleep. Such cases are not numerous ; and we possess no means of determining before- * See ' West Riding Rep.,' i, 153, and ' Jour, of Ment. Sci.,' Jan., 1879. 718 TREATMENT OF INSANITY haud in what instances these difficulties will present them- selves. Hyoscyamtis. — When such cases do occur hyoscyamus may be tried; the doses, however, of this medicine usually prescribed are far too small ; as a narcotic, we consider two drachms of the tincture of hyoscyamus a minimum dose ; most frequently we prescribe four drachms, and occasionally six or eight drachms, combined with one drachm of compound spirits of ammonia or half a drachm of sulphuric fether. We have never seen the slightest reason to regard the administration of this medicine, in these large doses, as attended with any special danger. Doubtless it has a virus, since it possesses an unquestionable virtue ; but, with common care, it appears a safe narcotic. The most serious objection to it, according to our experience, is that it soon loses its influence, and that, although it often relieves sleeplessness for a time, patients seldom pass into a state of convalescence from its use. It is a temporising medicine, with virtues far inferior to the opiates, and no more we think can be said of its alkaloid. The value of hyoscyamus as compared with bromide of potassium and chloral has been carefully tested by a series of experiments conducted by Dr Campbell of the Cumberland Asylum, and recorded in a paper which he read to the Medico- Psychological Society in 1871. {' Journal of Mental Science,^ No. 80.) The results he obtained were that two and a half drachms of tincture of hyoscyamus were equivalent to thirty grains of chloral. He considers hyoscyamus a sure sedative in maniacal excitement, although chloral acts more quickly, and that bromide of potassium is only an hypnotic to a certain extent, not being sufficiently powerful to allay intense excitement, or to compel sleep where great insomnia exists. The method Dr Campbell adopted was to give to sleepless patients on consecutive nights the following doses of the three drugs : Tr. Hyoscyami 5ij ; Potas. Bromid. gr, Ix ; Chloral gr. XXX. We could wish that opium had been included in the comparison. The result, however, is favorable to hyoscyamus as an important sleep producer. We have tried many other narcotics, and reputed narcotics, In the treatment of Insanity, especially stramonium and bella- donna, and the new drug, Indian hemp. Others have obtained, or thought they obtained, great benefit from these drugs. The conviction, however, which fair experiment has left on our CONIUM 7i9 mind is, that in tlie treatment of Insanity they are, in com- parison with opium, or even with hyoscyamus, of little value. The role of stramonium is in asthma, that of belladonna in tic and iritis ; but who would ever prescribe them to produce sleep, except by removing some symptom which prevents sleep ? Goniiim either in the form of the succus or as an alkaloid has been used largely by Dr Crichton Browne, and a paper of great physiological and therapeutic interest and value on its action, by Dr Burman, will be found in the 2nd vol. of the West Riding Reports. One thing, however, seems certain, that different preparations of either the succus or the alkaloid are most un- certain. Dr Burman says that conia varies so much in different specimens that too much caution cannot be observed in the use of a new specimen, until its strength is ascertained. The same remark is applicable to the succus conii of which the Continental preparations have been found much stronger and more efficient than the home-made ones. One London firm of druggists, however, does make a good succus from which we have obtained excellent results both in cases of Mania and Melancholia where there was great muscular restlessness. It appears to allay both irritability of temper and excessive mobility of muscle, and we have seen several well selected cases recover under its unaided influence. It may, however, be assisted by combi- nation with nervine stimulants and antispasmodics especially with camphor and ammonia. A considerable proportion of the cases in which narcotics are most useful require the aid of stimulants, either medicinal or dietetic, of highly nutritious food, and a tonic regimen, to re- establish mental health. Even the cases which require leeches to the temples, and cold lotions to the head^ sometimes need the frequent use of wine and beef tea very soon after, if not concur^ rently with, these remedies addressed to local hyperasmia. It is with these, as with many cases of typhus in which the general strength of the system has to be maintained by wine and beef tea at the very time that local congestionSj tending to inflam- mations, require to be obviated by local measures. The state- ment of this necessity in general terms is all that is possible ; the practical application of it can only be learnt by careful clinical observation. The task of restoring the balance of cir- culation and functional power between an excited and hyper- semic organ, and a depressed state of the general system, is one 720 TREATMENT Ot INSANIT? of the most delicate and difficult which falls to the lot of the physician. If local remedies are used too freely, they tell injuriously upon the general powers ; if wine and nourishment are administered too early, or too largely, they augment the local mischief. In many cases of recent Mania, or Melancholia, the physician must apply his remedies to the head with his finger on the pulse, and his remedies to the system with the thermo- meter upon the forehead. For many years before 1862, and therefore before the use of the thermometer became general in medical practice, we were in the habit of testing the tempera- ture of the forehead by means of a delicate instrument in which the mercury was contained in a flat helix of thin glass, which could be immediately applied to the skin of that or of any other part. In fever there is usually more danger from the failure of the general powers than from states of local hyperaemia ; and the predominance of caution must therefore be given to the means needful to support those powers. But, in cerebro-mental diseases, the danger of local mischief is often more urgent ; and cerebral hypersemia must be combated, however weak the pulse. This rule, however, has not unfrequent exceptions ; and in an asylum for the poorer classes at least, many cases are annually under treatment in which wine and beef tea require to be administered freely, notwithstanding that the brain may be in a state of decided hyperasmia. An eminent authority on the treatment of Insanity has stated that typhus-like cases of mania usually die; our experience does not accord with this, and enables us to state that they frequently recover both in body and mind. The cases which we have lost have either been admitted into the asylum in a moribund con- dition, or (which has happened twice) have been sent thither under an error of judgment, having been actually cases of typhoid fever, complicated with delirium, — a fact which was proved by the loost-mortem examination showing extensive ulce- ration of Peyer's glands. In many cases stimulants and nourishments act as hypnotics. If the patient swallows without opposition or difficulty, it is best not to concentrate them too much. Good port wine made into negus, and freshly-made beef tea, should be administered alternately every hour, or even every half hour. When food can only be administered with difficulty, it is best to mix the wine with the beef tea, and to let the latter be strong. Sulphuric ether, and sometimes carbonate of ammonia, ai'e OHLOEAL HYDEATE 721 frequently useful as medicinal stimulants; the former, however, is most useful in combination with opium ; and the latter with tonics in more chronic cases. Chloral or hydrate of chloral is. a new narcotic to which certainly the objection cannot be made that it is inefficacious. We heard Dr B. Eichardson read his paper on this new dis- covery of Liebreich and Dumas to the British Association at the meeting at Exeter^ in 1869, and little thought at that time of the important part it was about to play in the therapeutics of mental disease. Since brought prominently by that paper before the medical profession in this country, this powerful medicine has passed through what we may consider the intro- ductory stages in the history of new remedies. First it was given somewhat indiscriminately and vaunted to the skies; then its power of doing harm was ascertained and it became unduly depreciated. At the present time, perhaps, it will be more correct to say that it is passing through the second era than that it has escaped from it into the third period, when men, considering that they have a new drug of undoubted power in their hands, set steadfastly to work to determine its good and evil effects, and to discriminate the cases in which its use is indicated. Four years is not a long time for the therapeutic history of a new medicine, and we may safely assert that the real value of chloral has not yet been actually determined. The first person who employed chloral in the treatment of the insane was Dr Saunders, our successor at the Devon Asylum, who commenced its administration immediately after Dr Richardson^s paper was read, and in his Report for that . year he gives the following account of the results obtained : " As a hypnotic it deservedly ranks with opium, and often procures refreshing sleep when the latter remedy has failed. A passing notice can only here be made of the class of cases in which this remedy has been used. Its results have been most satis- factory in Mania, especially of the recurrent form, with absence of sleep, and restless- ness. Patients who have passed sleepless nights, in spite of the orduiary treatment by morphia, henbane, &c., have, after a two-scruple or drachm dose of the chloral hydrate, passed a tranquil night, and had midisturbed rest, lasting from six to twelve hours. In recurrent suicidal Melancholia, with excitement, it has proved equally valuable, as was shown in the case of a man recently under treatment, who suddenly became noisy, and in an excited tone carried on an imaginary conversation \vith the devil, who was tempting him to dash his brains out, and upbraided him for his cowardice in not at once doing so. A drachm dose of chloral was prescribed, and in twenty minutes he fell into a sound sleep, from which he awoke much refreshed both in mind and body. On the second day after the attack he was pursuing his employ- ment in his usual state of health. He had several previous attacks, which yielded to 46 ^22 toEATMENT OF INSANITY treatment by other remedies, but the prompt action of the drug in this instance was very marked. It has also been used successfully in puerperal Mania. In the maniacal excitement of epileptics it has been foimd to exert a calmative influence. The remedy is of great service in allaying the restless excitement, with destructive- ness and dirty habits, so often associated with General Paralysis. In a case of neuralgia of the face, recently under treatment, the patient had tried various reme- dies without effect, but was at once relieved of intense pain by a dose of cliloral. One great advantage that this remedy appears to possess is that its administration is not followed by headache, loss of appetite, or sickness, neither does it diminish the secretions. It may on this account be found a valuable soothing agent in the excite- ment so frequently associated with phthisis and bronchial affections, where the use of opium is objectionable." In a letter which we have recently received from. Dr Saunders, he informs us that these first impressions of the value of the drug have been fully confirmed by the further experience of four years^ practice, in which he has employed chloral very largely ; indeed, he writes that he has administered quite 2 cwt., or 224 lbs., to the patients in the Devon Asylum, and, as he considers, with almost unvarying success. He has found it of great value in the ordinary forms of acute and recurrent Mania, in Mania a potu, and in Delirium tremens. He seldom, how- ever, prescribes. a larger dose than half a drachm, to be repeated, if necessary, to produce sleep. In smaller and more frequently repeated doses it produces calmative effects, and Dr Saunders writes that he has patients now under treatment who have taken fifteen grains three times a day for many months, and who become very dejected, haggard, and wretched if the medicine be stopped for a single day, and in these smaller doses it does not produce heaviness or stupidity, and the patients thus tran- quillised are often capable of being employed. This latter point is of great importance, for if the chloral hydrate does not cure it may obviously become a means whereby influences more directly remedial may be applied, whether moral or medicinal, and this is the view which Dr Sherlock takes of its value. He says, " It is not considered to be a remedy having much cura- tive power over the progress and course of mental disease, but it is of undoubtedly high value in procuring rest and sleep with- out much, if any, constitutional disturbance; so that time is afforded for the due exercise of other moral and medical treat- ment.'' {' Worcester Report ' for 1872.) An important and valuable paper on the use of chloral hydrate, by Dr J. B. Andrews, of the New York Asylum, was published in the ^American Journal of Insanity ' for July, 1871. Dr Andrews' observations, which are accompanied by sphygmo- CHLORAL HYDRATE 723 graphic tracings, show that the physiological effect of the drug is, first, to reduce the hearths pulsations from eighty-four beats to fifty-four, and to increase the force of the hearths action and the arterial tension; large doses do not proportionately diminish the number of the hearths pulsations, although this effect is more prolonged; the secondary effect is to diminish the hearths action and the arterial tension. Dr Andrews considers that its advantages over other narcotics are, that it almost always causes sleep of from four to eight hours^ duration ; that the sleep resembles natural sleep so far that the patient is easily awakened from it; that it is better tolerated by the stomach than other sedatives; that it does not constipate the bowels nor disturb the secretions; that it does not diminish the appetite ; that it does not lose its effect by repetition, and indeed, that the dose may often be diminished when the patient has become accustomed to its use, and seldom needs to be increased. When the need of its use has ceased it of ten for the first time becomes disagreeable to the patient. It would be easy, did our limits permit, to supplement from various sources this testimony of the value of chloral as a hypnotic and tranquillising agent. The unfavorable testimony, on the other hand, is almost equally strong, and unfortunately for the reputation of the drug it is mainly directed against a fatal defect to its character as a remedy which has not yet been met by any positive evidence, namely, that, granting its efficacy in producing sleep, it does not tend to cure or even to shorten any form of mental disease. The sleep of a maniacal patient or of a melancholiac produced by opium has a restorative and remedial effect, which no one denies, but the sleep produced by chloral, it is averred with a concurrence of testimony which can scarcely be doubted, leaves the patient very much where he was before and no nearer to the goal of recovery. On this point Dr Blandford well observes : " Cliloral will produce sleep vnth. certainty if the dose be large enough. Some have said that this sleep is useless ; that procured by this means it does not shorten the attack. Experience of the drug is as yet limited, but I cannot but think that six or seven hours' sleep, even of this kind, repeated night after night, must be ui the end beneficial, and must tend to shorten, not to prolong the disorder." (Op. cit., p. 241.) But does it shorten the disorder ? It would seem a great point gained that a patient suffering from acute Mania 724 TEEATMENT OF INSANITY should have a good night's sleep secured for him^ and should awaken in the morning with strength in some degree reinvigo- rated to withstand the renewed access of excitement, with a clean tongue, moreover, and an appetite for food, which will re- plenish the strength, and support him onward through the battle with disease. From our own observation we do believe chloral to be a far more temporising remedy than opium. As a cura- tive agent, indeed, we think it is not to be compared with the vegetable narcotic. Yet, as there are many cases in which opium is contraindicated, and in which chloral is safe and effi- cacious as a hypnotic, its value as a temporising remedy must be admitted to be very considerable. Supposing even that two cases of acute Mania have run pretty much the same course in duration and termination, yet in one the nights have been spent in quiet sleep induced by chloral, and the other has presented one continuity of restless and noisy insomnolence, it can scarcely be doubted that the drug has had a practically good effect. In suicidal cases the security gained by the prolonged nightly sleep of chloral is a temporising advantage of great value. Moreover, the cases of restless sleepless Mania and melancholia, in which opium and all its preparations absolutely fail to procure sleep, are often found to be amenable to chloral. We remember watching such a case with great anxiety just after chloral first came into use. All the preparations of opium were tried in vain, but chloral acted like a charm ; the dose, however, was steadily diminished, and in ten days natural and restorative sleep was gained. Little as yet has been ascertained as to the therapeutic combi- nations of chloral, the most important of which, as far as we have yet seen, is that of its use with morphia. From this most important combination we have known the best effects, Fifteen grains of chloral, with a quarter of a grain of muriate of mor- phia, will often produce sleep which morphia alone would not effect, and after sleep leave a far greater amount of nervous tranquillity, and a tendency towards recovery which chloral alone would not induce. The combination of chloral with stimulants is only less important than that with morphia. Chloral alone frequently, if not always, has a depressing effect in hypnotic doses. We have seen the awakening from its sleep attended with great wretched- ness on this account, but this effect can be counteracted by administering it in combination with spirits, whisky, wine, or CHLORAL HYDRATE 725 porter ; and Dr Cloustorij whose authority on therapeutic agents is very high, recommends that it should always be so adminis- tered, not in small and repeated doses, but in one hypnotic dose, and mixed with a stimulant. The class of cases to which chloral seems to be most suited are those in which sleeplessness appears to arise from exhaus- tion of the brain, cases of Dementia with intercurrent maniacal excitement, cases of Mania in old age, of insanity following prolonged lactation, and many others in which a similar patho- logical condition may be diagnosed, and it is exactly in these cases that its combination with a stimulant is indicated — old Scotch whisky is as good as any. Dr Clouston has informed us that in his hands it has been efficacious in averting the maniacal excitement which so frequently follows an epileptic attack. "The sleep that so commonly follows the iits seems to, be nature's mode of allowing the disturbed brain to rest and right itself. Now, we can imitate nature in this particular, and produce in an epileptic who is beginning to show signs of excitement a long and deep sleep by means of a dose of twenty- five grains of choral with the best effects." In the sleepless excitement which occurs in General Paralysis it is also beneficial. Some physicians maintain that its use in this disease hastens the downward progress of the case, but in these and in epileptic cases its use should of course be interrupted when the imme- diate purpose has been served. Certain inconveniences and dangers which attend the frequent use of chloral are under discussion by psychiatric physicians, but as yet there is little concurrence of opinion respecting them. In a certain number of cases the drug does undoubtedly produce nausea and vomiting, and in these cases its use must be interrupted. Dr Richardson has pointed out its toxicological effects (' Jr. Mental S.,' No. 81, p. 118), but these are scarcely important from our point of view, with the exception of the fall in the bodily temperature, which also accompanies its therapeutic action, and indicates the prudence of sustaining the external temperature during its administration. When large doses fail to produce an adequate effect, the drug will probably be found to be passing off rapidly by the kidneys. Liebreich thought its action due to the evolution of chloroform from the alkalinity of the blood, and if so a defect of alkalinity may tend to inter- rupt its action, and to send it off in the urine unchanged. This estimate of the uses of chloral in Insanity was cri^ 726 TEEATMENT OF INSANITY ticised^ when first published, in 1874, as being too depre- ciatory of the new drug. It will now probably be considered too favorable, but our own extended experience leads us to abide by it as a just and true estimate of the value of the drug. Chloral we consider to be rarely curative, but fre- quently useful in alleviating distressing sleeplessness or more distressing violence after the epileptic paroxysm. In unskilful or unscrupulous hands there is great danger of its abuse, in which case it may well merit all the hard epithets which have been applied to it. We have seen cases in which Insanity appeared to have been produced by its voluntary abuse, and cases have been reported to us of Insanity from other causes in which its administration was followed by the development of delu- sions, which ceased when it was stopped. If there be any drug which can produce Insanity it would seem to be chloral, and cer- tainly its abuse may prolong indefinitely the duration of Insanity arising from other causes. But all this being conceded, it re- mains a powerful remedy in skilful hands against distressing symptoms ; and if all remedies capable of abuse were to be ex- cluded, the Pharmacopoeia would be a tabula rasa. The dangers of chloral abuse have been well stated by Dr Savage in a paper published in the ' Journal of Mental Science' for last January. Now they are so well known any asylum physician who uses the drug largely, and without cautious discrimination, will probably run the risk of being thought to care more for the tranquillity of his wards than for the curative treatment of his patients. But notwithstanding that there are not many cases in which we should prescribe chloral in the first instance, and still fewer in which we would continue its use for any length of time, there are cases in which, other remedies having failed to pro- duce sleep, we should think it right to resort to this drug. A full dose after an epileptic fit to avert the maniacal excitement which in the case is known to follow the fit, is the more direct indication for the use of chloral. Cases of mania a potn also often do better under chloral than under any other remedy, but the cases in which chloral will be an efficient and safe means of producing sleep after other remedies have failed are not easy to indicate. Notwithstanding many weighty opinions to the con- trary, we think that chloral is not so injurious, where cerebral congestion exists, as the preparations of opium, and that it will be found best to suit well-nourished patients. The danger of its ^se being in depressing nerve and brain power, the safety and BEOMTDE OF POTASSIUM 727 benefit of its employment will be found in those cases where the nutrition of the nervous system is so active that its functions are not easily depressed by the drug. In many cases, not easily determined without trial, chloral will be found a most useful sleep producer, and though the mischief it may cause must never be forgotten, it is but folly to denounce a great power in the hands of the physician because it may be used with rashness or ignorance. Bromide of Potassium is not a new remedy, but an old one applied to new uses. It is of greater value than chloral as a therapeutic agent in the treatment of Insanity and its compli- cations, because it is very often and undoubtedly remedial and curative, a quality which is denied to the other drug. It was prescribed with success by Thielmann and also by Binet in 1858, in doses of from one to two grammes every two hours, against satyriasis and priapism with nocturnal pollutions (Morel, ' Traite des Mai. Mentales,^ p. 783), and its efficacy in repressing undue sexual excitement is still recognised as one of its un- doubted and important uses. It is of undoubted efficacy in the cure or the amelioration of epilepsy, but its value as a narcotic and a calmative has also been established by a series of experiments and observations conducted with such scientific method by Dr Clouston, now of Morningside, that we may safely trust his conclusions without too much fear of the opinions which were announced at the Sooiete Medico-Psychologique, or in elaborate papers which have appeared in the German journals, which seem simply to prove that in the absence of systematic observation there may be even among learned and scientific men quot homines tot sententics. For a good history of this diversity of opinion our readers may refer to the ' Corre- spondenz Blatt fiir Psychiatric ' for June, 1872, by Dr Katz, but a perusal of Dr Clouston's and Dr CampbelFs paper in the ' Journal of Mental Science,^ Nos. 67 and 80, and of Dr Glou- ston^s Fothergillian Prize Essay, published in the ' British and Foreign Medico- Chirurgical Review,^ Oct., 1870, and Jan., 1871, will repay them better. By Dr Clouston^s kindness we are able to place before our readers his latest conclusions, which he' has communicated to us in the following terms : " The bromides of potassium, sodiuvi, ammonium, and iron. — I should place these at the very head of the list of neurotic drugs whose use is indicated, and whose beneficial results are proved, in a large number of cases of Insanity. Some of th§ 728 TREATMENT OF INSANITY best men in the medical profession in Great Britain, the Conti- nent, and America, concur in this opinion. The bromide of potassium is on the whole by far the most efficacious and the least hurtful of all the bromides. An Italian physician, however, claims for the bromide of iron all its virtues, with many important ones of its own besides. " Class of cases in tvhich bromide of 'potassium is most indi- cated. — 1 . Epileptic Insanity, beginning with gr. xv, three times a day, increasing up to gr. xxx or xxxv. The best dose for the greatest number of cases is gr. xxv, three times a day (after meals). In a large number of cases it diminishes the number of fits, lessens the irritability, mental and motor, the body- weight increases, and the temperature gets lowered. Remarkable improvement may be expected in about one fourth of the cases, perceptible and real improvement in another fourth, improve- ment in some respects with compensating disadvantages in another fourth, and no effect or ill effects in the last fourth of all the cases to whom it is given, speaking roughly. As yet no general rules that are quite reliable have been laid down as to the kind of cases in which it is likely to be beneficial, but often the more frequently the fits occur the more good it does. '^It is much less beneficial in Epileptic Insanity in women than in men. Its use may be continued for years with the original benefit whe^i the proper dose for the individual has been discovered. This point is of the greatest importance, for it has ■ been pretty well proved that its good effects result from a partial saturation of the system with the salt. It passes off by the kidneys, and its elimination proceeds at most different rates in different people. If this power is very great in any individual and a quantity of the given salt is at once thrown out, it does little good. If, on the contrary, it accumulates too much, its poisonous effects show themselves. I have cases under my care who have been taking it regularly for the last six years, with the original benefit to them, and no harm what- ever/' (My experiments and observations with the drug in epilepsy are contained in the ' Journal of Mental Science,' October, 1868.) " Effect of the bromide of potassium in Epileptic Insanity. " Summary. — 1. Twenty-nine cases of epilepsy of old standing, all having the same diet, and subject to the same conditions, were subjected to systematic treatment by bromide of potassium after their normal condition as to fits, weight, temperature, general health, and mental state, had been ascertained and noted. I gave them BROMIDE OF POTASSIUM 729 gradually increasing doses of the medicine up to fifty grains, three times a day, and the treatment was continued for thirty-eight weeks, every particular in regard to the disease and in regard to their bodily and mental condition being noted every week during that time. " 2. The total number of fits taken by the patients fell gradually under the use of the medicine to one sixth of their average number M'ithout medicine. " 3. The fits taken during the day were lessened to about one twelfth, and those taken during the night to about one third of the normal number. "4. The reduction in the fits was not uniform in all the cases. Li one case it amounted to 24,000 per cent., in one half of them to more than 100 per cent., and in five cases there was no reduction at all. " 5. In one fourth of the cases the fits were much less severe, in some being less severe, while as frequent as before. " 6. In one fourth of the cases the patients' mental state was very greatly improved. Nervous and mental irritability and tendency to sudden violence were wonderfully diminished in those cases, and they were the worst of the patients in that respect. Attacks of epileptic mania were diminished. In some cases the mental state was improved, while the fits remained as frequent as ever. " 7. The majority of the patients gained considerably in weight, while the doses were under thirty-five grains three times a day. Their aggregate weight was greater at the end of the thirty-eight weeks than it had been to begin ^\dth, though it began to fall after thirty-five grain doses had been reached. " 8. The patients' temperature fell somewhat until they got up to fifty-grain doses thriee a day. " 9. The pulse gradually fell about seven beats up to forty-grain doses. After that it rose, but not up to its usual standard, without medicine. " 10. None of the patients suffered in their general health except five. All the others were benefited in some way, except one. " 11. The ill effects produced by the medicine in those five cases were torpor of mind and body, drowsiness, increase of temperature, loss of weight, loss of appetite, and in three of them slight double pneumonia. " 12. The cases most benefited by the drug were very various as to the causes, number, and character of the fits, age, and in every other respect. On the whole the cases who took most fits benefited most. " 13. The cases in whom the medicine had iU effects had all taken fits from child- hood, were all very demented in mind, and took more than one fit per week, but seemed to have nothing else in common. " 14. The diminution of the fits and aU the other good effects of the medicine reached their maximum in adults at thirty-grain doses three times a day, wlule ill effects were manifested when thirty -five -grain doses three times a day were reached. " 15. There seemed to be no seriously ill effects produced in twenty of the cases by fifty-grain doses of the medicine thrice a day, continued for ten weeks. " 16. When the medicine was entirely discontinued in all the cases the average number of fits increased in five of the cases benefited, to or beyond their original number in four weeks ; in thirteen cases they remained considerably less. The total average during that time was a little more than one half the number of fits taken before the medicine was given, and the greatest number of fits occurred in the second week after the medicine was discontinued." " Olimacteric Insanity in Women. — This variety of Insanity in my experience benefits most by the bromide next to Epileptic 730 TREATMENT OF INSANITY Insanity. In its early stages I am sure I have seen attacks cut short by it, given in 5J doses. It calms the irritability, soothes the fearfulness, and overcomes the sleeplessness of this variety of Insanity in a larger number of cases than any other drug in my experience. If judiciously given, cases may very often be kept at home instead of being sent to asylums. " Senile Insanity is often much benefited by it ; but its continuous tise must, if possible, be avoided in these cases, on account of its ill eifects showing themselves. " Hysterical Insanity is often cured by it in combination with valerian. /' The Insanity of Puherty may in some cases be most success- fully treated with -the bromide in large and continuous doses (from 45 grains up to 90 three times a day), until the patient gets under its influence. Attacks of this disease can certainly in some cases be cut short by it. The acutely maniacal form of this disease is most benefited. " The Insanity of Alcoholism is most markedly benefited by it, given through the day, with a dose of chloral at night to cause sleep. " In Uterine Insanity and Ovarian Insanity it is often most useful. " In the preliminary stages of Insanity before the symptoms have actually developed into decided psychical aberi-ations, when the symptoms are chiefly sleeplessness, irritability, restlessness, commencing want of self-control, I know of no drug equal to the bromide of potassium for calming the irritability present. It does not interfere with the appetite (sometimes it increases it), and seldom produces any bad symptoms. " In all cases where continuous and large doses of the bromide are given the tongue must be watched. It always shows an ill effect, first by producing whiteness of the tongue, and it must be at once stopped when this is seen. Even after it is so stopped its effects will continue for days, showing its cumulative action. It sometimes causes slight paralysis of the muscles of the fauces, as well as partial reflex insensibility there. A troublesome variety of acne is another unpleasant effect of this drug, the only effectual treatment of which is to stop the medicine. "Conibination of the bromide of 'potassium ivitli other neurotics. — The action of the bromide on the nervous system being in many respects quite peculiar — tending to calm irritability. THE BROMIDE WITH OTHER NEUROTICS 731 motor and sensory^ and to produce motor paralysis if pushed far — it has been combined with the vegetable narcotics^ such as Indian hemp^ hyoscyamus, and opium, with remarkably good effects. I made a series of careful experiments in regard to the effects of its combination with Indian hemp (Fothergillian Prize Essay, 1870, 'Brit, and For. Med.-Chirurg. Eev./ Oct., 1870, and Jan., 1871), and the following were some of my conclusions : "3. A mixture of one draclim of bromide of potassium with one drachm of the tincture of Cannabis indica is more powerful to allay such excitement than any of the other drugs or stimulants tried. It is more imif orm and certain in its effects, more lasting, kiterferes less with the appetite ; and to produce the same effect the dose does not require to be increased after long- continued use. " 5. By giving bromide of potassium and Cannabis indica together, not only is the effect of either given separately immensely increased, but the combination has an essentially different action from either of them given alone. " 6. Bromide of potassium alone can subdue the most violent maniacal excitement, but only when given in immense and dangerous quantities, and its effects are so cumulative while so given, that after they have once begun to appear they increase for days after the medicine has been stopped, almost paralysing the cerebrum and sympathetic. " 7. To produce sleep in mild excitement, one drachm of the bromide of potassium is about equal to half a drachm of laudanum. To allay maniacal excitement forty-five grains of the bromide and forty-five minims of the tincture of Cannabis are rather more than equivalent to a di'achm of laudanum. " 8. Seven cases of chronic Mania were treated for twelve weeks with opium, in doses rising gradually fi'om twenty-five minims of the tincture up to ninety minims three times a day, and the results noted. After getting no medicine for several months the same cases were treated with a mixture of bromide of potassium and Cannabis indica in gradually increasing doses, and the results noted and compared ■nath those of the opium treatment. " 9. Under the opium treatment the patients all lost in weight continuously ; their mornmg temperature was lowered, and also their evening temperature, but the latter (which was too high, and its being high was a bad sign) very slightly, and their pulse was decreased iu frequency. The opium allayed the excitement in the larger doses, but it soon lost its effect. " 10. Under the bromide of potassium and Cannabis indica treatment the patients only lost in weight very slightly for the first six weeks, and after that they gained, their weight being more at the end of eight months' treatment than it was to begin ■nnth. Their appetites were not interfered with. Their temperature fell, especially their evening temperature, and the pulse was slightly increased in frequency and weakened in force, while the excitement was subdued, and the medicine showed no signs of losing its effect, even after being thus used for eight months. The maximum of good effects and the minimum of the ill effects of a sedative diiig were thus obtained by using the bromide of potassium and the Cannabis indica in combination. " 11. The bromide of potassium alone maybe continued for months in doses of half a drachm three times a day, and the patients gain in weight and remain healthy in body, but the proper dose, whether given alone or along with Cannabis indica, varies greatly in different cases. 732 TREATMENT OF INSANITY " 12. Cannabis indica being a diuretic, and the bromide of potassium being carried ofE by the kidneys, it is probable that the former in that way helps to prevent the cumulative action of the latter when given alone. " 13. "When the two are given together, the first symptoms developed are those of the Cannabis indica, but these soon merge into a state of drowsy calmness of the nervous system which is in all respects the opposite of nervous iiTitability. " 14. Fifty -one cases of various forms of Insanity were treated by bromide of potassium alone or along \vith Indian hemp, and the results were that eighty per cent, of these were benefited more or less in some way, and twenty-five per cent, were most decidedly benefited. "15. The milder cases of Puerperal and Climacteric Insanity were sometimes remarkably benefited by drachm doses of the bromide of potassium given at night. " 16. In some of the eases of acute Mania the excitement was subdued in a few days by the bromide combined with Indian hemp, in doses of from half a drachm to a drachm of each given three times a day. " 18. In three cases of periodic Mania, attacks were cut short by a mixture of the two medicines, or by the bromide alone. In one of these complete recovery followed. " 19. Fewer cases of simple Melancholia were benefited by the bromide alone or along with Indian hemp than any other form of insanity. Some were made worse by them, but in one case of this disease, where there was great excitement and hallucination of hearing and suspected organic disease of the brain, the combination gave immediate and complete relief of all the symptoms for four months. " 20. One case of senile Mania was successfully treated at home by a mixture of the bromide of potassium and tincture of Cannabis indica, when she was to have been sent to an asylum. It seems jirobable that some such cases, and also patients with short attacks of mania, might be treated by the same medicines at home, when at present they have to be sent to lunatic asylums, on account of the want of such a safe and powerful sedative. " The combination of tlie bromide with hyoscyamus has much the same effect as its combination with Indian hemp, in certain cases acting better and in certain others not so well. It does not make the pulse so weak as the Indian hemp combination does in some cases. When combined with opium its effects are so completely lost in those of the latter that they are scarcely seen. " In regard to the relative efficacy or strength of certain neurotics^ my friend and late assistant, Dr John A. Campbell, prepared certain experiments which may be relied on, and his conclusions are as follows : " 1st. — That both chloral and tincture of hyoscyamus are sure sedatives to maniacal excitement. " 2nd. — That of these two medicines chloral is the most certain sleep-producer. " 3rd. — That chloral acts more quickly than tincture of hyoscyamus. "4th. — That though bromide of potassium in such doses is a sedative to maniacal excitement, and to a certain extent a hypnotic, yet it is not a sufiiciently powerful sedative to allay intense excitement, or a hypnotic to compel sleep where great insomnia exists. " 5th. — That a two-drachm dose of tincture of hyoscyamus is not quite equivalent THE BROMIDE WITH OTHER NEUROTICS 733 to thirty grains of chloral. Two and a half drachms would probably be as nearly an equivalent as could be given. From the different sedative and soporific power of bromide of potassium, I think one can hardly form an idea of an equivalent dose. It appears to me to be useful only where the excitement or insomnia is of a slight character." The paper by Dr Jules Falret, in the ^Annales Medico- psychologiques/ 5tli vol.^ 5 serie^ p. 161, on the action of bro- mide of potassium on the epileptics of the Bicetre, is very valuable. Dr Pabet observed that from its use irritation of the throat was frequent, though transitory, and more unpleasant than painful. Some patients had pain in the stomach, with sensation of heat, difficulty of digestion, sometimes mucous vomithig, sometimes not ; un malaise stomachal nerveux, usually not intense nor durable, and many patients did not experience this in- convenience. Almost all the patients presented in various degrees the cutaneous eruption. So long as the dose is under three or four grammes a day, this acne does not manifest itself; but generally after the dose has passed four grammes one sees pointed and acuminated " boutons," like those of acne, on the face, the shoulders, and the back. Sometimes after two or three years this eruption becomes so painful and rebellious to external remedies that one is obliged to diminish the dose of the bromide, or even to suspend it completely, to make the general eruption cease, which has become an evil more grievous and painful than the epilepsy itself. The di'ug being stopped, the eruption decreases rapidly and soon disappears, but then also the epileptic attacks, which have been greatly diminished, reappear with new force and greater frequency, and we have to renew the use of the bromide. The great proportion of the patients who take bromide for any length of time emaciate and become pale and yellow (Jaunissent), although continuing to seem well and to eat with good appetite, and the bromide almost always produces one effect, namely, to diminish or even completely to destroy the energy of the genital functions. After prolonged use of the bromide in considerable doses, sometimes the intelli- gence degrades in a remarkable manner. The memory is lost, and the patient arrives jtisqu' a I'hebetude. Li others somnolence or a comatose state indicates a kind of satiu-ation from the accumulation of the drug in the system. Falret has given the bromide to fifty epileptics, and to half of them for three years contmuously. In half of the whole number there was no appreciable result ; they remained exactly as they were before with regard to the epilepsy — with the same number of fits of the same intensity as before. In the other half an amelioration either in the malady or in some of its symptoms took place. Li the greatest number of these a simple diminution in the intensity or in the number of the fits took place, and in the remainder the malady was so far ameliorated, or even for a time suspended, as to make one ask whether it was not really cured. The most favorable cases for the bromide are those in which there is no pronounced mental trouble, nor vertigos, nor absences, and in which the epileptic attacks, although intense and well characterised, are separated by sufficiently long intervals— les epilepties simples, avec grandes attaques elonguees, sans vertiges ni absences. The night attacks disappear sooner than those of the day. The patients who suffer from maniacal excitement before the attack see this dls» ^B4 I'EEATMENT OF INSANITY appear before the attack does so. The grand attacks diminish in frequency and intensity before they disappear. The patients most improved retain three or four attacks in the year. The grand attacks disappear before the absences and the vertigos, these often continuing after the fits cease. These symptoms (absences and vertigos), seeming to be an incomplete or abortive epilepsy, resist the action of the bromide most. Digitalis. — This remedy has been strongly advocated by Dr Lockhart Robertson and by Dr Duckworth Williams, his suc- cessor at Hay wards Heath. "We have had experience of its value in cases of Insanity complicated with heart disease, in which it undoubtedly diminishes the irritability and equalises the action of that organ. We have also in a few cases given it with the intention of reducing cerebral excitement, and we think, from the recorded experience of the physicians above named, that it is an important medicine for the latter purpose. Dr Robertson's first paper will be found in the ^ British Medical Journal,' October 3rd, 1863, and a subsequent one in the ' Journal of Mental Science,' No. 48, p. 547, and that of Dr Williams in No. 56 of the same journal. The conclusions arrived at are — " 1. That digitalis is a valuable sedative in the treatment alike of recent and chronic mania, and when those forms of disease are complicated with general paresis and with epilepsy. " 2. That the average dose of the tincture is from 5ss to 53, and that this quantity may be certainly given for several days with impunity, and subsequently — adjusted to the state of the pulse — may be advantageously used for many months. " 3. That the indication by which the use of this drug is regu- lated is the state of the pulse, any marked intermittence re- quiring its immediate discontinuance. ''4. That the weakness of the circulation is no indication against its employment ; on the contrary, experience shows that the most enfeebled subjects bear its administration as well as the most robust. " 5. That when sickness and a tendency to syncope follow the use of digitalis, without at the same time a corresponding- abatement of the excitement, a combination of the drug with chloric aether, morphia, and hydrocyanic acid, in some such pro- portions as those above given, often produce the desired results, which the digitalis alone has failed to obtain." Ergot of rye. — Dr Crichton Browne has made a number of experiments with this drug, and arrives at the conclusion that it STIMULANTS ^35 is of decided use in (1st) recurrent Mania, (2nd) clironic Mania with lucid intervals, and especially (3rd) epileptic Mania. " In these forms of cerebral derangement/^ he observes, "I have found it almost uniformly efl&cacious in reducing excitement, in shortening attacks, in widening the intervals between them, occasionally in altogether preventing their recurrence, and in averting that perilous exhaustion by which excitement is so often succeeded." Dr Browne explains its beneficial action by its influence in contracting the vessels of the brain, and administers the liquid extract of ergot in doses of from 5ss to 5J three times a day, or 53 to gij of the pharmacopceial tincture. (See the 'Practitioner,' June 1871, and the 'West Eiding Medical Eeports,' vol. ii, p. 230.) Galahar Bean {Physostigma venenosum) . — To Dr Crichton Browne we owe the knowledge of this remedy, especially in the excitement arising in the course of General Paralysis. The dose of the extract is from a quarter of a grain to a grain. (On the action of Calabar bean see Dr T. R. Eraser's article, ' Trans. Eoy. Soc. Edin.,' vol. xxiv.) The influence exerted on the pulse by this drug has been referred to in the section on General Paralysis, p. 321 of this volume. Several cases of General Paralysis which derived benefit from its use are given in Dr. Savage's paper in ' Guy's Hospital Eeports,' 1878. Stimulants. — Of dietetic stimulants there is great choice. The various fermented juices of the grape are those we prefer, selecting port, sherry, champagne, claret, or hock, according to constitutional indications. Well made egg-flip is sometimes useful, the spiritus vini gallici of Pall Mall, or the more homely recipe of egg and sugar beaten up with old ale, a nutritious and comforting beverage, upon the daily use of which we have seen great progress made towards health and strength. The ordinary diet of insane patients when, in chronic stages, it becomes part of regimen, instead of part of direct treatment, should be ample and nutritious. Patients from the higher classes of society will often improve by living somewhat below their average custom, and those from the lower classes far more frequently by living above it ; but for one patient who is likely to be injured by a too full diet, causing plethora, twenty are likely to derive the utmost benefit from an abundant supply of stimulating nutrition. In acute maniacal delirium the life of the patient, and with life his probable recovery, will depend upon the frequent admi- 736 TKEATMENT OF INSANITY nistration of dietetic stimulants and food. The proper treatment very much resembles that of a delirious typhoid or typhus patient. The muscular prostration of the latter, however, is absent, and the patient, instead of lying in his bed, and even sinking towards the foot of it, will wander about in ceaseless activity almost up to the time when fatal sinking comes on. In such cases place the patient in a small room, the floor of which is covered with mattrasses and bedding, and have one or more nurses with him constantly to keep him in a recumbent position, that the heart may have less work to do in supplying the brain with blood, and then feed and stimulate as you would in idiopathic fever to keep him alive. We have most faith in port and strong beef tea given every two hours ; but brandy and eggs, rum and milk, and other strong soluble diet combined with stimulants are useful variations. If you can get the patient to swallow solid or half solid food, by all means do so, for there is no fear of solid food irritating ulcerated intestines, as in fever. In these cases, also, endeavour to procure sleep by warm baths with cold lotions to the scalp or the ice cap ; but beware of hypnotics. On the use of Purgatives and Aperients. — The purgative treat- ment of Insanity by hellebore is the oldest on record, and it still enjoys some traditional favour. In the treatment of many troublesome symptoms which arise in the course of chronic and incurable Insanity, a brisk purge is often more useful than any other remedy ; but, as a means of curative treatment, active purgation is, according to our experience, of little value. Theo- retically, a purge is supposed to be a powerful derivative from the brain, not only by actually diminishing the bulk of the circulating fluid, but by causing a state of congestion of the intestinal mucous membrane, which derives from other parts. A headache, or sense of headfulness from plethora, is easily and speedily removed by a purge ; and, in chronic Insanity, the transitory excitements which are so common from this cause, often yield to a full dose of neutral salts, or to one of compound jalap powder, or to one of compound gamboge pill. But in treating acute Insanity with a curative intention, active purga- tion does not appear to exercise that influence upon the state of the cerebral circulation which might have been expected from its undoubted service in the conditions we have mentioned. Constipation, indeed, frequently exists, and needs to be obviated ; otherwise it becomes a source of disturbance, by perpetuating COUNTEE-l'EErrAtlON AND DEETVATION ^S^* Hel'VOUs irritation, and preventing tlie needful depuration of the blood. The most certain and useful medicine for removing constipation is a full dose of castor oil, to be repeated from time to time as occasion may demand; a daily dose of aloetio aperient in quantity sufficient to ensure one or two evacuations, is also of the utmost service. For this purpose, five or six grains of compound rhubarb pill, or four grains of extract of aloes with two of extract of hyoscyamus, will be found useful forms. When the state of the secretions and the colour of the skin indicate a deficient flow of bile into the intestines, the liver may be stimulated by a few moderate doses of hydrarg. c. creta, or blue pill. As a rule, however, mercurials do harm in a state of acute insanity. Gounter-irritation and Derivation. — The use of external deri- vatives, with a curative intention, if employed in the right cases, and at the right time, affords important and satisfactory results. The use of tartrate of antimony to the shaven scalp, in Insanity, was strongly recommended by Dr Jenner, who brought himself to believe that almost all cases were curable by its means, a persuasion in which he was of course very much mistaken, but which was, doubtless, grounded upon a limited but successful experience. The same remedy has been more recently advocated by a German alienist of high reputation, Dr Jacobi, of Siegburg. Before we were acquainted with the views of the above physicians, we had adopted the use of a counter-irritant, producing a purulent discharge upon the scalp resembling that of the antimonial ointment. This remedy is the oleum tiglii, rubbed into the shaven scalp. We had seen the practice adopted by Dr William Stokes, of Dublin, in some cases where, during convalescence from typhus fever, the patients had passed into a state resembling dementia, and in other instances, into a state of semi- coma. The benefit derived in these instances from this powerful counter-irritant induced us to try it in cases where, upon the subsidence of the symptoms of acute insanity, the patients were gradually passing into a state of chronic insanity or dementia. The result was most satisfac- tory, and after the experience of many years, we can recom- mend it in such eases the counter-irritation of the scalp thus produced, after the subsidence of acute symptoms, and when the head is cool and there are no signs of plethora. We have also found it very useful in many cases of chronic melancholia with delusion. The proper application of the oil 47 738 TEEATMENT Q¥ INSANITY requires some little attention and skill. Upon a scalp of average texture, lialf a drachm of the oil, rubbed in with the palm of the hand for twenty minutes, will produce the desired effect : upon the scalps of coarse or fine-skinned persons an increase or diminution of oil and rubbing is needful. It is also needful to watch restless patients for a few hours subsequently, to prevent them from rubbing their hands over the scalp and face, and producing pustules upon the latter. It will be found that this mode of counter-ii-ritation is far more manageable than the antimonial ointment so much em- ployed by French alienists, and which Morel says sometimes causes necrosis of the ci'anium, and it is more efficient and less likely to be rubbed into an irritable sore than the common cantharides blister. Setons in the nape we have tried in many cases, and they sometimes appear to aid the operation of medicines. Tonics. — The use of tonic medicines in Insanity is extensive and fi'equent. Sulphate of quinine, dissolved in port wine, is the most useful form, and often does good in the later stages of mania, when the system is broken down, either by the exhaust- ing processes of the disease, or by the want of food, and the other sources of exhaustion to which neglected cases are often exposed. Bitter infusions, with carbonate of ammonia, or with the mineral acids, are sometimes useful, when wine and quinine would prove too stimulating. The various preparations of iron are indispensable in anaemic menorrhagia and other conditions where the blood is poor and the heart is weak. The prepara- tions we prefer are the old tincture of the sesquichloride, and the ferrum redactum, and as a milder preparation the citrate. The former of these preparations has been found useful in checking the tendency to wet habits. Electricity. — Dr Allbutt, of Leeds, brought the electric treat- ment of Insanity prominently under the notice of alienist physi- cians in the second volume of the ' West Riding Lunatic Asylum Reports,' 1872, his experiments having been performed at that institution. Two years previously a paper appeared in ' Griesin- ger's Archiv ' on this subject, by Arndt. Dr Allbutt concluded that cases of acute primary Dementia were most benefited by the electric treatment ; that distinct improvement, but to a less degi'ee, was observed in Mania, Melancholia attonita, and perhaps recent secondary Dementia ; that no change was noticeable in chronic Dementia and in some cases of Melancholia ; and, MthS -^39 lastly, that tlie result was unfavorable in liypocliondriacal Melancholia and perhaps brain- wasting. The most recent trials o£ the effect of the continuous electric current have been made at the Sussex Asylum, at the suggestion of Dr Williams, by Dr Newth, A Stohrer^s battery was employed, a low power being tried in the first instance, and indeed more good appears to have resulted from a moderate than a powerful application. " In some cases the hands or feet were placed in a basin of acidulated water with one of the electrodes dipping in it, the other being applied to the head or spine : this increased the receptivity, and by leaving both hands or feet in the water it was possible to send a current up or down both extremities at the same time ^^ C Journal of Mental Science,^ April, 1873). Fifteen cases are reported in the Journal, and in nine the bene- ficial action of the remedy appeared to be decided. The treat- ment was found to be most promising in those cases in which the pulse increased in force and slightly in frequency. In a very unpromising case of Melancholia originating in sunstroke^ in whom the positive pole was applied to the side of the head over the temporal mascle, and the negative to the inner side of the foot first and then to the hand, the result is stated to have been marvellous. " Bach application was followed by decided improvement, so that in a few days he was conscious and able to feed himself; in less than a month the treatment was dis- continued. The patient himself fully appreciated the benefit he had received, and warmly expressed his thanks.'^ Baths. — There are few secondary remedies more useful in the treatment of Insanity than bathing, and there are few that have been more abused, from the time when Yan Helmont pro- posed to drive delirious ideas from the minds of the insane, by bringing them to the verge of dissolution from the body, by submersion, to the present time, when, according to the accounts given by Dr D. H. Tuke and Dr Moreau, some eminent German alienists treat their patients with the utmost severity of the douche, and we can testify that the same system was in operation even at Charenton in 1868. Even Bsquirol, who so boldly denounced some of the worst abuses in the treatment of Insanity, made use of the affusion of cold water to an extent which we should at the present day think highly dangerous, but to which he attributed the cure of several of his patients. Thus, in the case of M. L., ^ Maladies Mentales,' p. 206, of his second volume, he speaks of the affusion of cold water having 740 TREATMENT OF INSANITY produced a shivering, which lasted the whole day, followed, however, by tranquillity, and on repetition, resulting in a cure. In the case of F. M., a young lady of delicate constitution, and nervous temperament, recorded at page 209, he says that the affusion of cold water was continued fifteen minutes, "after which a shivering came on, her jaws chattered violently, her limbs were unable to support the weight of her body, and the pulse was small, slow, and contracted ; she was put to bed, and slept almost immediately. The sleep lasted four hours, during which an abundant sweat came on ; on awaking reason had returned, and there has not since been a moment of delii"ium." He concludes, " The douche on the head has a sedative physical action on account of the cold, and a moral action as a means of repression. The generality of convalescents declare that they have experienced benefit from it, and some patients ask for it, but, il ne faut i^as en ahuser.^' There is no need to cite lower authorities than this great and humane physician to prove the extent to which douches were used, before their danger was recognised. Like all powerful remedies they are capable of abuse, and in the hands of either ignorant or unfeeling persons, there is no doubt that they have often been greatly abused. To prevent such occurrences, the regulations which have been issued by the Commissioners in Lunacy are, on the whole, judiciously conceived. To be of practical use, some limit must of course be fixed, beyond which the duration of a bath must be considered exceptional, and a shower-bath of three minutes is doubtless quite long enough for all purposes of medical treatment ; indeed, with delicate persons, and in cold weather, a bath of that duration would be dangerously long. As a means of repressing the state of febrile excitement, with heat of head, and emotional erethism, which is common among the chronic insane, a bath of three minutes^ duration is more than sufficient. As a means of reducing cerebral hyperaemia, in acute cases of Insanity, it would probably be very inadequate ; but in such cases the shower-bath appears to us an inconve- nient and altogether objectionable method of applying cold to the head, since it drives the blood from the surface of the body at large, and thus tends to the congestion of the internal organs, and especially of the heart, a congestion unfavorable to the retui'n of blood fi'om the brain. In such cases far more benefit is to be derived by the application of cold to the head BATHS 741 alone, and not to the general surface. The medical use of the shower-bath is now almost confined to its tonic action in irritably nervous and hysterical patients, and in some Melan- cholic patients. The benefit to be derived from its habitual use in hysteria is well known. Among the insane of both sexes are a considerable number of persons whose nervous irritability and susceptibility are identical with that which pre- vails in the hysteric diathesis ; in such persons the daily use of the shower-bath, living in the open air, a well-regulated diet, healthy mental occupation, and the authority of a strong will to check irregularities of conduct, form a system which alike braces the physical and the moral nature, and often results in the happiest change of disposition. In Melancholia, a daily shower-bath is sometimes useful, even in cases where the strength of the system seems scarcely able to bear the shock. It should be of short duration — namely, from fifteen to thirty seconds ; the patient should be dried while standing in a pan of hot water ; but if the bath is followed by shivering, or even a feeling of chilliness, it should be discontinued. The use of the warm bath, either alone or in combination with cold to the head, is a most important remedy in the thera- peutics of mental disease. The simple warm bath allays irrita- tion and promotes sleep. Judging from the small effects resulting from a warm bath in other diseases, its tranquillising effect in Insanity is often wonderful. It frequently produces sleep when all other means fail. We have at the present time a young man under treatment, with gay and mischievous Mania; he is habitually sleepless. Morphia and opiates are not well borne by him ; they cause sickness and increase irritability. The tincture of hyoscyamus, in half-ounce doses at night, is borne well, and allays excitement ; but if given without a warm bath, little or no sleep results ; if given with a warm bath, eight or nine hours of sound sleep are obtained. In recent half-acute cases of Mania, with irritability and partial sleeplessness, a course of three or four warm baths at night, with some simple aperient in the morning, often changes the whole aspect of affairs, and leaves nothing to be done to complete a cure, but the employment of physical and mental regimen for a few weeks or months. The same is true, though to a less extent, in some cases of Melancholia. In general, those cases of Melancholia are most 742 TREATMENT OE INSANITY benefited by warm bathing in which the various secretions seem out of order; in which the skin is harsh and dry, and often sallow, the tongue is loaded, the pulse soft and slow, and the disease has not been of long duration ; while those are most benefited by cold bathing or cold sponging, in which there is most nervous irritability, a tendency to hysterical weeping, or to hypochondriacal notions, in which the skin is healthy, and the pulse more rapid than is usual, with a fair degree of force. The warm bath we usually prescribe is one of thirty minutes in duration, and ninty-five degrees of temperature. The warm bath combined with cold affusion to the head is a remedy much used and highly commended by the eminent French alienist, M. Brierre de Boismont ; he advises that it should be used for ten, twelve, or even fifteen hours — the patient being retained in the bath during the whole of the time, if possible by persuasion, but if not, by force. The tempera- ture is kept between twenty-five and thirty degrees Centigrade ; cold effusions to the scalp being applied at intervals, and con- tinued for ten or fifteen minutes at a time. Cold affusions and irrigations are inseparable from the employment of these pro- longed warm baths. M. Brierre de Boismont generally gives them in the form of an arrosoir falling from the height of a man ; they maintain the coolness of the head, and diminish its congestion ; they serve also to prevent that sanguineous afflux which the warmth of the bath might occasion; they are admin- istered many times during the continuance of the bath. It is not uncommon to observe patients cease from crying and become calm as the shower of water falls upon their head. Some of them cry that that does them good. " Of all the remedies,^^ he says, " most strongly recommended against the acute forms of Insanity, we know of none which are able to sustain a comparison with pi-olonged baths and continued irrigations.^^ M. Brierre employs this bath in a baignoir de force, with a covering of wood adapted to enclose the neck of the patient. We have tried the plan ; but it appeared so far dangerous, from the efforts of the patient to release himself, that it was soon discontinued. We have found the most convenient plan is to place the patient in a reclining chair, which fits into a warm bath of large size, and affords a good support for the head, which can then be held in the proper place by the hands of an attendant.* * The Combined Bath was originally a design of Pinel. After describing the THE TUEKISH BATH 743 The effects produced by the combined bath are so great that the length of time it is prescribed by M. Brierre de Boismont is to us unaccountable. We have known patients faint after the use of the warm bath, with a cold shower on the scalp, of no great force, continued for less than an hour. Once only we have used it for two hours ; and an experience of some years has convinced us that it is a most important and valuable remedy, but one by no means free from danger, and the use of which, for any period approaching ten, twelve, or fifteen hours, would be fraught with peril. (See ' Jr. of Ment. Sci.,^ Oct., 1878.) We have known a single application, for one hour, of the warm bath with cold to the head, effect the best part of a cure in a maniacal patient ; and in many instances of recent mania, with hot head, full pulse, and violent delirium, we have known the symptoms take a favorable turn from the first application of this powerful remedy. But we have known one patient affected with syncope, and die on removal from the bath after being in it only twenty minutes : and in several cases we have observed so decided a tendency to syncope, that we have been convinced that it is not safe practice, in all cases, to repel the blood from an hypergemic brain in the sudden and decided manner which the combined bath places at the disposal of the physician. Urgent cases, of course, need energetic measures ; but in the majority of cases of mania with cerebral hypersemia, a warm bath at ninety-two or ninety-six degrees, with pledgets of wet linen constantly renewed to the shaven scalp, or kept cool by a small shower of cold water poured from time to time from the rose of a small common watering-pot, and used after leeches to the temples, is sufficiently energetic and successful, and far safer, we think, than the practice recommended by the eminent author above quoted. In the words of the great French authority, Pinel. " il ne faut hrusquer rien." The TurTiish or Sot-air Bath was first used and advocated by o-eneral use of baths, which for eight years had been employed at the Salpetriere as " the fundamental basis of treatment for maniacs and melancholiacs ; in proportion as their importance became more and more manifest, their employment was varied and seconded by other means; twelve bath-rooms being in activity during a great part of the day," he proceeds : " A happy combination of the douche with the bath adds much to its efficacy, and obviates even the smallest inconvenience which might arise. At each bath, immediately above the head of the patient, is a tube, which, by means of a tap, lets fall from a height of three feet a thread of cold water, proportioned to the end in view, and graduated to the symptoms, but generally very small, and limited to a simple sprinkling [arrosement]." 744 TREATMENT OP INSANITY Dr Lockhart llobertsou and by Dr Power, of Cork, in the treatment of Insanity. During the last year of our residence in the Devon Asylum we constructed a large and commodious Turkish bath for the use of the patients. Our experience of its value as a therapeutic agent was not very favorable. If used frequently it appeared to us to be depressing, and if used only occasionally the benefit derived appeared to be but transitory. It certainly was beneficial in its action upon several cases of Melancholia, with harsh dry skin, and of Dementia, in which the skin and tissues were pale and flabby, the hearths action weak, and the functions of secondary nutrition inactive. We are inclined to think that the Turkish bath is more calculated to improve the health of chronic and incurable patients than to act remedially on those whose malady is recent and curable, or at most that its role will be to supplement methods of treatment which are capable of being applied more constantly. There are few patients for whom we should like to prescribe this form of bath so frequently as twice a week, and if used once a week or less frequently it becomes a luxurious and wholesome habit rather than a remedy. The Wet Sheet or Wet Pack was also first used by Dr Lock- hart Robertson with much benefit in cases of sthenic mania. It acts as an energetic sudorific, and may undoubtedly be of service, though it is open to the possibility of abuse as an indirect means of mechanical restraint. This caution, which was given in our second edition, appears to have been justified by the subsequent order of the Commissioners in Lunacy that the use of the tvet pack should be recorded as an instance of the employ- ment of mechanical restraint. We observe that this order has been protested against as an undue interference with medical treatment, but surely it is in every way justified, for the wet pack is mechanical restraint of the most stringent character, and the Commissioners must know that it has been used not merely with the intention of exciting the action of the glands of the skin, but also with the indirect purpose of re- straining muscular activity. We have never used it upon a lunatic because, having tried it upon our own person, we found the sense of muscular restraint so painful that we thought this objection would counterbalance any advantages it might possess over the warm or the Turkish bath. Still, if its use tran- quillises and benefits violent maniacs, the physician is clearly justified in prescribing it, and the Commissioners are equally FOECED ALIMENTATION 745 justified in requiring that its use should be recorded as restraint in obedience to the statutory law on the subject. Eestraint is avowedly admissible and necessary for medical as for surgical purposes. We tie a patient into a chair before we use the stomach-pump, and ought to record the fact or we break the law ; and the Commissioners do not prejudge the inadmissibility of restraint, even for moral purposes, in all cases. Dr Blandford, writing of acute Melancholia, says " Suicide is their one end and aim ; and at the suggestion of the Commissioners of Lunacy themselves I have employed mechanical restraint at night for such reasons as I have stated ^^ (op. cit., p. 211). Forced Alimentation. — Much has been written and much diversity of practice has existed on this subject. Dr Harrington Tuke read an important paper on it to the Medico-Psychological Association in 1857, and Dr Duckworth Williams published another in the 51st number of the ' Journal of Mental Science.^ Dr Harrington Tuke advocates feeding with a nasal tube not more than sixteen inches long and about the size of a No. 6 catheter. We have in practice found it more difficult to pass the nasal than the oesophageal tube, and when it becomes a question of passing a tube at all we prefer the old method of passing a large one through the mouth. If any of our readers should doubt this, let them try the nasal tube and they may suc- ceed better than we have done. Fortunately these passages to the stomach leave a choice, and they differ in different people. With small nostrils and an aquiline nose the nasal passage may be difficult. A complete set of strong teeth firmly clenched may not be easy to open. When a few teeth have been lost by natural decay there can be little difficulty in getting food through its natural passage. To pass a tube through the mouth the patient should be seated in a strong chair, in which, if he resists, he should be held by means of sheets wrapped round the body of the patient and the back of the chair and held by attendants. The jaws are then opened if necessary by means of an expanding wedge worked by a screw to admit the wooden gag with its orifice for the tube being inserted between the teeth. The patient^s head being held back the tube is passed and the food injected either with a brass syringe or an india-rubber bag, or allowed to gravitate from a funnel held above the head. We have never known any harm done to an insane patient by the use of the stomach-pump, although instances are on record of fatal injury to the coats of the 746 TEEATMENT OF INSANITY stomach wHen the instrument has been used to remove poison. Of the latter kind we remember an instance during our student- ship at the University College Hospital. A man was treated under the supposition that he had swallowed half an ounce of arsenic and he died. It turned out, however, that the chemist had supplied him with sulphate of lime instead of arsenic, and that the operator in washing the gypsum out of the stomach had sucked the mucous membrane into the holes of the tube and with fatal consequences. But in forcible alimentation this danger is not incurred, since the operation consists in injection only. One great advantage of the large oesophageal tube is that all manner of aliments can be passed through it. No longer are we restricted to wine and brandy, egg and beef tea ; we may and ought to supply not only the nitrogenous and carbonaceous foods, ground meat and meal, but also pulped vegetables as antiscorbutics, and a man might be made fat in this way like a crammed turkey, or like McNaughton, whom Dr Wood has told about refusing food until his physician fed him up with the stomach-pump, and until agent and patient laughed at each other across the syringe at the robustness and obesity of the man who would not eat. But after all either the regular stomach-pump, or the nasal tube, or any modifications of these injecting instruments are only of very rare and occasional value in the treatment of the insane. The refusal of food is only too common, but the instances in which any desired quantity of food cannot be introduced into the stomach by swallowing are very rare. In the Devon Asylum for every'patient fed through a tube there were at least twenty who were fed without or against their will by spoons, pap-boats, and various devices for introducing food into the mouth, from whence it was swallowed. With skilful and patient attendants under the immediate direc- tion of the physician food may be introduced into the mouth of an insane patient by various instruments. Dr Sankey prefers a wooden spoon ; Dr D. Williams two iron ones, one to depress the tongue and the other to give the food. We were in the habit of using for mindless patients a pap-boat with an air- tube controlled by the thumb so that the food could only flow when the thumb was removed. For patients who resisted we used a large medicine spoon with an air-tight lid, and also a thumb- tube. It contained two ounces for two acts of deglutition, one fluid ounce being about as much as a patient can be expected FOEOBD ALIMENTATION 747 to swallow at oncd. By persuasion, a little forcOj and much patiencOj the lip of this spoon can almost always be introduced within the mouth, and if the teeth are deficient on one side there can be no difficulty ; and thus patients were habitually fed in our asylum in a manner more or less forced and with such success that injection through a tube had not to be resorted to for years in an institution containing nearly 700 patients and admitting new patients at the rate of 150 in the year. One great advantage of this unformidable mode of feeding is that it is likely to be adopted at a sufficiently early date. When the apparatus of the stomach-pump, either through nose or mouth, is to be used, and of course used only by the profes- sional attendant, its use is apt to be delayed until the patient has suffered so much from inanition that his downward course cannot be arrested. Our strongest advice is that however you decide to feed, feed early. In cases of acute delirium you must begin to feed almost from the first outbreak of the disease, for it is a question between feeding and living. The only cases in which we advise delay are those in which there may be reason to suspect that the refusal of food is dependent upon a foul state of the prim^ vise. In these cases, indicated by fetid breath, creamy tongue, and disordered evacuations, endeavour by aperients, by enemata, and by alteratives, to act on the hepatic and alvine secretions to bring about a more favorable condition for the digestion of food. After this has been done, its ingestion will frequently be wonderfully facilitated. The decision as to the time when forcible feeding has become needful will depend, not only upon the degree of inani- tion, but upon the balance which exists between the degenerative exhaustion and the alimentative repair of the tissues. In acute delirium the exhaustion is rapid; in lunatics with delusions causing refusal of food it is often as slow as it would be in healthy people. The latter may safely be allowed to feel some of the pangs of hunger before food is pumped into their stomachs. Oftentimes they will not refuse to drink although they will refuse to eat, and if weak broths, milk, and other nutritive drinks be supplied to them, they will sometimes out- live the delusion without loss of health or strength. In the majority of cases, however, the golden rule is to feed early and to feed abundantly. Nutritive enemata are of not much use, so little, indeed, that they may well be dispensed with if the introduction of food into 748 TREATMENT OF INSANITY the stomach be possible. As an auxiliary resource we can recommend that the whole body should be well rubbed all mane. Fi'om this time she slowly but steadily improves; entirely loses all delusions, and angry irritable state of temper, enjoys quiet society and amusements ; warmly expresses gratitude for attentions paid her, and fears she has given gi'eat trouble. Sleep and appetite veiy good ; has a pleasant, cheerful expression of countenance ; the eye, however, is flashing and restless, the pulse continues above 90, and the bowels require daily doses of castor oil. She returned to her home perfectly recovered eighteen months from the time she came under our care. Since that time, now ten years ago, she has been the active mistress of a large household ; and, although she has suffered grief in the loss of children, she has not shown the slightest indication of a relapse. The termination of this case, in which the symptoms were so severe and prolonged, in a manner so APPENDIX I 775 completely satisfactory, must we think be attributed to tbe energetic employment of medicinal remedies. Suicidal Mania with Chorea relieved by opiate treatment. — S. S., No. 1595. — A boy, aged twelve, all bis lifetime affected to some extent with cborea. No cause of Insanity known. Had an attack of Mania two years since. A few days before admission made an attempt to bang bimself , but was cut down ; tbe rope bas left a distinct mark round tbe neck. "Was admitted in a state of acute Mania ; witb propensity to violence and self- destruction. He attempted to dasb bis bead against tbe walls ; and being placed in tbe padded room, be lay on tbe floor crying, " Ob, do kill me ! Dasb my brains out ; Ob, do let me die !" He kicked and bit at tbe legs and bands of tbe attendants wbo bad to feed bim. He twisted a stocking round bis tbroat, witb intent to suffocate bimself; and on its being removed, be tbrust it down bis tbroat witb tbe same intent. Head very bot, pulse quick, tongue red ; ref ased food ; no sleep. Treatment. — Warm batb, witb cold arrosoir to bead for balf an bour. Morpb. Mur. gr. 4 stat., and repeated every tbree bours ; castor oil. After four days, four leecbes to temples. Morpb. Mur. gr. J twice a day. Under tbese remedies tbe suicidal Mania ceased, Tbe morpbia was continued twice a day for some weeks, witb tbe effects of procuring good sleep, witb quiet mental state during tbe day, improved appetite and physical strengtb. Tbis patient recovered, witb tbe exception of tbe cborea (upon wbicb various remedies, nitrate of silver, oxide of zinc, &c., bave bad no effect) and a most passionate temper. Mania relieved by preventing Onanism. — J. B., No. 1710. — A carver and gilder, aged twenty-tbree, unmarried. Not bereditary, but tbe father was an habitual drunkard ; one of bis brothers is a patient in tbe asylum, and another died epileptic. No cause assignable except father's drunkenness. Second attack. Insane eight days before admission. Mental state. — Violent in conduct ; using abusive, blasphemous, and obscene language ; bas many delusions, tbe leading ones being — that be is a gi-eat personage, that an immense sum of money bas been stolen from bim, and that be shall be Mayor of Plymouth, &c. ; power of fixing attention lost. Bodily condition. — Head bot, conjunctiva suffused, pale face, muscular movements violent, pulse fast, and full, bowels constipated. Treatment. — Evaporating lotion to shaved bead ; ten leecbes to temples ; castor oil. Six days after — Calomel gr. X. P. Jalap, gr. xv. After a month, Tr. Hyoscyami, Mist. Campb., ana §J, omni nocte. A warm batb witb cold arrosoir to bead, for balf an bour every other night. After two months (the bead baving become cool) tbe violence subsided, and symptoms of imbecility appeared— croton oil nibbed on tbe shaven scalp ; Extr. Aloes gr. xv, omni mane. After four months — Extr. Aloes, reduced to gr. v. Tbe patient appeared likely to pass into a state of Dementia. He was discovered to be greatly addicted to Onanism ; to prevent tbis, Acetum Lyttss was applied under tbe prepuce, witb success. He gave up tbe babit, and from tbis date gradually improved. He is now convalescent, but cannot sleep without tbe nightly dose of byoscyamus. 776 APPENDIX I The improvement of tlie bodily and mental condition, after the habit of self-abuse was prevented, was very marked. Mania; recovery under emmenagogue treatment. — A. C, No. 1641. — A passionate excitable girl, aged eighteen; her father, brother, father's brother, and mothei-'s brother all insane. Two months before admission the catamenia became irregular, and mania supervened. She was exceed- ingly violent, running round and round rooms and airing courts ; talking all day and night to persons whom she fancied she saw around her. This active state subsided in about two months from admission; she became excessively passionate and indolent, would lie on a bench or couch all day long, and, if disturbed, was violent and abusive. Under treatment she im- proved, was moved into a quiet ward, and employed herself a little. The catamenia remained suppressed until the application of galvanism, seven months after admission; this brought on the catamenia, and complete mental restoration followed within a few weeks. The treatment was — warm baths, aperients, muriate of morphia, gr. ^ h. s. After a month — Pil. Ferri 0. gr. XV. ter die, used for thi'ee months without benefit ; afterwards leeches to the groin without effect. After a month the electro-galvanic current was passed across the pelvis for half an hovir daily ; it succeeded in two months. It was used for a few days before the monthly period for two months longer. She was discharged recovered eight months after admission. Mania; recovery on the removal of profuse Leucorrlioea. — M. A., No. 1707. — The wife of a butler, aged thirty-seven. A year ago was deserted by her husband ; since then she has endured great distress, and is said to have been intemperate and dissolute. Insane six months. Mental state. — Abusive and violent, breaks glass, very irritable ; fancies every one is her enemy ; restless, with feeble power of attention. Bodily condition. — Pale and emaciated, with very anxious expression ; pulse natural, tongue pale, sleep bad, appetite uncertain, functions of uterus irregular, profuse leucorrhcea. Treatment. — After some days. Decoct. Cort. Querci 5ij, Ali;- minis 5iv. Ft. Injectio per vaginam nocte maneque. This succeeded in stopping the leucorrhcea. After three weeks — Quinine gr. ii. Acid. Sulph. dil. Tl^xv. ter die. Under this treatment she recovered, and was discharged in good health, three months after admission. Mania inclining to Dementia from the irritation of a foreign hody in the Vagina. — J. W., No. 560. — A laundress, aged sixty-one ; stated to have been insane four months. Has made many attempts to destroy herself. Is wild and restless, pulling ofi" her clothes, tearing her hair ; says she is the Queen of Heaven. Is very violent, swearing, and incoherent. Pulse small and quick, head and skin perspiring and not hot ; desire for food voracious ; sleep broken. Antim. P. Tart. gr. ^ was given three times a day for four days. The patient rapidly improved, became tranquil and industrious. A month after admission she had a febrile attack, with severe lumbar pain. This recurred five times, prodiicing great languor and debility, and causing her to keep her bed. Yarious means of treatment APPENDIX I 777 — warm baths, alteratives and aperients, blisters, &c., &c. — were adopted without effect. The patient became very weak, with flying pains all over the body ; and at length she could not for a long time leave her bed, and her life seemed in imminent danger. Five months from her admission, a disagreeable purulent smell was observed about her ; and on seeking for the cause, an offensive vaginal discharge was observed, which she had doubtless taken measures to conceal. We desired the assistant medical officer to examine the vagina with the speculum. This he did in opposi- tion to the strenuous efforts of the patient, and reported to us the existence of extensive malignant disease. The cervix and part of the body of the uterus were found occupied by a large, ragged, foul ulceration ; the parts around of a greenish- black colour; and the whole covered with a most offensive discharge. Having ordered the use of chlorinated injections, after some days we used the speculum ourselves ; the patient again resisting most vigorously, and requii-ing to be held in position by nurses. We found a large ragged ulceration of the cervix uteri and the upper end of the vagina, lying across which a great piece of wood appeared- This we easily removed with the finger, and found to consist of a child's toy wooden trumpet. When the first examination had taken place, this thing had been concealed by granulation and discharge. The patient, of course, strenuously denied having introduced it ; and it certainly is singular that, at her age, she should have resorted to such a method of self-abuse. After the removal of the irritating cause the vaginal discharges ceased, and the patient began to improve ; but her bodily health had been so broken down that it took several months to restore it. She was discharged recovered twelve months after admission. Mania with resemblance to Delirium, Tremens. — A farmer, single, ao-ed thirty-three. Not hereditary. A professed wrestler. For the last two months has been attending wrestling matches in various parts of the country, maintaining himself upon the prize-money which he obtained. Came to his brother's from a wrestling match in Cornwall; was very excited and apprehensive of danger ; was tied down to a bedstead, which he tore up and used as a ram to burst open the door and force out the window frame. Mental state. — Greatly agitated; says that men, spirits, and demons are pursuing him, and attempting to kill and poison him; that demons in the shape of little terrier dogs are eating Lis flesh ; he tries to tear them off, and with his powerful grasp he inflicts bruises upon himself in so doing ; he fancies his medicine is poison, and resists taking it. Bodily condition. — Head cool and free from pain ; skin warm and clammy ; tongue broad, furred ; bowels open ; evacuations dark and copious; urine normal • pulse 92, weak ; sleep broken ; no muscular tremors. Treatment. — Calomel gr. vj, stat. ; Haust. Aloes eras mane ; ^ther. 5j, Tr. Opii, tlj^xxv, ter die. After two days, Tr. Opii 5j e cyatho cerevisise ter die. After ten days the patient was free from delusion, and fast gaining a natural healthy state. Was discharged recovered one month from admission. Acute Melancholia from moral causes; no improvement under treatment. 7/8 APPENDIX I M. P., No. 1691. — A. farmer's daughter, aged forty-four. Not hereditary. History. — Had for several years been living in habits of adultery with a married man. The man's "wife was in ill-health, and when she died he promised to marry M. P. When the wife did die, the sister of M. P. endeavoured to obtain this man for her husband, causing much jealousy, and the man eventually refused to marry either. Soon afterwards the patient became depressed, and attempted to hang herself. When admitted was greatly depressed j says her body and soul are lost, that she shall be burned alive, that she sees hell flames, that she cannot be cured, and wishes she was dead ; constantly moans and shouts aloud, and sti-ikes other patients. Physical symptoms. — Head hot, pulse quick and feeble, sleep disturbed, catamenia scanty. Treatment. — Tr. Opii, 11\xxx, ^ther. Sulph. ir^xx, horis 3tiis, continued three months with some improvement. Warm baths for thirty minutes at ninety degrees, with arrosoir of cold water on shaven scalp ; this treatment procured much better sleep. After three months, the health of body having improved, but the head being hot and the eyes suffused, leeches were occasionally applied to the temples. Want of sleep, with great distress of mind, continuing, five grains of crude opium were given three times a day, with good effect for the time, but it begun to cause sickness, and the head again being hot it was discontinued. The baths were recommenced, and she was cupped to six ounces from the nape, four times, at intei'vals of a week. This caused relief, and the patient has slept better and been more tranquil. She has a new delusion that her brain is too large, and that it is bursting through the skull ; no loss of power of attention or memory. Still under treatment; prognosis unfavorable. Quiet Melaticholia cured by Opium with ^ther. — W. F., No. 1427. — Married ; a fishmonger, aged fifty. Not hereditary. Insane two months before admission. Cause, a dispute with the Town Commissioners of Improvement respecting some thatched houses which she refused to slate, and which, as they were considered dangerous, the Commissioners seized and slated. Mental state. — Refused to answer questions ; constantly said she must die — she had no money, and must starve. Frequently wept ; walked about, wi-inging her hands day and night; could not be kept in bed. Before admission had attempted suicide several times, and thrusting articles down her throat. Bodily condition. — Head hot, extremities cold ; tongue covered with a brown fur, bowels constipated j refused food; pulse quick and feeble. Treatment. — Calomel gr. v, Pulv. Jalapa; gr. xv, stat. Four days after admission — Tr. Opii nixl, -^ther. Sulph. T(\xxx, ter die. Under the influence of this medicine she improved rapidly, sleep and appetite improved, and the constipation ceased. In seven days her delusions dis- appeared, and she became cheerful and active. Was discharged cui'ed one month from admission. Melancholia with Hallucinations; recovery without medicinal treatment. — M. N., No. 1729. — An artisan's wife, aged forty-eight; of steady industrious habits. Not hei-editary. Second attack. Supposed cause, the APPENDIX I 779 excessive drinking of strong tea. Mental state. — All things appear of a red colour. She sees most frightful animals and spirits, of a blood-red colour, which she knows are not real, but which make her wretched, and prevent sleep. Before admission, she attempted suicide by hanging. Bodily condition. — Head hottish, extremities cold; generally relaxed, ill-fed and nervous. No medicinal treatment was adopted. Under the influence of a regular mode of living, with cheerful occupations, she recovered in three months fi'om admission. Melancholia without Delusion, from distress ; recovery from good food. — W. P., No. 1684. — An agricultural labourer. Not hereditary. A year before admission had erysipelas, which was followed by ill health and incapacity to work. He had to support himself, a wife, and three children upon four shillings and sixpence a week derived from a sick club. He said he had been half starved, and that this alone was the cause of his mental depression, of which he was fully conscious. Mental state. — Extreme apathy ; he would sit in one position all day long, took no notice of any- thing passing around him; had no delusion, but great depression of spii-its. He was very feeble and emaciated, and had cough from chronic pleurisy. For this, Hydrarg. Bichl. gr. 1-lOth ter die was ordered, with benefit ; and under the influence of good food he gradually recovered, and was discharged four months after admission. Melancholia from chagrin ; recovery without medicinal treatment. — Y. W., No. 1687. — A gentleman's bailiff, aged fifty-five; the father died insane. This patient had borne through life an excellent character, and had been ostentatiously attentive to his public religious duties. Twelve months ago he married a young woman, and six months afterwards was blessed with offspring. This premature event brought upon him the jeers of those who saw in it a contradiction of his professions of sanctity. He gi'adually became depressed, said he liad mined his master, whose property he had wasted ; that his sins were many, and could never be forgiven ; that he must die, and go to hell and the sooner the better. Had a heavy, dejected appearance, and dulness of attention. Head and skin hot and moist; sleep modei-ately good. This patient iad no medicinal treatment. He was employed at first in the garden, and subsequ.ently in shooting excursions, in which he was of much use, being an excellent sportsman. He slowly and gradually improved, and was discharged six months after admission, and has remained well since. Mania from remorse ; recovery without medicinal treatment. — N. N., No. 1660. — Had been for many years the trusted attendant upon an insane lady. Upon the death of this person her friends settled upon .N. N. a handsome annuity, for her faithful services. She gradually became melancholic, as she said from remorse at not having done her duty to her late charge, whom she had permitted to be ill used and placed in severe mechanical restraint by the medical man in whose house she resided as a single patient. She said that her soul was lost for ever, that there was no 780 APPENDIX I hope for her, that her sins were mountains high ; was most anxious to resign her annuity. She was dull and listless and emaciated ; but her bodily functions were normal. No medicinal treatment was adopted ; she was made to occupy herself. For six months she did not improve ; she then improved rapidly, and was discharged recovered nine months from admission. Mania from grief ; recovery under opiate treatment. — M. D., No. 1672. — A master chimney-sweep, of industrious and steady habits, gaining two or three pounds a week by his trade. His wife ran away with another man twelve months before his admission. After this he became intemperate, and changed in character. Had been maniacal six weeks before admission. Was very violent, restless, and noisy; said he saw Christ bodily, that he had a mission to convert the world ; used blasphemous and disgiasting language. Head hot, pulse quick and weak, body emaciated ; no sleep. Treatment. — Warm bath, with cold to head, thirty minutes ; Morph. Mur. gr. ^ ter die ; this drug was continued six months ; attempts were made to diminish the quantity, but with bad effects. After three months he gained strength and flesh, the head became more heated, the conduct quarrelsome and violent. A pill, containing half a minim of croton oil, ordered every second day. This produced hypercatharsis, followed by great improvement in the bodily state ; the appetite also improved. This continued under the occasional use of Ext. Aloes gr. x. The patient was discharged recovered six months after admission. Mania from grief; opiate treatment. — A. W., No. 1658. — A married woman, aged fifty-seven, of quiet, domestic habits, and naturally cheerful temper. Became insane immediately after the death of a son and the seduction of a daughter, both of which events occurred about the same time. Said she was under the terrible power of witches, who whispered into her ear that her family were to be bui-ned. She believed all her family to be dead, even though she saw them about her. Said their letters were forged. Obscene in her conduct ; said the female patients were men. She was highly suicidal, and attempted to injure herself by throwing herself with violence on the ground, causing bruises on the head and face. Head hot, extremities cold, pulse natural, tongue red and glazed, sleep lost. Treatment. — Castor oil ; blue pill and aloes ; Morph. Mur. gr. h, every night, continued for three months without improvement. At this time she became very restless, the conduct violent and obscene, the delusions fixed. Ordered — croton oil to be rubbed on the shaven scalp, and a grain of muriate of morphia to be taken three times a day. This was followed by the happiest results ; in the course of a few weeks she gave up her delu- sions, but remained depressed fur some time. Was discharged cured six months after admission. Dementia following brain fever ; recovery iinder tonics and moral treatment. — E. T., No. 1654. — A mantua-maker, aged twenty-two. One uncle com- mitted suicide, another was insane. Four months before admission had APPENDIX I 781 brain-fever; afterwards lier mind was observed to be quite weak; sbe was foolisli, irritable, and frequently wept and laughed without cause. She was exceedingly mischievous, destroying windows and clothing without apparent motive. She was quite inattentive to the calls of nature, and had consequently to be treated in the idiot ward. No power of attention or memory. Appearance quite idiotic ; the saliva running from her mouth. Body ansemic and emaciated, temperature low; appetite fair; sleep good; catamenia suppressed. Treatment. — Pil. Ferri co. gr. x, ter die; Oleum Jecoris Aselli 5SS, ter die. Great physical improvement ; mental condition remaining much the same. After a month, croton oil rubbed on the shaven scalp, followed by marked improvement in the mental state. This was followed up by diligent moral treatment. One of the nurses employed her, danced and sang with her, and made her a constant companion. Under this treatment she gradually recovered the full power of her mind, and was discharged recovei'ed nine months after admission. Acute Dementia from Suppressio Mensium. — H. M., No. 1467. — A single woman, aged nineteen. Twelve months before admission she caught a bad cold dui-ing the catamenial flow, which was arrested. In her present state for five weeks ; can scarcely be made to speak or move ; when urged she says — " I shan't ! d — n you, get out !" Resists medicine violently ; requires to be fed; is exceedingly filthy, eating her own faeces so as to produce frequent sickness ; pulse natural ; bowels much confined ; tongue white ; sleeps heavily. Treatment. — A drop of croton oil in half a drachm of olive oil placed in the mouth every other day. After the resistance of medicine was overcome — Decoc. Aloes c. 3J, o. m. ; six leeches to the groins, with warm hip baths, once a month. After two months, some improve- ment ; begins to feed herself. After five months, begins to work a little in the ward, and to discontinue her filthy propensities. After seven months, the catamenia reappeared, and a marked change immediately followed ; she became talkative, lively and high-spirited, according to the bent of her dis- position; she was, however, docile and industrious. From our fearing a relapse, she was not discharged cured until three months later. Acute Mania, hecoming chronic under treatment. — A. P., No. 1222. — A cook, well educated; four years ago had a blow on the head, from a fall. For two years had betrayed oddity of manner, and her memory had failed ; still she " kept company " with a footman living in service in the same house with her. Her lover destroyed himself; after which, the rector of the parish talked to her religiously, and prevailed upon her to receive the sacrament. Since that time she has believed herself in hell, and that Mr A., the vicar, is the only person that can get her out ; she escaped fi'om her fi'iends, got into his house, and broke his consei-vatory windows. Brought to the asylum, she was violent to the attendants and patients, destructive of clothing and glass ; libidinous in expression and conversation, and given to masturbation ; the head hot ; otherwise strong, and in good health ; functions of uterus regular. Treatment. — Daily shower-baths, blisters over the ovaries, occupation in the laundry; under this the delusions and 782 APPENDIX I symptoms of nympliomania subsided, and the patient became tranquil and nianajjeable ; the memory remains impaired, the temper irritable, and the conduct prone to violence, under any excitement. Probably some mischief has resulted from the physical cause, which remains after the maniacal excitement, which followed the moral cause, has disappeared. SOME CASES ILLUSTRATING CAUSATION AND PATHOLOGY. Monomama, with Religious Exaltation, of long standing ; death from Per- forating Ulcer of the Intestines.- — A. V., No. 579. — A farmer's daughter, unmarried, aged fifty-three. Has been considered insane many years, and previously confined in four asylums. On Sunday went into the market- place of N , and attempted to preach, thus creating a disturbance. A week before her admission she smashed the windows of a tradesman who had once been concerned in placing her in an asylum. After her admis- sion the mental state was that of religious enthusiasm, with a haughty, dictatorial temper ; she fi'equently preached — or, as she said, lectured, to the inmates, in a loud, pertinacious manner. She insisted vehemently on her perfect sanity, and vowed legal vengeance on all concerned in her detention ; obstinately refused employment, but, with the exception of the loud preaching, was quiet and obedient to rules. Her intellectual powers' displayed in language and argument, were considerable ; she had no delu- sion. Bodily condition. — Sleep sound, pulse good, head and skin cool ; all the functions regular ; catamenia naturally suppressed. She remained in this state two years and a half, including a period of about nine months, during which she resided with her brother, a farmer living in the neigh- bourhood. She subsequently looked ill, and was ordei-ed to bed ; but she refused to acknowledge that she had anything the matter with her. She had a slight swelling of the wrists, and a trifling cough, and was thought to have a rheumatic cold. After three days the expression suddenly became pinched and anxious ; the pulse small, 120 ; the tongue white, and the abdomen tender to touch. Turpentine fomentations to the abdomen, and grain doses of calomel every four hours, were ordered ; after twelve hours she became rather suddenly weaker, and died. Post-mortem exami- nation. — Circumference of cranium I ft. 8^ in. ; weight of brain 3 lbs. | oz. av. ; capacity of brain for water 50^ oz. ; breadth of grey matter '08 of an inch ; sp. gr. of cerebrum 1041, of cerebellum 1"044 ; the dura mater was adherent to the cranium ; the choroid plexus contained many cysts ; the substance of the brain was natural in colour and consistence ; there was rather more subarachnoid fluid than was natural ; the arteries at the base of the brain were slightly atheromatous. Death had been caused by a perforating ulcer of the small intestines, near their lower end ; the other organs of the body were healthy. The case aff'ords an example of the slight deviations from the normal state which take place in cases of Emotional Monomania, or Moral Insanity, which arise from exaggeration of the natural disposition. This patient was only some degrees removed from those offensive preaching APPENDIX I 783 women one occasionally meets witli in society. Probably marriage and the cares of a family would have saved lier from an asylum. What, in tbis country, can a single woman do, with an energetic brain weighing more than three pounds, but get into some trouble or other ? Acute Nymphomania, with suicidal Impulse. — J. M., aged thirty, a dressmaker. Three years before, had an attack of Mania from which she recovered, and had been well ever since. She was a Roman Catholic pervert from the Protestant religion, and the causes of her first attack had to do with her change of faith. For her second attack no cause could be assigned. "Without any previous symptoms of Insanity she went into the parish cburch. of A during Divine service, threw herself prostrate upon the pavement, and made a scene. On being removed, she was found to be " raving mad." A strait-waistcoat was placed under her, to prevent self-destruction ; but, after this, she bit ofi" the end of her tongue, and attempted to bite off her lower lip, but only succeeded in lacerating it fearfully. Sbe dashed herself against a wall, and bruised herself so, that, when admitted into the asylum on the following Wednesdey, her dis- figui'ed face scarcely appeared human. She was bruised from head to foot, and her right ankle was abraded from ligatui-es. She was sensible and did not appear to be suffering from any delusion ; but she made repeated efforts to beat her head against a wall, and said she must kill herself. She refused food. The head was very hot. The catamenia were flowing on her admission. She was ordered a warm bath for an houi', with cold arrosoir on the shaven scalp. She tried to drown herself in the bath, by keeping her head under water. The bath had an excellent effect, and was followed by sleep. It was followed up by a drachm of black drop, night and morn- ing, and by a dozen leecbes to the temples, which were repeated tbree times. She was never left, as she seized every opportunity to suffocate or strangle herself. In the course of five or six days the symptoms abated greatly, and in nine days from her admission her mental health appeared to be perfectly restored. Her features were still greatly disfigured, but site occupied herself with needlework, spoke reasonably and gratefully, and was in her perfect rigiit mind. Five weeks after lier admission, and at the period when the catamenia again appeared, sbe suffered a sudden relapse ; sbe made a violent and indecent attack upon a woman whom she believed to be a man. Her head became hot, h.er face flushed ; ber eyelids drooped — the eye being turned upwards ; tbe carotids pulsated strongly, although the general pulse was weak. The same remedies which afforded relief before were tried in vain, and for five days she attempted to injure herself in every possible way, by thrusting her hand down her throat, by beating her head against the wall or the floor, and by attempting to drown herself in the bath. Several nurses were with her night and day, and upon them she made constant attacks of an indecent nature. She moaned and exclaimed, " Oh my God ! Oh, blessed Jesus ! Oh save me ! " and evidently suffered great mental anguish. The large doses of opium which were administered had not the slightest soporific effect, and during the whole of the attack she never lost consciousness in sleep. Within half an hour 78i APPENDIX I of her death she was conscious of the visit of the Catholic priest, and appeared to understand the last sacrament which he administered. But so long as she was able to lift her hand she seemed to be occupied with a firm purpose of self-destruction. Gradually the breathing became slower, and the pulse more feeble ; and, at the end of the fifth day of the attack, she died from asthenia. Post-mortem.— Complexion highly sanguine ; body well nourished, and more hirsute than is usual among women. The scalp bloodless. The calvarium very thick, hard and heavy ; being sawn off in the usual manner its weight was lO^ oz. Specific gravity: — cerebrum, grey matter 1038, white matter 1"040, cerebellum 1'042. The dura mater was somewhat adherent. The arachnoid was healthy, but there was a slight quantity of subarachnoid fluid. The pia mater was generally congested, the conges- tion being greatest over the anterior lobes. The grey matter of the con- volutions was paler than usual, but the white matter of the brain had the pink appearance of hypersemia. In the right middle cerebral fossa the dura mater was covered with a thick straw-coloured adventitious membrane. Over the whole of the base of the skull, the shining surface of the dura mater was of a yellowish colour, and the membrane was easily separable from the bone. The hepatic system was congested. The catamenia were flowing. The hymen was perfect. The uterus and its ligaments, and the ovaries, were greatly congested. The right ovary contained a cyst about the size of a small nut, having inside a yellowish fluid. The left contained a cavity about the size of a large pea — false corpora lutea — lined with a yellowish cartilaginous structui'e containing a clot of blood. The other organs were healthy. It is probable that the pathological appearances found at the base of the brain were the result of the previous attack of Mania, which, however, had left no ajiparent effect in the condition of the patient beyond the very serious one of a tendency to relapse. This poor young woman bore an exemplary moral character, directly at variance with that which might physiologically have been expected from the indications afforded by her conformation and temperament. "Vehement mental perturbation appears to have resulted from the struggle between mental purity and the physio- logical impulses of sex. The acute cerebral hypersemia was sympathetic with the state of the ovaries, and affords an illustration that the conditions of the brain in sympathetic disturbance are actual and tangible morbid conditions, and not the mere vibrations of an in'itation. The pale colour of the grey matter of the convolutions, in contrast with the hypersemic condition of the white substance, was remarkable. Probably the state of the grey matter did not exist long before death, and was an effect partly of the gradually failing powers of life — partly of the leeches and refrigeratory measures applied to the head. The grey substance of the convolutions appears to pass more readily into and out of a state of hypersemia than the Avhite substance. Chronic Mania ; death from suicide. — W. R., No. 883. — A shoemaker, aged sixty-one. Seven years before was noticed to be insane, parading the APPENDIX I 785 streets with a knife tied on a pole, and frightening people. Had continued strange ever since, seldom speaking to any one, or answering when spoken to. Requiring parochial relief, he was compelled to take it in the Union House. He became morose and excitable ; refused to work in the house, and was twice committed to Bridewell on that account ; but for the last two years, when he had refused to work, he had been treated in a summary manner — put under confinement in the house, and kept on bread and water. A week before his admission into the asylum, he obtained a knife and cut his throat ; he lost much blood. The wound was sewn up by the Union surgeon, but he twice tore it open, and said he would " tear the eyes of the attendant out, if he did not bring a razor for him to complete the job." On admission, extremely emaciated ; the cellular tissue emphysematous all over the body, even down to the wrists : the scrotum quite inflated with air. Respiration hurried but the stethoscope cannot be used on account of the crackling of the emphysema over the chest ; pulse 120, very feeble; an open wound into the larynx between the cricoid and thyroid cartilages, through which the thumb may be passed ; the air respired passes partly through the wound. He lay quietly, without being able to speak ; did not inter- fere with the di'essings ; took wine eagerly. Wine, brandy and egg, beef- tea, &c., were administered frequently; but he gradually sank, and died, after being in the asylum two clear days. Post-mortem. — Cranium thick ; dura mater firmly adherent ; Pacchionian bodies large, greatly indenting cranium ; venous congestion of pia mater ; subarachnoid eifusion in small quantity. Substance of brain soft and watery : weight 21b. 11| oz. Sp. gr. cerebrum 1-039 ; cerebellum 1"045. Grey matter of convolutions of a muddy-brown colour, the external layer darker than the internal; the tubular neurine also of a muddy colour, with numerous blood points. Heart 5-|- oz. Intestines dark in colour, inflated, covered with old false membrane. Cysts in surface of kidneys. The wound in the throat was not interfered with. Mania with changing delusions ; death from Chronic Gastritis. — J. B. W., a letter-carrier, aged forty-eight. Ten days before admission he requested his brother to accompany him in his rounds, as people were waylaying him with the intention of destroying him. Had since been very restless, excited and ungovernable; had suffered much grief from the immoral conduct and death of a daughter. ~No relatives insane. On admission, great anxiety and restlessness; heard noises of people coming to injure him ; head over- warm ; tongue furred ; pulse quick and weak ; sleep fair ; muscular movements active and normal. Aperients. Improved greatly during the first month ; acknowledged his delusions to be such, and said he had been subject to morbid fancies of plots and an impending evil for two years. After a game at cricket, he began to talk of his old delusions in a nervous excited manner; hot head, flushed face and quick pulse. Antim. P. Tart, gr., i, ex aqua — ter die. This medecine not well borne, and omitted after four days. The delusions of fear gradually changed to others of pride ; said he had £365,000 a-year, was a knight of the realm, constantly bowing and kneeling to Her Majesty. Bal. Pluv. o. m. C.C ad 50 786 APPENDIX I 3vj nucha). After a week, Bain. cal. c. affus. frigid, capiti. pr. hone dim. o. n. Afterwards head cool, free from pain ; pulse quick, of fair tone ; quiet at night, but wakeful. Warm baths omitted after a week ; morning shower- baths oi'dered, and omitted after a fortnight. After two months, acquired a new leading delusion, that a certain mesmerising sui-geon had gained complete power over his body and soul, and that he was going to hell ; gloomy and anxious, losing flesh, appetite indifferent. Sp. Ammon. Co. Sp., ^theris C, ana 5ss. Inf. Gent, c. 3J, ter die. After two months wished to be killed ; but would not attempt his own life, if Dr B. would cut off his head when the Queen sent her permission ; often refused food saying it was poisoned, and needed to be fed ; still lost flesh and became emaciated ; tongue thin with a red tip ; alvlne evacuations formed, of a pale clay colour, scanty ; complexion clear ; pulse quick and feeble ; sleep fail- ; no abdominal pain. 01. Jecoris Aselli ; Hydr. c. Creta, gr. v. o. n. ; Bain. Cal. 96°, altemis noctibus. Eggs and new milk diet. Strong ale and wine. For two months longer he gradually declined in health, the delusions remaining the same. Took nourishment better, but enjoyed beer and wine most. Ten months from admission became gradually weaker, lost his voice, did not recognise his relatives, became drowsy, and died without a struggle. Post-mortem. — Body greatly emaciated ; calvarium thick ; dui'a mater not adherent ; arachnoid transparent, containing 3iij of serum in its cavity. Vessels of the pia mater on right side much congested and enlarged. Subarachnoid effusion over the whole of the right hemisphere and the anterior convolutions of the left. Lateral ventricles normal. The colour of the grey matter of the convolutions not uniform, the external third of its thickness being darker than the internal. Both the vesicular and tubular neurine softer than usual ; cerebellum and medulla normal ; pituitary body smaller than usual. Weight of brain 2 lb. 2 oz. Sp. gr. 1045. Lungs healthy. Heart 7 oz., fii-mly contracted ; aortic valves thickened ; aorta contracted and atheromatous. (Esophagus presenting a jelly-like appearance of the mucous coat. Stomach : the mucous mem- brane soft and pultaceous ; decided marks of inflammatory action in cul-de- sac and along large cui-vature ; a patch of inflammation the size of a crown- piece near the cardiac orifice. Transverse arch of colon lying in the pelvis ; small intestines contracted, and lying in the pelvis ; some enlargement of the mesenteric glands ; spleen contracted. Other organs healthy. Mania from dissipation and intemperance. — S. A. S., No. 1223. — A public prostitute for twenty-five years ; during that time has had seven illegitimate childi-en; three years since was said to have been married, but this is doubtful. When the person calling himself her husband visited her in the asylum, she cried — " Oh, the brute ! the devil ! why did you allow him to come here ? He is not my husband, and never was !" Had been maniacal three months ; was extremely filthy in her habits, daubing her person with excrement, &c. ; used profane language, and would have been violent if her strength had permitted. Before being brought to the asylum, she was permitted to lie in bed until her legs had becomed flexed in a fixed position, the knees on the stomach and the heels on the buttocks ; she was extremely APPENDIX I 787 emaciated, and altogether an abject specimen of human wreteliedness. Wine and quinine, and her favourite liquor gin, were given her, with good soups, &c. ; but she gradually sank and died six weeks after admission. Post-mortem Examination. — Cii'cumference of cranium, Ift, Sin. ; weight of brain 2 lb. 7 oz. ; capacity of cranial cavity, 41^ fl. oz. ; displacement of water by brain 37 fl. oz. ; cerebral atrophy 4^ fl. oz. ; calvarium very thick and heavy, a quantity of sanguineous-serous fluid escaped on removing it ; dura mater congested ; arachnoid opaque and thick ; the vessels of the pia mater congested, and containing numerous bubbles of air ; gi'ey matter of convolutions '06 of an inch in thickness, its different layers obvious ; sp. grav. of grey matter of cerebrum 1'035, of white matter 1*041, of cerebellum. 1'041 ; substance of brain of normal appearance ; an effusion of coagulated blood into the middle cerebral fossae, to greatest extent on left side. Lungs healthy, the left pleural cavity containing an abundant sanguineous effusion, forming into laminae attached to the pleura pulmonalis and costalis. Heart small, flabby, 4| oz. in weight. General Paralysis following Apoplexy. — J. H., No. 668. — A builder, aged forty, always industrious and well conducted ; the father was insane. About three months before his admission into the asylum, a woman to whom he was engaged jilted him, and married another man. For some days after this occurrence he was taciturn and dejected ; he then showed symptoms of excitement in the management of his business. He then decked himself with garlands of flowers, and perambulated the streets in this masquerade guise. He visited the gardens of his neighbours, and helped himself to flowers and fruit. In the asylum he alternated between periods of depression and excitement ; but eventually he recovered perfectly, and was discharged in nine months from his admission. He remained well for four years, when he had a convulsive attack, and became palsied. The medical treatment to which he was subjected having failed to restore him to health, his friends called in the aid of witchcraft, by invoking the aid of the Wise Man of Plymouth. We have been informed by a person who assisted in the ceremonies, that this man flrst employed a charm and incan- tations, which consisted in burning the viscera of a sheep in a fire made in the centre of the floor of one of the rooms in the patient's house, the fuel consisting of an ashen faggot ; while the viscera were burning, incantations and passages from Holy Scripture were read. This charm having failed, in a week's time another was tried, consisting of burning tapers carried round the house at midnight, with the accompaniment of incantations said and sung. This charm also having failed, the patient was brought to the Devon Asylum, when he was found to be far advanced in Genei'al Paralysis. The symptoms, however, differed, in some respects, from the typical form of this disease; he had less tremor, and more palsy, than is usual. When asked to show his tongue, he attempted to drag it forward with his finger and thumb, so completely had he lost the power of protruding it. He had ptosis of the right eyelid. He had convulsive attacks frequently in the evening ; at night he was restless and noisy, groaning and talking. He died four months after his re-admission. Post-mortem.— The calvarium was 788 APPENDIX I normal ; the dura mater was not adherent to it, but at the vertex the dura mater and other membranes were adherent to each other, and to the substance of the convolutions, by means of fibro-albuminous effusion. The arachnoid was opaque and thick, the pia mater was infiltrated with serum the substance of the brain was atrophied to the extent of 10 oz., that being the difference between the capacity of the cranium and the displacement of water by the brain ; the arteries at the base were healthy ; the dura mater of the falx and the middle fossse of the brain were coated with a thin sanguineous eflFusion ; there was also a layer of effused blood in the left middle fossa of the cranium. The layers of the vesicular neurine were very distinguishable ; the tubular neurine was not obviously altered. The lateral ventricles were enlarged, and their lining membrane was covered with a granulated deposit. Sp. gr. vesicular neurine 1"033, tubular ditto, 1037. This case is interesting from the rare example it presents of general pai'alysis following Mania. It may, however, be doubted whether the general paralysis was a pure example of the affection. The sanguineous effusions wei'e probably of some standing, yet they offered no indications of a tendency to undergo the changes common to effused blood ; perhaps they ought rather to be considered in the light of albuminous exudates, coloured with blood pigment : Virchow has taken this view of similar appearances. Homicidal Monomania; death from Pneumonia. — J. K., No. 771. — An agricultural labourer of steady and industrious habits ; had thought, talked and read much on religious subjects ; twelve months previous to admission he became restless, gloomy and reserved, irregular at his labours, and dis- tressed about his soul. He had shown no disposition to suicide or violence, but had the constant feeling that he must destroy some one. On admis- sion he was twenty-six years of age, a fine, powerful man, six feet high, with more than the average intelligence of his class. He was aware that his mind was affected, and said that his head was filled with vain and evil thoughts, and that the moi-e he strove to get near the Scriptures the further he was from them ; he felt a strong desire to commit murder, which he struggled against and thought a temptation of the devil. His head was hot, and he had some pain in it, but was otherwise in good health. In the course of a month he improved greatly, but relapsed after a visit from his friends ; he however again improved, lost all his bad thoughts, and for some weeks laboured at spade-husbandry. Whilst thus engaged, he one day came to the writer and begged to be taken from the garden and placed in a safe wai-d, as he had experienced the strongest desire to kill some of the patients with his spade. His request was complied with, and from this time he never again lost the homicidal feeling. To avoid the murderous assault to which he felt himself impelled he often requested to be locked in his bedroom, and still more frequently tied his own hands together with a piece of packthread, which he could have snapped with the greatest facility, but which he said enabled him to resist the temptation ; he was sad and morose, but never displayed the slightest violence. Six months after his APPENDIX I 789 admission lie was attacked witli pneumonia, first of one lung and then of the other. Partial softening took place, followed by haemorrhage, of which he died. Post-mortem.— The calvarium was thick and dense, the dura mater strongly adherent ; the visceral arachnoid was opaque and thickened over the vertex ; over the anterior lobes it was in a state of general reddening from congestion. The pia mater, over the vertex, was infiltrated with serous fluid ; over the anterior lobes it partook of the congestion of the arachnoid ; over the right anterior lobe there was a patch of about an inch in extent, in which there was a rough opaque deposit of fibro-albumen in the pia mater and arachnoid. The Pacchionian bodies were very large. "With the exception of partial atrophy of the convolutions of the vertex, the substance of the brain presented a normal appearance. The lower lobes of both lungs were in a state of grey softening from pneumonia. Partial recovery after acute Mania ; death froTti a convulsive attach. — B. B., No. 708. — A baker, aged twenty-seven, of very intemperate habits ; had had a previous attack ; before admission had been bled very largely. Admitted with restless, mischievous Mania, with small pulse, haggard countenance and feeble powers. Under a stimulating treatment he re- covered sufficiently to pursue his handicraft in the asylum. Four months after his admission he was attacked with the symptoms of pulmonary gangrene ; the stethoscope, however, indicated that the disease was confined to a part of the middle of the left lung, and he entirely recovered from it, and resumed his occupation of baking. After the interval of a year, while apparently in good health, he fell from his seat at the supper table in con- vulsions which continued for twelve hours, when he died. Post-mortem. — The calvarium was found thick and dense ; the membrane and substance of the brain were adherent round the crista galli, which was largely deve- loped ; the arachnoid was generally thickened and opaque ; the pia mater was greatly congested, adhei'ent, and infiltrated with a considerable amount of serous fluid. Over the petrous portion of both temporal bones, the dura mater, arachnoid, pia mater and substance of the brain were firmly adherent. The colour of the grey matter of the brain was dark, but uniform ; the medullary matter was minutely injected, and of a pinkish colour. The lateral ventricles each contained 3 oz. of serous fluid ; their lining membrane was smooth and normal. In the upper part of the lower lobe of the left lung was an isolated spot of indurated tissue, carnified, about 1 in. by 2 in., containing an irregularly shaped concretion, the size of a pea. The thymus gland occupied a great part of the anterior medias- tinum, and was Sin. in length by 2 in. in breadth. Acute Melancholia from fear. — W. M. D., aged thirty-two, of good general health and temperate habits. Having a tumour in the front part of the chest, he consulted a medical man respecting its nature, and having been told by the latter that the tumour was an aneurism of the aorta, and that sometime or other it would burst and cause instant death, he became greatly depressed, and in about a week he displayed a tendency to suicide. On being brought to the asylum he was very taciturn, and refused to 790 APPENDIX 11 answer questions. He occasionally ejaculated, " O God, save my soul ; I am a lost sinner." His whole attention seemed to be concentrated upon his own state of religious feeling, he rarely moved, or spoke, or appeared to take notice of occurrences. He refused food but was regularly fed with as much wine, beef-tea, arrowroot and other aliments as would have sup- ported a healthy man; notwithstanding this, he rapidly lost flesh and strength, and died in three weeks after his admission. The tumour in his chest proved, on examination, to be a fibro-cartilaginous one ; he was assured of its harmless nature immediately after his admission into the asylum, but the information afforded him no comfort. Post-mortem. — The skull was found to be very thin ; in one place, on the parietal bone, it was as thin as paper. The dura mater adhered strongly to the calvarium, and was dark coloured from venous congestion ; there was extreme congestion of the arachnoid and pia mater, giving a general strong red hue to the right anterior lobe. There were also several patches of ecchymosis in the pia mater, over the right middle lobe. Over the left hemisphere the mem- branes were much less injected. Over the sulci the arachnoid presented a semi-opaque appearance. The pia mater adhered firmly to the substance of the brain. The whole substance of the brain was much injected. The ventricles and coats of the arteries of the brain were normal. No patho- logical appearances of importance existed in any other part of the body, except the remains of partial pleurisy in the lower lobe of the left lung. The partial congestion of the cerebral membranes observed in this case is a rare appearance. No 2. NOTE ON CLASSIFICATION. The writer of the chapter on Classification in this volume desires to aid a new nosological scheme, published in the 'Lancet' for November 15th by his collaborateur, Dr Bucknill. In the chapter refeiTed to, and at p. 310, we have variously classified mental disorders according to the several points of view fi-om which they may be advantageously regarded — psycho- logical, physiological, and somato-setiological. A strictly s^ieakmg patho- logical one, that is to say, one founded upon post-mortem examination, is confessedly not yet possible . We may, however, endeavour to approach it by introducing a few wide embracing divisions, such as the " orders " enumerated below, which indicate the pathogenetic relations of morbid mental states, while under these are grouped the various setiological forms of Insanity as " genera," these genera being differentiated by various " species " according to the pathological conditions of the brain and nerves, the blood and the nutrition. The readers of this Manual will be able to supplement the classifications already given for his guidance by extracting from this scheme so much of it as approaches more nearly to the actual pathology of Insanity. This in no degree need prevent him using the psycho- and setiological classifications employed in this work. APPENDIX II 791 " Altliougli this subject has been treated witli great learning and judgment by Dr Daniel Hack Tuke in tbe ' Manual of Psychological Medecine,' yet, considering the diflferent kinds, forms, or species, of Insanity, I have failed to find all the assistance which I hoped for fi-om some one or other of the existing systems of classification, especially in regard to treatment. Several of these systems are highly instructive on certain points — either, for instance as to the psychical varieties, or the physical forms, or the pathological conditions, or, lastly, the natural groups, a small number of which un- doubtedly do exist. Still I have not been able to find any one system which embraces all or nearly all the considerations which must be regarded in treatment. In this dilemma I was fiirst tempted to state objections to the work which others have done, and especially to criticise the system of natural groups which has been most elaborated by my lamented friend the late Dr Skae. But on reconsideration I have thought that, instead of finding fault with work which, however imperfect, is of undoubted value from one point of view, it would be more useful, if not more generous, to endeavour to construct a system of my own, which might more fully answer the purpose for which we needed it — namely, as a nosological scaf- folding of form for the guidance of treatment. " My objections to the setiological system of classification I have stated at length in a review of Morel's classifications;* and they apply in the main to Skae's similar but more elaborate one, which has been designated by Dr Clouston, its able expositor, as a system founded upon the principle of ' Tlie exclusion of everything mental or psychical connected with Insanity .'f " Without quoting these objections. I have the authority of the greatest intellect which has adorned oui- speciality — that of Griesinger — that ' all classifications of Insanity must again, in the end, come back to the piincipal psychological forms of Mania, Melancholia, and Dementia, because they are actually founded in natui'e.'J Moreover, the same high authority, in his introductory lecture, republished in the ' Journal of Mental Science ' ; (No. 48, p. 531), says; — 'This consideration of mental diseases, from a psychological point of view, is botb necessary and serviceable to a firm and constant connection with the other aspect of the subject ' — namely, its relation to practical medecine, and over and over again he points out that, in order to an-ive at a practical diagnosis for the purpose of treatment, we must consider the psychical with the physical symptoms and the Eetiology. * The real problem for solution is to determine not merely the character of the mental aberration, but, as far as possible, the nature of the lesion of the brain and of the nerves.' In the classification of Insanity there are some forms, he says, which, in framing our divisions, we must refer to the psychical characters alone, for they are deficient in all other symptoms, but in other cases we are not bound to adopt this course alone. He appears fully to have recognised the principle, although he did not attempt to carry it into effect, that the classification of Insanity should be made to * ' Journal of Mental Science,' No. 38, p. 286. t Ibid., No. 87, p. 343. X ' Die Pathologie und Therapie,' &c., p. 121. 792 APPENDIX IT depend upon a combination of the psychical characters and of the patho- logical conditions. " Tlie novelty of the scheme of classification now proposed consists in the combination of psychical characters of phenomena with imthogenetic relations and pathological conditions ; the first forming the Classes, the second the Orders and Genera, and the third the Species. " Since the etiological classifications of Van der Kolk, Morel, and Skae have been published a most important step, in my opinion, has been taken in advance by the pathological classification of Dr Batty Tuke ;* but even this thoughtful wi'iter entirely omits all consideration of mental symptoms, and such an omission in a classification of mental diseases seems to me somewhat like the omission of flowers and foliage in a botanical system. " In the formation of classes 1 have followed Griesinger's simple division into states of psychical depression, psychical exaltation, and psychical debility; substitutingyf however, the conventional and now thoroughly established terms of Melancholia, Mania, or Dementia. " I have reversed the usual order of Mania and Melancholia, because I believe that melancholia is the dominant psychical condition, and that Guislain was only wrong in being too exclusive in his theory thsit phrenalge was the source of all phrenesie. Idiocy I have relegated to a sub-class. Pinel included it in Dementia, and it was only separated therefrom by Esquirol. Pathologically, the distinction between primary and secondary Dementia is at least as great as between brain defect occurring before and after infancy. Cretinism is not congenital but toxic Dementia. " The foundation of the orders and genera on pathogenetic relations is no doubt a natural one, and I think it can scarcely fail to be practically useful by impressing on the mind the kind of relation which the mental disease has with the bodily condition ; for the treatment of the patient, both as to mind and body, must necessarily depend to a very great extent upon, this relation. "I do not presume to think that I have enumerated all the genera which, eventually, it may be found desirable to distinguish ; and am well aware that the correctness of the position which I have assigned to some of the genera in the orders is quite open to discussion. " The inclusion of Puerperal Insanity in the Climacteric order is open to grave objection. This order, however, is intended to include vesanias which arise from or in conditions which are not pathological ; and, although a deviation from bodily health generally precedes puerperal Insanity, still the puerperal state can no more be considered necessarily a diseased state than that of puberty or old age. If there be a diflBculty the identification of species will resolve it, seeing that Puerperal Insanity may be septicsemic, anaemic, or neuralgic. " Of the Species there is little to say, except that they are the most important of all the divisions, and the most imperfect. Much has been left out which oiight to have been admitted if knowledge had been snflScient. I trast, however, no condition has been admitted which ought to have been excluded. * ' Journal of Mental Science,' No. 74, p. 195. APPENDIX IT 793 " SucL Gonditions as are vaguely expressed by the BrunoDian terms * sthenic ' and ' asthenic ' have been omitted. The conditions of all the secreting organs have been omitted, simply from lack of sufficient know- ledge ; and the excess or defect of irritability of the muscles, which form such marked featui-es in mental disease, have been omitted for the same very unsatisfactory reason. " On the other hand, the consideration of abnormal cerebral conditions which have not hitherto been sufficiently regarded as nosologies has been introduced. The ill-understood but undisputed state in which either the brain or the nerves, or both, wear away their physiological powers with- out inteiiTiption or repose, and its reverse, I have designated by the terms hypertriptic and atriptic, from rpifSo), to rub. " The hypertrophic and atrophic conditions of nutrition are well defined, if not yet well investigated, but the caco-trophic is a wide field of inquiry, in which ground has hardly yet been broken. Sclerosis of the brain and of the spinal column is caco-trophic. How many varieties of it are there ? If there is a paresic variety, is there not also a syphilitic one, and, maybe, some others ? In this division into species I claim the aid of the micro- scopic and chemical pathologist, for upon it is founded the all-important question of ultimate diagnosis. " The field for clinical research is the correlation of the classes, species, and genera ; but, even while this correlation is in process of being worked out, any concrete case of mental disease which is assigned to its proper place in the division of this system will have attributed to it a succession of charac- teristics which will scarcely fail to aid in the more systematic knowledge of its nature and the more definite aim of its treatment. " If it should be objected that this system is a complicated and artificial one, like the botanical system of Linnaeus, the validity of the objection will be fully admitted, with the proviso that a complicated system is need- ful for complicated and iU-understood phenomena. With larger knowledge a more simple and more natural system will take its place. Classes of Psychical Phenomena. 1. Melancholia. 2. Mania. 3. Dementia. Sub-Classes of Psychical Combinations and Transmutations. 1. Melancholia, simple. 2. „ combined with Excitement. 3: ,, with Stupor [Melancholia attonita]. 4. ,, Mania and Dementia alternating [Folie circulaire]. 5. Mania, simple. 6. ,, with depressing Emotions. 7. „ intercurrent with Melancholia. 8. „ „ Dementia. 9. „ altei'nating with Sanity [jBecitJTen^ ilfawia], 794 APPENDIX II 10. Dementia, simple and primary. 11. „ consecutive on Mania or Melancliolia. 12. „ congenital. Idiocy and Imbecility. Oedees of Pathogenetic Relations. 1. Simple Insanity. Idio-encephalic. 2. Allied Insanity. 3. Sequential Insanity. 4. Concun'ent Insanity. 5. Egressing Insanity. 6. Metastatic Insanity. 7. Climacteric Insanity. Geneea of Pathogenetic Belations. Simple Insanity : 1. Insanity from Hereditary Predisposition. 2. „ Moral Influences. 3. „ Intellectual Overwork. 4. „ Direct Cerebral Injuries. 5. Insanity of General Paralysis [encephalo-racliitis]. Allied Insanity, influenced by other diseases, but independent : 1. Insanity with Cardiac Disease. 2. „ Pulmonaiy Disease, Emphysema, Phthisis, &c. 3. „ Enteric Disease. 4. „ Renal and Vesical Disease, &c. &c. Sequential Insanity, caused by other disease which has subsided : 1. Insanity following Idiopathic and Exanthematous Fevers. 2. „ „ Inflammations, as Pneumonia. 3. „ „ Injuries to the Cerebro- Spinal Axis, Apoplexies, &c. Concurrent Insanity, caused by other diseases or diseased conditions which continue to exist : 1. Insanity from Cachexias — Syphilitic, Chlorotic, Cretinic, &c. 2. Insanity from Epilepsy. 8. Insanity from Chorea. 4. „ Alcoholism. 5. „ Masturbation. 6. „ Starvation. Egressing Insanity, growing out of the former disease, of which it is an exaggeration : 1. Insanity egressing from Hysteria. 2. „ „ Ecstasy. 3. „ „ Hypochondriasis. APPENDIX III 795 Metastatic Insanity, from the shiftiiig or ceasing of otlier disease or sup- pression of discharges : 1. 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Lectures delivered in the R.C.S. 8vo, with 44 Engravings. Students' Edition, 2s. 6d. Also. Practical Lithotomy and Litho- trity", or, An Inf|uiryinto the Best Modes of Removing Stone from the Bladder. Third Edition. Svo, with 87 Engravings, los. jiso. The Preventive Treatment of Calculous Disease, and the Use of Solvent Remedies. Third Edition. Crown Svo, 2s. 6d. A/so. Tumours of the Bladder: Their Nature, Symptoms, and Surgical Treatment. Svo, with numerous Illustra- tions, 5s A/so. Stricture of the Urethra, and Uri- naryFistulse : their Pathology and Treat- ment. Fourth Edition. With 74 Engrav- ings. Svo, 6s. A /so. The Suprapubic Operation of Opening the Bladder for the Stone and for Tumours. Svo, with 14 Engravings, 3s. 6d. Electric Illumination of the Bladder and Urethra, as a Means of Diagnosis of ( )bscure \'esico-Urelhral Diseases. By E. Hurry Fenwick, F.R.C.S., Surgeon to London Hospital and St. Peter's I lospital for Stone. Second Edition. Svo, with 54 Engravings, 6s. 6d. Modern Treatment of Stone in the Bladder by Litholopaxy. By P. J. Fkk.vek, 'M.A., M.D., M.Ch., Bengal Medical Service. Svo, with En- gravings 5s. The Surgery of the Rectum. By Henry Smii H, Emeritus Professor of .Surgery in King's College, Consulting Surgeon to the Hospital. Fifth Edition. Svo, 6s. Diseases of the Rectum and Anus. By Harrison Cripps, F.R.C.S., Assistant Surgeon to St. Bartholomew's Hospital, Hartridge's Refraction of the Eye, 12 Harvey's Manuscript Lectures, 3 Heath's Certain Diseases of the Jaws, 10 Injuries and Diseases of the Jaws, 10 Minor Surgery and Band.aging, 10 Operative Surgery, 10 Practical Anatomy, 3 .Surgical Diagnosis, 10 Higgens' Ophthalmic Out-patient Practice, 12 Hillis' Leprosy in British Guiana, 13 Hirschfeld's Atlas of Central Nervous System, 4 Holden's Dissections, 3 Human Osteology, 3 Landmarks, 3 Hood's (D. C. ) Diseases and their Commencement, 6 Hood (P.) on Gout, Rheumatism, iS;c. , g Hooper's Physician's Vade-Mecum, 7 Htitchinson's Clinical -Surgery, 11 Rare Diseases of the Skin, 13 Hyde's Diseases of the Skin, 13 Jacobson's Operations of Surgery, 11 fames (P.) on Sore Throat, 12 Jessett's Cancer of the Mouth, &c. , 13 Johnson's Asphyxia, 8 Medical Lectures and Essaj's, 8 Jones (C. H.) and Sieveking's Pathological Anatomy, 4 Jones' (H. McN.) Diseases of the Ear and Pharynx, 12 Atlas of Diseases of Membrana Tympani, 12 Journal of Mental Science, 2 Keyes' Genito-Urinary Organs and .Syphilis, 13 Lancereaux's Atlas of Pathological Anatomy, 4 Fyane and Griffiths' Rheumatic Diseases, g Lawson's Milroy Lectures on Epidemiology, 5 Lewis (Bevan) on the Human Brain, 4 Liebreich's Atlas of Ophthalmoscopy, 12 London Hospital Pharmacopoeia, 2 Liickes' Hospital Sisters and their Duties, 6 Macdonald's (J. D.) Examination of Water and Air, 4 Mackenzie on Diphtheria, 12 Maclagan on Fever, 8 McLeod's Operative Surgery, 10 MacMunn's Clinical Chemistry of Urine, 13 IMacnamara's Diseases of the Eye, 12 Bones and Joints, 11 Mapother's Papers on Dermatology, 13 Martin's Ambulance Lectures, 10 Maxwell's Terminologia Medica Polyglotta, 14 Mayne's Medical Vocabulary, 14 INfiddlesex Hospital Reports, 2 Moore's (N ) Pathologii al Anatomy of Diseases, 4 Moore's (Sir W. J.) Family Medicine for India, 7 Manual of the Diseases of India, 7 Constitutional Requirements of Tropical Climates, 7 Morris' (H.) Anatomy of the Joints, 3 l\Iorton"s Spina Bifida, 11 Mouat and Snell on Hospitals, 4 Nettleship's Diseases of the Ej'e, 12 Nixon's Hospital Practice, 8 Ogle on Puncturing the Abdomen, 10 Ogston's Medical Jurisprudence, 4 Ophthalmic (Royal London) Hospital Reports, 2 Ophthalmological .Society's Transactions, 2 Oppert's Hospitals, Infirmaries, Dispensaries, &c., 4 Owen's Materia Medica, 6 Parkes' Practical Hygiene, 5 Pavy on Diabetes, 10 Pharmaceutical Journal, 2 Pollock's Histology of the Eye and Eyelids, 12 • Leprosy as a Cause of Blindness, 12 Priestley's Intra-Uterine Death, ■; [Confiiiucii OK the next f>agc. ISDEX—COnilKUec/. Cuicell on Cancer, i ^ Rae's Kczema and its 'I'reatment, 13 Raye's Ambulance Handbook, lo Renloul's Dignity of Woman's Health, 8 Reynolds' (J. J.) Diseases of Women, 5 Notes on Midwifery, 5 Richardson's Mechanical Dentistry, 12 Rol)erts' (D. Lloyd) Practice of Midwifery, 5 Robinson's (Tom) Eczema, 14 Illustrations of Skin Diseases, 14 • Syphilis, 14 Robinson (W.) Endemic Goitre or 'I'hyreocele, 12 Ross's Aphasia, 9 Diseases of the Nervous System, 9 Routh's Infant Feeding, 6 Royal College of Surgeons Museum Catalogues, 2 Royle and Harley's Materia Medica, 7 St. Bartholomew's Hospital Catalogue, 2 St. George's Hospital Reports, 2 .St. Thomas's Hospital Reports, 2 Sansom's Valvular Disease of the Heart, 9 Shore's Elementary Practical Biology, 4 Sieveking's Life Assurance, 14 Silk's Manual of Nitrous Oxide, 12 .Simon's Public Health Reports, 5 Smith's (E.) Clinical Studies, 6 Diseases in Children, 6 Wasting Dise.asesof Infants and Children, 6 Smith's (J. Greig) Aljdominal Surgery, 6 Smith's (Henry) Surgery of the Rectum, 14 Snow's Palliative Treatment of Cancer, 13 Reappearance of Cancer, 13 Southam's Regional Surgery, 11 Squire's (P.) Companion to the Pharmacopceia, 7 Pharmacopoeias of London Hospitals, 7 .Squire's (W.) Essays on Preventive Medicine, 7 Steavenson's Electricity in Disease, 11 Uses of Electrolysis, 11 Stocken's Dental Materia Medica and Therapeutics, 13 Sutton's General Pathology, 4 Swain's Surgical Emergencies, 10 Swayne's Obstetric Aphorisms, 6 Taylor's (A. S.) Medical Jurisprudence, 4 Taylor's (F.) Practice of Medicine, 8 Thin's Cancerous .^flections of the .Skin, 13 Pathology and Treatment of Ringworm, i Thomas's Diseases of Women, 6 Thompson's (Sir H.) Calculous Disease, 14 Diseases of the Prostate, 14 Diseases of the Urinary Organs, 14 — Lithotomy and Lithotrity. 14 -Stricture of the Urethra, 14 Suprapubic Operation, 14 .Surgery of the Urinary Organs, 14 Tumours of the Bladder, 14 Thorowgood on Asthma, 9 ■ on Materia Medica and Therapeutics, 6 Tibbits' Map of Motor Points, 10 How to use a Galvanic Battery, 10 Electrical and Anatomical Demonstrations, 10 Tilt's Change of Life, 6 L^terine Therapeutics, 6 Tirard's Prescriber's Pharmacopoeia, 7 Tomes' (C. S.) Dental Anatomy, 12 Tomes' (J. and C. S.) Dental Surgery, 12 Tooth's Spinal Cord, 9 Treves and Lang's German-English Dictionary, 14 Tuke's Influence of the Mind upon the Body, 5 Sleep- Walking and Hypnotism, 5 Unofficial Formulary, 2 Vintras on the Mineral Waters, Sec, of France, 10 Walsham'«r^urgery : its Theory and Practice, 10 Waring's Indian Bazaar Medicines, 7 Practical Therapeutics, 7 Warner's Guide to Medical Case-Taking, 8 Waters' (A. T. H.) Contributions to Medicine, 7 West (C.) and Duncan's Diseases of Women, 5 West's (S.) How to Examine the Chest, 8 Wilks' Diseases of the Nervous System, 8 Wilson's (Sir E.) Anatomists' Vada-Mecum, 3 Wilson's (G.) Handbook of Hygiene, 5 Healthy Life and Dwellings, 5 Wolfe's Diseases and Injuries of the Eye, 12 Wolfenden and Martin's Pathological Anatomy, 12 Wynter and Wethered's Practical Patholog}-, 4 \'ear Book of Pharmacy, 2 Yeo's (G. F.) Manual of Physiology, 4 The following CATALOGUES issued by J. & A. CHURCHILL" will be forwarded post free on application : — A. ./. <^' A. ChtcrdiilVs General List of about 650 works on Anatomy^ Physiology, Hygie/ie, Midivifery, Materia Medica, Medicine, Surgery, Chemistry, Botany, %c., Sfc, with a complete Index to their Subjects, for easy reference. N.B. — This List includes B, C, & D. B. Selection from J. tS* A. ChurchilPs General List, comprising all recent Works published by them on the Art and Science of Medicine. C. J. Sf A. Chuj-chiU's Catalogue of Text Books specially arranged for Students. D. A selected and descriptive List of J. ^- A. ChurchilPs Works on Chemistry, Materia Medica, Pharmacy, Botany, Photography, Zoology, the Mio'oscope, and other brandies of Science. America. — J. ^ A. Churchill being in constant conivinnication zvith various publishing houses in Boston, Neiv York, and PhiladelpJiia, are able, notwitJistanding the absence of international copyright, to conduct negotiations favourable to English Authors. LONDON: II, NEW BURLINGTON STREET. Pardon de .Sons, Printers,'] \_H'im' Office Court, Fleet Street, K.C. v COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, provided by the rules of the Library or by special ar- rangement with the Librarian in charge. C20(t 140) Ml 00 ^ CD y Mine ±±.