- ■ ,t MENTAL DISEASES MENTAL DISEASES. ^ A SYNOPSIS OF TWELVE LECTURES DELIVERED AT THE HOSPITAL FOR THE INSANE, TORONTO, TO THE GRADUATING MEDICAL >, CLASSES, DANIEL CLARK, M.D., Medical Superintendent ; Extra Mural Professor of Medical Psychology in the University of Toronto, Canada; e.\-President of the Msdical Council and of the College of Physicians and Surgeons of the Province of Ontario; ex-President of the American Medico- Psychological Association ; Vice-President of the New York Medico- Legal Society, etc., etc., etc. TORONTO : ^. Centre for coarse arm and leg movements. ' 10. Centre for complicated movements of hand, arm and legs. 11. Supposed centre for levator palpebrse superioris. 12. Centre for disturbances in all sensory tracts. 13. Centre for alexia. 14. Visual centre. 15. Doubtful centre for smell and taste. Fig. 4 (after Ballet). (a) The region of print images. (6) The region of language images. (c) The region of speech images, (d) The region of writing images.— From Kirchhoff. MIND. 21 CHAPTER II. MIND. Without going into an unprofitable discussion as to what mind is, it may be well merely to epitomize certain general statements as to its manifestations. We are not to forget, however, that in medical prac- tice we have to do with a unity called man. This integer is composed of two parts, viz. : Mind and body, in mutual relations and inter-dependent upon one another. When death severs these the physician and his remedies cease to be of any avail. Medical men have to do with life and not with death, hence metaphysical subtleties are of little practical benefit to them in fighting disease existing in the human organism. Suffice it to say that the definitions of mind are usually classified as follows : — 1. The metaphysical, (a) The mind as a distinct entity from matter ; (6) As proof of this, an appeal is made to the evidence of consciousness. Descartes' presumed axiom is accepted : " I think, therefore, I am " {Gogito ergo sum). He assumed the existence of the Ego as a self-evident fact based upon conscious- . ness. An inference is also drawn from the varied manifestations observed in all mental phenomena, as 22 . Mental diseases. \ ■■ ;i " , , ,> ' known in ourselves and seen in others by conduct. These proofs are two-fold, subjective and objective. I study my own mind in its varied moods, and I ob- serve what is being done by others of my race under like conditions of existence. 2. The study of neurology presents additional proof. The study of our bodies and of all animated nature in relation to mental tone and scope through nerve instrumentality is doing much to enlighten us about this mysterious union of the Ego and the Non-ego. Embryology, physiology, in short, biology, in all its wide domain, and pathology are doing wonders in this direction. The close study of the growth of nerve substance and the corresponding ex- pansive of the powers of the mind in juxtaposition and correlation to it, promise much in the future to solve the mysterious union. Metaphysical writers hold that consciousness is the fundamental condition of all intelligence, and consists of Feeling, Volition and Thought. On the other hand, many physiologists of to-day do not thus circumscribe mind activity. They hold that mental powers do not solely reside in the brain. Mind means nerve action of all kinds, whether in the brain, the spinal cord, or the sympathetic system. It will be remembered the ancient Greeks and Romans held that soul (psuch^) resided in every living thing, vegetable as well as animal. The trend of opinion to-day is in that direc- tion. This is, however, a matter of detinition. We do not know what mind is. We only know it MIND. 23 t by its manife.stations. Its essence is an unknown quantity. This is true of everything created. We are in the dark in respect to the atoms and molecules, and their groupings in chemical elements. We know nothing of the working of the ultimate elements of plant life in their selective power. Our bodies are in every different structure, various work-shops, which never make mistakes in building up cells, each accord- ing to its kind. Yet there is a world of atoms of which they are composed beyond our ken. Here our explorations end, even in the primordial and simple protoplasm. It is not to be wondered, then, that mind, in essence, has eluded our most searching ex- plorations. As a mental exercise it is interesting to study the history of mental philosophy from the early age.«: downwards to the present day. Going no further back than Lucretius, in his wonderful book De Merum Naturd, which contains the well-known statement that " matter has in it the promise and potency of life," we find a materialism, or rather pan- theism, which crops up in Shelley's Queen Mab : — " Infinity within, infinity without, Belie creation : The inexterminable it contains, Is nature's only God." So intimately related are mind and body that in medicine they are treated as a unity. The one affects the other so sympathetically that they seem, in fact, as one organism. Sleep is physically demanded because of exhaustion ; yet it means total unconsciousness. 24 MENTAL DISEASES. The stronj»est will cannot resist the soporific effect of a dose of opium, and the wisest philosopher will act silly from the effect of a stimulant such as alcohol. The poison of a fever will cause delirium, and a blow on the head may produce nonsensical utterances, a felon on the finger or a toothache affects concentration of thought, and would handicap a stu- dent passing his examination or a clergyman writing a sermon. On the other hand, a profound emotion may, and often does, produce insanity, and even death. The best appetite is immediately spoiled on the recep- tion of bad news, and good tidings act as a powerful tonic on our bodies. It is evident to every physician that, in treating man, he does so as an individual. Metaphysical subtleties as to our being dual or tripar- tite do not enter into his practice. There has been a sort of development of opinion in respect to mind throughout the centuries. The trend has been evolu- tionary, yet every now and then a reaction would take place, because of the powerful writings of some able metaphysician, whose reasonings would hold sway for many years among the learned of a country. As Bain succinctly puts it in " Body and Mind." I. Mind is two substances. 1st. Both material ; (a) The prevailing conception among the lower races > (6) The opinion of most of the ancient philosophers ' (c) Held by the early Christian Fathers. 2nd. One immaterial and one material ; (a) Com- mencing with Plato and with Aristotle ; (6) The later Fathers from the age of Augustine ; (c) The School- man ; {d) Descartes ; (e) The prevalent opinion. MIND. 26 II. Ist. Mind and matter the same; that is, identi- cal ; (a) The cruder forms and expressions of materi- alism ; (b) The pantheistic idealism of Fichte. 2nd. Contrasts of mind and matter as effect and cause. A guarded or qualified materialism held by many physiologists and metaphysicians of to-day. In addition to these views we have those of the theologians who hold that man is a tripartite being composed of body, soul and spirit. One of these psychic entities is held by such to mean a h?gher power and non-corporeal substance, having capacity to fornmlate abstract ideas, to grasp to some degree the conceptions of time and space, and in the ethical world, to reach beyond the brute creation, in forming and estimating ..^.oral judgments. Many of our ablest bioloofists hold that the minds of man and animals are similar in essence, but that of man by evolutional growth has much greater capacity, which is crowned by that faculty of man through which he can create moral judgments and appreciate their value in his daily conduct or in that of others. Such modern thinkers as Lotze are believers in the existence of a soul-entity, and not a mere nerve secre- tion. They hold that no discoveries in mechanical and biological exploration can annihilate that entity in which is spiritual force, but which is a substance and not gross matter. He bases his opinions on the unity of self-consciousness. We cannot predicate of this Ego any quality or property which is indispen- sible to the existence of matter. 26 MENTAL DISEASES. Wundt, on the other hand, scouts the argument based on conscious states, and holds the mind to be complex, and that consciousness is only an act of con- centrated attention ; that it is meaningless to speak of a spiritual substratum, that it is only material pheno- mena, or attributes inherent in matter. When great minds thus differ we can patiently wait for further developments. Psycho-physics are at present commanding a good deal of attention, especially in child-growth. The gradual development of body and mind, and the order of sequence in ideation in the young, from the simple to the complex and from the concrete to the abstract, is an inviting field for research. The dawn of the intellectual life and the gradual growth of the aesthetic and ethical elements in the juvenile mind under normal conditions must be sub- jects of surpassing interest, not only to the philoso- pher, but also to the alienist. The literature of the day shows that many able minds are being directed to the study of the evolu- tion of mind along these lines, with great promise of fruitage. BRAIN PATHOLOrtY. CHAPTER III BHAIN PATHOLOGY. Much cannot be said here upon that extensive subject, Brain Pathology. A few pointers are all which can be recorded. As a rule, the size of the head of the insane is below that of the sane. This is not always the case. There is in the majority of the insane a want of symmetry in the skull ; the one side being flatter or smaller than the other. Sometimes the skull is high and dome- like ; sometimes compressed laterally, and in others keel-shaped. These abnormalities are seen among the chronics, as it needs time to produce them. The most common changes in the membranes are those of thickening and opacity. In the pia mater is found, in addition, condensation and a varicose condition of the vessels. In insanity, the exudations of the pia mater are not organizable. When adhe- sions are found between the pia mater and the grey matter, as seen in paresis, the connections are probable through the connective tissue of the grey matter. Congestion of the pia mater and serous effusion into its meshes are always found in atrophy of the brain. The vacancy made because of the shrinkage, is filled in this way. In vigor and health the apices of the convo- 23ted than males among the insane. Statistics show that about 35 per cent, may be traced to neurotic inheritance. About 76 per cent, of all cases occur before the age of thirty; about 30 per cent, occur before the age of ten, and nearly 50 per cent, between the ages of ten and twenty. KPFI-KPSV OF THE INSANE. 143 14th. When epilepsy cornes on in early life it makes the child either an idiot with undeveloped inental faculties, as the organic precedes the psychical, or leaves such at best imbecile or feeble-minded. Such usually are .short-lived ; but if they ^'row up to adult life they are either irritable, morose, mali- cious and sometimes dangerous, or they become hope- less, helpless and harmless, with not even the instincts or intellijjence of the lowest of the brute creation. It will be seen that, in a medico-legal aspect, it is important to keep these distinctions in mind, as on a clear understanding of these may depend our intel- ligent evidence as to responsibility and mental capa- city. Those who are afflicted by fits in early life may possess a considerable amount of cunning and animal shrewdness, but are deficient of moral attributes, and usually gravitate into the criminal classes of a low grade. It is very important to bear in mind certain diag- nostic distinctions when called upon to distinguish between epileptic and hysterical fits. In epilepsy the attack, as a rule, comes on suddenly; in hysteria it attacks often gradually and with con- sciousness. In epilepsy the patient utters a scream — if at all — at the outset, and only then ; in hysteria screaming is indulged in during the course of the attack. In epilepsy the convulsion is characterized by rigidity, followed by regular jerking movements or clonic spasm ; in hysteria there are irregular rigid movements, and a general throwing about of the hea(l 144 MENTAL DISEASKS. and limbs. In epilepsy there is usually a bitinjj; of the tongue from a spasmodic eomin<^ together of the teeth ; in hysteria there may be a gentle biting of the lips and hands, but more often an attempt is made to bite other people. In epilepsy mieturation is often present during an attack ; in hysteria it very rarely, if ever, occurs. In epilepsy the patient never talks ; in hysteria talking is frequent. In epilepsy the dura- tion of the attack is commonly but a few minutes; in hysteria the duration of the tit may extend to hours. In epilepsy of the severe type unconsciousness is paten I ; in hysteria intelligence is often very keen> cunningly seeking for sympathy. Of course, it is not to be forgotten that epilepsy and hysteria may co- exist in the same individual. The one may not be the result of the other, as they may be only co- temporaneous, or may, as it were, simply co-habit. Then, again, they may antedate one another, or be synchronous, and yet maintain independently their distinctive features. The epilepsy may be the promi- nent and pronounced disease, and it may, at eacli attack, be followed by hysteriform symptoms. On the other hand, the hysteria may be chieiiy mani- fested, followed by a mild form of larvated epilepsy. Often, however, the two commingle in their symptoms, so that it is difficult to distinguish which was the primary and which the secondary attack. Wh'm the two persistently commingle, then have we hystero- epilepsy, often accompanied by mental alienation. Few asylums are without such cases. SYPHILITIC INSANITY. 145 CHAPTER XIV. SYPHILITIC INSANITY. There is no doubt syphilis is a great excitant to produce insanity. It is often difficult to procure all the data necessary to a correct diagnosis, but they often crop out months and years after insanity has commenced. The clinical features of this class of the insane may be thus summarized. The mental effect is an impair- ment or enfeeblement, at first trending towards semi- dementia, and ending in total mental deprivation. There often are intermittent attacks of mania of longer or shorter duration. There is seen early in the disease a childishness or emotional weakness. At one time fears and tears over groundless apprehensions, and at another time merriment over silly matters. The moral nature is overthrown, and at last even the animal instincts are lost. Many cases are in one aspect very much like those afflicted with paresis, and that is by manifesting delusions of grandeur and having muscular inco-ordi- nation. There is great irritability of temper, and capricious notions are common, 10 ( 146 MENTAL DISEASES. There are often aphasic conditions, and sometimes combined with amnesia. Syphilis may not be the cause of an invasion of insanity even if present. It may only be co-tempor- aneous v/ith the mental trouble. Two factors may be present to cause insanity, when the effect of one of these might not. Syphilis alone might not do it did there not exist an inherited ten- dency in addition. Syphilis is often an excitant to produce disease in the nerve elements of the posterior columns of the spinal cord. We then may have insanity following,' locomotor ataxy. The disease spreads upwards. The bodily features are so mutifarious that it is difficult to even classify them. The most prominent are : (a) Convulsive and para- lytic motor symptoms ; (h) these usually take the form of hemiplegia, palsy of the cranial nerves, im- pairment of inhibitory power of a wide-spread nature ; in short, a general paresis, not paralysis, (c) Epilepti- form seizures, clonic and tonic spasms, tremors which imitate chronic paralysis agitans. (d) Local numb- ness at one time, and at another intense nocturnal hemicranial pain, (e) The special senses are fre- quently more or less affected, and optic neuritis is very common as well as unilateral deafness. These defects lead to hallucinations and delusions from which often spring unfounded suspicions of friends and a fear of conspiracies. Many of these symptoms are not pathognomonic of SYPIHLITIC [NSANITY. 147 syphilis, as they are common to other forms of insan- ity ; but if persistent nocturnal hemicrania, giddiness, epileptoid fits, unilateral spasms and pains and local paresis exist, our diagnosis as to the syphilitic origin of these will usually be correct. . At the same time, we are not to neglect to look for characteristic glandular disease, ulcers of the skin, nodes, and disease of mucous membranes. Those persons in an anaRmic condition are more apt to become excited and maniacal. This condition is usually of short duration, and may be followed by melancholia, as an intermediate step to dementia. The premonitory symptoms may be an attack of apoplexy or epilepsy. A general depreciation of brain tissues takes place. It may be atheromatous, gummata, or sub-acuto meningitis. As a rule, how- ever, the atheroma, which consists of hypertrophy of the brain arteries and which goes on to fatty degeneration and calcification, is not present. The anterior cerebral arteries are chiefly afl'ected. The syphilitic condition is seldom found in nerve tissue proper, except in the form of softening from deficient blood supply, consequent on the reduced calibre of the blood vessels. Fibrous tissue, lymphatics, arteries, membranes and the skull bones are primarily the seat of diseased changes. The retrogressive change in the arteries is quite distinctive. The adventitious membranes formed in- side the arteries are firm and tenacious. So much so, 148 . MENTAL DISEASES. that in the larger vessels they can be removed entire, as if from a mould. This means reduced size, and in many of the smaller arteries occlusion. It is no matter of surprise, then, that serious physical and mental deterioration follows these extensive lesions. Brain syphilis is interesting, like paresis, because ^ve find characteristic physical changes, about which there can be little or no doubt as to their cause. Insanity does present itself in the first stage of syphilis before much pathological change can take place in the great nerve centres. It is possible that in many such cases the shame, contrition and moral sensitiveness in many natures may, at this early stage, be more causative than any such toxic agent. In the period of secondary syphilis a large number of this insane class are attacked. It then produces a sub-acute condition, and the mental state is usually that of insane melancholia or a mild form of mental exaltation or excitement. In the tertiary period we have the pronounced signs and symptoms which have been already enum- erated. The neural changes account for the varied delu- sions, the characteristic hebetude and the general depreciation so pathognomonic of this disease. These cases are very difficult to treat, often because of uncertainty in diagnosis in the early stages, but they are often greatly benefited by the use of anti-syphilitic remedies. ONANIC INSANITY. 149 CHAPTEE XV. ONANIC INSANITY. This vice of masturbation may begin with both sexes at an early age. At the age of puberty great physi- cal and mental changes take place. The development of sexual vigour and desire is accompanied by corres- ponding mental activity, not only along the old lines of thought, but also in the wakening up and growth of appetites and ambitions, which, when rounded up in normal outgrowth, constitute an im- portant element in the make-up of the womanly woman and the manly man. There is here a connect- ing link between the animal instincts and the higher faculties of the mind. The weak-minded, the idiotic and human monsters often show genital defects or want of development, although such may exhibit erotism. The brain sometimes excites to sexual attempts which are incapable of realisation, just as we see in some stages of senile decay, when the old man cannot realize that he is fatally attempting to blow into flame the dying embers of passion, forgetting that in old age " desire shall fail." We know what a great change morally and men- tally takes place, as a rule, in the eunuchs. Castra- 150 , MENTAL DISEASES. tion seriously affects animals, so veterinary surgeons testify. Such being the case, it is not difficult to understand that onanism and inordinate venery will produce mischief on the genital organs and through them on the whole system because of the undue excitement, great demand on secretion, and as a resultant, lower vitality even to impoteney and mental failure. It has been said by some writers that no harm can come from the use of organs along natural lines ; but, on the contrary, benefit as against continence and restraint. It is forgotten that any excesses are not natural, but are abuses of normal function. Self- abuse is unnatural, hence unhealthy and disastrous to mental integrity, ^ot only so, but it can and is indulged in by over-stimulation at least five times oftener than natural capacity could permit. This means a great strain on the nerve centres, which are roused to undue activity by artificial means. The moral effect is shown in these victims, and it is disas- trous to their offspring. The mother may be strong and healthy, but if the father is not capable of pro- ducing a vigorous spermatozoa the result means a degenerate progeny. The soil may be ^ood, but bad seed means a poor crop. The horrible orgies in Pagan and Christian countries arising out of sexual perversion show how its influence controls all mental attributes. This is strikingly true of the insane with erotic tendencies. There is no specific type of insanity among masturbators, but they usually gravitate into ONANIC INSANITY. 151 dementia in the end. After the insanity in the form of stupor takes place desire becomes in many largely extinct, and although there may exist spontaneous emissions, the habit is seldom indulged in, but at this stage the mischief has been done. It is not to be for- gotten, however, that this vice may be only a result of insanity, arising from a cause foreign to the habit. Erotic insanity, the prurient-paretic, the delusional patient, and the shameless, beastly insane may become onanists after brain disease has set in. The moral barrier is broken down and the animal instincts have the ascendency. A great many epileptics become so from this cause or from venereal excesses, and continue the habit after the tits have been established. The epileptics are usually very religious in their own esti- mation, vice or no vice. In fact, many of this class lay great claim to piety, and would look with horror on fornication, but compromise with conscience by indulging in this " enshrouded moral pestilence." The beginning of this vice is usually by example, especially among companions at school. Often it is accidental and arising from the awakening feeling at the pubescent age. When many realize how hateful it is and what direful results so often follow the practice, they have sufficient will-power to refrain from it, and if not long indulged in, no evil results of a permanent nature may follow. It is needful to say this plainly, not to minimize the evils of the vice, but because the after lives of such youths are often made miserable through their falling into the hands of the 152 MENTAL DISEASES. lying "specialist," so-called, and "nerve doctor," whose advertisements defile our walls and newspapers, and whose foul pamphlets find their way into respectable homes. All masturbators do not become insane, and no cure can be aflfected by merely taking medicine it* the habit continues. A great majority of beginners will recover from the primary malign condition by simply refraining from the habit, without taking the nostrums which are so persistently urged upon their notice by quack pretendors. If there should exist in the constitution a tendency to any nervous disease or to insanity, then such a vicious habit will precipitate a manifestation of the latent untoward heredity. It rouses into action diseased states which otherwise might have remained innocuous and latent. It is simply a spark put in the magazine of powder, which, otherwise, is as harm- less as a pile of sand. Such victims, before they reach asylums, often go to medical men for advice in a neurasthenic condition. They are usually anxious to know if they have not heart disease, dyspepsia or some form of nervous trouble. They complain of sleeplessness, nocturnal emissions, pain in the back and legs, dull headache, confusion of thought, partial loss of memory, desire to weep from low-spiritedness, anxiety to be alone, little care for any society, poor appetite, sallow countenance, often hectic cheeks, horrid and lascivious dreams, and a general lack of mental and physical energy. Such may be typical ONANIC INSANITY. 153 cases of sane victims, but on the borderland of insanity. The next step in the downward direction is seen in a pronounced case. For example: He is very shy; he has an evasive and cast-down look and a dull and irresolute character, inconsistency of demeanour ; he is subject to all kinds of suspicions and imaginings. Self -accusation and even fanatical notions prevail of a childish nature. We find in such, very often, irregular circulation, the hands cool and clammy, the head hot, more especially the neck and back of the head, biting of the nails, scratching of the fingers, restlessness of the body, carelessness to appearances and surroundings, loss of natural affection, want of concentration of thought, delusions, and, last stage of all, melancholia to be followed by semi-dementia and permanent in- sanity. Friends bring such patients to hospitals for the insane, and, if questioned as to what they know of the existence of such habits, grow quite indignant at the insinuation and burst out into eulogv on the good morals of the patient. " He is so shy, so retiring, so modest, so pious, so obedient, and so fond of solitude." The father and mother think he is a model of propriety and goodness. Do not take such a catalogue of all the virtues at par, if such symp- toms as have been enumerated are present. The fond relatives expect he will soon be well and get home ; but, as a rule, it is a vain hope, for, even if the habit should be stopped, the mischief has been done. The 154 MENTAL DISEASES. C9nstant and unnatural drain upoii the nervous system has produced such brain changes as to assume a chronic form before we see the patient. Here we have a demoralized and deteriorated character. He may have been manly, truthful, vigorous and trusty ; but now his moral nature is wrecked. Occasionally there are outbreaks of mania, based on delusions; sometimes a stubborn melancholia is present ; sometimes a stuporous condition sets in, or, rather, it might be called psychic inertia — all, however, mean mental unbalance and lethargy. Many examples of such have been presented from session to session to the classes called out of our wards ; and the majority of them had been intelligent and bright young men, but they have made shipwreck of their lives, for "their pleasant vices have scourged them." It has been my experience of such cases that the most of them come from those classes who have little outdoor or physical exercise ; in other words, from among those of sedentary habits. Hence, in rural districts, and among the more robust and healthy farmers and mechanics, this disgusting and filthy habit is not practised to the same extent as among the weaklings and prurient classes of our towns and cities. Many physicians recommend marriage as a remedy. This in a grievous mistake, and involves mischief and unhappiness to two persons. The man who, because of this vice, dislikes women, will not make an affectionate husband to any woman until ONANIC INSANITY. 155 his manhood is restored ; and he will be an object of disgust, in his inipotency, to any virtuous and healthy woman. Not only so, but he bequeaths a heritage of degeneracy to his children in one form or another, and adds his (juota to the already great army of defec- tives. The innocent descendants suffer for sins which they did not commit, and often curse the authors of their being when, in adult life, the truth becomes known to them. In treatment, many are the rules set down for guidance. It is useless to stuff such with medicine, give moral precepts, or scold them like a fish-wife, if the victims have not honestly set about reformation by their own efforts. This co-operation is essential to recovery. If they do not really wish to conquer and forsake this vice, help and encouragement are alike vain. They choose and seal their own fate in the face of the knowledge of the consequences. I think it is Whittier who truthfully sings : " The tissues of the life to be We weave in colours all our own, And in the field of destiny We reap as we have sown. " At the same iime, these victims can be assisted. Tonics may be given in such cases, if ana3mic or neurasthenic, but not such as strychnine or any spinal excitant. The physical treatment is given elsewhere in this manual. These unfortunates are not to be discouraged, but urged to abstinence by l")fi MENTAL DISEASES. holding out every good motive to stimulate them to make ettorts for thoir own deliverance. The Insane Ear. Huamatonia Auris (Orthrmatoma). — It is an effu- sion ot* blood under the perichondrium, between it and the cartilage of the ear. It may come on in a few hours, or gradually, and at first swells the exter- nal ear to a great size. After a time the swelling subsides, and leaves a mis-shapen ear, being shrivelled and withered, and often, but not always, of a bluish appearance. It is then only condensed tissue, but at first it consists of a bloody, gelatinous substance. So tense is the skin that it shines, and is very smooth in the acute stage. It is hard and painful on slight pressure, but when more firmly pressed a fluctuation is felt. Sometimes it breaks, and a sero-sanguineous fluid is discharged, The swelling is confined to the concave surface of the penna. These and such-like facts indicate that in the great majority of cases it is spontaneous, and indicates arterial degeneration of the terminal branches of the posterior auricular artery. There is also present a deterioration of the vaso-motor fibres of the cervical sympathetic. This passive condition is not to be mistaken for acute perichondritis, nor for cysts and tumours, which often grow in the substance of the external ear. Did we not allow for these diseased conditions as existing, rather than traumatism as the sole cause, ONANIC INSANITY. 157 then would it be impossible reasonably to account for its absence in such a larcje number of sane and insane who have injury of the ear inflicted without producing such results. The usual treatment is by the application of con- tractile collodion three times a day. A combination of collodion, oxide of zinc, and a few grains of carbolic acid made into a paste have been highly recom- mended. The lesion is only present in the cartilaginous por- tion of the auricle. It may be that injury from falls or self -infliction from tugging at the ear, or a slap from the hand of a rude attendant may be the occasion, but not the cause, of haematoma auris, the cause being in. the pathological state of the parts which violence may sometimes make manifest. Some reasons for so believing are as follows, viz.: In the flrst place, it is seldom or ever seen in acute mania, when injury to the body, including the ear, so often takes place. In the second place, it is seen most frequently in the left ear, but if traumatism were the principle cause, there is little reason to believe that this selection of the left ear would so frequently take place. In the third place, men are more subject to be aflflicted in this way than women, yet the latter are more rest- less and excited than men, and more likely to be bruised, and are more trying to the temper and patience of women nurses than are the men to the men nurses, In the fourth place, it is very prevalent 15S MENTAL DISEASES. only in certain forms of insanity. It is very com- mon among epileptics, chronic maniacs and paretics, but is not often seen in dementia or in the paranoiacs. Katatonia. Katatonia is said to be a brain disease which has alternations somewhat similar to circular insanity, with more variety. It ranges through the different phases of simple melancholia, mania and a stuporous condition merging on dementia. In addition to these there is found a convulsive and cataleptoid state. Kahlbaum, in 1874, claimed that, clinicall}^ these symptoms indicated a distinct form of insanity. Many thus afflicted have also a stage of exaltation with logical and fixed delusions, such as are seen in primare verriicktheit. Alienists have differed as to its being a newly-discovered disease, but the prepon- derance of opinions lead to the belief that it can fairly be classified under other forms of mental disease which are similar in etiology, with catalepsy and convulsions superadded. PARANOIA. 159 CHAPTER XVI. PARANOIA. Paranoia is called by many authors ,\ monomania, sc it is well to speak of it here. It has been f^iven a distinct place in the more recent literature of insanity, so it is necessary to <(ive a few details in respect to it. The name is old and is a Greek word, which denoted insanity of all kinds in classic times. It was so used by CEschylus, Plato, Aristotle and Plutarch {napavoia). Escjuirol used the word over sixty years ago to mean monomania with delusions of grandeur, to which the term megalomania is sometimes applied by the French. Griesinger used it in 1845, but added to the grandiose delusions those of succes- sive delusions of persecution. In 1852 Morel .saw in it a systemized form of delusions in which were logical sequents admitting the premises. At first it was supposed to be a secondary disease following mania and melancholia. This contention is now given up by many, hence the German name Primare Verriicktheit, although a number believe in both a primary and secondary variety. Some thought, and some authors now think, that it is always a hereditary disease, at least it only appears 160 MENTAL DISEASES. in those predisposed to insanity ; or, in other words, have the insane neurosis. I could quote at least half a dozen well-known authors of Continental Europe who class under this term all sorts of delusional insanity. Here is a partial list taken from a few^ of these writers. Such as puerperal insanity, post-febrile insanity, alcoholic, morphinic insanity, semi-insane neurosis, such as insanity of doubt, fear of certain localities (agoraphobia elautrophobia, topophobia), dipsomania, pyromania, kleptomania, homicidal and suicidal impulses and other forms of insanity, with distinctive outcroppings, are classed under the one name, called paranoia. Some authors describe this mental disease as being characterized by logical or systemized delusions of persecution and self-exaltation without excitement., emotion or impairment of memory. This disease may be hereditary or non-hereditary, chronic or acute, primary or secondary. As Dr. Carter Gray puts it, the clinical history shows, when it is fully developed, the patient full of suspicion. He misinterprets everything to have some covert meaning against himself. " Trifles light as air become as proof of Holy Writ." Othello's jealousy is an excellent picture of what is often seen. People are watching him, he thinks, on the street and in public conveyances ; somebody coughs as he passes by and immediately he believes the cough has some secret meaning; a match lies before PARANOIA. ]61 his feet aa he goes along the street and he checks himself and goes around it, convinced that there is some design about it ; his wife fastens a handkerchief in the window to dry, and he at once rushes to the conclusion that this is a signal set for some paramour or a headline in the paper, a bill-poster in the street, a sign over the store, a casual glance from a passer-by, an advertisement — each may have a fantastic meaning lurking in it to his distorted perceptions. As time passes, these delusions become more and more fixed. The patient, perhaps, reasons about them calmly ; and they differ from the delusions of melan- cholia and mania in the fact that any agitation in the patient is produced as the consequence of these delusions, and the excitement does not precede the delusions, as in the other forms of insanity. As the delusions become more and more fixed, there gradually arises a question in the morbidly logical mind of the patient as to why he should be thus persecuted, and out of this, in a natural enough way, gradually grows the delusion of self-exaltation, or the delusion of grandeur, as the French say. The patient then becomes, in his own estimation, a person of im- portance either bacause of his station in the world or because of his personal attributes ; hence these perse- cutions through jealousy. One patient will tell you that ho is persecuted because he has a valuable secret, like the Keely-motor scheme, which he refuses to divulge. Another is watched, and even his food is poisoned 11 162 . MENTAL DISEASES. to ^et him out of the way, because he is the custodian of financial secrets which would control the stocks and markets, or possesses state secrets which would shake dynasties to their centres, were he to speak out. Another has mental power to read all human thought, and thus he knows his enemies from his friends by intuition. Another may be deprived of his rights by his enemies of some estates or prerogatives, which he will minutely describe, with a good deal of logical sequence and with great earnestness. Infinite in working as is the human mind, so myriad are the phases of exaltation and self-importance. The judgment, the reasoning power, and the memory of these paranoiacs are remarkable ; indeed, often startling. So that they are almost certain to impress the lay observer, and many physicians also, as being perfectly sane, except upon unimportant points. I have had educated men and women of this class discuss abstruse subjects in a connected and even lucid way, yet in the line of their delusions. In fact, their delusions approach the nearest of all the insane delusions to the fixed and erroneous ^ beliefs of the sane, for they will reason about them logically, but will not be persuaded as to their unreasonableness. Between their delusions and the fixed beliefs of the sane, however, there lies this great difference, namely, that the sane do not have the predominant PARANOIA. , 3 63 and unfounded delusion of persecution, mingled, sooner or later, with that of absurd self-conceit. In a scientific sense or in a clinical sense, these patients are not responsible. They may, parrot-like, state that they know the nature and quality of their acts as jurisprudence requires, and what the punishment may be for viola- tion of law, yet it is evident to the most superficial observer that they do not really appreciate what they are doing because of their lack of moral sense, and because of the manner in which the mind, as a whole, is warped by the fixed and dominant delusions of persecution and insane self exaltation. They are dangerous lunatics, and should not be at large. There is a class of them who glory in the notoriety which litigation brings, and, if such can find lawyers to take up their cases, they will prosecute and perse- cute at the same time. Win or lose, they will press on to the bitter end. Of coui. e, the morbid idea of beinor ill-used lies at the bottom of this mania for law-suiting. This disease is often accompanied with hallucina- tions, and often illusions, and from the clear descrip- tions which are given of them they must be very vivid and distinct. Paranoia may arise in four ways, as Clouston puts them in respect to monomania, which he holds is the equivalent : 1st. It is a gradual evolution out of a natural dis- position : a proud man becoming insanely proud, or a 164 " MENTAL DISEASES. suspicious man passing the borderline of insanity with his suspicions. 2nd. It may remain as a permanent brain result after mania and melancholia. 3rd. It may follow alcoholic and syphilitic poison- inp[, injuries to the brain, sunstroke, and such like. 4th. From perverted organic sensations and local diseases misinterpreted by a weakened brain. There are three principal varieties : 1st. With delusions of unseen agency, suspicion or persecution. 2nd. With delusions of personal exaltation. 3rd. With delusions of perverted sensations. When a single morbid impulse or delusive suspicion exists, then it becomes an imperative conception, and dominates the whole being. Diagnosis from mania in the consistency of the delusions and their logical sequence. The emotional nature is kept in good control, and there is little motor restlessness as is seen in mania. From melan- cholia, in the absence of a sense of ill-heing, in the absence of insomnia, in the absence of the character- istic face-lines of the insane melancholv, in havingr no suicidal impulse, and little, if any, confusion of mind to which we would give the term nonsensical. Distinguished from paresis in the absence of those motor and psychic signs and symptoms found in paresis, especially in respect to the reflexes and tremors so abnormal in a paretic and yet so characteristic. PARANOIA. ^ 165 Treatment. All kinds of drugs have been recommended, but you must be guided largely by the condition of the patient as to the use of sedatives and tonics, such as opium, hyoscyamine and hyoscine, including the bromides. These may be helps, but trust largel}'^ to food and fresh air. The prognosis is bad in all. Out of the delusions of persecution necessarily grows the necessity of action to protect thfemselves from the persecutors, hence assault and homicide. In this respect they differ radically from the melan- cholic, who passively suffers the injury that is being done him, and which he attributes to some sin, fault, or shortcoming of his own, and not to others. The egotism and delusion of the paranoiac are entirely different from the delusions of those maniacal who are simply terrified, and proceed to no logical or connected acts, but only occasionally to impulsive ones, which is not the case in Primare Verriicktheit. I might observe, in passing, that the German term of Primare Verriicktheit corresponds in meaning very well with our English word "cracked," or the Ameri- can word " crank," or the Scotch word " a little daft." It means, literally, " shifted out of place." In other words, it is an abnormal condition in a definite line of conduct, but is a shifting from funda- mental sane mentality. These constitute the most dangerous class of the insane. The deeds which they commit are the dangerous 1()G MENTAL DtSEASV.S. deeds of deluded patients, who are yet possessed of all the intelligence which can concoct dangerous plans and stratagems. The history of the world is full of brutal murders that have been committed by this class without fear and without remorse. Their delusions are so fixed, and their intellects otherwise so keen, that there is no safety but in asylum or prison cus- tody and supervision. As a matter of fact, it is not a distinct phase of insanity. Neither its clinical his- tory nor its 88tiology points to its being any more than a form of delusional insanity, having two features prominent, viz., that of egotism and that of delusions of persecution. These abnormal features are seen in various forms of mental disease. A medical witness who would attempt to prove the existence of such a disease, is usually held up to sar- casm and scorn as a hair-splitting theorist. t>HTH ISIC A T. IN3A ]^itt^! '^ ^-^ ^ * ^i f^ J ,J Q.% I APR 1 7 1905 ■* CHAPTEK XVII; -^:;^-^^^ PHTHISICAL INSANITY. Lung disease is very prevalent among the insane, especially the tubercular form of it. It assumes the form of latent phthisis. In one member of a family may be seen dementia, and in another mania or melancholia, to end in death by lung disease. During this disease, vv^hen intermittent mania supervenes, all the most prominent symptoms of the disease dis- appear, only to return again when the maniacal attack has passed over. Sometimes mania and consumption are cotemporaneous ; but, as a rule, the latter succeeds the former. Very often the intellect improves before death ; but a majority go into dementia, if the disease should happen to be lingering. As a rule, however, a majority die within three years, and most of them within six years after the invasion ; about one-fourth die within twelve months. In latent phthisis there is seldom cough or expectoration. The hectic fever, the symptomatic diarrhoea and glittering eye may be present, with dyspnoea and night-sweats. The lungs are filled with miliary tubercles. Savage says: " Whatever in the future may be shown to be the relationship between bacilli and phthisis I 168 • MENTAL DISEASES. am .sure there will be proved to be a very distinct connection between some low forms of lung inflam- mation with destruction of tissue, and death, and dis- order of the nervous system." In the sane the hopeful side is usually seen, and such are expecting to recover if only they could get rid of some little cough. The consumption in the insane is usually found to be associated with melancholy As a rule this is associated with morbid suspicions of one kind or another. Very often there is a refusal to take food. Sometimes this is not from want of appetite, but from a dread or apprehension that there is tilth or poison in it. There are often near the end diarrhoea and haemoptysis, hallucinations of taste, smell and hearing, with delusions of persecution, In short, to sum up, it may be said : 1st. Phthisis kills a large number of insane patients. 2nd. It is associated with neurotic taint, which produces highly unstable nervous systems. 3rd. In the insane it is associated with certain groups of symptoms characterized by suspicion and refusal of food on the one hand, and with masking of the physical symptoms on the other. 4fth. Degenerative lung disease is common in melan- cholia and general paralysis. 5th. Sanity not uncommonly returns before death in phthisical lunatics, and some recover sanity to die in a year or two afterwards of phthisis. PHTHISICAL IXSANITV. 169 Gth. Glandular disease from trophic deficiency is a generic term which may include such morbidity as is found in the insane, the consumptive, the victim of kidney disease, heart trouble and such like. We are never to for^j^et the reflexes. The frequency of phthisis in chronic insanity is the strongest proof that mental disease has masked trophic causes. . ^ The frecjuent association of the depraved nutrition known as scrofula with idiocy and congenital imbe- cility has long been known. Perhaps two-thirds or even more are of the scrofulous constitution. This class of defectives is very often of the stru- mous diathesis, having weak circulation, a low tem- perature, a pale complexion, bad and badly set teeth ; the glandular and mucous structures being especially liable to disease. The likeness of idiocy and secondary dementia to each other trophically is in many ways marked ; and, therefore, it is not a matter of surprise that so many patients suffering from both states fall into consump- tion and die. Fully two-thirds of all idiots die of phthisis. The question arises : is not idiocy itself another though a rarer, manifestation of this diathesis ? " It is remarkable," says Kolk, *' when in the very same family some of the children suffer from mania or melancholia, and th3 brothers and sisters, who have remained free from these diseases, die of phthisis. I 170 MENTAL ntSKASKs. . have noticed that a great many epileptics die of con- sumption, especially if the epilepsy end in dementia." In all it is trophic failure. This leads to the forma- tion of the ricfht nidus, without which the tubercle bacillus would be perfectly harmless. The soil is ready for the colonization. Pathology finds no distinctive evidences in the brain beyond general antemia of the brain, with more or less atrophy of the grey matter ; we find very rarely any tubercular deposit in the brain. Now and then there is local softening in the white substance. In short, the brain is shown to be throughout an ill-nourished organ. Homicidal Insanity. This is the most deplorable of all the forms of mental alienation. Some have been sent to us by courts, having been held to be irresponsible because of insanity ; others have been sent to us as insane without a formal trial. The insane with homicidal impulses are usually divided into six classes, each indicating a difference in mental condition : 1st. Those who take life in a paroxysm of insane passion or fury. 2nd. Those who commit homicide from delusion, or who are deceived by their hallucinations, illusions or disordered imaginations. 3rd. Those who kill indiscriminately, and appar- ently from a mere love of taking life ; that is, from a p I»HTHISI('AT. INSAXITY. 171 diseased propensity and intense desire to destroy others, aj^ainst which act neither reason nor conscience remonstrates. * 4th. Those wlio ly horrid thon<^lits, and he tohl me that diaV)olical imprecations forced themscdves into his mind. ' The distress to a man so sincerely relij^ious as Allston may he imaj^ined. He wished to consult Colerid<;e, but could not summon resolution. Leslie, therefore, saw Coleridfi^e for him. Colerid^jje naid : " Allston should say to himself, ' Nothinj^ is but my will. These thoughts, therefore, that force thenjselves on my mind is no part of me, and there can be no guilt in them.' If he will make a strong effort to become indifferent to their re- currence they will either cease, or cease to bother him." The biographer says this reasoning was effectual. Bunyan tells us he was tortured with blasphemou.s thoughts of all kinds. He laid them at the door of Satan; and, of course, this diabolical train of malign suggestions was an artful design to keep him from the true path of duty. They occurred spontaneously while he was praying, preaching or writing ; but the immortal dreamer resisted them, and they finally disappeared, especially (ifter (I, rent Brain recuperation seemed to have driven the Evil Spirit away. All such are doubtless sane, but on the borderland. 176 ' MENTAL DfSKASES. You will notice no delusions exist. The bent of mind is simply some dominant idea leading, impul- sively, to action. Did delusions exist and action taken based on these delusions, then wouhl we have diseased conditions, weak will-power, and, doubtless insanity. Many such are among the criminal classes. Dean, in his " Medical Jurisprudence," tells us of a young man, twenty-one years old, who lo.st his father at an early age, and never evinced much love for his mother. When eighteen years of age he began to shun society, and felt a strong desire to commit murder. Sometimes, when embracing his mother, his face would flush, his eyes sparkle, and he would cry out : " Mother, save yourself ; I am forced to kill you." He kept his mental equilibrium by a strong effort of the will. C/Ould we read humanity in its promptings, impulses and inhibitions, we would be astonished at the number of bad acts refrained from. A dramatic poem by Rossetti has the confession of a murderer, who killed his mistress because of a dominant idea from which there was no release, except in the execution of the deed : — " ' Take it,' I said to hei" the secoiul time, ' Take it and keep it ; ' and then came a fire That burnt my hand, and then the fire was ))lood, And Hea and sky were blood and fire, and all The day was one red blindnena ; till it seemed. Within the whirling brain's entanglement, That she, or 1, or all things bled to tleatii. And then I found her lying at my feet, And knew that I had stabbed her, and .saw The lock she gave me when she took the knife Deep in her h«art." OENKIIAL BODILY CONDITIONS. 177 (JHAPTEJi XVIII. GENEUAL li(H)ILY CONDITIONS. In treatin;j^ those with brain disease, it is well to keep in mind the fact that ah extra abnormal conditions often occasion insanity, and that the removal of them means recovery. Heart disease, intestinal troubles, dyspepsia, antemia, hepatic complications, diabetes, albuminuria, and any state which will brin^;^ aV>out a general malaise are excitants, the result of which is insanity. Uterine and ovarian disturbances and diseases do not produce insanity to the extent supposed. This statement is now supported by some of the best and most conservative gyn;ecologists on this Continent, such as Skene and Goodell. It is a matter of regret that modern surgery, which has made such advances during tlie past decade, has unsexed so many women because of slight troubles in one or both ovaries, under the impression that they are the cause of many nervous diseases and mental troubles. It is safe to say that not over three per cent, of the female insane are aillicted with serious uterine or ovarian disease ; yet, a large percentage of those admitted show evidence of medical or surgical treat- ment along gynejocological lines, in 178 MENTAL disp:ases. In some of the United States legislative enactments are in force against oopliorectomy, except under stringent regulations. It is a matter of reirret that law is obliged to step in between a surgeon and his patient. Ura-rnic conditions are often present among the insane. Sometimes these are associated with mania, but more frequently with melancholia. This mental depression is sometimes slight, but is often so pro- found as to lead to suicide. Uric acid, when in excess seems to have a demoralizing effect upon the nerve centres. The tendency for self-destruction is greatest after wakening up in tlie morning. It is possible that the increased alkalinity of the blood at this period leads to consequent increased solubility of uric acid, hence tfie toxic effect on the mental condition. Many cases, with a sense of ill-being, are classified as neurasthenics because of brain starvation, who are simply the victims of slow uraimic poisoning; the nitro- genous waste products in any form, if unduly retained in the blood or abnormally produced, deteriorate the life current, and the first to feel the inimical influence is the brain. The condition of the blood stands first as a great causative agent of insanity. The order of sequence often is (a) trophic change, which, through nerve influence, afi'ect such excretory organs as the kidneys ; (h) dead tissues are retarded or changed to toxic ag(^nts, because of disturbed organic function before excretion can take place ; (c) as a result, the most susceptible centres are poisoned. GENERAL IJODILY CONDITIONS. 179 In this connection, it may be noted that in melan- cholia, stuporous insanity and dementia, it is found, as a rule, that the number of blood corpuscles is sensibly diminished, uiore especially amonf; the female insane. The hjemof^lobin is less in (juantity. In acute mania there is litte change in this respect. There has been found an increase in the specific ^^ravity of the blood, especially in epilepsy, melancholia, general paralysis, and secondary dementia. There is seen no character- istic change in the relative proportion between red and white corpuscles. The chlorides, phosphates and urea are often found in excess, but also below normal. The (juantity and quality are not sufficiently definite in each form of mental disease to enable us to formulate a clinical law. Among the pathological products of the kidneys, sugar and albumen are usually found, but their re- lation to the varied forms of insanity has not received that attention which the subject demands. There is a wide field open for exploration in ascer- taining the sympatfictic relation which exists between the physical disorders of all bodily organs and the nervous systems, especially the cerebrospinal centres. This intimacy is very great in the abdominal viscera, as was well known to the ancients, hence, the names melancholia, hypochondria and phrenitis. Temi'Ekatuue and Pulse. After a number of years of close observation of the heat of the body and the cjuality of the pulse in many, 180 . MENTAL DISEASES. if not the most, of the diseases of the insane, I have been convinced of tlie unreliability of those two tests, if depended upon alone. When we take into considera- tion the dilllculty of finding the same heat twice under apparently the same patholof^ical conditions, in the same patient ; also that scarcely any two thermometers indicate the same degree under exactly similar influ- ences of heat or cold, and that alarming conclusions are drawn from only a few degrees above or below the normal standard, it is evident that as a diagnostic method it needs to support it collateral confirmation in other quarters. If a number of thermometers are put in contact with the same axilla or under the same tongue it will be seen how fickle they are, and that no two of them agree exactly, even if adjusted as at pres- ent constructed. This untrustworthiness is also true of the pulse, both in respect to its fre(i[uency and inten- sity. A sudden bodily movement, a passing emotion, a transitory excitement, may accelerate the pulse, or a shock of depression may lower it without there being any disease present. All that we can glean from the tone and frequency of the pulse must be of a general nature, and may indicate disease, or adventitious circumstances not abnormal. Even in disease different persons have no uniformity in this respect, so that its diversity and changeableness often put medical men astray, were they not led to just conclusions by other and more certain researches. Many asylum reports give the temperature and v ' ■'> riENEUAL BODILV CONDITIONS. 181 pulse of a large number of patients afHicted with dementia, mania, paresis, latent phthisis, etc., or it might be of two combined. Conclusions are drawn from these two sources of information not altogether warranted from any observations I have made here. To put the matter fairly to the test, I selected a number of cases belonging to these classes, and the temperature and pulse were regularly taken for weeks together, morning and evening. No con- clusions could be drawn from these of a satisfactory character except in a general way ; in dementia we found the heat and pulse below the standard of health, but for several days at a time they would take a leap upward without any reason for so doing being dis- cernible. In cases where dementia and consumption were combined, both, as a rule, were found above normal, but in a erratic way they would come down consider- ably and stay there for a few days at a time. The nearest approach to stability was found in paresis and consumption combined ; both were above normal, and found to be uniformly high. In paresis alone the same uncertainty prevailed ; they rise and fall without any regularity, but oftener above normal than below. The temperature and pulse give general indications of bodily disturbance in disease ; but, so far in our investigations neither pulse nor thermometric tests show indications of the genus or species of insanity or its ally called latent phthisis. _._ .._._:,--..—- 182 • MKNTAI- DISEASES. CAlAV'VKll XIX. AMl'JNTrA. Amentia, \n(i&n'macon says : " An idiot is a fool or a rnadinan from liis nativity, and one ' who lias never had ariy lucid intervals. Such an one is descrihed as a person that cannot numlxir twenty, tell the days of the week, and • SPINAL CORD. BLOOD VESSELS. BRAIN. Sp.gr., Weight and Si^e. Scalp, Skull and Membranes. m wen o 6 % aj td ti 03 < ;4 1^ •A tf u \< *<5 ptj tf - ( 1 ei • o K 6 M ao OS H H < -si © 2 ;j H X D • © 2© 2§ H © O a pq u y. o H OQ M *1 t— I OS © 9 < o PC » ti « "' n a. « n © t2 © 05 » CO 3= < ■ - 1 &5 % td Sr, g H H ;; 1—1 o J? t © Oh CO < M H VI K < R • 2 Is- M B« J V S 5S fe •«1 H < <1 5 © «5 31 © OS n (In PS © p4 < 1-3 O © © «^ 05 © • X O g < u M ^ s 1^ s < -< -«3 >?; S^ « d d d sz; I ^ !25 202 MENTAL DISEASES. CHAPTEE XXII. TREATMENT OF TEE VABIOUS FOBMS OF mSANITY. In administering drugs to the insane it is to be remembered that the mentally diseased will often not express their feeling nor give a true statement of their aches and pains as the sane do. We must, to a great extent, judge of their condition by what knowledge our experience and senses give us. A maniacal, melancholy or demented patient may have retention of urine, loaded bowels, hernia, bleeding of the bowels or any one of numerous complaints and it may be of such an obscure nature as may escape the vigilance of the physician and attendant until such assumes a serious aspect. It should also be accepted as a truism that medicine is only an assistant to nature. The vital powers of the physical system in dts efforts to preserve live and restore health are the curative resources given to us in every form of disease. In the first place, then, we are not to frustrate these by undue intermeddling ; and, in the second place, we are not to expect medi- cines to take their place. There are no cure-alls in pharmacy and therapeutics. We give stimulants, we Treatment of insanity. 203 brace up with tonics, we quiet with sedatives, and we lull pain and give sleep with anodynes and narcotics, but, in all these efforts we only endeavour to guide nature to health. We cannot originate any powers it does not possess. We can only steer the vessel, but its propelling power must be left to nature's vital agency. Insanity, like many other forms of disease, will often run its course in spite of all remedies. Our aim must be to provide pabulum, and sustain nature in its struggle against the retrograde steps towards dissolution and death. One of the first considerations in treating the insane is sanitary surroundings. These are more apt to be neglected among the insane than among the sane at their homes. If they are violent or suicidal the windows are apt to be fastened down and shutters put up ; the doors of their rooms are kept shut ; the fresh air and sunlight are excluded ; a vivMated atmosphere is kept in. Personal cleanliness is too often neglected from ignorance of what attention in this respect is necessary, or from fear of unduly excit- ing the patient. Food is not given regularly, and the kind may be mere slops or abominable nick-nacks, instead of nourishing nitrogenous food, such as milk, eggs, fresh meat and fresh fowl. There is more fibre- building material in a good beefsteak than in a hogs- head of so-called beef-tea with the beef fibre left out of the decoction. In nursing the insane, the necessary combination of firmness and kindness is not often found in private 204 MENTAL DISEASES. houses, yet how indispensible are all thes*^ simple requirements to induce health, not to speak of mental recovery. Again, medicine is left by a physician to administer at stated times. It may be a necessary sedative, stimulant or tonic. His back is no sooner turned than some local wiseacre throws doubt on the wis- dom of the doctor, or on the efficacy of his remedies, or on the necessity of his dietetic and sanitary rules. They are ignored, and yet he is held responsible. Herein comes the advantage of asylum treatment, where no such untoward circumstances exist. All the conditions, except hospitalism, are favourable to recovery. These drawbacks are especially true of the pauper insane who are kept at home, and where, of necessity, the attendance and nursing must be of the most crude kind. Our diagnosis is often hampered, because of those who are full of delusions and imagine they have a disease of some kind, which has no existence. It is useless to reason the matter with such, and the only other alternative is to give a placebo of some kind, and in this way employ mental therapeutics and watch developments. In these three aspects — of (a) not noticing their ailments, (b) hiding real troubles, (c) having the mind filled with imaginary ones — we labour under disadvantaores which do not exist in treating the sane, if not delirious. Nor are these all our difficulties. When medicines are given to a sane person, on a second visit we are TREATMENT OF INSANITY. 205 greatly guided in our future treatment by the account an intelligent and non-delirious patient will give us of the effects of our previous administration. There may be idiosyncrasies against certain drugs, of which we were not aware. The medicine may not have the desired effect on account of causes which may be obscure, but which the patient may be able to assist in solving. A large number of the intelligent insane can be depended upon in describing symptoms, and on the other hand many cannot be relied upon in making our diagnosis, hence the physician labours under a disadvantage. Under these circumstances we must fall back upon our experience of the therapeutic value of different drugs as usually administered, until we are convinced of their injurious effects, their negative character, or beneficial results. It is possible that asylum medical officers cannot do much better for the insane than can an intelligent outside practitioner ; but in asylums all the conditions enumerated are imperative, and no outside interfer- ence is allowed. As a rule, the hospitals for the insane in christian countries adopt the most modern methods and endeavour to bring about the best con- ditions necessary to recovery. It is true that there are a few neurologists in some countries not far off, who sneer at that band of excellent and, in a majority of cases, able men who make their life work the care of the insane, because they do not devote more time to the study of neurology and kindred subjects. Now, 20(5 MENTAL DISEASES. as a matter of fact, the most advanced students along this line of thought in Christendom to-day are not these critical theorists without practical experience, but the men who are daily among the insane anu live in a clinical atmosphere. Synthetical chemistry is furnishing a large variety of sedatives and narcotics such as sulphonal, phena- cetine, chloralamide, trional and such like. While not coming up to all their advocates claim for them ; yet, there is no doubt, their calmative effect in mild mania and in the restlessness of melancholia makes them valuable additions to our therapeutic agents. At the same time, it is not well to accept as gospel ^ruth all that is said of the hundred-and-one chemical sub- stances which are being produced with wonderful rapidity in the myriad laboratories of to-day. New remedies — so-called — are being thrust upon the medi- cal profession ; so are old remedies, brought into use under new methods of manufacture and of chemical union. They are produced in many forms simply to sell, and in the purchase of many of them the profession is " sold." They serve their little day and pass into forgetful ness, usually with profit to the manufacturer, and are followed by the exhibition of new substances, which pass through the like evanescent stages of temporary popularity, largely because of the lauda- tions of some susceptible members of our profession. It is true, valuable remedies may be and are discovered by chemists and by physicians fond of experiments, yet it is well to be largely conservative in our opinions TREATMENT OF INSANITY. 207 of the efficacy of all new-fangled drugs which may be thrust upon the market. Puerperal Mania. In the treatment of puerperal mania, the following points may be remembered : (a) Absolute rest, if possible ; (6) the employment of a competent nurse, and, with few exceptions, the absence of such rela- tives who may have neither discretion nor judgment ; (c) child weaning without fail ; (d) bowels freely relieved by enema; (e) general antiseptic measures adopted immediately before and after delivery ; (f) seeing that the breasts are attended to, being of paramount importance ; (g) lochial discharges removed, thoroughly saturate the womb and passages with quinine held in suspension in tepid, distilled or boiled water. Condy's fluid is excellent, as it contains a large quantity of permanganate of potash. I have found a diff'usible stimulant have excellent results, and such a drug in this condition of the patient is calmative in its effects ; just as I have seen in dozens of cases in ordinary mania the administra- tion of whiskey in hot water, with a warm bath, quiet more satisfactorily than many of the standard sedatives and soporifics. A majority of such cases soon subside, and recover in two or three weeks. This statement refers to simple puerperal mania of the sympathetic form, and pot to the septic class, The outlook of the If^tter ia 208 MENTAL DISEASES. varied, and uncertain as to duration and recovery. Quinine is our sheet-anchor where poison exists. It is antagonistic to all forms of niicro-organisms and to putrefaction. Our forefathers knew this practi- cally when they put great faith in Peruvian bark and charcoal as poultices where pus existed. Hypnotics may require to be given as a final resort to allay maniacal excitement and consequent exhaus- tion, as a continuance of it, without cessation, means death. Chloral, or sulphonal, or paraldyhide may be used. A suppository of camphor and chloral per rectum not only is a good general sedative, but no doubt it allays local excitation. It is well to avoid hyoscyamus or any of the products therefrom, as it is a heart depressor, and as it dries the tongue and fauces it might cause a distaste for food. The bromides should be avoided. Any of such drugs should only be temporary expedients, to tide the patient over the critical period of mental and physical prostration. Stop their use as soon as possible. Should the patient recover from the blood poison- ing, and not immediately rally, the usual result is a period of mental weakness with or without stupor. Sometimes a mild mania may supervene. We have in the latter class patients hard to manage, as they are very often erotic, obscene, filthy and often destructive. A large number, however, of even this class recover inside of a year, but quite a few lapse into chronic TUEATMENT OF INSANITY. 209 and hopeless insanity, especially should there exist a hereditary tendency. On the whole, the prognosis is ^ood, and we are encouraged to persevere in our treatment. Our aim should be, among other aids to recovery, to ensure the feeding of nourishing food, fresh air, cleanliness and tonics. When the acute stage has passed away, we trust to the simple forms of iron in effervescent com- bine, or in the pyrophosphate of iron, cod liver oil, with one or other of the phosphites, or, better still, the phosphides, peptonized milk with eggs, soups of a substantial kind, and a fair amount of some form of stimulant. I prefer any of the malt liquors to wine or any distilled spirits, in such cases. Treat such patients at home, if possible ; but it must not be forgotten that home treatment too often means, of necessity, because of the situation, too much nar- cotism and too little of good nursing and general treatment ; too little building up, and consequent depression ; too much confinement, especially in towns and cities, and too little open-air exercise. These unfavourable conditions are often rendered more so by relatives exhibiting too much interference and too little tact. Because of these and other hindrances, especially among the poor, the medical attendant has his best endeavours very much neutralized. H 210 MENTAL DISEASES. CHAPTEli XXIII. TREATMENT OF MANIA. In former times mania was thought to be caused by meningitis, and as a consequence, this supposed in- flammatory condition was treated by the orthodox purging, bleeding and salivating. Occasionally, for a change, large doses of tartar emetic were given, the object being to lower the pulse, and consequently the circulation. Blisters were applied to the neck, and many years ago the actual cautery on the nape of the neck was u.sed in this province. This treatment was in accordance with the approved practice of those days. These heroic remedies and methods are unknown in our day. The levelling down has been followed by the levelling up. In most cases of acute mania we have to consider what is best to be done to reduce the excitement and quiet the patient. Shall we give sedatives or narcotics, or neither ? If we give neither, then one of three results will follow : that is, recovery after a time, if the natural strength should hold out, or a drifting into some form of chronic insanity, or death from sheer physical exhaustion. We are well aware that if we can husband the physical resources until the crisis is TREATMENT OF MANIA. 211 over-past, we have gained a good deal ; but we know that in mania it is not drugs alone that will do this. All the con aa gr. x. to xx. R Potassii Bromidi Sodii Bromidi Ext. Ergotse fl. ^ss. Tine. Nucis vora gtt. v. Atropise Sulph gr. yig. Spt. Menth. P m. v. Aquae Dist 3ss. — M. Dose : As above. The " enshrouded moral pestilence," masturbation, is often prevented by means of passing a tine silver wire through the prepuce and knotting it so as not to strangulate the part inclosed. This can be left in for months at a time, and while in situ the habit cannot be indulged in. The same object can be gained by vesication ; but it must not be extensive nor long continued, lest disagreeable cicatrices and contractions should be the result. The induction of Bromism • often takes away the erotic desire, but it must not be pushed too far, lest semi-dementia should be induced. 228 • MENTAL DISEASES. If the patient has any will-power left, he may be able to control the vicious habit by keeping the parts clean and by the application of ice-water when an impulse comes on, unless the desire is purely psychi- cal. The hope of cure lies in the period antedating the invasion of insanity. When brain disease sets in the habit may largely cease, but the mischief has been done to the great nerve-centres. The incurable and intractable disease, Progressive Paresis, in its first stages requires to be treated with sedatives. As it progresse.s, the most of those thus afflicted find their way to some hospital for the insane to end their days there. The syphilitic form may be staved off for some time by the use of such remedies as Donovan's solution, or some other form of mercury and arsenic with the iodides. The mania of paresis is treated very much as are any of the other manias. A pill of valerianate of zinc and extract of Bella- donna has good results to allay the restlessness so often seen in the daytime. It has little effect on positive mania. Treatment of Melancholia. Remember that in melancholia the condition is a weakening: and a diminution of the tension of the nerve currents. Treatment must be directed to arousing a more intense activity in organic life. The process of storing energy in the nerve-cells is a part EPILEPSY, MASTURBATION AND MELANCHOLIA. 229 of the general work of nutrition. If we can by any means increase the activity and vigor of the nutritive processes generally throughout the body, we can compel the nerve-elements to take a share in the increased activity, and may, by degrees, restore them to their normal state. First among: the restorative measures is the ad- ministration of food. Hunger is wanting, hence poor eatinof • but the taking of aliment must be insisted upon. Dyspepsia may be present of the atonic form, which so frequently co-exists with the mental depression. This fact should not prevent the ad- ministration of food. Abundance of food must always be administered, no matter what the state of the patient's digestion may appear to be, and no matter how directly contrary it may be to his inclina- tion. It is not enough to give slops and concentrated essences of meat and peptic fluids ; solid food of varied nature is the sheet-anchor, if the greatest benefit is to be obtained. To assist digestion, reasonable exercise and fresh air are needed, not to speak of cleanliness. The tendency is to sit and brood over imaginary ills. Ordinary cleanliness is often neglected. The friends are often poor nurses to see to sanitary conditions. For insomnia, opium, or choral, or sulphonal or some of the bromides are resorted to. My experience is that, as a rule, a patient is better without any of them. A natural sleep of even three hours in the twenty-four 230 • MENTAL DISEASES. has more restoration in it than has any number of hours in stupor or in drugged quietude. Of much more avail are drugs — such as iron, quinine, arsenic and strychnine — which tend to stimulate the processes of digestion and of nutrition generally. I have found good effects from the syrup of the phosphates of quinine, iron and strychnine (known as Easton's syrup). Beware of indulging in too much purgation. A laxative is needed sometimes to unload the colon, but there often is costiveness because of empty bowels, in which condition drastic remedies would do injury. Good feeding alone leads to peristaltic action of the bowels. The best aperients are some of the mineral waters given fasting in the morning. If there is exhaustion from continued sleeplessness (and, of two evils, the less has to be chosen) administer a full dose at once of the sedative used. There is so much hope in so many of these cases in the acute stage that we Are encouraged to persevere in all methods conducive to health, and which are taught to you in your Practice of Medicine lectures. It is well for you to intimate to the relatives of patients that usually recovery is slow, so as to keep them from wearying with the physician and usually seeking succour from charlatanism. I repeat, again, that I find it a very common practice to give sedatives, such as the bromides and hydrate chloral, or both combined, to produce temporary relief and sleep to the patient, and also to satisfy EPILEPSY, MASTURBATION AND MELANCHOLIA. 231 the urgent demands of relatives and friends to give something to procure sleep. In this way stupidity can be produced, but not a natural sleep. The nerve- centres are, for the time being, benumbed. Patients afflicted with melancholia may, at any time, manifest suicidal tendencies ; hence, constant watchfulness is of the first importance. If the patient's friends are wealthy, and can afford all neces- sary accommodation and competent nursing, then are home and its comforts and surroundinors a good refuge for such, unless delusions of persecution by friends exist. These would, in their effects, antagonize any benefits home might otherwise bestow. If these favourable conditions do not exist, then is a retreat or an asylum, with its treatment, imperatively needed at the outset. Unfortunately, at home and among friends, there are not that firmness and kindness combined, so necessary to cause the patient to eat well and to receive necessary exercise and air. Too often friends allow their sympathy to get the better of their judgment — the heart to control the head — and as a result, because of the v/ant of necessary attention, the patient suffers. There may be, and usually is, great constipation, especially in the colon, yet this irritating state is not attended to ; there may be refusal of food, and nimness and skill may be wanting to see that sufficient is administered; there may be no sleep, and consequent exhanstion, yet little attention is given to the insomnia; the patient may care little about personal cleanliness, and ^32 Mental DtsEAstes. it requires tact and firmness to insist upon it being attended to. These, as well as many minor atten- tions, which in the aggregate mean much in successful treatment, need intelligence, firmness, kindness, dis- cretion and knowledge in the nurse. Many such cases require to be fed against their will, especially if they think that all food given to them is poisoned. Some will take food by coaxing ; others require to be fed with a spoon ; others again can only be fed with a feeding cup ; and, as a last resort, the tube has to be used. Some prefer to use a rubber tube, by passing it through one of the nostrils well back into the throat and oesophagus. A large cathe- ter may be used in an extremity, with a tin funnel attached. Milk and egg will pass through them by gravitation. A larger tube and more flexible, with a hardened and perforated end, is now used, and which is better in every way. The stomach-pump is not difficult to use, unless the patient resists the tubes' in- troduction between the teeth. It will allow more solid food to be given than by the smaller tube through the nostril. If any of the back teeth are wanting, even with shut teeth food can be passed into the throat with a child's feeding-cup. We see now and then in the newspapers descrip- tions of cases who have starved to death at home, through the culpable negligence of relatives or friends or medical men, if called to see such cases, and then allow death to ensue through want ' of food. It is criminal to allow it in the delusional insane, and many EPILEPSY, MASTITRBATION AND MELANCHOLIA. ^33 are artificially fed for months, and make good recov- eries. I remember that, about sixteen years ago, one of our medical staff fed a young woman artificially twice a day for a year and a half. She had the delu- sion that she had no mouth — personal experience to the contrary. It is not well to give opiates in melan- cholia with delusions. In fact, if delusions exist in any form of insanity it is well not to prescribe opium or any of its salts. It has only a tendency to increase the malady because of consequent brain congestion. In melancholia, accompanied by merely emotional disturbance, opium has sometimes excellent results. The deodorized tincture of opium, with one of the ethers, is usually well borne, with an occasional laxa- tive to empty the bowels. Many such have gastro- intestinal catarrh with the costiveness. The tongue is coated with a brownish-yellow deposit, and anorexia is present. This state is largely brought about by imperfect mastication, or none at all in artificial feeding, and by insufficient or vitiated secretions of the stomachic fluids. This condition needs attention by the use of the usual peptonic remedies. Some patients cannot tolerate opium in any form. If so, other remedies must be used if hypnotics must be given. One of the bromides combined with morphia will often be tolerated, when either alone will not be well borne. As is so often the case in medical preparations, one drug modifies the action of another, in some unaccountable way. The giving of nerve pabulum is not to be neglected, 234 MENTAL DISEASES. and we know that phosphorus in the chemical union, which is easily disintegrated, is more readily assimi- lated. The phosphides excel the phosphites in this respect, and the phosphites the phosphates. Phos- phorus is essential to animal life. It is found in the solids and fluids of the body. If it is not supplied in the food or by medicine, the result is mal-nutrition, a neurasthenic condition and depreciated brain power. In fact, phosphorus, in one form or another, has been truly termed food, as it is present in all cell growth, and is indispensable to functional activity. As a rule, nitrogen and phosphorus are found to- gether as builders' material in the constructing and repairing the physical system. So it will be seen how important they are as sources of nerve force, and the stimulating agents of nutrition, hence the importance of supplying them to the body in nervous diseases and insanity. Give material in proper form and nature will perform the work. Phosphorus in conjunc- tion with cod liver oil, is an excellent combination, say, 1 -100th to l-15th of a grain at a dose. Fats enter largely into nerve composition, and it is necessary to organic integrity that the hydro-carbonates should be administered artificially, or built up in the system by nature's processes from material being furnished in the foods. The fats are an important element in nerve striic*;ure, as well as is phosphorus. In melancholia we have mental depression, or a sense of ill-being, to deal with. This means trophic lethargy or deficiency, in whose sluggishness is loss of physical activity, and, as a result, mental misery. EPILEPSY, MASTURBATION AND MELANCHOLIA. 235 It is evident that any useful therapeutic Si^ent must be largely tonic. In other words, it means that which will conduce to appetite, digestion and nerve stimulation of the vaso-motor or trophic system. In our experience, quinine, phosphorus, strychnia and iron stand first in insane melancholy. Give as few sedatives and narcotics as possible. Trust much to fresh air, wholesome diet, cleanliness, and gentle exercise. Bromides are not borne well in such cases. A recent author truly says : " Quite extravagant hopes have been based on the alleged curative effects of electricity on insanity. Superficial theorizers have even undertaken to indicate the special kinds of cur- rents and directions of such, to be applied to the head in various forms of insanity, and it is to be presumed that the more modern imposition of static electricity will come into vogue, and after a brief sway over the minds of the credulous, and an occasional success with a simulating or hysterical patient, share the fate of other epidemics of charlatanism. Electricity can have, from the very nature of the case, no specific efifect on insanity. Its applicability is limited to those in which there is simply atony, as in stuporous insanity, and to those which are associated with organic and functional disease of the nervous axis. In the latter case the ordinary rules of electro-therapy apply. In stuporous insanity its effect is to stir up the patient, but we should be sure of our diagnosis before applying it, and not confound atonic melancholia with dementia. 236 . MENTAL DISEASED. for in a luelancholic patient electrical manifestation and manipulation would probably provoke additional delusions of persecution to those he already entertains* If we were better acquainted with the molecular con- dition of the brain in health and disease, and if we understood better the exact influence of electricity on the atomic and dynamic states of that organ, we would be better able to formulate the indications for the use of this potent neurotic agent." — Spitza. There is a great deal of therapeutic value to get the mind to think of something away from itself. This is especially true of melancholia, in which the mind is centered all in self. If it is possible to get such to employ themselves in work of any kind a great point is gained. To work needs attention to it, hence the advantage obtained. It also means exercise. No one can be healthy without it, much less the insane, who are not maniacal. The circulation is languid ; the nutritive processes are slow, and need the natural stimulation which exercise gives. Amusements are not without their influence for good, and in the aggregate may do more to bring about recovery than we are aware of. They are pleasant recreations to even the chronics, and serve to beguile the weary hours of an otherwise monotonous life. Hypnotism has had its advocates in the treatment of delusional maniacs. Those who have studied the matter must now attach no importance to it as a therapeutic agent. HEREDITY. 237 CHAPTER XXV. HEREDITY. It is not my intention to discuss the general laws of heredity, as manifested in biology or in natural his- tory. It is a great subject in all its phases, and it must be acknowledged that, as yet, we are only on the threshold of enquiry into all the latent and mani- fest forces and potentialities which constitute the existence and possibility of transmission of physical and mental characteristics. The consideration of that aspect of the subject belongs to the physiologist. Much has been accomplished in this field of investi- gation by such eminent men as Lamarck, Beale, Spencer, Darwin, Romanes and Weismann. August Wiesmann, of Germany, has given recently" to the world of science two volumes, ably written, on the subject, and combats the Darwinian theory of " The transmission of acquired character." It will thus be seen, in the diversity of opinion, that fundamental facts are, as yet, only partially developed. Mercier, the English alienist, truthfully says : " That the subject of heredity has been regarded for generations as having a special bearing on the subject of insanity. It is considered ominous for in- 238 , MENTAL DISEASES. sanity to exist " in the family." Tiie tendency of late years has been to lay increasing emphasis upon the hereditary factor in this relation. In estimating the influence of heredity in producing a tendency to in- sanity, regard has to be had to the number of instances of insanity that have occurred among the relatives, direct or collateral, and of the taint of the patient under consideration. Heredity has been considered to exist in those cases, and in those only in which a record of insanity has been found amonfj the near relatives." 1st. This estimate is liable to error. The insanity of the relative may not have been heritable, or at least remotely so, as, for example, in general paralysis of the insane. 2nd. The insanity of the relative and that of the patient under consideration may arise from different sources, and not from a common cause. 3rd. The factor which is inherited cannot be in- sanity 'per se, but may be an instability or disordered arrangement of nerve tissue, which allows insanity to occur, and we must look for the bequeathed anteced- ents of insanity, not in insanity itself as existing in progenitors, but in all maladies which display evidence of undue instability or disorder of the highest nerve arrangements. For example, the nervous peculiarity which exhibits itself as insanity in the offspring may have become apparent in the progenitor, not as in- sanity but as epilepsy, as chorea, as hystero-epilepsy, as dipsomania, or in some other form of nervousness, HEREDITY. 239 4th. The law of trausmission in a fjeneral descent of characteristics is admitted, but it is halting and diverse in minor particulars. In ^enus " like produces like," but in species trans- mission may not be identical, and, in fact, is not, as children differ in many respects from either or both parents. We each have a distinctiveness and person- ality in which wo differ from every other human being, including progenitors. 5th. Recently acquired characteristics are unstable and evanescent in the human race. The more recent the appearance is of any character the more uncertain is its transmission ; and, on the other hand, the more numerous the generations through which a character has been transmitted the greater the certainty of its re-transmission. In coming down through a long line of ancestry the character seems like a falling body to gather momen- tum, and the further it has descended and the greater momentum it has acquired, the less liable is it to be diverted from its course, and the greater is its power to overcome any obstacle in the course of its descent. 6th. It is obvious that where the attributes of the parents are contradictory there are five possible alter- natives as to the appearance of these traits of charac- ter in the offspring, viz.: (a) The offspring may inherit the attributes of each parent solely, but not of both. (h) It may inherit the qualities of one parent in some respects, and those of the other parent in other respects. 240 MENTAL DISEASES. ♦ (c) The offspring may inherit the father's attribvites at one time of life, and at another time of life those may be displaced by the attributes of the mothor. {(I) The offspring may inherit a residue of charac- teristics of both parents, plus acquired ones of the child. No one is moulded exactly after parents. (e) The child may have physical resemblance to one parent, but may have psychic similarity to the other. The nerve centres are not subject to physical appear- ances. (/) The power of transmitting latent qualities is possessed by all highly-developed organisms, and this law is exceedingly important in its bearings on the occurrence of insanity. " It may be written," as Dar- win says, " in invisible ink, ready to appear on the proper test being applied." There seems to be a law of evolution and develop- ment, in which attributes tend to appear in the off- spring about the time of life at which they appeared in the parents, and this is especially true of traits that have been recently acquired. It is not merely the successive changes of development to which this rule applies, but also to other features, such as nervous defects. For example, in the family of Le Comte blindness was inherited through three generations, and no less than twenty-seven children and grandchildren were all affected about the same age. This rule is certainly true in some cases of insanity. In this institution at present is a mother and her three daughters, all HEREDITY. 241 accomplished and well-educated women. The four have the same form of delusional insanity, and have had since the invasion of the disease some ten years ago. Priorry tells of a family, every member of which became insane at the age of forty. Esquirol relates a case in which the grandfather, father, and son all committed suicide when in or near their fiftieth year. Of course, in many of these cases the law of sugges- tion must be taken into account. At the same time, the operation of this law may explain many an appar- ently causeless outbreak of insanity. The latent malign influence becomes the active agent of mischief. The seed, like that of the mustard seed, lay in the soil an inert germ until conditions favourable to its growth gave it developing energy. When the degree of kinship between the parents becomes too close the offspring deteriorates in every respect. Hereditary taint, when transmitted through several generations, gradually leads to degeneration somewhat in the fol- lowing sequence : 1st. In the first generation we find, apart from nerv- ous symptoms, the disappearance of ethical feelings. 2nd. In the next generation a tendency to various excesses appear, especially animalism and dipsomania. 3rd. In the third generation there is perhaps suicide, or an affective form of insanity ; and, finally, there appears more profound forms of mental disorders or want of development, such as congenital idiocy or imbecility. If little new blood is introduced the race becomes 16 242 MEICTAL DISEASES. extinct. It is not safe to establish laws of heredity based upon experiments on the lower animals. Their physical differences and mental aptitudes have not that stability which we find in man. They have not the variations found in man, nor have they the per- sistency in forms and conditions of existence. The veterinary surgeons can predict and obtain results in breeding which a law of selection could not obtain in human beings. In man's complex organism the law of inheritance of like qualities is largely moditied by laws of variation. The son is not the exact imaije of his father, nor of his mother, nor is he a simple mixture of their qualities, as he would be were the law of heredity one of simple inheritance ; that is, of like be- getting like. It is not possible to predict what will be the exact mental qualities and bodily features of the child of two persons, whose characteristics are very well known, nor so much as to tell what its sex will be. Not only so, but in a large family of children with the same parents no two are alike in mind and body. Each has a distinct personality of its own. Solomon, wisest of men, did not trust his wisdom to decide the quarrel between the two women about the child which each claimed to be hers. The resem- blance of the child to one or other of the claimants was not such as to found a decision upon. Twins, so like in features and bodily outline, may and do differ very much in their mental make up from one another. The Hungarian twin-sisters, that lived united by their backs for twenty- two years, had extremely TlEnEDITY. 243 different temperaments, althoucjh after their deaths their blood vessels were found to communicate, so that the same blood served both. The same was true of the Siamese twins, who died a few years a<:jo. It is also remarkable that a mother supplies the foetus and child for nine months of its intra-uterine life with her blood, and it has been evolved from her ovum, yet she does not always stamp her whole individuality, or any of it, on the child. We, in our ignorance, simply state that blood supply is one thing, and the selective law of cells, each according to its kind, is quite another. Dr. Oliver Wendell Holmes, in his " Elsie Venner," put the subject as follows : " There are things parents can see, and which they must take account of in edu- cation, but which few except parents can be expected to really understand. Here and there a sagacious person, old or of middle age, who has triangulated a race — that is, taken three or more observations from the several standing-places of three different genera- tions — can tell pretty nearly the range of possibilities and the limitations of a child, actual or potential, of a given stock ; errors excepted always, because children of the same stock are not bred just alike, because the traits of some less known ancester are liable to break out at any time, and because each human being has, after all, a small fraction of individuality about him which gives him a flavour, so that he is distinguish- able from others by his friends, or in a court of justice, and which occasionally makes a genius, or a saint, or ^44 • MENfAt WSEASfiS. a criminal of him. It is well that yoiihg persbiis cah- not read ttiese fatal oracles of nature. Blind impulse is her highest wisdom, after all. We make our great jump and then she takes the bandage off our eyes. That is the way the broad sea-level of average is maintained, and the physiological democracy is en- abled to fight against the principle of selection, which would disinherit all the weaker children. The mag- nificent constituency of mediocrity, of which the world is made up, are the people without biographies, whose lives have made a clear solution in the fluid menstruum of time, instead of being precipitated in the opaque sediment of history." The following points might be noted : Heredity is the most potent cause of insanity in its predisposing tendency. When it comes directly from either parent it is called immediate transmission. If it descend from both parents it is called double ; and if from collaterals then have we converging fac- tors. Simple heredity is its descent from either father or mother. If it skip a generation and reappears it is mediate heredity or reversion. If it has existed for a number of generations then is it cumulative. When insanity appears in children at the same time of life as it did in the parent it is styled homochron- HEREDITY. 245 It is anticipatory as to the parental disease if it should make itself manifest hefore the time it has appeared in the parent. It may be similar or it may be transformed into some other form of nervous dis- ease. It may intensify as the race continues and progress to personal extinction, or foreign blood may be intro- duced which would dominate over the tainted and the downward tendency, when it might and does disappear. The fight towards health is the salvation of our race. One parent being insane is not as strong evidence of heredity as if parent and ^grandparent or parent and uncle, or aunt, or both, were insane. The insanity of brothers and sisters is of little value in respect to inheritance, unless strong extra evidence is produced to show the conditions of the life history of each. Cousins may have very near blood relationship or very little, as so much depends on the bequeathment of foreign or kindred diatheses. For example, one parent may have a hereditary taint, or may have been insane. The other parent may have been the possessor of good mental and physical health. A child of these parents, as the saying is, " takes after" the father, for example, largely in mind and body. On account of the dominancy of the paternal vigor in the child it may escape the dangers which may lurk in the constitution of the mother, and if this line of ancestry is maintained with suitable marriages, in which there is no taint, 246 MENTAL DISEASES. then may the insane heredity die out. The converse is also true, and when there is a line of deterioration intensified and perpetuated by misalliances then ex- tinction is the result. It will thus be seen that one child in the family may escape this tendency when another may be very susceptible to it, depending on which parent each resembles the most, and from whom it receives its inheritance. Children may be born before insanity attacks either or both parents, and children may be born afterwards. The former chil'lren have immunity, and the latter have the tend- ency downwards. It will thus be seen that the relationship of cousins maybe very near if the similitude should continue along the collateral lines, but remote if the children should follow in constitution the foreign blood introduced into the descent. SYMPATHETIC INSANITY. 24»7 CHAPTEE XXVI. SYMPATHETIC INSANITY. This is an old name for a disorder of the brain con- nected with the disease of a more or less distant organ, which has no apparent biological relation with the brain. Sympathy is either physiological or abnormal; sympathetic insanity is a morbid sympathy which affects the brain in a secondary way. This word sympathy, when applied to mental troubles, was used as early as the days of Homer, as he mentions it in this relation in his " Iliad." Aristoplianes has this term in his " Comedies." Hippocrates, the father of medicine, investigated the relation between mania and the irritation of the stomach, and has described the mental disorder conr nected with menstruation in young women. Aretius, an ancient physician of Cappadocia, places the seat of mania and melancholia iu the intestines. Galen enunciated his famous theory cf humorism, and attributed insanity to the injurious action of the bile. This view of humors or moistures in the human hody held ground down to the 18bh century. It was held that there were four prii^cipj^ 248 MENTAL DISEASES. " humours " or " moistures " in the natural body, viz., blood, choler, phlegm and melancholy ; on the combination of which the disposition of body and mind depended ; in other words, temperaTnent, or the tempering by mixture of these human elements. HuTnoral pathology meant morbid changes in those four elementary humors or fluid parts of the body, without assigning a.ny influence to the state of the solids. This blood produced phlegmon ; bile produced erysipelas, etc. These views are now known to be fanciful ; yet, we know that all the body has not only a community of interests, but each part of it is in intimate relation to every other part in sympathy and function. It is not to be wondered at, then, that many excit- ants to mental diseases are found primarily outside the brain ; as, for example, some uterine affections, intestinal worms, hepatic suppuration, catamenial disorder, heart disease, tuburcular diathesis, the dyspepsias, and such like. As I have said before, however, we are not to put the effect before the cause, as is done so often by practitioners. Very often the reflex influence is from the nerve centres to the organs. So it would be bad practice to treat the errant organ which is only throwing out signals of distress functionally. Sympathetic insanity hiay be naturally divided into two categories ; SYMPATHETIC INSANITY. 249 1st. Insanity produced by functional disorder. 2nd. Insanity produced by morbid conditions. The disorders of the former class are such as puberty, puerperal, menstrual, ovarian and climac- teric insanity. The disorders of the latter are such as insanity from diathesis, derangement connected with general diseases and with neurotic conditions. Time would fail me were I to enter into details to show how derangements of the digestive and other organs affect the mind. Esquirol and Wichman tell us that they have found displacement of the transverse colon a common cause of insanity. I hav^e never done so. A large number of the melancholy afe afflicted with some form of intestinal trouble, especially duodenal catarrh. Organic lesion of the liver is not often found aniung the insane, but functional derangement of the liver and bile-ducts is quite common. The psychoses of renal origin are not few. Although diabetes is not actually primarily an affection of the kidneys, yet it plays an important part in the causation of mental disorders. Thirst and polyuria are often absent in patients thus afflicted. Cardiac affections are very common among the insane. Considering how much physical tone depends upon heart action, both as to volume and regularity, it is 250 MENTAL DISEASES. not to be wondered at that its condition affects brain diseases. The puerperal condition is a powerful factor. We see it in the eclampsias of child-birth. A sane mother, in an hour or two after sanity has been lost, becomes a raving maniac, either from blood poisoning through the disintegrating uterus, or because of shock in an explosive form to the greater and less sympathetic systems. We know how great are the reflexes mani- fested in the ramifications of this manifold system of fibres and ganglia. The vascular tone, the stimuli to heart and arteries, the influence on nutrition, the animal heat, not to speak of the effect on general pathology, all show the results produced through the influence of this system of nerves. The relation of one part to another is strikingly seen in diseased conditions. For example, facial neuralgia causes congestion of the conjunctiva and lachrymation ; salivation occurring in pregnancy ; faintness or constipation due to irritation of hepatic or renal calculus ; contraction of vessels and arrest of urine, set up b}^ calculus in the kidney ; partial cramp of vasomotors, confined to the extremities of the fingers, seen sometimes in angina pectoris ; the effects of cold on the vessels of the extremities, complain- ing various neuroses of the extremities; convulsions from teething, severe burns or bowel complaint ; tetanus from a slight prick in, say, one of the extremities ; flux from the intestinal vessels is a sequence of the irritation of some foreign body in SYMPATHETIC INSANITY. 251 the canal, or of the collapse, from perforating ulcer of stomach or intestines; contraction of cerebral ves- sels may be caused by the irritation of the proximal end of the divided posterior roots of the sciatic or other spinal nerves. All show sympathetic rela- tions. Sciatica may induce saccharine urine, the fourth ventricle being here the centre of the reflex arc. Examples might be multiplied to show what a I community of interests the nervous system has, and that any malign influence affecting even distant parts, may and does set up brain disease and in- sanity. A number of authors give to us particular forms of insanity as being allied to particular bodily lesions. They tell us that we may expect one organ to pro- duce melancholia when diseased, another delusions, another, it may be, mania, another stupidity, and so on. This coupling together specific mental conditions and definite organic morbid states is a classification more fanciful than real, as we know that no two people are physically or mentally counterparts of one another, so diseased influences are never uniform in their operations. To the above list might be added as active or predisposing causes, rheumatism, fevers, syphilitic poisoning, the various cachexias, gout, scrofula, pyeemia, and such like. 252 MENTAL DISEASES. These do often directly and indirectly become important factors in the production of insanity. In studying the life history of patients intellifrently the existence of one or more of these eccentric dis- eases should be diligently sought for, and their influ- ence valued in brain disease. " Recent physiological and clinical investigation more and more tend to set up the brain as the great inhibitor and stimulator of all nutrition; in short, the master of functions of all other organs and tissues. It influences strongly both the blood for- mation and the blood supply. Any alteration in the brain state has a more or less trophic efl'ect on the organs of the body. " On the other hand, we are coming more practically to recognize that the condition of the nutrition of all the tissues and organs aflect the brain directly through the changes they produce in the blood, and reflexly through their different nerves. " We are not surprised when an attack of indiges- tion causes irritability and depression of mind, or when impaired metabolism results in lassitude, or when badly-working kidneys produced sleeplessness with hallucinations of the senses. " The recognition of the action and reaction of peri- pheral organs and brain is now daily experience in medical practice. " This clearly implies an intense reactiveness of the highest of the b^-ain fi^nctions, manifested in mind SYMPATHETIC INSANITV. 253 phenomena, to all abnormalities of function and nutri- , tion throughout the body. " The mental centre is necessarily the highest and the most universally related of all the nerve centres." — Clouston, in Psijchologictd Dictionary. These central truths show that in our main divi- sions of the different forms of insanity there is an artificiality which excludes too much the central fact of a community of influence in all the organs focaliz- ing in the supreme nerve centre. Unless these sympathetic relations of the various parts of the body to the brain are constantly kept before the mind in our diagnosis, then will we fail to understand and properly appreciate all the factors influencing the object of our investigation. 254f Mental biSEASfiS: CHAPTEK XXYII. THE BORDERLAND OF INSANITY. Neurasthenia. The name neurasthenia, or muratropia, is as good as any term we can use to describe this nervous dis- order. The class of patients to which this formidable word can be applied is very large, and is growing larger day by day in this nerve-exhausting age. The patient's mind is " centred all in seU'." The woes and aches and pains such endure — real or imaginary — and which are recited to the physician with weari- some reiteration are legion. The old story is to such ever new. The history of these multiform afflictions becomes an old friend in its familiarity. The weary doctor in his rejoinder can only encore his previous homily to relieve the recurring distress. This sad recital is repeated from week to week, and from month to month, until recovery or insanity has taken place. The concentration of thought on all the varied moods and feelings which the patient may possess intensifies the mental pain and aggravates the nervous condition. We know in our own experience how much mental anxiety or anguish depresses physical function. Fear is more distressing than pain, and T»E borderlaNId Of insanity. 255 tngs at the heart-strings with greater intensity. Out of this class comes the many suicides who are not insane, and who leave behind them sensible but woeful epistles to friends or acquaintances. In medical literature this condition has been given many names, such as cerebrasthenia, brain exhaus- tion, general debility, nerve starvation, " run down," poverty of blood, spinal irritation, and other terms " too numerous to mention." This disease is not to be confounded with hypochondria, hysteria, or insanitJ^ Each of these conditions is well marked and easily discerned by any observant physician The morbid fears of insanity are usually dehnite and permanent, and accompanied by delusions, which are tixedly believed in by the insane patient. The neurasthenic, on the other hand, will tell you how unfounded are their extravagant ideas, and that they can temporarily banish these vagaries, but only to return again, like the swing of a pendulum. These cer-recurring whims pull down the physical energy, and the bodily depreciation reacts on the mental until the nerve masses and the physical activity are mutually put out of gear for the time. The functional want of harmony is bordering on the pathological. The morbid fears of people thus nervously un- strung are as varied as are the individuals. The list of their fancies and wild imafrininss is endless. All are based on some groundless alarm in respect to themselves or in their relation to others. Men full of energy and push succumb to the depression. 256 MENTAL DISEASES. " Enterprises of great pith and moment," which in their best estate they would have taken hold of without wavering, and have carried through successfully, row paralyse them in mere contemplation. The brain debility conjures up lions in the way, or mountains too high to climb over. The fears and forebodings of indefinable evil about to come, the unnatural and morbid dread of impending adverse circumstances have been the means of bringing about commercial or business disaster before friends see that worry of months, and it may be of years, has been drawing on the patient's stock. The reserves of the nervous sys- tem, which we all have in store for emergencies, have been consumed, and the fagged-out system has no alternative but capitulation, which it never does without a struggle. The neurasthenic may be divided into three classes : 1st. Those who complain of general weariness, be- coming easily tired, having poor or capricious appetites, being restless, yet look fairly nourished and healthy. 2nd. Those who are evidently feeble. They are usually pale, thin, and show generally a waste of tissue and a breaking-down without any evident local disease. 3rd. This latter class contains those in which we find a hysterical condition and anaemia, especially in chlorotie females. It is well, however, in all such cases not to jump too hastily at conclusions, lest organic and local THE BORDERLAND OF INSANITY. 257 disease should exist, and the nerve conditions only prove to be symptoms indicating permanent trouble, which may need special and direct treatment. 1 have made mistakes myself in this direction, and many cases have come under my care in which my pro- fessional brethren have been guilty of the same sins of omission. Be thorough in your examinations. All these phenomena are defects, outside of brain disease, of a permanent character. The identity is not present, but the family resemblance is striking in this brood of evils which border on insanity. The want of sleep, followed by a low power of thinking in the pursuit of daily business ; the weakening of the power of attention and a desire to wander from necessary thought ; a shrinkage from doing a business which heretofore was a delight ; becoming abnormally wearied in mind when doing routine and ordinary work ; not the natural facility to put ideas into words, and an unnaturalness of temper in respect to small matters and on small occasiois; and change of manners and feelings to near friends and relatives without any just reason, are cardinal characteristics. We sometimes meet with the other psychical extremes, such as unusual and constant buoyancy of spirits, mental exhilaration not natural, loquacity and flighti- ness, which are observed by everyone except by the individual himself. So marked are these changes of character, that many such are accused of having become drunkards. The accu«