- ■ ,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 :
^<VILLIA1VI BRIGOS,
WESLEY BUILDISOS.
Montreal: C. W. Coates. Halifax: S. F. Huestis,
<i-5%{
PREFACE.
This manual is simply an introduction to the study
of Mental Diseases.
It is intended for the senior medical student and
the busy physician, who may have neither time nor
opportunity to study the higher and more intricate
branches of psycho-physics.
The Author has attempted to be as practical as
possible, and has left out matters of secondary impor-
tance to the profession. It is to be hoped this hand-
book will accomplish what the writer had in view in
these respects.
Once for all, the Author acknowledofes his indebt-
edness to such eminent men as Bucknill, Tuke, Gower,
Hughlings Jackson, Gray, Bevan Lewis, Regis,
Mercier, Savage, Maudsley, Clouston, etc., etc.
p. C,
1895,
f *^ APR 1 7 WOf. J
C O N T E N T S^V T A^^^^*^
CHAPTER I'AOR
I. The Brain 9
II. Mind 21
III. Brain Pathology 27
IV. Insanity— What it is Not 37
V. A Delusion 47
VI. The Manias 56
VII. Dementia 69
VIII. General Progressive Paresis. 76
IX. Puerperal Insanity •:.... 87
X. Circular Insanity. 94
XI. Melancholia lOQ
XII. Moral Insanity . . 122
XIII. Epilepsy of the Insane ,.,.. 130
XIV. Syphilitic Insanity , 145
XV. Onanic Insanity 149
XVI. Paranoia 159
XVII. Phthisical Insanity 167
XVIII. General Bodily Conditions 177
XIX. Amentia 182
Vlll CONTENTS.
CHAPTER PAGE
XX. Mind Stress 188
XXI, Notes on the Condition of Patients on Exami-
nation 198
XXII. Treatment of the Various forms of Insanity. 202
XXIII. Treatment of Mania 210
XXIV. Epilepsy, Masturbation and Melancholia .... 221
XXV. Heredity 237
XXVI. Sympathetic Insanity. 247
XXVII. The Borderland of Insanity 254
XXVIII. The Borderland of Insanity— (Cojiimncrf).... 265
XXIX. Aphasia '. 285
XXX. Crime and Responsibility 291
XXXI. Legal Points in Relation to Insanity and
Crime 309
XXXII. Moilical Witnesses in the Courts 315
Index 325
""^ — ^^--5-^.
^ APR 1 7 1905 t
- — •• - , nl-l'-".- '■
MENTAL DISEASES.
CHAPTEK I.
THE BRAIN.
It is not my intention to describe in detail the
anatomy of the brain. You, no doubt, are well versed
in its structure, both gross and microscopic, yet there
are many anomalies in the arrangement of its blood
supply and cell clusterings, as well as in the relation
of its nerve fibres, which are of surpassing interest.
The organ of the mind is the capital of the body, and
all executive action of the whole organism, however
remote, is represented in it to a greater or less degree.
A few points in this relation are worthy of a passing
notice. The first is in respect to the circulation. You
will remember the difierent provision made on each
side of the body for the outflow of arterial blood from
the aorta. On the right side, and near the outlet of
the heart, the arteria innominata is inserted into the
aorta. About an inch and a half from this point it
ends in two arteries, viz., the subclavian and the
common carotid. This arrangement provides for only
10 MENTAL DISEASES.
• ■
one aperture in the aorta for these two large blood
vessels. On the left side the two corresponding
arteries spring independently from the aorta, and are
a considerable distance from the heart. Why this
want of symmetry in both sides of the body ? Nature
never does anything at haphazard, but always with a
purpose. It has no lumber-room for useless fur-
nishings, neither has it changes, but from design. It
seems to me that onlv one outlet is made so near the
heart on the right side for the two arteries, so as not
only to strengthen the aortic parietes at this point,
but also not to diminish, but as little as possible,
lateral pressure on the blood flow by having one
opening instead of two so near the outlet of this
muscular pump. .
It is also worthy of remark, that while the arteria
innominata springs at almost right angles from the
aorta, the left common carotid leaves it at an obtuse
angle, and to such an extent that the long axis of
both vessels is almost in a straight line, or with only
a slight divergence. This statement is also true as
between the left internal carotid and the middle
cerebral, so that emboli floating in the aorta more
readily fir^d their way into the left hemisphere than
into the right. The cuts in many books on anatomy
do not show this construction to the same extent as
is seen in the cadaver.
The two internal carotids and the two vertebral
arteries on entering the skull make curvatures almost
J ike the letter S, which are possiblv for the purpose
THE BRAIN. 11
of breaking, to some extent, the force of the powerful
intermittent impulses of the heart upon the current
of blood sent into the delicate nerve structures of the
brain. The goose-neck flexures may possibly be also
to allow elongation of the arteries in the various and
extensive movements of the head. This arrangement
is also seen on the lower jaw, in which is much
movement, as exemplified in the facial artery and in
the internal maxillary and pterygoid portion of this
artery.
The next observable arterial arrangement, as our
search goes upwards, is the wonderful circle of Willis,
whose main object is to enable the two vertebrals and
the two internal carotids to anastomose with one
another. This reservoir also checks to some degree
the blood flow. It is a local supply deposit which
may be necessary on a sudden demand, and as the
carotids supply the front part of the encephalon and
the vertebrals through the basilar, the posterior part,
the communicating branches which compose the most
part of the circle are lines of supply of blood from
one part to another. This remarkable arrangement
is the more necessary,, seeing that in the further
progress of the arteries to supply blood to the brain
proper, they seldom intercommunicate with one
another.
The next wonder upwards is the unusual distribu-
tion of blood on the surface of the brain, as from the
outside the arteries dip into the centre of the organ.
This is trqe of all the arterial blood in the skull going
12 MENTAL DISEASES.
to the brain, with the exception of a few nutrient
vessels which go into the medullary substance from
the basal vessels. We know this is not the arrange-
ment Jn the other organs of the body, such as the
kidneys, the lunsfs and the liver. In these, each large
artery seeks the central portion and from this point
sends out blood supply to the periphery. In the con-
gestion of these organs there is room to expand on
account of being surrounded by soft or yielding sub-
stances. Not so with the brain, as it is enclosed in a
bony envelope which is unyielding, hence the least
hurtful positions for the blood vessels are in the
limited space between the brain and the skull, in the
openings between the hemispheres and between them
and the cerebellum, as well as in the ventricles, such
as we see in the lateral ventricles, where a section of
the pia mater is deposited under the name of the
choroid plexus. Did the comparatively large arteries
go into the centre of the brain and branch off from
this to the cortical substance the result would be
that in active or passive congestions the delicate
nerve substance would be so impinged upon as to
seriously, if not dangerously, impair its function.
We are to remember that so functionally active is
the brain that nearly one-fifth of the whole blood of
the body is needed to do its work. When the blood
is largely sent along the various spaces in the skull
this untoward result is very much minimized. Room
is made in dangerous congestions by driving the
fluids of the brain for the time into and through the
THE BRAIN. IS
hundreds of foramina in the skull and in the spinal
column, and thus additional space is provided in such
emergencies. In spite of this well-known fact, learned
treatises have been written to show that brain con-
gestions is an impossibility because of static impedi-
ments.
The pia mater is the great arterial reservoir of
blood from which the brain is literally supplied. It
is a close-fitting envelope on the surface of the brain,
dipping into the sulci and sending into the brain
substance vascular loops of unequal length. These
anastomose very little with one another, nor with the
central arteries, and each has its own returning vein
going into one of the sinuses.
The veins which go into the longitudinal sinus
have several peculiarities. In the first place they
run from the arterioles away from the direction of
the heart upwards, which is not the rule with the
other veins of the body. The second strange arrange-
ment is that the mouths of the veins enter the sinus
towards the blood current and not in its direction.
It is possible this construction has two objects in
view — the one being to prevent the too rapid flow of
blood from the brain, and the other being to check the
current in the sinus, which might otherwise be too
impetuous, especially into that whirlpool of venous
blood, the torcular Herophil', where six large sinuses
converge before taking the downward direction to
the heart. A secondary result of impetuosity would
be to draw too rapidly after the venous stream
14 MENTAL DISEASES.
arterial blood before it unloaded its vitalizing ele-
ments ; not to speak of the venules not having time
to have their contents loaded with the dead matter
which is being constantly carried oflf in these ambu-
lances of nature to the various excretories. The
longitudinal sinus is connected with the outside parts
of the body in two ways. We know congestive
headache is often relieved by epistaxis, because there
is a connection between this sinus at its aiterior part
and some veins of the nostrils. Then there is a con-
nection by means of many small veins between the
scalp, the diploe, the skull and the sinus. This is
why erysipelas in the scalp is so dangerous, as it
often spreads inwards along the veins and attacks
the meninges, and even the brain substance. The
layers of the grey matter are superimposed on one
another like the coats of an onion. They are five in
number, although some German authors say there are
seven. With these your anatomy has made you
familiar, although the different laminae have many
cells in common, yet each has characteristic cells,
largely distinguished by their shape. The round,
irregular, ovoid, pyramidal, caudated, fusiform,
spindled-shaped, are names which indicate their
form. The particular function of each class has so
far not been yet definitely determined. Different
authors give the number in an average and fairly-
educated brain from five millions up to sixty
millions. There is no doubt the number of these
determine the brain capacity and not the size of
THE BRAIN. 15
brain nor the quantity of grey matter merely. In
the child, the idiot and the savage they are com-
paratively few in comparison with the number found
in the active brain of a normal man.
To ieason from analogy, it might be suggested
that the layers of the surface, having comparatively
small cells, may be centres of sensation, and the
deeper layers, in which are giant cells, centres of
motion.
In the spinal cord there are small cells in the
posterior cornua in which is the seat of sensibility,
and the large cells in the anterior cornua, the seat of
impulses. So it is a fair inference to draw that the
cortical layer of the grey matter in the brain is the
centre of sensibility, and the deeper layers, in which
is the larger class of cells, the centre for energizing
and emitting motor stimuli. The apices of the tri-
angular cells all point towards the cortex as if they
were polarized. There is no doubt each cell has an
autonomy, an individuality and an organic sensibility
of its own, and that clusters of them act in consensus
from sympathetic union to produce combined
functional results. Such a community has a head
centre from which directions emanate to bring about
definite results, so we find in the order of complexity,
the neural tissue made up of nerves, ganglia and
centres. Malpighi discovered cells in A.D. 1687, and
described them, yet little notice was taken of this
important discovery for nearly 200 years afterwards.
The brain is the larges mass of nerve substance
16 MENTAL DISEASES.
contained in the body of any animal possessing a
brain. The sum total in bulk of all the other parts
of the nervous system cannot equal the brain. In
its absolute weio;ht the average human brain is
heavier than that of any other animal, except those
of the elephant and the whale, but these are of much
lower organization. In relation to the weight of the
body the brain exceeds that of all other animals.
The relative size of the brain is no criterion of intel-
ligence. Man's brain only averages the one-fiftieth
of the weight of the body. A number of creatures
have greater averages than this, and with little
mind power.
The brain is very simple in its construction. This
is necessary when we considered its many-sided
work. Were it specialized as machines are it would
of necessity be limited in its operations. It is virtu-
ally a loose structure composed of cells, nerve fibres,
connective tissus and blood vessels, yet it is the seat
of sensation, ideation, volition, consciousness and all
the phenomena which are seen in the sensori-motor
and ideo-motor operations. No wonder it is the
centre of so much speculation and investigation.
klZJnedu
Fig. 1.
Fig. 2.
f0riorsive
Fig. 3. •
1. Centre for motor aphasia (Broca's region).
2. Centre for sensory aphasia, speech images, auditory centre, word
dearness.
3. Hypoglossal field.
4. Facial field.
5. Motor trigeminus field.
6. Centre for agraphia. , ' '
7. Centre for coarse arm movements.
8. Centre for coarse leg movements.
{>. 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-
2<S MENTAL DISEASES.
lutions are on a plain. In old age there is an uneven
atrophy apparent. This progressive shrinkage is also
seen in premature dotage, especially if brought about
by alcoholism. An uneven atrophy is always seen in
cases of paralytic dementia, and in chronic dementia
and melancholia.
When such a degenerative condition is found, the
colour changes from a normal grey to a yellowish
white, doubtless, because of the nerve cells decaying
into a granulo-fatty substance.
Out of sixty- three brains exa nined by Tucke, there
was an average atrophy of 5 J oz. per brain among the
chronic insane. In thirteen of these patients, who
were over sixty-five years of age, the average amount
of lost substance was 8 J oz. A few were atrophied
as much as 14 oz. Normal atrophy commences
between fifty and fifty-five years of age, and in some
at forty-five years of age. In such, shrinkage is not
condensation and increase of specific gravity, but a
loss of material. There are many exceptions to this
rule. A very little added to or taken from the sur-
face of a round or ovoid body, means a great deal in
the sum total, as our knowledge of the measurements
of such shaped solids indicates. It is a matter of cubic
calculation, and not of a mere superficial area.
When measuring the cavity of the skull, about 15
per cent, is deducted for space not occupied by the
brain. The average specific gravity in health is 1,040,
ranging from 1,026 to 1,046 and upwards.
The specific gravity may diminish by eff'usion of
BRAIN PATHOLOGY. 29
serum, or by the accumulation of fat globules. In
softening, fatty matter predominates. In degenera-
tion the organic elemento are apt to change into the
form of the hydro-carbonates.
Inflammation is seldom a primary cause of insanity.
It may be in a secondary way. The organizable pro-
ducts in inflammation may, after it subsides, remain,
and by contraction affect and partially impede blood
flow in the meninges, and in cerebritis produce, as a
result, atrophy of the brain tissues. We see this con-
dition in atrophy of the liver, from inflammation of
Glisson's capsule.
Because of any such impediments to vital action,
stasis may take place by adherence of blood cor-
puscles to the arterial walls and thereby prevent
plasmic exudation, or excessive nutritive exudation
may cause hypertrophy, and thus impede functional
action by pressure.
We have also hypertrophy largely made up of
adventitious tissue, amyloid corpuscles, calcareous
and fatty granules. All are evidences of retrograde
metamorphosis. Connective tissue may take the place
of nerve substance, or it may be an increase of other
depreciated elements of a low order.
We may have substances formed in a normal way,
but after being built up they deteriorate in structure,
vitality and tone.
We may have in brain disease then as causes of
insanity :
1st. Subacute inflammatory degeneration. In this
30 MENTAL DISEASES.
congested condition there are no fibrin exudates and
no pus cells, as seen in cerebritis.
2nd. Chronic hypersemia.
3rd. Fatty degeneration {a) as found in small blood
vessels ; (b) in nerve elements ; (c) in new morbid
products ; (d) in retrograde changes of hypertrophied
connective tissue.
4th. Amyloid degeneration, as seen in little starch-
like bodies which give starch reaction.
5th. Pigmentary degeneration, which is mostly met
with in the ganglionic centres.
6th. There is derangement of the connection be-
tween the nervous and vascular systems, causing
disease of the minute cerebral vessels, in the form of
fatty or calcareous decay in the coats.
7th. Albuminous matter may exist or serous fluid
may be effused into the structure of the brain, and
thereby separate vessels, tubules, fibres and cells.
8th. Molecular changes take place in same way by
th3 means of blows, violent concussions, vitiated blood,
emotional storms and such like. These changes may
be very serious, yet beyond the search of the scalpel,
the microscope and micro-photography.
9th. The blood supply is an important factor in
insanity. Deficient quantity and quality act upon
the nerve centres and these react upon the vessels,
thus brain structure and function are afifected. Heart
troubles are verj'- common among the insane, and the
blood circulation is affected thereby. Fatty degenera-
tion of the heart means loss of muscular tone, con-
BRAIN PATHOLOGY. 31
sequently feeble contraction and blood flow, hence
low brain vitality. Imperfection in the aortic valves
means regurgitation and clot formation, and embolic
results. Aortic aneurism is followed by a ^low blood
flow from the heart, feeble impulse and the existence
of clot, hence embolism. In addition to these untoward
conditions we often find hypertrophy of the left
ventricle, which of necessity hinders systolic action.
10th. Many of the cells seen in senile atrophy look
in the microscope like little blackish-brown spots, and
mi5ht easily be mistaken for blood clots. The opthal-
miscope often shows this condition in the retina.
11th. Calcification takes place in the cells as well as
in the coats of the arteries. It is a return of a living
cell to the primitive form of dead matter. The
retrograde step to disintegration is " to the earth,
earthy."
12th. Maudsley, in his "Pathology of Insanity,"
well describes the unknowable pathological con-
ditions : " There are numerous facts available to prove
that the serious modifications in the constitution of
nerve element many take place without any know-
ledge of them otherwise than by the correlation of
energy. After great and prolonged mental exertion,
there inevitably comes exhaustion, which may be so
great that the brain is utterly incapacitated for
further function. A greater increase of phosphates
in the urine testifies to the disintegration of nerve,
yet neither microscopist nor morbid anatomist would
succeed in discovering any diflPerence between the
32 , MENTAL DISEASES.
nerve substance of the brain of one who, after due
rest and nutrition, was prepared for a day of vigorous
activity."
The sudden shock of a powerful emotion may pro-
duce instantaneous death, just as a stroke of lightning
may end life perhaps in the same way, but neither in
the one case nor in the other may there be any detect-
able change. Electric fish are exhausted by constant
irritation, but there is no apparent nerve change.
Carbonic acid kills. So do such poisons as strychnine,
aconite and such like, but beyond temporary blood
congestion they leave no sign. Mechanical, chemical
and life changes doubtless do take place, but there
may be no, physical evidence of them. The change
is molecular and beyond human ken, just as is
seen by the blow of a hammer on a magnet lying on
an anvil when it is demagnetized at once, but no
microscope nor chemical analysis can detect the
atomic change. A colourless chemical solution of salts,
which will change their affinities when brought in con-
tact, do so in the common fluid without possibility of
detection by eyesight, yet when evaporation takes
place and chrystals are formed it is found that new com-
pounds with new forms and new properties have been
generated when the molecules were beyond human
observation. It is not to be wondered then that great
changes may take place in the ultimate elements of
the brain producing mental dethronement and not
discernible by our inspection.
We are not to forget what pathology has taught us
BRAIN PATHOLOGY. 33
as existing in all diseased conditions of the physical
system, and which has divided such into two classes.
1st. Injiltrdtion. This is a passive process and
means excessive no^'nial deposit out of place.
The fatty, calcareous, the amyloid and pigmentary
desrenerations are in the nature of chemical rather
than vital processes, and are often found in old age.
The phosphates and carbonates of lime are normal
constituents of the nutritive fluid, as well as are the
albuminates. The former are chiefly found in the
coats of arteries just as fats are found in liver cells,
muscles and nerve substances to excess.
2nd. Inrolution. — This is a physiological process.
The type of a structure is changed froui its normal
condition. It is a ^metamorphosis of tissue and not a
deposit. It commences in a cell, and changes its
nature. It is a living formation, and not merely an
inert deposition. It can reproduce itself as a normal
growth does, but mere deposits can do so only by
infiltration.
There are four recognized forms of involution : (a'»
Fatty metamorphosis ; {b) cloudy swelling ; (c) mucoid
softening ; {d) colloid degeneration.
What has been at first abnormal may continue in
this state, and after a time will put on a physiological
habit. We see this law of repair as a legacy in
zymotic diseases, and an irregular habit of functional
activity may be seen in special organs, such as the
stomach, the kidneys and the uterus. In all such it
is in fact perverted nutrition assuming a normal law,
8
34 \ MENTAL DISEASES.
A scar reproduces a scar. A callous, where a fracture
of bone existed, remains as such throughout a long
life. The adhesions of pleurisy or peritonitis organize
and reproduce themselves as readily as normal struc-
ture. Adventitious tissue reproduces itself in all
parts of the body when it assumes a permanent form,
so when insanity takes place, at first it produces
pathological changes of a pronounced kind. Mental
abnormality arises therefrom, when recovery takes
place and the mind seems to assume its normal con-
dition an abnormal habit has been formed which
leaves in a comparatively healthy state mental ab-
normalities. Patients, of whose recovery we ' ave no
doubt, state candidly that they have not the mental
robustness they formerly had, although to an outside
observer no weakness in mental capacity is observed.
It is possible that disease which attacks tissues never
has all its foot-prints eradicated, but always leaves
traces of its visit behind after its invasion has ceased
to be aggressive.
In all forms of insanity there are two classes of
lesions, as some one has well stated, viz.:
1st. The constructive. These include disorders of
function and structure, such as are involved in
inanition, indigestion, malnutrition, malassimilation
and toxic effects.
To counterbalance these disturbing elements and
agency, we need two classes of remedies : (a) The class
which gives nutrition ; (b) the depurating class. The
BRAIN PATHJl.OOY. 35
former furnishes building-up material, and the latter
rids the system of effete and toxic accumulations.
2nd. The second-class of diseases may be called
flia destructive. They embrace the various cachexias,
such as cancerous, syphilitic, tuberculous, the athero-
matous and other forms of degeneration.
The treatment in this class must be tonic, stimulant
or alterative. In the former class, nature is hampered
for want of material. In the latter class, gross
pathological changes have taken place. In treating
insanity these facts require to be noted.
Clinical Conditions.
Insanity may develop because of clinical conditions,
such as we find in :
1st. Anoemic insanity, which may be from malas-
similation and consequent brain starvation, or chlor-
osis, or indigestion, with consequent blood impoverish-
ment.
2nd. Diabetic insanity from blood poisoning. —
Post-mortems show want of brain nutrition, conse-
quently atrophy of the cortical substance. These two
classes of patients are usually afflicted with melan-
choly.
3r(l. Insanity of Bright s disease. — In this also
there is blood contamination, weak heart actior and
as a resultant of these two conditions we have dropsy.
Such cases are mostly maniacal, because of the toxic
agents aflfecting the great nerve centre, and which
have not been eliminated.
36 ■ MENTAL DISEASES.
4th. The metastatic insanity is far from beinj^
seldom .seen. The nerve centres are often attacked
because of rheumatic conditions. When syphilitic
psoriasis disappears, or old ulcers heal up, or erysipelas
.suddenly departs, or asthma is relieved, then in a
substitutionary way some form of insanity supervenes.
In addition to the.se metastatic chantjjes we see
in.sanitv occur in the inanition succeeding acute
febrile diseases, such as typhoid, in puerperal condi-
tions, in peritonitis, in persistent malarious fevers,
after the exhaustion of surojical operations, and after
an attack of la grippe, whether this is thoracic, abdom-
inal or affecting the nerve centres alone.
These, and such disea.ses, may not be causes of
in.sanity, but having established bodily weakness, the
mental enfeeblement, heretofore latent, becomes mani-
fest, and takes active possession of the brain to its
hurt.
INSANITY — WHAT IT IS NOT. 87
CHAPTER TV.
INSANITY— WHAT IT IS NOT.
It is not mere eccentricity. That is congenital. The
oddity is natural to the individual, hence this warp is
not a diseased condition.
It is not cranhism. That means the turning of the
crank of one idea to the partial exclusion of other
modes of thought. This is seen in every genius, who
has made his life-work turn in one direction, and who
is usually good for little in every other mode of
thought. The crank may be useful or useless, harm-
less or vicious, silly or scholastic, according to his bent
of mind. He may be naturally a man controlled by
a dominant idea, or this one-sidedness may be inten-
sified by education or environment. He is, however,
not insane.
The delirium or mania induced by fever, toxic
agents, such as alcohol, opium and its salts, cocaine,
hydrate chloral and such like, are not insane condi-
tions. They are fugitive in cause and sequence.
The natural decay of old age, with its loss of mem-
ory, its childishness, and even its delusions, is a
senility progressing along natural lines of decadence.
Unmistakable insane conditions must exist, superadded
to senile failure, in order to constitute mental disease.
38 MENTAL DISEASES.
Idiocy or imbecility are simply arrested brain
development from nutritive or trophic defect, with
the consequent mental limitation. This stunted con-
dition is brought about along physiological, not
pathological, lines, therefore is not insanity.
The delirium which precedes death, hysteria and
simple hypochondriasis are too temporary, evanescent
or intermittent to constitute psychic disease.
A number of these conditions are classed by some
authors as insanities under the head of " Toxic Insani-
ties," and are classified as saturnine insanity, alcoholic
insanity, morphinic insanity, haschish insanity, etheric
insanity, chloralic insanity, coeainic insanity, and
oxy-carbonic insanity.
On a pathological basis these distinctions are fanci-
ful and finical, unless a permanent mental disease
follows the use of and abstinence from these drugs.
Even then the toxic influence may not be the cause
but only the occasion of insane manifestations. Un-
less we adhere to morbid conditions as a basis of our
definition of insanity, then no definite formula can be
given. Mere ephemeral states cannot be classified.
: - Insanity.
Insanity is a fixed physical disease, which affects
and controls abnormally the language, conduct and
natural characteristics of the individual.
Any definition of insanity must, of necessity, be of
a general character, as the signs and symptoms vary
as does each individual from any other person in
INSANITY — WHAT IT IS NOT. 39
physical and in mental elements. The definition
(riven might be analyzed as follows : —
1st. Fixed, to distinLTuish it from the fugitive effects
of toxic agents, from tlie deliriums of fever, and such
like temporary mental unbalance.
2nd. It is always a physical disease. There is no
reason to believe that the entity called mind is ever
diseased. If the organ through which it makes itself
manifest is in tune, then will the operator be able to
healthily make known its normal condition. The
medium is at fault, and not the agent.
The term physical is used instead of simply brain
disease, because in a large class of insane the causes
primarily are found in parts of the body outside the
skull. ■
We observe this in puerperal insanity, insanity
from heart disease, insanity from dyspepsia, or from
kidney troubles. It is true, these disturbing centres
may only be the occasion rather than the cause if
hereditary conditions exist. Yet, the initiatory im-
pulse is given from without.
The reflexes and their potency in disease are being
better understood now-a-days, and in no realm of
medicine is a knowledge of them of more importance
than in nervous and mental abnormalities.
Until a comparatively recent period the locality of
a disease, when discovered, was thought sufficient for
our diagnosis ; but now we find it necessary to take
into consideration the trophic centres and the sympa-
thetic relations of the parts affected.
40 MENTAL DISEASES.
3rd. The disease is abnormal to each individual.
The natural traits and idiosyncrasies are changed,
so we have in common use the phrase: "He is not
himself." In studying an insane individual we must
measure his present conditions by the healthy standard
of himself. We have no common measurement ot
mankind as we have in cubic and lineal dimensions
in the British Museum. As there are no two persons
alike, except in a very general way, so no true estimate
can be made of any man's mental condition by com-
paring him with anyone else. ,
4th. It will not do to judge by language alone, nor
even by conduct alone. We must form an opinion
based upon all the elements which are characteristic
of the new departure from the life history of the
individual placed in juxtaposition with previous habits,
traits and experiences. On the one hand, we have
natural, mental equilibrium ; and, on the other, men-
tal inco-ordination.
Classification.
To enumerate the classifications of authors would
alone fill a good-sized volume. Each writer launches
into emendations on the groupings of his cotempor-
aries or predecessors as he supposes his own produc-
tions to excel.
Associations have taken up the task, but with
indiflferent success. This is to be expected in attempt-
ing to classify phenomena which change in details
almost as much as one person diflfers from another.
INSANITY — WHAT IT IS NOT. 41
Any attempt in that direction must be of a very
jreneral nature. We see mania exhibited in mild
forms of dementia, melancholia and excitement coin-
habit in the same patient at the same time. The
same is true of melancholia and semi-dementia. We
have in proj^ressive paresis, during its different stages,
almost all external forms of mental abnormality.
At the same time, it is important to have some
knowledge of the best known groupings. Skae's
classification is held by many alienists to be the best.
He follows the plan of Morel and Kolk, and looks
upon mental disease from a clinical standpoint. In
other words, he attempts to put in groups the pheno-
mena of mind disease, and thus, as it were, give a
natural history of it. It is too complicated to be
practical in the study of the various kinds of insanity.
It will be seen, however, it is not entirely {etiological,
but is an attempt iu that direction. It is as follows :
(1) General paralysis; (2) Paralytic insanity
(organic dementia) ; (3) Traumatic insanity ; (4) Epil-
eptic insanity ; (5) Syphilitic insanity ; (6) Alcoholic
and toxic insanity; (7) Rheumatic and Choreic in-
sanity ; (8) Gouty (Podagrous) insanity ; (9) Phthis-
ical insanity; (10) Uterine insanity; (II) Ovarian
insanity; (12) Hysterical insanity ; (13) Masturbatic
insanity ; (14) Puerperal insanity ; (15) Lactational
insanity ; (16) Insanity of pregnancy ; (17) Insanity
of puberty ; (18) Climacteric insanity ; (19) Senile
insanity; (20) Anaemic iuvsanity ; (21) Diabetic in-
sanity; (22) Insanity from Bright's Disease; (23) The
42 MENTAL DISEASES.
• * * -
insanity of oxaluria and phosphaturia ; (24) Insanity
of cyanosis from bronchitis, cardiac disease and
asthma ; (25) Metastatic ; (26) Post-febrile insanity ;
(27) Insanity from deprivation of the senses; (28)
The insanity of Myxnedema; (29) The insanity of
Exophthalmic goitre ; (30) The delirium of young
children ; (31) The insanity of lead poisoning ; (32)
Post-connubial insanity ; (33) The pseudo-insanity of
somnambulism.
It need scarcely be stated that these divisions are
arbitrary, too minute, and put into prominence minor
symptoms which are not causes nor occasions of in-
sanity, but are only concomitants of deep-seated
diseased conditions, whose latency has been made
manifest by favourable conditions being produced.
No man could go into any asylum and group patients
into the infinitesimal assortment of Skae's classifica-
tion.
There is a great deal of force in what Dr. Pritchard
wrote, over seventy years ago, on this matter, viz.:
" I cannot conceive anything more preposterously
absurd than to attempt to classify diseases with all
the divisions and technolog}'^ of a botanical or zoolog-
ical system, and to force what is essentially disorder
and confusion to assume the appearance of that order
and symmetry which nature displays in the arrange-
ment of the organized world."
Clouston endeavours to classify according to symp-
toms, and because of this method it is more practical,
INSANITY — WHAT IT IS NOT. 43
although somewhat pedantic. The grouping is as
follows :
Melancholia (Psychalgia), mania (psychlampsia),
circular insanity (psychorhythm), dementia (psycho-
paresis), mental stupor (psychocoma), defective inhibi-
tion (psychokinesia), insane diathesis (psychoneurosis),
fixed and limited delusions (monopsychosis).
The Medico-Pyschological Association of Great
Britain has adopted the following classification :
1st, Congenital or infantile mental deficiency ; 2nd,
epilepsy with insanitj'^ ; 3rd, general paralysis of the
insane; 4th, mania; oth, melancholia ; 6th, dementia ;
7th, delusional insanity ; 8th, moral insanity.
This classification has been virtually accepted by
the American Medico-Psychological Association, with
the exception of the division under the heading of
" Moral Insanity," which unjustly seems to have fallen
into disrepute, simply because of a lax definition
having been applied to it in some of the courts of the
United States, and thereby criminals escaped unwhipt
of justice.
German alienists are divided on this subject, the
one class adopting tables based on mental manifesta-
tions solely, and the other on bodily conditions.
Bucknill, in his Psychological Medicine, makes an
attempt to combine both the somatic and psychical
symptoms in a study of the different forms of
insanity.
As a historic fact, it is worthy of note that a com-
mission appointed at a congress held in Antwerp in
44 MENTAL DISEASES.
1885, brought in a plan, and presented it to the Con-
i^iess held at Paris in 1889. It was adopted, and is
as follows :
(1) Mania, (2) melancholia, (8) periodical insanity,
(4) progressive systematical insanity, (5) dementia (6)
organic and senile dementia, (7) general paralysis, (8)
insane neurosis, (9) toxic insanity, (10) moral and
impulsive insanity, (11) idiocy.
Professor Krafft-Ebing, a distinguished German
alienist, has a classification with seventeen divisions
and fortv-one sub-divisions.
These varied classes, arranged by different authors,
show how difficult it is to go beyond general features
in the groupings.
Hippocrates and Celsus recognized only three states
of insanity, viz.: Mania, melancholia and dementia.
Ancient Roman jurisprudence accepted only two
classes ; that is, mania (furiosi) and dementia (mente
capti.)
The metaphysical divisions are: 1st, Insanity
affecting the intellect; 2nd, the feelings and moral
sentiments ; 8rd, the propensities or instincts.
The forms of insanity usually adopted by us in this
country, and incorporated in our jurisprudence, are :
(1) Mania (acute, chronic or recurrent), (2) melan-
cholia (acute or chronic), (3) dementia (primary or
secondary), (4) amentia (idiocy or imbecility), (5)
general paralysis of the insane.
Insanity can be studied from three distinct stand-
points :
INSANITY — WHAT IT IS NOT. 45
1st. An insane patient is diseased and needs medi-
cal treatment. He is the object of a physician's
care.
2nd. He is irresponsible, hence not amenable to
law and its punishment when violated. He can be
deprived of his liberty without perpetrating any
crime because of his helplessness, or because of
danger to himself or others. He is the object of
medico-legal enactment as children or idiots are of
necessity, because of defective or undeveloped intel-
lects.
3rd. There is a sum total view of insane conditions
in which all the mental problems are considered.
This may be called the medico-p.sychological aspect
of such cases.
Memoranda.
It is well to put in a systematic way the notes
which should be taken at every examination of a luna-
tic or a supposed lunatic. A case book should be
kept for this purpose as it is often necessary to refer
to these, long after the enquiry has been made. This
caution is especially needed should litigation arise
based on the insanity of such a patient. Memory is
treacherous, but a record is not apt to be. It might
be put in some such form as the following :
LIFE HISTORY.
Previous attacks, if any ; number and character of
each.
46 MENTAL DISEASES.
HEREDITARY HISTORY.
Age of parents ; relationship of parents or grand-
parents ; health of the same ; family diseases and
kind ; peculiarities of character ; consumption, hys-
teria, epilepsy, narcomania, or any of the numerous
nervous disorders.
PREDISPOSING CAUSES.
Worry, over-worjc, dipsomania, habits, calling,
infantile diseases, child-bearing, fever, traumatic
injuries.
EXCITING CAUSES.
1st. The moral causes, such as those of the emotions,
the passions and inordinate desires.
2nd. Physical causes, such as those acting directly
on the brain, or sympathetically ; anaemia, cachexia,
or any diathesis. The two classes of necessity over-
lap, so they might be grouped into (a) local causes,
(b) general causes, (c) physiological causes, (d) specific
causes.
A DELUSION. V 47
CHAPTER V.
A DELUSION.
A DELUSION is a false concept. It is an idea
orenerated in the mind and not immediately suoj-
gested by the organs of perception.
If an insane man believes himself to be a monarch,
or a demon, or a diety, or being composed of glass, or
being any other absurd or impossible thing, he is the
victim of any insane delusion. Strictly speaking,
illusions and hallucinations are delusions as they also
are false ideas in respect to the objective world.
These definitions overlap each other, but all mean in
the end false conceptions. A mere delusion is not in
itself any evidence of mental dethronement. It is a
common mistake to think that the false beliefs of
the insane must of necessity differ from the delusions
of the sane. The impression is that those of the
former are controlling influences in conduct, are fixed
and cannot be reasoned awav, which is held not to be
the case with the sane. This view is an error and
against human experience. The delusions of the
insane are often evanescent, have little or no effect
on daily life and, if feeble, may be reasoned away.
On the other hand, the sane may have false, fixed
beliefs, to which they may cling with stubborn tena-
48 MENTAL DISEASES.
city. The superstitions of the hundreds of millions
of heathendom, the mythologic delusions of classic
and educated Greece and Rome, the absurd beliefs
of many religions, from fetechism to the more subtle
aspects of many creeds and dogmas, the accepted
quackeries by even the educated, the incredible fads,
more extravagant than any insane mind would accept
as real beliefs, and the quasi-science and varied fana-
ticisms existing up to this hour, show that delusions
ar(j legion among the sane , and, stranger than all, in
which they have implicit faith, even to the death of
martyrdom.
The mer^ existence of a delusion is not per se an
evidence of mental disease. Race, religion, educa-
tion and environment must be taken into considera-
tion, as well as mental calibre. All these must 1)0
considered, and from the stand-point of a person
handicapped along such lines a delusion must be
judged. Cetewayo, the Zulu king, w^as full of delu-
sions, as were also his followers, but if even he had
declared that he was a walking assegais, with head
and feet attached, the most ignorant of his tribe
would say he had lost his head.
Demosthenes would have been declared insane by ■
the Greeks if, in his Phillipics against the Macedonian
king, he had declared that he had fought at Thermo-
pola3, had led the Greeks at Marathon and Platoea,
and had commanded at the naval battle of Salamis.
At the same time, he and his countrymen believed in
many gods, omens without number, and saw in every
/
A DEIAJSION. 49
/ ,
convulsion of nature the mysterious working of some
malign diety. Credulous as we are in many other
directions, we know that all Much were the delusions
of brainy and intelligent men. Analogous examples
might be produced from the history of Judnea, Egypt,
or Rome, or from any of the great nations of ancient
or modern times, not to speak of the ghosts, fairies and
hohfroblins of our fathers. Enough has been said to
show that insanity is a question of diagnosis which
unreasonable delusions mav and often do corroberate,
but having due regard to all the factors specified in
our estimate of mental obliquity or health.
There are many forms of insanity without delusions;
and, on the other hand, the delusive idea in itself is
not alone diagnostic of insanity, unless it has the
element of impossibility in it under the circumstances.
Delusions are as various as are the manifestations
of human thought. They have been classified by
Ball and Ritti as follows, viz. : (1) Delusions of
satisfactions, of grandeur, of riches ; (2) delusions of
humility, despair, ruin, culpability ; (3) delusions of
persecution ; (4) hypochondriacal delusions ; (5) reli-
gious delusions ; (6) erotic delusions ; (7) delusions of
bodily transformation.
Hallucinations. ' ^
A hallucination is a false perception, as is an
illusion, but it ditfers from it in being false in its
entirety. It is a deception throughout.
The senses give to the mind, sights, sounds, smells
4
50 ' , . MENTAL DISEASES.
and various other sensations which have no real
existence. It is more correct to say that the mind
misinterprets the supposed evidences presented by
the senses of the external world. The objective is
not transformed subjectively into true ideation, as
there is truly nothing objective. Those which exist
from some perversion in the organs of sense, or in
partial congestion of the brain, or from meningitis,
or from toxic agents, must not be confounded with
the hallucinations of the insane. We find illusions,
hallucinations and delusions as phenomena associated
also with sane and nervous disorders, such as mania-a-
potu, epilepsy, hysteria, catalepsy, neurasthenia and
such like.
In passing, it is worthy of note, that in the sane
the hallucination" of sight are more frequent than
those of hearing, but in the insane the converse is true.
Shakespeare has dramatically illustrated this fact
when Macbeth sees the dagger. Also in " Hamlet "
when the prince sees hia father, the king.
Nicolai, the bookseller of Berlin, by holding his
breath and thereby producing temporary brain con-
gestion, could conjure up to himself vision as distinctly
as in real life a goodly company of persons, and could
describe the dress of each.
Napoleon saw his star of destiny, but he was
epileptic. Castlereagh saw a child at his hearth, time
and again,
Lincoln, at critical periods in his eventful life, saw
a sailing ship.
A DELUSION. 51
Sir Walter Scott saw at times phantoms of the
(lead Byron.
Malebranche, the metaphysician, often heard the
voice of God calling to him.
Descartes, also a great philosopher, states that
after long confinement and study he felt he was fol-
lowed by an invisible person urging him to search
for truth.
Dr. Jonson (rare Ben) says he often heard his
dead mother calling him.
Byron asserts he was sometimes visited by appari-
tions in various guises. He was an epileptic.
Goethe declares he saw a counterpart of himself at
various times coming towards him. He could conjure
up at will ocular spectra.
History is full of such examples. Most of those
cited were doubtless produced because of blood con-
gestion in the brain, or nervous exhaustion through
mental worry or overwork ; in short, mind stress.
Each of us has false perceptions at times, such as
seeing motes in the air, ringing in the ears, phosphor-
ence; seeing objects apparently moving when we
ourselves are travellinof onward in a rail-car or in a
boat, seeing a square tower as if round in the dis-
tance, or seeing a straight rod as if crooked when
immersed in water ; all are illusions of the sane.
If we imagine we see certain distant objects, especi-
ally if we expect to see them, our imagination often
produces an impression almost as real as if they
existed. The sane experience and judgment correct
52 MENTAL DISEASES.
these false impressions. A hallucination is, properly-
speaking, a sensation supposed to be received through
the senses, but without an object.
It is well to state that there are three theories in
respect to hallucinations and their primary cause.
1st. The mental theory, which centres this condition
in the mind only as a false ideal.
2nd. The physical theory, which constitutes them
merely organic phenomena, and produce false impres-
sions upon the mind thereby.
3rd. A psycho-sensorial theory, in which there is
supposed to exist derangement or want of co-ordina-
tion between mind and body.
The last of these views is the one most generally
held to be correct, largely because of the fact that
certain forms of insanity with illusions and hallucina-
tions are found to exist with specific diseased condi-
tions in the specialized sensory centres.
Illusions.
An illusion is an error of perception. It is the
transformation in the mind of an unreal perception,
and the imagining that a real object is partially or
wholly something else. An illusion is partly true, as it
has a substratum of reality to suggest the error and to
build the ideal upon it. In short, it is a false apprecia-
tion of a real sensation. ■' ' * •
It is not to be forgotten that both sane and insane
may have illusions arising from disorder of the senses,
and both classes may form errors of judgment upon
A DELUSION. 6S
data directly derived from the evidence of the senses.
Let me emphasize the fact by repeating that an illu-
sion is a mental conversion of something really per-
ceived, into something that is not perceived. For
example, if one should suppose that the table before
me is an elephant, or should imagine that the street
cars which we now hear are making the noise of
cannon, he mentally converts something real (the
table or street car noise) into something unreal ; that
is, into the elephant or cannon's roar.
If these hallucinations or illusions are believed in
then are they delusive ; but if not believed in they are
non-delusive, so we mav have the two classes of defects.
Many forms of insanity have unchanging delusions,
and become diagnostic. They are called by the
German alienists primordial delusions. All such
may yet be found to exist with definite pathological
conditions peculiar to each.
The following points in the clinical history of the
insane are worth noting and remembering in connec-
tion with delusions :
1st. To be sure that in insane cases there is no
disease in the organs of special sense. If there is,
then is it possible to give a wrong diagnosis in respect
to the existence of illusions and hallucination.
2nd. When recovery takes place it is seen that
delusions and hallucinations chronologically take there
departure together. '^
3rd. False lines of thought or dominant delusions
54 MENTAL DISEASES.
give character and direction to the hallucinations
when they exist.
4th. In the failure of mental activity such as is
seen in semi-dementia, hallucinations and illusions do
not usually exist, and if they do they are of a mild
form and often of a fugitive nature.
5th. Fixed delusions of a pronounced kind are
often seen in that unbalanced, mental activity which
is named chronic mania, or in insane melancholia.
6th. Entirely deaf and olind persons have hallu-
cinations of sight and hearing, when insane.
7th. Hallucinations of sight are prominent in the
dark as well as in the light.
8th. In the acute stages of insanity, in any of the
forms in which it presents itself, the mental changes
are accompanied by corresponding variations in the
illusions and hallucinations. This gives additional
proof of their mental origin.
9th. As has been well said by some writer, the
hallucinations of the insane are not simply vague
sounds, or words, or lights, or ghostly shadows flitting
about. They are complex and varied, and often con-
sisting in seeing and talking with people in long con-
versations. Thev are often like a reverie intensified
or personated.
10th. In all these delusional states there must of
necessity be complexity in mental make-up and in
physical manifestation, such as change of conduct,
depreciated mental and moral vigor, morbid fancies,
and it may be largely organic life, as is seen in semi-
dementia.
A DELUSION. 55
Impulse.
This is a term that contains no correct idea of a
phase of insanity, if taken alone. It is often taken
and used to describe a sane act, such as impulsive
suicide, or impulsive homicide.
To shield a culprit these terms are adroitly changed
into the form of suicidal impulse or homicidal im-
pulse. These are insane acts and the latter state-
ments mean irresponsibility in the actor.
Impulse is an unfortunate word in this relation,
and has been us^d with effect in legal courts. If
insanity be a disease it cannot begin and end in an
impulsive act any more than could hydrophobia or
typhoid fever. It must have time for invasion, pro-
gress, and termination of longer or shorter duration
as all other diseases exhibit.
Insanity may and often does begin with an
impulse, but it will not end with that. In insane
impulse, as in acute mania, there must exist more or
less disorder of thought. We often see motiveless or
purposeless homicide come on suddenly and then
followed by delusional mania or dementia, or it may
be, one may be a sequel of the other, if it assumes a
chronic form.
Impulsions are divided into besetting impulses
(obsessions) and reflex impulses (impulsions, so-called),
according as they act with or without resistance on
the part of the individual. They are also divided
into intellectual, emotional or motor impulsions,
according to the sphere affected. (Regis). --
56 MENTAL DISEASES.
CHAPTEE VI.
THE MANIAS.
You will notice in your text-books on the different
forms of mental disease, how many, in the one desig-
nation or another, have the word mania attached to
a term which is supposed to be distinctive of the
various manifestations.
Take, for example, the word monomania, to which
different authors attach different meanings. Esquirol
states it to consist of m-ental disorder in which are
expansive delusions of an egotistic nature. This is a
very narrow definition.
Dr. Bucknill says, to the contrary, that monomania
is secondary to some other form of insanity, and is
usually a sequel to melancholia and means depression
of spirits. This definition is diametrically opposite
to that of Esquirol. Blandford holds that it is
simply chronic insanity, free from extremes. Mania
and monomania are virtually used synonymously.
Clouston gives it the euphonious term of mono-
psychosis, which means not simply that there is one
dominant idea in the mind controlling action. It is
the neurosis springing out of hereditary predis-
position, accompanied by lack of trophic power, and
as a consequence brain anaemia. The records show
that a large number of such die of latent phthisis.
THE MANIAS. 57
Bucknill and Tuko truthfully say : " We heartily
wish monomania had never been introduced into
psychological nosology, for, if understood in a literal
sense, its very existence is disputed, and if not, the
various morbid mental conditions it is made to include
by different writers lead to hopeless confusion. With
one author it means only a fixed inorhid idea ; with
another, only partial exaltation, while a third re-
stricts it to a single inorhld iuipuhc." The list of
authors with different definitions might be extended
almost indefinitely. Some author says that it simply
means & fragmmitar// ruania, or insanity, on a single
topic. There is now a tendency to give a new name
to the condition of so-called monomania, when the
dominant ideas are egotistic exaltation coupled with
persecution. The term is paranoia, of which I will
have more to say hereafter.
The term "partial insanity" or "temporary in-
sanity " has no clinical conditions to correspond to
one or the other. To give a distinct term to only one
prominent feature of mental disorder is misleading,
but to twist a word out of its world-wide interpreta-
tion is likely to lead to error in diagnosis. We might
put the monomaniacal group in juxtaposition, thus :
Monomania.
Klepto-
Pyro-
Eroto-
Homicidal
Suicidal
Mania.
58 MENTAL DISEASES.
The homicidal monomaniac has only a tendency to
kill another, arising out of a substratal general disease
based on delusions or merely springing out of impulse.
Yet, he is usually quiet and orderly, except in the one
lethal act. He cannot justly be called a iivxniac, as
there is no general excitement of a continuous nature.
The true maniac never plots injury to himself or
others, except by misadventure. He is centred all in
self.
The pyromaniac may coolly, deliberately and cun-
ningly burn houses and barns, yet give no evidence of
maniacal furor from beginning to end of his acts.
His hankering to do this form of destruction never
leads him to show excitement of any form.
The kleptomaniac steals useless things or one set
of articles only, in which is no advantage to him ; or
useful things which are never utilized nor disposed
of for gain or profit, without one moment of mental
perturbation from first to last. The morbid desire
to simply possess is given way to without let or
hindrance ; but there is no sign in language or con-
duct to indicate mania. So I might go on describing
these so-called partial maniacs in which are no excite-
ments, and to which the generic name of monomania
is not applicable.
I read the other day a work on this subject in which
the author had the usual craze for an infinitesimal
nomenclature. He called the "insane desire to marry"
by the classic term of "gamomania." This has been
endemic since the days of Adam and Eve, and is
THE MANIAS. 59
likely to continue until the final consummation of all
things.
The other day a German designated " the mania to
steal women's shoes," Frauen Schulstehl.
I might be permitted to add to such absurd dis-
tinctions, by calling erotic desire in a woman Tnano-
mania. My newly coined term would at least be
clinically correct in part if not in its entirety.
The word mania being attached to so many terms
leads to serious error in jurisprudence, and teaches
the public, from which are drawn our juries, to believe
that an insane person must of necessity be a maniac.
When the quiet, delusional and homicidal lunatic is
tried for murder or attempted killing, his manner is
so orderly in prison or in the dock that no wonder
ordinary men, to many of whom a lunatic is a curio-
sity, think that such a well-behaved man must be sane
and responsible, and he is hanged accordingly.
They do not know that the typical maniac does not
belong to this class, and that "raving madness" is not
very prevalent, even in hospitals for the insane.
Some such term as " Impulsive Insanity " would be
more appropriate in describing the so-called mono-
maniac. Those thus afflicted manifest the morbid
mental bias through varied impulses — some of one
kind, and some of another — yet, the diseased con-
dition of the brain might be largely uniform in all.
It is not to be supposed that each of the monomanias,
or each of the general manias, or, in fact, any one
of the myriad forms of insanity, with isolated signs
60 . MENTAL DISEASES.
and symptoms, has reco<^nizahle patholoj^ical con-
ditions peculiar to each as exciting causes. The
least molecular disturbance, the lowering of organic
life without disease, simple anuMiiia or hypera;mia,
or the cell-world in our nerve centres in sluggish
conditions may and does bring to the surface latent
traits of character without supposing peculiar and
distinctive brain changes to correspond to each mental
condition. The same may be said in respect to diseased
changes of a gross nature. We have being made
manifest the trend of individual minds in the so-called
monomanias without the discovery of any specific
form of disintegration which could be labelled. Until
such is found to be the case it is well not to divide and
subdivide mere symptoms, and attach to each phenome-
non a name which has no clinical significance.
Even the word vianla must be taken in a circum-
scribed sense as it enters into other forms of insanity
not thus designated. We find mania a prominent
feature in intense melancholy. Excitement is often
present in a dementia which is not profound. Par-
esis, in its early stages, shows pronounced mania.
Epilepsy is scarcely without it of the severe kind. It
is often an element in syphilitic insanity and the
paranoiac with strong delusions of persecution may
become insanely excited, goaded thereto by his false
ideas.
It is evident, then, that the term mania in its widest
sense cannot constitute a distinct class of the insane.
There is, so to speak, a correlation of mental energy
THE MANIAS 61
I
in many of the forms of mental alienation. These
translations are seen in the dominant and imperative
impulses. This metamorphosis of one outbreak into
another is often seen in so-called homicidal and suicidal
mania, pyromania, kleptomania and narcomania. All
these manias have common characteristics, but chanf^e
according to the mental and physical idiosyncracies of
each individual. The inhibitory power is weakened.
In other words, the balance-wheel which regulates
the motion of the volitional centre is out of gear, and
the moral nature is blunted, which so often controls
conduct. As Ribot, on " Diseases of the Will," puts
it, " They are conscious, inco-ordinated and incapable
of struggle."
Mania Proper.
It has been my custom heretofore to classify the
general manias into two great groups, viz., sthenic
mania and asthenic mania. In this respect I was
following the plan of well-known authors.
In thinking the matter over I have felt that the
word sthenic (or strong) was virtually a misnomer, as
the manifested strength was a call upon the reserve
force and was really an evidence of weakness. This
fact is seen in other diseases. Clonic and tonic spasm
is evidence of weakness, although there is exhibited
great power for the time. The same might be said
of the strength put forth in delirium tremens, in the
delirium of fever, or in the temporary power given
to men under the stimulus of various excitants, yet
62 . MENTAL DISK ASKS.
we know that a proportionate equivalent of weakness
must follow.
The maniac is f^enerally credited with possessinjij
an absolutely larpje amount of physical power, and
although one is now and again astonished at some
feat of unusual strength, yet it is at the expense of
latent power. The singleness of purpose of th''' delu-
sional maniac gives intensity and force to the acts ;
the same is seen, for example, in the prodigies of
physical energy performed hy soldiers or sailors in
the excitement of a battle.
The maniac is not physically stronger than the
sfine, yet the power of endurance in many of this
class is .simply astonishing.
A weak woman, for example, will, day after day
and night after night, talk, walk and gesticulate, an«l
at the same time take little nourishment.
This state of excitement may with intervals con-
tinue for months together, yet during such a period
there is little abatement of physical strength. No
sane person could do this without dangerous exhaus-
ti(m ensuing.
In a general way, insane mania may be said to be
(I physical ajfection, characterized by unumial menial
activity ivith partial or (•omj)lete incoherence, accom-
panied hy bodily excitement not normal to the
individual, and for luhich there in no rational
cause.
In the acute stage we have usually presented (a)
physical agitation, (b) mental perturbation of an exalted
THE MANIAS. 63
kind, (c) inhibitory powers for the time inert or par-
tially so. There is no mental lever to ref^ulate the
power, (d) Consciousness, memory and coherence of
speech ab.sent. Any one thus afflicted is a typical
case.
This form of frenzy very often comes on suddenly
and sometimes runs a rapid course to death. When
we liave in addition to the above .symptoms an
increase of temperature, muscular wastinf^r^ wiry pul.se,
refusal of food, sordes gathering about the teeth, a
brown, dry tongue, clammy sweat, tympanitis, short-
ness of breath, perpetual motion, involuntary urina-
tion and fci'cal discharge, twitching of the tendons
and muscles and persistent insomnia, then we know
that death, possibly sudden death, is imminent.
So like typhoid fever in its latter stages is this
acute form of mania that many authors give it the
name of typhomania.
I repeat, it is well to remember in this connection, as
well as in other forms of insane mental exaltation, not
to u.se the word deliritim as being synonymous with
mania. The former word properly belongs to and
designates the temporary mental derangement which
accompanies bodily diseases of an inflammatory or
febrile type, and which is only symptomatic of such
diseases in a subsidiary way. This is an important
distinction which it may be well to keep in mind; at
the same time, it is right to know that continental
writers often hold the two terms to be synonymous.
This is q, serious error in nomenclature and in clinics,
64 . MENTAL DISEASES.
as tlie two conditions are syinptoniatically quite
distinct.
The following points are noticeable in acute mania :
1st. It usually begins with a period of depression
of longer or shorter duration, and usually two or
three weeks in duration.
2nd. Its time of invasion in a majority of cases is
from three to five months, in some, however, it L3ts
for a year and more.
3rd. When recovery sets in it is often very rapid,
from a few days to about two weeks.
4th. The more intense the attack, as a rule, the
shorter it is. " The hotter the lire, the sooner it
burns out."
5th. A sudden attack of mania of an intense type,
bordering on what might be called frenzy, wilt' often
as suddenly disappear. Such cases are more apt to
have relapses than are those who have invasions of a
more gradual kind and whose convalescence is equally
slow.
6th. As a general rule the mental disease which
comes on slowly goes away slowly. There is less
danger of a relapse in such cases unless it is only a
phase in circular insanity. ^
7th. As a rule, asylum statistics show a preponder-
ance of cases on the female side.
The fact that woman are more nervous than men
and more einotional may be factors. It is not to be
forgotten that the puerperal state is often a cause.
yth. A mania often terminates on the invasion^
THE MANIAS. 65
of some other disease, as if two such diseased con-
ditions could not exist cotemporaneously. An attack
of pneumonia, of infiammatory rheumatism, of diar-
rh(»'a and such like are examples of conditions which
seem to modify if not extinguish a mania.
9th. The return of health is usually seen in mental
oscillations, as it were, of the psychic pendulum, and
not in a continuous and progressive improvement
without drawbacks. It is like an incoming tide with
its ebbs and flows, but with the trend upwards and
inwards of each successive wave.
10th. Mania attacks the patient with abnormality
in the mental mechanism. Sensation, ideation, per-
ception, memor}', volition and judgment are out of
balance, and hence lack of mental co-ordination.
In chronic mania we have all degrees of intensity,
from the most pronounced to the mildest type, many
of these live to a good old age, as the excitement is
not sufficent to drain to an appreciable extent the life
forces. Many of the least excitable are useful in
doing ordinary work about asylums.
It is difficult to give of this class an epitome of the
symptoms in detail, except in a general way. There
is more variety in the manifestations of a disease so
pronounced as mania than in the negative symptoms
of dementia, or in the quiet and often unobtrusive
conduct of these afflicted with insane melancholia.
The trend of a varied mentality is most plainly seen
in mania, and as in all diseases the idiosyncrasies of
5
66 MENTAL DISEASES.
*
each individual come to the front and show native
diversity.
In chronic mania the furious maniac is seldom seen ;
although, in past ages writers tell us they were very
common. In fact, the word maniac was bsld to mean
a raving madness or a frenzy.
The comparative quietness in our large hospitals
for the insane is mostly due to little or no restraint,
to personal kindness and the absence of brutalizing
and degrading methods in their treatment. Madness
under aggravation was not always a necessary pro-
duct of the malady, but was a result of unnecessary
restraint and mismanagement.
Chief officers of asylums have brought to them
ever and anon patients who are violent and boisterous
because they are in irons or tied with ropes and straps
by friends and relations, based upon the mistaken idea
that to be insane necessarily means to be dangerous.
At the asylum door these are removed and, as a rule,
the result is comparative mildness, quietness and
tractability.
The animal instincts rebel against restraint. This
is strikingly true should the mania be of the delu-
sional type. The insane patient will naturally mingle
the realities of the treatment to which he is subjected
with his delusions and suspicions and fears. If a
patient imagines himself to be in some place of tor-
ment, or is about to be murdered by his persecutors,
who are standing around him, he is apt to have these
morbid ideas intensified if he is treated badly. The
I
THE MANIAS. 67
lowest natures, sane or insane, animal or man, appre-
ciate kindness and almost intuitively know friends.
Many of these chronics are filthy in their habits,
and some of them even beastly. Numbers of this class
will not even obey the calls of nature. Some of
them will, every night, besmear their bedrooms with
their own tilth as well as their persons, and w'ill even
drink their ov/n urine. This jj^eneral mania is not, as a
rule, apt to lead to dangerous acts, and, in the chronic
form, is often manifested in a childish disposition
more than in anv maliciousness. The rule is, that we
find blunted sensibility, but occasionally there is, in
tho sensory sphere, hypeniRsthesia. The senses of
smell and taste are often deficient in sensitiveness,
l)ut sometimes very acute.
Unless this class is bordering on dementia there is
a good deal of intelligence left, and, if the mania is
of a mild type, such are very good workers. Our
insane gardeners, farmers, tradesmen ar.d mechanics
are indispensable as helps in the varied occupations
which are carried on in asylums.
Acute mania is a form of insanity often simulated
by imposters. The sham is easily detected. No
amateur lunatic can readily put on the wild, restless
eve, the ceaseless movement, throw toorether the dis-
jointed ideas and use the rapid utterance of acute
mania as the insane do. In acute mania the skin is,
as a rule, dry and harsh, or cool and clammy. The
malingerer, who lashes himself into fury, on account
of his exertion is hot and sweatinor, The maniac will
6S MENTAL DISEASES.
pass clays without sleep, and even weeks with only a
few hours at a tiine. No imposter can do that, nor
can he keep up the excitement for a lengthened
period. A pretender not well skilled in the different
forms of insanity will mix them up. He is a poor
actor ; and if hints are given of his inconsistencies in
his acting in his presence, it is astonishing how readily
the bait is swallowed and the incidental hints acted
upon. No insane man will care about hints or advice.
The deceiver succeeds better in simulating chronic
mania. In this he overdoes the signs, and, in his
eagerness to appear insane, he oversteps the bounds
of insanity and overshoots the mark. He usually
thinks a lunatic must constantly gesticulate, bellow,
rant and rave, and therefore indulges in gross exag-
geration. He pretends that he has no memory of
anything, and puts on foolishness and stupidity. The
really insane with chronic mania, if not an imbecile
or an idiot, is not so deficient of mental power. Few
will pretend to be insane unless to excite pity or to
escape punishment for crime, or to avoid heavy labour
in prison. A few such deceivers have come to us
from the Central Prison to avoid work, or to have a
better opportunity to escape, or to have, as one of
them said, " a good time, with plenty to eat and
nothing to do."
DEMENTIA. 69
CHAPTER VII.
DEMENTIA.
Dementia is the lowest form of insane intellectuality.
In short, it is mental decay because of brain dej^enera-
tion. It effects every mental faculty, and is stamped
upon and is patent in the intellect, disposition, habits,
manners, temper and general character of the indi-
vidual. It is mental deprivation, and is contra-dis-
tinguished from the mental exaltation of mania.
Dementia is usually classified under five kinds : —
1st. Primary dementia is the result of deficient
brain development. This is not insane dementia-
We see it illustrated in idiocy, congenital imbecility
and cretinism. It is not to be forgotten that in
amentia we have simply want of growth of brain
cells, hence circumscribed mind growth. This is not
mental atrophy from a higher developed condition and
pathological ; it is mind deprivation from physiolo-
gical failure in growth and activity. The instrument
is circumscribed, so must be the agent's power which
operates upon it.
2nd. Secondary dementia, as a sequent of other dis-
eases, may be centric or eccentric.
8rd. Senile dementia. This is not only the natural
decay of old age, but includes premature natural
70 MENTAL DISEASES.
decay, which often bej^ins at the second trial epoch of
life in many, because of a life of mind stress, or it
may be handicapped by a bequeathment of malison
tendency which precipitates mental degeneracy early
in life, should the conditions be favourable.
4th. Organic dementia. Under this head is classed
those who are thus afflicted as a result of gross organic
or traumatic injury to the brain.
oth, Toxic dementia, following the undue use of
alcohol, opium and its salts, and such like, including
the long use, in large doses, of the iodides and bro-
mides. In such, childishness often supervenes early
in life.
Strictly stated, dementia is a term which should be
used only in referring to physical disease which pro-
duces thereby acquired mental enfeeblement, while
imbecility should be a term applied to mental weak-
ness, based upon congenital, fo'tal or infantile arrest
of development,
The moral faculties being based upon, and spring-
ing out of intelligence, must of necessity be absent in
this class of the insane.
The changes are often seen after attacks of apoplex}-,
of paralysis, or of continued alcoholism.
We see in typical cases of dementia a change of
physiognomy. The countenance becomes expression-
less. In extreme cases the eyes have a vacant stare.
There is a silly smile on the countenance, or more
often meaningless apathy. In short, the silliness, the
stupidity, the relaxation of facial muscles, the list-
DEMENTIA. 7 J
lessness, the hanging head and dangling arms, the
lolling about in an aimless way, the altered expres-
sions of countenance, the puffy hands and feet are
appearances when once seen are not soon forgotten.
When such are addressed, they may raise their eyes
and look out at the corners of them, but they will
seldom raise the head. Ihey would burn before a
tire before they would move. In summer, Hies will
settle on the eyes of a dement or round his nose and
mouth, but their tittillation will not disturb his stoli-
dity and apathy. The saliva and secretions from
mouth and nose are unheeded. The urine and fyeces
pass involuntary as in early childhood. In the lowest
forms such would neither eat nor drink. The natural
cravings of hunger and thirst are at a low ebb. The
same may be said of endurance to pain. The face is
often purple, and the skin and hair become harsh and
dry. The perceptive faculty is faint. The emotional
nature is blunted. The sexual instincts are weakened
or destroyed. Memory, attention, logical sequence and
knowledge gained from experience have little or no
existence. The above description is that of a pro-
found case of dementia. There are all gradations of
this class up to those who are merely childish, but
have sufhcient intelligence to be usefully employed.
To this class I apply the term semi-dementia.
Secondary dementia has some other form of insan-
ity preceding it, such as mania, melancholia, paresis,
and some of the fleeting forms of delusional insanity.
Tiiis form may be a direct sequel to other forms of
72 MENTAL DISEASES.
insanity and there may be periods of slight mental
brightness interjected into its ccurse which would
look like partial recovery ; this temporary waking-
up from mental lethargy may be followed by a stage
of confusional ideas, and then comes a lapse again into
the chronic condition. It is usual with some writers
of psychiatry to call this transition stage tertiary-
dementia. In fact, it is not a different form, but is
only a temporary waking-up of mentality under that
rhythmic law of periodicity which is seen to a
greater or less extent in all diseases.
In the profound forms of dementia there is more
or less loss of common sensibility. Sometimes there
is the loss of the use of one of the special senses.
Sense-loss always means to some extent mind-loss,
as the special senses are avenues of knowledge of
the external world from whence our primary ideas
are suggested and generated. This statement does
not absolutely hold good in the deprivation of
recollections or retrospects of the past. Loss of
memory alone is not an infallible test of mental
dethronement or even weakness of intellect. Many
imbeciles have a wonderfully retentive memory, and,
for example, show great capacity in arithmetical cal-
culation. The imbecile, blind Tom, had a phenomenal
recollection of musical notes never heard by him
before in the new and unlooked for relations and
combinations of harmony and melody. Some one
faculty of the mind seems to not only tower above its
fellows, but also to dwarf them in their development.
DEMENTIA. 73
The human mind seems to be like a reservoir with
many out-flowing rivulets. The complete or partial
stoppage of a few of these gives more force and im-
petuosity to that which is unimpeded. We see this
rule in so many sons of genius who are great in some
art, but whose biographies show them to be very
small, indeed, in every other direction.
As a rule, because of incapacity to be taught, added
to want of judgment, the imbecile prodigies are
useless as citizens, except to be exhibited at dime
museums. Insane semi-dements often show great
ingenuity and originality in some one direction, and
are foolish withal. Those who have learned trades
and thereby have acquired manual dexterity need
little mentality to carry on the same occupation.
Many of the movements become purely mechanical
because of repetition, and the mind itself in the same
direction becomes automatic. Our insane gardeners,
tailors, shoemakers, carpenters and blacksmiths come
largely from among our semi-dements.
These are very useful patients. Many of them are
more or less intelligent. Some have harmless delu-
sions which, when pleasant, beguile the hours away
as they are facts to them, even if this mental pano-
rama is a building of castles in the air.
Organic life is seemingly in a good state, hence
excellent bodily health. They eat well, sleep well,
work well, and are generally contented with their
lot. They are usually gentle in manners and obedient
in doing any work assigned to them. At times one
•'. ' ^'^
/
74 . MENTAL DISEASES,
or another may, for a day or two, become intractable,
because of some delusion becoming dominant, but
this state passes away in time and all is well again.
They have, as it were, children's minds in adult
bodies. The vegetative functions are apparently
normal and the nerve centre of the mind has in its
abnormality assumed a physiological habit, as it
were ; and if an Irish bull is permissible, becomes
normal in its abnormality, just as we find in a scar,
in the callus of a once broken bone, or in the life-time
adhesions of pleurisy. The brain degeneracy has
come to a standstill and as a result the mind has
returned to a permanent state of childishness.
We find, however, that such easily succumb to
diseases of an inflammatory nature. The healthful
appearances are often deceptive and we see the want
of tone and the low recuperative power when the
system is put to the test from the drainage which any
active and aggressive disease makes on its vitality.
The reserves are few and easily exhausted and disin-
tegrated in the sustained and continuous battle for
life against these inroads. i
We are also to be guarded not to confound natural
failure of memory with diseased conditions such as
the insane dements show.
Esquirol included idiocy in the term dementia. The
distinction between the two classes is radical. The
nascent state and the acquired ; the want of develop-
ment on the one hand and the loss of acquired mental
faculties on the other make a line of demarcation so
DEMENTIA. 7-3
plain as not to be misunderstood. Jurisprudence
extends the meaninfy to all classes of persons afflicted
with mental weakness, as its standard is simply that
of mind-loss irrespective of causes and physical
states. In law it is merely mental capacity which is
considered. It is the citizen, not the patient, that law
considers in its estimate of responsibility.
The child of immature age, the idiot, the imbecile
and the dement are held to be incapable to discharge
an obligation, and are, therefore, not accountable for
their actions.
1 \
76 \ii:ntal diseases,
CHAPTEK VIII.
GENERAL FROGRESSIVE PARESIS
(UENERAIi PARALYSIS).
This is primarily a brain disease in the eorfcical areas.
As it progresses, the diseased condition spreads until
all the nervous system is involved, including the
spinal cord and the sympathetic. Its invasion is not
always uniform, although the mental symptoms are
usually first noticed, especially in superabundant
egotism and erratic conduct not natural to the patient.
He has a recklessness in respects to plans and the
spending of money in speculations generally dis-
astrous because lacking in judgment. He becomes
silly, impulsive and restless; and, although abstemious,
may be thought to be under the influence of liquor.
Then may follow a change in articulation. It is not
such as we hear in hesitation or stammering. It is
simply as if the tongue were too big for the mouth ;
in short, it is lack of co-ordination, and means partial
loss of control over the vocal organs. At first the
change is very slight, and might not be noticed by an
ordinary observer. After a time, he may speak dis-
tinctly at first, but if the conversation should be
prolonged his control becomes impaired. In the
incubative stage, when such come under the notice
GENERAL PROGRESSIVE PARESIS. 77
of the medical man, he may be deceived by the
apparent physical health ot' the patient. His appetite
is good, and it may be ravenous ; he has splendid
dic^estion ; he complains of no pains, not even head-
ache ; he sleeps soundly ; he feels well, and any en-
(juiry in that direction is usually answered by such
expressions as " I feel first rate " ; or, " I never felt
better in my life.'' The physical activity shows that
mere orc^anic or vejjetative life is so far little im-
paired. The friends, however, will tell of the change
of natural mental characteristics, notwithstanding
these evidences of physical health. There crop up
irregularity of temper, transitory defects of mind,
especially of intellect; lack of judgment and discretion
in following his usual occupation, and moral perversion
in untruthfulness and in gross venereal excesses which
may surprise his friends who may have known him
through life as a model of propriety and religiosity.
Intellect and morals are being dethroned. The general
practitioner too often overlooks these premonitions,
which are truly pathognomic, and often in certificates
of insanity call this distinctive disease " mania," or
" delusional insanity," or " dementia." Any of these
may exist, but they are only symptoms of this under-
lying general condition.
It is not to be forgotten that we often have the
prominent physical symptoms appearing first, and at
the same time may not be able to detect any mental
trouble. In my experience, as a rule, the mental
deterioration antedates the physical, but often both
7(S MENTAL DISEASES.
•
are coexistent in the initiatory stai^^es of the disease.
Bein^ a disease of the higher nerve centres, it is
evident that much must depend on the resistin<jf
power of those nerve masses in detail as well as
combined, hence the variety of phenomena presented
in respect to the invasion of the disease. The <;eneral
depreciation of co-ordination is very marked as the
disease advances. The lips are tremulous, sucl) as we
.see in a child about to weep. There is often grindin^^
of the teeth in the. last stage ; when the ton<;uo is
held out it trembles and is often drawn slightly to
one side. It re({uires an effort to protrude it.
Irregularity in the size of o.ie pupil compared
with the other is well marked in most cases, others
have simply enlarged pupils. The patient has a
shuffling gait and a relaxation of the muscle of the
legs, such as we see in persons walking on slippery
places and w^ho are not sure of their footing. He
dots not drag his feet nor bring them down with
a clatter as is seen in locomotor ataxia. It is not
so much want of muscular power, although that is
somewhat deficient, as want of directing energy.
The same is true of his prehensile power and feeble
direction, as is seen in the attempt to pick up a grain
or a needle.
In these respects it is distinct from true paralysis,
in which sensation and motion are last. The last
organized centres fail first. As a result the higher
mental powers, as well as the more recently educated
physical acquirements, are the first to show signs of
OENEKAI. I'UOCiUKSSlVE PARESIS. 79
decay and to throw out signals of distress. Hence we
have weak inemoVy, feeble concentration of thouj^ht,
Haj^ginf]; attention, lack of judgment, erratic conduct,
wild imaginings, muscular enfeeblement and inco-
ordination, primarily seen in the last ac(]uired dex-
terity through handicrafts.
At the early stage of the disease the mental symp-
toms are usually well marked. (Jccasionally he may
be melancholy, but ninety-nine out of every hundred
are full of hope and cheerfulness. Self-pride and
self-praise are prominent. Although poor, the paretic
may, in his imagination, think himself to be a man
of immense wealth. Millions of dollars are at his
command. He owns kingdoms and can dethrone
monarchs at will. He bestow\s favors lavishly, in his
own mind. He has plans of all kinds, which show,
to him, such gigantic wisdom and intellection which,
when made known, will astonish the world. No man
can compare with him in the vast grasp of his mind
or the grandeur of his diverse schemes. The asylum
may be his palace, and every person in it his slave or
his most obedient servant. His grandiose ideas are
many, and enter into the warp and woof of his daily
life, giving colour to all his tangled strands of thinking.
In short, his panoramic ideal world is most pleasing,
in which, with wildest fancy, he is "biggin' castles in
the air."
All such delusions may exist without paresis, so
the diagnosis must include the evidence of the
distinctive physical deterioration. As the disease
80 MENTAL DISEASES.
proj^resses these symptoms intensify Uiitil, last stage
of all, he lapses into dementia; yet, as a rule, he
eats well and sleeps well until near the end. On
account of the partial throat paralysis, when in
this condition, his food, if solid, has to be cut up very
fine for him, else in his bolting of his food he would
choke himself. He has to be closely watched while
eating.
Towards the end he loses control of the sphincters,
and becomes very filthy. Hemiplegia oftei) sets in,
and remains until death ; but, if the attack comes on
early, he may partially recover from it for a time.
Death may ensue from mere exhaustion in the great
nerve centres, or from epileptoid or apoplectiform
convulsions superadded, and which precipitate the
end ; or life may be shortened by the invasion of
tubercular disease.
The disease seldom lasts longer than four years, and
so far is incurable. Cures are said to have been made
in pronounced cases, but the diagnosis is to be doubted.
The extensive and profound pathological changes
which take place in the nerve structures, in the inter-
stitial substance and in the envelopes are too great to
be restored to health by any therapeutic agent put
into the human stomach. The same is true in respect
to the attempts to relieve the brain of the super-
abundant fluid by trephining, which some ardent
surgeons have attempted, and with not very satisfac-
tory results. It is true, glowing accounts have been
given of the results of these operations ; but, however
GENERAL PROGRESSIVE PARESIS, 81
brilliant the operations may have been, the end was
death. Tapping the membranes will not affect favour-
ably the diseased conditions of all the contents of
the skull and spinal cord. Women are not as subject
to this disease as men. In this asylum the proportion
is one woman to twenty men. The statistics of a
number of other institutions f^ive a much larger
proportion of women, even up to one in four of the
men.
Our experience here is, that the better classes of the
community are afflicted ; those who have lived well
and did not know what want was. Our private
wards are never free from it, on the men's side of the
house. As in all forms of insanity, the causes of
paresis are varied. Taking the life-history of each
patient to judge from, the principal causes seem to
be principally four : (a) syphilis ; (6) drunkenness ;
(<') sexual excesses ; (d) worry or mental stress. These
may be results in many instances rather than causes,
Tht! indications of the insidious invasion of the
disease often show themselves anterior to the de-
bauchery, licentiousness, and domestic or business
troubles. Friends may not notice this change ; so an
outburst of strange language and conduct may seem
to them to be the initiatory stage of the disease,
although it may antedate this time.
It has sometimes remissions, and these are often so
complete as to deceive physicians into the belief that
they are recoveries. In fact, some authors declare them
to be such, but a disease which never loses its grip of the
82 MENTAL DISEASES.
system, and which we know is sure to return sooner or
later, and end fatally, cannot rightly be thus desig-
nated. I have seen such in the reiaissions go out and
engage in their usual occupation from a few months
to a year and a half, and act rationally during that
halting period, but at last they return to die. In
many cases, such periods of apparent convalescence
may be often during the course of the disease, but
they shorten in duration as the disease advances.
Like an outgoing tide the waves may come back upon
the sand, but each successive wave fails to reach the
boundary line of its predecessor. The disease may be
old, but a correct record of it was first given by Bayle
in 1822. About twenty years ago I came across a
volume of 225 pages written on this form of disease,
by Dr. T. I. Austin, of Bethnal Asylum, England, in
1859. The diagnosis is well pictured, and on the
whole correct, and the pathology shows painstaking^
research for that day. As to its cause, he says : "The
wear and tear of modern society, the intense and
therefore frequently unsuccessful struggh; for position
or livelihood, which is everywhere going on around
us, and which is so characteristic of our age, and the
more frequent occurrence of mental anguish ; the
conse(|uence of domestic trials, may have actually
augmented the number of its victims." In strikinj^
contrast to the treatment of tlie insane in this day,
he graphically states that " FVom parisli workhouses,
and even from respectable wealthy homes, comes
many a poor, demented victim of general paralysis,
GENERA F. IMJOGRESSI VE F'AKESIS. H'A
with his head shaven, his nape hlistered, with leech-
hites on his t(!inples, and cupping marks on liis should-
ers, his wrists and ankles abraded or ulcerated from
restraint, his abdoinen discolored from havinfr b(;en
bound to his bed by a sheet, emaciated to the last
fle^^ree, his trochanters nearly starting through the
tonse, livid skin, with bed-sores over the sacrum and
on the nates, and with the inguinal clefts excoriated
by ammoniacal urine. He has been neglected by his
rlomestic attendants, who liave probably thought such
an existence was not worth continuing ; or he has
Ijoen hurrie<l into dementia and extremity \)y the
fervour of his doctor, who has evidently imagined he
had to deal with an acute and curable disease." This
dreadful recital was made only thirty-five ycuirs ago,
and is in striking contrast to the treatment of the
insane to-day in Christendom. The pathology of
progressive paresis is very distinctive, and in a
g(!neral way the life-history of a paretic could be
outlined, based upon the footprints of the disease on
th(! nerve masses.
There are adhesions of the membranes principally
over the front part of the brain. The pia mater is
found firndy attached to the brain substance, as if
glued to it. Jf the membrane is torn away it leaves
a rough depression, with serrated edges, very much
as we find in a phagfedenic ulcer. The cause of this
is, that part of the brain substance comes away
strongly attache<l to the membrane, and leaves these
pits where it is torn away. These adhesions are very
84 . MENTAL DISEASES,
characteristic, and differ from the usual inflammatory
adhesions, in being attached in isolated parts. There
is no evidence of pus or of there having existed active
inflammatory processes. It is likely that the morbid
condition proceeds from the brain to the membrane,
and not vice versa. Puncta are very numerous, no
doubt because of the passive congestion which existed
ante-mortem.
In short, it mav be said to be a chronic non-inflam-
matory process of deterioration, springing out of
excessive functional activity, or from a diseased con-
dition of the blood vessels specific or otherwise.
There is no doubt a morbid change in the ultimate
elements of the brain, and this molecular disturbance
means defective metabolism. Granular and other
morbid deposits are found in patches seemingly pro-
ducts of a low form of vitality. These adventitious
substances give no evidence of being tubercular, and
reagents show they are not of a fatty nature, nor
merely inorganic as seen by the hydrochloric acid
test. These granular deposits seem to be a kind of
colloid degeneration.
Sometimes the adhesions of the dura mater to the
inner table of the skull are so tenacious that it is
torn away with difficulty, and sometimes in layers.
The arachnoid is opaque in patches, and the sac made
by the membranes is abnormally f?ned with a semi-
gelatinous fluid, which is also found in the ventricles.
There is usually brain atrophy and vascular loops in
the capillaries. The vessels of the pia mater are en-
GENERAL PROGRESSIVE PARESIS. <S5
larged and as might be expected that condition is
seen in the lateral ventricles where the 2^^<^<' 'gutter
takes the name of the choroid plexus. Very often
the walls of the arterioles are incrusted with granu-
lations, and the surface of the membranes in patches
present scattered cell granules and extravasated blood
ijlobules. The brain shrinkage seems to be in the
white substance, for the grey layers seem unchanged
in quantity ; in short, sometimes there is development,
or rather hypertrophy in the interstitial structure,
with vascular tree-like plexuses o+' arterial vessels.
One convolution is not adherent to another, nor
does the "pia mater adhere to the brain substance in
the sulci. The reason may be physiological as it dip
between them purely as a net-work of blood vessels,
unaccompanied by fibres and lymphatics as is the case
elsewhere. The ventricles are larger than normal,
and occasionally the grey matter in places is thinner,
but is more dense. The apices of the sulci are not
all on a plain, but many of them shov/ shrinkage.
The white matter is often very much congested in
patches.
The morbid processes in the nerve cells may be brief-
ly summarized. The pyramidal cells in the lower strata
of grey matter are always affected. The ganglion
cells contain nuclei and, if in large numbers, they may
swell the cells out of shape.
This is not the rule, for the multipolar cells are
often shrunken, lose their angular appearance and the
caudates disappear. There is often in the brain evi-
86 MENTAL DISEASES.
flence of the various forms of pathological change such
as fatty, pigmentary and calcareous deterioration.
Vacuohe are often seen under the microscope, doubt-
less from atrophy of tissue, as would be the case were
the threads of a piece of woven cloth shrunken.
There is atrophy in the medullary nerve fibres.
Lymphoid, spider and connective tissue cells are seen
in large numbers both in the grey and white matter,
but irregularly placed in the different brains of
the paretics.
It will thus be seen that it is essentially a death of
tissue and may vary very much like the slow
natural process of senile decay, precipitated by the
exhaustion of trophic energy or over stimulation, or
the loss of nerve-cell power of restoration, or from
tissue hypertrophy or abnormal blood supply from
want of tone in the vaso-motor centres.
These radical changes are sufficient to account for
the mental state and for the hopelessness of medica-
tion to affect a cure. Much, however, can be done to
ameliorate the condition of this class during the
progress of the disease.
ri'ERl'EKAL INSANITY. 87
CHAPTEE IX.
PUERPERAL INSANITY.
Puerperal insanity is a very common form, and on
an average one in every 450 child-bearing women is
aftticted with it.
As a matter of fact, however, it cannot be classed
as a distinct form of insanity in its manifestations.
The difference lies in the cause rather than in the
symptoms. The exciting cause or occasion is usually
and primarily in the disturbance set up in the sympa-
thetic system, and the brain trouble is a sequence to
it. It may assume the form of mania or melancholia,
and sometimes, though rarely, of dementia. One
form may follow another in succession; that is, a case
may show all in its progress towards recovery or
chronicity. We are to guard against confounding puer-
peral mania with puerperal fever and its deliriumi.
They are distinct diseases, and the delirium of fever
is not the mania of insanity. The muttering inanities
of fever have few features in common with the con-
sciousness and partial intellectual endowment seen in
the lesion of mania.
Puerperal insanity manifests itself at one of three
periods in a pregnant woman's life, viz : —
88 MENTAL DISEASES.
1st. The insanity at any time during the child-bear-
ing period.
2nd. The insanity taking place at child-birth.
3rd. The post-parturient period, consisting of the
time of lactation and weaning.
It is sometimes the case, that in the first-class the
insanity may pass away at child-birth. The gravid
uterus seeming to be the exciting cause. Such are
usually melancholia and delusional. Some physicians
have recommended in such cases the induction of pre-
mature labor, principally for two reasons : (a) To put
an end to or at least shorten the attack ; (b) To pos-
sibly prevent the production of idiocy in the child if
it should live, or to destroy it for the same rea-
son. Apart from the ethical feature of such a prac-
tice, I may say that there is no reason to believe that
the mother would be benefited in any way by such
a radical measure, as many miscarriages brought on
by maniacal excitement have shown no improvement
because of these mishaps.
In the period of labour, especially in the latter stage
of severe and protracted parturition, there is often
seen temporary delirium, and even a short period when
delusions may exist, but which immediately pass
away on the birth of the child. This is not insanity,
properly speaking, as it is evanescent, and not fixed
in duration. Hereditary predisposition is an import-
ant factor in its production. Physical causes are
more frequently present than are moral causes or
emotional excitation. At the same time anxiety,
PUERPERAL INSANITY. 89
worry, grief, fear and such like are often potent
factors as excitants.
The insanity of lactation is usually brought on by
the weakness engendered from nursing the child,
added to the only partially-recovered condition from
child-bearing and labour stress. In primiparous cases
the danger is great, especially late in life.
Six weeks after confinement is the arbitrary limit
given to this form; but, of course, it may occur several
weeks after this time. I would say that three months
would be nearer the mark, as so much depends on
constitutional, local or predisposing causes, and dis-
turbances beyond our knowledge, which may take a
long period of incubation, or may not until the later
period have produced conditions favourable to its ap-
nearance.
A great majority of those cases of the second-class
become insane within two weeks after confinement,
and the greater part of these within ten days.
It may be said there are two classes of those thus
afflicted, that is to say :
1st. When the cause is apparently and simply
syvi})athetic. In this class the uterus and appendages
seem to be normal. The cause seems to be the shock
to the nerve centres, which are in an unstable con-
dition and ripe for an outbreak.
2nd. The .septic. In this class is not only weakness
from loss of blood, physical exhaustion, mental excite-
ment, but also septic material from even normal
decomposition finds its way into the open blood-
J)0 MEXTAI, DISKASKS.
vesHolH of tho ut(3rus, thence into the .san^niineous
system, poisonin^^ the hrain in its flow.
3r(l. Some autliors have a dass which they name
phranic. They state that inflammation of the hrain
supervenes on the invasion of a child-bed mania. In
short, it is encephalitis, with sub-acute inHammation
of tlie meninges. In such an attack we find not
mania, but simply delirium. I havcj never seen such
a case, altliough it is possible such may exist throuf,di
the septic invasion into the skull cavity. If in puer-
peral patients we find i^reat restlessness, insomnia
and violence, with white-furred ton<,'ue, rif^ors, tym-
panitis, swollen lef(s, suppression of discharj^es or
f(etid discharffes, sallowness of complexion, excessive,
clammy sweating, and feeble and rapid pulse, with
temperature very chanj^eable, ran^^ing from 100' to
104', then has puerperal mania assumed a dangerous
type.
In addition to what has already been written, the
following points should* be remembered: —
1st. In a great many women there is a direct trans-
mission of a tendency to break -down at the repro-
ductive times, just as we see at the trial epochs of life
in women and men.
2nd. Bodily conditions are to a greater extent
exciting causes than is moral or emotional distress.
.Srd. Child-bearing is more dangerous if not within
ordinary physiological limits ; for example, first preg-
nancies after, say, thirty years of age and upwards.
4th. Women who have had children, but, after
IM'KI{|'KI{AI. INSANITY. 91
many ye'irs of a noii-bearinjr period, havo a cliil<l at
tlu; men jpausL', ura suscoptihlo to be attacked.
')tli. Durin;^ pr(.';^aiancy there is a peculiar immunity
from any severe sickness. This in not absolute, but
the absence of various troubles at tliis time has
attractiid my attention.
(jth. A woman who has one attack is specially liable
toother attacks, if the pre[,mancy follows (juickly on a
I)revi()us invasion. It is possible that the dread of
another attack has an untoward psychical effect.
7tli. Some women suffer more when pregnant with
boys than with <;irls, and it may happen that insanity
accompanies the one or the other, but not often both.
<Sth. Puerperal insanity is more prevalent amonw
the rich or well-to-do than among the poor. The
artificial living, the less vigorous organism, the
neurotic diathesis so prevalent in the higher stratum
of society, the flabby organization for want of proper
exercise, the overfeeding, late hours and the unnatural
life of fashionable society and such like, all tend to
})liysically and mentally unfit such to face the trials
(^f maternity. The introduction of healthy mothers
from the humbler classes saves the race from extinc-
tion, as the well-known laws of heredity show.
9th. Illegitimate pregnancies seem to be more
dangerous to mental integrity than child-birth among
the married. Grief, compunction of conscience, re-
proaches of relatives and social ostracism must
seriousl}^ affect the bodily and mental health of such,
especially seeing many are young and not hardened
92 MENTAL DISEASES.
in vice. The majority of these are not prostitutes ;
therefore, susceptible to the loss of the social status.
10th. Among the poor the birth of twins is a serious
cause of mental depression ; hence its influence on
the mother to her hurt.
11th. Sudden frights, emotional excitation, blows
received, which may cause the child-bearing mother
to apprehend, as a result, deformity or injury to the
unborn child. This may prey on the mind constantly
and become a predisposing cause.
12th. It is my opinion that the injudicious and too
frequent use of ana3sthetics, and the use of instru-
ments in many cases, which some mothers have a
terror of, may excite the malign influence in heredi-
tary tendency.
13th. A dislike of friends and relatives and a
tendency to kill her offspring are often present. In
such, there is usually an element of melancholy, ac-
companied by emotional disturbance.
14th. My former teacher, Sir James Y. Simpson, of
Edinburgh, used to say that albuminuria was common
in such cases. Dr. Campbell Clark, of London, asserts
the same thing. These statements are no doubt true ;
and, as renal complications are so often found in
insanity, they commonly cause that form of disorder
at such a time.
loth. K-Jecondary troubles often set up, such as
pneumonia, abscesses and such like. The medical
at*^^endant must be on the watch for these, as such a
development will complicate matters very much.
PUERPERAL INSANITY. 93
16th. The forms which puerperal insanity may
assume are ahnost as manifold as are all the other
varieties of insanity.
17th. The free use of instruments in labour may do
untold injury to the child. The pressure upon the
brain by them is very wreat through a powerful
leverage, and no doubt produces molecular change in
a susceptible organ, which may doom the unborn child
to idiocy or imbecility. The necessary use of instru-
ments always gave me chills from fear of untoward
consequences, not only to the infant, but also to the
mother. The mental anxiety of the mother when
their use is proposed, and when they are applied, in
addition to the usual distress, may be sufficient to
precipitate a mania where inherited instability exists.
\i APR 1 7 1905
u.
"S^i^TAl:?:}^^
94 MENTAL DISEASES.
CHAPTEK X.
CIRCULAR INSANITY.
The most remarkable series of mental and physical
phenomena are those which constitute what is called
Circular Insanity. (French, Folie Circulaire.)
As far as we know, the pathological condition
remains the same from year to year ; yet, in spite of
this uniformity, we find alternations of melancholia
and mania, with intermissions, remissions or apparent
recovery between.
This round of varied manifestations is invariable
in sequence and variable in kind.
In this morbid cycle the order usually is :
1st. Mania, then remission ; then melancholia, fol-
lowed by remission, and back again to mania. This
order of sequence is always carried out in the insane
life of each individual.
2nd. The initiatory attack may come in the form
of melancholia, then remission, followed by mania.
This relation will then continue.
8rd. Another class may have these two forms of
insanity in the same order, but in the intervals, as
far as language and conduct are concerned, the patient
appears quite sane for weeks at a time, and were it
CIRCULAR INSANITY. 95
not that we know the form of the insanity, might be
discharged as recovered.
A few years ago, a political superintendent of a
hospital for the insane, whose experience was some-
what limited, but whose boastfulness was ample,
entered in his annual statistics all such intermittent
cases as " cured." He prided himself on his superior
methods of treatment by his recoveries. His profes-
sional brethren, whom he was maligning by implica-
tion, showed the fallacy of such a record. Eight
persons had in twelve months been discharged thirty-
two times as " cured," making thirty-two recoveries,
not of persons, but of cases, as th.. persons were only
eight.
When the two stages are definitely bounded the
period of mental relief must of necessity be equally
well marked. In many the change takes place from
one form to another in a day, and in some in a few
hours. As a rule, the shorter the duration of each
form, the more intense is each. One of the distinc-
tions in our diagnosis of these phases, from ordinary
mania and melancholia, is in these sudden transitions
from one to the other, which is not a usual feature in
the distinct and separate forms. They usually change
gradually, and remain unchanged for a considerable
length of time.
•It seems to me that the exciting cause of these
remarkable and regular changes must be in the
coming and going, in waves as it were, of the vital-
izing energy, which is seen at ebb and flow tide, in all
96 MENTAL DISEASES.
physical structures in health and disease. In the
maniacal period of the cycle we have an over-activity,
which carries with it into the mental and physical
worlds low inhibitory power and great exhaustion.
From such depletion of the powers of life we have
the quietude of prostration, to be followed by mel-
ancholia, from enervation. Should the primary at-
tack be melancholy, then have we a step towards
mania in the recuperation and rest among easily-
disturbed elements, which gather up an energizing
power, which is misdirected and over-active. The
balance wheel to the engine is out of gear, hence the
irregular movements. In other words, the pendulum
swings from one extreme to the other by oscillations,
according to a general law of motion, seen everywhere
in operation in nature. Take another example :
An electric battery may, by undue or continuous
conduction, exhaust the fluid in store ; or, on the other
hand, the chemical energy by being generated too
rapidly soon becomes inert, as its manifested power
is lost. Allow rest, and this subtle agent will
reaccumulate, the necessary conditions being present
to generate it.
The application is evident by analogy in this form
of insanity.
Circular insanity might be illustrated as follows ;
CIRCULAR INSANITY.
97
INTERMISSION
NOI55llNd3±Nl
^^ M ANIA
^^
VINVIAI ^^
7
98 MENTAL DISEASES.
These are among the cases which friends tease us
to discharge. The patients seem so well to relatives,
either in the remissions or intermissions that no
reasoning to delay avails much. The heart of a near
friend gets the better of the head, and a clinic to such
against haste is often a " Wasting of our sweetness on
the desert air." Many such are brought back in a
few weeks or months with profuse apologies because
of the precipitancy. The friends are not aware that
the lowest point reached on the mental thermometer
must be permanently raised to the normal before
recovery can be said to have taken place.
The conditions in this form vary much in duration.
As a rule, in each cyclical invasion the melancholy
exists longer than the mania. The intervals of cessa-
tion may be very short, in some cases only lasting for
a few days at a time. In others there are apparently
no intervals, as the one condition is immediately
followed by the other. There is no doubt the inter-
val exists before such a diverse change could possibly
take place, but it is not perceptible, so evanescent is
it. The sudden plunging from the quietude and pros-
tration of melancholia into the excitement of mania is
often striking. Sometimes the two conditions have a
short period between them of apparent dementia,
or, more properly speaking, lethargy, yet this stupid-
ity is more apparent than real, for such will after-
wards astonish you by telling what they remembered
while in this condition.
We must be guarded against drawing conclusions
CIRCULAR INSANITY. 99
too rapidly from seeing one or two alternations in this
form of periodical insanity, as these may exist for
one or two changes, and yet not be a typical case of
the double form.
These may be only ephemeral coincidents, such aft
are seen in puerperal mania followed by melancholia.
Sometimes in periodic ovarian irritation we may
have alternations, not from inherent, but outside in-
fluences ; that is, from eccentric, not centric causes.
A large number of this class belong to those with
hereditary tendencies, hence so seldom any of such
recover, as the disease assumes a fixity of morbid
condition when a few cycles have made their malign
impressions on the organism.
It usually comes on early in life at the pubescent
and adolescent ages. There are exceptions, but they
are few. At the " trial epoch " of life the insane
diathesis, in this alternating form, makes itself mani-
fest in this persistent and enduring form. When
great physical changes are taking place the heredi-
tary neurotic weakness begins to make itself manifest.
The two forms may vary in intensity. The one
may be mild and the other severe ; both may be very
pronounced, or both may be mild. There is no uni-
formity in these respects, even in the same individual.
I came across, the other day, in some publication a
statement made by Dr. Thomas Willis, a celebrated
physician, who lived from A.D. 1G22 until 1670,
which describes in quaint language this periodic form
of insanity, accompanied with alternations. He says :
TOO , MENTAL DISEASES.
" After melancholia we have to treat of mania,
which has so many relations to the former that the
two disorders often follow each other, the former
chanoring into the latter and inversely. The melan-
choly diathesis, indeed, carried to its highest degree
causes frenzy, and frenzy subsiding, changes fre-
quently into melancholia or atrabiliar diathesis.
These two disorders, like fire and smoke, often
mask and replace one another, and if we may say
that in melancholia the brain and the animal spirits
are obscured by smoke and black darkness, mania
may be compared to a great fire destined to disperse
and to illuminate it,"
That is a free translation of the Latin of this great
physician living nearly three centuries ago. It is a
good description of alternating insanity, and shows
keen observation by this quaint old doctor.
The pathology of circular insanity is what might
be expected from its etiology.
There will be found atrophy of the convolutions to
some extent. The membranes are thickened, as is
also the calvarium, and very often the arterioles are
found to be aneurismal. Large quantities of fluid,
more or less opaque, are found in the ventricles and
in the subarachnoid spaces. The whole condition is
that usually found in the chronic insane, and ?^jhows
the hopelessness of medication.
The sanguine French alienists, however, think they
can modify or prevent attacks by the free use of
quinine, or haschish, or the bromides, or digitalis, or
CFROMLAH INSANITY. 101
morphia, and such like. When many dru<:!;s are
recommended to cure a disease, it is evident there is
no panacea for it.
Hysterial Mania.
Hysteria, in its myriad forms, is not insanity. It
has no fixity as to duration. There is no evidence of
pathologjical chancre anyv^rhere, nor is there reason to
believe that such exists unless nerve instability merely
can be looked upon as such. The temporary aberra-
tions are so evanescent and the consciousness of the
existence of such a state do not point to mental dis-
ease of s'jch a nature as to constitute it insanity any
more than we see in the mere hypochondriac, who is
ever at his dying hour, or the neurasthenic, who has
delusions which come to him with painful persistency,
but which he sees in their absurdity, and which he
reasons away for the time.
At the same time, this unstable condition is on the
border-land, and is so deceptive in its appearance that
we are to be guarded in diagnosing such a case, lest
we confounded it with epilepsy on the one hand and
insanity on the other.
In hysteria we have a mind looking out for sym-
pathy. The mental symptoms principally consist of
emotional disturbance, followed by weak will power.
There may be temporarily illusions, hallucinations
and delusions. The mental activity may appear in
any form. The shedding of tears, depression of spirits,
alternating with unusual laughter without cause or
102 MENTAL DISEASES.
tears, and for a time apparent letliargy, are well-
know syinptoins. Sometimes such ])ersons are
emotionless and simulate melancholy. The senses
convey in their imac^inations all kind of erroneous
impressions. It would take a volume to catalogue
all their aches and pains, real or unreal. The orj^ans
of the special senses are sensibly exalted in a larpje
number, and sometimes accompanied with pain. It
is said that tenderness over the region of the ovaries
is a pathognomic sign, but the mind may conjure
up pain when it does not exist, as we know it does
in so-called *• spine disease " or joint disease, or
hysterical paralysis; the sudden departure of which
has been a rich field to cultivate by Fetichism,
Voodooism, " Faith-cure " and such like. The emo-
tional or the devotional intensity puts an end to
the hysteria in those forms. The clonic and tonic
spasm, the hysterical aphonia, the tonic spasm of the
pharynx (globus hystericus), spasm of the stomach,
intestines, bladder and limbs are physical signs in
which there can be little deception.
Hysteria bears, in many of its aspects, a striking
simulation to some forms of mania, but any shrewd
practitioner, with his wits about him, needs never be
deceived.
It is a noticeable fact that simple hysteria exists to
a limited extent among the insane, although it is of
nervous origin. At the same time, it often has an
existence because of hereditary tendencies to insanity,
and may be the first degenerative step towards pro-
ctRCtrrAn insaihty. 10.*^
nounced and .subsequent insanity. When we have a
case of hysteria, epilepsy and insanity in conjunction,
then have wo a trio which indicate permanency.
Kystero-epileptic insanity is usually very intractable
and difficult to manage.
Concealed Insanity.
Many persons know by their feelings that insanity
is coming upon them. The mental depreciation is
recognized, and they heroically fight against its in-
vasion as far as their conduct is concerned. With
strong will the erraiiu, mental stream is stemmed for
a time ; but, as a rule, the flood comes with greater
impetuosity because of a temporary check to its
headway. This effort is made by many before they
are sent to an asylum, and if the brain lesion is not
extensive the mere force of will keeps language and
conduct within reasonable bounds, although, in the end,
the barrier is thrown down.
In circular insanity it is distressing to see the
patients struggling against the inevitable, which re-
peated experience tells them cannot be checked. In
the interval of mental quietness and rationality they
are cognizant of the coming invasion of one form or
another of melancholia or mania, and dread the assault.
These forebodings often precipitate the outbreak, for
"coming events cast their shadows before." Those
who have delusions and are otherwise sane, may and
do successfully conceal such for a time, until some
emotional shock or general personal disturbance
104 . MENTAL DISEASES.
brings to the surface the latent but potent factor in
the well-covered alienation.
When a physician is called to certify to the insanity
of such a person it needs all his adroitness and tact
to bring the patient to unmask himself. In fact, the
patient often puts the questioner on the defensive,
especially the delusional paranoiac or the cunning
melancholic. These classes often show so much
shrewdness, and at the same time so much suspicion,
that the questioner is supposed to be hostile to such,
or is forwarding his own plans or interests thereby,
so it may require many visits in order to procure
undoubted evidence of insanity based upon observa-
tion. If friends injudiciously attempt to remove
delusions by repeated arguments with the patient, he
soons learns that it is best for him not to touch upon
them, hence his reticence about the morbid ideas upon
which an opinion must be based. It is patients of
this class which make the public believe they are
sane and wrongfully detained in an asylum, and eager
newsmongers fill the newspapers with the presumed
outrage. On the other hand, we sometimes find even
the insane simulating insanity. The dement, nor the
melancholy, nor the maniacal will pretend this, be-
cause of the mental incapacity of the first, the pro-
found feeling of misery in the second, and the intense
self-exaltation of the last ; so these do not act the
deceivers. The cunning delusional lunatic is usually
the one, or he with "antic disposition." His object
usually is to excite extra sympathy, to have a good
CIRCULAR INSANITY. 105
excuse to avoid some kinds of distasteful work, or a
mere freak to imitate others whom he sees about him,
or to obtain some toothsome medical comfort as an
insane invalid ; thus tracing cause and effect. It is
not hard to detect such cunning in the actor, and it is
amusing to see such drop the mask when they have
failed in their purpose and resume unknowingly their
insane state ; yet these peculiarities they cannot ob-
serve in themselves. They can act insane as copyists,
but deny " the soft impeachment " when charged
against themselves.
I have often heard insane medical men diagnose
correctly the various classes of the insane around
them, yet fail to discern their own morbid '♦ondition.
This w^ant of self-knowledge is not, however, confined
to the insane.
106 MENTAL niSEASES.
CHAPTE [1 XI.
MELANCHOLIA.
The radical symptom of insane melancholia is in-
dicated by the expression of a feeling of misery in
which no sufficient justification exists in the circum-
stances of the individual.
Associated with this cardinal symptom are usually:
1st. Defect of nutrition and of other bodily pro-
cesses.
2nd. Defect or abnormality of conduct.
3rd. Commonly the existence of delusions.
The feeling of misery is expressed by (a) the
face, (6) by attitude, (c) by gesture, (d) by verbal
expression.
The lines of the face are changed into a woe- be-
gone expression.
The attitude is one of general flexion. An erect
figure is seldom seen in this malady. The head is
usually bowed ; the back is bent ; and, in severe
cases, the legs are flexed at the knees. The tendency
of the thumb is to lie, not opposed to the fingers, but
parallel with and alongside of them.
Among the gestures expressing misery, the most
prominent and characteristic is that of wringing the
MELANCHOLIA. 107
hands. Sometimes the eyes are dry, but often full of
tears. Very loud, obtrusive weeping does not appear
to be associated with deep melancholia. Wringing of
the hands may be either consfant, frequent or ocat-
sioncd. Sighing and groaning, striking the head with
the fists, sitting with the face buried in the hands,
standing for a considerable time in one attitude, sit-
ting and rocking the body backwards and forwards
are usual. The pulling of the hair is not by handfuls,
but possibly a hair at a time, not in a maniacal way,
but rather from a spirit of unrest.
The verbal expressions are not numerous, and, as
might be expected, are of an emotional character.
The utterance of misery is not always proportionate
to, nor a measure of, the degree of mental pain
which is felt. It may exceed it because of automatic
repetition, and thus the expression is in excess of the
feeling, or the expression may be suppressed while
the face and gestures may tell a story of mental
distress.
In this day we are largely trained to suppress
our emotions, and this inhibitory power often extends
to insane conditions.
The bodily functions are unsatisfactory, as a rule,
in true melancholy.
1st. Defect of nutrition throughout the whole body,
as is evident in non-assimilation r mal-assimilation
of food. \
2nd. The skin is dry and is often of an unwhole-
some tint.
108 MENTAL DISEASES.
8rd. The hair is dry, harsh, and often lacks natural
smoothness.
4th. The mouth is dry ; the tongue is furred ; the
bowels are constipated; the urine is loaded; the pulse
is slow ; the body temperature is lowered ; in short,
the sum total of the bodily processes are below par
or wanting in vigour.
This description is intended for a typical and pro-
found case of insane melancholia. When the feeling
of misery is not very great, these pronounced symp-
toms may be very much modified.
Many have delusions of a positive nature ; but we
have many cases, especially in the initiatory stages,
in which nothing is prominent but a sense of ill-
being, in which is abject misery. Melancholy comes
on in its invasion as such, and does not spring out of
any other form of insanity, as a rule. Other forms
may be planted on it, such as mania and dementia ;
but not it on them.
Usually the onset of melancholia is gradual. In
this it diflfers from many other forms. The dulness,
the inertia, the uneasiness and the lessened interest
in life may not be noticed by friends at first.
In a retrospect of a pronounced case, these changed
conditions are remembered as the first departures
from the normal standard, and also how insidiously
they come on.
A large proportion of young patients recover, and
often rapidly and completely. In elderly people I
have seen the disease progress rapidly towards re-
MELANCHOLIA. 109
covery and then come to a stand-still, and so remain
on the margin of mental recovery, yet such may
never reach the former land-mark of health.
Melancholia is very liable oo relapse, and it may
take place at any period of life. On the other hand,
this disease may terminate rapidly in death. The
patient is a poor eater and sleeper. He becomes
thinner, weaker, more dejected, with little energy, and
finally dies of exhaustion.
Death may occur in a few weeks after positive
invasion, or life may terminate after months of ill-
ness.
If recovery or death do not ensue in, say, about
a year, then is it usual for this disease to change its
form into some other phase of insanity, or other forms
alternate with it in circular insanity. It then takes
its place in the continuous round of remittent but
fixed alternations of different phases of insanity.
The varieties of melancholia are many, no fewer
than thirty kinds have been classified by authors.
For all practical purposes it may be said that we
have, viz. :
1st. Simple melancholia. This form consists only
of sufficient mental depression to afiect the usual con-
duct of the patient.
2nd. Melancholia, with delusions.
3rd. Stuporous melancholia. This form is accom-
panied with mental listlessness, bordering on de-
mentia.
All these forms are active or passive, depending
110 . MENTAL DISEASES.
apon outward manifestations or the want of them.
This, however, is an artificial class' fication, as the
same patient may alternately be in all these condi-
tions.
Some make a class to which they give the name of
"suicidal melancholia." This only means that the
impulse takes the form of suicide. Many of the
homicidal belong to this class also, as the delusions
are, so may be the mental bent ; and many names
would be needed if a particular bias requires a dis-
tinct term.
Many of the less melancholy are the most deter-
mined on self-destruction.
It is a curious fact, which I have noticed, that if a
particular method of suicide is determined upon no
other plan is usually concerted, hence the advantage
to us in supervising such, to study the form the
impulse takes.
When once a person has determined to kill himself
it is well nigh impossible to prevent him from carry-
ing out his intention, if this state continues for some
length of time.
A book might be written on the cunning and
strategy manifested by such. The capacity to keep
the mode secret and the tenacity of purpose, regard-
less of personal comfort or pain, are objects of wonder
to the sane.
The tendency to commit suicide having once exhib-
ited itself in any case, it renders that patient forever
after a source of anxiety to those who have the care
MELANCHOLIA. Ill
of him. In consequence of the want of proportion
between the tendency to suicide and the m'^-nifesta-
tions of melancholy it becomes impossible to infer,
with any safety, how strong the impulse may be.
Many cases are on record in which such patients,
who have apparently recovered from this condition,
have committed suicide on being freed from restraint.
The ingenuity with which such a patient will construct
deadly weapons out of the most harmless instruments,
such as the material of clothing; the secrecy with
which he will carry out his preparations, and the sud-
denness and determination with which he will carry
them into effect are such as, if persisted in over a
long period, to render futile the most stringent
watchfulness and precaution, especially if under home
supervision.
The sharpening of bits of barrel hoops, of nails
and pieces of wire, of bone and of small pieces of
glass — gathered, it may be, in the grounds while walk-
ing — are matters of almost daily occurrence when
suicide, by the use of them, is intended.
Female patients will pull threads out of their
sheets or clothing until they have enough to twist
into a cord wherewith to strangle themselves. They
will even utilize hairpins, or combs, or crochet-needles
for the same purpose. One man will hang himself
from a bedstead post three feet high ; another will
drown himself in a basin of water ; a third will stuff
a lump of meat into his throat and suffocate himself.
I have known one case of a woman, who committed
112 MENTAL DISEASES.
suicide by chocking herself to death by pulling a slip
noose on a handkerchief tight around her throat with
her hands, while she sat on the floor of her bedroom.
The notion of suicide varies with the e:lucation
and surroundings of the individual. Suicide is more
common in some forms of insanity than in others.
There is, however, hardly a distinct group of cases
deserving the term of suicidal mania.
Suicide may be accidental or intentional.
In acute mania and paresis, if suicide occur, it is
generally as the result of accident.
" In some cases of emotional disorder there may be
an intention to pretend to commit suicide, which may,
by accident, become effective.
" In maniacal states suicide is rarely the result of
deliberate purpose. It may result from impulse; or, in
mania of the frenzied delirious type, it may follow or
depend upon hallucinations of the senses, which may
lead to dread of something or someone ; or it may be
obeying some Divine command given by voices, or by
some inward monitor prompting to the deed. The
patient who thinks he can fly may jump from a three-
storey window, or he who thinks he can walk upon the
water may try and drown.
" In some neurotic persons, whether the neurosis
result from heredity, alcoholism, previous attacks,
injury to the head, or in connection with some other
bodily ailment, slight moral causes may lead to
suicide. Such cases may be called neurotic suicides,
and in these we frequently meet with a history of
MELANCHOLIA. 113
suicide in other members of the family. A slight
strain of mind leads to melancholy and .self-
destruction. It may even occur in the automatic
stage of epilepsy or as the result of uncontrollable
impulse." — Mercier.
The suicides of the insane form are usually divided
into two classes, viz.:
I. The impulsiv^e kind. These are subdivided into :
(a) Neurotic ; (b) Hysterical ; (c) Maniacal ; (d)
Alcoholic ; (e) Epileptic.
II. Deliberate suicide may depend on :
1st. Egotistical feelings, such as pain, worry, sleep-
lessness, ruin, shame, to avoid persecution, etc.
2nd. Altruistic feelings, such as to save others from
suffering or to benefit others.
3rd. Indifference to these existing causes, but as the
result of " voices," of fixed delusions, or of weak mind.
In diagnosis the nearest ally to melancholia, and
the maladies for which it is most likely to be mis-
taken, are dementia, hypochondriasis and hysteria.
To dementia it is allied not merely in appearance,
but in nature, for the melancholy feeling never
reaches a morbid degree without some general weaken-
ing of the mental powers, which constitutes a slight
degree of dementia ; and, in well-marked cases, it is
melancholia plus a veritable dementia. They blend
together, as, in fact, do all the forms of insanity in
some one or other of their stages.
Melancholia differs chiefly from dementia in the
superaddition to the symptoms of the latter of evi-
8
114 MENTAL DISEASES.
■
dence of depression of mind. This evidence over-
shadows all other conditions, and is paramount in the
patient's mind. The sadness stands in the front of
the mental photograph and is most conspicnous, and
this is the differentiating symptom in the diagnosis.
Hypochondriasis is distinguished from melancholia,
to which it is very nearly allied, by the persistence with
which thepatientassignshisfancies to bodily disease,and
by the degree in which his thoughts are enthralled and
engrossed by his bodily condition. Between hypo-
chondriasis and melancholia there is every possible
gradation.
The hypochondriac is distinguished by his en-
thusiastic acceptance of remedy after remedy, and his
eager pursuit after all nostrums which promise relief.
He is the bane of the medical practitioner, and his
whims are endless. Throughout all the dread and
wretchedness of his career he clings fast to the faith
that he will at length discover the man who shall
administer the drug that will cure him.
The melancholy man has no such hope. No ray of
comfort brightens the gloom of his life. So far from
entertaining hopes of recovery or confidence in treat-
ment, he rejects with something like contempt, the
advice that is tendered for his welfare.
There is not much danger in mistaking hysteria for
melancholy.
In hys^teria the whole aim and end of display of
symptoms by the patient will be found to have
MELANCHOliIA. 115
regard to the attraction of notice, of interest, and of
sympathy from others.
On the other hand, in melancholia the patient is
quite indifferent to the way in which his actions
and symptoms may impress other people. Such
are too much absorbed in the misery that they
suffer to bestow a single thought upon the way in
which their conduct is regarded. At the same time
it is not to be forgotten that misery, such as theirs, may
have a reasonable cause, and is not a diseased con-
dition at all.
If a patient appears afflicted with melancholy, and
declares that he is on the brink of ruin of character,
that his wife has deserted him or is unfaithful to
him, that he is a wicked and dishonest man, that he
is liable to arrest, that financial ruin is staring him
in the face, it is necessary to be cautious in regarding
his statements as unfounded. It may be they are
true, and that his feelings of misery are only the
natural outcome which such circumstances ought to
excite in a normal mind.
We have to do with the non-existent fancies as
primary causes or secondary results. All these
troubles may induce pathological conditions, but
caution is needed not to confound natural sorrow
with unnatural grief ; sane depression of spirits with
insane melancholia. When analyzed, the trans-
gressions of these insane melancholies are of a very
venial kind.
To patients they are of vast importance, and, in
116 MENTAL DISEASES.
their estimation, on them hang the issues of life and
death. Such may have sinned grievously in putting
on a wrong dress when preparing to go to church, or
in wearing a necktie of a particular color, or perhaps
in eating a particular kind of food. The most childish
notions are looked upon as being mortal sin; and,
because of cherishing them, they are doomed to
eternal torment.
Molehills of neglect are magnified into mountains
of guilt. To many such melancholy persons these
trifles are, in the sum total, "the sin against the Holy
Ghost," and, according to the Holy Scriptures, can
never be forgiven in this world nor in the world to
come.
Such expect no 'post-mortem salvation, and as a
result of these sad forbodings they are so miserable
that they wish to die ; and, as a consequence, this psy-
chic pain makes them intensely suicidal. Strange to
say, although such fear that their souls are to be for-
ever lost and that there is to be a terrible reckoning for
them in the future, they piteously beg to be allowed
to plunge into this supposed state of misery and to
receive this looked-for judgment of condemnation.
There cry is virtually, " Anyway to get out of this
present world." Anything, anywhere, to escape from
the horrible present and to avoid the hideous spectre
of an ever-present sense of apparent guilt.
To the insane all delusions are facts, and the most
cogent reasoning cannot drive them away. The mind
is constantly " racked with one idea." The one sunny
MELANCHOLIA. 117
^lint in the cloud is the fact, that, in spite of the
tears, the wringing of hands, the sad introspection,
the moaning, and self-accusation, many of them eat
and sleep fairly well, if in the chronic stage, and should
they remain insane, many live to a good old age.
Those who recover look back to those days of
morbid and sad fancies as they would to some dismal
night-mare, which leaves nothing but a sad memory
in the morning.
Outside of the possession of these ogres of imagin-
ation the intellect is comparatively unaffected, hence
is their condition the more deplorable as they know
well everything connected with their position and
surroundings. Their appeals to be put out of this
mental pain by premature death are pitiable, and
would wring sympathy from the most obdurate and
callous nature.
Those who believe they have committed the unpar-
donable sin are the most wretched of this class.
Women are more subject to this form of insanity than
are the men. The press very often gives us sad
accounts of mothers who are naturdly possessed of
the maternal instinct, but who have put to death
their children and then have committed suicide.
They usually belong to this melancholic class, and
on account of their intelligence outside of the pro-
found sadness, are not considered dangerous to them-
selves or others until some terrible tragedy has taken
place. They often reason to themselves thus : " This
is a wicked, heartless and miserable world, so I will
118 MENTAL DISEASES.
send my children, whom I love, to blissful regions in
the world beyond, and I will immediately follow them.
It is my duty so to do." The mothers see no harm
in the killing, as in such the moral judgments are
perverted.
Did the delusions of these sad unfortunates lead them
to believe there was no hereafter, and that suicide
meant annihilation and consequent freedom in death
from these sufferings, the intense desire to kill them-
selves might have some consistency. Such is not their
belief, however; but, on the contrary, they are believers
in an immortality, although their moral natures are
perverted and supersensitive to an abnormal degree.
All the judgments and denunciations they can find
in the Bible are, in their estimation and morbid im-
agination, hurled at them, and are meant personally
for them. They reason that the present is insufferable
and the future in the world to come can be no worse.
It is a common impression that the melancholy are
so taken up with themselves and their ever-present
sadness as to obliterate the past. Poets are very
much to blame for giving these impressions, purely
from ignorance of the facts.
Penrose (an old poet) sang falsely in saying :
" Forgotten quite, all former scenes of dear delight :
Connubial love — parental joy —
No sympathies like these his soul employ ;
But all is dark within. "
As a matter of fact, it is the past which troubles
them with its memory of sins.
MELANCHOLIA. 119
It is satisfactory to know that, sooner or later, a
goodly number of this class recover, especially if no
taint of an insane tendency is present in the constitu-
tion. Even then recovery is not hopeless, for nature
is ever struggling towards health.
Were it not for this grand principle or law of
health, mental vigor would soon be the exception to
the rule, and no one could be found to be mentally
competent to keep the keys of the doors of an
asylum.
As I have said, the canning of such to enable them
to bring about self-destruction is wonderful, and the
utmost vigilance of nurses and attendants is needed
to prevent it. A book might be written on the ways
and means they can and do adopt to accomplish their
ends.
Burton, in his " Anatomy of Melancholy," has
written a fascinating book on this subject, although
this was done many years ago, as did also the English
Chartist, Thomas Cooper, over half a century ago, in
his " Purgatory of Suicides."
Shakespeare has drawn, with the brain and pen of
poetic inspiration, a faithful portraiture of this class
in such a sublime creation as " Hamlet."
Burton exaggerated a good deal, as those possessed
with the versifying frenzy are apt to do, yet, on the
whole, his dismal picture is true when applied to the
delusionally ir.sane. See, for example, such stanzas as :
" Methinks I hear, methinks I see
Ghosts, goblins, fiends ; my phantasy
120 MENTAL DISEASES.
Presents a thousand ugly shapes :
Headless bears, black men and apes,
Doleful outcries and fearful sights ;
All my griefs to these are jolly,
None so damned as melancholy.
I'll change my state with any wretch
Thou canst from gaol or dunghill fetch ;
My pains past cure, another hell,
I may not in this toiment dwell.
Now desperate, I hate my life.
Send me a halter or a knife :
All my griefs to these are jolly,
Naught so damned as melancholy. "
The misanthropic but gifted Byron gave a mental
photograph of himself when he sang :
" Melancholy is a fearful gift ;
What is it but the telescope of truth ?
Which strips the distance of its phantasies,
And brings life near in utter darkness,
Making the cold reality too real. "
This is the agonizing cry of a sane soul, ever in
unrest, like the troubled sea.
Crabbe, the melancholy poet, could write from sad
experience such words as these :
*' Oh, how the passions, insolent and strong,
Bear our weak minds their rapid course along ;
Make us the madness of their will obey,
They die, and leave us to our griefs a prey."
Shakespeare, the greatest of the students of nature,
penned truthfully of those who are afflicted as Ham-
let was said to be :
MELANCHOLIA. 121
" His brain is wrecked —
For ever in the pauses of his speech
His lips doth work with inward mutteringa,
And his fixed eye is riveted fearfully
On something that no other eye can spy. "
' ' Canst thou minister to a mind diseased ?
Pluck from the memory a rooted sorrow,
Raze out the written troubles of the brain,
And with some sweet, oblivious antidote,
Cleanse the foul bosom of that perilous stuff
Which weighs upon the heart. "
It may be said in passing that many of those who
are afflicted with insane despondency are silent, and
give no expression of their grief in words. Their
manner and mute appeals tell the story of their woes.
Others are very talkative, and, with great volubility,
pour out their plaint and plead for succour from im-
aginary troubles to anyone who will listen to their
miserere.
Some, who are only afflicted with the milder form
of melancholy, seem to take a sort of pleasure in
reciting their miseries, and this is done with tiresome
repetition from day to day, even were it to the same
person.
It is a constant focalization of the mind upon itself
and its painful workings, yet these do not produce in
the chronic melancholic that profound physical and
mental prostration which such forbodings would do
were they possessed by the sane.
122 MENTAL DISEASES.
CHAPTEK XII.
MORAL INSANITY.
THE INSANITY OF MORALITY OR AFFECTIVE INSANITY.
It has been denied that there is a disease of the
moral powers apart from siriple and responsible
wickedness. This denial has largely arisen because
of abuses in courts of law, where a plea has been
made to shield sane culprits on the ground of the
possession of such a form of insanity. If there
exist emotional insanity and intellectual insanity, it
seems somewhat illogical to expurgate a form of
mental disease the principal feature of which is
dethronement of the moral feelings and of the
capacity to formulate moral judgments.
There is no doubt in my own mind such a disease
exists altogether distinct from responsible depravity.
It is not a steady advance from one degree of wicked-
ness to another ; but is a change, often suddenly, of a
man's moral being, which makes the man altogether
different in character and conduct when compared
with his previous life history. It may be a blow on
the head, a sunstroke, an attack of fever, a nervous
shock, or any such physical injury or disease which
is the precursor and cause of the great moral changes.
MORAL INSANITY, 128
From the stage of convalescence the moral change in
the man is seen. His views of his relations and duties
to his family, his friends, his neighbours and to society
have undergone a transformation for the worse. He
is unnaturally short-tempered and stubborn in errant
ways ; he becomes a great liar ; he is prompted by
dishonourable conduct, full of suspicions, profane and
abusive in language, and addicted to profligacy of
various kinds. In short, he is no longer himself, and
his change astonishes all who come in conduct with
him. The dividing line of the two diverse characters
in one person is at the termination of the disease.
Here the moral malaise begins. All these deviations,
so diametrically opposed to his former self and to his
own best interests, show intellectual as well as moral
lesion. Both co-exist and are manifested together in
some degree. He cannot see the inconsistencies in
his conduct and life. He cannot discern the sudden
and total change in himself, but readily accuses
others of all kinds of evil-doing. He has sufficient
cunning to torture, tease and annoy the members of
his family in all imaginable ways, and yet at times,
especially before strangers, is the model of propriety.
In some cases the disease, which has dulled the
moral faculty, has sharpened the intellectual ; and,
because of this want of balance and one-sided
capacity, there are a sharpness and a shrewdness, com-
bined with maliciousness, which renders the lunatic
the very incarnation of hate and mischief. At the
same time he may be able to cover under a plausible
124 MENTAL DISEASES.
i
exterior, with great skill, his own defects, and paint,
with considerable eloquence, the real or imaginary
shortcomings of others. If such have delusions, they
may hide them for a time from the keenest investiga-
tion, yet extravagant ideas may exist which no sane
man would harbour, but which lie in covert behind
the well -constructed curtain of a man's outward
conduct.
Such cases ^re not far removed, in brain and mind
action, from the congenital criminal, and the acquired
and vicious class of the sane.
The fulcrum diagnostic symptom between this class
of affective insanity and natural depravity is the mode
of causation. Is it a natural development and purely
physiological, or a disease, and therefore pathological ^
On the answer hinges the correct solution of each
case. Were it a natural development, then would it
come on gradually, and the man's previous life history
would show him to be a sinner revelling in his
depravity. If it is a disease, we can trace its in-
vasion and progress by the patient's language and
conduct. It is not the outcome of a habit of vicious-
ness formed by repetition or congenital, but a change
of nature superinduced and controlled by brain disease.
At the same time, if a man had, previous to the
attack of the causative disease, naturally vicious or
criminal propensities, or had acquired them from
habitual wrong-doing or because of prepept or exam-
ple until they had become a second nature to him,
then is it evident that such an ill-conditioned brain
MORAL INSANITY. 125
and mind are more likely to drop into the groove of
affective insanity than would those more favourably
constituted.
There is moral insanity without illusions, hallu-
cinations or delusions. There is a perverted state of
the active and moral power included under feeling^
volition, affections, propensities, temper, habits and
conduct.
At the same time we are not to ignore, in our
diagnosis, the existence of wUful vice, a wicked dis-
position, the influence of had associates, evil example
and recJdess depravity, either congenital or acquired.
In moral insanity reasoning must be tainted, and
the intellectual faculties are more or less involved.
The very reason why a patient is so eccentric and
perverse in conduct, so destitute of natural affection,
so changed in sentiment, is that he no longer realizes
his duties and his relations to his family and society.
His ideas in regard to himself are false and mis-
chievous, but, as his natural feelings are restored, the
intellectual pov/ers once more gain the ascendancy.
When recovery takes place, the comparison of the
two distinct lives is most striking, and shows ''from
what a depth he has risen. This change is evident
to the patient himself. It is well in courts of law to
distinctly state that, in the insanity of morality, there
is always an intellectual lesion, and that the moral
obliquity is an outcome of this mental dethronement.
If not thus distinguished, you will be asked how
you can diagnose sane anger, revenge, malice or a
126 MENTAL DISEASES.
wicked heart from insanity with these manifesta-
tions, and you will fail to do so to the satisfaction of
a judge and jury.
In fact, you will be accused of attempting to shield
a bad man from just punishment, under what they
may and delight to call " the groundless plea of
insanity."
It is often difficult to lay down rules by which to
differentiate moral insanity from moral depravity.
Each case must be decided in relation to the in-
dividual himself : his antecedents, education, sur-
roundings, social status, the nature of certain acts,
the mode in which they were performed, the diseases
and injuries (if any), the estimate of conduct from
definite periods, and any other circumstances which
would fairly raise the suspicion that these devious
ways are not under his control.
Do not mistake moral imbecility with the insanity
of morality.
The former means want of mind development,
while the latter means morbid perversion or a want of
proper direction and balance in the moral nature
because of mental disease.
The former class of persons may have great acute-
ness and mental scope in certain directions, such as
music, arithmetic or mechanics, yet may lie, steal, be
cruel beyond conception, and be beastly in their
instincts and destructive in their habits.
In the latter class we have the normal man in
feeling, intellect and morals up to a certain stage,
MORAL INSANITY. 127
then moral collapse. A number of cases might be
presented to illustrate this class of persons. Three
must suffice, as they are typical of all.
A man of about tifty years of age lived near where
I once practised. His occupation was that of a farmer,
and he lived in one location nearly the whole of his life.
He was honest, quiet, industrious — a good man — his
word was as reliable q.s his bond, and he was of a
retiring disposition. One day, while he was working
in the hay field, he had a sunstroke, and was semi-
unconscious for about hali' an hour. This was fol-
lowed by slight delirium for about twenty-four hours.
He then recovered his usual health, but in those few
hours of illness the man's moral nature had entirely
changed. He became peevish, erratic, profane, un-
truthful and thoroughly unreliable. With low cun-
ning he would tease the members of his family, for
whom he formerly had a strong affection during a
long lifetime, in all conceivable ways. No one would
believe he was the same man, yet the total change of
character took place in a day. This could not be
merely moral depravity of a sane person. We trace
the perversion from brain injury caused by sunstroke.
He remained in that condition until death, two years
afterwards.
Another case was that of a young man twenty-
five years of age. He was an exemplary son of aged
parents, and well spoken of by all the neighbours,
as he deserved to be. One day, in the winter-
time, he was felling a tree in the woods for fire-wood,
128 MENTAL DFSEASKS.
wnen a small dry branch became detached from the
tree near its top. It came down and struck him on
the head, knocking him insensible. He lay in this
condition i'or some time, and was found by friends
where he fell. For about a week he lay in a stupor,
with intervals of restlessness and muttering incoher-
ency. He finally recovered his reason as far as could
be detected, but his character was changed in many
ways. He would neglect his work, swear viciously
when reprimanded, use obscene language in the
presence of his parents and of his neighbours. At the
same time he was shrewd, and beyond these incon-
sistencies showed no lesion of intellect. We have
here a dividing line of conduct and character afc the
time of the accident. No one would dream of saying
that badness lay at the bottom of such moral
obliquity. The organ of the mind was, for the time,
out of order. In about a year he recovered, and
" came to himself " once more.
The third case was that of a young woman, the
oldest of a respectable mechanic's daughters. She
was a steady, quiet, well-behaved and intelligent
member of the family. Having an invalid mother,
and being the eldest, she was as a mother to the
other children. She was taken with an attack of
typhoid fever of a severe type, and was delirious for
nearly two weeks. On her recovery she manifested
a change of character, altogether unnatural to her.
She was talkative, nervous, irritable, erratic and
untruthful to a degree which astonished everyone
MORAL INSANITY. 129
who knew her. Some good people thought this was
caused by satanic influence, others that it was inher-
ent total depravity cropping up ; but in about six
months she returned to her former self. Diabolus
and sin seemed to have permitted the former excel-
lency to resume its sway. She married afterwards,
and was an exemplary wife and a fond mother.
These three cases might be multiplied indefinitely
from medical literature, to show that such causes and
such effects are very common. Now, in many brains,
lesion may come on from causes not so pronounced
or even unknown to us, but the ethical results
would be the same and based on diseased conditions,
producing utter irresponsibility.
Changes may take place in the molecular structure
of the brain, and may come on gradually, which might
HO change the direction and function of that organic
centre as to produce this form of affective insanity,
yet no initiatory stage could be pointed out.
I APR I 7 1905 ^ f^
— «^;"W'f
i'V*^^'
»
KiO MENTAL niSKASES.
CHAPTER XIII.
EPILEPSY OF THE INSANE.
In studying epilepsy it is well to remember the
various causes which may operate to produce this
distressing and paroxysmal condition. These may be
such as brain abscesses, exostosis inpinging upon or
into the brain, tumours of various kinds, haemor-
rhages, or some direct traumatic injury, such as bullet
wounds in the head of old soldiers, or blows affecting
the inner table of the skull. On the other hand,
there may be only molecular disturbance, which
results 'n epileptic attacks by explosive energy, or
in a discharging lesion from accumulated vital activ-
ity. The nervous system has an instability in its
ultimate elements which takes on violent action irregu-
larly as would electricity if pent up and no outlet
permitted while being generated. The two classes
or causes may operate together, or may be only
co-temporaneous. A system in a state of mutability
needs little irritation — toxic, anaBmic or traumatic —
to manifest great bodily disturbance.
Hughling's Jackson divides epilepsy into three
classes, based upon physiological lines rather than
anatomical divisions :
Ist. The lowest level is composed of the grey matter
EIMLKPSV OF THE INSANE. \'U
of the spinal cord, and its upward prolongation into
the brain as far forward as the oculo- motor nucleus.
This is a sensori-motor level. This is the first point
of resistance, and communicates vith the external
world, as well as being the first nervous depository.
It is the spinal centre of vital energy.
2nd. The next higher or middle centre is also
sensori-motor, but of a more complex nature, and
consequently a later organization in the evolutionary
building up of nerve structure. This area includes
the brain sections which lie alongside the fissure of
Rolando, and along the upper margins of the hemis-
pheres. These are now said to be the functional
centres for specific and localized action, and possibly
include the temporo-sphenoidal lobe as well as the
gyrus fornicatus. These areas are one more step
removed from the periphery of the body.
3rd. The highest centre or third level finds its nerve
activity in the frontal and occipital lobes, Seing the
highest and latest evolutional development. In each
successive section we find representation of the lower
in the order of building up. As Jackson puts it :
" All parts of the body are represented in the lowest
centres, are re-represented in the middle, and are
re-re-represented in the highest centre."
Epilepsy attacks the three levels in succession,
from above downwards ; that is : (a) The ideo-motor
centre in the grande mat form ; (b) then the specialized
functional centre; (c) then the spinal cord centre-
They might be illustrated thus :
132
MENTAL DISEASES.
In Jacksonian epilepsy this order is reversed, and
the lower resisting and accumulating centres may be
affected without the higher feeling the morbid
impulse. In the ordinary gross forms of epilepsy,
when the patient is seized he suddenly falls down
absolutely unconscious, and is universally convulsed ;
first becoming rigid in tonic spasm, then jerked in
clonic spasm. " The organ of the mind " is for the
time thrown completely out of function by the dis-
charge which has taken place in it, and which has
extended downwards through middle and lower
centres. At this period the patient seems to be and
is on the very verge of death, for dissolution has
reached the very lowest level compatible with life.
EPILEPSY OF THE INSANE. 133
Only those centres concerned with respiration and
circulation are intact, and even these, in most cases,
are gravely disordered, and in some rare cases death
ensues.
The spasms soon cease, to be followed by tempor-
ary paralysis, with a comatose condition. Exhaus-
tion has taken place in the three levels, and remains
so until vital energy has had time to again draw
upon its resources. This it does from the sensori-
reflex centre upwards. When cerebration is estab-
lished there may be slight stupidity for a time, to be
followed by normal mentality, or there may be a
maniacal condition, in which there is little or no control
of conduct. Should this continue after the immediate
effect of a fit has passed away, then have we in
such, insanity. The epileptic insane may be possessed
with any of the forms of mental disease, as no dis-
tinct class is associated with it. It will be seen that
epilepsy may exist in a person without insanity. In
fact, a majority of the epileptics are sane ; many
business men are thus afflicted, and many sons of
genius have been its victims
One of the peculiarities of the mild form is that
some patients suddenly lose their memory and as
suddenly recover it ; or, rather, they live in a state of
double consciousness without any recollection of this
dual existence. Such will wander away from home
without cause, and with apparently ordinary intelli-
gence seek and obtain shelter and food from strangers ;
and in this way will journey many miles from home,
134 MKNTAL DISEASES.
and suddenly come to themselves in bewilderment as
to their whereabouts. Incendiarism, manslaughter
and attempted suicide are often perpetrated in this
condition, of which the author has no recollection.
We see something analogous to it in somnambulism ;
or, more striking still, in the frenzy of a drunken bout.
The drunkard will destroy his own property, and
assault his well-liked neighbours and wife and chil-
dren with devilish cunning and ferocity. Worn out
with his furious onslaughts, he falls into a deep sleep,
and when he wakes remembers nothing of his
actions, and is amazed at the wreck and ruin about
him, and will scarcely believe that he was the per-
petratoi-. The victim of masked or larvated epilf^psy
kills his family, or attempts to do so, and often tries
to commit suicide, or may succeed in taking his own
life afterwards. The acts are purponeleHS and witJujut
inalice, usually against those who are loved best. Such
as fail in taking their own lives, will wander away
with apparent intelligence, and suddenly come to them-
selves without a solitary recollection of some terrible
tragedy in which they have been the chief actors.
Many of such will straggle about in a harmless and
aimless way for days at a time. I recollect two
instances of partially recovered memory in such, but
the parties were not sure how much was fact and
how much was fancy, as the mental photographs
seemed like a horrid dream or a no less terrible
nightmare.
This temporary amnesia which foll'^ws the mild
EPILEPSY OF THE INSANE. 135
forms of epilepsy shows no evidence of ataxia, and
the more mild the attack the more likely are we to
have following it this mental automatism. The
same is true when mental dethronement follows the
fits. The severe form comes on less frequently and
the brain has time to recover its tone between the
attacks, but in the petit mal there are in the majority
of cases such frequent assaults that the recuperative
powers are weakened and the fortified centres are
more easily overcome. "The constant drop wears
the stone."
The amnesic conditions thus engendered have many
methods of manifestation. For example, a man pays
money to liquidate a debt immediately before an
attack, but afterwards forgets all about it, and this
loss of memory of this act continues. An educated
and intelligent man feels ill and confused for a
moment or two. He remembers afterward that he
ordered his dinner at a restaurant, but forgets that
he ate and paid for it in a perfectly rational way.
A man goes into a house, and while there he has a
momentary unconsciousness and goes out without his
hat ; but finding he has lost it commences to enquire
for it in strange houses, having forgotten for a time
not only that he lost it, but also the house he had
visited.
I know a man in a northern town who suddenly,
on many occasions, lost consciousness while working
or talking. Immediately he wandered away from
home for days R,t a time a veritable tramp. He asked
136 MENTAL DISEASES.
for food and night-shelter in a rational manner.
When he recovered his normal consciousness he found
himself on several occasions more than thirty miles
from home, travel-tired and travel-stained, but he
had no recollection of his various journeys. After
treatment for epilepsy he ceased his wanderings and
has remained well for over ten years.
A man in this city some four years ago took a
hearty supper. While sitting in his chair afterwards
a fit of unconsciousness came over him. It passed
away. He then went to a drug store and procured
some medicine, but did not remember anything about
it. His memory otherwise was good, and mental
impairment was not noticed by me. He continued
his employment for a year afterwards as valuator of
property for a large loan company. A number of
times during the year following, these fits came on
him, followed by the usual hiatus of memory. At
last amnesic-aphasia set in, and was followed in a few
months by cerebral apoplexy and death.
A clergyman who became afflicted by loss of mem-
ory because of larvated epHepsy, left his boarding
house in a western town some years ago. He started
to visit his native place about 500 miles distant. He
procured a ticket at the railway station and paid for
it in a rational way. He travelled partly by rail
and partly by boat and reached his home in safety.
He preached two sermons of great eloquence to the
congregation of his youthful attachment. There was
no evidence of mental estrangement in his words or
EPILEPSY OF THE INSANE. 137
conduct during the journey nor in his conducting
public worship. He stated to me that he remembered
nothing after getting up in the morning on the day
he began his journey until one day, about a week
afterwards, he suddenly came to himself as if he had
awoke from a sleep of the most profound kind.
Within a year afterwards he had a number of these
lapses, which were followed by insane melancholy, and
now the brilliant intellect is buried in that tomb of
the mind, chronic dementia.
Here was mental activity without any psychic
record in the pigeon-holes of retrospective activity.
It was as if it had never been, and yet it was in-
telligent mind operation. It wis not simply uncon-
scious cerebration automatically repeating its former
actions and experience, because in this, and other such
cases as those cited, the mind provided for unforeseen
contingencies in an intelligent mariner and along lines
of thought not previously travelled. Here are two
mental states into which consciousness must enter,
one of which is forgotten. The remembrance of
mental conditions and acts which consciousness
presents to us needs two conditions, viz., intensity a.nd
repetition. It is possible these are wanting ; hence
no cerebral registration of a permanent kind because
of cortical ennervation, consequent upon the fit in the
ideo-motor centres. The brain receptivity was feeble,
so would be the registration of impressions. I have
not been able to ascertain whether memory in one of
these states is able to recall the events of a previous
1J^8 . MENTAL DISEASES.
similar condition. It would be interesting to know if
the mental register can be read, and that only at these
times and under these analogous circumstances.
I had the impression that roads formerly travelled,
or houses visited, or people interviewed might be
remembered in this secondary consciousness when
the brain had returned to this abnormality of
function.
Some authors state this to be the case in some
instances, but my research has not verified this
assertion. Frequent repetitions of these conditions in
the end lead to mental dethronement of a permanent
kind.
Trousseau records a case of a prominent citizen in
Paris, who attended a meeting of a learned society,
went out bare-headed, walked a considerable distance
in the city, returned and took an intelligent part in
the discussions, but knew nothing about his walk.
Such patients may be speaking or reading, and,
although unconsciousness may come on during the
mental exercise, they may go on and finish intel-
ligently what they were speaking or reading about,
but have no recollection of the matter after a certain
time. It can easily be seen, then, how suicide, homi-
cide, rape, incendiarism and other overt acts might be
and are committed in such a condition without any
recollection of them by any of the actors.
Law never allows for this state, and gives little
credence to witnesses who may testify as to its exist-
ence. They are looked upon as merely theorizing to
EPILEPSY OF THE INSANE. 139
allow a culprit to escape punishment for violation of
law.
Another form of temporary loss of memory because
of masked epilepsy is that in which there is no recol-
lection of the past of which a person was possessed
anterior to an attack. I remember a case of a sane
patient who, after a state of mental stupor, found
that she had forgotten a month of her life previous
to this confusional condition. The last she remem-
bered doing was the opening of a gate in going to
visit a neighbour. This lapse also extended for two
weeks after the attack. She told me, ten years after-
wards, that these six weeks of her life were still a
blank. This condition, in a milder degree, had visited
her several times afterwards. In such cases, some-
times memory returns suddenly, sometimes slowly,
showing that impressions, both objective and sub-
jective, had been normally made, but a dislocation
had, for the time being, taken place between the
ideational centre and the reproductive power. The
slides were in the machine, but they did not focalize
for a time.
By some Continental writers these conditions are
named epilepsy of the mind. This term is a mis-
nomer, principally for two reasons: (a) Such a state,
when applied to mind, is unknowable and unthink-
able ; (6) There is no doubt, if analogy proves
anything, that it is merely brain disturbance in its
energizing and directing functions, from which
follows mental paralysis or mental inco-ordination.
140 ^ MENTAL DISEASES.
In many cases cures are effected by the administration
of appropriate remedies, such as the bromides, the
phosphides and the arsenites. These can only produce
physical results, showing the seat of the disease ;
and what is serviceable in severe forms of epilepsy
is also indicated in this strange form of mental
oblivion or double consciousness, in which is intel-
ligence, but which carries with it no capacity of
retrospection or recollection.
The following points are worthy of notice :
1st. In epileptic insanity we have to study the
mental effects rather than the fits.
2nd. Eccentric acts may precede the fits, but the
more positive symptoms are the frenzy, the irasci-
bility, uncontrollable passion and violence, followed
by stupidity in many.
3rd. Although such are often homicidal, profane
and obscene, yet many of them have the exaltation
of religious ideas, and are very devotional.
4th. The mania is more intense after a few convul-
sions until it reaches a fixed standard of severity.
5th. The actions and manners which are noticed in
the first outburst of excitement will almost invariably
be found to characterize all the subsequent attacks
in the same order, although not always in the same
degree. This sequence of order is seen in the pre-
monitory symptoms. By carefully watching these,
and using precautionary medical means, the violence
of the attack may be very much mitigated.
6th. In true epilepsy. Dr. Strong, of Cleveland,
EPILEPSY OF THE LNSANE. 141
pointed out several years ago that there is an oscilla-
tion of each iris causing an abnormal dilatation and
contraction of the pupils. My observation confirms
this statement. Many mendicants seeking sympathy
simulate epilepsy with clever deception. With such,
this sign is of diagnostic value as no malingerer could
produce this result.
7th. The existence of aura, or what is called the
warning of a fit, is in reality the beginning of the fit
itself.
8th. It is not to be forgotten that what we see in
the disease is only the secondary result of a morbid
influence working behind it.
9th Assuming the seat of the disease to be in the
cortical substance of the brain and in the grey matter
of the spinal cord, yet we must take into account
what is evident, namely, an abnormal change in the
sympathetic nerve centres which supply tone and stim-
ulation to the arterial coats in these disturbed localities.
The hallucinations of all or any of the senses vary in
persons so that no two are alike. This shows that
the arterial spasm depends on the ganglionic centre
from which it maj' receive its energy in various
degrees of intensity.
10th. In bleeding an animal to death we have
analogous results in convulsions and loss of con-
sciousness. The same is true in a watery condi-
tion of the blood, in albuminuria, diabetes or in
parturient women. Excess of urea, uric acid and
poisons introduced into the blood will produce con-
142 MENTAF. DISEASES.
vnlsions, which are counterparts of epilepsy. All
such affect the calibre of the blood vessels. The same
is true in the convulsive state of children as seen in
the disturbance of the dij^estive organs, severe burn.s,
teething, irritation of worms, and such like.
nth. Strictly speaking, epilepsy is not a single
disease, because it has so many diverse phenomena.
It is a series of psycho-physical disturbances. It is
not merely a succession of stages of vine, progress and
cvylmirifdion as in other diseases. The impairment
comes from different cau.ses. The physical commo-
tioi:, the mental excitement, the unconsciousness, the
violence, th'^ enfeeblement, the fixed ideas, the irresist-
ible impulse and want of volitional control must
mean a congery of excitants, acting singly or con-
jointly.
12th. It is a matter of surprise that such shocks, so
violent and so sudden, do not in every instance pro-
duce insanity, yet a majority of the epileptics never
lose their minds, except during the invasion of each
fit, and many of bhem are useful citizens all their
lives.
13th. The influence of heredity is very great in its
production. More females are aff*>3ted 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 l<ill without any apparent motive,
but from a sudden impulse, of which they are not
conscious, and who retain no recollection of anything
which prompted them to the act nor of the act itself.
These are usually epileptics.
5th. Those disposed to commit the same crime and
without motive, from an irresistible impulse, of which,
however, they are conscious, and against which reason
often remonstrates.
6th. Those who kill from imitation, or from an
insane love of notoriety. As a rule, this class is
composed of imbeciles or paranoiacs.
In this connection it may be well to state what is
meant by imperative conceptions or dominant ideas
without delusions. Poe, the poet, knew full well
what they meant, and called them in an essay of his,
"The imps of the perverse." We all know, in a
rudimentary way, what they mean. An old song or
its music, or both, spring into memory in spite of our-
selves, and no mental effort of ours will drive them
away. . . . ^ ■ ■
By the law of association, some long-forgotten face
or deed, or idea, suddenly jumps into the conscious-
ness, and flicker in and out among our reminiscences,
like an ignis fatuus, without our bidding, and go
from our recollection, for the time, as suddenly as
they appeared. No force of will can drive them away.
172 . - / MENTAL DISEASES. /
A
Let iliis condition, so evanescent in the sane, become
fixed in the insane as a permanent state of morbid
mental phenomena, atid we liave iruperative eonrpp-
tions, which control action and determine conduct.
You will remember that the celebrated Dr. Johnson
tells us that he had an impulse to touch each post as
he walked along the street. This dominent idea was
so strong in his mind that if, perchance, he accidentally
pa.ssed one by without the usual tribute of a touch,
he felt irresistibly compelled to return and repair the
omission.
The overwhelming impulse to laugh on occasions
of peculiar solemnity is one which even the most
serious persons have experienced.
A still more marked instance is that which some-
times urges pious people to indulge in blasphemous
or profane language. Such tormented a great
English divine, Bishop Butler, who only mastered it
by strong and sustained efforts of the will. The
imperative conception sometimes assumes a suicidal
form, from which there is often no relief.
Dr. Ball, a French alienist, writes in L'Encephale
that he was consulted by a young man who was
engaged to be married, but who found it impossible
to visit his intended bride because it would involve
a journey of some length in a railway carriage, and
he could never enter one without feeling a desire to
jump out as soon as the train was in motion. He
was advised to accustom himself gradually to this
mode of travelling by taking short journeys on the
PHTHISICAL INSANITY. ITH
suburban train, but he could not p;et beyond the first
station. There he had to leave the coacli for fear of
accident.
It is not difficult to comprehend that were these
intruders to control our conduct to any ^reat extent
we would be insane, or on the borderland of insanity.
In these we have a faint idea of how overpowering
such imperative conceptions must be with insane
constancy and reiteration.
Hon.icidal imperative conceptions are likewise met
with.
Thouviot tells us he was tortured with a burning
desire to kill some woman, but never felt the slightest
wish to take the life of a man. He battled with the
impulse for years; but, at length, it overcame him.
One day he murdered a young girl, a perfect stranger,
whom chance threw in his way, in the kitchen of a
coffee-house.
Dr. Bell cites the case of an artist, who was a
victim of a murderous imperative conception. He
married early in life, his family was large, his cares
and anxieties many in proportion. When thirty-eight
years old, without any physical ailment apparent or
an}' specially unfavourable turn to his affairs, he began
to be thus affected mentally. If he .saw a mirror he
desired to smash it ; near a window he felt an im-
pulse to jump out ; he never got a banknote in his
hands that he did not feel inclined to tear it to
pieces. These imperative conceptions presently as-
sumed a more formidable shape ; he began to be
174 . MENTAL DISEASES.
I
assailed with an impulse to strangle his children. His
little (laughter was dying of croup, and he spent
night after night by her bedside nursing her with the
utmost tenderness: " Yet," said he to his pliysicians,
"at the moment when I was praying, with tears in
my eyes, that the child's life might be spared, I was
tormented with the horrible desire to take her out of
the cradle and throw her into the fire. Even now,"
he added, " as I speak to you, I feel a most intense
desire to strangle you, but / check rayf^elf." He was
a man of powerful build. He would have been
dangerous had his sanguinary impulses proved to be
beyond his control.
No bad results followed his impulses, as they were
successfully checked. His nearest f ionds did not
suspect that he v/'is subject to them, as ha fulfilled
all the duties of life in an exemplary manner.
I have often thought of the horrible doings of
" Jack-the-Ripper " in relation to depraved women
only, and the uniformity of his dissections upon tiiis
class of people. ^
It is to be remembered, that when an imperative
conception forces to action it has passed into an
"imperative impulse," and is uncontrollable. /
An imperative conception, like hypochondriacal
fancies, reminds one of what poor Lamb sings : —
" (y'rowding my privacy,
They cotno uiil)i<l(lfcii,
' ' • • - - Like foeH at a we<Miii^5, - -=., -^ _
Til ruHting their frtct'H
In Wetter nien's places;
PHTHISICAL INSANITY. 17")
C-ausing confusion,
Kiginents heretical,
Scruples fantastical,
Dowbts diaholical."
Leslie, in his life of Washinj^ton Allslon, r(!Ctjrds :
" When Allston was sutt'erinj]^ extreme deprossion of
spirits, immediately after the death of his wife, he
was haunted dnrin^^ sleepless nights \>y 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'm<j; rniriflloss, is an erroneous dofinition.
All of this class luivc; minds, althouf^di of a rudirrion-
tary nature. To he without mind must, of imccHHity ,
mean the (jxtinction of a liuman heing. Under tld.s
term two classes are usual I, y grouped.
1st. idiocy.
2nd. Imbecility.
Idiocy may he defined as a condition in which is
found circumscrihed brain structure, from want of
development. This defective j^rowtli may be from
birth, or inay exist by arrest of brain expansion dur-
ing the infantile period.
By virtue of this deficiency the mind is incapaV)le
of acfjuirinf^ such experience or mental capacity as
would fit the possessor in any way to fulfil the most
trivial duties of life as a social being. Some authors,
like Kscjuirol, make three degrees of idiocy, and others
make two, based upon the scale of intelligence.
They are usually deficient in physique, small and
symmetrical heads, but sometimes very large. The
sensibility is usually low, and they are subject to
neuropathic complications, especially chorea, epilepsy
AMMNTIA. IS.'i
and paralysis 'i'liey liavo no morals, and thoir lives
aro largely instinctive. Occasionally they develop
artistic capacity and a})titudes, which are capahle of
little develof)rnent or cultivation, l>acon 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 <loes not know liis
father and mother."
Psychologically, an idiot is a liuman heinjL( who,
from defect or disease of the hrain, at a period of life
before the mind has been develope<l, has sull'ered an
arrest of mental j^rowth. The time of attack may })o
before or after birth, sometimes so late as four or five
years after, and thus the lef^al definition that idiocy
is " from nativity," is not strictly correct.
Idiots of the lowest type; have merely organic life.
In a step Jii<^her the mental condition more nearly
approaches ordinary intellij^(;nce. Such patients have
sensations of heat and cold, }iun;^er and thirst, pain
and a low form of pleasure, as in the brute cnjation.
All are purely animal in instinct and lower than the
higher brute creation in intellect.
iMIJKCILnT.
The distinction is only one of def.5ree between the
imbecile and the idiot, althouf^h it is convenient to
give them two designations.
Like idiocy, imbecility may be congenital, or may
184 . MENTAL DISEASES.
be arrested development in early childhood. The de-
fect is less in degree, although of the same kind.
It is observed in the mental growth of the child by
improvement being more marked in the imbecile than
in the idiot. It is slower than is that of a merely so-
called " stupid child " in acquiring new ideas from
experience.
Some people differ from others in the amount of
their mental capacity ; so do imbeciles.
Some imbeciles approach so closely in intelligence
to the stupid citizer that it is sometimes difficult to
say to which class either belongs.
Some medical and legal writers make a test by the
number of the words such habitually use. It is not
based on that of cram, but of habitual use in every-
day life.
Shakespeare used about fifteen thousand words.
Milton used eight thousand. Ordinary, every-day,
ignorant people seldom used more than four hundred.
We can descend the scale to imbeciles, who may
use only one or two words, such as no and yes, or pet
and 'ma. '
When the process of development has come to a
premature end — that is, there exists congenital mental
deficiency — then we have what jurists call Deinentia
Naturalis.
We have an ascending scale of intelligence in idiocy,
imbecility and 'weakness of mind. In these classes
the process of development has not been carried far
enough. In insanity the process has been carried far
AMENTIA. 185
enough, but has, in adult life, diverged into a ivrong
and downward direction.
In mere weakness of mind there is every degree.
At one end of the scale is the person who is not quite
up to the average ; who is found by his friends and
acquaintances to be a little dull ; who was in a lower
class in school than others of his age ; who, in spite of
assiduous study, got plucked at his examinations ;
who is slow to appreciate humour ; who is incapable
of grasping ideas of a moderate degree of abstractness
or complexity ; who, if he reads works of fiction,
enjoys only those which deal with incidents and
adventures. Such men, if they possess industry and
power of application, often attain a degree of success
in life which surprises those who know the narrow-
ness of their intelligence. The solution is in the fact
that their interests are so circumscribed that their
application to the object they have in view is not apt
to stray. The attainment of any end depends more
on the steady, continuous application than on the
scope of mental ability.
The line which divides the dull or weak-minded
man from the imbecile is the ability to earn a living
in an intelligent way.
The man, who can earn his living, may be a dull
man, a stupid man, a man of feeble, limited intellect,
but he cannot be called an imbecile.
These two classes are in striking contrast to a
thoroughly healthy, vigorous man. He has not only
186 MENTAL DISEASES.
those activities by which he avoids direct physical
danger, but also defends himself f^om it. He earns
his livelihood with discretion and wisdom. He rears,
feeds, clothes and educates his offspring. He does
his share of the duties required of him as a social
being and a useful citizen with vigorous mental
power. ^
He has energy to spare to recreate himself — it may
be in the pursuit of literature, art or some other
hobby. The weaklings of the classes I have de-
scribed have no such ambitions or desires. Animal
pleasures or silly inanities or childish notions fill up
their cup of enjoyment, in which is that of to-day and
little, if any, care for to-morrow.
Occasionally a case of imbecility presents itself in
which one isolated group of faculties is of average or
even more than average development.
Such as the cases in which persons, otherwise im-
beciles, show a talent for music or for calculation. In
such examples the deficiency in brain development is
not uniform. In some directions the development has
proceeded to a normal extent, while in the remainder
it has failed.
The unlettered savage has average mental capacity
in the chase and in warfare, but otherwise he has a
child's mind in a man's body. The baubles of the
child please him, such as red cloth, beads, looking-
glasses, and such like.
AMENTIA.
187
The gradations of mental growth might be illus-
trated in this way, omitting the affective nature :
Arrested
Development.
Normal Growth.
Moral idiot.
No ethical feelings.
6th Step.
Moral nature developed.
5th Step.
Full intellectual development.
\
4th Step.
Average man possessed of ab
stract and concrete ideas.
Circumscribed mental
scope and arrest.
3rd Step.
Higher mental capacity.
Imbecility.
2nd Step.
Dawning intelligence above in-
stinct.
Idiocy.
1st Step.
Animal instincts only.
Birth.
188 MENTAL DISEASES.
CHAPTEK XX.
MIND STRESS.
The civil engineer will give the weight necessary to
break down a beam of wood, iron or steel, if the size
and kind of each is given. In other words, he knows
from experience the resisting power of various ma-
terials. It is a somewhat analogous law which exists
in respect to the capacity of the brain to preserve its
integrity against all kinds of physical and mental
strain. These powers on the one hand and the brain
tension on the other could be absolutely formulated
as in mechanics, w'^re all the conditions as well known.
These varied forms of stress may come in the form of
physical disease of the brain itself; from indirect
bodily disease in distant parts, or through mental
trouble such as worry, fear, emotional shock or any
form of mental excitement and consequent exhaus-
tion. Each brain, in respect to resistance, is a law
unto itself, but it is subservient to this general con-
dition. One may be robust and full of vigor, hard
to tire and soon rested. Another may be feeble and
languid, with the recuperative energies slow. The
former might have, in an analogous way, the vitality
and strength of the oak or the elasticity and dura-
MIND STRESS. 189
bility of steel ; and the latter only the weak fibre of
the bass-wood or the pliability of iron.
The organ of I he mind, when healthy and natur-
ally strong, is capable of a large amount of steady
work, but each person must gauge the tension upon
his own brain by the effect produced daily in its
working:. It will soon throw out siornals of distress
when overstrained. In this age of tireless and sleep-
less energy, wuth sharp competition in all the walks
of life, many a man is like the engineer who is
running a twenty horse-power steam engine at twenty-
five or thirty horse-power. The tear and wear will
be tenfold that which would take place from normal
work, just as running a mile expends more energy
than would walking five miles.
In the young and vigorous the unusual demand
may not always immediately show malign results ;
but as the years go by, and the vital powers have
reached the maximum of activity, or it may be, by
lapse of time they are on the decay, then nature has
its revenges, because of the violation of its laws in
early life, as it never shows pity to the transgressor.
Early or late the warning comes in one of many
ways : It may be by want of sleep, by a feeling of
fatigue when little or no work is done, by mental
lassitude and incapacity, by a feeling of goneness in
the body and a lack of power of concentration of
thought, by waning memory, lowness of spirits and
defective appetite.
190 MENTAL DISEASES.
In short, body and mind are at the ebb, and are
going downwards and outwards " beyond the bar."
Nature has its penalties inflicted for violations of
law, often long after the infraction. The fast young
man begins to know this in middle life, when the
executioner has overtaken him. The brilliant student
may so eat up his vital reserves in college spurting
as to shackle his mental vigour in after life. The
busi: v^ss man, immersed in mental strain beyond his
calibre, may see no loss of vital elasticity for years ;
but the day is sure to come in many such, when the
warning cry is too late. A man finds, to his consterna-
tion, that in middle life his energy is flagging, He
puts on an extra eflfort to make up for mental weari-
ness, and thereby intensities the evil. In his sleep-
lessness he hears the clock strike all the hours
throughout the darkness of a seemingly endless night
He rises in the morning unrefreshed, and possibly
with a tinge of low-spiritedness. The appetite is
impaired, and an otherwise equable temperament has
become irritable, and brooks little opposition. Busi-
ness, in which he formerly took a delight, has become
a bore. By noon mental exhaustion sets in, as the
brain has not procured its usual rest, nor the great
nerve-centres their well-digested pabulum. He was
a social man, but now he has no zest for the company
of relatives, friends or companions as he once had,
and he is himself annoyed at his hermit desires.
Intense introspection takes place, and even ordinary
feelings of body are magnified into monsters of
MIND STRESS. 191
disease. His mind is centred on self ; and, try as he
may to divert his attention objectively, the pendulum
of thought will swing back to the morbid point with
aggravating persistency. He feels and struggles
against this pelting from the first drops of the com-
ing mental storm, and often successfully, but if this
condition intensifies, then is the borderland of insan-
ity reached. Delusions usually set in, and although
the patient I'nows them to be such, yet they may
dominate his actions to some extent. A good business
man avoids Victoria Street, because he has the idea
that some calamity may happen to him on it. He
knows the morbid fear is absurd ; nevertheless, to
quiet the perturbed feeling, he avoids the street. An
intelligent professional man, actively engaged in his
daily work, cannot sleep in a detached house, because
he has the notion that it may blow down in the first
gale. He feels secure in a tenement house, and, at
the same time, laughs at the absurdity of his fears.
A commercial traveller dreads to ride upon a well-
built and well-equipped branch line of railroad, and
is in a nervous condition of alarm when he is com-
pelled to travel on it. He has often gone many miles
round to avoid it. He states he can give no reason
for the possession of this unreasonable fancy, yet, it
has remained with him for years. A woman who is
fond of shopping indulges in it as a recreation, but
never goes into one large store in this city, where she
could feed her propensity to the utmost, because
s]ie has a fes^r of the ceiling falling down about her
192 MENTAL DISEASES.
ears. The heavy pillars of support and the solidity
of structure have no influence on this dread. Scores
of analogous cases might be cited ; but, in all is found
a substratal condition of nerve starvation, accom-
panied by a general sense of ill-being. Strange to
say, the absurdity of the delusions is seen, yet they
dominate and control individual action. Such men
often struggle on for years in this unsatisfactory
conditioii, if insanity should not intervene, until
middle life is reached ; and at this trial epoch for
men, as well as for women, we often see premature
old age set in as the first step of senile decadence.
" The pith and moment " of vigorous manhood are
waning. The capacity for entering into new enter-
prises with the vim, judgment and discretion of
earlier years is very much weakened. In short, the
grip of mental life 13 being loosened prematurely
because of undue mental strain throughout a previous
period of abnormal energy, and, it may be, of excep-
tional trial.
It is often the case — especially in commercial
circles, in industrial centres and in professional
routine work — that, as life advances, the demands
upon time and upon mind increase rather than
diminish. The work enlarges and becomes more
complicated; and, as a result, the busy man — who
looked forward at, say, fifty-five years of age, to retire
with a competency — may have the riches he coveted,
but has not the opportunity nor even the desire to
s^ejc quietude and rest. We too often forget that the
MIND STRESS. 193
lit'e-work of a citizen becomes, by repetition, to him a
second nature, and, therefore, he has no enjoyment
but in doing that work until his sun has set, or at
least until the gradual decay of old age has made
him lose his former interest in mundane things. As
someone has well said : " He may have something to
fall back upon, but nothing to fall back to."
Of course, there are exceptions to this law of life.
Many brains of fine and tough structure luxuriate in
great activity. To such labour is life, and the tireless
capacity of such exceptions is often astonishing ; but
the masses of ordinary men are not thus endowed.
As a rule, the educated brain has more endurance and
more rebound to it, like a steel spring, than has that
of the ignorant. By the educated is meant not
simply the college-stuffed brain, but any organ of
thought which has been trained in the school of ex-
perience, and has been the recipient of knowledge
and wisdom from all sources of information.
The higher organization has in it greater recupera-
tion than has the less complex nerve centre, just as
have the skilled rower's or pugilist's arms, by training
the muscles of the body, more power than have those
of the clerk or cleric, who needs no great muacular
development in his daily work. It is also true that
unless these athletes are overtrained, their muscles
will recover from injury and disease more readily than
those of their more flabby fellow-citizens.
This law of repair is also seen in the percentage of
recoveries among the insane, wise and ignorant, It
13
194 MENTAL DISEASES.
is true there is little insanity amon^ savages, but
the reason of this exception is obvious. The mental
strain is little, and the indolence of such, especially
in the tropics, leads rather to mental i ;ertia than to
morbid exaltation. Their happy-go-lucky mode of
life is in striking contrast to that of '.he seething,
struggling masses of Christendom.
It is easy to propose a remedy. We say to such,
" Take life easy. Do not worry. Be content." The
answer is : " We cannot. On the farm, at the coun-
ter, in the shop, in the professions, on sea and on
land we must push our varied interests to the utmost
or we will come to ruin." Keen competition, low
prices for work and its products, the additional
demands of a social kind or of a public kind which
have come in with our civilization, all compel toil of
brain or hand, or both, from which there is little
cessation until life closes or, it may be, reason is
dethroned.
This indictment against themselves is true ; and, as
a rule, myriads of such perish mentally, and, what is
even worse, before the eclipse comes add in their
children to the great army of defectives, who now
swarm in every land and in every clime. Even the
mentally great of the earth have seldom equally
famous descendants, because genius burns out the
superabundant energy, and consequently has ) such
bequeathment as a legacy to descendants. Here is
where heredity shows its baneful effects, and which
f^re working untold woe iu all communities,
MIND STRESS. 195
Health Boards chase the microbe to . his lair and
seek his destruction. They charge the plumber with
culpable homicide because of his bad work. They
wage war against tilth and foul air. They throttle
endemics and epidemics, and face the various scourges
which march by sea and land with germicides, anti-
septics, fire and water. It is well, but the more
insidious mental diseases which produce a most
deplorable condition in the tens of thousands of our
fellow-beings, to which death itself is a relief, are
never thought of, except by a few, and these are only
voices crying in the wilderness. Prevention is better
than cure, yet at present we are, so to speak, picking
up human fragments at the bottom of a precipice,
but have no danger signals at the brink. Health
Primers on the baneful effects of secret vices; on
heredity; on unsuitable marriages from a health
point of view ; on the active and predisposing causes
of insanity ; on the evil effects of mental strain, and
such like, would be of invaluable benefit to the com-
munity. Many of these human ills are preventable,
but about the consequences, of which so many are
ignorant, because of a silly sentimentality among
those who are qualified to instruct, little is known by
the people.
There is a natural desire in those thus afflicted to
seek relief. Unfortunately, many such find it, tem-
porarily, in the use of some form of spirituous liquors.
The fleeting paralysis of body and mind induced
thereby gives comfort for the time ; but the effect has
196 MENTAL DISEASES.
to be kept up, else more profound trouble than ever
supervenes. The eid is often a state of chronic
alcoholism and final collapse. Some seek relief from
this thraldom of n.ind-pain by the use of opium,
morphia, chloral or some other such seductive druj^.
The constant use of such druofs ends in mental
enfeeblement or insanity, and in such wrecks of
humanity is seen the most deplorable affliction of a
livino: death. It is forgotten that, in the strucfjjle
through life, nature is ever fighting towards recovery
in disease or under any untoward circumstances. As
a condition towards health, it is handicapped by any-
thing which lowers the vitality or prevents recupera-
tion. This is espe2ially true when stupifying drugs
are used to produce so-called sleep in insomnia.
Natural sleep is re placed by stupor. The appetite is
interfe::ed with ; hence, insufficient food. Good
digestion is followed by dyspepsia, mal-assimilation
of food, mal-nutrition and the nervous debility in-
tensified. Under such drug influence remedial
measures are impotent. Wholesome food, cleanliness,
good air, exercise and short hours of mental work are
" Love's Labour Lost," yet they are our sheet-anchor in
all such cases.
At this stage the cure-alls are eagerl}'- sought after.
Drowning men catch at straws. The seductive
pamphlet, full of testimonials of wonderful cures ;
the flaming falsehoods in the secular and religious
press, which promise almost to raise the dead ; the
wonderful golden promises to cure evU habits by
MIND STRESS. 197
injections of paralyzing; nostrums into the body ; the
insane teachings that disease is only a mental fantasy ;
the equally nonsensical belief that faith alone can
cure all human ailments, but cannot set a broken leg
nor restore to their right minds the insane, the most
pitiful of all God's creatures, nor lessen by one the
inmates of the Home for the Incurables — have their
day. All such promises look so plausible, when
backed up by designing rogues or self-deluded
believers, and look so feasible to those whose mind-
stess is hard to bear, and who may find no immediate
remedy from their physicians ; hence the rich field
for quackery and its many allies. Credulity cannot
be eradicated from the minds of men as lonjj as a
belief in all human testimony exists. The distress is
present, and the possibility of immediate cure is so
seductive, when accentuated by so many who aflBrm
that such-and-such mixtures, extracts, pills or lini-
ments have done wonders in similar cases. The
fundamental law of our nature is forgotten, namely,
that all humanity can do with its best remedies is
simply to stimulate the master-builder into activity,
to repair the waste places and to furnish him with the
suitable material to build up the body or to carry
away the dead tissues by the excretories.
198 Mental diseases.
CHAPTER XXI.
NOTES ON THE CONDITION OF PATIENTS ON
EXAMINATION
A. Bodily Condition. — Such as wei<yht, temperament,
muscularity, fatness or leanness ; expression of face
and general appearance; any bodily injuries, or
wounds or scars of past hurts.
B. Organic Functions. — As to digestion, condition of
bowels, appetite.
Condition of the skin, as to eruptions, moisture and
abnormalities.
The circulation, as to pulse, cardiac sounds, and
injection of the conjunctiva.
The condition of the respiratory apparatus, as to
the state of the lungs, breathing, and rapidity of the
respiration.
The state of the glandular system, as shown in the
examination of the urine, state of liver, spleen and
thyroid.
G. Sexual Functions. — Esp3cially as to habit, mas-
turbation, and past or existin^ij syphilitic attacks.
In women, enquiry as to catamenia, discharges,
pregnancy, syphilis, and the trial epochs of life.
Enquiry as to previous attacks of such diseases as
rheumatism, fever, inflammation and gout.
EXAMINATION OF PATIENTS. 199
D. Nervous System. — Enquiry as to the existence —
present or past — of paralysis, epilepsy, hysteria, hypo-
chondria and neurasthenia. Any diseased conditions
along the line of nervous disturbance are to be care-
fully noted.
The special senses need attention, especially as to
illusions and hallucinations of sight, hearing, smell
and taste.
The touch and nervous sensibility often give valu-
able information in our diagnosis. Sense of pain,
reflex action, anaesthesia and hypersesthesia, are to be
thoroughly enquired into, as well as the various re-
flexes.
Heredity is never to be forgotten in its tendencies
and reproductions.
E. The mental symptoms not directly related to the
special senses. — In this class we are to seek for psychic
conditions onlj^ These would include consciousness,
identity, power of attention, memory for recent events
and for past events, coherence of language, mental
exaltation, mental deprivation, depression of spirits,
sleep or insomnia, delusions, propensities, habits and
bias; such as using obscene language, dangerous
to others, maniacal excitement in its various forms,
indecent conduct, suicidal and destructive tendencies,
or mere negation of normal mental activity, as in de-
mentia.
The following tables are used by me not only to
note the jpost-morteinx conditions, but also to record as
far as possible the insane life history of the individual :
O
o
»
O
g3
O
tC4
O
©
O
CO
BLOOD
VESSELS
OF BODY.
tLOOD
VESSELS
OF BRAIN.
BRAIN.
Sp. gr.. Weight
and Size.
Em .
oo<)
O
No.
o
©
PES
REMARKS.
hJOJ
>•
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<litions conducive to health need to be
present, especially good food, well cooked and plenty
of it, cleanliness, and fresh air. In all forms of
insanity this practice should be the golden rule. Let
it be repeated with emphasis that hygiene and
dietetics must always stand supreme in disease ; if
not, then our medicines will be of very secondary
importance, and will not have fair play. Were I
obliged to give up one of these two classes of curative
agents in sickness of any kind, then would I let the
medicines go, so important do I consider the former.
The doctrine of " the gospel of fatness " is a well-
tried dogmatism. These views being conceded, and
seeing that sleep is absolutely needed in acute mania,
we must consider what is the best drug to administer.
If there be great irritability and persistent in-
somnia, and no evidence of permanent lesion of the
brain, then some preparation of opium seems to do
best in our experience, either hypodermically, by the
mouth or per rectum. It is preferred in the natural
state, but if any of the salts are used, then atropine,
in the proportion of the twentieth part to one part of
the salt, is a good combination, as the one seems to
modify the action of the other. Sometimes the
deodorized tincture of opium added to bromide of
potassium or sodium produces excellent results.
It is well if we find a state of hyperaemia existing
not to give opium nor its salts. If we find the eyes
212 MENTAL DISEASES.
injected, turgesence of the superficial vessels of the
head and neck, a hot head, a pulse neither full nor
strong, then, as a rule, it is better not to give opium.
Notwithstanding what has been said to the contrary
as regards the effect of opium to produce congestion
of the brain, my experience has been that such is the
case, and if given when contra-indicated, it would
diminish the chances of recovery. We are threatened
with exhaustion and death of our patient unless rest,
artificial or natural, is procured. Even temporary
relief may tilt the natural forces in the direction of
recovery. The fire of acute mania will burn out
after a time, if we can only in the meantime keep up
the strength with food, and quiet the nervous system.
The waste of tissue and, of nervous energy are great,
so these must be provided for by every means at our
disposal, but medicine alone is neither meat nor drink.
If opium is indicated, then give full doses from the
beginning, which in mania, as in delirium tremens,
must be from a half more to twice the ordinary dose
if a decided effect is expected. Repeat every four
hours until three doses are given. If no effect is
produced do not continue the opium or any of its salts,
for more may produce a sudden cessation of the
mania and a dead patient. This is also true of
hydrate chloral and other remedies of the same class.
The exhaustion of the disease, and the sedative effect
of the drug combined, often repeated, may produce
fatal results. The pathological condition may be too
profound for the remedy to reach and effect.
TREATMENT OF MANIA. 213
Some patients tolerate opium to an enormous extent,
and others find it a very bane to thera. Idiosyncracies
are not to be lost sight of, because death from opium
may take place ivithout comia in a condition which
seems to be a combination of asthenia and asphyxia.
Sudden collapse takes place, followed by a failing
pulse, shortness of breath and death. When indicated,
where there is sleeplessness and mania, any one of
the following prescriptions may be used with good
eflfect :
R Chloral Hydrate i) ij.
Sodii. Brom. . . 3j-
Morphiae Sulph gr- f •
Syr. Zingiber \ .,. ^
Aquje Disi )
Dose : A tablespoonf ul at bedtime, to be repeated in an
hour, if necessary ; or
R Sodii. Bromid 5ij.
Chloral Hydrate 3iss.
Tine. Opium Deodor 7,j.
Syr. Aurantii.
cjyr. Aurantii ^
Aqu^ Dist / ^^ ^•«- ^^ ^"J-
-M.
Dose : One tablespoonful at a time. This may produce
the desired result as a sedative rather than as a narcotic.
When indicated, the following prescriptions are
satisfactory to use in any form of mania :
R Chloral Hydrate ^ss.
Tine, llyoscyarai fld o'j-
Aquae 5J. — M.
Dose : To be given at bedtime.
214 MENTAL DISEASES.
Dialyzed opium (the same strength as tincture of
opium) is a good form to use. The same is true of
the bimeeonate of morphia.
Neither of these has the unpleasant after effects of
opium in other forms.
If a small quantity of one of the ethers be added,
costiveness and nausea will be neutralized, and on
some systems this mixture acts as a laxative.
When resistance is made to taking these medicines
by the mouth, a suppository of them can be given
'per recfum. One-third additional quantity should
be given.
The monobromide of camphor often does well to
allay excitement of any kind. Four-grain capsules
every hour will generally have the desired effect after
the second or third dose is given, but sometimes one
dose is enough to quiet, if not to cause sleep.
In mania a good sedative or narcotic mixture is as
follows :
R Hyoscine Hydro. Brom gr. 5^)
Chloral Hydrate ^ j.
Sodii. Brom oj-
Morph. Sulph g^- I-
Syr. Zingiber |-- ^^. _^
Aqujie /
Dose : One tablespoonful at bedtime. It is to be
repeated every two hours until the patient is asleep, or
until three doses are given.
To produce quietness in the daytime the following
pill is good :
•
TREATMENT OF MANIA. 215
K Zinci Valerianat 3j.
Ex. Belladonnae gr. ij. — M.
Make into xxx pills.
Dose : One every two hours.
If the tincture o£ Hyoscyamus is used it must be
given in large doses in mania. It has often failed to
produce quieting results because we have been afraid to
give it in sufficient quantity to produce desired effects.
From two drachms to half an ounce of the tinc-
ture has been given by me with good results. When
exhaustion has set in and collapse is threatened, it is
well to combine it with compound spirits of ammonia
or with the same quantity of sulphuric ether. Three
drachms of it is equal to thirty grains of hydrate
chloral, and equal to about forty minims of laud-
anum. It is simply a good sleep producer when
indicated. The well-known remedy named " Brom-
idia " is composed of extract of hyoscyamus, chloral
hydrate, bromide of potassium and extract of can-
nabis indica in solution. Many use this prescription
in acute mania and praise its virtues.
In a number of cases of acute mania, the fluid
extract of ergot seemed to have a beneficial effect.
No doubt this is because the pathological lesions are
primarily in a state of great cerebral and spinal hyper-
aemia. This congestion is no doubt due to a vaso-
motor paresis. This remedy has the well-known
effect of reducing the calibre of the arterial system,
and is antagonistic to congestions. A fluid drachm
is given every four hours for about twenty-four
216 MENTAL DISEASES.
hours. This can then be intermitted with some such
medicine as about thirty grains ot* bromide of potash
and the hydrobromate of hyoscine, say 1- 100th of a
grain every four hours until the sedative effect is
produced. Hyoscyamine in the chrystaline form, has
been used largely by us hypodermically, mixed in
glycerine, to which is added a few minims of carbolic
acid to the ounce of solution, in order to keep it
fresh and ready for use. Lest there might be
idiosyncrasies against its use, give at first only the
l-16th of a grain. Its influence ex^.ends for about
eight hours. We find, however, it is soon tolerated
by the patient, and that after a few doses have been
given, they must be increased very much to produce
the same effect. We have sometimes given one-half of
a grain at a time hypodermically after a few doses
were taken, with no untoward results, and no more
soporific impressions than were evident in the smaller
doses previously given. It is often tolerated when
opium or any one of its salts, or hydrate chloral cannot
be given with safety. Hyoscyamine is prompt and
certain in its action. It is non-irritable as a hypo-
dermic injection. It is a good hynotic and a depresso-
motor, or an excitant to the psycho-motor centres,
according to the dose employed. It often tranquilizes
and shortens the duration of mania. It does not
affect nutrition if only given daily in a full dose at
night. Hyoscine is often used now instead, but
caution is needed as to dosage, as it is much more
powerful than is the hyoscyamine.
TREATMENT Ot MANIA. 2l7
Conium, in one or other of its forms, has been
highly recommended in mania. It has been tried
here, and that somewhat extensively, a number of
years ago, but it did not give the satisfaction its
advocates promised, although in combination with
any of the bromides, it gave better results in modify-
ing their depressing effects, and in seeming to increase
the sedative action of this class of drugs. It is not
to be forgotten that it is a very uncertain drug,
either in its natural state or as an alkaloid, hence the
necessity of caution in its administration.
Paraldehyde, which belongs to the alcoholic series,
is a good sleep producer. Like alcohol, it first acts
as a stimulant, then as a hypnotic, on the brain, then
upon the cord, and when given in dangerous doses
upon the medulla oblongata. The sleep produced by
it resembles the natural sleep. The dose ranges from
forty-five grains to two drachms. It is best given in
mucilage flavoured, or in liquor diluted and hot.
Sulphonal is a good hypnotic in cases of mania
and melancholia. It operates in about four hours
after being taken. It has no taste, and can be given
in a cup of coffee or tea while hot without the
knowledge of the patient. It is hard to dissolve, but
will do so if put into boiling water and then allowed
to cool suflSciently to be taken. It can be given in
syrup or in the form of a pill. It is more of a
sedative than a narcotic, and seems to act on the
system about forty-eight hours ; sometimes a second
dose is not needed on the following day. This con-
218 MENTAL DISEASES.
tinued effect may exist because of its slowness of
absorption. The dose is from twenty to forty grains.
Many of these quieting medicines may disappoint
the physician; then it may be well to fall back upon
a combination of bromide of potassium and cannabis
indica. This mixture may not narcotize. I am not
sure but this is an advantaore as far as the brain is
concerned, for it means less interference with normal
blood supply, and does not increase the congestion
already existing in mania.
A number of cases of acute mania of the mild form
are treated at home by the family physician. Many
such recover if sensibly nursed, fed and properly
medicated. Exhaustion and inanition are tugging
at the heart strings, so pabulum must be provided to
prevent death by keeping nature's reserves up to the
normal strength if possible.
The tireless builder, who is making heroic efforts
to keey the structure in good repair, is crying out for
material, and that of the right sort. In acute mania
the crisis comes soon, and our opportunity to tilt the
nature towards recovery has to be taken advantage
of at once, so as to possibly save from death or pre-
vent a lapse into a chronic and incurable condition.
In treating such it may be laid down as an aphorism
that medicine might be dispensed with and recovery
take place ; but that cannot be said, as a rule, with-
out nourishing food, cleanliness and fresh air. The
former is merely a valuable adjunct to the latter,
but it is not to be despised nor neglected. My repe-
fREATMENT OF MANIA. 219
tition ot' this rule of practice shows how important it
is in my estimation.
The quantity of food which a patient consumes is
to be considered in relation to what he digests. To
cram food into the stomach of a patient who is some-
what physically exhausted without considerinjr how
much of it may be used by the body does harm,
especially when the stomach is throwing out in various
ways signals of distress. We should do our best to
favour proper digestion and assimilation ; if not, then
will we have mal-assimilation and mal-nutrition from
engorgement. We have to consider the right selection
and proper administration of food. The nitrogenous
or animal and carbo-hydrates or starchy are the two
groups of food which our knowledge of chemistry
suggests. We have the representation of the first
class in flesh, milk, eggs and fish. The second kind
is represented by the different grains, vegetables and
fruits.
Animal foods supply material for the building up
of the tissues of the body, while starchy foods supply
the fuel, the burning up of which in the chemical
processes which are constantly going on developes the
energy necessary for the carrying on the activities of
the body. In mania both classes are required in tissue
building and in fuel producing. A uniform and con-
tinuous diet is not as satisfactory as are changes of
somewhat similar food. The stomach takes kindly
to varied food in disease as well as in health.
In any form of mania it should be a first principle
220 , MENTAL DISEASES.
not to use any soporific if it can be dispensed with.
If a patient can even only procure three hours' sleep
in the twenty-four hours of the day, it is better than
any length of time in sleeping because of the toxic
influence of any drug. Medical brain restraint is
only to be employed as an auxiliary when nature
fails. It gives the struggling and exhausted vital
powers a chance for life, but the dispensing of such
potent agents should be discontinued at as early a
period as possible. Three hours' natural sleep may
be followed after a few nights by four or five hours
of sleep ; and, as a rule, as the sleep increases the mania
subsides. This is always a good sign, especially in
acute cases. No powerful narcotic or sedative should
be used continuously day after day, except in great
emergencies. It is well even intermittently to let
nature get on its feet and have a chance to throw off
its thraldom along natural lines. Spitzka truly says :
" It is not so much the object to crowd down a
psychosis as to establish a series of relatively lucid
periods, and thus to tip the scale sufficiently on the
side of struggling nature to overcome the pathological
influence. It should be borne in mind that mania
disappears not suddenly, as a rule, but by a series of
oscillations between the healthy and the diseased
state, which finally merges into a healthful equili-
brium, and, in the absence of a specific remedy, it is
wisest to follow physiological lines of treatment. No
mania was ever choked down, but at most prolonged
or diverted into the channel of deterioration by the
excessive use of hypnotics and calmative drugs."
EPILEPSY, MASTURBATION AND MELANCHOLIA. 221
CHAPTER XXIV.
EPILEPSY, MASTURBATION AND MELANCHOLIA.
There are a great many remedies lauded in the treat-
ment of the various forms of epilepsy. That is usual
in these days of polypharmacy, especially in relation
to the intractable diseases which baffle our skill and
defy our efforts.
A few years ago amyl-nitrite was extensively
advertised as a cure for epilepsy. This drug produces,
as far as known, no special effect on the brain beyond
the dilatation of the cerebral vessels, and, as a conse-
quence of its action, there is a sensation of fullness
and oppression in the head. It lowers the reflex
irritability of the spinal c< id. After a brief inhala-
tion of it, the action of the heart becomes exceedingly
rapid, the face flushes and a violent throbbing in
all the arteries is experienced. That the vessels are
enlarged we have evidence, not only from the flushing
of the face, but also in the congestion of the retina,
and by the free flow from cupped j^urfaces, which had
previously yielded only a few drops of blood. This
effect is said not to be produced by the influence of
the vaso-motor system, but depends on a direct action
of th e drug on the muscular coats of the arteries. It
222 MENTAL DISEASES.
has also been asserted that it diminishes oxidation of
blood.
During the year 1877 we gave this remedy an
extensive trial in epilepsy Twenty-nine epileptics
took it for some time, and nearly all .were benefited
bv it. In some cases the lits ceased altogether for a
lengthened period; but, of course, there is a periodicity
in their invasion which must be taken into account.
In other cases the attacks, under the administration of
the drug, were as frequent as formerly, but not so
severe nor of the usual duration. Some of the more
intelligent patients told me that, since taking the drug,
when they felt that peculiar sensation which some
have before the attack, they had strength of will
sufficiently strong to overcome it. A third class had
fits, but much fewer and less severe than formerly.
All these cases had been treated in the orthodox way
before using this drug, and without any decided
benefit.
It is impossible to say with any degree of exacti-
tude what may be the condition of the brain in such
typical cases, but in this asylum a large proportion of
such cases were anaemic. It did not do well with the
plethoric. From the well-known effects of this drug,
in producing a temporary turgescence in the blood
vessels of the head, it is highly probable that the
medicine acts beneficially by its static effects on the
blood, and not by any direct therapeutic value it may
have on the disease. Whatever may be itp way of
EPILEPSY, MASTUKBATION AND MEFANCHOLIA. 223
working, the condition induced is no doubt antagonistic
to the epileptic aura.
The method of administration was by the inhala-
tion of four or five minims at a time. It is put up
by some chemists in small glass beads, and can thus
be carried in the vest-pocket. All that is necessary
for the patient to do is to crush one in a pocket-hand-
kerchief and it is ready for use.
In nocturnal epilepsy, or in the masked or larvated
form, strychnia is often very efficacious in doses of
l-30th of a grain three times a day, gradually increased
to l-15th of a grain. This is an excellent remedy, if
there is with the fits any gastric derangement.
The debilitating effects of the continued use of the
bromides in patients already weak, as are most epilep-
tics, ought to be prevented or lessened by the use of
strychnia, arsenic or cod liver oil, and a generous diet.
In making use of strychnia or arsenic, it is not to
be forgotten that not only the bad influence of the
bromides but als^ their favourable influence against
epilepsy can be diminished by these powerful agents
(especially strychnia). It is therefore necessary, when
these agents are used, to increase the quantity of the
bromides.
As a rule, epileptics do not do well on iron and
quinine, unless there exists anaamia of a pernicious
nature — chlorosis or cachexia from malarious poisons.
Curare and picrotoxine have their advocates, but
they are of doubtful efficacy.
The bromides are at present the great remedies to
224 MKNTAL DISEASES.
cure or modify epilepsy. This is the testimony of the
profession, in spite of many so-called specifics, which
have had temporary ascendancy, but soon disappeared,
to be succeeded by equally ephemeral drugs.
The action of the bromides on the human system is
general. It affects the nervous and muscular struc-
tures in every part. It acts as a nervous ana3sthetic,
and also on the mucus and integumentary surfaces.
It affects the muscular organs of digestion, respiration
and urinary excretion. Its sedative action on the
circulation, its partial eflf'ect on the temperature and
on the various secretions show perfectly the uses
which have been made of this salt, without explaining
its action on any special organs or on local parts.
It is by its anaesthetic and sedative action that it
controls the most extensive and complex neuroses,
such as hysteria, chorea, hystero-epilepsy and epilepsy.
These haloid salts also act upon local nervous affec-
tions, such as dysphagia, whooping cough, asthma,
spasmodic dysuria, spermatorrhoea, and where there
are isolated morbid conditions such as we find in the
neuralgias and rheumatism. Its sedative action con-
trols the circulation, and renders it a suitable agent
for the removal of any hypersemia, whatever be its
extent or situation.
While the bromides and iodides are thus invaluable
in manv of the neuroses, either alone or in combina-
tion, it is not well to give them continuously too long
at a time, lest glandular insufBciency might ensue
EPILEPSY. MASTURBATION AND MELANCHOLIA. 225
thereby, or it niii^ht be a teiiporary paralysis, because
of induced muscular weakness.
If a bromide has to be given regularly for some
time, to avoid the unpleasant results uf Broniism, it
is better to give the zinc bromide salt, say :
H Zinci hi'orn 7)ij-
Syr. simpli 5). — M.
Dose : Ten to thirty drops, three times a day,
gradually increased.
This form is a powerful tonic, and will neither
upset the stomach, nor produce cachexia, nor skin
eruption, even if given six months at a time.
We have found the same beneficial result whan
borax is used with any of the bromides. In Germany
and Russia the bromide of gold is lauded in epilepsy^
and a mixture of oold chloride and arsenic are fjiven
in these tits, as well as in locomotor ataxia. It is
possible the efficacy lies a good deal in the attractive
name, as in the much praised cure for dipsomania
from the same source.
Hydrobromic acid is a sedative neurotic like its
salts, and is a good occasional substitute or alternative
for them. The bromine in this acid state is not so
liable to enfeeble the muscular tissues nor produce
that alkalinity of blood and of the secretions, nor
weaken the digestive and assimilating process which
the long use of the salts does. It is also pleasant to
take. It is often beneficial in solution with one or
more of the salts. Less of both is required if con^-
10
226 • MENTAL DISEASES.
bined. In this wav the alkaline saturation of the
system is avoided. For example, when an epileptic
may be taking 25 or 30 grains of potassium bromide
three or four times a day ; the dose can be reduced
to 15 grains a day, if 6 or 8 grains of this acid are
added to each dose in solution. Be sure to give plenty
of fluids with any of the bromides. It is well not to
give any of the bromides, and especially the iodides,
on a full stomach, as their effect is not good on the
starch of foods.
The following prescription, first recommended by
Dr. Brown-Sequard, will often be found to do good in
epilepsy of the idiopathic form, and often when other
remedies fail. It is well known by the profession :
aa 5iij.
\ aa 3iss.
R Potassii Bromidi
Sodii Bromidi
Ammonii Bromidi
Potassii lodidi
Ammonii lodidi
Ammonii Carbonati 3j'
Tine. Calumbte 5Jss.
Aquse q.s. ad fit 3viij. — M.
Sig : A teaspoonful and a half an hour before each meal,
and three teaspoonful s at bedtime,
In hystero-epilepsy I have found a good deal of
benefit in some cases in the use of a one 'per cent.
solution of nitro-glycerine (Glonoinum). Dose : One
to three minims
It will thus be seen that the remedies used are
EPILEPSY, MASTURBATION AND MELANCHOLIA. 227
principally those of antispasmodics and sedatives. A
combination may be given in the following formulae :
R Potassii Bromidi ) a a ,
aa gr. xv. to xxx.
Chloral Hydrat J ^
Strychnise Sulph gr. ^(j-
Ext. Ergotse fl. ^ss.
Ext. Digitalis fl. m. j.
Spt. Menthse Pip ni. v.
Aquae q.s. ^3S. — M.
Sig : One such dose after morning and evening meal,
with water.
> 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«<ers do not know that
these symptoms are signals of distress. The inde-
17 ' --^ -;-^ -
258 MENTAL DISEASES.
cision of will, the bewildered judgment, the lack of
self-control and of discretion, the excitement alter-
nating with unaccountable mental depression may be
only temporary and evanescent, or they may be
" cominof events castingr their shadows before."
If there is any hereditary taint of insanity, or any
serious neurosis existing, then these evidences of
physical and mental deterioration are not to be lightly
thought of, for any such condition may evoke from
latent tendencies active diseases of an alarming
character. The deficient mental control of sane peo-
ple thus afflicted is a psychological study of great
interest. They know how absurd are their fears and
forebodings, yet no reasoning can shake them off or
remove the general nervousness. The hopelessness,
the silly fancies, the unnatural dread of being in
company or of being alone, the fear of contamination
in many ways undreamed of when well, the undefined
terror of walking certain streets or living in isolated
houses, and the general :.ense of ill-being with a
dread of something vague about to happen, are only
a few of the many psychical conditions found in the
neurasthenic. The most pronounced manifestations
underlying these morbidly tinged conceptions and
misconceptions are timidity, irresolution, and constant
irritability of manners and speech not natural to the
person. This state of feeling has a defined period of
invasion, and has not been gradually acquired through
daily experience and repetition, nor is it a congenital
trait of character. This abnormal condition is often
THE BORDERLAND OF INSANITY. 259
the primary stacje of insanity. It is interesting to
note how conversely we often find insane conval-
escents show merely this modification of mental
weakness in the last stages before recovery. Just as
the colours of the rainbow, or those of the spectrum
analysis, blend into one another so imperceptibly
that no boundary between each shade can be located,
so it is often difficult to know by observation, or to
detine in language, where the dividing line is in many
cases between that disease we call insanity and
nerve-starvation. It is not, however, a fixed physical
disease, and does not effect and control abnormally
the language and conduct of an individual, as in
insanity. The physical condition is not to be over-
looked. We often find abnormal dryness of the skin
and mucous membranes, tenderness of the spine in
circumscribed places, as, we often find in hysterical
women. Complaints of feeling heaviness of the loins
and limbs ; shooting pains, simulating those of ataxy ;
irritable heart-action, best known by a tremulous,
variable pulse, accompanied by palpitation and it may
be intermissions of beats, mostly the third and fifth
beats. Convulsive movements, especially on going to
sleep, which have often been mistaken for nocturnal
epilepsy ; localized hyper-sesthesia ; sudden giving out
of general or special functions; temporary paresis, or it
may be paralysis, and generally a feeling of profound
exhaustion unaccompanied by positive pain. Some
graphically say : " They have a feeling of goneness."
It need scarcely be added that these signs and
260 MENTAL DISEASES.
•
symptoms, as a whole, are not to be found in any one
patient, nor are all enumerated in the above recital.
When the imagination has full sweep, based upon
feeble or no impressions, then has it " no pent-up
Utica." The usual diagnostic and differential skill
will enable any one readily to distinguish this disease
from either hysteria or ordinary anaemia. It is not
chieHy found to exist in naturally nervous persons.
A patient may be plethoric and muscular — not
necessarily anaemic — and yet have impoverishment of
the nervous system. Neuratropia exists chiefly in
patients between the ages of twenty-five and fifty
years. Its presence does not depend on any im-
portant recognizable organic disease. I have found
in a majority of cases a full, normal pulse, but
sometimes it is very rapid, or abnormally slow, with
a fluttering feeling under the finger. There is no
cardiac disease present in most cases, and the face may
look the picture of health. The patients will often
apologize for their satisfactory appearance. In spite
of apparent strength, such are easily fatigued by
mental exertion, and complain of giving out long
before the usual time of resting. The memory is
often temporarily weakened ; consecutive thinking,
intense attention, or sustained mental activity of any
kind, is found to be impossible, even when there is
no muscular fatijrue. It is at this sta^e when in-
somnia is complained of, usually to be followed by
mental depression and by distressing forebodings of
some impending calamity, which they cannot define.
THE BORDERLAND OF INSANITY. 261
It is a general sense of ill-being and ill-liappening.
It is common to both sexes, but is more common in
the male sex. A frequent mistake is made by
medical men in attempting to lecture such patients
out of their notions about themselves. This will only
deepen the morbidity and intensify the evil. It is
best to accept the evil as a fact, but to raise hopes
for the future in a sunshiny way. This is mental
therapeutics.
No two cases can be treated alike. If it is a case
merely of brain exhaustion, then our main reliance
must be upon vigorous out-door exercise and light
mental exertion. The muscular and orfjanic life can do
much through activity in bracing up the nerve centres.
If we have an anaemic case, or one in which there is
evidently exhaustion of the cord, especially in the
chlorotic women, then absolute rest and quiet are
indicated. Digestive power and hygiene are our
auxiliaries. I am a great believer in alimentation —
not over-feeding, but what the system can fully
assimilate. It is nerve nutrition which we have to
do with, hence the necessary pabulum must be pro-
vided. Such usually recover, but gradually and so
slowly as to discourage patient, friends and physician.
The fact is, that all nerve deterioration needs a
protracted time to recuperate, and it is well to set
out in treatment with this understanding by all, that
this depressing condition has invaded the nervous
system by slow approaches, and that it will leave the
seat of disease with reluctance, under the most
262 MENTAL DISEASES.
favourable circumstances. It is necessary to start out
with a large stock of patience in treating such cases.
A close catechising of a number of young persons
has led me to believe that this abnormal condition is
often brought about, or at least intensified, by worry,
the vicious habit of self-abuse, or from syphilis. It
is also well to make minute inquiry as to the exist-
ence of the mild form of epilepsy, especially of the
nocturnal or larvafed or masked variety, which is
often overlooked, yet, by its enervating shocks, not
only does it pull the system down, but also keeps it
prostrated when the mischief is done. A rigid inquiry
on these points is of paramount importance in diag-
nosis of many cases. I am inclined to think that the
abnormal mental conditions are always secondary, and
that the primary trouble is in the sympathetic and
spinal systems.
The constant complaints of unusual sensations in
one or more of the abdominal organs are evidences of
this. The heart's irregularity, the atonic dyspepsia,
the obstinate costiveness, the kidney derangement, and
the temporary dyspnoea, all point to these great nerve
centres as the efficient causes of these derangements.
If we keep in mind that in the neurasthenic we
have mostly to do with reflexes of the sympathetic
and spinal cord, including all the organs to which
nerve stimulation is given from these centres of influ-
ence and control, we can understand how varied must
be the symptomatology of this generic disease. If we
add to these disturbing causes a tendency to insanity.
THE BORDERLAND OF INSANITY. 263
or at least find a nervous diathesis predominating,
then, of necessity must our prognosis be less favour-
able. I have found that those who usually complain
of pain in the back, show that the spinal nerve func-
tion is temporarily deranged. This fact is evident
when we find the oxalates, the urates, and uric acid
in excess. These are present only as results, and are
not pathognomonic, as in oxaluria, because on a return
of tonicity in the nervous system these abnormalities
disappear. They are at first only signals of distress,
which warn us of graver evils should the disease in-
tensify and continue. The pathology of the disease
is not yet fully determined. It may be a change in
the quality or quantity of blood supply to the nerv-
ous system, it may be an impoverishment of nerve
force, it may be bad nutrition from low power of
assimilation — one or all of these causes, or others yet
unknown, would account for the exhaustion, the posi-
tive uneasiness, the unsteadiness, the fluctuating char-
acter of the morbid sensations and phenomena. What-
ever may be the cause or causes, the result is nerve
starvation ; the cry is for more food and for more
reserve energy.
Let me summarize the treatment :
1st. Rest and cheerfulness for the anremic.
2nd. Outdoor exercise and work for the plethoric
and sedative.
3rd. Fresh air, substantial food and absolute clean-
liness for both classes, as a rule.
4th. No chloral, no opium, no alcohol ; in short, no
artificial stimulant, soporific, or narcotic of any kind.
264 MENTIL DISEASES.
Such short cuts to rest only murder natural sleep and
strangle the heroic efibrts of nature to come back to
normal conditions. Even when these stilts are used,
it must be after serious and thorouf^h deliberation.
5th. Any employment which will have a tendency
to divert the mind away from self-contemplation : in
short, it is seekinj^j relief by the law of substitution.
6th. I find the best remedies are such as the arsen-
ites, cod liver oil, zinc phosphide, ferri pyrophosphate,
nux vomica, bromides with caffeine, zinc oxide with
ergot, and such like.
These tonics and calmatives assist nature to seek
again the old paths. Allow me to add a word of
warning to the younger members of our profession.
If sedatives, or narcotics, or stimulants are adminis-
tered it is well to mask them as much as possible.
We all know their seductive power, and I have been
told by dozens of .victims to the alcohol, chloral or
opium habit, that the first knowledge they had of the
pleasurable potency rf such drugs was received from
the family physicians. After their visits ceased the
remedy became a luxury, and the druggist was
applied to for the material to inflict infinite injury to
many a valuable life. My method has been to use
some menstruum which would disguise the taste and
smell of these drugs, and to maintain a stubborn
silence as to their presence in my prescriptions. This
warning is given here, as there is a great temptation
to use them in neurasthenic cases, in which are found
insomnia, local trouble, and mental distress.
THE BORDERLAND OF INSANITY. 265
CHAPTER XXVIII.
THE BORDERLAND OF TNSANITY.-{Continuecl.)
Dipsomania.
The dipsomaniac has our pity, but mere compassion
is of little moment unless it can take a practical shape.
Essays on alcohol and on its physiological effects in
the human system have little power to reclaim an old
toper. Moral tracts on the sin of this excesy are mostly
thrown away on the confirmed inebriate. Sermons
depicting the future fate of such are practically useless.
He cares next to nothing for his present or future fate
with a burning thirst for spirits upon him. Carica-
ture may do its worst ; imitation of his stupid antics
and frolics may adorn the speech of the temperance
lecturer, and set his audience in a roar of mirth;
starvation and rags, filth and physical distress, scorn
and ostracism, all have no effect on the majority of the
pitiful victims of alcoholism. Nothing short of a
miracle or a Divine dispensation can save a vast
majority of those from their morbid and debasing
appetite, if left to themselves. The few are saved by
well-meaning philanthropists, but the many are lost
to themselves and society. It is, therefore, a social
206 MENTAL DISEASES.
problem, involving tremendous interests, how to save
these weaklings of humanity.
The writer may be permitted to divide the drunk-
ards into four classes.
1st. Those who become drunkards from a habit of
tippling.
2nd. Those who become drunkards from drinking
to relieve nervous prostration, or to drown sorrow or
worry. ,
3rd. Those who drink to excess because of a heredi-
tary tendency to thirst after some stimulant or seda-
tive, arising from nerve and brain susceptibility or
depreciation.
4th. Those who become drunkards because of some
injury to the brain, spinal ccrd, sunstroke, or great
nervous shock of any kind. The nature becomes
changed as well as the character, because of any of
these afflictions. They influence the whole man for
evil, and that without a truce.
Those who become drunkards from habitually im-
bibing are usually of three kinds.
(a) The weak-willed, who cannot resist the tempta-
tion to imitate others in a drinking bout, or who may
think it manly to toss off the glass with boon com-
panions.
(6) The genial, jolly, companionable fellow, who
loves company, and is usually good-hearted, generous
and free with his money.
(c) The mean-souled man, who cannot resist the
temptation to take a glass or two when others pay
THE BORDERLAND OF INSANITY. 267
for them, or who delights to " sponge " on the good-
will and pockets of his more free-giving neighbours.
Any or all of these varieties begin to imbibe as
sober men ; but, by repetition, the custom becomes a
habit, and at last it degenerates into a vice. Such
stimulants are insidious, and often do their stealthy
work before the victims are thoroughly aware of the
mighty grip these have upon them. They wake up
to the fact that they have generated and nursed a
craving want which it is misery not to satisfy. Some
can, by the exercise of great determination, refrain
from drinking in spite of the quenchless desire, but
t\\e many drift down the fatal stream without makinjj
one effort to reach the shore of safety.
Those who becom«^ drunkards by nightly potations,
to relieve mental trouble, are more numerous than is
supposed. They are not usually found among the
drunk and disorderly in a police court; they may not
make exhibitions of themselves in public places; they
may even give little trouble to their friends or families,
and many are not even suspected of drinking until
a vicious habit has been formed. The drinking is
done in secret. The victims pass sleepless nights,
and as a relief drink themselves nightly into pro-
found stupor. It is a drunkenness of which no one
may know, because the person has no excited stage,
seeing he has at once saturated his brain with an
overpowering quantity of the stupefying potion.
This demoralizing habit may go on for years, without
any particular symptoms being seen by others during
268 ilENTAL DISEASES.
the daytime, as the nocturnal drunkard wil • only take
a small dose in the morning to enable him to throw
off the stupidity of the nightly debauch, and to appear
as usual before the public. This truce cannot last
long, and outraged nature takes the punishment upon
itself. Paralysis, or apoplexy, or insanity, may be the
result. In many, before these sad inflictions super-
vene, the nightly soporific is followed by the daily
spree. The disguise is thrown off, and there is a full
surrender to the persistent victor. This class usiially
belongs to our active members of society.
The daily brain work above normal ; the worry of
competitive business; the humdrum of all work and no
relaxation ; the fierce battle for life all along the line;
the envies and jealousies in the world of fuss and
fashion, which end in commercial ruin am! disap-
pointed ambition, and a thousand such malign inilu-
ences cause sleeplessness, mental anguish and general
nervousness. Such victims fiee for refuge to any
temporary relief, and they find it most readily in the
oblivion of debauch from the use of alcohol or opium.
It might be mentioned here that such nightly
stupefactions are more fatal to mental integrity than
is any other form of drinking. In such, the excre-
tories have not time to remove the poison from the
system nor the brain to recover its tone from the
daily invasion, before they are again called upon to
defend the citadel of life. Each assault makes the
resistance more feeble, until, at last, there is uncon-
ditional surrender. It really means daily drunken-^
THE BORDERLAND OF INSANITY. 209
ness up to the point of stupor and narcotism. No
system can stand this constant strain and live out all
its appointed time.
The third class include all the unfortunate victims
of a hereditary tendency. These have bequeathed to
them a heritaore of woe. " Our fathers have sinned,
and we bear their iniquities." It is not to be for-
i^otten that it is not drunkenness which is inherited,
but only the nervous bias in that dir^^ction. It is a
sleeping lion, which is harmless until aroused. It is
a magazine of dynamite, which is as inert as a piece
of granite until rudely shaken or percussed. It is a
battery of electricity, whose latent energy is not
known until a condiCionfavourable to its manifestation
is created. Under a similar law this dang-jrous element
of tendency in a man's nature may reiiiain latent
until evoked by alcoholic stimulation. The dormant
demon is then aroused and will-power is tied hand
and foot by an infernal tenant, which no exorcism
can lay. The paroxysms come on the man thus
stricken, intermittently, as do the periodic impulses of
some forms of insanity. The dipsomaniac has his
tidal wave of all-conquering impulse. Occasionally
men of giant self-control belonging to this class can
successfully resist the burning desire to quench the
insatiable thirst for alcohol. They are the few, and
through life have an incessant strugijjle with the
tempter. These are among the heroes of our age.
The man who has no taste for spirits can easily avoid
this temptation, but the man to whom the whiff of
270 MENTAL DISEASES.
liquor from a bar-room door as he passes is almost
fatal to his integrity of purpose and sobriety has more
bravery in him, when he conquers his desire, and more
determination of will than has the soldier in a forlorn
hope. The hereditary foe is conquered by daily battles,
and not by a few isolated repulses or assaults of or
against the relentless enemy. This third class is com-
posed of persons in whom is easily discerned constitu-
tional disturbance before the invasion of the periodic
outbreaks of dipsomania.
Medical men can easily perceive the unusually
nervous condition, the irregular blood circulation, the
low nutrition, the morbid fears and forbodings, the
unnaturally irritable temper, the lack of resolution
and firmness so foreign to the individual in health,
and even misconceptions and delusions may supervene
when the attack is coming on. The physical and
mental conditions show undoubted signs and symptoms
of the cominnf outbreak which the victim cannot resist
any more than can the insane maniac. To blame such
a man to the same degree as we may those of the
other two classes shows ignorance and injustice in
respect to these unfortunates of inbred propensity.
During these bouts of drinking mania the man is
uncontrollable. He has inherited this defective tend-
ency. What in an ordinary man might be very
moderate drinking is to him destruction. To even
touch the fatal glass is to invoke the hidden energy
of incarnate mischief which has come to him as a
sad legacy. He is not to be put in the same category
THE BORDERLAND OF INSANITY. 271
as is the man who, solely by his own habits, puts him-
self in an irresponsible condition by reason of this
drunkenness. Such a person is much to blame for
the result of his voluntary acts. He could have
avoided being dragged into the frenzy, which often
ends in direful acts, perpetrated on himself or
others, and so far is without excuse. The person who
takes to drinking to excess by imbibing largely at
bedtime, to relieve nervousness and to procure sleep,
may scorn the idea of doing so for pleasure, as does
the tippler. He usually declares that of two evils he
is choosing the less, and treating himself medically.
His course of conduct generally ends disastrously to
himself, and cannot be excused or palliated. He is
responsible for his conduct, as the method adopted of
indulging in a nightly debauch is voluntary, and
medical experience warns him of its danger. He
ought to know what the end must be when he sets
out on this evil habit. It is astonishing what credulity
these people have in their own will-power. They
positively assert that they can stop the habit at any
time they choose, yet never make the endeavour.
With the most of them this idea of freedom is a
delusion and a snare. They boast much of what they
can do in throwing off the habit, but their vain-glory
is that of the braggart. Seldom is the faith in them-
selves followed by practical results. So faith without
works is dead.
The fourth class is remarkable. A sun-stroke, a
blow on the head, or a concussion of the brain, or of
272 MENTAL DISEASES.
the whole nervous system often brings about a change
of cliaracter. The chaste m.xn Vjccornes suddenly
licentious in word and action; the taciturn and
dignified become garrulouw and offensively familiar ;
the brave become cowards ; the honest man can no more
be trusted ; the total abstainer, who never had a desire
or taste for stimulants, becomes an inveterate drunk-
ard, not through tippling and confirmed haVjit, but
suddenly after any such nerve injury. The whole
nature has undergone 'i complete revolution, and the
morals suffer first. It is not a wickedness, Vjut a
physical perversion which has turned into a new
channel or modified the moral and intellectual attri-
butes of such a man. This condition might be called
insanity.
Experience has shown that many of those who have
received a shock or an injury to the nervous sy.stem
are much more irritable than was formerly natural.
As might be expected, such are more easily affected
by a powerful stimulant like alcohol, and its influence
is more deleterious than would be under the more
healthy conditions. As a rule, the persons in this
class are more intractable, excitable, and even mania-
cal than they would have been had no injury to the
nervous system taken place.
It will be seen, then, that we have floating about in
our midst, on the stream of life, these hapless slaves
to drink. We niay eliminate from this vast army of de-
fectives those who could reform if they would only try;
yet a large number remain on whom no moral suasion
nor social nor Christian influences have ever had any
THE liOllDEKLAND OF INSANITY. 273
eifcct to reform. It makes the heart sad to sec; the
futile efforts of such to escape from this maelstrom of
depraved habits, but only finally to be sucked down
remorselessly into its ever-devourinj^ vortex.
There is no help for these but enforced restraint.
They must be put in custody, where the temptation is
beyond their reach. The Insane Asylum is no place
for tliem. They need the same oversi<(}it as the in-
sane, but diflerent surroundings and medical treat-
ment suitable to such. To effect a cure, it is necessary
to provide them with healthy work, fresJi air, various
amusements and nourishing food. The buildings
should be as liomelike as possible; the prison-like
should be avoided, as far as practicable. Each case
has to be studied separately and treated on indi>fidual
necessitif.'s. The nervous system is starving for its
usual stinfiulant, and this ac(^uired and morbid de-
mand mu.^t be met by the administration of natural
food and sui)port. Nature seeks healthy highways,
if it is only assisted in its heroic efforts to return to
the old paths. Were it not for those noble efforts of
nature to seek its primal conditions an<l throw off
this man of the sea, woe betide drinking and drunken
Ciiristendom.
In the recuperative powers of nature is our great
hope in rescuing these perishing. Many of the
wealthy go voluntarily to pleasant asylums when
remorse is on them after a prolonged debauch. The
desire for drink may have left such for a time, then
are they in a penitential mood. They readily agree
ft
274 MENTAL DISKASES.
to abide by tlio ad vice oi tlie pliyHician. It proves to
be only uh U)r\ff jis tlie lull in tiie bi'ain-storni lasts.
The irresistible impulse returns, and nothing short of
personal restraint can then keep the di})sorrianiac
from liis cups. Jle cares nothing for the conditi(jns
of his bond ; he defies ever yone ; he is lost to appeals.
He Hies from the drurdvard's hos})itai, and (pienches
his intense thirst in the intoxicatinjx <lrau'dits. We
casuists and moralists have not the faintest idea of th.e
agony of such a man, seeking temporary relief to
(juiet the raging devil in his surging brain. At tliese
crises lie is irresponsible and helpless. Call liim a
sinner, a depraved man, a vicio\is citizen as you may,
but in the si^^ht of ili'fh Heaven he is held i^uiltlesH,
if no will of his and no moral influence can restrain
him. In the first stages of his downward career ho
rnay hav(5 been to blamo. but now he is an object of
pity. To hourifl such a creature in the last stage of
his career, because he at first brought it about by
voluntary acts is cru(;l, The man who })ecomes insane
by a sensual life, in which he is the victiin of a loath-
some syj)hilis,is none the less an object of pity thereby.
To refcjrm any such drunkard is a difficult work.
A refuge must be provided for him witli all the strin-
gent rules of a reformatory in active operation. It
must be free to " the drunk and disorderly," whoso
depraved tastes have brought beggary and disgrace
on themselves, as well as having an open door to the
rich. The notoriou.s and habitual drunkard, who has
become a pest to himself, hi.s family, and society,
The HORDEllLANt) OK INSANITY. 27f)
should be committed to an inebriate asylum under
the same sai'ef^uards and strinj^ency as are the insane.
It m<'itt<!rs not whether the admi.ssion i.s accomplished
by voluntary surrender of personal liberty, or by com-
nntnient of a inai^istrate, or by virtue of medical
certificates. All or any of these methods should be
stftuiory, and .should mean an indefinite and prolon;re<l
term of oversi^^ht and submission to prohibitory rules
and re<;ulations. The j^^reat want in the 'Province of
Ontario is the absence of such an asylum to which
the poor can go for succour and cure.
All such institutions conducted on the voluntary
principle have failed, and must fail to cure chronic
drunkards, however well these are conducted. The
principle of freedom to come and *.^o at will is practi-
cally of no avail to cure. This system of providinj^
pleasant boardinj^-houses for a few weeks or months
away from bo.unn and boon companions, and
without restraints, of necessity, cannot be curative
establishiiHjnts. 'J his is their record in Britain and
the ynit(;d States. A pauper drunkard has no needy
shelt(-'r to go to but the prison. The vast majority of
drunkards are poor, yet they need to be saved from
themselves as well as do the rich. The state has put
in their ])athway all the conditions neces.sary to make
sots, inebriates and maniacs of the feeble-willed, and
it is a pity that, after the cruel work has been done,
there is no haven of refuge and cure for them.
The longer a steady drinker of the tippling cla.ss is
kept from imbibing stimulants, the more easy is it for
276 MENTAL DISEASES.
him to continue a total abstainer. This is ttue of all
our habits for good or evil, hence the importance of
endeavouring to undo a habit of excess by introducing
in its place a habit of abstinence and industry.
A hospital to cure drunkards should, in its opera-
tions, insist upon healthful habits. Its hygiene and
sanitation, its necessary discipline, the absence of the
Usual temptations and associations, the precept and
example, the impossibility of indulging the drink
craving, the gradual return of nerve strength and
self-possession, the power to refrain from seeking
this evil — all contribute to the recovery of many who
could never be otherwise than chronic drunkards were
no restraint put upon their indulgence. Many storm-
tossed and pitiable wretches, who are now bringing
untold anguish upon themselves and families, and
who are a curse to society, as well as an expense to the
country in our gaols and reformatories, might, in
properly-conducted hospitals, reform and become use-
ful citizens.
The experience of centuries has .shown that w^ are
"wasting our sweetness on the desert air" to endeavour
to reform these who are thus afflicted by any other
means than personal restraint. Religious and moral
influences are not to be despised when the despotism
of disease has passed away and reason begins to assert
its sway. Noble eflbrts, by means of these agencies,
are continually being made. A few reform, who are
not too heavily handicapped in their struggle for
liberty, but they are only the few of the great army
THE IJOKDERLAND OF INSANITY. 277
of drunkards. Amons: this class of reformed drunl' ards
— so called— a lar^e proportion relapse, unless they are
daily kept under the influence which incites to sobriety.
With them it is a daily fight for the mastery.
In my official report of 1879 is the following para-
graph hearing on this subject: "Hereditary drunkards
must have the curse removed from them or they from
it. The former is not likely to be done at present;
the latter may be carried out under (jtovernment
supervision. The reformation of such is not abso-
lutely hopeless, but the chances of recovery are not
many : yet it is the duty of the State to aid such
in their efforts to reform ; and, if this be impossible,
then it is equally incumbent upon society to prevent
them injuring themselves or others. The immediate
injury done by such a drunkard to himself is not
by any means the worst feature of the case. If a
child inherit to a great extent the constitution and
individual peculiarities of one parent, who is a
drunkard, with no stronijlv marked traits of the other
to counterbalance them, the probabilities are that a
tendency to dipsomania will be the lot of some un-
fortunate member of that family not thus protected
unless moral influence and early habits of abstinence
have kept in check the exciting cause. ^
" The same rule which exists in respect to the insane
should prevail for the benefit of these sufferers. As
medical men it is our privilege and duty to educate
the rising generation, our legislators, our ministers of
the Gospel and our moral reformers that there is a
27'S MENTAL DIHKASKS,
■
class of inebriates who bonJer on insanitv, and who
are ol)jects for medical treatment. Experience trNiehes
that appeals to their religions instincts are in vain.
The moral nature is paralyHe<l and utterly helphiss to
control conduct. The physical system throu^di which
mind operates is out of tune, and nothing,' hut the
re[)air which time and health can bestow will brinf^
concord and harmony out of the instrument. 'J'h(i
experience of medical men is, that nothing; sliort of
personal restraint can cure the members of this class,
and to wliom is ^iven the nam*; of dif)somaniacs. It
is as futile to apjxjal to their manluxjd as it would
be to reason any maniac into rectitude of hiu<^\m(^ii
and conduct. This mania is not conlinc^d to drunk-
ards. Every druf^jLjist and every physician can t(!S-
tify to the increased number of opium and cldo)-aI
consumers. Those who have formed and are formin*{
the habit are daily increasing. Many who have
reformed in their spirit-drinking liabit betake them-
selves to such narcotics. These <lruf^s are stealthily
indulg<?d in as substitutes for li(jUor, and thus while
they hav(; driven out one devil they have cohabit(Ml
with a dozen in his stead. Tlie former j)unishes with
rods and th(; latter with scorpions. This is not refor-
mation, it is only a change of intoxicants to those of a
far more dehiterious nature. This habit is more pre-
valent than is dreamed of by social refonners, and a
cru.sade is needed against the indiscriminate sale and
consumption of all such intoxicants. In this neuralgic,
nervous, sleepless and bustling age, this tendency will
THK IKMIDKKLAND OF INSANITY. 27d
incroaso unless a warrun;^ cry is raisud l)y inedical
men."
Nakcomama.
Witliin tlu! last thirty yoars tlio us*; arul al)Usf; of
such narcotics as opium arwl its salts, chloral, al>sitith(s
cliloro(lyn(3, and sucli lil<(! drui^s liavc; iucniascd an hun-
dred fold. It is possil)lo tliat alcoliol, in all its harHd'ul
(ilU'cts, is doiijf^ loss injury in tin; world to-day tlian
those t(^xic a^'(3nts. Their victims arc; not di.'mon-
stiative as ura tin; alcoholic; drunkards, hcncij an; not
thrust prominently into vi(!vv. The insi<lious efl'ects
are produced (jni(!tly, unless at tlie lattfir sta.,'es of tlio
morl)i(iity delusional mania should superv(;ne aw a
result.
The (Ju.stoms returns show how much consumj)tion
of tlicse and kindred dru^s is tjikin;^ places, after
makin*^ li))eral deductions for those; used hy tho
medical profession. Tlw? (piantity is increasing from
year to year to a j^^reater j)roportionat<! extent tlian ia
the population.
Tho causes of tliis increase in narcotics an; many,
1'hey may Ijo classified under two luiads :
(a) B(;cause of pliysical discond'ort or pain.
(h) Because of m(;nt/il ill-h(;inf( or of some trouble
or disti-ess, for which it is a tesmporary solace.
The physical diseases for whicli an anod yne is taken
arc as many as are all the troubles which aUlict
humanity. The most common, however, are the
neural^^ias, headaches, hysteria, insomnia, rheumy-
280 ME^ £AI> DISEASES.
tism, cerebral affections, hypochondriasis and sane
melancholy.
The bodily symptoms are many in the narcomaniac,
and all are of a mo^t distressing nature.
The tremors, the temporary ataxy, the organic
derangements, especially those of nutrition, the tro-
phic feebleness and consequent low cell selection, all
point to serious derangements of the vital activities
in all the somatic domain. The victims of this habit,
when it has risen to a vice, are pitiable objects of
contemplation.
Many of these were at one time alcoholic drunk-
ards. On account of the frenzy which spirits pro-
duced, and which made them thereby the scandal of a
neighbourhood and a nuisance to relatives, they change
the agent of mischief to that of one of these drujjs
which satisfies their cravings. If such should have an
inherited neuratic constitution, then is their reforma-
tion one of extreme difficulty.
The permanent mental symptoms, apart from the
immediate effects of the drug, are usually melancholy,
irritability, loss of memory, suicidal tendencies,
lowered intellect, sometimes mental exaltation, and
always depreciated moral tone. The loss of good habits
is almost pathognomic, and the depths of depravity
many will go to is scarcely credible. This is more
true of opium and its salts than of drugs of a more
evanescent nature, yet these untoward results depart
when a cure is efiected by the removal of the
poisonous agent, so it cannot rightly be designated
insanity.
THE BORDERLAND OF INSANITY. 281
Treatment may be one of three kinds :
1st. Sudden withdrawal of the drug.
2nd. The deprivation being a little at a time, but
very slowly, extending over several months.
3rd. The entire withdrawal of the drug in, say, a
week or ten days.
The first plan is cruel and dangerous. I have, on
sev^eral occasions, seen collapse, heart failure and
death from this method. At other times delirium,
followed by mania, with delusions and hallucinations
of the most pronounced kind are present.
Half a usual dose of the druix given would drive
these away, unless permanent insanity should have
invaded the brain in the meantime.
The second mode of treatment is adopted by many,
and has stronor advocates in its favour. At the same
time, it is to be remembered that it is well to deprive
the patient of the drug as soon as it can be safely
done, and thus shorten his suffering to the least pos-
sible period, compatible with expected success.
The third method commends itself to my judgment,
and has been adopted with good results in a majority
of cases treated.
No drug of a kindred nature should be put in its
place, even in insomnia ; no cure can be affected by
a change in toxicants. Codeine and cocaine have
been recommended as substitutes. It is malpractice
to administer them, as experience has shown in too
many sad instances.
If we can tone up the system during the with-
282 MENTAL DISEASES.
drawal, especially by improving the appetite and
infusing moral courage into the invalid to exercise
will-power against the tempter, half the battle is
won. At the same time, if such are free agents to
procure the drug before normal conditions are set up,
then must we fear collapses into the former state,
especially in those of a neurotic diathesis. A goodly
number, however, of those at large recover under
judicious treatment.
My plan has been to gradually reduce the dose of
the drug so that at the end of, say, ten days its use is
discontinued. In the meantime baths and fresh air
should not be neglected. Three times a day, full
doses of bromo-cafFeine might be administered, which
should be given for some time after the noxious drug
has been entirely withdrawn.
The following prescription produce good results as
a substitute .
li SodfP Brom 5J.
Liq. StrychnifB . . . , 3i.j-
Tine. Capsici 3'ij-
AqusR 5viij.
M. Dose : One tablespooiiful in three tablespoonfuls
of water, morning ar^d evening, at least one hqur before
meals.
Or,
R Zinci Phosphidi g"*- J*
Extract Nucis Vom Si", i*
Extract Cannabis Ind gr. ^.
M, Dose : One pill of the above three times a day.
THE BORDERLAND OF INSANITY. 283
If a pure preparation of cocoa leaves is used it
proves an excellent anodyne in the opium habit. It
is much more satisfactory than is the alkaloid of the
erthroxylon coca.
For the thirst of inebriety the following is good :
R Tinct Ciipsici 1 drachm.
Tinct. Nucis Vom 1 drachm.
Acidi Nitro-hydrochloric, dilute. . . 1 drachm.
Infus. Gentian ad . . 12 ounces.
M. and make mixture. Sig. : Two tablespoonfuls as
often as three times a day. <
Or.
R Quinine Sulph. . , gr. ij.
Zinc Oxide gr. ij.
Strychnia Sulph gr. ^'^.
Arsenic gr. yj^jj.
Capsicum gr. ij.
M. et. ft. pil. no. j. Sig. : One three times a day.
Together with this pill, some use, for sixteen days,
the following hypodermic dosimetry :
R Strychnifie Nitrat g''- .]•
Aquie Dest oz. ss.
M. Sig. : Eight minins daily for eight days ; four
minims daily for another eight days. To quiet the morn-
ing nausea of alcoholics, two to three drops of wine of
ipecac on the tongue, fasting.
To induce sleep the following sedative is admin-
istered at night for a few days ;
284 MENTAL DISEASES.
R Tinct. Dpii. Deod x
Ext. Hydrosc, fld j
Chlo-al Hvdrat t^""- ^''- '•'
Pot. Bromid
I
Tinct. Capsici dr. ss.
Tinct. Aconit rad ni. v.
Aqu.ie Mentii. pip ad . . oz. iv.
M. Sig. : Two tablespoon fuls at bedtime for a few days
nly, freely diluted with water.
If the patient is very much excited, and is border-
ing on delirium tremens, the following is useful for
two or three nights :
Bt Hyoscin, bydrobroma^ g^'- j-
AqufB dest, dr. ix.
Spt. vini. rect, dr. j.
M. et. ft. hypodermic solution. Sig. ; Dose from five to
ten minims pro re nata.
These remedies are also excellent in the treatment
of dipsomania, as all toxic agents produce somewhat
analogous results on the nerve centres,
APHASIA. 285
CHAPTEE XXIX.
APHASIA.
Aphasia is an affection of the motor speech region
of the bfcun. The idea of what words are required
for expression is correct, but the co-ordinating vocali-
zation is impaired. Wrong words are attached to
correct ideation.
It is to be distinguished from the merely functional
aphasia seen in hysteria or where deep emotion exists,
as these are only temporary. The incorrect utter-
ances of the insane are not included in this term. It
is not paralysis of the organs of articulation, such as
we meet with in hemiplegia or glosso-labio-pharyn-
geal paralysis. It is not aphonia, for loss of voice is
caused by impairment of the vocal cords. It is a
singular dislocation between the ideational centre
and the motor region. The volition is rightly exer-
cised, but its command is not correctly obeyed. This
lack of co-ordinating power to articulate correct
words is called ataxic aphasia. If there is added to
this condition loss of memory of words, then have we
amnesic a^phasia.
Among the first class there may be no apparent
mental disturbance, but if the disease continue for
286 MENTAL DISEASES.
any length of time, the substance of the brain be-
comes diseased to such an extent as to result in mental
lesion.
Aphasia is often accompanied by hemiplegia, and
both are frequently seen in apoplexy in aged people.
The disease is usually caused by embolism of the
left middle cerebral artery, and, as a rule, is found in
the third left frontal convolution.
The uniformity is not sufficient to constitute it
solely the distinct functional centre for verbal ex-
pression.
The island of Reil, which lies immediately adjacent,
is often found to be the only brain substance affected,
including sometimes part of the corpus striatum.
This is not to be wondered at when we consider that
the same blood vessel supplies the island and the
second and third irontal convolutions, v^iere disease
is most often found in aphasia.
When words are uttered with the meaning of
which the aphasic patient is familiar and they are
not comprehended, although the intellect is unaffected,
then there exists what is termed word-deafness. The
sensory relation with hearing and speech is dis-
arranged.
If words which may be written, and which are
well-known to the patient in health, convey no mean-
ing to him, then have we word-hlindness.
Those afflicted with motor-aphasia are often able
to utter words, and are not deprived of phonation.
When the power to articulate distinct words is lost,
APHAStA. 287
sounds can be made by the vocal organs, showing that
their power still remains. Many such patients will
make intelligent signs, as the intellect remains un-
affected. It is only the medium that is out of order.
If he cannot understand seen words then has he
alexia. If his healthy arm and hand cannot co-
ordinate movements to write proper words, then has
he agraphia.
Amnesia.
This is a disease of memory.
1st. The loss of memory may be limited to a single
category of recollection, leaving the remainder appar-
ently intact ; these are so-called partial disorders of
memory.
2nd. Others affect the entire memory in all forms ;
completely dissever mental life ; produce chasms that
cannot be bridged over. These are called general
disorders of memory. — Rihot.
The different forms may be divided into :
1st. Temporary amnesia.
2nd. Periodical amnesia.
3rd. Progressive amnesia.
4th. Congenital amnesia.
In progressive amnesia the general law of experi-
ence is, that the more simple and early impressions
are the longest retained. The impressions remain the
longest which are received in childhood, and, as a
physiological fact, must be retained in a primitive form
of the brain, presumable in the medulla and in the
288 MENTAL rUSEASES.
basal nerve centres. The physical basis of memory
in its conservation and reproduction depends on two
conditions, (a) Certain modifications of cells, (b)
Formation of more or less complex groups of cells,
which have been called "dynamic associations."
This bald statement gives m little light in the ob-
scurity.
There is nothing more striking on the approach of
insanity in many than mental enfeeblement, as evi-
denced in lessened power of attention or lack of con-
centration of thought, added to impaired memory.
This is especially true in progressive paresis. Long
before pronounced symptoms are observed, trivial
matters connected with every day life are unaccount-
ably forgotten. Appointments, names, friends and
the days of the week glide away from the memory.
The impaired recollections of many persons not insane
may not rehabilitate at will some particular letter in
a word, or some numbers in arithmetic, or one of
several well-known languages, or some other particu-
lar phase of knowledge which was but slightly regis-
tered in the mind. It looks as if memory were
composed of successive layers of records, and those
last put on are tirst taken off, or that the plastic
brain of youth has had events and experiences more
deeply engraven on it than those of latter years, so
that in effacing these reminiscences the shallowest
hieroglyphics are the soonest and easiest obliterated.
The penmen who make these imprints on the brain
are attention and repetition. If these powers are
AMIASIA. \ 289
weak then are the fleeting ideas written gn sand and
easily destroyed beyond power of recall.
It is interesting; to observe how toxic aojents, as
well as some forms of insanity, affect memory. In
fever and on the approach of apoplexy memory is
often exalted in a remarkable degree. Past events
come back into introspection with startling distinct-
ness. The same is true with narcomaniacs. In the
insane utterances of those attacked with acute mania
this revivifying of forgotten past events is noticed.
Not only so. ^ut the mind seems enlarged in its capa-
city in some directions. The sceptic becomes highly
religious, and may be a walking volume "on Evi-
dences of Christianity." The prosaic man becomes a
poet, and sometimes shows himself to be no mean
rhymster. The man to whom arithmetic was a vexa-
tion glibly talks of figures, problems, and, if qualified
by previous training, of geometrical puzzles. Of
course, these evidences of latent power coming to
the surface are exceptional, yet their existence is a
wonder. At first thought it seems almost miraculous
that a person should be deprived of all recollection of
words and retain the other faculties of the mind
intact; that he should forget one language and retain
his knowledge of others ; that a language long for-
gotten should suddenly return, and one recently used
should for the time disappear as if it had never been
acquired. It is not to be forgotten how unequal is
the memory of each of us in respect to past experi-
ences, and how intuitively we select out of the past
19
290 MENTAL DISEASES.
facts in our own 'ife history with more or less vivid-
ness and correctness from among the millions of ideas
which have gone into oblivion. Not only so, but
new capacities are often evoked not known at first
even in the normal state.
If memory on its physical side depends upon blood
supply to the cells, then would it seem that not only
does increase of blood circulation to the tens of
millions of such bodies make these enlarged powers
possible and probable, but also the extra blood supply
may raise to psychical prominence tracts of nerve
energy not made manifest before.
We know that all the wild and impossible imagin-
ings of dreaming are determined by blood supply.
Were we to attempt to do what we dream of doing
then the result would be that we would require
restrain during our sleeping hours. At these times
imagination runs riot, yet, the varied panorama which
passes before our vision transcends any effort we could
put forth in that direction in our waking hours. The
ideation has no check, as we see in the frenzy of acute
mania, although from two different conditions of the
brain in its blood supply. On the one hand we have
physiological anaemia ; and on the other hand, patho-
logical congestion and cell deterioration. •
The varied capacity of brain and mind is thus seen
in two very different states. We nebd not wonder at
the vagaries of mentality found on record in abnormal
conditions.
CRIME AND RESPONSIBILITV. 291
CHAPTER XXX.
CRIME AND RESPONSIBILITY.
Crime has been defined to be a violation of iiuman
law or the law of the State; sin, a violation of the
Divine law or the precepts of religion ; vice is oppo-
site to virtue, and is an offence against morality, or a
violation of the moral law. Crime is especially the
object of jurisprudence ; vice, of ethics ; and sin, of
theology.
Responsibility is the capacity of discharging an
obligation, or ability to be accountable for actions.
We must bear these definitions in mind in discuss-
ing the relation of crime to responsibility. Some
classes of humanity must be held to be exempt from
responsibility. /
1st. The child of immature age.
2nd. The idiot with arrested brain-growth and
dwarfed mental development.
3rd. The imbecile in whom the mental powers exist,
but in a feeble and circumscribed condition.
4th. Various classes of the insane.
5th. The epileptic (not insane), when fits are coming
on or leaving.
6th. The dipsomaniacal in the frenzy of drunken-
ness.
^92 MENTAL DISEASES.
The last two classes are held in law to be respon-
sible, whether conscious of their acts and the quality
of them or not. Law says it cannot distinguish
between the knowing act of an epileptic and that
done unconsciously. It also says the drinking maniac
is in that condition because of his voluntary act of
drinking; hence his accountability. The law holds
that all insane are irresponsible, but bases its defini-
tion of insanity on the capacity of a person to know ,
the distinction between right and wrong in the
abstract. This fulcrum mind-test was laid down by
the English judges in the McNaughton case (1843).
In carrying out the law, judges never give a personal
opinion. To them the accepted lex scripta is gospel
truth, as far as the verdict and execution of law
are concerned. They do not question the received
decisions, authorities and precedents of their legal
ancestry. To them, it is what the law commands,
which is supposed to be founded on justice in its
fundamental principles. We need no other example
in this particular than that already mentioned. To
make a knowledge of right and wronjj the crucial
test of sanity has wrought untold mischief in the
administration of law. In fact, it is now acknow-
ledged by eminent jurists, such as the late Sir James
Fitzjames Stephens, in his work on " Criminal Law,"
and by Lord Chief Justice Cockburn, in his opinion
given before a Parliamer.tary Committee, that such a
rule of law is misleading and faulty. The consequence
has been that in recent works on medical jurisprud-
CRLME AND RESPONSIBILITY. 293
ence a new element has been introduced into the
legal definition. The ethical tC'st is not given up, but
there is added such a clause as, " the law allows that
a man who, by reason of mental disease, is prevented
from controlling his own conduct, is not responsible
for what he does." — {Stephens' " Relation of Madness
to Crime "). It is added, "No doubt there are cases in
which madness interferes with the power of self-con-
trol, and so leaves the sufferer at the mercy of any
temptation to which he may be exposed; and, if this
can be shown to be the case, I think the sufferer ought
to be excused." — Stephens.
In 1874, when Russell Gurney's bill was before the
English Parliament, a clause embodying the recog-
nized fact that the moral test was *ery fallacious, and
that a statement should be introduced accepting as
proof of unsoundness of mind or lack of responsibility
such brain disease as destroyed self-control. The law
officers of the Crown recommended its rejection, and
it was shelved accordingly. When this proposed
amendment was before the Committee of the House,
Lord Chief Justice Cockburn cordially accepted this
amendment, and significantly said : " The pathology
of disease abundantly establishes there are forms of
mental disease in which, though the patient is quite
aware he is about to do wrong, the will becomes over-
powered by the force of irresistible impulse. So the
power of self-control, when destroyed or suspended
by mental disease, becomes, I think, an essential ele-
ment in irresponsibility." At the same time, Sir
294 MENTAL DISEASES.
James Stephens suggested that in such cases a jury
should be allowed to bring in one of three verdicts,
viz. : 1st, Guilty. 2nd, Guilty, but the power of ..elf-
control was diminished by insanity. 3rd, Not guilty,
on the ground of insanity.
The judicial instructions to juries in rendering
verdicts remain as before, and even Chief Justice
Cock burn was obliofed to charore juries accordino; to
the written law, although he knew how inconsistent
with physical fact the law is. He was obliged to
abide by the traditions of the legal fathers. Hang-
ing under the old definition is still going on, in spite
of the flood of knowledge which has been poured
upon the subject by psychologists during the last
fifty-two years, since the moral test formula became
law. The more enlightened opinions of eminent
jurists must ultimately have weight in the British
Empire and in the United States, and will tend to
affect legislation in the right direction. This is not-
ably the case in the United States. Newly enacted
penal codes in some of the States have, in addition to
the morality definition of 1843, some form of recogni-
tion of loss of self-control by virtue of disease.
From these genet al statements it will be seen how
widely law and medicine differ on this radical and
all-important matter. The medical test for insanity is
based on the presence of physical disease and its
abnormal results on conduct ; the legal test is meta-
physical and theoretical. The medical diagnosis is
based on pathology and experience ; the legal ignores
CRIME AND RESPONSIBILITY. 295
any physical condition which does not affect the
moral attributes. The lejval cares nothing for im-
pulse, loss of will power, or sudden change of char-
acter and conduct without motive or from childish
incentives ; medicine takes in the whole man in all
his multifarious interests. The former tests bv the
ambiguous notion of i^ight and wrong ; but the latter
by the will not or cannot of each individual. The
one deals with an abstract idea ; the other in what is
found practically true every day in the wards of any
lunat'C asylum. Law adheres to tradition and the
iiat of statutes ; medicine points to the facts of clini-
cal experience and practical knowledge. Legal dicta
permit a counsel and judge to instruct a jury both as to
law and facts, both as to responsibility and value of
evidence ; but a medical witness — whatever his experi-
ence and skill may be — is not allowed to relate them
to the jury, although they may be of intrinsic value in
teaching and enlightening those in whose verdict lies
the destiny of a prisoner. The man, of all others,
who should know whereof he asserts, must be " a
dumb dog," while the man whose experience may be
of the most crude kind is legally allowed to appeal,
to instruct and direct a jury in the most abstruse of
all medico-legal subjects. The writer, not long since,
heard at a State trial a well-known Canadian barrister
and Queen's Counsel instruct a jury that any ordin-
ary man was as able to aetect any form of insanity as
could an expert. The absurdity of such a statement
might be seen any day by turning loose into the
296 MENTAL DISEASES.
wards of o> strange asylum this counsel, a jury, and
asylum medical officers, to select the sane from the
insane as they might be presented. A short experi-
ence in this discriminating work might not convince,
but it would certainly give ground for legal reflec-
tion and possibly prevent a repetition of such a state-
ment. Perhaps he should not be blamed too much,
as his text-books make the same assertion. It would
be rank heresy for him to fly in the face of accepted
authority, even were he convinced of its absurdity.
In reading the history of jurisprudence, it is satis-
factory to observe that the broad minds of the great
jurists and wise legislators are groping towards the
light. Let us take the question under discussion, for
example, and see its evolution.
During the last century, the definition laid down
by Lord Coke was accepted as law. In this it was
held that to be insane meant to be totally devoid of
mind, memory and understanding when an insane
act was committed. If this negative condition did
not exist, such were responsible. It need scarcely be
said to-day that no insanity ever existed to which
this definition would apply in its entirety.
In the beginning of this century it was held that
insanity should be tested solely on the basis of the
possession of delusions. Of course, the absence of
them would imply sanity, yet we know many insane
have no delusions. This phase of legal thought was
followed by the crucial test that any person who has
the capacity "to know the nature and quality of the
CRIME AND RESPONSIBILITY. 297
act he was doing " must be sane and responsible.
Manj' insane are quite capable of knowing as described.
This moral test is absurd in itself. What right and
wrong are in the abstract have not been determined.
Law is one thing and ethics may be quite another.
As one item of the curiosity of law penalty, it may be
noticed that at the beginning of this century more
than 200 offences, from robbing hen-roosts to treason
and murder, were punishable by death in the British
Isl^^s. In 1816, no less than fifty-eight persons were
under sentence of death for such offences, and one
was a child under ten years of age, who could neither
read Eor write. As the years rolled by, it became
evident that punishment and crime were unequally
associated, and law began to adopt a sliding scale in
the administration of justice more in keeping with
the quality of the crime. Anyone who will take the
trouble to wade through the evidence on which the
verdicts of those days were based, will see it fared
badly with the poor lunatics. The court suspended
the insane, in many instances, instead of the judg-
ment ! The putting the life of the assumed insane
in one scale and then placing these ever-changing
conditions of law in the other have been, are now,
and apparently will be the means of putting many
innocents to death. Definitions are mischievous when
they bind down judges, juries and legal evidence to
certain lines of opinion, from which there is no
deviation permitted. The results, so far, has been
that legal history in the past was full of records of the
298 MENTAL DISEASES.
victims of crude definitions and legal subtleties. Cast-
iron definitions have been the means of bespattering
the pathway of nations with the blood of these more
unfortunates.
The word insanity is a relative term, and means a
disease. It is always a brain disease, with gradations
of severity. As we cannot tell where the colours of
the rainbow blend, nor can we point out when the
steel-grey of the dawn commenced, nor when the last
glow departs of the closing day, neither can we define
where sanity ceases and insanity begins. There is a
borderland which lies in the shadows, and no one
can penetrate it with a pencil of light. Reason passes
into it, possibly unconsciously, or, it may be, with
dread forebodings, and emerges from the ominous
cloud into the positive region of mental alienation.
The foe comes stealthily, but surely, and ties the
captive to his chariot-wheel. There is at this stage
no mistake as to the mind-trouble. It has assumed
a definite form in its prominent features, which is
modified by the personal characteristics of each indi-
vidual ; hence no detailed definition of insanity can
ever be given. No two people are alike in any one
particular, so mental manifestations differ. In judg-
ing the insane, the temperament, peculiarities, educa-
tion, habits, surroundings and apparent motives must
always be taken into account. Does the man act
naturally ? Is he himself ? Is his unusual conduct
Drought about by anything but brain disease ? We
must measure all men by their own half-bushels, and
CRIME AND RESPONSIBILITY. 299
not by an arbitrary standard of capacity. The
ascendinsf series of intelligence seen in the normal
creation have a counterpart in insanity. If we take
an intellectual general test and apply it to each class
of the insane, we will find at the lowest points the
harmless dement in whom is little mental capacity
beyond that found in the helpless child. Such have
little vitality beyond organic life. At the other end of
the series are the cunning, clever, intelligent insane,
who puzzle even experts in their most searching
examinations, Among this higher class are found
the insane over whom courts sit in judgment, and
concerning whom juries give strange verdicts. The
stupid, the boisterous maniac, and suicidal and religi-
ous melancholies are easily known ; but the clever
possessor of delusions which he carefully hides, and
which may be the mainspring of his general conduct,
needs to be carefully examined, watched and studied
before the most experienced can pronounce definite
judgment and determine responsibility. These delu-
sions may be of a harmless kind, and control or may
not impel overt acts, or they may be mainsprings to
urofe to insane manifestations. Of course, we all
have delusions of some kind, but the judgments of
the sane give them proper value. The insane accept
them as facts, not fancies. There is a large class of
individuals between the feeble-minded and the normal
section of the community, and naturally animalism is
the predominating feature of such beings. The intel-
lect is developed to such a degree that they may be
300 MENTAL DISEASES.
tolerable citizens as far as intelligence is concerned.
They are, however, low in the scale, and are known to be
such by even ordinary observers. The cunning, selfish
instincts and impulses found in animals are strongly
dominant in them. They set lightly on law or any
of its restrictions so long as they can avoid detection.
With such, it is not a question of morals, but of
punishment. The sense of right and wrong is feebly
developed, and the moral judgments are seldom exer-
cised. Conscience is either not present, or, at best,
weak and functionless, and gives little trouble. It is
not an ethical nature blunted by repetitions of evil,
but a faculty never brought to maturity. Such have
been called " moral idiots." No crime, however dark
and horrible, will cause them to lose a meal or a
night's rest. Like brutes they live, and like brutes
they die. If they have not much mental activity
they may be harmless in a community from sheer
inertia, and are never heard of but as ne'er-do-weels;
but if the brutal instincts goad on the intelligence,
we have developed a low class of criminals for whom
there is little hope. They crop up as the chronic
vagrant, tramp, petty thief, or, in short, the inveter-
ably depraved all-around character. The whole being
is saturated with laziness and cupidity, because of
which a living is procured at the expense of the honest
workers of society.
The fact is, all intelligent creation is like a pyra-
mid. The first section from the base represents the
animal instincts of man and beast. The next section
CUIME AND KESPONSIBILITV. 801
may represent the higher intelligence, not instinctive;
it is much narrower in its scope. The section includ-
ing the apex might typify the moral nature, and repre-
sents a much more circumscribed and higher class of
being In humanity, the building up of our nature
is in the foUowinof order from birth : 1st. Animal
instincts. 2nd. Intellectual powers. 8rd. Moral con-
ceptions. In any or all of these we may have
arrested development.
Now, in the building up of this sympathetic whole
from childhood tc adult life, we may tind the growth
arrested at any of the stages. If development should
be checked in any stage of youth, only the animal
exists: hence the idiot and imbecile. If arrested in the
progress of intellectual growth, we have feeble-mind-
edness and dwarfed mentality. If atrophy takes
place in the last section oi: building a full manhood,
then have we intelligence, but no moral nature, or, at
best, only the rudiments of one.
No amount of metaphysical refinement can reason
away the physical fact that our whole entity of body,
intellect, will, affections, emotions and morals are
only manifestations of one organic whole, and are
interdependent upon one another in many relations
of this unity. The genesis of our conduct is largely
dominated over and affected by their development,
their relative power, and their controlling activity.
The elements of our existence have in them the
potentialities of the coming man. Habit, education,
and favourable surroundings do direct these primary
302 MENTAL DISEASES.
i
forces for good or ev^il, but they never can obliterate
the characteristic features which make us congenital ly
distinct from one another. Our individuality is born
with us, and goes with us to our graves. A very little
change in the relation o£ our constituent element of
character and of primal nature does alter very
much individual peculiarities, just as a very little
change in chemical elements brings about radical
differences in material substances. The old land-
marks, however, remain unchanged, and must, in the
nature of things, so continue. No two physical forms
or faces of humanity are alike; no two brains are alike ;
and no two minds are counterparts of one another, ex-
cept in a generic sense. The primal elements are varied,
and the growth of brain and mind is different in each
person. The immature brain of a child ma}^ be fully de-
veloped into the mature and complex brain of man-
hood, but the attempt to improve a partially dwarfed
brain, such as is seen in the feeble-minded, is well-
nigh hopeless. The juvenile brain grows, and men-
tality with it, in a corresponding ratio, so that an
equation might be made between the two. A brain
has only a mental scope equal to its capacity and
power.
The child is judged according to its mental power,
so ought the savage and the feeble-minded to
be. It is not by years we should measure mind
strength, but by the standard of the ordinary intelli-
gence of the ordinary man. There are children wise
CRIMi: AND RESPONSIBILITl 303
beyond their years, and there are men with childish
minds.
The brains of the lower forms of humanity and of
the higher beasts come close together in structure
and shape. The natures of both such men and beasts
have much in common. Both have intelligrence and
reasoning power, but there is no evidence that they
have a moral sense, or, if so, it must be in a rudiment-
ary degree. They have no contrition for acts. Pun-
ishment, not compunction, restrains them. The idiot
has not even the animal intelligence. The imbecile
is a step higher in the plane of instinct and know-
ledge, but is little, if any, higher in these than a
dog, elephant, or chimpanzee, and is held not to be
accountable because of mental deprivations. The
feeble-minded approach more nearly to the normal
man, but are lacking in keenness of judgment, the
abstractive faculty, and mental concentration. Such
are either verj'^ childish and harmless, or show vicious-
ness or many forms of depraved propensity. The
criminal and accountable, in the next stage, have no
keen appreciation of the rights of others. Many of
them are children with grown bodies, just as we find
in the habits, tastes and mental scope of the untutored
savage. The immature brain of a child, a barbarian,
and the weak-minded produce analogous mental
phenomena. It is to be remembered that there can
be no responsibility where there is no moral nature,
and there can be no moral nature where there is little
or no intellect. The fact of a knowledge and appre-
304 MENTAL DISEASES.
ciation of our relation to law and of the consequences
flowing from its infraction may exist without responsi-
bility. To simply know is one thing, but to be able
to determine and set in action responsible volitions is
quite another.
These statements are made to help to an apprecia-
tion of another class, which can be placed between
the feeble-minded and a fully-developed man. We
find a large class of the community who have, in a
low degree, judgment, discretion, common and moral
sense. From this class comes the vicious and low
criminal. Reference is nob here made to those who
become so by association, example and habit, but to
those who are congenitally weak in all the necessary
attributes of a well-ordered humanity. They start
life handicapped with low cunning, inordinate ac-
quisitiveness, selfishness, cruelty, low mental powers,
and lack of a moral sense. All of these deterrents
are seen in a lower plane in the brute creation. Such
prey on the public, do no work for a livelihood, in-
dulge in petty larceny, revel in the mere performance
of wickedness for the love of it, whether sensualistic
or destructive ; in short, indulge in all depraved
tastes and vices, and never know practically what is
meant by the stings of conscience. A love of wrong-
doing is an inborn and inbred condition in which
they take delight. As a matter of fact, the responsi-
bility of such is small, measured by any rule of
ethics, and it is a serious matter to consider if such
criminals should not be incarcerated for life when
CRIME AND KEsrONSlIUMTV. 30.')
they become chronics. They should be made to earn
ail honest living, not merely as a penalty for crime,
but as a charity towards the vicious, and as a protec-
tion to society against their ravages. Such ordin-
arily spend most of their time in prison because of
repeated offences, and are let out of durance inter-
mittently, only to prey on society, to educate others
to follow their example, and to leave behind them a
criminal progeny. The low criminal, by oft convic-
tions and repeated imprisonments, becomes an incur-
able law-breaker, and should be treated as incorri-
gible. Experience shows he is such, and being so,
has forfeited all right to liberty and personal con-
sideration beyond kind treatment and forbearance,
based on industrious habits and good conduct.
It is easily to be understood, then, that in this next
upward stratum is found the larger number of our
ignorant, depraved, lazy, bestial criminals. Their
cunning will make them sham religion when it suits
their purpose, their instability makes them yield
readily to temptation, their animalism makes them
the sport of their passions, their love of ease makes
them indulge in the luxury of vagrancy or petty
larceny, their low tastes make them victims of
strong drink and the seekers of like associates, and
their gregarious instincts cause them to form com-
binations which threaten to disturb the foundations
of society, and of necessity make them social pariahs.
In view of these facts, it is one of the great social
problems ,of to-day to determine, in equity, how much
20
306 MENTAL DISEASES.
conduct is influenced by natural and irresistible quali-
ties, and how much is modified by immediate and
proximate external causes and circumstances, or
wherein our actions and modes of thought are influ-
enced and directed by our natural aptitudes and pro-
pensities. As far as we can know these factors, they
should be taken into account in estimating the culp-
ability of actions. Law is based on abstractions, and
punishes absolutely according to act and not accord-
ing to turpitude. The man who commits a homicide
in a frenzy of drunkenness has little consideration
shown to him in his sentence, yet culpability may
depend largely on circumstances. In one case, the
passion for drink may have come on from a vicious
and acquired habit, therefore it is blamable ; in an-
other, it may be a dipsomania by reason of heredit-
ary transmission, from which there may be no manu-
mission. It is a heritage of uncontrollable impulse,
which is transmitted in its invasion and continuance.
In both classes the penalty is identical, hence the
injustice often meted out.
A forgery is committed by a man whose whole life
record has been that of honesty and truthfulness, but
who, by stress of financial pressure, has suddenly
fallen from his high estate. The trend of his whole
career has been in the direction of virtue and honest
living, but with commercial disaster staring him in
the face he commits a felony, which he hopes to
rectify before discovery. His whole moral nature
revolts against the act, but his sensitive fear of men
CRIME AND RESPONSIBILITY. 307
and of the effects of poverty on his family and
himself is a motive too strong to resist.
Another man has a mean, grasping, selfish nature.
He has been naturally so from childhood. He has
cultivated all evil influences, and has sought environ-
ments calculated to encourage their cffowth and
deepen their intensity. Because of these tendencies,
natural and acquired, he forges and cheats simply to
possess and increase his gains, based on the pure love
of greed.
The acts in both examples are the same, but in their
comparative guilt they are far asunder. In the one,
it is a sudden impulse to deviate from the well-beaten
track of a life-long rectitude ; in the other, it is the
natural o"tcome of an ingrained vicious nature. The
guilt in both cases is scarcely to be compared, but
the penalty is equal. The motives are not taken
into account. In fact, the man of heretofore good
reputation is held to be the greater culprit, although
it was only an incident in his life, and in the other
the outcome of a bad record.
In short, it may be said that : —
1st. The natural history of crime shows that brains
of chronic criminals deviate from the normal type
and approach those of the lower creation.
2nd. That many such are almost as impotent to
restrain themselves from crime as the insane are in
abnormal conduct.
3rd. That immoral bias may be hidden because of
expediency by cunning until evoked by circum-
stances.
308 MENTAL DISEASES.
4th. No man can shake himself free from the
influence of the physical surroundings in which he
is encased.
5th. Crime is an ethical subject of study outside of
its penal relations.
6th. Insanity and responsibility may coexist.
7th. Some insane can make competent wills, because
rational.
8th. The monomaniac may be responsible should
he do acts not in the line of his delusion, and which
are not influenced thereby.
9th. Many insane are influenced in their conduct
in the same way as the sane ; the rudiments of free-
will remain.
10th. Many insane have correct ideas in respect to
right and wrong, both in the abstract and concrete.
11th. Many insane have power to withstand being
influenced even by their delusions. Therefore, irre-
sponsibility and insanity do not always cover the
same ground.
.INSANITY AND CRIME — LEGAL POINTS. 309
CHAPTEK XXXI.
LEGAL POINTS IN RELATION TO INSANITY AND
CHIME.
There are three distinct definitions of insanity re-
quired by British law :
1st. In criminal cases, the legal test of insanity is
the knowledge of the distinction between right and
ivrong ; that is, a criminal is considered sane and
responsible when he committed a crime if " he then
knew the nature and quality of the act," and that it
was wrong. Some jurists hold that this knowledge
needs only extend to the civil law of the country,
and others hold that right and wronj; must also be
looked upon in an ethical sense. In other words, the
indicted person is or is not capable to understand
and formulate moral judgments is the test of sanity
or insanity.
2nd. In testamentary cases, the requirement of the
law is somewhat different. Here the nature and
quality, the rightness and lurongness of the act are
not considered. A testator is considered sane if he
is "of sound mind, memory and understanding;"
and, conversely, he is judged to be insane if his mind,
his memory and his understanding are unsound.
310 MENTAL DISEASES.
3rd. In tlie third class of cases a third test is
required by law, and this class is the most important,
because in it alone is the question of sanity or
insanity, pure and simple, of a person directly raised.
In an inquisition in lunacy, the actual issue placed
before the jury is : " Is the subject of this enquiry
sane or insane ? " To this investigation is attached
the test : " Is the patient capable of managing himself
and his affairs ? " This test is very widely different,
and of very far more comprehensive scope than either
of the others.
In both the previous case" the jury have to get, as
it were, inside the man's mind, and to guess as best
they may at what was the receptivity and scope of his
consciousness and intelligence on a certain date. They
have to attempt to discover what he then knew, what
his thoughts were, and what reliability could be placed
on his memory and judgment. It is self-evident that
there is only one person who can, by any possibility,
know without fail the state and validity of a man's
memory, of his knowledge and of his discretion and
judgment, and that person is the man himself.
We only know by inference and by judging from
their actions, what the consciousness of other persons
than ourselves may be. This is taking for granted
that actions in others are accompanied by states of
consciousness and motives similar to those which, in
us, accompany like actions of our own. This is far
from being an infallible guide. We know by daily
experience that like actions may be preceded and
INSANITY AND CRIME — LEGAL POINTS. 311
accompanied by very different states of mind. Similar
conduct may be prompted by very different motives.
It will thus be seen that our knowledge of modes of
mind in other people is not intuitive, but inferential,
and therefore uncertain.
In the third class of cases, however, the subject
matter of the investigation is very different. In an
investigation or inquisition of lunacy the jury have to
determine whether the person is capable of managing
his own affairs, and this they do by immediate infer-
ence from observation of whether he does manage
himself and his affairs in a common-sense manner.
In such a case there is no attempt to reach the
innermost thoughts of a man, and procuring a know-
ledge of the workings of his mind in its multifarious
activities. In this class the law only requires us to
look at his conduct, which is open to our direct obser-
vation. It will be seen that the distinctions made of
the first two classes are based upon metaphysical
classification, while in the last class we deal with what
we perceive and judge accordingly. The distinctions
are practically far from satisfactory, but it is well to
know that they are made by jurists.
It used to be the custom of judges to regard per-
sons deaf and dnmb as, in the sight of law, idiots.
This presumption is no longer recognized. It has
long been understood that persons who lack these
important senses may yet be possessed of very con-
siderable intelligence, and be capable of a very large
amount of culture, The general rule in such cases is that
312 MENTAL DISEASES.
the court should ascertain that such a witness possesses
the requisite amount of intelligence, that he under-
stands the nature of an oath, and that being satisfied
upon these points, it should direct the witness to be
sworn and receive his evidence through a sworn
interpreter. If the witness is able to communicate
his ideas perfectly in writing, he will be required to
adopt that as the most satisfactory method, but if that
cannot be done, he will be permitted lo testify by
means of signs.
Evidence given by a lunatic during a so-called
" lucid interval " or during a remission of the disease
is often accepted ; but in order to render such evi-
dence valid, it is in some cases necessary that no
serious fit of insanity has intervened between the
event and the testimony; at least no such attack as
would cloud the recollection of the witness ; and, as
Allison's " Court Practice of Scotland " says : " That
would cause him to mistake the illusions of imagina-
tion for events which actually took place."
The testimony of idiots is not admissible in courts
of law.
The word " witness " does not merely mean cor-
poreal presence of an individual in court. It also
includes the idea of the possession of suflBcient intelli-
gence to observe the circumstances of the event, and
retention of memory to recollect and relate these facts,
somewhat in the order of occurrence, so as to be
understood by another party.
It has been held in law that some imbeciles can
INSANITY AND CRIME — LEGAL POLNTS. 313
give evidence, and the statements of the highest
order of intellect of this class have been accepted.
The jury must determine the value of such testi-
mony. Although it is often difficult, in fact, impos-
sible, to gauge the mental capacity of such in regard
to right and wrong. Some imbeciles have a wonderful
facility to invent lies. Lying becomes the habitual
exercise of their minds.
in this relation, it is to be remembered that imbe-
cility, which is congenital, and the natural de-
mentia of old age appear very much the same. Yet
on one point they materially differ. In the childish-
ness of old age the memory loses its latest impres-
sions first, and while all traces of recent events have
disappeared, there is a distinct remembrance of many
remote incidents. On the other hand, the imbecile's
memory may be trusted with regard to the events of
yesterday more than of years gone by.
At one time, even those labouring under mild mania
were produced as witnesses, but it was seen there was
no consistency in the sequence of their ideas. This
commingling of events in the memory with delusions
of various kinds made them thoroughly unreliable, and
now-a-days such evidence is not admitted in our courts.
The writer is of the opinion that the evidence of
some insane persons should be received, with the
proviso that it would need corroborative evidence to
fully substantiate it, especially if the insane person
is delusional. A weak or rotten thread in the warp
and woof of the mind affects to some extent the
robustness of mentality. Hence the necessity o£
314 . MENTAL DISEASES.
caution in the acceptance of such evidence. The
question of credibility should be left to the jury after
the ex 'parte statements of counsel and the direction
of the judge have been heard and considered. Unfor-
tunately the motives for truth or falsehood are on a
lev er plane in the insane than in the sane. Some jurist
has said : " Every selfish act of a sane man is leavened
with some unselfishness ; every hell-ward tendency is
redeemed by a little reaching up to heaven ; but in the
case of many lunatics it is not so. They are almost in-
variably selfish. Large-heartedness is a rare virtue in
the insane." This is a sweeping statement which pro-
nounces a general truth, but makes no allowance for
many exceptions of unselfishness and kindness seen
every day among the insane. It is true, the animal
instincts remain the longest in all cases of mental
decay, and these, apart from paternal impulses, are
essentially selfish. This stage in humanity means the
extinction of the nobler qualities in man, hence
motives are a crucial test in the insane as well as in
the sane, but with circumscribed boundaries. These
conditions must be considered as factors in testing the
value of insane evidence. The judge, in all cases,
determines the competency of a witness, and the jury
his credibility.
These important points are fully discussed in
" Brown on Insanity," Roscoe's " Criminal Evidence,"
and " Best on Evidence." •
They show the difficulties which meet the jurist in
order to arrive at the truth, when the search for iti
must be made through such uncertain channels.
MEDICAL WITNESSES IN THE COURTS. 315
CHAPTEE XXXII.
MEDICAL WITNESSES IN THE COURTS.
A MEDICAL witness is often put in a difficult position
when he is attempting to explain to & petit '^ury any
form of insanity which is obscure and not maniacal.
The jury is often told by judge and counsel that each
member of it is as capable to judge of insanity as is
an expert witness. This statement is an echo of what
is found in law books of over a century ago, when
mania and insanity were held to be synonymous terms.
The more subtle and dangerous forms of mental dis-
order of the quiet, cunning and delusional type had
been relegated in those days to innate moral depravity,
or to the instigation of the devil. In criminal cases
the majority of suoh died upon the scaffold, as they
occasionally do now-a-days, because of the necessarily
inexperienced juries who tried such cases, not to otate
the prevalence of ignorance and superstition in former
times.
At the same time a medical witness must fearlessly
and intelligently endeavour to explain his views to a
jury either for or against the plaintiff or the criminal.
A few hints to him may not be out of place.
He should endeavour to keep his mind in a semi-
316 MKNTAL DISEASES.
judicial condition, and be uninfluenced except by
undoubted testimony or personal knowledge.
He should never lose his temper in the witness-box,
however j^reat the provocation. An angry witness is
usually at the mercy of his tormentor.
It is not well to retort on an annoying examiner by
personal sarcasm or cutting irony. It is better to have
the sympathy of the jury under the teasing of a brow-
beating catechist than to attempt to copy his method
by an exhibition of " smartness."
The witness should keep on solid ground by not
going beyond his depth in hypothesis and theory, as
only facts are wanted.
He may be caught tripping should he attempt to
split hairs over matters of which he may have only a
superficial knowledge.
He should never attempt to be scholastic in his
statements, as he has to do only with the jury. Pro-
fessional and scientific terms may be to a jury as un-
intelligible as Choctaw. It is seldom that a witness
cannot explain in every-day language what is in his
mind, even relating to professional matters. This an
intelligent jury will appreciate and weigh, when
a learned disquisition by some pedant will be
looked upon as unintelligible jargon. Even the
learned witness should be like the soldier and keep his
scholastic ammunition behind his back, to be used very
rarely in courts of law, especially seeing that the
Anglo-Saxon language is so prolific in every-day
words to explain every variety of thought. The
medk'aL witnesses in the OOUUTK. '.]\7
pedantic witness is usually found to be an egotist or
a silly fellow.
A witness is sometimes asked if he is familiar with
certain works of well-known authors, or even of
obscure authors, and is also examined as to their par-
ticular views. It is well to be sure that the witness
is familiar with them before sivinjj am^wers to such
questionii ;j. I remember a witness bein^r asked if he
was acquainted with the works of a certain author.
The name jijiven sounded very much like that of a
well-known writer. The witness answered in the
affirmative, yet there existed no such author. This
fatal mistake rendered his evidence nuj^atory.
Many questions are put to a witness, and a cateojori-
cal reply to each is imperatively demanded. It is not
to be forgotten that a yea or no may not be a correct
answer, hence caution is needed.
The old example in our logic lessons will illustrate
this. For instance, the following question is put:
" Have you finished whipping the boy ?" Were the
answer given " No," then would it mean that you
were whipping him and still continued so to do? Did
you answer " Yes," then it meant that you had
whipped him, but had ceased to do so. Neither
answer would be correct had no chastisement taken
place. The assumption was false, therefore would be
either of the answers. Many a medical witness has
been trapped into a wrong answer, on account of such
a simple logical fallacy not having been detected.
There is a large class of interrogations to which
318 MENTAL DISEASES.
affirmative or negative answers would be incorrect.
Be on the lookout for them.
It is well not to digress from giving a direct and
sufficient reply to each question put. Prolixity is to
be avoided, as well as the introduction of extraneous
matter largely foreign to the case. A witness will
have plenty of opportunity in his examination and
cross-examination, not to mention rebuttal testimony,
to inform the court all he knows of the subject in
dispute.
Let no cross-examination, however severe, force a
medical witness to be, or to appear, as if he had taken
a side so strongly that all his evidence is ex 'parte, be-
cause of the antagonism evoked by a sharp counsel
endeavouring to bring his truthful statements or evi-
dence into contempt. The imperturbable, intelligent
and conscientious witness will not be driven from a
judicial position irrespective of the results to any party
in the case. We are always to remember our oath
and the sacredness of absolute truthfulness.
Should a witness change his opinion before giving
testimony based upon the evidence heard, it is only
just to the party who has subpoened him to state the
fact at once to the counsel. Unfortunately, because of
our present faulty system of jurisprudence under
which an ordinary jury has to determine the value of
medical testimony on matters professional, about which
they of necessity must know little, medical witnesses
can be found to give evidence for both sides. This is
a matter of regret, but a witness should not allow
MEDICAL WITNESSES IN THE COURTS. 319
«
himself to be trapped into valuing the merits and
demerits of other medical witnesses. It is the province
of the jury under law to weij^h the value and relia-
bility of all evidence.
When authors are quoted he must be guarded in
respect to the quotation, lest part mF.y be only given,
and thus change the tenor of the meaning entirely.
Remember a part truth is the biggest lie. A witness
may be asked to give his opinion as to the respect-
ability of a medical journal from which a theory is to
be read. We are not to forget that the magazine may
be creditable, yet individual writers in it may venti-
late arrant nonsense.
The eminent barristers in the legal profession are
usually very fair and courteous to witnesses, while
anxious to do all they reasonably can for their clients.
Occasionally one will be found who thinks savagery
to a witness is evidence of forensic ability. When a
professional witness has the misfortune to encounter
such a lawyer he can always appeal to the presiding
judge for protection. Such appeals should, however,
be rare, and only made under the greatest provocation.
A witness should study thoroughly all the phases
of a case about which he is expected to testify.
It gives him confidence to know that he has all
sides of it at his fingers' ends, so to speak. This is
especially true in insanity cases. He should never be
ashamed to declare his ignorance on any subject he is
not familiar with.
The witness is safe to confine his evidence to what
320 MENTAL DISEASES.
-»
has come under his personal knowledge. Hearsay
evidence is not admissible. He may not be allowed to
quote the opinions of authors, however distinguished ;
but an examining counsel may read quotations from
them and ask the witness to give his opinion in re-
spect to them.
An expert witness is allowed to hear all the evi-
dence of facts about which he has no personal know-
ledge. He is then permitted to give his opinion on all
the evidence presented in court, taking for granted it
is true. He is not allowed to value the evidence in
forming his opinion. It must be taken by him, as a
whole, as being undoubted" truth.
He will not be allowed to judge of the case if only
part of the evidence is heard by him. This is only
just, as a partial hearing might mean much misconcep-
tion of the whole case.
An expert witness is one who is supposed, from his
opportunities and life-work, to know of and to be
thoroughly conversant with the subject upon which
he is called to testify.
He is called to enlighten the court on the question
at issue, and is therefore more than an ordinary wit-
ness and less than a judge.
Such an exalted position should impress the witness
with the importance of every word he utters.
It is true, many judges have said hard things about
him and his vocation, yet these should not influence
the witness, as no judge, or counsel, or jury, can take
from hira the importance of his truthful evidence,
MEDICAL WITNESSES IN THE COURTS. 321
based upon experience and not upon hair-splitting,
metaphysical subtleties. His statements may not be
heeded, and may even be the object of irony or biting
scorn, yet it is the duty of the witness to unswerv-
ingly adhere to what his matured judgment presents
to his mind. , -r-
A witness with a warped judgment, on whose
mind undoubted evidence has little influence, proves
thereby his incompetence to testify in any medical
case.
Technical skill makes many v/itnesses valuable in
courts, and such as the Admiralty Court find the
evidence of experts necessary. The maxim is accepted
that " every person should be believed in his own
art."
In insanity cases this rule is not adopted, but in
part, because jurisprudence cares nothing for diseased
states, nor for the evidence adduced to prove them. It
only considers ethical conditions, and the conduct
based thereon.
The testimony of the medical witness is thereby
circumscribed to very narrow grounds ; and, as a
matter of fact, is so limited as to be of very little use, as
the whole extent of his knowledge and experience and
inferences therefrom is not allowed to be presented to
the jury.
There is a tendency to more latitude in modern
times, but as precedence is against it, that freedom is
only permissible by the grace of the court.
A medical witness must not forget that the promise
21
322 MENTAL DISEASES.
of secrecy, ofiven in the strictest professional confidence,
is not privileged from disclosure in court. A medical
man should be prudent, and not allow himself to be
the custodian of secrets not strictly necessary to his
medical practice. Our motto: " Fidus in Arcanis"
will not save us, if, as witnesse;3, we are asked i
divulge them.
A witness may rightly come to the conclusion that
insanity exists in a person from a large number of
minor facts in language and conduct. They must,
however, be taken as a luhole, and a witness must not
allow himself to be cajoled into giving an opinion on
each of these facts taken separately. This is a com-
mon trick of counsel, whereby ridicule is thrown upon
the evidence of such a witness. The cumulative force
of evidence is lost in such details.
It is also not to be forgotten that in language and
conduct the sane and insane have much in common.
So far, these cannot differentiate the one class from
the other.
A witness is allowed to use notes to refresh his
memory, but they must be the original ones, and not
copies or abstracts, even if made out by himself.
Steps Taken to Admit Patients into the
Asylums in this Province.
There are two methods legally necessary to be
adopted before a patient can be received into an
asylum in this Province.
MEDICAL WITNESSES IN THE COURTS. 323
The one requirement is designated (a) hy ordinary
process, (6) the other is by virtue of 8, warrant.
What is necessary in the former step is that " two
legally qualified medical practitioners" shall examine
a patient separately, and if insane shall so declare in
a general statement, which must be followed by a
record of observed facts upon which such an opinion
is based. No general opinion will be taken, as specific
acts must be stated which indicate insanity.
To these assertions are added the presumed facts
given by friends and relatives. These alone are not
sufficient, as they are only hearsay evidence. All
blanks as to dates, the /it^Z names, and such like, must
be filled up. Two tvitnesses are necessary to each
signature.
These two medical certificates are important docu-
ments, hence great care should be exercised in filling
them up properly. They are virtually a warrant to
commit a citizen to an insane asylum, and a medical
man should appreciate his responsibility in the matter.
The second method is, that a warrant is issued to
arrest a person who is supposed to be insane. This
may be done by a constable if such a person is at
large, and has become a nuisance or a menace to him-
self or to the community. On the other hand, an
affidavit may be made by a friend, a relative, or a
neighbour, asserting that such a person is insane and
dangerous, or not able to look after himself. Based
on this sworn statement a warrant of arrest is issued
by a magistrate, and by virtue of it he is committed
324 MENTAL DISEASES.
to gaol. He is there examined by the County judge,
the gaol surgeon and another medical man, and if
declared insane by them he is sent under warrant to
an asylum. A warrant of discharge is needed, based
upon the recommendation of the superintendent. This
dismissal warrant must be signed by the Lieutenant-
Governor. Under the ordinary process no such
complicated and slow processes are needed. The
simplicity of the one method, and the complexity of
the others, under exactly similar conditions, show how
tenaciously we cling to obsolete and cumbersome red-
tapism. The necessary forms should be the same in
all cases of insanity. The one class should not be
treated as criminals simply because arrested, and the
other treated as patients, and sent as such to a hospital
for the insane, to be discharged by the chief officer
without any formality when recovery takes place.
INDEX
PAGK
Amentia 182
idiocy, 182
imbecility, . 182
distinction, 183, 184
weakness of mind, 18a
savage and cliild, 186
illustration, 187
Amyl-nitrite 221
Arsenic 223
Aphasia 285
different forms 286
word-deafness, word-blind-
ness, motor-aphasia, ... 286
Amnesia 287
difierent foi-nis, .... 287
Animal instincts 301
Admissions of patients to asyl-
ums 322
two methods, 323
Brain illustrations 1, 18, 19
circulation of Idood, cells, . 14
nerve substance, .... . . 15
relative and absolute weight, 16
pathology, 27
shape of skulls, 27
changes in membranes,. . . 27
size of brain, 28
atrophy and hypertrophy,. 29
various degenerations,. . .29, 30
Maudsley, 31
infiltration and involution,. 33
constructive and destruc-
tive, 34, 35
brains of lower creations, . 303
Bromides 223
Brown-»Se(iuard's formula 226
Borderland of insanity 254
PAOK
Circular insanity 94
remissions, 94
intermissions,' 94
time of life, 99
Dr. Willis, 99
pathology, 100
Concealed insanity 103
object 103
caution, 104
Conium 217
Cannabis indica 21 S
Chloral hydrJite 213
Crime and responsibility 291
different classes, 291
changes in law, 293
legal definitions, 296
natural history, 307
Clinical conditions of insane . . 35
anaemic insanity, 35
diabetic insanity, 35
insanity of Briglit'sdisease, 35
metastatic insanity, 36
Chlorides ' 179
Delusions 47
false concepts, 47
superstitions, 48
classification, 49
Dementia 69
primary, 69
secondary, 69
penile, 69
organic, 70
toxic, 70
Dialyzed opixnn 214
Dipsomania 265
classes, 266
treatment, 273
326
INDEX.
PAOR
Discharge of patients from asyl-
ums 324
two methods, 324
Epilepsy of the insane 130
three levels of Jackson, . . 131
grande mal, 131
tonic and clonic spasm, , . 132
symptoms, 132
temporary amnesia, ..... 1 34
mental automatism, 135
petit mal, 135
points of notice, . . 140, 141, 142
distinction l)etween epi-
lepsy and hysteria, 143, 144
treatment, 221
Ergot extract 215
Electricity 235
Expert witness 320
Functional disorders 249
General progressive paresis. ... 76
symptoms, 76, 77, 78
mental, physical, 79, 80
pathology, 83, 84, 85
General paralysis ... 76
General bodily conditions 177
clashes of disease, 177
trophic change, 178
dead tissues, . . 178
kidney products, 179
Gold bromide 225
Hallucinations 49
false perceptions, 49
siglit, 50
historic persons with hal-
lucinations, 50, 51
three theories of them, . . 52
Humoral pathology 248
Hysterical mania 101
symptoms, 102
hystero-epilepsy, 103
Hsematoma auris ( ortha-ma-
toma) 156
PAGE
Homicidal insanity 170
classes, 170, 171
impulse, \ . . 172
imperative conceptions,. . . 173
Heredity 237
difterent views, 237
formulated laws, .238, 239, 240
transmission, 241
immediate, 244
double, 244
simple, 244
mediate, 244
cumulative, 244
Hyoscyamine 216
Hyoscine 214
Hypnotism 236
Insanity 37
what it is not, 37
not eccentricity, .... . . 37
not crankism, 37
not delirium, 37
not natural decay of old age, 37
not idiocy nor imbecility, . 38
what it is, 38
classification, . . . 40, 41 , 42, 43
metaphysical divisions, . . 44
Hippocrates and Celsus, . . 44
Illusions 52
clinical history, .... 53
Intellectual powers 801
Impulse 55
intellectual, 55
emotional, 55
motor, 55
Insane ear 156
causes, 157
symptoms, 156
treatment, 157
Iron 230
Katatonia 158
Legal points in relation to in-
sanity and crime 309
criminal cases, 309
testamentary cases, 309
inquisition in lunacy, .... 310
INDEX.
327
PAGE
Moral insanity 122
mode of causation, 124
differs from wickedness, . . 126
from moral imbecility, ... 126
moral conceptions, 301
Mind 21
mind and body, 21
definitions, 21
metaphysical, ... 21
physiological, 21
materialism, 23
history of theories, 24, 25
Wundt's theory, 26
Monobromide of camphor 214
Melancholia 106
cardinal symptoms, 106
bodily functions, 107
simple, delusional, stupor-
ous, 109
suicidal, 110
ditferentiate, 113
treatment, 228
Memoranda of notes 4.")
life history, 45
hereditary history, 46
predisposing causes, excit-
ing causes, 47
Mind stress 188
Masturbation 149
Manias 66
treatment, 210
Monomania 57
kleptomania, 57
pyromania, 57
erotomania, 57
homicidal mania, 57
suicidal mania, 57
Mania proper 63
sthenic, 61
asthenic, ... 61
frenzy, 63
typhomania, 63
delirium, 93
chronic, 65
acute, 67
PAGE
Notes taken at examinatitm of
patient . . 198
organic functions, 198
sexual functions, 198
nervous system, 199
mental symptoms, 199
tables, 200, 201
Notes on life history 45
Nitro-glycerine 226
Neurasthenia 254
divisions 256
treatment, 261
tonics 264
Neuratropia. 254
Narcomania 279
classes, 279
symptoms, 2o0
treatment, 281
prescriptions, . . ..282, 283, 284
Onanic insanity 149
classes afflicted, 150, 151
symptoms, , . 153
results, 155
Opium 211
Puerperal insanity 87
mania and melancholia, . . 87
time of child-bearing, .... 88
at childbirth, 88
post-parturient period, . . , 88
sympathetic, 89
septic, 89
phrenic, 90
instruments, 93
Paranoia 1 59
history, 159
symptoms, 161
origin, . . 163
treatment, 165
Phthisical insanity 167
latent, 167
mortality, 168
trophic, 169
pathology, 170
328
INDEX.
Paraldehyde 2i7
Phosphates 230
Phosphorus 234
Phosphides 234
Quinine 250
Record of autopsies 200, 201
Simulated insanity 1 04
reasons for it, , 104
Syphilitic insanity .. 145
clinical features, 146
pathology, 147, 148
Sulphonal 217
Strychnia 223
Sympathetic 247
Steps taken to admit patients . 322
Temperature and pulse 179
differences, 180, 181
unreliability, 181
Treatment of different forms . . 202
general observations 202, 203,
204, 205, 206
puerperal mania, 207
rest, nursing, antiseptics,
stimulants, 207
' TAGB
Treatment — ( Continued).
hypnotics, 208
spirits, 209
tonics, 209
Treatment of "lania 210
hygiene, sanitation, 211
drugs, 211
Erescriptions, 213
rain restraint, rest, .... 220
Treatment of epilepsy, mastur-
bation and melancholia 221
different remedies, . . 222, 223,
224, 225, 226, 227
Treatment of melancholia, .... 228
feeding 232
medicines, 233
electricity, 235
Urea 179
Uterine disturbance 177
Valerianate of zinc 226
Witnesses in courts of law. . . . 315
points to be noted, 316
Zinc bromide 225
K